Exploring the harm reduction paradigm: the role of Board-Certified Psychiatric Pharmacists.

Deaths related to opioid overdoses continue to climb, and there remains a need for innovative strategies to address this ongoing crisis. Harm reduction (HR), a nonjudgmental philosophy aimed at reducing consequences associated with drug use and other potentially unsafe behavior, has emerged as a compassionate and effective approach. Harm reduction further emphasizes overdose prevention and fosters a shift in perspective that recognizes substance use disorder as a disease and not a moral failing. The tenets of HR collectively advocate for the well-being of individuals who use substances and support any positive change as defined by the individual. Given the high rate of morbidity and mortality associated with substance misuse and barriers or ambivalence to receiving treatment, awareness of and advocacy for HR practice is essential. This manuscript aims to describe evidence-based HR interventions, provide a foundation for the implementation of services, and further promote the importance of providing humanistic care without judgment. As valued members of the multidisciplinary treatment team, Board-Certified Psychiatric Pharmacists should implement and engage in HR services in the settings where people with substance use disorders receive care.

A theoretical explanation of naloxone provision among primary care physicians and community pharmacists in Tennessee.

BACKGROUND: Increasing access to naloxone reduces opioid-related morbidity and mortality. Primary care and community pharmacy settings are critical access points, yet limited theoretical research has examined naloxone prescribing and dispensing behaviors. OBJECTIVES: To determine if the theory of planned behavior (TPB) combined with theoretical constructs from communication science explains intentions to co-prescribe and discuss co-dispensing naloxone among primary care physicians and community pharmacists, respectively. METHODS: This cross-sectional study surveyed cohorts of licensed primary care physicians and community pharmacists in Tennessee in 2017. Intentions were measured using profession-specific case vignettes, whereby they were asked given 10 similar patients, how many times (0-10) would they co-prescribe or discuss co-dispensing naloxone. Bivariate and multivariable analyses were used. RESULTS: The analytic sample included 295 physicians (response rate = 15.6 %) and 423 pharmacists (response rate = 19.4 %). Approximately 65 % of physicians reported never intending to co-prescribe naloxone (0 out of 10 patients), while 47 % of pharmacists reported never intending to discuss co-dispensing. All TPB constructs-attitudes (AOR = 1.32, CI = 1.16-1.50), subjective norms (AOR = 1.17, CI = 1.06-1.30), and perceived behavioral control (AOR 1.16, CI = 1.02-1.33)-were associated with an increased likelihood of pharmacists always (versus never) discussing co-dispensing. Similarly, two TPB constructs-attitudes (AOR = 1.41, CI = 1.19-1.68) and subjective norms (AOR = 1.22, CI = 1.08-1.39)-were associated with an increased likelihood of physicians always co-prescribing. Among physicians only, one communication construct-self-perceived communication competence (AOR = 1.19, CI = 1.01-1.41)-was associated with an increased likelihood of always co-prescribing. CONCLUSION: Findings support the value of theory, particularly TPB, in explaining primary care physician intentions to co-prescribe and community pharmacist intentions to discuss co-dispensing naloxone.

Describing the decision process of post-operative opioid and pain prescribing patterns in orthopedic and general surgeons.

OBJECTIVE: To describe the post-operative opioid prescribing behaviors of orthopedic and general surgeons through the use of the Integrated Behavioral Model (IBM), and subsequently the steps and logic used by providers in determining post-operative pain prescriptions. DESIGN: This study was a prospective, cross-sectional, cohort study utilizing qualitative methods consisting of semistructured interviews. Data were analyzed using thematic analysis to categorize and identify themes to describe prescriber behavior. SETTING: All participants were from a regional health system in central Appalachia. PATIENTS AND PARTICIPANTS: Mixed population of orthopedic and general surgeons who completed residency training and performed nontraumatic procedures. MAIN OUTCOME MEASURE: Categorization and identification of themes within the constructs of the IBM that described surgeon opioid prescribing. RESULTS: Fifteen surgeons participated in this study. Themes were identified within the context of the IBM. Attitudes by surgeons consisted of blame toward the government, a lack of personal screening of patients, and a theme of the abusing population of patients only being a small group. Norms were identified that included prescribing based on a standard prescribing set, realization of patient fear, and the idea of past mentality. Surgeons believed in their ability to prescribe responsibly and conservatively. CONCLUSIONS: The prescribing patterns of surgeons and their keenness to assess patients for opioid abuse vary. Most surgeons did not actively participate in screening activities but rely on ancillary staff. Surgeons utilize federal and state laws to back prescribing patterns and thwart patient attempts for additional medications. Prescribers maintain a sense of self-confidence with their own knowledge and ability to taper and keep patients from becoming reliant on opioid prescribing.

Patient-reported perceptions of brexanolone in the treatment of postpartum depression: A qualitative analysis.

Introduction: Brexanolone demonstrates short-term efficacy for the treatment of postpartum depression (PPD). Postpartum depression is linked to infanticide and maternal suicide, and current treatment often fails to adequately control depressive symptoms. The purpose of this analysis is to further understand the experience(s) of women who have received brexanolone for the treatment of PPD. Methods: Semistructured interviews modeled after the theory of planned behavior (TPB) were conducted to assess women's perceptions of treatment for PPD with brexanolone. Women who received treatment with brexanolone at this inpatient facility were eligible to participate in this study. The TPB is often used to predict intention to perform health-related behaviors. Semistructured interviews were recorded and transcribed, and thematic analysis was conducted to identify common ideas across all interviews. Follow-up assessment of depressive and anxious symptoms was also conducted using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), respectively. Results: Five of the 10 women who received treatment with brexanolone at this facility were interviewed, and common themes related to the TPB were analyzed. Attitudes toward brexanolone were favorable, and having a strong support system was a motivating factor in receiving treatment for PPD. Insurance approval, need for childcare, and poor understanding of symptoms of PPD were barriers to receiving treatment with brexanolone. Symptoms of depression and anxiety were rated as low at the time of the follow-up interview as measured by the PHQ-9 (mean 1.6, range 1 to 3) and GAD-7 (mean 2.8, range 2 to 4), respectively. Discussion: Brexanolone rapidly and sustainably reduced symptoms of PPD and was well-received by patients. Despite significant barriers to use, women who received treatment with brexanolone advocated for its availability as well as increased awareness of PPD.

Community pharmacist engagement in opioid use disorder prevention and treatment behaviors: A descriptive analysis.

OBJECTIVES: This study describes community pharmacists' opioid analgesic and medication for opioid use disorder (MOUD) practice behaviors and behavioral intentions in the context of primary, secondary, and tertiary prevention of opioid use disorder (OUD). METHODS: The study sampling frame consisted of 2302 Tennessee community-practice pharmacists who were asked to complete a mailed, paper questionnaire. Behavioral intentions were elicited by asking pharmacists to indicate the number of times (0 to 10) they engage in a behavior, given 10 patients in 3 distinct vignettes. Perceptions of evidence-based MOUD and pain management patient care practices were also elicited. RESULTS: A response rate of 19.7% was achieved. Pharmacists reported using a brief questionnaire to evaluate risk of opioid misuse with 2.1 ± 3.7 (mean ± SD) out of 10 patients, screening 2.1 ± 3.7 patients for current opioid misuse, discussing co-dispensing of naloxone with 2.9 ± 3.4 to 3.3 ± 4 out of 10 patients at a risk of overdose, and dispensing buprenorphine/naloxone to a mean of 4.6 ± 4.2 patients when they presented a prescription. Respondents perceived 38% of pain management and 30% of MOUD prescribers in their area to practice evidenced-based care. CONCLUSION: Pharmacists have an opportunity to improve the outcomes for patients prescribed opioids by increasing engagement across OUD prevention levels.

Abuse-Deterrent Opioid Formulations: A Key Ingredient in the Recipe to Prevent Opioid Disasters?

The US Food and Drug Administration (FDA) is encouraging the innovation of long-acting opioid formulations that are manipulation-resistant. The purpose of this commentary is to assess the benefits and limitations of abuse-deterrent opioid formulations (ADFs) and discuss their role in mitigating the current opioid epidemic. ADFs have been created with chemical properties that make it difficult for people who non-medically use prescription drugs to crush and dissolve opioid tablets, as well as by combining opioids with antagonists such as naloxone or naltrexone, which are released only when the dosage form has been manipulated or the drug is taken by a non-intended route. Despite these and other technologies, consensus regarding the effectiveness of these formulations in preventing non-medical use is lacking given the difficulty in obtaining post-marketing data. Researchers also question if the creation of abuse-deterrent drugs will have a positive effect on those struggling with a severe opioid-use disorder, fearing that current opioid users will simply find a new - perhaps more dangerous - drug of choice. Abuse-deterrent opioids are still opioids, and although they may make manipulation more difficult than non-ADF formulations, they are not "abuse proof." The introduction of ADFs could provide a false sense of security among prescribers and dispensers, and we fear that ADFs may have a minimal impact on non-medical use of prescription opioids. Further epidemiological studies will be required to determine the large-scale impact of abuse-deterrent opioids in preventing opioid use disorder and its downstream consequences.