By Katherine E. Hamilton, PharmD Candidate 2019
In a culture where it seems like every other song mentions codeine, morphine, or heroin, it’s no surprise that substance misuse and abuse have become problems of epic proportion. What is surprising, however, is that although pharmacists are the final gatekeepers of patient access to medication treatment for these disorders,1 future pharmacists may not be receiving adequate education and training necessary to feel comfortable working with this patient population.2 The opioid crisis has been an issue of public concern for over 15 years, yet many pharmacists and student pharmacists are unprepared for their roles in the management and treatment of patients affected by this epidemic.
“Sorry, we don’t keep it in stock…”
I work part-time as an intern for a pharmacy chain, as do the majority of my pharmacy school classmates. One day, my pharmacy manager and a technician were discussing a recent development in patient patterns. My pharmacist stated that in order to prevent potential medication diversion she had been telling anyone with a buprenorphine product prescription that we did not keep it in stock and to check another location. Besides diversion, another compelling reason for turning away those patients was to prevent the attraction of an ever-increasing population who, from experience, oftentimes tended to be impatient and confrontational.
Immediately following the conversation, a woman approached me at the drop-off window with a buprenorphine prescription. An internal dilemma immediately ensued: Should I offer to fill the prescription, or should I repeat her line of “Sorry, we don’t keep it in stock,” denying to fill her prescription?
The Academic Disconnect
Preliminary results from our current survey of 250 student pharmacists at the University of Tennessee Health Science Center College of Pharmacy revealed that 32% of pharmacies where the students were employed refused to dispense buprenorphine to patients with a valid prescription at least some of the time.3 Many of our supervisors, preceptors, and mentors are modeling this questionable behavior. Twenty-eight percent of our surveyed students have observed a pharmacist lying to patients about buprenorphine availability, and another 57% have observed lying about stock of any controlled medication.3
Are students being encouraged to treat patients with substance use disorders like a patient with a chronic illness or as a person with a moral failing? Is the education provided in the classroom enough to overpower the reality of dealing with real-life patients and treatment stigmas? Our college devotes approximately three hours of the didactic curriculum to the science and treatment of addiction, and offers electives, but we don’t evaluate whether student pharmacists are comfortable interacting with these patients. Our survey results indicated that only 28% of students felt confident in providing pharmacy care services to patients with a chemical dependency, even though approximately 55% of students revealed that they had a family member or close friend with a substance use disorder.3
I attended the Annual 2017 APhA University of Utah School on Alcoholism and Drug Dependencies where physicians and pharmacists, a majority being addicts in recovery, provided insight into the patient experience and how we might best help them. As part of the program students could attend nightly open meetings of Alcoholics Anonymous, Al-Anon, and Narcotics Anonymous. This experience was eye-opening to me because I learned that:
- Addiction is sneaky, messy, devastating, and can happen to anyone;
- These patients need all the help I can provide them, whether I feel I am the best person for the job or not.
Dr. Tony Tommasello, a speaker at the conference, writes that “pharmacists need to be well informed about issues related to addiction and prepared not only to screen, assess, and refer individual cases and to collaborate with physicians caring for chemically dependent patients, but also to be agents of change in their communities in the fight against drug abuse”.4
Call for Action
Pharmacy education should involve both didactic and experiential opportunities for student pharmacists to prepare them to care for these patients. Preceptors should receive education in this area so that they can model appropriate behavior. The opioid epidemic is a national problem, and pharmacy curricula must shift to reflect this. How do we produce knowledgeable and empathetic pharmacists that will honestly advocate for their patients?
Dr. Tracy Hagemann, Pharm.D., FCCP, FPPAG, The University of Tennessee Health Science Center College of Pharmacy; Dr. Wesley Geminn, Pharm.D., BCPP, and Dr. Erica Schlesinger, Pharm.D., TN Dept of Mental Health and Substance Abuse Services
1. Hagemeier NE, Gray JA, Pack RP. Prescription drug abuse: A comparison of prescriber and pharmacist perspectives. Subst Use and Misuse. 2013;48:761–768.
2. Wenthur CJ, Murawski MM, et al. Opinions and experiences of Indiana pharmacists and student pharmacists: the need for addiction and substance abuse education in the United States. Res in Soc & Admin Pharm. 2012; 9(1):90-100. https://doi.org/10.1016/j.sapharm.2012.03.003.
3. Hamilton, KE, Hagemann, TM (2018). Unpublished manuscript, The University of Tennessee Health Science Center College of Pharmacy, Memphis, TN.
4. Tommasello AC. Substance abuse and pharmacy practice: what the community pharmacists needs to know about drug abuse and dependence. Harm Reduct J. 2004;1(1):3.
Katherine Hamilton is a final year student at The University of Tennessee Health Science Center College of Pharmacy. Educational scholarship interests include critical care and chemical dependencies. In her free time, Katherine enjoys reading a good book, traveling, and spending summer days on the river.
Pulses is a scholarly blog supported by Currents in Pharmacy Teaching and Learning
Thank you Katherine. I appreciated your input on this topic. I, too, am a final year pharmacy student and have had very similar experiences that you shared at several pharmacies I have been to. I agree that knowledge on this issue should begin during the didactic portion of PharmD candidates. It is interesting that despite the “opioid crisis” being such an issue, with new laws coming out to attempt regulation, professors are not taking advantage of shaping the minds of their students to be sensitive toward these patients. We are taught to treat each patient as an individual and not to judge patients based on the diseases they might be suffering from. To add to Dr. Tony Tommasello’s point, I think it is important that we, as healthcare providers, remember that addiction is a disease. We have an obligation to help these patients and I don’t think clearing the shelves of medications that are clinically proven to aid patients battling addiction just to keep a particular patient population away is the answer. I’m interested to see if/how teaching strategies might change in this regard over the next few years. I hope your findings have inspired others to think about this, as it has me.