Applying the capability, opportunity, motivation, and behavior model to identify opportunities to increase pharmacist comfort dispensing naloxone in Texas: A structural equation modeling approach

Abstract

Background: The prevalence of opioid use and misuse in the United States contributed to 48,000 opioid related deaths in 2018. Naloxone, a potent opioid reversal agent, can be dispensed by pharmacists without a prescription, however few do so. Previous studies on naloxone dispensing have contributed to our understanding of the determinants of naloxone in community pharmacy, however, none have focused on comprehensive behavioral change. This study utilized the Capability, Opportunity, Motivation, and Behavior (COM-B) model, a behavioral change and intervention design framework, to examine community pharmacists' comfort dispensing naloxone.

Methods: A 48-item questionnaire grounded in the COM-B and theoretical domains framework was developed and mailed to 1,000 community pharmacists in Texas, USA using a modified Dillman cross-sectional survey design. Confirmatory factor analysis was used to refine and establish dimensionality of the hypothesized scales and structural equation modeling was used to estimate the fit of the COM-B in explaining pharmacists' comfort dispensing naloxone.

Results: The usable response rate was 19.4%. Of surveyed pharmacists, 29.7% had ever had a patient request naloxone and 35.1% had dispensed naloxone without a prescription. Capability and opportunity explained 60% of the variance in motivation. Opportunity and motivation were the most salient predictors of comfort dispensing naloxone. Together, capability, opportunity, and motivation explained 78.1% of variance in pharmacists' comfort dispensing naloxone, indicating that the COM-B model is useful in this setting.

Conclusion: Despite previous findings, policy interventions to increase naloxone dispensing should go beyond providing additional education to the pharmacy workforce. Rather, these results suggest that a complex intervention designed with pharmacist input that enables them to act autonomously and evaluate whether patients need naloxone may increase their comfort dispensing. Without collaboration from pharmacy and managed care corporations, dissemination efforts will continue to be limited.

Keywords: COM-B; Naloxone; Opioid overdose; Pharmacy; Policy.