Knowledge, attitudes, and professional practices versus personal beliefs of pharmacists regarding chemically dependent patients

With the availability of medications to treat chemical dependency such as buprenorphine and buprenorphine / naloxone in the ambulatory and community setting, pharmacists are increasingly involved in delivering pharmacy services to chemically dependent populations. Specialized postgraduate education in chemical dependency is not universally available to pharmacy practitioners. Among pharmacists who do not receive special training in chemical dependency a number of barriers exist, such as negative attitudes toward substance abuse, pharmacist lack of confidence in discussing substance abuse with patients, and a lack of knowledge of community services.¹ 

In a survey of continuing education programs among Florida pharmacists, two thirds of pharmacists reported two hours or less of substance abuse education, with 29% reporting no education in chemical dependence in pharmacy school. Additionally, a majority of respondents in the survey had never referred a patient for chemical dependency counseling. In this survey pharmacists who reported greater amounts of education were more likely to answer questions accurately, counsel and educate patients regarding addictions, and report more confidence in counseling.² Research involving pharmacies in seven states specifically addressing buprenorphine dispensing and counseling demonstrated that when given adequate training, pharmacists are confident in providing counseling services to opiate dependent patients. While the respondents in this study believed that their training was sufficient, they supported the need for more specialized training in opiate dependence treatment.³ Lack of pharmacist education, particularly in early identification, referral, and patient counseling have been identified as barriers to effective pharmacist intervention with chemically dependent patients.⁴ Surveys of substance abuse education in Schools of Pharmacy have indicated the need for more extensive education and lack of preparation of pharmacists for counseling chemically dependent patients.^5,6 

The objectives of this study were to assess the attitudes, beliefs, knowledge, and practice habits of pharmacists regarding the delivery of pharmacy services to drug dependent patients. These could further be used to determine if the respondents' knowledge of chemical dependence was based in either fact or personal beliefs. In addition, the study sought to assess what factors predicted counseling of drug dependent patients by pharmacists.

A questionnaire to assess attitudes, beliefs, knowledge, and practices of pharmacists regarding chemically dependent patients was developed. The questionnaire was comprised of background data, dispensing practices, attitudes and beliefs of pharmacists regarding chemical dependency, counseling practices, and both self-rated and objective knowledge regarding chemical dependency. The knowledge section of the questionnaire did not focus specifically upon medication but rather attempted to assess the pharmacist's understanding of the overall treatment and disease state management of chemical dependency disorders. The self-rated knowledge and objective knowledge assessment had similar content areas. The questions regarding attitudes, beliefs and knowledge were gathered from current knowledge in the treatment of chemical dependency.⁷ The questionnaire was pre-tested upon eight pharmacists and academicians who were not included in the study and revised based upon the comments to introduce more clarity into the items.

A random sample of one thousand Pennsylvania pharmacists was gathered from a roster of licensed pharmacists obtained from the Pennsylvania State Board of Pharmacy. Initial mailings and follow-up reminder cards generated this response rate. The randomly selected sample was sent a cover letter explaining the study, assuring anonymity and asked to return the survey in a pre-addressed, postage paid envelope. The University Institutional Review Board approved the study.

The responses to the survey were analyzed utilizing SPSS for Mac 16.0 (SPSS, Inc, Chicago Ill). Descriptive analysis of data, factor analysis of attitudes and beliefs, and regression analysis of factors predicting counseling were performed. The level of significance for statistical tests was set a priori at P<. 05.

In order to further analyze the relationships between self-rated and actual knowledge among this sample of pharmacists, a number of scales were created from the individual knowledge items. The self-rated knowledge items were summed and a total score was calculated. The numbers of correct responses to the questions on the actual test of knowledge were then also summated.

Factor analysis was performed on the beliefs and attitudes toward chemical dependence questions. The criteria for the factor analysis were an Eigenvalue of 1.0 or greater and a factor loading of 0.5 or greater.

The survey yielded an 11% response rate. Table 1 reports the results of the characteristics of the sample. The majority of the sample reported practice in a community setting. Hospital pharmacists accounted for 19% of the sample. The majority of the sample (57.7%) held a Bachelor of Science. in pharmacy. The dispensing history and experience of the sample varied from approximately 48% having dispensed disulfuram to 58.5% having dispensed buprenorphine and buprenorphine/naloxone.

Table 2 summarizes the personal attitudes and beliefs of pharmacists in the sample toward chemical dependency. The majority of pharmacist's in the sample accept chemical dependency as a disease with slightly over 80% of the respondents rejecting the belief that addiction is a moral weakness. A small minority of respondents (under 4%) refused to treat patients with drug abuse problems. Sixty-four percent of the sample believed that the pharmacist plays a vital role in the treatment of addiction; however slightly more than one third of the respondents admitted to being annoyed rather than sympathetic toward addicted patients. Approximately 70% of the sample disagreed with the idea that the addicted person cannot be helped until they hit “rock bottom” and approximately 70% of the sample believed that any use of heroin will lead to excessive use. Forty-six percent of the pharmacists in the study did not feel that symptomatic treatment, or detoxification, was adequate to encourage recovery. In terms of motivating chemically dependent patients to enter treatment, slightly over two-thirds of the respondents did not feel that confrontation was necessary; however, 46% of the respondents felt that persons who refuse treatment should be “legally committed”. Finally, only 9% of the pharmacists in the survey felt that they received adequate education in chemical dependency in pharmacy school with 82% expressing a desire to know more and only 17% expressing confidence in their abilities to offer pharmacy care services to addicted populations.

Table 3 summarizes the counseling practices of pharmacists who stock buprenorphine. Most pharmacists will not dispense buprenorphine when prescribed by a physician without a waiver number when prescribed for opiate dependence. In addition, pharmacists claim that their most frequent counseling practices are to refer to physicians and drug treatment facilities. Pharmacists seem less likely to confront patients who they believe are addicted, yet they collaborate with physicians to deliver Medication Management for addicted populations. Additionally, the surveyed pharmacists were less likely to query patients regarding suicidal ideation and to emphasize relapse prevention counseling, responding negatively to these statements at a rate of 35.7% and 19.1% respectively. Fifty percent of pharmacists sampled have explained the role of medications in recovery with slightly over 50% suggesting psychotherapy to their depressed patients with addiction.

Table 4 reports self-rated knowledge of chemical dependency treatments. Over 80% of the respondents reported little or no knowledge of relapse prevention, after care, or rational recovery. At least sixty-five percent of respondents claimed no knowledge or little knowledge of medical detoxification, maintenance, or outpatient drug treatment. Finally, little or no knowledge of 12 step programs was reported among 55% of the respondents while 63% indicated little knowledge of inpatient treatments.

Table 5 reports that results from the portion of the survey that was a test of actual knowledge of chemical dependency. These questions, posed as attitude statements, actually had a basis in fact regarding chemical dependence. This method allowed researchers to determine if personal knowledge was more based in belief than fact. The respondents' mean percentage scores for the test were 38.5% correct with a mean percentage score of 48.1% for respondents when “don't know” answers were not scored as incorrect. Seventy–eight percent or more of respondents knew the difference between dependence and abuse, and tolerance and addiction. A majority of respondents knew of the chronic nature of addiction, the effectiveness of psychotherapy in treating co-morbid anxiety and depression, and the role of relapse in treatment. Between 33 and 50% knew the conditions under which inpatient treatment is offered, the role of psychotherapy in relapse prevention, the length of medical detoxification and the nature of 12 step programs. The correlation between actual knowledge and self-rated knowledge was .57 (p <. 001).

Table 6 summarizes the factor analysis of the belief and attitudes toward chemical dependency items. Two factors that were identified include a negative attitudes factor and a misinformation factor. The items in the negative attitudes factor were comprised of attitudes and beliefs of annoyance, reluctance to treat, belief in addiction as a moral weakness, and rejection of the role of the pharmacist in treating addiction. The misinformation factor was comprised of items endorsing the beliefs that the chemically dependent patient cannot be helped until they hit rock bottom, confrontation is necessary in treatment, and the request for more information regarding chemical dependency.

To further test what factors relate to pharmacist counseling of chemically dependent populations, two regression analyses were conducted. Table 7 describes the predictors of medication counseling for opioid dependent patients while Table 8 reports predictors of confidence in counseling chemically dependent patients. The model for predictors of medication counseling for opiate dependent patients was significant (P<001) with an adjusted R square of 0.337. The results of the regression analysis indicated that the more frequently pharmacists dispensed controlled opiate products the more likely they were to offer Medication Therapy Management Services for opiate dependent patients (b=0.415, p <. 001). In addition, the more frequently pharmacists offered Medication Therapy Management Services in their practice the more likely they were to offer them to opiate dependent patients (b=0.304, <. 001). The results for the regression analysis for confidence in counseling chemically dependent patients indicated that the frequency of dispensing medication to treat chemical dependency (b=. 225), lack of negative attitudes toward chemically dependent patients (b =−0.273) and knowledge of chemical dependency treatment (b=0.220) predict pharmacist self-reported confidence in counseling addicted patients. These coefficients were significant at p .05. The model was significant (p<. 001) with and adjusted R square of 0.256.

The findings in this study indicate that, for this sample of pharmacists, adequacy of education in chemical dependency was rated insufficient and the majority of the sample was not confident in providing services to chemically dependent patients. The majority of the sample expressed a need for more education. In their practice, the pharmacists in this sample were less likely to confront addicted patients, ask questions about suicidal ideation, counsel on relapse prevention, or collaborate with physicians. These deficiencies were consistent with both self-rated and objective knowledge deficits. On both the self-rated and objective knowledge scales the majority of the pharmacists in the study scored a lack of knowledge for relapse prevention, in-patient treatment, twelve step programs, medical detoxification, and outpatient treatment. Both in knowledge and practice the data demonstrates that pharmacists need go beyond a focus on medication alone and become more comfortable with counseling roles that motivate patients to seek treatment as well as to explain the importance of aftercare programs and relapse prevention.

The results of the regression analysis demonstrated that both the frequency of dispensing opiates and the frequency of offering medication therapy management services predicted counseling for opiate-treated patients while confidence in offering pharmacy care services to addicted populations was predicted by the frequency of dispensing medications, lack of negative attitudes, and knowledge of chemical dependency. These findings demonstrate that, in this patient population, the commitment to offering medication therapy management services to their patients and the more frequent interaction with patients requiring opiates increases the likelihood of counseling patients on opiate dependence as opposed to pharmacists who are less committed to medication management services and have less experience with patients prescribed opiates. Conversely, decreased knowledge of addiction, coupled with negative attitudes toward chemical dependence, induces reluctance in approaching their addicted patients. As seen in Table 7, predictors of counseling of opioid dependent patients may be due to the MTM model with perceived emphasis solely on medication counseling. In Table 8, the measure of confidence pertained to addicted populations in general. General knowledge regarding addiction and positive attitudes appear to be more likely related to confidence in counseling as opposed to opiate dependence counseling that may follow the more traditional medication information transfer model. Education that focuses upon both increased understanding of all treatment modalities and shaping better understanding of the chemically dependent patient may decrease negative attitudes and appears to have a positive effect upon pharmacist willingness and confidence in addicted patient interactions. Also greater exposure to working with chemically dependent patients and the more widespread acceptance of medication management as standard practice in pharmacy would appear to also increase pharmacist counseling of patients who are chemically dependent or who may be at risk.

There are some limitations of this study. The low response rate to the survey may hinder generalization of the results. Secondly, the randomized list of pharmacists included some Pennsylvania licensed pharmacists that lived out of state. Due to the anonymous nature of the responses in the study, no generalizations can be made to a broader population. Another limitation of the study is that pharmacists were assessed from a number of practice settings where opportunities for interaction with chemically dependent populations do not exist. Finally, the Eigenvalues and Cronbach's Alpha in the factor analysis were limited in predicting the factor loadings; however, there is some support for correlations among the items in the factors. In spite of these limitations, the exploratory data in this study are consistent with other studies documenting the lack of knowledge and a need for more education and experience regarding chemical dependency for the practicing pharmacist.^{2 ,4 ,5 ,6}