Commentary
Article
The Evolving Role of the Pharmacist in Addressing the Opioid Epidemic
Pharmacists' expertise is invaluable to prescribers who are unfamiliar with opioid use disorder treatment protocols.
The societal harm brought on by the opioid epidemic is incalculable. Due to their drug expertise and direct patient care, pharmacists are critical in addressing the crisis by both advocating for their patients and assisting providers.
In 2021, there were 80,411 opioid overdose deaths, which account for 75% of all drug overdose deaths.1 Opioids have a long history of use, however, and were first documented in 8th century BC in Mesopotamia, with Assyrian reliefs demonstrating Papaver somniferum, known as the opium poppy, being valued for its analgesic and sedative effects.2 However, the roots of opioid crisis lay much closer to the contemporary era, primarily in the 1990s when drug companies falsified data in order to convince both the Drug Enforcement Administration (DEA) and prescribers that opioids were safe and effective by citing the high number of patients with undertreated pain.3
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Traditionally, specialized clinicians have treated opioid use disorder (OUD). However, due to the overwhelming need, the guidelines recommend enlisting the aid of general practitioners, including primary care, obstetrics, and emergency providers.4 Often, providers are unwilling to treat OUD due to their lack of training and resources.3 The pharmacotherapeutic expertise of pharmacists in addiction services makes them vital resources to prescribers, by assisting in drug selection, dosing, monitoring guidelines, and treatment optimization.
OUD is characterized by abuse and dependency, and co-morbidities include psychiatric conditions, cardiovascular disease, metabolic disorders, overdose, and withdrawal. During treatment initiation, the patient is monitored closely for signs of withdrawal, which can be mild or life-threatening. It is characterized by insomnia, hyperalgesia, anxiety, hypertension, or even death.5
Treatment occurs in 3 phases: the induction phase, withdrawal management, and maintenance therapy. Medication assisted treatment (MAT) is the standard of care and FDA-approved interventions include methadone, buprenorphine, and naltrexone.4 In the induction phase, methadone and buprenorphine, long-acting synthetic opioids, are used to ease patients off euphoria-inducing, short-acting opioids. Eliminating the euphoric “highs” weakens the physiological drive of addiction. Maintenance involves continuing opioid replacement at low doses or ideally transitioning to naltrexone. Overall, methadone and buprenorphine reduce risk of overdose, reduce risky behavior, and improve outcomes.4
Historically, methadone (80 mg to 160 mg daily) has been the mainstay of treatment. A full mu-receptor agonist, it has the lowest withdrawal potential. Alternatively, it has a narrow therapeutic index due to its high abuse potential, difficulty tapering, overdose potential, complex dosing, and long half-life (12 to 150 hours).5
Buprenorphine (8 mg to 24 mg daily), a partial mu-receptor, increases the likelihood of withdrawal. However, compared to methadone, buprenorphine has decreased abuse potential, improved treatment retention, and better outcomes.6 With its superior safety profile, buprenorphine is preferred to methadone for induction and maintenance. Recently, the FDA has loosened buprenorphine prescribing restrictions to allow all practitioners with a DEA license to utilize it for treatment, without obtaining X-waiver certification.4
Naloxone, a short-acting opioid antagonist, is most known for its use as a nasal spray for overdose reversal.7 Additionally, naloxone can be added to buprenorphine products to reduce abuse potential, as it blocks intravenous or intranasal opioids.8
Naltrexone (50 mg daily), a full mu-receptor antagonist, has the greatest propensity for causing withdrawal if used for treatment induction.9 It has high bioavailability and blocks all routes of opioid use.8 Because of these characteristics, it is routinely used for maintenance therapy, in which it reduces cravings and prevents relapse. Naltrexone is initiated after the patient is opioid free for 7 days and is an excellent long-term therapy because it is well tolerated and lacks addictive potential.9
Due to their direct contact with patients, pharmacists can advocate for patients who would benefit from long acting injectables (LAIs). Given their high cost, patients may need assistance in accessing these medications. LAIs are increasingly being utilized for patients failing oral therapy due to their abilities to prevent diversion, improve adherence, and prevent relapse. In addition, they allow the patient to live a fuller life with long dosing intervals. Products include buprenorphine (Sublocade; Indivior), naltrexone (Vivitrol; Alkermes), and buprenorphine/naloxone (Suboxone; Indivior).
Adjunct medications are also required to address acute conditions seen with OUD treatment. These include insomnia, anxiety, nausea, hypertension, and hyperalgesia.4
Although buprenorphine is essential in reducing opioid related morbidity and mortality, there can be avoidable supply disruption, with wholesalers placing daily ordering limits. Due to this, even specialty addiction services pharmacies can experience shortages when supplying treatment rehabilitation centers, resulting in subtherapeutic drug levels, disruption of treatment initiation or maintenance, and increasing risk of withdrawal and relapse. As the opioid crisis continues, reform is needed to ensure stable buprenorphine supply.10
Given the extent of the opioid crisis and the complexity of treatment for OUD, the pharmacist is an essential member of the care team. Their expertise in the relevant fields is invaluable to prescribers who are unfamiliar with OUD treatment protocols and can help ensure that patients have the best possible chance of recovery.
About the Authors
Shamiron Shahbaz lives in Portland, Oregon. She is a P4 student at the Creighton School of Pharmacy and has worked in ambulatory care with vulnerable populations. Her pharmacy areas of interest include public health initiatives, behavioral health, and infectious disease.
Andrew Mocny, PharmD, lives in Portland, Oregon, and serves as pharmacist-in-charge at a behavioral health center. He has worked in the community health setting treating at-risk populations and his areas of interest include psychiatric medicine, long-term care, and home health care.
References
1. Centers for Disease Control and Prevention. Opioid Overdose. Last reviewed August 23, 2023. Accessed August 23, 2023. https://www.cdc.gov/drugoverdose/deaths/opioid-overdose.html
2. Buchanan WW, Rainsford KD, Kean CA, Kean WF. Narcotic analgesics. Inflammopharmacology. 2023;10.1007/s10787-023-01304-y. doi:10.1007/s10787-023-01304-y
3. Volkow ND, Blanco C. The changing opioid crisis: development, challenges and opportunities. Mol Psychiatry. 2021;26(1):218-233. doi:10.1038/s41380-020-0661-4
4. Srivastava AB, Mariani JJ, Levin FR. New directions in the treatment of opioid withdrawal. Lancet. 2020;395(10241):1938-1948. doi:10.1016/S0140-6736(20)30852-7
5. Substance Abuse and Mental Health Services Administration. Methadone. Last updated June 20, 2023. Accessed August 18, 2023. https://www.samhsa.gov/medications-substance-use-disorders/medications-counseling-related-conditions/methadone
6. Substance Abuse and Mental Health Services Administration. Buprenorphine. Last updated July 18, 2023. Accessed August 18, 2023. https://www.samhsa.gov/medications-substance-use-disorders/medications-counseling-related-conditions/buprenorphine
7. Substance Abuse and Mental Health Services Administration. Naloxone. Last updated April 25, 2023. Accessed August 18, 2023. https://www.samhsa.gov/medications-substance-use-disorders/medications-counseling-related-conditions/naloxone
8. Velander JR. Suboxone: Rationale, Science, Misconceptions. Ochsner J. 2018;18(1):23-29
9. Substance Abuse and Mental Health Services Administration. Naltrexone. Last updated June 9, 2023. Accessed August 18, 2023. https://www.samhsa.gov/medications-substance-use-disorders/medications-counseling-related-conditions/naltrexone
10. Ostrach B, Carpenter D, Cote LP. DEA Disconnect Leads to Buprenorphine Bottlenecks. J Addict Med. 2021;15(4):272-275. doi:10.1097/ADM.0000000000000762
