"The gatekeepers in prevention": Community pharmacist perceptions of their role in the opioid epidemic

Implementation Documentation and Process Assessment of the PharmNet Intervention: Observational Report

BACKGROUND

The number of overdose deaths in the United States involving opioids continues to exceed 100,000 per year. This has precipitated ongoing declarations of a public health emergency. Harm reduction approaches, such as promoting awareness of, ensuring access to, and fostering willingness to use naloxone to reverse opioid overdose, are a key component of a larger national strategy to address the crisis. In addition, overdose reversal with naloxone directly and immediately saves lives. Because of pharmacies' ubiquity and pharmacists' extensive clinical training, community pharmacies are well-positioned, in principle, to facilitate naloxone access and education.

OBJECTIVE

In 2022, a single-site pilot study of PharmNet, a community pharmacy intervention incorporating naloxone distribution, awareness building, and referral, showed promising outcomes for both naloxone and resource distribution in the community. As a next step, this study was intended to be a pilot randomized controlled trial of PharmNet in 7 pharmacies. However, due to circumstances outside of the study team's control, data collection was unable to be fully completed as planned. In keeping with open research standards, we transparently report all available data from the study and discuss trial barriers and processes. We do so both to provide insights that may inform similar studies and to avoid the "file-drawer" (publication bias) problem, which can skew the aggregated scholarly literature through nonpublication of registered trial results or selective publication of findings affirming authors' hypotheses.

METHODS

This paper reports an in-depth implementation study assessment, provides the available observational data, and discusses implementation considerations for similar studies in independent (eg, nonchain) community pharmacies.

RESULTS

Retrospective assessment of study outcomes and fidelity data provided for robust discussion around how resource differences in independent community pharmacies (vs well-resourced chain pharmacies), as well as high demands on staff, can affect intervention implementation, even when leadership is highly supportive.

CONCLUSIONS

Community pharmacies, particularly independent community pharmacies, may require more support than anticipated to be successful when implementing a new intervention into practice, even if it might affect estimates of real-world effectiveness. Further implementation science research is needed specific to independent community pharmacies. All study elements are outlined in the International Registered Report Identifier (IRRID) PRR1-10.2196/42373. Although this paper reports results associated with that registration, results and conclusions should not be given the weight assigned to findings from a preregistered study.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/42373.

Elucidating determinants of medication disposal programs at retail pharmacies in North Carolina

BACKGROUND

Pharmacy-based medication disposal programs is one approach to prevent diversion of unused prescription opioids.

OBJECTIVE(S)

The objective of this study was to assess the extent to which disposal programs have been implemented by retail pharmacies and identify determinants of implementation using the Consolidated Framework for Implementation Research.

METHODS

A sequential mixed-method design was used to examine implementation of medication disposal programs at pharmacies in Pitt County, NC. We conducted environmental scans of all retail pharmacies that served community members (N = 31) to assess the extent to which disposal programs had been implemented. Then, we conducted interviews with pharmacists (n = 15; 48.4%) to identify determinants of implementation. The following pharmacy types were represented in the completed interviews: corporate chain (n = 10), small chain (n = 1), independently owned and operated (n = 1), medical (n = 2), and government (n = 1).

RESULTS

We found that 32.3% of pharmacies (n = 10) had a medication disposal box and 12.9% (n = 4) had posted a flyer on medication disposal. Pharmacists perceived that patients benefit from disposal boxes and medication disposal is in their purview. Determinants of implementation included the cost of sustaining the intervention, polices of corporate and regional management, variable local control in the decision-making process to implement a disposal box, and experience with having a medication disposal box.

CONCLUSION

Our findings highlight one way in which pharmacists can have a vital role in preventing diversion of opioid analgesics and associated consequences. There is a need to expand disposal boxes at pharmacies to increase community member accessibility and use. Future research is needed to determine the cost-effectiveness of expanding the scale of disposal box implementation in community pharmacies.

Identification of Factors Necessary for Gatekeeper of Overdose

Overdose has become a global social problem. The Japanese government requires gatekeeper training to detect and prevent indicators of overdose and suicide. However, knowledge of necessary factors for the gatekeeper of overdose (patient intervention) is limited. This study aimed to investigate the characteristics of individuals who experienced intervening persons expected to overdose, and to identify the factors required of gatekeepers. A Google form was used to survey 298 pharmacists and registered sellers in Japan. We searched for factors by logistic analysis. Knowledge of prescription drugs used for overdose was higher among pharmacists than among registered sellers. Conversely, pharmacists and registered sellers had similar knowledge about OTC drugs. Overall multivariate logistic regression analysis revealed countermeasures against overdose at their workplace (odds ratio (OR): 4.01, 95% confidence interval (CI): 2.25-7.15, p < 0.01) and knowledge that overdose is on the rise (OR: 1.93, 95% CI: 1.04-3.69, p < 0.05) to be significantly associated with intervention experience as a gatekeeper. Countermeasures against overdose at their workplace (OR: 2.40, 95% CI: 1.10-5.25, p < 0.05) in pharmacists and years of work experience (OR: 1.13, 95% CI: 1.04-1.24, p < 0.05), countermeasure against overdose at their workplace (OR: 3.43, 95% CI: 1.18-10.0, p < 0.05), and willingness to participate in study sessions and workshops on overdose (OR: 3.50, 95% CI: 1.51-8.10, p < 0.05) in registered seller were significantly associated with intervention experience as a gatekeeper. These results are useful evidences for countermeasures and gatekeeper training for overdose at pharmacies and drugstores in the community.

Team Approach: Use of Opioids in Orthopaedic Practice

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The opioid epidemic represents a serious health burden on patients across the United States.

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This epidemic is particularly pertinent to the field of orthopaedics because it is one of the fields providing the highest volume of opioid prescriptions.

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The use of opioids before orthopaedic surgery has been associated with decreased patient-reported outcomes, increased surgery-related complications, and chronic opioid use.

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Several patient-level factors, such as preoperative opioid consumption and musculoskeletal and mental health conditions, contribute to the prolonged use of opioids after surgery, and various screening tools for identifying high-risk drug use patterns are available.

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The identification of these high-risk patients should be followed by strategies aimed at mitigating opioid misuse, including patient education, opioid use optimization, and a collaborative approach between health care providers.

The Impact of Provider Communication on Prescription Opioid Use: A Case Report

Over the past few decades, prescription opioids have greatly impacted our society, providing much needed relief for those in severe pain while simultaneously leading many to develop opioid use disorder. Although the scientific community has made great progress in combating this epidemic, there is still much work to be done. Physicians play a crucial role in this fight, as they are the ones in direct contact with patients. Proper and thorough communication is absolutely necessary when treating patients who are prescribed opioids. In this piece, we describe the case of a 62-year-old woman who experienced debilitating, cyclic opioid withdrawals after years of inappropriate prescription opioid use and how much of her suffering could have been avoided. Her case highlights the importance of patient-provider communication and the willingness of many patients to discontinue opioids.

"You didn't have a choice, but to be on your train. The train was moving": West Virginia pharmacists' perspectives on opioid dispensing during the evolution of the opioid crisis

BACKGROUND

West Virginia (WV) has been at the forefront of the opioid crisis in the United States, with the highest rate of opioid overdose mortality involving prescription opioids in the country. To curb the crisis, the state government implemented a restrictive opioid prescribing law in March 2018, Senate Bill 273 (SB273), to decrease opioid prescribing. However, sweeping changes in opioid policy can have downstream effects on stakeholders such as pharmacists. This study is part of a sequential mixed methods investigation of the impact of SB273 in WV in which we interviewed various stakeholders-including pharmacists-about the impact of the law.

OBJECTIVES

This paper aims to explore how pharmacy practice during the opioid crisis impacted the need for restrictive legislation and how SB273 impacted subsequent pharmacy practice in WV.

METHODS

Semi-structured interviews were conducted with 10 pharmacists who were practicing in counties that had been designated as high-prescribing counties based upon county-level prescribing/dispensing data from state records. Analysis of the interviews was informed by the methodological orientation of content analysis to identify emerging themes.

RESULTS

Participants described confronting questionable opioid prescriptions, treatment costs, and insurance coverage driving opioids as a first-line choice for pain management, as well as the influence of corporate policies and the immense responsibility of being the "last line of defense" in the opioid crisis. A central impediment to the care of patients was the inability of the pharmacists to effectively communicate their concerns to prescribers, making improved prescriber-dispenser communication an essential next step in minimizing opioid care gaps.

CONCLUSION

This is one of few qualitative studies that have explored pharmacists' experiences, perceptions, and role in the opioid crisis leading up to and during the enactment of a restrictive opioid prescribing law. In light of the difficulties they faced, a restrictive opioid prescribing law was viewed positively by pharmacists.

Pilot implementation of the PharmNet naloxone program in an independent pharmacy

BACKGROUND

The U.S. overdose epidemic has continued to escalate with more than 100,000 deaths per year in the past several years, most of which involve opioids. Widespread availability of naloxone is part of a national solution to the crisis, and community pharmacies are well-poised to facilitate such distribution and provide additional harm reduction services.

OBJECTIVES

The primary objectives of this study were to (a) examine the usability of each of the separate intervention components prepared for PharmNet, (b) observe intervention fidelity through regularly scheduled site visits, and (c) explore the association between PharmNet implementation and the volume of naloxone sales and distribution in the pilot site.

PRACTICE DESCRIPTION

Here, we describe a carefully designed and tailored pharmacy harm reduction intervention called PharmNet that is designed to maximize harm reduction impact while minimizing utilization of pharmacist resources. It is a pragmatic awareness, service provision, and referral program that was developed through careful, iterative feasibility studies with pharmacists.

PRACTICE INNOVATION

PharmNet procedures include tools and steps to create awareness (e.g., yard signs and messaging for patients, reminder tools for pharmacists), facilitation of naloxone delivery from nonprofits, and provision of referral cards featuring local resources.

EVALUATION METHODS

Evaluation included direct data collection and randomly scheduled fidelity site visits.

RESULTS

The intervention was associated with an increase of 3.33 naloxone doses/mo being dispensed at cost (34.4% relative increase) and an overall increase of 9.33 naloxone doses/mo being dispensed via any mechanism (96.48% relative increase). Around 2.85 referral cards were issued to patients daily. Intervention fidelity was moderate, and the study provides valuable information for how to modify the study prior to a randomized trial.

CONCLUSION

With modifications informed by this pilot study, the PharmNet intervention merits a randomized trial to determine whether it causes increased naloxone dispensing in independent community pharmacies.

A qualitative exploration of unintentional versus intentional exposure to fentanyl among people who use drugs in Austin, TX

BACKGROUND

The prevalence of deaths involving synthetic opioids has historically been lower in Texas than most U.S. states but more than quadrupled from January 2020 to January 2022. This paper explores the emergence of fentanyl in a drug supply where black tar heroin predominates, a factor considered protective against fentanyl adulteration, through the perspectives of people who use drugs (PWUD).

OBJECTIVES

We describe experiences of unintentional exposure to fentanyl, illustrate how some people identify fentanyl in their supply, and present harm reduction strategies that PWUD use to avoid overdose.

METHODS

Thirty rapid assessment interviews were conducted in July 2021 at 2 mobile outreach sites of a harm reduction organization in Austin, Texas. The brief semistructured interviews were designed to assess participant fentanyl exposure experiences.

RESULTS

Participants were clients who reported using heroin or fentanyl in the past week and had lived in Texas for at least 6 months. Seventeen participants identified as male, 10 as female, and 3 as nonbinary. Half identified as white; other participants were Latinx (6), black (2), American Indian (1), and mixed race (6). Two-thirds were unhoused or in transitional housing. The drug supply in Texas has evolved; most participants reported that the heroin and other drugs they obtained contain fentanyl. Participants detected differences by observing changes in the physical characteristics of the drug, experiencing unexpected effects, and using fentanyl test strips. Many had been unintentionally exposed to fentanyl and expressed concerns about fentanyl's presence. The presence of fentanyl had negative unintended consequences for participants, including adverse effects and developing a dependence on opioids.

CONCLUSION

PWUD in Austin, Texas, report increasing prevalence of unintentional fentanyl exposure, despite the predominance of black tar heroin. Pharmacists can provide crucial supplies and education to safeguard the health of this vulnerable population.

The Role of the Pharmacist in Combating the Opioid Crisis: An Update

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.

The PharmNet Harm Reduction Intervention for Community Pharmacies: Protocol for a Pilot Randomized Controlled Trial

Background

The overdose epidemic in the United States has continued to worsen despite substantial efforts to mitigate its harms. The opioid antagonist naloxone has been identified as a key means of reducing the prevalence of fatal overdoses. An important evidence-based approach to optimizing naloxone’s impact is to seed it throughout the community, because bystanders are often able to reverse overdoses more quickly than first responders and sometimes are the only possible means of overdose reversal. As part of a multipronged approach to distributing naloxone nationwide, community pharmacies have been identified as ideal venues for naloxone dispensing, especially under standing orders. However, dispensing rates remain surprisingly low, and there is a need to understand how best to engage community pharmacies in naloxone-based harm reduction services.

Objective

The objective of this trial is to determine whether a tailored, pragmatic pharmacy intervention (PharmNet) results in greater naloxone dispensing relative to baseline (the prior 3 months) compared to a control condition. This pilot trial is intended to determine whether it is appropriate to invest the substantial resources that would be required to conduct a full-scale, randomized controlled study of PharmNet.

Methods

We will conduct a 3-month randomized controlled pilot trial consisting of 2 parallel groups with a 4:3 allocation ratio. A group of 7 independent pharmacies from rural areas in Indiana will be randomly assigned to either the PharmNet intervention arm (n=4) or the control arm (n=3). The primary outcome will be overall naloxone dispensing (both at cost and free), and secondary outcomes will include the distribution of referral cards and multiple variables at the level of individual staff members. Dispensing data will be collected for the 3 months prior to the intervention and the 3 months of the intervention, and all other data will be collected using a pretest-posttest design. The primary analysis will be a generalized linear mixed model with a Poisson distribution with fixed effects for group, time, and their interaction and a random effect for pharmacy ID to account for repeated measures within pharmacies.

Results

This study was approved by the Indiana University institutional review board in 2 phases (August 2, 2021, and April 26, 2022) and was funded by the Indiana University Grand Challenge: Responding to the Addictions Crisis.

Conclusions

If this study produces evidence that the PharmNet intervention results in increased naloxone dispensing relative to control pharmacies, it will be both appropriate and important to study it in a large, full-scale randomized controlled trial.

International Registered Report Identifier (IRRID)

PRR1-10.2196/42373

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.