ASRA Pain Medicine Update

May 1, 2022, 02:00 AM by Randall W. Knoebel, PharmD, BCOP; Chris Herndon, PharmD, BCACP, FASHP, FCCP; and David M. Dickerson, MD

Cite as: Knoebel RW, Herndon C, Dickerson DM. Pharmacists on the front line of the opioid epidemic. ASRA Pain Medicine News 2022;47. https://doi.org/10.52211/asra050122.021  

 

---

 

The American Medical Association has described the current opioid epidemic as "more complicated and deadly" than ever before.¹ The prevailing theme is that the epidemic is now being driven by illicitly manufactured fentanyl,^1–3 revealing an urgent need for policies that better support the social and economic security of disadvantaged communities. Combating this crisis will continue to be complex and requires multipoint interventions along the patient care continuum.

---

Pharmacists possess unique knowledge, skills, and abilities that make them critical team members of any interprofessional team to help ensure that medication use is optimal, safe, and effective.

---

As hospitals look for ways to stem the opioid crisis, most large health systems have formed active stewardship programs to combat the problem at the local level. In 2018, the National Dialogue for Healthcare Innovation outlined an action roadmap developed at the Opioid Crisis Solutions Summit.⁴ The critical areas highlighted include improving healthcare system approaches to pain management and opioid misuse, expanding access to substance use disorder (SUD) treatment and behavioral health services, improving care coordination through data access and analytics, and developing payment systems supporting coordination and quality of care.⁴ Furthermore, the roadmap stressed the important role pharmacist expertise and participation plays on care teams and opioid stewardship efforts ability to achieve these goals.⁴

 

Pharmacists possess unique knowledge, skills, and abilities that make them critical team members of any interprofessional team to help ensure that medication use is optimal, safe, and effective.⁵ Aside from a moral and ethical responsibility, pharmacists are inextricably linked to any process involving a medication from a regulatory, operational, safety, or governance/policy perspective. In a report titled "Addressing the Opioid Epidemic in the United States: Lessons From the Department of Veterans Affairs," the authors state "pharmacists play a key role in the VA care delivery and have been instrumental in managing the opioid epidemic, from promoting naloxone use to recommending pain medications."⁶ Within health systems across the country, pharmacists have been involved in many quality improvement initiatives focused on improving the safe prescribing of opioids while providing and expanding harm reduction services. Some specific initiatives include: 

• Implementing controlled substance disposal process⁷ and drug take-back events⁸
• Developing multimodal analgesia pathways and order sets
• Expanding nonopioid options for managing complex pain
• Monitoring prescription drug monitoring databases
• Naloxone co-prescribing (emergency room and hospital discharge)⁹
• Screening for opioid misuse risk and urine toxicology screen interpretation^10,11
• Opioid (or substance) use disorder management¹²
• Patient education and academic detailing¹¹
• Population health management (ie, chronic pain, chronic opioid patients)¹³
• Opioid diversion detection programs
• Establishing community partnerships.^14,15

While many potential benefits of involving pharmacists in collaborative care improvement projects to address the opioid epidemic exist, several barriers prevent this work from being scalable.

• Pharmacists face several challenges that can prevent them from fully using their skill sets in interacting with patients. One key obstacle is the lack of payment mechanisms that explicitly provide for pharmacist services. Currently, pharmacists are not recognized by the Centers for Medicare and Medicaid Services (CMS) with "provider status," limiting their ability to be reimbursed for services delivered.¹⁶
• The other major challenge for pharmacists is the lack of information access. Pharmacists often interact with patients without getting the complete patient record, and access is usually limited to the patient's prescription details.¹⁶

Seeking to address these challenges and expand the pharmacist’s role in patient care, pharmacists have looked to legislative changes, with which they have had moderate success.¹⁶ Focusing on state regulations, advocacy efforts enabled a handful of states to implement statewide changes that allow pharmacists to have a higher level of integration and collaborative practice agreements (CPAs) into a team-based care model, creating a more significant role in medication authorization and patient safety. Currently, 48 states and the District of Columbia have some form of a CPA authority for pharmacists.¹⁷ Within these 49 jurisdictions, however, the extent of the authority and the types of requirements imposed by law on the practitioners are highly variable and non-reimbursable.¹⁷ The American Medical Association has recently developed a training module for physicians that includes specifics on how to add a pharmacist to a medical practice.¹⁸ Yet, the reaction of state medical boards to increasing pharmacists' scope of practice has been mixed. This tension highlights the critical responsibility policymakers have on pharmacists' roles in advancing the patient safety agenda as well as a need for ongoing cross-disciplinary advocacy.

The call to action is simple:

• Partner with pharmacists engaged in pain and SUD care and incorporate them into your quality improvement initiatives organizationally, regionally, and nationally.
• Encourage state legislators and regulators to follow the lead of innovative states through legislation that requires CMS and private payers to recognize and cover pharmacists as providers in healthcare provider networks.

Moving beyond CPAs to a provider status enables pharmacists to be reimbursed for non-dispensing cognitive services and promote integrated public health delivery models. As long as patient safety, addressing structural inequities, improving public health, and reducing healthcare worker burnout remain nationwide concerns, the role and authority of pharmacists within the broader health care delivery system must be expanded.

 

---

Randall W. Knoebel, PharmD, BCOP, is the pharmacy director of Health Analytics and Drug Policy, the pharmacy director of the Pain Stewardship University, the residency program director for the PGY1 Pharmacy Residency in the department of pharmacy, and a research associate professor in the department of medicine at the University of Chicago Medicine in Chicago, IL.

---

Chris Herndon, PharmD, BCACP, FASHP, FCCP, is a professor in the department of Pharmacy Practice at Southern Illinois University Edwardsville School of Pharmacy and a clinical associate professor in the department of Community and Family Medicine at St. Louis University School of Medicine in St. Louis, MO.

---

David M. Dickerson, MD, is the section chief of Pain Medicine and the medical director of Anesthesia Pain Management Services at NorthShore University HealthSystem, Section of Pain Medicine in Chicago, IL.

---

References

1. American Medical Association. Issue brief:nNation’s drug-related overdose and death epidemic continues to worsen. Updated February 15, 2022. Available at:  https://www.ama-assn.org/system/files/issue-brief-increases-in-opioid-related-overdose.pdf Accessed April 7, 2022.
2. National Institute on Drug Abuse. Opioids. Available at  https://www.drugabuse.gov/drug-topics/opioids Accessed April 7, 2022.
3. Chicago Department of Public Health. 2021 Chicago Mid-Year Opioid Report. Published online August 13, 2021. Available at: https://www.chicagohan.org/documents/14171/234367/2021_MidYr_Opioid_Report_AUg2021.pdf Accessed September 21, 2021.
4. National Dialogue for Healthcare Innovation. National Dialogue for Healthcare Innovation’s opioid crisis solutions summit: a roadmap for action. Published May 14, 2018. Available at https://www.ndhi.org/files/7415/2907/4391/Opioid_Roadmap_FINAL.pdf Accessed October 2, 2021.
5. Acquisto NM, Coralic Z. In the midst of an opioid epidemic: pharmacists on the frontline of substance use disorder treatment. Am J Heal Pharm 2021;78(4):277-8. https://doi.org/10.1093/AJHP/ZXAA410
6. Gellad WF, Good CB, Shulkin DJ. Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs. JAMA Intern Med 2017;177(5):611-2. https://doi.org/10.1001/JAMAINTERNMED.2017.0147
7. McCarthy BC, Dickerson DM, Knoebel RW. Implementation of a controlled substance collection receptacle. Am J Heal Pharm 2019;76(10):641-3. https://doi.org/10.1093/ajhp/zxz038
8. Eukel H, Steig J, Frenzel O, et al. Opioid misuse and overdose: changes in pharmacist practices and outcomes. J Contin Educ Health Prof 2020;40(4):242-7. https://doi.org/10.1097/CEH.0000000000000317
9. Bounthavong M, Harvey MA, Wells DL, et al. Trends in naloxone prescriptions prescribed after implementation of a National Academic Detailing Service in the Veterans Health Administration: a preliminary analysis. J Am Pharm Assoc 2017;57(2):S68-S72. https://doi.org/10.1016/j.japh.2016.11.003
10. Strand MA, Eukel H, Burck S. Moving opioid misuse prevention upstream: a pilot study of community pharmacists screening for opioid misuse risk. Res Soc Adm Pharm 2019;15(8):1032-6. https://doi.org/10.1016/j.sapharm.2018.07.011
11. Jacobs SC, Son EK, Tat C, et al. Implementing an opioid risk assessment telephone clinic: outcomes from a pharmacist-led initiative in a large Veterans Health Administration primary care clinic, December 15, 2014-March 31, 2015. Subst Abus 2016;37(1):15-9. https://doi.org/10.1080/08897077.2015.1129527
12. DiPaula BA, Menachery E. Physician-pharmacist collaborative care model for buprenorphine-maintained opioid-dependent patients. J Am Pharm Assoc 2015;55(2):187-92. https://doi.org/10.1331/JAPhA.2015.14177
13. Cox N, Tak CR, Cochella SE, et al. Impact of pharmacist previsit input to providers on chronic opioid prescribing safety. J Am Board Fam Med 2018;31(1):105-12. https://doi.org/10.3122/jabfm.2018.01.170210
14. Palombi LC, Vargo J, Bennett L, et al. A community partnership to respond to the heroin and opioid abuse epidemic. J Rural Heal 2017;33(1):110-3. https://doi.org/10.1111/jrh.12180
15. Palombi LC, LaRue A, Fierke KK. Facilitating community partnerships to reduce opioid overdose: an engaged department initiative. Res Soc Adm Pharm 2019;15(12):1406-14. https://doi.org/10.1016/j.sapharm.2018.07.002
16. Gale R. In patient safety efforts, pharmacists gain new prominence. Health Aff 2018;37. https://doi.org/10.1377/hlthaff.2018.1225
17. Cernasev A, Aruru M, Clark S, et al. Empowering public health pharmacy practice—moving from collaborative practice agreements to provider status in the U.S. Pharm 2021;9:57. https://doi.org/10.3390/PHARMACY9010057
18. American Medical Association STEPS Forward. Embedding pharmacists into the practice. Available at: https://edhub.ama-assn.org/steps-forward/module/2702554 Accessed October 2, 2021.