A survey of Alberta pharmacists’ attitudes, comfort and perceived barriers to a community-based naloxone program

Abstract

Background:

Community pharmacists play an important role in the wellness of patients, families and friends affected by prescription and illicit opioid drugs. They are key partners of the Community Based Naloxone (CBN) Program in Alberta and similar programs across other Canadian jurisdictions. This publicly funded program is an evidence-based response to the opioid overdose crisis, facilitating access to and distribution of naloxone kits through pharmacies. The study aimed to describe Alberta community pharmacists’ practices, training, comfort levels and views in dispensing naloxone kits through the CBN program and detail potential perceived barriers to program participation.

Methods:

The study was conducted as a cross-sectional online survey of Alberta pharmacists. Data collected from the survey were descriptive and evaluated using Microsoft Excel. Fisher exact tests were used to study the associations in responses among several demographic characteristics and related to dispensing practices, pharmacists’ beliefs and perceived barriers.

Results:

A total of 255 responses were included in the final analysis, with 89.8% of pharmacists replying “yes” to CBN program participation. Pharmacists on average were “comfortable” dispensing naloxone to patients for varying indications, with 85% reporting always providing education when dispensing naloxone to an individual for the first time. About 41% of pharmacists reported no barriers to the program, with the most common perceived barriers being lack of time (29%), demand (20%) and funding (19%).

Conclusion:

Most community pharmacists who responded to the survey participate in the CBN program in Alberta. They held positive beliefs about their role in screening patients for the risk of opioid overdose and are confident in their abilities to recommend and educate on naloxone kits. Proactive screening appeared lower, however, and dispensing kits were potentially variable. Addressing factors such as time, funding for services and demand may help further pharmacist uptake and success of the program. Can Pharm J (Ott) 2021;154:xx-xx.

Knowledge Into Practice.

• Community pharmacists are ideally positioned to assess and identify patients for naloxone distribution and are key partners of the Community Based Naloxone (CBN) program.

• There are limited Canadian data exploring pharmacists’ perceptions about community-based naloxone programs. Understanding these views and addressing possible barriers may aid in increasing engagement and participation in this type of harm reduction program.

• Highly variable dispensing practices and screening exist, despite community pharmacists holding positive beliefs about the importance of their role in screening patients and confidence in their abilities to recommend and educate on naloxone kits. Data suggest a low number of naloxone kits to opioid prescriptions distributed from community pharmacies.

• The article provides insight into possible barriers perceived by community pharmacists to participation in the CBN program, highlighting the need to address factors such as time, lack of sufficient funding for services and demand.

Mise En Pratique Des Connaissances.

• Les pharmaciens de la communauté sont très bien placés pour évaluer les patients concernés par la distribution de la naloxone et sont des partenaires clés du programme Community Based Naloxone (CBN).

• Il existe peu de données canadiennes concernant les perceptions des pharmaciens sur les programmes communautaires pour la naloxone. La compréhension de ces points de vue et l’élimination des obstacles éventuels peuvent contribuer à accroître l’engagement et la participation à ce type de programme de réduction des risques.

• Les pratiques de distribution et de dépistage sont très variables, bien que les pharmaciens de la communauté soient convaincus de l’importance de leur rôle dans le dépistage des patients et qu’ils aient confiance en leurs capacités à recommander la naloxone et à fournir sur celle-ci des informations. Des données indiquent un faible nombre de trousses de la naloxone pour les ordonnances d’opioïdes distribuées par les pharmacies communautaires.

• L’article donne un aperçu des obstacles possibles perçus par les pharmaciens de la communauté à la participation au programme communautaire pour la naloxone, en soulignant la nécessité d’aborder des facteurs tels que le temps et le manque de financement pour les services et la demande.

Introduction

The opioid crisis is a leading public health and safety concern across Canada. Between January 2016 and March 2020, there were 16,364 apparent opioid-related deaths. ¹ In response to the increasing number of deaths year-over-year associated with opioid-induced respiratory depression (OIRD), Alberta Health (AH) and Alberta Health Services (AHS) implemented Alberta’s Community Based Naloxone Program (CBN) (formerly Take Home Naloxone, THN). The program is an evidence-based response to the opioid overdose crisis.^2,3 It facilitates distributing naloxone kits as a lifesaving antidote to be administered by members of the public. The program allows for access and distribution of naloxone kits at no charge to Albertans who are at risk of OIRD or who may encounter others who have overdosed. ⁴ Currently, similar publicly funded programs exist across all Canadian provinces and territories.^5,6

THN programs have demonstrated efficacy in reducing opioid-related deaths. ⁷ To improve access for vulnerable populations, naloxone for use in the emergency treatment of opioid overdose outside of a hospital setting is classified as a Schedule II drug (requires pharmacist intervention for dispensing) in all provinces and territories except Alberta, British Columbia and Saskatchewan, where it is unscheduled.^5,8 Despite being an unscheduled product in Alberta, as per Alberta College of Pharmacy (ACP) guidelines, naloxone kits must be kept in the dispensary, and those who receive a naloxone kit must be offered training on the appropriate use and administration of the products—available in an intramuscular injectable form.^4,9

The inclusion of a CBN program in British Columbia’s THN program in 2017 had several benefits, including easier access to naloxone kits, screening patients for naloxone, opportunity to address stigma and providing education.^10,11 Pharmacies in Alberta began participating in the CBN program in January 2016. As of March 31, 2020, approximately 1241 community pharmacies have distributed 75,218 naloxone kits to Albertans. ¹² Pharmacists play an important role in the wellness of patients, friends and family affected by substance use and are key partners of the CBN program. ¹³ Given the uptake of the program by community pharmacies, there are limited data assessing community pharmacists’ perceptions about the CBN program in Alberta. ¹⁴

The objective of this study was to describe Alberta community pharmacists’ practices, training, comfort levels and views in dispensing naloxone kits through the CBN program and detail potential perceived barriers to program participation. A better understanding of pharmacists’ barriers, practices and views is critical to further increase the effectiveness of the CBN program, ultimately increasing access for individuals and their families and further preventing opioid-related deaths.

Methods

The study was conducted in the form of a cross-sectional online survey of Alberta pharmacists. Participants were recruited through email and the Alberta Pharmacists’ Association (RxA) e-newsletter. Emails were provided by the ACP registry of licensed pharmacists who opted into being contacted for approved research studies. A total of 5168 pharmacists were invited to participate. Pharmacists were eligible to participate in the survey if they were currently practising in a community or outpatient setting. ¹⁵ Each participant received a letter of invitation describing the proposed study and consent process. Participation in the survey was completely voluntary and confidential. An initial email was sent on December 16, 2019. A summary of the research study with a direct link to the survey was also included in the RxA newsletter, The Capsule, for December 2019 and January 2020 editions. Two follow-up reminder emails were sent coinciding with the RxA e-newsletter releases. ¹⁶ The survey was closed on January 23, 2020.

Survey

The survey was adapted from a similar survey used in Ohio, designed by 2 members of the research team. ¹⁷ It was initially tested by 2 PharmD P4 students at the University of Cincinnati, an expert in survey design, a pharmacist from RxA and a pharmacist from the ACP. Testers were directed to provide feedback via email or phone regarding survey logic, grammatical errors, instructions requiring clarification and terminology to ensure logical validity and reliability of the tool. The survey was conducted using an online survey tool, REDCap, and took approximately 10 minutes to complete. The survey design and methodology, including the approach to handling the data from incomplete surveys, were developed based on recommendations by Salant and Dillman ¹⁸ in How to Conduct Your Own Survey and Dillman ¹⁹ in Mail and Telephone Surveys: The Total Design Method. Survey introduction, instructions and questions are available from the corresponding author upon request.

Measures

The final survey comprised 15 closed-ended questions and 1 open-ended question that assessed pharmacists’ participation and dispensing practices regarding naloxone, comfort level in dispensing naloxone, beliefs surrounding impacts of implementing the naloxone program, perceived barriers to implementing the naloxone program and demographic information.

Pharmacist participation in and dispensing practices for the CBN program were determined based on the answers to 2 questions on a Likert-type scale and a multiple-choice question, where multiple answers could be selected. Pharmacists could also free-text their own answers.

Pharmacist “level of comfort” was assessed based on answers on a Likert-type scale that asked about willingness to dispense naloxone in various scenarios (e.g., How comfortable are you distributing/dispensing naloxone to an individual who has a current opioid prescription for the treatment of acute pain? [1 = very comfortable; 5 = very uncomfortable]). Beliefs about the impact of implementing the CBN program in the opioid crisis were assessed using a Likert-type scale. Pharmacists were asked to identify potential challenges to participating in the CBN program. Multiple-choice selections were available and pharmacists could also free-text their own answers. The survey contained an open-ended question to allow participants an opportunity to elaborate or clarify responses to closed-ended questions or provide additional feedback at the end of the survey.

Data analysis

Data collected from the survey were summarized using Microsoft Excel (Microsoft Corp., Redmond, WA). Complete case analysis was conducted. Responses were categorized as “other” in cases where the “other” option was selected in closed-ended questions. Free-text comments were aggregated and summarized for the open-ended question if the participant chose to provide written feedback. The research team reviewed responses from the open-ended question and identified key themes, then grouped responses accordingly. Fisher exact tests were used to assess for statistically significant differences in responses among several demographic characteristics and related to dispensing practices, pharmacists’ beliefs and perceived barriers. Characteristics explored included sex, rural or urban location (geography determined based on AHS standard geographic areas), community pharmacy type and if the respondent pharmacist was in a “management/leadership role” or not. The test was deemed to be statistically significant if the p-value was less than 0.05. The study was approved by the University of Cincinnati Institutional Review Board.

Results

A total of 255 pharmacist responses were included in the final analysis. There were 33 responses excluded due to the pharmacists not currently practising in a community setting and an additional 105 did not complete the full survey. The Alberta College of Pharmacy was unable to provide the information required to reliably extract data to determine an accurate denominator for registered community pharmacists in 2019. Subsequently, data from the Canadian Institute for Health Information (CIHI) were used to estimate the denominator of 3851 for community pharmacists practising in Alberta at the time the survey was open, with a calculated response rate of 6.6%. ²⁰

Descriptive statistics of pharmacist demographics and workplace setting characteristics are presented in Table 1. Of the respondents, 25.6% were under 30 years of age, 25.2% were 30 to 49 years and 17.8% were over 50 years, with 31.3% preferring not to answer. Females made up 69.3% of participants. Approximately 77% of respondents practised in an urban centre. Forty-nine percent of participants were in a “management/leadership role” in their current workplace. Fifty-nine percent of the respondents practised full-time. In this sample, 33.3% of respondents worked in a major pharmacy chain and another 25.9% reported working in an independent or banner pharmacy. In Alberta, the average age of practising pharmacists in 2016 was 41 years, with 18% under 30 years, 59% aged 30 to 49 years and 24% aged 50 years or older. Sixty percent were female, 26% were pharmacy owners or managers and 88% practised in an urban setting. Alberta data are similar to Canadian pharmacist demographics.^21,22

Table 1.

Survey respondents’ descriptive statistics and workplace setting characteristics (N = 255)^*

Characteristic	n (%)
Age 1
<30	59 (25.6)
30-49	58 (25.2)
≥50	41 (17.8)
Prefer not to answer/blank	72 (31.3)
Sex
Male	97 (22.9)
Female	147 (69.3)
Prefer not to answer	11 (7.8)
Management role 2
Yes	126 (49.4)
No	128 (50.2)
Years practising in current role and setting
≤5	145 (56.8)
6-15	68 (26.7)
≥16	42 (16.5)
Employment status
Full-time	194 (59.3)
Part-time	50 (30.6)
Other	11 (10.1)
Practice setting location
Calgary	76 (29.8)
Edmonton	89 (34.9)
Small cities	31 (12.3)
Rural Alberta	59 (23.1)
Workplace setting
Grocery store pharmacy (e.g., Safeway, Save-on-Foods)	40 (15.7)
Independent/Banner (e.g., Medicine Shoppe, IDA, Pharmasave, Guardian, Value Drug Mart)	66 (25.9)
Major pharmacy chain (e.g., London Drugs, Rexall)	85 (33.3)
Mass merchandiser (e.g., Walmart, Costco)	18 (7.1)
Other	5 (1.9)
Single independent pharmacy	41 (16.1)
Prescriptions dispensed count per week
0-499	44 (17.2)
500-999	83 (32.6)
1000-2499	96 (37.6)
2500-4999	20 (7.8)
≥5000	1 (0.4)
Unsure	11 (4.3)
CBN program participation
Yes	229 (89.8)
No	14 (5.5)
Unsure	12 (4.7)
Kits dispensed in the last 6 months 3
<5	59 (25.5)
5-10	59 (25.5)
10-20	41 (17.8)
>20	60 (26.0)
Unsure	12 (5.2)

^*Incomplete responses lead to minor variations in n according to the following notes: ¹n = 230, ²n = 254, and ³n = 231.

Approximately 90% of respondents indicated that they participated in the CBN program. Twenty-six percent of pharmacists had dispensed more than 20 naloxone kits in the previous 6 months, followed by 25% dispensing 5 to 10 kits, 25% dispensing fewer than 5 kits and 18% dispensing 10 to 20 kits.

Dispensing practices

The results characterizing pharmacist dispensing practices are presented in Figure 1. Eighty-five percent of respondents reported always providing education and/or training to an individual to whom naloxone is dispensed for the first time. Notably, about 90% of respondents provide verbal education and about 53% provide pamphlet education when dispensing a naloxone kit. About 38% of respondents reported always dispensing naloxone to an individual at risk for an opioid overdose via the program, while about 15% of respondents reported seldom or never dispensing a kit to this group. About 25% of participants reported always dispensing naloxone to a family member, friend or another person in a position to assist an individual at risk for opioid overdose, and about 24% seldom or never dispensed a kit to these individuals. When asked if respondents proactively identified individuals eligible to receive naloxone via the program, about 28% reported always doing so.

Figure 1.

Dispensing practices

Our analysis revealed there was a significant difference in how frequently pharmacists in a “managerial or leadership role” proactively identified individuals eligible to receive naloxone through the CBN program compared to those who were not in a “managerial or leadership role” (47.0%, n = 54 and 32.4%, n = 36, respectively) (p = 0.010). Significant differences were also noted in the frequency of dispensing naloxone kits to a family member, friend or another person in a position to assist an individual at risk for opioid overdose via the program from pharmacists working in large chain pharmacies compared to those working in independent pharmacies (always or sometimes dispensing, 84.1%, n = 116 and sometimes or seldomly, 70.5%, n = 62) (Fisher’s exact = 0.017).

Comfort levels

Results reporting pharmacists’ comfort levels in dispensing naloxone in varying patient scenarios are presented in Table 2 and in Appendix 1 (available online at www.cpjournal.ca). The comfort results show that on average, pharmacists report being between very comfortable and comfortable with dispensing naloxone to patients for a variety of indications. Pharmacists were “least comfortable” dispensing naloxone to an individual who had a current opioid prescription for the treatment of acute pain and “most comfortable” dispensing to an individual with an opioid prescription who had a current substance use disorder.

Table 2.

Comfort level with dispensing naloxone

How comfortable are you with dispensing naloxone to:	Mean	Standard deviation
An individual who has a current opioid prescription for the treatment of acute pain	2.04	0.99
An individual who has a current opioid prescription for the treatment of chronic pain	1.76	0.90
An individual with an opioid prescription who has a known or suspected history of substance use disorder	1.56	0.80
An individual with an opioid prescription who has a current substance use disorder	1.52	0.76
An individual without an opioid prescription who has known or suspected history of substance use disorder	1.87	0.96
An individual without an opioid prescription who has a current substance use disorder	1.87	0.98
An individual participating in methadone, buprenorphine or naltrexone program for opioid addiction	1.60	0.82
A family member/friend of an individual at risk of opioid overdose	1.58	0.82
An individual who believes he or she could be in a position to assist in an opioid overdose but has no specific at-risk person in mind	1.55	0.81

1 = very comfortable; 2 = comfortable; 3 = neutral; 4 = uncomfortable; 5 = very uncomfortable.

Impact of implementing CBN program

The majority of pharmacists agreed or strongly agreed to questions posed on the impact of implementing the CBN program (Appendix 2, available online). Most pharmacists strongly agreed that it has increased patient willingness to seek out naloxone for opioid overdose death prevention within their workplace. The majority of respondents agreed or strongly agreed that the CBN program increases the amount of patient/client education on naloxone administration in their workplace.

Beliefs

Pharmacists most strongly disagreed that opioid overdose reversal with naloxone encourages future misuse of opioids (Appendix 3, available online). Pharmacists reported most strongly agreeing that they are willing to educate patients/clients on how to recognize the signs and symptoms of an opioid overdose and that training individuals to respond to an opioid overdose sends the message that everyone’s life is valuable. Gender was found to be significantly associated with some of the pharmacists’ beliefs survey questions. There was a significant difference in agreement with the statement that harm reduction strategies prevent people from being responsible for their actions, with the majority of females disagreeing and males agreeing with the statement (p = 0.017). Also, there was a significant difference in the tendency of females to disagree or strongly disagree with the statement “opioid overdose reversal with naloxone encourages future misuse of opioids” compared to males (60.0%, n = 85 and 41.3%, n = 38, respectively) (p = 0.018).

Challenges/barriers

When asked about the top 3 challenges to participating in the CBN program in their workplace, about 41% of respondents indicated that no barriers existed, followed by lack of time at about 29% and lack of demand at 20% (Appendix 4, available online). It was also observed that pharmacists in a managerial or leadership role were significantly more likely to report that lack of support from management was a barrier to offering the CBN program (p = 0.009).

The final question of the survey was open-ended to allow pharmacists to elaborate on any topic related to the survey or that was not addressed in the previous questions. In total, 41 pharmacists contributed to this answer and the following themes were identified: 1) lack of adequate funding and support and need for additional training/resources, 2) appreciation of the value of the program and positive role pharmacists play, 3) need for collaboration with other health professionals, 4) supply chain issues and 5) potential abuse of the program.

Discussion

The CBN program has proven to be an effective tool in response to increasing opioid-related morbidity and mortality in Alberta. ²³ A lack of research exists on pharmacists’ perceptions of the CBN program in Alberta or of comparable programs in other Canadian jurisdictions. While Canadian data are lacking, a recent systematic review from the Journal of the American Pharmacists Association looked at American pharmacists’ roles, training and perceived barriers in naloxone dispensing, with 33 articles included. ²⁴ One other Canadian study, by Edwards et al., ¹⁴ has explored all registered pharmacists’ perceptions of the CBN program in Alberta. This study is the first to focus solely on community pharmacists’ practices, comforts and beliefs.

About 90% of community pharmacists who responded to the survey were participating in the CBN program. They held positive beliefs about the importance of health care professionals playing a role in harm reduction and screening patients at risk of an opioid overdose. They were confident in their understanding of the CBN program and in their ability to recommend and educate on CBN kits to patients for a variety of indications, including how to recognize signs and symptoms of an opioid overdose. This aligns with findings from Edwards et al., ¹⁴ who looked at pharmacists’ attitudes on the THN program in Alberta, Canada. However, one notable difference was that the pharmacists in their study were not as confident or comfortable in actual participation in the program.

As all of our participants provide patient care in a community setting, they are ideally positioned to provide this service and to proactively screen for individuals eligible to receive naloxone via the program. According to our results, pharmacists in managerial or leadership roles are more frequently engaged in proactive screening, but overall, one-third of pharmacists seldom or never perform this type of screening, potentially missing many patients at risk. Notably, while the Alberta program compensates for the distribution of kits at the same dispensing fee as other prescription products, the time required for assessment, education and training for an injectable product like this is considerable. This lower response to proactive screening may be associated with a lack of time for services, which was reported as a major barrier to implementing the program. Edwards et al. also found that a lack of time and education were barriers to address to facilitate increased uptake of the program, as did findings from the systematic review.^14,24

The number of naloxone kits dispensed by respondents over the 6-month period varied widely across respondents. Current data from the Alberta substance use surveillance system suggest naloxone kits were dispensed to about 4% of opioid prescriptions dispensed from community pharmacies in 2020. ²⁵ Highly variable dispensing practices and screening were also observed in a 2017 study looking at the uptake of THN in the Ontario Naloxone Program for Pharmacies. Over the study period, THN kits were provided to only about 7% of high-dose opioid prescriptions dispensed (>90 mg morphine equivalents per day), with one-third of naloxone kits dispensed by the top 1% of participating pharmacies. ²⁶ Additional feedback from respondents included the inability to order kits from their preferred wholesaler. This aligns with the barriers noted in the recent systematic review. ¹⁹ In Alberta, this gap might be explained by the CBN program’s public funding, with distribution through a single wholesaler. This is potentially modifiable if multiple wholesalers could be distributors, which might increase the reach of the program.

Given the stigma still surrounding opioid use, it is not surprising that lack of demand was reported as a barrier to implementing the CBN program. Pharmacists commented that some patients feel “there is still a negative stigma associated with having a kit on your person,” “patients may have a perception of invasion of privacy if additional counselling is offered or encouraged” and “people don’t think they will need/use it until it’s too late.” In addition, statistically significant differences were found between female and male responses in “harm reduction strategies prevent people from being responsible for their actions” and “opioid overdose reversal with naloxone encourages future misuse of opioids.” As no other data exist, further research would be needed to investigate the reasons for these differences. Pharmacists’ perceptions of a lack of demand for CBN kits by the public might suggest a more passive instead of proactive offering of the program and may support the potential need for additional pharmacist training and marketing of this service. This could help increase communication and education with patients on how the CBN program might be a positive proactive tool in the prevention of opioid overdose.

On average, 3 individuals die each day in Alberta due to an apparent accidental opioid poisoning. ²⁷ The most up-to-date data report that in 2020, the annual provincial per 100,000 person-years rate of opioid poisoning deaths was 25.3, up from 14.3 in 2019 and 18.8 in 2018. ²⁷ Given the negative impact the COVID-19 pandemic has had on decreasing opioid fatalities, it is imperative that current measures being taken by Alberta, including the CBN program, are supported to help curtail these current trends. From January 1, 2016, to June 30, 2020, community pharmacies have distributed a total of 81,998 naloxone kits in Alberta, with a 44% increase in dispensing from 2018 to 2019. ²⁷ Our results potentially suggest that pharmacists support this program and recognize the important role they play in access. However, there may still be hurdles to realizing its full potential. Pharmacists in our study found time, a lack of funding for services and demand to be the biggest barriers to delivering the program.

Limitations of this study include the use of a convenience sampling approach. In addition, because of a low response rate, there is a strong likelihood of response bias. Those pharmacists who are more interested in the naloxone kit program likely responded, thus limiting our ability to generalize results beyond the respondents.

Conclusion

Pharmacists play a vital role in aiding in the current opioid crisis. Most community pharmacists in this study participate in the CBN program in Alberta. Overall, they held positive beliefs about the importance of their role in screening patients for the risk of opioid overdose and are confident in their abilities to recommend and educate on CBN kits to patients. Many do not proactively screen for patients who could benefit from a naloxone kit, an essential step to providing naloxone to those who need it. Additionally, dispensing naloxone kits was highly variable. It is unclear whether other jurisdictions share similar pharmacist sentiments surrounding their pharmacist-provided naloxone programs. Addressing factors such as time, lack of sufficient funding for services and demand may help further increase the success of the program. ■