Introduction

Opioids – prescription and illicit – are the main driver of drug overdose deaths in the US. Opioids were involved in 42,249 deaths in 2016, and opioid overdose deaths were five times higher in 2016 than 1999.¹ In recent years, there has been a surge in deaths due to alcohol, drug abuse, and suicide, which some have described as “deaths of despair.”² Among the individuals involved in this trend are persons living with chronic pain and persons living with a substance use disorder.

The current opioid misuse crisis is made more complex for pharmacists because of concerns that many of those abusing prescription opioids, or even heroin, had a prescription medication as their entry point.^3-6 Prior to 1990, heroin addiction began with heroin use, but since that time, heroin addiction has primarily begun with prescription opioids.⁴ An estimated 25 million adult Americans suffer daily from pain and require some analgesic to provide relief.⁷ With liberalization of opioid prescribing practices, many opioid-naive patients were exposed to opioids. One in four patients receiving long-term opioid therapy in a primary care setting struggles with an opioid use disorder.⁸ This set the stage for a generation of patients unexpectedly misusing opioid medications.

Educating patients about their medications has been required of all Medicaid patients and, in many states, all patients (see Important Resources for more information). With controlled medications, patient education and counseling is even more critical. Pharmacists’ cognitive services are increasingly recognized as an essential added clinical value for patients. While the opioid misuse epidemic facing the country requires a multidisciplinary approach, community pharmacists are key players in ensuring patients use these medications safely and, if there are concerns, linking patients to needed care.

Case

CC: “I would like to have this prescription filled.”

Patient: BC is a 39-year-old male (70 in, 79.5 kg) with pain in his back and leg associated with a multi-car accident. He reports that he frequently experiences pain associated with his work as a temporary concrete layer.

HPI: Toward the end of the day, BC approaches your pharmacy counter with a new prescription for Percocet 10/325 #60 with directions to take 1-2 tablets every 4-6 hours as needed for severe pain. The prescription is from Dr. Stevens at the local urgent care facility.

PMH: Depression; anxiety; ADHD; alcohol use disorder; allergic rhinitis

FH:

• Mother (alive) with T2DM, depression, and HTN
• Father (deceased) with history of alcohol use disorder, HTN, cirrhosis

SH:

• Reports tobacco use
• Reports alcohol use
• Living alone and not in the same city as the rest of his family

Medications:

• Sertraline 50 mg daily
• Alprazolam 1 mg TID
• Cetirizine 10 mg daily (OTC)

Allergies: NKDA

SDH: BC has been working but does not have benefits. He had been covered by Medicaid previously, but since moving to this state, he hasn’t applied for it.

Additional context: Since he is a new patient, BC is asked to provide more comprehensive medical information. A new state law requires prospective review of the prescription drug monitoring program (PDMP) before dispensing any opioid prescription. His report is shown below.

Case Questions

1. What do you conclude based on BC’s PDMP review, and why?

Review of the PMP reveals that BC has received five similar prescriptions from three different prescribers in the last 30 days, and has also filled these prescriptions at three different pharmacies, making your pharmacy his fourth location in the past two months.

2. What is BC’s ORT score and what does that score mean?

ORT score

a. Personal and family history of alcohol abuse

b. Personal history depression

c. Age

d. Score = 10

3. Based on the risk factors identified above, what is your assessment of the patient’s risk of opioid misuse?

Based on PMP concerns, and ORT score greater than 8, the patient is at high risk of opioid misuse.

4. What is the risk for unintentional overdose?

High due to multiple opioid prescriptions and concomitant benzodiazepine (Alprazolam) and alcohol use

5. Will you dispense the Percocet for BC? Why or Why not?

No, high risk of opioid misuse, and accidental overdose.

6. What treatment options are recommended for this patient to reduce harm? Who else needs to be included in the treatment plan discussion? What can be done today?

If the Percocet is dispensed, patient should be prescribed naloxone to have on hand given high risk for opioid misuse. A relative, close friend, or other caregiver should be educated about the risk of overdose, the use of naloxone, and options for seeking help. Caregivers/friends/family should be encouraged to store controlled substances securely, and properly dispose of any unused controlled substances to reduce potential harm.

A partial fill should be considered if that is legal in your state.

7. What resources are available for referral? What resources are available for education for the patient?

Brochure on safe opioid use and storage (https://www.cdc.gov/drugoverdose/patients/prevent-misuse.html ). The SAMHSA Behavioral Health Treatment Services Locator is a confidential and anonymous source of information for persons seeking treatment facilities in the United States. Click here and enter your address to find resources near you: https://www.findtreatment.samhsa.gov/, TIP 63, Overdose toolkit, www.prescribetoprevent.org; www.prevent-protect.org; www.naloxonesavessc.org; National Institute on Drug Abuse

8. What are the discussion points that need to be conveyed to the patient and caregivers, including opioid safety and medication use?

Storage and disposal education; signs/symptoms to recognize overdose; use of naloxone; options for local treatment centers for substance misuse

9. What implications and/or opportunities for policy makers exist surrounding this case?

Opportunities to expand or implement best practices for managing the opioid crisis exist. These include expanding the availability and reimbursement for medication assisted treatment (MAT) to treat opioid and heroin addiction with medications like methadone, buprenorphine and naltrexone (Kattan et al. Public health detailing. AJPH, 2016; 106(8):1430-1438.); implementing partial fills of schedule 2 substances; increasing availability of cheaper formulations of naloxone; expanding and implementing medication take-back programs in the pharmacy; implementation of public health harm reduction approaches including syringe service programs; and providing academic detailing services to primary care providers (Kattan et al. Public health detailing. AJPH, 2016; 106(8):1430-1438.).

Author Commentary

The opioid epidemic was accelerated by liberalized opioid prescribing practices in the US. Therefore, as the medication experts in the healthcare system committed to safe use of all medications, pharmacists are the key professionals to ensure safe use of prescription opioids, and evidence-based care for patients with pain. This case highlights the difficult role that pharmacists play when dispensing medications to a patient for whom it may not be appropriate. The hope is that pharmacists will rely upon their professional judgement in evaluating the information available to them — the PDMP record, identified risk factors with the patient, and concomitant disease states and medications – in order to ensure the patient’s safe use of the medication. Although opioids are particularly high-risk medications, the vigilance promoted in this case study has relevance for the role in safe medication use that pharmacists play with other medications that carry significant risk as well.

Facilitator Notes

This case includes multiple parts to address many aspects of public health, including social determinants of health, health policy, and patient care. Given the diversity of pharmacy curricula and the time available to incorporate this type of learning activity, the following is a guide for how to use the case for student learning. Areas of the Pharmacists’ Patient Care Process as well as potential Entrustable Professional Activities are identified throughout the questions and sections above.

This case will reinforce the following four EPA domains for the learners¹⁵:

EPA 1 Patient Care Provider

Collect information to identify a patient’s medication-related problems and health-related needs.

Analyze information to determine the effects of medication therapy, identify medication-related problems, and prioritize health-related needs.

EPA 2 Interprofessional Team Member

Collaborate as a member of an interprofessional team.

EPA 3 Population Health Promoter

Identify patients at risk for prevalent diseases in a population.

Maximize the appropriate use of medications in a population.

EPA 4 Information Master

Educate patients and professional colleagues regarding the appropriate use of medications.

This case will reinforce the following CAPE 2016 Standards^a:

https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf

Standard 2: Essentials for Practice and Care (2.1, 2.3. 2.4)

Standard 3: Approach to Practice and Care (3.1, 3.2, 3.3, 3.5, 3.6)

Potential courses for incorporation:

• Experiential education, including introductory and advanced pharmacy practice experiences
  • Could be used to prepare students for patient care activities and/or review/refresh concepts
  • EPA: Patient care provider, interprofessional team member, information master
• Laboratory sessions-
  • If used as an observed structured clinical exam, consider developing a script for standardized patient use
  • Estimated time ~ 60 minutes
  • EPA: patient care provider, interprofessional team member
• Didactic lectures–
  • If used as a think-pair-share activity within a lecture
    • Estimated time ~ 20 minutes
  • EPA: patient care provider, population health promoter, information master
    • Therapeutics areas
      • Special populations
      • Neurology and/or psychiatry
      • Toxicology
    • Social and administrative courses
    • Public health courses

References:

a. Accreditation Council for Pharmacy Education. Accreditation Standards and Key Elements for the Professional Program in Pharmacy leading to the Doctor of Pharmacy Degree (Standards 2016). https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf. Accessed August 12, 2018.

Patient Approaches and Opportunities

Pharmacists serve as gatekeepers of safe medication use for patients. This includes verifying the appropriateness and safety of the medication being dispensed and educating patients about appropriate use of that medication.⁹ Screening followed by brief interventions (SBIRT) have been shown to be feasible and effective.^10,11 Therefore, pharmacists are well positioned to make essential contributions to the prevention and management of opioid misuse among their patients through screening and patient education.^12-14

Naloxone prescribing, strengthened pharmacist-prescriber communication channels, increased pharmacist access to patient health information (shared EHR), and access to prescription monitoring program data have created opportunities for pharmacists to practice the SBIRT model with opioid users.¹⁶

Derived (with permission) from Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432-42.