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ethically speaking
Lost, Stolen, or Discarded Medications
Amy Reese Hohmann
A man who has lived in a tent on the
street for months is forced by the local
police to clean his encampment and
move. He hurriedly picks up all his
belongings as fast as he can in order
to avoid getting arrested for illegal
camping. In the haste of cleaning his
area, he missed gathering the apixaban
he takes as a maintenance medication. After realizing this, he asked
the pharmacist if he could refill the
medication, but pharmacist informed
him that Medi-Cal will not pay for a
refill for another two weeks. This man
must go without the mediation for two
weeks because of his unstable housing
situation.
Justice for the Unhoused
When discussing the ethics pertaining
to the unhoused community, the normative principle of justice is typically
the focal point. Justice is the principle that pertains to fairness, equity,
and appropriateness to what is owed
to people.1 People who experience
homelessness face problems of justice
because of their current situation in
life. They do not have the same access
to healthcare services as others. Often
times their health suffers as a result.
Evidence has proven that people on the
lower spectrum of the socioeconomic
status experience “more illness, more
disability, and a shorter lifespan” on
average than their higher socioeconomic status counterparts.2 There are
many factors to why there are poorer
health outcomes in these communities
such as the physiological response to
chronic stress, lack of access to healthy
food (financial or locational) and lack
of access to healthcare services.2 Justice
for people who are unhoused ought
to include equitable access to healthy
food, healthcare services, and an
environment that provides less stress
The Ethically Speaking column
is coordinated by Amy Reese
Hohmann, PharmD, MBe,
Desert Regional Medical Center,
Palm Springs, California.
amy.c.reese@gmail.com
for individuals. With the same access,
these individuals can lead full lives that
are not cut short due to health disparities. Unfortunately, our society has a
long way to go to reach these ethical
equity goals.
Unhoused Data in California
According to the 2022 Annual Homelessness Assessment Report3 by the U.S.
Department of Housing and Urban
Development, there were approximately 171,521 people who experienced
homelessness in California on a single
night.3 This number accounts for about
30% of the total homelessness experienced in the U.S.3 The report identified “continuums of care” where the
majority of people who are unhoused
reside. California cities included in this
category with the largest number of
people are Los Angeles city and county,
San Jose/Santa Clara city and county,
Oakland/Alameda city and county, San
Bernardino city and county, Riverside
city and county, Santa Rosa/Sonoma
County, and Oxnard/Ventura County.3
Out of the 58 counties in California,
7 of them are “continuums of care”
that contain the largest number of
unhoused people.3 These data illustrate
the dire need of this community in our
state.
Lost, Stolen, and Discarded
One problem that has been elucidated
through healthcare professionals who
work with the unhoused community
is maintaining security of medications. Many people who are unhoused
have their medications lost, stolen,
or discarded. This issue poses a risk
to their health because maintenance
medications keep people from further
harm. In the scenario described earlier,
situations like this happen more often
than realized. Due to the transient
nature of life for chronically unhoused
people, losing items is commonplace; it
is also commonplace to have belongings stolen.4 The city can also sweep up
belongings and discard them.4 Some
of these belongings are medications.
Maintenance medications needed by
this community can disappear leading
to health concerns for their owners. If
medications are lost, stolen, or discarded, it may be difficult to replace the
medications if the refill has not passed
the 75% of the estimated duration
mark.5 If the medication is unable to
be refilled within a reasonable window
of time, its absence could cause poor
health outcomes.
Anticoagulants, antiretrovirals, and
antipsychotics are just three classes of
medications that can, when not taken
regularly, decrease health outcomes.
For instance, if a person with atrial
fibrillation is unable to take anticoagulants, it puts them at a higher risk of
thrombosis that could lead to disability
or death (depending on where the
thromboembolism becomes lodged).
Going without antiretroviral medications can cause an increased viral load
that increases the risk of spreading
the virus to others. Increased viral
load also decreases CD4+ count; a
low CD4+ count puts people at risk of
opportunistic infections that decrease
health outcomes even further. The inability to take antipsychotics can pose
health risks for people by increasing
the possibility of mood instability. If
a person is unable to maintain their
mental health due to lack of medication, it can worsen overall health
outcomes by aggravating symptoms of
issues such as schizophrenia or bipolar
disorder. Maintenance medications are
thus essential. Without these medications, negative health outcomes such
as further disability or death in some
cases can result.
Safety and Security
The heart of the issue of lost, stolen,
and discarded medications is that everyone ought to have access to security
and safety. People who do not have
access to these basics lack the ability to
be as healthy as possible. Health is not
just the “absence of disease or infirmity,” but it is the “state of complete
physical, mental, and social well-being.”6 The paucity of both security and
safety people who are unhoused face
puts them at risk for certain health
disparities. In this case, going without
maintenance medications for chronic
California Pharmacist | vol. 71, no. 4
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