Table 1 Template themes, representative quotes, explanation, and application for the SBI

Experience with opioid medications/care

Patients had many years of experience with opioid medications but also had issues accessing opioids. While prescribers were using their clinical judgement to taper, patients did not trust them and did not believe they were dependent. Pharmacists were aware of these issues and tried addressing them by providing education, counseling about opioid safety and building trust

“I haven’t had trouble until now because my primary doctor has been providing me prescriptions, but now trying to wean me off of it… I have been taking extended release and…I take short acting…she wants me to be off of it. But I had surgery and I'm recovering from that and…I need it more.”—Pt 2

“It sucks that they keep trying to decrease the medication I'm on. [Prescriber] just says something about the pain medication causes you to have more pain than you're really in. I don’t think it does.”—Pt 4

“There's a lot of people that take narcotics on a regular basis that don’t think there is a problem where maybe there is a problem. –RPh 11

“Whenever you talk to them about their controlled substances, they get defensive. But I think over time, once you explain our system and why it's important, you can build the rapport and trust with them.”—RPh 4

“If you're finding that you're needing more of it to basically treat the same type of issue, at that point we invite them to start talking to us or to start talking to their doctors…It's [opioids] there for a purpose, and we do want you to use it, we just want you to use it safely. So, that's how we spread our message to help combat and answer questions about possible opioid misuse.” -RPh 8

SBI should not be perceived as another barrier to accessing opioids, rather as an opportunity to receive more education about opioid use and safety

Knowledge and education about opioid safety

Patients did not have much knowledge of opioid safety. They described being directed to ‘take as intended’ but were not counseled regarding opioid safety. Pharmacists agreed that patient counseling provides opportunity to discuss chronic opioid use, misuse and opioid safety

“[All I was told about opioid safety is] that you should do what the bottle says, and not overuse it.”—Pt 02

“I had back surgery eight months ago, and I was prescribed…70 hydrocodone, and I still have 50 left…If I’m prescribed opiates [again], and I run out of those, can I use what I have left from the others?”—Pt 7

“We have these conversations with patients regarding refill too soon or usage of opioids and how often they should be using them at least every other week, if not more.”-RPh5

“We would use it as an educational opportunity to show patients how an opioid will actually work in the system for chronic use.”.”—RPh 10

BI must include patient education on general opioid safety

Beliefs about opioid safety, OUD

Patients strongly believed that they were not at risk of opioid misuse or developing dependence/ OUD. They believed that opioid misuse was common, but only among people who used drugs recreationally. Pharmacists were aware of these limiting beliefs and wanted to provide education address them

“I think that the opioid epidemic or whatever they want to call it, they make such a fuss about it. But I believe that it has a lot to do with the recreational drugs that people take, the alcohol intake. Where, myself, I don’t fit into that…My brain doesn’t work like an addict.”—Pt 7

“I don’t have the whatever in me that gets addicted to things, because some people do and some people don't. It's just like alcoholism.” –Pt 1

“Letting them know that overdoses are never planned. I've heard that so many times. Well, “Yeah, that's not going to happen to me, I'm not that kind of person”, there's, so many stigmas related to that. So, trying to break down some of those statements and just give education. I don’t think patients realize what risks are really out there all day.”—RPh 6

BI must address common patient misperceptions and limiting beliefs related to OUD and naloxone to improve opioid safety behaviors

Opioid care needs

Patients described various needs for people using opioid medications including counseling regarding non-opioid medications or pain management alternatives, more education and information about recognizing tolerance and dependence, how to handle an accidental overdose, contra-indicated substances, consequences of intentional misuse including legal issues, and in general more patient-centered counseling about opioids. Pharmacists also believed that patients needed opioid education, which could be met through SBI

“I'd be lying to you if I didn’t joke with people and say: Hey, I've got this prescription. Now, how much money can I make on the street? I would never do that. But other people might, and they need to know what the issues could be.”—Pt 8

“I don’t know if there’s such a thing as being more addicted to something when you’re already on [opioids], drinking alcohol and recreational drugs. But maybe a little more information on that.”—Pt 7

“If they're really, truly in pain and they need this prescription, they would be more than willing…to try to get a better understanding of what the pain medication is going to do.”—Pt 3

“For the short term [acute pain], their needs are probably best met with some education that there can be risks with these [opioids], take the minimum amount of medication that you need to help you, when you don’t need it anymore, destroy it, get it out of the house. For chronic pain patients, long-term, knowing that tolerance is very common, that doses tend to escalate, that there can be drug interactions to watch for, things can increase the risk of affecting your breathing.”—RPh 3

“A lot of people will bundle the possibility of dependency versus addiction, and that's really not the case.”—RPh 8

“We would use it [SBI] as an educational opportunity, to show patients how an opioid will actually work in the system for chronic use.”—RPh 10

BI can be beneficial to patients regardless of misuse if information on opioids, long-term opioid use (including concepts such as dependence, tolerance, sedation, and hyperalgesia), and overdose prevention are included

Self-efficacy

Patients had confidence in their ability to take opioids safely because they have been taking it for many years. Hence, they believed the SBI would be more useful for new patients and not for experienced patients. Pharmacists had high self-efficacy to deliver SBI, especially if they had existing relationship with their patients. They also believed first-time prescriptions were the greatest opportunity to deliver SBI

“I'm very confident because I've taken it for so long without having any issues.”—Pt 1

“I’ve taken them [opioids] for years and that I, without them, I can’t function. And I feel comfortable because my doctor explains anything that I have questions about.”—Pt 6

“I'm doing well, and I don’t need it [SBI] because I've already asked all the questions.”—Pt 4

“I have a pretty good relationship with my patients, so I would be able to talk with them, with empathy and understanding and that they would understand where I'm coming from, and that it's not accusing them of anything, but it's a matter of safety.”—RPh 3

“Whether or not they're getting this opioid for the very first time, because that presents the greatest opportunity for us to talk about the issue and everything with dependency or misuse.”—RPh 8

“Oh, incredibly confident. We’ve been doing it for years. That easy access—we’re the point person in healthcare, so people do have that conversation, for sure.”—RPh 1

SBI may be ideally delivered at index prescription, but long-term relationships with patients can make pharmacists more comfortable in delivering SBI

Stigma

While only some pharmacists admitted to being biased towards patients picking up opioid prescriptions, most patients discussed feeling stigmatized by healthcare professionals, which is a barrier to SBI participation

“It feels like every time you get an opioid medication, you're being looked at like you're an abuser, or like does this person really need it?”—Pt 1

“There was one time when I was at a local pharmacy… And he [pharmacist] treated me like I was a drug addict. And so I just quit going to him… he just, he looked at me, and he’s like, “Boy, this is a lot of medicine and for someone so young. Do you really need all of this?” And it was very discomforting.”—Pt 6

“I'm sorry but I have to bring some bias to some of this because I want to be aware of the entire situation and have that gut feelings saying, “Hey is this somebody who's maybe abusing? Are they telling me the whole story?”—RPh 6

“We have a lot of patients who want to fill their controlled substances up just a couple of days early…I think my coworkers are skeptical sometimes, of those situations… especially with opioids or other C2’s”—RPh 2

Patient centered education, anti-bias training to address stigma against OUD may be necessary

Patient –pharmacist—prescriber relationships

Patients used informal sources such as the internet for questions about their medications. They also had conversations with prescribers about their medications but most never discussed it with their pharmacists and did not view pharmacists as providers of clinical services. While many pharmacists attempted to intervene when they suspected misuse, some were not comfortable with it and did not view it as part of their practice scope

“…at some point, you would think the doctor could realize [recognize misuse]. Because I know my doctor takes steps…a lot of doctors are very good at telling that, seeing in a patient, whether they really need them [opioids] or they don’t. That’s what doctors get trained on. I truly think that it would be more up to the doctor in the 1st place, because he's the 1 who's going to prescribe it.”—Pt 3

“I research it [opioid medications] online, or I'll ask my general practitioner.”—Pt 5

“We have a few patients; they'll get five-day prescriptions for hydrocodone. And it'll be from a couple of different doctors sometimes it'll be one every six hours [or] it’ll be one every four [or] every eight, and it’s odd to me. So, I do try to delve into, like: “Hey,… what's still going on that you still need these three-day courses… couple times a month they'll get a couple of days of it. And I don’t really get anywhere because I am afraid of them jumping to conclusions.”—RPh 2

SBI may need to be marketed as a clinical service. Strategies may include advertising SBI and clinical role of pharmacist using posters and brochures that prompt patients to ask questions

Beliefs about SBI

Both patients and pharmacists believed SBI could be helpful in providing patient education regarding opioid safety and misuse. While patients would like more information about their prescription, they did not want to be told what to do or the pharmacist to ‘interfere’. Some patients also stated that people may not be honest about misuse behaviors. Pharmacists would like training in improving their comfort with screening for and providing counseling on such a sensitive subject and making it into their routine practice or policy for opioid medications

“I'm good with it [SBI]. I think my pharmacy is amazing. I prefer to know about the medications I'm taking. I mean, you're only helping yourself when they give you this information… my pharmacist does that [counseling]already. He’s very knowledgeable, he says if, if this [fentanyl]patch is working for you and you can go longer without your pills, then maybe we could cut down on the pills… he's already giving this information.” –Pt 3

“I think most people would think it [SBI] would be fine. But then some people would feel like it's interfering. So maybe for those patients, it would be helpful to tell them that this is just information only.”—Pt 4

“It all depends on the status of the person that's taking the opioids. If they're abusing them, I don’t feel they're going to be very open to any type of counseling, or they might not be honest, but I would hope that they would perceive those 3 or 4 questions as the pharmacist being concerned.” -Pt 5

“I'm pretty confident that we are at the very least get some momentum and set the groundwork for [SBI], what could evolve into this standard of practice.”—RPh 10

“I don’t want to be coming across like I'm accusing this person of being an abuser of medication. I don't seem to have a problem with it [counseling], because we do a lot of the homework and prep work ahead of time. As far as: “Hey, this is our policy about filling these prescriptions”… [SBI needs include] training more on making pharmacists feel comfortable that they can discuss that issue with patients. I think that's it.”—RPh 8

“I could really see this [SBI] being perceived as I’m now receiving better, personal touch, clinical care that I would never have expected.”- RPh 10

SBI must be patient-centered and provide information without using accusatory or labeling language. Pharmacist training and introducing SBI as personalized clinical care into routine practice may be helpful

Screening component

Patients discussed answering screening questions on a tablet, form, or app for privacy or wanting a face-to-face conversation with pharmacists. Pharmacists wanted the screening to be in addition to services already offered. They also discussed needing technician help to initiate the screening through a form or tablet. Some suggested doing the screening over the phone to make it more efficient and save pharmacist time

“I think an interactive tablet might be good. A form, obviously, you can certainly do that. But a form might, given all the germs and everything like that, form might actually be better than a tablet.”—Pt 1

“I think both [in-person and digital] would work. What would I prefer? Probably talking to the pharmacist.”—Pt 4

“The ideal screening would start with some of the things that were already just doing by default—checking the PDMP, calculating the morphine equivalence for everything, looking for diagnosis codes for what an opioid is being prescribed. We are assessing the risk of the other medications that they're on that would increase the risk such as concurrent benzos. That'd be part of our initial information gathering prior to any kind of screen.”—RPh 10

“You would have to involve the entire pharmacy. So, that technicians would be able to initiate the whole process, they'd recognize this is a controlled substance, and we have not talked with this patient before.”—RPh 6

Online, phone, and in-person formats of screening were suggested but opinions on feaibiliy and patient preferences varied.. Standardized screening tools may be used if they are brief (< 5 min) and easy to answer

Brief Intervention—Naloxone

Patients and pharmacists discussed naloxone as a potential brief intervention. Many patients did not think they needed it because they believed it was only for people who intentionally misused opioids. There were knowledge gaps as well such as being able to administer naloxone to themselves. Pharmacists wanted a script where naloxone is antidote for a potential side-effect of the opioid rather than patient’s intentional misuse behavior

“I think that the doctors are starting to, give counter measures so if people would accidentally OD they could help themselves at home with Narcan. And I think that’s good and that maybe people understand and know how to use that.”—Pt 6

“I'm afraid that if people could get narcan to carry with them…it’s giving them a reason to take more, because they could use that [naloxone] and it'll bring them back. I think that could go either way.”—Pt 3

“making it maybe a little bit easier to dispense [Narcan] sometimes. So, having a script to explain what it is, possibly having a script to say why we're dispensing it.”—RPh 5

“Everyone seems to understand the concept of an Epi-pen, we usually explain the Narcan is like an Epi-pen for an overdose.”—RPh 1

Naloxone counslign and dispensing can be potential BI but a non-stigmatizing script for pharmacists may be needed

Brief Intervention—Counseling

Patients were enthusiastic about BI if it improved their knowledge of opioid medication safety. They suggested both face-to-face conversations or online digital app-based education options for BI. Either way patients stressed the need for autonomy in the design of SBI. Pharmacists also suggested that counseling could be used as BI to improve patient knowledge on opioid use and safety. Handouts could be used to help with counseling and reduce the time needed

“Just ensuring people that they're [pharmacists] there for information, pretty much information only and that they're not telling them exactly that they have to change anything that they're doing, just being there for more knowledge and then leaving it up to them if they're going to change. Because when people have more knowledge, they're more willing to change things about what they're doing than just to be told, well, you should be doing it this way.”—Pt 04

“I think before you can accept or decline the prescription that you have to read through the information, which maybe people will, maybe people won’t. But at least you get, have a little box that says I acknowledge something.”—Pt 7

“My philosophy as far as counseling patients is not as strict as some other pharmacists, but I really truly believe in a much more collaborative type of interaction.” -RPh 11

“Educating people on opioids and the potential for misuse and Narcan, those are very attainable goals with a screening tool and an intervention.”—RPh 02

“To provide every patient who is getting an opioid prescription, locations of where medication can be discarded once it's done. More than just saying something to them, now we have a handout that we give to our patients.—RPh 10

Counseling as potential BI offers ample opportunity for patient education but the counseling offered must be patient –centered. Digital formats of SBI were suggested to provide this education

Brief Intervention—Contacting prescribers

Patients were comfortable with their pharmacist contacting prescribers regarding opioid medications. However, they wanted to be involved in that process and be aware of the conversation. Pharmacists also suggested that contacting prescribers regarding inappropriate opioid prescriptions must be done but with the patient’s approval

“I don’t know if currently there is a system or a program or procedures in place where pharmacists can have actual conversations with doctors. I don't know if that's a regular thing, if they regularly do. But I think that's not a bad thing if somebody feels that this stuff is just too strong, I don't need this much. Or it's not doing enough, because there might be a different medication or a higher dose or something along those lines that might be better for that patient. I think that that kind of conversation should be happening.”—Pt 1

“Let the patient know why you have reservations and then let them know what you're doing—contacting the doctor. Maybe the doctor's not aware. I've had a couple instances mostly with our ER doctors where they will prescribe pretty strong pain reliever, it's really potent medications in people who probably may or may not need them or the doses. So, they may or may not be aware of the history or other drugs that the person is taking. So if you see something that's not appropriate you'd want to contact the provider and discuss whether you should proceed, or whether they should try something different.”—RPh 7

Pharmacists can contact prescribers as part of BI as long as patients are involved in the process

Implementation Needs

Patients wanted education in a format that offered autonomy and privacy. They also wanted the prescriber to be involved. Pharmacists discussed needing a protocol (instead of relying on judgement) and training to provide the SBI. They also discussed prescriber education and involving prescribers as stakeholders in SBI implementation to get their buy-in

“Offering the benefit of what the program does, and then ask them, would you like to participate?…that's the best way to do it.”—Pt 1

“Face to face is the best. I think it forces the patients to communicate, to think about it because you have someone in your immediate presence as opposed to filling out a form, or even on a phone call where you can let your mind wander.”—Pt 8

“The world is going to cell phones and computers, so just somehow get information out on there…Maybe a pharmacist could send a text out and say, your refill is due in four days, and at that time, have a little skit that tells you about the opioid before you accept it.”—Pt 7

“I think the doctor and the pharmacists both need to have a discussion with this person.”—Pt 3

“My biggest problem right now—is making the professional judgment of when I should do this or when I should not.”—RPh 8

“There would have to be an education piece for pharmacists there. I don’t think I'm alone in saying that that I would be out of my comfort level.”—RPh 6

“Having communication with providers…there's the providers that don't care at all about it and are like: “Well, my patient’s in pain. I need them on as many pain meds as they can. Who are you to question me?” And then you have the providers that are like: “Well, I'm being judged now, so my patient's going to get nothing, and they're left with no meds.” And then those patients end up using drugs on the street or heroin or things like that.”—RPh 9

SBI may need multiple formats (face-to-face /online) to offer patients an individualized service. Prescribers must be involved in implementation as stakeholders. Educational material and training for pharmacists must also include a protocol for providing SBI

Implementation challenges—Time, Roles & Stigma/ Privacy

Both patients and pharmacists identified time required as the primary challenge for SBI. Some patients did not perceive that pharmacists’ role to provide SBI and pharmacists had similar concerns regarding their ability or scope of practice. Patients did not want have conversations without privacy and pharmacists did not want to be perceived as accusatory. Pharmacists suggested building rapport focused on patient autonomy to avoid perceptions of stigma/interference

“There's a certain amount of embarrassment that “I don't know what's going on,” or “I didn't listen to the prescribing doctor.” I think that's something that has to be taken into consideration. Time is an issue. Where do you find the time?”—Pt 8

“I like to have a relationship between my doctor and myself rather than the pharmacist. And when you go to the pharmacy,… I don’t know if people would be comfortable answering questions when there’s five people standing there listening to you.”—Pt 7

“I think some of the challenges we're going to face one is going to be time pressure. Two is going to be feeling like, perhaps you're not educated to really ask these questions and make the interventions. And I think three is going to be a certain fear that you're going to be perceived as somebody who is now the accuser of the patient.”—RPh 10

“One thing that helps is having a good rapport with the patient. If you come off the first interaction with that patient basically trying to be their parent on how they should take their medication, that rapport might not be very good.”—RPh 4

Using digital formats may provide more privacy and save time. Appropriate patient centered SBI training for pharmacists and marketing it as a clinical service may help improve pharmacist roles and reduce stigma