There is no end in sight for the opioid epidemic, as opioid-related deaths continue to rise, with 56,516 overdose deaths reported in 2020. One factor that elevates the lethality of opioid consumption is the concomitant use of alcohol. The FDA has issued a warning regarding the concomitant use of alcohol and other sedative medications with opioids.

Yet, it is unclear how often patients receiving opioid prescriptions in the community setting regularly consume alcohol. Knowledge of the prevalence of concomitant opioid and alcohol use may offer an opportunity for pharmacists to identify patients who are at high risk of overdose.

Data are presented of a substudy of a cross-sectional health assessment screening test conducted among patients filling opioid prescriptions in 19 community pharmacies in Indiana and Ohio between November 2019 and October 2020. In this convenience sample, patients receiving opioid prescriptions were asked to complete a self-screening health assessment survey.

To be included in the study, patients had to be aged at least 18 years, had to speak English, and could not be receiving the opioid for cancer pain management. Patients were excluded from enrolment in the study if they had already completed the survey, if they were currently involved with the criminal justice system, or if they were receiving a buprenorphine formulation. Study patients received a $50 gift card for their participation.

The self-assessment health survey asked about alcohol and substance use, behavior and physical health, and demographic data. However, patients were not directly questioned as to whether they simultaneously consumed alcohol with their opioid. This information was inferred from the participants' responses.

The primary tool used to assess alcohol use was the World Health Organization's Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). ASSIST subscales that were also included queried about use of prescription opioids, street opioids, cannabis, sedatives, cocaine, tobacco, alcohol, methamphetamine, hallucinogens, prescription stimulants, and inhalants during the past 3 months. A risk score of high, medium, and low risk was calculated for each substance subscale.

Although 2,090 patients received opioids at the participating community pharmacies during the study period, only 1,494 patients provided sufficient data to calculate an ASSIST drinking score. Of these patients, almost one-tenth (9.6%) reported moderate/high-risk drinking while using a prescription opioid.

The average age of the study population was 49 years. Fewer than two-fifths (38%) were males, 52.5% of whom reported moderate/high-risk alcohol use. Men were almost two times as likely (adjusted odds ratio [AOR] =1.94) to engage in moderate/high-risk drinking than women. Depression and perception of average general health did not play a role in alcohol use behavior.

Interestingly, while those reporting moderate/high-risk drinking were more likely to have higher pain interference (AOR = 1.44, P = .03), those reporting higher pain severity had reduced odds of moderate/high-risk drinking (AOR = 0.66, P = .03). A significantly greater proportion of those reporting moderate/high alcohol use had a history of illicit drug overdose (22.4%) compared with the low alcohol-use group (8.7%) (P <.001). Also, a significantly larger proportion of those with moderate/high-risk alcohol use reported moderate/high-risk use of prescription opioids (55.9%) compared with low alcohol-risk users (44.2%). A similar statistically significant correlation was seen between moderate/high-risk alcohol use and the use of cannabis, sedatives, cocaine, tobacco, and stimulants (all P values <.05). Overdose history and sedative and tobacco use were significantly associated with an increased likelihood of moderate/high-risk alcohol use.

Investigators found that a significantly higher proportion of moderate/high-risk alcohol users reported weekly alcohol use (35%) compared with low-risk alcohol use (15.6%) (P <.001). Even more striking was that 39.9% of moderate/high-risk alcohol users compared with only 2% of low-risk alcohol users reported daily use of alcohol (P <.001). A further breakdown revealed that 44.8% of those who reported daily alcohol use and 34.4% who reported weekly drinking also reported daily opioid misuse (i.e., recreational use of an opioid instead of for its intended therapeutic purpose). When further queried about daily or weekly desire/urge, more patients reported a desire/urge for prescription opioids as opposed to alcohol, indicating that the drug craving and physical dependence are greater for opioids than they are for alcohol.

The authors saw these findings as an opportunity for pharmacists to be more engaged when filling an opioid prescription. Pharmacists can conduct screening and interventions for concomitant alcohol and opioid use. They called for more dispensing and education on naloxone. This is especially important for those patients who fit the profile of moderate/high-risk alcohol use.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

« Click here to return to Retail Pharmacy Update.