Availability of Naloxone in Retail Pharmacies Following Introduction of Over-the-Counter Status.

Importance: Expanding access to naloxone is an essential strategy in addressing the overdose crisis in the US. In March 2023, the US Food and Drug Administration approved the first over-the-counter (OTC) naloxone nasal spray, representing a substantial shift in public health policy and pharmacy practice. Objective: To assess the same-day availability of naloxone without a prescription across US retail pharmacies and examine pharmacy and neighborhood factors associated with access following OTC approval. Design, Setting, and Participants: This cross-sectional study used a secret shopper design to assess availability of naloxone in retail pharmacies in the US from January 15 to April 30, 2024. Participants included a stratified random sample of 1108 pharmacies from the 7 largest corporate pharmacy chains and an eighth stratum incorporating other retail pharmacies. Exposures: Pharmacy characteristics (chain size, type, and affiliation) and neighborhood sociodemographic indicators (racial and ethnic composition and area deprivation index). Main Outcomes and Measures: Same-day naloxone availability without a prescription, location of naloxone within the store, price, and alternative access suggestions. Results: Among the 1108 pharmacies contacted, an estimated 61.40% (95% CI, 57.34%-65.46%) of those with naloxone in stock reported it was available without a prescription. Naloxone was located at the pharmacy counter (estimate, 58.14% [95% CI, 53.59%-62.68%]), self-service aisles (estimate, 31.74% [95% CI, 27.59%-35.89%]), and front checkout areas (estimate, 8.99% [95% CI, 6.64%-11.34%]). The mean (SE) cost was $52.07 ($1.50) (95% CI, $49.12-$55.02). Among pharmacies without same-day naloxone (estimate, 38.60% [95% CI, 34.54%-42.66%]), respondents equally referred callers to another pharmacy or had no suggestions (estimate, 45.84% [95% CI, 37.77%-53.91%]), 4.46% (95% CI, 0.70%-8.21%) offered other suggestions (hospital, public service agencies, online service, or cannabis dispensary), 3.87% (95% CI, 0.48%-7.25%) suggested the public health department, and 0.06% (95% CI, 0.00%-0.17%) suggested syringe service programs. Pharmacies classified as food and/or mass merchandisers, independent, or medical affiliated had a lower odds ratio of offering same-day naloxone compared with corporate chains. In separate analyses, pharmacies located in areas with higher proportions of White residents were more likely to offer naloxone. Area deprivation index-defined neighborhood disadvantage, which does not include race in its calculation, was not associated with naloxone availability. Conclusions and Relevance: In this cross-sectional study of pharmacies across the US, same-day naloxone availability and price remained uneven following OTC approval. As an initial national evaluation of same-day naloxone availability and price after OTC approval, the findings showed differences in implementation across pharmacy types and community demographic features. Although enactment of the OTC policy was necessary, its intended benefits were not realized equally in practice. Expanding pharmacist education and targeting support for independent and medical-affiliated pharmacies may help improve naloxone access, especially in rural and underserved areas.