Pharmacists' stigma toward patients engaged in opioid misuse: When "social distance" does not mean disease prevention

Relationships Between Stigma, Risk Tolerance, and Buprenorphine Dispensing Intentions Among Community-Based Pharmacists: Results From a National Sample

BACKGROUND

Concerns have been raised that pharmacists sometimes act as barriers to patients with opioid use disorder (OUD) accessing buprenorphine treatment. The present research explores how community pharmacists' endorsement (vs non-endorsement) of stigmatizing beliefs about patients taking buprenorphine relate to intentions, comfort, and decisions regarding dispensing buprenorphine for OUD. In addition, we assessed attitudes toward risk in pharmacy practice as a novel correlate of dispensing intentions and decisions.

METHODS

A sample of 207 active community-based pharmacists practicing in the United States responded to survey items measuring stigma, risk tolerance, and intentions to dispense buprenorphine. The survey included 2 vignettes in which patients presented to the pharmacy with a prescription for buprenorphine, and respondents rated their comfort with dispensing and decisions regarding dispensing in the vignette.

RESULTS

Results suggest that both stigma toward patients taking buprenorphine to treat OUD and tolerance for risk in pharmacy settings are related to differences in pharmacists' intentions to and willingness to dispense buprenorphine for OUD.

CONCLUSIONS

Findings support the need for interventions to reduce stigma associated with buprenorphine use among pharmacists and suggest that risk tolerance is an important determinant of pharmacists' behavior that merits further study.

Barriers and Facilitators to Harm Reduction for Opioid Use Disorder: A Qualitative Study of People With Lived Experience

STUDY OBJECTIVE

Although an increasing number of emergency departments (ED) offer opioid agonist treatment, naloxone, and other harm reduction measures, little is known about patient perspectives on harm reduction practices delivered in the ED. The objective of this study was to identify patient-focused barriers and facilitators to harm reduction strategies in the ED.

METHODS

We conducted semistructured interviews with a convenience sample of individuals in Massachusetts diagnosed with opioid use disorder. We developed an interview guide, and interviews were recorded, transcribed, and analyzed in an iterative process using reflexive thematic analysis. After initial interviews and coding, we triangulated the results among a focus group of 4 individuals with lived experience.

RESULTS

We interviewed 25 participants with opioid use disorder, 6 recruited from 1 ED and 19 recruited from opioid agonist treatment clinics. Key themes included accessibility of harm reduction supplies, lack of self-care resulting from withdrawal and hopelessness, the impact of stigma on the likelihood of using harm reduction practices, habit and knowledge, as well as the need for user-centered harm reduction interventions.

CONCLUSION

In this study, people with lived experience discussed the characteristics and need for user-centered harm reduction strategies in the ED that centered on reducing stigma, treatment of withdrawal, and availability of harm reduction materials.

Professional stigma towards clients with methamphetamine use disorder - a qualitative study

Background

Methamphetamine use disorder (MUD) is associated with poor health outcomes. Pharmacists play a role in delivery of substance use treatment, with several studies having examined their attitudes to people with opioid use disorder, but little is known about their attitude towards people with MUD. This study aimed to explore pharmacists' perspectives on the provision of services to clients with MUD.

Methods

A convenience sampling strategy was used to recruit community pharmacists across Sydney, Australia. Semi structured interviews examined views and ideas of pharmacists surrounding the treatment and management of MUD, followed by coding of transcribed interview data by all members of the research team.

Results

Nineteen pharmacists completed the interviews. The main theme identified was stigma held by healthcare professionals. The almost unanimous perception amongst pharmacists was fear and apprehension towards people with MUD, including underlying assumptions of criminality, misinformation regarding people with MUD, and lack of education and knowledge surrounding MUD.

Conclusion

A substantial amount of stigma towards people with MUD was found in this study. Negative attitudes by healthcare professionals can perpetuate healthcare disparities and impede the accessibility of future treatment programs for people with MUD. Appropriate educational interventions on MUD for pharmacists are needed.

Assessing pharmacists' knowledge, attitudes, and practices of opioid management within different patient populations

BACKGROUND

Racial disparities in drug overdose exist, with black, indigenous, and Hispanic individuals experiencing higher rates of opioid overdose deaths. Opioid use disorder prevention services, such as opioid deprescribing and naloxone dispensing, have been identified as ways to prevent opioid overdose. Pharmacists can help use these strategies, but racial disparities in use exist.

OBJECTIVE

This study aimed to evaluate North Carolina (NC) pharmacist knowledge, attitudes, and practices (KAP) of opioid management practices, including opioid deprescribing and naloxone dispensing, across different racial and ethnic groups.

METHODS

This was a prospective, cross-sectional study conducted through a Web-based KAP survey distributed via e-mail to all NC pharmacists using a modified Dillman's method. Descriptive statistics were used to analyze demographics and pharmacist KAP data. Attitudes data were further analyzed using one-way analysis of variance tests and Tukey's post hoc analyses.

RESULTS

After applying exclusion criteria, 527 participants were eligible for analysis; 254 of these individuals completed the entire survey. The survey response rate was 15.3% and respondents were mostly female (59.1%) and white (86.6%). Approximately half of pharmacists knew the correct opioid morphine milliequivalent cutoffs considered to be high risk (47.7%) and not to be exceeded (51.9%). When asked about chronic opioid statistics within the United States, respondents overestimated that 23.70% of patients on chronic opioid therapy receive naloxone (SD = 18.93%). Pharmacists believed that black patients were more likely to adhere to an opioid taper than any other race or ethnicity and Hispanic patients were more likely to adhere to naloxone treatment than any other race or ethnicity. Finally, 91% of pharmacists knew what an opioid taper was, but 77% of pharmacists had never designed one.

CONCLUSIONS

Gaps in knowledge may contribute to further disparities in opioid management. Pharmacists' attitudes may contribute to biases in opioid management practices and practices related to opioid deprescribing may limit the pharmacists' current role. More education is needed so pharmacists can play an increased role in opioid management across all patient populations.

Community Pharmacists' Knowledge and Attitude Towards Opioid Pain Medication Use in Bahir Dar City, North-West Ethiopia

Background

Opioid use is a major global public health problem, affecting 16 million individuals worldwide. According to a 2023 WHO report, out of the 600,000 substance-related deaths worldwide, 80% were attributed to opioid use. Pharmacists play a vital role in reducing unnecessary opioid exposure while facilitating access to non-opioid alternatives. To do so, pharmacists should have sufficient knowledge regarding opioid-containing medications and a positive attitude about opioid use problems.

Objective

This study aimed to evaluate community pharmacists' knowledge of opioid-containing medications and their attitude toward opioid use problems.

Materials and methods

A cross-sectional study was conducted using a self-administered, structured questionnaire distributed to 105 community pharmacists from July 1-30, 2023 in Bahir Dar City, Ethiopia. The tool included demographic information and questions designed to assess participants' knowledge and attitudes.

Results

Out of the 105 pharmacists included in this study, majority were males (54.3%), nearly half held a bachelor's degree (49.5%), and slightly above one-third had over a decade experience (39%). Regarding knowledge and attitude towards opioids, 62 individuals (59%) exhibited good knowledge, and 64 (61%) demonstrated less stigma toward opioid usage. Factors affecting knowledge include: education level (AOR (95% CI): 8.43 (1.76-40.35) and 9.93 (1.04-85.33) for bachelors and postgraduates respectively and age 1.45 (1.20-1.77)]. Meanwhile, experience [AOR (95% CI): 4.64(1.20-17.90) and 4.29 (1.23-15.05)] for 5-9 years and ≥10 years respectively and education level [AOR (95% CI): 4.08 (1.40-11.93) for bachelors and 6.40 (1.42-28.96)] for postgraduates were linked to attitude.

Conclusion

A gap in knowledge and more stigmatizing behavior was observed among community pharmacists. These findings imply the importance of tailored educational interventions to address knowledge gaps and promote positive attitudes toward opioid usage among community pharmacists. Therefore, it is imperative to deliver up-to-date information on opioids, emphasizing their high addiction potential, to ensure pharmacists are well-equipped with the latest information.

Facilitated telemedicine for hepatitis C virus: Addressing challenges for improving health and life for people with opioid use disorder

BACKGROUND

People who use drugs (PWUD) frequently delay or avoid obtaining medical care in traditional healthcare settings. Through a randomized controlled trial, we investigated facilitated telemedicine for hepatitis C virus (HCV) integrated into opioid treatment programmes. We sought to understand the experiences and meanings of facilitated telemedicine and an HCV cure among PWUD.

METHODS

We utilized purposive sampling to interview 25 participants, 6-40 months after achieving an HCV cure. We interpreted and explicated common meanings of participants' experiences of an HCV cure obtained through facilitated telemedicine.

RESULTS

Participants embraced facilitated telemedicine integrated into opioid treatment programmes as patient-centred care delivered in 'safe spaces' (Theme 1). Participants elucidated their experiences of substance use and HCV while committing to treatment for both entities. Facilitated telemedicine integrated into opioid treatment programmes enabled participants to avoid stigma encountered in conventional healthcare settings (Theme 2). Participants conveyed facing negative perceptions of HCV and substance use disorder. Improved self-awareness, acquired through HCV and substance use treatment, enabled participants to develop strategies to address shame and stigma (Theme 3). An HCV cure, considered by PWUD as a victory over a lethal infectious disease, promotes self-confidence, enabling participants to improve their health and lives (Theme 4).

CONCLUSIONS

Integrating facilitated telemedicine into opioid treatment programmes addresses several healthcare barriers for PWUD. Similarly, obtaining an HCV cure increases their self-confidence, permissive to positive lifestyle changes and mitigating the negative consequences of substance use.

PATIENT AND PUBLIC CONTRIBUTION

In this study of patient involvement, we interviewed patient-participants to understand the meaning of an HCV cure through facilitated telemedicine. Participants from a facilitated telemedicine pilot study provided essential input on the design and outcomes of a randomized controlled trial. Pilot study participants endorsed facilitated telemedicine in a testimonial video. They attended site initiation meetings to guide trial implementation. A Patient Advisory Committee (PAC) ensured that patient participants were active members of the research team. The PAC represented patients' voices through feedback on study procedures. A Sustainability Committee supported public involvement in the research process, including educational opportunities, feedback on implementation, and future sustainability considerations.

Assessing Stigma towards Mental Illness in Relation to Demographics Attitudes and Past Experiences among Pharmacy Students in a Jordanian University Sample

Stigma towards mental illness poses a significant risk for negative mental health outcomes. Efforts have been undertaken to mitigate self-stigma and stigmatizing behaviors among the public; however, few have considered stigma among healthcare providers, including pharmacists. This study aimed to assess the level of stigma towards mental illness, using the 15-item version of the Opening Minds Scale for Health Care Providers (OMS-HC), and associated factors among pharmacy students and was conducted via a printed questionnaire. A total of 125 students participated and the mean total stigma score was 47.9 with 58.4% of the participants scoring above 45, the midpoint of the possible range of scores. The stigma score was independent of participant demographics, except for grade point average. Higher total stigma scores were observed among subjects who have been prescribed a neuropsychiatric drug before, those who believe that pharmacists should have a role in mental healthcare, those who believe that pharmacists are qualified enough to provide mental health support, and those who are willing to seek help from a pharmacist. The results indicate an overall high stigma score among pharmacy students, which highlights the importance of enhancing pharmacy students' awareness and knowledge regarding mental healthcare through incorporating additional courses and/or training programs in pharmacy education curricula.

Research Priorities for Expansion of Opioid Use Disorder Treatment in the Community Pharmacy

In the last decade, the U.S. opioid overdose crisis has magnified, particularly since the introduction of synthetic opioids, including fentanyl. Despite the benefits of medications for opioid use disorder (MOUD), only about a fifth of people with opioid use disorder (OUD) in the U.S. receive MOUD. The ubiquity of pharmacists, along with their extensive education and training, represents great potential for expansion of MOUD services, particularly in community pharmacies. The National Institute on Drug Abuse's National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) convened a working group to develop a research agenda to expand OUD treatment in the community pharmacy sector to support improved access to MOUD and patient outcomes. Identified settings for research include independent and chain pharmacies and co-located pharmacies within primary care settings. Specific topics for research included adaptation of pharmacy infrastructure for clinical service provision, strategies for interprofessional collaboration including health service models, drug policy and regulation, pharmacist education about OUD and OUD treatment, including didactic, experiential, and interprofessional curricula, and educational interventions to reduce stigma towards this patient population. Together, expanding these research areas can bring effective MOUD to where it is most needed.

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.

Addressing the Opioid Crisis—The Need for a Pain Management Intervention in Community Pharmacies in Canada: A Narrative Review

Background: The opioid crisis is a public health concern in Canada with a continued rise in deaths and presents a significant economic impact on the healthcare system. There is a need to develop and implement strategies for decreasing the risk of opioid overdoses and other opioid-related harms resulting from the use of prescription opioids. Pharmacists, as medication experts and educators, and as one of the most accessible frontline healthcare providers, are well positioned to provide effective opioid stewardship through a pain management program focused on improving pain management for patients, supporting appropriate prescribing and dispensing of opioids, and supporting safe and appropriate use of opioids to minimize potential opioid misuse, abuse, and harm. Methods: A literature search was conducted in PubMed, Embase and grey literature to determine the characteristics of an effective community pharmacy-based pain management program, including the facilitators and barriers to be considered. Discussion: An effective pain management program should be multicomponent, address other co-morbid conditions in addition to pain, and contain a continuing education component for pharmacists. Solutions to implementation barriers, including pharmacy workflow; addressing attitudes beliefs, and stigma; and pharmacy remuneration, as well as leveraging the expansion of scope from the Controlled Drugs and Substances Act exemption to facilitate implementation, should be considered. Conclusions: Future work should include the development, implementation, and evaluation of a multicomponent, evidence-based intervention strategy in Canadian community pharmacies to demonstrate the impact pharmacists can have on the management of chronic pain and as one potential solution to helping curb the opioid crisis. Future studies should measure associated costs for such a program and any resulting cost-savings to the healthcare system.

Community-Centered Patient Journey Map in Opioid Use Disorder: A Tool to Address Compassion Fatigue among Community Pharmacists

Community pharmacists have become increasingly exposed to opioid use disorders in recent decades. However, both pharmacist training and traditional practice environments have not been adequate to prepare the pharmacist for both the patient care needs and regulatory barriers of patients experiencing opioid use disorders (OUD). As a result, there is a need to increase pharmacists' awareness of both the overall patient experience as they navigate their OUD and the role of the community pharmacy as a touchpoint within that experience. To this end, a Community-Centered Patient Journey in Drug Addiction Treatment journey map was developed with expert insights, clinical experience, and in-depth interviews (conducted in spring of 2021) with 16 participants enrolled in licensed opioid treatment programs in Tennessee. Patients, policymakers, clinicians, and academic researchers were involved in the map development. Lived experiences of key informants were captured via in-depth interviews. A consensus decision-making approach was used throughout the patient journey map development process. The final patient journey map illustrates a non-linear pathway, describes the central role of the patient's community, and emphasizes three major "pain points" within the system (access, adherence, and affordability). Future research should investigate the impact of such a journey map on pharmacy personnel's knowledge, attitudes, and behaviors.

Faculty, staff, and student perceptions of substance use disorder stigma in health profession training programs: a quantitative study

BACKGROUND

Research indicates that stigma impacts the care provided to individuals with Substance Use Disorders (SUDs), but perceptions of SUDs in various healthcare training programs are not well known. We aimed to characterize perceptions of faculty, staff, and students about SUD stigma in professional healthcare training programs.

METHODS

We conducted a cross-sectional survey of faculty, staff, and students employed at or enrolled in one of six health-related colleges at one Mid-South health science center in the United States, including medicine, pharmacy, dentistry, nursing, health professions, and graduate health sciences. Data collection occurred between February and March 2021. We used descriptive and frequency statistics to assess the constructs within the survey instrument.

RESULTS

A total of 572 respondents participated in this study (response rate = 9%; students, n = 428, 75%; faculty, n = 107, 19%; staff, n = 32, 6%). Most respondents reported interacting with persons with a SUD, cited challenges with the interaction, and perceived SUDs to be mental health condition (n = 463) or biological disease (n = 326). Most respondents believed that their college: emphasizes learning about SUDs; promotes an accurate perception of SUDs; and fosters respect for persons with. Few respondents reported they hear faculty, staff, or students express negative comments about persons with SUDs, but they were sometimes expressed by students.

CONCLUSIONS

Most faculty, staff, and students reported experiencing challenges when interacting with a person with a SUD, mainly communication, but few recalled hearing negative comments from their peers. Whether interventions tailored towards improving communication in academic healthcare training settings could minimize challenges experience by faculty, staff, and students when serving individuals with SUDs should be further evaluated.

Perceptions, policies, and practices related to dispensing buprenorphine for opioid use disorder: A national survey of community-based pharmacists

BACKGROUND

Increasing buprenorphine prescribing for opioid use disorder (OUD) has been a major focus of U.S. opioid response efforts. However, concerns related to dispensing buprenorphine have been identified among pharmacists.

OBJECTIVES

This study aimed to describe perceptions, policies, and practices reported by community-based pharmacists in relation to dispensing buprenorphine for OUD and to compare these responses by practice setting.

METHODS

A cross-sectional online survey was administered to a random sample of 6376 pharmacists. Responses were collected anonymously from October 16, 2021, to November 7, 2021.

RESULTS

A response rate of 5.1% was achieved with 325 responders, and 281 were eligible to complete the survey. Most reported practicing in a chain (50.9%) or independent pharmacy (34.7%) as a staff pharmacist (39.7%) or pharmacist-in-charge (37.0%). Most (68.1%) indicated they could usually or always fill a buprenorphine prescription promptly. The most common pharmacy policies related to buprenorphine dispensing were checking the prescription drug monitoring program (71.3%), validating the prescriber's X-waiver (44.9%), accepting only local prescribers (37.4%), and prohibiting refills more than one day early (35.8%). Policies limiting buprenorphine access to local prescribers, local patients, and established patients varied by practice setting and were most common in independent pharmacies. The strongest barriers to buprenorphine dispensing were insurance prior authorization, difficulty reaching prescribers with questions, and concerns about buprenorphine diversion. The strongest facilitators of buprenorphine dispensing were increased communication with prescribers, increased trust with prescribers, increased trust with patients, and increased education for pharmacists.

CONCLUSION

Most respondents indicated they were willing and able to dispense buprenorphine products for OUD promptly. However, they also reported discomfort dispensing when factors representing potential risk of diversion are present. Mitigating this hypersensitivity to diversion risk among pharmacists should be a focus of regulatory agencies and professional organizations. Efforts to address the unique concerns of independent pharmacists will also be essential to improve access.

Social determinants of health derived from people with opioid use disorder: Improving data collection, integration and use with cross-domain collaboration and reproducible, data-centric, notebook-style workflows

Deriving social determinants of health from underserved populations is an important step in the process of improving the well-being of these populations and in driving policy improvements to facilitate positive change in health outcomes. Collection, integration, and effective use of clinical data for this purpose presents a variety of specific challenges. We assert that combining expertise from three distinct domains, specifically, medical, statistical, and computer and data science can be applied along with provenance-aware, self-documenting workflow tools. This combination permits data integration and facilitates the creation of reproducible workflows and usable (reproducible) results from the sensitive and disparate sources of clinical data that exist for underserved populations.

Understanding the role of community pharmacies in current medication for opioid use disorder care practices

BACKGROUND

Many barriers for patient access to medications for opioid use disorder (MOUD) exist in current care practices. Previous literature has evaluated subsets of pharmacists, patients, and prescribers; however, few have collectively evaluated the perspectives of all 3 groups.

OBJECTIVE

The objective of the study was to identify barriers, facilitators, and opportunities for improvement in Indiana community pharmacy MOUD care practices from the perspectives of peer recovery coaches, community pharmacists, and prescribers to optimize patient care.

METHODS

Individual semistructured interviews were conducted with each participant. Interviews explored stakeholders' perspectives on their current role in MOUD care practices and how current pharmacy practices could be improved. Data were analyzed using preconceived deductive and iterative inductive codes. The first author analyzed all transcripts, of which 3 were also analyzed separately by the last author to confirm consistent utilization of codes. All transcripts were coded once, followed by a second coding to ensure inductive codes were thoroughly applied.

RESULTS

Ten peer recovery coaches, 10 pharmacists, and 6 prescribers were included. Interviews identified barriers, facilitators, and opportunities for improvement in current MOUD care practices. Stigma was a major barrier identified by all groups. Other barriers identified included limited patient engagement at pharmacies and lack of access to patient-specific health information in community pharmacy settings. Pharmacists also identified additional barriers including Drug Enforcement Administration regulations and difficulties balancing patient care with external factors like insurance and legal policies. Positive prescriber/pharmacist relationships were identified as a facilitator of care. Opportunities for improvement included having community MOUD resource information available at pharmacies, further education on MOUD for pharmacists, and increased collaboration between pharmacists and prescribers.

CONCLUSION

Many barriers exist in current MOUD care practices. Additional pharmacist MOUD education and intentional collaboration between pharmacists, peer recovery coaches, and prescribers would facilitate better care and leverage the accessibility of pharmacists within their communities.

Community pharmacist-provided opioid intervention frequencies and barriers

BACKGROUND

Community pharmacists are well-positioned to engage in opioid-related harm reduction activities (i.e., opioid interventions). However, several barriers to providing these interventions have been identified. Comparing the frequencies of opioid interventions and identifying which barriers are perceived to have the highest impact in providing interventions will yield valuable information for increasing opioid use disorder (OUD) care access within pharmacies.

OBJECTIVES

To (1) characterize the frequency of 9 opioid interventions in community practice settings and (2) assess community pharmacists' perceptions of what impact 15 key barriers have on providing opioid interventions.

METHODS

This was a multi-state, cross-sectional, and descriptive survey study. Opioid interventions evaluated included prevention (e.g., OUD screening) and treatment (e.g., OUD resource referral); barriers encompassed confidence and knowledge, work environment, provider interactions, and patient interactions. Respondents were recruited from 3 community pharmacy practice-based research networks in the Midwest and South regions of the US. Recruitment and telephone survey administration occurred between December 2021 and March 2022. Descriptive statistics were computed and open-ended items were reviewed to identify common themes.

RESULTS

Sixty-nine of 559 pharmacists contacted (12.3%) completed the survey. All opioid interventions were reported to be provided less frequently than indicated in practice. Screening and referral interventions were provided least frequently, at 1.2 and 1.6 times on average, respectively, to the last 10 patients for which respondents felt each intervention was needed. Patient refusal, minimal or no reimbursement, inadequate staffing and time, and negative patient reactions were identified as the highest-impact barriers to providing opioid interventions. Approximately 26% of respondents agreed or strongly agreed that pharmacy school adequately prepared them to provide opioid interventions in practice.

CONCLUSION

Prioritizing the resolution of pharmacy work environment barriers will support pharmacists in routinely providing opioid interventions. Changes in Doctor of Pharmacy curricula and continuing education are also indicated to further prepare pharmacists to engage in opioid-related harm reduction.

Patient-reported problems filling buprenorphine prescriptions and motivations for illicit use

Background

While barriers to accessing buprenorphine (BUP) therapy have been well described, little is known about pharmacy-related barriers. The objective of this study was to estimate the prevalence of patient-reported problems filling BUP prescriptions and determine whether these problems were associated with illicit use of BUP. The secondary objectives included identifying motivations for illicit BUP use and the prevalence of naloxone acquisition among patients prescribed BUP.

Methods

Between July 2019 and March 2020, 139 participants receiving treatment for an opioid use disorder (OUD) at two sites within a rurally-located health system, completed an anonymous 33-item survey. A multivariable model was used to assess the association between pharmacy-related problems filling BUP prescriptions and illicit substance use.

Results

More than a third of participants reported having problems filling their BUP prescription (34.1%, n = 47) with the most commonly reported problems being insufficient pharmacy stock of BUP (37.8%, n = 17), pharmacist refusal to dispense BUP (37.8%, n = 17), and insurance problems (34.0%, n = 16). Of those who reported illicit BUP use (41.5%, n = 56), the most common motivations were to avoid/ease withdrawal symptoms (n = 39), prevent/reduce cravings (n = 39), maintain abstinence (n = 30), and treat pain (n = 19). In the multivariable model, participants who reported a pharmacy-related problems were significantly more likely to use illicitly obtained BUP (OR=8.93, 95% CI: 3.12, 25.52, p < 0.0001).

Conclusion

Efforts to improve BUP access have primarily focused on increasing the number of clinicians waivered to prescribe; however, challenges persist with BUP dispensing and coordinated efforts may be needed to systematically reduce pharmacy-related barriers.

Pharmacists' experiences with a statewide naloxone standing order program in Massachusetts: a mixed methods study

OBJECTIVES

In a prior statewide naloxone purchase trial conducted in Massachusetts, we documented a high rate of naloxone dispensing under the state's standing order program. The purpose of this study was to understand the factors that facilitate naloxone access under the Massachusetts naloxone standing order (NSO) program and identify any remaining barriers amenable to intervention.

DESIGN

Mixed methods design involving a pharmacist survey and 3 pharmacist focus groups.

SETTING AND PARTICIPANTS

Focus groups were conducted at 3 separate professional conferences for pharmacists (n = 27). The survey was conducted among Massachusetts pharmacists (n = 339) working at a stratified random sample chain and independent retail pharmacies across Massachusetts. All data were collected between September 2018 and November 2019.

OUTCOME MEASURES

Facilitators and barriers to NSO implementation and naloxone dispensing and pharmacists' attitudes and beliefs regarding naloxone and opioid use.

RESULTS

Most pharmacists described NSO implementation as being straightforward, although differences were reported by pharmacy type in both the survey and focus groups. Facilitators included centralized implementation at chain pharmacies, access to Web-based resources, regularly stocking naloxone, and use of naloxone-specific intake forms. Barriers included patient confidentiality concerns and payment/cost issues. Only 31% of surveyed pharmacists reported always providing naloxone counseling; the most commonly cited barriers were perceived patient discomfort (21%) and time limitations (14%). Confidential space was also more of a concern for independent (vs. chain) pharmacists (18% vs. 6%, P = 0.008). A majority of pharmacists held supportive attitudes toward naloxone, although some reported having moral/ethical concerns about naloxone provision.

CONCLUSION

We documented several facilitators to NSO implementation and naloxone dispensing. Areas for improvement include addressing stigma and misconceptions around opioids and naloxone use. These remain important targets for improving pharmacy-based naloxone dispensing, although our overall positive results suggest Massachusetts' experience with NSO implementation can inform other states' efforts to expand pharmacy-based naloxone access.

Pharmacist Views Regarding the Prescription Opioid Epidemic

Community pharmacists have significant opportunity to contribute to prevention and treatment of opioid use disorders, but barriers to implementation still exist. Understanding their viewpoints is critical to designing future interventions. To qualitatively explore experiences and beliefs of community pharmacists regarding the misuse of prescription opioids in the United States. The study was part of a larger project that utilized a survey questionnaire to evaluate the relationships between knowledge, attitudes, and practices of community pharmacists in substance use disorders. The survey included an open-ended item on pharmacist views regarding the prescription opioid epidemic. The responses were used for inductive content analysis. Axial coding of themes was conducted to analyze underlying relationships: associations, consequences, intervening relationships, and action strategies regarding a central phenomenon. A model describing pharmacist experiences in the opioid epidemic was conceptualized. The open-ended question resulted in 50 (37.3%) usable responses. Final abstraction resulted in six themes including (1) overprescribing opioids: inappropriate prescribing as a contributor to the epidemic, (2) policy and practice recommendations: potential action strategies against the epidemic, (3) poor prescriber-pharmacist relationship: barrier to addressing the epidemic, (4) negative attitudes: intervening condition affecting roles of the pharmacist, (5) personal experience: facilitator to improve pharmacist roles and (6) decreased access to opioids: consequence of strict prescribing laws. The study identified themes that described pharmacist views, attitudes, barriers, and experiences related to their perceived role in prevention and treatment of opioid use disorders. Future research should consider the implications of the barriers and facilitators identified.