North Carolina Pharmacist Volume 105 Number 2 by North Carolina Association of Pharmacists

Call for Articles

North Carolina Pharmacist (NCP) is currently accepting articles for publication consideration. We accept a diverse scope of articles, including but not limited to: original research, quality improvement, medication safety, case reports/case series, reviews, clinical pearls, unique business models, technology, and opinions.

NCP is a peer-reviewed publication intended to inform, educate, and motivate pharmacists, from students to seasoned practitioners, and pharmacy technicians in all areas of pharmacy.

Articles written by students, residents, and new practitioners are welcome. Mentors and preceptors – please consider advising your mentees and students to submit their appropriate written work to NCP for publication.

Don’t miss this opportunity to share your knowledge and experience with the North Carolina pharmacy community by publishing an article in NCP.

Click on Guidelines for Authors for information on formatting and article types accepted for review.

For questions, please contact Tina Thornhill, PharmD, FASCP, BCGP, Editor, at tina.h.thornhill@ gmail.com

North Carolina Pharmacist is the official journal of the North Carolina Association of Pharmacists

Located at: 1101 Slater Road, Suite 110 Durham, NC 27703

Phone: (984) 439-1646

Fax: (984) 439-1649

www.ncpharmacists.org

Official Journal of the North Carolina Association of Pharmacists

1101 Slater Road, Suite 110

Durham, NC 27703

Phone: (984) 439-1646

Fax: (984) 439-1649

www.ncpharmacists.org

EDITOR-IN-CHIEF

Tina Thornhill

LAYOUT/DESIGN

Rhonda Horner-Davis

EDITORIAL BOARD MEMBERS

Anna Armstrong

Jamie Brown

Lisa Dinkins

Jean Douglas

Brock Harris

Amy Holmes

John Kessler

Angela Livingood

Bill Taylor

BOARD OF DIRECTORS

EXECUTIVE DIRECTOR

Penny Shelton

PRESIDENT Bob Granko

PRESIDENT-ELECT

Tom D’Andrea

PAST PRESIDENT

Ouita Gatton

TREASURER

Ryan Mills

SECRETARY

Beth Caveness

Cassey Zendarski, Chair, SPF

Micaela Hayes, Chair, NPF

Cornelius Toliver, Chair, Community

Tyler Vest, Chair, Health-System

Kimberly Hayashi, Chair, Chronic Care

Mackie King, Chair, Ambulatory

Angela Livingood, At-Large

Elizabeth Locklear, At-Large

Macary Weck Marciniak, At-Large

North Carolina Pharmacist (ISSN 0528-1725) is the official journal of the North Carolina Association of Pharmacists. An electronic version is published quarterly. The journal is provided to NCAP members through allocation of annual dues. Opinions expressed in North Carolina Pharmacist are not necessarily official positions or policies of the Association. Publication of an advertisement does not represent an endorsement. Nothing in this publication may be reproduced in any manner, either whole or in part, without specific written permission of the publisher.

North Carolina Pharmacist

Welcome to my second installment for the North Carolina Association of Pharmacists. As I write this, I am just over halfway through my presidency. Time is flying!

As I continue to build on my theme of being “Of Service,” I am reminded of the commitment I witnessed at the NCAP Annual Convention right here in my hometown of Cary, NC. Spending time with many of you and listening to the talented speakers from across the state and different practice settings was truly inspiring. Those conversations serve as the backdrop for this column and hopefully capture our collective commitment to advancing pharmacy practice through advocacy while maintaining our core value of service to our patients and communities.

Service has always been at the heart of pharmacy. As pharmacists, we are trusted healthcare providers, counselors, and advocates. Our roles encompass many facets of patient care, including educating patients, managing chronic diseases, and ensuring the safe and effective use of medications. NCAP is the home for pharmacists and pharmacy technicians, regardless of practice setting. In the coming year, NCAP and its leadership will continue to work on behalf of its members and those who have not yet joined our association, uniting, serving, and advancing our profession.

Robert P. Granko, PharmD, MBA, FASHP, FNCAP

Embracing the Future: A Vision of Service and Innovation

To truly make a difference, we must also look to the future and embrace innovation. The healthcare landscape is rapidly evolving, and we must be proactive in shaping that change through advocacy efforts. This involves enlisting others in our vision – from fellow pharmacists and pharmacy technicians to healthcare professionals, policymakers, and the public. Collaboration and teamwork are essential in addressing the complex health challenges we face today.

In our pursuit of excellence, we must continually search for opportunities to advance our profession. This means staying abreast of the latest research, technologies, and best practices. It also means advocating for policies that support pharmacists in expanding their scope of practice, allowing us to utilize our full potential in delivering comprehensive care.

Experimentation and a willingness to take risks are crucial in this journey. Innovation often requires stepping out of our comfort zones and exploring new ideas and approaches. This idea, “Off the Beaten Path: Trekking Toward Transformative Practice,” was illustrated well by our convention speakers, who encouraged us to be bold and adaptable across all patient care settings.

In closing, join me in a year of service and innovation. By envisioning a bold future, enlisting others, seeking oppor-

tunities, and daring to experiment, we can elevate the practice of pharmacy and continue to make a lasting impact on the health and well-being of our communities. Together, we can create a brighter, healthier future for all.

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Using Community Engagement Approach to Enhance Contraception Awareness in Female Undergraduate Students

By: Carson Helms, Doctor of Pharmacy Candidate, Emily Hiller, Doctor of Pharmacy Candidate, Yassmin Honeine, Doctor of Pharmacy Candidate, Josephine Ariella Lovings, Doctor of Pharmacy Candidate, Vidhi Shah, Doctor of Pharmacy Candidate, and Dr. Edward T. Chiyaka

Introduction

Safe sex education is crucial to ensuring the health and development of youth, the reduction of unnecessary health risks, and the improvement of opportunities for education. (1) Sexual health-related issues are wide-ranging and involve many factors, including sexual orientation, sexual expression, and relationships. (2) The number of women seeking family planning has continued to rise since the early 2000s. (3) Despite increased numbers of women seeking out contraception, the total of unintended pregnancies continues to rise. According to the World Health Organization, 55% of unintended pregnancies in females aged 15-19 years old end in abortion. (2) This statistic and others have driven the creation of community programs that promote both contraception use and safe sex practices to become prevalent within the United States. (4)

Research shows that individuals with lower levels of education have less knowledge of sexual health, including contraception, which leads to worse sexual health outcomes when compared to those with higher education. (5) In North Carolina, there are several counties with a large population with less than a high school diploma. (6) Statewide programs that seek to promote contraception knowledge and utilization have been implemented in counties with low high school graduation rates. (7) The effectiveness of these programs has been investigated by evaluating community knowledge and perceptions of promoting safe sex practices to increase both participants’ knowledge and confidence, leading to a reduction in unintend-

ed pregnancies and the spreading of sexually transmitted infections (STI). (9-11)

An earlier study highlights how the COVID-19 pandemic impacted the mental, physical, and social health of adolescents and young adults ages 12-24 years. (12) While the strategy of increasing contraception knowledge to prevent unplanned pregnancies is typically discussed in adolescent education, this emphasis fades quickly once people enter adulthood. (13) According to the Sexuality Information and Education Council of the United States (SIECUS), the COVID-19 pandemic caused a significant disruption in sex education for female adolescents aged 17-18 years old from 2019 to 2021, increasing the likelihood of unwanted pregnancies. (14) SIECUS directly attributed this gap in education to the COVID-19 pandemic, which has led to increased unplanned pregnancies within the past four years. (15) Furthermore, the shift to virtual learning during the COVID-19 pandemic also decreased the confidence and knowledge of contraception use. (16)

College-aged students (between 1829 years old) have the highest rates of unplanned pregnancy when compared to other women in the United States. (17) On a global scale, the number of unplanned pregnancies is significantly higher in the United States when compared to other developed countries. (18) This issue has major implications, as unexpected pregnancies account for approximately 7% of college dropouts nationwide, with an astounding 61% of these individuals declining to re-enroll to finish their educa-

tion. (19) In terms of financial stress, the average cost of pregnancy in the United States is almost $20,000, not to mention the cost of raising a child that follows afterward. (20) It also comes with the potential for physical harm and can cause anemia, depression, and heart conditions that might not cease once the pregnancy is over. (21) Effective contraception use requires more than just the choice to use one; every form of contraception is imperfect due to ease of misuse or varied effectiveness rates, so it is vital that the users receive education on their chosen method. Previous research on young adults aged 18-29 years old revealed a troubling lack of knowledge, with nearly 25% of women having little awareness of basic contraceptive methods such as condoms, pills, injectables, and IUDs. (17)

Sexually transmitted diseases are another health consequence that disproportionately impacts college students because of a lack of information about contraception. In 2020, only 51% of sexually active adolescents reported using a condom, which is one of the main STI preventatives. (22) The highest rates of STIs are reported among college students, with 61% of the national chlamydia cases being made up of 15-24-year-olds. (23) Proper screening and education, specifically for adolescents, are crucial in decreasing the spread of STIs, including efforts such as the HPV vaccine. (24) Due to the increase in telehealth visits, the screening and treatment of STIs have decreased, even with the increased focus on routine screening for younger females. (12) Research indicates that the person who is teaching young

adults about contraception and how it can prevent STIs can affect how well the information is comprehended. School-based peer-led education increased the use of contraception in under-resourced settings. (25) This gives students the opportunity to step up and help educate their peers and provide a safe space for discussion and learning.

The purpose of this study is to assess the current level of contraception knowledge and awareness among female undergraduate students and to evaluate the effectiveness of a community engagement program in increasing the same factors. We hypothesized that providing contraception education to female undergraduate students would improve their knowledge and confidence about their use. Previous studies have examined the effect of educational intervention in larger communities, as mentioned earlier, leaving a gap in research on the effect in much more specific populations. Therefore, the results of this study could show the benefit of a brief educational intervention in a much more defined population of female undergraduate students.

Methods

Undergraduate female students at least 18 years old enrolled at Wingate University were surveyed regarding their knowledge and confidence of contraception use using a pre-post study. Participants were asked to attend a 10-minute-long PowerPoint presentation that covered various types of contraception. Before the presentation, participants were instructed to complete an anonymous electronic survey. Within the survey, participants answered questions about their demographics, sexual experiences, attitudes towards, and knowledge of contraception. Immediately after the completion of the presentation, participants were instructed to complete a post-survey that included the same demographic, attitude, and knowledge questions as the pre-survey. The pre-survey and post-survey were both administered via QualtricsXM, which was accessible using a QR code or a shareable link. The study was approved by the Research Review Board of Wingate University.

Pre- and post-survey data collected from QualtricsXM was imported into Microsoft

Excel (Version 16.81) and combined into a singular dataset for data cleaning and analysis. The initial sample consisted of 43 undergraduate students. After the inclusion criteria were applied, the final sample included 33 participants. The 10 participants were excluded due to being male, under the age of 18 years, or not being a current Wingate undergraduate student.

Data Analysis

The data was collected through two questionnaires that were composed of four sections. The sociodemographic section had five questions, including age, religion, sexual orientation, associated university organization, and marital status. The sexual initiation section had six questions regarding previous sexual experience, number of sexual partners in the past five years, previous contraception use, first contraception used, and reasoning for using or not using contraception. There were five questions focusing on the participant’s attitude towards contraception that were answered on a scale from strongly agree to strongly disagree. The contraception knowledge section consisted of 5 items assessed through multiple-choice questions, which were recorded during analysis as the number of correct responses.

Data were analyzed using Microsoft Excel software version 16.81. T-tests were used to assess differences in knowledge levels, while chi-square tests of proportions were used to assess the change in perceptions and attitudes. A p-value less than 0.05 established statistical significance in this study.

Results

Most participants (78.8%) were between the ages of 18-20 years, identified as Christian (66.7%), heterosexual (68.8%), and were associated with the University Athletic Team (31.4%). All participants reported being unmarried. The characteristics of the participants are shown in Table 1.

Participants were asked to report previous sexual experiences, number of sexual partners in the past five years, previous contraception use, first contraception

method used, and reason for using/not using contraception. Out of the 33 participants, only 15 (45.5%) reported having a previous sexual experience. Of the participants who reported having previous sexual experience, 80% of them reported having used contraception. Additionally, the majority of the participants (73.3%) cited pregnancy prevention as the reason for using contraception. Moreover, the majority of participants (53.3%) reported using the barrier method as their first method of contraception. There were 3 participants who reported not using contraception due to respondent opposition, partner opposition, or lack of contraception access. Table 2 shows a summary of sexual patterns and contraception use of participants who reported having previous sexual experience.

Further analysis showed that heterosexual women used contraception for pregnancy prevention, whereas some homosexual or bisexual women used contraception to prevent sexually transmitted infections. Women in the older age range, 21-25, reported the highest numbers of previous sexual partners over the past five years.

The survey results show a significant improvement in students’ attitudes and knowledge about contraception after the intervention. Notably, the percentage of students who felt competent in making contraception decisions increased significantly, from 87.9% to 93.9%. Furthermore, perceptions of contraception accessibility in the community or on campus improved significantly, rising from 72.7% to 81.8%. Additionally, the number of students who knew where to purchase various contraceptives and students’ comfort levels in discussing contraception techniques with healthcare practitioners increased by about nine percentage points. Despite these gains, there was no substantial change in the fear of judgment about contraception, which remained stable at 42.4%. All reported p-values are above 0.05, suggesting that the observed changes in students’ attitudes and perceptions towards contraception may not be statistically significant. Table 3 shows a summary of pre- and post-intervention survey results on contraception attitudes and perceptions among students.

Changes in contraception knowledge were more substantial compared to changes in

attitudes, as shown in Figure 1. Pre-survey results showed that 93.8% of participants correctly answered the question about potential side effects of birth control pills, and post-survey results showed the same result to the same question. The questions addressing the length of time the vaginal ring is left in place, and the advantages of male condoms over other birth control methods received the fewest correct responses (18.2% and 27.3%, respectively) before the intervention. The question concerning the length of the vaginal ring was the one that received the most percentage of “unsure” responses. There was an improvement in general awareness of contraception following the session. All the knowledge questions had a higher percentage of correct responses. But with an increase of 46.5%, p = 0.002, the only question that had the biggest change and demonstrated statistical significance was “How long is the vaginal ring left in place?” Another big change following the intervention was noted for the question that sought to identify barrier methods of birth control with a change of about 25 percentage points.

Discussion

The objective of this study was to assess students’ attitudes and perceptions on contraception as well as to assess the level of contraception knowledge and awareness among female undergraduate students while evaluating the effectiveness of a community health engagement program. The study analyzed participants’ knowledge of and attitudes towards contraception, noting positive improvements between pre- and post-surveys. Approximately 46% of the participants indicated having a prior sexual experience. This finding sheds light on the diversity of sexual experiences and behaviors among female college students and can help inform strategies for sexual health education. Prior to the intervention, the participants’ average knowledge level was about 44.8%, which rose to 66.4% thereafter. Meanwhile, the participants’ attitudes towards contraception increased from 70.3% to 76.3%.

Our study findings showed an increase in attitudes and perceptions towards contraception after the brief intervention. However, the changes between pre- and

post-survey were not statistically significant. The inability of a short intervention to significantly improve a participant’s attitude towards contraception could be due to a multitude of reasons, such as the small sample size as well as participant characteristics, including the previous sexual education received, previous sexual experiences, and religion. Further analysis of participants’ religion and sexual behavior indicated that all Muslim women who were surveyed reported no previous sexual intercourse compared to Christians and Atheists. With Islam being a religion that disapproves of sex before marriage, it is not surprising that unmarried women might have worse attitudes and knowledge levels towards contraception as they have not necessarily had personal experience with them. It is already known that racial and ethnic minorities often have lower rates of contraception utilization compared to the general public.26 This shows the significance of making sure young women are receiving thorough and appropriate contraception education regardless of religious beliefs so they will be aptly prepared later on in life.

An intervention consisting of contraception education has been carried out before with similar results that involved peer education led by nursing students.27 After the education was carried out, a more statistically significant difference was seen in changes in knowledge versus attitudes towards contraception. These findings are in sync with our findings, where statistically significant differences were observed in knowledge level versus attitude. The study completed by Sanz-Martos et al. showed 81.04% of the sample as having sexual intercourse previously, whereas our study reports 45%. This could explain why the previous study had more success in seeing larger statistical significance, as people who are currently sexually active are going to be more interested in learning about contraception, whereas others will see that it doesn’t apply to them and not comprehend the knowledge as thoroughly.

Many practical applications can be drawn from this research. As mentioned previously, to promote positive changes in contraception use confidence levels, a longer intervention is needed. However, this study has shown that a very short intervention can also help improve contra-

ception knowledge levels and potentially lead to changes in health behavior. This can be applied to other settings, such as medical offices, schools, or community programs, by showing that even education that lasts only a few minutes long can be comprehended and remembered by the participant, potentially leading to safer decisions down the road. Brief contraception education will be a simple thing to integrate into many scenarios to help improve sexual education.

While our study offers valuable insights into contraception knowledge and utilization among female undergraduate students, it also has some limitations. Participants were only selected from one university and had to be involved in some kind of extracurricular activity. As a result, the findings may not be generalized to other universities or students who were not in any of the targeted groups. The survey also excluded males, so these results can only be applied to one gender, and the sample size that could be reached is restricted. Future research is needed to complete the understanding of the pathways connecting undergraduate students’ attitudes and knowledge to outcomes later in life, including potential change in attitude and knowledge as someone ages. This study has shown the need for more research on contraception knowledge and use among college students. As this short study did not show a significant improvement, perhaps a study that spanned over a longer period with a large sample would produce a better result.

Conclusion

A brief community engagement program was conducted among female undergraduate students to help enhance their understanding of contraception. Following the intervention, participants exhibited heightened confidence and knowledge levels on contraception use. The educational focus on contraception methods not only strengthened participants’ understanding but also influenced their attitudes toward contraception, increasing the likelihood of their utilization in future sexual encounters. Targeting female undergraduate students is crucial for mitigating the risk of unwanted pregnancies and sexually transmitted diseases.

Authors: Carson Helms, Doctor of Pharmacy Candidate, Wingate University School of Pharmacy; Emily Hiller Doctor of Pharmacy Candidate, Wingate University School of Pharmacy; Yassmin Honeine, Doctor of Pharmacy Candidate, Wingate University School of Pharmacy; Josephine Ariella Lovings, Doctor of Pharmacy Candidate, Wingate University School of Pharmacy; Vidhi Shah, Doctor of Pharmacy Candidate, Wingate University School of Pharmacy; Edward T. Chiyaka, Ph.D., Assistant Professor, Wingate University School of Pharmacy Email: e.chiyaka@wingate.edu

References

1. Sweya, M. N., Msuya, S. E., Mahande, M. J., & Manongi, R. (2016). Contraceptive knowledge, sexual behavior, and factors associated with contraceptive use among female undergraduate university students in Kilimanjaro region in Tanzania. Adolescent health, medicine and therapeutics, 7, 109–115. https://doi.org/10.2147/AHMT. S108531

2. World Health Organization. Sexual Health. Geneva: World Health Organization; 2023. [Accessed September 21, 2023]. Available from: https://www.who.int/health-topics/ sexual-health#tab=tab_1

3. United Nations Department of Economic and Social Affairs, Population Division (2022). World Family Planning 2022: Meeting the changing needs for family planning: Contraceptive use by age and method. UN DESA/POP/2022/TR/NO.

4. Lopez, L. M., Bernholc, A., Chen, M., & Tolley, E. E. (2016). School-based interventions for improving contraceptive use in adolescents. The Cochrane database of systematic reviews, 2016(6), CD012249. https://doi.org/10.1002/14651858. CD012249

5. Guzzo, K. B., & Hayford, S. R. (2018). Adolescent Reproductive and Contraceptive Knowledge and Attitudes and Adult Contraceptive Behavior. Maternal and Child Health Journal, 22(1), 32–40. https://doi. org/10.1007/s10995-017-2351-7

6. Future NC. NC Educational Attainment Dashboard. Demographic Information, 2018 [Accessed November 10, 2023] Available from: https://dashboard.myfuturenc.org/county-explorer/

7. Upstream USA. North Carolina - Upstream USA. [Accessed November 10, 2023]. Available from: https://upstream.org/ partnerships/north-carolina/

8. Coyle, K., Anderson, P., Laris, B. A., Barrett, M., Unti, T., & Baumler, E. (2021). A

Group Randomized Trial Evaluating High School FLASH, a Comprehensive Sexual Health Curriculum. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 68(4), 686–695. https://doi.org/10.1016/j. jadohealth.2020.12.005

9. Spach NC, Thach SB, Dellinger CB, Ritter EQ, Galvin SL. Using a Community Engagement Approach to Enhance Contraception Awareness in Rural Western North Carolina. N C Med J. 2021 NovDec;82(6):377-383.

10. Birgisson, N. E., Zhao, Q., Secura, G. M., Madden, T., & Peipert, J. F. (2015). Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review. Journal of women’s health (2002), 24(5), 349–353. https://doi.org/10.1089/ jwh.2015.5191

11. Lightfoot, A. F., Taboada, A., Taggart, T., Tran, T., & Burtaine, A. (2015). ‘I learned to be okay with talking about sex and safety’: assessing the efficacy of a theatre-based HIV prevention approach for adolescents in North Carolina. Sex education, 15(4), 348–363. https://doi.org/10.1 080/14681811.2015.1025947

12. Lindberg LD, Bell DL, Kantor LM. The Sexual and Reproductive Health of Adolescents and Young Adults During the COVID-19 Pandemic. Perspect Sex Reprod Health. 2020 Jul;52(2):75-79. doi: 10.1363/psrh.12151. Epub 2020 Jul 21.

13. Solomon D, Pantalone DW, Faja S. Autism and Adult Sex Education: A Literature Review using the Information-Motivation-Behavioral Skills Framework. Sex Disabil. 2019 Sep;37(3):339-351. doi: 10.1007/s11195-019-09591-6. Epub 2019 Aug 12.

14. Siecus. (2022, February 22). Siecus 2021 Sex Ed State Legislative Mid-year report SIECUS. https://siecus.org/siecus-2021sex-ed-state-legislative-mid-year-report/

15. Stavridou A, Samiakou C, Kourti A, et al. Sexual Activity in Adolescents and Young Adults through COVID-19 Pandemic. Children (Basel). 2021;8(7):577. Published 2021 Jul 5. doi:10.3390/children8070577

16. Diamond-Smith N, Logan R, Marshall C, Corbetta-Rastelli C, Gutierrez S, Adler A, Kerns J. COVID-19’s impact on contraception experiences: Exacerbation of structural inequities in women’s health. Contraception. 2021 Dec;104(6):600-605. doi: 10.1016/j.contraception.2021.08.011. Epub 2021 Aug 27.

17. Frost, J.J., Lindberg, L.D. and Finer, L.B. (2012) ‘Young adults’ contraceptive knowledge, norms and attitudes: Associations with risk of unintended pregnancy’, Perspectives on Sexual and Reproductive Health, 44(2), pp. 107–116. doi:10.1363/4410712.

18. Unintended pregnancy in the United States [Internet]. 2022 [Accessed 2024

Feb 6]. Available from: https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states

19. The National Campaign to Prevent Teen and Unplanned Pregnancy. (2015, July). Unplanned pregnancy among college students and strategies to avoid it. Power To Decide. https://powertodecide.org/sites/ default/files/resources/primary-download/briefly-unplanned-pregnancy-college.pdf

20. Rae, M., Cox, C., & Dingel, H. (2022, July 13). Health costs associated with pregnancy, childbirth, and postpartum care. Health System Tracker. https:// www.healthsystemtracker.org/brief/ health-costs-associated-with-pregnancy-childbirth-and-postpartum-care/

21. Centers for Disease Control and Prevention. (2023, February 8). Pregnancy complications. Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/ pregnancy-complications.html

22. The Lancet Child & Adolescent Health. Youth Stis: An epidemic fuelled by shame. The Lancet Child & Adolescent Health. 2022;6(6):353. doi:10.1016/ s2352-4642(22)00128-6

23. Reeves, J. M., Zigah, E. Y., Shamrock, O. W., Aidoo-Frimpong, G., Dada, D., Batten, J., Abu-Ba’are, G. R., Nelson, L. E., & Djiadeu, P. (2023). Investigating the impact of stigma, accessibility and confidentiality on STI/STD/HIV self-testing among college students in the USA: protocol for a scoping review. BMJ open, 13(2), e069574.

24. Shannon CL, Klausner JD. The growing epidemic of sexually transmitted infections in adolescents: A neglected population. Current Opinion in Pediatrics. 2018;30(1):137–43. doi:10.1097/ mop.0000000000000578

25. Wondimagegene YA, Debelew GT, Koricha ZB. Effectiveness of peer-led education interventions on contraceptive use, unmet need, and demand among adolescent girls in Gedeo Zone, South Ethiopia. A cluster randomized controlled trial. Global Health Action. 2023;16(1). doi:10.1080/1 6549716.2022.2160543

26. Budhwani, H., Anderson, J., & Hearld, K. R. (2018). Muslim Women’s use of contraception in the United States. Reproductive health, 15(1), 1. https://doi.org/10.1186/ s12978-017-0439-6

27. Sanz-Martos, S., López-Medina, I. M., Álvarez-García, C., & Álvarez-Nieto, C. (2021). Educational program on sexuality and contraceptive methods in nursing degree students. Nurse Education Today, 107, 105114. https://doi.org/10.1016/j. nedt.2021.105114

Table 1: Characteristics of participants

Age

18 – 20 years

Religion

Sexual Orientation

Heterosexual

University Organization

Table 2: Sexual behavior and contraception use of participants with previous sexual experience (n = 15) Count (%)

Table 3: Summary of pre- and post-intervention survey results on contraception attitudes and perceptions among students

Percentage of students that selected Agree or Strongly Agree

I feel confident in making decisions in regard to contraception

Contraception is easily accessible within my community/ campus.

I know where to obtain various contraceptives.

I feel comfortable discussing contraception methods with my primary care provider and/or the campus health center.

I fear judgment from my family, co-workers, peers, and/or members of my community in regard to using contraception.

Figure 1: Participants’ knowledge of contraception as assessed in both pre-survey and post-survey assessments.

World Contraception Day

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Myths, Misconceptions, and Truths about Buprenorphine

By: Dr. Daniel M. Strickland and Dr. Cheryl Viracola

Recently, a pharmacist working in a North Carolina branch of a national chain pharmacy refused to fill an electronic prescription for buprenorphine mono-product (BUP, without naloxone) for a patient of mine. They claimed that the policy of the parent company was to decline prescriptions for the mono-product unless the patient was allergic to naloxone.

When I heard about the problem and called the pharmacy, another pharmacist was on duty. I explained that the patient experienced severe headaches for several hours after taking the combination product (buprenorphine plus naloxone - BUPNx) but had no problem with the mono-product. The pharmacist filled the prescription. When a representative of the NC Association of Pharmacists (NCAP) was later able to query the original pharmacist, the alleged company policy could not be verified. The NCAP representative also contacted the company’s Executive Director of Regulatory Affairs, who revealed that there was no such company policy - to wit:

… The situation you described below to have documented allergy to dispense the mono-product is not (company) policy. The mono-product may be a potential red flag, but the pharmacist can resolve the red flag and dispense using their professional judgment (1).

Burson (2) also reported other recent problems with patients obtaining buprenorphine. “We have an urgent situa-

tion afflicting rural areas in North Carolina and across our nation. Patients new to buprenorphine treatment cannot find pharmacies willing to fill their prescriptions.”

For the record, I understand and respect the authority of the dispensing pharmacist to decline a prescription:

SECTION .1800 - PRESCRIPTIONS 21 NCAC 46 .1801 EXERCISE OF PROFESSIONAL JUDGMENT IN FILLING PRESCRIPTIONS (a) A pharmacist or device and medical equipment dispenser shall have a right to refuse to fill or refill a prescription order if doing so would be contrary to his or her professional judgment. (b) A pharmacist or device and medical equipment dispenser shall not fill or refill a prescription order if, in the exercise of professional judgment, there is or reasonably may be a question regarding the order’s accuracy, validity, authenticity, or safety for the patient. (c) A prescription order is valid only if it is a lawful order for a drug, device, or medical equipment issued by a health care provider for a legitimate medical purpose, in the context of a patient-prescriber relationship, and in the course of legitimate professional practice as recognized by the occupational licensing board governing the health care provider (3).

I discussed the issue with the representative of NCAP, who, in their professional opinion, believes that the prescription and my call to the pharmacist should have satisfied any reservations about its accuracy and validity. They also highlighted the importance of avoiding reliance on

unconfirmed company policies, which in this case only resulted in patient distress and wasted time and effort on the part of the prescriber.

In today’s complex healthcare landscape, where patient care is paramount, it is crucial to foster an environment of trust and collaboration among healthcare professionals. Pharmacists play a vital role in ensuring patient safety and optimizing medication therapy, but it is imperative to prioritize effective communication and collaboration between prescribers and pharmacists. This includes respecting each other’s expertise and judgment and verifying any policies or guidelines before acting upon them.

Discussion

The above anecdotes highlight a common problem in Appalachia (and possibly in other parts of the country): misconceptions about the synthetic opioid buprenorphine. Poliwoda et al. (4) provide an excellent overview of the compound.

Buprenorphine (BUP) is one of three Medications used in the treatment of Opioid Use Disorder (or dependence) – sometimes abbreviated MOUD. Buprenorphine, a Schedule 3 drug, has been available as an analgesic for many years. Still, the Drug Addiction Treatment Act of 2000 (DATA 2000) established the criteria for outpatient use of BUP as MOUD (5) in a setting commonly referred to as an Outpatient Based Opioid Treatment (OBOT) clinic. Medical providers no longer need to ob-

The Clinical Scenario From The Prescriber

tain a waiver from the Drug Enforcement Agency to prescribe BUP as a MOUD. Still, some states have exceeded the original requirements of DATA 2000 and inserted legislative and regulatory requirements between the patient and their medical provider and pharmacy of choice (6,7).

Some wholesalers have imposed limits on ordering all controlled substances, which seem to be arbitrary but may be related to well-publicized suits and actions against so-called “Big Pharma” manufacturers such as Johnson & Johnson, Teva, Purdue Pharma, and wholesalers such as AmerisourceBergen, Cardinal Health, and McKesson (8)

However, a recent notice jointly issued by DEA and HHS stated: “DEA supports collaboration amongst all DEA registrants to ensure an adequate and uninterrupted supply of MOUD products when these products are appropriately prescribed. Distributors should carefully examine quantitative thresholds they have established to ensure that individuals with OUD who need buprenorphine can access it without undue delay.” (9)

Further guidance was provided by the Diversion Control Division of the DEA (10):

“Question: Do the CSA or DEA regulations require DEA-registered manufacturers or distributors to establish limits (quantitative thresholds) on the amounts of controlled substances, including MOUD, that another DEA registrant can order or dispense?”

“Answer: No. Neither the CSA nor DEA regulations establish quantitative thresholds or limits on the amounts of controlled substances, including MOUD, that DEA registrants may order or dispense, nor do they require registrants to set such thresholds or limits.”

Despite these clarifications, however, there are some myths and misconceptions associated with buprenorphine, which persist and often compound problems with access to treatment or the availability of medication.

Even among health care providers (HCP), there are misconceptions about BUP. For instance, a survey of HCPs in Ohio found that 48.41% of participants endorsed at

least one piece of misinformation. The most endorsed items were that buprenorphine is ineffective at reducing overdose deaths and that its use substitutes one drug for another. HCP endorsement of buprenorphine misinformation significantly and negatively predicted willingness to work with patients with OUD (11).

Major et al. (12) also discuss the need to educate pharmacists on evidence-based practices for treating OUD and increase communication between prescribers and pharmacists). We should now add that communication between pharmacists and distributors regarding the position of the DEA on buprenorphine stocks may be necessitated.

The purpose of this article is to assist with such communication.

Myths & Facts

Myth: Buprenorphine is just substituting one addiction for another.

Fact: OUD is a chronic, relapsing brain disorder, not a moral failing (6). It is considered a medical disability under the ADA’s definition because it is a condition that substantially limits a significant life activity (13)

Importantly, the treatment of OUD is called medication-assisted treatment (MAT) and not medication-curative treatment because it often requires counseling, as well as support from family and community, and sometimes intensive inpatient rehabilitation. But along with methadone, it is an important, nay critical, modality to reduce or eliminate cravings and withdrawal symptoms. Please note that there is often a stigma associated with the term MAT; however, it is an acronym routinely used in addiction medicine circles. MOUD is used when referring to the three approved medications for treating OUD.

Myth: Buprenorphine is as dangerous as other opioids.

Fact: Unlike full agonist opioids such as fentanyl or prescription painkillers, buprenorphine is a partial opioid agonist, which means it has a ceiling effect on respiratory depression. This reduces the risk of overdose compared to full opi-

oid agonists. Indeed, buprenorphine is rarely even associated with drug overdose deaths (14-16). Additionally, because it produces minimal euphoric effects, buprenorphine has a much lower abuse potential than full agonists.

Myth: Buprenorphine treatment is only effective for a short period.

Fact: Like any medication to control a chronic disease, buprenorphine may be required as a long-term maintenance treatment for opioid dependence, but treatment duration must be individualized based on the patient’s needs. Unlike some full agonists, no tachyphylaxis is observed for the therapeutic effects of buprenorphine, so once a stable dose has been reached, it can be maintained in the long term.

Myth: Buprenorphine has a long halflife, similar to that of morphine (24-48 hours).

Fact: Contrary to common belief, the plasma half-life of sublingually administered buprenorphine, which equates to clinical half-life, is only 4-6 hours (17). This property requires that a daily dose be split into 2 or 3 doses so that the plasma concentration does not drop below a therapeutic level. This characteristic requires that Opioid Treatment Programs (OTP - daily dispensing programs) may require a higher daily dose for plasma concentrations to remain in the therapeutic range for 24 hours. Fortunately, because of the safety range of buprenorphine, this does not present a danger to patients (18-22).

Myth: Naloxone, the second component in “Suboxone” (buprenorphine/naloxone –BUPNx), is poorly absorbed via the sublingual route; therefore, it cannot cause unpleasant side effects.

Fact: In a study of urine drug screens in a large clinical practice, 93% of the patients prescribed the combination product had urine concentrations of naloxone over the “clinical cutoff” of 30 ng/mL (23). Intolerable side effects include headaches, muscle cramps, dyspepsia, and dysphoria.

Myth: Buprenorphine is often diverted for misuse, i.e., to get “high.”

Fact: Most of the diverted buprenorphine

is used to alleviate withdrawal symptoms, not to get “high” (24-27). It can almost be considered “therapeutic.” It is reported that most of the diverted buprenorphine is obtained from friends, but when purchased, it costs between $20-$30 per tablet. In the outpatient clinic where author DMS is a provider,100% of patients admitted show buprenorphine in their intake drug screen. When queried about why they spent so much on buprenorphine when fentanyl is so cheap, they uniformly answered something to the effect that they didn’t want to die.

Since 2010, NCAP has been dedicated to raising awareness, providing education, and offering advanced training in Opioid Stewardship to both its members and the wider pharmacy profession. To discover more about the resources available to you, please visit www.ncpharmacists.org. Click on the Resources and Professional Development tabs on the homepage to access toolkits, videos, on-demand webinars, and certificate-level programs designed to enhance your knowledge and professional development in this area of pharmacy practice. Their staff are also available to assist you. For any questions related to opioids, feel free to contact cheryl@ncpharmacists.org

Authors: Daniel M. Strickland, MS, MD, FACOG, High Country Recovery, Boone, NC; Cheryl Viracola, PharmD, FNCAP; Director of Practice Advancement, North Carolina Association of Pharmacists cheryl@ncpharmacists.org

References

1. Personal communication between Cheryl Viracola, PharmD, FNCAP, Director of Practice Advancement, North Carolina Association of Pharmacists and Lauren Paul, PharmD MS, Executive Director, Pharmacy Regulatory Affairs, of the subject chain pharmacy

2. Burson, J. Urgent Situation for Buprenorphine Patients. January 28, 2024. https:// janaburson.wordpress.com/2024/01/28/ urgent-situation-for-buprenorphine-patients/. Accessed 4/20/2024

3. NC Board of Pharmacy. 21 NCAC 46 .1801 EXERCISE OF PROFESSIONAL JUDGMENT IN FILLING PRESCRIPTIONS. http://www. ncbop.org/lawsrules/rules.1800.pdf. Accessed 4/20/2024

4. Poliwoda S, Noor N, Jenkins JS, et al.: Buprenorphine and its formulations: A

comprehensive review. Health Psychol Res. 2022; 10(3): 37517.

5. Drug Addiction Treatment Act of 106th United States Congress: 2000. Available at https://www.congress.gov/106/bills/ hr2634/BILLS-106hr2634pcs.pdf.

6. Strickland DM, Sorboro J. Adverse effects of regulation on buprenorphine prescribing and its impact on the treatment of opioid use disorder. J Opioid Manag. Vol 17, No 7 (2021): Special Issue - “Buprenorphine: Clinical and Public Policy Implications”

7. Strickland DM, Baker JT. Legislative and Regulatory Barriers to Pharmacies Dispensing Buprenorphine for OUD. J Opioid Manag, 2023 Special-Issue;19(7):135-140. doi: 10.5055/jom.2023.0807.

8. https://www.npr. org/2022/02/25/1082901958/opioid-settlement-johnson-26-billion

9. https://www.deadiversion.usdoj.gov/ pubs/docs/Dear_Registrant_MOUD.pdf

10. https://www.deadiversion.usdoj.gov/ GDP/(DEA-DC-065)(EO-DEA258)_Q_A_ SOR_and_Thresholds_(Final).pdf

11. Franz, B., Dhanani, L., Hall, O.T. et al. Buprenorphine misinformation and willingness to treat patients with opioid use disorder among primary care-aligned health care professionals. Addict Sci Clin Pract 19, 7 (2024). https://doi.org/10.1186/ s13722-024-00436-y

12. Major EG, Wilson CG, Carpenter DM, Harless JC, Marley GT, Ostrach B. Factors in rural community buprenorphine dispensing. Explor Res Clin Soc Pharm. 2022 Dec 26;9:100204. doi: 10.1016/j. rcsop.2022.100204. PMID: 36703716; PMCID: PMC9871294.

13. (https://www.ada.gov/topics/opioid-use-disorder/).

14. Drug Overdose Deaths in the U.S. Top 100,000 Annually. US Centers for Disease Control and Prevention. https://bit. ly/3yfs8Fb

15. Paone D, Tuazona E, Stajicb M, et al.: Buprenorphine infrequently found in fatal overdose in New York City. Drug Alcohol Depend. 2015;155:298-301. DOI:10.1016/j.drugal-cdep.2015.08.007

16. Strickland DM, Gale G. Buprenorphine and Drug Overdose Deaths. Ann Clin Toxicol. 2022;5(1):1036.

17. Strickland DM, Manandhar P: Buprenorphine Half-Life – Further Considerations. Acta Scientific Pharmacology 2021;2(2):03-10. https://actascientific. com/ASPC/ASPC-02-0086.php

18. Gueye PN, Borron SW, Risède P, et al. Lack of effect of single high doses of buprenorphine on arterial blood gases in the rat. Toxicol Sci 2001 Jul;62(1):148-54. doi:10.1093/toxsci/62.1.148.

19. Ahmadi J, Jahromi MS, Ghahremani D, London ED. Single high-dose buprenorphine for opioid craving during with-

drawal. Trials. 2018 Dec 10;19(1):675. doi: 10.1186/s13063-018-3055-z. PMID: 30526648; PMCID: PMC6288888.

20. Van Petten LE, Levin RA, Graham TC, Sutton ML. Parenteral toxicity of Buprenorphine (Buprenex) in Beagle Dogs and Sprague-Dawley Rats. The Toxicologist 1983;3(1):10

21. Dahan A, Yassen A, Romberg R, Sarton E, Teppema L, Olofsen E, Danhof M. Buprenorphine induces ceiling in respiratory depression but not in analgesia. Br J Anaesth. 2006 May;96(5):627-32. doi:10.1093/bja/ael051. Epub 2006 Mar 17.

22. Walsh SL, Preston K, Stitzer M, et al.: Clinical pharmacology of buprenorphine: Ceiling effects at high doses. Clin Pharmacol Ther. 1994;55(5):569-580. DOI:10.1038/ clpt.1994.71

23. Strickland DM, Burson JK: Sublingual Absorption of Naloxone in a Large Clinical Population. J Drug Metab Toxicol 2018, 9:3 DOI:10.4172/2157-7609.1000240

24. Cicero TJ, Ellisa MS, Chilcoat HD: Understanding the use of diverted buprenorphine. Drug Alcohol Depend. 2018;193:117-123. DOI:10.1016/j.drugalcdep.2018.09.007.

25. Chilcoat HD, Amick HR, Sherwood MR, et al.: Buprenorphine in the United States: Motives for abuse, misuse, and diversion. J Subst Abuse Treat. 2019;104:148-57. DOI: 10.1016/j.jsat.2019.07.005.

26. Lofwall MR, Walsh SL: A review of buprenorphine diversion and misuse: The current evidence base and experiences from around the world. J Addict Med. 2014;8(5):315-326. DOI:10.1097/ ADM.0000000000000045.

27. Bazazi AR, Yokell M, Fu JJ, et al. Illicit use of buprenorphine/naloxone among injecting and noninjecting opioid users. J Addict Med. 2011;5(3):175-180. DOI:10.1097/ ADM.0b013e3182034e3

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Evaluating the Impact of Wellness Events on Pharmacy Student Well-Being

By: William Mossman, PharmD Candidate, and Dr. Carrie L. Griffiths

Introduction

Literature has established that students enrolled in pharmacy school meet clinical cut points for depression as often as medical students and anxiety more often than medical students. (1) Despite this, a 2019 scan of pharmacy school websites found that a majority (77%) did not list mental health resources on their websites. Of those that did, information was not easily accessible, requiring over five minutes to locate information regarding mental health. (2) Additionally, a survey sent out as a part of the same study found that mental health resources available to pharmacy students were often within the universities themselves and not a part of the pharmacy program. It was common for these resources to be offered only during business hours on weekdays, which was not ideal for pharmacy students who had classes during that time. (2) Pharmacy schools that have implemented pilot wellness programs have had promising results, such as a program that consisted of required hour-long wellness sessions and student-led in-class wellness breaks where a post-survey discovered students experienced an increase in weekly exercise and sleeping more than four hours per night. (3) Evidence suggests that wellness events can improve the well-being of pharmacy students. One study surveyed a group of pharmacy students about the sources of stress. Researchers found that the well-being of pharmacy students is impacted by multiple sources ranging from the learning environment and workload to personal traits and life circumstances. (4) A study by Chatterjee and colleagues surveyed medical students, and

results showed that students preferred organic student-organized wellness events over mandatory school-organized events. (5) Since stressors arise from various student situations, pharmacy schools should evaluate common sources of perceived stress among students and tailor wellness events accordingly. The goal of this study was to evaluate the wellness events offered at Wingate University School of Pharmacy (WUSOP) over the last year and compare events to the sources of stress experienced by WUSOP students to assess if the offered wellness events adequately improved students’ well-being.