Author ORCID Identifier


Defense Date


Document Type


Degree Name

Master of Science


Pharmacy - Dean's Office

First Advisor

Julie A. Patterson

Second Advisor

Teresa M. Salgado

Third Advisor

Sharon B. Gatewood


Background: Opioids are a class of drugs that bind to opioid receptors (mu, delta, and kappa), located in the central and peripheral nervous systems, to exert responses such as analgesia, respiratory depression, euphoria, and miosis. The opioid epidemic is characterized in large part by an increase in opioid overdose deaths. Community pharmacists are one of the most accessible healthcare professionals who frequently interact with patients and can implement OUD and opioid overdose prevention strategies. Treatment for opioid overdose and OUD include naloxone for overdose deaths as well as medication-assisted treatment for OUD.

Objective: The specific aims of this thesis include i) to explore community pharmacists’ attitudes, subjective norm, perceived behavioral control, and behavioral intention towards dispensing opioid receptor antagonists (ORAs) under a standing order in Virginia and ii) to evaluate the cost-effectiveness of SSP alone, MOUD alone, and SSP+MOUD combination in preventing HCV cases among opioid IDUs in the US.

Methods: A broad search strategy of terms relevant to OUD was used to find evidence of pharmacist involvement in OUD management from PubMed/MEDLINE. Articles were excluded if not related to pharmacist OUD management, including pain management, not related to pharmacy practice, not involving OUD, or not relating to the opioid epidemic. The first aim was assessed by conducting semi-structured interviews of community pharmacists across Virginia between June 2018 – October 2019. The interview guide was based on the Theory of Planned Behavior. Interviews were recorded, transcribed verbatim, and thematically analyzed. The second aim assessed cost-effectiveness from a public payer perspective over a one-year time horizon by using a decision-tree analysis model based on published literature and publicly available data.

Results: Pharmacists were confused about the specifics and the processes involved with dispensing naloxone under the standing order. Furthermore, many recognized the underuse of the standing order. Community pharmacists in Virginia expressed mixed intentions toward dispensing ORAs under the standing order. The incremental cost savings per HCV case avoided per 100 opioid IDUs compared to “no intervention” were as follows: SSP+MOUD combination = $347,573; SSP alone = $363,821; MOUD alone = $317,428. The ICER for the combined strategy was $4,699 compared to SSP group. Sensitivity analysis showed that the results of the base case cost-effectiveness analysis were sensitive to variations in the probabilities of injection-risk behavior for the SSP and SSP+MOUD combination groups, probability of NO HCV with “no intervention”, and costs of MOUD and HCV antiviral.

Conclusions: Pharmacists expressed mixed behavioral intention toward dispensing ORAs under the standing order. Future research should focus on quantifying the uptake of the standing order at the state level. The SSP+MOUD combination and SSP alone strategies dominate MOUD alone and “no intervention” strategies. Pharmacists may incorporate a combination strategy as it is shown to be cost-effective if payers were willing to pay $4,699 or more per case of HCV avoided. Although these harm reduction programs will provide benefits in a one-year time frame, the largest benefit may become evident in the years ahead.


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