Geographic variation in the provision of naloxone by pharmacies in Ontario, Canada: A population-based small area variation analysis [2020]

Highlights
• There was large regional variation in pharmacy-dispensed naloxone rates.

• Dispensing rates were moderately correlated with regional rates of opioid overdose.

• Sources of variation in dispensing rates amenable to intervention were identified.

• Disparities in pharmacy-dispensed naloxone could undermine program effectiveness.

• Strategies are needed to address disparities in pharmacy-dispensed naloxone access.

Abstract
Background
Regional variation in pharmacy-dispensed naloxone rates could create access disparities that undermine the effectiveness of this approach. We explored individual and public health unit (PHU)-level determinants of regional variation in naloxone distribution through the Ontario Naloxone Program for Pharmacies.

Methods
We conducted a population-based study between April 1, 2017 and March 31, 2018. We calculated age- and sex-standardized pharmacy-dispensed naloxone rates for the 35 Ontario PHUs, and identified determinants of these rates using generalized estimating equations negative binomial regression.

Results
The age- and sex-standardized pharmacy-dispensed naloxone rate in Ontario was 5.5 (range 1.8–11.6) kits per 1000 population. Variables associated with higher naloxone dispensing rates included opioid use disorder history [rate ratio (RR) 2.27; 95% confidence interval (CI) 1.75–2.96], opioid agonist therapy (RR 11.17; 95% CI 7.15–17.44), and PHU opioid overdose rate (RR 1.09 per 10 deaths; 95% CI 1.06–1.13). Pharmacy-dispensed naloxone rates were lower in rural areas (RR 0.83; 95% CI 0.73–0.94) and among individuals dispensed one (RR 0.72; 95% CI 0.65–0.79), two to five (RR 0.67; 95% CI 0.54–0.84) or 6–10 (RR 0.92; 95% CI 0.74–1.14) opioids in the prior year relative to those receiving no opioids.

Conclusion
Pharmacy-dispensed naloxone programs are important components of a public health response to the opioid overdose crisis. We found considerable variation in pharmacy-dispensed naloxone rates that could limit program effectiveness, particularly in rural settings with limited access to health and harm reduction services.

Tony Antoniou, Daniel McCormack, Tonya Campbell, Rinku Sutradhar, Mina Tadrous, Nancy Lum-Wilson, Pamela Leece, Charlotte Munro, Tara Gomes
Drug and Alcohol Dependence, Volume 216, 1 November 2020
DOI
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