By: 2020 FIP Publications Team
Content Warnings: addiction, opioids, and overdose.
About the Documentary
“The Pharmacist” is a Netflix documentary released on 5 February 2020 that follows the story of Dan Schneider, a Louisiana pharmacist investigating his son’s death while unraveling the tangled web of corruption underlying the opioid epidemic in his community. Five pharmacists from the FIP YPG Publications Team engaged in a virtual roundtable to discuss the documentary and offer their perspectives as young pharmacy professionals. [Warning: this article is not spoiler-free!]
About Us
[BF] Barbrakaryne Nchinda Fobi, PharmD, MPH, CPPS, FISMP
Medication Safety Specialist, United States
[SM] Saurabh Mamtani, PharmD
Clinical Pharmacy Intern, India
[EO] Etashe Okpola, B.Pharm
Clinical Pharmacy Intern, Nigeria
[CO] Chidinma Omereji, B.Pharm
Hospital Pharmacy Intern, Nigeria
[LO] Leah Osae, PharmD
Public Health Advisor & MPH Student, United States
Episode 1 of this series largely introduces us to who Dan Schneider is as a person, which is a man who will never stop seeking justice for the death of his son, Danny Jr. Dan’s unrelenting one-man investigation tactics proved effective as he not only finds his son’s murderer, but also unveils the smoking gun in a larger opioid case investigating an alleged pill mill run by local physician Dr. Jacqueline Cleggett — we will get to that later.
First, we start with Danny Jr.’s death which resulted from a crack-cocaine deal gone wrong, a hidden struggle that devastates the entire Schneider family. Early on, Dan admits that “addiction was not spoken of in pharmacy school” and was not “something we thought we’d have to face” back in his day. As a young pharmacist today, how do you feel about your own education and training about opioids and addiction?
BF: While I was introduced to the opioid crisis through school, drug dependency and addiction was taught as a characteristic of certain drug types — controlled substances. Controlled substances were defined based on their extent of causing addiction or dependency. Addiction was not taught as a disease condition, but it was just mentioned as part of a definition of the scheduled drugs. Since the role of pharmacist in helping to reduce this epidemic is multifaceted including but not limited to counseling on opioid risks, naloxone dispensing, education on opioid storage and disposal, opioid deprescribing, and providing resources for addiction treatment, I feel like I need more training and education to embody these roles.
SM: India is referred to as an opioid paradox. It has been the largest opioid medicine producer in the world, yet opioids have been out of reach for a large number of the population in India. This was because of the stringent laws regulating pharmaceuticals in India (1985’s Narcotic Drugs and Psychotropic Substances Act [NDPS] and 1988’s Prevention of Illicit Trafficking in Narcotic Drugs and Psychotropic Substances Act). These stringent laws included a 10-year mandatory minimum prison term for violations involving narcotic drugs. These laws were revised crucially in 2014, and amendments recognised the need of opioid-based pain relief in the Indian market and liberalised its regulation in India.
Due to these tight regulations, we had never imagined opioid addiction as a real problem in the Indian population, and hence there was no particular focus on education and training about opioid addiction in my pharmacy school. We were taught about its medicinal use, antidotes, and its addiction potential, but we were told not to worry about its addiction potential as these are very highly regulated drugs and so uncommon to be prescribed for self-use. Now the rules and regulations are much more liberal compared to the previous era, and I feel that now we require to inculcate a more comprehensive opioid addiction management program right from the university level before it becomes an epidemic in India.
EO: There’s this thing I term the gap-effect in learning. When we learn something new, it typically should be accompanied by practice. Which creates a pathway for building familiarity within a particular subject matter. The absence of familiarity means that, after a while, old information fades off our memory to make room for newer ones. I describe the gap effect in learning as the disconnection between what we learn and what we know about a particular subject matter.
I would say that my education on opioids has been sufficient but I wouldn’t say the same for my training on addiction. And this is where the gap comes in — the knowledge gap that accompanies an absence of front-line experience. Addiction isn’t really prioritized. And this act of prioritizing could depend on the large-scale intervention demand that is posed by more common endemic diseases — such as Malaria — in Nigeria.
CO: In contrast to Dan Schneider’s education and training, I was taught about opioids and addictions. As a matter of fact, opioids were never taught without discussing its addiction tendencies.
Also, with opioid addiction being an already existing silent epidemic in my society, I knew I would have to face it. So I will say that I was well prepared in the course of my training to face opioid addiction.
LO: Most of my personal experience with opioids comes from training in ambulatory care settings. It was not unusual to come across patients in outpatient clinics who chronically used opioids — some displayed signs of addiction and some did not.
Most physicians and nurses were receptive to having us provide naloxone to higher risk patients, like those receiving long-term opioids and benzodiazepines. Deprescribing and building opioid tapers are far more daunting for me, particularly in cases where patients are resistant and show signs of addiction. Getting a patient’s buy-in to taper off their opioid is a huge obstacle in itself.
Over the course of the documentary, Dan transitions from trying to find his son’s killer to investigating Dr. Cleggett after repeatedly receiving suspicious opioid prescriptions from her practice. In your own community, do you consider opioid use to be a growing, a neutral, or an improving public health issue? How does opioid misuse and addiction affect your own work as a young pharmacist, if at all?
EO: From my perspective, the country is at the early stages of an endemic ladder, when it comes to the abuse of opioids. There has been a growing trend in the non-medical use of prescription opioids (mostly tramadol) across several states within the country. And from previous experience in the clinical field, reports of opioid abuse by physicians have also been documented. This has led to the implementation of newer prescribing guidelines, to curb both doctor shopping and patient dependency on opioid substances.
CO: In my community, I consider opioid use to be a growing public health issue because its rate has increased over time and so far — and to the best of my knowledge — not much work has been done to curb it.
Opioid misuse and addiction affects my work as a pharmacist, especially when practicing in a community pharmacy. In my country, we have patent and proprietary medicine vendors (PPMVs) who are allowed/licensed to sell only over-the-counter drugs since they are not pharmacists. They are commonly referred to as “chemists”.
Oftentimes, these people illegally dispense prescription drugs such as opioids and other drugs of abuse to their clients. The drug abusers are aware that most pharmacists/pharmacies will not dispense these drugs to them without a prescription, so they resort to patronising the PPMVs or other sources for the drugs. This in turn makes the people with addiction ignore pharmacists and whatever advice we may have to offer, as they have alternatives, thereby frustrating our efforts to curb it.
BF: Opioid use is not an improving public health issue. In my opinion, it is getting worse. On one hand, laws put in place to curb addiction are not respected by all. On the other hand, patients get frustrated with very strict laws and turn to street drugs like heroin. As a young pharmacist, the current opioid crisis affects my work by making it hard for me to find a balance between what is safe and what is ethically right. At work, I am faced with customers trying to refill their opioid sooner than expected. When you try to ascertain why they need to refill their prescriptions, you hear stories like “my dog ate all of my pills” or “it was stolen”. Since most customers do not present a police report nor a note from their vet, I am left at the junction of lies versus truth, joggling between refusing to fill a prescription for safety reasons or filling the prescription because I want to do no harm.
LO: Even though opioid death rates are technically decreasing in the U.S., I still view drug overdoses and addiction as huge issues, especially in my county. My county’s health department has actually seen an increase in relapses during COVID-19.
People are disconnected from their normal support systems and recovery groups due to extended stay-at-home orders in my state. My department has to work twice as hard not only to prevent the spread of COVID-19, but also to provide new and innovative harm reduction resources.
SM: Opioid use is a growing public health issue in India. Opioids are new to the Indian market, and drug abusers are unaware of its potential. Hence, the cases are few and restricted to a particular community, but there is no doubt in the fact that the number of people abusing pharmaceutical opioids is rising. As of 2019 there are an estimated 2.5 million people using pharmaceutical opioids for illicit use in northern and north-eastern states of India. Till now opioid misuse has made no significant impact on my work.
Time has changed since the events of this documentary, but opioid misuse continues to be a global problem. In 2019, the United Nations released the World Drug Report, which found an increase in the market for non-medical use of tramadol in West, Central, and North Africa as well as increased amphetamine use in parts of Asia (United Nations, 2019). Today, as a young pharmacist, do you feel empowered or confident enough to intervene in conduits to drug misuse like Dr. Cleggett’s pill mill? Why or why not?
BF: Yes. Although there is still a lot of push back when pharmacists contact physician offices regarding their prescription habits, deprescribing programs initiated by pharmacists have successful outcomes, such as decreased use of inappropriate medications and pill burden. I think we need guidelines on safe opioid tapering and discontinuation.
SM: Yes, I do feel confident enough to intervene in conduits to drug misuse like Dr. Cleggett’s pill mill, just like Mr. Dan. Being a pharmacist and being a part of the healthcare system it is our duty to intervene and stop such illicit activities and keep patients’ lives first and foremost before anything else. I believe we are part of the system and we have the knowledge and power to control this growing problem. I feel like “if not us then who.” Opioid misuse is our problem, it is a drug/medicine related problem, and we being the guardians of the medicine must solve it. Considering our locus standi in the healthcare system, we can serve as a checkpoint for illicit activities happening on either side of the system.
EO: The key thing that spurs action is interest. But the success of our actions are greatly dependent on our knowledge of the subject matter, as well as the presence of a support system.
One of the things we forget — amidst the noise of our different career paths — is the act of being human, through deliberate action. This means understanding that the things we do affect the next person, and the person after that, in a continuous chain of human connectivity. It means being conscious of intervening in issues — social, health, etc. — well within our capacity as human beings. And we sometimes believe that certain things are beyond our capacity, when in fact, they aren’t. We all belong to a global community and this means available support for our actions.
For the past few years, being a human being through deliberate action has been a core mantra of mine. And as someone currently in the health sector, and with a keen interest in fair balance between mental, physical and social health, I do feel confident enough to intervene.
But interest isn’t enough to see actions through. This is where knowledge and support comes in. Should I have to take action, I’m confident in my will to learn about the things I do not know, my knowledge of quality information sources, and my knowing that I belong to a community of professionals and youth — both locally and globally — through which support will be provided.
CO: As a young pharmacist, I feel confident enough to intervene in conduits to drug misuse. I also feel empowered, especially with the help of relevant government agencies and regulatory bodies who should be willing and ready to respond accordingly. This is because it is one thing to be willing to intervene in conduits to drug misuse and it’s another thing to have backing from the government. This is easy in an incorrupt system.
LO: Pill mills are well-researched in public health, and many people have a basic level of awareness on why they’re dangerous to communities. I feel confident intervening, mostly because I work in an environment where I know people would have my back — not just health professionals but also normal, everyday people in the community who have been hurt by the opioid epidemic. I am not certain if I would feel as empowered if I did not work in public health.
In Episode 3, we finally see the “smoking gun” moment when Dan confronts Dr. Cleggett over potentially lethal opiate prescriptions written for a young sickle cell patient. The tense altercation tentatively ends with Dr. Cleggett allegedly questioning Dan’s authority as a pharmacist, but ultimately results in the medical board having enough tangible proof to suspend Dr. Cleggett’s license. How can we navigate difficult conversations with physicians who may refuse intervention from pharmacists?
BF: This is a real yet difficult situation where the need for interprofessional collaboration cannot be overemphasized. We are the gatekeepers for dispensing opioid medications. We should strive to involve patients and caregivers through proper counseling on opioid risks, safe storage and disposals, naloxone, etc. In doing so, we can empower our patients with information about their health that will assist them in making informed decisions during their doctors’ visits.
Also, pharmacists have a corresponding medical responsibility to take care of patients. One major issue that our profession faces is standardization. When one pharmacist uses their professional judgement to refuse filling a prescription, another pharmacist fills it. In this case, the issue is not the prescriber refusing our interventions but the lack of standardization in pharmacy practice.
SM: Personally, I have had a lot of difficult conversations with physicians, even nurses, during my internship period. Clinical pharmacy is a very new domain in the Indian healthcare system, and the staff in the ward is not acquainted to see a pharmacist coming into the ward and intervene in their daily operations, Instead of recognising our potential, they feel like we are policing them every time when we try to intervene. Thus we were advised to stay polite, confident and were always asked to present our interventions or suggestions with evidence.
EO: Through my past experience in the clinical work space, I realize that there’s a disturbing distance between the confidence of physicians and the access they provide for the input of other health care professionals. This isn’t an absolute truth, of course, but it does sit heavy on a general scale — particularly in my clime. The primary goal of interprofessional collaboration within a health system is to ensure improved patient health. And when physicians lose sight of that big picture, the opinions of other healthcare professionals cease to add value.
On navigating difficult conversations, I believe that the same tactic used in negotiation — the right communication style — can be applied in dealing with difficult physicians. This is particularly useful for nations where guidelines are often disregarded without penalty. Beyond collaboration-based guidelines and laws, utilizing the right style of communication could play a huge role in collaborative interventions.
LO: Always advocate for your patients and in the words of one of my past preceptors, “Document, document, document!” Some providers are always going to refuse intervention from pharmacists, but we still have to be persistent and put forth our best effort.
CO: Physicians refusing intervention from pharmacists is one of the major factors limiting collaboration between pharmacists and other healthcare professionals. However, a way to navigate such difficult conversations would be in proper documentation. Medication therapy management (MTM) and medication error report forms are possible ways of documenting interventions whether accepted or refused by physicians.
In the same episode, we were also introduced to Chris Davis, a former Purdue Pharma sales representative. Davis’ involvement depicts how not only physicians, but also pharmaceutical sales representatives were involved in the rise of opioids like OxyContin® in the late ’90s. How can we as pharmacists also hold non-medical professionals accountable in the chain of opioid addiction?
LO: I think we need to be extremely mindful of the fact that at the end of the day, a salesperson’s goal is to make a sale. As health professionals, we need to be as unbiased as possible and truly understand what the data presented by a drug sales representative is actually telling us.
EO: Accountability starts with a clear set of expectations and consequences. These should be defined by the right governing bodies.
A part of the stated expectation — laws governing the distribution of opioid substances by non-medical staff — could include certified training. Non-medical professionals should be sufficiently trained on opioids, not by the pharmaceutical companies but by appropriate governing bodies. These training should be followed by an issuing of licenses that grant distribution power to the non-medical staff.
But there’s a flaw in that system. In merely training people and expecting them to do right. This is where measurement and implementation of clearly defined consequences come in. Data from sales records by non-medical professionals, as well as data on dispensing volume from pharmacies should be measured, to track regions with alarming consumption volumes and identify health facilities with an abnormal prescribing rate.
BF: We are not equipped or in the best place to hold non-medical professionals accountable in the chain of opioid addiction, but if there is anything pharmacists could do, I think it will be education. We need to educate these non-medical professionals on the big scheme of things and how they are contributing to the crisis. But the question that is yet to be answered is “can the education we offer be taken over a big fat bonus?”
SM: I believe pharmacists should always double check the information they receive from sales representatives, from trusted sources and should always take an informed decision on what will be the best suitable alternative for their patients. Pharmacists should also update the doctors with the correct information of the product which a sales representative might miss due to cognitive bias or economic interests.
CO: It is the job of the salesperson to make sales, hence we cannot really hold them accountable in the chain of opioid addiction. However, if suspicious activities of high supply of opioids by a salesperson are observed, I believe that the pharmaceutical company producing it should be held accountable to put things in check.
Throughout the documentary, former patients vividly described their experiences of addiction, like intentionally crushing extended-release opioids or using the Holy Trinity cocktail to get an “extra kick” or heroin-like effect. In Episode 4, we even saw signs of Dr. Cleggett’s own addiction to opioids. How did hearing addicts speak about their struggles change or impact your perspective of addiction?
CO: Prior to this time, my perspective of addiction was that it is like a chronic disease which has a gradual onset and characterized by a growing dependency on the drug of abuse/misuse. However, unlike chronic disease conditions which cannot be reversed, opioid addiction is reversible. This means that one can quit addiction but with great effort. I was reminded that most opioid addicts are willing to quit but have this stronghold in them that makes it difficult to quit. After watching this episode, my perspective did not change but it was rather interesting to see that my thoughts were their experiences.
LO: Addicts speaking on their own experiences is one of the most powerful tools for prevention that we have in public health. Before the documentary, I supported harm reduction and I support it even more after watching the documentary. Although my overall perception of addiction did not significantly change, I did find it interesting how the basic “no-no’s” of medication education that you learn about in school, like not crushing extended release formulations, are the exact same methods that people use for getting a high.
BF: As I listened to their stories, I felt empathy. Their accounts of their respective struggles reminded me of the fact that addiction is a complex disease of the brain that impairs choice or willpower. We usually lost sight of this fact and tend to blame addicts for their behavior. This documentary makes me ask the question “Should we blame patients for being diabetic or hypertensive?” If the answer is no, then we should not blame addicts too.
Most addicts feel helpless. Getting a “fix” is the only way they know to survive, although that is not true. We need to step in to help them. In order to beat this disease — addiction, we need all hands-on-deck — from the patient, family, friends, providers, healthcare systems and the government.
SM: Since I have never dealt with an opioid addict, I had this huge misconception that addicts are very reluctant and unwilling to get out of the situation they are currently in. After I saw the documentary , specifically the scene where a DEA officer went to Dr. Cleggett’s house to convince her to surrender her license and she was ready, as in she wanted to do it from a long time but was waiting for someone to convince her to do it. Also, hearing about quitting stories of other addicts, I now feel that they themselves are very willing to quit and lead a normal life. It’s just that they need a little push. I also strongly feel that pharmacists can provide this little push to their patients by conducting special counselling clinics for addicts at their pharmacies.
EO: Danny’s story reminded me that addiction is a chronic disease. And like every chronic disease, there is always an underlying cause of addiction — which could include traditional causes (like trauma, depression, and peer and societal pressure) or more access-based causes (like addiction from medical use, the availability of an opioid drug in a family member’s or friend’s cabinet, and doctor shopping). Access seems to precipitate the likelihood of addiction.
An understanding of this calls for active listening by pharmacists, to the core needs of patients. If root causes are well-identified and treated, there could be a significant decline in cases of addiction.
The documentary ends with a very brief mention of Narcan® (naloxone) and a sobering, indefinite conclusion to the opioid epidemic in the States. What changes do you think need to specifically happen in our profession in order to prevent opioid deaths?
SM: Pharmacists being the most accessible healthcare worker know the reality and the magnitude of the problem. Thus, it is imperative to include pharmacists at all levels, from educating the general population to policy-making and research — not only for the opioid crisis but also for other major public health issues.
BF: Among other strategies, young pharmacists will greatly benefit from training to detect patients that would benefit from naloxone. This is one arena where our role as public health advocates is vital. We need to educate not just patients on the necessity and use of naloxone in preventing unnecessary deaths, but also their families, neighbors and friends. Everyone needs to be held accountable. By the time a patient needs naloxone, only a bystander can help them in administering the drug.
LO: I think interprofessional education plays a huge role. Some physicians and nurses still do not understand how pharmacists can be an asset to preventing opioid misuse and overdoses. Pharmacists are frequently untapped resources, and we do so much more than count the pills. We can provide naloxone education, run syringe exchanges, teach healthcare teams about opioid safety profiles, and so much more.
EO: Campaigns are good agendas. When done right, they improve awareness and promote newer practices. But I also think that pharmacists should go beyond that realm of creating awareness to collaborate with organisations within the social health sector, in preventing death from opioids. This is specifically important within the community pharmacy setting, where spaces can be provided to accommodate substance abuse specialists and consequently aid holistic intervention services for addicted patients.
To improve the outcome of such interventions, pharmacies within the community and hospital setting should implement a peer-based patient management strategy by collaborating with recovered patients who could be trained to act as in-house counsellors and guide addicted patients through the cleansing process. This peer-based care method could boost trust in a treatment process.
A drug buy-back program can also be implemented, to encourage drug returns by patients with opioid prescriptions, to the community or hospital pharmacies. This may not apply to every clime but it could reduce access-based causes of addiction. I also believe that pharmacists should uphold ethics. Human health should be placed above financial profit. Pharmacy bodies could also monitor the dispensing rates of opioid medications. This could help with tracing over prescriptions by doctors.
CO: These aren’t new things but known facts that need to be enforced. MTM, public health campaign, interprofessional education among health care professionals, and patient counseling are things that can be employed.
Any final thoughts or impressions of the documentary?
BF: Every young pharmacist should watch this documentary. It shows the impact we have on the health of our community. While sheer determination, fueled by grief and anger, drove Dr. Schneider to affect change even in the face of a corrupt system, we must not wait for something to affect us personally before advocating for what is right. While watching this documentary, I could not help but ask myself what I could do to affect change in my neighborhood during this current COVID-19 pandemic?
Overall, everyone needs to play their part in fighting the opioid epidemic. Pharmacists need to wake up and do what they are trained to do. Government agencies, state boards, professional organizations and others also need to do what they were created for.
SM: I really enjoyed watching the documentary, I was really mesmerised by the efforts Mr. Dan had put in to save the lives of so many individuals. I was inspired by his ways of doing everything in the right way. One haunting thought that came to my mind is that pharmaceutical companies have a huge role in expanding the magnitude of the opioid epidemic. Clearly they are here for money and they can go to any extent for it. I believe the government should have some cap on the sale emphasising activities of pharmaceutical industries on such crucial drugs. Pharmaceutical giants should also understand that they have a social responsibility towards the community.
EO: Social acceptance, life crisis, medical use of opioids, poor regulations, prioritization of financial profit are common threats that spark the abuse of opioid substances. And these were well captured — reflected in young Danny’s death, commentary by other addicts, Dr. Cleggett’s practice, and the operations of Purdue Pharma — in the documentary.
The Pharmacist also highlighted important interventions on the opioid crisis. It showed the value of prescription and sales data, the need for persistent and thoughtful intervention, and the importance of a supportive community in managing the global opioid crisis.
LO: Overall, I loved how this documentary showed how essential pharmacists are in public health. As a young pharmacist pursuing a public health career, I enjoyed seeing a pharmacist refuse to be pigeonholed into a traditional box of what pharmacists should or should not do.
CO: I must say that I was impressed with Dan Schneider’s undauntedness in his pursuit for the truth about his son’s death and investigations about Dr. Clegget’s practices in spite of the challenges he faced in the process and the seemingly act of negligence from the DEA initially. It takes courage to do these things especially when you don’t have a hundred percent support from all angles.
References
- United Nations. (2019). Booklet 2: Global Overview Of Drug Demand And Supply. 2019 World Drug Report. Retrieved from: https://wdr.unodc.org/wdr2019/prelaunch/WDR19_Booklet_2_DRUG_DEMAND.pdf
