Using the behaviour change wheel to understand and address barriers to pharmacy naloxone supply in Australia

Stocking and supplying naloxone: Findings from a representative sample of community pharmacies in Victoria, Australia

INTRODUCTION

Naloxone is an opioid receptor antagonist, which can rapidly reverse the effects of an opioid overdose. Community pharmacists may experience several barriers to stocking and supplying naloxone including a lack of confidence or knowledge and time constraints. The current study aimed to examine the extent to which Victorian community pharmacies stock and supply naloxone and determine specific characteristics associated with stocking naloxone.

METHODS

A representative sample of community pharmacists (n = 558) in Victoria, Australia, were contacted between October and November 2020 and invited to participate in an online survey. Data related to pharmacy- and pharmacist-related characteristics, including stocking and frequency of supplying naloxone in the past year. Multivariate logistic regression analysis was performed to examine the effect of various covariates on stocking naloxone.

RESULTS

The sample comprised 265 pharmacists (response rate 47%). Most pharmacies were located in Melbourne (the capital city of Victoria, 59.6%) and were part of a pharmacy chain (61.5%). In total, 100 (38%) pharmacies stocked naloxone, a third of whom did not supply it in the past year. Pharmacies that provided opioid agonist treatment had 2.4 times higher odds of stocking naloxone (95% confidence interval 1.425-4.136; p = 0.001).

DISCUSSION AND CONCLUSION

Less than half of Victorian community pharmacies stock naloxone, with even fewer actually supplying it in the past year. Future efforts are needed to increase the number of pharmacies that stock naloxone and the frequency in which it is supplied, while also addressing possible barriers to stocking and supplying naloxone among community pharmacists.

Reducing perceived barriers to scaling up overdose education and naloxone distribution and medications for opioid use disorder in the United States in the HEALing (helping end addiction long-term®) communities study

BACKGROUND

Scaling up overdose education and naloxone distribution (OEND) and medications for opioid use disorder (MOUD) is needed to reduce opioid overdose deaths, but barriers are pervasive. This study examines whether the Communities That HEAL (CTH) intervention reduced perceived barriers to expanding OEND and MOUD in healthcare/behavioral health, criminal-legal, and other/non-traditional venues.

METHODS

The HEALing (Helping End Addiction Long-Term®) Communities Study is a parallel, wait-list, cluster randomized trial testing the CTH intervention in 67 communities in the United States. Surveys administered to coalition members and key stakeholders measured the magnitude of perceived barriers to scaling up OEND and MOUD in November 2019-January 2020, May-June 2021, and May-June 2022. Multilevel linear mixed models compared Wave 1 (intervention) and Wave 2 (wait-list control) respondents. Interactions by rural/urban status and research site were tested.

RESULTS

Wave 1 respondents reported significantly greater reductions in mean scores for three outcomes: perceived barriers to scaling up OEND in Healthcare/Behavioral Health Venues (-0.26, 95% confidence interval, CI: -0.48, -0.05, p = 0.015), OEND in Other/Non-traditional Venues (-0.53, 95% CI: - 0.84, -0.22, p = 0.001) and MOUD in Other/Non-traditional Venues (-0.34, 95% CI: -0.62, -0.05, p = 0.020). There were significant interactions by research site for perceived barriers to scaling up OEND and MOUD in Criminal-Legal Venues. There were no significant interactions by rural/urban status.

DISCUSSION

The CTH Intervention reduced perceived barriers to scaling up OEND and MOUD in certain venues, with no difference in effectiveness between rural and urban communities. More research is needed to understand facilitators and barriers in different venues.

Advancing the implementation of take-home naloxone by community pharmacists: Testing the role of COM-B

INTRODUCTION

Opioid-related overdose fatalities are rising despite the increased accessibility of take-home naloxone (THN). Targeted implementation strategies are needed to improve the distribution of naloxone. This study investigates the effectiveness of a short video targeting pharmacists that addresses implementation barriers.

METHODS

A pre-post, mixed methods design was adopted to examine the effect of a brief behaviour change intervention (an educational video informed by the capability, opportunity, motivation affecting behaviour (COM-B) model), on factors affecting pharmacists' implementation of THN in Western Australia. Paired samples t-tests for were used to investigate intentions, knowledge, skill, confidence, feasibility, appropriateness, acceptability, attitudes, anticipated patient reactions, social support and implementation climate. Structural equation modelling examined the associations between constructs and to test the proposed mediation of motivation on capability and opportunity affecting intentions to discuss and provide THN.

RESULTS

We analysed data from 102 participants. At follow-up and after all participants had viewed the video, participants had significantly improved intentions, skill, confidence, anticipated reactions, social support and perceptions that THN implementation was feasible, appropriate and acceptable. No significant differences were seen for attitudes, knowledge or implementation climate. The proposed mediation effect of motivation on the associations between opportunity and intentions and capability and intentions was not supported.

DISCUSSION AND CONCLUSIONS

A short video directly targeting identified implementation barriers has the ability to improve key influences in the provision of THN. Dissemination of information to community pharmacists is a challenge. Implementation strategies addressing knowledge and targeting other levels of influence on intentions and behaviour are required.

Application of the COM-B model to explore barriers and facilitators to participation in research by hospital pharmacists and pharmacy technicians: A cross-sectional mixed-methods survey

BACKGROUND

Combining research and clinical practice is crucial for advancing evidence-based healthcare and improving pharmacy service delivery. While hospital pharmacists report significant interest in research, this does not translate to high levels of research engagement. Furthermore, little is known regarding barriers and motivators for pharmacy technician involvement in research.

OBJECTIVE

To characterise the barriers and enablers to engaging in practice-based research reported by hospital pharmacy staff using the Capability, Opportunity, Motivation - Behaviour (COM-B) framework.

METHODS

An online cross-sectional survey, using the validated Research Capacity in Context tool, was sent to all employees of a statewide hospital pharmacy service. Respondent characteristics and quantitatively reported barriers and motivators were analysed using descriptive statistics. Qualitative data from open text responses were analysed through inductive thematic analysis. Results were mapped to the components of the COM-B framework at individual, team and organisation levels.

RESULTS

278 responses were received (response rate 43.3%) from pharmacists (68.0%) and pharmacy assistants/technicians (28.4%) across 19 hospitals. Research behaviour was influenced by factors linked to five of six COM-B subdomains. Reflective motivation, linked to a desire to improve practice and patient care, self-development, and recognition, indicates pharmacy staff would like to engage in research. However, barriers related to physical opportunity (lack of time for research, other work roles that take priority) and psychological capability (lack of skills and mentorship) hindered involvement. Social opportunity and automatic motivation, tied to managerial support, role perceptions and departmental research culture were also reported facilitators. Subtle differences in the factors that motivate hospital pharmacists and pharmacy technicians were identified.

CONCLUSIONS

Mapping factors associated with research participation by hospital pharmacy staff to the COM-B model is an important step towards identifying evidence-based intervention types that could form the basis of strategies to optimise hospital pharmacy staff engagement with practice-based research, using the behaviour change wheel.

Breastfeeding needs of mothers of preterm infants in China: a qualitative study informed by the behaviour change wheel

BACKGROUND

Although breastfeeding is strongly recommended, the breastfeeding rate of preterm infants in China remains significantly low. In addition to the global structural challenges to breastfeeding and the physiological immaturity of preterm infants, Chinese mothers of preterm infants face unique challenges of maternal-infant separation after birth. Moreover, little is known about Chinese mothers' specific needs in coping with the difficulties posed by these challenges. This study utilized the Behaviour Change Wheel to investigate the breastfeeding needs of Chinese preterm mothers that may facilitate its practice in the future.

METHOD

A qualitative descriptive design was implemented in Wuhan in 2022. Based on purposeful sampling, 13 preterm mothers were recruited from a NICU in a Grade III Class A hospital in Wuhan, China. Face-to-face semi-structured interviews were conducted to collect data using the interview guide developed by the Theoretical Domains Framework. Theoretical Thematic Analysis was used to review the data in 6 steps to identify themes.

RESULTS

Five major themes emerged: (1) capability: ability to interpret infants' cues and identify problems, and need for breastfeeding knowledge and skills training; (2) physical opportunity: cleanliness and quietness in household environment, private lactation spaces and breastfeeding tools in workplaces and hospitals; (3) social opportunity: family support, peer support, and authoritative support from healthcare providers; (4) reflective motivation: information on health impacts of breastfeeding; (5) automatic motivation: maternal-infant bonding, free of aversive stimulus.

CONCLUSION

Preterm mothers' needs to enable breastfeeding were diverse, including increasing their capability, physical and social opportunities, and reflective and automatic motivation. People, resources and environments associated with these needs should be engaged together to stablish a conducive structural environment for breastfeeding. The policy change for "zero separation" and implementation of kangaroo care should also be implemented in Chinese neonatal intensive care units. Future studies are needed to design effective interventions according to mothers' specific needs.

Injection Drug Use Frequency Before and After Take-Home Naloxone Training

Importance

Concerns that take-home naloxone (THN) training may lead to riskier drug use (as a form of overdose risk compensation) remain a substantial barrier to training implementation. However, there was limited good-quality evidence in a systematic review of the association between THN access and subsequent risk compensation behaviors.

Objective

To assess whether THN training is associated with changes in overdose risk behaviors, indexed through injecting frequency, in a cohort of people who inject drugs.

Design, Setting, and Participants

This cohort study used prospectively collected self-reported behavioral data before and after THN training of participants in The Melbourne Injecting Drug User Cohort Study (SuperMIX). Annual interviews were conducted in and around Melbourne, Victoria, Australia, from 2008 to 2021. SuperMIX participants were adults who regularly injected heroin or methamphetamine in the 6 months preceding their baseline interview. The current study included only people who inject drugs who reported THN training and had participated in at least 1 interview before THN training.

Exposure

In 2017, the SuperMIX baseline or follow-up survey began asking participants if and when they had received THN training. The first THN training date that was recorded was included as the exposure variable. Subsequent participant interviews were excluded from analysis.

Main Outcomes and Measures

Injecting frequency was the primary outcome and was used as an indicator of overdose risk. Secondary outcomes were opioid injecting frequency, benzodiazepine use frequency, and the proportion of the time drugs were used alone. Fixed-effects generalized linear (Poisson) multilevel modeling was used to estimate the association between THN training and the primary and secondary outcomes. Time-varying covariates included housing status, income, time in study, recent opioid overdose, recent drug treatment, and needle and syringe coverage. Findings were expressed as incidence rate ratios (IRRs) with 95% CIs.

Results

There were 1328 participants (mean [SD] age, 32.4 [9.0] years; 893 men [67.2%]) who completed a baseline interview in the SuperMIX cohort, and 965 participants completed either a baseline or follow-up interview in or after 2017. Of these 965 participants, 390 (40.4%) reported THN training. A total of 189 people who inject drugs had pretraining participant interviews with data on injecting frequency and were included in the final analysis (mean [SD] number of interviews over the study period, 6.2 [2.2]). In fixed-effects regression analyses adjusted for covariates, there was no change in the frequency of injecting (IRR, 0.91; 95% CI, 0.69-1.20; P = .51), opioid injecting (IRR, 0.95; 95% CI, 0.74-1.23; P = .71), benzodiazepine use (IRR, 0.96; 95% CI, 0.69-1.33; P = .80), or the proportion of reported time of using drugs alone (IRR, 1.04; 95% CI, 0.86-1.26; P = .67) before and after THN training.

Conclusions and Relevance

This cohort study of people who inject drugs found no evidence of an increase in injecting frequency, along with other markers of overdose risk, after THN training and supply. The findings suggest that THN training should not be withheld because of concerns about risk compensation and that advocacy for availability and uptake of THN is required to address unprecedented opioid-associated mortality.

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.

Implementation of behaviour change training in practice amongst pharmacy professionals in primary care settings: Analysis using the COM-B model

BACKGROUND

The Pharmacy Integration Fund (PhIF) was established in England in 2016, with funded learning programmes or 'pathways' designed to support the development of clinical pharmacy practice in a range of settings. Despite pharmacy staff being well positioned to provide more clinical work, limited research has investigated behaviour change training targeted at widespread practice transformation.

OBJECTIVE(S)

To investigate implementation of PhIF learning in practice, using the COM-B model of behaviour change.

METHODS

An online survey distributed in February and October 2020 included questions on motivations for learning, confidence in target behaviours and impact of PhIF training on behaviour. The October 2020 survey also included questions exploring the effect of the COVID-19 pandemic. Quantitative data were analysed in SPSS. v.27 (IBM). Inferential statistics were used to compare between the pathways (Primary care pathways [PCP], Post-registration pathway [PRP] and Accuracy Checking Pharmacy Technician [ACPT] pathway). Free text comments were categorised and themed.

RESULTS

Three-hundred and eighty-three responses were received (49% PRP learners, 39% PCP learners and 12% ACPT learners). Learners generally had the capacity and opportunities to apply learning, and were strongly motivated to implement behaviours in practice, although learners based in community pharmacy (those on the PRP) were less likely to report receiving employer support. Enhanced knowledge/skills (capacity) were more commonly reported than change to patient-facing activities, leading clinical services and conducting medication reviews with patients with complex needs (clinical practice behaviours targeted by the pathways). The COVID-19 pandemic heightened barriers to implementing practice change.

CONCLUSIONS

Implementation of a range of clinical practice behaviours following at scale training appears to have been largely successful. Despite this, the community pharmacy context, where funded service opportunities may be lacking, continues to present challenges to workforce transformation plans. More work is needed to understand how training can be implemented to promote practice change for pharmacy professionals in all settings.

Informing a collaborative-care model for delivering medication assisted treatment for opioid dependence (MATOD): An analysis of pharmacist, prescriber and patient perceptions

BACKGROUND

Demand for medication assisted treatment for opioid dependence (MATOD) in Australia exceeds capacity, particularly in rural and regional areas. There is increasing recognition that community pharmacists are well-positioned to take on expanded roles in MATOD delivery, however there has been limited Australian research exploring attitudes of pharmacists, prescribers, and patients to collaborative models of care.

OBJECTIVE(S)

This study aimed to better understand enablers and barriers to a collaborative model for MATOD, to inform implementation in regions where increases in treatment capacity are urgently needed.

METHODS

Semi-structured telephone interviews were conducted with pharmacists (n = 11), prescribers (n = 6), and patients (n = 8) recruited from the Frankston-Mornington Peninsula region in Victoria, Australia, where transport and access to services have impacts on health care utilisation. The COM-B model was used to explore perceptions of pharmacists' capability, opportunity, and motivations for delivering collaborative care.

RESULTS

There was strong motivation among healthcare professionals to participate in a collaborative model of care, with the main perceived benefits including improvements in accessibility, convenience, and continuity of care, and leverage of pharmacists' high level of patient engagement. Key barriers identified by both pharmacists and prescribers included a perceived lack of pharmacist skills in some areas (capability) and resources (opportunity) to deliver collaborative care in a community pharmacy setting. Established relationships between all stakeholders (social opportunity) and communication between pharmacists and prescribers were identified as facilitators. Barriers and facilitators aligned with seven key areas: skills, confidence, relationships, patient selection, protocols, communication and resources.

CONCLUSIONS

Findings informed the development of a collaborative model that was individualised, protocol based, and supported by training and clear processes.

PROJECT IMPACT

This study identifies specific barriers and facilitators to a pharmacist-prescriber collaborative model of care for MATOD. The resulting model will be tested in a hybrid implementation-effectiveness trial in the Frankston-Mornington Peninsula region.

Patient, family members and community pharmacists' views of a proposed overdose prevention intervention delivered in community pharmacies for patients prescribed high-strength opioids for chronic non-cancer pain: An explorative intervention development study

INTRODUCTION

Despite opioid prescribing for chronic non-cancer pain (CNCP) having limited therapeutic benefits, recent evidence indicates significant increases in the prescribing of high-strength opioids for individuals with CNCP. Patients prescribed opioids for CNCP have overdose risk factors but generally have low opioid overdose awareness and low perceptions of risk related to prescribed opioids. Currently, there are few bespoke overdose prevention resources for this group.

METHODS

This qualitative study investigated views on a naloxone intervention for people prescribed high-strength opioids for CNCP delivered via community pharmacies. The intervention included overdose risk awareness and naloxone training and provision. Interviews were conducted with eight patients, four family members and two community pharmacists. Participants were convenience sampled and recruited through networks within the Scottish pain community. The Framework approach was used to analyse findings.

RESULTS

All participants had positive attitudes towards the intervention, but patients and family members considered risk of overdose to be very low. Three themes were identified: potential advantages of the intervention; potential barriers to the intervention; and additional suggestions and feedback about the intervention. Advantages included the intervention providing essential overdose information for CNCP patients. Barriers included resource and time pressures within community pharmacies.

DISCUSSION AND CONCLUSION

While patients had low overdose knowledge and did not see themselves as being at risk of opioid overdose, they were receptive to naloxone use and positive about the proposed intervention. A feasibility trial is merited to further investigate how the intervention would be experienced within community pharmacy settings.

Identifying barriers and facilitators to deprescribing benzodiazepines and sedative hypnotics in the hospital setting using the Theoretical Domains Framework and the Capability, Opportunity, Motivation and Behaviour (COM-B) Model: a qualitative study

OBJECTIVES

Geriatric guidelines strongly recommend avoiding benzodiazepines and non-benzodiazepine sedative hypnotics in older adults. Hospitalisation may provide an important opportunity to begin the process of deprescribing these medications, particularly as new contraindications arise. We used implementation science models and qualitative interviews to describe barriers and facilitators to deprescribing benzodiazepines and non-benzodiazepine sedative hypnotics in the hospital and develop potential interventions to address identified barriers.

DESIGN

We used two implementation science models, the Capability, Opportunity and Behaviour Model (COM-B) and the Theoretical Domains Framework, to code interviews with hospital staff, and an implementation process, the Behaviour Change Wheel (BCW), to codevelop potential interventions with stakeholders from each clinician group.

SETTING

Interviews took place in a tertiary, 886-bed hospital located in Los Angeles, California.

PARTICIPANTS

Interview participants included physicians, pharmacists, pharmacist technicians, and nurses.

RESULTS

We interviewed 14 clinicians. We found barriers and facilitators across all COM-B model domains. Barriers included lack of knowledge about how to engage in complex conversations about deprescribing (capability), competing tasks in the inpatient setting (opportunity), high levels of resistance/anxiety among patients to deprescribe (motivation), concerns about lack of postdischarge follow-up (motivation). Facilitators included high levels of knowledge about the risks of these medications (capability), regular rounds and huddles to identify inappropriate medications (opportunity) and beliefs that patients may be more receptive to deprescribing if the medication is related to the reason for hospitalisation (motivation). Potential modes of delivery included a seminar aimed at addressing capability and motivation barriers in nurses, a pharmacist-led deprescribing initiative using risk stratification to identify and target patients at highest need for deprescribing, and the use of evidence-based deprescribing education materials provided to patients at discharge.

CONCLUSIONS

While we identified numerous barriers and facilitators to initiating deprescribing conversations in the hospital, nurse- and pharmacist-led interventions may be an appropriate opportunity to initiate deprescribing.

Readiness of community pharmacies to implement an opioid safety intervention

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

The cost and impact of distributing naloxone to people who are prescribed opioids to prevent opioid-related deaths: findings from a modelling study

BACKGROUND AND AIMS

Although most opioid-related mortality in Australia involves prescription opioids, most research to understand the impact of naloxone supply on opioid-related mortality has focused upon people who inject heroin. We aimed to examine the cost and probable impact of up-scaling naloxone supply to people who are prescribed opioids.

DESIGN

Decision-tree model. Four scenarios were compared with a baseline scenario (the current status quo): naloxone scale-up between 2020 and 2030 to reach 30 or 90% coverage by 2030, among the subgroups of people prescribed either ≥ 50 or ≥ 100 mg of oral morphine equivalents (OME).

SETTING

Australia.

PARTICIPANTS

People who are prescribed opioids.

MEASUREMENTS

Possible deaths averted, costs (ambulance and naloxone distribution) and cost per life saved for different scenarios of naloxone scale-up.

FINDINGS

Maintaining the status quo, there would be an estimated 7478 [uncertainty interval (UI) = 6868-8275] prescription opioid overdose deaths between 2020 and 2030, resulting in Australian dollars (A$)51.9 million (49.4, 56.0) in ambulance costs. If naloxone were scaled-up to 90% of people prescribed > 50 mg OME, an estimated 657 (UI = 245, 1489) deaths could be averted between 2020 and 2030 (a 20% reduction in the final year of the model compared with the no naloxone scenario), with a cost of A$43 600 (20 800-110 500) per life saved. If naloxone were scaled-up to 30% of people prescribed > 50 mg OME an estimated 219 (82-496) deaths could be averted with the same cost per live saved. If naloxone were restricted to those prescribed > 100 mg OME, an estimated 130 (UI = 44-289) deaths would be averted if scaled-up to 30% or 390 (UI = 131-866) deaths averted if scaled-up to 90%, with the cost per life saved for both scenarios A$38 200 (UI = 12 400-97 400).

CONCLUSION

In Australia, scaling-up take-home naloxone by 2030 to reach 90% of people prescribed daily doses of ≥ 50 mg of oral morphine equivalents would be cost-effective and save more than 650 lives.

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

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

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.

Opioid medicines management in primary care settings: A scoping review of quantitative studies of pharmacist activities

To undertake a scoping review of pharmacist activities in opioid medicines management in primary care settings, including those developed or led by pharmacists, or in which pharmacists were members of broader multidisciplinary teams, and to collate the activities, models of care and settings, and reported outcomes. The bibliographic databases MEDLINE, EMBASE, International Pharmaceutical Abstracts, CINAHL, SCOPUS and Web of Science were searched. Studies with quantitative evaluation and published in English were eligible. Participants were patients with any pain category or an opioid use disorder, and healthcare providers. Studies originating in hospitals or involving supply functions were not included. Screening of literature and data charting of results were undertaken by two researchers. The 51 studies included in the scoping review occurred in primary care settings collated into four categories: general practice or primary care clinics, healthcare organisations, community pharmacies and outreach services. Studies were primarily of opioid use in chronic, noncancer pain. Other indications were opioid use disorder, cancer and dental pain. Pharmacist activities targeted risk mitigation, patient and provider education and broader, strategic approaches. Patient-related outcomes included reduced opioid load, improved functionality and symptom management, enhanced access to services and medication-assisted treatments, and engagement in risk-mitigation strategies. Behaviour change of providers was demonstrated. The review has identified the significant contribution that pharmacists working in primary care settings can make to minimise harm from opioids. Strategies implemented in isolation have the potential to further reduce adverse clinical outcomes with greater collaboration and coordination, such as opioid stewardship.