Decreasing the harms of prescription opioids: a case for pharmacists

The attitudes and practice strategies of community pharmacists towards drug misuse management: A scoping review

WHAT IS KNOWN AND OBJECTIVE

Community pharmacists have a key role to play in addressing drug misuse. The objective of this research was to systematically review the current evidence and investigate the attitudes and practice strategies of community pharmacists towards drug misuse management.

METHODS

Data were extracted from 19 studies retrieved via a three-step search strategy using the Arksey and O'Malley methodological framework for conducting scoping reviews.

RESULTS AND DISCUSSION

The attitudes and practice strategies of pharmacists towards drug misuse management and relevance to years of practice experience were discussed in seven of the 19 studies. Pharmacists reported gaps in knowledge and insufficient education and training on drug misuse-related topics. Barriers to the effective management of drug misuse included lack of time and staff training. The most commonly reported strategy to address drug misuse was referral back to the doctor. Eight of the studies identified the benefits of real-time prescription monitoring systems. Pharmacists have a key role to play in addressing drug misuse. Opportunities exist in the development of new and innovative approaches for harm minimization led by pharmacists, and in the examination and evaluation of the pharmacists' role in referral services, interventions and screening.

WHAT IS NEW AND CONCLUSION

It is important to consider the role and contribution of early career pharmacists in the delivery of primary health care. They are the future of the pharmacy profession; therefore, it is critical that they are sufficiently trained and provided with the necessary resources to ensure high quality care in the management of drug misuse.

Challenges faced with opioid prescriptions in the community setting - Australian pharmacists' perspectives

BACKGROUND

Prescription opioids (POs) are well recognised for their role in pain management. However over recent years, use of POs has become an increasingly complex public health issue, with the emergence of increasing quantities of POs being misused and abused. Pharmacists represent the 'gatekeepers' of medicines, which can be a challenging role, relating in particular to POs.

OBJECTIVE

This study aimed to gain insight into the challenges Australian community pharmacists experience in the dispensation of POs.

SETTING

Sydney Australia.

METHOD

Twenty-five pharmacists were recruited from suburbs in and around Sydney, Australia. Pharmacists were interviewed using an in-depth, semi-structured protocol. All interviews were audio-recorded, transcribed and thematically analysed.

MAIN OUTCOME MEASURE

Identification of issues/factors that may influence the dispensing of POs.

RESULTS

Pharmacists were reportedly confronted with several issues in the dispensing of POs, particularly in relation to the patient and prescriber. Pharmacists reported some individuals becoming increasingly more "creative" in the methods used to obtain POs, rendering detection of potential abuse/misuse increasingly difficult. Poor professional relationships with prescribers-an apparent power dynamic between the two professions, and limited engagement with patients were issues also identified. The majority of participants suggested that an electronic monitoring database would help in the identification of PO abuse/misuse.

CONCLUSION

Education is required to emphasise the importance of inter-professional collaboration between pharmacists and prescribers, as is empathy in the pharmacist-patient relationship. Prescription drug monitoring programs and prescribers sending electronic prescriptions directly to the pharmacist were perceived as helpful initiatives to undertake.

Implementation of a clinical tool to assess and address pain management requests in the pharmacy

BACKGROUND

Morbidity and mortality associated with inappropriate use of over-the-counter combination analgesics containing codeine (OTC CACC) in Australia resulted in it being upscheduled in 2010 from "Pharmacy Only" (Schedule 2) to "Pharmacist Only" (Schedule 3), and further to "Prescription Only" (Schedule 4) in February 2018. There have been a number of concerns and challenges identified by community pharmacists in the provision of OTC CACC. In practice, sub-optimal management of patients accessing these medications has been demonstrated. To assist the management of patients using OTC CACC, the development of a management and referral pathway would be advantageous.

OBJECTIVES

To evaluate the use of an online interactive clinical tool and/or clinical information via an online PDF-based platform for managing OTC CACC requests and codeine dependence.

METHOD

Two interactive online clinical tools to aid management of patients who presented requesting OTC CACC were developed. Evaluation of these tools was undertaken using responses to multiple choice questions and feedback from pharmacist surveys.

RESULTS

Of the 904 pharmacists who responded to the evaluation survey, 66.7% had not used the tool in the preceding 12 months. The most common reason why pharmacists did not access either the online interactive, or online PDF clinical tools was that they had no knowledge of them. Older age of the pharmacist (50 years or older compared to younger than 30) predicted tool access (adjusted proportional odds ratio = 3.16, 95% CI 1.72-5.80, p < 0.001). The access of the tool was positively associated with it being perceived as useful (adjusted odds ratio = 14.7, 95% CI 6.7-32.5, p < 0.001).

CONCLUSION

A number of pharmacists participating in the evaluation had never accessed either the online interactive or online PDF clinical tool, as they were not aware of them. Further research needs to be conducted into how to best promote and increase awareness of online clinical tools to pharmacists, especially younger pharmacists, and determine the best way to integrate online clinical tools effectively and efficiently into current practice.

Opioid Prescribing Practices and Training Needs of Québec Family Physicians for Chronic Noncancer Pain

Aim

To examine medical practices and training needs of Québec family physicians with respect to pain management and opioid prescription for chronic noncancer pain (CNCP).

Methodology

An online survey was carried out in 2016.

Results

Of 636 respondents (43.0% men; 54.3% ≥ 50 years old), 15.2% and 70.9% felt very or somewhat confident that they could properly prescribe opioids for CNCP. Concerns related to abuse (72.5% strongly/somewhat agree), dependence (73.2%), and lack of support (75.4%) were the main barriers reported. Only 19.7% always/often screened their patients for risks of abuse and dependence using a screening tool. About two-thirds of participants (65.7%) had recently (last five years) taken part in continuing education programs on opioid use for CNCP and 73.4% on CNCP management. Patient evaluation and differential diagnoses of chronic pain syndromes were rated as a top priority for further training.

Conclusions

This study provides insights into Québec family physicians' concerns, practices, and needs with respect to the management of CNCP. Physicians' difficulties around the application of strategies to mitigate the problem of opioid abuse and addiction are worrying. The need to better train physicians in the field of pain and addiction cannot be emphasized enough.

Knowledge, Perceptions and Attitudes toward Chronic Pain and Its Management: A Cross-Sectional Survey of Frontline Pharmacists in Ontario, Canada

The treatment of chronic pain consumes a significant share of primary care. Community and family health team pharmacists frequently see patients with chronic pain, thus have the opportunity to improve their care. To assess the knowledge, perceptions, and attitudes of Ontario pharmacists, we invited 5,324 Ontario pharmacists, to participate in an online survey we developed using Qualtrics. The 31-question survey gathered demographic information, assessed pharmacists' knowledge of three chronic pain conditions; chronic lower back pain (CLBP, eight true/false statements); chronic headache disorder (CHD, eight true/false statements) and painful diabetic neuropathy (PDN, seven true/false statements), and their attitudes toward and perceptions of patients with these conditions, and knowledge, attitudes, and perceptions of opioids in pain management. We received 688 responses (12.9%) and 392 pharmacists completed the survey. The mean age of respondents was 48.5 years and 48.5% were male. More than 50% of respondents were in practice for more than 20 years and 58.7% worked 25-40 hours per week. The mean knowledge scores were 4.5/8, 5.5/8, and 5.3/8 for CBLP, CHD, and PDN respectively. While 95% of respondents were aware of the increasing death rates due to opioid use, only half were familiar with the Canadian guideline for safe opioid prescribing for non-cancer use. Responses were compared based on gender, time in practice and location of practice. Pharmacists with more than ten years of experience scored significantly higher than those with less experience. Fewer differences were found in comparisons of gender and location of practice. Safe and effective care of chronic pain patients, particularly with opioids, will require additional pharmacist education.

Patient recall of health care provider counseling for opioid-acetaminophen prescriptions

OBJECTIVE

The aim of this study was to determine the frequency and nature of physician, nurse, and pharmacist verbal counseling at the time of a new prescription for an opioid-acetaminophen containing medication as recalled by patients.

DESIGN

A mixed methods approach with data from cross sectional, structured interviews was used.

SETTING

The settings were one academic emergency department in Chicago, IL and one outpatient pharmacy at a public hospital in Atlanta, GA.

PATIENTS

One hundred forty-nine patients receiving a new prescription for an opioid-acetaminophen medication were enrolled.

METHODS

Interviews assessed patient recall of counseling they received from their physician, nurse, and pharmacist upon receiving the new prescription. Their responses were unitized and assigned to categories.

RESULTS

One hundred forty-nine patients were enrolled; 61.1% African American and 58.4% female. Seven major categories of responses were noted; frequencies of patient recall for counseling in these categories were reported. Four categories related to the content of the counseling discussion were (1) details of administration (patient recall counseling from: physician/nurse only 44.3%, pharmacist only 5.4%, both providers 12.8%); (2) activities to avoid and side effects (36.2%, 4.7%, 8.7%); (3) medication indication (32.9%, 4%, 4%); and (4) addictive potential (9.3%, 1.3%, 0%). Three categories describe patients' recall of the interaction in broad terms: (5) being referred to print informational material accompanying the prescription (MD/RN only 7.4%, pharmacist only 20.1%, both providers 2.7%); (6) having questions solicited (0%, 11.4%, 0%); (7) having no interaction relating to medication counseling (3.4%, 32.2%, 1.3%).

CONCLUSIONS

Patients infrequently recall counseling from providers on topics that are important to prevent harm from opioid-acetaminophen prescriptions. Future patient-centered clinical research should target identifying optimal strategies to convey these critical messages.