APhA coronavirus watch: Maintaining access to care for patients with chronic pain, OUD during pandemic
Even in the best of times, patients with chronic pain or opioid use disorder (OUD) struggle to get the help and relief they need. Now, with the nation engulfed in the COVID-19 pandemic and physicians and nurses focusing their time and energy on patients with COVID-19, they may find themselves triaged to the back of the line. Enter pharmacists, the health care providers who can make sure these patients have access to their medications—not just for chronic pain and OUD, but for common comorbid conditions like depression and anxiety.
“As with other medications for other chronic conditions, hoarding, closed pharmacies, and unknown future limitations on medication production limit access,” said Jeffrey Bratberg, PharmD, FAPhA, clinical professor at the University of Rhode Island College of Pharmacy and an expert on substance use disorder. “This is further compounded by the very real fear of withdrawal from opioid agonist medications used for pain and OUD should supply be interrupted.”
These barriers to access give pharmacists an opportunity to step in and provide their help and expertise. “Essential workers like pharmacists can help bridge, expand, and sustain access to care, whether through telepharmacy or in person, as safely as possible for the pharmacy workers and the patients and their caregivers,” Bratberg said.
Connect with patients
While acknowledging the challenges pharmacies face with workload and staffing, Bratberg urged pharmacists to “establish and maintain rapport and promote new ways to support patients through telemedicine, telepsychiatry, telepharmacy, longer duration regimens, and delivery and curbside pickup.”
It’s especially important for patients with OUD to know how to contact medication OUD prescribers, Bratberg said. “COVID has limited outreach; a poster that gets put up but isn’t seen isn’t effective, nor a poster that cannot even be distributed.”
‘A phone call and delivery away’
Some structural barriers to access, like transportation, have been mitigated: Opioid treatment programs can now deliver. The Substance Abuse and Mental Health Services Administration and DEA have eased regulations on in-person controlled substance prescribing, making sustainable access to care easier than ever. (See www.samhsa.gov/medication-assisted-treatment.)
Though methadone initiation still requires an in-person visit with exam, “regulatory changes expand delivery and pick-up services, particularly for opioid treatment programs that can now deliver take-home methadone, for longer durations, to people’s homes,” said Bratberg.
This is reassuring news for MAT [medication-assisted treatment] patients who have become “reluctant to leave their homes, as already marginalized people, if they even have stable housing and/or transportation,” he added.
Bratberg said he expects and hopes that with mortality-reducing medications like buprenorphine only “a phone call and delivery away,” more people will seek out care. This will be especially important as the supply of illegal opioids dries up, he noted.
These eased restrictions benefit providers, too. “By extending the time between doses, clinics are less crowded, and personnel can focus on protecting themselves to maintain care for as many patients as possible,” said Bratberg.
Bratberg urges pharmacists to continue to advocate for either eliminating the X waiver or becoming an additional profession to obtain a waiver, as long as reimbursements are equivalent to those of other providers. This would enable pharmacists to independently or collaboratively prescribe buprenorphine via telepharmacy, he said.
With the availability of phone-only buprenorphine maintenance and home induction for new starts, Bratberg noted that “the pandemic offers a glimpse of the safety and effectiveness of easing regulations.” Pointing out that “a majority of people with a diagnosed OUD never get access to the most effective intervention—medications,” he said he hopes these regulations are not reinstated once the pandemic ends.
Naloxone, needles, syringes
Patients and caregivers also need to know they can call pharmacies and get naloxone filled, paid by insurance, and delivered via standing order.
“Most pharmacies can deliver naloxone as any other prescription, both via prescription (or coprescription),” Bratberg said. “States that still have requirements for in-person counseling should be waived “to continue to maintain community saturation of naloxone.”
In some areas, pharmacies also may be the only source for harm reduction equipment like sterile syringes, needles, and alcohol swabs. They may become more essential if and when syringe service programs and their outreach efforts are limited because of the pandemic.
“Now, more than ever,” said Bratberg, “pharmacies need to sell and dispense as many syringes and safe injection supplies as possible at counters, drive-throughs, and by mail, as allowed by law—and advocate to change the law!”
For more on the COVID-19 pandemic, visit pharmacytoday.org for Pharmacy Today’s May 2020 issue.