This article first appeared in the PittPharmacy magazine.
Opioids, including both prescription narcotics and heroin, are in the news almost daily because of overdose deaths. More people in Pennsylvania died from opioid overdose in 2014 than died from car accidents and gun- shot wounds combined. Opioids accounted for 28,648 overdose deaths nationwide in 2014. This epidemic of opioid overdose deaths is now recognized as one of the leading public health issues in the United States. Many government agencies are offering programs to stem the epidemic. President Barack Obama announced in February 2016 that more than $1 billion is being allocated to ensure everyone with “heroin use disorder” can receive treatment. The FDA has announced new guidelines for pain medications to improve safety and prevent addiction. The United States attorney general recently initiated a program to reduce overdose deaths through prevention, treatment, and enforcement. The Centers for Disease Control and Prevention has issued guidance that physical therapy, exercise, and over-the-counter drugs be used before opiates.
Pharmacists have a great opportunity to help patients that may be at risk for addiction and are perfectly positioned to be positive force in stopping opioid overdoses. Frequent pharmacist-patient interactions provide pharmacists the ability to assess risk, educate, monitor patient behavior, and intervene when necessary. Pharmacists routinely perform these activities for chronic disease and can use them to improve safe use of pain medication.
Assessing Risk for Substance Abuse
PittPharmacy faculty member Ralph Tarter, director of the Center for Education and Drug Abuse Research (CEDAR) has been studying substance abuse. CEDAR is a longitudinal research study that began in 1990, following a cohort of 700 families. Tarter has been studying these characteristics in children who carried a high risk of addiction due to genetic and environmental factors with children who carried an average or low risk. In addition to following children and their families, the CEDAR team cross-referenced information such as brain waves, census data about the neighborhood, and other details that make up the mosaic of an individual’s potential for abusing drugs. The data created a platform for developing an algorithm used in screening tools to identify at-risk patients.
The CEDAR-based screenings are being tested in community pharmacies around Western Pennsylvania, where pharmacists take the key role of monitoring the patient’s drug experience and interacting with the prescribing physician if the potential for a problem is identified. In this first year of the project, patients will complete questionnaires while they wait for their prescriptions to be filled. Scores from the questionnaire will alert the pharmacist to the potential for addiction and the pharmacist will intervene. “Identifying at-risk patients as being on a potential trajectory to addiction would be a major step forward,” Tarter says.
Screening for Substance Use Problems
Janice Pringle, PittPharmacy faculty member and director of the Program Evaluation and Research Unit (PERU), has been implementing and evaluating Screening Brief Intervention and Referral to Treatment (SBIRT), a program to detect substance abuse problems at different points of access in health care for more than 15 years. SBIRT helps a health professional quickly identify if a patient has a substance abuse problem and the level of intervention that is required for that patient.
PERU was originally funded by the Substance Abuse and Mental Health Services Agency (SAMHSA) to create curriculum for training medical residents in to use SBIRT. PERU currently supports four SBIRT Training Initiatives funded by SAMHSA. These grants provide support to provide SBIRT training and champion development and evaluation services to programs in Western Pennsylvania, Philadelphia, Pa., and Atlanta, Ga. They also provide support to develop SBIRT Health Professionals Interdisciplinary Up Training within health science schools including pharmacy. The first grant, POSITive (www.positive.pitt.edu), is in the third and final year of implementation with the Allegheny Singer Research Institute and partners. The SBIRT Health Professions Student Training grants with Chatham University, University of the Sciences, and Morehouse College (sbirt.pitt.edu/) are each in their initial year of a total of three. Additionally, PERU supported SBIRT training and collaborative implementation initiatives with primary care and drug and alcohol programs in Blair County and currently supports a SBIRT project in Clearfield Jefferson County by providing SBIRT training, data collection, implementation consultation, and evaluation services.
From Screening to Treatment
One problem Pringle observed early in her work was health professionals were not using SBIRT because they weren’t sure where they could refer them for treatment. She created Project Safe Landing a collaborative initiative designed to connect an SBIRT model directly to community services that facilitate emergency department patient access to substance use disorder treatment and other services. Implemented in Allegheny County in late 2011, Project Safe Landing reduced the occurrence of repeat emergency department admissions by patients with high risk of substance abuse disorder. Project Safe Landing helps patients who have overdosed by providing access to evidence-based interventions such as education, Suboxone® induction, and naloxone prescriptions (used to treat opioid addiction and prevent death from overdose). Her team employs a continuous quality improvement process and quality metrics developed by community collaborators and PERU researchers to optimize the program’s success in reducing health care costs and helping patients.
Saving Lives—Preventing Overdose Deaths
On the front lines of first responders, the school is also taking a leading role in helping people survive overdose emergencies. Naloxone, a rescue drug first introduced in the 1970s in an injectable form, can reverse the effects of an opioid overdose within minutes. It has also been demonstrated that intranasal administration is equally effective. A nasal administration kit including naloxone vials, syringes, and nasal applicators has been used for years. In November, the FDA approved an “all-in-one” spray unit that will make naloxone even easier to administer in an emergency. Associate Professor Mike Zemaitis worked with Pennsylvania’s Department of Drug and Alcohol Programs and state Physician General Rachel Levine to make the naloxone spray available to first responders statewide through passage of Act 139. He also worked to have a statewide standing order issued to allow pharmacists to dispense naloxone to patients or third parties without a prescription. The Allegheny County Health Department, and eventually the state, issued such orders last year. Zematis has worked with the Pitt Police and University Pharmacy to assure that Pitt is at the forefront of ensuring police carry naloxone.
Connecting and Supporting Communities
The School of Pharmacy is serving as a major resource for the development of strategies to reduce overdoses in Western Pennsylvania. Pringle and PERU led the creation of OverdoseFreePA funded through a Substance Abuse Education and Demand Reduction grant from the Pennsylvania Commission on Crime and Delinquency. OverdoseFreePA.org began in April of 2014 as a collaborative project including the Pennsylvania Department of Drug and Alcohol Programs, the Allegheny County Medical Examiner’s Office, and several single county authorities along with the PERU at the University of Pittsburgh School of Pharmacy. The group organized as the Overdose Prevention Coalition (OPC) to develop a free, meaningful, credible, and accessible resource in the overdosefreepa.org web site to support multidisciplinary efforts to reduce overdose and overdose deaths. Advisory committees were formed for each of four main interest groups: family and friends; criminal justice; school and work; and health care professionals. Content and curricula for each target audience, a speaker’s bureau, and links to resources and reference materials developed with the working groups are available on the web site. Overdose death data for two pilot counties are screened to provide a close to real-time picture of who is affected, where, and by what substances. This data is critical to understand the current situation of overdose and implement effective strategies to reduce deaths.
The web site launched in August 2014 and is continually updated with current information and resources. The success of OverdoseFreePA led Pringle to create the Pennsylvania Heroin Overdose Prevention Technical Assistance Center, also funded by the Pennsylvania Commission on Crime and Delinquency. This technical assistance center will be the first ever resource and technical assistance hub for all counties within the Commonwealth of Pennsylvania. Based out of PERU, this center will assist counties in developing, implementing, and sustaining community-based initiatives for reducing overdose throughout Pennsylvania.
The Center is a joint effort between PERU and the Pennsylvania Commission on Crime and Delinquency (PCCD). PERU staff will expand the existing OverdoseFreePA Web site to a statewide audience and further develop the overdose death database, assist counties across the state in forming or developing coalitions to address overdose and develop a customized strategic plan, will assist PCCD with development of requests for funding proposals to support organizations in their efforts to reduce overdose and deaths. PERU staff also will apply a tested, evidence-based framework to assess each coalition and its leadership to optimize its effectiveness. Staff will provide ongoing technical support to coalitions as they implement, refine, and evaluate their efforts to reduce overdose deaths. Sharing Data to Prevent Diversion and Misuse Zemaitis and Pringle have been instrumental in helping Pennsylvania develop a new prescription-monitoring program, which won legislative approval in November 2014. Once it is implemented, pharmacists who fill prescriptions for controlled substances report that information within 72 hours to a database that is available to physicians, other pharmacists, law enforcement, licensing boards, coroners, and some insurers.
If a pharmacist is suspicious of a person seeking to fill a prescription—perhaps because of a screening tool like the one Tarter developed—they can consult the database and see the person’s history with obtaining the drug from other pharmacies or practitioners. Zemaitis became interested in developing the database six or seven years ago while consulting on a case for the Drug Enforcement Agency in New Jersey. Trough that case, he became aware of the importance of statewide prescription monitoring programs and contacted state and federal officials to learn what Pennsylvania was doing. “I was sort of determined to make myself an expert in the area,” he says. Though the database was supposed to go live by June 2015 and was funded with $2.1 million through the Department of Health, Pennsylvania’s budget impasse delayed the funding for the database. It has now been approved and is expected to go live in August 2016. Such public policy obstacles are a frustration for Pringle, who said the complexity of the overdose and addiction problem counters advocates’ efforts to address it. “We, as a culture, don’t embrace complexity well. We don’t really think through solutions that are effective,” she says. “People develop these problems in complex ways. Why do we think an easy solution can solve it?”
In order to enact effective public policies, Zemaitis and Pringle are leading the School of Pharmacy’s efforts in advocating for practices that they know will work. “Eventually, you do get heard, but it can take a long, long time and a lot of energy. Fortunately, we have a lot of passion and support at PittPharmacy,” Pringle says.
We are leading the way in helping all of pharmacy to grasp the opportunity to help solve this national crisis.
- has had research programs to understand substance abuse disorder and how to predict risk for more than 25 years.
- has been among the national leaders in developing and implementing screening and referral to treatment systems.
- participated in reducing the amount of unused medications through drug take-back days.
- is developing and implementing the prescription drug-monitoring program in Pennsylvania.
- faculty members are leaders in making the overdose antidote NARCAN widely available in the state.
- students and faculty are also working to raise public awareness of potential for misuse and diversion of pain medications.
- faculty are working to ensure those that need pain relief for chronic conditions and palliative care are able to continue to receive effective care.