When Two Pandemics Collide

It’s no secret that opioids can lead to dependence. Opioid use can increase a patient’s risk of respiratory depression, fatal and nonfatal overdose. During the COVID-19 pandemic, prescription and non-prescription opioid misuse or opioid use disorder has become a pressing public health emergency.

There is a significant stigma associated with use of opioid analgesics and medications for opioid use disorder (OUD). The COVID-19 pandemic has negatively impacted the opioid crisis. The public stigma of OUD also contributes to the national opioid public health crisis, such as reluctance to seek or provide treatment by patients and providers, respectively.

AACP has led efforts in collecting and publicizing opioid-related activities by colleges and schools of pharmacy. To date, the Association has more than 450 activities recorded by 114 academic pharmacy institutions from 45 states, the District of Columbia, and Puerto Rico in its Opioid-Related Activities Database. Education and research activities comprise the majority of activities. Activities related to service, practice, and advocacy have also been reported, but not as widely adopted as education and research activities. Therefore, clinical practice and patient advocacy initiatives within pharmacy programs can expand opioid-related activities in the university-wide community.

Below is a snapshot of opioid-related activities that are taking place at AACP member schools. The University of New Mexico (UNM) College of Pharmacy and the Massachusetts College of Pharmacy and Health Sciences (MCPHS) serve as key examples of successful co-curricular opportunities.

University of New Mexico College of Pharmacy

The University of New Mexico (UNM) Substance Use Research & Education (SURE) Center has approached barriers to communication and broader discussion about substance use disorder (SUD) by increasing the use of non-stigmatizing language when speaking with providers, patients, and the public. Person-centered language alternatives is an evidence-based principle of communication which can decrease public stigma surrounding OUD.

Discriminatory communication practices, such pejorative language, can appear to endorse negative social norms and present barriers to effective treatment for patients with OUD. UNM pharmacy education and experiential training integrates stigma-reducing strategies to communicate about OUD and harm reduction strategies for people who might be at risk of overdose. Strategic approaches in communication (e.g., use of terminology) during patient-provider interactions can help decrease harmful stigma and combat ideological barriers that are simultaneously perpetuating the opioid crisis during COVID-19. The goal of both destigmatizing language and person-first terminology aims to improve outreach during the COVID-19 pandemic in university-wide and rural communities. UNM College of Pharmacy faculty developed and disseminated an outreach intervention program to increase pharmacy-based naloxone dispensing to patients at risk of opioid-related breathing emergencies. The program primarily focuses on pharmacists’ and pharmacy technicians’ self-efficacy and communication skills and integration of opioid-related breathing emergencies prevention and naloxone counseling in community pharmacies. Emerging results indicate that this targeted educational outreach led to better identification of patients at risk of opioid-related breathing emergencies and increase in naloxone dispensing in rural areas.

In addition, Dr. Ludmila Bakhireva, director of the SURE Center, and Dr. Amy Bachyrycz shared their experience working with rural/under-served and special populations, such as pregnant women and young children, affected by the opioid crisis. UNM SURE Center leads several prospective cohort studies examining the effect of prenatal opioid exposure on infant. The College of Pharmacy faculty also participate in a number of clinical trials focusing on novel interventions for OUD conducted within the NIDA Southwest Clinical Trial Network (CTN) Node.

Massachusetts College of Pharmacy and Health Sciences (MCPHS) - Boston

Dr. Frank Melaragni, associate professor in the School of Pharmacy, has been instrumental in MCPHS University’s opioid-related activities and community outreach. As part of these efforts Melaragni has worked with student organizations such as Generation Rx and organized regular training sessions on how to recognize and respond to an opioid epidemic. This has results in over 5,000 MCPHS students, staff, and faculty learning about the opioid healthcare crisis and learning how to administer naloxone to those who have an opioid-related breathing emergency. Melaragni also initiated an MCPHS with the Public Health arm within the City of Boston to assist in reaching community members who wanted to learn about helping others with naloxone. Pharmacy students have received special training by the City of Boston, and delivered numerous naloxone training sessions across Boston.

Student pharmacists have also been involved in a pilot program at a local healthcare facility—the Newton-Wellesley Hospital. Drug disposal packets, instructions, and a survey are provided to post-surgery patients with an opioid prescription for acute pain. The goal of this program is to assess the efficacy of a simple intervention provided to patients in the hopes they will remove unused opioid prescriptions from their homes.

Previous research at MCPHS has evaluated community pharmacists’ training and understanding about naloxone products and barriers to prescribing buprenorphine. The study discovered that community pharmacists did not have sufficient understanding to properly counsel patients about naloxone products. Therefore, there is a need for increasing substance abuse education and training in pharmacy school and after graduation in professional practice.

In addition to his activities at MCPHS, Melaragni works with a local non-profit organization and launched the Opioid Epidemic Network to highlight front-line responders' efforts, and to involve student pharmacists in ongoing efforts to address the opioid epidemic during COVID-19.

Successful SUD Activities During COVID-19

It is difficult to fully understand the concurrent yet additive effect of SUD during the COVID-19 pandemic. The social stigma of OUD may add to a person’s reluctance to seek help.

Food and Drug Administration (FDA) approval of KLOXXADO®, an 8 mg high-dose naloxone nasal spray, fits a timely community-based health need; it is expected to improve outcomes of opioid-induced overdose during the COVID-19 recovery phase. Risk reduction and risk management programs, in concert with COVID-19 vaccination efforts, will improve clinical practice and health outcomes while decreasing the potential of opiate-related emergencies. Non-opioid, tamper-resistant or abuse-deterrent formulations of prescription medications also dissuades potential for drug misuse.

Increased access to and education about naloxone products directly combats opioid-involved overdose. Research findings have shown how pharmacists and pharmacy technicians can benefit from high-impact education and practice training in overdose emergency response and naloxone administration.

Changing from a stigmatizing to destigmatizing communication strategy, like adoption of person-first language with patients, is a data-based approach to reduce harm at both the patient and population level. Other strategies include clinical risk assessment tools and opioid tapering protocols. Opioid stewardship programs may be yet another avenue for student learning, community engagement, and healthcare practice. Student experiential learning opportunities in SUD and addiction can improve the skill set for future pharmacists.

Successful piloting and implementation of opioid-related activities during the COVID-19 pandemic are critical opportunities for students to learn more about substance abuse prevention and treatment. These activities, however, are likely to require an array of strategic planning efforts including recovery-oriented language, patient advocacy, and community outreach to increase access and quality care.

Study abstracts that will be presented during AACP’s annual Virtual Pharmacy Education 2021 is another opportunity to learn more about opioid-related research being conducted in the United States and worldwide. Opioid-related abstract topics include pharmacist-delivered counseling methods and opioid screening, mitigation, and tapering strategies. All 2021 meeting abstracts will be published online by the American Journal of Pharmaceutical Education (AJPE).

References

1. Phuong Duong., et al. “Understanding the Barriers to Prescribing Buprenorphine in Massachusetts”. Acta Scientific Pharmaceutical Sciences 4.12 (2020): 22–29.
2. Melaragni F, Levy C, Pedrazzi J, Andersen M. Assessing pharmacists' readiness to dispense naloxone and counsel on responding to opioid overdoses. J Am Pharm Assoc (2003). 2019;59(4):550-554.e2. doi:10.1016/j.japh.2019.04.012