Pharmacist in central Appalachia addresses the problems that hit her community hardest


Sarah Melton, PharmD, teaches student pharmacists about pharmacotherapy for anxiety disorders.

Nearly 70% of adults with a mental health condition also have a medical condition, such as diabetes, heart disease, or respiratory disease, according to the Robert Wood Johnson Foundation. Presence of one condition is often a risk factor for the other. Among people with mental illness, medication adherence is often less than 50%—similar to rates among people who don’t have mental illness, though the consequences can be more severe. The high rates of comorbidities and nonadherence among people with mental illness point to a special need for pharmacists’ patient care services in this population.

Sarah Melton, PharmD, BCPP, BCACP, CGP, FASCP, has built her career around caring for patients with mental illness and opioid addiction in the Appalachian region of Virginia and Tennessee. Melton, Associate Professor of Pharmacy Practice at the East Tennessee State University (ETSU) Gatton College of Pharmacy, provides patient care at nurse-run Johnson City Community Health Center in Tennessee and at HighPower, PC, in Lebanon, VA.

Finding her niche

When Melton came to work at Johnson City Community Health Center, which is operated by ETSU’s College of Nursing, she saw a need. Run by nurse practitioners, the clinic offers pediatric care, family medicine, midwifery, and behavioral health services. While Melton consults with nurse practitioners and patients in all of these areas, she noticed that the behavioral health nurse practitioner was extremely backlogged and hadn’t been able to take a new patient in more than a year.

“We have such a need in mental health, especially with medication management,” said Melton.

Board certified in psychiatric pharmacy, Melton devised a referral system through which nurses who identify a behavioral health issue in a patient can refer the patient directly to her. Melton takes over the patient’s complete medication management. She takes a full mental health and medication history and works with the nurse practitioner to initiate or change the patient’s medication. 

At HighPower, Melton also cares for patients with mental health conditions. Run by Melton’s husband, who is a family physician board certified in addiction medicine, HighPower is a team-based, patient-centered medical clinic that takes referrals from all around southwest Virginia for complicated patients with mental health conditions and/or substance use disorders.

As there’s a 6-month wait to see a psychiatrist in the region surrounding HighPower, Melton serves as a bridge to psychiatry; in some cases, her interventions may eliminate the need for a psychiatric appointment.

“I have a counselor who works right there with me, so she’s able to do the psychotherapy while I do the medication management,” she said. “Oftentimes the patients don’t even need to go to psychiatry after we’ve gotten them on appropriate medications and engaged in counseling.”

Patient-centered approach

Every one of Melton’s patients gets her direct cell phone number. She wants to ensure that patients let her know about any adverse effects or other issues with their medication without the additional barrier of coming in to see her. 

“It’s an easy way for patients to know that somebody is really looking out for them and caring,” Melton said. “I have found it to be so therapeutic and alleviate some of their anxiety.”

Offering patients her direct line is just one way that Melton makes patients feel included in their care plan. 

“I don’t just tell them ‘this is what I think.’ I give them options. We go through the pros and cons of each treatment option, so they’re actively involved with me as part of the team,” she said. “When they have buy-in and feel like they’re part of the decision, they do much better.” 

That’s been the case with patient Melissa Kelly, who sees Melton for management of her epilepsy medications. Though the 44-year-old Kelly has had seizures since she was a child and has seen many physicians for her epilepsy, no one ever taught her about her medications before Melton.

“She told me things I never knew about seizure medicine—that it would make your bones brittle,” Kelly explained. “I had to get all my teeth pulled, and I never knew that was because of the seizure medication.” 

In addition to putting Kelly on calcium and vitamin D for her bones, Melton referred her to a new neurologist. In the past, Kelly had seen physicians who suggested she was faking her seizures. Kelly was having three to five seizures a day and taking dozens of medications for them. Melton wanted her to see a neurologist who’d take her seriously.

“If it hadn’t been for Sarah [Melton], I would not have gone to Dr. Shields,” Kelly said. “And I would not have gotten the vagus nerve stimulator.” 

The intervention has reduced Kelly’s seizures from 3 to 5 per day to 30 over the last 2 years. She’s significantly reduced the number of medications she must take and reports less bone-related pain as a result of taking supplements.

Showing her gratitude for Melton’s care, Kelly speaks with Melton’s student pharmacists at an annual “lunch and learn.” “She tells them about spending her whole life dealing with a seizure disorder and how a pharmacist can make a difference,” Melton said.

Health disparities

As a pharmacist in Appalachia, Melton also makes a difference in the lives of patients battling opioid addiction. The central and southern Appalachian region has the highest rate of prescription drug abuse and overdose in the country.  

Melton attributes the problem to abject poverty, the preponderance of physical labor that can lead to injury and chronic pain, and a huge prescription drug black market. Studies have also cited as contributing factors the ease of acquiring an opioid prescription in the region and the cultural acceptance of addiction.

Melton and her husband moved to the central Appalachian region in 2000 because they wanted to work with the underserved. Seeing the prevalence of prescription drug abuse and addiction in the area, the pair decided to focus their practice on it.

At HighPower, Melton works with a physician, an addiction counselor, and peer-recovery specialists to help patients with substance use disorders. 

“We have three people who had active addiction and are now in long-term recovery who help lead the groups along with the addiction counselor,” Melton said. “Then I’m able to help address any of their mental health needs, in addition to the treatment of the substance use disorder.”

Perhaps the hardest part of the job, Melton said, is working with pregnant women and, later, their babies, who are born dependent on prescription drugs.

Getting to the source

One contributor to opioid addiction is lack of education and training on the part of prescribers. In addition to helping patients who struggle with these addictions, Melton educates pharmacists and prescribers on highly addictive prescription drugs. In collaboration with One Care of Southwest Virginia and the Medical Society of Virginia, her continuing education programs address appropriate prescribing, screening for substance use disorders, and procedures for referral, treatment, and documentation.  

Melton works with an addictionologist, the state prescription-monitoring program, and an attorney who represents prescribers who have had legal issues as a result of prescribing pain medications. The program has reached more than 2,500 providers.

“It has been amazing to have prescribers come in droves and leave saying, ‘I had no idea about these medications and I’ve been prescribing them,’” she said.

Pharmacy advocate

As a professor and an active member of APhA, Melton is an advocate for pharmacists (see page 67 of April Pharmacy Today for more information on Melton and pharmacists’ provider status). She’s involved with Gatton College of Pharmacy’s APhA Academy of Student Pharmacists chapter. Last year, the chapter won second place for its Generation Rx activities—an APhA-sponsored outreach program to prevent prescription drug abuse among youth.  

Student pharmacists rotate with Melton at the Johnson City Community Health Center. In addition, she works with the clinic’s interprofessional education program, a student-led clinic that includes student pharmacists and nursing and nutrition students.  

“It’s great because we’ve been able to expose more students and faculty from various disciplines to clinical pharmacy,” she said. “[They] wouldn’t otherwise know what pharmacists can do.”

Melton and students interact with women during group therapy for the treatment of opioid dependence.

Pharmacists’ role in confronting the stigma of mental illness and substance use disorders

Prescription drug abuse overdose deaths are at epidemic levels across the country. Pharmacists can play a key role in education, prevention, and referral, but first they must understand these key points:

  • Mental illness and substance use disorders are medical illnesses—not a moral weakness or a willful choice.
  • Our language perpetuates the stigma. Avoid judgmental and pejorative terms like “druggie,” “dirty,” “crazy,” “junkie,” “psycho,” “nutcase,” “dope fiend,” and “screw loose.”
  • The patient is a person—not a disease. Avoid calling your patient a schizophrenic or addict. Instead, call them a patient with schizophrenia or addiction.
  • Patients treated for opioid dependence with methadone and buprenorphine are not “trading one addiction for another.” The medicine is a small part of a comprehensive treatment program that includes psychotherapy, support group meetings, and regular monitoring programs. Medication-assisted treatment helps control craving and withdrawal so that patients are able to do the hard work necessary to reach recovery.
  • We all have attitudes, preconceived notions, and stereotypes about mental illness. Get involved with the National Alliance on Mental Illness (NAMI). NAMI’s In Our Own Voice programs can change the way we think.

—Sarah Melton, PharmD, BCPP, BCACP, CGP, FASCP