Frieda Wiley, PharmD, BCGP, is a writer and pharmacist. 

Frieda Wiley, PharmD

Stories about independent pharmacies not offering COVID-19 vaccines have flooded the local media in places like Philadelphia, Pennsylvania, and Colorado, but a different story is being told on the East and West coasts.

“Independent pharmacies and pharmacy owners can get the vaccine faster because it’s easier for them to communicate with county and city officials,” said Miguel Oseguera, CPhT, owner of Familia Farmacia in Modesto, California. “In fact, we get a lot of customers from chain pharmacies because they can’t get the vaccine there.”

Less than 2 weeks after having met with local government officials, Oseguera received his first batch of the COVID-19 vaccine. He believes the personal interaction helped increase his chances of getting the supply in his store.

Hossein Ejtemai, RPh, who owns Brookville Pharmacy and Wellness Center in Chevy Chase, Maryland, is still waiting for his first shipment, but he is ready to begin administering the vaccine as soon as it arrives. “I can vaccinate up to 500 patients a day if I get a vaccine,” he said.

Ejtemai has a plan that will allow him to immunize patients quickly and efficiently. His current strategy is to vaccinate 25 to 50 patients at the same time. His pharmacy has 2 rooms that can be used for the mass immunizations, where patients will be able to maintain a safe social distance. Each room will hold scheduled immunizations at least an hour apart.

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Store owners offer tips for supplying and giving shots.

Independent Pharmacy’s Best Kept Secret in Administering COVID-19 Vaccines

Complementary and alternative medicine (CAM) has grown steadily over the last decade but surged in popularity in 2020—likely due to the coronavirus disease 2019 (COVID-19) pandemic.1 According to the results of a survey conducted by the Council for Responsible Nutrition, users cited overall immune support (57%) and health/wellness benefits (53%) as the most common reasons for increasing their supplement intake.1 With many individuals seeking additional ways to stay healthy, pharmacists are ideally positioned to help educate patients on the appropriate use of these products.

Despite the uptick in CAM use, misconceptions abound among health care professionals, including pharmacists. Two integrative pharmacists seek to dispel these myths and offer their colleagues tips to improve their ability to assist their patients in navigating complementary and integrative care.

"The biggest myth about CAM I keep hearing from medical professionals is that CAM and herbal products don't have evidence behind clinical use," said Marina Buksov, PharmD, health coach, nutritionist, and clinical herbalist based in Brooklyn, New York. "I think because of the lack of education, health care professionals and patients alike are wary of herbal medicine, and there's a general consensus that it's potentially dangerous to use—guilty until proven innocent."

For Hossein Ejtemai, RPh, owner of Brookville Pharmacy and Wellness Center in Chevy Chase, Maryland, the misconceptions surrounding CIM seem to be demographic- and geographic-based.

"People often think there's a [cultural] gap with CAM because people from overseas—especially from the Asian culture—are more likely to use supplements, natural products, and natural remedies," he said. "The younger generation in this country is also changing to CAM because of access to information [via the internet].”



Pharmacists Offer Key Counseling Points for CAM

To optimize their patients' experience with CAM, Ejtemai said pharmacists should seek training.

"Health care professionals are [generally] aware of CAM but most medical professionals, including pharmacists, lack sufficient training in CAM,” he said. "The 3 credits you get in pharmacy school is not enough to assist your patients."

Pharmacists looking to expand their knowledge can choose from numerous certifications, many that are available online and take 6 to 18 months to complete. "Get certified to better educate your patients," Ejtemai said. The Institute for Integrative Nutrition, Duke University, and The George Washington University are among the institutions that offer programs.

After developing their CAM skills, pharmacists should keep several key concepts front of mind when counseling patients on CAM. Most importantly, pharmacists should take the time to ensure patients understand when and how to use these products.

"Natural products have a place in both Eastern and Western medicine, but you have to keep in mind that natural products are generally better for prevention than treatment," Ejtemai explained. "You cannot treat a disease with natural products in the late stages."

Ensure patients understand that, unlike many conventional medicines that often show results in a few days or weeks, natural products can take several weeks to months to work.

Below are more recommendations for pharmacists seeking to educate their patients on CAM use.

Use trustworthy sources to conduct your research.

"It's important to look to reputable resources on topics that we don't have enough education on," Buksov said. She recommends Lexicomp, the Natural Medicines database, and 

 by Memorial Sloan Kettering Cancer Center.

Educate patients taking nutrient-depleting medications on the importance of supplementation.

For example, Ejtemai recommended counseling patients taking metformin on the importance of vitamin B12supplementation to potentially ward off diabetic neuropathy.

Consult with a practitioner, educator, or

researcher who is an expert in the topic about which you are seeking information.

Conventional medicine has exchanged peer reviews for evidence-based medicine, but the sometimes nebulous nature of CAM sometimes warrants peer consultations.

Dietary supplement usage up dramatically during pandemic, new Ipsos-CRN survey shows. News release. Council for Responsible Nutrition. August 20, 2020. Accessed February 6, 2021. https://www.crnusa.org/newsroom/dietary-supplement-usage-dramatically-during-pandemic-new-ipsos-crn-survey-shows

Alternative healing approaches and therapies become increasingly popular among consumers. 

Pharmacists and Patients Navigating Complementary and Integrative Medicine 

Miguel Oseguera, CPhT, got his start in pharmacy by sweeping floors. Although he worked his way up to becoming a pharmacy technician, the first-generation Mexican American never envisioned owning his own pharmacy, let alone bridging the gap in culturally com- petent health care. But that is what happened in summer 2019, when he opened the doors to Familia Farmacia, which serves the Hispanic community of Modesto, California.

Oseguera saw an opportunity to fill a void when the only independent pharmacy in the South Modesto neighborhood

 closed after 34 years. The area, in California’s Central Valley nearly 100 miles from San Francisco, has a largely Mexican and Mexican American population.

“Let's face it: No chain pharmacies or other big businesses were going to come to this area,” he said. “Most of the businesses here are independently owned.”

Oseguera’s pharmacy has features that attract Hispanic patients, one being its location in their neighborhood. In addition, the staff provides service in English and Spanish, something Oseguera emphasized is essential in establishing strong patient rapport.

“Speaking the language is enough already,” he said. “But it’s also an important way to develop a sense of trust that helps your patients relate to you.”

Oseguera, a Modesto-area native, said his cultural ties give him another advantage. “I was born here and raised with Mexican values so that I can relate to the people here,” he said.

Not only are most of Oseguera’s patients Mexican or Mexican American, but many hail from the same region as his family, Michoacán. He equates the high concentration of immigrants from Michoacán in the Modesto area with those from Ireland, Italy, or Asian countries moving to specific regions.

The pharmacy’s inventory and layout reveal another draw for Oseguera’s patients: One wall houses a vast collection of prepackaged herbs used in traditional home remedies in the Mexican culture.

Oseguera’s initiatives are logical and appropriate to address health challenges in diverse populations, according to 

® Editorial Advisory Board member Lakesha Butler, PharmD, BCPS, clinical professor of pharmacy practice at Southern Illinois University Edwardsville.

Members of minority populations “understand the history of medical racism and mistreatment of people of color in this country, enduring it ourselves,” said Butler, who is African American. “This understanding often translates to providing compassionate care and advocating for minoritized communities.”

Innovative Pharmacist Uses Social Media to Reach Minority Populations

Frank North, PharmD, MPA, president-elect of the National Pharmaceutical Association and founder of Frank North and Associates, has dedicated his career to addressing disparities in the African American community. His family history—North’s father was among the first African American students to earn a PhD from the University of Colorado in Boulder—and professional goals illustrate a principle of cultural competency: valuing diversity.

“Many think all people of African descent have the same culture, but African Americans have their own subcultures within their families and throughout different regions of the United States,” North said. “Also, African American culture differs from Africans’ culture from other countries such as Ghana or Europe.”

As a clinical pharmacist for the Rowe Network, a company founded by Tisha Rowe, MD, North uses social media to reach out to African American patients. The company engages patients using a telemedicine network called RoweDocs. North addresses access and adherence issues. He also directs users to other health care providers.

“I try to connect with folks on social media and establish a rapport so I can direct them to health care services provided by people who look like them,” North said. 

Social media is hugely influential in the Black community. According to a 2020 report from Pew Research, 8 of every 10 Black social media users consider it an effective platform for raising awareness of social and political issues.1 Seven of 10 Black social media users view it as a useful tool in influencing decisions. The statistics in Hispanic and Asian communities are similar, and White social media users trail by roughly 10% in each category.

RoweDocs also disseminates information regarding health initiatives such as diabetes month

, breast cancer awareness, and the American Heart Association’s Go Red for Women. Prospective patients visiting the website may subscribe to the company’s newsletter, watch videos, and read blogs. The website also encourages users to leave comments—a feature North said creates opportunity for additional interaction.

Improving Health Literacy Helps Pharmacist Reach Non-English Speakers

Donney John, PharmD, uses his role as executive director of NOVA ScriptsCentral, a nonprofit pharmacy in Falls Church, Virginia, to improve health literacy in non-English-speaking communities. Like other charitable pharmacies across the nation, NOVA ScriptsCentral’s mission is to help underserved populations. John’s organization is predominantly grant-funded and focuses on providing uninsured patients prescriptions at little to no cost.

NOVA ScriptsCentral site users can choose to have the web copy translated from English into Spanish, Portuguese, Chinese, French, Hindi, or Vietnamese. The pharmacy’s efforts to connect with these patient populations do not stop there.

This year marks the launch of the NOVA ScriptsCentral’s Diabetes Access Pilot Initiative 2021

. NOVA ScriptsCentral will offer free insulin to uninsured patients who receive care at any of the 16 clinics with whom the pharmacy partners in northern Virginia.

“Virginia passed a law where the maximum co-pay for insulin is $50,” John told 

®. “This does nothing for people who have no insurance because they always pay cash.”

In addition to generating revenue from donors, NOVA ScriptsCentral is registered as a pharmacy allowed to accept old medications patients bring in and dispense them to others in need. John referenced a charitable pharmacy in California that dispenses medications it has repackaged from physician samples. However, he said, such a practice is illegal in many states. Other states observe a Good Samaritan law that allows them to engage in such activities to improve medication access for patients in need.

John traces his mission to his childhood, growing up among diverse cultures in New York City. Eventually, he would practice as a pharmacist working with underserved communities at a federally qualified health center in Boston. These experiences helped him recognize cultural nuances among minority communities.

“If people of color don’t have access to the right medical care or understand their health, they’ll never improve their health,” he said. “To change their behavior, you must first understand the people and where they’re coming from.”

Despite the efforts of Oseguera, North, and John, and other like-minded pharmacy professionals, Butler said pharmacy practice has yet to master authentic cultural competence.

“Unfortunately, cultural competency in pharmacy has only scratched the surface in addressing the pertinent factors contributing to health disparities,” she said. “There has been a significant gap in addressing racism in pharmacy and health care, resulting in health inequities that persist.”

For example, the coronavirus disease 2019 (COVID-19) pandemic challenged many aspects of the health care system while magnifying disparities regarding access to care, supplies, and mortality in minority communities.

“You see a level of disbelief about the coronavirus and the hesitancy around getting the vaccine that’s more prominent in communities of color—especially in African American communities,” North said. “Minority groups tend to respond better to health care providers who look like them, have their best interest at heart, and are able to break down barriers.”

Unfortunately, the odds that a minority patient can navigate the health care system by only interacting with minority professionals belonging to their communities is statistically impossible

. Consequently, all health care providers and clinicians must improve their skills in serving patients outside their own communities.

Butler emphasized the importance of building trust when bridging cultural gaps, regardless of whether the health care professional shares the same background.

“Patient-provider trust is critical when serving communities of color,” she said. “Trust can be built by addressing unconscious biases, using inclusive language that does not cause further marginalization, and taking the time to build relationships with communities of color, to name a few.”

In the meantime, pharmacies that serve minority communities remain steadfast in their efforts. “If we don’t help our people, who will help our people?” Oseguera asked.

For more information on cultural competency and the pharmacies mentioned in this story, please see the following resources:

http://www.hpoe.org/Reports-HPOE/becoming_culturally_competent_health_care_organization.PDF

Auxier B. Social media continue to be important in political outlets for Black Americans. Pew Research Center. December 11, 2020. Accessed January 7, 2021. https://www.pewresearch.org/fact-tank/2020/12/11/social-media-continue-to-be-important-political-outlets-for-black-americans/. 

Pharmacy professionals serving minority populations aim to bridge gaps in health care access.

Culturally Competent Care Fights Health Disparities

It is no secret that psychiatric conditions may predispose individuals to various comorbidities, including migraines. Similarly, patients with migraines tend to have a higher risk of developing psychiatric complaints.

The complexity of treating migraines is amplified when the patient also has psychiatric comorbidities. The spectrum of presentation and symptomatology in this population subset creates a prime opportunity for pharmacists to make sizeable contributions in managing these conditions.

Migraine Management Inundated with Complexity, Challenges

Migraine management in patients with psychiatric conditions must take into account the complications that plague both disease states.

“Compliance and adherence are the biggest pitfalls because studies have shown that patients [with psychiatric conditions] are more likely to over- or underuse [medications],” said 

, a postdoctoral fellow in the department of pharmacy practice and translational research at the University of Houston College of Pharmacy in Texas.

Both disease states can have severe consequences. Taking a nonsteroidal anti-inflammatory drug (NSAID) or triptan either more frequently than prescribed or at a higher dose can trigger migraines—a phenomenon known as medication overuse headache.

Conversely, medication underuse has its own set of hurdles, which El-Desoky finds particularly challenging when trying to optimize therapy in patients with migraines. Such is the case with prophylactic migraine therapy, which typically takes 4 to 12 weeks before symptoms start to improve. Often discouraged by not experiencing immediate results, many patients either stop taking prophylactic medications regularly or discontinue them altogether.

Poor adherence can give rise to a prescribing cascade, and the increasing complexity of the patient’s drug regimen can often worsen outcomes. Because patients with psychiatric conditions often have multiple prescriptions, adding migraine therapy can become a delicate balancing act when trying to prevent issues related to polypharmacy.

“The key here is to optimize the patients’ medications and decrease the pill burden,” El-Desoky said. She recommends choosing a preventative migraine medication that also can address other comorbidities the patients have. Venlafaxine makes a good choice for a patient who has posttraumatic stress disorder in addition to migraines. Nortriptyline and amitriptyline ease insomnia and depression as well as migraine symptoms.

Some medications routinely used in migraine management are not appropriate for certain psychiatric conditions. For instance, β-blockers and the calcium channel blocker verapamil can worsen depressive symptoms and should be avoided in patients with depression, according to Lama Al-Khoury, MD, associate clinical professor of neurology 

at the University of California, Riverside, School of Medicine.

Serotonin-norepinephrine reuptake inhibitors (SNRIs) should be avoided in patients who have bipolar disorder because they can trigger hypermanic episodes. Instead, a mood stabilizer such as divalproex sodium (Depakote) may be a better choice. Al-Khoury warns against the use of divalproex in women of childbearing age because of its teratogenicity.

Medications that can potentiate serotonergic effects, including serotonin syndrome, should be avoided or used with care in patients with migraines. Al-Khoury advises pharmacists to educate patients taking antidepressants/serotonergic medications to limit using abortive therapies such as triptans to no more than 2 days per week to prevent their serotonin levels from surging to dangerous limits. El-Desoky encourages pharmacists also to look for less-obvious culprits such as cyclobenzaprine and tramadol.

Experts say pharmacists have numerous opportunities to enhance patient care in this patient population.

 Even when questioned directly, a patient’s migraine or psychiatric condition can affect their ability to remember their medication history. As a result, they may forget to mention a medication or supplement. The negative stigmas associated with migraine and psychiatric conditions may cause some patients to omit the frequency of intake. Pharmacists’ access to prescription records and their increased patient interaction can help bridge the gap. 

“It’s always appreciated when pharmacists flag potential interactions in patients who may not be as forthcoming with all [their] medications, along with the frequency and dosing,” said Cristina Wohlgehagen, MD, a headache specialist and neurologist at Texas Health Presbyterian Hospital Dallas.

. The accessibility and frequent patient-clinician interaction make pharmacists excellent resources for providing patient information. Pharmacists can remind patients about potentially bothersome symptoms and teach them to recognize signs of harmful adverse effects (AEs).

The teaching aspect proves particularly critical with regards to improving adherence. El-Desoky urges her colleagues to ensure patients understand the importance of taking prophylactic medications regularly as prescribed and emphasizing it may take up to 12 weeks before their symptoms improve. Patients should leave the encounter understanding the importance of not skipping doses.

 Both El-Desoky and Al-Khoury encourage patients to keep headache diaries to document the frequency, time, and resolution of their migraines.

Consider nonpharmacological options when possible.

 “Pharmacological therapy is not appropriate for every patient—especially patients [with psychiatric conditions] who are already taking many medications and struggle with [adherence],” Al-Khoury said.

In some cases, this might entail investigating underlying causes of a patient’s migraines. Stress triggers migraines in 70% of those with the condition.

Patients facing insomnia and sleep disruption may benefit from a sleep study. “Sleep is critical, and a sleep study should be conducted when obstructive sleep apnea is suspected because you can sometimes avoid medications in these patients,” Al-Khoury said. Helping patients modify their daily habits, lifestyle, and sleep may be the only tool they need to gain control of their migraines. Al-Khoury sometimes uses melatonin or other insomnia treatments in patients with migraines and insomnia. 

 Migraine management in patients with psychiatric disorders is highly complex and variable. Clinicians should customize treatment based on the individual patient’s comorbidities, preferences, socioeconomic situation, lifestyle, and other circumstances.

Enacting weight management strategies is especially important in patients who are depressed and have poor body image. It may make sense to avoid initiating antimigraine therapies that also cause weight gain in patients who are already overweight. Tricyclic antidepressants should be avoided in such patients. If patients suffer from migraines in addition to depression and anxiety, venlafaxine makes a suitable substitution, as it is less likely to cause weight gain. Duloxetine and gabapentin should be avoided altogether.

 Monitoring is critical in this patient population, as many medications have bothersome AEs or other challenges. For example, high-dose venlafaxine therapy can raise blood pressure, and the pharmacist should follow up with patients when they refill their prescriptions or visit the pharmacy for other reasons.

Similarly, pharmacists’ recurring patient encounters offer numerous opportunities to assess the patient’s progress and reinforce adherence. El-Desoky recommended encouraging patients to use pill boxes and medication organizers. Although mobile device apps, phone messages, and alarms can also serve as helpful reminder tools, El-Desoky noted that her patients experienced greater benefit from making medication charts.

“I’ve made charts for patients to check off whether they took their meds,” she said. “From what I’ve seen, visual aids tend to be the most effective in helping people remember to take their meds.”

Despite the continued push toward collaborative practice, the health care industry remains largely fragmented regardless of the profession. Even with the prevalence of migraines in patients with psychiatric conditions, fewer than 1% of psychiatrists treat them.1 Similarly, pharmacist-physician interactions generally remain rare.

“I have rarely seen multidisciplinary interactions between pharmacists and physicians outside large academic facilities where you tend to have neurologists, psychiatrists, and pharmacists on board,” Al-Khoury said.

Despite this hurdle, El-Desoky seems optimistic and encourages pharmacists to capitalize on in-pharmacy services and any other opportunities to demonstrate their value and ability to educate patients and other health care professionals.

“Every facility has an opportunity for pharmacists and other practitioners to present their knowledge,” she said. “Tell them, ‘I’m here and able to help.’”

Cascade E, Kalali A, Smitherman T. Treatment of migraine and the role of psychiatric medications. 

The basics of headache medication & overuse. The Migraine Foundation. June 11, 2016. Accessed October 1, 2020. 

https://americanmigrainefoundation.org/resource-library/medication-overuse-headache/

Maleki N, Becerra L, Borsook D. Migraine: maladaptive brain responses to stress. 

2012;52(suppl 2): 102-106. doi:10.1111/j.1526-4610.2012.02241.x

Add value by optimizing medications, decreasing pill burden.