Geographic variation in the provision of naloxone by pharmacies in Ontario, Canada: a population-based small area variation analysis

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 to 11.6) kits per 1,000 population. Variables associated with higher naloxone dispensing rates included opioid use disorder history [rate ratio (RR) 2.27; 95% confidence interval (CI) 1.75 to 2.96], opioid agonist therapy (RR 11.17; 95% CI 7.15 to 17.44), and PHU opioid overdose rate (RR 1.09 per 10 deaths; 95% CI 1.06 to 1.13). Pharmacy-dispensed naloxone rates were lower in rural areas (RR 0.83; 95% CI 0.73 to 0.94) and among individuals dispensed one (RR 0.72; 95% CI 0.65 to 0.79), two to five (RR 0.67; 95% CI 0.54 to 0.84) or 6 to 10 (RR 0.92; 95% CI 0.74 to 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.