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When the U.S. Food and Drug Administration made the opioid overdose reversal drug naloxone an over-the-counter medication last summer, health care advocates praised the removal of the prescription barrier as an effective tool to prevent fentanyl deaths.
That is, if you can find it.
A February report from Rice University’s Baker Institute for Public Policy found that of the 156 pharmacies they contacted, 71 percent of the Houston pharmacies kept it behind the pharmacists’ counters or were entirely out of the product.
Pharmacies typically stock it in the nasal spray version of the life-saving drug, called Narcan. When used, Narcan can quickly reverse the effects of an opioid overdose. It’s not cheap. A box containing two doses of two nasal sprays goes for $43.
But inconsistent practices from pharmacy to pharmacy and slow resupply times can make Narcan a problematic drug to find.
“There seems to be a lot of confusion surrounding Narcan sales,” said Katharine Neill Harris, a drug policy fellow at Rice University’s Baker Institute for Public Policy. “Some places are sold out of it because of the demand. While others still keep it behind the counter to prevent it from being stolen or don’t carry it at all.”
From August 2022 to 2023, there were an estimated 5,566 drug-related deaths in Texas, 45% of which involved the synthetic opioid fentanyl, according to the Centers for Disease Control and Prevention. Texas Health and Human Services reported last year that, on average, five Texans die every day from fentanyl poisoning.
The rise in both the illegal use of the drug and now the manufacturing of counterfeit prescription drugs that contain fentanyl has made this a particularly deadly problem. But access to the quick-acting Narcan is inconsistent in Texas and nationwide.
Students at Rice University’s Baker Institute for Public Policy called major retail pharmacies in 48 zip codes – including 22 in high poverty zip codes – to ask about availability, brand, price, and location within the store. The group contacted a variety of retailers including Walgreens, CVS, H-E-B, Kroger, Walmart, Costco, and Sam’s Club pharmacies over several months in 2023.
The report found most pharmacies contacted in the Houston area had some version of naloxone, but 71% of them still kept it behind the counter. Of those reported carrying naloxone, 45% said pharmacist assistance is required, 26% said cashier assistance is needed, and three pharmacies even mentioned ID was required for purchase.
Narcan can usually be found on the websites of these pharmacies. The FDA’s decision to make naloxone, or Narcan, available without a prescription was to make this life-saving drug easily available. However, the price point for Narcan, roughly $22.50 per dose, usually means retail pharmacies will lock it up out of fear of it being stolen, reducing the odds someone will buy it because they will have to ask for assistance.
“This is the opposite of what is supposed to be occurring. When you put something behind the counter, it automatically makes people less likely to ask for it. It makes them think they need a prescription to ask for it,” Harris said.
A random visit to 15 pharmacies in Austin revealed the confusion surrounding the drug’s location or availability. Pharmacists, often busy with customers, had a few moments to quickly point to the last area where the Narcan might be located or mention they were sold out of the product.
In northwest Austin’s Allandale neighborhood, the H-E-B has two boxes of Narcan located on the shelf next to pain pills. Meanwhile, the Walgreens across the street has an empty Narcan display in front of their pharmacy counter.
At the same time, the Tarrytown Pharmacy northwest of downtown Austin offered customers multiple ways to obtain Narcan while in the store, such as picking it up from the aisle or having a pharmacist prescribe one at the desk to allow for insurance to cover the price. A Walgreen’s southwest of downtown, on Riverside Drive had no Narcan in stock.
The Texas Tribune reached out multiple times for comment from the Texas Pharmacy Association. The group did not immediately comment on the inconsistent availability of Narcan.
Texas is not alone in this problem. Mississippi Today reported more than 40% of the state’s pharmacies do not carry naloxone, despite a 2017 standing order from the state that allows pharmacists to dispense naloxone with or without a prescription.
According to a March 2023 report by the Reagan-Udall Foundation, 45% of the 17 million doses of naloxone in the United States in 2021 were distributed outside retail pharmacies and health care facilities. Local health departments, harm reduction organizations, first responders, schools, and other community organizations distribute millions of naloxone doses annually.
“This isn’t what was envisioned when Narcan was made available to the public,” Harris said.
Last year, President Joe Biden, in partnership with the Ad Council, the nonprofit organization that produces and promotes public service announcements, launched a fentanyl and naloxone awareness campaign following the FDA’s approval of Narcan for over-the-counter sales. The campaign, which includes digital billboards and social media posts from college athletes and content creators, is meant to teach young people how to use and find naloxone in their communities as opioid deaths continue to rise across the country.
Republican Gov. Greg Abbott, also launched his multimedia campaign last year known as “One Pill Kills” to emphasize the importance of Narcan and the dangers of the synthetic opioid known as fentanyl, as the drug 50 times more potent than heroin has ravaged the state.
The CDC also reported that in 2022, an estimated 43% of drug-related deaths nationally occur with a potential bystander present.
The Rice University report also noted that 17% of the pharmacies they contacted didn’t carry naloxone of any kind, and four zip codes contained multiple pharmacies without the drug, all having poverty rates of less than 10 percent.
“One of the reasons we heard for not carrying naloxone was the perception their clientele didn’t need it,” Harris said. “We are supposed to be encouraging everyone to have Narcan. It’s meant to be as common as a fire extinguisher.”
Kristen Clancy, a pharmacist and the director of the Houston Recovery Initiative, a volunteer network of prevention, intervention, treatment and post-treatment services for those with substance abuse problems, said she doesn’t think this is a case of pharmacies being negligent; they just don’t have the time to be educated on the problems in their community. She said that is why she has spent the past couple of years getting Narcan into the hands of independent pharmacies in Galveston County.
“When we put Narcan in an independent pharmacy, the pharmacist told us they didn’t want to do it. I told him your county is the second highest per capita for overdose deaths in the state, and your city is the third highest per capita. Why wouldn’t you want this? He had no idea and was completely on board once they learned,” Clancy said.
Jennifer Ruffcorn, a Texas Health and Human Services spokesperson, said their agency hasn’t notified pharmacies to tell them they should be selling over the counter. She also said the agency doesn’t have statistics on naloxone availability or what pharmacies currently sell naloxone over the counter.
Naloxone can be a vital piece to solving the opioid crisis in Texas, but Rice’s Harris said for this to happen, there will need to be some changes made by and for pharmacists.
“Pharmacies are one of the most accessible points of care. You get flu shots and pick up your medicine there, and other things. If we can put Narcan more in the public eye, then people will start to take more interest in it,” Harris said. “But our pharmacists are also facing their own challenges. Pharmacies have the potential to be great community care providers, but we got to support them.”
For pharmacist Julie Bennett, who works at the independent Tarrytown Pharmacy in Austin. making the opioid-reversal medication known as naloxone widely available is vital.
Bennett spends the free days her employer gives to pharmacists to do community outreach to search for available naloxone supplies. She searches online, contacts suppliers, and is always trying to find a new way to get more naloxone products to the public, including giving away some of their stockpile of Narcan to college students for free at events.
“The key is we have the staff in place to allow me to do this,” Bennett said. “When I was working at CVS, there was no time. I was alone, the phones were ringing, and people were in the drive-thru. It’s not easy for pharmacists right now, and I think that is holding things back when it comes to access to naloxone.”
Time is something most pharmacies around Texas have in short supply as the industry is dealing with staffing shortages.
CVS, Walgreens, and Walmart announced early last year the need to reduce hours to help manage the workload with fewer available pharmacists. Later that year, workers at some of the nation’s biggest pharmacy chains, Walgreens, CVS, and Rite Aid, pledged to start a “pharmageddon” by coming together and calling in sick for one day to demand better working conditions. This grassroots movement came after two separate protests by Walgreens employees nationwide and CVS employees in at least a dozen Kansas stores.
Clancy, the Houston pharmacist, said the work environment around pharmacies, especially busy retail ones, is challenging right now, making checking how much Narcan is in stock at the pharmacy a very low priority.
“You ask pharmacists to dispense 400 to 600 prescriptions daily with limited staff. You might get one lunch break, but you have to spend that time catching up on work,” she said. “These corporate pharmacies discovered during COVID-19 that you could push these pharmacists to the brink with a limited staff. You could add shots and vaccines on top of filling prescriptions, and now you are asking them to keep track of one more product.”
Disclosure: H-E-B, Rice University, Rice University’s Baker Institute for Public Policy and Texas Pharmacy Association have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.
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