How a Small Neighborhood Pharmacy Transformed Opioid Care in Durham

Since 2005, North Carolina has experienced a 73% spike in opioid overdose deaths. In 2020, the Durham Emergency Department responded to over 481 opioid overdoses. Statewide, drug overdose deaths have been responsible for more than 8 deaths every single day (Durham County Public Health 1) 

Within North Carolina, opioids, such as prescription pain relievers, heroin, and fentanyl, have been responsible for the lives of thousands. They have broken apart families, crushed communities, and left many without a second chance at life. While much of the blame has been shifted upon national and state governance, little focus has been given to the impact local interventions have had on the opioid epidemic (Durham County Public Health 3). 

Vipul Patel is the owner of Gurley’s pharmacy on Main-street Durham, an independent pharmacy, working within the Durham community for over 34 years. Through his time working as a traditional retail pharmacist and now an owner of his own pharmacy, Mr. Patel has been at the forefront of the opioid evolution within Durham. To gain a first-hand perspective on the opioid crisis in Durham, our team sat down with him to discuss his first hand perceptions of the crisis.

What has been your experience with the Opioid Crisis in Durham?

“The focus on the opioid crisis in Durham started in 2015. Between 2010 and 2015 nobody thought there was an actual crisis going on. When I was working at Eckerd in Durham, a chain drug store, we dispensed oxycodone and oxycontin prescriptions as prescribed mostly by the physician's orders”. 

Before 2015 the combination of the lack of a centralized database to track opioids as well as the lack of local government action to support pharmacists was a contributing factor to the rapid increase in the rate of opioid overdose. This made it hard for pharmacists and the local government to check over doctors who overprescribed opioids.

Using the 35,000 entities of raw data collected by the Durham Department of Health and Human services on opioid addiction, our team conducted regression analysis using R statistical software to further understand this rapid increase in the rate of opioid overdose as well as progression of naloxone treatment options within Durham (look to the methodology section for more information on methods, code, and the dataset used).

From figure 1, it is clear that there was an exponential increase in the rate of illicit opioid death per year in Durham between 2010 and 2015. This could be attributed to the many factors Mr. Patel mentions: “a lack of a centralized database”, “inaccessibility of Naloxone”, or “incentives big pharmaceuticals provided to doctors to dispense opioids”. Figure 1 also shows the plateau of this rate between 2015 and 2020, this could be attributed to the beginning of the “shift in focus on the Opioid Crisis in Durham”.

Further supporting Mr. Patel’s assertions, figure 2 demonstrates a strong linear association between community naloxone reversals and year. This indicates that although percent illicit opioid death is increasing per year in Durham, naloxone treatment and the amount of reversals is also increasing to match this rate. Although there is no data present for community naloxone reversals prior to 2013, the simple focus on beginning to track this data and the steady increase in treatment of opioid overdose demonstrates the “shift in focus” Mr. Patel mentions.

Have you ever dealt with a doctor who over prescribed opioids?

“Yes, in fact when we took over Gurley’s pharmacy we were getting...prescriptions of oxycodone from one particular doctor, which I won’t name. We realized that some of these prescriptions were for high quantities of opiates and decided that it was not in the interest of the patient to accept this doctor’s prescriptions. Later we found out the doctor lost his DEA license to prescribe opiates. Because the medical board is very protective of their provider status, it took a considerably long time for him to lose his license, but he did get prosecuted".

The presence of pill mill doctors, specifically, in Durham is surprising and shocking. Pill mills are medical clinics accused of distributing opioid medications without a legitimate medical purpose. Oftentimes they are prescribing opioids for a profit or other form of incentive. In the context of the opioid crisis, pill mills have been one of the primary culprits for opioid addiction. Yet as Mr. Patel mentions, the protectiveness of medical boards across the United States makes prosecuting these individuals very difficult. It alludes to the observation that within the United States healthcare providers are placed upon a pedestal, allowing for them to at times escape the law. 

Still, the ability for a small, independent pharmacy to recognize and stop dispensing medications for doctors overprescribing opioids is a promising sign. It shows that while there is still room for improvement, ethical and moral character is still a driving force in holding healthcare providers responsible.

How has this problem evolved since you started working in Durham? 

“The shift has been almost 180 degrees. You know pharmacists are a lot more responsible in terms of checking the dispensing of medication. Now in Durham and North Carolina, pharmacists have to verify opioid prescriptions to the controlled substance registry, which keeps track of opioids prescribed by doctors...We also have partnerships with Duke and UNC where we have access to electronic medical records and can track what a patient actually needs”.

The evolution of the opioid crisis from 2010 to 2020 in Durham has seen an increased focus on preventive measures in order to hold all aspects of the healthcare system accountable. Moreover, along with the interventions that Mr. Patel described, Durham County is also taking major pharmaceuticals to court in an attempt to seek millions of dollars in relief. Primary court documents show Durham county has joined a growing list of local governments suing Johnson and Johnson, Purdue Pharmaceuticals, McKesson, and more (Kaplan 2). 

Although Durham County as well as the Duke and UNC systems are taking action, Figure 1 still demonstrates that the percent of illicit opioid overdose deaths is increasing. Because the data is presented as a percent of opioid deaths from opioid overdoses, it is possible that there are far fewer opioid overdoses, contributing to a smaller denominator and as a result a larger percentage. Regardless, the renewed commitment from pharmacists, to doctors, to health entities, such as Duke and UNC, demonstrates that everyone has recognized the problem: increased attention must be given to quell the crisis within Durham. 

Are there any specific interventions you or the Durham Public Health Department has worked upon?

“As an independent pharmacy we have the flexibility of implementing programs to help our community. We have a program with the Durham Public Health Department and Alliance Behavioral Health centered around Opiate Based Assisted Treatments (OBAT) and we also work with the North Carolina Harm Reduction program to provide Naloxone and Suboxone free of charge”.

Independent pharmacies are unique in their ability to create individual relationships with patients as well as local partners. Independent pharmacies are especially equipped to provide Naloxone and Suboxone, opioid agonists that help lean patients off of opioid addiction. This is because these pharmacies have already established individual relationships with patients and community partnerships. As a result patients trust these institutions to provide them with accurate health information. As Mr. Patel further’s…

“That’s not a focus of Walgreens or CVS because they don’t have the infrastructure to do that...Specialized niches created by independent pharmacies is where we can outshine these big box chains”. 

Although Figure 2 demonstrates that when Durham is compared to the entirety of North Carolina, Durham is in the middle quantile for illicit opioid overdose death, the data also demonstrates that the city is in the highest quantile for community naloxone reversals. This data matches figure 1 as it demonstrates that although there is a relatively high amount of opioid overdose deaths within Durham, treatment programs are working to help reverse overdose. Widespread prevalence of independent pharmacies within Durham (over 15) along with programs that help provide opioid agonists for free may be a cause for the large amount of naloxone reversals administered in 2020 (Durham County Public Health 3). Investment into opioid treatment programs by Durham, can therefore be seen as an example for the power of local partnerships in promoting change within an entire community. 

Concluding Thoughts

For a neighborhood pharmacy that occupies a reconditioned tobacco warehouse, Gurley’s is embedded not only within the history of Durham, but also within its present community. In 2010 opioid treatment was hardly available. Today, whether it is providing free Suboxone and Naloxone to holding doctors accountable, county pharmacies in partnership with the Durham Public Health Department have worked to transform the opioid crisis. Although opioid overdose deaths continue to remain high, Durham County sets an example for how a community can rebuild healthcare foundations for everyone. As Mr. Patel furthers…

“Durham is a community that has infrastructure not just based on middle or upper income people, but also people who cannot afford healthcare. Patients need that. It’s here in Durham and Durham County supports that”.