Policy change to save lives: A pilot investigation into policy change for addressing disparities within care settings for overdose prevention in Veterans

ABSTRACT More than 4.4 million Veterans live in rural America, where older age, limited health care access, and social determinants of health—including distance, transportation, broadband access, stigma, and food insecurity—contribute to delayed care and higher morbidity and mortality. The US opioid crisis has disproportionately impacted Veterans and rural communities, with veteran overdose deaths occurring at twice the rate of non-Veterans. Naloxone access has helped reduce overdose fatalities, and same-day take-home naloxone is now a standard practice in Veterans Health Administration (VHA) care. However, rural Veterans face unique barriers due to VHA policies that could be easily revised. VHA's Directive 1108.7 restricts naloxone dispensing to Veterans Administration (VA)-licensed pharmacists, despite national laws allowing nonpharmacists to dispense it. Although the Urgent/Emergent Formulary offers expedited access through community pharmacies, regional variations in formulary lists leave some rural Veterans without same-day naloxone access. Those affected must wait for mailed naloxone, increasing overdose risk for an already extremely vulnerable population. This policy limits service providers, including nurse practitioners, in their ability to implement an effective and time-sensitive treatment plan. Recommendations include: (1) Revising VHA Directive 1,108.7 to allow all VA service providers to dispense same-day take-home naloxone to at-risk Veterans; (2) Mandating naloxone availability on all Urgent/Emergent Formulary lists, ensuring access for all Veterans prescribed opioids or diagnosed with an opioid or stimulant use disorder who have not received a naloxone kit in the past 335 days.