Karen Berger, PharmD

 project delved into the fascinating world of pharmacogenomics. Stephanie Davis, PharmD, BCACP, part-owner of Goodrich Pharmacy in Anoka, Minnesota, worked on the project with Elise Durgin, PharmD, BCPS, and Emily Hulke, PharmD, who were residents at the time.

Davis and her team have collaborated with CPF in the past and generally participate in many projects. “We had the idea to perform and interpret pharmacogenomic testing, and when we have a new idea and need help financially or with a collaboration, we reach out to CPF for a grant and to make sure the program is sustainable,” she explained.

Initially, the plan was for a 12-month study on pharmacogenomic testing in patients taking opioids. However, at the 9-month mark, only 3 patients had enrolled in the study. Davis explained that some of these patients were afraid that their test results would lead to their physician taking away their opioids.

With CPF approval, the team decided to shift their focus to mental health care, which attracted many referrals from primary care providers in the area. Candidates were patients who were unsatisfied with their mental health treatment due to adverse effects (AEs) or ineffective medications.

Effectively Integrate Certified Pharmacy Technicians Into Your Workflow

How did the process work? Hulke explained that after receiving a referral for pharmacogenomic testing, she set up an initial appointment with the patient. During this appointment, the pharmacist or resident performed a full comprehensive medication review, including current medications and previous medications and what occurred when the patient took these medications.

Althouh pharmacogenomic testing might not reveal all of their answers, the team explained to patients that it could provide a piece to the puzzle in helping to identify the most appropriate medication. After obtaining consent, they took a cheek swab from the patient and sent the sample to OneOme for testing. 

The resulting lab report provides information on the genes that may affect how the patient responds to certain medications. For example, in an ultrarapid metabolizer of a particular enzyme, a drug metabolized by that enzyme may not work, or the patient may need higher doses to achieve the desired response. On the other hand, a poor metabolizer may have an increased risk of AEs.

For example, citalopram is metabolized by cytochrome P450 (CYP) 2C19, which reduces activity in the body. An ultrarapid metabolizer of CYP2C19 would have lower levels of citalopram in the plasma and thus a higher probability of medication failure with citalopram. On the other hand, a CYP2C19 poor metabolizer would have higher levels of citalopram in the plasma, and patients would be more likely to experience AEs from this medication.

The pharmacists and residents would consider the patient’s entire profile, looking at enzyme pathways for all of their medications, and provide the report, along with a recommendation, to the patient’s physician. The results of the testing were also discussed with each patient individually.

The results of the project varied. “The majority of patients liked having this information. It made them not feel like guinea pigs––like there was more information being used to decide which medication they should take rather than just throwing different medications at them,” Hulke explained. “They felt empowered and wanted to know more, even if the reports didn’t show exactly what they wanted or expected.” Moreover, the physicians were grateful for the information and interpretation of results, and many patients ended up on a different medication as a result of the report and recommendation.

Insurance coverage for the test kit varied, as did coverage for the interpretation, which could be billed as an office visit or medication therapy management (MTM) visit. Goodrich Pharmacy pharmacists are hopeful that billable opportunities will increase in the future.

Even though the grant has ended, the pharmacists at Goodrich Pharmacy still offer pharmacogenomic testing services and interpretation. In addition to adults, they have had an increasing number of referrals for pediatric patients with attention deficit hyperactivity disorder.

In addition to gaining a wealth of knowledge about mental health medications, the pharmacists and residents learned about other drugs from pharmacogenomic testing, too. For example, “[clopidogrel (Plavix)] is a prodrug that is converted to its active metabolite through the 2C19 pathway,” Davis explained. “In patients who are poor metabolizers of 2C19, [clopidogrel] would not be as effective, leading to a higher risk of cardiovascular events. The patient would have to take [ticagrelor (Brilinta)] or a different antiplatelet medication.”

Hulke mentioned that many medications could be affected by enzymes, such as warfarin, which is metabolized by multiple enzymes, and protein pump inhibitors like omeprazole. However, there isn’t always a change in medication therapy that is recommended because of this.

Can pharmacists apply pharmacogenomics to their practice? Absolutely, but it may take a lot of studying, Davis and Hulke said.

They recommend obtaining a pharmacogenomics certificate, which can be done through programs such as the 

National Association of Chain Drug Stores’

 “Test2Learn” program. Pharmacists can also attend conferences and classes on the topic for more information. By doing so, pharmacists can help patients make sure their medications are working based on genetics.

Davis and Hulke have a call to action for pharmacists. “Never stop learning. Pharmacogenomics is a great service we can offer to our patients,” Davis said.

“If you are interested in and passionate about pharmacogenomics, take the time to learn about it and consider offering it as a service to your patients,” Hulke added.

 funds innovative ideas to advance the practice of pharmacy in the community setting. CPF is committed to transforming community-based pharmacy practice beyond filling prescriptions to a focus on providing patient care as a founding sponsor of the national 

Articles

A community pharmacy team built a pharmacogenomic testing program for patients with mental health disorders. 

Community-Based Pharmacogenomic Testing in Mental Health Care

In the United States, there were over 67,000 drug overdose deaths in 2018.

 Of these, about 70% were due to opioids.

 According to the CDC, from 2006 to 2017, there was a greater than 19% decrease in annual opioid prescribing, suggesting that “health care providers have become more cautious in their opioid prescribing practices.” 

As the most accessible health care providers, pharmacists are in a unique position to help patients find ways to treat pain without opioids.

As pharmacists, we may immediately start thinking about pharmaceuticals when a patient asks for a recommendation. However, pharmacists can counsel on both OTC and prescription medications, as well as other nonpharmacologic measures. When appropriate, encourage the patient to see a specialist to discuss nonopioid alternatives such as massage, physical therapy, acupuncture, injections, or nerve blocks, or even surgery.

When recommending medication for an adult aged 65 or older, it is prudent to check the 

 to ensure the medication is safe and appropriate.

 Checking a drug interaction database is also prudent in ensuring safety at any age. 

In terms of nonopioid medication for pain relief, acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) is a good starting point.

: Acetaminophen can help patients with mild to moderate pain. Counsel patients on maximum dosage, avoiding alcohol, and liver toxicity. Caution against combining products that contain acetaminophen, such as cough and cold products.

: NSAIDs are available in many OTC and prescription products and can help patients with mild to moderate pain and inflammation from various conditions. Those with gastrointestinal (GI) concerns may fare better with prescription celecoxib, a COX-2 inhibitor, which has fewer GI adverse effects (AEs). Patient counseling can include the risk of GI bleeds, perforation, and ulcers; hypertension; kidney problems; and cardiac thrombotic events.

 Medications such as gabapentin and pregabalin are often prescribed for nerve pain. Counsel patients on the risk of sedation, the possibility of suicidal thoughts and behavior, and the risk of misuse.

 Patient counseling on antidepressants should always include the risk of 

. In addition to reviewing the drug’s AEs with the patient, it is prudent to mention withdrawal symptoms due to abrupt discontinuation, and the importance of a tapering schedule when the drug will eventually be discontinued.

 and drugs that can interact with antidepressants (eg, triptans, opioids, muscle relaxants, St. John’s Wort, and dextromethorphan) can help prevent a life-threatening serotonin buildup.

: TCAs can be useful in chronic pain and nerve pain. In addition to the counseling points above, pharmacists can also counsel patients on the anticholinergic AEs: dry mouth, dizziness, sedation, memory problems, orthostatic hypotension, urinary retention, and cardiac conduction abnormalities.

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

: SNRIs such as duloxetine or venlafaxine can help various pain conditions, like nerve pain or fibromyalgia, and have fewer side effects than TCAs.

Selective serotonin reuptake inhibitors (SSRIs)

: SSRIs such as fluoxetine or escitalopram are effective as antidepressants but have less of an effect on pain relief than other classes of antidepressants.

 are sometimes used for muscle pain and spasms. In these patients, counseling on AEs and drug interactions is essential, as well as the importance of short-term use.

Several community pharmacists shared their experiences in talking to patients about pain relief. Trisha Winroth, PharmD, pharmacy manager at Walgreens in Lowell, Massachusetts, has plenty of recommendations she shares with her patients. “In community pharmacy, there aren’t many things that top the satisfaction of helping a patient in pain. Pain can and does affect a patient’s life in every way, from productivity to personal relationships, from sleep to work capacity. Helping a patient resolve pain will ensure you a trusted patient-pharmacist relationship forever,” she explained.

Winroth finds it helpful to offer solutions that she has personally tried, which adds more trust to the recommendation. Winroth noted that chronic pain patients “often dislike pharmacies and pharmacists because we've been put in the position to police narcotics and pain medications for years. Through corresponding responsibility, good faith dispensing, and a plethora of lawsuits and board of pharmacy cases, pharmacists must act judiciously to ensure prescriptions meet a number of requirements that often remove of us from a true patient care role.”

She reminds pharmacists to remember that caring for patients is of utmost importance. “Spending a few minutes listening and offering suggestions can be the difference between true patient care and merely a dispensing gatekeeper role,” Winroth said.

Some of the go-to products she recommends include:

ice packs, eye masks, and MigreLief supplements for headache and migraine,

lidocaine patches (remind patients to remove for 12 hours) or roll-on for sciatica or back pain.

Anne Henriksen, PharmD, is the pharmacist and owner of Malley’s Compounding Pharmacy in Richland, Washington. For nerve pain, Henriksen recommends a supplement that contains the methylated and active forms of B vitamins. She noted that “since opiates do not work for nerve pain, patients with nerve pain are typically very willing to try alternatives to alleviate their pain,” and this product helps a great deal with nerve pain. “Our pharmacists often recommend this supplement even before a prescription medication is started,” she said, noting that a local neurologist puts all of his patients on the supplement before starting any prescription medication for nerve pain.

Henriksen finds that many of her patients who take opioids are eager to learn more about OTC options for pain management. “As a compounding pharmacist, I often recommend low-dose naltrexone (LDN) for pain,” Henriksen said. “Naltrexone works with the body's inflammatory system to reduce pain levels. There is a growing body of evidence to support the use of LDN in pain and other disease states, and a conversation about LDN is worth having with any chronic pain patient.” Henriksen also recommends that her patients try cannabidiol (CBD) products, especially topicals with menthol, that “provide the familiar cooling relief of menthol but has the added healing and anti-inflammatory benefits of the CBD and herbs.”

Elaine Richer, RPh and CEO of MyCureAll, has 25 years of community pharmacy experience and now focuses her practice on CBD and medical cannabis. “Because cannabinoid receptors, unlike opioid receptors, are not located in the brainstem areas controlling respiration, lethal overdoses from cannabis and cannabinoids do not occur,” she explained. Richer noted that medical cannabis is becoming a popular alternative for patients who do not want to take opioids or cannot tolerate them. Richer advises talking to patients about CBD or medical cannabis. “Studies show that medical cannabis is effective for pain. In combination with opioids, medical cannabis can enhance pain relief and lower the incidence of side effects and overdoses from opioids. Patients are often able to lower opioid doses or taper to discontinuation.” She indicated that CBD or cannabis can help the patient reduce opioid use without the risk of overdose and relapse, providing a safe alternative treatment for pain and other conditions. 

With many treatment options, pharmacists can be a valuable resource to patients who require pain relief. By listening, understanding, and counseling, pharmacists can make a meaningful difference.

CDC. Drug Overdose Deaths. Last updated March 19, 2019. Accessed February 11, 2021.

https://www.cdc.gov/drugoverdose/data/statedeaths.html

CDC. Changes in Opioid Prescribing Practices. Last updated August 13, 2019. Accessed February 11, 2021. 

https://www.cdc.gov/drugoverdose/data/prescribing/prescribing-practices.html

American Geriatrics Society. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate medication use in older adults. Last updated November 2015. Accessed February 11, 2021. 

https://www.guidelinecentral.com/summaries/american-geriatrics-society-2015-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults/

US Department of Health and Human Services. Pain Management Best Practices Inter-Agency Task Force Report. Last updated May 9, 2019. Accessed February 11, 2021. 

https://painmed.org/wp-content/uploads/2021/01/pmtf-final-report-2019-05-23.pdf

Pharmacists can counsel on prescription and OTC options, as well as nonpharmacologic measures. 

Discussing Pain Management Options With Patients

Tanvee Thakur, PhD, BPharm, recently completed a project with the 

 (CPF) focused on enhancing transparent opioid education.

Thakur is currently a scientist at RTI Health Solutions. At the time of the project, Thakur was pursuing her PhD at the University of Wisconsin-Madison School of Pharmacy. During this time, Thakur recalled talking to pharmacists about the opioid crisis and the importance of patient education, but observed that very few providers were truly engaging with patients about the risks of opioids.

Through more discussion, Thakur realized that “both patients and doctors wanted pharmacists to educate patients about opioids, but pharmacists were sometimes unsure how to discuss this sensitive topic without sounding accusing,” she said. Thakur thought that a patient handout would help both pharmacists and patients discuss opioids.

Working with Betty Chewning, PhD, FAPhA, as a co-principal investigator, Thakur developed a handout for pharmacists to assist in counseling on opioid prescriptions. Pharmacists could use the handout during counseling to highlight important information, guide essential talking points, and distribute to the patient with a reminder to call with any questions. 

After using the handout during patient counseling, the pharmacist would fill out a survey to answer questions such as:

Do you feel more confident in counseling?

The research was done at 3 pharmacies (2 rural and 1 urban): Hayat Pharmacy in Milwaukee, Wisconsin and 2 Reedsburg Medical Center community pharmacies 

Thakur and Chewning analyzed 57 real-time surveys of pharmacists who used the opioid handouts. Pharmacists reported that using handouts in conjunction with counseling was the most helpful method, but the most important thing was just making an effort to talk about opioids. “It is up to the individual comfort of the pharmacist on which way to use the handout, but pharmacists felt more satisfied when they addressed opioid risks and safety, rather than avoiding the topic,” Thakur said.

“On the patient side, it was like a normal counseling session,” Thakur explained. The hardest part was finding pharmacists to participate, as many were too busy. Still, we had a few amazing pharmacists who participated and made sure the surveys were completed,” she said.

Although Thakur was not sure what to expect in terms of results, she noted that she was pleasantly surprised. Along the lines of adding more time, she mentioned how busy community pharmacists can easily incorporate opioid counseling. Pharmacists can access the handout from the CPF website. “Even though there is limited time to counsel, pharmacists can take 40-50 seconds and make a brief statement. We can show patients that we care about their safety by saying, ‘I care about you and your loved ones being safe. That’s why I’m telling you this medication is an opioid and has overdose and dependency risks.’

We can explain that opioids should only be used as prescribed, then disposed of safely to keep the patient and the patient’s family safe. Then remind the patient to read the handout at home and call if questions arise. This takes less than a minute and is a wholesome approach to patient education,” Thakur explained.

The CPF, led by Anne Marie (Sesti) Kondic, PharmD, executive director, is a non-profit organization dedicated to advancing community pharmacy practice and patient care delivery through grant funding and resource sharing.

Tanvee Thakur, PhD, BPharm, recently completed a project focused on enhancing transparent opioid education. 

Pharmacist-Led Project Targets Opioid Education and Safety

Two pharmacists recently completed a series of unique projects in collaboration with the Community Pharmacy Foundation (CPF) to address the opioid crisis in their communities.

, recently completed 2 projects with the help of CPF focused on the integration of community pharmacists into contingency management and opioid education. 

Throughout her experience in hospital pharmacy and clinical practice, Dragatsi became acutely aware of the unaddressed needs relating to adverse drug effects (ADEs) or interactions that undermined treatment goals.

Knowing she wanted to help patients in these situations, Dragatsi went on to earn her BCPS and formed her own company, 

As a consultant pharmacist, Dragatsi studied the most complex patient medication lists from all over Maine. She soon identified almost $50,000 worth of preventable ADEs in 11 patients. This discovery led Dragatsi to form new relationships with practice sites and federally funded health care centers.

“I saw an opportunity to perform innovative pharmacy practice...but needed to figure out how to do this in a financially viable way,” she said.

Dragatsi submitted a grant proposal to CPF on integrating pharmacists into the medication review process and addressing ADEs. The grant was approved.

Within just 1 week of beginning the project, Dragatsi became keenly aware of the opioid crisis’s effects on her community. New legislation forced patients to taper off opioids, but the patients needed help. Dragatsi incorporated this into her project.

“I accumulated a treasure trove of new clinical information centering around effective OTC medication use in patients as part of self-care when tapering off opioids,” Dragatsi said.

In the polypharmacy patients, Dragatsi was able to identify $280,890 worth of preventable adverse effects and reduce some of the concurrent medication use. In patients with chronic pain, there was a 43.3% reduction in morphine milligram equivalents due to patient self-care education.

Dragatsi applied (and was approved) for a second CPF grant to further tackle the opioid problem. “I knew that there was a need for pharmacists to be educated and integrated into the medication-assisted therapy process meaningfully, and to know how to reduce stigma using new terminology,” she said.

Dragatsi had many goals as part of this project, including:

creating a 17-month calendar of self-care clinical pearls, such as the beneficial impact of smoking cessation and OTC self-care tips on opioid tapering;

surveying pharmacists for baseline knowledge about 17 clinical pearls;

producing patient leaflets (with project support by 

educating pharmacists based on survey data, using written and live continuing medical education courses.

However, early in the project course, Dragatsi faced a major hurdle.

“I was diagnosed with a highly invasive and rare form of breast cancer,” Dragatsi shared. “I was not expected to live very long after project completion.” Her colleagues, 

Stephanie Nichols, PharmD, BCPS, BCPP, FCCP

, and Megan Jennison, PharmD, provided crucial project support during the treatment phase. “Day by day, my strength and cognitive acuity returned,” Dragatsi said.

In terms of results, Dragatsi observed that all of the material provided to patients “really contributed to patient resilience. This is beneficial for countering hypertension, high cholesterol, and bacterial and viral infections,” she said. She also emphasized that as pharmacists, we tend to focus on prescription drugs, often overlooking the benefits of OTC medications. “In the OTC realm, there is a lot of patient benefit to be realized,” she said.

In this project, Dragatsi was able to personally help 22 patients taper down and off of opioids by working closely with providers and using OTC products. Overall, Dragatsi & Co. assisted over 100 patients in tapering opioids.

Today, Dragatsi is “enjoying full health, strength, and cognition with no signs of the end of my remission.” She credits working on the CPF projects as part of her cancer recovery.

So what can pharmacists do in practice to help patients as Dragatsi did? Dragatsi recommends pharmacists think about how to take a few minutes to achieve maximum effect. “Work smart, not hard. Teach patients how to invest in personal resilience, and make their day better as well as your own for having done so,” she said.

Elizabeth Dragatsi, RPh, BCPS, worked on 2 projects integrating community pharmacists into contingency management and opioid education.  