Participants were interviewed via video or audio call except in one case, where responses were collected by e-mail. With permission, calls were recorded and transcribed.The analysis began with calculation of descriptive statistics, including the percentage of pharmacies that furnished naloxone identified in the telephone survey. For interviews with the subset of naloxone furnishing pharmacists, descriptive analysis summarized the extent of furnishing for medications other than naloxone. Transcripts of each interview conducted, as well e-mail responses, were uploaded to Atlas.ti software for qualitative data analysis and deidentified by numbering each interview. Beginning with codes developed from past research on furnishing practices as a preliminary guide, as well as inductive methods to identify potential novel concepts, the investigators developed a code book classifying statements as referring to barriers or facilitators, then further subdivided them by type in Atlas.ti. Complete sentences were the minimum unit of analysis coded in the transcripts to identify common themes.To ensure validity and consistency across interviews and coding, each interview was conducted by a minimum of 2 researchers, and coding was completed simultaneously by all of the researchers who had conducted interviews. Disagreements were resolved by discussion until the group reached consensus. Transcripts, findings, and key quotations used to illustrate them were summarized in drafts circulated to the entire research team. Findings were triangulated based on reviews of previous studies of furnishing. Only findings identified as relevant by the group were included in the final analysis.The second step of data collection was interviewing furnishing pharmacists in the region for interviews about barriers and facilitators to furnishing. Among the contacted pharmacies that furnished naloxone, 8 furnishing pharmacists agreed to be interviewed.
The stores where these pharmacists worked represented 5 of the 11 counties in the Central Valley. Of these, 5 were associated with a chain pharmacy,microgreen flood table while the remaining 3 were independent. Although previous research on furnishing rates is limited, it suggests that naloxone furnishing is more common than furnishing of other medications.Interview participants were asked whether they also furnished other medications; as some of the factors that discourage or encourage furnishing may be consistent across medications. Six respondents indicated that the stores where they worked also furnished hormonal contraception, 3 respondents that their stores also furnished nicotine replacement therapy , and 1 that their store also furnished preexposure prophylaxis/post exposure prophylaxis. Respondents indicated that the pharmacies where they worked filled between 250 and 1000 prescriptions per day, averaging approximately 500. The time that respondents had held their positions ranged from 5 months to 20 years, and none had completed a residency. Results are provided in Table 2. With respect to barriers to furnishing, all interview participants listed cost to patients as the primary barrier. They noted that insurance did not necessarily cover naloxone, and when it did not, patients would not purchase it. As one stated, “The biggest barrier to this is first of all money. If it’s zero copay, they probably will take it. If there’s any copay, they’re just normally not going to pay for it.”. Other barriers to furnishing included time, cost, stigma, and lack of a shared language. Reported heavy workloads and a lack of dedicated time to integrate naloxone screening into the pharmacy workflow was cited by 6 of 8 respondents as making it difficult to prioritize furnishing naloxone. One respondent noted, “It’s really time. We don’t really have time here to initiate for those implementing naloxone […] unless patients request it.”. With respect to stigma, 5 respondents stated that it was difficult to suggest supplying naloxone to patients due to its association with drug abuse. They indicated that patients perceived offers of naloxone as accusations of opioid abuse. One stated, “[T]here’s always like that lash back from a patient, like oh, I don’t need it because I’m not abusing it. That’s the common phrase.”
Lastly, one respondent reported that the absence of a shared language was a barrier due to lack of understanding and miscommunication, noting that, “[W]e have to get a translator to […] communicate with the patients. Maybe the patient’s not understanding correctly even [as] it’s being translated.”. Examples of responses regarding barriers to furnishing are shown in Table 3. Although California Assembly Bill No. 2760, which passed in 2018, required medical prescribers to offer a naloxone or equivalent prescription to populations at higher risk of opioid overdose, out-of-pocket costs to the uninsured in the United rose 500 percent from 2014 to 2018 for certain brands of naloxone.Generic naloxone has an average wholesale price of $64.80-$75.00.Participants believed that reducing out-of-pocket costs could increase naloxone purchase and use. A chain community pharmacist stated that they went “out of their way to try to find GoodRx discount cards to help bring down the price for patients.” and that doing so reduced patient reluctance to purchase naloxone. Similarly, an independent community pharmacist suggested that “lower [ing] restrictions and mak[ing] it OTC [over the counter]” would increase the likelihood of visitors purchasing naloxone. Participants were also asked to identify facilitators to furnishing. Responses included collaborating with other health professionals, closer proximity to pain clinics, expanded scope of pharmacy practice in California, supportive corporate policies, education and training on naloxone furnishing, and higher demand for naloxone. With respect to collaboration, 2 respondents stated that closer proximity to pain clinics increased the likelihood of pharmacies furnishing naloxone. One pharmacist stated that, “some pharmacies are located in regions [with] higher potential [of] abuse …that can also drive up having … more Naloxone in that location.”. One pharmacist indicated that demand was higher in their region, stating that, “people started asking for it. We dispensed it”. Additional examples of responses regarding facilitators to furnishing are provided in Table 4.Since 2013, California has sought to expand access to care by authorizing pharmacists to furnish medications.
Implementing naloxone furnishing by pharmacists in particular provides a potential opportunity to reduce opioid overdoses. These services are especially critical in rural areas like California’s Central Valley that have been disproportionately impacted by the opioid epidemic.We were unable to identify any prior studies that assessed the extent of pharmacist furnishing in rural, HPSAs such as the Central Valley, and our findings suggest that contrary to initial expectations, almost half of contacted pharmacies, including some mail-order pharmacies, furnished naloxone in the Central Valley. In contrast, a study of primarily urban pharmacies in California conducted in 2020 found that 42.4% furnished naloxone.Interviews with pharmacists who furnished naloxone suggested that pharmacies continued to face barriers to successful implementation,seedling grow rack many of which have been identified in previous research. These included time restrictions, high outof-pocket costs for purchasers, stigma associated with opioid use, and in 1 case, language barriers. All respondents indicated that out-of-pocket costs were the most critical barrier and that prices varied depending on insurance coverage; this finding is consistent with prior research.The findings regarding stigma as a barrier to offering and accepting naloxone are also consistent with previous research. This includes a study involving pharmacy students in Tennessee and their perceptions of naloxone use and opioid use disorder patients, which found that although pharmacy students are capable of and predisposed to furnish naloxone, successful furnishing is complicated by limited patient awareness and stigma, specifically the perception that naloxone is for “addicts” only.Another study examining undergraduates’ reactions to fictional vignettes about people with opioid use disorder found addiction was attributed to the opioid user’s character and varied by an user’s socioeconomic status.Studies examining perceptions of take-home naloxone conducted with both healthcare providers and opioid users have found that stigma influences both parties when providing education and seeking out information about naloxone and overdose prevention, respectively.These studies suggest that further interventions in pharmacy education to combat stigma against naloxone use and opioid use disorder might help facilitate increasing naloxone furnishing rates.Limitations to this study include generalizability, variable effects of coronavirus disease 2019, and self-reporting bias. The analysis only considered the 11 counties in the Central Valley, which may limit extrapolation outside of this region. The sample also did not include interview data from pharmacies that furnished but chose not to participate, which may have resulted in a biased sample. Another limitation is that this study was conducted 2 years after the most recent comparison study of naloxone furnishing in California. As a result, the higher furnishing rates observed in this study may have re- flected a time trend or effect of the coronavirus disease 2019 pandemic, such as difficulty securing appointments with physicians encouraging use of pharmacy services, rather than a difference in prevalence.
Interview data were self-reported and may have reflected social desirability bias or human error. One interview was done through e-mail, rather than a phone call, which limited the ability to probe for clarification and additional detail. Pharmacies that did not furnish naloxone were not included in interviews on the grounds that they would be unable to provide information on facilitators to naloxone furnishing; future studies could investigate if these pharmacies furnish other medications. Additional research could also address potential differences in furnishing practices between independent and chain pharmacies, as well as furnishing rates for other medications in this region. Irrespective of these limitations, the findings provide new information regarding pharmacist furnishing in HPSAs, barriers that prevent the widespread provision of naloxone, and potential strategies that may help overcome those barriers.Discrimination against LGBTQ+2 people has a significant impact on economic equity. LGBTQ+ people face higher rates of poverty than non-LGBTQ+ people, especially transgender and bisexual people, LGBTQ+ people of color, and those living in rural areas.3 Unions have aligned with LGBTQ+ advocacy groups to fight for legislation prohibiting discrimination in employment on the basis of sexual orientation and gender identity. In Canada, protections against discrimination in employment were recognized nationally under Section 15 of the Canadian Charter of Rights and Freedoms in 1995 and were then codified by the Canadian Human Rights Act in 1996 and 2017.4 In the US, 21 states and the District of Columbia have explicit legislative protections against discrimination based on sexual orientation and gender identity in employment, housing, and public accommodations.5 As of June 2020, protections from discrimination based on sexual orientation and gender identity were upheld by the Supreme Court as implicit in Title VII of the Civil Rights Act of 1964.6 Despite these recent gains, the fight for LGBTQ+ equity and social justice is far from over.Even in regions with long-standing nondiscrimination protections under the law, LGBTQ+ people continue to experience stigma and mistreatment on the job.8LGBTQ+ people are an increasingly organized portion of the United States and Canadian workforce. LGBTQ+ union members and their allies in both countries have mobilized to form coalitions and constituency groups to integrate civil rights protections into their union constitutions, contracts, collective bargaining agreements, and economic justice campaigns. The United Food and Commercial Workers union has joined broader labor organizing and solidarity movements to fight for the rights, safety, and dignity of LGBTQ+ union members and their families in Canada and the United States, mobilizing to form coalitions and constituency groups to integrate civil rights protections into their union constitutions, contracts, collective bargaining, and economic justice campaigns.Over the past three decades, LGBTQ+ union activists and leaders have won considerable gains within their local and international unions, including the successful formation of UFCW OUTreach as a recognized constituency group in 2013. This group has led robust collective bargaining strategies, education programming, and national advocacy campaigns. Union locals have also recently bargained contracts that include “protections around pronouns, anti-harassment language, non-discrimination, health and safety” and removal of provisions that exclude transgender people from health care coverage.UFCW is committed to diverse, inclusive, and growth-oriented organizational models that affirm and promote LGBTQ+ worker members and “recognize that oppression works to undermine workers across the lines of gender, race, class, Indigeneity and sexual orientation.”UFCW OUT reach joins the movement led for more than half a century by LGBTQ+ people and advocacy groups to secure protections for LGBTQ+ people against discrimination in hiring and on the job and to ensure equal access to workplace benefits such as parental leave and equitable health care.UFCW OUT reach collaborated with the UCLA Labor Center to conduct this study to gain a deeper understanding of the current experiences, issues, challenges, and barriers that LGBTQ+ workers face across diverse industries.