PROVIDENCE – Fatal drug overdoses are historically high in Rhode Island right now, forcing policymakers to look anywhere they can for solutions.
A team of Rhode Island researchers says one of those potential solutions can be found on street corners and strip malls around the state: pharmacies.
In a new study, the results of which are being published Thursday in the New England Journal of Medicine, a research team based at Rhode Island Hospital gave patients the option to get buprenorphine, a medication to treat opioid use disorder, at six specialty pharmacy locations – without having to go to a clinic or talk to a doctor first.
The pharmacists liked it, the patients liked it, and people stuck with treatment at high rates, with few adverse events, the researchers found. It makes sense, said Traci Green, a Lifespan research scientist and the lead author of the study: Going to a pharmacy can be more convenient and more routine than going to a clinic or a doctor’s office, especially for people who may lack transportation or face other barriers to getting care.
“Everyone goes to the pharmacy for something – a card for your mom’s birthday, some Halloween candy, some new nail clippers, or to refill an antibiotic,” Green said. “And here you can get your buprenorphine or your syringes or anything else – this is a really helpful pathway for conditions that are extremely stigmatizing, to open the door to embrace our patients in different ways.”
Buprenorphine is one of three approved medication treatments for opioid use disorder. It reduces withdrawal symptoms while also blocking some of the effects of other opioids. While it is itself an opioid, its euphoric effects extinguish fairly quickly, and it is much less likely to be abused or result in an overdose than illicit opioids like heroin and fentanyl, experts say. When it’s diverted, people are using it to treat their withdrawal; if people want to get high, they have other options.
But, those experts say, not enough people have access to buprenorphine.
Thursday’s federally funded study identifies pharmacies and their pharmacists as an important new avenue.
The researchers worked with six Rhode Island locations of a specialty pharmacy called Genoa Healthcare. Patients who were using opioids like heroin were able to go to the pharmacies and get a buprenorphine prescription without having to see a doctor.
How? In Rhode Island, pharmacists can’t directly prescribe drugs. But they can work with prescribers through what are called collaborative practice agreements. Those agreements are common for conditions like blood pressure or diabetes, where a pharmacist can manage the medications directly with a patient while working with prescribers in the background.
What’s novel about this study is the use of a collaborative practice agreement to prescribe buprenorphine, a controlled substance that’s regulated in a different way than, say, insulin.
In the study, which lasted from February 2021 to April 2022, a patient could go into a Genoa pharmacy and be evaluated by a pharmacist who’d undergone specialty training. The evaluation was intensive, involving everything from a drug test to a medical history to assessing how much withdrawal they were dealing with.
If buprenorphine was right for the patient, the pharmacist would call a doctor to explain what was going on. Though the doctors would sometimes talk to the patients directly over the phone, they wouldn’t have to in order to approve on the prescription. The pharmacist would sign the script, with the doctor’s name (which is standard for collaborative practice agreements in Rhode Island). The patient could leave with buprenorphine that day, a sort of one-stop-shop for a treatment that experts say works remarkably well. The patients could go back to the pharmacy for follow-up visits.
It worked, the study showed: Nearly 90 percent of the patients getting pharmacy-based care continued to attend visits one month later, compared to 17 percent of patients in a control group receiving the usual provider-based care.
“Instead of just having a clinic door open, you’ve opened the pharmacy door as well,” said Green, who’s also an adjunct associate professor of emergency medicine and epidemiology at Brown University.
Using a collaborative practice agreement for buprenorphine was only possible in this study because the federal government has waived rules that people have to go in-person to get started on those sorts of prescriptions. That came in response to the COVID-19 pandemic, when going places in-person was officially discouraged and practically challenging.
Because of that rule change, people in Rhode Island who wanted to get started on buprenorphine have been able to call a hotline and speak to a doctor, who would evaluate the patient over the phone and call in a prescription to a pharmacy.
This study flips that on its head. Instead of the patient calling a doctor, the patient goes to the pharmacist, who then does a lot of work evaluating a patient – and then calls a doctor to collaborate. It’s still telehealth, but by different means.
Jeffrey Bratberg, a pharmacy professor at the University of Rhode Island who was an investigator on the study, said it showed a clear path to involve pharmacists more extensively in the care of people with opioid use disorder.
“I can’t give a solid policy background to say, Massachusetts should do this and Maine should do this and West Virginia should do this, but I can say, if you do this, you will likely have success, and you will likely reach a group of people who are not being reached,” Bratberg said.
One hurdle – a common one in the American health care system – is funding. If the pharmacist is doing most or all of the direct patient work, how does he or she get paid? The time a pharmacist spends with a patient going over the medication they need and their medical history is not currently reimbursed by insurance, as it would be in a clinic or doctor’s office. It’s a problem that needs to be solved in order to scale the process beyond just six specialty pharmacies and into places like Walgreens and CVS.
In Rhode Island, the rules could also be changed to allow pharmacists to prescribe controlled substances directly, as they can in 10 states. That includes Massachusetts, although pharmacists can only prescribe controlled substances in institutional settings there, not in retail pharmacies, according to Bratberg. That would mean that this study wouldn’t have been possible in Massachusetts, Bratberg said.
Other rules and regulations do come into play when you’re talking about a medication like buprenorphine, but a law change in the recent federal spending bill made things easier.
The study was permitted under Rhode Island regulations; they didn’t have to get a special exemption for it. The main thing stopping it from happening tomorrow is a way to practically and financially implement it outside the confines of federally funded research.
But it’s also possible to go further and to make direct prescribing by pharmacists even easier – for example, not always having to use a collaborative practice agreement with a doctor on the other end of the phone line.
“The state can definitely make movements pretty quickly and pretty seamlessly,” Bratberg said.
Dr. Josiah “Jody” Rich, an attending physician at The Miriam Hospital and an adviser to the governor’s overdose task force, was a co-author of the study. He was also one of the physicians on the other end of the phone working with the pharmacists to get buprenorphine into patients’ hands.
He said he would be comfortable giving pharmacists even more leeway to directly prescribe buprenorphine, even without getting someone like him on the phone first. Pharmacists, he said, are the most highly trained and underappreciated people in the health care workforce.
“They’re ready to go, they just need a little bit of training and they’ll figure it out,” said Rich, who also a professor of medicine and epidemiology at Brown University. “They’ll knock this out of the park. This could be a real game-changer for the whole opioid epidemic – we’re doing something really stupid right now, which is, we have so many barriers to getting people on buprenorphine, it’s ridiculous. And boy, does this study shed some light on where we need to be going.”