As 2019 draws to a close, let’s look back at some of the top pharmacy news stories of the year.

The increasing price of insulin has been widely reported in 2019. Patients are traveling to Canada in search of cheaper insulin; many report rationing insulin to make it “last longer.” Insulin prices have tripled in the last decade; manufacturers are under pressure to lower prices.

Novo Nordisk, Sanofi, and Eli Lilly are the three biggest suppliers of insulin worldwide. All three companies have announced plans to attempt to lower costs in the near future, through authorized generics, manufacturer coupons, and discounted prices.

As the price of insulin has skyrocketed, insurance companies are getting involved. In April, Cigna and its PBM, Express Scripts, announced a new program for patients with diabetes in the commercial plan that would limit the copay of a 30-day supply of insulin to $25.

After cutting bonuses and making 2018 benefit changes, Walgreens said Q1 2019 was “difficult” and the company stated that it would save another $500 million per year (in December 2018, the company pledged to save $1 billion per year). Walgreens also said it would close 750 of the acquired Rite Aid stores, 150 more stores than first reported.

CVS also announced a slowing of expansion and plans to close 22 more stores next year. Fred’s Pharmacy announced that all remaining stores would be closing and the company filed for bankruptcy.

USP (US Pharmacopeia) General Chapter <800> went into effect on December 1.

Formally titled USP General Chapter <800> Hazardous Drugs-Handling in Healthcare Settings, it “provides standards for safe handling of hazardous drugs to minimize the risk of exposure to healthcare personnel, patients, and the environment.”

In the “Review of the Drug Enforcement Administration’s Regulatory and Enforcement Efforts to Control the Diversion of Opioids” released in September by the Office of the Inspector General, findings stated “that DEA does not capture sufficient data to detect the diversion of opioids or emerging drug trends in a timely manner.” The report states that despite the alarmingly increasing rates of deaths due to opioids, the DEA was allowing manufacturers to produce larger quantities of opioids, and that the DEA was “slow to respond to the significant increase in the use and diversion of opioids since 2000.”

The Sackler family, founders of Purdue Pharma, is being sued in thousands of cases. The family amassed a $13 billion fortune mostly from sales of OxyContin; they are accused of pushing OxyContin sales by deceiving prescribers and patients, even though they allegedly knew how dangerous and addictive the drug was. Purdue Pharma filed for bankruptcy in September.

Johnson & Johnson recently agreed to settle an Ohio opioid lawsuit for $20.4 million, and in August paid a $572 million settlement for its involvement in the Oklahoma opioid crisis. Several other companies are also facing lawsuits.

In 2019, CBD exploded in popularity. Cannabis research firm Brightfield Group projects CBD sales to exceed $5 billion by the end of 2019, a 706% increase from last year. The company projects that the CBD industry’s total market value could reach $23.7 billion by 2023.

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What Pharmacists Need to Know About COPD and Transitions of Care

Osteoarthritis is the most common type of arthritis, affecting nearly 54 million people. The condition causes a great deal of pain and distress, as well as limitations in daily activities and mobility, says Marcy O’Koon, senior director of Consumer Health at the Arthritis Foundation.

While opioids might seem to be an obvious solution, O’Koon says opioids are now discouraged-not just because of the nation’s opioid crisis and tightening access, but because there is a new recognition that they don’t work all that well. “Staying physically active and losing weight, if needed, are at the top of the list,” O’Koon says.

O’Koon recommends taking a 5- to 10-minute walk throughout the week and incrementally increasing the time and/or pace. Endurance will increase and the pain may recede over time. 

It’s also helpful to look at risks in groups. O’Koon points to CDC population surveys that have found that 50% of adults with heart disease and 50% of adults with diabetes have arthritis. “Those groups have double reason to be physically active. If they are over- weight and sedentary too, then overall health suffers.”

Pharmacists can help older adults who have osteoarthritis as well as heart disease. A major concern is that many of these individuals may be taking a lot of over-the-counter NSAIDs without their doctors’ knowledge.

A new study recently published in Arthritis Care & Research suggests there is a great need for improvement for man- aging older patients with arthritis. The study examined 2,297 physician visits for knee osteoarthritis and found rates for visits to orthopedists and physical ther- apists declined from 2007 to 2015. At the same time, prescriptions for NSAIDS and narcotics or opioids increased.

Lead author Samannaaz Khoja, PT, PhD, research assistant professor at the University of Pittsburgh School of Health and Rehabilitation Sciences’ Department of Physical Therapy says physicians tend to be more focused on helping patients manage their pain with medications, without considering the long-term benefits of exercise for mitigating declines in physical health. “Pain control should be just one aspect of treatment. The focus is mainly on pain medications; there should be greater emphasis on nonpharmacological approaches,” Khoja says.

Tom Bateman, PharmD, clinical assistant professor Ernest Mario School of Pharmacy Rutgers, The State University of New Jersey, New Brunswick, says because acetaminophen has a favorable safety profile when compared to alternatives like NSAIDs or opioid analgesics, it is considered the gold standard for treatment of osteoarthritis. The general principle of “start low, go slow” when dosing should be applied when recommending acetaminophen, says Bateman.

“If patients require additional pain control or if high doses of acetaminophen are not appropriate due to reduced hepatic function or alcohol use, then multimodal pain strategies can be used,” Bateman says. “Some would consider cannabis as a newer therapy. “

The Arthritis Foundation recently released the first CBD guidance for adults with arthritis. While there are no established clinical guidelines for CBD use, medical experts who worked in partnership with the Arthritis Foundation agree that CBD may help with arthritis-related symptoms; however, this has not been confirmed in clinical studies.

Osteoarthritis is the most common type of arthritis, affecting nearly 54 million people.

Encouraging Healthy Habits in Patients with Osteoarthritis

Technology has long pushed the limits of the possible in pharmacy. From the days of the best available lenses to help identify the seeds, flowers, and leaves that once provided the basic ingredients for most pharmaceuticals, to the latest in wearable electronics, technology has been a key driver in the effort to improve patient outcomes. All are changing the ways patients, pharmacists, and other providers work together to improve health

Instead of looking at pharmacy as physical stores or centralized call centers, Aspen RxHealth sees pharmacists as a community of providers serving patients who need their specialized knowledge and skills.

“Aspen’s software connects community pharmacists with clinical practice services, health plans, or patients who havesignedupfortheservice,”explains Carmen Catizone, MS, RPh, DP, executive director of the National Association of Boards of Pharmacy.

Humana is using Aspen to provide services for Medicare Advantage patients in the Tampa, FL area with plans to expand the program later in 2019. Aspen’s panel of community pharmacists will provide medication therapy management, patient education, and answer general questions about drug therapy.

Wearable pharmacy technology is a reality and it’s not just limited to consumer-oriented products like the FitBit or Apple Watch. For example, Amgen’s Neulasta (pegfilgrastin) is available in a wearable autoinjector for patients receiving chemotherapy.

The adhesive on-body injector is usually placed on the arm or abdomen immediately after the final chemotherapy infusion. The automated injector lets the patient rest at home instead of traveling back to a provider for one more injection and ensures that patients actually get the colony-stimulating factor to stimulate neutrophil production and reduce the risk of infection following chemotherapy.

The same repackaging machines that spit out strips of single tablets can be adapted to package multiple tablets to be taken at the same time in a single bubble.

For patients, packaging multiple medications together is added convenience; for pharmacies, it’s added profit.

“Why stop at packaging Rx meds that can be taken together?” asks Cliff Holt, PharmD, president of Hurricane Family Pharmacy in Gunnison and Hurricane, UT. “You can make things even more convenient for your patients by adding their regular OTCs and supplements to the same bubble as their prescription meds.

Regular fingerpricks, test strips, and glucometers to measure blood glucose levels are moving into history. Continuous glucose monitors (CGMs) let patients track glucose levels 24/7, upload data to their cell phones, and automatically send it to providers.

Direct involvement in outcomes makes a clear case for service-based reimbursement above and beyond device and medication reimbursement.

The Pharmacist eCare Plan (PeCP) is an interoperable standard that allows for a common method to exchange information related to patient care delivery.

“PeCP lets pharmacists document clinical services and patient activities that they have been doing for years,” says Lisa Schwartz, PharmD, senior director for professional affairs at NCPA. PeCP marks the first time pharmacy care data can be exchanged directly with other providers using an HL7 (Health Level Seven International Electronic Health Record) transaction.

“This communication standard lets pharmacists move beyond our siloed care team into the broader medical world,” Schwartz says.

Technology has long pushed the limits of the possible in pharmacy.

Technologies Moving Pharmacy Forward

Offering immunizations is a smart business move, especially for independent pharmacies. According to the 2018 

73% of community pharmacies now offer immunization services, although only a quarter of these pharmacies offer more than flu shots.

“Immunizations have actually become an issue of competitive parity,” says John Beckner, RPh, senior director of strategic initiatives at NCPA. “You can’t go to work for a chain these days without being certified to do immunizations. They make it mandatory for their pharmacists to do them. If you’re an independent pharmacist and you’re not doing them, you are really at a competitive disadvantage.”

Pharmacists are able to give flu vaccinations in all 50 states as well as Washington, DC and Puerto Rico, but a patchwork of state regulations govern which other vaccines can be administered, which protocol must be followed, and the minimum age patients must be before they can be immunized at a pharmacy.

A promising source of revenue for both chain and independent pharmacies is the inclusion of travel clinics that offer necessary CDC-recommended travel vaccinations, such as yellow fever, cholera, and malaria. States often put more restrictions around travel vaccines, such as needing a physician-signed protocol or prescription to administer.

“Practice acts are unlikely to look the same from one state to another,” says Jeffrey Goad, PharmD, MPH, professor and chair, department of pharmacy practice, Chapman University School of Pharmacy. “Within one state’s pharmacy practice act, that state can have very detailed regulations that describe which vaccines, which ages, and under which circumstances a vaccine may be given by a pharmacist.”

While some state details can cover pages, other states may have regulations that consist of a single sentence, authorizing a pharmacist to independently initiate and administer vaccines listed on the routine immunization schedules recommended by the federal Advisory Committee on Immunization Practices (ACIP), according to CDC guidelines, and on patients older than 3 years. 

“The US does not really have an oversight body or process for creating regulations specific to pharmacists in each state,” says Lauren Angelo, PharmD, MBA, assistant dean of academic affairs and associate professor of pharmacy practice at Rosalind Franklin University of Medicine and Science. “In some states, there are no restrictions on the types of vaccines or age limits.”

Given the absence of an oversight body or process, the trend to expand pharmacists’ authority is being enacted slowly, on a state-by-state basis.

The latest update to state regulations was enacted in October in North Carolina. The new regulations lowered both the minimum age for flu shots in pharmacies and added the authority to administer adult immunizations including: herpes zoster, hepatitis A and B, meningococcal, HPV, and tetanus. In 2018, Missouri lowered the minimum age requirement for immunizations from 12 to 7 years, if authorized by a physician; Iowa authorized vaccination, pursuant to statewide protocols, to any patient over the age of 6 months. Pennsylvania currently has a bill in committee that, if passed, would also lower the minimum age.

Authority to immunize has also been expanded during disease outbreaks, as was the case during the 2018 flu season when Governor Andrew M. Cuomo signed an executive order to let New York’s pharmacists administer flu vaccines to children from ages 2 to 18. The order was given in response to the rising number of reported cases-previously, pharmacists could only administer the flu vaccine to patients 18 and older.

“Laws and regulations are getting more friendly toward pharmacists immunizing,” says Beckner. “The restrictions tend to be either with age or certain vaccines and I think things are movinginthedirectionofpharmacists being able to give all the adult vaccines that the ACIP recommends. We have a way to go as certain states are more restrictive than others, but we’re definitely moving in that direction.”

States may grant authority to immunize independently, through a collaborative agreement or via a prescription. As of 2016, 17 states let pharmacists independently administer select vaccines, while the other 33 states, Puerto Rico, and Washington, DC followed other protocols.

“Collaborative practice agreements often take time and financial resources on the part of the pharmacist and physician to maintain,” says Goad. “States that require a prescription for certain vaccines definitely drive up the cost by requiring a patient to see the physician just to get a prescription for a vaccine that they then have to go to the pharmacy and have administered. The pharmacist still has to screen the patient for appropriateness even though there is a prescription.”

According to Mitchel C. Rothholz, RPh, MBA, chief strategy officer for the Amer- ican Pharmacists Association (APhA), the APhA vision for pharmacy-based immunizations is that pharmacists in every state should ultimately have the ability to administer any ACIP recommended vaccines. That goal is being realized on a state-by-state basis.

“Getting there is working with individual states, working closely in partnership with the National Alliance of State Pharmacy Associations (NASPA), and the state associations, trying to address this on a state level, working through what their priorities and needs are,” says Rothholtz.

Achieving the vision could benefit both pharmacists and patients. A study by the Pacific Research Institute suggests that letting pharmacists administer all adult vaccinations recommended by the CDC could help raise the vaccination rate and save lives. Statistics suggest that if immunizations are offered at convenient hours for patients (ie, at night, on weekends, and without having to make a doctor’s appointment), more people will get immunized.

That’s an important consideration-90,000 Americans die of vaccine-preventable deaths annually in the United States.

In the last 3 years, Idaho (2017), Rhode Island (2018), and Utah (2019) passed bills that allow technicians to immunize patients, freeing up pharmacists to focus on other services.

“When pharmacy technicians can immunize, under the supervision of the pharmacist, it frees the pharmacist to engage in other patient care or counsel- ing type activities,” says Beckner. “The role of the technician is expanding. They’re able to do more and more and they’re certainly able to do the technical tasks. That frees the pharmacist to do the cognitive functions and tasks that require judgment in the pharmacy.”

More states now also require pharmacists to report immunizations to registries, since digital records can help coordinate care among patients and multiple health professionals. All 50 states, US territories, and the District of Columbia have at least one regional or local immunization registry.

“People can access those registries and we can find out if somebody has gotten, say, dose 2 of the 2-dose series,” says Beckner. “If they forgot whether they got their pneumonia vaccine, the pharmacy can access the registry and find out without having to rely on the patient to provide that information.”

Another obstacle standing in the way of more vaccinations in pharmacies is training. While most graduates of pharmacy school have received immunization training, state laws don’t necessarily require it.

“Not all states specify training or even when they do, how much training or by what method,” says Goad. “That’s why state laws are antiquated as pharmacists follow the standard of practice which is the national training program or a program that mimics the CDC immunization training program. In addition, the school of pharmacy accrediting body stipulates that immunization training must occur. So, even with state law, the science and practice of pharmacy-based immunization has moved ahead. State laws are just out of date and can present an obstacle to people getting the vaccines they need, putting patient lives at risk.”

Offering immunizations is a smart business move, especially for independent pharmacies. 

State Laws and Vaccination Services

 asks pharmacists about their job experiences. In particular, we’re interested in what pharmacists are interested in: what’s the payment like for a pharmacist’s expertise, and how stressful is the job overall? 

As in previous years, we found that pharmacists are well paid, but also stressed out. So what’s stressing you out? The over 1,100 pharmacists

 surveyed cited everything from vaccination quotas to DIR fees to new USP regulations as their biggest concerns. While fewer pharmacists said that their stress levels increased at work this year compared to 2018, the number was still high: 61.08%.

As far as salary goes, pharmacists are largely making close to what they made last year (see Base Annual Salary). Looking at the beginning of the decade, however, the 2010 survey showed that the average salary was lower, with the majority (62.5%) reporting salaries in the $100,000-130,000 range. In 2019, nearly 40% made that amount, while nearly 50% said  they make over that $130,000 mark.

High stress levels aside, pharmacists are still, overall, fairly satisfied with their jobs. More than twice as many (18%) said they were “extremely satisfied” with their job compared to those who said they were “extremely dissatisfied” (9%) and the majority said they were either “very satisfied” or “satisfied.” On top of this, just 22% of pharmacists were looking for a new position in the next 12 months.

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Every year, Drug Topics® asks pharmacists about their job experiences. These are the results from the 2019 annual pharmacy salary survey. 

Salaries and Stress Stagnate: 2019 Pharmacy Salary Survey Results

 of opioid overdoses each day), pharmacists face a number of challenges: how do you keep potentially dangerous medications from those who abuse them while not making things overly difficult for the chronic pain patients who rely on them-all while maintaining a busy pharmacy?

While counseling is important, it’s difficult to do when there’s a massive backlog of unfilled orders. To help manage that, pharmacists at the recent NCPA convention in San Diego gave a talk titled “Caring for Patients on Opioids.”

In the talk, Lorri Gebo-Shaver, PharmD, owner of Shaver Pharmacy & Compounding Center in Pocatello, ID; Caitie Brown, PharmD, PGY1 community-based pharmacy resident for Idaho State University; Shanna O’Connor, PharmD, assistant professor, College of Pharmacy at Idaho State University; discussed how the pharmacy manages to help patients in the real world.

The first real step, O’Connor said, is to ask good questions. She said that it goes against what’s often done the pharmacy: the pharmacy is busy and pharmacists are overwhelmed, so they stick to largely yes/no questions to help speed along the process. She said in this case, however, it is important to ask open-ended questions that can help reveal a patient’s true situation.

In Idaho, pharmacists are able to prescribe naloxone, which Gebo-Shaver does for certain patients and has them sign a form acknowledging that she offered it to them-this creates a paper trail that helps protect her and her pharmacy, as well as shows the seriousness of the situation to the patient.

Even so, she said that “having that conversation at first is really hard.”

One of those hard questions involves naloxone-as Gebo-Shaver said, “How do you say appropriately what naloxone is for?” She said she compares it to epinephrine, saying that it’s something that can save your life in an accident-perhaps even for someone you don’t know.

She described one patient who, when offered naloxone, initially declined. But that patient then returned to her pharmacy the next day with his wife and son who he wanted to attend the training as well. He said that he had a friend recently pass away from an overdose, and was so thankful that the pharmacy was willing to take time to provide education.

), start by looking at pain holistically through a pain inventory. This can help the pharmacist make an informed decision about alternatives. As O’Connor said, “What got us into this situation is that we got very comfortable with very high doses of opioids,” so providing alternatives to those high doses is key.

The important thing to remember, Gebo-Shaver, stressed, is that the pharmacist isn’t the only one able to help. While technician duties vary by state, in Idaho where they are given more abilities, Gebo-Shaver says she sees herself as a quarterback in her pharmacy who is protected and helped out by a defensive line. (For states with weaker technician powers, she advocates reaching out to state boards of pharmacy and advocating for enhanced abilities).

O’Connor pointed to a workflow used to intake a new patient using an opioid monitoring form. With this form (

), as well as checking the state’s PDMP, O’Connor says most of the information can be collected before the patient’s packet gets to the pharmacist. This process also provides paperwork that can protect the pharmacist and create a record showing that patients were given correct counseling.

So, the speakers said, ask yourself questions such as “what steps does your state require be completed by the pharmacist, and what could be done by a technician or cashier?”

Utilizing a process that protects both patients and pharmacists doesn’t have to be time consuming-while it does take time, the speakers stressed that the more a pharmacist does it, the faster it goes.

Figures courtesy of Lorri Shaver, PharmD, Shanna O’Connor, PharmD, Caitlin Brown, PharmD, and NCPA

Practical tips to help keep patients safe.

Drug Topics December 2019

Top Pharmacy Stories of 2019

What Pharmacists Need to Know About COPD and Transitions of Care

Encouraging Healthy Habits in Patients with Osteoarthritis

Technologies Moving Pharmacy Forward

State Laws and Vaccination Services

Salaries and Stress Stagnate: 2019 Pharmacy Salary Survey Results

Opioids: The Pharmacist’s Role