As a pharmacist, I have encountered many patients on opioid prescriptions. I have dealt with prescription forgery, intervened with prescriptions that do not meet legal requirements, and met patients who were frustrated when their prescriptions could not be dispensed due to a variety of reasons. I have observed aberrant behaviours from patients requesting early prescription refills, asking for dose increases or claiming to have lost the medication supply. Some of my encounters with patients have resulted in tearful responses, as opioids have allowed them to function, to have a life without being affected by their debilitating conditions. For me, these situations are often filled with anxiety and sometimes fear. I am guessing they aren’t easy for other pharmacists either.
I also see a variety of prescribing patterns. I often see dentists prescribing Percocet when I think Tylenol No. 3 may offer similar pain relief and has less addictive potential. I have seen prescriptions from emergency physicians for large quantities of opioids when I wonder whether a smaller quantity may be sufficient. I once dealt with a nurse requesting a morphine infusion pump on behalf of a palliative patient, only to realize the patient had passed away weeks earlier, prompting a call to the College of Nurses. I also understand prescribers’ vulnerability, the fact that sometimes they want to discuss tapering or de-prescribing opioids, but may be fearful that the interactions with their patients will be difficult.
Recently in Ontario, the pharmacy community has focused on ensuring we have a controlled system to distribute fentanyl patches to prevent diversion (e.g. the Patch-For-Patch program). We also have a system to distribute naloxone kits and educate the public on how to administer them in case of opioid overdose. And there is an increased effort by the medical community as a whole to focus on providing opioid substitution therapy such as with methadone or buprenorphine/naloxone in the community, both for physicians, to learn how to prescribe, and for pharmacists to learn how to safely provide these medications to patients.
While these harm reduction efforts are important, I believe they do not address the root causes of the opioid crisis. I believe there is much work needed to improve mental health in the general population as well as the prescribing practices of opioids in the community. Below are some ways pharmacists can help.
More training for pharmacists in mental health
It is important for pharmacists to learn how to interact with patients who have depression, anxiety and other mental health conditions, especially if they also happen to be consuming high doses of opioids. Pharmacists should learn how to screen for mental health issues and where to refer people for community resources, especially those who may not have access to a family physician in the community. We could take a lesson from Nova Scotia, where they have established the Bloom Program, a partnership between pharmacy and the mental health and addiction community, through which pharmacists screen for at-risk patients and connect them with local resources as necessary. I would also like to see more training about mental health incorporated into the pharmacy curriculum. In addition, it would help if pharmacies were able to modify their spaces so that people could speak safely and privately with their pharmacists.
Collaboration with prescribers
Pharmacists should be working closely with prescribers in cases of both acute and chronic non-cancer pain. With patients receiving medication for acute pain, pharmacists can share relevant updates or warning signs of potential opioid use disorder. For chronic non-cancer pain, routine monitoring and assessment are important as well. If tapering is seen as necessary, the pharmacist could help adapt the prescription based on the agreed-upon goals, timeline, and availability of different opioids. Prescribers who are writing tapering prescriptions must take a variety of legal requirements and clinical considerations into account. They can focus on the overall goal of de-prescribing, while pharmacists can focus on executing the plan and following up with patients as needed in order to manage any withdrawal symptoms. The Canadian Pharmacists Association has identified the priority of encouraging an interdisciplinary approach to opioid prescribing and allowing pharmacists to adapt prescriptions as necessary.
Rethinking the funding structure for pharmacists
The majority of revenue made by community pharmacies is from prescriptions—more prescriptions are more lucrative for business. But we also know that more prescriptions often translate into more drug interactions, and adverse drug-related events. If we want to advocate for de-prescribing and for helping patients come off unnecessary medications, we need to think about how to utilize pharmacists’ knowledge and skills without connecting them to this business model. I think the government should develop some incentives for pharmacists to work directly with patients to taper off their medications. If we shift pharmacists to work within primary care offices, there would be no conflict of interest to “sell more drugs.” Incorporating pharmacists in the primary care setting has been shown to improve safe prescribing and prevent medication-related adverse events.
We need more thinking about how pharmacists can collaborate with prescribers and work closely with patients to address the opioid crisis with compassion and perseverance. Our entire system needs to be better integrated, and pharmacists’ unique perspective is an important voice in these efforts.
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That’s all chronic pain patients need are the pharmacist to have incentives to substitute their long term medications used for chronic pain for suboxone. You are ruining people’s lives. People are committing suicide because of so-called pharmacists like you. Your job is to fill prescriptions and not to judge people’s disabilities and pain issues Since when do you have a medical degree?
What does the prescriber’s vulnerability mean?
The interference in patients lives is immoral. Many people have led successfully for years on their opioid medications! People of 50, 60 and 70 who have worked, raised good families and could do so because of medication. Canada legalized weed but you can’t purchase Tylenol number one now. It’s a joke older people will now go to Cannabias which is more dangerous and unfimilar to them as they age. Pharmacists are now militant, and gleeful espresso when they can prevent you from getting your pain medication. Grown up people have been using opioid med for decades sensibly. We don’t need big brother making our final years harder. Young person who pharmacists and Drs gleefully stop their medication are now committing suitcase because they are desperate. The drs and pharmacists are contributing to Suicide because of their smug “I’m better than you” attitude. It’s becoming a police state in Canada. So much interference in our adult lives.
Well said.
YOUR JOB IS TOO FILL THE BOTTLES AND LABEL THEM. IT IS NOT YOUR PLACE TO QUESTION MY PERSCRIPTION FOR PAIN MEDS…THATS BETWEEN MY DOCTOR AND ME. YOU DONT REALIZE THE DAMAGE YOU DO WHEN YOU INTERFERE.THEY ARE DOING THE SAME THING WITH THE OPIOD CRISES AS THEY ARE DOING WITH THE GUN LAWS WHICH IS MAKING THE HONEST PEOPLE AND DESERVING PEOPLE AND THE ONES WHO NEED THIS MEDICATION…SUFFER…GO AFTER THE REAL CRIMINALS..THE ONES WHO ARE MANUFACTORING IT ILLEGALLY AND SELLING IT ON THE STREET.MY DOCTOR MONITORS ME ON THIS AND EVEN HAS ME GIVE A URIN SAMPLE EVERY TWO MONTHS OR SO AND HAS EDUCATED ME ON THE USE AND MIS-USE OF NARCOTICS…SO TO SUM IT ALL UP…BUT OUT AND MIND YOUR BUSINESS..
You’re 100% correct.
The main result of this so called opiate crisis, is an increase in suffering. I have multiple disks in my back that are compressing on my spinal cord, and the pain is worse than anything else. I work around electric power, often 480 volts, and have accidentally bumped up against it, and that does not cause me too much pain compared to what I feel in my back, as it just feels like I have been bit by some small nasty animal. Yet far too many people do not see limiting access to pain medications for those that need it as something important, and as a result of this crackdown I have decided if I loose my wife, or my stuff time for me to leave. That is because life to me is suffering, that suffering gets worse every day little by little. It is at the point that I am unable to work even part time due to pain with pain medications (as no doctor will prescribe anything strong enough to be able to function again, and sinus pain that is only helped by antibiotics. I figure that if the desire was to show me that life is worth living and the same for the many millions that take their life every year because of pain. That we would not be forced to suffer so much. Sure opiates can be dangerous, and the stuff over the counter is even more dangerous to people with severe pain, as the levels required to get any level of relief exceed the levels that cause liver and kidney failure. That can only mean that those that are making it so difficult for people to get such medications want people to die, far as I can see it. I know the risks involved with opiates, they cause respiratory depression can in some cases cause addiction, and should be available to those of us that have pain, but there is no excuse to give them to people that are only dealing with depression, as there are far better things that are far more effective. I am already past the point where I feel that life is enjoyable and should be promoted, as I decided that I do not want any child of mine to be born into such a cruel world that promotes suffering and the only real way to stop the suffering is death because it is too difficult for most to get medical help that will stop the pain enough to make life enjoyable. I don’t know how to earn enough to live on working about an hour 2 or 3 days a week either.
I agree with you Allen. It’s inhumane to force people to live with debilitating pain.
This is exactly why I am shifting career focus on Monday. Excellent article. You have identified many valid points, many valid opportunities for pharmacists to get involved in really making a difference for the future.
Bit of advise on changing carriers, even though there is said to be a demand and a need for people in some carrier field does not mean that it is a good choice, as there are many jobs that used to pay well that now days one could earn far better and have less education requirements than many other fields. There are things that all of us enjoy from time to time and think that it is a good choice, such as I and many others have done and then completely unable to find work in that field and places that are hiring in that field pay far less than one earns working as a sales person at a fast food restaurant. The biggest complaint that I heard from people with a doctorate in the former Soviet Union is that they earn the same as a garbage collector, and here in the USA garbage collectors earn more than the majority of electrical engineers when looking at global wages.
We need more funding to support the integration of pharmacists in primary care teams. Period.
As a pharmacist who has practiced in a hospital and community pharmacy, and now in a Family Health Team, I feel that I am fortunate to better utilize my knowledge and skills in a rewarding collaborative practice model. For example, I work closely with our team’s physicians and nurse practitioner in our clinic’s opioid stewardship program for chronic non-cancer pain.
I am hopeful that support of the Patient Medical Home enables further primary care transformation, and organizations such as the Ontario Pharmacists Association and the Canadian Pharmacists Association strengthen advocacy efforts to better integrate pharmacists in collaborative practice models in primary care.
There is a real need for pharmacists as there are many doctors that do not pay attention to what the possible interactions are or wrongly prescribe medications, and do often misdiagnose problems. There is the other problem with paperwork being more important than the lives of people, and testing that makes no sense other than for them to look like they are doing something that wastes money and does harm to those that need medical help.
Pharmacists have professional obligations to patients to address all of the issues raised by the author (e.g. advising about harmful drug interactions). So why aren’t pharmacists doing those things? oh, yeah, it’s easier to make money by simply following the prescriber’s prescription and then forget about it.