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Pharmacist roles, training, and perceived barriers in naloxone dispensing: A systematic review

      Abstract

      Objectives

      Pharmacists are well positioned to identify patients at risk of overdose, dispense naloxone, and counsel patients on appropriate use. In response to growing numbers of opioid-related deaths, many states have issued standing orders allowing pharmacists to dispense naloxone without a prescription. This systematic review examines the current state of naloxone use and dispensing regarding (1) roles for pharmacists dispensing naloxone, (2) barriers to their dispensing naloxone, and (3) pharmacist training to dispense naloxone.

      Data sources

      PubMed, Cinahl Plus, and Cochrane review databases were searched with the use of the terms "pharmacist OR pharmacy" AND "naloxone." Included for review were peer-reviewed original research studies conducted in the U.S. in the past 5 years.

      Study selection

      The preliminary search generated 155 studies, including 50 duplicate studies which were removed. From the remaining 105 studies, 33 were included that addressed pharmacist naloxone dispensing roles, barriers and facilitators to dispensing, or training for pharmacists.

      Data extraction

      Authors, publication year, study title, study objective, method, outcomes, and conclusions were extracted for all studies.

      Results

      Out of 33 studies, 14 focused on pharmacists’ roles in naloxone dispensing, 9 on barriers, and 10 on training pharmacists for dispensing naloxone. The review found that most states permit major naloxone dispensing roles for pharmacists, but pharmacists are often underutilized without programs to support their roles. A key barrier to pharmacist naloxone dispensing is limited pharmacist training to identify and educate patients at risk of overdose.

      Conclusion

      Although pharmacists have the legal opportunity to educate patients and dispense naloxone, barriers have limited their addressing naloxone with patients. There is a need for more intervention studies and in-depth understanding of pharmacist perspectives on barriers, training, and professional roles to facilitate tailored approaches for increasing pharmacist confidence in naloxone dispensing and consultation.

       Background

      • Pharmacists are well positioned to identify patients at risk of overdose, dispense naloxone, and counsel patients on appropriate use.
      • In response to growing numbers of opioid-related deaths, many states have issued standing orders allowing pharmacists to dispense naloxone without a prescription.
      • There is a need for a clear understanding of barriers and facilitators to naloxone dispensing by pharmacists, as well as strategies to help pharmacists contribute more effectively to naloxone use.

       Findings

      • Of the 33 studies included in this systematic review, 14 focused on pharmacists’ roles in naloxone dispensing, 9 focused on barriers to naloxone dispensing, and 10 focused on education and training for pharmacists and pharmacy students.
      • Pharmacists are recognized nationally and by individual states as important to address opioid overdose, and policies have been adopted to facilitate dispensing naloxone without prescription.
      • Pharmacists and pharmacy students report lack of confidence as a major barrier to dispensing naloxone and communicating with patients.
      • Additional training and education programs specific to naloxone and safe opioid use should be targeted toward both pharmacists and pharmacy students.
      Deaths related to opioid use, including prescription opioids, heroin, and synthetic opioids such as fentanyl, have dramatically increased in recent years. On average, 116 Americans die each day from opioid overdose.
      Department of Health and Human Services
      Help, resources and information: national opioids crisis.
      During 2017, more than 47,000 people died from respiratory depression attributed to opioids, and more than 15,000 people died from respiratory depression attributed to heroin use. These numbers equate to 5 deaths for every 100,000 individuals.
      Centers for Disease Control and Prevention
      Opioid overdose.
      Heroin-related deaths have increased 5-fold from 2010 to 2017. More potent synthetic opioids, such as fentanyl, have contributed to more deaths than other types of opioids.
      Centers for Disease Control and Prevention
      Opioid overdose.
      Prescription opioids also contribute significantly to respiratory depression and overdose, with more than 46 deaths attributed to prescriptions opioids every day.
      • Seth P.
      • Scholl L.
      • Rudd R.A.
      • Bacon S.
      Increases and geographic variations in overdose deaths involving opioids, cocaine, and psychostimulants with abuse potential—United States, 2015–2016.
      A large number of individuals, about 1,000 each day, seek treatment within emergency departments for emergencies related to prescription opioid misuse.
      Centers for Disease Control and Prevention
      Opioid overdose: understanding the epidemic.
      It is evident that deaths attributed to opioid use continue to increase and warrant mechanisms to promote safe patient use.
      One strategy to reduce deaths related to opioid use is with the reversal medication, naloxone. Naloxone is an opioid antagonist that binds to opioid receptors to block the effects of opioids and rapidly reverse respiratory depression.
      National Institute of Drug Abuse
      Naloxone for opioid overdose: life-saving science.
      Naloxone was approved by the Food and Drug Administration in 1971 to treat opioid overdose and has since been used in hospitals and emergency departments and by emergency medical responders.
      National Institute of Drug Abuse
      Naloxone for opioid overdose: life-saving science.
      • Yardley W.
      Jack Fishman dies at 83; saved many from overdose.
      U.S. Food and Drug Administration
      Statement from FDA Commissioner Scott Gottlieb, MD, on unprecedented new efforts to support development of over-the-counter naloxone to help reduce opioid overdose deaths [press release]. Silver Spring, MD: FDA; 2019.
      Naloxone can be administered by means of intramuscular or subcutaneous injection or intranasally to a patient experiencing respiratory depression.
      • Wickramatilake S.
      • Zur J.
      • Mulvaney-Day N.
      • Klimo M.C.
      • Selmi E.
      • Harwood H.
      How states are tackling the opioid crisis.
      An increase in state and national legislative and regulatory initiatives is due in part to the greater recognition and acceptance of naloxone use by health professionals, including pharmacists, people who use drugs (PWUD), and the general public. About half of the states in the U.S. have increased funding for expanded patient access to naloxone, pharmacologic treatment options for PWUD, and guidelines for safe opioid prescribing.
      • Wickramatilake S.
      • Zur J.
      • Mulvaney-Day N.
      • Klimo M.C.
      • Selmi E.
      • Harwood H.
      How states are tackling the opioid crisis.
      Specific legislative initiatives that support safe opioid prescribing and naloxone use include the 2016 21st Century Cures Act, which awarded funding to improve state prescription drug monitoring programs (PDMP).
      114th Congress
      H.R.34—21st Century Cures Act.
      The PDMP can serve as a resource for pharmacists to identify patients that might benefit from naloxone. In addition, the 2018 SUPPORT for Patients and Communities Act requires checking the PDMP before controlled substance prescription to Medicare beneficiaries, which may prompt further conversations with patients regarding opioid safety and naloxone use.
      115th Congress
      H.R.6—SUPPORT for Patients and Communities Act Congress.gov.
      The Substance Abuse and Mental Health Services Administration initiated the State Opioid Response Grants program focusing on statewide efforts to address the opioid crisis by increasing access to medication-assisted treatment and recovery activities for opioid use disorder.
      Substance Abuse and Mental Health Services Administration
      State Opioid Response Grants.
      A nationwide effort to increase patient access to naloxone is being made through the creation of standing orders for naloxone prescribing.
      • Wickramatilake S.
      • Zur J.
      • Mulvaney-Day N.
      • Klimo M.C.
      • Selmi E.
      • Harwood H.
      How states are tackling the opioid crisis.
      A standing order entails pharmacists and physicians signing an agreement that permits pharmacists to prescribe naloxone to patients that meet criteria specified in the agreement.
      • Green T.C.
      • Dauria E.F.
      • Bratberg J.
      • Davis C.S.
      • Walley A.Y.
      Orienting patients to greater opioid safety: models of community pharmacy-based naloxone.
      • Davis C.S.
      • Carr D.
      Legal changes to increase access to naloxone for opioid overdose reversal in the United States.
      Pharmacy standing orders, naloxone provision per protocol, and pharmacist as prescriber mechanisms are examples of strategies used to effectively dispense naloxone in pharmacies.
      • Green T.C.
      • Dauria E.F.
      • Bratberg J.
      • Davis C.S.
      • Walley A.Y.
      Orienting patients to greater opioid safety: models of community pharmacy-based naloxone.
      Specific protocols are pursuant to individual state regulations, but overall they have increased access to naloxone by eliminating the previously necessary patient–physician interaction and written prescription.
      Network for Public Health Law
      Using law to support pharmacy naloxone distribution.
      • Davis C.S.
      • Carr D.
      • Southwell J.K.
      • Beletsky L.
      Engaging law enforcement in overdose reversal initiatives: authorization and liability for naloxone administration.
      • Davis C.
      • Carr D.
      State legal innovations to encourage naloxone dispensing.
      As a result, pharmacists have expanded their roles in screening patients at risk for overdose and dispensing naloxone alongside opioid medications as appropriate.
      • Compton W.M.
      • Jones C.M.
      • Stein J.B.
      • Wargo E.M.
      Promising roles for pharmacists in addressing the U.S. opioid crisis.
      • Lambdin B.H.
      • Davis C.S.
      • Wheeler E.
      • Tueller S.
      • Kral A.H.
      Naloxone laws facilitate the establishment of overdose education and naloxone distribution programs in the United States.
      This expansion of naloxone access and pharmacist roles has been supported by national pharmacy associations and federal agencies through the dissemination of toolkits, guidelines, and other resources.
      Substance Abuse and Mental Health Services Administration
      Opioid overdose prevention toolkit.
      Department of Health and Human Services
      HHS recommends prescribing or co-prescribing naloxone to patients at high risk for an opioid overdose.
      Department of Health and Human Services
      Surgeon General releases advisory on naloxone, an opioid overdose-reversing drug.
      Pharmacists have the potential to promote safe opioid use because they are well positioned in various health care settings to identify patients at risk of overdose, dispense naloxone, and counsel patients on appropriate medication use. Pharmacists can provide additional services to PWUD, such as needle exchange programs, locations for supervised injection, and resources for safe disposal.
      • Goodin A.
      • Fallin-Bennett A.
      • Green T.
      • Freeman P.R.
      Pharmacists’ role in harm reduction: a survey assessment of Kentucky community pharmacists’ willingness to participate in syringe/needle exchange.
      • Freeman P.R.
      • Hankosky E.R.
      • Lofwall M.R.
      • Talbert J.C.
      The changing landscape of naloxone availability in the United States, 2011–2017.
      • Stock C.
      • Geier M.
      • Nowicki K.
      Pharmacist guide to harm reduction strategies for people who inject drugs.
      However, several barriers impede pharmacist interventions that promote safe opioid use. There is a need for clear understanding of pharmacist roles and barriers and facilitators to naloxone dispensing. Recommendations for future interventions and research based on the present systematic review have the goal of optimizing pharmacists’ roles in helping to prevent opioid overdose deaths.

      Objective

      This systematic review aimed to examine the current state of naloxone use and dispensing regarding (1) pharmacists’ roles in naloxone dispensing, (2) barriers and facilitators to naloxone dispensing by pharmacists, and (3) current training programs for pharmacists to dispense naloxone. Based on the review findings, recommendations are offered to help pharmacists contribute more effectively to the use of naloxone.

      Methods

       Search strategy

      A literature search was conducted with the use of Pubmed, Cinahl Plus, and Cochrane Review Library. The key terms included in the search were "pharmacist OR pharmacy" AND "naloxone". Search results from each database were exported to Microsoft Excel, merged, and sorted for removal of duplicate citations.

       Study selection

      This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidance.
      • Moher D.
      • Shamseer L.
      • Clarke M.
      • et al.
      Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) 2015 statement.
      Peer-reviewed original research was included. Initial screening of all abstracts and titles was conducted independently by the authors to determine whether to include or exclude an article based on selection criteria. Inclusion criteria were original research studies conducted in the United States from January 1, 2013, through June 30, 2018, and published in English, addressing at least 1 of the following topics: (1) pharmacist roles in naloxone dispensing, (2) barriers and facilitators to naloxone dispensing by pharmacists, or (3) current training or education programs available to prepare pharmacists or pharmacy students for naloxone dispensing. Research conducted outside of the United States was excluded because of different legislative processes, regulations, and health care system structures. The 5-year timeframe was used because the majority of state initiatives regarding pharmacist naloxone dispensing occurred after 2013. During the abstract and title screening phase, a level of agreement on inclusion or exclusion was set a priori at 90%. All screening disagreements were reconciled through discussion between the authors to achieve mutual consensus before moving to full-text review. Full-text articles were further assessed for inclusion, and reasons were documented for all excluded papers.

       Data extraction

      A standard data extraction form was used to collect study authors, article title, year published, journal title, study design, brief description of methods, primary outcome measures, and conclusions.

      Results

      A total of 155 records were obtained after searching Pubmed, Cinahl Plus and Cochrane Review Library, and 105 articles were identified for abstract reviews after removing duplicates; 57 studies were removed after abstract review and another 15 were removed after full-text reviews as not meeting the inclusion criteria. As a result, 33 articles were included in this systematic review (Figure 1).
      Figure thumbnail gr1
      Figure 1Summary of literature screening and selection.

       Pharmacists’ roles in naloxone dispensing

      Fourteen out of the 33 studies included in this review described pharmacists’ roles in naloxone dispensing across various pharmacy settings (Table 1). Overall, pharmacists are well positioned for naloxone dispensing, especially in outpatient or community pharmacy settings, where patients, caregivers, and PWUD have increased accessibility to naloxone.
      • 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.
      • Freeman P.R.
      • Curran G.M.
      • Drummond K.L.
      • et al.
      Utilization of prescription drug monitoring programs for prescribing and dispensing decisions: results from a multi-site qualitative study.
      The included studies emphasize how pharmacists can play a vital role in contacting providers, provision of naloxone, opioids, and related medications, education of patients and caregivers, dissemination of information throughout the community, and preventing opioid overdose–related deaths.
      • Bachyrycz A.
      • Shrestha S.
      • Bleske B.E.
      • Tinker D.
      • Bakhireva L.N.
      Opioid overdose prevention through pharmacy-based naloxone prescription program: innovations in health care delivery.
      Table 1Pharmacist roles in naloxone dispensing (n = 14)
      StudyTitleDesignSize/populationObjectiveMethodsOutcomes
      Adams et al. (2016)
      • Adams A.J.
      • Weaver K.K.
      The continuum of pharmacist prescriptive authority.
      The continuum of pharmacist prescriptive authoritySecondary database analysisPharmacy legislation and regulations as tracked by National Alliance of State Pharmacy Associations (NASPA)To characterize models of current prescriptive authority among pharmacistsNASPA data used to understand pharmacist prescriptive authorityMore states will likely pursue less restrictive approaches for pharmacists prescribing naloxone
      Bachyrycz et al. (2017)
      • Bachyrycz A.
      • Shrestha S.
      • Bleske B.E.
      • Tinker D.
      • Bakhireva L.N.
      Opioid overdose prevention through pharmacy-based naloxone prescription program: innovations in health care delivery.
      Opioid overdose prevention through pharmacy-based naloxone prescription program: innovations in health care deliveryCross-sectional study133 patients prescribed naloxone rescue kits in New MexicoTo describe emerging trends in naloxone rescue kit medication patterns by pharmacistsCross-sectional analysis of data on rescue kit prescriptions available from state pharmacist registryMost common reason to prescribe naloxone was patient’s request (56.4%), followed by high dose of prescription opioids (28.6%) and history of opioid misuse or abuse (15.0%)
      Bailey et al. (2014)
      • Bailey A.M.
      • Wermeling D.P.
      Naloxone for opioid overdose prevention: pharmacists’ role in community-based practice settings.
      Naloxone for opioid overdose prevention: pharmacists’ role in community-based practice settingsQualitative studySix pharmacists from Seattle and BostonTo describe outpatient naloxone dispensing practices, methods to implement dispensing programs, prescribing patterns, barriers to implementation, and methods for patient educationInterviews conducted with practitioners based in community pharmacies or clinics in large metropolitan cities across the country to obtain insight into the practice of dispensing naloxonePatient groups that would benefit from access to naloxone include licit users of high-dose prescription opioids (50%) or injection drug users and abusers of prescription medications (83%); patients were identified through prescription records or provider screening tools; dispensing naloxone required providers’ prescription at 5 of the 6 sites
      Burrell et al. (2017)
      • Burrell A.
      • Ethun L.
      • Fawcett J.A.
      • et al.
      The pharmacist’s role in overdose: using mapping technologies to analyze naloxone and pharmacy distribution.
      Pharmacists role in overdose: using mapping technologies to analyze naloxone and pharmacy distributionGeographic information system (GIS) mapping and database analysis87 pharmacies determined by ZIP Code Tabulation Areas (ZCTAs) in Allegheny County, PATo present preliminary research using GIS mapping as tool to increase access and utilization of pharmacy-based interventionsGIS mapping tool to analyze data on overdose deathsOf 322 active licensed pharmacies, 28 pharmacies were confirmed to stock and distribute naloxone; overdose deaths in zip codes with naloxone-distributing pharmacies was significantly higher than the average number of deaths in all zip codes: 7.38 deaths vs. 4.84 deaths (P = 0.021)
      Davis et al. (2017)
      • Davis C.
      • Carr D.
      State legal innovations to encourage naloxone dispensing.
      State legal innovations to encourage naloxone dispensingSecondary database analysisState laws and regulations, as catalogued by the Westlaw databaseTo describe laws related to pharmacist naloxone dispensingContent analysis of state laws and regulations44 states had laws allowing prescription of naloxone to a patient without relationship with prescriber; 42 states allowed for standing order or protocols; 5 states allowed pharmacists to prescribe naloxone
      DeVries et al. (2017)
      • Devries J.
      • Rafie S.
      • Polston G.
      Implementing an overdose education and naloxone distribution program in a health system.
      Implementing an overdose education and naloxone distribution program in a health systemIntervention study252 physicians, pharmacists, and nurses trained in overdose education and take-home naloxoneTo design and implement a program increasing provision of take-home naloxone in patients at risk of opioid overdoseChart reviews for multisite naloxone dispensing programIncrease in the number of prescriptions for naloxone from a baseline of 4.5 per month to 46 per month during 3 months after full implementation
      Green et al. (2015)
      • Green T.C.
      • Dauria E.F.
      • Bratberg J.
      • Davis C.S.
      • Walley A.Y.
      Orienting patients to greater opioid safety: models of community pharmacy-based naloxone.
      Orienting patients to greater opioid safety: models of community pharmacy-based naloxoneCase studyRhode Island and Massachusetts state case studyTo describe and provide 2 state-specific examples of innovative policy models of pharmacy-based naloxone accessCase study analysisPharmacies provide a high-yield setting where patients and caregivers can access naloxone
      Meyerson et al. (2018)
      • Meyerson B.E.
      • Agley J.D.
      • Davis A.
      • et al.
      Predicting pharmacy naloxone stocking and dispensing following a statewide standing order, Indiana 2016.
      Predicting pharmacy naloxone stocking and dispensing following a statewide order, Indiana 2016Cross-sectional survey study284 community pharmacists licensed in INTo identify factors associated with community pharmacy naloxone stocking and dispensing after the enactment of a statewide naloxone standing orderSurvey of Indiana community pharmacists> 50% of pharmacies stocked naloxone, but only 23% dispensed it; pharmacies where pharmacists received naloxone continuing education in the past 2 years were 1.3 times more likely to stock naloxone than those without continuing education
      Penm et al. (2017)
      • Penm J.
      • MacKinnon N.J.
      • Boone J.M.
      • Ciaccia A.
      • McNamee C.
      • Winstanley E.L.
      Strategies and policies to address the opioid epidemic: a case study of Ohio.
      Strategies and policies to address the opioid epidemic: a case study of OhioNot applicableGovernor’s Cabinet Opiate Action Team membersTo discuss the role that pharmacists can play in implementing, promoting, and enhancing effectiveness of these policiesAction team created to promote opioid safety and naloxone dispensingSince the action team was created, 81 million fewer doses of opioids were dispensed in 2015 compared with 782 million doses dispensed in 2011; the proportion of unintentional prescription opioid overdose deaths reduced from 45% in 2011 to 22% in 2015
      Strand et al. (2018)
      • Strand M.A.
      • Eukel H.
      • Burck S.
      Moving opioid misuse prevention upstream: a pilot study of community pharmacists screening for opioid misuse risk.
      Moving opioid misuse prevention upstream: a pilot study of community pharmacists’ screening for opioid misuse riskIntervention study11 pharmacists screened 412 patientsTo evaluate the utility of opioid misuse risk prevention toolkit in a community pharmacy11 pharmacists trained in using the toolkit; pharmacists kept track of number of patients screened and counseled26% of patients were identified at some risk of misuse, 30% at risk of accidental overdose; qualitative data analysis revealed that the toolkit helped in conversations with patients
      Tewell et al. (2017)
      • Tewell R.
      • Edgerton L.
      • Kyle E.
      Establishment of a pharmacist-led service for patients at high risk for opioid overdose.
      Establishment of a pharmacist-led service for patients at high risk for opioid overdoseIntervention study49 patients with risk of overdoseTo evaluate pharmacist roles in screening, educating, and dispensing naloxone to patients with risk of overdoseChart reviews for obtaining patient information after implementing updated controlled substance agreements and medical record in a pharmacist-led naloxone clinicIn the first 6 months, 49 patients were identified to be at risk for opioid overdose; 84% of them were educated by pharmacists and 69% were dispensed naloxone
      Wickramatilake et al. (2017)
      • Wickramatilake S.
      • Zur J.
      • Mulvaney-Day N.
      • Klimo M.C.
      • Selmi E.
      • Harwood H.
      How states are tackling the opioid crisis.
      How states are tackling the opioid crisisCross-sectional survey studyState alcohol and drug abuse agencies for all 50 states and DCTo demonstrate range and scope of state initiatives being used to deal with opioid crisis2015 National Association of State Alcohol and Drug Abuse Directors web-based survey data were analyzedStates reported initiatives to educate the general public (n = 48), prescribers (n = 31), patients and families (n = 24), and pharmacists (n = 22) about the risks of opioids. 28 states had expanded the availability of naloxone
      Wilson et al. (2017)
      • Wilson C.G.
      • Rodriguez F.
      • Carrington A.C.
      • Fagan E.B.
      Development of a targeted naloxone coprescribing program in a primary care practice.
      Development of a targeted naloxone coprescribing program in a primary care practiceIntervention study709 patients with chronic opioid useTo develop targeted naloxone coprescribing program in primary care practiceNaloxone coprescribing program involving pharmacists; pharmacists embedded in this practice developed a targeted naloxone coprescribing program for patients who were on chronic opioid therapy and had doses of ≥50 mg morphine equivalents daily, were taking benzodiazepines, had a history of substance use disorder, or had a history of overdose; data collected through patient chart reviews1297 patients were identified, 709 of which met criteria for chronic opioid use; 50% of patients met criteria for naloxone use, but only 3.4% of those patients were prescribed naloxone
      Wulz et al. (2017)
      • Wulz J.L.
      • Sung H.
      • Dugan B.D.
      • Wensel T.M.
      • Lander R.
      • Manzella B.
      The pharmacist role in the development and implementation of a naloxone prescription program in Alabama.
      The pharmacist role in development and implementation of a naloxone prescription program in AlabamaIntervention study83 pharmacists in Birmingham, ALTo describe the development and implementation of a pharmacist-led naloxone-training at a county health departmentPatient chart reviews. Frequency analysis of number of patients trained for using naloxone.83 clients were trained on naloxone use and 150 naloxone kits in total were distributed after implementation of the program

       Recognition of pharmacist services by states

      Three out of the 14 studies describing pharmacist roles focused on recognition and promotion of pharmacists’ roles by the states. Because pharmacists are an important part of state strategies to overcome opioid overdose,
      • Penm J.
      • MacKinnon N.J.
      • Boone J.M.
      • Ciaccia A.
      • McNamee C.
      • Winstanley E.L.
      Strategies and policies to address the opioid epidemic: a case study of Ohio.
      many states are taking initiatives to educate pharmacists about opioid overdose and misuse.
      • Wickramatilake S.
      • Zur J.
      • Mulvaney-Day N.
      • Klimo M.C.
      • Selmi E.
      • Harwood H.
      How states are tackling the opioid crisis.
      In 2017, 44 states had laws allowing prescription of naloxone to a patient without a relationship with the prescriber, 42 states allowed for a standing order or protocols for naloxone dispensing, and 5 states allowed pharmacists to prescribe naloxone. Liability risks associated with naloxone were not greater than any with other medications, and some states provided additional protection from civil liability or criminal action to pharmacists to encourage naloxone prescription and dispensing.
      • Davis C.
      • Carr D.
      State legal innovations to encourage naloxone dispensing.
      It is evident that potential pharmacist roles in opioid overdose prevention have been recognized by a majority of states with efforts promoting the role of pharmacists in naloxone dispensing.

       Overdose prevention education and naloxone rescue kits

      Five of the 14 studies that describe pharmacists’ roles focused on their dispensing naloxone to patients at risk of overdose. Despite state initiatives, empirical work suggests a gap between pharmacists’ potential roles and their actual roles. In a recent study, a retrospective chart review identified patients on chronic opioid therapy who met the Centers for Disease Control and Prevention recommendation for naloxone. Of these, only 3.4% of the patients had naloxone on their medication list.
      • Wilson C.G.
      • Rodriguez F.
      • Carrington A.C.
      • Fagan E.B.
      Development of a targeted naloxone coprescribing program in a primary care practice.
      The results of the chart review stimulated the organization to develop a systematic coprescribing program. Findings from such programs are promising. Implementing an overdose education and naloxone distribution program in a health system increased the number of naloxone prescriptions dispensed by pharmacists.
      • Devries J.
      • Rafie S.
      • Polston G.
      Implementing an overdose education and naloxone distribution program in a health system.
      In a study by Tewell et al., in the first 6 months 49 patients were identified as at risk for opioid overdose, 84% of them were educated by pharmacists, and 69% were dispensed naloxone after a pharmacist-led program was established for combating opioid overdose.
      • Tewell R.
      • Edgerton L.
      • Kyle E.
      Establishment of a pharmacist-led service for patients at high risk for opioid overdose.
      Other studies suggest contributing factors influencing naloxone distribution. Patients themselves may be a powerful influence. One study found that pharmacists reported that the most frequent reason they dispensed naloxone was in response to a patient’s request (56.4%), the second most frequent reason was when they perceived that the patient was taking a high dose of prescription opioids (28.6%), and third was a patient history of opioid misuse (15.0%).
      • Bachyrycz A.
      • Shrestha S.
      • Bleske B.E.
      • Tinker D.
      • Bakhireva L.N.
      Opioid overdose prevention through pharmacy-based naloxone prescription program: innovations in health care delivery.
      Strand et al. also found that perceptions of perceived overdose risk was important for the pharmacists’ role, with 30% of the patients receiving naloxone when the pharmacist recognized patients as having an overdose risk and 27% when recognized as having risk of misuse.
      • Strand M.A.
      • Eukel H.
      • Burck S.
      Moving opioid misuse prevention upstream: a pilot study of community pharmacists screening for opioid misuse risk.
      A misuse risk prevention toolkit which contained naloxone was reported to help pharmacists initiate conversations about dispensing naloxone to these patients. Pharmacists had a broader community role by educating and distributing naloxone kits to a network of supporting groups, such as churches and enforcement agencies, beyond just their patients.
      • Wulz J.L.
      • Sung H.
      • Dugan B.D.
      • Wensel T.M.
      • Lander R.
      • Manzella B.
      The pharmacist role in the development and implementation of a naloxone prescription program in Alabama.
      Although the strategies to promote naloxone dispensing varied among studies, all of them increased the identification of patients who would benefit from prescription of naloxone.

       Overdose risk screening protocols

      Three of the 14 studies describing pharmacists’ roles focused on screening protocols for identifying overdose risks for pharmacists. A number of studies suggest the value of overdose risk screening protocols. Community pharmacists have efficiently used medication profiles and screening tools, such as protocols and algorithms, to identify patients with higher needs to inform their dispensing of naloxone.
      • Bailey A.M.
      • Wermeling D.P.
      Naloxone for opioid overdose prevention: pharmacists’ role in community-based practice settings.
      In a recent study, 50% of pharmacies in Indiana reported stocking naloxone after standing orders were issued, but only 23% of them actually dispensed naloxone to patients.
      • Meyerson B.E.
      • Agley J.D.
      • Davis A.
      • et al.
      Predicting pharmacy naloxone stocking and dispensing following a statewide standing order, Indiana 2016.
      However, if a patient were screened and found to have a high risk of opioid overdose, pharmacists educated 85% of these patients about use of naloxone.
      • Meyerson B.E.
      • Agley J.D.
      • Davis A.
      • et al.
      Predicting pharmacy naloxone stocking and dispensing following a statewide standing order, Indiana 2016.
      In a study by DeVries et al., patients within a health system were screened with the use of a protocol for identifying patients at risk of opioid overdose. This protocol had 12 criteria for deciding if the patient was eligible for a naloxone prescription. Pharmacists and pharmacy technicians were provided with training regarding the epidemiology of the opioid overdose crisis, screening of patients eligible for naloxone prescription, and training of patients in naloxone use. The standing orders made it possible for pharmacists to identify patients with a risk of overdose and dispense naloxone via protocol without an order from a physician. In another study, where an interdisciplinary team including pharmacists was trained to screen patients with the use of naloxone-prescribing guidelines, the number of naloxone prescriptions dispensed increased from an average of 4.5 per month to 46 per month.
      • Devries J.
      • Rafie S.
      • Polston G.
      Implementing an overdose education and naloxone distribution program in a health system.
      All of these studies emphasized the need for structured screening protocols to help pharmacists identify patients at risk of overdose who would be candidates for naloxone dispensing.

       Barriers to naloxone dispensing

      Nine of the 33 studies included in this literature review described the barriers faced by pharmacists in dispensing naloxone (Table 2). The number of overdose deaths in zip codes with naloxone-distributing pharmacies was significantly higher than the average number of deaths in all zip codes.
      • Burrell A.
      • Ethun L.
      • Fawcett J.A.
      • et al.
      The pharmacist’s role in overdose: using mapping technologies to analyze naloxone and pharmacy distribution.
      Naloxone is not necessarily dispensed in the areas that have a population at high risk of opioid overdose.
      • Burrell A.
      • Ethun L.
      • Fawcett J.A.
      • et al.
      The pharmacist’s role in overdose: using mapping technologies to analyze naloxone and pharmacy distribution.
      Table 2Barriers pharmacists face in naloxone dispensing (n = 9)
      StudyTitleDesignSize/populationObjectiveMethodsOutcomes
      Bakhireva et al. (2017)
      • Bakhireva L.N.
      • Bautista A.
      • Cano S.
      • Shrestha S.
      • Bachyrycz A.M.
      • Cruz T.H.
      Barriers and facilitators to dispensing of intranasal naloxone by pharmacists.
      Barriers and facilitators to dispensing intranasal naloxone by pharmacistsMixed methods study390 pharmacists from all types of pharmacy settings in New MexicoTo identify barriers and facilitators to pharmacist dispensing of intranasal naloxoneFocus groups conducted to inform pharmacist survey assessing concerns and barriers to naloxone dispensing, characteristics or participating pharmacies, and measures needed to increase naloxone dispensing by pharmacistsMain barriers to naloxone dispensing included patient out-of-pocket costs, inadequate time, reimbursement, and perceptions of encouraging opioid abuse or attracting undesirable clientele; facilitators to naloxone dispensing included increased awareness and education among patients and public, and additional training on initiating conversations about naloxone with patients
      Carpenter et al. (2018)
      • Carpenter D.M.
      • Dhamanaskar A.K.
      • Gallegos K.L.
      • Shepherd G.
      • Mosley S.L.
      • Roberts C.A.
      Factors associated with how often community pharmacists offer and dispense naloxone [e-pub ahead of print].
      Factors associated with how often community pharmacists offer and dispense naloxoneCross-sectional survey study457 community pharmacistsTo identify factors associated with frequency of pharmacist offering and dispensing naloxoneSurvey to identify facilitators and barriers to naloxone dispensing by pharmacistsMajority of pharmacies stocked naloxone (81.2%), but many pharmacists never offered (36.6%) or dispensed naloxone (19.4%); pharmacies who stocked multiple naloxone formulations (β  =  0.15; P < 0.01) and pharmacists who were more comfortable in discussing naloxone (β  =  0.26; P  =  0.001) were more likely to offer it; barriers to teaching naloxone administration to patients included lack of time and training, and perceived lack of patient understanding
      Freeman et al. (2017)
      • 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.
      Pharmacist role in opioid overdose: Kentucky pharmacists’ willingness to participate in naloxone dispensingCross-sectional survey study1282 practicing pharmacists in KentuckyTo assess pharmacist willingness to dispense naloxone under physician-approved protocolE-mail survey to pharmacists to assess knowledge of opioid overdose and attitudes and barriers to naloxone dispensing54% of pharmacists reported willingness to dispense naloxone; women pharmacists were 1.3 times more willing than men; those who reported confidence in identifying risks were 1.3 times more willing to dispense it; those confident in educating patients about overdose were 1.6 times more confident to dispense it, community pharmacists reported more barriers to dispensing barriers than those in other practice settings
      Green et al. (2017)
      • 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.
      Perpetuating stigma or reducing risk? Perspectives from naloxone consumers and pharmacists on pharmacy-based naloxone in two statesQualitative study61 participants from Rhode Island and Massachussets: 15 patients with chronic pain, 19 people with opioid use disorders, 16 caregivers, and 11 pharmacistsTo understand patient, caregiver, and pharmacist perceptions of naloxone dispensed from pharmacists8 focus groups consisting of patients with chronic pain, people with opioid use disorders, caregivers, and pharmacistsMain themes related to patient concerns regarding consequences of requesting naloxone, pharmacist concerns related to dispensing, perceptions on addressing opioid safety in pharmacies, and overcoming barriers to dispensing; all groups supported pharmacist roles in naloxone dispensing to eligible patients
      Giannitrapani et al. (2014)
      • Giannitrapani K.F.
      • Glassman P.A.
      • Vang D.
      • et al.
      Expanding the role of clinical pharmacists on interdisciplinary primary care teams for chronic pain and opioid management.
      Expanding the role of clinical pharmacists on interdisciplinary primary care teams for chronic pain and opioid managementQualitative study60 members of Veterans Affairs (VA) primary care teams and 14 primary care providers and clinical pharmacistsTo identify pharmacist roles in primary care chronic pain management and understand barriers to role expansion in a VA settingFocus groups consisting of primary care team members followed by individual interviews with additional primary care providers and clinical pharmacistsPrimary care providers identified pharmacists as having an important role in managing therapy with opioids; barriers to role expansion included limited scope of pharmacist practice, lack of support from the institution, and dissemination of pharmacists’ expanded roles
      Rudolph et al. (2018)
      • Rudolph S.E.
      • Branham A.R.
      • Rhodes L.A.
      • Hayes Jr., H.H.
      • Moose J.S.
      • Marciniak M.W.
      Identifying barriers to dispensing naloxone: A survey of community pharmacists in North Carolina.
      Identifying barriers to dispensing naloxone: a survey of community pharmacists in North CarolinaCross-sectional survey study423 community-based pharmacists in NCTo determine barriers to naloxone dispensing and to identify additional training needsSurveys sent to community pharmacists to assess training, willingness to dispense naloxone, knowledge, and perceived barriers surrounding naloxone use, as well as demographic information1/3 pharmacists scored >90% on knowledge assessment of naloxone and opioid overdose; pharmacists were more willing to dispense naloxone if they had knowledge and training (r = 0.288; P < 0.001); additional training needs such as strategies to initiate a conversation were identified; >95% of respondents indicated that the pharmacy in which they are employed would benefit from additional naloxone training
      Thompson et al. (2018)
      • Thompson E.L.
      • Rao P.S.S.
      • Hayes C.
      • Purtill C.
      Dispensing naloxone without a prescription: survey evaluation of Ohio pharmacists.
      Dispensing naloxone without a prescription: survey evaluation of Ohio pharmacistsCross-sectional survey study170 pharmacists in OHTo assess OH pharmacists’ knowledge of naloxone and pertaining laws, barriers to dispensing naloxone, and overall confidence, comfort, perception, and experience with naloxone dispensingE-mail survey to pharmacists in OH to assess knowledge of various domains regarding naloxoneResponse rate of 2.2%; lack of awareness in pharmacists about the OH law on naloxone dispensing per physician protocol had a significant correlation with the lack of knowledge regarding how naloxone can be administered (r = 0.284; P < 0.001), how long the effect of naloxone lasts (r = 0.201; P < 0.001), and general knowledge about management of opioid overdose with naloxone (r = 0.220; P < 0.001); barriers identified by pharmacists included need for additional training and moral and ethical concerns among younger pharmacists
      Thornton et al. (2017)
      • Thornton J.D.
      • Lyvers E.
      • Scott V.G.G.
      • Dwibedi N.
      Pharmacists’ readiness to provide naloxone in community pharmacies in West Virginia.
      Pharmacist readiness to provide naloxone in community pharmacies in West VirginiaCross-sectional survey study157 pharmacists licensed in WVTo understand stocking and dispensing for opioid-related medications and educational needs for pharmacist-provided naloxoneSurvey sent to and completed by community pharmacistsFewer than 1/3 of pharmacists felt comfortable dispensing naloxone without a prescription, about 50% stocked buprenorphine, and >50% stocked buprenorphine/naloxone
      Zaller et al. (2013)
      • Zaller N.D.
      • Yokell M.A.
      • Green T.C.
      • Gaggin J.
      • Case P.
      The feasibility of pharmacy-based naloxone distribution interventions: a qualitative study with injection drug users and pharmacy staff in Rhode Island.
      The feasibility of pharmacy-based naloxone distribution interventions: qualitative study with injection drug users and pharmacy staff in Rhode IslandQualitative study21 injection drug users and 21 pharmacy staff (pharmacists and technicians) in RITo assess feasibility and barriers to naloxone dispensing by pharmacists for injection drug usersSemistructured interviews conducted with injection drug users and pharmacy staffBarriers to dispensing were identified as misinformation about naloxone, relationships between injection drug users and pharmacy staff, and cost of treatment
      Many reported barriers are related to naloxone dispensing apart from systems, tools, and policies. Some are related to barriers in the community pharmacy setting or pharmacist willingness and confidence to dispense naloxone. Pharmacists have been surveyed regarding the discrepancy between naloxone stocking and dispensing and barriers related to pharmacist roles regarding naloxone. One study found that although a majority of pharmacies stocked naloxone, many pharmacists never offered or dispensed it.
      • Carpenter D.M.
      • Dhamanaskar A.K.
      • Gallegos K.L.
      • Shepherd G.
      • Mosley S.L.
      • Roberts C.A.
      Factors associated with how often community pharmacists offer and dispense naloxone [e-pub ahead of print].
      Facilitators to naloxone dispensing reported by pharmacists include increased awareness and education of patients and the public, and additional pharmacist training on initiating conversations about naloxone with patients.
      • Moher D.
      • Shamseer L.
      • Clarke M.
      • et al.
      Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) 2015 statement.
      Barriers faced by pharmacists depended on the site and attitudes of patients and pharmacists.

       Site barriers

      Two of the 9 studies describing barriers to dispensing naloxone focused on site barriers faced by pharmacists. Pharmacists reported barriers such as time constraints, inadequate reimbursement, lack of support from management or prescribers, and lack of training and education.
      • Bakhireva L.N.
      • Bautista A.
      • Cano S.
      • Shrestha S.
      • Bachyrycz A.M.
      • Cruz T.H.
      Barriers and facilitators to dispensing of intranasal naloxone by pharmacists.
      In other pharmacy settings, pharmacists reported barriers to expanding pharmacist roles in pain management. These barriers included limited scope of practice and lack of support from the institution.
      • Giannitrapani K.F.
      • Glassman P.A.
      • Vang D.
      • et al.
      Expanding the role of clinical pharmacists on interdisciplinary primary care teams for chronic pain and opioid management.
      Lack of time, reimbursement, and support from the institution were reported as site barriers by practicing pharmacists for dispensing naloxone.

       Pharmacist and patient attitudes

      Five of the 9 studies describing barriers to pharmacists focused on pharmacist attitudes, 2 focused on patient attitudes, and 1 surveyed patients and caregivers and pharmacists to understand perceptions of naloxone dispensing.
      • 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.
      Patients and caregivers presented some concerns regarding potential consequences of requesting naloxone based on past negative experiences they reported with requesting syringes or opioids.
      • 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.
      • Zaller N.D.
      • Yokell M.A.
      • Green T.C.
      • Gaggin J.
      • Case P.
      The feasibility of pharmacy-based naloxone distribution interventions: a qualitative study with injection drug users and pharmacy staff in Rhode Island.
      When asked about perceived barriers to implementing a naloxone access program, pharmacists in various practice sites (59.9% community setting, 43.2% other settings) expressed concern about the time necessary to develop and implement a program.
      • 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.
      Pharmacist perceptions on patient use of opioids, including moral and ethical concerns, affect willingness to dispense naloxone. Many studies have shown that some pharmacists have perceptions regarding naloxone dispensing that include beliefs that naloxone dispensing could promote increased opioid use, attract undesirable patients to their pharmacy, or put the pharmacist in an unsafe situation.
      • Bakhireva L.N.
      • Bautista A.
      • Cano S.
      • Shrestha S.
      • Bachyrycz A.M.
      • Cruz T.H.
      Barriers and facilitators to dispensing of intranasal naloxone by pharmacists.
      • Thornton J.D.
      • Lyvers E.
      • Scott V.G.G.
      • Dwibedi N.
      Pharmacists’ readiness to provide naloxone in community pharmacies in West Virginia.
      • Thompson E.L.
      • Rao P.S.S.
      • Hayes C.
      • Purtill C.
      Dispensing naloxone without a prescription: survey evaluation of Ohio pharmacists.
      These barriers aligned with findings from a study conducted specifically with patients who used injection drugs.
      • Zaller N.D.
      • Yokell M.A.
      • Green T.C.
      • Gaggin J.
      • Case P.
      The feasibility of pharmacy-based naloxone distribution interventions: a qualitative study with injection drug users and pharmacy staff in Rhode Island.
      Pharmacist willingness to dispense naloxone is affected also by confidence of pharmacists in addition to time constraints, lack of support from management or prescribers, and perceived lack of patient understanding.
      • Carpenter D.M.
      • Dhamanaskar A.K.
      • Gallegos K.L.
      • Shepherd G.
      • Mosley S.L.
      • Roberts C.A.
      Factors associated with how often community pharmacists offer and dispense naloxone [e-pub ahead of print].
      • Bakhireva L.N.
      • Bautista A.
      • Cano S.
      • Shrestha S.
      • Bachyrycz A.M.
      • Cruz T.H.
      Barriers and facilitators to dispensing of intranasal naloxone by pharmacists.
      • Carpenter D.M.
      • Roberts C.A.
      • Westrick S.C.
      • et al.
      A content review of online naloxone Continuing Education courses for pharmacists in states with standing orders.

       Naloxone training and education programs

      Ten of the 33 studies included in this review described training and education programs about naloxone dispensing for pharmacists (Table 3).
      Table 3Naloxone education and training programs for pharmacists (n = 10)
      StudyTitleDesignSize/populationObjectiveMethodsOutcome
      Carpenter et al. (2017)
      • Carpenter D.M.
      • Roberts C.A.
      • Westrick S.C.
      • et al.
      A content review of online naloxone Continuing Education courses for pharmacists in states with standing orders.
      A content review of online naloxone continuing education courses for pharmacists in states with standing ordersContent review12 naloxone programs among 13 states with standing ordersTo assess online naloxone education programs to determine level of pharmacist preparation to counsel and educate on naloxone useReview of available training programs for pharmacists and categorization of topics covered in their contentProgram length was ∼1 hour (n = 9); many programs contained similar content; all programs (n = 12) described naloxone mechanism, duration of action, and patient monitoring after use; most programs (n = 11) contained information on pharmacist-patient communication, but extent of information was limited (e.g., <3 minutes of discussion); some programs (n = 8) discussed specific language to use when discussing naloxone
      Hines et al. (2018)
      • Hines J.
      • Deja E.
      • Black E.P.
      Student pharmacist perceptions of participation in hands-on naloxone counseling.
      Student pharmacist perceptions of participation in hands-on naloxone counselingCross-sectional survey study45 third- and fourth-year student pharmacists in Rho Chi Honor Society at University of KansasTo improve student pharmacist counseling on naloxoneStudent-developed volunteer activity for third- and fourth-year student pharmacists to practice patient counseling through naloxone education for patients at risk of overdose under physician-approved protocol; survey to understand impact of student participationSurvey response rate was 78% (35 of 45); students felt more comfortable counseling patients, had different perceptions on drug addiction (77%), and planned to pursue additional naloxone training after participation (91%)
      Jacobson et al. (2018)
      • Jacobson A.N.
      • Bratberg J.P.
      • Monk M.
      • Ferrentino J.
      Retention of student pharmacists’ knowledge and skills regarding overdose management with naloxone.
      Retention of student pharmacists’ knowledge and skills regarding overdose management with naloxoneCross-sectional survey study252 first- and second-year student pharmacists at University of Rhode Island College of PharmacyTo compare student pharmacist retention of overdose and naloxone education between participation in didactic teaching alone or with addition of an objective structured clinical examination (OSCE)First- and second-year student pharmacists attended a didactic lecture, second-year students also participated in an OSCE assessment, and retention of knowledge was measured with the use of a survey 6 months laterSurvey response rate was 76.7% for first-year students and 94.3% for second-year students; participation in an OSCE assessment did not improve knowledge retention but improved student confidence in patient counseling
      Maguire et al. (2018)
      • Maguire M.A.
      • Pavlakos R.N.
      • Mehta B.H.
      • Schmuhl K.K.
      • Beatty S.J.
      A naloxone and harm reduction educational program across four years of a doctor of pharmacy program.
      A naloxone and harm reduction educational program across four years of a Doctor of Pharmacy programIntervention study383 first-, second-, and third-year student pharmacists at Ohio State University College of PharmacyTo develop a pilot naloxone and harm reduction educational program for student pharmacistsStudents participated in a 3-part recorded lecture and interactive workshop and knowledge was measured with a post-activity assessmentSurvey response rate was 75%; students felt that the program was beneficial and valued the various hands-on activities and discussions; most students felt their questions had been answered (52%); students also had many suggestions for improvement
      Morton et al. (2017)
      • Morton K.J.
      • Harrand B.
      • Floyd C.C.
      • et al.
      Pharmacy-based statewide naloxone distribution: a novel “top-down, bottom-up” approach.
      Pharmacy-based statewide naloxone distribution: a novel top-down, bottom-up approachSecondary database analysisNaloxone Medicaid claims from 100 outpatient pharmacies in New MexicoTo share NM’s approach to naloxone distribution in pharmaciesMedicaid claims data were used to describe statewide distribution and use of naloxone in pharmacies, and the available training program was assessed with the use of an evaluation form808 naloxone Medicaid claims from 100 outpatient pharmacies were submitted in the first half of 2016; the statewide standing order resulted in a 9-fold increase in naloxone dispensing compared with 2014; the program provided training for 242 pharmacist, interns, and students; the greatest barriers to naloxone distribution included reimbursement, patient affordability, and lack of patient interest
      Palmer et al. (2017)
      • Palmer E.
      • Hart S.
      • Freeman P.R.
      Development and delivery of a pharmacist training program to increase naloxone access in Kentucky.
      Development and delivery of a pharmacist training program to increase naloxone access in KentuckyIntervention studyPharmacists and student pharmacists participating in a naloxone training program in KYTo describe KY’s comprehensive training program for pharmacist naloxone dispensingPharmacists and student pharmacists voluntarily achieved naloxone certification after completion of a webinar educational program focused on access to naloxone, pharmacology and use, developing protocols for dispensing, patient identification, and other resourcesOver 1 year, 1254 pharmacists and 348 student pharmacists participated in the training program; 52% of participants applied for naloxone certification; the usefulness of the information was rated as excellent by majority of participants (87%)
      Panther et al. (2017)
      • Panther S.G.
      • Bray B.S.
      • White J.R.
      The implementation of a naloxone rescue program in university students.
      The implementation of a naloxone rescue program in university studentsIntervention study150 university students at Washington State UniversityTo increase awareness about opioid overdose and naloxone use and to examine university students’ perceptions about the trainingTrained student pharmacists facilitated large and small-group discussions on prevention and response to opioid overdose, and post-training surveys were used to assess student pharmacist knowledge and perceptions74 of the 150 students attended the training, and 92% of these 74 participants completed the post-training survey; many participants had not received previous training about prescription drug abuse or assisting someone experiencing drug overdose (63% and 59%, respectively); participants thought the program met expectations (100%) and felt prepared to respond to an overdose situation (97%)
      Peckham et al. (2018)
      • Peckham A.M.
      • Niculete M.E.
      • Steinberg H.
      • Boggs D.L.
      A survey of prescribers’ attitudes, knowledge, comfort, and fear of consequences related to an opioid overdose education and naloxone distribution program.
      A survey of prescribers’ attitudes, knowledge, comfort, and fear of consequences related to an opioid overdose education and naloxone distribution programCross-sectional survey study114 prescribers in primary care, mental health, and substance use disorder at a single Veterans Affairs (VA) health systemTo identify attitudes, knowledge, and comfort related to program implementation of an overdose education and naloxone distribution program in the VA systemSurvey to assess domains of participant knowledge and identify barriers to program implementation based on individual professions or specialtySurvey response rate was 87.7%; prescribers practicing in substance use disorder specialties were most comfortable and knowledgeable in naloxone dispensing; overall, prescribers who received training regarding naloxone and opioid overdose were more comfortable (P < 0.001) and knowledgeable (P < 0.001) with these topics
      Roberts et al. (2018)
      • Roberts A.W.
      • Carpenter D.M.
      • Smith A.
      • Look K.A.
      Reviewing state-mandated training requirements for naloxone-dispensing pharmacists.
      Reviewing state-mandated training requirements for naloxone-dispensing pharmacistsContent reviewEnhanced pharmacy access laws and naloxone education programs in all 50 statesTo review naloxone training requirements for states with enhanced pharmacy access lawsInternet searches of public records to understand types of enhanced pharmacy naloxone access laws and state-specific naloxone training mandatesAll 50 states implemented enhanced pharmacy naloxone access laws by 2018, and 19 states required naloxone education for pharmacists engaged in naloxone dispensing or prescribing
      Schartel et al. (2018)
      • Schartel A.
      • Lardieri A.
      • Mattingly A.
      • Feemster A.A.
      Implementation and assessment of a naloxone-training program for first-year student pharmacists.
      Implementation and assessment of a naloxone-training program for first year student pharmacistsIntervention study158 first-year student pharmacists at University of Maryland School of PharmacyTo develop a naloxone training activity for first-year student pharmacists and assess changes in knowledge and confidence regarding managing opioid overdose and naloxone administration after participationTraining activity in skills laboratory courses and a lecture delivered on the topic of response to opioid overdose; student pharmacist knowledge assessed with the use of prelecture questions and OSCE; confidence measured with the use of self-assessment questions after completion of the activityAverage OSCE score was 82%; 93% of students self-reported improved confidence in counseling and >90% were somewhat to very confident in administration of naloxone and recognizing an opioid overdose

       Need for training and education for pharmacists

      Several of the studies in this review examined the need for education and training for pharmacists to effectively dispense naloxone. Surveys of practicing pharmacists have shown a strong correlation between participation in naloxone training and education programs and confidence in dispensing naloxone to pharmacy customers, especially within community pharmacy settings. In addition, pharmacists are more likely to initiate naloxone dispensing if pharmacists are trained to detect risk of overdose.
      • 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.
      The majority of pharmacists (75%) in one study did not consider themselves to be adequately trained to dispense naloxone.
      • Thornton J.D.
      • Lyvers E.
      • Scott V.G.G.
      • Dwibedi N.
      Pharmacists’ readiness to provide naloxone in community pharmacies in West Virginia.
      Overall, pharmacists felt most confident about use, pharmacology, and administration of naloxone, but reported limited awareness of state laws or standing orders for naloxone use. They had limited confidence in their ability to educate patients on overdose and were uncomfortable dispensing naloxone without a physician.
      • 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.
      • Thornton J.D.
      • Lyvers E.
      • Scott V.G.G.
      • Dwibedi N.
      Pharmacists’ readiness to provide naloxone in community pharmacies in West Virginia.
      • Thompson E.L.
      • Rao P.S.S.
      • Hayes C.
      • Purtill C.
      Dispensing naloxone without a prescription: survey evaluation of Ohio pharmacists.
      Pharmacists identified areas for additional training to include naloxone education, communication strategies, identifying patients who would benefit from naloxone, and guidance on service implementation.
      • Rudolph S.E.
      • Branham A.R.
      • Rhodes L.A.
      • Hayes Jr., H.H.
      • Moose J.S.
      • Marciniak M.W.
      Identifying barriers to dispensing naloxone: A survey of community pharmacists in North Carolina.
      These studies highlight how extent of training and education for pharmacists may contribute to the large discrepancies between naloxone stocking and dispensing, and between pharmacist willingness and confidence to dispense naloxone.

       Programs for practicing pharmacists

      Many states have recognized the potential role of pharmacists and are taking initiatives to educate and train pharmacists about opioid misuse, including naloxone dispensing. Five studies examined training and education programs for practicing pharmacists.
      • Carpenter D.M.
      • Roberts C.A.
      • Westrick S.C.
      • et al.
      A content review of online naloxone Continuing Education courses for pharmacists in states with standing orders.
      • Roberts A.W.
      • Carpenter D.M.
      • Smith A.
      • Look K.A.
      Reviewing state-mandated training requirements for naloxone-dispensing pharmacists.
      • Peckham A.M.
      • Niculete M.E.
      • Steinberg H.
      • Boggs D.L.
      A survey of prescribers’ attitudes, knowledge, comfort, and fear of consequences related to an opioid overdose education and naloxone distribution program.
      • Palmer E.
      • Hart S.
      • Freeman P.R.
      Development and delivery of a pharmacist training program to increase naloxone access in Kentucky.
      • Morton K.J.
      • Harrand B.
      • Floyd C.C.
      • et al.
      Pharmacy-based statewide naloxone distribution: a novel “top-down, bottom-up” approach.
      State-mandated training requirements were reviewed for pharmacists dispensing naloxone in states where the legislatures permitted enhanced access to naloxone through pharmacies.
      • Roberts A.W.
      • Carpenter D.M.
      • Smith A.
      • Look K.A.
      Reviewing state-mandated training requirements for naloxone-dispensing pharmacists.
      To date, all states except Nebraska have enhanced pharmacy naloxone access laws, including 43 states with standing orders and 14 state with protocol orders.
      • Davis C.S.
      • Carr D.
      • Southwell J.K.
      • Beletsky L.
      Engaging law enforcement in overdose reversal initiatives: authorization and liability for naloxone administration.
      Prescription Drug Abuse Policy System
      Naloxone prevention overdose laws.
      However, only 19 states require naloxone training or education programs for pharmacists. Specific institutions or multistate chain community pharmacies may have individual requirements for naloxone training outside of state-mandated training. The duration and frequency of required completion varies, but a majority of states consider a one-time continuing education program to be appropriate. Nevada and New Mexico require continuous training for pharmacists on an annual or biannual basis. For the 12 states with active standing orders and naloxone education programs, the topics addressed are variable.
      • Carpenter D.M.
      • Roberts C.A.
      • Westrick S.C.
      • et al.
      A content review of online naloxone Continuing Education courses for pharmacists in states with standing orders.
      All of the programs provided content regarding screening patients at risk for opioid overdose, recognizing signs of overdose, naloxone use, and steps to handle an overdose situation, including calling 911 or emergency medical services. Content included naloxone mechanism of action, onset and duration of action, and necessary follow-up for patients receiving naloxone. In addition, the majority of programs contained background information about opioid overdose and naloxone use including selecting an appropriate product, proper storage, billing, and insurance coverage.
      • Carpenter D.M.
      • Roberts C.A.
      • Westrick S.C.
      • et al.
      A content review of online naloxone Continuing Education courses for pharmacists in states with standing orders.
      Not all programs included information related to pharmacist communication with the patient or caregiver, and only 7 programs recommended evidence-based communication strategies, such as teach-back, use of patient handouts, motivational interviewing, and device instruction.
      Two studies highlighted state-specific approaches to naloxone distribution and training. In New Mexico, the initiation of a statewide standing order and standardized training program resulted in a 9-fold increase in naloxone dispensing by pharmacists.
      • Morton K.J.
      • Harrand B.
      • Floyd C.C.
      • et al.
      Pharmacy-based statewide naloxone distribution: a novel “top-down, bottom-up” approach.
      In Kentucky, participation in a 90-minute in-person or online webinar training on naloxone access and dispensing, opioid overdose, and identifying patients at risk allowed pharmacists to register as a “naloxone-certified pharmacist” with the state board of pharmacy.
      • Palmer E.
      • Hart S.
      • Freeman P.R.
      Development and delivery of a pharmacist training program to increase naloxone access in Kentucky.
      As a result, a large number of pharmacists and student pharmacists were trained and about half of trained pharmacists became certified.
      An additional study examined provider comfort and knowledge regarding opioid overdose and naloxone dispensing. Prescribers who had received training were more comfortable with and expressed less lack of knowledge about opioid overdose and naloxone dispensing compared with those without training, and prescribers who specialized in substance use disorders were most comfortable with and knowledgeable about these topics.
      • Peckham A.M.
      • Niculete M.E.
      • Steinberg H.
      • Boggs D.L.
      A survey of prescribers’ attitudes, knowledge, comfort, and fear of consequences related to an opioid overdose education and naloxone distribution program.
      Overall, much variability exists among naloxone training and education programs, with major differences in program content, requirements for mandatory or voluntary completion, and frequency of completion.

       Educational programs for pharmacy students

      Five studies examined education and training programs that have been conducted in schools of pharmacy across the country.
      • Carpenter D.M.
      • Dhamanaskar A.K.
      • Gallegos K.L.
      • Shepherd G.
      • Mosley S.L.
      • Roberts C.A.
      Factors associated with how often community pharmacists offer and dispense naloxone [e-pub ahead of print].
      • Panther S.G.
      • Bray B.S.
      • White J.R.
      The implementation of a naloxone rescue program in university students.
      • Jacobson A.N.
      • Bratberg J.P.
      • Monk M.
      • Ferrentino J.
      Retention of student pharmacists’ knowledge and skills regarding overdose management with naloxone.
      • Maguire M.A.
      • Pavlakos R.N.
      • Mehta B.H.
      • Schmuhl K.K.
      • Beatty S.J.
      A naloxone and harm reduction educational program across four years of a doctor of pharmacy program.
      • Schartel A.
      • Lardieri A.
      • Mattingly A.
      • Feemster A.A.
      Implementation and assessment of a naloxone-training program for first-year student pharmacists.
      Programs included a live or recorded lecture on opioid overdose and naloxone training or integration of training into skills laboratory courses. Improvements in student confidence in counseling resulted across the studies. In one study, 93% of students reported greater change in confidence after they participated in a skills assessment in addition to a lecture presentation.
      • Carpenter D.M.
      • Dhamanaskar A.K.
      • Gallegos K.L.
      • Shepherd G.
      • Mosley S.L.
      • Roberts C.A.
      Factors associated with how often community pharmacists offer and dispense naloxone [e-pub ahead of print].
      Another study included a unique approach, in which naloxone training and education were developed as a volunteer activity to improve third- and fourth-year student pharmacist ability to counsel patients on naloxone. This approach attained results similar to the other studies.
      • Hines J.
      • Deja E.
      • Black E.P.
      Student pharmacist perceptions of participation in hands-on naloxone counseling.
      Trained student pharmacists facilitated discussions with university students, and survey results showed increased confidence in students’ ability to respond to an overdose situation. Overall, educating pharmacy students through laboratory- and lecture-based learning are effective mechanisms to increase student knowledge and confidence in naloxone dispensing.

      Discussion

      This review reinforces that pharmacists can play a broad and vital role in identifying patients who are at risk of overdose and would benefit from naloxone based on their medication regimens, medical history, and comorbidities.
      • Bailey A.M.
      • Wermeling D.P.
      Naloxone for opioid overdose prevention: pharmacists’ role in community-based practice settings.
      • Adams A.J.
      • Weaver K.K.
      The continuum of pharmacist prescriptive authority.
      • Cochran G.
      • Hruschak V.
      • DeFosse B.
      • Hohmeier K.C.
      Prescription opioid abuse: pharmacists’ perspective and response.
      Preventing opioid overdose–related deaths should become a major focus of the pharmacy profession.
      • Bailey A.M.
      • Wermeling D.P.
      Naloxone for opioid overdose prevention: pharmacists’ role in community-based practice settings.
      This role for pharmacists has been recognized at the state and national levels by making policies more conducive to enabling pharmacists to address the opioid overdose crisis.
      • Penm J.
      • MacKinnon N.J.
      • Boone J.M.
      • Ciaccia A.
      • McNamee C.
      • Winstanley E.L.
      Strategies and policies to address the opioid epidemic: a case study of Ohio.
      • Puzantian T.
      • Gasper J.J.
      Provision of naloxone without a prescription by California pharmacists 2 years after legislation implementation.
      • Evoy K.E.
      • Hill L.G.
      • Groff L.
      • Mazin L.
      • Carlson C.C.
      • Reveles K.R.
      Naloxone accessibility without a prescriber encounter under standing orders at community pharmacy chains in Texas.
      All 50 states had implemented enhanced pharmacy naloxone access laws by 2018, and 19 states required naloxone education for pharmacists engaged in naloxone dispensing or prescribing.
      • Roberts A.W.
      • Carpenter D.M.
      • Smith A.
      • Look K.A.
      Reviewing state-mandated training requirements for naloxone-dispensing pharmacists.
      The standing orders issued by most states allow pharmacists to dispense naloxone via protocol without a written order from a physician, which makes it possible for pharmacists to screen patients at risk of overdose, dispense naloxone, and educate individuals about using naloxone. Despite the standing orders, a widespread issue of pharmacists not stocking naloxone is reported.
      • Meyerson B.E.
      • Agley J.D.
      • Davis A.
      • et al.
      Predicting pharmacy naloxone stocking and dispensing following a statewide standing order, Indiana 2016.
      • Puzantian T.
      • Gasper J.J.
      Provision of naloxone without a prescription by California pharmacists 2 years after legislation implementation.
      • Evoy K.E.
      • Hill L.G.
      • Groff L.
      • Mazin L.
      • Carlson C.C.
      • Reveles K.R.
      Naloxone accessibility without a prescriber encounter under standing orders at community pharmacy chains in Texas.
      • Graves R.L.
      • Andreyeva E.
      • Perrone J.
      • Shofer F.S.
      • Merchant R.M.
      • Meisel Z.F.
      Naloxone availability and pharmacy staff knowledge of standing order for naloxone in Pennsylvania pharmacies.
      Given the need and potential for this role, an important question is how to facilitate a more complete actualization of the role.
      Pharmacists reported a range of barriers, including lack of training for screening patients, communicating with patients about the need for naloxone, lack of time, reimbursement, and lack of support from the management.
      • 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.
      • Nielsen S.
      • van Hout M.C.
      What is known about community pharmacy supply of naloxone? A scoping review.
      Additional barriers included expenses associated with training requirements and limited scope for pharmacist involvement if no standing order or regulatory requirements is in place. Despite these barriers, pharmacists have successfully dispensed naloxone and educated patients about naloxone through training programs which offered structured education, resources, and guidelines for screening patients at risk of overdose.
      Naloxone programs that included screening protocols have aided in pharmacist identification of individuals with a high risk of opioid overdose and facilitated naloxone dispensing. There is a need to more widely disseminate and evaluate protocols and tools to assess and identify individuals with opioid risks. In addition, further evaluation of state laws and collaboration nationally will help to reduce variation in naloxone dispensing practices.
      In considering how to assist a larger-scale adoption of needs screening, education, and dissemination of naloxone, earlier studies offer possible strategies to facilitate these roles. Health systems and pharmacies with initiatives described in the current literature can create institution-specific guidelines or protocols to facilitate identifying patients at risk and offer important tools to build on. These protocols can address assessment roles, criteria for screening and flowcharts for education and disseminating naloxone.
      • Devries J.
      • Rafie S.
      • Polston G.
      Implementing an overdose education and naloxone distribution program in a health system.
      • Tewell R.
      • Edgerton L.
      • Kyle E.
      Establishment of a pharmacist-led service for patients at high risk for opioid overdose.
      Pharmacists have successfully dispensed and educated patients about naloxone following structured programs that offered rigorous training in screening patients at risk of overdose.
      • Penm J.
      • MacKinnon N.J.
      • Boone J.M.
      • Ciaccia A.
      • McNamee C.
      • Winstanley E.L.
      Strategies and policies to address the opioid epidemic: a case study of Ohio.
      • Devries J.
      • Rafie S.
      • Polston G.
      Implementing an overdose education and naloxone distribution program in a health system.
      • Tewell R.
      • Edgerton L.
      • Kyle E.
      Establishment of a pharmacist-led service for patients at high risk for opioid overdose.
      Naloxone kits that include screening protocols help pharmacists in identifying individuals with a high risk of opioid overdose and facilitate pharmacists to dispense naloxone. There is a need to disseminate and evaluate more widely these types of protocols and tools to assess and identify individuals with opioid risks. Dissemination and implementation research on these interventions would facilitate more efficient adoption.
      Although states have varied training programs and requirements for practicing pharmacists about dispensing naloxone, fewer training programs cover topics about screening and communicating with patients about the naloxone prescription. In this regard, some educational programs in schools of pharmacy offer helpful skill enhancement strategies for student pharmacists that might be integrated into programs for practicing pharmacists. In particular, these programs have included guidance about screening and educating patients. Programs with skills assessment have resulted in increased confidence in identifying patients with risk of overdose, dispensing naloxone, and communicating with patients.
      • Jacobson A.N.
      • Bratberg J.P.
      • Monk M.
      • Ferrentino J.
      Retention of student pharmacists’ knowledge and skills regarding overdose management with naloxone.
      • Maguire M.A.
      • Pavlakos R.N.
      • Mehta B.H.
      • Schmuhl K.K.
      • Beatty S.J.
      A naloxone and harm reduction educational program across four years of a doctor of pharmacy program.
      • Schartel A.
      • Lardieri A.
      • Mattingly A.
      • Feemster A.A.
      Implementation and assessment of a naloxone-training program for first-year student pharmacists.
      In addition to standardizing training for practicing pharmacists, education on naloxone and safe opioid use should be integrated into schools of pharmacy. Knowledge about prescription opioid overdose and skills to help patients through overdose counseling are core competencies of pharmacists that can be achieved by education and training at student and pharmacist levels.
      Association for Multidisciplinary Education and Research in Substance Use and Addiction
      Specific disciplines addressing substance use: AMERSA in the 21st Century—2018 update.
      • Hill L.G.
      • Sanchez J.P.
      • Laguado S.A.
      • Lawson K.A.
      Operation Naloxone: overdose prevention service learning for student pharmacists.
      Particular attention is needed to help pharmacists to initiate the conversations with patients in a nonjudgmental and nonthreatening manner because this seems to be an uncomfortable area for many pharmacists. Communication during patient consultations has been identified as a major barrier when pharmacists are not trained about the right terms and content to be used, thereby reducing their confidence to engage with patients in conversations regarding opioid overdose and naloxone use. More research is needed as to why pharmacists are uncomfortable and what can best facilitate their encounters. In addition, there is a necessity for destigmatization of naloxone dispensing and communicating about opioid risks among pharmacists in all practice settings.
      • 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.
      • Thompson E.L.
      • Rao P.S.S.
      • Hayes C.
      • Purtill C.
      Dispensing naloxone without a prescription: survey evaluation of Ohio pharmacists.
      • Paquette C.E.
      • Syvertsen J.L.
      • Pollini R.A.
      Stigma at every turn: health services experiences among people who inject drugs.
      The naloxone communication guide recently made available by the American Pharmacists Association is a helpful resource to guide pharmacists about communication regarding naloxone.
      Pain, Palliative Care, and Addiction Special Interest Group, Academy of Pharmacy Practice and Management, American Pharmacists Association
      Let’s talk about naloxone—it saves lives.
      The Department of Health and Human Services also recommends and provides guidance about coprescribing naloxone for opioid overdose.
      Department of Health and Human Services
      HHS recommends prescribing or co-prescribing naloxone to patients at high risk for an opioid overdose.
      Regarding naloxone training and education programs, more research is needed to promote best practice and standardization of content for consistent education among practicing pharmacists. Interprofessional collaborations and education in interventions about opioid risk counseling and naloxone prescribing have proven to be effective and should be implemented and devised for enhanced patient safety.
      • Hager K.D.
      • Blue H.L.
      • Zhang L.
      • Palombi L.C.
      Opioids: cultivating interprofessional collaboration to find solutions to public health problems.
      • Monteiro K.
      • Dumenco L.
      • Collins S.
      • et al.
      An interprofessional education workshop to develop health professional student opioid misuse knowledge, attitudes, and skills.
      • Han J.K.
      • Hill L.G.
      • Koenig M.E.
      • Das N.
      Naloxone counseling for harm reduction and patient engagement.
      • Follman S.
      • Arora V.M.
      • Lyttle C.
      • Moore P.Q.
      • Pho M.T.
      Naloxone prescriptions among commercially insured individuals at high risk of opioid overdose.
      National associations would then have an added opportunity to facilitate adoption of best practices and competencies for pharmacists dispensing naloxone. With this information, state associations can create education programs that align with state-specific regulations regarding standing orders and naloxone dispensing. Delivering programs via an online module or webinar with assessment questions to assess pharmacist competency adds further dissemination options. However, it is important to retain sensitivity to the need for programs to enhance communication skill development by including role rehearsal and assessment in keeping with best practices of education for self-efficacy and skills enhancement.
      • Bandura A.
      Social cognitive theory: an agentic perspective.
      Little attention has been paid to brochures and materials to assist patient, caregiver, and pharmacist education. Interestingly, patients themselves are an important resource. Pharmacists in one study were more likely to dispense naloxone when patients themselves requested naloxone.
      • Bachyrycz A.
      • Shrestha S.
      • Bleske B.E.
      • Tinker D.
      • Bakhireva L.N.
      Opioid overdose prevention through pharmacy-based naloxone prescription program: innovations in health care delivery.
      This suggests that educating patients about the potential relevance of naloxone and pharmacist roles is another understudied but key issue.

       Limitations

      First, it is important to note that with the accelerated rate of publications addressing pharmacists’ roles and naloxone, updated reviews of this literature are needed to stay abreast of resources and research. Second, the majority of legislation permitting naloxone dispensing by pharmacists was passed within the past few years. Therefore, limited research has been conducted analyzing naloxone dispensing behaviors by pharmacists. Third, of the research available, the population or sample size is limited to individual states or schools of pharmacy. Nevertheless, general trends emerged across studies for both barriers and facilitators. Fourth, only English-language articles were included from only the United States; international experience was not reviewed. Finally, the sustainability of specific interventions presented in the included studies is unknown. It is unclear if results of the original research summarized in this systematic review has been adapted or disseminated to a specific or general pharmacy audience or has influenced policy making directly or indirectly.

      Conclusions and implications

      It is evident from this literature review that pharmacists are now recognized as important to addressing opioid overdose. Policies have been adopted to facilitate their dispensing of naloxone without prescription. Yet at the same time, pharmacists report needing more training and education. A major barrier is the lack of pharmacist confidence about dispensing naloxone and communicating with patients. Educational programs that prepare both practicing pharmacists and student pharmacists are needed to address these areas. Future research on pharmacist perspectives on barriers, education and training, and professional roles will allow for tailored approaches to improve pharmacist confidence in naloxone dispensing and promotion of safe opioid use among patients, including PWUD, and caregivers. In addition, it is important to build on promising approaches with the use of protocols, guidelines, and assessment tools that health systems and pharmacies have implemented to help pharmacists identify patients interested in or in need of naloxone. Early research suggests that the field has begun to generate feasible approaches to help pharmacists actualize their potential roles and which could be adapted and evaluated in a variety of settings for larger dissemination and implementation studies.

      Acknowledgments

      The authors sincerely thank Aaron Gilson for providing constructive feedback on this manuscript.

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      Biography

      Tanvee Thakur, MS, BPharm, PhD student, Department of Social and Administrative Sciences, School of Pharmacy, University of Wisconsin, Madison, WI
      Meredith Frey, BS, 2019 PharmD candidate, School of Pharmacy, University of Wisconsin, Madison, WI
      Betty Chewning, PhD, FAPhA, Professor, Department of Social and Administrative Sciences, School of Pharmacy, University of Wisconsin, Madison, WI