Third Party Prescription for Naloxone

Research Brief

Allows a health care provider with naloxone-prescribing authority to prescribe to an at-risk person’s family member, friend, and/or other person in a position to assist the at-risk person in the event of an opioid-related overdose.

A panel of experts rated how they expect this type of policy to affect four outcomes: naloxone distribution through pharmacies, opioid use disorder (OUD) prevalence, rates of nonfatal opioid overdose, and opioid overdose mortality. Another panel of experts rated the policy on four implementation criteria: acceptability to the public, feasibility of implementation, affordability from a societal perspective, and equitability in health effects.

Policy Recommendations According to Expert Ratings

Oppose Uncertain Support
No
No
Yes

Summary of Expert Ratings

Outcomes Effect Rating
Harmful Little-to-no Beneficial
Naloxone Pharmacy Distribution
No
No
Yes
OUD Prevalence
No
Yes
No
Nonfatal Opioid Overdose
No
Yes
No
Opioid Overdose Mortality
No
Yes
No
Criteria Implementation Rating
Low Moderate High
Acceptability
No
No
Yes
Feasibility
No
No
Yes
Affordability
No
No
Yes
Equitability
No
No
Yes

Summary of Expert Comments

  • Experts expect the policy to substantially increase pharmacy distribution because it facilitates naloxone access for anyone (regardless of opioid use status), effectively removing barriers for laypersons. They expect minimal effects on other outcomes because the policy relies on physician prescriptions and focuses on laypersons who may not actually witness overdoses.
  • Experts think the policy would be acceptable to the public because it allows laypersons to access naloxone for loved ones without any mandates or requirements.
  • Experts believe the policy involves feasible changes to prescriber and dispenser practices because of successful implementation in the past and with other medications.
  • Experts generally rated the policy as affordable, although some raised concerns about payer costs.
  • Experts believe the policy was equitable because it increases access to naloxone through social networks that may overcome structural barriers.

Outcome Summaries

Naloxone Pharmacy Distribution

Amount of naloxone dispensed through retail pharmacies (e.g., chain pharmacy stores, independent community pharmacies).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial

(selected)
Increases the percentage of the general population eligible to receive a naloxone prescription and decreases the stigmatization of naloxone. “This is an important way for caregivers with less stigma (individual, societal, healthcare) to obtain naloxone for their loved ones”
Little-to-no Insufficient impact due to logistical factors. “Unclear that this would increase prescribing much, vs. current practices (give to patient with intention to share with family, prescribe to 3rd party without legal protection). However, I don’t see any potential harm from this type of policy”
Harmful N/A N/A

Opioid Use Disorder Prevalence

Percentage of the general population with a pattern of opioid use leading to clinically and functionally significant impairment, health problems, or failure to meet major responsibilities.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Could facilitate constructive engagement of family and friends in loved one’s opioid misuse. “It would open up the conversation for folks with OUD and their loved ones around OUD
Little-to-no

(selected)
No credible mechanism linking third party prescription and OUD prevalence. “I don’t see how those two are associated”
Harmful Potential for revival from overdose could (1) have a small, indirect, and mechanistic impact on OUD prevalence due to increased survivorship (rather than new cases of OUD) and (2) lead to continued opioid misuse. “Increasing the availability of naloxone will likely lead to an increase in opioid use disorder (due to risk compensation)”

Nonfatal Opioid Overdose

Per capita rates of nonfatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial N/A N/A
Little-to-no

(selected)
No credible mechanism linking third party prescription and nonfatal overdoses. “I do not think this has an effect on instances of overdose (assuming it is not coupled with an education provision)”
Harmful Potential for revival from overdose could (1) have a small, indirect, and mechanistic impact on nonfatal overdoses due to increased survivorship and (2) lead to continued opioid misuse. “This increase is mechanical: through wider distribution, more people use the medication and survive what would have been a fatal overdose (absent the medication)”

Opioid Overdose Mortality

Per capita rates of fatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Significantly increases access to naloxone to a broader population. “This seems like a substantial lever to increase broad access and address a real need (currently it-s not as clear how one gets [a prescription] on someone else’s account)”
Little-to-no

(selected)
Impact of increased naloxone distribution could be limited by lack of witnessing overdoses by third parties obtaining naloxone. “For this intervention to decrease fatal OD [overdose], a number of things have to happen: (1) it has to widely increase distribution and (2) family and friends need to be near the individual who is injecting or using heroin or fentanyl (the most common causes of fatal OD). I’m concerned that this intervention is not going to dramatically increase distribution of naloxone and that family might not be present when individual is using drugs”
Harmful N/A N/A

Implementation Criteria Summaries

Acceptability

The extent to which the policy is acceptable to the general public in the state or community where the policy has been enacted.

Implementation Rating Summary of Expert Opinion Representative Quotations
High

(selected)
Allows laypersons to access naloxone for loved ones without any mandates or requirements. “This seems like a win for people who are concerned and there is no mandate so it would seem people would be supportive”
Moderate Potential to be supported by advocates and those impacted by the overdose epidemic, though also potential public pushback due to concerns about moral hazards and strains on the health care system. “This is a mixed bag. While families/friends/advocates see the benefit of allowing third party prescriptions, unfortunately, the general public may see it as increasing non-fatal overdoses and increasing burden on the health care system”
Low N/A N/A

Feasibility

The extent to which it is feasible for a state or community to implement the policy as intended.

Implementation Rating Summary of Expert Opinion Representative Quotations
High

(selected)
Successful implementation in the past and with other medications. “I do not see why it would be any less feasible than allowing prescriptions for any other medication”
Moderate Concerns about the logistical complexities across insurance plans in tracking appropriate prescriptions and utilization. “Billing for a medication to be used by someone other than the enrollee can be difficult as different payers will have different policies. Tracking any sort of utilization is also a concern”
Low N/A N/A

Affordability

The extent to which the resources (costs) required to implement the policy are affordable from a societal perspective.

Implementation Rating Summary of Expert Opinion Representative Quotations
High

(selected)
Cost-effective from a societal perspective, especially considering cheap naloxone generics. “Cost-effective from societal perspective, affordable to individuals if covered by insurance with low/no copay, most formulations are not very expensive. Greater purchasing by payers would increase pressure on [the Food and Drug Administration] to figure out how to get generic versions of Narcan and Evzio to market”
Moderate Depends on insurance coverage. “If insurance covers the prescription, great. That makes the policy cost effective. If someone has to pay out of pocket or doesn’t have insurance, it can be cost prohibitive to fill the prescription”
Low N/A N/A

Equitability

The extent to which the policy is equitable in its impact on health outcomes across populations of people who use opioids.

Implementation Rating Summary of Expert Opinion Representative Quotations
High

(selected)
Increases access to naloxone through social networks that may overcome structural barriers. “Can help improve equity in access through existing community pharmacist, gaps would be in places without pharmacies. Could also help address some of the provider access gaps, as person at risk of overdose who may not have access to a provider, may be connected to someone who does have provider access”
Moderate Depends on how the cost of naloxone would be covered. “I think it can be equitable, but it depends on whether the prescription is affordable to fill. If a prescriber is able to provide naloxone free of charge to whomever wants/needs it, that would be very equitable. If someone has to fill a script and doesn’t have money, it would make it very difficult for people with little to no income to access”
Low Potential that interpersonal biases of prescribers and costs incurred by those obtaining the prescription could exacerbate inequities. “It has been shown that medication prescribing, including naloxone, to racial minority groups is reduced compared to Caucasian groups introducing potential inequitable racial bias. Additionally, people without insurance or prescription drug coverage may be unlikely to pay the retail price or high co-pay introducing additional inequity”

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