Let’s begin in the unlikeliest of places. Even in small-town Iowa, prescription drug abuse is a very real problem, according to Matt Osterhaus, BSPharm, FASCP, FAPhA, co-owner of the Osterhaus Pharmacy in Maquoketa, IA, and APhA’s Immediate Past President.
His wife, Marilyn Osterhaus, BSPharm, works with him in their pharmacy and serves on their county’s prevention coalition. She shared with him a survey of area high school juniors that found 6% have used other people’s prescription medications and 5% have overutilized their own medications.
“This survey looks at it from the youth standpoint, but I think it carries up from there,” he said. The best way to combat prescription drug abuse, he continued, is for everybody who has a stake in it “to be involved and communicate what role each of us can play to help get the problem under control.”
Pharmacists can start by understanding their patients at the ground level. In his practice, “every patient who comes in talks to a pharmacist,” Osterhaus said. “When we’re dealing with pain—especially chronic pain—[we get] an understanding of what the patient’s goal of their pain therapy is and if they’ve had that discussion with their physician.”
Where Osterhaus practices, physicians understand that pharmacists are part of the patient’s care team and have a role to play. If one of his pharmacists is working with a mental health clinic for a patient with legitimate pain needs, often the clinic doesn’t know the patient’s pain regimen; the potential for interactions with psych meds is enormous. Pharmacists can help “bridge that communication gap between the specialists and the family practice physician” about each patient’s medications, including OTCs and supplements.
His pharmacy also provides adherence packaging. “For someone who’s had a problem with substance abuse, when you are packaging their medications for them in a 30-day med bubble pack, it’s very clear when they come in and say they’re out of medication, and it’s the 23rd of the month,” Osterhaus said. “I feel adherence packaging helps the patient understand we’re here to help them, but it’s also a very clear monitoring tool that we can talk to our physician partners with if there’s somebody they think would benefit from adherence packaging”—another tool in the toolbox.
The community pharmacies in his county all stock lock boxes and bags for patients who may be older or in a household where unauthorized access could be possible. Some patients decide to purchase one. Others see and ask about them. This presents an opportunity to provide education on the spot that if they are concerned, they should think seriously about safeguarding their own medications at home.
From regular use of the state prescription drug monitoring program (PDMP) to working with law enforcement on disposal of controlled substances, pharmacists can collaborate broadly in their community to help with the problem. “A pharmacist volunteering to be on the county coalition is a big asset,” Osterhaus said.
In fact, many examples exist of pharmacists having the most impact on prescription drug abuse in the larger context of their community. Nathan Painter, PharmD, CDE, an associate clinical professor at the University of California, San Diego’s (UCSD) Skaggs School of Pharmacy and Pharmaceutical Sciences, was selected by APhA to receive the 2015 Generation Rx Award of Excellence. Generation Rx is a national program to increase public awareness of prescription drug abuse and encourages community members, including health care providers, to actively work to prevent abuse. The program is developed and funded in collaboration with Ohio State University College of Pharmacy, the Cardinal Health Foundation, and the APhA Foundation. The APhA Academy of Student Pharmacists (APhA–ASP) makes the program available to chapters at all colleges and schools of pharmacy.
“You can sit around and talk about the problem all day long, but unless you have solutions, which are going to be different in every community, nothing is going to get done and the problem’s not going to go away,” Painter said. “Eventually, policies have to change.”
This article on potential community solutions to the confluence of issues around prescription drug abuse is the third in Pharmacy Today’s “Challenges of Pain” series. The series shows how pharmacists and their patients with legitimate pain needs are affected by efforts to reduce prescription drug abuse. The first article, appearing in October’s Today, focused on the impact of federal and state government responses, including drug disposal and PDMPs. Last month’s article explored the law enforcement side of the crisis, including pharmacy crime and DEA enforcement in health care facilities such as pharmacies. The series is ongoing.
Pharmacists bring value to pain management and appropriate use of opioids. Physicians and pharmacists can collaborate in a team-based care model to promote appropriate opioid use and to work toward prescription drug abuse prevention.
Yet “a lot of times, the physicians I work with complain about the pharmacist just flat out saying, ‘No,’ or feeling like they’re asking for improper information about their patients, such as diagnosis, or telling the physician that they should be ordering certain tests,” Painter said. “There’s that fine line of being involved in patient care and trying to be an advocate for the patient, and just trying to cross ‘t’s and dot ‘i’s.” Pharmacists’ challenge is to show they’re on the same team with aligned interests to provide the best patient care.
At the 2016 APhA Annual Meeting & Exposition in Baltimore on March 4–7, the education session Teaming Up for Safer Pain Management Strategies is slated for Sunday, March 6, from 1:00 pm to 3:00 pm. The scheduled speakers are Jeffrey Fudin, PharmD, FCCP, FASHP, a Diplomate to the American Academy of Pain Management (AAPM), clinical pharmacy specialist at Stratton VA Medical Center, and Lynn Webster, MD, FACPM, FASAM, vice president of scientific affairs at PRA Health Sciences and former president of AAPM.
“I have always felt that pharmacists were a part of my team,” Webster said. “As members of the team, we have to trust each other. It is essential that lines of communication are open and invited.” Webster relies on pharmacists to check his prescriptions for errors and to help educate patients about risks. Pharmacists often see behaviors that prescribers do not; feedback can be helpful in achieving successful outcomes.
“Pharmacists are the last level of protection in some ways. After the drug is dispensed, the drug can be used as directed, inappropriately used, or diverted,” Webster said. Pharmacists can advise patients on drug–drug interactions and food effects. They can consider the condition of the patient and ensure the dose is appropriate. When a patient is switched from one opioid to another, pharmacists can be sure the dose of the new opioid is reasonable and safe; particularly when switching to methadone, a pharmacist can save a life by not dispensing a lethal dose to a person who is methadone naive.
“A strong collaboration between prescribing clinicians and dispensing pharmacists could go a very long way to ensuring patient safety,” said Fudin. “Pharmacists often see an entire family, and see when multiple family members are receiving various controlled substances.” In the wrong hands or in a family environment where substance abuse is prevalent, “there needs to be some counseling,” he said. Also, natural food and vitamin supplements could affect the metabolism of some drugs.
If a patient asks for a cough medicine because of an upper respiratory tract infection before visiting a physician, the pharmacist selecting the cough suppressant should take the prescribed medications into account, and should counsel the patient that labored respiration caused by a cold or influenza could elevate risk for opioid-induced respiratory depression, Fudin added.
Pharmacists must be astute in monitoring the situation, he said. Pharmacists should check PDMPs whether or not their state requires it. They should monitor early refill requests and behaviors. “Since the pharmacist is usually not writing the prescription, a patient with chronic pain has less to gain by walking with a painful gait [into the pharmacy] compared to when walking into an office visit,” Fudin said. “Therefore, the pharmacist may see the patient in a very different light than a prescribing physician.” Pharmacists might observe unusual behaviors such as friends and several family members all coming in with prescriptions for similar controlled substances in large quantities, or people willing to pay large cash sums for controlled substances, high doses, and very large quantities. “These are the sorts of behaviors that should be shared with the prescriber,” he said.
Painter is an active member of the San Diego County Prescription Drug Abuse Task Force and chairs its Pharmacy Committee. Founded in 2008 as the Oxy Task Force, today the task force is “a great combination of health professionals, law enforcement, prevention specialists, treatment specialists, and educators who come together and work on the overall goals of the task force, which are to reduce access, to improve prescribing, and to—overall—prevent people from abusing the prescription drugs in the first place.”
Because access is a major piece of the puzzle, the task force is working on proper drug disposal, including take-back days and year-round drop-off boxes at police stations, Painter said. The task force also encourages pharmacists to run the CURES report (pharmacists and prescribers in California must be registered for CURES, California’s PDMP, by July 1, 2016); to look up the red flags from the National Association of Boards of Pharmacy Coalition and the state board of pharmacy to promote corresponding responsibility; and to tell patients about proper drug disposal.
Sarah T. Melton, PharmD, BCPP, BCACP, CGP, FASCP, is an associate professor of pharmacy practice at East Tennessee State University’s (ETSU) Gatton College of Pharmacy and the clinical pharmacist at the Johnson City Community Health Center in Johnson City, TN, and at Highpower PC in Lebanon, VA. She chairs One Care of Southwest Virginia Inc., a coalition that has a vision of being a model for achieving significant reductions in substance abuse and related social, economic, and health factors by building and supporting community partnerships.
Melton highlighted a few strategies involving pharmacists in her part of the country. One is Virginia’s naloxone program, known as Project REVIVE! “Pharmacists are now being trained across the Commonwealth. We have a standing order protocol in place where all pharmacists can be trained [and] will be able to collaborate with a prescriber,” screen patients for whom naloxone would be appropriate, execute the prescription, and send the patient home with naloxone to decrease the risk of overdose in those who are at high risk.
Another is pharmacy participation in accepting controlled substances for disposal. “We’re trying to encourage the pharmacists in our region to actually do that” and are starting to see some participation, Melton said. Many pharmacists come out to the DEA take-back days to work with student pharmacists to receive the medications with law enforcement and dispose of them. In addition, the Virginia Pharmacists Association provided continuing education on prescription drug abuse at no charge to pharmacists who then went back to their counties and were agents of change as a result of the training.
“The more pharmacists who get involved in community coalitions, the better,” Melton said. Pharmacists who are interested in these issues and want to make a difference should find out where these coalitions are. “They’re always looking for health care providers to come join them,” she said.
Painter suggested contacting the local health department, law enforcement, or medical or pharmacy societies to find a coalition.
Painter is a coadvisor for the APhA/California Pharmacists Association’s ASP chapter at UCSD and is the advisor for the Generation Rx group. Across the United States, Generation Rx raises awareness on prescription drug abuse so that targeted populations—of all ages—use these medications responsibly.
“In general, public education just helps raise awareness. Like with any condition, disease, or topic, people don’t necessarily know there’s a problem unless somebody tells them that there’s a problem,” Painter said. “Making sure that parents know that this is an issue with their kids. Helping people just in general to be more aware about how to dispose of their medications to keep them out of anybody’s hands whom it doesn’t belong to.”
Melton is advisor to the Generation Rx group at ETSU’s APhA–ASP chapter that was the National Winner in 2015 for its work with naloxone, including developing a naloxone tool kit. Now the group is working with the five other schools of pharmacy in Tennessee. “We really use Generation Rx to make agents of change,” she said. “To join with us, and take our message out, and teach others … about the dangers of prescription drug abuse and overdose death.”
Since 2014, the House Energy & Commerce Subcommittee on Oversight and Investigations has held a series of hearings on opioid abuse. (Melton testified.) On September 1, 2015, APhA submitted comments to the subcommittee that recommended ways to help curb the illicit use of controlled substances.
These recommendations included making naloxone more widely available; better collaboration and communications among pharmacists and physicians to identify potential substance abuse problems, including an integrated, nationwide PDMP; comprehensive efforts to educate health professionals, including prescribers and pharmacists, about prescription drug abuse and mechanisms to prevent it; increased patient education on prescription drug abuse awareness; and increasing public access to prescription drug take-back opportunities.
Before 2016, APhA plans to develop and make available to the public an online resource center for opioid use, abuse, and misuse. To help inform pharmacists and pharmacy technicians, the resource center will include relevant news, research developments, and industry publications and list APhA’s continuing education offerings.
“The opioid abuse problem in America is everyone’s problem, as I doubt there’s a family that hasn’t been touched,” said APhA Executive Vice President and CEO Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA. “Solutions lie in our collaboration if we have any hope of eliminating the scourge while ensuring those who have legitimate pain issues receive effective treatment.”