In 2017, an estimated 17% of the US population filled at least 1 opioid prescription, an average of 3.4 opioid prescriptions per patient, resulting in more than 47,000 opioid-related deaths.1 In 2018, the US surgeon general released an advisory statement encouraging increased education regarding naloxone use and patient access to naloxone.2

In 2017, Idaho had 266 drug-induced deaths,3 accounting for 14.4 deaths per 100,000 individuals.4 The average number of opioid prescriptions remains higher than the national average at 70.3 compared with 58.7 per 100 individuals, respectively.5

Residents who died from an opioid overdose were more likely to be uninsured non-Hispanic whites, have a lower household income than average, live below the poverty line, and live in a frontier county (county with <6 persons per square mile), according to the Idaho Bureau of Vital Records and Health Statistics.6

Naloxone, a potent mu-receptor antagonist, displaces opioids from binding sites, reversing respiratory depression, with few adverse effects.7,8 Naloxone distribution programs have been shown to reduce rates of overdose, and patients who were co-prescribed naloxone were less likely to have opioid-related emergency department (ED) visits.8-10 Despite attempts to increase naloxone access, just 1.5% of commercially-insured, high-risk patients were prescribed naloxone, despite a large number of health care system visits, and just 5% of rural residents receive a naloxone prescription.11,12

Pharmacists are medication experts, receiving extensive training in pathophysiology, pharmacology, medication therapy management, and therapeutics.13 More than 90% of the US population lives within 5 miles of a community pharmacy.14 Pharmacists' involvement with drug therapy initiatives, such as immunization and tobacco cessation management, have resulted in increased access to cost-effective and safe medication therapy.15 In 2015, Idaho passed legislation allowing pharmacists to prescribe naloxone. However, anecdotal evidence suggests that community pharmacists in Idaho do not actively use their prescriptive authority.  

The theory of planned behavior (TPB), a social cognition theory for human behavior, is guided by 3 general constructs; behavioral, normative, and control beliefs (Figure 1). TPB has been used to explain intentions and prescribing behaviors of general practitioners, such as for asthma and pain management, and collectively represents the health practitioners' intentions and resulting health management behavior(s).16 Behavioral beliefs represent attitudes toward a behavior, normative beliefs are perceived subjective norms, and control beliefs give rise to perceived behavioral control. As a rule, the more favorable the attitude, subjective norm, and perceived control, the stronger the intention to perform the behavior in question, in this case, naloxone prescribing.

We assume that TPB can help explain and predict naloxone prescribing behaviors of community pharmacists in Idaho.

Methods
To create the survey, target, action, context, and time elements of the naloxone prescribing and the population of interest, community pharmacists practicing in Idaho, were used to develop a list of potential survey questions based on established question-stems using a collaborative and iterative process.17

Eighteen pharmacists, faculty with the Idaho State University (ISU) College of Pharmacy, pre-tested the 44-question survey, which contained 10 demographic questions, 24 pilot survey questions, and 10 qualitative questions, providing written feedback to team members on naloxone use, prescribing, barriers, and facilitators that could potentially affect item applicability and comprehension.

The final tool included 61 questions: 6 behavioral belief, 17 normative belief, 6 control belief, 5 attitude-toward-behavior, 9 social norm, and 10 perceived behavioral control. Eight additional questions included 2 environment, 2 behavioral intention, 2 self-reported behaviors, and 2 opportunity assessment questions.

A list of e-mails for all registered pharmacists in the state was obtained from the Idaho Board of Pharmacy. An e-mail invitation with a link to the survey was sent to all registered pharmacists, and a 3-day and 10-day reminders e-mails were sent. All participants were offered the opportunity to enter their name and contact information for a drawing to receive a $50 Amazon gift card.18

All analysis conducted was using SPSS 24.19

Results
The final number of participants used in the analysis was 110. The average participant age was 44+/-13 years (range, 26 to 71 years), with a mean of 19+/-14 years (range, 3 to 50 years) since graduating with a professional degree. The respondents' gender was 43% female, 52% male, with the remainder preferred not to respond. Many pharmacists worked in more than 1 setting, with 8.2% in a hospital, 6.4% in ambulatory care, 5.5% in academia, 1% in long-term care, 1% in policy/professional development, 1% in research, and 3.6% other. 

Unless otherwise stated, survey results were reported as positive for Likert scale score of 5 or greater. Less than half of community pharmacists responding to the survey said that they think that the public is aware of the opioid epidemic in Idaho (n=51, 46.6%), and an even smaller number said that they think that the public is aware of naloxone's role in reducing risk of dying from an opioid overdose (n=6, 5.5%). Most participants said that they had at least 1 opportunity in the previous 12 months to talk to patients about naloxone (n=79, 72%). However, fewer had at least 1 opportunity to prescribe naloxone in the previous 12 months (n=48, 44%). Most community pharmacists said that they intend to educate patients about naloxone (n=84, 77.1%) and prescribe naloxone (n=64, 58.7%).

The remaining results were grouped based on the 3-component beliefs: behavioral, normative, and control. When looking at behavioral beliefs and attitudes, most of the community pharmacists said that they agree that prescribing naloxone will educate patients about opioid overdose (n=93, 85.3%), initiate dialogue about opioid use (n=89, 81.6%), make it easier to obtain naloxone (n=95, 87.2%), and prevent deaths (n=95, 86.4%). However, the majority did not agree (Likert of 4 or less) that prescribing naloxone would decrease public stigma about opioid use (n=73, 66.4%) or that prescribing naloxone would likely contribute to the stigma that patients abuse opioids (n=82, 74.5%). When evaluating the outcome of the behavior of interest (prescribing naloxone), most respondents said that they agree that prescribing naloxone would be beneficial (n=90, 81.8%). They also said that prescribing naloxone is appealing (n=68, 61.8%) and that they are comfortable initiating a conversation about naloxone therapy (n=58, 53.7%) and prescribing naloxone (n=71, 64.5%). Community pharmacists do not think that they are judgmental in prescribing naloxone to at-risk individuals (n=79, 71.8%).

Assessing the strength of normative beliefs, a majority of community pharmacists said that they think that it is their responsibility to initiate a conversation about opioid use (n=84, 77.1%) and overdose (n=93, 85.3%). They think it is their responsibility to decrease public stigma by talking more openly about naloxone use (n=78, 71.6%) and that providing education is critical before naloxone prescribing (n=105, 96.3%). Pharmacists who prescribe naloxone are knowledgeable about the opioid epidemic (n=62, 56.9%), participate in direct patient care activities (n=58, 53.2%), support increased availability of naloxone (n=82, 74.5%) and prescribe naloxone to reduce the risk of dying from overdose (n=97, 89%). Most respondents said that they think that community members (n=71, 65.1%), co-workers (n=87, 79.8%), employers (n=84, 77.1%), other pharmacists (n=75, 68.8%), and supervisors (n=89, 81.7%) and would approve of them prescribing naloxone. 

A majority of the respondents said that they care what their mentor/supervisor thinks that they should do in practice (n=67, 61.5%). However, less than half of respondents care what their colleagues (n=50, 45.5%) think. Most think that pharmacists “like them” would prescribe naloxone (n=70, 64.2%). However, fewer pharmacists responding to the survey said that they think that other pharmacists would prescribe naloxone (n=30, 27.7%), suggesting that other pharmacists act differently than “they would” with respect to naloxone prescribing.

Only a small number of pharmacists’ report being knowledgeable about the opioid epidemic (n=40, 36.7%), participating in direct patient care activities (n=36, 32.7%), supporting the availability of naloxone (n=43, 39.4%), and wanting to be “like” their colleagues in regards to prescribing naloxone (n=20, 18.3%). Most pharmacists said that they do want to be "like" their colleagues in regards to reducing opioid death risk (n=69, 62.7%), suggesting that they think that individuals within the profession should support harm reduction strategies, such as naloxone prescribing. 

Most respondents said that they think that the decision to prescribe naloxone is up to them (n=70, 64.2%), that they have access to necessary naloxone protocols (n=65, 59.1%), that they have control over ordering necessary supplies (n= 79, 72.5%), and that they have sufficient information to prescribe (n=74, 67.9%). Community pharmacists feel confident prescribing naloxone (n=62, 56.9%). However, less than half said that they think they were provided enough information during their formal training to prescribe naloxone (n=52, 47.7%), but they expect to have an opportunity to prescribe naloxone in their practice (n=82, 75.2%). Respondents did not consider liability a barrier (n=82, 74.5%), were not concerned about liability associated with naloxone prescribing (n=69, 62.7%), and were not concerned about losing customers due to naloxone prescribing (n=98, 89.1%). Facilitators of naloxone prescribing include community awareness regarding the opioid epidemic (n=76, 69.1%) and public awareness regarding naloxone's role in reducing opioid-related deaths (n=86, 78.9%). Facilitators also include access to naloxone prescribing protocols in their workplace (n=98, 89.9%) and affordable naloxone (n=93, 86.9%). 

Discussion
Pharmacists are well-positioned to identify patients at risk of opioid overdose and prescribe naloxone. Idaho permits pharmacists to prescribe naloxone. However, barriers, such as cost, discrepancies in social norms, provider education, and public awareness, persist. 

Health care professionals have been shown to have gaps in naloxone knowledge and difficulty identifying populations that may benefit from access to naloxone.20 Although the majority of survey respondents said that it is critical to be knowledgeable about naloxone when prescribing it, fewer than half said that they had received enough education about naloxone during their formal training. Other studies assessing pharmacists' knowledge about naloxone have found that pharmacists lack knowledge regarding naloxone and think that they have not received proper training.21-24 Pharmacists are not alone in thinking that they have not received adequate education about naloxone. A study of ED physicians reported barriers to naloxone prescribing, including lack of knowledge and training about naloxone.25 Internal medicine residents also report a lack of knowledge about how to educate patients about overdose risk reduction and indications for prescribing as a barrier to prescribing.26 

To date, pharmacy school education about substance use disorders (SUD) and treatments has been minimal.27 The American Association of Colleges of Pharmacy strongly encourages pharmacy educators to prepare students to appropriately manage SUD. However,  while SUD education has increased in the past few years, it still falls short of recommendations.28,29 One potential teaching strategy employs active-learning techniques to increase students' attitudes, confidence, and knowledge about SUD and naloxone use.30, 31

Postgraduate formal training has also been shown to be effective. The American Pharmacists Association offers a summer program to provide pharmacists and students with addiction management training and resources.32 The program uses pharmacy and physician champions to provide education focused on naloxone administration, patient education, the prescribing process, and risk factor identification.33 Providers who received academic detailing, examples of naloxone prescriptions, indications for naloxone, language to use with patients, and pharmacy outreach had a greater number of naloxone prescriptions issued than providers who did not receive the education.34 In New Mexico, hands-on, peer-to-peer training for pharmacists and technicians increased naloxone prescribing 10-fold.35

To increase awareness, the CDC established the Rx Awareness campaign, sharing stories of individuals torn apart by opioid misuse.36 Despite increased outreach efforts, less than half of respondents said that they think that the public is fully aware of the risks associated with prescription opioid use and even fewer understand the role of naloxone in reducing risk. Differences in how clinicians and patients perceive and discuss opioid use risks contribute to understanding and buy-in.37  

Programming aimed at educating opioid users about opioid overdose risk and naloxone use has been shown to increase confidence, knowledge, the necessity of contacting emergency services, and the willingness to administer naloxone.38 Rates of personally experiencing overdose range from half to a third of drug users, and rates of witnessing an overdose range from 75% to 90%.38,39 Even untrained individuals can effectively and safely administer the vaccine.40 Evidence supports naloxone distribution and education to opioid users, and bystanders may reduce the risk of death from an opioid overdose.41 The results of a study using an online crowdsourcing technology evaluating public knowledge of naloxone showed that 61% are aware that an opioid antidote exists or had heard of naloxone. Additionally, more participants said that they would react positively to a pharmacist dispensing naloxone with their opioid prescription than if the provider offered to prescribe naloxone or if a pharmacist offered to call the prescriber to recommend that he or she prescribe naloxone. A majority of participants (88%) in this study said that they agree that naloxone is beneficial for people who overdose on opioids.42

Pharmacists, particularly those who work in the community setting, have the opportunity to interact with patients more frequently than primary-care or specialty medical providers and more patient counseling opportunities.43 Respondents reported that increased public awareness facilitates pharmacist’s naloxone prescribing, suggesting a more positive pharmacist attitude toward naloxone prescribing with greater community awareness. This is consistent with results seen in other disciplines, such as nurses, physician assistants, primary-care providers, and psychiatrists.44 A study of ED physicians found physicians were more willing to prescribe naloxone if it was a common practice in their department.25

Based on 2017 statistics, 49% of adults with opioid use disorder [OUD] live 200% below the federal poverty level. Eighteen percent of adults with OUD are uninsured and would have to pay out of pocket for naloxone.45 The average wholesale price is prohibitive. The FDA-approved nasal naloxone costs about $150, and the auto-injection naloxone costs about $5000. The most cost-effective naloxone is a solution for injection to be used with a syringe, a vial of which can cost between $15 and $25.46

Adults with OUD are more likely to live in poverty and are less likely to be insured, and if they are insured more, they are more likely to be insured by Medicaid.47 Recent estimates suggest that 40% of adults with OUD have Medicaid coverage. All state Medicaid programs cover naloxone for the individual insured with Medicaid. However, this is not the case for Medicare.48,49 The Centers for Medicare and Medicaid Services require that naloxone appear on all Medicare part D formularies, and even some commercial/private insurance payers provide naloxone. Co-payments vary depending on the individual plan, and not all provider prescriptions are covered by insurance.

Finally, Naloxone is also only covered for the insured individual for personal use. If an individual wants to purchase naloxone for third-party administration, he or she must pay out of pocket.50

Conclusion
Most respondents think that the decision to prescribe naloxone is up to them and that they have access to necessary naloxone-prescribing protocols, control over ordering necessary supplies, and sufficient information to prescribe. Increased support and training could further increase naloxone access and support life-saving opioid overdose management. Further study is necessary to evaluate the support needed, best way to disseminate information, and whether pharmacists in other states with prescriptive authority respond the same.
 
Julia Boyle, PharmD, is an assistant professor at Idaho State University College of Pharmacy in Meridian.

Jared Vineyard, PhD, is an adjunct faculty member of statistics and research design at the, Massachusetts College of Pharmacy and Health Sciences in Boston, Massachusetts, and a post-doctoral fellow at the Idaho State University Idaho Center for Health Research in Meridian.

Renee Robinson, PharmD, MPH, MS Pharm, is an associate professor at the Idaho State University College of Pharmacy in Anchorage, Alaska.

Catherine Oliphant, PharmD, is a professor and interim chair of the Idaho State University College of Pharmacy.


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