Empowering Community Pharmacists to Prevent Opioid Overdose Deaths: A Mixed Methods Study Exploring Implementation of Community Pharmacy-Based Naloxone Services
Type of DegreePhD Dissertation
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Background and Significance: Given the rising problem of prescription drug abuse and high number of opioid-related deaths annually in the United States, mechanisms to distribute naloxone are sorely needed. Community pharmacists represent one avenue to increase patient access to naloxone. However, many pharmacists miss opportunities to dispense naloxone. Objective and Specific Aims: The purpose of this study is to create and assess the effectiveness of a targeted pharmacist training program for naloxone therapy management to increase community pharmacists’ knowledge, intention, attitudes, confidence, and naloxone dispensing activities for prevention of opioid overdose deaths. This study was conducted using mixed methods and a two-group pragmatic randomized controlled trial design among community pharmacists in Alabama to address two specific aims: 1) to incorporate community pharmacists’ training needs and experts’ strategies to overcome barriers regarding community pharmacy-based naloxone services implementation into the development of a targeted training program; and 2) to evaluate a targeted naloxone training program among community pharmacists. Methods: Participants included community pharmacists in Alabama counties with high opioid overdose death rates. Pharmacists’ naloxone training needs (format and content), attitudes, barriers/facilitators, and current naloxone service implementation strategies were explored using semi-structured telephone interviews with community pharmacists. Opioid/naloxone experts were also interviewed to compare current practices to recommended implementation strategies. Results from qualitative analysis informed development of a training program, using a participatory design approach with a panel of pharmacists and experts to incorporate relevant needs and strategies to overcome barriers. After the training program was finalized, pharmacists were invited to participate in a 2-group pragmatic randomized controlled trial using a multi-modal recruitment method and randomized to a control (no training) or intervention (training) group. The impact of the training program on pharmacists’ knowledge, intention, attitudes, confidence, and perceived barriers regarding naloxone services implementation were assessed via online surveys at baseline, post-training, and 3 months. Self-reported naloxone dispensing behaviors (structure activities, process activities, number of naloxone prescriptions dispensed) were measured at baseline and 3 months. Mean differences between control and intervention groups across time-points were assessed using mixed ANOVA and adjusted analyses were conducted using generalized estimating equations (GEE) with negative binomial distribution. Factors motivating adoption/implementation of naloxone services were assessed to inform future strategies for increasing program uptake. Results and Implications: Interviews found that, although pharmacists were generally supportive of community pharmacy-based naloxone services, they were uncomfortable approaching and communicating with patients regarding opioid overdose risk and the need for naloxone. Perceived patient resistance, perceived high cost of naloxone for patients, and lack of time were also major barriers to community pharmacy-based naloxone services implementation in Alabama. Experts recommended creating a normative culture of safety in the pharmacy by utilizing safety-centered marketing and communication strategies, using a universal (time-efficient) rather than targeted (time-intensive) approach to recommend naloxone, and “closing the loop” by following up with both patients and providers after naloxone provision. The EmpoweringCommunityPharmacists training program was created based on these findings and delivered as a live webinar in 2018-2019. From pre- to post-training, there was a statistically significant increase in Alabama community pharmacists’ mean intention score (5.35 to 6.10, p=0.023) and confidence score (5.52 to 6.16, p<0.0005) for providing naloxone services among the intervention group. These changes in intention and confidence were statistically significant compared to control (intention p=0.014, confidence p=0.016) and were maintained at 3 months. There was no statistically significant change in pharmacists’ knowledge, attitudes, or perceived barriers from pre- to post-intervention among intervention compared to control. Compared to control, there was no difference in the number of naloxone service structure activities completed, process activities engaged in, or naloxone prescriptions dispensed in the intervention group. At baseline, pharmacists were most motivated by social gains. Results suggest that this training program, created using a participatory design approach, effectively increases intention and confidence to adopt/implement naloxone services among community pharmacists. Future studies should focus on leveraging pharmacists’ motivation to provide naloxone services by fostering a sense of professional fulfillment. Study outcomes are expected to inform adoption/adaptation of the training program in other states.