Nonprescription naloxone and syringe sales in the midst of opioid overdose and hepatitis C virus epidemics: Massachusetts, 2015

Accessibility of Naloxone in Pharmacies Registered Under the Illinois Standing Order

Introduction

To expand access to naloxone, the state of Illinois implemented a standing order allowing registered pharmacies to dispense the drug without an individual prescription. To participate under the standing order, pharmacies were required to opt in through a formal registration process. In our study we aimed to evaluate the availability and price of naloxone at registered pharmacies.

Methods

This was a prospective, de-identified, cross-sectional telephone survey. Trained interviewers posed as potential customers and used a standardized script to determine the availability of naloxone between February-December, 2019. The primary outcome was defined as a pharmacy indicating it carried naloxone, currently had naloxone in stock, and was able to dispense it without an individual prescription.

Results

Of 948 registered pharmacies, 886 (93.5%) were successfully contacted. Of those, 792 (83.4%) carried naloxone, 659 (74.4%) had naloxone in stock, and 472 (53.3%) allowed purchase without a prescription. Naloxone nasal spray (86.4%) was the formulation most commonly stocked. Chain pharmacies were more likely to carry naloxone (adjusted odds ratio [aOR] 3.16, 95% confidence interval [CI] 1.97-5.01, P < 0.01) and have naloxone in stock (aOR 2.72, 95% CI 1.76-4.20, P < 0.01), but no more likely to dispense it without a prescription. Pharmacies in higher population areas (aOR 0.99, 95% CI 0.99-0.99, P < 0.05) and rural areas adjacent to metropolitan areas (aOR 0.5, 95% CI 025-0.98, P < 0.05) were less likely to have naloxone available without a prescription. Associations of naloxone availability based on other urbanicity designations, overdose count, and overdose rate were not significant.

Conclusion

Among pharmacies in Illinois that formally registered to dispense naloxone without a prescription, the availability of naloxone remains limited. Additional interventions may be needed to maximize the potential impact of a statewide standing order.

Comparison of a national commercial pharmacy naloxone data source to state and city pharmacy naloxone data sources-Rhode Island, Massachusetts, and New York City, 2013-2019

OBJECTIVE

Accurate naloxone distribution data are critical for planning and prevention purposes, yet sources of naloxone dispensing data vary by location, and completeness of local datasets is unknown. We sought to compare available datasets in Massachusetts, Rhode Island, and New York City (NYC) to a commercially available pharmacy national claims dataset (Symphony Health Solutions).

DATA SOURCES AND STUDY SETTING

We utilized retail pharmacy naloxone dispensing data from NYC (2018-2019), Rhode Island (2013-2019), and Massachusetts (2014-2018), and pharmaceutical claims data from Symphony Health Solutions (2013-2019).

STUDY DESIGN

We conducted a descriptive, retrospective, and secondary analysis comparing naloxone dispensing events (NDEs) captured via Symphony to NDEs captured by local datasets from the three jurisdictions between 2013 and 2019, when data were available from both sources, using descriptive statistics, regressions, and heat maps.

DATA COLLECTION/EXTRACTION METHODS

We defined an NDE as a dispensing event documented by the pharmacy and assumed that each dispensing event represented one naloxone kit (i.e., two doses). We extracted NDEs from local datasets and the Symphony claims dataset. The unit of analysis was the ZIP Code annual quarter.

PRINCIPAL FINDINGS

NDEs captured by Symphony exceeded those in local datasets for each time period and location, except in RI following legislation requiring NDEs to be reported to the PDMP. In regression analysis, absolute differences in NDEs between datasets increased substantially over time, except in RI before the PDMP. Heat maps of NDEs by ZIP code quarter showed important variations reflecting where pharmacies may not be reporting NDEs to Symphony or local datasets.

CONCLUSIONS

Policymakers must be able to monitor the quantity and location of NDEs in order to combat the opioid crisis. In regions where NDEs are not required to be reported to PDMPs, proprietary pharmaceutical claims datasets may be useful alternatives, with a need for local expertise to assess dataset-specific variability.

Attitudes, beliefs, knowledge, and practices for over-the-counter syringe sales in community pharmacies: A systematic review

BACKGROUND

Community pharmacies are an important resource for people who inject drugs (PWID) to purchase over-the-counter (OTC) syringes. Access to sterile injection equipment can reduce the transmission of blood-borne illnesses. However, pharmacists and their staff ultimately use discretion over sales.

OBJECTIVE

To identify staff attitudes, beliefs, knowledge, and practices in the sale of OTC syringes in community pharmacies.

METHODS

This systematic review was reported according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and registered with PROSPERO (CRD42022363040). We systematically searched PubMed, Embase, and Scopus from inception to September 2022. The review included peer-reviewed empirical studies regarding OTC syringe sales among community pharmacy staff (pharmacists, interns, and technicians). We screened records and extracted data using a predefined data extraction form. Findings were narratively synthesized, and critical appraisal was conducted using the Mixed Methods Appraisal Tool.

RESULTS

A total of 1895 potentially relevant articles were identified, and 35 were included. Most studies (23; 63.9%) were cross-sectional descriptive designs. All studies included pharmacists, with seven (19.4%) also including technicians, two (5.6%) including interns, and four (11.1%) including other staff. Studies found relatively high support among respondents for harm reduction-related services within community pharmacies, but less common reports of staff engaging in said services themselves. When studies investigated the perceived positive or negative impacts of OTC syringe sales, prevention of blood-borne illness was widely understood as a benefit, while improper syringe disposal and safety of the pharmacy and its staff commonly reported as concerns. Stigmatizing attitudes/beliefs toward PWID were prevalent across studies.

CONCLUSION

Community pharmacy staff report knowledge regarding the benefits of OTC syringes, but personal attitudes/beliefs heavily influence decisions to engage in sales. Despite support for various syringe-related harm reduction activities, offerings of services were less likely due to concerns around PWID.

Prescribing Syringes to People Who Inject Drugs: Advancing Harm Reduction in Primary Care

Access to new syringes can reduce the risk of HIV and hepatitis C transmission, skin and soft tissue infections, and infectious endocarditis for people who inject drugs (PWID). Syringe service programs (SSPs) and other harm reduction programs are a good source of syringes. However, they are sometimes not accessible due to limited hours, geographic barriers, and other factors. In this perspective, we argue that when PWID faces barriers to syringes physicians and other providers should prescribe, and pharmacists should dispense, syringes to decrease health risks associated with syringe re-use. This strategy is endorsed by professional organizations and is legally permissible in most states. Such prescribing has numerous benefits, including insurance coverage of the cost of syringes and the sense of legitimacy conveyed by a prescription. We discuss these benefits as well as the legality of prescribing and dispensing syringes and address practical considerations such as type of syringe, quantity, and relevant diagnostic codes, if required. In the face of an unprecedented overdose crisis with many associated health harms, we also make the case for advocacy to change state and federal laws to make access to prescribed syringes uniform, smooth, and universal as part of a suite of harm reduction efforts.

Adapted "Break the Cycle for Avant Garde" intervention to reduce injection assisting and promoting behaviours in people who inject drugs in Tallinn, Estonia: A pre- post trial

In the context of established and emerging injection drug use epidemics, there is a need to prevent and avert injection drug use. We tested the hypothesis that an individual motivation and skills building counselling, adapted and enhanced from Hunt's Break the Cycle intervention targeting persons currently injecting drugs would lead to reduction in injection initiation-related behaviours among PWID in Tallinn, Estonia. For this quasi-experimental study, pre-post outcome measures included self-reported promoting behaviours (speaking positively about injecting to non-injectors, injecting in front of non-injectors, offering to give a first injection) and injection initiation behaviours (assisting with or giving a first injection) during the previous 6 months. Of 214 PWID recruited, 189 were retained (88.3%) for the follow-up at 6 months. The proportion of those who had injected in front of non-PWID significantly declined from 15.9% to 8.5%, and reporting assisting with 1st injection from 6.4% to 1.06%. Of the current injectors retained in the study, 17.5% reported not injecting drugs at the follow up. The intervention adapted for the use in the setting of high prevalence of HIV and relatively low prevalence of injection assisting, tested proved to be effective and safe.

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.

HCV serostatus and injection sharing practices among those who obtain syringes from pharmacies and directly and indirectly from syringe services programs in rural New England

BACKGROUND

Among people who inject drugs (PWID), obtaining syringes via syringe services programs (SSPs) and pharmacies reduces injection sharing practices associated with hepatitis C virus (HCV). Whether indirect use of SSPs via secondary exchange confers a similar benefit remains unknown, particularly in rural settings. We compared HCV serostatus and injection sharing practices by primary syringe source among a sample of rural PWID.

METHODS

Data are from a cross-sectional study of adults who use drugs recruited from eleven rural counties in New Hampshire, Vermont, and Massachusetts using respondent-driven sampling (2018-2019). Study staff performed HCV antibody testing. An audio computer-assisted self-interview assessed sociodemographic characteristics, past 30-day injection practices, and past 30-day primary syringe source. Primary syringe source was classified as direct SSP, pharmacy, indirect SSP (secondary exchange), or "other" (friend/acquaintance, street seller, partner/relative, found them). Mixed effects modified Poisson models assessed the association of primary syringe source with HCV seroprevalence and injection sharing practices.

RESULTS

Among 397 PWID, the most common primary syringe source was "other" (33%), then pharmacies (27%), SSPs (22%), and secondary exchange (18%). In multivariable models, compared with those obtaining most syringes from "other" sources, those obtaining most syringes from pharmacies had a lower HCV seroprevalence [adjusted prevalence ratio (APR):0.85, 95% confidence interval (CI) 0.73-0.9985]; however, the upper bound of the 95% CI was close to 1.0. Compared with those obtaining most syringes from other sources, PWID obtaining most syringes directly from SSPs or pharmacies were less likely to report borrowing used syringes [APR(SSP):0.60, 95% CI 0.43-0.85 and APR(Pharmacies):0.70, 95% CI 0.52-0.93], borrowing used injection equipment [APR(SSP):0.59, 95% CI 0.50-0.69 and APR (Pharmacies):0.81, 95% CI 0.68-0.98], and backloading [APR(SSP):0.65, 95% CI 0.48-0.88 and APR(Pharmacies):0.78, 95% CI 0.67-0.91]. Potential inverse associations between obtaining most syringes via secondary exchange and injection sharing practices did not reach the threshold for statistical significance.

CONCLUSIONS

PWID in rural New England largely relied on informal syringe sources (i.e., secondary exchange or sources besides SSPs/pharmacies). Those obtaining most syringes from an SSP or pharmacy were less likely to share injection equipment/syringes and had a lower HCV seroprevalence, which suggests using these sources reduces the risk of new HCV infections or serves as proxy for past injection behavior.

Pharmacy naloxone codispensing: A mixed methods study of practices and perspectives under a statewide standing order program

BACKGROUND

In a previous statewide naloxone purchase trial conducted in Massachusetts, we documented high levels of naloxone accessibility, upon patient request, under the state's naloxone standing order (NSO) program. Equally important for reducing overdose mortality rates is expanding naloxone access via codispensing alongside opioid prescription and syringe purchases at pharmacies.

OBJECTIVE

To understand naloxone codispensing from the perspective of pharmacists under the Massachusetts NSO program.

METHODS

The study used a mixed methods design involving 3 focus groups and a quantitative survey. Participants in both the focus groups (N = 27) and survey (N = 339) were licensed Massachusetts pharmacists. Focus groups were conducted at 3 separate professional conferences for pharmacists. The survey was conducted using a stratified random sample of 400 chain and independent retail pharmacies across Massachusetts. All data were collected between September 2018 and November 2019. Quantitative and qualitative analyses examined current policies, practices, and attitudes regarding naloxone codispensing for patients at risk of opioid overdose.

RESULTS

Most pharmacists (69%) reported that they, their pharmacy, or both promoted codispensing alongside opioid prescriptions. A majority promoting naloxone codispensing did so for patients prescribed high opioid dosages (80%); fewer promoted codispensing for patients also prescribed benzodiazepines (20%). Facilitators to codispensing were pre-existing relationships between pharmacists and prescribers, mandatory pharmacist consultation, and universal naloxone promotion to all patients meeting certain criteria. Barriers to codispensing were pharmacists' concerns about offending patients by initiating a conversation about naloxone, insufficient technician training, workflow and resource constraints, and misconceptions surrounding naloxone. We found no substantive differences in outcomes between chain and independent pharmacies.

CONCLUSION

We documented several facilitators and barriers to naloxone codispensing in Massachusetts pharmacies. Areas amenable to intervention include increased training for front-line pharmacy technicians, mandatory pharmacist consultation for opioid-prescribed patients, workflow reorganization, and addressing stigma concerns on the pharmacist end.

A qualitative examination of naloxone access in three states: Connecticut, Kentucky, and Wisconsin

BACKGROUND

Prevention of opioid-involved overdose deaths remains a public health priority in the United States. While expanding access to naloxone is a national public health strategy, it is largely implemented at the state and local level, where significant variability in policies, resources, and norms exist. The aims of the current study were to examine the social context of naloxone access in three different states (Connecticut, Kentucky, Wisconsin) from the perspectives of key informants (first responders, harm reduction personnel, and pharmacists), who play some role in dispensing or administering naloxone within their communities.

METHODS

Interviews were conducted with key informants who were in different local areas (urban, suburban, rural) across Connecticut, Kentucky, and Wisconsin. Interview guides explored the key informants' experiences with administering or dispensing naloxone, and their perspectives on opioid overdose prevention efforts in their areas. Data analysis was conducted using multistage inductive coding and comparative methods to identify dominant themes within the data.

RESULTS

Key informants in each of the three states noted progress toward expanding naloxone access, especially among people who use opioids, but also described inequities. The key role of harm reduction programs in distributing naloxone within their communities was also highlighted by participants, as well as barriers to increasing naloxone access through pharmacies. Although there was general consensus regarding the effectiveness of expanding naloxone access to prevent overdose deaths, the results indicate that communities are still grappling with stigma associated with drug use and a harm reduction approach.

CONCLUSION

Findings suggest that public health interventions that target naloxone distribution through harm reduction programs can enhance access within local communities. Strategies that address stigmatizing attitudes toward people who use drugs and harm reduction may also facilitate naloxone expansion efforts, overall, as well as policies that improve the affordability and awareness of naloxone through the pharmacy.

Factors associated with naloxone availability and dispensing through Michigan's pharmacy standing order

Background: Pharmacy standing order policies allow pharmacists to dispense naloxone, thereby increasing access to naloxone. Objectives: To describe pharmacy standing order participation and associations of pharmacy and community characteristics that predict naloxone availability and dispensing across eight counties in Michigan. Methods: We conducted a telephone survey of 662 standing order pharmacies with a response rate of 81% (n = 539). Pharmacies were linked with census tract-level demographics, overdose fatality rates, and dispensing data. County maps were created to visualize pharmacy locations relative to fatality rates. Regression models analyzed associations between pharmacy type, neighborhood characteristics, fatality rates, and these outcomes: naloxone availability, having ever dispensed naloxone, and counts of naloxone dispensed. Results: The prevalence of standing order pharmacies was 54% (n = 662/1231). Maps revealed areas with higher fatality rates had fewer pharmacies participating in the standing order or lacked any pharmacy access. Among standing order pharmacies surveyed, 85% (n = 458/539) had naloxone available and 82% had ever dispensed (n = 333/406). The mean out-of-pocket cost of Narcan_® was $127.77 (SD: 23.93). National chains were more likely than regional chains to stock naloxone (AOR = 3.75, 95%CI = 1.77, 7.93) and to have ever dispensed naloxone (AOR 3.02, 95%CI = 1.21,7.57). Higher volume of naloxone dispensed was associated in neighborhoods with greater proportions of public health insurance (IRR = 1.38, 95%CI = 1.21, 1.58) and populations under 44 years old (IRR = 1.24, 95%CI = 1.04, 1.48). There was no association with neighborhood overdose fatality rates or race in regression models. Conclusion: As deaths from the opioid epidemic continue to escalate, efforts to expand naloxone access through greater standing order pharmacy participation are warranted.

The Role of Nonprescription Syringe Sales in Ending the Human Immunodeficiency Virus Epidemic

In 2019, the executive branch of the United States released "Ending the Human Immunodeficiency Virus (HIV) Epidemic: A Plan for America" (EHE). EHE proposes to end the HIV epidemic in the United States by 2030. To do so requires a multifaceted effort from all health care providers addressing every possible avenue of HIV transmission. An important aspect of this mission is to increase access to sterile syringes for people who inject drugs (PWID). For many PWID, access to Syringe Service Programs is limited because of hours, location, and state laws. Pharmacies are able to provide clean syringes in a safe, clean, climate-controlled atmosphere with access to a health professional. Although published research shows pharmacist ambivalence toward the nonprescription sales of syringes, pharmacist involvement in states with established guidance and support from departments of health suggests that pharmacists are interested in this public health effort. However, without proper support from departments of health and access to training on the dignified delivery of services, pharmacies will continue to be an ineffective avenue for prevention of HIV spread through the provision of sterile syringes.

Spatial epidemiology: An empirical framework for syndemics research

Syndemics framework describes two or more co-occurring epidemics that synergistically interact with each other and the complex structural social forces that sustain them leading to excess disease burden. The term syndemic was first used to describe the interaction between substance abuse, violence, and AIDS by Merrill Singer. A broader range of syndemic studies has since emerged describing the framework's applicability to other public health scenarios. With syndemic theory garnering significant attention, the focus is shifting towards developing robust empirical analytical approaches. Unfortunately, the complex nature of the disease-disease interactions nested within several social contexts complicates empirical analyses. In answering the call to analyze syndemics at the population level, we propose the use of spatial epidemiology as an empirical framework for syndemics research. Spatial epidemiology, which typically relies on geographic information systems (GIS) and statistics, is a discipline that studies spatial variations to understand the geographic landscape and the risk environment within which disease epidemics occur. GIS maps provide visualization aids to investigate the spatial distribution of disease outcomes, the associated social factors, and environmental exposures. Analytical inference, such as estimation of disease risks and identification of spatial disease clusters, can provide a detailed statistical view of spatial distributions of diseases. Spatial and spatiotemporal models can help us to understand, measure, and analyze disease syndemics as well as the social, biological, and structural factors associated with them in space and time. In this paper, we present a background on syndemics and spatial epidemiological theory and practice. We then present a case study focused on the HIV and HCV syndemic in West Virginia to provide an example of the use of GIS and spatial analytical methods. The concepts described in this paper can be considered to enhance understanding and analysis of other syndemics for which space-time data are available.

Broadening access to naloxone: Community predictors of standing order naloxone distribution in Massachusetts

BACKGROUND

Naloxone is a prescription medication that reverses opioid overdoses. Allowing naloxone to be dispensed directly by a pharmacist without an individual prescription under a naloxone standing order (NSO) can expand access. The community-level factors associated with naloxone dispensed under NSO are unknown.

METHODS

Using a dataset comprised of pharmacy reports of naloxone dispensed under NSO from 70% of Massachusetts retail pharmacies, we examined relationships between community-level demographics, rurality, measures of treatment for opioid use disorder, and overdose deaths with naloxone dispensed under NSO per ZIP Code-quarter from 2014 until 2018. We used a multi-variable zero-inflated negative binomial model, assessing odds of any naloxone dispensed under NSO, as well as a multi-variable negative binomial model assessing quantities of naloxone dispensed under NSO.

RESULTS

From 2014-2018, quantities of naloxone dispensed under NSO and the number of pharmacies dispensing any naloxone under NSO increased over time. However, communities with greater percentages of people with Hispanic ethnicity (aOR 0.91, 95% CI 0.86-0.96 per 5% increase), and rural communities compared to urban communities (aOR 0.81, 95% CI 0.73-0.90) were less likely to dispense any naloxone by NSO. Communities with more individuals treated with buprenorphine dispensed more naloxone under NSO, as did communities with more opioid-related overdose deaths.

CONCLUSION

Naloxone dispensing has substantially increased, in part driven by standing orders. A lower likelihood of naloxone being dispensed under NSO in communities with larger Hispanic populations and in more rural communities suggests the need for more equitable access to, and uptake of, lifesaving medications like naloxone.

Study protocol for the Respond to Prevent Study: a multi-state randomized controlled trial to improve provision of naloxone, buprenorphine and nonprescription syringes in community pharmacies

Access to the opioid antidote naloxone is a critical component of addressing the opioid crisis. Naloxone is a population-level prevention intervention associated with substantial reductions in overdose mortality and reduction of nonfatal overdose. Pharmacies' pivotal role in dispensing medications like buprenorphine for the treatment of opioid use disorder and selling nonprescription syringes places them at the crossroads of opioid access and risk mitigation methods like naloxone provision. Testing ways to optimize pharmacy-based naloxone provision will be key as the country expands the implementation of naloxone through the medical system. In the Respond to Prevent Study, we conducted a large, practical study of a pharmacy-focused intervention in a sample of Washington, Oregon, Massachusetts and New Hampshire community chain pharmacies to increase naloxone dispensing and improve opioid safety. The intervention integrated two evidence-based educational toolkits and streamlined materials to enhance the focus on naloxone policy, stigma reduction, and patient communications around naloxone, nonprescription syringes and buprenorphine access. The real-world study implemented a stepped wedge, clustered randomized trial design across 175 community chain pharmacies to evaluate the effectiveness of the Respond to Prevent intervention in increasing: (a) pharmacy based naloxone distribution rates, naloxone-related patient engagement, and pharmacist and technicians' attitudes, knowledge, perceived behavioral control and self-efficacy toward naloxone; and (b) pharmacy nonprescription syringe sales, and pharmacist and technicians' attitudes, knowledge, perceived behavioral control and self-efficacy toward dispensing buprenorphine for opioid use disorder (secondary outcomes). This commentary provides a brief narrative about the study and presents insights on the design and adaptations to our study protocol, including those adopted during the unprecedented COVID-19 pandemic further compounded by Western wildfires in 2020.

Attitudes toward pharmacy-based HCV/HIV testing among people who use drugs in rural Kentucky

PURPOSE

Rural areas of the United States have experienced outbreaks of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections among people who use drugs (PWUD). Pharmacy-based interventions may play a crucial role in prevention and entry into care, especially when traditional health care access is limited. The willingness of rural PWUD to use pharmacies for HIV/HCV-related services remains unknown. The purpose of this study was to describe the factors associated with the perceived likelihood of participating in free pharmacy-based HIV and HCV testing among PWUD living in rural Kentucky.

METHODS

Baseline data from the CARE2HOPE study in five Appalachian counties in eastern Kentucky were used. Participants were recruited using respondent-driven sampling and completed interviewer-administered surveys. Guided by the Andersen and Newman Framework of Health Services Utilization, we examined distributions and correlates of items regarding willingness to participate in free pharmacy-based HIV/HCV testing using logistic regression. Analyses included individuals who reported being HIV (N = 304) or HCV (N = 185) negative.

FINDINGS

Seventy-five percent of PWUD reported being "very likely" to participate in free pharmacy-based HIV testing and 80% for HCV testing. Two factors were associated with being less willing to participate in free HIV testing: PWUD who previously tested for HIV (OR: 0.47, CI: 0.25-0.88) and PWUD who obtained a high school diploma or equivalent compared to those who completed less (OR: 0.50, CI: 0.26-0.99).

CONCLUSION

Free pharmacy-based HIV and HCV testing was invariably acceptable among most of the rural PWUD in our sample, suggesting that pharmacies might be acceptable testing venues for this population.

Community pharmacist engagement in HIV and HCV prevention: Current practices and potential for service uptake

Background

Objective

Methods

Results

Conclusions

•

Pharmacists are largely willing to help people who need HIV/HCV prevention services.

•

Perception of HIV/HCV prevention fit with pharmacist professional identity varies.

•

Cognitive HIV/HCV prevention services are preferred over hands-on clinical services.

•

Pharmacists often engage in gatekeeping to limit sales of non-prescription syringes.

•

Willingness to sell syringes potentially hinges on minimal contact with requestors.

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.

Prevalence and correlates of non-fatal overdose among people who use drugs: findings from rapid assessments in Massachusetts, 2017-2019

BACKGROUND

People who experience non-fatal overdose (NFOD) are at high risk of subsequent overdose. With unprecedented increases in fentanyl in the US drug supply, many Massachusetts (MA) communities have seen a surge in opioid-related overdoses. The objective of this study was to determine factors associated with lifetime and past year NFOD in at-risk MA communities.

METHODS

We conducted multiple rapid assessments among people who use drugs (PWUD) in eight MA communities using non-probability sampling (purposive, chain referral, respondent-driven) methods. We collected sociodemographic, substance use, overdose history, substance use treatment, and harm reduction services utilization data. We examined the prevalence of NFOD (lifetime and past year) and identified factors associated with NFOD through multivariable logistic regression analyses in a subset of 469 study participants between 2017 and 2019.

RESULTS

The prevalence of lifetime and last year non-fatal opioid overdose was 62.5% and 36.9%, respectively. Many of the study participants reported heroin (64%) and fentanyl (45%) use during the 30 days preceding the survey. Nonprescription buprenorphine and fentanyl use were independently associated with higher odds of lifetime NFOD, while marijuana use was associated with lower odds of lifetime NFOD (p < 0.05). Injection as the route of administration, benzodiazepine, nonprescription buprenorphine, heroin, and fentanyl use were independently associated with higher odds, while methadone use was associated with lower odds of past year NFOD (p < 0.05).

CONCLUSION

We documented a high prevalence of past year and lifetime NFOD among PWUD in MA. Our findings provide indicators that can help inform interventions to prevent overdoses among PWUD, including overdose prevention, medication treatment, and naloxone distribution.

Pharmacist furnishing of naloxone in California: A follow-up analysis

BACKGROUND

Increasing naloxone access in communities has been a priority to mitigate the increasing rate of opioid-related overdose deaths.

OBJECTIVES

The aims of this telephone survey were to estimate the availability of naloxone furnishing (provided without a prescription) by community pharmacists in California and examine the changes that occurred between 2018 and 2020.

METHODS

A telephone audit of a random representative sample of 1271 California licensed community pharmacies was conducted from January 22, 2020, to February 24, 2020. The results were compared with those of a survey of 1147 California licensed community pharmacies that was conducted from January 23, 2018, to February 28, 2018. The primary outcomes measured were naloxone availability without a prescription, information on formulations, cost, insurance billing, and stocking status.

RESULTS

There was a statistically significant increase in the furnishing of naloxone, as well as stocking and billing, in California from 2018 to 2020. Although fewer than half of the pharmacies were willing to provide naloxone without a prescription in 2020 (n = 487, 42.4%), this was an 80% increase from 2018 (P < 0.001). Of the pharmacies furnishing naloxone, many (n = 399, 81.9%) had nasal naloxone in stock, a large and statistically significant increase from 2018 when only 50.6% reported having it in stock (P < 0.001). In 2020, 90% of the pharmacies reported correctly that pharmacist-furnished naloxone could be billed to insurance compared with 56.9% in 2018 (P < 0.001). The median cash price of nasal naloxone (pack of 2) at chain pharmacies in 2020 was $131 (interquartile range [IQR] $129-$138) compared with $153 (IQR, $141-$163; P = 0.001) at independent pharmacies.

CONCLUSION

Community pharmacy-based access to naloxone increased in a statistically significant manner in California, although more than half of the pharmacies still do not provide such access. This study demonstrates the need for further efforts to expand community pharmacy-based access to naloxone.

Pharmacist attitudes and provision of harm reduction services in North Carolina: an exploratory study

BACKGROUND

Pharmacists are among the most accessible healthcare providers in the United States and uniquely positioned to provide harm reduction services. The availability of pharmacy-based harm reduction services and pharmacist attitudes toward delivering these services have been understudied to date. We examine North Carolina (NC) pharmacists' experiences with and attitudes about harm reduction services and explore differences between rural and urban pharmacists.

METHODS

A convenience sample of NC pharmacists participated in an anonymous, online survey regarding harm reduction services: non-prescription syringe sales; naloxone dispensing; and human immunodeficiency virus (HIV) and hepatitis C virus (HCV) screening. Urban-rural differences were analyzed using Pearson's chi-square or Fisher's exact tests. Open-ended responses were analyzed thematically.

RESULTS

Three hundred pharmacists responded to the survey; 68 (23%) practiced in rural counties. Dispensing non-prescription syringes and naloxone at least occasionally was reported by 77% (n = 231) and 88% (n = 263) pharmacists, respectively. Pharmacy-delivered HIV or HCV screening was rare. Urban pharmacists dispensed naloxone more frequently than rural pharmacies (p = 0.04). Only 52% of pharmacists agreed that persons who inject drugs should always be allowed to buy non-prescription syringes. Rural pharmacists' attitudes toward harm reduction services for persons who inject drugs were statistically, though marginally, less supportive when compared to urban pharmacists' attitudes. The most common barrier to non-prescription syringe access was requiring patients to provide proof of prescription injection medication use, which 21% of pharmacists reported was required by their pharmacy's policy on non-prescription syringe sales.

CONCLUSIONS

Although most pharmacies distributed naloxone and sold non-prescription syringes, pharmacy store policies and personal beliefs inhibited naloxone and non-prescription syringe dispensing. NC community pharmacies infrequently offer HIV and HCV screening. Paired with disseminating the evidence of the positive impact of harm reduction on individual and public health outcomes to NC pharmacists, institutional and systems changes to practice and policy may be important to promote harm reduction service availability, particularly for rural NC residents.

TRIAL REGISTRATION

N/A.

Availability of buprenorphine/naloxone films and naloxone nasal spray in community pharmacies in Texas, USA

BACKGROUND AND AIMS

Patients with opioid use disorder (OUD) must be able to obtain prescribed buprenorphine/naloxone films (BUP/NX) and naloxone nasal spray (NNS) from a pharmacy promptly to reduce risk for a recurrence of use and subsequent morbidity and mortality. Telephone audits have identified concerning gaps in availability of NNS within US pharmacies, but the availability of BUP/NX has not been rigorously evaluated. This study estimated the availability of BUP/NX and NNS in the US state of Texas and compared availability by pharmacy type and metropolitan status.

DESIGN

A cross-sectional telephone audit with a secret shopper approach conducted from 18 May 2020 to 7 June 2020. Setting and Participants A random sample of 800 of 5078 (16%) community pharmacies licensed with the Texas State Board of Pharmacy.

MEASUREMENTS

Primary outcomes included availability of a 1-week supply of generic BUP/NX 8/2 mg films and a single unit of NNS 4 mg, overall and by pharmacy type. Secondary outcomes included willingness and estimated time-frame to order BUP/NX if unavailable.

FINDINGS

Data from 704 pharmacies (471 chain, 233 independent) were included for analyses. Of these, 34.1% of pharmacies (45.0% of chains versus 12.0% of independents, P < 0.0001) were willing and able to dispense a 1-week supply of generic BUP/NX and a single unit of NNS. BUP/NX alone was available in 42.2% of pharmacies (52.4% of chains versus 21.5% of independents, P < 0.0001). NNS alone was available in 60.1% of pharmacies (77.9% of chains versus 24.0% of independents, P < 0.0001). Of the 397 pharmacies with generic BUP/NX unavailable, 62.2% of pharmacies (73.9% of chains versus 48.0% of independents, P < 0.0001) indicated willingness to order.

CONCLUSIONS

Most pharmacies in Texas do not appear to be willing and able to dispense prescribed buprenorphine/naloxone films and naloxone nasal spray to patients with opioid use disorder in a timely manner. Deficiencies in availability are markedly more pronounced in independent pharmacies compared with chain pharmacies.

Illicit sale of controlled drugs at community pharmacy/medical stores of Punjab, Pakistan: A road to demolition of public health

Sale of controlled drugs without prescription is a burning issue in developing countries like Pakistan. Illicit sale practices lead towards drug abuse and misuse among youngsters and negatively impact the health of youth and economy of any country. Present study aims to highlight the illicit sale practices at community pharmacies/drug stores of Punjab, Pakistan. Study was conducted at community pharmacies/drug stores (n = 200) of Punjab, Pakistan. Sales men at pharmacies/drugs stores were interviewed and then their statements were cross verified by sending fake customers at their community pharmacies to check the extent of illicit sale practices by them. Gathered data was analyzed using SPPS-22. Out of 200 pharmacies, pharmacists were physically present at 5% of pharmacies (n = 200), rest of the 95% pharmacies (n = 190) were being run by non-qualified persons and were found to be engaged in illicit sale practices. Controlled drugs were being provided to customers without prescription, which is a dilemma and need to be addressed for effective policy making. Physical presence of pharmacists at community pharmacies/drug stores is necessary to overcome the illicit sale practices. Effective policy must be developed and implemented by Governmental Authorities to prevent the youth from hazards associated with drug abuse and misuse.

Examining nonprescription syringe sales in Massachusetts and Rhode Island community pharmacies

Background:

The role pharmacies play in addressing the opioid crisis and drug-related risks such as injection drug use is evolving. Estimating the prevalence of injection drug use at the community level is challenging because of the stigma of drug use. Many community pharmacies sell nonprescription sterile syringes; thus, pharmacy-level sales of injection equipment may be an indicator of drug-related harms and unmet needs of high-risk populations.

Objectives:

To describe, compare, and assess the convergent validity of staff-reported nonprescription syringe (NPS) sales volume and NPS administrative sales data from community pharmacies in Massachusetts (MA) and Rhode Island (RI).

Methods:

This study employed both prospective cross-sectional survey data collection and utilization of administrative pharmacy sales data. Between November 2017 and January 2018, we administered a telephone-based survey to estimate average weekly NPS type and volume for 191 chain pharmacies (CVS Health) located in communities experiencing fatal opioid overdoses above the state’s 2015 annual median rate. For the same time period, we obtained NPS sales data from surveyed pharmacies and all CVS Health pharmacies in the 2 states. We calculated Spearman correlations to assess convergence of average weekly volume between pharmacy staff reports and sales data.

Results:

All pharmacies responded to the survey. Most (98.4%) pharmacies surveyed sold NPS, but 42.0% reported running out of stock monthly or more frequently. Pharmacy staff tended to under-report syringe sales. Staff-reported weekly NPS sales volume was 67,922 versus 70,962 syringes from administrative pharmacy sales data. Spearman correlation between reported and actual NPS sales was 0.40 (95% CI 0.27e0.51).

Conclusion:

The counts of administrative pharmacy syringe sales data in MA and RI indicate high need, substantial volume, and notable access at community pharmacies. Future research should use NPS sales data rather than self-report data to track emerging trends and tailor local responses.

Impact of COVID-19 Related Policy Changes on Buprenorphine Dispensing in Texas

OBJECTIVES

To measure the change in the daily number of patients receiving buprenorphine and buprenorphine prescribers during the early phase of the COVID-19 (SARS-CoV-2) pandemic in Texas.

METHODS

Counts of the number of patients filling and number of providers prescribing buprenorphine were calculated for each weekday between November 4, 2019 and May 12, 2020. The change in daily patients and prescribers between March 2, 2020 and May 12, 2020, was modeled as a change in slope compared to the baseline period using autoregressive, interrupted time series regression.

RESULTS

The rate of change of daily buprenorphine prescriptions (β = -1.75, 95% CI = -5.8-2.34) and prescribers (β = -0.32, 95% CI = -1.47-0.82) declined insignificantly during the COVID-19 period compared to the baseline.

CONCLUSIONS

Despite a 57% decline in ambulatory care utilization in the south-central US during March and April of 2020, health services utilization related to buprenorphine in Texas remained robust. Protecting access to buprenorphine as the COVID-19 pandemic continues to unfold will require intensive efforts from clinicians and policy makers alike. While the presented results are promising, researchers must continue monitoring and exploring the clinical and humanistic impact of COVID-19 on the treatment of substance use disorders.

Point-of-sale Naloxone: Novel Community-based Research to Identify Naloxone Availability

Introduction

Expanding naloxone availability is important to reduce opioid-related deaths. Recent data suggest low, variable urban naloxone availability. No reports describe naloxone availability at the point of sale (POSN). We characterize POSN without prescription across a Midwestern metropolitan area, via a unique poison center-based study.

Methods

Pharmacies were randomly sampled within a seven-county metropolitan area, geospatially mapped, and distributed among seven investigators, who visited pharmacies and asked, “May I purchase naloxone here without a prescription from my doctor?” Following “No,” investigators asked, “Are you aware of the state statute that allows you to dispense naloxone to the public under a standing order?” Materials describing statutory support for POSN were provided. Responses were uploaded to REDCap in real time. We excluded specialty (veterinary, mail order, or infusion) pharmacies a priori. POSN availability is presented as descriptive statistics; characteristics of individual sites associated with POSN availability are reported.

Results

In total, 150 pharmacies were prospectively randomized, with 52 subsequently excluded or unavailable for survey. Thus, 98 were included in the final analysis. POSN was available at 71 (72.5%) of 98 pharmacies. POSN availability was more likely at chain than independent pharmacies (84.7% vs 38.5%, p<0.001); rural areas were more commonly served by independent than chain pharmacies (47.4% vs 21.5%, p = 0.022). Five chain and five independent pharmacies (18.5% each) were unaware of state statutory support for collaborative POSN agreements. Statutory awareness was similar between independent and chain pharmacies (68.8% vs 54.6%, p = 0.453). Rationale for no POSN varied.

Conclusion

POSN is widely available in this metropolitan area. Variability exists between chain and independent pharmacies, and among pharmacies of the same chain; awareness of statutory guidance does not. Poison centers can act to define local POSN availability via direct inquiry in their communities.

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.

Assessing pharmacy-based naloxone access using an innovative purchase trial methodology

OBJECTIVES

Massachusetts was among the first states to allow standing orders to facilitate pharmacy-based naloxone purchases and reduce opioid overdose deaths. We conducted a unique purchase trial to establish a valid measure of standing order naloxone in Massachusetts, using purchasers from 2 high priority populations to determine whether naloxone is less accessible to those who use illicit opioids than other potential purchasers.

DESIGN

Purchase trial.

SETTING AND PARTICIPANTS

The study used a stratified random sample of 200 chain and independent retail pharmacies across Massachusetts. Each pharmacy underwent 2 purchase attempts-1 by a person who used illicit opioids (PWUIO) and 1 by a potential bystander who did not use illicit opioids but had a relationship with someone at risk of opioid overdose.

OUTCOME MEASURE

Successful or unsuccessful naloxone purchase attempt.

RESULTS

Overall, 322 of 397 purchase attempts (81%) were successful, with no statistically significant difference between PWUIO and bystanders (P = 0.221). Most purchases (93%) resulted in the acquisition of single-step nasal naloxone (Narcan; median cost $133.38). Forty percent of the purchases included state-mandated verbal counseling, and PWUIO were significantly less likely to receive counseling than bystanders (30% vs. 51%, P < 0.001). Common reasons for failed purchase were not stocking naloxone (47%), price > $150 (25%), and requiring a prescription (15%). Chain pharmacies were significantly more likely to sell naloxone than independent pharmacies (86% vs. 53%, P < 0.001).

CONCLUSION

We documented high levels of naloxone access for both PWUIO and bystanders, suggesting Massachusetts could serve as a model for states seeking to improve pharmacy-based naloxone access. Additional implementation efforts should focus on expanding availability at independent pharmacies and supporting pharmacies in proactively offering naloxone to PWUIO and other high-risk individuals.

Addressing the data guardian and geospatial scientist collaborator dilemma: how to share health records for spatial analysis while maintaining patient confidentiality

BACKGROUND

The utility of being able to spatially analyze health care data in near-real time is a growing need. However, this potential is often limited by the level of in-house geospatial expertise. One solution is to form collaborative partnerships between the health and geoscience sectors. A challenge in achieving this is how to share data outside of a host institution's protection protocols without violating patient confidentiality, and while still maintaining locational geographic integrity. Geomasking techniques have been previously championed as a solution, though these still largely remain an unavailable option to institutions with limited geospatial expertise. This paper elaborates on the design, implementation, and testing of a new geomasking tool Privy, which is designed to be a simple yet efficient mechanism for health practitioners to share health data with geospatial scientists while maintaining an acceptable level of confidentiality. The basic premise of Privy is to move the important coordinates to a different geography, perform the analysis, and then return the resulting hotspot outputs to the original landscape.

RESULTS

We show that by transporting coordinates through a combination of random translations and rotations, Privy is able to preserve location connectivity among spatial point data. Our experiments with typical analytical scenarios including spatial point pattern analysis and density analysis shows that, along with protecting spatial privacy, Privy maintains the spatial integrity of data which reduces information loss created due to data augmentation.

CONCLUSION

The results from this study suggests that along with developing new mathematical techniques to augment geospatial health data for preserving confidentiality, simple yet efficient software solutions can be developed to enable collaborative research among custodians of medical and health data records and GIS experts. We have achieved this by developing Privy, a tool which is already being used in real-world situations to address the spatial confidentiality dilemma.

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.

Beliefs Associated with Pharmacy-Based Naloxone: a Qualitative Study of Pharmacy-Based Naloxone Purchasers and People at Risk for Opioid Overdose

Drug overdose is the leading cause of unintentional death in the USA and the majority of deaths involve an opioid. Pharmacies are playing an increasingly important role in getting naloxone-the antidote to an opioid overdose-into the community. The aim of the current study was to understand, from the perspective of those who had obtained naloxone at the pharmacy, whose drug using status and pain patient status was not known until the interviews were conducted, as well as those who had not obtained naloxone at the pharmacy but were at risk for overdose, factors that impact the likelihood of obtaining pharmacy-based naloxone (PBN). Fifty-two participants from two New England states were interviewed between August 2016 and April 2017. We used a phenomenological approach to investigate participants' beliefs about pharmacy-based naloxone. The social contextual model was chosen to structure the collection and analysis of the qualitative data as it takes into account individual, interpersonal, organizational (pharmacy), community, and societal influences on a specific health behavior. Of the 52 people interviewed, 24 participants had obtained naloxone from the pharmacy in the past year, of which 4% (n = 1) self-disclosed during the interview current illicit drug use and 29% (n = 7) mentioned using prescribed opioid pain medication. Of the 28 people who had not obtained naloxone from the pharmacy, 46% (n = 13) had obtained an over the counter syringe from a pharmacy in the past month and had used an opioid in the past month, and 54% (n = 15) had used a prescribed opioid pain medication in the past month but did not report a syringe purchase. Several main themes emerged from the interview data. Individual-level themes were as follows: helplessness and fear, naloxone as empowerment to help, and past experiences at the pharmacy. Interpersonal-level themes were as follows: concern for family and friends, and sources of harm reduction information. Themes associated with pharmacy-level influence were as follows: perceived stigma from pharmacists, confusion at the pharmacy counter, and receptivity to pharmacists' offer of naloxone; community-level themes were as follows: community caretaking and need for education and training. Finally, themes at the societal-level of influence were as follows: generational crisis, and frustration at lack of response to opioid crisis. Overall our findings reveal factors at multiple levels which may play a role in likelihood of obtaining naloxone at the pharmacy. These factors can be used to inform interventions seeking to increase provision of pharmacy-based naloxone.

Perspectives on HIV pre-exposure prophylaxis (PrEP) utilization and related intervention needs among people who inject drugs

Background

Antiretroviral pre-exposure prophylaxis (PrEP) is clinically efficacious and recommended for HIV prevention among people who inject drugs (PWID), but uptake remains low and intervention needs are understudied. To inform the development of PrEP interventions for PWID, we conducted a qualitative study in the Northeastern USA, a region where recent clusters of new HIV infections have been attributed to injection drug use.

Methods

We conducted qualitative interviews with 33 HIV-uninfected PWID (hereafter, “participants”) and 12 clinical and social service providers (professional “key informants”) in Boston, MA, and Providence, RI, in 2017. Trained interviewers used semi-structured interviews to explore PrEP acceptability and perceived barriers to use. Thematic analysis of coded data identified multilevel barriers to PrEP use among PWID and related intervention strategies.

Results

Among PWID participants (n = 33, 55% male), interest in PrEP was high, but both participants and professional key informants (n = 12) described barriers to PrEP utilization that occurred at one or more socioecological levels. Individual-level barriers included low PrEP knowledge and limited HIV risk perception, concerns about PrEP side effects, and competing health priorities and needs due to drug use and dependence. Interpersonal-level barriers included negative experiences with healthcare providers and HIV-related stigma within social networks. Clinical barriers included poor infrastructure and capacity for PrEP delivery to PWID, and structural barriers related to homelessness, criminal justice system involvement, and lack of money or identification to get prescriptions. Participants and key informants provided some suggestions for strategies to address these multilevel barriers and better facilitate PrEP delivery to PWID.

Conclusions

In addition to some of the facilitators of PrEP use identified by participants and key informants, we drew on our key findings and behavioral change theory to propose additional intervention targets. In particular, to help address the multilevel barriers to PrEP uptake and adherence, we discuss ways that interventions could target information, self-regulation and self-efficacy, social support, and environmental change. PrEP is clinically efficacious and has been recommended for PWID; thus, development and testing of strategies to improve PrEP delivery to this high-risk and socially marginalized population are needed.

Factors associated with obtaining sterile syringes from pharmacies among persons who inject drugs in 20 US cities

BACKGROUND

Increased access to sterile syringes has been shown to reduce HIV risk among people who inject drugs (PWID). Where syringe services programs (SSPs) are limited, pharmacies are an important sterile syringe source. We assessed factors associated with using pharmacies as the primary source of syringes among PWID from 20 US cities.

METHODS

PWID ages ≥18 years were recruited for the 2015 National HIV Behavioral Surveillance using respondent-driven sampling. Using generalized estimating equation (GEE) models, we assessed demographic characteristics independently associated with participant-reported primary syringe source: pharmacies vs. SSPs. We calculated associations between primary syringe source and various behavioural outcomes, adjusted for participant characteristics.

RESULTS

PWID who were <30 years old, female, white, and less frequent injectors were more likely have used pharmacies as their primary syringe source. Accessing syringes primarily from pharmacies, as compared to SSPs, was associated with receptive syringe sharing and unsafe syringe disposal; using sterile syringes, recent HIV testing and participation in an HIV behavioural intervention were negatively associated with primary pharmacy use.

CONCLUSIONS

Pharmacies can play an important role in comprehensive HIV prevention among PWID. Linkage to HIV interventions and syringe disposal services at pharmacies could strengthen prevention efforts for PWID who cannot access or choose not to utilize SSPs.

Predicting pharmacy naloxone stocking and dispensing following a statewide standing order, Indiana 2016

BACKGROUND

While naloxone, the overdose reversal medication, has been available for decades, factors associated with its availability through pharmacies remain unclear. Studies suggest that policy and pharmacist beliefs may impact availability. Indiana passed a standing order law for naloxone in 2015 to increase access to naloxone.

OBJECTIVE

To identify factors associated with community pharmacy naloxone stocking and dispensing following the enactment of a statewide naloxone standing order.

METHODS

A 2016 cross-sectional census of Indiana community pharmacists was conducted following a naloxone standing order. Community, pharmacy, and pharmacist characteristics, and pharmacist attitudes about naloxone dispensing, access, and perceptions of the standing order were measured. Modified Poisson and binary logistic regression models attempted to predict naloxone stocking and dispensing, respectively.

RESULTS

Over half (58.1%) of pharmacies stocked naloxone, yet 23.6% of pharmacists dispensed it. Most (72.5%) pharmacists believed the standing order would increase naloxone stocking, and 66.5% believed it would increase dispensing. Chain pharmacies were 3.2 times as likely to stock naloxone. Naloxone stocking was 1.6 times as likely in pharmacies with more than one full-time pharmacist. Pharmacies where pharmacists received naloxone continuing education in the past two years were 1.3 times as likely to stock naloxone. The attempted dispensing model yielded no improvement over the constant-only model.

CONCLUSIONS

Pharmacies with larger capacity took advantage of the naloxone standing order. Predictors of pharmacist naloxone dispensing should continue to be explored to maximize naloxone access.

Predicting pharmacy syringe sales to people who inject drugs: Policy, practice and perceptions

BACKGROUND

Pharmacies have much to contribute to the health of people who inject drugs (PWID) and to community efforts in HIV and hepatitis C (HCV) prevention through syringe access. However, little is known about what predicts pharmacy syringe sales without a prescription.

OBJECTIVE

To identify factors predicting pharmacy syringes sales to PWID.

METHODS

A hybrid staggered online survey of 298 Indiana community pharmacists occurred from July-September 2016 measuring pharmacy policy, practice, and pharmacist perceptions about syringe sales to PWID. Separate bivariate logistical regressions were followed by multivariable logistic regression to predict pharmacy syringe sales and pharmacist comfort dispensing syringes to PWID.

RESULTS

Half (50.5%) of Indiana pharmacies sold syringes without a prescription to PWID. Pharmacy syringe sales was strongly associated with pharmacist supportive beliefs about syringe access by PWID and their comfort level selling syringes to PWID. Notably, pharmacies located in communities with high rates of opioid overdose mortality were 56% less likely to sell syringes without a prescription than those in communities with lower rates. Pharmacist comfort dispensing syringes was associated with being male, working at a pharmacy that sold syringes to PWID and one that stocked naloxone, having been asked about syringe access by medical providers, and agreement that PWID should be able to buy syringes without a prescription.

CONCLUSIONS

As communities with high rates of opioid overdose mortality were less likely to have pharmacies that dispensed syringes to PWID, a concerted effort with these communities and their pharmacies should be made to understand opportunities to increase syringe access. Future studies should explore nuances between theoretical support for syringe access by PWID without a prescription and actual dispensing behaviors. Addressing potential policy conflicts and offering continuing education on non-prescription syringe distribution for pharmacists may improve comfort distributing syringes to PWID, and therefore increase pharmacy syringe sales.

Pharmacy-level barriers to implementing expedited partner therapy in Baltimore, Maryland

BACKGROUND

Addressing record high rates of Chlamydia trachomatis incidence in the United States requires the utilization of effective strategies, such as expedited partner therapy, to reduce reinfection and further transmission. Expedited partner therapy, which can be given as a prescription or medication, is a strategy to treat the sexual partners of index patients diagnosed with a sexually transmitted infection without prior medical evaluation of the partners.

OBJECTIVE

There are multiple steps in the prescription-expedited partner therapy cascade, and we sought to identify pharmacy-level barriers to implementing prescription-expedited partner therapy for Chlamydia trachomatis treatment.

STUDY DESIGN

We used spatial analysis and ArcGIS, a geographic information system, to map and assess geospatial access to pharmacies within Baltimore, MD, neighborhoods with the highest rates of Chlamydia trachomatis (1180.25-4255.31 per 100,000 persons). Expedited partner therapy knowledge and practices were collected via a telephone survey of pharmacists employed at retail pharmacies located in these same neighborhoods. Cost of antibiotic medication in US dollars was collected.

RESULTS

Census tracts with the highest Chlamydia trachomatis incidence rates had lower median pharmacy density than other census tracts (26.9 per 100,000 vs 31.4 per 100,000, P < .001). We identified 25 pharmacy deserts. Areas defined as pharmacy deserts had larger proportions of black and Hispanic or Latino populations compared with non-Hispanic whites (93.1% vs 6.3%, P < .001) and trended toward higher median Chlamydia trachomatis incidence rates (1170.0 per 100,000 vs 1094.5 per 100,000, P = .110) than non-pharmacy desert areas. Of the 52 pharmacies identified, 96% (50 of 52) responded to our survey. Less than a fifth of pharmacists (18%, 9 of 50) were aware of expedited partner therapy for Chlamydia trachomatis. Most pharmacists (59%, 27 of 46) confirmed they would fill an expedited partner therapy prescription. The cost of a single dose of azithromycin (1 g) ranged from 5.00 to 39.99 US dollars (median, 30 US dollars).

CONCLUSION

Limited geographic access to pharmacies, lack of pharmacist awareness of expedited partner therapy, and wide variation in expedited partner therapy medication cost are potential barriers to implementing prescription-expedited partner therapy. Although most Baltimore pharmacists were unaware of expedited partner therapy, they were generally receptive to learning about and filling expedited partner therapy prescriptions. This finding suggests the need for wide dissemination of educational material targeted to pharmacists. In areas with limited geographic access to pharmacies, expedited partner therapy strategies that do not depend on partners physically accessing a pharmacy merit consideration.

Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: Challenges and innovations responding to a dynamic epidemic

Community-based overdose prevention programs first emerged in the 1990's and are now the leading public health intervention for overdose. Key elements of these programs are overdose education and naloxone distribution to people who use opioids and their social networks. We review the evolution of naloxone programming through the heroin overdose era of the 1990's, the prescription opioid era of the 2000's, and the current overdose crisis stemming from the synthetic opioid era of illicitly manufactured fentanyl and its analogues in the 2010's. We present current challenges arising in this new era of synthetic opioids, including variable potency of illicit drugs due to erratic adulteration of the drug supply with synthetic opioids, potentially changing efficacy of standard naloxone formulations for overdose rescue, potentially shorter overdose response time, and reports of fentanyl exposure among people who use drugs but are opioid naïve. Future directions for adapting naloxone programming to the dynamic opioid epidemic are proposed, including scale-up to new venues and social networks, new standards for post-overdose care, expansion of supervised drug consumption services, and integration of novel technologies to detect overdose and deliver naloxone.