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

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.

Figure 1.. Event Study Results of Naloxone Access Laws (NALs) on Naloxone Distribution, 2010-2016

Outcome was naloxone prescriptions per 1000 Medicaid beneficiaries. Vertical bars represent 95% CIs, adjusted for state-level clustering. All values in the figure were estimated jointly, along with state fixed effects, time fixed effects, and coefficients associated with policy variables and other covariates discussed in the text. Event study estimates were normalized to 0 in the year of adoption. Times to the left of zero refer to periods before adoption of NALs (−4 refers to periods ≥4 years before adoption); times to the right indicate periods after adoption of NALs (3+ refers to periods ≥3 years after adoption).

Figure 2.. Event Study Results for the Outcome of Naloxone Access Law (NAL) Policies on All Opioid Mortality, 2005-2016

Outcome was opioid-related fatal overdoses per 100 000 people. Vertical bars represent 95% CIs, adjusted for state-level clustering. All values in the figure were estimated jointly, along with state fixed effects, time fixed effects, and coefficients associated with policy variables and other covariates discussed in the Methods section. Event study estimates were normalized to 0 in the year of adoption. Times to the left of zero refer to periods before adoption of NALs (−4 refers to periods ≥4 years before adoption); times to the right indicate periods after adoption of NALs (3+ refers to periods ≥3 years after adoption).

Figure 3.. Event Study Results for the Association Between Naloxone Access Law (NAL) Policies and Nonfatal Opioid Overdoses, 2005-2016

Outcome was opioid-related emergency department visits per 100 000 people. Vertical bars represent 95% CIs, adjusted for state-level clustering. All values in the figure were estimated jointly, along with state fixed effects, time fixed effects, and factors associated with policy variables and other covariates discussed in the Methods section. Event study estimates were normalized to 0 in the year of adoption. Times to the left of zero refer to periods before adoption of NALs (−4 refers to periods ≥4 years before adoption); times to the right indicate periods after adoption of NALs (3+ refers to periods ≥3 years after adoption).