- Email: [email protected]
Attitudes and perceptions of naloxone dispensing among a sample of Massachusetts community pharmacy technicians
SCIENCE AND PRACTICE Journal of the American Pharmacists Association xxx (2019) 1e8
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Journal of the American Pharmacists Association journal homepage: www.japha.org
RESEARCH
Attitudes and perceptions of naloxone dispensing among a sample of Massachusetts community pharmacy technicians Shawn Kurian, Brianna Baloy, Janette Baird, Dina Burstein, Ziming Xuan, Jeffrey Bratberg, Abigail Tapper, Alexander Walley, Traci Green* a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 May 2019 Accepted 23 August 2019
Objectives: There is limited research on the attitudes of pharmacy technicians toward pharmacy naloxone provision, despite their widespread role in the pharmacy. We examined attitudes and perceptions of pharmacy technicians in the provision of naloxone in a sample of Massachusetts pharmacies. Design: Thirty-nine community retail pharmacies from 1 U.S. chain were purposely sampled in 13 municipalities across Massachusetts. Pharmacies were divided into high-risk municipalities (HRMs) versus low-risk municipalities (LRMs) based on the state average opioid-related death rate from 2011 to 2015. Setting and participants: A pharmacy technician working in each pharmacy was administered an in-person survey. Survey topics included technician beliefs about current naloxone provision practices; patient groups at greater risk of overdose; whether individuals filling prescriptions would benefit from naloxone; and whether individuals purchasing syringes would benefit from naloxone. Outcome measures: Closed-ended responses were analyzed by Mann-Whitney U, Fisher exact, and chi-square tests. Open-ended responses were summarized for themes and then contrasted by municipality risk status. Results: Technician participation was 100% (n ¼ 39). Technicians in both groups believed they could identify patient groups at risk of overdose in their practice, but HRM technicians recognized the need for naloxone for more of their at-risk patients (81% in HRM vs. 33% in LRM believed > 25% of patients need naloxone, P < 0.01). A willingness to provide naloxone was high (> 89%) in both groups. Open-ended responses revealed commonalities between groups, including the belief that patients need lower-cost naloxone, and a lack of patient and technician awareness that naloxone could prevent overdose in individuals at risk through use of prescription opioids not just through use of illicit drugs. Conclusion: Pharmacy technicians would benefit from overdose prevention training and are well positioned to recognize overdose risk and offer preventive interventions, such as naloxone. Among technicians, there is a high willingness to be involved in implementing broader naloxone access in pharmacies. © 2019 American Pharmacists Association®. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Funding: Support was provided by a grant from the Agency for Healthcare Research and Quality (R18 HS024021-Green (PI)). The funders had no role in the design, data collection, analysis, interpretation, or writing of the manuscript. Author contributions: TCG conceived and supervised the study and acquired funding. SK collected the survey data from pharmacy technicians and
contributed to data preparation and analyses. JB, ZX, TCG advised on data collection and analysis. TCG guided the concept and execution of the study. SK, TCG contributed to writing the original draft. All authors contributed to reviewing and editing. * Correspondence: Traci C. Green, PhD, MSc, Boston Medical Center Injury Prevention Center, Boston University School of Medicine, Department of Emergency Medicine, 771 Albany St., Rm 1208, Boston, MA 02118. E-mail address: [email protected] (T. Green).
https://doi.org/10.1016/j.japh.2019.08.009 1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
SCIENCE AND PRACTICE S. Kurian et al. / Journal of the American Pharmacists Association xxx (2019) 1e8
Key Points Background: Pharmacy technicians play an integral role in the pharmacy team and are well poised to initiate important conversations with patients. Little is known about the attitudes and perceptions of pharmacy technicians in the dispensing of pharmacy naloxone. Findings: Pharmacy technicians in both groups believed that they could identify patient groups at risk of overdose in their practice, but high-risk municipality technicians recognized the need for naloxone for more of their at-risk patients despite having comparable perceptions of patients in whom they believed used illicit or prescription opioids. Pharmacy technicians in both groups expressed a high degree of both willingness to provide naloxone and being comfortable participating in dispensing of naloxone. There is a perceived lack of both patient and technician awareness that naloxone could prevent overdose in individuals at risk through use of prescription opioids not just through use of illicit drugs.
The number of opioid-related overdose deaths in the United States has quadrupled since 1999, amounting to approximately 115 deaths each day.1 Opioid-related overdose deaths are attributable to both prescription opioids, as well as illicit opioids, such as heroin and illicitly manufactured fentanyl.2 Like many Northeastern and Midwestern states, Massachusetts has seen a marked increase in opioid-related death rates in recent years.3 Driven by severe opioid use disorder, some Massachusetts residents may be transitioning from using prescription opioids to misusing prescription opioids or initiating use of heroin or fentanyl.4,5 The rise in opioid use, perhaps coupled with the increasingly unpredictable drug supply, places those exposed to opioids, and especially people with opioid use disorder, at increased risk of nonfatal and fatal overdose. Naloxone is an opioid antagonist that is currently available only as a prescription medication. Within 3 minutes, it is able to rapidly reverse an opioid overdose and block the effects of opioids by antagonistically competing with them at their receptors.6 Through advocacy by public health and community members, both the availability and accessibility of naloxone for use by laypersons have greatly expanded in the United States over the past 2 decades.7-9 Laws in most states permit access to naloxone through community-based organizations and community pharmacies without having to see a prescriber first.10 Statewide pharmacy naloxone access began early in neighboring Rhode Island and quickly spread as a policy innovation to Massachusetts and then to other states across the country.10 The widescale provision of naloxone has been associated with reductions in community overdose mortality rates.11
2
Efforts to expand provision of naloxone as a preventive effort for opioid stewardship have been growing, culminating in recent guidance from the U.S. Department of Health and Human Services (HHS) to co-prescribe naloxone to those at known risk of overdose, such as people with opioid use disorder, and people taking certain prescription opioid medications. These include individuals taking high doses of opioids, as well as those taking opioids in conjunction with benzodiazepines.12 Preceding this guidance, grassroots efforts advocated for co-prescription of naloxone for overdose prevention,13 and the Centers for Disease Control and Prevention guidelines for the treatment of chronic pain included the co-prescription of naloxone as one of its key recommendations for addressing the harms of opioid use.14 Despite the benefits for patients, in recent years the number of naloxone prescriptions co-prescribed with high-dose opioids has been low.15 Physicians report facing obstacles in prescribing naloxone, including having limited awareness and clinical knowledge about naloxone prescribing, and a belief that naloxone might give patients a “false sense of security,” thereby fostering increased opioid use.16 Similarly, there remain many factors influencing the decisions of both pharmacists and patients to discuss the use of naloxone while in the pharmacy. In one study17, pharmacists expressed concerns that offering naloxone might negatively impact relationships with patients. They reported that patients might feel as though they were being accused of medication misuse or diversion, and that bringing up naloxone in general could come across as offensive. Likewise, fear of being treated poorly by pharmacists was a factor influencing patients’ decisions to purchase naloxone from the pharmacy. Some pharmacists also believed they lacked the training to adequately educate patients about naloxone, and thus were hesitant to do so.17 Other studies have also reported on pharmacists’ confusion regarding the standing order for naloxone and available formulations for laypersons.18,19 In addition to provision of naloxone, the pharmacy is a critical place for access and distribution of other illicit drugrelated harm reduction supplies, especially sterile syringes. In the United States, people who inject drugs are able to obtain sterile syringes from syringe exchange programs or, in many states, without a prescription from their local pharmacy. The sale of nonprescription syringes at a pharmacy is currently legal in 46 states, including Massachusetts.20 A heretofore unrecognized partner in the provision of naloxone in the pharmacy environment is the pharmacy technician. Pharmacy technicians work under the supervision of a pharmacist in both retail and hospital pharmacies, yet they are commonly the “face” of the pharmacy owing to their frequent interaction with patients. Traditionally, their roles have included processing and filling prescriptions, maintaining and recording drug inventories, and coordinating the billing of medications between patients and third-party insurance providers.21 In recent years, however, the roles of pharmacy technicians have been rapidly expanding. For example, 1 study demonstrated that involvement of technicians in immunization programs facilitated vaccine delivery and increased their administration, and another showed that inclusion of technicians significantly increased vaccination rates in pharmacies compared with control pharmacies having no technician.22-24 In the past year, Idaho took technician responsibilities one step further by becoming the first state to
SCIENCE AND PRACTICE Attitudes toward naloxone provision
permit technicians to administer vaccines under the supervision of a pharmacist.25 Follow-up studies involving Idaho technicians suggest that trained technicians are knowledgeable about the procedures involved in vaccination and are confident in participating in the process after completing a short training program.26 Previously, research on the topic of attitudes toward naloxone prescriptions and dispensing has focused primarily on 3 groups of people: (1) patients actively using illicit opioid drugs or living with chronic pain who have been prescribed opioid analgesics; (2) licensed physicians or prescribers; and (3) licensed pharmacists.17,27,28 Hence, although others have documented on pharmacy staff,29-31 there is limited research focused exclusively on the role of pharmacy technicians in the dispensing of naloxone. Objectives Given the barriers to both physician-patient and pharmacist-patient discussions on the topic of naloxone, and the rapidly expanding role and promising benefits involving pharmacy technicians in the provision of naloxone, this study aimed to explore the attitudes and perceptions of pharmacy technicians in the dispensing of naloxone in a selection of pharmacies located in high and low overdose burden municipalities in Massachusetts. Methods This study used cross-sectional survey administration as the primary means for data collection. As this was part of a larger research study, the Massachusetts community retail pharmacies included in the study were from 1 U.S. chain, CVS Health. A sample of 39 pharmacies were selected, with 21 in high-risk municipalities (HRMs) and 18 in low-risk municipalities (LRMs), based on community opioid overdose rates that were above or below the state average of 12.2 per 100,000 people.32 These pharmacies were purposely sampled to ensure geographical variability, as well as to mitigate influences from neighboring municipalities, which may have different rates of overdose. In all cases, research staff approached the pharmacist on duty and introduced them to the study. Research staff then asked permission to speak with a lead technician, if available, at which point the technician was introduced to the study and was asked permission to participate. Before beginning the survey, all participants went through an informed consent process and were informed that their answers would remain anonymous and no personal or identifying information would be collected. All pharmacies were visited between Monday and Friday from the hours of 9:00 AM to 5:00 PM Eastern Standard Time. Pharmacies were not visited outside of this timeframe in order to mitigate the chance of speaking with a part-time or relief technician. The survey instrument (available on JAPhA.org as supplemental content) was administered verbally by research staff to consenting pharmacy technicians. Survey topics included technician beliefs about current naloxone provision practices; patient groups at greater risk of overdose; whether individuals filling prescriptions would benefit from naloxone; and whether individuals purchasing syringes would benefit from naloxone. Survey items were closed-ended with some items
Table 1 Sample characteristics of participants in survey of Massachusetts pharmacy technicians Pharmacy technician characteristics Sex Male Female Age, y 18e21 22e25 26e34 35e44 45e64 65þ Racial identity White/Caucasian Black/African American Asian Native Hawaiian/Pacific Islander American Indian/Alaska Native Hispanic More than 1 racea Otherb Years of experience at that particular pharmacy 0e1 2e3 4e5 6e7 8e10 11þ
HRM n (%) nt ¼ 21
LRM n (%) nt ¼ 18
Row total N (%) Nt ¼ 39
2 (10) 19 (90)
1 (6) 17 (94)
3 (8) 36 (92)
1 4 9 4 3
(5) (19) (43) (19) (14) 0
5 6 3 4
0 (28) (33) (17) (22) 0
1 9 15 7 7
(3) (23) (38) (18) (18) 0
13 (62) 2 (10) 0 0
11 (61) 2 (11) 1 (6) 0
0
0
0
3 (14) 3 (14) 0
3 (16) 0 1 (6)
6 (15) 3 (8) 1 (3)
7 (33) 3 (14) 6 (29) 0 0 5 (24)
4 5 3 2 2 2
(22) (28) (17) (11) (11) (11)
24 (61) 4 (10) 1 (3) 0
11 8 9 2 2 7
(28) (21) (23) (5) (5) (18)
Abbreviations used: HRM, high-risk municipality; LRM, low-risk municipality. a “More than 1 race” was characterized as “White/Caucasian þ Black/African American” by 2 participants in HRMs and “Black/African American þ Hispanic” by the remaining participant in the HRM. b “ Other” was characterized as “Sinhalese” by the participant in the LRM.
being either taken or adapted from previous work completed by the MOON Study Team at Boston Medical Center.33 The final survey item welcomed open-ended feedback and comments regarding topics discussed, and research staff recorded verbatim responses from technicians in these instances. Descriptive summary statistics were calculated, and statistical tests examined differences by municipality risk level (i.e., high or low risk) for the survey responses. Owing to the nature of the dependent variables based on the responses to the survey items, a series of Mann-Whitney U tests, Fisher exact tests, and chi-square tests of independence were performed. The dependent variables for all tests were the responses to the survey items. All statistical analyses were conducted in IBM SPSS Statistics version 25 (Armonk, NY). Open-ended responses were summarized for themes and then contrasted by municipality risk status to explore for any differences. When relevant, direct quotes from technicians are presented in the results. This study was approved by the Boston University Medical Campus institutional review board.
Results In total, the sample included 39 CVS Health pharmacies across Massachusetts, yielding data from 39 pharmacy 3
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Figure 1. Study sample pharmacies in Massachusetts. The high-risk municipalities (HRMs) are labeled in blue with letters A through G (A, Salem; B, Malden; C, Medford; D, Worcester; E, Brockton; F, Taunton; G, Plymouth). The low-risk municipalities (LRMs) are labeled in red with numbers 1 through 6 (1, Framingham; 2, Wellesley; 3, Newton; 4, Brookline; 5, Dedham; 6, Milford).
technicians. An in-person survey was successfully administered to all 39 technicians, with both a response rate and completion rate of 100%. Table 1 depicts sample characteristics of the study participants, highlighting sex, age, racial identity, and years of work experience. Figure 1 depicts the state of Massachusetts, outlined in red, with markers for each of the pharmacies visited for the survey.34 Table 2 presents differences in risk perception and naloxone need by municipality risk status. Generally, actual risk of opioid overdose and naloxone need were aligned. Most technicians (81%) in HRMs believed that more than 25% of their patients could benefit from having a naloxone kit available, while this was true for only 33% of technicians in LRMs (P < 0.01), despite having comparable perceptions of patients in whom they believed used illicit or prescription opioids. Some of the discrepant responses from HRM technicians who endorsed a lower level of perceived naloxone need (i.e., less than 26% of patients could benefit from having a naloxone kit available) included unsolicited comments that “most patients are responsible,” and “patients with prescriptions are not at risk.” Table 3 presents technicians’ identification of patient groups at risk of overdose. A greater proportion of technicians in LRMs compared with those in HRMs indicated that they could easily identify patients receiving prescriptions for both 4
opioids and benzodiazepine medications (39% in LRM vs. 19% in HRM), while a greater proportion of technicians in HRMs compared with their peers in LRMs indicated they could easily identify patients purchasing syringes over the counter (67% in HRM vs. 44% in LRM). The top 2 most readily identifiable patient populations who could benefit from naloxone receipt as indicated by LRM technicians were populations 1 (high opioid dose recipients) and 5 (syringe purchasers), while, for HRM technicians, the most readily identifiable populations were 4 (buprenorphine patients) and 5 (syringe purchasers). Overall, willingness and comfort in participating in pharmacy naloxone dispensing was high in both types of municipalities. All HRM technicians and 89% of LRM technicians reported that they were both willing and comfortable participating in the dispensing of naloxone in the pharmacy. In addition, a willingness to learn more about naloxone and how it can be used in the pharmacy was nearly universally high (95% of HRM technicians, 94% of LRM technicians). Additional comments and feedback from both HRM and LRM technicians revealed many common themes (Table 4). Mainly, technicians conveyed concerns that patients were unwilling to pay out-of-pocket for naloxone and would benefit from lower-cost options, and that both they and patients may be misinformed about which patient populations could benefit
Table 2 Participants’ perceived comfort, benefit, and risk estimates pertaining to provision of naloxone in pharmacies, by level of overdose risk in municipality, n (%) Survey item
Risk level
Survey item Estimated at-risk population size and benefit for naloxone receipt Approximately what percent of patients do you think use illicit opioids (i.e., heroin, fentanyl, diverted prescription medications)? Approximately what percent of patients currently have prescription opioids prescribed to them?
Survey item
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Agree
Strongly agree
1 (5)
2 (10)
1 (5)
2 (10)
3 (13)
4 (19)
4 (19)
0.397
1 (5) 0
2 (11) 0
0 1 (5)
2 (11) 1 (5)
2 (11) 3 (14)
5 (28) 5 (24)
5 (28) 11 (52)
0.549
1 (6) 0
0 0
0 0
0 0
4 (22) 2 (10)
6 (33) 4 (19)
7 (39) 15 (71)
0.410
0 0
1 (6) 0
0 0
1 (6) 0
0 2 (10)
6 (33) 5 (24)
10 (55) 14 (67)
0.282
0 0
1 (6) 0
1 (6) 0
0 1 (5)
2 (11) 1 (5)
5 (28) 7 (33)
9 (50) 12 (57)
0. 443
0
1 (6)
0
0
0
4 (22)
13 (72)
0
0
0
2 (10)
1 (5)
4 (19)
14 (67)
0.922
0 1 (5)
0 1 (5)
0 0
1 (6) 2 (9)
0 2 (9)
6 (33) 5 (24)
11 (61) 9 (43)
0.105
0
1 (5)
1 (5)
4 (22)
4 (22)
5 (28)
3 (17)
Risk level
None
< 10%
10%e25%
26%e50%
HRM
0
4 (19)
6 (29)
3 (14)
8 (38)
0.156
LRM HRM
1 (5) 0
5 (28) 2 (10)
7 (39) 2 (10)
1 (5) 7 (33)
4 (22) 10 (47)
0.587
LRM
0
1 (6)
6 (33)
3 (17)
8 (44)
Risk level
0%e25%
HRM
4 (19)
17 (81)
LRM
12 (67)
6 (33)
Abbreviations used: HRM, high-risk municipality; LRM, low-risk municipality. a By Mann-Whitney U test. b Four participants in HRM (19%) and 1 participant in LRM (5%) selected N/A, thus their responses were not included in the table. c One participant in HRM (5%) selected N/A, thus their response was not included in the table. d By Fisher exact test.
< 25%
< 50%
P valuea
P valued 0.004
5
SCIENCE AND PRACTICE
Approximately what percent of patients do you think could benefit from having a naloxone kit available?
Disagree
Attitudes toward naloxone provision
Comfort with and a willingness to provide naloxone in the pharmacy HRM I am comfortable answering patient questions about naloxoneb LRM I am familiar with naloxone and its role HRM in reducing overdose risk in communities LRM I am willing to participate in the dispensing HRM of naloxone in this pharmacy LRM I am comfortable participating in the HRM dispensing of naloxone in this pharmacy LRM I am willing to learn more about naloxone HRM and how it can be used in this pharmacy LRM Perceptions of patient benefit of naloxone receipt It is good that naloxone is available to people in HRM Massachusetts by standing order LRM HRM The people who would benefit most from naloxone are those purchasing syringes for drug usec LRM
P valueb
Strongly disagree
SCIENCE AND PRACTICE S. Kurian et al. / Journal of the American Pharmacists Association xxx (2019) 1e8
Table 3 Participants’ identification of patient groups at risk of overdose Survey item Which of the following patients at risk of overdose are the easiest to identify? (Please select the 2 you feel are easiest to identify and will yield the most benefit for receiving naloxone to take home) (1) Patients receiving high doses of opioid medications (2) Patients receiving prescriptions for both opioids and benzodiazepine medications (3) Patients receiving opioids with a 28-day or more supply (4) Patients receiving prescriptions for buprenorphine/naloxone (5) Patients purchasing syringes over the counter
Option Option Option Option Option Option Option Option Option Option
1 1 2 2 3 3 4 4 5 5
selected not selected selected not selected selected not selected selected not selected selected not selected
HRM n (%) nt ¼ 21
LRM n (%) nt ¼ 18
P value
12 9 4 17 4 17 8 13 14 7
10 8 7 11 4 14 7 11 8 10
0.921a
(57) (43) (19) (81) (19) (81) (38) (62) (67) (33)
(56) (44) (39) (61) (22) (78) (39) (61) (44) (56)
0.285b 1.000b 0.959a 0.163a
Abbreviations used: HRM, high-risk municipality; LRM, low-risk municipality. a By chi-square test of independence. b By Fisher exact test.
from naloxone. Several comments across municipality type on the topic of syringes reflected a high degree of misunderstanding on why syringes were provided for sale in pharmacies, as well as discomfort in selling, and prejudice in the pharmacy. Some technicians, and only those in HRM, expressed concerns that naloxone, while useful as a rescue medication, is not a treatment medication and does not stop opioid misuse. In contrast, some technicians, and only those in
LRM, highlighted the expectation of greater prescriber involvement in addressing prescription opioid-implicated overdose risk in their municipality. Discussion This study is among the first to focus exclusively on the potential role of the pharmacy technician in naloxone
Table 4 Themes derived from review of verbatim comments and feedback from pharmacy technicians, by municipality risk statusa Category Naloxone does not alter underlying opioid misuse
Cost of naloxone
Sales of syringes
HRM quotes “People take advantage of naloxone and continue to overdose” “[Patients believe naloxone is a] magic fix… after using naloxone patients will return back to using drugs” “[Naloxone is] too expensive for all patients… patients are unwilling to pay out of pocket [for naloxone]”
“[I] would like the right to refuse to sell syringes to certain people when it’s evident they’re under the influence of other drugs.”
Physicians should co-prescribe naloxone
Technician and patient misperceptions about the potential uses of naloxone
“Patients with [opioid] prescriptions are not at risk [of overdose]”
“Most patients are responsible [and therefore do not need naloxone]”
6
LRM quotes
“Insurance is the primary factor affecting patient decisions to purchase [naloxone]… parents would buy [naloxone] for their children if it was not so expensive.” “Patients refuse to purchase naloxone due to cost and insurance issues.” “[Technicians are willing to dispense clean needles, regardless of patient appearance; however, the pharmacy manager often chooses to deny patients who fit a certain stereotype. That is, young patients with] blood shot eyes, long sleeves, and asking for syringes for grandma’s diabetes” “Doctors should [prescribe naloxone] with prescriptions too” and “[doctors should] show patients how to use [naloxone]… [I] find it difficult to [discuss naloxone as I am worried about] crossing the line… Patients might find it offensive if [technicians bring up naloxone] if they [are taking] pain medications due to a car accident.” “[Co-prescribing is important because] when the pharmacist brings up naloxone the patient might become offended.” “[In general], the patients’ perception is that they’re not a drug addict and therefore they don’t think they need naloxone… even though they have opioid prescriptions.” “Not everyone is knowledgeable about why naloxone is useful… [the belief is that] only people shooting up on the street need it.”
SCIENCE AND PRACTICE Attitudes toward naloxone provision
provision at the pharmacy. Findings suggest areas of potential training and intervention, which can be rendered more effective when informed by a deeper understanding of the community overdose risk environment. Among this sample of chain community pharmacy technicians in a state heavily affected by the opioid overdose crisis, it appears that pharmacy technicians would be receptive to taking on a larger role regarding naloxone provision. As others have documented in similar studies,29 technicians in our study were well aware of the risks that opioid use poses for patients and are ready to act to help prevent overdose with naloxone provision. Given this high degree of support, one possible approach would be to expand the scope of practice for pharmacy technicians, allowing them to initiate an offer of naloxone to a patient. Analogous to technician roles in Idaho surrounding vaccine administration,25 such an action may require legislative or regulatory change and also clear corporate and pharmacy manager support, such that technicians are given adequate training and materials to implement a successful strategy for pharmacy naloxone dispensing. Based on findings from HRM and LRM technicians, the content of the training should provide factual and clear information about overdose and opioid use risks, dispel myths about at-risk patient populations, and emphasize patient training that takes 5 to 10 minutes to complete.35 Additional efforts are needed to raise awareness among patients, too, that individuals taking high-dose prescription opioid medications or specific combinations of opioid medications are also at risk of overdose. A common theme seen across both municipality risk levels is that technicians express patients’ views of naloxone being too expensive. It would be useful to alleviate this barrier by achieving more, and more consistent, private and public insurance coverage of as many naloxone products as possible and to patients as well as to their caregivers (i.e., potential victim and witness of an overdose event), which would inevitably improve patient care, reduce confusion about medication accessibility, and save lives.7,36-39 Technicians working in HRMs were more apt to identify their patients’ need for naloxone, suggesting that they may be particularly well-suited to undertake a pharmacy technicianbased intervention for expanding naloxone access in their community. Such an intervention could also focus on overdose prevention for injection-related use of opioids, not just for opioid medication use, because HRM technicians self-reported greater adeptness in identifying syringe-purchasing patrons and identified their need for naloxone. It is notable that only the HRM technicians questioned the usefulness of naloxone in stopping opioid misuse and expressed prejudice in the provision of syringes, as others have documented in the pharmacy.40,41 In places such as HRMs that are heavily affected by the opioid overdose crisis, it may be even more important to take the time to reinforce the goals of harm reduction and rescue medication provision, explain the chronic nature of addiction, and to be explicit about the need to build resilience and address compassion fatigue among all health care and service providers. Future efforts that focus on shifting pharmacist’s and physician’s attitudes toward pharmacy-based harm reduction strategies should consider including technicians in their efforts. These survey data, and especially responses conveyed by LRM technicians, support the HHS guidance to co-prescribe
naloxone with opioid medications and to prescribe naloxone to those at known risk of overdose. Implementation of HHS guidance in LRMs may be readily adopted, because the LRM-based survey respondents indicated that, in the primary at-risk patient population, there may be individuals taking multiple prescription opioids. Thus, an evidence-based physician-directed intervention (i.e., co-prescribing naloxone with opioid prescriptions)42 may be an appropriate and synergistic approach in those municipalities. Coupled with the HHS guidance, universal education of providers, pharmacists, and technicians in LRM could help educate patients about the benefits of naloxone and reduce some of the concerns presented by LRM pharmacists and technicians about potentially offending patients. This study has important limitations. Many study pharmacies were quite busy, which might not have provided ideal circumstances for survey administration. As a result, the technicians might not have provided their most accurate or detailed responses. Because the survey was administered in the pharmacy, the proximity of other staff members (i.e., pharmacists, interns, students) may have influenced the participation or the social desirability of reported responses. If present, the effect of this bias would have been reporting of higher competence and positive attitudes toward participating in naloxone dispensing. These biases were minimized by offering to use the employee lunch-room and/or private consultation area, if available, for survey administration, and by keeping the survey responses anonymous. Finally, we did not capture some important details of the technicians, such as whether they work full time or part time, educational training, and other personal details. To protect the anonymity of the respondent and reduce response burden, such items were not included in this initial survey but would be important to gather in future work. Conclusion These results demonstrate that pharmacy technicians are well positioned to recognize overdose risk and offer preventive interventions, such as naloxone provision. Therefore, the pharmacy team seems capable of implementing HHS guidance on naloxone co-prescription to people at risk of overdose. To prevent more overdoses in their communities, HRM pharmacies could benefit from a technician-based intervention that focuses on harm reduction principles and materials, while LRM technicians would benefit from greater physician and pharmacist involvement in the co-prescription of naloxone with other opioid medications. Properly trained pharmacy technicians, with or without expanded authority, have the potential to expand community naloxone access and provision. Acknowledgments The authors thank the survey participants for their willingness to be part of this study. Supplementary Data Supplementary data related to this article can be found at https://doi.org/10.1016/j.japh.2019.08.009. 7
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References 1. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths d United States, 2010e2015. MMWR Morb Mortal Wkly Rep. 2016;65(50e51):1445e1452. 2. O’Donnell J, Gladden RM, Mattson CL, Kariisa M. Notes from the field: Overdose deaths with carfentanil and other fentanyl analogs detected 10 States, July 2016-June 2017. MMWR Morb Mortal Wkly Rep. 2018;67(27):767e768. 3. Massachusetts Department of Public Health. The Massachusetts opioid epidemic. Available at: http://www.mass.gov/chapter55/#addictions. Accessed May 4, 2019. 4. Somerville NJ, O’Donnell J, Gladden RM, et al. Characteristics of fentanyl overdose d Massachusetts, 2014e2016. MMWR Morb Mortal Wkly Rep. 2017;66(14):382e386. 5. Massachusetts Department of Public Health. Data brief: Opioid1-related overdose deaths among Massachusetts residents; 2017. Available at: http://www.mass.gov/eohhs/docs/dph/stop-addiction/current-statistics/ data-brief-overdose-deaths-aug-2017.pdf. Accessed May 4, 2019. 6. Adapt Pharma Inc. NARCAN. (Naloxone hydrochloride) nasal spray; 2015. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2 015/208411lbl.pdf. Accessed May 4, 2019. 7. Gertner AK, Domino ME, Davis CS. Do naloxone access laws increase outpatient naloxone prescriptions? Evidence from Medicaid. Drug Alcohol Depend. 2018;190:37e41. 8. Xu J, Davis CS, Cruz M, Lurie P. State naloxone access laws are associated with an increase in the number of naloxone prescriptions dispensed in retail pharmacies. Drug Alcohol Depend. 2018;189:37e41. 9. Lambdin BH, Davis CS, Wheeler E, Tueller S, Kral AH. Naloxone laws facilitate the establishment of overdose education and naloxone distribution programs in the United States. Drug Alcohol Depend. 2018;188: 370e376. 10. Davis C, Carr D. State legal innovations to encourage naloxone dispensing. J Am Pharm Assoc (2003). 2017;57(2S):S180eS184. 11. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174. 12. United States Department of Health & Human Services. HHS recommends prescribing or co-prescribing naloxone to patients at high risk for an opioid overdose; 2018. HHS.Gov. Available at: https://ww w.hhs.gov/about/news/2018/12/19/hhs-recommends-prescribing-or-coprescribing-naloxone-to-patients-at-high-risk-for-an-opioid-overdose. html. Accessed May 10, 2019. 13. Prescribe to prevent. Advocacy. Available at: https://prescribetoprevent. org/advocacy/. Published 2015. Accessed May 10, 2019. 14. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic paindUnited States, 2016. JAMA. 2016;315(15):1624e1645. 15. Stone S, Barnes E, McLouth CJ, McNeil CJ. Naloxone-prescribing practices: A missed opportunity. N C Med J. 2018;79(5):343e344. 16. Binswanger IA, Koester S, Mueller SR, Gardner EM, Goddard K, Glanz JM. Overdose education and naloxone for patients prescribed opioids in primary care: a qualitative study of primary care staff. J Gen Intern Med. 2015;30(12):1837e1844. 17. Green TC, Case P, Fiske H, et al. Perpetuating stigma or reducing risk? Perspectives from naloxone consumers and pharmacists on pharmacybased naloxone in 2 states. J Am Pharm Assoc(2003). 2017;57(2): S19eS27.e4. 18. Evoy KE, Hill LG, Groff L, Mazin L, Carlson CC, Reveles KR. Naloxone accessibility without a prescriber encounter under standing orders at community pharmacy chains in Texas. JAMA. 2018;320(18):1934e1937. 19. Puzantian T, Gasper JJ. Provision of naloxone without a prescription by California pharmacists 2 years after legislation implementation. JAMA. 2018;320(18):1933e1934. 20. Zaller ND, Yokell MA, Apeakorang N, Gaggin J, Case P. Reported experiences during syringe purchases in Providence, Rhode Island: implications for HIV prevention. J Health Care Poor Underserved. 2012;23(3): 1310e1326. 21. Maine LL, Knapp KK, Scheckelhoff DJ. Pharmacists and technicians can enhance patient care even more once national policies, practices, and priorities are aligned. Health Aff (Millwood). 2013;32(11):1956e1962. 22. Burson RC, Buttenheim AM, Armstrong A, Feemster KA. Community pharmacies as sites of adult vaccination: A systematic review. Hum Vaccin Immunother. 2016;12(12):3146e3159. 23. Powers MF, Hohmeier KC. Pharmacy technicians and immunizations. J Pharm Technol. 2011;27(3):111e116. 24. Hill JD, Anderegg SV, Couldry RJ. Development of a pharmacy technicianedriven program to improve vaccination rates at an academic medical center. Hosp Pharm. 2017;52(9):617e622.
8
25. Bright D, Adams AJ. Pharmacy technician-administered vaccines in Idaho. Am J Health Syst Pharm. 2017;74(24):2033e2034. 26. McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training pharmacy technicians to administer immunizations. J Am Pharm Assoc(2003). 2018;58(2):174e178.e1. 27. Freeman PR, Goodin A, Troske S, Strahl A, Fallin A, Green TC. Pharmacists’ role in opioid overdose: Kentucky pharmacists’ willingness to participate in naloxone dispensing. J Am Pharm Assoc(2003). 2017;57(2S):S28eS33. 28. Beletsky L, Ruthazer R, Macalino GE, Rich JD, Tan L, Burris S. Physicians’ knowledge of and willingness to prescribe naloxone to reverse accidental opiate overdose: challenges and opportunities. J Urban Health. 2007;84(1):126e136. 29. Raisch DW, Fudala PJ, Saxon AJ, et al. Pharmacists’ and technicians’ perceptions and attitudes toward dispensing buprenorphine/naloxone to patients with opioid dependence. J Am Pharm Assoc. 2005;45(1):23e32. 30. Zaller ND, Yokell MA, Green TC, Gaggin J, Case P. The feasibility of pharmacy-based naloxone distribution interventions: a qualitative study with injection drug users and pharmacy staff in Rhode Island. Subst Use Misuse. 2013;48(8):590e599. 31. Morton KJ, Harrand B, Floyd CC, et al. Pharmacy-based statewide naloxone distribution: a novel “top-down, bottom-up” approach. J Am Pharm Association. 2017;57(2S):S99eS106.e5. 32. Massachusetts Registry of Vital Records and Statistics, Massachusetts Department of Public Health. Average annual opioid-related death rate per 100,000 people 2011e2015; 2017. Available at: http://www. mass.gov/chapter55/js/data/csv/Introduction_MassMuni_5yrOpioidDeat hRate.csv. Accessed May 11, 2019. 33. Green TC. Maximizing OpiOid Safety with Naloxone (MOON) Study j. Boston Medical Center. Available at: https://www.bmc.org/research/ maximizing-opioid-safety-naloxone-moon-study. Published 2019. Accessed May 11, 2019. 34. Google. Google. Maps–Massachusetts with high-risk and low-risk CVS pharmacies. Available at: https://drive.google.com/open?id¼1eSh6Wq24 fyqVojNZBOXXKnjpgQ5kRz09&usp¼sharing. Accessed May 11, 2019. 35. Behar E, Santos GM, Wheeler E, Rowe C, Coffin PO. Brief overdose education is sufficient for naloxone distribution to opioid users. Drug Alcohol Depend. 2015;148:209e212. 36. Frank RG, Fry C. Medicaid expands access to lifesaving naloxone. The Commonwealth Fund. Available at: https://www.commonwealthfund. org/blog/2017/medicaid-expands-access-lifesaving-naloxone. Published 2017. Accessed May 14, 2019. 37. Franko T, Longyhore D. Naloxone coverage remains a barrier to use. J Am Pharm Assoc (2003). 2017;57(6):740. 38. Davis C, Carr D. Naloxone affordability measures needed. J Am Pharm Assoc (2003). 2017;57(6):740e741. 39. Gupta R, Shah ND, Ross JS. The rising price of naloxone drisks to efforts to stem overdose deaths. N Engl J Med. 2016;375(23):2213e2215. 40. Meyerson BE, Davis A, Agley JD, et al. Predicting pharmacy syringe sales to people who inject drugs: policy, practice and perceptions. Int J Drug Policy. 2018;56:46e53. https://doi.org/10.1016/J.DRUGPO.2018.02.024. 41. Chiarello E. Nonprescription syringe sales: resistant pharmacists’ attitudes and practices. Drug Alcohol Depend. 2016;166:45e50. 42. Albert S, Brason FW, Sanford CK, Dasgupta N, Graham J, Lovette B. Project Lazarus: community-based overdose prevention in rural North Carolina. Pain Med. 2011;12(Suppl. 2):S77eS85. Shawn Kurian, MS, Research Assistant, Boston University, Boston, MA Brianna Baloy, BA, Research Assistant, Boston University Medical Center, Boston, MA Janette Baird, PhD, Co-investigator, Alpert Medical School, Department of Emergency Medicine, Brown University and Rhode Island Hospital, Providence, RI Dina Burstein, MD, MPH, Assistant Professor, Emergency Medicine, Alpert Medical School, Department of Emergency Medicine, Brown University and Rhode Island Hospital, Providence, RI Ziming Xuan, ScD, SM, MA, Associate Professor, Boston University School of Public Health, Boston, MA Jeffrey Bratberg, PharmD, FAPhA, Clinical Professor of Pharmacy Practice, University of Rhode Island, Kingston, RI Abigail Tapper, MPH, Research Coordinator, Boston University Medical Center, Boston, MA Alexander Walley, MD, MSc, Co-investigator, Boston University School of Medicine, Boston, MA Traci Green, PhD, MSc, Principal Investigator, Boston University Medical Center, Boston, MA
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Journal of the American Pharmacists Association journal homepage: www.japha.org
RESEARCH
Attitudes and perceptions of naloxone dispensing among a sample of Massachusetts community pharmacy technicians Shawn Kurian, Brianna Baloy, Janette Baird, Dina Burstein, Ziming Xuan, Jeffrey Bratberg, Abigail Tapper, Alexander Walley, Traci Green* a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 May 2019 Accepted 23 August 2019
Objectives: There is limited research on the attitudes of pharmacy technicians toward pharmacy naloxone provision, despite their widespread role in the pharmacy. We examined attitudes and perceptions of pharmacy technicians in the provision of naloxone in a sample of Massachusetts pharmacies. Design: Thirty-nine community retail pharmacies from 1 U.S. chain were purposely sampled in 13 municipalities across Massachusetts. Pharmacies were divided into high-risk municipalities (HRMs) versus low-risk municipalities (LRMs) based on the state average opioid-related death rate from 2011 to 2015. Setting and participants: A pharmacy technician working in each pharmacy was administered an in-person survey. Survey topics included technician beliefs about current naloxone provision practices; patient groups at greater risk of overdose; whether individuals filling prescriptions would benefit from naloxone; and whether individuals purchasing syringes would benefit from naloxone. Outcome measures: Closed-ended responses were analyzed by Mann-Whitney U, Fisher exact, and chi-square tests. Open-ended responses were summarized for themes and then contrasted by municipality risk status. Results: Technician participation was 100% (n ¼ 39). Technicians in both groups believed they could identify patient groups at risk of overdose in their practice, but HRM technicians recognized the need for naloxone for more of their at-risk patients (81% in HRM vs. 33% in LRM believed > 25% of patients need naloxone, P < 0.01). A willingness to provide naloxone was high (> 89%) in both groups. Open-ended responses revealed commonalities between groups, including the belief that patients need lower-cost naloxone, and a lack of patient and technician awareness that naloxone could prevent overdose in individuals at risk through use of prescription opioids not just through use of illicit drugs. Conclusion: Pharmacy technicians would benefit from overdose prevention training and are well positioned to recognize overdose risk and offer preventive interventions, such as naloxone. Among technicians, there is a high willingness to be involved in implementing broader naloxone access in pharmacies. © 2019 American Pharmacists Association®. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Funding: Support was provided by a grant from the Agency for Healthcare Research and Quality (R18 HS024021-Green (PI)). The funders had no role in the design, data collection, analysis, interpretation, or writing of the manuscript. Author contributions: TCG conceived and supervised the study and acquired funding. SK collected the survey data from pharmacy technicians and
contributed to data preparation and analyses. JB, ZX, TCG advised on data collection and analysis. TCG guided the concept and execution of the study. SK, TCG contributed to writing the original draft. All authors contributed to reviewing and editing. * Correspondence: Traci C. Green, PhD, MSc, Boston Medical Center Injury Prevention Center, Boston University School of Medicine, Department of Emergency Medicine, 771 Albany St., Rm 1208, Boston, MA 02118. E-mail address: [email protected] (T. Green).
https://doi.org/10.1016/j.japh.2019.08.009 1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
SCIENCE AND PRACTICE S. Kurian et al. / Journal of the American Pharmacists Association xxx (2019) 1e8
Key Points Background: Pharmacy technicians play an integral role in the pharmacy team and are well poised to initiate important conversations with patients. Little is known about the attitudes and perceptions of pharmacy technicians in the dispensing of pharmacy naloxone. Findings: Pharmacy technicians in both groups believed that they could identify patient groups at risk of overdose in their practice, but high-risk municipality technicians recognized the need for naloxone for more of their at-risk patients despite having comparable perceptions of patients in whom they believed used illicit or prescription opioids. Pharmacy technicians in both groups expressed a high degree of both willingness to provide naloxone and being comfortable participating in dispensing of naloxone. There is a perceived lack of both patient and technician awareness that naloxone could prevent overdose in individuals at risk through use of prescription opioids not just through use of illicit drugs.
The number of opioid-related overdose deaths in the United States has quadrupled since 1999, amounting to approximately 115 deaths each day.1 Opioid-related overdose deaths are attributable to both prescription opioids, as well as illicit opioids, such as heroin and illicitly manufactured fentanyl.2 Like many Northeastern and Midwestern states, Massachusetts has seen a marked increase in opioid-related death rates in recent years.3 Driven by severe opioid use disorder, some Massachusetts residents may be transitioning from using prescription opioids to misusing prescription opioids or initiating use of heroin or fentanyl.4,5 The rise in opioid use, perhaps coupled with the increasingly unpredictable drug supply, places those exposed to opioids, and especially people with opioid use disorder, at increased risk of nonfatal and fatal overdose. Naloxone is an opioid antagonist that is currently available only as a prescription medication. Within 3 minutes, it is able to rapidly reverse an opioid overdose and block the effects of opioids by antagonistically competing with them at their receptors.6 Through advocacy by public health and community members, both the availability and accessibility of naloxone for use by laypersons have greatly expanded in the United States over the past 2 decades.7-9 Laws in most states permit access to naloxone through community-based organizations and community pharmacies without having to see a prescriber first.10 Statewide pharmacy naloxone access began early in neighboring Rhode Island and quickly spread as a policy innovation to Massachusetts and then to other states across the country.10 The widescale provision of naloxone has been associated with reductions in community overdose mortality rates.11
2
Efforts to expand provision of naloxone as a preventive effort for opioid stewardship have been growing, culminating in recent guidance from the U.S. Department of Health and Human Services (HHS) to co-prescribe naloxone to those at known risk of overdose, such as people with opioid use disorder, and people taking certain prescription opioid medications. These include individuals taking high doses of opioids, as well as those taking opioids in conjunction with benzodiazepines.12 Preceding this guidance, grassroots efforts advocated for co-prescription of naloxone for overdose prevention,13 and the Centers for Disease Control and Prevention guidelines for the treatment of chronic pain included the co-prescription of naloxone as one of its key recommendations for addressing the harms of opioid use.14 Despite the benefits for patients, in recent years the number of naloxone prescriptions co-prescribed with high-dose opioids has been low.15 Physicians report facing obstacles in prescribing naloxone, including having limited awareness and clinical knowledge about naloxone prescribing, and a belief that naloxone might give patients a “false sense of security,” thereby fostering increased opioid use.16 Similarly, there remain many factors influencing the decisions of both pharmacists and patients to discuss the use of naloxone while in the pharmacy. In one study17, pharmacists expressed concerns that offering naloxone might negatively impact relationships with patients. They reported that patients might feel as though they were being accused of medication misuse or diversion, and that bringing up naloxone in general could come across as offensive. Likewise, fear of being treated poorly by pharmacists was a factor influencing patients’ decisions to purchase naloxone from the pharmacy. Some pharmacists also believed they lacked the training to adequately educate patients about naloxone, and thus were hesitant to do so.17 Other studies have also reported on pharmacists’ confusion regarding the standing order for naloxone and available formulations for laypersons.18,19 In addition to provision of naloxone, the pharmacy is a critical place for access and distribution of other illicit drugrelated harm reduction supplies, especially sterile syringes. In the United States, people who inject drugs are able to obtain sterile syringes from syringe exchange programs or, in many states, without a prescription from their local pharmacy. The sale of nonprescription syringes at a pharmacy is currently legal in 46 states, including Massachusetts.20 A heretofore unrecognized partner in the provision of naloxone in the pharmacy environment is the pharmacy technician. Pharmacy technicians work under the supervision of a pharmacist in both retail and hospital pharmacies, yet they are commonly the “face” of the pharmacy owing to their frequent interaction with patients. Traditionally, their roles have included processing and filling prescriptions, maintaining and recording drug inventories, and coordinating the billing of medications between patients and third-party insurance providers.21 In recent years, however, the roles of pharmacy technicians have been rapidly expanding. For example, 1 study demonstrated that involvement of technicians in immunization programs facilitated vaccine delivery and increased their administration, and another showed that inclusion of technicians significantly increased vaccination rates in pharmacies compared with control pharmacies having no technician.22-24 In the past year, Idaho took technician responsibilities one step further by becoming the first state to
SCIENCE AND PRACTICE Attitudes toward naloxone provision
permit technicians to administer vaccines under the supervision of a pharmacist.25 Follow-up studies involving Idaho technicians suggest that trained technicians are knowledgeable about the procedures involved in vaccination and are confident in participating in the process after completing a short training program.26 Previously, research on the topic of attitudes toward naloxone prescriptions and dispensing has focused primarily on 3 groups of people: (1) patients actively using illicit opioid drugs or living with chronic pain who have been prescribed opioid analgesics; (2) licensed physicians or prescribers; and (3) licensed pharmacists.17,27,28 Hence, although others have documented on pharmacy staff,29-31 there is limited research focused exclusively on the role of pharmacy technicians in the dispensing of naloxone. Objectives Given the barriers to both physician-patient and pharmacist-patient discussions on the topic of naloxone, and the rapidly expanding role and promising benefits involving pharmacy technicians in the provision of naloxone, this study aimed to explore the attitudes and perceptions of pharmacy technicians in the dispensing of naloxone in a selection of pharmacies located in high and low overdose burden municipalities in Massachusetts. Methods This study used cross-sectional survey administration as the primary means for data collection. As this was part of a larger research study, the Massachusetts community retail pharmacies included in the study were from 1 U.S. chain, CVS Health. A sample of 39 pharmacies were selected, with 21 in high-risk municipalities (HRMs) and 18 in low-risk municipalities (LRMs), based on community opioid overdose rates that were above or below the state average of 12.2 per 100,000 people.32 These pharmacies were purposely sampled to ensure geographical variability, as well as to mitigate influences from neighboring municipalities, which may have different rates of overdose. In all cases, research staff approached the pharmacist on duty and introduced them to the study. Research staff then asked permission to speak with a lead technician, if available, at which point the technician was introduced to the study and was asked permission to participate. Before beginning the survey, all participants went through an informed consent process and were informed that their answers would remain anonymous and no personal or identifying information would be collected. All pharmacies were visited between Monday and Friday from the hours of 9:00 AM to 5:00 PM Eastern Standard Time. Pharmacies were not visited outside of this timeframe in order to mitigate the chance of speaking with a part-time or relief technician. The survey instrument (available on JAPhA.org as supplemental content) was administered verbally by research staff to consenting pharmacy technicians. Survey topics included technician beliefs about current naloxone provision practices; patient groups at greater risk of overdose; whether individuals filling prescriptions would benefit from naloxone; and whether individuals purchasing syringes would benefit from naloxone. Survey items were closed-ended with some items
Table 1 Sample characteristics of participants in survey of Massachusetts pharmacy technicians Pharmacy technician characteristics Sex Male Female Age, y 18e21 22e25 26e34 35e44 45e64 65þ Racial identity White/Caucasian Black/African American Asian Native Hawaiian/Pacific Islander American Indian/Alaska Native Hispanic More than 1 racea Otherb Years of experience at that particular pharmacy 0e1 2e3 4e5 6e7 8e10 11þ
HRM n (%) nt ¼ 21
LRM n (%) nt ¼ 18
Row total N (%) Nt ¼ 39
2 (10) 19 (90)
1 (6) 17 (94)
3 (8) 36 (92)
1 4 9 4 3
(5) (19) (43) (19) (14) 0
5 6 3 4
0 (28) (33) (17) (22) 0
1 9 15 7 7
(3) (23) (38) (18) (18) 0
13 (62) 2 (10) 0 0
11 (61) 2 (11) 1 (6) 0
0
0
0
3 (14) 3 (14) 0
3 (16) 0 1 (6)
6 (15) 3 (8) 1 (3)
7 (33) 3 (14) 6 (29) 0 0 5 (24)
4 5 3 2 2 2
(22) (28) (17) (11) (11) (11)
24 (61) 4 (10) 1 (3) 0
11 8 9 2 2 7
(28) (21) (23) (5) (5) (18)
Abbreviations used: HRM, high-risk municipality; LRM, low-risk municipality. a “More than 1 race” was characterized as “White/Caucasian þ Black/African American” by 2 participants in HRMs and “Black/African American þ Hispanic” by the remaining participant in the HRM. b “ Other” was characterized as “Sinhalese” by the participant in the LRM.
being either taken or adapted from previous work completed by the MOON Study Team at Boston Medical Center.33 The final survey item welcomed open-ended feedback and comments regarding topics discussed, and research staff recorded verbatim responses from technicians in these instances. Descriptive summary statistics were calculated, and statistical tests examined differences by municipality risk level (i.e., high or low risk) for the survey responses. Owing to the nature of the dependent variables based on the responses to the survey items, a series of Mann-Whitney U tests, Fisher exact tests, and chi-square tests of independence were performed. The dependent variables for all tests were the responses to the survey items. All statistical analyses were conducted in IBM SPSS Statistics version 25 (Armonk, NY). Open-ended responses were summarized for themes and then contrasted by municipality risk status to explore for any differences. When relevant, direct quotes from technicians are presented in the results. This study was approved by the Boston University Medical Campus institutional review board.
Results In total, the sample included 39 CVS Health pharmacies across Massachusetts, yielding data from 39 pharmacy 3
SCIENCE AND PRACTICE S. Kurian et al. / Journal of the American Pharmacists Association xxx (2019) 1e8
Figure 1. Study sample pharmacies in Massachusetts. The high-risk municipalities (HRMs) are labeled in blue with letters A through G (A, Salem; B, Malden; C, Medford; D, Worcester; E, Brockton; F, Taunton; G, Plymouth). The low-risk municipalities (LRMs) are labeled in red with numbers 1 through 6 (1, Framingham; 2, Wellesley; 3, Newton; 4, Brookline; 5, Dedham; 6, Milford).
technicians. An in-person survey was successfully administered to all 39 technicians, with both a response rate and completion rate of 100%. Table 1 depicts sample characteristics of the study participants, highlighting sex, age, racial identity, and years of work experience. Figure 1 depicts the state of Massachusetts, outlined in red, with markers for each of the pharmacies visited for the survey.34 Table 2 presents differences in risk perception and naloxone need by municipality risk status. Generally, actual risk of opioid overdose and naloxone need were aligned. Most technicians (81%) in HRMs believed that more than 25% of their patients could benefit from having a naloxone kit available, while this was true for only 33% of technicians in LRMs (P < 0.01), despite having comparable perceptions of patients in whom they believed used illicit or prescription opioids. Some of the discrepant responses from HRM technicians who endorsed a lower level of perceived naloxone need (i.e., less than 26% of patients could benefit from having a naloxone kit available) included unsolicited comments that “most patients are responsible,” and “patients with prescriptions are not at risk.” Table 3 presents technicians’ identification of patient groups at risk of overdose. A greater proportion of technicians in LRMs compared with those in HRMs indicated that they could easily identify patients receiving prescriptions for both 4
opioids and benzodiazepine medications (39% in LRM vs. 19% in HRM), while a greater proportion of technicians in HRMs compared with their peers in LRMs indicated they could easily identify patients purchasing syringes over the counter (67% in HRM vs. 44% in LRM). The top 2 most readily identifiable patient populations who could benefit from naloxone receipt as indicated by LRM technicians were populations 1 (high opioid dose recipients) and 5 (syringe purchasers), while, for HRM technicians, the most readily identifiable populations were 4 (buprenorphine patients) and 5 (syringe purchasers). Overall, willingness and comfort in participating in pharmacy naloxone dispensing was high in both types of municipalities. All HRM technicians and 89% of LRM technicians reported that they were both willing and comfortable participating in the dispensing of naloxone in the pharmacy. In addition, a willingness to learn more about naloxone and how it can be used in the pharmacy was nearly universally high (95% of HRM technicians, 94% of LRM technicians). Additional comments and feedback from both HRM and LRM technicians revealed many common themes (Table 4). Mainly, technicians conveyed concerns that patients were unwilling to pay out-of-pocket for naloxone and would benefit from lower-cost options, and that both they and patients may be misinformed about which patient populations could benefit
Table 2 Participants’ perceived comfort, benefit, and risk estimates pertaining to provision of naloxone in pharmacies, by level of overdose risk in municipality, n (%) Survey item
Risk level
Survey item Estimated at-risk population size and benefit for naloxone receipt Approximately what percent of patients do you think use illicit opioids (i.e., heroin, fentanyl, diverted prescription medications)? Approximately what percent of patients currently have prescription opioids prescribed to them?
Survey item
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Agree
Strongly agree
1 (5)
2 (10)
1 (5)
2 (10)
3 (13)
4 (19)
4 (19)
0.397
1 (5) 0
2 (11) 0
0 1 (5)
2 (11) 1 (5)
2 (11) 3 (14)
5 (28) 5 (24)
5 (28) 11 (52)
0.549
1 (6) 0
0 0
0 0
0 0
4 (22) 2 (10)
6 (33) 4 (19)
7 (39) 15 (71)
0.410
0 0
1 (6) 0
0 0
1 (6) 0
0 2 (10)
6 (33) 5 (24)
10 (55) 14 (67)
0.282
0 0
1 (6) 0
1 (6) 0
0 1 (5)
2 (11) 1 (5)
5 (28) 7 (33)
9 (50) 12 (57)
0. 443
0
1 (6)
0
0
0
4 (22)
13 (72)
0
0
0
2 (10)
1 (5)
4 (19)
14 (67)
0.922
0 1 (5)
0 1 (5)
0 0
1 (6) 2 (9)
0 2 (9)
6 (33) 5 (24)
11 (61) 9 (43)
0.105
0
1 (5)
1 (5)
4 (22)
4 (22)
5 (28)
3 (17)
Risk level
None
< 10%
10%e25%
26%e50%
HRM
0
4 (19)
6 (29)
3 (14)
8 (38)
0.156
LRM HRM
1 (5) 0
5 (28) 2 (10)
7 (39) 2 (10)
1 (5) 7 (33)
4 (22) 10 (47)
0.587
LRM
0
1 (6)
6 (33)
3 (17)
8 (44)
Risk level
0%e25%
HRM
4 (19)
17 (81)
LRM
12 (67)
6 (33)
Abbreviations used: HRM, high-risk municipality; LRM, low-risk municipality. a By Mann-Whitney U test. b Four participants in HRM (19%) and 1 participant in LRM (5%) selected N/A, thus their responses were not included in the table. c One participant in HRM (5%) selected N/A, thus their response was not included in the table. d By Fisher exact test.
< 25%
< 50%
P valuea
P valued 0.004
5
SCIENCE AND PRACTICE
Approximately what percent of patients do you think could benefit from having a naloxone kit available?
Disagree
Attitudes toward naloxone provision
Comfort with and a willingness to provide naloxone in the pharmacy HRM I am comfortable answering patient questions about naloxoneb LRM I am familiar with naloxone and its role HRM in reducing overdose risk in communities LRM I am willing to participate in the dispensing HRM of naloxone in this pharmacy LRM I am comfortable participating in the HRM dispensing of naloxone in this pharmacy LRM I am willing to learn more about naloxone HRM and how it can be used in this pharmacy LRM Perceptions of patient benefit of naloxone receipt It is good that naloxone is available to people in HRM Massachusetts by standing order LRM HRM The people who would benefit most from naloxone are those purchasing syringes for drug usec LRM
P valueb
Strongly disagree
SCIENCE AND PRACTICE S. Kurian et al. / Journal of the American Pharmacists Association xxx (2019) 1e8
Table 3 Participants’ identification of patient groups at risk of overdose Survey item Which of the following patients at risk of overdose are the easiest to identify? (Please select the 2 you feel are easiest to identify and will yield the most benefit for receiving naloxone to take home) (1) Patients receiving high doses of opioid medications (2) Patients receiving prescriptions for both opioids and benzodiazepine medications (3) Patients receiving opioids with a 28-day or more supply (4) Patients receiving prescriptions for buprenorphine/naloxone (5) Patients purchasing syringes over the counter
Option Option Option Option Option Option Option Option Option Option
1 1 2 2 3 3 4 4 5 5
selected not selected selected not selected selected not selected selected not selected selected not selected
HRM n (%) nt ¼ 21
LRM n (%) nt ¼ 18
P value
12 9 4 17 4 17 8 13 14 7
10 8 7 11 4 14 7 11 8 10
0.921a
(57) (43) (19) (81) (19) (81) (38) (62) (67) (33)
(56) (44) (39) (61) (22) (78) (39) (61) (44) (56)
0.285b 1.000b 0.959a 0.163a
Abbreviations used: HRM, high-risk municipality; LRM, low-risk municipality. a By chi-square test of independence. b By Fisher exact test.
from naloxone. Several comments across municipality type on the topic of syringes reflected a high degree of misunderstanding on why syringes were provided for sale in pharmacies, as well as discomfort in selling, and prejudice in the pharmacy. Some technicians, and only those in HRM, expressed concerns that naloxone, while useful as a rescue medication, is not a treatment medication and does not stop opioid misuse. In contrast, some technicians, and only those in
LRM, highlighted the expectation of greater prescriber involvement in addressing prescription opioid-implicated overdose risk in their municipality. Discussion This study is among the first to focus exclusively on the potential role of the pharmacy technician in naloxone
Table 4 Themes derived from review of verbatim comments and feedback from pharmacy technicians, by municipality risk statusa Category Naloxone does not alter underlying opioid misuse
Cost of naloxone
Sales of syringes
HRM quotes “People take advantage of naloxone and continue to overdose” “[Patients believe naloxone is a] magic fix… after using naloxone patients will return back to using drugs” “[Naloxone is] too expensive for all patients… patients are unwilling to pay out of pocket [for naloxone]”
“[I] would like the right to refuse to sell syringes to certain people when it’s evident they’re under the influence of other drugs.”
Physicians should co-prescribe naloxone
Technician and patient misperceptions about the potential uses of naloxone
“Patients with [opioid] prescriptions are not at risk [of overdose]”
“Most patients are responsible [and therefore do not need naloxone]”
6
LRM quotes
“Insurance is the primary factor affecting patient decisions to purchase [naloxone]… parents would buy [naloxone] for their children if it was not so expensive.” “Patients refuse to purchase naloxone due to cost and insurance issues.” “[Technicians are willing to dispense clean needles, regardless of patient appearance; however, the pharmacy manager often chooses to deny patients who fit a certain stereotype. That is, young patients with] blood shot eyes, long sleeves, and asking for syringes for grandma’s diabetes” “Doctors should [prescribe naloxone] with prescriptions too” and “[doctors should] show patients how to use [naloxone]… [I] find it difficult to [discuss naloxone as I am worried about] crossing the line… Patients might find it offensive if [technicians bring up naloxone] if they [are taking] pain medications due to a car accident.” “[Co-prescribing is important because] when the pharmacist brings up naloxone the patient might become offended.” “[In general], the patients’ perception is that they’re not a drug addict and therefore they don’t think they need naloxone… even though they have opioid prescriptions.” “Not everyone is knowledgeable about why naloxone is useful… [the belief is that] only people shooting up on the street need it.”
SCIENCE AND PRACTICE Attitudes toward naloxone provision
provision at the pharmacy. Findings suggest areas of potential training and intervention, which can be rendered more effective when informed by a deeper understanding of the community overdose risk environment. Among this sample of chain community pharmacy technicians in a state heavily affected by the opioid overdose crisis, it appears that pharmacy technicians would be receptive to taking on a larger role regarding naloxone provision. As others have documented in similar studies,29 technicians in our study were well aware of the risks that opioid use poses for patients and are ready to act to help prevent overdose with naloxone provision. Given this high degree of support, one possible approach would be to expand the scope of practice for pharmacy technicians, allowing them to initiate an offer of naloxone to a patient. Analogous to technician roles in Idaho surrounding vaccine administration,25 such an action may require legislative or regulatory change and also clear corporate and pharmacy manager support, such that technicians are given adequate training and materials to implement a successful strategy for pharmacy naloxone dispensing. Based on findings from HRM and LRM technicians, the content of the training should provide factual and clear information about overdose and opioid use risks, dispel myths about at-risk patient populations, and emphasize patient training that takes 5 to 10 minutes to complete.35 Additional efforts are needed to raise awareness among patients, too, that individuals taking high-dose prescription opioid medications or specific combinations of opioid medications are also at risk of overdose. A common theme seen across both municipality risk levels is that technicians express patients’ views of naloxone being too expensive. It would be useful to alleviate this barrier by achieving more, and more consistent, private and public insurance coverage of as many naloxone products as possible and to patients as well as to their caregivers (i.e., potential victim and witness of an overdose event), which would inevitably improve patient care, reduce confusion about medication accessibility, and save lives.7,36-39 Technicians working in HRMs were more apt to identify their patients’ need for naloxone, suggesting that they may be particularly well-suited to undertake a pharmacy technicianbased intervention for expanding naloxone access in their community. Such an intervention could also focus on overdose prevention for injection-related use of opioids, not just for opioid medication use, because HRM technicians self-reported greater adeptness in identifying syringe-purchasing patrons and identified their need for naloxone. It is notable that only the HRM technicians questioned the usefulness of naloxone in stopping opioid misuse and expressed prejudice in the provision of syringes, as others have documented in the pharmacy.40,41 In places such as HRMs that are heavily affected by the opioid overdose crisis, it may be even more important to take the time to reinforce the goals of harm reduction and rescue medication provision, explain the chronic nature of addiction, and to be explicit about the need to build resilience and address compassion fatigue among all health care and service providers. Future efforts that focus on shifting pharmacist’s and physician’s attitudes toward pharmacy-based harm reduction strategies should consider including technicians in their efforts. These survey data, and especially responses conveyed by LRM technicians, support the HHS guidance to co-prescribe
naloxone with opioid medications and to prescribe naloxone to those at known risk of overdose. Implementation of HHS guidance in LRMs may be readily adopted, because the LRM-based survey respondents indicated that, in the primary at-risk patient population, there may be individuals taking multiple prescription opioids. Thus, an evidence-based physician-directed intervention (i.e., co-prescribing naloxone with opioid prescriptions)42 may be an appropriate and synergistic approach in those municipalities. Coupled with the HHS guidance, universal education of providers, pharmacists, and technicians in LRM could help educate patients about the benefits of naloxone and reduce some of the concerns presented by LRM pharmacists and technicians about potentially offending patients. This study has important limitations. Many study pharmacies were quite busy, which might not have provided ideal circumstances for survey administration. As a result, the technicians might not have provided their most accurate or detailed responses. Because the survey was administered in the pharmacy, the proximity of other staff members (i.e., pharmacists, interns, students) may have influenced the participation or the social desirability of reported responses. If present, the effect of this bias would have been reporting of higher competence and positive attitudes toward participating in naloxone dispensing. These biases were minimized by offering to use the employee lunch-room and/or private consultation area, if available, for survey administration, and by keeping the survey responses anonymous. Finally, we did not capture some important details of the technicians, such as whether they work full time or part time, educational training, and other personal details. To protect the anonymity of the respondent and reduce response burden, such items were not included in this initial survey but would be important to gather in future work. Conclusion These results demonstrate that pharmacy technicians are well positioned to recognize overdose risk and offer preventive interventions, such as naloxone provision. Therefore, the pharmacy team seems capable of implementing HHS guidance on naloxone co-prescription to people at risk of overdose. To prevent more overdoses in their communities, HRM pharmacies could benefit from a technician-based intervention that focuses on harm reduction principles and materials, while LRM technicians would benefit from greater physician and pharmacist involvement in the co-prescription of naloxone with other opioid medications. Properly trained pharmacy technicians, with or without expanded authority, have the potential to expand community naloxone access and provision. Acknowledgments The authors thank the survey participants for their willingness to be part of this study. Supplementary Data Supplementary data related to this article can be found at https://doi.org/10.1016/j.japh.2019.08.009. 7
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