Aine Cryts

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.

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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.

Opioid Overdose Deaths Decreasing

All-cause deaths dropped 59% for adults who received methadone within 12 months of an opioid overdose, according to a study published in the 

 The study also found that taking buprenorphine within 1 year of an overdose led to a 38% reduction in all-cause deaths.

These 2 statistics spurred Kavita Babu, MD, chief of medical toxicology at UMass Memorial Health Care in Worcester, Massachusetts, to launch a telehealth-based program to connect patients with credentialed clinicians who can prescribe medication-assisted treatment (MAT). UMass Memorial is the second largest health system in Central and Western Massachusetts.

For context, the Massachusetts legislature passed a law in August 2018 requiring hospital emergency departments (EDs) to provide MAT to patients who present after an opioid overdose. To prescribe MAT, clinicians must have a Drug Enforcement Agency Category X waiver, which requires 8 hours of training. Seventy percent of UMass Memorial’s clinicians have participated in the training.

According to the CDC, Massachusetts ranked among the top 10 states with the highest rates of opioid overdose deaths.

 Synthetic opioids, mainly fentanyl, cause many of those deaths. The federal agency reports

 that opioids were involved in 68% of all drug overdose deaths in 2017. West Virginia, Ohio, and Pennsylvania had the highest rates of deaths due to drug overdose that year.

Since the UMass Memorial program launched in January, 1 patient has received a telehealth-based consult from a credentialed toxicologist. Babu described the patient as a young man with longstanding opioid use disorder. “He needed a prescription for Suboxone to continue treatment in a new facility,” she told 

Babu explained that, 5 years ago, the opioid overdose treatment protocol started with a first responder providing naloxone to reverse a patient’s overdose. After arriving in the ED, the patient was told by a physician that they almost died. The physician also told the patient to stop taking drugs, gave them a list of community resources, and discharged them.

Today, at UMass Memorial - Marlborough Hospital, the patient presents in the ED, after getting naloxone. Then a clinician captures their history and their interest in MAT. If the patient agrees, the ED clinician connects the patient with one of the trained toxicologists on Babu’s team via a HIPAA-compliant telehealth platform.

The toxicologist’s goal is to empower the patient by getting them to take home a prescription for MAT, said Babu. After providing consent, the patient is sent home with a prescription and a handout prepared by the National Institute on Drug Abuse that asks a series of questions such as the number of hours since opioid use and the patient’s experience with symptoms such as yawning, nausea, and diarrhea. This guides the patient’s home induction of MAT, she explained.

Pharmacists have been at the forefront of creating access to naloxone and MAT, said Babu. That’s why they can help increase access to MAT, especially if clinicians at their hospitals aren’t trained or are resistant to providing treatment.

For example, a pharmacist in a rural ED could struggle to expand access to MAT treatment without trained prescribers in the hospital, said Babu. Ensuring that clinicians receive training is part of the solution, but clinicians also need access to decision support to determine the appropriateness, as well as the timing and safety of the approach, she added.

Hospital committees focused on pharmacy and therapeutics and ED oversight, where pharmacists are involved, should be interested in this offering, said Babu.

This initiative received $200,000 in funding from UMass Memorial Medical Group.

1. Larochelle MR, Bernson D, Land T, et al. Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study. Ann Intern Med. 2018; 169:137–145. [Epub ahead of print 19 June 2018]. doi: 

2. National Institute on Drug Abuse. Massachusetts Opioid Summary. 

https://www.drugabuse.gov/opioid-summaries-by-state/massachusetts-opioid-summary

 Revised March 2019. Accessed February 13, 2020.

3. Centers for Disease Control and Prevention. Drug Overdose Deaths. 

https://www.cdc.gov/drugoverdose/data/statedeaths.html

 Last reviewed June 27, 2019. Accessed February 13, 2020.

4. Babu K, Lai J, Cushman P, et al. (2020) An emergency department order set for buprenorphine-naloxone (SUBOXONE®) initiation, Toxicology Communications, 4:1, 5-8, DOI: 10.1080/24734306.2019.1704978

A UMass Memorial telehealth-based program connects patients with credentialed clinicians who can prescribe medication-assisted treatment for opioid use disorder. 

Massachusetts Hospital Uses Telehealth to Increase Access to Opioid Treatment

One hundred forty four prescriptions filled in 7 days. That seems like a slow week at Novant Health Brunswick Medical Center. But those were the outpatient prescriptions, which the hospital doesn’t dispense normally.

The hospital in Bolivia, North Carolina, was hit hard by Hurricane Florence for 7 days in September 2018. Twenty-three inches of rain in Bolivia--and as much as 27 inches of rain in nearby Sunny Point--led to flooding and impassable roads. According to the National Weather Service, extensive wind damage caused thousands of downed trees and power outages throughout the eastern part of the state.

Pre-Hurricane Florence, Perry Allen, PharmD, pharmacy manager, a 26-year veteran at the hospital, had 2 priorities: Have the right team on scene before, during, and after the storm and secure the necessary medications to ride out the storm. Specifically, he ordered extra antibiotics, pain medications, and topical ointments and creams; the latter were required for treating patients injured by fallen trees.

Expected to impact the area for 3 days, the hurricane rendered roads impassable and flooding continued in many areas for a week. That’s why he worked with Novant Health’s logistics team to get additional medications from a tactical military convoy. The truck took a circuitous route from the hospital’s drug distributor in Virginia into South Carolina to avoid impassable roads to then head back to North Carolina. That’s where the military convoy was met by members of the Novant Health team who drove the medications and nursing supplies the final stretch to the hospital.

Day 2 of Hurricane Florence, the local pharmacies were closed. That made sense, since electricity was out. It meant Allen’s team had to dispense outpatient prescriptions to patients who, otherwise, wouldn’t have their emergency medications. Ordinarily, the hospital doesn’t dispense prescriptions on an outpatient basis.

Allen had to ensure that the labels on the outpatient prescriptions included the information required by state and federal laws. In part, that information included the names of the patient and the prescribing physician, in addition to the name and quantity of the medication and guidance on taking the medication. Allen tapped his IT team to help cull that information and print it on the labels that were stuck on the prescriptions for patients who came to the hospital to receive them.

“That was a sticking point. How to do that. Develop a good-looking label so that patients would understand how to take [the medication],” said Allen.

Patients learned that the hospital was dispensing prescriptions through its network of physicians treating patients in local practices, said Allen. His team was also tasked with dispensing medications for employees who ran out of their emergency medications and people in neighboring areas who got stuck on the hospital campus during Hurricane Florence and its aftermath.

Relying on Your Distributor Through Natural Disasters

Since most patients were within the Novant Health network, Allen’s team could view their prescriptions, including dosage and directions for taking the medications, in the hospital’s computer system, said Allen. To fill a prescription for an opioid-based pain medication, a member of his pharmacy team spoke with the patient’s prescribing physician.

As part of the Novant Health network of 15 medical centers and more than 640 care locations, Allen’s team had access to logistics expertise. He credits 1 Novant Health employee, a former logistics expert in the US Army, with mapping out a safe route to transport the medications from the hospital’s drug distributor in Virginia and ensuring their arrival at the hospital’s campus.

Allen also lauded Shelbourn Stevens, the hospital’s president and chief operating officer, for clearing operational barriers. Hospital staff who worked through the storm had packed clothes for 3 days, but due to flooding and blocked roads, many couldn’t leave the hospital for a week. Hospital leadership responded by buying a washing machine and dryer for staff to clean their clothes, said Allen. In addition, the cafeteria was stocked with many options for meals for employees, patients, and people who became stranded at the hospital, he added.

Empowering employees to serve patients is what drove his approach during the hurricane, said Stevens. “That’s what comes first. It’s always the patient first....we try not to let normal operational things get in the way,” he added.

On behalf of the hospital’s pharmacy team, Allen received the 2019 American Society of Health-System Pharmacists (ASHP) CEO’s Award for Courageous Service.

How the pharmacy team at Novant Health Brunswick Medical Center ensured patients got their medications during Hurricane Florence. 

Author | Aine Cryts

Articles

Pharmacy Schools Prepare Students for Specific Population Challenges

Opioid Overdose Deaths Decreasing

Massachusetts Hospital Uses Telehealth to Increase Access to Opioid Treatment

North Carolina Pharmacy Team Celebrated for Triumph Over Hurricane Florence