OPINION
Opioid use disorder
Over-prescribing of opioids is a concern on both sides of the Atlantic and at the 2018 ASHP Clinical Meeting,
attendees heard how pharmacists in the US are involved in schemes to tackle the problems
About one third of patients
taking opioids will be misusing
them, according to the Centers for
Disease Control (CDC), the leading
national public health institute of the
United States. In order to avoid
making the situation any worse,
specialist pain pharmacists are now
developing active management
programmes.
Two immediate measures have been
to reduce the amounts supplied and to
use alternatives wherever possible. For
example, opioid treatment for acute
pain is now limited to 3–7 days in
the Veterans’ Administration Medical
Center (VAMC), Atlanta, Georgia.
Patients are told that the goal is not to
be pain-free but to have ‘tolerable pain’.
For chronic pain management,
a combination of non-opioids with
non-pharmacological measures is now
recommended. Immediate-release
products are preferred over slowrelease
products.
Such measures only deal with
new patients but many people
are now chronic opioid users who
are physically and psychologically
opioid-dependent. Active protocols
to reduce opioid dosage for these
patients are now being implemented.
Doses are gradually tapered down
– typically at a rate of 5–20% per
month, explained Kathy Davari
(Associate Chief Pharmacist, VAMC,
Atlanta). It is critical to discuss the
plan with patients first and explain
that “we are on your side…”. A rapid
taper is recommended if diversion is
suspected and a slow taper if genuine
dependence is suspected, she added.
Another part of the treatment for
chronic opioid users is integrated selfcare
coaching for pain. This includes
relaxation techniques, exercise
(yoga or Tai Chi) and “acceptance
and commitment therapy” for
pain. The programme is achieving
positive results. So far, 500 patients
have successfully completed the
programme and it is now being
taken up by other VA hospitals
(in other states), said Dr Michael
Saenger, a pain management
Christine Clark
PhD FRPharmS FCPP(Hon)
consultant and Programme Director.
Reducing the prescribed dose of
opioid does not always reduce deaths
due to overdoses because people are
simply driven to illicit sources of
drugs, with which the risk of overdose
is higher. The risk of accidental overdosage
is ever-present for chronic
opioid users. There were 72,000
deaths due to opioids in the US in
2017, approximately 30,000 of which
involved fentanyl. Patients taking
opioids should always have three
naloxone kits because sometimes this
much is need to reverse an accidental
overdose, said Dr Davari.
The electronic medical records have
been mined to compile an ‘opioid
dashboard’ that allows pharmacists to
identify patients at high risk of opioid
dependence and share the details with
the treatment team.
Medical marijuana
A alternative approach to the over-use
of opioids is the use of marijuana in
the management of chronic pain as
an alternative. In states where the use
of medical cannabis is permitted, the
numbers of prescriptions for opioids
have decreased.
The use of medical marijuana has
now been legalised or decriminalised
in 30 states in the US and medical
cannabis dispensaries have now
opened. Some states allow only
the sale of cannabidiol, the nonpsychoactive
component of marijuana.
Some states require a pharmacist to
be involved in the supply process,
either present on site or available
as a consultant. A few pharmacists
have seized the opportunity to open
medical cannabis dispensaries and
develop this new field of practice.
Marijuana was legalised in the state
of Colorado in 2012 and dispensaries
began selling to consumers in 2014.
There is a registration process
for patients and a specified list
of conditions for which medical
marijuana can be recommended. By
June 2018, more than 450 physicians
in Colorado had recommended
medical marijuana and nearly 87,000
patients had active registrations.
Confusingly, cannabis remains
an illegal drug at federal level but
marijuana law enforcement has
been devolved to state governments.
Needless to say, a number of practical
problems remain. Importantly,
pharmacists and doctors lack
the knowledge and experience
to prescribe marijuana products
and advise patients appropriately.
Moreover, information about doses,
effects and interactions is scarce and
there is no product standardisation.
What can we learn from all this?
Pain is a multifaceted phenomenon
and it sometimes needs a multimodal
approach to manage it. However,
we should not forget that opioids
are very useful drugs in the right
place and we will serve patients
badly if we simply allow them to be
demonised. Pharmacists should take
the lead in educating patients, carers
and prescribers – about effective
and appropriate use of opioids and
cannabinoids.
The American Society of Health-
System Pharmacists (ASHP)
Midyear Clinical Meeting took
place in Anaheim, California in
December 2018
12 | Issue 91 | 2019 | hospitalpharmacyeurope.com