Naloxone Accessibility by Standing Order in North Carolina Community Pharmacies.

BACKGROUND: According to a standing order in North Carolina (NC), naloxone can be purchased without a provider prescription. OBJECTIVE: The objective of this study is to examine whether same-day naloxone accessibility and cost vary by pharmacy type and rurality in NC. METHODS: A cross-sectional telephone audit of 202 NC community pharmacies stratified by pharmacy type and county of origin was conducted in March and April 2023. Trained "secret shoppers" enacted a standardized script and recorded whether naloxone was available and its cost. We examined the relationship between out-of-pocket naloxone cost, pharmacy type, and rurality. RESULTS: Naloxone could be purchased in 53% of the pharmacies contacted; 26% incorrectly noting that naloxone could be filled only with a provider prescription and 21% did not sell naloxone. Naloxone availability by standing order was statistically different by pharmacy type (chain/independent) (χ2 = 20.58, df = 4, P value < 0.001), with a higher frequency of willingness to dispense according to the standing order by chain pharmacies in comparison to independent pharmacies. The average quoted cost for naloxone nasal spray at chain pharmacies was $84.69; the cost was significantly more ($113.54; P < 0.001) at independent pharmacies. Naloxone cost did not significantly differ by pharmacy rurality (F2,136 = 2.38, P = 0.10). CONCLUSION: Approximately half of NC community pharmacies audited dispense naloxone according to the statewide standing order, limiting same-day access to this life-saving medication. Costs were higher at independent pharmacies, which could be due to store-level policies. Future studies should further investigate these cost differences, especially as intranasal naloxone transitions from a prescription only to over-the-counter product.

North Carolina pharmacists' willingness to sell fentanyl test strips: a survey study.

BACKGROUND: Although fentanyl test strips (FTS) can accurately determine the presence of fentanyl in unregulated substances, access to FTS remains limited. This study aimed to examine North Carolina community pharmacists' attitudes and willingness to engage in various behaviors related to FTS sales and distribution. METHODS: A convenience sample of community pharmacists completed an online survey that assessed: (1) comfort initiating an FTS conversation; (2) willingness to sell FTS, distribute FTS instructions, counsel on FTS, refer patients to harm reduction organizations, and advertise FTS; (3) perceived barriers and benefits of selling FTS; and (4) interest in FTS training. Data were collected from March to May 2022. Descriptive statistics were calculated. RESULTS: Of the 592 pharmacists who participated, most were somewhat or very willing to refer patients to harm reduction organizations for FTS (514, 86.9%), counsel on FTS (485, 81.9%), distribute FTS instructions (475, 80.2%), sell FTS (470, 79.3%), and advertise FTS for sale (372, 62.9%). The most commonly reported benefits of selling FTS were reducing overdose deaths in the community (n = 482, 81.4%) and participating in community harm reduction efforts (n = 455; 76.9%). Barriers commonly reported to selling FTS were: not knowing where to order FTS (n = 295, 49.8%) and discomfort initiating a conversation about FTS (n = 266, 44.9%). Most respondents (88.3%) were interested in FTS training. CONCLUSION: North Carolina community pharmacists are willing to engage in various behaviors related to FTS sales and distribution. Most pharmacists were interested in receiving FTS training, which should be created to address pharmacist-reported barriers to FTS sales. Pharmacist distribution of FTS could increase access to FTS at the community level and has the potential to change drug use behavior and reduce overdose deaths.

Psychological safety and accountability in longitudinal integrated clerkships: a dual institution qualitative study.

BACKGROUND: Psychological safety and accountability are frameworks to describe relationships in the workplace. Psychological safety is a shared belief by members of a team that it is safe to take interpersonal risks. Accountability refers to being challenged and expected to meet expectations and goals. Psychological safety and accountability are supported by relational trust. Relational continuity is the educational construct underpinning longitudinal integrated clerkships. The workplace constructs of psychological safety and accountability may offer lenses to understand students' educational experiences in longitudinal integrated clerkships. METHODS: We performed a qualitative study of 9 years of longitudinal integrated clerkship graduates from two regionally diverse programs-at Harvard Medical School and the University of North Carolina School of Medicine. We used deductive content analysis to characterize psychological safety and accountability from semi-structured interviews of longitudinal integrated clerkship graduates. RESULTS: Analysis of 20 graduates' interview transcripts reached saturation. We identified 109 discrete excerpts describing psychological safety, accountability, or both. Excerpts with high psychological safety described trusting relationships and safe learning spaces. Low psychological safety included fear and frustration and perceptions of stressful learning environments. Excerpts characterizing high accountability involved increased learning and responsibility toward patients. Low accountability included students not feeling challenged. Graduates' descriptions with both high psychological safety and high accountability characterized optimized learning and performance. CONCLUSIONS: This study used the workplace-based frameworks of psychological safety and accountability to explore qualitatively longitudinal integrated clerkship graduates' experiences as students. Graduates described high and low psychological safety and accountability. Graduates' descriptions of high psychological safety and accountability involved positive learning experiences and responsibility toward patients. The relational lenses of psychological safety and accountability may inform faculty development and future educational research in clinical medical education.

Addressing buprenorphine bottlenecks in the context of MAT Act implementation: A shared responsibility.

Medications for opioid use disorder (OUD) such as buprenorphine reduce overdose mortality and other opioid related acute health events but have historically been highly regulated. The recent Mainstreaming Addiction Treatment (MAT) Act ended the requirement clinicians complete a specified training and apply for a DATA 2000 ("X") waiver on their Drug Enforcement Administration (DEA) number, to prescribe buprenorphine. With the MAT Act, any practitioner with Schedule III prescribing authority (a regular DEA number) can now prescribe buprenorphine for OUD. While this has potential to improve OUD treatment access, the impact will depend on implementation. Though the MAT Act may facilitate increased buprenorphine prescribing, ensuring adequate buprenorphine dispensing is also critical to improving Medications for opioid use disorder. Recognized buprenorphine bottlenecks arise from a complex convergence of factors in community pharmacies, threatening to undercut the benefits of the MAT Act. If prescribing increases but is not matched by increased dispensing, bottlenecks may worsen. Any worsening of buprenorphine bottlenecks could have a disproportionate impact in rural areas where residents may rely on fewer pharmacies to fill prescriptions for people in larger geographic area and where larger prescribing-dispensing gaps already exist such as in Southern states. Rigorous research will be needed to document the overall impact of the MAT Act on community pharmacists and their patients. At the federal level, pharmacists and their professional organizations should lobby the DEA to de-schedule or re-schedule buprenorphine. The DEA should announce a moratorium on enforcement actions against wholesalers and pharmacies related to buprenorphine distribution and dispensing. More supports should be offered to community pharmacies by state pharmacy boards and associations including continuing pharmacy education and technical assistance for advocating with wholesalers to increase buprenorphine order sizes, and to more effectively communicate with prescribers. Pharmacies should not have to face these challenges alone. Regulators, wholesalers, and researchers must join together with community pharmacies to further reduce regulatory barriers to dispensing, provide evidence-based interventions where needed to support pharmacy dispensing efforts, conduct rigorous implementation research, and be constantly vigilant in identifying and addressing multi-level buprenorphine bottlenecks in the wake of the MAT Act.

Hepatitis C and HIV Screening, Testing, and Risk Perceptions among South-Central Appalachian County Health Department Staff.

OBJECTIVES: Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are significant public health concerns, especially given the risks for disease interactions. Rates of HCV and HIV are increasing, especially in rural areas. Local health departments (LHDs) play an important role in rural health care, offering screening, testing, and treatment for HCV and HIV. Gaps persist in LHD resources for meeting these demands, especially in Appalachia and the US South. METHODS: To explore HCV/HIV screening, testing, and treatment approaches and perspectives in south-central Appalachian North Carolina, structured telephone questionnaires were administered to communicable disease nurses and other health department staff directly involved in screening and testing. Mixed-methods data analyses were conducted and triangulated with stakeholders. RESULTS: Eighteen participants representing 19 counties completed the questionnaire, achieving a saturation sample. Participants reported barriers to screening and testing, including housing insecurity, lack of transportation and insurance, unemployment, and the isolation of living in a rural area. Divergence in perceptions of barriers between public health regions emerged, as did perceptions of who is at risk and use of stigmatizing language about people at risk for HCV/HIV. CONCLUSIONS: This study highlights the impact of LHD behaviors and perceptions on screening and testing, and offers recommendations to improve HCV/HIV screening and testing accessibility in south-central Appalachia, a high-risk region.

Eligible Prescriber Experiences with Substance Use Disorder Treatment and Perceptions of Pharmacy Barriers to Buprenorphine.

OBJECTIVES: The primary aim of this study was to better understand North Carolina providers' specific substance use disorder (SUD) and opioid use disorder treatment practices and buprenorphine prescribing. Furthermore, this study aimed to provide novel information regarding US South and rural providers' opioid use disorder treatment behaviors and perceptions of patient experience at community pharmacies. METHODS: An online survey consisting of closed-ended and open-ended questions was used. Surveys were delivered to healthcare providers' e-mails and self-administered. Surveys were administered through an online survey platform. RESULTS: In total, 332 healthcare providers, who were eligible to be X-waivered to prescribe buprenorphine, completed the online survey. Survey participants reported not having their X-waiver to prescribe buprenorphine or actively prescribing buprenorphine. The majority of participants were uncertain of potential barriers to filling buprenorphine prescriptions. Providers treating a mix of rural and urban patients reported being less likely to screen for SUDs. Although there were no rurality differences in SUD screening, providers who treat mostly rural patients reported a lack of SUD treatment options in their area. CONCLUSIONS: Early detection of SUDs can help prevent negative health outcomes for patients. Regardless of patient rurality, providers should screen for SUDs and familiarize themselves with the patient's experience when filling a buprenorphine prescription, along with possible barriers. Furthermore, providers should incorporate questions about their patient's ability to receive buprenorphine to help ensure that patients are receiving proper and necessary treatment.

"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.

Ensuring buprenorphine access in rural community pharmacies to prevent overdoses.

BACKGROUND: Opioid-related drug overdoses have been rapidly increasing in the United States, especially in rural Southern and Appalachian regions. The use of buprenorphine-containing medications to treat opioid use disorder (OUD) is an evidence-based approach proven to reduce overdose death risks. Access to such treatment is uneven, with less access in parts of the United States where overdose rates are higher. Pharmacy dispensing of buprenorphine is a key component of access, yet barriers related to perceived and actual regulatory constraints, training gaps, stigma, and challenges to prescriber-pharmacist communication limit dispensing of this life-saving medication. OBJECTIVES: The objectives of this study were to explore the experiences of rural patients with OUD filling prescriptions for buprenorphine-containing medications at community pharmacies. PRACTICE DESCRIPTION: Rural community pharmacies, both commercial chain and independent, in 2 rural South-Central Appalachian counties where the local health departments prescribe buprenorphine-containing medications. PRACTICE INNOVATION: The local county health departments each entered into dedicated dispensing arrangements with a local independent community pharmacy to ensure a stable supply of medication for their patients with OUD who were prescribed buprenorphine. EVALUATION METHODS: Qualitative interviews (n =16) with patients prescribed buprenorphine from their county health department; county health department staff, local harm reduction program staff, and harm reduction program participants prescribed buprenorphine. Transcripts were analyzed using thematic analysis. RESULTS: Participants reported problems with buprenorphine dispensing at rural community pharmacies, dispensing delays that resulted in experiencing withdrawal symptoms and hesitation to continue in treatment, high medication costs, and stigmatizing treatment by some pharmacists. Participants also reported that access improved after dedicated dispensing arrangements began. CONCLUSION: Agreements between prescribing health departments and community pharmacies could increase access to buprenorphine, especially in rural areas.

North Carolina community pharmacists' buprenorphine dispensing practices and attitudes.

BACKGROUND: Many barriers, including stocking behaviors and pharmacist attitudes, can limit access to buprenorphine in pharmacy settings. OBJECTIVES: To assess North Carolina (NC) pharmacists' (1) buprenorphine stocking behaviors, (2) awareness and interpretation of federal and state policy regarding buprenorphine, (3) perceptions about changes in buprenorphine demand, and (4) reasons for not dispensing buprenorphine, including attitudes. METHODS: A convenience sample of currently practicing community pharmacists was recruited to participate in a 10-minute online survey. The survey included demographic questions and assessed pharmacists' buprenorphine ordering, stocking, and dispensing behaviors. Descriptive statistics were calculated, and logistic regressions examined associations with whether pharmacists (1) had ever refused to fill a buprenorphine prescription and (2) perceived buprenorphine dispensing limits. RESULTS: The majority (96%) of respondents (n = 646, completion rate = 5.5%) kept buprenorphine in stock regularly or ordered it as needed, with generic formulations being stocked most often. Many pharmacists (62%) had refused to fill a buprenorphine prescription. Pharmacists with more negative buprenorphine attitudes were more likely to refuse to fill a buprenorphine prescription. Many pharmacists (31%) believed there were buprenorphine ordering limits, with wholesalers most commonly being perceived as the source. Pharmacists with more negative buprenorphine attitudes were more likely to perceive buprenorphine ordering limits, while pharmacists who worked at national chain, grocery or regional chains, and other pharmacy types were less likely to perceive ordering limits than independent pharmacies. CONCLUSION: Although most pharmacies stocked buprenorphine products, pharmacists' refusal to dispense and perceived ordering limits could limit patient access. Refusal and perceived ordering limits were associated with pharmacist attitudes and pharmacy type. Training that addresses logistical and attitudinal barriers to dispensing buprenorphine may equip pharmacists to address buprenorphine access barriers.

Increasing North Carolina's Workforce Capacity for Prescribing Buprenorphine Products.

BACKGROUND Inadequate access to opioid use disorder (OUD) treatment is a public health concern. Rates of opioid-related poisoning deaths are increasing in North Carolina and access to OUD treatment is especially sparse in rural areas. DEA-X-waivered providers that can prescribe buprenorphine as a medication for opioid use disorder (MOUD) play an essential role in treating OUD. Increased workforce capacity to treat OUD in an evidence-based, equitable, and patient-centered way is needed. Gaps persist in continuing professional education and academic training.METHODS Description of an interdisciplinary training team effort to engage medical residencies and advanced practice provider (APP) programs across North Carolina in a set of subsidized trainings about substance use disorder treatment and medication-assisted treatment (MAT), with the goal of increasing capacity to administer MOUD, based on each program's needs. Uptake was independently evaluated.RESULTS Engagement exceeded initial goals: 72 unique trainings related to MAT were administered to 1512 providers from 30 residency and 7 APP programs. By the end of the grant period, 902 participants completed a training required to obtain a DEA-X waiver. Evaluation of training uptake identified facilitators and barriers specific to residents and APP trainees.LIMITATIONS Limitations included difficulty coordinating training with existing didactic and clinical schedules during the project time frame and challenges identifying implementation leaders at training sites.CONCLUSION This project highlights a successful and potentially replicable approach to offering structured MAT capacity-building training in combination with technical assistance (TA) within medical education programs.

"The elephant in the room;" a qualitative study of perinatal fears in opioid use disorder treatment in Southern Appalachia.

BACKGROUND: Diagnoses of perinatal opioid use disorder (OUD) continue to rise in the United States. Patients and providers report obstacles to OUD treatment access. Difficulties include legal ambiguity related to Social Services notification requirements following a birth to people using opioids or in medication-assisted treatment for OUD. METHODS: Through semi-structured interviews, participant-observation, and a focus group conducted in a mostly rural, region of the Southern United States (where perinatal OUD is more prevalent), patients' and providers' perspectives about perinatal substance use treatment were initially sought for a larger study. The findings presented here are from a subset analysis of patients' experiences and perspectives. Following ethics review and exemption determination, a total of 27 patient participants were opportunistically, convenience, and/or purposively sampled and recruited to participate in interviews and/or a focus group. Data were analyzed using modified Grounded Theory. RESULTS: When asked about overall experiences with and barriers to accessing perinatal substance use treatment, 11 of 27 participants reported concerns about Social Services involvement resulting from disclosure of their substance use during pregnancy. In the subset analysis, prevalent themes were Fears of Social Services Involvement, Preparation for Delivery, and Providers Addressing Fears. CONCLUSIONS: Perinatal OUD patients may seek substance use treatment with existing fears of Social Services involvement. Patients appreciate providers' efforts to prepare them for this potential reality. Providers should become aware of how their own hospital systems, counties, states, and countries interpret laws governing notification requirements. By becoming aware of patients' fears, providers can be ready to discuss the implications of Social Services involvement, promote patient-centered decision-making, and increase trust.

"I'll tell you what's important to me ": lessons for women's health screening.

BACKGROUND: Providers face increasing demands to screen for various health issues. Family medicine, primary care, and obstetric providers are encouraged to screen women universally for intimate partner violence, which could be challenging without comprehensive screening tools. The screening expectations and demands motivated providers and staff in south-central Appalachia (U.S.) to engage community members in streamlining women's health screening tools, and integrating intimate partner violence screening questions, through a Human-Centered Design (HCD) process. The objective of this article is to present participants' experiences with and perceptions of the HCD process for developing screening tools for women's health. METHODS: This was a qualitative, phenomenological study conducted with community members (n = 4) and providers and staff (n = 7) who participated in the HCD process. Sampling was purposive and opportunistic. An experienced qualitative researcher conducted open-ended, semi-structured interviews with participants. Interviews were transcribed and coded for thematic analysis. RESULTS: Community members reported that in the HCD sessions they wanted clinicians to understand the importance of timing and trust in health screening. They focused on the importance of taking time to build trust before asking about intimate partner violence; not over-focusing on body weight as this can preclude trust and disclosure of other issues; and understanding the role of historical oppression and racial discrimination in contributing to healthcare mistrust. Providers and staff reported that they recognized the importance of these concerns during the HCD process. CONCLUSIONS: Community members provided critical feedback for designing appropriate tools for screening for women's health. The findings suggest that co-designing screening tools for use in clinical settings can facilitate communication of core values. How, when, and how often screening questions are asked are as important as what is asked-especially as related to intimate partner violence and weight.

Exploration of the STOP Act and Opioid Deaths in North Carolina, 2010-2018.

Objectives. To examine the impact of North Carolina's 2017 Strengthening Opioid Misuse Prevention (STOP) Act on opioid overdose deaths.Methods. We used quarterly data from the North Carolina Opioid Dashboard to conduct an interrupted time series analysis ranging from 2010 to 2018. Results were stratified by heroin-fentanyl deaths and other opioid deaths.Results. After the STOP Act, there was an initial rate increase of 0.60 opioid deaths per 100 000 population (95% confidence interval [CI] = 0.04, 1.15) and a decrease of 0.42 (95% CI = -0.56, -0.29) every quarter thereafter. Results differed by stratification.Conclusions. Our results suggest that North Carolina's STOP Act was associated with a reduction in opioid deaths in the year following enactment. The changes in opioid overdose death trends coinciding with the STOP Act were similar to outcomes seen with previous opioid policies.Public Health Implications. Future policies designed to reduce the availability of opioids may benefit from encouraging and increasing the availability of evidence-based treatment of opioid use disorder.

Human-Centered Design for a Women's Health Screening Tool: Participant Experiences.

OBJECTIVES: Screening is a priority in primary care and women's health, and increasingly used for intimate partner violence. Integrating such routine screening into primary care screening may be challenging for clinicians. Human-centered design (HCD) is a participatory process emphasizing stakeholder input and is used increasingly in health care. A growing body of literature has examined the science of patient and community engagement in health research, yet few qualitative studies investigate how participants recruited to collaborate in designing screening tools perceive HCD processes. This study examined participants' perceptions of an HCD process used as an engagement tool to inform the development of a women's health screening tool. METHODS: Qualitative study using data collected from community members and providers and staff recruited through a southern Appalachian medical education center and network of family medicine clinics and in the surrounding community. Using opportunistic and key informant sampling, study participants (some of whom were also intimate partner violence survivors) were part of an earlier HCD process undertaken to redesign a women's health/primary care screening tool and were invited to be interviewed about their perceptions of and experiences in the HCD process. Interviews were conducted using a semistructured guide. Interviews were audio-recorded, transcribed, hand-coded, and analyzed using modified grounded theory. RESULTS: All of the participants reported that they valued the opportunity to be part of the HCD process; however, they reported divergent views of the process itself. Some found it easy to engage, whereas others found it confusing or embarrassing. All valued the opportunity to be part of determining the best process for screening, yet concerns were expressed about access to and full participation in the process. Community members reported more concerns; providers and staff reported fewer concerns about their own involvement and participation, although some expressed doubts about community members' full engagement. CONCLUSIONS: Although a promising option and valuable process, the HCD process was not equally comfortable for or accessible to all participants. Community engagement beyond the clinical team is important for improving practices in health screening and health care, but it must be undertaken thoughtfully.

Syndemics and the biosocial conception of health.

The syndemics model of health focuses on the biosocial complex, which consists of interacting, co-present, or sequential diseases and the social and environmental factors that promote and enhance the negative effects of disease interaction. This emergent approach to health conception and clinical practice reconfigures conventional historical understanding of diseases as distinct entities in nature, separate from other diseases and independent of the social contexts in which they are found. Rather, all of these factors tend to interact synergistically in various and consequential ways, having a substantial impact on the health of individuals and whole populations. Specifically, a syndemics approach examines why certain diseases cluster (ie, multiple diseases affecting individuals and groups); the pathways through which they interact biologically in individuals and within populations, and thereby multiply their overall disease burden, and the ways in which social environments, especially conditions of social inequality and injustice, contribute to disease clustering and interaction as well as to vulnerability. In this Series, the contributions of the syndemics approach for understanding both interacting chronic diseases in social context, and the implications of a syndemics orientation to the issue of health rights, are examined.

Navigating Social and Institutional Obstacles: Low-Income Women Seeking Abortion.

Nearly half of all women in the United States will have at least one abortion during their lifetime, and many will encounter economic, logistical, and/or social obstacles while attempting to undergo the procedure. The purpose of this project was to examine the abortion-seeking experiences of a volunteer sample of Oregon women, to identify key barriers and the strategies women employed to overcome them. Using a mixed-methods approach combining survey and interview data with participant observation, we found that low-income women experienced structural and economic barriers to abortion even though abortion is covered by the state Medicaid program in Oregon. Social support helped women overcome obstacles, and a lack of support was itself experienced as an obstacle. Women of lower socioeconomic status also encountered more barriers and had a more difficult time overcoming them. Our findings indicate the need for improved advocacy to reduce structural delay, and to improve access to social support and other resources needed for timely abortion care.

A culture of future planning: perceptions of sexual risk among educated young adults.

In this study we examined how social processes, specifically the acquisition of postsecondary education and capital, shaped perceptions of sexual risk and impacted sexual practices and sexual health among young adults. Using qualitative research methods we collected and analyzed data among students attending a 4-year university in the northeastern region of the United States over a 1-year period. By analyzing participants' narratives, we found that the reproduction of shared norms and values encouraged educated young adults to focus on educational and professional success, pressing many of them to be concerned about preventing pregnancy rather than preventing disease transmission, and increasing their risk for sexually transmitted infections, including HIV/AIDS. Sexual-health educators need to address how social processes shape sexual practices, encourage educated young adults to challenge unequal gender expectations, and consider how sexually transmitted infections might also interfere with life plans.

"When people who use drugs can't differentiate between medical care and cops, it's a problem." Compounding risks of law Enforcement Harassment & Punitive Healthcare Policies.

BACKGROUND: Community-based harm reduction programming is widely recognized as an effective strategy for reducing the increased risks for and spread of HIV, HCV, and for reducing the growing rate of overdose deaths among people who use drugs (PWUD). PWUD in the United States (US) are a highly justice-involved population, also at increased risk for law enforcement interaction, arrest, and incarceration. These risks compound and interact in the context of criminalization and law enforcement surveillance. Justice involvement increases risks for overdose and for riskier injecting behavior among PWUD, in turn increasing HCV and HIV risks. In Central and Southern Appalachia specifically, PWUD have identified fear of law enforcement harassment and arrest as a barrier to engaging in harm reduction behavior, and a deterrent to seeking help at the scene of an overdose. Moreover, stigmatizing and punitive treatment in healthcare settings can deter PWUD from seeking care, with life or death consequences. This evaluation research study assessing the successes and impacts of a grant-funded project to increase access to safer drug consumption supplies and overdose prevention education for PWUD, including justice-involved participants of a syringe access program (SAP), in public housing and beyond in a South-Central Appalachian setting used key informant and opportunistic sampling. Mixed-methods data were compiled and collected including secondary program data; primary interview and participant-observation data. RESULTS: The evaluation research identified that grant deliverables were largely achieved, despite challenges presented by the COVID-19 pandemic. In addition, SAP participants and staff reported larger themes surrounding grant-funded activities, in which they perceived that widespread local law enforcement harassment of PWUD increased participants' risks for overdose death and infectious disease risks and that punitive local healthcare settings and policies acted as deterrents to care-seeking for many PWUD. CONCLUSIONS: Overall, the evaluation research found that participants' experiences with and perceptions of local law enforcement harassment combined with their understandings and experiences of local punitive healthcare settings and policies; together compounding and increasing overdose risks and negative health consequences for local justice-involved PWUD.

A Brief Online Training to Address Pharmacists' Willingness to Dispense Buprenorphine.

BACKGROUND: The recent passage of the Mainstreaming Addiction Treatment (MAT) Act could increase the number of patients seeking to fill buprenorphine prescriptions at community pharmacies; however, multiple barriers limit community pharmacists' ability and willingness to dispense buprenorphine. We assess whether a brief online buprenorphine training program (Buprenorphine Understanding in the Pharmacy Environment) improves community pharmacists' outcomes, including willingness to dispense buprenorphine. METHODS: A convenience sample of practicing community pharmacists participated in a 30-minute buprenorphine training. The training was codeveloped with pharmacy advisors and presented solutions to common buprenorphine dispensing barriers. Participants completed a pretest and posttest that assessed their buprenorphine knowledge (5 multiple-choice items based on training content), self-efficacy to engage in various buprenorphine-related behaviors (7 items), buprenorphine attitudes (8 items), and willingness to dispense buprenorphine to 4 different types of customers. Descriptive statistics were calculated, and paired-samples t tests were used to evaluate the impact of the training on pharmacist outcomes. RESULTS: Of 266 individuals who accessed the pretest, 104 responses were included in the analysis (response rate, 39%). Buprenorphine Understanding in the Pharmacy Environment improved pharmacists' mean buprenorphine knowledge scores (pretest, 2.2; posttest, 3.5; P < 0.001), all 7 self-efficacy items (all P < 0.001), mean buprenorphine attitudes (pretest, 3.1; posttest, 3.4; P < 0.001), and willingness to dispense to all four types of buprenorphine customers (all P < 0.01). CONCLUSIONS: A brief buprenorphine training increased pharmacists' willingness to dispense buprenorphine. Although generalizability of the results may be limited by use of a convenience sample, our pharmacist-oriented training showed promising results and may be an important step in increasing availability of buprenorphine in community pharmacies.