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Pharmacy Times
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Pharmacists should educate patients about proper medication storage and offer naloxone to optimize safety.
Opioids are controlled substances that are often prescribed for severe pain. Some examples of opioids include codeine, fentanyl, hydrocodone, morphine, oxycodone, and tramadol. Opioids can be addictive, especially when used to treat chronic pain, and can cause adverse effects such as respiratory depression. The misuse of prescription pain relievers, often leading to overdose, is a national epidemic.1
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The American Medical Association issued a report in 2021 indicating a more than 44% decrease in opioid prescribing in the United States than in the previous decade. Yet the country is facing a worsening drug-related overdose and death epidemic2 driven by a shift to heroin and synthetic fentanyl because of changing preferences, availability, and costs. Even methamphetamine and cocaine are resulting in overdose deaths because they are often laced with opioids.3
Preventing Opioid Misuse
Pharmacists can use a variety of techniques to prevent opioid misuse, including education methods, provision of naloxone, proper prescribing, and prevention of diversion. Specifically, pharmacists should:
Kathleen Kenny, PharmD, RPh, earned her doctoral degree from the University of Colorado Health Sciences Center in Aurora. She has more than 25 years of experience as a community pharmacist and works as a clinical medical writer based in Homosassa, Florida.
Treatment
One medication used to treat opioid misuse is lofexidine (Lucemyra; US WorldMeds, LLC), a central α-2 adrenergic agonist. Lofexidine is used to reduce withdrawal symptoms when discontinuing opioids before starting maintenance treatment with buprenorphine or methadone. Lofexidine, available in tablet form, works by blocking the release of norepinephrine, a neurotransmitter that contributes to withdrawal symptoms. Lofexidine, however, will not treat addiction.4 This medication is designed for short term use and should be used for 5 to 14 days.5
Buprenorphine is a partial μ-receptor agonist, a weak κ-receptor antagonist, and a δ-receptor agonist. Partial agonism at the μ-receptor is a unique characteristic with properties that allow a plateauing of analgesic effects at higher doses when its effects become antagonistic. Buprenorphine also limits respiratory depression, allowing for a safe treatment for opioid dependence.6 It can be administered through various methods. A transdermal patch is used for chronic pain relief. In addition, there are buccal films and sublingual tablets for oral administration. Parenteral routes include subcutaneous implants and intravenous or intramuscular injections.6
Buprenorphine is also available as a sublingual tablet formulation in combination with naloxone. Naloxone, an opioid antagonist, is not absorbed orally; therefore, the drug’s effect is derived from buprenorphine when the combination drug is taken sublingually. Naloxone is added to buprenorphine to reduce the potential for its misuse when injected. If the tablet is dissolved and injected in an intravenous form, the absorbed naloxone antagonizes μ-receptors, thereby counteracting the euphoric effects of buprenorphine and potentially inducing withdrawal in opioid-dependent patients. Isolated buprenorphine carries a higher potential for misuse compared with the buprenorphine-naloxone combination.6
Methadone is a synthetic opioid that acts as a full agonist of the μ-receptor and affects other receptors. Methadone is used for both detoxification and maintenance therapy in patients with opioid use disorder. Although methadone activates opioid receptors, it does so more slowly than other opioids. When used in appropriate treatment doses, methadone does not produce a euphoric state.7 Methadone is one component of a whole-patient approach that also includes behavioral health therapies.
In addition to a combination with buprenorphine, naloxone is available independently as a nasal spray and an injectable and is used to treat acute opioid overdose. Naloxone is a strong, competitive μ-receptor antagonist. It acts to rapidly remove all drugs bound to these receptors.8 Naloxone is also available in combination with pentazocine as a treatment for pain and not for the treatment of acute overdose. It is important to note that naloxone, if given to a patient not experiencing an opioid overdose, will not harm the patient. It should have no effect on the patient.
Conclusion
Pharmacists have the knowledge, skills, and responsibility to play an important role in substance abuse prevention, education, and treatment. Pharmacists, as highly accessible health care providers, should be actively involved in reducing the negative effects that opioid use disorder has on society, health systems, and individuals. By collaborating with patients and other health care providers, pharmacists can help reduce substance abuse incidents.
