8 Safe opioid use in the community setting: reverse the curse?

Introduction

Opioids – prescription and illicit – are the main driver of drug overdose deaths in the US. Opioids were involved in 42,249 deaths in 2016, and opioid overdose deaths were five times higher in 2016 than 1999.¹ In recent years, there has been a surge in deaths due to alcohol, drug abuse, and suicide, which some have described as “deaths of despair.”² Among the individuals involved in this trend are persons living with chronic pain and persons living with a substance use disorder.

The current opioid misuse crisis is made more complex for pharmacists because of concerns that many of those abusing prescription opioids, or even heroin, had a prescription medication as their entry point.^3-6 Prior to 1990, heroin addiction began with heroin use, but since that time, heroin addiction has primarily begun with prescription opioids.⁴ An estimated 25 million adult Americans suffer daily from pain and require some analgesic to provide relief.⁷ With liberalization of opioid prescribing practices, many opioid-naive patients were exposed to opioids. One in four patients receiving long-term opioid therapy in a primary care setting struggles with an opioid use disorder.⁸ This set the stage for a generation of patients unexpectedly misusing opioid medications.

Educating patients about their medications has been required of all Medicaid patients and, in many states, all patients (see Important Resources for more information). With controlled medications, patient education and counseling is even more critical. Pharmacists’ cognitive services are increasingly recognized as an essential added clinical value for patients. While the opioid misuse epidemic facing the country requires a multidisciplinary approach, community pharmacists are key players in ensuring patients use these medications safely and, if there are concerns, linking patients to needed care.

Case

CC: “I would like to have this prescription filled.”

Patient: BC is a 39-year-old male (70 in, 79.5 kg) with pain in his back and leg associated with a multi-car accident. He reports that he frequently experiences pain associated with his work as a temporary concrete layer.

HPI: Toward the end of the day, BC approaches your pharmacy counter with a new prescription for Percocet 10/325 #60 with directions to take 1-2 tablets every 4-6 hours as needed for severe pain. The prescription is from Dr. Stevens at the local urgent care facility.

PMH: Depression; anxiety; ADHD; alcohol use disorder; allergic rhinitis

FH:

• Mother (alive) with T2DM, depression, and HTN
• Father (deceased) with history of alcohol use disorder, HTN, cirrhosis

SH:

• Reports tobacco use
• Reports alcohol use
• Living alone and not in the same city as the rest of his family

Medications:

• Sertraline 50 mg daily
• Alprazolam 1 mg TID
• Cetirizine 10 mg daily (OTC)

Allergies: NKDA

SDH: BC has been working but does not have benefits. He had been covered by Medicaid previously, but since moving to this state, he hasn’t applied for it.

Additional context: Since he is a new patient, BC is asked to provide more comprehensive medical information. A new state law requires prospective review of the prescription drug monitoring program (PDMP) before dispensing any opioid prescription. His report is shown below.

Case Questions

1. What do you conclude based on BC’s PDMP review, and why?

2. What is BC’s ORT score and what does that score mean?

3. Based on the risk factors identified above, what is your assessment of the patient’s risk of opioid misuse?

4. What is the risk for unintentional overdose?

5. Will you dispense the Percocet for BC? Why or Why not?

6. What treatment options are recommended for this patient to reduce harm? Who else needs to be included in the treatment plan discussion? What can be done today?

7. What resources are available for referral? What resources are available for education for the patient?

8. What are the discussion points that need to be conveyed to the patient and caregivers, including opioid safety and medication use?

9. What implications and/or opportunities for policy makers exist surrounding this case?

Author Commentary

The opioid epidemic was accelerated by liberalized opioid prescribing practices in the US. Therefore, as the medication experts in the healthcare system committed to safe use of all medications, pharmacists are the key professionals to ensure safe use of prescription opioids, and evidence-based care for patients with pain. This case highlights the difficult role that pharmacists play when dispensing medications to a patient for whom it may not be appropriate. The hope is that pharmacists will rely upon their professional judgement in evaluating the information available to them – the PDMP record, identified risk factors with the patient, and concomitant disease states and medications – in order to ensure the patient’s safe use of the medication. Although opioids are particularly high-risk medications, the vigilance promoted in this case study has relevance for the role in safe medication use that pharmacists play with other medications that carry significant risk as well.

Patient Approaches and Opportunities

Pharmacists serve as gatekeepers of safe medication use for patients. This includes verifying the appropriateness and safety of the medication being dispensed and educating patients about appropriate use of that medication.⁹ Screening followed by brief interventions (SBIRT) have been shown to be feasible and effective.^10,11 Therefore, pharmacists are well positioned to make essential contributions to the prevention and management of opioid misuse among their patients through screening and patient education.^12-14

Naloxone prescribing, strengthened pharmacist-prescriber communication channels, increased pharmacist access to patient health information (shared EHR), and access to prescription monitoring program data have created opportunities for pharmacists to practice the SBIRT model with opioid users.¹⁶