Perpetuating stigma or reducing risk? Perspectives from naloxone consumers and pharmacists on pharmacy-based naloxone in 2 states.

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. Eight focus groups (4 per state) were held in October to December 2015. Participants were recruited from pharmacies, health clinics, and community organizations; pharmacists were recruited from professional organizations and pharmacy colleges. 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. 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. 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.

Green TC ，Case P ，Fiske H ，Baird J ，Cabral S ，Burstein D ，Schwartz V ，Potter N ，Walley AY ，Bratberg J ... -  《-》

Revisiting pharmacy-based naloxone with pharmacists and naloxone consumers in 2 states: 2017 perspectives and evolving approaches.

Pharmacies provide accessible sources of naloxone to caregivers, patients taking opioids, and individuals using drugs. While laws permit expanded pharmacy naloxone access, prior work identified barriers like concerns about stigma of addiction and time constraints that inhibit scale-up. We sought to examine similarities and differences in experiences obtaining naloxone at the pharmacy over a 1-year period in 2 states, and to explore reactions from people with opioid use disorder, patients taking opioids for chronic pain, caregivers of opioid users, and pharmacists to communication tools and patient outreach materials designed to improve naloxone uptake. Eight focus groups (FGs) held December 2016 to April 2017 in Massachusetts and Rhode Island. Participants were recruited from pharmacies, health clinics, and community organizations; pharmacists were recruited from professional organizations and pharmacy colleges. The FGs were led by trained qualitative researchers using a topic guide and prototypes designed for input. Five analysts applied a coding scheme to transcripts. Thematic analysis involved synthesis of coded data and connections between themes, with comparisons across groups and to first-year findings. A total of 56 individuals participated: patients taking opioids for chronic pain (n = 13), people with opioid use disorders (n = 15), caregivers (n = 13), and pharmacists (n = 16). Fear of future consequences and stigma in the pharmacy was a prominent theme from the previous year. Four new themes emerged: experience providing pharmacy naloxone, clinician-pharmacist-partnered approaches, naloxone coprescription, and fentanyl as motivator for pharmacy naloxone. Prototypes for prompting consumers about naloxone availability, materials facilitating naloxone conversations, and posters designed to address stigma were well received. Experiences dispensing naloxone are quickly evolving, and a greater diversity of patients are obtaining pharmacy naloxone. Persistent stigma-related concerns underscore the need for tools to help pharmacists offer naloxone, facilitate patient requests, and provide reassurance when getting naloxone.

Green TC ，Donovan E ，Klug B ，Case P ，Baird J ，Burstein D ，Tapper A ，Walley AY ，Bratberg J ... -  《-》

Pharmacy naloxone codispensing: A mixed methods study of practices and perspectives under a statewide standing order program.

In a previous statewide naloxone purchase trial conducted in Massachusetts, we documented high levels of naloxone accessibility, upon patient request, under the state's naloxone standing order (NSO) program. Equally important for reducing overdose mortality rates is expanding naloxone access via codispensing alongside opioid prescription and syringe purchases at pharmacies. To understand naloxone codispensing from the perspective of pharmacists under the Massachusetts NSO program. The study used a mixed methods design involving 3 focus groups and a quantitative survey. Participants in both the focus groups (N = 27) and survey (N = 339) were licensed Massachusetts pharmacists. Focus groups were conducted at 3 separate professional conferences for pharmacists. The survey was conducted using a stratified random sample of 400 chain and independent retail pharmacies across Massachusetts. All data were collected between September 2018 and November 2019. Quantitative and qualitative analyses examined current policies, practices, and attitudes regarding naloxone codispensing for patients at risk of opioid overdose. Most pharmacists (69%) reported that they, their pharmacy, or both promoted codispensing alongside opioid prescriptions. A majority promoting naloxone codispensing did so for patients prescribed high opioid dosages (80%); fewer promoted codispensing for patients also prescribed benzodiazepines (20%). Facilitators to codispensing were pre-existing relationships between pharmacists and prescribers, mandatory pharmacist consultation, and universal naloxone promotion to all patients meeting certain criteria. Barriers to codispensing were pharmacists' concerns about offending patients by initiating a conversation about naloxone, insufficient technician training, workflow and resource constraints, and misconceptions surrounding naloxone. We found no substantive differences in outcomes between chain and independent pharmacies. We documented several facilitators and barriers to naloxone codispensing in Massachusetts pharmacies. Areas amenable to intervention include increased training for front-line pharmacy technicians, mandatory pharmacist consultation for opioid-prescribed patients, workflow reorganization, and addressing stigma concerns on the pharmacist end.

Pollini RA ，Slocum S ，Ozga JE ，Joyce R ，Xuan Z ，Green TC ，Walley AY ... -  《-》

Assessing pharmacists' readiness to dispense naloxone and counsel on responding to opioid overdoses.

The United States declared the opioid crisis a Public Health Emergency in 2017 and recommended increasing access and availability of naloxone, a reversal agent for opioid overdose. In Massachusetts, there is a statewide standing order for naloxone, which allows pharmacists to dispense it without a prescription to any person at-risk of experiencing an opioid overdose or other persons who can assist individuals at-risk. The objective of this study was to determine whether pharmacists in Massachusetts have sufficient education and training to fulfill the duties associated with dispensing naloxone in community pharmacy settings. The researchers investigated the pharmacists' ability to counsel patients both on naloxone and management of patients with an opioid overdose. At the time of the study, pharmacies could elect to have a standing order for naloxone. A randomized sample of 100 pharmacies was generated from the 792 pharmacies with a standing order. From this sample, 79 of the 100 pharmacies were visited on the basis of convenience and distribution in eastern and central Massachusetts. At each pharmacy, a validated 25-item survey was administered to pharmacists. Fewer than half of participants knew that different formulations of naloxone possess different quantities. Although 52% of pharmacists indicated the need to call 9-1-1 when witnessing an opioid overdose, 8% knew to start rescue breathing, and 4% knew to place patients in the recovery position. Despite regulations requiring all pharmacies with a standing order to provide training on naloxone, many of the pharmacists surveyed did not have a strong understanding about naloxone products or its pharmacology. The level of education Massachusetts pharmacists possess on naloxone products and administration is not sufficient to counsel patients regarding this medication. Increasing training requirements in pharmacy schools and continuing education offers potential solutions to the lack of knowledge in the community pharmacy setting.

Melaragni F ，Levy C ，Pedrazzi J ，Andersen M ... -  《-》

Pharmacists' readiness to provide naloxone in community pharmacies in West Virginia.

The objective of this study is to assess West Virginia pharmacists' stocking and dispensing practices of opioid-related medications and to identify the educational needs relating to providing naloxone in community pharmacies. A cross-sectional, anonymous, 49-item survey was created and validated to assess the educational needs of West Virginia community pharmacists. West Virginia. The data collection instrument was administered to 266 pharmacists currently licensed in West Virginia at 6 continuing pharmacy education events throughout the state from March 1 to June 15, 2016. Pharmacists' educational needs were determined using the Extended Parallel Process Model, which has 4 main constructs: perceived severity, perceived susceptibility, response efficacy, and self-efficacy. Pharmacists' stocking and dispensing of opioids and related medications were also assessed. Pharmacists completed 157 surveys. They were mostly male (56.1%), full-time employees (67.5%), worked mostly in community pharmacies (69.4%), and had a mean age of 50.19 years (SD = 13.62). The newly adapted opioid perceived efficacy and perceived severity of opioid adverse events scales were tested for reliability and validity. Only 20.4% of the community pharmacists surveyed felt comfortable selling naloxone without a prescription. As for the other opioid-related medications, only 53.3% stocked buprenorphine and 74.8% stocked buprenorphine/naloxone. As the most accessible health care providers, community pharmacists are acutely aware of how the opioid epidemic affects their communities. Some pharmacists in West Virginia are hesitant to stock and dispense opioids and opioid-dependence medications. Although this may decrease the flow of potentially abused drugs into the community, it may also restrict access to necessary therapy for patients with opioid use disorder. Furthermore, pharmacists in West Virginia are not yet comfortable stocking and dispensing naloxone. Tailored educational materials can help in controlling the pharmacists' fear and reinforce the benefits of over-the-counter naloxone use.

Thornton JD ，Lyvers E ，Scott VGG ，Dwibedi N ... -  《-》