The pharmacist's role in overdose: Using mapping technologies to analyze naloxone and pharmacy distribution

Benefits and challenges of geographic information systems (GIS) for data-driven outreach in black communities experiencing overdose disparities: results of a stakeholder focus group

BACKGROUND

Black individuals in the U.S. face increasing racial disparities in drug overdose related to social determinants of health, including place-based features. Mobile outreach efforts work to mitigate social determinants by servicing geographic areas with low drug treatment and overdose prevention access but are often limited by convenience-based targets. Geographic information systems (GIS) are often used to characterize and visualize the overdose crisis and could be translated to community to guide mobile outreach services. The current study examines the initial acceptability and appropriateness of GIS to facilitate data-driven outreach for reducing overdose inequities facing Black individuals.

METHODS

We convened a focus group of stakeholders (N = 8) in leadership roles at organizations conducting mobile outreach in predominantly Black neighborhoods of St. Louis, MO. Organizations represented provided adult mental health and substance use treatment or harm reduction services. Participants were prompted to discuss current outreach strategies and provided feedback on preliminary GIS-derived maps displaying regional overdose epidemiology. A reflexive approach to thematic analysis was used to extract themes.

RESULTS

Four themes were identified that contextualize the acceptability and utility of an overdose visualization tool to mobile service providers in Black communities. They were: 1) importance of considering broader community context; 2) potential for awareness, engagement, and community collaboration; 3) ensuring data relevance to the affected community; and 4) data manipulation and validity concerns.

CONCLUSIONS

There are several perceived benefits of using GIS to map overdose among mobile providers serving Black communities that are overburdened by the overdose crisis but under resourced. Perceived potential benefits included informing location-based targets for services as well as improving awareness of the overdose crisis and facilitating collaboration, advocacy, and resource allocation. However, as GIS-enabled visualization of drug overdose grows in science, public health, and community settings, stakeholders must consider concerns undermining community trust and benefits, particularly for Black communities facing historical inequities and ongoing disparities.

Application and utility of geographic information systems in pharmacy specific health research: A scoping review

BACKGROUND

Geographic Information Systems (GIS) are considered essential tools to analyze spatially referenced health data.

OBJECTIVES

The purpose of this scoping review is to describe how GIS is used in pharmacy specific health research.

METHODS

During July 2020, the following databases were searched: EMBASE, MEDLINE (PubMed), Web of Science and Scopus. The search strategy included terms relating to spatial analysis and pharmacy. Studies were considered eligible if they involved the use of GIS and focused on pharmacies. A narrative and tabular synthesis of the results was carried out, structured around the spatial analysis methods utilized across studies, as well as the characteristics of pharmacies evaluated in studies.

RESULTS

After a review of 6967 sources, 48 studies were included in this review. Twenty-nine studies were conducted in the United States (60.4%) and thirty-six focused on accessibility (75.0%; n = 36). Twenty-two studies investigated the relationship between sociodemographic aspects of the population and the accessibility and availability of pharmacies (45.8%). Twelve studies (25.0%) performed distance analysis and six studies (12.5%) performed geostatistical analysis. Community pharmacies were the setting evaluated most frequently, with over-the-counter selling products being the most evaluated pharmacy variable (13.3%; n = 6). Population density (58.3%; n = 28), income indicators (43.8%; n = 21) and minority community composition rates (41.7%; n = 20) were the most used population variables.

CONCLUSIONS

GIS have been increasingly used in pharmacy specific health research. Generally, research has sought to identify potential barriers to access and their effects on the population. Future research may benefit by utilizing robust spatial methods and applications across countries outside of the United States. Doing so could help to confirm the impact of sociodemographic characteristics on the availability and/or accessibility of pharmacies globally.

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..

Optimizing the Distribution of Pharmacy-Dispensed Naloxone Using Spatial Mapping Techniques in Rural Areas

With the worsening opioid epidemic, recent changes allow pharmacies to sell naloxone through standing orders to reverse opioid overdoses. This study assesses direct dispensed naloxone availability through pharmacy chains in California in 2016, and utilizes spatial analysis techniques to suggest optimal stocking of naloxone. Rural counties were less likely to have a pharmacy selling naloxone even though overdose death rates were higher in rural counties (odds ratio [OR] = 0.225; 95% confidence interval [CI] = [0.059, 0.854]). Pharmacies closest to the center of the population in these rural counties were identified as ideal stocking locations. Rural counties with high overdose death rates have the lowest rates of naloxone, but spatial analysis can determine pre-existing chain pharmacies that can stock naloxone.

Pharmacies and features of the built environment associated with opioid overdose: A geospatial comparison of rural and urban regions in Alabama, USA

BACKGROUND

Elements of the physical environment have been shown to influence health behaviors including drug use and overdose mortality. Throughout the opioid epidemic in the United States, rural regions have been disproportionately affected by opioid overdose. Although the relationship between the urban built environment and opioid overdose has been established, little is known as to how trends may differ in rural areas.

METHODS

Risk terrain modeling was used as a spatial analytical approach to assess environmental features that significantly increase the risk of opioid overdose in Jefferson County, Alabama. Spatial risk assessments were conducted for urban and rural regions as well as for the county as a whole. Criminogenic, opioid-related, and community variables were included and compared across spatial risk models.

RESULTS

The geographic context, rural or urban, influenced the relationship between environmental features and opioid overdose. In rural areas, community features such as bus stops and public schools were related to the occurrence of opioid overdose. In urban areas, inpatient treatment centers, transitional living facilities, express loan establishments, and liquor vendors were significantly related to the locations of opioid overdose.

CONCLUSION

Risk terrain modeling can be used to locate high-risk areas for opioid overdose while identifying factors that are contributing to the risk of events occurring in communities. The patterns of overdose risk differ in rural and urban contexts and may be used to inform the placement of treatment and prevention resources.

The spatio-temporal distribution of naloxone administration events in rural Ohio 2010-16

INTRODUCTION

In 2017, Ohio had the second highest rate of drug overdose deaths in the United States. Current opioid related epidemiologic literature has begun to uncover the environmental level influences on the opioid epidemic and how the end results may ultimately manifest over space and time. This work is still nascent however, with most clustering research conducted at a spatial unit such as county level, which (1) can obscure differences between urban and rural communities, (2) does not consider dynamics that cross county lines, and (3) is difficult to interpret directly into strategic and localized intervention efforts. We address this gap by describing, at the Census block level, the spatial-temporal clustering of opioid related events in rural Ohio.

METHODS

We use the outcome of the administration of naloxone emergency medical service (EMS) calls in rural Ohio Census blocks during 2010-16 in a Poisson model of spatial scan statistics.

RESULTS

We found that naloxone event clustering in rural Ohio in the recent decade was widely dispersed over time and space, with clusters that average 17 times the risk of having an event compared to areas outside the cluster. Many of the larger spatial clusters crossed administrative boundaries (i.e., county lines) suggesting that opioid misuse may be less responsive to county level policies than to other factors.

DISCUSSION

Timely identification of localized overdose event clustering can guide affected communities toward rapid interventions aimed at minimizing the morbidity and mortality resulting from contagious opioid misuse.

Strengths and weaknesses of existing data sources to support research to address the opioids crisis

Better opioid prescribing practices, promoting effective opioid use disorder treatment, improving naloxone access, and enhancing public health surveillance are strategies central to reducing opioid-related morbidity and mortality. Successfully advancing and evaluating these strategies requires leveraging and linking existing secondary data sources. We conducted a scoping study in Fall 2017 at RAND, including a literature search (updated in December 2018) complemented by semi-structured interviews with policymakers and researchers, to identify data sources and linking strategies commonly used in opioid studies, describe data source strengths and limitations, and highlight opportunities to use data to address high-priority public health research questions. We identified 306 articles, published between 2005 and 2018, that conducted secondary analyses of existing data to examine one or more public health strategies. Multiple secondary data sources, available at national, state, and local levels, support such research, with substantial breadth in data availability, data contents, and the data's ability to support multi-level analyses over time. Interviewees identified opportunities to expand existing capabilities through systematic enhancements, including greater support to states for creating and facilitating data use, as well as key data challenges, such as data availability lags and difficulties matching individual-level data over time or across datasets. Multiple secondary data sources exist that can be used to examine the impact of public health approaches to addressing the opioid crisis. Greater data access, improved usability for research purposes, and data element standardization can enhance their value, as can improved data availability timeliness and better data comparability across jurisdictions.

Beyond mapping: a case for geospatial analytics in humanitarian health

The humanitarian sector is increasingly adopting geospatial data to support operations. However, the utilization of these data in the humanitarian health arena is predominantly in thematic map format, thereby limiting the full insight and utility of geospatial information.

Geospatial analytics, in contrast, including pattern analysis, interpolation, and predictive modeling, have tremendous potential within the field of humanitarian health. This paper explores a variety of historical and contemporary geospatial applications in the public health and humanitarian fields and argues for greater integration of geospatial analysis into humanitarian health research and programming. From remote sensing to create sampling frames, to spatial interpolation for environmental exposure analysis, and multi-objective optimization algorithms for humanitarian logistics, spatial analysis has transformed epistemological paradigms, research methods and programming landscapes across diverse disciplines.

The field of humanitarian health, which is inextricably bounded by geography and resource limitations, should leverage the unique capacities of spatial methods and strategically integrate geospatial analytics into research and programming not only to fortify the academic legitimacy and professionalization of the field but also to improve operational efficiency and mitigation strategies.

Spatial Methods to Enhance Public Health Surveillance and Resource Deployment in the Opioid Epidemic

OBJECTIVES

To improve public health surveillance and response by using spatial optimization.

METHODS

We identified cases of suspected nonfatal opioid overdose events in which naloxone was administered from April 2013 through December 2016 treated by the city of Pittsburgh, Pennsylvania, Bureau of Emergency Medical Services. We used spatial modeling to identify areas hardest hit to spatially optimize naloxone distribution among pharmacies in Pittsburgh.

RESULTS

We identified 3182 opioid overdose events with our classification approach, which generated spatial patterns of opioid overdoses within Pittsburgh. We then used overdose location to spatially optimize accessibility to naloxone via pharmacies in the city. Only 24 pharmacies offered naloxone at the time, and only 3 matched with our optimized solution.

CONCLUSIONS

Our methodology rapidly identified communities hardest hit by the opioid epidemic with standard public health data. Naloxone accessibility can be optimized with established location-allocation approaches. Public Health Implications. Our methodology can be easily implemented by public health departments for automated surveillance of the opioid epidemic and has the flexibility to optimize a variety of intervention strategies.

Community pharmacies as access points for addiction treatment

BACKGROUND

There is growing interest in utilizing community pharmacies to support opioid abuse prevention and addiction treatment efforts. However, it is unknown whether the placement of community pharmacies is conducive to taking on such a role.

OBJECTIVE

To examine the distribution of community pharmacies in Wisconsin and its relationship with the location of addiction treatment facilities and opioid-related overdose events in rural and urban areas.

METHODS

The total number of opioid-related overdose deaths and crude death rates per 100,000 population were determined for each county in Wisconsin. Substance abuse treatment facilities were identified in each county to estimate access to formal addiction treatment. A list of pharmacies in the state was screened to identify community pharmacies in each county. Descriptive statistics and Pearson correlation coefficients were used to describe the distribution of and relationships between county-level opioid-related overdose death rates and the number of treatment facilities and community pharmacies in the state.

RESULTS

Wisconsin has 72 counties, of which 45 (62.5%) are classified as rural. Although the number of opioid-related overdose deaths was highly concentrated in urban areas, crude death rates per 100,000 population were similar in urban and rural areas. Rural counties were significantly less likely to have formal substance abuse treatment facilities (r = -.42, P = .00) or community pharmacies (r = -.44, P = .00) compared to urban counties. However, community pharmacies were more prevalent and more likely to be located in rural counties with higher rates of opioid-related overdose deaths than substance abuse treatment facilities. All but 1 of the 14 counties without a formal substance abuse treatment facility had access to 1 or more community pharmacies.

CONCLUSIONS

Community pharmacies are ideally located in areas that could be used to support medication-assisted addiction treatment efforts, particularly in rural areas lacking formal substance abuse treatment facilities.