Systematic Analysis of the Service Process and the Legislative and Regulatory Environment for a Pharmacist-Provided Naltrexone Injection Service in Wisconsin

Informing an Intervention to Improve Access to Community Pharmacist-Provided Injectable Naltrexone for Formerly Incarcerated Individuals in Wisconsin

In Wisconsin, opioid use disorder (OUD) is highly prevalent among individuals impacted by the criminal justice system. Medications for opioid use disorder (MOUD), including injectable naltrexone, are crucial for treating OUD and especially important for individuals transitioning out of correctional facilities and back into the community. Unfortunately, few formerly incarcerated individuals are able to access MOUD upon community reentry, remaining at high risk of overdose and rearrest. Community pharmacists are a promising resource for providing injectable naltrexone to formerly incarcerated individuals using this treatment option, but are underutilized during reentry planning and by formerly incarcerated individuals upon release. This is due, in large part, to several barriers that exist across the socioecological scale. Accordingly, this study utilized a participatory design process to inform an intervention that address these barriers and improves access to community pharmacist-provided injectable naltrexone for formerly incarcerated individuals upon community reentry. Three iterative focus groups were conducted with five community pharmacists who have experience providing injectable naltrexone and treating formerly incarcerated patients. The goals of each focus group were to: 1) discuss perceptions of existing barriers and prioritize barriers to be addressed, 2) discuss and rank potential interventions to address the prioritized barriers, and 3) discuss components and anticipated challenges related to the prioritized intervention. Focus groups were analyzed via deductive content analysis using a priori categories. Based on discussions of perceived impact and feasibility, the participants prioritized two barriers to be addressed: lack of awareness of community pharmacist-provided injectable naltrexone services and lack of interagency collaboration among primary care clinics, community pharmacies, and correctional facilities. The final intervention included pharmacist-led educational meetings with correctional providers and reentry staff. Several intervention components and anticipated challenges were also identified. Next steps include developing, implementing, and evaluating the efficacy of the intervention on improving access to community pharmacist-provided injectable naltrexone for formerly incarcerated individuals.

Barriers and Facilitators to Community Pharmacist-Provided Injectable Naltrexone for Formerly Incarcerated Individuals During Community Reentry in Wisconsin

Medications for opioid use disorder (MOUD), including injectable naltrexone, are a key component in the treatment of opioid use disorder (OUD). These medications are especially important for individuals transitioning out of correctional facilities and back into their communities, as individuals receiving MOUD are 85% less likely to die due to drug overdose in the first month post-release and have a 32% lower risk of rearrest. Unfortunately, few formerly incarcerated individuals have access to MOUD upon reentry, incurring a 40-fold greater likelihood of overdose following release compared to the general population. While 84% of Wisconsin jails offering MOUD offer naltrexone, less than half provide linkage to community treatment for reentering individuals. In Wisconsin, community pharmacists have the authority to provide naltrexone injections. However, they have not been explored as a resource for improving access to this medication for formerly incarcerated individuals. As a first step, the goal of this study was to understand the barriers and facilitators impacting access to community pharmacist-provided injectable naltrexone for this patient population during community reentry period. The researcher conducted semi-structured interviews with 18 individuals representing five stakeholder groups. Deductive and inductive content analysis were used to identify barrier and facilitator categories across the five levels of the Socioecological Model. Overall, participants discussed factors at every level, and many barriers and facilitators confirmed findings from existing literature focused on MOUD access for formerly incarcerated individuals. Participants also identified factors more specific to community pharmacies, including 1) lack of interagency collaboration between pharmacists, prescribers, and correctional facilities and 2) lack of awareness of community pharmacist-provided MOUD services. Future research should explore interventions to address the barriers identified in this study and improve connections between community pharmacists and formerly incarcerated individuals. This work can help ensure that these individuals are given the chance to successfully reintegrate into society.

Access to medications for opioid use disorder for formerly incarcerated individuals during community reentry: a mini narrative review

Medications for opioid use disorder (MOUD) are especially important for formerly incarcerated individuals with opioid use disorder (OUD) and can reduce the risk of re-arrest and overdose during community reentry. Unfortunately, few formerly incarcerated individuals are able to access MOUD within the community, missing a critical tool for rehabilitation. A mini narrative review was conducted to highlight the published work that has been done to improve access to MOUD for formerly incarcerated individuals during reentry. The results yielded 15 records describing intervention evaluations, program descriptions, and research in progress. Most work is ongoing, showing promise that researchers have identified the importance of this problem. However additional research should be done to include other stakeholders and address the limitations of existing interventions and programs. Continued efforts can help ensure that formerly incarcerated individuals can safely and successfully reintegrate into society.

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

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

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.

Systematic review of community pharmacist administration of long-acting injectable antipsychotic medications

BACKGROUND

Long-acting injectable antipsychotic (LAIA) medications offer an effective treatment option for patients with serious mental illness. Despite demonstrated clinical safety and efficacy as well as increased adherence and less frequent administration compared with daily oral regimens, LAIAs remain underutilized in clinical practice. With legislation allowing pharmacists to administer injectable medications in 48 U.S. states, community pharmacies are uniquely positioned to serve as an access point for patients with serious mental illnesses to receive LAIA injections.

OBJECTIVE

This study aimed to conduct a systematic review of the health and economic benefits and costs of community pharmacist administration of LAIA medications.

METHODS

A systematic search of the literature published from January 1996 to April 2022 was conducted across 3 databases (Embase, PubMed, and Scopus Plus). Publications describing pharmacist administration of LAIA medications in outpatient settings were included. Publications that examined the use of LAIAs but did not involve a pharmacist administering the medication were excluded.

RESULTS

Of 2261 publications reviewed, we identified 8 publications (4 articles and 4 abstracts) that met our inclusion criteria, of which only 7 included results. Four studies reported high medication adherence achieved by patients receiving pharmacist-administered LAIAs. Two publications surveyed patient satisfaction with pharmacist administration of LAIAs in community pharmacy settings. One study found pharmacists' mixed attitudes regarding LAIA administration and time and safety barriers to offering the service.

CONCLUSION

We found very little evidence on the impact of pharmacist administration of LAIAs on patient outcomes. This review highlights the need to generate greater evidence on the health and economic benefits as well as financial models for pharmacists to administer LAIA medications in outpatient and community pharmacy settings. Such evidence could support more community pharmacists to offer LAIA medications and contribute to the shift toward value-based care.

Pharmacists and opioid use disorder care during COVID-19: Call for action

Opioid use disorder (OUD) is a chronic relapsing condition characterized by problematic opioid use causing significant impairment in daily life. Medication for opioid use disorder using buprenorphine, methadone, and naltrexone with behavioral therapy reduces illicit opioid use and risk of overdose death. Despite evidence and decades of experience, barriers limit access to treatment and care for individuals with OUD. Barriers include a lack of treatment centers particularly in rural areas, regulations on buprenorphine prescribing, and stigma from the community and health care professionals. While many barriers are longstanding, the coronavirus disease 2019 (COVID‐19) pandemic‐forced isolation and associated stress has exacerbated challenges for individuals with mental health conditions such as OUD. Pharmacists are well‐positioned to bridge existing gaps in OUD care, particularly during the COVID‐19 pandemic. Roles for pharmacists include OUD risk identification and screening, referral of patients to treatment and support programs, ensuring medication access, expanding naloxone access, and advocacy initiatives. This review article identifies barriers to care for patients with OUD during the COVID‐19 pandemic and explores opportunities and resources for pharmacists to improve OUD care during the pandemic and beyond.

Pilot testing a tool to determine the costs and time associated with community pharmacy-based administration of injectable naltrexone

BACKGROUND

Medications for opioid use disorder (MOUD), including injectable naltrexone (IN), are part of evidence-based OUD treatments. MOUD access often is limited, especially in rural communities. When authorized to administer non-vaccination injections, pharmacists can increase IN accessibility. However, inadequate reimbursement for pharmacist-administered IN can hinder widespread adoption.

OBJECTIVES

To pilot test a process to obtain a preliminary estimate of the total costs and time associated with community-pharmacist administered IN.

METHODS

A purposively-selected sample of key informants at community pharmacies administering IN were surveyed about time and cost for best practice IN activities. Respondents estimated the time to perform activities and average pharmacist/pharmacy technician hourly salary, which were used to calculate administration costs.

RESULTS

The approach to estimate time and costs was feasible. Administrative costs (mean = $93, range: $48-$164) and time (mean = 123 min., range: 63-220 min.) to administer IN varied widely. Pharmacists'/pharmacy technicians' roles varied by pharmacy.

CONCLUSIONS

Pharmacists allocate significant time and resources to administer IN. Insufficient reimbursement may disincentivize pharmacy-involved OUD treatment and ultimately slow needed expansion of MOUD services. Increasing IN services requires engaging pharmacies to expand their practice through educational campaigns, along with a commitment to reimburse the cost of medications and related administration activities.

The Role of Board-Certified Psychiatric Pharmacists in Expanding Access to Care and Improving Patient Outcomes

Although approximately 20% of adults in the United States experience a mental health condition annually, there continues to be a gap in the provision of care because of a shortage of behavioral health providers. The National Council for Behavioral Health Medical Director Institute has recommended that the number of board-certified psychiatric pharmacists (BCPPs), who are clinical pharmacists with advanced specialized training and experience in the treatment of patients with psychiatric and substance use disorders, be expanded to help meet this need. Although BCPPs currently assist in expanding care access, improving medication-related outcomes, and reducing health care costs by working collaboratively with physicians and other health care providers, BCPPs are often underutilized. This lack of utilization results in lost opportunity to better address the needs of persons with psychiatric or substance use disorders and to meet these needs in a timely manner. Here, the authors bring attention to five key areas-opioid use disorder, antipsychotic use among children, long-acting injectable antipsychotics, clozapine use, and transitions of care and care coordination-in which BCPPs, along with other pharmacists, provide evidence-based care and could be more extensively used as a collaborative solution to the mental health and substance use disorder crisis in the United States.

Community pharmacy-based injectable naltrexone service delivery models and best practices

BACKGROUND

Opioid use disorder (OUD) is a major public health issue in the United States. Medications for OUD (MOUD), which combines the use of approved medications with counseling and behavioral therapies, represents an evidence-based approach to treat individuals living with an OUD. However, MOUD has not kept up with increased demand and new treatment approaches are needed. One approach is injectable naltrexone, an approved and effective MOUD treatment, provided by pharmacists, who are more geographically accessible and have legal authority to administer it in some states.

OBJECTIVES

To explore how different community pharmacists provide injectable naltrexone treatment and identify best practices.

METHODS

An exploratory sequential mixed-methods design was used to investigate pharmacy-based naltrexone injection practices, involving a pharmacist questionnaire and interviews with pharmacists, prescribers, and community stakeholders. An inductive/iterative content analysis approach, guided by an initial straw model, was used to identify and explore conceptual categories for the interviews.

RESULTS

The final sample included 68 pharmacy surveys and 14 total interviews with pharmacists (n = 9), prescribers (n = 3), and community stakeholders (n = 2). Pharmacies providing naltrexone injections reported administering over 700 injections in the past year. Interviews revealed benefits and barriers to pharmacist-provided injections and the importance of the prescriber-pharmacist relationship in OUD treatment. Three pharmacy treatment delivery models were identified, compared to the initial straw model, and informed development of a best practices checklist for community pharmacies interested in establishing or expanding a naltrexone injection service.

CONCLUSIONS

The study demonstrates how community pharmacies developed and implemented a naltrexone injection service. Pharmacists' and prescribers' feedback clearly suggests an untapped interest, as well as resources, in realizing pharmacists' roles as providers of injectable naltrexone treatment. Implementation research could inform the development and evaluation of an intervention based on these best practices to further explore the utility of community pharmacy-based naltrexone injection services.

Implementation of hepatitis C screening within a pharmacist-managed medication-assisted therapy opioid use disorder protocol program

OBJECTIVES

(1) To describe an innovative medication-assisted therapy (MAT) opioid use disorder (OUD) protocol in an independent community pharmacy, (2) to assess patient retention of the protocol, and (3) to describe the implementation of pharmacist-initiated hepatitis C virus (HCV) screenings of patients enrolled in the protocol.

SETTING

Independent pharmacy affiliated with a detox and rehabilitation center in Louisville, KY.

PRACTICE DESCRIPTION

A postgraduate year 1 (PGY-1) pharmacy resident-led OUD and HCV screening protocol.

PRACTICE INNOVATION

Under the Kentucky MAT OUD protocol, pharmacists at St. Matthews Community Pharmacy recognized the lack of HCV screening as a protocol requirement. To provide comprehensive care, the pharmacists added an HCV screening assessment for all patients enrolled in the pharmacy MAT OUD program.

EVALUATION

The pharmacy was the first in Kentucky to implement the MAT OUD protocol after state board approval in January 2018. Patient retention rates of the MAT OUD protocol were evaluated during the 2018-2019 PGY-1 pharmacy residency program. HCV screening was implemented and assessed during this time.

RESULTS

The service was implemented by the pharmacy practice resident with 77 patients enrolled in the MAT OUD program and 36 consenting to the HCV screening assessments. More than half (52%) of the study participants remained in the MAT OUD program for the recommended duration of 6 months or more. All study participants (n = 36) had recent HCV screenings.

CONCLUSION

This practice innovation, led through the PGY-1 pharmacy residency program, allowed patients to enroll in a MAT OUD program in the privacy of their community pharmacy. The patient retention rate was similar to those found in physician-provided OUD programs. HCV positive screenings were found in individuals with no previous history of intravenous drug use. This provides reasoning to consider adding HCV screenings as a requirement to OUD protocols.