Help Patients Using Opioids Avoid Stigma

In February 2020, Netflix released a documentary series depicting the early years of what is now known as the opioid epidemic.

The Pharmacist follows a journey that is familiar to many working in pharmacies across the United States. The story is told through the eyes of Louisiana pharmacist Dan Schneider, who begins noticing increased opioid use, misuse, and the first mass opioid—dispensing clinics now commonly referred to as pill mills. Like many who work in community pharmacy, he wants to do something to halt its spread but feels powerless to make an impact.

A driving factor for Schneider is the loss of his son in a drug-related shooting. This personal connection to addiction allows him to see his patients in a unique light. Schneider views each individual walking through his door as his son, daughter, or other loved one and consequently warns each of his patients about the dangers of opioids and provides them with resources.

The opioid epidemic continues to affect American communities at staggering rates. Since 1999, it has been a constant subject of newspaper headlines, on social media, and on television, with about half a million opioid-related deaths.^1-3

Perhaps no other health care workers have been exposed to this epidemic more frequently than pharmacists and pharmacy technicians (techs). Like the fictional Schneider, they are on the front lines and are placed almost daily in situations where they desire to do “something” but lack the ability to directly help. Because of the frequency of these encounters, pharmacists and techs often suffer from something known as compassion fatigue, the phenomenon when a care provider experiences secondary trauma from caring for someone else, which can affect job satisfaction and morale and result in decreased empathy for patients.⁴ Further complicating the issue is that pharmacy staff members are both patient care advocates and regulatory enforcers, and these divergent roles often put them at odds with patients.

The community pharmacy is a key link in the chain of opioid prescribing but is often overlooked, leaving pharmacists and techs wondering how and to what extent they can make an impact. Although pharmacy personnel bear witness to much of the opioid epidemic, they may not always see its whole picture. However, as new research continues to demonstrate, that whole picture is complex and often hidden, and it is directly linked to both addiction and the potential for recovery. One critical example of this is the idea of adverse childhood experiences (ACEs) and their connection to future addiction.⁵ ACEs include experiencing abuse, neglect, or violence; having a family member attempt or die by suicide; and witnessing violence in the community or home.

Each additional ACE increases the likelihood of early initiation into substance use disorder 2- to 4-fold.⁶ And the more traumas an individual is exposed to, the greater the chance for opioid misuse.^7,8 Similarly, hopelessness and social isolation are other hidden factors affecting opioid misuse.⁹ In other words, there are clear links between human suffering and opioid misuse that cannot be explained simply by genetics or neurobiology. A recent nationwide study confirmed the heterogeneity of patients who misuse opioids, including many who suffer from poor physical health.¹⁰

In lieu of understanding these “hidden” indicators, pharmacy personnel are often left to draw their own conclusions about drug-seeking behavior. And they are not alone. Study results show that health care professionals’ views of the opioid epidemic are varied but often include judgmental, uncompassionate, or unsupportive perceptions, which decrease care quality and ultimately increase patient morbidity and mortality.¹¹ Collectively, this concept is referred to as stigma and may include labeling (eg, “addicts” or “early fillers”), negative stereotypes (eg, inaccurate beliefs about individuals who misuse opioids), and othering (eg, not treating opioid use disorder [OUD] as a disease and separating these patients from others suffering from chronic diseases).¹²

Although the subject of stigma has been well researched across various health worker professions, it had yet to be researched among techs. To this end, investigators conducted a nationwide study involving focus groups of techs working in different areas of the US health care system and practicing in different geographic regions. This is the first pilot study conducted in the United States on this topic and is supported and sponsored by the National Healthcareer Association (NHA).

The overall goal of this research study will be to determine techs’ views, roles, facilitators, and barriers to providing care to patients with OUD. The comprehensive results of this research will directly affect future education efforts and assist in achieving NHA’s mission and vision: to develop, advance, and advocate for the frontline tech, resulting in improved patient care.

INITIAL FINDINGS

Although the study is ongoing, early results have shown a couple of key concepts. When describing interactions with patients suspected of opioid misuse, participants noted features of appearance or behaviors that may be viewed as stigmatizing. Words such as agitated and dirty were used to describe the appearance of patients who were suspected of opioid misuse. However, participants also discussed methods that could potentially overcome the impact of such stigmatizing views. These include counseling on opioid risks and alternatives by pharmacists; providing patient resources; and using nonjudgmental language when discussing patients with other pharmacy staff members.

NEXT STEPS

The finding that stigma was present among techs was not abnormal and does not represent a state of permanence. There are steps that techs can take right away to improve care for patients with OUD. These include:

• assisting pharmacists with the use of prescription drug monitoring programs,
• modeling and promoting a culture of understanding and empathy toward patients suspected as having or who do have OUD,
• promoting naloxone codispensing when legally allowable, and
• providing resources for recovery and treatment.

Above all, the importance of compassion and support for patients cannot be overstated. Given the scientific evidence on emotional trauma, hopelessness, and social isolation as risk factors for addiction, how much more harm could pharmacy personnel—based stigma cause? For Schneider, it was the loss of a son that set him on his journey to give patients that compassion and support. Perhaps these initial study results on stigma may serve to do the same for techs across the United States.

Kenneth C. Hohmeier, PharmD, is an associate professor of clinical pharmacy and translational science and director of community affairs in the College of Pharmacy at the University of Tennessee Health Science Center in Nashville.Alina Cernasev is an assistant professor at the University of Tennessee Health Science Center.Shane P. Desselle, PhD, RPh, FAPhA, is a professor of social and behavioral pharmacy at Touro University California College of Pharmacy in Vallejo and president of Applied Pharmacy Solutions.

REFERENCES

• Understanding the epidemic. CDC. Updated March 19, 2020. Accessed July 14, 2020. https://www.cdc.gov/drugoverdose/epidemic/index.html
• Annual surveillance report of drug-related risks and outcomes: United States, 2019. CDC. Accessed July 14, 2020. https://www.cdc.gov/drugoverdose/pdf/ pubs/2019-cdc-drug-surveillance-report.pdf
• Wilson N, Kariisa M, Seth P, Smith H IV, Davis NL. Drug and opioidinvolved overdose deaths—United States, 2017-2018. MMWR Morb Mortal Wkly Rep. 2020;69(11):290-297. doi:10.15585/mmwr.mm6911a4
• Winstanley EL. The bell tolls for thee & thine: compassion fatigue & the overdose epidemic. Int J Drug Policy. Published online June 1, 2020. doi:10.1016/j. drugpo.2020.102796
• Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. Am J Prev Med. 1998;14(4):245- 258. doi:10.1016/s0749-3797(98)00017-8
• Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics. 2003;111(3):564-572. doi:10.1542/peds.111.3.564.
• Austin AE, Shanahan ME, Zvara BJ. Association of childhood abuse and prescription opioid use in early adulthood. Addict Behav. 2018;76:265-269. doi:10.1016/j.addbeh.2017.08.033
• Quinn K, Boone L, Scheidell JD, et al. The relationships of childhood trauma and adulthood prescription pain reliever misuse and injection drug use. Drug Alcohol Depend. 2016;169:190-198. doi:10.1016/j.drugalcdep.2016.09.021
• McLean K. “There’s nothing here”: deindustrialization as risk environment for overdose. Int J Drug Policy. 2016;29:19-26. doi:10.1016/j.drugpo.2016.01.009
• Cochran G, Hruschak V, Bacci JL, Hohmeier KC, Tarter R. Behavioral, mental, and physical health characteristics and opioid medication misuse among community pharmacy patients: a latent class analysis. Res Social Adm Pharm. 2017;13(6):1055-1061. doi:10.1016/j.sapharm.2016.11.005
• Wakeman SE, Rich JD. Barriers to medications for addiction treatment: how stigma kills. Subst Use Misuse. 2018;53(2):330-333. doi:10.1080/10826084.20 17.1363238
• Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27:363- 385. doi:10.1146/annurev.soc.27.1.363