Another Pandemic Rages on Beyond Our Consciousness
Opioid overdoses are killing nearly as many of our neighbors and patients as COVID-19 and in much younger populations.
Against the backdrop of (COVID-19), the CDC reports that 81,230 deaths occurred from drug overdoses for the 12-month period ended May 2020, just a few months into the pandemic.
This increase of more than 18% from the 12 months prior represents the largest number of drug overdoses ever reported.1 Even more concerning are anecdotal evidence and some more recent localized data points suggesting that the drug epidemic and the pandemic and resulting economic downturn for tens of millions of Americans have created increased despair, more joblessness, and reduced social interactions.
Judicious Prescribing and Dispensing Are Now Largely in Place
Over the past decade, much effort has been made to increase opioid prescribing and dispensing stewardship. Although treatment for substance misuse itself has been historically under appreciated, a focused effort to reduce the total number of opioids dispensed has been largely successful, with multi provider prescribing of opioids dropping by 62% in 11 states after prescription drug monitor programs were implemented.2 Nationwide, opioid prescribing fell about 40% from its peak in 2012 to the end of 2019.
Rates of Death Increase From Other Means of Access
Replacing many prescription-related opioid overdoses are community acquired synthetic, illicit, and non prescribed fentanyl drug trade) overdoses. In 2013, deaths from synthetic opioids (some prescribed but most illicit) were approximately 1 per 100,000 individuals. That skyrocketed 10-fold over the ensuing 3 years, exactly the time when judicious prescribing efforts began in earnest. This substitution effect was entirely predictable. We continue to fail at addressing the underlying issues, namely economic and social despair and lack of recognition and treatment for substance use disorder.
Our Role Will Expand to Include More Emphasis on Rescue and Treatment
The COVID-19 pandemic has brought upon pharmacy both recognition and strain through additional newsworthiness and responsibilities from activities like testing and mass vaccination efforts needing community penetration even beyond influenza vaccinations. We have done a lot as a pharmacy community to combat prescription-involved opioid overdoses. Yet, lack of access to treatment, both through formal treatment facilities and generalist health care providers, such as pharmacy or primary care, continues to plague our country.
Expect a Postpandemic Renewed Focus on Overdoses
The COVID-19 pandemic may never go away (yes, we might have COVID-21 and COVID-22) and some form of the virus may become endemic worldwide over the next few years, but it will abate in our consciousness, emergency departments, and hospitals. That abatement will lead to a renewed focus on one of our leading causes of death in individuals younger than 65 years. Overdoses take away more life-years that some of our most prominent disease states and lead to more parents burying their own children than COVID-19 or any other infectious disease. And the number of overdoses is increasing, not abating.
What Health Care Providers Can Do, Including Pharmacists
The CDC recommends that health care providers engage in 3 categories of activities.3 For pharmacists, most of these are not new concepts, but we can aspire to more accessible and comprehensive versions of the pharmacy-based deployments we have now. Consider the following points:
Expand the provision and use of naloxone, and provide overdose prevention education.
• Co-prescribe naloxone to patients with high morphine milligram equivalents and those receiving benzodiazepines and opioids.
• Counsel patients that multiple doses of naloxone may be needed for a single overdose event because of the potency of illicitly manufactured fentanyl and fentanyl analogs and that multiple doses of naloxone may be needed over time because of the prolonged effects of opioids in some cases.
• Expand locations in which overdose prevention education and take-home naloxone are provided. These locations can include counseling and support groups, inpatient and outpatient treatment programs, primary care settings, retail pharmacies, and other community-based settings. Expanding locations may be especially important in rural areas.
• Prescribe naloxone to individuals at risk for opioid overdose, such as individuals with a prior history of overdose, patients with opioid use disorder (OUD), and those using illicit opioids and other drugs that might be mixed with illicitly manufactured fentanyl.
• Talk to patients about the changing illicit drug supply and risks for overdose and exposure to highly potent opioids, such as illicitly manufactured fentanyl.
Expand access to and the provision of treatment for substance use disorders.
• Provide medications for OUD.
Intervene early with individuals at the highest risk for overdose.
• Continue or initiate medications for OUD among individuals leaving correctional and detention facilities.
• Implement post overdose response protocols, including in emergency departments, that incorporate links among community-based service organizations, health care and treatment providers, and public health agencies. These protocols promote linkage to care, medication for OUD, overdose education, naloxone distribution, and treatment.
• Provide active referral-to-treatment options and recovery support services.4
We can assume that more will be asked of all health care providers including pharmacists in response to this continuing and growing epidemic overshadowed by the COVID-19 headlines. We should engage in new funding and programming from federal, local, and state legislation. It will soon be a good time to revisit the opioid stewardship and safety practices in place at pharmacies and broaden newly formed relationships with departments of health that resulted from the pandemic response.
TROY TRYGSTAD, PHARMD, PHD, MBA, is the vice president of pharmacy provider partnerships for Community Care of North Carolina, which works collaboratively with more than 1800 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University in Des Moines, Iowa, and his PhD in pharmaceutical outcomes and policy from the University of North Carolina at Chapel Hill. He also serves on the board of directors for the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.
1. Provisional drug overdose death counts. CDC. Updated February 17, 2021. Accessed March 4, 2021. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
2. Strickler GK, Kreiner PW, Halpin JF, Doyle E, Paulozzi LJ. Opioid prescribing behaviors - prescription behavior surveillance system, 11 states, 2010-2016. MMWR Surveill Summ. 2020;69(1):1-14. doi:10.15585/mmwr.ss6901a1
3. Increase in fatal overdoses across the United States driven by synthetic opioids before and during the COVID-19 pandemic. CDC. Updated December 17, 2020. Accessed March 4, 2021. https://emergency.cdc.gov/han/2020/han00438.asp
4. US opioid dispensing rate maps. CDC. Updated December 7, 2020. Accessed March 4, 2021. https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html