When the overdose-reversal drug Narcan hit pharmacy store shelves last fall, it was widely heralded as a major breakthrough in the decades-long fight to curb the soaring number of overdose deaths nationwide.
For the first time, people could walk into any pharmacy and buy the nasal spray as easily as cough medicine or toothpaste. Soon, public health experts predicted, ordinary Americans would be carrying the miracle drug in their purses and back pockets — ready to rescue overdose victims from the brink of death with a quick spritz.
Yet several months later, the life-saving drug is still maddeningly difficult to find in Massachusetts, according to a Boston Globe survey of more than 60 pharmacies statewide. From Pittsfield to Cape Cod, large chains CVS and Walgreens often do not have Narcan in stock, or keep it hidden behind a pharmacy counter or locked in a plastic box, forcing consumers to ask for it. Many independent pharmacies have Narcan on hand but are wrongly telling consumers they need a doctor’s prescription to buy it.
This is occurring despite a Massachusetts law requiring all licensed retail pharmacies to maintain a continuous supply of naloxone, the active ingredient in Narcan, and state guidelines recommending that retailers make it as visible and accessible as possible.
“Frankly, this level of inconsistency and confusion will cost lives,” said Leo Beletsky, a professor of law and health sciences at Northeastern University in Boston. “The risk of overdosing is burden enough. People looking for [Narcan] shouldn’t face the additional burden of having to ask five people to find a life-saving product.”
Massachusetts pharmacies cited a variety of reasons for why Narcan is often unavailable or hard to find, including low demand and the fragmented nature of the pharmacy industry, in which local drug stores often determine what product to stock. “Any time a new drug goes over the counter, there is always a period of transition,” said Allison Burns, a pharmacist and director of the Massachusetts Pharmacists Association. “But we are in the middle of a public health crisis [with overdoses] and we need to take a closer look at this.”
Narcan’s primary ingredient, naloxone, known as an opioid antagonist, reverses the effects of opioids such as fentanyl, heroin, and prescription painkillers such as OxyContin in minutes. It works by binding to the same receptors in the brain as opioids and putting up a shield, preventing opioids from shutting down the respiratory system. It does not work for nonopioid drugs such as cocaine, alcohol, and benzodiazepines like Xanax and Ativan.
Before the Food and Drug Administration’s decision, states including Massachusetts had what is known as a “standing order” in place that allowed residents to get naloxone without an individual prescription. To do so, however, customers had to visit a pharmacy counter and provide their personal information to a store employee.
The FDA’s decision on March 29 to make Narcan available over the counter permitted pharmacies to stock the nasal spray on store shelves for the first time, allowing customers to avoid a stigma when asking for it. The wider rollout began last September, with major retail pharmacies charging $45 to $50 for a two-dose pack.
The Globe called or visited 70 independent and chain pharmacies statewide since late December and found 22 did not have the nasal spray in stock. Most of the drug stores that didn’t have Narcan said they carried the generic version of naloxone, though only behind the pharmacy counter. Nearly half, 33, of the pharmacies surveyed said they kept Narcan behind the counter as well, in violation of state guidelines.
Even when pharmacies did carry Narcan, the drug was hard to track down.
The pink cartons are often stacked on pharmacy store shelves in a seemingly random fashion — next to unrelated items such as protein mixes and Tylenol. And many pharmacy employees are still unfamiliar with the drug and where it is located. When asked about Narcan, they sometimes point to the wrong aisle or confuse it with products such as nasal sprays for allergies or nicotine gum. In some cases, the product was on the shelves but employees didn’t know it was there, according to visits to dozens of stores statewide.
Other pharmacies displayed Narcan on store aisles in locked plastic boxes that must be opened by store personnel.
“If you want people to buy this life-saving product, then you have to be real about stigma,” said Traci Green, an epidemiologist and director of the Opioid Policy Research Collaborative at Brandeis University. “For a lot of people, verbalizing the need for Narcan involves publicly acknowledging one’s addiction and one’s fears about death, which is not easy to do at the pharmacy counter.”
Recognizing the urgent need to stem overdoses, state health officials are urging retailers to make Narcan easier to find.
On Dec. 20, the state Department of Public Health issued guidelines clarifying that retailers should place over-the-counter naloxone near the front of stores or cash registers to “maximize visibility” and to allow customers to access the drug anonymously and without having to visit a pharmacy counter. The agency also said the product should not be placed in locked cabinets or containers.
Many independent drug stores appear unaware of the state law requiring them to maintain a continuous supply of naloxone, or of the state guidance saying it should be visible near the front of the stores. Of 15 independent pharmacies included in the survey, from Jamaica Plain to Worcester, only four said they had Narcan on hand and could sell it immediately over the counter. Staff at five of the independent pharmacies incorrectly said it required a prescription.
Several independent drug stores that don’t carry Narcan blamed low demand, and a customer clientele that is accustomed to seeking help at pharmacy counters, where they can still access the generic naloxone under the state’s standing order. “In our case, over-the-counter [Narcan] is useless,” said Igor Kuzmin, owner of Brighton Pharmacy. “We buy what we can sell and the demand just isn’t there.”
At a CVS pharmacy near Harvard Square in Cambridge, a staff person behind the counter was not familiar with Narcan and initially suggested checking the vitamin aisle. Another employee checked further and found the store had none in stock. At a CVS in Framingham, staffers said they had no over-the-counter Narcan available, and would only sell the generic version under the standing order requiring customers to submit personal information at the pharmacy counter.
At a CVS inside a Target in Danvers, the pink Narcan boxes were tucked at the bottom of a shelf in an aisle filled with protein mixes, blood pressure monitors, and diabetic testing products. Yet unlike other items on the shelf, the Narcan cartons were placed inside locked plastic cases.
In a written statement, a CVS spokesman said the retail chain encourages customers to go to the pharmacy counter for Narcan so that employees can check the person’s insurance plan for possible savings and see if the drug is covered under the person’s insurance. The pharmacy counter “also provides customers with a knowledgeable resource to answer any questions they may have about the product,” CVS said.
In three stores in Greater Boston, including at a Walgreens in Downtown Crossing, pharmacies declined to sell the Narcan they had on hand, citing the need to keep some doses on hand in case anyone overdosed on drugs in the store.
In a statement, Walgreens said the chain has adequate supplies to meet demand and did not respond to questions about the product’s sporadic placement in the stores and why it was often behind the pharmacy counters.
Based on the survey, Wal-Mart and Costco were the most reliable about stocking Narcan. A survey of a half-dozen of the big-box stores statewide found that all of them had at least several boxes of the drug in stock, and some had dozens. Yet, like many pharmacies, the retailers keep the drug behind its pharmacy counters and not in its general store aisles.