Opioid over-prescribing, medical cannabis and digital health developments were just some of the topics covered at the recent American Society of Health-System Pharmacists (ASHP) mid-year clinical meeting in Anaheim, California

Tackling the opioid problem

Opioids continue to be a major cause of concern in the US. There were 72,000 deaths in 2017 due to opioids and about 30,000 of those involved fentanyl.

According to the Centers for Disease Control (CDC), the leading national public health institute of the United States, about one-third of patients taking opioids will be misusing them. In order to avoid making the situation any worse, specialist pain pharmacists are now focusing on active management steps.

For acute pain management opioid treatment is now limited to three to seven days, according to Kathy Davari, associate chief pharmacist, Veterans’ Administration Medical Center (VAMC), Atlanta, Georgia. Patients are told that the goal is not to be pain-free but to have tolerable pain.

For chronic pain management, non-opioids in combination with nonpharmacological measures are preferred. Immediate-release products are better than slow-release products and anything more than 50 ‘morphine milligram equivalent doses’ per day is to be avoided. Combinations of morphine and benzodiazepines should also be avoided, said Dr Davari.

For chronic opioid users, active protocols to reduce the dosage are now being implemented. Doses are gradually tapered down – typically at a rate of 5-20 per cent per month. It is critical to discuss the plan with patients first and explain that “we are on your side…”, Dr Davari said. A rapid taper is recommended if diversion is suspected and a slow taper if genuine dependence is believed to be the case, she added.

The risk of over-dosage is ever-present and patients taking opioids should always have three naloxone kits because sometimes this much is needed to reverse an accidental overdose. Up to 10mg of naloxone may be needed to reverse an overdose but emergency services must also be called because the effects of naloxone are shortlived.

The use of an ‘opioid dashboard’ allows pharmacists to identify patients at high risk of opioid dependence and share the details with the treatment team.

Medical marijuana reduces opioid over-prescribing?

Marijuana is finding a place in the management of chronic pain as an alternative to opioids. In states in America where the use of medical cannabis is permitted, the number of prescriptions for opioids has decreased.

Thirty states in the US have now passed laws to legalise or decriminalise the use of medical marijuana and medical cannabis dispensaries have now opened (some 16 states allow only the sale of cannabidiol, the nonpsychoactive component of marijuana). However, cannabis remains an illegal drug at federal level (but marijuana law enforcement has been devolved to state governments) and a number of practical problems remain to be solved.

Not least of these is the fact that pharmacists and doctors lack the knowledge and experience to prescribe marijuana products and advise patients appropriately. In addition, information about doses, effects and interactions are absent from the standard compendia and there is no product standardisation. There are also regulatory inconsistencies and no funding for research.

The state of Colorado is a good example here because marijuana was legalised in 2012 and dispensaries began selling to consumers (only state residents) in 2014. There is a registration process for patients and a specified list of the conditions for which medical marijuana can be recommended. By June 2018 more than 450 physicians in Colorado had recommended medical marijuana and nearly 87,000 patients had active registrations.

Some states require a pharmacist to be involved in the supply process, either present on site or available as a consultant.