Welcome to AJHP Voices, a series of discussions with AJHP authors and interviews focused on contemporary practice issues. AJHP is the official journal of ASHP, and its mission is to advance science, pharmacy practice, and health outcomes. Hi, this is Daniel Coba, the editor-in-chief of AJHP. Thanks for joining us in this episode of AJHP Voices. The hesitancy to receive COVID-19 vaccines continues to be a profound public health problem. Joining me today to discuss their article, Pharmacist-Implemented Intervention to surmount COVID-19 vaccination hesitancy in adults with substance use disorder. Are Dr. Zoe Caravolas, Clinical Pharmacists, McLean Hospital, and Dr. Antoine Duhe, Professor of Psychiatry and Medicine at the University of Pittsburgh School of Medicine. Zoe Antoine, welcome. Thank you so much for having us. So Zoe, as we start off talking about this very interesting article, it's wondering if you could really take a step back and talk about the magnitude of COVID-19 vaccine hesitancy at this point in the United States. So as you mentioned, Dan, vaccine hesitancy really is a major barrier to COVID vaccine coverage across the United States. I would say that as the acceptance the COVID vaccine has shifted with time, with maybe a little more hesitancy following its rollout, whereas now we're almost in a place where there's kind of this general acceptance that it's just part of standard medical practice. The last estimate that the CDC published at the end of July 2024 was that about 81% of adults in the United States have received at least one COVID vaccine, and that number has been stagnant for about two years. There has been some studies published looking at vaccine hesitancy over time, but that hasn't really showed anything compelling. It mostly shows that vaccine hesitancy is labile, that it waxes and vanes, and hasn't really resolved any inequities in terms of vaccines received amongst different populations. Antoine, when you look at that hesitancy and the typical reasons for hesitancy and that percentage of the population that remains unvaccinated, how does that translate into people with substance use disorders? People with substance use disorders, they face a lot of barriers and unique barriers to getting vaccinated when it comes to COVID-19. So obviously, the similarities are between the general population and people who have substance use disorders, and particularly also with co-occurring psychiatric disorders, because a lot of the population that we have, where we did the study, where majority of them have also, in addition to the substance use disorders, they have psychiatric disorders, which can complicate obviously the whole picture and lead to reading more barriers when it comes to vaccination. And we know very well also, the big aspect related to the vaccine hesitancy in people who have substance use disorders, and psychiatric disorders, is a lot of that misinformation and distrust in the healthcare system. You know, you're talking about really populations that have been stigmatized, that have been criminalized, so a lot of it plays into a similar trend when it comes to the vaccine hesitancy. In fact, we see more problems with vaccine uptake, as we call it, in people who have substance use disorders and co-occurring psychiatric disorder, which kind of really makes it so important to look at these factors and elements that are associated with vaccine hesitancy as well as figuring out different interventions that can really mobilize people to resolve their hesitancy and accept the importance of having the vaccine. A multitude of factors, and you talked about intervention, and one of the first steps towards intervention is screening and identification. And Zoe, in this study, you used the screening brief intervention and referral to treatment protocol. How did it come into play? How was it used? The screening brief intervention and referral to treatment, which is something commonly referred to as "espert," is an evidence-based treatment that was developed to identify and intervene an individual who has a substance use disorder with potentially hazardous or harmful consumption of substances. So really, the overarching goal of "espert" is to reduce or prevent some of those health consequences that may come from hazardous drug use, so think injuries, accidents, different diseases associated with substance use, which really just makes this an ideal tool for something like vaccines. "espert" has three main components, the screening, a brief intervention, and then referral to treatment, which in this case is COVID-19 vaccination. And "espert" is also something that can be done in a lot of different health care settings from primary care, emergency grounds, other community settings, and can be used with patients of all levels of substance use. So really, this is a particularly useful tool for pharmacists in particular. Got it. Now, Antoine, what was the overarching purpose of this study? Let me give you a little bit of a context, because I know we start talking about in terms of the difference between people who use substances, you know, substance use disorders and psychiatric disorder versus VA general populations. So it's been very well determined from a lot of the research and the studies that the vaccine uptake in people who have substance use disorder, who use drugs, you know, or I call it significantly lower that among people, obviously, who use the drugs versus the general population. So we have basically here a serious public health issue, you know, that need to be addressed. And a lot of that vaccine uptake, since, you know, that is a high percentage of people who use drugs that have struggled with vaccine hesitance or refusal, we have to keep that in mind. And the vaccine hesitancy can go to the other extreme, which is really told to refusal, even not wanting to have a conversation about it. And that could be also related to a lot of situations, a lot of what we call social determinants of health, like, you know, unstable housing, not having access. And we see that a lot in people who have substance use problems. So a lot of people who struggle with substance use problems, they have a lot of these other psychosocial issues that can get in the way of really getting the vaccine. And also in addition to that being also very much hesitant about it, in regards to trusting the health care system, being misinformed about it, or disinformed about it. So the whole purpose of the study was to really kind of look at that particular population. And we know very well that people have substance use disorder also, they really suffer more kind of potential severe complications as a result of COVID-19. So we're talking about treating more vulnerable populations to begin with, which makes it much more urgent to really address the vaccine hesitancy and refusal. So that's the whole purpose. And particularly, we chose basically the populations on an inpatient form, which is really kind of patients with mostly majority of them have severe substance use disorder. So the key issue here is that we're looking at basically how the severity of the substance use disorder could affect obviously the vaccination status and whether people are receptive to the one session, as Joey was talking about, to the expert intervention that was delivered by a pharmacist. And also, the other aspect of it is that whether they accept to be referred for vaccinations after the intervention, after the expert intervention that was discussed. And one issue here, so again, it goes back to that multifactorial, complicated issue that with different elements that need to be addressed. And if they are not all addressed, the likelihood of people resolving their vaccine hesitancy or coming to terms with the fact that it's important that they get vaccinated, particularly I'll talk about the populations with substance use disorders, makes it really a major public health problem. You made reference, for example, to social determinants of health. And again, we've talked here about multiple factors. When you look at the screening component of the tool, does it address all of those factors or do some of them still come into play even though you're not specifically screening for those through the tool itself? What would the intervention and so if you can jump in also here, the intervention is specifically focused on increasing the motivation and helping people resolve that hesitancy, that ambivalence about taking the vaccine. Obviously, it can really, in a way, bring up issues related to the practical issues. Let's put it this way, the logistical issues about whether they're going to be able to have access to it and how they can have access to it. Let's say if they don't have any kind of transportation, where they can get it and how you can really meet people where they are in the sense. So in a way, on some level, the aspect of the intervention can address some of it but not all of, not all of these psychosocial issues and social determinants of health. So we've talked about the population to a great degree here. We've talked about the intervention. So what about what the measures that you used as you look for associations in this study? What measures were used? So we gave each patient a 10-item questionnaire and they asked some demographic information and also asked if they had received any COVID vaccines and if so, what type, how many doses. So that was really that S part of the S part for us. And then if they hadn't received any vaccines, the pharmacist proceeded into a further discussion with the patient. The pharmacist performed a one-session intervention model done expert with really the aim of motivating individuals who were unvaccinated to receive the COVID vaccine. And that was primarily this 15-minute focus discussion that talked about the benefits of receiving the vaccine, reasons hindering vaccination. And then after that intervention, that's when we asked patients to rate on a 10-point scale, whether they had no interest at all, all the way up to very high interest in receiving a COVID vaccine. So other than vaccination, other measures that we collected included substance psychiatric diagnoses, as well as baseline characteristics, like sex, race, ethnicity, et cetera. And how did you prepare those pharmacists to do that education? Was that part of their standard practice or was that standardized for the protocol and for the study? A little bit of both. The conversation was primarily initiated with a standardized document that was essentially the health system-wide info sheet on COVID vaccines, if you will. So that was the basis of the discussion, but pharmacists were welcome to incorporate some of their own personal experience with the vaccine and clinical knowledge, as well. So Antoine, what did you find? Obviously, the results are really fascinating, and one of the things that I want to emphasize that I believe makes the study very important from a public health point of view is the use of the model of the IRT model, which is a statistical model that looks at basically more quantifying the severity of the substance use disorder, because that kind of feeling, in a way, changes the whole kind of dynamics here. And instead of looking at symptoms, we're looking at kind of feeling more the continuum of the severity, and we have a clear kind of, in a sense, result of the higher the severity of the substance use is associated with the lower vaccination rate. How do you measure severity, then? What are the components that go into a determination around severity of substance use disorder? The way the severity is determined is based on the classification that we have in the DSM, you know, the diagnostic and statistical manual of psychiatric disorders, the revise, that goes on the continuum, it's based on criteria, consensus criteria, like based on mild, moderate severe depends on how many criteria you have, that you meet these criteria for the diagnosis, and then you go under either the mild or moderate or the severe kind of spectrum. Obviously, the model that was used at Zoe has used, and she can probably talk about it, also the IRT is really kind of very strong statistical model that kind of determine these kind of different levels. From my perspective, as a scientist, and also informing, you know, potentially public health decisions and measures is that we need to keep in mind that we still need to meet the patients where they are, where they are in terms of the continuum, and so obviously, the people who have a mild substance use disorder might not need as many interventions necessarily to really kind of get them to move in the process of getting more motivated to accept the vaccine or to resolve that vaccine hesitancy versus people who have really the severe, who are on the severe end of the spectrum. So in a sense, it can really in a way inform some of the approaches that really some people might need more doses than just one dose of 15-minute asper. So again, this is something really important that to individualize it, let's put it this way. You want to always look at the results of what you do. How is it going to translate into clinical outcomes? How is it going to translate into the real world? So that the issue of the severity of the substance use disorder is important. The other aspect is the substances themselves. What sort of substances are associated with the higher rates frequently associated with unvaccinated status? And we know that from how we're studying and from also previous studies that have been done, the nicotine opioid and particularly opioid, we're talking about the fentanyl, which now, as we know, out there, you know, there's no much heroin anywhere. It's all fentanyl. And obviously, the sedative use. From previous studies, there hasn't been any kind of also demonstration that it's associated with the alcohol piece. So it's just more of these kind of really substances, even with the cannabis too. This is important because also kind of, in a sense, can really inform what sort of interventions in that sort of a context would be potentially really helpful. But again, there is the association with what type of substances lead to kind of an unvaccinated status that people have these sort of substance use problems that really urgently need these kind of interventions, otherwise, they are not going to potentially seek to get vaccinated. So along with the types of substances that are involved and the number of substances involved as well, were there other variables that came into play such as racial differences? Yeah, before we get to racial differences, since, you know, you mentioned that there is the receptivity, you know, to what looked at as a part of the aims to the intervention itself. So there was no basically association between the severity of the substance use and receptivity. So this whole idea that people are not going to really accept to be approached about that kind of a conversation, you know, using the expert intervention is not really true. People are going to be receptive, regardless of where they are with the spectrum of the substance use disorders. I mean, this is really kind of important to emphasize, which means, you know, that we need to kind of be more proactive in approaching everybody, obviously. So when it comes to the racial differences, again, the social determinants and the context of people of filiration and ethnic minority groups, obviously they have more of the challenges related to trusting the health care system being misinformed, not having the resources out there, obviously, you know, there's a lot of the discrimination. So if you think about it, race, trust, and I mean, all these kind of are very much intertwined and that they create a lot of discrepancy in terms of whether to really get vaccinated or whether to really kind of in a way to be approached about getting vaccinated. So because a lot of people, if you don't have any sort of an outreach, because you need to meet people where they are, and this is kind of a big challenge for us throughout this whole kind of pandemic where, wait a second, I mean, not every person is going to come through the health care system. So what are we going to do to reach out to people who are really out there? And particularly when it comes to racial and ethnic minorities doing that outreach in places where people hang out in their community. So the community outreach is important and honestly, and the reason why even, you know, to train pharmacists, to train any kind of a sort of staff or workers to be out there and really do these sort of interventions to mobilize people towards thinking more about the importance of the vaccination and also debunking a lot of that misinformation and inaccurate information that they have. So I really would love to get into this a little bit more because there are a number of interesting dimensions. At the beginning of your paper, you really frame this and you build the rationale and you return to this in your discussion as well, about using this as a starting point to determine whether this could be an effective intervention actually in the community pharmacy setting. And that seems to be where you're going. But to your point, Antoine, as a native Pittsburgher, I think about some of the aspects of health care delivery in the city. And I know, for example, that there's been a real emphasis on going to barbershops at churches. And then in Pittsburgh, you have some of the pioneering work that was done by Dr. Jim Withers around medicine, really out in the streets for people who do not have housing. So let's talk about that a bit. So let's start with the community setting, but I'd be very interested in both of your perspectives on applicability and maybe Antoine, this is what you were saying when you talked about meeting people where they are. Maybe those are the settings you were talking about. So we absolutely, so I mean, implementing an expert for COVID vaccines into a community pharmacy setting almost seem seamless. Community pharmacies are almost the ideal space for this to happen for a few reasons. One, like Dr. Dwayne, he mentioned you're meeting people where they're at. They're in their communities. You can engage with them on a more regular basis. There's a lot of reasons that people visit community pharmacies. You're also in a space that people are familiar with and are able to share information about vaccines in kind of a more trusting manner. There's some good literature out there about pharmacists being, you know, rated amongst one of the most trusted healthcare professionals, right? And that's for a reason. People are interacting within them in a place that's familiar to them. There are certainly limitations, of course. So community pharmacies face a lot of challenges with staffing, workload, reimbursement for things like interventions, conducting interventions like this. But on the flip side, community pharmacies are already places that are giving vaccines. So this is not really a new practice for them. And this is space for pharmacists to normalize vaccination, to discuss vaccines on an ongoing basis to share stories because they know people on a personal basis. So really, I think it's more about kind of us reducing system-wide barriers in community pharmacy to allow this to happen because it's something that an ideal space community pharmacy would be great for. And community pharmacy is such a great example. But is it fair to say when you think about this population that was studied here specifically, people with substance use disorders, maybe multiple substance use disorders, it may be out on the streets, Antoine, is that a possible place to intervene? That's what we call like the hospital when people really show up and you see them. It's like a window of motivational opportunity to jump on. So, which means that you have the person there. So if you miss on that opportunity to approach them about the vaccination, and there has been like a little bit of that, as you know, now very well, COVID is resurfacing now, you know, in a sense, there has been, unfortunately, within our healthcare systems, this really lack of, it's like what is the point that other issues now need to address. It kind of really moved away from that priority. That needs to be addressed. And in fact, you know, like on our unit now where basically we recruited all the patients, I still intervene and I still kind of really encourage our staff, our medical trainees and everybody to intervene. The conversation doesn't take more than five to ten minutes, twelve minutes, fifteen minutes. And the patients are there. They are particularly loss-wise. So we need to really kind of take advantage of also other opportunities in community. And so we were talking about in community, the pharmacy, you know, where you're going to have face-to-face with the patient, you're going to have that interaction with the patient. How about really having a conversation, you know, for these ten minutes about that? How could that not be possible? It's about really changing the cultural mindset that this is something really important and particularly we know very well that people who are really more vulnerable, more compromised, you know, who have substance use disorders plus all these medical issues that which we have, a lot of medical complications as a result of the substance use problems, they are at higher risk of dying from really getting the infection. So I mean, I think it's just, it's like you want to kind of address it on multiple fronts here and the outreach, as we talked about, and you said that you articulated it very well, is to be more out and activate people because, you know, the intervention itself, it's just the conversation itself, the aspect of interventions, how we always kind of try to be, understand how it works. Does it really work? What it does in fact, it really activates what we call self-regulatory processes. Self-regulatory processes are processes in the brain that helps you start thinking a little bit more. I mean, it's kind of translate directly into somebody, oh yeah, I'm going to get the vaccine right away. It could. We've seen patients said, okay, well now you're telling me this and then I want to do it. But it really moves people in that direction of started thinking and reflecting, oh, maybe, you know, my family had the vaccine, they are doing very well, they feel it's safe, maybe I can consider it now. So that kind of intervention that is done could really mobilize people towards that phase where they're going to consider taking the vaccine. And particularly, as we said, it's really because, you know, now, as you know, with the variants and everything, you know, they ask people to have more vaccines and more so it becomes really much more challenging for a lot of people and there is this kind of a tendency even among healthcare practitioners to say, well, you know, some they've been vaccinated twice or three times, that's enough. In fact, what about all these variants that keep surfacing and the vaccines that we have on board are not really effective for these type of variants. The other thing to just point I want to make very quickly here is that we did a study basically here at Pitt that was led by Dr. Hoffman and we looked at basically tweets, we looked at social media, what sort of messages, what could promote people to really be less hesitant about getting the COVID-19 vaccine. And we know very well the sharing of narrative stories is really crucial, telling personal stories on social media, you know, that, oh, it worked for me, it helped me out and I didn't experience any side effects. And along with that basically doing these interventions that we've been talking about, the expert or other interventions, we know very well that if you combine these both and, you know, very well now, the social media is taking over any sort of communication. And unfortunately, it comes with a lot of the misinformation and disinformation about it and it becomes really challenging. But still we need to also remember, you know, that we want to do it in so many different ways that can optimize and mobilize people towards resolving their hesitancy and accepting the vaccine. Absolutely. You talk about meeting people where they are and for a segment of the population that may be on social media. So you discuss in the article crossover between COVID-19 vaccine hesitancy and hesitancy toward other vaccines. We focused a lot on COVID-19 here, but as an example, a very current example, WHO recently declared MPOCs a global health emergency. Is it fair to expect hesitancy to the MPOCs vaccine as well and people with substance use disorder? So what we found in this study is relevant to other vaccines in a lot of ways. One, we know that people who have a substance use disorder are less likely to be vaccinated but in the general population. And two, we know that intervention works and that many of these people are willing to get vaccinated when asked about it, when talked to about it. There are other studies published that show that there is a significant gap in people who have substance use disorders between people who are vaccinated and those who want to get vaccinated. So really it leads me to think that hesitancy is not the only player when we're talking about substance use disorders and vaccination in general. There's a lot of interplay here with access and stigma in healthcare that prevent people from getting the care that they want. In fact, there was actually a study published in 2023 that looked at the way these two parallel epidemics of COVID and then overdoses and found that vaccine hesitancy was positively associated with substance use stigma towards things like opioids, methamphetamine and cocaine use. And in general, I think one of the biggest misconceptions about folks who use substances is that they don't care about their health or they don't want to take measures to keep themselves healthy and that really is just very far from the truth. Antoine. So we just talked about really the interplay and we've talked a lot about this multiple factors here interplay between them and something that you were beginning to touch on I think a few moments ago is really some of the other characteristics of people who have substance use disorders that might relate to rejecting societal norms that there could be differences and executive cognitive capacity. Can you talk about how those factors also come into play here and need to be considered? Sure. There is a clear association between the severity of the substance use disorders and all these behaviors that do not conform to the social norms because there are a lot of people who engage in a lot of what we call addictive behaviors, addictive behaviors that get them basically into the legal system, they get them arrested, they end up being incarcerated and all this more stigmatized and unfortunately we have a system like the criminal justice system that has a tendency to really want to punish people and we know very well that not every person who has a substance use disorder engage in these behaviors or if they engage in these behaviors they are kind of most of the time really related to their addiction and so we talked about it also that kind of really in a way stigmatizes people more and more and this is a population gets more and more in a way alienated becomes more disconnected from the immunity and then the reactions from a lot of the healthcare systems is to really kind of it's like was the point you know these people need to be really in jail so again it kind of feeds into that sort of dehumanizing people and this is something that I've been dealing with for a long time to debunk that kind of thinking and looking at people as human beings who are really struggling and suffering yes I mean there are consequences for their behaviors but we know very well some of these behaviors that do not kind of fit with what the social norms are that they're going to be really perceived in a way that is very negative and they're not going to receive in all the treatment that they need and we know very well they are the part of our community so if they are not going to be receiving the treatment they need for example here if we're talking about the COVID-19 vaccine uptake then it's going to affect other people in their communities too and again it's just that sense of having a narrow-minded approach to this issue by really kind of more labeling people stigmatizing people and justifying the reason why we should not put more effort into helping people who really are struggling and would exhibit you know a lot of these behaviors that are addiction-related behavior that could be in a way managed and they would need treatment and again that kind of fits into really the bigger picture of the treatment for people who have substance use disorders so I mean we could do a lot with that and unfortunately as I mentioned we are doing much better now compared to what we used to do 15-20 years ago where a lot of the punitive approaches you know were really used in the system we're moving but we're moving slowly there's still a lot of work that needs to be done. So Antoine with the findings of this study in hand where do you go next are there opportunities that you're contemplating for application of this approach in other settings other populations what comes next? So as we alluded to through this article really our next target site would be in the community pharmacy setting there's of course our community pharmacies have been offering the covid vaccine throughout the pandemic but really starting to gear up to offer expert training to our community pharmacists and create a model where they can start to integrate this more regularly into their practice. And Antoine what about in your practice at Western psychiatric are you contemplating how this study could inform maybe that next study or practice changes that rely on these data? That's a very good question yeah I mean the practice changes and really a cultural change in the mindset. I mean we have been talking about standardizing or applying this as a kind of sustaining that approach in different like inpatient units on the outpatient settings any kind of an opportunity where you're going to be seeing patients but also you know as Zoe was mentioning is that also how you could really basically incorporate it with community pharmacists. I mean a lot of our patients are going to end up going and refilling their prescriptions in all these kind of community pharmacies and I'll tell you it has been a big challenge because the sustainability or let's put it this way the diffusion of innovative approaches implementation in the real world of research stuff that you do or quality improvement has been a huge challenge you know in the field of addiction particularly at the same time we shouldn't be having that kind of a sort of an attitude while people are not going to really do it or people are not going to have the time. I mean we could redefine all these excuses but this is a huge public health problem. So we need to understand better also and more studies looking at the factors that play because there is a complexity to all this kind of issue of vaccine hesitancy we can say just people are ambivalent about taking the vaccine but we know that there's a lot of factors that play into it and the education is important improving knowledge how conversations with patients could be about addressing misinformation and these are very important things that can be done and can be implemented easily but again it requires a change in the mindset and people being more really accepting of the importance of doing it. I mean I still do it with my patient but I still also try to disseminate it to my trainees you know other physicians our staff please you know like for example we're seeing now more people getting infected on the inpatient unit so this is an opportunity to really talk with the patients about the masking talk with the patients about whether they are vaccinated to an intervention which is the aspect intervention so I mean I'm kind of really pushing for this more and more because there was that kind of a sort of laziness or whatever you want to call it lack of understanding of really the seriousness of the problem and you know why it's not happening if it's not going to happen to me it's not going to be happening and in fact you know now we're experiencing it more and more on our inpatient unit so this is an opportunity to really intervene and to really make sure that people are getting the vaccine and addressing their ambivalence about it but also setting that up and if you can do it on site right away and which what we have done at Western site just at the moment what they tell you I would like to really have the vaccine get the vaccine right away don't tell them oh we'll give you some to referral you know you can go to these places it's very unlikely they're going to go and do it there if you do it on site and do the intervention on site the impact is going to be huge and significant and with that that's all the time we have today I want to thank Dr. Zoe Caravolas and Dr. Antoine Duhehi for joining us today to discuss their article Pharmacist implemented intervention to surmount COVID-19 vaccination hesitancy in adults with substance use disorders which was recently published on hhp.org please join us here each month for discussions on contemporary pharmacy practice issues and interviews with hhp authors if you enjoyed this podcast please share it with your colleagues and via your social media of choice thank you for listening to hhp voices for more information about hhp the premiere source for impactful relevant and cutting edge professional and scientific content that drives optimal medication use and health outcomes please visit ajhp.org
