Optimizing naloxone distribution in Canadian community pharmacies: Exploring barriers, intervention approaches and public funding considerations

Abstract

Background: Community pharmacies are well positioned to expand access to take-home naloxone (THN) because of their accessibility and frequent interactions with individuals at risk of opioid-related harm. Despite national recommendations that pharmacists proactively offer naloxone to all patients receiving opioid prescriptions, pharmacy-based naloxone provision remains inconsistent and largely reactive. Important evidence gaps remain regarding the implementation of pharmacy-based naloxone programs, approaches to measuring and addressing opioid-related stigma, the effectiveness of interventions designed to support proactive naloxone offering, and the economic value of pharmacy-based naloxone distribution.

Objectives: The overall objective of this thesis was to optimize pharmacy-based naloxone distribution in Canada by synthesizing the existing evidence, developing and evaluating a theory-informed educational intervention to support proactive naloxone offering, and assessing the cost-effectiveness of community pharmacy-based naloxone distribution.

Methods: This thesis comprises five manuscripts describing four complementary studies. The first study was a scoping review of community pharmacy-based THN programs. The second adapted the Opening Minds Stigma Scale for Healthcare Providers (OMS-HC) to measure opioid-related stigma. The third developed and evaluated the Optimizing Naloxone Dispensing in Pharmacies (ONDP) continuing education program using a randomized controlled trial, process evaluation, and contribution analysis. The fourth study evaluated the cost-effectiveness of community pharmacy-based intramuscular (IM) and intranasal (IN) naloxone distribution in Canada.

Results: The scoping review identified a wide range of community pharmacy-based take-home naloxone program interventions and demonstrated variability in naloxone availability and dispensing patterns. Key barriers included cost, stigma, and pharmacist education, while important pharmacist and patient knowledge gaps highlighted the need for standardized interventions evaluated through randomized controlled trials. Adaptation of the OMS-HC provided a standardized instrument to measure opioid-related stigma in pharmacy practice research and enabled evaluation of stigma within the ONDP intervention. The ONDP intervention significantly improved pharmacy professionals' naloxone knowledge and dispensing. Although changes in opioid-related stigma, confidence, and motivation were not statistically significant, the contribution analysis demonstrated that behaviour change occurred primarily by reducing uncertainty surrounding proactive naloxone offering, normalizing naloxone as routine care, and facilitating integration into existing pharmacy workflows. This evaluation further demonstrated that implementation and sustainability were influenced by organizational support, staffing, workflow, patient receptivity, and provincial funding policies. The economic evaluation demonstrated that community pharmacy distribution of both IM and IN naloxone was cost-effective across multiple patient populations in the Canadian context, supporting continued public investment in pharmacy-based naloxone programs and broader funding of IN naloxone.

Conclusion: This thesis demonstrates that optimizing pharmacy-based naloxone distribution is fundamentally an implementation challenge rather than simply an access challenge. Sustainable implementation depends on addressing interacting individual, practice-environment, and system-level factors that influence proactive naloxone offering within routine community pharmacy practice. Collectively, these findings provide evidence to inform future pharmacy practice, educational interventions, implementation strategies, and policy development aimed at improving equitable access to naloxone and reducing opioid-related harms in Canada.