Pharmacist Ethics and the Four Overdose Crisis Waves

The American Pharmacists Association Code of Ethics states that a pharmacist “promises to help individuals achieve optimum benefit from their medications, to be committed to their welfare, and to maintain their trust.”¹ The profession has maintained an excellent commitment to this role and responsibility when it comes to legend and over-the-counter drugs, and to some extent, nutraceuticals. Have we maintained the same commitment to the opioid crisis that is now extending into more than 20 years of overdoses? Let us examine the opioid crisis in more detail before answering this question. 

We have witnessed an opioid crisis for almost 2 decades. More than 900,000 medication-related deaths have occurred since 1999, with 75% of deaths associated with an opioid.² These death statistics represent a 5-fold increase in opioid-related deaths since 1999.³  

The first wave of overdose deaths was associated with prescription opioids, sometimes combined with other central nervous system depressant medications. With the recognition for greater control of opioid prescribing, these agents became more difficult to obtain, thereby starting a second wave of opioid deaths that began in 2010 with the increased use of heroin. Lower use of prescription opioids continues today.³  

The third wave, which began in 2013, has been marked by large increases in deaths from illicit synthetic opioids (tramadol), especially fentanyl.⁴ There is growing concern with the use of fentanyl contamination of other medications. Fentanyl and fentanyl-analogs (carfentanil, furanylfentanyl, acetylfentanyl) are 50 times more potent than heroin.

The fourth wave involves polysubstances where fentanyl-analogs are combined with non-opioid drugs.⁵ Vulnerable persons purchase these drugs from sources other than traditional pharmacy outlets and then become unexpectedly exposed to these illicit fentanyl products. The Centers for Disease Control and Prevention’s Unintentional Drug Overdose Reporting System (SUDORS) indicates there was a 109% increase in average monthly overdose deaths among people aged 15-24 years between late 2019 and late 2021.⁶ One-quarter of deaths in this group involved counterfeit pills.

What can we do as pharmacists to reduce the morbidity and mortality from the crisis? First, the profession needs to recognize the crisis and take responsibility to affect these toxic drug outcomes. Second, an advertising media campaign encouraging patients to talk to their pharmacists about medications should be launched by retail, professional organizations, and academia. The focus of this campaign needs to be on drug overdoses and medication safety. Third, each and every pharmacist should talk to all of their patients about the opioid crisis; warn patients about the risks associated with taking any medication, whether it be a legend, over-the-counter, nutraceutical, or illicit medication, without first talking to your provider or pharmacist. Our covenant with our patients must be committed to their welfare. Every life is worth saving!

References:

1. Code of Ethics for Pharmacists. American Pharmacists Association. Accessed February 7, 2023. https://pharmacist.com/Code-of-Ethics 
2. The Drug Overdose Epidemic: Behind the Numbers. Centers for Disease Control and Prevention. Reviewed June 1, 2022. Accessed February 7, 2023. https://www.cdc.gov/opioids/data/index.html 
3. Santo L, Schappert SM. Opioids Prescribed to Adults at Discharge From Emergency Departments: United States, 2017-2020. Reviewed January 19, 2023. Accessed February 7, 2023. https://www.cdc.gov/nchs/products/databriefs/db461.htm
4. Understanding the Opioid Overdose Epidemic. Centers for Disease Control and Prevention. Reviewed June 1, 2022. Accessed February 7, 2023. https://www.cdc.gov/opioids/basics/epidemic.html
5. Hogan A. Watch: The ‘fourth wave’ of the overdose crisis. STAT News. December 29, 2022. February 7, 2023. https://www.statnews.com/2022/12/29/the-fourth-wave-of-the-overdose-crisis/  
6. Kuehn BM. Fentanyl drives startling increases in adolescent deaths. JAMA. 2023;329(4):280-281. doi:10.1001/jama.2022.23563