A Primary Prevention Approach to the Opioid Epidemic

Fraser and Plescia recently published an essay in AJPH, “The Opioid Epidemic’s Prevention Problem,” which called out the elephant in the room—primary prevention’s role in the opioid crisis.¹ While we grieve the lives lost because of opioid overdoses and wring our hands over the rate of drug overdose deaths increasing another 9.6% in 2017 from 2016, calls for more upstream work including primary prevention remain unanswered.² Dispensing naloxone and prescription drug monitoring programs have had a positive impact on the opioid crisis. However, as the authors declare, “these strategies alone will not end the opioid epidemic.”^1(p215) As is, naloxone stands to reduce the opioid overdose mortality rate, and treatment stands to reduce opioid use disorder (OUD) prevalence. However, ending the opioid crisis will require reducing the incidence of opioid misuse rate, and this will be achieved by protecting unsuspecting victims from starting down the road to OUD in the first place.

As medication experts, pharmacists serve as gatekeepers of safe medication use for patients. This includes verifying the appropriateness and safety of the medication being dispensed, and educating the patient about appropriate use of that medication. The focus of this editorial is on the role of the community pharmacist in preventing OUD in high-risk individuals. We propose a means to prevent OUD in the community pharmacy setting. We will also share our own experience implementing a statewide community pharmacy initiative called ONE Rx (Opioid and Naloxone Education).

PREREQUISITES FOR PRIMARY PREVENTION

Prevention of OUD depends upon the public health principle of primary prevention being integrated into health care delivery more broadly. One reason that it is not happening as often as it should is lack of clarity about the conditions necessary for primary prevention to be effective. Successful primary prevention is contingent on three critical prerequisites.

First, the disorder being prevented must have a detectable preclinical phase, during which individuals with elevated risk of the disorder can be identified and their progression stopped. This also allows the identification of individuals in the early stages of the disorder, but that is secondary prevention, which is beyond the purpose of this editorial. It is known that OUD is a chronic and progressive disease, more common among individuals presenting with certain risk factors; therefore, there is the opportunity to identify these individuals and provide evidence-based, individualized, nonstigmatizing care for them to prevent the start of an OUD.

Second, a tool for identifying individuals at risk who would benefit from primary prevention is required; frequently, this is a risk-stratification tool. The Opioid Risk Tool (ORT) is a tool used to stratify patients receiving an opioid prescription for risk of opioid misuse.³ This tool needs to be feasible, affordable, and acceptable to patients, and must be able to effectively identify patients in need. The ORT, incorporated in our intervention, the North Dakota ONE Rx project, has been shown to be easily administered in community pharmacies and able to identify patients with high risk for OUD.⁴

Third, this risk-stratification tool needs to be used among a population with elevated prevalence of the condition seeking to be identified, which increases the overall accuracy of the results. Individuals being first exposed to opioid medications, those on chronic medication, and patients with chronic pain are just such a population. This allows us to evaluate and identify individuals who may be at elevated risk for OUD. Furthermore, this activity needs to occur in the ideal setting to access this high-risk population. After a pain clinic, there is no health care setting with more direct access to this high-risk population than the community pharmacy.

COMMUNITY PHARMACY INVOLVEMENT

There is need for a more proactive, prevention-based approach to patient care, and what we have done through the ONE Rx project holds promise for doing just that to prevent opioid use disorder.⁵ Pharmacists across the state of North Dakota were offered a three-hour continuing education seminar on OUD and accidental overdose.⁴ Trained pharmacists were given a toolkit for patient education and referral in the community, educated on the application of screening results to clinical decision-making and outcomes for individual patients, and authorized to prescribe and dispense naloxone to high-risk individuals.

Through ONE Rx, each and every patient receiving an opioid prescription is screened for OUD with the ORT (Figure 1).⁴ On the basis of the screening results, pharmacists provide education and interventions such as naloxone prescribing and dispensing, referral to community support services, opioid misuse consultation, provider contact, and medication take-back consultation. In four months of work through ONE Rx, 1032 individuals have been screened. Of the 1032 encounters, 4.6% were identified at an elevated risk for OUD, and 18% of the 1032 received one or more of the ONE Rx interventions regarding safe opioid use. Previous research has reported on opportunities for community pharmacists to provide preventive services and referral in the community pharmacy.⁶ Cochran et al. used a Motivational Intervention and Medication Therapy Management model and reported a new randomized controlled trial to support patients with opioid medication misuse in the community pharmacy setting.⁷ ONE Rx provides further supporting evidence for the role of the community pharmacist in preventive services and care for patients in the midst of the opioid crisis.

FIGURE 1—

Statewide Community Pharmacy Initiative ONE Rx (Opioid and Naloxone Education): North Dakota

Note. Community support services = available addiction support in local community discussed; medication take-back = appropriate disposal of opioids; naloxone = prescribed and dispensed; opioid misuse risk consultation = risk of accidental overdose and potential for misuse discussed with every patient; patient care partial fill = medication dispensed with smaller quantity than prescribed; referral = to community support services.

Depriving individuals in pain of needed analgesics increases the risk that they will seek more dangerous opioids elsewhere. However, what is proposed in the ONE Rx project is not pushing patients with aberrant behaviors away but rather drawing them in for counseling, patient education, and referral, as necessary. This includes introducing them to nonopioid alternative medications as well as nonpharmacological approaches to pain control.

Fraser and Plescia have called out the opioid epidemic’s prevention problem. A primary prevention approach of identifying patients at high risk for OUD and then providing patient care is one opportunity to respond to this call and reduce the incidence of OUD. ONE Rx is an innovative process by which community pharmacists identify those at high risk for opioid misuse and care for patients receiving an opioid prescription and thus participate in primary prevention of an OUD, ultimately reducing the incidence of OUD.