Aine Cryts

Warfarin, a lifesaving medication, is commonly used to treat blood clots and reduce their occurrence, thus preventing heart attack, stroke, or other serious conditions such as deep vein thrombosis in the legs or a pulmonary embolism in the arteries of the lungs.

Warfarin is a derivative of a naturally occurring substance originally discovered in 1940 as a compound in moldy hay.

 In 1948, the substance was marketed as rat poison. Because of its high degree of acute oral toxicity, warfarin is in the FDA’s Toxicity Category I, the most serious such designation.

Elizabeth Isaac, PharmD, a medication safety pharmacist at UMass Memorial Medical Center in Worcester, Massachusetts, said safe disposal of warfarin requires pharmacists to contract with a biomedical waste vendor. Patients taking warfarin are advised to go on birth control as warfarin can interfere with fetal development.

 It is also important for women who are pregnant or breastfeeding and men who want to become fathers to take precautions when handling this substance, Isaac added.

Pharmacists are busy but focusing on pharmacy waste must be a priority, said Isaac. “[For one thing] we know that pharmaceutical waste, if not disposed of correctly, can end up in our drinking water….The [Environmental Protection Agency (EPA)] has come out with guidance about not allowing pharmaceutical waste into our water supply,” she said.

 They’re classified as an antineoplastic drug, along with cytotoxic and oncology drugs. Working with these substances during pregnancy could impact a woman’s chance of miscarriage or having a child with a birth defect.

. This substance is formulated in low concentrations in shampoo to treat head lice and is only applied for brief periods of time. It’s highly toxic to humans, which means it has to be kept out of drinking water.

. Although the drugs inside inhalers aren’t considered hazardous, they are stored in compressed gas; this means they could be combustible.

, depending on the state where you practice. This substance was reevaluated by the Environmental Protection Agency in January 2020 for removal as hazardous, but not all states have adopted this change.

 showed that pharmaceuticals in treated wastewater released into streams and other bodies may affect fish. The pharmaceuticals included in the study were hydrocodone, methadone, oxycodone, tramadol, methocarbamol, fluoxetine, paroxetine, venlafaxine, and temazepam.

Isaac said pharmacists should work with waste management vendors and their colleagues in hospital-based environmental health and safety departments for guidance on appropriate disposal of drugs.

She also has some practical advice: Creating open and clearly labeled containers to capture pharmaceutical waste is a must. “You need to make it as easy as possible [for employees] to do the right thing.”

Understand the Relevant Federal and State Agencies

Chris Smith, RPh, director of product strategy for provider solutions at Inmar Intelligence, a Winston-Salem, North Carolina-based technology and data analytics services provider, observes that there are numerous federal and state agencies engaged in regulating pharmaceutical drugs.

Specifically, he recommends that pharmacists learn how the various drug lists published by the Resource Conservation and Recovery Act, the United States Pharmacopeial Convention (USP) USP 800, and the National Institute for Occupational Safety and Health (NIOSH) may affect their pharmacies.

“It’s super-important to understand the various lists of drugs because the EPA list is different from the USP 800 list. Additionally, NIOSH, [a] subsidiary of the CDC, has undergone extensive changes to their list and [has] published a new draft list in 2020 that is up for approval now.”

The implications of these changes are numerous, including additions and removals of various active product ingredients and their classifications, said Smith. NIOSH recently communicated that modifications to its list should be approved in 2021, he added.

Keep Track of Medication Expiration Dates

 showed that a form of tetracycline, an antibiotic that can be used to treat acne and skin infections, caused renal tubular acidosis when outdated. However, some researchers disputed4 this finding. Other medications lose their potency over time. Examples include oral nitroglycerin, insulin, anticonvulsant, warfarin, digoxin, thyroid preparations, and oral contraceptives.

 certain expired medications can succumb to bacterial growth, whereas antibiotics that have lost their potency may be unsuccessful in treating infections, which can result in more serious illness and antibiotic resistance.

Most medications expire when they get to approximately 90% effectiveness, said Timothy Burkart, PharmD, an assistant professor of clinical practice in pharmacy at the University of Findlay in Findlay, Ohio. After that, the chemicals start to break down and the medications become less stable.

Managing medication expiration dates is often done manually, explained Burkart. That means an intern pharmacist or a pharmacy technician will each be responsible for their own section of the pharmacy where they are tracking expiration dates. Once a month, they’ll look at the medications’ expiration dates and pull to the front medications that will expire after a year. An easy way to manage expiring medications is to flag them by marking the label with a bright dot, he said. Medications that are due to expire within a year should be pulled off the shelves and disposed of appropriately, advised Burkart.

Stephen Eckel, PharmD, MHA, associate dean for global engagement and associate professor at UNC Eshelman School of Pharmacy in Chapel Hill, North Carolina, said that although pharmacy interns and technicians can do this work, it is ultimately the pharmacist’s responsibility.

There are costs associated with having these medications incinerated, which is something pharmacy leaders should know, added Eckel. Expired medications are less likely to be an issue at retail pharmacies, where less inventory is kept on hand. By contrast, it is much more time-consuming and an ongoing process at hospital pharmacies where inventory is higher, he explained.

Isaac said hospital pharmacists should sustain relationships with team members in the environmental health and safety department who work closely with waste management vendors. It is just as important to work collaboratively with nurse managers throughout the hospital about proper medication disposal, she added.

Expired or unused medications can have a negative impact on the environment and their communities. For example, unused opioid medications that are not disposed of appropriately can be diverted and exacerbate the nation’s opioid crisis, said Burkart. Burkart has helped organize Drug Take Back Days, where members of the public can safely and easily turn in prescription drugs.

Overdose death accounts reached more than 86,000 people for the 12-month period that ended in July 2020, 

 Nora Voklow, MD, director of the National Institute on Drug Abuse, told 

, “2020 has by far the highest number of [overdose] deaths.”

Pharmacists can participate in National Prescription Drug Take Back Day, which occurs on April 24 this year. They can also plan events with local law enforcement, said Burkart.

Partnering with local law enforcement is a must because opioids are regulated by the United States Drug Enforcement Administration, among other federal and local agencies, he explained. “There are special rules about how you get rid of these drugs. They have to be taken out of circulation from the general population.”

Typically, opioid medications are destroyed through incineration at locations—sometimes old steel mills—at high temperatures. Filters are used to manage the release of smoke, which prevents the smoke from leaking into the environment, Burkart explained.

Smith advises pharmacists to conduct a thorough assessment of the pharmacy through the lens of regulatory compliance, employee and patient safety, and public safety. Also helpful is building a plan for handling exposures, spills, or other potentially harmful incidents; the plan should inform policies that deter abuse and diversion, he added.

Pharmacists must provide training for staff and patients, said Smith. Staff members need to know what to do if an incident occurs. Equally important, patients need to know about safe medication disposal techniques; advertising Drug Take Back Days helps, as does providing a drug take-back kiosk at the pharmacy, he said.

1. Lim GB. Warfarin: from rat poison to clinical use. 

 Published online December 14, 2017. doi:10.1038/nrcardio.2017.172

2. Mayo Clinic. Warfarin (Oral Route). IBM Micromedex. Updated February 1, 2021. Accessed March 4, 2021.

https://www.mayoclinic.org/drugs-supplements/warfarin-oral-route/precautions/drg-20070945

3. Understanding how pharmaceuticals in the environment affect fish. News release. U.S. Geological Survey. November 13, 2015. Accessed March 4, 2021. 

https://www.usgs.gov/news/understanding-how-pharmaceuticals-environment-affect-fish

4. Gross JM. Fanconi syndrome (adult type) developing secondary to the ingestion of outdated tetracycline. 

. 1963;58:523-528.
doi:10.7326/0003-4819-58-3-523

5. Drug expiration dates — do they mean anything? Harvard Health Publishing. Updated August 9, 2020. Accessed March 4, 2021. 

https://www.health.harvard.edu/staying-healthy/drug-expiration-dates-do-they-mean-anything

6. Shapiro M. The truth about expired meds. AARP. December 15, 2015. Accessed March 4, 2021. https://www.aarp.org/health/drugs-supplements/info-2015/expired-medication.html 

7. Don’t be tempted to use expired medicines. FDA. Updated February 8, 2021. Accessed March 4, 2021. 

https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines

8. Facher L. The ‘other’ epidemic: amid Covid-19, addiction experts fear Biden could back-burner the overdose crisis. 

https://www.statnews.com/2021/03/02/addiction-overdose-crisis-covid-biden-backburner/

9. Environmental Protection Agency. § 261.33. 40 CFR Ch. I (7–1–19 Edition). 2019. Accessed March 8, 2021. https://www.govinfo.gov/content/pkg/CFR-2019-title40-vol28/pdf/CFR-2019-title40-vol28-sec261-33.pdf

Articles

Pharmacists can take steps to ensure safe disposal of unused or expired medications.

Reducing Pharmaceutical Waste in the Store

Minh Dang, RPh, was in high school working as a cashier at an Osco Drug in a suburb of Boston, Massachusetts, in the late 1980s. A friendly kid who loved math and science, she wasn’t sure what career to pursue. One day, the store’s pharmacy manager pulled her aside and asked, “What do you think about a career in pharmacy?”

She was 16 or 17 years old at the time. Although there were doctors and nurses in her family, there wasn’t a single pharmacist. Dang now looks at that conversation as a pivotal point in her life.

Dang credits her success in the pharmacy profession today to the skills she learned working with patients early in her career. For example, during an internship at a pharmacy in Boston, she encountered a patient who insisted on speaking with a pharmacist instead of her. Dang calmly explained that she was the pharmacist, which confused him. Most pharmacists at the time were white men and she doesn’t remember knowing any Asian American women pharmacists at the time, she said. But Dang took the conversation in stride.

She asked how she could help, and that simple question persuaded the patient to open up to her. Dang’s advice for handling tense conversations with patients? “Be professional and kind and caring. They will convert.”

Since 2013, Dang has served as assistant dean for experiential education and professor of practice for clinical sciences at the School of Pharmacy and Health Sciences at Keck Graduate Institute in Claremont, California. This is a full-circle moment in her career because it’s now her mission to inspire students and connect them with real-world work experiences in pharmacy.

Women Are In the Majority, But Leadership Roles Lag

Dang is one of 5 women pharmacists featured in this story. Unlike her experience with the pharmacy manager at Osco Drug, most of the women featured had a role model in a relative who was a pharmacist. Some attributes shared by all of these women: an early passion and affinity for math and science and a desire to help people.

According to the American Pharmacists Association (APhA), 67% of its members are women. And the industry can look forward to welcoming many more women into its ranks in the future: As of fall 2019, 64% of pharmacy students were women, a metric that’s held steady for 20 years, according to Frank Fortin, CAE, senior vice president for communications, marketing, and media relations at APhA.

Debra Parker, PharmD, dean and associate professor at the College of Pharmacy at University of Findlay in Findlay, Ohio, looks to the 1960s as a decade when things started to change for women in professional roles, including pharmacists. In 1964, the Civil Rights Act was passed. The law made it illegal for most employers to discriminate against women in decisions about hiring and promotions; creating a work environment that’s hostile based on sex and sexual harassment was also rendered illegal. That was preceded in 1963 by the passage of the Equal Pay Act, which made it illegal to pay women a lower wage than their male colleagues when the decision is based on their sex.

That’s when you started to see women become more prevalent in many fields, said Parker, who noted that women represented only 15% to 16% of pharmacists in the mid-1960s. Although women will likely continue to form the majority of the pharmacist workforce, she said there are more men in leadership roles in pharmacy.

First Female Pharmacy School Dean in Ohio

In 2000, there were 82 pharmacy schools in the United States.

 Fifteen percent of them were led by a female dean, according to Parker. As of October 2020, there were 143 pharmacy schools

, 25% of which have a female dean, she said. That’s at odds with the number of pharmacy school graduates and women working as pharmacists.

The statistics about the percentage of women leading pharmacy schools were “startling” to Parker, she said. Parker is the only female dean among the 7 pharmacy schools in Ohio. She’s also the first female pharmacy school dean in the state. Although her counterparts at Ohio’s other pharmacy schools are all men, 2 of them have recently stepped down from their roles as dean and women have taken on those roles on an interim basis.

Parker didn’t have her sights set on a leadership role in academia. That said, she embraces the “lean in” approach, which, for her, means she doesn’t turn away from opportunities because she’s a mother. Instead, Parker focuses on how to make it work. She also credits her extremely supportive spouse.

While serving as a faculty member and an academic chair at the College of Pharmacy at University of Findlay, Parker was asked to take on the role of interim dean. “That was a little bit scary for me,” she said. “I had never aspired to being a dean, but I also felt that I knew the operations of our program and our university well enough that I could hold down the fort.”

But after serving on an interim basis starting in August 2014, she said to herself: “Why are you selling yourself short here? [You] can do this job.” She applied for it and was named dean in April 2015.

 published in a student newspaper at Findlay University after she was named dean, Parker stressed that the pharmacy program’s “family focus” is a distinguishing factor; it also makes her “confident and comfortable” in her role as dean.

Joy Vreeland, PharmD, BCPS, director of inpatient pharmacy at Boston Medical Center, had an uncle who was a pharmacist. That inspired her decision to work as a tech at CVS Pharmacy during her senior year of high school.

“I got a little taste of what retail pharmacy looks like,” she said. “The techs were wonderful. I had a lot of customer interaction. I thought, ‘This seems like it would be a good fit for my long-term interests.’”

That was before she understood the role of a hospital pharmacist. While she was a student at Northeastern University, she had a work experience in the intravenous room at Boston Children’s Hospital, where she helped treat very sick patients. “That was like a whole new world,” said Vreeland, who described the experience as “invigorating.”

She grew more certain about a career in hospital pharmacy in her last year of pharmacy school during a clinical rotation. That’s where Vreeland witnessed pharmacists working side by side with nurses and doctors in the treatment of patients.

Vreeland continues to make an impact at Boston Medical Center. “The easiest way to describe how great Joy is to describe the operation she runs,” said David Twitchell, PharmD, MBA, vice president and chief pharmacy officer at Boston Medical Center. “The [Boston Medical Center] inpatient and clinical pharmacy programs are [in my opinion] among the best in the country by any metric…The [Boston Medical Center’s] team shines because of Joy’s leadership.”

Firmly planted in Sebastian, Florida, for 37 years, Bay Street Pharmacy is owned by Theresa Tolle, BPharm, FAPhA, a pharmacist, and her husband, Joe.

The pharmacy is a short drive from Walgreens Pharmacy and Sebastian Discount Pharmacy. When asked how Bay Street Pharmacy thrives in the midst of heady competition, Tolle said she works hard to maintain relationships in the community. She registers the pharmacy to sponsor the American Cancer Society’s Relay for Life, is active in the local chamber of commerce, and serves on the board of the local hospital.

It helps that many of her employees have been at the pharmacy for 15 years or more, Tolle said. While she followed in her aunt’s footsteps as a pharmacist, she also spent years learning about working with customers at her parents’ feed store.

Tolle is past president of the Florida Pharmacy Association. In March, she starts her term as 2021-2022 president-elect of the American Pharmacists Association before she takes the reins as the organization’s president in March 2022.

Infectious Diseases Pharmacist Tackling COVID-19

Kaitlyn Rivard, PharmD, BCPS, an infectious diseases clinical pharmacist at Cleveland Clinic in Ohio, was 13 years old when she realized she wanted to be a pharmacist. At the time, her aunt had just graduated from pharmacy school. “She was a young professional. I liked that she was able to support herself and be independent, and she always genuinely liked her job. I wanted to be just like her,” she said.

She typically fills her days at Cleveland Clinic working collaboratively with physicians to select the timing, dosing, and the right combination of antibiotics to treat patients. Always in Rivard’s sights is making sure that drugs are used safely.

But she hasn’t been doing her day job at Cleveland Clinic since November. That’s when Rivard started leading the health system’s COVID-19 vaccination response from a pharmacy standpoint. At first, she thought her days would be spent managing the vaccine supply. Instead, because inventory is scarce and the need is so acute, she has been plugged into all aspects of the vaccination process, including deciding how many vaccination bays are required and keeping an eye on day-to-day operations.

Elizabeth Gooking Greenleaf, who started an apothecary shop in Boston in 1727, is recognized as the country’s first female pharmacist.

 As a mother of 12, she certainly embraced “leaning in,” as do the pharmacists featured here.

Although there is more work to be done to close gender gaps, women are increasingly breaking ground in pharmacy leadership. According to the 2019 National Pharmacist Workforce Study, of the actively practicing pharmacists who were in management positions in 2019, 58.8% were female, compared with 40.5% in 2009.

 Today, women are serving as pharmacists behind the counter, in team-based care at the patient bedside, and in boardrooms, as well as tackling the logistics to ensure an end to the deadly COVID-19 pandemic.

Surely, Greenleaf would be proud of the accomplishments of women in pharmacy today. But despite strides, a gender gap remains. To further advance women in the profession, continued mentorship and leadership development will be key.

Brown L. Years of rampant expansion have imposed Darwinian survival-of-the-fittest conditions on US pharmacy schools. 

Stubbs S. Debra Parker selected as new dean for the College of Pharmacy. The Pulse. April 7, 2015. Accessed February 6, 2021. 

https://pulse.findlay.edu/2015/uncategorized/news/debra-parker-selected-as-new-dean-for-the-college-of-pharmacy/

Women Pharmacist Day spotlights important contributions, accomplishments of female pharmacists. News release. PR Newswire. October 3, 2018. Accessed February 8, 2021. 

https://www.prnewswire.com/news-releases/women-pharmacist-day-spotlights-important-contributions-accomplishments-of-female-pharmacists-300723013.htm

American Association of Colleges of Pharmacy, American Pharmacists Association. 2019 National Pharmacist Workforce Study, Executive Summary. January 10, 2020. Accessed February 8, 2021. 

https://www.aacp.org/sites/default/files/2020-03/2019_NPWS_Executive_Summary.pdf

During Women’s History Month, we celebrate the achievements of women in pharmacy practice. 

Women in Pharmacy Making Strides to Close the Leadership Gap

Educating patients about the healing properties of lavender oil and reminding them to get flu vaccinations are 2 examples of advice that pharmacists can share on social media. But before doing so, securing buy-in from top management is essential, said Joey Mattingly, PhD, PharmD, an associate professor at University of Maryland School of Pharmacy in Baltimore.

Mattingly, who has 15 years of experience engaging in social media in the pharmacy field, was a pharmacy technician early in his career. A director-level leader at a large for-profit company near his employer didn’t like one of Mattingly’s social media posts about health policy and tried to get him fired. Mattingly emphasized that he wasn’t blogging on behalf of his employer and didn’t mask his identity online. He also kept his job, because of a leader in his organization who helped guide Mattingly in his career.

Choosing the right online platforms for engagement is a good first step, said Mattingly, who added that Facebook is a great tool for a variety of audiences.

Mattingly advises pharmacies to be mindful of patient privacy. Although a patient can send tweets or post publicly to the pharmacy on Facebook about medical history, the pharmacy must respond off-line, he explained. He recommends that patients call the pharmacy instead.

Joe Moose, PharmD, a clinical pharmacist and co-owner of Mount Pleasant, North Carolina–based Moose Pharmacy,tells pharmacies to use Hootsuite, a software program that allows users to schedule posts and push them out to multiple social media platforms. He hires young people—some are high school students—to post on the pharmacy’s social media account. They understand the technology, he explained.

Creating a content calendar helps, added Moose. Still, he tells employees at Moose Pharmacy’s 8 locations to watch for special moments to capture for social media. For example, a customer came in praising the pharmacy for saving her cat. That’s a perfect story for social media, said Moose.

Theresa Tolle, BPharm, FAPhA, a pharmacist and owner of Bay Street Pharmacy in Sebastian

, Florida, recently chose to work with an agency to develop her social media strategy. The agency is well established in the pharmacy field, and she learned about its work at an industry trade show. Tolle also checked references among the agency’s current clients.

One thing that persuaded her to work with the agency was that it sent her free material for social media posts. For example, some posts helped remind customers to wear masks during the coronavirus disease 2019 (COVID-19) pandemic, said Tolle. The agency also helps craft posts to timely events relevant to patients, such as open enrollment periods, and national awareness days like World Diabetes Day (November 14), and even World Kindness Day (November 13) and National Nachos Day (November 6).

Focus on Established Science; Avoid Politics

Pharmacies should focus on using social media to share evidence-based information.

For example, although wearing a mask to prevent the spread of COVID-19 has become politicized in some parts of the country, Moose insists that pharmacies should use social media to advise customers and patients to wear them. “Wearing masks saves lives,” he said.

If a patient disagrees in a post on the pharmacy’s Facebook page, the best way to handle it is to respond like this, said Moose: “Thanks for your response. We want to keep our community healthy. We think masks are a way to do that.”

Pharmacists share tips for engaging with patients online.

Social Media for Your Pharmacy

s the pandemic dominates headlines, the United States continues to face another major public health crisis—the opioid epidemic.

One bright spot is at Boston Medical Center, where the city’s safety net hospital’s pharmacy team has reduced inpatient opioid use among surgical patients by 41% since 2017 and cut discharge opioid prescribing for surgery patients by 25%. The initiative involved pharmacists across the hospital’s ambulatory, inpatient, 

Kevin Horbowicz, PharmD, BCPS, associate director of inpatient clinical pharmacy services, described witnessing the opioid overdose epidemic as his driving force. “It was very central to us at Boston Medical Center… where it’s having a big impact on our patients, many of whom struggle with opioid use disorder and other disorders,” he said.

Success depended on coordinating with the hospital’s information technology team and more than 20 surgical specialties. Today, surgeons can order sets in the electronic health record that prompt them to prescribe agents such as acetaminophen to manage patients’ pain.

included procedures such as abdominal surgeries, which tend to involve large incisions and “a lot of pain,” said David McAneny, MD, the medical center’s chief surgical officer. He was so impressed by how well using agents such as angiotensin-converting enzyme inhibitors and acetaminophen managed postsurgical pain that he supported including all surgeries in the program.

In line with this effort, the hospital was implementing the enhanced recovery after surgery (ERAS) protocols, McAneny said. This multimodal, multidisciplinary approach to the care of surgical patients includes surgeons, anesthesiologists, and surgical care staff. ERAS protocols generally include minimally invasive approaches rather than large surgical incisions, and early mobilization.

Before this initiative, even a patient with mild pain would typically be discharged with 60 to 90 oxycodone pills, Horbowicz said. That’s dangerous for an individual who might become dependent or whose medication is accessible to other household members, he explained.

Pharmacist participation during rounds with the surgical team is key, McAneny said. The pharmacist can provide insight on topics such as appropriate medications, when to 

stop antibiotics, and when to switch from an intravenous to an oral route. McAneny, who mostly performs endocrine surgery, said he hasn’t prescribed opioids for postsurgical recovery in 10 years.

He also emphasized the importance of patient education. For example, McAneny tells patients who have had thyroid surgery that neither oxycodone nor acetaminophen will take away the resulting sore throat, which should subside by the end of the day.

Developing a consensus among more than 20 surgery subspecialties proved the most difficult part of implementing the program, according to Horbowicz. The fields of orthopedics, plastic surgery, and trauma have very different needs, he said. 

Another challenge involved scheduling a meeting with the chair of neurosurgery to discuss the program, he added. Still, he highlighted Boston Medical Center’s “collaborative, multidisciplinary culture,” with physicians, nurses, and pharmacists working well together. “That was part of the secret sauce,” Horbowicz said. 

As a result of Horbowicz’ leadership, Boston Medical Center’s Opioid Utilization Improvement Team won the Pharmacy Health-System Award from the Massachusetts Society of Health-System Pharmacists.

Pharmacists, nurses, and physicians work together to combat the overuse of powerful pain relievers.