No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Pharmacists and Naloxone: Barriers to Dispensing and Effectiveness of an Educational Outreach Program
Abstract
Background:
The Illinois Naloxone Standing Order allows community pharmacists to dispense naloxone; however, this policy initiative may be underutilized.
Objective:
Our study aims to characterize naloxone dispensing barriers, overall and by pharmacy type, make recommendations that can inform future policies to improve naloxone access, and evaluate outreach initiative effectiveness from academic detailers' perspectives.
Methods:
We conducted a retrospective analysis of semistructured data collected as part of an educational outreach program targeting Illinois community pharmacists in 2021. Academic detailers conducted educational outreach visits across community pharmacy settings (i.e., primary pharmacy, grocery pharmacy, or independent pharmacy) to promote standing order use and discuss barriers pharmacists face when dispensing naloxone. Following each visit, detailers recorded visit characteristics, pharmacist-identified obstacles impacting naloxone dispensing, and visit effectiveness.
Results:
Detailers performed in-person visits at 270 (78%) of 348 targeted sites. A lower proportion of independent pharmacies (61%) routinely stock naloxone than primary (95%, P < 0.001) or grocery (98%, P < 0.001) pharmacies. Among pharmacists at independent pharmacies, 43% indicated they were highly or extremely comfortable dispensing naloxone, a significantly lower proportion than pharmacists at grocery (79%, P < 0.001) or primary (68%, P < 0.001) pharmacies. The prevalence of salient barriers to naloxone dispensing was: cost/insurance issues (primary pharmacy = 38% vs. grocery pharmacy = 36% vs. independent pharmacy = 28%, P = 0.46), stigma (36% vs. 49% vs. 16%, P < 0.05), and lack of standing order enrollment (0% vs. 0% vs. 49%, P < 0.05). On average, detailers perceived visits as less useful to pharmacists working at independent pharmacies than those at primary or grocery pharmacies.
Conclusions:
Over 80% of pharmacists reported facing greater than one naloxone dispensing barrier. While cost/insurance issues appear ubiquitous, patient stigma-related factors were prevalent in primary and grocery pharmacies. Although many pharmacists are comfortable dispensing naloxone under the standing order, pharmacists at independent pharmacies are less comfortable, potentially secondary to lower standing order enrollment.
... Examples of pharmacists providing HR education to peers and other healthcare professionals occur in various settings, including health-systems and community pharmacies. 41,103,109,110 One well-defined role that psychiatric pharmacists may serve in to further the knowledge of colleagues in HR and management of SUDs is academic detailing. Academic detailing is a one-on-one educational approach with providers to address knowledge gaps and shape prescribing and outcomes within their own practices. ...
Deaths related to opioid overdoses continue to climb, and there remains a need for innovative strategies to address this ongoing crisis. Harm reduction (HR), a nonjudgmental philosophy aimed at reducing consequences associated with drug use and other potentially unsafe behavior, has emerged as a compassionate and effective approach. Harm reduction further emphasizes overdose prevention and fosters a shift in perspective that recognizes substance use disorder as a disease and not a moral failing. The tenets of HR collectively advocate for the well-being of individuals who use substances and support any positive change as defined by the individual. Given the high rate of morbidity and mortality associated with substance misuse and barriers or ambivalence to receiving treatment, awareness of and advocacy for HR practice is essential. This manuscript aims to describe evidence-based HR interventions, provide a foundation for the implementation of services, and further promote the importance of providing humanistic care without judgment. As valued members of the multidisciplinary treatment team, Board-Certified Psychiatric Pharmacists should implement and engage in HR services in the settings where people with substance use disorders receive care.
... Although pharmacists can dispense naloxone with or without a prescription in many states, a recent systematic review identified several barriers to pharmacist-driven naloxone distribution (74). These barriers include time constraints, inadequate reimbursement, possible inducement to increased opioid use, placing the pharmacist in an unsafe situation, inadequate training in detecting overdose risk or application of state laws or standing orders, and hesitation in dispensing a medication without a prescription (74)(75)(76). ...
Opioids refer to chemicals that agonize opioid receptors in the body resulting in analgesia and sometimes, euphoria. Opiates include morphine and codeine; semi-synthetic opioids include heroin, hydrocodone, oxycodone, and buprenorphine; and fully synthetic opioids include tramadol, fentanyl and methadone. In 2021, an estimated 5.6 million individuals met criteria for opioid use disorder. This article provides an overview of the pharmacology of heroin and non-prescription fentanyl (NPF) and its synthetic analogues, and summarizes the literature related to the management of opioid use disorder, overdose, and withdrawal. This is followed by a description of barriers to treatment and best practices for management with a discussion on recent updates and their potential impact on this patient population. This is followed by a description of barriers to treatment and best practices for management with a discussion on recent updates and their potential impact on this patient population.
Introduction
Naloxone is an opioid receptor antagonist, which can rapidly reverse the effects of an opioid overdose. Community pharmacists may experience several barriers to stocking and supplying naloxone including a lack of confidence or knowledge and time constraints. The current study aimed to examine the extent to which Victorian community pharmacies stock and supply naloxone and determine specific characteristics associated with stocking naloxone.
Methods
A representative sample of community pharmacists ( n = 558) in Victoria, Australia, were contacted between October and November 2020 and invited to participate in an online survey. Data related to pharmacy‐ and pharmacist‐related characteristics, including stocking and frequency of supplying naloxone in the past year. Multivariate logistic regression analysis was performed to examine the effect of various covariates on stocking naloxone.
Results
The sample comprised 265 pharmacists (response rate 47%). Most pharmacies were located in Melbourne (the capital city of Victoria, 59.6%) and were part of a pharmacy chain (61.5%). In total, 100 (38%) pharmacies stocked naloxone, a third of whom did not supply it in the past year. Pharmacies that provided opioid agonist treatment had 2.4 times higher odds of stocking naloxone (95% confidence interval 1.425–4.136; p = 0.001).
Discussion and Conclusion
Less than half of Victorian community pharmacies stock naloxone, with even fewer actually supplying it in the past year. Future efforts are needed to increase the number of pharmacies that stock naloxone and the frequency in which it is supplied, while also addressing possible barriers to stocking and supplying naloxone among community pharmacists.
Background
Community pharmacies are well-positioned to improve the health of people with opioid use disorder and who use drugs by providing naloxone and other essential public health supplies. Respond to Prevent (R2P) is a clinical trial which sought to accelerate provision of harm reduction materials through a multicomponent intervention that included in-store materials, online training, and academic detailing.
Objectives
The objective of this study was to explore pharmacists’ attitudes, knowledge, and experiences in providing naloxone, dispensing buprenorphine, and selling nonprescription syringes following participation in the R2P program.
Methods
Two online asynchronous focus groups were conducted with community-based chain pharmacists across Massachusetts, New Hampshire, Oregon, and Washington who had participated in the R2P program. Participants accessed an online repository of group interview items and responded to questions over a short period. Each pharmacist participated anonymously for approximately 30 min across over 2 ½ days. Pharmacists answered questions on experiences with pharmacy-based harm reduction care and R2P intervention implementation barriers and facilitators. Qualitative data analysis was conducted by a multidisciplinary team using an immersion-crystallization approach.
Results
A total of 32 pharmacists participated in the two focus groups. Most participants were female (n = 18, 56%), non-Hispanic (n = 29, 91%), and white (n = 17, 53%). Four major themes were identified related to (1) addressing bias and stigma toward people with opioid use disorder and who use drugs, (2) familiarity and comfort with naloxone provision, (3) perspective and practice shifts in nonprescription syringe sales, (4) structural challenges to harm reduction care in the pharmacy.
Conclusions
Community pharmacists across the four states identified attitudes, knowledge, and experiences that create barriers to providing care to people with opioid use disorder and who use drugs. R2P approaches and tools were effective at reducing stigma and changing attitudes but were less effective at addressing structural challenges from the pharmacists’ perspective.
Introduction
Academic detailing has been used as a preferential method to increase pharmacists’ awareness of naloxone, however, its impact on actual dispensing rates is not well established.
Objective
The aim of this pilot study is to determine if a student‐led academic detailing on naloxone use and communication increased the amount of naloxone ordered from independent pharmacies in various geographic settings throughout Northeast Pennsylvania.
Methods
39 independent pharmacies which utilized a single wholesaler were randomized to receive an in‐person, student‐led training about naloxone use and communication. Students attended a train‐the‐trainer presentation to ensure a universal training was provided to all pharmacies. Students were provided with intranasal naloxone demonstration devices, handouts on effective communication, and talking points for each pharmacy visit. All academic detailing sessions were held live at each pharmacy during that pharmacy's regular business hours. Topics covered included appropriate naloxone use, what to expect after giving naloxone, and evidence‐based communication methods for engaging with patients about purchasing naloxone. Devices and handouts were left behind for pharmacists to use in daily practice. Naloxone and opioid shipping data for three months prior to and three months post‐intervention were compared.
Results
Naloxone ordered in the pre‐intervention period was 21 vs. 26 (intervention vs. control) (p = 0.59) and 31 vs. 29 post‐intervention (p = 0.25). There was no statistically significant difference in the number of pharmacies which ordered more naloxone pre vs. post‐intervention or in the total amount of opioids ordered pre vs. post‐intervention.
Conclusion
While pharmacies which received academic detailing did order more naloxone that pharmacies which did not, the difference did not rise to a level of statistical significance. As the population of this pilot study was small, expanding this approach to academic detailing to a larger population is warranted to possibly see more robust results.
This article is protected by copyright. All rights reserved.
Background:
Community pharmacies are an important resource for people who inject drugs (PWID) to purchase over-the-counter (OTC) syringes. Access to sterile injection equipment can reduce transmission of bloodborne illnesses. However, pharmacists and their staff ultimately use discretion over sales.
Objective:
To identify staff attitudes, beliefs, knowledge, and practices in the sale of OTC syringes in community pharmacies.
Methods:
This systematic review was reported according to PRISMA and registered with PROSPERO (CRD42022363040). We systematically searched PubMed, EMBASE, and Scopus from inception to September 2022. The review included peer-reviewed empirical studies regarding OTC syringe sales among community pharmacy staff (pharmacists, interns, and technicians). We screened records and extracted data using a pre-defined data extraction form. Findings were narratively synthesized, and critical appraisal was conducted using the Mixed Methods Appraisal Tool (MMAT).
Results:
A total of 1895 potentially relevant articles were identified and 35 were included. Most studies (23; 63.9%) were cross-sectional descriptive designs. All studies included pharmacists, with seven (19.4%) also including technicians, two (5.6%) including interns, and four (11.1%) including other staff. Studies found relatively high support among respondents for harm reduction-related services within community pharmacies, but less common reports of staff engaging in said services themselves. When studies investigated the perceived positive/negative impacts of OTC syringe sales, prevention of bloodborne illness was widely understood as a benefit, while improper syringe disposal and safety of the pharmacy and its staff commonly reported as concerns. Stigmatizing attitudes/beliefs toward PWID were prevalent across studies.
Conclusion:
Community pharmacy staff report knowledge regarding the benefits of OTC syringes, but personal attitudes/beliefs heavily influence decisions to engage in sales. Despite support for various syringe related harm reduction activities, offerings of services were less likely due to concerns around PWID.
Abstract
Introduction: Academic detailing (AD) is an educational outreach strategy to provide clinicians with current evidence-based information, which has been shown to change prescribing behaviours. The overall effectiveness of AD interventions is associated with prescriber satisfaction; however, most approaches use single items or nonvalidated measures. This study aims to develop and validate an instrument to assess prescriber satisfaction with AD interventions.
Methods: A group of candidate items was generated and refined based on constructs identified through a literature review and in consultation with an expert panel. The initial instrument was piloted with 183 primary care providers who participated in an AD intervention on opioid-related pain management. To support the validity and reliability of the measure, psychometric properties were examined.
Results: Ten candidate items were developed based on the following themes: acceptability, feasibility of implementation, usefulness, perception of efficacy, overall satisfaction, willingness to repeat and willingness to change. One item related to willingness to change did not contribute to assessing an individual’s ability and lowered the measure’s internal consistency and was therefore dropped.
Conclusion: Results supported the validity and reliability of a refined 9-item measure of Provider Satisfaction with Academic Detailing (the PSAD). This measure should be considered for broad use across educational outreach programmes as a standardized measure to assess provider satisfaction and provide continuous quality improvement.
Keywords: academic detailing, instrument development, prescriber satisfaction, psychometric, validity.
Introduction:
Academic detailing (AD) is an effective, evidence-based education outreach method of promoting clinician behavior change. Detailer feedback is important for program evaluation but is rarely systematically collected. The study's objective was to develop a measure capturing the detailer's perception of the effectiveness of an AD program.
Methods:
A six-item measure with a five-level scale was initially developed from the literature review and expert panel consultation. Item constructs were usefulness, acceptability, feasibility, relevance, effectiveness of communication, and readiness to change. The measure was piloted, refined, and tested during an opioid-focused AD program that included two visits. The instrument structure was evaluated using exploratory factor analysis, measure reliability was assessed using item–item correlation (rho), corrected item–total correlation, Cronbach alpha (α), and item response theory.
Results:
The initial six-item instrument demonstrated unidimensionality. The Cronbach α for the measure was 0.74 (visit 1) and 0.79 (visit 2); one item (relevance) was redundant (α = 0.73 and 0.79 when deleted) and therefore dropped. Items related to usefulness, acceptability, and readiness to change displayed high item–item correlation (rho ≥ 0.50) and contributed the most information and seemed to operate as a single scale (ie, “likelihood to change”) based on item response theory analysis. Items related to feasibility and communication were slightly different constructs and should be reported separately.
Discussion:
The five-item detailer assessment of visit effectiveness (the “DAVE”) instrument provides a standardized approach to assess AD. Further study of its validity and broader use in other programs and educational outreach activities is encouraged.
Importance:
Despite the increasingly important role of pharmacies in the implementation of naloxone access laws, there is limited information on the impact of such laws at the local level.
Objective:
To evaluate the availability (with or without a prescription) and cost of naloxone nasal spray at pharmacies in Philadelphia, Pennsylvania, following a statewide standing order enacted in Pennsylvania in August 2015 to allow pharmacies to dispense naloxone without a prescription.
Design, setting, and participants:
A survey study was conducted by telephone of all pharmacies in Philadelphia between February and August 2017. Pharmacies were geocoded and linked with the American Community Survey (2011-2015) to obtain information on the demographic characteristics of census tracts and the Medical Examiner's Office of the Philadelphia Department of Public Health to derive information on the number of opioid overdose deaths per 100 000 people for each planning district. Data were analyzed from March 2018 to February 2019.
Main outcomes and measures:
Availability and out-of-pocket cost of naloxone nasal spray (with or without a prescription) at Philadelphia pharmacies overall and by pharmacy and neighborhood characteristics.
Results:
Of 454 eligible pharmacies, 418 were surveyed (92.1% response rate). One in 3 pharmacies (34.2%) had naloxone nasal spray in stock; of these, 61.5% indicated it was available without a prescription. There were significant differences in the availability of naloxone by pharmacy type and neighborhood characteristics. Naloxone was both more likely to be in stock (45.9% vs 27.8%; difference, 18.0%; 95% CI, 8.3%-27.8%; P < .001) and available without a prescription (80.6% vs 42.2%; difference, 38.4%; 95% CI, 23.0%-53.8%; P < .001) in chain stores than in independent stores. Naloxone was also less likely to be available in planning districts with very elevated rates of opioid overdose death (≥50 per 100 000 people) compared with those with lower rates (31.1% vs 38.5%). The median (interquartile range) out-of-pocket cost among pharmacies offering naloxone without a prescription was 119-$150); costs were greatest in independent pharmacies and planning districts with elevated rates of opioid overdose death.
Conclusions and relevance:
Despite the implementation of a statewide standing order in Pennsylvania more than 3 years prior to this study, only one-third of Philadelphia pharmacies carried naloxone nasal spray and many also required a physician's prescription. Efforts to strengthen the implementation of naloxone access laws and better ensure naloxone supply at local pharmacies are warranted, especially in localities with the highest rates of overdose death.
Background:
While misuse of prescription opioids has reached epidemic proportions, pharmacy-based preventive services to combat this epidemic are limited. The aims of this study were to identify barriers and facilitators to the dispensing of intranasal naloxone (INN) by pharmacists in New Mexico.
Methods:
For this mixed methods study, a qualitative component (focus group) informed the development of a quantitative component (electronic survey) distributed to all pharmacists registered with the New Mexico Board of Pharmacy and practicing in the state. A 46-item survey included questions about pharmacists' concerns regarding dispensing INN, barriers and facilitators to dispensing INN, efforts needed to increase availability and utilization of pharmacist-dispensed INN, and characteristics of respondents and their pharmacies.
Results:
Pharmacists from all geographical regions and all types of pharmacy settings were represented in the sample (final n = 390, participation rate 23.5%, including a subset of 182 community pharmacists). The main barriers identified were: 1) out-of-pocket costs for patients; 2) time constraints for pharmacists; and 3) inadequate reimbursement for pharmacists. The main facilitators were: 1) increased awareness among opioid-using patients and family members about the need for INN; 2) additional education to the general public; and 3) additional training for pharmacists on how to initiate discussions about INN with high-risk patients. Some community pharmacists were concerned that INN dispensing would promote opioid abuse (16.5%) and attract undersirable clientele (14.3%). In a multivariable logistic regression analysis of a community pharmacy subset, a higher number of concerns about INN (OR = 0.87; 95% CI: 0.82-0.93), and a pharmacy setting in a chain grocery or a 'big box' store (OR = 0.38; 95% CI: 0.16; 0.92) were associated with decreased odds of dispensing INN.
Conclusions:
Effective intervention strategies for increasing dispensing of intranasal naloxone by pharmacists should focus on pharmacist concerns, include education to multiple audiences, and address provider-level, system-level, and society-level barriers.
Objectives:
Little is known about attitudes of pharmacists and consumers to pharmacy naloxone. We examined perceptions and experiences of pharmacy naloxone from people with opioid use disorder, patients taking chronic opioids for pain, caregivers of opioid users, and pharmacists from 2 early pharmacy naloxone adopter states: Massachusetts and Rhode Island.
Design:
Eight focus groups (4 per state) were held in October to December 2015.
Setting and participants:
Participants were recruited from pharmacies, health clinics, and community organizations; pharmacists were recruited from professional organizations and pharmacy colleges.
Outcome measures:
Focus groups were led by trained qualitative researchers using a topic guide, and recorded and transcribed for analysis. Five analysts developed and applied a coding scheme to transcripts. Thematic analysis involved synthesis of coded data and connections between key themes, with comparisons across the groups.
Results:
Sixty-one participants included patients with chronic pain (n = 15), people with opioid use disorders (n = 19), caregivers (n = 16), and pharmacists (n = 11). A majority of pharmacists had dispensed naloxone to patients; a minority of all consumer participants had obtained pharmacy naloxone. Four themes emerged: consumer fear of future consequences if requesting naloxone; pharmacists' concerns about practice logistics related to naloxone; differing perceptions of how opioid safety is addressed in the pharmacy; and solutions to addressing these barriers. Whereas consumer groups differed in awareness of naloxone and availability at pharmacies, all groups expressed support for the pharmacist's role and preferences for a universal offer of naloxone based on clear criteria.
Conclusion:
Pharmacies complement community naloxone provision to patients and caregivers. To overcome stigma of naloxone receipt, increased public awareness of naloxone and pharmacist training about naloxone and addiction are required. Pharmacists should offer naloxone via universal opt-out strategies-where all patients meeting evidence-based criteria are offered naloxone-rather than targeted or opt-in strategies-where only patients perceived as high risk or patients who request it are offered naloxone.
Introduction
Improving access to naloxone is an important public health strategy in the U.S. This study examines the state-level trends in naloxone dispensing from 2012 to 2019 for all 50 states and the District of Columbia.
Methods
Data from IQVIA Xponent were used to examine the trends and geographic inequality in annual naloxone dispensing rates and the number of naloxone prescriptions dispensed per high-dose opioid prescription from 2012 to 2019 and from 2016 to 2019 to correspond with the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain release. Annual percentage change was estimated using linear regression. Analyses were conducted in 2020.
Results
Naloxone dispensing rates and the number of naloxone prescriptions per 100 high-dose opioid prescriptions increased from 2012 to 2019 across all states and the District of Columbia. Average state-level naloxone dispensing rates increased from 0.55 per 100,000 population in 2012 to 45.60 in 2016 and 292.31 in 2019. Similarly, the average number of naloxone prescriptions per 100 high-dose opioid prescriptions increased from 0.002 in 2012 to 0.24 in 2016 and 3.04 in 2019. Across both measures of naloxone dispensing, the geographic inequality gap increased during the study period. In 2019, the number of naloxone prescriptions dispensed per 100 high-dose opioid prescriptions ranged from 1.04 to 16.64 across states.
Conclusions
Despite increases in naloxone dispensing across all states, dispensing rates remain low, with substantial variation and increasing disparities over time at the state level. This information may be helpful in efforts to improve naloxone access and in designing state-specific intervention programs.
Background
Pharmacists are critical to public health in supporting safe use of prescription opioids by ensuring that all patients are offered and counseled on naloxone. Academic detailing may be an effective educational outreach strategy for improving pharmacists’ knowledge and behavior related to naloxone.
Objective
To describe an academic detailing program to pharmacists on the topic of counseling and promoting naloxone to patients.
Methods
Pharmacists were recruited by convenience sampling. Three pharmacists who were experienced with academic detailing techniques provided the education. Survey data were collected to evaluate the program.
Results
Thirty-three pharmacists participated, including 16 sessions that were delivered virtually. The pharmacists worked in a variety of ambulatory settings, including chain or corporate-owned pharmacies (58%), hospital-owned specialty pharmacies (15%), hospital-owned community pharmacies (15%), and independently owned or other pharmacies (12%). Twenty-eight pharmacists (85%) completed an immediate post-session evaluation survey. Twenty-seven pharmacists (96%) indicated they felt the information presented will impact their practice or patient care. Eleven pharmacists (33%) completed a second post-session survey, self-reporting improvements related to counseling patients about naloxone. Conclusion: Participating in academic detailing supports community pharmacists’ providing patient counseling about naloxone. Further study, particularly related to virtual academic detailing, is necessary to understand the full potential of academic detailing to pharmacists.
IntroductionClinical 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.ResultsAmong 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 US9.74 for the index opioid (SD 19.75). The average deductible was US3.74 for the index opioid (SD 25.56), with 94% and 88% having deductibles of US31.01 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.
Objectives
Tennessee has one of the highest rates of opioid prescribing in the United States; therefore, the objectives of this study were to examine availability, pricing, and pharmacist-initiated recommendations of naloxone in retail community pharmacies in Eastern and Western Tennessee; to identify the most common barriers to naloxone dispensing and strategies to improve access; and to determine regional differences in access to naloxone.
Design
A cross-sectional survey conducted via telephone.
Setting and participants
All retail community pharmacies located in the most populous counties in the eastern and western regions of Tennessee were eligible for inclusion, as were all retail community pharmacies in the 5 counties in each region that had the highest rates of opioid prescriptions (316 pharmacies identified in 12 counties).
Outcome measures
Outcome measures included availability, price, and pharmacist-initiated recommendations of naloxone products, barriers to dispensing, and suggestions to improve naloxone access. Survey responses were summarized as descriptive statistics. Chi-square, independent samples t test, and inductive content analysis were conducted.
Results
Response rate was 56.3%. Most participants (92.7%) reported that naloxone (Narcan) was available from their pharmacies at a mean cash price of $132.49, with no statistically significant differences between regions. The most commonly reported barrier was cost (70.2%). When queried about recommendations to various groups at a high risk of overdose, as advised by the U.S. Department of Health and Human Services, 42.1% to 69.1% of pharmacies reported recommending naloxone to at least 50% of high-risk patients. Suggestions to increase naloxone access included lowering the cost and improving naloxone-related education for patients, pharmacists, and other providers.
Conclusion
Although Narcan was widely available, cost was a frequently cited barrier to dispensing. Pharmacist-initiated recommendations for coprescribing and dispensing naloxone to patients at a high risk of overdose were limited. Addressing cost issues in addition to increasing patient and pharmacist education concerning the use and benefit of naloxone were suggested to improve naloxone access.
Objective: Each U.S. state and the District of Columbia has passed legislation expanding access to naloxone, the opioid overdose antidote. Most naloxone access laws allow for standing orders, whereby prescribers may authorize pharmacists to dispense naloxone without an outside prescription. A recent study from our group assessing naloxone accessibility via standing order identified continued access barriers. The present study assessed whether brief, in-person, student-led academic detailing of community pharmacists improved naloxone accessibility.
Methods: A telephone audit of all 2317 CVS, Walgreens, H-E-B, and Walmart pharmacies in Texas was conducted to determine naloxone accessibility under standing orders. Within 2 months following the initial audit, student pharmacists visited the Austin and San Antonio, Texas area pharmacies that indicated they would not dispense naloxone without a prescription, to provide brief (<5 minutes) academic detailing to the pharmacist on duty. Students followed a scripted outline designed to inform pharmacists about naloxone standing orders and naloxone use for opioid overdose response. Then they provided a flyer and requested that it be displayed in the pharmacy to inform patients about naloxone. An identical telephone audit was conducted 1-2 weeks following the education.
Results: Of the 49 pharmacies receiving education, 37 (76%) responded that they would dispense naloxone without an outside prescription appropriately. When comparing each pharmacy before and after detailing, respectively, it was observed that 51% versus 71% (P = 0.008) stocked naloxone; 43% versus 71% (P = 0.002) would dispense naloxone to a third-party customer; and 12% versus 37% (P = 0.005) would submit a claim to the insurance of a third-party customer.
Conclusion: Student-led academic detailing was effective in improving pharmacists' willingness to dispense naloxone under standing orders and increasing naloxone accessibility from community pharmacies. Studies beyond Texas chain pharmacies are warranted to validate the effectiveness of this technique on a larger scale.
Objectives:
Pharmacists are well positioned to identify patients at risk of overdose, dispense naloxone, and counsel patients on appropriate use. In response to growing numbers of opioid-related deaths, many states have issued standing orders allowing pharmacists to dispense naloxone without a prescription. This systematic review examines the current state of naloxone use and dispensing regarding (1) roles for pharmacists dispensing naloxone, (2) barriers to their dispensing naloxone, and (3) pharmacist training to dispense naloxone.
Data sources:
PubMed, Cinahl Plus, and Cochrane review databases were searched with the use of the terms "pharmacist OR pharmacy" AND "naloxone." Included for review were peer-reviewed original research studies conducted in the U.S. in the past 5 years.
Study selection:
The preliminary search generated 155 studies, including 50 duplicate studies which were removed. From the remaining 105 studies, 33 were included that addressed pharmacist naloxone dispensing roles, barriers and facilitators to dispensing, or training for pharmacists.
Data extraction:
Authors, publication year, study title, study objective, method, outcomes, and conclusions were extracted for all studies.
Results:
Out of 33 studies, 14 focused on pharmacists' roles in naloxone dispensing, 9 on barriers, and 10 on training pharmacists for dispensing naloxone. The review found that most states permit major naloxone dispensing roles for pharmacists, but pharmacists are often underutilized without programs to support their roles. A key barrier to pharmacist naloxone dispensing is limited pharmacist training to identify and educate patients at risk of overdose.
Conclusion:
Although pharmacists have the legal opportunity to educate patients and dispense naloxone, barriers have limited their addressing naloxone with patients. There is a need for more intervention studies and in-depth understanding of pharmacist perspectives on barriers, training, and professional roles to facilitate tailored approaches for increasing pharmacist confidence in naloxone dispensing and consultation.
Importance
Given high rates of opioid-related fatal overdoses, improving naloxone access has become a priority. States have implemented different types of naloxone access laws (NALs) and there is controversy over which of these policies, if any, can curb overdose deaths. We hypothesize that NALs granting direct authority to pharmacists to provide naloxone will have the greatest potential for reducing fatal overdoses.
Objectives
To identify which types of NALs, if any, are associated with reductions in fatal overdoses involving opioids and examine possible implications for nonfatal overdoses.
Design, Setting, and Participants
State-level changes in both fatal and nonfatal overdoses from 2005 to 2016 were examined across the 50 states and the District of Columbia after adoption of NALs using a difference-in-differences approach while estimating the magnitude of the association for each year relative to time of adoption. Policy environments across full state populations were represented in the primary data set. The association for 3 types of NALs was associated: NALs providing direct authority to pharmacists to prescribe, NALs providing indirect authority to prescribe, and other NALs. The study was conducted from January 2017 to January 2019.
Exposures
Fatal and nonfatal overdoses in states that adopted NAL laws were compared with those in states that did not adopt NAL laws. Further consideration was given to the type of NAL passed in terms of its association with these outcomes. We hypothesize that NALs granting direct authority to pharmacists to provide naloxone will have the greatest potential for reducing fatal overdoses.
Main Outcomes and Measures
Fatal overdoses involving opioids were the primary outcome. Secondary outcomes were nonfatal overdoses resulting in emergency department visits and Medicaid naloxone prescriptions.
Results
In this evaluation of the dispensing of naloxone across the United States, NALs granting direct authority to pharmacists were associated with significant reductions in fatal overdoses, but they may also increase nonfatal overdoses seen in emergency department visits. The effect sizes for fatal overdoses grew over time relative to adoption of the NALs. These policies were estimated to reduce opioid-rated fatal overdoses by 0.387 (95% CI, 0.119-0.656; P = .007) per 100 000 people in 3 or more years after adoption. There was little evidence of an association for indirect authority to dispense (increase by 0.121; 95% CI, −0.014 to 0.257; P = .09) and other NALs (increase by 0.094; 95% CI, −0.040 to 0.227; P = .17).
Conclusions and Relevance
Although many states have passed some type of law affecting naloxone availability, only laws allowing direct dispensing by pharmacists appear to be useful. Communities in which access to naloxone is improved should prepare for increases in nonfatal overdoses and link these individuals to effective treatment.
Objectives:
The primary objective of this study was to identify barriers to dispensing naloxone under the North Carolina statewide standing order in the community pharmacy setting. Secondary objectives included identifying areas for additional training.
Methods:
This study was conducted as a cross-sectional survey distributed to community pharmacists in North Carolina through an Internet-based questionnaire platform. The questions assessed pharmacists' training regarding naloxone, willingness to dispense naloxone, knowledge of naloxone and opioid overdose, perceived barriers to implementing a naloxone distribution program, and demographic information. Descriptive statistics and Pearson correlation coefficient were used in data analysis.
Results:
Only 30% of survey respondents scored greater than 90% on the knowledge assessment portion of the survey. Furthermore, more than 50% of respondents indicated that they were not very comfortable dispensing naloxone, based on their responses to a series of Likert-type scale statements. A statistically significant positive correlation (r = 0.288; P < 0.001) was found between pharmacists' knowledge of naloxone and opioid overdose and willingness to dispense naloxone. The majority of respondents indicated that lack of training was a major barrier to dispensing naloxone. Additional training needs included information regarding naloxone, strategies to initiate patient discussion, identifying eligible patients, and workflow implementation. More than 95% of respondents indicated that the pharmacy in which they are employed would benefit from additional naloxone training.
Conclusion:
Community pharmacists in North Carolina would like to receive additional training regarding naloxone and opioid overdose. Given the statistically significant positive correlation between knowledge concerning naloxone and opioid overdose and willingness to dispense naloxone, it is possible that increased pharmacist training could lead to increased willingness to dispense naloxone under the statewide standing order. These results can be used in a meaningful way to determine the best ways to better educate pharmacists on naloxone and improve patient access to this life-saving medication.
Thirty-eight years ago, a US federal research agency issued a request for proposals on “Improving the Quality and Economy of Prescription Drug Use.” Recently out of my residency and concerned about the mismatch I was seeing between the best evidence and prevailing patterns of prescribing, I suspected that the problem might result in part from an imbalance in the effectiveness of communication coming from commercial vs academic sources. The pharmaceutical industry was impressively adept at sending well-trained change agents (drug “detailers”) to provide information about company products engagingly and interactively to physicians in their offices, in order to increase product sales. Academics, by contrast, who may have had a more impartial and thorough understanding of the evidence, tended to be passive and inelegant communicators, standing behind podiums in optional continuing education courses, delivering one-way didactic presentations in darkened rooms, often doing little to change actual practice.
Background:
Academic detailing is an outreach education technique that combines the direct social marketing traditionally used by pharmaceutical representatives with unbiased content summarizing the best evidence for a given clinical issue. Academic detailing is conducted with clinicians to encourage evidence-based practice in order to improve the quality of care and patient outcomes. The adoption of academic detailing has increased substantially since the original studies in the 1980s. However, the lack of standard agreement on its implementation makes the evaluation of academic detailing outcomes challenging.
Objective:
To identify consensus on the key elements of academic detailing among a group of experts with varying experiences in academic detailing.
Methods:
This study is based on an online survey of 20 experts with experience in academic detailing. We used the Delphi process, an iterative and systematic method of developing consensus within a group. We conducted 3 rounds of online surveys, which addressed 72 individual items derived from a previous literature review of 5 features of academic detailing, including (1) content, (2) communication process, (3) clinicians targeted, (4) change agents delivering intervention, and (5) context for intervention. Nonrespondents were removed from later rounds of the surveys. For most questions, a 4-point ordinal scale was used for responses. We defined consensus agreement as 70% of respondents for a single rating category or 80% for dichotomized ratings.
Results:
The overall survey response rate was 95% (54 of 57 surveys) and nearly 92% consensus agreement on the survey items (66 of 72 items) by the end of the Delphi exercise. The experts' responses suggested that (1) focused clinician education offering support for clinical decision-making is a key component of academic detailing, (2) detailing messages need to be tailored and provide feasible strategies and solutions to challenging cases, and (3) academic detailers need to develop specific skill sets required to overcome barriers to changing clinician behavior.
Conclusion:
Consensus derived from this Delphi exercise can serve as a useful template of general principles in academic detailing initiatives and evaluation. The study findings are limited by the lack of standard definitions of certain terms used in the Delphi process.
With the efficacy and costs of medications rising rapidly, it is increasingly important to ensure that drugs be prescribed as rationally as possible. Yet, physicians' choices of drugs frequently fall short of the ideal of precise and cost-effective decision making. Evidence indicates that such decisions can be improved in a variety of ways. A number of theories and principles of communication and behavior change can be found that underlie the success of pharmaceutical manufacturers in influencing prescribing practices. Based on this behavioral science and several field trials, it is possible to define the theory and practice of methods to improve physicians' clinical decision making to enhance the quality and cost-effectiveness of care. Some of the most important techniques of such "academic detailing" include (1) conducting interviews to investigate baseline knowledge and motivations for current prescribing patterns, (2) focusing programs on specific categories of physicians as well as on their opinion leaders, (3) defining clear educational and behavioral objectives, (4) establishing credibility through a respected organizational identity, referencing authoritative and unbiased sources of information, and presenting both sides of controversial issues, (5) stimulating active physician participation in educational interactions, (6) using concise graphic educational materials, (7) highlighting and repeating the essential messages, and (8) providing positive reinforcement of improved practices in follow-up visits. Used by the nonprofit sector, the above techniques have been shown to reduce inappropriate prescribing as well as unnecessary health care expenditures.(JAMA. 1990;263:549-556)