Rates and costs of drug testing practices for private payors in the outpatient setting in the United States, 2015-2019

INTRODUCTION

Clinical practice guidelines recommend drug testing patients who are receiving opioids chronically for pain or medication for a substance use disorder (SUD)-particularly opioid use disorder (OUD)-but practices vary due to a lack of consensus on testing frequency during follow-up. This study aimed to evaluate rates and costs of outpatient drug testing practices for patients receiving opioids for chronic pain or medication for an SUD.

METHODS

Using claims data from a large de-identified claims data warehouse, we conducted a retrospective cohort study of chronic opioid, buprenorphine, and naltrexone users between January 2015 and December 2019. We identified two cohorts-chronic opioid medication cohort (CO) and SUD-indicated medication cohort (SUD). We assessed drug testing rates during follow-up using procedure codes and costs using copayment, deductible, co-insurance, and out-of-pocket data.

RESULTS

Among 6,657,515 eligible claimants, 367,118 (5.5 %) received opioids chronically and 73,303 (1.1 %) received an SUD-indicated medication. The cumulative proportion of drug testing during follow-up was similar between cohorts (CO: 36 %; SUD: 35 %), but rate of testing was consistently twice as frequent for the SUD cohort. All cost variables for the first drug test were higher on average in the SUD cohort than the CO cohort except copay: deductible (SUD: $18.54; CO: $7.33); co-insurance (SUD: $10.36; CO: $2.53); out-of-pocket (SUD: $29.39; CO: $10.57); copay (CO: $0.71; SUD: $0.49) (all p < 0.001).

CONCLUSIONS

Overall proportion of drug testing was similar between cohorts, but testing frequency was at least double during follow-up in the SUD cohort. Most cost variables were higher in the SUD cohort. Whether the high cost of drug testing is a barrier to medication use or is associated with treatment discontinuation should be evaluated.

Evaluating the impact of a pharmacy technician training program within a college of pharmacy

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Ensuring pharmacy technicians are adequately trained and prepared to enter the workforce is an important first step in addressing technician staff shortages. How pharmacy technician learners perceive their experiences after completion of a training program remains unknown. This study evaluated participant outcomes and self-efficacy ratings for common technician competencies after completion of a pharmacy technician training program.

METHODS

Between December 2021 and March 2023, we distributed a survey to participants who successfully completed the program approximately 3 months after their estimated completion date. The survey assessed 6 domains: enrollment and academic progression, utilization of educational resources, self-perceived proficiency on core competencies of a pharmacy technician, employment information, program recommendations, and student demographics.

RESULTS

Thirty-six participants completed the survey, corresponding to a 60% response rate. Participants were attracted to the pharmacy technician program due to its affiliation with a college of pharmacy, online format, and affordability. Half of respondents were actively employed as pharmacy technicians, and the self-reported certification exam passage rate slightly exceeded national averages (78% vs 70% to 71%). Participants' self-efficacy ratings for pharmacy technician competencies were high (mean rating of 4.12 out of 5). Overwhelmingly, 97% of participants agreed that the program prepared them well for becoming a pharmacy technician.

CONCLUSION

A pharmacy technician training program housed within a college of pharmacy presents one potential solution in addressing pharmacy technician workforce shortages. Participants positively viewed their training experience, with high self-efficacy ratings for pharmacy technician competencies. Moreover, national certification exam results were slightly better than national averages.

Moving Naloxone Over the Counter Is Necessary but Not Sufficient

Naloxone is an opioid antagonist that is available in numerous formulations and can be easily administered to avert death from opioid overdose. Amid a historic overdose crisis in the United States, naloxone has a crucial role in stemming the loss of life. However, it remains largely inaccessible to the public. Recently, the U.S. Food and Drug Administration announced the approval of the first over-the-counter formulation of naloxone. Although this historic change provides an important opportunity to increase distribution of naloxone, we must take careful steps during this transition so that it does not paradoxically threaten overall access to this life-saving medication. Specifically, we must ensure that a larger supply of naloxone will meet the newly increased demand at a sustainable price for consumers who are most in need. We must also continue to prioritize comprehensive methods of distribution, such as overdose education and naloxone distribution programs, that serve as important tools to reach the most vulnerable populations. In addition, simultaneous investment in harm-reduction strategies, such as supervised consumption spaces, is critical to ensure that naloxone is available in settings where its life-saving potential can be most fully realized.

Student Perspectives on the Pharmacist's Role in Deprescribing Opioids: A Qualitative Study

INTRODUCTION

Opioid over-prescribing has led to changes in prescribing habits and a reduction in the amount of opioid prescriptions per patient. Deprescribing has proved to be an effective way of decreasing the number of opioids patients are receiving, and pharmacists are in the optimal position to provide these services for their patients. However, student pharmacists require additional education and training to be able to understand their role in deprescribing opioids upon entering the profession.

METHODS

Student pharmacists at three United States of America schools of pharmacy were invited to participate in virtual focus groups about deprescribing opioids in Fall 2021. A trained qualitative researcher conducted the focus groups, which were audio-recorded and later transcribed verbatim for thematic analysis. Two independent qualitative researchers coded the transcripts using both inductive and deductive approaches. The researchers then met to identify, discuss, and describe themes from the data.

RESULTS

Thematic analysis revealed two themes: (1) perceived obstacles and enablers to initiate deprescribing for opioid medications and (2) additional pharmacy curricula experiences are necessary to better equip student pharmacists to address deprescribing. These themes emphasize the challenges student pharmacists face as well as opportunities to enhance their knowledge to be practice-ready.

CONCLUSION

Varying educational approaches to teaching deprescribing in the pharmacy curriculum, including objective structured clinical exams, interprofessional education, and motivational interviewing, should be further assessed.

Student Perceptions of Substance Use Disorder Stigma as a Factor for Health Disparities: A Mixed-Methods Study

BACKGROUND

The prevalence of substance use disorders (SUDs) is an alarming problem in the United States; however, only a fraction of patients receive treatment. Stigma from both healthcare professionals and society at large negatively impacts SUD treatment. There are limited data regarding the perceptions of healthcare students on SUD stigma as a health disparity.

METHODS

We conducted a concurrent mixed-methods study among students enrolled in six health-related colleges at one mid-south health science center in the US over 3 months. Both an electronic survey consisting of 17 close-ended questions and researcher-led focus groups were conducted to understand their perceptions of stigma and SUDs. The research team followed the six steps recommended by Braun and Clarke regarding the data that aimed to capture associations between categories and extract and conceptualize the themes, and thematic analysis was done using Dedoose^® (Manhattan Beach, CA, USA) qualitative software, which facilitated all the codes being kept organized and compared the frequency of codes across categories.

RESULTS

A total of n = 428 students participated in the survey (response rate = 13%), and n = 31 students took part in five focus groups. Most student respondents, on average, either agreed or strongly agreed that: stigma currently exists in the healthcare field; stigma can lead to patients' not receiving the appropriate care for an SUD; and stigma can lead to lower quality care provided to patients with SUDs. Two themes were identified based on the thematic analysis: (1) additional training is necessary to better equip students for addressing SUDs in practice and (2) suggestions were formed to develop synergy between didactic and clinical rotations to improve SUD training.

CONCLUSIONS

It is evident that students perceive the stigma surrounding SUDs as a detriment to patient care. Opportunities may exist in professional training programs to more seamlessly and intentionally weave SUD treatment and management concepts throughout the curriculum, as well as to empower students to operate in the complex regulatory scheme that exists for SUDs in the US.

Federal Funding For Discovery And Development Of Costly HIV Drugs Was Far More Than Previously Estimated

In July 2012, tenofovir disoproxil fumarate-emtricitabine (TDF-FTC, brand name Truvada) was approved by the Food and Drug Administration (FDA) to prevent HIV infection. To estimate the extent of the US government's direct financial contribution to the discovery and development of Truvada, we identified National Institutes of Health awards using FDA documents, peer-reviewed literature, patent records, court filings, and other publicly available materials. We classified seventy-three federal government awards to eleven researchers as being directly linked to the development and clinical testing of Truvada for prevention therapy, through which the US government spent an estimated $143 million. The substantial public funding raises questions about the high price charged by the drug's manufacturer, which reduced its affordability and limited its accessibility as HIV preventive therapy.

A Survey of Hiring and Non-hiring Pharmacists' Perceptions of a Primary Care Certificate Training Program

Objective. To survey pharmacists, including those who make or contribute to hiring decisions, regarding certificate training programs and specifically about a primary care certificate for pharmacists.Methods. We conducted a cross-sectional survey of pharmacist registrants of the Office of Continuing Professional Development at the University of Tennessee Health Science Center College of Pharmacy's listserve, including both hiring and non-hiring pharmacists. The 40-question survey probed perceptions of various types of postgraduate training and the design of a primary care certificate training program for pharmacists. Data were collected between November and December 2020.Results. A total of 230 pharmacists participated in this study (14% response rate), and most reported practicing in the community (n=126, 57%). Nearly half of the respondents reported making or contributing to hiring decisions of other pharmacists (n=94, 41%), and, of those, most reported that completion of a primary care certificate program by a candidate would increase their likelihood of hiring that candidate (n=50, 78%). Both groups (hiring and non-hiring pharmacists) most commonly reported that a primary care certificate training program should be 30 hours total and 12 weeks in length, ranked communication as the most important topic to be included, and indicated the didactic and simulation/experiential components should be similarly weighted.Conclusions. Pharmacists, including those who make or contribute to hiring decisions, reported valuing certificate training programs. Developing a certificate training program that is at least 30 hours in length over 12 weeks may serve as an opportunity to address gaps in primary care in the United States.

Teaching Deprescribing and Combating Polypharmacy in the Pharmacy Curriculum: Educational Recommendations from Thematic Analysis of Focus Groups

In the last two decades in the United States (US), the previous research has focused on medication optimization, including polypharmacy. Polypharmacy is associated with several negative outcomes, which may be resolved by deprescribing medications that are no longer necessary. Although deprescribing is a critical aspect of a pharmacist's role, some studies have demonstrated that student pharmacists are less familiar with their future role in deprescribing. Thus, this study aimed to explore student pharmacists' perceptions of deprescribing in the pharmacy curriculum. This qualitative study was conducted with student pharmacists enrolled in three Doctor of Pharmacy (Pharm.D.) programs in the US. The participants, all student pharmacists at the time of the study, were identified via an email requesting their voluntary participation in a focus group study. The focus groups were conducted via an online platform over three months in 2022, and recruitment continued until thematic saturation was obtained. Using thematic analysis, the corpus of the transcribed data was imported into Dedoose^®, a qualitative software that facilitated the analysis. Three themes emerged from the data: (1) the importance of deprescribing; (2) barriers to deprescribing; (3) education recommendations. The data highlight that the student pharmacists believe integrating deprescribing content into the clinical, didactic, and simulation education would help them overcome the identified obstacles. Colleges of pharmacy should consider emphasizing the importance of deprescribing in their curriculum, creating programs to assist future pharmacists in addressing the barriers to deprescribing, and adopting the suggested educational strategies to improve the deprescribing education that is offered.

US public investment in development of mRNA covid-19 vaccines: retrospective cohort study

OBJECTIVE

To estimate US public investment in the development of mRNA covid-19 vaccines.

DESIGN

Retrospective cohort study.

SETTING

Publicly funded science from January 1985 to March 2022.

DATA SOURCES

National Institutes of Health (NIH) Report Portfolio Online Reporting Tool Expenditures and Results (RePORTER) and other public databases. Government funded grants were scored as directly, indirectly, or not likely related to four key innovations underlying mRNA covid-19 vaccines-lipid nanoparticle, mRNA synthesis or modification, prefusion spike protein structure, and mRNA vaccine biotechnology-on the basis of principal investigator, project title, and abstract.

MAIN OUTCOME MEASURE

Direct public investment in research and vaccine development, stratified by the rationale, government funding agency, and pre-pandemic (1985-2019) versus pandemic (1 January 2020 to 31 March 2022).

RESULTS

34 NIH funded research grants that were directly related to mRNA covid-19 vaccines were identified. These grants combined with other identified US government grants and contracts totaled $31.9bn (£26.3bn; €29.7bn), of which $337m was invested pre-pandemic. Pre-pandemic, the NIH invested $116m (35%) in basic and translational science related to mRNA vaccine technology, and the Biomedical Advanced Research and Development Authority (BARDA) ($148m; 44%) and the Department of Defense ($72m; 21%) invested in vaccine development. After the pandemic started, $29.2bn (92%) of US public funds purchased vaccines, $2.2bn (7%) supported clinical trials, and $108m (<1%) supported manufacturing plus basic and translational science.

CONCLUSIONS

The US government invested at least $31.9bn to develop, produce, and purchase mRNA covid-19 vaccines, including sizeable investments in the three decades before the pandemic through March 2022. These public investments translated into millions of lives saved and were crucial in developing the mRNA vaccine technology that also has the potential to tackle future pandemics and to treat diseases beyond covid-19. To maximize overall health impact, policy makers should ensure equitable global access to publicly funded health technologies.

Faculty, staff, and student perceptions of substance use disorder stigma in health profession training programs: a quantitative study

BACKGROUND

Research indicates that stigma impacts the care provided to individuals with Substance Use Disorders (SUDs), but perceptions of SUDs in various healthcare training programs are not well known. We aimed to characterize perceptions of faculty, staff, and students about SUD stigma in professional healthcare training programs.

METHODS

We conducted a cross-sectional survey of faculty, staff, and students employed at or enrolled in one of six health-related colleges at one Mid-South health science center in the United States, including medicine, pharmacy, dentistry, nursing, health professions, and graduate health sciences. Data collection occurred between February and March 2021. We used descriptive and frequency statistics to assess the constructs within the survey instrument.

RESULTS

A total of 572 respondents participated in this study (response rate = 9%; students, n = 428, 75%; faculty, n = 107, 19%; staff, n = 32, 6%). Most respondents reported interacting with persons with a SUD, cited challenges with the interaction, and perceived SUDs to be mental health condition (n = 463) or biological disease (n = 326). Most respondents believed that their college: emphasizes learning about SUDs; promotes an accurate perception of SUDs; and fosters respect for persons with. Few respondents reported they hear faculty, staff, or students express negative comments about persons with SUDs, but they were sometimes expressed by students.

CONCLUSIONS

Most faculty, staff, and students reported experiencing challenges when interacting with a person with a SUD, mainly communication, but few recalled hearing negative comments from their peers. Whether interventions tailored towards improving communication in academic healthcare training settings could minimize challenges experience by faculty, staff, and students when serving individuals with SUDs should be further evaluated.

Designing a pharmacist primary care certificate training program based on employer perceptions

Background

As the pharmacy profession transforms toward practice centered around direct patient care and clinical services, upskilling the existing workforce may be required for pharmacists to take on expanded roles, especially in an increasingly competitive job market.

Objective

To explore pharmacist employer perceptions of a primary care certificate training program including its design, value, and relevance and to develop and implement a pharmacist primary care certificate training program based on study results.

Methods

Focus groups were conducted to a point of saturation in December 2020 via video conference. Participants were identified via the study institution's continuing professional development registrant listserv and invited to participate via self-selection. Interviews were recorded, transcribed, and underwent inductive thematic analysis.

Results

Four focus groups were conducted with 15 pharmacist employers. Employers perceived primary care certificate training as valuable, helping pharmacists sustain shifting roles and increasing opportunities in a competitive job market. A combination of clinical and practice management topics with emphasis on an experiential component was recommended to achieve expected competency levels and favorably influence hiring decisions. The primary care certificate was specifically recommended to pharmacists aiming to transition into primary care or for pharmacists who did not complete residency training.

Conclusions

This study's findings informed development of a pharmacist primary care certificate program containing didactic and experiential training on a variety of key topics. As pharmacists' roles evolve, this program may prepare pharmacists to engage in direct patient care and develop skills and expertise necessary to succeed in outpatient primary care.

A Qualitative Systematic Review of Access to Substance Use Disorder Care in the United States Criminal Justice System

BACKGROUND

The majority of patients with a substance use disorder (SUD) in the United States do not receive evidence-based treatment. Research has also demonstrated challenges to accessing SUD care in the US criminal justice system. We conducted a systematic review of access to SUD care in the US criminal justice system.

METHODS

We searched for comprehensive qualitative studies in multiple databases through April 2021, and two researchers reviewed 6858 studies using pre-selected inclusion criteria. Once eligibility was determined, themes were extracted from the data. This review provides a thematic overview of the US qualitative studies to inform future research-based interventions. This review was conducted in compliance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).

RESULTS

There were 6858 unique abstract results identified for review, and seven qualitative studies met the inclusion criteria. Two themes were identified from these results: (1) managing withdrawal from medication-assisted treatment, and (2) facilitators and barriers to treatment programs in the criminal justice system.

CONCLUSIONS

Qualitative research evaluating access to SUD care in the US criminal justice system varied, with some interventions reported not rooted in evidence-based medicine. An opportunity may exist to develop best practices to ensure evidence-based treatment for SUDs is delivered to patients who need it in the US criminal justice system.

Examining Preparatory Testing and Other Factors Associated With Performance on the Multistate Pharmacy Jurisprudence Examination

Objective. To evaluate whether the score on the Pre-Multistate Pharmacy Jurisprudence Examination (Pre-MPJE) predicts pharmacy students' performance on the MPJE, and to determine whether demographics, pre-pharmacy school factors, or pharmacy school factors affect MPJE outcomes.Methods. We performed a retrospective review of pharmacy school graduates' (N = 156) MPJE scores, Pre-MPJE scores, demographics, pre-pharmacy school academic performance factors, and pharmacy school academic performance factors. Bivariate and correlational analyses were conducted along with multiple linear regression models to determine the influence of variables on the MPJE total scaled score.Results. A total of 136 pharmacy school graduates were included, with most being female (59%) and non-Hispanic White students (75%). The score on the Pre-MPJE was not significantly correlated with students' first-attempt MPJE pass-fail outcome or total scaled score. Factors that were correlated with passing the MPJE were a younger age at graduation, a higher pharmacy law course grade, Pharmacy Curriculum Outcomes Assessment (PCOA) examination scores, specifically scaled total scores and scaled scores for content areas 1-4 and final pharmacy school grade point average (GPA). The MPJE total scaled score was correlated with a higher pre-pharmacy school GPA, pharmacy law course grade, PCOA total and content area 1-4 scaled scores, and final pharmacy school GPA. However, regression models found that the greatest variance in MPJE total scaled score was contributed by the pharmacy law course grade. The total scaled score on the PCOA contributed to some variance for all MPJE takers, but only the pharmacy law course grade significantly influenced the in-state MPJE total scaled score.Conclusion. The findings did not show that the Pre-MPJE score was a predictor for passing the MPJE or for the MPJE total scaled score. The most important determinant of the MPJE total scaled score was a student's performance in the pharmacy law course.

Tennessee Pharmacists' Opinions on Barriers and Facilitators to Initiate PrEP: A Qualitative Study

Pre-exposure prophylaxis (PrEP) is recommended to prevent the transmission of the human immunodeficiency virus (HIV). Although an effective treatment, the uptake in the United States remains low. Pharmacists are well-positioned to initiate the conversation with patients about PrEP, but few studies exist exploring their unique roles. The objective of this study was to characterize Tennessee pharmacists’ perceptions about access to PrEP. A qualitative study was used to gather the data that consisted of virtual Focus Groups over four months in 2021 from practicing Tennessee pharmacists. Emails were sent to all Tennessee licensed pharmacists to recruit them to participate in the study. Recruitment continued until Thematic Saturation was obtained. The corpus of data was audio-recorded, transcribed, and analyzed by the research team. Thematic Analysis revealed two themes: (1) Barriers to accessing PrEP; (2) Potential solutions to address barriers identified. These findings highlighted barriers and identified solutions to improve access to PrEP in Tennessee; additional financial assistance programs and marketing programs targeting patients and providers are needed to enhance PrEP access.

Review and assessment of drug disposal state statutes in the United States, 2022

BACKGROUND

Ensuring opportunities exist to dispose of unused or unwanted drugs that are appropriate, accessible, and affordable is critical to avoid misuse and lasting harm to the environment.

OBJECTIVE

The objectives of this study were to identify state statutes promulgated in all 50 states and the District of Columbia (DC) facilitating disposal of unused or unwanted drugs in the community setting and assess their characteristics.

METHODS

A retrospective review of state statutes in all 50 U.S. states and DC between October 2020 and May 2022 was conducted. Statutes using terms "drug and disposal or collection" and that were intended to facilitate disposal of unused or unwanted drugs were included. Drug donation programs or repositories, drug returns to the pharmacy, charitable clinics, and others not intended to dispose or unused or unwanted drugs were excluded. Publicly available resources and Westlaw, a legal resource, were used to identify state statutes. Descriptive statistics were used to describe the findings.

RESULTS

Of the 50 U.S. states and DC, we found that most states enacted a statute pertaining to drug disposal (63%; n = 32) as of May 2022. Of states with a drug disposal statute, few had funding mechanisms or required pharmacy participation. Most statutes specified the type of product that may be accepted for disposal, what site may accept them, and who may dispose of the product. Few states specified which health care provider or other individual may accept the product(s) for disposal.

CONCLUSION

Most states have enacted statutes facilitating drug disposal, but their characteristics varied widely. Opportunities may exist at the state level to further incentivize proper drug disposal, and further research is needed to measure possible effects of these state statutes.

“I Think Deprescribing as a Whole Is a Gap!”: A Qualitative Study of Student Pharmacist Perceptions about Deprescribing

Introduction: Older adults often manage multiple medications simultaneously, contributing to significant pill burden. Pill burden is a major concern for both patients and providers alike, and student pharmacists may play a role in decreasing that burden. Few studies exist evaluating student pharmacists’ roles in and perceptions of deprescribing in the healthcare team. Thus, the aim of this study was to explore student pharmacist perceptions regarding deprescribing in their pharmacy curricula. Methods: This study used a focus group discussion (FGD) methodology to facilitate discussion on deprescribing among student pharmacists. The theory of planned behavior (TPB) informed the conceptualization of this study, data collection, and thematic analysis. Student pharmacists enrolled in three different colleges of pharmacy across various geographical regions of the U.S. were recruited to participate in the study. Data collection occurred in the Fall of 2021, and recruitment proceeded until thematic saturation was achieved. The audio recordings were transcribed verbatim, and the transcripts were uploaded into Dedoose®, a qualitative software that facilitated the data analysis. The inductive codes were grouped into categories based on similarities that resulted in the themes. Results: Three colleges, totaling 1366 student pharmacists across different geographic regions of the U.S., were invited to participate in this study (UTHSC, N = 682; UNE, N = 158, University of Arizona, N = 526). Twenty-six student pharmacists participated in four FGDs. Of 26 participants, fourteen self-identified as male and two declined to state their gender identity. The mean age was 24 years old, with participants ranging from 21 to 37 years old. Thematic analysis revealed two major themes: (1) student pharmacists indicated that they possessed limited information about the deprescribing process, which is best illustrated by the following quote: “I think deprescribing as a whole is a gap!”; and (2) student pharmacists recommended increasing emphasis on deprescribing in pharmacy curricula. Conclusions: Student pharmacists identified few educational experiences on deprescribing in their curriculum while demonstrating a strong desire for more emphasis on deprescribing in the pharmacy curricula. This study highlights an opportunity to improve the integration of deprescribing education into pharmacy curricula, and colleges of pharmacy should evaluate whether, where, and to what extent the incorporation of this topic into their curricula is appropriate.

The Academy Is Well Positioned to Offer Pharmacy Technician Training Programs

Schools and colleges of pharmacy are optimally positioned to train the entire pharmacy team, including pharmacists and pharmacy support personnel, because they can provide comprehensive workforce development, utilize established faculty expertise, harness existing infrastructure, afford opportunities for intraprofessional education, and support institutional growth and reputability. As the emphasis of training shifts towards team-based approaches and expanded responsibilities, ensuring the existing and future pharmacy workforce is equipped to serve their communities becomes increasingly important. Thus, schools and colleges of pharmacy should consider offering a pharmacy technician training program to meet the needs of their community and the profession.

Associations Between Copays, Coverage Limits for Naloxone, and Prescribing in Medicaid

Aims:

To describe naloxone dispensing in Medicaid fee-for-service (FFS) and examine relationships between copays and coverage limits for naloxone and its dispensing rates.

Methods:

Cross-sectional study using Medicaid FFS State Drug Utilization Data to quantify the use of naloxone in 2018. The primary outcomes of this study were the proportion of naloxone prescriptions relative to all prescriptions and all opioid prescriptions dispensed in each state. We obtained drug benefit design information from the Medicaid Behavioral Health Services Database. The primary analysis examined the influence of copays (yes/no), copay amounts, and coverage limits on medication dispensing using simple linear regression, excluding states with no measurable use or less than 5% Medicaid FFS.

Results:

We found substantial variability across 50 states and DC in the proportion of prescriptions dispensed for Narcan and generic naloxone. We found a positive relationship between copay and copay amount and dispensing of generic naloxone. However, a sensitivity analysis including the broadest possible cohort of states failed to confirm this relationship. We found no other relationships between copays or coverage limits and dispensing of any naloxone formulation.

Conclusions:

Substantial variation exists between the rates of naloxone dispensing across the US for Medicaid patients, but we did not find a meaningful relationship between plan design and dispensing. Whether drug benefit designs in Medicaid influence naloxone use requires further evaluation to avoid limiting access to this life-saving medication.

A social media microinfluencer intervention to reduce coronavirus disease 2019 vaccine hesitancy in underserved Tennessee communities: A protocol paper

Background

Central to effective public health policy and practice is the trust between the population served and the governmental body leading health efforts, but that trust has eroded in the years preceding the pandemic. Vaccine hesitancy among adults is also a growing concern across the United States. Recent data suggest that the trustworthiness of information about the coronavirus 2019 (COVID-19) vaccine was a larger concern than the vaccine’s adverse effects or risks.

Objective

This study aims to describe the methods used to create a public health microinfluencer social media vaccine confidence campaign for the COVID-19 vaccine in underserved Tennessee communities. A secondary objective is to describe how the Social-Ecological Model (SEM) and Social Cognitive Theory may address vaccine hesitancy using community pharmacies.

Methods

In late 2020, 50 independent community pharmacies in underserved communities across Tennessee were involved in a public health project with the State of Tennessee Department of Health and the University of Tennessee Health Science Center College of Pharmacy. The project involved a 3-pronged, pharmacy-based COVID-19 vaccination outreach project, including (1) social media messaging (i.e., microinfluencer approach), (2) community partner collaboration, and (3) in-pharmacy promotion. Quantitative and qualitative data will assess the quality and effectiveness of the program. Social media outcomes will also be assessed to measure the impact of the microinfluencer social media training.

Results

Project implementation is planned for 6 months (January 2021 to June 2021) after an initial month of planning by the research team (December 2020) and preceding several months of assessment (July 2021 and beyond).

Conclusions

Novel, theory-based approaches will be necessary to improve vaccine confidence. One approach to promoting public health, derived from the SEM, may be to use trusted microinfluencers on social media platforms, such as local community pharmacists and community leaders.

Rates and Costs of Dispensing Naloxone to Patients at High Risk for Opioid Overdose in the United States, 2014-2018

INTRODUCTION

Clinical practice guidelines recommend co-prescribing naloxone to patients at high risk of opioid overdose, but few such patients receive naloxone. High costs of naloxone may contribute to limited dispensing.

OBJECTIVE

The aim of this study was to evaluate rates and costs of dispensing naloxone to patients receiving opioid prescriptions and at high risk for opioid overdose.

METHODS

Using claims data from a large US commercial insurance company, we conducted a retrospective cohort study of new opioid initiators between January 2014 and December 2018. We identified patients at high risk for overdose defined as a diagnosis of opioid use disorder, prior overdose, an opioid prescription of ≥ 50 mg morphine equivalents/day for ≥ 90 days, and/or concurrent benzodiazepine prescriptions.

RESULTS

Among 5,292,098 new opioid initiators, 616,444 (12%) met criteria for high risk of overdose during follow-up, and, of those, 3096 (0.5%) were dispensed naloxone. The average copayment was US$24.83 for naloxone (standard deviation [SD] 67.66) versus US$9.74 for the index opioid (SD 19.75). The average deductible was US$6.18 for naloxone (SD 27.32) versus US$3.74 for the index opioid (SD 25.56), with 94% and 88% having deductibles of US$0 for their naloxone and opioid prescriptions, respectively. The average out-of-pocket cost was US$31.01 for naloxone (SD 73.64) versus US$13.48 for the index opioid (SD 34.95).

CONCLUSIONS

Rates of dispensing naloxone to high risk patients were extremely low, and prescription costs varied greatly. Since improving naloxone's affordability may increase access, whether naloxone's high cost is associated with low dispensing rates should be evaluated.

Associations Between Copays, Coverage Limits for Opioid Use Disorder Medications, and Prescribing in Medicaid, 2018

BACKGROUND

Opioid use disorder (OUD) affects millions of Americans, but only a fraction receive treatment. Many patients with OUD are enrolled in Medicaid, but elements of different state Medicaid programs' drug benefit designs may impact patients' access to life-saving care.

OBJECTIVE

To describe medication for OUD (mOUD) use in Medicaid and examine the relationship between mOUD use and state drug benefit design plans.

DESIGN/SUBJECTS

Cross-sectional study using Medicaid State Drug Utilization Data from 2018 to quantify office-based mOUD and the Medicaid Behavioral Health Services Database to extract copay amounts and coverage limits for mOUD. We excluded states with <5% coverage and assessed for associations between copays or coverage limits and mOUD dispensing using simple linear regression.

MEASURES

Proportion of mOUD prescriptions relative to all prescriptions, opioid prescriptions, and the state-level prevalence of pain reliever use disorder and association between copays, coverage limits and these proportions.

RESULTS

There was substantial variability in mOUD use. Although state Medicaid drug benefit designs also varied, we found no significant relationship between copay requirements (yes/no), coverage limits (yes/no), copay amount ($0-$0.99 vs. $1 or more), and mOUD utilization measures.

CONCLUSIONS

Substantial state-level variation exists in mOUD use, but we did not find a significant association between copays or coverage limits and use in Medicaid. Further research is needed to assess other potential impacts of mOUD drug benefit design elements in Medicaid.

Factors Affecting Buprenorphine Utilization and Spending in Medicaid, 2002-2018

OBJECTIVE

Buprenorphine is an essential medication for the treatment of opioid use disorder (OUD), but studies show it has been underused over the last 2 decades. We sought to evaluate utilization of and spending on buprenorphine formulations in Medicaid and to evaluate the impact of key market and regulatory factors affecting availability of different formulations and generic versions.

METHODS

We first identified all buprenorphine formulations approved by the Food and Drug Administration for OUD using Drugs@FDA. We then used National Drug Codes to identify each drug in the Medicaid State Drug Utilization Data and extracted annual utilization rates and spending between 2002 and 2018 by drug and according to whether a brand-name or generic version was dispensed. We compared these trends to market and regulatory factors that affected competition, which we identified through searching the Federal Register, Westlaw, PubMed, and Google News.

RESULTS

Brand-name buprenorphine-naloxone sublingual tablet and film formulations (Suboxone) were dispensed 2.7 times more (n = 634 213 140) and reimbursed 4.4 times more (n = $4 440 556 473) than all other formulations combined (n = 237 769 689; $1 018 988 133). We identified numerous market and regulatory factors that contributed to an estimated 9-year delay in generic versions of the tablet formulation and 6-year delay for generic versions of the film formulation.

CONCLUSIONS

Brand-name buprenorphine formulations have been widely used in Medicaid, leading to substantial costs, in part because generic versions were delayed by multiple years owing to market and regulatory factors. Timely availability of low-cost generics could have helped encourage OUD treatment with buprenorphine during the height of the opioid crisis.

Buprenorphine for opioid use disorder: The role of public funding in its development

BACKGROUND

Buprenorphine is a highly effective, office-based treatment for opioid use disorder (OUD), but affordable access to it remains challenging despite initial government investment in its development. We aimed to estimate the public sector's contribution to the development of buprenorphine for OUD.

METHODS

We researched buprenorphine's timeline of development as an OUD treatment to identify key terms (e.g., authors of pivotal studies, labeled indication). We then conducted a PubMed search for each key term. We extracted article identification numbers and linked them to federal funding through the NIH RePORTER. We reviewed the title, investigator, and organization of each award distributed up to and including 2002 and classified awards as "highly related," "possibly related," or neither. Amounts of related awards were converted to 2019 US dollars.

RESULTS

Over the course of nearly four decades, the active ingredient in buprenorphine was synthesized by a pharmaceutical manufacturer, but it was developed for OUD primarily by investigators in government and academic centers, including a formal government-industry partnership for commercialization. We identified 29 key terms related to its development as an OUD treatment that linked to 7060 NIH awards. Among these awards, 40 were "highly related" ($39.9 million) and 20 were "possibly related" ($22.4 million).

CONCLUSIONS

An estimated $62.3 million in NIH awards to institutions and investigators supported the development of buprenorphine as a treatment for OUD. Despite this investment by the public sector, buprenorphine remains expensive, which limits access to this important treatment.

Public funding for transformative drugs: the case of sofosbuvir

The approval of sofosbuvir (Sovaldi) in 2013 transformed chronic hepatitis C virus (HCV) care, but its high cost was criticized in part because of reports of substantial public involvement in its development. We developed a methodology to assess the public's contribution through the National Institutes of Health (NIH) in developing sofosbuvir. Using key terms from the timeline of sofosbuvir, we identified articles in PubMed; linked them to federal funding using the NIH RePORTER; reviewed the title, organization, and investigator of each resulting award for relatedness; and converted related awards to 2018 US dollars. Of 6043 unique awards, we identified 29 that were directly (US$7.7 million) and 110 that were indirectly (US$53.2 million) related awards made to major academic institutions and companies engaged in the development of the drug. These findings indicate that public funding had a key role in developing sofosbuvir, with an estimated US$60.9 million provided in NIH funding.

Preferences for and experiences with pill appearance changes: national surveys of patients and pharmacists

OBJECTIVES

To better understand patients' and pharmacists' preferences for and experiences with changes in pill appearance (size, shape, color, and markings).

STUDY DESIGN

Cross-sectional.

METHODS

We conducted independent national surveys of patients 50 years and older taking generic drugs for depression, diabetes, epilepsy, HIV, hyperlipidemia, or hypertension and of licensed pharmacists practicing in chain, franchise, or independent pharmacies. Responses were collected between January and April 2016.

RESULTS

Of 1000 patient respondents (30% response rate), most reported experiencing changes in pill appearance (51%) and preferred to be notified about them (82%), but less than half recalled being notified (verbally: 36%; via sticker: 45%). Among patients who reported experiencing a change, 12% reported stopping their medication or using it less frequently. Of 710 pharmacist respondents (33% response rate), many reported changes in pill appearance occurring frequently in their pharmacies (47% reported that changes occurred 6 or more times per month) and more than three-fourths reported notifying patients about them often (verbally: 88%; via sticker: 77%).

CONCLUSIONS

Our findings reveal opportunities to improve patients' experiences with pill appearance changes through better notification practices and patient education.