, Donald Miller, PharmD, discussed how the recent Supreme Court decision overturning Roe v. Wade has created confusion around access to methotrexate for patients in some states that are limiting abortion access. Although methotrexate is commonly used for rheumatoid arthritis and a host of autoimmune diseases, it can be used to treat ectopic pregnancy. Although Miller said pharmacists should know their patients’ diagnoses and should be able to counsel them on their routine methotrexate use, the restrictions in some states have left patients and providers unsure about whether methotrexate can be dispensed in some cases.

Now states can pretty much do whatever they want. So, obviously, a number of states have banned or very soon will have a ban on abortion in almost all circumstances. For a pharmacist to dispense a medication that could be used in abortion puts them at some legal risk. Methotrexate usually is not thought of as an abortion drug, but it is sometimes used to treat an ectopic pregnancy. Both physicians and pharmacists, now, are afraid to give it out, especially to any young female patients.

 Outside of the use for abortion, can you talk about what it is mostly used for? And why that access is so important?

It’s used especially for rheumatoid arthritis because it’s really just a mainstay disease-modifying drug for almost everyone who develops rheumatoid arthritis. It’s also used in a lot of autoimmune diseases, psoriasis, psoriatic arthritis, lupus, inflammatory bowel disease, among others. So it does affect quite a few people. That probably is not a first-line drug for most of those, other than rheumatoid arthritis.

 From what you’ve heard so far, how are pharmacists handling this issue if they’re in a state where this is restricted?

 I think it’s all over the board. I’ve read lots of stories about this too. It seems like even in some states that don’t restrict abortion, pharmacies and physicians are becoming very careful. I’m sure there’s also a lot of pharmacists just dispensing it routinely. But certainly, there’s fear, and well-documented, at least some pharmacies are refusing to fill prescriptions. Also, some doctors or even whole medical systems apparently have put a hold on prescribing methotrexate until they get more clarity on what they can and can’t do.

 Can you discuss how pharmacists are being potentially impacted? There are liability concerns. There’s also just the toll it takes not being able to care for patients the way you normally would.

 It’s got to be stressful, in a lot of ways. A lot of it is confusion, I think, whether it’s a medical system, doctor, pharmacist. It’s like, I don’t know what I can do and what I can’t do. And if I do the wrong thing, I could go to jail, or nevermind even that, if I do the wrong thing, I could be accused of participating in an abortion, which affects your reputation. It would be nice to just sit it out for a couple of months, let everything settle down, but our patients need methotrexate right now. I’m hoping that most pharmacists are simply using their professional judgment and continuing to dispense methotrexate appropriately.

 Have you heard of any litigation efforts or other ways that that people are helping or trying to clarify the confusion?

 I think there’s going to be a lot of litigation. But unfortunately, sometimes these things don’t get resolved until there’s actually a case. I think it’s almost inevitable—some people are going to be accused of dispensing an abortifacient and it’s going to go to a trial or something. And it’ll be settled either in courts with precedents. But hopefully—this is going take some time—everyone’s contacting their legislators and their different states, try to get 

 any clarity. A lot of these abortion laws were passed, I think, probably pretty quickly. This was the idea that we don’t want abortion at all. Legislators didn’t think at all about all the medical implications, and so I would think that there would be, eventually, some further legislation in many states that would create some safe harbors. But legislative sessions don’t meet all the time, could be a year or 2 years before that’s figured out. And again, case law would take a while. I think we’re going to be kind of a mess for quite a while.

 Are there any more immediate actions that pharmacists could take or their patients could take to ensure access to methotrexate or to talk to legislators? Anything else you would encourage?

I think we all have to use professional judgment. Most pharmacists are probably just talking to the patient and/or talking to the prescribing physician to get clarity and get documentation of exactly what's being done. I think your best protection against any liability is always know your patient. Most of your patients on methotrexate have probably been on it for a long time. It shouldn't even be a question about the appropriateness, and again, prescribers, many of them, pharmacists will know. It shouldn't be an issue other than maybe your occasional brand new patient who's seeing a doctor you don't know, but you can still clarify. I think it's also very easy for retail pharmacy to recognize a suspicious prescription. Not only should you know many of your patients already, but the only time methotrexate is used for abortion is specifically for ectopic pregnancy. When it's used for ectopic pregnancy, it has to be used in a high dose by injection. The smaller doses that patients use for rheumatoid arthritis and so on won’t be effective with ectopic pregnancy. There's no way you can accumulate enough oral methotrexate to use it in an abortion or ectopic pregnancy, because a patient simply can't tolerate much more than 20-25 milligrams methotrexate at one time. To use it in an abortion or ectopic pregnancy, it has to be given by injection. Now, some of our patients also will get methotrexate by injection for rheumatoid arthritis. But again, that's at most probably 25 milligrams once a week. So, if someone was to divert that to her friend, they'd be giving up a month's worth of their own methotrexate. It just seems ridiculous that it would be trafficked or misused by any patient that you know of. I think a lot of the fear is way overblown. I think, again, if you use your professional judgment, do the same thing you do every day, I think pharmacists are going to be fine.

 Is there anything you want to add anything that I didn’t think to ask about?

 Well, the other thing that's kind of interesting is apparently physicians are also more reluctant to prescribe methotrexate for a young woman. It's always been a concern, because with methotrexate, it can cause birth defects if you become pregnant. If a young woman's taking methotrexate, she would need to be on birth control. Hopefully that works, but there’s always that chance that birth control will fail. Now, I think physicians are having to have really good talks, even more important talks with their patients—if they're taking methotrexate and they’re to become pregnant, that if you do become pregnant, abortion is no longer an option. You have to be really sure you want to use the medication. You have to be sure you're using a contraceptive appropriately.

Videos

Donald Miller, PharmD, discussed how the recent Supreme Court decision overturning Roe v. Wade has created confusion around access to methotrexate for patients in some states that are limiting abortion access.

Methotrexate Access Becomes Challenging for Some Patients Following Supreme Court Decision on Abortion

®, Donald Klepser, PhD, MBA, professor and dean of academic affairs at the College of Pharmacy in the University of Nebraska Medical Center, discusses his session at the American Association of Pharmacy Technicians Annual Convention and how 

 can manage their own stress and burnout.

Q: Due to the increased role of pharmacy technicians, there has been an increased feeling of stress and burnout. How should pharmacy technicians manage their own stress and burnout?

It's a great question, and it's certainly it's not limited to pharmacy technicians, we see it in pharmacists, I see it in my students, it's across the board. I think the first step is to recognize that you are feeling stressed that you are overwhelmed. That's definitely got to be the first step. Then, taking advantage of services that are available to you. Unfortunately, because of the heightened awareness of stress and burnout, a lot more workplaces have programs to support, so take advantage of those. Take care of yourself, and I know it sounds trite, but get sleep, get some exercise eat, lay off alcohol, and all of those things that also contribute to that stress in some of those feelings are important.

Then I think the last thing is talk to somebody, talk to somebody at work, talk to your supervisor, make sure they understand what you're going through. Are there programs available at your workplace? Or that they can connect you with? Or is it simply just an understanding that, “Hey, maybe I need to dial back for a while. I need help.” I think, again, going back to the first, recognizing you have an issue, recognizing that it's okay, that you are stressed and feeling a little overwhelmed and taking advantage of those resources. I think that's the advice for pharmacy technicians and everyone else.

Q: How has automation helped improve pharmacies and decrease burnout among pharmacy technicians and pharmacists alike?

The utilization of automation is going to vary widely from one pharmacy to the other, but at its core, it should make people more efficient. It should take away some of the repetitive tasks, if there's a software or machine or something that can help. It should allow people to spend less time on those things and focus more time on higher value higher cognitive services. Is that necessarily going to improve stress and burnout? Well, hopefully, it reduces workload. I think that's where care has to be taken is that we're not introducing something that actually makes things worse or the level of stress remains the same. So, great opportunity just has to be thoughtfully implemented.

Donald Klepser, PhD, MBA, professor and dean of academic affairs at the College of Pharmacy in the University of Nebraska Medical Center, discusses how pharmacy technicians can manage their own stress and burnout.

Pharmacy Technicians Burnout Increases as Role in Pharmacy Increases

Logan Franck, PharmD, BCACP, a clinical associate professor in the College of Pharmacy at the University of Nebraska Medical Center, discuses his American Association of 

 session on over-the-counter medications.

Q: What are some considerations for pharmacy technicians when counseling patients on OTC medications?

First and foremost, I'd say ensure that pharmacy technicians are not actually making recommendations straight to a patient. There should always be a discussion with the pharmacist that's there that day. I will admit that pharmacy technicians oftentimes do have a lot of those answers in and can provide a lot of those recommendations, but there might be a little nuance or something small that gets missed that could create a little bit of liability issue.

Running everything by a pharmacist and making sure a pharmacist signs off on that would be better care for our patients. Ultimately, just keeping that decision making to the pharmacist that's been studying this drug interactions and drug nuances for many years.

Q: Why is it important for patients to seek counseling from pharmacy staff on the concurrent use of OTC medications with prescription medications?

This is kind of a hot topic right now. It's something that often gets missed. It's known that a lot of patients think that anything that's over-the-counter is good to take, doesn't have side effects, it's very safe, and it works. That's just not the case.

Each over-the counter-medication, just like prescription medications, have drug interactions or side effects from taking it. A good example of that is acetaminophen, or Tylenol, is in about every medication over-the-counter, any combination product. It does work well with reducing fever and reducing mild pain, but if we take too much, we can cause liver damage. Keeping that in mind and letting patients come to you and ask questions, instead of simply grabbing things over-the-counter will be beneficial to them, let alone the concept of drug interactions.

Medications over-the-counter do the same thing they interact with prescription medications. Pharmacist will benefit from knowing what medications the patients already on that will also tell them kind of what disease states they have, and ultimately, be able to make better informed decisions of possible safety hazards.

Q: For those not in attendance for your presentations, what are some of the key takeaways you would like to highlight?

The 3 takeaway points, I would say, first and foremost, like you just heard, combination products are not your friend. Over-the-counter medications have a lot of different things in them, but you should pick products that only have 1 single ingredient in it, and hopefully that single ingredient is all you need to treat a certain symptom or the reason that you're taking the medication.

Number 2 is generics are just as good as brand name medications. So do the patient a favor, recommend and point them to in the direction of the generic instead of the brand name. Just save them some money.

Last one, discuss all recommendations with pharmacist. Make sure that they sign off on what's going on and they keep in consideration that safety of that patient.

Logan Franck, PharmD, BCACP, a clinical associate professor in the College of Pharmacy at the University of Nebraska Medical Center, discuses his American Association of Pharmacy Technicians session on over-the-counter medications.

Patients Should Consult Pharmacy Staff Before Taking OTC Medication

Ryan Burke, PharmD, director of professional affairs at Pharmacy Technician Certification Board, discusses a session at the American Association of Pharmacy Technicians Annual Convention 2022 and how the changing role of 

 has also helped the role of the pharmacist.

How has the COVID-19 pandemic changed the role of the pharmacy technician long term?

 I think for one thing, it has reinforced something that we've known for a really long time, which is that pharmacy technicians are critical to the successful and efficient operation of a pharmacy, right? Related to COVID at least, testing and immunizations remain really a core part of what people in community pharmacy are doing every day, and it doesn't seem like that is going to go away anytime soon.

The other thing that is interesting about immunization administration, in particular, is that we use a tool to track job postings for pharmacy technicians throughout the country. Immunization administration is actually now showing up as 1 of the top 5 requested skills from employers. I think that demonstrates that employers kind of anticipate this being a long term thing, where pharmacy technicians are very much engaged in helping to vaccinate the community.

Q: How has the increased responsibilities for pharmacy technicians made the job of pharmacists easier?

 it's important to acknowledge that there are increasing demands on everybody who works in a pharmacy whether it's technician, pharmacist, cashier, clerk, you name it. It's really important as we think about the current environment, increased demands, we hear from employers that hiring is particularly difficult right now, there are lots of open positions for pharmacy technicians, and flu season, which is usually one of the busiest times and community pharmacy is not that far away. It's really important that everybody on the team, whether it be pharmacist or technician, work together.

I think one of the ways that we've heard from pharmacists that having technicians, who are engaged in immunizations is really helpful, is that if they haven't trained pharmacy technician who can step out of the core pharmacy workflow to go administer a vaccine, that really helps the pharmacist stay focused on somebody waiting on the phone, to talk to them, somebody's waiting at the window to be counseled, the pile of prescriptions that need to be checked by the pharmacist. I think it's important to recognize that there are still a lot of demands. I'm not sure that anyone's job is necessarily easier right now. If everybody works together, and we have those really well trained pharmacy technicians, that's how we can get through this this pretty challenging time in pharmacy.

Ryan Burke, PharmD, director of professional affairs at Pharmacy Technician Certification Board, discusses how the changing role of pharmacy technicians has also helped the role of the pharmacist.

Increased Responsibilities for Pharmacy Technicians Helps Role of Pharmacist

, Debbie Weitzman, president of pharmaceutical distribution at Cardinal Health, discussed how independent retail pharmacies quickly adjusted during the pandemic in order to offer patient services and expand care. She also discussed highlights from the Cardinal Health Retail Business Conference, happening July 13 through 16 in Las Vegas, Nevada.

. I'm here with Debbie Weitzman, president of pharmaceutical distribution at Cardinal Health, to discuss the future of pharmacy, what's coming next, and how that's being explored at the RBC conference this week. So, how have retail independent pharmacies really pivoted over the last 3 years to serve patients and what parts of these changes do you think will stay the same long-term?

 Well, if we go all the way back to the beginning of the pandemic, really, independent pharmacies never closed the door. [They were] really one of the only retail entities of any kind that, within days or, you know, maybe a week, they really all figured it out quickly. Those that didn't have already a drive thru, I saw some incredibly creative alternatives to the drive thru, like curbside pickup, people put up signs that had, text to get the delivery at your door. And that was really just for picking up scripts and basic stuff. And then it transitioned into testing and having drive thru testing or curbside testing, then, of course, was followed by vaccinations. So really, it's not even like pivot, right? Because it's just been like one after another after another layering on all the different services in ways that community pharmacies stepped up to meet the needs of patients. So, they really worked very tirelessly, they faced all the same challenges as any business would have, which was keeping their own employees safe and themselves safe, as well as dealing with any work shortages, if people did get sick and they had to have coverage. So, it’s been a really extraordinarily taxing time for pharmacists. But you know, they never wavered, they really stepped up in a big way.

And what's been great is that this story has emerged about the value of pharmacy in the community and things that pharmacy associations and pharmacists and companies like ourselves have been saying, literally for years, if not decades, which is that, you know, we need to let pharmacists practice at the top of their license. And we need to recognize the value of the pharmacist and the pharmacy as part of the care team. The moment has come where that recognition has really come to fruition. We're seeing it legislatively, where initially it was the PREP Act and the emergency measures that were taken to empower pharmacists to provide all the services directly to respond to the pandemic. And now we're seeing a continuation of that momentum to keep making those things permanent, and adding more capabilities or enabling pharmacists to use their skills to now move into that space of doing more provider-type activities. So, I think it's fantastic that they were rewarded, that pharmacists were rewarded and recognized for all of the extraordinary work that they did during the pandemic. And, you know, we all have to even try to figure out, like, when people say the pandemic is over, it's not really over, right? It just keeps evolving and morphing into the next phase. So now, I think we're we are in more of what they call the endemic stage or the steady state. And then you're seeing pharmacists just continue the services that they did on an emergency basis on a regular basis. And it's one of the big themes we have here this week during our RBC, which is how can pharmacists just really keep that momentum going and keep layering on more and more services now that this recognition is in place of what they're capable of doing?

Absolutely. I love how you say layering on because that's really what it is. Can you speak to the ways that the health care industry is evolving to meet changing consumer needs and preferences?

 Yeah, I think we talked about it this morning in one of our sessions, that really where consumers’ minds are now is omni-channel. There's no one solution for any customer and the very same customer who likes to buy online, sometimes they want to shop in the store, and sometimes they want to buy online [and] pick up in store, you know? We have all these different models now that meld together, you know, digital services with brick-and-mortar physical services. So, we're talking a lot about the ability to provide the different opportunities to consumers to address their health care needs in the fashion that's most relevant to them. And that could even mean different methodology for different parts of their health care. So, you know, you might be really comfortable with a tele-visit with a doctor for one thing, but really want a face to face for another type of condition. And I think pharmacists are also embracing that. They're bringing introducing more technology into their store so that they can have an online presence, make shopping online an option. I mean, a lot of them have already had some limited digital services, like, you know, an app for refill, those types of things. And again, the idea of layering on, they need to take that technology to the next level and make sure people can shop online for their store, they need to be able to do consults and things like that, perhaps over a video chat. So, this kind of melding together of the physical space and the digital space is something that we're really pushing our pharmacy customers to, to embrace and just sort of step by step take, take a little step in the direction of a new technology advance, until they really get comfortable with it. 

I mean, you have the whole spectrum, right? You have some pharmacies that really have very little offerings in that space, and you have some that are on the other opposite end of the spectrum with very sophisticated different opportunities for patients to engage with them digitally. So, we're just trying to make sure everybody gets on that curve. And you know, wherever they're comfortable with, they keep pushing themselves to make sure they keep up because it's been proven that it's not really just newfangled young people, you know, [who are] tech savvy. It's really everybody. You know, we have Nielsen research that shows that people 65 and older, 50% of them are shopping online. So, it's really the whole spectrum now. That is also a result of the pandemic. When everybody was shut in their homes for a long time, pretty much everybody was forced to figure out how to use technology to get the goods and services that they needed. So, we've had this giant leap forward in the use of technology and day to day life and I think that is a really game changing event for health care and the delivery of health care services.

Absolutely. Can you share more about how pharmacies can prepare for this evolution and kind of take those steps, as you mentioned?

 There's a ton of suppliers and vendors out there, you know, willing to do things. There's a lot of very specialized areas, we're offering a lot of services around buying online and setting up your own website. The PMS system, you know, the vendors who provide PMS systems to the stores, they also have suites of services. I do recommend to our customers that they try to find, as a starting point, somebody they're already close to, somebody they're already worked with. That's why for us, it's a real priority to develop some of those services, because we already have this trusted advisory relationship with our customers. And we have the staff to kind of coach them through things. So, it's always easiest when you have a sort of out-of-the-box solution, and you don't have to invent it yourself. I think there's a lot of opportunities to do that. 

You have to pick the area that's right for your business, whether that's clinical consulting—and we have a solution for that, you could go heavily into the clinical areas—or if you want to push the front end of store, then you need an online shopping tool. So I think each owner of a pharmacy has to decide, evaluate their business, where their opportunities are, understand their community and what the needs are, the demands are there, and pick one service, one new thing to get started. You don't want to launch 3, 4, or 5 new things all at the same time and overwhelm yourself or your staff, you want to kind of pick 1 thing, do it well, and then, you know, continue, as we said before layering on.

Perfect. So, talking more about the RBC conference, what are some highlights for you?

 Well, we just had our opening session, it was very exciting and actually a little bit emotional. We had a really heavy emphasis on community impact. We really wanted to thank all of our participants and our pharmacy owners for the incredible work they've done in their communities, you know, not only because of the pandemic or during the pandemic, but they always do that, right? That's what they're really all about. And they're all sort of uniquely independent, they respond to the needs of their community. So, in doing that, you know, making that an emphasis this year, we had 2 outstanding speakers. One is one of our pharmacy owners, one of our customers who has a very personal story about a health challenge of a family member of his and a foundation that he supports as result to try to get more research for this particular disease. And then we had our guest speaker who was very inspirational. He's got a fantastic story. His name is Jon Dorenbos, he is a magician, an ex-NFL football player, and an inspirational speaker who mixes his own personal story and the challenges he's faced along with magic tricks, which are incredibly impressive and fascinating. So, it really resonated with everybody, you know, his story, his energy. Yeah, his message was fantastic. And, you know, we had a few executives up there on stage to try and continue the message of congratulating and acknowledging all the fantastic work that our customers do and giving them a little background on the things they will be seeing over the next couple of days on our show floor.

Wonderful. More pharmacists are continuing to operate at the very top of their license, so can you discuss the push for provider status?

 I think that we talked about a little bit already. Every day, we're getting a little bit closer. The decision to let pharmacists prescribe COVID treatment is critical, it's a recognition of the need to keep moving in that direction. So, I think one of the big challenges we face is that it's still a decision that's going to be made by pharmacy boards at the state level. But the overarching goal should be to make it at the federal level. And, you know, there's a number of different trade associations working hard on that. So, I think it's just something that the industry has to keep pushing for, and now there's a lot of momentum in that direction. And I think all of the ecosystem challenges around labor shortages, you know, doctor, primary physician shortages, but think about not only as a primary physician shortage, but just think about running doctor's offices, everybody's having trouble with front office staff, billing staff. So, if you've already got this incredible infrastructure in place through the pharmacy, then it's going to be such a big need and such a big demand. I think we're moving in the right direction—I can't say when or if it's going to become a federal law, but I think that we're going to keep kind of knocking down the barriers and move in that direction.

As we start looking to the future, maybe not after COVID but living with COVID, do you see more changes in pharmacist roles in patient care?

 I do, I feel like there's a really interesting partnership that is evolving. We work a lot with payers for our outcomes business, and our outcomes business makes a huge network out of all the pharmacies. So virtually every independent pharmacist is part of the outcomes network. And we've now established kind of this constant dialogue, both with payers as well as manufacturers, about leveraging that network to push patient care and the direction that they need to do so. Whereas, you know, the original premise of founding that network was just really focused on star ratings. Now, we've been able to do sort of micro programs and very targeted programs based on disease state, based on geography, based on a specific goal that a payer or manufacturer might want to achieve. And it's been, you know, proven to be a very cost-effective way to get patients to act a particular way. So, you know, it could be adherence, it could be understanding, like just an educational piece. It could be pushing out information that they need. So, what we what we love about this is that it also is like a virtuous circle, you're helping pharmacists get the information they need, it's a paid engagement for them. So, it is helping to insert them into the care team. And, you know, it's great for their business, it's great for patient care, it's great for the relationship between the pharmacist and the patient. So, like I said, it’s this sort of virtuous circle on just the overall health of the patient.

Debbie Weitzman of Cardinal Health, discussed how independent retail pharmacies quickly adjusted during the pandemic.

Expert: Independent Pharmacies “Layered On” New Patient Services During the Pandemic

®, Ryan Burke, PharmD, director of professional affairs at Pharmacy Technician Certification Board, discusses more advanced roles for 

and how they can continue to grow beyond their current roles, which will be covered in a session at the American Association of Pharmacy Technicians Annual Convention 2022.

Q: In general, could you give us an overview of some of the more advanced roles pharmacy technicians have taken on?

More advanced roles are not new. We're just talking about them a lot more now, which is great. One of the ones that has been around for decades actually is having pharmacy technicians engaged in product verification. There are about 20 states that allow technicians to engage in product verification in some capacity. In some places, it's very limited. It's only in hospitals, whereas there are some states in recent years, at least, that have expanded product verification to also be allowed in the community setting.

There are plenty of studies that demonstrate the safety. There are plenty of studies that show pharmacy technicians who are trained in product verification can verify do that final check as accurately as pharmacists.

The other one is medication history. There are many health systems that have pharmacy technicians working in the emergency department collecting medication histories from patients. There was actually a study, not all that long ago, that a health system looked at sort of a cost savings associated with having a pharmacy technician engaged in collecting medication history. Based on what they estimate to be the cost of a single medication error, and then comparing that to salary and benefits of a technician working in that emergency department. They found they could actually save the health system more than a million dollars a year by having a technician trained and working in that role.

There are plenty of others right there. technicians who work in procurement and inventory management, billing, point-of-care testing, immunizations is obviously a really big one. So there are plenty of opportunities out there, and I think it's great that we are we're talking about these advanced roles more and more.

Q: What are some opportunities where technicians can continue to grow beyond their current roles?

There are a few things that I can mention here. One is to find opportunities to get involved, so you can learn about all the potential career paths that are out there for a technician. That might mean joining some sort of organization, whether it be at the state level or the national level. Maybe it means attending a conference, going to continuing education programs. There are also lots of organizations that provide advanced training and professional development opportunities.

Here at PTCB, we've been really focused on creating advanced and specialized credentials for pharmacy technicians in various areas of practice. We now have more than 10 credentials for pharmacy technicians who have specialized knowledge and things like regulatory compliance, supply chain management is coming very soon, immunization, administration, billing, and reimbursement, just to name a few, and we expect these to continue to grow.

We also have almost 1000 pharmacy technicians who have earned our Advanced Certified Pharmacy Technician credential, which is great because it shows that there is this population of pharmacy technicians who are looking to advance their careers, who are looking for a way to showcase the knowledge and skills that they have. We really believe that these new credentials provide them with an opportunity to do that.

We also had just in the last few weeks, we've heard from a couple of pharmacy technicians who feel like going through specialized training or advanced training and earning some of these credentials have opened doors for them in terms of their career that they did not think would have been possible without them.

Q: How has the career path of the pharmacy technician evolved with advanced training?

I think we are certainly starting to hear from employers and pharmacy technicians that some of the advanced training opportunities, some of the credentials, are beginning to be incorporated into job descriptions and career ladders. Certainly, when we talk about career ladders, aside from the opportunity to advance, often that also comes with an increase in pay, right, which is something that we hear from a lot of pharmacy technicians is very important to them. They also think that in general, just that we have, this population of technicians who have begun to earn these advanced credentials really speaks to the interest that's out there, in terms of pharmacy technicians wanting to advance their careers.

Ryan Burke, PharmD, director of professional affairs at Pharmacy Technician Certification Board, discusses more advanced roles for pharmacy technicians and how they can continue to grow beyond their current roles.

Expert Discusses Advanced Roles for Pharmacy Technicians

®, Donald Klepser, PhD, MBA, professor and dean of academic affairs at the College of Pharmacy in the University of Nebraska Medical Center, discusses his session at the American Association of Pharmacy Tecnicians Annual Convention, regarding how the 

 has changed the role of pharmacy technicians and what is expected as we move forward.

Q: In general, how has the COVID-19 pandemic changed the role of pharmacy technicians?

It is really kind of increased the profile and the role of technicians. Some of this is related to the emergency health measures, and so what we've seen is a kind of an increase in the roles and responsibilities of technicians, and I think the 2 things that probably jumped to mind, first, are our immunizations, clearing the path that allows for technicians to do immunizations, under the supervision of a pharmacist, and then also probably related to point-of-care testing. Again, opening up the opportunities and clearing the path for technicians to be more involved in specimen collection and running the point-of-care tests.

Q: What can pharmacy technicians expect moving forward from the COVID-19 pandemic?

My expectation is probably more of the same. I think, probably, formalizing and extending the privileges around immunization and around point-of-care testing, for sure. I think certainly even more responsibility in the dispensing activities, kind of strengthening some of the tech-check-tech type programs, the things reducing technician, or eliminating technician ratios all together. I see the technician moving to having a little bit more autonomy probably at least in the foreseeable future, still, we're under the oversight of a pharmacist, but they're really playing an even bigger role in the delivery of patient care.

Q: How have we seen pharmacy technicians take a more active role in pharmacies?

I think some of the things that we've talked about the immunizations, the testing, stepping up being just being more involved. I think of the evolution over time, from when a technician was really just there to count by fives and put things into the bottle, and now I've seen that that role, expand. I think we would all there's no way pharmacy as it is practiced in America today would exist without pharmacy technicians.

Q: What are some opportunities for pharmacy technicians when it comes to billing and insurance?

I'm not sure if it's a privilege or a punishment. I mean, right? these are some of the necessary things that are struggles for a lot of pharmacies, and certainly the role that that technicians can play, whether that means sitting on hold on a phone call, or I think, one of the better is to just take that part over in the pharmacy, become familiarized with all of the billing mechanisms, the coding, all of those things to help the pharmacy really maximize the revenue for the services that they're providing. Every pharmacy needs a resident expert, and I think that's a fantastic role for pharmacy technician.

Donald Klepser, PhD, MBA, professor and dean of academic affairs at the College of Pharmacy in the University of Nebraska Medical Center, discusses how the COVID-19 pandemic has changed the role of pharmacy technicians and what is expected as we move forward.

Role of Pharmacy Technicians Continues to Grow in Post-COVID-19 Era

, Yi Lin, MD, PhD, discussed new developments with CAR T therapies for the treatment of multiple myeloma. From idecabagene vicleucel (Abecma), the first approved CAR T therapy for multiple myeloma, to the recently-approved ciltacabtagene autoleucel (Cilta-Cel), Lin said significant steps have been taken.

Q: Abecma was the first CAR T therapy approved for multiple myeloma, and Cilta-Cel is the latest. Can you discuss how Abecma works and how it differs from Cilta-Cel?

So, idecabagene vicleucel, or Ida-Cell, or the name is Abecma, has now been available in standard of care practice for a little over 1 year. This particular CAR construct, CAR T therapy, is also an autologous product made from patients’ own T cells, and it's also prescribed as a one-time treatment. So really, that's I think the most exciting thing about CAR T right now, is it’s a one-time treatment with no maintenance follow up. They are given as essentially a fixed dose, not weight-based, 300 to 460 million CAR T cells per dose. And that's totally dependent on how many of those cells can be manufactured on the patient's own T cells.

In the registration study that led to its approval—again, this is also a very late, relapsed/refractory patient population—the median line of prior therapy was also 6. And again, it was one time dosing. [We saw a] very impressive response—73% of those patients responded, 33% of those patients had deep response. And on that study, we've had longer follow up. So, we are seeing that the median progression-free survival is over 8 months, 8.8 months to be exact, for the entire treated population. But if you look at patients who were able to get that higher dose in the range, or patients were able to achieve deep response, the median progression-free survival is much longer, closer to a year. So, I think in the current landscape of myeloma treatment, this is a very impressive treatment option that's available for our patients.

Q: What is pharmacists’ role in CAR T therapies?

Pharmacists are an integral member of our CAR T teams. They play a critical role. From the very first appointment, where we are evaluating patients and considering their eligibility, planning to go towards that collection of the patient's own cells, pharmacists are very much involved in looking at what was the patient's most recent exposure to the prior salvage treatment, [and] the washout period, because this directly impacts the health of the cell that's collected and the likelihood for successful manufacturing. They are, of course, involved in terms of any bridging management that is needed, trying to optimize the care and preserve organ functions from the drugs that are given to improve the chance that the patients can make it to CAR T dosing. Most of our patients will need a line placement for the cell infusion and there may be need to manage anticoagulation around that time. And then, of course, once we actually get to the CAR T treatment, that is always given with the lympho-depletion chemotherapy drug. And in our myeloma patient population, they don't always have normal kidney functions, for example. So, pharmacists work very closely with our team to look at the appropriate dosing adjustments for the lympho-depletion chemotherapy. Part of the REMS requirements by the FDA, the risk evaluation mitigation system requires that for all patients, prior to getting those with CAR T, that we have reserved for them the first line treatment for cytokine release syndrome, which is tocilizumab IL-6 receptor blockade, so it's ready to go when we need it and there's no delay. And so pharmacists are the essentially the keeper to ensure that we have adequate supplies, and it's ready to go for patients, as well as if there's a need to escalate the management, all the different drugs that are used, including in the acute monitoring periods, really looking very carefully over all the other medication that may be needed for symptom management to also make sure that they are not masking anything we need to monitor, from the standpoint of infection, cytokine release syndrome, and neurologic symptoms. And then moving on, during that time and moving beyond that for even longer-term follow up, antimicrobial prophylaxis and some of the other medication management considerations when you're working with a living drug.

Q: Is there anything you would like to add?

Absolutely. So, I think right now what we're basically telling everybody is that the CAR T is a very individualized treatment that is made from patients’ own cells. There's a lot of logistics in getting the patient through to treatment, and so we definitely encourage everybody who's taking care of these patients to be thinking early about their referral, and if the patient might be a candidate for CAR T, and any considerations in their management to improve the odds to get the patients to treatments. And, as I mentioned at the beginning of the interview, there's a lot of investigations going on for next generation CAR T and innovative CAR T. And so, I think as we learn about these CAR Ts, for example, those that may be more rapidly manufactured or allogeneic platform, we may start to learn what are some of the unique side effects or considerations for management? And I think that's very relevant for the pharmacist practice to understand as these things evolve. How does their management change with the new treatment modalities?

From the first approved CAR T therapy for multiple myeloma, to the recently-approved ciltacabtagene autoleucel, significant steps have been taken.

With New Developments in CAR T Therapies, Progress is Being Made for Patients With Multiple Myeloma

, Ajeet Gajra, MD, MBBS, FACP, discussed research into how an intelligence-based system could help improve the timeliness of referrals to palliative care and hospice services in a community oncology environment.

Q: Can you explain the augmented intelligence-based tool that you discuss in your presentation?

So, this was born out of the work and the tool is owned by Jvion, it’s called Jvion CORE. So, what it is, is a machine learning tool that is commercially available and we published other data ahead of this current study in the 

, where this tool basically integrates clinical information, which is, you know, your tumor, your stage, comorbidities, polypharmacy, age of the patient, gender, all of that. So that's the clinical information. Then it has all of the claims data, you know, because patients may be getting oncology care at the center, but then they also have all this other care that they're receiving, so that gets pulled in from there. The novel piece of this AI tool, the Jvion CORE, is that they integrate data from social determinants of health. So, this is beyond just income, poverty, education. So, many people say, oh, yeah, just use the zip code. No, zip code is too broad. So, this goes much further than the zip code. And this is data that they are able to collect from publicly available databases, like the US Census Bureau, or the USDA, or the NOAA.

And so all of this is brought in, and what essentially, to put it very simply, what they're doing is they're creating these clusters of patients which are similar based on their disease and their social structure, and then trying to assess the trajectory of a patient. So essentially, a patient is being matched to other patients with similar clinical and social characteristics to determine what the outcome or the trajectory might be. So, the key component of this is that the risk of deterioration, risk of mortality, risk of doing poorly, you know, is what is identified. And so, once a patient like that is identified, and of course, in the context of an advanced cancer diagnosis, then these patients are the ones who are appropriate for a palliative care consult.

So, a clinician might say, “Oh, why do I need all of this? Because I know.” But the surprising part has been that there are patients who are obviously, unfortunately, not doing well clinically. And so, everyone knows they need palliative care. But then there are patients who may appear clinically sound or not at risk, but then based on all of these other factors are determined to be at risk. And then also, there's a component of patients who may appear as high risk, but they may have a modifiable risk factor or, you know, a latent infection or some other social issue, like lack of transportation, which can maybe put them in the high-risk bucket. So, it basically amalgamates a lot of information from various sources, and this has been previously validated. And like I said, it's a commercially available tool that we've used for this purpose.

Q: How can this tool be implemented in the real-world setting?

Yeah, so you know, there are some practices utilizing this tool already. And of course, we've worked with one of these practices for the data that we're presenting at ASCO 2022—and this was the Northwest Medical Practice, Dr. Sibel Blau and her team out of Seattle Tacoma area in Washington State. So, the way it works is that the AI system needs to be integrated, or rather, it sits on top of the EMR. So it is EMR [and] EHR agnostic, so it doesn't matter what type of electronic medical record the practice may be using. This AI tool can, let's just say, read off and communicate with the EHR and derive the information that is needed from the HER, and it will generate output and this is a continuous outcome. So, essentially, every week all of the patients that are in the practice or in the EHR are reviewed by the AI tool to identify those at highest risk. Now, there are also other vectors or other components to this AI so, you know, patients can be assessed not only for deterioration and mortality risks, but for pain, for depression, for mental health. Again, a slew of other possibilities and new vectors can be created. You essentially have to train the machine and the learning set and then a validation set, but the bottom line is in the mortality vector or at-risk factor, or risk of deterioration, the tool creates essentially a report for each week in terms of who are the patients who are highest risk. And this report is literally pulled off by the practice to identify the patients, you know, that have been identified with this tool. And then you can take corrective measures, which may include palliative care, or if that is not the case, say someone with adjuvant therapy who doesn't have active cancer, if they are at high risk, well, then they may have something preventable or you know, reversible, that is putting them at high risk, and so it can be addressed in that manner.

Q: What did you find about how the tool impacted timely referrals?

Yeah, so what we've demonstrated in our earlier work with this tool is that utilizing it in the context of palliative care increased the number of palliative care referrals, and also the referrals to hospitals within this practice. This is a large community-based practice, and we also have similar data actually from another practice that has piloted this tool.

But what we found in the current work is about the timeliness. So, we're looking at, okay, well the referrals increased but were they timely referrals? So, what we really found was that, and we chose because this is a real-world study, real world data. So, this is a retrospective look. So, all patients who unfortunately had a mortality event at this practice in the given timeframe, we reviewed their records to see if these patients received a palliative and hospice care referral. So, we did a before and after analysis. So, we did it a before analysis for the time period before the tool was implemented, before the Javion CORE was launched at the practice. And then we did a post period after the Javion CORE launch to see if there was a difference. We know we would like for patients to be referred as early as possible to palliative care, so we chose a 90- to 180-day window. So, again, it could even be longer, but we just have a time point.

So, we noticed that there was almost a 2-fold increase in patients being referred to palliative care in that window. And similarly, we use the shorter window with hospice, to assess if patients were being referred 14 days prior to their mortality to hospice. And we basically quantified it at various time points. And, of course, that's in the poster, I would have to probably look at those numbers quickly. So, the 90- to 180-day window for palliative care was doubled, like I said, [with an] increase by 111%. And then for hospice, actually, the 14- to 90-day pre-mortality referrals increased also by 179%. So, almost a tripling of those referrals in a timely manner. The other important piece was that before the launch of this tool in this practice, 86% of patients were not getting a palliative care referral at all. And so, after the tool was launched, that number decreased to 72%. Of course, you may argue there's still a lot of patients not receiving palliative care. But again, you know, we have the whole pandemic and all of that in this time period. But the bottom line is that it was a movement in the appropriate direction. And similarly, prior to the deployment of this tool, 83% of folks were not receiving a former hospice referral—that doesn't mean that they weren't getting hospice. And this number dropped to almost 52%, so a dramatic decrease in patients who were not being formally referred to hospice, and then we saw in the longer time points, a lot of patients being referred earlier in their course. So, that's the takeaway: Patients started to be referred earlier in the course of palliative care, earlier in the course of hospice, because the bottom line and the takeaway is, you know, the earlier in the course that we can do that, the better I think it is for patient outcomesand for quality of life.

You know, I think this is a valuable tool. It's already shown utility in a community oncology setting and, you know, certainly larger studies would generate more data and greater confidence in its utility across various practice types.

An intelligence-based system could help improve the timeliness of referrals to palliative care and hospice services in a community oncology environment.

Augmented Intelligence Tool Helps Ensure Timely Referrals to Palliative Care for Patients With Advanced Cancer

 and today I'm speaking with Elizabeth Ruzzo, founder and CEO of Adyn, about the impact of the reversal of Roe v Wade and how it will affect pharmacies. So, before the Roe v Wade reversal, what was the pharmacist’s role in 

 My understanding is that pharmacists play a really important role in reproductive health care, including prescribing hormonal contraception and emergency contraception in some states, but pharmacists have had a limited role and involvement in abortion care, primarily due to FDA’s regulations around dispensing abortion pills specifically. My understanding is, that even prior to Roe, pharmacists in most states weren't able to dispense this directly. Usually, it was done in clinics themselves.

 I think for now, because of that, there aren't going to be big implications for pharmacies, specifically, because they weren't yet dispensing. I think, hopefully, they will see an increase in volume for helping provide highly effective methods of contraception.

What are the long-term ramifications of this ruling on women's health care and women's health care access?

 I mean that is a loaded question, right? I think that women are not going to stop getting abortions, they're going to stop getting legal abortions, and abortion is health care. It's also really important if someone has, for example, an ectopic pregnancy, if there's a problem with the fetus, sometimes if a woman has severe preeclampsia. It is a lifelifesaving technique used to save the living mother. Part of the problem here is that also doctors in these states are not going to be trained even in how to do these procedures. So the real truth is that the impact is that women are going to die. Estimates are that there'll be a 21% increase in pregnancy related deaths, and that number rises to 33% in non-Hispanic Blacks, so it just has devastating implications.

I think the other implication is that women are going to need to rely more than ever on highly effective methods of birth control, and potentially Plan B.

How might the reverse will impact the right to privacy? And what does our right to privacy have to do with birth control?

 This ruling basically was based on a right to privacy. That is the same underpinning of several other rulings like Griswold, which gave us the constitutional right to privacy. Specifically, that a married couple was free to choose their own contraception. There was another case after that in 1973 that also extended that right to unmarried women, and so by taking down this right to privacy-related rule with Roe, it opens the door for not just those to specific to contraception, but a number of other rulings related to gay marriage, interracial marriage, and more.

What are the economic benefits of birth control?

 I really think that birth control is freedom, right? It gives individuals the freedom to pursue higher education, and as a result, careers that are higher paying. There's also a big economic burden of unintended pregnancy to the country at large. In 2019, there was an estimate that annual direct medical costs from unintended pregnancy in the US were at least $5.5 billion. It's a really massive strain on the economy, and even when we've seen declines in pregnancy rates, the annual costs of unintended pregnancies have continued to climb.

The other thing I like to point out about potential economic benefits is what an economic benefit an individual would get from finding the best method for them more quickly. What I mean by that is a lot of times people experience unwanted side effects on birth control, and frequently, what this means is that they have to go to a different specialist. Let's say you have acne, maybe then you go to your dermatologist, you have to pay that copay. Maybe you get a prescription for a topical drug to treat that, and so on. So part that's a big part of what we're doing at Adyn, we're trying to help people skip that trial and error and instead use precision medicine to find the right birth control more quickly and get a personalized contraceptive counseling visit for that same reason and save people the burden of both time and money associated with not being on the right birth control.

What are the implications of this decision on future birth control access? 

 I think hopefully right now, the answer is, it's not having an impact. But the reality that we spoke about before with regard to Griswold, and the right to privacy means that potentially access to birth control is very much next on the chopping block. That is just a devastating reality. I think it's really important for us to make sure that we're out there educating about what all of the reasons birth control is really used. It is a hormonal medicine that is used to do all kinds of things and treat reproductive health disorders of all kinds. It's not just about preventing pregnancy.

Are there states where legislators are attempting to interpret IUDs as abortion and what are the implications of this?

 I've heard of at least 1 anti-abortion bill in Louisiana that luckily did not pass that was trying to include the IUD. So the copper IUD can be used as emergency contraception. It's 99% effective and present preventing pregnancy if it's used within 120 hours.

However, there is no evidence whatsoever that the copper IUD is an abort efficient. The World Health Organization talks about the effect of copper being pre-fertilization. So what that means is, it's having an effect on the sperm or the ovum. It is not in any way hurting a fertilized embryo.

What might the role of the pharmacy be if contraceptive access were impacted by future decisions at the state level?

 I think if contraceptive access were to be taken away, the pharmacist’s role would really be to help provide unbiased and factually accurate information and resources to patients, in particular, if there were still ways for them to legally obtain birth control. Unfortunately, maybe start having to rely on less highly effective methods like barrier methods. 

What is the importance of contraceptive access for health for both men and women?

 I think it's really important to remember that reproductive health and contraception affect both men and women. It means freedom for both of them. Men also experienced benefits, including economic benefits, from not having unintended pregnancy happened in their life that lets them continue to pursue education and reach different career goals and earning potential as a result.

The other thing is just that birth control, like we talked about a little bit here already, it is medicine. It's really important for the health of women to be able to have access to that it can do things from alleviate PMS symptoms, to manage really serious medical conditions like endometriosis and PCOS. The men in our lives should be supportive of us living our healthiest and most pain free life possible.

And lastly, how can pharmacists help patients during this time?

 I think they can help provide unbiased and factually accurate information and really just act as a resource as much as they can to patients. I think that I would encourage pharmacists to spend extra time with patients fulfilling a highly effective method of contraception to make sure they don't have questions about its use, its safety, that they understand how to quickly recognize any potential side effects, so that they can switch if needed and make sure that they're not suffering unnecessarily because birth control isn't one size fits all. It's really a matter of finding one that that works for you, and with nearly 200 options, there will be 1 out there that should work for you.

I think pharmacists can also remind patients to keep Plan B on hand for instances if they miss several pills or even just to have to share with a friend.

Elizabeth Ruzzo, PhD, founder and CEO of Adyn, discusses the impact of the reversal of Roe v. Wade and how it will affect pharmacies.

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