Availability and Cost of Naloxone Over Time: A Longitudinal Secret Shopper Study in North Carolina Community Pharmacies

Abstract Background Data on long-term longitudinal trends in naloxone availability and cost following the introduction of both brand-name and generic over-the-counter (OTC) products are sparse. Objectives To examine how naloxone availability and cost changed over time in North Carolina (NC) and explore variation by pharmacy type, rurality, and product type (generic vs. brand-name). Methods We conducted a three-phase secret shopper study: phase 1 (March-April 2023; before OTC sales began), phase 2 (November 2023-January 2024; ∼2 months after OTC sales began), and phase 3 (November 2024-January 2025; ∼1 year after OTC sales began). Trained shoppers called a stratified sample of pharmacies to inquire about naloxone nasal spray cost and same-day availability. Generalized linear mixed-effects models examined changes in cost and availability, adjusting for pharmacy type and rurality. Phase 3 cost and availability differences in product type were examined using nonparametric and Fisher's exact tests. Results A total of 174 pharmacies provided data for all phases; 54.6% chain and 45.4% independent; 43.6% urban, 14.4% suburban, and 42.0% rural. Same-day availability increased significantly (phase 3 vs. phase 1: OR=2.59, P=0.0005). Adjusted mean out-of-pocket cost decreased across phases ($98 phase 1, $67 phase 2, $56 phase 3; P<0.0001). Independent pharmacies were approximately $14 more expensive (P<0.0001) and had lower odds of same-day availability than chain pharmacies (OR=0.14, P<0.0001). No significant rurality differences were observed. Generic naloxone was more expensive on average than brand-name ($59.83 vs. $49.23), though median costs were similar. Availability for both product types was low for both chains and independents. Chains primarily stocked brand-name naloxone (58.2%), whereas independents were more evenly split between brand-name only (44.8%) and generic only (50.0%). Conclusion Naloxone availability and cost improved over time. Independent pharmacies continued to have lower availability and higher costs than chain pharmacies. Generic naloxone was more expensive on average than brand-name naloxone, and few pharmacies stocked both products.