By Clarissa Donnelly-DeRoven
It’s 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’t have one.
I’m sorry, the tech says, I can’t sell them to you without an ID. The man stares at him blankly. He asks again for the syringes. The store’s pharmacist chimes in, repeating what the tech said.
It’s 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’t 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 — 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, “syringe sales do not require a prescription and pharmacies are free to sell syringes and needles to patients without a prescription,” Campbell explained.
Years ago, the pharmacy board and the North Carolina Harm Reduction Coalition put together a pamphlet, which is now published on the pharmacy board’s website. 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’t 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 News made calls to various pharmacies — chain and independent — across the state and found that the policies vary widely by store, and sometimes prove oddly difficult to find out.
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.
“Our team members are not allowed to speak to anyone who identifies themselves as media regardless of the topic unless authorized to do so,” 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’ve required a prescription. He said the policy changed because of “misuse” and “recreational use.”
Drug use poses a significant public health burden for the residents of Robeson County. As of December 2021, Robeson had the third highest proportional rate of admission to the emergency department for overdoses, according to data from the North Carolina Department of Health and Human Services. New diagnoses of hepatitis C in the county are also high, as are new cases of HIV.
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.
“We don’t want an influx of people just looking for syringes,” he said. “We 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.”
“It will probably drive away some of our folks,” 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 similar variations in syringe sale policies from store to store.
But despite the discrepancies, in another study that’s 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.
“I think pharmacists recognize the public health benefits of syringes,” Carpenter said. “They don’t want HCV and HIV to spread in their communities. They understand that.
“But then they also balance that against [the thought] ‘If 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?’ So as a small business — which a lot of rural pharmacies are — they have a balancing act.”
The concern that if more people who use drugs come into the pharmacy, other people won’t come — while harmful and hurtful to people who use drugs — 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 October 2021 study, 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, 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 many videos available on their website to teach pharmacists about harm reduction strategies.
Anna Stein, the Overdose Prevention Legal Specialist at NCDHHS, argues that attacking stigma is the most important first step to creating healthier communities.
“This 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,” she said. “Is it an ‘us’ and a ‘them’? And a ‘good’ and ‘bad’? Is there this separation? Or do we view ‘us’ as a whole, and that we’re in this together, trying to get people the health care that they need?”
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’s Center for Rural Health Policy Analysis, the number of chain and independent pharmacies in rural areas is in decline. If there’s only one pharmacy left in town, and it has a strict policy on selling syringes, people may resort to re-using or sharing needles.
“In a number of areas, particularly in rural areas, the pharmacist may very well be the only professional health care provider in the area,” said Fred Ullrich, a researcher at the university who co-authored a 2018 study on the decline of rural independent pharmacies nationwide. He and others are in the process of publishing an updated version of the study.
“They can be extraordinarily important in the role of preventive health,” he said. “People can feel free to drop in at their pharmacy and say, ‘I have this problem — you have anything for it?’” Even though pharmacists can’t prescribe medications, they can point people in the right direction.”
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.
“There’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,” Carpenter said. “The fact that you could go in and see a trained health professional without the need for an appointment, without health insurance, that’s open after hours — that’s just huge in a rural community.”
However, the research has shown that while many pharmacists understand that more lenient syringe sales can help their community, they worry that they don’t have the time or money to implement a new policy.
“Rural pharmacies are well-positioned to be advocates for harm reduction,” Carpenter said. “But they need to be given the resources.”
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.
“Getting 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,” Stein said. Buying syringes at a pharmacy “is kind of a last resort, and not a great resort because of the cost,” 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 in order to receive immunity from prosecution under drug paraphernalia laws. People can be charged for having syringes bought from a pharmacy. Other states, such as Oregon, fully exempt needles and hypodermic syringes from its drug paraphernalia law, regardless of where they come from.
While syringe services are immensely helpful, they’re not everywhere.
“[There aren’t] enough to serve the entire community and especially in rural communities,” 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’ 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’t think they had the time or money for a new project.
However, Roberts’ 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.
“If 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,” she said.
The N.C. Association of Pharmacists and the Governor’s Institute are in the process of piloting a project that would do something similar to what Roberts’ 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’t, receive care and services in the same spot.
“Just because somebody chooses to use drugs, whether it’s injection or otherwise, doesn’t mean that they don’t care about their health,” Roberts said. “They deserve to have the protection.”
This story was updated to clarify that the pilot project between the N.C. Association of Pharmacists and the Governor’s Institute will not put syringe service programs inside of pharmacies, but will expand and strengthen relationships between pharmacies and syringe service programs.