Drug Topics published a piece this week with a headline that should resonate deeply with every pharmacist who has watched the opioid crisis unfold over the past decade: as the pharmacist’s role continues to expand throughout healthcare, they are now being challenged to step in as opioid stewards in a rapidly evolving pain management landscape.
The urgency of this opportunity in 2026 is genuinely new. Purdue Pharma’s closure and $7.4 billion settlement, covered in this newsletter earlier this year, officially closed one chapter of the crisis. The settlement funds are now flowing into communities. Health systems are under regulatory scrutiny. And the question of who is best positioned to lead opioid stewardship at the clinical level has a clear answer backed by new published data.
The VA Pilot Study That Proves This Works
The most consequential new evidence this week came from a Drug Topics recap of perioperative opioid stewardship data published in the Journal of Pain and Palliative Care Pharmacotherapy, covering a VA health system program where clinical pharmacist practitioners took systematic ownership of opioid risk at the surgical care transition.
Clinical pharmacist practitioners completed 1,290 preoperative opioid risk interventions for 289 patients. These interventions included overdose education for 88.9% of patients, naloxone prescribing for 63.3%, prescription drug monitoring program queries for 97.2%, and suicide risk assessment for 83% of patients. Pharmacists also provided 59 preoperative pain management interventions, including 24 pharmacotherapy and 35 nonpharmacologic interventions. Postoperative pain medication management recommendations were provided by pharmacists for 97.9% of patients. Postoperatively, pharmacists completed overdose education and suicide risk assessments for 83% of patients, as well as unused opioid disposal education for 78.5% of patients. In total, they provided 134 nonpharmacologic, 96 opioid, and 74 nonopioid pain management interventions in the postoperative setting. Average patient pain scores were 5.1 preoperatively and 3.7 at discharge.
Three numbers in that dataset deserve specific attention. Naloxone was prescribed to 63.3% of preoperative patients. PDMP queries occurred for 97.2% of patients. And pain scores dropped from 5.1 to 3.7 at discharge. These outcomes don’t describe a pharmacist providing supplementary support to an existing opioid program. They describe a pharmacist functioning as the primary systematic risk manager in a clinical setting where that role had not been systematically filled before.
A companion smaller pilot at the Lexington VA confirmed the same pattern: 74% of patients expressed interest in a naloxone prescription when offered directly by a pharmacist during perioperative contact, and 48% expressed interest in a medication disposal envelope. Among patients with excess opioid tablets postoperatively, 80% had not yet properly disposed of them before pharmacist contact, identifying a specific community diversion risk that pharmacist outreach directly addressed.
Why the Perioperative Setting Is the Highest-Leverage Intervention Point
The transition from acute surgical pain management to outpatient opioid prescribing is where the diversion, dependence, and overdose risk concentrates most. The clinical oversight at that transition has historically been most fragmented.
The surgical team’s attention peaks at the procedure and the immediate recovery. The prescribing physician’s cognitive focus is on clinical outcomes, not post-discharge medication risk. The patient goes home with a 30-day opioid prescription, a general instruction to call if pain is uncontrolled, and no systematic plan for what happens to the remaining tablets after the acute pain phase resolves.
VA’s Clinical Pharmacist Practitioner program positions pharmacists to function as the systematic owners of opioid safety across this entire transition. As of May 2023, VA had dispensed more than 1 million naloxone prescriptions, with CPPs prescribing more than 21% of all naloxone prescriptions ever written and 62% of CPPs in the field prescribing this life-saving care.
That naloxone prescribing data is not a coincidental metric. It reflects a program structure in which pharmacists were explicitly positioned to review opioid risk, offer naloxone as standard practice rather than an afterthought, and document the outcome of every intervention. The 62% CPP naloxone prescribing rate exists because the VA deliberately gave clinical pharmacist practitioners the authority and the expectation to perform systematic opioid risk mitigation. The pilot data shows what happens when they do.
The Oncology Context: Stewardship Beyond the Perioperative Setting
The Drug Topics piece also highlighted opioid stewardship data from the oncology setting that extends the pharmacist’s role beyond surgical pain management into one of the highest-complexity opioid prescribing environments in medicine.
In an oncology-focused analysis, investigators identified 36,800 prescriptions written by 495 prescribers during the study timeframe. Among these, 31% were long-acting agents such as buprenorphine and methadone. Average opioid morphine equivalents per day was 88, excluding the two long-acting drugs. High-risk medication combinations, including muscle relaxants, benzodiazepines, hypnotics, or barbiturates, were present in 28%, 14%, and 36% of all prescriptions, respectively.
“There are several process metrics beyond OME per day and quantity of prescriptions that opioid stewardship programs can use to assess prescribing practices,” the lead investigator concluded. “These metrics can be used to identify specific interventions to improve safe prescribing in the oncology setting.”
High-risk concurrent prescribing of opioids with benzodiazepines, muscle relaxants, or hypnotics is exactly the kind of polypharmacy interaction that clinical pharmacists are trained to identify and mitigate. In an oncology population where prescribers are managing complex, evolving pain management alongside disease treatment, the pharmacist’s systematic medication profile review is the clinical function most likely to catch those interactions before they become adverse events.
The Naloxone Co-Prescribing Gap That Defines the Opportunity
The VA pilot data showing 74% patient interest in naloxone when directly offered by a pharmacist stands in sharp contrast to the national co-prescribing baseline.
Among 181,964 patients on long-term opioid therapy in a national outpatient dataset, only 1% received a naloxone co-prescription. Even among the highest-risk subgroups, those receiving more than 50 MME per day, only 3.3% received naloxone. Among patients with concurrent benzodiazepine prescriptions, 2.6% received naloxone. Among patients with a documented opioid use disorder history, only 7.8% received naloxone.
These numbers describe a gap that is not a failure of patient willingness. The VA perioperative data shows patients accept naloxone at high rates when offered. They describe a failure of systematic offering. The prescriber who sees the opioid prescribing decision as the primary clinical task does not systematically offer naloxone because naloxone is not part of the prescribing workflow. The pharmacist who reviews every opioid prescription against a patient’s risk profile, using a defined protocol, can make naloxone offering systematic in a way that individual prescriber practice never reliably does.
The clinical logic is direct: every patient on long-term opioid therapy is a potential naloxone candidate. Every patient starting acute surgical pain management is a potential naloxone candidate. Every patient on opioids plus a concurrent CNS depressant is a high-priority naloxone candidate. The pharmacist reviewing those prescriptions is the person with complete visibility into all three categories simultaneously.
Building Your Opioid Stewardship Position
The proposal that gets a pharmacist formally embedded in a perioperative or oncology opioid stewardship program is not a scope expansion argument. It is a patient safety and cost avoidance argument with a specific evidence base attached.
The VA pilot produced a specific metrics set: PDMP query rates, naloxone prescription rates, preoperative and postoperative pain score changes, and intervention counts by type. The Lexington VA pilot added disposal education rates and quantified the excess opioid tablet problem at discharge. The national co-prescribing data quantifies the baseline gap. The opioid settlement cost framework provides the financial context: $177.8 million in annual direct healthcare costs attributable to opioid-related morbidity at the national level, with per-overdose costs averaging $2,700 to $31,000 depending on disposition.
A one-page proposal built on those numbers, framed as patient safety improvement and cost avoidance rather than pharmacist scope expansion, is the document that gets a meeting with a surgical department chief, a perioperative committee chair, or a pain management program director.
The structure: current gap in your institution’s perioperative opioid risk review. Quantified consequence of that gap using published rate data. Pharmacist intervention model based on VA pilot. Projected cost avoidance from naloxone prescribing and disposal education. Requested resource: pharmacist inclusion in presurgical assessment protocol.
That proposal, reviewed against the VA pilot’s outcomes data, is an argument about patient safety and healthcare economics. It is the same risk management framing documented in this newsletter’s earlier issue on the risk manager identity. The clinical work is the mechanism. The harm reduction and cost avoidance are the story.
The Abatement Fund Connection
This newsletter covered Purdue Pharma’s closure and the $7.4 billion settlement structure in May. The settlement funds flowing to state, local, and tribal governments are specifically designated for opioid abatement programs, including naloxone distribution, treatment access, and harm reduction infrastructure.
Pharmacists who are already embedded in formal opioid stewardship programs, or who build standing naloxone dispensing and counseling protocols, are positioned to receive referrals and partnership funding from abatement-funded community programs. The county health department distributing abatement dollars for naloxone access will call the pharmacy with an established naloxone protocol, not the one that handles it case by case when a patient asks.
Building the opioid stewardship infrastructure now, while abatement dollars are flowing into communities and while health systems are under regulatory attention, positions the pharmacist as the clinical partner of choice for those programs rather than a downstream recipient of whatever access infrastructure others build without them.
Your Action This Week
Identify whether your institution or practice has a formal opioid stewardship program. If it does, find out whether pharmacists are formally embedded in the perioperative pain management protocol.
If they are not, that is your opening. A one-page proposal showing the VA pilot’s outcomes data, framed as cost avoidance and patient safety improvement, is the argument that gets a pharmacist added to the surgical care team. The evidence is already there. The proposal just needs someone to write it.
For community pharmacists outside a health system setting: build your naloxone standing order protocol now. Every state permit pharmacist-initiated naloxone dispensing understanding order or statewide protocol. Identify your state’s specific authorization, document your counseling workflow, and train your technicians on the naloxone discussion so that every patient on long-term opioid therapy or high-risk opioid prescriptions receives a systematic naloxone offer at pickup.
The pharmacist who owns the opioid stewardship function in their clinical setting is not performing extra work. They are performing the systematic clinical review that prevents the adverse outcomes that cost the healthcare system $177 billion annually and that cost communities in ways the settlement funds are only beginning to address.
The most qualified opioid steward in the building has a pharmacy degree. The role is available. Claim it.
Sources: Drug Topics (Pharmacists Role in Opioid Stewardship, Perioperative Pain Management Crucial, April 24, 2026), Journal of Pain and Palliative Care Pharmacotherapy (Enhancing Perioperative Prescription Opioid Risk Mitigation Through Pharmacist Intervention, published January 28, 2026), VA Pharmacy Benefits Management Services (Clinical Pharmacist Practitioner Role in Opioid Safety, External Fact Sheet), VA Pharmacy Benefits Management Services (Clinical Pharmacist Practitioner Role in Substance Use Disorders, External Fact Sheet), Cureus (Naloxone Prescribing Among Long-Term Opioid-Prescribed Patients: Disparities and Opportunities, April 2025), AHA / American Hospital Association (The Societal Cost of the Opioid Epidemic), New York Times / Reuters (Purdue Pharma Sentencing and Settlement Final Coverage, April-May 2026)