Pharmacists on the front line in the opioid crisis

By Beth Slamowitz

Pharmacists, who are considered among the most accessible and trusted health professionals, can answer questions about reducing the risk of overdose, what to do in case of an overdose and where to seek help with addiction management services. Pharmacists are the gatekeepers for prescription painkillers and play a key role in preventing and identifying opioid misuse and abuse.

Because pharmacists have access to patients’ medication records, they can identify those at high risk earlier than other health care professionals can. Many are doing just that and going further by offering addiction management services, such as by dispensing buprenorphine/naloxone.

Furthermore, pharmacy science represents potential opportunities for new areas of research in opioid use through the National Institutes of Health (NIH) Opioid Initiative. This leverages a three-pronged approach: non-opioid based strategies for management of pain and pain disorders; new and innovative medications and technologies for opioid addiction treatment; and interventions to reduce the mortality of opioid overdose.

Being on the “frontlines of co-prescribing” positions pharmacists to be readily involved in the care of pain patients. Some of the novel practice strategies specific to pharmacists’ and pharmacies’ involvement include:

  1. Expanded roles of pharmacists in protecting the community from diversion, or theft, ensuring appropriate access while protecting the public from the dangers of misuse and abuse.
  2. Integration with prescription drug monitoring programs’ (PDMP) data systems.
  3. Balancing the needs of pain patients while minimizing opioid overexposure.
  4. Educating patients about opioids and setting realistic expectations for pain control.
  • Patients should leave the pharmacy knowing how to take their medication, the side effects (including the potential for addiction and overdose), how to safely store their medication, and where to dispose of any remaining medication once they no longer need to take it.
  • Pharmacists should explain what “as needed” means on medication labels. Patients should know that they can take less, but not more, than the maximum amount of medication listed on the label for a 24-hour period.
  1. Recognizing the signs of opioid addiction.
  • Be concerned when a patient consistently asks for prescriptions to be filled early, especially when no dose escalation is indicated by his or her prescription.
  • Be concerned about defensiveness regarding the early-fill request or worries about the pharmacist contacting the prescriber. The patient may also appear angry or combative when the pharmacist denies the early refill.
  1. Dispensing and educating patients about the use of naloxone
  • Many states have approved naloxone as an auto injector or as the newly approved nasal spray for pharmacist dispensing without a prescription, often through a standing order or collaborative practice agreements.
  • Pharmacists should educate purchasers about proper use and explain that emergency medical care is required after an overdose, even with successful naloxone reversal.

Many pharmacists are expanding on these roles to combat the opioid crisis. Pharmacists at St. Matthews Community Pharmacy in Louisville, Kentucky, have administered more than 1,000 injections of Vivitrol (a long-acting naltrexone) in an effort to combat the opioid epidemic. But the pharmacists took their program a step further. Not only have they received training that allows them to be reimbursed for administering long-acting injectables, but they now also provide counseling and appointment reminders to improve treatment compliance.

Collectively, pharmacists are taking a lead role in tackling the crisis. The National Community Pharmacists Association (NCPA) provided a statement to the U.S. Senate Committee on Health, Education, Labor and Pensions in support of the committee’s hearing on “The Federal Response to the Opioid Crisis” and to provide lawmakers with additional ideas to combat the crisis.

NCPA recommendations include:

  • Expand consumer access to naloxone by allowing pharmacists to directly prescribe it.
  • Establish limits on maximum day supply for certain controlled substances.
  • Prohibit certain controlled substances from being delivered to patients via physician offices or through the mail.
  • Expand electronic prescribing of controlled substances by mandating its use where feasible.
  • Enhance PDMPs by creating national standards.
  • Increase health care provider education by emphasizing a verification infrastructure with minimal administrative burdens.
  • Increase the usage and access to medication-assisted treatment. NCPA supports expanding practitioner eligibility for Drug Addiction Treatment Act (DATA) waivers, including pharmacists. Advancement of the pharmacist’s role in medication-assisted treatment (MAT) for opioid use disorders can help improve access and outcomes, while reducing the risk of relapse.
  • Expand the ability of pharmacies to identify individuals with substance abuse disorders by participating in screening, brief intervention, and referral to treatment (SBIRT) activities. For example, Virginia Medicaid’s Addiction and Recovery Treatment Services (ARTS) program is a transformative new benefit being offered for Medicaid patients. The benefit includes coverage for SBIRT provided by pharmacies.

Pharmacists should help educate prescribers and implement new standards from The Joint Commission that have been published and went into effect January 2018. This education will need to reach the wide array of opioid prescribers, including orthopedists, nurse practitioners, physician assistants, dentists, internists and family doctors.

Pharmacists stand at the intersection of prescribing practices, dispensing, limiting risk and drug diversion. This position, along with the fact that pharmacists see patients frequently, allows for multiple touchpoints in the process of improving the opioid crisis. Law enforcement, drug courts, police officers and social workers are at the front lines of this epidemic as well. They are acutely aware of detox and treatment availability (or the lack thereof) and the often vicious cycle that accompanies prescription opioid addiction as it shifts into illegal activity. These individuals need to be included as full partners in addressing the opioid crisis. We need to see the opioid crisis as a systemic issue and fix it accordingly. Physicians cannot be the only champions in our new approach to pain management. The entire healthcare team must work together with law enforcement and the community to facilitate the systemic changes that are needed.

Learn more about efforts to combat the opioid crisis by downloading the white paper, Fighting the opioid crisis with data, analytics and waivers – a coordinated approach.

Visit DXC at HIMSS 18, booth 1617.


Beth Slamowitz is a pharmacy services manager for DXC Technology on the Nevada MMIS account located in Reno, Nevada. She received her Doctor of Pharmacy degree from Creighton University in Omaha, Nebraska in 1999 and has worked in many areas of the Pharmacy profession.

 

 

RELATED LINKS

Using waivers to tackle the opioid crisis: Opportunities and challenges

States make progress on tackling the opioid crisis by using federal grants

 

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