 Hi, my name is Beth Mitchell and I'm senior director of government affairs at AmerisourceBergen.

The power and the impact of independent pharmacy has been on full display throughout the pandemic as independent pharmacists maintain consistent care for patients and helped create equitable access to COVID-19 vaccines and tests. There has never been a more important time for independent pharmacists to get their voices heard by lawmakers and knowing where to start is often one of the biggest hurdles to overcome when engaging in advocacy at the local, state, or federal level.

So, I'd like to share 3 tips for pharmacists to consider to advocate for pro pharmacy legislation.

Tip 1 – Position yourself as a resource and tell your story

The first tip for pharmacists is, when meeting with an elected official - whether it's state or federal - definitely take the approach of positioning yourself as a resource and tell your story.

Legislators and their staff deal with hundreds of bills every legislative session, and every Congress, on a variety of policy topics. And they also have to serve and be a representative to thousands of constituents. Given the sheer number of issues that legislators work on and that they represent, care about, it's next to impossible for every elected official to be an expert on every piece of health care legislation.

However, pharmacists are in a unique position because pharmacists can help position themselves as the subject matter expert on pharmacy, medication, and reimbursement issues. And as health care subject matter experts, pharmacists really know the intricacies of their industry and the regulations that govern what they do. And I think that puts pharmacists in a very unique position to offer the insight, explanations, and technical information on pharmacy and many health care issues that an elected official really needs to hear in order to make an informed decision on a piece of legislation or public policy.

Independent pharmacist also have an incredible story and a wealth of knowledge to share with legislators. They're obviously an incredibly accessible point of health care in our country. And independent pharmacists have also proven themselves as essential health care destinations throughout the COVID-19 pandemic.

In addition to that, independent pharmacists are voters in their state or local community and constituents of several elected officials, so they have that unique perspective that a lot of health care experts don't have because they're not only providing care directly to the patient, seeing their patients and knowing them every day, but they're also coming from a voter and a constituent perspective, in addition to having that expertise in health care.

I think pharmacists, when they take the time to really highlight their real world experiences and share stories with elected officials about issues, that they'll find a highly receptive audience in elected officials. If a pharmacist is preparing for an upcoming meeting with a legislator, whether it's local, state, or federal, I would really encourage the pharmacist to do their homework before the meeting and come prepared with facts and data on whatever the policy topic may be, so that they can show the legislator their expertise and help to build that trust and relationship with the elected official.

Doing that homework ahead of the meeting will also help to make your advocacy arguments that much stronger. Being prepared with real world, real life stories that you can share with an elected official on a topic that you care about and helping connect that back to the elected official about why those legislative issues important to them – sharing examples of a real world scenario in your pharmacy that impacted you or impacted your patients, having data related to percentage of Medicare, Medicaid population you share – doing all of that homework and taking the approach of positioning yourself as a resource will really go a long way and help to make your advocacy arguments and your presence that much more effective.

Tip 2 – Do your homework and be clear with your ask

The second tip I'd like to recommend to pharmacists is make sure you know going into a meeting clearly what you want to ask the elected official to do and what action would you like them to take.

Do that preparation before you walk into the meeting and have in your mind what do you want to ask them to do to help with. Frame your ask in a way that's truly easy for the elected official to understand. It's important not to assume that lawmakers know every potential aspect of a pending policy or piece of legislation related to independent pharmacy issues. But if you walk into the meeting and you show the legislator that you've done your homework, you know exactly how they can help and take action on an issue, that will really make a difference.

When you're going into a meeting, take the time to prepare and know what piece of legislation would you like for them to consider and develop in your mind and in your arguments why is it important, and how can you connect that back to the elected official to their state or their district, and why it matters for their constituents.

And then after you've explained the topic in an easy-to-understand way, make sure you're very clear about what ask you'd like them to do. Would you like them to co-sponsor the bill? Would you like them to - maybe they already are a co-sponsor. Would you like them to ask another legislator in your state to support the bill as well? We have seen an incredible form of advocacy, especially at the state level since December of 2020, when the United States Supreme Court ruled in favor of an Arkansas state law regulating pharmacy benefit managers’ (PBMs) reimbursement practices. And this was a unanimous landmark ruling that really has paved the way for other states to enact similar legislation and take regulatory action to prevent PBMs from under reimbursing pharmacists. And I think that this is an excellent example of an issue where pharmacists can really do their homework before they go into a meeting with an elected official, and go in and take action and ask the legislator to take action.

We’ve seen, just this year, nearly 300 bills in 48 states pending seeking to regulate or reform PBMs in some fashion, and more than 50 of those have been enacted just in 2021. So, clearly, independent pharmacists are making a big difference. And I would encourage you to also look into your state and see if there are similar bills pending that are modeling the Arkansas law or potentially taking different approaches that could potentially help the pharmacy profession, your businesses and your patients.

Tip 3 – Engage in grassroots and grasstops calls to action

Most importantly, the third tip I'd like to recommend for pharmacists to really think about when they're advocating for legislation is to take the time to get involved in grassroots and grasstops calls to action.

There are a variety of bills, state and federal, that pharmacists can get engaged in today. In order to do that, for example, there's current bills pending in Congress that would potentially address pharmacy direct and indirection remuneration (DIR) reform. The 

Pharmacy DIR Reform to Reduce Senior Drug Costs Act

 has been introduced in both the House of Representative and the Senate. It's bipartisan and bicameral.

There's also legislation and a strong effort this year to enact a permanent federal law to recognize pharmacists as providers in Medicare and I think we'll be seeing more evolving in that area. And those are 2 examples of issues that pharmacists can get involved today in grassroots or grasstops engagement.

And AmerisourceBergen has a variety of resources to help pharmacists do that. So, for example, we have a website called 

, which is publicly available; any pharmacist or pharmacist advocate can go to that site. And we share a lot of updates on the latest updates page. We also push out state and federal grassroots calls to action to our Good Neighbor Pharmacy (GNP) pharmacists and independent pharmacy customers, encouraging them to get engaged. We're not the only ones doing this. I'm sure many of your state and local and national pharmacy groups have similar efforts.

And you may think, “Oh, well I don't have time,” or “I'm just sending another letter, another email or another phone call,” but that's really not the case. Your voice, as a pharmacist, a voter and a constituent in your community is incredibly impactful and elected officials want to and need to hear from you. And they absolutely keep track of these types of communications coming in from their constituents into their offices.

So, again, grassroots and grasstops efforts can take a variety of forms. It can be a phone call a letter and email. I've also seen some very effective video messages that pharmacists have recorded and shared on LinkedIn, Twitter, Instagram, Facebook, and then tagged elected officials. And that message, that's a great example of a grassroots tool you can use. And then from a grasstops perspective, there's many pharmacists, especially independent community pharmacists that have direct relationships with elected officials - their children might go to the same school as their local mayor or state representative. And if you have these types of relationships, then that gives you an opportunity to really participate in a grasstops initiative and take the time to build upon that relationship.

Find specific time to meet with the elected official about pharmacy legislation and discuss ways that you can potentially work together to achieve your goal, whatever that might be, on a piece of legislation or public policy.

These are examples of some quick actions that pharmacists can take to advocate for pharmacy legislation. Again, please take the time to do it. It's worth it. And on almost every piece of legislation I work on related to pharmacy, whether I'm speaking with a member of Congress, a governor, or a state legislator, they asked me, “Are they hearing from pharmacists?” They asked their staff, are they hearing from pharmacists, so they absolutely want to and need to hear from the individuals in their community that are serving patients.

National Community Pharmacists Association (NCPA)

). They have some excellent legislative and grassroots resources and action centers, so I encourage you to visit those pages as well.

And then lastly, our government affairs and policy team at AmerisourceBergen is working to be more active on social media, so anyone interested to follow along the legislative work that our team is doing on behalf of AmerisourceBergen and our customers, to follow @advocacy_ABC on both 

And so, in closing, I'd like to say thank you to all independent pharmacists for what you do every day, but especially all you have done throughout the last year and a half during the COVID-19 pandemic, you are truly making a difference in patients’ lives. And you can make just as important of a difference when you take the time to leverage the power of your own voice and experiences and share those with elected officials to educate them and encourage them to take action on important public policy issues.

Change definitely doesn't happen overnight, especially in the legislative and political arena, so I'd encourage you to take the time to take those steps, stay engaged, and continue to advocate because significant and lasting advances for the pharmacy profession will occur and have occurred, but you have to continue to build upon that and stay engaged. Thank you.

Expert Interviews

In an exclusive interview with Drug Topics, Beth Mitchell, senior director of government affairs at AmerisourceBergen, explores the ways that pharmacists can take action on legislation that affects their practice. 

Three Actions to Advocate for Pro-Pharmacy Legislation

With all the talk about COVID-19 vaccines and flu season approaching, it is almost easy to forget the importance of the pneumonia vaccine. The good news is that pneumonia vaccinations are increasing. According to the National Health Interview Survey, from 2000-2018

percentage of adults aged 65 to 74 years who had ever received pneumonia vaccine increased from 48% to 64.8%,

percentage of adults aged 75 to 84 years who had ever received pneumonia vaccine increased from 59.5% to 74.9%, and

percentage of adults 85 years and older who had ever received pneumonia vaccine increased from 56.4% to 76.3%.

Pneumonia is a lung infection involving 1 or both lungs. Pneumonia causes the air sacs of the lungs to fill with pus or fluid. Symptoms vary in severity, depending on factors such as cause of the infection, the patient’s age, and other medical conditions. Bacteria (usually Streptococcus pneumoniae in the United States) are the most common cause of pneumonia, which can occur on its own or secondary to a viral infection. Pneumonia may be viral or fungal. Fungal pneumonia occurs more often in patients who are immunocompromised or have other chronic health problems.

The CDC’s Advisory Committee on Immunization Practice (ACIP) recommends vaccination to prevent pneumococcal disease (any illness caused by S pneumoniae). There are 2 vaccines available in the United States

pneumococcal conjugate vaccine (PCV) 13 (Prevnar 13; Pfizer)—pneumococcal conjugate vaccine for intramuscular (IM) or subcutaneous injection; prevents pneumonia caused by Spneumoniae serotypes 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, and 33F8 

ACIP recommends the following for pneumococcal vaccination

PCV13 for all children under 2 years, individuals 2 or older with certain medical conditions, and adults 65 or older who are not immunocompromised and do not have a cerebrospinal fluid leak or cochlear implant

PPSV23 for all adults 65 or older, individuals aged 2 to 64 years with certain medical conditions, and adult smokers aged 19 to 64 years

Regimens vary based on individual circumstances. For adults 65 and older who are not immunocompromised and do not have a cerebrospinal fluid leak or cochlear implant, a standard regimen is 1 dose of PCV13 first, followed by 1 dose of PPSV23 at least 1 year later.

Pneumococcal vaccine 20-valent (Prevnar 20; Pfizer) was approved by the FDA in June 2021 and is anticipated to be available in August 2021. The ACIP is expected to meet in October to review recommendations for vaccination.

Globally, pneumonia kills more children younger than 5 each year than any other infectious disease.

 About 50,000 individuals die due to pneumonia each year; most are adults.

Pharmacists have the resources and knowledge to provide vaccines to patients who need them. What are some ways we can help get the word out to our patients? Bruce Kneeland is an independent pharmacy specialist based in Prescott, Arizona, and host of the popular 

podcast. He has helped independent pharmacies for over 40 years.

Kneeland is a longtime advocate of pharmacy immunizations. Kneeland acknowledged that some pharmacists may be apprehensive about conflicts with physicians. He recommends finding ways to assure physicians that the goal is not to steal patients but to provide a critical service

that pharmacists are qualified to deliver. “Reach out to key physicians in your immediate area and let them know you’re vaccinating,” Kneeland said. “Explain that you are trained, have the infrastructure to support vaccine administration, and you look forward to cooperating with them to help people get the vaccines they need.”

Pharmacists may also contact their key technology partners to find out how they can identify who needs a specific vaccination by accessing their state’s Immunization Information System, Kneeland said. From there, pharmacists can approach targeted patients with a quick consult in person, asking, “Have you gotten your pneumonia shot yet?”

According to Kneeland, patients often require time to consider the need for vaccination. Pharmacists should not be discouraged if a patient visits the pharmacy 2 or 3 times before agreeing to receive the vaccine. Pharmacists can also send text messages, emails, or snail mail to targeted patients about the importance of the pneumonia vaccine, suggesting that they ask to speak with the pharmacist on their next visit. 

Importantly, pharmacists should become comfortable talking to patients who may be in a hurry or are unsure why they need a particular vaccine, Kneeland said. Keeping up with available vaccines and new ones on the market helps pharmacists stay current and able to address patients’ questions Kneeland also suggests setting up a designated area for vaccine administration in the pharmacy.

Bridget Hanna, CPhT, a marketing consultant for independent pharmacies in the United States and Canada, noted that pharmacists can utilize various marketing platforms and resources to develop a successful plan for promoting the pneumonia vaccine. “To effectively educate patients on these topics, you need to create content on multiple platforms,” Hanna explained.

“Social media is an extremely effective way to deliver your message to multiple target audiences. You need to create different forms of content to provide information on the vaccine,” Hanna said.

She suggests live videos, educational posts, webinar events, and links to the pharmacy’s website or to a PDF with important information. Hanna also recommends strategically placed in-store signage, printed material, newsletters, bag stuffers, and email marketing. “This brings awareness to the vaccine and lets patients know that your pharmacy can provide a solution by vaccinating patients,” she explained.

Keeping the community and patients updated, educated, and supported is of utmost importance. “The more you communicate with your patients and community with this information, the more you build trust and loyalty, resulting in long-term retention,” she added.

Articles

Pharmacists can promote vaccinations to at-risk individuals. 

Getting Patients Immunized Against Pneumonia Is Important

Selling CBD can be profitable for pharmacies, if they follow regulatory guidelines.

https://www.drugtopics.com/view/cbd-legislation-remains-in-limbo

Good Neighbor Pharmacy Reflects on the Success of the Federal Retail Pharmacy Program

Good Neighbor Pharmacy (GNP) has allocated more than 2 million doses of COVID-19 vaccines to more than 1500 independent pharmacies through its partnership with the Federal Retail Pharmacy Program.

https://www.drugtopics.com/view/good-neighbor-pharmacy-reflects-on-the-success-of-the-federal-retail-pharmacy-program

How to discuss CBD and answer questions frequently asked by patients

https://www.drugtopics.com/view/boosting-confidence-in-cbd-counseling

Artificial Intelligence Has Come in Waves

Artificial intelligence has been an integral part of pharmacy for decades. It is called the pharmacy management system: the collection of digital tools that houses patient utilization and drug data in virtually all pharmacy settings.

https://www.drugtopics.com/view/artificial-intelligence-used-in-pharmacy-has-come-in-waves

Challenges and Opportunities Facing Independent Community Pharmacies

AmerisourceBergen and Good Neighbor Pharmacy are working to support policies that will help advance the pharmacy profession.

https://www.drugtopics.com/view/challenges-and-opportunities-facing-independent-community-pharmacies

Ovarian Cancer Treatment Update and Pharmacists' Role

New targeted therapies known as PARP inhibitors (PARPis) used to treat patients with advanced ovarian cancer are transforming the treatment landscape through precision medicine.

https://www.drugtopics.com/view/ovarian-cancer-treatment-update-and-pharmacists-role

Here’s a roundup of the latest news coverage from Drug Topics®.

News Roundup: CBD, Artificial Intelligence in Pharmacy 

Joan Vos MacDonald is a freelance writer living in upstate New York. 

According to a 2019 Gallup poll,1 14% of Americans use cannabidiol (CBD) products, which makes the hemp derivative a potentially profitable addition to pharmacy shelves. However, the lack of a regulatory standard for selling CBD has created a gray area for pharmacists.

“What really makes that difficult is that as pharmacists we’re not comfortable operating in a gray area,” said Tim Gregorius, RPh, vice president of operations for PRS Pharmacy Services in Latrobe, Pennsylvania, and chief adviser for the National Community Pharmacist Association CBD resource page. “Our line of work is usually very cut and dried. You want to know how many you can sell and the exact strength and how to report it.”

In February 2021 the bipartisan bill HR 8412 proposed classifying and regulating CBD as a supplement. However, legislators await FDA input. Two years ago, the FDA promised a statement on CBD’s potential uses but research continues. The FDA has not issued a conclusion. HR 841, also known as the Hemp and Hemp-Derived CBD Consumer Protection and Market Stabilization Act of 2021, is identical to HR 8179,3 which was proposed in 2020. Both bills urge the regulatory agency to approve CBD for use in dietary supplements. 

Before the Farm Act4 legalized hemp and hemp products in 2018, many individuals were already buying unregulated CBD products online. After the Farm Act passed, CBD products proliferated in retail markets while pharmacies faced a confusing patchwork of federal and local laws governing CBD sales.

“Pharmacy came to the game late, in 2018 and 2019,” said Gregorius. “We got there and said, ‘This is safe, there’s no THC [tetrahydrocannabinol], we’re going to sell this,’ and that’s where it got really sticky because a lot of state boards said, ‘No, you don’t.’ And in a few states, agencies such as the department of agriculture or the department of transportation had an issue. Nebraska had an issue where it was not the state Board of Pharmacy but it was the state Department of Agriculture that said, ‘CBD comes from marijuana and marijuana is illegal. Therefore, don’t bring it into our state.’”

Despite the growing number of states legalizing marijuana for medical and/or regulatory use, it remains illegal at the federal level. However, CBD has less than 0.3% THC, the compound responsible for the marijuana high, and the hemp product falls under the Farm Act. So far, the FDA has only approved5 1 CBD product, a prescription drug that treats seizures associated with Lennox-Gastaut syndrome, Dravet syndrome, or tuberous sclerosis complex.

The FDA has not approved any other therapeutic use for CBD. It cannot be used as a dietary supplement or added to a food product. Some state pharmacy boards have prohibited selling CBD, whereas others told pharmacists to follow existing FDA guidelines.

“Those are the only things the FDA has been clear about,” said Gregorius. “And the state boards of pharmacy said, ‘We are not going to stop you from selling it because it is not illegal. It doesn’t have THC.’ If the FDA says, ‘If you’re going to sell it, we’re going to look the other way’—which is effectively what their enforcement discretion says—then sure, go and sell it. Just make sure you do it under FDA guidelines. And that’s where we are now.”

In March 2021, the FDA issued warning letters6 to 4 companies for selling CBD products, citing a violation of the Federal Food, Drug, and Cosmetic Act. Although these letters raise the possibility of seizing CBD products, they are targeted at manufacturers who do not meet the requirements to legally market their products. Pharmacists need not worry if they follow the existing guidelines.

“What we’re telling pharmacies and what the state boards of pharmacy are telling pharmacists is just don’t make those claims,” said Gregorius. “The manufacturers who are making those claims on their packaging and in their marketing are the ones that are the target of the FDA.”

Brenan M. 14% of Americans say they use CBD products. Gallup. August 7, 2019. Accessed July 30, 2021. 

https://news.gallup.com/poll/263147/americans-say-cbd-products.aspx 

Hemp and Hemp-Derived CBD Consumer Protection and Market Stabilization Act of 2021, HR 841, 117th Cong (2021). Accessed July 30, 2021. 

https://www.congress.gov/bill/117th-congress/house-bill/841/all-actions?r=24&overview=closed&s=2#tabs

Hemp and Hemp-Derived CBD Consumer Protection and Market Stabilization Act of 2020, HR 8179, 116th Cong (2019-2020). Accessed July 30, 2021. 

https://www.congress.gov/bill/116th-congress/house-bill/8179

Hemp Production and the 2018 Farm Bill; testimony before the Senate Committee on Agriculture, Nutrition, and Forestry (testimony of Amy Abernathy, MD, PhD, principal deputy commissioner, Office of the Commissioner, Food and Drug Administration, Department of Health and Human Services). FDA. July 25, 2019. Accessed July 30, 2021. 

https://www.fda.gov/news-events/congressional-testimony/hemp-production-and-2018-farm-bill-07252019

FDA regulation of cannabis and cannabis-derived products, including cannabidiol (CBD). FDA. Updated January 22, 2021. Accessed July 30, 2021. 

https://www.fda.gov/news-events/public-health-focus/fda-regulation-cannabis-and-cannabis-derived-products-including-cannabidiol-cbd

Warning letters and test results for cannabidiol-related products. FDA. Updated March 22, 2021. Accessed July 30, 2021. 

https://www.fda.gov/news-events/public-health-focus/warning-letters-and-test-results-cannabidiol-related-products

Selling CBD can be profitable for pharmacies, if they follow regulatory guidelines. 

CBD Legislation Remains in Limbo

Over the past year, AmerisourceBergen (AB) and Good Neighbor Pharmacy (GNP) have supported independent community pharmacies and boosted the COVID-19 vaccination efforts in the United States through leveraging the GNP network and its service offerings.

GNP Backs Independents for COVID-19 Vaccinations

GNP got involved with the Federal Retail Pharmacy Program when it was selected to provide early support in certain communities with hard-to-reach populations. AB and GNP informed the CDC about how their members are uniquely positioned to address health equity issues, including vaccine access. “Independent pharmacy, in general, is inherently located in very socially vulnerable markets and have such intimate relationships with their patients that they are a wonderful asset to federal partners,” said Jenni Zilka, group vice president, GNP Field Programs and Services, AmerisourceBergen. Zilka emphasized that the discussions helped bring vaccines to the patients, “rather than the patients having to make their way to find the vaccine,” she said.

“Through our conversations, we really spent a fair amount of time helping the CDC understand the role that independent pharmacies could play in the rollout,” Zilka said, “In February, we were very excited to see the decision to pull the federal partners forward in the vaccination process…and we were able to put forward our independent pharmacies to participate in the efforts.”

Zilka pointed to GNP customers that have been engaging with fellow leaders in their communities to prioritize socially vulnerable populations. In rural Kansas, Moffet Drug and Ward Drug joined pop-up clinics at local churches in underserved areas. “They even drove a mobile clinic around the metro area to reach homeless individuals with vaccines,” she said. In Pacific Grove, California, one of the AB offices partnered with local organizations to administer vaccines at domestic violence shelters. “And all of them worked with public schools,” Zilka added.

AB became a network administrator for the program, placing COVID-19 vaccine orders with the CDC for its members. “In our early conversations with the CDC, they indicated that they didn’t have the bandwidth or the licenses to contract with every single independent pharmacy in the US,” Zilka explained. AB and GNP poured thousands of associate hours in advocacy, administration, data analytics, personalized support, and marketing materials to keep up demand and support their member pharmacies.

During the first week of vaccine rollouts, AB and GNP allocated more than 10,000 doses to 102 GNP members across Texas, Nebraska, Kansas, and Kentucky. By week 6 of the program, 152 across 10 states received 20,000 doses of vaccine. Only 3 weeks later, GNP expanded to over 143,000 doses to more than a thousand pharmacies in 46 states and Guam.

AmerisourceBergen Delivers Technology Solutions

As vice president of program development and market intelligence at AmerisourceBergen, Phyllis Houston’s primary focus is finding solutions for pharmacies and anticipating what capabilities independents may need going forward. “These solutions can take the form of technology offerings, bringing a vendor partner to them, or it could be data analytics support – looking at data and providing them information feedback,” Houston said.

Houston pointed to AmerisourceBergen’s insight analytics platform, one of the tools that support Good Neighbor Pharmacy members. The tool leverages pharmacy claims data, “and provides really actionable business insights back to our pharmacy customers,” she said.

During the early COVID-19 vaccination efforts in the US, the AB program development team got to work in creating solutions for data reporting requirements set by the CDC. “Once AmerisourceBergen realized that we were going to be the network administrator for the Federal Retail Pharmacy Program, that’s when my team was brought on to really understand what we would need to do from a data and reporting standpoint,” said Houston. “And then we were tasked with putting together a solution as quickly as we could to really enable some of those daily reporting requirements that the CDC was asking for.”

Equipped with existing infrastructure around claims data and an impressive data team, AmerisourceBergen was able to streamline the process and quickly roll out a solution for COVID-19 vaccine administration reporting. AB collaborated with multiple vendor partners and with its participating pharmacies to ensure that the program would capture key data fields that the CDC needed and report back on a daily basis. “That was really to allow [the CDC] to measure the impact of what the Federal Retail Pharmacy Program was doing nationwide, and how much that impacted vaccine administration rates across the country,” Houston explained.

The CDC also requested that pharmacies collect data related to race and ethnicity, which aren’t typical for a data feed, according to Houston. “Some of these data points needed new pathways just for reporting, and then a new pathway to pass that data along,” she said. As pharmacies made headway in vaccinating Americans for COVID-19, they were also able to use the webform to quickly place COVID-19 vaccine orders, as well as leverage Good Neighbor Pharmacy resources to educate their patients with reliable, fact-based information about COVID-19 vaccines at a time when misinformation was spreading. “The pharmacies could use these digital resources to be very targeted and provide great detail to their communities,” Houston added. For example, one New Jersey-based GNP member pharmacy has been offering both digital and print materials in Spanish to address vaccine hesitancy in their community. As trusted health care professionals, pharmacists can make a difference in dispelling misinformation, educating their communities, and reducing health disparities.

Houston underscored AmerisourceBergen’s efforts in prioritizing equitable COVID-19 vaccine access. Based on weekly allocation numbers, the AB team would identify and activate pharmacies that showed a high social vulnerability index (SVI). Over 55% of GNP members that are participating in the Federal Retail Pharmacy Program are in zip codes that have been designated with a high SVI, according to Houston. “This really reinforces that critical role that community pharmacy is playing in ensuring an accessible reach for all patients,” she said.

AmerisourceBergen and Good Neighbor Pharmacy are also committed to helping independents expand their role in patient care through services like vaccinations outside of the demands of the COVID-19 pandemic. But while independents continue to demonstrate their value and accessibility as health care professionals, provider status remains out of reach for many pharmacists in the US. “As of October 2020, only 37 states allow pharmacists to qualify as medical providers under [Medicare] Part B, and they don’t have full provider status at the federal level,” Zilka said. “This really limits their ability to be reimbursed for the health care services that they are already providing to patients.”

Moving forward, AB and GNP are going to double down on advocacy, Zilka said. “We’re going to continue to work with other entities and industry partners to push for policies that empower [pharmacists] to utilize their education, their training, their expertise, and continue to provide the high level of care that they already bring to their communities.”

This article was written in partnership with AmerisourceBergen and Good Neighbor Pharmacy

Good Neighbor Pharmacy (GNP) has allocated more than 2 million doses of COVID-19 vaccines to more than 1500 independent pharmacies through its partnership with the Federal Retail Pharmacy Program.  

Given the popularity of cannabidiol (CBD), patients are curious about this natural remedy, asking more questions than ever. We consulted 4 pharmacists knowledgeable about CBD for advice on counseling patients. Our experts are:

, PharmD, ND, MBA, RPh, owner of Owensboro Family Pharmacy and Wellness in Owensboro, Kentucky, and certified endocannabinoid specialist

, RPh, CEO of MyCureAll, based in Fair Lawn, New Jersey

, PharmD, owner of Alpine Apothecary in Whitefish, Montana

, PharmD, owner of Malley’s Compounding Pharmacy in Richland, Washington

Our experts recommend that pharmacists advise patients to discuss CBD use with their health care providers before starting it. Here are some of the most frequently asked patient questions and our experts’ answers.

: Patients will typically ask how CBD works and whether it will really help with pain, inflammation, [gastrointestinal] issues, anxiety, etc. We explain that CBD works by allowing the cannabinoids their body makes [eg, (anandamide) AEA and (2-arachidonoylglycerol) 2-AG] to stay in their body longer and that it helps to strengthen the endocannabinoid system [ECS]. The ECS is a system that functions to bring the body back into balance and to decrease inflammation. It reduces inflammation by decreasing proinflammatory chemicals (eg, cytokines and chemokines) and helping the immune system become better at recognizing what it should attack (ie, T-cell upregulation). If they have a symptom that is due to inflammation…it should help.

: As a pharmacist who is a certified endocannabinoid specialist, I love providing education and counseling my patients on the benefits and effective use of CBD. When a patient [is deciding] what product to try, I ask what they are interested in using it for. If they have pain in the wrist, elbow, or knee, or skin conditions, we will start using a balm or topical product. If they have pain in multiple joints, autoimmune conditions, inflammatory diseases, or mental health issues such as anxiety, I recommend using an oil or capsule.

: Match your intention with the application. Topical applications are great for localized support of your muscles and joints. Oral and under-the-tongue formulations are better for systemic absorption and support of your whole body. Supporting your sleep with CBD is a great way to start and then adjust when or if necessary.

: Patients often ask about the dose they should use, how long it takes to work, and how they should use it. I advise starting low and going slow. I recommend a starting dose of 15 mg once or twice daily, explaining that the timing of effectiveness typically depends on the state of their endocannabinoid system. If they have had illness or pain that the body has tried to bring back into balance for a while, it typically takes longer for the full benefit to show. I recommend [for the patient to try] the product for at least 10 days and to increase the dose every 3 days if needed. For oils and tinctures, I advise them to hold it under the tongue for at least 30 seconds, but 1 minute is usually best.

For capsules, I let them know that it takes longer for the effects to kick in, because they must wait for the stomach to empty. We discuss how oils have the fastest absorption rates, because there are a lot of blood vessels under the tongue. For my patients [who are] taking antacids, [proton pump inhibitors], have gastroparesis, or any condition of the gut that makes me question the intestinal permeability and function, I recommend the oils, because bioavailability will differ in edibles or capsules depending on how the gut is functioning.

: Remind the patient to consult a professional when adjusting, because more is not always better. Switching up routes or sites may be more beneficial. Teaching patients to read and understand a label is also crucial. Product labeling isn’t always standard or clear, so advising consumers to pay attention and understanding things like mg per bottle vs mg per serving becomes important. Serving sizes can be listed as per ml or per dropperful, and those distinctions can make a difference and often lead to confusion with consumers.

: More is not always better. Once someone has found an effective dose… taking more can either decrease the effect, increase [adverse] effects [AEs], or provide no further benefits. In my experience, most patients take between 10 and 40 mg daily in divided doses every 12 hours. 

Is it safe to purchase CBD from anywhere?

: I recommend that patients only purchase CBD from a reputable source, because some preparations can become contaminated with fungus, which may be especially harmful to patients with a compromised immune system. If the patient needs to take a drug test, [they] should always ask for the certificate of analysis when purchasing CBD to ensure the product is [tetrahydrocannabinol] THC free. 

: Verify your product with the certificate of analysis, and never buy from a company that doesn’t provide lot-specific analysis that is conducted by a third-party lab.

: I always ask the patient whether they are in a profession where they are drug tested or in pain management. If so, I recommend a product that is THC free. I always recommend THC-free CBD for children. We discuss that products can have the legal limit of THC, and although that amount will not cause any psychoactive [AEs], the urine test limit is so low that they can still fail a drug test for THC.

: In my experience, the most common adverse events [AEs] of CBD are tiredness and drowsiness, dry mouth, dizziness and lightheadedness, and changes in appetite. I recommend taking the first dose in the evening and not doing anything else for the day until one knows how they respond to the CBD. We often forget that most accidents happen in the home. With any prescription, over-the-counter [OTC] medicine, or supplement that might affect cognition, I recommend that one does not do tasks around the house where they could hurt themselves afterward until they have adjusted to the medication.

: We educate that the ECS is a different system than the central nervous system and that added sedation is not a concern. As far as CBD AEs, clinically we have had patients say they would become drowsy, which can be mitigated by decreasing the dose and checking the product to make sure it doesn’t have melatonin or other ingredients. We have had a few patients say the oil caused mild stomach discomfort, to which we suggest taking it with food and allowing it to sit under the tongue for 30 to 60 seconds.

: CBD is a strong inhibitor of both cytochrome P450 3A4 (CYP3A4) and cytochrome P450 2D6 (CYP2D6). CBD may increase levels of:

macrolide antibiotics (azithromycin, erythromycin, clarithromycin)

calcium channel blockers (verapamil, diltiazem)

benzodiazepines (lorazepam, diazepam, alprazolam, clonazepam)

erectile dysfunction drugs (sildenafil, tadalafil, vardenafil, avanafil)

certain statins (atorvastatin and simvastatin)

CYP2D6 metabolizes many antidepressants, so CBD may increase levels of these drugs in the patient’s body:

selective serotonin reuptake inhibitors (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline)

tricyclic antidepressants (amitriptyline, nortriptyline)

β-blockers (atenolol, metoprolol, propranolol, bisoprolol)

Levels of opioids, such as oxycodone, codeine, hydrocodone, morphine, or tramadol, increase when CBD is introduced.

: CBD can have potential drug interactions with prescription medications. Some of these drug interactions may cause increased AEs of either the medication or the CBD. Other times the drug interaction may cause an increased level of the medication or the CBD. It is vital for the patient to inform the pharmacist and medical provider about CBD usage. Another valuable tool for screening for drug interactions includes an interaction checker, such as on drugs.com, which helps screen for interactions between cannabis, CBD, and THC and prescription drugs.

 Retail CBD comes from the hemp plant and has no high or psychoactive effect. When given with THC, CBD inhibits the psychoactive effects of THC.

: We counsel our patients that although CBD can help with a wide variety of symptoms, it may not be their miracle or silver bullet and solve every problem they have. It can help decrease inflammation, but the source of the inflammation is the root cause, and we should work to correct the source.

 As medical professionals, it is very important to ensure collaboration with other caretakers of the patient. Informed and shared decision-making is a must. We need to ensure ongoing monitoring and adapting the treatment plan as needed.

, PharmD, graduated from the University of Pittsburgh School of Pharmacy, and her experience includes chain and independent pharmacy as well as medical writing and reviewing.

How to discuss CBD and answer questions frequently asked by patients 


Boosting Confidence in CBD Counseling 

Wayne Salverda, RPh, senior director of clinical services for National CooperativeRx, remembers visiting Eli Lilly and Company while in pharmacy school. “They had a crazy supercomputer working on drug design and that was 30 years ago,” he said. “About 1 in 10 drugs in development makes it to market, but companies like Vertex or Regeneron that have invested in and leveraged AI see 30% to 40% of their new molecular entities make it to market. It’s not a coincidence; it’s putting smart science and AI into drug development.” 

AI can be just as useful in medication management. Pharmacy benefit manager Prime Therapeutics worked with AI provider SAS to save clients $355 million over 18 months by consolidating and analyzing data from pharmacy, drug claims, and medical services to target fraud.

“We have gotten some good recoveries and great cost avoidances with AI,” Salverda said. “We will be able to leverage AI even more in the future to help make sure that individual patients are getting the most appropriate medications at the most appropriate dose by factoring in their specific genetics and health conditions. We’re going to see a lot of advances in pharmacogenomics with AI.”


AI is a concept, not a gadget like the robot Maria in the 1927 film Metropolis or R2-D2 in Star Wars 50 years later. “AI is nothing more than a means to an end, improving processes and improving outcomes,” said Codrin Arsene, chief marketing officer for Digital Authority Partners. “It’s just an automation of data, rules, and statistical processes that help people do their jobs more efficiently.”

When the American Society of Health-System Pharmacists (ASHP) and the American Medical Association discuss AI, they mean augmented intelligence: leveraging the strengths of computers and clinicians to improve outcomes for patients. “AI today is everywhere in pharmacy: drug discovery, drug design, drug development, trial design, participant selection, clinical decision support, drug response and risk prediction, personalized therapy, everywhere,” said Wei-Hsuan Lo-Ciganic, PhD, MS, MSPharm, associate professor in the Department of Pharmaceutical Outcomes and Policy at the University of Florida College of Pharmacy.


AI has come to pharmacy in 3 waves, noted Chenglong Li, PhD, a professor in the Medicinal Chemistry, Biochemistry, and Biophysics Department at the University of Florida College of Pharmacy (see Sidebar). Pharmacy management systems, IVR, and DUR screens are first-wave products. Second-wave AI powers some of the more advanced decision-support tools and systems that are starting to track fraud. Third-wave applications will change pharmacy in ways that are difficult to imagine, Li explained.

“AI is going to have the kind of impact we see with digital cameras,” Lo-Ciganic said. “When I was in school, people laughed at digital cameras. But when the iPhone came out, with its smart camera, the world changed. We are going to see the same kind of change in the world of pharmacy.” Lo-Ciganic is using AI to improve risk prediction for opioid misuse by linking Medicaid, human services, and criminal justice data. AI helped her identify 30 key predictors of opioid overdose.

“The methods used today can predict about 30% of opioid overdoses,” she said. “When we use our machine learning rule, we can improve to 70% to 90% accuracy for individuals who have an opioid overdose or misuse. That helps focus time and resources on the people at highest risk.”

Li’s lab modeled an enzyme that represses tumor suppressor genes and a native compound that blocks the enzyme, which allows suppressor genes to be expressed and kill the tumor. “We have a few collections of really potent compounds, maybe 10,000-fold more potent than the native compounds that work in cell culture,” Li said. “We are trying them in animal models to see if they are active in vivo.”

More changes in drug discovery are coming. In July 2021, DeepMind announced the latest version of its AlphaFold platform has identified the 3D structure of 98% of the entire human protein complement. More than 350,000 protein structures are available in a public database hosted by the European Molecular Biology Laboratory’s European Bioinformatics Institute.


AI isn’t making any of these advances on its own. AI needs human intervention as much as humans need AI.

“AI has the potential to help pharmacists improve their workflows.,” said Sophia Chhay, PharmD, assistant director of the ASHP Innovation Center. “Any pharmacist will tell you that ‘anything that gets me away from the computer and spending more time with patients is going to be an answer.”

Freeing up pharmacist time is key, said Ken Perez, vice president of healthcare policy and government a¡airs at Omnicell. The typical pharmacist spends 75% of working hours on nonclinical tasks.

“If you think about every medication as a node on a network, every drug has a journey, and where every dose goes is important,” he said. “Pharmacists spend too much time as de facto supply chain specialists, figuring out where drugs are [and] how to get them to the right patient at the right time. That time would be better spent with patients, not products. And that’s where AI can make a huge difference. The real prize of AI is helping pharmacists [to] practice at the top of their licenses, spending more time with the patients who need them the most.”


AI may shift pharmacist roles by giving them more hands-on time with patients, but don’t expect massive layoffs. “I don’t think any state board is at all comfortable with turning over critical decision-making to automation or AI,” said Lisa Schwartz, PharmD, senior director for professional a¡airs at the NCPA. “AI might make a recommendation, maybe a medication adjustment to avoid an interaction or adjusting the time of day a patient takes something, but it’s up to the pharmacist to decide what needs to be done.”


US clinicians, including pharmacists, are slow to adopt AI, Arsene noted. About 25% of European Union physicians are using voice assistants in daily practice. “For all the research that goes on, this is an industry that has a very low level of innovation and too much bureaucracy to change quickly,” he said. Arsene likened pharmacy to the financial services industry. It wasn’t until Credit Karma, Mint.intuit.com, and other new entrants began to affect customer preferences and banking profits that traditional providers moved to AI.

New entrants in pharmacy are presenting similar challenges. Kit Check uses AI to audit 100% of hospital-controlled substance use in less time than a conventional 5% random audit.

“Nobody can track controlled substances manually; there is just too much information,” said Doug Zurawski, PharmD, Kit Check’s senior vice president of clinical strategy. “We and our competitors can give you a dynamic picture of everything and everyone in your system relative to controlled substances.”

AI systems developed for the relatively closed universe of health systems can be expanded to ambulatory care and retail pharmacy, he added. On the dispensing side, InterLink-AI is expanding Rx verification by identifying every pill as it goes into a patient vial. Different versions of image-based verification can be adapted for a single pharmacy, telepharmacy, load sharing across multiple pharmacies.

“You have a clean record of the chain of custody from the raw materials used in a batch of medication through distribution of the stock bottle,” said Ram Subramanian, PhD, InterLink’s chief business officer. “But from the stock bottle on, there are questions. Verifying 100% of the pills that go into every vial optimizes the pharmacy workflow and frees up time for technicians and pharmacists. Improving the workflow puts the pharmacist in the driver’s seat regarding patient care.”

Artificial intelligence has been an integral part of pharmacy for decades. It is called the pharmacy management system: the collection of digital tools that houses patient utilization and drug data in virtually all pharmacy settings. 

Despite long-standing challenges, independent community pharmacies continue to fight on the front lines of the pandemic and prioritize the health of their patients. AmerisourceBergen (AB) and 

 (GNP) are committed to fighting for independents in Washington and in the states to improve and expand pharmacy practice.

During ThoughtSpot 2021, Beth Mitchell, senior director, government affairs, AmerisourceBergen, and Brian Nightengale, president, 

 to discuss current federal and state legislation affecting independent pharmacies, how pharmacists can support policies that will help advance the profession, and the ways that AB and GNP are investing and advocating on behalf of customers to protect their long-term viability.

AmerisourceBergen was the first pharmaceutical wholesale distributor to have a presence in Washington DC. Since 2004, AB’s government affairs and policy team has continuously supported issues affecting provider customers and independent community pharmacies in particular. 

“I think independent pharmacists have clearly shown, throughout the COVID-19 pandemic, just how critical and essential…they are to our health care system,” Mitchell said.

The team collaborates with legislators from both sides of the aisle and at the state and federal levels. “We work with all parties, so Republicans, Democrats, Independents in Congress, state legislatures, governors, and the administration,” Mitchell said. “I am fortunate to spend a lot of time on pharmacy legislation, which is very fulfilling because pharmacists provide such an important element of care to their communities which I have felt and seen because I grew up going to a community pharmacy in my home town in North Carolina, and this pharmacy continues to provide quality care for my parents and many friends in the community.” she added.

AmerisourceBergen and Good Neighbor Pharmacy Invest in Independents

AB and GNP recognize the unique and trusted experience independent pharmacies offer their customers and have continually supported their viability. Through the Elevate Provider Network, AB’s pharmacy services administrative organization (PSAO), the company has heavily invested in add-on services that may bolster the financial viability of independents. “We really enhanced our service offerings,” Nightengale said. “We built, with our partners, a central pay mechanism to complete cash flow visibility, incorporated pre and post-edit services so small mistakes don’t jeopardize their full reimbursement, as well as reconciliation services, where pharmacy owners can simply verify their payments. We also enabled a patient engagement center that gives owners all the data they need to focus their efforts on patients,” he added.

During the pandemic, one of AmerisourceBergen’s most significant investments centered around enlisting GNP pharmacies into the Federal Retail Pharmacy Program (FRPP), which was designed to leverage pharmacy networks to quickly disseminate COVID-19 vaccines to Americans.

“We invested heavily in personnel time, content training, education materials, and IT infrastructure to be able to do the ordering and recording [of COVID-19 vaccinations] to make sure our customers could participate in this program,” Nightengale said. “Hundreds of thousands of personnel hours, millions of dollars in hard development costs, in order to enable our pharmacies to be able to order, receive, administer, and report the vaccines back to the CDC.” The investments helped nearly 1600 GNP pharmacies in nearly every state the ability to administer COVID-19 vaccines to patients. “We have shipped more than two million vaccines to independents since the start of our program,” Nightengale said.

Federal and State Priorities for Pharmacy

Amid COVID-19 vaccination rollouts, the last several months have also been witness to a surge of legislation impacting pharmacies. “At the same time that our staff and teams are working full time on supporting customers in our network, the legislative and regulatory activity escalated quickly,” Nightengale said.

At the federal level, Mitchell explained that for pharmacists to administer COVID-19 vaccinations and be reimbursed by Medicare, the federal government had to issue several guidances under the Public Readiness and Emergency Preparedness (PREP) Act.“ At the onset of COVID-19, the AB Government Affairs & Policy team partnered with many pharmacy entities to advocate for the federal government to empower pharmacists to be able to provide COVID-19 vaccinations and additional services to patients during the pandemic, including fair reimbursement by Medicare and Medicaid.We are grateful that our advocacy efforts were successful as these federal actions had to take place for the FRPP to be successful for independent pharmacies and patients,” Mitchell said.

Mitchell also explained that many pieces of legislation pending in state legislatures and Congress aim to address big-picture issues on drug pricing. “We know that the Democrats in the House and the Senate have ideas of what they’d like to do on drug pricing, and President Biden does as well,” she said. In addition, the Department of Health and Human Services (HHS) is expected to release its drug pricing plan, per President Biden’s July Executive Order, in the next few weeks. This is an opportunity to push for policy changes that can address long-standing drug pricing and reimbursement challenges that have been affecting pharmacies.

“I think a broader focus in Washington on drug pricing provides a great opportunity for many important pharmacy priorities to be included in some of those larger packages that Congress is likely to consider this fall,” Mitchell said.

Nightengale pointed to the complex issue of reimbursement as being one of those priorities. Reimbursement issues can severely impact other facets of a pharmacy, Nightengale explained, including patient and product access. “You’ve got this balance between patient access and reimbursement, and it really hits the independents hard,” he said.

AmerisourceBergen and Good Neighbor Pharmacy are working to support policies that will help advance the pharmacy profession. 

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