Helping Pharmacists to Help their Patients: The Opioid Epidemic

The news headlines tell it all: the incomprehensible deaths of healthy individuals in their 20s – sadly, no longer such unusual occurrences. Babies born to opioid-addicted mothers, whisked into the NICU for days of harrowing withdrawal. And the shocking news story recently published in the New York Times, describing impoverished, recovering drug addicts who often deliberately relapse and begin new drug treatment programs – just to keep a roof over their heads by allowing their unscrupulous landlords to pocket the Medicaid kickbacks from their revived substance abuse treatment.

All of the above scenarios illustrate that the opioid epidemic, which had in the past been seemingly contained to the periphery of society, has now become everyone’s problem. According to a report cited by Mass.gov, nearly 4 in 10 residents of Massachusetts know someone who has misused prescription drugs within the past five years.  There are 17 branches of the state-wide, peer-led support group Learn to Cope – and each one holds weekly meetings. More than 6500 residents of Massachusetts have died from opioid overdoses in the past 11 years.

Given the scope of the crisis, the Massachusetts Pharmacists Association applauds Governor Charlie Baker for convening a working group focused on the epidemic. The Baker work group recommendations follow on the heels of several measures adopted by the state’s legislature and Patrick administration in the past few years, including the passage of Chapter 258 of the Acts of 2014, which established the Opioid Drug Formulary Commission and requires a pharmacist  to dispense: “an interchangeable abuse deterrent product if one exists; or, if none exists, a less expensive, reasonably available, interchangeable drug product as allowed by the most current formulary or supplement thereof.”  

Baker’s working group released its new recommendations in late June.  MPhA supports the recommendations; here are just a few we think are great:

Provide state funding for evidence-based opioid prevention programs in school. Although “Just Say No,” First Lady Nancy Reagan’s anti-drug campaign from the 80s, now seems almost wildly simplistic, it made an impact in educating young people about the dangers of drugs.  Recreational drug abuse declined during the Reagan administration. (Benze, James G., 2005). Hopefully, if a child learns about the dangers of opioids from an early age, he or she will be less likely to start using and get hooked.

Improve affordability of Naloxone through bulk purchasing. Since Naloxone sprung into widespread use in Massachusetts starting early last year, it has reversed hundreds of potentially fatal opioid overdoses. (It is, after all, known as the “rescue drug.”) It is crucial to keep Naloxone as affordable as possible.

Certify and register alcohol and drug-free housing to increase accountability and credibility. In order to maintain sobriety, addicts need to live in a safe place. If they return to their previous living situation, they often use again. The creation of more specialized housing for addicts will be an important step in their recovery.

Encourage the American College of Graduate Medical Education to adopt requirements for pain management and substance use disorder education. A recent survey by the Johns Hopkins School of Public Health revealed that physicians are surprisingly uninformed about opiate abuse, and many are unable to identify the most common manner in which opioids are abused (pharmacytimes.com). In addition, doctors from the VA Medical system violated the agency’s own rules when they prescribed opiates over too long a timeframe or in conjunction with benzodiazepines —  a mix that has proven fatal in far too many cases.

While this education requirement would require legislation from the state, it could be well worth the effort. As the prescribers, doctors need to be informed of the dangers of opiates, as well as the benefits.

As Massachusetts starts to implement these and other recommendations, MPhA wants to ensure that pharmacists join the medical community on the “front lines” of the war against opioid addiction – and that they are armed with the tools they need. Pharmacists, who assume such responsibility when dispensing opiates, must be supported.

Here are a few ideas to help make this happen:

Gov. Baker’s working group recommended that the Prescription Monitoring Program be improved to ensure data compatibility with other states.  MPhA endorses this. “It is important that Massachusetts join the 29 other states that are actively sharing PMP data,” says Karen Ryle, RPh, MS and member of MPhA, “This is particularly important for pharmacies bordering another states, where ‘doctor shopping’ may occur.”

In addition, the working group proposed that legislation be filed to require pharmacists to submit data to the state’s Prescription Monitoring Program (PMP) within 24 hours of receipt. In theory, this sounds great. Yet, as we know, not all pharmacies are created equal – or at least, not equal in terms of resources and manpower. It will be more difficult for smaller independents than large chain pharmacies to keep on top of the additional workload, for example. Perhaps this new requirement could be rolled in gradually, until all employees are trained.

The workgroup also recommended that addiction specialists be installed to the state medical boards of medicine, nursing, physician assistants, and dentistry. But what about the Board of Pharmacy? The Board regularly takes up such issues as controlled substance security and diversion. An addiction specialist could add a valuable perspective to the Board. Pharmacists need to learn all they can about the patterns of addicts if they are to combat diversion and other crimes that occur in pharmacies.

Finally, in the call for regulation over opioid prescribing, MPhA encourages a balanced approach. With the increased awareness of the dangers of addiction, legitimate prescriptions can be harder for patients to fill. Recently, a patient contacted MPhA because he had difficulty securing his prescription from the pharmacy, and felt like he was treated “like a criminal” by the pharmacist. While checks and balances on opioid prescriptions are undoubtedly necessary, a little sensitivity by prescribers and dispensers can go a long way for patients.

MPhA supports Gov. Baker’s working group and applauds its recommendations. We know the opioid epidemic has hurt too many families and ravaged too many lives. As medical professionals, pharmacists want to do their part — and we stand ready.