The development and feasibility of a pharmacy-delivered opioid intervention in the emergency department

Abstract

The nonmedical use of prescription opioids has been associated with diversion, drug overdose, and increased risk of addiction. Research suggests that many individuals with opioid use disorders initiated nonmedical use of prescription opioids before transitioning to heroin.^1,2 The nonmedical use of prescription opioids is associated with significant financial costs to health insurance companies,³ and improper storage or disposal likely contributes to the availability of opioids for nonmedical use or accidental exposure. People who are prescribed opioids may not be aware of how to store and dispose of opioids properly; furthermore, they may not be aware of the risks associated with nonmedical use of prescription opioids or accidental exposure to children. While there have been efforts to increase prescriber and patient education on the safe use of prescription opioids, it is unknown to what extent these efforts have occurred and whether the content has been empirically demonstrated to improve knowledge and health behaviors. When prescribing opioids, physicians may recommend against driving or operating heavy machinery, but often do not mention the risk of overdose and abuse potential.⁴ Opioids are routinely dispensed in the emergency department (ED), and ED physicians are one of the leading prescribers of opioids in the United States.⁵ Research suggests patients being discharged from the ED with an opioid prescription are not practicing safe storage and disposal of opioids,^6,7 and patients are not educated on the safe use of opioids and their potential side effects while in the ED.⁸ When patients pick up their prescription from an outpatient pharmacy, pharmacists may offer counseling, but this may only occur if the patient informs the pharmacy technician that they have a question for the pharmacist about their prescription. It is not routine practice in community-based pharmacies to provide education on the safe use of prescription opioids.

The ED offers a unique opportunity to educate patients on the safe use of opioids, safe disposal, potential for abuse and dependence, and overdose prevention.⁹ In the busy setting of an ED, doctors and nurses may not have time to provide opioid counseling, especially counseling tailored to the patient’s experience and knowledge of opioid use and misuse. Pharmacists have knowledge of the pharmacodynamics and pharmacokinetics of opioids and naloxone, and some pharmacy schools may provide training in motivational interviewing (MI).^10,11 MI is an evidence-based practice that is an effective strategy to deliver health education during a brief visit.^12,13 Fourth-year student pharmacists, students enrolled in a doctor of pharmacy program, have in-depth knowledge of prescription opioid safety and are increasingly learning overdose prevention education counseling as part of their degree program. Student pharmacists have unique skills to be able to provide counseling to patients of all types, including those being prescribed opioids and those who have overdosed. There is a limited number of studies on interventions to improve opioid medication safety or overdose prevention in the ED, with the majority focusing on patients at high risk of an opioid overdose.^9,13 A small, randomized, clinical trial found that MI reduced overdose risk behaviors among adults who reported nonmedical use of prescription opioids and were seen in the ED.¹⁴ To our knowledge, there has not been a study on the use of pharmacists or student pharmacists in the ED to counsel patients specifically on opioid safety and opioid overdose prevention.

Objectives

The objective of this project was to develop a brief educational intervention and to assess the feasibility of pharmacist-delivered education on opioid safety and overdose prevention in the ED. More specifically, the authors developed educational content that could be provided to patients in the ED on opioid safety and overdose; they also developed scripted educational content that could be delivered in person by a pharmacist or student pharmacist. This project is the first step toward developing a novel approach to opioid safety and overdose prevention education.

Methods

The intervention is titled “Prescription Opioid Safety Education (POSE)^®.” The intervention content was developed by the study team and piloted with a convenience sample of patients (n = 102) approached between May and June 2016 at a single community-based suburban ED located in the Midwest. This ED has approximately 22,000 visits annually and the hospital is involved with several regional initiatives to address the opioid epidemic, including a grant-funded project to provide screening, brief intervention, and referral to treatment (SBIRT) for depression and substance use disorders. Two fourth-year student pharmacists documented their interaction with the patient in a REDCap database and systematically tracked the discussion points of each counseling session, in addition to the specific educational materials that were provided to the patients. REDCap is a Web-based, secure survey research tool that is available through academic institutions (for more information see https://projectredcap.org).¹⁵ The questions asked were developed specifically for this project and did not include items or scales from validated instruments. The student pharmacists documented any additional information regarding the interaction in a miscellaneous note box. As this project was initiated as a quality improvement project and an initial test of feasibility, it was determined by the West Virginia University Institutional Review Board to not be human subject research.

The intervention, consisting of 2 educational brochures and scripted educational content, was developed by the study team. The study team was led by a PhD-level addiction scientist and included a pharmacist, 2 student pharmacists, and a research assistant. The addiction scientist and research assistant have been involved with several overdose prevention programs in the region. The pharmacist is a pharmacy director, with oversight of 17 hospitals within her health care system. One brochure included information on the safe use of prescription opioids, how these medications should be used only as prescribed, how to store medications safely, local places to dispose of medication safely, signs of an overdose, a brief overview of naloxone, and local resources (e.g., poison control center hotline number and addiction treatment programs). Naloxone was not prescribed or dispensed in the ED at the time of the intervention; however, there are overdose prevention programs in the local area. The second brochure focused specifically on opioid overdose, including risk factors for overdose, how to identify the signs of an opioid overdose, and how to respond, and information on obtaining and using naloxone to reverse an opioid overdose. The educational brochures were reviewed and approved by the hospital’s medical director, the pharmacy director for the health system, the study team members, and the health systems marketing department (see the Appendix for the brochures). Two other patient handouts were available for the student pharmacists to distribute at their discretion. One was a list of local pharmacies that provide naloxone, specified by whether the pharmacy required a prescription or whether naloxone could be dispensed with a standing order. Given the high rate of opioid overdose in this region and that the region is known to have heroin adulterated with fentanyl, the project used a fact sheet on fentanyl that was developed for another overdose prevention program in the area.

Before beginning their rotation in the ED, the student pharmacists were provided with in-person education on opioid safety, overdose, and naloxone by the lead author (E.L.W.). The student pharmacists were also provided with recommended reading to improve their knowledge on these topics. The student pharmacists used the ED’s electronic medical record to track the patients’ chief complaints and discharge orders. The student pharmacists approached patients with a chief complaint of opioid overdose or with a discharge prescription for an opioid. In addition, patients could be referred to the student pharmacist by an SBIRT technician if the patient had screened positive for drug use. Patients were excluded if they were younger than 18 years, entered under police custody, or were in a physical or mental state that inhibited the intervention. Patients were also excluded if they had cancer pain, intentional overdose (suicide attempt), or with a disposition that resulted in admission to the hospital units or transfer to another institution. The student pharmacists were located in the ED for 1 month each, 4–5 days per week (typically Monday–Friday), typically during the day shift.

Once the physician submitted the patient’s discharge orders, the student pharmacist had a window of approximately 15 minutes to approach the patient before they left the ED. The student pharmacist initiated contact with the patient by first introducing themselves and explaining the reason for their presence, which was to discuss opioid medication safety or opioid overdose prevention. The student pharmacist began by asking the patient whether they had ever taken an opioid, followed by 5 short questions to assess their knowledge of opioid side effects and risk of addiction and overdose (Figure 1). The student pharmacist then tailored the scripted counseling using the patient’s knowledge of opioid side effects and risk of addiction. The specific elements of the counseling included opioid safety and precautions, safe storage, proper disposal of opioids, opioid side effects, overdose risk factors and prevention, signs of an overdose, response to an overdose, naloxone overview, naloxone administration, and naloxone adverse effects. Fentanyl was also discussed with patients who self-disclosed personal or family member use of heroin.

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Figure 1

Knowledge questions.

After the intervention was complete, patients were given a self-reported satisfaction survey that asked the following 4 questions about their experience and preferences:

1. Overall, how would you rate the information or education you received from the student pharmacist (poor, fair, good, very good, excellent)?
2. Did the information provided by the student pharmacist improve your understanding of pain medication side effects (significantly improved, moderately improved, slightly improved, did not improve)?
3. Which type of educational format would you prefer to learn more about pain medication safety while in the ED (receiving educational materials and talking with a pharmacist, only talking with a pharmacist, only receiving educational materials, or do not want any education on pain medication safety)?
4. Is there anything else you would like to tell us?

The patient satisfaction survey was confidential and completed directly into REDCap using a tablet computer or paper version. Although the paper version of the satisfaction survey did not have any patient-identifying information, the collection process did not ensure anonymity.

Results

One hundred patients were counseled on opioid safety or overdose prevention, or both, by the student pharmacist. Two patients who were approached refused counseling. The counseling took from 2 to 25 minutes; the median and the mode were 5 minutes. The vast majority of patients (94.8%, n = 92) had previously received an opioid pain medication. Of those who could recall which opioids they had received, slightly more than half (51.2%, n = 43) had received 2 or more different types of opioids. Many of the patients (62.0%, n = 62) were able to list at least 1 side effect of prescription opioids. Patients thought that their own risk of addiction was significantly less than the general public’s risk of addiction when taking opioids. The majority of patients (88.4%) said they themselves had little to no risk for addiction; however, 89.3% of patients (n = 84) reported that the general public was at moderate to high risk for addiction. The majority of patients (77.4%) were also aware of the moderate to high risk of overdose. During the counseling sessions, the student pharmacist noted that 19 patients specifically mentioned that themselves, a family member, or close friend used heroin or was at risk of an opioid overdose.

Counseling and education on the following topics were provided by the student pharmacists: 88% (n = 88) opioid safety and precaution information, 86% (n = 86) opioid adverse effects, 80% (n = 80) opioid safety brochure, 70% (n = 70) proper disposal, 56% (n = 56) brief overview on naloxone, 28% (n = 28) opioid overdose brochure, 27% (n = 27) opioid overdose risk and prevention, 20% (n = 20) signs of an overdose, 15% (n = 15) pharmacies dispensing naloxone, 10% (n = 10) response to an overdose, and 9% (n = 9) of patients received other resources (Figure 2). Five patients received information on fentanyl, 2 patients were counseled on naloxone administration in depth, and 2 patients were counseled on the adverse effects of naloxone (e.g., acute opioid withdrawal; Figure 2).

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Figure 2

Topics covered during counseling.

The patient satisfaction survey was completed by 78% (n = 78) of the patients. Among the patients who responded to the satisfaction survey, all reported that the information received from the student pharmacist was good (14.1%), very good (20.5%), or excellent (65.4%). The vast majority reported that the information provided by the student pharmacist moderately (28.2%) or significantly (62.8%) improved their understanding of opioid side effects. Patients preferred the format that was used in the intervention, counseling, and educational materials (59.0%) to talking to a pharmacist only (18.0%) or educational materials only (15.4%). Only 6 patients reported that they would prefer not to have any opioid safety or overdose education.

Discussion

In 2015, the Centers for Disease Control and Prevention estimated that more than 15,000 people died of an overdose involving a prescription opioid,¹⁶ and in 2011 there were approximately 1.4 million ED visits related to the nonmedical use of prescription drugs.¹⁷ The nonmedical use of prescription drugs is an urgent public health issue, and the ED is a critical health care setting to provide education on opioid safety and overdose prevention, yet few interventions have been developed and empirically tested to address this issue.

The opioid safety and overdose prevention intervention included scripted counseling to be delivered in person by a student pharmacist and 2 brochures. Adult patients in the ED who were going to be discharged with an opioid or who went to the ED because of an overdose were willing to receive the counseling. The counseling took approximately 5 minutes, and only 2 patients refused counseling. Although 94.8% of patients had previously been prescribed an opioid, 97.4% reported that the student pharmacist’s counseling improved their knowledge of opioid side effects. Anecdotally, the student pharmacists reported that the intervention delivery was easy. Overall, patients were very satisfied with the intervention and preferred that the opioid safety information be provided in person and with educational materials to take home.

It was interesting to note that patients believed that the general public’s risk of addiction to prescription opioids was significantly higher than their own. Similar findings have been demonstrated in other research.¹⁸ In the Health Belief Model,¹⁹ perception of risk is an important component in changing health behaviors; thus, it may be worth further investigation. Only 2 patients received education on how to administer naloxone, in part because Ohio’s standing order legislation requires that pharmacies provide such education at the time of dispensing.

Given that the intervention is brief and can easily fit within the ED flow process, it seems feasible that it could be widely disseminated if future research supported that it was effective and improved patient outcomes. Pharmacists and student pharmacists have a unique role in the opioid epidemic given their in-depth knowledge of opioids and naloxone. Brief interventions to address alcohol or drug misuse and abuse are usually delivered by behavioral health counselors or clinicians. However, behavioral health counselors may have limited to no training on pharmaceuticals such as opioids and naloxone.

Limitations

This pilot study was conducted at a single site—a community-based hospital in a suburban area. It is unknown whether the process to deliver the intervention or the patient’s willingness to receive the counseling would be acceptable in urban-based EDs. Furthermore, given that the vast majority of patients had previously been prescribed an opioid and the ED is in an area with high rates of drug overdose, it is unknown whether the results would generalize to settings with a higher proportion of opioidnaive patients. The student pharmacists did not review all of the patient’s prescriptions for the purposes of identifying medication errors, as this was not part of the intervention design. The patient knowledge and patient satisfaction questions were developed specifically for this project and the reliability and validity of these items was not assessed. The patient satisfaction survey was not anonymous, and patients could have been reluctant to evaluate the student pharmacists negatively, potentially resulting in positively biasing the results.

Conclusions

This study provides preliminary evidence that student pharmacist or pharmacists may be able to deliver opioid safety and overdose prevention in the ED. Additional research is needed to determine whether patients who received this intervention will retain the opioid safety or overdose education, and to determine whether this intervention is associated prospectively with changes in behavior (e.g., safe storage and disposal of medication).

Supplementary Material

Footnotes

Contributor Information

Erin L. Winstanley, School of Pharmacy and Department of Behavioral Medicine and Psychiatry, School of Medicine, West Virginia University, Morgantown, WV.

Rebecca Mashni, Research Assistant, James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH.

Sydney Schnee, Student Pharmacist, James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH.

Nate Miller, Student Pharmacist, James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH.

Susan M. Mashni, Chief Pharmacy Officer, Mercy Health, Cincinnati, OH.

References