US Pharm. 2022;47(7):41-44.
ABSTRACT: Substance use disorder (SUD) is a significant public health concern associated with negative health consequences. Pharmacists play an essential role in the care of patients with SUD, understanding their needs and prioritizing them. There are numerous ways in which pharmacists can receive specialized training, engage in conversations with patients, screen for unhealthy and risky substance-use behaviors, and deliver medical care and services within a pharmacy setting.
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), substance use disorder (SUD) is defined as the recurrent use of alcohol and/or other substances causing impairment and leading to significant consequences such as health problems, disability, and failure to meet major responsibilities at work, school, or home.1 The misuse of prescription medications is a common practice associated with SUD. Nonmedical use of prescription medications (NUPM) is the use of a prescription medication for other than its intended directions or time period prescribed, or by a person for whom the drug was not prescribed. NUPM is most prevalent among adolescents and young adults. Opioids are reported to be used most frequently, followed by stimulants and sedatives.2 Nonmedical use of these medications alone or in combination with alcohol and/or illicit drugs is associated with a substantial number of substance-abuse cases. Misuse of prescription drugs has increased simultaneously with increased prescribing of medication for therapeutic use. It is notably seen with opioid analgesics prescribed for patients with chronic pain, stimulants for attention-deficit/hyperactivity disorder (ADHD), and benzodiazepines for anxiety and sleep disorders.2
Prevalence and PatternsA national survey conducted by SAMHSA reported that one in 12 Americans (approximately 18.7 million adults) had an SUD.3 With SUD being so prevalent, it is important for pharmacists to understand the risk factors involved with substance misuse. Mental health status and family and social history are significant risk factors for unhealthy substance use, which negatively impacts a patient’s everyday life.
Patients with mental health disorders are at an increased risk of developing an SUD. Personality disorders, especially borderline personality disorder and antisocial personality disorder, are commonly associated with an increased risk of SUD. Patients with SUD are also at higher risk of experiencing comorbid disorders, as well such as depression, bipolar disorder, generalized anxiety disorder, posttraumatic stress disorder, eating disorders, schizophrenia, and ADHD.
Social history factors (e.g., having a romantic partner with an SUD, having friends who have SUDs, living in a community characterized by poverty, violence, and high drug availability) can all increase the risk of developing an SUD. Prior family history of an SUD has been shown to be a risk factor, and environments where a parent or primary caregiver has an SUD are related to higher rates of physical and sexual abuse and trauma, poor parenting skills, and poor-quality parent-child interactions, which are all risk factors for SUDs. Social roles and relationships are often affected by the development of an SUD. This can include the loss of friendships and disrupted family relationships, loss of a job or poor grades in school, and legal involvement (e.g., arrests, driving under the influence, and theft).4
Recognizing Potential Signs of SUD
Pharmacists play a pivotal role in recognizing potential signs of SUD. Patients with an SUD may exhibit withdrawal symptoms of anxiety, agitation, sleep disturbances, and behavioral changes. It is important for pharmacists to have open communication with patients with a potential SUD and invite them to engage in conversations about their history and treatment response, utilizing open-ended questioning and motivational interviewing techniques, thereby improving treatment access and outcomes for patients.5
Behaviors of medication misuse or the presence of an SUD may include use of multiple pharmacies or doctors, obtaining prescriptions from providers outside of their scope of practice, presenting with prescriptions for unusual quantities or combinations of medications or very high dosages, presenting to the pharmacy intoxicated, demanding certain types of medications, requesting frequent and early refills, or filling prescriptions only for controlled substances even when accompanied by other noncontrolled prescriptions.5
Effects From Commonly Misused Substances and MedicationsWhen examining a patient’s substance use, it is important to ask about all medications they may be taking (prescription and nonprescription). Initial assessments of substance use can be an uncomfortable conversation for patients. To help establish a trusting relationship, it may be beneficial to address socially acceptable substances, working gradually towards illicit drugs.4 In addition to certain medications, other commonly misused substances include caffeine, tobacco/nicotine, and alcohol. While these may seem harmless to patients since they are legal and easy to obtain, it is imperative for pharmacists to assess patient usage and counsel on the potential negative impacts with frequent and continued use. Stimulants are commonly misused for performance enhancement in academics and athletics; however, patients may not be aware of the risks associated with using these products.7 For example, patients may experience psychosis from stimulants, alcohol, cocaine, and hallucinogens alike. They can also experience psychosis while withdrawing from alcohol or sedative/hypnotic drugs, such as barbiturates or benzodiazepines.4
Mixing medications with alcohol and illicit drugs presents additional dangers that patients need to be educated on. Mixing a medication with another substance can lead to decreased drug efficacy or harmful drug interactions within the body. These interactions can often cause nausea and vomiting, headaches, drowsiness, fainting, or loss of coordination. Internal bleeding, heart problems, and difficulties in breathing are also risks from mixing substances. Alcohol mixed with depressants such as a benzodiazepine can have synergistic effects including dizziness, stumbling, loss of sphincter control, memory loss, and potential death. Mixing stimulants, like methamphetamine, with alcohol can block the alcohol’s effects, making it difficult for patients to gauge their level of intoxication, and can result in overconsumption, significant impairment of coordination and judgment, blacking out, passing out, or a potential fatality. Patients have also been found mixing alcohol with prescription opiates.7 Combining opioids with alcohol can result in slowed or arrested breathing, lowered pulse and blood pressure, unconsciousness, coma, and potential fatality.4
Screening, Brief Intervention, and Referral to TreatmentPharmacists, especially in a community setting, are uniquely positioned to screen patients for SUD and provide brief intervention and referral when necessary. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based approach to identifying patients who use alcohol and other drugs at risky levels, which often goes undetected.8 The goal of SBIRT is to reduce and prevent related health consequences, disease, accidents, and injuries. SBIRT can be performed in a variety of settings and incorporates screening for all types of substance use with brief, tailored feedback and advice. Simple feedback on risky behavior can be one of the most important influences on changing patient behavior.
Patients are first prescreened using short “yes” or “no” questions related to alcohol and drug use. Depending on the prescreening tool used, one or more “yes” responses indicate a positive prescreen, necessitating the need for a full screen. Full screens are individualized and ask a series of validated questions to assess the level of an individual’s substance use. Some questionnaires used include, but are not limited to, the Alcohol Use Disorder Identification Test, the Alcohol, Smoking, and Substance Abuse Involvement Screen Test, or the Drug Abuse Screening Test.8
See TABLE 1 for additional resources and training for pharmacists.
Pharmacist-Led Smoking Cessation Service
The 2020 Surgeon General’s Report on Smoking Cessation highlights the latest evidence on the benefits of quitting smoking.9 Tobacco use and dependence often requires repeated intervention and long-term support to help patients quit. Pharmacists can assist in helping patients by advising them to quit, offering brief counseling, and recommending OTC nicotine replacement therapies and/or FDA-approved prescription medications. Connecting patients to additional resources like a tobacco quit line and frequent follow-ups to help prevent relapse are all roles that pharmacists can play in obtaining information and support necessary for a successful quit attempt.10 Tobacco-treatment training programs are also available to pharmacists and other professionals who would like to become specially trained in providing counseling and treatment to individuals seeking to stop using tobacco.11
Overdose Prevention and Response
Pharmacists also need to embrace their vital role in preventing and responding to opioid overdoses. Opioid overdose deaths, many of which could have been prevented, have risen exponentially over the last 2 decades. An initiative of the Department of Health and Human Services began in 2015 to address opioid- and heroin-related use and overdose deaths, including increasing access and promoting use of overdose-reversing drugs.12 If a known opioid overdose is suspected, naloxone (an opioid antagonist) can reverse the effects of opioids and prevent overdose deaths. Naloxone competes and displaces opioids at opioid receptor sites in the brain to partially or completely reverse opioid depression induced by natural and synthetic opioids.13 Overdose prevention and response trainings are available for pharmacists to learn how to recognize the signs and symptoms of an overdose, recommend the coprescribing of naloxone with all chronic opioid medications, increase naloxone accessibility, and educate the public on its use.14 Depending on state-specific laws, standing orders may be in place that allow pharmacists to prescribe naloxone without a prescription.15
Prescription Drug Monitoring Program
Utilizing a prescription drug monitoring program (PDMP) can help identify patients who may be misusing prescription opioids or other prescription drugs and who may be at risk for overdose. A PDMP is an electronic database that tracks controlled-substance prescriptions. Clinical practice guidelines encourage use of the PDMP prior to prescribing to assess a patient’s history of controlled-substance use. It is possible to improve the way opioids and other controlled substances are prescribed, reducing the number of people who misuse, abuse, or overdose from them, while making sure patients have access to a safe, effective medication therapy. As a public health tool, PDMPs can be used by state health departments to understand the behavior of the epidemic and inform and evaluate interventions. PDMPs can also be used to send “proactive” reports to authorized users to protect patients at the highest risk and identify inappropriate prescribing trends.16
Stigma often stems from the negative thoughts and attitudes in which society perceives patients with an SUD. A patient who feels stigmatized in turn is less willing to seek treatment.
These negative views and stereotyping result in the public exhibiting feelings of fear, anger, and a desire to avoid people with an SUD. Stigmatizing language can also negatively influence healthcare-provider perceptions of people with an SUD, which can impact the care they provide.
When speaking to patients with an SUD, their family, or colleagues, it is important to be mindful in utilizing nonstigmatizing language that reflects an accurate, science-based understanding of SUD and is consistent with a pharmacist’s professional role. Using person-first language and allowing patients to choose how they want to be described aids in maintaining a patient’s integrity. TABLE 2 provides a list of words and terms that should be avoided or used, including why it is necessary. All pharmacists and other healthcare providers should consider using these recommended terms to reduce stigma and negative bias when talking about substance use and addiction.17
SUDs are a major societal issue. Pharmacists, as healthcare providers, play a vital role in actively reducing the negative consequences associated with substance abuse. Pharmacists have unique knowledge about medication safety, management, and monitoring, and they are qualified to serve as leaders in initiatives addressing SUD prevention and education. Screening and engaging in patient conversations about substance use, utilizing harm-reduction strategies, avoiding stigmatizing language, and maintaining competency through continuous professional development training are necessary in SUD prevention, patient education, and assistance.
1. Substance Abuse and Mental Health Services Administration (SAMHSA). Mental health and substance use disorders. April 2020. www.samhsa.gov/find-help/disorders. Accessed March 23, 2022.
2. Barman-Adhikari A, Hsu HT, Brydon D, et al. Prevalence and correlates of nonmedical use of prescription drugs (NMUPD) among young adults experiencing homelessness in seven cities across the United States. Drug Alcohol Depend. 2019;200:153-160.
3. Center for Behavioral Health Statistics and Quality. Results from the 2017 National Survey on Drug Use and Health: Detailed Tables. 2018. www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2017/NSDUHDetailedTabs2017.pdf#page=1282&zoom=100,0,240. Accessed June 9, 2022.
4. Dugosh KL, Cacciola JS. Clinical assessment of substance use disorders. UpToDate. www.uptodate.com/contents/clinical-assessment-of-substance-use-disorders. Accessed March 11, 2022.
5. DiPaula BA, Gasper JJ, Love RC. Opioid use disorders: interventions for community pharmacists. College of Psychiatric and Neurologic Pharmacists (CPNP). 2021. www.cpnp.org/guideline/opioid. Accessed March 11, 2022.
6. National Institute on Drug Abuse. Sex and gender differences in substance use. April 2020. www.nida.nih.gov/publications/research-reports/substance-use-in-women/sex-gender-differences-in-substance-use. Accessed March 11, 2022.
7. National Institute on Alcohol Abuse and Alcoholism. Harmful interactions. 2014. www.niaaa.nih.gov/publications/brochures-and-fact-sheets/harmful-interactions-mixing-alcohol-with-medicines. Accessed March 11, 2022.
8. New York State Office of Addiction Services and Supports. Screening, brief intervention and referral to treatment (SBIRT): a clinicians’ tool for identifying risky behaviors and providing appropriate intervention. www.oasas.ny.gov/providers/sbirt. Accessed March 11, 2022.
9. U.S. Department of Health & Human Services. Smoking cessation: a report of the Surgeon General. 2020. www.cdc.gov/tobacco/data_statistics/sgr/index.htm. Accessed June 9, 2022.
10. CDC. Smoking cessation—the role of healthcare professionals and health systems. February 2020. www.cdc.gov/tobacco/data_statistics/sgr/2020-smoking-cessation/fact-sheets/healthcare-professionals-health-systems/. Accessed March 25, 2022.
11. Council for Tobacco Treatment Training Programs. www.ctttp.org/. Accessed March 25, 2022.
12. Opioid abuse in the U.S. and HHS actions to address opioid-drug related overdoses and deaths. March 2015. www.aspe.hhs.gov/sites/default/files/migrated_legacy_files//56406/ib_OpioidInitiative.pdf.Accessed March 25, 2022.
13. Naloxone. In: Lexi-Drugs. Lexi-Comp, Inc. March 2022. https://online.lexi.com. Accessed March 25, 2022.
14. National Harm Reduction Coalition. Overdose prevention. www.harmreduction.org/issues/overdose-prevention/. Accessed March 22, 2022.
15. NASPA. Pharmacist prescribing: naloxone. January 2019. www.naspa.us/resource/naloxone-access-community-pharmacies/. Accessed March 25, 2022.
16. CDC. Prescription drug monitoring programs (PDMPs). May 2021. www.cdc.gov/drugoverdose/pdmp/index.html. Accessed March 25, 2022.
17. National Institute on Drug Abuse. Words matter - terms to use and avoid when talking about addiction. November 2021. www.nida.nih.gov/nidamed-medical-health-professionals/health-professions-education/words-matter-terms-to-use-avoid-when-talking-about-addiction. Accessed March 25, 2022.
18. Substance Abuse and Mental Health Services Administration (SAMHSA). Screening, brief intervention, and referral to treatment (SBIRT). www.samhsa.gov/sbirt. Accessed March 20, 2022.
19. Substance Abuse and Mental Health Services Administration (SAMHSA). Training materials and resources. www.samhsa.gov/medication-assisted-treatment/training-resources. Accessed March 20, 2022.
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