{"id":100,"date":"2019-09-30T13:39:24","date_gmt":"2019-09-30T13:39:24","guid":{"rendered":"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/chapter\/safe-opioid-use-in-the-community-setting-reverse-the-curse\/"},"modified":"2019-12-30T19:29:08","modified_gmt":"2019-12-30T19:29:08","slug":"safe-opioid-use-in-the-community-setting-reverse-the-curse","status":"publish","type":"chapter","link":"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/chapter\/safe-opioid-use-in-the-community-setting-reverse-the-curse\/","title":{"raw":"Safe opioid use in the community setting: reverse the curse?","rendered":"Safe opioid use in the community setting: reverse the curse?"},"content":{"raw":"<h2>Kayce M. Shealy, PharmD, BCPS, BCACP, CDE<span lang=\"en\" xml:lang=\"en\">\u00a0<\/span><\/h2>\r\n<h2>Mark A. Strand, PhD, CPH<\/h2>\r\n<div class=\"textbox key-takeaways\">\r\n<h3 class=\"import-Normal\"><strong class=\"import-Heading2Char\">Topic Area<\/strong><\/h3>\r\n<p class=\"import-Normal\" style=\"text-align: center\"><span lang=\"en\" xml:lang=\"en\">Opioid safety<\/span><\/p>\r\n\r\n<\/div>\r\n<div class=\"safe-opioid-use-in-the-community-setting:-reverse-the-curse?\">\r\n<div class=\"textbox learning-objectives\">\r\n<h3>Learning Objectives<\/h3>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">At the end of this case, students will be able to:<\/span><\/p>\r\n\r\n<ul>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Describe the epidemiology of the opioid crisis in the 21<\/span><sup>st<\/sup><span lang=\"en\" xml:lang=\"en\"> century<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Identify patients at risk of opioid misuse when provided patient information<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Identify harm reduction and safety solutions for opioid users<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Discuss the opportunities for policy, legislative, or regulatory changes that will improve the pharmacist\u2019s ability to optimize the public\u2019s health regarding opioid use<\/span><\/li>\r\n<\/ul>\r\n<\/div>\r\n<h2 class=\"import-Normal\"><strong class=\"import-Heading2Char\">Introduction<\/strong><\/h2>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Opioids \u2013 prescription and illicit \u2013 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.<\/span><a href=\"#h1\"><sup>1<\/sup><\/a><span lang=\"en\" xml:lang=\"en\"> 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.\"<\/span><a href=\"#h2\"><sup>2<\/sup><\/a><span lang=\"en\" xml:lang=\"en\"> Among the individuals involved in this trend are persons living with chronic pain and persons living with a substance use disorder.<\/span><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">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.<\/span><sup><a href=\"#h3\">3<\/a><a href=\"#h6\">-6<\/a><\/sup><span lang=\"en\" xml:lang=\"en\"> Prior to 1990, heroin addiction began with heroin use, but since that time, heroin addiction has primarily begun with prescription opioids.<\/span><a href=\"#h4\"><sup>4<\/sup><\/a><span lang=\"en\" xml:lang=\"en\"> An estimated 25 million adult Americans suffer daily from pain and require some analgesic to provide relief.<\/span><a href=\"#h7\"><sup>7<\/sup><\/a><span lang=\"en\" xml:lang=\"en\"> 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.<\/span><a href=\"#h8\"><sup>8<\/sup><\/a> <span lang=\"en\" xml:lang=\"en\">This set the stage for a generation of patients unexpectedly misusing opioid medications.<\/span><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Educating patients about their medications has been required of all Medicaid patients and, in many states, all patients (see <\/span>Important Resources<span lang=\"en\" xml:lang=\"en\"> for more information). With controlled medications, patient education and counseling is even more critical. Pharmacists\u2019 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.<\/span><\/p>\r\n\r\n<h2 class=\"import-Normal\"><strong class=\"import-Heading2Char\">Case<\/strong><\/h2>\r\n<div class=\"textbox exercises\">\r\n<h3>Scenario<\/h3>\r\n<span lang=\"en\" xml:lang=\"en\">You are a floater pharmacist working at a new pharmacy on the weekend in the outskirts of an urban area.<\/span>\r\n\r\n<\/div>\r\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">CC<\/span><\/span><span lang=\"en\" xml:lang=\"en\">: \u201cI would like to have this prescription filled.\u201d<\/span><\/p>\r\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">Patient<\/span><\/span><span lang=\"en\" xml:lang=\"en\">: 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.<\/span><\/p>\r\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">HPI<\/span><\/span><span lang=\"en\" xml:lang=\"en\"><span style=\"text-decoration: underline\">:<\/span> 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.<\/span><\/p>\r\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">PMH<\/span><\/span><span lang=\"en\" xml:lang=\"en\"><span style=\"text-decoration: underline\">:<\/span> Depression; anxiety; ADHD; alcohol use disorder; allergic rhinitis<\/span><\/p>\r\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">FH<\/span><span lang=\"en\" xml:lang=\"en\">: <\/span><\/span><\/p>\r\n\r\n<ul>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Mother (alive) with <\/span><span lang=\"en\" xml:lang=\"en\">T2DM, depression, and HTN<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">F<\/span><span lang=\"en\" xml:lang=\"en\">ather (deceased) with history of alcohol use disorder, HTN, cirrhosis<\/span><\/li>\r\n<\/ul>\r\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">SH<\/span><span lang=\"en\" xml:lang=\"en\">: <\/span><\/span><\/p>\r\n\r\n<ul>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Reports tobacco use<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Reports alcohol use<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Living alone and not in the same city as the rest of his family<\/span><\/li>\r\n<\/ul>\r\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">Medications<\/span><span lang=\"en\" xml:lang=\"en\">: <\/span><\/span><\/p>\r\n\r\n<ul>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Sertraline 50 mg daily<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Alprazolam 1 mg TID<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Cetirizine 10 mg daily (OTC)<\/span><\/li>\r\n<\/ul>\r\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">Allergies<\/span><\/span><span lang=\"en\" xml:lang=\"en\"><span style=\"text-decoration: underline\">:<\/span> NKDA<\/span><\/p>\r\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">SDH<\/span><\/span><span lang=\"en\" xml:lang=\"en\">: <\/span><span lang=\"en\" xml:lang=\"en\">BC has been working but does not have benefits. He had been covered by Medicaid previously, but since moving to this state, he hasn\u2019t applied for it. <\/span><\/p>\r\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">Additional context<\/span><\/span><span lang=\"en\" xml:lang=\"en\">: <\/span><span lang=\"en\" xml:lang=\"en\">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. <\/span><\/p>\r\n\r\n<table>\r\n<thead>\r\n<tr>\r\n<td><strong>Medication and dose<\/strong><\/td>\r\n<td><strong>Instructions<\/strong><\/td>\r\n<td><strong>Quantity (date)<\/strong><\/td>\r\n<td><strong>Refills remaining<\/strong><\/td>\r\n<td><strong>Prescriber<\/strong><\/td>\r\n<td><strong>Pharmacy<\/strong><\/td>\r\n<\/tr>\r\n<\/thead>\r\n<tbody>\r\n<tr>\r\n<td rowspan=\"2\">Hydrocodone\/ acetaminophen 7.5\/325 mg<\/td>\r\n<td rowspan=\"2\">1 tab every 4-6 hours prn pain<\/td>\r\n<td>15<\/td>\r\n<td rowspan=\"2\">0<\/td>\r\n<td rowspan=\"2\">Smith<\/td>\r\n<td rowspan=\"2\">ABC<\/td>\r\n<\/tr>\r\n<tr>\r\n<td>(10 days ago)<\/td>\r\n<\/tr>\r\n<tr>\r\n<td rowspan=\"2\">Hydrocodone\/ acetaminophen 7.5\/325 mg<\/td>\r\n<td rowspan=\"2\">1 tab q6 hours prn pain<\/td>\r\n<td>30<\/td>\r\n<td rowspan=\"2\">0<\/td>\r\n<td rowspan=\"2\">Jones<\/td>\r\n<td rowspan=\"2\">123<\/td>\r\n<\/tr>\r\n<tr>\r\n<td>(15 days ago)<\/td>\r\n<\/tr>\r\n<tr>\r\n<td rowspan=\"2\">Methylphenidate 10 mg<\/td>\r\n<td rowspan=\"2\">1 tab BID<\/td>\r\n<td>60<\/td>\r\n<td rowspan=\"2\">0<\/td>\r\n<td rowspan=\"2\">Jones<\/td>\r\n<td rowspan=\"2\">123<\/td>\r\n<\/tr>\r\n<tr>\r\n<td>(15 days ago)<\/td>\r\n<\/tr>\r\n<tr>\r\n<td rowspan=\"2\">Hydrocodone\/ acetaminophen 5\/325 mg<\/td>\r\n<td rowspan=\"2\">1 tab every 4-6 hours prn pain<\/td>\r\n<td>30<\/td>\r\n<td rowspan=\"2\">0<\/td>\r\n<td rowspan=\"2\">Hite<\/td>\r\n<td rowspan=\"2\">XYZ<\/td>\r\n<\/tr>\r\n<tr>\r\n<td>(20 days ago)<\/td>\r\n<\/tr>\r\n<tr>\r\n<td rowspan=\"2\">Alprazolam 1 mg<\/td>\r\n<td rowspan=\"2\">1 tab TID<\/td>\r\n<td>90<\/td>\r\n<td rowspan=\"2\">1<\/td>\r\n<td rowspan=\"2\">Hite<\/td>\r\n<td rowspan=\"2\">XYZ<\/td>\r\n<\/tr>\r\n<tr>\r\n<td>(20 days ago)<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<h2 class=\"import-Normal\"><strong lang=\"en\" xml:lang=\"en\">Case Questions<\/strong><\/h2>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">1. What do you conclude based on BC\u2019s PDMP review, and why? <\/span><\/p>\r\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">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.<\/em><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">2. What is BC\u2019s ORT score and what does that score mean?<\/span><\/p>\r\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">ORT score<\/em><\/p>\r\n<p class=\"instructor-notes\" style=\"padding-left: 90px\">a. Personal and family history of alcohol abuse<\/p>\r\n<p class=\"instructor-notes\" style=\"padding-left: 90px\"><em lang=\"en\" xml:lang=\"en\">b.\u00a0<\/em><em lang=\"en\" xml:lang=\"en\">Personal history depression <\/em><\/p>\r\n<p class=\"instructor-notes\" style=\"padding-left: 90px\"><em lang=\"en\" xml:lang=\"en\">c.\u00a0<\/em><em lang=\"en\" xml:lang=\"en\">Age <\/em><\/p>\r\n<p class=\"instructor-notes\" style=\"padding-left: 90px\"><em lang=\"en\" xml:lang=\"en\">d.\u00a0<\/em><em lang=\"en\" xml:lang=\"en\">Score = 10<\/em><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">3. Based on the risk factors identified above, what is your assessment of the patient\u2019s risk of opioid misuse?<\/span><\/p>\r\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">Based on PMP concerns, and ORT score greater than 8, the patient is at high risk of opioid misuse. <\/em><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">4. What is the risk for unintentional overdose?<\/span><\/p>\r\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">High due to multiple opioid prescriptions and concomitant benzodiazepine (<\/em><em>Alprazolam<\/em><em lang=\"en\" xml:lang=\"en\">) and alcohol use<\/em><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">5. Will you dispense the Percocet for BC? Why or Why not?<\/span><\/p>\r\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">No, high risk of opioid misuse, and accidental overdose.<\/em><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">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?<\/span><\/p>\r\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">If the Percocet is dispensed,<\/em> <em lang=\"en\" xml:lang=\"en\">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. <\/em><em lang=\"en\" xml:lang=\"en\">Caregivers\/friends\/family should be encouraged to store controlled substances securely, and properly dispose of any unused controlled substances to reduce potential harm.<\/em><\/p>\r\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">A partial fill should be considered if that is legal in your state.<\/em><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">7. What resources are available for referral? What resources are available for education for the patient? <\/span><\/p>\r\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">Brochure on safe opioid use and storage (<\/em><a class=\"rId104\"><em lang=\"en\" xml:lang=\"en\">https:\/\/www.cdc.gov\/drugoverdose\/patients\/prevent-misuse.html<\/em><\/a><em lang=\"en\" xml:lang=\"en\"> ). <\/em><span lang=\"en\" xml:lang=\"en\">The SAMHSA <span lang=\"en\" xml:lang=\"en\">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: <\/span><a class=\"rId105\"><span lang=\"en\" xml:lang=\"en\">https:\/\/www.findtreatment.samhsa.gov\/<\/span><\/a><em lang=\"en\" xml:lang=\"en\">, TIP 63, Overdose toolkit, <\/em><a class=\"rId106\"><em lang=\"en\" xml:lang=\"en\">www.prescribetoprevent.org<\/em><\/a><em lang=\"en\" xml:lang=\"en\">; <\/em><a href=\"http:\/\/www.prevent-protect.org\"><em lang=\"en\" xml:lang=\"en\">www.prevent-protect.org<\/em><\/a><em lang=\"en\" xml:lang=\"en\">; <\/em><a class=\"rId107\"><em lang=\"en\" xml:lang=\"en\">www.naloxonesavessc.org<\/em><\/a><em lang=\"en\" xml:lang=\"en\">; National Institute on Drug Abuse<\/em><\/span><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">8. What are the discussion points that need to be conveyed to the patient and caregivers, including opioid safety and medication use?<\/span><\/p>\r\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">Storage and disposal education; signs\/symptoms to recognize overdose; use of naloxone; options for local treatment centers for substance misuse<\/em><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">9. What implications and\/or opportunities for policy makers exist surrounding this case?<\/span><\/p>\r\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">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 (<\/em><em lang=\"en\" xml:lang=\"en\">Kattan<\/em><em lang=\"en\" xml:lang=\"en\"> et al. Public health detailing. AJPH, 2016; 106(8):1430-1438.)<\/em><em lang=\"en\" xml:lang=\"en\">; 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 (<\/em><em lang=\"en\" xml:lang=\"en\">Kattan<\/em><em lang=\"en\" xml:lang=\"en\"> et al. Public health detailing. AJPH, 2016; 106(8):1430-1438.).<\/em><\/p>\r\n\r\n<h2 class=\"import-Normal\"><strong class=\"import-Heading2Char\">Author Commentary<\/strong><\/h2>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">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 \u2013 in order to ensure the patient\u2019s 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.<\/span><\/p>\r\n\r\n<h2 class=\"instructor-notes\"><strong>Facilitator Notes<\/strong><\/h2>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">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\u2019 Patient Care Process as well as potential <span lang=\"en\" xml:lang=\"en\">Entrustable<\/span><span lang=\"en\" xml:lang=\"en\"> Professional Activities are identified throughout the questions and sections above. <\/span><\/span><\/p>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">This case will reinforce the following four EPA domains for the learners<a href=\"#h15\"><sup>15<\/sup><\/a><span lang=\"en\" xml:lang=\"en\">:<\/span><\/span><\/p>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">EPA 1 Patient Care Provider<\/span><\/p>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Collect information to identify a patient\u2019s medication-related problems and health-related needs.<\/span><\/p>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Analyze information to determine the effects of medication therapy, identify medication-related problems, and prioritize health-related needs.<\/span><\/p>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">EPA 2 Interprofessional Team Member<\/span><\/p>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Collaborate as a member of an interprofessional team.<\/span><\/p>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">EPA 3 Population Health Promoter<\/span><\/p>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Identify patients at risk for prevalent diseases in a population.<\/span><\/p>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Maximize the appropriate use of medications in a population.<\/span><\/p>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">EPA 4 Information Master<\/span><\/p>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Educate patients and professional colleagues regarding the appropriate use of medications.<\/span><\/p>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">This case will reinforce the following CAPE 2016 Standards<a href=\"#h16\"><sup>a<\/sup><\/a><span lang=\"en\" xml:lang=\"en\">:<\/span><\/span><\/p>\r\n<p class=\"instructor-notes\"><a href=\"https:\/\/www.acpe-accredit.org\/pdf\/Standards2016FINAL.pdf\"><span lang=\"en\" xml:lang=\"en\">https:\/\/www.acpe-accredit.org\/pdf\/Standards2016FINAL.pdf<\/span><\/a><\/p>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Standard 2: Essentials for Practice and Care (2.1, 2.3. 2.4)<\/span><\/p>\r\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Standard 3: Approach to Practice and Care (3.1, 3.2, 3.3, 3.5, 3.6)<\/span><\/p>\r\n\r\n<h3 class=\"instructor-notes\"><span style=\"color: #000000\"><strong lang=\"en\" xml:lang=\"en\">Potential courses for incorporation: <\/strong><\/span><\/h3>\r\n<ul class=\"instructor-notes\">\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Experiential education, including introductory and advanced pharmacy practice experiences<\/span>\r\n<ul class=\"instructor-notes\">\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Could be used to prepare students for patient care activities and\/or review\/refresh concepts<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">EPA: Patient care provider, interprofessional team member, information master<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Laboratory sessions-<\/span>\r\n<ul class=\"instructor-notes\">\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">If used as an observed structured clinical exam, consider developing a script for standardized patient use<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Estimated time ~ 60 minutes<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">EPA: patient care provider, interprofessional team member<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Didactic lectures--<\/span>\r\n<ul class=\"instructor-notes\">\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">If used as a think-pair-share activity within a lecture<\/span>\r\n<ul class=\"instructor-notes\">\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Estimated time ~ 20 minutes<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">EPA: patient care provider, population health promoter, information master<\/span>\r\n<ul class=\"instructor-notes\">\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Therapeutics areas <\/span>\r\n<ul class=\"instructor-notes\">\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Special populations<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Neurology and\/or psychiatry<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Toxicology <\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Social and administrative courses <\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Public health courses<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<em class=\"instructor-notes\">References:<\/em>\r\n\r\n<em class=\"instructor-notes\">a.\u00a0<span lang=\"en\" xml:lang=\"en\">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).\u00a0<\/span><a class=\"rId118\" href=\"https:\/\/www.acpe-accredit.org\/pdf\/Standards2016FINAL.pdf\"><span lang=\"en\" xml:lang=\"en\">https:\/\/www.acpe-accredit.org\/pdf\/Standards2016FINAL.pdf<\/span><\/a><span lang=\"en\" xml:lang=\"en\">.\u00a0<\/span><span lang=\"en\" xml:lang=\"en\">Accessed August 12, 2018.<\/span><\/em>\r\n<h2 class=\"import-Normal\"><strong class=\"import-Heading2Char\">Patient Approaches and Opportunities<\/strong><\/h2>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">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.<\/span><a href=\"#h9\"><sup>9 <\/sup><\/a><span lang=\"en\" xml:lang=\"en\">Screening followed by brief interventions (SBIRT) have been shown to be feasible and effective.<\/span><sup>10<\/sup><sup>,11<\/sup><span lang=\"en\" xml:lang=\"en\"> 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.<\/span><sup><a href=\"#h12\">12<\/a><a href=\"#h14\">-14<\/a><\/sup><\/p>\r\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">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.<\/span><a href=\"#h17\"><sup>16<\/sup><\/a><\/p>\r\n\r\n<div class=\"textbox key-takeaways\">\r\n<h3 class=\"import-Normal\"><strong class=\"import-Heading2Char\">Important Resources<\/strong><\/h3>\r\n<p class=\"import-Normal\"><em lang=\"en\" xml:lang=\"en\">Related chapters of interest:<\/em><\/p>\r\n\r\n<ul>\r\n \t<li class=\"import-Normal\"><a href=\"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/chapter\/saying-what-you-mean-doesnt-always-mean-what-you-say-cross-cultural-communication\/\"><span lang=\"en\" xml:lang=\"en\">Saying what you mean doesn\u2019t always mean what you say: cross-cultural communication <\/span><\/a><\/li>\r\n \t<li class=\"import-Normal\"><a href=\"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/chapter\/more-than-just-diet-and-exercise-social-determinants-of-health-and-well-being\/\"><span lang=\"en\" xml:lang=\"en\">More than just diet and exercise: social determinants of health and well-being<\/span><\/a><\/li>\r\n \t<li class=\"import-Normal\"><a href=\"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/chapter\/communicating-health-information-hidden-barriers-and-practical-approaches\/\"><span lang=\"en\" xml:lang=\"en\">Communicating health information: hidden barriers and practical approaches<\/span><\/a><\/li>\r\n<\/ul>\r\n<p class=\"import-Normal\"><em lang=\"en\" xml:lang=\"en\">External resources:<\/em><\/p>\r\n\r\n<ul>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Guidelines<\/span>\r\n<ul>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">TIP 63. <\/span><a class=\"rId108\" href=\"https:\/\/store.samhsa.gov\/product\/TIP-63-Medications-for-Opioid-Use-Disorder-Full-Document-Including-Executive-Summary-and-Parts-1-5-\/SMA18-5063FULLDOC\"><span lang=\"en\" xml:lang=\"en\">https:\/\/store.samhsa.gov\/product\/TIP-63-Medications-for-Opioid-Use-Disorder-Full-Document-Including-Executive-Summary-and-Parts-1-5-\/SMA18-5063FULLDOC<\/span><\/a><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Overdose toolkit. <\/span><a class=\"rId109\" href=\"https:\/\/www.samhsa.gov\/capt\/tools-learning-resources\/opioid-overdose-prevention-toolkit\"><span lang=\"en\" xml:lang=\"en\">https:\/\/www.samhsa.gov\/capt\/tools-learning-resources\/opioid-overdose-prevention-toolkit<\/span><\/a><\/li>\r\n<\/ul>\r\n<\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Websites:<\/span>\r\n<ul>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Prescribe to Prevent <\/span><a class=\"rId110\" href=\"http:\/\/prescribetoprevent.org\/\"><span lang=\"en\" xml:lang=\"en\">http:\/\/prescribetoprevent.org\/<\/span><\/a><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Prevent-protect <\/span><a class=\"rId111\" href=\"https:\/\/prevent-protect.org\/\"><span lang=\"en\" xml:lang=\"en\">https:\/\/prevent-protect.org\/<\/span><\/a><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Prescription Drug Abuse Policy System (PDAPS) <\/span><a class=\"rId112\" href=\"http:\/\/pdaps.org\/\"><span lang=\"en\" xml:lang=\"en\">http:\/\/pdaps.org\/<\/span><\/a><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Healthy People 2020: HP2020 \u2013 Substance Abuse. <\/span><a class=\"rId113\" href=\"https:\/\/www.healthypeople.gov\/2020\/topics-objectives\/topic\/substance-abuse\/objectives\"><span lang=\"en\" xml:lang=\"en\">https:\/\/www.healthypeople.gov\/2020\/topics-objectives\/topic\/substance-abuse\/objectives<\/span><\/a><\/li>\r\n<\/ul>\r\n<\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Screening Tools:<\/span>\r\n<ul>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Opioid Risk Tool. <\/span><a class=\"rId114\" href=\"https:\/\/www.drugabuse.gov\/sites\/default\/files\/files\/OpioidRiskTool.pdf\"><span lang=\"en\" xml:lang=\"en\">https:\/\/www.drugabuse.gov\/sites\/default\/files\/files\/OpioidRiskTool.pdf<\/span><\/a><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">The Screener and Opioid Assessment for Patients with Pain-Revisited tool (SOAPP-R). <\/span><a class=\"rId115\" href=\"http:\/\/www.ccwjc.com\/Forms\/Chronic%20Pain\/SOAPP-R.pdf\"><span lang=\"en\" xml:lang=\"en\">http:\/\/www.ccwjc.com\/Forms\/Chronic%20Pain\/SOAPP-R.pdf<\/span><\/a><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">The Brief Risk Interview. <\/span><a class=\"rId116\" href=\"http:\/\/www.painmed.org\/2014posters\/abstract-206\/\"><span lang=\"en\" xml:lang=\"en\">http:\/\/www.painmed.org\/2014posters\/abstract-206\/<\/span><\/a><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<\/div>\r\n<div class=\"textbox shaded\">\r\n<h3 class=\"import-Normal\"><strong class=\"import-Heading2Char\">References<\/strong><\/h3>\r\n<ol>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Centers for Disease Control and Prevention. Drug Overdose Death Data. Centers for Disease Control and Prevention website. <\/span><a class=\"rId117\" href=\"https:\/\/www.cdc.gov\/drugoverdose\/data\/statedeaths.html\"><span lang=\"en\" xml:lang=\"en\">https:\/\/www.cdc.gov\/drugoverdose\/data\/statedeaths.html<\/span><\/a><span lang=\"en\" xml:lang=\"en\">. <\/span><span lang=\"en\" xml:lang=\"en\">Published December 2017. Accessed August 12, 2018.<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Dwyer-Lindgren L, <\/span><span lang=\"en\" xml:lang=\"en\">Bertozzi<\/span><span lang=\"en\" xml:lang=\"en\">-Villa A, Stubbs RW, et al. Trends and patterns of geographic variation in mortality from substance use disorders and intentional injuries among US counties, 1980-2014. JAMA. 2018<\/span><span lang=\"en\" xml:lang=\"en\">;319<\/span><span lang=\"en\" xml:lang=\"en\">(10):1013-1023.<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Compton WM, Boyle M, Wargo E. Prescription opioid abuse: problems and responses. <\/span><em lang=\"en\" xml:lang=\"en\">Prev<\/em><em lang=\"en\" xml:lang=\"en\"> Med. <\/em><span lang=\"en\" xml:lang=\"en\">2015<\/span><span lang=\"en\" xml:lang=\"en\">;80:5<\/span><span lang=\"en\" xml:lang=\"en\">-9.<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. <\/span><em lang=\"en\" xml:lang=\"en\">JAMA <\/em><em lang=\"en\" xml:lang=\"en\">Psychiat<\/em><em lang=\"en\" xml:lang=\"en\">. <\/em><span lang=\"en\" xml:lang=\"en\">2014<\/span><span lang=\"en\" xml:lang=\"en\">;71<\/span><span lang=\"en\" xml:lang=\"en\">(7):821-826.<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Unick<\/span><span lang=\"en\" xml:lang=\"en\"> GJ, Rosenblum D, Mars S, <\/span><span lang=\"en\" xml:lang=\"en\">Ciccarone<\/span><span lang=\"en\" xml:lang=\"en\"> D. Intertwined epidemics: national demographic trends in hospitalizations for heroin- and opioid-related overdoses, 1993\u20132009. <\/span><em lang=\"en\" xml:lang=\"en\">PLOS ONE. <\/em><span lang=\"en\" xml:lang=\"en\">2013<\/span><span lang=\"en\" xml:lang=\"en\">;8<\/span><span lang=\"en\" xml:lang=\"en\">(2):e54496.<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Peavy<\/span><span lang=\"en\" xml:lang=\"en\"> KM, Banta-Green CJ, Kingston S, Hanrahan M, Merrill JO, Coffin PO. \u201cHooked on\u201d prescription-type opiates prior to using heroin: results from a survey of syringe exchange clients. <\/span><em lang=\"en\" xml:lang=\"en\">J Psychoactive Drugs. <\/em><span lang=\"en\" xml:lang=\"en\">2012<\/span><span lang=\"en\" xml:lang=\"en\">;44<\/span><span lang=\"en\" xml:lang=\"en\">(3):259-265.<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Meldrum ML. The ongoing opioid prescription epidemic. Am J Public Health 2016<\/span><span lang=\"en\" xml:lang=\"en\">;106<\/span><span lang=\"en\" xml:lang=\"en\">(8):1365-66.<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Boscarino<\/span><span lang=\"en\" xml:lang=\"en\"> JA, <\/span><span lang=\"en\" xml:lang=\"en\">Rukstalis<\/span><span lang=\"en\" xml:lang=\"en\"> M, Hoffman SN, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. <\/span><em lang=\"en\" xml:lang=\"en\">Addiction. <\/em><span lang=\"en\" xml:lang=\"en\">2010<\/span><span lang=\"en\" xml:lang=\"en\">;105<\/span><span lang=\"en\" xml:lang=\"en\">(10):1776-1782.<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Compton WM, Jones CM, Stein JB, Wargo EM. Promising roles for pharmacists in addressing the U.S. opioid crisis. [published online ahead of print December 31, 2017] <\/span><em lang=\"en\" xml:lang=\"en\">Res Social <\/em><em lang=\"en\" xml:lang=\"en\">Adm<\/em><em lang=\"en\" xml:lang=\"en\"> Pharm. <\/em><span lang=\"en\" xml:lang=\"en\">10.1016\/j.sapharm.2017.12.009<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Cochran G, Gordon AJ, Field C, et al. <\/span><span lang=\"en\" xml:lang=\"en\">Developing<\/span><span lang=\"en\" xml:lang=\"en\"> a framework of care for opioid medication misuse in community pharmacy. Res Social <\/span><span lang=\"en\" xml:lang=\"en\">Adm<\/span><span lang=\"en\" xml:lang=\"en\"> Pharm. 2016; 12(2):293\u2013301.<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Zahradnik<\/span><span lang=\"en\" xml:lang=\"en\"> A, Otto C, <\/span><span lang=\"en\" xml:lang=\"en\">Crackau<\/span><span lang=\"en\" xml:lang=\"en\"> B, et al. Randomized controlled trial of a brief intervention for problematic prescription drug use in non-treatment-seeking patients. Addiction. 2009<\/span><span lang=\"en\" xml:lang=\"en\">;104<\/span><span lang=\"en\" xml:lang=\"en\">(1):109-117. <\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Bratberg JP. Opioids, naloxone, and beyond: The intersection of medication safety, public health, and pharmacy. J Am Pharm Assoc. 2017<\/span><span lang=\"en\" xml:lang=\"en\">;57<\/span><span lang=\"en\" xml:lang=\"en\">(2):S5 - S7.<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Cochran G, Field C, and Lawson K. Pharmacists who screen and discuss opioid misuse with patients: Future directions for research and practice. <\/span><em lang=\"en\" xml:lang=\"en\">J Pharm <\/em><em lang=\"en\" xml:lang=\"en\">Pract<\/em><em lang=\"en\" xml:lang=\"en\">. <\/em><span lang=\"en\" xml:lang=\"en\">2015<\/span><span lang=\"en\" xml:lang=\"en\">;28<\/span><span lang=\"en\" xml:lang=\"en\">(4):404-412.<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Strand MA, <\/span><span lang=\"en\" xml:lang=\"en\">Eukel<\/span><span lang=\"en\" xml:lang=\"en\"> H, <\/span><span lang=\"en\" xml:lang=\"en\">Burck<\/span><span lang=\"en\" xml:lang=\"en\"> S. Moving opioid misuse prevention upstream. [<\/span><span lang=\"en\" xml:lang=\"en\">published<\/span><span lang=\"en\" xml:lang=\"en\"> online ahead of print July 17, 2018]. Res Social <\/span><span lang=\"en\" xml:lang=\"en\">Adm<\/span><span lang=\"en\" xml:lang=\"en\"> Pharm. 2018.<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Haines ST, <\/span><span lang=\"en\" xml:lang=\"en\">Pittenger<\/span><span lang=\"en\" xml:lang=\"en\"> AL, <\/span><span lang=\"en\" xml:lang=\"en\">Stolte<\/span><span lang=\"en\" xml:lang=\"en\"> SK, et al. Core <\/span><span lang=\"en\" xml:lang=\"en\">entrustable<\/span><span lang=\"en\" xml:lang=\"en\"> professional activities for new pharmacy graduates. Am J Pharm Educ. 2017; 81(1): Article S2.<\/span><\/li>\r\n \t<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Cochran G, Field C, and Lawson K. Pharmacists who screen and discuss opioid misuse with patients: future directions for research and practice<\/span><em lang=\"en\" xml:lang=\"en\">. J Pharm <\/em><em lang=\"en\" xml:lang=\"en\">Pract<\/em><span lang=\"en\" xml:lang=\"en\">. 2015<\/span><span lang=\"en\" xml:lang=\"en\">;28<\/span><span lang=\"en\" xml:lang=\"en\">(4):404-412.<\/span><\/li>\r\n<\/ol>\r\n<\/div>\r\n\r\n[caption id=\"\" align=\"aligncenter\" width=\"1406\"]<img src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/4834\/2019\/09\/30133922\/image1.png\" alt=\"image\" width=\"1406\" height=\"1328\" \/> 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.[\/caption]\r\n\r\n<div class=\"textbox examples\">\r\n<h3>Glossary and Abbreviations<\/h3>\r\n<ul>\r\n \t<li><a href=\"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/front-matter\/glossary\/\">Glossary<\/a><\/li>\r\n \t<li><a href=\"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/front-matter\/abbreviations\/\">Abbreviations<\/a><\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>","rendered":"<h2>Kayce M. Shealy, PharmD, BCPS, BCACP, CDE<span lang=\"en\" xml:lang=\"en\">\u00a0<\/span><\/h2>\n<h2>Mark A. Strand, PhD, CPH<\/h2>\n<div class=\"textbox key-takeaways\">\n<h3 class=\"import-Normal\"><strong class=\"import-Heading2Char\">Topic Area<\/strong><\/h3>\n<p class=\"import-Normal\" style=\"text-align: center\"><span lang=\"en\" xml:lang=\"en\">Opioid safety<\/span><\/p>\n<\/div>\n<div class=\"safe-opioid-use-in-the-community-setting:-reverse-the-curse?\">\n<div class=\"textbox learning-objectives\">\n<h3>Learning Objectives<\/h3>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">At the end of this case, students will be able to:<\/span><\/p>\n<ul>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Describe the epidemiology of the opioid crisis in the 21<\/span><sup>st<\/sup><span lang=\"en\" xml:lang=\"en\"> century<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Identify patients at risk of opioid misuse when provided patient information<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Identify harm reduction and safety solutions for opioid users<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Discuss the opportunities for policy, legislative, or regulatory changes that will improve the pharmacist\u2019s ability to optimize the public\u2019s health regarding opioid use<\/span><\/li>\n<\/ul>\n<\/div>\n<h2 class=\"import-Normal\"><strong class=\"import-Heading2Char\">Introduction<\/strong><\/h2>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Opioids \u2013 prescription and illicit \u2013 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.<\/span><a href=\"#h1\"><sup>1<\/sup><\/a><span lang=\"en\" xml:lang=\"en\"> In recent years, there has been a surge in deaths due to alcohol, drug abuse, and suicide, which some have described as &#8220;deaths of despair.&#8221;<\/span><a href=\"#h2\"><sup>2<\/sup><\/a><span lang=\"en\" xml:lang=\"en\"> Among the individuals involved in this trend are persons living with chronic pain and persons living with a substance use disorder.<\/span><\/p>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">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.<\/span><sup><a href=\"#h3\">3<\/a><a href=\"#h6\">-6<\/a><\/sup><span lang=\"en\" xml:lang=\"en\"> Prior to 1990, heroin addiction began with heroin use, but since that time, heroin addiction has primarily begun with prescription opioids.<\/span><a href=\"#h4\"><sup>4<\/sup><\/a><span lang=\"en\" xml:lang=\"en\"> An estimated 25 million adult Americans suffer daily from pain and require some analgesic to provide relief.<\/span><a href=\"#h7\"><sup>7<\/sup><\/a><span lang=\"en\" xml:lang=\"en\"> 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.<\/span><a href=\"#h8\"><sup>8<\/sup><\/a> <span lang=\"en\" xml:lang=\"en\">This set the stage for a generation of patients unexpectedly misusing opioid medications.<\/span><\/p>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Educating patients about their medications has been required of all Medicaid patients and, in many states, all patients (see <\/span>Important Resources<span lang=\"en\" xml:lang=\"en\"> for more information). With controlled medications, patient education and counseling is even more critical. Pharmacists\u2019 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.<\/span><\/p>\n<h2 class=\"import-Normal\"><strong class=\"import-Heading2Char\">Case<\/strong><\/h2>\n<div class=\"textbox exercises\">\n<h3>Scenario<\/h3>\n<p><span lang=\"en\" xml:lang=\"en\">You are a floater pharmacist working at a new pharmacy on the weekend in the outskirts of an urban area.<\/span><\/p>\n<\/div>\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">CC<\/span><\/span><span lang=\"en\" xml:lang=\"en\">: \u201cI would like to have this prescription filled.\u201d<\/span><\/p>\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">Patient<\/span><\/span><span lang=\"en\" xml:lang=\"en\">: 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.<\/span><\/p>\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">HPI<\/span><\/span><span lang=\"en\" xml:lang=\"en\"><span style=\"text-decoration: underline\">:<\/span> 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.<\/span><\/p>\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">PMH<\/span><\/span><span lang=\"en\" xml:lang=\"en\"><span style=\"text-decoration: underline\">:<\/span> Depression; anxiety; ADHD; alcohol use disorder; allergic rhinitis<\/span><\/p>\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">FH<\/span><span lang=\"en\" xml:lang=\"en\">: <\/span><\/span><\/p>\n<ul>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Mother (alive) with <\/span><span lang=\"en\" xml:lang=\"en\">T2DM, depression, and HTN<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">F<\/span><span lang=\"en\" xml:lang=\"en\">ather (deceased) with history of alcohol use disorder, HTN, cirrhosis<\/span><\/li>\n<\/ul>\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">SH<\/span><span lang=\"en\" xml:lang=\"en\">: <\/span><\/span><\/p>\n<ul>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Reports tobacco use<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Reports alcohol use<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Living alone and not in the same city as the rest of his family<\/span><\/li>\n<\/ul>\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">Medications<\/span><span lang=\"en\" xml:lang=\"en\">: <\/span><\/span><\/p>\n<ul>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Sertraline 50 mg daily<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Alprazolam 1 mg TID<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Cetirizine 10 mg daily (OTC)<\/span><\/li>\n<\/ul>\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">Allergies<\/span><\/span><span lang=\"en\" xml:lang=\"en\"><span style=\"text-decoration: underline\">:<\/span> NKDA<\/span><\/p>\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">SDH<\/span><\/span><span lang=\"en\" xml:lang=\"en\">: <\/span><span lang=\"en\" xml:lang=\"en\">BC has been working but does not have benefits. He had been covered by Medicaid previously, but since moving to this state, he hasn\u2019t applied for it. <\/span><\/p>\n<p class=\"import-Normal\"><span style=\"text-decoration: underline\"><span lang=\"en\" xml:lang=\"en\">Additional context<\/span><\/span><span lang=\"en\" xml:lang=\"en\">: <\/span><span lang=\"en\" xml:lang=\"en\">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. <\/span><\/p>\n<table>\n<thead>\n<tr>\n<td><strong>Medication and dose<\/strong><\/td>\n<td><strong>Instructions<\/strong><\/td>\n<td><strong>Quantity (date)<\/strong><\/td>\n<td><strong>Refills remaining<\/strong><\/td>\n<td><strong>Prescriber<\/strong><\/td>\n<td><strong>Pharmacy<\/strong><\/td>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td rowspan=\"2\">Hydrocodone\/ acetaminophen 7.5\/325 mg<\/td>\n<td rowspan=\"2\">1 tab every 4-6 hours prn pain<\/td>\n<td>15<\/td>\n<td rowspan=\"2\">0<\/td>\n<td rowspan=\"2\">Smith<\/td>\n<td rowspan=\"2\">ABC<\/td>\n<\/tr>\n<tr>\n<td>(10 days ago)<\/td>\n<\/tr>\n<tr>\n<td rowspan=\"2\">Hydrocodone\/ acetaminophen 7.5\/325 mg<\/td>\n<td rowspan=\"2\">1 tab q6 hours prn pain<\/td>\n<td>30<\/td>\n<td rowspan=\"2\">0<\/td>\n<td rowspan=\"2\">Jones<\/td>\n<td rowspan=\"2\">123<\/td>\n<\/tr>\n<tr>\n<td>(15 days ago)<\/td>\n<\/tr>\n<tr>\n<td rowspan=\"2\">Methylphenidate 10 mg<\/td>\n<td rowspan=\"2\">1 tab BID<\/td>\n<td>60<\/td>\n<td rowspan=\"2\">0<\/td>\n<td rowspan=\"2\">Jones<\/td>\n<td rowspan=\"2\">123<\/td>\n<\/tr>\n<tr>\n<td>(15 days ago)<\/td>\n<\/tr>\n<tr>\n<td rowspan=\"2\">Hydrocodone\/ acetaminophen 5\/325 mg<\/td>\n<td rowspan=\"2\">1 tab every 4-6 hours prn pain<\/td>\n<td>30<\/td>\n<td rowspan=\"2\">0<\/td>\n<td rowspan=\"2\">Hite<\/td>\n<td rowspan=\"2\">XYZ<\/td>\n<\/tr>\n<tr>\n<td>(20 days ago)<\/td>\n<\/tr>\n<tr>\n<td rowspan=\"2\">Alprazolam 1 mg<\/td>\n<td rowspan=\"2\">1 tab TID<\/td>\n<td>90<\/td>\n<td rowspan=\"2\">1<\/td>\n<td rowspan=\"2\">Hite<\/td>\n<td rowspan=\"2\">XYZ<\/td>\n<\/tr>\n<tr>\n<td>(20 days ago)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h2 class=\"import-Normal\"><strong lang=\"en\" xml:lang=\"en\">Case Questions<\/strong><\/h2>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">1. What do you conclude based on BC\u2019s PDMP review, and why? <\/span><\/p>\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">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.<\/em><\/p>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">2. What is BC\u2019s ORT score and what does that score mean?<\/span><\/p>\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">ORT score<\/em><\/p>\n<p class=\"instructor-notes\" style=\"padding-left: 90px\">a. Personal and family history of alcohol abuse<\/p>\n<p class=\"instructor-notes\" style=\"padding-left: 90px\"><em lang=\"en\" xml:lang=\"en\">b.\u00a0<\/em><em lang=\"en\" xml:lang=\"en\">Personal history depression <\/em><\/p>\n<p class=\"instructor-notes\" style=\"padding-left: 90px\"><em lang=\"en\" xml:lang=\"en\">c.\u00a0<\/em><em lang=\"en\" xml:lang=\"en\">Age <\/em><\/p>\n<p class=\"instructor-notes\" style=\"padding-left: 90px\"><em lang=\"en\" xml:lang=\"en\">d.\u00a0<\/em><em lang=\"en\" xml:lang=\"en\">Score = 10<\/em><\/p>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">3. Based on the risk factors identified above, what is your assessment of the patient\u2019s risk of opioid misuse?<\/span><\/p>\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">Based on PMP concerns, and ORT score greater than 8, the patient is at high risk of opioid misuse. <\/em><\/p>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">4. What is the risk for unintentional overdose?<\/span><\/p>\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">High due to multiple opioid prescriptions and concomitant benzodiazepine (<\/em><em>Alprazolam<\/em><em lang=\"en\" xml:lang=\"en\">) and alcohol use<\/em><\/p>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">5. Will you dispense the Percocet for BC? Why or Why not?<\/span><\/p>\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">No, high risk of opioid misuse, and accidental overdose.<\/em><\/p>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">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?<\/span><\/p>\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">If the Percocet is dispensed,<\/em> <em lang=\"en\" xml:lang=\"en\">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. <\/em><em lang=\"en\" xml:lang=\"en\">Caregivers\/friends\/family should be encouraged to store controlled substances securely, and properly dispose of any unused controlled substances to reduce potential harm.<\/em><\/p>\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">A partial fill should be considered if that is legal in your state.<\/em><\/p>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">7. What resources are available for referral? What resources are available for education for the patient? <\/span><\/p>\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">Brochure on safe opioid use and storage (<\/em><a class=\"rId104\"><em lang=\"en\" xml:lang=\"en\">https:\/\/www.cdc.gov\/drugoverdose\/patients\/prevent-misuse.html<\/em><\/a><em lang=\"en\" xml:lang=\"en\"> ). <\/em><span lang=\"en\" xml:lang=\"en\">The SAMHSA <span lang=\"en\" xml:lang=\"en\">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: <\/span><a class=\"rId105\"><span lang=\"en\" xml:lang=\"en\">https:\/\/www.findtreatment.samhsa.gov\/<\/span><\/a><em lang=\"en\" xml:lang=\"en\">, TIP 63, Overdose toolkit, <\/em><a class=\"rId106\"><em lang=\"en\" xml:lang=\"en\">www.prescribetoprevent.org<\/em><\/a><em lang=\"en\" xml:lang=\"en\">; <\/em><a href=\"http:\/\/www.prevent-protect.org\"><em lang=\"en\" xml:lang=\"en\">www.prevent-protect.org<\/em><\/a><em lang=\"en\" xml:lang=\"en\">; <\/em><a class=\"rId107\"><em lang=\"en\" xml:lang=\"en\">www.naloxonesavessc.org<\/em><\/a><em lang=\"en\" xml:lang=\"en\">; National Institute on Drug Abuse<\/em><\/span><\/p>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">8. What are the discussion points that need to be conveyed to the patient and caregivers, including opioid safety and medication use?<\/span><\/p>\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">Storage and disposal education; signs\/symptoms to recognize overdose; use of naloxone; options for local treatment centers for substance misuse<\/em><\/p>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">9. What implications and\/or opportunities for policy makers exist surrounding this case?<\/span><\/p>\n<p class=\"instructor-notes\"><em lang=\"en\" xml:lang=\"en\">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 (<\/em><em lang=\"en\" xml:lang=\"en\">Kattan<\/em><em lang=\"en\" xml:lang=\"en\"> et al. Public health detailing. AJPH, 2016; 106(8):1430-1438.)<\/em><em lang=\"en\" xml:lang=\"en\">; 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 (<\/em><em lang=\"en\" xml:lang=\"en\">Kattan<\/em><em lang=\"en\" xml:lang=\"en\"> et al. Public health detailing. AJPH, 2016; 106(8):1430-1438.).<\/em><\/p>\n<h2 class=\"import-Normal\"><strong class=\"import-Heading2Char\">Author Commentary<\/strong><\/h2>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">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 &#8212; the PDMP record, identified risk factors with the patient, and concomitant disease states and medications \u2013 in order to ensure the patient\u2019s 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.<\/span><\/p>\n<h2 class=\"instructor-notes\"><strong>Facilitator Notes<\/strong><\/h2>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">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\u2019 Patient Care Process as well as potential <span lang=\"en\" xml:lang=\"en\">Entrustable<\/span><span lang=\"en\" xml:lang=\"en\"> Professional Activities are identified throughout the questions and sections above. <\/span><\/span><\/p>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">This case will reinforce the following four EPA domains for the learners<a href=\"#h15\"><sup>15<\/sup><\/a><span lang=\"en\" xml:lang=\"en\">:<\/span><\/span><\/p>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">EPA 1 Patient Care Provider<\/span><\/p>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Collect information to identify a patient\u2019s medication-related problems and health-related needs.<\/span><\/p>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Analyze information to determine the effects of medication therapy, identify medication-related problems, and prioritize health-related needs.<\/span><\/p>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">EPA 2 Interprofessional Team Member<\/span><\/p>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Collaborate as a member of an interprofessional team.<\/span><\/p>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">EPA 3 Population Health Promoter<\/span><\/p>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Identify patients at risk for prevalent diseases in a population.<\/span><\/p>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Maximize the appropriate use of medications in a population.<\/span><\/p>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">EPA 4 Information Master<\/span><\/p>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Educate patients and professional colleagues regarding the appropriate use of medications.<\/span><\/p>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">This case will reinforce the following CAPE 2016 Standards<a href=\"#h16\"><sup>a<\/sup><\/a><span lang=\"en\" xml:lang=\"en\">:<\/span><\/span><\/p>\n<p class=\"instructor-notes\"><a href=\"https:\/\/www.acpe-accredit.org\/pdf\/Standards2016FINAL.pdf\"><span lang=\"en\" xml:lang=\"en\">https:\/\/www.acpe-accredit.org\/pdf\/Standards2016FINAL.pdf<\/span><\/a><\/p>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Standard 2: Essentials for Practice and Care (2.1, 2.3. 2.4)<\/span><\/p>\n<p class=\"instructor-notes\"><span lang=\"en\" xml:lang=\"en\">Standard 3: Approach to Practice and Care (3.1, 3.2, 3.3, 3.5, 3.6)<\/span><\/p>\n<h3 class=\"instructor-notes\"><span style=\"color: #000000\"><strong lang=\"en\" xml:lang=\"en\">Potential courses for incorporation: <\/strong><\/span><\/h3>\n<ul class=\"instructor-notes\">\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Experiential education, including introductory and advanced pharmacy practice experiences<\/span>\n<ul class=\"instructor-notes\">\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Could be used to prepare students for patient care activities and\/or review\/refresh concepts<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">EPA: Patient care provider, interprofessional team member, information master<\/span><\/li>\n<\/ul>\n<\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Laboratory sessions-<\/span>\n<ul class=\"instructor-notes\">\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">If used as an observed structured clinical exam, consider developing a script for standardized patient use<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Estimated time ~ 60 minutes<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">EPA: patient care provider, interprofessional team member<\/span><\/li>\n<\/ul>\n<\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Didactic lectures&#8211;<\/span>\n<ul class=\"instructor-notes\">\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">If used as a think-pair-share activity within a lecture<\/span>\n<ul class=\"instructor-notes\">\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Estimated time ~ 20 minutes<\/span><\/li>\n<\/ul>\n<\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">EPA: patient care provider, population health promoter, information master<\/span>\n<ul class=\"instructor-notes\">\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Therapeutics areas <\/span>\n<ul class=\"instructor-notes\">\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Special populations<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Neurology and\/or psychiatry<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Toxicology <\/span><\/li>\n<\/ul>\n<\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Social and administrative courses <\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Public health courses<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><em class=\"instructor-notes\">References:<\/em><\/p>\n<p><em class=\"instructor-notes\">a.\u00a0<span lang=\"en\" xml:lang=\"en\">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).\u00a0<\/span><a class=\"rId118\" href=\"https:\/\/www.acpe-accredit.org\/pdf\/Standards2016FINAL.pdf\"><span lang=\"en\" xml:lang=\"en\">https:\/\/www.acpe-accredit.org\/pdf\/Standards2016FINAL.pdf<\/span><\/a><span lang=\"en\" xml:lang=\"en\">.\u00a0<\/span><span lang=\"en\" xml:lang=\"en\">Accessed August 12, 2018.<\/span><\/em><\/p>\n<h2 class=\"import-Normal\"><strong class=\"import-Heading2Char\">Patient Approaches and Opportunities<\/strong><\/h2>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">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.<\/span><a href=\"#h9\"><sup>9 <\/sup><\/a><span lang=\"en\" xml:lang=\"en\">Screening followed by brief interventions (SBIRT) have been shown to be feasible and effective.<\/span><sup>10<\/sup><sup>,11<\/sup><span lang=\"en\" xml:lang=\"en\"> 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.<\/span><sup><a href=\"#h12\">12<\/a><a href=\"#h14\">-14<\/a><\/sup><\/p>\n<p class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">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.<\/span><a href=\"#h17\"><sup>16<\/sup><\/a><\/p>\n<div class=\"textbox key-takeaways\">\n<h3 class=\"import-Normal\"><strong class=\"import-Heading2Char\">Important Resources<\/strong><\/h3>\n<p class=\"import-Normal\"><em lang=\"en\" xml:lang=\"en\">Related chapters of interest:<\/em><\/p>\n<ul>\n<li class=\"import-Normal\"><a href=\"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/chapter\/saying-what-you-mean-doesnt-always-mean-what-you-say-cross-cultural-communication\/\"><span lang=\"en\" xml:lang=\"en\">Saying what you mean doesn\u2019t always mean what you say: cross-cultural communication <\/span><\/a><\/li>\n<li class=\"import-Normal\"><a href=\"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/chapter\/more-than-just-diet-and-exercise-social-determinants-of-health-and-well-being\/\"><span lang=\"en\" xml:lang=\"en\">More than just diet and exercise: social determinants of health and well-being<\/span><\/a><\/li>\n<li class=\"import-Normal\"><a href=\"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/chapter\/communicating-health-information-hidden-barriers-and-practical-approaches\/\"><span lang=\"en\" xml:lang=\"en\">Communicating health information: hidden barriers and practical approaches<\/span><\/a><\/li>\n<\/ul>\n<p class=\"import-Normal\"><em lang=\"en\" xml:lang=\"en\">External resources:<\/em><\/p>\n<ul>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Guidelines<\/span>\n<ul>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">TIP 63. <\/span><a class=\"rId108\" href=\"https:\/\/store.samhsa.gov\/product\/TIP-63-Medications-for-Opioid-Use-Disorder-Full-Document-Including-Executive-Summary-and-Parts-1-5-\/SMA18-5063FULLDOC\"><span lang=\"en\" xml:lang=\"en\">https:\/\/store.samhsa.gov\/product\/TIP-63-Medications-for-Opioid-Use-Disorder-Full-Document-Including-Executive-Summary-and-Parts-1-5-\/SMA18-5063FULLDOC<\/span><\/a><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Overdose toolkit. <\/span><a class=\"rId109\" href=\"https:\/\/www.samhsa.gov\/capt\/tools-learning-resources\/opioid-overdose-prevention-toolkit\"><span lang=\"en\" xml:lang=\"en\">https:\/\/www.samhsa.gov\/capt\/tools-learning-resources\/opioid-overdose-prevention-toolkit<\/span><\/a><\/li>\n<\/ul>\n<\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Websites:<\/span>\n<ul>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Prescribe to Prevent <\/span><a class=\"rId110\" href=\"http:\/\/prescribetoprevent.org\/\"><span lang=\"en\" xml:lang=\"en\">http:\/\/prescribetoprevent.org\/<\/span><\/a><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Prevent-protect <\/span><a class=\"rId111\" href=\"https:\/\/prevent-protect.org\/\"><span lang=\"en\" xml:lang=\"en\">https:\/\/prevent-protect.org\/<\/span><\/a><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Prescription Drug Abuse Policy System (PDAPS) <\/span><a class=\"rId112\" href=\"http:\/\/pdaps.org\/\"><span lang=\"en\" xml:lang=\"en\">http:\/\/pdaps.org\/<\/span><\/a><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Healthy People 2020: HP2020 \u2013 Substance Abuse. <\/span><a class=\"rId113\" href=\"https:\/\/www.healthypeople.gov\/2020\/topics-objectives\/topic\/substance-abuse\/objectives\"><span lang=\"en\" xml:lang=\"en\">https:\/\/www.healthypeople.gov\/2020\/topics-objectives\/topic\/substance-abuse\/objectives<\/span><\/a><\/li>\n<\/ul>\n<\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Screening Tools:<\/span>\n<ul>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Opioid Risk Tool. <\/span><a class=\"rId114\" href=\"https:\/\/www.drugabuse.gov\/sites\/default\/files\/files\/OpioidRiskTool.pdf\"><span lang=\"en\" xml:lang=\"en\">https:\/\/www.drugabuse.gov\/sites\/default\/files\/files\/OpioidRiskTool.pdf<\/span><\/a><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">The Screener and Opioid Assessment for Patients with Pain-Revisited tool (SOAPP-R). <\/span><a class=\"rId115\" href=\"http:\/\/www.ccwjc.com\/Forms\/Chronic%20Pain\/SOAPP-R.pdf\"><span lang=\"en\" xml:lang=\"en\">http:\/\/www.ccwjc.com\/Forms\/Chronic%20Pain\/SOAPP-R.pdf<\/span><\/a><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">The Brief Risk Interview. <\/span><a class=\"rId116\" href=\"http:\/\/www.painmed.org\/2014posters\/abstract-206\/\"><span lang=\"en\" xml:lang=\"en\">http:\/\/www.painmed.org\/2014posters\/abstract-206\/<\/span><\/a><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div>\n<div class=\"textbox shaded\">\n<h3 class=\"import-Normal\"><strong class=\"import-Heading2Char\">References<\/strong><\/h3>\n<ol>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Centers for Disease Control and Prevention. Drug Overdose Death Data. Centers for Disease Control and Prevention website. <\/span><a class=\"rId117\" href=\"https:\/\/www.cdc.gov\/drugoverdose\/data\/statedeaths.html\"><span lang=\"en\" xml:lang=\"en\">https:\/\/www.cdc.gov\/drugoverdose\/data\/statedeaths.html<\/span><\/a><span lang=\"en\" xml:lang=\"en\">. <\/span><span lang=\"en\" xml:lang=\"en\">Published December 2017. Accessed August 12, 2018.<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Dwyer-Lindgren L, <\/span><span lang=\"en\" xml:lang=\"en\">Bertozzi<\/span><span lang=\"en\" xml:lang=\"en\">-Villa A, Stubbs RW, et al. Trends and patterns of geographic variation in mortality from substance use disorders and intentional injuries among US counties, 1980-2014. JAMA. 2018<\/span><span lang=\"en\" xml:lang=\"en\">;319<\/span><span lang=\"en\" xml:lang=\"en\">(10):1013-1023.<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Compton WM, Boyle M, Wargo E. Prescription opioid abuse: problems and responses. <\/span><em lang=\"en\" xml:lang=\"en\">Prev<\/em><em lang=\"en\" xml:lang=\"en\"> Med. <\/em><span lang=\"en\" xml:lang=\"en\">2015<\/span><span lang=\"en\" xml:lang=\"en\">;80:5<\/span><span lang=\"en\" xml:lang=\"en\">-9.<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. <\/span><em lang=\"en\" xml:lang=\"en\">JAMA <\/em><em lang=\"en\" xml:lang=\"en\">Psychiat<\/em><em lang=\"en\" xml:lang=\"en\">. <\/em><span lang=\"en\" xml:lang=\"en\">2014<\/span><span lang=\"en\" xml:lang=\"en\">;71<\/span><span lang=\"en\" xml:lang=\"en\">(7):821-826.<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Unick<\/span><span lang=\"en\" xml:lang=\"en\"> GJ, Rosenblum D, Mars S, <\/span><span lang=\"en\" xml:lang=\"en\">Ciccarone<\/span><span lang=\"en\" xml:lang=\"en\"> D. Intertwined epidemics: national demographic trends in hospitalizations for heroin- and opioid-related overdoses, 1993\u20132009. <\/span><em lang=\"en\" xml:lang=\"en\">PLOS ONE. <\/em><span lang=\"en\" xml:lang=\"en\">2013<\/span><span lang=\"en\" xml:lang=\"en\">;8<\/span><span lang=\"en\" xml:lang=\"en\">(2):e54496.<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Peavy<\/span><span lang=\"en\" xml:lang=\"en\"> KM, Banta-Green CJ, Kingston S, Hanrahan M, Merrill JO, Coffin PO. \u201cHooked on\u201d prescription-type opiates prior to using heroin: results from a survey of syringe exchange clients. <\/span><em lang=\"en\" xml:lang=\"en\">J Psychoactive Drugs. <\/em><span lang=\"en\" xml:lang=\"en\">2012<\/span><span lang=\"en\" xml:lang=\"en\">;44<\/span><span lang=\"en\" xml:lang=\"en\">(3):259-265.<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Meldrum ML. The ongoing opioid prescription epidemic. Am J Public Health 2016<\/span><span lang=\"en\" xml:lang=\"en\">;106<\/span><span lang=\"en\" xml:lang=\"en\">(8):1365-66.<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Boscarino<\/span><span lang=\"en\" xml:lang=\"en\"> JA, <\/span><span lang=\"en\" xml:lang=\"en\">Rukstalis<\/span><span lang=\"en\" xml:lang=\"en\"> M, Hoffman SN, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. <\/span><em lang=\"en\" xml:lang=\"en\">Addiction. <\/em><span lang=\"en\" xml:lang=\"en\">2010<\/span><span lang=\"en\" xml:lang=\"en\">;105<\/span><span lang=\"en\" xml:lang=\"en\">(10):1776-1782.<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Compton WM, Jones CM, Stein JB, Wargo EM. Promising roles for pharmacists in addressing the U.S. opioid crisis. [published online ahead of print December 31, 2017] <\/span><em lang=\"en\" xml:lang=\"en\">Res Social <\/em><em lang=\"en\" xml:lang=\"en\">Adm<\/em><em lang=\"en\" xml:lang=\"en\"> Pharm. <\/em><span lang=\"en\" xml:lang=\"en\">10.1016\/j.sapharm.2017.12.009<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Cochran G, Gordon AJ, Field C, et al. <\/span><span lang=\"en\" xml:lang=\"en\">Developing<\/span><span lang=\"en\" xml:lang=\"en\"> a framework of care for opioid medication misuse in community pharmacy. Res Social <\/span><span lang=\"en\" xml:lang=\"en\">Adm<\/span><span lang=\"en\" xml:lang=\"en\"> Pharm. 2016; 12(2):293\u2013301.<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Zahradnik<\/span><span lang=\"en\" xml:lang=\"en\"> A, Otto C, <\/span><span lang=\"en\" xml:lang=\"en\">Crackau<\/span><span lang=\"en\" xml:lang=\"en\"> B, et al. Randomized controlled trial of a brief intervention for problematic prescription drug use in non-treatment-seeking patients. Addiction. 2009<\/span><span lang=\"en\" xml:lang=\"en\">;104<\/span><span lang=\"en\" xml:lang=\"en\">(1):109-117. <\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Bratberg JP. Opioids, naloxone, and beyond: The intersection of medication safety, public health, and pharmacy. J Am Pharm Assoc. 2017<\/span><span lang=\"en\" xml:lang=\"en\">;57<\/span><span lang=\"en\" xml:lang=\"en\">(2):S5 &#8211; S7.<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Cochran G, Field C, and Lawson K. Pharmacists who screen and discuss opioid misuse with patients: Future directions for research and practice. <\/span><em lang=\"en\" xml:lang=\"en\">J Pharm <\/em><em lang=\"en\" xml:lang=\"en\">Pract<\/em><em lang=\"en\" xml:lang=\"en\">. <\/em><span lang=\"en\" xml:lang=\"en\">2015<\/span><span lang=\"en\" xml:lang=\"en\">;28<\/span><span lang=\"en\" xml:lang=\"en\">(4):404-412.<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Strand MA, <\/span><span lang=\"en\" xml:lang=\"en\">Eukel<\/span><span lang=\"en\" xml:lang=\"en\"> H, <\/span><span lang=\"en\" xml:lang=\"en\">Burck<\/span><span lang=\"en\" xml:lang=\"en\"> S. Moving opioid misuse prevention upstream. [<\/span><span lang=\"en\" xml:lang=\"en\">published<\/span><span lang=\"en\" xml:lang=\"en\"> online ahead of print July 17, 2018]. Res Social <\/span><span lang=\"en\" xml:lang=\"en\">Adm<\/span><span lang=\"en\" xml:lang=\"en\"> Pharm. 2018.<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Haines ST, <\/span><span lang=\"en\" xml:lang=\"en\">Pittenger<\/span><span lang=\"en\" xml:lang=\"en\"> AL, <\/span><span lang=\"en\" xml:lang=\"en\">Stolte<\/span><span lang=\"en\" xml:lang=\"en\"> SK, et al. Core <\/span><span lang=\"en\" xml:lang=\"en\">entrustable<\/span><span lang=\"en\" xml:lang=\"en\"> professional activities for new pharmacy graduates. Am J Pharm Educ. 2017; 81(1): Article S2.<\/span><\/li>\n<li class=\"import-Normal\"><span lang=\"en\" xml:lang=\"en\">Cochran G, Field C, and Lawson K. Pharmacists who screen and discuss opioid misuse with patients: future directions for research and practice<\/span><em lang=\"en\" xml:lang=\"en\">. J Pharm <\/em><em lang=\"en\" xml:lang=\"en\">Pract<\/em><span lang=\"en\" xml:lang=\"en\">. 2015<\/span><span lang=\"en\" xml:lang=\"en\">;28<\/span><span lang=\"en\" xml:lang=\"en\">(4):404-412.<\/span><\/li>\n<\/ol>\n<\/div>\n<div style=\"width: 1416px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/4834\/2019\/09\/30133922\/image1.png\" alt=\"image\" width=\"1406\" height=\"1328\" \/><\/p>\n<p class=\"wp-caption-text\">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.<\/p>\n<\/div>\n<div class=\"textbox examples\">\n<h3>Glossary and Abbreviations<\/h3>\n<ul>\n<li><a href=\"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/front-matter\/glossary\/\">Glossary<\/a><\/li>\n<li><a href=\"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/front-matter\/abbreviations\/\">Abbreviations<\/a><\/li>\n<\/ul>\n<\/div>\n<\/div>\n\n\t\t\t <section class=\"citations-section\" role=\"contentinfo\">\n\t\t\t <h3>Candela Citations<\/h3>\n\t\t\t\t\t <div>\n\t\t\t\t\t\t <div id=\"citation-list-100\">\n\t\t\t\t\t\t\t <div class=\"licensing\"><div class=\"license-attribution-dropdown-subheading\">CC licensed content, Original<\/div><ul class=\"citation-list\"><li><strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/\">CC BY-NC: Attribution-NonCommercial<\/a><\/em><\/li><\/ul><\/div>\n\t\t\t\t\t\t <\/div>\n\t\t\t\t\t <\/div>\n\t\t\t <\/section>","protected":false},"author":53384,"menu_order":8,"template":"","meta":{"_candela_citation":"[{\"type\":\"original\",\"description\":\"\",\"author\":\"\",\"organization\":\"\",\"url\":\"\",\"project\":\"\",\"license\":\"cc-by-nc\",\"license_terms\":\"\"}]","CANDELA_OUTCOMES_GUID":"","pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-100","chapter","type-chapter","status-publish","hentry"],"part":3,"_links":{"self":[{"href":"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/wp-json\/pressbooks\/v2\/chapters\/100","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/wp-json\/wp\/v2\/users\/53384"}],"version-history":[{"count":13,"href":"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/wp-json\/pressbooks\/v2\/chapters\/100\/revisions"}],"predecessor-version":[{"id":357,"href":"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/wp-json\/pressbooks\/v2\/chapters\/100\/revisions\/357"}],"part":[{"href":"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/wp-json\/pressbooks\/v2\/parts\/3"}],"metadata":[{"href":"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/wp-json\/pressbooks\/v2\/chapters\/100\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/wp-json\/wp\/v2\/media?parent=100"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/wp-json\/pressbooks\/v2\/chapter-type?post=100"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/wp-json\/wp\/v2\/contributor?post=100"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/courses.lumenlearning.com\/suny-public-health-in-pharmacy-practice\/wp-json\/wp\/v2\/license?post=100"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}