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Identifying barriers to dispensing naloxone: A survey of community pharmacists in North Carolina

Published:April 17, 2018DOI:https://doi.org/10.1016/j.japh.2018.04.025

      Abstract

      Objectives

      The primary objective of this study was to identify barriers to dispensing naloxone under the North Carolina statewide standing order in the community pharmacy setting. Secondary objectives included identifying areas for additional training.

      Methods

      This study was conducted as a cross-sectional survey distributed to community pharmacists in North Carolina through an Internet-based questionnaire platform. The questions assessed pharmacists' training regarding naloxone, willingness to dispense naloxone, knowledge of naloxone and opioid overdose, perceived barriers to implementing a naloxone distribution program, and demographic information. Descriptive statistics and Pearson correlation coefficient were used in data analysis.

      Results

      Only 30% of survey respondents scored greater than 90% on the knowledge assessment portion of the survey. Furthermore, more than 50% of respondents indicated that they were not very comfortable dispensing naloxone, based on their responses to a series of Likert-type scale statements. A statistically significant positive correlation (r = 0.288; P < 0.001) was found between pharmacists' knowledge of naloxone and opioid overdose and willingness to dispense naloxone. The majority of respondents indicated that lack of training was a major barrier to dispensing naloxone. Additional training needs included information regarding naloxone, strategies to initiate patient discussion, identifying eligible patients, and workflow implementation. More than 95% of respondents indicated that the pharmacy in which they are employed would benefit from additional naloxone training.

      Conclusion

      Community pharmacists in North Carolina would like to receive additional training regarding naloxone and opioid overdose. Given the statistically significant positive correlation between knowledge concerning naloxone and opioid overdose and willingness to dispense naloxone, it is possible that increased pharmacist training could lead to increased willingness to dispense naloxone under the statewide standing order. These results can be used in a meaningful way to determine the best ways to better educate pharmacists on naloxone and improve patient access to this life-saving medication.
      According to the U.S. Department of Health and Human Services, the percentage of adults prescribed opioids quadrupled from 1999 to 2010.
      • Frenk S.M.
      • Porter K.S.
      • Paulozzi L.J.
      Prescription opioid analgesic use among adults: United States, 1999–2012. NCHS data brief, no. 189. Hyattsville, MD: National Center for Health Statistics.
      During that time frame, overall drug overdoses reflected this upward trend.
      • Rudd R.A.
      • Seth P.
      • David F.
      • Scholl L.
      Increases in drug and opioid-involved overdose deaths—United States, 2010–2015.
      As recently as 2016, opioid overdoses have continued to increase and surpassed 42,000 deaths, more than any year before.
      • Centers for Disease Control and Prevention
      Opioid overdose.
      Although younger populations tend to be more likely to use prescription pain relievers for nonmedical uses, the use of opioids prescribed for chronic pain is most common in adults 40 years of age and older and is as high as 7.9% in patients 60 years of age or older.
      • Center for Behavioral Health Statistics and Quality
      Behavioral health trends in the United States: results from the 2014 National Survey on Drug Use and Health. HHS publication no. SMA 15-4927, NSDUH series H-50.
      Across all of these populations, it has become increasingly apparent that even when used for legitimate medical purposes, opioid administration does not come without safety concerns.
      • Center for Behavioral Health Statistics and Quality
      Behavioral health trends in the United States: results from the 2014 National Survey on Drug Use and Health. HHS publication no. SMA 15-4927, NSDUH series H-50.
      • Bohnert A.S.
      • Valenstein M.
      • Bair M.J.
      • et al.
      Association between opioid prescribing patterns and opioid overdose-related deaths.
      Furthermore, the use of opioids combined with benzodiazepines or certain chronic conditions increases the risk of respiratory depression and death.
      National and state organizations have issued policies and regulations to combat the opioid epidemic. Certain policies have been effective in reducing the prescribing of opioids, such as mandatory Prescription Drug Monitoring Programs (PDMP) and the 2016 Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain.
      • Dowell D.
      • Zhang K.
      • Noonan R.K.
      • Hockenberry J.M.
      Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.
      • National Alliance of State Pharmacy Associations
      Naloxone access in community pharmacies.
      Although prescribing rates have declined, opioid use rates (both prescription and illicit) remain high, resulting in increased health care costs and the cost of human lives.
      Pharmacists are well positioned to help resolve the opioid epidemic. As of January 2017, 46 states have issued legislation to allow pharmacists to dispense naloxone, a life-saving opioid reversal agent, directly to patients without a physician-issued prescription.
      • National Alliance of State Pharmacy Associations
      Naloxone access in community pharmacies.
      • Davis C.
      • Carr D.
      State legal innovations to encourage naloxone dispensing.
      Per North Carolina's standing order, any licensed pharmacist may dispense naloxone to a patient at risk of opioid overdose, or their family member, friend, caregiver, or other individual able to assist in an opiate-related overdose.
      • National Alliance of State Pharmacy Associations
      Naloxone access in community pharmacies.
      North Carolina State Health Director's Standing Order for Naloxone.
      Therefore, almost every pharmacist in North Carolina (NC) has increased authority to improve patient safety amid the opioid crisis. This is particularly important in NC because it ranks in the top 5 states in the nation regarding increased rate of opioid-related deaths and hospital admissions.
      • Rudd R.A.
      • Seth P.
      • David F.
      • Scholl L.
      Increases in drug and opioid-involved overdose deaths—United States, 2010–2015.
      • Weiss A.J.
      • Elixhauser A.
      • Barrett M.L.
      • Steiner C.A.
      • Bailey M.K.
      • O'Malley L.
      Opioid-related inpatient stays and emergency department visits by state, 2009–2014. Healthcare Cost and Utilization Project. Statistical brief no. 219.
      Despite increased access to naloxone, many individuals who may benefit from naloxone may not initiate discussions with their health care providers because they are unaware of the risks of opioids, underestimate their risk of overdose, are unfamiliar with naloxone, and are concerned about stigma or consequences of accepting naloxone, or for other potential reasons.
      • Mueller S.R.
      • Koester S.
      • Glanz J.M.
      • Gardner E.M.
      • Binswanger I.A.
      Attitudes toward naloxone prescribing in clinical settings: a qualitative study of patients prescribed high dose opioids for chronic non-cancer pain.
      Therefore, the successful implementation of a naloxone standing order relies largely on pharmacists' ability to identify patients that would benefit and provide education regarding naloxone.
      • Bailey A.M.
      • Wermeling D.P.
      Naloxone for opioid overdose prevention: pharmacists’ role in community-based practice settings.
      Previous studies have shown that not all pharmacists are comfortable dispensing naloxone without a prescription (via standing order, protocol, or over the counter).
      • Thornton J.D.
      • Lyvers E.
      • Scott V.G.G.
      • Dwibedi N.
      Pharmacists' readiness to provide naloxone in community pharmacies in West Virginia.
      • Freeman P.R.
      • Goodin A.
      • Troske S.
      • Strahl A.
      • Fallin A.
      • Green T.C.
      Pharmacists' role in opioid overdose: Kentucky pharmacists' willingness to participate in naloxone dispensing.
      Therefore, the present study sought to identify the barriers that exist to dispensing naloxone. This project is significant because opioid overdose is a major public health concern. Once the barriers to dispensing naloxone are better understood, efforts can be made to resolve these barriers and increase the number of at-risk patients that receive naloxone and opioid overdose education, and thereby potentially reduce the number of fatal overdoses.

      Objectives

      The primary objective of this study was to identify the barriers to dispensing naloxone in the community pharmacy setting. A secondary objective included identification of additional training needs for pharmacies.

      Methods

      This study was conducted as a cross-sectional survey through an Internet-based questionnaire platform, Qualtrics.
      The survey consisted of 40 closed-ended questions that assessed pharmacists' training regarding naloxone, willingness to dispense naloxone, knowledge of naloxone and opioid overdose, perceived barriers to implementing a naloxone distribution program, preferred method of receiving educational training, and demographic information. See Appendix 1 for the survey questionnaire. A pilot survey using a convenience sample of pharmacists and student pharmacists was conducted to obtain feedback regarding question interpretation, structure, and validity. Furthermore, the convenience sample reported that the survey took approximately 15 minutes to complete. The “back button” option was removed from the survey to ensure that questions later in the survey did not influence the participants’ answers to questions that appeared earlier.
      A “knowledge score” was determined based on 25 objective questions (22 true-false, 3 multiple choice) adapted from the Opioid Overdose and Knowledge Score assessment.
      • Williams A.V.
      • Strang J.
      • Marsden J.
      Development of Opioid Overdose Knowledge (OOKS) and Attitudes (OOAS) Scales for take-home naloxone training evaluation.
      Questions focused on the indication, proper administration, and duration of action of naloxone, action steps to take in a suspected overdose emergency, and other counseling points. Each question was weighted equally, and the final scores were reported as a percentage of questions answered correctly.
      The “level of comfort” was determined based on the answers to questions 4–14 on a Likert-type scale that assessed pharmacists' willingness to dispense naloxone in various scenarios and their perspective on naloxone's role in therapy. The statements were developed by the researchers with input from pharmacists, student pharmacists, and a quantitative survey analysis expert. Pharmacists could select from a range of 5 answers, which were each assigned a point value from 1–5, with 1 being “strongly disagree” and 5 being “strongly agree.” All 11 statements exhibited the same direction meaning that responses of “strongly agree” always meant that the pharmacist was very comfortable dispensing naloxone in that situation, and “strongly disagree” meant they were very uncomfortable dispensing naloxone. The answers to the 11 statements were then averaged to give an aggregate level of comfort score. Scores were categorized as very uncomfortable (1.00 to 1.99 average points), somewhat uncomfortable (2.00 to 2.99), somewhat comfortable (3.00 to 3.99), and very comfortable (4.00 to 5.00).
      Pharmacists were also asked to report barriers to dispensing naloxone, and multiple answers were permitted. Multiple choice selections were available, but pharmacists could also free-text their own answers. They were also asked to state whether they thought their practice site would benefit from additional training and what focus areas of training would be needed to implement an effective naloxone distribution program.
      Using the NC Board of Pharmacy's database, an e-mail with a link to the survey was distributed to all actively licensed community pharmacists with a functional e-mail address on file. This e-mail included a brief introduction to the survey. The Qualtrics survey was open for a total of 30 days with a reminder e-mail sent at day 15. Participation in the survey was completely voluntary and confidential. To improve survey response, participants had the option to enroll in a drawing to win 1 of 3 $100 gift cards. Winners were chosen at random with the use of a random number generator that was keyed to a numbered list of participants.
      Descriptive statistics were primarily used in this study when analyzing survey responses. A Pearson correlation coefficient was also calculated to compare respondents' knowledge and willingness to dispense naloxone. Before the survey was distributed, the study received exemption status from the Institutional Review Board at the University of North Carolina at Chapel Hill.

      Results

      The survey was successfully delivered to 5,695 community-based pharmacists in North Carolina. There was a response rate of 7.4% (n = 423). Demographic information of survey respondents is listed in Table 1.
      Table 1Demographics of pharmacists participating in survey (n = 423)
      Populationn (%)
      Gender
       Male166 (39.2)
       Female257 (60.8)
      Pharmacy setting
       National chain194 (45.9)
       Single independent91 (21.5)
       Multiple independent67 (15.8)
       Grocery store chain54 (12.8)
       Other17 (4.0)
      Number of opioid prescriptions dispensed daily
       0–25227 (53.7)
       26–50142 (33.6)
       51–10037 (8.7)
       >10017 (4.0)
      Pharmacy degree (multiple answers permitted)
       BS Pharm178 (42.1)
       MS Pharm4 (0.9)
       PharmD250 (59.1)
      Pharmacists' responses to the knowledge assessment portion of the survey were reported as percentages. The results were as follows: 60% or less correct: 3.3% [n = 14]; 61% to 70% correct: 3.1% [n = 13]; 71% to 80% correct: 26.5% [n = 112]; 81% to 90% correct: 37.1% [n = 157]; and 91% to 100% correct: 30.0% [n = 127].
      Only 49.2% (n = 208) of respondents were very comfortable dispensing naloxone in these scenarios. Another 33.8% (n = 143) were found to be somewhat comfortable, whereas 12.3% (n = 52) were somewhat uncomfortable and 4.7% (n = 20) very uncomfortable dispensing naloxone.
      There was a statistically significant positive correlation (r = 0.268; P < 0.001) between pharmacists’ knowledge score and level of comfort regarding naloxone dispensing. The researchers did not find any significant correlations between level of comfort for dispensing naloxone with type of pharmacy practice setting nor number of opioids dispensed daily. However, a statistically significant correlation was found between gender and level of comfort dispensing naloxone. Men were slightly more comfortable than women dispensing naloxone (men, 3.9359; women, 3.6990; P = 0.011).
      The most commonly reported barriers included inadequate training (53.7%; n = 227), workflow concerns (35.5%; n = 150), and lack of support from management (35.2%; n = 149). Other barriers reported were cost and reimbursement concerns (16.5%; n = 70) and ethical and moral concerns (15.4%; n = 65). Multiple answers were permitted. Ninety-five percent of pharmacists surveyed indicated that additional training regarding naloxone would be helpful at their practice site. Pharmacists also identified 1 or more areas where they believed additional training would be necessary to implement an effective naloxone dispensing program. The most common response was a need for more knowledge regarding naloxone and opioid overdose (67.4%; n = 285). Other areas of training interest included strategies for initiating patient discussion (65.1%; n = 275), identifying eligible candidates (49.9%; n = 211), implementing a program into workflow (46.1%; n = 195), and triaging patients to other resources when appropriate (41.6%; n = 176).

      Discussion

      As statewide protocols and standing orders for dispensing naloxone have become more common, there is an increased need to understand pharmacists' participation in such efforts. Some studies have surveyed pharmacists already actively participating in naloxone distribution efforts, but little is known about how to further engage other pharmacists not yet participating.
      • Green T.C.
      • Case P.
      • Fiske H.
      • et al.
      Perpetuating stigma or reducing risk? Perspectives from naloxone consumers and pharmacists on pharmacy-based naloxone in 2 states.
      Pharmacists participating in this study identified multiple barriers to dispensing naloxone under a standing order. The most common barriers were reported to be inadequate training, workflow concerns, and lack of support from management. Areas of additional training that were most commonly requested were more education regarding naloxone and opioid overdose, strategies for initiating patient discussion, and criteria for determining eligible candidates.
      Related studies support the findings of this study, such as knowledge deficits presenting as a major barrier to dispensing naloxone to patients.
      • Thornton J.D.
      • Lyvers E.
      • Scott V.G.G.
      • Dwibedi N.
      Pharmacists' readiness to provide naloxone in community pharmacies in West Virginia.
      • Freeman P.R.
      • Goodin A.
      • Troske S.
      • Strahl A.
      • Fallin A.
      • Green T.C.
      Pharmacists' role in opioid overdose: Kentucky pharmacists' willingness to participate in naloxone dispensing.
      However, some of those previous studies reported pharmacists' self-attested confidence in recognizing risk factors for opioid overdose, and the present study addresses subjective knowledge regarding opioid overdose. Furthermore, this study found a correlation between knowledge and willingness to dispense naloxone. In addition to knowledge-based educational offerings, the results of this study suggest that skill-based teaching methods may also be useful. For example, pharmacists may benefit from resources to address concerns with workflow and discussing opioid risk and naloxone with patients. Although more knowledge may help to improve naloxone dispensing, pharmacy stakeholders may also consider developing toolkits and strategies that provide practical skill-based solutions.
      The results of this study can be used by NC, as well as other states implementing naloxone standing orders, to guide the development of educational programming and resources. As standing orders, statewide protocols, and various levels of prescriptive authority for pharmacists become more common across the country, it is imperative that pharmacists are well trained and have the resources needed to be successful with an expanded scope of practice.
      Potential limitations of this study include a limited response rate and response bias for those who did participate. Despite a midpoint reminder e-mail and incentive to participate, the response rate was 7.4% (n = 473). The low response rate may indicate a lack of generalizability to the entire population of community pharmacists in NC.

      Conclusion

      Community pharmacists surveyed in NC would like to receive additional naloxone training, especially pertaining to knowledge of naloxone and opioid overdose, strategies for discussing naloxone with patients, and identifying patients that may benefit from naloxone. Given the positive correlation between knowledge of naloxone and comfort level dispensing naloxone, it is likely possible that increased training would lead to greater willingness to dispense naloxone under a standing order. The results of this study can be used by stakeholders, such as pharmacy associations, pharmacy management, and academic institutions, to better educate pharmacists and student pharmacists on naloxone, opioid overdose, and the role of pharmacy in reducing fatal opioid overdose.

      Acknowledgments

      The authors acknowledge Teresa Edwards, Assistant Director for Survey Research and Development, H.W. Odum Institute for Research in Social Science, University of North Carolina, Chapel Hill, for assistance with survey development and statistical analysis, and the North Carolina Board of Pharmacy for survey distribution.

      Appendix 1. Survey

      Questions 1–3 will assess your training regarding naloxone
      • 1.
        To the best of your knowledge, are pharmacists in North Carolina legally allowed to dispense naloxone under a standing order?
        • □ YES
        • □ NO
      (Next screen)
      As of June 26, 2016, pharmacists in North Carolina are able to dispense naloxone under the North Carolina State Health Director’s Standing Order for Naloxone. This allows pharmacists to dispense naloxone to eligible candidates without a patient-specific prescription issued by a prescriber.
      • 2.
        To the best of your knowledge, does your pharmacy dispense naloxone under the North Carolina Standing Order?
        • □ YES
        • □ NO
      • 3.
        What type of training have you received regarding naloxone administration and/or education? (please select the one best answer)
        • □ Live lecture
        • □ Prerecorded lecture/presentation
        • □ Online-learning module
        • □ Staff discussion
        • □ Other ___________
        • □ None
      (Question 3b appears if the participant indicated that he/she has received naloxone training based on his/her response to question 3)
      • 3b.
        How long ago did you most recently receive naloxone training?
        • □ Less than 6 months ago
        • □ 6 months to 1 year ago
        • □ 1–2 years ago
        • □ 2–5 years ago
        • □ More than 5 years ago
      Questions 4–14: Please indicate how strongly you disagree or agree with each of the following statements regarding naloxone dispensing.
      1 = strongly disagree2 = somewhat disagree3 = neutral4 = somewhat agree5 = strongly agree
      • 4.
        I am comfortable dispensing naloxone without a prescriber-issued prescription
      • 5.
        I am confident in my ability to identify patients who may benefit from naloxone
      • 6.
        I am comfortable dispensing naloxone to a patient who is prescribed high-dose opioids
      • 7.
        I am comfortable dispensing naloxone to a known opioid abuser
      • 8.
        I am comfortable dispensing naloxone to a family member, friend, or caregiver of a patient who may benefit from naloxone
      • 9.
        I am able to properly counsel a patient or caregiver on naloxone administration
      • 10.
        I am able to properly counsel a patient or caregiver on symptoms of an opioid overdose
      • 11.
        I am able to properly counsel a patient or caregiver on steps to take during an opioid overdose emergency
      • 12.
        Naloxone is an important part of preventing fatal opioid overdose
      • 13.
        Pharmacists should have a role in preventing fatal opioid overdose
      • 14.
        Pharmacists should offer to dispense naloxone to patients that may benefit from naloxone
      Questions 15–24:
      Due to recent changes in North Carolina policy regarding naloxone, pharmacists’ knowledge regarding naloxone varies. We are interested in gauging pharmacists’ current level of knowledge regarding naloxone. Please answer the following questions honestly without the utilization of outside resources. Answers will be provided at the end of the survey for your information.
      • 15.
        Which of the following are indicators of an opioid overdose? (select all that apply)
        • □ Having bloodshot eyes
        • □ Slow/shallow breathing
        • □ Lips, hands, or feet turning blue
        • □ Loss of consciousness
        • □ Unresponsive
        • □ Deep snoring
        • □ Very small pupils
        • □ Agitated behavior
        • □ Rapid heartbeat
      • 16.
        Which of the following should be done when managing an opioid overdose? (select all that apply)
        • □ Call an ambulance
        • □ Stay with the person until an ambulance arrives
        • □ Inject the person with salt solution or milk
        • □ Mouth to mouth resuscitation
        • □ Give stimulants (e.g., cocaine or black coffee)
        • □ Place the person in the recovery position (on their side with mouth clear)
        • □ Check for breathing
        • □ Check for blocked airways (nose and mouth)
        • □ Put the person in bed to sleep it off
      • 17.
        What are the indication(s) of naloxone?
        • □ To reverse the effects of an opioid overdose
        • □ To reverse the effects of an amphetamine overdose
        • □ To reverse the effects of a cocaine overdose
        • □ To reverse the effects of any overdose
        • □ Don't know
      • 18.
        What is the onset of action of naloxone?
        • □ 2–5 minutes
        • □ 5–10 minutes
        • □ 10–20 minutes
        • □ 20–40 minutes
        • □ Don’t know
      • 19.
        What is the duration of action of naloxone?
        • □ Less than 20 minutes
        • □ About 1 hour
        • □ 1–6 hours
        • □ 6–12 hours
        • □ Don’t know
      Please mark “true”, “false”, or “don’t know”TrueFalseDon't Know
      • 20.
        If the first dose of naloxone has no effect, a second dose can be given
      • 21.
        Caregivers do not need to call for an ambulance if they know how to manage an overdose
      • 22.
        Someone can overdose again even after having received naloxone
      • 23.
        The effect of naloxone is shorter than the effect of heroin and methadone
      • 24.
        Naloxone can provoke opioid withdrawal symptoms
      Questions 25–32. Please indicate how strongly you disagree or agree with the following statements regarding potential barriers to dispensing naloxone
      1 = strongly disagree2 = somewhat disagree3 = neutral4 = somewhat agree5 = strongly agree
      • 25.
        My pharmacy's workflow is streamlined enough to incorporate a naloxone dispensing program
      • 26.
        My pharmacy has provided its staff enough training to successfully implement a naloxone dispensing program
      • 27.
        There is adequate support from pharmacy owners/management to successfully implement a naloxone dispensing program
      • 28.
        Dispensing naloxone will increase the number of opioid abusers who visit my pharmacy
      • 29.
        The cost of stocking naloxone products is a concern in my pharmacy
      • 30.
        The reimbursement associated with dispensing naloxone products is a concern in my pharmacy
      • 31.
        I have ethical or moral concerns with dispensing naloxone
      • 32.
        Please list any barriers you see to dispensing naloxone at your pharmacy site: ____________
      Questions 33–34 will assess your opinion regarding additional training
      • 33.
        Would you be interested in receiving additional naloxone training?
        • □ Yes
        • □ No
      (Question 33b appears if the participant indicated that he/she would be interested in receiving additional training)
      • 33b.
        My most preferred medium for additional training is:
        • □ Live CE course
        • □ Live webinar
        • □ Prerecorded presentation/lecture
        • □ Pharmacy blogs
        • □ Pharmacy newsletters
        • □ Other: __________________
      (Question 34 is asked differently based on the participant's answer to question 2)
      • 34.
        (If the participant answered YES to question 2, his/her pharmacy already dispenses naloxone under the standing order:)
      • In your opinion, what training needs, if any, does your pharmacy need to resolve in order to improve your current naloxone dispensing program? (select all that apply)
        • □ Identifying patients that would benefit from naloxone
        • □ Strategies to initiate a discussion about naloxone with appropriate patients
        • □ Understanding naloxone administration, duration, and effects
        • □ Inventory concerns
        • □ Incorporating the program into workflow
        • □ Triaging patients for other services they may require (mental health services, pain management, etc.)
        • □ Other _________________________
        • □ None, our pharmacy already implements a naloxone program that is efficient and effective
        • (If the participant answered NO to question 2, his/her pharmacy does not dispense naloxone under the standing order:)
        • In your opinion, what training needs does your pharmacy need to resolve in order to successfully implement a naloxone dispensing program? (select all that apply)
        • □ Identifying patients that would benefit from naloxone
        • □ Strategies to initiate a discussion about naloxone with appropriate patients
        • □ Understanding naloxone administration, duration, and effects
        • □ Inventory concerns
        • □ Incorporating the program into workflow
        • □ Triaging patients for other services they may require (mental health services, pain management, etc)
        • □ Other _________________________
      Questions 35–40 will gather some basic demographic information
      • 35.
        In what year did you graduate pharmacy school? ___________________
      • 36.
        Which pharmacy degree(s) do you hold? (select all that apply)
        • □ BS in Pharmacy
        • □ MS in Pharmacy
        • □ PharmD
      • 37.
        Please select your gender.
        • □ Male
        • □ Female
      • 38.
        What type of setting best describes your pharmacy?
        • □ Single independent
        • □ Multiple independents under the same ownership
        • □ Grocery store chain
        • □ National chain
        • □ Other _____________
      • 39.
        Is the pharmacy in which you are employed a Community Pharmacy Enhanced Services Network (CPESN) participant?
        • □ Yes
        • □ NO
      • 40.
        Approximately how many opioid prescriptions does your pharmacy fill daily?
        • □ 0–25 opioid prescriptions daily
        • □ 26–50 opioid prescriptions daily
        • □ 50–100 opioid prescriptions daily
        • □ >100 opioid prescriptions daily

      References

        • Frenk S.M.
        • Porter K.S.
        • Paulozzi L.J.
        Prescription opioid analgesic use among adults: United States, 1999–2012. NCHS data brief, no. 189. Hyattsville, MD: National Center for Health Statistics.
        (Available at:)
        http://www.cdc.gov/nchs/data/databriefs/db189.htm
        Date accessed: September 13, 2017
        • Rudd R.A.
        • Seth P.
        • David F.
        • Scholl L.
        Increases in drug and opioid-involved overdose deaths—United States, 2010–2015.
        MMWR Morb Mortal Wkly Rep. 2016; 65: 1445-1452
        • Centers for Disease Control and Prevention
        Opioid overdose.
        (Available at:)
        https://www.cdc.gov/drugoverdose/index.html
        Date accessed: January 22, 2017
        • Center for Behavioral Health Statistics and Quality
        Behavioral health trends in the United States: results from the 2014 National Survey on Drug Use and Health. HHS publication no. SMA 15-4927, NSDUH series H-50.
        SAMHSA, Rockville, MD2015 (Available at:)
        • Bohnert A.S.
        • Valenstein M.
        • Bair M.J.
        • et al.
        Association between opioid prescribing patterns and opioid overdose-related deaths.
        JAMA. 2011; 305: 1315-1321
        • Dowell D.
        • Zhang K.
        • Noonan R.K.
        • Hockenberry J.M.
        Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.
        Health Aff. 2016; 35: 1876-1883
        • National Alliance of State Pharmacy Associations
        Naloxone access in community pharmacies.
        (Available at:)
        • Davis C.
        • Carr D.
        State legal innovations to encourage naloxone dispensing.
        J Am Pharm Assoc. 2016; 57: S180-S184
      1. North Carolina State Health Director's Standing Order for Naloxone.
        (Available at:)
        • Weiss A.J.
        • Elixhauser A.
        • Barrett M.L.
        • Steiner C.A.
        • Bailey M.K.
        • O'Malley L.
        Opioid-related inpatient stays and emergency department visits by state, 2009–2014. Healthcare Cost and Utilization Project. Statistical brief no. 219.
        (Available at:)
        • Mueller S.R.
        • Koester S.
        • Glanz J.M.
        • Gardner E.M.
        • Binswanger I.A.
        Attitudes toward naloxone prescribing in clinical settings: a qualitative study of patients prescribed high dose opioids for chronic non-cancer pain.
        J Gen Intern Med. 2017; 32: 277-283
        • Bailey A.M.
        • Wermeling D.P.
        Naloxone for opioid overdose prevention: pharmacists’ role in community-based practice settings.
        Ann Pharmacother. 2014; 48: 601-606
        • Green T.C.
        • Case P.
        • Fiske H.
        • et al.
        Perpetuating stigma or reducing risk? Perspectives from naloxone consumers and pharmacists on pharmacy-based naloxone in 2 states.
        J Am Pharm Assoc. 2017; 57: S19-S27.e4
        • Thornton J.D.
        • Lyvers E.
        • Scott V.G.G.
        • Dwibedi N.
        Pharmacists' readiness to provide naloxone in community pharmacies in West Virginia.
        J Am Pharm Assoc. 2017; 57: S12-S18.e4
        • Freeman P.R.
        • Goodin A.
        • Troske S.
        • Strahl A.
        • Fallin A.
        • Green T.C.
        Pharmacists' role in opioid overdose: Kentucky pharmacists' willingness to participate in naloxone dispensing.
        J Am Pharm Assoc. 2017; 57: S28-S33
        • Williams A.V.
        • Strang J.
        • Marsden J.
        Development of Opioid Overdose Knowledge (OOKS) and Attitudes (OOAS) Scales for take-home naloxone training evaluation.
        Drug Alcohol Depend. 2013; 132: 383-386

      Biography

      Shannon E. Rudolph, PharmD, Executive Fellow, Iowa Pharmacy Association, Des Moines, IA; at time of study: PGY1 Community-based Pharmacy Resident, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, and Moose Pharmacy, Concord, NC
      Ashley R. Branham, PharmD, BCACP, Director of Clinical Services, Moose Pharmacy, Concord, NC, and Director of Network Development and Marketing, CPESN USA, Raleigh, NC
      Laura A. Rhodes, PharmD, BCACP, Community Practice Engagement Fellow, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
      Harskin “HJ” Hayes Jr, PharmD, Assistant Professor, Department of Pharmacy Practice, South University School of Pharmacy, Columbia, SC; at time of study: Clinical Pharmacist, Moose Pharmacy, Concord, NC
      Joseph S. Moose, PharmD, Pharmacy Owner, Moose Pharmacy, Concord, NC, and Director of Strategy and Luminary Development, CPESN USA, Raleigh, NC
      Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA, Assistant Dean of Experiential Programs—Community, Clinical Associate Professor, and Director, PGY1 Community-based Pharmacy Residency Program, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC