Most of the pharmacists we surveyed expressed concerns about opioid use in several or many of their patients. These concerns were based on direct observations of patient behaviour, such as coming in for early refills and opioid intoxication. Many pharmacists reported difficulty in communicating these concerns to physicians. These findings echo previous research on physician-pharmacist communication. For example, in a qualitative study, community pharmacists reported that they had great difficulty in accessing GPs, because receptionists would not transfer their calls.5
In another qualitative study, 27 pharmacists and 36 GPs kept diaries of the nature of their interprofessional contacts. Most contacts (57%) were to clarify prescription details, while only 4% were related to patient care,6
suggesting that pharmacists and physicians do not often discuss clinical issues. This is unfortunate because pharmacists could play an important role in the care of chronic pain patients. They could alert the physician to aberrant drug-related behaviour, or to potentially dangerous drug interactions (eg, coprescribing of opioids and benzodiazepines). They could also assist physicians with specific clinical protocols, such as opioid switching and tapering, and with referral to methadone or buprenorphine programs.
Pharmacists’ attitudes toward opioid use for chronic pain would likely improve if they had greater involvement in patients’ treatment. Several surveys have found that pharmacists have positive attitudes toward opioid-dependent patients when they are actively involved in their treatment plan.7–9
For example, a large survey of Scottish pharmacists found providing services to drug misusers (eg, methadone dispensing, needle exchange) was associated with more positive attitudes.8
One limitation of this study is that the survey was only mailed to pharmacists who had indicated an interest in research (45% of the total number of pharmacists with an active Ontario licence). Also, the respondents were on average older and more likely to be male than Ontario pharmacists in general. Thus the survey results might be skewed, if older male pharmacists have different experiences with patients taking opioids than younger or female pharmacists do. Also, 37% of the respondents were concerned about codeine use, but the survey did not distinguish between over-the-counter codeine and prescribed codeine.
Another limitation is that the survey only measured pharmacists’ subjective experiences with patients taking opioids, and it relied on respondents’ subjective estimates of the frequency of events (using categories such as sometimes and frequently). This could create an exaggerated picture of the prevalence and effects of addiction. For example, a patient who runs out early is not necessarily misusing or addicted to opioids; and perhaps some pharmacists believe that this behaviour occurs more often than it actually does.
Recent evidence, however, suggests that the pharmacists’ concerns are valid. Physicians’ prescriptions are a major source of opioids for opioid-addicted patients and for opioid overdose deaths, and both these opioid-related harms are increasing rapidly in Canada.1,10
Furthermore, the survey results are consistent with findings from a recent survey of 1000 primary care physicians in Ontario,3
which found that most physicians had had at least 1 patient with an opioid-related adverse event in the past year. The most common factors causing the events were the same as those cited by pharmacists: the patient took more than prescribed, the prescribed dose was too high, or the patient took alcohol or sedating drugs with the opioids. Both physicians and pharmacists rated a provincial prescribing database and opioid prescribing guidelines as the most helpful strategies for improving opioid prescribing. Physicians and pharmacists differed in only one respect: Whereas pharmacists reported difficulties in communicating with physicians, physicians were generally satisfied with their interactions with pharmacists.
Further research is needed to define more clearly the nature of the difficulties faced by pharmacists. For example, focus groups could elucidate in more detail the barriers they face in communicating with physicians. Research is also needed to develop and evaluate the effectiveness of interventions to improve pharmacist-physician communication and to manage opioid intoxication and aberrant drug-related behaviour.
Pharmacists commonly observe opioid intoxication and aberrant drug-related behaviour in their patients, and they find it difficult to communicate their concerns to physicians. These results emphasize the urgent need for a system-wide response, including national opioid prescribing guidelines, provincial prescribing databases, and strengthened protocols for physician-pharmacist communication.