Informing a collaborative-care model for delivering medication assisted treatment for opioid dependence (MATOD): An analysis of pharmacist,prescriber and patient perceptions

BackgroundDemand for medication assisted treatment for opioid dependence (MATOD) in Australia exceeds capacity, particularly in rural and regional areas. There is increasing recognition that community pharmacists are well-positioned to take on expanded roles in MATOD delivery, however there has been limited Australian research exploring attitudes of pharmacists, prescribers, and patients to collaborative models of care.Objective(s)This study aimed to better understand enablers and barriers to a collaborative model for MATOD, to inform implementation in regions where increases in treatment capacity are urgently needed.MethodsSemi-structured telephone interviews were conducted with pharmacists (n = 11), prescribers (n = 6), and patients (n = 8) recruited from the Frankston-Mornington Peninsula region in Victoria, Australia, where transport and access to services have impacts on health care utilisation. The COM-B model was used to explore perceptions of pharmacists’ capability, opportunity, and motivations for delivering collaborative care.ResultsThere was strong motivation among healthcare professionals to participate in a collaborative model of care, with the main perceived benefits including improvements in accessibility, convenience, and continuity of care, and leverage of pharmacists’ high level of patient engagement. Key barriers identified by both pharmacists and prescribers included a perceived lack of pharmacist skills in some areas (capability) and resources (opportunity) to deliver collaborative care in a community pharmacy setting. Established relationships between all stakeholders (social opportunity) and communication between pharmacists and prescribers were identified as facilitators. Barriers and facilitators aligned with seven key areas: skills, confidence, relationships, patient selection, protocols, communication and resources.ConclusionsFindings informed the development of a collaborative model that was individualised, protocol based, and supported by training and clear processes.Project impactThis study identifies specific barriers and facilitators to a pharmacist-prescriber collaborative model of care for MATOD. The resulting model will be tested in a hybrid implementation-effectiveness trial in the Frankston-Mornington Peninsula region.     

Developing interagency collaboration to address the opioid epidemic: A scoping review of joint criminal justice and healthcare initiatives

BackgroundWith the current opioid epidemic impacting well over half of all counties across the United States, initiatives that encourage interagency collaboration between first responder organizations appear necessary to comprehensively address this crisis. Police, fire, and emergency medical services (EMS) are in a unique position to identify substance users and provide necessary resources to initiate treatment, yet there is not sufficient evidence of joint collaborative programs between law enforcement/first responders and healthcare providers.MethodsIn this scoping review we examine the current state of joint criminal justice and healthcare interventions, specifically, opioid and substance use pre-arrest initiatives via emergency first responders and police officers. We relied on data from the last 10 years across three major databases to assess the extent of criminal justice (CJ) and healthcare collaborations as a response to individuals with opioid use disorder (OUD). We specifically focused on interventional programs between criminal justice first responders (pre-arrest) and healthcare providers where specific outcomes were documented.ResultsWe identified only a small number (6) of studies involving interventions that met this criteria, suggesting very limited study of joint interagency collaboration between law enforcement first responders and healthcare providers. Most had small samples, none were in the southern states, and all but one were initiated within the last 5 years.ConclusionsAlthough studies describing joint efforts of early intercept criminal justice responses and healthcare interventions were few, existing studies suggest that such programs were effective at improving treatment referral and retention outcomes. Greater resources are needed to encourage criminal justice and healthcare collaboration and policies, making it easier to share data, refer patients, and coordinate care for individuals with OUD.     

Routine opioid outcome monitoring in community pharmacy: Pilot implementation study protocol

BackgroundIncreases in opioid use and related harms such as mortality are occurring in many high income countries. Community pharmacists are often in contact with patients at risk of opioid-related harm and represent an ideal point for intervention. Best practice in monitoring opioid-related outcomes involves assessing analgesia, pain functioning, mood, risks and harms associated with opioid use. Community pharmacists are well-placed to undertake these tasks.ObjectivesOur pilot study will test the implementation of a computer-facilitated screening and brief intervention (SBI). The SBI will support pharmacist identification of opioid-related problems and provide capacity for brief intervention including verbal reinforcement of tailored information sheets, supply of naloxone and referral back to the opioid prescriber. The SBI utilises software that embeds study procedures into dispensing workflow and assesses opioid outcomes with domains aligned with a widely accepted clinical framework.MethodsWe will recruit and train 75 pharmacists from 25 pharmacies to deliver the Routine Opioid Outcome Monitoring (ROOM) SBI. Pharmacists will complete the SBI with up to 500 patients in total (20 per pharmacy). Data will be collected on pharmacists’ knowledge and confidence through pre- and post-intervention online surveys. Data on feasibility, acceptability and implementation outcomes, including naloxone supply, will also be collected.Project impactOur study will examine changes in pharmacists’ knowledge and confidence to deliver the SBI. Through the implementation pilot, we will establish the feasibility and acceptability of a pharmacist SBI that aims to improve monitoring and clinical management of patients who are prescribed opioids.     

The Tennessee medication therapy management program: A hybrid type 2 effectiveness-implementation trial study protocol

BackgroundPharmacist-led medication therapy management (MTM) programs are considered evidence-based and have clearly defined core components. Despite this, MTM programs are often implemented without fidelity due to notable implementation barriers, such as physician-pharmacist relationships and pharmacist access to patient medical records. To improve MTM implementation, the Tennessee Medicaid program developed a MTM intervention that incorporates implementation strategies to address some of the known barriers to implementation (e.g., formalizing pharmacist-physician relationships through collaborative practice agreements, ensuring pharmacists’ access to medical records).ObjectivesThe purpose of this hybrid type 2 effectiveness-implementation study is to (1) assess the effectiveness of the MTM pilot program in Tennessee (e.g., medication adherence, healthcare utilization, quality and cost of care) and (2) assess the implementation of the MTM pilot program (e.g., feasibility, appropriateness, acceptability, penetration).MethodsThe Tennessee MTM pilot program is being assessed as a hybrid type 2 effectiveness-implementation study with a quasi-experimental design. A mixed methods approach (QUAN + QUAL) for the purpose of complementarity (e.g., answering related research questions). Data will include surveys, interviews, MTM platform encounter information, and medical and pharmacy claims. Initial analyses will include data between January 2018 and December 2019.ConclusionThe study will further add to the evidence base of MTM interventions by testing an intervention that addresses known barriers to implementation and simultaneously collecting data on effectiveness and implementation to speed up MTM translation. The Tennessee MTM program is expected to serve as a guide to other states seeking to expand pharmacist-delivered clinical services to their Medicaid members, particularly those intending to incorporate MTM into programs seeking to improve primary care delivery. Further, by improving the implementation of MTM, the pilot program is expected to improve the reliability of MTM program benefits including healthcare quality and cost and patient outcomes.     

Protocol for a pilot and feasibility study of nurse practitioner-pharmacist telehealth collaboration to simplify complex medication regimens

IntroductionNew and flexible multidisciplinary workforce models are needed to address unnecessary medication regimen complexity in residential aged care facilities (RACFs). This study will investigate the feasibility of a nurse practitioner-pharmacist telehealth-based collaborative care model to simplify complex medication regimens.MethodsThis is a pragmatic, non-randomized pilot and feasibility study of up to 30 permanent residents from 4 RACFs in Western Australia. Simplification will be conducted in accordance with a validated 5-step implicit process. Nurse practitioners will identify residents potentially interested in and who may benefit from simplification, including any regulatory or safety imperatives that might preclude simplification. Medication regimens will be assessed by an off-site clinical pharmacist to identify opportunities for simplification in terms of drug–drug, drug–food, or drug–time interactions, and the availability of alternative formulations. The pharmacist will communicate simplification opportunities to nurse practitioners via video case conferencing. Nurse practitioners will then discuss simplification opportunities with the resident, caregiver and the health and care team, including any unintended consequences for the resident or RACF. The primary outcome measure will be feasibility (stakeholder acceptability, protocol adherence, recruitment and retention rates). Secondary outcomes include change in the number of medication administration times per day, medication and behavioral incidents, falls and fractures, hospitalization and mortality at 4 months.Ethics and disseminationEthical approval has been obtained from the Monash University Human Research Ethics Committee. Research findings will be disseminated through industry report, lay summaries, conference presentations and peer-reviewed publications.     

Perceived need and availability of psychosocial interventions across buprenorphine prescriber specialties

IntroductionPsychosocial interventions are often recommended as part of buprenorphine treatment for patients with opioid use disorder, but little is known about prescriber perspectives on their use and how this varies across buprenorphine prescriber specialties.MethodsA large US sample of physicians actively prescribing buprenorphine (n = 1174) was surveyed from July 2014 to January 2017. Analyses examined prescriber characteristics and their perceptions and use of psychosocial interventions across three groups of physicians: primary care providers (PCPs), addiction physicians/psychiatrists, and other physicians.ResultsAcross all prescribers, 93.3% (n = 1061) report most patients would benefit from formal counseling during buprenorphine treatment while only 36.4% (n = 414) believe there are adequate number of counselors in their communities. Among addiction physicians/psychiatrists, 75.9% (n = 416) report their treatment settings have the resources to provide psychiatric services to patients with complex psychiatric problems compared to 29.1% (n = 130) of PCPs and 29.6% (n = 39, p < .001) of other physicians. Addiction physicians/psychiatrists report a higher percentage of patients receive counseling from clinicians in their practice while PCPs report a higher percentage of patients receive counseling from external providers.ConclusionsThe majority of prescribers believe patients receiving buprenorphine would benefit from psychosocial interventions and there is variation in how these services are delivered. However, many prescribers, especially those without addiction or psychiatry backgrounds, report their settings do not have adequate psychosocial treatment resources for patients with complex psychosocial needs. Future work developing novel models of psychosocial interventions may be helpful to support prescribers to effectively treat complex patients with opioid use disorders.     

“Before the training I just assumed they've done something bad”: Reporting on professional training for pharmacy assistants and pharmacy dispensary technicians on medically assisted treatment of opioid dependence

BackgroundA study that examined the lived experiences of Medically Assisted Treatment of Opioid Dependence (MATOD) consumers suggested that they had experienced discrimination and stigma in pharmacies in regional Victoria, Australia. To address this, the need for professional training opportunities for Pharmacy Assistants (PAs) and Pharmacy Dispensary Technicians (PTDs) had been emphasised. A research project was undertaken to develop training modules using Social Determinants of Health (SDH) for PAs and PDTs involved in providing MATOD pharmacy services in regional Victoria, and to evaluate their effectiveness.ObjectivesThe study aimed to examine and evaluate changes in attitudes and practices amongst PAs and PDTs involved in MATOD services in regional Victoria, Australia and who had undertaken the training modules.MethodsThe paper reports primarily on the in-depth qualitative interviews that were completed after the training with PAs and PTDs. Thematic analysis was employed to code the data.ResultsThematic analysis generated five themes: understanding of the professional role of PAs and PTDs, initial judgements concerning MATOD consumers, reflection on the SDH, training content analysis, and the post-training impact upon Professional Practice. These themes reflected participants’ insights with regards both to MATOD consumers and the impact the training itself had had on their professional practice.Conclusion“Consciousness-raising” from participation in the training can positively influence the development of participants’ professional attitudes and practices with regards to MATOD service delivery. This development supports that training informed by SDH and ideas of critical reflection can help facilitate the creation of knowledge around the social construction of health and increased understanding of the impacts of language-use, attitudes and behaviour.     

Application of consolidated framework for implementation research to improve Clostridioides difficile infection management in district hospitals

BackgroundClostridioides difficile infection (CDI) contributes the global threats of drug resistant infections, healthcare acquired infections and antimicrobial resistance. Yet CDI knowledge among healthcare providers in low-resource settings is limited and CDI testing, treatment, and infection prevention measures are often delayed.Objectives: to develop a CDI intervention informed by the local context within South African public district level hospitals, and analyze the CDI intervention and implementation process.MethodsA CDI checklist intervention was designed and implemented at three district level hospitals in the Western Cape, South Africa that volunteered to participate. Data collection included a retrospective medical records review of patients hospitalized with C. difficile test orders during the 90 days post-implementation. Patient outcomes and checklist components (e.g. antibiotics) were collected. Qualitative interviews (n = 14) and focus groups (n = 6) were conducted with healthcare providers on-site. The Consolidated Framework for Implementation Research (CFIR) and the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) were applied to collected data and observations in order to identify drivers and barriers to implementation and understand differences in uptake.ResultsOne of the three hospitals displayed high intervention uptake. Highly relevant CFIR constructs linked to intervention uptake included tension for change, strong peer intervention champions, champions in influential leadership positions, and the intervention's simplicity (CFIR construct: complexity). Tension for change, a recognized need to improve CDI identification and treatment, at the high uptake hospital was also supported by an academic partnership for antimicrobial stewardship.ConclusionsThis research provides a straight-forward health systems strengthening intervention for CDI that is both needed and uncomplicated, in an understudied low resource setting. Intervention uptake was highest in the hospital with tension for change, influential champions, and existing academic partnerships. Implementation in settings with fewer academic connections requires further testing of collaborative implementation strategies and proactive adaptations.     

Nurses’ readiness to prescribe under supervision in Saudi Arabia: A cross-sectional study

AimTo explore nurses’ readiness to prescribe medications under supervision and identify associations between prescribing practices under supervision and demographic characteristics in Saudi Arabia.DesignA cross-sectional study.MethodsUsing convenience sampling, this study used a 32-item survey to collect data on nurses prescribing medications under supervision between December 2022 and March 2023.ResultsA total of 379 nurses were recruited from different regions in Saudi Arabia. Approximately 7% (n = 30) of the participants were prescribing medications independently, and 70% (n = 267) expressed their likelihood of becoming prescribers. The highest motivating factors to become prescribers were improvement of patient care (52.2%) and contribution to the multidisciplinary team (52.0%). Most participants (60%–81%) agreed that prescribing medications under supervision would improve potential outcomes at the system, nurse, and patient levels. Availability of appropriate mentors or supervisors (72.9%) was the highest rated facilitating factor, followed by support of nursing colleagues (72%). Based on demographic characteristics, findings revealed significant differences in the: a) likelihood and motivators of becoming prescribers; b) required minimum qualification, years of experience, and continuing professional education hours to become prescribers; and c) type of organizations delivering educational programs for nurse prescribing.ConclusionMajority of nurses in Saudi Arabia favored becoming prescribers, and motivating factors were mostly relevant to optimizing patient care outcomes. Having the proper supervision was rated as the most facilitating factor for nurse prescribing. Nurses’ views on potential outcomes, facilitating factors, and possible motivators varied based on nurses’ demographical characteristics.Implications for the professional and/or patient careNurses favored prescribing under supervision to improve patient care outcomes, which is an opportunity to expand the benefits of health services, including easy access to healthcare.ImpactResults revealed that nurses support the implementation of prescribing practice under supervision. Thus, the findings may inform practice change in Saudi Arabia to allow prescribing under supervision, which was perceived to have a positive impact on patient care outcomes.Reporting MethodThis study adhered to STROBE guidelines.     

Barriers to Buprenorphine Expansion in Ohio: A Time-Elapsed Qualitative Study

ABSTRACT

Buprenorphine partial opioid agonist pharmacotherapy, a key treatment for opioid use disorders (OUDs), is underutilized in the United States. Qualitative interviews, conducted in 2012/2013 and repeated in 2015, identified systemic barriers to providing buprenorphine treatment in Ohio. A representative sample of Ohio’s Alcohol, Drug Abuse and Mental Health Services (ADAMHS) county boards (n = 18) was selected based on percentage of OUD admissions, density of buprenorphine prescribers, and county board area population. Boards reported that the barriers to the use of buprenorphine in 2012/2013 included (1) negative attitudes toward the use of buprenorphine among substance use disorder treatment providers; (2) a lack of prescribers; and (3) lack of funding. The 2015 interviews suggested that the lack of prescribers surpassed lack of funding as the main impediment to buprenorphine expansion. Negative provider attitudes were no longer problematic. Concerns about buprenorphine diversion, however, had emerged as a new barrier. This article offers recommendations for future policy efforts to overcome these barriers and expand the use of evidence-based opioid treatments. It highlights the need for payers and policymakers to increase the number of buprenorphine prescribers to make best use of funding available to fight the opioid epidemic.     

Collaborative prescribing: A qualitative exploration of a role for pharmacists in mental health

BackgroundCollaborative prescribing has been proposed as an extension of practice for advanced pharmacist practitioners. A lack of research investigating how pharmacists might be most effective as prescribers in mental health was identified.ObjectiveTo explore health professionals’ and consumers’ attitudes and beliefs that relate to the role of specialist mental health pharmacists working as collaborative prescribers within their advanced scope of practice in secondary care.MethodsSemistructured interviews were conducted with key informants in the New Zealand mental health sector. Participants were selected via a purposive sampling method, including health professionals (n = 9) and consumers (n = 3). NVivo software was used to analyze data, using a thematic analysis approach to develop a series of key themes from the interviews. Common themes were extracted, which were used to gather results and draw conclusions.ResultsThe key findings include a widespread acknowledgment of the role of specialist pharmacists as collaborative prescribers in mental health and as integral members of the multidisciplinary team; however, consumers were unaware of pharmacists’ role in secondary care. The role was seen to extend current practice particularly in medication management after assessment and diagnosis by a medical practitioner. Concerns regarding demonstrating competence, practitioner role/boundary confusion, insufficient training and workforce development, hesitancy by pharmacists to extend role, consumer awareness, and public perception of the traditional pharmacist role were identified. Solutions discussed included education by the profession; relationship building, training, and robust competency assessments; and a structured framework for implementing a collaborative prescribing model.ConclusionsThis study suggests there was recognition and acceptance of the role that specialist pharmacist practitioners could play in contributing to the care of mental health consumers as collaborative prescribers; their medication expertise being regarded highly. Further research is necessary to investigate how current resource constraints will allow for collaborative prescribing to be implemented within the context of mental health practice.     

Layered double hydroxide nanoparticles in gene and drug delivery

ABSTRACT

Introduction: Since the 1990s, opioid maintenance treatments (OMTs), i.e. mostly methadone and buprenorphine, have represented the therapeutic cornerstone of opioid dependence. In France, the public health strategy on opioid dependence, identified here as the ‘French model’, has consisted of offering a facilitated access to buprenorphine, to reach a large treatment coverage and reduce opioid-related mortality.

Areas covered: Recently, a new formulation of subcutaneous buprenorphine depot (Buvidal®) has been approved in Europe for treatment of opioid dependence. The place of Buvidal® among the pre-existing arsenal of OMTs is discussed in the light of the pharmacological specificities of this new formulation, and with the particular standpoint of the French model on opioid dependence.

Expert opinion: Buvidal® could constitute a promising treatment option mainly in case of: 1) OMT initiation, including in non-specialized addiction medicine care; 2) Discharge from prison or hospital; Diversion/misuse of 3) buprenorphine or 4) methadone; 5) Clinically stabilized patients wishing to avoid daily oral taking of the medication. As such, this new formulation should be highly accessible, which will require specific pathways through care as the product is intended to be administered by a healthcare professional.