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Table 6 Example of reflection discussions by domain

From: Assessing pharmacy student experience with, knowledge of and attitudes towards harm reduction: illuminating barriers to pharmacist-led harm reduction

Domain Sub domain Quotes (SN = student number)
Domain I
Curriculum/student view “I am a perfect example of how education can help because I had the preconceived notions mentioned above on how these programs can be harmful before I heard the presentation in class and before I read the articles on them.” SN 156
Patients/community “I think education is crucial if we want to reduce substance abuse.” SN 113
Pharmacist “If I had more training on how to help someone in an overdose situation besides calling 911 and knowing that I should [use] naloxone, I would feel more comfortable dispensing naloxone to my patients because then I could counsel them on how to use it as well.” SN 24
Domain II
Dispensing Needles
Personally opposed but professionally support “I believe that syringes should be used for medical purposes only and that they should be reserved for those who need to use them in the treatment of a medical condition. My younger brother is a Type 1 diabetic and has a need to use syringes for the maintenance of his diabetes. So, if a pharmacy dispenses needles to people without prescriptions that would mean less inventory for those who need needles to treat an actual medical condition such as insulin dependent diabetes, like my younger brother.” SN 53
“On a personal level, I feel that by dispensing more needles, more used needles will accumulate on those playgrounds, making the likelihood of children developing HIV/AIDS much higher.” SN 126
Professionally opposed but personally support “I have to follow the rules as well as the practice that I have learned. Freely dispensing needles can cause problems for the society since we cannot control how many needles and syringes are in used.” SN 161
Personally and professionally for support “By default, I think that pharmacies should dispense needles and that they should do so until it becomes a public health concern for the overall population. In this case, I think that my personal and professional stance are very similar. I personally am a little conflicted in saying that all pharmacies should dispense needles to anyone that asks for them, because there are potentially harmful consequences of that stance. While at the same time with the right programs put into place, sharps containers being available in public places and promoting treatment, the outcome of a reduction in infectious diseases would be a benefit to overall public health.” SN 134
Personally and professionally opposed “Although, there has been studies shown that access to needle reduces transmission of infections I think otherwise.” SN 136
Domain III
Dispensing Naloxone
Personally opposed but professionally support “When you have a close friend who passed away from having an adverse reaction from being served a meal he was allergic to and did not have the chance to use an epinephrine pen to save his life, you begin to wonder why should someone abusing drugs be given a ‘just-in-case’ card to save their life.” SN 51
Professionally opposed but personally support “I feel the cost of treating and preventing an overdose should fall on the patient because they made a life choice to take a drug inappropriately and against doctors’ orders. I do not feel like naloxone should not be accessible though.” SN 21
Personally and professionally support “My personal opinion is that naloxone should be dispensed freely through pharmacies, because in order to treat drug-reliant individuals, we first need to keep them alive.” SN 31
“I do not think it encourages risky behavior, rather, it provides patients with a backup to use in emergencies. For instance, I do not think dispensing an epi pen encourages patients to encounter their allergens, but it serves as a vital potential lifesaver in case of an emergency.” SN 91
Personally and professionally opposed “I believe we cannot be making excuses to a drug problem by counteracting it with another drug that might in the end promote the abuse more. Naloxone will only promote overall opioid substance use.” SN 136
Domain IV
Past work experience
No subdomains “I have started to implement this already at my current pharmacy intern position by creating syringe kits to sell to patients that request them. In these kits, patients get 10 syringes, a sheet on safe needle disposal, information on how to acquire and administer naloxone, a list of phone numbers for treatment centers, and the national suicide hotline. Having this information in the kits is a discrete, non-judgmental, and pressure free way to get patients the information that could help them on the road to recovery.” SN 149
“I have a certain bias that comes from the pharmacy [...]We did not dispense needles without an injectable prescription on file, and I believe that it was the correct thing to do for that location. The pharmacy is located directly on a green line station, meaning we had people from all over the twin cities coming to our store. If that store dispensed needles, the amount of problems it would create would not outweigh the benefits of potentially reducing disease transmission or infection. However, I am completely onboard with other stores dispensing needles, if they are distributing them to a population base that truly needs it.” SN 159
“Many of the people I sell syringes to already appear dangerously high, and a few weeks ago we had to close the pharmacy and call an ambulance as a syringe customer overdosed and began seizing in our parking lot. Another day, though, when I asked the pharmacist if we should hold a patient’s hydrocodone prescription because she was slurring her words and had white powder around her nose, the pharmacist told me that we did not have the right to determine whether or not she needed her prescription and that it would be an infringement on her privacy to make any assumptions.” SN 110
Domain V
The role of the pharmacist
Open minded “I will have an open mind as to why people need clean needles and to take the time to talk to them without judgment so they feel that they can trust me enough to come for help when needed.” SN 84
Non-judgmental “They are still people, their addiction does not define them or who they are as person. It would be unethical and cruel to ignore the medical risks my patients who struggle with addiction face because it would mean giving them a lesser quality of care simply because of their addiction status” SN 149
Recognizing stigma addiction/mental health “People are all people, whether they have an addiction or not. We all crave compassion and for someone to listen.” SN 19
Communication/interprofessional “Healthcare professionals and government officials need to learn how to communicate with one another because both sides depends on the other when it comes to keeping our communities healthy” SN 19
Public health role “I believe that all pharmacists should have the public health mindset that overall population livelihood comes before personal beliefs. Naloxone can prevent death, and I do not believe one gets to ‘play God’ by deciding someone who uses (or anyone for that matter) does not deserve to be saved.” SN 33
Domain VI
Barriers within students
Would be okay with giving out for prescription but not for illicit drugs “I believe if a patient needs needles they should have to show evidence of either a past prescription that indicates they are still using the needles or some documentation that provides that the patient requires the needles for a medical reason. If a patient cannot show documentation of why they need the needles then they most likely do not need the needles and will be using them to shoot heroin.” SN 30
Incorrect knowledge “As for the naloxone dispensing, I do not support the idea that it should be wildly available to citizens. Naloxone is an opiate antagonist which is used intravenously in emergency situations to reverse the respiratory depression caused by overdoses of heroin, morphine or other opioids.” SN 165
Misunderstand the questions I am only half agree with the statement of the former FDA head that “Opioid epidemic is one of ‘the great mistakes of modern medicine.’ The reason for my half agreement is that at the time opioid was invented, none would think that humans would addict to it. The medication was purely intended for relieving pain, but humans figured another way to abuse the substance and eventually die from overdose.” SN 67
Miscellaneous views “Ultimately I believe that opioid and other narcotic abusers can get well, but they need to have a strong enough desire to quit, and unfortunately that generally does not happen until the impact of their drug abuse has caused massive consequences that force them to examine their choices. As a result, on a personal level, I feel that harm reduction approaches to addiction, like needle exchange, can actually do more harm than good.” AN 103
Domain VII
Past experiences and exposures to addiction
No subdomains “I recently lost a family member to a prescription drug overdose, but there was no antidote for that drug. My family was still devastated by our loss even though we knew the doctors/pharmacists did everything they could to save this family member. I cannot even imagine how devastating it would be for someone else to lose a family member to an opioid, knowing that an antidote does exist yet they did not have it accessible at the right time.” SN 18
“Personally, my good friend has been saved twice because naloxone was easily available to be purchased and was kept in her home. If naloxone was not available to be purchased by the general public, I am confident that my friend would no longer be alive.” SN 102
“It’s also important for me personally because as someone who struggles with mental health disorders, though they are not related to addiction, people treat you differently. They see you as broken and pity you or even get angry because they do not understand why you do the things you do.” SN 149
Domain VIII
Leading causes of opioid epidemic
Overprescribing “Overprescribing of opioids is what sets the path for addiction in many patients.” SN 1
Manufacturing the opioid “What we are hoping to see is the actions taken in reducing the manufacturing the opioids because those companies are facing decreases in profit if the consumption of opioids goes down.” SN 11
Lack of education towards opioids “My doctors did not even ask me about the pain, that they did not try to stop me from taking those powerful drugs, and I did not realize that I was getting addicted until three weeks later.” SN 82
Prescription drugs → increased use of illegal street drugs “As it becomes harder to obtain prescription opioid both legally and illegally, more individuals are moving to heroin which is cheaper and more addictive.” SN 49
Domain IX
Potential solutions
No subdomains “I feel that when a patient is found abusing substances and instead of taking that person to jail, they should be taken to a rehab facility instead” SN25
“I believe in my future pharmacy practice these vending machines could be placed in the pharmacy and I could provide patient education on safety of needles, risks of drug use, and options for treatment programs” SN 21