Findings From a National Survey of Older US Adults on Patient Willingness to Use Telehealth Services: Cross-Sectional Survey.

BACKGROUND: Telehealth (telemedicine and telepharmacy) services increase access to patient services and ensure continuity of care. However, few studies have assessed factors that influence patients' willingness to use telehealth services, and we sought to investigate this. OBJECTIVE: This study aims to examine respondents' (aged between 45 and 75 years) willingness to use telehealth services (telepharmacy and telemedicine) and the correlates of the willingness to use telehealth services. METHODS: We administered a cross-sectional national survey of 1045 noninstitutionalized US adults aged between 45 and 75 years in March and April 2021. Multiple logistic regression analyses were used to identify demographic and health service use correlates of self-reported willingness to use telehealth services. RESULTS: Overall willingness to use telemedicine was high (674/1045, 64.5%). Adults aged 55 years and older were less willing to use telemedicine (aged between 55 and 64 years: odds ratio [OR] 0.61, 95% CI 0.42-0.86; aged 65 years or older: OR 0.33, 95% CI 0.22-0.49) than those younger than 55 years. Those with a regular provider (OR 1.01, 95% CI 1-1.02) and long travel times (OR 1.75, 95% CI 1.03-2.98) were more willing to use telemedicine compared to those without a regular provider and had shorter travel times, respectively. Willingness to use telemedicine services increased from 64.5% (674/1045) to 83% (867/1045) if the service was low-cost or insurance-covered, was with their existing health care provider, or was easy-to-use. Overall willingness to use telepharmacy was 76.7% (801/1045). Adults aged older than 55 years were less willing to use telepharmacy (aged between 55 and 64 years: OR 0.57, 95% CI 0.38-0.86; aged 65 years or older: OR 0.24, 95% CI 0.15-0.37) than those younger than 55 years. Those who rated pharmacy service quality higher were more willing to use telepharmacy (OR 1.06, 95% CI 1.03-1.09) than those who did not. CONCLUSIONS: Respondents were generally willing to use telehealth (telemedicine and telepharmacy) services, but the likelihood of their being willing to use telehealth decreased as they were older. For those initially unwilling (aged 55 years or older) to use telemedicine services, inexpensive or insurance-covered services were acceptable.

Assessing pharmacists' knowledge, attitudes, and practices of opioid management within different patient populations.

BACKGROUND: Racial disparities in drug overdose exist, with black, indigenous, and Hispanic individuals experiencing higher rates of opioid overdose deaths. Opioid use disorder prevention services, such as opioid deprescribing and naloxone dispensing, have been identified as ways to prevent opioid overdose. Pharmacists can help use these strategies, but racial disparities in use exist. OBJECTIVE: This study aimed to evaluate North Carolina (NC) pharmacist knowledge, attitudes, and practices (KAP) of opioid management practices, including opioid deprescribing and naloxone dispensing, across different racial and ethnic groups. METHODS: This was a prospective, cross-sectional study conducted through a Web-based KAP survey distributed via e-mail to all NC pharmacists using a modified Dillman's method. Descriptive statistics were used to analyze demographics and pharmacist KAP data. Attitudes data were further analyzed using one-way analysis of variance tests and Tukey's post hoc analyses. RESULTS: After applying exclusion criteria, 527 participants were eligible for analysis; 254 of these individuals completed the entire survey. The survey response rate was 15.3% and respondents were mostly female (59.1%) and white (86.6%). Approximately half of pharmacists knew the correct opioid morphine milliequivalent cutoffs considered to be high risk (47.7%) and not to be exceeded (51.9%). When asked about chronic opioid statistics within the United States, respondents overestimated that 23.70% of patients on chronic opioid therapy receive naloxone (SD = 18.93%). Pharmacists believed that black patients were more likely to adhere to an opioid taper than any other race or ethnicity and Hispanic patients were more likely to adhere to naloxone treatment than any other race or ethnicity. Finally, 91% of pharmacists knew what an opioid taper was, but 77% of pharmacists had never designed one. CONCLUSIONS: Gaps in knowledge may contribute to further disparities in opioid management. Pharmacists' attitudes may contribute to biases in opioid management practices and practices related to opioid deprescribing may limit the pharmacists' current role. More education is needed so pharmacists can play an increased role in opioid management across all patient populations.

Systematic review of community pharmacist administration of long-acting injectable antipsychotic medications.

BACKGROUND: Long-acting injectable antipsychotic (LAIA) medications offer an effective treatment option for patients with serious mental illness. Despite demonstrated clinical safety and efficacy as well as increased adherence and less frequent administration compared with daily oral regimens, LAIAs remain underutilized in clinical practice. With legislation allowing pharmacists to administer injectable medications in 48 U.S. states, community pharmacies are uniquely positioned to serve as an access point for patients with serious mental illnesses to receive LAIA injections. OBJECTIVE: This study aimed to conduct a systematic review of the health and economic benefits and costs of community pharmacist administration of LAIA medications. METHODS: A systematic search of the literature published from January 1996 to April 2022 was conducted across 3 databases (Embase, PubMed, and Scopus Plus). Publications describing pharmacist administration of LAIA medications in outpatient settings were included. Publications that examined the use of LAIAs but did not involve a pharmacist administering the medication were excluded. RESULTS: Of 2261 publications reviewed, we identified 8 publications (4 articles and 4 abstracts) that met our inclusion criteria, of which only 7 included results. Four studies reported high medication adherence achieved by patients receiving pharmacist-administered LAIAs. Two publications surveyed patient satisfaction with pharmacist administration of LAIAs in community pharmacy settings. One study found pharmacists' mixed attitudes regarding LAIA administration and time and safety barriers to offering the service. CONCLUSION: We found very little evidence on the impact of pharmacist administration of LAIAs on patient outcomes. This review highlights the need to generate greater evidence on the health and economic benefits as well as financial models for pharmacists to administer LAIA medications in outpatient and community pharmacy settings. Such evidence could support more community pharmacists to offer LAIA medications and contribute to the shift toward value-based care.

"They don't go by the law around here": law enforcement interactions after the legalization of syringe services programs in North Carolina.

BACKGROUND: In 2016, the US state of North Carolina (NC) legalized syringe services programs (SSPs), providing limited immunity from misdemeanor syringe possession when law enforcement is presented documentation that syringes were obtained from an SSP. This study explores the law enforcement interactions experienced by SSP participants since the enactment of this law. METHODS: This study used a convergent, mixed-methods design consisting of structured surveys and semi-structured interviews with SSP participants in seven NC counties. Survey and interview data were collected simultaneously between January and November 2019. This survey was designed to capture demographics, characteristics of drug use, SSP services used, and past-year negative experiences with law enforcement (officer did not recognize SSP card, did not believe SSP card belonged to participant, confiscated SSP card, confiscated syringes, or arrested participant for possessing syringes). Semi-structured interviews explored lived experiences with and perspectives on the same topics covered in the survey. RESULTS: A total of 414 SSP participants completed the survey (45% male, 54% female, 1% transgender or non-binary; 65% White, 22% Black, 5% American Indian/Alaskan Native, 8% some other racial identity). 212 participants (51.2%) reported at least one past-year negative experience with law enforcement. Chi-square testing suggests that Black respondents were more likely to report having experienced law enforcement doubt their SSP card belonged to them. Interview data indicate that law enforcement practices vary greatly across counties, and that negative and/or coercive interactions reduce expectations among SSP participants that they will be afforded the protections granted by NC law. CONCLUSION: Despite laws which protect SSP participants from charges, negative law enforcement responses to syringe possession are still widely reported. Evidence-based policy interventions to reduce fatal overdose are undermined by these experiences. Our findings suggest NC residents, and officers who enforce these laws, may benefit from clarification as to what is required of the documents which identify participants of registered SSPs where they may legally obtain syringes. Likewise, more thorough trainings on NC's syringe law for law enforcement officers may be merited. Further research is needed to assess geographic differences in SSP participants' law enforcement interactions across race and gender.

The Kynurenine Pathway and Kynurenine 3-Monooxygenase Inhibitors.

Under normal physiological conditions, the kynurenine pathway (KP) plays a critical role in generating cellular energy and catabolizing tryptophan. Under inflammatory conditions, however, there is an upregulation of the KP enzymes, particularly kynurenine 3-monooxygenase (KMO). KMO has garnered much attention due to its production of toxic metabolites that have been implicated in many diseases and disorders. With many of these illnesses having an inadequate or modest treatment, there exists a need to develop KMO inhibitors that reduce the production of these toxic metabolites. Though prior efforts to find an appropriate KMO inhibitor were unpromising, the development of a KMO crystal structure has provided the opportunity for a rational structure-based design in the development of inhibitors. Therefore, the purpose of this review is to describe the kynurenine pathway, the kynurenine 3-monooxygenase enzyme, and KMO inhibitors and their potential candidacy for clinical use.

Integrating targeted consultant pharmacists into a new collaborative care model to reduce the risk of falls in older adults owing to the overuse of opioids and benzodiazepines.

Using central nervous system (CNS)-active medications increases older adults' risk for falls and fall-related injuries. Opioids and benzodiazepines are among the most widely used CNS-active medications and because of their addictive potential and widespread use for common ailments such as chronic pain, anxiety, or sleep, are also among the most difficult to deprescribe. Reducing the dose burden of these 2 medication classes in older adults-to balance safety with efficacy-is a challenge that requires persistence and strategic support structures to be successful. We propose a novel care model that uses the support of targeted consultant pharmacist services to help primary care providers reduce the unnecessary use of opioids and benzodiazepines in their patients who are older adults. This care model holds promise to not only offer providers additional time-saving clinical support but to help their practices improve patient outcomes, such as a reduction in medication-related falls and excess opioid use.

Empowering Pharmacists: Strategies for Addressing the Opioid Crisis through a Public Health Lens.

BACKGROUND: The opioid crisis in the US is a severe public health issue, prompting pharmacists to adopt various strategies for prevention, harm reduction, treatment, and recovery. Despite progress, barriers persist. RESULTS: This commentary examines five determinants of public health in relation to pharmacist-led interventions for the opioid crisis: individual behavior, social factors, policymaking, health service accessibility, and biological/genetic considerations. Pharmacists can influence individual behavior through education and support, address social determinants like stigma, advocate for policy changes, ensure health service accessibility, and personalize opioid prescriptions based on biological factors. CONCLUSION: Pharmacists play a crucial role in addressing the opioid crisis by navigating these determinants. Pharmacists' engagement is essential for reducing opioid-related harms and improving public health outcomes through advocacy, service provision, and education.

Association of Average Daily Morphine Milligram Equivalents and Falls in Older Adult Chronic Opioid Users.

Opioids remain commonly prescribed in older adults, despite the known association with falls and fall-related injuries. This retrospective cohort study sought to determine the association of opioid use and falls in older adult opioid users. Using a one-year lookback period in electronic health records, daily morphine milligram equivalents (MMEs) were calculated using prescription orders. Fall history was based on patient self-reporting. A receiver operating characteristic (ROC) curve was used to identify the threshold of average daily MMEs at which the likelihood of falls was increased. Older opioid users were most often women and White, with 30% having fallen in the prior year. In ROC analyses (n = 590), the threshold where fall risk increased was 37 MMEs (p = 0.07). Older adults prescribed more than 37 MMEs daily may be at increased fall risk and should be targeted for deprescribing interventions. Additionally, analysis on patient characteristics and covariates suggest that sex, age, COPD, sleep apnea, cancer, and psychiatric conditions may indicate an increased risk of falls in older adults taking chronic opioids (p < 0.05). Multifactorial interventions may be needed to modify fall risk beyond medication use alone.

Codeine and promethazine: Exploratory study on "lean" or "sizzurp" using national survey data and an online forum.

BACKGROUND: The concoction known as "lean" containing codeine and promethazine, holds a prominent cultural presence and is often referenced in mass media platforms (e.g., music and social media). Surprisingly, there's a scarcity of national data characterizing the use of lean. Therefore, the current study investigated the use of lean using national survey data and online forum participant input, and focused on identifying concurrent substance use, exploring co-administration with other substances (e.g., alcohol, cannabis), and determining lean-related experiences. METHODS: We analyzed data from the National Survey on Drug Use and Health (NSDUH) spanning 2007-2019, identifying persons who used lean (weighted N = 42,275). Additionally, we conducted a Reddit-based study to gather insights about lean consumtion (N = 192). RESULTS: The NSDUH data indicated that lean use was most prevalent among teenagers and young adults (ages 13-21), accounting for 66% of the sample. This trend was more pronounced in male respondents (75%) compared to females. Additionally, the use was predominantly observed among Black/African American (29%), Hispanic (28%), and White (33%) populations, with these groups also reporting higher levels of concurrent alcohol and cannabis use. Similarly, findings from Reddit showed that individuals who used lean were predominantly male (67%) and exhibited elevated concurrent rates of alcohol (83%) and cannabis (46%) use in the past 30 days. Moreover, approximately 66% of respondents met criteria for severe lean use disorder, and 37% acknowledged driving under its influence. CONCLUSION: The NSDUH data found that mostly young adult males reported consuming lean in the past twelve months, though the racial/ethnic breakdown of persons who used lean was diverse. The Reddit data found that most individuals in the sample met the criteria for a substance use disorder pertaining to their lean consumption. These findings underscore the clinical significance and necessity for further controlled research on lean.

Examining facilitative services for entry into substance use disorder treatment: A cluster analysis of treatment facilities.

OBJECTIVES: We examined services to facilitate access to entering substance use disorder (SUD) treatment among a national sample of SUD treatment facilities. METHODS: We analyzed data from the National Survey of Substance Abuse Treatment Services (N-SSATS) 2020. Facilities were included in the sample based on criteria such as SUD treatment provision and being in the U.S. Cluster analysis was conducted using variables including ownership, levels of care, and whether facilities provide services or accept payment options aimed at reducing treatment barriers. National and state-level data on the percentage of facilities in each cluster were presented. RESULTS: Among N = 15,788 SUD treatment facilities four distinct clusters were identified: Cluster 1 consisted of for-profit and government outpatient facilities with high proportions of services to reduce barriers (22.2%). Cluster 2, comprised of non-profit outpatient facilities, offered the most comprehensive array of services to minimize barriers to treatment among all four clusters (25.2%). Cluster 3 included facilities with diverse ownership and care levels and provided a moderate to high degree of services aimed at reducing entry barriers to treatment (26.0%). Cluster 4 was primarily for-profit outpatient facilities with a low proportion of these services (26.6%). CONCLUSIONS: This study revealed facility-level groupings with different services to reduce barriers to SUD treatment across various clusters of SUD treatment facilities. While some facilities offered extensive services, others provided fewer. Differences in cluster distributions point to possible facilitators to treatment access for some persons seeking admission to specific treatment facilities. Efforts should be made to ensure that individuals seeking SUD treatment can access these services, and facilities should be adequately equipped to meet their diverse needs.

Racial and Ethnic Disparities in Community-Based Pharmacies: A Scoping Review.

As pharmacy practice shifts its focus toward population health care needs that serve public health, there is a need to understand community-based pharmacies' contributions to the reduction in health disparities. A scoping review was conducted to identify what community-based pharmacies in the United States are doing to target racial and ethnic disparities in community-based pharmacies. Forty-two articles revealed that community-based pharmacy services addressed racial and ethnic inequities in a variety of ways, including the types of interventions employed, as well as the ethnicities and conditions of the sample populations. Future work should focus on ensuring interventions are carried out throughout pharmacy practice and accessible to all racial and ethnic minoritized populations.

Patterns and disparities in prescribing of opioids and benzodiazepines for older adults in North Carolina.

BACKGROUND: We characterized real-world prescribing patterns of opioids and benzodiazepines (BZDs) for older adults to explore potential disparities by race and sex and to characterize patterns of co-prescribing. METHODS: A retrospective evaluation was conducted using electronic health data for adults ≥65 years old who presented to one of 15 primary care practices between 2019 and 2020 (n = 25,141). Chronic opioid and BZD users had ≥4 prescriptions in the year prior, with at least one in the last 90 or 180 days, respectively. We compared demographic characteristics between all older adults versus chronic opioid and BZD users. We used logistic regression to identify characteristics (age, sex, race, Medicaid use, fall history) associated with opioid and BZD co-prescribing. RESULTS: We identified 833 (3.3%) chronic opioid and 959 chronic BZD users (3.8%) among all older adults seen in these practices. Chronic opioid users were less likely to be Black (12.7% vs. 14.3%) or other non-White race (1.4% vs. 4.3%), but more likely to be women (66.8% vs. 61.3%). A similar trend was observed for BZD users, with less prescribing among Black (5.4% vs. 14.3%) and other races (2.2% vs. 4.3%) older adults and greater prescribing among women (73.6% vs. 61.3%). Co-prescribing was observed among 15% of opioid users and 13% of BZD users. Co-prescribing was largely driven by the presence of relevant co-morbid conditions including chronic pain, anxiety, and insomnia rather than demographic characteristics. CONCLUSIONS: We observed notable disparities in opioid and BZD prescribing by sex and race among older adults in primary care. Future research should explore if such patterns reflect appropriate prescribing or are due to disparities in prescribing driven by biases related to perceived risks for misuse.

Patient Perceptions of Opioids and Benzodiazepines and Attitudes Toward Deprescribing.

BACKGROUND: Opioids and benzodiazepines (BZDs) pose a public health problem. Older adults are especially susceptible to adverse events from opioids and BZDs owing to an increased usage of opioids and BZDs, multiple comorbidities, and polypharmacy. Deprescribing is a possible, yet challenging, solution to reducing opioid and BZD use. OBJECTIVE: We aimed to explore older adult patients' knowledge of opioids and BZDs, perceived facilitators and barriers to deprescribing opioids and BZDs, and attitudes toward alternative treatments for opioids and BZDs. METHODS: We conducted 11 semi-structured interviews with patients aged 65+ years with long-term opioid and/or BZD prescriptions. The interview guide was developed by an interprofessional team and focused on patients' knowledge of opioids and BZDs, perceived ability to reduce opioid or BZD use, and attitudes towards alternative treatments. RESULTS: Three patients had taken opioids, either currently or in the past, three had taken BZDs, and five had taken both opioids and BZDs. Generally, knowledge of opioids and BZDs was variable among patients; yet facilitators and barriers to deprescribing both opioids and BZDs were consistent. Facilitators of deprescribing included patient-provider trust and slow tapering of medications, while barriers included concerns about re-emergence of symptoms and a lack of motivation, particularly if medications and symptoms were stable. Patients were generally unenthusiastic about pursuing alternative pharmacologic and non-pharmacologic alternatives to opioids and BZDs for symptom management. CONCLUSIONS: Our findings indicate that patients are open to deprescribing opioids and BZDs under certain circumstances, but overall remain hesitant with a lack of enthusiasm for alternative treatments. Future studies should focus on supportive approaches to alleviate older adults' deprescribing concerns.

Addressing COVID-19 vaccine hesitancy in rural community pharmacies: a protocol for a stepped wedge randomized clinical trial.

BACKGROUND: Uptake of COVID-19 vaccines remains problematically low in the USA, especially in rural areas. COVID-19 vaccine hesitancy is associated with lower uptake, which translates to higher susceptibility to SARS-CoV-2 variants in communities where vaccination coverage is low. Because community pharmacists are among the most accessible and trusted health professionals in rural areas, this randomized clinical trial will examine implementation strategies to support rural pharmacists in delivering an adapted evidence-based intervention to reduce COVID-19 vaccine hesitancy. METHODS: We will use an incomplete stepped wedge trial design in which we will randomize 30 rural pharmacies (unit of analysis) to determine the effectiveness and incremental cost-effectiveness of a standard implementation approach (consisting of online training that describes the vaccine hesitancy intervention, live webinar, and resource website) compared to adding on a virtual facilitation approach (provided by a trained facilitator in support of the delivery of the vaccine hesitancy counseling intervention by pharmacists). The intervention (ASORT) has been adapted from an evidence-based vaccine communication intervention for HPV vaccines through a partnership with rural pharmacies in a practice-based research network in seven southern US states. ASORT teaches pharmacists how to identify persons eligible for COVID-19 vaccination (including a booster), solicit and address vaccine concerns in a non-confrontational way, recommend the vaccine, and repeat the steps later if needed. The primary trial outcome is fidelity to the ASORT intervention, which will be determined through ratings of recordings of pharmacists delivering the intervention. The secondary outcome is the effectiveness of the intervention, determined by rates of patients who agree to be vaccinated after receiving the intervention. Other secondary outcomes include feasibility, acceptability, adoption, reach, and cost. Cost-effectiveness and budget impact analyses will be conducted to maximize the potential for future dissemination and sustainability. Mixed methods will provide triangulation, expansion, and explanation of quantitative findings. DISCUSSION: This trial contributes to a growing evidence base on vaccine hesitancy interventions and virtual-only facilitation of evidenced-based practices in community health settings. The trial will provide the first estimate of the relative value of different implementation strategies in pharmacy settings. TRIAL REGISTRATION: NCT05926544 (clinicaltrials.gov); 07/03/2023.

Beyond refill alignment: Evaluating the impact of appointment-based model.

BACKGROUND: The appointment-based model (ABM) is a framework for medication synchronization (med sync) which allows improved efficiency in pharmacy operations. Refill alignment forms the foundation of med sync programs and has proven to improve medication adherence. However it is uncertain if the remaining four components of ABM including the identification and enrollment of patients, medication review and patient assessment, preparation of medications, and delivery of medications can positively impact adherence. OBJECTIVE: To identify ABM core component(s) that significantly improve medication adherence and evaluate the extent to what prescription volume utilizing ABM impacts adherence. METHODS: A retrospective, cross-sectional analysis was conducted on 68 community pharmacies. Medication adherence rates were collected for antihypertensive, antihyperlipidemic, and oral hypoglycemic agents. Analyses were performed to determine the impact of ABM operations on adherence. RESULTS: Four components of ABM were associated with significant improvement in adherence. The ABM operations related to those components include patient recruitment, medication delivery, flexible payment options, documenting synchronized medications and refill date, assessing patient ability to fill medications prior to refill date, refill timelines, and inquiring about medication changes during the patient outreach call (p < 0.05). While synchronizing at least 16% of a pharmacy's total prescription volume improved adherence, synchronizing at least 31% produced significant improvement across all chronic disease categories (p < 0.05). CONCLUSION: Operationalization of four core components from the ABM process - identifying and enrolling patients, medication review and assessment, alignment of refills and preparation of medications - were all found to significantly improve adherence. Pharmacies wanting to improve adherence rates across chronic disease categories should aim to have a minimum of 31% of their prescription volume synchronized.

An exploration of barriers, facilitators, and practical solutions for adopting medication synchronization into community pharmacies: A qualitative analysis.

Background: Community pharmacies across the nation have adopted medication synchronization (Med Sync) services with the aim of improving medication adherence. To help incorporate Med Sync into a pharmacy's workflow, pharmacy associations and organizations developed implementation guides for community pharmacies. However, considerable variability in the adoption of this service exists as pharmacies struggle to implement Med Sync into traditional workflow. Researchers identified early adopters of Med Sync who dispense majority of their prescriptions as part of a Med Sync program. An exploratory study was undertaken with the aim to reveal themes surrounding facilitators and barriers to adoption of Med Sync in community pharmacies. Objectives: The objective of this study was to explore the barriers and facilitators associated with Med Sync adoption in community pharmacies and generate practical solutions for service adoption. Methods Community pharmacies participating in the North Carolina's Community Pharmacy Enhanced Services Network (CPESNsm) who were early adopters of Med Sync and had greater than 50% of their prescription volume being dispensed as part of a Med Sync program were recruited to participate in semi-structured interviews. Interviews were conducted, recorded, and transcribed verbatim with representatives who led the adoption of Med Sync in their pharmacy. Inductive coding and summary analysis were used to analyze the interview data and determine themes associated with facilitators and barriers. Results: Analysis of the interviews revealed four key themes: program organization, staff engagement, patient engagement, and provider engagements for Med Sync adoption. Each of these themes had several sub-themes, contributing to facilitators and barriers to Med Sync adoption. Subthemes of program organization included having organizational infrastructure, including a pharmacy software system, a dedicated area, and a consistent enrollment process. Subthemes of staff engagement included having a team-based approach, job training, and staff incentives. Patient engagement's subthemes included communication, finances, health literacy, and transportation. Provider engagement resulted with subthemes including lack of communication and provider-pharmacist relationships. Conclusion: To ensure successful adoption of Med Sync into traditional workflow, community pharmacies should employ a multi-factorial approach that includes internal and external components to the community pharmacy. This study identified facilitators associated with successful Med Sync adoption such as adequate staff engagement and requisite program organization. Barriers hindering successful Med Sync adoption resulted from challenges with provider and patient engagement. This study also makes an important contribution by providing practical solutions to Med Sync adoption based on participant responses and identified themes and sub-themes.

A deprescribing medication program to evaluate falls in older adults: methods for a randomized pragmatic clinical trial.

BACKGROUND: Opioids and benzodiazepines (BZDs) are some of the most commonly prescribed medications that contribute to falls in older adults. These medications are challenging to appropriately prescribe and monitor, with little guidance on safe prescribing of these medications for older patients. Only a handful of small studies have evaluated whether reducing opioid and BZD use through deprescribing has a positive impact on outcomes. Leveraging the strengths of a large health system, we evaluated the impact of a targeted consultant pharmacist intervention to deprescribe opioids and BZDs for older adults seen in primary care practices in North Carolina. METHODS: We developed a toolkit and process for deprescribing opioids and BZDs in older adults based on a literature review and guidance from an interprofessional team of pharmacists, geriatricians, and investigators. A total of fifteen primary care practices have been randomized to receive the targeted consultant pharmacist service (n = 8) or usual care (n = 7). The intervention consists of several components: (1) weekly automated reports to identify chronic users of opioids and BZDs, (2) clinical pharmacist medication review, and (3) recommendations for deprescribing and/or alternate therapies routed to prescribers through the electronic health record. We will collect data for all patients presenting one of the primary care clinics who meet the criteria for chronic use of opioids and/or BZDs, based on their prescription order history. We will use the year prior to evaluate baseline medication exposures using morphine milligram equivalents (MMEs) and diazepam milligram equivalents (DMEs). In the year following the intervention, we will evaluate changes in medication exposures and medication discontinuations between control and intervention clinics. Incident falls will be evaluated as a secondary outcome. To date, the study has enrolled 914 chronic opioid users and 1048 chronic BZD users. We anticipate that we will have 80% power to detect a 30% reduction in MMEs or DMEs. DISCUSSION: This clinic randomized pragmatic trial will contribute valuable evidence regarding the impact of pharmacist interventions to reduce falls in older adults through deprescribing of opioids and BZDs in primary care settings. TRIAL REGISTRATION: Clinicaltrials.gov NCT04272671 . Registered on February 17, 2020.

Primary-Care Prescribers' Perspectives on Deprescribing Opioids and Benzodiazepines in Older Adults.

PURPOSE: Opioids and benzodiazepines (BZDs) are frequently implicated as contributing to falls in older adults. Deprescribing of these medications continues to be challenging. This study evaluated primary-care prescribers' confidence in and perceptions of deprescribing opioids and BZDs for older adults. METHODS: For this study, we conducted a quantitative analysis of survey data combined with an analysis of qualitative data from a focus group. A survey evaluating prescriber confidence in deprescribing opioids and BZDs was distributed to providers at 15 primary-care clinics in North Carolina between March-December 2020. Average confidence (scale 0-100) for deprescribing opioids, deprescribing BZDs, and deprescribing under impeding circumstances were reported. A virtual focus group was conducted in March 2020 to identify specific barriers and facilitators to deprescribing opioids and BZDs. Audio recordings and transcripts were analyzed using inductive coding. RESULTS: We evaluated 61 survey responses (69.3% response rate). Respondents were predominantly physicians (54.8%), but also included nurse practitioners (24.6%) and physician assistants (19.4%). Average overall confidence in deprescribing was comparable for opioids (64.5) and BZDs (65.9), but was lower for deprescribing under impeding circumstances (53.7). In the focus group, prescribers noted they met more resistance when deprescribing BZDs and that issues such as lack of time, availability of mental health resources, and patients seeing multiple prescribers were barriers to deprescribing. CONCLUSION: Findings from quantitative and qualitative analyses identified that prescribers were moderately confident in their ability to deprescribe both opioids and BZDs in older adults, but less confident under potentially impeding circumstances. Future studies are needed to evaluate policies and interventions to overcome barriers to deprescribing opioids and BZDs in primary care.

Pharmacist interventions to deprescribe opioids and benzodiazepines in older adults: A rapid review.

BACKGROUND: Many older adults are prescribed opioids and benzodiazepines (BZDs), despite increased susceptibility to adverse events. Challenges of deprescribing include fragmented care and lack of knowledge or time. Pharmacists are well-positioned to overcome these challenges and facilitate deprescribing of these medications. OBJECTIVES: We sought to evaluate interventions utilizing pharmacists to deprescribe opioids and BZDs in older adults. METHODS: We conducted a rapid review following a comprehensive literature search to identify interventions with pharmacist involvement for deprescribing opioids and BZDs in older adults. Studies were included based on: (1) inclusion of patients ≥ 65 years old receiving BZDs and/or opioids, (2) evaluation of feasibility or outcomes following deprescribing (3) pharmacists as part of the intervention. We included randomized, observational, cohort, and pilot studies. Studies that did not report specific results for BZD or opioids were excluded. RESULTS: We screened 687 abstracts and included 17 studies. Most (n = 13) focused on BZD deprescribing. Few studies focused on opioids (n = 2) or co-prescribing of opioids and BZDs (n = 2). The most common intervention was educational brochures (n = 8), majority being the EMPOWER brochure for deprescribing BZDs. Other interventions included chart review with electronic notes (n = 4), pharmacist-led programs/services (n = 2), and multifactorial interventions (n = 3). Many studies were underpowered or lacked suitable control groups. Generally speaking, interventions utilizing educational materials and those in which pharmacists engaged with patients and providers were more effective. Interventions relying on electronic communication by pharmacists were less successful, due to low acceptance or acknowledgement. CONCLUSIONS: We identified a number of feasible interventions to reduce BZD use, but fewer interventions to reduce opioid use in older adults. An optimal approach for deprescribing likely requires pharmacists to engage directly with patients and providers. Larger well-designed studies are needed to evaluate the effectiveness of deprescribing interventions beyond feasibility.

Design and effect of performance-based pharmacy payment models.

BACKGROUND: Community pharmacy participation in performance-based payment models has increased in recent years. Despite this, there has been neither much research done to evaluate the effect of these models on health care quality and spending nor is there extensive literature on the design of these models. OBJECTIVES: To (a) describe the types of measures used in performance-based pharmacy payment models (PBPPMs); (b) describe the financial impact of PBPPMs on pharmacies; (3) explore pharmacy owners' perceptions of PBPPMs; and (4) describe any practice changes made in response to PBPPMs. METHODS: This is a cross-sectional study that surveyed independent community pharmacy owners between November 2019 and January 2020. The survey included 45 items split into 5 sections that covered respondent characteristics and the 4 domain objectives. Descriptive statistics were used for quantitative responses, and free-text responses were assessed for themes. RESULTS: Of the 68 individuals who responded to the survey, 42 were community pharmacy owners who met the study eligibility criteria, and 30 responded to most survey items. Owners expressed frustration at the design of PBPPMs, with 90% stating that they did not feel that the actions necessary to meet or exceed performance standards were within their control, and 90% also reported a loss of revenue because of these models. In addition, large numbers of respondents felt that they did not have enough information on how performance measures were computed (76.7%) or how cut-points were determined (86.7%). Despite negative feelings, most owners reported implementing changes in service offerings as a result of these models. CONCLUSIONS: PBPPMs appear to be commonplace and put substantial financial burden on community pharmacies. Study results suggest that greater education by payers could improve pharmacist engagement, as could involvement of pharmacies in the design and maintenance of PBPPMs. DISCLOSURES: This work was supported by a grant from the American Association of Colleges of Pharmacy, which was not involved in the collection, analysis, and interpretation of data; writing of the report; or the decision to submit this article for publication. Urick reports consulting fees from Pharmacy Quality Solutions. The other authors declare no conflicts of interest with respect to the research, authorship, and/or publication of this article.