Confronting the National Opioid Crisis
A Multipart Series
Strategies for Smarter Service
As medication experts, pharmacists can perform a key role in mitigating the risks to patients and communities associated with opioid use while still providing medications for patients who suffer from pain and offering non-judgmental assistance to those who struggle with using opioids properly. Pharmacists must embrace their position as an access point for public health intervention. States have recognized the central role pharmacists play in the response to the opioid crisis, by instituting prescription drug monitoring programs (PDMPs) and allowing pharmacists to dispense naloxone without a physician’s prescription. But many community pharmacists still face challenges providing services aimed at addressing opioid safety and misuse.
Numerous tools are available to prevent diversion and promote safe opioid use, but researchers want to ensure that evidence-based strategies exist for deploying these tools. Pharmacists report that they receive insufficient guidance in using PDMPs, are unsure how to approach patients with concerns about opioid safety and have not been educated about naloxone distribution and use. In addition, they are typically not reimbursed for providing counseling and services related to opioid safety, and struggle to find time to provide these services in busy pharmacies. Faculty at pharmacy schools are designing and testing strategies that enable pharmacists to deliver evidence-based care that fits into existing workflows and leverages the specialized training pharmacists receive in medication safety to meet the needs of patients who use opioids.
Dr. Mark Strand, professor of pharmacy practice and public health at North Dakota State University, sees an opportunity to capitalize on community pharmacists’ unique position as the first point of contact for patients being prescribed opioids to promote prevention, safe use and full awareness of potential risks. The Opioid Risk Tool (ORT) from the National Institute on Drug Abuse is a brief, self-reported screening tool validated for assessing risk of opioid misuse in patients prescribed opioids for chronic pain. The researchers combined the ORT with a patient intake form that provides crucial information about a patient’s disease state(s) and complete medications list, information a pharmacist is often missing. This patient information provides a picture of the risks facing a patient who may, as Strand noted, be unknowingly starting down a dangerous path to opioid use disorder.
In 2017, Strand and his colleagues began a pilot training program for community pharmacists to implement risk screening and counseling and referral to resources for patients identified as being at heightened risk for harm due to opioid use. Unsurprisingly, the pilot study found that pharmacists were able to identify at-risk patients using the tools and training provided. But the researchers also found that pharmacists preferred having objective tools to gauge patient risk rather than relying strictly on professional judgment.
Having neutral screening tools empowered pharmacists to begin conversations with patients and lowered the barrier for patients to accept advice about their risk. These conversations provide opportunities for patients to raise their own concerns, which may arise from history or experiences they might not share unprompted. The pilot program’s success resulted in state funding for ONE Rx (Opioid and Naloxone Education), a program to make the training available to all pharmacists in North Dakota. More than 900 patients have been screened so far, and 4.6 percent of patients have scored as high-risk for opioid use disorder, based on the ORT, while 28 percent were identified as being at risk of accidental overdose based on medication interactions, patient profile or disease states. This risk identification led to 4 percent of patients leaving the pharmacy with naloxone, reflecting their increased willingness to have a “fire extinguisher” at home.
Tools to Improve Communication
Communication between pharmacists and patients is also at the heart of the Agency for Healthcare Research and Quality (AHRQ)-funded RESPOND (Resources Encouraging Safe Prescription Opioid & Naloxone Dispensing) project at Oregon State University. Dr. Daniel Hartung, associate professor of pharmacy in the Oregon State University/Oregon Health & Science University College of Pharmacy, has worked with colleagues to create good practices for integrating PDMPs and risk assessment into pharmacy workflows. The goals are to help pharmacists systemize the way they use these tools to provide decision support when working with opioid prescriptions and to enhance communication between pharmacists and patients and pharmacists and prescribers.
To understand how pharmacists and patients considered the pharmacist’s role in opioid safety, the researchers convened focus groups. They found that while pharmacists and patients agreed pharmacists are responsible for patient safety, tensions exist between the obligation pharmacists have to prevent diversion of opioids and their responsibility for a patient’s well-being and safety. Patients felt stigmatized as drug-seekers when pharmacists questioned their prescriptions or contacted prescribers without speaking to patients first. And pharmacists expressed uncertainty about how to use PDMPs effectively and how to engage with patients when they had concerns about a prescription. Resolving these tensions requires prioritizing patient safety and emphasizing that consultation with a prescriber or referral to naloxone are protective, not punitive, measures. An essential feature is pharmacist education in non-judgmental communication styles based on motivational interviewing techniques.
The RESPOND toolkit supports processes that effectively address opioid safety while being workable even in busy urban pharmacies. The team developed an algorithm that pharmacists use to weigh information about the prescription and patient and determine if follow-up with either the prescriber or patient is indicated. The toolkit embeds the algorithm in a communication strategy checklist that promotes patient-centered, non-stigmatizing interactions. Online training modules provide pharmacists with information on the roots of the opioid crisis, the purpose and appropriate use of PDMPs, tools for communicating with patients and the value of naloxone. This additional training is intended to increase self-efficacy in providing patient services related to opioid safety.
Having established the value and feasibility of pharmacist services for opioid users, the next step is developing sustainable models for service delivery and expanding use. The North Dakota team has shown that patient intake in their model takes an average of 4.8 minutes per patient for the pharmacist. State funding is currently enabling $20 payment to pharmacists for the service, while the team gathers evidence of the value of the intervention to share with a working group of third-party payers.
The ONE Rx program expansion is also creating a rich stream of data for further research. More than 50 pieces of information are being collected on each patient related to their medical history, disease states and medication lists. These data help patients and pharmacists arrange for better individual care, but they also enable research on patient outcomes that is critical to improving care management for all patients and supports the value proposition of the services. Strand hopes projects like ONE Rx will help build a critical mass of pharmacists to provide these services with or without reimbursement. One additional part of any effective response to the crisis is recognizing the potential dangers presented by opioids and careful appraisal of the evidence base for prescribing practices. Many prescribers are slow to adapt alternative approaches to pain management and reduce reliance on opioids for chronic pain relief, but Strand and his colleagues continue to engage with prescribers as they seek to move prevention efforts further upstream. As Strand noted, “We need better and safer ways to manage non-cancer pain, including more holistic treatment plans for chronic pain patients, including non-opioid medication options.”