From bad to worse: Pharmacy professors address opioid epidemic intensified by the coronavirus
As the coronavirus consumes much of the world’s attention, health care issues that existed prior to the outbreak haven’t politely receded to the shadows. On the contrary, the opioid epidemic has been exacerbated by the pandemic and its massive social and financial ramifications.
According to data released in July by the Michigan Department of Health and Human Services, there were 3,756 EMS responses for probable opioid overdoses in the state from April through June of this year, compared to 2,994 during the same period last year. What’s more, emergency department visits for opioid overdose from April to May of this year — as the coronavirus took hold in Michigan — increased by 42%.
“The opioid epidemic and the coronavirus pandemic are colliding,” said Clinical Professor of Pharmacy Practice Victoria Tutag Lehr of the Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences. “We’re faced with significant stressors ranging from people losing their jobs to anxiety and depression exacerbated by isolation.”
Experts had predicted that overdoses would increase during the pandemic due to the stress of sheltering at home, employment issues and other hardships. The coronavirus also decreased the amount of support that’s been available, as rehab facilities and services have either temporarily closed or reduced care, and many health care providers have shifted to telemedicine, which is not accessible to or effective for all patients.
“Opioid use disorder is a chronic, relapsing, lifelong condition,” said Tutag Lehr. “Managing it requires sustained treatment and support, similar to other chronic conditions such as diabetes and heart disease.”
She believes pharmacists can provide crucial help during the pandemic’s dire circumstances, and is working with Assistant Clinical Professor of Pharmacy Practice Insaf Mohammad to increase pharmacists’ awareness about the importance of ensuring that patients with opioid use disorder (OUD) have access to buprenorphine, a medication used to treat OUD, and naloxone, an opioid antagonist used to reverse opioid overdose, commonly known by the brand name Narcan.
Pre-pandemic, Tutag Lehr and Mohammad — both of whom are graduates of the Wayne State Doctor of Pharmacy program — began preparing a review for publication to educate pharmacists on the benefits of buprenorphine access, particularly in the rural areas of Michigan where the need is greatest yet providers are limited in number. They also introduced an initiative through the Michigan Pharmacists Association to explore having pharmacists prescribe this drug in a collaborative practice model.
Buprenorphine is a partial opioid agonist that offers an alternative to methadone, a powerful opioid agonist drug used for medication-assisted treatment that can only be prescribed and dispensed in federally certified outpatient treatment programs (known as methadone clinics). Under the Drug Addiction Treatment Act of 2000 (DATA 2000), physicians and midlevel practitioners with a special DEA number can prescribe buprenorphine for OUD in their office (physicians only), hospital, health department or correctional facility (by midlevel practitioners such as nurse practitioners). Pharmacists are not considered to be qualified midlevel providers, however they may participate in DATA waiver training to expand their knowledge on the medication. Buprenorphine may be dispensed in a community pharmacy like other controlled substance prescriptions, offering patient convenience.
“But some pharmacists are reluctant to carry buprenorphine — which can manage opioid use disorder by preventing withdrawal symptoms and cravings — because they don’t understand the role of medication-assisted treatment,” said Tutag Lehr. “Buprenorphine is a Schedule III controlled substance and pharmacists may have the usual concerns of robberies, drug diversion or may believe in abstinence-based therapy and have a bias about medication-assisted treatment. Education is key to working with buprenorphine providers in the community to ensure safe access.”
Mohammad added, “We don’t pass judgment on patients with other chronic conditions who are trying to get their maintenance medications, so why would a pharmacist refuse to fill a buprenorphine prescription? As a community, we need to examine our biases and destigmatize opioid use disorder and its treatment.”
That work begins at WSU Applebaum through case studies, role playing and candid discussions with health care professionals in all disciplines.
“We educate our students to reflect on and address their biases regarding opioids, and then we send them into practice with this knowledge,” said Mohammad.
For example, “we had a recovery coach tell our students about a skeptical pharmacist he encountered when he was using heroin,” Tutag Lehr said. “The pharmacist was unwilling to fill his prescription — even though it was for an antibiotic to treat an infection.” The goal is that narratives like this help students examine their own perceptions, and they will carry this insight with them throughout their careers.
During an opioid overdose, a person’s respiratory center can be depressed to the point where breathing stops, resulting in death. Naloxone can reverse this effect within minutes. With minimal training, it can be safely administered in various forms — nasal spray, auto-injector or intramuscular injection — to effectively buy more time to get medical help for someone who has overdosed on opioids.
In nearly every state including Michigan, pharmacists are now able to dispense naloxone under a standing order that doesn’t require a prescription, so that friends, family and those at risk of an overdose can keep it on hand.
“Research shows that wider access to naloxone is associated with fewer deaths,” Tutag Lehr wrote in an article for The Conversation in April. “Naloxone could successfully reverse every witnessed opioid overdose.”
But only if it’s in the right hands at the right time. Tutag Lehr says there is need for widespread, convenient naloxone access accompanied by training on how to administer this reversal drug. But stigma stands in the way. People may be afraid to request naloxone because they could be accused of misusing drugs, and pharmacists are hesitant to perpetuate the problem.
This frustrates Mohammad. “Statistics show that only one in every 70 high-dose opioid prescriptions comes with a co-prescription for naloxone — but in reality, everyone on opioid therapy should get it,” she said. “If we’re willing to prescribe and dispense an opioid, we should have no hesitation to prescribe and dispense naloxone.”
Tutag Lehr advocates for pharmacists to recommend and provide naloxone, opioid education, and overdose prevention information to high-risk individuals and their support network, saying, “Pharmacists are well positioned to provide connections to local programs for recovery and support, even if those programs have been modified due to the coronavirus.” She and Mohammad are hopeful that the announcement by the U.S. Food and Drug Administration in July that it is requiring labeling for opioid pain medicine and medicine to treat OUD be updated so that it recommends co-prescribing naloxone will help put this lifesaving medication into the hands of those who need it most.
One focus of the pair’s review paper is on pharmacists having more ad hoc interactions with patients that will help them determine next steps. “There are brief screening tools that can easily be integrated into daily practice, such as a modified SBIRT [screening, brief intervention and referral to treatment],” said Mohammad.
“Or like the CRAFFT screening tool, which is designed for adolescents,” Tutag Lehr added. “Do you drive a car while using? Do you use to relax? Do you use while alone? Do you ever forget things? Have your friends or family asked you to cut down on your drug use? Have you ever gotten in trouble because of drugs?”
Tutag Lehr says the answers to these questions help pharmacists make decisions when working with a vulnerable population that may not otherwise be receiving medical attention. “People who misuse drugs often can’t or don’t want to go to a traditional health care provider for a wide range of reasons,” she said. “Pharmacists offer easy-access health care — we’re almost always open and you don’t need an appointment.
“We need to treat opioid use disorder patients as respectfully and as sensitively as we would a person with diabetes who wasn’t adherent to insulin, because both are chronic, relapsing, lifelong conditions.”