Engaging Community Pharmacies in Practice-Based Research: Lessons from Opioid-Focused Research

Abstract

There is an established need to translate evidence-based practices into real-world practice. Community pharmacists and their corresponding pharmacies are well-positioned to be effective partners as researchers seek to study and implement practice-based research. Challenges exist when partnering with community pharmacies which can vary based on the study type, the nature of the community pharmacy, and stakeholder groups (i.e., patients, staff, leadership, physicians). This commentary seeks to describe these challenges and provide recommendations that can help mitigate and/or overcome these challenges. Recommendations are provided for team structure, communication, research tools/technology, motivational factors, workflow, and sustainability. These recommendations are based on the authors’ experience in partnering with community pharmacy for opioid-related research in a variety of study types, states, and pharmacy environments.

BACKGROUND

There has been an increasing interest in balancing the pursuit of new discoveries with translating those discoveries into real world practice. It takes 17 years, on average, for new evidence to become mainstream practice,^1,2 requiring an estimated 15+ years for 50% utilization of new evidence-based practices from landmark studies.³ Impacting this is the fact that the vast majority of patients receive care from somewhere other than the academic medical centers where the vast majority of evidence-based research practices are developed.⁴

By nature, clinical studies do not represent the settings and environment found in real world practice; one example is the use of strict inclusion and exclusion criteria that create an artificial sample of patients.¹ While these study designs certainly have their advantages and place in research, they can frustrate the implementation of the conclusions into real world practice which can hinder its spread and scale.^5,6 In contrast, practice-based research makes strategic sacrifices to internal validity in order to place emphasis on its external validity, namely the ability to replicate the intervention across other settings and regions.⁵

In the context of opioid use and misuse related research, important evidence-based practices have yet to become standard of practice. For example, despite the overwhelming evidence of benefit for and positive impact of medications for opioid use disorder (MOUD) in opioid use disorder (OUD), only 28% of patients with OUD report treatment with MOUD.⁷ Additionally, 62% of patients with OUD have concomitant mental health conditions, but only 24% of those patients report receiving mental health treatment.⁸ Community pharmacies also have lagged behind evidence-based practices with some areas lacking pharmacies willing to dispense MOUD therapies.⁹ Extending this area of practice-based research to community pharmacies may help accelerate the uptake of these evidence-based practices and subsequently improve patient outcomes.

Community pharmacies are highly accessible, with abundant sites in nearly every community in America.¹⁰ Approximately 95% of Americans live within 5 miles of a pharmacy,¹⁰ and patients frequent community pharmacies almost twice as often as physician offices.¹¹ Pharmacies are also highly efficient organizations capable of rapidly scaling evidence-based practices into most areas of the United States as evidenced by the rapid adoption and sustainment of pharmacy-based immunizations over the past two decades.¹² Moreover, pharmacists indicate their willingness to provide advanced roles, including offering behavioral interventions for opioid use disorder.¹³ Community pharmacists are the last touchpoint between the patient and a prescribed opioid and can therefore potentially serve several roles in facilitating safe opioid use, opioid use disorder care, and provision of medications for opioid use disorder.¹⁴

Despite these community pharmacy advantages, there are community pharmacy-specific barriers to implementation, operation, and sustainability. These challenges vary by study type, nature of the community pharmacy utilized, and stakeholder groups within and outside of the community pharmacy. This article seeks to describe these challenges and provide recommendations, based on the authors’ experiences, to mitigate and/or overcome these challenges. The authors hope this article will aid other research teams in more easily engaging with community pharmacies in opioid-focused research or practice-based research in general.

CHALLENGES AND SOLUTIONS – BY STUDY TYPE

During the past 15+ years, the authors have conducted different types of research studies with community pharmacies including pharmacists, technicians, administrators, and other pharmacy support staff/personnel.^15–22 These studies have included surveying pharmacy staff regarding their attitudes and beliefs regarding opioid misuse and interventions;²¹ screening patients for opioid misuse and or addiction related behaviors;^16,17,20 clinical trials for opioid misuse;^19,23 leveraging and utilizing prescription drug monitoring data;²⁰ and developing/testing clinical decision support tools for pharmacists to address opioid misuse or addiction related behaviors.²² The authors have gained critical insights regarding these various study types.

Studies that Screen Patients at the Pharmacy

The following are important considerations in studies that seek to screen patients at the point of opioid dispensing to identify: (1) incidence or prevalence of opioid related conditions, or (2) patients for inclusion for clinical trials.

Team structure.

To ensure efficient and regular communication channels, especially in studies involving multiple pharmacy locations, pharmacy leadership should identify a champion at each pharmacy who can be the primary point of contact. These champions are immensely helpful in facilitation of information, scheduling, and “boots-on-the-ground” perspectives and feedback to the study team. In many circumstances, these champions are also those who, often by default, end up implementing the screening with patients at the pharmacies. As a result, it is of paramount importance that the individual selected be reliable, confident in the topic being researched, and have some degree of motivation to see the project succeed at their pharmacy (e.g., financial incentive). In circumstances where resources allow, a modest stipend for the champion may help facilitate and offset any additional workload taken on by the champion. A pharmacist or a technician can be this champion. Technicians are often chosen as their responsibilities at the pharmacy can more easily be adapted. While pharmacists may have more knowledge of the respective research topics, given the responsibilities described above, the primary requirement of a champion is often their understanding of the pharmacy workflow/team which is knowledge that either a pharmacist or technician possess.

Communication support with patients.

A central challenge usually voiced by pharmacy staff is uncertainty regarding specific language to be used when engaging with patients regarding their use of opioids. Opioid medications can be a highly charged topic causing pharmacy staff to feel unsure and uncomfortable when communicating, and patients can feel defensive and threatened that their medications may be withheld.²⁴ Providing training and resources has been helpful to facilitate this communication, especially when research includes topics such as opioid medications. As researchers, preparing staff with the appropriate language and tools is key. The following communication tactics have been found to be helpful:

• Communicate the research as something the pharmacy is doing with all patients filling these types of medications—no individual patient should feel “singled out.”

• Communicate genuine interest and concern for patients’ health from the pharmacy staff, capitalizing on the already existing trust patients feel for the pharmacy team.

• Use language that invites the patient to learn more about the study, not participate in the study at that moment (the research team should enroll the patient; enrollment should not be completed by the pharmacy staff).

• Do not center communication on the specific patient or any inference that problematic behavior is suspected.

• Do not use pejorative words that stigmatize the patient, such as drug abuser, opioid misuser, addict, etc.^25,26

Communication tactics and example language can be printed and sized to fit on lanyards or the back of identification badges so staff can always have access to these materials. In circumstances where pharmacy staff do not use lanyards or identification badges, the authors have used long, narrow laminated cards attached to the side of computer monitors at the pharmacy.²⁷

Tools for the job.

Tools to help the pharmacy staff engage patients are also highly valuable. A common strategy is to supply the pharmacy team with a tablet device (connected to the internet either via a data plan or Wi-Fi) that has been preprogrammed by the research team to have the screening platform and screening survey as the only available application. This tablet can either be handed to the patient by the pharmacy staff, or a tablet stand can house the tablet at a location near the point of contact in the pharmacy and staff can simply direct the patient to the stand; when combined with signage, the use of a tablet and stand could potentially be used for passive recruitment, allowing patients to self-identify if they should fill out the screening. Any information the patient sees is designed to be brief, concise, and targeted to transmit patient contact information to a secure server that will allow the research team to contact the patient. The goal is not to store information on the tablet device but rather to connect the patient with the research team without overwhelming pharmacy staff. An advantage worth noting about the use of a tablet device is the ability to use technology to recruit and engage with patients that historically are underrepresented in research (e.g., patients with sensory disabilities, non-native speakers).

Another critical aspect of preparing the screening tool is working closely with Institutional Review Boards to ensure that pharmacy-based screening can be anonymous. This allows the research team to contact patients only when patients screen positive. The screening tool requests the patient to voluntarily input their contact information that will allow study staff (rather than the pharmacy staff) to contact them to provide study related information and possibly informed consent. However, to ensure patients are not counted twice in study consort flowcharts, patients create an anonymous identification code (usually based on last two letters of last name, last two digits of birth year, and last two digits of zip code).

Supplementing good will of pharmacy staff.

Even when pharmacy staff are engaged and adequately prepared to communicate with patients, enrollment goals will likely not be able to be met via pharmacy screening activities alone. In two clinical trials,^19,23 the authors have supplemented in-person patient recruitment efforts with active outreach to patients based on a retrospective review of medical/medication records. In one study, the research team advertised to individuals with an opioid use disorder noted in the medical record who also had a prescription for opioid medications.²³ In another study,¹⁹ the research team implemented a modified version of the opioid medication misuse algorithm published by Sullivan et al,²⁸ which only uses medication information, not medical information, to identify possible participants. In both cases, patients were mailed information about the opportunity for the respective studies, and in the latter study, they received a follow-up phone call. The study team envisions that text message advertising may be a feasible and more real-world substitute for mailed advertisements and have had positive experiences with this in other disease states within the community pharmacy setting.²⁹ Regardless, this medical record identification, outreach, and enrollment process has provided a meaningful way to identify patients for potential enrollment and should be considered a valuable resource. In addition, this method could be used by payors and systems mining patient data to identify individuals for possible pharmacist-led interventions.³⁰

In addition to supplementing patient identification efforts through record searching, the research team provides regular visits to the pharmacy sites, often with food and training materials. In the studies where there are multiple pharmacy sites, weekly and monthly newsletters are emailed to pharmacy leadership and site champions. Some studies have also offered small gift card incentives (i.e., $5 USD per screening completed) to staff for screening patients (regardless of the screen outcome).

The pharmacy workflow.

An incredibly important point that must continually be considered is the workflow of a community pharmacy. In working with studies that have an in-person screening option, being sensitive to what is asked of staff interacting with patients and the time involved is crucial. First, with executive and site leadership, it is critical to outline what is going to be asked of pharmacy staff and the time associated with these duties to gain or negotiate buy-in. Based on the authors’ experience, 1 to 2 minutes per patient is likely the most a study will be able to request. As was mentioned above, the communication must be concise and simple with next steps completed utilizing technology platforms (not the pharmacy staff); the research workflow should be designed to quickly and efficiently accomplish core intervention elements and not trigger long or charged conversations with patients about opioids. It is also important to ensure staff are well supplied with handouts or other promotional materials that are placed in convenient locations to readily distribute to patients; staff should never have to search for study-related resources. Since the point of the interaction at the pharmacy is to help the patient connect with the research staff (rather than pharmacy staff), pharmacy staff should be trained that it is acceptable and encouraged that patients be directed to call the research team if patients have questions and want to have longer conversations.

Studies that Leverage Prescription Monitoring Program Data

Conducting research that collects patient-reported outcomes that is subsequently merged with prescription drug monitoring program (PDMP) data is an immense opportunity to combine powerful sources of information to understand the health, wellbeing, and challenges experienced by patients. While each state has its own laws and requirements that can impact patient care,³¹ the following are general principles based on the authors’ research experience in 4 different states. In states that utilize the predominant vendor platform in the US, there is an avenue for research partnership; however, permission from state leadership (e.g., state pharmacy board) is needed to gain access to the data. The authors have had success working directly with the vendor to make use of their established relationships with state leaders; vendors have either made needed introductions to key leadership or have directly facilitated requests to the state.²⁰ Once permission is granted, the vendor can act as a broker to link and curate datasets for the research team to allow for protection of patient information and other data security measures.

In the case where there is not a vendor who can aid in the various aspects of data access and a research team must work directly with the state, it is important to begin these conversations extremely early in anticipation of data needs. Not only are state entities large and sometimes difficult to navigate in terms of identifying key decision makers, but these organizations are also often understaffed and running with short bandwidth to meet needs external to the day-to-day functions of their positions. Additionally, some circumstances require individual patient consent (potentially notarized) before respective patient data is shared. The research team must enact thoughtful, intentional, and detailed processes in order meet the requirements of data access. When dealing with vendors or states directly, it is best practice to arrange for “test” data mergers and exports to ensure quality and accurateness of information provided. An alternative to PDMP data is purchasing access to data from third-parties, but this data is limited as it is aggregate, less complete, and does not include real-time data.

Studies that Assess Pharmacy Staff Perceptions

Studies that seek to administer quantitative surveys or qualitative interviews of pharmacists or staff are highly valuable for advancing research within the field, even when these studies occur outside of a community pharmacy practice setting. Our experience has involved both surveying²¹ and interviewing³² community pharmacy staff and leaders.

For surveying, the most effective approaches we have identified have involved electronic means that leverage lists of pharmacists and technicians from state boards of pharmacy and professional licensing groups or associations. In most cases, there are fees associated and guidelines for accessing these lists. Our preferred method is working through the means in which our team can own the list, manage messaging and communication, control the timing of follow-up messages, and then calculate accurate response rates.

Alternatively, if the study requires surveying pharmacy staff at a particular organization, a multimodal approach has worked best. This includes working with organizational leadership to announce the survey and encourage participation, posting the online link to the survey on pharmacy software dashboards, and emailing the survey to either the general pharmacy or individual staff email accounts if available. In cases where email is unavailable or inconsistently used by pharmacy staff, facsimile of a study survey flyer including a QR code and survey web addresses has been used successfully to allow pharmacy staff to complete surveys anonymously on their personal smart phones.

In terms of interviews, if a team is working with a specific pharmacy or chain, relationships with managers or leaders can be leveraged to promote outreach to potential participants employed by these entities. Another highly effective method is attending state or national pharmacy conferences and setting up a table or purchasing an exhibitor booth that can be used as a space for recruiting interviewees and conducting interviews. Identifying interviewees usually requires a small team of qualitative interviewers and a team leader to attend these conferences to recruit via signage, availability sign-ups, and/or word-of-mouth approaches.

It is worth noting for survey studies (and other types of studies) that stigma may be a challenge for participant recruitment, communication, and study implementation. Addressing, or at least acknowledging, potential stigmatizing norms is important at the outset of the study.

CHALLENGES AND SOLUTIONS – BY STAKEHOLDERS

In addition to the distinct types of research that teams may want to undertake, there are consistent concerns that are expressed by various stakeholders that must be addressed.

Within Pharmacy Practice

“Patients will get mad at me.”

A common concern that is raised by many community pharmacy professionals is that patients will have negative reactions to them if asked about their opioid medications. The authors have conducted multiple studies engaging patients at point of dispensation, collectively screening more than 2,000 patients who are taking opioid medications.^20,23,33 To date, the research teams have not received a complaint from a patient nor have the staff at the dozens of pharmacies reported that patients have become upset with them. In fact, in the authors’ first study demonstrating screening feasibility,¹⁷ patients indicated they felt it was appropriate for pharmacists to have conversations with them about opioid medication use; no difference was observed when comparing responses between patients misusing opioids and those not misusing opioids.

“We are too busy to do one more thing.”

Pharmacy staff and leadership indicate that adding extra steps to their workflow is onerous and makes their work overwhelming. Some strategies to address this concern have been described above. Minimizing the impact of study procedures on workflow is a major endeavor throughout the research process. Regardless of streamlined processes or pharmacy buy-in/motivation, many interventions do require additional actions of the pharmacy staff. However, pharmacies should be motivated to proactively consider their opportunities to provide solutions to healthcare issues and practice-based research provides an effective avenue for pharmacies to partner to develop and evaluate these solutions. If not motivated to proactively consider opportunities, the harsh reality is that, due to legal ramifications, additional actions have come and will likely continue to come to community pharmacies regarding opioid medication dispensing. As the tide of litigation from states and other interested groups sweeps the nation,³⁴ pharmacies will have less control over what autonomous actions they take related to dispensing these medications. Hesitating to be proactive in patient engagement (i.e., because “staff are too busy”) may perpetuate and strengthen the case of the plaintiffs against community pharmacy on the whole.

“Who is going to pay for this?”

One of the consistent questions raised by pharmacy leadership is cost. Unfortunately, pharmacies have slim margins for profit based almost solely on prescription sales, the inability to bill medical payers for services rendered, direct and indirect remuneration (DIR) fees, and pharmacy benefit manager (PBM) clawbacks; these challenges combine to create immense stresses for competing demands. This challenge is both immediate, when doing research projects, and conceptual, when trying to convince leadership of the long-term goals of the research project (e.g., establishing evidence to support future services). The authors have found that it is paramount to have financial resources available to offset costs of efforts for site leaders or corporations who may incur slowed productivity by participating in research. Informing stakeholders that the research ideally will pay for itself is helpful in starting dialogues and moving conversations forward. In the authors’ experience, the money paid to the pharmacies is less than the actual costs incurred by working on the project. However, it is important for pharmacy leaders to recoup some costs. While financial challenges that pharmacies face may be a barrier in their ability/willingness to partner, those same challenges also highlight the need for partnering in research investigating sustainability of non-dispensing services; framing the research as a partnership in investigating these shared goals can help recruit partners. Given the more intense staffing shortages and workload demands that are unique to the present moment, it is even more important to supplement financial motivators with a multimodal approach which also harnesses intrinsic motivation and minimizes disruption to workflow. Often, researchers must be patient, especially when pharmacies experience pharmacist or staff turnover which often deprioritizes research initiatives. During implementation, physically visiting the pharmacies and facilitating discussion with staff can be beneficial in reminding, motivating, and resolving issues; this facilitation can be external (e.g., visits conducted by non-pharmacy personnel such as research staff), but it is also helpful when it is combined with internal facilitators (e.g., regional manager, corporate leader). Facilitation is often accompanied by provision of a meal or treats.

Another strategy is to align research goals with real world feasibility. It is important that investigators ensure that research designs (e.g., interventions, screenings) are grounded in the reality of how finances work within community pharmacy and the broader health care industry. There are many excellent research ideas; however, many of those proposed ideas lack practicality in actual pharmacy practice and thus do not gain traction. In one study,²² the authors designed the intervention based on pre-existing service billing codes; this design allowed for the intervention to demonstrate value based on traditional payer channels. A major objective of practice-based research is to identify effective strategies that are more likely to be implemented community-wide.

Outside of Pharmacy Practice

“Pharmacists should stick to dispensing.”

In doing this research over the past 15 years, the authors have encountered consistent comments from critics from professions outside pharmacy that express concern that pharmacists do not have the knowledge, skill, or ability to engage patients on sensitive topics such as possible misuse or addiction to opioid medications. This argument may have had merit when pharmacist training and education was less extensive (e.g., Bachelor of Pharmacy degrees). However, with the proliferation of the Doctor of Pharmacy (PharmD) degree,³⁵ a new generation of pharmacists is practicing across the US with training compatible with advanced roles. The high level of skill possessed by pharmacists is demonstrably salient in services and intervention modalities that target improvements to adherence coupled with safe and effective use of medications.³⁶ The national increase in development and utilization of pharmacist collaborative practice agreements (CPAs) for many disease states/therapies (including MOUD) also signals the growing awareness of the value of the pharmacist beyond dispensing.^37,38

Beyond the ability and training of the pharmacist, another common concern is whether pharmacies have the private, physical space for speaking with patients. Somewhat dated research has shown that about 40% of pharmacies nationally have private consultation rooms.³⁹ In addition to what has existed previously, there is a national trend for pharmacy chains to invest in building out such spaces for patient and pharmacist interactions. Given that health screenings and immunizations (which require private space) are quickly becoming major sources of income for pharmacies,⁴⁰ the availability of these private spaces will likely only continue to expand in the future. Moreover, with the advent of telehealth and mobile health (mHealth) and its rapid expansion during the COVID-19 pandemic, remotely conducted pharmacist-led interventions are likely to continue to grow and evolve.

“Patients do not want to talk to pharmacists about behavioral health.”

Not only are pharmacists continually ranked among the most trusted professionals in the US each year,⁴¹ empirical research has also demonstrated that patients are willing to receive behavioral health information from their pharmacists.^13,17 Furthermore, in a pilot study of a pharmacist-led intervention for opioid medication misuse, patients gave the pharmacist session nearly perfect scores for satisfaction.²³

CHALLENGES AND SOLUTIONS – BY PHARMACY TYPE

When working with community pharmacies, an additional emphasis must be placed on navigating the organizational, business, and administrative relationships with the entities that own the community pharmacies. When initially establishing relationships with pharmacy organizations, it is important to establish expected value to the pharmacy and organization; in order to buy-in to the research, pharmacies should have a clear sense of the short and long-term advantages of partnering with a research institution on research. The motivation for academic medical centers and other medical institutions can be drastically different from those of a pharmacy chain organization and also drastically different from those of an independent pharmacy. Whether the setting be a chain, independent, or institutional (i.e., a setting that exists within a larger organization, such as a health system or academic medical center) pharmacy setting, there is traction to be gained by unifying behind mutual desires. For example, in opioid-related research, all pharmacies can agree on the need to address the opioid epidemic.

Independent Pharmacies

In addition to motivations discussed above, independent pharmacy staff can often be motivated to engage due to their affinity for the university that a research team represents. Many of the employees often are alumni of these universities. While this affinity may occur in staff from chains and institutional settings, it often holds less sway given that decision making power often resides with externally located corporate or administrative leaders. Additionally, many independent pharmacies do not have the same leveraging power with insurers and PBMs and thus patient costs at these pharmacies may be slightly higher; however, many independent pharmacies attempt to offset this by marketing their “above and beyond” and “niche” patient care services. As a result, independent pharmacies may be more open to engaging in research when the research provides a clear potential advantage to their patients. Independent pharmacies can also often be nimbler in their ability to adjust workflows, policies, and procedures while also being less likely to view research engagement as a burden or disruption to workflow. Engaging with pharmacy groups can also help in networking and identifying independent pharmacies with interest in partnering in research; examples of organizations include Community Pharmacy Enhanced Services Network (CPESN), National Community Pharmacy Association (NCPA), and others. Finally, most independent pharmacies are not connected to large electronic health record systems nor share a common pharmacy management system which can make collection of pharmacy-specific data from multiple pharmacies difficult to efficiently obtain and utilize for research purposes.

Chains and Institutional Pharmacies

Corporate leaders and decision makers at large organizations often have different motivations than their pharmacy staff. An effective strategy may include forming relationships with leaders charged with program development and/or residency/fellowship training programs. These leaders are often motivated to bring new services/programming to their sites as well as educational experiences which often has research components. Thus, externally led research projects help these leaders accomplish some aspect of their jobs and can synergize with pre-existing research endeavors. Furthermore, within institutional pharmacy settings, universities or academic medical centers usually possess a common mission that includes research as one of its’ pillars. Identifying underlying organizational priorities and aligning those priorities with those of the research study can be a useful strategy.

All Pharmacies

During the initial process of setting up and starting research projects, there is often a “honeymoon period” when the relationship between the research team and pharmacy leadership/staff is strong; however, maintaining those relationships as the research study continues on can be more of a challenge. To maintain strong relationships, it is important to include pharmacy leaders in study-related meetings, which may be operational/frequent or more supervisory/infrequent. The more a research team can enable pharmacy leaders to join in the management structure of the study, the more these leaders will be involved in decision making, supporting, and information sharing. This collaboration can also include partnering on publications, presentations, or other academic products. In the authors’ experience, leaders from all settings (e.g., independent, chain, institutional) find value in and rewarding experiences from participating in the development and dissemination of academic products (e.g., manuscripts, posters) to highlight the work that has been done in their practice settings. If possible, the research team should make efforts to join in on internal pharmacy leadership meetings. It is valuable for the research team to present progress of the project; highlight the positive efforts of the organization, staff, and its leaders; and request feedback. Importantly, summarizing high-level findings for pharmacy leadership can help those leaders “sell” the project and the value of the collaboration internally with those less inclined to support research endeavors. These are also good settings in which constructive feedback from the research team can be tactfully given to leaders if issues arise and require action.

Overall, the research team should view the relationship with the pharmacy as a long-term one that extends well beyond the length of the project. A general disposition of viewing the pharmacy staff/leaders as a “customer” of the research team has been a successful strategy for the authors (e.g., always assume the research team’s schedule is more flexible than the pharmacy staff’s schedule, make every effort to solicit feedback from all stakeholders [e.g., leaders, pharmacists, staff] whenever possible).

CONCLUSIONS AND FUTURE DIRECTIONS

Community pharmacies are effective partners to engage with for research. Community pharmacies have unique advantages but also have unique challenges. As described in this article, the challenges and corresponding solutions can depend on the study type (e.g., screening, PDMP, surveying), stakeholders (e.g., patients, physicians, leadership, pharmacy staff), and pharmacy type (e.g., independent, chain, institutional). The authors’ experience in partnering with community pharmacies on opioid-related topics has provided opportunities to identify proven strategies to maximize the partnership and overcome obstacles. As practice-based research continues to grow and evolve, partnering effectively in research with community pharmacies will be essential for research teams. Changes within the pharmacy profession that would enhance the ability for pharmacists to partner in research (including opioid-related research) include: creation of mechanisms for Medicaid, Medicare, and commercial insurances to pay for more advanced clinical services; removal of pre-existing state barriers to pharmacist MOUD prescribing; creation of clear authority for pharmacists to initiate MOUD (e.g., CPAs, standing orders); and increased utilization by pharmacists in existing CPAs and standing orders. Partnering with community pharmacies will be essential in order to advocate for these changes and improve patient care.