Clinical briefing: Opioid deaths
A recent RPS report considers pharmacy’s role in reducing harm and preventing drug deaths from opioid misuse. As recent statistics show, something needs to be done says Mark Greener.
For years, opioid addicts were caricatured with emaciated bodies, indifferent to responsibilities, indulging in criminality to feed their irresistible, insidious cravings. More recently, opioid dependency moved from city streets to the suburbs as a growing number of people became hooked on prescription painkillers.
Overdosing on opioids is notoriously easy. In 2020, according to the Office for National Statistics, 2,263 of the 4,561 deaths from drug poisoning across England and Wales involved opiates (natural opioids, such as heroin) – that’s 49.6 per cent of drug poisonings registered during that year. The proportion increased to 64.5 per cent when analysts excluded deaths that had no drug type recorded on the certificate.
Meanwhile, in Scotland, there were 1,339 drug-related deaths during 2020, a rate three-and-a-half times that of England and Wales, and the highest recorded by any country in Europe – a terrible statistic.
However, there is growing recognition of pharmacists’ importance in tackling opioid misuse. A recent report from the Royal Pharmaceutical Society (RPS), ‘Pharmacy’s role in reducing harm and preventing drug deaths’, made 14 recommendations covering harm reduction; prescribing, treatment and review; improved multidisciplinary working; education and training; and future developments, such as involving pharmacists in regulated supervised drug consumption rooms and heroin-assisted treatment. The report focuses on Scotland but there is much for pharmacists everywhere to ponder.
The RPS suggests five ways in which pharmacists can help reduce harm, starting with the uptake of take-home naloxone being lower than is ideal. And many of those who do take the drug home don’t carry it with them as they go about their daily lives. Pharmacists can educate people about the correct use of this life-saving drug.
The report argues that pharmacists should be allowed to offer naloxone to people they believe are at risk of, or likely to witness, an opioid overdose. In addition, naloxone “must be available” from every community pharmacy and staff trained to use the opioid antagonist in case of an emergency nearby.
First-aid boxes in any clinical setting attended by people who use drugs should contain naloxone. Again, pharmacy teams in these settings should be among the staff trained to use the rescue drug.
Community pharmacies and other settings should have the tools to prevent and identify possible dependence on POM and OTC medicines and be able to offer brief interventions. Teams should record purchases of OTC medicines liable to cause abuse or dependence. This will help identify overuse or misuse and contribute to harm prevention.
New and high-risk medication tools used in community pharmacy should encompass medicines with a risk of dependence. The RPS argues that this will “encourage and enable education to start at the point of prescribing and dispensing”. The report adds that “community pharmacies are ideally placed to host targeted public health campaigns” around dependence on prescribed, illegal and over-the-counter medicines.
The report also made several recommendations about prescribing, treatment and review. For example, pharmacists could review instances of polypharmacy and check the health of drug-dependent people. They could also widen treatment options through depot buprenorphine injection clinics, independent prescribing and deprescribing. For pharmacists embedded in their community, offering these interventions could make accessing treatment that much easier.
The report also called for clear referral pathways to enable prisons and hospitals to refer at-risk people who need medication to a trained and resourced community or primary care pharmacist when addiction services are not available.
Against this background, as we report in more detail later in this issue, a group led by Margaret Jordan, a general practice pharmacist in Woonona, New South Wales, recently published a review of studies of opioid medicines management by primary care pharmacists. The review identified that pharmacists can minimise harm from opioids using a variety of interventions from education to opioid stewardship, similar to the approach used to tackle inappropriate antibiotic use.
“Community pharmacists are well placed to recognise risks, and develop and utilise referral pathways, or if available, offer take-home naloxone,” Ms Jordan told Pharmacy Magazine. As I was finishing writing this column came news that pharmacists could be allowed to supply naloxone for home use under new plans put out for consultation by the Government.
It is up to us all – pharmacists, healthcare professionals, pharmaceutical companies, politicians and society more widely – to address the huge problems posed by illegal, legal or diverted drugs. After all, prescribers issue these drugs in good faith to help. However, for myriad reasons, good intentions unfortunately can often go astray.