The pandemic’s disruptive effect on healthcare delivery exposed a gap that pharmacists can fill in treating patients with substance use disorder.
By Jane E. Rooney
Disruptions in care due to the pandemic created headaches and delays for many providers and patients. But for some populations, such as individuals being treated for substance use disorder, those disruptions went beyond being inconvenient to becoming dangerous or even deadly in some instances. Last month the Biden administration announced that more than 100,000 people died of drug overdoses between April 2020 and April 2021—the first time that drug-related deaths have reached six figures in any 12-month period. The pandemic appears to be at least partly responsible for the increase.
An article published by the American Psychological Association in March noted that the early months of the pandemic brought an 18 percent increase nationwide in overdoses compared with those months in 2019. It also reported on findings from the American Medical Association that as of last December, more than 40 states had seen increases in opioid-related mortality. Healthcare providers across the country have observed an uptick in quantity and frequency of drug use during the pandemic. The isolation brought on by lockdowns, added stress related to finances and childcare and difficulty accessing treatment exacerbated an already tenuous situation.
“There was acute destabilization for a system that already had limitations,” noted Dr. Lucas Hill, clinical associate professor and director, Pharmacy Addictions Research & Medicine Program, The University of Texas at Austin College of Pharmacy. “This is a patient population that is likely experiencing other major struggles in their life on a day-to-day basis, such as chronic health issues—sometimes psychiatric—maybe difficulties with transportation getting to a clinic. Any minor disruption can throw them into severe crisis of not being able to access medication. One thing that has been missed a bit during COVID is that if you look back at the available data on drug overdose deaths in the U.S., they began to trend upward in August 2019 through February 2020. It definitely accelerated after lockdowns and social isolation, but there’s no doubt that drug overdose death was increasing prior to COVID. Those numbers have increased almost exclusively due to potent synthetic opioids. The pandemic certainly made things worse, but we were already on a problematic trajectory.”
The disruptions in healthcare over the past year and a half have prompted conversations about expanding the pharmacist’s role in caring for patients with substance use disorder and how to address any future gaps or disruptive events. “As pharmacists we’ve been trying to figure out what our appropriate role is, not only in preventing misuse but expanding access to treatment and harm reduction services,” Hill said. “The COVID disruption has shined a spotlight on the role we need to play going forward and areas we need to improve.”
Opportunities to Expand Services
The loss of in-person support for those with substance use disorder and the pandemic’s toll on mental health led to more substance use and overdose death. That reality hit rural communities especially hard, explained Dr. Keri Hager, associate professor and co-associate dean for clinical affairs, University of Minnesota College of Pharmacy, because the already limited access to providers coincided with staffing shortages.
“The pandemic opened the dialogue about access via pharmacies with the vaccine and testing, so that’s opened a broader dialogue about the role pharmacists can play in public health, especially in rural areas,” Hager said. “In rural Minnesota, we’re having more conversations about providing harm reduction services. We can sell syringes without a prescription here and we can provide naloxone. We’re trying to find ways to enable the pharmacists working in these rural areas to provide that level of service. Our state association annual meeting is coming up and we have a few sessions around that issue. What can we do to stem overdose death through pharmacy services? [In my clinic] I’m providing comprehensive medication management services. Taking a comprehensive look at all of the medications for my patients and helping connect and bridge across the treatment plan has been really important, and I can see an opportunity for expansion there.”
There are good signals that there are things states can do to increase stocking of [buprenorphine and naloxone kits]. That is the most important area where we could have an impact. We need to expand education for community pharmacists about the role these medications play in opioid response. If community pharmacists could maintain a supply of these, it would go a long way in showing that pharmacists can play a helpful role.
Dr. Lucas Hill
Hager’s colleague Dr. Laura Palombi, associate professor, University of Minnesota College of Pharmacy-Duluth, agreed that, particularly for patients in recovery, losing their social connections and support groups was a major setback. “There are more barriers to shifting to online treatment in rural communities. There are also transportation barriers,” Palombi said. “There are a shortage of treatment facilities and patients often have to go long distances to get treatment. In rural communities, people don’t have the same ability to telework. Their jobs require them being there and doing something in person. If those places shut down, they don’t have the resources. That’s another barrier as well—people can’t just take time off to go to treatment.”
Perhaps the biggest barrier, Hager pointed out, is stigma. “We did a survey with the recovery community. What came out loud and clear is how stigmatized people feel if they have a substance use disorder. My colleagues have done some work in surveying to understand pharmacists’ perceptions of harm reduction strategies for individuals who inject drugs and need sterile equipment so we can better create educational interventions.”
It’s saving lives and saving money but some pharmacists still have a problem dispensing sterile syringes. As pharmacy educators we need to do a better job showing the benefits. We are working on this at pharmacy schools across the nation. I would like to see community pharmacies selling sterile syringes and referring people to treatment facilities and engaging more with the public health community and harm reduction agencies. Ambulatory or hospital pharmacies can take on greater roles and become experts in that area.
Dr. Laura Palombi
While the pandemic presented few silver linings, it did allow the pharmacy community to consider the opportunities that exist to offer their services when care is disrupted. “Pharmacists and pharmacies did adapt quickly. In our state it was ‘all hands on deck’ figuring out how we really expand access to the vaccine because so much needed to be delivered as quickly as possible,” Hager said. “I saw a lot of collaboration among associations and organizations across the state. There are ongoing conversations about how we respond in a more coordinated way. I have seen a lot of innovative pharmacies that were quick to deliver both the vaccine and COVID testing. We should be working better to mobilize quickly.”
Telehealth was another silver lining in terms of bolstering infrastructure, she acknowledged, but not everyone in rural areas has access to that technology. While telehealth is likely here to stay, a needs assessment about clinical pharmacy services that Hager is undertaking indicates that physicians prefer to have a pharmacist on site.
UT-Austin’s Hill said that at the national level, professional organizations and research funders are working on engaging pharmacists in learning about treatment for substance use disorder as well as providing community pharmacists with training and support and addressing underlying barriers. “Ongoing projects are seeking to engage pharmacists in co-management of opioid use disorder, safe use of medications and testing out different levels of autonomy for clinical pharmacists,” he noted. “I’m hopeful that early findings from these novel approaches will lead to pharmacists being more intentionally included when federal regulators are considering how they manage access to these medications.”
Hill and some colleagues conducted an audit of 5,000 pharmacies in the U.S. and found that most were not prepared to supply buprenorphine and naloxone kits. “There are good signals that there are things states can do to increase stocking of those medications. That is the most important area where we could have an impact. We need to expand education for community pharmacists about the role these medications play in opioid response,” he said. “If community pharmacists could maintain a supply of these, it would go a long way in showing that pharmacists can play a helpful role. Pharmacists could identify certain moments when a person is showing signs that they might have substance use disorder and could use help. For example, if someone is buying syringes without a prescription, the pharmacist could sell syringes to that individual, recognizing that increased access to sterile syringes helps [to limit adverse outcomes] and also offer naloxone. There would be potential to discuss ongoing treatment. Building that credibility and connection to members of our community who might need support is really an important area where I think we could grow.”
As Palombi suggested, “We know our healthcare systems are stretched extremely thin. How can we support our healthcare system and also practice at the top of our license? As more people see the value in [offering medications for substance use disorder treatment], hopefully there will be more demand. We can play a huge role with our accessibility. It makes sense for us to have those conversations about how to train our students to be in those roles and how we adapt as a profession.”
Providing Stability to Patients
One of the biggest disruptions for patients with substance use disorder during the pandemic was decreased access to syringe service programs, according to Hill. “Those are the people in the most need of support. Those programs are run by volunteers and are underfunded but they provide services directly to those individuals,” he emphasized. “When they weren’t operating for several months, people needed to be able to turn to a pharmacy. We could be that support system when other services are not available. There’s a role for clinical pharmacists as well. In hospitals, they play a role in ensuring that buprenorphine can be initiated during a hospitalization. It can be important to ensure that patients don’t experience withdrawal or leave the hospital too early. Outpatient clinical pharmacists can help prescribers stay up to date on guidance related to buprenorphine. Pharmacists can provide support for ongoing evaluation and medication management.”
At Minnesota’s College of Pharmacy, the curriculum is frequently updated to ensure that student pharmacists are prepared to treat patients with substance use disorder and to discuss naloxone use. “It is so important and so underprescribed. We want them to be well-versed in naloxone,” Palombi said. “They can talk to patients about it and have it become part of transitions of care. Now our students are trained in it in the fall of their first year. When it comes to syringe access, a lot of community pharmacies struggle. There is bias and stigma within the field. How do we self-check to make sure we are not contributing to the stigma? We are constantly adapting our curriculum and we look to AACP for guidance and competencies and we are talking to other schools. We’re always learning from each other about what’s working and what’s not.”
Local community partners in public health also offer guidance in terms of where pharmacy practice could expand. A recent study involving focus groups with students from eight pharmacy schools helped identify gaps in the curriculum. “I think across the Academy this is an area [we need to address]…it is tough to convince some pharmacists of the value of syringe access,” she continued. “It’s saving lives and saving money but some pharmacists still have a problem dispensing sterile syringes. As pharmacy educators we need to do a better job showing the benefits. We are working on this at pharmacy schools across the nation. I would like to see community pharmacies selling sterile syringes and referring people to treatment facilities and engaging more with the public health community and harm reduction agencies. Ambulatory or hospital pharmacies can take on greater roles and become experts in that area.”
Hager agreed that more can be done to expand curricular offerings regarding addiction, treatment and the pharmacist’s role in harm reduction. “I would love to see community pharmacy practice [expand] and for pharmacists and technicians to feel empowered to be the first line champions and cheerleaders for anyone with a substance use disorder,” Hager said. “Have the welcome mat out for those who come to a pharmacy just like they would for any other patient. Think about having empathy and compassion for a person using drugs. Meet them where they are. If they need sterile equipment, provide that and ask if they are connected with testing to make sure they are safe. Help people get what they need. If they show up and you are open and kind, that goes a long way. It’s being a portal to them getting treatment. All of medicine is harm reduction.”
And for many patients, the counseling and a supportive recovery community is crucial, Palombi added. “People do get better. As the recovery community grows, that’s helpful for pharmacists to hear those stories because maybe they just see the negative. How to help patients connect to those social services is just as important as the drug itself.”
Hill noted that he has heard encouraging stories about small community pharmacies connecting with treatment programs and engaging in proactive outreach to ensure that patients have stable access. “That’s a lot to ask of pharmacists who already have full plates, but reaching out now when things aren’t quite as stressful to see what collaborations can be developed would be important. The number one thing we need to convey to pharmacists is that we should be taking a harm reduction-oriented approach,” he said. “Many of us were trained in a time when enforcement and prevention were prioritized in our education. We were seen as a gatekeeper to prevent drug misuse. That’s a role we need to play in some cases, but we don’t want to prevent access to buprenorphine and we need to ensure that people with a substance use disorder don’t feel so uncomfortable entering a pharmacy that they don’t seek us out for support, that they won’t obtain naloxone because of a fear of how we see them. Being compassionate is a crucial mindset going forward as opioid deaths are only accelerating.”
Hager encouraged pharmacists to take a “there’s no wrong door” approach for people with substance use disorder who are seeking help. “This is a primary care issue. We have a huge opportunity to step up and improve this public health emergency specifically in the community pharmacy setting and specifically in the rural setting where the pharmacy may be all that’s there.”
Jane E. Rooney is managing editor of Academic Pharmacy Now.