Ashley Branham, PharmD, BCACP

When you think about recent “disruptors” to the consumer marketplace, you can look around your own neighborhood to see the effects of Uber, Airbnb, and even the craft beer movement. What is it that makes them a disruptor to the industry? What has allowed them to thrive against odds? As you take a deeper look into the success of these businesses, you’ll discover that consumers value the combination of quality, convenience, and cost in these various industries.

Particularly in the beer industry, it is the small, independent brewers that have created the dramatic shift by bringing a high-quality product and an innovative style to restaurants, taprooms, and now even grocery stores in almost every community around the nation. What is even more remarkable about the movement is that the brewers who perfect their craft have an ever-changing quality improvement process; they have laboratories where they have freedom to experiment with new flavors and different techniques to hone their art. Then they share their findings with other brewers who are doing the same. They endorse each other’s product, and they aggregate together to market their differentiation on a larger scale. You can find the brewers by locator tools on the Internet, posters, and endorsements by fellow brew masters or local shops that respect the quality and passion behind the craft.

So, how does this relate to community pharmacy? Just as not all beers in the marketplace are the same, not all community pharmacies are the same. Local brew masters pour their passion into the process to perfect their craft, and we can observe a similar movement in our industry as a subset of community pharmacies around the country test new strategies to effectively manage complex patients across the continuum of care in a setting of health reform. A consumer should expect a different pharmacy experience when interacting with a community pharmacy that is focused on care delivery than he or she might receive at a pharmacy model focused on delivering medications “fast, accurate, and cheap.” These “craft” pharmacies are aligning in a Community Pharmacy Enhanced Service Network (CPESN) to aggregate on a larger scale so that they can share best practices in medication distribution, clinical service delivery, and quality improvement processes. Pharmacies within the CPESN focus on implementing innovative services to better meet the needs of patients with complex medical conditions and build relationships with providers and community support services so that they can collectively and collaboratively manage those patients. In these pharmacies, the staff takes a care-team approach to go above and beyond to make sure patients have the access to the correct medication regimen customized to meet the their unique social and health considerations. These activities require reengineering the workflow, maintaining dedicated staff to interact frequently with patients to identify any potential drug therapy problems, and engaging in outreach to providers to reconcile gaps in therapy. Delivery to patients’ homes by a pharmacy staff member, medication synchronization programs, medication adherence monitoring, and transitions of care programs are beginning to be a minimum standard offering of pharmacies that are “perfecting their craft” and trying to resolve complex patient issues.

When just one pharmacy in the community is committed to delivering enhanced services beyond traditional dispensing services, it is likely that only a few valued partners—such as doctors, care managers, and discharge planners&mdash;will realize or appreciate the differentiation in the marketplace. However, when several pharmacies in a geographic location join together to perform enhanced services and market themselves as something different for the chronic care patients, then the perception of community pharmacy in that marketplace is likely to shift. Pharmacies belonging to the CPESN undergo constant transformation to perfect their craft so that they ultimately can provide patient care services in a way that translates to improved patient safety, better patient education, and enhanced collaboration among all of those involved in caring for the patient. And … no longer do all pharmacies look the same. They have a craft that sets them apart in a crowded marketplace. The way pharmacies deliver their “craft” may differ, but if the product or service lends itself to improving patient outcomes, when it does so, our patients, our partners in the medical community, and our valued purchasers will all perceive this subset of community pharmacies differently&mdash;and, just maybe, they’ll admire it as one of the great and recent disruptors.

Articles

When you think about recent “disruptors” to the consumer marketplace, you can look around your own neighborhood to see the effects of Uber, Airbnb, and even the craft beer movement.

Your Practice Is Your Craft: Differentiating Your Community Pharmacy Practice

Acute pain is the body’s normal response to noxious stimuli. Acute pain typically lasts for days to weeks, but it may last for months during the healing process.

 Because pain is a highly subjective experience, it is important for a thorough assessment to be conducted to determine the cause of pain and the most appropriate course of treatment. A pain management plan should consider the assessment of pain and all pertinent patient factors, as well as drug and nondrug measures that can be employed to relieve a patient’s pain. When a medication is selected to treat pain in a geriatric patient, factors that should be considered include drug metabolism mechanism, renal or kidney function, concomitant medical conditions, and social history, including the potential for drug abuse or history of addiction. If an assessment takes place in a community pharmacy setting, it is important to consider when a patient may require referral to a health care provider for a more in-depth acute pain evaluation.

The assessment of pain requires a multidimensional approach by clinicians because pain can present in many different ways and can affect patients physically and psychologically. A patient’s report of pain, in his or her own words, is the most reliable indicator of pain. A thorough pain assessment should inquire about the characteristics of the pain, past and current management strategies, medical history, family history, psychosocial concerns, and the patient’s goals and expectations for pain management. Characteristics of pain may include location and distribution, duration and periodicity, quality, and associated signs or symptoms.

Pain may be assessed using a unidimensional or multidimensional tool. Unidimensional scales are useful for a quick measurement of the intensity of an individual’s pain. The most common unidimensional pain assessment tools are the numeric rating scale, the visual rating scale, or a categorical rating scale. The 

 provides illustrations of unidimensional pain assessment tools. Because of potential “oversimplification of the pain problem” when using only unidimensional pain assessment tools, experts often prefer to use a multidimensional pain assessment tool. Multidimensional tools offer the advantage of providing information on characteristics of pain, in addition to pain intensity. They may be provided in a visual, verbal, or written format. Examples of multidimensional assessment tools include the initial pain assessment tool, a brief pain inventory, the McGill pain questionnaire, a memorial pain assessment card, and a pain drawing.

Elderly patients, in particular, may have difficulty articulating an accurate description of their pain for several reasons. It is common for this population of patients to underreport their pain due to fear, cultural factors, or stoicism. Changes in the patterns of an individual’s activities of daily living, such as walking or participating in social activities, may be an indicator of unrelieved pain. Elderly patients should be assessed for hearing, vision, or verbal impairments that may affect the assessment technique. When assessing pain in elderly patients, ensure that enough time has been allocated to perform a thorough assessment and that the tool selected is amendable to the needs of the patient.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are best used to treat pain that is inflammatory in nature, such as muscle sprains or strains.

 Particular patients who should be cautious of NSAID use include those who are at risk for cardiovascular events (eg, heart attack, stroke), those with high blood pressure, and those with renal impairment.

 NSAIDs contribute to elevated blood pressure, even if only used for 1 week.

 If an NSAID must be used in someone with a high cardiovascular risk, naproxen is the agent of choice. Patients with a high cardiovascular risk who take aspirin for cardioprotection should use NSAIDs with caution, as they may interfere with the antiplatelet effect of aspirin. Because the clearance of NSAIDs is affected by renal function, individuals with poor renal function should use NSAIDs cautiously. NSAIDs also increase the risk of gastrointestinal (GI) bleeding, and should be used cautiously in patients with a moderate to high GI risk. Selective cyclooxygenase-2 inhibitors pose a lower risk of GI bleeding and are preferred for use in patients with this risk if an NSAID must be used. NSAIDs may also pose a risk of drug interaction with several common medications used in elderly patients, including warfarin, blood pressure agents, and bisphosphonates.

Acetaminophen (APAP) is an excellent agent for treating many types of pain, particularly those that are noninflammatory in nature, such as arthritis. APAP does not bear the same cardiovascular risk as NSAIDs, making it a preferred agent in patients with a medium-to-high cardiovascular risk. In general, APAP has fewer drug interactions than other agents that may be used to treat pain. APAP may increase the risk of bleeding, particularly in patients who are taking concomitant warfarin. This risk of bleeding is lower with APAP compared with NSAIDs or aspirin, making APAP the agent of choice in individuals who take warfarin.

 An important factor regarding APAP is that it may cause liver toxicosis, particularly in patients who already have poor liver function, or in doses in excess of 150 mg/kg/day (~7.5 g in an average-sized adult). Therefore, individuals should not consume more than 3.25 to 4 g of APAP per day. Elderly patients and those with impaired liver function may benefit from a lower maximum daily dose (2 to 3 g) of APAP.

Aspirin is typically used for cardioprotection; however, at higher doses, aspirin may also be used to alleviate pain. Because high doses of aspirin must be used to alleviate pain, it is typically not the agent of choice. Aspirin increases the risk of bleeding, especially if it is used in conjunction with another agent that increases the risk of bleeding. Because aspirin is cleared renally, patients with severe renal impairment, defined as <10 mL/min, should avoid the use of this agent.

Opioid agents may be used to treat acute pain, but they should be reserved for moderate to severe pain. Several organizations have provided position statements discussing their concern over the use of opioid medications due to increasing drug dependence and abuse, in addition to adverse effects and drug interactions.

 In geriatric patients, adverse effects of concern include those that mimic the anticholinergic system, such as constipation, dryness, increased sedation, and decreased respiration. It is important to assess a patient’s other medications that may also increase sedation. A key concern with increased sedation in the elderly is the risk of falls. Decreased respiration is of concern for individuals with underlying respiratory disorders, such as asthma or chronic obstructive pulmonary disease. To minimize opioid use for acute pain, the following suggestions have been proposed

		Use the shortest course of therapy possible

		Never use long-acting or extended-release products

		Use opioids cautiously in elderly patients

		Include shared decision making: educate patients on the benefits and risks of the medication and allow them to make an informed decision

		Maximize appropriate nonopioid therapies

When considering acute pain management in elderly patients, clinicians must keep several factors in mind. Geriatric patients may have hearing, verbal, visual, or mental impairments that may make it difficult to accurately assess their pain; therefore, in affected individuals, the pain assessment technique may require modification. In addition, agents used to treat acute pain in adult patients may not be appropriate in the elderly, depending on the individual’s concomitant disease states and medications. Therefore, in elderly patients, a careful approach is suggested as clinicians assess pain and select an appropriate nondrug or drug treatment regimen. 

Laura Rhodes, PharmD, is a PGY1 community pharmacy resident with the University of North Carolina at Chapel Hill and Moose Pharmacy in Concord, North Carolina.

Ashley Branham, PharmD, is the director of clinical services at Moose Pharmacy, in Concord, North Carolina. 

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Acute pain is the body's normal response to noxious stimuli.

Acute Pain: Considerations in Geriatric Patients

It is estimated that 46 individuals die of prescription opioid overdoses every day in the United States. The Centers for Disease Control and Prevention reported that more than 16,000 individuals in the United States died of opioid overdoses in 2013.

 Results from the National Survey on Drug Use and Health demonstrate that almost 2 million Americans, 12 years or older, misused or abused opioid pain relievers in 2013.

 The rise in overdose deaths resulting from the misuse and abuse of prescription drugs has been linked to overprescribing, a 300% increase in prescription opioid sales since 1999, and improper medication disposal.

On March 10, 2016, the United States Senate passed a bill to combat the growing heroin and opioid epidemic throughout the nation. The Comprehensive Addiction and Recovery Act, a bipartisan bill, was passed with a vote of 94 to 1, demonstrating overwhelming support to reduce opioid addiction and related deaths. This bill will provide $725 million of federal grant money to local and state governments, and nonprofit organizations, to expand program resources, education, and monitoring programs. In addition, funds could be used to develop drug treatment programs.

“Today, Americans suffering with opioid addiction are closer than ever before to getting the help they need,” said Senator Richard Burr (R-NC). “There are thousands of North Carolina families currently grappling with this addiction, and I am encouraged that the Senate has produced bipartisan legislation that will help end the devastating crisis hurting families across the country. We can reverse this disturbing trend that has ravaged the United States over the past few decades.”

Pharmacists are equipped to play an important role in reducing opioid misuse and abuse, but are often an underused resource. Pharmacists have unique clinical knowledge, as well as an obligation to ensure that all efforts are made to prevent substance abuse in their communities by providing education, using prescription drug monitor programs, and providing patients and families with lifesaving resources.

Education is a crucial first step in tackling prescription abuse. Parents and teenagers should be targeted for education due to the many misconceptions about drug use. Illegal drugs are commonly discussed, but many individuals fail to understand the risks associated with prescription drugs, especially opioids. Many parents are also unaware that teens are abusing prescription drugs and, therefore, are unsuccessful in safeguarding access to those medications in the home. In the 2009 National Survey on Drug Use and Health, 70% of individuals who reported nonmedical use of pain relievers obtained them from relatives or friends, whereas only 5% of individuals reported getting them from a drug dealer or via the Internet.

 Because opioids are commonly prescribed and are readily available in most homes, it is important to educate families on the potential abuse that can result from easy access.

Pharmacists can reach out to their communities by participating in public substance abuse education and prevention programs, collaborating with other health care providers (HCPs), and working with local, state, and federal authorities to combat controlled substance abuse. Educating patients on proper storage and disposal of excessive, unused, and expired medications should become routine practice for pharmacists. Directing patients to local drop boxes, or other safe ways to dispose of medications, can further help to prevent medication diversion and abuse.

Statewide electronic databases, such as prescription drug monitoring programs (PDMPs), can be effective tools for pharmacists in identifying the appropriate use of controlled prescription medications. As of 2014, 49 US states have operational PDMPs in place to track the prescribing and dispensing of controlled prescription medications.

 This statewide electronic tool is used by prescribing physicians and pharmacists to provide data on prescribing and dispensing histories of controlled substance prescriptions, including opioid medications. Although this tool has proven to be useful in preventing drug diversion, it is only useful if HCPs use the system prior to prescribing and dispensing.

 Pharmacists must continue to regularly use their state PDMP  and inform other HCPs of the importance of its use. With added federal funding, additional local and state governments may be encouraged to establish effective PDMPs to monitor prescription drug use in their states.

Patient Resources and Assistance Programs 

Pharmacists can play a role in patient assistance by identifying individuals who have a substance abuse problem and referring them for evaluation and treatment. Pharmacists are equipped to identify individuals at greater risk for overdose or addiction, as well as recommend and provide lifesaving antidotes to family members in case of an opioid overdose. Family members should be counseled to look for signs of an opioid overdose (Table 1

). The typical signs of an opioid overdose should be communicated to family members of an opioid user. With opioid antagonists, such as naloxone nasal spray and Evzio auto-injection, lives can be saved by simply administering the medication to reverse the effects of opioids. Available naloxone products are listed in Table 2

. Community-based overdose prevention programs, such as Project Lazarus, focus on increasing access to naloxone for prescription opioid users. Physicians are encouraged to prescribe the antidote to patients at high risk for opioid overdose. Through this program, patients taking opioids, and their family members, are educated on how to use naloxone and are provided with a naloxone kit for home use.

Through new laws and increased funding, HCPs can expect to see an increase in the use of drug monitoring programs, drug treatment programs, and education and resources for families of individuals using opioids. To help prevent misuse or abuse of these drugs, pharmacists must be diligent in ensuring that opioid medications are dispensed to individuals who legitimately need them. Although pharmacists may not be able to eliminate all opioid misuse and abuse, a number of resources and strategies can be used to improve patient care and public safety, including adequately educating patients and the public about the dangers of prescription medications, ensuring that patients are aware of proper medication disposal practices, diligently using operational statewide PDMPs, and providing families of opioid users with opioid overdose kits. 

The authors thank Jordan Ballou, PharmD; Harkin Hayes Jr., PharmD; Laura Rhodes, PharmD; Chelsea Renfro, PharmD; and Alicia Watkins, PharmD, for their suggestions regarding the content of this article.

Desiree Gaines is a PGY1 community pharmacy resident with the University of North Carolina at Chapel Hill and Moose Pharmacy. Ashley Branham, PharmD, is the director of clinical services at Moose Pharmacy, in Concord, North Carolina. 

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It is estimated that 46 individuals die of prescription opioid overdoses every day in the United States.

Opioid Addiction and Overdose: New Legislation and How Pharmacists Play a Critical Role in the Epidemic

Our aging population will require continuous medication management for chronic conditions.

If you have been keeping up with the policy updates surrounding the profession of pharmacy, you have likely come across news about HR 4190, which would amend title XVIII of the Social Security Act to cover pharmacist services. Commonly referred to as the “provider status” bill, this legislation has gained traction since its introduction in March 2014, with support from more than 100 members of Congress. It is anticipated that a companion bill will be introduced in the Senate next year. Currently, the Centers for Medicare & Medicaid Services grants provider status to physicians, chiropractors, clinical social workers, nutritionists, clinical psychologists and other health care professionals, which allows these providers to bill health insurance for their services. HR 4190 seeks Medicare coverage for pharmacist’s services in medically underserved areas. The implications of this bill have the potential to significantly impact the practice of pharmacy through advanced scope of practice and an expansion of payment mechanisms. What does that mean for you and how would practice change as result of the passage of legislation such as this?

A 2010 study reported that on average, a physician spends 20.8 minutes in a face-to-face encounter with a patient.

 With the fee-for-service payment model still prevalent, providers balance the challenge of obtaining an accurate medical history, completing an assessment, encouraging behavior change, providing education, and documenting the patient encounter within a short time frame, all while trying to maintain a financially viable practice. This is increasingly a challenge for an already bursting-at-theseams practice model contending with the health care needs of our aging baby boomer generation. We expect baby boomers, born between 1946 and 1964, to appreciate a longer life expectancy than any generation that preceded them. By 2030, there will be more than 70 million Americans older than 65 years.

 The number of baby boomers with multiple chronic conditions is expected to grow to nearly 37 million by 2030. By 2030, more than 6 of every 10 individuals of the baby boomer generation will be managing more than one chronic condition.

 Furthermore, data trends indicate that 1 out of every 4 baby boomers (14 million) will be living with diabetes mellitus and more than 21 million will be considered obese.

 With a notable rise of health care demands in this segment alone, there is a critical need for an increase in the creation and assembly of health care teams to address the demand, uphold quality, and improve patient access to care.

Each state’s pharmacy practice act authorizes pharmacists to deliver patient care services that may include immunizations, diabetes education, medication reconciliation, and home visits, but there are other professions that also deliver these services to patients. What makes our profession different and why should we pursue legislation to cover our services? The reason is that a pharmacist’s training goes beyond medication reconciliation or the delivery of preventive services. Pharmacists are best qualified to work with complex medication regimens, systematically reviewing medications for effectiveness, safety, and appropriateness considering the indication. The evaluation of the medication regimen is best completed through collaboration among the prescriber, other members of the health care team, and direct interaction with the patient. Patients taking multiple medications may benefit from additional education and oversight, which are often omitted during a routine physician visit.

To date, there have been limited payment mechanisms that financially support pharmacists in these roles. If enacted, HR 4190 could open up opportunities for pharmacists to offer and deliver these services and financially justify the effort. With nearly 75 cents per health care dollar spent on the treatment of chronic disease states, even modest improvements by the health care team involved in the management of chronic disease states focusing on appropriate medication use would result in significant health cost savings.

Attaining coverage for services through HR 4190 will impact all types of practice settings. To maximize patient encounters, pharmacists across all segments of health care, including community, chronic care, and health-system practice, must be ready to intercept medication lists at every transition point to ensure that patients clearly understand and have access to the appropriate medications. When considering the geriatric population specifically, pharmacist involvement with interdisciplinary care teams can be beneficial in reducing the number of drug-related problems occurring at times of transition. Nearly one-third of hospitalizations and one-half of skilled nursing facility admissions have been associated with medication- related problems.

 Pharmacists’ ability to detect medication-related problems and recommend appropriate treatment can ensure a smooth transition for the patient across the continuum of care. Moreover, the reduction in or prevention of medication- related problems will allow a patient to remain in an independent living setting longer. Recognition and coverage for pharmacist-provided services will incentivize pharmacists and pharmacist employers to implement, expand, and integrate patient care services into a collaborative care delivery model. Pharmacists should employ strategies of enhanced communication using all technology available, without eliminating the value of face-to-face interaction.

When it comes to evaluating potential for cost savings as a result of adding a pharmacist to the care team, we cannot promise that the addition of these services will result in decreased drug spending. If pharmacists are involved, it should be expected that drug costs will be increased to ensure that patients are adherent to quality, individualized regimens that will offer optimal health outcomes. The Congressional Budget Office estimates that in the Medicare program, a 1% increase in prescription drug use would result in a decrease of total medication spending by approximately one-fifth of 1%.

 It is a true possibility that passage of HR 4190 will result in the opportunity to deliver pharmacy care that will offset total health care costs. In order to improve health care delivery to address the growing number of patients with chronic conditions, creative solutions are needed for enhancing health-system and community-based collaboration and strengthening outpatient services. With increased longevity and an increasing number of patients managing chronic conditions, our patient population is going to require continuous medication management across all practice settings. Relying on pharmacists to address complex medication issues can be one solution to meeting the rising demand for patient care.

Ashley Branham, PharmD, BCACP, is director of clinical services at Moose Pharmacy in Concord, North Carolina. Branham received her PharmD from Campbell University. She completed a community pharmacy residency at the UNC Eshelman School of Pharmacy and Moose Professional Pharmacy in Concord. She also completed a PGY2 community pharmacy residency with a focus in academia with the UNC Eshelman School of Pharmacy and Moose Professional Pharmacy in 2010. Branham is involved with the implementation and enhancement of clinical activities. She is currently a preceptor for student pharmacists completing advanced pharmacy practice rotations with the UNC Eshelman School of Pharmacy.

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