How prepared are pharmacists to provide over-the-counter naloxone? The role of previous education and new training opportunities

Pharmacists' use of guidelines for the supply of non-prescription medicines: a cross-sectional survey

OBJECTIVES

Guidelines support best practice for healthcare practice. In Australia, some non-prescription medicines are only accessible after consultation with a pharmacist and are known as Pharmacist Only medicines. Guidelines for providing some Pharmacist Only medicines are available, however, it is currently unknown if and how these guidelines are used in practice.The objective was to characterise pharmacists', intern pharmacists and pharmacy students' use of guidelines for Pharmacist Only medicines.

METHODS

A cross-sectional electronic survey of Australian registered pharmacists, intern pharmacists and pharmacy students was administered in July 2020. Questions explored the participants' use of Pharmacist Only medicine guidelines (available both in print and online; available online only) in the preceding 12 months. Data were analysed descriptively (i.e. frequencies, percentages).

KEY FINDINGS

In total, 574 eligible respondents completed the survey. Overall, 396 (69%) reported accessing the online and in-print guidelines in the previous 12 months with 185 (33%) accessing online-only guidelines. The guideline on emergency contraception was used the most out of all guidelines in the past 12 months (278, 48%). Overall, respondents reported accessing guidelines to update knowledge, check their practice reflected best practice and content familiarisation. Respondents' reasons for not accessing guidelines were due to respondents stating they did not need the information or that they had previously accessed the guidelines more than 12 months ago. These reasons varied between respondent groups.

CONCLUSIONS

Access and use of the Pharmacist Only medicines guidelines varied between pharmacists, interns and students. Further understanding of the influences of the use of these guidelines will help inform professional bodies on how best to develop guidelines to increase consistent use in practice and implement interventions to increase use.

Developing a single-session strategy for the implementation of take-home naloxone by community pharmacists using COM-B and design-thinking

Background

Despite the overwhelming evidence of its effectiveness, there is poor implementation of take-home naloxone by pharmacists. Barriers have been explored and mapped to the capability, opportunity, motivation-behaviour (COM-B) model of behaviour change, yet no theoretically informed implementation strategies that target known barriers have been developed. Single-session implementation strategies have been proposed as a simple, scalable way to target multiple barriers.

Methods

Qualitative participatory methods, incorporating design-thinking principles, were used to develop the key messages of a single-session implementation strategy. The key messages were drafted against COM-B mapped implementation barriers identified in the literature. A participatory workshop involving a pre-mortem exercise and incorporating design-thinking principles were used to refine the messages and generate methods for dissemination. Messages were mapped to interview questions to naturally illicit stories and delivered via storytelling from a pharmacist, a general practitioner, and a person with lived experience of using naloxone.

Results

A 3 minute 40 second video and a two-page printable infographic were developed and hosted on a website, with links to additional downloadable resources as a single-session implementation strategy. Email was the preferred method for receiving simple professional development communications, with social media also widely accessed.

Discussion

Implementation science, behavioural change theory, and participatory design methods are a complementary combination to develop implementation strategies. Some pharmacists questioned the participatory design approach to developing an implementation strategy, as it was outside of their comfort zone. However, the participatory process involving end-users resulted in unique ideas that are unlikely to have been generated using more traditional consultative approaches. The delivery as a single-session implementation strategy allows for widespread dissemination and delivery at scale.

Expanding naloxone education in the doctor of pharmacy curriculum

INTRODUCTION

Pharmacists are well-positioned to provide patients with access to the opioid-induced breathing emergency reversal agent naloxone, but many do not feel they have received adequate training to do so. The purpose of this project was to develop, implement, and evaluate an enhanced teaching approach to naloxone education in the doctor of pharmacy (PharmD) curriculum.

METHODS

The educational intervention incorporated active learning, technology, and interprofessional education components. Surveys were developed and administered pre-intervention and at one-week, six-month, and one-year post-intervention to evaluate changes in knowledge, perceptions, and confidence in clinical skills related to opioid-induced breathing emergencies and naloxone.

RESULTS

After participating, students' confidence (rated 0 to 5) in their ability to administer both intranasal (2.54 vs. 4.37, P < .001) and intramuscular (IM) (2.8 vs. 4.02, P < .001) naloxone increased, which was reflected in their improved performance on an opioid-induced breathing emergency simulation activity. Students ≤25 years old and females experienced significantly greater increases in their confidence to administer IM naloxone than those >25 years old and male. Most of these effects persisted at six months and one-year post-intervention.

CONCLUSIONS

The educational intervention increased pharmacy students' skills and confidence related to opioid-induced breathing emergency and naloxone. Improvements observed were in line with results of similar pedagogical studies. Age and gender differences in self-reported confidence levels also reflected previously reported findings. Materials and methods have been made available for other PharmD programs to utilize in expanding their curricula in these areas.

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.

Geographic variation in the provision of naloxone by pharmacies in Ontario, Canada: A population-based small area variation analysis

BACKGROUND

Regional variation in pharmacy-dispensed naloxone rates could create access disparities that undermine the effectiveness of this approach. We explored individual and public health unit (PHU)-level determinants of regional variation in naloxone distribution through the Ontario Naloxone Program for Pharmacies.

METHODS

We conducted a population-based study between April 1, 2017 and March 31, 2018. We calculated age- and sex-standardized pharmacy-dispensed naloxone rates for the 35 Ontario PHUs, and identified determinants of these rates using generalized estimating equations negative binomial regression.

RESULTS

The age- and sex-standardized pharmacy-dispensed naloxone rate in Ontario was 5.5 (range 1.8-11.6) kits per 1000 population. Variables associated with higher naloxone dispensing rates included opioid use disorder history [rate ratio (RR) 2.27; 95% confidence interval (CI) 1.75-2.96], opioid agonist therapy (RR 11.17; 95% CI 7.15-17.44), and PHU opioid overdose rate (RR 1.09 per 10 deaths; 95% CI 1.06-1.13). Pharmacy-dispensed naloxone rates were lower in rural areas (RR 0.83; 95% CI 0.73-0.94) and among individuals dispensed one (RR 0.72; 95% CI 0.65-0.79), two to five (RR 0.67; 95% CI 0.54-0.84) or 6-10 (RR 0.92; 95% CI 0.74-1.14) opioids in the prior year relative to those receiving no opioids.

CONCLUSION

Pharmacy-dispensed naloxone programs are important components of a public health response to the opioid overdose crisis. We found considerable variation in pharmacy-dispensed naloxone rates that could limit program effectiveness, particularly in rural settings with limited access to health and harm reduction services..

Addiction stigma and the production of impediments to take-home naloxone uptake

Opioid overdose deaths are a major health issue in Australia and around the world. Programmes to provide opioid consumers with 'take-home' naloxone to reverse overdose exist internationally, but uptake by mainstream health services and consumers remains inconsistent. Researchers have identified a range of important educational, training and logistical impediments to take-home naloxone uptake and distribution, yet they have focused less on the social dynamics that can enhance or limit access, such as stigma. In this article, we also explore impediments to uptake, drawing on qualitative interview data gathered for an Australian research project on take-home naloxone. Mobilising a performative approach to stigma, we argue that overdose and prevention are shaped by the social dynamics of stigma and, as such, responsibility for dealing with overdose, as with take-home naloxone, should also be considered social (i.e. shared among peers, the public, communities and governments). Our interview data illuminate the various ways in which addiction stigma limits the possibilities and capacities of take-home naloxone and overdose prevention. First, we focus on how stigma may impede professional information provision about take-home naloxone by limiting the extent to which it is presented as a matter of interest for all opioid consumers, not just those who consume opioids illicitly. Second, we explore how stigma may limit the scale-up and expansion of programmes and access points. From here, we focus on how stigma co-constitutes the politics of overdose and prevention, rendering take-home naloxone ill-suited to many social settings of overdose. In closing, we point out that stigma is not just a post hoc impediment to access to and use of take-home naloxone but is central to opioid overdose production itself, and to effective prevention. While take-home naloxone is an excellent life-saving initiative, uncritically valorising it may divert attention from broader goals, such as the de-stigmatisation of drug consumption through decriminalisation, and other ambitious attempts to reduce overdose.

What predicts pharmacists' engagement with opioid-outcome screening? Secondary analysis from an implementation study in community pharmacy

Background Pharmacists have a key role to play in identifying and responding to emerging clinical problems with prescribed opioids. A pilot study in Australia examined the implementation of screening and brief intervention (Routine Opioid Outcome Monitoring [ROOM]) to identify and respond to opioid-related problems in community pharmacies. In this implementation study, the rate of screening varied considerably between pharmacies. Objective The aim of this study was to examine pharmacist characteristics associated with implementation of ROOM. Setting Community pharmacies in Victoria and New South Wales, Australia. Methods We implemented a validated computer-facilitated screening (ROOM), combined with brief intervention for opioid-related problems based on a widely accepted framework for monitoring outcomes. In this analysis, we examined the correlates of ROOM completion for individual pharmacists. Negative binomial regression was used to identify baseline predictors of greater screening, with the number of ROOM screens as the dependent (outcome) variable and pharmacist demographics, knowledge, confidence and comfort responding to prescription opioids problems, and attitudes towards evidence based practice examined as independent (predictor) variables. Main outcome measure Number of screens completed by an individual pharmacist as reported in follow-up surveys by pharmacist. Results Fewer years of practice was associated with a greater number of screenings conducted. On average, each additional decade of practice was associated with a 31% (95% CI 0%, 53%) reduction in the number of screenings undertaken by pharmacists. A multivariable analysis revealed that each additional decade practicing, lower knowledge of naloxone and lower confidence in identifying unmanaged pain were all independently associated with reduced engagement in screening after controlling for other variables. Conclusion Findings from this pilot study identified potential barriers to implementing opioid outcome monitoring. Further studies could test different groups of community pharmacists' experience of different barriers when implementing monitoring outcomes with prescribed opioids, to inform future implementation and clinical practice.

Pharmacy: Addressing substance use in the 21st century

Across all care environments, pharmacists play an essential role in the care of people who use and misuse psychoactive substances, including those diagnosed with substance use disorders. To optimize, sustain, and expand these independent and collaborative roles, the Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA) has developed core competencies for pharmacists to address substance use in the 21st century. Key concepts, skills, and attitudes are outlined, with links to entrustable professional activities to assist with integration into a variety of ideally interdisciplinary curricular activities.

Impact of the take ACTION Train-the-Trainer model of opioid overdose education with naloxone distribution- who benefits?

BACKGROUND

Overdose education with naloxone distribution (OEND) is a key national strategy to reduce morbidity and mortality related to opioid overdoses. Train-the-trainer model has been one method to increase the pool of trainers to facilitate greater dissemination of OEND. This exploratory study seeks to (1) evaluate participant's change in knowledge and confidence, (2) examine if pre- and post-training test outcomes differed by occupation and level of experience, and (3) determine if train-the-trainer participants trained others 6 months later. Methods: Fifteen train-the-trainer sessions were delivered to staff from community organizations who served high-risk clients in four counties whose overdose death rates ranged from 11.2 to 32.8 per 100,000. Participants were administered pre- and post-training tests from September 2017 to December 2018. A follow-up survey was conducted 6 months post-training to evaluate outcomes. Final paired pre-and post-training surveys of 109 participants were used for analysis. Paired sample t-tests were used to evaluate changes in the knowledge and confidence in teaching others. One-way ANOVA compared the change scores across groups with different demographic or experiential characteristics. Kruskal-Wallis Test was used for Likert scales. Results: The one and one-half hour train-the-trainer curriculum increased participants' knowledge and confidence to teach others (p < .001). This was particularly true for participants who had no prior experience compared to those who had some experience with naloxone (p = .0003). Changes in confidence to teach others significantly improved among demographic subgroups of participants. At 6 months after completing the train-the-trainer curriculum, 14 participants had trained 243 new trainees. Conclusions: Implementing a train-the-trainer model for OEND increases knowledge and participants' confidence to teach others. This demonstrates the important potential of the train-the-trainer model to respond to the growing opioid overdose epidemic.