Today it’s difficult to go more than a few days without hearing about the opioid epidemic and its devastating effects on U.S. communities. Afterall, an average of 115 Americans die every day from an opioid overdose, according to the Centers for Disease Control and Prevention.
Consider these statistics: From 2000 to 2009, the number of opioid prescriptions increased by 48 percent —a startling uptick. Not coincidentally, from 1999 to 2016, more than 630,000 people died from a drug overdose, and around 66 percent of drug overdose deaths in 2016 involved an opioid.
How did the United States get so far down this path before finally giving the opioid epidemic the attention it deserves?
The answers are complicated, but most experts point to a confluence of events that include:
- New recommendations for pain management (the result of deepening cultural emphasis on the topic)
- Misleading claims by pharmaceutical companies that their drugs were non-addictive
- Overreliance by doctors on opioids to treat chronic pain, and
- An influx of ever-more potent heroin targeted at these patients.
Looking at the diverse factors that have caused this issue, it’s clear that treating addiction on a case-by-case basis will do little to address it.
Our healthcare industry, business community, regulatory bodies and American culture have all contributed to the opioid epidemic. That’s why, to be effective, our solutions must be multifaceted.
How pharmacists can help
The opioid crisis touches all healthcare disciplines, and each has an important perspective to lend as we consider how best to address it. From a pharmacist’s perspective, we operate at the intersection of prescribing practices, dispensing and drug diversion, and have relatively direct access to patients. Potential solutions that pharmacists can contribute include:
Conduct a gap analysis. When faced with a systemic and daunting problem such as opioid over-use, a gap analysis can help your pharmacy team find one to two issues that you can realistically tackle to help. A gap analysis will take you through the steps of looking at key components of pain management in your organization and identifying the weaknesses and barriers that prevent your interdisciplinary teams from changing their opioid prescribing habits
Implement prescription drug monitoring programs. The first step in getting a handle on the opioid epidemic is better reporting at the state-level. Prescription drug monitoring programs (PDMPs) are one way to leverage data to both spot and prevent over-prescription and identify problem users.
These programs provide visibility into patients’ prescription histories, enabling providers to make
more informed decisions (e.g., spot a “doctor shopper”) and connect them with resources rather than prescribing more medication. PDMPs also promote accountability since pharmacists may intervene and offer education if a doctor is unwittingly conducting unsafe prescribing practices. The CDC has reported evaluation of PDMPs has contributed to improvements in prescribing behaviors, lowered the use of multiple providers by patients and resulted in decreased substance abuse treatment admissions.
Guidance from the Pharmacy Quality Alliance provides the following performance measures to identify problem patients and reduce the rate of opioid prescriptions:
- Concurrent use of opioids and benzodiazepines
- High dosage opioid use in persons without cancer (daily dosage of >120mg morphine equivalent dose for 90 days or longer);
- Persons without cancer receiving opioids from four or more prescribers, and four or more pharmacies;
- Persons without cancer who receive high daily dosages with four or more prescribers from four or more pharmacies.
Information from PDMPs also can be used to spot trends, such as hospitals or communities that are disproportionately struggling with opioid use. This data can then be leveraged by state insurance
programs, healthcare licensure boards, state health departments and law enforcement to take corrective action.
Embrace pharmacy-led education. By nature, pharmacists have a wealth of information on drug uses, efficacy and side effects, all of which is highly relevant to pain management. If you’re not already doing so, move from a passive to an active role in physician and nurse education about holistic pain management and new standards of care.
Share the best practices well known in pharmacy circles such as the mantra “start low and go slow” to encourage physicians to prescribe the lowest effective dose or to consider non-opioid options. Doctors who take a bludgeon approach to pain management should be educated on the “mild, moderate and severe” step ladder of pain management. You should also discourage the practice of prescribing opioids “just in case” and question the initial diagnosis when a patient’s pain isn’t reduced.
When interacting with patients, pharmacists can help set realistic expectations for pain management. For example, a patient may not realize that being completely pain-free is impossible in their case, but that they can still go about the activities of daily living with reduced pain.
Finally, the U.S. Food & Drug Administration offers a risk evaluation and mitigation strategy for extended-release and long-acting opioid analgesics, that requires physicians, nurses and pharmacists to educate patients on the elevated risk of such medications.
Explore alternative pain management options. While opioids may seem like the most intuitive pain management solution to some, they are far from the only—and sometimes even far from the most effective—tool.
Dozens of alternatives, such as medical marijuana (where legal), chili pepper, capsaicin, nerve-growth inhibitors, Tanezumab, non-steroidal anti-inflammatory drugs, acetaminophen, nitrous oxide, anticonvulsants and certain anti-depressants, might do a better job of addressing a patient’s pain and thus, provide long-term improvement without the downsides of opioids. In some cases, even non-drug options, such as massage or acupuncture, may be helpful alternatives.
In one example, the emergency department at St. Joseph Regional Medical Center in Paterson, N.J., implemented an alternatives-to-opioid (ALTO) program, in which it used targeted, non-opioid medications, trigger point injections, nitrous oxide and ultrasound nerve blocks to treat 300 patients with kidney stones, lower back pain, broken bones and headaches. Through this program, it was able to reduce opioid use by 38% in three months.
Alternative pain management techniques can be wildly successful and well received by patients. However, doctors and patients—many of whom have been desensitized to the risks that opioids present and are accustomed to a strong and immediate response to pain—might need to adjust their expectations.
Prevent drug diversion. According to the Institute for Safe Medication Practice, partially filled vials and syringes in sharps containers contribute to diversion (i.e., drugs ending up in unintended hands for illicit purposes). The Drug Enforcement Administration (DEA) requires all hospitals and health systems to destroy controlled substances to the degree that they are unsalvageable. Health systems should consider creating additional safeguards to ensure controlled substances are destroyed properly and in compliance with DEA standards to reduce their availability in communities.
Comply with Joint Commission standards. The Joint Commission’s updated pain management standards went into effect January 2018 and among other things, include:
- Identifying a leader responsible for safe opioid prescribing
- Involving patients in developing their treatment plans
- Setting realistic expectations and measurable goals
- Monitoring high-risk patients and
- Facilitating clinician access to PDMPs.
The Joint Commission also provides several suggestions for pain management alternatives to opioids.
The opioid crisis is a systemic issue that requires a systemic response. While historically, the brunt of pain management might have fallen on physicians, they shouldn’t be expected to work in a vacuum. Pharmacists should make what recommendations they can to tackle this problem.
By Julie Rubin, Pharm.D., BCPS, Director of Clinical Services CompleteRx
 “Opioid Overdose.” Centers for Disease Control and Prevention. Accessed Sept. 19, 2018.  Blake V. “Fighting Prescription Drug Abuse with Federal and State Law.” American Medical Association Journal of Ethics. May 1, 2013;15(5):443-448.  “PQA Performance Measures.” PQA Measures Information. Pharmacy Quality Alliance. Accessed Sept. 19, 2018.  “Information by Drug Class—Risk Evaluation and Mitigation Strategy (REMS) for Extended-Release and Long-Acting Opioid Analgesics.” U S Food and Drug Administration Home Page. Center for Drug Evaluation and Research. Accessed Sept. 19, 2018.  “Partially Filled Vials And Syringes In Sharps Containers Are A Key Source Of Drugs For Diversion.” Institute For Safe Medication Practices, Institute for Safe Medication Practices.  “Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals.” The Joint Commission Perspectives, July 2017.