By: Erin Merico, Student Pharmacist and Kunal Amin, BSPS, PharmD
A directive to protect public health!
The opioid crisis continues to devastate America, and pharmacists have the ability to reduce the overwhelming familiarity of opioid induced deaths. Pharmacists can actively contribute to the decline and prevention of opioid use disorder by using their knowledge of medications to assess and intervene on opioid prescriptions.
…but how can pharmacists really help with this national problem?
While some individuals may get opioids illicitly, studies show 32% of all opioid overdose deaths in 2018 involved prescription opioids. 1 Dispensing prescription opioids, many of which end up in the community, is a pharmacist’s responsibility. They are the gatekeepers between prescription drugs and the public. They have the unique ability to intervene by completing drug utilization reviews or through provider and patient communication. Moreover, pharmacists are the most accessible member of the healthcare team, manage complex medication regimens and make recommendations for initiation, modification and termination of drug therapy. 2 So, why can’t pharmacists tell doctors prescribing opioids and patients “NO?”
It’s not that simple…
While opioids can be extremely dangerous, they can also be life altering medications for many patients such as those with chronic pain, post-surgical pain, trauma or cancer. That is why we are suggesting all State Boards of Pharmacy reevaluate their role in opioid addiction and consider temporarily mandating opioid management continuing education (CE) for their licensed pharmacists until this crisis resolves.
What are some states already doing?
Currently, a handful of states require pain management or safe opioid use continuing education for pharmacists including Michigan, Oregon, Virginia, West Virginia, Pennsylvania, and New Mexico 1 According to the Centers of Disease Control (CDC), West Virginia has the highest rates of opioid deaths, but Oregon has some of the fewest. There are no clear statistics as to how this education is helping, however, studies are looking at why pharmacists simply are not speaking up about this issue.
Pharmacists think they cannot challenge doctors.
- One study looked at the communication between pharmacists and primary care physicians when prescribing opioids by interviewing a group of 60 pharmacists and 48 primary care physicians.3 The researchers found most communication involved “dosing, timing of the prescription, and/or evidence of potential diversion/misuse.” The study concluded most pharmacists did not “challenge” prescribers out of fear of angering the prescriber. The researchers attribute the fear to a “hierarchy” that exists between pharmacists and physicians.
Pharmacists are not confident in opioid use.
- University of Wisconsin-Madison School of Pharmacy found that most pharmacists are aware of the provisions to help reduce unsafe opioid usage, but lack “confidence, training and resources, [and] structured guidelines.”4 When pharmacists approached patients for opioid addiction, they were not well equipped to give proper guidance and suggested more education should focus on rehabilitation programs and resources pharmacists can use to help their patients with addiction.
Pharmacists are taught about opioid addiction in pharmacy school, however, literature implies additional education can help pharmacists’ confidence and knowledge regarding opioid uses and abuses.3,4
What would this education look like?
Several topics can be covered via a multiple module system, where pharmacists can obtain numerous CE credits. The program could be live, self-study or a combination of both for convenience. A live component would allow for practice and role play. This could be particularly useful during the communications module, allowing pharmacists to practice skills.
Suggested topics include:
| Uses and abuses of opioid medications | – Abuse related behavior – Indications for prescription opioids |
| Communications | – Building patient relationships – Building prescriber-pharmacist relationships – Challenging unsafe prescribing trends |
| Screening, Brief Intervention, and Referral to Treatment (SBIRT) | – Using SBIRT to reduce opioid related deaths – Utilization and access to state prescriptions drug monitoring program (PDMP) |
| Patient and caregiver resources | – Local rehabilitation programs – Local pain management groups – Naloxone (Narcan) access and training |
| Pharmacist resources | – Caring for patients using opioids – Avoiding judgment in dispensing opioids – Counseling and talking points for patients using opioids |
American Pharmacist Association (APhA) has implemented a program for pharmacist training that focuses on opioid misuse. The CDC also offers a program for all healthcare providers at no charge. States can utilize these pre-established training programs to fulfill the CE requirements or approve other programs as desired that focus on managing patient care to diffuse the opioid crisis.
Pharmacists need education to protect the public health!
State Boards of Pharmacy should implement or eliminate continuing education contact hours based on the level of crisis impeding their states’ public health. A longitudinal approach and constant development of such topics would allow pharmacists to remain current with ongoing trends in healthcare and provide better patient-care. Whether or not education will be helpful is up for debate, however, providing pharmacists extra resources is another step in the right direction in mitigating this growing problem.
What are other means of ensuring pharmacists are well educated on this growing problem?
References:
1.Overdose Death Maps. Centers for Disease Control and Prevention. Published March 19, 2020.
2.Manolakis PG, Skelton JB. Pharmacists’ contributions to primary care in the United States collaborating to address unmet patient care needs: the emerging role for pharmacists to address the shortage of primary care providers. Am J Pharm Educ. 2010;74(10):S7.
3. Curran GM, Freeman PR, Martin BC, et al. Communication between pharmacists and primary care physicians in the midst of a U.S. opioid crisis. Research in Social and Administrative Pharmacy. 2019;15(8):974-985.
4. Thakur T, Frey M, Chewning B. Pharmacist Services in the Opioid Crisis: CurrentPractices and Scope in the United States. Pharmacy. 2019;7(2):60.
Erin Merico is a Pharm.D. candidate at Northeast Ohio Medical University. Erin currently works in Investigational Drug Services at University Hospitals Cleveland Medical Center where she assists in dispensing and preparation of medications in clinical trials. She loves her role because she is constantly learning about new treatments. Through her role, she recognizes the importance of pharmacists staying current with changing medical developments. She hopes to bring positive change to continuing education for pharmacists in hopes pharmacists will have a more rewarding continuing education experience. In her free time she enjoys spending time with her two dogs, family, and friends.
Dr. Kunal Amin graduated from the University of Toledo with his PharmD degree in 2009. He started his academic career at Northeast Ohio Medical University (NEOMED) in 2018 as an Assistant Professor of Pharmacy Practice and VP & Director of Clinical Services at NEOvations Pharmacy Services. In his previous role at Giant Eagle Inc. for 9 years, he served in various roles expanding his experiences in managing multiple pharmacies, mentorship/coaching, system informatics, workflow implementation, and training pharmacists and interns as a regional clinical coordinator. In his free time he enjoys spending time with his family, hiking, and travelling.
Pulses is a scholarly blog supported by a team of pharmacy education scholars
Pulses 
Thanks to the authors for this thoughtful piece addressing an essential topic for pharmacists and pharmacy educators. While I agree there is a need for a CPE requirement related to opioids, I do not believe most of the topics suggested in this article represent optimal content areas. Opioid analgesics are involved in a shrinking proportion of all opioid-related overdoses in the U.S., and the majority of even these cases are the result of diversion to someone other than the intended patient. Pharmacy-based interventions which focus primarily on screening for and reducing misuse among patients prescribed opioids will miss the vast majority of opioid-related overdoses while risking unintentional harm to patients with severe chronic pain. Instead, I would propose mandating 1-2 hours of CPE related to medications for opioid use disorder treatment, naloxone distribution for acute overdose reversal, and non-prescription syringe sales for infection prevention. These are the opioid-related interventions with the strongest supporting evidence. However, studies continue to demonstrate major gaps in access to buprenorphine, naloxone, and non-prescription syringes in community pharmacies. In the midst of this deadly public health crisis, we must have the courage as a profession to directly address widespread stigma and ignorance regarding these topics within our profession. Requiring education related to primary prevention interventions, which are more broadly accepted but substantially less efficacious, will not be sufficient.
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