Knowledge and Beliefs Surrounding Nalmefene Among Alabama Pharmacists: A Cross-Sectional Survey Informed by the Theory of Planned Behavior

Abstract

The opioid epidemic continues to be a major public health crisis in the United States, and nalmefene has recently emerged as an alternative opioid overdose reversal agent. However, little is known about pharmacists’ awareness and beliefs regarding nalmefene use and distribution. Therefore, the purpose of this study was to assess Alabama pharmacists’ knowledge, perceptions, and behavioral intentions related to nalmefene. This study used a cross-sectional survey design. Practicing pharmacists in the state of Alabama were eligible to participate, and were recruited through the Alabama Board of Pharmacy email listserv. An anonymous online survey was distributed via email, and respondents were eligible to enter a lottery for one of five $100 electronic gift cards. The survey instrument was developed by the investigators, adapted from prior overdose reversal literature and informed by the Theory of Planned Behavior. Primary outcome measures included: knowledge of nalmefene (12 items); perceived barriers regarding nalmefene stocking and recommendations (19 items); and Theory of Planned Behavior concepts including attitudes (15 items), subjective norms (perceived social support) (six items), perceived behavioral control (confidence in ability to stock or recommend nalmefene) (11 items), and behavioral intentions surrounding nalmefene stocking and recommendations (13 items). Outcomes were measured via multiple-choice (objective knowledge) and Likert-type scale (1 = strongly disagree, 5 = strongly agree) questions. Differences in mean scale scores across pharmacy setting (pharmacists employed in inpatient versus outpatient settings), community pharmacy type (chain vs. independent), and geographic location (rural vs. urban) were analyzed using two-sided Mann–Whitney U tests for non-parametric data or t-tests for parametric data, as appropriate. Multiple linear regression analyses examined associations between TPB constructs and pharmacists’ intentions to stock or recommend nalmefene over the next six months. All data were analyzed using SPSS statistical software version 29 with an alpha of 0.05. There were 119 pharmacist respondents (n = 25 inpatient, n = 94 outpatient). The majority were female (68.1%), White (94.1%), and worked in community settings (35.3% independent, 10.9% corporate, 10.1% big-box, 5.0% grocery). Median age was 42 years (IQR: 36–51). Awareness of nalmefene was low: only 39.5% had heard of it and 5.9% had seen it in practice. Inpatient versus outpatient pharmacists reported higher subjective norms external to the workplace (median [IQR]: 3.00 [2.33, 3.58] vs. 2.33 [1.67, 3.00]; p = 0.004) as well as subjective knowledge (mean [SD]: 2.96 [0.94] vs. 2.55 [0.74]; p = 0.023), while outpatient versus inpatient pharmacists reported higher perceived barriers related to fiscal/logistical concerns (mean [SD]: 3.45 [0.59] vs. 3.07 [0.66]; p = 0.009). Among community pharmacists, stocking and procurement confidence was higher among independent versus chain pharmacists (3.75 [3.00–4.17] vs. 3.17 [2.67–3.92]; p = 0.026). Furthermore, external workplace norms among urban pharmacists were higher than among rural pharmacists (2.50 [2.00–3.00] vs. 2.33 [1.67, 2.67]; p = 0.027), while stocking and procurement confidence was higher among rural than urban pharmacists (3.83 [2.83–4.50] vs. 3.17 [2.67–4.00]; p = 0.034). In adjusted reduced regression models, perceived behavioral control regarding nalmefene stocking and procurement (B = 0.189, 95% CI: 0.049, 0.329; p = 0.009), subjective norms external to the workplace (B = 0.232, 95% CI: 0.047, 0.418; p = 0.015), and interprofessional recommendation attitudes (B = 0.237, 95% CI: 0.037, 0.437; p = 0.021) positively predicted nalmefene implementation intentions. These findings suggest practice-setting differences that could be further explored for optimal implementation of nalmefene distribution and access, and highlight the need for targeted education, interprofessional collaboration, procurement guidance, and workflow tools to improve pharmacist preparedness for nalmefene services.