The role of pharmacists in opioid stewardship: A scoping review

https://doi.org/10.1016/j.sapharm.2021.06.018Get rights and content

Abstract

Background

The opioid epidemic is an international public health concern. Pharmacists are in a strategic position to promote and implement effective opioid stewardship due to both their central role on health care teams and frequent interaction with patients. Despite this integral role, pharmacists do not have harmonized scopes of practice in opioid stewardship.

Objectives

This scoping review was conducted to identify and critically review the role of pharmacists in opioid stewardship and identify future areas of study.

Methods

The scoping review was conducted according to the methodological framework proposed by Arksey and O'Malley, which was further modified by the Joanna Briggs Institute. Six databases were searched for original, peer-reviewed research; PubMed (MEDLINE), Ovid Embase, Ovid International Pharmaceutical Abstracts, Scopus, Cochrane Library, and APA PsycInfo.

Results

In 92% of the included studies (n = 77), opioid stewardship interventions led by either a pharmacist or in an interdisciplinary team resulted in improvements in at least one outcome measure, with education and medication therapy adjustments being the most predominant activities. Other areas supported by evidence include community stakeholder education, policy and guideline setting, and risk assessment.

Conclusion

This scoping review provides valuable insight into the various roles pharmacists can have in opioid stewardship. The findings from this review identified opioid stewardship activities that can make significant contributions towards reducing the impact of the opioid crisis. This review informs future research and has the potential to influence pharmacy practice on a national and international scale.

Introduction

The opioid epidemic is an international public health concern. Three million citizens of the United States of America (USA) and 16 million individuals worldwide have had, or currently suffer from opioid use disorder (OUD); OUD is diagnosed according to eleven criteria that describe opioid dependence or problematic use.1 Globally, the top 3 national consumers of opioids are the USA, Germany, and Canada (40,240; 28,862, and 26,029 defined daily dosages of opioids per million inhabitants, respectively).2 Since the late 1990s, the number of opioid-related deaths worldwide has risen. For example, in 2016 alone, approximately 9000 lives were lost to drug overdoses in the European Union (EU) member states.3 In the USA, deaths involving opioids have increased by over 500% since 1999 and experts predict that by 2029 nearly 500,000 Americans could lose their lives due to opioid toxicity.4 In Canada, 17,602 apparent opioid-related deaths occurred between January 2016 and June 2020 with the highest quarterly count on record occurring from April to June 2020 (1628 apparent opioid-related deaths).5 The recent increase in opioid related deaths reported in countries like Canada, may be directly correlated to the onset of the COVID-19 pandemic.6,7

Opioid use also correlates with increased morbidity. Patients who suffer from OUD rely on health care resources and have an increased probability of requiring emergency department (ED) care, hospitalization, medication, and outpatient mental health services.3,8, 9, 10 For example, between January 2016 and June 2020, 21,824 opioid-related poisoning hospitalizations occurred across Canada; additionally, more than 21,000 suspected opioid-related overdoses occurred in 2019 alone.11 In the USA, ED services related to opioids have increased annually since 2010, with rates of opioid related ED visits tripling between 1999 and 2013; in 2017, there were 967,615 nonfatal drug overdose ED visits (300.2 per 100,000 population).1,12 The global economic burden of drug use disorders is substantial, contributing to 10%, 57% and 6% of global estimates of disease burden in terms of disability-adjusted life year (DALY), years of life lost (YLL) and years lost due to disability (YLD).13 Opioid use disorder has also resulted in a global increase of 8.1% in the years of life lost due to premature mortality (YYLs).14

There is evidence that a surge in opioid prescriptions is one of the key contributors to the opioid crisis.15,16 Though there is a major focus on the role of illicit opioids in the opioid epidemic, prescription opioids also contribute to opioid misuse and an increased risk of OUD. From 2002 to 2011, 25 million people in the USA used pain relievers for non-medical uses, and more than 11 million misused the medications; by 2015, 4 million people had endorsed the nonmedical use of prescription opioids.1 Given that over 200 million opioid prescriptions were dispensed in the USA in 2016, it is not surprising that in 2017 there was an overwhelming number of Americans (1.7 million) with prescription opioid use disorder.1,17 In Canada, approximately 37% of people with OUD in 2017 reported accessing opioids solely through legal channels (e.g. prescriptions), and a further 26% reported obtaining their opioids through both prescriptions and unregulated, illegal channels.18

In many nations, opioids are regarded as the gold standard for the management of acute (moderate to severe) and chronic pain.19 However, opioid use in chronic non-cancer pain is controversial.20 Due to increased awareness of the risks associated with opioids, an interdisciplinary approach has been taken to recognizing and addressing clinical factors that play a role in the unnecessary or excessive prescribing and/or dosing of opioids.20, 21, 22 Evidence suggests that an inter-professional team based approach can enhance clinical outcomes in chronic disease management.23 Pharmacists (regardless of their specialty) contribute significantly to patients' health care teams, as they can offer medication expertise and have regular access to patients. Therefore, pharmacists are strategically positioned to exercise and advocate for effective opioid stewardship.24

At the public health level, various initiatives have been adopted to address the opioid epidemic, including but not limited to: increasing access to treatment and recovery sites, increased advocacy for the utilization of medications that can reverse the effects of an opioid overdose and increased research on pain, addiction, and related public health trends.17 The distribution of naloxone is a major public health initiative that the pharmacist's role has supported.25 In Canada, community pharmacies are a key point of naloxone distribution because they are accessible to patients in most contexts, and pharmacists frequently interact with patients who use opioids and are therefore able to identify patients at risk of overdose.25 In fact, evidence suggests that pharmacies are a good avenue to distribute naloxone and there should be increased participation of pharmacies in naloxone distribution efforts.26 Another example of pharmacists' supporting role in public health is the fentanyl patch for patch program. This program was legislated in Ontario, Canada to reduce the misuse of fentanyl patches.26 The patch for patch program requires that patients dispensed fentanyl patches must return their used patches to the pharmacy before receiving a refill of their prescription. In the event that the patches have been tampered with, or the expected number of patches are not returned, the pharmacist is responsible for notifying the police and the prescriber.27 Therefore, pharmacists play a major role in opioid stewardship not only with individual patients, but at the public health level.

Opioid stewardship is described by the Institute for Safe Medication Practices (ISMP) Canada as “coordinated interventions designed to improve, monitor, and evaluate the use of opioids in order to support and protect human health”.28 One of the factors that can impede effective opioid stewardship in pharmacy practice is the lack of a standardization due to a range of scopes of practice across various jurisdictions.29 Although pharmacists contribute effectively to opioid stewardship, a critical and synthesized examination of the available evidence for implementation of opioid stewardship activities and their clinical impact has not yet been conducted. The aim of this scoping review is to provide a narrative synthesis of the evidence on the scope and role of pharmacists in opioid stewardship, the impact of their activities and identify opportunities for further research. The main research question this review addresses is: what types of pharmacist interventions or activities in opioid stewardship are reported in the literature and what is the impact of these activities on outcomes?

Section snippets

Methods

The protocol for this scoping review has been previously published.30 The methods will be briefly summarized accordingly.

Results

A total of 77 articles were included in the review (Fig. 1). As shown in Table 1, 78% of articles (n = 60) were published in the last decade (2010 to – 2020), 16% (n = 12) and 6% (n = 5) were published between 2009 to 2000 and 1999 to 1980, respectively. The majority (82%, n = 63) of studies were conducted in North America, 5% were conducted in Europe (n = 4), 8% in Asia (n = 6), and the remaining 5% in Australia (n = 4) (Fig. 2). Seventy four percent of studies (n = 57) were conducted in a

Discussion

This scoping review identified 77 studies that reported on the role of the pharmacist in opioid stewardship. Evidence to support the role of pharmacists in opioid stewardship was reported, with the most notable being improved outcomes when either a pharmacist or interdisciplinary team led the intervention. Areas where pharmacists had significant impacts were in patient or health care professional education, medication therapy adjustments, community stakeholder education, policy and guideline

Conclusions

This scoping review identified 77 studies that evaluated the pharmacist's role in opioid stewardship and the impact on patient outcomes. In the majority of studies, opioid stewardship interventions led by either a pharmacist or an interdisciplinary team resulted in improvements in at least one outcome measure. The studies were categorized according to pharmacists' scope of practice and specific interventions. The areas where the pharmacist had the biggest impact were in education, medication

Funding

This study was supported by the Canadian Pharmacists Association (CPhA).

Declaration of competing interest

Shelitta Dattani was an employee of the Canadian Pharmacists Association during the course of this project. Dana Turcotte has received consulting fees as an independent clinical consultant for Novartis neuroscience division. Michael A. Beazely serves on an advisory board for Emergent Biosolutions without financial compensation. Katelyn Halpape has received an honorarium as chapter editor for the Clinical Handbook of Psychotropic Drugs, 23rd Edition. Mona Kwong is an advisor with British

Acknowledgements

We would like to thank Chiranjeev Sanyal, Zahava Rosenberg-Yunger, Heather Mohr and Amy Morris for providing input into the scoping review.

References (104)

  • M.S. Medina et al.

    Center for the advancement of pharmacy education 2013 educational outcomes

    Am J Pharmaceut Educ

    (2013 Oct 14)
  • T. Bertsche et al.

    Multidisciplinary pain management based on a computerized clinical decision support system in cancer pain patients

    Pain

    (2009)
  • J. Chen et al.

    Impact of a Clinical Pharmacist-Led Guidance Team on cancer pain therapy in China: a prospective multicenter cohort study

    J Pain Symptom Manag

    (2014)
  • S. Gernant et al.

    Development and evaluation of a multidisciplinary controlled substances committee within a patient-centered medical home

    J Am Pharm Assoc

    (2015)
  • J. Kowiatek et al.

    Assessing and monitoring override medications in automated dispensing devices

    Joint Comm J Qual Patient Saf

    (2006)
  • M.-T. Wu et al.

    A pharmacist-initiated project to reduce meperidine use in surgical patients

    J Exp Clin Med

    (2012)
  • J. Liu et al.

    Evaluation of pharmacist interventions as part of a multidisciplinary cancer pain management team in a Chinese academic medical center

    J Am Pharm Assoc

    (2020)
  • V. Manzur et al.

    Implementation and assessment of a pilot, community pharmacy-based, opioid pain medication management program

    J Am Pharm Assoc JAPhA

    (2020)
  • E. Skoy

    A pilot evaluation of incorporating “opt-out” naloxone dispensing within a chain community pharmacy

    Res Soc Adm Pharm RSAP

    (2019)
  • M. Azadfard et al.

    Opioid Addiction [Internet]

    (2020)
  • K. Verhamme et al.

    Are we facing an opioid crisis in Europe?

    Lancet Public Health

    (2019)
  • E. Crane

    Emergency Department visits involving narcotic pain relievers [Internet]

    (2015)
  • Combating the international dimensions of the opioid crisis [Internet]

  • Opioid-and stimulant-related harms in Canada [Internet]

    (2020)
  • The Ontario Drug Policy Research Network

    The Office of the Chief Coroner for Ontario/Ontario Forensic pathology service, public health Ontario, centre on drug policy evaluation. Preliminary patterns in circumstances surrounding opioid-related deaths in Ontario during the COVID-19 pandemic [Internet]

  • The Covid-19 pandemic is fueling the opioid crisis! [Internet]. National Institute of Envrionmental Health Sciences....
  • J. Braden et al.

    Emergency department visits among recipients of chronic opioid therapy

    Arch Intern Med

    (2010)
  • L. Braker et al.

    Screening for potential prescription opioid misuse in a Michigan Medicaid population

    Fam Med

    (2009)
  • A. White et al.

    Economic impact of opioid abuse, dependence, and misuse

    Am J Phamracy Benefits

    (2011)
  • Opioid-related harms in Canada [Internet]

    (2020)
  • A. Vivolo-Kantor et al.

    Nonfatal drug overdoses treated in emergency departments - United States, 2016-2017 [Internet]

    (2020)
  • Alcohol and drug use disorders: global health estimates [Internet]

    (2017)
  • GBD 2016 Causes of Death Collaborators

    Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016

    The Lancet

    (2017)
  • I. Dhalla

    Clustering of opioid prescribing and opioid-related mortality among family physicians in Ontario

    Can Fam Physician

    (2011)
  • Vital signs: overdoses of prescription opioid pain relievers - United States, 1999-2008 [Internet]

    (2011)
  • Opioid overdose crisis [Internet]

    (2020)
  • Canadian centre on substance use and addiction

  • A. Rosenblum et al.

    Opioids and the treatment of chronic pain: controversies, current status and future directions

    Exp Clin Psychopharmacol

    (2008)
  • The 2017 Canadian guideline for opioids for chronic non-cancer pain [Internet]. National Pain Center. [cited 2020 Sep...
  • Federal actions on opioids to date [Internet]

    (2020)
  • L. Manchikanti et al.

    Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines

    Pain Physician

    (2017)
  • Optimizing the value of team-based primary care: review of the literature [Internet]

    (2015)
  • Pharmacists in Canada [Internet]

    (2015)
  • R. So et al.

    The status of naloxone in community pharmacies across Canada

    Can Pharm J Rev Pharm Can

    (2020 Nov)
  • B. Choremis et al.

    The uptake of the pharmacy-dispensed naloxone kit program in Ontario: a population-based study

    PloS One

    (2019)
  • Opioid stewardship [Internet]. Institute for safe medication practices Canada

  • P. Emberley

    Canadian pharmacists scope 20/20: a vision for harmonized pharmacists' scope in Canada

    Can Pharm J

    (2018)
  • N. Gondora et al.

    The role of pharmacists in opioid stewardship: protocol

    Res Soc Adm Pharm

    (2020)
  • G.C. Welham et al.

    Type and frequency of opioid pain medications returned for disposal

    Drugs - Real World Outcomes

    (2015)
  • N. Gandhi et al.

    Impact of a communication technique training on rates of naloxone dispensing

    J Am Pharm Assoc

    (2020)
  • Cited by (12)

    • Opioid stewardship

      2023, BJA Education
    • Pharmacist clinical interventions: Five years' experience of an efficient, low-cost, and future-proofed tool

      2023, Research in Social and Administrative Pharmacy
      Citation Excerpt :

      The impact of pharmacists in improving patient safety by reducing medication related problems (MRPs) and the associated morbidity, mortality, and cost burdens to the healthcare system has been well studied internationally.1–10

    • Exploring the frontline experiences of pharmacy technicians during the opioid epidemic in community pharmacies

      2022, Journal of the American Pharmacists Association
      Citation Excerpt :

      Still, recent studies suggest that pharmacy personnel, including pharmacists, pharmacy technicians, and student pharmacists, desire to do more to educate patients about opioid risks and to help those with opioid use disorder.19,27,38 Furthermore, a recent scoping review found that in over 90% of the pharmacist-provided opioid stewardship programs, at least 1 outcome measure was improved.42 Providing “consciousness raising” training for pharmacy personnel serves an important role in improving care for these patients.

    • Pharmacists expanded role in providing care for opioid use disorder during COVID-19: A qualitative study exploring pharmacists’ experiences

      2022, Drug and Alcohol Dependence
      Citation Excerpt :

      It is evident that pharmacists can and should play a critical role as active members of their patient's healthcare team. This is not only because they can provide timely access to therapy and contribute to patients’ continuity of care, but they are also medication experts who provide clinical support and expertise (Gondora et al., 2021). The pharmacist's role is essential in OUD where patients need more personalized care.

    View all citing articles on Scopus
    View full text