Erik Hefti holds a PharmD as well as a Master's and PhD degrees in pharmaceutical science from the University at Buffalo. His research focuses on pediatric pharmacogenomic factors impacting cardiovascular toxicity following cancer chemotherapy and genetic testing utilization to improve healthcare outcomes. His clinical focus involves optimizing pharmacotherapy in patients with genetic disorders. He is the program director and assistant professor of pharmaceutical sciences at Harrisburg University in Harrisburg, PA.

Erik Hefti, PharmD, MS, PhD

The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on the United States’ health care system and its workers. During this pandemic, I have had the opportunity to practice pharmacy in a dedicated COVID-19 treatment facility. This facility is a converted suburban hospital that only admits patients diagnosed with COVID-19. Practicing pharmacy in this unique environment poses multiple challenges.

I am sharing some insight regarding pharmacy practice in a dedicated COVID-19 treatment facility for 2 reasons. The first is to contribute to the conversation regarding the role of pharmacists during the COVID-19 pandemic. The second is to give those interested in a similar role some information and context based on my experience. It is my hope that we can all utilize our talents and expertise to help patients in these historic times.  

My first observation is that the treatment paradigms for COVID-19 are constantly changing. This is a new disease with many unknowns. While there is often little consensus on the best treatment, there is a near constant flow of new discoveries being published. As pharmacotherapeutic strategies are being intensely studied, it is imperative for pharmacists to stay up to date on these latest findings. Now, more than ever, critically analyzing primary scientific research is imperative to implementing the best patient care. Traditionally, pharmacists have been curators of pharmacotherapeutic modalities and information. For pharmacists to continue in this role, we need to be updating ourselves on the best practices regarding COVID-19 therapy.

Beyond rapidly changing pharmacotherapeutic approaches to the disease, the logistics of caring for these patients necessitates new institutional policies. COVID-19 is highly infectious, requiring structural and policy adaptations to suit this reality. Just as our knowledge of COVID-19 treatments is constantly evolving, so is our understanding of the virus itself. This leads to internal policies that require constant adaptation. These updates need to be disseminated to relevant departments quickly and efficiently. This can lead to some confusion between (and within) various services and departments. Email fatigue can make communicating new policies difficult; however, organization-wide efforts that keep all relevant parties informed multimodally does work.

While COVID-19 is often the immediate threat to patients admitted to a dedicated treatment center, it is rarely the only condition that requires attention. Pharmacists in COVID-19 treatment centers should not overlook other conditions that may require pharmacotherapeutic intervention. These other health conditions, such as heart failure, diabetes mellitus, and convulsive disorders, can still require a thorough work-up to ensure optimal pharmacotherapy for the entire patient. Treating the whole patient, rather than just the COVID-19, is critical in a dedicated treatment center. This also necessitates a more ‘typical’ pharmacy operations architecture with regards to order entry, therapeutic drug monitoring, and formulary interchanges to remain intact. Given this reality, secure remote order entry has the potential to minimize the number of centrally located personnel in the pharmacy and reduce pharmacist fatigue. With existing technology, it is possible to perform many pharmacy operations from a distant site, including the home. This technology should be considered, when appropriate, in inpatient facilities with high COVID-19 patient populations.

COVID-19 is a resource-intensive disease to manage. Multiple health care professionals are needed to care for these patients safely and effectively. It is not uncommon for these individuals to work multiple shifts back-to-back, which can go beyond 8 hours each. This can lead to pharmacist fatigue and burnout. Burnout, as well as multiple novel drug combinations and treatments, can make for an environment that is conducive to making medication errors.

With regards to novel agents currently being utilized, most have not been thoroughly studied for this application, if at all. It is imperative to attain a good working familiarity with drugs that are being used in this population to minimize drug interaction, adverse drug events, and errors related to dose or administration.

A dedicated COVID-19 treatment facility requires excellent teamwork to operate effectively. Pharmacists play a crucial role coordinating with other members of the health care team to deliver the best pharmacotherapy possible. Understanding the current institutional policies, the up-to-date scientific consensus on pharmacotherapeutic strategies, and medication delivery logistics within the building is necessary for a pharmacist in a COVID-19 treatment facility.

We, as pharmacists, must be aware that our purpose is to optimize care for patients, not just COVID-19. Each patient represents a unique set of challenges that requires focus and knowledge. Pharmacists are up to this challenge and are indispensable members of the team in a dedicated COVID-19 treatment facility. I am privileged to have the opportunity to contribute to such an important mission.

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Each patient represents a unique set of challenges that requires focus and knowledge.

Considerations for Pharmacists Practicing in Dedicated COVID-19 Treatment Facilities

Retail and inpatient careers continue to dominate the pharmacy landscape. Careers in the pharmaceutical industry also can offer pharmacists a different environment to practice in with unique challenges, rewards, and considerations.

Numerous pharmaceutical and biotechnology companies offer a variety of positions a pharmacist could fill. Although careers in research and development often come to mind when considering an industry trajectory, there is also a need for pharmaceutical professionals outside the lab. One such role is that of a Medical Science Liaison (MSL).

Pharmacists may find a career as an MSL challenging and rewarding. MSLs are biomedical professionals who are responsible for scientific management of multiple aspects of a product, such as a drug, diagnostic test, or medical device, before and after launch. MSLs generally work within a medical affairs department of a company and have an integral role in the success of a product.

MSLs have numerous responsibilities that can vary from company to company. Most MSLs have a minimum of a doctorate degree, often with additional advanced training in a therapeutic area or relevant field. Pharmacists who hold a PharmD and relevant focused training, such as a fellowship, residency, or additional graduate degrees, will be the most competitive candidates for these positions.

Academic pharmacists can be especially well suited to transitioning to an MSL role given their research and training. MSLs are among the most highly credentialed and diversely skilled professionals employed by a pharmaceutical or biotechnology company. The advanced training is necessary as MSLs are expected to be scientific peers, thought leaders, and other influential individuals in a particular field. Beyond hard clinical and scientific skills, MSLs also need to be expert communicators and possess the soft skills needed to advance the company’s goals in an ethical, evidence-based way.

In general, MSLs coordinate cooperation between the company and Key Opinion Leaders (KOLs) in the relevant therapeutic field. KOLs are prominent health care providers, scientists, academics, and others that possess knowledge and influence in the relevant therapeutic area. These KOLs are important for the safe and effective utilization of a specific product and product development. MSLs can effectively communicate key scientific information to relevant parties with their company from the KOLs.

MSLs also are responsible for workforce training of regional sales personnel within the company on a given product, while serving as the key scientific resource for the sales personnel on the team. Although MSLs may occasionally interact with the sales arm of the company, they are expected to approach issues in an evidence-based way. Often, there is a ‘firewall’ between sales and medical affairs in order to preserve the scientific integrity of the MSL team.

Education of health care professionals using the biomedical product can also fall to the MSL. Given the MSL’s advanced scientific training and breadth of knowledge of the product, and the associated therapeutic area, they are commonly tasked with presenting key data and clinical trial findings at relevant conferences.

These are some of the tasks that MSLs are responsible for, but they may vary depending on the employer and product itself.

Beyond some of the unique qualifications and responsibilities that go along with being an MSL, there are some lifestyle considerations as well. MSLs live and work on the road and in the air. Like sales representatives, MSLs are generally assigned a region to cover. The size of the region can vary greatly. An MSL could be responsible for a single state or a quarter of the country, depending on the product and employer. An MSL can expect to be traveling up to 80% of the time, often by plane and car. While many pharmacists work fixed shifts, an MSL is rarely ‘off the clock.’ Depending on expectations, an MSL can spend most of their time away from home. This also requires a savvy understanding of efficient travel methods in a particular region.

A career as an MSL has many positives, in my experience. As an MSL that had New York State, including the New York City metropolitan area as my territory, I was able to travel to some exciting places, and meet some incredibly talented people.

The ability to network is a key positive to a career as an MSL. It is also rewarding to be an integral part of a corporate team that is comprised of diverse professionals sharing a common goal. The financial incentives are often generous, with compensation packages that dwarf those offered to most practicing pharmacists in retail or inpatient roles. There is also upward mobility in industry compared to health care and retail institutions. In my experience, there is also more independence and ability to implement change, compared to more traditional pharmacist roles.

While a career as an MSL can be exciting and rewarding, there are potential negative aspects as well. From my experience, burnout is a real possibility. MSLs generally do not have defined hours. They often have key productivity indicators (KPIs) to meet monthly or quarterly. The time needed to complete these KPIs varies and depends on the season, availability of KOLs, or territory. It could take 20 hours a week to achieve the goals or it could take 60 hours.

The travel aspect can also be a negative. While it is enjoyable to see new places (especially with a comprehensive expense account), travel can be the most grueling aspect of the role. In the northeast, getting stranded in the winter due to cancelled flights was common. There are often stipulations in employment contracts that require residency near an airport. This can make the work-life balance a difficult one. A good manager that stresses the importance of maintaining work-life balance can mitigate this negative factor.

MSLs can be laid off when a product loses a patent or sales suffer. Although some would argue job stability is a potential negative, this is not a large concern. After 1-3 years of experience as an MSL, job prospects are high, minimizing any potential unemployment window.

A career as an MSL should be on the radar for pharmacists interested in a new direction. Although challenging, a career as an MSL can be rewarding and exciting. Expertise in pharmacotherapy, communication strategies, and health care logistics make pharmacists well suited for these unique roles in industry.

 holds a PharmD as well as a Master's and PhD degrees in pharmaceutical science from the University at Buffalo. His research focuses on pediatric pharmacogenomic factors impacting cardiovascular toxicity following cancer chemotherapy and genetic testing utilization to improve healthcare outcomes. His clinical focus involves optimizing pharmacotherapy in patients with genetic disorders. He is the program director and assistant professor of pharmaceutical sciences at Harrisburg University in Harrisburg, PA.

Medical science liaisons are biomedical professionals who are responsible for scientific management of multiple aspects of a product, such as a drug, diagnostic test, or medical device, before and after launch.

Opportunities and Considerations for Pharmacists as Medical Science Liaisons

PharmD/PhD programs are grueling, time consuming, and can be expensive. Are they worth it?

There is not a simple, objective answer to that question. It really depends on what are a prospective candidate’s personal and professional goals.

The length of a PharmD/PhD program can range from 7 years to well over 9 years, depending on the PhD component. It took me 8 years of study post-bachelor’s degree to attain both degrees.

PharmD/PhD programs produce candidates that are highly qualified and competitive for jobs in industry (including roles such as senior scientist, medical affairs, and consulting positions), clinical practice, academia, and in regulatory agencies. Since completing a PharmD/PhD program, I have had success in an array of positions otherwise out of reach, due to specialization and experience requirements. I have been able to pivot from position to position when it best suited my goals and advance my career quickly following graduation. Having both a PharmD and a PhD has made me competitive for tenure-track or clinical academic positions and industry positions alike.

The bottom line is that PharmD/PhDs are generally qualified to do more than those with a PharmD or PhD alone. This can also give PharmD/PhDs additional career stability. With the rising numbers of pharmacists and PhDs in the workforce, as well as current and potential market disrupting forces, future job availability and security are a concern. In my opinion, the largest benefit of getting both degrees is the enhanced ability to pivot as the market dictates and as opportunities arise. I feel this degree combination lowers the risk of being rendered 'obsolete' by evolving technologies or oversaturation of a specific job market.

Having a PharmD and a PhD has some intangible benefits as well. Completing (arguably) some of the most advance training possible in pharmacy and related biomedical sciences confers enormous confidence when applying and interviewing for potential positions. A PharmD/PhD program also will often inherently result in a competitive CV, in many cases due to the presentation and publication requirements for a PhD. After completing a PharmD/PhD, it is easy to distinguish yourself from others early in your career when actual experience in a specific position may be low.

There are not many programs that offer this combination given the infrastructure needed to train and graduate both PharmDs and PhDs. Those with both degrees are indeed a rare breed.  

However, there are other important considerations when considering enrolling in a PharmD/PhD program.

These are academically grueling programs that require an enormous amount of time to complete. The extra work it takes in obtaining a PhD has not been found to guarantee a higher paycheck when graduating. This was shown in a 2011 paper published in the 

American Journal of Pharmaceutical Education

, although it is important to note that the authors looked at adding a PhD 

 obtaining a PharmD rather than graduating from a dual degree program

. The authors also do not assume that the individual is practicing as a pharmacist while completing the PhD.

I disagree with the report’s conclusion that the PhD component is a ”poor return on investment," but another reality is that it is very possible to find positions in academia, industry, and in regulatory agencies with either a PharmD or PhD alone. Having both degrees may put you closer to the front of the hiring line, but relevant experience, a stellar reputation, and preexisting relationships with people in a specific field generally outweighs having 2 relevant terminal doctoral degrees.

I have been asked multiple times if I would do it again? I would say 'yes,' but I would have strongly considered enrolling in a program that waived the tuition for the PharmD component. I would not recommend pursuing a PharmD/PhD program in an institution that requires the candidate to pay for the entire PharmD portion.

If one looks at many analogous MD/PhD programs, tuition waivers or stipends are used to incentivize dedicated students to pursue these programs. There needs to be added incentive for top talent to complete these programs. Schools offering PharmD/PhD programs need to invest more in the students. 

For those in a PharmD/PhD program, I would also strongly recommend becoming licensed as a pharmacist as soon as possible and practicing pharmacy in some capacity while completing the PhD component. While daunting at times, the benefits of building additional professional experience will pay dividends when entering the workforce. Candidates should not think that just because they have 2 doctorates that they will immediately get any job that has a PharmD or PhD requirement. Again, I have found that experience is often more important in most cases, as well as networking with influential individuals in the relevant field.

Overall, PharmD/PhD programs are critical for producing clinical scientists needed by various public and private sectors. Attaining the PharmD and PhD combination is difficult but also rewarding. It can lead to a fulfilling career with the right attitude and expectations.

1. Hagemeier NE, Murawski MM. Economic analysis of earning a PhD degree after completion of a PharmD degree. 

PharmD/PhD dual degree programs are large investments of time and effort, and potential candidates need to make decisions that are right for them.

Opinion: A Dual Degree Program May Be the Right Investment for a Pharmacy Career

Patients that require surgery generally exhibit some degree of anxiety. There are numerous reasons for this anxiety, especially for someone who has never undergone such a surgical procedure previously. Pain, fear of the unknown, and potential disability are all common sources of anxiety in this patient population. These fears can be difficult for healthcare professionals to fully ameliorate. Pharmacists are uniquely suited to addressing apprehension toward postoperative pain and associated medication regimens in patients that require surgery. Incorporating pharmacists into preoperative education and postoperative counseling routines may help relieve some of this anxiety and improve a patient’s overall surgical experience. Improving a patient's experience at a healthcare facility benefits all involved, including the healthcare institution itself.  

At Sisters of Charity Hospital, St. Joseph Campus in New York, pharmacists have been comprehensively incorporated into pre- and postoperative patient education, focused on medications these individuals will typically receive before and after their respective procedure. Specifically, pharmacists give a formal presentation to preoperative patients prior to undergoing surgery. This presentation focuses on typical medications the patients will be started on following the procedure and details on each drug. This was largely precipitated by the need for a healthcare professional to be available to address the patients’ concerns regarding new medications they would be prescribed. Pharmacists are trusted healthcare professionals who are able to provide high quality information on the safe and effective use of medications, so it was a logical incorporation

Over the past few years, we, the pharmacists, have observed an increase in patient apprehension regarding opioid pain medications typically used following surgery. Opiates are frequently used for postoperative pain control, especially for more invasive procedures

. The epidemic of opioid addiction that can start with the use of prescription narcotics is cited as a source of concern. As the opiate crisis continues to grip the country, more patients are worried about starting these medications. They are generally concerned about becoming addicted to opiates if they are started on the medications. Other concerns often cited range from medication side effects to family members stealing prescription narcotics. Pharmacists are in a unique position to assuage and address these legitimate patient concerns. Safe and effective 

 is a major goal in surgical patients. The pharmacists who see these patients discuss strategies to minimize the risk of uncomfortable side effects, addiction, and diversion.   

Sisters of Charity pharmacists address the patients’ concerns over existing medication regimens and how they may change following the procedure. Non-opiate drug-related counseling is also performed and often focuses on the safe use of anticoagulants that are commonly prescribed after certain surgical procedures. Observationally, the patients have responded well to pharmacist presence, and we have seen improvements in patient satisfaction. When we considered responses to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, we began to see modest score increases when considering questions measuring pain control

. Pharmacists in our facility are having a positive impact on patient satisfaction and look to continue the trends we are seeing.

Many hospital pharmacists have fewer opportunities to speak directly with patients. Presurgical and postsurgical education programs represent an excellent opportunity for hospital pharmacists to directly interact with patients in a meaningful way. This benefits everyone involved, from the patient to the facility as a whole. Increased patient satisfaction can positively impact reimbursement rates for the hospital. Pharmacist involvement can also benefit other healthcare professionals and allow them to better care for patients. While pharmacists focus on addressing medication-related issues, nurses and providers can focus on caring for other patient needs. Pharmacists themselves can benefit from increased patient interaction and expanding their profile in the hospital ecosystem.  

Overall, incorporating pharmacists into pre- and postoperative patient management and education benefits both patients and healthcare workers. It also represents an excellent avenue for continued pharmacist involvement in healthcare facilities.

Auyeung V, Patel G, McRobbie D, Weinman J, Davies G. Information about medicines to cardiac in-patients: patient satisfaction alongside the role perceptions and practices of doctors, nurses and pharmacists. 

Buvanendran A, Fiala J, Patel KA, Golden AD, Moric M, Kroin JS. The incidence and severity of postoperative pain following inpatient surgery. 

Hefti E, Remington M, Lavallee C. Hospital consumer assessment of healthcare providers and systems scores relating to pain following the incorporation of clinical pharmacists into patient education prior to joint replacement surgery. 

Surgical patients can exhibit anxiety about the medications they will be started on following surgery. Pharmacists are in a position to address those concerns to the benefit of all.

The Benefits of Integrating Pharmacists into Surgical Patient Education

 approximately a year ago that focused on so-called "hangover remedies” that are often advertised in drug stores, supermarkets, and on the Internet.

The goal was to critically consider any evidence associated with the use of over-the-counter (OTC) supplements to treat the symptoms of an alcohol-induced hangover. I still receive positive feedback regarding this article, so I wanted to write a follow-up that considers more ingredients purported to ameliorate hangover symptoms.

As previously described, hangovers are an unpleasant after-effect of ethanol consumption. Dehydration and the accumulation of toxic metabolites resulting from ethanol metabolism (acetaldehyde) are key contributors to hangover symptoms. Common hangover symptoms include headache, nausea, lethargy, and a general state of malaise. These symptoms can vary in intensity depending on the individual consuming the ethanol, the amount of ethanol consumed, and the type of ethanol. There are countless supplements marketed as “hangover cures” that can be taken before or after ethanol consumption. These supplements generally contain multiple herbal ingredients that have varying amounts of evidence supporting their efficacy.

We will discuss 6 OTC herbal supplements that are commonly used in commercially-marketed supplements or by themselves to treat the symptoms of a hangover:

1. Kudzu root is generally used to describe multiple species in the genus 

. Kudzu root is used in traditional Chinese medicine for multiple ailments, including the after-effects of alcohol consumption. Multiple formulations have become available OTC in Western countries. Some species have been shown to induce acetaldehyde removal. Acetaldehyde is an ethanol metabolite responsible for some hangover symptoms.

 Not all species referred to as Kudzu root have shown this property. Rat studies have shown mixed results when ethanol toxicity was considered. Human trials are scarce, small, and generally did not show Kudzu having an impact on drinking habits or ethanol disposition. Kudzu is one of the more well-studied herbal supplements in relation to the effects of ethanol, but solid evidence as a hangover cure in humans remains elusive.

2. Ginger, a perennial root herb from the plant 

 officinale, is commonly thought of as a mild antiemetic. While no studies have assessed the effectiveness of ginger formulations alone on reducing the severity of hangover symptoms, a formulation used in traditional Chinese medicine called Kami-Shoyo-san (KSS), consisting of ginger root, brown sugar, and tangerine, was shown in a modest study to decrease the severity of nausea, vomiting, and diarrhea when doses were given prior to alcohol consumption. It was not found to alter the time required to recover from hangover symptoms.

 There have been some small studies that have concluded that inhalation of ginger oil had a statistically significant effect in reduction of post-operative nausea level, but most studies that consider the use of ginger as an anti-emetic are small and poorly controlled.

 The use of ginger to control hangover symptoms may help some, but convincing evidence that quantifies efficacy is not currently available.

3. Peppermint oil has been studied for its clinical utility in the treatment nausea and upset stomach. The proposed mechanism involves interacting with receptors in the gut that are involved in pathways associated with nausea. Preliminary studies have evaluated peppermint oil for the treatment of post-operative nausea, chemotherapy, and irritable bowel syndrome. One study reported that peppermint was found it was more effective than placebo, but not superior to current standard therapies.

 In relation to ethanol-induced hangover treatments, peppermint has not been well characterized in the literature as a potential treatment modality.

4. White willow bark is often isolated from several species of the willow tree and has been used to treat various inflammatory conditions. The bark contains salicin, a compound that is structurally similar to aspirin and may also carry the same risks.

 Due to its antiinflammatory properties, it has been proposed as a possible hangover remedy to combat the inflammatory effects of ethanol and its metabolites, but human trials have not explored or confirmed this. Due to this lack of evidence and possible risks associated with salicin, white willow bark should be avoided.

5. An active constituent of tumeric, curcumin, has been of interest to the scientific community due to research related to cancer. Turmeric supplements may have antiinflammatory properties. Small studies have shown that turmeric reduced pain and improved function on individuals with osteoarthritis of the knee.

 Currently, there is scant evidence exists on its use as an anti-inflammatory drug for the treatment of hangover-related symptoms.

6. The prickly pear cactus has been a domesticated crop plant for thousands of years and is purported to have anti-inflammatory properties. A double-blind study that examined the use of a prickly pear extract (1600 IU) given prior to ingestion of alcohol found that the 55 subjects received the extract reported a moderate reduction in alcohol symptoms. An overall decrease in hangover symptoms that approached statistical significance was observed.

 While interesting, this is a single study that has yet to be corroborated by larger clinical study. Prickly pear is an edible plant and toxicity of ingesting the plant appears to be low, making the risk of trying this supplement low compared to some other supplements. The current conclusions mirror those reached in my previous article. Supplements marketed for hangover management generally have little evidence of clinical efficacy. While many of the supplements mentioned are generally considered safe for consumption, there is always a risk associated with taking dietary supplements. There does not appear to be a “silver bullet” approach to hangover management besides avoiding ethanol altogether or drinking ethanol in moderation with adequate hydration and food.

Dominick Varis, a 3rd year pharmacy student at the University of Buffalo contributed to this article. 

1. Hefti E. A Pharmacist's Guide to OTC Hangover Remedies. 

2. McGregor NR. Pueraria lobata (Kudzu root) hangover remedies and acetaldehyde-associated neoplasm risk. 

3. Takahashi M, Li W, Koike K, Sadamoto K. Clinical effectiveness of KSS formula, a traditional folk remedy for alcohol hangover symptoms. 

4. Golembiewski J, Chernin E, Chopra T. Prevention and treatment of postoperative nausea and vomiting. Amer J Health-System Pharm. 2005. 62(12).

5. Ford AC, Talley NJ, Spiegel BM, et al. Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis. 

6. Vlachojannis J, Cameron M, Chrubasik S. A systematic review on the effectiveness of willow bark for musculoskeletal pain. 

7. Madhu K, Chanda K, Saji M. Safety and efficacy of Curcuma longa extract in the treatment of painful knee osteoarthritis: a randomized placebo-controlled trial. 

8. Wiese J, McPherson S, Odden MC, Shlipak MG. Effect of Opuntia ficus indica on symptoms of the alcohol hangover. 

We will explore some common herbal remedies for hangover symptoms and consider the peer-reviewed evidence behind their use.