Feng Chang, PharmD

Download PDF

Pharmacists and prescribers represent two main types of healthcare providers that are involved in caring for people with opioid use disorder (OUD), and in particular, in the provision of opioid agonist therapy (OAT), an effective treatment for OUD. Currently, pharmacists and prescribers have relatively separate roles in patient care. This represents a missed opportunity for collaborative, interdisciplinary care.

As healthcare providers, we are acutely aware of the severity of the opioid crisis affecting Canada and other parts of the world. This crisis has continued to reach new peaks, with opioid deaths increasing substantially in recent years.¹ The COVID-19 pandemic has worsened the opioid epidemic, but it has also highlighted the role pharmacists have as vital and accessible primary care clinicians.² Pharmacists are well-trained in the effectiveness and safety of medications, injections, and serving as the final point of access to medications for patients with OUD. Pharmacists are therefore in a good position to work together with prescribers and patients using a coordinated approach to successfully make an impact on the opioid crisis.

Pharmacists are a competent group of medical professionals capable of doing more. This article outlines the current evidence for pharmacist work in this area, their current role, and opportunities in the future. Re-imagining the role of pharmacists working alongside prescribers and patients is the first step towards efficient, synergistic, and complementary practices supporting opioid-related patient care.

Evidence for the impact of pharmacists as opioid stewards

Opioid stewardship has been defined by the Institute for Safe Medication Practices Canada as “coordinated interventions designed to improve, monitor, and evaluate the use of opioids in order to support and protect human health”.³

There is clear evidence to suggest that pharmacists can make an impact when acting as opioid stewards. Studies have shown positive outcomes related to pharmacist interventions, whether in independent practice or as a member of an interdisciplinary team. A recent review of pharmacist interventions in opioid stewardship found that in 92% of 77 included studies, the intervention resulted in improvements in at least one patient outcome.^4,5 Outcomes included reduced consumption of opioids, improved pain management, reduced hospital stays, increased access to naloxone, and better identification of patients at risk of opioid misuse.^4,5 The most impactful pharmacist opioid stewardship interventions were preventative measures such as opioid tapering, and active collaboration with patients and other health care professionals to identify and target pain management goals.⁵ This highlights the benefits of a collaborative care model.

Pharmacists are also an important part of public health measures targeting the opioid crisis. The fentanyl patch-for-patch program implemented in Ontario is an excellent example. To reduce diversion and misuse of prescribed fentanyl patches, a program requiring patients to return used patches to the pharmacy in order to receive a new supply was implemented between 2012-2015. The patch-for-patch program was associated with a decline in the number of fentanyl patches dispensed, and no change in the dispensing of other kinds of opioids.⁶ Ontario pharmacists also have the authority to provide injectable and intranasal naloxone to patients at no charge through the Ontario Naloxone Pharmacy Program (ONPP). Evidence from the US showed that states where pharmacists could dispense naloxone had greater reductions in opioid-related deaths than other jurisdictions.⁷

Current role of pharmacists as opioid stewards in Canada

The current role of the pharmacist in opioid stewardship is inconsistent. There are barriers in the way of optimizing this role. Even though pharmacy education is accredited nationally, clinical practice is regulated provincially leading to variations across Canada. For example, pharmacists in Alberta can prescribe Schedule 1 drugs while pharmacists in Ontario cannot. Pharmacists in primary care are also limited by the product-focused model for reimbursement which disincentivizes unpaid activities like patient follow-up and monitoring. Traditional workplace designs and workflow patterns further deter confidential, in-depth discussion with patients and prescribers. In working collaboratively with prescribers, pharmacists lack access to patient’s medical information, lab or other relevant test results, and often do not have convenient means for direct communication. Many community pharmacies open long hours with pharmacists working different shifts, further complicating communication efforts following up with prescribers or patients. Mutual role recognition and integration remain challenges.

In response to the ongoing COVID-19 pandemic, several changes were made to the pharmacist’s scope of practice with respect to controlled substances such as opioids and opioid agonist therapy. In various provinces, pharmacists have been granted temporary permission to do some or all of the following: extend and renew prescriptions, transfer prescriptions to other pharmacists, receive verbal prescriptions from prescribers, and deliver controlled substances to patients.⁸ These changes have been a step in the right direction. Pharmacists felt these exemptions enabled them to provide uninterrupted care to patients, especially symptomatic patients, and facilitated stronger patient relationships.⁹ Community pharmacists, in particular, felt the exemptions improved collaborative care with prescribers, and resulted in increased sharing of patient information and greater appreciation for reciprocal support. This may provide a proof-of-concept that pharmacists are capable of more than they have been thus far permitted to do. Research into outcomes related to these changes will help guide the development of new roles.

Future role of pharmacists in fighting the opioid crisis

A new role for pharmacists in opioid stewardship should be complementary, collaborative, and synergistic to the role of the prescriber. Both should serve the patient as a triad instead of the patient connecting with each in linear fashion. In the context of limited healthcare resources, clinician time needs to be spent on activities that deliver the most value based on evidence and need. This is easiest when providers interact collaboratively and with clearly defined roles.

Based on their training and expertise, pharmacists are well-qualified to help prescribers implement and or monitor safe dose titration or tapering, medication rotation, and transitioning between medications. In opioid stewardship, there is good evidence to support pharmacists’ capacity to adjust therapy, conduct medication reviews, provide OAT and naloxone, offer screening and monitoring tests, and provide education to patients, the public, and other medical professionals.⁵ Policies and regulations that maximize use of pharmacist capability could further improve access to medications and medication-related services, especially for rural and underserved regions, patients without primary care prescribers, or patients in transition of care. This would help free up the resources of prescribers.

In developing updated roles with the goal of improving the opioid crisis, both pharmacists and prescribers need to be consulted in detail on the best ways they can support one another, gaps in professional training, and system-level factors that need to be addressed. Input from people with lived experience will provide foundation to the discussion. Some work toward this end has been done. In 2018, the Canadian Pharmacists Association began an initiative to define a harmonized scope of practice for Canadian pharmacists. The initiative resulted in the development of four pillars for a harmonized scope of practice for pharmacists in Canada.¹⁰ These included prescriptive authority not limited by drug classes; dispensing authority; medication administration authority, including subcutaneous or intramuscular injections; and the authority to order, receive, conduct, and interpret health tests. The group agreed that a harmonized scope of practice should be patient-centred, focused on improved patient care or improved access, supportive of patient safety, supportive of interdisciplinary collaboration, and supportive of professional autonomy.

Communication between pharmacists and prescribers will be essential for both to fully benefit from this partnership. Poor communication between healthcare professionals tends to fragment patient care, leading to poorer health outcomes.¹¹ A 2020 review on the impact of integrating pharmacists into primary care teams in Ontario found that physicians report many benefits related to the involvement of pharmacists in primary care teams. These benefits included “having a colleague who is able to provide reliable drug information, optimize medication prescribing, improve clinical documentation, services, and recommendations, and enhance patient care”.¹¹ Community pharmacists do not yet enjoy all the infrastructure offered in an interprofessional team setting but increasingly, innovations in technology are reshaping our ability to connect with each other and offering new opportunities for system design. Future research underlying the development of a structured collaborative model, its practical implementation, and ultimately tracking outcomes will be needed.

Conclusion

The opioid crisis is reaching a critical juncture where significantly more support is needed to save lives and improve quality of life. This support necessitates reimagining our current healthcare system and leveraging innovative new ways of doing things. The lack of integrated, collaborative roles for pharmacists and prescribers in opioid stewardship represents an opportunity for productive change.

Pharmacists and prescribers are working together as effectively as possible within their current roles, but there is significant room to improve and optimize value for the system by maximizing the benefit of clinicians’ training and time. Working within the bounds of limited healthcare resources, each provider should use their time on activities that deliver the most value based on evidence and need.

It’s time for Canadian healthcare providers and policymakers to champion change toward clear, collaborative, redefined roles for pharmacists and prescribers and support their integration in order to fight the growing opioid crisis and ultimately help the people and families affected by opioid use disorder, as well as Canadian society at large.

ACKNOWLEDGEMENTS
Editorial Assistance. Editorial assistance was provided by Laura Tennant, HBSc, and STA Healthcare Communications (Montreal, Canada). Support for this assistance was funded by Indivior Canada.
Disclosures. Feng Chang has received honorarium from Indivior Canada for speaking engagements.

References
1. Opioid- and Stimulant-related Harms in Canada. Accessed October 28, 2021. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/
2. Preliminary Patterns in Circumstances Surrounding Opioid-Related Deaths in Ontario during the COVID-19 Pandemic. https://odprn.ca/wp-content/uploads/2020/11/Opioid-Death-Report_FINAL-2020NOV09.pdf
3. Opioid Stewardship | ISMP Canada. Accessed February 1, 2022. https://www.ismp-canada.org/opioid_stewardship/
4. Gondora N, Chang F. Canadian Pharmacists Association’s webinar: Pharmacists as opioid stewards: a showcase of the evidence, Oct 28, 2020. https://www.pharmacists.ca/cpha-ca/assets/File/education-practice-resources/WebinarSlideDeck/2020/VT-SlideDeck-Pharmacists-as-opioid-stewards.pdf. Accessed May 17, 2022.
5. Gondora N, Versteeg SG, Carter C, et al. The role of pharmacists in opioid stewardship: A scoping review. Res Soc Adm Pharm. Published online July 2021:S1551741121002357. doi:10.1016/j.sapharm.2021.06.018
6. Tadrous M, Greaves S, Martins D, et al. Evaluation of the fentanyl patch-for-patch program in Ontario, Canada. Int J Drug Policy. 2019;66:82-86. doi:10.1016/j.drugpo.2019.01.025
7. Abouk R, Pacula RL, Powell D. Association Between State Laws Facilitating Pharmacy Distribution of Naloxone and Risk of Fatal Overdose. JAMA Intern Med. 2019;179(6):805-811. doi:10.1001/jamainternmed.2019.0272
8. Health Canada. Frequently asked questions: Exemptions for practitioners and pharmacists prescribing and providing controlled substances, and for patients, during the coronavirus pandemic. Published November 2, 2021. Accessed February 1, 2022. https://www.canada.ca/en/health-canada/services/health-concerns/controlled-substances-precursor-chemicals/policy-regulations/policy-documents/section-56-1-class-exemption-patients-pharmacists-practitioners-controlled-substances-covid-19-pandemic/frequently-asked-questions.html
9. Bishop LD, Rosenberg-Yunger ZRS, Dattani S. Pharmacists’ perceptions of the Canadian opioid regulatory exemptions on patient care and opioid stewardship. CPJ. Published online August 16, 2021:171516352110345. doi:10.1177/17151635211034530
10. Emberley P. Canadian Pharmacists Scope 20/20: A vision for harmonized pharmacists’ scope in Canada. CPJ. 2018;151(6):419-420. doi:10.1177/1715163518804148
11. Khaira M, Mathers A, Benny Gerard N, Dolovich L. The Evolving Role and Impact of Integrating Pharmacists into Primary Care Teams: Experience from Ontario, Canada. Pharmacy. 2020;8(4):234. doi:10.3390/pharmacy8040234