Expert: To curb synthetic opioid deaths, a multipronged approach is necessary

BUFFALO, N.Y. — Opioid abuse and addiction, a crisis that has surged across the United States over the last two decades, has resulted in hundreds of thousands of fatal overdoses.

There is a sliver of good news: deaths attributed to synthetic opioids, such as fentanyl, dropped slightly nationwide in 2023, the first decrease in five years, according to a recent report from the National Center for Health Statistics. Some attribute this, at least partly, to the increasingly availability of naloxone (brand name Narcan), a drug that reverses opioid overdoses.

Edward Bednarczyk, clinical associate professor in the Division of Outcomes and Practice Advancement in the University at Buffalo School of Pharmacy and Pharmaceutical Sciences, has studied opiates for years and points to other efforts that have contributed to this tentative turnaround. They include opioid prescription databases and better monitoring of patients by physicians and pharmacists. Online trainings for prescribers, which UB helped initiate in New York state, is another important tool in the arsenal fighting opioid misuse.

UB’s online training program

In 2017, Bednarczyk led a team of UB pharmacy researchers to develop a four-hour accredited training program for all licensed professionals in New York who have a Drug Enforcement Administration authorization to prescribe controlled substances.

Now called the Opioid Prescriber Education Program, the training includes state and federal requirements for seven areas: prescribing controlled substances, pain management, appropriate prescribing, managing acute pain, palliative care, prevention, and screening for signs of addiction.

The program is funded by the Centers for Disease Control and Prevention, supported by the New York State Department of Health and accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

By the beginning of July 2017, almost 32,000 participants had completed the first training module, followed by almost 30,000 for the second one, the majority of whom originated in New York state.

“Our primary objective was to answer the question: Would a large-scale, enduring, online training program administered in an academic environment be feasible?” he explained. “We found that the doctors, pharmacists, nurses and others who went through the program demonstrated an increased knowledge afterwards.”

In one module, developed by Robert Wahler, clinical associate professor of pharmacy practice, they trained pharmacists to recognize people who are at risk for opioid dependency or overdose, based upon the number of pills they were getting, along with other factors.

“In this training, we also taught pharmacists how to counsel those patients,” Bednarczyk said, adding that they were advised to give a patient a few doses of naloxone to take home.

The two-part program was updated in 2023 into one comprehensive new program. Since its inception, more than 90,000 prescribers have completed the training, which is ongoing.

 “I’d love to say that all this training has made the opioid crisis go away,” he said, “but it’s much more complicated than that.”

Tracking opioid prescriptions for more than 100 years  

New York started monitoring prescription drug use long before the contemporary opioid crisis or the digital world in which we live.

In 1914, New York established a short-lived system to track prescriptions of opiates under the Boylan Act, according to the National Center for Biotechnology Information. It required prescribing physicians to submit duplicate prescription forms to a centralized state database, at a time when many providers were considered “over-prescribers” of opioids. Those safeguards were relaxed a few years later with the passage of the Whitney Act, which was prompted by concerns that supply-side restrictions were fueling the illicit opioid market.

In the ensuing years, New York, along with many other states, adopted a prescriptions drug monitoring program (PDMP) as electronic databases that track controlled substance prescriptions from health care providers on a state level. PDMPs are designed to keep pharmacists and physicians in the loop and patients from obtaining opioids from multiple providers, a practice known as “doctor shopping.” Missouri became the 50^th state to adopt a statewide database in 2021.

While the databases have definitely made a small dent in the opioid crisis, Bednarczyk noted it’s just one tool.

‘The fifth vital sign’

Bednarczyk began studying synthetic drugs and opioid receptors in the early 1990s, soon after arriving in Buffalo.

He noticed public service advertisements cropping up everywhere from medical facilities to bus shelters, touting “Pain as the 5th vital sign.” The campaign was intended to encourage physicians to listen to patients’ often untreated and ignored pain.

“Everybody thought these painkillers were as safe as mother’s milk,” he said. “And somehow along the way, we lost track of a couple of things. We forgot that morphine, when it was first introduced, was touted as being safer and far less addictive than opium. But it was replaced by another drug that was promised to be less addicting and more efficacious than morphine. And that was heroin.”

By the beginning of the 2000s, doctors started prescribing Oxycontin and other painkillers in large numbers; fentanyl followed and made an insidious path onto the streets.

Relationships between prescribers and pharmacists

While in some communities, tight relationships between prescribers and pharmacists help keep tabs on opioid prescription abuse, that often isn’t the case in big cities, even with the databases, he said.

“If someone is rotating through six pharmacies and seeing a physician while also rotating through six emergency rooms, it’s very challenging,” he said. “In hectic settings, it’s difficult to make the databases work.”

At the same time, physicians and dentists are becoming much more restrictive on the number of pain meds they’re prescribing at once.

“While it used to be 60 pills for one procedure, they’re often giving the patients just enough to make it until Monday,” he said. “Then they’ll follow up in the office if needed. That’s progress. The problem is when people run out of their prescription, they find the pills on the street. And when they take one pill too many they’re dying — everywhere from Washington, D.C., to rural Ohio.”

Progress still to be made

While the drop in synthetic opioid deaths is encouraging, Bednarczyk noted that more widespread treatment programs are still needed.

“Let’s say we bust the person who is doctor shopping. We may have stopped him from getting another prescription, but we haven’t fixed him. He’s still addicted,” he said. “We need to get people to the point where they can handle their addiction.

“I think we’ve made a meaningful dent in the mis-prescribing of opioids. And I think that we’ve done a much better job of managing patients’ pain,” he said. “However, we see a whole bunch of new drugs that are being blended with fentanyl. While deaths may plateau or even drop, we need to keep an eye on this.”

Stopping patients from doctor or pharmacy shopping is only one step. Obviously, he said, if the person is addicted, having adequate and available treatment options is a needed piece for a lasting solution.

“It’s not time to declare victory,” he added, “but to look at new ways to look at the misuse of opioids and have more available and timely treatment options.”