Pharmacy-based naloxone practices, knowledge, attitudes, and barriers in the rural United States: A systematic review

Naloxone reverses opioid overdose and prevents overdose deaths. Access is particularly important in rural areas where healthcare resources are limited, and overdose mortality is often higher. Community pharmacies can expand naloxone access, but their presence does not ensure availability. Pharmacists' knowledge, attitudes, and perceptions, along with pharmacy- and patient-level barriers, may influence stocking and dispensing. Examining these practices and strategies to improve service delivery may identify opportunities to strengthen rural pharmacy-based naloxone services. Although previous reviews have examined pharmacy-based naloxone services, none have systematically synthesized evidence specific to rural U.S. community pharmacies.

This systematic review aimed to synthesize evidence on naloxone stocking and dispensing practices, knowledge, attitudes, barriers, and pharmacist-led interventions to support naloxone service delivery and uptake in rural U.S. community pharmacies.

PubMed, Web of Science, and CINAHL were searched for peer-reviewed, U.S.-based original research articles published in English from 2000 through May 2026 examining naloxone services in rural community pharmacies. A narrative synthesis was conducted following PRISMA guidelines.

Thirty-four studies met the inclusion criteria. Naloxone stocking and availability varied across rural pharmacies and did not consistently translate into dispensing. Pharmacists reported favorable attitudes toward naloxone provision; however, knowledge gaps, workflow and staffing constraints, reimbursement issues, stigma, and patient affordability were identified as barriers. Pharmacist-led interventions incorporating patient screening, clinical decision support, counseling, and workflow modifications reported improvements in naloxone offers, counseling participation, and/or dispensing.

Naloxone service delivery in rural community pharmacies remains inconsistent despite stocking and favorable pharmacist attitudes. Pharmacist-, pharmacy, and patient-level barriers may limit naloxone provision and uptake. Although pharmacist-led interventions in rural pharmacies have reported promising outcomes, including increased naloxone dispensing, evidence regarding their effectiveness and long-term sustainability remains limited. Further research is needed to evaluate the integration and impact of these interventions into routine rural community pharmacy practice.