Perpetuating stigma or reducing risk? Perspectives from naloxone consumers and pharmacists on pharmacy-based naloxone in 2 states

Naloxone Distribution Models in the United States: A Scoping Review

BACKGROUND

Increasing naloxone distribution is a high priority means to mitigating opioid overdose rates in the United States. Since a variety of naloxone distribution models exist, with differences in infrastructure and funding between states and health-systems, it is important to review their differences and understand the strengths and barriers to widespread implementation of each model.

METHODS

The following 4 databases were searched for articles reporting on naloxone distribution models: (1) PubMed/Medline (National Library of Medicine), (2) Embase (Elsevier), (3) Scopus (Elsevier), and (4) the Cochrane library. Reports from all years written in English that discussed naloxone distribution models in the United States were included, as were all study designs.

RESULTS

Of 5825 articles initially identified, 173 were selected for full text review. Of these, 49 met full criteria and were included for data extraction and analysis. Most distribution models occurred in community-based opioid education and naloxone distribution programs and in community pharmacies via a standing order/statewide protocol. Most programs reported strengths related to feasibility, but frequently reported cost as a limitation. Fewer studies described distribution models in ambulatory care or hospital settings, though these studies also highlighted strengths related to feasibility, particularly with support from working partners, and when utilizing an interprofessional care approach. Few studies reported health/economic outcomes data associated with naloxone distribution, such as changes in the number of patient/layperson access, the number of opioid overdose reversals, or cost-savings.

CONCLUSIONS

This review outlines the many ways in which naloxone is distributed in the United States and emphasizes a need for improved outcomes data collecting/reporting in the various settings where naloxone is distributed. This would allow for future studies to evaluate which distribution model factors are associated with improvements in health outcomes, such as increased layperson access, and lower opioid overdose/mortality rates.

Naloxone Acceptance among Nightclub Attendees in New York City

As the opioid crisis continues, now driven by use of fentanyl, naloxone is an increasingly important intervention to reverse overdoses. More research is needed on the willingness of populations at risk for unintentional fentanyl exposure (through adulterated drugs) to accept naloxone to reverse potential overdoses. Adults (n = 991) entering randomly selected nightclubs in New York City (NYC) were surveyed at the point-of-recruitment in 2024 and were asked about their willingness to accept a free naloxone kit. We examined the prevalence of reported willingness to accept naloxone and reasons for refusal, and we examined prevalence and correlates of participants accepting naloxone. During the survey, 65.2% of participants reported being familiar with naloxone, 62.1% agreed to accept naloxone, and 49.6% were recorded as accepting a kit. Those residing in NYC, compared to visitors, had a higher prevalence of recorded acceptance (aPR = 1.41, 95% CI: 1.11-1.79), as did those reporting familiarity with naloxone (aPR = 1.27, 95% CI: 1.02-1.58), and those with an average higher readiness to intervene in an opioid overdose (aPR = 1.18, 95% CI: 1.04-1.33). The majority who refused (56.1%) reported not being interested; 10.1% reported that they were not worried about overdoses, and 8.2% reported that they already had naloxone. Although 83.4% agreed that naloxone is used to reverse opioid overdoses, 35.4% reportedly thought that naloxone is used to reverse the effects of cocaine or any drug. While at least half of attendees were willing to accept a naloxone kit, lack of interest and lack of knowledge about naloxone were potential barriers to carrying naloxone.

Over-the-counter naloxone availability at North Carolina community pharmacies: A secret shopper study

BACKGROUND

Over-the-counter (OTC) naloxone became available for sale at community pharmacies in September 2023. This study examines whether naloxone availability and cost are associated with pharmacy type (independent vs chain), pharmacy rurality, and their interaction.

METHODS

Using a cross-sectional secret shopper study design, data were collected by phone from a stratified random sample of 600 community pharmacies in North Carolina from November 2023 to January 2024. Trained secret shoppers enacted a standardized script and documented whether the pharmacy: dispensed naloxone, sold OTC naloxone, and offered same-day pick-up. Shoppers also documented the location of OTC naloxone and out-of-pocket cost. Generalized Estimating Equations (GEEs) were used to examine whether naloxone availability and cost varied by pharmacy type (independent vs chain), rurality (urban, suburban, rural), and a rurality*type interaction.

RESULTS

Sampled pharmacies were 48.5 % urban, 11.7 % suburban, and 39.7 % rural, with 50.4 % being chain, 48.2 % independent, and 1.4 % health department pharmacies. Among the 500 pharmacies that sold naloxone, 57.4 % sold the OTC product, which was primarily stored behind-the-counter (62.5 %). Same-day pick-up was available at 82.8 % of pharmacies. In GEE models, rurality was not significant. However, independent pharmacies were significantly less likely than chain pharmacies to sell naloxone, have same-day pick-up, and store OTC naloxone on-the-shelf. Interaction terms were not significant, suggesting that the effect of pharmacy type on naloxone availability and cost did not vary by rurality.

CONCLUSIONS

Pharmacy type, not rurality, was consistently associated with naloxone access and out-of-pocket cost. Interventions should address barriers to naloxone access and cost at independent pharmacies.

Price Sensitivity and Information Barriers to the Take-Up of Naloxone

We conducted a field experiment that randomized advertisements, advertisement content, and prices across 2,204 counties in the United States to study the impacts on online purchases of naloxone, an opioid overdose reversal drug. Advertising increased website users but only impacted purchases when combined with a price reduction. Messages emphasizing the discreet nature of online sales had no additional impact on purchases. Comparing counties with advertisements featuring a highly discounted price to those featuring the full price, we estimate a price elasticity of demand for online naloxone of -1.3. Price is a significant barrier to online purchases of this lifesaving medication.

Pharmacy Naloxone Standing Order and Community Opioid Fatality Rates Over Time

Importance

Despite the proliferation of pharmacy standing-order naloxone dispensing across many US states before the change to over-the-counter status, few policy analyses have evaluated the implementation of pharmacy naloxone standing orders in addressing opioid overdose fatality among communities.

Objective

To determine whether the implementation of pharmacy standing-order naloxone was associated with lower opioid fatality rates compared with communities without pharmacies with standing-order naloxone.

Design, Setting, and Participants

This retrospective multisite study was conducted with an interrupted time series analysis across 351 municipalities in Massachusetts over 24 quarters (from January 1, 2013, through December 31, 2018). Standing-order naloxone dispensing data were collected from 2 sources for all major chain pharmacies and many independent pharmacies, covering 70% of retail pharmacies in Massachusetts. Municipalities had various standing-order naloxone implementation inceptions during the study period. Data were analyzed from December 2021 to November 2023.

Exposure

The main exposure was measured by the first quarter with standing-order naloxone dispensation as the actual implementation inception.

Main Outcomes and Measures

The primary study outcome was municipal opioid fatality rate per 100 000 population obtained from the Massachusetts Registry of Vital Records and Statistics.

Results

The median (IQR) population size across 351 municipalities was 10 314 (3635 to 21 781) people, with mean (SD) proportion of female individuals was 51.1% (2.8 percentage points). Pharmacies from 214 municipalities (60.9%) reported dispensing standing-order naloxone over the study period. At the baseline of the first quarter of 2013, municipalities that eventually had standing-order naloxone had greater quarterly opioid fatality rates compared with those that never implemented standing-order naloxone (3.51 vs 1.03 deaths per 100 000 population; P < .001). After adjusting for municipal-level sociodemographic and opioid prevention factors, there was significant slope decrease of opioid fatality rates (annualized rate ratio, 0.84; 95% CI, 0.78-0.91; P < .001) following standing-order naloxone dispensing, compared with the municipalities that did not implement standing-order naloxone. There were no significant level changes of opioid fatality rates in the adjusted models. Sensitivity analyses yielded similar and significant findings.

Conclusions and Relevance

These findings suggest that community pharmacy dispensing of naloxone with standing orders was associated with a relative, gradual, and significant decrease in opioid fatality rates compared with communities that did not implement the standing-order naloxone program. These findings support the expansion of naloxone access, including over-the-counter naloxone as part of a multifaceted approach to address opioid overdose.

Community pharmacists' attitudes toward and practice of pharmacy-based harm reduction services in Pittsburgh, PA: a descriptive survey

BACKGROUND

In Pittsburgh, PA, legal changes in recent decades have set the stage for an expanded role for community pharmacists to provide harm reduction services, including distributing naloxone and non-prescription syringes (NPS). In the wake of the syndemics of the COVID-19 pandemic and worsening overdose deaths from synthetic opioids, we examine knowledge, attitudes, and practices of harm reduction services among community pharmacists in Pittsburgh and identify potential barriers of expanded pharmacy-based harm reduction services.

METHODS

We provided flyers to 83 community pharmacies within a 5-mile radius of the University of Pittsburgh Medical Center to recruit practicing community pharmacists to participate in an anonymous electronic survey. We used a 53-question Qualtrics survey consisting of multiple-choice, 5 or 6 point-Likert scale, and open-ended questions adapted from 5 existing survey instruments. Survey measures included demographics, knowledge, attitudes, and practices of harm reduction services (specifically naloxone and NPS provision), and explored self-reported barriers to future implementation. Data was collected July-August 2022. We conducted descriptive analysis using frequencies and proportions reported for categorical variables as well as means and standard deviations (SD) for continuous variables. We analyzed open-ended responses using inductive content analysis.

RESULTS

Eighty-eight community pharmacists responded to the survey. 90% of participants agreed pharmacists had a role in overdose prevention efforts, and 92% of participants had previously distributed naloxone. Although no pharmacists reported ever refusing to distribute naloxone, only 29% always provided overdose prevention counseling with each naloxone distributed. In contrast, while 87% of participants had positive attitudes toward the usefulness of NPS for reducing disease, only 73% of participants ever distributed NPS, and 54% had refused NPS to a customer. Participants endorsed a lack of time and concerns over clientele who used drugs as the most significant barriers to offering more comprehensive harm reduction services.

CONCLUSIONS

Our findings highlight that while most community pharmacists have embraced naloxone provision, pharmacy policies and individual pharmacists continue to limit accessibility of NPS. Future expansion efforts for pharmacy-based harm reduction services should not only address the time and labor constraints identified by community pharmacists, but also fear-based policy and stigma toward people who inject drugs and harm reduction more broadly.

Effectiveness of direct patient outreach with a narrative naloxone and overdose prevention video to patients prescribed long-term opioid therapy in the USA: the Naloxone Navigator randomised clinical trial

INTRODUCTION

Public health efforts to reduce opioid overdose fatalities include educating people at risk and expanding access to naloxone, a medication that reverses opioid-induced respiratory depression. People receiving long-term opioid therapy (LTOT) are at increased risk for overdose, yet naloxone uptake in this population remains low. The objective of this study was to determine if a targeted, digital health intervention changed patient risk behavior, increased naloxone uptake, and increased knowledge about opioid overdose prevention and naloxone.

METHODS

We conducted a pragmatic randomized clinical trial among patients prescribed LTOT in a health care delivery system in Colorado. Participants were randomly assigned to receive an animated overdose prevention and naloxone educational video (intervention arm) or usual care (control arm). The 6-minute video was designed to educate patients about opioid overdose and naloxone, increase overdose risk perception, and prompt them to purchase naloxone from the pharmacy. Over an 8-month follow-up, opioid risk behavior was assessed with the Opioid-Related Behaviors in Treatment survey instrument, and overdose and naloxone knowledge was measured with the Prescription Opioid Overdose Knowledge Scale after viewing the video at baseline. Naloxone dispensations were evaluated using pharmacy data over a 12-month period. Data were analyzed with generalized linear mixed effects and log-binomial regression models.

RESULTS

There were 519 participants in the intervention arm and 485 participants in the usual care arm. Opioid risk behavior did not differ between the study arms over time (study arm by time interaction P=0.93). There was no difference in naloxone uptake between the arms (RR = 1.13, 95% CI: 0.77-1.66). Knowledge was significantly greater in the intervention arm compared to usual care (P<0.001).

CONCLUSIONS

A targeted, digital health intervention video effectively increased opioid overdose and naloxone knowledge, without increasing opioid risk behavior. Naloxone uptake did not differ between the intervention and usual care arms.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT03337009.

Naloxone Accessibility by Standing Order in North Carolina Community Pharmacies

BACKGROUND

According to a standing order in North Carolina (NC), naloxone can be purchased without a provider prescription.

OBJECTIVE

The objective of this study is to examine whether same-day naloxone accessibility and cost vary by pharmacy type and rurality in NC.

METHODS

A cross-sectional telephone audit of 202 NC community pharmacies stratified by pharmacy type and county of origin was conducted in March and April 2023. Trained "secret shoppers" enacted a standardized script and recorded whether naloxone was available and its cost. We examined the relationship between out-of-pocket naloxone cost, pharmacy type, and rurality.

RESULTS

Naloxone could be purchased in 53% of the pharmacies contacted; 26% incorrectly noting that naloxone could be filled only with a provider prescription and 21% did not sell naloxone. Naloxone availability by standing order was statistically different by pharmacy type (chain/independent) (χ2 = 20.58, df = 4, P value < 0.001), with a higher frequency of willingness to dispense according to the standing order by chain pharmacies in comparison to independent pharmacies. The average quoted cost for naloxone nasal spray at chain pharmacies was $84.69; the cost was significantly more ($113.54; P < 0.001) at independent pharmacies. Naloxone cost did not significantly differ by pharmacy rurality (F2,136 = 2.38, P = 0.10).

CONCLUSION

Approximately half of NC community pharmacies audited dispense naloxone according to the statewide standing order, limiting same-day access to this life-saving medication. Costs were higher at independent pharmacies, which could be due to store-level policies. Future studies should further investigate these cost differences, especially as intranasal naloxone transitions from a prescription only to over-the-counter product.

"I go out of my way to give them an extra smile now:" A study of pharmacists who participated in Respond to Prevent, a community pharmacy intervention to accelerate provision of harm reduction materials

BACKGROUND

Community pharmacies are well-positioned to improve the health of people with opioid use disorder and who use drugs by providing naloxone and other essential public health supplies. Respond to Prevent (R2P) is a clinical trial which sought to accelerate provision of harm reduction materials through a multicomponent intervention that included in-store materials, online training, and academic detailing.

OBJECTIVES

The objective of this study was to explore pharmacists' attitudes, knowledge, and experiences in providing naloxone, dispensing buprenorphine, and selling nonprescription syringes following participation in the R2P program.

METHODS

Two online asynchronous focus groups were conducted with community-based chain pharmacists across Massachusetts, New Hampshire, Oregon, and Washington who had participated in the R2P program. Participants accessed an online repository of group interview items and responded to questions over a short period. Each pharmacist participated anonymously for approximately 30 min over 2 ½ days. Pharmacists answered questions on experiences with pharmacy-based harm reduction care and R2P intervention implementation barriers and facilitators. Qualitative data analysis was conducted by a multidisciplinary team using an immersion-crystallization approach.

RESULTS

A total of 32 pharmacists participated in the two focus groups. Most participants were female (n = 18, 56%), non-Hispanic (n = 29, 91%), and white (n = 17, 53%). Four major themes were identified related to (1) addressing bias and stigma toward people with opioid use disorder and who use drugs, (2) familiarity and comfort with naloxone provision, (3) perspective and practice shifts in nonprescription syringe sales, (4) structural challenges to harm reduction care in the pharmacy.

CONCLUSIONS

Community pharmacists across the four states identified attitudes, knowledge, and experiences that create barriers to providing care to people with opioid use disorder and who use drugs. R2P approaches and tools were effective at reducing stigma and changing attitudes but were less effective at addressing structural challenges from the pharmacists' perspective.

Factors Associated with Gaps in Naloxone Knowledge: Evidence from a 2022 Great Plains Survey

Background

The rising prevalence of fast-acting opioids in the United States suggests the increased need for non-first responder administration of naloxone. Effective administration of naloxone during an overdose requires that bystanders are familiar with, have access to, and know how to use naloxone.

Methods

Drawing on the 2022 Nebraska Annual Social Indicators survey, we analyzed naloxone familiarity, access, and competency to administer among a statewide, address-based sample of Nebraskan adults.

Results

There were significant gaps in naloxone knowledge in Nebraska. Although 75.6% of respondents were familiar with naloxone, only 18.6% knew how to access naloxone and 17.6% knew how to use naloxone. We find that more frequent religious service attendance is associated with lower odds of naloxone familiarity. Among those familiar with naloxone, a higher perception of community stigma towards opioids generally is associated with lower odds of naloxone access and competency. Higher perception of community stigma towards heroin, methamphetamines, and cocaine, however, is associated with higher odds of naloxone access. Finally, past overdose experience, lifetime illicit opioid use, being close to a person who uses opioids, and having access to illicit opioids was not significantly associated with naloxone familiarity, access, or competency among respondents in Nebraska's two largest cities, Omaha and Lincoln. Outside of these cities, past overdose experience and access to illicit opioids was associated with higher odds of naloxone access and competency, but lifetime opioid use and being close to a person who uses opioids had no effect.

Conclusions

Our findings highlight the continued need for education on naloxone with a specific focus on access and competency to further reduce opioid-related overdose deaths. Education campaigns targeted at places of worship or individuals close to people who use opioids may further serve those with a lower likelihood of naloxone familiarity and promote knowledge of naloxone among those with higher odds of encountering an overdose. Further work is needed to understand differences in the relationship between substance-specific perceived stigma and its association with naloxone access.

Community pharmacists' naloxone counseling: A theory-informed qualitative study

BACKGROUND

Opioid-related overdose (ORO) deaths have reached a record high in the United States. Naloxone is an opioid antagonist that can rapidly reverse an opioid overdose. Pharmacists are in an ideal position to provide naloxone and related counseling, given their accessibility and expertise. However, minimal research is available on community pharmacists' naloxone counseling.

OBJECTIVES

The aim of this study was to investigate Georgia community pharmacists' naloxone counseling as well as explore their attitudes, subjective norms, and perceived behavioral control toward counseling.

METHODS

Semi-structured telephone interviews were conducted to elicit pharmacists' beliefs and practices regarding naloxone counseling. The interviews were guided by open-ended questions based on the theory of planned behavior (TPB). Thematic analysis was performed to identify the modal salient beliefs expressed by the pharmacists. The Consolidated Criteria for Reporting Qualitative Research was used to report the study findings.

RESULTS

A total of 12 community pharmacists participated. Pharmacists held mixed attitudes toward naloxone counseling. While they recognized it as a vital part of their profession to prevent ORO deaths, they also expressed concerns about offending patients. Regarding normative beliefs, pharmacists identified several groups, including regulatory agencies (e.g., Board of Pharmacy, CDC), managers, news/media, patients, and doctors, influencing their provision of naloxone counseling. Facilitators to counseling included receiving naloxone training and having access to counseling guidelines and resources. Reimbursement issues, high costs of naloxone, and lack of patient awareness were the most commonly cited barriers. Pharmacists reported participating in counseling and providing information on identifying signs of opioid overdose and administering naloxone.

CONCLUSIONS

The TPB is a useful framework for understanding community pharmacists' beliefs and practices regarding naloxone counseling. Capitalizing on facilitators and targeting barriers related to pharmacists' reimbursement issues, high costs of naloxone, and increasing patients' awareness of naloxone use and benefits may enhance pharmacists' naloxone counseling.

Pharmacists' perceptions regarding feasibility, acceptability, and usefulness of student-delivered naloxone education services in community pharmacy: A mixed methods study in Alabama

BACKGROUND

Given that Alabama has the highest opioid prescribing rate in the nation, efforts to promote safe opioid use and reduce overdose mortality are critical. To address this, the Auburn University Harrison College of Pharmacy developed and piloted a didactic-experiential naloxone learning model in the first-year PharmD curriculum in 2020-2021 consisting of lectures, skills laboratory, and 120-hour community pharmacy introductory pharmacy practice experience (IPPE). Student-delivered naloxone education services (SDNES), including naloxone counseling and dispensing, were incorporated into the IPPE.

OBJECTIVES

The objective of this study was to evaluate the feasibility, acceptability, and usefulness of SDNES frovm the perspective of community pharmacy IPPE preceptors.

METHODS

This study used a mixed methods design including cross-sectional online surveys and follow-up semistructured telephone interviews. Survey measures were informed by validated scales and included feasibility (11 items), acceptability (13 items), and usefulness (6 items) of SDNES. Survey outcomes were assessed via 5-point Likert-type scales (1 = strongly disagree, 5 = strongly agree) and analyzed using descriptive statistics. Follow-up semistructured telephone interview questions were guided by the Consolidated Framework for Implementation Research domains of inner and outer setting and focused on SDNES barriers and facilitators, recommended strategies for service enhancement, and resource needs. Interview transcripts were analyzed using deductive and inductive rapid content analysis to determine themes and subthemes.

RESULTS

Twenty-five preceptor surveys were completed (22.52% response rate). Overall, SDNES was rated as feasible (mean [SD] scale score 4.04 [0.77]), acceptable (3.95 [0.83]), and useful (3.87 [0.98]). Interviewees (N = 8) discussed 13 barrier subthemes, 12 facilitator subthemes, 7 recommended strategies, and 8 resource needs across 3 overarching themes, most of which were related to the inner setting.

CONCLUSION

Community pharmacy IPPE preceptors found SDNES feasible, acceptable, and useful in their practices. The SDNES model may be used to build capacity for naloxone services delivery in community pharmacies, potentially increasing patient access to naloxone education and distribution.

The effects of race and class on community-level stigmatization of opioid use and policy preferences

BACKGROUND

With opioid use and overdose rates continuing to plague minority communities in the U.S., we explored whether a geographic community's racial composition and social class affect how opioid use in the community is stigmatized and what policy preferences arise in response.

METHODS

We use case vignettes in a randomized, between-subjects study (N = 1478) with a nation-wide survey. The vignettes describe a community where opioids are harmfully used, varying whether the community was (1) wealthy or poor, (2) predominantly Black or White and (3) facing prevalent use of painkillers or heroin. We tested how these variables affect public stigmatization of opioid use (measured with ratings of responsibility, dangerousness, sympathy, concern, anger, and disappointment) preferred levels of social distance from communities with opioid use (measured with responses to questions about living, working, and interacting in the community), and policy preferences for responding to opioid use (measured with levels of support for providing a safe-consumption site in the community, treating drug use in the community punitively, treating drug use in the community as an illness, and funding drug treatment in the community through income redistribution).

RESULTS

Compared to wealthy communities with opioid use, poor communities with opioid use were less stigmatized in terms of responsibility, sympathy, concern, anger, and disappointment; they were also met with less support for punitiveness, more support for treating drug use as an illness, and preferences for greater social distance. Compared to White communities with opioid use, Black communities with opioid use were less stigmatized in terms of responsibility, and they were met with stronger preferences to not live and work there and with reduced support for using income redistribution to provide drug treatment for people in the community. Poor-Black communities with opioid use were also perceived to be more dangerous than both poor-White and wealthy-Black communities with opioid use.

CONCLUSION

These results point to class- and race-based territorial stigma affecting how communities with opioid use are judged and whether policies for providing communities with treatment are supported.

A scoping literature review of pharmacy-based opioid misuse screening and brief interventions

BACKGROUND

Although prescription opioid dispensing rates have continued to decrease, overdose deaths involving prescription opioids have increased during the COVID-19 pandemic. Screening and brief interventions (SBI) are an effective prevention strategy to identify and address opioid misuse and safety risks. Emerging literature on pharmacy-based SBI needs to be systematically appraised to develop robust interventions.

OBJECTIVE

Our objective was to conduct a scoping review of the literature regarding pharmacy-based opioid misuse SBI to identify relevant literature that explore the topic, evaluate the patient-centeredness of included studies, and explore the use of dissemination and implementation science in the literature.

METHODS

The review was conducted according to Preferred Reporting of Systematic Reviews and Meta-analyses -Scoping reviews (PRISMA-Sc) guidelines. We searched PubMed, CINHAL, PsychInfo, and Scopus for studies regarding pharmacy-based SBI, published in the last 20 years. We also conducted a separate grey literature search. Two of three total reviewers screened each abstract individually and identified eligible full-texts for inclusion. We critically appraised quality of included studies and qualitatively synthesized the relevant information.

RESULTS

The search resulted in 21 studies (categorized as intervention, descriptive, and observational research) and 3 grey literature reports. Of the recently published 21 studies, 11 were observational research, with six interventions in the pilot stages. Screening tools varied but naloxone was the brief intervention in 15 of the 24 results. Only eight studies had high validity, reliability, and applicability and only five were patient-centered. Implementation science principles were addressed in eight studies (mainly interventions). Overall, the findings suggest high potential for evidence-based SBI to be successful.

CONCLUSIONS

Overall, the review suggested a strong lack of a patient-centered and implementation science-focused approach to designing pharmacy-based opioid misuse SBI. Findings suggest that a patient-centered, implementation focused approach is needed for effective and sustained pharmacy-based opioid misuse SBI.

"It can save your life, that's all I know," barriers and facilitators for engagement in take-home naloxone for people receiving opioid substitution treatment in regional Australia: An explorative study

Engagement in take-home naloxone (THN) programs by people receiving opioid substitution treatment (OST) in Australia is low despite methadone being a significant contributor to opioid overdose deaths. Our aim was to explore barriers and facilitators for OST patients to engage in THN. We used a descriptive qualitative design with thematic analysis to gain insight into naloxone uptake by people engaged in an OST program in regional Australia. Eleven participants were interviewed; eight had previously engaged with THN. Barriers to THN included limited knowledge and understanding, lack of information, and not personally experiencing an overdose. Facilitators included having a traumatic experience of overdose, knowledge and understanding of THN and overdose, empowerment in carrying naloxone, and expanding THN programs. Support for the expansion of THN programs is desired among participants, and widespread peer distribution is understood to be the key to success. This study found that prior traumatic experience of overdose facilitates acceptance of THN, and being offered THN was the most important factor in engagement. Less clear is how to engage people who lack a traumatic overdose experience.

The Opioid Overdose Resuscitation Education for Addiction Counselors and Trainees (Opioid Overdose REACT) naloxone response education pilot project improved confidence and knowledge among addiction counselors and trainees

INTRODUCTION

Community programs to teach nonmedical laypeople how to recognize an opioid overdose and effectively resuscitate the victim using naloxone have proliferated recently as a significant component of harm-reduction efforts. Although many such programs target laypeople like first responders or friends and family members of people who use drugs, there are currently no programs that specifically target addiction counselors, despite their work with a client population at high risk of an opioid overdose.

METHODS

The four-hour curriculum designed by the authors covered opioid agonist and antagonist pharmacology; opioid toxidrome signs; legal implications and indications for using the naloxone kits; and hands-on training. Participants were two cohorts of addiction counselors and addiction counseling trainees at our institution and an affiliated Opioid Treatment Program methadone clinic. Surveys testing participant knowledge and confidence were conducted at baseline, immediately post-training, six months post-training, and 12 months post-training.

RESULTS

Overall, opioid and naloxone pharmacology knowledge, as well as the confidence to intervene in an overdose emergency, improved among participants in both cohorts. Knowledge scores at baseline (n = 36, median 5/10) improved significantly immediately post-training (n = 31, median 7/10, P < 0.0001, Wilcoxon signed-rank test) and were sustained six (n = 19) and 12 months (n = 11) later. Two participants reported using their naloxone kits to successfully reverse a client overdose in the 12 months after taking the course.

DISCUSSION

These results from our knowledge translation pilot project suggest that our educational program to train addiction counselors in opioid pharmacology and toxicology, allowing them to recognize and respond to an opioid overdose, is feasible and could be effective. Specific barriers to implementing such educational programs include cost, stigma, and unclear best practice for designing and conducting these programs.

CONCLUSIONS

Further study of providing opioid pharmacology education and overdose and naloxone training to addiction counselors and counseling trainees appears to be warranted.

Organizational Readiness to Implement Community Pharmacy-Based Opioid Counseling and Naloxone Services: A Scoping Review of Current Practice Models and Opportunities

The purpose of this study was to explore existing practice models and opportunities surrounding community pharmacist-delivered opioid counseling and naloxone (OCN) services in the U.S., with the goal of enhancing organizational readiness and improving patient access. A scoping literature review was conducted. English-language articles published in peer-reviewed journals from January 2012-July 2022 were sought via PubMed, CINAHL, IPA, and Google Scholar using permutations of terms such as "pharmacist/pharmacy", "opioid/opiate", "naloxone", "counseling", and "implement/implementation". Original articles reporting the resources/inputs (personnel; pharmacist full-time equivalents; facilities and expenses; in-house versus outsourced personnel), implementation processes (legal source of pharmacist authority; patient identification strategies; intervention procedures; workflow strategies; business operations), and programmatic outcomes (uptake and delivery; interventions made; economic impact; patient or provider satisfaction) of pharmacist-delivered OCN services in community (retail) settings were retained. Twelve articles describing ten unique studies were included. The studies primarily used quasi-experimental designs and were published from 2017 to 2021. The articles described seven broad program elements/themes: interprofessional collaboration (n = 2); patient education format including one-on-one patient education (n = 12) and group education sessions (n = 1); non-pharmacist provider education (n = 2); pharmacy staff education (n = 8); opioid misuse screening tools (n = 7); naloxone recommendation/dispensing (n = 12); and opioid therapy and pain management (n = 1). Pharmacists screened/counseled 11-2716 patients and provided 11-430 doses of naloxone. Limited implementation costs, patient/provider satisfaction, or economic impact measures were reported. This review may serve as a guide for community pharmacists in implementing OCN services in their own practices. Future studies should clarify OCN program implementation costs, patient/provider satisfaction, and the economic impact.

Opioid Use Disorder Curricular Content in US-Based Doctor of Pharmacy Programs

OBJECTIVES

To characterize the instructional settings, delivery methods, and assessment methods of opioid use disorder (OUD) content in Doctor of Pharmacy (PharmD) programs; assess faculty perceptions of OUD content; and assess faculty perceptions of a shared OUD curriculum.

METHODS

This national, cross-sectional, descriptive survey study was designed to characterize OUD content, faculty perceptions, and faculty and institutional demographics. A contact list was developed for accredited, US-based PharmD programs with publicly-accessible online faculty directories (n = 137). Recruitment and telephone survey administration occurred between August and December 2021. Descriptive statistics were computed for all items. Open-ended items were reviewed to identify common themes.

RESULTS

A faculty member from 67 (48.9%) of 137 institutions contacted completed the survey. All programs incorporated OUD content into required coursework. Didactic lectures were the most common delivery method (98.5%). Programs delivered a median of 7.0 h (range, 1.5-33.0) of OUD content in required coursework, with 85.1% achieving the 4-hour minimum for substance use disorder-related content recommended by the American Association of Colleges of Pharmacy. Just over half (56.8%) of faculty agreed or strongly agreed that their students were adequately prepared to provide opioid interventions; however, 50.0% or fewer perceived topics such as prescription interventions, screening and assessment interventions, resource referral interventions, and stigma to be covered adequately. Almost all (97.0%) indicated moderate, high, or extremely high interest in a shared OUD curriculum.

CONCLUSION

Enhanced OUD education is needed in PharmD programs. A shared OUD curriculum was of interest to faculty and should be explored as a potentially viable solution for addressing this need.

Characteristics and health service use of Medicaid-insured individuals filling naloxone under a standing order in Louisiana

BACKGROUND

Naloxone distribution is a key intervention to reduce opioid overdose deaths. On January 23, 2017, Louisiana implemented a standing order that permits pharmacies to dispense naloxone to patients without a patient-specific prescription.

OBJECTIVES

To examine the characteristics and health service use of Louisiana Medicaid members filling naloxone under the standing order.

METHODS

We conducted a retrospective cohort study of Louisiana Medicaid members from January 23, 2017 to December 31, 2019. We extracted fee-for-service claims and managed care encounters for naloxone dispensed under the standing order.

RESULTS

Overall, there were 2053 naloxone fills by 1912 unique individuals. The total number of naloxone fills increased from 22 in 2017 to 1218 in 2019. Most members (n = 1,586, 83.0%) received any type of health service and 20.4% (n = 391) received an opioid-related health service in the 30 days prior to filling naloxone. Additionally, 12.7% (n = 242) of members had received medication for opioid use disorder (MOUD), and 42.6% (n = 815) filled a prescription opioid analgesic within the 60 days prior to filling naloxone. Nineteen members (1.0%) had an emergency department visit for overdose within 90 days after filling naloxone.

CONCLUSION

Standing orders play an important role in providing access to naloxone, even among Medicaid members who had recent encounters with health care providers. We identified multiple opportunities to improve naloxone prescribing among providers caring for Medicaid-insured people who use opioids, including prescribers of opioid analgesics or MOUD.

Motivation to Carry Naloxone: A Qualitative Analysis of Emergency Department Patients

PURPOSE

Our aim was to explore perspectives of patients who received naloxone in the emergency department (ED) about (1) naloxone carrying and use following an ED visit and (2) motivation for performing these behaviors.

DESIGN

Semi-structured interviews of patients prescribed naloxone at ED discharge.

SETTINGS

Three urban academic EDs in Philadelphia, PA.

PARTICIPANTS

25 participants completed the in-depth, semi-structured interviews and demographic surveys. Participants were majority male, African American, and had previously witnessed or experienced an overdose.

METHODS

Interviews were recorded, transcribed and analyzed using content analysis. We used a hybrid inductive-deductive approach that included prespecified and emergent themes.

RESULTS

We found that naloxone carrying behavior was variable and influenced by four main motivators: (1) naloxone access; (2) personal experience and salience of naloxone, (3) comfort with naloxone administration, and (4) societal influences on naloxone carrying. In particular, those with personal history of overdose or close friends or family at risk were motivated to carry naloxone.

CONCLUSIONS

Participants in this study reported several important motivators for naloxone carrying after an ED visit, including ease of naloxone access and comfort, perceived risk of experiencing or encountering an overdose, and social influences on naloxone carrying behaviors. EDs, health systems, and public health officials should consider these factors influencing motivation when designing future interventions to increase access, carrying, and use of naloxone.

Readiness of community pharmacies to implement an opioid safety intervention

BACKGROUND

We report on efforts to measure readiness to adopt opioid safety initiatives in community pharmacies within 2 large chains. Previous studies identified lack of knowledge, confidence, or enthusiasm in addressing harm reduction efforts. We implemented an intervention that provided training to improve opioid safety. The goal was to increase naloxone prescribing and nonprescription syringe sales, reduce stigma, and decrease opioid overdoses among patients and customers.

OBJECTIVES

To assess pharmacy readiness for intervention delivery, by characterizing pharmacy culture around opioid safety; describing current practices and challenges interacting with patients and customers on naloxone, nonprescription syringe sales, and buprenorphine; and determining pharmacy defined goals for implementing the intervention.

METHODS

The sample included pharmacy managers and staff pharmacists from 2 large chains who completed a brief phone interview. Interviews consisted of Likert-scale and open-ended, theoretically driven questions. Questions focused on workplace culture, patient engagement, naloxone and buprenorphine prescribing, nonprescription syringe sales, and intervention goals. Coding categories for the open-ended questions were derived using a thematic review of responses.

RESULTS

A total of 163 respondents described both workplace culture and how they encourage patient opioid safety as including public health awareness, patient engagement, and naloxone prescribing. Sale of nonprescription syringes exhibited high variability: no sales barriers (53.9%), sales with barriers (21.5%), and no sales (20.9%). Half of pharmacists (50.3%) interacted with buprenorphine prescribers outside of medication fills. Most respondents (68.7%) endorsed being ready to promote the intervention. Pharmacists named goals in adopting the intervention of wanting more knowledge and educational materials, talking points with patients, and best practices for offering naloxone.

CONCLUSION

Community pharmacists, before implementation, described awareness of and receptiveness to opioid safety initiatives, with substantial barriers around nonprescription syringe sales. Assessed knowledge level, culture, and identified barriers that emerged in the readiness assessments can be used to tailor future pharmacy-specific programming.

Implementation of an academic detailing intervention to increase naloxone distribution and foster engagement in harm reduction from the community clinician

BACKGROUND

Respond to Prevent (R2P) is a randomized clinical trial which sought to accelerate distribution of naloxone and other harm reduction materials from community pharmacies. R2P combined an online continuing education course with in-store materials, specifically designed for use in community pharmacies, and then supported implementation through the one-on-one educational technique of academic detailing.

OBJECTIVE

The objective of this paper is to describe and synthesize our experiences providing academic detailing as part of the R2P randomized trial.

METHODS

Closed-ended items from standardized post detailing questionnaires were analyzed with descriptive statistics. Open-ended items were content analyzed for key themes using immersion-crystallization qualitative methods.

RESULTS

A total of 176 pharmacies participated in R2P with 175 receiving their initial academic detailing visit between August 2019 and May 2021. Initial visits were in-person and lasted a median of 35 minutes (interquartile range, 20-45 minutes). The R2P naloxone guide was the most common topic covered (n = 162, 92.6%). Following a fidelity check to assess adequacy of the R2P program implementation, 80 pharmacies (45.7%) required secondary academic detailing. Secondary detailing was more targeted and most frequently focused on the sale of nonprescription syringes (n = 28; 35.2%) or disposal container distribution (n = 30; 37.5%). Analysis of the open-ended items identified factors that the detailers perceived to affect the quality of academic detailing sessions, including the pharmacy environment, participant knowledge of and attitudes toward the subject matter, and ability of the detailer to remain flexible yet consistent.

CONCLUSION

R2P provided a standardized process to foster naloxone distribution and engagement in harm reduction with demonstrated implementation in 175 community pharmacies across 4 states. Academic detailing was perceived to be well-received and effective at providing education and promoting distribution of naloxone and nonprescription syringes in community pharmacies. Additional research is needed to confirm these perceptions through evaluation post-intervention behavioral and attitude changes.

Community pharmacist-provided opioid intervention frequencies and barriers

BACKGROUND

Community pharmacists are well-positioned to engage in opioid-related harm reduction activities (i.e., opioid interventions). However, several barriers to providing these interventions have been identified. Comparing the frequencies of opioid interventions and identifying which barriers are perceived to have the highest impact in providing interventions will yield valuable information for increasing opioid use disorder (OUD) care access within pharmacies.

OBJECTIVES

To (1) characterize the frequency of 9 opioid interventions in community practice settings and (2) assess community pharmacists' perceptions of what impact 15 key barriers have on providing opioid interventions.

METHODS

This was a multi-state, cross-sectional, and descriptive survey study. Opioid interventions evaluated included prevention (e.g., OUD screening) and treatment (e.g., OUD resource referral); barriers encompassed confidence and knowledge, work environment, provider interactions, and patient interactions. Respondents were recruited from 3 community pharmacy practice-based research networks in the Midwest and South regions of the US. Recruitment and telephone survey administration occurred between December 2021 and March 2022. Descriptive statistics were computed and open-ended items were reviewed to identify common themes.

RESULTS

Sixty-nine of 559 pharmacists contacted (12.3%) completed the survey. All opioid interventions were reported to be provided less frequently than indicated in practice. Screening and referral interventions were provided least frequently, at 1.2 and 1.6 times on average, respectively, to the last 10 patients for which respondents felt each intervention was needed. Patient refusal, minimal or no reimbursement, inadequate staffing and time, and negative patient reactions were identified as the highest-impact barriers to providing opioid interventions. Approximately 26% of respondents agreed or strongly agreed that pharmacy school adequately prepared them to provide opioid interventions in practice.

CONCLUSION

Prioritizing the resolution of pharmacy work environment barriers will support pharmacists in routinely providing opioid interventions. Changes in Doctor of Pharmacy curricula and continuing education are also indicated to further prepare pharmacists to engage in opioid-related harm reduction.

Pharmacists and Naloxone: Barriers to Dispensing and Effectiveness of an Educational Outreach Program

BACKGROUND

The Illinois Naloxone Standing Order allows community pharmacists to dispense naloxone; however, this policy initiative may be underutilized.

OBJECTIVE

Our study aims to characterize naloxone dispensing barriers, overall and by pharmacy type, make recommendations that can inform future policies to improve naloxone access, and evaluate outreach initiative effectiveness from academic detailers' perspectives.

METHODS

We conducted a retrospective analysis of semistructured data collected as part of an educational outreach program targeting Illinois community pharmacists in 2021. Academic detailers conducted educational outreach visits across community pharmacy settings (i.e., primary pharmacy, grocery pharmacy, or independent pharmacy) to promote standing order use and discuss barriers pharmacists face when dispensing naloxone. Following each visit, detailers recorded visit characteristics, pharmacist-identified obstacles impacting naloxone dispensing, and visit effectiveness.

RESULTS

Detailers performed in-person visits at 270 (78%) of 348 targeted sites. A lower proportion of independent pharmacies (61%) routinely stock naloxone than primary (95%, P < 0.001) or grocery (98%, P < 0.001) pharmacies. Among pharmacists at independent pharmacies, 43% indicated they were highly or extremely comfortable dispensing naloxone, a significantly lower proportion than pharmacists at grocery (79%, P < 0.001) or primary (68%, P < 0.001) pharmacies. The prevalence of salient barriers to naloxone dispensing was: cost/insurance issues (primary pharmacy = 38% vs. grocery pharmacy = 36% vs. independent pharmacy = 28%, P = 0.46), stigma (36% vs. 49% vs. 16%, P < 0.05), and lack of standing order enrollment (0% vs. 0% vs. 49%, P < 0.05). On average, detailers perceived visits as less useful to pharmacists working at independent pharmacies than those at primary or grocery pharmacies.

CONCLUSIONS

Over 80% of pharmacists reported facing greater than one naloxone dispensing barrier. While cost/insurance issues appear ubiquitous, patient stigma-related factors were prevalent in primary and grocery pharmacies. Although many pharmacists are comfortable dispensing naloxone under the standing order, pharmacists at independent pharmacies are less comfortable, potentially secondary to lower standing order enrollment.

Public Perceptions of Community Pharmacy-Based Naloxone Services: A National Cross-Sectional Survey

Little is known about the general public's perceptions regarding community pharmacist-delivered naloxone services at the national level. Accordingly, the purpose of this study was to describe the US general public's awareness, knowledge, beliefs, comfort, perceived barriers, abilities, and communication preferences related to community pharmacy-based naloxone services. A national, online cross-sectional survey was conducted in September 2021 among US adults ≥18 years recruited via Amazon Mechanical Turk (MTurk). Primary outcome measures were assessed via 5-point Likert-type scales, including: (1) naloxone awareness and knowledge; (2) naloxone beliefs; (3) comfort with pharmacist-provided naloxone; (4) perceived barriers to pharmacy-based naloxone; (5) opioid overdose competencies, concerns, and readiness; and (6) preferred pharmacist-patient naloxone communication strategy. Analyses included descriptive statistics and logistic regression models to assess predictors of preferred communication strategies. Of 301 respondents, 82.1% were White, 48.8% female, and mean 43 years. Eighty-five percent were unaware of pharmacy-provided naloxone and mean [SD] knowledge score was low (29.3% [16.8]). Mean [SD] beliefs (3.78 [0.61]) and comfort (3.70 [0.54]) were positive, while perceived barriers were low/neutral (2.93 [0.78]). For communication, 54% preferred general advertisement, 32.9% universal offer, and 13.3% targeted offer. The odds of preferring a general advertisement or universal offer over a targeted offer increased with greater awareness (AOR:4.52; p = 0.003) and comfort (AOR:3.79; p = 0.003), and decreased with greater competence (AOR:0.35; p = 0.001). Although awareness and knowledge regarding community pharmacy-based naloxone services was low, beliefs and comfort were positive and perceived barriers were low/neutral. General or universal offers of naloxone were preferred over targeted approaches. Future studies should test the impact of communication strategies on naloxone uptake.

Contact based intervention reduces stigma among pharmacy students

INTRODUCTION

Interventions to reduce the stigma of substance use disorders by health professionals often include didactic instruction combined with an interactive component that includes a guest speaker in recovery. Few interactive studies have focused on pharmacy students. Community pharmacists are moving to the front lines to battle the opioid epidemic; therefore, pharmacy students should be included in interventions aimed at reducing stigma by health professionals.

METHODS

This study examined the effects of a contact-based interactive intervention delivered by a peer recovery support specialist on perceived stigma of opioid use disorder among third-year pharmacy students (N = 115) enrolled in an integrative psychiatry course. Stigma was measured using the Brief Opioid Stigma Scale.

RESULTS

Our study found significant differences in students' perceived stigma, both with their personal beliefs and their beliefs regarding the public, supporting the use of interactive presentations by peer recovery support specialists to decrease perceived stigma of opioid use disorder by health professionals.

CONCLUSIONS

This type of intervention for pharmacy students shows promise in reducing substance use disorder stigma and should be further explored.

An observational study of the extent of naloxone furnishing in California Central Valley community pharmacies

BACKGROUND

California has sought to expand medication access and improve public health by authorizing pharmacists in California to prescribe certain medications since 2014. Medications with pharmacist-initiated prescribing, or furnishing, include naloxone, hormonal contraception, postexposure prophylaxis/preexposure prophylaxis, and nicotine replacement therapy. In light of the United States' opioid epidemic, naloxone, an opioid antagonist, this study considered furnishing rates in urban areas of California. Research from 2020 found 42.5% of pharmacies furnished naloxone. However, there has been limited study of furnishing outside of urban areas.

OBJECTIVE

This study assessed pharmacist furnishing rates of naloxone in California's Central Valley and identified barriers and facilitators to implementation.

METHODS

From April to May 2022, the researchers first conducted a cross-sectional, observational study of community and mail-order pharmacies in California's largely rural Central Valley, then collected interview data from a subset of pharmacists in stores that indicated they furnished naloxone.

RESULTS

Forty-three percent of Central Valley pharmacies reported that they furnished naloxone. Interview respondents reported that barriers to furnishing included time restrictions, cost to patients, stigma, and language barriers.

CONCLUSIONS

Furnishing rates in the Central Valley were slightly higher (43.4%) than those reported in previous research focusing on urban areas of California (42.5%). Identified barriers to furnishing were consistent with those identified in previous research. These findings suggest that further policy interventions may be needed to reduce out-of-pocket costs, establish stronger pharmacist-provider relationships, and provide education combatting stigma against opioid users to increase naloxone furnishing.

Pharmacy naloxone codispensing: A mixed methods study of practices and perspectives under a statewide standing order program

BACKGROUND

In a previous statewide naloxone purchase trial conducted in Massachusetts, we documented high levels of naloxone accessibility, upon patient request, under the state's naloxone standing order (NSO) program. Equally important for reducing overdose mortality rates is expanding naloxone access via codispensing alongside opioid prescription and syringe purchases at pharmacies.

OBJECTIVE

To understand naloxone codispensing from the perspective of pharmacists under the Massachusetts NSO program.

METHODS

The study used a mixed methods design involving 3 focus groups and a quantitative survey. Participants in both the focus groups (N = 27) and survey (N = 339) were licensed Massachusetts pharmacists. Focus groups were conducted at 3 separate professional conferences for pharmacists. The survey was conducted using a stratified random sample of 400 chain and independent retail pharmacies across Massachusetts. All data were collected between September 2018 and November 2019. Quantitative and qualitative analyses examined current policies, practices, and attitudes regarding naloxone codispensing for patients at risk of opioid overdose.

RESULTS

Most pharmacists (69%) reported that they, their pharmacy, or both promoted codispensing alongside opioid prescriptions. A majority promoting naloxone codispensing did so for patients prescribed high opioid dosages (80%); fewer promoted codispensing for patients also prescribed benzodiazepines (20%). Facilitators to codispensing were pre-existing relationships between pharmacists and prescribers, mandatory pharmacist consultation, and universal naloxone promotion to all patients meeting certain criteria. Barriers to codispensing were pharmacists' concerns about offending patients by initiating a conversation about naloxone, insufficient technician training, workflow and resource constraints, and misconceptions surrounding naloxone. We found no substantive differences in outcomes between chain and independent pharmacies.

CONCLUSION

We documented several facilitators and barriers to naloxone codispensing in Massachusetts pharmacies. Areas amenable to intervention include increased training for front-line pharmacy technicians, mandatory pharmacist consultation for opioid-prescribed patients, workflow reorganization, and addressing stigma concerns on the pharmacist end.

Impact of a Multicomponent Educational Intervention on Community Pharmacy-Based Naloxone Services Implementation: A Pragmatic Randomized Controlled Trial

BACKGROUND

Despite US naloxone access laws, community pharmacists lack training and confidence in providing naloxone.

OBJECTIVE

To assess the impact of the Empowering Community Pharmacists program on pharmacists' knowledge, perceived barriers, attitudes, confidence, and intentions regarding naloxone services implementation, as well as naloxone prescriptions dispensed.

METHODS

A 3-month pragmatic randomized controlled trial was conducted from December 2018 to March 2019. Alabama community pharmacists were recruited by mail, email, phone, and fax and randomized to intervention (monthly resources/reminders + educational webinar) or control (monthly reminders only). Outcome measures were assessed via online surveys at baseline (T1), immediately post-intervention (T2), and 3 months post-intervention (T3), including naloxone knowledge (%correct); perceived barriers, attitudes, confidence, and intention regarding naloxone services implementation (7-point Likert-type scale; 1 = strongly disagree, 7 = strongly agree); and number of naloxone prescriptions dispensed. Mean differences between control and intervention from T1 to T3 were assessed using 2-way mixed analysis of variance and adjusted analyses were conducted using generalized estimating equations with negative binomial distribution to assess associations between variables.

RESULTS

Of 55 participants (n = 27 intervention, n = 28 control), most were female (80.3%), white (80.6%), in independently owned pharmacies (39.1%). Increases in mean [SD] confidence (5.52 [1.03]-6.16 [0.74], P < 0.0005) and intention (5.35 [1.51]-6.10 [0.96], P = 0.023) occurred from pre- to post-program within the intervention group and were statistically significant compared with control (confidence P = 0.016, intention P = 0.014). Confidence (exp(β) = 1.46, P = 0.031) and perceived barriers (exp(β) = 0.75, P = 0.022) were associated with number of naloxone prescriptions dispensed.

CONCLUSION AND RELEVANCE

The Empowering Community Pharmacists program improved community pharmacists' confidence and intention regarding naloxone services implementation. Other states can adapt program elements according to their laws.

CLINICALTRIALS.GOV IDENTIFIER

NCT05093309.

Naloxone Co-Dispensing with Opioids: a Cluster Randomized Pragmatic Trial

BACKGROUND

Although naloxone prevents opioid overdose deaths, few patients prescribed opioids receive naloxone, limiting its effectiveness in real-world settings. Barriers to naloxone prescribing include concerns that naloxone could increase risk behavior and limited time to provide necessary patient education.

OBJECTIVE

To determine whether pharmacy-based naloxone co-dispensing affected opioid risk behavior. Secondary objectives were to assess if co-dispensing increased naloxone acquisition, increased patient knowledge about naloxone administration, and affected opioid dose and other substance use.

DESIGN

Cluster randomized pragmatic trial of naloxone co-dispensing.

SETTING

Safety-net health system in Denver, Colorado, between 2017 and 2020.

PARTICIPANTS

Seven pharmacies were randomized. Pharmacy patients (N=768) receiving opioids were followed using automated data for 10 months. Pharmacy patients were also invited to complete surveys at baseline, 4 months, and 8 months; 325 survey participants were enrolled from November 15, 2017, to January 8, 2019.

INTERVENTION

Intervention pharmacies implemented workflows to co-dispense naloxone while usual care pharmacies provided usual services.

MAIN MEASURES

Survey instruments assessed opioid risk behavior; hazardous drinking; tobacco, cannabis, and other drug use; and knowledge. Naloxone dispensings and opioid dose were evaluated using pharmacy data among pharmacy patients and survey participants. Intention-to-treat analyses were conducted using generalized linear mixed models accounting for clustering at the pharmacy level.

KEY RESULTS

Opioid risk behavior did not differ by trial group (P=0.52; 8-month vs. baseline adjusted risk ratio [ARR] 1.07; 95% CI 0.78, 1.47). Compared with usual care pharmacies, naloxone dispensings were higher in intervention pharmacies (ARR 3.38; 95% CI 2.21, 5.15) and participant knowledge increased (P=0.02; 8-month vs. baseline adjusted mean difference 1.05; 95% CI 0.06, 2.04). There was no difference in other substance use by the trial group.

CONCLUSION

Co-dispensing naloxone with opioids effectively increased naloxone receipt and knowledge but did not increase self-reported risk behavior.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov ; Identifier: NCT03337100.

A qualitative examination of naloxone access in three states: Connecticut, Kentucky, and Wisconsin

BACKGROUND

Prevention of opioid-involved overdose deaths remains a public health priority in the United States. While expanding access to naloxone is a national public health strategy, it is largely implemented at the state and local level, where significant variability in policies, resources, and norms exist. The aims of the current study were to examine the social context of naloxone access in three different states (Connecticut, Kentucky, Wisconsin) from the perspectives of key informants (first responders, harm reduction personnel, and pharmacists), who play some role in dispensing or administering naloxone within their communities.

METHODS

Interviews were conducted with key informants who were in different local areas (urban, suburban, rural) across Connecticut, Kentucky, and Wisconsin. Interview guides explored the key informants' experiences with administering or dispensing naloxone, and their perspectives on opioid overdose prevention efforts in their areas. Data analysis was conducted using multistage inductive coding and comparative methods to identify dominant themes within the data.

RESULTS

Key informants in each of the three states noted progress toward expanding naloxone access, especially among people who use opioids, but also described inequities. The key role of harm reduction programs in distributing naloxone within their communities was also highlighted by participants, as well as barriers to increasing naloxone access through pharmacies. Although there was general consensus regarding the effectiveness of expanding naloxone access to prevent overdose deaths, the results indicate that communities are still grappling with stigma associated with drug use and a harm reduction approach.

CONCLUSION

Findings suggest that public health interventions that target naloxone distribution through harm reduction programs can enhance access within local communities. Strategies that address stigmatizing attitudes toward people who use drugs and harm reduction may also facilitate naloxone expansion efforts, overall, as well as policies that improve the affordability and awareness of naloxone through the pharmacy.

Gaps in naloxone ownership among people who inject drugs during the fentanyl wave of the opioid overdose epidemic in New York City, 2018

Background: Community distribution of naloxone, a medication that reverses opioid overdose, is an effective public health strategy to prevent overdose deaths. However, data are limited on who has naloxone during the current fentanyl wave of the opioid overdose epidemic in the United States. We aim to determine correlates of naloxone ownership among a community sample of people who inject drugs (PWID) from New York City (NYC). Methods: Data were drawn from the National HIV Behavioral Surveillance Study among PWID. Participants were recruited via respondent-driven sampling. Eligible participants completed an interviewer-administered survey. Log-linked Poisson regression was used to determine adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) current naloxone ownership. Results: Of 503 PWID, 60% currently owned naloxone. In the past 12 months, 74% witnessed an opioid overdose and 25% experienced one. Those who experienced current homelessness were less likely to own naloxone (aPR: 0.79; 95% CI: 0.68, 0.91), as were those who had been recently incarcerated (aPR: 0.83; 95% CI: 0.71, 0.97). Respondents who reported recent known or possible fentanyl use were more likely to own naloxone (aPR: 1.23; 95% CI: 1.07, 1.43) as were those who experienced an opioid overdose in the past 12 months (aPR: 1.33; 95% CI: 1.15, 1.53). Conclusions: The prevalence of naloxone ownership among PWID in NYC was high, potentially due to widespread community naloxone distribution programs; however, gaps in naloxone ownership existed. Interventions that further ease access to naloxone, such as reclassifying naloxone as an over-the-counter medication and making it available "off the shelf," should be considered. More research is needed to identify barriers to access, uptake, and sustained possession within this group to maximize the impact of naloxone distribution during the ongoing fentanyl wave of the opioid overdose epidemic.

Stigma by Association: To what Extent is the Attitude Toward Naloxone Affected by the Stigma of Opioid Use Disorder?

The United States opioid epidemic is fueled by illicit opioid abuse and prescription opioid misuse and abuse. Consequently, cases of opioid use disorder (OUD, opioid addiction), opioid overdose, and related deaths have increased since the year 2000. Naloxone is an opioid antagonist that rapidly reverses opioid intoxication to prevent death from overdose. It is one of the major risk mitigation strategies recommended in the 2016 Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain. However, despite the exponential increase in dispensing and distribution of naloxone, opioid overdose and related deaths have continued to increase; suggesting that the increased naloxone supply still lags the need. This discordance is attributed at least in part to the negative attitude toward naloxone, which is based on the belief that naloxone is only meant for "addicts" and "abusers" (OUD patients). This negative attitude or so-called naloxone stigma is therefore considered a major barrier for naloxone distribution and consequently, overdose-death prevention efforts. This article presents evidence that challenges common assertions about OUD stigma being the sole and direct driving force behind naloxone stigma, and the purported magnitude of the barrier that naloxone stigma constitutes for naloxone distribution programs among the stakeholders (patients, pharmacists, and prescribers). The case was then made to operationalize and quantify the construct among the stakeholders to determine the extent to which OUD stigma drives naloxone stigma, and the relative impact of naloxone stigma as a barrier for naloxone distribution efforts.

Structural and community changes during COVID-19 and their effects on overdose precursors among rural people who use drugs: a mixed-methods analysis

BACKGROUND

Drug overdose rates in the United States have been steadily increasing, particularly in rural areas. The COVID-19 pandemic and associated mitigation strategies may have increased overdose risk for people who use drugs by impacting social, community, and structural factors.

METHODS

The study included a quantitative survey focused on COVID-19 administered to 50 people who use drugs and semi-structured qualitative interviews with 17 people who use drugs, 12 of whom also participated in the quantitative survey. Descriptive statistics were run for the quantitative data. Qualitative coding was line-by-line then grouped thematically. Quantitative and qualitative data were integrated during analysis.

RESULTS

Findings demonstrate how COVID-19 disruptions at the structural and community level affected outcomes related to mental health and drug use at the individual level. Themes that emerged from the qualitative interviews were (1) lack of employment opportunities, (2) food and housing insecurity, (3) community stigma impacting health service use, (4) mental health strains, and (5) drug market disruptions. Structural and community changes increased anxiety, depression, and loneliness on the individual level, as well as changes in drug use patterns, all of which are likely to increase overdose risk.

CONCLUSION

The COVID-19 pandemic, and mitigation strategies aimed at curbing infection, disrupted communities and lives of people who use drugs. These disruptions altered individual drug use and mental health outcomes, which could increase risk for overdose. We recommend addressing structural and community factors, including developing multi-level interventions, to combat overdose. Trial registration Clinicaltrails.gov: NCT04427202. Registered June 11, 2020: https://clinicaltrials.gov/ct2/show/NCT04427202?term=pho+mai&draw=2&rank=3.

If we build it, will they come? Perspectives on pharmacy-based naloxone among family and friends of people who use opioids: a mixed methods study

BACKGROUND

Expanding access to the opioid antagonist naloxone to reduce overdose mortality is a public health priority in the United States. Naloxone standing orders (NSOs) have been established in many states to increase naloxone dispensing at pharmacies, but increased pharmacy access does not ensure optimal uptake among those likely to witness an overdose. In a prior statewide purchase trial, we documented high levels of naloxone access at Massachusetts pharmacies under a statewide NSO. In this study, we characterize barriers to pharmacy-based naloxone uptake among potential opioid overdose "bystanders" (friends or family of people who use opioids) that may be amenable to intervention.

METHODS

Eligible bystanders were Massachusetts residents ≥ 18 years of age, did not use illicit opioids in the past 30 days, and knew someone who currently uses illicit opioids. We used a sequential mixed methods approach, in which a series of semi-structured qualitative interviews (N = 22) were conducted April-July 2018, to inform the development of a subsequent quantitative survey (N = 260), conducted February-July 2020.

RESULTS

Most survey participants (77%) reported ever obtaining naloxone but few (21%) attempted to purchase it at a pharmacy. Qualitative participants revealed that barriers to utilizing the NSO included low perceived risk of overdose, which was rooted in misconceptions regarding the risks of prescription opioid misuse, denial about their loved one's drug use, and drug use stereotypes; inaccurate beliefs about the impact of naloxone on riskier opioid use; and concerns regarding anticipated stigma and confidentiality. Many participants had engaged in mutual support groups, which served as a source of free naloxone for half (50%) of those who had ever obtained naloxone.

CONCLUSIONS

Despite high levels of pharmacy naloxone access in Massachusetts, few bystanders in our study had attempted to obtain naloxone under the NSO. Low perceived risk of overdose, misinformation, stigma, and confidentiality were important barriers to pharmacy naloxone uptake, all of which are amenable to intervention. Support groups provided a setting for addressing stigma and misinformation and provided a discreet and comfortable setting for naloxone access. Where these groups do not exist and for bystanders who do not participate in such groups, pharmacies are well-positioned to fill gaps in naloxone availability.

Using Qualitative, Community-Based Input to Steer Post-COVID-19 Pharmacy Practice in Substance Use

Background

The coronavirus disease 2019 (COVID-19) pandemic has had a disproportionately negative impact on individuals with a substance use disorder (SUD). A rapidly changing public health and treatment environment has resulted in increased needs for pharmacist engagement in SUD-focused patient care.

Objectives

This study used semistructured interviews of SUD professionals to evaluate where they believe pharmacy practice could better support people at risk of or having SUD in light of challenges posed by the COVID-19 pandemic.

Methods

Professionals dedicated to the care of individuals with SUD were recruited from a large community substance use coalition to participate in a qualitative study examining how pharmacists could take a more active role in SUD prevention, intervention, recovery, and harm reduction (HR). A consensual qualitative research approach was used in data analysis.

Results

Domains identified in analysis included pharmacists as educators of patients and communities, pharmacists as educators of health care providers, pharmacists as advocates for individuals with SUD, the need for increased pharmacist engagement owing to COVID-19 challenges for individuals with SUD, the need for expanded pharmacy practice interventions, and the need for pharmacist self-development.

Conclusion

Increased medication counseling, HR practices, addressing stigma, and community-level education focused on SUD were among the most commonly reported areas for pharmacy practice development. In addition, the urgent need to adjust pharmacy practice in response to the COVID-19 pandemic was also identified by interviewees.

Protocol for the Optimizing Naloxone Dispensing in Pharmacies (ONDP) Online Continuing Education Program: A Randomized Controlled Trial

The number of opioid-related deaths in Canada has steadily increased since 2016 and the COVID-19 pandemic has worsened this trend. Naloxone has been pivotal for reducing opioid-related harms and death, and pharmacists play a crucial role in ensuring the supply of naloxone to Canadians through community pharmacies. However, naloxone dispensing by pharmacists is not optimal; in fact, in Ontario, only 50% of pharmacists offer naloxone, despite national guidelines that pharmacists should offer naloxone to everyone with an opioid prescription. When asked why pharmacists do not proactively offer naloxone, recent research has identified that pharmacists need continuing education to boost confidence and knowledge on how to start conversations with patients. The study involves a delayed start, double-blind randomized controlled trial, for Canadian licensed pharmacists and pharmacy technicians. The goals of the program are to increase Canadian pharmacy professional’s knowledge, confidence, and motivation to proactively offer naloxone, as well as to decrease stigma associated with naloxone. The program incorporates behaviour change techniques from the Theoretical Domains Framework and the Theory of Planned Behaviour. The intervention program includes three modules that focus on improving pharmacists’ communication skills by teaching them how to proactively offer naloxone, while the control group will complete a reading assignment on the naloxone consensus guidelines. The program will involve a process and outcome evaluation in addition to a contribution analysis. This program is important for breaking down previously identified barriers and knowledge gaps for why pharmacists currently do not proactively offer naloxone. This study will provide important new information about what behaviour change techniques are successful in improving confidence and motivation in the pharmacy profession and in an online environment. Findings from this study can be used to produce a national naloxone education program that can also be implemented into current pharmacy school curriculum.

Limited access to pharmacy-based naloxone in West Virginia: Results from a statewide purchase trial

BACKGROUND

West Virginia (WV) has the highest overdose mortality rate in the United States and expanding naloxone access is crucial for reducing opioid overdose deaths. We conducted a purchase trial to establish an objective measure of naloxone access under WV's naloxone standing order (NSO) program.

METHODS

A stratified random sample of 200 chain and independent retail pharmacies across WV were included. Each pharmacy underwent two purchase attempts-one by a person who used illicit opioids (PWUIO) and one by a potential bystander who did not use illicit opioids but had a relationship with a PWUIO. We used matched-pairs analysis to identify differences in outcomes by purchaser type (PWUIO vs bystander). Chi-square and independent-samples t-tests were used to compare outcomes by pharmacy type (chain vs independent).

RESULTS

Overall, 29% of purchase attempts were successful, with no significant difference between PWUIO and bystanders (p = 0.798). Fewer than half (44%) of successful purchases included verbal counseling, and bystanders were more likely to receive counseling than PWUIO (33% vs 4%, p = 0.018). Common reasons for failed purchases were naloxone not being in stock (41%), requiring a naloxone prescription (35%), and/or requiring formal identification (23%). Chain pharmacies were more likely to sell naloxone than independents (35% vs 19%, p = 0.001).

CONCLUSIONS

We documented limited naloxone access under the WV NSO. These findings indicate that simply establishing an NSO program is insufficient to expand access. Implementation efforts should ensure adequate naloxone stocks, pro-active delivery of NSO-related information and pharmacist training, and avoidance of recordkeeping requirements that may impede access.

Associations between naloxone prescribing and opioid overdose among patients with acute and chronic pain conditions

AIMS

To assess whether naloxone prescribing in clinical contexts targeted pain patients most at risk for opioid overdose.

DESIGN

A retrospective cohort study using data from the Health Facts Database.

SETTING

Over 600 United States healthcare facilities.

PARTICIPANTS

Three patient groups were followed for 2 years during 2009 to 2017: individuals with shoulder or long bone fractures (n = 252 424), chronic pain syndrome (CPS) (n = 76 141), or non-traumatic low back pain (n = 792 956) who received an opioid prescription. Groups were chosen based on previous work.

MEASUREMENTS

The outcome was opioid overdose identified by International Classification of Diseases codes (ICDs) and the primary predictor was number of naloxone prescriptions identified by National Drug Codes (NDCs).

FINDINGS

Opioid overdoses occurred among 0.16% of fracture patients (average follow-up time to overdose [AFU] = 240 days), 1.28% of CPS patients (AFU = 244 days), and 0.30% low back pain patients (AFU = 264 days). A total of 58 083 bone fracture patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (hazard ratio [HR] = 1.87, 95% CI = 1.68-2.09), and number of subsequent overdoses (incidence rate ratio [IRR] = 1.89, 95% CI = 1.69-2.12). A total of 19 529 CPS patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR = 1.69, 95% CI = 1.61-1.78) and number of subsequent overdoses (IRR = 1.74, 95% CI = 1.67-1.83). A total of 110 608 low back pain patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR = 1.33, 95% CI = 1.27-1.40) and number of subsequent overdoses (IRR = 1.35, 95% CI = 1.29-1.41).

CONCLUSIONS

Receiving a naloxone prescription appears to be associated with increased risk of subsequent opioid overdose among patients with acute and chronic pain, suggesting prescribers often identify patients most in need of naloxone.

A qualitative examination of responses from a survey of pharmacy staff in Georgia regarding access to Narcan®

Georgia state lawmakers enacted legislation designed to reduce opioid overdose deaths by increasing public access to rescue products, such as Narcan®. This article explores whether pharmacy employees have effectively adopted such changes into pharmacy practice. We analyzed unsolicited remarks noted during a parent telephone survey of 120 Georgia pharmacy staff regarding price, availability and barriers to layperson purchase of Narcan®. Comments regarding dispensing requirements and challenges in obtaining inventory and changes in communication style were recorded. Around 15% were unfamiliar with Narcan® as an opioid overdose reversal agent or were unaware of their pharmacy's policies governing its sale. Nearly half of those contacted did not have Narcan® in stock with some reporting that receiving Narcan® would take several days after placing an order. Over half specified requirements for purchasing Narcan® not required by law. Fewer than 15% had Narcan® available and imposed no unnecessary requirements for its purchase. During approximately 10% of the survey calls, respondents used a tone of voice or made comments suggestive of bias. We conclude that non-compliance with current laws, lack of familiarity with Narcan® and negative communication tendencies that suggest implicit bias and stigmatizing behaviors could ultimately inhibit access to opioid overdose treatment.

Perspectives of Stakeholders of Equitable Access to Community Naloxone Programs: A Literature Review

The purpose of this review is to examine the existing literature about facilitators and barriers influencing equitable access to naloxone programs by individuals who use opioids. A total of 49 published articles were examined, which generated four overarching themes:(1) Stigma as a barrier to access; (2) Lack of a wide range of stakeholder perspectives; (3) Need for a comprehensive understanding of factors affecting equitable access to naloxone programs; (4) Facilitators to increase the access of community naloxone programs. Our review highlighted the importance of advocacy in practice, education, administration, and policy to address the health inequities that exist in naloxone distribution programs. Advocacy activities involve the need for health care professionals to engage in social justice practice through evidence-based informed research about the facts of opioid use; challenging the stigma toward victim-blaming against naloxone users; as well as promoting program development and health policy to bring about equitable access to naloxone programs by marginalized and socially disadvantaged populations.

Pharmacists' experiences with a statewide naloxone standing order program in Massachusetts: a mixed methods study

OBJECTIVES

In a prior statewide naloxone purchase trial conducted in Massachusetts, we documented a high rate of naloxone dispensing under the state's standing order program. The purpose of this study was to understand the factors that facilitate naloxone access under the Massachusetts naloxone standing order (NSO) program and identify any remaining barriers amenable to intervention.

DESIGN

Mixed methods design involving a pharmacist survey and 3 pharmacist focus groups.

SETTING AND PARTICIPANTS

Focus groups were conducted at 3 separate professional conferences for pharmacists (n = 27). The survey was conducted among Massachusetts pharmacists (n = 339) working at a stratified random sample chain and independent retail pharmacies across Massachusetts. All data were collected between September 2018 and November 2019.

OUTCOME MEASURES

Facilitators and barriers to NSO implementation and naloxone dispensing and pharmacists' attitudes and beliefs regarding naloxone and opioid use.

RESULTS

Most pharmacists described NSO implementation as being straightforward, although differences were reported by pharmacy type in both the survey and focus groups. Facilitators included centralized implementation at chain pharmacies, access to Web-based resources, regularly stocking naloxone, and use of naloxone-specific intake forms. Barriers included patient confidentiality concerns and payment/cost issues. Only 31% of surveyed pharmacists reported always providing naloxone counseling; the most commonly cited barriers were perceived patient discomfort (21%) and time limitations (14%). Confidential space was also more of a concern for independent (vs. chain) pharmacists (18% vs. 6%, P = 0.008). A majority of pharmacists held supportive attitudes toward naloxone, although some reported having moral/ethical concerns about naloxone provision.

CONCLUSION

We documented several facilitators to NSO implementation and naloxone dispensing. Areas for improvement include addressing stigma and misconceptions around opioids and naloxone use. These remain important targets for improving pharmacy-based naloxone dispensing, although our overall positive results suggest Massachusetts' experience with NSO implementation can inform other states' efforts to expand pharmacy-based naloxone access.

The Impact of Stigma on People with Opioid Use Disorder, Opioid Treatment, and Policy

Illicit drug use disorders are the most stigmatised health conditions worldwide, and stigma acts as a meaningful barrier to treatment entry and treatment provision. In the context of dramatically rising opioid-related harms, it is critical that we understand the drivers of stigma and how it affects opioid use disorder treatment and policy. The aim of this narrative review is to discuss how opioid-related stigma impacts treatment provision and harm reduction, and provide potential strategies to reduce stigma at a social and structural level. We used the Framework for Integrating Normative Influences on Stigma (FINIS) to identify sources of opioid-related stigma at the macro (structural stigma), meso (public stigma) and micro (internalised stigma) levels. Reducing stigma requires strategies that target multiple levels, however addressing inequity in the laws, regulations, and rules that segregate people with opioid and other substance use disorders from mainstream society is essential.

Individual and County-Level Disparities in Drug and Opioid Overdose Mortality for Hispanic Men in Massachusetts and the Northeast United States

BACKGROUND

This study aimed to identify individual- and county-level inequalities that may underlie disparities in drug overdose mortality for Hispanic men in Massachusetts and the broader Northeast region.

METHODS

The study first used data from the State Unintentional Drug Overdose Reporting System to compare the 635 Hispanic and 3593 Non-Hispanic (NH) White men who died of unintentional/undetermined opioid-related overdoses in Massachusetts in 2016-2018. Next, the study used 2015-2019 data from the Multiple Cause of Death online platform to: a) compare rates of drug overdose mortality in Hispanic versus NH White men in 54 counties in the Northeast United States; and b) examine associations with inequalities in poverty, educational attainment, unemployment, and uninsurance (from 2015-2019 American Community Survey data).

RESULTS

At the individual level, in Massachusetts, Hispanic and NH White men who died of opioid-related overdose differed in terms of educational attainment, birthplace, urbanicity, substance use disorder treatment history, and specific drugs involved in death. At the county level, in the Northeast region, each one-standard deviation increase in the ratio of the Hispanic to NH White poverty rate was associated with a 27% increase in the ratio of Hispanic to NH White male overdose mortality; each one-standard deviation increase in the ratio of the Hispanic to NH White unemployment rate was associated with a 43% increase in the ratio of Hispanic to NH White male overdose mortality.

CONCLUSIONS

Findings underscore the importance of equitable interventions and efforts to address inequalities in social determinants of health for Hispanic populations in the Northeast.

Study protocol for the Respond to Prevent Study: a multi-state randomized controlled trial to improve provision of naloxone, buprenorphine and nonprescription syringes in community pharmacies

Access to the opioid antidote naloxone is a critical component of addressing the opioid crisis. Naloxone is a population-level prevention intervention associated with substantial reductions in overdose mortality and reduction of nonfatal overdose. Pharmacies' pivotal role in dispensing medications like buprenorphine for the treatment of opioid use disorder and selling nonprescription syringes places them at the crossroads of opioid access and risk mitigation methods like naloxone provision. Testing ways to optimize pharmacy-based naloxone provision will be key as the country expands the implementation of naloxone through the medical system. In the Respond to Prevent Study, we conducted a large, practical study of a pharmacy-focused intervention in a sample of Washington, Oregon, Massachusetts and New Hampshire community chain pharmacies to increase naloxone dispensing and improve opioid safety. The intervention integrated two evidence-based educational toolkits and streamlined materials to enhance the focus on naloxone policy, stigma reduction, and patient communications around naloxone, nonprescription syringes and buprenorphine access. The real-world study implemented a stepped wedge, clustered randomized trial design across 175 community chain pharmacies to evaluate the effectiveness of the Respond to Prevent intervention in increasing: (a) pharmacy based naloxone distribution rates, naloxone-related patient engagement, and pharmacist and technicians' attitudes, knowledge, perceived behavioral control and self-efficacy toward naloxone; and (b) pharmacy nonprescription syringe sales, and pharmacist and technicians' attitudes, knowledge, perceived behavioral control and self-efficacy toward dispensing buprenorphine for opioid use disorder (secondary outcomes). This commentary provides a brief narrative about the study and presents insights on the design and adaptations to our study protocol, including those adopted during the unprecedented COVID-19 pandemic further compounded by Western wildfires in 2020.

UNDERSTANDING PREFERENCES FOR TYPE OF TAKE-HOME NALOXONE DEVICE: INTERNATIONAL QUALITATIVE ANALYSIS OF THE VIEWS OF PEOPLE WHO USE OPIOIDS

Background

Take-home naloxone (THN) is provided to non-medically trained people to reverse potential opioid overdoses. There is an increasing range of effective intramuscular (IM) and intranasal (IN) naloxone devices and this paper explores the types preferred by people who use opioids, using consumer behaviour literature to interpret the findings.

Methods

Data derive from two unconnected qualitative studies involving audio-recorded semi-structured interviews. Study 1 was conducted in the United States (n=21 users of non-medical/illicit opioids). Study 2 was conducted in Australia (n=42 users of non-medical/illicit or prescribed opioids).

Findings

Most participants preferred IN naloxone. Preferences were based on the ease, speed, safety and comfort of each device and underpinned by accounts of overdose revivals as being very rushed and frightening situations. Preferences related to complex interactions between the naloxone device ('product'); the knowledge, skills, experience and attitudes of the lay responder ('consumer'), and when, where and how naloxone was to be used ('usage situation').

Conclusions

THN programs should offer choice of device when possible and nasal naloxone if resources permit. Asking people which devices they prefer and why and treating them as valued consumers of naloxone products can generate insights that improve future naloxone technology and increase THN uptake and usage.

Effectiveness and implementability of state-level naloxone access policies: Expert consensus from an online modified-Delphi process

BACKGROUND

Naloxone distribution, a key global strategy to prevent fatal opioid overdose, has been a recent target of legislation in the U.S., but there is insufficient empirical evidence from causal inference methods to identify which components of these policies successfully reduce opioid-related harms. This study aimed to examine expert consensus on the effectiveness and implementability of various state-level naloxone policies.

METHODS

We used the online ExpertLens platform to conduct a three-round modified-Delphi process with a purposive sample of 46 key stakeholders (advocates, healthcare providers, human/social service practitioners, policymakers, and researchers) with naloxone policy expertise. The Effectiveness Panel (n = 24) rated average effects of 15 types of policies on naloxone pharmacy distribution, opioid use disorder (OUD) prevalence, nonfatal opioid-related overdoses, and opioid-related overdose mortality. The Implementation Panel (n = 22) rated the same policies on acceptability, feasibility, affordability, and equitability. We compared ratings across policies using medians and inter-percentile ranges, with consensus measured using the RAND/UCLA Appropriateness Method Inter-Percentile Range Adjusted for Symmetry technique.

RESULTS

Experts reached consensus on all items. Except for liability protections and required provision of education or training, experts perceived all policies to generate moderate-to-large increases in naloxone pharmacy distribution. However, only three policies were expected to yield substantive decreases on fatal overdose: statewide standing/protocol order, over-the-counter supply, and statewide "free naloxone." Of these, experts rated only statewide standing/protocol orders as highly affordable and equitable, and unlikely to generate meaningful population-level effects on OUD or nonfatal opioid-related overdose. Across all policies, experts rated naloxone prescribing mandates relatively lower in acceptability, feasibility, affordability, and equitability.

CONCLUSION

Experts believe statewide standing/protocol orders are an effective, implementable, and equitable policy for addressing opioid-related overdose mortality. While experts believe many other broad policies are effective in reducing opioid-related harms, they also believe these policies face implementation challenges related to cost and reaching vulnerable populations.

Exploration of pharmacist comfort with harm reduction behaviors: Cross-sectional latent class analysis

BACKGROUND

Pharmacists are positioned to play important roles in implementing evidence-based prevention and harm reduction approaches for opioid misuse and related health care outcomes such as human immunodeficiency virus (HIV) and hepatitis C. More research is needed to understand how best to facilitate harm reduction practices among pharmacists.

OBJECTIVES

This hypothesis-generating study investigated (1) whether subgroups (latent classes) were observable among pharmacists based on self-reported comfort with specific harm reduction behaviors, (2) whether having reported expertise in key content areas was associated with any latent classes that might be identified, and (3) whether comfort and training were associated with actually having dispensed syringes for likely nonprescription drug use.

METHODS

This was a statewide census of community managing pharmacists in Arizona conducted from December 2018 to May 2019. Participants reported their degree of comfort with 10 harm reduction behaviors, their expertise (e.g., recent continuing pharmacy education or specialization) in selected content areas, and their syringe dispensing behavior. Additional sociodemographic information was also collected. Subgroups related to harm reduction were computed using latent class analysis, and associations between study variables were assessed using the Fisher's exact tests.

RESULTS

Data suggested the existence of 4 latent, comfort-based harm reduction classes: high comfort, moderate comfort, and clinical comfort, and opioid prevention only. Reported expertise in pre-exposure prophylaxis for HIV was likely associated with harm reduction class. However, class membership was not associated with reporting having dispensed nonprescription syringes, although the single comfort item for syringe dispensing, by itself, was associated therewith.

CONCLUSION

Comfort with harm reduction likely clusters, so pharmacists may be broadly comfortable with topics or methods of harm reduction; however, comfort with a specific harm reduction pharmacy practice may be a better predictor of engaging in that behavior than harm reduction comfort class. In contrast, strategies to improve comfort, such as intervention development, might successfully be informed by pharmacists' latent class.