- Email: [email protected]
Pharmacy leaders’ beliefs about how pharmacies can support a sustainable approach to providing naloxone to the community
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Contents lists available at ScienceDirect
Research in Social and Administrative Pharmacy journal homepage: www.elsevier.com/locate/rsap
Pharmacy leaders’ beliefs about how pharmacies can support a sustainable approach to providing naloxone to the community Elizabeth Donovana,∗, Jeffrey Bratbergb, Janette Bairdc, Dina Bursteinc, Patricia Cased, Alexander Y. Walleye, Traci C. Greenc,f,g a
Department of Psychology, Simmons University, Boston, MA, USA College of Pharmacy, University of Rhode Island, RI, USA c Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA d Institute for Urban Health Research and Practice, Northeastern University, Boston, MA, USA e Clinical Addiction Research Education Unit, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA f Department of Epidemiology, Alpert Medical School of Brown University, Providence, RI, USA g Boston Medical Center Injury Prevention Center, Boston University School of Medicine, Department of Emergency Medicine, Boston, MA, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Pharmacy Naloxone Opioid Overdose
Background: Naloxone is an antidote to opioid overdose, and community pharmacies nationwide now provide broad access to this medication. Objective: The aim of this qualitative study was to understand how leaders in pharmacy organizations perceive pharmacies and pharmacy staff can optimize dispensing of naloxone. Methods: In-depth interviews were conducted with 12 pharmacy leaders in Massachusetts and Rhode Island. Participants were recruited from three types of community pharmacies: (1) chain; (2) independent; and (3) hospital outpatient. Theory-driven immersion crystallization, using Brownlee et al.'s model of healthcare quality improvement, was used to inform coding of the interview data, with predetermined categories of staff; organization; and process. Results: Five main themes were identified: (1) Importance of staff training to increase comfort; (2) Strength through coordination of efforts; (3) Pharmacy as a community leader in the opioid crisis; (4) Persisting stigma; and (5) Ongoing workflow challenges. Conclusions: The results uniquely reflect the experiences and insights of pharmacy leaders implementing public health initiatives during the opioid crisis and can be used for gaining insight into how pharmacists can efficiently provide naloxone to their communities.
Introduction Drug overdose is the leading cause of unintentional death in the United States. In 2017, 70,237 overdose deaths occurred in the United States, the majority (68%) of which involved an opioid.1 Naloxone restores normal respiration to a person whose breathing has slowed or stopped because of opioid overdose.2 When naloxone and overdose education are available to potential bystanders in the community, overdose deaths decrease in those communities.3 Pharmacists are well-positioned to provide naloxone to their community.4 Using claims data, Freeman, et al.5 reported an 8-fold increase in the number of naloxone prescriptions in the US between the end of 2015 to mid-2017, from less than 20,000 to nearly 90,000 prescriptions. Using the same data, Guy, et al.6 further reported a doubling of ∗
2017 numbers to 2018. This is in part because most states now have laws that allow pharmacists to dispense naloxone without a prescription (standing orders).7 For example, in Rhode Island, pharmacy-based naloxone became available starting in 2013 via a statewide collaborative practice agreement with one community pharmacy chain (10% of pharmacies), and in 2014 via standing order.8 The innovation spread to neighboring Massachusetts, which adopted standing orders in 2014.9 Yet, as with other healthcare initiatives, changes must be made at the staff, process and organization level to efficiently dispense naloxone and meet community needs.10 Currently, factors that impact uptake of pharmacy-based naloxone (PBN) include status as a chain pharmacy and number of full-time licensed pharmacists at a location,11 as well as adequacy of pharmacist training,12,13 time constraints, and perceived lack of patient comprehension about naloxone administration.12
Corresponding author. Department of Psychology, Simmons University, 30 Fenway, Boston, MA, 02115, USA. E-mail address: [email protected] (E. Donovan).
https://doi.org/10.1016/j.sapharm.2020.01.006 Received 13 June 2019; Received in revised form 11 January 2020; Accepted 13 January 2020 1551-7411/ © 2020 Elsevier Inc. All rights reserved.
Please cite this article as: Elizabeth Donovan, et al., Research in Social and Administrative Pharmacy, https://doi.org/10.1016/j.sapharm.2020.01.006
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crystallization (I/C), an approach that involves thoroughly examining, and reflecting on, qualitative data until reportable interpretations are reached.19 We chose this inductive approach so as to remain open to emerging themes, while acknowledging that we approached the data with theoretical assumptions, thus we explicitly incorporated Brownlee et al.’s model of healthcare quality improvement10 as a framework to guide our interpretation of the data. Recognizing that our own backgrounds as researchers would inevitably impact our interpretation of the findings,20 we incorporated a range of researcher perspectives into the procedure: two researchers with different backgrounds (psychology and epidemiology) conducted the main analysis; soliciting feedback from other team members (backgrounds were epidemiology, public health, psychology, medicine, and pharmacy) as data analysis progressed. To further enrich our understanding, we also discussed interpretations of the data in the context of the wider literature (e.g.,11–13,21,22). In combination, these strategies were adopted to reduce bias resulting from using a single perspective.23 The specific steps to data analysis were as follows: The two main analysts (ED and TCG) independently reviewed the recordings and transcripts; They then agreed upon broad codes based on factors identified by Brownlee et al.10 as contributing to healthcare quality and improvement (Table 1) and independently applied the codes to the interview data; ED and TCG met to discuss application of the codes to the interview data, resolving all discrepancies (e.g., whether copay difficulties represent a workflow challenge) through discussion. To identify themes, ED and TCG independently immersed themselves in the coded data, rereading the text and noting patterns in data within codes (e.g., patterns and possible themes associated with data coded as relating to “Staff”), as well as patterns seen across codes; They then met to discuss emerging themes, making frequent references to the wider literature (e.g.,11–13,21,22) to try to gain a rich understanding of the phenomena being discussed by the interviewees. Finally, insights were brought to larger team meetings to solicit feedback from team members with different backgrounds and to discuss alternative ways of interpreting data. ED and TCG incorporated the team’s feedback into the analysis and agreed on a small set of themes associated with each code. Through discussion, ED and TCG finalized labels for the themes to describe the range of ideas that the theme was intended to represent.
The aim of this qualitative study was to understand how leaders in pharmacy organizations perceive pharmacies and pharmacy staff can optimize dispensing of naloxone. Method Study design As part of a demonstration study14–17 conducted from 2015 to 2019, we collaborated with independent, outpatient hospital, and retail chain pharmacies to determine the best ways to provide pharmacy naloxone to people at risk of opioid overdose. In the final years of the project (2018 and 2019), in-depth, semi-structured interviews were conducted with leadership from the study pharmacies in Massachusetts and Rhode Island. Recruitment Members of the research team (TCG and JPB) approached via phone or email 12 pharmacists (> 18 years of age, English speaking, and in a leadership role— owner of independent pharmacy or in an administrator role at a chain or outpatient hospital pharmacy —with direct knowledge of PBN initiatives). To understand a range of perspectives, leaders were purposefully recruited from the three types of community pharmacies with standing orders represented in a larger study being conducted with a range of stakeholders to determine the best way to provide naloxone in the pharmacy setting: (1) chain; (2) independent; and (3) urban hospital outpatient. Participants provided informed verbal consent and did not receive compensation. The institutional review boards of Boston University Medical Campus and Rhode Island Hospital approved study protocols. Data collection From December 2018 to February 2019, three trained qualitative interviewers (PhD; MPH; PharmD), conducted 30–45-min, audio-recorded audio phone interviews with pharmacy leaders. Interviews were transcribed and deidentified. Given our interest in how pharmacies approach creating a sustainable method of disseminating naloxone into the community, our semi-structured interview guides were informed by Brownlee et al.’s model of healthcare quality improvement10 which identifies three factors fundamental to innovation sustainability: staff (including staff engagement, training and leadership), organization (including infrastructure and culture that help to sustain change) and process (including an organization's ability to adapt to an innovation, measure its success and foster value among employees). Authors ED and TCG created broad, open-ended questions to address each of the three main categories in the model, as well as stigma, as stigma within the pharmacy is well-established.17,18 The research team (PharmD, PhDs, MDs) reviewed the questions and suggestions were incorporated into the interview guide. See Table 1.
Results Twelve pharmacy leaders (Pharm.D.s) participated (Table 2) and five main themes were identified (Table 1). Data from both states are presented together as no state differences were observed. Importance of staff training to increase comfort Almost all interviewees stressed the importance of helping staff to overcome stigma and decrease hesitancy to offering naloxone. Delivery of information varied depending on pharmacy type, for example, pharmacy leaders in chain pharmacies described trying to reach these goals through standardized trainings:
Data analysis
Breaking down the pharmacists' thinking [through standardized trainings] that it is just for IV illicit drug users. Really it is for the elderly
Data analysis was conducted using theory-driven immersion/ Table 1 Key factors contributing to healthcare quality and improvement and associated interview themes Key factor
Example interview question
Interview theme
Staff Organization
Tell me about training within your organization to engage staff around pharmacy-based naloxone? Do you feel there has/has not been sufficient support from within the organization for initiatives like this? How do people in your institution view the work of your pharmacy with respect to naloxone? Tell me about any changes that still need to be made to optimize naloxone distribution Tell me about stigma in the pharmacy
Importance of staff training to increase comfort Strength through coordination of efforts
Process Additional theme
2
Pharmacy as a community leader in the opioid crisis Ongoing workflow challenges Persisting stigma
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of coordination of efforts among independent pharmacies to get more naloxone into the community.
Table 2 Participant characteristics (n = 12) Frequency Gender Male Female Pharmacy type Chain Independent Hospital Years in current role 1-4 5-8 9-12
I think everyone [independent pharmacies] is working towards the same goal [naloxone provision], but I think everyone is working in their own silo. I think it would be much more effective if we found a way to work together. – P07, independent pharmacy leader
7 5
Another independent pharmacy leader expressed that they found success in collaborating with doctors who co-prescribe naloxone to patients at risk of overdose, while also acknowledging that their current approach to educating patients may not be feasible in the long-term.
5 3 4 5 3 4
I'm finding the combination of the co-prescription with us having that conversation [with the patient], almost all of those patients leave with it … I'm as tapped out as I can get in terms of time dedicated to having that conversation with people, like if I dedicated any more time to it, it would not be a sustainable model – P04, independent pharmacy leader
population that is also taking some high dose opioids. Or maybe it's for that mom that's standing in front of you that has two teenagers at home. So how do we get pharmacists to think about patients that need naloxone in different ways. – P11, chain pharmacy leader
Pharmacy as a community leader in the opioid crisis
A leader from an independent pharmacy described an environment that encouraged staff to ask for assistance in improving naloxone provision.
As well as finding partnerships to support ways to optimize dispensing naloxone, Brownlee et al.’s model10 also emphasizes the importance of recognizing the values embedded in the organizational cultures. Most interviewees expressed the importance to the mission of the pharmacy of being a public health leader in the community during the opioid crisis. Beyond their naloxone programs, leaders at chain pharmacies described talking to students in schools about prescription drug safety; holding talks for parents; offering workplace lunch and learns and launching drug disposal programs. One pharmacy leader described the benefits that pharmacists derive from talking with school children, and how it, in turn, affects their practice.
I think there's still a level of nervousness about this [naloxone provision] so usually they'll come to me first, we'll do a little role play of what they are going to say…we don't necessarily have a formal training [beyond the hour of training required as part of the Massachusetts standing order], more like on the fly. – P07, independent pharmacy leader Brownlee et al. emphasize that sustainable changes are not imposed but are done with staff involvement.10 A leader from a hospital pharmacy described how trainings resulted in a more comfortable and engaged staff.
Our pharmacists feel very, very connected to the issue … It's good for them also to see local teens, and their ability to be able to prevent opioid misuse, and then apply that in terms of their filters as they fill prescriptions. –P11, chain pharmacy leader
There was almost like a competition in the pharmacy, who could engage the most patients to receive a [naloxone] kit – P02, hospital pharmacy leader
Leaders at hospitals typically described the hospital at large as their community and participated or led on-campus events such as promoting recovery month; naloxone training; and displaying signs about naloxone that served to cement their role as public health leaders.
Strength through coordination of efforts External efforts such as state regulations and federal initiatives (e.g., the Surgeon General's Health Advisory,24) as well as increased co-prescribing of naloxone by physicians, were cited by many as helping to “hardwire” efforts to streamline and optimize dispensing of PBN. Within their organizations, strength from internal collaborations was also cited as important. Leaders at chain pharmacies described successful coordination of efforts across corporate teams within their pharmacy organization, such as professional practice; corporate communications, government affairs; regulatory affairs; training; marketing and legal.
We're pretty much in ground zero of this epidemic here in Boston, MA, so when you come on our campus, you will have some kind of contact, some kind of discussion or some kind of information that lets you know- either directly or in passing- that we are here to help with substance use disorder—P01, hospital pharmacy leader In contrast, a leader at an independent pharmacy described frustration at being unable to spend time in the community in part because of a lack of coordination between independent pharmacies, but also time constraints, and lack of compensation for counseling patients about naloxone.
“Everyone's really supportive and know it's [their naloxone program] important. It's [opioid overdose crisis] not going to go away. – P12, chain pharmacy leader
Persisting stigma All the interviewees perceived that stigma of addiction was decreasing as a result of growing public awareness as well as efforts to train pharmacists; still, there was acknowledgement that the presence of stigma in the pharmacy is hard to measure and remains an ongoing challenge. One leader from a hospital pharmacy described positive change on the hospital campus as a result of efforts to reduce stigma associated with addiction.
One interviewee from a hospital described the importance of the role the pharmacy in supporting other groups providing naloxone, such as the hospital's emergency department and substance use disorder clinic. It's really about removing barriers that may come up, complementing their programs versus being a barrier … We could say, ‘we can't have you having special treatment.’ Instead of taking that route we say “What are your sore points, and how can we make sure we close those gaps for you and your patient and help your program and be successful” – P10, hospital pharmacy leader
So I think a lot of patients who come here know that we accept [people who use drugs] … so they feel more at home here and I think all the communication from the state, the city, and of course here on campus,
But independent pharmacy leaders described frustration at the lack 3
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about harm reduction; need for focused efforts addressing risk communication to diminish stigma;importance of increasing proactive naloxone offers25; challenges with health insurance21,22; importance of coprescribing mandates,26 and calls for reimbursing pharmacy opioid safety conversations, including naloxone offer and overdose education.21,22 Our study furthers understanding of these systems-level challenges and describes setting-specific considerations. The roles of community pharmacies, pharmacists, and pharmacy leaders in harm reduction and public health remain understudied and underutilized.27 Within the current opioid crisis, future studies may address challenges to dispensing naloxone by focusing on the content and delivery of pharmacist training28; results from our study suggest that considering ways to tailor training to the setting may be important. It is also important to examine outcome differences between states with different pharmacy naloxone prescribing laws29; document pharmacists’ perception of stigma30; develop ways to measure stigma, which pharmacists in our study described as difficult, and understand how pharmacists can optimize naloxone dispensing at health-system touchpoints with people at high risk of overdose.31 Importantly, there should be continued examination of how low- and high-risk populations use pharmacies for naloxone and harm reduction..32 Pharmacists in our study identified reaching caregivers of people at risk for overdose as an ongoing challenge. It is important to acknowledge factors that can impact the quality of qualitative research, including how researchers' beliefs impact the research process; appropriateness of sampling; and the process of organizing and interpreting data.20 Undoubtedly, interpretation of the data was influenced by our past experiences; however, we made efforts to reduce bias by involving multiple researchers, with different backgrounds (epidemiology, public health, psychology, medicine, pharmacy) throughout the research process (e.g., during development of the codebook and discussion of the findings). During the data analysis phase, the researchers supplemented each other's interpretations of findings with discipline-specific knowledge, research articles, and experiences, which helped the group to gain a deeper understanding of the phenomena described by the pharmacy leaders. The research team used a purposeful sampling strategy to recruit pharmacy leaders from a range of settings to include diversity of experiences in our descriptions. Still, we acknowledge that while our descriptive findings may be helpful for gaining insight into pharmacy leaders' perspectives on ways to optimize dispensing naloxone, the pharmacy leaders in our study did not represent all possible settings, for example, hospitals in rural areas, where other concerns may be relevant to dispensing naloxone. Finally, we acknowledge that it can be challenging to fully convey all the nuances involved in analyzing qualitative interview data but we madeefforts to address this by documenting our theory-driven IC approach; explicitly noting how Brownlee et al.’s model was used throughout the research process, and describing the specific steps involved in data analysis. Community pharmacists and pharmacies are a critical source of naloxone and results of this study suggest that a continued focus on overcoming challenges to naloxone provision are warranted. This study may be helpful for gaining insight into how pharmacists working in different settings can address barriers to efficiently providing naloxone to their communities.
when you step on the [hospital] campus really help break that stigma if you will.—P01, hospital pharmacy leader In contrast, a pharmacy leader from an independent pharmacy described ongoing stigma within the context of serving a small community. Because of our community situation, that small, tightknit close community, a lot of the customers that we see are close to us and our families and vice versa … that makes people hesitant to get it [naloxone]. – P08, independent pharmacy leader One leader from a chain pharmacy described difficulty in measuring any change in stigma in the pharmacy. The leader described relying on changes in volume of negative customer feedback and reports from “secret shoppers” in the community as a possible indicator of reduced stigma: I do see less and less complaints [about PBN] coming in; it was more frequent a year ago. And also, there is less feedback from [community] coalitions saying, ‘we went into stores and your pharmacist didn't know about it’. We still get them, but not as many. – P12, chain pharmacy leader
Ongoing workflow challenges Consistent with Brownlee et al.’s10 emphasis on understanding the workflow of a problem, all interviewees described an evolving process of naloxone provision, with barriers still to overcome. Some interviewees named insurance as a barrier to efficiently dispensing naloxone. When someone is interested in obtaining a naloxone kit, we usually bill out at least the two nasal options and the third IM option if they're interested; the only way to figure out what's covered and what's not is to bill all three out and then determine from there what's happening. – P07, independent pharmacy leader Another reported that insurance copays continue to slow naloxone uptake for some patients. As long as the co-pay was zero, they were all about it. If it's anywhere $25 or more, people are just like, “I care, but I don't care that much.” – P04, independent pharmacy leader Others described the importance of pharmacists taking more steps to proactively offer naloxone to those at risk for overdose who have previously refused an offer of naloxone. In those instances where people sort of refuse, I don't know that we are really going back and revisiting it with them … maybe like once a quarter we could follow up with them and see how it's going and if they are now interested in getting the kit – P07, independent pharmacy leader Others described workflow challenges in identifying and offering naloxone to a crucial but hard-to-identify population: caregivers of people using opioids. Caregivers. Figuring out a way to get to these people because they are the people who are actually going to be using it and probably would make the most difference if we had it in their hands – P12, chain pharmacy leader
CRediT authorship contribution statement Elizabeth Donovan: Formal analysis, Writing - review & editing, Writing - original draft. Jeffrey Bratberg: Formal analysis, Writing review & editing, Writing - original draft. Janette Baird: Formal analysis, Writing - review & editing. Dina Burstein: Formal analysis, Writing - review & editing. Patricia Case: Formal analysis, Writing review & editing. Alexander Y. Walley: Formal analysis, Writing review & editing. Traci C. Green: Formal analysis, Writing - review & editing, Conceptualization, Writing - original draft.
Discussion This is the first study to examine the perspectives of pharmacy leaders on efforts to efficiently provide naloxone to their communities. Results from our study reflect a high level of awareness among pharmacy leaders about challenges to naloxone provision in their varied practice settings, including need for graduate pharmacy education 4
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Declaration of competing interest
14. Kurian S, Baloy B, Baird J, et al. Attitudes and perceptions of naloxone dispensing among a sample of Massachusetts community pharmacy technicians. J Am Pharm Assoc. 2019;59(6):824–831. https://doi.org/10.1016/j.japh.2019.08.009. 15. Green TC, Bratberg J, Baird J, et al. Rurality and differences in pharmacy characteristics and community factors associated with provision of naloxone in the pharmacy. Int J Drug Policy. 2019. https://doi.org/10.1016/j.drugpo.2019.11.010. 16. Burstein D, Baird J, Bratberg J, et al. Pharmacist attitudes toward pharmacy-based naloxone: a cross-sectional survey study. J Am Pharm Assoc. 2019. https://doi.org/ 10.1016/j.japh.2019.11.004. 17. Green TC, Case P, Fiske H, et al. Perpetuating stigma or reducing risk? Perspectives from naloxone consumers and pharmacists on pharmacy-based naloxone in 2 states. J Am Pharm Assoc. 2017;57(2):S19–S27. https://doi.org/10.1016/j.japh.2017.01. 013 e4. 18. Donovan E, Case P, Bratberg JP, et al. Beliefs associated with pharmacy-based naloxone: a qualitative study of pharmacy-based naloxone purchasers and people at risk for opioid overdose. J Urban Health. February 2019. https://doi.org/10.1007/ s11524-019-00349-1. 19. Crabtree BF, Miller WL, William L. Doing Qualitative Research. Sage Publications; 1999. 20. Malterud K. Qualitative research: standards, challenges, and guidelines. The Lancet. 2001;358(9280):483–488. https://doi.org/10.1016/S0140-6736(01)05627-6. 21. Bakhireva LN, Bautista A, Cano S, Shrestha S, Bachyrycz AM, Cruz TH. Barriers and facilitators to dispensing of intranasal naloxone by pharmacists. Subst Abus. 2018;39(3):331–341. https://doi.org/10.1080/08897077.2017.1391924. 22. Thakur T, Frey M, Chewning B. Pharmacist roles, training, and perceived barriers in naloxone dispensing: a systematic review. J Am Pharm Assoc. July 2019. https://doi. org/10.1016/j.japh.2019.06.016. 23. Patton MQ. Enhancing the quality and credibility of qualitative analysis. Health Serv Res. 1999;34(5 Pt 2):1189–1208http://www.ncbi.nlm.nih.gov/pubmed/10591279, Accessed date: 6 January 2020. 24. General S. Surgeon General's advisory on naloxone and opioid overdose. https:// www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory. html, Accessed date: 26 May 2018. 25. Mahon LR, Hawthorne AN, Lee J, Blue H, Palombi L. Assessing pharmacy student experience with, knowledge of and attitudes towards harm reduction: illuminating barriers to pharmacist-led harm reduction. Harm Reduct J. 2018;15(1):57. https:// doi.org/10.1186/s12954-018-0262-6. 26. Sohn M, Talbert JC, Huang Z, Lofwall MR, Freeman PR. Association of naloxone coprescription laws with naloxone prescription dispensing in the United States. JAMA Netw. Open. 2019;2(6):e196215https://doi.org/10.1001/jamanetworkopen. 2019.6215. 27. Bach P, Hartung D. Leveraging the role of community pharmacists in the prevention, surveillance, and treatment of opioid use disorders. Addict Sci Clin Pract. 2019;14(1):30. https://doi.org/10.1186/s13722-019-0158-0. 28. Roberts AW, Carpenter DM, Smith A, Look KA. Reviewing state-mandated training requirements for naloxone-dispensing pharmacists. Research in social & administrative pharmacy. RSAP. 2019;15(2):222–225. https://doi.org/10.1016/j.sapharm.2018.04. 002. 29. Abouk R, Pacula RL, Powell D. Association between state laws facilitating pharmacy distribution of naloxone and risk of fatal overdose. JAMA Intern. Med. 2019;179(6):805. https://doi.org/10.1001/jamainternmed.2019.0272. 30. Do V, Behar E, Turner C, Geier M, Coffin P. Acceptability of naloxone dispensing among pharmacists. J Pharm Pract. September 2018:089719001879846https://doi. org/10.1177/0897190018798465. 31. Larochelle MR, Bernstein R, Bernson D, et al. Touchpoints – opportunities to predict and prevent opioid overdose: a cohort study. Drug Alcohol Depend. 2019;204:107537. https://doi.org/10.1016/J.DRUGALCDEP.2019.06.039. 32. Famiyeh I-M, MacKeigan L, Thompson A, Kuluski K, McCarthy LM. Exploring pharmacy service users' support for and willingness to use community pharmacist prescribing services. Res Soc Adm Pharm. 2019;15(5):575–583. https://doi.org/10. 1016/j.sapharm.2018.07.016.
This work was supported by the Agency for Healthcare Research and Quality (1R18HS024021-01). The sponsor was not involved in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. Acknowledgments We would like to thank Abigail Tapper, Brianna Baloy, Rachel Plotke and Carlie Alfaro for their assistance with data collection. References 1. Drug Overdose Deaths | Drug Overdose | CDC Injury Center. https://www.cdc.gov/ drugoverdose/data/statedeaths.html. Accessed May 12, 2019. 2. Opioid overdose reversal with naloxone (Narcan, Evzio) | national institute on drug abuse (NIDA). https://www.drugabuse.gov/related-topics/opioid-overdose-reversalnaloxone-narcan-evzio, Accessed date: 12 May 2019. 3. 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. https://doi.org/10.1136/bmj.f174. 4. Nielsen S, van Hout MC. What is known about community pharmacy supply of naloxone? A scoping review. Int J Drug Policy. 2016;32:24–33. https://doi.org/10. 1016/J.DRUGPO.2016.02.006. 5. Freeman PR, Hankosky ER, Lofwall MR, Talbert JC. The changing landscape of naloxone availability in the United States, 2011 – 2017. Drug Alcohol Depend. 2018;191:361–364. https://doi.org/10.1016/j.drugalcdep.2018.07.017. 6. Guy GP, Haegerich TM, Evans ME, Losby JL, Young R, Jones CM. Vital signs: pharmacy-based naloxone dispensing — United States, 2012–2018. MMWR (Morb. Mortal. Wkly. Rep.). 2019;68(31):679–686. https://doi.org/10.15585/mmwr. mm6831e1. 7. Life-saving naloxone from pharmacies | VitalSigns | CDC. https://www.cdc.gov/ vitalsigns/naloxone/index.html, Accessed date: 19 September 2019. 8. Green TC, Dauria EF, Bratberg J, Davis CS, Walley AY. Orienting patients to greater opioid safety: models of community pharmacy-based naloxone. Harm Reduct J. 2015;12(1) https://doi.org/10.1186/s12954-015-0058-x. 9. Wu C, Brown T, Moreno JL. Access to naloxone at community pharmacies under the Massachusetts state-wide standing order. J Am Pharm Assoc. 2019. https://doi.org/ 10.1016/J.JAPH.2019.11.009 0(0). 10. Brownlee K, Minnier TE, Martin SC, Greenhouse PK. A paradigm shift toward systemwide quality improvement education: meeting the needs of a rapidly changing health care environment: meeting the needs of a rapidly changing health care environment. Qual Manag Health Care. 2013;22(1):25–35. https://doi.org/10.1097/ QMH.0b013e31827deaaa. 11. Meyerson BE, Agley JD, Davis A, et al. Predicting pharmacy naloxone stocking and dispensing following a statewide standing order, Indiana. Drug Alcohol Depend. 2016;188:187–192. https://doi.org/10.1016/J.DRUGALCDEP.2018.03.032 2018. 12. Carpenter DM, Dhamanaskar AK, Gallegos KL, Shepherd G, Mosley SL, Roberts CA. Factors associated with how often community pharmacists offer and dispense naloxone. Res Soc Adm Pharm. July 2018. https://doi.org/10.1016/j.sapharm.2018.07. 008. 13. Rudolph SE, Branham AR, Rhodes LA, Hayes H, Moose JS, Marciniak MW. Identifying barriers to dispensing naloxone: a survey of community pharmacists in North Carolina. J Am Pharm Assoc. 2018. https://doi.org/10.1016/J.JAPH.2018.04. 025 0(0).
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Contents lists available at ScienceDirect
Research in Social and Administrative Pharmacy journal homepage: www.elsevier.com/locate/rsap
Pharmacy leaders’ beliefs about how pharmacies can support a sustainable approach to providing naloxone to the community Elizabeth Donovana,∗, Jeffrey Bratbergb, Janette Bairdc, Dina Bursteinc, Patricia Cased, Alexander Y. Walleye, Traci C. Greenc,f,g a
Department of Psychology, Simmons University, Boston, MA, USA College of Pharmacy, University of Rhode Island, RI, USA c Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA d Institute for Urban Health Research and Practice, Northeastern University, Boston, MA, USA e Clinical Addiction Research Education Unit, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA f Department of Epidemiology, Alpert Medical School of Brown University, Providence, RI, USA g Boston Medical Center Injury Prevention Center, Boston University School of Medicine, Department of Emergency Medicine, Boston, MA, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Pharmacy Naloxone Opioid Overdose
Background: Naloxone is an antidote to opioid overdose, and community pharmacies nationwide now provide broad access to this medication. Objective: The aim of this qualitative study was to understand how leaders in pharmacy organizations perceive pharmacies and pharmacy staff can optimize dispensing of naloxone. Methods: In-depth interviews were conducted with 12 pharmacy leaders in Massachusetts and Rhode Island. Participants were recruited from three types of community pharmacies: (1) chain; (2) independent; and (3) hospital outpatient. Theory-driven immersion crystallization, using Brownlee et al.'s model of healthcare quality improvement, was used to inform coding of the interview data, with predetermined categories of staff; organization; and process. Results: Five main themes were identified: (1) Importance of staff training to increase comfort; (2) Strength through coordination of efforts; (3) Pharmacy as a community leader in the opioid crisis; (4) Persisting stigma; and (5) Ongoing workflow challenges. Conclusions: The results uniquely reflect the experiences and insights of pharmacy leaders implementing public health initiatives during the opioid crisis and can be used for gaining insight into how pharmacists can efficiently provide naloxone to their communities.
Introduction Drug overdose is the leading cause of unintentional death in the United States. In 2017, 70,237 overdose deaths occurred in the United States, the majority (68%) of which involved an opioid.1 Naloxone restores normal respiration to a person whose breathing has slowed or stopped because of opioid overdose.2 When naloxone and overdose education are available to potential bystanders in the community, overdose deaths decrease in those communities.3 Pharmacists are well-positioned to provide naloxone to their community.4 Using claims data, Freeman, et al.5 reported an 8-fold increase in the number of naloxone prescriptions in the US between the end of 2015 to mid-2017, from less than 20,000 to nearly 90,000 prescriptions. Using the same data, Guy, et al.6 further reported a doubling of ∗
2017 numbers to 2018. This is in part because most states now have laws that allow pharmacists to dispense naloxone without a prescription (standing orders).7 For example, in Rhode Island, pharmacy-based naloxone became available starting in 2013 via a statewide collaborative practice agreement with one community pharmacy chain (10% of pharmacies), and in 2014 via standing order.8 The innovation spread to neighboring Massachusetts, which adopted standing orders in 2014.9 Yet, as with other healthcare initiatives, changes must be made at the staff, process and organization level to efficiently dispense naloxone and meet community needs.10 Currently, factors that impact uptake of pharmacy-based naloxone (PBN) include status as a chain pharmacy and number of full-time licensed pharmacists at a location,11 as well as adequacy of pharmacist training,12,13 time constraints, and perceived lack of patient comprehension about naloxone administration.12
Corresponding author. Department of Psychology, Simmons University, 30 Fenway, Boston, MA, 02115, USA. E-mail address: [email protected] (E. Donovan).
https://doi.org/10.1016/j.sapharm.2020.01.006 Received 13 June 2019; Received in revised form 11 January 2020; Accepted 13 January 2020 1551-7411/ © 2020 Elsevier Inc. All rights reserved.
Please cite this article as: Elizabeth Donovan, et al., Research in Social and Administrative Pharmacy, https://doi.org/10.1016/j.sapharm.2020.01.006
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crystallization (I/C), an approach that involves thoroughly examining, and reflecting on, qualitative data until reportable interpretations are reached.19 We chose this inductive approach so as to remain open to emerging themes, while acknowledging that we approached the data with theoretical assumptions, thus we explicitly incorporated Brownlee et al.’s model of healthcare quality improvement10 as a framework to guide our interpretation of the data. Recognizing that our own backgrounds as researchers would inevitably impact our interpretation of the findings,20 we incorporated a range of researcher perspectives into the procedure: two researchers with different backgrounds (psychology and epidemiology) conducted the main analysis; soliciting feedback from other team members (backgrounds were epidemiology, public health, psychology, medicine, and pharmacy) as data analysis progressed. To further enrich our understanding, we also discussed interpretations of the data in the context of the wider literature (e.g.,11–13,21,22). In combination, these strategies were adopted to reduce bias resulting from using a single perspective.23 The specific steps to data analysis were as follows: The two main analysts (ED and TCG) independently reviewed the recordings and transcripts; They then agreed upon broad codes based on factors identified by Brownlee et al.10 as contributing to healthcare quality and improvement (Table 1) and independently applied the codes to the interview data; ED and TCG met to discuss application of the codes to the interview data, resolving all discrepancies (e.g., whether copay difficulties represent a workflow challenge) through discussion. To identify themes, ED and TCG independently immersed themselves in the coded data, rereading the text and noting patterns in data within codes (e.g., patterns and possible themes associated with data coded as relating to “Staff”), as well as patterns seen across codes; They then met to discuss emerging themes, making frequent references to the wider literature (e.g.,11–13,21,22) to try to gain a rich understanding of the phenomena being discussed by the interviewees. Finally, insights were brought to larger team meetings to solicit feedback from team members with different backgrounds and to discuss alternative ways of interpreting data. ED and TCG incorporated the team’s feedback into the analysis and agreed on a small set of themes associated with each code. Through discussion, ED and TCG finalized labels for the themes to describe the range of ideas that the theme was intended to represent.
The aim of this qualitative study was to understand how leaders in pharmacy organizations perceive pharmacies and pharmacy staff can optimize dispensing of naloxone. Method Study design As part of a demonstration study14–17 conducted from 2015 to 2019, we collaborated with independent, outpatient hospital, and retail chain pharmacies to determine the best ways to provide pharmacy naloxone to people at risk of opioid overdose. In the final years of the project (2018 and 2019), in-depth, semi-structured interviews were conducted with leadership from the study pharmacies in Massachusetts and Rhode Island. Recruitment Members of the research team (TCG and JPB) approached via phone or email 12 pharmacists (> 18 years of age, English speaking, and in a leadership role— owner of independent pharmacy or in an administrator role at a chain or outpatient hospital pharmacy —with direct knowledge of PBN initiatives). To understand a range of perspectives, leaders were purposefully recruited from the three types of community pharmacies with standing orders represented in a larger study being conducted with a range of stakeholders to determine the best way to provide naloxone in the pharmacy setting: (1) chain; (2) independent; and (3) urban hospital outpatient. Participants provided informed verbal consent and did not receive compensation. The institutional review boards of Boston University Medical Campus and Rhode Island Hospital approved study protocols. Data collection From December 2018 to February 2019, three trained qualitative interviewers (PhD; MPH; PharmD), conducted 30–45-min, audio-recorded audio phone interviews with pharmacy leaders. Interviews were transcribed and deidentified. Given our interest in how pharmacies approach creating a sustainable method of disseminating naloxone into the community, our semi-structured interview guides were informed by Brownlee et al.’s model of healthcare quality improvement10 which identifies three factors fundamental to innovation sustainability: staff (including staff engagement, training and leadership), organization (including infrastructure and culture that help to sustain change) and process (including an organization's ability to adapt to an innovation, measure its success and foster value among employees). Authors ED and TCG created broad, open-ended questions to address each of the three main categories in the model, as well as stigma, as stigma within the pharmacy is well-established.17,18 The research team (PharmD, PhDs, MDs) reviewed the questions and suggestions were incorporated into the interview guide. See Table 1.
Results Twelve pharmacy leaders (Pharm.D.s) participated (Table 2) and five main themes were identified (Table 1). Data from both states are presented together as no state differences were observed. Importance of staff training to increase comfort Almost all interviewees stressed the importance of helping staff to overcome stigma and decrease hesitancy to offering naloxone. Delivery of information varied depending on pharmacy type, for example, pharmacy leaders in chain pharmacies described trying to reach these goals through standardized trainings:
Data analysis
Breaking down the pharmacists' thinking [through standardized trainings] that it is just for IV illicit drug users. Really it is for the elderly
Data analysis was conducted using theory-driven immersion/ Table 1 Key factors contributing to healthcare quality and improvement and associated interview themes Key factor
Example interview question
Interview theme
Staff Organization
Tell me about training within your organization to engage staff around pharmacy-based naloxone? Do you feel there has/has not been sufficient support from within the organization for initiatives like this? How do people in your institution view the work of your pharmacy with respect to naloxone? Tell me about any changes that still need to be made to optimize naloxone distribution Tell me about stigma in the pharmacy
Importance of staff training to increase comfort Strength through coordination of efforts
Process Additional theme
2
Pharmacy as a community leader in the opioid crisis Ongoing workflow challenges Persisting stigma
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of coordination of efforts among independent pharmacies to get more naloxone into the community.
Table 2 Participant characteristics (n = 12) Frequency Gender Male Female Pharmacy type Chain Independent Hospital Years in current role 1-4 5-8 9-12
I think everyone [independent pharmacies] is working towards the same goal [naloxone provision], but I think everyone is working in their own silo. I think it would be much more effective if we found a way to work together. – P07, independent pharmacy leader
7 5
Another independent pharmacy leader expressed that they found success in collaborating with doctors who co-prescribe naloxone to patients at risk of overdose, while also acknowledging that their current approach to educating patients may not be feasible in the long-term.
5 3 4 5 3 4
I'm finding the combination of the co-prescription with us having that conversation [with the patient], almost all of those patients leave with it … I'm as tapped out as I can get in terms of time dedicated to having that conversation with people, like if I dedicated any more time to it, it would not be a sustainable model – P04, independent pharmacy leader
population that is also taking some high dose opioids. Or maybe it's for that mom that's standing in front of you that has two teenagers at home. So how do we get pharmacists to think about patients that need naloxone in different ways. – P11, chain pharmacy leader
Pharmacy as a community leader in the opioid crisis
A leader from an independent pharmacy described an environment that encouraged staff to ask for assistance in improving naloxone provision.
As well as finding partnerships to support ways to optimize dispensing naloxone, Brownlee et al.’s model10 also emphasizes the importance of recognizing the values embedded in the organizational cultures. Most interviewees expressed the importance to the mission of the pharmacy of being a public health leader in the community during the opioid crisis. Beyond their naloxone programs, leaders at chain pharmacies described talking to students in schools about prescription drug safety; holding talks for parents; offering workplace lunch and learns and launching drug disposal programs. One pharmacy leader described the benefits that pharmacists derive from talking with school children, and how it, in turn, affects their practice.
I think there's still a level of nervousness about this [naloxone provision] so usually they'll come to me first, we'll do a little role play of what they are going to say…we don't necessarily have a formal training [beyond the hour of training required as part of the Massachusetts standing order], more like on the fly. – P07, independent pharmacy leader Brownlee et al. emphasize that sustainable changes are not imposed but are done with staff involvement.10 A leader from a hospital pharmacy described how trainings resulted in a more comfortable and engaged staff.
Our pharmacists feel very, very connected to the issue … It's good for them also to see local teens, and their ability to be able to prevent opioid misuse, and then apply that in terms of their filters as they fill prescriptions. –P11, chain pharmacy leader
There was almost like a competition in the pharmacy, who could engage the most patients to receive a [naloxone] kit – P02, hospital pharmacy leader
Leaders at hospitals typically described the hospital at large as their community and participated or led on-campus events such as promoting recovery month; naloxone training; and displaying signs about naloxone that served to cement their role as public health leaders.
Strength through coordination of efforts External efforts such as state regulations and federal initiatives (e.g., the Surgeon General's Health Advisory,24) as well as increased co-prescribing of naloxone by physicians, were cited by many as helping to “hardwire” efforts to streamline and optimize dispensing of PBN. Within their organizations, strength from internal collaborations was also cited as important. Leaders at chain pharmacies described successful coordination of efforts across corporate teams within their pharmacy organization, such as professional practice; corporate communications, government affairs; regulatory affairs; training; marketing and legal.
We're pretty much in ground zero of this epidemic here in Boston, MA, so when you come on our campus, you will have some kind of contact, some kind of discussion or some kind of information that lets you know- either directly or in passing- that we are here to help with substance use disorder—P01, hospital pharmacy leader In contrast, a leader at an independent pharmacy described frustration at being unable to spend time in the community in part because of a lack of coordination between independent pharmacies, but also time constraints, and lack of compensation for counseling patients about naloxone.
“Everyone's really supportive and know it's [their naloxone program] important. It's [opioid overdose crisis] not going to go away. – P12, chain pharmacy leader
Persisting stigma All the interviewees perceived that stigma of addiction was decreasing as a result of growing public awareness as well as efforts to train pharmacists; still, there was acknowledgement that the presence of stigma in the pharmacy is hard to measure and remains an ongoing challenge. One leader from a hospital pharmacy described positive change on the hospital campus as a result of efforts to reduce stigma associated with addiction.
One interviewee from a hospital described the importance of the role the pharmacy in supporting other groups providing naloxone, such as the hospital's emergency department and substance use disorder clinic. It's really about removing barriers that may come up, complementing their programs versus being a barrier … We could say, ‘we can't have you having special treatment.’ Instead of taking that route we say “What are your sore points, and how can we make sure we close those gaps for you and your patient and help your program and be successful” – P10, hospital pharmacy leader
So I think a lot of patients who come here know that we accept [people who use drugs] … so they feel more at home here and I think all the communication from the state, the city, and of course here on campus,
But independent pharmacy leaders described frustration at the lack 3
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about harm reduction; need for focused efforts addressing risk communication to diminish stigma;importance of increasing proactive naloxone offers25; challenges with health insurance21,22; importance of coprescribing mandates,26 and calls for reimbursing pharmacy opioid safety conversations, including naloxone offer and overdose education.21,22 Our study furthers understanding of these systems-level challenges and describes setting-specific considerations. The roles of community pharmacies, pharmacists, and pharmacy leaders in harm reduction and public health remain understudied and underutilized.27 Within the current opioid crisis, future studies may address challenges to dispensing naloxone by focusing on the content and delivery of pharmacist training28; results from our study suggest that considering ways to tailor training to the setting may be important. It is also important to examine outcome differences between states with different pharmacy naloxone prescribing laws29; document pharmacists’ perception of stigma30; develop ways to measure stigma, which pharmacists in our study described as difficult, and understand how pharmacists can optimize naloxone dispensing at health-system touchpoints with people at high risk of overdose.31 Importantly, there should be continued examination of how low- and high-risk populations use pharmacies for naloxone and harm reduction..32 Pharmacists in our study identified reaching caregivers of people at risk for overdose as an ongoing challenge. It is important to acknowledge factors that can impact the quality of qualitative research, including how researchers' beliefs impact the research process; appropriateness of sampling; and the process of organizing and interpreting data.20 Undoubtedly, interpretation of the data was influenced by our past experiences; however, we made efforts to reduce bias by involving multiple researchers, with different backgrounds (epidemiology, public health, psychology, medicine, pharmacy) throughout the research process (e.g., during development of the codebook and discussion of the findings). During the data analysis phase, the researchers supplemented each other's interpretations of findings with discipline-specific knowledge, research articles, and experiences, which helped the group to gain a deeper understanding of the phenomena described by the pharmacy leaders. The research team used a purposeful sampling strategy to recruit pharmacy leaders from a range of settings to include diversity of experiences in our descriptions. Still, we acknowledge that while our descriptive findings may be helpful for gaining insight into pharmacy leaders' perspectives on ways to optimize dispensing naloxone, the pharmacy leaders in our study did not represent all possible settings, for example, hospitals in rural areas, where other concerns may be relevant to dispensing naloxone. Finally, we acknowledge that it can be challenging to fully convey all the nuances involved in analyzing qualitative interview data but we madeefforts to address this by documenting our theory-driven IC approach; explicitly noting how Brownlee et al.’s model was used throughout the research process, and describing the specific steps involved in data analysis. Community pharmacists and pharmacies are a critical source of naloxone and results of this study suggest that a continued focus on overcoming challenges to naloxone provision are warranted. This study may be helpful for gaining insight into how pharmacists working in different settings can address barriers to efficiently providing naloxone to their communities.
when you step on the [hospital] campus really help break that stigma if you will.—P01, hospital pharmacy leader In contrast, a pharmacy leader from an independent pharmacy described ongoing stigma within the context of serving a small community. Because of our community situation, that small, tightknit close community, a lot of the customers that we see are close to us and our families and vice versa … that makes people hesitant to get it [naloxone]. – P08, independent pharmacy leader One leader from a chain pharmacy described difficulty in measuring any change in stigma in the pharmacy. The leader described relying on changes in volume of negative customer feedback and reports from “secret shoppers” in the community as a possible indicator of reduced stigma: I do see less and less complaints [about PBN] coming in; it was more frequent a year ago. And also, there is less feedback from [community] coalitions saying, ‘we went into stores and your pharmacist didn't know about it’. We still get them, but not as many. – P12, chain pharmacy leader
Ongoing workflow challenges Consistent with Brownlee et al.’s10 emphasis on understanding the workflow of a problem, all interviewees described an evolving process of naloxone provision, with barriers still to overcome. Some interviewees named insurance as a barrier to efficiently dispensing naloxone. When someone is interested in obtaining a naloxone kit, we usually bill out at least the two nasal options and the third IM option if they're interested; the only way to figure out what's covered and what's not is to bill all three out and then determine from there what's happening. – P07, independent pharmacy leader Another reported that insurance copays continue to slow naloxone uptake for some patients. As long as the co-pay was zero, they were all about it. If it's anywhere $25 or more, people are just like, “I care, but I don't care that much.” – P04, independent pharmacy leader Others described the importance of pharmacists taking more steps to proactively offer naloxone to those at risk for overdose who have previously refused an offer of naloxone. In those instances where people sort of refuse, I don't know that we are really going back and revisiting it with them … maybe like once a quarter we could follow up with them and see how it's going and if they are now interested in getting the kit – P07, independent pharmacy leader Others described workflow challenges in identifying and offering naloxone to a crucial but hard-to-identify population: caregivers of people using opioids. Caregivers. Figuring out a way to get to these people because they are the people who are actually going to be using it and probably would make the most difference if we had it in their hands – P12, chain pharmacy leader
CRediT authorship contribution statement Elizabeth Donovan: Formal analysis, Writing - review & editing, Writing - original draft. Jeffrey Bratberg: Formal analysis, Writing review & editing, Writing - original draft. Janette Baird: Formal analysis, Writing - review & editing. Dina Burstein: Formal analysis, Writing - review & editing. Patricia Case: Formal analysis, Writing review & editing. Alexander Y. Walley: Formal analysis, Writing review & editing. Traci C. Green: Formal analysis, Writing - review & editing, Conceptualization, Writing - original draft.
Discussion This is the first study to examine the perspectives of pharmacy leaders on efforts to efficiently provide naloxone to their communities. Results from our study reflect a high level of awareness among pharmacy leaders about challenges to naloxone provision in their varied practice settings, including need for graduate pharmacy education 4
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Declaration of competing interest
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This work was supported by the Agency for Healthcare Research and Quality (1R18HS024021-01). The sponsor was not involved in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. Acknowledgments We would like to thank Abigail Tapper, Brianna Baloy, Rachel Plotke and Carlie Alfaro for their assistance with data collection. References 1. Drug Overdose Deaths | Drug Overdose | CDC Injury Center. https://www.cdc.gov/ drugoverdose/data/statedeaths.html. Accessed May 12, 2019. 2. Opioid overdose reversal with naloxone (Narcan, Evzio) | national institute on drug abuse (NIDA). https://www.drugabuse.gov/related-topics/opioid-overdose-reversalnaloxone-narcan-evzio, Accessed date: 12 May 2019. 3. 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. https://doi.org/10.1136/bmj.f174. 4. Nielsen S, van Hout MC. What is known about community pharmacy supply of naloxone? A scoping review. Int J Drug Policy. 2016;32:24–33. https://doi.org/10. 1016/J.DRUGPO.2016.02.006. 5. Freeman PR, Hankosky ER, Lofwall MR, Talbert JC. The changing landscape of naloxone availability in the United States, 2011 – 2017. Drug Alcohol Depend. 2018;191:361–364. https://doi.org/10.1016/j.drugalcdep.2018.07.017. 6. Guy GP, Haegerich TM, Evans ME, Losby JL, Young R, Jones CM. Vital signs: pharmacy-based naloxone dispensing — United States, 2012–2018. MMWR (Morb. Mortal. Wkly. Rep.). 2019;68(31):679–686. https://doi.org/10.15585/mmwr. mm6831e1. 7. Life-saving naloxone from pharmacies | VitalSigns | CDC. https://www.cdc.gov/ vitalsigns/naloxone/index.html, Accessed date: 19 September 2019. 8. Green TC, Dauria EF, Bratberg J, Davis CS, Walley AY. Orienting patients to greater opioid safety: models of community pharmacy-based naloxone. Harm Reduct J. 2015;12(1) https://doi.org/10.1186/s12954-015-0058-x. 9. Wu C, Brown T, Moreno JL. Access to naloxone at community pharmacies under the Massachusetts state-wide standing order. J Am Pharm Assoc. 2019. https://doi.org/ 10.1016/J.JAPH.2019.11.009 0(0). 10. Brownlee K, Minnier TE, Martin SC, Greenhouse PK. A paradigm shift toward systemwide quality improvement education: meeting the needs of a rapidly changing health care environment: meeting the needs of a rapidly changing health care environment. Qual Manag Health Care. 2013;22(1):25–35. https://doi.org/10.1097/ QMH.0b013e31827deaaa. 11. Meyerson BE, Agley JD, Davis A, et al. Predicting pharmacy naloxone stocking and dispensing following a statewide standing order, Indiana. Drug Alcohol Depend. 2016;188:187–192. https://doi.org/10.1016/J.DRUGALCDEP.2018.03.032 2018. 12. Carpenter DM, Dhamanaskar AK, Gallegos KL, Shepherd G, Mosley SL, Roberts CA. Factors associated with how often community pharmacists offer and dispense naloxone. Res Soc Adm Pharm. July 2018. https://doi.org/10.1016/j.sapharm.2018.07. 008. 13. Rudolph SE, Branham AR, Rhodes LA, Hayes H, Moose JS, Marciniak MW. Identifying barriers to dispensing naloxone: a survey of community pharmacists in North Carolina. J Am Pharm Assoc. 2018. https://doi.org/10.1016/J.JAPH.2018.04. 025 0(0).
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