Pharmacy Technicians, Stigma, and Compassion Fatigue: Front-Line Perspectives of Pharmacy and the US Opioid Epidemic

Barriers and motivational factors for engaging in novel opioid and medication disposal-related services in community pharmacies

OBJECTIVE

This study aimed to explore and identify motivational factors and barriers for pharmacy personnel participation in specific opioid mitigation programs, using the Theory of Planned Behavior (TPB) as an investigational framework.

METHODS

A naturalistic inquiry method was employed involving semi-structured interviews with pharmacy personnel to assess their intentions, attitudes, normative beliefs, and behaviors towards participating in naloxone dispensing and provision of at-home drug disposal solutions. Purposive sampling was utilized to recruit participants, with saturation achieved after 12 interviews. Interviews were transcribed and coded to identify recurring themes.

RESULTS

Four primary themes emerged: 1) the value and benefits of helping others, emphasizing societal, patient, and environmental benefits; 2) limits and barriers to participation, including financial concerns, management support, and time constraints; 3) pharmacists' intrinsic motivators, highlighting personal motivations and differentiation between programs for specific patient types; and 4) program implementation challenges and strategies.

CONCLUSION

The findings underscore the applicability of the TPB in understanding pharmacy engagement in opioid abatement programs. Despite facing barriers such as financial considerations and time constraints, the overall positive attitudes towards the programs indicate a strong motivation to contribute to public health efforts. Addressing identified barriers and leveraging motivators could enhance participation, potentially mitigating the opioid crisis. Future research should incorporate patient perspectives to fully understand the impact and effectiveness of pharmacy-led interventions, such as naloxone dispensing and disposal solutions, in opioid misuse prevention.

Could pharmacy technicians play a role in supporting the appropriate and safe use of traditional and complementary medicines?

Across the world traditional and complementary medicine (T&CM) product use is prevalent with some countries reporting greater than 50% of the population using these products. T&CM products are primarily self-selected through retail outlets including pharmacies. Pharmacists across the world generally agree they should play a role in ensuring the appropriate and safe use of T&CM products but report being time and resource poor to do so. In this commentary, it is proposed that pharmacy technicians as members of the pharmacy workforce, who with adequate education, and supportive technologies could support pharmacists in providing guidance to consumers and patients about the appropriate and safe use of T&CM products. Pharmacy technicians play a crucial role in the pharmacy workforce, serving as integral members of healthcare teams fulfilling a wide array of tasks essential for the efficient functioning of pharmacies and ensuring the safe dispensation of medications. They have been described by pharmacists as the "the face of the pharmacy" in the community setting and relied on not only for mitigating and triaging problems, but also be primarily responsible for developing rapport, eliciting trust and even loyalty from pharmacy patrons. As such, there is a momentous opportunity for pharmacy technicians to play a role in providing T&CM advice and triaging the need for pharmacists' intervention where harm, or risk of is identified.

Substance use Attitudes, Beliefs, Experience, and Knowledge Among Nursing and Nursing Assistant Students

Stigma is a public health concern. Stigmatizing attitudes toward persons with substance use disorders (SUDs) can adversely impact clinical care and outcomes. Beliefs about SUD, prior experience and familiarity to persons with SUD, and educational curricula drive attitudes among health-care workers. In 2019, nursing and nursing assistant students were recruited through an online survey platform. Participants completed an SUD knowledge test and a survey assessing education, beliefs, personal experience, and confidence in recognizing the signs and symptoms of SUD. One hundred and ten health-care students (nursing students, n = 67 and nursing assistant students, n = 43) completed the survey. Among nursing assistant students, endorsing a disease model of addiction (F(2, 40) = 5.83, p < .001, R2 = .23), and personal familiarity with SUD (F(2, 40) = 4.46, p < .001, R2 = .18), were significantly positively predictive of positive regard toward working with persons with SUD. For nursing students, endorsing a disease model of addiction, educational curricula involving persons with SUD, and personal familiarity were significantly positively predictive of positive regard toward working with persons with SUDs (F(2, 61) = 11.52, p < .001, R2 = .36). Interventions to mitigate drug-related stigma among health-care students should center students with personal familiarity, promote the disease concept of addiction, and incorporate contact-based training.

Engaging community pharmacies in practice-based research: Lessons from opioid-focused research

There is an established need to translate evidence-based practices into real-world practice. Community pharmacists and their corresponding pharmacies are well-positioned to be effective partners as researchers seek to study and implement practice-based research. Challenges exist when partnering with community pharmacies which can vary based on the study type, the nature of the community pharmacy, and stakeholder groups (i.e., patients, staff, leadership, physicians). This commentary seeks to describe these challenges and provide recommendations that can help mitigate and/or overcome these challenges. Recommendations are provided for team structure, communication, research tools/technology, motivational factors, workflow, and sustainability. These recommendations are based on the authors' experience in partnering with community pharmacy for opioid-related research in a variety of study types, states, and pharmacy environments.

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.

Drug Use-Related Discrimination in Healthcare Settings and Subsequent Emergency Department Utilization in a Prospective Cohort Study of People With a History of Injection Drug Use

BACKGROUND

 People with a history of injection drug use face discrimination in healthcare settings that may impede their use of routine care, leading to greater reliance on the emergency department (ED) for addressing health concerns. The relationship between discrimination in healthcare settings and subsequent ED utilization has not been established in this population.

METHODS

 This analysis used longitudinal data collected between January 2014 and March 2020 from participants of the ALIVE (AIDS Linked to the IntraVenous Experience) study, a community-based observational cohort study of people with a history of injection drug use in Baltimore, Maryland. Logistic regressions with generalized estimating equations were used to estimate associations between drug use-related discrimination in healthcare settings and subsequent ED utilization for the sample overall and six subgroups based on race, sex, and HIV status.

RESULTS

 1,342 participants contributed data from 7,289 semiannual study visits. Participants were predominately Black (82%), mostly male (66%), and 33% were living with HIV. Drug use-related discrimination in healthcare settings (reported at 6% of study visits) was positively associated with any subsequent ED use (OR = 1.40, 95% CI: 1.15-1.72). Positive associations persisted after adjusting for covariates, including past sixth-month ED use and drug use, among the overall sample (aOR = 1.28, 95% CI: 1.04-1.59) and among some subgroups.

CONCLUSIONS

 Drug use-related discrimination in healthcare settings was associated with greater subsequent ED utilization in this sample. Further exploration of mechanisms driving this relationship may help improve care and optimize healthcare engagement for people with a history of injection drug use.

Community Pharmacists' Knowledge and Perceptions of Buprenorphine for Patients with Opioid Use Disorder

OBJECTIVES

The aims of the study are to evaluate community pharmacists' knowledge and perceptions regarding buprenorphine for opioid use disorder and their willingness to dispense buprenorphine and to identify opportunities for education.

METHODS

An electronic survey of Michigan pharmacists (n = 11,123) assessed demographics, training, buprenorphine knowledge, dispensing, perceptions of stigma, diversion, and confidence in patient/provider interactions. Composite scores for knowledge, stigma, diversion, and confidence were calculated. Cross-tabulations and logistic regressions examined associations.

RESULTS

There were 775 surveys returned (response 7%, n = 11,123) with 390 community pharmacists completing the survey. Twenty-five percent practiced in a rural area. Common practice sites were chain or independent pharmacies (30% each). Ninety-seven percent had buprenorphine training, 50% from Accredited Continuing Pharmacy Education. Eighty percent reported that their pharmacy dispensed buprenorphine with 90% of rural pharmacists compared with 71% urban responding yes. Composite knowledge scores did not differ between urban or rural location ( P > 0.05). Predictors of willingness to dispense buprenorphine were urban location (odds ratio, OR, 0.55; 95% confidence interval [CI], 0.34-0.91; P = 0.01), independent pharmacy (OR, 0.53; 95% CI, 0.30-0.94; P = 0.03), Accredited Continuing Pharmacy Education training (OR, 0.54; 95% CI, 0.34-0.87; P = 0.01), low stigma/diversion (OR, 0.51; 95% CI, 0.37-0.70; P = 0.00), and confidence in patient/provider interactions (OR, 0.14; 95% CI, 0.10-0.19; P = 0.00).

CONCLUSIONS

Most survey pharmacists practice at pharmacies that dispense buprenorphine for opioid use disorder, with a larger proportion from rural pharmacies reporting availability. Pharmacists at independent pharmacies in urban locations have increased willingness to dispense buprenorphine, with urban pharmacists having lower perceptions of diversion compared with rural. Differences in buprenorphine availability, pharmacist willingness to dispense, and perceptions are opportunities for education. Limitations include one state, response bias, self-assessed competencies, and small samples.

"Like it was just everyday business": A qualitative study of pharmacy-based naloxone and syringe customer experience

BACKGROUND

As rates of overdoses involving opioids continue to rise in the United States, community pharmacies are uniquely positioned as a central access point of care for individuals to access harm reduction supplies, such as naloxone and nonprescription syringes (NPS).

OBJECTIVES

This study aimed to identify the facilitators and barriers of obtaining naloxone and NPS at community pharmacies that participated in Respond to Prevent (R2P), a multicomponent intervention to increase dispensing rates of naloxone, buprenorphine, and NPS.

METHODS

Pharmacy customers were recruited to participate in semistructured qualitative interviews conducted immediately after they obtained, or attempted to obtain, naloxone and NPS (when applicable) from R2P-participating pharmacies. Thematic analysis was conducted on the transcribed interviews, and content coding was applied to ethnographic notes and text messages from participants.

RESULTS

Of the 32 participants, most (n = 28, 88%) successfully obtained naloxone and most of those seeking NPS successfully (n = 14, 82%) purchased them as well. Participants reported positive overall experiences at the community pharmacies. Participants described using the intervention advertising materials, as designed, to facilitate the request for naloxone. Many participants shared that they felt respected by pharmacists and that they valued naloxone counseling sessions that were tailored to meet their needs and allowed space for them to ask questions. Barriers included experiences where the intervention did not address structural challenges that prohibited the purchase of naloxone and where certain types of staff lacked knowledge, treated participants poorly, or did not adequately provide expected naloxone counseling.

CONCLUSION

Pharmacy customer experiences obtaining naloxone and NPS in R2P-participating pharmacies identify facilitators and barriers to access that may be used to reform implementation and future interventions. Barriers identified can help enhance strategies or inform policies to improve pharmacy-based harm reduction supply distribution not addressed through existing interventions.

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.

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 direct and indirect effect of neuroticism on work engagement of nurses during COVID-19: A temporal analysis

Healthcare professionals such as nurses faced a tough time during the pandemic. Despite the personal and professional challenges, they contributed immensely during the pandemic. However, there were variations in nurses’ work engagement during the pandemic. One reason could be their personality, especially neuroticism. Neuroticism represents individuals’ proneness to distress in stressful situations, such as COVID-19. Hence, understanding how and in which conditions neuroticism influences work engagement is crucial. We used the Job Demand-Resource (JD-R) model to test the association between neuroticism and work engagement. As neuroticism represents the stress-proneness of an individual, we further investigated if stress mediates the neuroticism-work engagement link. For the nurses, patient interaction is an integral part of their job. Based on the data collected from the nurses, we tested if contact with patients (i.e., beneficiary contact) alleviates the adverse effect of neuroticism on work engagement. During COVID-19, there was an intense need for nursing support. Hence, avoiding duty when society is looking for support might induce a fear of stigmatization among the nurses. We examined if the perceived stigma of duty avoidance would affect the neuroticism-engagement relationship. Our results indicated that higher patient contact alleviated the adverse effect of neuroticism on work engagement. On the other hand, higher fear of stigma exacerbated the adverse effect of neuroticism on work engagement. We further checked the combined effect of beneficiary contact and fear of stigma on neuroticism-work engagement relationships. The findings highlighted the importance of societal factors and policymakers in enhancing nurses’ work engagement.

Barriers and Facilitators to DATA Waivered Providers Prescribing Buprenorphine: A Qualitative Analysis Applying the Theory of Planned Behavior

Background: Provider beliefs about the treatment of people with addiction may influence their prescribing behavior. Objective: This study applied the Theory of Planned Behavior (TPB), to identify the salient beliefs of Drug Addiction Treatment Act of 2000 (DATA 2000) waivered providers, concerning prescribing buprenorphine to patients with Opioid Use Disorder (OUD). Methods: Texas buprenorphine providers participated in one of four online focus group discussions conducted in fall 2019. The focus group discussion were audio recorded and the total length was between 60-90 minutes. Thematic analysis was conducted to identify emerging themes and to categorize the behavioral, normative, and control beliefs related to buprenorphine prescribing. Results: Of the 14 total participants, 57% of the participants were male and annually treated between zero to sixty patients with buprenorphine. The codes generated were represented in thematic maps, specifying the positive or negative aspects of buprenorphine prescribing. Results indicate that providers' primary motivation to prescribe buprenorphine was, implementation of a whole-patient approach through collaboration with behavioral health providers, in the provision of medications for opioid use disorder (MOUD). Providers primary normative belief was the recognition of key members of the medical community and patients' families and friends as influential groups. Providers' control beliefs focused on their ability to use buprenorphine in different practice settings. Conclusion: These results indicate that buprenorphine access may be expanded by increasing support for DATA waivered providers from other parts of the healthcare system such as behavioral health providers and pharmacists. Implications for clinical practice and future research will be discussed.

CONSIDER New Mexico: Effects of naloxone training among pharmacists and pharmacy technicians

BACKGROUND

Pharmacists serve a critical role in providing health care, especially in medically underserved areas. Despite the opioid crisis and legislation in most states allowing pharmacists to dispense naloxone without a prescription from another provider, pharmacists face multiple barriers to dispensing naloxone.

OBJECTIVE

This study tested the effectiveness of CONSIDER New Mexico, an innovative educational initiative designed to increase naloxone dispensing by pharmacies.

METHODS

A quasi-experimental study was conducted in New Mexico in 2019-2020. Community pharmacists and pharmacy technicians were recruited from a purposive sample of pharmacies. Data were collected through pre- and postintervention surveys with 65 pharmacists and 44 technicians from 49 pharmacies. Data analysis included hybrid fixed-effects regression models of variables associated with pre-post intervention change in intent to dispense naloxone and generalized least squares with maximum likelihood estimation for pre-post intervention change in naloxone dispensing.

RESULTS

Positive intervention effects were observed for measures of normative beliefs, self-efficacy, and intent to dispense naloxone (P < 0.05). Changes in normative beliefs and self-efficacy were associated with greater intent to offer naloxone to patients (P < 0.05). In addition, the median number of naloxone prescriptions dispensed per month increased 3.5 times after intervention. A statistically significant positive association was observed between the intervention and naloxone dispensing after adjusting for other factors (P < 0.001). Pharmacies providing more than 4 additional health services were more likely to increase naloxone dispensing postintervention than pharmacies offering not more than 2 services (P < 0.01). This difference averaged 19 naloxone prescriptions per month. Estimated change in dispensing postintervention was statistically significantly lower at independent, clinic-based, and other pharmacies where an average of 36 fewer naloxone prescriptions were dispensed per month compared with chain drug stores (P = 0.03).

CONCLUSION

The CONSIDER New Mexico intervention effectively increased self-efficacy, intent to dispense, and naloxone dispensing. Findings will inform future research examining widespread dissemination and implementation of the intervention and the sustainability of intervention effects.