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COVID-19: Imagine All Those [PAIN] People – Pain Dr.

Last updated: 04-01-2020

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COVID-19: Imagine All Those [PAIN] People – Pain Dr.

So many important points to make, it’s hard to know where to start! But, it seems reasonable to recognize right up front that “social isolation” has been a way of life for many patients with chronic pain syndromes – for months, years, even decades.

“Imagine” all those people, so aptly co-written by John Lennon and Yoko Ono about a half century ago, reflects perfectly on the worldwide pandemic we are facing today.

Back then IMAGINE called for peace during the Vietnam War, and urged people around the world to live in unity. While the song has lived on, it has never been more applicable when considering the current environment and war on COVID-19. More particularly, governments worldwide, PEOPLE, communities, religious organizations, atheists, neighbors, families, and everyone alone and combined need to act in unity to combat this virus that sees no boundaries by race, creed, color or geographic location.

That said, certain behaviors we’ve all observed nationally are wholly unacceptable. As such, I teamed up with Dr. Amelia Persico to unmask (pun intended) some of the common transgressions and to provide a reminder to pharmacy colleagues on the simple compounding options for compounding hand sanitizer.

The New York Times reported that a pair of brothers in Tennessee began hoarding hand sanitizer and cleaning supplies following the first U.S death from COVID-19 in early March 2020. The pair ended up with over 17,000 bottles of hand sanitizer which they subsequently donated to those in need. A quick Google search reveals countless articles and accounts of similar situations of consumers hoarding toilet paper, hand sanitizer, cleaning wipes, canned goods and more. This has resulted in empty store shelves and panic induced stockpiling. Beyond consumer hoarding, the medical community is facing a shortage of ventilators, N95 respirator masks, and other person protective equipment (PPE). The CDC has issued ‘extended use’ guidelines to permit sanitizing and re-using PPE such as face shields and respirator masks.

In light of the increased demand for alcohol based hand sanitizers secondary to actual need due to the COVID-19 pandemic and panic driven hoarding, the FDA has issued a policy to temporarily authorize compounding of alcohol based hand sanitizer by licensed pharmacists in State-licensed pharmacies or Federal facilities.  The FDA has set forth parameters for compounding of hand sanitizer stating that it must be completed using the following United States Pharmacopoeia (USP) grade ingredients: 80% v/v ethanol or 75% v/v isopropyl alcohol in aqueous solution, 1.45% v/v glycerol, 0.125% v/v hydrogen peroxide and sterile distilled or boiled cold water. Compounding must be completed pursuant to USP General Chapter guidelines for nonsterile compounding.

The USP guidance, updated as of March 25, 2020, states that the hand-rub must have a final concentration of at least 60% ethanol or 70% isopropyl alcohol.  The USP has released three formulations for topical solutions, each is outlined HERE. The guidance has been updated periodically to include information on how to proceed if there are shortages on various products recommended in the initial formulations.  Frequent review of their page for updated information is recommended as this is a rapidly evolving situation.

Beyond the hoarding of hand sanitizer, toilet paper and cleaning products medical providers and consumers alike have begun hoarding  disease modifying anti-rheumatic drug (DMARD), hydroxychloroquine. At the time of this writing the World Health Organization (WHO) is in the midst of exploring the potential role of hydroxychloroquine (and chloroquine) in management of COVID-19. Despite inadequate evidence of efficacy of hydroxychloroquine as a COVID-19 treatment option,  there have been reports of patients and facilities hoarding this medication and concerns have arisen of a potential shortage, which may jeopardize disease control and increase the risk of flare for patients utilizing hydroxychloroquine as a DMARD. On March 23 the Washington Post reported that the U.S. had “all but exhausted its supplies” of hydroxychloroquine and chloroquine.Individual states, the federal government and large community pharmacy chains/ prescription benefit managers have all issued guidelines to limit the dispensing of hydroxychloroquine to those patients with an FDA approved indication for therapy OR those with a positive SARS-CoV-2 test actively enrolled in a trial. When this is all over, medical providers, family, and neighbors need to reflect on ALL THE PEOPLE with chronic pain disorders that are forced to live in social isolation on a daily basis because they cannot leave their houses due to crippling pain syndromes. The last thing these patients need is judgement by others who until now have largely unappreciated their social isolation, which in their case is heightened by whatever pain befalls them.

In closing, we wish good health and happiness to all, and ask for special thoughts to ALL THE PEOPLE socially isolated in pain now and beyond this pandemic. Finally, we ask readers to reflect on these thought-provoking lyrics in these difficult times…

Imagine there’s no heavenIt’s easy if you tryNo hell below usAbove us only skyImagine all the people living for today

Imagine there’s no countriesIt isn’t hard to doNothing to kill or die forAnd no religion tooImagine all the people living life in peace, you

You may say I’m a dreamerBut I’m not the only oneI hope some day you’ll join usAnd the world will be as one

Imagine no possessionsI wonder if you canNo need for greed or hungerA brotherhood of manImagine all the people sharing all the world, you

You may say I’m a dreamerBut I’m not the only oneI hope some day you’ll join usAnd the world will be as one 

As always, comments are enthusiastically welcomed.

Dr. Amelia Persico, PharmD, MBA is a PGY2 Pain and Palliative Care Pharmacy Resident at the Stratton VA Medical Center in Albany, NY

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