On the Front Lines: Pharmacists' Role in Combating America's Opioid Epidemic
The ongoing opioid crisis in the United States shows no signs of slowing down. As trusted community health care professionals, pharmacists must play a key role in fighting it.
In 2010, there were 21,089 overdose deaths involving opioids in the United States.1 That number may seem significant contrasted with years prior, but it pales in comparison to the overdose rates of today: Data from the CDC showed there were over 109,000 drug overdose deaths in 2022, with nearly 70% due to synthetic opioids such as fentanyl.2 That represents an almost 6-fold increase in opioid overdose deaths in just over a decade, something any person would find wholly difficult to comprehend.
Map of the US filled with pills / Victor Moussa - stock.adobe.com
Although drug overdose deaths had been on the rise for years, the issue—like many others—was exacerbated by the COVID-19 pandemic. This is starkly shown in emergency department visit rates. Compared with 2018 and 2019, visits to the emergency department due to an opioid overdose increased by 28.5% in 2020 across the country.3 This is likely due to several factors associated with the implementation of public health safety measures, which left countless patients feeling isolated and with a lack of access to support and interventions.4
Plenty has been done to quell the flames of the opioid crisis. Both the Obama and Trump administrations threw billions of dollars at the issue and signed legislation to improve access to treatments. More recently, the Biden administration implemented a nearly $450 million initiative to strengthen prevention, harm reduction, treatment, and recovery support services.5
And while physicians obviously play an integral part in combating the public health crisis, what about pharmacists? What role do they play in this story? What barriers do they face in helping to alleviate the untold burden that so many people face?
“People working in community pharmacies are really frustrated,” said Nina Vadiei, PharmD, BCPP, clinical associate professor of pharmacotherapy at University of Texas at Austin. “They feel like there are huge barriers in the operation and structures of retail pharmacies that prevent them from fulfilling the role that they were taught to take on in their pharmacy training. [Pharmacists] see their role as very important. They’re at the front lines meeting with patients more often than their prescribers. They’re able to pick up on potential opioid misuse or even uncontrolled pain and other problems.…Their role is kind of called into question both by the prescribers and the patient because of the structure of pharmacies, where they often don’t have the time and the resources and staff support to have in-depth conversations with their patients and demonstrate what their role really is.”
How Did We Get Here?
The current opioid epidemic in the US began in the 1990s, which is recognized as the first of 3 waves of the crisis. Prior to that point, the majority of medical professionals believed opioids should be prescribed only in the most severe of cases, such as for patients who were terminally ill with cancer, due to the drugs’ high potential for addiction and abuse. However, everything changed with the 1996 arrival of oxycodone hydrochloride, a synthetic opioid more commonly known as OxyContin.6
The drug, developed and patented by Purdue Pharma, was approved by the FDA in 1995. The medication treats moderate to severe pain and chronic pain, and provides a sustained release of its active ingredient, oxycodone, over a 12-hour period. Although research at the time showed that OxyContin had no advantage over appropriate doses of other opioids, it was heavily marketed and promoted by Purdue. Sales of the drug skyrocketed, growing from $48 million in 1996 to over $1 billion in 2000. With the significant increase in supply, OxyContin soon became a major drug for abuse by 2004.7
The second wave of the epidemic, characterized by a rise in heroin use, grew out of the first wave. Many new heroin users transitioned from opioid pills due to their growing dependence and an inability to get enough supplies through prescriptions or illegal means. The wider availability of heroin on the street, as well as its more affordable price, made it much more attractive to younger users. Indeed, a main difference between the first and second waves was the age of users: The first wave was mostly confined to those aged 50 to 64 years, whereas those aged 20 to 34 years made up most of the second wave.8
Synthetic opioids are the drivers of the third wave of the opioid epidemic, with fentanyl playing a starring role. Fentanyl is prescribed to treat complex pain conditions and pain related to surgery. It is 50 times stronger than heroin and 100 times stronger than morphine, making even a tiny dose potentially lethal.9 However, the main culprit to blame in the opioid crisis is illegally made fentanyl, sourced almost exclusively from China.8 In 2016, there were 46.6 per million fentanyl-associated deaths outside of hospitals. That number rose to 178 per million in 2021, representing an astonishing 282% increase.10
The Pharmacist as Gatekeeper
Because independent pharmacists are medication experts and trusted members of their communities, it may seem obvious that they are crucial to solving the opioid epidemic. But in reality, that doesn’t seem to be the case: Although pharmacists see themselves as important to solving the issue, providers and even patients are not entirely sold on the idea. Vadiei and her colleagues conducted a study in 2021 to find out how pharmacists saw their role in the opioid crisis and to identify some of the biggest challenges to fulfilling it.11
Among the findings, pharmacists said they see themselves as gatekeepers in preventing opioid misuse and overdose. A couple of the common pharmacy practices they believe can help are providing education to patients and communicating with prescribers. However, aside from the reported challenges in pharmacy structure, operation, and time, a lack of communication with patients and providers about the pharmacists’ scope of practice was the biggest concern.
“There are no good, direct communication lines between the prescriber and the pharmacist,” Vadiei said. “To a patient, the pharmacist and the prescriber are just 2 different people who are not in direct lines of communication. The prescriber is the one who makes the decision on what they’re taking. The pharmacist’s job is just to make sure they get it.”
But, Vadiei explained, “that’s not our role. We’re supposed to ensure safe and effective use of the medication, not just give it to them.”
The study concluded that although pharmacists see their role in preventing opioid misuse and overdose as vital, the many challenges—chief among them a lack of recognition from patients and providers—was hampering their ability to help.
"I think it’s really crucial,” Vadiei said. “The only way I’ve seen pharmacists work collaboratively with prescribers is to talk frequently with one another. The more frequently you actually have that line of communication, that’s when it’s normalized. But when you work in a community setting, where all you can do is call and leave voicemails, and oftentimes not even the doctor is calling back, it’s their assistant or [someone else], then we can’t have that collaborative relationship to have those important conversations about how to help patients.”
Improving Patient Support
Nathaniel M. Rickles, PharmD, PhD, BCPP, is a professor of pharmacy practice and the associate dean for admissions and student affairs at the University of Connecticut School of Pharmacy. His research focuses on how community pharmacists can improve medication adherence and safety in vulnerable populations. But he also works on getting pharmacists more engaged in the issues of opioid abuse and overdose, as well as educating providers on best practices around opioids. To Rickles, open collaboration with prescribers is key to improving support for pharmacists battling the opioid crisis.
“If [a pharmacist] take[s] the time out to call a doctor, and to express [their] concern, is the doctor going to want to hear from [them]?” Rickles asked. “Are they going to support [their] involvement? Or are they going to say, ‘You know what, community pharmacists, bug off. I don’t want to hear from you. I made this decision to prescribe this medication for my patient; leave me alone.’” Instead, Rickles said, “if we can really, truly support one another and our engagement in this and be receptive to any feedback that we get about potential concerns, I think that would be a great place to start.”
Technology that gives pharmacists a set of questions to ask patients and sends referrals to local recovery or treatment centers also could help, Rickles said. Because pharmacists often lack the time to follow up with patients, once patients leave the pharmacy, they could easily get lost in the noise. Software that sends immediate referrals could largely alleviate that problem and get the patient the help that they need.
Vadiei added that support for day-to-day pharmacy functions is another key barrier keeping pharmacists from taking on the issue of opioid abuse. According to a poll conducted by the National Community Pharmacists Association in 2022, 67% of respondents said they are having trouble filling open positions, with more than 80% saying the pharmacy technician position is the hardest one to fill. A lack of staff impacts daily operations and increases the time patients wait for their prescriptions.12 Vadiei said that pharmacists being reimbursed for their services would help, as well.
“Pharmacies are struggling financially,” Vadiei said. “I think on a greater scale we need to address reimbursement of pharmacist clinical services. If we want pharmacists to have a bigger role in intervening and referring patients for harm reduction services, for example, or anything they need related to opioid use disorder, we need to be reimbursed for that time. Otherwise, corporate leaders are not incentivized to have pharmacists prioritizing those types of tasks.”
An Evolving Problem
The opioid epidemic in America doesn’t seem to be slowing down. Provisional data from the CDC estimates there were over 111,000 drug overdose deaths in the 12-month period ending in September 2023.13 Research is also now pointing to a fourth wave of the crisis, thought to be driven by the widespread polysubstance use of stimulants and fentanyl. Overdose deaths involving both drugs have increased drastically, from 235 in 2010 to 34,429 in 2021.14 As the problem continues to evolve, health care providers must evolve along with it.
Part of that evolution entails erasing the negative stigma that has long followed people dealing with opioid use disorder; pharmacists are well positioned to accomplish this. Many of the stigmas faced by those with opioid use disorder stem from views that it is entirely a personal choice, and that those dealing with the issue are somehow immoral or have a weak character. This only serves to ostracize those with the disorder, making them less likely to seek help.15 Independent pharmacists can help stop the stigmatization of people with opioid use disorder, as the pharmacists are viewed as trusted health care professionals in their community.
Rickles said that pharmacies should seek out a recovery-friendly designation, which would let people know that it is a safe environment to ask for help. He also said that advocating within the community would go a long way in informing people about opioid use disorder, helping to further break down barriers.
“We should be getting out there and doing community fairs,” Rickles added. “Not to be cliche, but we really need to put community back into the [term] community pharmacists. We really need to be there in the public, in different places, and actually putting up tables, having our students with us, and really educating the public and actually getting out to practices.”
READ MORE: Substance Use Disorder Resource Center
References
1. Drug overdose death rates. National Institute on Drug Abuse. June 30, 2023. Accessed March 8, 2024. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates
2. Tanz LJ, Gladden RM, Dinwiddie AT, et al. Routes of drug use among drug overdose deaths—United States, 2020-2022. MMWR Surveill Summ. 2024;73(6):124-130. doi: 10.15585/mmwr.mm7306a2
3. Harringa A. Emergency department visits related to opioid overdoses up significantly during COVID-19 pandemic. Mayo Clinic. July 26, 2021. Accessed March 8, 2024. https://newsnetwork.mayoclinic.org/ discussion/emergency-department-visits-related-to-opioid-overdoses-up-significantly-during-covid19-pandemic/#
4. Ghose R, Forati AM, Mantsch JR. Impact of the COVID-19 pandemic on opioid overdose deaths: a spatiotemporal analysis. J Urban Health. 2022;99(2):316-327. doi:10.1007/s11524-022-00610-0
5. Fact sheet: on Int’l Overdose Awareness Day, the Biden-Harris administration announces more than $450 million in new funding to support President Biden’s unity agenda efforts to beat the overdose epidemic and save lives. News release. The White House. August 31, 2023. Accessed March 8, 2024. https://www.whitehouse.gov/briefing-room/statements-releases/2023/08/31/fact-sheet-on-intloverdose-awareness-day-the-biden-harris-administration-announces-more-than-450-million-in-newfunding-to-support-president-bidens-unity-agenda-efforts-to-beat-t
6. Ho JY. The contemporary American drug overdose epidemic in international perspective. Popul Dev Rev. 2019;45(1):7-40. doi:10.1111/padr.12228
7. Van Zee A. The promotion and marketing of OxyContin: commercial triumph, public health tragedy. Am J Public Health. 2009;99(2):221-227. doi:10.2105/AJPH.2007.131714
8. Ciccarone D. The triple wave epidemic: supply and demand drivers of the US opioid overdose crisis. Int J Drug Policy. 2019;71:183-188. doi:10.1016/j.drugpo.2019.01.010
9. Fentanyl facts. CDC. September 6, 2023. Accessed March 8, 2024. https://www.cdc.gov/stopoverdose/ fentanyl/index.html
10. Jeffery MM, Stevens M, D’Onofrio G, Melnick, ER. Fentanyl-associated overdose deaths outside the hospital. N Engl J Med. 2023;389(1):87-88. doi:10.1056/NEJMc2304991
11. Vadiei N, Eldridge LA, Meyerson BE, Agley J. “The gatekeepers in prevention”: community pharmacist perceptions of their role in the opioid epidemic. Subst Abus. 2022;43(1):319-327. doi:10.1080/0889707 7.2021.1941516
12. Survey: three-quarters of community pharmacies report staff shortages. News release. National Community Pharmacists Association. August 11, 2022. Accessed March 8, 2024. https://ncpa.org/ newsroom/news-releases/2022/08/11/survey-three-quarters-community-pharmacies-report-sta"- shortages
13. Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug overdose death counts. CDC. February 14, 2024. Accessed March 8, 2024. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm#notes
14. Friedman J, Shover CL. Charting the fourth wave: geographic, temporal, race/ethnicity and demographic trends in polysubstance fentanyl overdose deaths in the United States, 2010- 2021. Addiction. 2023;118(12):2477-2485. doi:10.1111/add.16318
15. Cheetham A, Picco L, Barnett A, Lubman DI, Nielsen S. The impact of stigma on people with opioid use disorder, opioid treatment, and policy. Subst Abuse Rehabil. 2022;13:1-12. doi:10.2147/SAR.S304566
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