Pharmacy News

Entries for May 2017

Opioid Epidemic: The Opioid Exit Plan

Scott Kollmeyer, Pharm.D., PGY1 pharmacy practice resident, St. Joseph Mercy Hospital, Ann Arbor

 

Opioid use and prescribing has been on an astronomical rise since 1999. According to the Centers for Disease Control and Prevention (CDC), opioid prescriptions have quadrupled from 1999 to 2014, while the amount of pain reported has stayed the same.1 Michigan clinicians are not immune to this issue and are actually among the largest prescribers of opioids with close to one opioid prescription per person.1 Nationwide this increase in prescriptions has correlated with a four-fold increase in opioid-related deaths to approximately one death per 10,000 people per year.1 This is an extensive problem that will only progress farther if practices are not changed.

 

Some of the highest rates of opioid prescribing occur after surgery. Approximately 50 percent of patients who undergo surgery are discharged with an opioid prescription.2 Many patients are prescribed quantities greater than what is required for their pain management. In a survey published in the Journal of the American Medication Association, over half of respondents had or expected to have leftover medications, and of those, 60 percent were keeping the opioid for future use.3 One particularly concerning statistic from this study is that one out of five respondents reported sharing their opioid medication with another person.3 These concerns are the focus of several opioid related programs at St. Joseph Mercy Hospital –Ann Arbor (SJMH-AA).

 

In order to combat these issues, several initiatives are ongoing in the surgical population (orthopedic, colorectal, neurologic and most recently, gynecologic) at SJMH-AA to standardize and reduce opioid prescriptions in the post-operative patient population. The goals of these initiatives are to adequately treat the patient's pain while giving the patient an opioid exit plan to help taper off of their opioid medication. An important aspect of pain management and reducing opioid use is utilizing non-opioid therapies. While in the hospital, all patients without contraindications are started on scheduled around-the-clock acetaminophen and ibuprofen as the backbone of the pain regimen. An opioid is started for breakthrough pain, typically oxycodone 5mg every four hours as needed and adjusted based on the pain requirements. The opioid utilized in these patients is oxycodone because it is not combined with acetaminophen and can be tapered down without affecting the amount of acetaminophen the patient is receiving. Intravenous opioid medications are avoided if possible, and patients are transitioned to oral medications as soon as appropriate. This regimen is continued until the patient is ready for discharge.

 

One of the most important aspects of these programs is the discharge plan. When ready for discharge, patients are given a written tapering schedule that walks through a stepwise plan to safely decrease their opioid medication. To aid in the taper, the smallest strength tablet is prescribed even if larger doses have been required while in the hospital. This allows the patient to easily decrease the dose without splitting tablets and offers some flexibility when designing the exit plan. The plan is individualized based on the opioid need during the 24-hours leading up to discharge. The general structure of the plan is to decrease the dose or frequency every two to three days (example provided below). The exit plan generally lasts one to two weeks, and the quantity written should reflect the tapering plan. Importantly, the scheduled around-the-clock acetaminophen is continued for the entire duration that the opioid is used, and the scheduled ibuprofen is continued for one week. Also included in the exit plan is information for the proper disposal of medications. This is a general guideline for tapering opioids; however, every patient is unique and experiences pain differently and therefore may require alterations to the original plan. Close follow up is necessary to make sure pain is adequately controlled and that the taper is going well.

 

Here is an example exit plan for a patient who received four doses of oxycodone 10mg during the 24 hour period leading up to discharge:

 

Home Days One-Three

Home Days

Four-Five

Home Days

Six-Seven

Quantity of oxycodone 5mg to prescribe

Two tabs x four doses

Two tabs x three doses

One tab x three doses

#50

 

References

  1. National Centers for Disease Control and Prevention. Opioid Overdose. Centers for Disease Control website. https://www.cdc.gov/drugoverdose/data/index.html. Updated Dec. 16, 2016. Accessed March 2017.
  2. Clarke H, Soneji N, Ko DT, et al. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ. 2014;348:g1251.
  3. Kennedy-Hendricks A, Gielen A, McDonald, et al. Medication sharing, storage, and disposal practices for opioid medications among US adults. JAMA Intern Med. 2016;176(7):1027-29.
Posted in: Professional Practice
Western Michigan Society of Health-System Pharmacists Update

By Katie Axford, Pharm.D., BCPS, WMSHP president, assistant professor, Ferris State University College of Pharmacy, western regional society representative, Grand Rapids

The 2017 calendar year is off to a great start for the Western Michigan Society of Health-System Pharmacists (WMSHP). 

Our monthly programming kicked off on Jan. 12, with Tracey Mersfelder, Pharm.D. presenting “What’s New on TAP? The ADRs of PPIs" at Martell’s restaurant in Kalamazoo. On Feb. 16, at Mercy Health Saint Mary’s in Grand Rapids, CJ Michaud, Pharm.D., BCPS, enlightened the crowd with his presentation entitled “Mechanical Circulatory Support: Sounds Highly Non-Pharmacologic to Me.” The following month, on March 9, Zach Smith, Pharm.D., BCPS, BCCP shared his “Review of the 2016 HAP/VAP Guidelines: Focus on Application at the Patient and Health-System Level” at Bronson Methodist Hospital in Kalamazoo. And finally, last month on April 13 at Gravity Taphouse Grille in Grand Rapids, two western Michigan residents had the opportunity to present their research projects at our annual Pharmacy Residency Project Showcase. Ben Kulwicki, Pharm.D. (Mercy Health Saint Mary’s) shared his project titled “Impact of an Emergency Medicine Pharmacist on Appropriate Empiric Antibiotic Prescribing” and Katie Guido (Borgess Medical Center) presented “Pharmacist Addition to the Stroke Team: Evaluation of the Time to Intravenous Thrombolytic Therapy for Acute Ischemic Stroke With and Without a Pharmacist on the Stroke Response Team (PhAST Trial).” As always, our monthly programming would not be possible without our speakers, and our thanks goes out to all of them!

This month, on May 9, the 48th Annual WMSHP Spring Seminar was held at the Prince Conference Center in Grand Rapids. Pharmacists and technicians received five hours of live CE credit, with a variety of topics including antimicrobial stewardship in the emergency department, inpatient pharmacy services for heart failure patients, practical use of GLP-1 receptor agonists in Type 2 diabetes, pain management in palliative care and a pharmacy law update.

In addition to providing networking opportunities and continuing education programming for our members, WMSHP enjoys supporting area pharmacy students in a variety of ways. In February, WMSHP sponsored two P4 student pharmacists through the Michigan Pharmacy Foundation Adopt-a-Student program at the Michigan Pharmacists Association’s Annual Convention & Exposition. And later this month, WMSHP will present one $1000 scholarship and one $500 scholarship to P3 student pharmacists. It truly is a privilege to recognize deserving students from the west Michigan area through these activities!

WMSHP will be on summer break through August and will resume monthly meetings in September. For more information about WMSHP or our upcoming programs, please visit www.WMSHP.net.

Posted in: Member News
Get the Word Out!
By Peggy Malovrh, Pharm.D., BCPS, clinical coordinator, Sparrow Health-System, Lansing

The Michigan Pharmacists Association (MPA) Local Associations hold the key to educating the public and increasing awareness of the services provided by pharmacists.

When the layperson thinks of MPA, what comes to mind is the person in a lab coat behind the counter or the person who explained the medication plan prior to discharge from the hospital. This person may be a neighbor, a fellow church or health club member. When a layperson thinks of MPA, hopefully a personal encounter with a pharmacist comes to mind, and not a building, a convention or a Senate bill. Education of the public is best done at the grassroots level, not at the state or national level.

Anyone who has helped organize a health fair knows it can be discouraging if the event is poorly attended. There is a Turkish proverb that says: “If the mountain will not come to Mohammed, Mohammed will go to the mountain.” Instead of coaxing people to attend a Pharmacy Event, why not go to them?

The MPA website has a Hosting a Health Fair Toolkit that offers great ideas for getting the word out as well as many helpful tips for communicating with the community. To find these resources, visit the MPA website here—don’t’ forget to log into your MPA member account to access this member exclusive content. Described below are some successful actions that the Capital Area Pharmacists Association (CAPA) has had in reaching out to the public:

Get permission to set up a booth at a popular event: Think about your community and where people congregate. One example of a great location is a Saturday morning Farmer’s Market. Here people like to browse, and on a relaxed weekend morning, they are fresh and willing to listen. Another idea is hosting a booth at a special event at a children’s museum. Or how about a booth at a popular 10K or half marathon? There’s a lot of down time before and after the race, and providing bottled water might be just the thing to get the message out about osteoporosis or arthritis treatment. 

Develop a TV commercial: This is easier than you think, and there are plenty of television viewers out there! A simple call to schedule a short appointment at your local broadcasting station is all it takes. The commercial and message doesn’t need to be elaborate. When CAPA did this we chose a 30-second spot to stay within our budget. A series of photographs of pharmacists engaged in service-related activities floated in all directions across the screen while the Oath of the Pharmacist was read. We provided the pictures of local pharmacists and technicians. We chose the background music and the cable company arranged a professional to read the oath. It turned out very well, and we were able to select the stations and times to coincide with high viewership to the populations we wanted to reach.

Design a video to play prior to movies at the local cinema: The content can be similar to the TV commercial, but the key is to use local pharmacists and pharmacies. The message can be more dynamic and interesting by including other disciplines, such as physicians or nurses, with their permission. Our group was surprised by the number of people who commented on the video, and it really became a conversation starter!

Create a billboard: This is a very simple way to reach the public, as all that is needed is the picture to be displayed and billboard location. The ideal location for the advertisement maximizes its viewing potential to the community.

Stream a public service message on the Weather Channel or similar station: For constant exposure of a key message, having a sentence or two continually stream at the bottom of the television screen on the Weather Channel or a similar station can be effective. We are so accustomed to receiving information this way, be it sports scores or news alerts, that this has the potential to reach thousands of people.

Promoting the profession and pharmacy services is most effective at the grass roots level. Attend your next local association or regional society meeting and kick around some of these ideas. We must inform our communities about the value of pharmacist’s interventions. We must get the word out!


Posted in: Professional Practice
Overcoming the Challenges of Implementing Residency Training Programs
By Nimisha Sulejmani, Pharm.D., BCPS, residency program director, Henry Ford Health System, Detroit and Angela Michael, PharmD, BCOP, pharmacy specialist – hematology/oncology, Henry Ford Health System, Detroit


The easiest part of implementing a residency program is establishing the need for the training program and whether your institution provides a comprehensive experience to produce a successful resident. The challenge that follows is gaining adequate funding for the position. There are several avenues that can be explored for funding a residency program, such as a grant or outside funding sources, but the route you want to choose is the one that can be sustained over the long-term. This usually requires assessing the value a resident would add to the institution and how that would offset the cost associated with having a resident. Having a solid return on investment plan helps achieve the buy-in from the institutional budget oversight committee as well as maintaining the funds for the long-term. 

Once the funding is secured, and the residency is at the phase of implementation, establishing the residency structure along with assigning goals and objectives for the program to the appropriate learning experiences can be challenging. It is critical for the success of a resident to find the right balance between structured rotational experiences and longitudinal experiences, including those that do not involve direct patient care, such as practice management or research development. Reviewing the required goals and objectives to be taught and evaluated during the residency can help overcome these challenges. Then, determine whether tangible evidence related to detailed activities performed to achieve the objectives can be produced to minimize redundancy and preceptor burden and maximize evaluation quality. Often times, these objectives do not fit into a clinical learning experience and may require a unique circumstance that would have to be evaluated outside the context of a structured rotation through the use of longitudinal experiences and on-demand evaluations. 

One of the most important aspects of establishing a successful residency program is the preceptors. As a program director, it is important to ensure the preceptors have the appropriate qualifications for your residency, and if not, there is a plan in place for them to meet the qualifications in the future. Having qualified preceptors and an appropriate preceptor development plan helps ensure success of the resident as well as the residency program. Technology has played an important role in the success of pharmacy residency training programs and has improved significantly over time but still requires fine tuning. Setting up the programs (PharmAcademic™ and PhorCas™) appropriately for the residency training and recruitment can be challenging as the instructions on the functionality of the programs are not always user friendly and intuitive. 

In regard to resident development throughout a new program, it is imperative to maintain an open line of communication with the residents in the program through the use of customized development plans, frequent bidirectional feedback and structured self-assessment. This will allow for identification of challenges within the resident’s progress early on to encourage individual program customization and assist with ongoing overall program improvement.

One of the most important facets to developing a new residency is creating contacts with other similar programs within your practice area. These programs become an indispensable resource while navigating the many challenges associated with creating, implementing and maintaining a successful residency. Establishing these mentorship relationships can significantly improve the process of navigating the complex system surrounding residency accreditation and will likely lead to a higher rate of success in implementation.


Posted in: Professional Practice
Specialty Certification
By Curtis Smith, Pharm.D., BCPS, FCCP, professor, Ferris State University, Sparrow Hospital, Lansing

This year, the Michigan Society of Health-System Pharmacists is “gearing up” for implementation of the Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592 and S. 314 in the 114th Congress). In February, Nancy McDonald, MSHP president-elect, encouraged everyone to review the Pharmacy Forecast 2017 from the American Society of Health-System Pharmacists (ASHP) Pharmacy Foundation.1 This document provides a glimpse into the future of the pharmacy profession. One section of the Pharmacy Forecast discusses the shift in roles, responsibilities and training for pharmacists. It is projected that pharmacists’ patient care roles will continue to expand, with almost 75 percent of the panelists deeming it likely or very likely that the vast majority of pharmacists in healthcare systems will have prescribing authority for inpatients and discharged outpatients. This will result in the continued shift of pharmacist time from distribution functions to clinical activities.

As part of this continued shift in roles, pharmacists need to consider how to develop, refine, advance and demonstrate their clinical skills. This will be vital in a healthcare environment where pharmacists have prescribing authority. To meet this challenge, pharmacy education has significantly increased its focus on clinical skills over the last 20 years, and the NAPLEX exam recently changed to be more clinically focused. However, pharmacists still need to focus on skill development after graduation and licensure. Last month Shawna Kraft, MSHP director, provided a number of excellent resources to help pharmacists in this area (find her article here). However, as pharmacy roles expand, pharmacist specialty certification will take an even greater importance.

Currently there are over 28,500 pharmacists worldwide who are board certified through the Board of Pharmacy Specialties, a division of the American Pharmacists Association.2These numbers continue to increase significantly each year including a 15.3 percent increase from 2014 to 2015 and another 17 percent increase from 2015 to 2016. There are eight pharmacy specialty areas including ambulatory care, critical care, nuclear, nutrition support, oncology, pediatric, pharmacotherapy and psychiatric pharmacy. Soon, three more specialty areas will be added including infectious diseases, cardiology and geriatrics (the current certified geriatric pharmacist credential will move to BPS as a specialty certification in 2018). In Michigan, there are 606 certified pharmacy specialists (as of April 2017), including those with added qualifications in infectious diseases and cardiology (17th highest state in the nation). This is less than seven percent of all of the pharmacists in the state.


So, as we “gear up” for provider status, why is specialty certification vitally important? First, it is a method where pharmacists can demonstrate their skills and abilities in a particular specialty area. It’s important that all stakeholders, including insurance companies, healthcare organizations and other healthcare providers, are assured that our skills and knowledge meet a high standard. Specialty certification is a validated method that recognizes these required abilities. Second, the process of preparing to take the specialty exam allows clinicians to advance their skills and become better caregivers for their patients. Many pharmacists reflect and recognize, after taking a pharmacy specialty certification exam, how preparing for the exam significantly improved their skills and made them a better pharmacist. Finally, recertification occurs every seven years and requires extensive continuing education or retaking part of the recertification exam. This process assures that a pharmacist’s skills will remain at a high level long after passing the exam for the first time.


Therefore, as we gear up for pharmacist provider status, consider taking your practice to the next level by demonstrating your knowledge, skills and abilities in pharmacy practice through specialty certification. Registration for Fall 2017 testing opened on May 8.

References:

  1. Zellmer WA, ed. Pharmacy forecast 2017: strategic planning advice for pharmacy departments in hospitals and health systems. Am J Health-Syst Pharm. 2017;74(2):27-53.
  2. American Pharmacists Association. BPS Annual Report 2015. Board of Pharmacy Specialties website. http://www.bpsweb.org/about-bps/annual-reports. Accessed March 31, 2017.

 

Posted in: Professional Practice