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BACKGROUND: Chronic non-malignant pain (CNMP) is common in low- and middle-income countries (LMICs), yet access to potent opioids is often constrained by fears of misuse and diversion. In Pakistan, community pharmacists (CPs) have no patient-oriented opioid optimisation services despite specialised roles in medicines optimisation in high-income settings. OBJECTIVE: This study aimed to explore and identify barriers, facilitators, and strategies for developing and implementing a novel opioid optimisation service for CNMP in Pakistan. METHODS: A mixed-methods study was conducted in Pakistan from November 2019 to December 2020. Qualitative data were collected through six case studies , semi-structured interviews with pharmacy policymakers (n = 11) and individuals with CNMP (n = 14), and focus groups with doctors (n = 31) and CPs (n = 36). Data were inductively analysed using reflexive thematic analysis supported by NVivo 12, and case study observations in six community pharmacies were examined using cross-case synthesis with an explanation-building approach. Findings were deductively mapped to an adapted implementation science framework (LMIC-CFIR and FISpH), and an implementation research logic model was developed to theorize how implementation strategies might operate through underlying mechanisms to support service delivery and implementation. RESULTS: Barriers and corresponding strategies were identified across five domains (intervention, system, community, organisation, individual). strategies included CP remuneration, regulatory reform and policymaker support, public awareness initiatives, organisational support in community pharmacies, and enhancement of CP knowledge, skills, and motivation. CONCLUSIONS: The study outlines strategies to address multilevel barriers to implementing a novel opioid optimisation service and proposes a pathway for policymakers to mobilise the community pharmacy workforce to optimise opioid use among people with CNMP in Pakistan.
Iqbal et al. (2026) studied this question.