Community pharmacists' engagement in opioid harm reduction: A rural-urban analysis from a rural state

To evaluate disparities in opioid misuse risk and pharmacist-led harm reduction interventions by comparing rural and urban community pharmacies participating in an opioid misuse and accidental overdose prevention program in North Dakota.

The ONE Program is a statewide opioid harm reduction initiative that screens patients receiving opioid prescriptions for risk of opioid use disorder and opioid overdose. Pharmacists delivered interventions based on risk stratification, including naloxone education/dispensing, prescriber contact, and community support referrals. Risk and outcomes were analyzed comparing rural and urban pharmacy settings using odds ratios (ORs) with 95% confidence intervals.

Between April 2022 and July 2024, a total of 21,295 patient opioid risk screenings were conducted across 63 pharmacies (32 rural, 31 urban). Urban pharmacies screened a higher proportion of at-risk patients (26.2%) compared to rural pharmacies (17.1%). While naloxone was recommended at similar rates, rural patients were significantly less likely to accept naloxone (11.2% vs. 20.7%, OR = 0.49). Urban pharmacies were more likely to contact prescribers (9.9% vs. 1.9%, OR = 0.18) and introduce medication take-back programs (OR = 6.65). Conversely, rural pharmacies were more likely to provide partial opioid fills (OR = 1.67) and education on community support services (OR = 3.95). Overall, rural patients were 24% less likely to receive at least one of six critical interventions defined by the ONE Program. (OR = 0.76).

The ONE Program effectively identifies at-risk patients and delivers harm reduction interventions in both rural and urban pharmacy settings. However, significant differences in intervention delivery highlight the need for tailored strategies to address geographic disparities in opioid harm reduction.