Remember the first and one of the most important lines in the Oath of a Pharmacist? You likely recited it at least a few times in your career-during your white coat ceremony, your graduation, and attendance of either of these ceremonies. It is: 

“I promise to devote myself to a lifetime of service to others through the profession of pharmacy.”

 It is followed by another important statement: 

“I will hold myself and my colleagues to the highest principles of our profession’s moral, ethical, and legal conduct.”

Two Arizona pharmacists made headlines when it seems they may have not adhered to this pledge. 

In the first case, a community pharmacist chose not to fill a hormone prescription for a transgender patient. Based upon news reports, the pharmacist apparently denied filling the prescription and continually asked the patient why she needed the therapy, in front of other customers. The patient claimed the pharmacist refused to give her back the written prescription, forcing the prescriber to call in a new prescription to another pharmacy. The patient reported feeling “mortified.” She eventually filed a complaint with the Arizona State Board of Pharmacy.

In the second case, a nine-week pregnant woman was told by her prescriber that there was no fetal heartbeat and that her pregnancy would likely end in a miscarriage. The woman had two options: have a surgical procedure to remove the fetal tissue or take a medication, i.e., misoprostol, to produce a miscarriage. She chose the latter. 

When she presented the prescription to the community pharmacy, the pharmacist refused to fill it based upon “ethical beliefs,” and refused to give the prescription back. The patient left the pharmacy feeling “ashamed” and “humiliated,” and contacted her husband. The husband came to the pharmacy to explain the situation, but the pharmacist continued to refuse to fill the prescription. Eventually, the pharmacist sent the prescription to another pharmacy location where the patient was able to pick up the medication. She also filed a complaint with the Arizona State Board of Pharmacy.

In both cases, the pharmacists refused to fill the prescriptions based upon personal moral objections. And while I may morally disagree with their actions, they legally had the right to refuse to fill the medications. 

Arizona is a state with a law that allows pharmacists to refuse to fill a medication because of “sincerely held religious beliefs.” However, pharmacists must make a good faith effort to refer or transfer the prescription to another pharmacist to meet the clinical needs of the patient in a timely manner, as required by the Arizona law. By not doing so, pharmacists may end up getting fired (as was the case with the pharmacist who refused to fill the hormone prescription), and they may be investigated by the State Board of Pharmacy. 

If you live in a state that allows you to refuse to fill a medication based on moral or religious beliefs-and you have beliefs that could lead you to refuse-consider identifying pharmacists to whom you will be able to refer prescriptions. If you are a pharmacist who does not hold such beliefs, offer to be a referral for pharmacists who do. Also, review your own company and state policies to clarify how you should effectively manage a prescription that you are morally conflicted about. 

Doing so will allow you to continue to devote your lifetime of service to not only patients, but other pharmacists as well.

Articles

Two Arizona pharmacists made headlines when it seems they may have not adhered to the Oath of the Pharmacist.

Opinion: Upholding Our Oath 

The move toward value-based reimbursement can be a plus for health-system pharmacists.

Pharmacists can help health systems develop and meet benchmarks and performance targets in accountable care organizations (ACOs), bundled payment models, and other value-based systems.

Related article: Pharmacists Step into Leadership Roles

To help the C-suite recognize their value, pharmacists must show them that pharmacy is a cost saver, says Michael Korczynski, PharmD, BCAP, manager of clinical services, Pharmacy-Ambulatory Care, for 

 in Pittsburgh. “Dispensing medicine is about 1% of my career. I’m a provider of medication management services, educating patients, educating staff, ordering labs, ordering referrals, being a contributor to the development of policy and procedure.”

Korczynski is hardly an outlier. Pharmacists nationwide are following examples set by Kaiser Permanente, Geisinger Health System, the VA, and other integrated health systems that rely on pharmacists for comprehensive medication management services.

“These systems are so integrated that physicians and pharmacists work in a shared success model where the number one goal is to focus on the disease state,” says Fred Pane, RPh, senior director for pharmacy at Coordinated Health. “While you are taking cost out of the system by improving medication use and management, you are improving clinical outcomes. That’s what pharmacists can contribute to value-based reimbursement.”

There are two reasons more health systems don’t rely more heavily on pharmacy, says Eric Maroyka, PharmD, director of 

’s Center on Pharmacy Practice Advancement. One is some health system leaders don’t recognize the value pharmacists bring. The other is pharmacy managers and directors don’t reach out to executives.

“You have to be proactive,” Maroyka says. “The level and complexity of drug therapy today is such that you cannot manage either outcomes or costs without the assistance of a pharmacist. [ASHP] members are finding success by thinking like the C-suite, learning what is important to them, and weaving a story that resonates around quality, revenue, and spending.”

The key step in helping an organization meet value-based targets is getting leadership to buy in. But don’t wait until value-based contracts have been signed.

“You have to have a seat at the table when quality, financial, and clinical are discussing and following up on value-based plans,” says Ashley G. Woodhouse, PharmD, manager of the St. Joseph’s/Candler 

 in Savannah, GA. “You have to know exactly what kind of value-based plans are being considered, the benchmarks being used, and what is not being assessed even if we know it should be.”

Related article: 10 Tips for New Pharmacy Managers

ACOs that track costs using the Medicare Savings Program, for example, are focused on Part B costs. Leaders need and want pharmacy to help manage Part B medications. “What you, in pharmacy, focus on,” Woodhouse says, “depends on the value-based programs your system is involved with.” 

Pharmacists add value, but you need to show that to health-system executives.

Pharmacists Help Meet Value-Based Targets

When a 71-year-old woman left the hospital after being treated for uncontrolled hypertension and acute kidney injury, her medication list included prescriptions for amlodipine (Norvasc), metoprolol, and doxazosin. 

Over the next few months, the woman’s health continued to decline and she experienced fatigue, personality changes, and a “stoic” facial expression. She returned to the hospital several times and underwent an angioplasty after complaining of chest pain.

On her third trip to the emergency room, she was described as having a shuffling gait and bradykinesia. Her creatinine levels were elevated, but medical professionals could not determine the cause of her symptoms until a medication reconciliation revealed she’d been mistakenly given the antipsychotic Navane rather than Norvasc at her outpatient pharmacy three months earlier.

Related article: Top 5 Tips for Preventing Medication Errors

It was a mistake that caused significant negative health effects and 

 in a 2016 Journal of Community Hospital Internal Medicine Perspectives article.

Experts say this isn’t an isolated incident.

Medical errors of all kinds, including medication errors, are now the third highest cause of death in the United States and may be responsible for 10% of all deaths in the country, 

 by Johns Hopkins Medicine. According to the

, preventable medication errors harm 1.5 million Americans annually and cost hospitals an additional $3.5 billion each year.

“I think the problem is becoming worse because this is a complex medical system that we have,” says Deborah A. Pasko, PharmD, MHA, senior director of medication safety and quality for 

Strategies to prevent medication errors in recent years include a move to electronic prescribing and adding barcodes to drug products. But experts say these efforts have not eliminated the need for vigilance among pharmacists, technicians, and other healthcare professionals in the community and hospital setting. Here’s more on the actions pharmacists need to take to avoid some of the most common medication errors.

In busy community pharmacy settings, the most common errors are related to processing more than one prescription in a confined space, 

 Editorial Advisor Michael R. Cohen, RPh, MS, FASHP, president of the Institute for Safe Medication Practices (

), says. ISMP is devoted to improving medication safety and runs a voluntary practitioner medication-error reporting program.

“They put one patient’s prescription in another patient’s prescription, and then once it’s in the bag, they often will seal the bag,” Cohen says. The patient is sent home with the wrong medication and may not realize it. “It’s a very common thing when people come home with someone else’s bag due to this type of mix-up,” he says. “Usually it’s because [pharmacists] are working quickly.”

Cohen says the error can be avoided by leaving the prescription out of a bag until the patient arrives to pick up the medication.

 in Two Rivers, WI, goes one step further. It performs a “show and tell” on every prescription. 

 Editorial Advisor Marvin Moore, PharmD, owner of the pharmacy, says during patient counseling sessions they actually open up the bottle, pour some of the pills out onto the counter, and show them to the patient. This not only ensures the patient has the right prescription before they leave the pharmacy, but also opens up a dialogue between the patient and pharmacist.

“There are opportunities to catch things where the patient will say, ‘Oh, that was supposed to be changed,’ or, ‘I am supposed to take two a day now instead of one?’” Moore says.

If a potential error is noted, pharmacists contact the prescribing physician to verify any prescription orders.

Electronic prescriptions were introduced to reduce medication errors and have been said to increase adherence to first fill medications since their introduction.

In recent years, electronic prescribing systems have been embraced by most prescribers in the United States. According to 

 from SureScripts, 77% of all prescriptions in 2017 were delivered electronically.

Related article: Why Drug Labels Are Set Up for Failure

But while experts say it’s been a move in the right direction, electronic prescribing hasn’t eliminated medication errors. Electronic systems just pose different types of error-related problems, says Carter High, PharmD, director of legislative affairs for 

 in Texas. “The downside is they are only as good as the people who put in the information on the other side.”

Cohen says common errors include selecting the wrong item from the computer screen.

Moore says electronic prescribing can also introduce confusing or conflicting instructions in the patient directions, or Sig (signetur/label). “We also get a lot of prescriptions where they will pick a drug and a strength, and then in the Sig they’ll have a different strength,” he says.

Related article: What Bartenders and Pharmacists Have in Common

For instance, a prescription may be written for 20 mg of prednisone, but then the instructions will say to take 5 mg daily. Moore says the error may occur because prescribers don’t know how to correct certain defaults in the system, or they accidentally select the wrong strength from a dropdown list.

To avoid this type of error, Moore’s staff looks back at previous prescription data for a patient and follows up if there are any dose changes or other significant alterations to a prescription.

“We make a lot of calls during the day to prescribers’ offices to clarify,” he says. “Basically any time we see a change, if there’s not a note that says dose decrease or dose increase, then we call to verify, because you just don’t know. We’d rather be on the safe side and pester the nurse a little bit versus hand out the wrong strength.”

Best Value Pharmacies has implemented a six-point check that requires technicians and pharmacists to verify the patient’s name, drug name, strength, directions, quantity, and doctor for each prescription they fill to reduce errors. Walgreens has also instituted a multistep prescription filling process with numerous safety checks built in to reduce human error, says Tasha Polster, RPh, vice president of Pharmacy Quality, Compliance, and Patient Safety. “We continually evaluate ways to enhance our operations, technology, and training to help improve healthcare delivery and promote a culture of continuous quality improvement.”

Another common time for medication errors is during transitions of care when patients move to different types of settings, such as the hospital to home, or from a rehabilitation facility to a long-term care center.

“The more steps we build in and the more transitions of care we have, unfortunately, it brings to light broken systems and where things could happen,” Pasko says.

This can be particularly problematic for 

 prescriptions, as there is no longer a standard concentration in insulin products. Many hospitals may only carry certain types of insulin on their formularies or may use a different concentration than the patient uses as an outpatient. This can create potentially dangerous situations.

Pasko says pharmacists should always be involved in transitions of care if possible. If a patient is being seen in an outpatient setting, Pasko, who used to work in a pediatric intensive care unit, says pharmacists need be proactive and ask patients questions such as whether any of their medications seem different, whether they look the same, and what time of day they are taking medications.

“If a patient comes to me and says, ‘At home I was taking it and it was peach and round and now it is green and oblong,’ that would prompt me to just take a step back and verify that’s the right thing,” she says.

Given the increased chance of a medication error during a transition in care, Moore says his pharmacists typically do a medication reconciliation for anyone recently transitioning from one care setting to another.

Related article: How to Differentiate Between Look-Alike Sound-Alike Drugs

Alerts are designed to warn healthcare providers about potential allergies, adverse reactions, or other health concerns, but they also bombard busy healthcare providers with information that may not be clinically relevant.

The result is that these alerts can be overridden or ignored. According to one 2013 study published in PLOS One that examined providers habits for drug-drug interaction warnings, more than 30% of alert overrides were considered inappropriate and subsequently put patients at increased risk for adverse events.

“That is a very, very common problem where people just hit the return key when they see an alert up on the screen,” says Cohen, who is also cochair of an allergy alert subcommittee for the National Information Technology Collaborative.

Related article: Four ways Pharmacists Can Improve Patient Counseling Skills

He points to a recently reported case in which a woman’s health history included information that she was allergic to fluoroquinolones. Yet, when she developed a urinary tract infection, a resident in the emergency room placed a verbal order for Levaquin. The nurse processed the order, as well as the pharmacy, never noticing the system alert to the allergy. They were about to administer the drug, when the woman told them of her allergy and refused to take it.

Medication errors also occur when pharmacies or electronic prescribers confuse similar sounding drug names. Tall man lettering, or capitalizing unique portion of a name, was designed to reduce these types of errors, but Cohen believes it isn’t fully being utilized.

He says the FDA has required manufacturers to use tall man letter for 20 name pairs but says ISMP believes this list should be expanded. The strategy would be more effective if the differences in drug names were highlighted by more than just capital letters, he adds.

“What we need to do is enlarge the font, not just with capital letters, but twice the size,” he says. “We need to bold those letter characters, we need to italicize them, we need to put background on them so they shout out to you: This is different.”

Other errors occur when pharmacists try to work too quickly or select the wrong containers. For instance, a pharmacist loading three containers into an automated dispensing machine may scan the barcode on one of the containers three times rather than scanning each one separately.

An effective strategy to preventing these type of errors is improving communication within the pharmacy and with patients.

High, who also serves as the operating manager for Best Value Rhome Pharmacy in Texas, holds monthly meetings to discuss potential errors that he caught before they left the pharmacy, using the meeting as a chance for his staff to learn.

“The feedback has worked really well,” he says, adding that in the last nine months that he’s been holding the meetings, the number of potential errors has been reduced by 70%.

Related article: Top Ways Pharmacists’ Roles Are Changing

Cohen says pharmacists also need to make a more concerted effort to talk with patients when a prescription is filled, particularly for high-alert drugs such as anticoagulants or insulins.

Technology can also be a critical aspect of reducing medication errors that can occur throughout the medication use cycle, such as barcode scanning, integrated electronic health orders, and tools such as smart infusion pumps.

“We really see the organizations that are moving the needle are the ones that have truly integrated electronic systems, which many still do not,” Pasko says of hospital settings.

, which promotes sound deployment of medication-use automation, says bedside barcoding in hospitals is now nearly universal. It’s effective and reduces errors, as long as it’s used correctly. “If somebody gives the medication and then scans later, that’s like not putting your seat belt on until you are on the highway,” he says.

Neuenschwander is also a proponent of technology used to prepare medications that have to be reconstituted or remixed at a hospital.

Related article: Your 10 Worst Pharmacy Mistakes

“Liquids are high risk. So, we can use the same technologies in the clean room as we use at the bedside,” he says. This includes an automated check list of the recipe, product verification tools that use barcoding, and volume verification that must meet all the requirements before a label and barcode can be made.

Only about 20% of hospitals currently use this type of technology, and may not use it for everything, but he hopes it will become more widespread, says Neuenschwander, a 

 editorial advisor. “I am not going to rest until we have universal adoption of preparation technologies for compounding,” he says. 

Drug errors generally fall into one of four categories-here's how the experts say those errors can be eliminated. 

How to Prevent the Top 4 Medication Errors

Cisplatin or carbaplatin? Prednisone or prednisolone? Similarities between many drug names are a source of continuing confusion and medication errors. One method to reduce this confusion is “tall man lettering,” using capital letters, or bold face, or another color, to distinguish the different parts of two similar drug names. PredniSONE and prednisoLONE, for example.

In 2001, the FDA requested that makers of 16 generic drugs with look-alike names use tall man lettering on labeling, according to Michael Cohen, RPh, MS, FASHP, president of the Institute for Safe Medication Practices (

 of look-alike names that it recommends be given the tall man treatment, Cohen says. Cohen is a member of the 

But does using capitals or boldface really help differentiate look-alike drug names or preventing errors? No, says Bruce L. Lambert, PhD, director of the Center for Communication and Health and professor at 

 School of Communication. “There is no evidence that tall man reduces the rate of drug confusion errors in a real clinical practice setting. None,” he tells 

Although several studies have been done in simulated circumstances rather than real pharmacies, the results have been mixed, Lambert notes, which Cohen agrees with. Results appear to depend on whether studies were done on health professionals or laypeople and other factors. The 

 done in real-world circumstances was conducted in children’s hospitals over nine years and found no significant reduction in medication errors after tall man lettering was introduced.

That study had flaws, says Lambert, but it shows no benefits in a real clinical setting. “It’s not a perfect study, but it still is the only really good large-scale study we have,” he says.

Cohen says more analysis would be good. “I would love to see a real-world study where they go into pharmacies and look at whether or not people choose the wrong item.”

With tall man lettering, some efforts just capitalize parts of the name when more should be done, says Cohen. The drug name should include “anything you can do-color, underlining, italics, background-to make those letter characters stand out so that it catches people’s attention,” he says.

And it is not just about labeling, Cohen says. Databases and electronic prescribing systems should be amended to use as many ways as possible to differentiate look-alike names.

One of advantage of tall man lettering is that it is inexpensive. Labels costs little, and making changes to databases might have some costs at first due to new programming, but not much, Cohen notes.

There are few downsides to using tall man lettering. The biggest, according to Lambert, is that it can confer a false sense of security that enough has been done. “Everyone’s doing tall man because it’s cheap and easy, but you’d better keep measuring your error rate, you’d better keep doing other things, because  . . .  if you’ve just implemented tall man, that’s not enough.”

Related article: The Top 4 Medication Errors Your Patients are Making

Barcoding is one of the best ways to help keep from confusing two similarly named drugs, both Cohen and Lambert say. “So as long as the name is entered correctly, and the order is processed, the pharmacist is going to scan in the container and get an error message,” Cohen says.

Using indication alerts would also cut down on drug confusion, Lambert says. If the EHR alerts that a drug being prescribed does not match a patient’s disease or condition, it could prevent a patient from getting a vial of hydralazine rather than hydroxyzine, he says. 

Tall man lettering is supposed to help reduce medication errors-but some say it doesn’t go far enough.

Why Drug Labels Are Set Up for Failure

Express Scripts’ 2019 Formulary Exclusions

Express Scripts’ 2019 National Preferred Formulary excludes certain blockbuster drugs. It also removes new categories of medications that the 

 had shied away from excluding in the past.

The annual list of excluded medications encompasses 48 new medications, including the anticoagulant dabigatran (Pradaxa), the hepatitis C medication sofosbuvir (Sovaldi), and the HIV antiviral combo drug efavirenz/emtricitabine/tenofovir disoproxil fumarate (Atripla).

New therapy areas with excluded drugs include hemophilia, HIV, and hereditary angioedema.

Related article: Pharmacy Community Reacts to Cigna/Express Scripts Deal

“The reasons for the exclusions are likely multifactorial. One reason could be changes in cost, but it may also be due to the increased competition within the class,” Jeremy Schafer, PharmD, senior vice president at 

Schafer is concerned about the exclusion of drugs for rare diseases, such as hemophilic factor (Xyntha) for hemophilia A, and C1 esterase inhibitor (Berinert) for hereditary angioedema. “Patients may be started on these products in the hospital and then discharged home. Will the patient be stopped by an exclusion and have a delay in therapy as the doctor files for a prior authorization or considers an alternative?”

However, Express Scripts says formulary preference is given to high-value therapies with the lowest net cost for clients, achieved through low list price, rebate or both. For example, efavirenz/lamivudine/ tenofovir disoproxil fumarate (Symfi, and Symfi Lo) are preferred to treat HIV-1. Those medications have 40% lower list prices than Atripla.

Meanwhile, CVS Health will likely announce its 2019 formulary changes in early October. It is expected to exclude 23 drugs, and add four. 

CVS Health’s MinuteClinic recently launched 

, which will provide patients with access to healthcare services 24 hours a day from their mobile devices.

MinuteClinic partnered with Teladoc to offer Video Visits, which are initiated through the CVS Pharmacy app. “Patients who opt to seek care through a fully customized MinuteClinic Video Visit experience the same high-quality, evidence-based care they receive at traditional MinuteClinic locations inside select CVS Pharmacy and Target stores,” CVS Health says.

The Telehealth service is for patients with minor illnesses and injuries. MinuteClinic charges $59 for the visits, and will add insurance coverage over the next few months.

The service is available in nine states-Arizona, California, Florida, Idaho, Maine, Maryland, Mississippi, New Hampshire, and Virginia-and Washington, DC. CVS Health expects Video Visits to be available nationwide, where allowed, by the end of this year.

Online Pharmacy Delivery Service Threatens Amazon, Drug Stores

Amazon and PillPack have yet another major competitor in the growing online pharmacy business-and drug store chains have reason to be concerned.

, which boasts same-day delivery for prescriptions and a frictionless, personal pharmacy experience, recently landed $50 million in funding. The funding boost will allow Capsule, currently operating in New York City, to expand nationwide in the future.

After Amazon acquired PillPack, which delivers medications in presorted dose packaging and coordinates refills and renewals, earlier this summer, drug store chains’ stock sank. CVS Health, Walgreens Boots Alliance, and Rite Aid collectively lost more than $11 billion in stock market value the day the news was announced.

Capsule Founder and CEO Eric Kinariwala doesn’t seem fazed by competitors such as PillPack. “We’re definitely excited to see that Amazon has entered the space with PillPack, as its further validation that the conventional pharmacy experience is broken. Increased momentum toward fixing the problem is great for everybody,” he tells 

Related article: What Amazon’s PillPack Acquisition Means for Your Pharmacy

Capsule differs from other online pharmacies and traditional brick-and-mortar drug stores, Kinariwala contends. “Traditionally, digital commerce companies have used their technology to remove human interaction, but at Capsule, we’ve built our platform to amplify its power in your healthcare.”

For example, Capsule handles patients’ prescription refills, and coordinates with doctors and insurance companies, so consumers don’t have to deal with them when filling scripts. It promises to provide caring, friendly service in which consumers “never have to wait in line again.” The company website says, “Never talk to a voicemail autobot. Text, call, email, or chat with your pharmacist whenever is convenient.”

In addition, Capsule is not simply “layering on” delivery services, like many conventional pharmacies, Kinariwala says. “Our view is that delivery will become a commodity and that it is only part of the solution. Where Capsule differentiates is that it’s been specifically designed to connect humans and technology at every point to create value for all the stakeholders in healthcare.” 

Contaminated Synthetic Marijuana Products Killing Users

 is warning about severe illnesses and deaths from the use of contaminated synthetic cannabinoid (marijuana) products.

The products, sold at convenience stores and gas stations, are contaminated with brodifacoum, a very long-acting anticoagulant commonly used in rat poison. The marijuana substitutes are sold under the names “K2,” “Spice,” and others.

Over the past few months, hundreds of individuals in about 10 states have been hospitalized after experiencing severe bleeding. Several deaths have also been reported, according to a statement from the FDA Commissioner Scott Gottlieb, MD, and other officials.

“Use of these illegal products pose significant public health concerns for both individuals who may use the contaminated products and the U.S. blood supply, as there is the potential for contamination of blood products donated by those individuals who have used these substances,” say the FDA officials.

A number of synthetic marijuana products are being illegally marketed. The FDA has worked with the DEA to place several synthetic cannabinoids into Schedule I of the Controlled Substances Act to avoid an imminent hazard to public safety.

“Individuals who have possibly used synthetic marijuana products should be vigilant for signs of bleeding. These include easy bruising, oozing gums, and nose bleeds. People experiencing these symptoms after using synthetic marijuana products should immediately seek medical attention, as the effects of brodifacoum are treatable,” Gottlieb and his colleagues say.

“We also want to alert healthcare providers, particularly those delivering care in emergency settings, to be aware of these risks and consider the possibility of synthetic cannabinoid exposure when individuals present with unexplained bleeding. Standard coagulation tests, such as the prothrombin time, can be dramatically elevated in these settings, and prompt treatment with high doses of vitamin K and other supportive care can potentially be life-saving,” Gottlieb and his colleagues add. 

Opioid Dosages Increase, Despite Awareness

The dosages of opioids increased over a 10-year period in the United States, particularly among disabled Medicare beneficiaries.

, published in the August 1 issue of BMJ, lead author Molly Moore Jeffery, PhD, scientific director of emergency care research at Mayo Clinic, wrote that disabled Medicare beneficiaries had the highest rates of opioid use, the highest rate of long-term use, and the largest average daily dose.

The retrospective cohort study of administrative claims data examined opioid prescribing trends from 2007 to 2016. Researchers examined data from 48 million individuals, including commercial beneficiaries, Medicare Advantage beneficiaries aged 65 years and older, and Medicare Advantage beneficiaries less than 65 years old (due to permanent disability).

In the group of patients on permanent disability, both quarterly use rates (39%) and average daily dose (56 mg morphine equivalents or MME) were higher at the end of 2016 than the low points observed in 2007 for each end point (26% prevalence and 53 MME).

“Opioid use and average daily dose have not substantially declined from their peaks, despite increased attention to opioid abuse and awareness of their risks,” Jeffery writes. 

How Patients Really Feel About Opioid vs. Nonopioid Meds for Chronic Pain

A new study investigated pre-existing perceptions about pain medications by individuals with chronic pain and how these perceptions relate to patients’ experiences with these medications.

in the Journal of Pain, the journal of the American Pain Society, found that, despite strongly held beliefs about opioid and nonopioid medications, patients were often surprised by their results.

The study provides insights into the results of “The Strategies for Prescribing Analgesics Comparative Effectiveness” (

) trial, which compared benefits and harms of opioid versus nonopioid medications over 12 months for chronic musculoskeletal pain. SPACE found that opioid meds were not better at improving pain that interfered with walking, work, or sleep over 12 months for individuals with chronic back pain or arthritic hips or knees compared to nonopioid medications. SPACE also found that adverse medication-related symptoms were more common in the patients who took opioids.

Related article: Four Ways Pharmacists Are Fighting Opioid Abuse

For the Journal of Pain study, Marianne Matthias, PhD, Regenstrief Institute investigator, and colleagues, interviewed 34 SPACE participants, all of whom were patients at a VA hospital.

“Patients’ expectations do not always match their experiences,” says Matthias. “Patients in this study, who for the most part believed that opioids were the strongest pain medicines available-even if they didn’t want to take them-were often surprised when either: 1) the opioids didn’t work as well as they thought (for patients randomized to the opioid arm), or 2) when nonopioids, such as NSAIDS or topical creams, helped reduce their pain much more than expected (for patients randomized to the nonopioid study arm). Most patients seemed not to be aware of the large number of options available to them or that many of these (nonopioid) options can actually be quite effective for pain relief.”

In addition, patients in many cases learned that function was more important than pain levels, according to Matthias. “In other words, some patients described having lower pain on opioids but not being able to do much of anything because of the lethargy associated with these medications. On the other hand, some patients who took nonopioids described being able to do more-be active, play with their kids, etc. It would be important . . . to work to manage patients’ expectations to keep patients open to trying a number of other treatment options, and to shift patients’ focus from pain levels/intensity to function, i.e., what they are able to do.”

The September Small Doses brings you the latest news that affects pharmacists.

Online Pharmacies, Formulary Exclusions, and More News

A certification program in compounded sterile preparation (CSP) will benefit both pharmacy technicians and pharmacists, and indicates how the technician’s role is evolving.

Since the program launched last December, the Pharmacy Technician Certification Board (

), has granted more than 300 Compounded Sterile Preparation Technician (

) certifications. These certify pharmacy technicians in the compounding of medications prepared using aseptic techniques.

Related article: FDA Adds New Compounding Pharmacy Regulations

“Certifying technicians who prepare CSPs with the CSPT Certification helps advance the level of medication safety and strengthens the pharmacy team,” William Schimmel, executive director and CEO of PTCB, tells 

In addition to improving medication safety and offering professional advancement opportunities to technicians, the certification can assure pharmacists in charge of final checks on CSPs that their CSPTs are knowledgeable and qualified to compound IV solutions, including chemotherapy IVs.

CSPs are made in hospitals and health systems, at infusion centers, community pharmacies, and compounding centers. In hospitals for example, with the assistance of a CSPT, pharmacists would have more time to devote to safety checks, and preparing drugs for IV use and other regimens. 

An advanced certification represents an opportunity for technicians to move up in their careers. In addition, the certification improves patient safety for the overall benefit of the pharmacy.

“The new certification reflects the changes that are happening in the pharmacy profession as pharmacists play a greater role in the delivery of healthcare,” Schimmel says. “The CSPT certification is another rung on a career ladder for technicians. Motivated, professional teams with low turnover are going to perform better. This can contribute to better medication outcomes and decrease long-term costs,” he says.

The CSPT program is the first new certification program PTCB has offered since the organization was founded in 1995.

Allen L. Horne, RPh, an oncology pharmacy specialist at 

, Columbia, SC, says, “Technicians are finally being rewarded for their knowledge of sterile compounding. Now they can bring a new level of expertise to the IV team, and raise the level of safety and quality.”

Horne, who chaired the CSPT Exam Development Committee, explained that his hospital is developing a career ladder for pharmacy technicians since the certification was created. “With CSPT certification, the technician may rise up a level on the ladder and be recognized as being set apart from beginning technicians. Depending on their current level on the career ladder, they may also be incentivized through salary increases.”

“CSPT certification raises the safety and quality level of sterile product preparation, and frees up hospital pharmacists, giving them added time to calculate dosing, review drug regimens, and generally devote more time to supervisory tasks, including checking patient records for drug interactions,” Horne adds.

Related article: Four Ways to Help Pharmacy Technicians Improve Job Performance

, a compounding pharmacy in Leesburg, VA, says that her pharmacy already uses technicians in sterile compounding. “Still, I would definitely consider the (CSPT) certification for our technicians,” Garvin says. “Certification represents a more standard approval and would be better than one person training another,” she adds, noting that certification would expand a technician’s knowledge base and help improve career opportunities. “Certification would really help the smaller pharmacies, which have limited staff for training,” she noted.

A CSPT must recertify each year, which requires completing five continuing education hours in sterile compounding and the submission of a supervisor’s attestation form, according to PTCB.

How a new program is benefiting techs, pharmacists, and patients.

New Pharm Tech Certification Is Taking Off 

In February, the DEA Office of Diversion Control moved to revoke a Florida pharmacy’s certificate of registration, a decision that should make pharmacists take notice.

 This decision can educate pharmacists and technicians on what to do before the Feds enter the pharmacy.

Trinity Pharmacy II is a full-service family-owned independent pharmacy in Clearwater, FL, that specializes in compounding.

 In February 2018, the DEA Office of Diversion Control 

 proposing revocation of Trinity II’s DEA Certificate of Registration for its Clearwater location, alleging that the pharmacy’s “continued registration is inconsistent with the public interest.”

The DEA’s order set forth several reasons,

 saying that Trinity II failed to comply with 

 and dispensed controlled substances outside the usual course of pharmacy practice. The order alleged it ignored red flags and dispensed prescriptions without resolving those red flags. In addition, the DEA alleged the pharmacy, on at least one occasion, dispensed “a Schedule II controlled substance outside the usual course of professional practice . . . and in contravention of its corresponding responsibility.”

 in FDA Law Blog noting Trinity II was a “must-read” for any pharmacy registrant or their counsel.

 The DEA revoked one pharmacy controlled substance license in 2017, but by mid-2018, has revoked four, including Trinity II, he says.

Of particular note is the DEA’s discussion of the pharmacy’s 

, or knowledge of wrongdoing, often referred to as intent. In particular, the hearing officer looked at the concept of “willful blindness,” ignoring what was in plain sight.  

An important government witness was its pharmacy expert 

 A red flag is “a term that’s come to be used to give examples to pharmacies of things that might indicate or suggest that prescriptions were filled outside the usual course of pharmacy practice,” he said in testimony. A red flag could be indicative of abuse or misuse, over or under compliance, drug-drug interactions, or a “forged or altered prescription.”

More from the author: Refusal to Fill Prescriptions Under Conscience Clauses

Such issues would be reviewed and resolved by a pharmacist “before filling any prescription” as part of the “prospective drug use review,” the testimony states. The pharmacist’s resolution of these red flags “would be documented on the face of the prescription, on the rear of the prescription, or in the patient profile.” The standard of practice regarding such documentation is that it has to include a reason that makes sense to the average pharmacist and that the prescription is legitimate despite the red flag(s). In other words: “If it’s not written down, you didn’t do it.”

Why pharmacists need to be paying attention to the Trinity II case and its consequences.

Drug Topics September 2018