Aine Cryts

s the pandemic dominates headlines, the United States continues to face another major public health crisis—the opioid epidemic.

One bright spot is at Boston Medical Center, where the city’s safety net hospital’s pharmacy team has reduced inpatient opioid use among surgical patients by 41% since 2017 and cut discharge opioid prescribing for surgery patients by 25%. The initiative involved pharmacists across the hospital’s ambulatory, inpatient, 

Kevin Horbowicz, PharmD, BCPS, associate director of inpatient clinical pharmacy services, described witnessing the opioid overdose epidemic as his driving force. “It was very central to us at Boston Medical Center… where it’s having a big impact on our patients, many of whom struggle with opioid use disorder and other disorders,” he said.

Success depended on coordinating with the hospital’s information technology team and more than 20 surgical specialties. Today, surgeons can order sets in the electronic health record that prompt them to prescribe agents such as acetaminophen to manage patients’ pain.

included procedures such as abdominal surgeries, which tend to involve large incisions and “a lot of pain,” said David McAneny, MD, the medical center’s chief surgical officer. He was so impressed by how well using agents such as angiotensin-converting enzyme inhibitors and acetaminophen managed postsurgical pain that he supported including all surgeries in the program.

In line with this effort, the hospital was implementing the enhanced recovery after surgery (ERAS) protocols, McAneny said. This multimodal, multidisciplinary approach to the care of surgical patients includes surgeons, anesthesiologists, and surgical care staff. ERAS protocols generally include minimally invasive approaches rather than large surgical incisions, and early mobilization.

Before this initiative, even a patient with mild pain would typically be discharged with 60 to 90 oxycodone pills, Horbowicz said. That’s dangerous for an individual who might become dependent or whose medication is accessible to other household members, he explained.

Pharmacist participation during rounds with the surgical team is key, McAneny said. The pharmacist can provide insight on topics such as appropriate medications, when to 

stop antibiotics, and when to switch from an intravenous to an oral route. McAneny, who mostly performs endocrine surgery, said he hasn’t prescribed opioids for postsurgical recovery in 10 years.

He also emphasized the importance of patient education. For example, McAneny tells patients who have had thyroid surgery that neither oxycodone nor acetaminophen will take away the resulting sore throat, which should subside by the end of the day.

Developing a consensus among more than 20 surgery subspecialties proved the most difficult part of implementing the program, according to Horbowicz. The fields of orthopedics, plastic surgery, and trauma have very different needs, he said. 

Another challenge involved scheduling a meeting with the chair of neurosurgery to discuss the program, he added. Still, he highlighted Boston Medical Center’s “collaborative, multidisciplinary culture,” with physicians, nurses, and pharmacists working well together. “That was part of the secret sauce,” Horbowicz said. 

As a result of Horbowicz’ leadership, Boston Medical Center’s Opioid Utilization Improvement Team won the Pharmacy Health-System Award from the Massachusetts Society of Health-System Pharmacists.

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Pharmacists, nurses, and physicians work together to combat the overuse of powerful pain relievers.

Boston Medical Center Reduces Opioid Use in Surgical Patients 

Since Governor Charlie Baker of Massachusetts issued a stay-at-home advisory in response to the coronavirus disease 2019 (COVID-19) pandemic, UMass Memorial Health Care in Worcester, Massachusetts, has dispensed more than 5000 medications to patients and employees using its curbside prescription service.

The top 3 medications filled are those for blood pressure, cholesterol, and acid reflux, said Jackie Breeds, PharmD, RPh, pharmacy supervisor at the health system.

UMass Memorial offers the service at 2 separate locations, both in downtown Worcester. Patients and employees start the pickup process by entering an order in the patient portal or calling the pharmacy team, said Breeds. In either case, they are prompted to call the pharmacy team to schedule a pickup and discuss paying co-pays by credit card or cash.

“Staffers stay far back from the car window. They don’t want to sneak up on people.”

A pharmacy order takes approximately 2 hours to fill, although the turnaround time can depend on the current volume of prescription requests; Mondays are the busiest days, Breeds said. Patients park in 1 of 2 designated parking spots at each location, and a sign instructs them to call the pharmacy. The pharmacy staffer captures information about the make, model, and color of the patient’s or employees’ car, which makes identifying them easier. The staffer also verifies their birthdate to ensure the individual is getting the correct medication. The staffer typically brings out the medications within 3 to 5 minutes.

“[Staffers] stay far back from the car window,” said Breeds. “They don’t want to sneak up on people. They wait until [the person] unrolls their window.” Staffers are required to wear masks, she added, and they use hand sanitizer upon reentering the building.

When a medication order is generated, a pharmacy staffer bills insurance and determines the patient co-pay. If they come across any formulary issues, they call the patient’s doctor to make changes or ask questions.

Some of UMass Memorial’s pharmacy techs have been furloughed. The staffers bringing medications to patients’ cars are typically recent nursing school graduates and medical assistants from clinics with reduced patient volume, said Neil Gilchrist, PharmD, BCPS, DPLA, senior director of pharmacy services. Nonpharmacy tech employees can serve in these roles during the state of emergency declared by Governor Baker on March 10. For opioid-based medications, the prescribing physician sends the order to UMass Memorial electronically, said a health-system spokesperson. The pharmacy staffer tells the patient that they’ll need to show photo identification at pickup. During pickup, the staffer verifies the patient’s birth date and photo to ensure the correct individual receives the medication.

Because of the positive response from patients and employees, many of whom have been working remotely during the pandemic, UMass Memorial is considering continuing the program when the health system returns to steady-state operations.

An inside look at the process from prescription to dispensing.

UMass Memorial Provides Model for Curbside Medication Delivery

A pharmacy desert is defined as an area where limited access to pharmacies is acute. A 2014 study in Health Affairs found that segregated black and Hispanic communities in Chicago, Illinois are more likely to be host to pharmacy deserts and that 1 million people in the city were living in these pharmacy deserts. Fifty-three percent of those individuals were living in segregated black communities.

In addition to dispensing prescription medications, local pharmacies have a role to play in the sale of OTC products and, increasingly, the provision of diagnostic, preventive, and urgent-care services, wrote the study coauthors.

Pharmacists, in particular those practicing in retail environments, are often the most accessible health care professionals, said Sean Nordt, MD, PharmD, associate dean of academic affairs, chief medical officer, and professor of pharmacy at Chapman University School of Pharmacy in Irvine, California. Whereas a patient needs to register at the hospital to see a physician, all they need to do is walk into their local pharmacy to ask questions, he explained.

That’s why lack of access to pharmacies can have a detrimental effect on patients, in particular those with chronic conditions, said Stephanie Kiser, PharmD, clinical assistant professor at The University of North Carolina Eshelman School of Pharmacy in Chapel Hill. A pharmacist for more than 25 years, Kiser grew up in a rural area and witnessed firsthand that accessing care often requires driving far distances.

She cited the example of a patient who needs to be monitored in person twice weekly until their body adjusts to an anticoagulant. Although that involves 4 inconvenient 10-minute car rides for someone in a suburban area, it could require a 90-minute drive twice a week for the person who lives in a rural area, she explained.

According to a 2018 study in Rural Policy Brief, 16.1% of independently owned rural pharmacies closed between 2003 and 2018. A 2019 study3 in JAMA Network Open found that pharmacy closures “are associated with persistent, clinically significant declines in adherence to cardiovascular medications among older adults in the United States.”

Engaging Homeless Populations in Accessing Care

Skid Row is a 53-block area east of downtown Los Angeles, California where approximately 2700 members of the homeless community live.

To encourage members of Skid Row’s homeless population to seek health care, Jemal Hussein, a PharmD student at Keck Graduate Institute’s School of Pharmacy and Health Sciences in Claremont, partners with students at local health sciences graduate schools, such as the Univiersity of California, Los Angeles, School of Dentistry and the Marshall B. Ketchum University School of Physician Assistant Studies in Fullerton.

One tangible impact of their work is the care kit, which includes items such as a toothbrush, toothpaste, sanitary pads, articles of clothing (such as a T-shirt, socks, or a sweater), and a hand-written note from one of the student volunteers. The idea behind the note is to tell the person that “you’re loved and thought about,” said Hussein, who leads the graduate school’s Community. Advocacy. Resources. Education. organization. Volunteers use the interaction to spark a conversation, which can help get members of the homeless population access to the medication, dental, and health care services they need, he explained.

Connecting to Patients Through Shared Language and Culture

Samantha Garcia, who is also pursuing a PharmD degree at Keck Graduate Institute, said that speaking the same language as the person you’re treating makes a difference. In particular, patients need to understand that taking their blood pressure medication can keep them out of the hospital, she noted. “It’s difficult if your pharmacist or doctor can’t speak your language and you need to take this medication to prevent [you from] having a stroke or a heart attack,” said Garcia.

According to Garcia, her proficiency in Tagalog, the primary language spoken in the Philippines, came in handy last semester at a clinic held for members of the homeless community in nearby Pomona. Services at the clinic included blood pressure checks and education about the signs and symptoms of stroke. As soon as her patient heard her speak in Tagalog, she “perked up,” Garcia said, despite the fact that she was counseling the patient against eating fried pig, a popular Filipino dish, which isn’t good for her health.

It’s important for providers to make that connection with patients and close that gap in a culturally aware manner, said Garcia, who leads the Student  National Pharmaceutical Association chapter at the graduate school.

Diagnosing and Treating Asthma in Children

More than 22% of schoolchildren in Pittsburgh, Pennsylvania, have asthma, according to a Journal of Allergy and Clinical Immunology study published in 2018.4 That’s more than double the state’s asthma prevalence rate of 10.2%5 among children and significantly higher than 7.5% for children across the country.

Patients with persistent asthma need access to their daily medications for the condition to be well controlled, explained Jennifer Padden Elliott, PharmD, associate professor at Duquesne University’s School of Pharmacy in Pittsburgh. If their asthma isn’t well controlled, children end up in the emergency room and miss school days, she added.

In 2014, Elliott developed a community-based screening model to diagnose asthma in children and connect them with the care they need. The free service is available in schools throughout Allegheny County, which is home to Duquesne University. The screening model starts with a health questionnaire sent to parents at the start of the school year. Students in Duquesne University’s pharmacy program help tabulate the results and reach out to parents.

In addition, Elliott launched school-based asthma clinics in partnership with federally qualified health centers in the surrounding neighborhoods in 2017. For clinical pharmacists from Duquesne University’s pharmacy, schoolwork takes place at the asthma clinics, where the condition is managed during the school day and medication changes and other updates are communicated to the student’s primary care physician. For example, students can have their lung function assessed using a spirometer at the asthma clinics.

Students in Duquesne University’s pharmacy program can participate in rotations with the asthma clinics, said Elliott. They shadow pharmacists who staff the program and help counsel children and their families on topics such as inhaler techniques and adherence with treatment plans.

Exposing Pharmacy Students to Urban and Rural Experiences

Patients struggle to manage chronic conditions such as diabetes in rural and urban areas, explained Estela Lajthia, PharmD, clinical assistant professor at Howard University in Washington, DC.

The same challenges associated with drug prices and lack of access to preventive care also plague people in rural and urban settings, she said.

To expose its students to the experi- ence of serving as pharmacists in a rural environment, Howard University has partnered with the University of Wyoming School of Pharmacy in Laramie on an exchange program, with 4 students from both schools traveling to the other school since fall 2018.

Students from Wyoming School of Pharmacy learn about health care systems in inner-city Washington, DC, and meet congressional leaders, and Howard University students are exposed to critical-access hospitals and health care systems in rural settings, said Lajthia, an ambulatory care pharmacist.

Lack of convenient access to health care services and increasing closures of independent pharmacies contribute to gaps in patient care in both rural and urban settings. Exposing pharmacy students to these work experiences in pharmacy desert neighborhoods can prepare the next generation of pharmacists to close these gaps.

Pharmacists are often the most accessible health care professionals, which is why a lack of access to pharmacies can have a detrimental effect on patients, especially those with chronic conditions. 

Pharmacy Schools Prepare Students for Specific Population Challenges

The opioid epidemic is far from over, but after years of increasing relentlessly, the trendline for the number of drug overdose deaths in the United States finally turned the other direction. According to federal health statistics, there were 67,367 drug overdose deaths in the United States in 2018, a notable 4.1% decline from the 70,237 deaths that occurred in 2017. 

The rate of overdose deaths from natural and semisynthetic opioids (oxycodone, hydrocodone) and heroin were lower in 2018 than in 2017. It’s not all good news: The rate for synthetic opioids (fentanyl, tramadol) increased from 2017 to 2018.

Combating the opioid epidemic is a popular cause, and many organizations, government entities, and health care groups have responded. 

Mothers are more likely to show up for their infants’ check-ups than they are for their own check-ups. It’s a simple maxim followed by clinicians at Boston Medical Center’s Supporting Our Families through Addiction and Recovery-SOFAR, for short-clinic to “hook” mothers into managing their health and maintaining their recovery from dependence on opioids. Launched in July 2017, the program, which is run by largest safety-net hospital in Massachusetts, has seen 200 mother-child pairs since its start. 

The mother-child pairs are connected to SOFAR through Project RESPECT, another Boston Medical Center program that provides obstetric and substance use disorder treatment for pregnant women and their newborns. While the infant participates in their well-baby visit, in the SOFAR clinic, the mother receives  treatment for her dependence on opioids, including access to medication-assisted treatment and a mentor who has been through a similar life experience.

Eileen Costello, MD, chief of ambulatory pediatrics at Boston Medical Center and medical director at SOFAR, and other specially trained pediatricians engage with mothers by asking them about family support, their living situations, and their children. Many of these women are raising  children without the help of a partner, notes Costello. Some are living in group homes or struggling with custody issues. If they are taking one of the drugs used in medication-assisted treatment, such as methadone, they often must deal with criticism from family members and others. To help, says Costello, clinicians educate mothers about the research that shows that opioid-dependent women who don’t take methadone or buprenorphine in the prenatal and postpartum periods are at greater risk of relapse in the first year of their child’s life.

The program also supports mothers who are struggling with the shame of potentially having harmed their infant by taking opioids during their pregnancy. SOFAR celebrates their efforts and successes by, for example, recognizing the achievement of arriving at 6 a.m. to get their methadone with an infant in tow, especially during a bitter cold Boston winter.

The greatest challenges with launching the program were associated with overcoming “all the silos” in the hospital setting, says Costello; for example, getting internal medicine and pediatric physicians co-located and tracking clinicians’ time effectively for billing purposes.

Data from the program are collected and analyzed to measure its effect. One finding so far: In its first year, clinicians treated and cured 335 of the mothers with hepatitis C in the SOFAR program, says Costello.

Combating the opioid epidemic is a popular cause, and many organizations, government entities, and health care groups have responded.