The opioid crisis is making headlines across America. According to CDC, between 1999 and 2010, pharmacies, hospitals, and physicians’ offices bought four times the amount of prescription opioids. The iatrogenic misuse of opioids has led to different approaches by health care providers to address the opioid epidemic. As a student pharmacist and future health professional, I recognize that I will play an important role in helping to stop the opioid crisis. I believe the pharmacists’ approach to the opioid epidemic is unique because of practitioners’ expertise in medication.
As a future medication expert, I hope to apply my knowledge for the appropriate use of medications, and work collaboratively with physicians, dentists, and physical therapists to end the opioid epidemic
Pain management
Together, pharmacists and physicians can manage acute pain. For instance, after surgery, physicians may prescribe opioids for patients who have mild to severe pain. Although these prescription opioids are for the short-term management of their acute pain, patients may use these long-term.1 Because of pharmacists’ expertise in proper use of medication and its adverse effects, they have an important role in pain management. When physicians prescribe opioids, a pharmacist-led opioid exit plan (OEP) can assist physicians in choosing an optimal analgesic agent while preserving safety in patients who are opioid tolerant or naive. In an OEP, pharmacists can provide patient-specific information to find which opioid may be the most suitable, including which dosage strength, form, and duration for the regimen.
Performing a medication reconciliation and interview prior to admission, pharmacists can take and apply this information to develop a personalized pain management regimen. Working collaboratively, pharmacists and physicians can discuss this with the surgical team to finalize the patient’s regimen post-surgery and at discharge. This plan is multi-modal, considering the patient’s needs from non-opioid analgesics to PRN opioids. Pharmacists can be included at every step to monitor patients’ pain, including providing recommendations and modifications to optimize patient’s pain therapy to the physician during rounds. By discharge, the physician can consult the pharmacist to taper the patient down from opioids.
This opioid discontinuation plan includes all the collected patient-specific information and counseling pertaining to the proper duration, safe use, withdrawal symptoms, adverse effects, disposal, and a scheduled follow-up appointment. As noted in the March/April 2017 JAPhA Supplement article “Opioid exit plan: A pharmacist’s role in managing acute postoperative pain,” this collaboration and inclusion of pharmacists minimizes opioid overuse by tailoring a tapering plan to treat the patients’ pain.
A partnership with dentists?
In addition to minimizing opioid overuse with physicians, pharmacists can do so with other prescribers. For health care providers, CDC published a guideline for chronic pain in 2016; however, it states that acute care settings and specialists such as dentists and emergency medicine physicians are not the focus of these guidelines. Dentists frequently perform one-time surgery.
The American Dental Association (ADA) has called upon the federal government to create additional guidelines for all opioid prescribers, including dentists. To assist dentists, ADA has released a “Statement on the Use of Opioids in the Treatment of Dental Pain,” which recommends non-steroidal anti-inflammatory analgesics as first-line therapy for acute pain management. Although ADA has made this recommendation, dentists are among the top five opioid prescribers for patients of all ages.2 ADA also encourages “Dentists [to] consider coordination with other treating doctors, including pain specialists when prescribing opioids for management of chronic orofacial pain.” While dentists may have medical doctors in mind as pain specialists, they should consider PharmDs as well, due to pharmacists’ special knowledge of pain medications.
With a unique skill set and knowledge of medications, pharmacists can coordinate with dentists to form an appropriate pain regimen. Pharmacist integration can minimize the over prescription of opioids for their patients to reduce opioid misuse and abuse. Dentists typically practice as independent practitioners. However, there can be a partial or full integration between these two health professions. A dentist may consult the pharmacist for recommendations, if desired, during a partial integration. Moreover, a full integration requires the dentist to consult the pharmacist prior to ordering the medications. These consultations may reduce medication errors, where they discuss patients’ allergies, drug interactions, non-opioid alternatives, and dosing.
Despite these benefits and mutual goals to solve the opioid crisis, pharmacists and dentists often do not work together, as indicated in the March/April 2017 JAPhA Supplement article “The impact of pharmacy services on opioid prescribing in dental practice.” While pharmacists typically do not share the same practice site, dentists can have collaborative practice agreements with multiple pharmacies, or multiple dental practices and pharmacies can form a preferred network. Dentists can refer patients to pharmacies and vice versa due to these pooled resources in addition to having access to therapeutic recommendations. As prescribers, dentists have an important role in curbing opioid misuse, and they can draw upon pharmacists’ expertise through examining non-opioid analgesic options and educating their patients.3
Including physical therapists
CDC’s Guideline for Prescribing Opioids for Chronic Pain lists non-pharmacologic therapy and non-opioid therapy as options to be used prior to considering opioids for chronic pain. Opioids should be used if the clinician anticipates the benefits pertaining to pain outweighs the risks. However, as the guideline indicates, this should be supplemented with the necessary nonpharmacological and non-opioid therapy. The pharmacist can recommend a multi-modal non-opioid pain medication regimen, factoring in the adverse effects and the physical therapist’s exercise therapy to the physician.
For example, in chronic pain conditions such as knee and hip osteoarthritis, exercise therapy can reduce pain and improve physical function, lasting for 2 to 6 months immediately after treatment.4,5 The patients’ opioid therapy can be tapered down during exercise therapy, so they may initially experience pain. Physical therapists are essential during exercise therapy because they can provide additional support. By educating patients on their pain, instructing patients on their posture awareness and body mechanics, conducting manual therapy, strength training, flexibility exercises, and determining the need for ice, heat, or electrical stimulation, physical therapists have a large responsibility and role when managing patients’ pain.6,7 Physical therapists have patient-centered goals which often include improving mobility and motion, an alternative to surgery, thus reducing a patient’s need for medication.8
As detailed in the September 2017 Pharmacy Today article “Pharmacists are partners with physical therapists in non-opioid pain management,” by including physical therapists in collaboration with pharmacists and physicians in the pain management team, they can minimize opioid use while improving function and reducing pain.
Complex solution required
There is no single prescriber and no single force that is driving the opioid epidemic. Because this opioid crisis is so multi-faceted, it warrants a complex solution. Patients use multiple health services; therefore, leaving health care practitioners in isolated silos is not a viable solution. While they each have their own individual role, they each have mutual interests to provide safe and effective treatments for patients. They have a responsibility to collaborate to prevent opioid misuse and abuse and achieve their goal in ending the opioid epidemic.
According to CDC, pharmacists are “on the frontlines” of the opioid epidemic. They are the last health professional that stand between the patient, opioids, and possible addiction. As medication experts, pharmacists can partner and provide therapeutic interventions to prescribers, and together, create a patient-specific pain regimen that minimizes opioid use, such as physical therapy.
Melissa Nguyen is a third-year PharmD candidate at the University of the Sciences Philadelphia College of Pharmacy.
References
- Alam A. Long-term analgesic use after low-risk surgery. Archives of Internal Medicine. 2012;172(5):425.
- Volkow ND. Characteristics of opioid prescriptions in 2009. JAMA. 2011;305(13):1299–1300.
- Valle-Oseguera C, Boyce EG. Dentists and pharmacists: paradigm shifts and interprofessional collaborative practice models. J Calif Dent Assoc. 2015;43(10):591-595.
- Fransen M, McConnell S, Harmer AR, Van Der Esch M, Simic M, Bennel KL. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD004376.
- Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014 Apr 22;(4):CD007912.
- Benefits of a Physical Therapist [Internet]. moveforwardpt. American Physical Therapy Association; 2016. Available from: http://www.moveforwardpt.com/ForHealthCareProfessionals/Detail/benefits…. Accessed November 29, 2017.
- Physical Therapist’s Guide to Pain [Internet]. moveforwardpt. American Physical Therapy Association; 2016]. Available from: http://www.moveforwardpt.com/
- SymptomsConditionsDetail.aspx?cid=e6dabed7-c6d5-4362-8260-9ce807427619#.U6TMB0DIJbV. Accessed November 29, 2017.
- Chronic Pain Syndromes [Internet]. moveforwardpt. American Physical Therapy Association; 2016. Available from: http://www.moveforwardpt.com/Symptoms
- ConditionsDetail.aspx?cid=dd79c11d-9ac3-42cc-bcc2-2edd5079a57a#.U6TMEkDIJbV. Accessed November 29, 2017.