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.

Surgical Removal of Rheumatoid Nodule That Presented as a Thyroglossal Duct Cyst: A Case Report.

Rheumatoid nodules are extraarticular complications in rheumatoid arthritis (RA). This report details how a 63-year-old female patient with a history of lung and kidney cancer presented to the otolaryngology clinic with left submandibular region neck pain and a lesion that looked like a thyroglossal duct cyst on imaging. The patient also had accompanying joint pain. After the patient underwent a full workup including positron emission tomography and computed tomography scans, she underwent surgery to remove the suspected thyroglossal duct cyst via a Sistrunk procedure. Pathology indicated that it was a rheumatoid nodule. The patient was never diagnosed with RA until after removal of the nodule was done. The patient ended up being evaluated by rheumatology and has subsequently been treated for RA. This rare case highlights the importance of interdepartmental communication and assessment of all patient symptoms on examination.

A call to develop opioid risk assessment programs for implementation in the pharmacy setting.

The United States persists in combatting the opioid epidemic. Collectively, researchers should be in search of evidence-based solutions. One such could be an appropriate screening tool to determine a patient's risk of opioid misuse. The screening tool should be transparent, provide high specificity, be validated across a variety of healthcare settings, and be a guided clinical decision-making tool to avoid weaponizing an opioid risk score. We should shift our focus from the number of opioid prescriptions dispensed to appropriateness of each prescription. We should be aware of utilizing non-opioid therapy options. In addition, healthcare providers should be knowledgeable of opioid misuse resources in their area to avoid practicing defensively, while instead concentrating their efforts on patients' best interests. The patients' dignity should be upheld through empathetic care from healthcare providers. We need to reduce the stigma surrounding opioid use, and ensure patient safety with one, cohesive, validated, opioid risk assessment tool.

Managing the Risk of COVID-19 Using Model Based Predictors: The Case of North Dakota.

OBJECTIVE: North Dakota (ND) had the highest coronavirus disease 2019 (COVID-19) case and mortality rate in the United States for nearly 2 mo. This study aims to compare 3 metrics ND used to guide public health action across its 53 counties. METHODS: Daily COVID-19 case and death totals in North Dakota were evaluated using data from the COVID-tracker website provided by the North Department of Health (NDDoH). It was reported as: active cases per 10,000, tests administered per 10,000, and test positivity rate (the North Dakota health metric). The COVID-19 Response press conferences provided data for the Governor's metric. The Harvard model used daily new cases per 100,000. A chi-squared test was used to compare differences in these 3 metrics on July 1, August 26, September 23, and November 13, 2020. RESULTS: On July 1, no significant difference between the metrics was found. By September 23, Harvard's health metric indicated critical risk while ND's health metric was moderate risk, and the Governor's metric was still low risk. CONCLUSIONS: ND's and the Governor's metric underrepresented the risk of the COVID-19 outbreak in North Dakota. The Harvard metric reflected North Dakota's increasing risk; it should be considered as a national standard in future pandemics. PUBLIC HEALTH IMPLICATIONS: Model-based predictors could guide policy-makers to effectively control spread of infectious disease; proactive models could reduce risk of disease as it progresses in vulnerable communities.

Nurse delivered medication safety screening program for home care visits.

Home care clients have safety barriers related to medication storage, disposal, and safe use of opioids. Limited research is available regarding medication safety initiatives in the home care setting. This study evaluates a medication safety initiative, linked with opioid misuse and overdose prevention screening, for home care clients with different levels of service. Training and screening tools designed for community pharmacies by the Opioid & Naloxone Education (ONE) Program were modified for use by home health nurses. All new admits to the home health services were screened for medication storage, medication disposal, and use of pain medications. Patients taking opioids were screened for opioid-specific risks. Interventions based on screening results included education, provision of medication lock boxes, drug disposal packets, and/or naloxone. Most home care clients (85%) are properly storing their medication and 38% were not properly disposing unused medications. Higher levels of care had greater pain medication needs, including the provision of naloxone. This study demonstrates the opportunity to incorporate medication safety screening into nursing home health visits.

Qualitative Analysis of a Roundtable Exercise "Reflecting on the COVID-19 Experience of Public Health Professionals".

CONTEXT: Public health professionals around the country faced significant challenges responding to the COVID-19 pandemic. Reflecting on their experience is an essential element in making sense of their experience and learning from it. OBJECTIVE: The objective of this qualitative study was to (1) describe the lived experiences of public health professionals working during the COVID-19 pandemic, (2) discuss the effectiveness of a guided reflection exercise to help public health professionals process these experiences, and (3) provide lessons learned and best practices to inform preparation for a future infectious disease pandemic. DESIGN: Qualitative focus group study design. SETTING: This activity was conducted at a Midwestern state public health professional meeting. PARTICIPANTS: Forty-eight public health professionals self-selected to participate in this study. RESULTS: Five themes were elicited in this analysis, including Communication, Leadership and Collaboration, Data Management, Community Relationships, and Resources and Planning. In addition, public health professionals reported numerous lessons learned, including the need for more leadership from the state government, the conflicted response of their communities, and the benefits of community solidarity where it was present. CONCLUSIONS: This article provides a detailed account of public health workers' experiences during the COVID-19 pandemic. It also provides lessons learned that will help public health workers lead more effectively in the future. Guided reflection on a traumatic professional experience can assist participating individuals in making sense of their experience and learning important lessons from it.

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.

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.

Evaluating the Association of Face Covering Mandates on COVID-19 Severity by State.

OBJECTIVE: During the COVID-19 pandemic in the United States, mitigation measures were implemented on a state-by-state basis. Governors were responsible for establishing interventions appropriate for their states and the timing of implementation. This paper evaluated the association between the presence and timing of a mask mandate and the severity of the COVID-19 epidemic by state. METHODS: The states were divided into 3 categories based on when the governors of each state implemented a mask mandate: Early (mask mandate implemented between March 2020 and June 2020), Late (July 2020-December 2020), and Never (no mask mandate implemented). The rates of hospitalizations and mortality (per 100 000) were assessed at the different time points during the pandemic across these categories from March to December 2020. RESULTS: The mortality rates across all 3 groups were observed to be highest in the beginning and toward the end of the pandemic in 2020 with the peak observed in the Early group between April and May 2020. Also, the rates of hospitalization increased steadily across all groups. The Early mask group was comprised of 86.7% and 13.3% states with Democratic and Republican governors respectively, and no states in the Never category had Democratic governors. CONCLUSION: These results support the benefit of implementing a mask mandate to minimize the impact of the COVID-19 pandemic and the role of political affiliation of governors on that impact.

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.

Screening at a Federally Qualified Health Center in the Midwest for Hepatitis C Among People Who Inject Drugs, 2019-2020.

INTRODUCTION: Hepatitis C virus (HCV) infection is a public health epidemic. People who inject drugs (PWID) are at high risk for transmitting and contracting HCV. The objective of this study was to assess the effectiveness of a multifaceted intervention at a federally qualified health center in the US Midwest to improve HCV screening rates among PWID. METHODS: A prospective quality improvement initiative was conducted to increase the proportion of PWID screened for HCV. Inclusion criteria consisted of being seen by a primary care provider from April 16, 2019, through February 28, 2020, being aged 18 years or older, and confirmation of intravenous drug use. PWID status was confirmed by reviewing electronic health records. The multifaceted intervention consisted of educational sessions for the health care team and workflow changes. We analyzed the proportion of patients screened preintervention and postintervention by using χ2 tests. RESULTS: Of 742 patients who met the inclusion criteria, the proportion of PWID screened preintervention was 59.6% (n = 329) and the proportion of PWID screened postintervention was 65.1% (n = 283), increasing the screening rate by 5.5 percentage points. A χ2 test of homogeneity indicated a significant relationship between the preintervention and postintervention periods, and screening outcomes (P < .001). CONCLUSION: This multifaceted intervention to increase HCV screening resulted in a modest increase in the proportion of PWID screened. Consistent and health care system-wide screening approaches are needed to optimize the potential of HCV treatment and cure options now available.

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.

Community Pharmacists' Contributions to Disease Management During the COVID-19 Pandemic.

Community pharmacists assist patients to manage disease and prevent complications. Despite the enormous challenge the coronavirus disease 2019 (COVID-19) pandemic has dealt to the health care system, community pharmacists have maintained the delivery of critical health services to communities, including those most at risk for COVID-19. Community pharmacists are in a key position to deliver priority pandemic responses including point-of-care testing for chronic disease management, vaccinations, and COVID-19 testing.