The Role of The Pharmacist In The Treatment  Of Opioid Addiction

  

Prior to DATA, pharmacologic treatment of opioid addiction was conducted in federally certified drug treatment facilities with minimal involvement of community physicians and pharmacists. With the adoption of this legislation, office-based treatment of addiction is possible, and physicians and pharmacists will play a significant role in this treatment.  The new treatment paradigm requires those physicians who choose to prescribe buprenorphine for management of opioid addiction to acquire relevant training and waivers, and it requires all pharmacists to understand and uphold their responsibilities under the new legislation.   

The key responsibilities of pharmacists in the office-based treatment of opioid addiction: 

Acquiring an adequate knowledge base.

Developing a positive attitude toward patients with addiction.

Ensuring prescribers are eligible to prescribe buprenorphine for the management of opioid addiction.

Ordering and stocking buprenorphine.

Referring opioid-dependent individuals to physicians certified to prescribe buprenorphine for management of opioid addiction.

 Keeping appropriate records and ensuring patient confidentiality.

Taking appropriate steps to avoid diversion.

Counseling patients regarding treatment of opioid addiction.

Role of the Pharmacist In The Treatment of Opioid Addiction

Acquiring An Adequate Knowledge Base

 Pharmacists may have a limited knowledge of the treatment of opioid addiction, since they had only limited involvement with this therapeutic area in the past.  Now, however, it is imperative that pharmacists acquire an adequate knowledge base regarding regarding addiction and its treatment, especially in the office setting. The knowledge is important for expanding the access of patients to needed treatment and to ensure compliance with federal regulations.  This monograp provides the basic knowledge pharmacists need. 

Developing a Positive Attitude Toward Patients With Addiction

Previously, pharmacists may have had negative interactions with patients who have opioid addiction:  dealing with argumentative patients trying to use falsified prescriptions for opiates, informing prescribers that a patients had multiple concurrent prescriptions for prescription analgesics, or experiencing pharmacy robberies by indivduals attempting to obtain drugs for abuse or diversion. 

Under the new treatment paradigm, pharmacists must adopt a positive attitude toward patients with addiction who are engaged in a legitimate therapeutic relationship with a physician.  This may  be especially challenging since patients with buprenorphine prescriptions are likely to be experiencing mild withdrawal and, therefore, may be irritable or impatient.  It may be helpful to remember that  these patients are motivated to seek treatment but at present are experiencing uncomfortable symptoms.  

It is important to remember that opioid addiction, especially to prescription drugs, is widespread and affects people in American communities every day. As health professionals working in the community setting, pharmacists have an excellent opportunity to intervene in drug addiction and to support and to support treatment. 

It is also important to remember  that the treatment of addiction is a protracted process that can be filled with abstinence and relapse. Many patients continue to use illicit or prescription opioids during treatment for addiction.  An accepting, positive attitude on the part of pharmacists, physicians or other healthcare providers is critically important in supporting patients seeking care for addiction. 

It is recommended that pharmacists who work with patients under treatment for opioid addiction by dispensing buprenorphine/naloxone have frequent interactions with prescribers. Frequent communications help pharmacists play an integral role in treatment, optimizing its effectiveness.

Ensuring Prescribers Are Eligible to Prescribe Buprenorphine For the Management of Opioid Addiction

When filling a prescription for buprenorphine  for the management of opioid addiction, pharmacists must verify that the prescriber is certified to prescribe buprenorphine for this indication. Most physicians who are qualified to treat opioid addiction with buprenorphine have agreed to be listed in the physician locator maintained by the Substance Abuse and Mental Health Services Administration (SAMHSA). 

Several Web sites maintain links to the locator.  Pharmacists cancontact  SAMHSA by phone  (301) -443-0457 to verify that physicians who do not appear on the locator have valid waivers In addition, SAMHSA and the DEA encourage physicians to write their waiver registration number on prescriptions of buprenorphine.  In the future this number may be required for all  buprenorphine prescriptions.

Ordering and Stocking Buprenorphine

Buprenorphine and buprenorphine/naloxone can be ordered through a pharmaceutical wholesaler or by contacting the drug manufacturer, Reckitt Benckiser Pharmaceuticals (866-282-2107). Under  federal law, pharmacists and pharmacies do not need any special waiver or credentials to store and dispense buprenorphine beyond those required for Schedule III medications.  As a Schedule III controlled substance, buprenorphine is subject to certain federal regulations covering areas such as inventory, proper dispensing,disposal and record-keeping. 

For more information, see the DEA's Pharmacist Manual, at http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/index.htm.
Some states, however, have additional requirements for pharmacists dispensing controlled substances.  Links to individual state boards of pharmacy can be found at the Web site of the National Association of Boards of Pharmacy at
http://www.nabp.org.

Buprenorphine should be stored at controlled room temperature(25'C[77'F])and in the same manner as other Schedule III controlled substances. 

Referring Patients to Physicians Certified to Prescribe Buprenorphine for the Management of Opiate Addiction

During discussions with their pharmacists, patients may request information on accessing buprenorphine.  Alternately, when querying prescribers about a patient's prescription opioid use , it may become clear that a patient has developed opioid dependence, and both the prescriber and the patient may need information on physicians approved for prescribing buprenorphine for the management of opioid addiction.

Pharmacists should refer patients and prescribers to the online buprenorphine physician locator maintained by SAMHSA.Several Web sites maintain links to the locator which allows the viewer to search by city and state and ZIP code. The locator then provides the viewer with the physician's name, address, and telephone number.  The locator does not indicate, however, whether the physician is still accepting new patients ot has reached the 100-patient limit stipulated by DATA. 

Ensuring Patient Confidentiality

There are special federal regulatios concerning the confidentiality of substance abuse treatment records (42CFR Part 2) that are distinct from the Health Insurance Portability and Accessibility Act (HIPAA). It is recommended that the physician prescribing buprenorphine obtain a patient release of information at the time of the office visit; this is especially important if the physician will be telephoning or faxing in prescriptions, since these modes of communication involve disclosure of the patient's treatment. A sample patient release is available athttp://www.suboxone.com.

In addition, if a buprenorphine prescription is directly transmitted by the physician to the pharmacist, there are restrictions on the further redisclosure of patient-identifying information by the pharmacist.   These regulations do not apply when the patient delivers the prescription to the pharmacist without direct communication between the physician and the pharmacist. More information about these regulations is available at http://www.hipaa.samhsa.gov.

Finally, given the sensitivity of drug addiction , it is especially important to safeguard patients' confidentaility  during counseling. It is essential to provide a private area to counsel patients when they ask questions or express concerns about office-based treatment of opioid addiction or the use of buprenorphine.

Taking Appropriate Steps To Avoid Diversion

Pharmacists have a legal obligation to question prescriptions that may be falsified or used to obtain drugs for diversion. Communication between pharmacists and prescriber's is crucial for ensuring the validity of prescriptions for Scheduled drugs.  It is a sensible policy to require identification when dispensing buprenorphine and  buprenorphine/naloxone in an outpatient setting  and to strongly suggest that patients pick up their own prescriptions.

In addition, there are several scenarios specific to buprenorphine prescriptions of which pharmacists should be aware. Patients may try to obtain simultaneous prescriptions for buprenorphine from more than one prescriber. Pharmacists have a legal responsibility to recognize the possibility that these prescriptions are being used for drug diversions. The additional prescriptions should be refused, and all prescribing physicians should be notified.

Also, since a single provider or a group practice can treat only 100 patients at a time, pharmacists should be suspicious of a large number of prescriptions from a single prescriber or a group practice. The pharmacist should contact the the prescriber or group practice to verify that the prescriptions are valid.    

Counseling Patients Regarding The Treatment of Opioid Addiction

Pharmacists play an important role in counseling patients about the treatment of opioid addiction.  Pharmacists should ensure that patients are informed about the monitoring and treatment of opioid withdrawl and about adverse events associated with the use of pharmacologic treatment of opioid addiction. 

Pharmacists should also ensure that patients are receiving needed care for comorbid conditions, such as human immunodeficiency virus infection, psychiatric illness, and skin abscesses.  Finally,pharmacists should ensure that patients are aware of the correct method for taking a sublingual medication and the importance of allowing the tablet to fully dissolve under the tongue for proper administration.

Reference:  Pharmacy Today 2004 -Topics In Patient Care- The Pharmacist's Role In The Management of Opioid Addiction 

Wriiten and Compiled:  Deborah Shrira      Published:  5 September 2007