Evaluation of Bexar County community pharmacist attitudes toward harm reduction.

INTRODUCTION: Harm reduction is a term for strategies that minimize the negative outcomes of drug use. Given the progressing opioid epidemic, identifying barriers to harm reduction dispensing in community pharmacies is essential.
METHODS: This online, survey-based study assessed community pharmacist attitudes toward harm reduction and perceived dispense rates of both naloxone and needles/syringes to patients without verifiable injectable prescriptions. The online survey was distributed to members of the Bexar County Pharmacist Association and university alumni. The survey collected demographics, perceived dispense rates of naloxone, needles and syringes, availability of pharmacy protocols for dispensing these products, and Likert-scaled attitudinal questions. Responses were collected for 6 weeks.
RESULTS: Thirty-two survey responses were analyzed. Participants were generally white (n = 14) or Hispanic/Latino (n = 14), had a median age of 37 years (interquartile range, 32-49 years), and had a median graduation year of 2011 (interquartile range, 1988-2016). Most pharmacists agreed or strongly agreed they should be involved in harm reduction (n = 26) and that pharmacies are an appropriate place to access these resources (n = 26). However, most reported never or rarely dispensing both naloxone (n = 19) and needles and syringes (n = 22). Naloxone or needle and syringe protocol use was reported by 66% (n = 21) and 47% (n = 15) of pharmacists, respectively. Pharmacy protocols significantly enhanced the likelihood of naloxone dispensing (P = .007) but not needle and syringe dispensing (P = .24).
CONCLUSION: Community pharmacists exhibited positive attitudes toward harm reduction but reported low rates of dispensing both naloxone and needles and syringes. Pharmacy protocols could be enhanced to better support community pharmacists in this area.

Introduction

Pharmacy is a diverse profession, and pharmacists continue to offer increasing numbers of clinical services in the community setting. Pharmacists must continue to seek opportunities to enhance health care, especially considering the severity and progression of the US opioid epidemic. Few answers exist to address this public health crisis; however, the Centers for Disease Control and Prevention1 has proposed a 5-point strategy to help prevent opioid overdoses and harm. Harm reduction is the use of strategies that decrease the negative consequences of drug abuse. The use of harm reduction aids patient and public health with support, education, and access to resources; examples of harm reduction include needle exchange and community-based naloxone distribution, which have been associated with reductions in blood-borne disease transmission and opioid overdose deaths, respectively.2 Empowering people to make safe choices and partnering in public safety efforts are specific strategies that community pharmacists may be uniquely suited to address, given their high degree of availability to the public, expertise in patient education, and ability to dispense harm reduction tools.

The dispensing of needles and syringes in community pharmacies is regulated on a state-by-state basis. For example, in Rhode Island it is legal to sell needles and syringes to patients without an identifiable prescription for an injectable medication. Zaller and colleagues3 completed a survey study in Rhode Island that collected information on pharmacists' views of current syringe laws, willingness to provide human immunodeficiency virus (HIV)-related services, substance use treatment, medical and social services for people who inject drugs, and past experiences with people who inject drugs. The study showed pharmacists supported selling and educating patients on needles and syringes and believed their work setting is an important resource for providing these types of services. In Texas, the retail sale of needles and syringes is not regulated; therefore, dispensation is at the discretion of the pharmacist. Texas does not currently offer community-wide syringe service programming.4 Currently, there are no published data describing attitudes of Texas pharmacists toward overall harm reduction resources.

Naloxone is an opioid receptor antagonist used for reversal of opioid overdose.5 All states have passed legislation aimed at improving community access to this lifesaving medication. The availability and regulations for Overdose Education and Naloxone Distribution (OEND) differ by state and can range from legislation targeted at improved first-responder access to standing orders permitting community pharmacies to dispense naloxone in a process similar to that for immunizations. In 2006, Massachusetts declared a statewide public health emergency and established an OEND program. This program served as an example for effectively dispensing OEND to the public from community pharmacies through a standing order protocol.6,7 As of 2015, Texas allows community pharmacies to dispense naloxone through a standing order process. According to a recent study of community pharmacies in Texas, 83.7% (n = 1940) of pharmacists reported willingness to dispense naloxone under a standing order, and three-fourths reported having at least 1 formulation of naloxone in stock.8

Although community pharmacies in Texas have the ability to provide naloxone, needles, and syringes to patients, no data exist on the general attitudes of Texas pharmacists toward dispensing these products, nor is there information on the effects attitude may have on overall dispense rates. Given the progression of the opioid epidemic and the climbing rate of hepatitis C and HIV transmission in Bexar County, it is important to characterize the attitudes of community pharmacists toward providing harm reduction resources.9

Methods

This study used a descriptive survey research method to assess the attitudes of Bexar County community pharmacists toward harm reduction and to evaluate factors influencing pharmacists' perceived rate of dispensing these products. The protocol was approved by the Institutional Review Board at the University of the Incarnate Word, and all participants gave informed consent. A Bexar County Pharmacists Association (BCPA) list was used to share the survey via e-mail. To participate, respondents needed an active Texas pharmacist license, registered employment in Bexar County, and to practice in a community pharmacy.

An online survey was developed using published literature that evaluated harm reduction in community pharmacy settings and consultation with content experts. The survey used Likert scale assessments and collected demographic information, perceived dispense rates of harm reduction, and attitudinal data. A preliminary paper survey was piloted on a small population of pharmacists to assess the readability and functionality, and feedback was incorporated. A second real-time, electronic survey was piloted to assess readability and determine average survey completion time before finalization. Readability statements were integrated in the survey, and participants who answered those statements incorrectly were excluded from data analysis as a quality assurance measure. A complete survey can be found in the Appendix.

The survey was e-mailed to Texas pharmacists through the BCPA and university pharmacy alumni using Google® Forms (Mountain View, CA). Survey data were collected from July 17, 2018, through September 1, 2018. Data collected included demographics, perceived dispense rates of naloxone or needles and syringes, information on pharmacy protocols, and attitude-based questions. Attitudinal data included Likert-scaled statements about naloxone, access of needles and syringes to patients without verifiable injectable prescriptions, and general beliefs about harm reduction. Participants were eligible for a drawing to receive a $50 electronic gift card.

Data were analyzed using JMP® Pro 14 (SAS Institute Inc, Cary, NC) and Microsoft® Excel (Redmond, WA). Demographic data and attitudinal data were evaluated using descriptive statistics. General belief and attitude-based data were pooled into summary charts and analyzed using logistic fit and contingency analyses; analyses compared attitude-based data with demographic, general belief, and perceived dispensation rates of naloxone or needles and syringes. Contingency analyses were used to compare protocol data with perceived dispensation rates of naloxone or needles and syringes.

Results

A total of 40 responses were collected, and 32 were included in the final analysis. Eight responses were excluded because of failed quality control measures. The median age of participants was 37 years (interquartile range, 32-49 years), and participants were primarily white (n = 14 [44%]) or Hispanic/Latino (n = 14 [44%]), with a median pharmacy school graduation year of 2011 (interquartile range, 1988-2016). A summary of demographic data can be found in Table 1.

TABLE 1

Demographics of the study (n = 32)

	No. (%)a
Sex
Male	14 (44)
Female	15 (47)
I do not wish to disclose	3 (9)
Age, y, median (IQR)	37 (32-49)
Race
White	14 (44)
Hispanic/Latino	14 (44)
Black/African American	0 (0)
Native American	0 (0)
Asian/Pacific Islander	2 (6)
I do not wish to disclose	2 (6)
Graduation year, median (IQR)	2011 (1988-2016)
Dispensing: naloxone
Never	13 (41)
Rarely	6 (19)
Sometimes	11 (34)
Often	2 (6)
Very often	0 (0)
Dispensing: needles and syringes
Never	16 (50)
Rarely	6 (19)
Sometimes	2 (6)
Often	5 (16)
Very often	3 (9)
Aware of the opioid continuing education requirements
Yes	26 (81)
No	6 (19)
Pharmacist general belief: Pharmacies are an appropriate place to access harm reduction resources
Strongly agree	10 (32)
Agree	16 (50)
Neutral	2 (6)
Disagree	2 (6)
Strongly disagree	2 (6)
Pharmacist general belief: Pharmacists should be involved in harm reduction
Strongly agree	12 (38)
Agree	14 (44)
Neutral	4 (12)
Disagree	1 (3)
Strongly disagree	1 (3)

IQR = interquartile range.

Unless otherwise noted by IQR.

Most pharmacists agreed or strongly agreed they should be involved in harm reduction (n = 26) and that pharmacies are an appropriate place to access these resources (n = 26). When assessing the 6 attitude-based naloxone statements, more than 80% of pharmacists reported they agreed or strongly agreed with 5 of the 6 statements. Similarly, among the 4 attitude-based needle and syringe statements, more than 60% of respondents reported they agreed or strongly agreed with 3 of the 4 statements (Figure 1; Tables 2 and 3). However, most respondents reported never or rarely dispensing both naloxone (n = 19 [59%]) and needles and syringes (n = 22 [69%]; Table 1).

FIGURE 1

Pharmacist attitudes and relationships to demographic: (A) needles and syringes and (B) naloxone dispensing (pie charts show the Likert scale distribution for specific attitude questions that were answered in the survey; see Tables 2 and 3 for further information)

TABLE 2

P value needles and syringes results of the logistic fit and contingency analysis that compared attitude-based data with general beliefs (pharmacy access and pharmacist involvement), demographics (age, race/ethnicity, graduation year), and perceived dispense ratesa

Data	Patients Who Abuse Drugs	Safe Harm Reduction Strategy	Reduce Bloodborne Pathogen Transmission	Community Pharmacies Are Optimal Place for Accessibility
Pharmacy access	.63	.88	.69	.35
Pharmacist involvement	.51	.22	.75	.02
Age	.55	.66	.19	.58
Sex	.43	.49	.71	.97
Race/ethnicity	.45	.56	.33	.95
Graduation year	.25	.43	.64	.46
Perceived dispense rate	.45	.96	.91	.71

Bold indicates significant value.

TABLE 3

P value naloxone results of the logistic fit and contingency analysis that compared attitude-based data with general beliefs (pharmacy access and pharmacist involvement), demographics (age, race/ethnicity, graduation year), and perceived dispense ratesa

Data	Dispensing Naloxone to Patients With a Substance Use Disorder	Naloxone Is an Effective Way for Non–Medically Trained People to Treat Overdoses	Naloxone Is a Safe Harm Reduction Strategy	Providing Naloxone to Patients Who Use Opioids as Prescribed	Providing Naloxone to Patients Who Abuse Opioids	Community Pharmacies Are an Optimal Place to Access Naloxone
Pharmacy access	.02	.06	.049	.05	.15	.01
Pharmacist involvement	.003	.08	.02	.01	.003	<.001
Age	.04	.24	.05	.048	.11	.04
Sex	.47	.47	.23	.11	.42	.89
Race/ethnicity	.26	.22	.06	.15	.27	.49
Graduation year	.19	.34	.047	.01	.03	.04
Perceived dispense rate	.62	.44	.54	.73	.51	.42

Bold indicates significant value.

When comparing baseline demographics to Likert-scaled attitude statements, graduation year and age had significant relationships with most naloxone-based attitude statements. There were no significant relationships between demographics and attitudes toward dispensing needles and syringes to patients without a verifiable injectable prescription. Pharmacists' general beliefs that “Pharmacists should be involved in harm reduction” and that “Pharmacies are an acceptable place to access harm reduction” demonstrated significant relationships with nearly all naloxone-based attitude statements but only one needle and syringe-based attitude statement (Figure 1; Tables 2 and 3). Attitudes and general beliefs did not have a statistically significant impact on pharmacists' perceived dispensing rates of either naloxone, or needles and syringes (Figure 1; Tables 2 and 3).

Most respondents indicated they had a protocol for dispensing naloxone (n = 21), whereas fewer pharmacists reported they had a protocol for dispensing needles and syringes to patients without a verifiable injectable prescription (n = 15). Among pharmacists who reported having a protocol for dispensing naloxone, 58% indicated they sometimes or often dispense naloxone (n = 12, P = .007). Among pharmacists who reported not having a naloxone protocol, all reported never dispensing naloxone. More than two-thirds of pharmacists reported that they rarely or never dispense needles and syringes to patients without verifiable injectable prescriptions, regardless of if they had a protocol (n = 10, P = .24) or not (n = 11; P = .24; Figure 2).

FIGURE 2

Protocol for (A) needle and syringe dispensing and (B) naloxone dispensing

Discussion

Our findings demonstrate that Bexar County community pharmacists have a generally favorable attitude toward providing harm reduction resources but overall low perceived dispense rates of naloxone, needles, and syringes. Previous publications on pharmacists' attitudes toward harm reduction have also reported positive attitudes, but they have also reported that lack of time and training, wariness of unruly customers, and communication between providers limit pharmacist engagement in these activities.10 A Rhode Island investigation reported factors that might be barriers to pharmacists providing harm reduction resources, such as concern for safety, customer perception, lack of time, and confidential space.3 Pharmacists' fear of potential customer behaviors, such as shoplifting and staff safety, continues to be the most frequent barrier reported in the literature, despite evidence to the contrary.10 Most of these studies were published prior to nationwide expansion of community-based naloxone and increases in community education on the opioid epidemic. However, perceived dispense rates of naloxone and needles and syringes remained low among our population, despite favorable attitudes, supportive legislation, high rates of naloxone stock in Texas pharmacies, and national shifts in community naloxone access.8

To our knowledge, previous publications did not evaluate the role of pharmacy protocols or specific pharmacist demographics or attitudes on rates of dispensing harm reduction products. Our work evaluated the relationship between pharmacist attitudes, demographics, and protocols with perceived harm reduction dispense rates. Pharmacist demographics did not have a significant effect on the perceived dispense rates of naloxone or needles and syringes among our population. There were no significant relationships between pharmacist demographics and attitudes toward dispensing needles and syringes to patients without identifiable injectable prescriptions. Pharmacists in our cohort were generally more likely to identify naloxone as a safe harm reduction resource, compared with needles and syringes, despite 82% of pharmacists agreeing “Needles and syringes reduce bloodborne pathogen transmission.” Differences in these findings may be a consequence of many pharmacists and student pharmacists now being exposed to OEND training and mandated opioid continuing education requirements.

Perceived dispense rates for both naloxone and needles and syringes were low for all respondents. Our findings suggest pharmacy protocols are lacking in their ability to optimize dispense rates of harm reduction resources. However, the presence of a pharmacy protocol for dispensing naloxone had a significant effect on if a pharmacist reported ever dispensing naloxone. Among pharmacists who reported not having a naloxone protocol, all reported never dispensing naloxone. Needle and syringe protocols did not influence dispensing, because rates were consistently low for this resource. The contents of pharmacy protocols and their ability to assist pharmacists in dispensing harm reduction products warrant further investigation and may be useful, given that pharmacists report time constraints as a barrier. These issues will become increasingly pertinent as the US Food and Drug Administration extends support for over-the-counter status of naloxone.3,10

This work has several limitations. The most significant limitation was overall sample size, which was low in part because of difficulty obtaining participant contact information. Using BCPA membership and university alumni as our recruitment list potentially limited our sample size; this population could represent pharmacists who are engaged in updates to guidelines, protocols, literature, and laws, thus influencing the overall characteristics of these survey responses. Further, overall response rate was not able to be calculated given that organizational distribution lists were not made available to the researchers. The availability of the survey in electronic format limited the response rate, because we were unable to accommodate distribution of paper copies. No data were collected on the specific county location of pharmacists who completed the survey. Additionally, no information was collected on the content of the protocols. Despite these limitations, the information gleaned from this study can help inform efforts within the county to encourage pharmacist involvement in harm reduction strategies.

Conclusion

Despite favorable attitudes, supportive legislation, high rates of naloxone stock in Texas pharmacies, and national shifts in community-based naloxone access, perceived dispense rates of harm reduction remain low among Bexar County community pharmacists. Future investigations should continue to evaluate barriers to dispensing harm reduction in the community pharmacy setting, with emphasis in evaluating the content of pharmacy protocols for dispensing these products.