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.