When a nonadherent patient was admitted to the emergency department several times a month for several months, Kim Tran, PharmD, a pharmacist at the Community-University Health Care Center at University of Minnesota in Minneapolis, started meeting with him once a week. “During the first meeting, I introduced myself and my role on the care team and established goals with the patient,” she says. “Then we moved on to troubleshoot why he wasn’t meeting his health goals.”

The patient shared that he was a chronic alcohol user who also had a seizure disorder. When he drank, he would pass out and not take his antiseizure medications, which then led to having seizures that sent him to the emergency department, Tran recalls.

“We explored several ways that he could remain on his antiseizure medications even if he was not ready to stop drinking,” Tran says. “He first kept his medications in bottles by his bedside to try and remember, but found it difficult to recollect if he took the dose that day or not. Then, we tried placing weekly medications in a medication box, with each day written on it so the patient could tell if he took medication that day. By doing this and continuing weekly check-ins, the patient was in the driver’s seat of managing his own health. He was allowed to set his own goals and empower himself. This eventually led to decreased emergency department use because his seizures disappeared when he took his medications daily.”

A study in the journal Social Health estimated that poor medication adherence in the United States leads to $100 billion in healthcare expenditures annually. Because of the variety of services pharmacists provide, they have unique opportunities to work closely with patients to help them understand barriers to medication adherence and develop individualized plans that address those barriers, says Batoul Senhaji-Tomza, PharmD, MPH, assistant dean of curriculum and associate professor at Touro College of Pharmacy in New York. Here are nine methods to help nonadherent patients.

1. Assess why the patient is nonadherent.

“Before you can begin to help someone, you need to get to the root cause of why they stopped taking or are not taking their medications properly,” says Fernando Gonzalez, RPh, MS, assistant professor of pharmaceutical sciences at Long Island University Arnold and Marie Schwartz College of Pharmacy in Brooklyn.

According to a survey conducted by Express Scripts in collaboration with Russell Research, more than two-thirds of medication nonadherence is behavior-driven; it’s either caused by forgetfulness or procrastination. “Respondents stated that they didn’t want human intervention to correct these harmful behaviors and rated family members as the least effective source of medication reminders,” says Kyle Amelung, PharmD, BCPS, senior manager of clinical solutions at Express Scripts. “However, technology-based medication reminders are well-received, especially among adults under age 55.”
	Other common reasons why a patient may be nonadherent are busy schedules, substance abuse, depression, misconceptions about potential adverse effects or therapy outcomes, high cost, having a complex medication regimen, and low literacy, says Senhaji-Tomza.

Six Healthcare Technologies Coming in the Next Five Years

When conducting medication adherence assessments, pharmacists can address barriers by guiding patients by asking open-ended questions. For example, pharmacists can adopt a variation of the Morisky Medication Adherence Scale (MMAS). “The MMAS scale uses an eight-point scale of open-ended questions geared toward measuring specific medication-taking behaviors and attitudes,” Senhaji-Tomza says.

2. Review a patient’s medication plan with them.

When meeting with a patient, Tran says pharmacists should discuss each medication individually and highlight the reason for taking the medication, how it will help achieve health goals, possible side effects, and how the patient can obtain it and take it safely. The pharmacist should assess all of a patient’s current medications and how they interact, taking into consideration the patient’s individual lifestyle and health conditions. By doing a review, pharmacists may be able to find out if a patient isn’t adherent and why.

Counseling considers a patient’s lifestyle and diet based on region and culture. “These factors can have varying effects on the way a medication may behave in someone’s body,” Tran says.

Sarah A. Boswell, PharmD, a clinical pharmacist at Cherokee Health Systems in Knoxville, TN, is a proponent of using the teach-back method during counseling to determine if a patient comprehends the information she provides by having the patient summarize it. “If a patient understands their drug therapy and buys into it, they are much more likely to adhere,” she says.

A pharmacist can establish trust by answering the patient’s questions, being an attentive listener, and showing empathy to their concerns and feelings. “The patient will see you as a resource to help them improve their health and be more motivated to be accountable,” Boswell says.

Following up with patients helps ensure they’re meeting goals and that side effects and concerns are quickly addressed. “Through frequent followups, trust is formed and relationships are built,” Tran says. “Once patients trust a pharmacist and they start meeting their health goals, they are more likely to continue with the current therapy.”

Effective communication is born out of effective listening. “It can be tempting to only provide information; however, starting with open-ended questions enables a pharmacist to learn more about a patient’s specific difficulties and tailor any counseling to that specific situation,” says Clark Kebodeaux, PharmD, BCACP, clinical assistant professor at the University of Kentucky College of Pharmacy in Lexington, Kentucky.

Tran emphasizes that pharmacists use accessible and respectful language to help patients understand health issues and how medications and lifestyles contribute to and treat each disease state. “When needed, we use interpreters who are more familiar with a patient’s individual culture and are able to help pharmacists understand more about a patient’s lifestyle, such as meal choices,” she says.

Tran says she sets all goals together, such as laboratory goals (such as A1c or blood pressure) and the patient’s personal goals (such as running a mile or playing with grandchildren). As laboratory goals start to improve, patients may feel physically better. “With each encounter, we revisit goals and assess whether or not the patient has achieved them. If not, the care team assesses how to adjust the goal and make it more achievable,” she says.

Many consumers are tech savvy and embrace opportunities to use technology. Express Scripts, for example, has capitalized on mobile health applications that allow patients to review medication lists, set reminders, and receive clinical messaging and coaching sessions from certified healthcare professionals. “Patients can even add over-the-counter medications and herbal or dietary supplements to their profile, allowing medication interactions to be flagged based on their complete medication list,” Amelung says. “These tools are also leveraged during physician and pharmacy visits, which leads to better health discussions and decisions at the point of care.”

To promote clinical engagement and greater adherence, Express Scripts offers a game-like approach to medication management. “Through a mobile application, patients can accumulate points and earn rewards by logging health data and achieving medication goals,” Amelung says.

“Our data show that improved clinical engagement equates to better care experiences, better health outcomes, and lower costs year-over-year.”

One way to help patients save money is for pharmacists to help Medicare Part D patients choose the best plan for them during the open enrollment period, Gonzalez says.

“A pharmacist can input the patient’s prescription needs as well as other important healthcare information, such as deductibles, copayments, and mail order options to help them choose the plan that would save them the most money,” he says.

Several nationally sponsored programs are available to support pharmacists in reinforcing medication adherence, Senhaji-Tomza says. For example, Simplify My Meds is a free service available through the NCPA. “The program helps pharmacists consolidate and coordinate all of a patient’s prescription pickups on the same day every month,” she says. “Participation saves patients multiple trips to the pharmacy while streamlining pharmacy operations, therefore freeing time for pharmacists to engage in more meaningful patient interactions.”

Articles

Poor medication adherence leads to $100 billion in healthcare expenditures annually.

Nine Ways to Help Patients Better Adhere to Their Medications

God didn’t waste any time telling us that we must work for a living. Right after God created the heavens and earth, He tells us it is our turn to get to work:

“By the sweat of your brow you will eat your food until you return to the ground, since from it you were taken; for dust you are and to dust you will return.”

Work isn’t meant to be fun, but when it turns into drudgery, we must do something. I feel there are three stages to any pharmacist’s career:

Most new pharmacists fit here. With student loans exceeding $100,000 for most, they need to get moving to pay down this dark cloud over them. Once student loans are under control, they accumulate more debt through car payments, house payments, getting married, and starting a family. This group is looking for the maximum salary and other benefits.

After Stage 1, many pharmacists fall into this group as family life takes hold. This stage includes pharmacists who have been practicing between five and 20 years. Salary is important to fund the family lifestyle, but the hours of family time become more important. “Sorry boss, I can’t work on Sunday. We’re going camping.”

This stage is where my wife, Denise, and I fit into. The house is paid off, and the kids are educated and on their own. We drive cars with more than 100,000 miles because we don’t have anyone to impress. We hate debt and are busy stuffing our 401ks for eventual retirement. The salary and schedule are not nearly so important as good working conditions. Our group loves the patient interactions and gets involved in patient care. We’re looking for adequate technician help, less prescription volume, and most of all, less supervision and more freedom to practice our profession.

When the wants of the pharmacist in those stages are not met, burnout occurs. Burnout is a chronic condition like hypertension and type 2 diabetes. Like those disease states, it is frequently diagnosed by someone else. The three major dimensions of burnout are cynicism, which is manifested by negative job and workplace attitude; emotional exhaustion, which is feeling emotionally depleted, apathetic, and indifferent; and ineffectiveness, defined as devaluing one’s work, or new tasks that are meaningless.

How Hospital Pharmacists Are Dealing with Drug Shortages

Stress, however, is an acute condition, usually causing emotional exhaustion. Stress includes somatic symptoms, such as a racing heart, elevated blood pressure, and a good bit of sweating. The individual pharmacist is aware of stress and can easily diagnose it. But we don’t always identify burnout in ourselves when it happens. The symptoms of burnout-hopelessness, cynicism, detachment from others-might take months to surface. If someone close to you points out changes in your attitude or behavior that are typical of burnout, listen to that person.

But then what do you do? Maybe you need to think about changing something. Pharmacists don’t quit their jobs, they quit their bosses.

Steve Jobs said: “I have looked in the mirror every morning and asked myself: ‘“If today were the last day of my life, would I want to do what I am about to do today?’ And whenever the answer has been “No” for too many days in a row, I know I need to change something.” Perhaps we all need to take that advice to heart as we wipe the sweat from our brows.

Note the physiological signs of stress and consider necessary changes.

Opinion: Hard Work is Inevitable, but Burnout is Not

Just in time for this flu season, the Infectious Diseases Society of America (IDSA) has issued updated recommendations for healthcare professionals for the diagnosis, treatment, prevention, and outbreak management of seasonal influenza.

The new guidelines–the first update in 10 years–focus on three areas: adding groups to those at high risk for flu complications, recommending use of newer fast and accurate molecular tests to diagnose influenza, and prescribing antiviral medications for those at high risk even if they have been sick for more than two days.

Tax Cuts and Jobs Act of 2017 Affecting Pharmacy Accounting

Andrew Pavia, MD, professor and chief of infectious diseases at the University of Utah in Salt Lake City and part of the IDSA committee updating the guidelines, notes the last recommendations were released before the 2009 H1N1 epidemic.

“Since 2008, we have really developed a lot of new evidence about when and where antivirals work,” Pavia tells Drug Topics. “It’s important to get the message out. They can be life-saving to those with high risk of complications. They are important to people with high risk whether they are hospitalized or not.”

Additional High-risk groups  Pregnant women and those who have given birth within the last two weeks are among those considered at high risk for flu complications and should be tested and treated as soon as possible. Others added to the high-risk groups include people who are morbidly obese, those with neurological and neurodevelopmental disorders, those with weakened immune systems, nursing home residents, and Native Americans and Native Alaskans, who had a higher mortality rate during the 2009 pandemic.

Molecular testing Using highly accurate molecular tests that give results in 15 to 60 minutes instead of rapid-influenza diagnostic tests (RIDTs) that produce false negatives in at least 30% of outpatients with flu.

Updated recommendations for the diagnosis, treatment, prevention, and outbreak management of seasonal influenza. 

Influenza Update: Antivirals are an Important Part of New IDSA Flu Guidelines

Despite numerous studies evaluating interventions to improve medication adherence and frameworks to understand barriers to adherence, approximately 50% of Americans are considered nonadherent to their chronic medication regimens. This can be because they are not taking their medications at all or are taking them at doses and/or times that are not recommended by their healthcare team. Either way, this is a critical issue that contributes to poor health outcomes and unnecessary healthcare expenditures.

Pharmacists can play a critical role in helping patients with medication adherence because they have a unique role in interacting with healthcare systems, insurers, and patients.

Social and economic issues (unemployment, social support, needs for housing/food)

Healthcare issues (multiple healthcare providers, insurance coverage)

Condition-related issues (symptom severity, impact on quality of life)

Therapy-related issues (perceived benefits/risks)

Patient-related issues (knowledge, beliefs)

Understanding how these factors play a role is a key to assisting a patient to optimal adherence. Even if barriers are identified and addressed, they might change from refill to refill.

So, what can we do as the pharmacist? Taking the time to speak with the patient on a regular basis can allow us to learn about the patient’s situation and what could be done to address adherence barriers. By learning more about the individual patient, the pharmacist can anticipate potential medication issues and then discuss a plan with the patient. For example, if side effects develop, educating the patient about other treatment options or ways to mitigate side effects can alleviate their concerns. Educating the patient about the need to notify providers about any side effect before the next scheduled visit is important as well. Although this might seem like common sense to healthcare providers, many patients just stop their medication until the next visit, and it might be months between visits. By stressing the importance of open communication with their healthcare provider, this lapse in therapy can be prevented.

Whatever the barrier may be, it is important to note that continual assessment of adherence is necessary because the factors affecting the patient can frequently change. It is prudent to assess if new factors affecting medication adherence have arisen at each visit, and if therapeutic goals have changed.

Working with health insurers on behalf of the patient is another way to facilitate adherence. Although insurers often have rules on prior authorization, quantity limits, and such, discussing patient-specific situations with the insurer can help allow for exceptions. In some cases, pharmacists can justify payment for adherence services by collecting data on patient satisfaction, improvements in prescription claims-measured adherence, and impact on retail and prescription refill sales.

Methods for Elderly Medication Management

Pharmacists can offer patients tools to assist with adherence as well. Several medication apps are available. Calendars and notebooks have been used for decades. Newer methods such as smart vials, tablets with electronic tracking, rewards for filling refills on time, and texts from the healthcare team are all being evaluated, but none has proven successful in all settings. Thus, the pharmacist who can holistically assess these factors might be the most well suited to facilitate medication adherence. Take the opportunity to talk with your patients. You are uniquely positioned to make a real difference.

Learning a patient's specific situation might help overcome adherence barriers. 

Opinion: Pharmacists Are Best Suited to Improve Adherence

Forty pharmacists in 26 states won elections in November, including four in statewide or federal races.

In California, State Sen. Jeff Stone, PharmD, won reelection to his second term in the 28th District, which stretches from southwest Riverside County across the Coachella Valley to the Arizona border.

Stone opened the Temecula (CA) Pharmacy in 1983 and became involved in local politics as a small business owner and a champion of the business community.

During his rise through positions in Temecula’s government, county board positions, and eventually the state senate, he has supported legislation to reduce regulations imposed on large and small businesses, which he says are the backbone of California’s economy. He has been an outspoken supporter for the pharmacy profession and a public health advocate throughout his career.

For his advancement of the profession and public health in California, Stone will be recognized as the Pharmacist Planning Services Inc. (PPSI) Distinguished Person of the Year in March. He will receive the award at the annual meeting of the California Pharmacists Association.
	PPSI is a nonprofit public health advocate that has helped organize The Great American Smoke Out, National Condom Week, and programs on birth control, hepatitis C, and medicinal cannabis.

Stone continues to own and operate a local business, Innovative Compounding Pharmacy, in La Quinta, CA.

DT: Community pharmacists are often driven by the people they serve. Was this mentality part of what drove you to public service?

: When I opened my first pharmacy in 1983 in Temecula, I never imagined running for public office. It was only when I saw the impact that graffiti was having on my community that I decided to get involved in 1992.

I ran for City Council because I wanted our city to crack down on vandals who were responsible for graffiti, and the voters in that election agreed. I’m proud to say I won handily and the City of Temecula still has the strongest anti-graffiti ordinance in the country. I quickly realized the common denominator between being a pharmacist and an elected official is helping people.

DT: What are some of the hallmarks of pharmacy practice that helped prepare you for public service?

: Being a pharmacist comes with many attributes, including the ability to study and retain complex health-related issues. What does that have to do with being an elected official? In order to be an effective elected official, one must have the discipline to study and understand new issues in order to then mitigate the problems or improve situations. As an independent pharmacy owner, I know firsthand the impacts of government regulations that can help or hurt my business. As the owner of the pharmacy, I need to understand accounting, workers compensation, insurance, employee laws, etc., hence making me more sensitive to the governmental mandates and unneeded bureaucracy.

Understanding these laws helps make me a better elected official. Having a medical background gave me a strong foundation as a county supervisor with a county hospital and helps me now as a state senator serving as vice chairman of the Senate Health Committee.

DT: As small business owners, how important is it for independent pharmacists to engage with state and local governments?

: If members of our profession do not get elected to state legislatures or federal office, then we succumb to bad laws authored by people that do not fully understand what we do and the challenges we face. As one of the most educated, but underutilized healthcare professionals, we need people in office who can help expand our scope of practice in accordance with our exceptional educational attributes.

DT: What advice would you give pharmacists who are considering public service? Is there a process for preparing yourself or methods that you’ve identified as essential to be successful?

: Public service comes in many forms. It isn’t just running for public office. I would encourage those with a passion to serve to become involved in their local Chambers of Commerce, their local Rotary Club, and to serve on various city boards and commissions. It is truly amazing how much a person can get done to change the way things are run if they just step up and get involved in a meaningful way.

My best advice can be summed up easily-get interested, get involved, show up, and work to change the things you believe need changing. You would be surprised how effective you can be if you just do these few simple things.

DT: What are your top priorities for this term?

: I will be once again attempting to pass legislation that expands the scope of pharmacists to independently treat disease in cooperation with a physician, as a way to ease the burden on our healthcare system. Additionally, I will be working with several of my colleagues to enact strong regulations over how pharmacy benefit managers operate in California.

PBMs are the least regulated part of the healthcare delivery system, and they should not be allowed to force pharmacies to lose money when filling prescriptions or to automatically claw back payments previously authorized. In addition to pharmacy-related legislation, I will also focus on economic development, public safety, and issues affecting taxpayers across the State of California.

DT: How is California dealing with the opioid crisis? Are there new initiatives being discussed or implemented? What is the role of pharmacists in what many are calling a public health emergency?

: We have a statewide and national crisis over opioid addiction and overdoses. Fentanyl has burst onto the scene as a major killer of people who have become addicted to these dangerous drugs, and I am working with my colleagues on both sides of the political aisle to come up with a solution to stop the illicit importation of drugs like fentanyl.

One solution we are looking at involves improving the CURES database in California, to make it accessible to pharmacists on a real-time basis so pharmacists will know if patients are filling prescriptions at multiple locations. If we can bring this database into the 21st Century and make it accessible to physicians and pharmacists, we can save lives.

DT: Drug prices, gag clauses, direct-to-consumer advertising, and pharmacy reimbursements have been thrust into the national debate. What role should pharmacists play as these discussion progress? How should we articulate the balance between price and innovation? How will this debate play out at the national level?

: This is an issue that is particularly troubling to me as both a pharmacist and a state senator. The issue over gag clauses and reimbursement rates prompted me to successfully request a legislative audit of a local health system in California that has been slashing reimbursement rates to below acquisition costs to local independent pharmacies, presumably as a way to force patients to begin using the preferred PBM’s mail order services.

This issue was raised by a local pharmacist, and legislators and public policy leaders need to hear more from individual pharmacists to teach decision makers about the ramifications of so-called “cost cutting” measures that ultimately put patients at risk by reducing access to quality care.

DT: California Governor Gavin Newsom’s first executive order directed the state’s health department to negotiate drug prices directly with pharmaceutical companies, and he took steps to enable states to manage a single-payer system. How would these initiatives affect pharmacists in the California? Do these changes have the potential to deliver on their intent?

: I am looking closely at the governor’s order, but I am greatly concerned that having the state involved in drug price negotiations will severely reduce patient access to quality pharmacy services. Having the state be in charge of purchasing drugs directly poses many challenges to physicians, pharmacists, and patients by potentially limiting the availability of necessary medications in many special circumstances.

Also, having the State of California function as a “super PBM” would likely force hundreds of pharmacies to close because it will certainly result in a rapid growth of mail-order pharmacy services, which might be fine in many circumstances, but these services do not necessarily work for patients needing specialized individual care and treatment.

State Senator Jeff Stone tackles PBM reform, reimbursement rates. 

PPSI Honors Distinguished Person  of the Year

As pharmacies, doctors’ offices, and hospitals fill up with patients with influenza-like symptoms, the CDC reports seasonal influenza activity remains elevated and is widespread in most parts of the United States, with at least 22 flu-associated pediatric deaths through mid-January.

“In the last few weeks, influenza has really picked up across the country,” says Pritish K. Tosh, MD, an infectious diseases specialist at the Mayo Clinic in Rochester, MN.

The CDC estimates that, from Oct. 1 through Jan. 11, up to 7.3 million people have been sick with the flu; 2.9 million to 3.5 million have seen a doctor because of flu symptoms, and up to 83,500 people were hospitalized because of flu. For the week ending Jan. 19, there was a rate of about 14.8 hospitalizations per 100,000 people. The highest rate of hospitalization for that week was among adults 65 and older (38.3 per 100,000). The proportion of outpatient visits for influenza-like illness was 3.3%.

The Walgreens Flu Index reported Nebraska had the most flu activity in the week ending Jan. 26, followed by Kentucky, Mississippi, Texas, and Alabama. The index ranks the top markets and states for flu activity in the United States and Puerto Rico and is compiled using prescription data for antiviral medications used to treat flu across thousands of Walgreens and Duane Reade locations.

This year’s top virus is the H1N1, but H3N2 viruses have been hitting the Southeast United States particularly hard, too. Tosh says the most commonly prescribed antiviral medication for flu treatment–oseltamivir phosphate (Tamiflu) appears to be working against the H1N1 virus.

“So far the CDC has not reported oseltamivir resistance,” Tosh tells Drug Topics, adding the CDC has not reported any resistant viruses this flu season.

The 2008 flu strain was resistant to oseltamivir, but that has not reoccurred, notes Andrew T. Pavia, MD, professor and chief of infectious diseases at the University of Utah in Salt Lake City. Pavia is on a committee of the Infectious Disease Society of America (IDSA) that has updated clinical practice guidelines for treating influenza.

“Resistance is an issue, but not a huge one yet,” says Pavia, senior author on the IDSA recommendations. “But it’s always out there as a threat.”

High levels of resistance to the antiviral drugs amantadine and rimantadine were seen with influenza A viruses in past seasons. These two drugs are not effective against influenza B, so they are not recommended by the CDC this season, Pavia says.

Antiviral medications are most effective when taken within the first 48 hours after the start of flu symptoms such as fever, chills, cough, sore throat, runny or stuffy nose, muscle aches, and headaches. In otherwise healthy patients, antivirals are not very useful if started more than 48 hours after onset of symptoms, Pavia says.

“But in hospitals, where illnesses last a lot longer, they’ve been given as late as five or seven days after onset,” he notes.

Oral oseltamivir can be prescribed for a patient of any age suffering from an influenza A or B strain. Adverse effects can include nausea, vomiting, and headache, and there have been some reports of serious skin reactions and sporadic transient neuropsychiatric events. In adults, the recommended dose is 75 mg twice a day for five days. For children over age 1, the dose varies by weight. Dosage can range from 30 mg twice daily for a child weighing 15 kg or less to a 75-mg dose twice daily for a child weighing more than 40 kg.

Tosh says oseltamivir reduces symptoms in otherwise healthy people, who are unlikely to have complications from influenza, and helps prevent severe outcomes in those with underlying conditions.

Inhaled zanamivir (Relenza) also works well against influenza A and B and can be used to treat those age 7 and older who do not have respiratory diseases like asthma and COPD, Pavia says. It should not be prescribed to those with allergies to milk proteins. Adverse reactions include bronchospasm, sinusitis, and dizziness. Some serious skin reactions and sporadic transient neuropsychiatric events were also reported. Treatment of two 5-mg inhalations lasts for five days. It’s primarily used for hospitalized patients and others who can’t swallow oral oseltamivir, he says.

Intravenous peramivir (Rapivab) can be used for influenza A and B4 in patients 2-years-old and older and is often used in hospital settings. For children age 2 to 12, one 12-mg/kg dose up to 600 mg is given via IV infusion for at least 15 minutes. Those age 13 and older should be given one 600 mg for at least 15 minutes. The most common side effect is diarrhea.

This year, pharmacists are seeing prescriptions for a new antiviral, baloxavir marboxil (Xofluza). It is for treatment of uncomplicated flu in people 12-years-old and older. It is not recommended for pregnant women, breastfeeding mothers, those with chronic illnesses, or hospitalized patients because it has not been studied in those groups.

Baloxavir is a one-dose tablet that can be used for influenza A and B6 in patients 12 and older who weigh at least 40 kg. Those weighing 40 kg to 80 kg should get one 40-mg dose, and those above 80 kg should receive one 80-mg dose. The most common adverse reactions are diarrhea and bronchitis.

Pavia notes that baloxavir’s side effects, which can also include headaches, are consistent with flu symptoms, so pharmacists need to advise patients and families of that.

He says pharmacists need to be familiar with side effects of all antivirals so they can be shared with patients.

CDC reports seasonal influenza activity remains elevated and widespread throughout U.S.

Influenza Update: Antivirals Advance in Options, Indications

A recent study in the American Journal of Health-System Pharmacy reported that more than half of health-system pharmacists have a high-degree of burnout. Healthcare experts say all involved in the pharmacy industry-including student pharmacists and pharmacy residents-are also at risk of burnout in their careers.

The study revealed that 53.2% of health-system pharmacists reported scores indicating a high degree of burnout on at least one subscale of the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). This is similar to published burnout rates for physicians and nurses.

Shareen El-Ibiary, PharmD, BCPS, FCCP, professor and chair of the Department of Pharmacy Practice, Midwestern University College of Pharmacy-Glendale, was involved in a study that looked at burnout rates among pharmacy practice faculty. That study revealed that 41% were experiencing high levels of emotional exhaustion, one dimension of burnout.

Additionally, a 2017 study among clinical pharmacists also showed high levels of emotional exhaustion (61%).

“We found that many faculty work longer hours, and those that worked 50 hours or more per week had higher levels of emotional exhaustion,” she says. “We also found that women, junior faculty, those with young children (1 to 12 years old), those without a mentor, and those without a hobby had higher levels of emotional exhaustion.”

Christina Martin, PharmD, director of membership forums with the ASHP, says burnout is associated with compromised patient safety and a loss of productivity in the workforce.

“Stress and burnout can be caused by individual factors, external factors, or a combination,” she says. “Individual factors can include personal factors, such as family dynamics, sense of purpose, or personal financial stressors.” External factors, which the research suggests carry more weight in contributing to burnout, can include maintenance of license and certification, increased rules and regulations, workload, high employee turnover, and drug shortages.

Erin Albert, PharmD, senior director for education for the American Society of Consultant Pharmacists, says some of the reasons for burnout in pharmacy are pressure to perform at better and faster rates, needing to do more with fewer resources and time, and increased competition in the workplace with more pharmacy schools producing more pharmacists.

“It’s not a new problem, but it’s a problem that has increased over time and accelerated due to increased competition, decreased margins on traditional prescription filling and metric constraints,” she says.

“We see it in all areas of practice too, even areas where there is a (false) perception that pharmacy jobs are ‘easier’ than retail or hospital, such as pharmacy academia,” she adds.

A systematic review on burnout across industries found that problems like cardiovascular diseases, pain, depression, job dissatisfaction and higher absenteeism in the workplace are all effects of burnout.

“Burnout literally changes our brains,” Albert says. “That’s why it is so important for self-care with healthcare professionals.”

Maria Marzella Mantione, PharmD, CGP, FAPhA, an associate clinical professor at St. John’s University College of Pharmacy and Health Sciences in New York, says the problem is prevalent.

“The list of responsibilities keep growing, but the resources, even with technology and all the efficiency we have available, keeps narrowing,” she says.

“I think the burnout is due to how much pharmacists care. They have little autonomy over how they spend their time, and want to be doing what they can, what they are trained for, and to follow their purpose; but the pressure on them to do things their management expects, how their management expects, without being heard as to how [they] think it would be best to do, leads to a cycle of frustration.”

Sonia Martinez, RPh, pharmacist-in-charge at Marco Drugs and Compounding in Miami, says exhaustion among pharmacists is widespread and believes it’s even more pervasive among independent pharmacist-owners, due to lower reimbursements and increased regulations.

“Pharmacy practice can feel repetitive, and, candidly, many tasks could be tedious,” she says. “As a pharmacist, we are required to juggle many responsibilities almost simultaneously like filling and verifying the accuracy of scripts, answering the phones and questions from insurances, providers or patients. We are also required to fulfill several administrative and or regulatory tasks with little real clinical meaning, adding to the workload burden.”

Moreover, in these times of low reimbursements adding additional help-more pharmacists or pharmacy techs-may not be financially sustainable.

It’s important that people in the field do not ignore the signs of burnout and pay attention to the people they work with. When a colleague snaps back at coworkers or even customers, that’s a telling sign. Albert believes the best way to recognize early signs of burnout both in yourself or in your staff, is by self-monitoring.

“I personally do self-monitoring a la the ‘Sunday night effect.’ On Sunday night, are you totally excited that you’re headed back to work on Monday morning, or are you dreading it? Dread over time shows a pattern of burnout,” she shares. “Anger can be an early warning sign, and apathy typically shows up later. If an employee hits apathy, it might be too late.”

Martinez says pharmacists should check for warning signs in themselves, such as whether they are cynical in one’s comments and thoughts or perceive that there is no progress in their career.

“When one sees that their own state is more pessimistic than usual,” she says. “But this requires a lot of personal knowledge and awareness.”

Mantione says a simple way to check is to ask. “Taking some time to reflect after a busy day could make a bit of a difference,” she says. “Management can check in on staff and listen when they say that they need more help getting everything done.”

She adds that most pharmacists went into the profession because of that desire to help, but find it harder and harder to do that with the resources they have. “We pride ourselves as a profession on being accessible, but that accessibility makes us feel as though we are being pulled in many different directions,” she says. “We need breaks, time to rest, time to eat, and use the restroom, etc. We have situations where pharmacists are going into work sick because they feel so responsible. They can’t take breaks sometimes even when given them because they know the work will just pile up while they are gone and the situation will get worse. In so many instances, it is simply unmanageable.”

When it comes to burnout, every pharmacist is dealing with their own personal struggles, so solutions will be different from person to person. The best advice is to find the positive differences that one makes each day and hold onto them, and try your best to let the frustrations go.

Mantione has turned to social media for help. She belongs to a group on Facebook called Pharmacist Moms that provides a platform for women in the field to share ideas, exchange information and support each other.

“Having that kind of tribe can go a long way to improving your mental health and managing stress,” she says.

One helpful trick that Martinez learned from Mark Robert Waldman, neuroscience researcher at Loyola Marymount University, is to yawn purposefully every hour or so. “Based on his research, this gives our brain a break. I call it a mental reboot,” she says. “I also do a daily meditation practice, and that’s what keeps me sane.”

The No. 1 piece of advice from many is that it’s absolutely critical for those in the industry to use every last bit of vacation. “If you don’t use your vacation, you’re leaving something more precious than money on the table. You’re leaving time behind, and time is something you never, ever get back,” Albert says.

She also recommends channeling negative energy into something positive. For those who have a boss, she also recommends discussing concerns and trying to alter responsibilities to more of the work one enjoys.

“I also think it’s a good idea to join associations and groups, and find a mentor,” Albert says. “You need a sounding board for your career. Learn from others. Attend association events and experiences that get you out of your day-to-day office environment and provide you a list of ideas and other ways of working.”

And not all your time needs to be spent doing things that are pharmacy-specific. Sometimes it’s good to get out of one’s comfort zone to reduce burnout. For example, in November, Albert attended the 39th Edition of the Toronto International Festival of Authors and attended a lecture by two historians about Canadian WWII war heroes.

“I was absolutely fascinated by the experience of attending this festival, in another country outside of my own,” she says. “I retained more cool ideas from attending that one-hour session than I have sitting in my office grinding out my work in the past two weeks.”

ASHP’s policy statement on clinician well-being and resilience states that workforce well-being and resilience requires a shared responsibility between individuals and organizations.

“Individuals need to identify and bolster their own resiliency and coping skills and organizations need to meaningfully promote well-being and lead system-level changes to address the external factors contributing to burnout,” Martin says.

“On the individual side, mindfulness and meditation have shown promising and validated improvements; however, this approach doesn’t resonate with everyone,” she adds.

One specific technique has been identified as a means to increase positivity in the minds of a healthcare worker. It is the “three good things” approach. You write down three good things that happened that day for 21 consecutive days until the practice becomes a habit.

Once burnout has occurred, it is difficult to recover. Still, reducing pharmacist burnout isn’t impossible. Martin says there is much that can be done.

ASHP offers a member-only resource center devoted to the topic and offer several webinars on a variety of topics ranging from mindfulness and meditation to leadership strategies.

The National Academy of Medicine has an Action Collaborative to promote clinician and healthcare provider well-being and resilience. Another program is one by the American Medical Association that promotes resiliency, called STEPS Forward. It is designed for physicians and medical students, but many of the concepts can also apply to pharmacists.

“Commitment to addressing and preventing burnout needs to be adopted by everyone from the top level executive to the front line clinician,” Martin says.

Durham ME, Bush PW, Ball AM. Evidence of burnout in health-system pharmacists. Am J Health Syst Pharm. 2018 Dec 1;75(23 Supplement 4):S93-S100; 2018. doi: 10.2146/ajhp170818. Epub 2018 Oct 17.

 Salvagioni D et al. (2017). Physical, psychological and occupational consequences of job burnout: A systematic review of prospective studies. PloS One, 12(10), e0185781. doi:10.1371/journal.pone.0185781

El-Ibiary SY, Yam L, Lee KC. Assessment of burnout and associated risk factors among pharmacy practice faculty in the United States. Am J Pharm Educ, 81(4): 75; 2017.

 Jones GM et al. Factors associated with burnout among US hospital clinical pharmacy practitioners: Results of a nationwide pilot survey. Hosp Pharm. 52(11): 742-751; 2017.

Professional associations, gratitude can keep you engaged, healthy

Avoiding Pharmacist Burnout

First, do no harm. We’ve all heard these words from the Hippocratic Oath. But from the sounds of it, we might not be listening very well. A shocking 2016 report out of Johns Hopkins indicates that medical error is now the third leading cause of death in the United States. While all of these fatalities are not medication-related errors, many are.

Medication errors can happen in any setting, but I am especially sensitive to the challenge of preventing errors in a retail pharmacy where there are so many competing priorities and constant distractions. My advice, therefore, is especially aimed at my brothers and sisters on the bench.

Preventing errors has to become the very flavor and language of your pharmacy. When you travel, you learn about different cultures by immersing yourself in their language, food, customs, and style. Visitors to your pharmacy should likewise get a sense that “safety” is your custom, the way you live and move. You do this by talking about it frequently, sharing examples, telling stories, and being a champion of error-prevention yourself.

believe the training programs in most of our organizations are inadequate for the demands of a busy, distracting retail pharmacy. Sure, we expect our personnel to have a baseline drug knowledge. But where we fall short are the computer-training, problem-solving, communication-techniques, and people-skills needed to efficiently work together as a team. Untrained people get flustered and then make mistakes. Well-trained people work more efficiently. Good training brings all the parts together. And this requires an investment in great trainers and training programs.

I urge you to have a zero-tolerance policy for chaos in the pharmacy. The mantra I communicate frequently to my team is: “Busy is good, chaos is not.”
	Chaos is usually the result of one or more good people making one or more bad choices.
	For example, we might cut corners to try and speed things up to an unsafe pace. Baskets in the work flow might get disorganized. Patients might be promised unrealistic timelines, thus putting inappropriate pressure on the team. Someone might get flustered, distracted, or upset. You need a leader, ideally the pharmacist, to exude a calming influence and to insist on maintaining decency and order in the work flow steps.

I tell my pharmacists to picture themselves in a courtroom every time they verify a prescription, trying to explain to a jury why they allowed that prescription to go out. A scary thought-but we need sobering reminders of just how serious our job is.

Take a breath. Read the label carefully. Think. You must train yourself to look for all of the possible errors that may be in front of you. Is this a commonly confused drug or dosage form? Does the dosing make sense? Does the prescription seem reasonable for this patient given their age, gender, and history? There’s simply no checklist that will replace the importance of getting your head in the game. Every time. Every single prescription.

Pharmacists must cultivate a culture of safety, training to protect patients.

How to Prevent Medication Errors

The FDA approved sublingual sufentanil (Dsuvia, AcelRx Pharmaceuticals) in November for management of severe acute pain refractory to alternative treatments in adults being treated in a medically supervised healthcare setting. Sufentanil is a relatively selective full agonist of the mu-opioid receptor, which provides analgesia and sedation.

The efficacy of sublingual sufentanil was assessed in three Phase 3 clinical trials.

 SAP301 was a multicenter double-blind placebo-controlled trial with 161 participants that compared 30 mcg of sublingual sufentanil to placebo for postoperative pain following abdominal surgery. The primary outcome is the summed pain intensity difference over 12 hours (SPID12), which uses a score from 0 (no pain) to 10 (worst possible pain) to calculate the difference in pain intensity over the 12 hours. Sublingual sufentanil showed a statistically significant greater difference in SPID12 compared to placebo.

SAP302 was an open-label study with 76 participants assessing safety and efficacy of 30 mcg of sublingual sufentanil for moderate-to-severe acute pain in emergency room patients with obvious trauma or injury. The primary outcome was the summed pain intensity difference over 1 hour (SPID1). Pain was measured at baseline and every 15 minutes over the hour and then hourly for 5 hours. The study demonstrated a decrease in the pain intensity of participants during the study period.

SAP303 was a multicenter open-label trial with 140 participants assessing safety and efficacy of 30 mcg sublingual sufentanil for postoperative pain. Similar to SAP302, the primary outcome is the SPID12. Results demonstrate a decrease in pain intensity of participants during the 12-hour study period.

The safety of sublingual sufentanil was assessed in a total of 646 patients in both controlled and uncontrolled studies, including SAP301, SAP302, and SAP303.

 In the combination of all three SAP studies, two patients in the sublingual sufentanil groups reported a severe adverse event. One patient in the SAP302 study experienced angina pectoris, and one in the SAP303 study experienced an acute stroke.

 Sublingual sufentanil was well-tolerated by patients, Adverse effects occurring in more than 10% of patients included nausea and headache.

Serotonin syndrome has been reported in patients taking sufentanil and serotonergic drugs.    

Sublingual sufentanil should not be used for more than 72 hours as it has not been studied beyond this time frame. Its use in pediatrics is not recommended because safety and efficacy in this population have not been established. Geriatric patients should be monitored closely due to risk of central nervous system and respiratory depression. Use caution in pregnant patients as prolonged use of opioids can lead to neonatal opioid withdrawal syndrome.

Sublingual sufentanil is a single-use tablet that must be administered by a healthcare professional in a certified medically supervised healthcare setting. The tablet should be delivered to the space under the tongue using a prefilled applicator to limit accidental exposure to the healthcare professional and to ensure proper placement. The recommended dose of sublingual sufentanil is 30 mcg as needed. The maximum cumulative daily dose is 12 tablets (360 mcg) with a minimum of 1 hour between doses.

1. Sufentanil sublingual package insert. Redwood City, CA: AcelRx Pharmaceuticals, Inc.; 2018
	2. ClinicalTrials.gov [Internet]. 2017 Feb. 13. NCT02356588; A trial evaluating the efficacy and safety of the sublingual sufentanil tablet 30 mcg for post-operative pain after abdominal surgery: Available at: 

https://clinicaltrials.gov/ct2/show/NCT02356588

. Accessed on Jan. 3, 2019.
	3. ClinicalTrials.gov [Internet]. 2017 March 15. NCT02662556; A multicenter, open-label trial to evaluate the safety and efficacy of the sufentanil sublingual tablet 30 mcg in patients with post-operative pain: Available at: 

https://clinicaltrials.gov/ct2/show/results/NCT02662556

. Accessed on Jan. 3, 2019.
	4. ClinicalTrials.gov [Internet]. 2017 Oct. 19. NCT02447848. Open-label safety and efficacy of the sufentanil sublingual tablet 30 mcg for acute pain: Available at: 

https://clinicaltrials.gov/ct2/show/NCT02447848

Sublingual form approved for short-term use.

New Drug Review: Dsuvia (Sufentanil) for Acute Refractory Pain

The Tax Cuts and Jobs Act of 2017 (TCJA) made significant changes to the tax code. One of the noteworthy changes that will impact pharmacies is the option to change from the accrual accounting method to the cash accounting method.

An accounting method is the method a taxpayer uses to compute income. It determines the timing of when income and deductions are recognized. The two overall accounting methods applicable to pharmacies are the accrual and the cash methods of accounting.

The accrual method recognizes revenue when earned, such as when a prescription is adjudicated, and it recognizes expenses when incurred, such as when a purchase is made instead of when it is paid. The cash method of accounting recognizes revenues when the revenue is received and recognizes expenses when the expenses are paid. The key distinction between the two methods is simply the timing of when income and expenses are recognized.

, pharmacies were required to report on the full accrual method of accounting, unless exceptions were met. The TCJA changed the accounting method options available for pharmacies. Unless your prior three-year average gross revenues (gross receipts test) in the pharmacy exceed $25 million, pharmacies are now allowed (but not required) to report on the cash method of accounting instead of the accrual method.  Owners with multiple pharmacies under common ownership, such as controlled groups, must aggregate revenues when determining the gross receipts test.

 has its own set of rules under the accrual and cash methods of accounting.  If you choose the cash method, the TCJA allows taxpayers to either treat inventories as nonincidental materials and supplies or conform to the taxpayer’s financial accounting treatment of inventories. There are complex issues outside the scope of this article with regard to inventory under the TCJA, so consideration should be taken with your tax professionals to navigate this area of tax law.    

An IRS Form 3115 Change in Accounting Method will need to be filed with your tax return if you change accounting method.  The accounting adjustment from the accrual method to the cash method is called a Code Section 481(a) adjustment. If the adjustment is negative (an expense), it can be deducted in the current tax year. If the adjustment is positive (income), it may be taken in year one or, if over $50,000, is spread over a four-year period.

: Assume  a pharmacy has the following accrual balance sheet items: accounts receivable third-party of $300,000, accounts payable of $50,000, accrued payroll payable of $25,000, and accrued interest payable of $5,000. The pharmacy elects to report on the cash basis. An adjustment to remove these accounts from the balance sheet would be a negative 481(a) or expense of $220,000 ($300,000 - $50,000 - $25,000 - $5,000). This expense would be deducted in the current tax year and would decrease net income , and thus taxable income,  of the pharmacy for the year. As you see, it results in significant tax savings!

 is necessary to proactively plan and analyze these changes with an experienced tax advisor. Issues that relate to ownership basis and losses, potentially selling your pharmacy in the near term, and how this accounting change will affect your books and records are just some of the items to  be considered. With careful planning, the potential tax savings for pharmacies under the TCJA are extraordinary, especially with the option to change accounting methods.

Pharmacies now may switch from accrual to cash accounting.

Drug Topics February 2019

Nine Ways to Help Patients Better Adhere to Their Medications

Opinion: Hard Work is Inevitable, but Burnout is Not

Influenza Update: Antivirals are an Important Part of New IDSA Flu Guidelines

Opinion: Pharmacists Are Best Suited to Improve Adherence

PPSI Honors Distinguished Person of the Year

Influenza Update: Antivirals Advance in Options, Indications

Avoiding Pharmacist Burnout

How to Prevent Medication Errors

New Drug Review: Dsuvia (Sufentanil) for Acute Refractory Pain

Tax Cuts and Jobs Act of 2017 Affecting Pharmacy Accounting

How Hospital Pharmacists Are Dealing with Drug Shortages

Small Doses: February eNews Roundup

Most Profitable Pharmacy Services to Offer

5 Tips for Getting Started with Niche Services

Six Healthcare Technologies Coming in the Next Five Years

Diversify and Prosper

Independent Pharmacies, Chains Enter Specialty Pharmacy