During my freshman year in high school, my science teacher assigned us to interview people in the community about how they use science in their careers. Although I don’t remember most of the people I spoke with, I can tell you that I spent meaningful time with a local community pharmacist who changed my life.
What I saw was a man who loved his career and truly cared for his patients. In an instant, I knew that I wanted to become a pharmacist, and I never wavered from that goal throughout high school.
Knowing what you want to be when you grow up at age 14 is unusual, but it is very liberating. I simply had to work backwards to figure out how to achieve my goal of becoming a pharmacist.
After high school, I chose to attend Ohio Northern University (ONU) because it had a unique pharmacy program. Rather than attending college for 2 years and then applying to the pharmacy program, ONU students were admitted to the College of Pharmacy from day one.
Although it was expensive, being in pharmacy school from day one and avoiding the risk of rejection made it worthwhile for me.
In college, I spent a lot of time in the library. Although the classwork was difficult, I did well with one exception: organic chemistry.
I did fail organic chemistry—a notorious “weed out” course—but I successfully retook the class over the summer and graduated on time with the rest of my classmates. Failing a course is a difficult stumbling block, but I stood strong and persevered.
Today, I’m thankful for the wonderful pharmacy profession for so many reasons.
First, I’m thankful that community pharmacists are the health care professionals most accessible to the public. If my local pharmacist wasn’t accessible to me, then I likely would have taken a different career path.
Second, I’m proud of the work we pharmacists do, the diversity of our career options, and the relationships we share with our patients and fellow health care providers.
Pharmacy is a profession that makes a real difference in people’s lives. It certainly has made all the difference in mine.
Artist Pablo Picasso surprised a burglar at work in his new chateau. The intruder got away, but Picasso told the police he could do a rough sketch of what he looked like. On the basis of his drawing, the police arrested a mother superior, the minister of finance, a washing machine, and the Eiffel tower.
Pharmacy | Atlanta, GA, USA | Right | November 6, 2015
(I am working the closing shift one evening, with my only other company being my boss, the head pharmacist. A man comes in to pick up a fairly mundane prescription.)
Me: “Before I ring this up, do you have any questions for the pharmacist?”
Customer: “Yeah, will this have any interactions with marijuana?”
Me: *looking to the pharmacist* “Um…”
(My boss comes over to the registers and makes a show of looking through the printed information pamphlet that comes with every prescription.)
Pharmacist: “I don’t believe so…”
Customer: *picking up on our unease* “Oh, don’t worry. I don’t go out on the road or anything when I get high. I just stay home until my trip ends.”
(He then paid his bill and left.)
Me: *to pharmacist* “…Well, at least he’s being responsible about it.”
Pharmacy | Arlington, VA, USA | Right | November 3, 2015
(I have been waiting on line for a long time, but am finally next. Just as the person in front is finishing up their transaction, a woman cuts right in front of me.)
Me: “Excuse me.”
Woman: “Are you next?”
Me: *in an annoyed tone* “Yes.”
Woman: “And are you a total b****?”
Me: “…Also yes, but I don’t see what that has to do with it.”
(I am checking out a woman’s prescriptions. She had just finished paying and signing for them when this happens.)
Customer: “Hey there is a big spot of something here on the counter.”
Me: “Oh, yeah, so there is. It’s probably someone who dripped some of the hand sanitizer from the bottle over there on the counter. But to be on the safe side I have some alcohol in a spray bottle and I will clean that right up.)
(I walk over to the other side of the counter grab the bottle and some paper towels to clean it up. When I get over there she had taken the pump out of the bottle of sanitizer and dumped almost the entire bottle on the counter and spread it over almost 2/3 of the counter. See looks at me all smiles.)
Customer: “There, all better. Nice and clean for you!”
(She then just walked away leaving me to have to clean up the GIANT puddle of goop off the counter.)
(When I was hired at this store, it was under the condition that I will not have to work midnight shifts because the last bus I can take home leaves at nine. I am not the only special case when it comes to scheduling, but I am the only one in the store who takes the bus. About six months later, the store goes through a change in management. Throughout the change and the holiday season that year, the majority of the store employees realize the new manager is not so great and is firing people for arbitrary and possibly illegal reasons. After the holiday season he stops scheduling me entirely unless it is to cover sick call outs. Then I get this phone call.)
Manager: “Hi, [My Name], this is [Manager]. I’m calling because you never filled out this paperwork.”
Me: “I didn’t know I had any paperwork to fill out. I’m sorry.”
Manager: “Well, you have to do it on the store computer and it was due three weeks ago. Everyone had to do it, but you didn’t.”
Me: “So, you do know you haven’t scheduled me in the last two months, right? I call every week.”
Manager: “Right, but this was due three weeks ago.”
Me: “How was I supposed to do it on the store computer if you never have me in the store? Why didn’t anyone tell me about it when I called to see if I was on the schedule?”
Manager: “Yeah, it was due three weeks ago.”
Me: “I didn’t know about it and you haven’t scheduled me in months. Why are you calling me now if it was due three weeks ago?”
Manager: “Well, you should just come in sometime and we’ll talk in person.”
(A couple days later, I go in to talk to him. After repeating that I should have known about something I had no way of knowing, I ask why I haven’t been scheduled.)
Manager: “Well, can you work midnight shifts?”
Me: “No. I take the bus and the last bus home for me leaves at nine.”
Manager: “Everyone has to work at least one midnight shift a week. You can get someone to give you a ride home.”
Me: “I’m not really comfortable with that. I don’t want to have to ask a different person for a ride home every night and have the entire store know where I live. I take the bus. When I was hired, I was told I did not have to work until midnight because of the bus schedule.”
Manager: “Everyone has to do it.”
(At this point I ask if several employees who have only ever worked one specific shift in the ten-plus years they had been there were now working midnights. He says no to each one.)
Manager: “Everyone has to work until midnight at least once a week, so you’ll just have to get a ride home or get a car.”
Me: “I would love to get a car, but I don’t have enough money for one. It’s hard to make money when you’re not on the schedule.”
Manager: “What about the people you live with?”
Me: “They have a newborn and jobs they wake up early for. I can’t ask them to pick me up. As for the people here, I am not comfortable asking perpetual strangers to take me home. When I was hired [Old Manager] promised I would not be forced to work beyond the bus schedule.”
Manager: “Well, if you won’t work midnights, I’ll have to fire you.”
Me: “Let me get this straight. You’re firing me for not having a car?”
Manager: “For refusing to work.”
Me: “I can’t work midnights. I was hired on the condition I would never have to work midnights. There are no buses past nine. I can work any other shift up to 8:50 pm. I want to work. I need a paycheck.”
Manager: “Okay, well, I’m just going to have to let you go. If you want, I can put a note in your file that this was a mutual decision so you can work for the company again in the future.”
Me: “Absolutely not. This is NOT a mutual agreement. You are FIRING me. And don’t worry. After my experience in the last year with you, I would never try to work for the company again. They clearly do not care about their employees!”
(I was friends with several of the shift managers and heard that over the next year, more than half the store had either quit because of his policies or had been fired for similarly flimsy reasons.)
Pharmacy | Kansas City, MO, USA | Working | September 24, 2015
(This happens on my second trip to the pharmacy in the same day. Note, I have plenty of experience as a cashier and actually own a small shop, but I generally pretend to be ignorant as a customer so as not to offend cashiers who do not know what they are doing.)
Pharmacy Tech: *referring to the Point of Sale machine* “It’s going to tell you to sign before you swipe your card.”
Machine: *displays words* “Please swipe card.”
Me: *swipes card without waiting for the screen I am supposed to sign*
Machine: *flashes rapidly between the screen I was supposed to sign and the total, then says* “Processing, please wait.”
Me: “Oops! I was supposed to sign first.”
Pharmacy Tech: “On my end, it says it is waiting for you.”
Me: *turning POS around so he can read it* “On my end, it says, “Processing, please wait.””
Pharmacy Tech: “Well, these are new. I have no idea what to do about that! Try hitting cancel.”
Me: *hits cancel*
(The pharmacy tech hits cancel about twenty times, which any cashier who has used a POS before should know causes the system to freeze. He calls to another employee behind him.)
Pharmacy Tech: “She swiped her card before signing. It’s frozen. What am I supposed to do now?”
Pharmacy Tech #2 : “I don’t know. Just shut it down and move to another register.”
(I left wondering how long it would take before they froze all three of their registers.)
(My wife is a pharmacist for a large chain. She works overnight shifts. A woman comes in with a prescription from the ER. She notes that there are allergies on the patient’s record which may be present in the medication.)
Pharmacist: “There is a possible allergy with this; I’ll need to check the ingredients for this manufacturer.”
Customer: “You don’t need to check that. I’ve taken this before. I have twins at home and I’m in a hurry.”
Pharmacist: “What kind of reactions do you get?”
Customer: “Well, my tongue and throat swell up, and I get bad rashes on my feet.”
(What she is describing is anaphylaxis and Stevens-Johnson Syndrome respectively, both serious and potentially lethal reactions even on their own. Unsurprisingly my wife feels the patient’s assurance isn’t sufficient and decides to check the ingredients to be sure it won’t kill her. The customer is obviously pissed that she has to wait. Unfortunately the ingredients show the allergens are present.)
Pharmacist: “I’m sorry, there are [allergens] present in this medication and I can’t fill it. However, I will try to contact the ER doctor to get a substitute.”
(The patient begins to give death looks and muttering angrily. The medication in question is a narcotic and a controlled substance. The laws which control the filling of the medications require a hard copy, and cannot usually be taken over the phone at all. The only way around this is to use certain emergency protocols which require the doctor to get the prescription hard copy to the pharmacy in a very short time. This is always a risky business for pharmacists in case the hard copy doesn’t make it. Most of the time a pharmacy will just refuse to fill the script, which they are within their rights to do. Against the odds, my wife manages to get the ER doctor on the phone. He agrees to switch the medication to Percoset and says he will personally deliver the hard copy in a couple hours after his shift ends.)
Pharmacist: “We got the prescription changed to Percoset, and the doctor will bring—”
Customer: “I don’t want Tylenol.”
(The customer begins getting even louder and more surly and increases the death stare. My wife knows that this customer has just decided to be angry and will just escalate it from here.)
Pharmacist: “Please, just stop. I can’t fill something that might hurt you. I’ll contact the doctor again to try to get something else.”
(She gets a hold of him and they switch it to Oxycodone. The doctor will still bring the new prescription over. During the call another doctor calls in on the second line. My wife briefly switches over to speak to them before resuming the original call. This takes about a minute. At this point not only has the patient been saved from a possible allergic reaction, but a doctor who has been who-knows-how-long at the ER is going to make a special trip on his own time to make sure she can get her prescription.)
Pharmacist: “Okay, we’ve got it switched to Oxy—”
Customer: “I don’t want to hear what you have to say.”
(She holds up her hand like a mouth and does a movement which clearly indicates “shut up”. My wife is livid at this point, but tries to focus on what she’s doing. She goes to ring her up.)
Pharmacist: “I think it might be better if [coworker from the front end] rang you out.”
Customer: “I think it might be.”
(My wife stepped away and tried to calm down and get her focus back on her other work. While Coworker was ringing the customer out she could hear her complaining about her. One of her complaints was that she took a minute to talk to on the phone to the other doctor. The punchline to all this is that the patient was given some pills at the ER and could have gone straight home with the meds if she was really in such a hurry, and filled the prescription the next day.)
(I’m a female pharmacist finishing up business with a male customer
Customer: “Oh, I’d also like a woman; can you please get me one?”
Me: “I’m sorry, what do you mean?”
Customer: “I want a woman, the cheap kind!”
(He looks at me dead serious.)
Me: “I’m not quite sure I understand…”
Customer: *slower* “I want a woman! But it has to be the cheap kind.”
(I keep looking at him in complete disbelief.)
Customer: *sighs* “How hard can it be? My wife asked me to get her one box of woman or whatever they are called. Where do you keep it? I can get it myself if you tell me where I can find it.”
Me: “Oh… you must mean the multi-vitamin. Wait, I’ll get it for you.”
Customer: *yells after me* “It has to be the cheap kind!”
(We have two kinds of multi-vitamin pill intended for women and both are labeled WOMAN. Apparently that was what he wanted.)
Pharmacy | Tilehurst, England, UK | Right | September 7, 2015
(I overhear the following conversation in the pharmacy
Customer: “I’d, um, like some, er, suppositories, please. Sorry, but I’m not really sure which ones. They’re for my wife, who called out for me to get some when I was half-way out the door on an errand to do something else.”
Pharmacist: “Certainly, sir, let’s go and look for some. Here: would they be these?” *offering him a particular brand*
Customer: “Pff. Not sure. Could be; I know she suffers from the H word, but on the other hand…”
Pharmacist: “You can bring them back for a refund and replace them with the other kind.”
Customer: “What, even if…” *at this point he cracks up laughing* “Even if…” *and he’s laughing so hard he can’t say what he’s trying to say*
Pharmacist: *knowing exactly what he’s trying to say; it’s an old joke, but so funny she can’t help laughing herself* “…even if they’ve been used?”
(Both customer and pharmacist laughed like grade school children
Pharmacy errors can occur in many different ways. A recent case from Missouri reviewed several key sources of pharmacy error and eventually restored an aggravating damages claim in a pharmacy error case.
According to the court, a patient was discharged from a hospital, and a nurse phoned prescriptions to the patient’s pharmacy. The prescriptions were received by a pharmacy technician who had no formal training and had worked in the floral department before being transferred to the pharmacy.
The technician made many errors transcribing the prescriptions. The most significant was confusing once-daily methotrexate for the metolazone that had been prescribed. The pharmacist approved the once-daily methotrexate, later explaining “for some reason I didn’t recognize the weekly versus daily. It didn’t click in my mind.” The pharmacy’s computer system did not flag the once-daily methotrexate dosing schedule.
The patient’s husband picked up the medication. He was asked if he had any questions, to which he replied no. No additional patient education was provided. The patient used the methotrexate daily as instructed on the label, and she died less than 1 month later from the effects of the drug.
A lawsuit was filed against the pharmacy. The pharmacy admitted negligence, and the jury returned a verdict for the plaintiffs in the amount of $2 million. This was reduced to $125,000 based on statutory damages caps. The plaintiffs claimed additional damages for “aggravating circumstances,” but the lower court granted a pharmacy motion to deny these damages.
From this ruling, the plaintiffs appealed.
Rationale
In reversing the lower court, the Missouri Court of Appeals cited four factors that would support an award of additional damages based on aggravating factors.
First, the court noted that in the absence of a computerized “hard stop” for once-daily methotrexate prescriptions, it is imperative that pharmacists conduct their own personal verification of prescriptions. A pharmacy corporate representative testified that, based on her analysis of the facts, “the pharmacist really did not perform a medication review of this drug and of this patient.” The court was skeptical of the pharmacist’s claim that he had reviewed the prescription and concluded that the failure to perform such a review could justify a finding of aggravating circumstances.
Second, the court was critical of the pharmacy technician receiving a new prescription over the telephone. Although the court cited evidence that Missouri is one of only a few states allowing this practice, the court noted the pharmacy’s own policies and procedures that state only pharmacists are allowed to accept prescriptions over the phone.
Third, the court was critical of the pharmacy’s failure to provide patient education when dispensing a high-risk medication like methotrexate. An expert witness for the plaintiffs testified that simply asking if the person receiving a medication has any questions is inadequate. He testified that it is “absolutely inadequate and absolutely deadly in the case of high-alert drugs to not do that counseling.”
Fourth, the court noted that the pharmacy “had made no meaningful changes to its procedures as a result of [the patient’s] death.” The pharmacy corporate representative testified that the pharmacists as a group “have had an in-depth conversation about being more conscientious than we already were, you know, just trying to be more safe in everything that we do.” The court was not impressed.
For these reasons, the appellate court reversed the lower court’s dismissal of the aggravating circumstances claim.
Discussion
This case is a classic example of how pharmacists can be set up to fail by a dysfunctional system. This error did not occur because pharmacists weren’t conscientious and weren’t trying to be safe. Remedial measures after a fatal error of this type must go beyond a platitudinous pep talk.
Computer systems must be designed to implement a “hard stop” when a lethal prescription is entered into the pharmacy computer. Pharmacy technicians must be adequately trained and forbidden to perform functions for which they are unqualified. Patient counseling is absolutely mandatory when dispensing a high-alert drug to a patient for the first time.
Based on: Oyler v Hy-Vee, Inc., 2017 Mo.App. LEXIS 1070 (October 24, 2017).
Column coordinator: David B. Brushwood, BSPharm, JD, senior lecturer, School of Pharmacy, University of Wyoming, Laramie
Capitol Hill Health Fair promotes pharmacists as providers
Diana Yap
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In the brightly lit foyer at the center of the maze-like Rayburn House Office Building in Washington, DC, pharmacists and student pharmacists provided free health care screenings and influenza vaccinations as well as education on the provider status legislation to the public, including Members of Congress and their staff, on a bustling Wednesday during American Pharmacists Month.
Hosted by APhA on October 11, the fifth annual Capitol Hill Health Fair was a showcase for the profession. At the various health care stations arranged in the foyer, Walgreens pharmacists administered influenza vaccinations while student pharmacists provided screenings for blood pressure, cholesterol and blood glucose, and body composition. The student pharmacists hailed from nearby colleges, including Howard University College of Pharmacy, Shenandoah University Bernard J. Dunn School of Pharmacy, University of Maryland Eastern Shore School of Pharmacy and Health Professions, and University of Maryland School of Pharmacy. More than 100 people registered for pharmacist services during the fair.
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Rep. Buddy Carter (R-GA) talks to pharmacists and student pharmacists at the Capitol Hill Health Fair.
The services are “great,” said Rep. Buddy Carter (R-GA), BSPharm. “Well-care is so important.” A little later, Rep. Dave Loebsack (D-IA) stopped by, chatting with student pharmacists at a table.
Serving a dual purpose, the annual health fair provides pharmacist services and “enhances awareness and recognition of the role of pharmacists in patient care and public health in the present and ongoing effort to pursue provider status being led by APhA,” said Maryland Pharmacists Association Past President Hoai-An Truong, PharmD, MPH, FAPhA, FNAP, associate professor of pharmacy practice and administration at the University of Maryland Eastern Shore.
At press time, the Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592/S. 109) had accumulated 230 cosponsors in the House and 47 cosponsors in the Senate. The Senate bill, S. 109, was introduced by Sen. Chuck Grassley (R-IA) on January 12, 2017, while the House bill, H.R. 592, was introduced by Rep. Brett Guthrie (R-KY) on January 20, 2017.
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Walgreens pharmacists, tasked with administering influenza immunizations, celebrate American Pharmacists Month.
Showcasing pharmacists
Walgreens administered more than 100 influenza vaccinations. Among those receiving their influenza vaccination from a Walgreens pharmacist was APhA Executive Vice President and CEO Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA.
“It’s an amazing opportunity to be on Capitol Hill,” said Walgreens Healthcare Supervisor Denise Felluca, PharmD. “We are here to share the critical role pharmacists play in administering immunizations and advocating.”
Providing a cholesterol and blood glucose screening, Divya Vepuri, a second-year PharmD candidate at the University of Maryland Eastern Shore, swabbed a patient’s finger with alcohol. The patient was David Winfrey, a legislative correspondent on staff in the U.S. House of Representatives.
Vepuri moved the new tester’s lancing device to prick Winfrey’s finger for a blood sample. She obtained the sample using a capillary tube. “You’re not scared of blood, are you?” Vepuri asked pleasantly.
“No, not really,” Winfrey said. He added, “I didn’t know they [pharmacists and student pharmacists] knew how to do all these tests. It’s cool.”
Bolstering public awareness
On the far left of the foyer, people stood on devices that looked like a futuristic scale but also contained a body composition monitor. Each device measured body fat, visceral fat, body age, body mass index, skeletal muscle, resting metabolism, and body weight.
John Lee, third-year PharmD candidate at the University of Maryland and its APhA Academy of Student Pharmacists chapter president, said the event was great because it “put our skills on full display so that people are aware of pharmacists’ training and abilities.”
Participating in his first Capitol Hill Health Fair, Patrick Fotso, second-year PharmD candidate at Howard University, advocated for the provider status legislation while providing a blood pressure screening for Justin Maturo, a senior legislative assistant on staff in the U.S. House of Representatives.
Joking about his high-energy ebullience, Maturo said, “My wife and my colleagues have asked me not to drink coffee.” He eyed his blood pressure reading and said, “I don’t like this number.”
But Fotso said, “You’re in a good range. Keep on doing what you’re doing.”
Asked if he knew pharmacists could do all this, Maturo said, “I did not. I thought they just gave drugs over the counter.”
Fotso handed Maturo materials from APhA on H.R. 592.
At rural clinic in Oregon, pharmacist restarts widower’s meds under a CPA
Sonya Collins
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“Howard” lost his wife to lung cancer 2 years ago. When he still felt depressed and anxious months after her death, he started antidepressant and antianxiety medications to alleviate his symptoms. Last year, however, Howard and his providers at Monroe Health Center in Monroe, OR, agreed that he was doing better and tapered off his medications.
Then a few months ago, Howard called the health center. He was having suicidal thoughts, depression, and anxiety. He wanted to restart his medications. Monroe Health Center, a federally qualified health center in rural Oregon, 20 miles south of Corvallis, is the only health care available locally to the town’s 500 residents. When the doctor isn’t in—as was the case on the day that Howard called—pharmacists, behaviorists, and other health care team members fill in the gap.
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Adriane Irwin
“If I hadn’t been there,” said Adriane Irwin, MS, PharmD, BCACP, CDE, a clinical assistant professor at Oregon State University College of Pharmacy in Corvallis and a clinical pharmacy specialist at the Monroe Health Center, “there wouldn’t have been anyone in the office to manage that type of problem for about a week.”
Lack of federal recognition
In fact, that would have been the case in most rural outpatient clinics. Pharmacists are not recognized federally by CMS as health care providers, which means few payers reimburse for their services. This distinction sets pharmacists apart from virtually all other health professionals, who can simply bill insurance for the services they provide. Monroe Health Center, a teaching site for student pharmacists at Oregon State University, covers Irwin’s salary with assistance from the university. But not all rural clinics—strapped for cash and personnel—have the support of a nearby university. Without that, a pharmacist is a luxury most rural clinics can’t afford.
“The lack of reimbursement mechanisms is a significant barrier to integration of pharmacists in primary care medical homes,” Irwin said. “If you don’t have a university with a vested interest in the site, it’s very hard to justify a pharmacist in the clinic.”
Collaborative care
Lucky for Howard, the pharmacist was in. After a meeting with the clinic’s behavioral health specialist to ensure he was not suicidal, Howard met with Irwin. With the verbal go-ahead from a doctor in a nearby town, she had the authority to reinitiate his medications under a collaborative practice agreement.
Howard restarted his antidepressant and antianxiety medications that day and came in for a follow-up appointment with the doctor 2 weeks later. “He’s still on those medications, and he’s doing great,” Irwin said.
Rural physician shortages
Howard, like nearly one in four nonolder adults in rural America, has Medicaid. Some 70% of the patients at the Monroe Health Center do. However, Oregon delivers Medicaid through managed care organizations, and many of these organizations do not recognize pharmacists as health care providers. Which is unfortunate, said Irwin, because “using pharmacists as extenders aligns really well with rural areas that are challenged by the number of patients.”
Americans living in rural areas are disproportionately burdened by chronic disease, while they rely on fewer physicians per capita than their urban counterparts for their care. Rural physician shortages show no signs of improving any time soon. “You’re going to continue to have struggles recruiting primary care physicians to these rural areas,” Irwin said. “So why don’t we look for other ways to meet the needs of those patients?”
For Irwin, it’s a question of basic human rights. “It comes down to ensuring equity for all citizens. Everybody has the right to access health care.”
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Provider status stories
Pharmacists are health care providers. In a series of profiles appearing in Pharmacy Today and on pharmacist.com, pharmacists explain how their patients would benefit from provider status. And as part of our campaign for provider status, APhA has asked pharmacists to share their story of how they provide care to their patients and how provider status will improve health care. These stories are collected on the APhA YouTube channel at https://www.youtube.com/user/aphapharmacists/playlists. If you would like to share your story, please visit PharmacistsProvideCa re.com.
FDA calls out kratom use risks; new AHA/ACC guidelines redefine high blood pressure; community pharmacists enhance care in patient-centered medical home; PTCB names SSgt Mary Johnson CPhT of the Year
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FDA calls out kratom use risks
FDA issued a public health advisory in November warning consumers about the risks associated with kratom, a botanical substance that is being used to treat a host of conditions ranging from pain and opioid withdrawal to anxiety and depression. The plant-based product has gained popularity in the United States, with some marketers touting it as a safe treatment with broad healing properties.
However, according to FDA, calls to U.S. poison control centers in which kratom was involved increased 10-fold from 2010 to 2015. FDA said it was aware of 36 deaths associated with use of kratom-containing products.
“I understand that there’s a lot of interest in the possibility for kratom to be used as a potential therapy for a range of disorders,” wrote FDA Commissioner Scott Gottlieb in a statement. “But the FDA has a science-based obligation that supersedes popular trends and relies on evidence.”
FDA has an established process in place for evaluating botanical drug products for which parties seek to make therapeutic claims. In the statement, Gottlieb said the agency is committed to facilitating development of botanical products that can help improve people’s health, but consumers should know that no FDA-approved therapeutic uses of kratom currently exist.
New AHA/ACC guidelines redefine high blood pressure
High blood pressure is now defined as a reading of 130/80 mm Hg, according to the first new comprehensive guidelines in more than a decade from the American Heart Association (AHA) and the American College of Cardiology (ACC).
The new guidelines eliminate the category of prehypertension, which was used for blood pressures between 120–139 mm Hg over 80–89 mm Hg. Patients with those readings now will be categorized as having either elevated blood pressure (120–129/<80 mm Hg) or Stage 1 hypertension (130–139/80–89 mm Hg). Readings of measures at or above 140/90 mm Hg are considered Stage 2 hypertension under the new guidelines.
The guidelines strongly recommend a team-based care approach to treatment and include pharmacists in the discussion.
“There is high-quality evidence demonstrating that team-based care models, particularly with pharmacists and nurses, improve hypertension treatment and control,” said Eric MacLaughlin, PharmD, FASHP, FCCP, BCPS, who coauthored the new guidelines as APhA’s representative member of the Guideline Writing Committee. “With the formal recommendation to use a team-based approach for care of hypertension patients, there would be [an] expanded role and opportunities [for pharmacists].”
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While more Americans will be classified as having high blood pressure under the new guidelines, only a small percentage more may need medication in addition to the lifestyle changes that are emphasized in the recommendations. The guidelines point out that patients with Stage 1 high blood pressure (130–139/80–89 mm Hg) who also have other issues that increase their risk for heart attack and stroke, such as diabetes, should start medication while also making lifestyle changes. These patients are also advised to re-evaluate with a physician monthly until their numbers have improved.
Those with Stage 2 high blood pressure are being advised under the guidelines to start medication—likely two medications—while making healthy lifestyle changes. These patients will then re-evaluate monthly with a physician until their blood pressure is under control.
As for patients with elevated blood pressure (120–129/<80 mm Hg) or Stage 1 high blood pressure (130–139/80–89 mm Hg) who are otherwise healthy, the guidelines say they should make healthy lifestyle changes.
The new guidelines incorporate data from the Systolic Blood Pressure Intervention Trial (SPRINT), a large, randomized, controlled trial designed to assess the impact of more aggressive versus standard blood pressure goals on hard cardiovascular outcomes. In addition, the authors analyzed more than 900 research studies in developing the guidelines, excluding those that did not meet strict research requirements.
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APhA supports the guidelines and is committed to advancing pharmacists’ roles in hypertension management in a coordinated team-based care environment. APhA will be providing education for pharmacists on the new guidelines in various capacities, including at the 2018 APhA Annual Meeting & Exposition in downtown Nashville on March 16–19.
Community pharmacists enhance care in patient-centered medical home
Community pharmacists who work directly with patients in a patient-centered medical home (PCMH) can help improve rates of influenza vaccination and improve outcomes in diabetes and hypertension management, according to a study published online in JAPhA (doi: 10.1016/japh.2017.10.006). In the article, researchers described a collaboration between Kroger Pharmacy and a medical practice that consisted of seven physicians, a registered dietitian, and a medical home coordinator.
Between January 2013 and January 2014, a community pharmacist worked in the medical practice for 8 hours per week, divided into two 4-hour shifts. While in the office, the pharmacist provided one-on-one appointments with patients, built relationships with office staff, and answered patient and prescriber questions. Appointments with patients included medication therapy management, diabetes education, and weight loss education, as needed. The pharmacist also offered follow-up services in the office or the pharmacy as patients wished. Kroger Pharmacy received a fixed fee per patient per month for high-risk patients.
For the year evaluated in the study, 105 patients had appointments with the pharmacist. Medication review was the most common reason for referral, followed by diabetes education and weight loss counseling. Overall, the rate of documented influenza vaccinations was greater in the practice where the pharmacist worked compared with a control practice. Among patients who had appointments with the pharmacist, the mean A1C dropped from 8.7% to 7.8% for those with diabetes, and the mean systolic blood pressure decreased from 145 mmHg to 127 mmHg.
In their conclusion, the researchers noted that partnering with PCMHs offers an opportunity for community pharmacists to expand their scope of services while working in a sustainable reimbursement structure.
Over the years of my involvement with magazines and journals, I’ve often wondered whether publishers eavesdropped when pharmacists learned to “start low and go slow” with doses. In the same way, when we tweak Pharmacy Today, we do it incrementally, which I think is actually publisher code for “really, really slowly.” Lately, though, we’ve been making some great changes in Today to ensure we continue to have articles that are relevant, helpful, and meet your needs—well, today.
One exciting change is including cover stories that provide a fresh perspective on key professional issues and news, such as high drug costs in last month’s magazine. You’ll see these join cover articles that highlight innovative practice models and approaches. December’s Innovations cover story (page 34) focuses on new technologies that help pharmacists tailor patient communication and increase patient safety across many practice settings and sometimes even between practices—such as health information exchanges to communicate patient data between health systems and community pharmacies.
Kicking off this month’s issue is breaking news on the release of comprehensive guidelines from the American Heart Association and the American College of Cardiology, supported by APhA, that redefine high blood pressure as a reading of 130/80 mm Hg (page 1) and the vote by the CDC Advisory Committee on Immunization Practices to recommend preferred use of a recently approved herpes zoster vaccine (page 18).
The Today team also reports on looming drug shortages from hurricane-impaired manufacturing in Puerto Rico (page 32) and pharmacists having to navigate changes in opioid prescribing and dispensing (page 40). We also prepared a visually appealing guide to what you should know about Medicare prescription drug plans for 2018 (page 48). This month’s CPE provides information on new therapeutic agents marketed in 2017 (page 52).
Keep an eye out for the January 2018 issue of Today, with more new features—including the launch of our Patient Care Pearls and Career Coach columns. Let me know what you think about any of these, or what else we can do to help you, at pt@aphanet.org. I’d love to hear from you!
(I make a quick stop to pick up an over the counter allergy medication, and after a minute or two of choosing between two brands it’s finally my turn.)
Me: “I’ll take two boxes of the Claritin D, please.”
Tech: “Certainly. I just need your ID.”
(After a few minutes she still hasn’t given it back, and is looking confused.)
Me: “Um, is something wrong?”
Tech: “Well, the computer isn’t finding you in the system.”
Me: “Oh! I’ve never been here before. I’m not in the system.”
Tech: “Don’t worry, I’ll find you in it. This is your correct birth date?”
Me: “Yes, but I’ve never—”
Tech: “Don’t worry! I’ll find you!”
(This continues for TWELVE MINUTES before she goes to speak with the pharmacist, and I quickly cut in.)
Me: “I AM NOT IN THE SYSTEM. I have never been to this store before. You can’t look me up!”
Pharmacist: “…[Tech], you need to enter her in as a new patient, not try to look her up.”
Diễn Đàn Người Việt Hải Ngoại. Tự do ngôn luận, an toàn và uy tín. V́ một tương lai tươi đẹp cho các thế hệ Việt Nam hăy ghé thăm chúng tôi, hăy tâm sự với chúng tôi mỗi ngày, mỗi giờ và mỗi giây phút có thể. VietBF.Com Xin cám ơn các bạn, chúc tất cả các bạn vui vẻ và gặp nhiều may mắn.
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