by Clarissa Donnelly-DeRoven
It鈥檚 early evening in mid-December when a middle aged man walks up to the pharmacy counter at a Walgreens in Asheville. He asks to buy a bag of syringes. The pharmacy technician walks to grab them from a shelf toward the back. When the tech returns to the register, he asks the customer for his ID. The man doesn鈥檛 have one.
I鈥檓 sorry, the tech says, I can鈥檛 sell them to you without an ID. The man stares at him blankly. He asks again for the syringes. The store鈥檚 pharmacist chimes in, repeating what the tech said.
It鈥檚 state law. We can lose our license if we sell them to you without an ID, she says, apologetically.
Well, can I get someone else who has an ID to buy them for me? He asks.
The tech looks apprehensively at the pharmacist.
I can鈥檛 tell you what to do one way or the other, she says, but we can only sell syringes to someone with an ID.
When asked, the pharmacist explains that state law requires that she see an ID to confirm that the person buying the syringes is over 18 years old. She says the law is enforced similarly to alcohol sales: secret shoppers from the pharmacy board go to stores and ask to buy syringes. If the pharmacist sells to them without asking for an ID, the pharmacist can be fired, lose their license, the store can be sued 鈥� a whole host of bad bad things.
The only issue? None of that is true.
A public health-approved law, with a caveat
There are no age restrictions for selling syringes under North Carolina law, said Jay Campbell, executive director of the North Carolina Board of Pharmacy.
Additionally, 鈥渟yringe sales do not require a prescription and pharmacies are free to sell syringes and needles to patients without a prescription,鈥� Campbell explained.
Years ago, the pharmacy board and the North Carolina Harm Reduction Coalition put together a pamphlet, which is now . It clarifies the law, and says, in essence, the best thing to do for public health is to sell syringes to anyone who wants them, and to not exclude people that a pharmacist thinks might use the syringes for illicit drugs. This is because people who use drugs are at high risk of contracting hepatitis C and HIV if they share or reuse needles.
While there are syringe exchange programs and some county health departments that offer new needles and drug use supplies for free, they aren鈥檛 located in every community. Many people who inject drugs still rely on pharmacies for syringes.
Although state law makes syringes available over-the-counter for everyone, there's nothing in the law that prohibits a pharmacy from setting a stricter policy. NC Health 瓜神app made calls to various pharmacies 鈥� chain and independent 鈥� across the state and found that the policies vary widely by store, and sometimes prove oddly difficult to find out.
The first section of the pamphlet co-published by the North Carolina Harm Reduction Coalition and the North Carolina Board of Pharmacy. Credit: NC Board of Pharmacy.
Pharmacy staff at Walgreens, Walmart, Ingles and CVS stores across North Carolina said they were not allowed to tell a reporter what policy they followed regarding syringe sales.
鈥淥ur team members are not allowed to speak to anyone who identifies themselves as media regardless of the topic unless authorized to do so,鈥� said Fraser Engerman, a Walgreens spokesperson. He also explained Walgreens policy in North Carolina is not to sell syringes to anyone younger than 18.
Ingles CFO, Ron Freeman, said the company follows all state and federal rules regarding syringes sales but did not respond to questions about what actual policies its pharmacy staff follow in its North Carolina stores.
CVS spokesperson Matthew Blanchette said anyone can buy syringes over the counter at CVS stores in North Carolina. Walmart did not respond to questions.
Dustin Packer, one of the pharmacists at Drugs America Pharmacy in Robeson County, said the store used to sell syringes over the counter, but since 2017 they鈥檝e required a prescription. He said the policy changed because of 鈥渕isuse鈥� and 鈥渞ecreational use.鈥�
Drug use poses a significant public health burden for the residents of Robeson County. As of December 2021, Robeson had the , according to data from the North Carolina Department of Health and Human Services. New diagnoses of hepatitis C in the county are , as are new .
At Cochrane-Ridenhour Drug Co. in Montgomery County, a pharmacist, who declined to give his name, explained that the store does sell syringes over the counter without restrictions, but requested that information not be publicized.
鈥淲e don't want an influx of people just looking for syringes,鈥� he said. 鈥淲e do it in the normal course of our business operations, but I just don't want people around the county or people who don't live around here just coming here and just getting syringes. We don't want to promote that. We want to be a pharmacy for the public.鈥�
鈥淚t will probably drive away some of our folks,鈥� he said.
A balancing act
Delesha Carpenter, a researcher and professor at the UNC Eshelman School of Pharmacy, studies patient-provider communication as it relates to complicated topics, such as injection drug use. In a survey study she and other researchers conducted, they found s in syringe sale policies from store to store.
But despite the discrepancies, in another study that鈥檚 currently under review, she and other researchers found that pharmacies were still one of the most common locations where rural people who inject drugs say they get their syringes.
鈥淚 think pharmacists recognize the public health benefits of syringes,鈥� Carpenter said. 鈥淭hey don't want HCV and HIV to spread in their communities. They understand that.
鈥淏ut then they also balance that against [the thought] 鈥業f I have people who inject drugs coming in, is that going to affect the other customers that are coming in? Am I going to get some negative pushback from that?鈥� So as a small business 鈥� which a lot of rural pharmacies are 鈥� they have a balancing act.鈥�
The concern that if more people who use drugs come into the pharmacy, other people won鈥檛 come 鈥� while harmful and hurtful to people who use drugs 鈥� is not unfounded. Shatterproof, a nationwide organization that studies attitudes toward people who use drugs and advocates for people experiencing addiction, has documented how deeply seated stigma against drug users can be.
In an , the researchers documented that nearly 60 percent of people surveyed said they would not want someone experiencing substance use disorder to live next door to them, to be their friend, to socialize with them, or to marry into their family. They also found similar rates of stigma among health care workers.
Stigma against people who use drugs is intense. A 2021 survey by Shatterproof found people were very wary of having close personal contact with people experiencing substance use disorder. Credit: Shatterproof.
Stigma, though, especially when held by pharmacists, is not immovable. Carpenter has found that emphasizing the public health benefits of non-prescription syringe sales can help get more pharmacists on board. The North Carolina Association of Pharmacists has available on their website to teach pharmacists about .
Anna Stein, the Overdose Prevention Legal Specialist at NCDHHS, argues that attacking stigma is the most important first step to creating healthier communities.
鈥淭his idea that we don't want to rub elbows in the same pharmacy, I just think it's more a symptom of what's going on in the broader community,鈥� she said. 鈥淚s it an 鈥榰s鈥� and a 鈥榯hem鈥�? And a 鈥榞ood鈥� and 鈥榖ad鈥�? Is there this separation? Or do we view 鈥榰s鈥� as a whole, and that we're in this together, trying to get people the health care that they need?鈥�
The impact on rural communities
Rural people who use drugs can find themselves especially caught up in the prejudices and diverging policies. According to research from the University of Iowa鈥檚 , the number of chain and independent pharmacies in rural areas is in decline. If there鈥檚 only one pharmacy left in town, and it has a strict policy on selling syringes, people may resort to re-using or sharing needles.
鈥淚n a number of areas, particularly in rural areas, the pharmacist may very well be the only professional health care provider in the area,鈥� said Fred Ullrich, a researcher at the university who co-authored a . He and others are in the process of publishing an updated version of the study.
鈥淭hey can be extraordinarily important in the role of preventive health,鈥� he said. 鈥淧eople can feel free to drop in at their pharmacy and say, 鈥業 have this problem 鈥� you have anything for it?鈥欌�� Even though pharmacists can鈥檛 prescribe medications, they can point people in the right direction.鈥�
If someone who uses drugs lives in a rural area and has a stigmatizing interaction with a pharmacist, one of the few health care providers in town, they might be less inclined to seek care from them in the future.
鈥淭here's over 65,000 pharmacies in the United States, and many of those are in rural areas that are Health Professional Shortage Areas, that don't have hospitals, that don't have specialty treatment clinics,鈥� Carpenter said. 鈥淭he fact that you could go in and see a trained health professional without the need for an appointment, without health insurance, that鈥檚 open after hours 鈥� that's just huge in a rural community.鈥�
However, the research has shown that while many pharmacists understand that more lenient syringe sales can help their community, they worry that they don鈥檛 have the time or money to implement a new policy.
鈥淩ural pharmacies are well-positioned to be advocates for harm reduction,鈥� Carpenter said. 鈥淏ut they need to be given the resources.鈥�
A new partnership
This predicament has led some in the field to argue that rather than advocating for pharmacies to improve their syringe sale policies, resources should be focused on creating partnerships between pharmacies and syringe service programs. The service has been legal in North Carolina since 2016 and provides free syringes to anybody who wants them.
鈥淕etting a syringe exchange law on the books was really leaps and bounds in improvements for public health because what we really need is free syringes for people who use drugs,鈥� Stein said. Buying syringes at a pharmacy 鈥渋s kind of a last resort, and not a great resort because of the cost,鈥� she said.
Buying syringes from pharmacies also places people who use drugs in a complicated legal situation. In North Carolina, people have to prove that they received their syringes from a syringe exchange program under drug paraphernalia laws. People can be charged for having syringes bought from a pharmacy. Other states, , fully exempt needles and hypodermic syringes from its drug paraphernalia law, regardless of where they come from.
While syringe services are immensely helpful, they鈥檙e .
鈥淸There aren鈥檛] enough to serve the entire community and especially in rural communities,鈥� said Heather Roberts, a nurse and the director of clinical research for a liver care center within Atrium Health. Expanding syringe service programs into local pharmacies could help them reach more people.
Roberts conducted research on North Carolina pharmacists鈥� support for implementing a syringe service program within their store. Some of her findings echoed others: pharmacists expressed stigmatizing concerns about having people who inject drugs in the pharmacy and said they didn鈥檛 think they had the time or money for a new project.
In a survey, researchers found something surprising: nearly 70 percent of pharmacists expressed openness to having a syringe exchange program at their store. Opinions varied significantly depending upon if the pharmacist worked at an independent store, or a chain. Credit: Heather Roberts; UNC Greensboro.
However, Roberts鈥� top level finding was more surprising: nearly 70 percent of pharmacists surveyed supported the implementation of a syringe service exchange program within their pharmacy. Some factors, including offering training on culturally competent care and strategies for implementing the program, were associated with higher degrees of support.
Roberts argues that putting syringe service programs inside of pharmacies holds massive potential.
鈥淚f you have a pharmacy that's willing to do it, they put it in their pharmacy, then it doesn't matter who's working that day or who's working the next day. Everybody has to be on board when that's implemented because you've agreed with the state to do that,鈥� she said.
The N.C. Association of Pharmacists and the Governor鈥檚 Institute are in the process of piloting a project that would do something similar to what Roberts鈥� research proposed: extend and strengthen relationships between syringe service programs and pharmacies. This could help thousands more access clean syringes for free, prevent the rise of new hepatitis C and HIV infections, and provide a space in which people who use drugs and people who don鈥檛, receive care and services in the same spot.
鈥淛ust because somebody chooses to use drugs, whether it's injection or otherwise, doesn't mean that they don't care about their health,鈥� Roberts said. 鈥淭hey deserve to have the protection.鈥�
This story was updated to clarify that the pilot project between the N.C. Association of Pharmacists and the Governor鈥檚 Institute will not put syringe service programs inside of pharmacies, but will expand and strengthen relationships between pharmacies and syringe service programs.
This first appeared on and is republished here under a Creative Commons license.
North Carolina Health 瓜神app is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.
