University of Rhode Island College of Pharmacy

Jeffrey Bratberg, PharmD, FAPhA, University of Rhode Island College of Pharmacy 

 In the little time that we have left, I want to go around and get some final thoughts from each one of you. I would like you to address the whole issue of using naloxone. How do you address this with patients? How do you address this with clinicians, and what is your view about going forward? How is this going to change the landscape of opioid use in the United States? Why don’t we start with Jeremy, and we will keep going from there? Take 30 seconds, and we will just keep going.

 I think we have covered a lot of ground today. We know, and have known for a long time, that opioids have certain risks. They pose risks to patients, and they pose risks in the community when they are taken unsupervised or misused. From a safety measure perspective, there are things we can do. We can do a better job identifying the patients at risk or when identifying those patients who should or should not receive opioids. At the same time, I think we need more community awareness, and we can do this by using the naloxone program or some of the other programs discussed today. Rhode Island sounds amazing, and I am interested to learn more about what is happening out there. The tools we have today can enhance the safety of what we are doing on the medical side and help out there in the community with the substance misuse and illicit side. That is outside of the reach for some of us who do not work in settings where one can reach out to the community, but I think that these types of tools are underutilized. If these tools are utilized on a more frequent basis, and in a more normalized way, we have the potential to reverse what we have seen here with opioids and the subsequent harm caused by them.

 While acknowledging that opioids are still commonly used as part of a multidisciplinary approach to pain management and that opiates are still being misused illicitly, we need to have strategies that emphasize the availability of naloxone so that people can be as safe as possible. As Dr Adler said, this must be normalized, and we need to realize, when we think about this, it is going to take more years than we would like before it will become normalized, but we need to step it up and work toward that.

 I cannot agree more with my colleagues. I think that, when it comes to normalizing naloxone, we need to take the lessons we have learned from what successfully normalizes this method of treatment. Whether it is enacting policy interventions, having naloxone everywhere, putting up billboards, or getting that access. What we are doing is studying people, saying what makes you dispense naloxone, to pharmacists? Saying what makes you dispense it, to primary care physicians? What makes you want to give it, to a caregiver? What are those barriers? How do we break them down? I look forward to the day of over-the-counter naloxone that is still covered by insurance so we do not have financial barriers. There is a lot that we know, areas where we have been successful, and I think that yes, it is going to be around a long time. We have seen how COVID-19 has created these divisions. I think, by solving those divisions during COVID-19, we will solve some of the divisions in access to care for people with opioid use disorder or people who use opioids.

I see naloxone as one part of the puzzle here, one part of the comprehensive approach that we try to take in the emergency department [ED], and that is decreasing the barriers that patients need to overcome to get naloxone. This is improving their access to naloxone not only in the ED but also in other areas of life where they have access to health care, and in their daily lives. Having it available works, whether it is having a naloxone box sitting next to an AED [automated external defibrillator] box somewhere or offering it to patients proactively and not requiring them to have to ask for it.

Additionally, I think that, as science for medication-assisted treatment continues to be redefined every day—how effective that is for treatment—it is our responsibility to not only make sure that our patients are safe as they go out and use this, or that their community is safer because naloxone is out there. But we also need to provide multiple opportunities for patients to get linked to treatment, to be linked to peers, and to have access to medication-assisted treatment. I think this is equally important and should be offered as routinely as possible.

Theresa, some people hate to be the last one to speak when all the good stuff is taken.

Theresa Mallick-Searle, MS, RN-BC, ANP-BC:

heresa Mallick-Searle, MS, RN-BC, ANP-BC: 

As the token nurse on the platform here, I am really big into listening to my patients. It is not that my colleagues are not, but I want to hear what is important to the patient. I want to be able to have them partner with me in their health care. I want to be able to encourage my peers to look at the bigger community and be in it for the long term, to decrease the amount of fear out there. As a health care provider, for anything that we do, we are trying to do the best we can to take care of our patients.

Thank you all very much. I want to thank you at home as well for watching this HCPLive® Peer Exchange. If you enjoyed this content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox.

I am Dr Peter Salgo, and I will see you again next time.

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The multidisciplinary panel of experts share final thoughts on strategies to normalize naloxone and decrease barriers to its obtainment and utilization. 

Final Thoughts on the Opioid Crisis and Normalizing Naloxone

What about pain contracts? That is something that we heard a lot about for years. Do they work?

First, I would not use the term “contract” unless my colleagues—I love the example that you gave, Joshua, about sitting down with the PDMP [prescription drug monitoring program] and talking to your patient. That is what the agreement is about. It is all about how to promote safety in prescribing for the patients’ betterment and safety. This is the way I think we can do this in the most safe and effective manner. It is more an agreement and not a contract. It is outlining those behaviors that would be problematic, and why they are problematic, and expectations. It is a shared understanding of what to expect, so I would not use the term contract. We use that and we remind our patients. We ask people to reaffirm these agreements every year so that our patients are reminded about the importance of this.

 We are getting away from the, I said it before, the “I got you!” mentality, and I would throw contracts under that header for sure. It is really important. Call it destigmatization, or just call it doing the right thing—we are making patients who use these drugs feel more normal. I think it all falls under the same kind of solution.

An example from the emergency department [ED] is that we do far fewer urine drug screens on overdoses that we know are opiate overdoses than we had in the past. Most patients who come in with an opiate overdose—they overdosed, they got naloxone, they came to the ED, they’re in naloxone-precipitated withdrawal, and in some cases, they are getting buprenorphine right away, which is awesome. Most of our opinions now reflect that doing the urine drug test to catch patients who are misusing cocaine too is of no clinical benefit at all. Not doing the urine drug test helps patients feel a bit normal. We are not going to change the treatment; we are still going to refer them, give them naloxone, hopefully get them on buprenorphine in the ED, and refer them to treatment. 

I think it lines up with other things we do that may say, “We have one up on you. Here is a contract.” It is all in the delivery. We talked about this many times in regard to making the patient feel good. Do they feel better at home, seeing us via telemedicine? Great. Do they feel better sitting down and talking one-on-one about an agreement that we need to do for their safety? Great. Again, I think a lot of it is based on delivery and approach.

That is what I was trying to get at. A contract is almost like, “OK, we made a deal—you broke your end of the deal. Somehow or other, it is your fault.” That always struck me as a bit off when you are trying to get patients to buy in to do this as a team.

 I would echo Dr Argoff. I would move away from a contract-type relationship because it is not the case that, if they follow all the rules, they are guaranteed to get an opioid. That is not what the document is for; it is for guidance and an agreement. My MA [medical assistant] I work with tells our patients as she goes through process things like, “If you have lost medicine or stolen medicine, a police report is necessary.” That always is a point of discussion. She says, “If somebody is picked up with a bottle that has your name on it because it was stolen from you, who do the police think sold it to that person? You have to file this for your own protection.” The patients often say, “Oh, that makes a lot of sense.” It is a great way to provide a lot of education regarding opioids, safety measures like naloxone, urine drug monitoring—all the different things that we do, I think, can be summarized in these agreements. I think they are really important. It is not a “Got you!” We are not trying to establish a set of rules where, if you adhere to them, you are going to have an opioid, and if you do not follow the rules, you are not. It is not used in that manner.

Charles Argoff, MD, leads a discussion on the use of pain contracts versus pain agreements between clinicians and patients to bring about desired outcomes. 

Pain Contracts vs Agreements Between Clinicians and Patients 

 I would love to see an initiative to have peer-to-peer discussions. You might have patients who do not want to talk to their health care provider because of stigma, for a whole host of reasons. But I would love to see a movement where a person misusing these drugs, or an individual who is on the street, or a homeless person who is at high risk could experience some kind of peer-to-peer discussion. It could be just like AA [Alcoholics Anonymous] or other groups like that, where there is that discussion to normalize and safely use naloxone and also discuss what these medications mean.

 We have that. We innovated that in Rhode Island; I keep mentioning that.

Theresa Mallick-Searle, MS, RN-BC, ANP-BC: 

 Maybe that is why I am here; anyway, we have peer recovery specialists, and they are trained folks. They are people in recovery themselves, and we adopted this program. I think the easiest way to think about it is that when the doctor, the provider in the white coat, comes in and says, “I’m going to give you naloxone,” the patient is going to say, “Whoa, people like you have not treated me well.” If the person comes in and says, “I’ve been where you have; I was saved by naloxone.” About 90% of people, when they're told, “I was saved by naloxone,” take naloxone and get into treatment. We need people to tell them that there is life after this, that they should not leave against medical advice, or whatever that is. That is a really important point.

 I think attaching patients to peers is underutilized. There are a lot of folks who could be peers out there who probably want to take on that role, and just have trouble. We wanted to lower the barrier when pairing patients to peers. We started a text for naloxone program where, instead of calling, which is also awkward, you can just send a text message. This is on billboards, too. You send a text message with an address, and we will mail you naloxone. We will also text back and ask if you want to talk to somebody about this. If patients say no, that is totally cool. If they say yes, it is even better, and that somebody the patient will talk to is a peer. That peer is well aware of our emergency department referral program, and often, as Jeff had mentioned, patients are much more willing to talk to somebody in that category than someone with a shirt and tie on.

We are in the middle of the COVID-19 crisis, and that means we are doing an awful lot of telemedicine. It is one thing to be in the same room, to be peer-to-peer, and to reach out. It is another to do this behind a screen. Does it work as well? What are the techniques people are using in telemedicine?

I’ve found it very challenging because, when I have this discussion with patients, I feel that I need to give them time. Even though you are eye to eye—sometimes it may be eye to forehead, sometimes eye to sky—when you are on a computer, being able to sit there and hold their hand and have this discussion in person is a lot more earnest. And I think I get more patient compliance. For me, in my practice, even though we’ve made it work, it has been very challenging to start these discussions.

 We have taken a look at it from a different angle. We see this as the creation of virtual emergency departments; these are patients we would not have seen. I think we would all prefer an in-person encounter, but the way we look at it, in regard to the emergency department, is that these are patients who would not have come to the hospital. So we try to create a market where if you are not feeling safe or you do not want to be in person, you can use this virtual emergency department. 

We have taken it one step further to better help those with substance use disorder. We have given cellular-based iPads to police departments, and if they run into somebody with opioid use disorder or a substance disorder on the street, they can do a telemedicine visit from the side of a road or the back of a police car with an emergency provider. That provider can run them through a quick assessment, and then the treatment and referral program. That is a link to a peer; that is a 14-day script for buprenorphine, all provided while they’re sitting in their kitchen. That is a link to care; that is mailing a naloxone box. I think telemedicine is something that has been simmering for years in a lot of different areas of health care and society in general. This has just forced us to find innovative ways to fast track the rollout of this. I think, for substance use disorder, telemedicine is a perfect fit. Is it ideal? No. Does it allow us to treat patients we would not normally treat? For sure it does.

 There is a bit of a silver lining in the midst of this entire pandemic?

 I would say that, in some respects, it is a little more than a sliver. I think that patients are sometimes more comfortable in their own homes, looking at a screen and having this conversation virtually rather than actually being in front of us in a room. Plus, we can ask patients, “How do you keep your medicines at home? What would you do if…?” It creates an environment, in some respects, of safety for them when we have this kind of conversation. I do not do emergency care; I do chronic pain management. Our population is a little different than who might be in the [emergency department]. It is amazing what is being done here out in the community to address some of these substance misuse problems. That is pretty exciting. In our practice, I think there are some patients with whom we have connected who respond better when discussing these issues at home, rather than in the office where there is a lot of distraction and a lot of other things occurring simultaneously.

I think the interesting thing about telehealth too is, again, social determinants of health. Transportation is a huge issue when you need to go to your treatment visit, your urine toxicology screening, your chronic pain specialist, or to see a specialist. If you are in a rural area and there are no pain specialists, or there are no buprenorphine prescribers. We have seen what these temporary regulation releases from SAMHSA [the Substance Abuse and Mental Health Services Administration] and DEA [Drug Enforcement Administration] allow. We have a buprenorphine hotline in Rhode Island; it is 24/7. You call a waiver provider; they’ll call in a script to a pharmacy, and we’ve flipped that. I am part of a federal grant where you can walk into a pharmacy and say, “I want to treat my withdrawal,” or “I would like to start treatment,” and in an hour, they leave with no scheduled induction, or home induction that day. We have done 4 of them. It is amazing.

Experts discuss the need for and impact of peer-to-peer discussion initiatives, as well as the impact telemedicine utilization has had on the opioid crisis. 

Peer to Peer Discussion Initiatives and Telemedicine Impact 

 Let’s take a look at the overall picture: the 10,000-foot view, if you want. There are prescription monitoring programs in clinical practices; how does that fit in? Where does naloxone fit in with that? Jeremy, do you want to start on that?

The PDMPs [prescription drug monitoring programs] are certainly important tools. I found them to be much more of an educational tool, useful for good decision-making in patient care. We have already talked today about how so many of these individuals abusing opioids are getting them illicitly. The PDMPs do not monitor illicit opioids or diverted opioids. We cannot see that; but what these programs can do is show us, certainly, if a patient is receiving opioids from more than 1 source and what they are receiving. Often, we find that the PDMPs are even more important when identifying drugs that we know have significant comorbidity with concomitant use, like benzodiazepines; that is the class for which we look.

We use the PDMPs as a way to assess risk, put together plans for our patients, and know when to give naloxone. In California, where I practice, we have—as Theresa already mentioned—legal requirements to offer naloxone if a patient is taking an opioid and benzodiazepine. Certainly, if we see through the PDMPs that they are on a benzodiazepine, then that, for us, is an immediate indication to offer naloxone. I think it is an important part of this equation.

 Riddle me this, Batman: if there are PDMPs out there—and PDMPs actually are not only a good idea, but they are required by the law in lots of places—I’m encouraged by that, until I hear Jeff. Jeff and Joshua say that opioid overdoses are skyrocketing. How do you reconcile these 2 things?

 The point that was just made by Dr Adler, or Jeremy, was that we are not going to catch the people who are using opioids illicitly merely by looking at the PDMP, which is why, as we discussed earlier, we cannot put every difficult situation involving opioids into the same bucket. There are people for whom we are trying to optimize the use of opioids in the proper setting who are being prescribed, monitored, and cared for, and we have some more control of that. We do not have as much control over the hardcore drug misuser, or the illicit drug user, and we certainly want to make their experience as safe as possible, we don’t want them to die either, but we do not have the same control, and we are not going to see what they do.

I would even go one step further: if you are not required to talk about naloxone when prescribing opioids—and yes, you may be utilizing all those of those referral techniques—if that patient is unable to tell Dr Lynch in the ED [emergency department] that she is taking Suboxone, how many people are going to reveal their cocaine, fentanyl, or occasional heroin use? How many are going to reveal that, whether they are taking opiates or not? Again, we are skilled clinicians; we’ll find out about that and compassionate clinicians will ask about that, but the stigma against illegal drugs is so strong that if the patient decided to seek care, there is going to be an even bigger barrier for them to reveal that. This is why I think naloxone should be universal; we should just say we recommend this everybody. PDMPs are just a tool to recognize that.

It needs to be out in the community. One other thing I want to add to Jeremy’s discussion about the PDMP, think about these patients. We want to make sure the patients are safe. We want to make sure they are not doctor shopping, that they are not getting 2 prescriptions for every 1, and that they’re not using it with benzodiazepines. Think of those patients who are diverting. This comes back to the number of opiates that might be out there and how important it is to have the knowledge out in the community about the safe use of naloxone for inadvertent overdoses for patients who are using prescription opiates recreationally.

 What I hear everybody saying is that the PDMP is a great idea. People change their prescribing practices and have done so over time based on what they see in the PDMP. But it does not cover this enormous pool of nonprescribed opiates, and that pool of nonprescribed opiates is associated with an enormous death risk. The only way to attack this is to not only to give naloxone to people you are prescribing opiates to, but to give it to everybody, because there is a pool out there of people illicitly using opioids that you will never see, that you cannot find. That pool of people is not on the state registry. The only way you hit that is to hit everybody across the board, or am I missing the point?

 You made the point about how widely available naloxone is in New York state and Rhode Island with that pharmacy, so it is easy to get, and you want to make people want to be as safe as possible. You want to make that into a cool thing. Let’s be cool. We also may want to utilize other resources when evaluating people, like urine drug screening. We have not talked about that. You want to trust and verify your information, and you can use other ancillary measures when assessing someone. We want people to become comfortable under all circumstances with trying to be safe.

 One other use of the PDMP that we have not talked about, and what I and a lot of emergency physicians also use it for: we print out the report and instead of taking the “I got you,” angle, I take it right into the room and sit down with the patient. I print out 2 copies and give the patient one and I look at the other, and we talk about how this is dangerous, we discuss what is going on here. It may be that the patient has had multiple addresses down or 50 prescriptions in the last 3 months. What is going on here? That acknowledges that the prescriptions mean a lot of opioids are going out into the community, but we also need to talk about the patient getting into treatment or if there is an opportunity for naloxone. We have identified many patients who come in looking for pain medication; we print out the PDMP report and we have a serious discussion that takes us in a totally different direction. Hopefully, this discussion can end up with the patient getting into treatment, getting onto MAT [medication-assisted treatment], or both. That is a less used opportunity to maximize what the PDMP can give us.

I would say that the PDMP can be a double-edged sword, and it should be used as a conversation starter to meet people where they are. People do not reveal all of the illegal things that they do because society has labeled them as illegal; they are shameful about it and many health care professionals have not dealt well with patients who have revealed that. I love that approach—use the PDMP, approach them with it, and say, “What can we do? Where are you at?” As Theresa said, we should ask why the patient is diverting. We should say, “It looks like there is a pattern. Are you using your opioids? Your urine opioid screen is negative and yet you have been prescribed these things. I am not trying to accuse you of anything. I want to help you.” We need to go back to that initial point: where are we at?

Experts share insights on how they have utilized Prescription Monitoring Programs to combat the opioid crisis and improve the safety of prescribed opioids. 

Jeffrey Bratberg, PharmD, FAPhA, University of Rhode Island College of Pharmacy

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