Good in a crisis: pharmacists’ roles in opioid stewardship

Year to year, Canada consistently ranks second or third in the world for per capita opioid consumption.1 Despite efforts to reduce opioid use in Canada and mitigate opioid-related harms, the COVID-19 pandemic has increased the severity of the situation even further.2 Data related to opioid harms during the COVID-19 pandemic show undeniably that our opioid problem is escalating substantially, with one report noting an 88% increase in opioid-related deaths and a significant increase in hospitalizations due to opioid-induced harms.2 At this tipping point, one thing is very clear—we need to drastically reduce the amount of opioids being used in Canada and improve prescribing practices to mitigate future risk. Pharmacists on the frontlines As pharmacists in the community, you are undoubtedly hyperaware of the ongoing opioid crisis, since you see it in your practice every day. Remember that postsurgical prescription for a 30-day supply of morphine from the other day? Or, that elderly man with chronic low back pain who brought in a prescription for another increase in the dose of his fentanyl patch? Every day, pharmacists truly are at the frontline of the opioid crisis in Canada and, as a result of this proximity to the problem, are perfectly situated to be part of the solution. Although opioid stewardship is a relatively new practice concept, the fundamentals are not dissimilar to those of antimicrobial stewardship, which has had a profound impact on ensuring appropriate use of antibiotics.3-5 As drug utilization experts, pharmacists have been leaders in antibiotic stewardship, helping to ensure that the right drug is used at the right time and for the right individual.3-5 Establishing pharmacists in opioid stewardship initiatives will help to improve opioid utilization and ultimately reduce opioid-associated harms. In fact, a recent scoping review exploring the role of pharmacists as opioid stewards found overwhelmingly that stewardship interventions involving pharmacists resulted in improved clinical outcomes.6 Practice (direction) makes perfect Tackling a problem this complex can feel overwhelming. Thankfully, several guidelines for improved opioid utilization are available, highlighting practice areas to which pharmacists can contribute, to ultimately reduce opioid-related harms.7,8 With direct patient contact throughout the pain care continuum, there are multiple opportunities in both acute and chronic pain where pharmacists can and should intervene.6 For instance, in acute pain, evidence strongly supports the use of lowest effective doses of opioids and selecting immediate-release formulations whenever possible.9,10 As well, studies show that limiting outpatient prescription quantities of opioids for acute pain to less than a three-day supply results in improved short- and long-term outcomes.9,10 Finally, ensuring that patients are educated on the risks of opioids, and on the transient nature of acute pain, will contribute to enhanced overall safety of opioid use.9,10 All of these actions are accessible to the community pharmacist, who is often the first point of contact upon hospital discharge for acute pain. In chronic pain scenarios, pharmacists are similarly situated to make impactful changes to optimize care and reduce opioid harms.6 Community pharmacists are privy to signs indicating that an individual’s pain is not optimally controlled. Early refill requests, escalating opioid doses, new prescriptions for concurrent mood and sleep disorders, among other details, can all suggest poorly managed pain. Armed with this insight, pharmacists can provide clinical care to mitigate risks of long-term opioid therapy. Working collaboratively to ensure optimization of nonopioid medications and nonpharmacological strategies should continue throughout the continuum of care. Additionally, pain assessment should be performed regularly by pharmacists to evaluate the appropriateness of continued opioid therapy. Furthermore, with significant emphasis on reducing opioid doses to below 50–90 morphine milligram equivalents (MME) per day, pharmacists should monitor dose escalations, and intervene when appropriate to ensure safer opioid use.7,8 Pharmacists also play a significant role in overall risk mitigation. To ensure appropriateness of new and continuing opioid prescriptions, pharmacists should use tools at their disposal, including prescription monitoring databases, and substance use disorder screening/opioid risk assessments.6-8 Table 1 highlights some of the actions that pharmacists can take as opioid stewards. Further reading will provide a more comprehensive look at how pharmacists can contribute as opioid stewards.6 No pain, no gain In a profession already spread thin with many uncompensated services, it can seem unrealistic to now take on the monster that is opioid stewardship. It’s important to remember that, like antimicrobial stewardship initiatives, this needs to be a team effort, a collaboration between numerous disciplines working together towards a common goal. To get started, think about your own practice and pick two or three actionable tasks that you can begin consistently incorporating into your daily interactions with patients on opioid therapy. Once you gain comfort with these tasks—and perhaps even begin to see positive impacts on patients as a result—you will gain momentum. Un- fortunately, with the opioid crisis growing more and more toxic each day, we don’t have much time to dip our toes into these waters. Now is the time to jump right in; lives in Canada literally depend on it. Dana Turcotte, BSc(Pharm), PhD, is a clinical pharmacist at a multidisciplinary primary care clinic in Winnipeg, MB, and an Assistant Professor at the College of Pharmacy, University of Manitoba. Her practice focuses on safer opioid use and pain management. 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The effect of an educational intervention to improve patient antibiotic adherence during dispensing in a community pharmacy. Aten Primaria 2014;46:367-75. doi: 10.1016/j.aprim.2013.12.003. 6. Gondora N, Versteeg SG, Carter C, et al. The role of pharmacists in opioid stewardship: a scoping review. Res Social Adm Pharm 2021:S1551-7411(21)00235- 7. doi: 10.1016/j.sapharm.2021.06.018. Epub ahead of print. 7. Health Quality Ontario. Opioid prescribing for acute pain: care for people 15 years of age and older. Queen’s Printer for Ontario 2018. (accessed December 7, 2021). 8. Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ 2017;189:E659-66. 9. Herzig SJ, Calcaterra SL, Mosher HJ, et al. Safe opioid prescribing for acute non-cancer pain in hospitalized adults: a systematic review of existing guidelines. J Hosp Med 2018;13:256-62. 10. Hsu JR, Mir H, Wally MK, et al. 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