Wilkes Faculty, Students and Alumni Lead the Charge Against the Opioid Epidemic
By Vicki Mayk MFA’13
When Tom Franko talks about the impact of the United States’ opioid epidemic, he likens it to an image from a popular 1980s film. “It’s like the picture of the family from the film Back to the Future,” says Franko, as assistant professor of pharmacy practice in Wilkes, Nesbitt School of Pharmacy. “As people look at the picture, one person’s image fades until it disappears. That is what addiction is like. It is a disease of isolation, separating people from their families, their jobs, everything that is important to them.” Franko says he and his colleagues in pharmacy are uniquely positioned to play a key role in the deadliest drug crisis in American history.
“Our main goal is to change the education of pharmacists for the future so that they can be successful and better handle the condition,” Franko states. “I believe that the profession that is going to have the 100 percent greatest impact in dealing with this is the pharmacists. We’re the ones who are going to take charge.”
He cites two reasons for that claim: pharmacists’ accessibility in most communities and the profession’s emphasis on patient education.
“In every single town across the country, there are probably five things: a church, a McDonald’s, some type of Chinese restaurant or pizza place, a funeral home and a pharmacy,” Franko says. Educating patients about prescription drugs is an important part of the pharmacists’ role, so involving them makes sense, he adds. Schools of pharmacy, like the one at Wilkes, can help make that happen.
In the last two years, Franko led efforts addressing pharmacists’ role in an epidemic that was declared a public health emergency in October 2017 by President Donald J. Trump. Franko co-chairs the education committee for the pain, palliative care and addiction special interest group of the American Pharmacists Association. In that position, he is involved in recommending certification programs and education that could impact the profession nationwide.
In the past two years, he and his students have presented continuing education events about the opioid crisis in northeastern Pennsylvania, initiated research projects related to improving pharmacists’ training to administer the anti-overdose drug naloxone, and joined with faculty colleagues to involve student pharmacists in drug take-back programs, education and training efforts.
Pharmacy isn’t the only Wilkes academic program preparing students to deal with the opioid issue after graduation. The Passan School of Nursing in April 2016 was among 191 nursing programs in the nation recognized by the White House for its early commitment to requiring advanced-practice registered nursing students to take some form of prescriber education by the time they graduate. Undergraduate nursing students learn about opiates and the use of naloxone in the junior-level Pharmacology course and as seniors in the Advanced Care Concepts class. Nurses in graduate-level courses also cover the material, and those earning master’s degrees to become nurse practitioners who can prescribe medications must complete a minimum number of state-mandated education hours covering pain management, addiction and prescribing or dispensing opioids. Addiction and related issues also are examined in criminology, psychology and neuroscience classes.
Preparing students to deal with the issue makes sense. According to an October 2017 story in The New York Times, overdoses—which have risen dramatically in recent years due to opioids—are the leading cause of death for Americans under 50, outpacing deaths caused by guns or car accidents. A report for The National Institute on Drug Abuse, part of the National Institutes of Health, states that 115 Americans die each day after overdosing on opioids. Wilkes graduates entering health-care, law-enforcement and human-services careers in the next decade will deal with the epidemic and its related health and social issues.
According to the Centers for Disease Control, 18 out of 100 Americans have used illicit drugs or misused prescription drugs.
Associate Professor Andrew Wilczak cites additional reasons for discussing the issue with students in his criminology classes.
“I think it’s important for students in my major to study this because, not only is it something they’re going to encounter in their careers, it’s also something they’re likely to encounter in their personal lives, if they haven’t already,” Wilczak says. “It helps provide more context to what they’ve experienced, it helps them recognize that they aren’t the only people in their situation, and it helps them see that there are ways for people to get better. It shows them that healing and redemption are possible.”
ANATOMY OF AN EPIDEMIC
Franko’s interest in the opioid epidemic grew out of his work as Geisinger Health System’s first pain management pharmacist. He experienced firsthand the delicate balance involved in managing chronic pain—from prescribing appropriate medications to using treatments such as physical therapy. He acknowledges that chronic pain is difficult to manage while still ensuring a patient has a good quality of life. Too often in the past, the goal was most easily achieved by prescribing opioids.
Several factors that Franko calls “a perfect storm” led to the opioid crisis of today. It included drug company marketing of opioids—particularly the medication OxyContin—as safe and non-addictive. It was compounded by dramatic increases in prescribing opioids and the designation of pain as “the fifth vital sign” in evaluating patients’ conditions by the Veterans Administration and the Joint Commission on Accreditation of Healthcare Organizations.
“The Joint Commission tied hospitals’ financial reimbursement to pain control,” Franko explains. When patients evaluated the care they received, one measurement was how effectively they felt their pain was managed. Hospitals felt the pressure to get a good score.
More people received more opioid pain medication for longer periods. Opioids act on the nervous system to relieve pain, and they can lead to physical dependency. Physical dependency— different than addiction—can cause patients to continue the drug long after the need for it has passed. People who have become dependent develop a physical tolerance that can cause them to experience severe, unpleasant symptoms if they abruptly stop taking it. Pharmacists trained in pain management understand that there are appropriate ways to wean people off the drugs. Every person is different.
“It’s the worst flu that you’ve had plus the worst panic attack that you’ve had, combined at the same time,” Franko says, describing the symptoms of an opioid-dependent person suddenly stopping the drug. “It won’t kill you, it’s totally safe, but you will want to die. They will feel like garbage if you do not appropriately wean people.” Heroin, cheap and obtainable without a prescription, becomes a next step for some severely dependent people. Eighty percent of the people using heroin got their start using a prescription medication, Franko says. They may be addicted or dependent on opioids.
More recently, the introduction of the synthetic opioid, fentanyl, has further complicated an already critical situation. The drug, which is relatively inexpensive to manufacture, is said to be 50 to 100 times more potent than morphine.
The United States uses the largest share of the world’s opioids.
WHEN DEPENDENCY BECOMES ADDICTION
At the most basic level, addiction is when a person uses a drug, alcohol or even an activity—such as gambling—to excess, regardless of consequences. The American Society of Addiction Medicine states that “addiction is a chronic relapsing disease of the brain which affects multiple aspects of a person’s life.” Edward Schicatano, professor of psychology and director of Wilkes’ neuroscience program, covers addiction in two neuroscience classes: Psychopharmacology and Behavioral Neuroscience. His students learn that when someone becomes addicted to opioids, or any other drug, the brain literally undergoes a neurological change. “And once it changes, it’s hard to change it back,” Schicatano says. “The changed brain is what triggers the uncontrollable cravingthat tells an addicted person that they must have a drug.”
Research suggests that severe stressors early in life—sexual abuse, a trauma experienced in utero—may trigger a genetic pattern predisposing some to addiction. The result is the same. “In addiction, the brain is saying, ‘Without this—the drug, the act of gambling, whatever— you die.’ That’s what the brain says to the addict. They can’t give it up,” Franko says.
Franko and Schicatano agree that addiction isn’t restricted to a particular socio-economic group. People of all ages, races, occupations and backgrounds are part of the opioid crisis.
WILKES BECOMES A REGIONAL LEADER
In March 2017, President Trump established The President’s Commission on Combating Drug Addiction and the Opioid Crisis. The commission’s report included 56 recommendations, ranging from screening and treatment programs to research.
- promoting programs aimed at opioid addiction prevention,
- better prescribing guidelines for opiates,
- training health-care professionals to screen for substance use,
- training pharmacists on best practices to evaluate legitimacy of opioid prescriptions,
- establishing more medication “take back” initiatives to collect prescription drugs when no longer needed, and
- broader use of the overdose reversal drug naloxone by emergency medicine and other health-care providers.
In 2016, the five states with the highest rates of death due to drug overdose were West Virginia, Ohio, New Hampshire, Pennsylvania and Kentucky.
By the time the recommendations were issued, faculty and students in the Nesbitt School of Pharmacy, joined by colleagues in nursing, had already worked for more than a year, implementing projects to combat the problem. Students involved in the student chapter of the American Pharmacists Association embraced its Generation Rx initiative to combat the problem. A key part of that work included medication take-back programs and community education. Learning to screen for possible addiction is part of courses for students in pharmacy and nursing. (See sidebar on student involvement on page 25.)
One key community education effort happened in February 2017. A class focusing on addiction and substance abuse was offered by Wilkes Continuing Education. Aimed at health-care professionals, first responders and social workers, it was taught by Franko and Eugene Lucas, an assistant professor who teaches in the Passan School of Nursing’s Doctor of Nursing Practice program. It drew more than 60 attendees, leading the University to offer the Pain and Addiction Summit in spring 2018. (See box on page 27.)
At the continuing education program, Lucas, whose clinical practice in psychiatric mental health nursing includes treating addiction, covered new Pennsylvania requirements for monitoring narcotic prescriptions, including prescriber guidelines. Franko’s portion of the program focused on opioid overdose and on administering naloxone, a drug that reverses the effects of overdose.
Franko’s community presentation mirrored training that he is piloting with Wilkes student pharmacists as part of their Care Lab. Pennsylvania, like a number of other states, has issued a standing order for naloxone as part of combatting the opioid crisis. A standing order means that the prescription drug, known by the brand names Narcan and Evzio is available to anyone. It is administered primarily by inhalation. Franko says that in Pennsylvania the only required training for pharmacists for administering naloxone is an online program. Noting that pharmacists are required to complete hands-on clinical training to administer flu shots and other immunizations, Franko believes similar training is in order for naloxone.
Working with students Lauren Lewis and Danielle DiStefano, a hands-on simulation was developed for the pharmacy Care Lab. In the training, the student pharmacist enter an
“apartment” in the nursing simulation center to find a “patient” who has overdosed lying on the floor. While another student plays the role of an hysterical “friend,” the pharmacist must locate the naloxone and administer it while following the required steps. To maintain legal immunity, those steps include calling 911, administering naloxone “in good faith,” staying with the patient until help arrives, and having completed the required training. In their Wilkes simulation, students check a patient’s breathing and, after administering the drug, place the patient on his or her side. (See photos below.)
Franko is in the second year of piloting the hands-on training, which he hopes eventually will be adopted by other schools of pharmacy. He has done one presentation about it at a national conference. He also is engaged in other research to assess a more challenging issue: pharmacists’ knowledge about administering naloxone and their attitudes toward using the overdose-reversing drug. He acknowledges that some pharmacists have mixed feelings about the degree to which they want to become involved with addicted individuals. By arming Wilkes student pharmacists with talking points about the issue while they are completing their community pharmacy rotation, he is hoping to change some attitudes.
It’s important, he says, because pharmacists are needed to combat the epidemic. “We are the ones to take the lead.”
STUDENT PHARMACISTS BECOME EDUCATORS AND ACTIVISTS
Third-year Wilkes pharmacy student Alex Ponce has spent most of the last two years involved in professional activities related to the opioid crisis. He became active through
the Generation Rx initiative of the American Pharmacy Association. The program focuses on educating people about the potential dangers of misusing prescription medications. In 2016, Wilkes pharmacy professor and associate pharmacy dean Jennifer Malinowski received a grant in partnership with Geisinger Health System to develop community education and medication take-back events. Ponce became the student lead on the project, which eventually earned Wilkes’ student chapter of the association regional chapter of the year honors for its outreach.
The award-winning work carried out by Ponce and other student pharmacists included community medication take-back events— including one at Pittston High School that impacted more than 900 people. Ponce and his peers also tried novel approaches such as partnering with funeral homes to collect medications from families of the recently deceased and staffing a drive-through medication take-back day. Under the same project, Wilkes student pharmacists worked with the art department at Pittston Intermediate
School near Wilkes-Barre, helping students design posters illustrating proper medication disposal.
Recently Ponce has served as the student coordinator for the University-sponsored pain and addiction summit. In March, he joined Thomas Franko, assistant professor of pharmacy practice, in presenting a poster highlighting research they conducted on pharmacists’ attitudes about dispensing the anti-overdose drug naloxone at the American Pharmacy Association conference. Not content with what he was already doing, Ponce founded a student-initiated committee in the Nesbitt School of Pharmacy. Started in fall 2017, the Opioid Epidemic and Addiction Committee drew more than 30 students interested in starting their own projects related to the opioid issue.
Although Ponce was a bit surprised by the level of interest from his peers, he’s clear about why student pharmacists should be involved. “It’s a growing epidemic, but we still don’t have many solutions,” Ponce says. “Because we’re pharmacists dispensing medication, our obligation—as well as doctors’—is to see people use opioid medications as prescribed.”
Although it’s difficult to summarize all of the students’ involvement, the following are examples of student initiatives:
- Fourth-year student pharmacist Danielle DiStefano co-chaired the Generation Rx initiatives with Ponce. She also partnered with Lauren Lewis, another fourth-year student, to create the naloxone training program being piloted in the Nesbitt School of Pharmacy. The training was first presented to health-care professionals at a February 2017 event presented by Wilkes Continuing Education at Mohegan Sun in Wilkes-Barre.
- Second-year pharmacy students Jenny Lee, Brittany Atherholt, Sarah Ahearn,Austin Paisley, Lauren Albright and Quan Nham developed a training for the Wilkes Public Safety Department to teach officers how to administer the anti-overdose drug naloxone. The project was developed as part of a community outreach requirement for first-year student pharmacists in the Foundations of Pharmacy course.
- Mia Lussier, a second-year student pharmacist, is starting the “Luzerne County Faces of Addiction” campaign, which aims to raise awareness of the effects of addiction—all through the power of story. Lussier is working with a joint opioid epidemic and addiction committee on the campaign. The project will include sharing videos, voice memos and written stories about those who face addiction or those impacted by it, such as friends and family members.
- Fourth-year pharmacy students working with faculty member Jennifer Malinowski developed medication protocols for substance abuse disorders at the Wright Center for Primary Care. The project helped to earn Malinowski the 2017 Innovations in Teaching award sponsored by the American Association of Colleges of Pharmacy.
- Bethany Chmil, who attended the American Pharmacists Association Institute on Alcoholism and Drug Dependencies, presented on naloxone to the University’s Substance Abuse Task Force.
WILKES SPONSORS PAIN AND ADDICTION SUMMIT
Wilkes University took a leadership role in northeast Pennsylvania in educating about the opioid crisis when it presented the 2018 Pain and Addiction Summit in April. New York Mets All-Star pitcher and keynote speaker Dwight “Doc” Gooden was one of baseball’s brightest stars of the 1980s until his career was sidetracked by addiction. The continuing education event brought together medical, legal, and law enforcement professionals to discuss the current state of the opioid crisis, share methodology and interprofessional approaches to deal with critical issues, and identify opportunities to approach the treatment of pain and substance abuse.