As soon as lockdown lifted and states started reopening, the question on most people's minds was the same: What are the riskiest places when it comes to potential COVID-19 infection? Nonprofit journalism outlet CivicMeter conducted a survey of 27 epidemiologists, asking them to rate the risk of contracting COVID-19 at each venue in the United States on a scale of 1-10. Whether you prefer the hair salon, church, your local watering hole, or your local Target store, you might be surprised how your go-to locales rank—click through to find out. And to ensure your health and the health of others, don't miss these 21 Subtle Signs You've Already Had Coronavirus.
No matter what job you hold in pharmacy, you’re likely to run into some funny situations.
Recently, I was reminiscing about my time as a pharmacy intern and student on PharmD rotations. Here are some of my favorite stories.
Price Check
As an intern at a retail pharmacy chain, I often spent time price matching prescription drugs at other stores.
One time, a customer brought in more than 10 prescriptions and asked me to price match every possible competitor for each drug. I think it took me about 90 minutes to make all the calls.
I was checking the customer out at the register when he suddenly flew into a rage. He angrily shouted, “This is 25 cents more than last time!”
I interrupted the man’s rant with, “Are you really going to hassle me over 25 cents?” I then reached into my pocket and handed the man a quarter.
We never saw him again.
Itchy Leg Aid
Another time as an intern, a man asked me to help him pick out some cream for an itchy insect bite.
We were in the OTC aisle looking at hydrocortisone cream when he rolled up his pant leg and revealed a red, swollen leg with red streaking in the vein from his ankle all the way up past where I could see. The patient obviously had an advanced case of cellulitis.
I told him, “There’s no OTC cream that can fix that,” and then I quickly walked him out of the pharmacy, pointed to an urgent care center across the street, and said, “If you want to keep that leg, you’ll go seek medical treatment right now.”
Thankfully, he took my advice.
Inappropriate Exam
As a Pharm D student, I spent a month working with an internal medicine physician. This physician believed that students should be actively involved, so I ended up participating in patient care rather than observing it.
One day, a patient came in with classic symptoms of benign prostatic hyperplasia. Without warning or asking me to leave the room, the physician had the patient drop his pants for a digital rectal examination.
After the test was completed, the physician asked if I would like to feel the enlarged prostate. I quickly declined, saying, “If you go to a pharmacy that does that, you're in the wrong pharmacy.” It was the only time I ever saw the physician laugh.
Jailhouse Script
Here’s a bonus story courtesy of my wife, who is also a pharmacist.
As an intern, my wife was working at a retail store when a man pulled up to the drive-thru window. He presented a script for Percocet and said, “I need this in a hurry because I’m on my way to jail.”
The pharmacist overheard him and said, “I don’t think they’re going to let you take those pills with you to jail!”
If you’re a retail pharmacist or pharmacy technician, you’ve likely experienced issues with getting compounded prescription drug claims paid.
Although compounding has a long-standing tradition in clinical practice, insurers and pharmacy benefit managers (PBMs) have recently instituted policies to decrease claims for compounded medications, citing questions about their safety, efficacy, high costs, and lack of FDA approval. In fact, the PBM Express Scripts announced in June 2014 that 1000 ingredients used in compounding would no longer qualify for reimbursement beginning July 1, 2014.1
For the past few years, compounded medications have been among employers’ most expensive drug categories. According to Express Scripts, “compounded drugs” ranked as the third most expensive drug class in 2014 after “diabetes” and “high cholesterol.”1
Under a 2012 requirement of the Health Insurance Portability and Accountability Act (HIPAA), all components of compounded drugs must be specified and billed using average wholesale price at the ingredient level. Previously, compounded prescription claims were billed under the highest-priced ingredient.
Since this change, bulk manufacturers and compounding pharmacies have substantially raised average wholesale price prices for the components of many compounded drugs, creating “unsustainable cost increases,” according to Express Scripts.1
A recent retrospective claims analysis examined trends in the use of compounded medication between 2012 and 2013. Compound users represented 1.4% of eligible members in 2013.2
In 2012, the average cost was $308.49 for compounded prescriptions and $148.75 for non-compounded prescriptions. In 2013, the average cost of compounded prescriptions increased by 130.3%, to $710.36, while non-compounded prescriptions increased by 7.7%, to $160.20.2
Gabapentin, ketamine, cyclobenzaprine, baclofen, lidocaine, flurbiprofen, and fluticasone were consistently among the most expensive compound ingredients for patients aged 10 years or older in 2013. The most expensive ingredients for patients younger than 10 years in 2013 were used for influenza (oseltamivir), gastric acid suppression (omeprazole, lansoprazole) and skin conditions (zinc oxide, hydrocortisone).2
In addition to concerns about cost, there has been greater scrutiny of compounded drugs by citizens, regulators, and insurers ever since the 2013 tragedy of contaminated steroid injections from the New England Compounding Center. This event caused serious infections and other injuries in at least 751 patients and also resulted in at least 64 patient deaths.
It’s highly likely that someone you know has autism.
According to the US Centers for Disease Control and Prevention, autism affects 1 in 68 children and is reported to occur in all racial, ethnic, and socioeconomic groups.1
Autism treatment consists of behavior and communication approaches, dietary approaches, medication, and complementary and alternative medicine. Risperidone is currently the only FDA-approved drug for the treatment of specific autism symptoms, which involve irritability in children aged between 5 and 16 years.
A casein-free, gluten-free, soy-free diet may be tried, and immunoglobulin G levels can be measured to determine whether limiting these foods may have a beneficial effect on the child.2 Currently, there is insufficient evidence to recommend this diet. If caregivers wish to try it, pharmacists should encourage them to do so in a safe and reliable manner.
Keeping a food and behavior journal is a helpful way to quantify the effect of dietary changes and supplements. On a personal note, I can tell you that a lot of these food substitutes are not very palatable and are also very expensive.
As a pharmacist, patients may ask you about supplements. This puts you in a difficult position because there is very little data to support the majority of autism supplements.
In addition, a product that works in 1 child may have either no effect or a detrimental effect in another child. Encourage caregivers to consult with a physician about the need for laboratory monitoring before initiating therapy with any supplement or special diet.
Potential autism supplements may include the following:
Vitamins
In a study by the Autism Treatment Network, investigators found that supplements and special diets for children with autism often result in excessive amounts of some nutrients, but deficiencies in others.3
Zinc
Zinc deficiency has been found in infants with autistic spectrum disorders. Some patients with autism may have immune dysfunction, and zinc is given to enhance immunity. However, the Autism Treatment Network’s supplements study found that many children may be receiving too much zinc.4
Fish Oil
Fish oil supplementation may be tried to decrease autism symptoms and encourage language development. While itis generally safe, a small Autism Treatment Network study found no benefits of omega-3 fatty acid supplement versus placebo.5
Probiotics
Probiotics have been found to ease autism-like behaviors in a mouse model.6
N-Acetylcysteine (NAC)
In small study, NAC has been shown to lessen irritability in children with autism, as well as reduce children’s repetitive behaviors.7
Remember that it’s perfectly appropriate to tell patients that you can’t make specific recommendations for autism supplements. While you may not feel confident in making specific recommendations, remember to show empathy towards patients with autism and their caregivers.
Marijuana Use Linked to Lower Metabolic Syndrome Risk
2016-01-25 10:13:03
Despite record-high support for legalizing marijuana in the United States (58%), health care professionals do not have adequate clinical information about its potential uses.
The United States is currently facing epidemic levels of obesity, type 2 diabetes, and cardiovascular disease. For the latter 2 conditions, metabolic syndrome is a significant risk factor. Some studies have reported an association between marijuana use and individual metabolic syndrome factors, while others have found no relationship.
A recent analysis of 8478 US patients aged 20 to 59 years evaluated the relationship between marijuana use and metabolic syndrome. Participant data was collected from in-home questionnaires, laboratory results, and physical examinations.
The primary outcome was metabolic syndrome, in addition to a cluster of 3 of the following risk factors: waist circumference, systolic/diastolic blood pressure, high-density lipoprotein (HDL) cholesterol, triglycerides, and fasting glucose.
Overall, 60% of participants reported using marijuana at some point in their lifetimes, while 20% reported using the substance within the past month. About 11% of adults reported current marijuana use.
Notable results regarding metabolic syndrome risk factors included the following:
• Waist circumference was significantly lower among males who reported current marijuana use (93.8 cm, P< 0.0001) compared with never users (100.7 cm).
• Current marijuana users had higher systolic blood pressure (119.4 mm Hg) than never users (117.7 mm Hg, P= 0.01).
• Past (47.0 mg/dL, P= 0.01) and current (51.1 mg/dL, P< 0.0001) marijuana users had significantly higher mean HDL cholesterol than never users (45.4 mg/dL).
• There was no difference in terms of triglycerides between marijuana users and never users.
• Mean fasting glucose levels were significantly lower among current marijuana users (97.3 mg/dL) than never users (99.6 mg/dL, P= 0.02).
About 14% of current and 17.5% of past marijuana users presented with metabolic syndrome, compared with 19.5% of never users (P= 0.0003 and P= 0.03, respectively). The study authors concluded that current and past marijuana use were both associated with a lower prevalence of metabolic syndrome
My first job as a pharmacist was working for Merck Medco in a mail-order pharmacy outside of Cincinnati, Ohio. We had more than 300 pharmacists (not counting pharmacy technicians and other staff) in the facility, and I got to meet a lot of different people.
There were 3 main groups of pharmacists working there at the time: recent grads, working mothers, and “retail burnouts”—pharmacist s who would rather leave the profession than return to retail pharmacy.
Are you looking to leave the traditional path of retail or hospital pharmacy as a New Year’s resolution?
I’ve previously discussed the types of pharmacy benefit manager (PBM) jobs that are generally available. However, I've left the biggest question unanswered until now: how can you actually get one of these positions?
A good place to start is to determine if there are any PBMs operating in your area. Going to the “PBM directory” on the Pharmacy Benefit Management Institute (PBMI) website would be a good way to check.
PBMI is an organization that provides research and education on the design and management of drug benefit programs. Their directory is a convenient list of PBMs operating in the United States. You can visit each individual company’s website to see if they have job openings near you.
If your most recent pharmacist position has been in retail pharmacy, I recommend looking for a position where your retail experience would be valued. In my opinion, retail experience would translate well into mail-order or medication therapy management (MTM) roles.
If you’re looking to transfer from hospital pharmacy, my advice would be to explore positions in PBM specialty pharmacy, where your sterile compounding experience should prove useful.
If you are a pharmacy student, I recommend pursuing an internship at a PBM. Also, consider a managed care experiential rotation through your school. I’ve seen multiple young people jump-start their careers through a PBM or managed care residency.
Remember, your first PBM job won’t necessarily be your ideal role. However, getting your foot in the door is a key step in your career path.
I’ve seen retail and hospital pharmacists apply for niche PBM clinical jobs and get passed over because their job experience wasn’t relevant to the position. Determine which job is a good fit for your skills, and customize your resume accordingly.
If you’re looking for additional information, but not ready to make the jump to a PBM role yet, consider becoming a member of the Academy of Managed Care Pharmacy (AMCP). It is a national professional association for pharmacists who work (or are interested) in managed care pharmacy. They also offers student members
Pharmacists are trained to counsel patients and provide them with understandable drug information. If you are like me, however, then you find it extremely frustrating to counsel your friends and relatives.
When discussing drug therapy with someone who changed your diapers when you were a baby, what should you do? Proceed with caution and be tactful.
You may know people who make every excuse imaginable to avoid taking their medication. It doesn’t matter if there is a strong, clinical need for the medication; they are dead set against taking it.
Recently, I’ve been facing this situation with a relative. This person was recently diagnosed with hypercholesterolemia and prescribed a statin.
In speaking with this relative, I learned that he still hadn’t filled his statin a week after it was prescribed. The first thing he did after receiving the prescription was to search the Internet for reasons not to take a statin.
As we debated this, I quickly realized that chiding or lecturing him would not be effective. In fact, discussing the medication at all wasn’t effective, as he was too resistant to taking it.
The successful approach was focusing on the consequences of leaving the hypercholesterolemia untreated. It is easy for patients to see a potential laundry list of side effects for each medication without considering the benefits. In this case, the prescriber didn’t clearly explain how taking a statin would be a key step in avoiding a myocardial infarction (MI) or stroke.
I reminded my relative of other people he knew who had experienced strokes or MI, as well as the difficulties these people have encountered.
Counseling friends and relatives always has the potential to be difficult. The next time you encounter this situation, take the clinical high ground. Appeal to them as a caring health care provider, and focus on the outcomes.
The value of vitamin D supplementation is regularly debated.
Whenever I see my primary care physician, he asks me whether I’m taking a vitamin D supplement and insists on checking my serum vitamin D level. I think it’s time to take a look at some common questions and answers about vitamin D.
What does the evidence say about vitamin D’s health benefits?
There is ample evidence that vitamin D promotes bone health.
Along with calcium, vitamin D helps to protect older adults from bone loss. Vitamin D supplementation also appears to prevent falls in the frail elderly who are at risk for vitamin D deficiency.
Beyond bone health and possibly fall prevention, no other benefits for vitamin D supplementation have been proven.
Research comprised of mostly observational studies over the last 15 years suggests that adequate vitamin D levels might provide other benefits such as reduced risk for cardiovascular disease, cancer, diabetes, autoimmune diseases, and infectious respiratory diseases. Several large trials are underway to investigate the effects of vitamin D supplementation on outcomes such as cancer and cardiovascular disease.
Many health care providers promote vitamin D supplementation even in the absence of proven benefits. However, pharmacists must ensure that their recommendations are supported by strong clinical evidence.
Remember when vitamin E was deemed the magic elixir that was going to cure Alzheimer’s disease? Beta-carotene and selenium were also hyped in the past, but clinical trials demonstrated not only a lack of benefit, but also potential harm.
Can vitamin D supplementation treat depression or improve mood?
Virtually no evidence links vitamin D status to depression or related conditions.
Should health care providers regularly screen for vitamin D deficiency?
Most organizations do not recommend universal screening for vitamin D.
The US Preventive Services Task Force concluded that it could not determine the benefits or potential harms from vitamin D screening and early interventions. Furthermore, groups such as the Endocrine Society, the American Geriatrics Society, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists have concluded that routine screening is not necessary.
In short, routine testing is a waste of health care resources.
Why do so many lab reports indicate a vitamin D deficiency?
There is no agreed-upon serum vitamin D level linked to health benefits. Therefore, laboratories often establish cut points based on their interpretation of the current literature.
An apparent increase in the prevalence of vitamin D deficiency is explained by the use of high cut points.
Are there concerns about vitamin D over-supplementation?
There is a common misconception that vitamin D supplementation is safe at any reasonable level, or that if some is good, then more may be better.
Vitamin D intake and serum 25-hydroxyvitamin D levels must be very high—perhaps 200 ng/mL to 400 ng/mL—to cause the classic toxicity of marked hypercalcemia and kidney and liver damage. There is also little concern about vitamin D supplementation at doses between 400 IU and 1000 IU per day.
However, concerns have been raised about supplementation in the range of 10,000 IU to 50,000 IU per day, which may be excessive.
Two recent journal articles highlight the exorbitant prices for cancer drugs in the United States. While I’m far from being an expert in oncology, I strongly feel that anticancer treatments should be affordable and insurers should give patients access to the best medication for their condition.
One study from the National Bureau of Economic Research evaluated pricing trends for 58 anticancer drugs approved by the FDA between 1995 and 2013. It also evaluated information on the incremental survival benefits of these drugs.
The study found that anticancer drugs’ average benefit- and inflation-adjusted launch prices increased by 10% annually from 1995 to 2013. This represents an average increase of $8500 per year.
Of note, newer anticancer drugs were not associated with greater survival benefits compared with older drugs.
Another analysis by University of Liverpool pharmacologist Andrew Hill found that Americans pay up to 600 times what the medications cost to manufacture. The United States also pays more than double the price charged in Europe for tyrosine kinase inhibitors (TKIs).
While Gleevec costs only $159 a year to produce, US insurers pay $106,000 for a year’s worth of treatment. Similarly, Tarceva costs $236 to produce against a US price of $79,000, and Tykerb costs $4000 to produce against a price of $74,000.
In all of these cases, the US cost was far above the prices charged in certain western European countries.
“Why should the U.S. bear this huge burden cost?” Hill asked. “It is not as if the GDP of the United States is so much higher than that of European countries, but they just seem to pay these big premiums.”
A lesser-known reason why the United States pays more for these anticancer medications is reimbursement from federal discount programs. Certain hospitals and outpatient clinics are eligible to receive deep discounts from drug manufacturers through the 340B Drug Pricing Program.
From 2001 to 2011, the number of providers eligible for this program nearly doubled, which means non-eligible providers may be paying more to make up the cost.
The American Society of Clinical Oncology (ASCO) encourages its members to consider costs when they choose drugs, but these efforts are mostly focused on costs to patients, rather than the system.
Oncologists are in a strong position to influence the market share of anticancer drugs. Although they do not have direct incentives to avoid costly drugs, oncologists may balk at prescribing drugs with prices they perceive as exploitative.
In my mind, pricing for life-sustaining medications comes back to the argument of whether health care is a right or a privilege. If health care is truly a right, then we need to ensure that drug pricing is based on the benefits a therapy provides over other existing ones.
When I listen to music from 20 years ago, I frequently ask myself whether the song still holds up today.
Some older songs would probably be hits if they were released now, but others seem outdated. For example, I still like to listen to Nirvana, but I cringe when I hear Stone Temple Pilots.
Likewise, it’s important for pharmacists’ drug knowledge to stay current.
One of the most frequent questions new pharmacists ask is how to keep up with new drug approvals and treatment guidelines.
Here are some ways to stay current in the ever-changing drug landscape.
1. Learn on the job.
You’re already working, so why not use this time to learn? If you have downtime, read about new drugs that you aren’t familiar with.
Does your employer provide a newsletter for new drug approvals? Do you have paid access to continuing education (CE) resources? If so, take advantage of these resources.
2. Find interesting CE.
A lot of pharmacists look around for free CE, complete it, and then never give it another thought.
Why not search out quality CE that covers topics you want to learn more about? If you’re looking for a change of pace, perhaps you could attend a live CE event or a state board meeting.
3. Find a part-time job in another aspect of pharmacy.
Consider seeking out an opportunity that broadens your drug knowledge.
If you work full-time in a hospital, then you will learn all about formulary drugs, but you may not absorb much information about non-formulary drugs. Working an occasional shift at a retail pharmacy could provide you with these learning opportunities.
4. Speak with other pharmacists.
If you have friends that are pharmacists in other areas of the industry, ask them about what they do and what drugs they frequently dispense.
If you don’t have a lot of friends in pharmacy, or you don’t get much time to speak with them, consider joining a local pharmacists association and meeting some people who work in different environments.
5. Consider a board certification.
Obtaining a board certification provides the opportunity for growth and development. Seek out the certification that seems interesting to you, not necessarily the one that benefits your current role the most. You may even be able to use a certification to change your career path.
I was recently listening to a national sports talk radio program and heard Arthur J. Siegel, MD, discussing exercise-associated hyponatremia (EAH), a potentially deadly hyponatremia that occurs during or up to 24 hours after physical activity due to sustained, excessive fluid intake.
As easily accessible health care providers, pharmacists have an opportunity to provide patient education regarding proper hydration before exercise.
I contacted Dr. Siegel and he graciously agreed to answer the following important questions about EAH.
Q: What is the mechanism of EAH and why it is potentially deadly?
A: When the intake of hypotonic fluids (water or sports drinks) during exercise exceeds losses, acute brain swelling may occur with headache, nausea, confusion, and disorientation.
Runners may continue to drink avidly, thinking that these are symptoms of dehydration, but this causes progression to seizures and coma. Brain injury and death may result from acute cerebral edema unless reversed by emergent treatment with hypertonic (3%) saline.
Q: What are the risk factors of EAH?
A: The main risk factor is avid intake of hypotonic fluids driven by a fear of dehydration.
Q: Which patient population is at highest risk of EAH?
A: Athletes, especially young women, who exercise for more than 3 or 4 hours at low intensity but drink like they are running at the front of the pack.
Q: Nonsteroidal anti-inflammatory drugs (NSAIDs) have been implicated as a risk factor for EAH development. Should patients avoid NSAIDs before extended, vigorous exercise?
A: More than 40% of marathoners report using NSAIDs. The risk for kidney injury is small, but acetaminophen is safer.
Q: The general public frequently sees advertisements for sports drinks and water with electrolytes, and as a result, they are generally more concerned about dehydration than overhydration. What should pharmacists tell their patients who are preparing for an endurance competition or training?
A: Overhydration is more dangerous than dehydration, so drink to thirst! Trust your body to tell you how much to consume.
Test your EAH knowledge with this true or false quiz:
1. EAH occurs in >10% of asymptomatic marathon runners [Boston, London].
2. EAH is overhydration due to net fluid retention during exercise.
3. EAH may be due in part to dysregulation of the stress hormone AVP.
4. EAH is more dangerous than dehydration.
5. Sports drinks do not prevent EAH if fluid intake exceeds net losses [fluid in>fluid out].
6. Salt supplements before and during exercise do not prevent EAH if fluid balance is positive.
7. Stop intake of hypotonic fluids including sports drinks if feeling confused or disoriented.
8. Rehydrate slowly after races until urination resumes.
9. Seizures or coma require emergent IV hypertonic (3%) saline to reverse cerebral edema.
10. EAH could never happen to me!
Dr. Siegel is the director of the Internal Medicine and Primary Care Clinic at McLean Hospital and MGH Internal Medicine Associates in Belmont, Massachusetts. He is an associate professor of medicine at Harvard Medical School and a fellow of the American College of Physicians. As a former marathoner, his research on runners in Boston has contributed to the prevention and emergent treatment of rare yet life-threatening complications, including cerebral edema from water intoxication in young females and cardiac arrest in middle-aged males. He advocates for use of pre-race aspirin to prevent cardiac events in susceptible runners.
Quiz Answers
1-9: True
10: False
References:
1. Hew-Butler T, Rosner, MH, Fowkes-Godek, S, et al. Statement of the Third International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015. Clin J Sport Med. 2015;25:303–320.
2. Rosner, MH. Preventing Deaths Due to Exercise-Associated Hyponatremia: The 2015 Consensus Guidelines. Clin J Sport Med. 2015;25:301–302.
3. Siegel AJ. Fatal Water Intoxication and Cardiac Arrest in Runners During Marathons: Prevention and Treatment Based on Validated Clinical Paradigms. Am J Med. 2015;21: S0002-9343(15)00353-8. DOI: http://dx.doi.org/10.1016/j.amjmed.2015.03.031
4. Ayus JC, Varon J, Arieff AI. Hyponatremia, cerebral edema, and noncardiogenic pulmonary edema in marathon runners. Ann Intern Med. 2000; 132:711–714.
5. Davis DP, Videen JS, Marino A, et al. Exercise-associated hyponatremia in marathon runners: a two-year experience. J Emerg Med. 2001;21:47–57.
6. Wharam PC, Speedy DB, Noakes TD, et al. NSAID use increases the risk of developing hyponatremia during an Ironman triathlon. Med Sci Sports Exerc. 2006;38:618–622.
The majority of pharmacists practice in either a retail pharmacy or a hospital setting, according to the US Bureau of Labor Statistics. Since pharmacy benefit manager (PBM) jobs are relatively rare, most pharmacists don’t know what it’s like to work for one.
In a 2013 American Pharmacists Association survey, pharmacists employed by PBMs found the following job aspects most appealing: client interaction, constantly changing issues and challenges, flexible schedule, researching and evaluating clinical studies and peer-reviewed literature, and the opportunity to change pharmacy to a provider profession.
These same PBM pharmacists found the following job aspects least appealing: sitting at a desk for 8 to 10 hours a day and day-to-day functions such as answering emails, statistics, and paper work. Another frequent concern that these pharmacists had was a lack of direct patient contact.
Mail order
In my experience, this is the best-known aspect of PBM jobs. Many employers require their employees to use mandatory 90-day mail-order services for their chronic medications. Mail-order pharmacies account for about 19% of the total outpatient prescriptions filled in the United States.
Mail-order pharmacists typically work in large centers and translate scanned pictures of prescriptions into the ordering system. These prescriptions are then filled by automated dispensing systems. Mail-order pharmacists perform drug utilization review (DUR) and call prescribers to clarify prescriptions.
In my opinion, one of the hardest things about filling mail-order prescriptions is the lack of context. You are filling a prescription that was written by a prescriber you don’t know for a patient you’ve never met.
Call center
Pharmacists working in a call center perform a variety of functions such as calling prescribers, medication therapy management (MTM), disease management programs, and patient consultation. Call centers also handle and process prior authorization requests.
Office setting
A number of PBM pharmacist positions are performed in an office setting. Here is a brief list of possible roles:
• Formulary management
• DUR (prospective, concurrent, retrospective)
• Drug information
• Fraud and abuse programs
• Utilization management (prior authorization, step therapy, limits, post-limits)
• Quality assurance
Client support/account management
These pharmacists work directly with clients to discuss client plan benefit design (formulary, utilization management, etc). They allow their clients to customize clinical and reporting requirements to meet their individual population needs and assess the appropriateness of new medications.
This role may require frequent travel in order to meet with clients and attend business meetings.
4 Types of Managers and How to Succeed with Each
Unless you are self-employed, you almost certainly have a manager. Each manager has his or her own thoughts, philosophies, and styles.
The way I personally categorize managers is by their attitude (positive or negative) and how competent they are in their decision making. Assessing these characteristics can give you an idea on how to best work with your boss while providing optimal patient care.
Attitude
Determining a person's attitude is usually easy. Is the person upbeat, optimistic, or inspiring? Is the person negative and downtrodden? Are your spirits brightened when they enter the room or when they leave the room?
One interesting thing about attitude is that people can control it. Some people tend to be more positive or negative, but anyone can choose to have a positive attitude at work. The problem is that most people with negative attitudes don’t try to improve them.
Competency
Competency is notoriously difficult to assess. If it was easy to assess, then no one would ever hire an employee with substandard job performance.
It can be hard to determine whether your manager is competent, but consider the quality of their decisions. Are they generally successful? Is their direction clear? Do their decisions lead to problems and confusion? Low competency can occur from a variety of factors, including inadequate training, boredom, or not using one’s strengths.
In my opinion, there are 4 possible management styles. Let’s consider how to succeed under each type:
Low competency, negative attitude
This is the worst-case scenario. This manager has a negative attitude and makes poor decisions. Your best option is to keep a low profile, be professional, and update your resume in case you need to pursue other career options. These managers are unlikely to be successful. In the table, I’ve highlighted this field as red (hide).
Low competency, positive attitude
This type of manager is pleasant but doesn’t make sound business decisions. One strategy is to offer to take on more responsibility in your role. If you can get this manager to delegate day-to-day decisions to you, then you’ll lighten their load and prevent future problems for yourself. In the table, I’ve highlighted this field as yellow (survive).
High competency, negative attitude
This manager is highly effective; however, he or she can be difficult to work under. This type of manager will generally not like to delegate. It is a good idea to frequently ask this manager for direction and implement their ideas without any pushback on your part. In the table, I’ve highlighted this field as yellow (survive).
High competency, positive attitude
This is the ideal manager. This manager makes sound decisions, is supportive, and inspires you in your career. In the table, I’ve highlighted this field as green (thrive).
This article is clearly about managers, but how would you rank yourself? Is your attitude positive or negative? If it’s negative, consider how a cheerful attitude will enhance your work and improve relationships.
Are you highly competent, focusing on providing quality patient care? If not, determine whether you need additional job training or even a career change. Consider assessing your strengths to determine how you can be the most effective.
Do you carefully examine the explanation of benefits (EOB) forms that you receive from your health insurer?
I recently checked an EOB and found out that getting an allergy shot at a local allergist’s office costs $35, but getting the same injection at a family doctor only costs $23. This led me to wonder how I could check health care costs before receiving services.
According to an April 2015 Kaiser Health Tracking Poll, 55% of respondents believe that the US government needs to take action to make health care pricing information more available to patients. Overall, 31% of poll respondents have seen information comparing physicians, hospitals, and health insurance plans in the past 12 months. However, fewer than 20% have seen information comparing prices or quality across plans and providers.
In addition, nearly two-thirds (64%) of respondents said it is difficult to find out how much medical treatments and procedures provided by different doctors or hospitals would cost. Three-quarters (76%) of the uninsured noted it is difficult to find this information.
In light of soaring health care costs, consumers need to be aware of what they are being charged. Those with health insurance are finding that they are now responsible for more of their health care costs than ever before. For example, more than half of employed Americans pay a percentage of the price of outpatient surgery and hospital admissions, rather than just flat co-payments.
Consumers cannot rely on their health plan’s contracts to always deliver the lowest price, because insurers may pay very different amounts to different care providers. Those who have a high deductible health plan (HDHP) may be particularly focused on health care prices, as the plan does not make any payments until the patient’s deductible has been met.
Have you heard the Jerry Seinfeld joke where he describes a pharmacist’s "whole job" as taking pills from a big bottle and putting them in a little bottle? That’s how some folks have traditionally viewed the pharmacy profession.
Luckily, the image of pharmacy has come a long way since that joke was first made. The Oregon law recognizing pharmacists as health care providers is a huge step in the right direction. The state now joins California and Washington in recognizing pharmacist provider status.
For pharmacists practicing in other states, there is still much to accomplish. As medication use experts, pharmacists are the backbone of the entire health care system. The time is right to change the public’s opinion.
You may be asking yourself, "What can I do?" Well, a small change you can make today is to refocus on patient counseling.
In my limited experience at retail pharmacies, I rarely see patients being counseled. Most patients are all too eager to sign their counseling right away and leave the pharmacy as soon as possible. However, many of these patients are not taking their medications as prescribed. In fact, half of patients new to therapy stop refilling their prescription within a year and 15% to 30% new prescriptions are never filled at all.
I understand that pharmacies make money by dispensing medications. Still, I wonder how many great counseling opportunities slip by because patients aren’t valuing pharmacists' vast knowledge. Our hard work in pharmacy school puts us in the perfect position to counsel patients, increase adherence, and optimize drug treatment.
I hope more states take the next steps so that all pharmacists have provider status. I don't know how to convince politicians to enact pharmacy provider status legislation, but I do know that we can engage our patients. We can start changing minds through counseling.
The peak of summer is finally here. As I enjoy the warm weather, my thoughts go out to the 2015 pharmacy school graduates.
These eager young pharmacists are securing employment and taking the North American Pharmacist Licensure Examination (NAPLEX) and the Multistate Pharmacy Jurisprudence Exam (MPJE).
Here is some advice I have for these recent graduates:
Don’t overlook the MPJE exam.
While studying for the NAPLEX is recommended, you’ve spent many years in school focusing on the material it covers, such as pharmacotherapy and drug information. Pharmacy law, however, is generally covered in just a few short lectures within the pharmacy curriculum.
Careful study of your state's pharmacy laws is a critical step toward becoming a licensed pharmacist. I’ve taken the MPJE for 4 different states and have passed only because I made it a priority to ace the exam.
Consider getting licensed in multiple states through the NAPLEX Score Transfer.
When you originally take the NAPLEX, you have the opportunity to use the Score Transfer program to pursue a license in another state.
Doing so allows you to become conveniently licensed in several states, each of which acts as your “original state.” In other words, you can drop a state license at any time if you never want to practice there again.
If you don’t do Score Transfer and you want to obtain additional licensure, then you have to go through Reciprocity, which requires you to maintain your original state license throughout your career. For example, if you became licensed in Ohio, “score transferred” to North Carolina, and passed their MPJE, then you could drop your Ohio license at any time. With Reciprocity, you are stuck paying for your original Ohio license even if you know you will never move back to Ohio.
Life has a funny way of taking you places that you can’t imagine. Be prepared and flexible by becoming licensed in 2 or more states.
Remember that you are not rich yet!
Because pharmacists walk into a quality salary on day 1 of their career, it may be tempting to splurge on some big-ticket items to reward yourself for getting through pharmacy school and becoming licensed. However, chances are that you have a great deal of debt.
You may also be living on your own now, which requires paying rent, buying furniture, and paying bills. You may even need a new car.
I recommend spending your new earnings cautiously because it’s hard to amass wealth when you have to pay off student loans and tackle all of those other expenses.
Keep in mind that your first job may not work out.
A lot of new pharmacists start their career and expect to work for their employer for many years. Many young pharmacists also expect to start climbing the career ladder right away.
The simple truth is you may find that your first job isn’t what you wanted. It’s certainly possible that you may love your first job, but don’t fret if things go awry. There will always be other opportunities. Be professional in your current role until you can determine how best to proceed.
Follow your career aspirations now.
There is a pharmacy job shortage in many parts of the country. While there is little you can do about it, there are steps you can take to be successful.
Take your career seriously and go above and beyond what your employer asks of you. Analyze the job market and decide where your true passions lie and how you can obtain your dream job. Consider obtaining a Board of Pharmacy Specialties certification or a Master of Business Administration degree to separate yourself from other candidates.
Proton pump inhibitors (PPIs) have been among the most prescribed medications for decades, and they have also been available OTC since 2003
.
Although PPIs are widely used, they are not without risks. According to the American College of Gastroenterology's guidelines for gastroesophageal reflux disease (GERD), potential risks associated with PPIs include: • Osteoporosis due to reduction in gastric acid and decreased release of ionized calcium from calcium salts and protein-bound calcium.
• Clostridium difficile infection due to increased gastric pH levels and growth of gut microflora.
• Community-acquired pneumonia with short-term usage.
In 2009, the FDA issued warnings about the potential for adverse cardiovascular events among clopidogrel users taking PPIs.
One year later, it warned about the potential for wrist, hip, and spine fractures among PPI users.
In June 2015, PLOS One published the results of a large data-mining study that linked PPIs to an elevated risk of heart attack. These results have led many patients to consider discontinuing PPI therapy.
In the eyes of many health care professionals, PPIs are overprescribed. While not every patient who receives a PPI is using it for the correct indication, the American Gastroenterological Association (AGA) stated that this study shouldn’t spur changes in practice.
The AGA recommends reminding patients that all treatments have risks and benefits and that PPIs should be used at the lowest effective dose. The study showed a modest absolute increased risk in that only 1 of 4000 patients treated with PPIs would have a heart attack.
In 2011, noted gastroenterologist Colin W. Howden, MD, AGAF, discussed the risks of long-term PPI therapy on the AGA website. Dr. Howden acknowledged that he discontinued PPI therapy far more often than he initiated it because many of his patients were started on a PPI inappropriately.
Nevertheless, he felt “strongly that the benefits of PPI therapy for appropriate clinical indications greatly outweigh any risks for most patients.” Based on the AGA's heart attack risk statement, patients should continue therapy until they receive individual advice from their prescriber.
Novartis's new heart failure drug, sacubitril and valsartan (Entresto), was recently approved by the FDA.
Entresto is indicated to reduce the risk of cardiovascular death and hospitalization for heart failure (HF) in patients with chronic HF (NYHA Class II-IV) and reduced ejection fraction (EF). With this broad indication, the drug will have a patient population of about 2.2 million Americans. Novartis will also be conducting a trial to determine whether Entresto is effective in those with preserved EF, which accounts for about half of HF cases.
Traditional pharmacologic options for HF include angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), diuretics, and beta-blockers. Despite this variety of treatment options, about half of patients who develop HF die within 5 years of diagnosis.
HF costs the United States an estimated $32 billion each year, and roughly 80% of that cost is related to hospitalization.
The anticipation for Entresto was based on the PARADIGM-HF study, which compared the drug with the ACE inhibitor, enalapril, in roughly 8,500 HF patients with reduced EF. The primary outcome was a composite of death from cardiovascular causes or a first hospitalization for HF, and the trial was stopped early because of the overwhelming benefit seen with Entresto.
The results showed that death or hospitalization for HF occurred in only 21.8% of patients in the Entresto group compared with 26.5% in the enalapril group. The Entresto group had higher proportions of patients with hypotension and nonserious angioedema, but lower proportions of renal impairment, hyperkalemia, and cough than the enalapril group. The most common side effects among patients treated with Entresto were low blood pressure, high blood potassium levels, and renal impairment.
Entresto will cost about $12.50 a day, or about $4500 for a year for 2 tablets taken daily, according to Novartis. The manufacturer is considering a risk-sharing model with some health plans, meaning it could charge more if the drug keeps patients out of the hospital and charge less if it doesn’t. This idea is still in the early stages.
Like most pharmacists, I have a very high opinion of generic medications.
As medication experts, pharmacists understand that the FDA requires generics to have the same active ingredients, strength, dosage form, and route of administration as their corresponding brand-name product. Generics comprise more than 80% of all prescriptions filled in the United States, and they save consumers an estimated $8 billion to $10 billion a year at retail pharmacies alone.
The FDA allows variance in the bioavailability between generic medications and brand-name products. Its rules ensure that a generic’s maximum concentration and area under the curve (AUC) does not fall more than 20% below or 25% above that of the brand name.
These limits may seem exceedingly broad to many health care professionals. Still, the FDA has conducted more than 2000 studies on bioequivalence and determined that the average difference in AUC between the generic and the brand name was only 3.5%.
There are a number of reasons patients may be concerned about taking a generic medication. One reason is that generics may have different inactive ingredients than brand-name products, while another reason is that they may have a different appearance.
Patients become familiar with the shape and color of their current medication. Switching to a generic with a different appearance may cause patients to believe they have received the wrong medication. This may burden the pharmacy staff with unnecessary phone calls and complaints. Patients may also mistakenly take a double dose of a medication because they didn't know that their generic and brand-name medications are the same drug.
While these issues are important, they do not give me pause in recommending a generic medication. What really concerns me isa patient receiving a refill from a different generic manufacturer. This is critical when dispensing a narrow therapeutic index (NTI) drug, such as carbamazepine, digoxin, levothyroxine, phenytoin, or warfarin.
A generic may be 20% below or 25% above that of the brand, but what would happen if we switch from a generic that is 20% below the brand to one that is 25% above it? That’s a potentially deadly swing in drug concentration, resulting in either a subtherapeutic dose or a supratherapeutic dose.
A close friend of mine was recently discharged from the hospital on warfarin 5 mg daily. His INR was stable at 2.5 when he left the hospital. During his 6 months of therapy, he received a different generic product every single time he refilled his warfarin at his local pharmacy.
Despite his physician’s best efforts, his INR swung wildly between 1.8 (subtherapeutic) and 3.6 (supratherapeutic). He was taking no prescription, OTC, or herbal medications that interacted with warfarin. He even refrained from eating foods high in vitamin K.
Luckily, my friend is no longer taking warfarin, but I cannot shake the feeling that constantly switching between different warfarin generics contributed to his problem. This leaves me wondering why the FDA allows such broad variations in bioavailability between generic medications and brand-name products, and why a local pharmacy would stock a different generic every month.
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