Capstone Research Project

Summer 2019

Assessing Knowledge and Attitudes Towards Harm Reduction among Pharmacy and Health

Science Students

Tayler Clark

i

Abstract

As the opioid epidemic continues to grow, harm reduction strategies are being offered to

individuals with substance use disorder (SUD) to minimize the harmful effects of drugs.

Pharmacists play a unique role as the most accessible healthcare professional in communities.

Pharmacy students must receive high-quality education and training regarding harm reduction to

assure that they are prepared to serve patients with SUD in a positive manner. The goal of this

study was to assess the knowledge and attitudes among pharmacy and other health science

students to determine if pharmacy students are more educated about harm reduction strategies. A

total of 149 students participated in this cross-sectional study. Participants, including pharmacy,

physician assistant, and nursing students, took a survey focused on harm reduction that evaluated

their perceptions and familiarity with different strategies, such as naloxone and needle exchange

programs. All statistical analysis was performed using SPSS version 25.0 (IBM Corp., Armonk,

NY). The results revealed that pharmacy students are more knowledgeable and accepting of

harm reduction than other health science students. Pharmacy students scored significantly higher

than other students when asked about access to naloxone and needle exchange services for drug

users. Overall, students demonstrated a lack of knowledge about specific strategies. Stigma and

biases associated with individuals with SUD were present in the findings, however students

exhibited the desire to help and educate patients about harm reduction strategies while

acknowledging harm reduction as a significant public health initiative. To provide students with

the capability to serve patients confidently and without bias, curricula must be created in a way

that addresses the gaps in student knowledge and the existing stigma associated with individuals

with SUD. Assessing student knowledge and attitudes allows for improved harm reduction

education that prepares pharmacists to serve their community.

ii

Competencies

F6. Discuss the means by which structural bias, social inequities and racism undermine health

and create challenges to achieving health equity at organizational, community, and societal

levels.

R2. Analyze the governmental, social, economic, and professional factors that influence

the availability and quality of health professionals in rural areas—including public

health professionals as well as health care providers.

iii

TABLE OF CONTENTS

Page

ABSTRACT.....................................................................................................................................i

COMPETENCIES...........................................................................................................................ii

TABLE OF CONTENTS...............................................................................................................iii

INTRODUCTION...........................................................................................................................1

The Role of Structural Bias in Achieving Health Equity....................................................2

Substance Use and Harm Reduction Education...................................................................4

Harm Reduction Laws in North Carolina............................................................................6

Availability and Quality of Pharmacists in Rural Areas......................................................7

Objective............................................................................................................................10

METHODS....................................................................................................................................11

Sampling............................................................................................................................11

Instrument Development....................................................................................................11

Procedure and Recruitment................................................................................................12

Analysis Plan.....................................................................................................................12

RESULTS......................................................................................................................................13

Descriptive Statistics..........................................................................................................13

Table 1. Participant Characteristics......................................................................14

Table 2. Survey Questions with Low Mean Scores................................................15

Figure. Percentage of Students that Agree vs. Disagree.......................................15

Inferential Statistics...........................................................................................................16

Table 3. Mean Comparison Between Pharmacy and Other Health Science Students..................................................................................................................18

DISCUSSION................................................................................................................................19

Limitations.........................................................................................................................22

CONCLUSION..............................................................................................................................23

REFERENCES..............................................................................................................................24

1

Introduction

The opioid epidemic has brought tragedy to communities across the United States.

Approximately 130 people in the United States die each day from overdosing on prescription

opioids.1 These numbers have been steadily increasing since the early 1990s when opioids

became a popularly prescribed medication to treat pain and people began dying due to overdose.1

This epidemic is comprised of harmful prescription opioid usage and use of illicit opioids, such

as heroin. In an effort to decrease morbidity and mortality associated with overdose, harm

reduction strategies have been utilized to minimize the harms associated with risky behaviors.

Harm reduction is a public health initiative that works to promote healthy communities

and alleviate some of the harmful effects of opioid drug use.2 A few of the strategies

implemented for the opioid epidemic include needle exchange programs where users can

exchange dirty needles for clean needles and the use of naloxone to manage and prevent opioid

overdose. Despite the established effectiveness of harm reduction strategies that have been

proven, many healthcare professionals do not accept these strategies and may have negative

feelings towards individuals with substance use disorders (SUD).2,3 Negative feelings from

healthcare professionals are largely due to structural biases found at societal, community, and

organizational levels regarding drug use and SUD. Biases and stigma play an important role in

whether an individual will seek care. Without acceptance of harm reduction strategies from

healthcare professionals and realization of the structural biases in place that hinder individuals

with SUD from finding care, many harm reduction programs are not readily available to those

who would benefit from them. One way to make harm reduction more accessible is by providing

these services somewhere that can be easily accessed without an appointment, such as a

pharmacy.4 More than 90% of Americans live within five miles away from a pharmacy.2 Patients

2

can easily ask pharmacists questions without needing to schedule an appointment beforehand.

This accessibility is even more important in rural areas where many individuals face barriers to

healthcare access, like geographic isolation, transportation, and provider shortage. The patient

interaction that is inherent within the pharmacy profession makes it ideal for pharmacists to be

equipped with resources and education regarding harm reduction strategies. For this to happen,

pharmacists must be willing to educate patients and participate in supporting these controversial

harm reduction strategies. Therefore, it is imperative that pharmacy students are prepared when

they graduate to enter the field with specialized knowledge and training on harm reduction

strategies that can be used to provide services and support those that may be suffering from this

important public health issue.

The Role of Structural Bias in Achieving Health Equity

Stigma associated with SUD plays a central role in how healthcare professionals perceive

and view the actions of drug users. Kulesza et al.5 found that when the general public was asked

about their beliefs regarding individuals who inject drugs, participants implicitly associated these

individuals with deserving punishment rather than help. This stigma associated with drug use has

a powerful effect on the way that individuals with SUD are portrayed in society. Related to

stigma, structural bias is founded on certain “structures” built within society that characterize

social norms and the way that those norms contribute to biases against certain groups of

marginalized people. In this case, structural bias against individuals with SUD undermines their

health in many ways. For example, at a societal level, policies surrounding drug use are being

created to punish drug users through incarceration, instead of helping them navigate through

treatment.5 These policies make it clear that as a society, we are more focused on punishing those

3

with SUD, rather than trying to find ways to rehabilitate and support them. This focus placed on

policy is harmful to drug users, especially when it pertains to healthcare. If an individual

perceives that there are structural bias and stigma associated with their disorder, they are less

likely to seek treatment.5

The structural biases found at a societal level are also present at a community level.

Within the drug-using community, there are structural biases present that create challenges for

individuals with SUD to achieve health equity. Women who use drugs are often more

stigmatized within the drug-using community and in the outside world.6 This marginalization

causes many women to hide the fact that they use drugs from other people and healthcare

professionals. While women are negatively viewed for their drug use, especially if they are

mothers, men are viewed in a more positive manner as being masculine or attractive.6 If women

are poor or of minority status, the chance that they will not have the resources to receive help for

their disorder is even more likely.6 Because of the structural biases built within the drug-using

community, the health of marginalized groups is threatened by creating a perception that they are

not worth helping or that they are less worthy than others.

At an organizational level, especially within healthcare organizations, these same

structural biases are built into the care provided to individuals with SUD. Without prior

experience working with individuals with SUD, many healthcare professionals are not

knowledgeable about the process of treatment and rehabilitation. Healthcare professionals often

feel unsatisfied and unmotivated when caring for individuals with SUD and would prefer that

they see an addiction specialist.7 When attempting to explain why healthcare professionals felt

this way about caring for individuals with SUD, Boekel et al.7 found that professionals perceived

these patients to be dangerous, emotionally challenging, manipulative, and poorly motivated.

4

These perceptions come from the biases and stigmas associated with drug use and SUD. To

change these perceptions, healthcare professionals must have educational and training

opportunities regarding SUD. If more education and training were incorporated into professional

education programs before students graduated, healthcare professionals would be better equipped

to realize their biases and offer supportive, informed education to patients with SUD.

Substance Use and Harm Reduction Education

Due to the rise of opioid prescribing and associated overdose, many professional schools

are restructuring their current curriculum to incorporate more material to educate students on

prevention and treatment for individuals with SUD.2.8 While it is important that schools are

including this education, the way in which individuals with SUD are portrayed and the stigma

associated with addiction must be addressed. Boekel et al.7 found that healthcare professionals

treat individuals with SUD with less concern and motivation to help when compared to other

patient groups. This negative attitude towards individuals with SUD makes it more difficult for

them to seek treatment and be successful. These attitudes also make it less likely that individuals

will reach out to healthcare professionals for help in the future.7 It is possible that these negative

feelings and perceptions towards SUD come from the lack of education that healthcare

professionals receive while in their professional education program.

When implementing substance use and harm reduction education into the curriculum,

information should be taught to students in a positive manner. Providers who have interacted

more with a certain group of people with stigmatized conditions are more likely to treat these

patients with a positive attitude and more certainty.7 To ensure that students are knowledgeable

and confident about treating individuals with SUD, there needs to be more training and education

5

for future providers with a focus on treating patients with positive attitudes and support.7 Using

education and training to change perceptions is a valuable way to better prepare students for

when they graduate. In a study by Goddard9 that evaluated the effects of harm reduction

education in changing the attitudes of treatment professionals towards harm reduction, it was

found that after attending the educational presentation about harm reduction, participants were

much more supportive of using harm reduction strategies than they were before the presentation.

The results from this study prove that by using education and training, attitudes towards harm

reduction can be improved. This is extremely important for the future of health science student

education to make sure that future practitioners are knowledgeable about the benefits of harm

reduction strategies.

When students enter into their professional education programs, they have limited real

world knowledge regarding SUD because of their lack of experience with this disorder and the

individuals who struggle with SUD.2 Recent studies have found that it is important to gauge what

students and providers at different levels of education know so that gaps in knowledge can be

addressed more efficiently and students can become more prepared for the real world.2,10 A study

assessing medical students and physician attitudes towards the opioid epidemic found that there

was a need for significant changes within medical school curricula and for continuing education

opportunities for physicians.10 This study found that student and physicians were aware that

physicians played a key role in the epidemic due to prescribing practices, but all participants had

negative views of relapse as it relates to treatment and recovery.10

Even though physicians and medical students are taking some responsibility for this

issue, there are still many barriers to treating patients with SUD with positive attitudes,

especially when considering treatment options. By assessing the knowledge and attitudes of

6

physicians and medical students, educational programs will be able to better address the deficits

that remain in harm reduction and substance use education. Similar to these findings, a study that

assessed pharmacy student knowledge and attitudes towards harm reduction found that these

students also exhibited significant knowledge gaps regarding substance use and overdose.2 The

study also established biases within student responses when asked about willingness to help

individuals with SUD.2 The results from these studies that demonstrate broad knowledge gaps

within students are concerning for the future of this public health issue. Many of these students

graduate from undergraduate programs with health backgrounds and should have some basic

knowledge and understanding of the opioid epidemic and harm reduction. Although there are

concerning results from these studies, there are also positive results. Most of the students in these

studies stated that they would be interested in more education and training regarding the

treatment of substance use and overdose.2,10 The willingness to participate in more training and

education is promising for the future of treating individuals with SUD with motivation and

positive attitudes.

Harm Reduction Laws in North Carolina

As the opioid epidemic continues, it is increasingly important that individuals with SUD

have access to treatment options and harm reduction strategies that reduce the negative

consequences of drug use. One way that these harm reduction strategies can become more

accessible is by placing pharmacists at the forefront of addressing the opioid epidemic. A

common harm reduction strategy being used is needle/syringe exchange programs (NEP/SEP).

These services provide drug users with clean needles and disposal of used needles. This strategy

aims to reduce the transmission of HIV and hepatitis C from used needles, thereby reducing the

7

harm associated with injecting drugs. Syringe exchange became a legal practice in North

Carolina as of July 11, 2016, when House Bill 972 (HB972) was signed into law.11 This law

made it legal for individuals who inject drugs to trade in used needles for sterile ones. Even

though HB972 legalizes syringes to be sold at pharmacies, individual pharmacists have the right

to deny them to customers.11 Also, under this law, individuals who state that they are in

possession of syringes before being searched by law enforcement officers cannot legally be

charged for possession of syringes or substances found within them.11

Another popular harm reduction strategy is the use of naloxone to prevent drug overdose.

Education on the administration of naloxone is an important part of this strategy. Patients and

their families must be aware of how to recognize signs of overdose and administer naloxone in

order to reverse an overdose. In North Carolina, a bill that was signed into law on June 20, 2016,

allowed a standing order for naloxone dispensing at any pharmacy in the state.12 Pharmacists

may choose whether they would like to participate.12 Since these laws are new, many curricula in

pharmacy and health science education programs do not cover them. To become informed

healthcare professionals, it is important for students to learn about the laws regarding harm

reduction strategies in their state.

Availability and Quality of Pharmacists in Rural Areas

According to the World Health Organization, pharmacists are the most accessible

healthcare professional.2 Pharmacists spend more time talking and addressing issues with

community members than any other healthcare professional. Community pharmacies are open at

convenient times and do not require an appointment. The convenience of being able to go to a

pharmacy and speak with a pharmacist is especially beneficial for individuals who live in rural

8

areas where it may be more difficult to reach a healthcare provider. Many rural areas suffer from

a shortage of healthcare providers. Even if there are providers in the area, rural residents may

face barriers such as distance and transportation. By allowing pharmacists to provide resources

and educate patients, unaddressed needs would be met, and communities would be healthier.

In rural areas, availability and quality of pharmacists are affected greatly by

governmental factors that play a role in regulating and determining the scope of practice for

pharmacists. Policymakers in some states have responded to the opioid epidemic by making

naloxone and syringes more available to individuals who use drugs.13 Pharmacists have been the

target of these policies because of their increased accessibility to communities. The new policies

that some states are putting into place allow pharmacists to dispense and even prescribe naloxone

directly to the public.13 With every state that puts a policy like this into place, the scope of

pharmacists broadens. Along with the policies comes more training and education. Pharmacists

must be trained to screen for patients that may be at increased risk for overdose and counsel the

patients and caregivers about the medication.13

Another factor that impacts the availability and quality of pharmacists in rural areas is the

social influence of the surrounding community. For rural communities, pharmacists are trusted

individuals that provide medication and counseling to patients.14 In recent years, the services that

pharmacists provide have expanded to include preventive services, such as naloxone distribution

and NEP.13-15 This expansion has allowed patients to put even more trust in their local

pharmacists by allowing them to provide services that they would normally have to see a

physician for. A sense of community and trust are important social factors that play into the

quality and availability of pharmacists.

9

As for economic factors, many rural pharmacies are independent stores and struggle

financially to stay in business. This can put a strain on the quality and availability of pharmacists

who work in rural areas. If pharmacists do not feel that they can grow as a professional and earn

more at a pharmacy, they may move to other opportunities. On the other hand, some pharmacies

may not provide services that are needed within the community, such as naloxone distribution

and NEP, due to economic barriers.4,15 These services can be costly depending on how they are

funded, and the costs associated with implementation.

Professional factors that affect pharmacist quality and availability include being part of

the healthcare team and being utilized within the community. It is important for pharmacists to

work closely with physicians and other members of the healthcare team so that patients can

receive optimal care. When considering naloxone distribution to patients at risk for overdose,

pharmacists can partner with physicians to prescribe and dispense this medication. Another

factor that affects the quality of pharmacists is the quality of students as they graduate from

pharmacy schools. By educating pharmacy students about harm reduction and the laws

surrounding harm reduction strategies, the quality of pharmacists can be improved, which will

improve the community’s health in turn.2

For pharmacists to be equipped with the education and training that they need regarding

harm reduction and drug use, pharmacy students must be taught about these subjects before they

graduate. It is especially important for pharmacy students to receive specialized training and

education about SUD and harm reduction strategies because of the unique role of the pharmacist

within communities. Maguire et al.8 found that pharmacy students were better prepared to

distribute naloxone and teach other practicing pharmacists about dispensing after being

introduced to harm reduction and naloxone educational program. In another study by Jacobson et

10

al.,16 researchers found that students retained more information regarding naloxone when they

were taught in multiple learning styles. The students who received education based off of a

lecture and an objective structured clinical examination (OSCE) where they were able to counsel

standardized patients retained more information than those students who only participated in the

lecture.16 These results exhibit the need for comprehensive education concerning harm reduction

strategies in which students learn in a variety of formats. With more experience, students will be

better prepared to treat patients in the real world.

Objective

This research study will focus on pharmacy students’ knowledge and perception of

different harm reduction strategies in comparison to other health science students. Previous

literature has focused on knowledge and perceptions of medical students, physicians, and

practicing pharmacists.4,10,15 More recent literature has been focused on pharmacy students’

attitudes towards harm reduction when entering their professional programs and how perceptions

change after being exposed to harm reduction education. 2,8,16 There is a gap in the literature for

how perceptions of pharmacy students towards harm reduction compare to those of other health

science students. This is important to the literature regarding this subject because all future

healthcare professionals should be receiving harm reduction education so that they are

knowledgeable and unbiased when it comes to caring for patients with SUD, but pharmacy

students have a unique role within healthcare systems because of their increased accessibility to

the public and their underutilization as healthcare professionals. It is important that pharmacy

program curricula are made to provide students with the knowledge and capacity to care for

patients without bias.

11

Methods

Sampling

Students who were asked to participate in this cross-sectional study included pharmacy,

nursing, and physician assistant students at Campbell University. These students were on clinical

rotations for the Spring 2019 semester. Clinical rotations are often the last step for health science

students before graduating and becoming healthcare professionals. This research focused on

these students to assess how well their program curricula had prepared them regarding harm

reduction and what kind of healthcare professionals Campbell University is shaping their

students to be once they graduate. Professors were contacted via email to set up times that

students would be available to take surveys.

Instrument Development

A survey instrument was developed to assess student knowledge and attitudes towards

harm reduction strategies. The survey focused on strategies such as naloxone use and needle

exchange programs. Questions were focused on student knowledge of these strategies and

perceptions about how these strategies should be utilized. Other questions focused on attitudes

towards drug users, overdose, and education regarding harm reduction. Furthermore, students

were asked how well they felt Campbell University had educated them on these topics and if

they would be willing to attend educational and training programs. The survey included

questions that were adapted from the Opioid Overdose Attitudes Scale (OOAS) and other

questions that were designed with suggestions from students and professors.17 Paper copies of the

survey were printed out and distributed to students.

12

Procedure and Recruitment

The research took place at Campbell University during April and May of 2019. A total of

149 students participated in this research. Of these students, 61 were pharmacy students, 52 were

physician assistant students, and 36 were nursing students. For each health science program,

students were asked to participate during a class break. A recruitment speech was read aloud to

each class that detailed the reasoning for the research and why they were being recruited.

Students were eligible to participate if they were over 18 years of age and were on clinical

rotations for the Spring 2019 semester. Participation in the study was completely voluntary,

surveys were anonymous, and students were reminded that they could withdraw from the

research at any time. Students who chose not to participate in the study were asked to leave the

room for the privacy of those who participated. Two paper consent forms were passed out to

each student. Students who chose to participate signed one consent form and submitted it. The

second consent form was for the students to keep for their own personal records. Once students

submitted their consent form, they were given a paper survey that took 10-15 minutes to

complete. Students answered a 20-question survey that assessed their knowledge, perceptions,

and attitudes surrounding harm reduction strategies. Each question was rated on a 5-point Likert

scale (completely disagree, disagree, unsure, agree, and completely agree) to prevent random

guessing and encourage honest answers. Once students were done with the surveys, they were

collected and analyzed.

Analysis Plan

Data collected from the paper surveys were entered into Excel. A codebook was made to

keep track of the data in relation to the questions on the survey. Questions asked on the survey

13

were made into variables and each Likert scale answer was given a numerical score (1 =

completely disagree, 2 = disagree, 3 = unsure, 4 = agree, and 5 = completely agree). These scores

were reversed for questions that were negatively worded to make sure that the numerical values

of each question indicated the same type of response. Data was then transferred into SPSS

version 25.0 (IBM Corp., Armonk, NY) where all statistical analysis was performed. Mean

scores for each question were calculated to determine the average answer of students. To

calculate the percentage of students that agreed versus those who disagreed, responses for each

question were dichotomized into “agree” and “disagree” variables. Numerical responses of 4 =

agree and 5 = completely agree were recoded into one variable, 2 = agree. All other numerical

responses were recoded as 1 = disagree. Once again, the scores were reversed for questions that

were negatively worded to ensure consistency of response (1 = agree, 2 = disagree). To compare

pharmacy students with other health science students, nursing and physician assistant students

were recoded into one variable. Independent samples T-tests were run for each question to

compare the mean scores between pharmacy students and other health science students. These

tests were also used to determine if the difference between the mean scores of the two groups

was statistically significant or not.

Results

Descriptive Statistics

The survey was offered to a total of 197 students and 149 consented to participate in the study

(response rate=75.6%). All students who participated in the study were included in the analysis

(n=149). Response frequencies were calculated for each survey question, including demographic

questions. Participant characteristics are shown in Table 1. Of the students who participated, 61

14

(40.9%) were pharmacy students,

and 88 (59.1%) were from other

health science programs

(physician assistant and nursing).

When asked if they had ever been

enrolled in a health science

program at an institution other

than Campbell University, only 23

(15.4%) students responded that

they had. This means that most of

the students had only received health science related education from Campbell University.

Therefore, the knowledge and attitudes of the students in this study represent the quality of harm

reduction education at Campbell University well.

Mean scores for each question determined the average response from students. A score of

5 represented the most desirable answer choice for all questions, while a score of 1 represented

the undesirable answer choice. An average score between 3.5 and 5 was representative of a high

score. An average below 3.5 was considered a low score. Table 2 shows questions that received a

mean score of less than 3.5. Out of 20 questions, five resulted in a low score with the average

below 3.5. Three of the questions resulting in low mean scores were questions that were

negatively worded, and reverse scored.

Table 2. Survey Questions with Low Mean Scores Survey question Mean score

Table 1. Participant Characteristics (n=149)Demographic Characteristic Mean (SD)Age (years) 26 (11.3)   Gender n (%)

Male 41 (27.5)Female 108 (72.5)

Race/ethnicity  White/Caucasian Only 119 (79.9)Other race/ethnicity 30 (20.1)

CPHS program  Pharmacy 61 (40.9)Other HS program 88 (59.1)

Ever enrolled in any other HS program  Yes 23 (15.4)No 126 (84.6)

Abbreviation: HS, Health science.

15

Q8. Providing naloxone to drug users promotes drug misuse and overdose.*

3.24

Q9. I am familiar with the services that needle exchange programs provide.

3.42

Q10. Needle exchange programs promote illicit drug use by providing clean needles to drug users.*

3.35

Q16. Drug users should only have access to harm reduction strategies if their goal is to become clean.*

3.42

Q18. I believe that Campbell University has provided me with the education to be adequately informed about the laws surrounding needle exchange programs.

3.01

*These questions were reverse scored.

The percentage of students who agreed was compared to those who disagreed for each

question. The figure above shows the results when the question responses were dichotomized

into “agree” and “disagree.” Numerical responses of 4 = agree and 5 = completely agree were

16

recoded into one variable, 2 = agree. All other numerical responses were recoded as 1 = disagree.

The scores were reversed for questions that were negatively worded (1 = agree, 2 = disagree).

Responses of Each question from the survey is represented. This figure allows for easy

interpretation of the survey results. For the questions that are reverse scored, disagree is the

desirable response, whereas agree is the desirable response for questions that are normally

scored. Questions with a high percent disagree rate include “familiar with needle exchange

services” and “Campbell University adequately informed me about needle exchange laws.”

Negatively worded questions with high percent agree rates include “naloxone promotes misuse,”

“needle exchange promotes illicit drug use,” and “drug users should have access to harm

reduction only if becoming clean is their goal.”

Inferential Statistics

To compare the means between pharmacy students and other health science students,

independent samples T-tests were run for each question. An alpha level of 0.05 and two-tailed

tests were used for all statistical analysis. Table 3 summarizes the results from the T-tests. On

average, pharmacy students scored higher than other health science students for almost every

question. The independent samples T-tests indicated that pharmacy students (N=61, M=4.13,

SD=0.532) were significantly more familiar with harm reduction strategies than other health

science students (N=87, M=3.85, SD=0.638) ( p=0.006). Pharmacy students (N=61, M=4.13,

SD=0.741) also felt better prepared to be able to provide harm reduction resources than other

students (N=88, M=3.88, SD=0.785) (p=0.047). When asked if all illicit drug users should have

access to naloxone, pharmacy students (N=61, M=4.23, SD=1.023) were more likely to agree

than other health science students (N=88, M=3.86, SD=1.095) (p=0.041). Pharmacy students also

17

seemed to be more supportive of needle exchange services. The T-tests showed that pharmacy

students (N=61, M=3.92, SD=0.781) demonstrated increased support for organizations providing

clean needles than other students (N=88, M=3.58, SD=0.906) (p=0.016). The same was found to

be true for organizations that dispose of used needles. Pharmacy students (N=61, M=4.34,

SD=0.574) scored 0.25 points higher than other students (N=88, M=4.09, SD=0.783) (p=0.033).

When students were asked if they felt that Campbell University had adequately informed them

about harm reduction strategies, pharmacy students (N=61, M=4.02, SD=0.785) felt more

informed than other health science students (N=88, M=3.69, SD=0.876) (p=0.022).

18

Question Program N Mean Std. Deviation p-valueFamiliar with HR Strategies Pharmacy 61 4.13 0.532

Other 87 3.85 0.638Wants to help if someone ODs Pharmacy 61 4.69 0.501

Other 88 4.65 0.548Knows How to Help if Someone ODs Pharmacy 61 4.31 0.620

Other 88 4.23 0.638Able to Provide HR Resources Pharmacy 61 4.13 0.741

Other 88 3.88 0.785All Illicit DUs Should Have Access to Naloxone Pharmacy 61 4.23 1.023

Other 88 3.86 1.095Able to Administer Naloxone Pharmacy 61 4.39 0.759

Other 88 4.33 0.707OD & Naloxone Education is Important Pharmacy 61 4.77 0.424

Other 88 4.70 0.483Naloxone Promotes Misusea Pharmacy 61 3.33 1.179

Other 88 3.18 1.140Familiar with NX Services Pharmacy 61 3.41 0.883

Other 88 3.42 0.840NX Promotes Illicit DUa Pharmacy 61 3.46 1.058

Other 88 3.27 1.069NX Programs Should be Accessible Pharmacy 61 3.87 0.866

Other 88 3.67 0.893Educating DUs is a Waste of Timea Pharmacy 61 4.38 0.610

Other 88 4.28 0.710Providing HR Resources Encourages Misusea Pharmacy 61 4.21 0.686

Other 88 4.11 0.749I Support Orgs. that Provide Clean Needles Pharmacy 61 3.92 0.781

Other 88 3.58 0.906I Support Orgs. that Dispose of Used Needles Pharmacy 61 4.34 0.574

Other 88 4.09 0.783Access to HR Only if Becoming Clean is Goala Pharmacy 61 3.39 1.255

Other 88 3.44 1.202CU Adequately Informed Me About HR Pharmacy 61 4.02 0.785

Other 88 3.69 0.876CU Adequately Informed Me About NX Laws Pharmacy 61 3.18 1.073

Other 88 2.89 1.129Willing to Attend HR Education & Training Pharmacy 61 4.13 0.806

Other 88 4.14 0.714HR Has Significant PH Impact Pharmacy 61 4.61 0.525

Other 88 4.52 0.525Abbreviations: HR, Harm reduction. OD, Overdose. DU, Drug user. NX, Needle exchange. Orgs., Organizations. CU, Campbell University. PH, Public Health.aThese questions have been reverse scored.*p <0.05 indicates statistical significance

0.033*

0.808

0.022*

0.113

0.967

0.339

0.941

0.295

0.179

0.407

0.411

0.016*

0.424

0.047*

0.041*

0.599

0.380

0.450

Table 3. Mean Comparison Between Pharmacy and Other Health Science Students

0.006*

0.644

19

Discussion

The purpose of this study was to compare pharmacy students’ knowledge and perceptions

of harm reduction strategies with other health science students. No previous research has been

done to explore the differences between pharmacy students and other students as it relates to

harm reduction and the unique role that pharmacists play within the healthcare system. This

study found that pharmacy students are more knowledgeable and accepting of harm reduction

strategies than other health science students. Even though pharmacy students seem to be more

educated about harm reduction strategies, there are still important gaps in students’ knowledge

that need to be addressed in program curricula. Similar to the findings of Mahon et al.,2 this

study found that pharmacy students felt as if they played an important part in addressing issues

surrounding drug use specifically related to naloxone use and needle exchange programs.

The low mean scores (shown in Table 2) found for five of the survey questions revealed

that there are some knowledge gaps when it comes to naloxone use, the laws surrounding these

needle exchange programs, and the services needle exchange programs provide for respondents

as a whole. A low mean score indicates that the average answer for these questions was the

undesirable answer. One reason for low scores could be that students have not had enough

education regarding different harm reduction strategies to be aware of the benefits that these

services provide. The lowest mean score was for the question “I believe that Campbell

University has provided me with the education to be adequately informed about the laws

surrounding needle exchange programs.” This shows that program curricula are not doing

enough in the way of harm reduction education to prepare students for their future careers as

healthcare professionals. Chouinard et al.10 expressed the need for more emphasis placed on

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chronic illnesses, like SUD, in program curricula. Findings from this current study support this

change, as well.

This study also found stigma towards individuals with SUD throughout student

responses. As seen from Table 2, students felt that by providing naloxone and needle exchange

services to drug users, they would be promoting drug use and overdose. Mahon et al.2 had similar

findings where students felt that they could not be supportive of harm reduction strategies

because they believed that it supported misuse. Another stigmatized response included students’

beliefs that drug users should only have access to harm reduction strategies if their goal is to

become clean. The goal of harm reduction is not to become abstinent. In fact, harm reduction

accepts that people will continue to participate in risky behaviors, such as using drugs.18 The true

aim of harm reduction is to reduce the harms associated with risky behavior. By continuing to

maintain stigmas associated with drug use and SUD, harmful structural biases are being

preserved that threaten the health of those who use drugs. Students must be properly educated on

realizing their biases and working to promote health, instead of undermining it.

The figure shows the percentage of students that agree and disagree with each question.

For five of the questions, the percentage of students that agreed was almost equal to the

percentage of those that disagreed. These results are concerning because they demonstrate that

students are unsure about harm reduction strategies. Similar conclusions from what has already

been established from the data can be drawn from the figure. Responses show that students are

uncertain about needle exchange services and about drug misuse related to harm reduction.

Stigma and biases are evident in these responses because students are equating harm reduction

with drug misuse. Alternatively, there are positive findings from these results. Almost all of the

students agreed that they want to help someone if they were to overdose. Students felt that

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educating patients about overdose and naloxone are important and they believed that harm

reduction has a significant public health impact. Within the drug-using community, there are

misguided beliefs about what to do when someone overdoses that could be potentially harmful.3

By providing accurate information to patients about signs of overdose and prevention, lives

could be saved.

In comparing pharmacy and health science students, Table 3 shows the different means of

each group and the associated p-value. Pharmacy students had significantly higher scores for

quite a few questions specifically focusing on knowledge about overall harm reduction

strategies, access to naloxone, needle exchange services, and how well Campbell has informed

them regarding harm reduction. Pharmacy students may be more knowledgeable about harm

reduction because pharmacy education involves a doctoral program that typically lasts four

years. Physician assistant education is a master’s level program that lasts between two to three

years and nursing school is a baccalaureate program where practice experience only lasts two

years. Pharmacy school curricula are much more extensive than these other programs. While

there are similar topics are covered, pharmacy school addresses subjects that are not focused on

in other health science programs. Pharmacy students also have more clinical experience

throughout their educational program than physician assistant or nursing students. The impact of

this more comprehensive program is revealed is pharmacy students’ responses when asked if

Campbell had sufficiently informed them of harm reduction strategies. Pharmacy students scored

0.33 points higher than other students. While this is the case for overall harm reduction, both

groups scored low when asked if they were adequately informed about laws regarding needle

exchange. Harm reduction education for all health science programs needs to be more

comprehensive and educate students about the laws surrounding important public health issues.

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Another reason why pharmacy students know more about harm reduction is because of

the unique role of the pharmacist. Pharmacists are more accessible within the community than

any other healthcare professional. As students go through pharmacy school, this mindset is

ingrained within the curriculum. Pharmacy students are cultivated to have a community-oriented

perspective. Pharmacists are situated perfectly within the community to be able to address

important public health issues, such as harm reduction and the ongoing opioid epidemic.2 Other

health science programs are more patient and disease-focused. Therefore, they may be missing

out on some of the important community aspects of healthcare.

Limitations

There are a few limitations to be considered for this study. Despite efforts made to ensure

that students were aware that their participation was not required for a class or a grade, response

bias may have influenced findings since the surveys were given in a classroom setting. Students

may have felt pressured to participate due to their environment. Another limitation to note is that

this study was performed at only one school. These findings may not be representative of

pharmacy and health science students from other schools. Pharmacy students and other health

science students do not receive the same type of education and training. Therefore, it is possible

that the findings from comparing these two groups are not as relevant as they would be if

pharmacy students were compared with students who had received similar education and

experience, such as medical students. These programs are not identical, but, like pharmacy

school, medical school curricula are more extensive and go further in-depth. Future research

should investigate student knowledge and attitudes from multiple schools and should include

other health science programs. Additionally, future studies should evaluate pharmacy and health

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science program curricula to develop and improve education regarding substance use and harm

reduction.

Conclusion

Harm reduction is an effective approach to minimize some of the harmful effects of the

ongoing opioid epidemic. Healthcare professionals must be prepared to offer services to patients

in a way that does not prevent individuals with SUD from reaching out for help. In order for

healthcare professionals to be well-informed about harm reduction strategies and the laws

surrounding services, the education that health science students receive must incorporate these

subjects in a way that does not promote structural biases and stigma associated with SUD.

Pharmacists are well positioned in communities to have the ability to address concerns about

drug use and incorporate harm reduction strategies. To become high-quality pharmacists,

pharmacy students must receive specialized training and education that allows them to be

confident in their knowledge and perceptions surrounding harm reduction. This study found that

pharmacy students are more informed about harm reduction than other health science students.

Responses indicated that there are knowledge gaps related to specific strategies, like naloxone

use and needle exchange services. This study also found stigma and biases associated with

student responses regarding drug users. However, the majority of students have the desire to help

and educate individuals who struggle with substance use. Students also felt that harm reduction

has a significant public health impact. By working to create a curriculum that introduces harm

reduction education in a positive way, students will be more confident in implementing strategies

as they graduate into their professional careers. Using harm reduction education to change

perceptions about individuals with SUD will help to promote health in the communities that need

it the most.

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