Physician and nurse practitioner perspectives of a modified Routine Opioid Outcome Monitoring (ROOM) Tool
Cynthia Lam 1 2 , Patricia Marr 1 3 , Kori Leblanc
1 2 * , Christine Papoushek 1 3 , Debbie Kwan 1 2 , Beth Sproule 4 , Laura Murphy 1 2
1 University Health Network, Department of Pharmacy, Toronto, ON, Canada.
2 University of Toronto, Leslie Dan Faculty of Pharmacy, Toronto, ON, Canada.
3 University of Toronto, Department of Family and Community Medicine, Toronto, ON, Canada.
4 Centre for Addiction and Mental Health, Toronto, ON, Canada.
Journal of Primary Health Care 15(3) 246-252 https://doi.org/10.1071/HC23022
Published: 13 July 2023
Abstract
The Routine Opioid Outcome Monitoring (ROOM) Tool was developed for use in community pharmacies in Australia. It facilitates pharmacists’ screening and brief interventions regarding an individual’s opioid use for chronic pain. At our academic teaching hospital, the ROOM Tool was adapted to incorporate a communication tool that includes a pharmacist’s assessment and recommendations for primary care providers. This modified ROOM Tool was implemented as part of usual care in our outpatient pharmacies; however, the value to primary care providers is unknown.
The aim of this study was to determine primary care provider perspectives on the modified ROOM Tool.
Focus groups were conducted with primary care providers from an Academic Family Health Team. The focus group encompassed topics related to the positive and negative aspects of the modified ROOM Tool in supporting the care of patients using opioids for chronic pain. Qualitative content analysis of transcripts was performed to identify themes.
Three focus groups were conducted with a total of six participants. Four themes emerged: (i) Facilitators to using the tool, (ii) Barriers to using the tool, (iii) Recommendations for improvement, (iv) Impact of the tool on patient care and safety.
The ROOM Tool paired with the communication tool supports collaboration between pharmacists and primary care providers. The communication tool standardises the approach for communicating the pharmacist’s assessment and recommendations. Recommendations to refine this modified ROOM Tool may increase its utility to primary care providers and enhance the impact on patient care and safety.
Keywords: chronic pain, community pharmacy, facilitators and barriers, medication review, opioid use disorder, opioids, pharmacy practice, primary care.
| WHAT GAP THIS FILLS |
| What is already known: Interprofessional collaboration is an important component of providing optimal care to patients living with chronic pain. Community pharmacists are well positioned to support primary care providers in assessing safety and efficacy of opioid use by patients for chronic pain. |
| What this study adds: The validated ROOM Tool guides community pharmacists to assist in screening, preventing, and reducing harms associated with opioid use. This research shares primary care provider perceptions of a combined communication and ROOM Tool, and highlights an opportunity for community pharmacists to more effectively collaborate with primary care providers when providing care for patients living with chronic pain. |
Introduction
About one in five Canadians experience chronic pain, defined as pain lasting more than 3 months.1 Chronic pain negatively impacts quality of life and is one of the most common reasons patients seek health care in North America.1,2 Unfortunately, many patients experience challenges in receiving timely and appropriate care for this multi-faceted disorder. Management is further complicated by the use of opioids long-term. Even when opioids are prescribed appropriately, there are still risks including opioid overdose, opioid use disorder, cognitive impairment, sedation, and falls.1,2 In addition, there are often risk factors that may increase safety concerns. These factors include depression, anxiety, concurrent benzodiazepine or alcohol use, and advanced age. As a result, it is often challenging for primary care providers (PCPs) to provide safe care to patients requiring opioids for chronic pain.2
Pharmacists are well positioned to assist primary care providers in caring for patients with chronic pain. Pharmacists can help improve pain management and reduce opioid related adverse effects and harms. Patients interact with pharmacists up to 10 times more frequently than they do with their PCPs.3 Pharmacists have the knowledge and skills required to identify and address safety concerns related to opioid use. When concerns arise, they can engage the patient and team to optimise care and safety. A collaborative practice model including pharmacists may help improve pain management and prevent opioid related harms.4,5
In Australia, the Routine Opioid Outcome Monitoring (ROOM) Tool was developed to provide a structured approach to support a pharmacist’s ability to optimise care and safety for patients on opioid therapy. The ROOM Tool is a 12-item screening tool validated for use in community pharmacies for patients using opioids for chronic pain and was embedded into the dispensing software of community pharmacies in Australia.6,7 The tool is composed of questions to assess level of analgesia and impact of pain on physical activity or mobility. In addition, it aids in the identification of potential opioid-related issues requiring further assessment, including opioid-related adverse effects, problematic behaviours, mood, and alcohol use. The ROOM Tool was set up in community pharmacies so that the screening questions were self-completed by patients, followed by pharmacists providing education and written information sheets tailored to each patient’s response. At our multi-site academic institution in Toronto, Canada, the ROOM Tool was reformatted into a paper version and adapted to include a communication tool. The appended communication tool included a template to document the pharmacist’s assessment and interventions, and a template for communication of recommendations to the PCP (Supplementary File S1). This study will refer to the ROOM Tool with the appended communication tool as the modified ROOM Tool. No changes were made to the original validated ROOM Tool. The modified ROOM Tool was implemented as part of usual care in select outpatient pharmacies at our academic institution. PCP perspectives on the use of the ROOM Tool with the appended communication tool (modified ROOM Tool) are unknown.
The aim of this study was to determine PCP perspectives of the modified ROOM Tool. The primary objectives were: (1) identify PCP perspectives of the modified ROOM Tool including aspects that facilitate its use in clinical practice; (2) identify barriers and limitations to the integration of the modified ROOM Tool in clinical practice. The secondary objective was to identify perspectives on the impact of the modified ROOM Tool on patient care and safety. Understanding PCP perspectives will help to inform the utility and value of the modified ROOM Tool. The perspectives may guide future revisions.
Methods
This qualitative study involved focus groups using a semi-structured approach.
The modified ROOM Tool was implemented as part of usual care by community pharmacists in two outpatient pharmacies in August 2020. Patients prescribed opioids for chronic pain for greater or equal to 3 months were eligible. All completed tools were faxed from the outpatient pharmacies to PCPs as part of usual practice. Faxing is a key communication mechanism between community pharmacists and PCPs in Ontario (eg prescriptions, queries). Physicians and nurse practitioners who received a completed modified ROOM Tool by fax or who worked in a primary care setting (eg Academic Family Health Team) were eligible to participate in the study. Participants were recruited via a study invitation letter that was attached to each completed tool from March to July 2021. An individual from the Family Health Team (FHT) leadership, not part of the research team, also emailed the invitation letter to all PCPs involved in this clinic, regardless of whether or not they received a completed tool. Participants received a $50 gift card as a token of appreciation. The study was approved by the University Health Network’s Research Ethics Board (CAPCR ID #20-6347).
Once written consent was obtained, participants were emailed a link to complete an anonymous survey prior to the focus group. The survey included six questions about the participant’s demographics (Supplementary File S2). A semi-structured interview guide (Supplementary File S3) was developed by the study team prior to participant enrolment. Question development took into account three measures often used in quality improvement projects: outcome, process, and balance.8 Outcome refered to the perceived impact of the tool on patient care with respect to management of chronic pain and safety concerns. Process refered to the steps involved in how PCPs receive a tool and take action as needed in response to the information provided. Balance refered to the potential impact on current practice efficiencies such as satisfaction or identification of possible inconveniences or challenges from incorporation of the modified ROOM Tool in usual practice.
An example of an anonymised completed modified ROOM Tool was emailed to participants in advance, and were shared during the focus group. The documents provided a refresher for PCPs who may have not seen the tools recently or provided an example to those who had not seen one before. Focus groups were about 60 min long, conducted over Microsoft Teams©, and facilitated by the project lead (CL). The facilitator was completing clinical training at the site where participants practiced; however, not all participants had previous interactions with the interviewer. The focus groups were audio recorded and anonymously transcribed verbatim; no field notes were taken.
Descriptive statistics were used to report participants’ baseline characteristics. Inductive content analysis was performed to determine key themes. Two independent analysts (CL, PM) coded the verbatim interview transcripts. The two codes were compared, and discrepancies were discussed with a third analyst (LM) to determine a final code key. This key was used by one analyst to recode all transcripts (CL). The three analysts identified themes together. These findings were then brought to the larger study team for discussion and refinement, with no further input from participants.
Results
In total, 14 tools were completed from the implementation date of the modified ROOM Tool in August 2020 to the end of the study recruitment period in July 2021. Four out of these 14 tools were completed during the study recruitment period, and these prescribers were provided a study invitation letter as outlined in the methods. In addition to the individuals who received a completed ROOM Tool, 62 PCPs from the FHT were invited to participate in the study. There was a response rate of about 9% as six individuals participated. All participants were from the FHT and none of them received a completed modified ROOM Tool. The six participants were divided into three focus groups, with two participants in each group. The participants included nurse practitioners, family medicine residents, and staff family physicians with varying years of experience from less than 2 years to over 20 years. Participant demographics are reported in Table 1.
| Characteristic | n (%) | |
|---|---|---|
| Participants from the Family Health Team | 6 (100) | |
| Family physician | 4 (67) | |
| Nurse practitioner | 2 (33) | |
| Level of confidence providing care to patients with chronic pain requiring opioids | ||
| Unconfident | 1 (17) | |
| Neutral | 2 (33) | |
| Confident | 3 (50) | |
| Years of clinical practice | ||
| < 2 years | 2 (33) | |
| 2–5 years | 0 (0) | |
| 6–20 years | 3 (50) | |
| 21 years | 1 (17) | |
Four themes were identified
All participants commented that the pharmacist assessment and recommendations in the communication tool were helpful. Participants reflected that the content appeared similar to current best practice tools. Furthermore, they suggested that the tool facilitated the community pharmacist being recognised as a care partner. Most participants agreed that the document was easy to follow, and everyone liked the tick box format. Most participants expressed that fax would be the most appropriate method of communication. Supporting quotes for subthemes identified can be found in Table 2.
| Subtheme | Sample quotes | |
|---|---|---|
| Comprehensive and valuable information | … this very much fits with like our clinical, the clinic standard opioid monitoring tool that we use for documentation … it kind of looks at side effects and risk factors and how they are functioning … I think it fits well with kind of best practice tools that are out there as well as my current workflow. (Participant 3) | |
| The information that helps with the unknowns for me such as is there another prescriber that I am not aware of … that would be really helpful for me to know because then I could address that with the patient … that is actually dangerous. (Participant 1) | ||
| … it is information and there are actions that maybe happen you know with the pharmacist that I am not as privy to. Like the multiple prescribers, like the duplicate therapies. (Participant 4) | ||
| Enables collaboration between pharmacist and prescriber | I think this is very collaborative and kind of highlights what the pharmacist has done. So, I know what they’ve done as well as opportunities for me to address with the patient … (Participant 3) | |
| Integrated mode of communication | …[fax] works the best because community pharmacies are already accustomed to communicating via fax. And similarly on our end so when fax is received it does get scanned in by our reception team and it goes directly to the patient chart. So, it is a bit of a more streamlined or established process … (Participant 5) | |
| … especially as a provider where I do a lot of shared care with other people … I think going into the patient chart is good … I think emails would get pretty lost. And any communication about patient I think is more effective if it is attached to the patient as opposed to attached to the provider. (Participant 6) | ||
| Ease of use | In general, I think the layout is easy to read … I think it’s nice and clear yes or no. And nice and clear like I can ignore things that weren’t ticked boxed but pay attention to what was ticked boxed kind of thing. So, I think it is relatively clear. (Participant 3) |
Barriers identified and supporting quotes for subthemes are represented in Table 3. All participants agreed that limited time was a key barrier to reviewing the ROOM and communication tools. Several expressed the tool was not succinct. Another key reflection by three participants was that although the tool included important information, it was difficult to identify key action items for the PCP. Half of the participants explained that it would be logistically difficult to communicate questions to the pharmacist who completed the tool. Lastly, two prescribers shared concern that the use of the tools by the pharmacist could cause perceived redundancy in healthcare roles.
| Subtheme | Sample quotes | |
|---|---|---|
| Lack of clarity regarding action items for prescribers | … it’s not clear to me. I’m looking at it, I’m still looking at it, (Laughing). And I am still unsure what I should do … It is a lot of information, unclear of what my action is. (Participant 2) | |
| Form too long | … we will frequently not open four pages, right? It just becomes overwhelming. (Participant 1) | |
| … there are way too many words on this page … I would say that content-wise I want to see 90% less words on the page (Participant 2) | ||
| Administrative and communication barriers | I actually fear that the risk is that this would become very much like those pharmacy reconciliation things like no action required. Well please don’t send this to me. I get 60 faxes a day. I don’t need another one to open if there is no action required. (Participant 2) | |
| … the biggest thing that you could do is be considerate of the time and attention. And I think the shorter you can make it, the more succinct that you could make it, that is all I can repeat over and over again. (Participant 2) | ||
| I am thinking phone or either faxing back and asking for more detail that is a little bit annoying … I don’t always have time to wait on the phone … if it is a simple clarification, sometimes I find that written communication is useful. And probably fax would be the most logical thing. (Participant 3) | ||
| I think again like so fax might be a good way to get one piece of information but for back-and-forth communication it is rather slow. So, I would probably rather call if I had a question specific to the tool. (Participant 6) | ||
| Perceived redundancy in healthcare provider roles | … to have somebody come out of the blue, unless they have a long-term relationship, I think it could cause distress, upset and anger in some patients as to why they are being asked these questions. (Participant 1) | |
| I think for mine, it will not be direct distress for the patient, but … quite frankly an added burden to the caregiver burden of sort of having to work through this, fill this out. And not actually gain benefit because this is stuff that you know, is well within my awareness. (Participant 2) |
All participants provided recommendations for improvement (Table 4). Including information that may be unknown to PCPs and was thought to help guide future management. For example, participants suggested indicating the morphine equivalent (MEQ) breakdown. In order to reduce administrative burden, recommendations to change wording, formatting, and content were shared. Several participants also expressed a desire for the pharmacist to provide further interventions in addition to flagging items for the prescriber to follow-up on.
| Subtheme | Sample quotes | |
|---|---|---|
| Optimise content and format | … knowing how [the MEQ] is broken down if they’ve got multiple agents I think it is helpful. Because sometimes exactly what we have prescribed isn’t actually what they are using as we know. (Participant 6) | |
| … this is a document that flows from page 1 to page 4, page 1 and 2 are done by the pharmacist and then page 3 and 4 have the recommendations, that makes no sense if you want me to look at it. You’ve got to start up front with here is what you need to know, and pages 2 to 5 are FYI. (Participant 2) | ||
| … I have already filled like 26 hours in an average day … I just need clear what do you need me to do. Map it out for me. Tell me I will do it … it would have to be on the front page that there is an action item. (Participant 1) | ||
| … I don’t know if there is a huge value add in [the screen for depression and anxiety] because like you said chronic pain, anxiety and depression like we know that there is a certain component of it. So, I don’t know that … getting a flag back on this is going to necessarily change anything. (Participant 6) | ||
| Enhance pharmacist brief interventions | I do think that for some patients … especially if there is a component of the pharmacist kind of being a care partner in that they are also you know ‘it is probably not great that you are drinking’, or ‘it not great that you are using benzos with your like current opioid because of this’. I feel like that would be a big value add. (Participant 5) |
MEQ, Morphine equivalent; FYI, For your information.
Although the tool may be used for any patient taking opioids for more than 3 months, participants thought it was unlikely to benefit all individuals who meet this criterion. They identified certain populations they thought would receive most benefit from the tool. Participants also acknowledged pharmacists are well-equipped in identifying risk factors for harm related to opioids and engaging in interventions. Subthemes and participants’ reflections can be found in Table 5.
| Subtheme | Sample quotes | |
|---|---|---|
| Prioritise population at greatest risk | I think the way to get the most bang for your buck is in the population that don’t have that regular contact with primary care. (Participant 1) | |
| I can see this being incredibly useful, for those post OR, post ER patients. This would be so helpful to that family doc who isn’t really sure what is happening. They have 1500 patients as opposed to our 700. And it is a slippery slope to be closing that three-month mark, post-operatively and post ER. (Participant 1) | ||
| I can see this being so useful in a different ambulatory younger otherwise unattached population whose doctor has not asked them, are you depressed. (Participant 2) | ||
| Optimise pharmacist role and expertise in improving safe patient care | I think the point of doing this tool is obviously because pharmacists have obviously an expertise in understanding opioid use and risk factors… for example they have said no to RAAM resources from me 10 times … maybe hearing it from someone else or phrased a different way is important. (Participant 6) | |
| … the flag for the pharmacist to self-direct the patient to RAAM is wonderful. And even if the communication to know that they gave that information about accessing RAAM so that I can follow up and see if they actually did … I can follow up on in terms of readiness and things like that if they didn’t access. (Participant 3) | ||
| Harm reduction | … it says here multiple opioid prescribers. Like it is great if pharmacists let me know that in the system there is nobody else prescribing … Naloxone, I think that is a great thought. That is a thought that I don’t have often enough with my chronic opioid users. (Participant 2) | |
| And then the Naloxone kit like in terms of harm reduction, and do they have a Naloxone kit and was it discussed. And did they decline it? (Participant 4) | ||
| … flagging things like duplicate long acting … it may happen if there are multiple prescribers or some confusion … the pattern of requesting for early refills, usually we know that but not always … the urgent or alcohol risk I think if they showed up in withdrawal or things like that. I certainly see value to that. (Participant 4) |
OR, Operating Room; ER, Emergency Room; RAAM, Rapid Access to Addictions Medicine.
Discussion
This study provides rich descriptions from PCP perspectives on the value of the completed ROOM Tool and associated communication tool that included the pharmacists’ assessment and recommendations. The ROOM Tool along with the new communication tool facilitated a collaborative approach to promoting safety for patients receiving opioids for chronic pain.
Participants reflected that this modified ROOM Tool may facilitate a collaborative approach to promoting patient care and safety for patients receiving chronic opioids. Participants recognised that there is information that pharmacists would be more likely to have access to, such as the presence of multiple opioid prescribers. In Ontario, community pharmacists at the point of dispensing receive alerts from the provincial Narcotic Monitoring System regarding opioid prescriptions for a given patient. Furthermore, the tool can foster collaboration and enhance the opioid-related care of the patient, through reinforcement of self-care messages, providing referral to addiction programs, and provision of naloxone kits. This aligns with existing literature describing the positive contributions pharmacists in the community can have on minimising opioid related harms.9 In a study by Jordan et al. it was found that pharmacists are involved in a range of activities that have been established to reduce opioid-related harms. These activities include pharmacist collaboration with prescribers to decrease opioid load, increasing patient uptake of naloxone kits, and increasing patient access to services and therapies for opioid use disorder.9 The modified ROOM Tool provides a structured method for community pharmacists to assess pain control, identify opioid related risks and adverse effects, make brief interventions, and communicate recommendations to PCPs. The goal is that completion of the ROOM Tool and communicating the assessment and recommendations can ultimately help to decrease opioid-related patient harm. This supplements existing literature that has also demonstrated the value of pharmacy-based clinical assessment tools aimed at reducing opioid related risks.10 In a study by Strand et al., a tool was developed and implemented in community pharmacies to provide pharmacists with a more structured approach to identify and provide care for patients who may be at risk of opioid use disorder, and a structured method to communicate with PCPs.10
Not surprisingly, the lack of time to review the tools, along with administrative burden, were the most significant barrier. This was an expected finding given how commonly PCPs are overwhelmed with a large volume of faxes, notes, and other forms of communication.11 A repeated recommendation was to make the tools more clear and concise. Participants recommended that a summary list of action items be given to the PCP on the front page of the communication tool. This may help ensure the value of the tools without adding significant administrative burden.
There were also concerns regarding the potential for perceived redundancy in healthcare provider roles to patients – that patients who had an already established strong therapeutic relationship with their PCPs may question the need to participate or feel distressed or burdened by repeating their chronic pain experiences with the pharmacist. Furthermore, an unexpected finding was that select participants believed the screen for depression and anxiety had low value, citing that they follow their chronic pain patients regularly and would be aware of changes in mood status. However, this may not be the case in other settings. There was a suggestion to focus completion of the tool on more vulnerable groups including patients who do not have a PCP, or patients recently discharged after surgery or from the emergency department. This suggestion was not unexpected given that it is not uncommon for opioid naïve patients to be prescribed opioids after surgery and to continue taking them beyond 3 months.12 Existing studies have suggested that the time after surgery is a vulnerable period for opioid naïve patients to be at risk of developing opioid use disorder.12,13
These reflections may point towards prioritising completion of the modified ROOM Tool for specific patients or implementation in certain geographical areas, attempting to identify patients with the greatest potential to benefit from the intervention. However, the feasibility of identifying these patients, particularly for community pharmacists, may be challenging. Furthermore, despite participant reflection that patients with an established therapeutic relationship with a PCP may not benefit as much from this tool, research has shown that a collaborative model for caring for patients living with chronic pain is essential for optimising effective and safe care.14 It is possible that with wider implementation and more feedback from primary care partners, it may be more valuable for community pharmacies to have a structured, inclusive approach to completing the modified ROOM Tool. A standard, structured approach may also help to reduce the stigma of completing a questionnaire related to opioid use.
A unique feature of this study is that it explores PCP perspectives on a tool that is completed specifically by another health care provider. This is new, given most literature to date focuses on screening tools primarily used by PCPs (eg Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition or DSM-5) and not necessarily an interprofessional team member such as pharmacists. Furthermore, opportunities for improvement of the tool were identified, and detailed recommendations were provided. Consequently, the results provide rich information on how the communication of pharmacist assessment and recommendations after completion of the ROOM Tool can be refined and optimised in the next stages of this research.
This study had several limitations. None of the participants had personal experience with a completed tool for one of their own patients. Given the small number of participants in this study, there was a potential risk of not reaching data saturation. However, the data analysts did not identify any new or emergent themes by the third interview, suggesting that data saturation was reached. All participants were from the same urban, academic, and group practice site. As a result, findings may not encompass perspectives from those who work in other primary care sites, in specialised clinics (eg ambulatory oncology, pain clinics), and in other geographical areas with different demographics (eg other urban or rural communities).
Future research that includes participants who have received a completed tool for their own patient, and who work in other practice sites, would be beneficial. Perhaps even more importantly, patient perspectives on their experience of the discussion and intervention are also needed. This would further inform how the tool can be refined to be more effective and provide greater impact in settings beyond ours.
Conclusion
This study identified PCP perspectives on facilitators, barriers, and value of a pharmacist completed ROOM Tool and communication tool. Overall, this study demonstrated this modified ROOM Tool may support collaboration between the pharmacist and PCP to improve care and safety for patients prescribed opioids for chronic pain. Opportunities to refine the communication tool were identified and will be used to guide revisions.
Acknowledgements
The authors thank the pharmacists, nurse practitioners, and physicians who participated in this study. Thanks to Dr Benjamin Kassa as well for providing input to the study.
References
1 Canadian Centre on Substance Use and Addiction. Prescription Opioids. Canada: Canadian Centre on Substance Use and Addiction; 2020. Available at https://www.ccsa.ca/prescription-opioids-canadian-drug-summary [updated 2020; cited 28 November 2021].
2 Harle CA, Bauer SE, Hoang HQ, et al. Decision support for chronic pain care: how do primary care physicians decide when to prescribe opioids? a qualitative study. BMC Fam Pract 2015; 16: 48.
| Crossref | Google Scholar |
3 Giannitrapani KF, Glassman PA, Vang D, et al. Expanding the role of clinical pharmacists on interdisciplinary primary care teams for chronic pain and opioid management. BMC Fam Pract 2018; 19: 107.
| Crossref | Google Scholar |
4 Tsuyuki RT, Beahm NP, Okada H, et al. Pharmacists as accessible primary health care providers: review of the evidence. Can Pharm J 2018; 151(1): 4-5.
| Crossref | Google Scholar |
5 Iqbal A, David Knaggs R, Anderson C, et al. Role of pharmacists in optimising opioid therapy for chronic non-malignant pain; A systematic review. Res Social Adm Pharm 2020; 18: 2352-2366.
| Crossref | Google Scholar |
6 Nielsen S, Kowalski M, Wood P, et al. Routine opioid outcome monitoring in community pharmacy: pilot implementation study protocol. Res Social Adm Pharm 2019; 15(8): 1047-1055.
| Crossref | Google Scholar |
7 Picco L, Middleton M, Bruno R, et al. Validity and reliability of the computer-administered Routine Opioid Outcome Monitoring (ROOM) tool. Pain Med 2020; 21(12): 3645-3654.
| Crossref | Google Scholar |
8 Quality improvement primers. ON, Canada: Queen’s Printer for Ontario; 2013. Available at http://www.hqontario.ca/portals/0/documents/qi/qi‐science‐primer‐en.pdf
9 Jordan M, Latif A, Mullan J, et al. Opioid medicines management in primary care settings: a scoping review of quantitative studies of pharmacist activities. Br J Clin Pharmacol 2021; 87(12): 4504-4533.
| Crossref | Google Scholar |
10 Strand MA, Eukel H, Burck S. Moving opioid misuse prevention upstream: a pilot study of community pharmacists screening for opioid misuse risk. Res Social Adm Pharm 2019; 15(8): 1032-1036.
| Crossref | Google Scholar |
12 Clarke H, Soneji N, Ko DT, et al. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ 2014; 348: g1251.
| Crossref | Google Scholar |
13 Burcher KM, Suprun A, Smith A. Risk factors for opioid use disorders in adult postsurgical patients. Cureus 2018; 10(5): e2611.
| Crossref | Google Scholar |
14 Dubé P-A, Vachon J, Sirois C, et al. Opioid prescribing and dispensing: experiences and perspectives from a survey of community pharmacists practising in the province of Quebec. Can Pharm J 2018; 151(6): 408-418.
| Crossref | Google Scholar |
