Revisiting the opioid and naloxone education (ONE) program: Program evaluation using the RE-AIM model four years later.

OBJECTIVE: The Opioid and Naloxone Education (ONE) Program focuses on community pharmacy-based patient screening and interventions to improve population health with regard to opioid use. The purpose of this paper is to reevaluate the ONE Program performance using the RE-AIM model, in comparison to the review performed in 2019. METHODS: The program performance of the ONE Program was evaluated from January 1, 2021 to December 31, 2022 was evaluated using the five domains of the RE-AIM model. Reach was defined as the proportion of patients receiving opioid prescriptions who completed the screening. Efficacy was defined as the proportion of individuals identified as at risk who received a pharmacist intervention. Adoption was defined as the proportion of community pharmacies who enrolled in the ONE Program. Implementation was defined as the proportion of pharmacies that enrolled that provided at least five patient screenings. Maintenance was defined as the proportion of pharmacies that completed at least one screening three months. These results were compared against evaluation of the program from October 12, 2018 to June 1, 2019. RESULTS: Approximately 7.28 % of patients receiving opioid prescriptions were screened for risk of opioid misuse and accidental overdose (Reach). Of the patients screened, 97.4 % of patients at risk for opioid misuse or accidental overdose received a pharmacist-led intervention (Efficacy). Additionally, 49.6 % of the pharmacist that enrolled in the ONE Program completed at least five screenings (79 %) and of those, 86.4 % maintained the program three months later. CONCLUSIONS: In years four and five of implementation, the ONE Program demonstrated improvement in four of the five domains of the RE-AIM model compared to years one and two. However, Reach declined over time. This reevaluation has demonstrated the importance of longitudinal program assessment, and the possibility of improved program performance over time.

Implementation of a Pharmacy Follow-Up Program for Dispensed Opioid Medications.

BACKGROUND: There have been multiple reported pharmacy initiatives to reduce opioid misuse and accidental overdose to address our nation's public health crisis. To date, there has not been a description in the literature of a community pharmacy follow-up initiative for dispensed opioids. METHODS: A follow-up program was designed and implemented in community pharmacies as part of a previously developed opioid overdose and misuse prevention program (ONE Program). Five to twelve days after the dispensing of an opioid, pharmacy technicians called the patient to follow up on opioid safety topics. Pharmacy technicians used a questionnaire to inquire about medication disposal plans, if the patient was taking the medication more than prescribed, medication side effects, and if the patient needed a pharmacist consultation. The results from that questionnaire were documented. RESULTS: During the first 18 months of the follow-up program, 1789 phone calls were completed. Of those contacted, 40% were still using their opioid medication, and over 10% were experiencing side effects which triggered a pharmacist consult. Patients were reminded of proper medication disposal methods, and most patients (78%) desired to dispose of unused medication at the pharmacy medication disposal box. CONCLUSIONS: Follow-up phone calls post-opioid medication dispensing were shown to add value to a previously established opioid misuse and accidental overdose prevention program and allowed for the fulfillment of the Pharmacist Patient Care Process.

A Longitudinal Comparison of Pharmacy Documentation Platforms Using the Technology Acceptance Model: Experiences With Opioid Risk Screening.

Background: Pharmacy practice continues to expand in scope, and technology platforms to assist with meeting the standards for documentation of billable services are needed. The ONE Program (Opioid and Naloxone Education) is an initiative centered on the community pharmacy focused on opioid risk screening for patients receiving opioid prescriptions. Objective: Opioid risk screening results and pharmacist interventions were documented using first REDCap and later the DocStation platforms. This study compared pharmacy staff experience with these 2 platforms. Methods: A survey using the Technology Acceptance Model (TAM) was designed to compare usability, ease of use, social influence, and facilitating conditions. Results: Analyses using descriptive statistics and open-ended responses showed similar results for each platform; however, pharmacy staff indicated that REDCap required less time when entering information, whereas the DocStation platform offered elevated pharmacy practice service opportunities, management support, and available informational technology support services. Conclusion: Health care technology continues to advance in meeting the needs of expanded service provision through pharmacy. This longitudinal study shows the value of the TAM framework in identifying efficiencies and deficiencies of health care technology systems.

Assessing a Medication Safety and Disposal Educational Program using the Health Belief Model.

Background: Self-medication practices continue to grow due to reclassification of prescription to OTC status and self-care information on the internet, however unintended injuries and inappropriate use of medications continue to challenge healthcare providers during the provision of patient care. Pharmacists have an integral role in pharmacovigilance and patient education activities to ensure safe medication use, storage, and disposal practices. Objectives: The objective of this medication safety and disposal educational program was to provide comprehensive informational support to the community coupled with an assessment using the Health Belief Model (HBM) to gauge participants' perceived behavior change. Methods: The HBM was selected to assess the understanding of the community members' benefits and barriers to safe medication practices. The HBM posits that health behaviors are influenced by perceptions of a diseases' severity, perceived susceptibility, perceived barriers to health practices, perceived benefits of health practices, self-efficacy, and cues to action. An 8 item pre/post survey following the HBM constructs was developed which used a 5 point Likert scale. Results: A total of 25 senior participants attended the educational program. Twenty-three pre/post surveys were completed (RR=92%). Five items revealed a statistically significant change from pre to post-educational content including understanding risk of herbal/OTC products (p=0.021), improved awareness of medication disposal methods (p=0.044), comprehension of OTC 'Drug Facts' information (p=0.004), understanding OTC label information to prevent medication interactions and side effects (p=0.008), and routinely reviewing expiration dates on medications and disposing of these properly (p=0.019). Conclusion: This study suggests a comprehensive approach which covers a wide range of medication safety topics and disposal practices can successfully improve the knowledge and skill of community participants and potentially improve medication harm reduction practices.

Opioid risk stratification in the community pharmacy: The utility of the Opioid Risk Tool.

OBJECTIVE: The objective for this paper is to report on the utility of the Opioid Risk Tool (ORT) to identify patients at elevated risk for opioid misuse and deliver medication safety-related services to them. Patient characteristics based on ORT risk stratification are also described. METHODS: Data from patients screened from September 17, 2018 to May 12, 2021 were descriptively evaluated for distribution of ORT scores, characteristics of patients stratified by ORT score, and services delivered to patients based on ORT score. The ORT generates a score from 0 to 26, with scores of 0-3, 4-7, and 8 or higher representing low, moderate, and high risk of opioid use disorder, respectively. Based upon screening results, pharmacists provided patient-specific education and interventions. RESULTS: A total of 6,460 patients were evaluated. Low, moderate, and high ORT scores were found among 87.5, 8.2 and 3.9% of the patients receiving opioids, respectively. Males comprised 46.1% of the patients, and 27.7% of the patients had received a prior opioid prescription in the last 60 days. As a result of risk stratification, the pharmacist explained opioid use disorder to 18.8, 36.1, and 47.0% of patients with low, moderate and high ORT scores, respectively (p < .001). High ORT scores were significantly associated with the pharmacist introducing the patient to community support services (OR = 2.35), the pharmacist having contacted their provider (OR = 6.41), male gender (OR = 2.06), and having taken an opioid in the last 60 days (OR = 1.76). CONCLUSIONS: The ORT is a useful tool for opioid risk stratification of patients receiving opioid medications in the community pharmacy setting. Such stratification allows the pharmacist to provide individualized services to patients based on their risk profile.

Evaluation of a Program to Screen Patients in Community Pharmacies for Opioid Misuse and Accidental Overdose.

INTRODUCTION: Community pharmacies nationwide have adopted new strategies to combat the opioid epidemic. One strategy to prevent opioid misuse and accidental overdose is patient screening to identify those at risk. The purpose of our study was to determine whether such screening in community pharmacies led pharmacy personnel to intervene with patients at risk and to describe the proportion of patients they identified as at risk. METHODS: We implemented the Opioid and Naloxone Education (ONE) program in North Dakota to give community pharmacies and pharmacists training and tools to provide preventive screening for opioid misuse and accidental overdose before dispensing a prescribed opioid. Data were collected and analyzed from September 15, 2018, through May 15, 2021, to evaluate overall patient risk characteristics for opioid misuse and accidental overdose. RESULTS: Of 8,217 patients screened, 3.9% were identified as at high risk for opioid misuse, and 18.3% at risk for accidental overdose. Nearly 1 of 3 screenings (31.7%) indicated opioid medication use in the past 60 days. Pharmacists delivered 1 or more risk-factor-dependent interventions to 41.1% of patients in the study. Following screening, naloxone dispensing in pharmacies increased to 6 times the national average. CONCLUSION: Pharmacy-based patient screening for risk of opioid misuse and accidental overdose led to risk-dependent interventions targeted to individual patients. The tools and risk-dependent interventions applied in the ONE program increased patient awareness of opioid risks and ways to reduce risk. Future studies should examine long-term outcomes, including reduction in overdose, treatment of opioid use disorder, and reduced opioid-related acute care.

Improving Community Pharmacist-Delivered Care for Patients With Psychiatric Disorders Filling an Opioid Prescription.

Pharmacists tend to provide care to patients with psychiatric disorders less frequently than to other types of patients, yet patients with psychiatric disorders experience more drug-related problems and use more opioids than those without psychiatric disorders. The Opioid and Naloxone Education (ONE) program equipped pharmacists to screen for opioid misuse and overdose risk and to implement a set of interventions for any patient filling an opioid prescription. Patients with a psychiatric disorder (N=1,980; 24.1% of those screened) were significantly more likely to receive more than one intervention from a ONE program pharmacist than were those without a psychiatric disorder. The use of an objective screening tool and training in stigma reduction and nonjudgmental communication approaches, which are part of the ONE program process, deserve further exploration as ways to increase the frequency of pharmacist-provided education and other critical interventions for patients with psychiatric disorders.

Longitudinal evaluation of pharmacists' social distance preference and attitudes toward patients with opioid misuse following an educational training program.

Background: Pharmacist stigma via examination of social distance preference and negative attitudes toward persons who misuse opioids is prevalent and may lower the quality of care provided to patients. Few studies have previously extended beyond the immediate post-intervention period to examine stigma change. Methods: This longitudinal cohort study utilized a pre-survey administered before the training program, a post-survey immediately upon completion of the training program, and a delayed post-survey, administered 12 months after the training program. Co-primary outcomes were changes in social distance scale (SDS) total score from baseline to post-survey and from baseline to 12 months. Secondary outcomes included change in SDS question scores and change in negative attitudes. One hundred eighty-seven of the 1211 eligible pharmacists in the state completed the training. Matched responses of forty-four pharmacists who completed all three surveys were examined. Results: The mean total SDS score was significantly lower in the immediate post-training survey than the pre-training mean (14.75 vs. 16.57, p = .000). The 12 months mean total SDS score was also significantly lower than the pre-training mean (15.32 vs. 16.57, p = .017). Significant changes in negative attitudes from baseline to post-survey and from baseline to 12 months were seen. Conclusion: Stigma reduction components integrated into opioid training decreased pharmacist social distance preference and negative attitudes toward patients who misuse opioids immediately after the training and, most notably, were sustained for 12 months.

Opioid risk screening: Program evaluation from the community pharmacists' perspective.

BACKGROUND: Pharmacist-implemented screening programs can be improved through continuous program evaluation. Pharmacists are in a position to determine whether interventions are realistic and efficacious when used in practice. OBJECTIVE: The purpose of this study is to evaluate how community pharmacists perceive the use of an opioid risk screening for patients receiving opioid prescriptions and the associated implications for improved patient-centered care. METHODS: North Dakota community pharmacists received training on the use of an opioid risk tool for all patients filling an opioid prescription to evaluate for opioid misuse and overdose risk potential. Pharmacists then implemented the screening in their community pharmacy to screen all patients prescribed an opioid. Six months after implementation, pharmacists across the state were surveyed regarding their perception of the value of screening patients for the risk of opioid misuse and overdose. The survey questions used the Joint Committee on Standards for Educational Evaluation focusing on utility, propriety, feasibility, and accuracy. RESULTS: All pharmacists (n = 35) indicated the opioid risk screening improved patient communication and patient-centered interventions. A total of 97% of pharmacists agreed the opioid screening tool provided an objective measure in providing care to patients and improved the potential for patient safety during prescription opioid use. Although 66% of pharmacists disagreed that the screening process was time consuming, 14% of respondents agreed with this statement indicating they may require additional assistance to optimize their workflow. CONCLUSION: The results of this study support that opioid risk screening ensures utility for opioid risk stratification, feasibility to incorporate into existing workflow, and propriety for patient safety and well-being.

Pharmacists' stigma toward patients engaged in opioid misuse: When "social distance" does not mean disease prevention.

Background: Health professionals may stigmatize and prefer social distance from patients with opioid misuse, leading to poorer quality of care provided. The degree to which pharmacists prefer social distance from patients with opioid misuse and opioid use disorder (OUD) is not known. Methods: Pharmacists (n = 187) completed a survey comprised of demographics, attitudinal, and Social Distance Scale (SDS) questions based on a vignette patient who displayed opioid misuse. SDS question responses and total scores (maximum of 30; higher scores representing great preference for social distance) were tallied and associations with attitudes and demographics were examined. Results: Mean SDS total score was 16.32 (range 9-23). More than 59% of respondents had an SDS score >15, indicating overall lack of willingness to interact with the vignette patient. Females had a higher mean SDS score vs male pharmacists (16.58 vs. 15.36, respectively; p = 0.023). Pharmacists were more likely to prefer social distance from the vignette patient in personal situations (i.e. renting a room) than work-related interactions (i.e. providing patient education). Pharmacists with >10 years of experience, those without personal experience with a substance use disorder, those who strongly agreed that patients with OUD require excessive time and effort, and those who agreed that some people lack self-discipline to use prescription pain medication without becoming addicted had significantly higher SDS scores than pharmacists without these characteristics. Conclusions: Pharmacists expressed significant preference for social distance indicating stigmatization of patients with opioid misuse. Pharmacists were comfortable performing pharmacy tasks with patients with opioid misuse, but were less comfortable forming therapeutic relationships, an important tenet of patient-centered care. Efforts are needed to examine contributions to social distance preferences and implement measures to reduce them. Targeting of pharmacists with >10 years' experience and without personal experience with OUD may also be most beneficial.

Patient acceptance of naloxone resulting from targeted intervention from community pharmacists to prevent opioid misuse and accidental overdose.

Background: Community pharmacists are in a unique position to prevent opioid-related deaths through the provision of naloxone. However, for those identified as candidates for take-home naloxone, the acceptance rate remains low. Value would be gained from knowing what patient demographics and pharmacist actions are associated with increased patient acceptance of naloxone. Methods: Through a state-wide program, community pharmacists screened all patients receiving an opioid prescription for risk of opioid misuse and/or accidental overdose. Pharmacists prescribed and/or dispensed take-home naloxone to patients at elevated risk. Naloxone acceptance rates were stratified based on risk factors for misuse and overdose to determine which patients are most likely to accept naloxone. Patient acceptance of naloxone and risks were captured electronically. Results: Pharmacist-initiated naloxone recommendations based on risk screening resulted in a 5.81% take-home naloxone acceptance rate. Individuals that were taking multiple opioid medications were most likely to accept the naloxone (20.45%). Concurrent disease states or medications (COPD, concurrent anxiety/depression medication, concurrent sleep aid) were associated with a statistically significant increase in the rate of naloxone acceptance. Acceptance of take-home naloxone increased as a patient risk for opioid misuse and/or accidental overdose increased. Conclusion: Patient acceptance of naloxone at the community pharmacy level was notably higher compared to national naloxone dispensing rates when pharmacists implemented a patient screening and systematic risk-based approach to identify candidates in need of take-home naloxone.

Opioid Misuse and Overdose: Changes in Pharmacist Practices and Outcomes.

BACKGROUND: Continuing education (CE) provides educational opportunities for health professionals to adequately respond to issues in practice but infrequently evaluate sustained practice change. The opioid epidemic has risen to the forefront of health priorities in our nation. The Opioid and Naloxone Education (ONE Rx) CE program provides pharmacists the opportunity to expand their abilities and impact in the opioid crisis. METHODS: ONE Rx CE included risk assessment for opioid misuse/overdose, role of naloxone, disease of addiction, and communication strategies for patients and providers. Pharmacists who completed the CE screened patients and provided interventions over 12 months. CE participants were provided presurveys, postsurveys, and delayed postsurveys coordinated with the educational program. The Kirkpatrick Model was used to evaluate the effectiveness of the program by examining the four levels of assessment: reaction, commitment, behavior, and results. RESULTS: The Kirkpatrick Model was used to evaluate the impact of the CE. Reaction: 97% of respondents recommended the ONE Rx program. Commitment: 77% of respondents indicated commitment to provide ONE Rx opioid risk screening and interventions to patients. Behavior: Twelve months after training, pharmacists registered to prescribe naloxone increased by 67% and the number of pharmacists reporting naloxone dispensing doubled from 23% to 46%. OUTCOMES: Pharmacist interventions included medication take back programs explained (88.4%), naloxone dispensing to high-risk patients (10.9%), and discussion of opioid use disorder with patients with risk factors (49%). CONCLUSION: By using the Kirkpatrick Model, the ONE Rx CE program demonstrated high-quality opioid and naloxone education to pharmacists. Survey results and opioid harm reduction interventions indicate the CE resulted in sustained pharmacy practice behavior change.

Examining Attitudes and Beliefs that Inhibit Pharmacist Implementation of a Statewide Opioid Harm Reduction Program.

BACKGROUND: A statewide opioid risk screening program was introduced to pharmacists to provide them with resources to screen patients who are prescribed an opioid medication. Using opioid risk screening equips pharmacists to deliver education and patient-centered interventions for opioid harm reduction. Nearly 50% of pharmacists that enrolled their pharmacy to participate in this program did not actively implement the program to patients. Little research is dedicated to examining factors which contribute to unsuccessful implementation of pharmacy-centered interventions. This research aims to describe barriers and beliefs which may hinder the ability of pharmacists to integrate innovative practices into existing workflow. OBJECTIVES: Using the theory of planned behavior, determine what attitudes and beliefs contribute to unsuccessful implementation of opioid risk screening. METHODS: A survey was developed within the context of a theoretical framework and distributed to pharmacists who did not successfully implement opioid risk screening 12 month following program inception. Attitude, subjective norm, and perceived behavioral control constructs of the theory of planned behavior were used to identify barriers to opioid risk screening implementation. The responses were analyzed using Mann-Whitney U test, ANOVA, and descriptive statistics. RESULTS: Twenty-three pharmacists consented to participate in this study and 17 pharmacists completed the survey (response rate 74%). Pharmacists indicated positive attitudes toward reducing negative opioid outcomes for patients using opioid medications. Positive subjective norm responses indicated a perception that patients and collaborative healthcare providers would approve of pharmacists using opioid risk screening for patients. The highest proportion of negative responses was observed in the perceived behavioral control construct which included difficulty in offering the screening and unsuccessful integration of past interventions. CONCLUSIONS: These results suggest that perceived behavioral control of pharmacists is the most influential factor in unsuccessful implementation of opioid risk screening.

Implementation of a statewide program within community pharmacies to prevent opioid misuse and accidental overdose.

OBJECTIVE: To describe the implementation of a statewide pharmacy program called ONE Rx (Opioid and Naloxone Education) within community pharmacies. SETTING: Thirty community pharmacies. PRACTICE DESCRIPTION: Community pharmacies throughout the state of North Dakota were invited to participate. Pharmacists in North Dakota can legally prescribe and dispense naloxone. PRACTICE INNOVATION: ONE Rx is a statewide program that provides pharmacists with the education and tools to screen every patient who was prescribed an opioid medication for the risk of opioid misuse and accidental overdose. The goal of ONE Rx is to prevent opioid misuse and accidental overdose through patient screening and individualized education and intervention within the community pharmacy. EVALUATION: Outcomes to measure the implementation of ONE Rx included the number of pharmacists and technicians who participated in the training, the number of pharmacies who chose to implement ONE Rx, and the number of patients screened for the risk of opioid misuse and accidental overdose. RESULTS: The ONE Rx training was completed by 240 pharmacists and 41 registered pharmacy technicians. Thirty community pharmacies implemented the program between October 2018 and May 2019, and more than 1700 patients were screened for the risk of opioid misuse and accidental overdose. CONCLUSION: A statewide program to screen for opioid misuse and accidental overdose was successfully implemented.

Program evaluation of the Opioid and Naloxone Education (ONE Rx) program using the RE-AIM model.

OBJECTIVE: Opioid and Naloxone Education (ONE Rx) is a program that focuses on community pharmacy-based patient screening and interventions to improve population health with regard to opioid use. The objective for this paper is to describe how ONE Rx was implemented, report on the populations impact using the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) Model, and explain future implications of the program. METHODS: ONE Rx is a statewide program in which pharmacists screen patients who receive an opioid prescription for the risk of opioid misuse and accidental overdose. The five domains of the RE-AIM Model were used to evaluate ONE Rx. Reach was defined as the proportion of patients receiving opioid prescriptions who completed the screening. Efficacy was defined as the proportion of individuals identified as at risk of opioid misuse or accidental overdose and who received a pharmacist intervention. Adoption was defined as the proportion of eligible community pharmacies who enrolled in ONE Rx. Implementation was defined as the proportion of pharmacies that enrolled in ONE Rx that provided at least five patient screenings. Maintenance was defined as the proportion of pharmacies that adopted ONE Rx that completed at least one screening three months after the initial provision. RESULTS: Approximately 16.9% of all patients receiving opioid prescriptions were screened for risk of opioid misuse and accidental overdose. Of the patients screened, 97.1% of patients at risk for opioid misuse or accidental overdose received a pharmacist-led intervention. Additionally, 44.8% of the pharmacist that enrolled in ONE Rx completed at least five screenings and of those, 80.0% maintained the program three months later. CONCLUSIONS: ONE Rx demonstrated success and positive population impact. The RE-AIM Model identified strength in the areas of efficacy, adoption and maintenance, and the need for improvement in the areas of reach and implementation.