Pharmacist Prescriptive Authority for Naloxone

Research SummaryPublished Dec 19, 2023

Involves the legislature expanding pharmacist scope of practice to allow pharmacists to directly prescribe or furnish naloxone to patients without any physician involvement.

A panel of experts rated how they expect this type of policy to affect four outcomes: naloxone distribution through pharmacies, opioid use disorder (OUD) prevalence, rates of nonfatal opioid overdose, and opioid overdose mortality. Another panel of experts rated the policy on four implementation criteria: acceptability to the public, feasibility of implementation, affordability from a societal perspective, and equitability in health effects.

Policy Recommendations According to Expert Ratings

Oppose Uncertain Support
No
Yes
No

Summary of Expert Ratings

Outcomes Effect Rating
Harmful Little-to-no Beneficial
Naloxone Pharmacy Distribution
No
No
Yes
OUD Prevalence
No
Yes
No
Nonfatal Opioid Overdose
No
Yes
No
Opioid Overdose Mortality
No
Yes
No
Criteria Implementation Rating
Low Moderate High
Acceptability
No
No
Yes
Feasibility
No
No
Yes
Affordability
No
No
Yes
Equitability
No
Yes
No

Summary of Expert Comments

  • Experts expect this policy to increase naloxone pharmacy distribution by removing patient barriers to acquiring naloxone (prescriptions and physician involvement) and enabling pharmacist autonomy. They expect minimal effects on other outcomes due to pharmacist knowledge about and attitudes toward naloxone.
  • Experts think the policy is acceptable to the public because of its successful adoption without much public pushback.
  • Experts believe the policy could be feasible — conditional on pharmacist willingness and lack of opposition from prescribers concerned about professional scope creep.
  • Experts rated the policy as affordable due to eliminating the costs of prescriber office visits — and lower administrative costs compared with collaborative practice agreements.
  • Experts believe the policy to be only moderately equitable because of the possibilities of pharmacist bias and limited access to pharmacies.

Outcome Summaries

Naloxone Pharmacy Distribution

Amount of naloxone dispensed through retail pharmacies (e.g., chain pharmacy stores, independent community pharmacies).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial
(selected)
 Removes barrier of needing a physician prescription to dispense naloxone. "Putting the authority to prescribe Naloxone in the hands of the pharmacist and removing the additional barrier of having to go through a doctor would increase pharmacy distribution"
Little-to-no Depends on pharmacist interest in prescribing or furnishing naloxone. "Not convinced that there is a large demand among pharmacists to do this. Could improve with training and the emergence of more harm reduction interested pharmacists"
Harmful N/A N/A

Opioid Use Disorder Prevalence

Percentage of the general population with a pattern of opioid use leading to clinically and functionally significant impairment, health problems, or failure to meet major responsibilities.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial N/A N/A
Little-to-no
(selected)
 No credible mechanism linking pharmacist prescriptive authority and OUD prevalence. "Not the target of this type of legislation"
Harmful N/A N/A

Nonfatal Opioid Overdose

Per capita rates of nonfatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Could facilitate pharmacist identification of patients at risk for an overdose. "Would allow pharmacists in community pharmacies to identify at-risk patients from a wider range of prescribers and would allow for more doses to be available in the community"
Little-to-no
(selected)
 No credible mechanism linking pharmacist prescriptive authority and nonfatal overdoses. "Won't impact initial OD [overdose], just lethality of OD"
Harmful Potential for revival from overdose could (1) have a small, indirect, and mechanistic impact on nonfatal overdoses due to increased survivorship and (2) lead to continued opioid misuse. "I think there will be more lives saved, which will lead to a mechanical increase in non-fatal opioid overdoses"

Opioid Overdose Mortality

Per capita rates of fatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Increase in naloxone pharmacy distribution (by removing barrier of needing to obtain individual prescriptions) would yield meaningful decreases in fatal overdoses. "Could have a bigger impact than other interventions if done well. To take physician or other prescriber out of the picture increases access"
Little-to-no
(selected)
 Does not address pharmacist knowledge about and attitudes toward naloxone. "Many limitations and stigma among pharmacists, lack of confidence, knowledge, mandate means little effect"
Harmful N/A N/A

Implementation Criteria Summaries

Acceptability

The extent to which the policy is acceptable to the general public in the state or community where the policy has been enacted.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
 Successful adoption without much public pushback (likely due to general trust in pharmacists). "This has been done in several states to general approval"
Moderate Concerns about mixed views from public and prescribers about pharmacists writing prescriptions (rather than simply dispensing medications). "People have mixed acceptance of pharmacists prescribing anything on their own e.g. vaccines"
Low N/A N/A

Feasibility

The extent to which it is feasible for a state or community to implement the policy as intended.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
 Feasible so long as pharmacists are willing to dispense naloxone without physician involvement and there is no opposition from prescribers concerned about professional scope creep. "Allowance is easy, just need pharmacists who are willing to implement"
Moderate Concerns about getting pharmacists to stock and dispense naloxone and about prescribers viewing this policy as scope creep. "Some pharmacists may be unwilling to furnish naloxone to patients under these rules"
Low N/A N/A

Affordability

The extent to which the resources (costs) required to implement the policy are affordable from a societal perspective.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
 Eliminates costs associated with prescriber office visits. Added benefit of less administrative costs compared with collaborative practice agreements (i.e., one statewide policy versus multiple agreements). "This could both reduce societal costs by reducing fatal overdose, as well as reducing costs associated with seeking naloxone because it would not require an office visit, and instead someone could go to a pharmacy in the community whenever it is open. There would be lesser administrative costs for pharmacies compared to the collaborative practice model"
Moderate Depends on costs of naloxone, potential legal action, and the monitoring and enforcement of the policy. "State/community may have to pay for the naloxone, to cover people who are underinsured or uninsured"
Low N/A N/A

Equitability

The extent to which the policy is equitable in its impact on health outcomes across populations of people who use opioids.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Increases the number of pharmacies where people can access naloxone while removing the need to access prescribers. "Can improve equitable access to naloxone through available community pharmacies"
Moderate
(selected)
Concerns about potential pharmacist bias and limited access to pharmacies. "Voluntary nature may lead to inequitable access and pharmacist attitudes/biases may lead to inequitable implementation"
Low N/A N/A
Cover: Pharmacist Prescriptive Authority for Naloxone

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Pharmacist Prescriptive Authority for Naloxone. Santa Monica, CA: RAND Corporation, 2023. https://www.rand.org/pubs/research_briefs/RBA3054-11.html.
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