Pharmacists’ perspectives on MedSMA℞T: A serious game to educate youth about opioid safety

Abstract

Introduction

Adolescent opioid misuse has been recognized as a dire public health issue. Despite efforts to address the opioid epidemic in the United States, opioid-related morbidity and mortality have continued to rise. Few interventions have been tailored to prevent adolescent opioid misuse. MedSMA℞T: Adventures in PharmaCity (MedSMA℞T), is a serious game that educates the end-user by challenging them to make applicable decisions in a low-stakes environment.

Objective

The objective is to characterize pharmacists’ perspectives on using MedSMA℞T to educate adolescents and families about opioid medication safety.

Methods

Pharmacists were recruited from the Pharmacy Practice Enhancement and Action Research Link (PearlRx) and the Pharmacy Society of Wisconsin. Consented pharmacists played the MedSMA℞T game for 30 minutes while a research team member observed via Zoom. Virtual semi-structured interviews (45 minutes) were recorded and transcribed verbatim. Two members of the research team independently coded each transcript using NVivo software to conduct inductive thematic analyses. Bi-weekly meetings were held to discuss and refine codes as well as the master codebook, and identify prevalent themes (intercoder reliability, kappa = 0.91).

Results

Twenty-two pharmacists were interviewed between August and November 2021. Four themes were identified: game content and design, patient education, implementation barriers, and implementation facilitators. Most pharmacists perceived MedSMA℞T to be an effective resource for opioid safety education. Pharmacists reported that age-appropriate language was used in combination with realistic scenarios and relatable characters. Pharmacists also highlighted the value of interactive gameplay to engage the player to actively learn and recall educational content.

Conclusion

Pharmacists play an integral role as medication experts and contributed valuable insights into using and incorporating the MedSMA℞T game into various pharmacy practice settings. Future work is necessary to understand parents’ and adolescents’ perceptions of using MedSMA℞T as an opioid safety education tool in pharmacies.

Introduction

Misuse of prescription opioids has become the leading cause of inadvertent injury and death among the adolescent population in the United States.¹ In 2019, 7.6% of adolescents reported prescription opioid misuse.² Misuse refers to using opioids in a way that they are not prescribed such as taking too much, unnecessarily taking medication, or sharing the prescription with others. Adolescents who misuse prescription opioids tend to obtain them from friends, family members, or through a prescriber.^1,3 Even when adolescents take opioids as prescribed, they are 33% more likely to misuse opioids such as developing long-term use dependence or taking opioid medications improperly in the future.⁴

Fortunately, education on the safe use of prescription opioids for adolescents can be a preventive measure for future misuse.^4–7 Studies have found that preoperative opioid education significantly decreases narcotic consumption by patients post-surgery.^8,9 However, most current educational interventions and tools target adults. Despite several studies demonstrating that adolescents have inadequate knowledge about opioid use and safety, there are few interventions explicitly designed to prevent opioid misuse through education tailored for adolescents and parents in pharmacies.^10–13

Tailoring educational interventions to align with adolescents’ learning preferences is paramount to the success of the intervention. Literature suggests that adolescents prefer technology-based education, and studies have demonstrated an increase in the working memory and problem-solving ability in children who play video games.^14,15,16 Educational games can motivate adolescents to study low-interest topics by providing an interactive and thought-provoking experience.^17–20 Considering 97% of all teens aged 12 to 17 years old have played a video game at some time in their life, most adolescents are familiar with this interactive format of learning information.^21,22

As medication experts, pharmacists are trained to educate patients receiving opioids and are easily accessible yet underutilized resources for young patients and their families.^23,24 Pharmacists are the last healthcare providers that patients interact with before taking their opioid prescription home. As medication “gatekeepers,” it is critical for pharmacists to provide patients with the knowledge they need to use their opioid medication safely and appropriately. For example, research suggests that practitioner-led counseling encourages the safe disposal of unused opioid medication.²⁵ However, besides medication leaflets and hand-outs, few other interactive, effective counseling tools exist that specifically address adolescent opioid misuse. Supplementing verbal counseling with additional interactive educational tools has the potential to optimize patient engagement, satisfaction, and safety.^26–28

As potential providers of this intervention, clarifying pharmacist perspectives is essential to tailoring this intervention to the pharmacy setting. Research has demonstrated pharmacists’ willingness to and perception of importance of combating the opioid crisis.^29–30 Pharmacists’ perspectives provide the study team with needed information that can make the intervention more amendable to the constraints and challenges created by pharmacy infrastructure, culture, and expectations. Health services research literature suggests that provider-engaged research leads to better implementation outcomes and translation to clinical settings.^31–32 Specifically, pharmacist-led interventions have shown effectiveness in improving outcomes such as vaccine uptake or blood pressure control, among others.^33–34

MedSMA℞T: Adventures in PharmaCity is an educational game intended to educate adolescents on critical opioid safety practices including proper use, disposal, and storage.^35–37 The study team designed and tailored an educational video game, specifically a serious game, to address the issue of opioid prescription safety behavior in adolescents. MedSMA℞T: Adventures in PharmaCity is a serious game that incorporates real-life scenarios involving opioid medication. Serious games are video games whose primary objective is not pure entertainment but to educate the player or improve other psycho-socio-behavioral outcomes. Players navigate through this responsive narrative as the anthropomorphized sheep character, Shan. Shan is an adolescent who has broken their arm and must manage their own opioid medication safely. Throughout a handful of levels, the player is exposed to aspects of safe opioid management such as storage, disposal, resisting peer pressure, and not sharing medications. Previously published research discussed pharmacist’s perspectives, the Family Medication Safety Plan, and has graphic images of MedSMA℞T Families gameplay.³⁸ More information and related publications can be found at the CRoME Lab’s website.³⁹ The current game version is playable on a laptop and is built on the web-based game engine, Unity.⁴⁰ The game is available to study participants and key stakeholders at no cost as we refine and test the intervention. The objective of this study was to characterize pharmacists’ perspectives on the design and use of MedSMA℞T: Adventures in PharmaCity to counsel adolescents and their families on opioid safety.

Methods

Participants and Recruitment.

The Institutional Review Board (IRB) at the University of Wisconsin-Madison granted approval for this research. To be eligible, participants needed to be a pharmacist practicing in Wisconsin. Eligible pharmacists were recruited from the Pharmacy Practice Enhancement and Action Research Link (PearlRx) and the Pharmacy Society of Wisconsin. PearlRx is a practice-based network of Wisconsin pharmacists intended to help exchange information and research findings to improve pharmacy practice. PSW is the Wisconsin-based organization for pharmacists, pharmacy technicians, student pharmacists, and allied healthcare professionals which supports educational, legislative, and social growth throughout the state and across practice types. Interested pharmacists were instructed to contact the study group directly via email or to complete a brief Qualtrics online consent form. The study team followed up with pharmacists no more than three times via email to schedule a virtual (Zoom) meeting session.

Interview Question Development.

Question development was primarily guided using two implementation frameworks. One framework relied upon for this purpose was RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance).⁴¹ In particular, this framework helped develop questions around potential implementation into the pharmacy setting as well as perceived efficacy. A second theoretical framework involved in question development was the Consolidated Framework for Implementation Research (CFIR).⁴² With a specific focus on constructs related to contextual barriers and facilitators, the study team chose to adapt questions that applied to pertinent constructs such as workplace infrastructure, compatibility, and culture.⁴² Questions were also informed by user experience testing wherein participants were asked about their likes and dislikes of the game as well as suggested improvements. In summary, questions focused on implementation, perception, and suggestions for improvement. The interview guide is presented in Appendix A.

Data Collection.

Data were collected between August and December 2021. During the virtual (Zoom) meeting session, pharmacists played the MedSMA℞T: Adventures in PharmaCity game for 30 minutes while observed by a member of the research team, and then participated in a semi-structured interview lasting about 45 minutes. Participants were observed during gameplay for the purpose of intervening in the event of a technological error and documenting any issues during gameplay. Then participants completed a semi-structured interview that lasted for about 45 minutes. Gameplay and interviews were recorded via Zoom. Demographic characteristics of participants were also collected. Audio-recordings of interviews were professionally transcribed, verbatim.

Data Analyses.

Qualitative data was analyzed using a standard, semantic inductive approach to explore factors related to pharmacists’ perspectives on the implementation and design of the game.⁴³ This approach allows for flexibility in exploring and defining patterns related to implementation and iterative design based on the responses provided by participants. Two members of the research team (ES, ZP) independently coded each transcript using inductive thematic analyses via NVivo software. The coding members of the research team familiarized themselves with the data and generated preliminary codes. The coding team held bi-weekly meetings to discuss and refine codes, address any discrepancies, and finalize the master codebook. Once the verbatim transcripts had been individually coded, they were exported and collated to elucidate prevalent themes. The principal investigator (OA) reviewed codes and their prevalence which were used to identify major themes and subthemes from the dataset. Coded transcripts were compared and used to calculate the intercoder reliability (kappa = 0.91).

Results

Interviews were conducted with 22 pharmacists, all of whom also played the game. Table 1 provides the demographic characteristics of study participants. The average age of pharmacists was 35 years old, and most participants were female (80%). The most frequently reported clinical settings for pharmacists in the study were inpatient pharmacies (35%), chain pharmacies (15%), or independent pharmacies (10%). Accordingly, most respondents identified as either clinical hospital/inpatient (35%) or community pharmacists (25%). On average, pharmacists had spent 11 years in pharmacy practice and 5.5 years at their current practice. Among pharmacists who regularly filled prescriptions, they filled about 1,383 prescriptions per week on average.

Table 1.

Descriptive Statistics of Pharmacists (N = 20^*)

Demographic Characteristics	n (%)
Average Age (SD) in years	35.1 (8.7)
Gender
Female	16 (80%)
Male	4 (20%)
Pharmacy Practice Setting
Inpatient	7 (35%)
Other	4 (20%)
Community-Chain	3 (15%)
Ambulatory	3 (15%)
Community-Independent	2 (10%)
Specialty	1 (5%)
Pharmacy Profession
Clinical Hospital	7 (35%)
Community	5 (25%)
Other	4 (20%)
Ambulatory Care	3 (15%)
Specialty	1 (5%)
Pharmacist Status
Clinical	10 (50%)
Other	5 (25%)
Manager	4 (20%)
Staff	1 (5%)
Average Years in Current Position (SD)	5.5 (5.7)
Average Total Years in Pharmacy Practice (SD)	11 (7.8)
Average Weekly Prescription Volume (SD)	1383.1 (805.7)
Average Daily Technicians Staffed (SD)	6.2 (6.6)
Average Daily Pharmacists Staffed (SD)	5.8 (5.2)

Abbreviation used: SD, standard deviation.

^*Only 20 participants provided demographic information.

Four main themes emerged: (1) game content and design, (2) patient education, (3) implementation barriers, and (4) implementation facilitators. Table 2 provides a summary of the themes, subthemes, and verbatim quotes from study participants. Themes and subthemes are described and summarized in detail below.

Table 2.

Main Themes, Subthemes, and Verbatim Quotes

Theme	Subtheme	Verbatim Quote
1. Game Content and Design	Gameplay (1a)	“…You only remember 10% of what you hear, but if you do something, you remember far more of it, and you’re more invested.” -P19 (Community Pharmacist) “I liked how the characters were, you know, younger in school, so the, hopefully, kids can kind of see themselves or identify with them.” -P12 (Population Health: Disease Management Pharmacist) “And I would say for children at least, it’s really helpful to see the situation that you could be in and see what might happen…” -P10 (Pediatric Inpatient Hospital Pharmacist)
2. Patient Education	Existing Pharmacy Patient Education Tools (2a)	“But usually I’ll just kind of walk through like how to take it, what side effects to watch out for, how to potentially manage them.” -P1 (Community Pharmacist)
	Learning Outcomes (2b)	“I think the main goal is to reinforce safe use of painkillers and really to highlight some of the detriment that can come from not following, you know, safe handling of medicine.” -P6 (Clinical Hospital Pharmacist)
3. Implementation Barriers	General Implementation Barriers (3a)	“…like potentially if you have, you know, a child who doesn’t speak the language or is blind or has other disabilities, they would, it might not be, it might not work for them.” -P20 (Inpatient Pharmacist)
	Evidence Needed (3b)	“There would probably need to be plenty of data to show that it’s effective in preventing error or preventing overdose.” -P7 (Community Pharmacist)
	Suggestions for Improvement (3c)	“I guess making it a little quicker would help with the time barrier, like maybe taking some of extraneous information from the scenes.” -P11 (Ambulatory Care Pharmacist)
	Usefulness of Game Translation (3d)	“I think it would depend on where the location is, whether or not you’ve seen another language…I have friends who work at other pharmacies who, 80% of them speak Spanish.” -P11 (Ambulatory Care Pharmacist)
4. Implementation Facilitators	General Implementation Facilitators (4a)	“I think it would be useful to have as like an ancillary material…if someone is picking up prescriptions for their kids and they were worried about their kid taking their medication, I’d say like, well, if you want to, here’s a game that you could play.” -P1 (Community Pharmacist) “But I did like the idea of having, like if I give them a sheet of paper with a QR code…that could actually end up taking less of my individual time, while getting them better information than we currently give.” -P16 (Clinical Hospital Pharmacist) “I think that our group would be eager to try and implement something like this, just because it has more of that focus on the patient and the patient’s family.” -P17 (Clinical Hospital Pharmacist)
	Target Audience (4b)	“If somebody was getting pain medication for like wisdom teeth pulls, extraction or, you know, broken arm, etc., like you’re getting this prescription, play this game to kind of just teach you about opioid safety.” -P22 (IHS Tribal Pharmacist) “I think parents will learn stuff too…It’s meant for kids, but those are also good things that all parents need to know about, you know, disposal, locking things up, whatever.” -P20 (Inpatient Pharmacist) “So I think for kids like games, this is great. It gives them something to do that they might be familiar with or they like doing while also giving them a learning activity.” -P11 (Ambulatory Care Pharmacist)

Theme 1: Game Content and Design

1a. Gameplay.

Pharmacists stated that the modality and content of the MedSMA℞T: Adventures in PharmaCity game leads to a more engaging, memorable experience. The interactive game could allow players to engage with educational content through decision-making and viewing subsequent consequences. Pharmacists reported that the game’s characters were relatable and placed in practical situations, which allowed players to evaluate realistic scenarios and make difficult decisions in a safe, low-stakes environment. Pharmacists appreciated that after the player made a decision during gameplay, the corresponding consequence was shown to players to help them understand why one decision was the (best) safest choice. Feedback provided after an unsafe decision motivated players to learn from their mistakes and retry the game level.

“I definitely think it’s better than traditional counseling. It’s, you know, it’s more interactive. It actually gets the patient involved.”

-P5 (Managed Care Pharmacist)

“…You only remember 10% of what you hear, but if you do something, you remember far more of it, and you’re more invested.”

-P19 (Community Pharmacist)

Theme 2: Patient Education

2a. Existing Pharmacy Patient Educational Tools.

Pharmacists noted that currently, their best opioid educational tool was verbal consultation. Consultations educate patients on appropriate use of opioids, storage, disposal, and how to respond to an overdose using Narcan. Pharmacists stated that MedSMA℞T: Adventures in PharmaCity could be used to optimize current patient counseling practices. The interactive gameplay has the potential to reinforce key opioid information discussed during the consultation.

“But usually I’ll just kind of walk through like how to take it, what side effects to watch out for, how to potentially manage them.”

-P1 (Community Pharmacist)

“Like I think that sometimes it [medication information] sticks with you more when you have an interactive scenario versus, you know, just like a few sentences the short time that you’re able to give one-on-one in a pharmacy.”

-P8 (Clinical Hospital Pharmacist)

2b. Learning Outcomes.

Pharmacists correctly identified the educational learning objectives (medication safety, storage, disposal, and consequences of opioid misuse) and affirmed that the objectives were well represented in the game.

“I think the main goal is to reinforce safe use of painkillers and really to highlight some of the detriment that can come from not following, you know, safe handling of medicine.”

-P6 (Clinical Hospital Pharmacist)

Theme 3: Implementation Barriers

3a. General Implementation Barriers.

Pharmacists stated multiple factors that could negatively impact the feasibility of implementation in their pharmacy setting. The barrier mentioned most frequently by pharmacists was the lack of time patients spend in the pharmacy. Pharmacists also identified patient characteristics that could be potential barriers to using the intervention such as patients with visual impairments or patients with limited English proficiency. Another barrier pharmacists cited was that pediatric patients were infrequently physically present in the pharmacy when their medication is dispensed, as parents often pick up medications for their children. This phenomenon limits pediatric patients’ direct interaction with pharmacists.

“Many of the people that come in the pharmacy are limited on time, where they just want to get their medicine and get out.”

-P7 (Community Pharmacist)

“…like potentially if you have, you know, a child who’s doesn’t speak the language or is blind or has other disabilities, they would, it might not be, it might not work for them.”

-P20 (Inpatient Pharmacist)

“…oftentimes at my pharmacy, there’s not, like the children don’t come in the car for their medication. Usually, it’s the parents picking it up for their children.”

-P2 (Community Pharmacist)

3b. Evidence Needed.

Pharmacists noted that evidence of MedSMA℞T: Adventures in PharmaCity’s effectiveness and adaptability to specific healthcare environments would provide proof to health care leadership that implementation is warranted and feasible. Most participants agreed that a quantifiable reduction in the misuse of opioids and an increase in patient safety would justify implementation of MedSMA℞T in their work environments. Other pharmacists emphasized that the cost of implementing MedSMA℞T: Adventures in PharmaCity would have the greatest impact on whether pharmacies adopt the intervention or not. Accordingly, pharmacists indicated if there was no cost to implement MedSMA℞T: Adventures in PharmaCity, more pharmacies would be likely to use the intervention.

“Leadership to like fund this would probably need to see some stats about like cost-effectiveness for reducing hospital stay cost after kids overdose maybe, or like some of the costs for treating opioid dependency in the community.”

-P3 (Community Pharmacist)

“I think if it was free, there wouldn’t be any [evidence needed]. We could just use it if we wanted.”

-P12 (Population Health: Disease Management Pharmacist)

3c. Suggestion for Improvement.

Pharmacists mentioned aspects of MedSMA℞T: Adventures in PharmaCity that could be improved upon. Some pharmacists cited duration of the game as a potential barrier while others wanted the game to include more information on subjects such as additional educational content on appropriate opioid disposal methods.

“But I think it would have been nice to see some additional information on how to dispose of the medication, for example, they could be disposed of at the police station, or they could go into the pharmacy and buy the kits…”

-P11 (Ambulatory Care Pharmacist)

3d. Usefulness of Game Translation.

Based on the patient population, certain pharmacy locations may find language translations of MedSMA℞T: Adventures in PharmaCity to be helpful. Most pharmacists agreed that providing a few different translated versions of the game dialogue into locally common languages would be beneficial. Translation could improve the quality of consultations by reducing communication barriers experienced with patients that speak different languages than the pharmacist.

“I think it would depend on where the location is, whether or not you’ve seen another language…I have friends who work at other pharmacies who, 80% of them speak Spanish.”

-P11 (Ambulatory Care Pharmacist)

“I know our consultations aren’t the greatest with people who speak other languages, so just having more tools to help would be awesome.”

-P2 (Community Pharmacist)

Theme 4: Implementation Facilitators

4a. General Implementation Facilitators.

Pharmacists mentioned patient safety as one of the most important reasons to implement this patient-centered intervention in their pharmacy. Furthermore, pharmacists who practiced in different settings had different suggestions on how to incorporate MedSMA℞T: Adventures in PharmaCity into their practice. Community pharmacists stated that implementation of the intervention in patient waiting areas could provide patients with an extra educational resource to review while they wait for their prescription(s) to be filled. Inpatient pharmacists suggested that the intervention could be used as a resource given to patients prior to discharge from the hospital with an opioid prescription. Pharmacists reported that implementing MedSMA℞T: Adventures in PharmaCity could provide a robust counseling experience without requiring extra time from the pharmacist. Some pharmacists stated the game could increase their efficiency while providing patients with better care.

“I think that our group would be eager to try and implement something like this, just because it has more of that focus on the patient and the patient’s family.”

-P17 (Clinical Hospital Pharmacist)

“…They could be given this [MedSMA℞T: Adventures in PharmaCity] as their, in their room on, you know, the day before they go home”

-P10 (Pediatric Inpatient Hospital Pharmacist)

4b. Target Audiences.

Pharmacists indicated that one of the greatest strengths of MedSMA℞T: Adventures in PharmaCity was its ability to reach a wide variety of audiences. Although intended for adolescent patients, the learning objectives were applicable to individuals across the lifespan. Parents or other adult players can learn about opioid safety either directly by playing the game or indirectly from watching others family members play. Pharmacists recognized that some younger adults may find it difficult to talk to or connect with pharmacists on the topic of opioid medication safety. The game provided a solution so that patients are still able to get the educational information they need to use their opioid prescription safely and appropriately in a setting most comfortable to them. Pharmacists specifically highlighted that this game would be valuable to educate patients who are prescribed an opioid medication after surgery.

“And I think parents will learn stuff too…It’s meant for kids, but those are also good things that all parents need to know about, you know, disposal, locking things up, whatever.”

-P20 (Inpatient Pharmacist)

“If they don’t connect well with the pharmacist or the nurse educating them, it [MedSMA℞T: Adventures in PharmaCity] might provide a better opportunity for kids to feel connected…”

-P20 (Inpatient Pharmacist)

Discussion

This is the first study to characterize pharmacists’ perspectives on the use of MedSMA℞T: Adventures in PharmaCity to educate adolescents and families about opioid safety. Pharmacists found MedSMA℞T: Adventures in PharmaCity to be an interactive and engaging serious game that incorporated realistic scenarios and relatable characters to improve educational outcomes. Pharmacists appreciated that unlike real life, players can make different decisions in a consequence-free environment. Responses from pharmacists upheld previous research suggesting serious games can help pediatric patients to develop cognitive skills and decision making for topics including substance misuse and opioid safety.^{11–14, 35–37, 44–46}

Pharmacists identified potential facilitators and barriers to implementation of the game in pharmacies. Overall, implementation was deemed feasible, and pharmacists provided examples of the implementation of MedSMA℞T into different pharmacy and clinical settings. In particular, leadership buy-in would be important for adoption and ensuring that its use did not result in time barriers for pharmacists and patients. Future work is necessary to pilot the implementation and use of the MedSMA℞T: Adventures in PharmaCity game in pharmacies. Pilot testing will allow for increased data on the effectiveness of this intervention as it is used in the pharmacy setting. The pilot study could improve the buy-in potential for pharmacy leadership as well as demonstrate the intervention’s effects on workflows for pharmacists.

MedSMA℞T: Adventures in PharmaCity, is a serious game designed and tailored to improve adolescent knowledge regarding opioid medication safety. However, pharmacists suggested that some of the topics such as safe opioid storage and disposal would be helpful for parents and other adults. As pharmacists described, patients may flush leftover opioid medication down the toilet as a means of disposal. It is now recognized that this practice has negative environmental consequences, meaning that inappropriate disposal of opioids can cause substances to leach into water sources, causing contamination.^47,48 Literature has shown that when patients are educated about handling leftover opioids, they are significantly more likely to appropriately dispose of them.^49,50 This suggests that lack of knowledge is the issue as opposed to lack of motivation to appropriately dispose of opioids. Increasing awareness of appropriate opioid disposal methods is the first step in changing harmful disposal behaviors that impact personal, community, and environmental health. This finding also indicates that the MedSMA℞T serious game could be beneficial for educating patients across the lifespan about safe disposal of prescription medications since much of the information about safe handling of opioids can extend to other prescriptions.

Pharmacists reported that MedSMA℞T: Adventures in PharmaCity was a valuable patient education tool. Some pharmacists thought that the interactive nature of the game would help reinforce important medication safety information discussed during consultation. Pharmacists reported different intentions for using the game based on individual patient characteristics and emotions regarding opioid safety. Pilot studies will be integral to characterize how pharmacists use this intervention in practice and how this intervention shapes consultations. In sum, these perceptions align with current literature which suggests that serious educational games improve engagement, retention, and overall interest when compared to traditional learning materials.^{35–37, 44–46}

Pharmacists identified potential patient barriers that could limit the interventions’ ability to reach the entire target audience. Individuals with limited English proficiency would likely require translation of the game’s dialogue into their native language along with tailoring the intervention to ensure relevance dependent on their cultural background and cognitions. Translating the game dialogue to another language may seem relatively easy but tailoring the intervention to be culturally relevant could pose an even greater challenge. Feedback from stakeholders who know the language and share culture with the target population will be crucial to successful tailoring. Evidence is needed to determine if and how MedSMA℞T: Adventures in PharmaCity impacts socio-economic groups and cultures differently. Using this information, the study team can create translations and cultural adaptations to improve opioid safety outcomes for marginalized groups. As stated by pharmacists, these sorts of adaptations could make consultation more robust when language and cultural barriers are present between pharmacist and patient. Another group that might not benefit from this intervention are individuals with certain cognitive and physical disabilities (such as visual impairments). Future research is necessary to understand how to adapt tools like MedSMA℞T: Adventures in PharmaCity to specific populations including individuals with limited English proficiency and individuals with cognitive and/or physical disabilities.

The implementation of MedSMA℞T: Adventures in PharmaCity is supported by favorable perceptions of pharmacists, interactive design, salient learning objectives and offering a novel way to engage adolescents. While these factors will bolster the implementation in pharmacy settings, there are looming, consequential barriers that will need to be addressed. There is a lack of literature on the implementation and sustainment of pharmacist-led serious game interventions in the pharmacy setting for patients. To our knowledge, there are no published works which integrate pharmacists into participatory design of serious games at the pre-implementation stage. Including pharmacists early in development and understanding their perceptions of implementation are integral to designing pilot programs for this intervention. Anticipating barriers through characterizing pharmacist perspectives will allow the study team to refine the intervention before testing in situ. A primary barrier to implementation is the time-constraint. The study team will work to address this concern through the development of implementation packages which take into consideration the limited time that both patients and pharmacists have during verbal consultation. These could be adaptations to the length of gameplay, the ability to play the game at home as well as making the intervention simple enough that long periods of training are not needed before implementation. Another important consideration is the need for evidence of MedSMA℞T: Adventures in PharmaCity’s efficacy and effectiveness in improving opioid safety outcomes for patients and families. This need is fulfilled by ongoing work to establish the educational and motivational outcomes of this intervention for patients. Adequate evidence will facilitate buy-in from pharmacy stakeholders and patients alike, leading to greater uptake of this intervention.

Therefore, considering the positive response from pharmacists and the presence of common barriers, it is reasonable that of MedSMA℞T: Adventures in PharmaCity should be piloted in various settings (e.g., community pharmacies, emergency departments, primary care clinics) to establish specific, local barriers and facilitators to implementation and long-term management.

Limitations

Study participants were all from the same state, Wisconsin, which may not be representative of pharmacists from other regions of the United States. However, interviews were conducted until the point of data saturation was reached, indicating that our sample size was sufficient for the aims of this study. Accordingly, the sample was relatively homogenous in terms of gender, race, and ethnicity. Further research using a more diverse sample of pharmacists is warranted to inform culturally appropriate information and gameplay. Research with culturally diverse patients will also inform the need for translations and cultural adaptations. Interviews were recorded via Zoom; hence, pharmacists could have been more likely to answer interview questions in a socially desirable manner. Additionally, these interviews happened during the COVID-19 pandemic when pharmacists—and other parts of the health care system—were overwhelmed by increased patient loads, immunizations, and staffing shortages. While these issues are expected to last for the foreseeable future, findings must be contextualized to understand how this pandemic has shaped pharmacies and implementation factors.

Conclusion

Pharmacists play an integral role as medication experts within the healthcare system and contributed novel and valuable insights into how the MedSMA℞T: Adventures in PharmaCity game could be incorporated into various practice settings. The MedSMA℞T game is one of the first serious game to target opioid medication safety education for young patients and their parents in pharmacies. Similar to other existing serious games for health, the MedSMA℞T game has potential to engage and better retain the attention of younger patients. Future research is necessary to understand parents’ and adolescents’ perceptions of MedSMA℞T: Adventures in PharmaCity as an opioid safety education tool.

Key Points:

What Was Already Known:

• Adolescent opioid safety education is a critical component to curtail the opioid epidemic in the US.

• There are limited opioid safety educational tools created explicitly for adolescents.

• Adolescents have expressed increased interest in serious games and interactive educational tools to improve medication knowledge retention.

What This Study Adds:

• Improved understanding of pharmacists’ perspectives on the use and implementation of a novel serious game to improve opioid safety education for adolescent populations and their families.

• A new, interactive platform to educate adolescents about opioid safety and potentially dangerous real-life situations in a safe environment.

• Increased access to opioid medication safety education for those with limited health literacy and English proficiency through visual aids and interactive gameplay.

Appendix A: Semi-structured Interview Guide

PHARMACIST INTERVIEW GUIDE (Post-Gameplay)

Thank you for participating in this interview. As stated in the consent form, this interview will be audio recorded and will not be linked to any of your identifiable information. Avoid saying names of people or organizations or mentioning any sensitive topics in the interview. Feel free to stop me if you have questions at any point during this interview. You may also skip any questions you are uncomfortable answering. If you begin the interview and change your mind, you may end participation at any time without penalty. Today we will be asking you questions about the MedSMART: Adventures in PharmaCity game.

What questions do you have before we begin?

Start recording.

First, we have some questions about the game.

• A
  Feedback on Game and Game Efficacy

  1. What are your first thoughts after playing the MedSMART game?
  2. What did you like about the game and why?
  3. What did you dislike about the game and why?
  4. What changes could be made to improve the game? Would you add or remove anything? (Prompt if needed: scenarios, characters, game content, information provided)
  5. What do you think is the main goal of this game? What features of the game were effective in helping deliver its message?
  6. How do you think the game would impact your patients’ ability to learn about opioid safety? Your pediatric patients’ (12–18 year old) ability? The ability of parents picking up a prescription for their child?
  7. In what ways will the game impact your patients’ ability to learn about opioid safety? Your pediatric patients’ (12–18 year old) ability? The ability of parents picking up a prescription for their child?
  8. What do you think could make it difficult for patients to participate in the game? How about pediatric patients (12–18 year old)? Parents picking up a prescription for their child? What could help these patients overcome barriers?
  9. What platform do you think this game should be available on? (phone, computer, app etc.)
  10. Would it be useful to translate this game into other languages? How often do you interact with patients who speak a language other than English?

Next, we’d like to know about your current practices and how the game compares.

• B
  Current Practices and Advantage of Game

  1. What types of educational materials do you currently use to provide medication education for patients prescribed opioids, if any? Pediatric patients (12–18 year old) prescribed opioids? Parents picking up an opioid prescription for their child?
  2. If none, how do you provide education for patients who are prescribed opioids?
  3. How does the game compare to other similar materials used in your setting?
  4. What advantages does the game have compared to these other materials?
  5. What disadvantages does the game have compared to these other materials?

Next, we’d like to ask you some questions about implementation of the game.

• C
  Implementation of Game

  1. Would you use this game in your practice setting to provide education on safe opioid use? Why or why not?
  2. How might you be able to implement the game into your practice setting?
  3. Who at your practice setting should be using this game with patients, if anyone?
  4. Do you think the game would be effective in your practice setting? Why or Why not?
  5. What kind of supporting evidence or proof would be needed about the effectiveness of the game to get staff or leadership at your practice setting on board?
  6. What would facilitate the implementation of the game?
  7. What would impede the implementation of the game?
  8. How would the infrastructure of your practice setting impact implementation of the game? (Prompt, if needed: age, size, physical layout?)
  9. How do you think your organization’s culture would affect the implementation of the game? (Prompt, if needed: general beliefs, values, assumptions that people embrace)
  10. What kinds of changes or alterations would need to be made to the game so it would work effectively in your setting?

Is there anything else you’d like to add?

Stop recording.