Implementing a text-message-based intervention to increase access to naloxone for patients on chronic opioid therapy.

OBJECTIVE: To implement a text-message-based intervention for primary care patients taking chronic opioid therapy to increase access to naloxone. DESIGN: Retrospective analysis of a hospital quality improvement initiative. SETTING: This study was conducted with selected primary care practices affiliated with an academic medical center between March and July 2022. PARTICIPANTS: Patients were eligible for receiving the intervention if they had chronic (≥90 days) opioid use of ≥50 morphine milligram equivalents/day and had not previously opted out of receiving text messages. INTERVENTIONS: Text messages were sent to patients inquiring about interest in obtaining a naloxone kit, which prompted a pharmacist to contact the patient and provide the medication by mail. MAIN OUTCOME MEASURES: We examined response rates to text messages and numbers of naloxone kits dispensed. RESULTS: There were 243 patients identified who were sent the text message. Of these, 230 (94.7 percent) had a primary language of English, 150 (61.7 percent) were White, and 57 (23.5 percent) were Black/African American. The mean age was 57.3 years. After receiving the text messages, 64 (26.3 percent) of the 243 patients responded with "unsubscribe." Thirty-five (14.4 percent) patients responded to the message, and 18 patients (51.4 percent of those who responded or 7.4 percent of all included patients) wanted the medication and were contacted by a pharmacist who filled and mailed the prescription to them. CONCLUSIONS: A text-message-based program to provide naloxone to patients with chronic opioid use was feasible. However, fewer than 15 percent of patients responded to the message, and just half of those wanted the medicine.

Systemized approach to equipping medical students with naloxone: a student-driven initiative to combat the opioid crisis.

BACKGROUND: Naloxone is an effective and safe opioid reversal medication now approved by the U.S. Food and Drug Administration (FDA) for use with or without a prescription. Despite this, naloxone dissemination lags at a time when U.S. opioid-related mortality expands. The authors proposed distributing naloxone to all U.S. medical students using established statewide standing prescription orders for naloxone, eliminating the financial burden of over-the-counter costs on students and streamlining workflow for the pharmacy. By focusing naloxone distribution on medical students, we are able to capitalize on a group that is already primed on healthcare intervention, while also working to combat stigma in the emerging physician workforce. METHODS: Beginning August 2022, the authors established a partnership between Harvard Medical School (HMS) and the outpatient pharmacy at Brigham and Women's Hospital (BWH) to facilitate access to naloxone for HMS medical students. BWH developed a HIPAA-secure electronic form to collect individual prescription information. BWH pharmacists processed submissions daily, integrating the naloxone prescription requests into their workflow for in-person pick-up or mail-order delivery. The electronic form was disseminated to medical students through a required longitudinal addiction medicine curriculum, listserv messaging, and an extracurricular harm reduction workshop. RESULTS: Over the 2022-2023 academic year, 63 medical students obtained naloxone kits (two doses per kit) through this collaboration. CONCLUSIONS: We propose that medical schools advocate for a hospital pharmacy-initiated workflow focused on convenience and accessibility to expand naloxone access to medical students as a strategy to strengthen the U.S. emergency response and prevention efforts aimed at reducing opioid-related morbidity and mortality. Expansion of our program to BWH internal medicine residents increased our distribution to over 110 healthcare workers, and efforts to expand the program to other BWH training programs and clinical sites such as the emergency department and outpatient infectious disease clinics are underway. With more than 90,000 medical students in the U.S., we believe that widespread implementation of targeted naloxone training and distribution to this population is an accessible approach to combating the public health crisis of opioid-related overdoses.

An electronic pillbox intervention designed to improve medication safety during care transitions: challenges and lessons learned regarding implementation and evaluation.

BACKGROUND: Adverse drug events are common during transitions of care. As part of the Smart Pillbox study, a cluster-randomized controlled trial of an electronic pillbox designed to reduce medication discrepancies and improve medication adherence after hospital discharge, we explored barriers to successful implementation and evaluation of this intervention. METHODS: Eligible patients were those admitted to a medicine service of a large teaching hospital with a plan to be discharged home on five or more chronic medications. The intervention consisted of an electronic pillbox with pre-filled weekly blister pack medication trays given to patients prior to discharge. Pillbox features included alarms to take medications, detection of pill removal from each well, alerts to patients or caregivers by phone, email, or text if medications were not taken, and adherence reports accessible by providers. Greater than 20% missed doses for three days in a row triggered outreach from a pharmacist. To identify barriers to implementation and evaluation of the intervention, we reviewed patient exit surveys, including quantitative data on satisfaction and free-text responses regarding their experiences; technical issue logs; and team meeting minutes. Themes were derived by consensus among the study authors and organized using the Consolidated Framework for Implementation Research. RESULTS: Barriers to implementation included intervention characteristics such as perceived portability issues with the pillbox and time required by pharmacists to enter medication information into the software; external policies such as lack of insurance coverage for early refills and regulatory prohibitions on repackaging medications; implementation climate issues such as the incompatibility between the rushed nature of hospital discharge with the time required to deploy the intervention; and patient issues such as denial of previous problems with medication adherence. We founds several obstacles to conducting the study, including patients declining study enrollment and limited attempts by the hospital to streamline logistics by building the intervention into usual care. Several solutions to address many of these challenges were implemented or planned. Despite these challenges, many patients with the pillbox were pleased with the service and believed the intervention worked well for them. CONCLUSIONS: In this evaluation, several barriers to implementing and conducting a study of the effectiveness of the intervention were identified. Our findings provide lessons learned for others wishing to implement and evaluate HIT-related interventions designed to improve medication safety during care transitions. TRIAL REGISTRATION: Clinicaltrials.gov NCT03475030.