Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. This podcast is Narrator - ? 00:12 provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice, and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Speaker 1 00:31 Welcome to HelixTalk episode, 161 I'm your co host, Dr. Kane, and I'm Dr. Patel, and the title of today's episode is my loss is your gain how drug repository programs are helping patients afford high cost medications. Dr. Khyati Patel 00:47 Dr. Kane, I love this topic because I practice in Wisconsin, and I kid you not, for how many patients I have who cannot afford their medications, don't have good insurance, can't go through pap programs and stuff, I have utilized this program. It's a boon for those who need like high cost medications and can't get them. Speaker 1 01:07 Yeah, and Dr. Patel, prior to designing this episode, I had actually not even heard about prescription drug repository programs. So one goal I have today is to have healthcare providers understand what this is, and we're focusing on the state of Illinois and Wisconsin, but these are national programs. About 40 states in the US have a program like this, and I think that better understanding of the program makes the program work better. And I think the listeners will understand why in a little bit. Yeah. Dr. Khyati Patel 01:35 And from my knowledge, most of these repository programs were started off as oncology medications repository programs, because, as we know, oncology meds are really expensive, and sometimes the regimens are changing. Maybe patient is recovering, or patient no longer needs to be on those medications, and those are perfectly great medication that are getting wasted, and so most of the states, drug companies, you know, pharmacies, stakeholders, came together to put the thinking hat on and decided, Hey, why waste this perfectly good medications? And then now, you know, fast forward to maybe a decade or so. While these programs have been established, it has trickled down to other drugs that are high cost and not just oncology. Speaker 1 02:22 So why don't we kind of give a typical example, Dr. Patel, of kind of the thought experiment that likely happens that eventually turned into what we call this drug repository program. So imagine, Dr. Patel, that you're working in a community pharmacy, and a family member comes to you and says, Hey, my loved one recently passed away, and they had all of these bottles of these very expensive oral chemotherapy medications that they never used, never opened, and you say, oh, okay, so you take those. And fortunately, your pharmacy has a drug take back center, or maybe it's at a local police or fire station, and you direct them to the proper place to dispose of that medication. Then later in that day, someone you know, a different patient, comes to you, and they start chatting with you about how expensive their loved ones oral chemotherapy medication is. And it turns out that that medication that is really expensive is the same one between the patient that passed away, who no longer needs that medication and this other patient who is now in need of the medication, but it's extremely expensive. And you probably think to yourself at this point, Dr. Patel, why did we just throw away this perfectly good oral chemotherapy medication? Wouldn't it be great if there is a way that we could somehow take in that medication that's not being used and then give it to the patient who needs it for a very low or reduced cost? Dr. Khyati Patel 03:41 Absolutely, I would be all over the place trying to find solutions for this problem. So Dr. Patel, today's Speaker 1 03:47 episode is going to be a little bit different than normal. We do have two experts on the prescription drug repository program in Illinois and in Wisconsin, and we'll introduce both of them in a second, but the format of today's episode will be a little bit different from the listener perspective. We're trying something new here. We're trying kind of an NPR esque interview style, where we're going to be clipping back and forth between these two separate interviews that Dr. Patel did and I did, and we'll be coming back where you and I reflect on the interviews that we each did separately. Dr. Khyati Patel 04:18 That sounds like fun. NPR is my favorite. Speaker 1 04:21 So the first person that I wanted to introduce is Dr. Shannon Rotolo. She's a clinical pharmacy specialist at the University of Chicago, and as the listeners will learn, she actually has first hand experience in helping write and pass the Illinois legislation. So I'm going to let Dr. Rotolo introduce herself on her own. Speaker 2 04:40 I'm Shannon Rotolo. I'm a clinical pharmacy specialist at the University of Chicago. I originally completed my Pharm D at the University at Buffalo School of Pharmacy and Pharmaceutical Sciences, and I did my residency at the Golisano Children's Hospital. At the University of Rochester. So originally from New York State, have done a couple different roles, or did a couple of different roles immediately post residency at a couple of different institutions. But a little over 10 years ago, I moved to Chicago to join the team at the University of Chicago, and really loved it. There have got some really unique experiences, starting on the inpatient side and eventually moving into the outpatient world. And our specialty pharmacy team Dr. Khyati Patel 05:26 there and Dr. Alex Burris is the president CEO, as well as a staffing pharmacist at good value pharmacy, which is a small, independent pharmacy business located in Racine and Kenosha regions of Wisconsin, all three of their pharmacies participate in drug repository sites, and Dr. Burris has the first hand knowledge for how these regulations work and how to maintain the process to benefit the surrounding community. And here is Dr. Burris introducing himself. Speaker 3 05:57 My name is Alex Burris. I'm with good value pharmacy. I'm the president, so I am in charge of operations for the whole company, but I also practice as a pharmacist about half the time at work, so I do maintain that patient interaction, which I really love. Brief History of how I got into pharmacy. I started working at my dad's pharmacy when I was in high school as a technician, and was interested in math and science, and wanted to kind of follow my father's footsteps, and so I went to Madison for undergrad, and then got into the pharmacy school there. Graduated in 2012 and then came back and started working for him, and I ran a few of his pharmacies for for a couple years, and then transitioned into my role now in 2015 so I've been I've been doing this for about seven years now. Speaker 1 06:47 So, Dr. Patel, I think we've kind of alluded to it that a prescription drug repository program is a state based legislated program that allows people or entities to donate medications, and then those medications can then be received at a very reduced cost by a patient who's in need. So why don't we let Dr. Rotolo kind of describe what exactly these programs are in a little bit more detail. Speaker 2 07:12 So prescription drug repositories are a little different from state to state, because each state will have unique legislation describing what can and can't be done. But I think nationally, I would sort of think of them as often central locations, but not necessarily places where medications are donated. Those medications are inspected for safety, usually by a pharmacist, and then redistributed to other sites or to other patients. So it's a way for individuals who have a medication that they're not going to use or not going to finish to be able to pass that on to someone else in need. Dr. Khyati Patel 07:49 So, you know, there is a there is a donation part of the repository, and there is a recipient part of the repository. And so, you know, let's talk about who are the people who can donate these medications. And really it's any patients, families of the patients, any clinics or pharmacy who can donate medication, as long as they meet the state law for donation, which we will talk about in just a little bit. Speaker 1 08:15 And Dr. Patel, as soon as I heard about this kind of a program, my MPJE, my pharmacy law spidey sense immediately went up, and I started thinking about, well, what about drug adulteration? And anyone who has passed their pharmacy law exam in pharmacy school, they learned about misbranded and adulterated drugs. Misbranded means that there's a problem with the labeling, like the label says that it's a medication that's not an adulteration, is where the components inside the bottle have been modified in some way, where it's wrong in some way. So it could be that the drug is degraded, it could be that there is an Excipient that was added that was not supposed to be in there. And anyone who's worked in retail pharmacy knows that once a medication leaves the pharmacy and someone tries to bring it back, you can't return that to stock because you no longer had control over how it was stored if someone potentially put some some substance into the medication. At least for me, that was kind of my first thing that came to my brain in terms of that would be a big barrier to this kind of a program where you're receiving medications from families where you don't know how it was stored. So Dr. Patel, as we'll hear from Dr. Rotolo, the kinds of medications that can be donated actually addresses the concern of adulteration to some extent, and you'll hear from her in just a second about the kinds of meds that are accepted are not your typical Amber vial where a pharmacy technician dumped a bunch of pills into a bottle and handed it to a patient. It's a little bit more complicated. Bit more complicated than that. Speaker 2 09:44 I think probably first thing that will kind of check something off the list of being eligible for donation is that this wouldn't include controlled substances, so no narcotics, no opioids, just ends up being much more complicated than non controlled medication. And the next thing is that the medication should not expire for at least the next six months. You want enough time for that to sort of make it to another patient and be used by another patient before it's expired. It does need to be in sealed packaging, so kind of the obvious. What doesn't count there are those sort of standard Amber vials that are often dispensed from community or retail pharmacy locations. Ideally, the medication that's being this is a little complicated, but I would say ideally, most of these medications won't require refrigeration, and a site that is accepting donations might not even want to deal with sort of the logistics beyond that, they might just say, we here don't want to take refrigerated meds. There is an exception in the legislation that if something is packaged with a device that would monitor temperature control, you could actually donate and someone could accept a refrigerated medication. But just based on the way drugs are currently packaged, like current manufacturing standards, we really almost never see that. So I would say, in general, this probably won't apply to drugs that require refrigeration, and those are kind of the key things. Dr. Khyati Patel 11:07 And then to kind of hear the take from Dr. Burris in Wisconsin, you know, he says that there are some consideration that the pharmacy takes to make the medication, quote, unquote, worth it, to be acceptable for donation. And so again, they're looking at the cost, and then they're looking at the difference from maximum dispensing fee to the cost of the medication it had the patient had to pay out of pocket. So here, here's Dr. Alex describing some of the requirements for donation in Wisconsin, as well as examples of typical meds that he has accepted for donation at his sites, Speaker 3 11:42 we typically have to ask a few questions to qualify the donation, right? Because we don't do we don't just take any medication that the patient has. We have to ensure the donator is 18 years old. We have to make sure the product is expensive enough to warrant donation, right? Because if, if someone comes in with a bottle of lisinopril or something that's very inexpensive. It doesn't really make sense, because oftentimes the cash price or the insurance price is going to be lower than the dispensing fee through the repository. So we have to train our staff to to only take donations that are more expensive and and there's no like, hard, fast rule about how much it has to cost, we just have to use common sense with not taking inexpensive medications. We have to ensure the product, and at least in Wisconsin, the product has to be the in the original sealed packaging, which it actually ruins a lot of the donation requests, because so many medications are dispensed in the amber vials, the prescription vials, and because it's not original seal packaging. We can't take those medications, unfortunately. And I mean, there's good reason for it, because there's more risk of adulteration or the product not being what it's labeled as. That's an unfortunate cause for us. Having to throw out a lot of the requested donations. There has to be at least 90 days of shelf life left before expiration, we can't take controlled substances, and it can't be subject to FDA restricted requirements, like, there's so many drugs out there that the FDA and the manufacturer have to work together to make sure the distribution is in through certain channels and certain suppliers. And so if it's one of those medications, we can't take donations for that. Dr. Khyati Patel 13:20 And in this excerpt from Dr. Alex first when he was talking about certain medications that have FDA rules and regulations or restrictions for distribution, he's talking about medications that are in the REMS program. We know there are tiers of rems, and the most extreme rems program is where there is closed distribution, where the drugs are given from manufacturer to the patient or manufacturer to the provider, instead of through the pharmacy, and so those medications cannot be accepted in Wisconsin. Speaker 1 13:49 And Dr. Patel, Dr. Rotolo, chatted with me about, you know, in terms of drug repository programs, we are seeing a lot of oral chemotherapy because of the cost and because those patients tend to have the drug dispensed in the original packaging and things like that. But I really liked what Dr. Burris talked about when you interviewed him was the kinds of medications that he's typically seen in his community pharmacy. So let's hear from Dr. Burris about what some of those medications are. Speaker 3 14:17 I'd say some of the more common medications are Lovenox or generic Lovenox and noxaparin, and also medications like insulin or doacs, Xarelto and Eliquis and those common, commonly dispensed brand name medications. We get donations for all sorts of things, but for this to work, you need a donator and a recipient. So sometimes, you know, sometimes, it doesn't always happen. So what we find is the more common the medication is, as far as how often it's prescribed, the more likely the medication will be used. Dr. Khyati Patel 14:51 So I guess one thing that's opposing in the Wisconsin law for drug repository compared to Illinois, that it does not exclude refrigerated medications. Dr. Burris said that they are accepting insulins, and I actually have had sent my patients to obtain insulin at his pharmacy. So this is true for Wisconsin, but not for Illinois, and this is a perfect example of how drug repository programs are different across different states. Obviously, you know you need to make sure or assure that the box was stored at properly refrigerated temperatures before accepting it. And in a sense, you know, think about a regular pharmacy dispensing an insulin package to a patient, and the time it takes the patient to travel from the pharmacy and put it into their refrigerator when they got home, you know, so I guess in that sense, if they were stored at refrigerated temperatures, and, you know, travel to good value pharmacy for donation, that travel time outside of refrigerator is acceptable. Speaker 1 15:54 And as Dr. Rotolo mentioned in Illinois, the law allows for refrigerated items, but those items have to have a device that shows whether it was kept outside of its normal temperature, and insulin typically does not have that. So that would exclude it on average in Illinois, but in Wisconsin, it is nice, especially given the cost of insulin. And I will say Dr. Patel that the first medication that Dr. Burris mentioned was enoxaparin. And I can tell you that this is such a good example where you have a patient, let's say who is bridging for a couple days of enoxaparin. That is often a very substantial cost for the patient. So outside of kind of chemotherapy land, it isn't that surprising that some of these newer anticoagulants and also Lovenox, are some of the most common meds that he's seen in his pharmacy, Dr. Khyati Patel 16:39 and the enoxaparin tends to have longer expiration date, right? So the patient doesn't need it. Definitely a great medication for it to be stored. It's room temperature, so it's not temperature sensitive. I think some of the examples he gave, and in my experience, the medications patients have received have been really helpful to them. One contrast Thing. Thing I want to bring up from what Dr. Rotolo said in Illinois is that the pharmacies will have to make sure that they have a refrigerated storage area for these repository drugs. And just kind of talking about operations and logistics with Dr. Burris, he said that they do so they have a regular shelf area for non refrigerator medications that are donated, and then a refrigerator that's dedicated for repository, drugs that are temperature sensitive. And so the key has to make sure that that's been operated. Temperatures are monitored, all that stuff. Speaker 1 17:34 And you know, Dr. Patel, just like with 340B drugs, where you have to keep that inventory separate from your normal pharmacy inventory. The same is true here. And as you kind of pointed out, this does cost money, time and effort for a pharmacy to conduct this so I loved Dr. Patel that you had asked Dr. Burris, kind of, why do you do it? What is, what is the benefit for you as the pharmacy to participate in this program that is going to take time away from your other pharmacy tasks. So let's hear from Dr. Burris, what his answer was. Speaker 3 18:05 We purchased a pharmacy in 2013 that was involved in the repository program, and we realized right away how much of a benefit it was to both the patients by keeping costs down and increasing access to medications that they might not otherwise have, but it was also a benefit to the pharmacy, because you're, you know, you're getting a good reputation in the community for meeting the needs of people that that need your help. And we also noticed right away, and we've kind of knew for a long time, that patients don't really have the ability to use their unused medications and for a good purpose, they would usually get destroyed or thrown away, and it's so wasteful, given the climate of how expensive medications are and and how so many people can't afford them or don't have insurance to cover them, so we realized right away that it was benefit to both the community, the patient, and the pharmacy. Dr. Khyati Patel 19:03 And Dr. Kane, this is a perfect example of small community pharmacies trying to do just more than business. They're actually serving the community. And you know, as you would hear in future clips of Dr. birds, that there's not enough advertisement about this programs like it should be, but they're content with the number of patients they've been able to assist with the program. Speaker 1 19:28 No, Dr. Patel. There is some exchange of money that occurs. This is not going to be a huge profit center for a pharmacy, but you know, in the legislation, it does outline who can receive money or ask for money as part of this process. So on the donor side, in terms of the person donating the medication, one question that came to my mind is, do they get any money for donating, right? And the answer is no. So the person donating the medication is doing it because they are just donating the medication out of the kindness of their heart, right? Part of this is that it's a way to properly discard of a medication, kind of, quote, unquote, the right way, as opposed to just throwing it in the trash. Sometimes even more convenient to donate in this program, as opposed to going to a drug take back day, or finding a site where you can dispose of medications properly. And Dr. Rotolo mentioned that in Illinois, at least the drug repository website, which is linked in our show notes at ilrx drug repository.org on that website, you can actually print a mailing label where you can mail in and donate one of your unused medications that meets the qualifications, which, in my mind, is probably one of the easiest things to do, as opposed to going through some of these other processes. Dr. Khyati Patel 20:43 I like that Illinois has made it a little bit easier to donate medication via mail. Option on the flip side, though, Dr. Kane. What about patients who are receiving the medications? How much do they end up paying? Speaker 1 20:55 So, let's hear from Dr. Rotolo on the Illinois side, and then we'll immediately go to Dr. Burris on the Wisconsin side, essentially, you can charge a handling fee, but that has to be a fee consistent with other fees that you normally charge. So let's hear from Dr. Rotolo first. Speaker 2 21:11 So the site that signs up as a donation site has the option of charging a handling fee, and that could be 50 cents or $1 or maybe it could be $3 it's intended to be very low amount to cover any overhead or logistics, or, you know, just the effort of managing these sort of things. But it is okay to charge a handling fee. The one caveat to that as a handling fee has to be consistent. So if you're dispensing, let's say, a bottle of prep, that should be the same handling fee as a set of syringes of an ox parent. So it shouldn't be based on the cost of the medication. It's just the effort of you doing this task. Speaker 1 21:49 And then we'll hear from Dr. Burris next, Speaker 3 21:53 the state dictates a maximum allowable fee, and right now that fee is $15 so we get $15 per prescription dispensed, and we feel like that's a fair a fair price for the work that we do. It's much lower than the cost of the medication always, and the patients are usually very grateful, and you know, we're happy to do the service, but it's nice to get a little reimbursement for Dr. Khyati Patel 22:18 it as well. And in addition to what Dr. burr said about the cost of dispensing these medications, there are some additional requirements of who can receive the medications, where the recipient needs to be a resident of Wisconsin. And I asked him, you know what? How do you decide who to dispense? And he said, in a grand scheme of things, the regulations said that the medicines should go out to uninsured patients first, the next priority will go to those who have governmental insurances, including Medicare or Medicaid, and then the next priority to any patients who need the medication. He says that, in all honesty, though, this ends up being more of a first come first serve practice at all of his sites. Speaker 1 23:03 So Dr. Patel, the state law for both Illinois and Wisconsin are fairly specific in terms of the kind of documentation and procedures involved in being a drug repository site. I will let Dr. Burris talk about his experience in terms of the documentation and inventory process for being a drug repository site. Speaker 3 23:23 Yeah, we just keep the repository inventory physically separate from our regular inventory for obvious reasons, and there's really not much else to it. We obviously, if we get a prescription request and someone asked if we have a medication in our repository, we go over to that repository section do a quick scan of the shelves and identify if we have the product. And obviously we have refrigerated items as well. So there's two places that they're kept, one for the refrigerate and one for regular inventory. Dr. Khyati Patel 23:54 And as I said, you know earlier too, they have good number of patients who have benefited from this program, but they definitely do not actively promote that their sites are repository sites, except for their locations being listed on a centralized pool of repository sites, on the Wisconsin's website, state's website. But in general, when I asked Dr. Burris about, you know, what's the number? What are they dispensing? What? How many medications are they dispensing? How many patients they have served? He said, typically they're dispensing about one to 10 medications per month through the repository, pool or inventory. And he thinks about a few 100 patients have received donations since he acquired the business in 2013 and so he couldn't provide any cost saving data, and he thought that that was a great opportunity to for us to look in. But it wouldn't be surprising if you think about cumulative cost saving, if you consider, you know, patients, cost of, let's say, maximum fee that was charged, that was $15 to some of these drugs you know, for, just say insulin, you know, could. $300 that's a huge cost saving on a patient's part. Speaker 1 25:04 And you know, you can think of it two different ways. Dr. Patel, one way is that you could think about dollars saved on the pharmacy side, in terms of all of these repository sites have saved, you know, several $1,000 for patients, but even on a patient per patient basis. Thinking about that patient on a fixed income, who needs insulin or needs an ox a parent, the fact that you're able to save them so much money that $300 of insulin savings for them is astronomically high, and really, I think, is the key point here that these these are almost always patients in need, who have a need for medication, but are uninsured or under insured or can't afford their co pays, and this is really serving a very important area where the healthcare system has kind of failed these patients. Dr. Khyati Patel 25:52 And I loved what you said, Dr. Kane, I know kind of provides a good avenue for medication affordability. One thing when it comes to helping patients through this program, that providers or healthcare providers need to keep in mind is that the supply of these medication is not guaranteed. Your patients gonna get the medication as long as the pharmacy has it. If the pharmacy doesn't have have it, or they have to travel, I don't know, five hours to another side of the states to obtain this medication, then that's something that patient would have to take in consideration as well. And so you got to let your patients know that, you know, you may get a nine, you know, three months supply, 90 days supply, right now from the pharmacy. But you got to plan ahead and say, What after if it's a chronic medication, you got to plan ahead and be like, Hey, what's going to be after those 90 days? And normally, I try to, you know, find medications they're chronic in nature for 90 days at a time, so patients have enough time to stay proactive and secure further supply. They have more window and time. Speaker 1 27:03 Dr. Patel, I love that, and I have the same feeling when I think about drug company, patient assistance coupons and things like that. Usually those coupons are only good for one month or three months, and then after that, you can't use them anymore. And if it is a chronic medication, you do have to have a plan after that fact, otherwise, you've given them a bridge to nowhere where they're started on a medication but they can't continue on it if it is a chronic, longer term medication. Yes, that's right. So you know Dr. Patel, I love hearing from Dr. Burris about his firsthand experience as a drug repository program. And as I mentioned earlier, I was actually completely unfamiliar with this as a program in Illinois, and one of the reasons is that it is a new program in Illinois. So so it was signed into law August 2021 and became effective about a year ago in January of 2022 and I actually asked Dr. Shannon Rotolo about this, you know, I wasn't sure if we were kind of a leader in the space or a little bit farther behind, and this was her answer for that. Speaker 2 28:04 So Illinois is a little bit behind, although, I will say, while there were 38 other states that had a law on the books, not every state had a law that was really operational or functional. So even though most states were ahead of us in passing something like this, not everyone's got it implemented, so we're not fully behind. And I think that the way that this was done, hopefully we'll have some good success with it in terms of ease of implementation. A couple states that might be good examples. So Iowa has a great program. There should be an example of a funded program. Ours in Illinois is not so there's this one where the funding was tied into the legislation, and I think that's part of why they are so successful. Our legislation, we really did intend to make it sort of user friendly and easy onboarding, so that despite not having that public funding, there would hopefully be some success. And then another state that this is done really well in is Georgia. There's a nonprofit called serum there that kind of facilitates their program. And that's just another so, two different ways of approaching it, I guess, but still with great results. Dr. Khyati Patel 29:15 And that's great to hear Dr. Kane that Dr. Rotolo was at the forefront of writing and passing this law, law in Illinois. And you know, with that comes great. You know, advocacy example in mind. You know, she, she, she has demonstrated that your voice can be heard if you try to do the right thing. For the patient, what was kind of her experience with the advocacy process? You know, working with the lawmakers, how did she just generally, get started with the law? Speaker 2 29:46 I really early on was actually searching on Twitter at the time for other pharmacists who were interested in a number of issues related to medication access. And three. Researching the right hashtags and keywords, came across Elizabeth Lindquist, she works out in Rockford. She's an oncology pharmacist, and also is an elected official in her county as well. So has a little bit of experience and a little bit more know how than I do in terms of how to navigate bringing on new legislation. So I met with her in real life, the internet on a very rainy afternoon. We also met up with a couple of medical students at the time. One was Dr. Alan Hutchison, or now Dr. Alan Hutchison, who's since graduated med school, done his residency, and, you know, we're all these years later now, in terms of the process, but he had also gotten interested because of, sort of organically, some work that he had done with patients needing access to medications, and some of the barriers that he had seen in our state, and then the that kind of group of people from there met with various legislators, called a lot of people on the phone, trying to figure out how to resurrect because there had previously been a bill six or eight years prior, maybe that had just never gotten passed, like sort of never made it through most years, never even made it out of committee. So we really were looking for the right person to sponsor it, to be able to sort of push or promote that bill, and then needed to do a lot of education of different elected officials to make sure that people understood the intent of that bill and were able to support it. So there was already a great framework in terms of language for the bill between past versions and things that had been passed in other states. So that's not something that really required a lot of me in terms of getting that language finessed, that was something we did, sort of work with folks from the nonprofit serum that operates programs in Georgia and in Tennessee, kind of gave us an idea of why certain states, although the legislation was in place, maybe hadn't been able to operationalize a program. So we knew kind of what pieces needed to stay in there and what things were maybe negotiable. The parts that I was more hands on with, I would say, is actually meeting with elected officials, so showing up at the state capitol, making appointments, knocking on doors, trying to educate folks. I also had a couple of pharmacy students from a local school of pharmacy that were able to do that on a day that I wasn't able to go, was able to send them off site to get that experience. And then my favorite part of the process was probably providing oral testimony again at the State Capitol in Springfield, to be able to speak with the members of the committee in which this bill was first presented. Speaker 1 32:40 So Dr. Patel, kind of crazy that she connected initially through Twitter, which is a great example of using social media from a professionalism standpoint, to kind of build your career and make a difference. And I love that. And you know, as I was talking to Dr. Rotolo, in my brain, I was thinking, who could possibly be opposed to this kind of a law? Why is this not a slam dunk, no brainer kind of bill. And as she talks about, there was an entity in Illinois that did kind of oppose the bill, and that was one of the things that she and other advocates of the bill had to work around to kind of make it so that this was a passable bill in Illinois. So let's hear from her about one of those bigger barriers. Speaker 2 33:20 Yeah, so I think Illinois is pretty unique in this. One of the major lobbying entities in Illinois is the Illinois trial lawyers. So because to make this functional, to make it operational, you do need to grant some level of immunity to people that will be participating, whether that's people donating pharmacists who are inspecting the product, you know, you sort of have to hope that people are doing this in good faith. And you put, you know, come some common sense language about having things not be expired, having them in Tamper Evident packaging. But of course, you want to provide immunity for healthcare professionals that are going to be involved in this. And that was something that, and this is not unique to our bill, certainly, but something that the Illinois trial attorneys were very opposed to, and we ended up going through a number of different potential sponsors, co sponsors of the bill, to find the right person who would really push this issue with them. So the individual who ended up being kind of the key in this was someone who was usually aligned, actually with that lobbying group in terms of what they were supporting, but sort of because of that relationship, was able to get them to move from opposed to neutral. And that was really key. Because while we did have bipartisan support, and I think going into this, I initially thought like, Oh, this is we're going to have to sell this a little harder to our Republican elected officials than we are to the Democrats. It was the reverse, just because of the very close relationship that Illinois trial attorneys have with the Democratic elected officials. So I think that was a bit of a surprise to me, but like you said, it really is pretty. They, you know, seems like it should be bipartisan, and common sense that if medications aren't going to get used, they should go to someone that can use them. It's both more sort of fiscally responsible, it's more environmentally friendly. There's sort of that large coalition we built, everyone had a different interest or reason to be invested in the bill, and I think that that was a huge help, too. So both working with that organization that was against it and moving them to neutral, and also having that really broad coalition, so we could say, hey, everyone wants this. This is good in so many ways. Dr. Khyati Patel 35:33 That was really interesting to hear that there was this lawyer group that was opposing it, just because they couldn't, then sue pharmacies or people who donated the medications for being adulterated medications or harming the patient and stuff that's that's really interesting. What was your experience being at the forefront and providing oral testimonies to these lawmakers and the sessions in the Illinois State Capitol? Yeah. Speaker 1 35:56 So let's hear from her about that. And as she mentions, this is way less intimidating than you might think. So let's hear from Dr. Rotolo about Speaker 2 36:03 that oral testimony. Sounds like it's going to be very intimidating, but I think for folks listening to this podcast, one thing that I would love for them to take away is it is actually totally fine. It is, if you are a pharmacy resident presenting like a grand rounds, it is going to be easier than that, I promise. If you're a pharmacy student with a really high stakes presentation in a class, this is actually going to be easier than that, because you are truly the expert in the room. When you do one of these, you have the first hand experience. You work one on one, on the front lines, with patients. You know what you're talking about. When you're talking about medication access, when you're talking about barriers that your patients face, barriers that you face as a pharmacist. So I would really encourage people that while this is very different than presenting in a classroom or at the institution you work at or at even maybe a state or national meeting, it is very, very doable. Just feels intimidating before you've done it. Speaker 1 36:59 And then, Dr. Patel, I know that you are fierce advocate of pharmacy advocacy, as is Dr. Rotolo. And I asked her kind of why is pharmacy advocacy so important? And as she talks about, it's not enough to just have a law on the books that law has to be functional and to have a content expert like a pharmacist be involved in the law makes it a piece of legislation that is actually applicable and functional in everyday practice. So let's hear from her about why pharmacy advocacy is so important for laws like this, Speaker 2 37:32 pharmacists and just people with experience with these type of programs as well. That was really key for us in getting a bill passed that would be able to be operational leader. There are definitely other pieces of legislation that I've seen kind of through different circles of the advocacy I'm involved with where you can tell maybe some physicians were involved in drafting it. Other people who are very well meaning, had great intentions, were involved in drafting it. But then it never gets to sort of the rules phase where it becomes implementable. And I think that pharmacists are really uniquely positioned to understand the logistics that go into getting drug to a patient. And also, of course, are uniquely positioned in terms of understanding some of the intricacies of pharmacy law, which is so variable from state to state that we can sort of predict some of those things that could be a barrier to actually getting a piece of legislation not just passed, but to be functional. Dr. Khyati Patel 38:28 And you know, this advocacy doesn't just have to start from one person, and Dr. Shannon, you know, Rotolo, is a great example of somebody who started this process in Illinois. But this, this advocacy or call to action can go out to pretty much any practicing pharmacist or healthcare provider in terms of, you know, how can they be involved as a site, as Dr. Burris mentioned, you know, you got to go to the websites from your state. There are a lot of rules and regulations that you have to follow. You know, start the documentation process, maintain inventory listing, all that stuff. We also have a link in our show notes for national conference, for state legislatures, NCSL page that kind of describes drug repository programs. This is, you know, not just Illinois, Wisconsin, kind of all programs in the in in this country in itself, talks about addresses issues or concerns for the pharmacy as well who are wanting to be a site. And the idea here is that they want to reduce the waste, and they want to provide access to high cost medications for patients who can't afford them, Speaker 1 39:37 and for the listeners out there that maybe aren't running their own pharmacy, and they want to learn more about getting involved in pharmacy advocacy. I thought Dr. Rotolo gave a great answer here about how anyone can be more involved, even at a local level, when it comes to pharmacy advocacy. So let's hear from Dr. Rotolo here. Speaker 2 39:56 So I actually started with, you know, sort of pie in the sky. Hopes, when I was seeking out other pharmacists to connect with, looking at things that I wanted to see done on a national level, that I would say, getting involved in your own community first, whether that's on the state level or even more, smaller, more local than that, is really important, right in terms of seeing that impact on patients, and in terms of maybe being able to follow through with a piece of legislation that you know, if you're only interested in goals nationally, that may take a very long time to come to fruition, as we have all felt with provider status, goals and things like that, right? So I would say, you know, just really connecting with people, not being afraid to get yourself out there, and keeping in mind that these really are bipartisan issues. When you're talking about medication access and other pharmacy related issues, majority of Americans, no matter where they lean politically, will tell you that drug prices are too high, will tell you that they have issues accessing their medications. So it's something that affects everyone. It's really sort of like a kitchen table issue that you could talk about with your uncle or your sister at Thanksgiving over a holiday. So don't be afraid to share your knowledge, and don't be afraid to just ask questions and connect with other people. Dr. Khyati Patel 41:12 And Dr. Kane, another way to promote the utility of this programs, both from donation and recipient side, is is to talk about the sites. And you know, if you have a patient calling you and asking you, hey, I have this unused medication, or, you know, you are switching this patient's medication to something else, and they told you, oh, I have, like, I don't know, six months supply of this medication sitting at home that's unused, encourage them, provide them a listing of the sites nearby their home and say, Hey, these pharmacies might be looking for donations. You know you should consider them. And I guess knowing the type of medications that are accepted now through the programs can also help you select the patients to encourage them for donations. And I felt personal responsibilities, because I feel like my patients who need medications have benefited from repository programs. We need to kind of maintain that supply chain, and so those who want to get rid of medications, I also direct them to go to these pharmacies to donate. Speaker 1 42:14 I love that. Clearly, there's a supply and demand equation to these programs, and we need the supply so that the demand can be met as much as possible. Well, Dr. Patel, I thought this episode was fantastic. I learned a ton, and it really made me appreciate how important it is that healthcare providers know about this program and are encouraging patients to participate in the program. For the listeners, we have a number of links in our show notes. So we have both the drug repository program links for Illinois and Wisconsin. That is kind of a normal web page to give you more information about how to get involved. We also have the actual legislation. So if you want to literally see the law in Illinois and Wisconsin, we have links to that as well. And then finally, if you're not in Illinois or Wisconsin, we have the National Conference of State Legislatures, or NCSL web page that shows a map of the United States and what states have and don't have legislation related to drug repository programs. Again, it's about 40 states have a law on the books about this. So for those other 10 states, there's still opportunity there. And if you're in those states, I'd encourage you to maybe even start being involved in pharmacy advocacy and seeing if you can get your state to be the next one on board with this. So again, for the listeners, if you want to access the show notes, we're at HelixTalk.com this is episode 161 we're also on Twitter at HelixTalk. We have a mailing list. You can get through our website as well. And I wanted to give a special thank you to both Dr. Shannon Rotolo and Dr. Alex Burris for participating in this kind of NPR Interview esque style of an episode that's kind of new for us. Dr. Khyati Patel 43:49 I 100% agree, as you know, been the user of this program for my patients, I did not understand what it takes to implement this type of advocacy and legislation in a state, and really what takes to operate a pharmacy behind the scenes when these medications are donated and dispensed. And so I'm really thankful for their partnership for Speaker 1 44:10 this episode as well. So Dr. Patel, with that, I am Dr. Kane Dr. Khyati Patel 44:14 and I'm Dr. Patel, and as always, advocate hard. Narrator - Dr. Abel 44:19 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there Narrator - ? 44:30 to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.