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Xuan Z, Walley AY, Yan S, Chatterjee A, Green TG, Pollini RA. Pharmacy Naloxone Standing Order and Community Opioid Fatality Rates Over Time. JAMA Netw Open 2024; 7:e2427236. [PMID: 39207758 PMCID: PMC11362859 DOI: 10.1001/jamanetworkopen.2024.27236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 06/13/2024] [Indexed: 09/04/2024] Open
Abstract
Importance Despite the proliferation of pharmacy standing-order naloxone dispensing across many US states before the change to over-the-counter status, few policy analyses have evaluated the implementation of pharmacy naloxone standing orders in addressing opioid overdose fatality among communities. Objective To determine whether the implementation of pharmacy standing-order naloxone was associated with lower opioid fatality rates compared with communities without pharmacies with standing-order naloxone. Design, Setting, and Participants This retrospective multisite study was conducted with an interrupted time series analysis across 351 municipalities in Massachusetts over 24 quarters (from January 1, 2013, through December 31, 2018). Standing-order naloxone dispensing data were collected from 2 sources for all major chain pharmacies and many independent pharmacies, covering 70% of retail pharmacies in Massachusetts. Municipalities had various standing-order naloxone implementation inceptions during the study period. Data were analyzed from December 2021 to November 2023. Exposure The main exposure was measured by the first quarter with standing-order naloxone dispensation as the actual implementation inception. Main Outcomes and Measures The primary study outcome was municipal opioid fatality rate per 100 000 population obtained from the Massachusetts Registry of Vital Records and Statistics. Results The median (IQR) population size across 351 municipalities was 10 314 (3635 to 21 781) people, with mean (SD) proportion of female individuals was 51.1% (2.8 percentage points). Pharmacies from 214 municipalities (60.9%) reported dispensing standing-order naloxone over the study period. At the baseline of the first quarter of 2013, municipalities that eventually had standing-order naloxone had greater quarterly opioid fatality rates compared with those that never implemented standing-order naloxone (3.51 vs 1.03 deaths per 100 000 population; P < .001). After adjusting for municipal-level sociodemographic and opioid prevention factors, there was significant slope decrease of opioid fatality rates (annualized rate ratio, 0.84; 95% CI, 0.78-0.91; P < .001) following standing-order naloxone dispensing, compared with the municipalities that did not implement standing-order naloxone. There were no significant level changes of opioid fatality rates in the adjusted models. Sensitivity analyses yielded similar and significant findings. Conclusions and Relevance These findings suggest that community pharmacy dispensing of naloxone with standing orders was associated with a relative, gradual, and significant decrease in opioid fatality rates compared with communities that did not implement the standing-order naloxone program. These findings support the expansion of naloxone access, including over-the-counter naloxone as part of a multifaceted approach to address opioid overdose.
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Affiliation(s)
- Ziming Xuan
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Alexander Y. Walley
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Shapei Yan
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Avik Chatterjee
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Traci G. Green
- Institute for Behavioral Health, The Heller School for Social Policy and Management at Brandeis University, Waltham, Massachusetts
| | - Robin A. Pollini
- Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Morgantown
- Department of Epidemiology and Biostatistics, West Virginia University School of Public Health, Morgantown
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Floyd AS, Silcox J, Cousin E, Irwin AN, Gray M, Bolivar D, Bratberg J, Arnold J, Al-Jammali Z, Hansen RN, Hartung DM, Green TC. Readiness of community pharmacies to implement an opioid safety intervention. J Am Pharm Assoc (2003) 2023; 63:275-283.e1. [PMID: 36496310 PMCID: PMC9870924 DOI: 10.1016/j.japh.2022.10.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 10/31/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
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.
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Kosobuski L, O’Donnell C, Koh-Knox Sharp CP, Chen N, Palombi L. The Role of the Pharmacist in Combating the Opioid Crisis: An Update. Subst Abuse Rehabil 2022; 13:127-138. [PMID: 36597518 PMCID: PMC9805704 DOI: 10.2147/sar.s351096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022] Open
Abstract
Introduction The opioid overdose crisis has claimed hundreds of thousands of lives in the United States in the last decade, with overdose numbers continuing to climb. At the same time, the role of the pharmacist in combating the opioid crisis continues to evolve. Methods A literature search was conducted in Ovid MEDLINE that incorporated both MeSH terms and keywords to describe two concepts: the opioid epidemic and pharmacists/pharmacies. The search was limited to articles published after 2010 through the end of 2021 and returned 196 articles that were analyzed thematically. Results Thematic analysis revealed the following themes: prevention, interventions, public health role of the pharmacist, pharmacists in multiple roles, barriers, pharmacist and healthcare provider attitudes, educational initiatives for pharmacists and student pharmacists, and future research. Discussion While a great deal of progress has been made in the role of the pharmacist in supporting individuals with opioid use disorder (OUD) in the last two decades, pharmacists must seek to invest time and resources into practices with a strong evidence base to better mitigate the growing, devastating impact of the opioid crisis. Pharmacists must be willing to embrace new and non-traditional roles in patient care, service and research, and seek to advance evidence-based knowledge and practice. Conclusion Pharmacy practice has expanded greatly in the past decade with pharmacists taking on new and creative approaches to addressing the opioid crisis. Collaborative and interdisciplinary approaches to addressing the root causes of opioid misuse and opioid overdose are still desperately needed. These include attention to the critical roles of social determinants of health, stigma elimination, legislative advocacy for patients with OUD, and focused education for providers, pharmacists, and the community. Recognition and support of the value of collaboration to both improve public health and individual patient care, continued investments in pharmacy practice advancement in OUD treatment and harm reduction, and the creation of workflows and prescribing algorithms to assist in dosing medications to prevent withdrawal symptoms and achieve improved pain control are desperately needed.
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Affiliation(s)
- Lucas Kosobuski
- Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota - College of Pharmacy, Duluth, MN, USA
| | - Carolyn O’Donnell
- Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota - College of Pharmacy, Duluth, MN, USA
| | | | - Nathaniel Chen
- Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota - College of Pharmacy, Duluth, MN, USA
| | - Laura Palombi
- Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota - College of Pharmacy, Duluth, MN, USA,Correspondence: Laura Palombi, Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota – College of Pharmacy, 1110 Kirby Drive, 232 Life Science, Duluth, MN, 55812, USA, Tel +1 218-726-6000, Fax +1 218-726-6500, Email
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Wunderlich JR, Engelberg RS, Tofighi B, Schwartz MD. Time for Pharmacy Co-dispensing of Naloxone with Prescribed Opioids? J Gen Intern Med 2022; 37:2621-2623. [PMID: 35581455 PMCID: PMC9411499 DOI: 10.1007/s11606-022-07643-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
| | - Rachel S Engelberg
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Babak Tofighi
- Department of Population Health, NYU Grossman School of Medicine, Bellevue Hospital Center Division of General Internal Medicine, Nathan Kline Institute for Psychiatry Research, New York, NY, USA
| | - Mark D Schwartz
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA.
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Green TC, Stopka T, Xuan Z, Davis TC, Boggis J, Irwin AN, Gray M, Hartung DM, Bratberg J. Examining nonprescription syringe sales in Massachusetts and Rhode Island community pharmacies. J Am Pharm Assoc (2003) 2021; 61:e237-e241. [PMID: 33820716 PMCID: PMC8827136 DOI: 10.1016/j.japh.2021.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/23/2021] [Accepted: 03/05/2021] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Traci C. Green
- Correspondence: Traci C. Green, PhD, MSc, Professor and Director, Opioid Policy Research Collaborative, Heller School for Social Policy and Management, Brandeis University, 415 South Main St., MS035, Waltham MA 02454. (T.C. Green)
| | - Thomas Stopka
- Department of Community Health, Tufts University School of Medicine, Tufts University, Boston, MA
| | - Ziming Xuan
- Department of Community Health Sciences, Boston University School of Public Health, Boston University, Boston, MA
| | - Tyler C. Davis
- Pharmacy Professional Practice Standards, CVS Health, Woonsocket, RI
| | - Jesse Boggis
- Heller School for Social Policy & Management at Brandeis University, Brandeis University, Waltham, MA
| | - Adriane N. Irwin
- Oregon State University College of Pharmacy, Oregon State University, Corvallis, OR
| | | | - Daniel M. Hartung
- Oregon State University College of Pharmacy, Oregon State University, Corvallis, OR
| | - Jeffrey Bratberg
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI
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Santa HM, Amirova SG, Ventricelli DJ, Downs GE, Nowalk AA, Pringle JL, Aruru M. Preparing pharmacists to increase naloxone dispensing within community pharmacies under the Pennsylvania standing order. Am J Health Syst Pharm 2021; 78:327-335. [PMID: 33336254 DOI: 10.1093/ajhp/zxaa387] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Opioid misuse and overdose deaths remain a public health concern in the United States. Pennsylvania has one of the highest rates of opioid overdose deaths in the country, with Philadelphia County's being 3 times higher than the national average. Despite several multimodal interventions, including use of SBIRT (screening, brief intervention, and referral to treatment) methods and naloxone distribution, the rate of overdose deaths remains high. METHODS To gain insights on strategies for improving access to naloxone and naloxone distribution by pharmacists in Philadelphia County, a study was conducted in 11 community pharmacies (chain and independent) in Philadelphia. Twenty-four pharmacists were recruited and completed SBIRT and naloxone trainings. Each pharmacy elected to have at least 1 pharmacy champion who received additional training on and helped develop pharmacy site-specific naloxone dispensing protocols. RESULTS Pre-post survey results showed a reduction in stigmatizing attitudes regarding naloxone dispensing and an increase in pharmacists' understanding of the standing order and appropriate naloxone use. There was an increase in pharmacists' self-reported confidence in their ability to appropriately identify, discuss, and dispense naloxone to patients. All pharmacies increased their average monthly dispensing rate following protocol implementation. CONCLUSION Pharmacists who received both trainings were more likely to change naloxone dispensing practices, leading to an overall increase in naloxone dispensing by community pharmacists. The study addressed overall gaps in pharmacists' knowledge, reduced stigma, and prepared pharmacists to address opioid use and overdose prevention with their patients. The described pharmacist-led patient counseling and intervention service for overdose prevention may be explored as a model for other community pharmacies to adopt to improve naloxone dispensing and similar interventions to reduce overdose deaths.
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Affiliation(s)
- Heather M Santa
- Program Evaluation and Research Unit (PERU), University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Samira G Amirova
- Program Evaluation and Research Unit (PERU), University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | | | - George E Downs
- Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA
| | - Alexandra A Nowalk
- Program Evaluation and Research Unit (PERU), University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Janice L Pringle
- Program Evaluation and Research Unit (PERU), University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Meghana Aruru
- Program Evaluation and Research Unit (PERU), University of Pittsburgh School of Pharmacy, Pittsburgh, PA
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