Pharmacies, prescription providers dangerously clueless about naloxone policies

America’s top doctor recently issued a nationwide advisory — the first from the Office of the Surgeon General in 13 years — urging all of us to carry the opioid overdose-reversal medication naloxone, also known as Narcan — the brand name for a device that delivers the medication. Efforts like this are nothing new to Philadelphians: The city has launched a $100,000 campaign aimed at encouraging everyone to do the same.

But in states with standing orders — including Pennsylvania, Delaware, and New Jersey — individuals don’t need a prescription from a doctor. Yet we are met at the prescription drop-off window by pharmacy staff who don’t understand.

In Pennsylvania (where I live), here’s how the standing order is supposed to work:  Any individual can walk into any pharmacy and ask the pharmacist for naloxone. As long as the pharmacy has it in stock (which is often not the case, because it’s outrageously expensive to shelf), the pharmacist uses a blanket prescription written by a doctor for that pharmacy, just as they would for a flu shot. Once that person’s prescription enters the system, it then joins the prescriptions queue with all the others, and, within 20 minutes or so, it’s filled. The prescription can be used by the person it’s written out to or someone else, which the standing order explicitly states.

Once the prescription is filled, an individual can pay out of pocket (about $150) or use their prescription coverage to pay a reduced rate, ranging from nothing for those whose prescription benefits providers have waived the fee, to $25, $60, $85, or more. My co-pay, for example, is $25, which is supposed to get me two 4-milligram doses. You can check how much it will cost you here.

I’ve attempted to get naloxone through Pennsylvania’s standing order three times, but I’ve succeeded just once.

In January, I tried to use my prescription plan to get Narcan at a CVS in Delaware County. The pharmacist there told me I needed a prescription from my doctor. This began an hourlong process of me explaining what the standing order is, who I needed the naloxone for, and the pharmacist making phone calls trying to confirm that I could not use my prescription benefits to pay for a standing order script (which is untrue).

Eventually, the pharmacist presented me with two very frustrating options: I could spend $135 out of pocket for Narcan, or I could get a prescription from my doctor’s office (which was closed for the weekend) to pay $25. I needed it that day, so I broke the bank and spent the money. Many would have had no other choice but to wait.

Last month, I tried again. My overcomplicated experience (which I documented on Twitter) began at a Rite Aid in North Philadelphia and ended 12 hours later at a CVS on City Line Avenue. Before driving to CVS, I called my prescription benefits provider to make sure I could walk into the pharmacy and use my benefits to purchase naloxone (unlike I’d been told before).

She told me that yes, I could go to any CVS and purchase it with my prescription plan, and that it would cost me  $25.

But when I got to CVS, I once again encountered a pharmacist unfamiliar with the standing-order policy. When I asked for naloxone, she checked the prescription bin and said there was nothing waiting for me. I explained the standing order, again. She looked me up in her database and delivered what she thought would be good news: I did, in fact, have a prescription for naloxone. However, there was just one catch: I had to drive to Delaware County to pick it up — even though she had it in stock, 15 feet from where I was standing; there was a standing order in place; and the other pharmacy closed in 25 minutes. So I fought back. Ten minutes later, I walked out of that pharmacy with Narcan.

Unfortunately, my experiences are not unique. When I shared my 12-hour debacle on Twitter, others chimed in with experiences as frustrating as mine.

According to one Twitter user, a pharmacist said he needed to special order naloxone under IBX’s new policy, which waives the co-pay for prescription benefits members, so they weren’t able to get it. However, according to IBX, as long as a pharmacy has it in stock, there’s no special order required. The cost is waived when the pharmacist or staff rings it up.

Another said that an Acme pharmacist told her she wasn’t allowed to give her Narcan through the standing order, because she planned to use the life-saving drug not on herself but on a family member. When she challenged the pharmacist’s logic, the pharmacist explained that if people know that they’re overdosing, they can inject themselves with Narcan.

At an overdose-reversal training I attended, the trainer noted that some pharmacists still don’t understand how the standing order works — even though it’s been in effect here since 2015.

In the midst of a public health crisis, this is unacceptable.

Now that our federal, state, and local governments are committed to increasing the public’s access to naloxone, it’s time for drug stores and pharmacists to do their part. Drug stores need to provide pharmacists and pharmacy staff with better training regarding standing-order policies specific to each state. While pharmacists wait for that training, they should reread their state’s standing-order policy to clarify exactly how it’s supposed to work.

Remember that when someone walks into a pharmacy to get naloxone, he or she is more likely than not to be in crisis. Had I been fighting my own cravings or the emotional pain of needing it for my husband or daughter, I’m not sure I’d have put up a fight.

—

Jillian Bauer-Reese is an assistant professor of journalism at Temple University, where she teaches a course called Solutions Journalism: Covering Addiction. She is also a person in long-term recovery. Contact her at atjbr@temple.edu.