ReviewWhat is known about community pharmacy supply of naloxone? A scoping review
Introduction
With the rising rates of opioid overdose deaths, naloxone has become one of a range of important strategies to address overdose (Straus, Ghitza, & Tai, 2013). Naloxone has been used for more than 40 years to reverse the effects of opioids in clinical and medical settings. Supply of naloxone for bystander administration is more recently becoming a well-established practice in the United States, Canada and the United Kingdom, with numerous studies and reviews confirming the feasibility, efficacy and cost-effectiveness of such programmes (Bennett et al., 2011, Clark et al., 2014, Coffin and Sullivan, 2013, Giglio et al., 2015, Walley et al., 2013).
Community based naloxone for overdose reversal was first implemented through community based initiatives established through peer-led advocacy work, with the Chicago Recovery Alliance prescribing and dispensing naloxone in an outreach model in 1998 (Maxwell, Bigg, Stanczykiewicz, & Carlberg-Racich, 2006). Iinitial models of supply were based in systems that had a strong harm reduction focus and included peer-training through a developed training curriculum, and supply through peer-outreach services (Maxwell et al., 2006). These early programmes, developed through advocacy from organisations oriented towards the needs of people who inject drugs (PWID), described hundreds of reports of successful reversals of opioid overdose in the first published programme descriptions (Maxwell et al., 2006).
In the past 15 years momentum has gathered to expand the reach take-home naloxone programs for opioid reversal within communities and in order to reach the diverse profile of potential recipients. A shift in the nature of opioid dependence and mortality has been observed in some geographic regions over the same time period, from illicit opioids such as heroin to prescription opioids (Maxwell, 2011, Roxburgh and Burns, 2014). The increased role of prescription opioid medication in overdose fatalities, combined with the desire to expand the geographic reach of take-home naloxone initiatives has brought into sharp focus the opportunity for community pharmacy to become an important outlet and harm reduction partner in responding to concerns around opioid-related mortality.
Although benefits of existing models of naloxone supply are clear, with the involvement of peers and programs embedded in services targeted to reach people who use and inject drugs, there may be a number of advantages to expanding the capacity of community pharmacy as a distribution point for take-home naloxone. Community pharmacies already supply medications to the general public and represent widely accessible health care sites in terms of geographic locations and opening hours. Many patients with an overdose risk may not be in contact with existing providers of take-home naloxone. Those not accessing naloxone through existing services may include pain patients using prescription opioids, in addition to those that choose to avoid services identified for people who use drugs due to concerns such as anonymity. In Scotland and England community pharmacy is already well integrated into the harm reduction provider network, with increasing engagement demonstrated over time (Matheson et al., 2007, Sheridan et al., 2007).
Community pharmacy also has some unique challenges when it comes to the supply of naloxone, in contrast with other existing programmes designed to meet the needs of people who use and inject drugs. Attitudes and knowledge in community pharmacy with respect to harm reduction measures vary greatly, with confidence and attitudes being potential barriers to access as seen in other aspects of substance use treatment (Butler and Sheridan, 2010, Hagemeier et al., 2015). In a study from Scotland it was highlighted that some members of the public may not perceive pharmacies as a suitable location for harm reduction services (Gidman & Coomber, 2014). A study conducted in Tijuana, Mexico found that people who use and/or inject drugs may also show reluctance towards accessing harm reduction services in community pharmacies (Davidson et al., 2012). Preliminary work in Indiana, USA, suggests that pharmacists appear interested in further training in the area of substance use and addiction treatment (Wenthur et al., 2013). A further study of pharmacists in Estonia identified that not all pharmacists understand or support the provision of harm reduction (Vorobjov, Uusküla, Abel-Ollo, Talu, & Jarlais, 2009). There is great variation in different countries with the involvement of community pharmacy in different aspects of harm reduction (Hammett et al., 2014). Levels of engagement with harm reduction more broadly vary between the US, Australia, Europe and the United Kingdom (UK), with supervised dosing of opioid substitution treatments for example not being common practice in the US, in contrast with being an accepted practice model in Australia (Green et al., 2015, Watson and Hughes, 2012). Analyses of changing attitudes over time demonstrate that in Scotland, pharmacists have demonstrated a willingness to receive further training, which in turn appears to increase their participation in harm reduction activities (Matheson, Thiruvothiyur, Robertson, & Bond, 2016).
Given the potential to expand the provision of naloxone initiatives for bystander administration through community pharmacy, the aim of this scoping review was to understand what is currently known about community pharmacy supply of naloxone, with a particular focus on understanding current practice and supply models, and barriers that may need to be addressed in order to embed and optimize the expansion of naloxone supply through this community route.
Section snippets
Methods
Scoping review methodologies have become an increasingly popular and adopted approach across a variety of disciplines in recent years (Anderson et al., 2008, Arksey and O’Malley, 2005, Daudt et al., 2013, Levac et al., 2010, Pham et al., 2014). For the purposes of this study, the definition of a scoping review as a type of research synthesis that aims to ‘map the literature on a particular topic or research area and provide an opportunity to identify key concepts; gaps in the research; and
Results
The initial search identified 93 articles, of which 12 were identified to directly relate to community pharmacy supply of naloxone. A further four references were identified through the review process, including conference presentations and articles identified by the project Expert Group. Five themes were explored after initial review of the data and consultation with the scoping review Expert Group. The themes of (1) Pharmacists’ Perceptions of Naloxone: Facilitators and Barriers, (2) Patient
Discussion
The review scoped the extant available literature around what is known about community pharmacy supply of naloxone. We identified a foundation of work which can inform the direction of provision of naloxone to diverse patient groups and their relatives accessing community pharmacy settings. A range of pharmacy specific supply models and logistical barriers were identified. Further work to address these barriers may help harness to capacity of community pharmacy to extend and enhance the reach
Conclusion
Provision of naloxone for bystander administration to prevent opioid overdose deaths appears increasingly feasible and warranted given the rise in rates of overdose deaths. Community pharmacy supply of take home naloxone warrants further development and consideration, in light of general support from the small number of pharmacists included in research so far. Barriers including cost and remuneration for community pharmacists’ time, and how pharmacists may effectively identify and train
Acknowledgements
SN is supported by a NHMRC Research Fellowship (#1013803). The National Drug and Alcohol Research Centre at the University of New South Wales is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvements Grant Fund. SN is an investigator on a study titled ‘Expanding the capacity of community pharmacy to respond to pharmaceutical opioid problems’, funded by an untied educational grant from Indivior.
Research conducted by MCVH leading to
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