A qualitative study of a publicly funded pharmacy-dispensed naloxone program

AimsTo characterize the experiences of individuals accessing pharmacy-based naloxone and relate these experiences to the risk environments and discourses in which they are embedded.MethodsWe conducted a qualitative study using in-depth interviews of 37 adults aged 18 years and over who had accessed pharmacy-dispensed naloxone. Participants were recruited from across Ontario, Canada, and comprised individuals taking opioids for chronic pain, those taking opioids for reasons other than chronic pain, and individuals acquiring naloxone to act as bystanders in an opioid overdose setting. We drew upon risk environment theory to interpret participants’ accounts.ResultsFollowing analysis and interpretation, we generated five theoretically-informed themes characterizing the experiences of individuals accessing pharmacy-dispensed naloxone: ‘intersection of naloxone narrative with pharmacy environment’, ‘individual risk environment and pharmacy-dispensed naloxone uptake’, ‘safe spaces: creating an enabling environment for pharmacy-dispensed naloxone’, ‘individuation: becoming a first responder’ and 'beyond naloxone: the macro risk environment’. Specifically, participants described how judgement and stereotyping associated with the broader naloxone narrative can be amplified in the space of the pharmacy, leading to fears of reprisals and strategies to mitigate social risk. In addition, the social construction of naloxone as a drug for ‘problematic’ opioid use and a lack of pharmacist awareness regarding the risk environments in which opioid use occurs was perceived to limit opportunities for optimizing naloxone distribution and training. Finally, participants described approaches that could create enabling environments in the space of the pharmacy while remaining cognizant of the structural changes required in the macro risk environments of people who take opioids.ConclusionsDespite increasing the availability of naloxone, participants characterized several social and environmental factors that could limit the accessibility of the drug from pharmacies. Strategies to address these factors could create enabling environments within pharmacies that optimize the reach and impact of pharmacy-dispensed naloxone.     

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

BackgroundNaloxone is an antidote to opioid overdose, and community pharmacies nationwide now provide broad access to this medication.ObjectiveThe aim of this qualitative study was to understand how leaders in pharmacy organizations perceive pharmacies and pharmacy staff can optimize dispensing of naloxone.MethodsIn-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.ResultsFive 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.ConclusionsThe 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.     

Attitudes and availability: A comparison of naloxone dispensing across chain and independent pharmacies in rural and urban areas in Alabama

BackgroundFatal opioid overdoses remain the leading cause of accidental deaths in the United States, which have contributed to implementation of standing order laws that allow pharmacists to dispense naloxone to patients. Although pharmacy distribution of naloxone is a promising approach to increase access to this intervention, understanding barriers preventing greater uptake of this service is needed.MethodsData for the current study were collected via telephone survey assessing the availability of various formulations of naloxone at chain and independent pharmacies in rural and urban areas in Birmingham, Alabama (N = 222). Pharmacists’ attitudes toward naloxone and potential barriers of pharmacy naloxone distribution were also assessed. One-way analysis of variance (ANOVA) and logistic regression analyses were utilized to examine differences in stocking of naloxone in chain and independent pharmacies and to determine predictors of the number of kits dispensed by pharmacies.ResultsIndependent pharmacies were less likely to have naloxone in stock, especially those in rural areas. Furthermore, rural pharmacies required more time to obtain all four formulations of naloxone, and offered less extensive training on naloxone use. Pharmacists endorsing the belief that naloxone allows avoidance of emergent treatment in an overdose situation was associated with fewer dispensed kits by the pharmacies. Over 80% of pharmacists endorsed at least one negative belief about naloxone (e.g., allowing riskier opioid use). Pharmacists noted cost to patients and the pharmacy as contributing to not dispensing more naloxone kits.ConclusionThe current study demonstrates the lower availability of naloxone stocked at pharmacies in independent versus chain pharmacies, particularly in rural communities. This study also highlights several barriers preventing greater naloxone dispensing including pharmacists’ attitudes and costs of naloxone. The potential benefit of standing order laws is not being fully actualized due to the structural and attitudinal barriers identified in this study. Strategies to increase naloxone access through pharmacy dispensing are discussed.     

Factors associated with how often community pharmacists offer and dispense naloxone

BackgroundA recent Surgeon General's report encourages people to ask pharmacists about naloxone, but whether pharmacists are well-prepared to respond to these requests is unclear.ObjectivesDetermine factors that are associated with how often pharmacists offer and dispense naloxone.MethodsA convenience sample of 457 community pharmacists in North Carolina completed a 5-min online survey. Linear regressions were conducted to identify factors that are associated with how often pharmacists offer and dispense naloxone. Pharmacists' self-reported barriers to teaching naloxone administration were identified.ResultsMost pharmacists (81.2%) worked in pharmacies that stocked naloxone, but many never offered (36.6%) or dispensed (19.4%) naloxone. Pharmacists offered (β = 0.15, p < 0.01) and dispensed (β = 0.15, p < 0.01) naloxone more often when their pharmacy stocked more naloxone formulations. Pharmacists who were more comfortable discussing naloxone offered it more often (β = 0.26, p = 0.001). Pharmacists who worked in regional/local/grocery chain pharmacies dispensed and offered naloxone less often than other pharmacy types. Barriers to teaching naloxone administration included: time constraints, inadequate training, and perceived lack of patient comprehension.ConclusionsMany community pharmacists do not offer or dispense naloxone. Pharmacists who are uncomfortable discussing naloxone or work at smaller chain pharmacies may benefit from targeted naloxone training.     

Providers' perceptions on barriers and facilitators to prescribing naloxone for patients at risk for opioid overdose after implementation of a national academic detailing program: A qualitative assessment

BackgroundAcademic detailing is an educational outreach program that aligns providers' prescribing with evidence-based practice. The U.S. Department of Veterans Affairs (VA) Opioid Overdose Education and Naloxone Distribution (OEND) Program partnered with the VA Pharmacy Benefits Management National Academic Detailing Service to deliver naloxone education to providers who cared for patients at risk of opioid overdose. In this pilot study, we interviewed providers’ who received academic detailing to capture their perceptions of facilitators and barriers to prescribing naloxone.ObjectiveTo identify providers’ perceptions of facilitators and barriers to prescribing naloxone for patients at risk for opioid overdose after implementation of a national academic detailing program.MethodsThis was a hybrid inductive-deductive qualitative pilot using semi-structured interviews with VA providers to explore constructs associated with facilitators and barriers to prescribing take-home naloxone to patients at risk for opioid overdose from August 2017 to April 2018.ResultsEleven participants were interviewed, six physicians, three clinical psychiatric pharmacists, and two nurse practitioners. Participants identified patient-level barriers (social stigma and lack of homeless patient support), poor data integration, and burden of data validation as barriers to prescribing naloxone. However, they also identified patient lists, repeat visits, and face-to-face/one-on-one video conferencing visits as important facilitators for naloxone prescribing.Conclusions/importanceAcademic detailing will need to address issues of social stigma regarding naloxone, educate providers about existing support systems for homeless veterans, and develop tools for data integration to improve naloxone access for veterans at risk for an opioid overdose.