Correlates of stocking naloxone: a cross-sectional survey of community pharmacists

BACKGROUND

Provision of take-home naloxone (THN) and overdose education reduces opioid-related mortality. In Australia, from July 2022, all Australian community pharmacies were eligible to supply naloxone for free through the national THN Program.

AIM

This study aimed to identify naloxone stocking rates and correlates of stocking naloxone across Australian pharmacies.

METHOD

Data were collected from a representative sample of Australian pharmacists in Victoria, New South Wales, Queensland and Western Australia via an online survey. Data collected included pharmacy and pharmacist characteristics and services offered within the pharmacy, including needle and syringe programs, opioid agonist treatment (OAT) and stocking naloxone. Binary probit regression analysis was used to identify correlates of stocking naloxone after controlling for key covariates.

RESULTS

Data from 530 pharmacists were analysed. In total, 321 pharmacies (60.6%) reported stocking naloxone. Chain pharmacies and pharmacies that provided OAT had a greater probability of stocking naloxone (B = 0.307, 95%CI: [0.057, 0.556], and B = 0.543, 95%CI: [0.308, 0.777] respectively). Most (61.7%) pharmacists felt comfortable discussing overdose prevention with patients who use prescription opioids, and this comfort was associated with a higher probability of stocking naloxone (B = 0.392, 95%CI: 0.128, 0.655). Comfort discussing overdose prevention with people who use illicit opioids was lower (49.4%) and was not associated with stocking naloxone.

CONCLUSION

There is scope to increase stocking of naloxone and comfort with overdose prevention, particularly through addressing comfort working with higher risk groups such as people who use illicit opioids.

Estimating the total utilization of take home naloxone during an unregulated drug toxicity crisis: A Bayesian modeling approach

BACKGROUND

British Columbia (BC) Canada has a large take-home naloxone (THN) program, implemented as part of the provincial response to the ongoing toxic unregulated drug supply emergency. Ascertaining the rate of use of THN kits is vital to understanding the full impact of the program. However, this is a challenging problem due to under-reporting of kit distribution. This study aims to estimate the total number of THN kits used based on the number of THN kits shipped, the number of THN kits reported as distributed, and the number of THN kits reported as used.

METHODS

We used BC THN shipment and distribution records (February 2015 to August 2023) to inform a simple Bayesian model of naloxone kit distribution and use. A logistic regression term by health region and distribution site type was incorporated to account for variable under-reporting, and a convolution term was incorporated to account for kit distribution.

RESULTS

We find the number of THN kits reported as used, and the number of total THN kits distributed, are largely under-reported. An estimated 1,500 (95 % CrI: 1,430 - 1,590) THN kits per 10,000 BC population were used, of which 288 per 10,000 had been reported as used. Of all the THN kits shipped, the model estimated that 43 % (95 % CrI: 41-45 %) of kits were used. We also found variation in both distribution and use by distribution site type, with kits distributed from overdose prevention sites having the highest rate of use (56 %; 95 % CrI: 53-59 %).

CONCLUSION

Across all sites, kit use is approximately five times higher than has been reported. Our framework can also be applied to other localities where THN programs operate, in order to better estimate the true reach and impact of take home naloxone distribution.

The Feasibility of Using the National PulsePoint Cardiopulmonary Resuscitation Responder Network to Facilitate Overdose Education and Naloxone Distribution: Protocol for a Randomized Controlled Trial

BACKGROUND

The use of naloxone, an opioid antagonist, is a critical component of the US response to fatal opioid-involved overdoses. The importance and utility of naloxone in preventing fatal overdoses have been widely declaimed by medical associations and government officials and are supported by strong research evidence. Still, there are gaps in the current US national strategy because many opioid-involved overdose fatalities have no evidence of naloxone administration. Improving the likelihood that naloxone will be used to prevent fatal overdoses is predicated on facilitating an environment wherein naloxone is available near each overdose and can be accessed by someone who is willing and able to use it. How to accomplish this on a national scale has been unclear. However, there exists a national network of >1 million cardiopulmonary resuscitation (CPR) layperson responders and 4800 emergency responder agencies linked through a mobile phone app called PulsePoint Respond. PulsePoint responders certify that they are trained to administer CPR and are willing to respond to possible cardiac events in public. When such an event occurs near their mobile phone's location, they receive an alert to respond. These motivated citizens are ideally positioned to carry naloxone and reverse overdoses that occur in public.

OBJECTIVE

This randomized controlled trial will examine the feasibility of recruiting first responder agencies and layperson CPR responders who already use PulsePoint to obtain overdose education and carry naloxone.

METHODS

This will be a 3-arm parallel-group randomized controlled trial. We will randomly select 180 first responder agencies from the population of agencies contracting with the PulsePoint Foundation. The 3 study arms will include a standard recruitment arm, a misperception-correction recruitment arm, and a control arm (1:1:1 allocation, with random allocation stratified by zip code designation [rural or nonrural]). We will study agency recruitment and, among the agencies we successfully recruit, responder certification of receiving overdose and naloxone education, carrying naloxone, or both. Hypothesis 1 contrasts agency recruitment success between arms 1 and 2, and hypothesis 2 contrasts the ratios of layperson certification across all 3 arms. The primary analyses will be a logistic regression comparing the recruitment rates among the arms, adjusting for rural or nonrural zip code designation.

RESULTS

This study was reviewed by the Indiana University Institutional Review Board (20218 and 20219). This project was funded beginning September 14, 2023, by the National Institute on Drug Abuse.

CONCLUSIONS

The hypotheses in this study will test whether a specific type of messaging is particularly effective in recruiting agencies and layperson responders. Although we hypothesize that arm 2 will outperform the other arms, our intention is to use the best-performing approach in the next phase of this study if any of our approaches demonstrates feasibility.

TRIAL REGISTRATION

OSF Registries osf.io/egn3z; https://osf.io/egn3z.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/57280.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/42373.

Developing a single-session strategy for the implementation of take-home naloxone by community pharmacists using COM-B and design-thinking

Background

Despite the overwhelming evidence of its effectiveness, there is poor implementation of take-home naloxone by pharmacists. Barriers have been explored and mapped to the capability, opportunity, motivation-behaviour (COM-B) model of behaviour change, yet no theoretically informed implementation strategies that target known barriers have been developed. Single-session implementation strategies have been proposed as a simple, scalable way to target multiple barriers.

Methods

Qualitative participatory methods, incorporating design-thinking principles, were used to develop the key messages of a single-session implementation strategy. The key messages were drafted against COM-B mapped implementation barriers identified in the literature. A participatory workshop involving a pre-mortem exercise and incorporating design-thinking principles were used to refine the messages and generate methods for dissemination. Messages were mapped to interview questions to naturally illicit stories and delivered via storytelling from a pharmacist, a general practitioner, and a person with lived experience of using naloxone.

Results

A 3 minute 40 second video and a two-page printable infographic were developed and hosted on a website, with links to additional downloadable resources as a single-session implementation strategy. Email was the preferred method for receiving simple professional development communications, with social media also widely accessed.

Discussion

Implementation science, behavioural change theory, and participatory design methods are a complementary combination to develop implementation strategies. Some pharmacists questioned the participatory design approach to developing an implementation strategy, as it was outside of their comfort zone. However, the participatory process involving end-users resulted in unique ideas that are unlikely to have been generated using more traditional consultative approaches. The delivery as a single-session implementation strategy allows for widespread dissemination and delivery at scale.

The cost and impact of distributing naloxone to people who are prescribed opioids to prevent opioid-related deaths: findings from a modelling study

BACKGROUND AND AIMS

Although most opioid-related mortality in Australia involves prescription opioids, most research to understand the impact of naloxone supply on opioid-related mortality has focused upon people who inject heroin. We aimed to examine the cost and probable impact of up-scaling naloxone supply to people who are prescribed opioids.

DESIGN

Decision-tree model. Four scenarios were compared with a baseline scenario (the current status quo): naloxone scale-up between 2020 and 2030 to reach 30 or 90% coverage by 2030, among the subgroups of people prescribed either ≥ 50 or ≥ 100 mg of oral morphine equivalents (OME).

SETTING

Australia.

PARTICIPANTS

People who are prescribed opioids.

MEASUREMENTS

Possible deaths averted, costs (ambulance and naloxone distribution) and cost per life saved for different scenarios of naloxone scale-up.

FINDINGS

Maintaining the status quo, there would be an estimated 7478 [uncertainty interval (UI) = 6868-8275] prescription opioid overdose deaths between 2020 and 2030, resulting in Australian dollars (A$)51.9 million (49.4, 56.0) in ambulance costs. If naloxone were scaled-up to 90% of people prescribed > 50 mg OME, an estimated 657 (UI = 245, 1489) deaths could be averted between 2020 and 2030 (a 20% reduction in the final year of the model compared with the no naloxone scenario), with a cost of A$43 600 (20 800-110 500) per life saved. If naloxone were scaled-up to 30% of people prescribed > 50 mg OME an estimated 219 (82-496) deaths could be averted with the same cost per live saved. If naloxone were restricted to those prescribed > 100 mg OME, an estimated 130 (UI = 44-289) deaths would be averted if scaled-up to 30% or 390 (UI = 131-866) deaths averted if scaled-up to 90%, with the cost per life saved for both scenarios A$38 200 (UI = 12 400-97 400).

CONCLUSION

In Australia, scaling-up take-home naloxone by 2030 to reach 90% of people prescribed daily doses of ≥ 50 mg of oral morphine equivalents would be cost-effective and save more than 650 lives.

Effectiveness and implementability of state-level naloxone access policies: Expert consensus from an online modified-Delphi process

BACKGROUND

Naloxone distribution, a key global strategy to prevent fatal opioid overdose, has been a recent target of legislation in the U.S., but there is insufficient empirical evidence from causal inference methods to identify which components of these policies successfully reduce opioid-related harms. This study aimed to examine expert consensus on the effectiveness and implementability of various state-level naloxone policies.

METHODS

We used the online ExpertLens platform to conduct a three-round modified-Delphi process with a purposive sample of 46 key stakeholders (advocates, healthcare providers, human/social service practitioners, policymakers, and researchers) with naloxone policy expertise. The Effectiveness Panel (n = 24) rated average effects of 15 types of policies on naloxone pharmacy distribution, opioid use disorder (OUD) prevalence, nonfatal opioid-related overdoses, and opioid-related overdose mortality. The Implementation Panel (n = 22) rated the same policies on acceptability, feasibility, affordability, and equitability. We compared ratings across policies using medians and inter-percentile ranges, with consensus measured using the RAND/UCLA Appropriateness Method Inter-Percentile Range Adjusted for Symmetry technique.

RESULTS

Experts reached consensus on all items. Except for liability protections and required provision of education or training, experts perceived all policies to generate moderate-to-large increases in naloxone pharmacy distribution. However, only three policies were expected to yield substantive decreases on fatal overdose: statewide standing/protocol order, over-the-counter supply, and statewide "free naloxone." Of these, experts rated only statewide standing/protocol orders as highly affordable and equitable, and unlikely to generate meaningful population-level effects on OUD or nonfatal opioid-related overdose. Across all policies, experts rated naloxone prescribing mandates relatively lower in acceptability, feasibility, affordability, and equitability.

CONCLUSION

Experts believe statewide standing/protocol orders are an effective, implementable, and equitable policy for addressing opioid-related overdose mortality. While experts believe many other broad policies are effective in reducing opioid-related harms, they also believe these policies face implementation challenges related to cost and reaching vulnerable populations.

Using the behaviour change wheel to understand and address barriers to pharmacy naloxone supply in Australia

BACKGROUND

There has been low community pharmacy-based naloxone supply in Australia despite its over-the-counter status. The Behaviour Change Wheel (BCW) is a method used to understand individual and system-level barriers and facilitators to a particular behaviour to inform program implementation. The BCW is focused on three essential conditions of behaviour change (capability, opportunity, and motivation (termed the COM-B)) which we use to assess pharmacists perceptions and experiences of naloxone provision with the aim of using informing targets for interventions to improve naloxone distribution.

METHOD

Qualitative interviews with community pharmacists (n = 37) from four Australian jurisdictions explored naloxone knowledge, expectations and experiences dispensing the medicine. Audio-recorded interviews were transcribed verbatim and coded against the a priori domains in the COM-B (capability, opportunity, and motivation). Results were analysed to identify key barriers and facilitators to naloxone provision within each domain. Finally, we mapped our analysis against the intervention functions and policy-level strategies provided in the BCW to identify example intervention strategies.

RESULTS

Underlying all pharmacists' descriptions of naloxone were structural impediments to dispensing including poor communication regarding pharmacists' role and disrupted supply chains. Mapped across the three COM-B domains, we find two divergent groups of pharmacists. Pharmacists' capability and motivation to supply naloxone was higher amongst those who did not problematize people who inject drugs and who worked in pharmacies already supplying harm reduction services. Pharmacists were less likely to discuss capabilities and opportunities for naloxone dispensing when harm reduction was not normalised in their workplace and/or they described people who inject drugs using negative and stigmatising language.

CONCLUSIONS

Analysis using the COM-B framework reveals key areas where implementation and policy strategies are needed to increase naloxone supply. Individual- and structural-level supports are needed to improve pharmacists' knowledge of naloxone and address other logistical and cultural barriers that limit naloxone provision in pharmacy settings.