State laws that authorize pharmacists to prescribe naloxone are associated with increased naloxone dispensing in retail pharmacies

Naloxone Dispensing to Youth Ages 10-19: 2017-2022

BACKGROUND AND OBJECTIVES

Naloxone is lifesaving in the event of an opioid overdose but is underutilized in adolescents. Youth-serving clinicians can play a role in expanding naloxone access by offering it to all youth at risk for opioid-involved overdose, including by prescription. Understanding naloxone dispensing trends to youth can inform efforts to expand its use.

METHODS

We used IQVIA National Prescription Audit Patient Insights data, which contains prescriptions dispensed from ∽48 900 retail pharmacies, representing 93% of all prescriptions from all payers in the United States. Cross-sectional analyses were used to describe naloxone dispensing trends among youth ages 10 to 19 years over time and by patient sex, out-of-pocket cost, prescriber specialty, and payer.

RESULTS

From 2017 to 2022, 59 077 prescriptions for naloxone were dispensed to youth ages 10 to 19. Dispensing rates increased 669%, from 6.6 to 50.9 prescriptions per 100 000 adolescents, with increases each year. Dispensing varied by specialty and sex. Pediatricians accounted for an increasing proportion of prescriptions dispensed with a 6-year increase of 991%. Seventy-four percent of prescriptions were paid through commercial insurance. Although most prescriptions dispensed had low to 0 cost-sharing, 20% had out-of-pocket costs exceeding $25, and over 6% had out-of-pocket costs exceeding $75.

CONCLUSIONS

Pediatricians and other youth-serving clinicians can play an important role in expanding access to naloxone and harm reduction information by prescribing naloxone to all youth who are at risk for overdose. Clinician prescribing of naloxone can augment community distribution and over-the-counter access by making naloxone more widely available at all touchpoints with the health care system.

Investigating the complexity of naloxone distribution: Which policies matter for pharmacies and potential recipients

Despite efforts to expand naloxone access, opioid-related overdoses remain a significant contributor to mortality. We study state efforts to expand naloxone distribution through pharmacies by reducing the non-monetary costs to prescribers, dispensers, and/or potential recipients of naloxone. We find that laws that only address liability costs have small and insignificant effects on the volume of naloxone dispensed through pharmacies. In contrast, we estimate large effects of laws removing the need for patients to obtain prescriptions from traditional prescribers (e.g., primary care physicians): laws authorizing non-patient-specific prescription distribution and laws granting pharmacists prescriptive authority. We test whether areas designated as primary care shortage areas-where it would be costlier to obtain a prescription-were disproportionately impacted. Shortage areas experienced sharper growth in pharmacy naloxone dispensing in states adopting prescriptive authority policies. These gains were primarily due to those facing low out-of-pocket costs, suggesting that price barriers also must be addressed to increase naloxone purchases.

The association between naloxone claims and proportion of independent versus chain pharmacies: A longitudinal analysis of naloxone claims in the United States

BACKGROUND

Expanding access to naloxone through pharmacies is an important policy goal. Our objective was to characterize national county-level naloxone dispensing of chain versus independent pharmacies.

METHODS

The primary exposure in our longitudinal analysis was the proportion of chain pharmacies in a county, identified through the U.S. Department of Homeland Security 2010 Infrastructure Foundation-Level Data. We defined counties as having "higher proportion" of chain pharmacies if at least 50% of pharmacies were large national chains. The primary outcome was quarter-year (2016Q1-2019Q2) rate of pharmacy naloxone claims per 100,000 persons from Symphony Health at the county level. We compared the naloxone dispensing rate between county types using 2-sample t tests. We estimated the association between county-level chain pharmacy proportion and rate of naloxone claims using a linear model with year-quarter fixed effects.

RESULTS

Nearly one-third of counties (n = 946) were higher proportion. Higher proportion counties had a significantly higher rate of naloxone claims across the study period, in 4 of 6 urban-rural classifications, and in counties with and without naloxone access laws (NALs). The linear model confirmed that higher proportion counties had a significantly higher rate of naloxone claims, adjusting for urban-rural designation, income, population characteristics, opioid mortality rate, coprescribing laws, and NALs.

CONCLUSION

In this national study, we found an association between naloxone dispensing rates and the county-level proportion of chain (vs. independent) pharmacies. Incentivizing naloxone dispensing through educational, regulatory, or legal efforts may improve naloxone availability and dispensing rates-particularly in counties with proportionately high numbers of independent pharmacies.

The accessibility of pharmacist prescribing and impacts on medicines access: A systematic review

BACKGROUND

Pharmacist prescribing has been introduced in several countries as a strategy to improve access to health care and medicines. However, the direct impacts of pharmacist prescribing on medicines access, and the overall accessibility of pharmacist prescribing services, are not well known.

OBJECTIVES

This systematic review aimed to assess the direct impacts of pharmacist prescribing on medicines access, and the accessibility of pharmacist prescribing services, in community and primary care settings.

METHODS

PubMed, Embase, and CINAHL were searched for studies published in English between 01 January 2003 to 15 June 2023. Both quantitative and qualitative primary studies were included if they described pharmacist prescribing in a primary care setting. Outcomes included findings related to access to medicines as a result of pharmacist prescribing (primary outcome), and access to pharmacist prescribing services overall (secondary outcome). Narrative synthesis of outcomes was undertaken.

RESULTS

A total of 47 studies were included from four countries (United States, United Kingdom, Canada, New Zealand). Thirteen studies provided evidence that pharmacist prescribing may improve medicines access in several ways, including: increasing the proportion of eligible people receiving medicines, increasing the number of overall dispensed prescriptions, or reducing time to receipt of treatment. The remainder of the included studies reported on the accessibility of pharmacist prescribing services. Published studies highlight that pharmacist prescribers practicing in community settings are generally accessible, with pharmacist prescribers viewed by patients as easy and convenient to consult. There was limited evidence about the affordability of pharmacy prescribing services, and a number of potential equity issues were observed, including reduced access to pharmacist prescribers in more socioeconomically disadvantaged areas and those with greater proportions of populations at risk of health inequities, such as culturally and linguistically diverse communities.

CONCLUSIONS

This systematic review found that pharmacist prescribing services were both highly accessible and beneficial in improving access to medicines. However, measures of medicines access varied, and few studies included direct measures of medicines access as an outcome of pharmacist prescribing, highlighting a need for future studies to incorporate direct measures of medicines access when assessing the impact of pharmacist prescribing services.

The effect of untargeted naloxone distribution on opioid overdose outcomes

Opioid overdose has claimed the lives of over 340,000 Americans in the last decade. Over that same period, policymakers have taken steps to increase the availability of naloxone-an opioid antagonist used to rescue overdose victims-to people in the community. Previous studies, most of which have examined the effects of state laws designed to facilitate access to naloxone, have reached mixed conclusions about the effects of naloxone access on fatal and non-fatal overdoses. This paper exploits a unique policy experiment provided by two naloxone giveaways intended to increase naloxone possession among the general public in Pennsylvania to estimate the causal impact of naloxone distribution on fatal overdoses and opioid-related emergency department (ED) visits. Using a difference-in-differences design, I find evidence that opioid overdose deaths fell immediately following the first giveaway but increased following the second giveaway and discuss these apparently contradictory findings in the context of the changing composition of the opioid supply. I also find some evidence of a decline in opioid overdose-related ED visits following the giveaways. This study is the first to examine the effects of untargeted naloxone distribution and has implications for other novel, naloxone distribution efforts currently underway.

Empowering Tennessee Pharmacists to Initiate PrEP Using Collaborative Pharmacy Practice Agreements

BACKGROUND

The uptake of Pre-Exposure Prophylaxis (PrEP) has revolutionized the fight against the Human Immunodeficiency Virus (HIV) epidemic. Consistent obstacles remain that have influenced the slow uptake of PrEP in the United States of America (USA). In order to address these barriers, pharmacists must be included in the dispensing and management of PrEP through collaborative pharmacy practice agreements (CPPAs). Our aim for this study was to characterize pharmacists' perceptions of initiating PrEP through a CPPA in the state of Tennessee.

METHODS

This qualitative study was conducted in the USA in 2021 with pharmacists practicing in Tennessee. A framework and specific questions guided the thematic analysis. The words and phrases were coded inductively and later collapsed into categories and placed into emergent themes.

RESULTS

Two themes illustrate the voices of practicing pharmacists' integration in the dispensing and management of PrEP: (1) Learning from other states and previous successful CPPAs to advance and expand innovative models of patient care and (2) advocacy through public policy change to empower pharmacists to initiate PrEP.

CONCLUSION

This qualitative study focused on exploring pharmacists' perceptions on the opportunity of initiating PrEP through a CPPA in Tennessee. These findings highlight the preparedness of pharmacists to advocate for easier initiative of PrEP in pharmacies across Tennessee, whether through relaxing existing CPPA regulation or pursuing independent prescriptive authority for pharmacists.

The Role of the Pharmacist in Combating the Opioid Crisis: An Update

Introduction

The opioid overdose crisis has claimed hundreds of thousands of lives in the United States in the last decade, with overdose numbers continuing to climb. At the same time, the role of the pharmacist in combating the opioid crisis continues to evolve.

Methods

A literature search was conducted in Ovid MEDLINE that incorporated both MeSH terms and keywords to describe two concepts: the opioid epidemic and pharmacists/pharmacies. The search was limited to articles published after 2010 through the end of 2021 and returned 196 articles that were analyzed thematically.

Results

Thematic analysis revealed the following themes: prevention, interventions, public health role of the pharmacist, pharmacists in multiple roles, barriers, pharmacist and healthcare provider attitudes, educational initiatives for pharmacists and student pharmacists, and future research.

Discussion

While a great deal of progress has been made in the role of the pharmacist in supporting individuals with opioid use disorder (OUD) in the last two decades, pharmacists must seek to invest time and resources into practices with a strong evidence base to better mitigate the growing, devastating impact of the opioid crisis. Pharmacists must be willing to embrace new and non-traditional roles in patient care, service and research, and seek to advance evidence-based knowledge and practice.

Conclusion

Pharmacy practice has expanded greatly in the past decade with pharmacists taking on new and creative approaches to addressing the opioid crisis. Collaborative and interdisciplinary approaches to addressing the root causes of opioid misuse and opioid overdose are still desperately needed. These include attention to the critical roles of social determinants of health, stigma elimination, legislative advocacy for patients with OUD, and focused education for providers, pharmacists, and the community. Recognition and support of the value of collaboration to both improve public health and individual patient care, continued investments in pharmacy practice advancement in OUD treatment and harm reduction, and the creation of workflows and prescribing algorithms to assist in dosing medications to prevent withdrawal symptoms and achieve improved pain control are desperately needed.

Antioxidant Effects of Statins by Modulating Nrf2 and Nrf2/HO-1 Signaling in Different Diseases

Statins are competitive inhibitors of hydroxymethylglutaryl-CoA (HMG-CoA) reductase and have been used to treat elevated low-density lipoprotein cholesterol (LDL-C) for almost four decades. Antioxidant and anti-inflammatory properties which are independent of the lipid-lowering effects of statins, i.e., their pleiotropic effects, might be beneficial in the prevention or treatment of many diseases. This review discusses the antioxidant effects of statins achieved by modulating the nuclear factor erythroid 2 related factor 2/ heme oxygenase-1 (Nrf2/HO-1) pathway in different organs and diseases. Nrf2 and other proteins involved in the Nrf2/HO-1 signaling pathway have a crucial role in cellular responses to oxidative stress, which is a risk factor for ASCVD. Statins can significantly increase the DNA-binding activity of Nrf2 and induce the expression of its target genes, such as HO-1 and glutathione peroxidase) GPx, (thus protecting the cells against oxidative stress. Antioxidant and anti-inflammatory properties of statins, which are independent of their lipid-lowering effects, could be partly explained by the modulation of the Nrf2/HO-1 pathway.