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Featured Clinical Topic: Pain Management

17 Jul 2018 12:25 PM | Anonymous

Pharmacists’ Role in Pain Management and Combatting the Opioid Epidemic

Authors: Samantha Breckenridge, Pharm.D. Candidate 2019, UMKC School of Pharmacy

Bradley Erich, Pharm.D. Candidate 2019, UMKC School of Pharmacy

Maureen Knell, Pharm.D., BCACP, UMKC School of Pharmacy

Turn on your television or scroll through the internet, it won’t take long to see headlines related to the “opioid epidemic” or “opioid addiction”. Take a step further, a google search of “opioid” suggests topics such as crisis, abuse, and dependence, to note a few. Behind the media stir lies a deeply rooted issue that requires intervention from many angles. Since 1999, the number of opioid prescriptions in the United States has quadrupled.1 While one may think this indicates better pain control, the amount of pain reported by Americans has remained the same. In that same time frame, 165,000 deaths have been attributed to prescription opioid overdose alone.1

There are many Americans dealing with severe pain due to various causes, each deserving of safe and adequate pain relief. Opioid painkillers are known to be effective in the acute treatment of severe pain, but there is little to no evidence to support their long-term usage.1 With an increased duration of exposure to these medications comes an increased risk of dependence and addiction.1 The Centers for Disease Control and Prevention evaluated data from roughly 1.3 million patients who underwent or are currently undergoing opioid therapy. Patients were more likely to continue opioid pain reliever therapy when the first, acute prescription exceeded 10 or 30 days.2 The Centers for Disease Control and Prevention guidelines advocate that sufficient pain relief in an acute setting is often achieved with a three-day supply of an opioid prescription and that patients rarely require more than seven days.1 Having extra, unused opioid pills not only leads to an increased risk that the patient will consume more than needed, but it also leads to the risk of friends and/or family having access to a prescription not intended for them. In 2013 and 2014, there were 10.7 million people aged 12 or older who misused prescription painkillers. Of those, 50.5% reported having obtained the medications through a friend or family member for free.3

Increasing awareness of the opioid epidemic has led to speculation on who is to blame and demands for a quick fix to the problem. However, this is a nationwide issue that will require thoughtful problem-solving by various entities working together to enhance future safety while providing adequate pain management. As of April 2018, twenty-eight states have enacted legislation regarding opioid limits, requirements, or guidance.4 Prescription health plans around the country are also implementing similar quantity limits. The Food & Drug Administration (FDA) is encouraging the drug industry to develop abuse-deterrent opioid dosage forms.5 Lastly, the Drug Enforcement Administration (DEA) is decreasing Annual Production Quotas (APQs) of opioids by 20% to be made in 2018.6

Although there are multiple efforts being made to curb opioid abuse via various mechanisms, these efforts are not without flaws. For instance, many hospitals and health systems are experiencing critical shortages in injectable opioids which may effectively delay patient care and leave patients in pain before action can be taken. According to the American Society of Health Systems Pharmacists (ASHP)7, intermittent shortages of specific injectable opioid products may lead to substitution with other more readily available products. Unfortunately, opioids are not all interchangeable, making improper conversions and substitutions possible, which may lead to risking patient safety. While opioid side effect profiles remain similar, there may be differences between medications. Therefore, patient monitoring is of paramount importance during this conversion to avoid severe side effects such as respiratory depression.

Another challenge for patients, pharmacists, and other members of the healthcare team is quantity limits and formulary restrictions that may force providers to change a patient’s well controlled chronic pain regimen. During this transition, the patient could suffer from opioid withdrawal from chronic therapy, in addition to poor pain control.

The aforementioned concerns and considerations that have arisen throughout the opioid epidemic raise the question: What can healthcare professionals such as pharmacists do about it?

In terms of injectable opioids, ASHP makes recommendations for pharmacists in order to help mitigate this impact. These steps include switching therapy to a clinically appropriate oral or enteric opioid formulations, whenever possible; Engage the institution’s experts on pain and palliative care to further develop guidance and formulate strategies for dealing with intermittent shortages; And ensure relevant institutional pain medication guidelines are up to date, to name a few.7 Additionally, there are programs such as ASHP’s Pain Management Certificate program that equip pharmacists with the skills to provide appropriate and effective pain management for patients suffering from chronic pain. Programs like these provide pharmacists with proficiency in pain management including treatment with non-opioids that can ensure proper pain control while reducing the risk for inappropriate use of opioids.12

Pharmacists in the community and ambulatory care setting have a unique opportunity to work with prescribers and patients to assess opioid pain management. They can provide education for appropriate use, assess for dangerous use, and offer innovative options such as tapering opioid plans and finding the lowest effective opioid dose when quantity limits or access to opioids becomes an issue. In these settings, pharmacists can also make an impact by showing empathy to patients who have relied on opioids for a long time for pain management and are not aware of other options that can help control their pain safely and effectively. Through advanced knowledge about pain control learned in schooling, residencies, and unique opportunities like ASHP’s Pain Management Certificate program, pharmacists in these settings are also able to offer alternatives to opioids such as non-opioid pharmacologic agents and non-pharmacologic therapies to help in controlling chronic or acute pain.

Pharmacists also play an integral role in pain management through transitions of care. Some of these roles include medication reconciliation, drug monitoring and assessment during hospitalizations, patient and healthcare provider education, discharge counseling, post-discharge follow-up and counseling. These roles in transitions of care can help in potentially minimizing medication errors while ensuring safe, appropriate, and effective use of medications throughout the patient care continuum.8

Additionally, pharmacists in Missouri are able to dispense naloxone, a competitive opioid antagonist, to patients who are eligible through screening. This Missouri law authorizes pharmacists to dispense nasal or intramuscular naloxone without a prescription by standing order issued by the Missouri Department of Health and Senior Services or by protocol with a physician.9 The law offers pharmacists a unique role in screening eligible patients for potential naloxone use, education regarding the risk factors for overdose, signs and symptom of overdose, overdose response steps, and the administration of naloxone.9 Naloxone is also fully or partially covered by many insurances including Medicare, Medicaid, and commercial insurance carriers.13,14

Missouri pharmacies may now voluntarily collect medications from the public for destruction that are in compliance with CSR 2220-2.095. While this law does not apply to controlled substances (e.g. opioids), it is a step in the right direction for disposal of medications after they are expired or no longer needed to avoid diversion. Pharmacists may also provide patients with information on disposal of opioids through rxdrugbox.org or medreturn.com, which offer locations such as community pharmacies and law enforcement agencies to dispose of their medications (including controlled substances) safely. The United States FDA also provides guidance on disposal of medications, as there can be misconceptions about the disposal of various formulations and types of medications.15 There are also multiple innovative ways to dispose of controlled substances that do not have to be flushed or thrown away in other household garbage. In early 2018, Wal-Mart began using a technology called DisposeRx that they dispense with opioid prescriptions. According to the manufacturer, when this powder is poured into a prescription bottle with warm water, it ultimately enables patients to dispose of leftover medications in their other household garbage.10 Mallinckrodt Pharmaceuticals provides medication disposal pouches that contain active carbon that inactivates any medication when mixed with water. Mallinckrodt provides a complimentary six pouches to patients who request through their website, in addition to providing pouches to local health departments and other community outreach programs.11

While there is no single way that pharmacists, patients, and other healthcare professionals can tackle the opioid epidemic, there are multiple ways that all who are involved can take action. Pharmacists play an integral role in educating patients and communicating with other healthcare professionals on the proper use of opioids and other pain medications, in addition to ensuring appropriate medication use. Patients also have opportunities to take action, from properly disposing their unneeded/unused medications, to storing their medications safely and securely in a locked medication box or other storage area where they cannot be diverted or accidentally ingested by children. Patients also have the opportunity to carry naloxone for a family member or friend who may need it in the case of an overdose emergency. Collectively, these actions can aid in decreasing the inappropriate use of opioids while still ensuring adequate pain control for patients.

References:

1. Factsheet CDC Guideline for Prescribing Opioids for Chronic Pain. Centers for Disease Control and Prevention website. www.cdc.gov/drugoverdose/pdf/guidelines_at-a-glance-a.pdf Updated August 29, 2017. Accessed June 10, 2018.

2. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017; 66: 265–269. DOI: http://dx.doi.org/10.15585/mmwr.mm6610a1

3. Lipari RN, Hughes A. How people obtain the prescription pain relievers they misuse. The CBHSQ Report. 2017. URL: www.samhsa.gov/data/sites/default/files/report_2686/ShortReport-2686.html

4. Prescribing Policies: States Confront Opioid Overdose Epidemic. National Conference of State Legislatures website. http://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx Published April 5, 2018. Accessed June 11, 2018.

5. Abuse-Deterrent Opioid Analgesics. U.S. Food & Drug Administration website. https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm600788.htm Updated April 23, 2018. Accessed June 11, 2018.

6. Quotas - 2017. DEA Diversion Control Division. https://www.deadiversion.usdoj.gov/fed_regs/quotas/2017/fr1108.htm. Published November 8, 2017. Accessed June 11, 2018.

7. Injectable Opioid Shortage FAQ. ASHP. 2018. https://www.ashp.org/Drug-Shortages/Shortage-Resources/Injectable-Opioid-Shortages-FAQ. Accessed June 11, 2018.

8. Sourial M. The Pharmacist's Role in Pain Management During Transitions of Care. U.S. Pharmacist – The Leading Journal in Pharmacy. https://www.uspharmacist.com/article/the-pharmacists-role-in-pain-management-during-transitions-of-care. Published August 18, 2017. Accessed June 11, 2018.

9. Board of Pharmacy. Missouri Department of Agency. https://www.pr.mo.gov/pharmacists-naloxone.asp. Accessed June 11, 2018.

10. Solving the Problems of Drug Disposal. DisposeRx™. https://disposerx.com/. Accessed June 11, 2018.

11. Safe Medication Disposal. Inclusion and Diversity at Mallinckrodt Pharmaceuticals. http://www.mallinckrodt.com/corporate-responsibility/safe-drug-disposal. Accessed June 11, 2018.

12. New ASHP Certificate Program Offers Advanced Training in Pain Management. ASHP. March 2018. https://www.ashp.org/news/2018/03/16/new-ashp-certificate-program-offers-advanced-training-in-pain-management. Accessed June 11, 2018.

13. NARCAN® NASAL SPRAY AFFORDABILITY. NARCAN®(naloxone HCl) Nasal Spray. https://www.narcan.com/affordability. Accessed June 20, 2018.

14. EVZIO2YOU. EVZIO®. https://www.evzio.com/patient/evzio2you/. Accessed June 20, 2018.

15. Center for Drug Evaluation and Research. Safe Disposal of Medicines - Disposal of Unused Medicines: What You Should Know. US Food and Drug Administration Home Page. https://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm. Accessed June 21, 2018.


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