Alina Cernasev, PharmD

In February 2020, Netflix released a documentary depicting the early years of what became the opioid epidemic. The documentary, called 

 follows a journey that is familiar to many working in pharmacies across the United States.

The story is told through the eyes of Louisiana pharmacist Dan Schneider, who began noticing increased opioid use, misuse, and the first mass opioid-dispensing clinic now commonly referred to as “pill mills.” Like many working in community pharmacy, he wanted to do something to halt its spread, but felt powerless to make an impact.

A driving factor for Schneider was the loss of his son in a drug-related shooting. This personal connection to addiction allowed him to see his patients in a unique light.

Schneider saw each individual walking through his door as his son, daughter, or other loved one, and consequently warned each of his patients about the dangers of opioids and provided them with resources.

The opioid epidemic continues to affect American communities at staggering rates. Since 1999, the opioid epidemic has been an increasingly constant headline in newspapers, social media, and on television with approximately a half-million opioid-related deaths (CDC, 2018; CDC, 2019; Wilson, 2020).

Perhaps no other health care worker has been exposed to this epidemic more frequently than pharmacy technicians and pharmacists. Like Schneider, they are on the frontlines of the opioid epidemic and are placed almost daily in situations in which there is a desire to do “something,” but without the ability to directly help.

Because of the frequency of these encounters, pharmacists and pharmacy technicians often suffer from something known as “compassion fatigue.” This is a phenomenon in which a care provider experiences secondary trauma from caring for another, which can result in turnover, decreased morale and job satisfaction, and reduced empathy toward patients (Winstanley, 2020).

Further complicating the issue is that pharmacy staff are both patient care advocates and regulatory enforcers, and these divergent roles often put them at odds with their patients.

The community pharmacy is a key link in the chain of opioid prescribing, but is often overlooked, leaving pharmacists and pharmacy technicians wondering how and to what extent they may make an impact.

Although pharmacy personnel bear witness to much of the opioid epidemic, they may not always see the whole picture. However, as new research continues to reveal, the “whole picture” is complex, often hidden, and is directly linked to both addiction and the potential for recovery.

One critical example of this is the idea of adverse childhood experiences (ACE) and their connection to future addiction (Felitti, 1998). ACEs include:

witnessing violence in the home or community

having a family member attempt or die by suicide

Each additional ACE increases the likelihood of early initiation into substance use disorder by 2- to 4-fold (Dube, 2003). Further, the more traumas a person is exposed to, the greater the chance for opioid misuse (Austin, 2018; Quinn, 2016).

Similarly, social isolation and hopelessness have been uncovered as other hidden factors affecting opioid misuse (McLean, 2016). In other words, there are clear links between human suffering and opioid misuse that cannot be explained simply by genetics or neurobiology. A recent nationwide study confirmed the heterogeneity of patients who misuse opioids, including many who suffer from poor physical health (Cochran et al., 2017).

In lieu of understanding these “hidden” indicators, pharmacy personnel are often left to draw their own conclusions regarding drug-seeking behavior—and, we are not alone.

Studies show that health care professionals’ views of the opioid epidemic across professions are varied, but often include unsupportive, uncompassionate, or judgmental perceptions that decrease care quality and ultimately increase patient morbidity and mortality (Wakeman, 2018).

Collectively, this concept is referred to as “stigma,” and may include (Link and Phelan, 2001):

labeling (eg, “addicts” or “early fillers”)

negative stereotypes (eg, inaccurate beliefs about people who misuse opioids)

othering (eg, not treating opioid use disorder as a disease and separating these patients from others suffering from chronic diseases)

Although the idea of stigma has been well researched across health workers, it has yet to have been investigated with pharmacy technicians. To this end, researchers conducted a nationwide study involving focus groups of pharmacy technicians working in different areas of the US health care system and practicing in different geographic regions. This is the first pilot study conducted in the United States on this topic and is being supported and sponsored by the 

The overall goal of this research study will be to determine pharmacy technicians’ views, roles, facilitators, and barriers to providing care to patients with opioid use disorder (OUD). The comprehensive results of this research will directly affect future education efforts and assist in achieving NHA’s mission and vision: to develop, advance and advocate for the frontline pharmacy technician, resulting in improved patient care.

Although the study is still ongoing, early findings have uncovered multiple key concepts.  When describing interactions with patients suspected of opioid misuse, technician participants noted features of patient appearance or behaviors that may be viewed as stigmatizing.

Words such as "dirty" and "agitated" were used to describe the appearance of the patients who were suspected of opioid misuse. However, participants also discussed methods found to potentially overcome the impact of the stigmatizing view of some pharmacy technicians.

These include providing patient resources such as pamphlets and brochures, counseling on opioid risks and alternatives by pharmacists, and using non-judgmental language when discussing patients with other pharmacy staff.

Although stigma was found to be present among pharmacy technicians, this finding was not abnormal and does not represent a state of permanence. Although the study is ongoing, there are steps pharmacy technicians can take today to improve care for patients suffering from OUD. These include:

Promoting and modeling a culture of understanding and empathy toward patients with or suspected to have substance use disorder.

Compiling and providing resources for recovery and treatment.

Promoting naloxone co-dispensing when legally allowable.

Assisting the pharmacist with prescription drug monitoring program use.

Above all, the importance of support and compassion for these patients cannot be overstated. Given the scientific evidence on emotional trauma, social isolation, and hopelessness as risk factors for addiction, then how much more damage does pharmacy personnel-based stigma cause?

For Schneider, it was the loss of a son that set him on his journey to provide his patients with that support and compassion. Perhaps these initial study findings on pharmacy technician stigma may serve to do the same for pharmacy technicians across the United States.

Centers for Disease Control and Prevention. Understanding the epidemic https://www. cdc. gov/drugoverdose/epidemic/index. html. Published December 19, 2018. 2019;6.

Centers for Disease Control and Prevention, Prevention. Annual Surveillance Report of Drug-Related Risks and Outcomes—United States. Surveillance Special Report. Centers for Disease Control and Prevention, US Dept of Health and Human Services. In:2019.

Wilson N. Drug and opioid-involved overdose deaths—United States, 2017—2018. MMWR. Morbidity and Mortality Weekly Report. 2020;69.

Winstanley EL. The bell tolls for thee & thine: compassion fatigue & the overdose epidemic. International Journal of Drug Policy. 2020 Jun 1:102796.

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine. 1998 May 1;14(4):245-58.

Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics. 2003 Mar 1;111(3):564-72.

Austin AE, Shanahan ME, Zvara BJ. Association of childhood abuse and prescription opioid use in early adulthood. Addictive Behaviors. 2018 Jan 1;76:265-9.

Quinn K, Boone L, Scheidell JD, Mateu-Gelabert P, McGorray SP, Beharie N, Cottler LB, Khan MR. The relationships of childhood trauma and adulthood prescription pain reliever misuse and injection drug use. Drug and alcohol dependence. 2016 Dec 1;169:190-8.

McLean K. “There's nothing here”: Deindustrialization as risk environment for overdose. International Journal of Drug Policy. 2016 Mar 1;29:19-26.

Cochran G, Hruschak V, Bacci JL, Hohmeier KC, Tarter R. Behavioral, mental, and physical health characteristics and opioid medication misuse among community pharmacy patients: A latent class analysis. Res Social Adm Pharm. 2017;13(6):1055-1061.

Wakeman SE, Rich JD. Barriers to medications for addiction treatment: How stigma kills. Substance use & misuse. 2018 Jan 28;53(2):330-3.

Link BG, Phelan JC. Conceptualizing stigma. Annual review of Sociology. 2001 Aug;27(1):363-85.

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Perhaps no other health care worker has been exposed to the opioid epidemic more frequently than pharmacy technicians and pharmacists.