High cost of naloxone prompts rural Arkansas pharmacists to keep life-saving medicine behind counter

The life-saving medicine naloxone was approved for nonprescription sale more than two years ago, but many rural Arkansas pharmacies still keep the overdose-reversal kit behind the counter.

Of 15 pharmacies the Advocate contacted for this article, all but two kept naloxone behind the counter. Pharmacists and business owners said requests for the drug have been low or nonexistent among their clientele, and they haven’t thought of moving it to a different area. Others cited shoplifting and the drug’s expense as a concern; several said more insurance providers should cover the cost.

Goodman Drug in Corning, a town of about 3,000 people in Clay County, was one of two pharmacies that makes naloxone available over the counter. Though owner Cathy Goodman said she didn’t have many customers come in looking for the product, she said it was important to keep it in an accessible location.

“Some people have prescription drugs and children in the house,” Goodman said. “[Naloxone] may not necessarily be for them, but it should be readily available to anybody who has anything [with opioids] in their household,” she said.

More than 82,000 people in the United States died of a drug overdose in 2024, according to preliminary data from the Centers for Disease Control and Prevention. The same data shows Arkansas had 386 drug overdose deaths in 2024, though the figure could change as the data is finalized. The CDC reported a 28% decrease in Arkansas overdose deaths from 2023 to 2024.

Naloxone is packaged as many brands, and the Narcan nasal spray was a commonly known label when the U.S. Food and Drug Administration expanded its availability in March 2023. While the nasal spray is effective and designed for easy use, experts say 911 should still be called immediately in the event of an overdose.

Arkansas officials stress the importance of naloxone distribution as they gradually allocate the state’s $216 million share of the national $26 billion opioid settlement funds. The funds were divided between the state, counties and cities. The Arkansas Association of Counties and the Arkansas Municipal League pooled their allocations together and formed the Arkansas Opioid Recovery Partnership, which former state drug director Kirk Lane leads.

“I think there’s a stigma attached to anything that has to do with substance use disorder, and there always has been,” Lane said, acknowledging that naloxone carries a stigma. “It’s what’s always made it difficult for us to give resources to people who need it.”

Lane agreed that keeping naloxone behind the counter where a customer has to ask for it establishes a barrier. However, ARORP has distributed about 100,000 dosage units of naloxone statewide, and Lane said if someone has a will to access the medicine, they could get it very quickly from a local participating organization, law enforcement agency or emergency services group.

Lane said the recovery partnership has approved funding for a handful of pharmacies to provide naloxone kits free of charge to patients who can’t afford it.

Per Arkansas Act 651 of 2021, health care professionals are required to prescribe an opioid antagonist like naloxone under certain conditions, including when a patient has a history of opioid use disorder or if they receive an opioid dosage of at least 50 morphine milligram equivalents per day for at least five days.

Patient hurdles

Spence Reed, an owner of the ReedHutchins Pharmacy in Heber Springs, said he could see how the behind-the-counter placement of naloxone in his Cleburne County store would create an additional hurdle for customers. But Reed said he’s also concerned that people might steal the $60 medicine. He compared the product to pregnancy tests or condoms, which he said are commonly taken to avoid embarrassment.

Several other pharmacy operators said they were worried naloxone would be taken unknowingly out of their business and have kept it behind the counter so they can keep an eye on it.

Chris Cooper, director of operations for Heartland Pharmacy’s 11 Arkansas locations, said the location of the drug depends on the storefront. While smaller businesses with less to oversee may stock it on their shelves, it’s mostly kept behind the counter as a preventative for shoplifting.

“It’s not cheap, so contrary to what a lot of people think — they think that it is still very affordable, a cheap medication that they can just snag. Unfortunately, it’s not,” he said.

Cooper said the behind-the-counter placement is not meant to deter use of the drug in any way, and he expressed support for naloxone access as drug overdose continues to affect thousands nationwide each year.

Naloxone is typically packaged in a small box containing two nasal sprays. Most Arkansas pharmacies sold the product for about $65, though Eudora Drug Store’s pharmacist Clara Rice said the price was up to $250.

Eudora is a town of about 2,000 people in the Arkansas Delta, not far from the Mississippi River. Data shows the town’s median age is 52, and an average household income is about $27,000. Rice described the area as having high crime.

“We don’t want to take any chances with having [naloxone] out front,” Rice said. “Of course, if there were an emergency, it would be easy to get to if that was the case.”

Such is the notion that many rural pharmacies described: If a customer came in and asked for naloxone, they would still be able to buy it.

“It’s a financial thing for me,” said Tyler Staten, manager of Gannaway Drug in Warren, the seat of south Arkansas’ Bradley County. “If nobody’s demanding it — then just like stocking anything else, if you don’t have a demand for it there’s no need to stock it on the shelf. As soon as somebody wants it or needs it, I’m willing to do that. We will do that.”

While theft may play a small factor in Larry Thomerson’s decision to keep the medicine behind the counter at the Gurdon Pharmacy in Arkansas’ south central Clark County, he also wants to talk with his customers beforehand and ensure they know how to use it, he said.

Thomerson, a pharmacist of 50 years, said he doesn’t consider naloxone to carry a stigma, and there are no restrictions on buying naloxone in his shop. “I’ll be glad to sell it to anyone who wants one,” he said.

Cissy Clark, pharmacist and owner of Clarks Family Pharmacy in Earle, also pushed back on the idea that purchasing naloxone is complicated by stigma.

“I live in a really, super small town. I’ve known these people since 1995; raised them from diapers,” Clark said. “I think they’re comfortable enough with me to come in and ask for it.”

She also said that she recommends naloxone to customers who are headed off to college soon in case of any emergencies. 

Earle is located in Crittenden County on the Arkansas-Mississippi border. In 2020, the town had a population of about 1,800. The town takes up about 3.25 square miles, and staff said Clarks Family Pharmacy is the only local provider in town.

Still, Clark said she keeps naloxone behind the counter because of the area’s financial standing.

Financial burden

In Heber Springs, Reed said not many people have asked for naloxone over the counter, but it is included with frequent pain medicine prescriptions. He said that if a medicine could save a life and prescribers have to include it on their opioid scripts, insurances should cover it.

“We often try to tell them it could be somebody who doesn’t know what it is that gets a hold of [pain pills] in your house — could be another family member or grandchild — somebody that accidentally gets a hold of them and takes them,” Reed said. “That way, you would have [naloxone] on hand to hopefully rescue them or prevent an unwanted outcome.”

Mayflower Family Pharmacy owner Michael Thilo tells his Faulkner County customers something similar. Rather than highlight how a customer’s dependency on pain medicine is a physical addiction itself, Thilo said he puts a “soft spin” on naloxone to encourage people to keep the overdose-reversal medicine around.

Thilo said he prompts his clientele to think about what would happen if a child accidentally consumed the pills, which shifts the focus away from the person using the pain medicine.

“I definitely think there’s a stigma,” Thilo said. “I think most people see it as, ‘I don’t need that because I don’t have that problem,’ whether they realize they do have the problem or not. I think most people that have been on opioids long term just need it for day-to-day, but they don’t realize they’re addicted to it.”

Thilo said he hasn’t had anyone ask for naloxone over the counter, and affordability may be another barrier.

Of the most common insurance providers — including Medicare for whom Thilo considers the most vulnerable population — about half won’t cover the medicine, he said. He estimated that one customer out of every 10 who receive an opioid prescription at his pharmacy will pick up naloxone because of the copay expense.

“I think all insurances should be required to cover it for no cost,” Thilo said. “If we’re worried about it as a population, as a society, then I think we should take it seriously and remove the financial burden.”

Heath Branscrum, a pharmacist and part owner of Health-Wise Pharmacy in the small Sebastian County town of Lavaca, shared similar sentiments about his patients not jumping to pay the cost of the preventative medicine.

“One of the barriers to people gaining access to Narcan is the fact that their insurance is not covering, particularly Medicare-affiliated insurances, the over-the-counter version of Narcan,” Branscrum said. “…There’s a large number of people out there that are supposed to have Narcan available to them, but they don’t get it because it’s going to cost them $50.”

Other resources

Purchasing naloxone at a pharmacy isn’t the only way residents living in rural Arkansas can access resources to stop the opioid epidemic. 

River Valley Medical Wellness, a primary care provider with offices in Russellville and Hot Springs, in 2023 launched the Arkansas Mobile Opioid Recovery (ARMOR) nonprofit, which sends mobile health units with critical substance use care to rural pockets in the state.

Attorney General Tim Griffin funded the first mobile health unit with a $777,000 grant from the state’s opioid settlement funds. After seeing some success, the Arkansas Department of Human Services provided the same funding amount for a second mobile unit. Tucker Martin, chief operating officer at River Valley Medical Wellness and co-founder of ARMOR, said the goal is to have five mobile health units that provide services in each corner of the state and in the Little Rock metro area.

According to results from a twice yearly River Valley Medical Wellness social determinants of health survey, Martin said patients consistently list transportation to care at the top of the list.

“They’re making a decision about whether they’re going to buy food to put on the table for their family, or they’re going to put gas in their car, travel 38 miles or whatever it is, to go to the doctor,” Martin said. “That’s the kind of decision that these people are facing, so that birthed the idea of, ‘Let’s create an environment where we can take health care directly to communities.’”

April 14 marked the one-year anniversary of ARMOR’s mobile health unit launch, and Tucker said 1,785 patients in a handful of towns were treated during that time. Each of the meetings are “very meticulously scheduled” and coincide with a providing service already in the community, such as a local church, he said.

More than 1,200 free naloxone kits were distributed to the community in the last year, according to an impact report from ARMOR.

“My deep, deep desire is to give the same thing that was given to me, which is access to a little bit of hope,” said Martin, who celebrated nine years of continuous sobriety in October. 

At the state level, Griffin also has distributed a portion of opioid settlement funds to a variety of organizations focused on providing help to those with opioid addiction. Griffin recently launched a pilot program for the state’s specialty courts system and helped fund opioid research at Arkansas Children’s Hospital.

The Arkansas Opioid Recovery Partnership funds projects in all 75 counties that aim to abate the opioid epidemic. While Lane said ARORP doesn’t allow applications for naloxone kits from individuals, the organization works to provide funding for local entities that can distribute the resource in the community.

ARORP’s Naloxone Hero Project distributed more than 100,000 dosage units statewide, the majority of which went to local organizations. Recently, ARORP started distributing units to law enforcement agencies, first responders and fire departments.

The ReviveAR mobile app also teaches residents how to use naloxone, where they can access it locally and how to provide support for family and friends. The app provides step-by-step opioid reversal instructions in English, Spanish and Marshallese.

“I think in every ability where there’s any possibility of somebody overdosing … [naloxone] ought to be considered as a resource to reverse an overdose,” Lane said.