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Association Between State Laws Facilitating Pharmacy Distribution of Naloxone and Risk of Fatal Overdose

Educational Objective
To identify which types of naloxone access laws (NALs), if any, are associated with reductions in fatal overdoses involving opioids and examine possible implications for nonfatal overdoses.
1 Credit CME
Key Points

Question  Are state laws regarding naloxone access associated with reductions in fatal overdoses involving opioids?

Findings  In this population-based study of data from the 2005-2016 National Vital Statistics System, a difference-in-differences design to evaluate 50 states and the District of Columbia, found that states adopting naloxone access laws granting direct authority to pharmacists experienced statistically significant declines in fatal opioid-related overdoses. Other types of naloxone access laws appear not to be associated with decreases or increases in mortality.

Meaning  Naloxone access laws have the potential to improve naloxone access and save lives, but the details of the laws matter; permitting pharmacists to dispense directly and under their own authority appears to maximize the potential benefits of these policies.

Abstract

Importance  Given high rates of opioid-related fatal overdoses, improving naloxone access has become a priority. States have implemented different types of naloxone access laws (NALs) and there is controversy over which of these policies, if any, can curb overdose deaths. We hypothesize that NALs granting direct authority to pharmacists to provide naloxone will have the greatest potential for reducing fatal overdoses.

Objectives  To identify which types of NALs, if any, are associated with reductions in fatal overdoses involving opioids and examine possible implications for nonfatal overdoses.

Design, Setting, and Participants  State-level changes in both fatal and nonfatal overdoses from 2005 to 2016 were examined across the 50 states and the District of Columbia after adoption of NALs using a difference-in-differences approach while estimating the magnitude of the association for each year relative to time of adoption. Policy environments across full state populations were represented in the primary data set. The association for 3 types of NALs was associated: NALs providing direct authority to pharmacists to prescribe, NALs providing indirect authority to prescribe, and other NALs. The study was conducted from January 2017 to January 2019.

Exposures  Fatal and nonfatal overdoses in states that adopted NAL laws were compared with those in states that did not adopt NAL laws. Further consideration was given to the type of NAL passed in terms of its association with these outcomes. We hypothesize that NALs granting direct authority to pharmacists to provide naloxone will have the greatest potential for reducing fatal overdoses.

Main Outcomes and Measures  Fatal overdoses involving opioids were the primary outcome. Secondary outcomes were nonfatal overdoses resulting in emergency department visits and Medicaid naloxone prescriptions.

Results  In this evaluation of the dispensing of naloxone across the United States, NALs granting direct authority to pharmacists were associated with significant reductions in fatal overdoses, but they may also increase nonfatal overdoses seen in emergency department visits. The effect sizes for fatal overdoses grew over time relative to adoption of the NALs. These policies were estimated to reduce opioid-rated fatal overdoses by 0.387 (95% CI, 0.119-0.656; P = .007) per 100 000 people in 3 or more years after adoption. There was little evidence of an association for indirect authority to dispense (increase by 0.121; 95% CI, −0.014 to 0.257; P = .09) and other NALs (increase by 0.094; 95% CI, −0.040 to 0.227; P = .17).

Conclusions and Relevance  Although many states have passed some type of law affecting naloxone availability, only laws allowing direct dispensing by pharmacists appear to be useful. Communities in which access to naloxone is improved should prepare for increases in nonfatal overdoses and link these individuals to effective treatment.

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Article Information

Accepted for Publication: January 26, 2019.

Corresponding Author: Rahi Abouk, PhD, William Paterson University, 300 Pompton Rd, Wayne, NJ 07410 (aboukr@wpunj.edu).

Published Online: May 6, 2019. doi:10.1001/jamainternmed.2019.0272

Author Contributions: Dr Powell had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Obtained funding: Powell.

Administrative, technical, or material support: Powell.

Supervision: All authors.

Conflict of Interest Disclosures: Dr Pacula reported receiving funding through grants R21DA041753 and P50DA046351 from the National Institute on Drug Abuse. Dr Powell reported receiving support through grant R01CE002999 from the Centers for Disease Control and Prevention and P50DA046351 from the National Institute on Drug Abuse. No other disclosures were reported.

Funding/Support: Dr Pacula received funding through grant R21DA041753-01 from the National Institute on Drug Abuse. Dr Powell received support through grant R01CE002999 from the Centers for Disease Control and Prevention.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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