Factors in rural community buprenorphine dispensing.

Background: There are pharmacy-related barriers to the dispensing of buprenorphine for the treatment of opioid use disorders. These include pharmacists' moral objections and mistrust of treatment regimens; the perception of a limit on the amount of buprenorphine able to be ordered and dispensed; stigma and concerns about diversion; and knowledge and communication gaps. Objectives: To document pharmacy stakeholders' awareness and interpretation of regulatory policies that may impact rural community pharmacists' willingness and ability to dispense buprenorphine. To identify factors that affect rural community pharmacists' willingness and ability to dispense buprenorphine in Appalachian North Carolina. Methods: Qualitative analysis and thematic coding of phone interviews with eight pharmacists from several rural North Carolina counties where local health departments recently began prescribing MOUD and four pharmacy industry stakeholders representing knowledge of wholesale distributors and pharmacy education. Results: Three major themes were identified: stigma and misinformation, provider-prescriber communication, and perceived and actual regulatory constraints. A number of respondents indicated a desire to better understand MOUD treatment plans and displayed a misunderstanding of evidence-based treatment guidelines. Stakeholders indicated the importance of pharmacists establishing a relationship with prescribers and described pharmacist preference for dispensing buprenorphine to established patients over new or out-of-area patients. Pharmacist stakeholders and industry/education stakeholders expressed concern over a perceived DEA 'cap' for buprenorphine ordering. Conclusions: This study provides insight on possible approaches to address rural pharmacy-related barriers patients may face when filling buprenorphine prescriptions. There is a demonstrated need for further pharmacist training on evidence-based practices for treating opioid use disorders and ordering limits, as well as a need for increased communication between prescribers and pharmacists.

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.

Project ECHO® in Primary Care: Informing Providers about COVID-19 and Its Impact on Health Care Delivery.

BACKGROUND Rural, primary care providers face particular challenges with adapting the delivery of care in the setting of the Coronavirus Disease of 2019 (COVID-19) pandemic. Project ECHO® is a virtual, case-based platform centered on collective learning. As a regional Area Health Education Center (AHEC), we developed two Project ECHO® series aimed at disseminating best practices and creating a community of shared experiences for rural providers.METHODS On March 30, 2020, we launched two Project ECHO® series pertaining to COVID-19: the Primary Care COVID-19 Collaborative series and the Practice Support for COVID-19 Preparedness series. These series each occurred twice weekly, concluding in February 2021, and were free to attend. Topics include COVID-19-specific management as well as strategies for adapting the delivery of care during the pandemic. We assessed engagement per county as well as attendee evaluations.RESULTS In the first month, we hosted 19 sessions with 283 participants from 37 counties in North Carolina. Providers felt the most impactful aspects of the sessions were the changes to their practice and the lateral learning from peers in the region.LIMITATIONS In review of our survey responses, a small percentage of our participants do not appear to have direct patient care roles, so we believe this impacted our survey results particularly in regard to relevance to clinical practice and change to clinical practice.CONCLUSIONS Project ECHO® is an effective platform for quickly disseminating information and creating a sense of community in the midst of the social distancing required during the pandemic.

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.

An examination of telehealth policy impacts on initial rural opioid use disorder treatment patterns during the COVID-19 pandemic.

PURPOSE: Tracking changes in care utilization of medication for opioid use disorder (MOUD) services before, during, and after COVID-19-associated changes in policy and service delivery in a mixed rural and micropolitan setting. METHODS: Using a retrospective, open-cohort design, we examined visit data of MOUD patients at a family medicine clinic across three identified periods: pre-COVID, COVID transition, and COVID. Outcome measures include the number and type of visits (in-person or telehealth), the number of new patients entering treatment, and the number of urine drug screens performed. Distance from patient residence to clinic was calculated to assess access to care in rural areas. Goodness-of-Fit Chi-Square tests and ANOVAs were used to identify differences between time periods. FINDINGS: Total MOUD visits increased during COVID (436 pre vs. 581 post, p < 0.001), while overall new patient visits remained constant (33 pre vs. 29 post, p = 0.755). The clinic's overall catchment area increased in size, with new patients coming primarily from rural areas. Length of time between urine drug screens increased (21.1 days pre vs. 43.5 days post, p < 0.001). CONCLUSIONS: The patterns of MOUD care utilization during this period demonstrate the effectiveness of telehealth in this area. Policy changes allowing for MOUD to be delivered via telehealth, waiving the need for in-person initiation of MOUD, and increased Medicaid compensation for MOUD may play a valuable role in improving access to MOUD during the COVID-19 pandemic and beyond.

Does XR injectable naltrexone prevent relapse as effectively as daily sublingual buprenorphine-naloxone?

YES. MONTHLY EXTENDED-RELEASE INJECTABLE NALTREXONE (XR-NTX) TREATS OPIOID USE DISORDER AS EFFECTIVELY AS DAILY SUBLINGUAL BUPRENORPHINE-NALOXONE (BUP-NX) WITHOUT CAUSING ANY INCREASE IN SERIOUS ADVERSE EVENTS OR FATAL OVERDOSES. (STRENGTH OF RECOMMENDATION: A, 2 GOOD-QUALITY RCTS).

Reprint of: Impact of elective on students' perceptions of treating patients with a substance use disorder.

OBJECTIVE: To evaluate the impact of a substance use disorder (SUD) elective curriculum on students' perceptions of treating patients with SUDs using the Drug and Drug Problems Perceptions Questionnaire (DDPPQ). METHODS: In 2017, a third-year pharmacy elective, conceptualizing SUD as a chronic, relapsing brain disease with psychosocial and societal influencers, was introduced. A linked pre- and postcourse assessment using the DDPPQ was carried out for the following categories: role adequacy, role support, job satisfaction, role-related self-esteem, and role legitimacy. RESULTS: A total of 63 students were enrolled in the elective and 54 paired questionnaires were available for analysis. There was a statistically significant improvement in attitude across all 5 categories of the DDPPQ. CONCLUSION: Students' attitudes toward working with patients with SUD improved after completing the elective. This study indicates that teaching student pharmacists about effectively recognizing and treating SUDs may result in more willingness to work with these patients in the future.

The Value of Treating Opioid Use Disorder in Family Medicine: From the Patient Perspective.

INTRODUCTION: Despite evidence demonstrating that medications for opioid use disorder (OUD) reduce morbidity and mortality, the majority of patients do not receive treatment. The National Academies of Science call for more research exploring the patient's perspective of treatment modalities to increase access to individualized, patient-centered care. We aim to build on existing literature by describing patient experiences treated for OUD in a rural family medicine setting. METHODS: We employed a convenience sampling methodology to complete brief, structured interviews with thematic data analysis for 30 of 57 eligible patients receiving office-based opioid treatment (OBOT) in the primary care setting. RESULTS: Participants' experiences with OBOT were generally positive and shaped by societal structures and institutions, their life before treatment, their treatment history, and the kind of care they received in OBOT. Patients identified accessibility and privacy as advantages to receiving OBOT in primary care. DISCUSSION: This research identifies ways providers can provide individualized and effective OUD treatment within the family medicine setting.

Impact of elective on students' perceptions of treating patients with a substance use disorder.

OBJECTIVE: To evaluate the impact of a substance use disorder (SUD) elective curriculum on students' perceptions of treating patients with SUDs using the Drug and Drug Problems Perceptions Questionnaire (DDPPQ). METHODS: In 2017, a third-year pharmacy elective, conceptualizing SUD as a chronic, relapsing brain disease with psychosocial and societal influencers, was introduced. A linked pre- and postcourse assessment using the DDPPQ was carried out for the following categories: role adequacy, role support, job satisfaction, role-related self-esteem, and role legitimacy. RESULTS: A total of 63 students were enrolled in the elective and 54 paired questionnaires were available for analysis. There was a statistically significant improvement in attitude across all 5 categories of the DDPPQ. CONCLUSION: Students' attitudes toward working with patients with SUD improved after completing the elective. This study indicates that teaching student pharmacists about effectively recognizing and treating SUDs may result in more willingness to work with these patients in the future.

A Financial Model for Team-Based Opioid Use Disorder Treatment.

INTRODUCTION: Opioid use disorder (OUD) affects 2 million Americans, yet many patients do not receive treatment. Lack of team-based care is a common barrier for office-based opioid treatment (OBOT). In 2015, we started OBOT in a family medicine practice. Based on our experiences, we developed a financial model for hiring a team member to provide nonbillable OBOT services through revenue from increased patient volume. METHODS: We completed a retrospective chart review from July 2015 to December 2016 to determine the average difference in medical visits per patient per month pre-OBOT versus post-OBOT. Secondary outcomes were the percentage of visits coded as a Level 3, Level 4, and Level 5, and the percentage of patients with Medicaid, private insurance, or self pay. With this information, we extrapolated to build a financial model to hire a team member to support OBOT. RESULTS: Twenty-three patients received OBOT during the study period. There was a net increase of 1.93 visits per patient per month (P < .001). Fourteen patients were insured by Medicaid, 7 had private insurance, and 2 were self pay. Twenty-three percent of OBOT visits were Level 3, 69% were Level 4, and 8% were Level 5. Assuming all visits were reimbursed by Medicaid and accounting for 20% cost of business, treating 1 existing patient for 1 year would generate $1,439. Treating 1 new patient would generate $1,677. CONCLUSIONS: In a fee-for-service model, the revenue generated from increased medical visits can offset the cost of hiring a team member to support nonbillable OBOT services.

Evaluation of a pharmacist-led naloxone coprescribing program in primary care.

OBJECTIVES: To determine the impact of a pharmacist-led coprescribing initiative on patient access to naloxone in a primary care setting. SETTING: Family medicine residency practice with embedded pharmacists in western North Carolina. PRACTICE INNOVATION: In June 2016, clinical pharmacists embedded in a primary care clinic initiated a naloxone coprescribing initiative with the aim of increasing access to naloxone for patients on chronic opioid therapy who were on 50 mg or greater morphine-equivalents daily (MED), on a concomitant benzodiazepine, had a history of an overdose, or had a diagnosis of a substance use disorder. Pharmacists' roles included educating providers and clinical staff regarding naloxone, creating quick links within the electronic health record to more easily prescribe naloxone, identifying patients who met criteria for naloxone, and counseling patients about naloxone. EVALUATION: This study was a single-cohort pre- and postintervention study. One year after initiation of the program, data were manually collected to assess the rates of naloxone prescribing and the reason for requiring naloxone. In addition, pharmacy students called pharmacies to determine fill rates and obtain reasons given by patients for not filling naloxone. RESULTS: A total of 234 patients remained candidates for naloxone at the end of 1 year. Naloxone coprescribing increased from 3.4% at baseline to 37.2% at follow-up (P = 0.0001). Seventy-one percent of patients required naloxone because of chronic opioid therapy doses of 50 mg or more MED, 55% were on a benzodiazepine, 6% had a diagnosis of a substance use disorder, and 1% had a history of overdose. Of the patients who received a naloxone prescription, 31.4% filled it. CONCLUSION: Embedded clinical pharmacists in primary care have the potential to increase naloxone coprescribing for high-risk patients treated with chronic opioid therapy for pain.

Teaching Opioid Tapering Through Guided Instruction.

BACKGROUND AND OBJECTIVES: Given the current opioid epidemic, national practice guidelines and many state laws are shifting the treatment paradigm for chronic, noncancer pain to a judicious use of opioids. This has prompted a need to teach family medicine residents how to appropriately taper opioids. We created a multifaceted approach to integrate teaching of opioid tapering into a family medicine curriculum with an emphasis on guided instruction. We assessed the degree to which this curriculum affected guideline-concordant opioid prescribing within the family medicine practice. METHODS: A retrospective chart review of 707 patients on chronic opioid therapy (COT) for noncancer pain was conducted before and after the incorporation of a guided instruction experience to the residency curriculum. The primary outcomes included the number of patients on chronic opioids, the average morphine equivalent daily (MED) per patient, the percentage of patients on >50 MED or >90 MED, and the number of patients on concomitant benzodiazepines. RESULTS: Of the original 707 patients, 188 tapered off COT. Of those remaining on COT, the average MED did not change (53.4±76.9 vs 58.5+89.1, P=0.053). The percentage of patients on >50 MED and >90 MED decreased significantly (30.6% vs 25.0%, P=0.001; 19.4% vs 14.0%, P=0.027). The total number of patients on concomitant benzodiazepine decreased from 212 to 131. CONCLUSIONS: Providing opportunities for guided instruction with opioid tapering allowed for an increased concordance with national practice guidelines.

Development of pharmacy resident leadership skills through creation of a regional ambulatory care forum.

BACKGROUND AND PURPOSE: Action-based leadership activities help refine leadership skills. This paper describes an experiential, longitudinal leadership experience for post-graduate year two (PGY2) pharmacy residents in ambulatory care. EDUCATIONAL ACTIVITY AND SETTING: As part of a leadership and advocacy rotation, two PGY2 ambulatory care pharmacy residents collaborated with a state association, North Carolina Association of Pharmacists, to co-chair a newly formed regional ambulatory care forum in the western part of the state. The residents developed charges for the group, directed and organized the leadership team meetings, moderated the member events of approximately 30 participants, and served as liaisons to the state association and its members. Two residency preceptors who supervised the academic and leadership experiences for the residency program provided oversight for the residents with the forum. Residents completed written and oral self-reflections, received formative feedback from the forum's leadership team and leadership preceptor, participated in a 360-degree leadership evaluation, and received quarterly summative evaluations. FINDINGS: Skills developed included leading a group, event planning, advocacy, networking, communication, professional writing, creating a shared vision, teamwork, and collaboration. SUMMARY: Serving in leadership roles within professional organizations can provide PGY2 pharmacy residents with practical hands-on leadership opportunities to help prepare them for positional and non-positional leadership roles in the future.

Essential factors demonstrating readiness of primary care practices for clinical pharmacy services.

PURPOSE: The characteristics of primary care practices that are necessary to establish and maintain ambulatory care clinical pharmacy services were identified. METHODS: A focus group of 15 ambulatory care pharmacists in Western North Carolina developed a survey of 26 practice readiness statements pertaining to the development of clinical pharmacy services in primary care. National ambulatory care pharmacy experts were then surveyed using a modified Delphi model for consensus building to determine which items were essential. Four rounds of surveys were completed. After each round, statements were accepted as consensus, modified, or removed from the survey based on responses. Statements were deemed to have reached consensus when 80% of respondents were in agreement. RESULTS: A total of 6 statements reached agreement after 4 rounds of survey: (1) full integration into the team, (2) access to the electronic health record (EHR), (3) a physician or administrative champion, (4) appropriate equipment provided by the clinic, (5) a private room to see patients, and (6) a practice that is open to team-based care. CONCLUSION: An expert panel of ambulatory care pharmacists identified 6 factors that should be considered prior to establishing ambulatory care services in primary care practices. Of these, foundational elements included full integration into the care team, presence of a physician or administrative champion, and a practice that is ready for team-based care. Operational elements included access to the practice's EHR, equipment provided by the practice, and private space to see patients.

Physician perceptions of integrating advanced practice pharmacists into practice.

OBJECTIVES: Barriers have prevented full integration of advanced practice pharmacists (APPs) into collaborative practice in some areas despite evidence describing their value. APPs in North Carolina can be recognized as Clinical Pharmacist Practitioners (CPPs) under a collaborative practice agreement and provide comprehensive medication management under physician supervision. This study describes the perceptions of physicians regarding the barriers and benefits of integrating CPPs into interprofessional teams and compares physician and CPP perceptions. METHODS: This prospective descriptive study surveyed CPP supervising physicians in North Carolina. The questionnaire consisted of 17 multiple-choice and free-response questions. Questions included demographics, perceived benefits and challenges of incorporating CPPs into health care teams, and services provided by CPPs. Findings were compared with previously published data that assessed CPP perceptions about the same topics to gain insight into common perspectives of team members. RESULTS: Fifty-six physicians (23.1%) responded, identifying enhanced clinical outcomes (87.5%), access to drug knowledge (58.9%), and creation of a multidisciplinary model for learners (57.1%) as the top benefits of working with CPPs. Primary barriers included limited reimbursement (60.7%) and billing difficulties (51.8%). More CPPs acknowledged provider acceptance as a barrier (25.9% vs. 3.6%; P = 0.001). Twelve physicians (21.4%) and no CPPs identified space as a barrier. CONCLUSION: Physicians identified enhanced clinical outcomes, access to drug knowledge, and creation of a multidisciplinary model for learners as the top benefits of incorporating CPPs into teams, and billing difficulties and limited reimbursement were the primary barriers. These findings were similar to the perceptions of CPPs, with exceptions being that physicians were more concerned about space limitations and CPPs noted that provider acceptance may be difficult. These findings may provide guidance to providers desiring to establish collaborative practice.