Naloxone Analogy and Opioid Overdose Terminology Preferences among Rural Caregivers: Differences by Race.

BACKGROUND: Despite national and state policies aimed at increasing naloxone access via pharmacies, opioid overdose death rates rose during the COVID-19 pandemic, particularly among Blacks and American Indians (AI) in rural areas. Caregivers, or third parties who can administer naloxone during an overdose event, are important individuals in the naloxone administration cascade, yet no studies have explored rural caregivers' opioid overdose terminology and naloxone analogy preferences or whether these preferences differ by race. OBJECTIVES: To identify rural caregivers' overdose terminology and naloxone analogy preferences and determine whether preferences differ by race. METHODS: A sample of 40 caregivers who lived with someone at high risk of overdose and used pharmacies in four largely rural states was recruited. Each caregiver completed a demographic survey and a 20-45-minute audio-recorded semi-structured interview that was transcribed, de-identified and imported into a qualitative software package for thematic analysis by two independent coders using a codebook. Overdose terminology and naloxone analogy preferences were analyzed for differences by race. RESULTS: The sample was 57.5% White, 35% Black, and 7.5% AI. Many participants (43%) preferred that pharmacists use the term "bad reaction" to refer to overdose events over the terms "accidental overdose" (37%) and "overdose" (20%). The majority of White and Black participants preferred "bad reaction" while AI participants preferred "accidental overdose." For naloxone analogies, "EpiPen" was most preferred (64%), regardless of race. "Fire extinguisher" (17%), "lifesaver" (9.5%), and other analogies (9.5%) were preferred by some White and Black participants but not AI participants. CONCLUSION: Our findings suggest that pharmacists should use the "bad reaction" term and "EpiPen" analogy when counseling rural caregivers about overdose and naloxone, respectively. Caregivers' preferences varied by race, suggesting that pharmacists may want to tailor the terminology and analogy they use when discussing naloxone with caregivers.

Utilization of preventive services by women enrolled in the Affordable Care Act's Health Insurance Marketplace.

The Health Insurance Marketplace has offered access to private health insurance coverage for over 10 million Americans, including previously uninsured women. Per Affordable Care Act requirements, Marketplace plans must cover preventive services without patient cost-sharing in the same way as in employer-sponsored insurance (ESI). However, no study has evaluated whether the utilization of preventive services is similar between Marketplace enrollees and ESI enrollees. Using the Medical Expenditure Panel Survey data for 2014-2016, we identified working-age women with Marketplace plans (n = 792, N = 2,567,292) and ESI (n = 13,100, N = 52,557,779). We compared the two groups' receipt rates of five evidence-based preventive services: blood pressure screening, influenza vaccine, Pap test, mammogram, and colorectal cancer screening. Unadjusted results showed marketplace enrolled women had significantly lower odds of influenza vaccination, Pap test, and mammogram. However, after controlling for other factors, Marketplace insurance was not associated with lower receipt rates of preventive services, except for influenza vaccination (Adjusted OR = 0.64; 95% CI = 0.50-0.82). Regardless of an individual's private insurance type, higher educational attainment and having a usual source of medical care showed the strongest association with the receipt of all investigated preventive services. With the increased role of the Marketplace as a safety net in the COVID-19 pandemic, more research and outreach efforts should be made to facilitate access to preventive services for its enrollees.

Lessons learned recruiting a diverse sample of rural study participants during the COVID-19 pandemic.

Residents of rural areas have been a hard-to-reach population for researchers. Geographical isolation and lower population density in rural areas can make it particularly challenging to identify eligible individuals and recruit them for research studies. If the study is about a stigmatizing topic, such as opioid overdose, recruitment can be even more difficult due to confidentiality concerns and distrust of outside researchers. This paper shares lessons learned, both successes and failures, for recruiting a diverse sample of rural participants for a multi-state research study about naloxone, an opioid overdose reversal agent. In addition, because our recruitment spanned the period before and after the COVID-19 pandemic in the U.S., we share lessons learned regarding the transition to all remote recruitment and data collection. We utilized various recruitment strategies including rural community pharmacy referrals, community outreach, participant referrals, mass emails, and social media with varying degrees of success. Among these modalities, pharmacist referrals and community outreach produced the highest number of participants. The trust and rapport that pharmacists have with rural community members eased their concerns about working with unknown researchers from outside their communities and facilitated study team members' ability to contact those individuals. Even with the limited in-person options during the pandemic, we reached our recruitment targets by employing multiple recruitment strategies with digital flyers and emails. We also report on the importance of establishing trust and maintaining honest communication with potential participants as well as how to account for regional characteristics to identify the most effective recruitment methods for a particular rural area. Our suggested strategies and recommendations may benefit researchers who plan to recruit underrepresented minority groups in rural communities and other historically hard-to-reach populations for future studies.

Medicaid prescription limits and their implications for naloxone accessibility.

BACKGROUND: Expanding access to and utilization of naloxone is a vitally important harm reduction strategy for preventing opioid overdose deaths, particularly in vulnerable populations like Medicaid beneficiaries. The objective of this study was to characterize the landscape of monthly prescription fill limit policies in Medicaid programs and their potential implications for expanding naloxone use for opioid overdose harm reduction. METHODS: A cross-sectional, multi-modal online and telephonic data collection strategy was used to identify and describe the presence and characteristics of monthly prescription fill limit policies across state Medicaid programs. Contextual characteristics were described regarding each state's Medicaid enrollment, opioid prescribing rates, and overdose death rates. Data collection and analysis occurred between February and May 2020. RESULTS: Medicaid-covered naloxone fills are currently subject to monthly prescription fill limit policies in 10 state Medicaid programs, which cover 20 % of the Medicaid population nationwide. Seven of these programs are located in states ranking in the top 10 highest per-capita opioid prescribing rates in the country. However, 8 of these programs are located in states with opioid overdose death rates below the national average. CONCLUSIONS: Medicaid beneficiaries at high risk of opioid overdose living in states with monthly prescription fill limits may experience significant barriers to obtaining naloxone. Exempting naloxone from Medicaid prescription limit restrictions may help spur broader adoption of naloxone for opioid overdose mortality prevention, especially in states with high opioid prescribing rates. Achieving unfettered naloxone coverage in Medicaid is critical as opioid overdoses and Medicaid enrollment increase amid the COVID-19 pandemic.