"It's Took Over This Region": Patient Perspectives of Prescription Drug Abuse in Appalachia.

Background: Prescription drug abuse is a public health problem in the United States and the region of Appalachia, specifically. Primary care and addiction medicine-as possible points of access for prescription drugs with abuse potential and points of intervention for prescription drug abuse-are among the medical fields at its forefront. Little is known, however, about perceptions of prescription drug abuse across the two patient populations. Objectives: The objective of this qualitative analysis was to explore perceptions of the scale and context of prescription drug abuse among primary care and addiction medicine patients in Appalachia. Methods: As part of a mixed methods study, semi-structured interviews were conducted with 20 patients from primary care and addiction medicine in Central and South Central Appalachia from 2014 to 2015. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was used to identify themes. Results: Three themes were identified: (1) pervasiveness of prescription drug abuse, describing perceptions of its high prevalence and negative consequences; (2) routes and routine practices for prescription drug acquisition and distribution, describing perceptions of routes of access to prescription drugs and behaviors exhibited to acquire and distribute prescription drugs; and (3) rationales for prescription drug acquisition and distribution, describing perceptions of the two underlying reasons for these processes-tolerance/addiction and revenue source. Conclusions/Importance: Perceptions of prescription drug abuse among primary care and addiction medicine patients in Appalachia are multifaceted, especially regarding prescription drug acquisition and distribution. Clinical practice implications for mitigating prescription drug abuse are discussed.

Communication Experiences of DATA-Waivered Physicians with Community Pharmacists: A Qualitative Study.

Background: Patients engaged in evidence-based opioid use disorder (OUD) treatment can obtain prescriptions for buprenorphine containing products from specially trained physicians that are subsequently dispensed by community pharmacists. Despite the involvement of physicians and community pharmacists in buprenorphine prescribing and dispensing, respectively, our understanding of their interactions in this context is limited. Objective: To qualitatively describe the communication and collaborative experiences between Drug Addiction Treatment Act 2000 (DATA)-waivered physicians and community pharmacists from the perspective of the physician. Methods: Ten key informant interviews were conducted with DATA-waivered physicians practicing in Northeast Tennessee. A semi-structured interview guide was used to explore communication and collaborative experiences between the physicians and community pharmacists. Interviews were audio recorded and transcribed verbatim. A coding frame was developed using concepts from the scientific literature and emerging codes from physician interviews. Interviews were coded using NVivo 11, with the data subsequently organized and evaluated for themes. Results: Four themes were identified: (1) mechanics of communication; (2) role specification and expectations; (3) education and understanding; and (4) climate of clinical practice. Physician-pharmacist communication primarily occurred indirectly through patients or staff and perceived challenges to collaboration included; lack of trust, stigma, and fear of regulatory oversight. Physicians also indicated the two professionals may lack clear roles and responsibilities as well as common expectations for treatment plans. Conclusions: Communication between DATA-waivered physicians and community pharmacists is influenced by multiple factors. Further research is warranted to improve physician-community pharmacist collaboration (PCPC) in the context of OUD pharmacotherapy and addiction treatment.

Provider-patient communication about prescription drug abuse: A qualitative analysis of the perspective of prescribers.

Background: Provider-patient communication underpins many initiatives aimed at reducing the public health burden associated with prescription drug abuse in the United States. The purpose of this qualitative analysis was to examine the characteristics of provider-patient communication about prescription drug abuse from the perspective of prescribers. Methods: From 2014 to 2015, 10 semi-structured interviews were conducted with a purposive sample of prescribers from multiple professions and medical fields in Central and South Central Appalachia. The interviews were conducted using a guide informed by Social Cognitive Theory and community theory research, audio-recorded, and transcribed verbatim. Thematic analysis, facilitated by NVivo 10 software, was used to generate themes. Results: Prescribers described 3 primary communication patterns with patients related to prescription drug abuse-informative, counteractive, and supportive. Prescribers also reported multiple factors-personal (e.g., education, experiences, and feelings of tension) and environmental (e.g., relationship with a patient, clinical resources, and policies on controlled prescription drugs)-that affect provider-patient communication and, by association, delivery of patient care related to prescription drug abuse. Conclusions: The findings suggest that provider-patient communication about prescription drug abuse is multidimensional and dynamic, characterized by multiple communication patterns and contributory factors. They have implications for (1) research aimed at advancing theoretical understanding of prescriber prescription drug abuse communication behaviors with patients and (2) interventions aimed at strengthening prescriber prescription drug abuse communication behaviors with patients.

Community pharmacist engagement in opioid use disorder prevention and treatment behaviors: A descriptive analysis.

OBJECTIVES: This study describes community pharmacists' opioid analgesic and medication for opioid use disorder (MOUD) practice behaviors and behavioral intentions in the context of primary, secondary, and tertiary prevention of opioid use disorder (OUD). METHODS: The study sampling frame consisted of 2302 Tennessee community-practice pharmacists who were asked to complete a mailed, paper questionnaire. Behavioral intentions were elicited by asking pharmacists to indicate the number of times (0 to 10) they engage in a behavior, given 10 patients in 3 distinct vignettes. Perceptions of evidence-based MOUD and pain management patient care practices were also elicited. RESULTS: A response rate of 19.7% was achieved. Pharmacists reported using a brief questionnaire to evaluate risk of opioid misuse with 2.1 ± 3.7 (mean ± SD) out of 10 patients, screening 2.1 ± 3.7 patients for current opioid misuse, discussing co-dispensing of naloxone with 2.9 ± 3.4 to 3.3 ± 4 out of 10 patients at a risk of overdose, and dispensing buprenorphine/naloxone to a mean of 4.6 ± 4.2 patients when they presented a prescription. Respondents perceived 38% of pain management and 30% of MOUD prescribers in their area to practice evidenced-based care. CONCLUSION: Pharmacists have an opportunity to improve the outcomes for patients prescribed opioids by increasing engagement across OUD prevention levels.

A Dissemination and Implementation Science Approach to the Epidemic of Opioid Use Disorder in the United States.

PURPOSE OF REVIEW: This review aims to (1) conceptualize the complexity of the opioid use disorder epidemic using a conceptual model grounded in the disease continuum and corresponding levels of prevention and (2) summarize a select set of interventions for the prevention and treatment of opioid use disorder. RECENT FINDINGS: Epidemiologic data indicate non-medical prescription and illicit opioid use have reached unprecedented levels, fueling an opioid use disorder epidemic in the USA. A problem of this magnitude is rooted in multiple supply- and demand-side drivers, the combined effect of which outweighs current prevention and treatment efforts. Multiple primary, secondary, and tertiary prevention interventions, both evidence-informed and evidence-based, are available to address each point along the disease continuum-non-use, initiation, dependence, addiction, and death. If interventions grounded in the best available evidence are disseminated and implemented across the disease continuum in a coordinated and collaborative manner, public health systems could be increasingly effective in responding to the epidemic.

Interprofessional prescription opioid abuse communication among prescribers and pharmacists: A qualitative analysis.

BACKGROUND: Prescribers and community pharmacists commonly perceive prescription opioid abuse to be a problem in their practice settings and communities. Both cohorts have expressed support for interventions that improve interprofessional communication and reduce prescription opioid abuse. The objective of this study was to describe prescription opioid abuse-related communication among and between prescribers and community pharmacists in South Central Appalachia. METHODS: The investigators conducted five focus groups with 35 Appalachian Research Network practice-based research network providers between February and October, 2014. Two prescriber-specific, two pharmacist-specific, and one interprofessional (prescribers and pharmacists) focus groups were conducted, recorded, and transcribed. Data collection and analysis occurred iteratively. Emerging themes were inductively derived and refined. Five member-checking interviews were conducted to validate themes. RESULTS: Providers noted several factors that influence intraprofessional and interprofessional communication, including level of trust, role perceptions, conflict history and avoidance, personal relationships, and prescription monitoring program use. Indirect communication approaches via patients, office staff, and voicemail systems were common. Direct pharmacist to prescriber and prescriber to pharmacist communication was described as rare and often perceived to be ineffective. Prescriber to pharmacist communication was reported by prescribers to have decreased after implementation of state prescription monitoring programs. Difficult or uncomfortable conversations were often avoided by providers. CONCLUSIONS: Interprofessional and intraprofessional prescription opioid abuse communication is situational and influenced by multiple factors. Indirect communication and communication avoidance are common. Themes identified in this study can inform development of interventions that improve providers' intra- and interprofessional communication skills.

Correlates of Prescription Opioid Legitimacy Judgments Among Community Pharmacists.

BACKGROUND: Community pharmacists are legally required to evaluate and confirm the legitimacy of prescription opioids (POs) prior to dispensing. Yet, previous research has indicated community pharmacists perceive nearly 50% of dispensed POs to be issued lacking a legitimate medical purpose. OBJECTIVE: To analyze correlates of PO legitimacy judgments across pharmacist and pharmacy setting characteristics. METHODS: A cross-sectional study of 2000 Tennessee pharmacists was conducted during October and November of 2012. Community pharmacists' self-reported attitudes, beliefs, and behaviors specific to PO legitimacy were elicited. Step-wise multinomial logistic regression techniques were used to model correlates of PO legitimacy across low, moderate and high PO legitimacy estimations. RESULTS: Being female, practicing in a chain or independent practice setting, fear of employer disciplinary action if PO legitimacy is questioned, and self-confidence in one's ability to detect PO abuse increased the odds of low (vs. high) PO legitimacy estimation (p < 0.05). Employment in chain and independent pharmacies, having POs as a greater percent of total prescriptions filled, and having the perception of PO abuse as a problem in the practice setting were significant positive correlates of moderate (vs high) PO legitimacy estimation (p < 0.05). CONCLUSIONS: Both modifiable and non-modifiable correlates were statistically significantly associated with PO legitimacy judgments. Distinct correlates were noted across low and moderate as compared to high estimations of PO legitimacy. Legitimacy judgments can inform theoretical exploration of PO dispensing behaviors and inform intervention development targeted at reducing and preventing prescription drug abuse.

Fellowships in community pharmacy research: Experiences of five schools and colleges of pharmacy.

OBJECTIVE: To describe common facilitators, challenges, and lessons learned in 5 schools and colleges of pharmacy in establishing community pharmacy research fellowships. SETTING: Five schools and colleges of pharmacy in the United States. PRACTICE DESCRIPTION: Schools and colleges of pharmacy with existing community partnerships identified a need and ability to develop opportunities for pharmacists to engage in advanced research training. PRACTICE INNOVATION: Community pharmacy fellowships, each structured as 2 years long and in combination with graduate coursework, have been established at the University of Pittsburgh, Purdue University, East Tennessee State University, University of North Carolina at Chapel Hill, and The Ohio State University. EVALUATION: Program directors from each of the 5 community pharmacy research fellowships identified common themes pertaining to program structure, outcomes, and lessons learned to assist others planning similar programs. RESULTS: Common characteristics across the programs include length of training, prerequisites, graduate coursework, mentoring structure, and immersion into a pharmacist patient care practice. Common facilitators have been the existence of strong community pharmacy partnerships, creating a fellowship advisory team, and networking. A common challenge has been recruitment, with many programs experiencing at least one year without filling the fellowship position. All program graduates (n = 4) have been successful in securing pharmacy faculty positions. CONCLUSION: Five schools and colleges of pharmacy share similar experiences in implementing community pharmacy research fellowships. Early outcomes show promise for this training pathway in growing future pharmacist-scientists focused on community pharmacy practice.

Prescription Disposal Practices: A 2-Year Ecological Study of Drug Drop Box Donations in Appalachia.

OBJECTIVES: We quantified controlled substance donations via permanent drug donation boxes over 2 years in a region with high prescription abuse, assessing medication characteristics, time between dispensing and donation, and weight of medications donated per capita. METHODS: In partnership with Drug Enforcement Administration and local law enforcement, we analyzed permanent drug donation box collections in 8 Northeast Tennessee locations from June 2012 to April 2014. We recorded controlled substance dosage units along with the product dispensing date. RESULTS: We collected 4841 pounds of pharmaceutical waste, 4.9% (238.5 pounds) of which were controlled substances, totaling 106,464 controlled substance doses. Analysis of dispensing dates for controlled substances indicated a median of 34 months lapsed from dispensing to donation (range = 1-484 months). The mean controlled substance donation rate was 1.39 pounds per 1000 residents. Communities with fewer than 10,000 residents had a statistically higher controlled substance donation rate (P = .002) compared with communities with 10,000 or more residents. CONCLUSIONS: Permanent drug donation boxes can be an effective mechanism to remove controlled substances from community settings. Rural and urban community residents should be provided convenient and timely access to drug disposal options.

A theoretical explanation of naloxone provision among primary care physicians and community pharmacists in Tennessee.

BACKGROUND: Increasing access to naloxone reduces opioid-related morbidity and mortality. Primary care and community pharmacy settings are critical access points, yet limited theoretical research has examined naloxone prescribing and dispensing behaviors. OBJECTIVES: To determine if the theory of planned behavior (TPB) combined with theoretical constructs from communication science explains intentions to co-prescribe and discuss co-dispensing naloxone among primary care physicians and community pharmacists, respectively. METHODS: This cross-sectional study surveyed cohorts of licensed primary care physicians and community pharmacists in Tennessee in 2017. Intentions were measured using profession-specific case vignettes, whereby they were asked given 10 similar patients, how many times (0-10) would they co-prescribe or discuss co-dispensing naloxone. Bivariate and multivariable analyses were used. RESULTS: The analytic sample included 295 physicians (response rate = 15.6 %) and 423 pharmacists (response rate = 19.4 %). Approximately 65 % of physicians reported never intending to co-prescribe naloxone (0 out of 10 patients), while 47 % of pharmacists reported never intending to discuss co-dispensing. All TPB constructs-attitudes (AOR = 1.32, CI = 1.16-1.50), subjective norms (AOR = 1.17, CI = 1.06-1.30), and perceived behavioral control (AOR 1.16, CI = 1.02-1.33)-were associated with an increased likelihood of pharmacists always (versus never) discussing co-dispensing. Similarly, two TPB constructs-attitudes (AOR = 1.41, CI = 1.19-1.68) and subjective norms (AOR = 1.22, CI = 1.08-1.39)-were associated with an increased likelihood of physicians always co-prescribing. Among physicians only, one communication construct-self-perceived communication competence (AOR = 1.19, CI = 1.01-1.41)-was associated with an increased likelihood of always co-prescribing. CONCLUSION: Findings support the value of theory, particularly TPB, in explaining primary care physician intentions to co-prescribe and community pharmacist intentions to discuss co-dispensing naloxone.

Prescription drug abuse: a comparison of prescriber and pharmacist perspectives.

This study compared perceptions of prescribers and pharmacists (N = 89) regarding multiple aspects of prescription drug abuse. Questionnaires were developed to assess perceptions regarding the prevalence of prescription drug abuse, self-perceived communication competence, and additional communication and prescription drug abuse domains. Pharmacists perceived a larger percentage of patients (41%) to be abusing opioid pain relievers as compared with their prescriber colleagues (17%). Both prescribers and pharmacists indicated improvements in prescriber-pharmacist communication would serve to deter prescription drug abuse. Self-efficacy beliefs for detecting and discussing prescription drug abuse with patients were low for both cohorts. Implications and limitations are noted. Year of data collection: 2012 SETTING: Rural Appalachia Data Collection Instruments: Prescriber- and pharmacist-specific survey instruments Data Analysis Techniques: Independent samples t-test; Mann-Whitney U test.

Motives for nonmedical use of prescription stimulants in community college students.

Objective: The present study identified common motives for nonmedical use of prescription stimulants (NMUS) among community college (CC) students and examined behavioral and demographic correlates of certain motives. Participants: The survey was completed by 3,113 CC students (72.4% female; 81.7% White). Methods: Survey results from 10 CCs were evaluated. Results: NMUS was reported by 9% (n = 269) participants. The most common motive for NMUS was to "focus on studies or to improve academic performance" (67.5%) followed by to "have more energy" (52.4%). Females were more likely to report NMUS for weight loss, and males were more likely to report NMUS to experiment. The motive "to feel good or get high" was linked to polysubstance use. Conclusions: CC students report similar motives for NMUS to those commonly endorsed by 4-year university students. These findings may help identify CC students susceptible to risky substance use.

Primary care physicians' opioid-related prevention behaviors and intentions: A descriptive analysis.

OBJECTIVE: Primary care physicians (PCPs) are positioned to mitigate opioid morbidity and mortality, but their engagement in primary, secondary, and tertiary opioid-related prevention behaviors is unclear. The objective of this study was to evaluate Tennessee PCPs' engagement in and intention to engage in multiple opioid-related prevention behaviors. METHODS: A survey instrument was developed, pretested, and pilot tested with practicing PCPs. Thereafter, a census of eligible Tennessee PCPs was conducted using a modified, four-wave tailored design method approach. Three patient scenarios were employed to assess physician intention to engage in 10 primary, secondary, and tertiary prevention behaviors. Respondents were asked to report, given 10 similar scenarios, the number of times (0-10) they would engage in prevention behaviors. Descriptive statistics were calculated using SPSS version 25. RESULTS: A total of 296 usable responses were received. Physician intention to engage in prevention behaviors varied across the 10 behaviors studied. Physicians reported frequently communicating risks associated with prescription opioids to patients (8.9 ± 2.8 out of 10 patients), infrequently utilizing brief questionnaires to assess for risk of opioid misuse (1.7 ± 3.3 out of 10 patients), and screening for current opioid misuse (3.1 ± 4.3 out of 10 patients). Physicians reported seldomly co-prescribing naloxone for overdose reversal and frequently discharging from practice patients presenting with an opioid use disorder. CONCLUSIONS: This study noted strengths and opportunities to increase engagement in prevention behaviors. Understanding PCPs' engagement in opioid-related prevention behaviors is important to effectively target and implement morbidity and mortality reducing interventions.

Community pharmacist engagement in HIV and HCV prevention: Current practices and potential for service uptake.

Background: The central Appalachian region is at an elevated risk for HIV/HCV outbreaks, primarily due to injection drug use. Regional risk assessments highlight gaps in the evidence-based continuum of primary, secondary, and tertiary prevention strategies to minimize HIV/HCV transmission. One potential strategy for increasing the reach of HIV/HCV prevention efforts in rural areas is through provision of services at community pharmacies. Objective: To qualitatively describe community pharmacists' HIV/HCV-related prevention behaviors, attitudes, and beliefs in a 3-state central Appalachian region. Methods: Key informant interviews were conducted with 15 practicing community pharmacists. Theory of Planned Behavior-based questions probed for perceptions about the role of pharmacies in preventing and reducing HIV/HCV outbreaks in rural areas through activities such as syringe services, screening for HIV/HCV, and linking people to treatment when appropriate. Investigators applied thematic analysis to deductively and inductively generate themes from the interview transcripts. Results: Two overarching themes regarding pharmacist engagement in HIV/HCV-related prevention services were generated: 1) current approaches to primary prevention through nonprescription syringe sales (e.g., gatekeeping behaviors) and 2) potential for uptake of the continuum of HIV/HCV-related prevention services in community pharmacies. Future engagement of community pharmacists in the continuum of HIV/HCV-related prevention services comprised 2 subthemes as possible underlying factors: general and specific willingness to provide services and perceived fit within the pharmacy profession. Conclusions: Central Appalachian community pharmacists express a general willingness to help patients who may benefit from HIV/HCV-related prevention services, but current engagement, willingness, and perceived fit for offering specific prevention services in the community pharmacy setting is variable. This has potential immediate implications, such as prioritizing the introduction of more widely accepted services (e.g., provision of HIV/HCV-related prevention education) to community pharmacy practice, and longer-term implications, such as the integration and framing of HIV/HCV-related prevention services as helping behavior within the pharmacist professional identity.

The Impact of Transitions Related to COVID-19 on Pharmacy Student Well-being.

Objective. To characterize the impact of COVID-19 transitions on first professional year (P1) students' domain-specific and overall well-being.Methods. All P1 students (N=74) enrolled at one college of pharmacy self-reported their career, community, financial, physical, social, and overall well-being on a weekly basis from January 6 through April 27, 2020. Parametric statistical tests and effect sizes were used to compare well-being scores pre-transition and post-transition and to compare well-being scores to a previous cohort of P1 students.Results. Mean well-being scores decreased when comparing pre-transition vs post-transition scores, with effect sizes ranging from dav=.16 for financial well-being to dav=.84 for social well-being. The average percent of students that reported struggling increased by 86.1% (16.8% vs 31.2%) post-transition, and the average percent of students that reported suffering post-transition was 351% higher (1.3% vs 6%) than pre-transition.Conclusion. Pharmacy students' domain specific and overall well-being significantly decreased with COVID-19-related transitions. The percentage of students reporting struggling or suffering significantly increased post-transition.

An analysis of pharmacists' workplace patient safety perceptions across practice setting and role characteristics.

Background: Lay press investigations have been published that describe pharmacist errors and the workplace environment in the community pharmacy setting. However, recent studies that explore pharmacists' perceptions of patient safety in the workplace are limited. Objectives: 1) To describe pharmacists' perceptions of workplace patient safety; 2) To compare pharmacists' perceptions of workplace patient safety across practice setting type, pharmacist roles, average hours worked per shift, and average hours worked per week. Methods: Actively licensed Tennessee pharmacists were recruited from January 1 and June 30, 2019 to complete a 13-item survey of workplace patient safety perceptions ( N =1391). Descriptive statistics were calculated, and nonparametric statistical tests employed to compare differences in perceptions across practice setting type, pharmacist roles, and hours worked per shift and per week. Results: Statistically significant differences in workplace patient safety perceptions were noted across practice setting type (p values <.001) and pharmacist roles (p values <.001). The extent to which pharmacists agreed/strongly agreed that their employer provides a work environment that allows for safe patient care ranged from 29.7% of chain community pharmacists to 85% of compounding pharmacists. Fifty-two percent of staff pharmacists, 56.5% of relief pharmacists, and 58.5% of managers/pharmacists in charge agreed or strongly agreed that their employer provides a work environment that allows for safe patient care, whereas 89.3% of regional managers/directors/vice-presidents and 72.5% of clinical/specialty pharmacists indicated the same. Average hours per shift was inversely correlated with perceptions of workplace patient safety (p values <.001). Conclusion: Tennessee pharmacists' perceptions of workplace patient safety varied widely across practice setting type and pharmacist roles. Perceptions of safety were notably lower in the chain community pharmacy setting. Additional research is warranted to better understand the relationship between pharmacist perceptions and quantifiable patient safety metrics, particularly in the chain community pharmacy setting.

Pharmacists' nonprescription syringe dispensing perceptions and behaviors: A three-state descriptive analysis.

BACKGROUND: One approach to increasing the reach of syringe programs in rural areas could be through provision of syringes at community pharmacies. This study evaluated relationships between state-specific syringe policies, pharmacy, and pharmacist characteristics and pharmacists' nonprescription syringe dispensing behaviors in a 3- state Appalachian region at high risk for HIV and HCV transmission. METHODS: We conducted a telephone census of community pharmacies in the Appalachian counties of North Carolina, Tennessee, and Virginia from April-June 2018. Behaviors studied included having ever sold syringes without a prescription, quantity of individuals to whom nonprescription syringes were dispensed in the past 30 days, having ever denied a request for nonprescription syringes, and past 30-day denial of nonprescription syringe requests. Behavioral intention and perceptions of legality were elicited. RESULTS: A response rate of 52.3 % was achieved (N = 391). North Carolina pharmacists reported increased past 30-day dispensing, less denial of nonprescription syringe requests, and decreased justification for syringe dispensing (proof of medical need) as compared to Tennessee and Virginia pharmacists. Behavioral intention to dispense did not vary by state but did vary by political affiliation. Perceptions of syringe dispensing legality in NC were significantly different from those in TN and VA. CONCLUSIONS: Significant differences in pharmacists' perceptions and behaviors were noted across state lines with North Carolina pharmacists reporting more engagement in syringe dispensing as compared to pharmacists in Tennessee and Virginia. Policy allowing pharmacists to dispense syringes to people who inject drugs appears to foster some but not all pharmacist engagement in this harm reduction intervention.

A Longitudinal Analysis of First Professional Year Pharmacy Student Well-being.

Objective. To assess and characterize Doctor of Pharmacy (PharmD) students' well-being across the first professional year (P1) and determine the relationship between the number of examinations taken, student grade point average, and well-being scores. Methods. All P1 students (N=76) enrolled at one college of pharmacy self-reported their career, community, financial, physical, social, and overall well-being on a weekly basis during the fall and spring semesters. Parametric statistical tests were used to examine the extent to which students' well-being scores varied throughout the academic year, the extent to which their domain-specific well-being scores predicted overall well-being scores, and the association between their well-being scores and the number of examinations they had taken in a week and their grade point average. Results. Overall and domain-specific well-being scores significantly decreased from the beginning to the end of fall semester. Students' overall well-being across the academic year was most frequently predicted by their career well-being, physical well-being, and social well-being scores. Career, community, physical, and overall well-being scores were significantly negatively associated with the number of examinations the students completed during the week. Students' self-reported overall well-being during the fall semester was positively associated with their fall semester GPA. Conclusion. Significant variation was found in students' domain-specific and overall well-being across the P1 year. These findings can guide both the development and timing of school interventions to promote student well-being.

Explaining Pharmacy Students' Dispensing Intentions in Substance Abuse-Related Gray Areas Using the Theory of Planned Behavior.

Objective. To examine the extent to which theory of planned behavior (TPB) constructs and demographic characteristics explain pharmacy students' dispensing intentions in ethically or legally gray areas involving potential substance misuse or abuse. Methods. Two cohorts of third-year Doctor of Pharmacy (PharmD) students (n=159) were provided with five written cases describing common "gray area" dispensing scenarios in community practice involving medications and devices with potential for misuse or abuse (eg, long-term buprenorphine maintenance prescription without evidence of tapering, early refill of a narcotic for an out-of-town patient, non-prescription sale of pseudoephedrine). Students completed a 12-item survey instrument for each case. Items assessed whether the student would dispense the medication or device in the given scenario, how many times in 10 similar scenarios the student would dispense the medication or device, attitudes regarding dispensing, and subjective norm and perceived behavioral control beliefs. Results. Wide variation in the percentages of students who would dispense the medications or devices was noted across the five scenarios (14% in the buprenorphine scenario to 61% in the pseudoephedrine scenario). Attitude scores significantly predicted dispensing decisions in all scenarios (p<.001), whereas subjective norm and perceived behavioral control beliefs were significant predictors of dispensing only in select case scenarios. Gender and community pharmacy work experience did not consistently predict dispensing intentions. Conclusion. Student attitudes consistently predicted intent to dispense across five gray practice scenarios. These findings can be used to inform development of educational interventions that influence students' attitudes and self-awareness in community practice decision-making scenarios involving potential substance misuse or abuse.

Student Pharmacists' Personal Finance Perceptions, Projected Indebtedness Upon Graduation, and Career Decision-making.

Objective. To evaluate the extent to which Doctor of Pharmacy students' personal finance perceptions, projected student loan indebtedness, and demographic characteristics predict postgraduation career intentions. Methods. Students at three pharmacy colleges completed a 31-item survey instrument that assessed personal finance perceptions, self-efficacy beliefs, anticipated student loan debt upon graduation, postgraduate intentions, anticipated practice setting upon graduation, and demographic characteristics. Logistic regression models were used to examine the extent to which personal finance perceptions, student loan indebtedness, and demographic characteristics predicted postgraduate intentions and anticipated practice setting. Results. There were 763 usable responses obtained (response rate=90.3%). Students reported an anticipated personal student loan debt at graduation of $162,747 (SD=$87,093) and an estimated 7.4 (SD=5.8) years to pay off non-mortgage debt postgraduation. Fifty-three percent of students reported planning to practice in a community pharmacy setting postgraduation, and 54% indicated they intended to enter practice directly. Student loan indebtedness was not a significant predictor of whether students planned to pursue postgraduate training. There was a significant association between debt influence and pressure perceptions and students' plans to pursue postgraduate training (aOR=0.78; 95% CI=0.65-0.94). The odds of indicating hospital (vs chain community) pharmacy as the anticipated setting decreased 36% with every one point increase in debt influence and pressure perceptions (aOR=0.64; 95% CI=0.50-0.81). Conclusion. Pharmacy students' perceived debt pressure and influence predicted their intention to enter practice directly (vs pursuing postgraduate training) and to select a career in chain community pharmacy (vs hospital pharmacy). Student loan indebtedness was not a significant predictor of postgraduate training intentions. These findings suggest that interventions that equip students to manage the pressure associated with large student loan debts should be explored.