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Salwan A, Mathis SM, Brooks B, Hagemeier NE, Tudiver F, Foster KN, Alamian A, Pack RP. A theoretical explanation of naloxone provision among primary care physicians and community pharmacists in Tennessee. Res Social Adm Pharm 2024:S1551-7411(24)00204-3. [PMID: 38981793 DOI: 10.1016/j.sapharm.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Increasing access to naloxone reduces opioid-related morbidity and mortality. Primary care and community pharmacy settings are critical access points, yet limited theoretical research has examined naloxone prescribing and dispensing behaviors. OBJECTIVES To determine if the theory of planned behavior (TPB) combined with theoretical constructs from communication science explains intentions to co-prescribe and discuss co-dispensing naloxone among primary care physicians and community pharmacists, respectively. METHODS This cross-sectional study surveyed cohorts of licensed primary care physicians and community pharmacists in Tennessee in 2017. Intentions were measured using profession-specific case vignettes, whereby they were asked given 10 similar patients, how many times (0-10) would they co-prescribe or discuss co-dispensing naloxone. Bivariate and multivariable analyses were used. RESULTS The analytic sample included 295 physicians (response rate = 15.6 %) and 423 pharmacists (response rate = 19.4 %). Approximately 65 % of physicians reported never intending to co-prescribe naloxone (0 out of 10 patients), while 47 % of pharmacists reported never intending to discuss co-dispensing. All TPB constructs-attitudes (AOR = 1.32, CI = 1.16-1.50), subjective norms (AOR = 1.17, CI = 1.06-1.30), and perceived behavioral control (AOR 1.16, CI = 1.02-1.33)-were associated with an increased likelihood of pharmacists always (versus never) discussing co-dispensing. Similarly, two TPB constructs-attitudes (AOR = 1.41, CI = 1.19-1.68) and subjective norms (AOR = 1.22, CI = 1.08-1.39)-were associated with an increased likelihood of physicians always co-prescribing. Among physicians only, one communication construct-self-perceived communication competence (AOR = 1.19, CI = 1.01-1.41)-was associated with an increased likelihood of always co-prescribing. CONCLUSION Findings support the value of theory, particularly TPB, in explaining primary care physician intentions to co-prescribe and community pharmacist intentions to discuss co-dispensing naloxone.
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Affiliation(s)
- Aaron Salwan
- Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA.
| | - Stephanie M Mathis
- College of Public Health, East Tennessee State University, Johnson City, TN, USA
| | - Bill Brooks
- College of Public Health, East Tennessee State University, Johnson City, TN, USA
| | - Nicholas E Hagemeier
- Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
| | - Fred Tudiver
- Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Kelly N Foster
- Department of Sociology and Anthropology, East Tennessee State University, Johnson City, TN, USA
| | - Arsham Alamian
- School of Nursing and Health Studies, University of Miami, Coral Gables, FL, USA
| | - Robert P Pack
- College of Public Health, East Tennessee State University, Johnson City, TN, USA
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Campopiano von Klimo M, Nolan L, Corbin M, Farinelli L, Pytell JD, Simon C, Weiss ST, Compton WM. Physician Reluctance to Intervene in Addiction: A Systematic Review. JAMA Netw Open 2024; 7:e2420837. [PMID: 39018077 PMCID: PMC11255913 DOI: 10.1001/jamanetworkopen.2024.20837] [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: 02/06/2024] [Accepted: 05/07/2024] [Indexed: 07/18/2024] Open
Abstract
Importance The overdose epidemic continues in the US, with 107 941 overdose deaths in 2022 and countless lives affected by the addiction crisis. Although widespread efforts to train and support physicians to implement medications and other evidence-based substance use disorder interventions have been ongoing, adoption of these evidence-based practices (EBPs) by physicians remains low. Objective To describe physician-reported reasons for reluctance to address substance use and addiction in their clinical practices using screening, treatment, harm reduction, or recovery support interventions. Data Sources A literature search of PubMed, Embase, Scopus, medRxiv, and SSRN Medical Research Network was conducted and returned articles published from January 1, 1960, through October 5, 2021. Study Selection Publications that included physicians, discussed substance use interventions, and presented data on reasons for reluctance to intervene in addiction were included. Data Extraction and Synthesis Two reviewers (L.N., M.C., L.F., J.P., C.S., and S.W.) independently reviewed each publication; a third reviewer resolved discordant votes (M.C. and W.C.). This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the theoretical domains framework was used to systematically extract reluctance reasons. Main Outcomes and Measures The primary outcome was reasons for physician reluctance to address substance use disorder. The association of reasons for reluctance with practice setting and drug type was also measured. Reasons and other variables were determined according to predefined criteria. Results A total of 183 of 9308 returned studies reporting data collected from 66 732 physicians were included. Most studies reported survey data. Alcohol, nicotine, and opioids were the most often studied substances; screening and treatment were the most often studied interventions. The most common reluctance reasons were lack of institutional support (173 of 213 articles [81.2%]), knowledge (174 of 242 articles [71.9%]), skill (170 of 230 articles [73.9%]), and cognitive capacity (136 of 185 articles [73.5%]). Reimbursement concerns were also noted. Bivariate analysis revealed associations between these reasons and physician specialty, intervention type, and drug. Conclusions and Relevance In this systematic review of reasons for physician reluctance to intervene in addiction, the most common reasons were lack of institutional support, knowledge, skill, and cognitive capacity. Targeting these reasons with education and training, policy development, and program implementation may improve adoption by physicians of EBPs for substance use and addiction care. Future studies of physician-reported reasons for reluctance to adopt EBPs may be improved through use of a theoretical framework and improved adherence to and reporting of survey development best practices; development of a validated survey instrument may further improve study results.
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Affiliation(s)
| | - Laura Nolan
- JBS International, Inc, North Bethesda, Maryland
| | - Michelle Corbin
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Lisa Farinelli
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Jarratt D. Pytell
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Caty Simon
- National Survivors Union, Greensboro, North Carolina
- NC Survivors Union, Greensboro, North Carolina
- Whose Corner Is It Anyway, Holyoke, Massachusetts
| | - Stephanie T. Weiss
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Wilson M. Compton
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
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Osinski K, Afseth J. A systematic review exploring healthcare professionals' perceptions of take-home naloxone dispensing in acute care areas. J Adv Nurs 2024. [PMID: 38563492 DOI: 10.1111/jan.16181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 03/13/2024] [Accepted: 03/20/2024] [Indexed: 04/04/2024]
Abstract
AIMS To explore healthcare professionals' perceptions and experiences of take-home naloxone initiatives in acute care settings to gain an understanding of issues facilitating or impeding dispensing. DESIGN Systematic literature review. DATA SOURCES Cochrane, MEDLINE and CINAHL were searched from 15/03/2021 to 18/03/2021, with a follow-up search performed via PubMed on 22/03/2021. The years 2011 to 2021 were included in the search. REVIEW METHODS A systematic literature review focused on qualitative studies and quantitative survey designs. Synthesis without meta-analysis was undertaken using a thematic analysis approach. RESULTS Seven articles from the United States of America (5), Australia (1) and Canada (1) with 750 participants were included in the review. Results indicate ongoing stigma towards people who use drugs with preconceived moral concerns regarding take-home naloxone. There was confusion regarding roles and responsibilities in take-home naloxone dispensing and patient education. Similarly, there was a lack of clarity over logistical and financial issues. CONCLUSION Take-home naloxone is a vital harm reduction initiative. However, barriers exist that prevent the optimum implementation of these initiatives. IMPACT What is already known: Deaths due to opioid overdose are a global health concern, with take-home naloxone emerging as a key harm reduction scheme. Globally, less than 10% of people who use drugs have access to treatment initiatives, including take-home naloxone. An optimum point of distribution of take-home naloxone is post-acute hospital care. WHAT THIS PAPER ADDS There is role confusion regarding responsibility for the provision of take-home naloxone and patient education. This is exacerbated by inconsistent provision of training and education for healthcare professionals. Logistical or financial concerns are common and moral issues are prevalent with some healthcare professionals questioning the ethics of providing take-home naloxone. Stigma towards people who use drugs remains evident in some acute care areas which may impact the use of this intervention. Implications for practice/policy: Further primary research should examine what training and education methods are effective in improving the distribution of take-home naloxone in acute care. Education should focus on reduction of stigma towards people who use drugs to improve the distribution of take-home naloxone. Standardized care guidelines may ensure interventions are offered equally and take-home naloxone 'champions' could drive initiatives forward, with support from harm reduction specialists. REPORTING METHOD This has adhered to the PRISMA reporting guidelines for systematic reviews. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- Karen Osinski
- National Poisons Information Service, NHS Lothian, Edinburgh Napier University, Edinburgh, UK
| | - Janyne Afseth
- Edinburgh Napier University, Robert Gordon University, Aberdeen, UK
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Aquizerate A, Rousselet M, Cochard A, Guerlais M, Gerardin M, Lefebvre E, Duval M, Laforgue EJ, Victorri-Vigneau C. "Naloxone? Not for me!" First cross-assessment by patients and healthcare professionals of the risk of opioid overdose. Harm Reduct J 2024; 21:20. [PMID: 38263159 PMCID: PMC10804588 DOI: 10.1186/s12954-024-00941-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/17/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Opioid-related mortality is a rising public health concern in France, where opioids were in 2021 implicated in 75% of overdose deaths. Opioid substitution treatment (OST) was implicated in almost half of deaths related to substance and drug abuse. Although naloxone could prevent 80% of these deaths, there are a number of barriers to the distribution of take-home naloxone (THN) among opioid users in France. This study is the first one which compares patients' self-assessment of the risk of future opioid overdose with the hetero-assessment provided by healthcare professionals in a population of individuals eligible for naloxone. METHODS This was a multicenter descriptive observational study carried out in pharmacies across the Pays de la Loire region (France) during April and May 2022. All adult patients who visited a participating pharmacy for a prescription of OST and provided oral informed consent were enrolled in the study. Retrospective data were collected through cross-sectional interviews conducted by the pharmacist with the patient, utilizing an ad hoc questionnaire. The patient's self-assessment of overdose risk was evaluated using a Likert scale from 0 to 10. The pharmacist relied on the presence or absence of overdose risk situations defined by the French Health Authority (HAS). The need to hold THN was assessed using a composite criterion. RESULTS A total of 34 patients were interviewed; near one third were aware of the existence of THN and a minority had THN in their possession. Out of the 34 participants, 29 assessed their own risk of future opioid overdose: 65.5% reported having zero risk, while 6.9% believed they had a high risk. Nevertheless, at least one risk situation of opioid overdose was identified according to HAS criteria in 73.5% of the participants (n = 25). Consequently, 55% of the participants underestimated their risk of experiencing a future opioid overdose. Yet, dispensing THN has been judged necessary for 88.2% of the participants. CONCLUSION This study underscored the imperative need to inform not only healthcare professionals but also the patients and users themselves on the availability of THN and the risk situations of opioid overdose.
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Affiliation(s)
- Aurélie Aquizerate
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Morgane Rousselet
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-Centered Outcomes and HEalth Research, SPHERE, 44000, Nantes, France
| | - Axel Cochard
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Marylène Guerlais
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Marie Gerardin
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Emilie Lefebvre
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Mélanie Duval
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Edouard-Jules Laforgue
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-Centered Outcomes and HEalth Research, SPHERE, 44000, Nantes, France
| | - Caroline Victorri-Vigneau
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France.
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-Centered Outcomes and HEalth Research, SPHERE, 44000, Nantes, France.
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Daffron A, Koon K, Gruenke NP, Wettergreen S. Effects of pharmacist-driven protocol on naloxone prescribing rates in two primary care clinics. Prev Med Rep 2023; 36:102493. [PMID: 38116254 PMCID: PMC10728458 DOI: 10.1016/j.pmedr.2023.102493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 12/21/2023] Open
Abstract
The Centers for Disease Control and Prevention (CDC) Guidelines for Prescribing Opioids for Chronic Pain recommend co-prescribing naloxone as a harm reduction strategy when there is an increased risk of opioid overdose. Although naloxone co-prescribing is an important harm reduction strategy, many at risk patients are not prescribed naloxone. The objective was to assess the effectiveness of a pharmacist-driven protocol at increasing the number of patients co-prescribed naloxone according to CDC recommendations. The study design was a multi-center retrospective cohort to evaluate the outcomes of a quality improvement intervention at two primary care clinics which aimed to increase naloxone co-prescribing. The intervention used a two-pronged approach consisting of telephonic outreach to eligible patients by pharmacists and pharmacy interns related to naloxone education and recommendations for naloxone co-prescribing. Additionally, recommendations were sent to the primary care provider in the electronic medical record (EMR) for consideration and implementation. After the 3 month intervention, 57 of the 86 patients contacted were co-prescribed naloxone (66.3%). Most naloxone initiation occurred at the time of telephonic outreach as a new medication order (n = 36), however an additional 12 patients were co-prescribed naloxone at a subsequent primary care provider visit. The proportion of patients at each clinic with MME ≥ 50 co-prescribed naloxone significantly increased after implementation of the intervention (pre 25/64 vs. post 43/76, p = 0.043). Overall, telephonic outreach to patients with recommendations to primary care providers in the EMR were effective methods to increase the rate of naloxone co-prescribing in primary care based on this study.
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Affiliation(s)
- Ashley Daffron
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, C238 Aurora, CO 80045, United States
| | - Kelly Koon
- PGY-2 Ambulatory Care Pharmacy Resident, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, C238 Aurora, CO 80045, United States
| | - Nathan P Gruenke
- Pharmacy Student, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, C238 Aurora, CO 80045, United States
| | - Sara Wettergreen
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, C238 Aurora, CO 80045, United States
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Zalmai R, Hill LG, Loera LJ, Mosgrove Q, Brown C. Independent community pharmacists' attitudes and intentions toward dispensing buprenorphine/naloxone for opioid use disorder. J Am Pharm Assoc (2003) 2023; 63:1558-1565.e4. [PMID: 37331654 DOI: 10.1016/j.japh.2023.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/11/2023] [Accepted: 06/11/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Buprenorphine/naloxone (BUP/NX) for opioid use disorder (OUD) is associated with positive health outcomes; however, challenges accessing prescribed BUP/NX at community pharmacies have been identified. OBJECTIVE The theory of planned behavior was applied to determine whether independent community pharmacists' attitudes toward dispensing BUP/NX for OUD predict intentions to dispense. METHODS A 40-item survey was administered to 185 Texas Community Pharmacy Enhanced Services Network pharmacists. The survey assessed intentions to dispense BUP/NX (3 items), attitudes toward BUP/NX (24 items), current barriers to dispensing BUP/NX (2 items), and demographics (10 items). Inferential statistics determined associations among pharmacists' attitudes, practice setting characteristics, and intentions to dispense BUP/NX. Regression analysis determined whether attitude predicted intention to dispense BUP/NX, controlling for practice setting and demographic characteristics. RESULTS Responses were obtained from 82 community independent pharmacists (response rate = 44%). Respondents were predominantly non-Hispanic white (45.8%) and women (56.6%) and practiced in pharmacies with an average 1129.1 (± 1034.5) dispensed prescriptions/week. Pharmacists had positive intentions (6.2 ± 3.5) and attitudes (14.4 ± 24.9) toward dispensing BUP/NX and attitudes did not predict intentions to dispense (P = 0.330). Positive drivers of attitude were related to improving patient outcomes, fulfilling a community need, and absence of conflicts with pharmacists' personal and religious beliefs. A negative driver of attitude was financial reimbursement/loss. Pharmacists dispensing 2000 or more prescriptions/week had higher intentions (b = 3.22, P = 0.014) to dispense than those dispensing less than 500 prescriptions/week. The most common barrier to dispense BUP/NX was "refill was too soon" (54.8%). CONCLUSION Community independent pharmacists had positive attitudes toward and intentions of dispensing BUP/NX for OUD. However, attitudes did not predict intentions to dispense. Negative drivers of attitudes were related to factors not within pharmacists' control, such as time to refill or financial reimbursement.Future studies focused on community pharmacy-based access to BUP/NX are warranted to elucidate issues that are impactful in improving pharmacists' dispensing intentions and behavior.
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Amaram-Davila J, Reddy A, Arthur J, Narayanan S, Gogineni M, Mallipeddi T, De Moraes AR, Maddi R, Shelal Z, Urbauer D, Chen M, Bruera E. Efforts to Improve Naloxone Co-Prescription for Patients With Cancer Pain at Risk of Opioid Overdose. J Palliat Med 2023; 26:969-973. [PMID: 37074064 PMCID: PMC10316523 DOI: 10.1089/jpm.2022.0389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 04/20/2023] Open
Abstract
Importance: Naloxone can be lifesaving in an opioid-related overdose (OD). However, the co-prescription of take-home naloxone (THN) is not widely adopted in routine clinical practice. We implemented a pilot program focused on increasing clinicians' awareness of THN and observed if this impacts THN prescriptions for our patients with cancer pain receiving opioids. Intervention: In January 2020, we initiated an educational program by twice-weekly video presentations and installed pamphlets in all clinic workstations highlighting the risk factors for ODs. We retrospectively reviewed electronic health records (EHR) of randomly selected patient visits, 200 each from eight weeks before intervention (BI) and eight weeks after the intervention (AI). Data on patient characteristics, risk factors for ODs, and THN prescriptions were collected. Results: In all, 380 unique patients were eligible for analysis. The median age was 60, 53% female, and 70% Caucasian. Eighty-two percent (152) BI and 73% (142) AI carried risk factors for ODs (p = 0.13). THN was prescribed to 21% (32/152) BI and 26% (37/142) AI (p = 0.53). Morphine-equivalent daily dose (MEDD) ≥100 mg (30%) and pulmonary disease (25%) were the most prevalent risk factors. The patient's likelihood of receiving a THN prescription increased by 0.9% for every 1-milligram increase in MEDD (p < 0.001, 95% confidence interval: 1.006-1.011). Conclusion: The educational intervention did not significantly increase the frequency of THN prescriptions. More direct interventions, including automatic EHR triggers, may need to be tested in future trials.
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Affiliation(s)
- Jaya Amaram-Davila
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Joseph Arthur
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Santhosshi Narayanan
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Meghana Gogineni
- The University of Texas, University of Southwestern School of Medicine, Dallas, Texas, USA
| | - Tarun Mallipeddi
- The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Aline Rozman De Moraes
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Rama Maddi
- Department of Leukemia, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Zeena Shelal
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Diana Urbauer
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Minxing Chen
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
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Rawal S, Osae SP, Cobran EK, Albert A, Young HN. Pharmacists' naloxone services beyond community pharmacy settings: A systematic review. Res Social Adm Pharm 2023; 19:243-265. [PMID: 36156267 DOI: 10.1016/j.sapharm.2022.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Pharmacists' provision of naloxone services in community pharmacy settings is well-recognized. Recently, studies describing pharmacists' naloxone services in settings other than community pharmacies have emerged in the literature. There is a need to synthesize evidence from these studies to evaluate the scope and impact of pharmacists' naloxone services beyond community pharmacy settings. OBJECTIVES The objectives of this systematic review were to a) identify pharmacists' naloxone services and their outcomes, and b) examine knowledge, attitudes, and barriers (KAB) related to naloxone service provision in non-community pharmacy settings. METHODS Eligible studies were identified using PubMed, Web of Science, and CINAHL. Inclusion criteria were as follows: peer-reviewed empirical research conducted in the U.S. from January 2010 through February 2022; published in English; and addressed a) pharmacists' naloxone services and/or b) KAB related to the implementation of naloxone services. PRISMA guidelines were used to report this study. RESULTS Seventy-six studies were identified. The majority were non-randomized and observational; only two used a randomized controlled (RCT) design. Most studies were conducted in veterans affairs (30%) and academic medical centers (21%). Sample sizes ranged from n = 10 to 217,469, and the majority reported sample sizes <100. Pharmacists' naloxone services involved clinical staff education, utilization of screening tools to identify at-risk patients, naloxone prescribing and overdose education and naloxone dispensing (OEND). Outcomes of implementing naloxone services included improved naloxone knowledge, positive attitudes, increased OEND, and overdose reversals. Pharmacists cited inadequate training, time constraints, reimbursement issues, and stigma as barriers that hindered naloxone service implementation. CONCLUSION This systematic review found robust evidence regarding pharmacist-based naloxone services beyond community pharmacy settings. Future programs should use targeted approaches to help pharmacists overcome barriers and enhance naloxone services. Additional research is needed to evaluate pharmacist naloxone services by using rigorous methodologies (e.g., larger sample sizes, RCT designs).
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Affiliation(s)
- Smita Rawal
- Clinical and Administrative Pharmacy, University of Georgia, Athens, GA, USA.
| | - Sharmon P Osae
- Clinical and Administrative Pharmacy, University of Georgia, Albany, GA, USA
| | - Ewan K Cobran
- Department of Quantitative Health Science, Mayo Clinic College of Medicine and Sciences, Scottsdale, AZ, USA
| | - Alexis Albert
- College of Pharmacy, University of Georgia, Athens, GA, USA
| | - Henry N Young
- Clinical and Administrative Pharmacy, University of Georgia, Athens, GA, USA
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Winstanley EL, Thacker EP, Choo LY, Lander LR, Berry JH, Tofighi B. Patient-reported problems filling buprenorphine prescriptions and motivations for illicit use. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100091. [PMID: 36844166 PMCID: PMC9949336 DOI: 10.1016/j.dadr.2022.100091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/04/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022]
Abstract
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.
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Affiliation(s)
- Erin L. Winstanley
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States,Corresponding author at: Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States.
| | - Emily P. Thacker
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Lyn Yuen Choo
- West Virginia Clinical and Translational Science Institute, West Virginia University, Morgantown, WV, United States
| | - Laura R. Lander
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States
| | - James H. Berry
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States
| | - Babak Tofighi
- Department of Population Health, New York University School of Medicine, United States
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10
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Binswanger IA, Rinehart D, Mueller SR, Narwaney KJ, Stowell M, Wagner N, Xu S, Hanratty R, Blum J, McVaney K, Glanz JM. Naloxone Co-Dispensing with Opioids: a Cluster Randomized Pragmatic Trial. J Gen Intern Med 2022; 37:2624-2633. [PMID: 35132556 PMCID: PMC9411391 DOI: 10.1007/s11606-021-07356-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/15/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Although naloxone prevents opioid overdose deaths, few patients prescribed opioids receive naloxone, limiting its effectiveness in real-world settings. Barriers to naloxone prescribing include concerns that naloxone could increase risk behavior and limited time to provide necessary patient education. OBJECTIVE To determine whether pharmacy-based naloxone co-dispensing affected opioid risk behavior. Secondary objectives were to assess if co-dispensing increased naloxone acquisition, increased patient knowledge about naloxone administration, and affected opioid dose and other substance use. DESIGN Cluster randomized pragmatic trial of naloxone co-dispensing. SETTING Safety-net health system in Denver, Colorado, between 2017 and 2020. PARTICIPANTS Seven pharmacies were randomized. Pharmacy patients (N=768) receiving opioids were followed using automated data for 10 months. Pharmacy patients were also invited to complete surveys at baseline, 4 months, and 8 months; 325 survey participants were enrolled from November 15, 2017, to January 8, 2019. INTERVENTION Intervention pharmacies implemented workflows to co-dispense naloxone while usual care pharmacies provided usual services. MAIN MEASURES Survey instruments assessed opioid risk behavior; hazardous drinking; tobacco, cannabis, and other drug use; and knowledge. Naloxone dispensings and opioid dose were evaluated using pharmacy data among pharmacy patients and survey participants. Intention-to-treat analyses were conducted using generalized linear mixed models accounting for clustering at the pharmacy level. KEY RESULTS Opioid risk behavior did not differ by trial group (P=0.52; 8-month vs. baseline adjusted risk ratio [ARR] 1.07; 95% CI 0.78, 1.47). Compared with usual care pharmacies, naloxone dispensings were higher in intervention pharmacies (ARR 3.38; 95% CI 2.21, 5.15) and participant knowledge increased (P=0.02; 8-month vs. baseline adjusted mean difference 1.05; 95% CI 0.06, 2.04). There was no difference in other substance use by the trial group. CONCLUSION Co-dispensing naloxone with opioids effectively increased naloxone receipt and knowledge but did not increase self-reported risk behavior. TRIAL REGISTRATION Registered at ClinicalTrials.gov ; Identifier: NCT03337100.
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Affiliation(s)
- Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA.
- Colorado Permanente Medical Group, Aurora, CO, USA.
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Deborah Rinehart
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Denver Health, Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, Denver, CO, USA
| | - Shane R Mueller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Melanie Stowell
- Denver Health, Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, Denver, CO, USA
| | - Nicole Wagner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stan Xu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Rebecca Hanratty
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Medicine, Denver Health, Denver, CO, USA
| | - Josh Blum
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Medicine, Denver Health, Denver, CO, USA
| | - Kevin McVaney
- Department of Medicine, Denver Health, Denver, CO, USA
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Colorado School of Public Health, Aurora, CO, USA
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11
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Gugala E, Briggs O, Moczygemba LR, Brown CM, Hill LG. Opioid harm reduction: A scoping review of physician and system-level gaps in knowledge, education, and practice. Subst Abus 2022; 43:972-987. [PMID: 35426772 DOI: 10.1080/08897077.2022.2060423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: Harm reduction includes treatment and prevention approaches rather than abstinence, as a public health strategy for mitigating the opioid epidemic. Harm reduction is a new strategy for many healthcare professionals, and gaps in knowledge and practices may lead to barriers to optimal treatment. Our objective was to identify and describe gaps in physicians' knowledge, education, and practice in harm reduction strategies related to opioid overdose. Methods: We searched the PubMed, CINAHL, and Web of Science databases for articles published between 2015 and 2021, published in English, containing empirical evidence, addressing opioid harm reduction, and identifying gaps in physicians' knowledge, education, or practice. Results: Thirty-seven studies were included. Studies examined how physicians' perceptions or stigma influenced harm reduction efforts and addressed clinical knowledge gaps in overdose treatment and prevention and OUD treatment. Less than half of the studies addressed access issues at the system level, above the individual healthcare professional. Conclusion: Individual-level interventions should be addressed with professional continuing education and curricular-based changes through experiential and interprofessional education. System-level gaps can be remedied by increasing patient access to care, creating policies favorable to harm reduction, and extending resources to provide harm reduction strategies.
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Affiliation(s)
- Emma Gugala
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Owanate Briggs
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Leticia R Moczygemba
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Carolyn M Brown
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Lucas G Hill
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
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12
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Slocum S, Ozga JE, Joyce R, Walley AY, Pollini RA. If we build it, will they come? Perspectives on pharmacy-based naloxone among family and friends of people who use opioids: a mixed methods study. BMC Public Health 2022; 22:735. [PMID: 35418048 PMCID: PMC9006069 DOI: 10.1186/s12889-022-13078-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Expanding access to the opioid antagonist naloxone to reduce overdose mortality is a public health priority in the United States. Naloxone standing orders (NSOs) have been established in many states to increase naloxone dispensing at pharmacies, but increased pharmacy access does not ensure optimal uptake among those likely to witness an overdose. In a prior statewide purchase trial, we documented high levels of naloxone access at Massachusetts pharmacies under a statewide NSO. In this study, we characterize barriers to pharmacy-based naloxone uptake among potential opioid overdose "bystanders" (friends or family of people who use opioids) that may be amenable to intervention. METHODS Eligible bystanders were Massachusetts residents ≥ 18 years of age, did not use illicit opioids in the past 30 days, and knew someone who currently uses illicit opioids. We used a sequential mixed methods approach, in which a series of semi-structured qualitative interviews (N = 22) were conducted April-July 2018, to inform the development of a subsequent quantitative survey (N = 260), conducted February-July 2020. RESULTS Most survey participants (77%) reported ever obtaining naloxone but few (21%) attempted to purchase it at a pharmacy. Qualitative participants revealed that barriers to utilizing the NSO included low perceived risk of overdose, which was rooted in misconceptions regarding the risks of prescription opioid misuse, denial about their loved one's drug use, and drug use stereotypes; inaccurate beliefs about the impact of naloxone on riskier opioid use; and concerns regarding anticipated stigma and confidentiality. Many participants had engaged in mutual support groups, which served as a source of free naloxone for half (50%) of those who had ever obtained naloxone. CONCLUSIONS Despite high levels of pharmacy naloxone access in Massachusetts, few bystanders in our study had attempted to obtain naloxone under the NSO. Low perceived risk of overdose, misinformation, stigma, and confidentiality were important barriers to pharmacy naloxone uptake, all of which are amenable to intervention. Support groups provided a setting for addressing stigma and misinformation and provided a discreet and comfortable setting for naloxone access. Where these groups do not exist and for bystanders who do not participate in such groups, pharmacies are well-positioned to fill gaps in naloxone availability.
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Affiliation(s)
- Susannah Slocum
- Department of Behavioral Medicine & Psychiatry, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Jenny E Ozga
- Department of Behavioral Medicine & Psychiatry, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Rebecca Joyce
- Department of Behavioral Medicine & Psychiatry, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Alexander Y Walley
- Department of Community Health Sciences, School of Public Health, Boston University, Boston, MA, USA.,Grayken Center for Addiction, Clinical Addiction Research Education Unit, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Robin A Pollini
- Department of Behavioral Medicine & Psychiatry, School of Medicine, West Virginia University, Morgantown, WV, USA. .,Department of Epidemiology and Biostatistics, School of Public Health, West Virginia University, Morgantown, WV, USA.
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13
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Martignetti L, Sun W. Perspectives of Stakeholders of Equitable Access to Community Naloxone Programs: A Literature Review. Cureus 2022; 14:e21461. [PMID: 35223245 PMCID: PMC8858082 DOI: 10.7759/cureus.21461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 12/02/2022] Open
Abstract
The purpose of this review is to examine the existing literature about facilitators and barriers influencing equitable access to naloxone programs by individuals who use opioids. A total of 49 published articles were examined, which generated four overarching themes:(1) Stigma as a barrier to access; (2) Lack of a wide range of stakeholder perspectives; (3) Need for a comprehensive understanding of factors affecting equitable access to naloxone programs; (4) Facilitators to increase the access of community naloxone programs. Our review highlighted the importance of advocacy in practice, education, administration, and policy to address the health inequities that exist in naloxone distribution programs. Advocacy activities involve the need for health care professionals to engage in social justice practice through evidence-based informed research about the facts of opioid use; challenging the stigma toward victim-blaming against naloxone users; as well as promoting program development and health policy to bring about equitable access to naloxone programs by marginalized and socially disadvantaged populations.
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14
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Stein BD, Smart R, Jones CM, Sheng F, Powell D, Sorbero M. Individual and Community Factors Associated with Naloxone Co-prescribing Among Long-term Opioid Patients: a Retrospective Analysis. J Gen Intern Med 2021; 36:2952-2957. [PMID: 33598891 PMCID: PMC8481397 DOI: 10.1007/s11606-020-06577-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Naloxone co-prescribing to individuals at increased opioid overdose risk is a key component of opioid overdose prevention efforts. OBJECTIVE Examine naloxone co-prescribing in the general population and assess how co-prescribing varies by individual and community characteristics. DESIGN Retrospective cross-sectional study. We conducted a multivariable logistic regression of 2017-2018 de-identified pharmacy claims representing 90% of all prescriptions filled at retail pharmacies in 50 states and the District of Columbia. PATIENTS Individuals with opioid analgesic treatment episodes > 90 days MAIN MEASURES: Outcome was co-prescribed naloxone. Predictor variables included insurance type, primary prescriber specialty, receipt of concomitant benzodiazepines, high-dose opioid episode, county urbanicity, fatal overdose rates, poverty rates, and primary care health professional shortage areas. KEY RESULTS Naloxone co-prescribing occurred in 2.3% of long-term opioid therapy episodes. Medicaid (aOR 1.87, 95%CI 1.84 to 1.90) and Medicare (aOR 1.48, 95%CI 1.46 to 1.51) episodes had higher odds of naloxone co-prescribing than commercial insurance episodes, while cash pay (aOR 0.77, 95%CI 0.74 to 0.80) and other insurance episodes (aOR 0.81, 95%CI 0.79 to 0.83) had lower odds. Odds of naloxone co-prescribing were higher among high-dose opioid episodes (aOR 3.19, 95%CI 3.15 to 3.23), when concomitant benzodiazepines were prescribed (aOR 1.12, 95%CI 1.10 to 1.14), and in counties with higher fatal overdose rates. CONCLUSION Co-prescription of naloxone represents a tangible clinical action that can be taken to help prevent opioid overdose deaths. However, despite recommendations to co-prescribe naloxone to patients at increased risk for opioid overdose, we found that co-prescribing rates remain low overall. States, insurers, and health systems should consider implementing strategies to facilitate increased co-prescribing of naloxone to at-risk individuals.
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Affiliation(s)
- Bradley D Stein
- RAND Corporation, Pittsburgh, PA, USA.
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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15
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New and Emerging Opioid Overdose Risk Factors. CURRENT ADDICTION REPORTS 2021; 8:319-329. [PMID: 33907663 PMCID: PMC8061156 DOI: 10.1007/s40429-021-00368-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 11/16/2022]
Abstract
Purpose of Review The purpose of this review is to provide a review of the current literature surrounding opioid overdose risk factors, focusing on relatively new factors in the opioid crisis. Recent Findings Both a market supply driving force and a subpopulation of people who use opioids actively seeking out fentanyl are contributing to its recent proliferation in the opioid market. Harm reduction techniques such as fentanyl testing strips, naloxone education and distribution, drug sampling behaviors, and supervised injection facilities are all seeing expanded use with increasing amounts of research being published regarding their effectiveness. Availability and use of interventions such as medication for opioid use disorder and peer recovery coaching programs are also on the rise to prevent opioid overdose. Summary The opioid epidemic is an evolving crisis, necessitating continuing research to identify novel overdose risk factors and the development of new interventions targeting at-risk populations.
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