A drug central to the push to reduce Pennsylvania's soaring opioid overdose death rate isn't on the shelves of many pharmacies, and numerous drug stores Tuesday showed confusion about a state order meant to put naloxone in the hands of any resident who could witness an overdose.
The Pittsburgh Post-Gazette called 32 area pharmacies, including chains and independent stores in and around Pittsburgh, on Tuesday and found that 16 did not have Narcan, the most consumer-friendly version of naloxone. The Inquirer found similar results in the state's southeastern corner. In calls to 38 pharmacies in Philadelphia, Montgomery County and South Jersey, reporters found chain pharmacies were more likely than independents to sell naloxone without a prescription, as the law requires.
Most of those pharmacies had the brand-name Narcan, a nasal spray version marketed directly to consumers by Radnor-based Adapt Pharma L.P. Physicians and emergency crews would be more likely to use injectable forms of the generic drug naloxone.
The overdose-reversing, lifesaving naloxone is supposed to be available to anyone in Pennsylvania without a prescription.
In October, Physician General Rachel Levine signed a standing order allowing anyone to get naloxone as a nasal spray or injection. In an interview, Levine acknowledged that some pharmacists haven't gotten the message.
"We would want pharmacies, and the pharmacists, to know about the standing order, and more and more do," she said. "I think it would be great . . . that they have it in stock."
She said the administration has written to every pharmacist in the state and referenced the standing order at events and "countless press conferences." Next month, she will go before the Board of Pharmacy and urge it to echo the call.
Of the 16 pharmacies around Pittsburgh that did not stock the drug, staff members at eight said they did not know where it could be found. Others suggested other pharmacies, or referred callers to the Allegheny County Health Department.
Some pharmacy staff seemed unaware of or confused about the state order making the drug available without a doctor's prescription.
Pharmacy staff at some Pittsburgh-area Rite Aids said the stores did not have the drug. One referred the caller to the Rite Aid on Market Square downtown, which had the nasal version - but charged $187.99 for a single dose. A Rite Aid spokeswoman said that the chain has "strategically placed naloxone in areas where there has been a demand or need observed," and stores that don't have it refer customers to ones that do. She declined to comment on the price quoted, but said cash prices for some formulations range from $33 to $97.
Other pharmacies quoted prices around $50 for the nasal product, and the three that had the intramuscular injection product provided prices ranging from $45 to $60.
Of 14 pharmacies in Philadelphia, five said they had it in stock and no prescription was required. Another five said they had it, but wanted a doctor's prescription. The rest said they couldn't get it. One independent store told a caller to go to a chain store. Just six of 14 Montgomery County pharmacies had the drug in stock; two said they required a prescription.
In New Jersey, the Overdose Prevention Act allows "health care professionals" to "provide naloxone to any person" at risk for opioid overdose or in a position to help a person experiencing an overdose. Pharmacies may dispense naloxone to anyone they deem capable of administering it if they have a standing order from a prescribing physician allowing them to do so.
Of the 10 pharmacies - five chains, four independents, and a grocery store pharmacy - called in South Jersey, only one said no prescription was required. Both Walgreens and CVS have announced they would make Narcan available without prescriptions in their New Jersey stores, though outlets of each chain called by Inquirer reporters said they could order the drug, but a prescription was required.
Prices quoted ranged from $44 for a vial of an injectable generic to $160 for a package of two nasal sprays. Conflicting information also was given about insurance coverage, with some saying a prescription was needed to get insurance coverage for the drug.
This confusion and uneven availability of the drug is a problem familiar to Alice Bell, overdose prevention project coordinator for Prevention Point Pittsburgh.
"There are lots and lots of pharmacies that don't have naloxone," she said. "We get calls from people who say, 'I called my local pharmacy. They don't have it. They don't know anything about it.' "
As to why the statewide standing order had not translated to full availability at every pharmacy, Bell has a few theories. Any new policy takes time to figure out, pharmacists must learn more about the issue, and there may be a lack of understanding, or a sense that this is wrong or enabling drug use.
Some confusion could be because standing orders are rare, said Pat Epple, CEO of the 2,300-member Pennsylvania Pharmacists Association.
"The rarity of this is what is catching people off guard," she said. Even more unusual is a standing order that allows for third parties to purchase a drug that will not be used on themselves (because the drug is administered not by the person who is overdosing, but someone nearby). Additionally, not every pharmacy will stock naloxone, likely due to its cost, she said.
The association has been communicating with members about the order, she said, adding that she believes word is getting out and availability is improving.
Allegheny County Health Department Director Karen Hacker said her agency has heard similar complaints about naloxone availability, and called for more outreach with pharmacists. She also noted that a standing order is not a mandate to carry naloxone.
"The policies are in place. Now we have to get it to filter down to folks on the front lines," she said.