SCIENCE AND PRACTICE

Journal of the American Pharmacists Association xxx (2023)

Contents lists available at ScienceDirect

Journal of the American Pharmacists Association

journal homepage: www.japha.org

ADVANCES IN PHARMACY PRACTICE

Assessment of an education tool to improve knowledge and
reduce stigma of a syringe service program (SSP) at a VA Medical
Center
Jaclyn Collier, Elijah Coker, Mark Triboletti, Jeremy Hooker, Amanda P. Ifeachor*,
Kelly K. Houck

a r t i c l e i n f o a b s t r a c t

Article history: Background: Drug overdose deaths are a growing epidemic in the United States owing in part
Received 7 July 2023 to inadequate support from health care systems. In response, the Veterans Health Adminis-
Accepted 31 October 2023 tration (VHA) plans to implement syringe service programs (SSPs) across VHA medical centers.
This SSP education project aims to positively affect health care staff perceptions regarding SSPs
and reduce the stigma surrounding substance use.
Objectives: The purpose of this research was to allow Advanced Pharmacy Practice Experience
(APPE) students to implement and assess an educational program regarding SSP enactment at
this institution. Furthermore, the objectives of the educational program were to address the
stigma associated with substance use and provide knowledge to staff about SSPs.
Practice description: Eleven complete and one abbreviated (no questionnaire) presentations
were delivered by APPE students throughout the main facility and outpatient clinics, with
presentations being delivered to physicians, nurses, and a range of other professions.
Practice innovation: APPE students developed educational content and pre- and postsurveys
that were used to assess for changes in knowledge and perception surrounding substance use
and SSPs.
Evaluation methods: The primary outcome was to assess individual pre- and postprogram
survey responses using mean, SD, and mean change to measure the impact that the presen-
tation had on individualized stigma.
Results: A total of 104 completed surveys were analyzed in Microsoft Excel and subcategorized
by profession; 10 of the 15 questions asked in the questionnaire yielded statistical significance
when comparing pre- and postpresentation results (P < 0.05).
Conclusions: A presentation method developed and delivered by APPE students resulted in a
statistically significant change in perception and knowledge, proving to be an effective method
for educating health care staff on SSPs.
Published by Elsevier Inc. on behalf of the American Pharmacists Association.

Background than 107,000 deaths occurred because of overdose.1 Persons

Substance use has been a rapidly growing epidemic in the
United States since the late 2000s with an estimated 59.3
million people using illicit substances in 2020.1 In 2021, more
Previous presentation: Midyear Advanced Pharmacy Practice Experience
Student Poster Presentation (December 5, 2022).
* Correspondence: Amanda P. Ifeachor, PharmD, MPH, BCPS, Clinical
Pharmacy Specialist, Ambulatory Care (Gastroenterology/Hepatitis C Virus
Care), Roudebush VA Medical Center, 1481 W 10th St. (119), Indianapolis, IN
46202.
E-mail address: amanda.ifeachor@va.gov (A.P. Ifeachor).
who inject drugs (PWID) are at an increased risk of con-
tracting blood-borne infections such as viral hepatitis, hu-
man immunodeficiency virus (HIV), and other bacterial and
fungal infections that ultimately increase mortality.2 In a
2018 large-scale Centers for Disease Control and Prevention
HIV surveillance report, approximately 1 in 3 of PWID re-
ported engaging in receptive sharing. In addition, 43% of the
participants reported giving a syringe they had used to
someone else or distributive sharing. Approximately 1 in 4
HIV-positive participants reported distributive sharing,
which leads to viral transmission.2 Sharing of injection drug
equipment accounts for the second leading mode of

https://doi.org/10.1016/j.japh.2023.10.035
1544-3191/Published by Elsevier Inc. on behalf of the American Pharmacists Association.
SCIENCE AND PRACTICE
J. Collier et al. / Journal of the American Pharmacists Association xxx (2023)
Key Points
Background:
 Predisposed stigma to substance use and substance
use disorder
 Epidemic of substance use and substance use
disorder
Findings:
 Stigma can be reduced and exposed with this novel
education tool.
 Importance of education before implementing
controversial programs
transmission for HIV3 and the primary mode of transmission
for hepatitis C virus.4
Syringe service programs (SSPs) are resources for people
who use drugs, which often include clean supplies for safer
smoking, snorting, and injection; naloxone rescue kits; fenta-
nyl test strips; access to safe disposal of supplies; and items to
prevent sexually transmitted infection. Contrary to the com-
mon misconception that SSPs encourage substance use,
studies show that PWID are 5 times more likely to engage in
treatment for substance use and stop unsafe practices if they
are enrolled in an SSP.2 SSPs have been proven to reduce the
transmission of blood-borne infections and overdoses.2
SSPs also reduce health care-associated costs. A cost esti-
mate conducted by Teshale et al.5 found that the cost to
distribute a SSP kit in a large urban area could be as low as $2
per person per day. For every dollar spent on SSP services,
$6.38-$7.58 is saved in HIV treatment cost savings alone.6
Stigma is an important barrier that must be overcome to
reduce harm in people who use substances. Fear of judgment
or mistreatment from family, friends, authorities, and health
care professionals can reduce health care engagement. At least
one study reported 75% of people who use substances have
experienced discrimination related to their substance use.7
This discrimination has been linked to higher rates of
depression and poorer mental health.7
In response to the substance use epidemic, the Veterans
Health Administration (VHA) preliminarily disseminated Draft
Directive 1102.09 in May 2021 for internal comment.8 Once
formally approved and issued, it will mandate SSP availability
throughout all VHA facilities (more than 170 medical centers
and more than 1100 outpatient clinics)9 unless restricted by
state or local law. This directive acknowledges that SSPs are
proven and endorsed harm reduction methods and empha-
sizes the critical need for providers to interact with and
educate PWID.7 Therefore, it is essential that VHA health care
workers receive accurate information and training regarding
SSPs before national implementation.
Staff who currently operate SSPs have reported that lack of
support from medical facilities impedes overdose prevention,
which underscores the critical need for staff education.10 Pio-
neers of SSP implementation at individual VHA facilities have
laid out proposed steps for SSP implementation and other
harm reduction resources, a key component of which is the
2
need to provide staff education to address employee con-
cerns.11 The need for more comprehensive staff education has
been noted to address misconceptions and provide health care
professionals with sound evidence of the benefits of SSPs.11
Literature suggests that teaching methods that use active
participation aid in knowledge translation.12 It is essential to
engage health care workers in education tailored toward
addressing the stigma associated with substance use.13 In the
health care setting, it is recommended to educate stakeholders
about using appropriate language to improve patient experi-
ence and build nonjudgmental environments for health care
delivery.13
Objectives
The purpose of the SSP Clinical Education Research Project
was to implement and assess educational programming at
Richard L. Roudebush Veterans Affairs Medical Center, Indi-
anapolis, United States, which cares for patients in the Central
Indiana region and consists of a tertiary care medical center
and more than 10 outpatient clinics located either onsite or
throughout the state.14 The educational program was designed
to address the stigma surrounding illicit substance use and
provide evidence-based education regarding SSPs to health
care workers. The study aimed to assess changes in knowledge
and perception after an educational programming
intervention.
The same survey was distributed before and after educa-
tional programming to gauge changes in participants’ knowl-
edge regarding the value and role of SSPs, beliefs and potential
stigma, and comfort level in discussing SSPs and substance use
with patients.
Practice description
This educational program was designed as a collaborative
effort from 3 fourth-year pharmacy students throughout a 4-
month Advanced Pharmacy Practice Experience (APPE) track
program. During months 1 and 2, students formulated ideas
on how to engage and educate health care workers on the
stigma of substance use and the concept of SSPs. They created
3 common stressful theoretical scenarios: 2 friends asking for
money, a peer-pressure situation, and how to unwind after a
stressful work week. Then, they created 3 parallel situations
involving substance use to make substance use more relatable.
Students completed a literature search, created a pre- and
postsurvey, developed a formal protocol, and presented their
project idea to our facility’s Pharmacy Research Advisory
Workgroup. This workgroup and Indiana University institu-
tional review board (IRB) both deemed this project as a quality
improvement initiative. During months 3 and 4, students
created a Microsoft PowerPoint presentation (Microsoft, Red-
mond, WA) (that was vetted by our Infectious Disease team for
accuracy and clarity) and then delivered their educational
program 12 times to different audiences through in-person
and virtual presentations (via Microsoft Teams [Microsoft,
Redmond, WA]) between July 12, 2022, and August 25, 2022.
Except for inpatient providers (owing to their limited
availability), any physician, advanced practice nurse, physician
assistant, nurse, social worker, pharmacist, pharmacy
 SCIENCE AND PRACTICE
Assessment of an education tool for SSPs

Table 1
Mean, mean change in score, SD, and P value of questions

Question number Question Mean scorea Mean change in score SD P value

1 When I talk about a patient that has a positive 2.25 0.6796 1.0955 < 0.001b
urine or blood drug test for substance use, I
would refer to this patient as a “user” or
“substance abuser.”
2 I feel comfortable asking a patient about their 4.02 0.1923 0.7642 0.0117b
history with substance use.
3 It is relevant to my practice as a health care 4.43 0.0480 0.6880 0.4777
professional to ask about substance use.
4 Health care providers caring for a person who 4.33 0.0576 0.7736 0.4487
injects drugs should inquire about substance
use every visit.
5 Education on proper injection techniques and 4.32 0.2500 0.7851 0.0015b
access to supplies positively affect patient
health.
6 I feel comfortable counseling a patient on safer 2.91 0.5490 1.011 < 0.001b
injection techniques.
7 People who inject drugs once are more likely to 4.14 0.1553 0.8373 0.0625
inject again.
8 People with substance use disorders are from a 2.23 0.3980 0.7048 < 0.001b
lower socioeconomic class.
9 People who inject drugs do so for the pleasure 3.38 0.3365 0.9410 < 0.001b
or euphoria associated with illicit drugs.
10 People who inject drugs should not be helped 1.47 0.1650 0.7014 0.0187b
since it is their decision to continue injecting
drugs.
11 People who inject drugs hesitate to seek help 3.96 0.2115 1.0113 0.0352b
from an SSP owing to the stigma surrounding
substance use.
12 SSPs enable people who inject drugs to continue 2.56 0.2692 1.2086 0.0251b
with injecting illicit substances.
13 The cost of SSPs outweighs the benefits to the 2.42 0.2352 1.4635 0.1075
community.
14 SSPs provide 2 things to the patient: clean 3.77 0.0577 1.1644 0.6144
syringes and injection supplies.
15 SSPs reduce the incidence of blood-borne 4.57 0.1826 0.5532 < 0.001b
infections.
Abbreviation used: SSP, syringe service program.
a
All 15 questions were answered using a Likert scale: (1) strongly disagree, (2) disagree, (3) neither disagree nor agree, (4) agree, and (5) strongly agree.
b
Denotes a statistically significant value.

technician, or other health care member could participate in
the program. The 12 presentations were delivered to these
individual groups: Emergency Medicine key stakeholders,
General Internal Medicine providers, inpatient clinical phar-
macists, outpatient pharmacists and technicians, ambulatory
care clinical pharmacists, mental health clinical staff, pain and
palliative care staff, social workers, pharmacy residents, onsite
primary care staff, and offsite primary care staff (delivered
twice) that included staff from 7 VHA clinics throughout
Indiana.
Practice innovation
Each educational program presentation was approxi-
mately 30 minutes and consisted of several parts. First,
approximately 5 minutes was allotted for participants to
complete the presurvey. The survey included 15 questions
about the stigma surrounding SSPs, the health care workers’
level of comfort discussing SSPs/substance use, and the
components/benefits of SSPs using a Likert scale: (1) strongly
disagree, (2) disagree, (3) neither disagree nor agree, (4)
agree, and (5) strongly agree (Table 1). Second, students
presented 3 common stressful theoretical scenarios
referenced earlier. After each scenario, the responses were
recorded, and the statistics on human behavior or reasoning
involving the likelihood of choosing each answer was pro-
vided. Third, students presented 3 parallel situations
involving substance use. The goal was to promote empathy
and a better understanding of PWUD’s decision-making
process. Therefore, participants were instructed to select
the same answer option from the original scenarios. Statistics
and information about substance use and SSPs were provided
after the scenario. Fourth, students presented several slides
that focused on the intent of an SSP, common components,
benefits, and avoidance of stigmatizing language and be-
haviors in the context of the future national VHA directive.
Fifth, participants completed the postsurvey, which was
identical to the presurvey. Time was allotted at the end for
questions and discussion.
Innovation of student experience
APPE students gained project management experience
(such as writing an IRB protocol and submitting it to a research
advisory board), practice creating new content that greatly
influenced facility-wide staff education, and the chance to

3
SCIENCE AND PRACTICE
J. Collier et al. / Journal of the American Pharmacists Association xxx (2023)

Figure 1. Mean score.

collaborate with interprofessional teams. In addition, ample the anonymity of the survey, participants had the option to
practice delivering formal presentations accelerated their indicate their position (i.e., nurse, physician, pharmacist,
growth in preparation for future pharmacy residencies and pharmacy technician, social worker, or other), but no other
careers. personal information was collected.

Evaluation methods Data analysis

The same survey was distributed for participants to
complete before and after the presentation. The intent of the
presurvey was to assess participants’ baseline knowledge
regarding the value and role of SSP, their beliefs and po-
tential stigma, and their comfort level discussing SSPs and
substance use with patients. In-person attendants
completed a hardcopy survey. Virtual participants
completed the survey online via Qualtrics (Qualtrics XM,
Seattle, WA). Survey completion was voluntary. To maintain
The primary outcome was to assess for changes in indi-
vidual scores on the pre- and postsurvey responses using a
Likert scale. Mean, SD, and mean change were collected to
assess the impact of the educational program. Participant data
were only analyzed for those who fully completed both pre-
and postsurveys. Participants who only completed one survey
were excluded given that changes in individual scores could
not be paired. Incomplete surveys were also excluded from the
analysis. A paired Student’s t test was used with a statistically

Figure 2. Mean change in score between pre- and postsurvey.

4

Assessment of an education tool for SSPs
significant P value of less than 0.05. APPE students analyzed
the data with guidance from a collaborating biostatistician.
Results
Study participants
Data were collected and analyzed from 104 completed
surveys. Surveys were completed by 30 nurses, 27 pharma-
cists, 20 social workers, 10 physicians, 9 “other” health care
workers, and 8 pharmacy technicians.
Survey results
At least one survey was completed by 155 participants and
51 of these were excluded owing to incomplete survey data.
This left 104 participants for analysis (pre- and postsurveys
fully completed). Survey results were analyzed in Microsoft
Excel (Microsoft, Redmond, WA) and stratified by profession.
Of the 15 survey questions, 10 questions had a statistically
significant change in response between pre- and postsurveys
(Table 1). The question with the most significant change (P <
0.001) was the first question, which asked the participants
what terminology to use when addressing a patient with
substance use. Most participants agreed with avoiding the use
of stigmatizing terms such as “user” or “substance abuser” on
the postsurvey. More specific survey results are detailed in
Figures 1 and 2.
Practice implications
Important findings
We intentionally delivered this educational programming
before the official launch of the SSP at our site to gauge current
understanding and prime our staff for future harm reduction
training. Presurvey results revealed there was a lack of
knowledge about resources available to patients through SSPs.
This program allowed the participants to become more
knowledgeable about the resources SSPs can offer. Throughout
the development and implementation of the SSP educational
programming, the most important finding was the presence of
stigma regarding substance use and how the educational
programming was able to reduce the stigma.
Future implications
As the implementation of SSPs proceeds at VHA facilities
nationwide, it is critical that we continue providing education to
health care staff locally. Further education may target groups and
departments not included in the original education effort by
APPE students, such as inpatient clinical staff. Future topics to
review with the facility at large include how to access SSP kits and
how to connect this vulnerable patient population to relevant
care (i.e., infectious disease, liver clinic, primary care, substance
use treatment, mental health services, and housing and social
work needs). In addition, topics on survey questions that did not
reach a statistically significant change could be revised for clarity
with the goal of remaining flexible to accommodate the educa-
tional needs of the facility. With the continuous onboarding of
new employees and clinical rotation students/residents, it will be
SCIENCE AND PRACTICE
important to consider revisiting SSP education regularly so
health care members at our site are equipped to provide high-
quality care to patients who use substances.
Strengths and limitations
One of the main strengths of this program was the coop-
eration and participation of the health care system. The
pharmacy department had the endorsement of this education
by medicine service leadership. APPE students, along with
their preceptors, were able to educate physicians, nurses, so-
cial workers, pharmacists, pharmacy technicians, and other
health care professionals. The team used virtual communica-
tion platforms for offsite staff so education could be delivered
to a larger audience. The major limitation of this educational
programming was the exclusion of inpatient providers owing
to limited inpatient provider availability during the APPE
students’ track months. Virtual presentations reduced the
ability to assess audience engagement.
Conclusions
This program used a presurvey, educational intervention,
and postsurvey that relayed valuable information to health
care members about SSPs, reduced stigma, and changed per-
ceptions about patients who use substances. This effort
demonstrated that APPE track students can successfully inte-
grate into a pharmacy department to the point they can lead
facility-wide educational programming. Moving forward, the
rest of the project team is exploring how this initial presen-
tation and delivery can be further refined to effectively address
all education topics as SSP implementation at our site ap-
proaches. This program will help to educate new and existing
staff for years to come.
Disclosure
The authors declare no relevant conflicts of interest or
financial relationships. The contents do not represent the
views of the U.S. Department of Veterans Affairs or the U.S.
Government. This material is the result of work supported
with resources and the use of facilities at RLR VA Medical
Center, Indianapolis, Indiana.
Acknowledgments
The SSP team would like to express sincere gratitude to those
who contributed to our research efforts. First and foremost, we
thank one of the APPE students, Daniel Coil, for assisting with the
development of the protocol and presentation and helping to
analyze the collected surveys. Second, we thank Dr Matthew
Miles for his shadowing opportunities and engaging presenta-
tion about substance use that sparked the idea of the parallel
scenarios. Next, we acknowledge Infectious Disease team
members Dr Andrew Dysangco, Dr Cassidy Overpeck, Dr Carmen
Tichindelean, and Jacqueline Burton, RN, for their review and
feedback on our initial presentation that allowed us to improve
and formalize the material. Finally, we thank George J. Eckert,
MAS, Indiana University School of Medicine, and Richard M.
Fairbanks, School of Public Health Biostatistician Supervisor, for
5
SCIENCE AND PRACTICE
J. Collier et al. / Journal of the American Pharmacists Association xxx (2023)
his knowledge about the intricacies of Microsoft Excel and
assistance with interpreting our results.
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Updated August 30, 2023.
Jaclyn Collier, PharmD, PGY-1 Pharmacy Resident, Deaconess Health System,
Deaconess Midtown Hospital, Evansville, IN; at time of study, APPE Rotation Stu-
dents, Butler University, Indianapolis, IN
Elijah Coker, PharmD, PGY-1 Pharmacy Resident, Gulf Coast Medical Center,
Fort Myers, FL; at time of study, APPE Rotation Students, Butler University, Indi-
anapolis, IN
Mark D. Triboletti, PharmD, MBA, BCPS, Chief, Pharmacy Service, Roudebush
VA Medical Center, Indianapolis, IN
Jeremy Hooker, PharmD, BCGP, Clinical Pharmacy Program Manager e Pain and
Palliative Care, Roudebush VA Medical Center, Indianapolis, IN
Amanda P. Ifeachor, PharmD, MPH, BCPS, Clinical Pharmacy Specialist,
Ambulatory Care (Gastroenterology/Hepatitis C Virus Care), Roudebush VA
Medical Center, Indianapolis, IN
Kelly Houck, PharmD, BCPS, Facility PMOP Coordinator, Roudebush VA Medical
Center, Indianapolis, IN