Integration of prescription drug monitoring programs (PDMP) in pharmacy practice: Improving clinical decision-making and supporting a pharmacist's professional judgment

Patient and pharmacist perspectives on opioid misuse screening and brief interventions in community pharmacies

BACKGROUND

Pharmacy-based screening and brief interventions (SBI) offer opportunities to identify opioid misuse and opioid safety risks and provide brief interventions that do not overly burden pharmacists. Currently, such interventions are being developed without patient input and in-depth contextual data and insufficient translation into practice. The purpose of this study is to qualitatively explore and compare patient and pharmacist perceptions and needs regarding a pharmacy-based opioid misuse SBI and to identify relevant SBI features and future implementation strategies.

METHODS

Using the Consolidated Framework for Implementation Research, we conducted semi-structured interviews with 8 patients and 11 pharmacists, to explore needs and barriers to participating in a pharmacy-based SBI. We recruited a purposive sample of English-speaking patients prescribed opioids for chronic or acute pain and pharmacists practicing in varied pharmacies (small independent, large-chain, specialty retail) settings. We used an inductive content analysis approach to analyze patient interview data. Then through a template analysis approach involving comparison of pharmacist and patient themes, we developed strategies for SBI implementation.

RESULTS

Most patient participants were white, older, described living in suburban areas, and were long-term opioid users. We identified template themes related to individual, interpersonal, intervention, and implementation factors and inferred applications for SBI design or potential SBI implementation strategies. We found that patients needed education on opioid safety and general opioid use, regardless of opioid use behaviors. Pharmacists described needing patient-centered training, protocols, and scripts to provide SBI. A short-self-reported screening and brief interventions including counseling, naloxone, and involving prescribers were discussed by both groups.

CONCLUSIONS

Through this implementation-focused qualitative study, we identified patient needs such as opioid safety education delivered in a private and convenient format and pharmacist needs including training, workflow integration, protocols, and a time-efficient intervention for effective pharmacy-based SBI. Alternate formats of SBI using digital health technologies may be needed for effective implementation. Our findings can be used to develop patient-centered pharmacy-based SBI that can be implemented within actual pharmacy practice.

Exploring knowledge, perceptions, and practices of antimicrobials, and their resistance among medicine dispensers and community members in Kavrepalanchok District of Nepal

BACKGROUND

Inappropriate use of antimicrobials is a global public health issue, particularly in developing countries, including Nepal, where over-the-counter sales and self-medication of antimicrobials are common.

OBJECTIVES

To explore knowledge, perceptions, and practices of antimicrobials and their resistance among medicine dispensers and community members in Nepal.

METHODS

The study was conducted in three rural and five urban municipalities of the Kavrepalanchok district from May 2021 to August 2021. Data were collected using two qualitative approaches: In-Depth Interviews (IDIs) and Focus Group Discussions (FGDs). Data were analyzed using thematic analysis that combined deductive and inductive approaches to identify codes under pre-specified themes.

RESULTS

A total of 16 In-depth interviews with medicine dispensers and 3 focus group discussions with community members were conducted. Knowledge regarding antimicrobial resistance varied among dispensers. Those with a prior educational background in pharmacy often had good knowledge about the causes and consequences of antimicrobial resistance. Meanwhile, consumers were less aware of antimicrobial resistance. Community members perceived antimicrobials as effective medicines but not long-term solution for treating diseases. They reported that dispensing without a prescription was common and that both consumers and dispensers were responsible for the inappropriate use of antimicrobials. On the contrary, several dispensers said that self-medication was common among the consumers, especially among more educated groups. The medicine dispensers and consumers expressed concerns about the weak enforcement of policies regarding pharmacy drug use and dispensing practices.

CONCLUSION

Promoting and strengthening the appropriate use of antimicrobials among medicine dispensers and community members is crucial. Bold policies and collective implementation of regulations could help combat antimicrobial resistance.

An Implementation-Focused Qualitative Exploration of Pharmacist Needs Regarding an Opioid Use Disorder Screening and Brief Intervention

BACKGROUND

Screening and brief interventions (SBI) can help identify opioid safety risks and healthcare professionals can accordingly intervene without a significant increase in workload. Pharmacists, one of the most accessible healthcare professionals, are uniquely positioned to offer SBI. To design an effective intervention with high potential for implementation, we explored pharmacist needs and barriers regarding SBI for opioid use disorders.

METHODS

Using the Consolidated Framework for Implementation Research (CFIR), we conducted 11 semi-structured 60-minute interviews with community pharmacists. We used a purposeful sample of English-speaking pharmacists practicing in varied pharmacies (small independent, large-chain, specialty-retail) and positions (managers, owners, full-time/part-time pharmacists). Transcriptions were analyzed using deductive content analysis based on CFIR constructs, followed by inductive open coding. Utilizing a theoretical framework for data collection and analysis, a diverse sample of pharmacist roles, peer debriefing, and 2 independent coders for each transcript, altogether increased the credibility and transferability of our research. Data collection and analysis continued until data saturation was achieved.

RESULTS

Pharmacists described good working relationships with colleagues, organization cultures that were open to new initiatives, and believed the SBI to be compatible with their organization goals and pharmacy structure, which are facilitators for future SBI implementation. Pharmacists were motivated by improved patient outcomes, more patient interaction and clinical roles, representing facilitators at the individual level. They also described stigma toward patients, mixed need for change, and lack of knowledge regarding SBI, which are potential barriers to be addressed. Pharmacists believed that the SBI model was adaptable, not complicated, and benefits outweighed implementation costs.

CONCLUSIONS

We addressed current SBI literature gaps-mainly lack of focus on implementation and contextual data, through rigorous implementation-focused qualitative research. Our exploratory findings have direct implications on future pharmacy-based SBI implementation.

A scoping review of health system guidelines for pharmacist responsibilities when dispensing opioids

Introduction

Prescription opioid use and evidence of the harm caused by these medicines has increased over the past 20-30 years. Despite a number of system level interventions, the opioid crisis has not yet resolved in Australia or globally. Pharmacists are increasingly required to take a proactive, clinical role to fulfil their responsibility for patient outcomes relating to both medication efficacy and safety.

Aim

To evaluate the current health system guidelines available to pharmacists dispensing opioids and to examine the implications of this guidance on pharmacist responsibility.

Methods

A scoping review was conducted by searching in CINAHL, MEDLINE, Embase, PubMed and Web of Science, in addition to the grey literature and referral from topic experts to collate a list of current health system guidelines relevant to pharmacists dispensing opioids. These guidelines were then examined through thematic analysis and the use of the "Appraisal of Guidelines Research & Evaluation-Health Systems" tool (AGREE-HS).

Results

Ten health system guidelines were identified in the search. Identified guidelines were published in Australia, the United States, and the United Kingdom. Health system guidelines analysed in this study most commonly provide general practice statements that are not specific to opioid medicines. Current guidelines frequently recommend risk assessment, but less commonly provide implementable risk mitigation advice. Additionally, guidelines are of poor overall quality when analysed through metrics relating to their development and implementation.

Conclusion

There are gaps in current health system guidelines which contribute to perceived barriers in pharmacy practice. Current health system guidance does not provide a clear account of the responsibilities of pharmacists when dispensing opioids. This study provides an argument for the development of implementable health system guidelines that support pharmacists in taking direct responsibility for patient outcomes when dispensing opioid medicines.

Physician perspective on the implementation of risk mitigation strategies when prescribing opioid medications: a qualitative analysis

OBJECTIVE

To understand the physician perspective on the barriers and facilitators of implementing nine different opioid risk mitigation strategies (RMS) when prescribing opioid medications.

METHODS

We created and dispersed a cross-sectional online survey through the Qualtrics© data collection platform among a nationwide sample of physicians licensed to practice medicine in the United States who have prescribed an opioid medication within the past year. The responses were analyzed using a deductive thematic analysis approach based on the Consolidated Framework for Implementation Research (CFIR) to ensure a holistic approach to identifying the barriers and facilitators for each RMS assessed. In concordance with this method, the themes and codes for the thematic analysis were defined prior to the analysis. The five domains within the CFIR were used as themes and the 39 nested constructs were treated as the codes. Two members of the research team independently coded the transcripts and discussed points of disagreement until consensus was reached. All analyses were conducted in ATLAS.ti© V7.

RESULTS

The completion rate for this survey was 85.1% with 273 participant responses eligible for analysis. Intercoder reliability was calculated to be 82%. Deductive thematic analysis yielded 2,077 descriptions of factors affecting implementation of the nine RMS. The most salient code across all RMS was Knowledge and Beliefs about the Intervention, which refers to individuals' attitudes towards and value placed on the intervention. Patient Needs and Resources, a code referring to the extent to which patient needs are known and prioritized by the organization, also emerged as a salient code. The physicians agreed that the patient perspective on the issue is vital to the uptake of each of the RMS.

CONCLUSIONS

This deductive thematic analysis identified key points for actionable intervention across the nine RMS assessed and established the importance of patient concordance with physicians when deciding on a course of treatment.

Assessing the Impact of Indiana Public Law 194 on Curbing the Concurrent Opioid Prescribing for Indiana Medicaid Enrollees

Background

Several US states have introduced legislation to support the legitimate medical use of opioids while limiting misuse and diversion. One concern which has been addressed through legislation is preventing individuals from seeking opioid prescriptions concurrently from multiple providers. However, the impact of this legislation on the incidence of patients receiving concurrent prescriptions remains relatively unexplored. This study examines this phenomenon based on claims data from Medicaid enrollees and the enactment of legislation in Indiana.

Methods

Indiana Medicaid claims data over the period of January 2014 to December 2019 were used to determine the changes in the percentage of individuals receiving opioid prescriptions from multiple providers within a 30-day period, that is, concurrent opioid prescription (COP) individuals. Indiana Medicaid enrollees with a diagnosis of opioid use disorder (OUD) receiving opioid prescriptions, that is, the OUD-group, were identified and separated from the enrollees without a diagnosis but receiving opioid prescriptions, that is, the non-OUD group. The mean percentages of COP individuals (with or without an OUD diagnosis) within the subset of individuals that received opioid prescriptions were compared before and after the passage of Indiana Public Law 194.

Results

There were 5336 who met the criteria of COP individuals, and 2050 of those were in the OUD-group. In either group, there was a significant difference in the change in percentages (slope) before and after Indiana Public Law 194 passed. In addition, there was a significant decrease in the mean percentage of COP individuals in the non-OUD group, while the difference was not significant in the OUD group.

Conclusion

Our study suggests that Indiana Public Law 194 had a positive impact on curbing COP. This study is limited by the level of details available from claims data and suggests additional studies to evaluate prescription use and prescribing practices are warranted.

Patient experiences of prescription drug monitoring programs: a qualitative analysis from an Australian pharmaceutical helpline

BACKGROUND

Prescription Drug Monitoring Programs (PDMP) are electronic databases that are used to track and monitor the prescribing and dispensing of controlled substances, such as opioid analgesics and benzodiazepines. PDMP have been used widely throughout North America and have recently been implemented in Australia. Several unintended harms have been associated with PDMP in North America, including increased stigma, discrimination, and dismissal from care for patients prescribed these medications.

AIMS

This study aimed to better understand how people who use prescription medications extramedically and their loved ones give meaning to their consumption and their treatment experiences and concerns in the context of a newly implemented real-time PDMP in Victoria, Australia.

METHOD

Nineteen audio recordings of telephone calls made to the PDMP Pharmaceutical Helpline were transcribed and thematically analysed.

RESULTS

Patients and their families were hopeful that PDMP would stop the extra medical use of medications. However, many were deeply concerned about how they would cope with withdrawal or life stressors without the support these medications afforded. Patients reported experiences of stigma and strained therapeutic relationships associated with PDMP implementation.

CONCLUSION

PDMP have the potential to both assist and harm patients whose prescription medication use has been identified as 'risky' by the PDMP. The findings from this study suggest that clear and open communication, as well as reflection on unconscious bias and stigma may assist healthcare providers to facilitate better patient experiences and outcomes in the context of prescription medication dependence.

Mapping the research addressing prescription drug monitoring programs: A scoping review

ISSUES

Prescription drug monitoring programs are a harm minimisation intervention and clinical decision support tool that address the public health concern surrounding prescription drug misuse. Given the large number of studies published to date and the ongoing implementation of these programs, it is important to map the literature and identify areas for further research to improve practice.

APPROACH

A scoping review was undertaken to identify the research on prescription drug monitoring programs published between January 2015 and April 2021.

KEY FINDINGS

A total of 153 citations were included in this scoping review. The majority of the studies originated from the USA and were quantitative. Results on program effectiveness are mixed and mainly examine their association with opioid-related outcomes. Unintended consequences are revealed in the literature and this review also highlights barriers to program use.

IMPLICATIONS

Overall, findings are mixed despite the large number of studies published to date. Mapping the literature identifies priority areas for further research that can advise policymakers and clinicians on practice improvement.

CONCLUSION

Results on prescription drug monitoring program effectiveness are mixed and mainly examine their association with opioid-related outcomes. This review highlights barriers to prescription drug monitoring program effectiveness related to program use and system integration. Further research is needed in these areas to improve prescription drug monitoring program use and patient outcomes.

How prescription drug monitoring programs influence clinical decision-making: A mixed methods systematic review and meta-analysis

BACKGROUND

Opioid prescribing, for chronic non-cancer pain, has increased substantially in the past two decades and is associated with significant harms. Various public health approaches have been adopted to address these harms including the implementation of prescription drug monitoring programs (PDMPs). This systematic review aims to identify how PDMP use influences healthcare providers' clinical decision-making.

METHODS

Six databases were searched for literature up until April 2021. Empirical studies were included, with no restrictions placed on year, location, language or study design. Thematic analysis of the identified articles was conducted and where possible, meta-analyses were conducted using a random effect model in Stata.

RESULTS

Forty-one articles related to 39 studies were included. All studies were conducted in the United States, published between 2005 and 2021 and most (n = 28) related to one state-level PDMP. PDMP utilisation influenced healthcare providers' clinical decision-making across seven broad themes: (i) the supply of controlled substances, (ii) refusal to prescribe or treat, (iii) risk mitigation strategies, (iv) communication, (v) education and counselling, (vi) referrals and care coordination and (vii) stigma.

CONCLUSIONS

PDMP use influenced healthcare providers' clinical decision-making, resulting in both intended and unintended outcomes for patients. PDMPs are a public health initiative designed to reduce harms associated with increased opioid prescribing, yet their use is associated with multiple unintended outcomes. Targeted research is needed to understand the impact of healthcare providers' clinical decision-making after PDMP utilisation, and the clinical outcomes for patients identified through these tools.

Changes in Quantity of Opioids Dispensed following Florida's Restriction Law for Acute Pain Prescriptions

Objective

To assess the impact of Florida’s 3-day opioid prescription supply law, effective July 2018, on opioids dispensed for acute pain patients.

Methods

Pharmacy claims from a health plan serving a large Florida employer from January 2015 through March 2019 were analyzed. We used an interrupted time series study design accounting for autocorrelation of trends before and after policy change. Acute pain patients met inclusion criteria if they had not received any opioid containing medications in the past 180 days. Patients could contribute to additional new use time if subsequent opioid claims occurred ≥180 days since the previous claim. Outcomes included mean number of units dispensed of the initial opioid prescription, mean morphine milligram equivalents (MMEs) per day of initial prescription by month, and mean total MMEs per initial prescription by month.

Results

A total of 8,375 enrollees had 10,583 unique opioid starts in the given timeframe. Following the policy, there was an immediate significant decrease in the units dispensed per prescription of 4.9 (95% confidence interval [CI] −8.95, −.82 units). Additionally, there was a significant immediate reduction in total MMEs dispensed per prescription of 25.6 (95% CI −44.76, −6.44 MMEs).

Conclusions

Among a group of privately-insured plan enrollees in Florida, and as a result of the law, there were significant decreases in the number of units dispensed, and total MMEs of opioid prescriptions. The immediate reduction in new opioid utilization following policy implementation suggests effective policy; however, impacts on chronic pain patients were not assessed.

Health Care Provider Utilization of Prescription Monitoring Programs: A Systematic Review and Meta-Analysis

OBJECTIVE

To synthesize the literature on the proportion of health care providers who access and use prescription monitoring program data in their practice, as well as associated barriers to the use of such data.

DESIGN

We performed a systematic review using a standard systematic review method with meta-analysis and qualitative meta-summary. We included full-published peer-reviewed reports of study data, as well as theses and dissertations.

METHODS

We identified relevant quantitative and qualitative studies. We synthesized outcomes related to prescription monitoring program data use (i.e., ever used, frequency of use). We pooled the proportion of health care providers who had ever used prescription monitoring program data by using random effects models, and we used meta-summary methodology to identify prescription monitoring program use barriers.

RESULTS

Fifty-three studies were included in our review, all from the United States. Of these, 46 reported on prescription monitoring program use and 32 reported on barriers. The pooled proportion of health care providers who had ever used prescription monitoring program data was 0.57 (95% confidence interval: 0.48-0.66). Common barriers to prescription monitoring program data use included time constraints and administrative burdens, low perceived value of prescription monitoring program data, and problems with prescription monitoring program system usability.

CONCLUSIONS

Our study found that health care providers underutilize prescription monitoring program data and that many barriers exist to prescription monitoring program data use.

Assessing the impact of Indiana legislation on opioid-based doctor shopping among Medicaid-enrolled pregnant women: a regression analysis

Background

States have passed various legislative acts in an attempt to reduce opioid prescribing and corresponding doctor shopping, including prescription drug monitoring programs. This study seeks to determine the association between two state-based interventions enacted in Indiana and the level of doctor shopping among Medicaid-enrolled pregnant women.

Methods

Indiana Medicaid claims data over the period of January 2014 to March 2019 were used in a regression model to determine the longitudinal change in percentage of pregnant women engaged in doctor shopping based on passage of Indiana Administrative Code Title 884 in 2014 and Public Law 194 in 2018. The primary reasons for prescribing were also identified.

Results

There were 37,451 women that had both pregnancy and prescription opioid claims over the time horizon. Of these, 2130 women met the criteria for doctor shopping. Doctor shopping continued to increase over the time between the passage of the two interventions but decreased after passage of Public Law 194.

Conclusion

The decrease in doctor shopping among Medicaid-enrolled pregnant women after passage of Public Law 194 points to the importance of addressing this issue across a broad set of healthcare professionals including nurse practitioners and physician assistants. It is also possible that the potential punitive component in the Law for non-compliance played a role.

Clinical decision making involving prescription drug monitoring programs: A factorial, vignette-based study among student pharmacists

OBJECTIVES

Prescription drug monitoring programs (PDMPs) are state-maintained databases that providers may reference when deciding to prescribe or dispense controlled substances. As more states begin to mandate PDMP use at the point of care, it is imperative to assess how pharmacists use PDMP information when determining whether to fill a controlled substance prescription (CSP). The objective of this study was to evaluate which factors affected fourth-year student pharmacists' decision to fill an opioid prescription, their level of confidence in their decision making, and familiarity with the PDMP.

METHODS

We used a 2⁴ factorial design to present a series of text-based vignettes to fourth-year student pharmacists. Each participant received 8 vignettes (5 randomly selected, 3 fixed), representing a hypothetical hydrocodone-acetaminophen combination prescription with varying levels of the following dichotomous factors: doctor shopping, dosage, pharmacy shopping, and concurrent benzodiazepine prescription. Participants were asked to decide whether or not they would fill each of the hypothetical prescriptions they received. A multilevel model was used to measure the association between each of the vignette factors, age, race, sex, experience with PDMP, and the decision to refuse to fill a prescription. Each vignette response served as an independent observation.

RESULTS

A total of 87 participants yielded 696 vignette responses. Participants were significantly more likely to refuse to fill prescriptions with doctor shopping (adjusted odds ratio [aOR] 19.86 [95% CI 10.78-36.58]), pharmacy shopping (6.78 [4.13-11.12]), dosage (1.83 [1.16-2.90]), or if the student pharmacist was of female sex (1.73 [1.02-2.93]). Concomitant benzodiazepine use was not associated with a no-fill decision (1.45 [0.92-2.27]).

CONCLUSION

This study reveals that student pharmacists' decision to fill a prescription is dependent on both prescription characteristics and a patient's CSP history. The importance of PDMP history cannot be downplayed and suggests that PDMP use may be effective in informing patient care decisions. Still, the variability in filling decision highlights the need to teach a formulaic approach to CSP dispensing in colleges of pharmacy.

A Rapid Review of the Impact of Systems-Level Policies and Interventions on Population-Level Outcomes Related to the Opioid Epidemic, United States and Canada, 2014-2018

OBJECTIVES

In the United States, rising rates of overdose deaths and recent outbreaks of hepatitis C virus and HIV infection are associated with injection drug use. We updated a 2014 review of systems-level opioid policy interventions by focusing on evidence published during 2014-2018 and new and expanded opioid policies.

METHODS

We searched the MEDLINE database, consistent with the 2014 review. We included articles that provided original empirical evidence on the effects of systems-level interventions on opioid use, overdose, or death; were from the United States or Canada; had a clear comparison group; and were published from January 1, 2014, through July 19, 2018. Two raters screened articles and extracted full-text data for qualitative synthesis of consistent or contradictory findings across studies. Given the rapidly evolving field, the review was supplemented with a search of additional articles through November 17, 2019, to assess consistency of more recent findings.

RESULTS

The keyword search yielded 535 studies, 66 of which met inclusion criteria. The most studied interventions were prescription drug monitoring programs (PDMPs) (59.1%), and the least studied interventions were clinical guideline changes (7.6%). The most common outcome was opioid use (77.3%). Few articles evaluated combination interventions (18.2%). Study findings included the following: PDMP effectiveness depends on policy design, with robust PDMPs needed for impact; health insurer and pharmacy benefit management strategies, pill-mill laws, pain clinic regulations, and patient/health care provider educational interventions reduced inappropriate prescribing; and marijuana laws led to a decrease in adverse opioid-related outcomes. Naloxone distribution programs were understudied, and evidence of their effectiveness was mixed. In the evidence published after our search's 4-year window, findings on opioid guidelines and education were consistent and findings for other policies differed.

CONCLUSIONS

Although robust PDMPs and marijuana laws are promising, they do not target all outcomes, and multipronged interventions are needed. Future research should address marijuana laws, harm-reduction interventions, health insurer policies, patient/health care provider education, and the effects of simultaneous interventions on opioid-related outcomes.

Factors influencing the inappropriate use of antibiotics in the Rupandehi district of Nepal

INTRODUCTION

Antimicrobial resistance is a global public health crisis. A major driver of resistance is inappropriate antibiotic use, resulting from practices of prescribers, dispensers and patients. The purpose of this study was to identify the perception of service providers and policymakers about the inappropriate use of antibiotics in Nepal.

METHODS

A qualitative study was conducted to explore factors influencing antibiotic use. Participants included 17 service providers and policymakers from the Rupandehi district in Nepal, with a semi-structured interview schedule adopted. Data were analysed using thematic analysis to identify themes relating to the inappropriate use of antibiotics.

RESULTS

Inappropriate use of antibiotics was found to result from the interaction of demand and supply factors, together with a weak regulatory environment. Lack of knowledge by consumers and financial constraints resulted in practices such as self-medication and pressure being placed on providers to prescribe or dispense antibiotics. An insufficient choice of antibiotics, and health services not having investigation facilities, was also factors leading to inappropriate use of antibiotics. Additionally, in the private sector, the profit motive arising from incentives provided by pharmaceutical companies contributed to prescribing or dispensing antibiotics inappropriately.

CONCLUSION

Promoting appropriate antibiotic use is critical to reduce the growing public health threat of antibiotic resistance. A multi-faceted approach involving policymakers, providers, and the general public using both educational and regulatory measures is required to address this problem in Nepal, and potentially also in other low-income countries with a similar healthcare system.

Development and reliability assessment of a tool to assess community pharmacist potential to influence prescriber performance on quality measures

OBJECTIVE

To develop and assess the reliability of a tool that measures community pharmacist potential to influence prescriber quality measure performance.

METHODS

Multidisciplinary, health care subject matter experts were convened to determine the criteria that evaluate the community pharmacist's ability to influence quality measure performance and a scoring mechanism. The draft tool was reviewed by investigators and subject matter experts in various health care professional settings to assess face validity and make refinements. Interrater reliability was assessed by 2 independent reviewers using a random 20% sample of the 2017 Merit-based Incentive Payment System (MIPS) measure set. Absolute agreement and kappa statistics were calculated, and the tool was iteratively refined based on the results. The tool was then applied to the full 2017 MIPS measure set by 2 reviewers, and interrater reliability was assessed.

RESULTS

The quality measure impact tool-community pharmacy (QMIT-CP) comprised 5 criteria, which assessed the quality measures of the community pharmacist's influence potential. The criteria evaluated whether the quality measures: (1) addressed the use of medications or immunizations; (2) included a condition treatable by medications; (3) treated patients in an outpatient setting; (4) included outcomes; and (5) evaluated whether relevant measure data were available to community pharmacists. All criteria used a dichotomous scale, and the summed scores were used to categorize the pharmacist's influence potential as "high" (4-5), "moderate" (2-3), or "low" (0-1). Kappa statistics ranged from "substantial agreement" (≥0.6) to "almost perfect agreement" (≥0.8) for individual QMIT-CP criteria and overall pharmacist influence potential categorization.

CONCLUSIONS

The QMIT-CP is a reliable tool to identify quality measures and assess the high, moderate, or low influence potential that community pharmacists may have. The QMIT-CP can be used to support innovative team-based care and enhance value-based contracting by identifying relevant measures that community pharmacists have the potential to influence.

Differences between pharmacists' perception of counseling and practice in the era of prescription drug misuse

Objective

This study was conducted to assess pharmacists' practices when counseling patients on their prescription medications, and their preferences for training.

Methods

Five focus group discussions of community pharmacists (n=45, with seven to eleven participants in each group) were conducted in a major metropolitan city in the southern United States. Participants were recruited via email using a list of community pharmacists provided by the Texas State Board of Pharmacy. All focus group discussions were structured using a moderator guide consisting of both discrete and open-ended questions. Qualitative analysis software was used to analyze the data with a thematic analysis approach.

Results

The participants in this study had a high self-efficacy regarding their ability to counsel on both new and opioid prescriptions. Many pharmacists experienced the same barriers to counseling and agreed on the components of counseling. However, the themes that emerged showed that the participants exhibited only a partial understanding of the components of counseling. The themes that emerged in the thematic analysis were perceived confidence and discordant counseling practices, inadequate infrastructure, lack of comprehensive counseling, inconsistent use of the Prescription Drug Monitoring Program (PDMP), and pharmacists' desired training/assistance.

Conclusions

Community pharmacists are in a unique position to help combat the opioid crisis; however, there has been very little research on the pharmacist-patient interaction in this context. With policy changes, such as the PDMP mandate, going into effect across the country, it is important to capitalize on the potential community pharmacists have in ameliorating the opioid crisis in the United States.

Impact of Iowa's Prescription Monitoring Program on Opioid Pain Reliever Prescribing Patterns: An Interrupted Time Series Study 2003-2014

OBJECTIVE

To evaluate the impact of Iowa's prescription monitoring program (PMP), implemented in 2009, on opioid pain reliever (OPR) prescribing patterns.

METHODS

We conducted interrupted time series analyses using 2003-2014 health insurance claims from a private health insurer in Iowa. OPR prescriptions for all beneficiaries were included. Another data set included only OPR prescription for new opioid users required to have six months of insurance coverage. We evaluate four OPR prescribing patterns: 1) average daily dosage in morphine milligrams equivalents (MME), 2) MME per prescription, 3) average days' supply per prescription, and 4) prescription rate per 1,000 insured person-years. We examined confounding and effect measure modification of the relationship between PMP and prescribing patterns by age and sex.

RESULTS

During the 12 years of follow-up, 1,512,388 insured Iowans contributed 6,169,634.92 person-years of follow-up. Of these, 505,274 patients filled 2,401,818 OPR prescriptions and 360,688 new OPR users filled as many first OPR prescriptions. The increasing trend of OPR prescription rates from 2003 to 2009 declined post-PMP. Similarly, there was a large decline in MME per day and MME per prescription. The OPR days' supply kept increasing post-PMP implementation, albeit at a slightly slower rate than pre-PMP implementation. There was no confounding by age and sex; however, we observed heterogeneity by age and sex; patients aged ≥50 years and females received higher doses and more prescriptions pre-PMP and experienced the greatest declines post-PMP.

CONCLUSIONS

Our study suggests that Iowa PMP implementation may have resulted in declines in OPR prescribing, and this impact varies by patient age and sex.

Doctors' perceptions, expectations and experience regarding the role of pharmacist in hospital settings of Pakistan

Background The inclusion of pharmacist in health care system is essential to ensure optimal patient care. However, with the passage of time, pharmacist's role has transcended from dispensing, compounding and counting of pills, to more sophisticated clinical duties. Objective To evaluate doctors' experience, perceptions and expectations regarding pharmacists' role in Pakistani healthcare settings. Setting All tertiary care hospitals across 26 cities of Pakistan. Method A cross-sectional study using a self-administered questionnaire was carried out targeting doctors practising in Pakistan. The survey was conducted from January to April 2018. Chi square (χ²) test was used to analyse responses of doctors regarding pharmacist's role in the healthcare system of Pakistan. The associations were considered significant at p value less than 0.05. The study was approved by concerned ethical committee. Main outcome measure Doctors' experience, perceptions and expectations regarding pharmacists' role. Results A total of 483 questionnaires were received and analysed (response rate; 87.9%). Most participants (67.5%) reported interaction with pharmacists at least once daily, and that was mostly related to drug availability inquiry (73.7%). 86.7% of doctors expected pharmacists to ensure safe and appropriate use of medicines to patients. 87.6% of doctors expected pharmacists to monitor patient's response to drug therapy (p < 0.05) and 66.5% expected pharmacists to review patient's medicines as well as discuss possible amendments to therapy (p < 0.05). Besides, most doctors (84.9%) disagreed with the notion of pharmacists prescribing medicine for patients (p < 0.05). Most participants (81.6%) did not want pharmacists to prescribe independently. Conclusion The study highlights that doctors considered pharmacists as drug information specialists, dispensers, educators and counsellors; however, their expectation of pharmacists performing the clinical role and being involved in direct patient care was limited. They negated the idea of prescription intervention and direct involvement of pharmacists in pharmacotherapy plan for patients. It is imparative  to increase doctors' awareness regarding the role pharmacists could play in Pakistan's healthcare system. Currently, the clinical role of pharmacists in Pakistan's healthcare system seems minimal and is seen with scepticism within the community of doctors.

Provider beliefs on the Barriers and Facilitators to Prescription Monitoring Programs and Mandated Use

Background: Underutilization of Prescription monitoring programs (PMP), especially in states where participation is voluntary could limit their impact against opioid epidemic. Objectives: To (1) examine PMP use among Iowa healthcare providers (HCPs); (2) identify factors prompting and impeding PMP use, and (3) assess beliefs toward mandating PMP use. Methods: A cross-sectional survey of Iowa HCPs was conducted using a 12-item questionnaire. Survey domains include demographics, current PMP utilization, conditions and barriers associated with PMP use, and perspectives on use mandates. Analyses were based on descriptive statistics, proportional odds and poisson regression models. Results: There were 704 usable responses. Almost all respondents were registered with the PMP with dentists having the lowest rate (p < .001). Nurse practitioners consulted the PMP for the largest proportion of prescriptions, while pharmacists and dentists used significantly less (p < .001). Lack of time was the most common reported barrier impeding PMP use. Red flag behaviors and unfamiliarity with patient were the most common conditions prompting PMP review. HCPs estimated their use of the PMP would significantly increase if integrated into their electronic health records (p < .001). Almost half of HCPs held the opinion that PMP use should never be mandated, although inter-provider variation was present with nurse practitioners most amenable to mandates. Discussion: HCPs displayed variation in PMP use. EMR integration appears to be a strategy for increasing PMP use. There was resistance to mandating PMP use for all controlled substances prescribed and dispensed, with some interest in mandates for new patients only or new controlled substance prescriptions only.

Opioid prescribing patterns after dental visits among beneficiaries of Medicaid in Washington state in 2014 and 2015

BACKGROUND

Dentists contribute to the prevailing opioid epidemic in the United States. Concerning the population enrolled in Medicaid, little is known about dentists' opioid prescribing.

METHODS

The authors performed a retrospective cohort study of beneficiaries of Medicaid in Washington state with dental claims in 2014 and 2015. The primary outcome was the proportion of dental visits associated with an opioid prescription. The authors categorized visits as invasive or noninvasive by using procedure codes and each beneficiary as being at low or high risk by using his or her prescription history from the prescription drug monitoring program.

RESULTS

A total of 126,660 (10.3%) of all dental visits, most of which were invasive (66.9%), among the population enrolled in Medicaid in Washington state was associated with opioid prescriptions. However, noninvasive dental visits and visits for beneficiaries who had prior high-risk prescription use were associated with significantly higher mean days' supply and mean quantity of opioids prescribed. Results from the multivariate logistic regression showed that the probability of having an opioid-associated visit increased by 35.6 percentage points when the procedures were invasive and by 11.1 percentage points when the beneficiary had prior high-risk prescription use.

CONCLUSIONS

This baseline of opioid prescribing patterns after dental visits among the population enrolled in Medicaid in Washington state in 2014 and 2015 can inform future studies in which the investigators examine the effect of policies on opioid prescribing patterns and reasons for the variability in the dosage and duration of opioid prescriptions associated with noninvasive visits.

PRACTICAL IMPLICATIONS

Dentists must exercise caution when prescribing opioids during invasive visits and to patients with prior high-risk prescription use.

Pharmacist Services in the Opioid Crisis: Current Practices and Scope in the United States

Introduction: Pharmacist roles promoting safe opioid use are recognized in literature and practice. Pharmacists can offer services such as counseling on opioid risks, naloxone dispensing, education on opioid storage and disposal, prescription drug monitoring program (PDMP) utilization, opioid deprescribing, and providing resources for addiction treatment to help mitigate the opioid crisis. Objective: This commentary seeks to describe current and potential roles for pharmacists to combat the United States opioid crisis and identify key factors affecting service provision. Methods: The paper summarizes evidence-based studies describing current pharmacist roles and services, factors affecting service implementation, and strategies to further improve pharmacist roles and services related to promoting safe opioid use for patients. Results: Pharmacists recognize their roles and responsibilities to counsel patients on opioid risks, dispense naloxone, educate on opioid storage and disposal, utilize prescription drug monitoring programs (PDMPs), offer opioid deprescribing, and provide resources for addiction treatment. However, pharmacists express low confidence, time, and training as barriers to service provision. This suggests a need for structured training, resources, and organizational support for pharmacists to improve confidence and participation in such services. Conclusions: Although pharmacists are aware of roles and responsibilities to help reduce the opioid crisis, more training, education, organizational support and resources are needed to increase their ability to embody these roles.

Utilization of prescription drug monitoring programs for prescribing and dispensing decisions: Results from a multi-site qualitative study

BACKGROUND

Prescription drug monitoring programs (PDMPs) track the dispensing of prescription-controlled substances with the goal of mitigating misuse and diversion. Authorized users query the PDMP for controlled substance prescription histories at the point of care. Despite widespread implementation of PDMPs, there is much not known about how PDMPs influence prescribing and dispensing decisions.

OBJECTIVES

The objective of this study was to investigate how primary care providers (PCPs) and pharmacists utilize PDMPs when making prescribing and dispensing decisions.

METHODS

Data from in-depth, qualitative interviews with PCPs (n = 48) and community pharmacists (n = 60) across four states- Arkansas, Idaho, Kentucky, and Washington were analyzed for themes around PDMP use.

RESULTS

Both PCPs and pharmacists reported that PDMPs are key tools for aiding prescribing and dispensing decisions. PCPs reported variable use of PDMPs with most querying the PDMP when there are "red flags" and fewer reporting having clinic policies that direct PDMP use. Primary care providers in Kentucky reported more consistent and routine use of the PDMP as a result of a state law that mandates query prior to the initial prescribing of Schedule II controlled substances. Community pharmacists practicing in chain pharmacies reported formal policies requiring PDMP query prior to dispensing opioids, while utilization of PDMPs by pharmacists practicing in independently-owned pharmacies was more variable. Pharmacists and PCPs reported barriers to PDMP use, such as having to "log in on a separate machine" and perceived that PDMP utility could be improved by integrating it within pharmacy dispensing systems and electronic health records.

CONCLUSIONS

Pharmacists and PCPs reported the importance of PDMP information to aid their prescribing and dispensing decisions. Efforts to enhance state PDMP programs should consider processes that seamlessly integrate all available controlled substance prescription history for a given patient at the point of care so that PDMP utility for prescribing and dispensing decisions is maximized.

Perception of prescription drug monitoring programs as a prevention tool in primary medical care

BACKGROUND

Prescription drug monitoring programs (PDMPs) are primary prevention tools to reduce substance use disorders (SUD) and sequelae. Evidence regarding perceptions of PDMPs from different primary care providers, which may impact PDMP utilization for women, is unavailable.

OBJECTIVE

To examine perceived PDMP effectiveness among obstetrician-gynecologists (OB/GYNs) compared to primary care physicians (PCPs).

METHODS

Independent surveys of PDMP users in Florida, Kentucky, and California were evaluated based on a Likert-type item to assess perception of PDMP effectiveness in reducing prescription drug abuse and diversion. Response distributions of OB/GYNs versus PCPs were compared using chi-square tests.

RESULTS

In Florida, there were 41 OB/GYN and 511 PCP respondents; Kentucky, 46 OB/GYNs and 265 PCPs; and California, 41 OB/GYNs and 162 PCPs. In each state OB/GYNs viewed PDMPs as less effective, positive, or useful compared to PCPs (p ≤ 0.01, all states): Florida: 64.1% OB/GYN vs. 83.7% PCP "agree positive impact"; Kentucky: 45.0% OB/GYN vs. 68.5% PCP "effective". California: 73.2% OB/GYN vs. 86.4% PCP "useful".

CONCLUSIONS

These results suggest OB/GYNs view their state's PDMP as less effective than do PCPs, which may present barriers to PDMP utilization and decrease opportunities for SUD interventions. Engagement of all healthcare team members is needed to inform future strategies and policies to increase PDMP effectiveness.

Psychosocial Correlates of Clinicians' Prescription Drug Monitoring Program Utilization

INTRODUCTION

The purpose of this study is to extend prior research on barriers to use of a prescription drug monitoring program by examining psychosocial correlates of intended use among physicians and pharmacists.

METHODS

Overall, 1,904 California physicians and pharmacists responded to a statewide survey (24.1% response rate) from August 2016 to January 2017. Participants completed an online survey examining attitudes toward prescription drug misuse and abuse, prescribing practices, prescription drug monitoring program design and ease of use, professional obligations, and normative beliefs regarding prescription drug monitoring program use. Data were analyzed in 2017.

RESULTS

Perceived prescription drug monitoring program usefulness and normative beliefs fully mediated the relationship between concern about prescription drug abuse and intentions to use the prescription drug monitoring program. Clinicians' sense of professional and moral obligation to use the prescription drug monitoring program was unrelated to intention to use the prescription drug monitoring program despite a positive relationship with concern about misuse and abuse. Compared with physicians, pharmacists reported greater concern about prescription drug misuse, greater professional and moral obligation to use prescription drug monitoring program, and greater rating of prescription drug monitoring program usefulness.

CONCLUSIONS

Interventions that target normative beliefs surrounding prescription drug monitoring program use and how to use prescription drug monitoring programs effectively are likely to be more effective than those that target professional obligations or moralize to the medical community.

Pharmacist contributions to the ten essential services of public health in three National Association of Boards of Pharmacy regions

BACKGROUND

Pharmacists have contributed to improved population health through the delivery of public health services, but their contributions often go unrecognized within the larger health care system.

OBJECTIVES

To determine pharmacist perceptions of their contributions to the 10 essential services of public health and to compare those contributions among pharmacists in Iowa, North Dakota, and Manitoba.

METHODS

Licensed pharmacists in Iowa, North Dakota, and Manitoba were sent an online survey of their perceived level of achievement of the 10 essential services of public health.

RESULTS

A total of 649 pharmacists completed the survey. The 3 essential services that scored the highest overall were enforce laws and regulations that protect health and ensure safety, inform and educate people about health issues, and participate in ongoing training beyond continuing education requirements. Contributions of pharmacists to the 10 essential services of public health were previously evaluated by frequency of citation in the published literature. There was relative agreement between what was reported in the literature and what was determined by survey. One exception was "enforce laws and regulations that protect health and ensure safety," which was rarely reported in the literature but was reported in the survey to be the most frequently delivered service.

CONCLUSION

Pharmacist contributions to improved population health should be reported with the use of the 10 essential services of public health. This will increase recognition of pharmacist contributions and better align the disciplines of pharmacy and public health. In particular, pharmacists should consider ways to increase their level of involvement in the community and in partnership with other health care professionals.