ASSOCIATION REPORT
Report of the APhA and APhA–ASP Houses of Delegates Andrew Bzowyckyj, Julie Oestreich, and Loren Madden Kirk
APhA–APPM The sun shined bright over this year’s APhA Annual Meeting and despite the beautiful weather, your dedicated representatives were bunkered up in the windowless ballrooms of the San Diego Convention Center thoroughly discussing several pressing issues Bzowyckyj facing the profession of pharmacy. Below is a summary of the policies that were passed by the APhA House of Delegates from the perspective of the APhA Academy of Pharmacy Practice and Management. The complete wording of these policies is available at www.pharmacist.com/house-ofdelegates and in the House of Delegates report in this issue of JAPhA. Interoperability of communications among health care providers to improve quality of patient care Despite enhancements in interoperable communications between different health care settings and electronic systems over the years, several barriers persist that inhibit collaboration of health care professionals across all settings. This affects many aspects of patient care, including medication/patient safety, transitions of care, and pharmaceutical waste, in addition to contributing to overall inefficiencies within the health care system. This policy emphasizes that pharmacists desperately need to be more connected with the rest of the health care system to improve the 340
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overall health of the public and efficiency of the system. Pharmacists can help advance patient care and patient safety through adequate access to complete patient information and records. Integrated nationwide prescription drug monitoring program Currently, 49 states, the District of Columbia, and Guam have legislation authorizing a prescription monitoring program (PMP) in order to decrease the abuse and misuse of controlled substances.1 Missouri continues to stand alone as the only state without active legislation authorizing a PMP. Furthermore, several states are participating in the National Association of Boards of Pharmacy (NABP) PMP Interconnect,2 which allows for a secure exchange of PMP data across state
lines to further reduce interstate doctor-shopping. With this policy, pharmacists can look forward to further integration of different state-specific PMPs and calls for interprofessional advisory boards to make better use of the aggregate data. With a nationwide PMP, pharmacists can be well positioned to help alleviate the public health emergency of abuse and misuse of controlled substances. Role of the pharmacist in care of patients using cannabis There was much debate regarding this topic from a variety of perspectives along the supply chain, including research, production, dispensing, and counseling. There was a large amount of agreement surrounding the need for more rigorous research on the medical benefits of cannabis and the alignment of state and federal laws. However, the debate over the pharmacist’s role in dispensing was met with some heated resistance at first. This element of the policy initially failed to pass out of the House until a brave individual from within the student pharmacist delegation resurrected the statement, which
The Association Report column in JAPhA reports on activities of APhA’s three academies and topics of interest to members of those groups. The APhA Academy of Pharmacy Practice and Management (APhA–APPM) is dedicated to assisting members in enhancing the profession of pharmacy, improving medication use, and advancing patient care. Through the APhA–APPM Special Interest Groups (SIGs), the Academy provides members a mechanism to network and support the profession by addressing emerging issues. To access a listing of APhA–APPM SIGs, visit www. pharmacist.com. The mission of the APhA Academy of Pharmaceutical Research and Science (APhA–APRS) is to stimulate the discovery, dissemination, and application of research to improve patient health. Academy members are a source of authoritative information on key scientific issues and work to advance the pharmaceutical sciences and improve the quality of pharmacy practice. Through the three APhA– APRS sections (Clinical Sciences, Basic Pharmaceutical Sciences, and Economic, Social, and Administrative Sciences), the Academy provides a mechanism for experts in all areas of the pharmaceutical sciences to influence APhA’s policymaking process. The mission of the APhA Academy of Student Pharmacists (APhA–ASP) is to be the collective voice of student pharmacists, to provide opportunities for professional growth, to improve patient care, and to envision and advance the future of pharmacy. The Association Report column is written by Academy and section officers and coordinated by JAPhA Executive Editor L. Michael Posey of the APhA staff. Suggestions for future content may be sent to [email protected].
ja p h a.org
Journal of the American Pharmacists Association
ASSOCIATION REPORT
FOR MORE COMPLETE ALLERGY RELIEF*...
*Total nasal symptom relief vs. single-ingredient Claritin® 10 mg. Claritin® is a registered trademark of Bayer.
Works to block 6 key inflammatory mediators, not just histamine†1-4 Available in 60- and 120-metered spray bottles.
†
Mechanism vs. OTC allergy pills. FLONASE acts on multiple inflammatory substances (histamine, prostaglandins, cytokines, tryptases, chemokines, and leukotrienes). The exact number and precise mechanism are unknown. References: 1. Derendorf H, Meltzer EO. Molecular and clinical pharmacology of intranasal corticosteroids: clinical and therapeutic implications. Allergy. 2008;63 (10):1292-1300. 2. Hallgren J, Pejler G. Biology of mast cell tryptase: an inflammatory mediator. FEBS J. 2006;273(9):1871-1895. 3. Broide DH. The pathophysiology of allergic rhinoconjunctivitis. Allergy Asthma Proc. 2007;28(43):398-403. 4. Ratner PH, van Bavel JH, Martin BG, et al. A comparison of the efficacy of fluticasone propionate aqueous nasal spray and loratadine, alone and in combination, for the treatment of seasonal allergic rhinitis. J Fam Pract. 1998;47(2):118-125. FLONASE, the FLONASE logo, the bottle and cap designs, and other design elements are trademarks of the GSK group of companies. ©2015 GSK group of companies. All rights reserved. Printed in USA. CHUS/CHFLO/0190/15 April 2015
Journal of the American Pharmacists Association
histamine cytokines leukotrienes
chemokines prostaglandins tryptases
NOW AVAILABLE OTC Visit FLONASEprofessional.com j apha.org JU L/A U G 2015 | 55:4 | JAPhA 341
ASSOCIATION REPORT
allowed for further discussion and modifications of the policy to achieve a sufficient amount of consensus. For more information about the debate over the pharmacist’s role in the care of patients using cannabis, please refer to the series of briefs featured in Pharmacy Today: http:// www.pharmacist.com/cannabisgains-acceptance-debate-growsover-pharmacists-role. The spotlight is on pharmacists to become more knowledgeable about cannabis in order to help patients receive the correct information. Pharmacist participation in executions Until this year, pharmacists were the only health care professionals without an official policy explicitly discouraging pharmacists from participating in executions. Several media outlets and advocacy groups have called out this fact amidst all of the recent controversy surrounding capital punishment. This policy ensures pharmacists join the remainder of the health professions in discouraging participation in these activities. As a delegate noted during the open comments part of the House of Delegates final session, the Associated Press tweeted the outcome of the debate within minutes of this policy getting approved, showing just how important and timely this policy is within the health-related professions. Disaster preparedness With the continued threat of bioterrorism and emerging public health threats, this policy helps ensure pharmacists are well prepared and equipped to assist should another situation arise similar to the Ebola epidemic earlier this year. Pharmacists are readily accessible and possess the skills necessary to educate the public about the risks of infection, how to minimize exposure, and consequences from potential threats. Pharmacists can also play a vital role in deploying countermea342
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sures in response to emerging infectious diseases. Pharmacists’ role in promoting medication adherence Everyone is likely familiar with the staggering direct and indirect costs of medication nonadherence to the health care system. This policy reminds pharmacists to identify the issues surrounding medication nonadherence in an attempt to better understand the root causes and identify best practices to promote medication adherence. Pharmacists can play a central role ensuring the effective use of prescription drugs through medication therapy management and clinical pharmacist– provided patient care services. Prenatal and perinatal care and maternal health In 1979, the Food and Drug Administration (FDA) introduced the pregnancy categories that we have all come to know (and possibly even hate) due to the general vagueness of the categories, most notably categories B, C, and D. Those categories are plenty flawed–most notably due to the lack of specificity regarding which trimester does the medication present the most harm. The Pregnancy and Lactation Labeling Final Rule (PLLR) instituted by FDA took effect on June 30, 2015.3 This rule is just one small facet of the complexity involved with maternal and newborn health and wellness. Questions will arise from patients and other health professionals during this transition, and pharmacists will need to be at the forefront of informing and educating colleagues and patients. Pharmacists have the knowledge and resources to educate and counsel women on lifestyle and pharmacotherapeutic modifications in an effort to optimize both maternal and child health. Antimicrobial stewardship Antimicrobial resistance and antibiotic overuse is now of such concern that articles on the topic appear ja p h a.org
regularly in both professional and lay media. Antimicrobial stewardship programs have traditionally focused on specific health systems but perhaps the time has come for a paradigm shift to look at a broader context (e.g., a specific metropolitan area or population). Pharmacists play a vital role in ensuring the safe and effective use of medications and antimicrobials are certainly no exception to this professional obligation. This policy emphasizes that pharmacists can help improve patient outcomes and decrease emergence of resistant bacteria by ensuring the continued safety and efficacy of antibiotics. Moving forward Each year, I look forward to seeing what will play out on the floor of the APhA House of Delegates and this year was certainly no exception. With so many issues facing the profession of pharmacy, the House of Delegates is a vital component of the Association since it is the place for practitioners from across the country to express concerns and truly effect change in a positive way. This was certainly reaffirmed this year with the passage of some truly cutting edge policies leading the way for pharmacists to continue advancing the profession. 1. http://www.pdmpassist.org/ content/prescription-drugmonitoring-frequently-askedquestions-faq 2. http://www.nabp.net/programs/pmp-interconnect/ nabp-pmp-interconnect 3. http://www.fda.gov/Drugs/ DevelopmentApprovalProcess/DevelopmentResources/ Labeling/ucm093307.htm APhA–APPM: Andrew Bzowyckyj, PharmD, BCPS, CDE, Clinical Assistant Professor, School of Pharmacy, University of Missouri–Kansas City, Gladstone, MO, and 2013–15 APhA–APPM New Practitioner Officer and 2015–17 Coordinator-elect, APhA–APPM Diabetes Management SIG, [email protected]
Journal of the American Pharmacists Association
ASSOCIATION REPORT
APhA-APRS At this year’s APhA House of Delegates, the importance of sound science and evidence-based practices for the profession was highlighted in many adopted policies. Several topics addressed the need for further research to optimize pharmacy systems and validate new therOestreich apeutic entities and the pharmacist’s role in strategies to improve patient care. The covered topics of electronic communication, nationwide drug monitoring, cannabis, executions using lethal injections, and medication adherence are relevant to the members of the APhA Academy of Pharmaceutical Research and Science (APhA–APRS) and the pharmacy profession as a whole. Interoperability of communications among health care providers to improve quality of patient care As electronic health systems are further implemented throughout health care settings, the importance of collaboration and interconnectivity is increasingly recognized. Newly adopted policy advocates for the inclusion of pharmacists in the establishment and enhancement of electronic health technologies and systems. The goal is to enhance communication among prescribers and pharmacists and ultimately advance quality care, facilitate care transitions, and improve patient safety. In addition, APhA supports a voluntary, nonpunitive reporting system to record and analyze errors associated with electronic health data since continuous quality improvement and research are essential for effective use of this technology.
Integrated nationwide prescription drug monitoring program Collaboration and communication among states is the focus of another adopted policy. APhA now supports nationwide and timely integration of federal, state, and territory databases for prescription drug monitoring of controlled substances, so that information will be available across all state lines. This policy is driven by the desire to assist the clinical decision-making process for pharmacists by providing more complete and real-time knowledge to assess potential misuse, abuse, diversion, and fraud. APhA also encourages the development of interprofessional advisory boards that include pharmacists. In addition to compiling and analyzing trends, the advisory boards would provide focused education to providers, initiate patient referral, and support research activities to evaluate prescription drug monitoring. Role of the pharmacist in care of patients using cannabis The Policy Committee created a buzz this year by tackling the controversial topic of cannabis use. Cannabis remains a Schedule I substance under federal law and regulations issued by the Drug Enforcement Administration; the conflict between state and federal laws creates potential litigation risks for pharmacies and pharmacists. The process is further complicated by variability in the product, inconsistent public acceptance of dispensaries,1 and the high cost of authorized marijuana compared to other sources.2 Despite limited scientific evidence and questionable legality, at least one state—Connecticut—allows pharmacists to dispense inhaled cannabis for medical use. In the context of these events, the Policy Committee proposed and the House ultimately adopted policy to address the role of pharmacists in furnishing cannabis:
Journal of the American Pharmacists Association
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APhA supports pharmacist participation in furnishing cannabis and its various components when scientific data support the legitimate medical use of the products and delivery mechanisms and federal, state, or territory laws or regulations permit pharmacists to furnish them. From an APhA–APRS perspective, there are important scientific and safety issues to consider related to the lack of standardized products and FDA scrutiny. In addition, the lack of appropriate research is concerning, as highlighted by APhA– APRS members in the January/ February 2015 JAPhA Association Report3: ”While a number of studies and publications examine medical marijuana use, most are anecdotal or a series of case reports. Very few of these research studies have used scientifically rigorous and valid methods or well-controlled research designs to assess the safety, effectiveness, or long-term use of marijuana.… The state laws authorizing marijuana use for medical purposes have been passed largely as a result of public opinion rather than scientific evidence.” Pharmacist participation in executions A single statement discouraging pharmacist participation in executions by lethal injection was introduced by former APhA–APRS President William Fassett and adopted by the House. The ethical statement regarding the role of pharmacists as providers of care received publicity in several media outlets, including NPR,4 CNN,5 and the Huffington Post.6 Pharmacists’ role in promoting medication adherence New policy advocates for pharmacist leadership to help design systems for improving medication adherence. These activities complement the research of several APhA– APRS members who study and disseminate evidence-based methods for medication adherence. As part of this process, the adopted policy also JU L/A U G 2015 | 55:4 |
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encourages education of the public, employee benefits managers, thirdparty payers, and other decision makers about the value of pharmacists in this role. Call for academy delegates APhA members with an interest in the Basic Sciences, Clinical Sciences, or Economic, Social, and Administrative Sciences are encouraged to join APhA–APRS. Any APhA–APRS member interested in the policy development process is also welcomed and encouraged to apply to serve as a delegate to the House for its deliberations at the 2016 APhA Annual Meeting in Baltimore by completing a brief questionnaire at https://fs10.formsite. com/APhA-APPM/form108/index.html. Serving as a delegate is a great way to forge connections with dedicated pharmacists, researchers, and scientists who have a passion to advance the pharmacy profession and improve the lives of the patients we serve. References 1.
Berger J. Connecticut allows medical marijuana, but sellers encounter hurdles. NY Times. 2014(May 1). http:// www.nytimes.com/2014/05/02/nyregion/medical‐marijuana‐is‐legal‐in‐ connecticut‐but‐not‐yet‐sold.html. Accessed June 24, 2015.
2.
Dixon K. In Connecticut, legal marijuana comes at high cost. Newstimes. com. 2014(Sept 23). http://www.newstimes.com/news/article/In‐Connecticut‐legal‐marijuana‐comes‐at‐high‐ cost‐5776347.php. Accessed June 24, 2015.
3.
Fikru B, Schondelmeyer SW. Medical marijuana: policy topic for 2015 APhA House of Delegates. J Am Pharm Assoc. 2015;55:10–16.
4.
Peralta E. Pharmacists group votes to discourage members from providing execution drugs. 2015(Mar 30). http://www.npr.org/sections/thetwo‐ way/2015/03/30/396419514/pharmacists‐group‐votes‐to‐discourage‐members‐from‐providing‐execution‐drugs. Accessed June 24, 2015.
5.
Goldschmidt D. Pharmacists discouraged from providing meds for lethal
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injection. 2015(Apr 3). http://www.cnn. com/2015/04/03/health/pharmacists‐ discouraged‐from‐providing‐drugs‐ for‐lethal‐injection. Accessed June 24, 2015. 6.
Bellware K. American Pharmacists Association discourages members from providing lethal injection drugs. 2015(Mar 31). http://www.huffingto n p o s t . c o m / 2 015 / 0 3 / 3 1 / a m e r i can‐pharmacists‐association‐lethal‐ injection_n_6973920.html. Accessed June 24, 2015.
APhA–APRS: Julie Oestreich, PharmD, PhD, 2015–16 APhA–APRS Clinical Sciences Section Chair
APhA–ASP The APhA Academy of Student Pharmacists (APhA–ASP) policy process is a unique forum established to engage the more than 34,000 student pharmacist members around the country in envisioning and advancing the future of pharmacy. Throughout its 42-year history, the APhA–ASP Kirk policy process has yielded strong position statements for the Academy and provided a basis for resolutions developed by the APhA Policy Committee. More recent examples of such APhA–ASP Adopted Resolutions and their APhA Adopted Resolution counterparts include: “Proper Medication Disposal and Drug Take-Back Programs” (2012), “Medication Take-Back/Disposal Programs” (2013), as well as “Development of an Effective and Financially Viable Care Transitions Model” (2013), and “Care Transitions” (2014). This year, student pharmacists narrowed the focus of the Academy from the more than 75 resolutions that passed the 2014 Midyear Regional Meetings to consider four resolutions, each with multiple strong position statements. APhA2015 in San Diego, CA, played host to two APhA–ASP House of Delegates ja p h a.org
(HoD) sessions during which student pharmacists participated in constructive debate, powered through Robert’s Rules in record time, and stewarded their ideas to the next step of the policy process. With the assistance of 2011 Linwood F. Tice Award recipient and APhA– ASP Parliamentarian Michael Moné, BSPharm, JD, chapter delegates voted to adopt four new resolutions. Medication synchronization Medication adherence is one of the most formidable challenges to positive patient outcomes and, consequently, has remained a prominent field of study within the profession. Medication synchronization promotes a collaborative relationship between the patient and pharmacist to align their refill dates and improve medication adherence. Student pharmacists recognized the benefits of this practice to patients. Medication synchronization programs comprehensively improve medication adherence, reduce the cost burden of medication nonadherence, promote the benefits regular medication reviews, and reduce inefficiencies and time wasted in the pharmacy.1 As a result of the recognition of these benefits by student pharmacists and a strong belief in establishing such programs as a standard of practice, Resolution 2015.1 was adopted as followed: 1. APhA–ASP supports stakeholders’ implementation of medication synchronization as a standard of practice. 2. APhA–ASP supports state and federal legislation encouraging third-party payers to cover the alignment of refills without the patient incurring additional outof-pocket expenses. 3. APhA–ASP encourages pharmacists and student pharmacists to provide education to all health care providers regarding medication synchronization. 4. APhA–ASP encourages pharmacists and student pharmacists
Journal of the American Pharmacists Association
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to promote patient awareness of the benefits and accessibility of medication synchronization programs. 5. APhA–ASP encourages all schools and colleges of pharmacy to incorporate medication synchronization education in the curriculum. Labeling and measurement of oral liquid medications Between 2002 and 2012, 81.9% of medication errors involving children ages 6 years or younger were attributed to liquid medications. The second and third most common causes of these medication errors were incorrect dose and confused unit of measure, respectively.2 The provision of and education about precision measuring devices, such as an oral syringe, and the establishment of metric units as the standard measurement were three mechanisms by which student pharmacists, pharmacists, drug manufacturers, and other stakeholders can reduce these medication errors and ensure patient safety. Resolution 2015.2 was adopted as followed: 1. APhA–ASP supports mandatory inclusion of a precision measuring device, such as an oral syringe, with all prescription and nonprescription oral liquid medications. 2. APhA–ASP encourages student pharmacists and pharmacists to educate patients and caregivers on accurate oral liquid medication administration. 3. APhA–ASP supports the use of metric units (versus teaspoons and tablespoons) as the standard measurement on all oral liquid medications and precision measuring devices. Point-of-care testing Student pharmacists believe that the future of the profession involves increasing the provision of quality patient care services and the practice shifting towards primary and 346
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preventive care. Point-of-care testing and related clinical services are becoming increasingly fundamental to the profession and its future; as the most accessible health care provider, pharmacists are poised to take the lead in offering these services. These clinical opportunities will expand patient access to care, increase community surveillance of infectious diseases, and continue the expansion of pharmacy services.3 In the context of this resolution, point-of-care testing includes but is not limited to the Clinical Laboratory Improvement Amendments (CLIA)–waived laboratory services for human immunodeficiency virus, influenza, respiratory syncytial virus, and group A streptococcal pharyngitis. Resolution 2015.3 was adopted as followed: 1. APhA–ASP supports state and federal legislation that allows pharmacists and student pharmacists to provide point of care tests and related clinical services—through appropriate protocol and in collaboration with other members of the health care team—to increase patient access to care and screen or monitor for indications requiring care follow-up, referral, or therapy adjustment. 2. APhA–ASP supports the incorporation of point of care testing education and training throughout the pharmacy curriculum to train student pharmacists on appropriate administration of tests and management of results, including but not limited to, relevant counseling, documentation, reporting, and follow-up. 3. APhA–ASP encourages the development of continuing education and training programs to enhance existing practitioner understanding and utilization of point of care testing. 4. APhA–ASP encourages all stakeholders, including but not limited to, employers, patients, pharmacists, community pharja p h a.org
macies, health-systems, and third party payers to develop a compensation model recognizing the value and cost of pharmacist-provided point of care testing and the provision of related clinical services that is both financially viable and in the best interest of patients. 5. APhA–ASP encourages all public health stakeholders and agencies to promote patient awareness of pharmacist–provided point of care testing and related clinical services for the purpose of improving community surveillance of disease prevalence and incidence. Increased access to opioid reversal agents In 2012, health care providers wrote more than 250 million prescriptions for opioid analgesics.4 Over the past 30 years, fatal drug overdose has increased more than 6‐fold, largely because of prescription opioid overdose–related deaths.5 In 2014, the APhA House of Delegates appropriately adopted the timely resolution titled “Controlled substances and opioid reversal agents.” Student pharmacists felt strongly about adoption of a similar resolution to specifically address the legislative environment regarding access to opioid reversal agents and the necessity of public education in the campaign to combat the growing incidence of fatal drug overdoses. As a result, Resolution 2015.4 was adopted as followed: 1. APhA–ASP supports state and federal legislation to increase access to opioid reversal agents. 2. APhA–ASP encourages pharmacists and student pharmacists to provide public education about opioid reversal agents, including proper administration in situations of opioid-related drug overdose. Next steps Student pharmacists will continue to shape the profession in the up-
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coming year with the leadership of the newly elected APhA–ASP National Executive Committee. See you at APhA2016 in Baltimore, MD! APhA–ASP: Loren Madden Kirk, Student Pharmacist, Bill Gatton College of Pharmacy, East Tennessee State University, and 2014–15 APhA–ASP Speaker of the House doi: 10.1331/JAPhA.2015.15521
References 1. Holdford DA, Inocencio TJ. Adherence and persistence associated with an appointment‐based medication synchronization program. J Am Pharm Assoc. 2013;53:576‐-583.
3. Gubbins PO, Klepser ME, Dering-Anderson AM, et al. Point‐of‐care testing for infectious diseases: opportunities, barriers, and considerations in community pharmacy. J Am Pharm Assoc. 2014;54:163‐-171. 4. Opioid painkiller prescribing. CDC Vital Signs. 2014(Jul). http://www.cdc.gov/vitalsigns/opioid-prescribing/index.html. Accessed January 9, 2015. 5. Legal interventions to reduce overdose mortality. Network for Public Health Law. https://www.networkforphl.org/_ asset/qz5pvn/network‐naloxone‐10‐4. pdf. Accessed January 9, 2015.
2. Smith MD, Spiller HA, Casavant MJ, et al. Out‐of‐hospital medication errors among young children in the United States, 2002–2012. Pediatrics. 2014;134:867‐-876.
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Report of the APhA and APhA–ASP Houses of Delegates Andrew Bzowyckyj, Julie Oestreich, and Loren Madden Kirk
APhA–APPM The sun shined bright over this year’s APhA Annual Meeting and despite the beautiful weather, your dedicated representatives were bunkered up in the windowless ballrooms of the San Diego Convention Center thoroughly discussing several pressing issues Bzowyckyj facing the profession of pharmacy. Below is a summary of the policies that were passed by the APhA House of Delegates from the perspective of the APhA Academy of Pharmacy Practice and Management. The complete wording of these policies is available at www.pharmacist.com/house-ofdelegates and in the House of Delegates report in this issue of JAPhA. Interoperability of communications among health care providers to improve quality of patient care Despite enhancements in interoperable communications between different health care settings and electronic systems over the years, several barriers persist that inhibit collaboration of health care professionals across all settings. This affects many aspects of patient care, including medication/patient safety, transitions of care, and pharmaceutical waste, in addition to contributing to overall inefficiencies within the health care system. This policy emphasizes that pharmacists desperately need to be more connected with the rest of the health care system to improve the 340
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overall health of the public and efficiency of the system. Pharmacists can help advance patient care and patient safety through adequate access to complete patient information and records. Integrated nationwide prescription drug monitoring program Currently, 49 states, the District of Columbia, and Guam have legislation authorizing a prescription monitoring program (PMP) in order to decrease the abuse and misuse of controlled substances.1 Missouri continues to stand alone as the only state without active legislation authorizing a PMP. Furthermore, several states are participating in the National Association of Boards of Pharmacy (NABP) PMP Interconnect,2 which allows for a secure exchange of PMP data across state
lines to further reduce interstate doctor-shopping. With this policy, pharmacists can look forward to further integration of different state-specific PMPs and calls for interprofessional advisory boards to make better use of the aggregate data. With a nationwide PMP, pharmacists can be well positioned to help alleviate the public health emergency of abuse and misuse of controlled substances. Role of the pharmacist in care of patients using cannabis There was much debate regarding this topic from a variety of perspectives along the supply chain, including research, production, dispensing, and counseling. There was a large amount of agreement surrounding the need for more rigorous research on the medical benefits of cannabis and the alignment of state and federal laws. However, the debate over the pharmacist’s role in dispensing was met with some heated resistance at first. This element of the policy initially failed to pass out of the House until a brave individual from within the student pharmacist delegation resurrected the statement, which
The Association Report column in JAPhA reports on activities of APhA’s three academies and topics of interest to members of those groups. The APhA Academy of Pharmacy Practice and Management (APhA–APPM) is dedicated to assisting members in enhancing the profession of pharmacy, improving medication use, and advancing patient care. Through the APhA–APPM Special Interest Groups (SIGs), the Academy provides members a mechanism to network and support the profession by addressing emerging issues. To access a listing of APhA–APPM SIGs, visit www. pharmacist.com. The mission of the APhA Academy of Pharmaceutical Research and Science (APhA–APRS) is to stimulate the discovery, dissemination, and application of research to improve patient health. Academy members are a source of authoritative information on key scientific issues and work to advance the pharmaceutical sciences and improve the quality of pharmacy practice. Through the three APhA– APRS sections (Clinical Sciences, Basic Pharmaceutical Sciences, and Economic, Social, and Administrative Sciences), the Academy provides a mechanism for experts in all areas of the pharmaceutical sciences to influence APhA’s policymaking process. The mission of the APhA Academy of Student Pharmacists (APhA–ASP) is to be the collective voice of student pharmacists, to provide opportunities for professional growth, to improve patient care, and to envision and advance the future of pharmacy. The Association Report column is written by Academy and section officers and coordinated by JAPhA Executive Editor L. Michael Posey of the APhA staff. Suggestions for future content may be sent to [email protected].
ja p h a.org
Journal of the American Pharmacists Association
ASSOCIATION REPORT
FOR MORE COMPLETE ALLERGY RELIEF*...
*Total nasal symptom relief vs. single-ingredient Claritin® 10 mg. Claritin® is a registered trademark of Bayer.
Works to block 6 key inflammatory mediators, not just histamine†1-4 Available in 60- and 120-metered spray bottles.
†
Mechanism vs. OTC allergy pills. FLONASE acts on multiple inflammatory substances (histamine, prostaglandins, cytokines, tryptases, chemokines, and leukotrienes). The exact number and precise mechanism are unknown. References: 1. Derendorf H, Meltzer EO. Molecular and clinical pharmacology of intranasal corticosteroids: clinical and therapeutic implications. Allergy. 2008;63 (10):1292-1300. 2. Hallgren J, Pejler G. Biology of mast cell tryptase: an inflammatory mediator. FEBS J. 2006;273(9):1871-1895. 3. Broide DH. The pathophysiology of allergic rhinoconjunctivitis. Allergy Asthma Proc. 2007;28(43):398-403. 4. Ratner PH, van Bavel JH, Martin BG, et al. A comparison of the efficacy of fluticasone propionate aqueous nasal spray and loratadine, alone and in combination, for the treatment of seasonal allergic rhinitis. J Fam Pract. 1998;47(2):118-125. FLONASE, the FLONASE logo, the bottle and cap designs, and other design elements are trademarks of the GSK group of companies. ©2015 GSK group of companies. All rights reserved. Printed in USA. CHUS/CHFLO/0190/15 April 2015
Journal of the American Pharmacists Association
histamine cytokines leukotrienes
chemokines prostaglandins tryptases
NOW AVAILABLE OTC Visit FLONASEprofessional.com j apha.org JU L/A U G 2015 | 55:4 | JAPhA 341
ASSOCIATION REPORT
allowed for further discussion and modifications of the policy to achieve a sufficient amount of consensus. For more information about the debate over the pharmacist’s role in the care of patients using cannabis, please refer to the series of briefs featured in Pharmacy Today: http:// www.pharmacist.com/cannabisgains-acceptance-debate-growsover-pharmacists-role. The spotlight is on pharmacists to become more knowledgeable about cannabis in order to help patients receive the correct information. Pharmacist participation in executions Until this year, pharmacists were the only health care professionals without an official policy explicitly discouraging pharmacists from participating in executions. Several media outlets and advocacy groups have called out this fact amidst all of the recent controversy surrounding capital punishment. This policy ensures pharmacists join the remainder of the health professions in discouraging participation in these activities. As a delegate noted during the open comments part of the House of Delegates final session, the Associated Press tweeted the outcome of the debate within minutes of this policy getting approved, showing just how important and timely this policy is within the health-related professions. Disaster preparedness With the continued threat of bioterrorism and emerging public health threats, this policy helps ensure pharmacists are well prepared and equipped to assist should another situation arise similar to the Ebola epidemic earlier this year. Pharmacists are readily accessible and possess the skills necessary to educate the public about the risks of infection, how to minimize exposure, and consequences from potential threats. Pharmacists can also play a vital role in deploying countermea342
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sures in response to emerging infectious diseases. Pharmacists’ role in promoting medication adherence Everyone is likely familiar with the staggering direct and indirect costs of medication nonadherence to the health care system. This policy reminds pharmacists to identify the issues surrounding medication nonadherence in an attempt to better understand the root causes and identify best practices to promote medication adherence. Pharmacists can play a central role ensuring the effective use of prescription drugs through medication therapy management and clinical pharmacist– provided patient care services. Prenatal and perinatal care and maternal health In 1979, the Food and Drug Administration (FDA) introduced the pregnancy categories that we have all come to know (and possibly even hate) due to the general vagueness of the categories, most notably categories B, C, and D. Those categories are plenty flawed–most notably due to the lack of specificity regarding which trimester does the medication present the most harm. The Pregnancy and Lactation Labeling Final Rule (PLLR) instituted by FDA took effect on June 30, 2015.3 This rule is just one small facet of the complexity involved with maternal and newborn health and wellness. Questions will arise from patients and other health professionals during this transition, and pharmacists will need to be at the forefront of informing and educating colleagues and patients. Pharmacists have the knowledge and resources to educate and counsel women on lifestyle and pharmacotherapeutic modifications in an effort to optimize both maternal and child health. Antimicrobial stewardship Antimicrobial resistance and antibiotic overuse is now of such concern that articles on the topic appear ja p h a.org
regularly in both professional and lay media. Antimicrobial stewardship programs have traditionally focused on specific health systems but perhaps the time has come for a paradigm shift to look at a broader context (e.g., a specific metropolitan area or population). Pharmacists play a vital role in ensuring the safe and effective use of medications and antimicrobials are certainly no exception to this professional obligation. This policy emphasizes that pharmacists can help improve patient outcomes and decrease emergence of resistant bacteria by ensuring the continued safety and efficacy of antibiotics. Moving forward Each year, I look forward to seeing what will play out on the floor of the APhA House of Delegates and this year was certainly no exception. With so many issues facing the profession of pharmacy, the House of Delegates is a vital component of the Association since it is the place for practitioners from across the country to express concerns and truly effect change in a positive way. This was certainly reaffirmed this year with the passage of some truly cutting edge policies leading the way for pharmacists to continue advancing the profession. 1. http://www.pdmpassist.org/ content/prescription-drugmonitoring-frequently-askedquestions-faq 2. http://www.nabp.net/programs/pmp-interconnect/ nabp-pmp-interconnect 3. http://www.fda.gov/Drugs/ DevelopmentApprovalProcess/DevelopmentResources/ Labeling/ucm093307.htm APhA–APPM: Andrew Bzowyckyj, PharmD, BCPS, CDE, Clinical Assistant Professor, School of Pharmacy, University of Missouri–Kansas City, Gladstone, MO, and 2013–15 APhA–APPM New Practitioner Officer and 2015–17 Coordinator-elect, APhA–APPM Diabetes Management SIG, [email protected]
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APhA-APRS At this year’s APhA House of Delegates, the importance of sound science and evidence-based practices for the profession was highlighted in many adopted policies. Several topics addressed the need for further research to optimize pharmacy systems and validate new therOestreich apeutic entities and the pharmacist’s role in strategies to improve patient care. The covered topics of electronic communication, nationwide drug monitoring, cannabis, executions using lethal injections, and medication adherence are relevant to the members of the APhA Academy of Pharmaceutical Research and Science (APhA–APRS) and the pharmacy profession as a whole. Interoperability of communications among health care providers to improve quality of patient care As electronic health systems are further implemented throughout health care settings, the importance of collaboration and interconnectivity is increasingly recognized. Newly adopted policy advocates for the inclusion of pharmacists in the establishment and enhancement of electronic health technologies and systems. The goal is to enhance communication among prescribers and pharmacists and ultimately advance quality care, facilitate care transitions, and improve patient safety. In addition, APhA supports a voluntary, nonpunitive reporting system to record and analyze errors associated with electronic health data since continuous quality improvement and research are essential for effective use of this technology.
Integrated nationwide prescription drug monitoring program Collaboration and communication among states is the focus of another adopted policy. APhA now supports nationwide and timely integration of federal, state, and territory databases for prescription drug monitoring of controlled substances, so that information will be available across all state lines. This policy is driven by the desire to assist the clinical decision-making process for pharmacists by providing more complete and real-time knowledge to assess potential misuse, abuse, diversion, and fraud. APhA also encourages the development of interprofessional advisory boards that include pharmacists. In addition to compiling and analyzing trends, the advisory boards would provide focused education to providers, initiate patient referral, and support research activities to evaluate prescription drug monitoring. Role of the pharmacist in care of patients using cannabis The Policy Committee created a buzz this year by tackling the controversial topic of cannabis use. Cannabis remains a Schedule I substance under federal law and regulations issued by the Drug Enforcement Administration; the conflict between state and federal laws creates potential litigation risks for pharmacies and pharmacists. The process is further complicated by variability in the product, inconsistent public acceptance of dispensaries,1 and the high cost of authorized marijuana compared to other sources.2 Despite limited scientific evidence and questionable legality, at least one state—Connecticut—allows pharmacists to dispense inhaled cannabis for medical use. In the context of these events, the Policy Committee proposed and the House ultimately adopted policy to address the role of pharmacists in furnishing cannabis:
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APhA supports pharmacist participation in furnishing cannabis and its various components when scientific data support the legitimate medical use of the products and delivery mechanisms and federal, state, or territory laws or regulations permit pharmacists to furnish them. From an APhA–APRS perspective, there are important scientific and safety issues to consider related to the lack of standardized products and FDA scrutiny. In addition, the lack of appropriate research is concerning, as highlighted by APhA– APRS members in the January/ February 2015 JAPhA Association Report3: ”While a number of studies and publications examine medical marijuana use, most are anecdotal or a series of case reports. Very few of these research studies have used scientifically rigorous and valid methods or well-controlled research designs to assess the safety, effectiveness, or long-term use of marijuana.… The state laws authorizing marijuana use for medical purposes have been passed largely as a result of public opinion rather than scientific evidence.” Pharmacist participation in executions A single statement discouraging pharmacist participation in executions by lethal injection was introduced by former APhA–APRS President William Fassett and adopted by the House. The ethical statement regarding the role of pharmacists as providers of care received publicity in several media outlets, including NPR,4 CNN,5 and the Huffington Post.6 Pharmacists’ role in promoting medication adherence New policy advocates for pharmacist leadership to help design systems for improving medication adherence. These activities complement the research of several APhA– APRS members who study and disseminate evidence-based methods for medication adherence. As part of this process, the adopted policy also JU L/A U G 2015 | 55:4 |
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encourages education of the public, employee benefits managers, thirdparty payers, and other decision makers about the value of pharmacists in this role. Call for academy delegates APhA members with an interest in the Basic Sciences, Clinical Sciences, or Economic, Social, and Administrative Sciences are encouraged to join APhA–APRS. Any APhA–APRS member interested in the policy development process is also welcomed and encouraged to apply to serve as a delegate to the House for its deliberations at the 2016 APhA Annual Meeting in Baltimore by completing a brief questionnaire at https://fs10.formsite. com/APhA-APPM/form108/index.html. Serving as a delegate is a great way to forge connections with dedicated pharmacists, researchers, and scientists who have a passion to advance the pharmacy profession and improve the lives of the patients we serve. References 1.
Berger J. Connecticut allows medical marijuana, but sellers encounter hurdles. NY Times. 2014(May 1). http:// www.nytimes.com/2014/05/02/nyregion/medical‐marijuana‐is‐legal‐in‐ connecticut‐but‐not‐yet‐sold.html. Accessed June 24, 2015.
2.
Dixon K. In Connecticut, legal marijuana comes at high cost. Newstimes. com. 2014(Sept 23). http://www.newstimes.com/news/article/In‐Connecticut‐legal‐marijuana‐comes‐at‐high‐ cost‐5776347.php. Accessed June 24, 2015.
3.
Fikru B, Schondelmeyer SW. Medical marijuana: policy topic for 2015 APhA House of Delegates. J Am Pharm Assoc. 2015;55:10–16.
4.
Peralta E. Pharmacists group votes to discourage members from providing execution drugs. 2015(Mar 30). http://www.npr.org/sections/thetwo‐ way/2015/03/30/396419514/pharmacists‐group‐votes‐to‐discourage‐members‐from‐providing‐execution‐drugs. Accessed June 24, 2015.
5.
Goldschmidt D. Pharmacists discouraged from providing meds for lethal
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injection. 2015(Apr 3). http://www.cnn. com/2015/04/03/health/pharmacists‐ discouraged‐from‐providing‐drugs‐ for‐lethal‐injection. Accessed June 24, 2015. 6.
Bellware K. American Pharmacists Association discourages members from providing lethal injection drugs. 2015(Mar 31). http://www.huffingto n p o s t . c o m / 2 015 / 0 3 / 3 1 / a m e r i can‐pharmacists‐association‐lethal‐ injection_n_6973920.html. Accessed June 24, 2015.
APhA–APRS: Julie Oestreich, PharmD, PhD, 2015–16 APhA–APRS Clinical Sciences Section Chair
APhA–ASP The APhA Academy of Student Pharmacists (APhA–ASP) policy process is a unique forum established to engage the more than 34,000 student pharmacist members around the country in envisioning and advancing the future of pharmacy. Throughout its 42-year history, the APhA–ASP Kirk policy process has yielded strong position statements for the Academy and provided a basis for resolutions developed by the APhA Policy Committee. More recent examples of such APhA–ASP Adopted Resolutions and their APhA Adopted Resolution counterparts include: “Proper Medication Disposal and Drug Take-Back Programs” (2012), “Medication Take-Back/Disposal Programs” (2013), as well as “Development of an Effective and Financially Viable Care Transitions Model” (2013), and “Care Transitions” (2014). This year, student pharmacists narrowed the focus of the Academy from the more than 75 resolutions that passed the 2014 Midyear Regional Meetings to consider four resolutions, each with multiple strong position statements. APhA2015 in San Diego, CA, played host to two APhA–ASP House of Delegates ja p h a.org
(HoD) sessions during which student pharmacists participated in constructive debate, powered through Robert’s Rules in record time, and stewarded their ideas to the next step of the policy process. With the assistance of 2011 Linwood F. Tice Award recipient and APhA– ASP Parliamentarian Michael Moné, BSPharm, JD, chapter delegates voted to adopt four new resolutions. Medication synchronization Medication adherence is one of the most formidable challenges to positive patient outcomes and, consequently, has remained a prominent field of study within the profession. Medication synchronization promotes a collaborative relationship between the patient and pharmacist to align their refill dates and improve medication adherence. Student pharmacists recognized the benefits of this practice to patients. Medication synchronization programs comprehensively improve medication adherence, reduce the cost burden of medication nonadherence, promote the benefits regular medication reviews, and reduce inefficiencies and time wasted in the pharmacy.1 As a result of the recognition of these benefits by student pharmacists and a strong belief in establishing such programs as a standard of practice, Resolution 2015.1 was adopted as followed: 1. APhA–ASP supports stakeholders’ implementation of medication synchronization as a standard of practice. 2. APhA–ASP supports state and federal legislation encouraging third-party payers to cover the alignment of refills without the patient incurring additional outof-pocket expenses. 3. APhA–ASP encourages pharmacists and student pharmacists to provide education to all health care providers regarding medication synchronization. 4. APhA–ASP encourages pharmacists and student pharmacists
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DON’T GUESS. ASSOCIATION REPORT
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to promote patient awareness of the benefits and accessibility of medication synchronization programs. 5. APhA–ASP encourages all schools and colleges of pharmacy to incorporate medication synchronization education in the curriculum. Labeling and measurement of oral liquid medications Between 2002 and 2012, 81.9% of medication errors involving children ages 6 years or younger were attributed to liquid medications. The second and third most common causes of these medication errors were incorrect dose and confused unit of measure, respectively.2 The provision of and education about precision measuring devices, such as an oral syringe, and the establishment of metric units as the standard measurement were three mechanisms by which student pharmacists, pharmacists, drug manufacturers, and other stakeholders can reduce these medication errors and ensure patient safety. Resolution 2015.2 was adopted as followed: 1. APhA–ASP supports mandatory inclusion of a precision measuring device, such as an oral syringe, with all prescription and nonprescription oral liquid medications. 2. APhA–ASP encourages student pharmacists and pharmacists to educate patients and caregivers on accurate oral liquid medication administration. 3. APhA–ASP supports the use of metric units (versus teaspoons and tablespoons) as the standard measurement on all oral liquid medications and precision measuring devices. Point-of-care testing Student pharmacists believe that the future of the profession involves increasing the provision of quality patient care services and the practice shifting towards primary and 346
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preventive care. Point-of-care testing and related clinical services are becoming increasingly fundamental to the profession and its future; as the most accessible health care provider, pharmacists are poised to take the lead in offering these services. These clinical opportunities will expand patient access to care, increase community surveillance of infectious diseases, and continue the expansion of pharmacy services.3 In the context of this resolution, point-of-care testing includes but is not limited to the Clinical Laboratory Improvement Amendments (CLIA)–waived laboratory services for human immunodeficiency virus, influenza, respiratory syncytial virus, and group A streptococcal pharyngitis. Resolution 2015.3 was adopted as followed: 1. APhA–ASP supports state and federal legislation that allows pharmacists and student pharmacists to provide point of care tests and related clinical services—through appropriate protocol and in collaboration with other members of the health care team—to increase patient access to care and screen or monitor for indications requiring care follow-up, referral, or therapy adjustment. 2. APhA–ASP supports the incorporation of point of care testing education and training throughout the pharmacy curriculum to train student pharmacists on appropriate administration of tests and management of results, including but not limited to, relevant counseling, documentation, reporting, and follow-up. 3. APhA–ASP encourages the development of continuing education and training programs to enhance existing practitioner understanding and utilization of point of care testing. 4. APhA–ASP encourages all stakeholders, including but not limited to, employers, patients, pharmacists, community pharja p h a.org
macies, health-systems, and third party payers to develop a compensation model recognizing the value and cost of pharmacist-provided point of care testing and the provision of related clinical services that is both financially viable and in the best interest of patients. 5. APhA–ASP encourages all public health stakeholders and agencies to promote patient awareness of pharmacist–provided point of care testing and related clinical services for the purpose of improving community surveillance of disease prevalence and incidence. Increased access to opioid reversal agents In 2012, health care providers wrote more than 250 million prescriptions for opioid analgesics.4 Over the past 30 years, fatal drug overdose has increased more than 6‐fold, largely because of prescription opioid overdose–related deaths.5 In 2014, the APhA House of Delegates appropriately adopted the timely resolution titled “Controlled substances and opioid reversal agents.” Student pharmacists felt strongly about adoption of a similar resolution to specifically address the legislative environment regarding access to opioid reversal agents and the necessity of public education in the campaign to combat the growing incidence of fatal drug overdoses. As a result, Resolution 2015.4 was adopted as followed: 1. APhA–ASP supports state and federal legislation to increase access to opioid reversal agents. 2. APhA–ASP encourages pharmacists and student pharmacists to provide public education about opioid reversal agents, including proper administration in situations of opioid-related drug overdose. Next steps Student pharmacists will continue to shape the profession in the up-
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coming year with the leadership of the newly elected APhA–ASP National Executive Committee. See you at APhA2016 in Baltimore, MD! APhA–ASP: Loren Madden Kirk, Student Pharmacist, Bill Gatton College of Pharmacy, East Tennessee State University, and 2014–15 APhA–ASP Speaker of the House doi: 10.1331/JAPhA.2015.15521
References 1. Holdford DA, Inocencio TJ. Adherence and persistence associated with an appointment‐based medication synchronization program. J Am Pharm Assoc. 2013;53:576‐-583.
3. Gubbins PO, Klepser ME, Dering-Anderson AM, et al. Point‐of‐care testing for infectious diseases: opportunities, barriers, and considerations in community pharmacy. J Am Pharm Assoc. 2014;54:163‐-171. 4. Opioid painkiller prescribing. CDC Vital Signs. 2014(Jul). http://www.cdc.gov/vitalsigns/opioid-prescribing/index.html. Accessed January 9, 2015. 5. Legal interventions to reduce overdose mortality. Network for Public Health Law. https://www.networkforphl.org/_ asset/qz5pvn/network‐naloxone‐10‐4. pdf. Accessed January 9, 2015.
2. Smith MD, Spiller HA, Casavant MJ, et al. Out‐of‐hospital medication errors among young children in the United States, 2002–2012. Pediatrics. 2014;134:867‐-876.
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