A Primary Prevention Approach to the Opioid Epidemic

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.

Toxicology Test Results for Public Health Surveillance of the Opioid Epidemic: Retrospective Analysis

Background

Addressing the opioid epidemic requires timely insights into population-level factors, such as trends in prevalence of legal and illegal substances, overdoses, and deaths.

Objective

This study aimed to examine whether toxicology test results of living individuals from a variety of sources could be useful in surveilling the opioid epidemic.

Methods

A retrospective analysis standardized, merged, and linked toxicology results from 24 laboratories in Marion County, Indiana, United States, from September 1, 2018, to August 31, 2019. The data set consisted of 33,787 Marion County residents and their 746,681 results. We related the data to general Marion County demographics and compared alerts generated by toxicology results to opioid overdose-related emergency department visits. Nineteen domain experts helped prototype analytical visualizations. Main outcome measures included test positivity in the county and by ZIP code; selected demographics of individuals with toxicology results; and correlation of toxicology results with opioid overdose-related emergency department visits.

Results

Four percent of Marion County residents had at least 1 toxicology result. Test positivity rates ranged from 3% to 19% across ZIP codes. Males were underrepresented in the data set. Age distribution resembled that of Marion County. Alerts for opioid toxicology results were not correlated with opioid overdose-related emergency department visits.

Conclusions

Analyzing toxicology results at scale was impeded by varying data formats, completeness, and representativeness; changes in data feeds; and patient matching difficulties. In this study, toxicology results did not predict spikes in opioid overdoses. Larger, more rigorous and well-controlled studies are needed to assess the utility of toxicology tests in predicting opioid overdose spikes.

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.

Evaluation of a Program to Screen Patients in Community Pharmacies for Opioid Misuse and Accidental Overdose

Introduction

Community pharmacies nationwide have adopted new strategies to combat the opioid epidemic. One strategy to prevent opioid misuse and accidental overdose is patient screening to identify those at risk. The purpose of our study was to determine whether such screening in community pharmacies led pharmacy personnel to intervene with patients at risk and to describe the proportion of patients they identified as at risk.

Methods

We implemented the Opioid and Naloxone Education (ONE) program in North Dakota to give community pharmacies and pharmacists training and tools to provide preventive screening for opioid misuse and accidental overdose before dispensing a prescribed opioid. Data were collected and analyzed from September 15, 2018, through May 15, 2021, to evaluate overall patient risk characteristics for opioid misuse and accidental overdose.

Results

Of 8,217 patients screened, 3.9% were identified as at high risk for opioid misuse, and 18.3% at risk for accidental overdose. Nearly 1 of 3 screenings (31.7%) indicated opioid medication use in the past 60 days. Pharmacists delivered 1 or more risk-factor–dependent interventions to 41.1% of patients in the study. Following screening, naloxone dispensing in pharmacies increased to 6 times the national average.

Conclusion

Pharmacy-based patient screening for risk of opioid misuse and accidental overdose led to risk-dependent interventions targeted to individual patients. The tools and risk-dependent interventions applied in the ONE program increased patient awareness of opioid risks and ways to reduce risk. Future studies should examine long-term outcomes, including reduction in overdose, treatment of opioid use disorder, and reduced opioid-related acute care.

It Is Time to Implement Primary Prevention in the Workplace to Ameliorate the Ongoing U.S. Opioid Epidemic

The United States' opioid public health crisis continues having disastrous consequences on communities, including workers and employers. From May 2019 to May 2020, the largest number of drug overdose deaths was recorded over a twelve-month period. The "twindemics" of COVID-19 and opioids underscore the urgent need to address workers' physical and mental health. Although much has been written about the negative impacts of the opioid epidemic on the workplace, few initiatives have focused on primary prevention, addressing work-related root causes of opioid use disorders (e.g., injury, stress) that may lead to prescription or illicit opioid use. We suggest primary prevention efforts to address the connection between workplace hazards and opioid misuse, dependence, and addiction such as examining patterns of work injury and stress with records of opioid prescription. Government funding should be expanded to support primary prevention and research efforts to strengthen the evidence-base to support workplace primary prevention endeavors.

Primary prevention of prescription opioid diversion: a systematic review of medication disposal interventions

Background: In the U.S., 50-75% of nonmedical users of prescription opioids obtain their pills through diversion by friends or relatives. Increasing disposal of unused opioid prescriptions is a fundamental primary prevention strategy in combatting the opioid epidemic.Objectives: To identify interventions for disposal of unused opioid pills and assess the evidence of their effectiveness on disposal-related outcomes.Methods: A search of four electronic databases was conducted (October 2019). We included all empirical studies, systematic literature reviews, and meta-analyses about study medication disposal interventions in the U.S. Studies of disposal interventions that did not include opioids were excluded. We abstracted data for the selected articles to describe the study design, and outcomes. Further, we assessed the quality of each study using the NIH Study Quality Assessment Tools.Results: We identified 25 articles that met our inclusion criteria. None of the 13 studies on drug take-back events or the two studies on donation boxes could draw conclusions about their effectiveness. Although studies on educational interventions found positive effects on knowledge acquisition, they did not find differences in disposal rates. Two randomized controlled trials on drug disposal bags found higher opioid disposal rates in their intervention arms compared to the control arms (57.1% vs 28.6% and 33.3%, p = .01; and 85.7% vs 64.9%, p = .03).Conclusions: Peer-reviewed publications on opioid disposal interventions are limited and either do not address effectiveness or have conflicting findings. Future research should address these limitations and further evaluate implementation and cost-effectiveness.

Methocinnamox (MCAM) antagonizes the behavioral suppressant effects of morphine without impairing delayed matching-to-sample accuracy in rhesus monkeys

RATIONALE

Opioid abuse remains a serious public health problem. The pseudoirreversible mu opioid receptor antagonist methocinnamox (MCAM) might be useful for treating opioid abuse and overdose. Because endogenous opioid systems can modulate cognition and decision-making, it is important to evaluate whether long-term blockade of mu opioid receptors by MCAM adversely impacts complex operant behavior involving memory.

OBJECTIVE

This study tested the effects of MCAM in rhesus monkeys responding under a delayed matching-to-sample task, with correct responses reinforced by sucrose pellets. Because MCAM did not alter performance, antagonism of the rate-decreasing effects of morphine was used to confirm that an effective dose of MCAM was administered. Moreover, the muscarinic receptor antagonist scopolamine and the N-methyl-D-aspartate antagonist phencyclidine were studied as positive controls to demonstrate sensitivity of this procedure to memory disruption.

RESULTS

Neither MCAM (0.32 mg/kg) nor morphine (1-5.6 mg/kg) impaired delayed matching-to-sample accuracy. Morphine dose-dependently decreased the number of trials completed before MCAM administration, and a single injection of MCAM blocked the behavioral suppressant effects of morphine for at least 7 days. Scopolamine (0.01-0.056 mg/kg) and phencyclidine (0.1-0.56 mg/kg) dose-dependently decreased delayed matching-to-sample accuracy and the number of trials completed.

CONCLUSIONS

MCAM did not impair memory (as measured by accuracy in a delayed matching-to-sample task) and did not decrease responding for or consumption of sucrose pellets. This dose of MCAM attenuates self-administration of opioids and reverses as well as prevents opioid-induced respiratory depression. These results provide further support for a favorable adverse effect profile for MCAM.

Opioid Misuse and Overdose: Changes in Pharmacist Practices and Outcomes

BACKGROUND

Continuing education (CE) provides educational opportunities for health professionals to adequately respond to issues in practice but infrequently evaluate sustained practice change. The opioid epidemic has risen to the forefront of health priorities in our nation. The Opioid and Naloxone Education (ONE Rx) CE program provides pharmacists the opportunity to expand their abilities and impact in the opioid crisis.

METHODS

ONE Rx CE included risk assessment for opioid misuse/overdose, role of naloxone, disease of addiction, and communication strategies for patients and providers. Pharmacists who completed the CE screened patients and provided interventions over 12 months. CE participants were provided presurveys, postsurveys, and delayed postsurveys coordinated with the educational program. The Kirkpatrick Model was used to evaluate the effectiveness of the program by examining the four levels of assessment: reaction, commitment, behavior, and results.

RESULTS

The Kirkpatrick Model was used to evaluate the impact of the CE. Reaction: 97% of respondents recommended the ONE Rx program. Commitment: 77% of respondents indicated commitment to provide ONE Rx opioid risk screening and interventions to patients. Behavior: Twelve months after training, pharmacists registered to prescribe naloxone increased by 67% and the number of pharmacists reporting naloxone dispensing doubled from 23% to 46%.

OUTCOMES

Pharmacist interventions included medication take back programs explained (88.4%), naloxone dispensing to high-risk patients (10.9%), and discussion of opioid use disorder with patients with risk factors (49%).

CONCLUSION

By using the Kirkpatrick Model, the ONE Rx CE program demonstrated high-quality opioid and naloxone education to pharmacists. Survey results and opioid harm reduction interventions indicate the CE resulted in sustained pharmacy practice behavior change.