PHARMACIST STEVE

Efforts to address the opioid epidemic are as complex as the problem, with involvement ranging from government agencies to state pharmacy boards to addiction specialists to medical professionals.

Pharmacists may be the first to suspect opioid abuse and misuse, and many have altered the way they interact with patients who take opioids. Studies have found that pharmacists say the epidemic has changed the way they counsel patients about pain management and potential problems.

“A growing awareness of the dangers posed by prescription opioids seems to be leading to more proactive discussions between pharmacists and patients regarding this issue,” says Lucas Hill, PharmD, BCPS, BCACP, clinical assistant professor at the University of Texas at Austin College of Pharmacy.

Here are some of the biggest ways pharmacy practice is changing.

1. Adopting New Protocols

Some chain and independent pharmacies are implementing policy changes to protect patients and pharmacists. CVS, for example, has strengthened counseling for patients filling a first-time opioid prescription.

“During this counseling, our pharmacists will talk to the patient about the recommendations from the CDC around opioid use,” says Tom Davis, RPh, vice president for pharmacy professional services at CVS Pharmacy. “The key message to patients initiating opioid treatment for an acute use is to use the lowest effective dose for the shortest possible duration of time. Pharmacists will also talk to patients about the importance of safely storing and appropriately disposing of opioids to prevent misuse or diversion.”

CVS uses the CDC Guideline for Prescribing Opioids for Chronic Pain to frame its prescribing policy, limiting the supply of opioids dispensed for certain acute prescriptions to seven days for patients new to the therapy.

Related article: The Other Side of Opioid Limits

“The program also employs MME [morphine milligram equivalent] limits consistent with the CDC Guidelines,” Davis tells Drug Topics. “And, it requires the use of immediate-release formulations of opioids before extended-release opioids are dispensed.” These changes went into effect in September 2017.

Tana Kaefer, PharmD, clinical coordinator at Bremo Pharmacies in Richmond, VA, says her protocol is to emphasize opioid alternatives. “If the patient gets two prescriptions, one for ibuprofen and one for an opioid, I may tell them to try the ibuprofen first.”

Kaefer also lets her patients know their options so they don’t have extra medication in the house, such as by only filling part of a prescription. Laws in Virginia allow pharmacists to split the prescription, for example, dispensing five pills when 10 are prescribed and having the patient come back if more are needed.

She also tells patients how to correctly dispose of leftovers. “We know this is a huge problem if medication is left in the medicine cabinet and other people come into the house looking for it,” she says.

2. Embracing a Team-Based Approach

Teamwork is helping reduce opioid abuse in hospital and long-term care settings, says Deb Pasko, PharmD, MHA, director of medication safety and quality with ASHP. Doctors, nurses, and pharmacists work together to determine and monitor the optimal medication for patients, and respond quickly when changes are needed. “We may have a trauma patient come into the ER who has acute needs, then go to the operating room and need a high dosage, then on to intensive care,” says Pasko.

She says pharmacists should help decide what medication is indicated, the best interval, and identify any potential interactions. They can also help determine if patients should continue receiving opioids, if medication should be tapered, or if an alternative should be considered. 

3. Using PDMPs

More than two dozen states now require pharmacists to check prescription drug monitoring programs (PDMPs). These electronic databases that track controlled substance prescriptions are among the most promising state-level interventions to improve opioid prescribing, inform clinical practice, and protect patients at risk, according to the CDC.Click to expand

“For me the prescription monitoring program is very helpful,” says Kaefer. “If I have concerns it allows me to see the bigger picture of a patient. I can see if a patient is visiting other pharmacies. I find it very helpful that I can connect to other states.”

There have been “remarkable successes” in controlling the prescribing and dispensing of controlled substances, particularly opioids, when PDMPs are accessed, says Carmen Catizone, RPh, MS, DPh, executive director of the National Association of Boards of Pharmacy.

As more states embrace PDMPs, their potential to help curb the epidemic is growing. Promising developments in PDMPs, according to the CDC, include:

• More seamlessly integrating them into electronic health records
• Permitting physicians to delegate PDMP access to other allied health professionals in their office (physician assistants and nurse practitioners)
• Streamlining the process for providers to register with the PDMP.

While monitoring is helping decrease the abuse of prescription opioids, some industry experts fear it may be contributing to more dangerous practices among abusers. In the last few years, overdoses from illicit opioids, such as heroin and fentanyl, have skyrocketed.

“The most serious concern about [PDMP] implementation is that it could push people who are misusing prescription opioids to an illicit drug market that is flooded with ultra-potent fentanyls.” says Hill. “In my opinion, that isn’t an argument against [PDMPs] so much as an argument for expanded access to evidence-based treatment with methadone and buprenorphine.”

4. Preparing for Worst-Case Scenarios

Expanding pharmacists’ authority to administer and dispense opioid-reversing medications such as naloxone may help pharmacists prevent patient overdoses from legal and illegal drugs.

Some states permit pharmacists to dispense naloxone through a collaborative practice agreement. In states where pharmacists can prescribe naloxone, they must complete training provided by their employer or a local school of pharmacy.

“This initiative requires significant outreach to pharmacists, patients and caregivers, first responders, and legislators,” says Catizone. “Besides educating people on when and how to properly administer such medications, there is the need to educate stakeholders and naysayers about addiction as a disease and not a stigma or indictment of an individual.” 

More legislation empowering pharmacists, caregivers, and first responders to ensure the widespread availability of naloxone and other similar products across all states would help save many lives, Catizone says.

“Until the number of patients who are at risk or dying from the use and abuse of opioids is zero or as close to zero as humanly possible,” Catizone says, “there is much more than can be done by pharmacists, pharmacy boards, and other stakeholders.