Latest Publication from Talia Puzantian Reveals Significant Increase in Availability of Naloxone Among California Pharmacies Since 2018

For years, Dr. Talia Puzantian, Professor of Clinical Sciences for Keck Graduate Institute (KGI)’s School of Pharmacy and Health Sciences, has educated pharmacists on the benefits of naloxone, the opioid overdose reversal medication. After conducting a telephone survey of a random representative sample of 1,271 California licensed community pharmacies from January 22 to February 24, 2020, and comparing the results to a similar 2018 phone survey of 1,147 California pharmacies, Puzantian and her team found a significant increase in the availability of naloxone without a prescription as well as the number of pharmacies who had the medication stocked and immediately available.

The findings of this most recent survey were published by Puzantian, Dr. James J. Gasper, and Dr. Christina M. Ramirez in the Journal of the American Pharmacists Association. Although fewer than half of the pharmacies were willing to provide naloxone without a prescription in 2020 (42.4%), this was an 80% increase from 2018, when less than a quarter of pharmacies provided the same service.

“It was a really low number, especially compared to other states,” Puzantian said of the 2018 figure. “And it had already been two years since the legislation had passed that made it legal for pharmacists in California to do this.”

Thus, Puzantian and Gasper, who was also her co-author for the 2018 study, worked with the California Board of Pharmacy to raise awareness and educate pharmacists. They created a free online webinar training along with other educational resources and engaged the board to spread the word through a series of email blasts to the 40,000 pharmacists licensed in the state.

Over those two years, their efforts combined with others’ advocacy efforts, increased awareness, and public demand increased to pharmacists willing to provide naloxone without a prescription.

Additionally, in their 2020 survey, they found that of the pharmacies furnishing naloxone, over 80% had nasal naloxone in stock, a large and statistically significant increase from 2018 when only 50.6% reported having it in stock. In 2020, 90% of the pharmacies reported correctly that pharmacist-furnished naloxone could be billed to insurance, compared with 56.9% in 2018.

Recently, the CDC reported 93,000 overdose deaths in 2020 in the U.S.—mostly from opioids—which is a 30% increase from 2019.

“A lot of it was likely due to COVID, of course, and many of these deaths were caused by very potent opioids,” Puzantian said. “It’s not prescription opioids that are contributing to the majority of deaths but rather illicitly manufactured fentanyl and other synthetic opioids. So they’re not necessarily seeing providers and getting prescriptions, but they might want to come into the pharmacy and get access to the naloxone. Thus, access must be broader because these deaths are preventable.”

The next step may be to make naloxone available over the counter. Some hurdles still stand in the way, though, including requirements that companies have to meet for this to happen.

“Naloxone is very safe to use, but people can’t use it to save a life if it’s not more widely available,” Puzantian said. “While we saw an improvement over these two years, the reality is that less than half of pharmacies will provide the life-saving medication without a prescription.”

The study didn’t examine why pharmacies don’t engage in this practice. It could be that some belief still exists that having access to naloxone would lead people to take greater risks using opioids, but so far, studies examining the correlation between the two have found that this is not the case.

While naloxone works in the short-term to bring back an individual who has overdosed, methadone and buprenorphine help in the long term to get people off of opioids and prevent relapse. Challenges also exist when it comes to increasing access to these drugs.

“Any doctor with a DEA license can prescribe the opioids that might lead to an opioid use disorder, but there are restrictions on providing the treatments for opioid use disorder,” Puzantian said. “Methadone is heavily regulated on how it’s prescribed, and buprenorphine is restricted to prescribers who’ve done extra training and have a special waiver to their DEA license. So very few people are able to access the treatments which have been shown to effectively reduce not only opioid use but also relapse and overdose deaths.”

Thus, Puzantian and Gasper have been working with the California State Board of Pharmacy to help pharmacists get engaged in increasing access to these medications as well.

“Pharmacists are often the first line of contact with patients because we’re available 24/7 and we’re on every corner.” 

“So we can really raise awareness about these treatments. But first, we need to educate the pharmacists better, too—starting with our students,” Puzantian said.

To this end, Puzantian and her team engaged students in the research process. The 2020 phone survey was completed with the help of 20 KGI PharmD students—many of whom are now alumni. They spent many hours calling and interviewing over 1,000 pharmacies throughout the state. They are as follows:

Ramisha Ali, BS; Priscilla Arteaga, PharmD; Yelena Bagdagulyan, PharmD; Winnie Chan, BS; Gerald Chen, PharmD; Nour Dabbas, BS; Sohaila Habibi, PharmD; Shana Henderson, PharmD; Garabet Keshishian, PharmD; Danielle Le, BS; Thomas Lee, PharmD; Chris Lim, PharmD; Hollie Maguire, BS; Dominique Miller, MS; Tanya Moukhtarian, PharmD; Amarachi Okafor, BS; Howard Park, PharmD; Tiffany Samouha, BS; Ani Sarkisyan, PharmD; Emily Tat, PharmD.