Implementation of an academic detailing intervention to increase naloxone distribution and foster engagement in harm reduction from the community clinician

Abstract

Background:

Respond to Prevent (R2P) is a randomized clinical trial which sought to accelerate distribution of naloxone and other harm reduction materials from community pharmacies. R2P combined an online continuing education course with in-store materials, specifically designed for use in community pharmacies, and then supported implementation through the one-on-one educational technique of academic detailing.

Objective:

The objective of this paper is to describe and synthesize our experiences providing academic detailing as part of the R2P randomized trial.

Methods:

Closed-ended items from standardized post-detailing questionnaires were analyzed with descriptive statistics. Open-ended items were content analyzed for key themes using immersion-crystallization qualitative methods.

Results:

A total of 176 pharmacies participated in R2P with 175 receiving their initial academic detailing visit between August 2019 and May 2021. Initial visits were in-person and lasted a median of 35 minutes (interquartile range [IQR], 20–45 minutes). The R2P naloxone guide was the most common topic covered (n=162, 92.6%). Following a fidelity check to assess adequacy of the R2P program implementation, 80 pharmacies (45.7%) required secondary academic detailing. Secondary detailing was more targeted and most frequently focused on the sale of nonprescription syringes (n=28; 35.2%) or disposal container distribution (n=30; 37.5%). Analysis of the open-ended items identified factors that the detailers perceived to affect the quality of academic detailing sessions, including the pharmacy environment, participant knowledge of and attitudes towards the subject matter, and ability of the detailer to remain flexible yet consistent.

Conclusion:

R2P provided a standardized process to foster naloxone distribution and engagement in harm reduction with demonstrated implementation in 175 community pharmacies across four states. Academic detailing was perceived to be well-received and effective at providing education and promoting distribution of naloxone and nonprescription syringes in community pharmacies. Additional research is needed to confirm these perceptions through evaluation post-intervention behavioral and attitude changes.

Introduction:

Opioids account for approximately two-thirds of drug overdose deaths.¹ As a result, increasing the safe use of prescription and nonprescription opioids is a priority for health care providers, public health officials, and policymakers. A wide variety of approaches have been deployed to improve opioid safety, and one of the most effective is increasing distribution of naloxone. With approximately 90% of Americans living within 5 miles of a community pharmacy,² pharmacies have emerged as key partners in naloxone distribution efforts.³

Studies have suggested that prescribers generally support increased access to naloxone to improve opioid safety.^4,5 However, translating support into behavior change is challenging.⁵ Education is a key component to changing behavior, and numerous education-based interventions have been reported to increase healthcare provider engagement in opioid safety initiatives.^6,7 One proven approach is academic detailing. Academic detailing is an outreach technique that uses content experts to provide one-on-one education, usually at a health care provider’s workplace, to improve prescribing practices and clinical decision-making on a specific subject.^8,9 Research has demonstrated it to be effective at changing practice as a both a sole intervention and part of a multicomponent approach.¹⁰

Academic detailing of prescribers or interdisciplinary teams in outpatient medical offices is an effective strategy to increase naloxone prescribing.^11–14 However, despite all states in the United States having a pathway for naloxone access directly through a community pharmacy,³ there has been less investigation into using academic detailing to increase distribution of naloxone and other harm reduction materials by community pharmacists. Two studies have reported positive impacts of academic detailing as assessed through pharmacist self-reported improvements in naloxone counseling¹⁵ or increased likelihood of dispensing of naloxone without an outside prescription.¹⁶ These studies are limited by small sample sizes in restricted geographic areas, as well as a singular focus on naloxone provision. A more recent study built upon these experiences through statewide detailing, expanded educational messaging (naloxone, syringes, and medications to treat opioid use disorder), and use of pharmacist and patient education tools.¹⁷ Detailing efforts were well-received by participating community pharmacists; however, the impact of the intervention is unknown since objective measures of behavior change were not assessed and the intervention was a one-time visit without a longitudinal component to identify and address ongoing pharmacy needs.

Respond to Prevent (R2P) is a stepped-wedge cluster randomized trial of a multi-component educational intervention directed at improving the distribution of naloxone, nonprescription syringes, and buprenorphine in 176 community pharmacies across four states (Massachusetts, New Hampshire, Oregon, and Washington) within two large pharmacy chains. The intervention combines an online continuing education course with in-store materials specifically designed for use in community pharmacies, and then supports implementation through one-on-one education. Overall outcomes of R2P, which include self-reported changes in attitudes and behaviors by pharmacy staff and objective data on the distribution of harm reduction materials, are still pending. The purpose of this paper is to describe the academic detailing aspect within the R2P intervention.

Objective:

The objective of this paper is to describe and synthesize our experiences providing academic detailing as part of a large clinical trial, which sought to accelerate distribution of naloxone and normalize and sustain engagement in harm reduction strategies in community pharmacies.

Methods:

R2P is a stepped-wedge cluster randomized trial¹⁸ funded by the National Institute on Drug Abuse (NIDA) conducted in 176 community pharmacies across four states (Oregon, Washington, New Hampshire, Massachusetts), and two large chain community pharmacy settings. Study activities were reviewed and approved by the institutional review boards at Brandeis University and Oregon Health & Science University, and it is registered on clinicaltrials.gov (NCT03545321). The study protocol for R2P has been described elsewhere.¹⁹

The R2P intervention consisted of a toolkit of materials to increase distribution of naloxone and engagement in harm reduction initiatives (nonprescription syringes and buprenorphine). Toolkit resources were largely derived from two prior studies, MOON (Maximizing Opioid Overdose prevention with Naloxone)^20,21 and RESPOND (Resources Encouraging Safe Prescription Opioid & Naloxone Dispensing),^22,23 which were both initiatives to develop evidence-based educational materials for community pharmacists to increase opioid safety. The MOON study was focused on naloxone access while RESPOND was focused on usage of prescription drug monitoring databases and pharmacist-prescriber communication strategies.^20–23

During the first year of R2P, materials from these two toolkits were integrated by the study team with feedback provided by state-specific external advisory panels. The final toolkit included materials that were aimed at enhancing the pharmacy staff’s knowledge of harm reduction (“pharmacy-facing”) with other materials intended to increase public awareness and encourage patient conversations about naloxone (“patient-facing”). These resources are detailed in Appendix A with images of select resources in Figure 1.

Figure 1:

Images of select materials in the Respond to Prevent toolkit. Patient-face materials on the left and pharmacy facing materials are on the right.

Toolkit implementation was then supported through a novel academic detailing model. The purpose of the academic detailing session was to provide education to the pharmacy staff on opioid safety and harm reduction, set-up R2P materials in the pharmacy, encourage participation in an optional online educational program, and invite pharmacists and pharmacy technicians to join a longitudinal study on attitudes and behaviors towards naloxone and harm reduction. As shown in Figure 2, academic detailing in R2P was comprised of four steps: (1) pre-visit data analysis and readiness assessment, (2) completion of the initial academic detailing visit, (3) a fidelity check (a.k.a., “secret shopper” visit), and (4) a feedback loop via follow-up communication from the academic detailing team and/or pharmacy chain partners.

Figure 2:

Overview of the Respond to Prevent intervention. The larger box highlights the elements associated with the in-person academic detailing session.

Step 1: Pre-visit data analysis and readiness assessment

Prior to the initial academic detailing visit, information on each enrolled pharmacy was gathered in two ways. First, data were provided from pharmacy chain partners on the volume of naloxone, buprenorphine, and nonprescription syringe sales at each pharmacy. Volume was then categorized into low, medium, and high to provide a quick, high-level overview of the pharmacy’s baseline provision of harm reduction materials. Second, a pharmacy manager or other representative participated in a brief telephone-based readiness assessment survey. The survey was a standardized set of 30 Likert scale and open-ended items to collect information about past initiatives (e.g., immunization campaigns), existing practices and culture around opioid safety, and perceived readiness to implement the R2P intervention. Information from both sources was then combined and available for use at the initial academic detailing visit, which were generally conducted in the next 1 – 2 weeks, although there was some variation in the later waves due to coronavirus (COVID-19) pandemic. Readiness assessment data are summarized separately.²⁴

Step 2: Initial academic detailing visit

After the readiness assessment was completed, a single detailer traveled to each enrolled pharmacy to provide education and orient the pharmacy staff to the toolkit materials (Figure 1 and Appendix A). The visit was designed to last approximately 30 minutes with about 20 minutes dedicated to educating the pharmacy manager and other pharmacists about R2P and then 10 minutes to set-up study materials and connect with other pharmacy staff. Pharmacists and pharmacy technicians were also encouraged to participate (outside of the workday) in an optional online continuing professional educational program and invited to enroll in a longitudinal study to assess changes in attitudes toward harm reduction. Following each visit, academic detailers completed a standardized post-detailing questionnaire (REDCap, Nashville, TN)²⁵ to collect objective information about the enrolled pharmacy and the visit, as well as more subjective detailer impressions. The questionnaire was adapted from a post-detailing questionnaire developed for MOON and took 15 – 30 minutes to complete.

Scheduling of the initial academic detailing visit was different between east coast (NH, MA) versus west (OR, WA) coast states. On the east coast, the pharmacy partner provided a float pharmacist who traveled with the academic detailer, so they could manage the operational needs of the pharmacy and allow the pharmacy manager to step out of the workflow and focus on the academic detailing visit. On the west coast, visits were scheduled to maximize use of times where there was staff overlap (usually early afternoon), periods of the day that tended to be slower, or scheduling outside of business hours or over the lunch period (if requested only); however, academic detailers needed to be flexible and recognize that visits were frequently delayed and interpreted with patient care and operational needs.

Academic detailing was completed by a team of 7 paid detailers (4 on the east coast and 3 on the west coast). Most were pharmacists (n=6), and all were employed by or closely affiliated with a college of pharmacy, state professional pharmacy association, or local health system, so they were familiar with pharmacy practice prior to serving in this role. Additional demographic information on the detailers is available in Appendix B. To ensure consistency in the intervention, all academic detailers went through a standardized training that included didactic sessions, interactive role plays, and an observed practice visit. Additionally, the full academic detailing team participated in a debrief to discuss challenges and successes after completing the first group of pharmacies, or approximately 8 pharmacies per states; they also participated in standing meetings with the research team and pharmacy chain pharmacy partners as needed.

Step 3: Fidelity check

After the initial academic detailing visit, a “secret-shopper” fidelity check was conducted at each pharmacy to assess real-world translation of the intervention’s implementation. Using a standardized protocol and script, separate, trained study personnel anonymously visited each enrolled pharmacy to verify placement of educational materials, purchase a 10-pack of syringes, and determine naloxone access. Fidelity checkers also documented key verbal and non-verbal elements of interactions with pharmacy staff for quality improvement.

Step 4: Feedback loop with follow-up communication from the academic detailing team and/or pharmacy chain partners.

Results from the fidelity checks were then compiled into a data dashboard and used in two capacities. First, pharmacy-level results were shared with the two pharmacy chain partners at standing monthly meetings. During these discussions, the R2P team provided a high-level overview and then highlighted any notable positive or negative findings. A copy of the data dashboard, with identifiers for the cohort of fidelity checked study pharmacies, was also distributed after these meetings, so the information could be used by each pharmacy chain partner and individual pharmacy as desired. Second, results were used by the R2P team to identify which pharmacies required further support, termed secondary detailing, from the academic detailing team to fully implement the intervention.

Since the primary focus of R2P was to increase naloxone provision, knowledge or behavioral gaps related to naloxone identified during the fidelity check were prioritized for additional support. Implementation gaps for nonprescription syringes were only addressed if pharmacies were also being contacted for naloxone deficiencies or at the discretion of the academic detailer. Follow-up detailing was initially all in-person, however, the COVID-19 pandemic required safety adaptations, so they were conducted as a mix of in-person and telephone later in the study period. Secondary detailing ranged from repeating the full academic detailing visit to a targeted communication about a single topic, and if related to naloxone, could be followed by a repeat fidelity check.

Data Source and Analysis:

Immediately after each academic detailing visit, detailers completed a standardized online survey containing closed- and open-ended items (REDCap, Nashville, TN)²⁵ to document the interaction. We extracted responses from the web-based survey and then conducted a descriptive analysis of information captured. Discrete variables are reported using descriptive statistics, either number (percentage) or median (interquartile range [IQR]). Open-ended items from the initial detailing visits were also content analyzed using qualitative methods. These open-ended items included – 1) What went well? 2) In what ways could it have been improved? 3) Do you feel additional follow-up is needed? Why? 4) Any additional comments? These questions were only included in the survey completed after the initial academic detailing visit. Detailers consistently answered the first three questions. The fourth question was inconsistently answered and often comments were not related to the academic detailing session, so while responses were reviewed and coded where possible, these responses contributed minimally to the analysis.

For the open-ended items, we reviewed all survey responses and then used an immersion-crystallization approach to identify emerging themes.¹⁴ This analysis was led by the two study investigators who served as the academic detailing leads for the east and west coast teams (JB and AI, Detailers 2, and 4, respectively). Both of whom were also familiar with qualitative research methods, including the immersion-crystallization approach.^26,27 In the immersion phase, they met to review responses and sort concepts into categories. Each investigator independently reviewed all of the comments for a single question and then met virtually to discuss. During these meetings the investigators reviewed responses line-by-line (read data out loud) to discuss concepts and form a coding structure. As concepts began to repeat within a single question, indicating data saturation, investigators would move more quickly through the comments, eventually reading comments independently and only highlighted those warranting further discussion because they represented new concepts, lacked clarity, or were particularly strong. After the meeting, one investigator (AI) coded the responses based on the discussion, and the second investigator (JB) reviewed and approved the coding. This process repeated until all responses achieved consensus coding. Each question served as a silo for coding, and no coding drift was identified.

In the crystallization phase, the same two investigators sorted the codes into broader categories. These categories were then presented at multiple meetings with members of the academic detailing and/or study team for review and discussion. Through these discussions, categories were then synthesized into preliminary themes, which were further developed and refined. During the process, all academic detailers had the opportunity to provide feedback on the themes. Through the process, data were organized and coded manually.

Results:

Initial Academic Detailing

A total of 176 pharmacies participated in the R2P program with 175 receiving an initial academic detailing visit between August 2019 and May 2021. This included 42 New Hampshire pharmacies with 41 initial visits completed, 45 Massachusetts pharmacies, 42 Oregon pharmacies, and 46 Washington pharmacies. Pharmacies were geographically distributed across each state, as visible in Figure 3, and were selected in collaboration with each pharmacy chain partner because they were located in areas with overdose rates above the state median and low naloxone dispensing. Characteristics of the pharmacy staff who participated in the visit are summarized in Table 1. The majority of visits were conducted with one pharmacist (n=135, 77.1%). Less than half were conducted with the pharmacy manager (n=73; 41.7%). Most pharmacists reported having received some prior training on naloxone (n=124; 70.9%), as well having experience dispensing naloxone from that pharmacy (n=155; 88.6%).

Figure 3:

Geographic distribution of community pharmacies enrolled in Respond to Prevent.

Table 1:

Characteristics of the pharmacy and pharmacy staff who participated in the initial academic detailing visits

Visit Characteristic		Pharmacies (n = 175)	East Coast (n=87)	West Coast (n=88)
Pharmacists Detailed, n (%)
	None	1 (0.6)	1 (1.1)	0 (0.0)
	1 pharmacist	135 (77.1)	82 (94.3)	53 (60.2)
	2 pharmacists	38 (21.7)	4 (4.6)	34 (38.6)
	3 or more pharmacists	1 (0.6)	0 (0.0)	1 (0.0)
Pharmacy manager, yes, n (%)		73 (41.7)	33 (37.9)	69 (78.4)
Other pharmacy staff detailed, n (%)
	None	111 (63.4)	63 (72.4)	48 (54.5)
	1 staff member	41 (23.4)	18 (20.7)	23 (26.1)
	2 staff members	16 (9.1)	6 (6.9)	10 (11.3)
	3 or more staff members	7 (4.0)	0 (0.0)	7 (8.0)
Pharmacists trained on naloxone provision, n (%)
	Yes	124 (70.9)	57 (65.5)	67 (76.1)
	No	17 (9.7)	13 (14.9)	4 (4.5)
	Did not discuss	34 (19.4)	17 (19.5)	17 (19.3)
Past experience dispensing naloxone, n (%)
	Yes	155 (88.6)	72 (82.8)	83 (94.3)
	No	12 (6.9)	7 (8.0)	5 (5.7)
	Unknown or did not speak with a pharmacist	8 (4.6)	8 (9.2)	0 (0.0)

Pharmacy characteristics are summarized in Table 2. Visits were conducted at a median time of 12:30 pm (IQR, 10:00 am – 14:30 pm), and the majority of pharmacies were perceived by the detailer as being slightly to moderately busy (n=127, 72.6%) at the time of the visit. Signage on naloxone and medication safety (e.g., storage and disposal) at baseline was present in 30.3% and 26.9% of pharmacies, respectively. Signage at baseline to promote opioid safety or increase awareness of overdose risk that was independent of naloxone messaging was even less common at 6.8% and 4.0%, respectively. Naloxone was in stock at 93.1% of pharmacies with the branded single-step nasal spray being the most common product stocked (n=154, 88.0%) followed by the multi-step nasal atomizer (n=10, 5.7%).

Table 2:

Pharmacy characteristics at the time of the initial academic detailing visits

Pharmacy Characteristic		Pharmacies (n = 175)	East Coast (n=87)	West Coast (n=88)
Busyness of the store, n (%)
	Not busy at allA	19 (10.9)	9 (10.3)	10 (11.4)
	Slightly busy	30 (17.1)	13 (14.9)	17 (19.5)
	Average	53 (30.3)	30 (34.5)	23 (26.4)
	Moderately busy	44 (25.1)	19 (21.8)	25 (28.7)
	Extremely busy	29 (16.6)	16 (18.4)	13 (14.9)
Opioid safety signage, yesB, n (%)		12 (6.8)	10 (11.5)	2 (2.3)
If yes, location of the opioid safety signage
	At the pharmacy counter	10 (5.7)	9 (10.3)	1 (1.1)
	Around the store	1 (0.6)	0 (0.0)	1 (1.1)
	Other	1 (0.6)	1 (1.1)	0 (0.0)
Naloxone signage, yesB, n (%)		53 (30.3)	30 (34.5)	23 (26.1)
If yes, location of the naloxone signage
	At the pharmacy counter	46 (26.3)	29 (33.3)	17 (20.5)
	Around the store	3 (1.7)	0 (0.0)	3 (3.4)
	Other	4 (2.3)	1 (1.1)	3 (3.4)
Overdose awareness signage, yesB, n (%)		7 (4.0)	5 (5.7)	2 (2.3)
If yes, location of the overdose awareness signage
	At the pharmacy counter	4 (2.3)	3 (3.4)	1 (1.1)
	Around the store	1 (0.6)	0 (0.0)	1 (1.1)
	Other	2 (1.1)	2 (2.3)	0 (0.0)
Medication safety signage, yesB, n (%)		47 (26.9)	43 (49.4)	4 (4.5)
If yes, location of the overdose awareness signage
	At the pharmacy counter	39 (22.3)	37 (42.5)	2 (2.3)
	Around the store	4 (2.3)	3 (3.4)	1 (1.1)
	Other	4 (2.3)	3 (3.4)	1 (1.1)
Naloxone in stock, yes, n (%)		163 (93.1)	81 (93.1)	82 (93.2)
Naloxone form(s) in stock, yes, n (%)
	Intramuscular injection, generic	7 (4.0)	2 (2.3)	5 (5.7)
	Intramuscular injection, brand	3 (1.7)	2 (2.3)	1 (1.1)
	Multi-step nasal naloxone	10 (5.7)	3 (3.4)	7 (8.0.)
	Single-step nasal naloxone	154 (88.0)	79 (90.8)	75 (85.2)
Location of syringes
	At or close to the register	29 (16.6)	11 (12.6)	18 (20.5)
	In front of the pharmacy	23 (13.1)	15 (17.2)	8 (9.1)
	In back of the pharmacy	89 (50.9)	42 (48.3)	47 (53.4)
	Other	7 (4.0)	6 (6.9)	1 (1.1)
	Not collected	27 (15.4)	13 (18.4)	14 (15.9)

^ACategory includes academic visits conducted when the pharmacy was closed either for lunch or being outside of business hours.

^BRemaining percentage includes both “This signage does not exist” and “Don’t remember.”

The initial academic detailing visits lasted a median of 35 minutes (IQR, 20 – 45 minutes). The most common topic covered was a review of the naloxone guide (n=162, 92.6%); however, a wide range of topics were covered (Table 3). The majority of visits were perceived by the academic detailer as “good” (n=74; 42.3%) or “excellent” (n=71; 40.6%), with a smaller number rated “poorly” (n=3; 1.7%), “not good” (n=1, 0.6%) or “average” (n=26, 14.9%).

Table 3:

Elements of academic detailing (AD) sessions by pharmacies with initial and secondary visits, n (%)

Visit Elements	Initial AD (n = 175)	Secondary AD (n = 80)
Reviewed the laminated naloxone guide	162 (92.6)	24 (30.0)
Practiced the naloxone offer language	114 (65.1)	12 (15.0)
Discussed naloxone coverage for major payers in area	19 (10.9)	0 (0.0)
Reviewed the syringe fact sheet	147 (84.0)	28 (35.0)
Reviewed the buprenorphine factsheet	135 (77.1)	5 (6.3))
Reviewed treatment resources	141 (80.6)	8 (10.0)
Checked where syringes are stored or kept for sale	146 (83.4)	14 (17.5)
Discussed the disposal units and handing them out	159 (90.9)	30 (37.5)
Located or discussed the store on-site overdose policy	122 (69.7)	1 (1.3)
Helped set-up or orient team to materials about naloxone for the pharmacy	143 (81.7)	4 (5.0)

Secondary Academic Detailing:

Following the “secret shopper” fidelity check, 80 pharmacies (45.7%) received secondary academic detailing visits, which were then completed through 87 contacts. Five pharmacies had two or more contacts; either a phone call was paired with an in-person visit (n=4), or in one case, the pharmacy was transitioning managers resulting in four phone calls over a month. Most secondary detailing was conducted by phone (n=65; 74.7%); however, 22 pharmacies (25.2%) did require an in-person visit to reinforce information or elements of the intervention. Following secondary academic detailing, 34 pharmacies received a fidelity recheck.

In contrast to initial academic detailing visits, secondary detailing was narrower in scope; only covering a median of one topic (IQR, 0 – 2). While naloxone was often discussed (n=24, 30.0%), in contrast to the initial visits, secondary academic detailing was more frequently focused on access to nonprescription syringes by either providing re-education on state law, the chain’s policy, or public health goals (n=28, 35.0%) or reviewing procedures for distributing disposal containers (n=30, 37.5%).

Qualitative Analysis

Analysis of the open-ended response to the questions above identified three themes.

Theme 1: Environmental factors affected academic detailing efforts.

The community pharmacy environment was frequently viewed as impacting the quality of the detailing session. This was most notably seen through comments about the impact of the length of time available, as well as whether the participant(s) was able to fully focus on the session due to interruptions (e.g., medication counseling), distractions (e.g., ringing telephones), or the general busyness of the pharmacy. In some instances, responses simply stated that the pharmacy was “less busy,” which then created the opportunity for a meaningful conversation. However, in others, there were references to specific factors (e.g., staff overlap) or use of non-pharmacy spaces (e.g., private counseling rooms, employee break rooms, waiting areas) to create that opportunity.

“Slow pharmacy. Phone not ringing / space to talk” (Detailer 4, WA)

“It was pretty busy compared to normal for him, so he was really distracted and wanted to get back to work.” (Detailer 6, MA)

The use of these non-pharmacy spaces, though often leading to fewer distractions and interruptions for the detailing visit, were also identified as a source of challenge. Aspects of the detailing visit were aimed at ensuring that R2P intervention materials were set-up, surveying the pharmacy to identify and mitigate potential barriers for patients seeking naloxone and nonprescription syringes, and connecting with pharmacy technicians. These goals of the academic detailing visit were more difficult to accomplish without a physical presence in the pharmacy.

“AD session was conducted in a room off the pharmacy. It was good because this minimized distractions; however, it was harder to get some information (e.g., naloxone products stocked), actually set-up the materials, and interact with other pharmacy staff. Asked if the pharmacy manager wanted help in setting up R2P materials, but he declined.” (Detailer 2, OR)

Similar comments were also made once the coronavirus disease 2019 (COVID-19) pandemic began because some pharmacy managers were reluctant to allow detailers to enter the pharmacy, which then resulted in detailing over the pharmacy counter. This practice was generally viewed as awkward and sub-optimal by the detailer.

Finally, factors were identified that highlighted differences in academic detailing in the community pharmacy as compared to other health care environments. These included distinct seasonal variations in work volume (e.g., influenza immunizations in the fall, insurance changes in January), communication barriers as there were some stores with limited pharmacist overlap or unstable staff (e.g., floater pool coverage), and sessions being disrupted following unscheduled visits from district managers or a regulatory inspector.

Theme 2: Attitudes, knowledge, and self-efficacy played roles in participant engagement in the detailing session and openness to the intervention.

The quality of the interactions was often linked to underlying attitudes, knowledge, and self-efficacy, or some combination of the three. Sessions that were perceived by the detailing team as going well were frequently described with the terms that reflected receptiveness to the information, active listening, and engagement in the session.

“The manager was asking many good questions and expressed that she is interested in passing the information to her staff.” (Detailer 3, OR)

Conversely, in sessions that were perceived as less effective, detailers felt that it was hard to get buy-in for the project due to topic-related stigma, inability to prioritize academic detailing engagement over other responsibilities, or both. This was most notable during the visits in the fall that overlapped with influenza vaccines, and then at the end of the study with the arrival of COVID-19 vaccines.

“She appeared agitated due to either the topic or for pulling her away from her station (even though it was being covered).” (Detailer 6, MA)

“He could have been expecting me, he could have wanted to talk to me, he could have agreed to sell syringes... A lot could have gone better.” (Detailer 1, WA)

Detailing visits provided education on naloxone, nonprescription syringes, and buprenorphine. While extensive knowledge of opioid crisis was not viewed as essential for a productive session, detailers commented that existing knowledge of the opioid crisis was often associated with a positive attitude toward the project, ability to have a higher level or more nuanced discussion, and less stigma toward the topics. This was most frequent and pronounced with discussion on nonprescription syringes. Despite state laws and corporate policies allowing the sale of nonprescription syringes, some pharmacies elected not to sell nonprescription syringes, as readiness assessments had foreshadowed for the detailers. Strategies to alter behavior incrementally (e.g., encourage sales of 10 packs versus only boxes of 100, usage of the free disposal containers that came with pharmacy enrollment) were often tried, rather than solely focusing on absolute change. Still, academic detailers frequently commented on limited change in attitude or store policies in this space, although there were some exceptions.

“The conversation about the opioid crisis with the pharmacist went well. We were able to engage on many levels about this and syringe disposal.” (Detailer 5, NH)

“I hope that I made an impact with respect to the importance of selling syringes.” (Detailer 1, WA)

Sessions that went well were also associated with pharmacists’ self-efficacy in that the detailers commented about them making immediate changes to the pharmacy environment to reduce stigma (e.g., moving syringes closer to the register), communicating plans for future changes (e.g., policies surrounding nonprescription syringe sales), or actively brainstorming strategies to integrate R2P intervention activities into the workflow (e.g., flagging prescription for a naloxone offer when checking the prescription drug monitoring program). Some pharmacists also had personal experiences administering naloxone to treat in-store opioid overdoses, which reinforced the importance of this information, as well as provided confidence that they could manage an overdose situation.

“Pharmacist was engaged and moved the syringes while I was there. The pharmacy manager had used naloxone per [company name] policy to save a patient a few weeks prior, so they were well aware of the policy and experienced in administration.” (Detailer 5, NH)

Similarly, detailers commented that visits with pharmacy managers that seemed organized went well, regardless of whether they seemed vested in the subject matter. This was often evident by pharmacy managers reviewing, and sometimes setting-up, intervention materials prior to the detailing session.

“The encounter went well from pharmacist engagement to timing. All the materials were displayed on the spot.” (Detailer 3, OR)

Theme 3: Detailing needed to be flexible, and sessions were often adapted based on pre-visit pharmacy communications, initial impressions from interactions with the pharmacy staff, and/or after a visual survey of the pharmacy.

Sessions were regularly adapted by the detailers using information from a variety of sources. Some of the flexibility was driven by direct requests of the pharmacy manager, such as the location of the session or length time available. However, other adaptations originated from the detailers based on information collected in the readiness assessment or visual cues.

“It was very busy, and the pharmacist seemed anxious to get back to work. I have noticed that the later in the day, the less focused they are on the detailer - the early mornings seem to be much better.” (Detailer 6, MA)

There was also a struggle by detailers on how to best balance the motivational interviewing underpinning of academic detailing with the time constraints of a busy community pharmacy. Detailers felt that techniques to increase interactivity positively impacted the session. Interactivity was key to assessing underlying knowledge and attitudes of pharmacy staff, as well as identifying pharmacy-specific barriers. Additionally, interactive dialogue provided opportunity actively listen and acknowledge concerns prior to exploring how these concerns might be addressed through R2P efforts.

“A technician there sounded frustrated at the needles left in the bathroom, and not wanting to support that. I showed compassion for that not being okay in their workplace, and for their community. I stated that the goals of the study was to have them sell syringes, but I understood they needed to do what they thought was best.” (Detailer 1, WA)

However, while the benefit of interactivity was clear, it was also recognized that these techniques often lengthened the detailing session and that effectively managing the time available for the session was equally important to the visit’s success. As a result, active engagement was sometimes forgone, and information delivery streamlined.

“Being brief made sure I kept her focus the whole time, but the brevity meant that I couldn’t discuss in as much detail nuances.” (Detailer 1, WA)

Discussion:

Community pharmacies are ideal partners in addressing the opioid epidemic. However, pharmacists can also be barriers by not stocking or being unwilling to dispense harm reduction materials.^28–30 There is a clear need to determine optimal ways to promote these practices in community pharmacies, and by leveraging academic detailing, R2P provides a standardized process to foster naloxone distribution and engagement in harm reduction with demonstrated implementation in 175 community pharmacies across four states.

The use of academic detailing to evoke practice change in community pharmacies is gaining traction. Initially trialed to increase awareness of pneumococcal immunization recommendations³¹ and referrals to a tobacco quiteline,³² recent efforts have focused largely on naloxone with a secondary focus on medication to treat opioid use disorder.^15–17 Results from these efforts have a number of similarities with our experiences, such as a lack of signage to increase public awareness of opioid safety and the ability to access naloxone from the pharmacy,^16,17 a desire by pharmacists to improve in how they engage patients in conversations about naloxone,^15,17 and gaps between community pharmacies and the broader public health ecosystem.^15,17 As a result, not only does R2P build on existing academic detailing models through a formal partnership with two pharmacy chains, fidelity checks to assess the quality of the intervention implementation, and longitudinal support to the pharmacy staff, but the complementing toolkit of materials addresses barriers that require attention if provision of harm reduction materials from community pharmacies is to accelerate.

Our findings also echo emerging research on pharmacy policies related to nonprescription syringe access. Interestingly, despite naloxone being prioritized over nonprescription syringe access for secondary academic detailing, nonprescription syringes were still more frequently discussed. Qualitative research of pharmacists has suggested that restrictive pharmacy policies are often grounded in stigmatizing views of people who inject drugs.³³ This would align with some of our academic detailing experiences in R2P. Analysis of the open-ended comments in the survey following the initial academic detailing visits highlighted how pharmacists’ attitudes toward the topics often impacted the quality of detailing; this was particularly evident with respect to nonprescription syringes. The aforementioned study concluded that education about substance use disorder, human immunodeficiency virus (HIV), and Hepatitis C virus is needed to shift policies.³³ We do not disagree; however, dialogue about education-based solutions likely requires more nuance. As naloxone has become increasingly mainstream, objective education that can be delivered quickly on state laws or company policies can reduce barriers; however, brief education may be unlikely to shift behavior tied to more deeply rooted attitudes and views, such as those surrounding nonprescription syringes.

Most research into best practices for academic detailing has been conducted in the outpatient medical office setting, and many of those practices were applicable to the community pharmacies enrolled in R2P. Academic detailing in the community pharmacy setting, however, did create some unique challenges. Most notably, as compared to outpatient medical offices, the staffing model for community pharmacies is often flexible. While each pharmacy had a dedicated staff, most often a pharmacy manager and one or more staff pharmacists, pharmacy chains also rely heavily on float pools who travel between multiple locations. This made it hard to ensure consistent messaging, particularly since not all stores in a geographic area were participating in the project. Similarly, pharmacy staff did not have monthly staff meeting or a similar protected time that could be dedicated to the academic detailing visit. Thus, visits were worked into the daily operations of the community pharmacy by either scheduling to accommodate the pharmacy manager’s preference or using a floater pharmacist who traveled with the detailing team. Finally, hosting a practical trial in the community pharmacy setting can be challenging. Balancing the priorities of research, healthcare, and the pharmacy business model, which is still almost exclusively tied to medication dispensing, is tricky and became especially pronounced as pharmacies became hubs for COVID-19 testing followed by immunizations. If pharmacists are going to be expected to address public health priorities, then changes to the business model are paramount.

Finally, it should be noted that R2P occurred during the COVID-19 pandemic, as many research procedures were adapted to reduce in-person activities. We did explore transitioning academic detailing to telephone or a virtual platform. However, there were distinct challenges with this transition (e.g., videoconferencing capability in the pharmacy). There were also concerns about limited pharmacy engagement in a virtual session with the workload pressure and staff constraints faced by many community pharmacies, as well as whether essential intervention materials would be set-up if this task was not completed by the academic detailer at the time of the session. Recent research from the Veterans Health Administration’s academic detailing program has suggested virtual detailing can be as effective in-person,³⁴ so use of virtual detailing likely warrants future exploration, although the generalizability of findings from a unified healthcare system or outpatient medical offices to community pharmacies remains unclear. Ultimately, the pharmacy chain partners, academic institutions, and detailers were willing to continue in-person visits with safety precautions. As a result, initial academic detailing continued in person with some expansion of secondary detailing by phone.

There are several limitations of this work. First, while R2P is the most comprehensive academic detailing intervention implemented in the community pharmacy environment, it is still limited to experiences with two pharmacy chains in four states. Access to harm reduction materials have been shown to vary by geographic region and pharmacy type,³⁰ so our experiences may not be reproducible in other settings. Second, all members of the R2P detailing team were either pharmacists or had substantial knowledge of pharmacy practice. This allowed for flexibility and quick adaptions, which were viewed as essential to the project’s success, but similar adaptions may not be possible by detailers with other backgrounds. Finally, although the fidelity check provided a mechanism to quickly identify pharmacies requiring further support to fully implement the R2P intervention, it may not reflect its ultimate effectiveness, which is being assessed through survey, dispensing, and point-of-sale data provided by the chain pharmacy partners.

Conclusion:

Community pharmacies are well-positioned to increase access to harm reduction materials. However, there is limited understanding of the optimal ways to engage community pharmacies in these activities. Leveraging an academic detailing approach, R2P provided a standardized process to foster naloxone distribution and engagement in harm reduction with demonstrated implementation in 175 community pharmacies across four states. From the detailer’s perspective, academic detailing was a well-received and effective way to provide education and distribute resources to assist pharmacists and other pharmacy staff to engage with naloxone, buprenorphine, and nonprescription syringes. Additional research is needed to confirm these perceptions by evaluation post-intervention behavioral and attitude changes.

Key Points:

Background:

• Access to naloxone is an established strategy to decrease mortality from prescription and nonprescription opioids, but there is less understanding of the optimal ways to promote this practice in the community pharmacies.

• To improve distribution of the opioid antidote naloxone and normalize engagement in harm reduction strategies in community pharmacies, the Respond to Prevent (R2P) clinical trial combined an online continuing education course with in-store materials, specifically designed for use in community pharmacies, and then supported implementation through the educational technique of academic detailing.

• Academic detailing is an established face-to-face, interactive educational intervention directed at clinicians to improve clinical practice that is increasingly being used to foster change in community pharmacies.

Findings:

• R2P is a standardized process to foster naloxone distribution and engagement in harm reduction with demonstrated implementation in the community pharmacy setting.

• Academic detailing was perceived to be well-received and effective at providing education and distributing resources to assist pharmacists and other pharmacy staff to engage with naloxone and nonprescription syringes.

• Factors were identified that affected the detailers’ perception of the quality of academic detailing sessions on harm reduction materials, including the pharmacy environment, participant knowledge of and attitudes towards the subject matter, and ability of the detailer to remain flexible yet consistent.