Perceptions of disposal options for unused opioid analgesics among people who have been prescribed an opioid analgesic in North Carolina.

Background: Medication disposal programs have been promoted as one solution to the opioid crisis, but uptake by community members has been minimal.Objectives: To clarify perceptions of medication disposal options among people who have been prescribed an opioid analgesic in North Carolina to inform interventions that can facilitate the disposal of unused opioids.Methods: In 2022, we conducted focus groups with participants who received an opioid medication in the past year to gain information to develop an intervention related to the disposal of unused opioid medication (12 focus group discussions (FGDs); total N = 37; 30 identified as female, 6 as male, and 1 as another gender). Participants were shown a slide with the Food and Drug Administration's recommended disposal options and asked about their perceptions of each option. Themes were derived using an inductive, thematic, qualitative approach.Results: Seven themes about perceptions of medication disposal programs emerged from the data. Four of the themes reflect potential barriers to medication disposal: failed disposal attempts, lack of sufficient education on proper disposal, unclear meaning of specific disposal language, and concerns about existing disposal options. Three of the themes provide insight on potential facilitators of medication disposal: preference of low-cost disposal options, ease and accessibility among disposal methods, and preferred disposal methods.Conclusion: Patients should be provided clear and consistent guidance from prescribers and dispensing pharmacists on when and how to dispose of unused medications and opportunities to dispose of medications at no cost to the patient.

Likelihood of Young Adult Engagement in Protective Behavioral Strategies for Alcohol Use across Drinking Contexts: Implications for Adaptive Interventions.

OBJECTIVE: This study examined how young adults' likelihood to engage in protective behavioral strategies (PBS) to reduce alcohol harms varies across physical and social contexts for drinking. METHOD: We conducted an online survey with 514 heavy drinking young adults (Mage = 22.4 years, 52% women, 30% Hispanic/Latin(x), 40% non-White). Participants were asked to rate their likelihood to engage in 26 PBS generally, and specifically in six physical contexts (e.g., bar/club), and six social contexts (e.g., in a large group). We conducted regression analyses to examine the overall effect of context on the likelihood to engage in each PBS and post-hoc Tukey tests to assess pairwise comparisons of the differences in likelihood to engage in each PBS across response options for physical and social context. Analyses were conducted using the full sample, and for men and women separately. RESULTS: There were significant differences in six strategies across physical contexts; likelihood to engage in PBS varied across public and private spaces for different strategies. We also found significant differences in five strategies across social contexts; participants were more likely to engage in PBS among larger numbers of people and those who are intoxicated. There were numerous differences in pairwise comparisons of PBS engagement across physical and social contexts for women, while men demonstrated only two differences in PBS across physical context. CONCLUSIONS: Results suggest that alcohol interventions for young adults that include PBS should consider tailoring strategies to the individual and the specific context of the drinking event.

Elucidating determinants of medication disposal programs at retail pharmacies in North Carolina.

BACKGROUND: Pharmacy-based medication disposal programs is one approach to prevent diversion of unused prescription opioids. OBJECTIVE(S): The objective of this study was to assess the extent to which disposal programs have been implemented by retail pharmacies and identify determinants of implementation using the Consolidated Framework for Implementation Research. METHODS: A sequential mixed-method design was used to examine implementation of medication disposal programs at pharmacies in Pitt County, NC. We conducted environmental scans of all retail pharmacies that served community members (N = 31) to assess the extent to which disposal programs had been implemented. Then, we conducted interviews with pharmacists (n = 15; 48.4%) to identify determinants of implementation. The following pharmacy types were represented in the completed interviews: corporate chain (n = 10), small chain (n = 1), independently owned and operated (n = 1), medical (n = 2), and government (n = 1). RESULTS: We found that 32.3% of pharmacies (n = 10) had a medication disposal box and 12.9% (n = 4) had posted a flyer on medication disposal. Pharmacists perceived that patients benefit from disposal boxes and medication disposal is in their purview. Determinants of implementation included the cost of sustaining the intervention, polices of corporate and regional management, variable local control in the decision-making process to implement a disposal box, and experience with having a medication disposal box. CONCLUSION: Our findings highlight one way in which pharmacists can have a vital role in preventing diversion of opioid analgesics and associated consequences. There is a need to expand disposal boxes at pharmacies to increase community member accessibility and use. Future research is needed to determine the cost-effectiveness of expanding the scale of disposal box implementation in community pharmacies.

Alcohol protective behavioral strategies for young adults: a content analysis across drinking contexts and gender.

Background: Protective behavioral strategies (PBS) are specific harm reduction behaviors which mitigate alcohol-related consequences among young adults. Prior work indicates PBS utilization varies according to drinking context and gender, suggesting a need for further research assessing whether young adults employ unidentified PBS according to such factors.Objectives: This study examined alcohol PBS young adults suggest using across drinking contexts and gender to inform alcohol-related harm reduction interventions.Methods: An online survey with 514 young adult heavy drinkers (n = 269 female, Mage = 22.36 years) assessed PBS use generally, and across 12 physical and social contexts. We utilized qualitative content analysis methods to code and derive themes from open-ended responses from a prompt asking participants to state additional PBS used per context. The frequency of each theme's appearance was calculated across the overall sample, by gender, and within each context.Results: PBS endorsement varied across context and gender within each theme. Young adults who reported PBS use most frequently endorsed utilizing strategies related to drink content (18.30%), social support (12.36%), and engaging in other activities (10.34%). Participants infrequently endorsed strategies related to awareness of time (0.23%), standards of behavior (0.78%) and avoiding environments (0.87%).Conclusions: Young adults endorse utilizing additional PBS in varying frequency according to drinking context and gender. Given PBS are often a key component of alcohol harm reduction interventions, monitoring trends in young adult PBS use is crucial to ensure continued relevance and efficacy of such interventions to minimize harms associated with young adult heavy alcohol use.

Rates and correlates of medicine disposal program implementation at pharmacies in North Carolina: A longitudinal study, 2016-2021.

BACKGROUND: Unused prescription opioids from family and friends continue to be the primary access point to prescription opioids for nonmedical use among youth. Implementation of medicine disposal boxes at pharmacies is one approach to facilitate removal of unused prescription opioids from the home to prevent diversion. OBJECTIVES: We sought to examine the implementation rates of disposal boxes at pharmacies in North Carolina from 2016 to 2021 and place-based health disparities in availability. METHODS: We identified pharmacies with a disposal box in 2016, 2018, and 2021 among licensed pharmacies in North Carolina in 2018 (N = 2587). We computed descriptive statistics to describe disposal box implementation rates over time and used geographic information systems to identify spatial trends. We used separate logistic regression models in 2018 and 2021 to assess the relationship between neighborhood characteristics and the likelihood of a pharmacy implementing a disposal box. RESULTS: We found an increase in disposal boxes over time with 43 pharmacies (1.7%) in 2016, 144 (5.6%) in 2018, and 350 (13.5%) in 2021 implementing a disposal box. In 2018, independent pharmacies were more likely than chains to have a disposal box. In 2021, medical-affiliated and pharmacies defined as "other" were less likely than chains to have a disposal box. In both 2018 and 2021, pharmacies in census tracts with a higher percentage of the population below the federal poverty line were more likely to have a disposal box. In 2021, pharmacies in tracts with a higher percentage of the population unemployed were less likely to have a disposal box. In 2018, pharmacies located in counties with a greater number of opioid overdose deaths were more likely to have a disposal box. CONCLUSION: Our findings highlight the growth of disposal boxes in North Carolina over time and the potential for continued expansion to provide opportunities to prevent prescription opioid diversion.

Rural, Suburban, and Urban Differences in Chronic Pain and Coping Among Adults in North Carolina: 2018 Behavioral Risk Factor Surveillance System.

INTRODUCTION: Our study aimed to examine the prevalence of chronic pain, its severity, its causes, and coping mechanisms that are used by North Carolina adults in rural, suburban, and urban areas. METHODS: We analyzed data from the Behavioral Risk Factor Surveillance System's first chronic pain module in 2018, representing 3,598 respondents. Self-reported chronic pain was defined as the affirmative response to the question, "Do you suffer from any type of chronic pain, that is, pain that occurs constantly or flares up often?" We computed prevalence of chronic pain and use of coping mechanisms by rural, suburban, or urban residential status. We used multiple logistic regression to assess the association between chronic pain and residential location, adjusting for demographic characteristics, employment, and health insurance. RESULTS: In 2018, an estimated 27.5% (95% confidence interval [CI], 25.6%-29.3%) of North Carolina adults experienced chronic pain. Prevalence of chronic pain in rural areas (30.9%) and suburban areas (30.8%) was significantly higher, compared with urban areas (19.6%). Compared with urban residents with chronic pain, those with chronic pain in suburban areas (adjusted odds ratio [AOR], 0.44; 95% CI, 0.26-0.76) and in rural areas (AOR, 0.39; 95% CI, 0.24-0.65) were less likely to use nonmedication therapies (eg, acupuncture, physical therapy, yoga) and were less likely to use 3 or more types of chronic pain treatment (suburban AOR, 0.47; 95% CI, 0.25-0.88; rural AOR, 0.53; 95% CI, 0.29-0.95). CONCLUSION: Our results indicate that persons living in rural and suburban areas may be more likely to have chronic pain and less likely to use nonmedication treatments than those in urban areas.

Exposure to Medicines in the Family Medicine Cabinet: Is It a Harbinger of Later Opioid Dependence?

Background: Despite research on prescription opioids and dependence being a national priority, little is known about the association between several potential adolescent risk factors and later opioid dependence among those who use opioids non-medically. Objectives: To investigate the association between lifetime opioid dependence and adolescent self-perceived health, health beliefs (thinking there was a pill for everything), health behaviors (onset of alcohol use before 15, onset of prescription opioid use before 15) and parental health practices (having opioids in the family medicine cabinet at age 14, parental suggestions to take pills when sick). Methods: A sample of 343 community members who non-medically used prescription opioids in the past 12 months were recruited for the Prescription Drug Misuse, Abuse, and Dependence Study and retrospectively assessed for adolescent risk factors of lifetime opioid dependence (DSM-IV). Results: Logistic regression revealed the strongest predictor of lifetime opioid dependence was having a prescription opioid in the family medicine cabinet at age 14. Those who grew up believing there was a pill for everything and those who initiated alcohol use before 15 were 1.83 and 1.78 times as likely, respectively, to meet dependence criteria than their counterparts. Demographics and other adolescent predictors were not associated with opioid dependence. Conclusions: Findings suggest several adolescent exposures can be targeted to reduce opioid dependence. Through their behavior, parents can reduce their teens' risk for opioid dependence.

Modifiable Risk Factors Associated With Disposal of Unused Prescription Drugs by Parents of Adolescents.

The safe disposal of unused medications is one primary prevention strategy to reduce nonmedical prescription drug use among adolescents. We sought to identify modifiable risk factors associated with disposal of unused prescription drugs by parents of adolescents residing in ten south central Kentucky counties with disposal programs. In the fall of 2017, 4148 parents of adolescents participated in an anonymous, paper-based survey. We conducted generalized logit mixed models adjusted for within-school clustering to assess the relationship between disposal behaviors and modifiable risk factors while controlling for respondents' sociodemographic characteristics. The analytic sample consisted of parents in households in which someone had been prescribed an opioid medication within the past 12 months (N = 627). Our findings indicated that almost 42% of parents reported disposing of unused prescription medication within the past 12 months, and the majority disposed of medications at home rather than using a disposal program. Parents who perceived that any, compared to none, of their child's close friends engaged in nonmedical prescription opioid use had higher odds of reporting use of a disposal program. Parents who were aware of disposal programs, compared to those who were not aware, had greater odds of using them, rather than not disposing at all or disposing unused prescription medications at home. Compared to parents who perceived prescription drugs to be hard for adolescents to obtain for nonmedical use, parents who believed that prescription drugs were easily accessible to adolescents for nonmedical use had lower odds of using disposal programs than disposing of medications at home. Collectively, our findings suggest that enhancing awareness of disposal programs, while addressing parents' perceptions of their children's peers' use of nonmedical prescription opioids, should be considered to facilitate the disposal of unused medications and optimize current public health prevention efforts related to adolescent nonmedical use of these drugs.

Encouraging Disposal of Unused Opioid Analgesics in Appalachia.

The Appalachian region has been disproportionately impacted by the opioid epidemic. This study, informed by the Health Belief Model (HBM), explored Appalachian community members' perspectives on prescription opioid misuse and community-based programs to dispose of unused opioid analgesics. In 2018, we conducted ten focus groups (n=94 participants) in 5 Appalachian counties. Thirteen themes across 5 of the HBM constructs emerged from our analysis. Participants perceived that their communities are susceptible to the harms associated with opioid misuse, these harms are serious, suggesting they could be motivated to change disposal behaviors. Many participants recognized the benefit to disposing of unused prescription opioids including protecting household members from misusing and protecting the home from robbery. Nevertheless, participants identified barriers to proper disposal, including keeping the medications "just in case" for future ailments and the location of drop boxes near law enforcement (due to deep-seated mistrust of law enforcement agencies). Self-efficacy was difficult to assess as many participants were completely unaware of the presence of dropboxes in the community and also expressed concerns about the inconvenience of proper disposal using dropboxes These findings have implications for developing community-based campaign messages promoting proper disposal of unused opioids.

Social and Situational Party Characteristics Associated With High-Intensity Alcohol Use Among Youth and Young Adults.

BACKGROUND: Rates of high-intensity drinking, which is alcohol consumption that exceeds standard heavy drinking levels, have increased in recent years and peak in young adulthood. To identify modifiable environmental targets for prevention of high-intensity drinking, we identified characteristics of parties attended by youth and young adults that were associated with high-intensity drinking and the consequences of this excessive form of drinking. METHODS: Data are from 15- to 20-year-old participants in an online survey (n = 2,442; 55.4% female, 74.8% White) who resided in 24 communities across 7 states that were a part of a community randomized intervention trial to reduce the incidence and consequences of underage drinking parties. We used multinomial logistic regression to predict level of drinking by 6 party characteristics (size, location, age and gender composition, supervision, others' drinking behavior), and to predict 6 consequences (hangover, not remember event, passed out, punished by parents, broke something/got in fight, and sex against will) from level of drinking. We tested study hypotheses in 2 models, one that used a single binge drinking threshold (below binge vs. at or above binge level) and one that additionally used a high-intensity drinking level (below binge, 1 to 2 times binge, 2+ times binge level). RESULTS: We found that larger party size and a mostly male composition were unique predictors of high-intensity drinking when compared to those who consumed 1 to 2 times the binge drinking level. Odds of passing out, not remembering the drinking event, breaking/damaging property, or getting in a fight were more than double for high-intensity drinkers compared to standard binge level drinkers. CONCLUSIONS: Results from this study indicate there are unique precursors and consequences of high-intensity alcohol consumption among youth and young adults. These environmental factors associated with high-risk drinking contexts can be used to develop prevention strategies to mitigate the harms associated with excessive alcohol consumption.

Power of the Peer and Parent: Gender Differences, Norms, and Nonmedical Prescription Opioid Use Among Adolescents in South Central Kentucky.

This study examined risk factors of nonmedical prescription opioid use (NMPOU) among adolescents and how risk factors differ by gender. In the fall of 2017, adolescents attending 6th through 12th grades across 44 schools in 10 south central Kentucky counties were invited to participate in an anonymous, school-based survey. A total of 11,761 adolescents completed the survey. Logistic regression was conducted to examine the association between NMPOU and constructs of the Theory of Reasoned Action (i.e., attitudes and subjective norms), descriptive norms (i.e., peer use), and parental control of prescription medications in the home. There were 297 (2.7%) adolescents who reported NMPOU in the past 12 months. In the adjusted multivariate logistic regression model, for both males and females, the adolescents who perceived that more of their peers engaged in NMPOU were significantly more likely to endorse NMPOU, whereas male and female adolescents who perceived their peers disapproved of use were significantly less likely to report NMPOU. Parent disapproval was significantly associated with decreased NMPOU for females only. Moderated regression analyses revealed that gender moderated the relationship between parental disapproval and NMPOU. We found that during adolescence, NMPOU is influenced by peer norms for both genders and parental norms for females. These results indicate that prevention efforts should focus on changing adolescents' peer and parental norms related to NMPOU.

More than just Alcohol: Marijuana and Illicit Drug Use at Parties Attended by 15-20 Year Olds.

BACKGROUND: Parties are a common setting for marijuana and illicit drug use among adolescents. OBJECTIVES: This study examined the context of parties with alcohol, marijuana and illicit drug use attended by adolescents and young adults. METHODS: In 2016, an address-based sample of 1,764 15-20-year-olds in 24 U.S. communities participated in an online survey. Parties were categorized as alcohol-only (Alc-only), marijuana + alcohol (Mj + Alc), and illicit + marijuana + alcohol (ID + Mj + Alc) based on survey participants' observations and self-reported drug use at the last party attended. Multivariable logistic regression was used to identify correlates of substance use at parties. RESULTS: 1,089 participants (61.7%) reported ever attending a party where alcohol was consumed. Of those, 60.1% reported that the last party they attended had Alc-only, 24.9% had Mj + Alc, and 10.0% had ID + Mj + Alc. Older participants were more likely to attend a party with Mj + Alc or ID + Mj + Alc. Participants whose mother had a college degree (compared to less than a college degree) were less likely to attend a party with ID + Mj + Alc. Parties with Mj + Alc and ID + Mj + Alc were larger and the majority of attendees were under 21. Parties with ID + Mj + Alc were more likely to be majority female compared to mixed gender. Parties with Mj + Alc were more likely to occur at someone else's home and be in states where medical and recreational marijuana use was legal. CONCLUSION: One-third of parties attended by 15-20-year-olds had marijuana and/or illicit drug use in addition to alcohol consumption. The identified risk factors of parties with marijuana and illicit drug use can be used to develop targeted prevention strategies.

Disposal of prescription drugs by parents of middle and high school students.

To determine how parents dispose of unused prescription medications and correlates of disposal, we recruited 3,043 parents of adolescents to complete a survey. Multivariate and multinomial logistic regression was conducted to examine correlates of disposal of prescription medication. Only 17.8% of parents in a household prescribed a controlled medication in the past year disposed of unused medications. Of those, 36.7% used organized disposal (e.g., take-back event or drop box) and 63.3% disposed of medications at home. Organized disposal was associated with awareness of disposal opportunities. Increasing awareness of organized disposal opportunities is a promising mechanism to increase their use by parents.

Availability and Placement of Electronic Nicotine Delivery Systems at the Point-of-Sale.

Introduction: Electronic nicotine delivery systems (ENDS) are widely available and come in a variety of forms, including disposable cigalikes and refillable tank systems. However, little is known about their placement at the point-of-sale. We explored the placement of various ENDS types among tobacco retailers. Methods: Systematic assessments at the point-of-sale were completed by trained data collectors in 90 tobacco retailers, including grocery stores, convenience stores, and pharmacies in North Carolina, United States. Availability and placement of various ENDS types including cigalikes, e-hookahs, tank systems, and e-liquids was recorded. Results: Almost all retailers (97.8%) sold cigalikes; 41.4% sold devices labeled as e-hookahs; 54.4% sold tank systems; and 56.2% sold e-liquids. Fewer than half of stores placed ENDS exclusively behind the counter; significant differences in ENDS placement were found by store type. Grocery stores carried cigalikes, tank systems, and e-liquids and placed them exclusively behind the counter. Pharmacies only sold cigalikes; most placed them exclusively behind the counter (91.7%) with cessation aids and other tobacco products. Convenience stores carried all ENDS types and placed them with other tobacco products (55.1%) and candy (17.4%). Only about one-third of convenience stores placed ENDS exclusively behind the counter. Conclusions: This exploratory study shows ENDS availability and placement at the point-of-sale varies by retailer type. Pharmacies placed cigalikes with cessation aids behind the counter suggesting their ability to aid in smoking cessation. Most convenience stores placed ENDS in self-service locations, making them easily accessible to youth. Findings highlight the need for ENDS regulation at the point-of-sale. Implications: Our study highlights the need for regulatory efforts aimed at ENDS placement at the point-of-sale. While pharmacies and grocery stores offered fewer ENDS types and typically placed them in clerk-assisted locations, all ENDS types were found at convenience stores, some of which were placed in youth-friendly locations. Regulatory efforts to control ENDS placement and limit youth exposure should be examined, such as requiring products be placed in clerk-assisted locations and banning ENDS placement next to candy.

From dispensed to disposed: evaluating the effectiveness of disposal programs through a comparison with prescription drug monitoring program data.

BACKGROUND: Organized disposal of controlled medications, such as take-back events and permanent drug donation boxes, is a prevention strategy that has been widely used to reduce the availability of controlled medications for diversion or abuse. However, little is known as to whether this strategy actually reduces the overall availability of these medications for the purposes of diversion or abuse. OBJECTIVES: The objective of this study was to compare the number and types of controlled medications that were disposed through organized efforts to the number dispensed in local communities. METHODS: The quantity and type of controlled medication collected from three take-back events and permanent drug donation boxes over 4-week-long periods in five counties in south-central Kentucky was measured and compared to the number of controlled medications dispensed, as reported by Kentucky All Schedule Prescription Electronic Reporting system. RESULTS: In 2013, 21,121,658 controlled medications units were dispensed in the participating counties. Of those, 46.9% were opioid analgesics, 13.1% tranquilizers, and 37.3% "other." During the assessment periods, a total of 21,503 controlled medication units were collected. Of those, 39.9% were opioid analgesics, 2.7% tranquilizers, and 57.4% "other." Annually, controlled medications disposed were estimated to account for 0.3% of those dispensed. CONCLUSION: Controlled medications collected by take-back events and permanent drug donation boxes constituted a miniscule proportion of the numbers dispensed. Our findings suggest that organized drug disposal efforts may have a minimal impact on reducing the availability of unused controlled medications at a community level.

K2 and Spice use among a cohort of college students in southeast region of the USA.

BACKGROUND: K2 and Spice consist of an herbal blend of plant matter and chemical synthetic cannabinoids. These substances emerged in the early 2000s as a popular alternative to marijuana among youth and young adults. OBJECTIVES: This study sought to identify rates and correlates of K2 and Spice at college entry and first use during college. METHODS: In Fall 2010, 3146 students at 11 colleges in North Carolina and Virginia were recruited to participate in a longitudinal cohort survey. The cohort was invited to participate in a total of six surveys over their college career. Random-effects logistic regression models were used to identify factors associated with lifetime K2 and Spice use at college entry and first use during college, adjusting for clustering within schools and sample weights. RESULTS: Weighted lifetime prevalence of K2 and Spice use at college entry was 7.6%. An additional 6.6% of students reported first use during college. By the cohort's fourth year, 17.0% reported lifetime K2 and Spice use. While lifetime prevalence increased, past 6-month prevalence decreased substantially over time. K2 and Spice use at college entry was associated with sensation seeking; hookah, marijuana, and illicit drug use; and low religiosity. First use during college was associated with having a father with less than a four-year degree; alcohol and hookah use. CONCLUSION: Universities should ensure that prevention efforts address current substance use, including K2/Spice, and that treatment options are available for first year students who use substances.

The role of smokeless tobacco use in smoking persistence among male college students.

BACKGROUND: Significant changes in the tobacco industry have led to heightened concern about co-use of cigarettes and smokeless tobacco (SLT) products. OBJECTIVES: The aim of this study was to assess whether male cigarette smokers who also used SLT products, in the first semester of their first year of college, were more or less likely than male cigarette smokers who did not use SLT products to still be smoking by the first semester of their senior year. METHODS: Using a longitudinal, observational study, we followed a cohort of undergraduate students from 11 four-year universities in North Carolina and Virginia through their college career. Mixed-effects logistic regression analysis was conducted to estimate the likelihood of being a current smoker fall of senior year for male students who used both cigarettes and SLT at baseline, compared to those who only smoked cigarettes, after adjustment for potential confounders (n = 274). RESULTS: At baseline, 67.2% of participants were smoking cigarettes only (no SLT use) and 32.8% were dual users (cigarettes and SLT). A total of 62% were still smoking at senior year. Dual users were 30% more likely to be current smokers senior year compared to cigarette only users, although this difference was not statistically significant. Having at least one friend who smoked cigarettes and heavier cigarette smoking at baseline were significantly related to senior year smoking. CONCLUSIONS: Our findings do not support the argument that SLT use may help male college smokers discontinue their smoking habit. In fact, it may contribute to smoking persistence.

E-cigarette availability and promotion among retail outlets near college campuses in two southeastern states.

INTRODUCTION: E-cigarettes are relatively new products that simulate the smoking experience. This descriptive study assessed changes in e-cigarette availability and promotions among retailers in 11 college communities in North Carolina and Virginia during a 1-year period. METHODS: During the spring of 2012 and 2013, observers completed assessments in 320 tobacco-selling retailers, including grocery and convenience stores, pharmacies, and tobacco shops. Assessors collected e-cigarette availability, advertising, price, and promotions. RESULTS: E-cigarette availability increased among retailers from 24.7% in 2012 to 59.9% in 2013. They were available in the form of disposables and reusable kits and were most frequently available in tobacco shops, convenience stores, and pharmacies. The average price for disposables was $9.70 (SD = 1.07) in 2012 and $9.61 (SD = 2.10) in 2013; the average price for kits was $39.58 (SD = 15.79) in 2012 and $32.59 (SD = 18.65) in 2013. The presence of interior advertising increased from 12.7% to 50.6% (p < .0001), and the presence of exterior advertising increased from 7.6% to 22.8% (p = .0002). Convenience stores with gas (16.4%-70.4%; p < .0001) and without gas (6.0%-48.4%; p < .0001) had significant increases in the presence of interior advertising. Convenience stores with gas also had a significant increase in the presence of exterior advertising (8.2%-33.3%; p < .0001). Only 3% of retailers offered price promotions. CONCLUSIONS: Availability of e-cigarettes, including rechargeable kits and disposables, more than doubled during the study. The presence of interior and exterior advertising also significantly increased. Results underscore the need for further surveillance to understand how these environmental characteristics impact individual exposure and use of e-cigarettes.

Drug Deactivation Pouches for Primary Prevention of Opioid Overdose: Perceptions and Attitudes of Community Members.

IMPORTANCE: A substantial number of opioid analgesics dispensed into communities will go unused and be susceptible to diversion for misuse. Convenient, efficient, and environmentally safe mechanisms for disposal are needed to prevent the diversion of unused opioid analgesics. OBJECTIVE: This initiative piloted the feasibility of distributing drug deactivation pouches in a community setting and examined community members' acceptance, intention to use drug deactivation pouches, and their current disposal practices of unused opioid analgesics. Although many studies have examined the benefits of deactivation pouches in preventing drug overdose, few have explored community members' perspectives, the feasibility, and the acceptability of these pouches in disposing of unused medications. METHODS: In the fall of 2017, we piloted the distribution of drug deactivation pouches to assess the overall interest in the pouches at a 3-day community event and continued the second wave of this pilot in the community from the summer of 2018 to the spring of 2019.Our main outcomes and measures included the acceptance of the drug deactivation pouches and the intention to use the pouches. "Acceptance" was defined as study participants physically taking the kit and "Intention" was how participants intended to use the pouch. RESULTS: A total of 170 community members were approached at a community event about the drug deactivation pouches and 116 accepted at least 1 pouch (68.2% acceptance rate). In the second wave, 124 community members were approached by Community Health Workers; 100% accepted the pouch. Overall, the acceptance rate was 81.6%. People mentioned significant interest in using the pouches. Furthermore, surveys that assessed community members' intention to use the deactivation pouches showed that 48% intended to use the pouch. CONCLUSIONS AND RELEVANCE: The distribution of drug deactivation pouches is feasible in a community setting and although community members expressed interest in using drug deactivation pouches to dispose of unused opioid analgesics and other drugs, the majority still disposed of their unused medications through other avenues. This, underscore the need to raise community members' awareness about the importance, benefits, and viability of these pouches as a tool for the primary prevention of opioid overdose because of their ease of use, safety, environmental considerations, and cost-effectiveness.

Naloxone Availability and Cost After Transition to an Over-the-Counter Product.

Importance: The US Food and Drug Administration approved Narcan, a nasal spray formulation of naloxone, for sale as an over-the-counter (OTC) medication in March 2023. The purpose of OTC approval was to improve naloxone accessibility to reduce opioid overdoses; however, research has not yet evaluated whether naloxone's availability and cost changed since this policy was implemented. Objective: To evaluate whether the accessibility and cost of naloxone at North Carolina community pharmacies changed after OTC naloxone became available and whether cost and availability varied by pharmacy type and urbanicity. Design, Setting, and Participants: This longitudinal telephone-based secret shopper survey study included a stratified sample of 202 North Carolina community pharmacies, including health department, independent, and chain pharmacies. There were 2 separate data collection efforts from March to April 2023 (before OTC naloxone could be sold at pharmacies) and November 2023 to January 2024 (after OTC naloxone was sold at pharmacies). Exposure: OTC naloxone first became available for sale at community pharmacies in September 2023. Main Outcomes and Measures: The main outcomes were same-day availability of naloxone without a clinician-issued prescription and the quoted out-of-pocket cost for cash-paying patients. Results: Data were collected from 192 pharmacies. Same-day naloxone availability increased from 42.2% (81 of 192) before OTC naloxone availability to 57.8% (111 of 192) after (P < .001). The mean (SD) quoted out-of-pocket cost decreased from $90.93 ($42.6) pre-OTC availability to $62.67 ($41.0) post-OTC availability (P < .001). Independent pharmacies had higher mean (SD) costs than chain pharmacies in both the pre-OTC phase ($109.47 [$37.90] vs $86.40 [$35.70]; P < .001) and post-OTC phase ($77.59 [$38.90] vs $57.74 [$35.90]; P = .004). Out-of-pocket costs did not differ by urbanicity in the pre-OTC phase; however, mean (SD) costs were higher at suburban ($88.67 [$66.80]) and rural ($65.43 [$35.00]) pharmacies compared with urban pharmacies ($53.58 [$29.00]) in the post-OTC phase (P = .003). Conclusions and Relevance: The Food and Drug Administration's approval of OTC naloxone nasal spray contributed to an increase in pharmacy-based availability of naloxone and a reduction of its cost for cash-paying patients. Cost was higher at independent pharmacies compared with chain pharmacies and lower in urban pharmacies compared with suburban and rural pharmacies.