Although COVID-19 remains a real threat, it seems we are now progressing toward a return to normalcy thanks to the widespread availability of vaccines and tireless efforts of our health care workers.

As the country continues to reopen, vaccinated Americans are gearing up to resume normal summertime activities, such as vacations and outdoor gatherings. Because June signals the beginning of summer—bringing warmer weather—Jennifer Gershman, PharmD, CPh, discusses in this issue 

how pharmacists can counsel patients with certain autoimmune conditions during summer months

 on ways to reduce symptom flares associated with rising temperatures.

June is also LGBTQ Pride Month, so we are examining the stark health disparities affecting LGBTQ+ individuals and how pharmacists can provide more inclusive care and services. In addition to being the medication experts, pharmacists are often the most frequent touchpoints a patient has with the health care system. Our 

t focuses on how pharmacists can best support LGBTQ+ patients and create a more inclusive environment in the pharmacy.

In this issue, we also recognize National Headache and Migraine Awareness Month by highlighting how pharmacists can assist patients in prevention, treatment, and medication management. This month, you’ll find an 

 of the various pharmacologic and nonpharmacologic therapies available for migraine

Health Insurance Portability and Accountability Act compliance

Articles

Although COVID-19 remains a real threat, it seems we are now progressing toward a return to normalcy thanks to the widespread availability of vaccines and tireless efforts of our health care workers. 

Pharmacists Can Help Patients as Signs of Normalcy Return

On April 2, 2021, the FDA approved viloxazine (Qelbree; Supernus Pharmaceuticals, Inc) for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children aged 6 to 17 years. Viloxazine is a selective norepinephrine reuptake inhibitor and is the first new nonstimulant medication for treatment of ADHD in children in more than 10 years. 

The FDA evaluated the safety of viloxazine in 3 randomized, placebo-controlled trials. Studies 1 and 2 included participants aged 6 to 11 years and lasted either 6 or 8 weeks that included a titration period to achieve maintenance dosing of 100 mg, 200mg, or placebo daily (study 1) and 200mg, 400mg, or placebo daily (study 2). Participants aged 12 to 17 years were titrated to either 200 mg or 400 mg or placebo in study 3. The primary end point in each study is a change in total score on the ADHD Rating Scale (AHD-RS-5), comparing baseline to the end of the maintenance period assessments. The change in Clinical Global Impression-Improvement (CGI-I) score from baseline served as a secondary end point in each study. In all 3 studies, patients administered viloxazine demonstrated statistically significant improvements in ADHD rating scale scores and in CGI-I scores compared with participants administered placebo. 

In trials, 826 participants were exposed to a dose of viloxazine that ranged from 100 mg to 400 mg. In this group, the most common adverse effects (AEs) included nausea, vomiting, insomnia, irritability, decreased appetite, and somnolence. The most common AEs leading to discontinuation of the medication included somnolence, nausea, fatigue, decreased appetite, headache, tachycardia, and irritability. Viloxazine carries a boxed warning regarding higher rates of suicidal thoughts and behaviors among participants administered viloxazine in clinical trials compared with participants administered placebo. Patients treated with viloxazine should be monitored for suicidal ideation or behaviors, particularly when initiating or increasing therapy. Patients experiencing these symptoms may require a discontinuation of viloxazine therapy. Viloxazine may activate mania in patients at risk for bipolar disorder. Patients should be screened prior to initiating therapy for a history of suicide, depression, or bipolar disorder. 

Viloxazine may also cause an increase in blood pressure and heart rate. A patient’s blood pressure and heart rate should be assessed at baseline when initiating therapy and periodically throughout treatment. Somnolence and fatigue associated with viloxazine administration may affect a patient’s mental alertness. Until a patient knows how viloxazine will affect them, they should avoid operating machinery or driving. Concomitant administration of viloxazine with monoamine oxidase inhibitors is contraindicated due to an increased risk of hypertensive crisis. Viloxazine strongly inhibits cytochrome P450 1A2 (CYP1A2) and will increase exposure to concomitant CYP1A4 substrates and increase the risk of AEs to those medications. In addition, viloxazine weakly inhibits CYP2D6 and CYP3A4. Patients should be monitored for AEs associated with any additional medications they take that may be impacted by this interaction.

In patients aged 6 to 11 years, the recommended starting dosage of viloxazine is 100 mg once daily and may be titrated in 100-mg increments weekly to a maximum dosage of 400 mg once daily. The recommended starting dosage for patients aged 12 to 17 years is 200 mg once daily. In this age group, the dosage may be titrated up in 1 week to the maximum recommended dosage of 400 mg once daily. Capsules may be swallowed whole with or without food or may be opened and contents sprinkled on applesauce. The capsule or applesauce with sprinkled medication must not be chewed. Medication mixed with applesauce must be used within 2 hours of mixing and cannot be stored for later use.

Qelbree. Prescribing information. Supernus Pharmaceuticals Inc; 2021. Accessed May 11, 2021. 

https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/211964s000lbl.pdf

Viloxazine is a selective norepinephrine reuptake inhibitor and is the first new nonstimulant medication for treatment of ADHD in children in more than 10 years.  

New Nonstimulant Medication Is Approved for ADHD in Children

However, my 4-year-old grandson Luke lives near a golf course, and one of our favorite activities is walking through the woods searching for golf balls. Luke describes these golf balls as the ones hit by “bad golfers.” We have collected more than 250 golf balls, and about 200 of them are white. Therefore, Luke feels it is safe to conclude that bad golfers buy white golf balls, since that is the predominant color we find. If you want to be a great golfer, don’t buy white golf balls.

As failed as this logic appears, we have individuals with vaccine hesitancy applying the same logic. Many nonexperts frequently take to social media to express their antivaccine views, with virtually no understanding of virology or immunology. It’s like getting golf advice from a 4 year old.

One simple statistic should convince everyone who is reluctant to get the COVID-19 vaccine. According to an analysis conducted by the Kaiser Family Foundation, “Since vaccinations began in mid-December 2020, the number of COVID-19 deaths in long-term care facilities across all states in this analysis has declined by 89% as of April 2021.”

Currently, our nation doesn’t have half of our citizens fully vaccinated. We community pharmacists are seeing vaccine hesitancy with the same zeal we saw for 

 the vaccine 6 months ago. I’ve even had discussions with pharmacists who have no interest in getting vaccinated. For the first 4 months of this year, there has been little movement of getting the “definitely nots” vaccinated. According to epidemiologists, we need to vaccinate 80% of the population to reach herd immunity. And to think we have 13% of Americans who are “definitely nots” that will never accept vaccination.

In my 40 years of health care, I’ve seen nothing like this. I remember that mysterious disease in the 1980s that devastated many communities in our nation. Three years after the first cases were reported, the etiology was discovered and named human immunodeficiency virus. Yes, it took a worldwide effort of 3 years to even name and elucidate the cause of HIV. It took another dozen years to have effective treatment protocols to include combinations of different HIV drugs to save lives. Today, treating HIV is easier than treating type 2 diabetes; patients simply need to be adherent to their medications

Here we are 15 months after the pandemic, and we have a vaccine that is 95% effective in preventing disease and nearly 100% effective in preventing death due to COVID-19. We pharmacists are struggling to find arms to get vaccines into from our overstocked refrigerators and freezers. Individuals read posts on social media, get advice from family members and friends and apply it to their decision whether to get the vaccine or not. Thanks to social media, everyone is an expert and has a forum to post their unsubstantiated opinions. 

I’m glad that in the middle of the HIV epidemic in the 1980s and 1990s, we had no such venue as social media. We listened to the experts and waited for the scientists to come up with treatment protocols and then treated our patients accordingly.

We are blessed to have a number of COVID-19 vaccination options, all efficacious, with the only substantial differences among them being storage requirements. We community pharmacists need to engage our patients and encourage them to get vaccinated; we don’t need them to turn to social media. 

If they believe everything on social media and they need to improve their golf game, I know a 4 year old who can give them advice from his scientific study. “Don’t buy white golf balls.”

Chidambaram P, Garfield R. COVID-19 long-term care deaths and cases are at an all-time low, though a rise in LTC cases in a few states may be a cause for concern. Kaiser Family Foundation. April 22, 2021. Accessed May 11, 2021. 

https://www.kff.org/coronavirus-covid-19/issue-brief/covid-19-long-term-care-deaths-and-cases-are-at-an-all-time-low-though-a-rise-in-ltc-cases-in-a-few-states-may-be-cause-for-concern/#:~:text=Since%20vaccinations%20began%20in%20mid,1%20and%20Appendix%20Table%201

Huetteman E. Covid vaccine hesitancy drops among all Americans, new survey shows. Kaiser Health News. March 30, 2021. Accessed May 11, 2021. 

https://khn.org/news/article/covid-vaccine-hesitancy-drops-among-americans-new-kff-survey-shows/

Many Americans still do not want to get vaccinated. Vaccine myths spread on the internet are a major part of the problem. 

Social Media Incites the COVID-19 Misinformation Epidemic 

An increasing number of pharmacists are now prescribing birth control, further expanding their role as public health service providers.

Lincoln Alexander, PharmD, residency program director in Portland, Oregon, for Albertsons Companies, has been prescribing birth control for just over 5 years and has received a positive response from his patients.

“Patients are highly appreciative of the service. Nowadays, [pharmacists prescribing birth control] seems like second nature to many, which is a testament to the effective rollout we have had here in Oregon,” said Alexander, who is also president-elect of Oregon State Pharmacy Association.

Oregon isn’t alone. Allie Jo Shipman, PharmD, MBA, director of state policy for the National Alliance of State Pharmacy Associations, said 13 states and the District of Columbia currently allow pharmacists to prescribe oral contraceptives independently.

“There are also 13 states with legislation pending this session that would allow for the same thing,” she said.

Although the prescriptive authority, age limits, and requirements for each state vary, the overall message is clear: Pharmacies in all practice settings are stepping up to the challenge.

In 2013, California became the first state to pass a bill allowing pharmacists to “furnish” contraception without a physician prescription. However, Oregon was the first state to implement independent pharmacist-prescribed contraception.

“We had a physician legislator, Dr [Knute] Buehler, who just decided this is an access issue for patients,” said Paige Clark, RPh, director of alumni relations and professional development at Oregon State University College of Pharmacy in Corvallis.

According to Shipman, state policies are typically structured using 1 of 3 types of prescriber authority: 

General prescriber authority, where the pharmacist is the prescriber of record

Statewide protocol, where the pharmacist serves as the prescriber of record but the overall protocol is developed and approved by a state pharmacy board

Under the last option, the state offers a statewide blanket prescription issued by a medical official in the department of health, who is often the chief medical officer. That official is considered the prescriber of record, but pharmacists are responsible for consulting and making clinical decisions.

Although some states have no age limits in place, Shipman said others only allow pharmacists to prescribe to those 18 years or older. Alternatively, they may allow prescribing to patients younger than 18 only if they have had a previous contraception prescription.

Capitalizing on a Need for Public Health Service Providers

A growing number of states are exploring options that go beyond collaborative practice agreements for birth control prescribing. The move follows a larger trend of enlisting pharmacists to provide public health services to patients for areas that don’t require a diagnosis.

“I think the pandemic has shown just how pharmacists have shined in
a time of a public health emergency where pharmacies have stayed open...when other providers have closed,” said Veronica Vernon, PharmD, an assistant professor of pharmacy practice at Butler University in Indianapolis, Indiana. “We have seen during the pandemic that access to contraception has been a significant concern.”

Pharmacists can bring their unique set of skills to address what Vernon referred to as “contraception deserts,” geographic regions where access to birth control prescribers might be limited. They can also save states significant money in public costs.

One study examined the policy’s impact on Oregon’s Medicaid program in the first 2 years since it went into effect in 2016. According to the results, published in 

, pharmacist prescription of contraception averted more than 50 unintended pregnancies and saved the state an estimated $1.6 million in public costs.

Pharmacist contraception prescription may come with big benefits, but it also brings its own set of challenges. Not least among these is ensuring that pharmacists are getting paid for their services.

“We want to remove barriers for patients and we can be a more cost-effective approach for patients when accessing contraception, but you want to make sure you are not giving away the service for free,” Vernon said.

Clark said that in Oregon the Medicaid system has put pharmacists in the provider lane, allowing them to use billing codes that are also available to physicians and physician assistants. However, to date, their adoption hasn’t been widespread because of the systems many pharmacies need to put into place in order to process medical billing.

“There are some hoops they have to jump through, and there are some connectivity issues,” she said.

Vernon said patient consultations and assessments can last up to 20 minutes or more. This makes it essential that pharmacists are paid not only for dispensing the medication but also for their time to properly assess the patient.

“If you are going to do this, make sure there is a payment pathway in place and that you are meeting with insurance companies in your state to talk about what this would look like...The states that have been most successful in pharmacists’ prescribing of contraception have ensured that there is a pathway for payment for pharmacists’ time,” she explained.

Vernon recommends having a designated space within the pharmacy to conduct patient assessments in community pharmacy settings.

She also stressed the need to evaluate the workflow within the pharmacy to manage day-to-day responsibilities and billing. It will most likely mean using technicians to their highest skill levels to increase overall efficiency.

“I think including them in your workflow so that the pharmacist can step away from checking prescriptions and counseling on other prescriptions to spend time with the patient...would be really helpful,” Vernon said.

For example, one pharmacy she talked with had tasked their lead technician with medical billing to streamline the workflow. Alexander echoed Vernon’s comments, saying one of the biggest challenges he has seen in practice is adapting the workflow.

“Time constraints with performing a contraceptive consultation with the patient can sometimes make this service a challenge to fit into the workflow, especially with the ongoing COVID-19 pandemic and vaccination efforts,” he said.

To accommodate all the workflow demands, Alexander said he has done his best to educate patients on the best time of day to come to the pharmacy for prescribing services, such as in the mornings when there is pharmacist overlap. However, he has also found that patients are generally “amenable [to] a short wait” if he clearly communicates to them the other demands going on at the time.

“It starts with treating each person that walks through our doors with courtesy, dignity, and respect,” he noted. He also stressed the importance of training pharmacy technicians, interns, and other associates on workflow procedures.

“Though these associates cannot make prescribing or consultation decisions, they are very helpful in onboarding the patient,” he said. He added that they can check IDs, gather insurance cards, or ask the patient to begin by filling out a self-screening questionnaire.

As an employee of the public state university in Oregon, Clark and her team were tasked with developing a thorough training program for pharmacists in the state and other areas. She recommends that pharmacists who assume the new role invest in an educational program, even if it isn’t specifically required in their state.

“We have a 4-hour course that literally [covers] the entire process from the beginning of that patient walking in the door all the way through all the safety guidelines,” she said. The course makes it very doable for frontline pharmacists to begin offering the service, she added.

When working with patients, Vernon said, most states require pharmacists to follow the CDC’s US Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2016 and the US Selected Practice Recommendations For Contraceptive Use, 2016 to guide patient eligibility and selection.

Many states also require pharmacists to administer a patient questionnaire that can be a “great jumping off point” to begin a conversation with the patient, she continued.

“The best option is what the patient decides on, and so using a shared decision-making approach with the patient is really crucial,” she said. Having patient buy-in on the product will likely increase consistent adherence, she pointed out.

The last step is to find ways to successfully advertise the new services.

“It’s not if you build it, they will come, you also have to let patients know that you are doing this,” Vernon said.

1. Anderson L, Hartung DM, Middleton L, Rodriguez MI. Pharmacist provision of hormonal contraception in the Oregon Medicaid population. 

 2019;133(6):1231-1237. doi:10.1097/AOG.0000000000003286

Pharmacists’ Public Health Role Grows as Birth Control Prescribing Authority Expands 

Although pharmacists understand that all of a patient’s medical information is confidential and access to that information is protected by the Health Insurance Portability and Accountability Act (HIPPA) of 1996, some still have challenges staying 100% compliant. That is why independent pharmacy owners should establish a compliance checklist and ensure their staff does annual HIPPA training.

“Pharmacy staff need to be aware of who they are providing health information to over the phone, in person, or via mail,” said Chirag Patel, PharmD, MBA, chief operating officer and brand ambassador for Carolina Pharmacy Group in Charlotte, North Carolina “The staff also need to ensure all health information at the pharmacy—prescription vials, labels, print outs, handouts, etc—is properly disposed of. That disposal source is most often an information security company that disposes of personal health information via shred boxes.”

Arielle T. Miliambro, Esq, a partner at Pine Brook, New Jersey-based health care law firm Frier Levitt, outlined the components of HIPAA:

The HIPAA Privacy Rule protects the privacy of individually identifiable health information.

The HIPAA Security Rule sets standards for the security of electronic protected health information (PHI).

The HIPAA Breach Notification Rule requires covered entities and business associates to provide notification following a breach of unsecured PHI.

Each HIPPA rule may have different requirements and exceptions. Miliambro explained that the Privacy Rule contains certain limited exceptions for which PHI may be disclosed without authorization, such as to coordinate care among health care providers or to obtain reimbursement from a patient’s health insurer or payer.

Russell Dowdell is director of solutions engineering for 

in Austin, Texas, which provides health care organizations with a centralized solution for managing privileged access for their third-party vendors.

What independent pharmacists need to know. 

A Guide to HIPAA Compliance in the Pharmacy

Twelve percent of the US population experiences migraine, according to the Migraine Research Foundation. Migraine is the third most prevalent illness globally, and it affects 1 out of 4 US households. Moreover, migraine can be disabling, with 90% of those affected worldwide unable to work or function normally during a migraine attack.

Although migraine is sometimes thought of as just a headache, a migraine attack can involve 4 phases of various symptoms. Not every stage is present in every migraine. Pharmacists can counsel patients to keep track of their migraines with a headache journal or app because neurologists and headache specialists may be able to pinpoint patterns and detect a migraine attack before it arrives.

A migraine attack can manifest with any of the 4 phases:

: This is a “preheadache” and can last several hours to several days. Symptoms include mood changes (eg, depression, irritability), sensitivity to light and sound, insomnia or fatigue, and stomach problems (eg, nausea, vomiting, diarrhea). Unique symptoms include yawning, food cravings, and increased urination.

: This phase can last from 5 to 60 minutes. Symptoms include vision disturbances, such as blurry vision or vision loss, and/or seeing patterns or flashing or shimmering lights.

: This phase can last from 4 to 72 hours. The hallmark symptom is pain, often on one side or one part of the head. Other symptoms like nausea, vomiting, anxiety, and sensitivity to light and sound may occur.

 This “hangover” phase usually lasts 24 to 48 hours. Symptoms may include fatigue, body pain, dizziness, and mood changes.

One way to remember migraine symptoms is with the acronym POUND

 1-day duration of severe untreated attacks

It is prudent to refer patients who have frequent headaches, headaches that are increasing in severity or frequency, or headaches that interfere with functioning to a headache specialist for evaluation and a treatment plan, including preventive and acute treatment.

If the patient experiences a new or unusual symptom, such as a headache that occurs within a few seconds or the worst headache they’ve ever had, refer the patient to the emergency department. Other symptoms that require emergency treatment include pain for more than 72 hours, fever, weakness, vision loss or changes, and confusion or if the patient is pregnant, is immunocompromised, or has a severe medical condition like liver or kidney disease.

Nonpharmacological prevention of migraine

Some nonpharmacological migraine prevention tips for patients include

: Keep detailed information in a headache diary or app.

: Avoid known triggers such as odors, smoke, alcohol, stress, and food triggers.

: Keep a regular sleep schedule by waking up and going to bed at the same times every day, including weekends.

: Eat regular, healthy meals and limit sugar. Drink plenty of water to avoid dehydration. Limit alcohol and caffeine. Avoid food triggers such as aged cheeses, chocolate, MSG, and cured meats.

: Try to get moderate, regular exercise 3 to 5 times weekly.

: Lower stress with relaxation, yoga, or stress management.

Patients who have 4 or more migraine attacks, 8 or more migraine days per month, or other qualifying factors may need preventive treatment.

 Many options are available, and some of the more common preventive treatment medications include the following

Counsel patients on adverse effects (AEs) such as fatigue, depression, sexual problems, decreased heart rate, and low blood pressure.

Anticonvulsants (divalproex or topiramate)

Divalproex: Counsel on nausea, vomiting, fatigue, and lab monitoring due to possibility of liver or pancreas problems.

Topiramate: Counsel on paresthesia, stomach pain, fatigue, memory problems, kidney stones, nausea, vomiting, altered taste, weight loss, eye pain, and lab monitoring due to possibility of liver problems and metabolic acidosis.

Antidepressants (such as amitriptyline or venlafaxine)

Counsel patients on the risk of suicidal thoughts and behavior and the importance of tapering when discontinuing medication.

Amitriptyline: Counsel on anticholinergic AEs such as dry mouth, blurry vision, constipation, urinary retention, and weight gain.

Calcitonin gene-related peptide (CGRP) inhibitors are a newer class of drugs that prevent migraine by targeting CGRP, which is found in higher levels during a migraine attack. CGRP inhibitors are monoclonal antibodies that block the effects of CGRP and are the first class of medications specifically designed to prevent migraine.

CGRP inhibitors approved by the FDA for the prevention of migraine are as follows

Erenumab-aooe (Aimovig; Amgen): 70 to 140 mg injected subcutaneously once monthly

Fremanezumab-vfrm (Ajovy; Teva Pharmaceutical Industries Ltd): 225 mg injected subcutaneously once monthly or 675 mg injected every 3 months (as 3 consecutive injections of 225 mg each)

Galcanezumab-gnlm (Emgality; Eli Lilly and Company): 240 mg (2 consecutive doses of 120 mg) injected subcutaneously as a loading dose, then 120 mg once monthly

Eptinezumab-jjmr (Vyepti; Lundbeck Seattle BioPharmaceuticals, Inc): 100 mg or 300 mg by intravenous infusion every 3 months

Common AEs associated with CGRP inhibitors include injection-site reactions (pain, redness, itching) and hypersensitivity reactions.

 Other AEs of erenumab-aooe include constipation (possibly with complications including hospitalization) and increased blood pressure.

 Eptinezumab-jjmr may also cause nasopharyngitis.

Many options are available for migraine treatment. Product selection may be based on a variety of factors, including symptoms, medical history, other medications, patient preference for specific formulation(s), AEs, and cost or insurance considerations (

Pharmacists can provide counseling on the following popular first-line medications for migraine treatment.

For mild to moderate migraine attacks, acetaminophen and oral nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, diclofenac, ibuprofen, or naproxen may be used. Although acetaminophen is less effective than NSAIDs for migraine, it has fewer AEs. The combination in acetaminophen/aspirin/caffeine (Excedrin; Novartis) is also a first-line option.

Counseling can include dosage, limitations, and the importance of avoiding alcohol. For NSAIDs and acetaminophen/aspirin/caffeine, also counsel patients on the risk of potential gastrointestinal and cardiovascular effects.

Triptans are effective as a first-line treatment for moderate to severe migraine. Triptans approved by the FDA for the treatment of migraine include the following14:

Almotriptan (Axert; Teva Pharmaceutical Industries Ltd)

Triptans have slight differences that may cause patients to respond to certain triptans but not others. Triptans are most effective when taken early in a migraine attack and are generally well tolerated. Most triptans, with the exception of almotriptan and frovatriptan, can cause fatigue, dizziness, chest pain, and nausea.

Additional Considerations for Migraine Treatment

Other new drugs have entered the market for migraine prevention and/or treatment.

; Biohaven) is an orally disintegrating tablet indicated for both the treatment and prevention of migraine. The main AEs are nausea and abdominal pain.


; Allergan) is indicated for acute treatment of migraine. The most common AEs are nausea and somnolence.

; Eli Lilly and Company) is indicated for acute treatment of migraine. The most common AEs are dizziness, fatigue, paresthesia, and sedation.

An important consideration when talking with patients is the possibility of medication-overuse headache, also known as a rebound headache—part of a vicious cycle of having headaches and taking more and more medication to relieve them, which results in near-daily or daily headaches.

Patients who experience headaches every day, or almost every day, especially when the pain begins upon awakening, may be experiencing a medication-overuse headache. Refer the patient to a headache specialist, who can help the patient establish a new treatment plan that includes stopping acute medications, starting preventive treatment, and slowly reintroducing a limited amount of acute medicines as needed.

An essential consideration in either preventive or acute treatment is the presence of drug interactions. Pharmacists can help patients by checking for drug interactions and being especially aware of the possibility of serotonin syndrome, a life-threatening condition that is more likely to occur with triptans and other medications that increase serotonin levels.



Migraine facts. Migraine Research Foundation. Accessed April 12, 2021. 

https://migraineresearchfoundation.org/about-migraine/migraine-facts/

The timeline of a migraine attack. American Migraine Foundation. January 18, 2018. Accessed April 12, 2021. 

https://americanmigrainefoundation.org/resource-library/timeline-migraine-attack/

When headaches are more than a pain. Harvard Health Publishing. March 2019. Accessed April 15, 2021. 

https://www.health.harvard.edu/pain/when-headaches-are-more-than-a-pain

Know your headaches. Cedars-Sinai blog. February 8, 2018. Accessed April 12, 2021. 

https://www.cedars-sinai.org/blog/know-your-headaches.html

When to go to the emergency room for a headache or migraine. American Migraine Foundation. February 13, 2017. Accessed April 12, 2021. 

https://americanmigrainefoundation.org/resource-library/when-to-go-to-the-er-for-headache-migraine/

Trigger avoidance information. American Headache Society. Accessed April 12, 2021. 

https://americanheadachesociety.org/trigger-avoidance-information/

Ha H, Gonzalez A. Migraine headache prophylaxis. 

 2019;99(1):17-24. Accessed April 27, 2021. 

https://www.aafp.org/afp/2019/0101/p17.html

Mohanty D, Lippmann S. CGRP inhibitors for migraine. 

. 2020;17(4-6):39-40. Accessed April 27, 2021. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413335/

New drug class employs novel mechanism for migraine treatment and prevention. FDA. Updated January 29, 2019. Accessed April 14, 2021.

https://www.fda.gov/drugs/news-events-human-drugs/new-drug-class-employs-novel-mechanism-migraine-treatment-and-prevention

Aimovig- erenumab-aooe injection. DailyMed. Updated February 11, 2021. Accessed April 14, 2021. 

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b998ed05-94b0-47fd-b28f-cddd1e128fd8

Ajovy- fremanezumab-vfrm injection. DailyMed. Updated October 27, 2020. Accessed April 14, 2021. 

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=98e344ea-5916-4947-b6f2-4a76ccc04b6b

Emgality- galcanezumab-gnlm injection, solution. DailyMed. Updated September 28, 2020. Accessed April 14, 2021.

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=33a147be-233a-40e8-a55e-e40936e28db0

Vyepti- eptinezumab-jjmr injection. DailyMed. Updated February 21, 2020. Accessed April 14, 2021. 

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=79065861-6aa5-4d1f-829f-3a6471286b36

Mayans L, Walling A. Acute migraine headache: treatment strategies. 

. 2018;97(4):243-251. Accessed April 27, 2021. 

https://www.aafp.org/afp/2018/0215/p243.html

Ghlichloo I, Gerriets V. Nonsteroidal anti-inflammatory drugs (NSAIDs). In: 

StatPearls Publishing; 2021. Accessed April 14, 2021. 

https://www.ncbi.nlm.nih.gov/books/NBK547742/

Medication overuse headaches. Cleveland Clinic. Updated December 18, 2020. Accessed April 14, 2021.

https://my.clevelandclinic.org/health/diseases/6170-medication-overuse-headaches

Migraines can be disabling for those affected, but various pharmacologic and nonpharmacologic therapies are available.

Migraine Care: Prevention, Treatment, and Medication Management 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Drug Topics June 2021

Pharmacists Can Help Patients as Signs of Normalcy Return

New Nonstimulant Medication Is Approved for ADHD in Children

Social Media Incites the COVID-19 Misinformation Epidemic

Pharmacists’ Public Health Role Grows as Birth Control Prescribing Authority Expands

A Guide to HIPAA Compliance in the Pharmacy

Migraine Care: Prevention, Treatment, and Medication Management

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

Preventing Autoimmune Disease Flare-ups During the Summer

Enhancing Medication Adherence With Smart Packaging