How did fentanyl end up in a naxolone kit?

That’s the question the Ontario College of Pharmacists is trying to answer after a kit containing the powerful opioid was given to customer at a Shopper’s Drug Mart in Elmira on February 5th.

Naxolone is a medication used to reverse the effects of an overdose.

Todd Leach, a spokesperson for the Ontario College of Pharmacists, told CP24 earlier this month that “the pharmacy is fully cooperating and we are confident that immediate action has been taken to begin to determine how this happened and how it could have been prevented. We have not been made aware of any similar incidents occurring at other pharmacies.”

News of the mix up was revealed earlier this month but was only recently confirmed that the pharmacy in question was located in Elmira.

At the University Square Pharmacy in Guelph, naxolone kits come preassembled. Fentanyl is stored separately in a locked safe.

“Whereever this pharmacy obtained their naloxone kit, either they made a mistake there,” says owner Kenneth Chan. “Or when they assembled the kit themselves something happened.”

In a statement, issued earlier this month, spokesperson Catherine Thomas said:

“We share the view that this is a considerable error, and one that absolutely should not have happened. Our local pharmacist-owner took immediate action to ensure consumer safety, visiting the customers to secure the product and provide the correct medication, and to offer a detailed apology.”

“We are taking appropriate steps to reinforce professional and operational expectations and procedures to help prevent this type of unfortunate situation from reoccurring.”

Thomas also called it was an “isolated event.”

Naloxone kits are available for free at Ontario pharmacies.