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Societal Structure, Care Access and Stigma: Strategies to Enhance Safe Opioid Use

The Opioid Epidemic and High-Risk Opioid Use in the U.S


Prescription opioids may be used to treat chronic and acute pain for a variety of health conditions. Different categories of opioid analgesics include: natural opioid analgesics (e.g., morphine, codeine), semi-synthetic opioid analgesics (e.g., oxycodone, hydrocodone, hydromorphone, oxymorphone), and synthetic opioid analgesics (e.g., methadone, tramadol, fentanyl).1 In the United States, there has been an increased use and acceptance of prescription opioids despite the serious risks that can be associated with these medications such as addiction, overdose, and death. Approximately 841,000 deaths have occurred in the United States since 1999 due to drug overdose; over 70% of drug overdose deaths in 2019 were due to opioids.2 The number of deaths associated with opioid use (other than methadone) have dramatically increased since 2013, and have involved both illicit and prescription opioids.1 The most common prescription medications involved in prescription overdose deaths involve methadone, oxycodone, and hydrocodone. This illustrates an alarming trend of opioid prescription misuse that is contributing to the overall opioid epidemic. To highlight this trend further, there has been a 1040% increase in the age-adjusted rate of deaths involving synthetic opioids from 2013 to 2019, from 1.0 to 11.4 deaths per 100,000 age-adjusted. The latest numbers from the Centers for Disease Control and Prevention (CDC) report that there were approximately 50,000 overdose deaths in 2019 involving opioid medications.

The steady rise in opioid overdose deaths can be attributed to 3 distinct waves, as described by the CDC.1,3

  1. First Wave: increased prescribing of opioids in the 1990s leading to overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone).
  2. Second Wave: increased overdose deaths involving heroin starting in 2010.
  3. Third Wave: increased overdose deaths involving synthetic opioids, especially combinations involving illicitly manufactured fentanyl, starting in 2013.

The CDC released its annual surveillance report of drug-related risks and outcomes in 2019, which culminated data from different sources including the National Survey on Drug Use and Health (NSDUH) and the Agency for Healthcare Research and Quality (AHRQ).3 According to the report, approximately 15% of the US population (49,515,948 people) filled at least 1 opioid prescription during 2018. The daily dosage per prescription that was considered high dosage was defined as ≥90 morphine milligram equivalents [MME]/ day. Of those patients filling an opioid prescription, each received an average of 3.4 opioid prescriptions per year. Opioid prescribing filling rates (at least 1 opioid) were highest among persons 65 years of age and older (25%), followed by persons aged 55 to 64 years (23.9%). The average days of supply per opioid prescription filled between 2006 and 2018 increased by 37.6% from 13.3 days to 18.4 days.

Taking prescription opioids for extended periods of time or at increased dosages can increase the risk of addiction, overdose, and death. Even though the overall opioid prescribing rate has been in decline, decreasing 29% from 2006 to 2018, the percentage of persons reporting use of illicit drugs or misuse of prescription drugs remains high.3 In 2018, 19.4% of the US population reported illicit drug use or misuse, with 3.7% specifically reporting opioid misuse. While various factors can affect high-risk opioid use, this article will focus on the impact of social determinants of health, care access and stigma on high-risk opioid use.


High-risk opioid use: patterns that indicate a high likelihood of current or future opioid misuse. This can encompass the use of illegal drugs or prescription medications in way other than what is directed by a prescriber (e.g., use in increased amounts, greater frequency or duration, utilizing someone else’s prescription).1

Opioid use disorder (OUD): a pattern of opioid misuse that causes significant impairment or distress.1 High-risk opioid use can lead to OUD.

High-dose opioid prescriptions: prescriptions with a dose greater than or equal to 90 MME/day as defined by the CDC.3

Social Determinants of Health: non-medical factors that influence health outcomes as defined by the World Health Organization (WHO).4 Social determinants of health have a major impact on people’s health and are comprised of many different components, as shown in Table 1. Health outcomes affected by social determinants of health include mortality, morbidity, health status, and life expectancy.5

Table 1: Social Determinants of Health Examples5
Economic Stability Neighborhood and Physical Environment Education Access and Quality Food Community and Social Context Health Care Access and Quality
· Employment
· Income
· Expenses
· Debt
· Medical Bills
· Support
· Housing
· Transportation
· Safety
· Walkability
· Zip code
· Literacy
· Language
· Vocational training
· Higher education
· Hunger
· Access to healthy options
· Social integration
· Support systems
· Community engagement
· Discrimination
· Health Coverage
· Provider availability
· Quality of Care

Stigma: negative attitudes or discrimination against a certain group of people. There are different types of stigmas related to opioid use:6

  • Public stigma: perceived dangerousness and moral failings, which can translate into negative attitudes and stereotypes towards people who participate in high-risk opioid use.
  • Anticipated stigma: occurs when people are aware of negative attitudes and expect rejection when their stigmatized identity becomes known.
  • Internalized stigma: when people come to accept their stigmatized identity and the negative attitudes the public has about them.
  • Enacted stigma: the behavioral manifestations of public stigma, which can include discrimination.
  • Structural stigma: the way societies reinforce stigmatized identities. This can occur via policy enforcement, societal norms, or various institutions.

Access to Care:  timely use of health services to achieve the best health outcomes, which consists of medical coverage, access to a usual source of care (both preventative and acute treatment), ability to receive care when needed, and having qualified, culturally competent healthcare providers.7 Care for patients who engage in high-risk opioid use may be limited and can contribute to the continuation of high-risk circumstances. For example, in 2018, only 25.9% of patients who met the criteria for substance abuse disorder had accessed any form of treatment.3

Metropolitan areas: Large metropolitan areas have a total population of 1 million or more people. Small metropolitan areas have a total population between 20,000 and 1 million people.3 The terms the terms “urban” and “metropolitan” will be used interchangeably in this monograph.

Nonmetropolitan/rural areas: encompass counties in micropolitan statistical areas (less than 20,000 people) and counties that are completely rural.3 The terms the terms “rural” and “nonmetropolitan” will be used interchangeably in this monograph, in line with the Federal Office of Rural Health Policy (FORHP) in the Health Resources and Services Administration.

Natural and semisynthetic opioids: morphine, codeine, hydrocodone, and oxycodone.8

Synthetic opioids: methadone, fentanyl, fentanyl analogs, and tramadol.8

High-Risk Opioid Use in Specific Populations

Rural Populations

According to the 2019 CDC annual surveillance of drug-related risks and outcomes, the prevalence of illicit drug use and prescription drug misuse was 12.5% in nonmetropolitan areas.3 Reported opioid misuse to prescription pain medications (e.g., oxycodone, hydrocodone) was similar in large and small metropolitan counties, 3.4% and 4%, respectively. Opioid use and misuse in rural populations have been rising steadily. Despite the decline in opioid prescription prescribing, the rural opioid prescribing rates continue to be higher than in urban areas. Patients that resided in geographically isolated rural counties were 87% more likely than patients in large metropolitan counties to receive an opioid prescription between 2014 and 2017.9 In 2017, the majority of counties with the highest opioid prescribing rates were rural (14 out of 15 counties).

Consequences of increased opioid use and misuse in rural communities was highlighted in a National Vital Statistics System report that examined urban-rural differences in drug overdose rates. Generally, the age-adjusted rate of drug overdose deaths increased in urban areas (6.4 to 22.0 deaths per 100,000 from 1999 to 2017) and rural areas (4.0 to 20.0 deaths per 100,000 over the same time period).8 However, in 2017, the overall drug overdose death rates were higher in rural than urban counties for deaths involving natural and semisynthetic opioids. In contrast, urban counties had increased rates of drug overdose deaths involving heroin, cocaine, and synthetic opioids other than methadone. Concerns over drug overdose death rates across the US led the White House to declare the opioid crisis a public health emergency in 2017; some of the elements of the directive included an expansion of telemedicine and increased resources in rural areas to allow better access to care.10

Research has shown that rural communities are more likely to experience particular opioid-related use patterns and consequences than urban communities.11 This includes an increased mortality rate from prescription opioids and utilizing combinations of pain medications including opioids. Risk factors for rural populations that correlate to drug-related mortality and overdose trends include age, sex, ethnicity, lower education level, history of chronic pain, history of previous substance use and/or treatment, and mental health disorders (such as depression, anxiety and post-traumatic stress disorder [PTSD]).12 Young (typically between aged 25 to 45 years), white men are often at the greatest risk for fatal and nonfatal overdose in rural communities.


The 2019 NSDUH surveyed Veterans (excluding active military personnel) and reported that 595,000 Veterans participated in opioid misuse.13 The majority of opioids misused were prescription medications (hydrocodone, oxycodone, and fentanyl). Younger veterans (aged 18 to 25 years) were more likely to misuse opioids versus older veterans (≥ 26 years old). Data from the Veterans Health Administration (VHA) illustrates the increasing rate of opioid overdoses in the Veteran population from 14.47 deaths per 100,000 in 2010 to 21.08 deaths per 100,00 in 2016.14,15

Veterans and military personnel are at increased risk for opioid overdose due to factors like opioid prescribing patterns in this population (e.g. high doses, long durations, coprescribing with benzodiazepines), history of medical diagnoses such as chronic pain, and history of mental health disorders (e.g. PTSD) and substance use disorders (SUDs).16,17 Pain, in particular, is a significant risk factor for OUD, and pain is highly prevalent in the Veteran population, which can lead to increased exposure to opioids for pain management.18

Due to the overall increasing trend of opioid misuse in the past 2 decades, the VHA initiated the Opioid Safety Initiative (OSI) in 2013.19 The goal of the OSI was to promote safer opioid-related prescribing in VHA facilities, which impacts a large population as the VHA is the largest integrated health system in the US with over 141 facilities nationwide. A study assessing the OSI and its impact on outpatient opioid prescriptions found that there was an overall reduction in high-dosage opioid regimens of >100 morphine equivalents (MEQ) and >200 MEQ by 16.05% and 24.21%, respectively, from 2012 to 2014. However, a large proportion of patients remained on high-dosage regimens by the end of the study period and prescribing practices varied widely between facilities.

Barriers to Treatment and Access to Care

Patient-Specific Barriers

Numerous barriers for the prevention and treatment for high-risk opioid use exist and prevent individuals from accessing the resources they need. In 2019, less than 35% of adult patients with OUD obtained treatment in the past year.20 Further, there is an average delay of 4 to 7 years between the time of OUD diagnosis to receipt of treatment. Medication treatments for OUD include methadone, buprenorphine, and extended-release naltrexone.15,21 Methadone is offered at opioid treatment programs (OTPs), and buprenorphine can be offered at OTPs, non-OTP facilities, and office-based settings.21 Due to these setting requirements, OUD treatment access for patients, including access to healthcare providers who are equipped to diagnose and treat high-risk opioid use, can be a barrier for patients.20

Stigma can also cause a barrier for patient acceptance and maintenance of OUD treatment. Additionally, stigma is highly prevalent towards patients with high-risk opioid use and OUD from both the general public as well as providers.20 This was highlighted in a 2016 national survey, where more than 75% of general public respondents stated that individuals with OUD were to blame for their condition and characterized patients with OUD as lacking self-discipline. Even survey respondents who had a personal connection with someone who experienced OUD reported equally negative attitudes towards patients with OUD. Stigma towards people with OUD and SUDs is also intertwined within US history, as shown by drug policies that have disproportionately targeted marginalized groups, as well as negative media portrayals of opioid and substance abuse.

A systematic review, that included 37 studies that assessed barriers to OUD treatment from the patient perspective, found that the most common barrier was negative perceptions about OUD treatment.22 Negative perceptions included perceived or actual side effects of OUD treatment, hearing negative things about treatment from others, and the perception that when utilizing OUD treatment patients were replacing one addiction for another. The next most common barriers for patients were treatment cost, stigma, perceived lack of control or flexibility with treatment (which included daily visits and strict regulations), and difficulty of treatment access.

Rural Populations

In rural communities there are specific social determinants of health and barriers to medication treatment access that can exacerbate and perpetuate the risk of high-risk opioid use.11 Social determinants of health that affect rural communities such as income-related struggles and health insurance gaps have also been connected with a greater risk for opioid-related consequences.

A systematic review of rural-specific barriers to medication treatment for OUD in the US conducted in 2019 included 18 studies published between 2004 and 2018.11 The review found that there was a relative lack of opioid specialty clinics and waivered buprenorphine practitioners in rural areas as compared to urban areas. Two studies in the review also identified a lack of concurrent psychiatric and behavioral health services among rural populations being treated for OUD. Patient-focused studies reported accessibility to providers as a barrier of seeking care, with rural populations having further distances and longer travel times to get to medication treatment clinics. Further, the disparities in access to OTPs was highlighted in a 2021 U.S cross-sectional analysis at the census block level.21 The study found that 2,915,949 adults lacked access to OTPS within a 2 hour drive of their community and 86,605 adults did not have access to office-based buprenorphine treatment. Adults living in Alaska, Wyoming, and South Dakota had the largest disparities, with the largest percentage of the population without access to OTPs or office-based buprenorphine treatment.

A 2020 systematic review of 57 studies focusing on the rural Appalachia region and high-risk opioid use found that there was a high prevalence of polysubstance abuse and reported mental health issues.12 Access to mental health services may not be as readily available and accessible in these areas due to cost, stigma, social norms, insurance issues, and lack of transportation. Additionally, Appalachian culture has a potential role in perpetuating substance use due to social networks being more close-knit, which could facilitate increased diversion of opioids for misuse. Familial and social networks in rural communities are central to the culture in these populations, and sociological research has documented that individuals in rural areas trust and engage socially with their neighbors more so than urban populations.23 Thus, the diversion of prescriptions filled by parents, friends, and acquaintances is one of the main sources of illicit prescription opioids in rural communities. The breadth of the social network in these areas can allow for faster distribution of prescription opioids to potential nonmedical users.


Veterans face specific risk factors that can exacerbate and perpetuate high-risk opioid use such as increased rates of chronic pain, higher rates of opioid prescriptions, history of medical diagnoses such as chronic pain, and history of mental health disorders (eg, PTSD) and SUD compared to the general US civilian population.16,17 When comparing VHA patients to privately insured patients, veterans are almost 7 times more likely to misuse opioids.17 Additionally, veterans are not immune to disparities in access to medications for OUD. A retrospective chart review study of VHA clinical data found that among 53,568 veterans diagnosed with OUD, vulnerable populations (ie, racial/ethnic minorities, women, older, rural, homeless, and justice-involved) had decreased odds of receiving OUD medications than nonvulnerable counterparts.24

The Veterans Affairs Evidence Synthesis Program has reported on barriers and facilitators for underutilization of OUD medications.15 The review focused on buprenorphine and extended-release naltrexone because these agents can be prescribed in office-based settings, thus are more suitable for widespread use. Identified barriers were categorized into 4 types: stigma, logistical, treatment experiences and beliefs, and knowledge gaps. For patients, the most commonly cited barriers consisted of stigma (including not wanting to be associated with OUD treatment or having negative connotations associated with treatment) and logistical challenges (such as access to a provider and concerns with high out-of-pocket costs for treatment). The most common facilitator for patients to get OUD treatment was support from family, peers, and treatment providers.

Provider Barriers

There are numerous barriers that affect health care professionals from providing optimal preventative and treatment care for high-risk opioid use. The impact of stigma amongst healthcare professionals has been evaluated within the literature. One large scale study evaluated primary care physician viewpoints on patients with OUD and reported that the rates of stigma were as high, if not higher, than stigma rates among the general public.20 The Veterans Affairs Evidence Synthesis Program 2019 report found that stigma was a common barrier among providers for not prescribing OUD treatment medications within the VHA system.15 This included the stigma that patients on OUD treatment medications were still addicted. Additionally, a 2018 survey of buprenorphine prescribers in the US suggested that prescribers may be less willing to start buprenorphine treatment in patients that have SUDs (like binge alcohol use or misuse of benzodiazepines).25 Overall, these stigmas can lead to a decreased willingness of providers to prescribe medications for OUD treatment due to concerns about potential misuse and diversion.20

Logistical and knowledge barriers have also been documented. In the Veterans Affairs Evidence Synthesis Program 2019 report, logistical barriers such as time constraints, insurance, and regulatory issues were also cited.15 Providers’ lack of training and lack of experience with methadone and buprenorphine are another significant barrier to care. Surveys have found that providers cite education and access to a qualified interdisciplinary team are crucial in treating patients with OUD.26 Among primary care providers, a lack of training, lack of time, and belief that treating OUD is not a primary care issue have been identified as additional barriers. In rural settings, these barriers may be further exacerbated. Implementation of integrated OUD treatment in rural areas faces challenges such as inadequate training of providers, limited access to care, personnel shortages, and an inadequate availability of telehealth services.27

These logistical and knowledge barriers also contribute to opioid-related adverse events. For example, a retrospective analysis of reported opioid-related adverse events in the VHA found that lack of and/or not following policy and procedures was the most common root cause of adverse events involving opioid overdoses.17 This points to a need for increased staff education and training in opioid management, medication-related equipment, and recognition of opioid overdoses.

Legal and Regulatory Barriers

There are legal restrictions in place for OUD medication treatment that can make it more difficult for patients to receive treatment. Methadone is the most rigorously regulated FDA-approved OUD treatment, and it can only be dispensed by an opioid treatment program that is certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and registered by the Drug Enforcement Administration (DEA).20 There may also be other methadone regulations that vary by state such as supervised medication consumption and mandated urine testing and counseling. In order to prescribe buprenorphine, providers must receive specialized training and certification by the DEA. Even though there have been federal regulations passed that have made it easier to obtain buprenorphine prescribing privileges (like The Drug Addiction

Treatment Act [DATA] of 2000 and The Comprehensive Addiction and Recovery Act [CARA] of 2016), there are estimates that suggest that less than 30% of waivered physicians are actively prescribing buprenorphine. Laws that govern both public and private insurance coverage can also pose as a barrier for patient’s accessing OUD treatment. Medicaid is the largest U.S health insurance program and covers 4 out of 10 adults with OUD. Medicaid coverage can help patients access OUD treatment, if they are able to enroll; many states have expanded Medicaid eligibility, but there are still states that exclude buprenorphine and methadone from their Medicaid coverage policies.

Strategies and Recommendations

Increasing Access to Care 

Community pharmacists are often the first health care providers who are available to detect signs of opioid prescriptions misuse, abuse, and diversion. Pharmacists have extensive training in appropriate medication use, safety profiles of medications and medication counseling. Over 89% of the US population live within a 5-mile radius of a pharmacy, which makes pharmacists the most accessible community healthcare professionals.28 The increased distribution of naloxone in community pharmacies have been one actionable strategy to reduce opioid-related risks. Naloxone is available without a patient-specific prescription in all 50 states, and pharmacists can help identify individuals who are at high-risk for opioid overdose (e.g., high-dose opioid prescriptions, receiving OUD treatment) and provide them with naloxone.

Pharmacists may also interact with patients with undiagnosed OUD, and there are evidence-based approaches that pharmacists can use to identify and reduce risk associated with high-risk substance use. The screening, brief intervention (SBI), with or without Referral to Treatment (SBIRT) models have been successfully utilized in different clinical and community settings.28,29 Prescription drug monitoring program (PDMP) data may be used to identify high-risk controlled substance utilization, and the SBIRT model utilizes that data to implement an interview-based screening approach for patients presenting to community pharmacies.29 Based on the screening results, at-risk patients would receive education or a brief intervention for alcohol, tobacco, or drug education.

There are also other validated patient-reported assessments and screening tools that pharmacists can utilize to detect patients at risk for opioid misuse and abuse which are displayed in Table 2.30 These tools can be given to patients in both community and inpatient settings and their results can be discussed with a pharmacist during a counseling session. If there are concerns for opioid misuse, the assessment results can be discussed with the patient’s prescriber.

Table 2: Patient-Reported Assessments for High-Risk Opioid Use30
Assessment Number of Questions Description
Opioid Risk Tool (ORT) 5 Assesses family and personal history of substance abuse, sexual abuse, and psychological disease
Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) 24 Helps predict abnormal medication-related behaviors in patients with chronic pain
Current Opioid Misuse Measure (COMM) 17 Measures risk for abnormal medication-related behavior in patients with chronic pain who are currently taking opioids
Risk Index for Overdose or Serious Opioid-Induced
Respiratory Depression (RIOSORD)
4 question groups Assigns point values to different conditions, medications, or events to quantify risk

Telehealth Services

Telehealth can also be a strategy to mitigate access to care barriers that many high-risk opioid users face, especially in rural communities. During the COVID pandemic, the DEA and SAMHSA modified guidelines for providing OUD treatment medications that allowed for buprenorphine induction via telehealth services and waived the Ryan Haight Act’s requirement of an in-person visiting when prescribing controlled substances.31 A retrospective chart review study analyzed data of OUD patients in a primary care clinic in rural Appalachia during 3 different time periods: pre-COVID (January 16–March 15, 2020), COVID transition (March 16– April 15, 2020), and COVID (April 16 –June 15, 2020). There were 242 patients who had at least 1 office-based opioid treatment during the 5-month study period. The study found that there was an overall increase in visits (436 pre-COVID versus 581 post-COVID; p<0.001), whereas the number of overall new patients remained consistent. During COVID, telemedicine visits were also greater utilized for patients who lived significantly further away (on average 16.4 miles) from the clinic. This illustrates the increased demand for such services and need for expansion of telehealth for patients to have easier access to care.

Provider Considerations 

Providers can play a crucial role in addressing the mentioned barriers to preventative and treatment care access for high-risk opioid users. The Veterans Affairs Evidence Synthesis Program 2019 report found that provider-identified facilitators in providing optimal care to this patient population included having access to mentoring from addiction medication specialists, increased training on OUD medication treatments, the ability to refer patients to support services (such as psychosocial support), and having support resources at their institutions.15 The National Academy of Medicine along with an expert panel including the Prevention, Treatment, and Recovery Working Group of the Action Collaborative on Countering the US Opioid Epidemic collaborated on a strategies to combat barriers for the treatment of OUD. Table 3 outlines strategies to combat provider-specific barriers.32

Table 3: Barriers and Strategies to Address Them32
Barrier Strategy
Many providers (including pharmacists) have stigmatizing attitudes toward patients with opioid use disorder and toward medications for opioid use disorder · Development and implementation of an evidence-based stigma reduction campaign targeting providers, by professional organizations
· Targeted education early on in training on high-risk opioid use
· Emphasizing the efficacy of medications for OUD treatment
· Academic detailing
Many providers have insufficient training to provide evidence-based care for patients with opioid use disorder · Accreditation agencies should require that clinicians receive training in screening, diagnosis, and treatment high-risk opioid use
There is an insufficient number of addiction treatment specialists · Increased funding for loan repayment programs for addiction specialists who treat substance use disorders in underserved areas
· Increased opportunities (residencies, positions) to train and recruit clinicians in rural and medically underserved areas
The provision of medications for opioid use disorder is often not standardized · Standards and metrics should be created for primary care, community health centers, certified community behavioral health clinics, emergency departments, detention facilities, and mental health programs to screen for and treat OUD
· Organize and fund evidence-based assistance for clinicians prescribing buprenorphine and extended-release naltrexone, linking them to specialists and other resources.
· Improve care coordination by increasing data sharing for high-quality care (such as increased integration with prescription drug monitoring programs).
Abbreviations: OUD, opioid use disorder.

An interprofessional approach to address the opioid crisis is needed in order to care for patients with high-risk opioid use and OUD. Physicians, pharmacists, nurses and other providers can work to optimize patient pain regimens, educate patients, and identify opioid misuse and abuse.33 Collaborations among pharmacists and other providers on the patient care team can include: opioid exit plans, discharge planning, collaborative practice agreements in pain clinics, pharmacist participation in OUD treatment plans, pharmacist counseling and education on pain medications, medication reviews/medication therapy management, and distribution of naloxone and opioid rescue kits. 

Pharmacy-Specific Considerations 

Pharmacists can play a pivotal role in the prevention and treatment of high-risk opioid use. Along with the above-mentioned provider and access to care strategies, there are other pharmacy-specific considerations as well. One way to fight stigmas in the pharmacy profession regarding high-risk opioid use is to target pharmacy schools.34 The University of New Mexico (UNM) College of Pharmacy has increased use of non-stigmatizing language when talking to providers, patients and the public. UNM has emphasized stigma reducing communication and person-first terminology strategies during coursework and student experiential education to discourage harmful language that can endorse negative perceptions about patients with OUD. College faculty have also developed an outreach intervention program to increase pharmacy-based naloxone dispensing. The program focuses on communication skills and education on naloxone counseling strategies in community pharmacies to increase outreach efforts in rural areas. At the Massachusetts College of Pharmacy and Health Sciences (MCPHS), student organizations (such as Generation Rx) are organizing training sessions on how to recognize and respond to the opioid epidemic, which includes training on naloxone. Previous research at MCPHS had shown that community pharmacists in the surrounding area were not comfortable with counseling on naloxone. The training sessions at MCPHS have resulted in over 5000 faculty, students and staff learning more about high-risk opioid use and how to administer naloxone, thus increasing knowledge and preparedness in that community.

In regards to high-risk opioid prescription use, community pharmacists are usually also the last healthcare providers that patients will encounter before using prescription medications; this puts pharmacist in a position to screen for diversion, educate patients about opioid-related risks, and monitor for high-risk opioid use behaviors.28 Prescription drug monitoring programs are electronic databases that track all controlled substance prescriptions.30 Pharmacists can utilize PDMPs to identify patients who are participating in high-risk prescription opioid use behaviors such as obtaining prescriptions from multiple providers, high daily dosages of opioids, and potential drug-drug interactions. A program called PMP InterConnect®, which facilitates PDMP data transfer across state lines, has also been established, which is aiding pharmacists and prescribers in obtaining a more comprehensive patient prescription history. However, there is still an opportunity to optimize and expand this program because it is not currently in all states.

To decrease opioid prescription sharing and theft, mandates for prescription limitations have been set by numerous state legislatures and insurance companies. By limiting day supply, patients will need to return to the pharmacy more often to pick up prescriptions, which allows pharmacists the opportunity to reinforce instructions on proper use and disposal of opioids.30 Patients should be encouraged to dispose of their unused opioid medications through drug take-back events or permanent medication disposal sites to deter opioid diversion behaviors. Unused prescription opioids can be sold, stolen or misused and patients should also be counseled on proper safe storage of their prescriptions. Another strategy to remove excess, unused prescription opioids is by providing patients with take-home drug disposal products. A prospective cohort study at a children’s hospital outpatient pharmacy evaluated the effectiveness of a drug disposable bag.35 Patients and families filling opioid prescriptions received a drug disposal bag containing activated charcoal; when water and opioid medications were added to the bag, the medications were rendered unusable. Among patients who received a disposal bag (n=117), the likelihood of unused opioid drug disposal was higher than patients (n=98) who did not receive a bag (71.7% vs. 52.1%, respectively; P=0.04).

More recent federal legislation, the 2018 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act contains several conditions that are relevant to pharmacists. There is provision that charges the U.S. Department of Health and Human Services with developing and disseminating programs and materials to inform pharmacists how to decline to fill a prescription for a controlled substance that seems fraudulent or forged.28 This will help empower pharmacists and help decrease uncertainty in the controlled substance screening process. There are also conditions that call for controlled substances covered by Medicare Part D to be transmitted electronically which will help streamline the verification process and help screen for fraudulent prescriptions.


There are many factors that can affect high-risk opioid use including social determinants of health, stigma, and access to care. Vulnerable populations such as rural communities and veterans can have specific barriers that inhibit them from getting the preventative and treatment care they need. In order to improve care for these populations, health care providers should work together to implement new strategies and utilize protocols and procedures in place to break down barriers for patients with high-risk opioid use.


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