Differences in Perceived Threat and Efficacy in Managing Opioid Use Disorder versus Alcohol Use Disorder.

Background: Efforts to increase the availability of Medication Assisted Treatment for alcohol use disorder (AUD) and opioid use disorder (OUD) may be futile if patients lack motivation for recovery and are unwilling to seek treatment. Objectives: In this cross-sectional, online survey, we used the Extended Parallel Process Model (EPPM) to assess how participants at risk of AUD or OUD react to their perceived threat and assess their response to pharmacotherapy as a potential treatment. EPPM constructs were assessed using the Risk Based Diagnosis Scale. Descriptive statistics measure the proportion of treated vs untreated participants. Untreated participants were sorted into one of three groups categorizing perceived threat - low threat appraisal, and danger or fear control. Results: Of 411 total responses, most (n = 293[71.29%]) sorted into the AUD cohort and 118(28.71%) into the OUD cohort. Overall, 104(25.30%) had received treatment and 307(74.70%) didn't. Within the OUD cohort, there were 67 untreated participants - 16(23.88%) exhibited low threat appraisal, 13(19.40%) were likely to undergo fear control, and 38(56.72%) were likely to undergo danger control. Within the AUD cohort, there were 240 untreated participants - 75(31.25%) exhibited low threat appraisal, 100(41.67%) were likely to experience fear control, and 65(27.08%) were likely to experience danger control. Participants in the OUD cohort were more likely to undergo danger control than those in the AUD cohort (χ2 = 19.26, p < 0.05). Conclusions: This study identified perceived threat and efficacy when an individual was at risk of a SUD, but more insight into potential early interventions is needed - particularly in those individuals with polysubstance use disorder.

Intention to get naloxone among patients prescribed opioids for chronic pain.

BACKGROUND: Prescription opioids have been increasingly prescribed for chronic pain while the opioid-related death rates grow. Naloxone, an opioid antagonist, is increasingly recommended in these patients, yet there is limited research that investigates the intention to get naloxone. This study aimed to investigate intention toward getting naloxone in patients prescribed opioids for chronic pain and to assess the predictive utility of the theory of reasoned action (TRA) constructs in explaining intention to get naloxone. METHODS: This was a cross-sectional study of a panel of U.S. adult patients prescribed opioids for chronic pain using a Qualtrics®XM survey. These patients participated in the study during February to March 2020. The online internet survey assessed the main outcome of intention to get naloxone and constructs of TRA (attitudes and subjective norms); additional measures assessed the characteristics of patients' opioid overdose risk factors, knowledge of naloxone, and their demographics. The relationship between TRA constructs, namely, attitudes and subjective norms, and the intention variable was examined using logistic regression analyses with the intention outcome contrasted as follows: high intention (scores ≥ 5) and non-high intention (scores < 5). RESULTS: A total of 549 participants completed the survey. Most of them were female (53.01%), White or Caucasian (83.61%), non-Hispanic (87.57%) and had a mean age of 44.16 years (SD = 13.37). Of these, 167 (30.42%) had high intention to get naloxone. The TRA construct of subjective norm was significantly associated with increased likelihood of higher intentions to get naloxone (OR 3.04, 95% CI 2.50-3.70, P < 0.0001). CONCLUSIONS: Our study provides empirical support of the TRA in predicting intention to get naloxone among chronic pain patients currently taking opioids. Subjective norms significantly predicted intention to get naloxone in these patients. The interventions targeting important reference groups of these patients would have greater impact on increasing intention to get naloxone in this population. Future studies should test whether theory-based interventions focusing on strengthening subjective norms increase intention to get naloxone in this population.

Barriers and Facilitators to DATA Waivered Providers Prescribing Buprenorphine: A Qualitative Analysis Applying the Theory of Planned Behavior.

Background: Provider beliefs about the treatment of people with addiction may influence their prescribing behavior. Objective: This study applied the Theory of Planned Behavior (TPB), to identify the salient beliefs of Drug Addiction Treatment Act of 2000 (DATA 2000) waivered providers, concerning prescribing buprenorphine to patients with Opioid Use Disorder (OUD). Methods: Texas buprenorphine providers participated in one of four online focus group discussions conducted in fall 2019. The focus group discussion were audio recorded and the total length was between 60-90 minutes. Thematic analysis was conducted to identify emerging themes and to categorize the behavioral, normative, and control beliefs related to buprenorphine prescribing. Results: Of the 14 total participants, 57% of the participants were male and annually treated between zero to sixty patients with buprenorphine. The codes generated were represented in thematic maps, specifying the positive or negative aspects of buprenorphine prescribing. Results indicate that providers' primary motivation to prescribe buprenorphine was, implementation of a whole-patient approach through collaboration with behavioral health providers, in the provision of medications for opioid use disorder (MOUD). Providers primary normative belief was the recognition of key members of the medical community and patients' families and friends as influential groups. Providers' control beliefs focused on their ability to use buprenorphine in different practice settings. Conclusion: These results indicate that buprenorphine access may be expanded by increasing support for DATA waivered providers from other parts of the healthcare system such as behavioral health providers and pharmacists. Implications for clinical practice and future research will be discussed.

Comparing Two Databases to Identify Access to Buprenorphine Treatment for Opioid Use Disorder.

OBJECTIVE: The objective of this study is to assess the differences in buprenorphine prescribers from a county level in the state of Texas by comparing the Substance Abuse and Mental Health Services Administration (SAMHSA) Buprenorphine Practitioner Locator to the Drug Enforcement Administration's (DEA) Controlled Substance Act (CSA) database. METHODS: County-level counts of buprenorphine prescribers were calculated from both the publicly available SAMHSA buprenorphine practitioner locator list and the DEA CSA database. These were then used to estimate the number of providers per 100,000 residents in each county. Regional variation in access to buprenorphine was compared descriptively across the state using poverty data from the US Census and county-level demography from the Texas Demographic Center. RESULTS: This study found 68.8% more X-waivered providers on the DEA CSA database (n = 2,622) with at least one provider reported in 125 of 144 counties in the state (49.2%) compared to the SAMHSA Buprenorphine Practitioner Locator (n = 1,553) with at least one provider reported in 103 counties (40.5%). CONCLUSIONS: The lack of a complete public registry of buprenorphine prescribers can inhibit the ability of patients to identify a convenient treatment. More work is needed to quantify the gap between treatment capacity and treatment need.

Impact of COVID-19 related policy changes on filling of opioid and benzodiazepine medications.

BACKGROUND: Healthcare access has changed drastically during the COVID-19 pandemic. Elective medical procedures, including routine office visits, were restricted raising concerns regarding opioid and benzodiazepine provider and prescription availability. OBJECTIVE: To examine how the cancelation of elective medical procedures due to COVID-19 impacted the dispensing of opioid and benzodiazepine prescriptions in Texas. METHODS: Interrupted time series analyses were preformed to examine changes in prescription trends for opioids and benzodiazepines before and after the restriction on elective medical procedures. Samples of patients who filled an opioid or benzodiazepine prescription from January 5, 2020 to May 12, 2020 were identified from the Texas Prescription Monitoring Program. Elective medical procedures were restricted starting March 23, 2020 indicating the beginning of the intervention period. RESULTS: Restricting elective procedures was associated with a significant decrease in the number of patients (ß = -6029, 95%CI = -8810.40, -3246.72) and prescribers (ß = -2784, 95%CI = -3671.09, -1896.19) filling and writing opioid prescriptions, respectively. Also, the number of patients filling benzodiazepine prescriptions decreased significantly (ß = -1982, 95%CI = -3712.43, -252.14) as did the number of prescribers (ß = -708.62, 95%CI = -1190.54, -226.71). CONCLUSION: Restricting elective procedures resulted in a large care gap for patients taking opioid or benzodiazepine prescriptions.

Impact of COVID-19 Related Policy Changes on Buprenorphine Dispensing in Texas.

OBJECTIVES: To measure the change in the daily number of patients receiving buprenorphine and buprenorphine prescribers during the early phase of the COVID-19 (SARS-CoV-2) pandemic in Texas. METHODS: Counts of the number of patients filling and number of providers prescribing buprenorphine were calculated for each weekday between November 4, 2019 and May 12, 2020. The change in daily patients and prescribers between March 2, 2020 and May 12, 2020, was modeled as a change in slope compared to the baseline period using autoregressive, interrupted time series regression. RESULTS: The rate of change of daily buprenorphine prescriptions (ß = -1.75, 95% CI = -5.8-2.34) and prescribers (ß = -0.32, 95% CI = -1.47-0.82) declined insignificantly during the COVID-19 period compared to the baseline. CONCLUSIONS: Despite a 57% decline in ambulatory care utilization in the south-central US during March and April of 2020, health services utilization related to buprenorphine in Texas remained robust. Protecting access to buprenorphine as the COVID-19 pandemic continues to unfold will require intensive efforts from clinicians and policy makers alike. While the presented results are promising, researchers must continue monitoring and exploring the clinical and humanistic impact of COVID-19 on the treatment of substance use disorders.

Health care practitioner counseling encourages disposal of unused opioid medications.

OBJECTIVE: The objective of this study was to estimate the association between health care practitioner counseling on medication disposal and disposal of unused opioid medications. DESIGN: A 41-item survey instrument was created and administered to a nationally representative panel of adult opioid users with chronic pain using a cross-sectional, internet survey design via Qualtrics®. PARTICIPANTS: Four hundred adult opioid users with chronic pain were randomly selected from the Qualtrics® panel-base to participate. SETTING: United States. OUTCOME MEASURES: The dependent variable, disposal of unused opioid medications, was assessed with a single item asking participants how often they had disposed of unused opioid medications in the past year. Multiple logistic regression was used to assess the association between opioid disposal and the receipt of health care practitioner counseling on medication disposal. RESULTS: A total of 400 surveys were completed. Participants were mostly white (70.8%) and under the age of 40 (54.1%). Less than one-half of all participants (44.5%) had disposed of opioid medications in the past year, while 60.75% had received health care practitioner counseling on disposal. Of those counseled, only 21.4% were counseled by a pharmacist. Flushing medication down the toilet (33%) was the most common method of opioid disposal. After adjustment for covariates, those who received health care practitioner counseling were more likely to have disposed of opioid medications in the past year (adjusted odds ratio 1.66, 95% CI 1.03-2.69). CONCLUSIONS: Participants who received counseling on opioid disposal were more likely to have disposed of unused opioid medications. Pharmacists are uniquely positioned to counsel patients on opioid disposal and thus must be active in preventing harm and diversion due to improperly stored opioid medications. This study demonstrates the need for enhanced provider education and policy to ensure that patients are adequately counseled on proper opioid disposal.

Using the theory of planned behavior to investigate community pharmacists' beliefs regarding engaging patients about prescription drug misuse.

INTRODUCTION: Opioid misuse causes over 50,000 deaths in America each year. Prescription drug monitoring program (PDMP) databases serve as a useful decision analysis tool in managing patients with known or potential opioid use disorder (OUD). To date, however, little research has sought to determine how pharmacists use PDMPs to engage patients with potential OUD. OBJECTIVES: To elicit modal salient beliefs of community pharmacists regarding their willingness to engage patients (i.e., provide interventional counseling) with suspected controlled substance misuse as identified from reviewing PDMP data. METHODS: Focus groups were conducted among Texas community pharmacists using the theory of planned behavior as a theoretical framework. Open-ended questions were used to capture behavioral beliefs, normative beliefs and control beliefs associated with pharmacists' engagement. Qualitative analysis using ATLAS.ti software was conducted to identify modal salient beliefs elicited by at least 20% of the study sample. RESULTS: A total of 31 community pharmacists participated. Fifteen behavioral beliefs, thirteen normative beliefs and eleven control beliefs were identified as modal salient beliefs. The most prevalent behavioral belief was the disadvantage associated with patient confrontations. Pharmacists also believed that engaging patients may cause loss of customers/business but may help patients receive appropriate counseling. When asked about their normative beliefs, pharmacists identified regulatory agencies (e.g., pharmacy boards, law enforcement) and family/friends of patients as groups of individuals who influence their willingness to refer. Time required for counseling was found to be the most commonly cited control belief. CONCLUSION: The results illustrate some of the challenges faced by community pharmacists when considering engagement of patients with misuse of prescription opioids. Addressing these barriers to patient engagement is critical to increasing pharmacists' willingness to engage patients with potential OUD.

Prescribers' perceptions on the impact of hydrocodone rescheduling on geriatric pain management: A qualitative study.

OBJECTIVE: To qualitatively assess prescribers) perceptions regarding the consequences associated with hydrocodone rescheduling among geriatric patients being discharged from inpatient settings. DESIGN: This was a cross-sectional study. SETTING: Two focus groups were conducted by a trained facilitator in a metropolitan academic medical center in January 2016. PARTICIPANTS: Prescribers who manage noncancer pain for geriatric patients were recruited. Focus groups were recorded, transcribed, and then analyzed using ATLAS.ti Qualitative Data Analysis software. Codes were derived from six primary research questions and results were summarized into key themes regarding the impact of rescheduling. MAIN OUTCOME MEASURES: Prescribers) perceptions regarding hydrocodone rescheduling. RESULTS: Prescribers mentioned that they review the prescription monitoring program (PMP) more often before prescribing opioids after rescheduling. They expressed concern regarding the required special serialized prescription forms needed to issue schedule II prescriptions. This led to substituting hydrocodone with potentially less effective pain medications, the inability to issue refills on hydrocodone prescriptions, and an ethical concern over prescribing hydrocodone to patients not under their direct care. Additionally, rescheduling has affected the coordination of care upon discharge, as patients moving to long-term care or skilled nursing facilities may not have adequate pain management when transferred. CONCLUSIONS: The majority of physicians felt rescheduling negatively impacted both practical and ethical aspects of patient care related to pain management after discharge. Rescheduling has changed physicians) hydrocodone prescribing patterns, leading to more caution when prescribing hydrocodone and greater use of the PMP. Future studies should assess geriatric patients) satisfaction and quality of life regarding pain management since hydrocodone was rescheduled.

Development of Prescription Drug Information Leaflets: Impact of Cognitive Effort and Patient Involvement on Prescription Medication Information Processing.

OBJECTIVE: The objective of this study was to develop a one-page (1-page) prescription drug information leaflet (PILs) and assess their impact on the information processing variables, across 2 levels of patient involvement. METHODS: One-page PILs were developed using cognitive principles to lower mental effort and improve comprehension. An experimental, 3 × 2 repeated measures study was conducted to determine the impact of cognitive effort, manipulated using leaflet type on comprehension across 2 levels (high/low) of patient involvement. Adults (≥18 years) in a university setting in Houston were recruited for the study. Each participant was exposed to 3 different types of prescription drug information leaflet (the current practice, preexisting 1-page text-only, and 1-page PILs) for the 3 drugs (Celebrex, Ventolin HFA, Prezista) for a given involvement scenario. A prevalidated survey instrument was used to measure product knowledge, attitude toward leaflet, and intention to read. RESULTS: Multivariate analysis of variance indicated significant positive effect of cognitive effort, involvement, and their interaction effect across all measured variables. Mean scores for product knowledge, attitude toward leaflet, and intention to read were highest for PILs ( P < .001), indicating that PILs exerted lowest cognitive effort. Univariate and post hoc analysis indicate that product knowledge significantly increases with high involvement. CONCLUSION: Patients reading PILs have higher comprehension compared with the current practice and text-only prototype leaflets evaluated. Higher levels of involvement further improve participant knowledge about the drug, increase their intention to read the leaflet, and change their attitude toward the leaflet. Implementation of PILs would improve information processing for consumers by reducing their cognitive effort.

Role of Information Anxiety and Information Load on Processing of Prescription Drug Information Leaflets.

In this study, we evaluate the role of information anxiety and information load on the intention to read information from prescription drug information leaflets (PILs). These PILs were developed based on the principals of information load and consumer information processing. This was an experimental prospective repeated measures study conducted in the United States where 360 (62% response rate) university students (>18 years old) participated. Participants were presented with a scenario followed by exposure to the three drug product information sources used to operationalize information load. The three sources were: (i) current practice; (ii) pre-existing one-page text only; and (iii) interventional one-page prototype PILs designed for the study. Information anxiety was measured as anxiety experienced by the individual when encountering information. The outcome variable of intention to read PILs was defined as the likelihood that the patient will read the information provided in the leaflets. A survey questionnaire was used to capture the data and the objectives were analyzed by performing a repeated measures MANOVA using SAS version 9.3. When compared to current practice and one-page text only leaflets, one-page PILs had significantly lower scores on information anxiety (p < 0.001) and information load (p < 0.001). The intention to read was highest and significantly different (p < 0.001) for PILs as compared to current practice or text only leaflets. Information anxiety and information load significantly impacted intention to read (p < 0.001). Newly developed PILs increased patient's intention to read and can help in improving the counseling services provided by pharmacists.

Abuse of over-the-counter medicines: a pharmacist's perspective.

Self-care and self-medication practices are essential components of any health care systems. The use of over-the-counter (OTC) medications is a part of the self-medication process. The popularity of OTC medication use among patients may increase the abuse potential of OTC medications. With pharmacists being as accessible as they are, they are often the first line of contact for patients, and have the opportunity to educate and counsel patients on appropriate OTC medication use. The presence of a pharmacist ensures safe and effective use of OTC medications. Pharmacists can liaise with other health care providers in the management of self-care practices by patients. However, a pharmacist has traditionally been underutilized in this role. This article provides a brief review on OTC medications with abuse potential and the effect of self-medication on OTC medication abuse. This review further describes the barriers faced by pharmacists in OTC medication abuse management, given the increased potential of prescription-to-OTC switch in recent years. In addition, the potential for a behind-the-counter drug category to boost patient-pharmacist interaction was discussed. The current review supports the positive role played by pharmacists in the management of OTC medication abuse. This review adds to the knowledge base of the barriers faced by pharmacists to prevent OTC medication abuse while developing appropriate intervention strategies. By expanding the role of pharmacists, OTC medication abuse may be controlled more effectively, thereby providing better patient medication therapy management and outcomes.