“I go out of my way to give them an extra smile now:” A study of pharmacists who participated in Respond to Prevent, a community pharmacy intervention to accelerate provision of harm reduction materials

Abstract

Background:

Community pharmacies are well-positioned to improve the health of people with opioid use disorder and who use drugs by providing naloxone and other essential public health supplies. Respond to Prevent (R2P) is a clinical trial which sought to accelerate provision of harm reduction materials through a multicomponent intervention that included in-store materials, online training, and academic detailing.

Objectives:

The objective of this study was to explore pharmacists’ attitudes, knowledge, and experiences in providing naloxone, dispensing buprenorphine, and selling nonprescription syringes following participation in the R2P program.

Methods:

Two online asynchronous focus groups were conducted with community-based chain pharmacists across Massachusetts, New Hampshire, Oregon, and Washington who had participated in the R2P program. Participants accessed an online repository of group interview items and responded to questions over a short period. Each pharmacist participated anonymously for approximately 30 minutes across over 2 ½ days. Pharmacists answered questions on experiences with pharmacy-based harm reduction care and R2P intervention implementation barriers and facilitators. Qualitative data analysis was conducted by a multidisciplinary team using an immersion-crystallization approach.

Results:

A total of 32 pharmacists participated in the two focus groups. Most participants were female (n=18, 56%), non-Hispanic (n=29, 91%), and white (n=17, 53%). Four major themes were identified related to (1) addressing bias and stigma toward people with opioid use disorder and who use drugs, (2) familiarity and comfort with naloxone provision, (3) perspective and practice shifts in nonprescription syringe sales, (4) structural challenges to harm reduction care in the pharmacy.

Conclusions:

Community pharmacists across the four states identified attitudes, knowledge, and experiences that create barriers to providing care to people with opioid use disorder and who use drugs. R2P approaches and tools were effective at reducing stigma and changing attitudes but were less effective at addressing structural challenges from the pharmacists’ perspective.

Introduction

The opioid epidemic remains an ongoing, public health crisis in the United States (U.S.).¹ Initially fueled by prescription opioids, over time, the crisis evolved to involve heroin, and now, synthetic opioids, such as illicitly-manufactured fentanyl.² Effective response to this crisis requires policymakers, healthcare professionals, and other stakeholders to be flexible and adapt to this changing landscape, as well as be committed to fostering and implementing evidence-based solutions.

With a geographic proximity to the vast majority of U.S. residents and expanded operating hours as compared to outpatient medical offices and syringe service programs, community pharmacists and other pharmacy team members are well-positioned to support the public health response.^3,4 States have rapidly modified laws and developed pathways for patients to access naloxone directly from a pharmacy,⁵ and community pharmacies have emerged as important partners in the distribution of other harm reduction materials, such as nonprescription syringes, to high-risk community members.⁶ Unfortunately, despite this opportunity to serve as community caretakers, pharmacists’ engagement in harm reduction initiatives has not been universally embraced.^7,8 As a result, a myriad of efforts has been developed and implemented to accelerate pharmacy-based naloxone provision and foster engagement in harm reduction and opioid safety efforts.⁸

This study is a part of a pharmacy-based intervention, Respond to Prevent (R2P), that used a stepped wedge, clustered randomized trial design over 5 waves to accelerate access to naloxone, nonprescription syringes, and buprenorphine through community pharmacies in 4 states.¹⁰ In collaboration with 2 pharmacy partners, 176 community pharmacies from 2 chains in Massachusetts, New Hampshire, Oregon, and Washington participated in the R2P intervention, with approximately 9 pharmacies in each state enrolled per wave. R2P was developed using a participatory design process with multiple stakeholders to integrate 2 evidence-based opioid safety-focused training toolkits (MOON and RESPOND) and then enhance content related to buprenorphine dispensing and nonprescription syringe sales.^11–15

R2P aims to increase pharmacists’ engagement with patients and caregivers around opioid safety and harm reduction materials. The intervention had 3 key elements that have been detailed elsewhere,^16,17 and included 1) an in-person, peer-to-peer pharmacist education delivered through an academic detailing model, 2) a 90-minute online continuing education course, and 3) provision of pharmacist-and patient-facing printed materials, specifically designed for use in community pharmacies, to facilitate engagement in harm reduction care. Broadly, the R2P intervention was directed at increasing naloxone distribution, improving access to non-prescriptions syringes, and reducing barriers to dispensing buprenorphine. All participating pharmacies received an in-person academic detailing session and the printed materials as part of a corporate quality improvement initiative, and then pharmacists and pharmacy technicians could opt to enroll in an accompanying individual-level research study that included the online course and 3 survey assessments delivered at baseline, 6-month, and 12-month follow-up.

The objective of this research was to capture and synthesize the experiences of pharmacists who participated in both the quality improvement initiative and optional online, continuing education course within the R2P intervention. This was accomplished by exploring pharmacists’ attitudes, knowledge, and experiences in providing naloxone, dispensing buprenorphine, and selling nonprescription syringes following participation in the R2P program using asynchronous online focus groups.

Methods

Two asynchronous online focus groups were conducted using Qualboard 20|20 (Sago, Iselin, NJ) with pharmacists practicing in the 4 states (Massachusetts, New Hampshire, Oregon, and Washington) who participated in the R2P intervention. Asynchronous online focus groups is a data collection method where participants access an online repository (e.g., virtual messaging board) showing a series of group interview items and respond to questions over a short period.^18,19 Participants were expected, although not required, to respond to each research question, so this format allowed each participant to contribute at their own preferred time and pace, as well as both start new and respond to existing threads, permitting multiple conversations to occur simultaneously.¹⁹ This enabled our study team to collect data from pharmacists who were geographically dispersed and worked disparate schedules, while maintaining anonymity. The first focus group (n = 18), held in March 2020, included pharmacists from the first 2 (of 5) waves of R2P, and then the second group (n = 14) was conducted in June 2020 and included pharmacists from third wave. A focus group was conducted with pharmacists from the fourth and fifth waves, but it was focused on the disruptions caused by the coronavirus disease 2019 pandemic and corresponding community pharmacy adaptations, and thus it is not included in this analysis. All focus group participants had consented to participate in R2P trial and then completed the online course and baseline assessment. This research was reviewed and approved by the institutional review boards at Brandeis University and Oregon Health & Science University.

Participants and Procedures

Purposive sampling was used to recruit pharmacists from the 3 waves that were eligible based on the following criteria: (1) consented into the individual-level study within R2P; (2) completed the online courses, and (3) completed the baseline survey assessment. Eligible pharmacists were emailed 2 weeks in advance of the scheduled focus group inviting them to participate, with 3 additional recruitment emails sent 7-days, 4-days, and 24-hours immediately prior. Of the 76 pharmacists that were eligible, 32 participated in a focus group (42% participation rate).

Focus group questions are available as Appendix A. One social scientist and one academic pharmacist, who were experienced in qualitative methods, co-moderated both focus groups. These two individuals interfaced with participants through the anonymous virtual messaging board to facilitate the discussion and ask probing questions to add depth and insight. Neither of these individuals had conducted in-person academic detailing at the enrolled pharmacies nor had any established relationship to study participants. As a result, study leadership, including the study’s principal investigator and the 2 pharmacists that oversaw the academic detailing efforts on the East and West Coasts, observed the online focus groups in real time. These individuals did not interact with the focus group participants but rather provided prompts and probes to the moderators, as well as context to participant comments (if possible) in real-time. The full study team reviewed the data prior to analysis. Focus group transcripts were uploaded into NVivo software (version 12) (Victoria, Australia) for analysis.

Analysis

Data analysis was conducted with an immersion/crystallization approach,²⁰ leading into the development and implementation of a codebook. The analytic team consisted of 3 social scientists and 4 academic pharmacists experienced in qualitative methods. Data immersion started immediately, concurrent with the online focus groups, where the research team reviewed the online transcript data in real time, noting emergent patterns and insights. To form a codebook post-focus group, 2 lead analysts conducted in-depth data immersion, reading all transcripts multiple times, taking margin notes, and formulating preliminary open and axial codes. Coding was used to make meaning of the unstructured data efficiently and systematically. The preliminary codebook was brought to the broader team for discussion and edited iteratively over a series of weekly meetings. After a codebook was finalized, the 2 lead analysts coded a random subset of data and then ran a coding comparison query. Across nodes the Kappa Coefficients ranged from 0.49 to 0.96, with 63% falling within moderate to substantial agreement range and percent agreements (98.73% to 99.76%) were high. After all data were coded using NVivo software, the analysts conducted a within theme analysis by chunking data²¹ to understand the complexity of each theme, identifying subthemes and the associated program elements being addressed within each theme. Themes were shared at full team meetings and supported by illustrative participant quotes. Themes were refined based on feedback, questions, and discussions, and finally named and written into manuscript form and edited by all co-authors.

Study’s Rigor and Trustworthiness

The study’s rigor and trustworthiness were ensured by using various strategies proposed by Lincoln and Guba by establishing credibility, dependability, confirmability, and transferability.^22,23 Credibility was established using prolonged engagement and including the 2 academic detailing leads, who were also pharmacists, to help oversee the focus groups and provide context to participant comments in real-time. Dependability in the coding was achieved using a coding dictionary with coding comparison queries and Kappa Coefficient calculations to ensure consistency. An audit trail was then maintained throughout the analysis, which included coding frameworks and iterations of how the themes were developed and informed by subthemes and elements of the R2P intervention to further support dependability and confirmability. A “thick” description of participants’ beliefs and experiences enhanced transferability and enables the reader to assess the relevance of these findings within their specific context. This “thick” description includes exemplary quotes, both in the manuscript text and a complementary table, to offer insight into participant views on naloxone, nonprescription syringes, and buprenorphine, as well as the R2P intervention.

Results

Participants

Most of the participants were female (n=18, 56%), non-Hispanic (n=29, 91%), and White (n=17, 53%) (Table 1). Pharmacist participants represented all 4 states participating in R2P and were practicing in Massachusetts (n=6, 19%), New Hampshire (n=9, 28%), Oregon (n=8, 25%), and Washington (n=9, 28%). Each pharmacist participated anonymously for approximately 30 minutes over the course of the two and a half days when the virtual discussion boards were open.

Table 1:

Characteristics of focus group participants, n (%)

Characteristic	Pharmacists (n=32)
Gender
Female	18 (56%)
Male	13 (41%)
Prefer not to answer	1 (3%)
Ethnicity
Non-Hispanic	29 (91%)
Hispanic	2 (6%)
Prefer not to answer	1 (3%)
Race
Asian	9 (28%)
Black or African American	2 (6%)
White	17 (53%)
Unknown	3 (9%)
More than one race	1 (3%)
State
Massachusetts	6 (19%)
New Hampshire	9 (28%)
Oregon	8 (25%)
Washington	9 (28%)

Several themes emerged from the focus group data (Table 2). Most notably, participants described how R2P served to reduce bias and stigma they once held toward people with opioid use disorder (PWOUD) and who use drugs and embrace their role as community caretakers, increased their self-efficacy when interacting with patients about naloxone, and changed their perspectives and practices regarding nonprescription syringe sales. Participants also described challenges they encountered when dispensing naloxone and syringes that included barriers identified at multiple ecological levels including staff personnel, store-level, and systems-level barriers. For each of the 4 main themes, common or unique sub-themes were described in detail and provide illustrative quotations, while other sub-themes are listed briefly.

Table 2:

Emergent themes, subthemes, and additional supporting quotes

Theme 1: Addressing bias and stigma toward people with opioid use drugs and who use drugs.
	“The course helped me to look at each of my patients in a more human aspect, rather than generalizing them as opioid users. It also has helped me to further my understanding on the medications these patients are taking to manage their disease” (Participant 32, Washington Wave 3)
	“…the module helped to reinforce some of approaches I was already taking and was enlightening on some of the difference info I wasn’t fully aware of. Like others I found the buprenorphine info to be helpful as this often is a topic that I feel like is just brushed over and we don’t always have the time to delve deeper into with busy schedules.” (Participant 19, Oregon Wave 1)
	“Our pharmacy did not make an effort to have syringe sales available OTC and this information swayed me to take care of our community as opposed to dissuade users from purchasing syringes at our pharmacy.” (Participant 9, New Hampshire, Wave 2)
Theme 2: Familiarity and comfort with naloxone provision.
Initiating conversations about naloxone while minimizing stigma	“I am comfortable counseling on naloxone use and I am comfortable counseling on overdose prevention. As pharmacists, we are constantly asked about medications and various diseases, this is no different, these are medications that help patients” (Participant 7, New Hampshire, Wave 1)
	“I’m really open now to getting that conversation started and I’d say much better at taking any stigma out of the encounter.” (Participant 18, Oregon, Wave 2)
	“We have been offering more naloxone to patients on certain drug combos. I’ve had some great conversations with patients… My biggest goal was for my techs to not treat these patients different. I like the message meet the patient where they are at now. It was all very useful.” (Participant 15, New Hampshire, Wave 3)
Counseling patients about naloxone using intervention materials	“I use the verbiage in the binder but also just kind of let the conversation flow. The key for my team has simply been to treat everyone equally and don’t judge. We even had a random patient come by and thank us.” (Participant 27, Washington, Wave 2)
	“I’ve had a few patients come in for naloxone. I think most of them were patient that came back after purchasing needles and seeing the sticker on the bag!” (Participant 8, New Hampshire, Wave 1)
Theme 3: Perspective and practice shifts in nonprescription syringe sales.
Barrier reversal	“Although every aspect was useful, syringe sales was something that was ‘common knowledge,’ but this perspective did allow us to sell packs of 10 instead of a box of 100.” (Participant 21, Washington, Wave 2)
Dignity and Harm Reduction	“I think patients are becoming more comfortable asking for syringes knowing that we won’t question them and we will even offer a sharps container.” (Participant 14, New Hampshire, Wave 3)
Safe syringe disposal impact	“Providing sharps containers is a great idea. Used needles are frequently found in our bathroom and parking lot, which is not a pleasant experience for those who have to clean up those areas.” (Participant 32, Washington, Wave 3)
Theme 4: Structural challenges to harm reduction care in the pharmacy
Staff resistance creates barriers to access and puts pressure on one individual	“Unfortunately my colleagues are more along the notion that if the doctor didn’t prescribe it than obviously it isn’t important. So it would be a very rare instance for them to mention Narcan to a patient let alone prescribe it. Most any Narcan involvement gets defaulted to myself.” (Participant 19, Oregon, Wave 1)
Stocking issues leave stores out of stock of naloxone and preferred sizes of syringes	“Stocking. System doesn’t recognize to order specific size syringes if we don’t dispense them as rx” (Participant 3, Massachusetts, Wave 1)
	“Stocking was sometime an issue. Some days we would 3–4 [Narcan] and not have any residual stock on the shelf for the next morning” (Participant 32, Washington, Wave 3)
Cost and co-pay amount can be prohibitive and patients may want purchase to be anonymous	“Price is major factor why most patient refuse it even explaining the importance of having it on-hand” (Participant 29, Washington, Wave 3)
	“It’s difficult when patients are open to Narcan and want the product after discussing, but then the insurance won’t cover it and my patients can’t all afford various copays ranging from $8 to $130. I wish there was legislation requiring insurances to completely cover Narcan for at least high risk chronic opioid patients that they can clearly see are at higher risk.” (Participant 19, Oregon, Wave 1)

Theme 1: Addressing bias and stigma toward people with opioid use disorder and who use drugs.

Participants described how the R2P program helped them and their pharmacy staff to reduce the biases they held toward PWUD and PWOUD and embrace their role as community caretakers. Some participants shared how they gained a more nuanced understanding of medications their patients were taking, specifically buprenorphine. Participants generally focused on their individual learning, offering that buprenorphine is a topic that was “glazed over in schools” or “has been overlooked in other courses,” and they were appreciative of the information. However, others went a step further and discussed how the information helps them engage with these patients more compassionately and with greater knowledge of opioid use disorder (OUD). For example, participant 15 shared:

“So, I admit when people came in so eager for their prescription buprenorphine I did an internal eye roll. Now I understand that this is them trying to get back on track. I honestly go out of my way to give them an extra smile now.

[New Hampshire, Wave 3]

Several participants explained how the R2P program reset or reinforced their perspectives of their role as community caretakers and practice at the top of their license. They described how the community pharmacy is a healthcare facility and how the program gave them “more tools to increase patient safety in the community.” For example, participant 31, a pharmacist in Washington, explained that R2P gave “us all much more understanding and knowledge in how we can further aid our community and provide better healthcare to patients in need.” In addition to reflecting on their own personal shift(s) in perspective, some participants described how they utilized the program materials to encourage shifts in the perspectives and practices of their staff. For example, participant 10 shared:

“Early on, my staff was not totally on board with offering syringes. Mostly, they felt it would attract the wrong people into the store, especially later hours when we have minimal staff. I used the materials provided, as well as other information, to educate and remind them we are a healthcare facility. Patients seeking syringes may be diabetic, or they may have an OUD. Failing to provide syringes to either is not good for their health and the healthcare system as a whole.

[New Hampshire, Wave 2]

Theme 2: Familiarity and comfort with naloxone provision.

Participants described how R2P helped them gain confidence to initiate conversations about naloxone with patients. This was first seen through knowledge gains, as participants discussed gaps in their knowledge and/or training around naloxone provision. The educational modules expanded who participants viewed as candidates for naloxone, particularly around buprenorphine. For example, participant 29, a Washington pharmacist, shared that she “learned about the importance of giving naloxone to these to these patients,” in reference to patients prescribed buprenorphine. Participants also mentioned growing their confidence in counseling patients on naloxone and overdose prevention. For example, participant 10 shared:

“I am much more comfortable counseling on naloxone and overdose prevention thanks to these modules and trainings. In the past, I would’ve said ‘continue therapy at a stable dose’ and they don’t need to be offered naloxone again. Now I think of the potential for them to be prescribed an interacting med unknowingly and go into overdose. The other point I bring up about overdose prevention is that someone else in the household or a friend may take the medication, either inadvertently or intentionally.”

[New Hampshire, Wave 2]

In describing how the R2P program helped them to feel comfortable initiating conversations about naloxone, participants described how the program provided them with added information that they could share with participants and templated language that they could follow to start the conversation without fear of stigmatizing the patient. For example, participant 1 described:

“For me, personally, I have a hard time approaching patients to offer naloxone because I don’t want to offend them. The courses helped me open up conversation with facts and information that I think most patients haven’t heard before (such as syringe disposal and safety). It made me more comfortable and remove some of the stigma with naloxone or syringe buying.”

[Massachusetts, Wave 1]

Participants described how they used the specific language promoted by R2P to initiate conversations with patients about naloxone, such as using breathing emergency instead of “drug overdose,” and using analogies, such as “epi pen” or “fire extinguisher,” as a “just in case” preventative measure to decrease stigma. Participants further described how the R2P templated language helped to expand their offers of naloxone and increase awareness of who is at risk of overdose because it helped communicate that patients were not being singled out. Participants explained how this language around naloxone elicited a better response from the patient and increased the likelihood of patient acceptance of naloxone. For example, participant 11 described:

“It gives pharmacists the tools to offer in the form of what instances to offer (mme, specific drugs used in combination). This takes away a bit of the subjectiveness of whom to offer. Also, it reinforces the seriousness of the inherent dangers of the medications without pointing fingers at those who are prescribed the medications.”

[Oregon, Wave 3]

Some participants described how they used the patient-facing materials provided by R2P to help facilitate conversations. Specific examples included use of the “Save a life, get naloxone, ask a pharmacist” stickers on syringe 10-packs and naloxone information sheet to initiate the conversation about naloxone. Participants also described how these materials resulted in patient-initiated conversations about naloxone, such as the one described by participant 25 in which a patient returned a few days after purchasing syringes with a sticker on it and asked about naloxone – “Syringe buyer. I put the naloxone sticker on the package and offered a sharps container. Few days later, patient requested a naloxone kit” [Washington, Wave 2]. Finally, some participants described how the program helped them increase access to naloxone broadly, including patients who purchase syringes, patients with prescriptions for specific combination of medications, family members or caretakers of patients with an opioid prescription, and other community members. For example, as described by participant 27,

“Definitely dispensed naloxone during the study initiated by pharmacy staff as well as patient initiated. We put naloxone stickers on all narcotic rx and that initiated patients to ask about it. We initiate naloxone with high MMEs and patients are happy to have it. We’ve even had firefighters ask to have one after seeing pamphlets.”

[Washington, Wave 2]

Theme 3: Perspective and practice shifts in nonprescription syringe sales.

Shifts related to nonprescription syringe sales varied across the participating pharmacies. Some participants shared that the R2P program did not impact their views on nonprescription syringe sales because they had “been selling syringes for so long,” while others described clear changes in their attitudes and practices that expanded access to nonprescription syringes for PWUD. Most significantly, this included pharmacies shifting from not selling nonprescription syringes to selling syringes. As shared by participant 9:

“Dramatically. We did not sell syringes prior and feel the materials provided were essential in choosing to change our stance. We will continue to sell syringes with handout/sticker/disposal container going forward. Patients appreciate the care although not very receptive to treatment resources in my experience.”

[Participant 9, New Hampshire, Wave 2]

These changes also included a willingness to sell syringes as 10-packs rather than only by the box (i.e., 100 syringes), which is bulkier and more expensive, further expanding access. For example, participant 26 from Washington, said “It was very informative and well presented… it made me reconsider the selling of syringes in packs instead of by the box.”

Motivations to shift behavior around syringes often paralleled with pharmacists’ view as a community caretaker. Selling syringes was described as making “the community safer” by reducing exposure to used syringes and increasing safety for both the patient and community. Additionally, participants described how selling syringes is important to address the health needs of all patients, as well as promoting respect. Participants further described how selling nonprescription syringes resulted in positive responses from patients, which reinforced the importance of this practice. Others shared experiences with patients expressing gratitude for selling them syringes. For example, participant 31 described:

“Someone came and thanked me after explaining how happy she was that we provided syringes over the counter because she always had such trouble finding any pharmacies that would do this and preferred it to having to reuse needles.”

[Washington, Wave 3]

As part of the R2P program, pharmacies were provided with syringe disposal containers to distribute free of charge to patients. Participants described the impact of being able to provide these disposal units in driving changes in syringe sale practices. These disposal containers helped them to feel more comfortable selling nonprescription syringes, such as making the sale “easier on my conscience,” as well as facilitate more honest and open dialogue with patients. For example, participant 19, shared:

“Having the sharps containers I felt like allowed for a more honest dialogue when patients feel like you were looking out for their safety by offering one to them free of charge. It allowed for a more honest response from patients about syringe use and opened the door for asking the patient about Narcan.”

[Oregon, Wave 1]

Though most participants reported that they now currently sell nonprescription syringes, one participant shared that their store does not sell nonprescription syringes because they “don’t want that type of crowd attracted,” so these changes were not universal.

Theme 4: Structural challenges to harm reduction care in the pharmacy

Participants described challenges they faced dispensing naloxone and nonprescription syringes at multiple levels, and how they address these challenges, often employing the training and tools provided by the R2P program. First, at the individual level, participants described how some of their fellow pharmacists and pharmacy technicians were resistant to change. For example, participants described how staff biases can negatively impact interactions with patients, which then came alongside reminders of the importance of education and communication among pharmacy team members to revisit these attitudes. As participant 19 describes:

“I had a technician that added unnecessary complications and acted very poorly to a patient looking to buy syringes. I again went over with our staff that it is not our job to pass judgement (our thoughts aren’t going to change their mind) but rather to be providing clean supplies and making sure that the patient has the best safety precautions in place with sharps containers and Narcan as an option.”

[Oregon, Wave 1]

Others described how their fellow pharmacists and pharmacy technicians were unwilling to prescribe or dispense naloxone, some believing that if it were important, then the patient’s primary care provider should have prescribed it. For some of these individuals, their role transformed into a de-factor champion or the “go-to pharmacist” when it came to any mention of naloxone.

Second, participants described pharmacy-level stocking challenges of both nonprescription syringes and naloxone as a barrier to dispensing. Participants recounted how nonprescription syringes, generally 10-packs, can be sold under a generic identifier, so stocking quantities in the computer were often incorrect in the computer. Naloxone was also not automatically reordered when out-of-stock at some pharmacies, and others cited a short shelf life of naloxone products as a barrier to keeping a larger quantity on hand. As a result, pharmacists sometimes did not have a patient’s preferred size needle or naloxone available for immediate purchase. As participant 3 describes:

“Sometimes, patients get mad when we do not have the size needles they want and they think we are purposely not selling them to them. We explain its nothing against specific group of people we were simply out of stock at the moment”

(Massachusetts, Wave 1)

Finally, the most commonly reported barrier to obtaining naloxone described by participants was associated at the systems-level, specifically the cost and insurance coverage. The cost of naloxone for those without insurance was the largest barrier to successfully providing these patients with naloxone, and even those with insurance, the cost sharing and insurance requirements were challenging to navigate. Others also described how they understood that insurance would not cover naloxone for a family member, and thus created an additional barrier to obtaining naloxone. As participant 14 describes:

“Most problematic issue with dispensing naloxone is price and insurance. Also people who want to get it for a family member don’t want to have it filled in their name.”

(New Hampshire, Wave 3)

Discussion:

Community pharmacies are well-positioned to improve the health of people who use drugs (PWUD) and have OUD by providing essential public health supplies. However, pharmacies often struggle with this provision. The results of 2 focus groups with pharmacists engaged in community-based practice in 4 states suggest that the R2P intervention, content, and tools can address many of the individual challenges that limit provision of lifesaving public health tools, including naloxone, nonprescription syringes, and buprenorphine.

The stigma of drug use and medication treatment are major drivers of opioid-related morbidity and mortality.^24,25 Fear of judgement and discrimination undermine help seeking and spread mistrust of healthcare providers.²⁶ Data demonstrates that interventions can improve knowledge, attitudes, and behaviors toward related harm reduction and opioid safety;^15,27–30 however, addressing the diverse contributors of stigma requires multicomponent, complex interventions. R2P was designed with this in mind through development and implementation of a pharmacy-based intervention imbued with stigma-reducing tools and approaches. The focus group data suggests that, from the pharmacist’s perspective, the R2P program strengthened motivation and activated individual-level change to improve care toward PWUD and POUD. The impact of these behavioral changes extended beyond the participants, as R2P content stimulated peer discussions and fostered a workplace culture to reduce stigma.

Naloxone access is a core strategy in reducing opioid-related mortality. As a result, targeted efforts, such as communication campaigns (e.g., signage),^12,13 online trainings,^15,31 and academic detailing,^27,32 have focused on community pharmacies. Evidence suggests that naloxone access improvements are occurring;³³ however, evaluation of these pharmacy-based efforts is often limited. There is often minimal assessment of the elements that led to an initiative’s success, or conversely failure, as well as on their impact on interactions between patients and pharmacy staff members. This focus group data suggests that the R2P program facilitated offers and counseling on naloxone from the pharmacists’ perspective, and notably, these findings are further corroborated by the perspectives of patients who reported positive experiences obtaining naloxone from R2P participating pharmacies following intervention.³⁴ Those patients frequently focused on characteristics of effective communication, including being treated with respect, having space for questions and dialogue, and the use of educational and harm reduction materials to support patient safety.³⁴ The consistency in qualitative work with both pharmacists and patients makes this research particularly unique, and supports the stigma-reducing tools and approaches encouraged by the R2P program.

Also consistent with the findings from patients were references to structural barriers that pharmacists wrestle with to expand care to PWUD and POUD, such as stocking, supply tracking, inadequate pharmacy reimbursement, and insufficient insurance coverage for patients; barriers that have been previously well documented in existing literature.^9,32,35 Unfortunately, the R2P program was less effective in addressing these challenges, which supports a clear need for action by stakeholders who are positioned to initiate system-level changes, rather than rely upon individual efforts by frontline staff. Similarly, often overlooked in the pharmacy naloxone access literature is the opportunity to amplify patient access to other harm reduction materials, namely nonprescription syringes. In the 2 focus groups, pharmacists articulated specific and compelling changes in behaviors and attitudes toward providing nonprescription syringes, such as a willingness to start selling syringes or sell in smaller quantities. The ability to provide a disposal container alongside the syringe purchase was often an important contributor in this behavior change. As a result, stakeholders wishing to leverage community pharmacies to expand syringe access might consider disposal containers as a strategy to foster behavior change. Many communities have limited resources to help patients dispose of syringes and other biomedical waste, so similar to cost and insurance barriers, overcoming these structure barriers likely requires system-level solutions.

This study is strengthened by including pharmacists who participated in the same intervention to glean insight into the effectiveness of specific stigma-reducing approach and tools. This provided considerable opportunity to revise and refine for future implementation efforts. However, this does create limitations. All participants were employed by one of 2 national pharmacy chains, so their experiences may not be generalizable to those practicing in other community pharmacy settings, as well as geographic areas not represented in this intervention. Participants also largely identified as non-Hispanic White or Asian, so participants may not fully reflect the pharmacists practicing nationwide. Finally, there was also no opportunity for participants to provide feedback on the themes. Although findings are consistent with other evaluations of the R2P program, inclusion of a member checking step would have further ensured trustworthiness.

Conclusions:

In conclusion, community pharmacists across the 4 states identified attitudes, knowledge, and experiences that create barriers to providing care to PWUD and PWOUD. From the pharmacist perspective, R2P approaches and tools were effective at reducing stigma and changing attitudes but were less effective at addressing structural challenges from the pharmacists’ perspective. Future research on the R2P intervention is planned to assess the impact on objective markers of improved patient care.

Highlights.

• Pharmacies are well-positioned to provide harm reduction services.

• Education can address stigma and attitudinal barriers to harm reduction care.

• Efforts to address system barriers to naloxone are needed.

Appendix A: Focus group questions

Day 1: Experiences with R2P study materials and online course

Post-intervention: online course reflection:

• 1
  Thinking specifically about the online course “Respond to Prevent: Opioid Safety for the Pharmacy,” what are your overall impressions of the course? And by course we mean…

  1. The online course contained 3 modules on patient-provider interactions about 1) naloxone, naloxone dispensing, 2) over-the-counter syringe sales, and 3) buprenorphine safety. Did you take all three modules?
  2. Did you find certain modules more informative than others? How did you decide which modules you wanted to complete?
  3. What aspects of the online course do you feel were the most useful?
  4. What aspects of the online course do you feel were the least useful? What could be improved?
  5. What impact do you think this online course has had on pharmacy practices in your setting? For you? For pharmacists? Pharmacy managers? Technicians? Store managers? Customers?
  6. How, if at all, do you feel the online course would affect the way you engage in patient education about opioid safety? About pain medications and controlled substance safety?
  7. To what extent do you feel the course would affect the use of the prescription drug monitoring program in daily pharmacy practice, if at all?

Impressions of R2P materials:

• 2
  What was your overall impression of the materials provided by the Respond to Prevent study*?

  1. How, if at all, do you feel the materials influenced interactions about syringe purchase at the pharmacy?
  2. To what extent do you feel the online course and study materials affected the provision of naloxone by pharmacists, if at all?
  3. What additional materials did you feel were missing or that you would have liked to have seen made available on the website or available on site?
  4. What other ideas do you have of materials or communication strategies that would facilitate providing naloxone, counseling on buprenorphine or syringe safety to your patients?

Impressions of academic detailing:

• 3What was your impression of the Academic Detailing visit by study staff?
• 4Who in your pharmacy participated in the Academic Detailing session?
• 5What worked well during their visit? What could be improved?

Thank you for your participation today! We encourage you to log in throughout the day to see what others have written and comment on their responses. A new set of questions will be posted tomorrow.

Day 2: Patient Interactions and study experiences:

Experiences providing naloxone

• 1
  Have you provided naloxone to a patient at your pharmacy during the study? Tell us about the circumstances of the naloxone provision—specifically, did you offer it to the patient or did they come in asking for it, or something else?

  1. Did the customer/patient tell you how they knew you had it available? How do you think they found out about this service?
  2. What was the role of your technician(s) in the naloxone interaction?
  3. What counseling did you provide with the naloxone?
  4. What helped/didn’t help in talking with the patient about naloxone? Did you use any of the educational materials, the laminated guide, or from the Academic Detailing visit?
  5. How do you feel about counseling patients on naloxone use? How do you feel about overdose prevention counseling in general?
  6. What problems, if any, did you experience in providing the naloxone? (e.g., Stocking, labeling, training/counseling was not clear/hard to do, insurance barriers, confusion on prescriptions vs. standing order permission, etc.)

Experiences providing syringes:

• 2
  We’d like to hear about your experiences (both positive and negative) providing syringes in your pharmacy. Can you share a positive experience when providing syringes over the counter to patients at your pharmacy during the study? Can you share about a negative interaction when selling syringes at your pharmacy during the study, if one occurred? How did you handle the situation? How did the training modules and materials help with this experience?

  1. Going into this study, what were your thoughts about providing syringe disposal containers to patients purchasing syringes from your pharmacy? How did counseling patients on syringe safety, proper use, and disposal evolve when/if you provided a free study disposal container to patients?
  2. How did provision of the syringe disposal containers affect the interaction at the counter for the syringe purchase, if at all?
  3. What helped/didn’t help in talking with patients about syringes? Did you use any handouts, educational materials, etc.?
  4. What problems, if any, did you experience in providing the syringes? (e.g. stocking, counseling, staff training, etc.)

We have reached the end of the focus group! If you have not already, please check back in throughout the day to comment on other people’s posts.