Knowledge, practice and attitudes regarding substance use disorder treatment and harm reduction strategies among pharmacists: a scoping review protocol

Abstract

Introduction

Pharmacists provide a spectrum of services and comprehensive medication management for patients with substance use disorders (SUDs) with many providing timely and increased access to care for patients. Prior studies have evaluated other healthcare professionals’ attitudes, knowledge and practice in regard to SUD treatment and harm reduction services. However, no reviews to date summarise the available literature on the attitudes, knowledge and practice in regard to SUD treatment and harm reduction services from the pharmacist perspective. This scoping review aims to systematically map the extent, range and nature of available evidence and identify and describe gaps in knowledge, practice and attitudes towards SUD treatment among pharmacists with the goal of providing information for meaningful integration of pharmacists into SUD care.

Methods and analysis

We will use the framework proposed by Arksey and O’Malley (2005) updated with recommendations by Levac et al (2010) and the Joanna Briggs Institute (2020). The protocol is registered via Open Science Framework (https://osf.io/92dek). We will search for peer-reviewed literature containing empirical evidence investigating SUD treatment or harm reduction with outcomes pertaining to the knowledge, practice or attitudes of pharmacists. Findings will be guided and assessed by research objectives and summarised using descriptive statistics and thematically for quantitative and qualitative findings, respectively. This review will be conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews.

Ethics and dissemination

Our findings will provide crucial information and support for future interventions and programmes which aim to meaningfully integrate pharmacists into SUD care. We will disseminate findings at conferences and publish in a peer-reviewed journal. In addition, we will integrate feedback on search strategy, data extraction and our dissemination approach from multidisciplinary collaborators including those within our team’s institution and outside experts with clinical or administrative knowledge in SUD care.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This review protocol outlines a comprehensive search strategy focused on the role of pharmacists in integrating substance use disorder treatment and harm reduction approaches.

• The proposed scoping review will not assess effectiveness of the interventions or quality of the included studies since this precludes the objective of scoping review methods which is to identify current gaps in knowledge.

• This proposed scoping review will establish an essential knowledge base on which to build future interventions that meaningfully integrate pharmacists into substance use disorder treatment and care.

Introduction

Pharmacists can play an integral role in implementing evidence-based prevention and treatment for substance use disorders (SUD) due to their specialised knowledge of medications and greater accessibility to patients compared with other health professionals. Pharmacists can screen and refer patients with SUD to treatment, counsel patients, provide SUD prevention and treatment education, and deliver comprehensive medication management to ensure patients receive individualised, appropriate, effective and safe medications alongside other co-occurring mental or physical conditions.^1–5 Pharmacists are particularly essential for reaching vulnerable patients with SUDs living in rural areas where physicians are scarce and overburdened.^{1 6} Research has shown that pharmacists are effective at engaging, improving outcomes and reducing wait times for patients with SUDs and patients report positive attitudes when pharmacists are included in their care team.^{1 7}

Awareness of the role that pharmacists can play in increasing access to SUD treatment has been growing over the years, with many states adopting initiatives aimed at leveraging the expertise of pharmacists to address the opioid epidemic.⁸ Most states allow pharmacists to dispense naloxone without a prescription, and several states have granted expanded scope of practice to pharmacists allowing them to prescribe and dispense medications like buprenorphine, an opioid partial agonist medication proven safe and effective in treating opioid withdrawal.⁸ Other states have collaborative practice agreements that integrate pharmacists into care teams managing patients with SUD by allowing pharmacists to initiate, modify or continue therapy for patients under the supervision of a prescribing provider.⁸

In addition to expanded clinical and prescribing roles, many pharmacists are also becoming integral in harm reduction, or a public health strategy aimed at minimising harms associated with injection drug use and empowering people who use substances (PWUS). Harm reduction strategies include, among others, an overall emphasis on reducing stigma, overdose reversal education and training, distribution of naloxone and fentanyl test strips, syringe and needle exchange programmes, safe injection sites and providing support and respect for PWUS beyond abstinence. Harm reduction services offered by pharmacists often include lessening the adverse consequences of drug use by dispensing naloxone, offering sterile injection supplies and providing information about safe injection.^{9 10} While treatment standards for SUDs and a harm reduction approach are known to be effective and cost-saving in mitigating and preventing harms associated with substance use,¹¹ they remain politically and socially controversial practices, even among some healthcare professionals.^{12 13} For instance, one study found that pharmacists had moral objections to provide sterile injection supplies to PWUS.¹⁴

Although prior work has evaluated other healthcare professionals’ attitudes, knowledge and practice with SUD treatment and harm reduction services, research focusing on pharmacists is limited. Typically, reviews have focused narrowly on pharmacist attitudes or knowledge regarding groups of pharmacotherapies (eg, medications for opioid use disorder)¹⁵ or specific harm reduction strategies.^{16 17} These reviews have found that pharmacists are generally supportive of providing access to medications for opioid use disorder and hold positive attitudes towards harm reduction strategies; however, pharmacists report a lack of training, time, remuneration and sometimes hold stigmatising attitudes towards patients with SUD.^15–17

In order to understand how pharmacists’ roles can be expanded across a spectrum of SUD treatment and harm reduction strategies, we have decided to conduct a scoping review, which is specifically meant to map and summarise available literature, in order to understand pharmacist knowledge, practice and attitudes towards SUD treatment generally and ways in which expertise or stigma may influence access towards SUD treatment, implementation of harm reduction strategies or linking patients to recovery support services. Without adequate information on pharmacist-led SUD treatment and harm reduction strategies, it is difficult to plan for meaningful integration of pharmacists into SUD care.

Objective

The objective of this scoping review is to systematically map the extent, range and nature of available evidence and identify and describe gaps in knowledge, practice and attitudes regarding SUD treatment among pharmacists. This scoping review will establish an important knowledge base for future design and implementation of pharmacist-led SUD treatment and harm reduction interventions.

Methods and analysis

We structure the stages of our scoping review using the framework proposed by Arksey and O’Malley¹⁸ updated with improvements recommended by Levac et al ¹⁹ and the Joanna Briggs Institute (JBI).²⁰ The Arksey and O’Malley framework proposes organising the scoping review process into six stages: (1) identifying a research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; (5) collating, summarising and reporting the results; and (6) consultation. This scoping review protocol was further informed by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for Scoping Reviews.²¹ The protocol is registered via Open Science Network (https://osf.io/92dek).

Stage 1: identifying the research question

Our research question was developed using Levac et al’s¹⁹ enhanced framework, which suggests starting broad in scope and then refining a scope of inquiry aligned with the main purpose of the review. Our review question is ‘What is known about the knowledge, practice, and attitudes regarding SUD treatment and harm reduction strategies among pharmacists?’ We will rely on the Substance Abuse and Mental Health Services Administration definition of SUD as ‘the recurrent use of alcohol and/or drugs caus[ing] clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school or home’.²² For the purposes of our review, SUD treatment will encompass medication-assisted therapy, behavioural interventions and digital therapeutics. Although related, harm reduction is distinct from SUD treatment as a model-of-care delivery aimed at reducing negative consequences of drug use. For this review, we will include well-studied harm reduction strategies including safe injection sites, syringe exchange programmes, overdose education and naloxone distribution.^{23 24} In addition, we will include any strategies to link PWUS to other healthcare and recovery support services like infectious disease testing, housing support and connections to culturally and linguistically appropriate services.²⁵ Given the iterative nature of scoping reviews, we may refine and clarify our research question as we are becoming familiar with the available body of evidence.

A preliminary search of PubMed revealed one scoping review from 2012 focusing on pharmacist practices and attitudes about harm reduction approaches broadly,¹⁷ but did not specify SUDs or SUD treatment. Two other scoping reviews were found assessing pharmacist attitudes towards naloxone and medications for opioid use disorder,^{15 16} but did not examine other SUDs or alternative SUD treatments, harm reduction strategies or linkages to recovery services. Therefore, our review attempts to answer the following questions:

1. What is known about pharmacist knowledge and experience of SUDs that may impede or facilitate SUD treatment or harm reduction strategies?

2. What are the characteristics of pharmacy practice that impede or facilitate SUD treatment or harm reduction strategies?

3. What is known about pharmacist attitudes, including stigma, regarding SUDs or PWUS that may impede or facilitate SUD treatment or harm reduction strategies?

4. How are pharmacists understood by other clinical team members in regard to their role in SUD treatment or harm reduction strategies?

Per the Population, Concept and Context mnemonic recommended for scoping reviews, these questions clearly state the population (pharmacists), concept (SUD and harm reduction) and context (care of SUD or PWUS patients) of our planned review.²⁰

Stage 2: identifying relevant studies

We will conduct a comprehensive review of the current literature using a search strategy developed alongside an academic librarian (JS) and guided by JBI²⁰ recommendations. Initially, we searched several databases of peer-reviewed journals including Medline (PubMed), PsychINFO, Embase, ProQuest Health and Medical and ProQuest Psychology. The following combination of search and MeSH terms was used: “pharmacists,” “pharmacy,” “pharmacies,” “substance-related disorders,” “substance disorder,” “alcohol use disorder,” “stimulant use disorder,” “recover,” “rehab,” “harm reduction,” “supervised injection,” “supervised drug consumption,” “syringe service program,” “need exchange,” “drug overdose prevention,” “naloxone distribution”. This initial search resulted in 2968 studies. The search strategy for these databases is further detailed in the online supplemental appendix table 1). Finally, we will screen relevant research organisations for references such as the Veterans Affairs Clinical Pharmacy Practice Office and the National Institute on Drug Abuse. Our search strategy will be an iterative process as we engage with the current evidence base and consult with key collaborators (stage 6) which may result in additional search terms or sources being added to our approach. We will keep detailed documentation of our search strategy within Excel by tracking sources, search dates, key terms used and the number of references found to ensure our approach can be replicated. EndNote software will be used to organise, store and remove duplicate references.

Stage 3: study selection

Covidence software will be used by two independent reviewers to conduct an iterative screening process. First, titles and abstracts of all references will be screened using the inclusion and exclusion criteria outlined next. A pilot test of the first 50 articles will be done to ensure both reviewers are applying the review criteria consistently. Next, references deemed appropriate to include will be pulled for full-text review and screened for inclusion. Studies marked for final inclusion will be further assessed via ‘citation chaining,’ or reviewing sources cited within included references to determine if any references meet the inclusion criteria. Any conflicts arising from the initial reference, full-text or citation screening will be resolved via discussion with a third reviewer to assess alignment with inclusion and exclusion criteria.

Inclusion and exclusion criteria

Published English-language peer-reviewed literature containing empirical evidence investigating SUD treatment or harm reduction with primary or secondary outcomes pertaining to the knowledge, practice or attitudes of pharmacists will be eligible for inclusion. There will be no restrictions on time limit, population age, sex, region, country or pharmacist type. Commentaries, editorials, opinion pieces, case reports and case series will be excluded. Reviews will also be excluded; however, references cited within relevant reviews will be scanned to assess if references were missed.

Stage 4: charting the data

Data extraction from the full texts will be charted across the following variables using Excel: author(s), publication month and year, country, setting, objective(s), study design, study target population, patient target population, sample size, intervention(s), control, outcome(s), limitations, related to pharmacist knowledge, practice, or attitudes, key finding(s) and additional notes. These variables may be adjusted during the review process as necessary to include additional variables deemed worthy of inclusion or exclude variables that yield little information. An initial data extraction pilot will be done independently by two reviewers on a random sample of five studies and then compared with test for extraction consistency and variable applicability. Discrepancies in variable extraction will be resolved alongside a third independent reviewer. We will consult with our larger research team and seek additional expert feedback on refining and validating the final variables for inclusion. Final data extraction of relevant variables will be completed independently by two reviewers, with a third reviewer stepping in to resolve discrepancies in reporting.

Stage 5: collating, summarising and reporting results

Our analytical approach will be primarily narrative as guided by our research objectives. The initial synthesis will collate extracted data; quantitative data will be summarised using descriptive statistics as appropriate, and qualitative data will be summarised thematically. To align with our specific research questions, we will summarise key findings into tables or figures by grouping findings into those that assess outcomes related to (1) pharmacist knowledge, (2) practice and (3) attitudes. We will further attempt to delineate barriers and facilitators to SUD treatment or harm reduction strategies within each grouped outcome. Finally, we will discuss important implications for future research, including gaps in findings and potential policy impacts or recommendations. We will use the PRISMA diagram to illustrate the steps taken during the review process, including reporting the number of references included and excluded with associated reasons.

Stage 6: consultation

Aligned with Levac et al,¹⁹ we will include the consultation stage of Arksey and O’Malley’s¹⁸ scoping review framework to enable collaborator engagement and provide valuable feedback during each previous stage outlined earlier. We will rely on the expertise of our multidisciplinary colleagues within our team’s institution and outside experts, including pharmacists and patients, who have clinical and administrative knowledge of SUD treatment and care. The feedback we receive from these collaborators will ensure that a comprehensive search strategy is undertaken, results are accurately collated and our findings are interpreted and contextualised appropriately. All collaborators will be acknowledged in the final publication and during additional dissemination efforts such as conference presentations.

Patient and public involvement

None.

Anticipated timeline

Our anticipated timeline for completing each stage of the scoping review is detailed in table 1.

Table 1.

Anticipated timeline for scoping review activities

	Research month
	1	2	3	4	5	6
Stage 1: identifying the research question (completed)	X
Stage 2: identifying relevant studies	X	X
Stage 3: study selection		X	X
Stage 4: charting the data			X	X
Stage 5: collating, summarising and reporting results				X	X
Stage 6: consultation	X	X	X	X	X	X

Anticipated strengths and limitations

This proposed scoping review will be a comprehensive search attempting to collate all information on the knowledge, practice and attitudes of pharmacists regarding SUD treatment and harm reduction strategies. Our approach will follow recommended guidelines for scoping reviews and our results will be disseminated to the public, researchers and policy-makers in order to detail potential research gaps or inform policy. Since we are conducting a scoping review which precludes assessing effectiveness of interventions, we will not be assessing references for methodological quality or risk of bias. Due to resource and personnel constraints, only literature available in English will be assessed. However, through collaborations with key partners and disseminating our findings, we hope to learn from and reach contexts beyond those that we are able to formally include in our review.

Ethics and dissemination

Ethics approval is not a requirement for this review as no human research participants will be involved. All data will be obtained from publicly available documents, and no primary data will be generated. The review may be presented at local and national conferences and other relevant and appropriate platforms. In addition, we will share our findings by publishing in a peer-reviewed journal.

Ethics statements

Patient consent for publication

Not applicable.