Clinical Pearls: Navigating the opioid crisis and the role of clinical pharmacists 

March 26, 2024
By Mojan Fazelipour 

This article is part of a series appearing in Interactions, our biweekly newsletter, written and researched by CSHP's students. We've created this series as a valuable learning activity for pharmacy students undertaking rotations at CSHP. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the students to select hot topics that are of interest and utility to both the students and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca.
 

Background

In the first quarter of 2023, opioid-related hospitalizations averaged 15, up from 13 in 2016 and 12 in 2019, pre-COVID-19. Base on the latest national data in the fall of 2023, the opioid-related deaths rose from 8 per day in 2016 to 21 per day.1 

This upward trend  underlines the increased strain on healthcare systems, marking a rising demand for emergency services and hospitalizations.2 The economic burden of opioid misuse is immense, leading to significant disability-adjusted life-year (DALY) losses .3,4 A multitude of factors drive the ongoing opioid crisis, prominently including the management of pain through opioids for non-cancer conditions. While opioids are widely prescribed for both acute and chronic pain, their application for chronic non-cancer pain remains controversial.5 

The misuse of both prescription opioids and illicit drugs has escalated in recent years, resulting in more deaths than those from suicides and motor vehicle accidents combined.1 This scenario brings to light   the opportunity for hospital pharmacists to play a vital role in combating the overdose epidemic.6 In numerous hospitals, unnecessary or over-prescription of opioids is common, at times even contravening Canadian guidelines.7 Although the importance of proper opioid prescriptions is often overlooked in many hospital settings, evidence indicates that inappropriate practices can lead to adverse effects, including prolonged use after discharge, opioid disorders, and overdoses.8 

In spite of their critical nature, there is a scarcity of research on interventions aimed at improving the safety and adequacy of opioid prescriptions in hospitals. Emerging as a potential solution is the "opioid stewardship" model, which advocates for safer opioid prescriptions. However, studies reveal that only a minority of hospitals have adopted such programs.Pharmacists in healthcare settings, notably hospitals, are at the frontline in addressing in-hospital substance use and mitigating the associated stigma – a primary barrier to opioid stewardship and management programs.Additionally, stigma can lead to patients hiding substance use and experiencing disbelief or disregard from healthcare providers regarding their pain and medication requests.10 The stigma and shame associated with the fear of disclosing drug use can significantly impede appropriate care.11 It is imperative for pharmacists to be advocates for patient-centered care and harm reduction efforts, yet a standardization in pharmacy practices concerning opioid stewardship is lacking across jurisdictions.By engaging in medication reviews and reconciliations, managing  pain clinics, and providing dedicated education on pain management and medication safety, pharmacists play a pivotal role in opioid stewardship. Pharmacists guide treatment referrals, conduct patient screenings, assess and optimize medication therapies, educate both patients and healthcare professionals, and influence policy and guideline development, thereby becoming an integral part of the solution to the opioid crisis.78,9,12

The multifaceted role of clinical pharmacists in opioid stewardship

Clinical pharmacists, with their profound expertise in medication management, are uniquely positioned to advocate for and implement effective opioid stewardship.8,14,15,17 Their strategic role is emphasized as they tackle barriers and facilitate access to medications for Opioid Use Disorder (OUD), marking them as essential players in addressing the opioid epidemic.

In their capacity as opioid stewards, clinical pharmacists take a proactive approach to identify and rectify misuse and suboptimal opioid prescribing. Their rigorous regimen assessments provide insightful recommendations, identifying potential therapeutic pitfalls and adding another layer of safety to pain management.15 The development of patient-centered care plans and collaboration with physicians can optimize the provision of safe and effective pain management strategies. Moreover, clinical pharmacists’ skillset to perform substance use disorder screenings and assessment, coupled with their ability to provide referrals and inter-professional collaborations, adds another layer to their multifaceted role in opioid stewardship.14 Their integration into primary care settings further amplifies clinical outcomes, especially in chronic disease management, culminating in a comprehensive approach to the opioid crisis.18

Empirical evidence consistently highlights the influential roles clinical pharmacists play in opioid stewardship, spanning domains such as education, medication therapy adjustments, pain care plan formulation, policy development, and risk assessments.8,14
By championing these roles, clinical pharmacists stand as allies in the battle against the opioid epidemic. 

Screening and therapeutic optimization

Addressing co-morbid conditions (i.e. psychiatric comorbidities) within pain management programs is crucial for a comprehensive approach to effective pain management.14 This focus on opioid stewardship accentuates the multifaceted roles of pharmacists in ensuring safe opioid use, de-prescribing, and education.14,19 For example, the development of the MORE tool reinforces this need for a multifaceted approach.16 Amidst the opioid crisis, new hospital regulations have emerged, placing an increased emphasis on opioid stewardship by clinical pharmacists and underscoring the necessity for actions that enhance care, safety, and the monitoring roles of pharmacists.20
 

Academic detailing and patient education 

Equipped with public health training, emergency preparedness, and OUD management expertise, pharmacists are uniquely positioned to lead research and educational initiatives addressing the opioid crisis. Their expanded roles in chronic pain management, equipped with interdisciplinary collaboration, promise to relieve pressures on physicians and strengthen guideline-concordant opioid care.17 However, as these roles expand, challenges arise. It's imperative to clearly define their scopes of practice and bolster awareness among primary care providers about these expanded capacities.17 Among the strategic tools employed, academic detailing shines as a potent educational outreach method, proven to refine prescribing practices and curb inappropriate opioid use. Such initiatives have catalyzed improvements in knowledge, attitudes, and prescribing behaviors across healthcare professionals, resulting in superior patient outcomes and a downturn in opioid-related harms and hospitalizations.8,21 The successful integration of such education-centric initiatives reiterates the significant influence of pharmacists in promoting safe opioid usage.It reinforces the assertion that education remains a cornerstone of holistic opioid stewardship approaches.

Pharmacists as advocates in policy and guideline developments 

Programs centered on opioid and pain stewardship are instrumental in identifying opportunities to enhance adherence to best practice guidelines. This encompasses standardizing opioid dosing strategies, prescribing multimodal and opioid-sparing regimens, recognizing substance misuse, reviewing patient histories, acknowledging pain as a disease state, and increasing the dispensing of opioid reversal medications.22 Pharmacists can play a pivotal role in opioid stewardship, actively participating in policy and best practice guideline developments. Indeed, clinical pharmacists are instrumental in operationalizing opioid stewardship guidelines within general practice, guiding reviews for long-term opioid patients, and aiding the de-prescribing journey.15 Moreover, they offer education to patients and healthcare peers on opioid safety and usage, oversee adverse effect monitoring and drug interactions, and work in tandem with healthcare teams to guarantee coordinated care.15 Particularly within interdisciplinary teams, clinical pharmacists contribute significantly by fostering a collective, inter-professional approach to care, influencing opioid stewardship at the initial stages of prescription and playing a key role in both policy creation and execution.7,8,23,24 

Organizations such as the Centre for Disease Control (CDC) and the American Society of Health-System Pharmacists recognize pharmacists for their unique skills in substance abuse prevention, patient education, and integrated pain management approaches, highlighting their indispensable role in executing opioid and pain stewardship programs effectively.22 Effective implementation and uptake of opioid stewardship programs are essential for ensuring consistent best practices in pain treatment and reducing opioid use and availability. Further research into pharmacist-driven opioid stewardship programs is encouraged to continue enhancing their impact and effectiveness.22

Collaborative care 

Evidence underscores the effectiveness of an inter-professional, team-based approach in enhancing clinical outcomes in chronic disease management, spotlighting the critical role pharmacists play in collaboratively addressing the opioid crisis with other healthcare professionals.25 Recognized as medication experts on interprofessional healthcare teams, pharmacists find their roles continually expanding and integrating more closely with the broader healthcare system. This emphasizes the importance of collaborative and interdisciplinary approaches.25 In public health emergencies, clinical pharmacists can collaborate with authorities, manage medical/biological waste, provide quality counseling and medication management for at-risk groups, and prevent opioid misuse through education and pain care plan development.14 Moreover, fostering collaboration and open communication between physicians and pharmacists has been proven to yield positive outcomes, improving opioid decision-making and indicating a need for ongoing research to enhance the quality of such communication.14,24

Pharmacists are progressively positioning themselves at the forefront of addressing public health crises, advocating for safe opioid use policies, and drawing from their medication expertise to contribute substantively to policy development. 19 Recognizing the expanding scope of their practice, there's a pressing need to amend regulations to maximize the potential contributions of pharmacists in this field. At the core of their approach is the intent to challenge stigma, advocate for patient-centered care, and ensure the safe use of opioids—actions which undoubtedly reduce societal costs and impacts associated with misuse.19 As pillars in public health, pharmacists are expanding their preventive services in primary care settings and strategizing to accomplish these roles effectively.26 Their proactive stance has addressed issues ranging from low immunization rates to adverse drug event management, and optimizing therapeutic strategies, underlining their versatility and commitment in combating public health issues.27

In response to the public health emergency presented by the opioid crisis hospital and community pharmacists are leading the way in harm reduction strategies, and playing a pivotal role in reducing the stigma surrounding opioid addiction by addressing deeply entrenched attitudes and beliefs about opioid use through knowledge translation. Notable strategies include conduction of medication reviews, academic detailing and education, opioid use risk assessment and pain management, and collaboration with the interdisciplinary teams as the medication experts. These measures, along with the community-based strategies (e.g., Safe Injection Sites, Drug checking with fentanyl test strips, and Naloxone distribution and training) not only shift the perception of substance use away from criminality and moral judgment but also underscore the importance of compassionate care. Validating the efficacy and suitability of such interventions, especially in clinical pharmacy settings, is essential to ensure sustained impact and success in combating this crisis.12

Opioid stewardship in hospitals 

The ongoing opioid crisis has precipitated a significant increase in hospital-related adverse events, with opioids now ranking as the second leading cause of such incidents.13 In response, a cross-sectional, descriptive survey, funded by the American Society of Health-System Pharmacists (ASHP) Foundation, was conducted to assess best practices in opioid use and determine the prevalence of opioid stewardship programs across hospitals.13 Of the 133 hospitals surveyed, a mere 23% had established an opioid stewardship program, and only 14% implemented proactive screening for patients at high risk of opioid-related adverse events (ORAEs). The survey revealed variability in screening criteria and formulary restrictions, contingent on specific opioid types. Notably, 45% of the hospitals had imposed restrictions on patient-controlled analgesia. Although a majority of hospitals (90%) maintained pain management services, palliative care offering pain management was available in only 67% of them. These findings underscore a pressing need for more hospitals to adopt opioid stewardship programs, integrate proactive ORAE screening, and employ best practices to ensure safe opioid use.13

Hospital pharmacists have the opportunity to collaborate with community pharmacists to address opioid overdoses and related harm. Initiatives that uphold a patient-centered and individualized approach to opioid use disorder recovery are crucial. These efforts should also aim to shift perceptions of opioid use away from criminality and moral judgment, fostering an environment of compassionate care and challenging the stigma associated with substance use.11

Examples of hospital pharmacist-led initiatives in opioid stewardship

Pharmacists play an integral role in ensuring the safe and appropriate use of opioids, involving not only proper prescribing, dispensing, and education but also participating in ongoing training within pain management programs. Their essential responsibilities encompass minimizing opioid misuse and implementing effective opioid stewardship strategies, including de-prescribing practices, to further protect patient health.

To address this, a study assessed a pharmacist-led initiative in primary care between November 2017 and May 2018.14 The initiative involved pharmacists in identifying at-risk patients, formulating care plans, and liaising with physicians. Results showed a substantial increase in the number of patients with pharmacist-created care plans and a marked rise in opioid tapering.14 Furthermore, the intervention led to an 11% decrease in daily opioid doses and an 8% drop in benzodiazepine doses. This underscores the potential of clinical pharmacists in mitigating opioid-related risks and emphasizes their role as opioid stewards.

Another notable example of a pharmacist-led initiative is a hospital-based opioid stewardship program that was initiated in January 2020 by The British Columbia Centre on Substance Use and St Paul’s Hospital in Vancouver, BC.Comprising of a diverse team of healthcare professionals, including physicians, pharmacists, and researchers, the program aimed to refine opioid prescription practices. The initiative involved an advisory committee and incorporated patients as key stakeholders, emphasizing the importance of "Audit and Feedback" in identifying and assessing patients exposed to prescription opioids. The program, which also incorporated a consultation service and multiple educational initiatives, screened over 3,000 patients in its inaugural year and achieved a 93% intervention acceptance rate. Overall, a total of 576 patient encounters resulted in 1,599 interventions, with the primary recommendations including adjusting opioid dosages, adding non-opioid analgesics, and providing patient education on opioid use.The success of this program, defined by the acceptance rate of the recommended interventions, at St Paul’s highlights the transformative role pharmacists can play in the broader health system, although the unique demographic of the hospital may influence the wider applicability of such initiatives.  

Additionally, a study was conducted as part of a mixed-methods pharmacist pilot initiative, aiming to enhance opioid management in general practice through a pharmacist-led program.15 The initiative, supported by organizational policy, leadership, and education, facilitated a person-centered approach to opioid review and weaning. GPs reported increased accountability and reflection regarding opioid prescribing, and feedback on successful de-prescribing outcomes further reinforced commitment to the program. Despite initial challenges in patient communication, the learnings from this initiative were applied to other high-risk medicines, showcasing the practicality and effectiveness of such pharmacist-led approaches in improving opioid management.15 

In Canada, amidst the escalating opioid overdose crisis, the development of the MORE tool (Medication review, Optimization, Reassessment, and Education) emerged as a strategic response to fortify opioid prescribing practices within hospital settings.16 Designed through rigorous literature reviews and deliberative pharmacist focus groups, this tool was subsequently piloted among clinical pharmacists, highlighting their instrumental role in opioid stewardship. The clinical tool was tested by pharmacists on general medical and surgical wards of the St. Paul’s hospital in Vancouver, BC, over a 3-week period in February 2018. Clinical pharmacists employed the tool for patient assessment when an opioid was combined with a benzodiazepine, a regular opioid medication was ordered, or opioids were prescribed as-needed for over 5 days. These criteria aimed to optimize the pharmacists’ impact without adding excessive work to their existing duties. This innovative tool demonstrated notable efficacy in discerning pertinent risk factors and suggesting potential interventions for patients exhibiting non-malignant pain symptoms within general medical and surgical wards.16 The study's findings underscore the necessity for further refinement in the tool's structural design and content presentation, a step deemed crucial for enhancing its overall user experience and fostering more widespread acceptance within the clinical pharmacist community.16

Future directions 

Moving forward, the expanding role of pharmacists in public health—including pharmacist-led opioid agonist treatment prescribing and opioid stewardship programs—presents a promising avenue for more integrated and holistic approaches to combating opioid harm and other public health challenges. There is a palpable need for additional research in design, implementation, and evaluation of clinical pharmacist-led opioid stewardship programs. This underscores the necessity for continued innovation, research, and collaboration to maximize the impact and reach of pharmacist-led initiatives.

References

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