By Fran Grabowski, Lead Diabetes Educator

AN is a hardworking mother of five grown children, 20 grandchildren and three great-grandchildren. In the past, she has had custody of some of her grandchildren and great grandchildren. She works 10 hours five nights a week, and recently added a weekend job because she has not been able to pay her bills. She is currently in danger of having her electric service terminated.

When you look at AN, you can see the joy, gratefulness and strength in her eyes. She has respect for work and for her family and community. And like 11 percent of other African-Americans in Camden, she has diabetes.

For three months, AN came every week to diabetes self-management education classes offered on Friday mornings through the Camden Citywide Diabetes Collaborative in the Fairview section of the city. She comes with records of her blood glucose and food, sets behavior change goals, and works with her provider to make healthful decisions.

But all this good work with lifestyle change is not enough. Eight years after diagnosis, AN needs four injections of insulin daily—and she is afraid of needles. She knows not taking her insulin would mean complications: amputation, dialysis, blindness and heart disease. Yet, unfortunately, she misses doses because of her fear of injecting.

Most people think of a syringe and insulin vial when they think of injecting a medicine into the body. Though insulin was once injected with a hollow-pointed needle, syringe needles are now produced thinner, shorter and sharper, and are often specially coated for ease in entry and exit. People injecting rarely feel pain. Patients tell me fingertip checking of their blood glucose hurts more than taking insulin.

In the past, AN’s fear was lessened by using an insulin delivery device called a pen. A cartridge in the pen is prefilled with 300 units of insulin. Pen needles attached to the cartridge are even thinner and shorter than needles for syringes. Insulin pens are easy to store, convenient and very accurate. When you want to inject 13 units of insulin, you know that you are getting 13 units of insulin. Insulin pens are used by 95% of insulin-treated patients in Europe, Asia, and Scandinavia.

A pen would reduce AN’s fear and increase the likelihood of her consistently taking her insulin. Overall, it would provide better outcomes and improve her quality of life. Research on insulin pens shows better patient reported outcomes, greater medication adherence, less pain, and improved convenience. Healthcare resource utilization and costs were found to decrease with the use of pen devices compared to vials.

But AN cannot afford the $140/month copayment for pens. I spoke to her insurance company. They cannot help.  I spoke to the manufacturer who offered a $25 rebate. Unfortunately, rebates are ineffective for low-income patients. AN cannot afford the initial cost, much less wait for the rebate. She can write a letter describing her situation to get free medications. But AN does not have the ability or time to write this letter. Her life is very complex. She gets very little sleep and helps her extended family every day.  (I tracked eight hours calling, writing letters and trying to find a way to remove this obstacle to care.)

Fascinating but true: Getting a pen would be an option if she did not work, had Medicaid, or was uninsured. Prescription assistance is available if you are uninsured.  But if you have insurance, the only option is to write a letter to the pharmaceutical company detailing the unfortunate circumstances, or hope hope your primary provider has “samples.”

Unfortunately, our healthcare system is not designed to support people who work low-paying jobs. As far as AN, her doctor was able to get pens through a pharmacy assistance program.  And, not surprisingly, she continues to need support to take her insulin consistently. We have developed a respectful and caring relationship.   She is a most courageous woman and testimony to strength and determination to do more than her share in caring for herself and others.

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