The ongoing opioid crisis in Alberta requires a coordinated approach from government, Alberta Health Services, regulated health professionals, and others. Pharmacists are front line health providers working closely with individuals prescribed opiates, in particular those who have the potential for dependence, misuse, addiction, and diversion. Pharmacists are often the most accessible members of individuals’ healthcare team and play a vital role in their medication assessment and management. This includes many strategies including harm reduction.
It is essential that pharmacists adequately assess and monitor individuals using opioid medications and work collaboratively within multidisciplinary teams to optimize health outcomes and minimize harm.
The Standards of Practice for Pharmacists and Pharmacy Technicians provide a framework for appropriate patient care however, due to the complexity of opioid use, additional guidance and interpretation of the Standards is required. Adherence to the guidelines, based on the Standards, is an expectation of practice.
Here are some external resources you may want to use when treating individuals using opioid medications:
Questions about how to incorporate the new opioid guidelines into your practice? Many of the questions you have are likely answered in the Link articles below.
What is meant by “thorough assessment?” Does a thorough assessment have to be conducted for refills?
For general information on assessment, you can refer to the ACP Standards of Practice for Pharmacists and Pharmacy Technicians. Standards 3, 4, 5 & 6 provide pharmacists with the expectations of an assessment and what to do if a drug related problem is identified.
Many pharmacists use the ACP Chat Check and Chart tool to frame their assessment processes. The ‘check’ portion of the tool involves four questions to assess whether a prescription is indicated, effective, safe, and if the patient is adherent to therapy. The opioid guidance document provides additional interpretation for each of these four questions within the context of opioid therapy.
Assessments need to be relevant to the health status and needs of the patient at that point in time. Be patient-centered in your approach.
Yes, thorough assessments need to be performed for refills, but use your professional judgement as to what that assessment looks like compared to an initial assessment. It may be monitoring a treatment plan, finding out what has changed since the patient’s last visit, and following up accordingly.
Does a written assessment need to be done every time a Methadone or Suboxone patient comes in for their daily dose?
Yes. Please review Sections 6.4.2. and 8.8.2 of the Opioid Agonist Therapy (OAT) guidelines. Medication-assisted treatment for opioid use disorder: Guidelines for pharmacists and pharmacy technicians for more information on what is required in this assessment.
Will ACP provide a standardized assessment form to help with assessing patients?
We encourage pharmacists to work with peers to develop tools that best meets your needs and workflow of your pharmacy.
Many pharmacies already use a standardized worksheet as the basis for assessment and documentation of injections. Consider adopting a similar process using tools specific to opioid therapy. These documents can be used in their current state or modified as required to fit the needs of your pharmacy.
What documentation is required for opioid refills, as opposed to the initial baseline assessment?
An initial assessment should document baseline data for the patient and set appropriate monitoring parameters. Typically, on a refill assessment, the pharmacist would review the prior documentation, assess the patient and update the record as required. All assessments need to be documented. For more on documentation, click here.
What documentation is required for an acute opioid prescription vs. a chronic one?
There is no distinction. Documentation is required for all assessments but the amount and type of documentation will vary depending on the complexity of the patient and the situation.
Will ACP provide pharmacists with any training specific to these guidelines?
ACP is exploring opportunities to provide pharmacists with further support. Check in with ACP’s website and read future editions of the Link for details.
The opioid risk interview tool has very sensitive questions on it. Does this tool need to be used in every assessment? If not, when should it be used?
The tools and resources provided by ACP are not mandatory. They can be used to help assess if an individual might be at risk of developing problems with opioids. Use your professional judgement if the tool is relevant for the patient in front of you. If you choose to use the tool, select questions from it that are most relevant for that patient.
I am trying to collaborate with my patient and the physician, but they are uncooperative. What should I do?
Start with explaining to patients why pharmacists are asking these questions and what our role is in the management of their health. Remember that pain and addiction are sensitive issues and it is important to build trust to avoid stigmatizing the patient or making them feel judged. Pharmacists, like all healthcare professionals, may not always have access to all the information they would like. It is important for the pharmacist to use their judgement to determine if they can adequately assess the patient and meet the requirements of the Standards of Practice and the Opioid Guidelines based on the information available to them.
Are exempted, non-prescription, codeine-containing products included as part of the guidelines?
Yes.
I have a patient who goes south for the winter and requires more than a 30-day supply of his opioid medication. But the guidelines say a patient should not get more than a 30-day supply. What should I do?
There may be a valid reason to exceed a 30-day supply for some patients. In circumstances when it is determined that the dose or duration exceeds accepted clinical guidelines, thorough documentation of the assessment, including a rationale and an individualized monitoring plan, must be created.
Are medications that act on opioid receptors but are not listed in the Controlled Drugs and Substances Act included as a part of the guidelines?
While the guidelines were written to support practices important to the opioid crisis, the practices and behaviours they address are relevant to caring for individuals using any drug that may have central effects. What’s important is not which specific drugs the guidelines apply to, but rather using them to guide your practice in addressing the unique needs of each patient, each time they seek your care. How you use the guideline will differ with each interaction depending on the health history of the patient, plans you have developed with them, and their immediate health status and needs.
Why is my pharmacist asking me about my medications?
Among other things, your pharmacist is here to support you in managing drug therapy. Your pharmacist considers a variety of information including the conditions you are treated for, the symptoms you are experiencing, medications you are taking, laboratory results, and lifestyle factors to determine if drug therapy is safe and effective for you. Your pharmacist’s goal is to ensure that you get the right medications to achieve your health goals and support you in using them properly, while minimizing the possibility and impact of unwanted effects.
Pharmacists are an important part of your healthcare team, and as outlined in our Standards of Practice for Pharmacists and Pharmacy Technicians, they work collaboratively with other health professionals, such as physicians, to help ensure you receive the most appropriate treatment for you. Often, this includes discussion about other health and lifestyle measures. Sometimes, the answer may be not using medications at all.
I’ve heard a lot about opioids lately. Why are opioid medications a concern?
Opioid medications are used to treat certain types of severe pain, most often when treating pain resulting from surgery or cancer. If pain results from other causes, there may be other alternatives that work better or have less risk associated with them. If opioids are not needed, they should be avoided, as the longer they are taken, the more risk may be associated with them.
Anyone taking an opioid medication can develop dependence over time. This is a known risk of the medication, and is not the fault of individuals using them.
Questions?
Pharmacists are medication management experts. Discuss your health and medication needs with your pharmacist. If you require additional privacy, ask to have your discussion in a private location at the pharmacy.
Here are some resources you may find helpful:
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