Christopher Epps, PharmD Candidate

International Overdose Awareness Day is August 31 each year.

This somber day functions as a remembrance of more than 500,000 lives lost and a reminder of how far we have come in combatting addiction across America.

 True awareness requires reflection on the crisis' origins, actions to mitigate its consequences, and ideas to move us forward to overcome this opioid pandemic.

Several factors initiated the opioid pandemic and propelled its growth. The American Pain Society introduced pain as the fifth vital sign in 1995.

 That same year, Purdue Pharma marketed oxycodone (OxyContin), employing marketing campaigns that emphasized the benefits that extended pain relief provided while downplaying the implications. Purdue, as well as Allergan, Endo International, and Teva Pharmaceutical Industries Ltd, also downplayed the serious risk and likelihood of addiction that occurs with their opioids.

Fast-forward 17 years, and prescribers had written more than 259 million opioid prescriptions, enough for every adult in the country to have a bottle of pills.

Advertising and false information concerning extended-release opioids' addictive properties are not the only reasons this epidemic continued to spiral.

 The FDA found that several major drug distributors were complicit in the unregulated narcotics distribution.

Distributors shipped a staggering number of shipments to retail pharmacies across the country, neither questioning nor reporting them to the Drug Enforcement Administration.

Chain retailers operated within loopholes of the law to dispense opioids to an unwitting public.

Some tactics include providing seminars on pain management and safety, self-policing opioid orders without oversight, and using work-arounds to evade hard limits on purchasing.

The United States has enacted legislation and constructed evidence-based guidelines over the past 5 years to mitigate excessive opioid use. The CDC issued evidence-based guidelines in 2016 for prescribing opioids for chronic pain in adults. The recommendations include prescribing the lowest effective dose and analyzing risks and benefits when prescribing up to 50 morphine milligram equivalents (MME) per day. Prescribers should avoid or justify daily doses of 90 MME or more.

 The Centers for Medicare & Medicaid Services followed in the CDC's footsteps in 2018; Medicare Part D sponsors must limit opioid prescriptions to 7 dates in opioid-naive patients.

Stricter regulations on opioids have provided mixed outcomes. Approximately 80% of new heroin users reported that prescription pills were their gateway.

 Individuals suffering from opioid use disorder have drug-seeking behaviors that cannot be corrected through law.

When obtaining a prescription becomes too difficult, their next step is finding illicit drugs.

The figure summarizes the FDA's actions pertaining to the opioid crisis over the past 20 years.

Pharmacists carry a unique responsibility in the fight against opioid abuse. Pharmacists in community settings are the final gatekeepers to ensure that opioid prescriptions are legitimate, employed in accordance with guidelines, and dispensed according to the law. Pharmacist-provided patient counseling and education, especially for opioid-naive patients, can make all the difference. The first step to combatting the opioid crisis is being aware of the issue and spreading knowledge about it.

Public awareness has significantly increased over the past 5 years. Just 6 states had laws that expanded access to naloxone or limited criminal liability prior to 2012. By the end of 2017, 46 states and the District of Columbia enacted laws that provide protection for laypeople or first responders who administer naloxone.

In addition, 46 states now have statutes that allow pharmacists to dispense naloxone to third parties or first responders via direct prescription or standing order.

 The FDA approved the nasal spray formulation of naloxone for use in the community setting without medical training being required in April 2019.

This FDA approval takes an all-hands-on-deck approach, with statistical models suggesting that 21% of opioid overdose deaths can be averted.

Although preventable overdose-related deaths still occur daily, not all lives lost are in vain. The table lists the unexpected benefits evolving from the opioid crisis.

The loss of life due to an opioid overdose does not have to be senseless. We can learn from our failures and forge forward on a path that emphasizes awareness and understanding. Let's end the stigma surrounding addiction and provide individuals with the resources they need to recover. Open dialogue is critical. Pharmacists play a key role in combatting this scourge.

 is a PharmD candidate at the University of Connecticut School of Pharmacy in Storrs.

1. Bernstein L. Major drugstore chains sue doctors in sprawling federal opioid case. 

 January 8, 2020. Accessed July 1, 2021. 

https://www.washingtonpost.com/health/major-drugstore-chains-sue-doctors-in-sprawling-federal-opioid-case/2020/01/07/3ac9cd70-317d-11ea-9313-6cba89b1b9fb_story.html

2. Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999–2017. CDC. Updated November 29, 2018. Accessed July 1, 2021. 

https://www.cdc.gov/nchs/products/databriefs/db329.htm

3. Randazzo S. Drugmakers go on trial over opioid epidemic.

https://www.wsj.com/articles/drugmakers-go-on-trial-over-opioid-epidemic-11618758002

4. Madras BK. The president’s commission on combating drug addiction and the opioid crisis: origins and recommendations. 

 2018;103(6):943-945. doi:10.1002/cpt.1050 

5. Anderson J. ‘The Crime of the Century’ review: manufacturing the opioid epidemic. 

 May 6, 2021. Accessed July 1, 2021. https://www.wsj.com/articles/the-crime-of-the-century-review-manufacturing-the-opioid-epidemic-11620339231

6. Hoffman J. Big pharmacy chains also fed the opioid epidemic, court filing says. 

https://www.nytimes.com/2020/05/27/health/opioids-pharmacy-cvs-litigation.html

7. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. 

 2016;65(1):1-49. doi:10.15585/mmwr.rr6501e1

8. Anson P. Medicare finalizes plan to reduce high dose opioids. Pain News Network. April 2, 2018. Accessed July 1, 2021. 

https://www.painnewsnetwork.org/stories/2018/4/2/medicare-finalizes-plan-to-reduce-high-dose-opioids

9. Timeline of selected FDA activities and significant events addressing opioid misuse and abuse. FDA. Updated July 2, 2021. Accessed July 20, 2021. 

https://www.fda.gov/drugs/information-drug-class/timeline-selected-fda-activities-and-significant-events-addressing-opioid-misuse-and-abuse

10. Compton WM, Jones CM, Stein JB, Wargo EM. Promising roles for pharmacists in addressing the U.S. opioid crisis. 

. 2019;15(8):910-916. doi:10.1016/j.sapharm.2017.12.009

11. Davis C, Carr D. State legal innovations to encourage naloxone dispensing. 

. 2017;57(2S):S180-S184. doi:10.1016/j.japh.2016.11.007

12. FDA approves first generic naloxone nasal spray to treat opioid overdose. News release. FDA. April 19, 2019. Accessed July 1, 2021. 

https://www.fda.gov/news-events/press-announcements/fda-approves-first-generic-naloxone-nasal-spray-treat-opioid-overdose

13. Dinerstein C. Opioid crisis’ grim silver lining: more organs for transplant. American Council on Science and Health. April 16, 2018. Accessed July 1, 2021. https://

www.acsh.org/news/2018/04/16/opioid-crisis%E2%80%99-grim-silver-lining-more-organs-transplant-12842

14. Osborne S. The ‘silver lining’ of the opioid crisis: more pain research. 

. November 18, 2019. Accessed July 1, 2021. https://

15. Hamm S. New strategies for combating the opioid epidemic. Yale School of Medicine. 2018. Accessed July 1, 2021. 

https://www.medicine.yale.edu/news/yale-medicine-magazine/new-strategies-for-combating-the-opioid-epidemic/

Articles

Pharmacists carry a unique responsibility in the battle that has claimed 500,000 lives in the past 2 decades.

International Overdose Awareness Day Is Somber Reminder

Vaccine hesitancy continues to be a concern for the United States as we strive to reach herd immunity against COVID-19. However, these vaccines are not the only ones drawing speculation. Reaching adequate levels of vaccine coverage proves difficult for various reasons, such as barriers of awareness, availability, and hesitancy.

Although vaccines are one of the best public health interventions created, the United States has vaccinated only 35% of eligible adults against herpes zoster, 52% of females and 21% of males against human papillomavirus (HPV), and around 45% of adults annually against influenza.

Researchers from Boston College and Microsoft Research may have found a way to combat these low percentages. Participating search engines showed advertising campaigns in related web searches to approximately 69,000 individuals. The data collected through the search engines counted ad clicks and tracked any future searches concerning vaccines of interest.

Targeted ad campaigns revealed 2 primary effects on an individual’s behavior. The first effect discovered by the study is the congruence effect. When individuals who express initial interest in the disease or vaccine were shown a targeted advertisement, it increased the likelihood of ad clicks and future searches by up to 116%.

The second effect that advertisements revealed is the priming effect. This occurs when the targeted advertisement is displayed within a search that is unrelated to the disease or vaccine eligible to them. A significant portion of individuals who received an unrelated vaccine ad searched for vaccine information shortly after.

The researchers also discovered that increasing the number of sponsored advertisements appearing in web searches had a negative correlation with ad clicks. Advertisers should be cautious to not overwhelm individuals when designing public health campaigns.

­The findings presented in this study demonstrate the need to advertise vaccinations to a broader spectrum of individuals who do not necessarily look like existing customers. Doing so can draw in an untapped subset of the United States population. These individuals can and should be influenced by advertising to ultimately increase the number of people who vaccinate against preventable, communicable diseases.

 is a 2022 PharmD Candidate at the University of Connecticut in Storrs.

Krupenkin M, Yom-Tov E, Rothschild D. Vaccine advertising: preach to the converted or to the unaware? 

Researchers from Boston College and Microsoft Research may have found a way to combat these low percentages. 

The Benefits and Limitations of Vaccine Advertising

Diabetes is one of the most prevalent noncommunicable diseases across the world, with a projection to affect 552 million people by the year 2030. Most attempts to curb its growth focus primarily on lifestyle interventions to slow or stop type 2 diabetes (T2D) onset.

Screening and diagnosing tools currently in practice do not include modifiable factors such as nutritional intake and anthropometric data. However, anthropometric markers and dietary intake are indicators of an individual’s relative risk of developing T2D. Studies have shown that the available screening tools that examine limited known predictors result in the underdiagnosis of early hyperglycemia. The inclusion of modifiable factors may be invaluable in approaches to prevent the onset of T2D more aggressively.

Investigators from Monash University in Australia determined the prevalence of undiagnosed T2D to be 5.26% when utilizing machine learning to analyze modifiable markers not included in current screening guidelines. This equates to up to 29 million people worldwide with undiagnosed T2D by the year 2030.

The research team compiled 16,429 medical files and stratified them based on the confirmation of undiagnosed T2D. They identified patients who lacked a current diagnosis and had a positive glycemic response to 1 of 3 tests. Three machine learning algorithms analyzed this group against 114 potential nutritional markers with 13 behavioral and 12 socio-economic variables.

Investigators found significant anthropometric markers that included upper leg length, age at heaviest weight, waist circumference, and arm circumference. Significant dietary markers found in the study included number of meals not prepared at home, number of ready-to-eat foods, daily fat consumption, and amount of water consumed daily.

Across the data, ultra-processed food consumption was an emerging risk factor for the development of type 1, type 2, and gestational diabetes. Conversely, caffeine intake positively reduced risk of disease development. Ninety countries have established food-based dietary guidelines and this study’s findings could help create disease-specific nutritional guidance.

This analysis revealed that current diagnosing guidelines miss important data that can lead to an earlier diagnosis. Health care providers can use diet-related, anthropometric, and nutrient-based variables to enhance current prediction models and diagnose T2D sooner.

 is a 2022 PharmD candidate at the University of Connecticut in Storrs.

De Silva K, Lim S, Mousa A, et al. Nutritional markers of undiagnosed type 2 diabetes in adults: Findings of a machine learning analysis with external validation and benchmarking. 

. 2021;16(5):e0250832. DOI:10.1371/journal.pone.0250832

Investigators from Monash University determined the prevalence of undiagnosed type 2 diabetes utilizing machine learning to analyze modifiable markers not included in screening guidelines. 