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 2020.1 The pair ended up with over 17,000 bottles of hand sanitizer which they subsequently donated to those in need.1 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.2 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.2 Compounding must be completed pursuant to USP General Chapter <795> guidelines for nonsterile compounding.3
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.3 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.4 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-19.5 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.5 On March 23rd the Washington Post reported that the U.S. had “all but exhausted its supplies” of hydroxychloroquine and chloroquine.4 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.6
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 heaven
It’s easy if you try
No hell below us
Above us only sky
Imagine all the people living for today
Imagine there’s no countries
It isn’t hard to do
Nothing to kill or die for
And no religion too
Imagine all the people living life in peace, you
You may say I’m a dreamer
But I’m not the only one
I hope some day you’ll join us
And the world will be as one
Imagine no possessions
I wonder if you can
No need for greed or hunger
A brotherhood of man
Imagine all the people sharing all the world, you
You may say I’m a dreamer
But I’m not the only one
I hope some day you’ll join us
And the world will be as one
As always, comments are enthusiastically welcomed.
Written collaboratively with:
Dr. Amelia Persico, PharmD, MBA is a PGY2 Pain and Palliative Care Pharmacy Resident at the Stratton VA Medical Center in Albany, NY
References
- Nicas J. He Has 17,700 Bottle of Hand Sanitizer and Nowhere to Sell Them. The New York Times. 14 Mar 2020. Updated 15 Mar 2020. Available From: https://www.nytimes.com/2020/03/14/technology/coronavirus-purell-wipes-amazon-sellers.html
- S. Food and Drug Administration. Policy for Temporary Compounding of Certain Alcohol-Based Hand Sanitizer Products During the Public Health Emergency. March 2020. Available from https://www.fda.gov/media/136118/download.
- United States Pharmacopoeia. Compounding Alcohol-Based Hand Sanitizier During COVD-19 25 Mar 2020. Available From: https://www.usp.org/sites/default/files/usp/document/about/public-policy/usp-covid19-handrub.pdf.
- Rowland C. Hospital and doctors are wiping out supplies of an unproven coronavirus treatment. The Washington Post. 20 Mar 2020. Available from: https://www.washingtonpost.com/business/2020/03/20/hospitals-doctors-are-wiping-out-supplies-an-unproven-coronavirus-treatment/
- World Health Organization. COVID-1 Informal consultation on the potential role of chloroquine in the clinical management of COVID19 Infection. WHO R&D Blueprint. 13 Mar 2020. Available From: https://www.who.int/blueprint/priority-diseases/key-action/RD-Blueprint-expert-group-on-CQ-call-Mar-13-2020.pdf?ua=1
- Humer C, Mishra M. Pharmacies set policies to stop U.S. hoarding of potential coronavirus treatments. Reuters. 26 Mar 2020. Available from: https://www.reuters.com/article/us-health-coronavirus-usa-order/u-s-health-agency-lists-hydroxychloroquine-under-hoarding-prevention-after-trumps-order-idUSKBN21D1TI
- Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings. Updated 27 Mar 2020 Available From: https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html
Jeff and Amelia. Thanks for the kind thoughts. Stay healthy.
Great article Jeff.
Imagine if we were all equal.
I wonder if you can
Pain that controls people
Treated like every other man
Cheers
Love that verse! Thank you Lynn!!!
Thank you Dr. Fudin and others who helped with this article! Isolation is a hard place to be, especially in these situations, but this is only temporary. “Normal folks” will be able to go back to work hopefully very soon, and lives will return back to some sense of normalcy.
For patients who suffer with chronic, constant pain, their lives will continue in isolation, just as before this virus. I hope that this forced isolation on everyone will help them understand what CPP go through on a daily basis, but with added horiffic pain.
Isolation is a devistating place to be, and suffering in pain can bring hopelessness, depression, and loss of self worth.
I hope people will think twice before they judge those of us who suffer with constant pain, and debilitating diseases, and realize that isolation is just a small part of what people in chronic pain go through.