22 minute read
Pharmacists should be the OUD experts
Pharmacists Can Be OUD Experts and Combat Abuse
By Dave Doolittle and Bob Kronemyer
Health-system pharmacists should continue to play a major role in the treatment of people with opioid use disorder (OUD), particularly patients on long-term buprenorphine therapy.
That’s why ASHP was involved recently in a joint venture of several health societies that developed recommendations on how to boost use of the opioid partial agonist after surgery and before discharge for patients with OUD.
The recommendations, published in Regional Anesthesia & Pain Medicine (2021;46[10]:840-859), are intended to be an educational resource for anesthesiologists and pain physicians but can be used by anyone on the care team, according to its developers.
The American Society of Regional Anesthesia and Pain Medicine (ASRA) led the venture along with ASHP, American Society of Anesthesiologists, American Academy of Pain Medicine and American Society of Addiction Medicine.
“ASHP advocates for a collaborative approach to pain management and ensuring access to care across all care settings and for patients across the continuum of opioid prescribing, including prevention, treatment and supportive therapy,” Sophia Chhay, PharmD, an assistant director of the ASHP Innovation Center, in Bethesda, Md., told Pharmacy Practice News. “Moreover, ASHP advocates for a shared decision model that puts the patient at the center of care decisions.”
A Challenge From Former Surgeon General
Jerome Adams, MD, MPH, sparked the review of the recommendations during the ASRA spring 2019 meeting, where he, a former U.S. surgeon general, was a speaker. “Dr. Adams, of course, spoke about the opioid crisis and his initiatives,” said Eugene R. Viscusi, MD, the senior author of the recommendations and an immediate past president of ASRA. “We started talking about the specific role of anesthesiologists and pain physicians in addressing the opioid crisis.”
Dr. Viscusi and his colleagues shared some of their clinical initiatives and research in this area with Dr. Adams. “Dr. Adams essentially challenged me to produce some sort of initiative that would spur anesthesiologists to embrace their role in treating patients with OUD and to help initiate buprenorphine, specifically in these patients, when they enter the perioperative arena,” said Dr. Viscusi, the chief of pain medicine and a professor of anesthesiology at Sidney Kimmel Medical College of Thomas Jefferson University, in Philadelphia.
In the case of a patient admitted to the hospital with a complication from addiction, such as infection, the recommendations support transitioning the patient from the use of standard opioids to buprenorphine after surgery and before discharge. The recommendations detail an approach that can be relatively easily accomplished without causing opioid withdrawal, assuming the patient is interested in treatment.
For example, starting buprenorphine can be considered “for postoperative analgesia in patients with suspected OUD, using available social work or ancillary services to help facilitate linkage to outpatient buprenorphine prescribers when possible,” the recommendations state.
Additionally, “in circumstances in which a warm hand-off has not been definitely established, the amount of buprenorphine prescribed can be consistent with appropriate postoperative discharge standards; however, a longer course of treatment could be provided, depending on the prescribing physician’s comfort level.”
The other scenario is patients in drug addiction recovery currently on buprenorphine, for whom the recommendations advocate continuing the medicine during hospitalization and after discharge without interruption.
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The recommendations state that in preoperative planning for patients on long-term buprenorphine therapy, the drug should not be discontinued before surgery. In addition, for postoperative pain management in patients on long-term buprenorphine therapy, multimodal analgesia, including adjunctive nonopioid medications and regional anesthesia, should be instituted.
“Supporting patient access to buprenorphine perioperatively, as the paper outlines, is a pragmatic and efficient way to initiate and maintain therapy,” Dr. Chhay said.
Pharmacists’ Expertise Called Crucial
ASHP was involved in the joint venture as part of its commitment to advocating for pharmacists’ role in increasing patient access to OUD medications, which in general are severely underused, Dr. Chhay said.
“While not specific to the perioperative setting, it is estimated that as low as 10% of the population with an indication for a medication treatment of opioid use disorder, like buprenorphine, receive it or have access to it,” said Dr. Chhay, who pointed to an American Medical Association article on OUD treatment (JAMA Netw Open 2022;5[3]:e223821).
Pharmacists play a crucial role on the interprofessional care team as medication experts and patient care providers, Dr. Chhay said. For example, pharmacists can provide health professionals with details specific to buprenorphine, such as indications, dosing, mechanism of action and side effects, she said. For patients, pharmacists can offer counseling, prescription assistance information and education regarding a specific pain management plan, she added.
Multidisciplinary Approach
Although the new recommendations are specific to anesthesiology, they are relevant to any clinician involved in the inpatient setting and OUD, noted Dr. Viscusi, who is a member of the editorial advisory board of Anesthesiology News, a sister publication to Pharmacy Practice News. In determining optimal pain management for these patients, he urged clinicians to take a multi-pronged approach.
“Opioids are not fully effective for this population because of the patient’s chronic opioid exposure and tolerance,” he said. “Therefore, to increase the analgesic efficacy, you must use an aggressive multimodal approach, with regional anesthesia if you can, and likely ketamine and other nonopioid analgesics.”
As for any challenges in implementing the OUD recommendations, they usually are caused by the healthcare system itself, Dr. Viscusi noted. To avoid problems, “you need to have a prescriber at the other end of this process,” he said. “You cannot just simply start patients on buprenorphine. Patients have to be plugged into a system, so once they leave the hospital, they have the appropriate follow-up.”
Having said that, buprenorphine still will play a key role, in part due to the 100,000 deaths attributed to opioid use over the past 12 months. “If anything, the number of these patients is spiraling out of control,” Dr. Viscusi said. “We are going to have to get used to dealing with these patients and do everything we can to get them through the system. Foremost, it is an ethical issue, and secondarily, it is going to bankrupt the healthcare system. Buprenorphine is an important component to treating opioid addiction and keeping patients out of trouble.”
The sources reported no relevant financial disclosures.
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Ensuring Medication Access Amid Chaos
How an outpatient pharmacy served its patients during George Floyd protests
Anitha Nagelli, MPH-HPA, MEd
Clinical Assistant Professor College of Pharmacy - Ambulatory Care Pharmacy University of Illinois Chicago N obody expects civil disorder to break out in the streets near their hospital, but that’s exactly what happened to us in May 2020, when violent protests spurred by the George Floyd incident threatened to distrupt outpatient pharmacy services. Fortunately, we were able to ensure access to medications for patients who were affected by pharmacy closures during the turmoil.
The front-line pharmacy team was able to absorb the influx of patients, address immediate medication needs, and identify and tag patients for followup. A central team was able to participate and provide longitudinal patient access to the rest of the medications.
As a result of these efforts, our team, working in the University of Illinois (UI) Health outpatient pharmacies in the Outpatient Care Center (OCC), provided care to many patients whose medications needs may not otherwise have been met during the unrest. Here are some notes from the field on how our front-line pharmacies and a central remote team used a collaborative workflow to meet the needs of our providers and patients.
Background
Access to pharmacy services and medication therapy can be a barrier to disease treatment, leading to poor patient outcomes. The inability to access medications can lead to nonadherence, resulting in increased hospital admission rates as high as 69%. Various reasons may lead to nonadherence, such as affordability, transportation, or pharmacy deserts.1
During the summer of 2020, the pandemic had caused a high degree of strain on patients and pharmacies due to sickness, quarantine, and social distancing. Pharmacy teams were frantically evolving and adapting their workflow and services to continue to provide much-needed pharmacy care in a safe manner. From May 28 to June 1, 2020, the City of Chicago experienced mass lootings and destruction of businesses as a result of civil unrest related to the George Floyd incident. Many pharmacies were closed due to the danger presented to employees.2 According to an estimate from the Illinois Pharmacists Association, about 60 Chicago pharmacies were damaged or
Front-Line Team
Centralized Remote Team
Figure 1. Collaborative workflow model of patient engagement and prescription access to relieve front-line burden.
MTM, medication therapy management; UI, University of Illinois
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Figure 2. Medication needs met per month.
closed during this period. The pharmacies were mainly located in the Loop and South Side.3
The closure of these pharmacies led to a frantic flood of patients trying to gain access to their medications at UI Health outpatient pharmacies. Working at the UI Health OCC pharmacy, we were able to engage and provide care for patients who were affected by these closures. Absorbing this influx of patients with unique challenges to access to medication in the midst of a pandemic required some workflow and staffing interventions. To support the OCC pharmacy front-line team and expand their capacity to care for these patients longitudinally, a collaborative model of workflow was created to promote coordination between the frontline pharmacy team and a centralized remote team (Table).
Role of the Front-Line Team
The UI Health OCC pharmacy frontline team responded to patients who walked up to or called the pharmacy to access their medications. The team gathered information regarding the patients’ immediate medication needs and the pharmacies where the prescriptions were housed. An attempt was made to contact each pharmacy; however, the closed pharmacies had automated phone messages and did not provide options for transfer of medications. As a second step, the UI Health OCC pharmacy front-line team contacted the prescribers to initiate a new prescription to create medication access. The front-line team encountered refill-too-soon rejections from payors and made calls to get overrides. Once the immediate need medications were filled, patients were flagged for follow-up so we could meet the continued needs for medications in the event that the pharmacies did not reopen in a timely manner or remained closed indefinitely (Figure 1).
Role of the Central Remote Team
The centralized remote team consisted of 1 pharmacist and 2 pharmacy student externs. The pharmacy externs completed medication reconciliation on patients to tabulate their medication needs. Once reconciliation was complete, a data collection sheet was created to house data related to patient identifiers; patient contact information; list of medications; and the name, address, and contact number of the pharmacy where the prescriptions were housed. A list of prescriptions that needed to be transferred was created.
Pharmacy externs were trained on how to transfer medications. A transfer data sheet was created to guide, establish scope, and document the transfer information for all the prescriptions that were to be transferred for each patient. Several virtual phone lines were created to allow for telephonic patient engagement. Each patient was engaged telephonically to review ongoing medication needs, obtain consent to transfer medications, or acquire new prescriptions, if needed.
Patients also were asked whether they were able to come to the pharmacy to pick up the medications or needed the medications to be delivered to their homes. The initial patient engagement calls, as well as calls to the pharmacy for transfer of prescriptions, were made by the pharmacist and subsequently by pharmacy student externs. A time study revealed that pharmacists spent a total of approximately 36 hours engaging patients and transferring their prescriptions. The student externs spent approximately 8 hours in medication reconciliation, prepping the transfer forms, and entering the prescriptions.
Results
Sixty patients had an initial encounter with our front-line team. All 60 patients were referred to the central team for triage and further assistance with prescription access and longitudinal pharmacy care. Eventually, 40 patients chose to continue to receive their pharmacy care from the UI Health OCC pharmacy, and 20 patients returned to their original pharmacies. A total of 692 medication needs were met from June to December 2020 (Figure 2). The top categories of medications included antihypertensive agents, diabetic agents, and statin therapies.
Conclusion
Creating a remote centralized team and process to support a front-line pharmacy team allowed the UI Health OCC pharmacy to provide access to medications to patients who were affected by pharmacy closures due to the Chicago riots. A centralized remote team and workflow allowed for increased capacity, efficiency, social distancing, and off-loading of work burden from the front lines during the pandemic. It also allowed for the creation of remote telephonic patient engagement capabilities.
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References
1. CDC. Overcoming barriers to medication adherence for chronic diseases. Accessed
March 3, 2022. bit.ly/3CpJfGx 2. Fields HE, Shaw TE. Looting during a time of civil unrest affects pharmacies on the South
Side of Chicago. J Am Pharm Assoc (2003). 2020;60(6):e39-e40. 3. Schencker L. ‘It’s catastrophic’: Chicago-area patients struggle to get medications as pharmacies close amid George Floyd unrest. Chicago Tribune. June 3, 2020. Accessed March 3, 2022. bit.ly/3tl9idu
Ms Nagelli reported no relevant financial disclosures.
Students Get Hands-on Supply Chain Experience
By Jillian Mock
This spring, four students from the College of Pharmacy of Xavier University of Louisiana, a historically Black university, started an unusual new supply chain elective course. The class is the result of a collaboration with AmerisourceBergen, which pro-
vides the students with a closer look at the life of medications before they hit pharmacy shelves.
The new six-week class (bit. ly/3uuOke8) is an Advanced Pharmacy Practice Experience (APPE) Pharmacy Distribution Leadership Rotation for fourth-year pharmacy students. In its first iteration, the class was entirely virtual, although the course creators hope to include in-person site visits in the future. The students are exposed to multiple business areas within AmerisourceBergen, including business operations, financials, customer service, consultative selling, and value-added services and solutions to support AmerisourceBergen customers.
The class grew out of an existing sales course that XULA and AmerisourceBergen created together. Goals of the class include expanding students’ understanding of the drug supply chain, exposing them to alternative career paths in the pharmaceutical industry, and empowering young, Black pharmacists to step into leadership roles. AmerisourceBergen plans to continue offering rotations each year depending on XULA’s schedule and needs.
“It’s the supply chain … as a pharmacist you don’t typically think about [that
part of pharmacy practice],” said Rashad Haynes, a XULA pharmacy student who participated in the course in a video promotion about the class. “As a pharmacy student, you definitely don’t see ... how many hands are involved in the process of getting medication to the patients” (vimeo.com/684405627/e375614b2f).
In the first week of the course, the students receive an overview of AmerisourceBergen distribution centers and replenishment operations. In the second and third weeks, the students rotate with account services, learning about health-system and services solutions and community and specialty pharmacy. In the final three weeks of the program, the students learn about working with many different types of clients, including community and regional hospitals, physician distribution (oncology and nononcology) and children’s hospitals. Students also learn about account services, specialty distribution and transportation.
In the final week, the students give an oral presentation on an assigned topic, in which they demonstrate the skills they learned over the course of the rotation. In the final presentation, students are expected to demonstrate skills such as problem solving, effective communication and leadership.
Linking the Supply Chain To Patient Care
The primary goal of the new course is “to give students an understanding of supply chain and how it links to [patient care delivery],” said Minh Duong, PharmD, the vice president of commercial solutions, client strategies and services at AmerisourceBergen and one of the course preceptors. “We really strive to expose learners to the wholesale business, distribution business, as well as the process—the interconnectivity between all the different stakeholders in this ecosystem.”
The course focus is unique in pharmacy education, said Milena Murray, PharmD, MS, an associate professor of pharmacy practice at Midwestern University College of Pharmacy, in Downers Grove, Ill., who is not involved with the project. Pharmacy students learn about distribution and supply chains during their didactic education, but this course provides hands-on experience with drug distribution. “I don’t think many pharmacy students are able to do that on a regular basis with their APPEs,” she said.
As a result of the traditional approach to pharmacy education, many students who end up working in a retail or hospital pharmacy don’t have a good idea of what happens to get all the drugs to their shelves every day, according to Kara Poole, the vice president of specialty distribution and community health at AmerisourceBergen, and the
Table. Tentative Rotation Schedule
Time Experience Preceptor
Week 1 Welcome/orientation, distribution services • Learning management system training modules • Distribution center overview • Replenishment operations Various copreceptors
Weeks 2 & 3
Weeks 4-6
Account services
• Health system and specialty services • Community and specialty pharmacy • Presentation topic assigned
Client strategies, including but not limited to the following:
• Group purchasing organization • National and strategic accounts • Regional and community health systems • Physician distribution: oncology supply • AmerisourceBergen specialty distribution • Pharmacy solutions • Marketing/legal • American Health Packaging • Global emerging therapies and channel strategy—branded products • Global generic pharmaceuticals • Coffee chats with AmeriSourceBergen leaders • Consignment • Solution development and commercialization • Supplier diversity • Topic presentation (week 6) Various copreceptors
Various copreceptors will be assigned throughout the course of the rotation
other course preceptor.
Kathleen B. Kennedy, PharmD, the dean of XULA’s College of Pharmacy, said this was the case with her own education. She received primarily clinical pharmacy experience and instruction on how to work with patients during her initial training at the University of California, San Francisco. But early in her career, Dr. Kennedy was thrust into a role as the director of pharmaceutical services at a large teaching hospital. “From inventory control to managing personnel, all of those things—it was learning on the spot, learning while you’re doing,” Dr. Kennedy said.
Another course goal is to “showcase all the different nontraditional roles that the pharmacist has available to them within this industry,” Dr. Duong said, adding that many young pharmacists are not aware of these other career paths.
“Knowing that with my background I can use both my degrees and my experiences in a company, I didn’t know that was an opportunity,” Linda Nguyen, a XULA pharmacy student who enrolled in the course, said in the video about the class.
Empowering Black Students For Leadership
In addition to providing practical skills, the class aligns with XULA’s mission to empower Black pharmacy students to be future leaders in the pharmaceutical industry, Dr. Kennedy said. “Xavier’s overall mission is to promote a more just and humane society,” she noted. “In the college of pharmacy, we train our students to make an impact, particularly in underserved communities to eliminate health disparities.”
Black and other minority students have been excluded so often from opportunities that they can make a difference just by being a part of the conversation, she said. “If we’re talking about the supply chain or distribution, again, being knowledgeable about what your role could be in making an impact is really important.”
The partnership with XULA is a component of AmerisourceBergen’s global diversity, equity and inclusion (DEI) strategy, according to a company press release about the project. “We are always trying to do more and be a part of diversity and inclusion,” Ms. Poole said. “It’s one thing to say you are …[but] this has allowed us to be more actionable.”
Although the COVID-19 pandemic forced the team to adapt the course
to be entirely virtual, there have been some advantages to that approach, Ms. Poole said. Virtual tours and meetings have made it possible to integrate multiple AmerisourceBergen business units and teams that work at different sites and offices into the course, she said. The preceptors plan to keep the course mostly virtual in the future, but ideally will add some in-person meetings, such as a distribution site visit.
Having a course like this one developed with a wholesaler like AmerisourceBergen allows a unique level of access, Dr. Murray said. “The students get to see behind the scenes what actually happens before the drug hits the shelf. I would imagine it’s a more complicated process than any of us imagine.”
Dr. Duong and Ms. Poole said they are not aware of another partnership and course like this one in the United States. “I’ve been in academia for a while,” Dr. Duong said, “and I have not seen a specific rotation experience structured with a distribution partner to give a level of exposure to this industry as we’ve created.”
—Kathleen B. Kennedy, PharmD
The sources reported no relevant financial disclosures.
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