Pharmacy News

Entries for March 2018

Northern Michigan Society of Health-System Pharmacists Regional Society Update

by Matt Satkowiak, Pharm.D., BCPS, clinical pharmacist, Munson Medical Center, Traverse City and northern regional representative


The landscape in northern Michigan may remain covered with snow, but Northern Michigan Society of Health-System Pharmacists (NMSHP) members are anxiously awaiting upcoming meetings in the spring. NMSHP is currently on winter break, following its last two meetings in October and November. The October meeting was held at Munson Medical Center, where Nicholas Torney, infectious disease pharmacist at Munson Medical Center, presented an update in the treatment of the bacteremic patient. The November meeting also took place at Munson Medical Center, where Katelin Anderson, PGY2 pharmacy practice resident in infectious disease at Munson Medical Center, gave an informative presentation on HIV treatment.


NMSHP is excited to offer its second Annual Meeting at the Otsego Club and Resort in Gaylord on April 14, along with two additional spring meetings on April 19 and May 17. The Annual Meeting will kick-off with keynote speaker Curtis Smith, professor of pharmacy practice at Ferris State University, whose presentation will focus on the topic of antiplatelet therapy and will also include presentations covering non-opioid options in pain management, oncologic emergencies, as well as two PGY1 resident research projects from Munson Medical Center PGY1 residents. This meeting will offer four hours of continuing education (CE) credits to attendees. The April monthly meeting will feature a presentation by Kevin Przbylski, pharmacist at MidMichigan Medical Center Alpena, who will be speaking on the topic of traumatic brain injury. The May meeting will also be held at Munson Medical Center, where Munson PGY1 and PGY2 residents will present their research projects. CE will be available at all spring NMSHP meetings, so look no further for a reason to come spend a day in beautiful northern Michigan!


For more information on upcoming meetings, please contact NMSHP president Emily Warner at

Posted in: Member News
In-TEG®-rating Thromboelastography Into Clinical Practice

By Zack LaDuke, Pharm.D., PGY1 pharmacy resident, St. Joseph Mercy Hospital, Ann Arbor


First introduced in 1980, thromboelastography (TEG®) is a diagnostic process that analyzes components of a patient's blood and allows clinicians to get a clearer picture of a patient's intrinsic hemostatic activity. Over the years, the technology has evolved into a point-of-care machine that can be used in multiple different clinical situations, including, but not limited to pre-operative, post-operative and trauma patients. On a general level, the different hemostatic components of the blood that the TEG® system analyzes includes: coagulation factors, heparin, cross-linked fibrin and platelets. To go more in depth, a demonstration of the TEG® interpretation result can be seen below (Figure 1). The R-value represents the time it takes for the patient to form the initial clot. A prolonged R-time is indicative of a clotting factor deficiency. The "Clot Strength (Fibrin)" component represents the amplitude of only the cross-linked fibrin clot. The "Clot Strength (Total)" component represents both the strength of the cross-linked fibrin and the aggregated platelets. Intuitively speaking, one would then be able to calculate the platelet component by subtracting the fibrin clot strength from the total clot strength. By analyzing each of these components, the clinician can determine if, and what type of, transfusion or procedure may need to be initiated for their patient.


Figure 1. Thromboelastography Interpretation Guide. Reference Ranges: R (4.6-9.1 mins), Fibrin Clot Strength (15-32 mm), Total Clot Strength (52-70 mm).

Several studies have shown that TEG® is an early predictor of coagulopathy. For example, at a level one trauma center that sees approximately 1,000 activations per year, TEG® was able to identify that of the patients with major active bleeding, 45 percent demonstrated hypercoagulability, 16 percent demonstrated hypocoagulability and nine percent had primary hyperfibrinolysis as the major cause of the bleed.1 Furthermore, there have been studies that show use of the TEG system has been associated with decreased resource utilization due to its ability to analyze each patient's hemostatic activity, resulting in targeted therapy. At The Toledo Hospital, usage of the TEG® system led to a 62 percent, 50 percent and 23 percent reduction in fresh frozen plasma (FFP), cryoprecipitate and platelets, respectively, per procedure. There was also a 50 percent reduction in reoperations for bleeding. This resulted in an estimated $250,000 annual savings for the hospital.2

As part of the primary care team, pharmacists have an opportunity to be involved in the interpretation of the TEG® assay and the subsequent treatment choice. Medications are either a cause or a solution to most of these hemostasis instabilities; therefore, it makes sense that a pharmacist would have a hand in the utilization of a TEG® assay. One instance where pharmacists would be valuable is deciding whether or not there is a need for prothrombin complex concentrate (PCC) for reversal of pre-admission use of either warfarin. By analyzing the R time, pharmacists will be able to interpret the affect that the anticoagulant agent may be having on the patient's hemostatic state. If the R-time is prolonged (>9.1 minutes), the patient would be deemed hypocoagulable, indicating that the patient may still have the anticoagulant on board and that administration of PCC would be appropriate. Another instance where a pharmacist would be involved in determining an appropriate course of action would be for the possible reversal of pre-admission antiplatelet use. For example, if the total clot strength is normal, but the fibrin component is larger than the normal reference range, then that would indicate that the patient is deficient in platelets and administration of 1-deamino-8-D-arginine vasopressin (DDVAP) may be appropriate if the patient was on an antiplatelet agent at home. A platelet infusion may be an appropriate intervention as well if the DDAVP proves to be inadequate.

In addition to determining appropriate transfusions for a bleeding patient, pharmacists will be able to assess certain drug therapies that the patient may be taking as an outpatient. By analyzing the clot strength of the platelets that the patient has, the pharmacist can determine if a patient on an antiplatelet agent, such as clopidogrel, is being treated with an appropriate dose. Furthermore, using this same analyzation could prove useful in determining when a patient who was using antiplatelet agents prior to surgery would be an appropriate candidate for operating. Instead of waiting an arbitrary amount of time before operating, the TEG® assay can be used to determine when the patient is back to normal platelet function.

With the implementation of the point-of-care TEG® system at St. Joseph Mercy Hospital Ann Arbor, the hospital is taking another step in the right direction for providing high-quality care for patients. Furthermore, the hospital will likely experience the added benefit of cost savings from utilizing less blood product resources in bleeding patients.


1. Johansson, PI. Treatment of massively bleeding patients: introducing real-time monitoring, transfusion packages and thromboelastography (TEG®). ISBT Science Series 2007;2(1):159–167.

2. Shapiro S, Fleming K, Rachwal W, Morant M. Case Study: The TEG® system has helped The Toledo Hospital save approximately $250,000 annually. Haemonetics Corporation website.

Posted in: Pharmacy Technology
Combating the Opioid Epidemic

By Marla Ekola, Pharm.D., BCPS, MBA, director of pharmacy, Memorial Healthcare, Owosso and Whitley Shaver, Pharm.D. candidate 2018, Ferris State University

In March 2016, Gov. Snyder created the Michigan Prescription Drug and Opioid Abuse Commission. In October 2017, the Trump Administration declared the opioid epidemic a national public health emergency. In Dec. 2017, Lt. Gov. Calley signed into law several bills which change how prescribers prescribe, dispense and administer controlled substances. These laws work to decrease opioid prescribing and increase utilization of the Michigan Automated Prescription System (MAPS). The new updated MAPS not only provides real-time prescription information but also has added features that help prescribers make informed decisions about medication use. While most of these laws focus on prescribers, their impact will definitely be felt in the pharmacy world as well. Here are some of the highlights and effective dates of these new laws.

New Michigan OPIOID Laws 


Date Effective

Pharmacists can fill C-II prescriptions in increments

Immediate Effect

When treating a patient for opioid-related overdose, the prescriber must provide the patient with information about substance use disorder prevention or treatment services

Immediate Effect

Prescriber must have a bona fide prescriber-patient relationship to prescribe a controlled substance. The Department of Licensing and Regulatory Affairs is required to promulgate rules defining what constitutes a bona fide prescriber-patient relationship by the effective date. If rules are promulgated by an earlier date, then the effective date will be the date in which rules are finalized. 

March 31, 2019

Prescriber must register with MAPS before prescribing or dispensing a controlled substance

June 1, 2018

Prescriber must review the patient’s MAPS report if prescribing more than a three-day supply of an opioid

June 1, 2018

Prior to prescribing methadone or buprenorphine for substance abuse, a prescriber must review the patient’s MAPS report

June 1, 2018

Before prescribing an opioid, the prescriber must provide information to the patient regarding the dangers of opioids

June 1, 2018

Before prescribing an opioid to a minor, the prescriber must obtain parental consent and a signature and counsel the patient and guardian on the risk of addiction and overdose.

June 1, 2018

For the treatment of acute pain, no more than a seven-day supply may be prescribed within a seven-day period

July 1, 2018


The Department of Licensing and Regulatory Affairs (LARA) will be providing funding for integrating the new MAPS with the electronic medical records (EMR) and pharmacy dispensation systems of hospitals, physician groups and pharmacies across the state to help combat the misuse of prescription drugs. Thanks to efficiencies in the implementation of the new MAPS system and additional federal grants, the state will cover full integration and one year of licensing fees for users that apply for the LARA funding within the next two years. However, if a health-system signs the terms and conditions, and their EMR vendor is enabled quickly, they may end up getting more than a year’s worth of licensing fees covered as the initiative runs until Aug. 31, 2019. It is advantageous to integrate early. Hospitals can apply with LARA and request software integration here.

Treatment Options

With these changes come several questions, including how to treat patients who will no longer be on these opioid medications. While there are several non-opioid pain management alternatives available, the treatment of addiction and opioid withdrawal has fewer options.

Opioid withdrawal alone is not life-threatening. It often presents similarly to a severe case of influenza.1 However, the severe discomfort associated with withdrawal acts as a barrier to sobriety for many patients. Along with symptom management, medication-assisted treatment (MAT), which combines Federal Drug Administration (FDA)-approved medication and psychosocial intervention, can assist in overcoming the barrier.

Some non-opioid medications can be used to reduce withdrawal symptoms and can be prescribed by any practitioner. The following chart lists these medications as well as the specific withdrawal symptoms they are used to treat.


 Adjunctive Medications to Use in Opioid Withdrawal

Medication to Treat Withdrawal

Withdrawal Symptom(s)

Alpha-2 adrenergic agonists



Tachycardia, increased blood pressure, anxiety, chills, piloerection




Insomnia, anxiety








Nausea, vomiting


 Medications for the Treatment of Opioid Use Disorder




Buprenorphine + Naloxone

Brand name(s)

Dolophine, Methadose


Bunavail, Suboxone, Zubsolv

DEA Schedule




Action at Opioid Receptors


Partial agonist

Partial agonist + antagonist

Requirements to prescribe

DEA-certified OTP

Prescriber with DATA waiver

Prescriber with DATA waiver

DEA = Drug Enforcement Administration; OTP = opioid treatment program; DATA = Drug Addiction Treatment Act

While these treatments should only be initiated in certified opioid treatment programs or by physicians with a Drug Addiction Treatment Act (DATA) waiver, opioid-addicted patients are commonly treated for non-addiction conditions in the hospital. If a patient on these medications ends up in your healthcare system, there are several important things to remember. To provide opioid agonist treatment for a patient during an acute hospital stay, there are steps that must be taken by the inpatient healthcare providers to ensure the safe and effective treatment of the patient. These steps are detailed in the chart below.

It is important for the pharmacy team to take the lead in helping these patients safely transition into and out of health-systems. Knowing limitations to prescribing, dispensing and discontinuing these medications can help ensure that our patients are cared for.

 Inpatient Use of Methadone and Buprenorphine for Opioid Use Disorder2,3 

Patient enrolled in an Opioid Treatment Program (OTP)

Patient NOT enrolled in OTP

Physician must:

  • Determine patient is enrolled in OTP
  • Contact OTP to:

o Confirm enrollment

o Verify dose

o Inform OTP of hospital admission

  • Document verification and OTP location in progress notes

o May delegate documentation to nurse or pharmacist

Pharmacist must:

  • Confirm proper documentation exists in patient chart

Opioid agonists may be used for opioid-dependent patients to prevent withdrawal if the following apply:

  • Patient is being treated for a condition other than addiction
  • Withdrawal would complicate the primary medical problem


NOTE: Inpatient physicians do not need a DATA waiver to prescribe opioid agonists for inpatient use


As patients transition out of the hospital, a prescription for buprenorphine would only be acceptable if the prescriber has a DATA waiver and intends to continue treatment of the patient’s opioid dependency out of his/her office-based practice.

Opioid Treatment Programs (OTPs) in Michigan4


Program Name

Phone number


CRC Recovery, Inc.

(734) 585-7970

Ann Arbor Treatment Services, LLC

(734) 544-1523


Harbortown Treatment Center

(269) 926-0015


The Brighton Center

(810) 229-9220


Premier Services of Michigan, LLC

(313) 277-3293


John D. Dingell VA Medical Center

(313) 576-1000

Nardin Park Recovery Center

(313) 834-5930

S.T.A.R. Center, Inc.

(313) 493-4410

Metro East Substance Abuse Treatment Corporation Harper/ Chalmers Clinic

(313) 371-0055

New Light Recovery Center, Inc.

(313) 867-8015

Wayne State University Physicians Group – Tolan Park Research Program

(313) 993-3964

Sunshine Treatment Institute, PLLC

(313) 368-4800

Institute of Supportive Services, Inc.

(313) 733-4528


Biomedical Behavioral Health

(586) 783-4802

Sacred Heart Rehabilitation Center, Inc.

(810) 732-1652


Michigan Therapeutic Consultants, PC

(989) 732-4357

Northern Michigan Substance Abuse Services, Inc.

(989) 732-1791


NuPoint Services

(616) 243-6262

Cherry Street Services, Inc.

(616) 965-8390


CRC Recovery, Inc.

(855) 380-8272


Rainbow Center of Michigan, Inc.

(313) 865-1580


Victory Clinical Services III, LLC

(517) 784-2929


Victory Clinical Services

(269) 344-4458


Victory Clinical Services Lansing

(517) 394-7867

Michigan Therapeutic Consultants, PC

(517) 272-4357

Red Cedar Clinic

(517) 371-1111


Ultimate Solutions, Inc.

(734) 513-2800


Sacred Heart Rehabilitation Center, Inc.

(810) 392-2167


Rainbow Center of Michigan

(734) 243-8707

Passion of Mind Healing Center

(734) 344-5269


Recovery Unlimited Treatment Center

(810) 785-4930


Michigan Therapeutic Consultants, PC

(989) 953-4357


Cherry Street Services, Inc.

(231) 767-1921


Eastside Outpatient Services, PLLC

(231) 739-4359


Metropolitan Rehabilitation Clinics, Inc

(248) 967-4310


Sunrise Treatment Center

(248) 481-2267


Biomedical Behavioral Health

(586) 783-4802


Victory Clinical Services IV

(989) 752-7867


Quality Behavioral Health

(313) 922-7777


Premier Services of Michigan, LLC

(586) 758-6670


Biomedical Behavioral Health

(586) 783-4802


Therapeutics, LLC

(248) 525-6832


  1. American Addiction Centers. Drug Withdrawal Symptoms, Timelines, & Treatment. Accessed March 2018.
  2. Substance Abuse and Mental Health Services Administration. Medication Counseling and Treatment. Accessed February 2018.
  3. Department of Licensing and Regulatory Affairs, Board of Pharmacy. Pharmacy—Controlled Substances. Accessed February 2018.
  4. Substance Abuse and Mental Health Services Administration. Opioid Treatment Program Directory. Accessed February 2018.

Posted in: Patient Safety
Demonstrating our Value: “Give me more students!”

By Dana Staat, Pharm.D., clinical pharmacy lead, internal medicine, Specturm Health-Butterworth, Grand Rapids and Michigan Society of Health-System Pharmacists immediate past-president

It’s true. I have uttered those words: Give me more students!

How many times in the last year have you wished for more students on rotation? Or maybe you haven’t offered a rotation for students because of time constraints, lack of ideas for student projects or competing responsibilities?

As I was considering the 2018 Michigan Society of Health-System Pharmacists (MSHP) theme of “Demonstrating our Value,” I reflected on my own professional practice site, and the most striking thing I noticed were the numerous opportunities that pharmacy students have on my rotation to demonstrate the value of the pharmacy profession.

The health-system that I work at, Spectrum Health, hosts 16 P4 students through a direct pharmacy experience program called the Spectrum Health Advance Pharmacy Practice Experience (SHAPPE) program. The 16 students in the SHAPPE program rotate through all their APPE experiences at Spectrum Health facilities. I precept a six-week APPE internal medicine (IM) rotation for P4 students. My IM partner and I have two students on our joint rotation each month. Every student on the IM rotation works with two clinical pharmacists each day. Many of the projects and activities that are completed by the IM students have been designed specifically around the consistent presence of students and are described below.

Participation in Interdisciplinary Rounds/Completion of Clinical Tasks/Pharmacy Consults

Students round with pharmacists daily on three different interdisciplinary teams. Depending on their experience and ability, students may also be asked to round independently. This experience often occurs toward the end of their P4 year. Students are responsible for working up each patient on rounds, paying special attention to patient home medications and the medication reconciliation process. Students are also integral to therapeutic drug monitoring and starting pharmacy consults. Students complete initial pharmacokinetic consults including monitoring and assessment as well as other specialized drug monitoring for drugs like argatroban, dofetilide and u500 insulin. After initial assessment, students will follow-up with their assigned pharmacist to discuss recommendations and write consult and handoff notes thereby saving valuable pharmacist time and allowing the students to develop their clinical skills.

Patient Counseling

Nearly all IM patient medication counseling is completed by P4 pharmacy students. Students are alerted to patients who require counseling by automated tasks. Students complete counseling on all new warfarin and direct oral anticoagulants. Students have also enabled our health-system to teach breastfeeding patients about lactation-medication concerns and breastfeeding medication safety. Discharge counseling on new medications is also completed by students on rotation.

Pharmacy Education-Clinical Pearl

In every block, students are formally assigned a complex drug information question to research. The students are responsible to research the question, assess the data and present their findings in a short presentation format. They develop a handout and distribute it to the rounding pharmacists. Their handout is also placed on the internal Spectrum Health website which are searchable for pharmacists’ future use.

Projects/Data Collection/Medication Use Evaluations

Every student completes one “extra” project while on their six-week rotation. Often these projects are items on our clinical project list. The students commonly complete new drug monographs for additions to formulary and/or drug class reviews. Recent projects have included a urea drug monograph and a long-acting muscarinic antagonist/long-acting beta2-agonist (LAMA/LABA) drug class review. Students may also complete medication use evaluations, such as the evaluation of inpatient adalimumab (Humira). A prospective medication use evaluation is planned to look at insulin discharge orders and instructions. Many SHAPPE students also complete their doctoral projects within Spectrum Health. Recent projects include “Evaluation of diabetic ketoacidosis treatment in the emergency department” and “Scheduled vs. as-needed pain medication in post-partum patients.”

At Spectrum, students can be utilized in many ways. By taking more students on rotation and designing consistent services around them, they can extend pharmacist clinical services in the hospital and demonstrate the value of the pharmacy profession in numerous ways.

Posted in: Professional Practice
Impact of New Legislation on Informatics and Technology

By Heather Somand, Pharm.D., BCPS, manager medication use informatics, Michigan Medicine, Sinai Grace Hospital, Ann Arbor


During the last week of 2017, Lt. Gov. Calley signed into law a number of bills addressing opioid prescribing, monitoring, education and consent. As clinical informatics pharmacists, we will be asked to develop functionality within our electronic health records (EHR) to address the new requirements and/or capture data for auditing purposes to assist providers in complying with the new requirements. In the following paragraphs, a description of each law, the date it goes into effect and potential implications to the EHR are described.

Senate Bill 166 (Public Act 248) is significant for prescribers and those that support the EHR. Effective Friday, June 1, 2018:

  • All licensed prescribers in Michigan must be registered with the Michigan Automated Prescription System (MAPS) before prescribing or dispensing a controlled substance
  • Prescribers will be required to run and review a MAPS report on all patients who receive a controlled substance prescription for greater than a three-day supply.

As a result, IT teams across the state may be asked to help facilitate compliance with these requirements by integrating the MAPS vendor, Appriss, into your EHR . This will make it easier for providers to check MAPS and/or develop a way to capture a MAPS check either automatically or through an attestation statement. Appriss is able to integrate within certain EHRs and provide single-sign on functionality. Of note, the latter requirement to check MAPS prior to prescribing a controlled substance does not apply to hospital inpatient orders, freestanding surgical clinic orders or veterinary prescriptions filled by a pharmacist.

Senate Bill 274 (Public Act 251) is also significant in that it limits a prescription containing an opioid for treatment of acute pain to a seven-day supply in a seven-day period. The bill does define “acute pain” and goes into effect July 1, 2018. IT teams should start brainstorming options to remind prescribers of this limitation. Options that may be considered include pop-up alerts to the providers during the prescribing process, education built into the short-acting opioid prescription orders, defaulting the sig and quantity in the orders to a seven-day supply, if possible, or limiting the prescription fields.

Some additional details about schedule II controlled substance prescriptions were mentioned in the bill including permitting a pharmacist to do partial fills for CII prescriptions in certain situations.

Senate Bill 47 (Public Act 252) requires prescribers to obtain and review a MAPS report before prescribing or dispensing buprenorphine, a buprenorphine containing medication or methadone to a patient in a substance use disorder program. Any actions taken to enhance your EHR to comply with Senate Bill 166 above should be followed here as well.

House Bill 4408 (Public Act 246) requires education and signed informed consent documents when prescribing an opioid to an adult or minor. In the case of minors, a specific form called the “Start Talking Consent Form” for parental consent is required before prescribing the first prescription in a single course of treatment for a controlled substance containing an opioid. This form must be a separate document from any other informed consent documents a prescriber may use. To see an example of the “Start Talking” document, see Ohio’s version here. The state of Michigan has indicated it will release the Michigan version by May, just in time for the June 1, 2018, due date. IT teams across the state should engage their Health Information Management teams now, since initially, this consent document will need to be uploaded into the EHR and easily accessible.

The bill does outline certain exceptions to parental consent of a minor’s treatment if related to a medical emergency, surgery, hospice or oncologic treatment. See the full bill here.

The second part of House Bill 4408 addresses education to all other patients prior to prescribing an opioid containing prescription and obtaining their signature indicating they received the education. The consent form will also be specific; although, the bill only indicates it will come from the Department of Health and Human Services. This document will also need to reside within the patient’s EHR.

Senate Bill 273 (Public Act 250) requires a licensee or registrant who treats a patient for opioid related overdose to provide information on substance abuse disorder services. Conveniently, the MAPS vendor Appriss provides some resources on their website by zip code, so the need to develop something home grown may not be necessary until the state further defines what information must be provided. This requirement goes into effect March 27, 2018.

Lastly, Senate Bill 167 (Public Act 249) and SB 270 (Public Act 247) both speak to the requirement of a bona fide prescriber-patient relationship. Although this may not directly affect IT teams, details are included incase you receive questions. Some providers initially questioned what this meant in relation to ambulatory clinic visits where a patient may see multiple providers within the practice. However, a bona fide relationship is defined as a prescriber who has all of the following:

  • Reviewed the patient's relevant medical or clinical records and completed a full assessment of the patient's medical history and current medical condition, including a relevant medical evaluation of the patient conducted in person or via telehealth.
  • Created and maintained records of the patient's condition in accordance with medically accepted standards.

If you would like to read the full bills, you can find them at Collectively as a state, we should identify the best methods within the EHR to address the legislative requirements from a technology perspective. I encourage you to get involved in the MSHP Informatics and Technology Committee. If you have questions about the Committee, feel free to reach out to me at Our next meeting is Thursday, May 3, 2018, in Okemos, Mich. We also have a Google group to post questions, benchmark with your colleagues and share experiences. If you’re interested, request membership by visiting!forum/mshp-informatics

Posted in: Laws and Regulations
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