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. Author manuscript; available in PMC: 2026 Feb 1.
Published in final edited form as: J Subst Use Addict Treat. 2024 Dec 12;169:209606. doi: 10.1016/j.josat.2024.209606

Barriers and Facilitators to the Implementation of Screening and Intervention for Co-use Opioid Medications and Alcohol among Community Pharmacy Patients

Grace Broussard 1, Kenneth C Hohmeier 2, Craig Field 3, Adam J Gordon 1, Kristi Carlston 1, Alina Cernasev 2, Melissa Tyszko 1, Ashley M Snyder 1, Gerald Cochran 1
PMCID: PMC11769736  NIHMSID: NIHMS2042855  PMID: 39672335

Abstract

Introduction

A significant risk for overdose among patients prescribed opioid medications is co-use of alcohol. Community pharmacies are underutilized as a resource to prevent and address co-use. The barriers and facilitators that promote or impede the adoption of universal alcohol screening and intervention at point of opioid medication dispensing are unknown. We assessed community pharmacy leaders, pharmacists, and technician’s perceptions towards the implementation of a pharmacy-based screening/intervention for the co-use of opioids and alcohol among patients.

Methods

We conducted a multi-method study that included one-time key informant interviews combined with a close-ended survey to inform our understanding of pharmacy system/practice-level barriers and facilitators for universal screening and intervention. Participants were recruited from Utah and Tennessee and were required to have active employment as pharmacy leaders, pharmacists, or technicians, be English-speaking, and believe they could provide feedback regarding co-use screening and intervention within community pharmacies. Interviews used the Consolidated Framework for Implementation Research and the Organizational Readiness for Implementing Change assessment. Qualitative analysis included both inductive and deductive coding. Themes followed a cycle of open, initial coding whereby codes were derived inductively from the data.

Results

Themes from interviews (N=68) included a) emphasizing a need to overcome the stigma associated with patients who engage in co-use and a mindset shift to treat the challenges and risks associated, b) need for corporate-level support, management buy-in, and c) appropriate technology to support the workflow including system-wide changes to support the integration of medication therapy management services within community pharmacies. However, barriers were offset by pharmacists eager to understand their role in screening patients and reiterated a focus on patient-centered care to achieve this goal.

From the ORIC assessment, 75% (n=51) of respondents reported that community pharmacy staff wanted to implement the screening and intervention, and 69.1% (n=47) reported motivation to implement the screening and intervention. Finally, 67.6% (n=46) felt that community pharmacies are committed to implementing the screening and intervention, but only 10.3% (n=7) expressed strong support to do “whatever it takes” to implement the screening and intervention.

Conclusion

These results provide critical insights into implementation strategies for the adoption of brief intervention by community pharmacists. These data are foundational to developing strategies for a powered trial and possible future system/practice-level implementation of universal alcohol screening and intervention for co-use.

Introduction

Prescribed opioid medications continue to play a large role in opioid poisonings, with nearly 21% of all opioid overdose deaths in 2021 involving prescription opioids (CDC, 2023). Opioid pain medication-involved overdose remains as the second type of opioid involved overdose in the U.S. (KFF, 2021). Among common risk factors for overdose include central nervous system depressants, interactions with which can cause serious adverse effects, including sedation, respiratory depression, coma, and death (Lee et al., 2021). Alcohol is a commonly used central nervous system depressant that has been observed to be involved in approximately 1 in 7 opioid-related deaths (CDC, 2024). Existing literature among patients dispensed opioid medications has shown that co-use of alcohol and opioids is widespread with 20–30% reporting current high-risk drinking (Cochran et al., 2021; Cochran, Charron, et al., 2022; Cochran et al., 2017). Co-use of opioids and alcohol is strongly discouraged by the U.S. Centers for Disease Control and Prevention (CDC), National Institute on Alcohol Abuse and Alcoholism (NIAAA), and packaging inserts for opioid medications specifically warn against co-use (CDC, 2022; FDA, 2016; NIAAA, 2023).

Community pharmacists are an underutilized resource to expand the continuum of care to better identify and address co-use. In the U.S., nearly 90% of Americans live within 5 miles of a community pharmacy (Berenbrok et al., 2022), and in rural areas, pharmacies are frequently a first point of contact for patients (Ashcraft et al., 2022). Patients visit their community pharmacies 1.5 to 2 times as often as their primary care provider or other health care professionals (Valliant et al., 2022). Accessibility, paired with the unique skill set of a pharmacist, places pharmacists and pharmacy staff in a unique position to provide care to patients receiving opioids during dispensation and screen for alcohol co-use.

A number of tools have been developed to address co-use in community pharmacy settings. For instance, brief motivational interventions targeting alcohol use are widely accepted and successful in a variety of healthcare settings in addressing alcohol misuse among patients (Barata et al., 2017; Floyd, 2021; Kamath et al., 2022) and mounting evidence points towards brief intervention as an effective tool for lowering misuse of opioid medication (Bohnert et al., 2016; Cochran et al., 2019; McCauley et al., 2013; Zahradnik et al., 2009).

Pharmacists across the U.S. (including both Utah and Tennessee) are bound by corresponding responsibility – meaning the pharmacist must use their own professional judgement when dispensing medication (Pharmacy, 2021; Tennessee, 2020). The goal of a screening and brief intervention program would be to empower pharmacists to live that policy and exercise their corresponding responsibility when dispensing controlled substances such as opioids when there is a concern about co-use of alcohol. There is growing support to fund SBIRT (Screening, Brief Intervention, and Referral to Treatment) programs within community pharmacy to support these efforts (SAMHSA, 2023), but these are limited (only 10 awards in 2024). Further, pharmacy curriculum and the National Association of Boards of Pharmacy have limited focus on screening and brief intervention in pharmacy – screening for substance use disorders, alcohol, co-use, and brief intervention programs aren’t mentioned in a review of either (Education, 2024; Pharmacy, 2023). This lack of emphasis on addressing substance use in community pharmacy points to a need for further development of screening and intervention programs to address this gap in care. There is evidence of the efficacy of a Brief Intervention Medication Therapy Management (BI-MTM) program delivered in the community pharmacy setting (Cochran et al., 2019). These existing models lay the foundation for scaling interventions in community pharmacy.

Nevertheless, a significant challenge is scaling evidence-based practices across pharmacies (Curran & Shoemaker, 2017; Michel et al., 2022; Smith et al., 2020). Challenges may arise at multiple levels of delivery; the patient level and intervention reception, provider/pharmacist level to successfully deliver the intervention, and the organizational level to adequately support the intervention (Damschroder et al., 2009; Seaton, 2017). If successful interventions are identified and implemented into pharmacy practices, then the community pharmacy setting will represent a critical patient touchpoint to reduce co-use of opioids and alcohol, and ultimately reduce adverse health outcomes for patients in almost every area of the U.S. (Fitzgerald et al., 2012; Hattingh & Tait, 2017; Le & Hotham, 2010).

Methods

Design and Participants

This study employed a multi--methods approach and included cross-sectional key informant interviews and a structured online survey to pharmacy leaders, pharmacists, and technicians related to pharmacy system and practice-level barriers and facilitators for universal screening and intervention delivery between April and August 2023. The study recruited participants through convenience sampling in Tennessee and Utah of respective boards of pharmacy and licensing bodies, state pharmacy association conferences, and professional networks of study investigators.

Potential participants were approached and screened for eligibility criteria. Inclusion criteria required participants to be actively employed as a pharmacy technician, pharmacist, or in roles related to pharmacy management or within a pharmacy corporate setting; English-speaking; and acknowledge they had an interest and opinion on universal screening and intervention for co-use of alcohol and opioids within community pharmacy. Finally, a snowball method supplemented recruitment whereby at the end of each interview, interviewers asked participants for suggestions of other individuals who would represent the perspective of a pharmacy corporate leader, pharmacist, or pharmacy technician.

Interested individuals who met inclusion criteria provided informed consent. Researchers of diverse gender identities, including both men and women, all holding graduate degrees conducted interviews. Interviews typically lasted approximately 40 minutes in person and over the phone. Participants received a $75 gift card after completing the interview and survey. The University of Utah and University of Tennessee Institutional Review Boards approved the study.

Procedures

The multi-methods approach for this study took place in two steps. Interviewers established rapport with the participants before the interview through introductions and by providing background information about the study and the proposed screening and intervention. Interviews were audio recorded and transcribed verbatim using Rev.com, a web-based transcription software. A study team member reviewed each transcript prior to coding to ensure accuracy. Following the interview, the study emailed each participant a survey including demographic questions and a 12-question quantitative assessment adapted from the Organizational Readiness for Implementing Change (ORIC) assessment (Shea et al., 2014; Toolkit, 2024).

Assessments

The study team adapted the semi-structured interview guide from the 2009 Consolidated Framework for Implementation Research (CFIR), a multidimensional framework comprised of constructs for drawing out information related to implementing evidence-based interventions into practice (Damschroder et al., 2009). The CFIR was adapted using a stepwise approach guided by experts to address the specific pharmacy setting. The interview guide underwent multiple rounds of adaptation to ensure it mapped back to their respective CFIR domain and was relevant for the specific community pharmacy setting. The final guide consisted of 11 open-ended questions (Serhal et al., 2018; VanDevanter et al., 2017; Warner et al., 2018), see Table 1 for full interview guide and corresponding adapted CFIR domain. The ORIC assessment evaluated how well pharmacy staff feel they can implement the changes required to implement the screening and intervention. This measure has demonstrated high inter-item reliability and construct validity (Shea et al., 2014).

Table 1.

Adapted Interview guide with corresponding CFIR domain

CFIR Domain Interview Question
Outer Setting What do you believe are the needs and preferences of patients who are prescribed an opioid and also co-use alcohol? Why do you think this? Can you share a specific example or situation?
How do chain pharmacies currently address these needs and preferences when providing care for patients taken a prescription opioid who may also use alcohol?
Intervention Characteristics How well do you think an opioid/alcohol MTM service for patients who co-use alcohol and prescribed opioids will meet the needs of the patients served by chain pharmacies? Why do you think this?
Inner Setting What barriers do you anticipate in providing this intervention?
Outer Setting What are the barriers to patients accepting the service? Why do you think this?
Characteristics of Individuals In your opinion, what is the level of need for an opioid/alcohol MTM service for patients with prescribed opioids and alcohol co-use? Why?
What type of financial or other incentives for pharmacy staff would influence the decision to implement such a service line? Why?
Intervention Characteristics What kind of supporting evidence or proof is needed about the effectiveness of this service line to get pharmacy staff (pharmacists, pharmacy technicians, and pharmacy interns) on board?
Inner Setting In your opinion, what types of workflow changes will be needed to accommodate an opioid/alcohol MTM service? Why?
In your opinion, how can the pharmacy software or other technology help you to implement this opioid/alcohol MTM service? Why?
So how would you describe the culture of your organization right now?
How do you think your organization’s culture, general beliefs, values, and assumptions that people maybe hold could affect the implementation of this intervention?
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Data Analysis

Qualitative analysis included both inductive and deductive coding. Concurrent with coding of constructs using CFIR, open coding was used for concepts not otherwise captured, whereby codes were derived inductively from the data. Open coding captured additional questions or commentary during the interview process that didn’t fit into CFIR domains. To expedite data analysis for use by the research team in adapting the evidence-based screening and intervention being studied, the team conducted analysis using rapid assessment procedures (RAP) using an iterative cycle of data collection and analysis (Beebe, 2001; Renfro & Hohmeier, 2022; Vindrola-Padros et al., 2020). RAP is an evidence-based, rigorous qualitative analysis method which is well-suited for use with CFIR (Keith et al., 2017). Using the RAP framework, study team members developed a case memo template to code each transcript. The template included the deductively derived codes pulled from the four CFIR domains employed in the interview guide as well as an opportunity to include any inductively derived codes not captured by the CFIR interview guide and relevant supporting quotes. To improve the rigor of the analysis, a small group of study participants from various backgrounds reviewed the preliminary codes to ensure quality. Once case memos were completed, codes were developed and added to a matrix. Once the matrix was complete, the study team thoroughly reviewed it to determine when saturation had been reached. The study team utilized the consolidated criteria for reporting qualitative research (COREQ) checklist, see Appendix A for full checklist. (Tong et al., 2007).The study team that conducted the majority of the data collection and analysis was supervised by the Principal Investigator with extensive experience in both community pharmacy and qualitative research.

For quotes, participants are identified using their anonymous study ID number, pharmacy role, location, and pharmacy type (Table 2). Quotes were denaturalized, including removing utterances (e.g., “like,” “you know,” repeated words or sounds from a word) that could distract from a participant’s message. Some words were added or replaced for clarity or to protect the participant’s identity. However, the meanings of quotes were not changed. Additional illustrative quotes are noted in the Appendix B. The ORIC assessment was analyzed using frequencies and percentages to describe participant’s perceptions of organizational change.

Table 2.

Components of quote identifiers, which are reported as (Study ID-Role-Location-Type)

Study ID: #
Role: P (Pharmacist), PT (Pharmacy Technician), CL (Corporate Leader)
Location: UT (Utah), TN (Tennessee)
Pharmacy Type: Independent Pharmacy (IP), Chain Pharmacy (CP)
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Results

Pharmacy technicians (n=22), pharmacists (n=24), and corporate leaders (n=22) participated in the interviews. Participants were from Tennessee (n=37) and Utah (n=31). Participants included professionals from various community pharmacy settings including 35% from independent pharmacies (n=24), 44% from chain pharmacies (n=30), and 15% from academic, clinical, or government settings (n=10). Only 6% of participants (n=4) did not identify their pharmacy setting. Over half (54%) of participants (n=37) had been working at their pharmacy location for over five years.

Themes and Patterns were identified using CFIR Domains:

Domains included in our analysis were outer setting, intervention characteristics, characteristics of individuals, and inner setting. Each domain is briefly described below:

Outer setting is defined by CFIR as “The setting in which the Inner Setting exists…there may be multiple Outer Settings and/or multiple levels within the Outer Setting” (CFIR, 2009d).

Intervention characteristics are defined as the “key attributes of interventions that influence the success of implementation” (CFIR, 2009c).

Characteristics of Individuals refers to the “interplay between individuals and their ripple effects through their teams, units, networks, and organizations on implementation” (CFIR, 2009a).

Inner setting is defined as “the setting in which the innovation is implemented, there may be multiple Inner Settings and/or multiple levels within the Inner Setting” (CFIR, 2009b).

Themes and Patterns Within Outer Setting

When discussing the outer setting, participants highlighted the influence of local attitudes, societal pressure, and policies on the implementation of a co-use screening and intervention in community pharmacy. There was strong emphasis on the need to provide patients with comprehensive information regarding the health effects of co-use of opioids and alcohol and the importance of honest and direct conversations with patients (see Appendix B). Participants discussed the importance of understanding patients’ unique pain management needs and goals of care, especially to combat stigma surrounding opioid prescriptions. Understanding patient goals of care while maintaining safety would require a proactive approach to intercepting patients during opioid dispensation at pharmacies.

“I think one of the other needs…that I thought of right away was empathy from the pharmacy team. I think a lot of them have understandings about opioid prescriptions that they might be stigmatized.”

(4-P-UT-CP)

Participants acknowledged societal pressures, specifically the opioid crisis, as a motivator for implementing patient safety interventions. They recognized the need for robust harm reduction measures (see Appendix B) to provide adequate safety for patients further than the standard methods (e.g., warning labels and informational pamphlets). Further, participants expressed concerns that the opioid crisis has heightened their liability associated with prescription opioid dispensing and felt that strict regulations impact their ability to provide adequate patient care for those at risk for co-use (see Appendix B). Although counseling is already mandatory in many U.S. states, participants felt the depth of counseling may not be sufficient, and there could be inconsistencies between providers on the counseling they provide.

“I think if there was more time, chain pharmacies would be able to handle it a little bit better. But a lot of times it boils down to, “You need to read the pamphlet, or the package insert.” They give you the drug information. And how often do people do that? Rarely ever, right?”

(8-PT-UT-CP)

Participants identified various barriers to patients receiving a co-use screening and intervention within community pharmacy, including privacy concerns (specifically fears and concerns about losing access to medication), cultural norms, and insufficient education about the risks of opioid and alcohol co-use (see Appendix B). Among these concerns, opinions on the perception of the role of the pharmacist varied. Some participants believed patients would rather discuss their medication management with their primary care provider and would not want to spend extra time in the pharmacy to receive the intervention (see Appendix B). Other participants felt that patients would be more receptive to a conversation about co-use with their pharmacist over prescriber because they may feel more confident in discussing co-use without risk of losing access to medication.

“Many times, the offer to counsel is there, but patients aren’t willing to receive it. Sometimes they feel like they’ve received everything they needed to know from their provider that’s providing the prescription, but oftentimes they don’t, or they’re not interested in it, they don’t really want to learn about it.”

(28-CL-UT-IP)

Themes and Patterns Within Intervention Characteristics

Participants reported that the screening and intervention’s efficacy in meeting patients’ needs is contingent upon its development with a focus on reducing stigma, educating and improving patient awareness of risks of co-use, and leveraging the unique role of pharmacists in its delivery. Participants recognized that pharmacists have an opportunity to provide counseling, and patients may be more receptive and more comfortable talking to the pharmacist than their physician. Some participants felt the screening and intervention would be an effective addition to existing counseling services and would be easily incorporated into the workflow.

The adaptability of the screening and intervention was noted as a potentially valuable aspect, specifically, its ability to target specific patient demographics and use behaviors, spanning from short-term or chronic opioid users. By keeping specific patient characteristics in mind, participants felt the screening and intervention could address patient stigma, educate patients about co-use of opioids and alcohol, and utilize the unique pharmacist-patient dynamic to keep patients safe.

“I feel like that would be a huge benefit, just because doctors are wonderful and they have a relationship, but people see their pharmacist and have better accessibility to their pharmacist on a daily basis.”

(37-CL-TN-IP)

“I think it’s very patient-specific. […] I think it would be helpful maybe [for] the chronic opioid users.”

(61-CL-TN-IP)

In order to get buy-in from pharmacy staff, participants reported needing an empirical evidence base of the screening and intervention’s effectiveness. This included evidence derived from pilot studies and peer-reviewed literature, the prevalence of co-use within their patient population, and a demonstration of the screening and intervention’s successful implementation in pharmacy settings. Further, many emphasized the need for professional support to back the screening and intervention’s credibility.

“…I think it’s just studies on it happening, trying it out in a few areas and seeing what happens, what works, what doesn’t, it’s helping at all or if it’s just being a waste of time and the patients aren’t agreeing to do it for the most part, and how to streamline the process so that it’s the most efficient and best for the patient.”

(17-PT-UT-IP)

While some participants requested evidence to back the screening and intervention, other participants felt the need was already high and the screening and intervention would be an effective addition to services already available and would be easily incorporated into the workflow.

“For something like this, I don’t even think you need supporting evidence or proof. We’re going to believe it. If you tell us that a million people die a year to something like this, or if you tell us half a million people die a year, either way, we’re going to believe it.”

(11-PT-UT-CP)

Themes and Patterns Within Characteristics of Individuals

There were widespread perceptions among corporate leaders, pharmacists, and pharmacy technicians that the screening and intervention was a high priority. Many felt it would fulfill patient needs and had the potential to foster patient autonomy and self-efficacy (see Appendix B). Participants highlighted the professional responsibility and ethical duty to address co-use among opioid users and agreed that pharmacy leadership support would be necessary, but some felt their organizations already support similar patient counseling initiatives.

“I think that every single pharmacist who dispenses an opioid has a moral as well as a professional obligation… to have that conversation with every patient that receives an opioid.”

(58-CL-TN-IP)

While participants generally supported the screening and intervention, some expressed concerns about the pharmacy staff’s ability to address the nuances of each patient’s goals of care, pain management, and the patient’s reception to the screening and intervention. Further concerns surrounding feasibility included lack of support from corporate leaders, logistics surrounding the actual dispensing of prescription opioids, and insufficient resources for pharmacy staff.

“I think that the biggest one would have to be adherence. So yes, there’s time, yes, there’s reception, but adherence in any sort of therapy is one of the biggest barriers. Like getting patients to take their prescription every day or getting patients to go to the doctor once a year.”

(8-PT-UT-CP)

When asked about financial incentives as a tool to motivate buy-in, many participants thought that small bonuses for each screening and intervention delivery or insurance reimbursement could be a motivating factor to deliver the screening and intervention. While some believed financial incentives would be effective, others emphasized intrinsic motivation, driven by the desire to positively impact their patients’ lives. Many participants expressed concern that financial incentives would be ineffective as pharmacy staff don’t often see the results of their work and would not work in community pharmacy settings. Finally, many felt that other kinds of support would be more effective, such as increased staffing or formal recognition of work (see Appendix B).

“Let’s be honest, at a chain store level, the pharmacist is not going to receive those incentives. The chain will receive those incentives. Pharmacists have so long not been reimbursed for what they offer.”

(1-CL-TN-CP)

Themes and Patterns Within Inner Setting

Participants were able to identify significant barriers that existed within community pharmacy structures and work environments that might hinder the success of the screening and intervention. These include time pressure, staffing issues, heavy workload, and high rates of burnout (see Appendix B). Many felt that the screening and intervention would put too much pressure on pharmacists, as they are already heavily burdened by the existing workflow. The existing staff shortages and limits of pharmacy technician responsibilities further exacerbate this issue, limiting the capacity of the pharmacist to deliver the screening and intervention.

“…the main thing that comes to mind is just all the time restraints…being able to get everything done that you want to do at the same time of filling prescriptions. And managing employees, managing individuals, managing inventory, managing third party billing restraints. There’s a lot of things going on.”

(29-CL-UT-IP)

Participants recognized that patients may be reluctant to engage in a discussion about opioids and alcohol, as this can be extremely sensitive, and the topic is frequently stigmatized. Participants were concerned that pharmacists may not have the specific communication skills to navigate these sensitive conversations in an efficient and effective manner. This was connected to both a lack of trust between pharmacists and patients, as well as a lack of training and development (see Appendix B). Further, participants suggested that a disparity between training, experience, and setting may lead to inconsistencies in screening and intervention delivery and quality of care provided.

“There’s a lot of stigma surrounding alcohol use, and patients may be shameful and may not want others to know about their alcohol, their substance abuse if at all possible.”

(47-P-TN-CP)

“…there has to be some training done for the pharmacist on bringing this up in a non-judgmental way to make the patient not feel defensive.”

(67-CL-TN-IP)

Accessibility barriers, including language barriers and access to transportation, also may hinder patients’ access to the screening and intervention. Financial considerations were at the forefront of participant discussions, particularly concerning patient costs, reimbursement mechanisms, and partnerships with insurance companies and healthcare systems.

“Cost is going to play into this, right? That’s going to be the cost to the patients. Are we charging for this [medication therapy management] service? [Does the patient] have to pay a copay? [Does the patient] have to pay something for this? I mean, that’s definitely going to put in barriers to patients.”

(5-P-UT-IP)

Technology was also identified as a barrier; some participants reported that the screening and intervention would fit in well with existing software and expressed compatibility, but others felt that new software would need to be developed to support and sustain implementation (see Appendix B). A small group of participants expressed concerns about the potential for technology (i.e., Artificial Intelligence) to replace the role of a traditional pharmacist.

“Well, so there’s the alert fatigue, so trying to avoid that…but maybe like a flag or something just to kind of remind the pharmacist while they’re verifying the order that maybe they’d be a good candidate.”

(42-P-TN-IP)

When specifically focusing on how workplace culture could impact implementation, positive aspects of workplace culture were highlighted that could be supportive including ongoing education and patient-centered practice. On the other side, negative aspects of workplace culture, such as lack of professional respect, profit-driven priorities, and outdated systems could impede implementation. Overall, participants pointed to time pressures as a strong influence on screening and intervention delivery and patient-centered care.

“…I think, traditionally, pharmacy in general and where I have worked has been a business rather than an area for professional services. And it’s very difficult to separate the business aspect from the professional aspect, even in physician’s offices and things.”

(40-P-TN-IP)

These results focus on the multifaceted challenges and considerations for screening and intervention implementation in community pharmacies. These cultural, technological, social, and structural factors must be addressed for successful implementation and patient outcomes to occur.

Quantitative Results

Following the qualitative interview, the study emailed participants (n=68) the ORIC assessment to complete independently. All participants completed the assessment. This assessment is an effective tool for healthcare leaders to assess change and focus implementation in their own settings (Shea et al., 2014).

From the ORIC assessment, 75% (n=51) of respondents reported that community pharmacy staff wanted to implement the screening and intervention, and 69.1% (n=47) reported motivation to implement the screening and intervention. Although motivation to implement was high, confidence to manage politics of implementation was lower, with only 57.4% (n=39) reporting some confidence, and 42.6% (n=29) reporting neutral or little to no confidence. This could be due to their confidence in their organization to support them while they adjust to the new change, 58.9% (n=40) reported only at least “some confidence” in their organizations. Further, 67.7% (n=46) reported that their organization could get people invested in implementing the screening and intervention, and 58.9% (n=40) felt confident in their organization to support them as they adjust to implementation change.

Finally, 67.6% (n=46) felt that community pharmacies are committed to implementing the screening and intervention, but only 10.3% (n=7) expressed strong support to do “whatever it takes” to implement the screening and intervention.

There were interesting differences between the role of the participants and their ORIC results. Specifically, the question “People who work in community pharmacies are committed to implementing this change” the corporate leaders felt stronger with over 79% (n=17) agreeing, while 72% (n=16) of pharmacy technicians agreed, but only 56% (n=13) of pharmacists agreed. This connects back to the pharmacists’ feeling of burnout and their higher load of responsibility in their setting. Further, when asked “People who in community pharmacies here feel confident that they could keep the momentum going in implementing this change” the pharmacy technician group agreed the most with 81% (n=18) with 74% (n=17) of the corporate leader group agreeing. Within the pharmacist group, only 43% (n=10) agreed, and 35% (n=8) disagreed with this statement. These differences in responses point to the specific responsibilities and workload that would fall on each individual when implementing a screening and intervention program for co-use of opioids and alcohol in community pharmacy settings.

While community pharmacies are strongly motivated to provide this service, proper development and implementation will be paramount to the success of the screening and intervention, its impact, and long-term sustainability in community pharmacy.

Discussion

This multi-methods study identified barriers and facilitators to the implementation of a co-use screening and intervention in a community pharmacy setting. These findings suggest that pharmacy staff believe community pharmacies are underutilized as a means to reduce co-use of opioids and alcohol, and that a pharmacist-led co-use screening and intervention would be feasible in a community pharmacy setting. However, pharmacists also noted several barriers that would impede screening and intervention implementation in addressing this concern. These results have the potential to facilitate the implementation of a screening and intervention in community pharmacy aimed at directly addressing co-use and reducing risks of overdose among patients.

Both survey and interview data indicated that a co-use screening and intervention could be feasible and important in capitalizing on the community pharmacist’s existing relationship with the patient to improve patient outcomes. This is consistent with other studies that have found that pharmacy staff desire to have a greater role in opioid use disorder interventions (Hohmeier et al., 2021; Thakur et al., 2019). Given brief intervention use in various healthcare settings, such as primary care, emergency departments, and telehealth (Kamath et al., 2022), this track record lays an important foundation for possible implementation in community pharmacy. It is important to note that recent research has demonstrated that pharmacists are capable of delivering high fidelity, brief motivational interviewing interventions focused on opioid medication use when provided corresponding training (Kinsey et al., 2024).

Stigma was identified as a common barrier to the ability of the pharmacist to perform the co-use screening and intervention, and this included the pharmacist’s expectation of the patient’s resistance to the screening and intervention, and the ability for a subsequent discussion to occur on co-use without defensiveness or retribution. Although pharmacists possess general patient communication skills as part of their professional education, participants noted that pharmacists had limited training on having stigmatizing conversations and motivating behavior change. Respondents reported that pharmacists did not often have the opportunity in practice to engage in nuanced and sensitive discussions with their patients. Pharmacists have similar feelings regarding screening patients for opioid misuse (Cochran et al., 2013) and point to supplemental training to bridge this gap in order to best engage in conversations with patients on their co-use.

Trust between pharmacist and patient was another critical topic identified as a potential facilitator to success. Pharmacists can provide care and education to their patients in a comfortable setting facilitating strong relationships. In such interactions, it is essential that practitioners demonstrate effective listening, acknowledgment of complex health care needs, and availability to foster a strong patient-pharmacist relationship to bolster a patient’s confidence in their pharmacist (Gregory & Austin, 2021). Such communication skills specific to sensitive and stigmatized topics are critical to delivering patient-centered care in this population (Goggin et al., 2010) and promoting therapeutic alliance between the screening and interventionist and the patient (Flückiger et al., 2012). Pharmacists are among the most trusted healthcare professionals (Brenan, 2023) and may present an additional source in which to confide health concerns or questions. To carry out such interactions or interventions with patients, participants suggested pharmacists need resources to support implementation including dedicated physical space to have conversations with patients (such as pre-existing rooms for vaccinations which exist in at least 40% of community pharmacy settings, (Peacock et al., 2007)), corporate support and buy-in, and payment structures in place to ensure program sustainability. These barriers have been widely reported in the published literature, specifically concerns with addressing corporate buy-in and programs to incentivize pharmacy staff to implement new interventions (Shoemaker et al., 2017). Such resources are highly relevant to ensure program longevity and can reduce negative outcomes. For instance, increasing responsibility while under-resourcing pharmacists may result in burnout and subsequent turnover (Dee et al., 2023; Durham et al., 2018).

Although participants had positive views of the co-use screening and intervention, context-specific adaptations were suggested as necessary to ensure implementation was successful. By adapting a screening and intervention that accounts for constraints of pharmacy, skillset of the deliverer, and is sensitive to the climate surrounding opioid use and the epidemic, pharmacists can become a more active member in the care team. To that end, participants suggested screening and intervention which were mindful of existing workload, workflow, and which were brief in nature. Such adaptations may be guided by pharmacy-specific adaptation frameworks which already exist, or by similar interventions (Cochran, Shen, et al., 2022; Hohmeier et al., 2019).

Limitations

While this study has many strengths including a contextual understanding of the pharmacy setting and barriers faced, flexibility in adapting a large sample size representative of the population, and in-depth interviews that allowed for a holistic approach to all factors influencing this screening and intervention—it nevertheless possesses limitations that should be taken into account when considering its findings. The primary limitation was that the study was conducted in two geographic areas (Utah and Tennessee) and could be limited in its generalizability of results beyond these areas. Future research on this topic may benefit from sampling additional locations with variations in pharmacy regulation, culture, and practice across states. In addition, while we collected limited professional information, more detailed demographic data, such as age, sex, and experience with alcohol and other drug use were not collected. Further research should examine differences between professional and demographic groups given the possible impact of those characteristics on perspectives regarding co-use services provided in community pharmacies. However, the data collected was not limited in its ability to inform understanding of community pharmacies and the nuance of these settings.

Finally, this study was limited in its scope. While we examined the barriers and facilitators to implementation success through the lens of a pharmacy staff members and leadership, we did not address the perspective of the patient. This perspective is extremely important in the screening and intervention’s success and further research to understand their role would inform implementation strategy. Although this perspective was focused, we believe the responses we received from pharmacy staff and leadership are insightful and will further pharmacy practice.

Conclusion

The opioid epidemic is ongoing and a significant risk to patients is the co-use of opioids and alcohol. Pharmacists, pharmacy technicians, and corporate leaders in Utah and Tennessee were interviewed about their perceived barriers and facilitators to implement a screening program for patients using opioids to address co-use of opioids and alcohol in community pharmacy. Implementing resources to identify and intervene on co-use of opioids and alcohol has the potential to reduce risks for adverse outcomes among patients. These results provide critical insights that may be helpful for executing future research to large scale services implementation.

Supplementary Material

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Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism, R34AA029447.

Footnotes

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Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Compliance, Ethical Standards, and Ethical Approval

The aims of this study and its protocol have been approved by the University of Utah and University of Tennessee Institutional Review Boards.

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NIHMS2042855-supplement-2.docx (31.6KB, docx)

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