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Daily Archives: January 3, 2018

First Edition: January 3, 2018

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Pharmacists Slow To Dispense Lifesaving Overdose Drug

Gale Dunham, a pharmacist in Calistoga, Calif., knows the devastation the opioid epidemic has wrought, and she is glad the anti-overdose drug naloxone is becoming more accessible.

But so far, Dunham said, she has not taken advantage of a California law that allows pharmacists to dispense the medication to patients without a doctor’s prescription. She said she plans to take the training required at some point but has not yet seen much demand for the drug.

“I don’t think people who are heroin addicts or taking a lot of opioids think that they need it,” Dunham said. œHere, nobody comes and asks for it.”

In the three years since the California law took effect, pharmacists have been slow to dispense naloxone, which reverses the effects of an overdose. They cite several reasons, including low public awareness, heavy workloads, fear that they won’t be adequately paid and reluctance to treat drug-addicted people.

In 48 states and Washington, D.C., pharmacists have flexibility in supplying the drug without a prescription to patients, or to their friends or relatives, according to the National Alliance of State Pharmacy Associations. But as in California, pharmacists in many states, including Wisconsin and Kentucky, have divergent opinions about whether to dispense naloxone.

“The fact that we donât have wider uptake … is a public health emergency in and of itself,” said Virginia Herold, executive officer of the California State Board of Pharmacy. She said both pharmacists and the public need to be better educated about the drug.

Pharmacists are uniquely positioned to identify those at risk and help save the lives of patients who overdose on opioids, said Talia Puzantian, a pharmacist and associate professor of clinical sciences at Keck Graduate Institute School of Pharmacy in Claremont, Calif.

There’s a Starbucks on every corner. What else is on every corner? A pharmacy. So we are very accessible,” Puzantian told a group of pharmacy students recently as she trained them on providing naloxone to customers. “We are interfacing with patients who may be at risk. We can help reduce overdose deaths by expanding access to naloxone.”

Talia Puzantian, associate professor of clinical sciences at Keck Graduate Institute School of Pharmacy in Claremont, Calif., teaches students about naloxone, which reverses the effects of an opioid overdose. Puzantian got a federal grant to teach more pharmacists around California about naloxone. (Ivan Alber/Keck Graduate Institute)

Opioid overdoses killed 2,000 people in California and 15,000 nationwide in 2015.

Naloxone can be administered via nasal spray, injection or auto-injector. Prices for it vary widely, but insurers often cover it. The drug binds to opioid receptors, reversing the effect of opioids and helping someone who has overdosed to breathe again.

At least 26,500 overdoses were reversed from 1996 to 2014 because of naloxone administered by laypeople, according to the National Institute on Drug Abuse. Since then, the drug has become much more widely available among first responders, law enforcement officers and community groups. The drug is safe and doesn’t have serious side effects, apart from putting someone into immediate withdrawal, according to the institute.

Information on how many pharmacists are dispensing naloxone is limited, but one study last year showed access to the drug at retail pharmacies increased significantly from 2013 to 2015 from previously small numbers.

Interviews and available evidence from around the U.S. indicate that pharmacists have varying perspectives. In Kentucky, for example, one study found that 28 percent of pharmacists surveyed were not willing to dispense naloxone.

In Pennsylvania, pharmacists weren’t exactly lining up to hand out naloxone when the state passed a law in 2015 allowing them to do it, said Pat Epple, CEO of the Pennsylvania Pharmacists Association. She said there were some initial obstacles, including the cost of the drug and pharmacists’ limited awareness of the law. The association worked with state health officials to raise awareness of naloxone among patients and pharmacists and reduce the stigma of dispensing it, Epple said.

Wisconsin is also among the states that allow pharmacists to dispense naloxone. Sarah Sorum, a vice president at the Pharmacy Society of Wisconsin, said the state’s pharmacists want to expand their public health role and help curb the opioid epidemic. But reimbursement has been a challenge, she said.

Not all health plans across the nation cover the full cost of the drug, and pharmacists also are concerned about getting paid for the time it takes to counsel patients or their relatives.

California and other states require pharmacists to undergo training before they can dispense naloxone to patients who don’t have a doctor’s prescription. Puzantian and others say that in California not enough pharmacists are getting the training, which can be taken online or in person and can cost a few hundred dollars.

So far, the California State Board of Pharmacy has trained between 4Ȓ and 500 pharmacists, and the membership-based California Pharmacists Association has added an additional 170. Other smaller organizations offer the naloxone training, according to the association. There are about 28,000 licensed pharmacists in the state.

Once trained, California pharmacists who provide naloxone must screen patients to find out if they have a history of opioid use. They also must counsel people requesting the drug on how to prevent, recognize and respond to an overdose.

Some say training requirements are an unnecessary barrier, especially given the high level of education already required to become a pharmacist.

Some of the bigger pharmacy chains, including CVS, Rite Aid and Walgreens, have made the drug available without a prescription in the states that allow it. Walgreens has announced that it would stock the nasal spray version of naloxone at all of its pharmacies. It said it offers the drug in 45 states without requiring the patient to have a prescription.

Peter Lurie, president of the Center for Science in the Public Interest, said not every pharmacy has to dispense naloxone for people to have access to it. “But the greater the number of dispensing pharmacies the better,€ he said, adding that it is “especially important in more sparsely populated areas.”

Corey Davis, deputy director of the Network for Public Health Law, said making naloxone available over the counter would also increase access, since people could buy it off the shelf without talking to a pharmacist.

Bryan Koschak, a community pharmacist at Shopko in Redding, Calif., said people should go to a hospital or doctor’s office for naloxone. “I am not champing at the bit to do it,” he said. “It is one more thing on my plate that I would have to do.”

Michael Creason, a pharmacist in San Diego expressed a different view. He did the training after his employer, CVS, required it. He said pharmacies are a great vehicle for expanding access to naloxone because patients often develop a rapport with their pharmacists and feel comfortable asking for it.

Pharmacy associations should educate their members about the laws that allow naloxone to be provided without a doctor’s prescription and persuade more of them to provide the drug to customers who need it, Lurie said. Others say more pharmacists should put up signs to make customers aware that naloxone is available in their shops.

The California Pharmacists Association said it is trying to raise awareness through newsletters and emails to pharmacists in the state. “We want to see every pharmacy be able to furnish naloxone and every person at risk have access to it,” said Jon Roth, the association’s CEO.

The state’s pharmacy schools also include the training in their curriculum. One day recently, Puzantian explained to a classroom full of pharmacy students that naloxone is effective, safe and can prevent death.

âYou can’t get a dead addict into recovery,” she told the students. Drug users “might have multiple overdoses, but each overdose reversal is a chance for them to get into recovery.”

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‘Put The Fire Under Us’: Church Spurs Parishioners To Plan For Illness And Death

“It would feel like murder to pull her life support,” a young woman tells the doctor.

The woman sits by a hospital bed where her mother, Selena, lies unresponsive, hooked up to a breathing tube. The daughter has already made one attempt to save her mother’s life; she pulled Selena out of the car and performed CPR when her heart stopped en route to the hospital — an experience she calls “beyond terrifying.”

Now the doctor tells the family Selena will never wake up in a meaningful way. But the daughter says she can’t let her mother go: “I’m always looking for another miracle.”

The scene, captured in the documentary œExtremis,” took place in a hospital’s intensive care unit in Oakland, Calif.

Three thousand miles away, at Boston’s Bethel AME Church one recent fall evening, the Rev. Gloria White-Hammond watched the film with a group of women from her predominantly black congregation. As they gathered around a long table in the church’s youth center at 7 p.m., White-Hammond offered oranges and chocolate chip cookies — and a warning that the film might be very hard to watch.

White-Hammond, an energetic 67-year-old activist and minister who also teaches at Harvard Divinity School, is accustomed to broaching difficult subjects. She often speaks out about being sexually abused by her father during childhood — an experience that motivated her to work with survivors of sexual violence in Sudan. Now, she’s using her unusual credentials as a pastor — and a pediatrician — to take on a new subject: death.

Pastor Gloria White-Hammond speaks with parishioners after a Sunday service at Boston’s Bethel AME Church. White-Hammond wants to get all 600 congregants to write down their end-of-life wishes and discuss them with their families. (Kayana Szymczak for KHN)

As the film ended, White-Hammond and her congregants sat quietly as letters on the screen revealed Selena’s fate: The family had Selena surgically attached to a breathing machine. She lived that way, drifting in and out of consciousness, for nearly six months.

White-Hammond broke the silence with a prayer.

“We know Selena,” she said, speaking metaphorically. “Her brothers are our brothers.”

Like Selena, most of the people in the room were black women. They are grappling with the question: If they end up like Selena, what would they want their families to do?

“God, guide us and direct us,” said White-Hammond as heads bowed. After they die, she said, her parishioners may see the face of Jesus, and “sit at his feet and be blessed.”

But first, they have work to do.

Pastor Gloria White-Hammond and her husband and co-pastor, Ray Hammond, stand during a Sunday service at Bethel AME Church on Dec. 3, 2017, in Boston. (Kayana Szymczak for KHN)

White-Hammond is determined to get all of her 600 congregants to write down their end-of-life medical wishes and discuss them with their doctors and families.

White-Hammond treated patients until about seven years ago, and her husband and co-pastor, Ray Hammond, is a doctor, too. But when an organization called The Conversation Project approached her a few years ago about leading death-and-dying workshops with her congregation, she discovered she hadn’t planned for her own death or serious illness.

“I didn’t have my own documents” outlining medical wishes, she said. €œI was kind of embarrassed.”

Nationwide, only a third of Americans have documented their end-of-life wishes, according to a recent poll by the Kaiser Family Foundation. For black adults 65 or older, rates are much lower: Only 19 percent have documented their end-of-life wishes, compared with 65 percent of whites. Older black adults are half as likely as whites to have named someone to make medical decisions on their behalf if they became incapacitated, the poll found. (Kaiser Health News is an editorially independent program of the foundation.)

Another KFF poll found that blacks are more likely than whites to say that living as long as possible is extremely important,” and that the U.S. medical system places too little emphasis on extending life.

As part of the discussion at Bethel AME, White-Hammond asked attendees to look through the “Five Wishes” end-of-life planning document. At monthly workshops, White-Hammond has introduced over 100 parishioners to the document over the past two years. She said people often get stuck when filling out the second wish, which asks whether they want life support in certain grim scenarios that they may not be familiar with, such as permanent brain damage.

White-Hammond screened “Extremis” to illustrate what ventilators and feeding tubes are really like €” and what it’s like for families to make decisions without explicit instructions. The documentary, which lasts an intense 24 minutes, provoked a strong response.

Pastor Gloria White-Hammond distributes Holy Communion during a Sunday service at Bethel AME Church in Boston. (Kayana Szymczak for KHN)

Pastor Gloria White-Hammond has introduced over 100 of her parishioners to the “Five Wishes” end-of-life planning document at monthly workshops over the past two years. (Kayana Szymczak for KHN)

Janine Hackshaw, a 35-year-old black immigrant from Trinidad who works in microfinance, told the group she felt anger toward one ICU doctor in the film. She felt the doctor was rushing a family to make a life-or-death decision about whether to put their loved one on a ventilator.

“Why is she rushing?” Hackshaw asked. “Do you need the machine for something else?”

Mistrust of the medical establishment is one major reason black Americans are less likely to write down their end-of-life wishes, and more reluctant to end life support, White-Hammond later said. That mistrust stems partly from historical racism, including segregated hospitals, forced sterilization of black women and the infamous, government-led Tuskegee syphilis experiment that denied effective treatment to black men.

The mistrust persists today as “race becomes more tense” across the country, and as people continue to experience disparities, White-Hammond said. Like some other black church leaders across the country who are trying to change perceptions around hospice, White-Hammond believes cultural change can start at church.

“We’re capitalizing on our credibility as an institution of faith” to drive conversations around end-of-life care, she said. The goal, she said, is to make these discussions “part of the culture.”

Another obstacle, White-Hammond said, is that people don’t want to talk about death.

Rhona Julien, another parishioner who hails from Trinidad, said she regrets avoiding the discussion with her mother before she died three years ago. When her mother started to talk about dying, Julien would change the subject.

“I never wanted to deal with it,” she said.



But she said she learned a lot from her mother’s death, including the pressure families could create to keep a person alive. Julien, a 58-year-old environmental scientist, was the sole caretaker for her mother, who had pulmonary fibrosis. At the very end, Julien said, her siblings wanted to put their mother on a ventilator, to keep her alive long enough so that they could fly from Trinidad to say goodbye. Julien refused.

“She’s not going to be connected to a machine to keep her alive for other people’s benefit,” Julien recalled thinking.

“Nobody should be hooked up to this and that, like Frankenstein,” she said.

A 23-year-old Haitian-American woman in the group said she has not been comfortable speaking up to her family about her grandmother’s care. (She declined to give her name, for fear of upsetting her family.)

She described her grandmother, who moved to the U.S. from Haiti, as an independent, strong-minded woman who would regularly walk an hour to church instead of taking a bus. She raised three kids on her own and made a life in the U.S., even though she didn’t speak English, couldn’t read and had no formal education.

Her grandmother was so prepared for death that she had a drawer in her room with clothes that she planned to wear at her funeral — an elegant white suit and white, wide-brimmed hat. She would check the drawer every couple of weeks.

But when the grandmother had a stroke a couple of years ago in Randolph, Mass., doctors asked if she should be kept on feeding tubes or offered only comfort care. The family chose feeding tubes. The grandmother, who is 85 and cannot walk or talk, has been living in a bed ever since.

The young woman said she feels frustrated that her family didn’t prioritize what her grandmother would want.

“We were hoping for a miracle,” she said. But she knew her grandmother “wouldn’t have decided to live a life where she would be bound to a bed.”

Dr. Alice Coombs, one of three black female doctors participating in the evening’s discussion, turned to the young woman and gently suggested that she speak up on her grandmotherâs behalf.

“I took it as a challenge,” the young woman later said, “to talk about this topic.”

Julien said she was initially reluctant to talk to her own kids about her end-of-life wishes — “Are you jinxing yourself?” she wondered — but she successfully broached the subject as part of homework for the workshop.

After watching the film “Extremis, she said, she felt motivated to take the next step: â€I’m going to fill out these forms!”

As the discussion ended, White-Hammond prayed to God for help filling out those end-of-life forms. “Put the fire under us,” she asked, so the task doesn’t languish âon the to-do list.”

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