The new ACP opioid guidelines for pharmacy professionals that come into effect October 1, 2017, may mean some big changes to the way that some pharmacists practice.
Before considering how these changes are to be made, it’s important to step back and explore why these changes need to happen.
The ongoing opioid crisis has a huge cost to Albertans, both in healthcare resources and human suffering. As highly accessible healthcare professionals, pharmacists are well positioned to make an impact and our guiding principles, the standards or practice, and the code of ethics require us to do what we can.
Alberta Health publishes surveillance reports every quarter on opioids and substances of misuse. From this data, pharmacists can gain insight on how frequently they encounter individuals who are most at risk.
Between January 1, 2016, and March 31, 2017, 476 individuals in Alberta were reported to have died from an apparent overdose related to fentanyl. An additional 196 individuals died from an apparent overdose related to an opioid other than fentanyl.
In the 30 days prior to their fentanyl related death due to overdose:
- three per cent of these 476 individuals received a pain related health service,
- 10 per cent had a mental health related service,
- 10 per cent of patients visited an emergency department (ED) regarding an opioid/substance of misuse, and
- 14 per cent obtained a substance abuse related health service.
During this same time, 20 per cent of these individuals obtained an opioid from a community pharmacy and 24 per cent had an antidepressant/anxiolytic dispensed at a community pharmacy.
“You may not believe pharmacists play a large role when it comes to fentanyl related overdose but the data suggests otherwise,” said ACP Compliance Officer Monty Stanowich. “Individuals who overdose on fentanyl are accessing pharmacy services more frequently than other healthcare professionals.”
When you look at data for death due to an apparent overdose related to an opioid other than fentanyl, the potential role for pharmacists to intervene is even more evident. In the 30 days prior to death:
- only six per cent of these 196 individuals visited an emergency department (ED) regarding an opioid/substance of misuse,
- eight per cent received a pain related health service,
- 11 per cent obtained a substance abuse related health service and
- 11 per cent had a mental health related service.
In contrast, during this time, 51 per cent of these individuals had an antidepressant/anxiolytic dispensed from a community pharmacy and 62 per cent had an opioid dispensed from a community pharmacy. Clearly, pharmacists are among the healthcare professionals who have the most access to these individuals at their most vulnerable time.
Another area where pharmacists may have an impact is by checking Netcare.
For the period of Jan 1, 2016, to Dec 31, 2016, 23 per cent of patients who died from an apparent overdose to fentanyl had an opioid dispensed from three or more pharmacies in the year prior, and 37 per cent had opioids prescribed from three or more practitioners.
These numbers are increased to 34 per cent and 39 per cent respectively for patients who died from an apparent overdose to an opioid other than fentanyl. As well, for the non-fentanyl deaths during this time, 26 per cent of individuals had used an oral morphine equivalent (OME) ≥90mg per day and 13 per cent had used ≥200mg per day.
“All the above statistics were taken from Netcare,” said Monty. “Pharmacists have access to this data when providing pharmacy services and this information can help when conducting an assessment and developing a treatment plan.”
It is also important to note where these apparent overdoses resulting in death are occurring.
A perception exists that deaths occur in the inner city of large population centres. Indeed, the largest numbers, from January 1, 2016, to December 31, 2016, do occur in Edmonton and Calgary, but when we examine the rates per 100,000 people, it becomes evident that this issue exists in all the zones and cities in Alberta. Cities such as Red Deer, Medicine Hat, and Grand Prairie report a higher rate of death in some measures than either large city.
Within Edmonton itself, 71 per cent of apparent fatal overdoses occurred in individuals residing outside the central urban core. In Calgary, this number is higher yet at 81 per cent.
Thus, the scope of the problem is geographically widespread and affects people of all socio-economic circumstances and it must be the concern of every pharmacist.
The ACP guidance document for assessment and monitoring of individuals using opioid medications was created with several goals in mind:
- Ensuring that patients with acute pain are treated with the safest, most effective treatment.
- Preventing individuals using short-term opioid therapy from becoming long-term users.
- Identifying patients who are at risk and appropriately managing their care to prevent drug related adverse effects and misuse.
- Identifying patients who suffer from addiction and/or misuse and ensuring they are accessing the care they require, while employing strategies for harm reduction.
This document is part of a broader strategy that ACP is undertaking in association with government, the College of Physicians and Surgeons, and other stakeholders to ensure Albertans receive the best possible healthcare with regards to opioids, pain, and addiction. Alberta pharmacists already play a large role in managing overdoses by providing Naloxone kits to at risk individuals. The requirements outlined in the Guidance Document for Assessment and Monitoring of Individuals using Opioid Medications are the next logical step, shifting the focus of the pharmacist to a more proactive, preventative role in the management of the health of these individuals. While what we do may not prevent every overdose, it will surely have a positive impact on the lives and health of many Albertans.