A unique experiment in Rhode Island will provide care for opioid addiction in an unexpected place — the local pharmacy.
Under the proposal, some 125 patients will receive much more than their medication when they fill their doctor’s prescriptions for anti-addiction treatments at six pharmacies. The pharmacist will take over their ongoing care, with broad discretion to change doses and frequency of visits. This will free up physicians to treat more patients and to focus on the most complex cases.
For now, the program is just a study, but if successful it could open a new pathway to treatment for people addicted to opioids, amid a crisis that has affected Rhode Island as badly as Massachusetts. In 2017, according to federal data, Massachusetts had the 10th-highest death rate from overdoses; Rhode Island took 11th place.
“The real lesson I’ve learned from the opioid crisis is we need everybody,” said Traci C. Green, a Brown University addiction researcher, who is leading the study. “We’re not putting anyone out of any jobs. It’s a growth industry, unfortunately.”
The move to involve pharmacists in addiction care reflects the immensity of the problem and the reality that physicians can’t do it all. Few doctors are trained in addiction care, and many are reluctant to tackle it.
Only a small fraction of doctors, though a growing one, have undergone the eight-hour training required to obtain a “waiver” to prescribe buprenorphine, a key medicine to treat addiction. In Rhode Island, according to Green, 451 prescribers have such waivers but only 234 prescribe the medication regularly.
Funded with a $1.6 million grant to Rhode Island Hospital from the National Institute on Drug Abuse, the three-year research study will enroll 250 people, with half getting the pharmacy-based care and half the usual care, for comparison.
Rhode Island Hospital this week announced the beginning of the second year of the project. The first year was devoted to project development and a pilot involving 11 patients.
The participants will receive their initial prescription from a physician at CODAC, a large addiction-treatment program with seven locations around Rhode Island.
Most are expected to take buprenorphine (often referred to by a brand name, Suboxone), which quiets cravings for drugs and prevents overdoses. Patients will also have the option of Vivitrol, a once-a-month injection of naltrexone, which blocks the effects of opioids. (The third drug that treats opioid addiction, methadone, can be obtained only at federally regulated clinics.)
Once doctors determine the patients are “stable” on their medications, a process that can take from two days to a month, the pharmacists will take over their care.
The pharmacies participating in the study — the six Rhode Island branches of the national chain, Genoa Healthcare — are located within community mental health centers and specialize in managing chronic mental illnesses and addiction.
Visiting once or twice a week, patients meet in a private room with their pharmacist. They place a swab under their tongue for several minutes, which will be sent to a lab for analysis. The swabs reveals whether patients have taken the full dose of their prescribed medication or used any illicit substances.
With that information in hand, pharmacists will talk with patients about recovery goals, struggles, and successes, employing motivational interviewing, a counseling technique that helps patients overcome ambivalence and make changes.
Pharmacists will keep the prescribing doctors at CODAC up to date on patients’ progress. Some patients may also see addiction counselors, something that is encouraged but not required.
Linda Rowe-Varone, a clinical pharmacist who participated in the pilot, said one of her patients is a mother who lives near the Genoa Healthcare pharmacy in Providence. This woman finds the pharmacy hours much more convenient than the clinic she previously visited and, in contrast with the clinic, the pharmacy feels so safe that she brings her children to appointments.
Rowe-Varone said she loves participating in the study.
“I met people who could be my family members, my neighbors, people I work with, people I pass walking on the street, and they would come into our pharmacy for help,” she said. “They wanted to become healthy again. . . . I feel as if we’re right there for them.”
Participating pharmacists undergo the same training course that doctors take to be certified to prescribe buprenorphine, plus additional hours focused on how to perform the toxicology swab, how to do motivational interviewing, and the terms of the collaborative practice agreement. So far 16 have been trained.
Green, co-director of Rhode Island Hospital’s NIH-funded Center of Biomedical Research Excellence on Opioids and Overdose, said she expects the program to be especially beneficial for people leaving prison, where CODAC runs the treatment program for addicted inmates.
“It’s hard to make the transition from incarceration back into the community. This is one pathway,” Green said. In fact, she said, one of the participants in the pilot was briefly incarcerated, and his care remained “seamless.”
“It worked like clockwork,” Green said. “He came out and came directly to the pharmacy.”
Although the project allows pharmacists to tiptoe on doctors’ turf, the Rhode Island Medical Society supports it and helped craft the law that makes it possible, according to spokesman Steven R. DeToy.
The law allows “collaborative pharmacy practice agreements” in which pharmacists manage chronic illnesses, such as diabetes. Some 48 states, including Massachusetts, have such laws on the books.
But Rhode Island is the only state to adopt a pharmacy-based addiction treatment project of this scope. For example, Green said, a Kentucky project allows pharmacists to manage only patients on Vivitrol, and Maryland offers buprenorphine through a single pharmacy connected to the Health Department. But the Rhode Island project is alone in managing two medications at community pharmacies around the state.
Addiction specialists in Massachusetts reacted with enthusiasm when told of the study.
“In the midst of the ongoing overdose crisis, we desperately need better access to these life-saving medications,” Dr. Sarah E. Wakeman, medical director of the Substance Use Disorders Initiative at Massachusetts General Hospital, said in an e-mail. “In my opinion, the more providers offering treatment and the more sites available to patients to receive care, the better.”
Dr. Michael F. Bierer, president of the Massachusetts Society of Addiction Medicine, agreed. “There’s no reason why a pharmacist can’t do an excellent job at this,” he said. “This is a good way to expand access to high-quality care.”
Although the study does not allow pharmacists to start patients on medication, Green believes that might happen in the future. It would require amending the collaborative practice agreement, but pharmacists who have participated in the study will be well-positioned to take on the task.