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 ... -  《-》

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 ... -  《-》

Pharmacy leaders' beliefs about how pharmacies can support a sustainable approach to providing naloxone to the community.

Naloxone is an antidote to opioid overdose, and community pharmacies nationwide now provide broad access to this medication. The aim of this qualitative study was to understand how leaders in pharmacy organizations perceive pharmacies and pharmacy staff can optimize dispensing of naloxone. In-depth interviews were conducted with 12 pharmacy leaders in Massachusetts and Rhode Island. Participants were recruited from three types of community pharmacies: (1) chain; (2) independent; and (3) hospital outpatient. Theory-driven immersion crystallization, using Brownlee et al.'s model of healthcare quality improvement, was used to inform coding of the interview data, with predetermined categories of staff; organization; and process. Five main themes were identified: (1) Importance of staff training to increase comfort; (2) Strength through coordination of efforts; (3) Pharmacy as a community leader in the opioid crisis; (4) Persisting stigma; and (5) Ongoing workflow challenges. The results uniquely reflect the experiences and insights of pharmacy leaders implementing public health initiatives during the opioid crisis and can be used for gaining insight into how pharmacists can efficiently provide naloxone to their communities.

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

Beliefs Associated with Pharmacy-Based Naloxone: a Qualitative Study of Pharmacy-Based Naloxone Purchasers and People at Risk for Opioid Overdose.

Donovan E ，Case P ，Bratberg JP ，Baird J ，Burstein D ，Walley AY ，Green TC ... -  《-》

If we build it, will they come? Perspectives on pharmacy-based naloxone among family and friends of people who use opioids: a mixed methods study.

Expanding access to the opioid antagonist naloxone to reduce overdose mortality is a public health priority in the United States. Naloxone standing orders (NSOs) have been established in many states to increase naloxone dispensing at pharmacies, but increased pharmacy access does not ensure optimal uptake among those likely to witness an overdose. In a prior statewide purchase trial, we documented high levels of naloxone access at Massachusetts pharmacies under a statewide NSO. In this study, we characterize barriers to pharmacy-based naloxone uptake among potential opioid overdose "bystanders" (friends or family of people who use opioids) that may be amenable to intervention. Eligible bystanders were Massachusetts residents ≥ 18 years of age, did not use illicit opioids in the past 30 days, and knew someone who currently uses illicit opioids. We used a sequential mixed methods approach, in which a series of semi-structured qualitative interviews (N = 22) were conducted April-July 2018, to inform the development of a subsequent quantitative survey (N = 260), conducted February-July 2020. Most survey participants (77%) reported ever obtaining naloxone but few (21%) attempted to purchase it at a pharmacy. Qualitative participants revealed that barriers to utilizing the NSO included low perceived risk of overdose, which was rooted in misconceptions regarding the risks of prescription opioid misuse, denial about their loved one's drug use, and drug use stereotypes; inaccurate beliefs about the impact of naloxone on riskier opioid use; and concerns regarding anticipated stigma and confidentiality. Many participants had engaged in mutual support groups, which served as a source of free naloxone for half (50%) of those who had ever obtained naloxone. Despite high levels of pharmacy naloxone access in Massachusetts, few bystanders in our study had attempted to obtain naloxone under the NSO. Low perceived risk of overdose, misinformation, stigma, and confidentiality were important barriers to pharmacy naloxone uptake, all of which are amenable to intervention. Support groups provided a setting for addressing stigma and misinformation and provided a discreet and comfortable setting for naloxone access. Where these groups do not exist and for bystanders who do not participate in such groups, pharmacies are well-positioned to fill gaps in naloxone availability.

Slocum S ，Ozga JE ，Joyce R ，Walley AY ，Pollini RA ... -  《BMC PUBLIC HEALTH》