A Pharmacist’s Take: Pharmacy Deserts and Patient Care – Part 2

Today On Medical Grounds we will be speaking with Dr. Heather Whitley for part two of our discussion. Dr. Whitley is a Clinical Professor in the Department of Pharmacy Practice at the Auburn University Harrison College of Pharmacy. She is a Board Certified Pharmacotherapy Specialist and a Certified Diabetes Educator. Earlier this year, Dr. Whitley spoke with us about screening for diabetes in high-risk individuals. Dr. Whitley is well published—predominantly in diabetes related research.

In part 1 we explored options for patients with diabetes who can’t obtain their GLP-1 receptor agonist drugs due to a nationwide storage. In part 2 we expand this conversation by bringing in the concept of pharmacy deserts and the pharmacist’s role in patient care.

Dr. Whitley has provided us with two websites that can be used by patients to determine whether there is a shortage of their medications:

FDA Drug Shortages
https://www.fda.gov/drugs/drug-safety-and-availability/drug-shortages

 ASHP Current Drug Shortages
https://www.ashp.org/drug-shortages/current-shortages

(00:22) General drug shortages
(03:09) What drugs are currently in short supply?
(04:46) What can patients do about shortages?
(07:40) Ideas to boost supply
(09:34) Pharmacy deserts
(14:23) Amazon Pharmacy: friend or foe
(15:40) What can pharmacists do for patient care?

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Transcript

37. A Pharmacist’s Take: Pharmacy Deserts and Patient Care – Part 2

SOUNDBITE:

Dr. Heather P. Whitley 

It’s putting these little pharmacies that are already functioning on a very narrow margin in a position where they no longer can make ends meet. And I think that’s why we’re seeing a lot of these independent small pharmacies go out of business, which is hurting particularly the rural areas.

00:22 

Dr. Jane Caldwell

Today On Medical Grounds we will be speaking with Dr. Heather Whitley for part two of our discussion. In part 1 we explored options for patients with diabetes who can’t obtain their GLP-1 receptor agonist drugs due to a nationwide storage. In part 2 we expand this conversation by bringing in the concept of pharmacy deserts and the pharmacist’s role in patient care.

Dr. Whitley is a Clinical Professor in the Department of Pharmacy Practice at the Auburn University Harrison College of Pharmacy. She is a Board Certified Pharmacotherapy Specialist and a Certified Diabetes Educator. Earlier this year, Dr. Whitley spoke with us about screening for diabetes in high-risk individuals. Dr. Whitley is well published—predominantly in diabetes related research. Let’s get back to where we left off in part 1.

So I’d like to have a broader conversation about the role of the pharmacy in patient care. We often think about pharmacies as handing out medications and we don’t consider how they help nationwide drug shortages or patient testing or even immunizations. Importantly, we also don’t think about what happens in smaller communities when pharmacies close. First, I’d like to ask about general drug shortages. We’ve discussed the GLP-1 receptor agonists, but it seems to me like news reports are updated weekly with various medications that are out of stock in pharmacies. How much of this are you seeing in your practice?

Dr. Heather P. Whitley 

Yes, we have. With as many drugs that we have available there, it’s no wonder we’re having drug shortages, but it does seem to have increased a good bit, particularly since the COVID timeframe. And it does ebb and flow, I will say, for a given product where we’ll have a drug shortage, we’ll have to manage off of that. That’s in the retail community setting, but also in the hospital setting too. There’s certainly drug shortages of antibiotics or pain medications, or chemotherapeutics and they have to jockey in those positions as well. And then there’ll be a recovery time, we’ll get an influx of that therapy, but it seems to ebb and flow for therapies over time. For the GLP-1s, we have the shortage that we experienced over the winter and spring last year. It seemed like we had some recovery in the late spring, early summer, and then it just seems like a new emergent wave that we’ve been experiencing in our clinic and that I think many of my pharmacy colleagues have been experiencing across the country where we’ve had to re-jockey this supply challenge. And so I appreciate being able to provide this education to your listeners so that we can talk about these ways of how to manage these challenges.

03:09 

Dr. Jane M. Caldwell

Are there some other medications that are suffering from a shortage right now?

Dr. Heather P. Whitley 

There is, there always seems to be, and some are antibiotics, some are pain medications, we see chemotherapeutics, it seems to be across the board. Thankfully, I haven’t seen any full class being depleted, even within the GLP-1 receptor agonist class, when we have a shortage of one. Usually there’s availability of another one, so you can kind of jockey those doses, as we discussed, among two, or between two different GLP-1s. And I think it’s the same way for many of the other products, you just have to be thoughtful about your available alternatives, be thoughtful about how to dose it differently in a given patient. And a very important part is to educate the patient about how this new product might affect them differently. So within the GLP-1s, they are all delivered through different injectable devices. So it’s important for that class to educate the patient that while we’re switching from this product to that product. The new therapy might be in a very different delivery method or delivery device, and we need to take that time to educate them about how to use that. I suspect that might be similar among other classes of medications too. 

If you’re interested in looking to see if a particular drug is in a short supply, you can go search up FDA drug shortage and they have a comprehensive list of medications that are in short supply, and it will drill down all the way to which doses are available, which doses are not available. And then there’s another list through a SHP, which is a pharmacy-specific website, and that will give comparable information for a listener that’s interested in a particular product that might be in short supply.

04:46 

Dr. Jane M. Caldwell 

Okay, we’ll get copies of those websites and put those in our references. So it seems to me that patients need to be proactive if they are on life-saving medications and should have a backup plan with their pharmacy and provider in case they can’t get their prescriptions.

Dr. Heather P. Whitley 

It’s always thoughtful to know what needs to come next. And as a provider, I’m always kind of thinking in that way. I’m always talking to my patients when I’m meeting with them saying, okay, here’s where we are, here’s where we need to go, here’s a possible plan of how we get there. And that’s just typical of how I function within the clinic setting and working with my patients. But when there’s a time of a drug shortage, we might have to take a detour if you will, take a different route to get to that end place. So having that clear communication from me, to my patients, from me, to my physician colleagues, and then patients as well is very important. Sometimes you don’t know that a drug shortage is coming until you’re up on it. And so from a patient perspective, I truly believe the best thing that they can do is refill their medications in a timely fashion proactively before they completely run out. And if they, when they get to the point where they need new refills, which is common, have that the pharmacist can either reach back out to the prescriber or the patient can be proactive to help facilitate that communication as well so they don’t go without. And if they can stay up on top of their regular refills and taking their medications, when there’s a time of a drug shortage, they will always already have established that good communication with their pharmacist and their prescriber to help figure out that detour around the missing therapy.

06:46 

Dr. Jane M. Caldwell 

As a pharmacist, how much of your time or your organization’s time is spent trying to source medications that are in low supply?

Dr. Heather P. Whitley 

It really depends, Jane, on what product is out and how commonly we use that particular product. As I’ve said these shortages that happened this time last year and now we’re kind of entering in that, it seems again, I’m spending a good bit of my time reworking a patient’s pharmacotherapy regimen or trying to figure out which pharmacies might have a given product available or other alternatives. During the summer when they were in supply, it was smooth sailing. So it really does seem to ebb and flow depending on what products are out, how commonly utilized those products are, and we just have to take it from there.

07:40 

Dr. Jane M. Caldwell

It seems to me that production isn’t tied in any way to demand. Is there any way to have a positive feedback to production?

Dr. Heather P. Whitley 

I have been aware that some of the manufacturers of these GLP-1s have started establishing new manufacturing facilities in the United States. I know that some have come up or emerged in North Carolina. I think there’s a few others across the country. But as you might expect, it takes time to build those facilities and start the manufacturing of it. I believe that some of these GLP-1 producing companies were surprised a bit surprised of that the shortage gap happened with how fast the demand caught on for these products, particularly once data came out, not only about their cardio renal benefits, but truly about their impressive weight loss components. And then they’ve had to try to rebalance that. So I was encouraged to see the new establishment of some manufacturing plants in this country to help meet that supply and hopefully their production will start helping to overcome that burden.

08:54 

Dr. Jane M. Caldwell 

You mentioned North Carolina. I remember earlier this year, there was a tornado that hit a drug manufacturing plant and it was down. Do we need more redundancy in production with these plants?

Dr. Heather P. Whitley 

I think that can always help. Just like anything else in life, it’s kind of an insurance policy of having redundancy in whatever that component is. I think having more manufacturing of these valuable products in our country is a good way to go. That way that helps to cut out a lot of the other challenges that we experience when they’re manufactured elsewhere.

09:34 

Dr. Jane M. Caldwell

So let’s pivot slightly. I know many people have heard of food deserts. These are areas that have limited access to affordable nutritious foods. Now we have a new issue on the public health horizon, the pharmacy desert. In October of this year, The Washington Post reported that over 1,500 closures by major pharmacies such as Rite Aid, CVS, and Walgreens leave many Americans without easy access to pharmacies.

And in the past several years, these retail pharmacies often have bought out the smaller independent pharmacies in their areas. And now with these closures, millions will be living in these so-called pharmacy deserts. What are your thoughts and potential strategies for patients living in pharmacy deserts?

Dr. Heather P. Whitley 

That has been very challenging, to be honest. I used to work in rural communities in what we call the Black Belt of Alabama, most rural portions of Alabama. And there we would have only one pharmacy for a very large territory, and patients would have to travel miles, many miles, just to get their monthly refills of their products. And it has hurt these rural communities when we’ve had the loss of pharmacies. And truthfully, it seems like the loss of those pharmacies are often the independent pharmacies, those mom and pop shops that are providing not only medications to their patients, but lots of other care, their immunizations or screenings, their over-the-counter products, just with a very patient-centered and friendly and warm support of those patients they provide. And I do believe a big challenge and a big reason for why we’ve had that impact is from the pharmacy benefit managers. These are the unseen, kind of invisible to the public, middle man in the managing of medications from the manufacturer to the pharmacy that they are truly the ones that are manipulating and controlling the cost of drugs. And they can bundle products, they can increase the cost of a product for any given particular pharmacy. When a patient comes in, with one insurance versus another, the pharmacy might make $4 on a medication, they might make $50 on dispensing the medication, or they might take a $75 loss. It’s completely across the board, and these independent pharmacies, like large chain pharmacies also, are in a position where they cannot tell the patient that they can’t fill a product because they’re going to take a tremendous financial loss on it. 
 They are expected to fill it.

And it’s putting these little pharmacies that are already functioning on a very narrow margin in a position where they no longer can make ends meet. And I think that’s why we’re seeing a lot of these independent small pharmacies go out of business, which is hurting particularly the rural areas. Now these corporations that you mentioned, they have many, many pharmacies under their belt. And so they’re able to manage on a much larger budget and have more flexibility to maintain control. But I’ll also say that some of these pharmacies actually are the owners of PBMs, these pharmacy management managers. And so they have that other avenue of cash flow. I think that there needs to be some significant federal evaluation of the PBMs to consider how this is dramatically monopolizing the cost of our drugs and figure out a more transparent way for patients to appreciate the flow of that money and the ultimate cost. I believe that the independent pharmacies should be able to not only charge for dispensing, but also be able to charge for their clinical services that they’re already providing, but providing for free. So when you or I go to the pharmacy to pick up a prescription, that pharmacist is not just putting that 30 tablets in a bottle with a label on it. They’re looking at your comprehensive medication profile to consider whether there are any drug interactions, any duplicates, and if it is based on the information available to them, the right medication for a given patient. And then they’re counseling the patient not only about how to use the product properly, but about potential adverse events, whether they’re tolerability or they’re significant and a safety concern. All of that is not being reimbursed to the pharmacy, which would dramatically improve the pharmacists and the pharmacy’s ability to stay open and continue to provide the services to these patients including in rural areas that need to have them remain present.

14:23 

Dr. Jane M. Caldwell

Amazon has entered the healthcare arena with Amazon One Medical and Amazon Pharmacy. Is this disruptive technology what we need to reduce healthcare disparities in diagnosis and treatment?

Dr. Heather P. Whitley 

It’s a double edged sword, isn’t it? So on one hand, if there is a gap in care, say in a rural area, if a patient, first of all, has high speed internet, broadband access, then they can be able to access the medical services through Amazon. But that can also short out those local pharmacies and those small mom and pop facilities to be able to provide that care. So a patient might start using Amazon instead, and then that depletes that small mom and pop independent pharmacy or for that matter, doctor’s office in a rural area from being for providing those services and then they go under. So on one hand, I can see the benefit of it, but on the other hand, I can also see how it’s undercutting those local community services that are already present and facilitating the demise of some of these valuable local services.

15:40 

Dr. Jane M. Caldwell 

If there’s one thing that you could tell providers and patients about what pharmacies can do for patient care, what would it be?

Dr. Heather P. Whitley

Pharmacists really have a wealth of knowledge, which sometimes I believe is underutilized, particularly in the community setting. And so I’d say for the patient, talk to your pharmacist, go in and ask questions about your drugs. Don’t just blindly pick up the prescription and go home. Sometimes as a patient, you might not know what to ask. And so ask a general question, like what is the most important thing I need to know about taking this medication?

And that will just open the door for that pharmacist to stop and share some of the knowledge that they have about that individual product. Realize that pharmacist is in a position to be your advocate. They can help connect you to your prescriber or to other local resources that can help mitigate risk for a given patient. And so have those open conversations with them. And lastly, I’ll say every study that has evaluated an interdisciplinary approach to healthcare as opposed to just a single discipline approach, meaning the addition of not only a physician, but a pharmacist and a dietician and these other health specialties coming together, the patient always benefits, no matter what research study that is. So having a clinical pharmacist or pharmacist on your team is a valuable resource because each one of those individual disciplines has a unique depth of knowledge that the other one only has a superficial depth on. So having a comprehensive team of different healthcare professionals to guide that care for any one patient is always going to be provided, proven to be beneficial.

Dr. Jane M. Caldwell 

That’s great advice. Dr. Whitley, thank you for educating health care professionals and their patients on these important issues, and for taking time from your busy schedule to speak with us. It was wonderful to have you back On Medical Grounds.

Dr. Heather P. Whitley 

My pleasure, great to see you again.

Dr. Jane Caldwell

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