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

Frieda Wiley, PharmD

The long reach of the COVID-19 pandemic has engulfed every industry, including pharmacy. Although many industries have worked to adapt or survive, the variety of issues affected by the pandemic has triggered positive shifts in community pharmacy practice overall, according to Bri Morris, PharmD, senior director of program development at the National Community Pharmacists Association (NCPA) in Alexandria, Virginia.

Across the country, many pharmacists have long been waiting to practice closer to the top of their licenses. These emerging trends offer community pharmacists unprecedented opportunities to do exactly that. Here are some potential pharmacy trends to watch in 2022.

Expect to See an Uptick in Point-of-Care Services

Community pharmacies increased their point-of-care testing services during the pandemic—a feat that Morris says many pharmacists have “embraced…to meet their patients’ immediate needs.”

“Now that so many pharmacists have [obtained] their CLIA [Clinical Laboratory Improvement Amendments] certificates of waiver and introduced COVID-19 testing into their regular practice, there is an opportunity to branch into other acute infectious disease and chronic disease management,” Morris told Drug Topics®. “In many states, pharmacists are able to test and treat these patients for minor ailments as well.”

Immunization services have been trending in pharmacy for years, and the surge in recommended infectious diseases immunizations has only increased patient demand. Yet despite the apparent opportunity, providing these services remains a significant pain point for pharmacists on the front line, who often operate under the mounting pressure of meeting high prescription volumes with minimal staff support. Morris, though, is optimistic that recent technological interventions and logistic strategies have helped alleviate some of the pressure.

“Now community pharmacies have adopted scheduling platforms and designed a staffing workflow to integrate immunizations into pharmacy workflow,” she said. “Gaps still exist in routine immunizations for both adults and children, and community pharmacies can meet those gaps.” The numbers speak for themselves: As of November 9, 2021, community pharmacies and federal programs had administered and reported nearly 163 million doses of COVID-19 vaccines, according to data collected by the NCPA. This number does not include the data for vaccine doses administered and reported by state-administered programs.

The soaring demand for immunizations has expanded roles for pharmacy technicians. Much like the pharmacist’s role, that of pharmacy technicians’ has evolved over the years, and the concept of expanding the services that technicians provide is not new either.

 The COVID-19 pandemic led to the declaration of the Public Readiness and Preparedness (PREP) Act. Initially enacted by Congress on December 30, 2005, the PREP Act endows the secretary of the Department of Health & Human Services with the authority to declare the act whenever an emergent event poses a threat to public health.

In the pharmacy world, the PREP Act allows medical professionals to engage in the provision of services that may exceed their ordinary scope of services under usual circumstances, in an effort to address the shortage of responders and improve the availability of services and resources.

 On February 2, 2021, Acting Secretary of the Department of Health and Human Services Norris Cochran moved to amend the PREP Act declaration for the COVID-19 pandemic to define the list of individuals able to prescribe, dispense, and administer vaccines. The amendments culminated with one defining pharmacy technicians as “qualified persons” able to administer the seasonal influenza vaccine to adults in the state in which they are legally allowed to practice.

Secretary Xavier Becerra was responsible for the final amendment, which also grants pharmacist interns similar authority to administer seasonal influenza vaccines to the adult population. The act also allows pharmacy technicians to facilitate point-of care testing during the pandemic. Both pharmacy technician–provided immunizations and point-of-care services require pharmacist supervision. Morris anticipates that these services temporarily allowed by the PREP Act are the gateway for an entire suite of services that pharmacy can expect to fall under technician ownership.

“This expansion of scope combined with increased workforce demands brings about new roles for pharmacy technicians,” Morris said. “Medical billing specialist, immunization administrator, med sync [medication synchronization] lead, and community health worker are just a few of the titles we can expect technicians will have in the coming years.”

“With more than 10,000 Americans aging into Medicare daily, providing medical-at-home services to keep patients who might otherwise be in a nursing home in the familiarity of their homes is a patient care no-brainer, and many pharmacies are currently caring for these patients,” Morris explained. “Currently, the incentives and payment don’t match the effort.”

However, Morris anticipates that the historically poor reimbursement for the services that pharmacies provide will change with services that allow patients to age in place. For example, a new clinically integrated network focused on helping patients age in place, combined with advocacy efforts led by NCPA’s long term care division, helps pharmacies capitalize on potential business opportunities.

 NCPA has asked the Centers for Medicare & Medicaid Services (CMS) to formally “recognize medical at-home pharmacy services regardless of where the patient resides.” The Community Pharmacy Enhanced Services Networks (CPESN) USA started CPESN At-Home, a new network that contracts for enhanced services designed to address the needs of patients. Such patients would otherwise be candidates for a nursing facility, including those who are homebound, have trouble accessing a pharmacy, or require some level of caregiving assistance.

“You, as the pharmacist, are able to provide the same level of care that that same patient would receive in the nursing home, but you’d provide it at their home,” Morris said.

Improvements in a pharmacists’ longstanding battle for formal recognition by the US government and payors as health care providers continues, and with that comes the challenge not only of seeking compensation but also of gaining respect. However, a 2021 article by Deloitte, The Pharmacist of the Future,

suggests that a lack of the latter may prove advantageous from an accessibility standpoint.

“Pharmacists are not seen as authority figures the way that doctors are seen,” said an anonymous educator and research scientist who was quoted in the article.” [I]in a way, that’s probably sad, but what it means is that the pharmacist is more approachable than the doctor, and that can be really useful.”

The article’s authors also highlighted how pharmacists’ approachability, coupled with frequent patient contact, automatically enhances the opportunity to build trust. The patient-pharmacist rapport establishes a gateway into the patients’ worlds, with pharmacists able to form a bond that allows them to take a deep dive into their patients’ experiences and collect vital problem-solving information.

Being central figures in the health care equation uniquely allows pharmacists to identify additional resources for their patients and help them navigate the health care system. Watching these and other trends unfold over the past year suggests the consulting firm’s crystal ball is quite clear. Only time can tell how the industry will truly take shape.

Articles

As change continues to sweep the industry, we take a closer look at the trends that may be coming to a pharmacy near you.

2022 Pharmacy Trends

Diversity and inclusion remain a hot topic, but the embers that continue burning into the American conscience far transcend race and ethnicity. Like minority communities, the LGBTQ+ community also wrestles with its own struggles as another medically underserved population smoldering under the ashes, and pharmacists and other health care professionals who serve the LGBTQ+ community are working to establish methods to address these patients’ needs better.

“Historically, the barriers to care for LGBTQ+ individuals are complex and encompass many determinants,” said Tam Phan, PharmD, AAHIVP, assistant professor of clinical pharmacy and clinical pharmacist at the Jeffrey Goodman Special Care Clinic at the USC School of Pharmacy in Los Angeles, California.

The underlying barriers hindering access to health care in the LGBTQ+ community are numerous. Discriminatory practices such as patients having been refused care simply because they are LGBTQ+ and individuals lacking access to affordable health care due to uninsured status (as a result of family rejection, unemployment, and requiring services not covered by insurance) are a few examples.

The number of individuals identifying as LGBTQ+ is on the rise, having increased from 3.5% in 2012 to an estimated 4.5% in 2017 in the United States, with millennials (defined here as individuals born between 1980 and 1999) as contributing to the majority of the uptick, according to Gallup.

Not only do these statistics indicate a growing number of those who identify as LGBTQ+, but they also highlight an opportunity for health care professionals to ensure the provision of inclusive services for this patient population. Pharmacists play an important role in the health care system and can work to address the health disparities that exist for their LGBTQ+ patients.

The factors that compromise health outcomes in the LGBTQ+ community mirror those famously noted in communities of color and exacerbate health disparities by amplifying medical mistrust within the community. Examples include societal stigmas and discrimination.

The sources interviewed for this article did not reach a consensus regarding pinpointing the most significant barrier to creating a quality health care experience in the LGBTQ+ community. However, all cited the lack of awareness regarding population-specific health challenges and negative health care provider interactions as underlying contributors in preventing the LGBTQ+ patient from experiencing an equitable and quality health care experience.

“In a busy clinic or health setting, there will be many staff members who can interact with the patient—all of [whom] can either affirm or hinder the patient’s experience,” Phan said. “In many cases, problems can come from simple oversights or mistakes [from health care staff] who lack understanding—patients having reported hearing jokes or slurs and/or having received insensitive criticism about their appearance or behavior.”

Scott Nass, MD, MPA, a family physician based in Santa Rosa, California, noted that only in recent years has this started to change.

“In this context, we can’t ignore the fact that homosexuality and gender dysphoria were, for so many years, pathologized by organized health care,” he said. Only recently has so-called conversion therapy been widely condemned.”

Nass also serves as the president of Health Professionals Advancing LGBTQ Equality (GLMA) and noted that survey data indicate that more than half of lesbian, gay, and bisexual respondents and nearly 3 out of 4 (70%) of all transgender and gender-nonconforming individuals reported having experienced some degree of discrimination when using the health care system.

Another element amplifying the complexities of serving the LGBTQ+ lies in the community’s diversity, as it transcends many other cultural identifiers such as race, ethnicities, religious affiliation, and socioeconomic class.

These complexities include lack of access to quality health care, lower rates of health insurance coverage, failure to routinely and comprehensively include questions about sexual orientation and gender identity in health surveys and other data collection, and lack of consistent nondiscrimination protections for LGBTQ+ individuals in health care, workplace, housing, and other areas of everyday life.

Although HIV/AIDs is often associated with LGBTQ+ health, the community faces increased risks for many other conditions beyond this infectious disease. LGBTQ+ face greater risks for substance use, obesity, cancers, sexually transmitted diseases, and cardiovascular diseases than the general population.

In particular, those who are gender transitioning encounter compounded complexities and often find themselves at increased risks for some of these health challenges.

“This process often involves hormone replacement therapy that helps in physical transformations, such as the development of breasts, widening of hips, and growth of facial hair, etc,” explained Maria Perez, PharmD, AAHIVP, a clinical pharmacist at Gateway Apothecary in St. Louis, Missouri. “Although these are desirable developments, some patients may develop [adverse] effects such as obesity and cancers or overdose by adjusting their medications.”

Mental health conditions affecting the community deserve special attention, as the circumstances under which the LGBTQ+ population grows up often weigh on their mental, emotional, and psychological health throughout their lives. Children are more prone to bullying, isolation, rejection, depression, and suicide than the general population and are more likely to report suicidal ideations (30% vs 6%; 

 < .0001) and engage in self-harm (21% vs 6%; 

 < .0001) than their heterosexual and non-transgendered counterparts. In addition, LGBTQ+ patients may face societal ostracism, which also predisposes them to circumstances that threaten their health and livelihood early in life. For example, LGBTQ+ youth comprise 40% of all young individuals who experience homelessness.

Unfortunately, inadequate data collection contributes to the inequities affecting the medical treatment for those who identify as LGBTQ+. Many state and national surveys fail to include questions regarding sexual orientation and gender identity.

The health issues impacting the community affect all members—regardless of age. However, LGBTQ+ youth wrestle with their own set of challenges, including increased susceptibility to substance abuse, sexually transmitted diseases, cardiovascular disease, obesity, cancers, isolation, bullying, rejection, depression, anxiety, and suicide.

Establishing Best Practices for Inclusive Care

Despite the barriers hindering the provision of LGBTQ+-inclusive care, sources say there are several steps clinicians and their organizations can take to better serve the community.

For example, Perez’s institution encourages patients to self-identify. The practice allows patients to express how they want to be addressed by elucidating the pronouns they prefer.

Phan also recommends incorporating certain elements into the practice setting that members of the LGBTQ+ community often seek out as indicators that the care they receive will meet their needs. Pharmacists can assess their practice site for nondiscrimination policies. 

Assessment may include examining whether specific needs are met in the daily course of practice, including the following:

Does the practice site include gender-neutral bathrooms?

Are questions on the registration forms and electronic health records tailored to collect information for this demographic?

Is Your Pharmacy Inclusive of the Transgender and Gender-Diverse Community?

The American Pharmacists Association and Human Rights Campaign Foundation recently released a new guide for pharmacies on transgender and gender-diverse inclusion. The guide, which was released on International Transgender Day of Visibility on March 31, serves as an educational tool and resource for pharmacists and pharmacy staff on how to be inclusive to transgender, nonbinary, and gender-diverse patients.

According to the guide, the 6 qualities of a pharmacy that are inclusive of transgender, nonbinary, and gender-diverse individuals are:

To help address mental health concerns, Perez encourages her pharmacist colleagues to establish a rapport with patients by engaging them in conversation. The discussions might reveal mental or psychological challenges.

“The feelings of rejection, unacceptance, confusion, and loneliness are common in this patient population,” she said. And such feelings can lead to psychiatric illnesses such as depression and anxiety, among many others. “A simple conversation can open up a [larger] conversation,” she added. 

Perez recommends pharmacists ask their patients the following questions:

To determine whether patients warrant referral:

“Do you feel little interest in doing things?”

“Are you feeling down and hopeless?” (

a component of Patient Health Questionnaire-2, a screening tool for depression)

Nass and Phan agree that continuing education ranks among some of the most critical strategies organizations can implement to help ease clinician bias and improve patient trust by building a better rapport. For nearly 40 years, the GLMA has offered its 

. The conference is just one of the organization’s initiatives aimed at improving LGBTQ+ health, and its programming includes workshops and research presentations for pharmacists. Phan emphasizes that all health care professionals must take steps to improve their ability to serve the LGTBQ and that these efforts begin with introspection.

“I think it starts with a reflection and reassessment of individual practice and conduct and then [transitions] to reflect on practice policies applied to all workers,” he said.

He encourages pharmacists to educate themselves and their colleagues about LGBTQ+-inclusive care, such as terminology and various social and health disparities. Once this has been accomplished, clinicians can then devise a plan to address these topics in their practice settings. Phan also noted that customizing care for this patient population often requires interdisciplinary and external collaboration, engaging the LGBTQ community itself to learn about patients’ individual experiences and needs.

However, education, training, assessment, and exploration are only part of the work. Successful implementation and practice of such LGBTQ+-inclusive policies require cadence and an ongoing commitment. Institutions must periodically reevaluate their new politics to determine how the practice has changed and the degree of effectiveness.

Check out the following materials for more information on providing LGBTQ+-inclusive care:

Learning resources from the National LGBTQ+ Health Education Center: 

https://www.lgbtqiahealtheducation.org/resources/

Transgender and Gender Diverse Pharmacy Resource Guide

 from the Human Rights Campaign Foundation and American Pharmacists Association: 

https://www.thehrcfoundation.org/professional-resources/transgender-pharmacy-guide

Providing LGBTQ-Inclusive Care and Services at Your Pharmacy

 from the Human Rights Campaign Foundation: 

https://www.thehrcfoundation.org/professional-resources/providing-lgbtq-inclusive-care-and-services-at-your-pharmacy

Newport F. In US, estimate of LGBT population rises to 4.5%. Gallup. May 22, 2018. Accessed May 1, 2021. 

https://news.gallup.com/poll/234863/estimate-lgbt-population-rises.aspx

Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health care disparities among lesbian, gay, bisexual, and transgender youth: a literature review. 

. 2017;9(4):e1184. doi:10.7759/cureus.1184

Lesbian, gay, bisexual, and transgender health. HealthyPeople.gov. Updated October 8, 2020. Accessed April 30, 2021. 

https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health

Human Rights Campaign Foundation, American Pharmacists Association. 

Providing Inclusive Care and Services for the Transgender and Gender Diverse Community: A Pharmacy Resource Guide

https://hrc-prod-requests.s3-us-west-2.amazonaws.com/Transgender-Pharmacy-Resource-Guide.pdf?mtime=20210331072012&focal=none

Addressing the needs of LGBTQ+ patients requires insight, innovation, and introspection.

 Advancing LGBTQ+-Inclusive Care: How Pharmacists Can Better Support Patients

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.

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. 

Add value by optimizing medications, decreasing pill burden.