Raising Awareness to End an Epidemic

Opioid use and the spread of illicit fentanyl continue to pose a risk to public health. Pharmacy schools are working to educate students and the public about substance use disorder, reduce stigma and encourage communities to embrace harm-reduction strategies.

By Jane E. Rooney

The story of the ongoing opioid crisis in the United States has unfortunately become too familiar, the distressing statistics no longer a surprise. Opioids were involved in 75 percent of all drug overdose deaths in 2020, according to the Centers for Disease Control and Prevention (CDC). Recently, a sharp increase in overdose deaths due to illicitly made fentanyl has raised new concerns. The CDC reported that 71,238 Americans died in 2021 as a result of a fentanyl-related overdose. With at least 18 states now reporting the emergence of “rainbow” fentanyl pills that are brightly colored and could be mistaken for candy, the need to raise awareness and educate communities is paramount.

Prescription Drug Misuse Education and Research (PREMIER) Center: https://uh.edu/ pharmacy/research/ centers-and-institutes/ the-premier-center/

“We have a chronic opioid issue that’s been going back decades and now an acute fentanyl issue on top of that,” said Dr. Douglas Thornton, associate professor of pharmaceutical health outcomes and policy and director of the Prescription Drug Misuse Education and Research (PREMIER) Center at the University of Houston College of Pharmacy. “In Houston we’re getting hit particularly hard but it’s nationwide. Any street drug can have a fatal dose of fentanyl in it. That’s the big message coming out of DEA: One pill can kill. It sounds dramatic but it’s especially important today. Individuals think they are purchasing Adderall or a sleeping pill when they are actually contaminated with a lethal dose of fentanyl. Compounding that problem is a practice of pressing pills—these substances are being pressed to look like pharmaceutical products. Students can buy a stimulant and inadvertently consume fentanyl.”

Evidence also indicates that the opioid epidemic worsened during the pandemic. “We’re wired for interacting with each other,” noted Dr. Mark Garofoli, clinical assistant professor, West Virginia University School of Pharmacy. “In Covid times, it was completely foreseeable in the beginning that if everyone is isolating and distancing and we’re not interacting, that would not bode well for patients with substance use disorder. In the past few months we’ve been seeing numbers coming in and it’s not surprising. That needed isolation facilitated more of the tragic parts associated with that.”

Dr. Kelsey Schmuhl, assistant professor of clinical pharmacy, The Ohio State University College of Pharmacy, agreed with Garofoli’s assessment. “Anecdotally I know from the patients in my clinic that we saw more social isolation, a lack of access to resources as things went virtual, a loss of in-person support groups…a lot of things combined to make the situation worse for our patients. It was a perfect storm. We did see overdose deaths increase during the pandemic.”

Substance use disorder (SUD) has been included in the curriculum at most pharmacy schools for some time. Now some schools are broadening their approach and training future pharmacists to take a more holistic look at how to care for these patients and decrease the stigma surrounding SUD.

Conversations Within Communities

West Virginia has been hit particularly hard by the opioid crisis. According to the West Virginia Office of Drug Control Policy, 91 percent of fatal overdoses in the state in 2021 involved fentanyl. The state is now seeing a surge in illicitly made fentanyl. “Illicit fentanyl has been made all across the globe. Precursors of chemicals made in other countries and being exported here—that’s nothing new,”

Garofoli explained. “That was done with heroin. Before that it was cocaine. What is new is the criminal genius of the illicit supply chain. They are always adapting. They are well ahead of law enforcement, healthcare and the public. Fentanyl is much more friendly to the illicit supply chain because its potency affords it the opportunity to be shipped and distributed across the globe much more easily.”

Rainbow fentanyl’s colorful appearance does make it more provocative and therefore potentially a greater threat, but Garofoli cautioned against sensationalizing the danger. “What we’ve talked about in our communities is to go to the objective information,” he said. “We need to have more conversations in healthcare to educate student pharmacists and medical students to go over soft skills and how to have these conversations and be impactful. That happens through one-on-one interactions and going out into communities.”

Giving student pharmacists the opportunity to interact with patients in the community is a priority at WVU’s School of Pharmacy. One APPE rotation at a clinic in downtown Morgantown that helps underserved populations provides students with the chance to care for patients with SUD. “Students have these moments of, ‘wow, how have I been thinking about this?’ This is the ground zero of the opioid crisis,” he noted. “It’s about getting a little uncomfortable while making sure all educational outcomes are being met. The experiential education realm allows student pharmacists to be in these eye-opening patient care situations.”

Almost every pharmacy school curriculum addresses the topics of SUD, addiction and drug use, Garofoli continued, but there is an opportunity to effect change in how students approach care for this population. “It’s important to remember that there is a lot of stigma around this genre of patient care. We have to be training our student pharmacists to handle it when the opportunity arises. Everyone has preconceived notions, so it’s about going over all the information and watching our words so we remain objective. We want to be able to train and educate our student pharmacists to handle the conversations but we have to remember the audience.”

The vast majority of pharmacy schools are doing a good job educating students on substance use disorder, he said, by talking to experts and keeping current with new developments. “Pharmacy educators have to think about how this is being taught. Whether it’s going to conferences or pulling in people from across the country to do guest lectures. If a given school leader or course coordinator is trying to figure out if they need to do anything different…sometimes we need to change things up. Getting feedback from students and educators to exchange best practices is key.”

While Garofoli acknowledged that dispensing pharmacists are saving lives every single day with naloxone, he cautioned, “For us as pharmacists to think we are going to solve the crisis by manning every man, woman and child with naloxone is not realistic. We do need naloxone next to every defibrillator and to have it in a location where people can utilize it. Many of us do trainings on naloxone administration. It’s very easy to administer, but you can’t help someone if you don’t have it.” As the most accessible healthcare professionals, pharmacists are present in every community and can capitalize on that to help inform the public. “That education needs to transcend from the healthcare setting into everyday life.”

Separate but Connected Issues

As Houston’s Thornton pointed out, prescription opioid misuse is not a new problem in the United States. Prescriptions peaked in 2012 and have been declining, but many individuals became predisposed to receiving opioids for pain control. “We were somewhat in a stabilization phase before Covid. During Covid, the data that came out show that deaths have increased dramatically,” he said. “Part of it is the chronic issue. There was more social isolation, more financial issues that are driving people to consume mind-altering substances to cope with hardships. Essentially, we had to do a lot of things in this country to protect people from disease, but for people who are predisposed to misuse substances— drugs, alcohol, even food—we’re in a place now where we’re dealing with two different arms of it. Pharmacists need to understand that as a piece of the public health infrastructure, it is two separate issues that are connected.”

In 2020, Thornton and two colleagues received funding to build a curriculum around substance use disorders, making Houston one of only two colleges of pharmacy to do so at the time. “We were able to develop and implement a 12-hour curriculum for pharmacy, medicine, social work and nursing,” he explained. “There was a need on a national level for pharmacy schools to step into leadership roles alongside other healthcare disciplines. We’re trying to spread this curriculum, which addresses stigma, screening, referrals, social assessment, treatment options and resources.” The key is interdisciplinary training, looking beyond treatment to focus on the broader health services and letting students hear directly from patients afflicted with substance use disorder. “Some of that was lost during Covid. It’s been critical for us to make sure the students are hearing from the people they will ultimately be serving and treating in the community.”

Thornton is a founding co-director of The PREMIER Center, which was established in December 2018 to improve patient outcomes by providing education on safe and effective controlled substance prescription use. Research efforts concentrate on optimizing pharmacotherapy to manage pain and substance use disorders. “We have 10 faculty, three post-doc fellows, one of which is a Pharm.D., five graduate students and 4-10 Pharm.D. students doing research with us,” he said. “We serve as a local and statewide resource for a lot of these things. We are advocates for the pharmacy profession but also because most of us are pharmacists, we hopefully serve as a benchmark of sorts.”

Pharmacists have been asked to shoulder a significant workload during the parallel opioid and pandemic crises, he continued. “It’s a difficult time to be a community pharmacist when we are asking them to do more with little incentive. We want to figure out more administrative ways to incentivize our pharmacy workforce to help patients in desperate need.” Most pharmacists are willing to go the extra mile to help patients with screening and referral, but patients aren’t always receiving equitable care due to the stigma against people using opioids. “We need to be reimbursing pharmacists for their time and effort to help patients navigate the complex healthcare system.”

Interprofessional Engagement

An innovative program in Ohio could provide a model for other schools seeking a more comprehensive approach to training healthcare professionals about SUD. When the Ohio Attorney General’s Scientific Committee on Opioid Prevention and Education (SCOPE) identified a gap in provider training for SUD and a need for standardized educational experiences, The Ohio State University College of Pharmacy designed an interprofessional program that ran as a pilot last spring. Schmuhl, who co-chaired the committee that helped design the course, said, “The results [of SCOPE’s survey] showed some gaps not only in training, but also in understanding things like social determinants of health and the ethics surrounding treating someone with SUD, so there were a few objectives they identified.”

Participating students engaged in a six-week asynchronous course that covered six modules: the neurobiology of opioid use disorder; treatment; adverse childhood experiences; social determinants of health; motivational interviewing; and ethics and stigma. Students then applied that knowledge during a threehour synchronous virtual symposium that concluded with a collaborative escape room learning experience. “It was an engaging way for students to work together through a complex patient case and show their knowledge and what they gained from the program,” Schmuhl noted. “Our instructional designers helped us develop the escape room in a virtual platform. In spring 2022 we had 238 students complete both portions. We had students from around the state representing dentistry, nurse practitioners, medicine, physician assistants and pharmacy. It was mainly marketed through members of our subcommittee so they offered it in different ways. Some faculty incorporated it into a course. I offered it as an elective course at Ohio State.”

Schmuhl and a colleague received a grant from OSU’s Office of Outreach and Engagement to expand the program, which they plan to continue with some tweaks. “Some of the student feedback was about the lack of social work representation. They wanted more content related to social work within the modules,” she explained. “We did offer it again in the fall with social work students participating. We’re planning to do another round this spring. One of our goals is to do a research study to learn about student perceptions of working on an interprofessional team to care for patients with substance use disorder. A longerterm goal is to turn the program into CE for practicing healthcare professionals.”

In teaching SUD to third-year student pharmacists, Schmuhl said she advocates for harm-reduction strategies and carrying naloxone. Regarding fentanyl, she noted that there are fentanyl test strips but they are still considered to be drug paraphernalia in the state. “We need to work to decriminalize those strips in Ohio. That’s a barrier to increasing access to harm-reduction strategies.”

As Thornton noted, raising awareness among younger audiences is also a key strategy. “We need to make sure all of our adolescent kids and older understand that any previous relative ease of access to street drugs is not as innocuous as they think. It’s very dangerous right now the amount of fentanyl in what is sold,”

Scientific Committee on Opioid Prevention and Education

(SCOPE): https://www. ohioattorneygeneral. gov/SCOPE