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Pharmacy Practice in Focus: Health Systems
Pharmacists Can Help Slow the Opioid Crisis
Patient education, naloxone training, and monitoring programs make a difference.
Rates of problematic opioid use have been increasing since the 1990s, attributable in large part to rising life expectancy, the misuse of and surge in opioid prescriptions, and socioeconomic factors. As the opioid crisis continues, pharmacists can help alleviate and reduce the resulting morbidity and mortality.
As many as 25% of patients receiving long-term opioid therapy in a primary care setting have an addiction, and although sales of prescription opioids in the United States nearly quadrupled between 1999 and 2014, the amount of pain that Americans reported remained unchanged, according to the CDC.1
How Did We Get Here?
Although opiates have been used for more than 8000 years, the catalyst of the current opioid crisis can be traced to the late 20th century. In the 1980s, Purdue Pharma assured health care providers that their opiate drugs carried low addiction potential and were safe for chronic pain. In addition to drug coupons for patients and incentives for Purdue Pharma’s employees, the company recruited more than 5000 physicians to speak on its behalf. Policies were enacted protecting physicians against regulatory action for prescribing opioids. As a result, providers began prescribing OxyContin liberally, and Purdue Pharma’s profits jumped more than 20-fold between 1996 and 2001. By 2012, 259 million prescriptions for opioid pain medication had been written, and by 2015, deaths by overdose had almost tripled in less than 20 years.2,3
Pharmacist's Role
In 2016, the CDC created a guideline for prescribing opioids for chronic pain, which included recommendations for addressing harm and assessing risks of opioid use; determining when to continue or initiate opioids for chronic pain; and detailing opioid selection, dosage, duration, follow-up, and discontinuation.4 Pharmacists are on the front lines and can directly educate patients about proper medication efficacy and safety.
However, barriers can hinder pharmacists’ ability to fight the opioid crisis. These include inadequate or no training, a lack of confidence, and most commonly, a lack of time. In addition, patients may not fully understand the role of pharmacist and do not seek proper help.
Despite this, there have been multiple successful measures taken to address the opioid crisis. For instance, the Prescription Drug Monitoring Program (PDMP) is an electronic database that tracks controlled substance prescriptions in each state. The PDMP improves opioid prescribing, informs clinical practice, and protects at-risk patients.
PDMPs have changed prescribing behavior and decreased substance use treatment admission and the use of multiple providers by patients, according to the CDC.5
A caveat to the PDMP program is that it often puts pharmacists in a difficult dual position in which they must both police patients and treat them.
Another intervention is medication-assisted treatment (MAT), which uses medications in combination with behavioral and counseling therapies to provide a patient-centered approach to the treatment of substance use disorders. Pharmacists are involved in community, inpatient, and outpatient settings to help prevent overdose mortality and provide education on the use of abuse-deterrent formulations of opioid analgesics. The MAT program uses FDA-approved medications to treat opioid dependence, such as buprenorphine, methadone, and naltrexone. The MAT program also uses naloxone (Narcan) to prevent opioid overdose by reversing the toxic effects of the overdose.6 Pharmacy schools are incorporating naloxone training into their curricula to prepare future pharmacists in the management of opioid overdose. The program has resulted in lower costs and a reduction in opioid overdoses. Pharmacists are the key to informing patients about these programs and making sure they adhere to these treatments.
In an inpatient setting, pharmacists are integral to managing patients’ pain. Clinical pharmacists review active medications, assess the need for opioids, and encourage deescalation or discontinuation of opioid treatment. Throughout the health care system, pharmacists are partnering with prescribers to ensure effective, optimal, and safe pain management for patients to prevent opioid use disorder (OUD) and overdose. The CDC Guideline for Prescribing Opioids for Chronic Pain emphasizes patient safety and encourages pharmacists and prescribers to collaborate in integrated
pain management and team-based practice models. Pharmacists and prescribers should apply the guideline and work collaboratively to optimize pain management while preventing OUD and overdoses. This will improve patient outcomes.4 Through these efforts, pharmacists closely monitor for misuse by health care professionals and patients.
Pharmacists also have been at the front line of educating patients about overdose education and naloxone prescribing, distribution, and appropriate use. When pharmacists evaluate new prescription orders, they should assess for signs of OUD or medication diversion. Signs include altered or forged prescriptions, cash payment, early or inconsistent fills, multiple prescribers, or prescriptions originating from outside the immediate geographic area. Community pharmacists should verify customer identification and the prescriber’s United States Drug Enforcement Administration registration in addition to using tools such as the PDMP.
Some pharmacies provide an FDA-approved DisposeRx at-home medication disposal packet with each prescription, which is a convenient, effective, and simple way for patients to dispose of expired or unused medications. When the DisposeRx powder and water are added to a prescription vial and shaken, a polymer gel forms that traps the drugs. It can be used with capsules, liquids, pills, and powders, and it can be thrown away in the household trash.7 This is yet another way to lessen the potential for opioid addiction or overdose.
Conclusion
Evidence supports a collaborative and multifaceted approach to the opioid crisis. Pharmacists, both inpatient and outpatient, can help combat the opioid crisis through monitoring the PDMP, naloxone and opioid training and dispensing, and patient education. Pharmacists are essential to helping prevent opioid misuse.
About The Authors
Khadija Khan-Chan is a PharmD candidate at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, in Piscataway.
Deepali Dixit, PharmD, BCPS, BCCCP, FCCM, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, and a clinical pharmacy specialist, critical care, at Robert Wood Johnson University Hospital in New Brunswick.
References
1. Pharmacists: on the front lines. CDC. Accessed June 14, 2022. https://www.cdc.gov/drugover- dose/pdf/pharmacists_brochure-a.pdf
2. Van Zee A. The promotion and marketing of OxyContin: commercial triumph, public health tragedy. Am J Public Health. 2009;99(2):221-227. doi:10.2105/AJPH.2007.131714
3. A timeline of the opioid epidemic. Leidos. September 3, 2019. Accessed June 14, 2022. https:// www.leidos.com/insights/timeline-opioid-epidemic
4. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain - United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49. doi:10.15585/mmwr.rr6501e1
5. Prescription drug monitoring programs (PDMPs). CDC. Updated May 19, 2021. Accessed April 18, 2022. https://www.cdc.gov/drugoverdose/pdmp/index.html
6. Medication-assisted treatment (MAT). Substance Abuse and Mental Health Services Administration. Updated June 10, 2022. Accessed June 14, 2022. https://www.samhsa.gov/ medication-assisted-treatment
7. DisposeRx. Accessed April 18, 2022. https://disposerx.com/page/5/product-and-program
