ARRX - The Arkansas Pharmacist Fall 2016

FALL 2016 Award-Winning Quarterly Publication of the Arkansas Pharmacists Association

NEW STUDY SHOWS

Pharmacists Support Increased Role Jeff Mercer Takes Role As New Harding Dean

APA Staff

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Scott Pace, Pharm.D., J.D. Executive Vice President and CEO Scott@arrx.org John Vinson, Pharm.D. Vice President of Practice Innovation John@arrx.org Jordan Foster Director of Communications Jordan@arrx.org Susannah Fuquay Director of Membership & Meetings Susannah@arrx.org Celeste Reid Director of Administrative Services Celeste@arrx.org

Office E-mail Address Support@arrx.org Publisher: Scott Pace Editor: Jordan Foster Design: Gwen Canfield - Creative Instinct Arkansas Pharmacists Association 417 South Victory Street Little Rock, AR 72201-2923 Phone 501-372-5250 Fax 501-372-0546 AR•Rx The Arkansas Pharmacist © (ISSN 0199-3763) is published quarterly by the Arkansas Pharmacists Association, Inc. It is distributed to members as a regular service paid for through allocation of membership dues ($5.00). Non-members subscription rate is $30.00 annually. Periodical rate postage paid at Little Rock, AR 72201.

Current edition issue number 77. © 2016 Arkansas Pharmacists Association.

POSTMASTER: Send address changes to AR•Rx The Arkansas Pharmacist 417 South Victory Little Rock, AR 72201 Opinions and statements made by contributors, cartoonists or columnists do not necessarily reflect the attitude of the Association, nor is it responsible for them. All advertisements placed in this publication are subject to the approval of the APA Executive Committee. Visit us on the web at www.arrx.org.

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CONTENTS

Debra Wolfe Director of Government Affairs Debra@arrx.org

4 Inside APA: APA Shifts Focus to

19 Staff Profile: Debra Wolfe Sheppard,

5 From the President: The Inevitability of

20 UAMS College of Pharmacy: What

Pharmacy Future

APA Director of Government Affairs

Change

6 FEATURE: New Study Shows

Pharmacists Support Increased Role

8 Member Spotlight: Chris Allbritton,

Pharm.D. - Veterans Healthcare System of the Ozarks - Springdale

11 New Drugs: Moseying Along at

Does Provider Status Mean for Pharmacists?

21 Harding University College of Pharmacy: 2016 - A Year of Transition 23 APA Consultants Academy: The Death Rattle and the Pharmacist

25 2016 APA District Meetings Photos

the FDA

31 APA Compounding Academy:

12 FEATURE: Jeff Mercer Takes Role

Compounding Update

As New Harding Dean

32 AAHP Celebrates 50 Years of Fall Seminar

15 Legislator Profile: Representative Mathew Pitsch, Fort Smith

34 2016 Calendar of Events

16 Rx and the Law: Advocacy

34 Member Classfieds

17 Safety Nets: Unacceptable 18 Compliance Corner: State Pharmacy

35 USPS Statement of Ownership

Audits: Knowledge & Preparation is Key

DIRECTORY OF ADVERTISERS 2 5 9 9 10 22

Pace Alliance The Law Offices of Darren O'Quinn EPIC Pharmacies Retail Designs, Incorporated Pharmacists Mutual UAMS College of Pharmacy

22 Wright Lindsey Jennings 24 Pharmacy Quality Committment 34 Arkansas Pharmacy Support Group Back Cover: APA Honors McKesson

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APA Board of Directors

INSIDE APA

2016 - 2017 Officers

INSIDE APA

President - Eddie Glover, P.D., Conway President-Elect - Lynn Crouse, Pharm.D., Eudora Vice President - Stephen Carroll, Pharm.D., Arkadelphia Past President - Brandon Cooper, Pharm.D., Jonesboro

APA Shifts Focus to Pharmacy Future

Area Representatives Area I (Northwest) Michael Butler, Pharm.D., Hot Springs Area II (Northeast) Darla York, P.D., Salem Area III (Central) Clint Boone, Pharm.D., Little Rock Area IV (Southwest/Southeast) Dean Watts, P.D., DeWitt

District Presidents District 1 - Denise Clayton, P.D., Mayflower District 2 - Max Caldwell, P.D., Wynne District 3 - Dylan Jones, Pharm.D., Fayetteville District 4 - Betsy Tuberville, Pharm.D., Camden District 5 - James Bethea, Pharm.D., Stuttgart District 6 - Yanci Walker, Pharm.D., Russellville District 7 - Lacey Parker, Pharm.D., Centerton District 8 - Rodney Richmond, P.D., Searcy Academy of Consultant Pharmacists Anthony Hughes, P.D., Little Rock Academy of Compounding Pharmacists Becca Mitchell, Pharm.D., Greenbrier Arkansas Association of Health-System Pharmacists Kendrea Jones, Pharm.D., Little Rock

Ex-Officio APA Executive Vice President & CEO Scott Pace, Pharm.D., J.D., Little Rock Board of Health Member Gary Bass, Pharm.D., Little Rock AR State Board of Pharmacy Representative John Kirtley, Pharm.D., Little Rock UAMS College of Pharmacy Representative (Dean) Keith Olsen, Pharm.D., Little Rock

Harding College of Pharmacy Representative (Dean) Jeff Mercer, Pharm.D., Searcy Legal Counsel Harold Simpson, J.D., Little Rock Treasurer Richard Hanry, P.D., El Dorado UAMS COP Student Mary Elizabeth Bradley, Little Rock Harding COP Student Alyssa Stormes, Searcy

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Find the APA on Facebook, or visit our website at www.arrx.org

Scott Pace, Pharm.D., J.D. Executive Vice President & CEO

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he annual District Meeting tour throughout the state has just ended and we are blessed to have such a great group of pharmacists that dedicate one evening a year to come out and hear the leaders of our profession discuss what has happened during the past year. Since this was my first year as the CEO of the APA, I wanted to share a forward looking vision for what we want to happen as a profession in Arkansas.

As APA fights for legislative issues that impact your practice, we will need your help to make sure your voice is heard. We’ll keep you posted on the legislative issues.

For those of you who missed the District Meetings, I identified four buckets where we need to place our focus for the upcoming several years. The buckets are:

1. Focus on creating a stable, predictable business model – knowing that many

of our day to day business struggles are based on a lack of both stability and predictability, we must focus on creating a market solution that meets the needs of patients, payers and pharmacists by creating predictability and stability.

2. Creation of an Enhanced Pharmacist Services Network – modeled after

North Carolina’s Community Care of North Carolina network, Arkansas needs to build out a network of pharmacists that will agree to provide services over and above core dispensing services that will provide additional value to patients, payers, other healthcare providers, and pharmacists.

3. Evaluate existing laws to ensure most optimal collaborative environment for practice – we must continue to look for

ways to add more value to healthcare and to look for places where we can be even more collaborative with other providers by looking at existing laws.

4. Fighting the fight – while we must look forward, we must continue to take on battles to fight for fundamental fairness in the healthcare system, such as inclusion in patient-centered medical homes, unfair auditing, below cost payments, restrictive networks, etc.

I believe that the creation of an Enhanced Pharmacist Services Network will be an important part of moving the profession forward, and I’m excited that APA along with both UAMS College of Pharmacy and Harding College of Pharmacy are all facilitating the development of this important initiative. Network development is moving quickly and the first meeting of our luminaries and workgroup members is happening this Fall. Stay tuned for more information in the coming weeks and months.

Finally, as this political season comes to a close I want to encourage you to know your local Representative and Senator. APA’s greatest strength as an advocate for pharmacists is YOU! You are the people that help to make your communities a success. You are in every county in the state, you provide care to patients in need, you are a vital part of your community’s health care team.

Your voice is powerful at the Capitol building in Little Rock. As APA fights for legislative issues that impact your practice, we will need your help to make sure your voice is heard. We’ll keep you posted on the legislative issues affecting you and how you can help. §

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FROM THE PRESIDENT

FROM THE PRESIDENT

The Inevitability of Change

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s we finished up district meetings and went to 11 different cities throughout Arkansas, I was reminded about how truly excited I am to be your President and representative of the APA Board of Directors. Like every other non-profit company in the world, we have a Board of Directors comprised of practicing pharmacists that are elected from the membership as a whole that work closely with our great staff to carry out the mission of the Arkansas Pharmacists Association. I was honored to give a report in each district about the important accomplishments that the APA board and staff have accomplished this year, most notably hiring Scott Pace to lead the APA as the new CEO and a complete overview and updating of the APA bylaws that will allow the association to run more smoothly.

Although I talked to members during the meetings about the important work that’s going on at APA, I also spoke about something much more personal. I’ve been a pharmacist for 40 years, and I have seen unimaginable change during that time. I started working right out of pharmacy school and I was hooked! I loved the profession, I loved taking care of people, and I loved the opportunity to mix my pharmacy knowledge with my entrepreneurial spirit.

our products. This was truly an eye opening experience. It made clear that a regulator can stick their hand in my practice and alter it.

Eddie Glover, PD President

Colleagues, we are all experiencing the same thing. Change has come to healthcare in a way that is dramatically altering what we are expected to do as pharmacists. This change is affecting how we get paid and is forcing us out of our comfort zone. I want to encourage you to not look at these challenges as a bad thing. These are opportunities. It is our responsibility to be optimistic and to persevere in turning these challenges into the evolution of our profession. I can promise you that APA is more geared up than ever to help the profession and to help each of you evolve your practice in this evolving healthcare landscape. §

The culmination of my years in pharmacy led me to work with a great set of business partners to start US Compounding in 2005. US Compounding started out as a way to take chances to meet a need for patients, to grow professionally as a medication expert, and an opportunity to grow a business. And that’s what we did. We continued to grow and to meet the needs of patients in Arkansas and throughout the country. The one constant that we faced along the way was change. We faced the constant regulatory challenges of complying with the state boards of pharmacy in each state we were licensed. We also constantly faced scrutiny from the Food and Drug Administration.

Then one day, the compounding world and the entire pharmacy world was changed with the tragedy of New England Compounding Center sending out contaminated product that led to the deaths of a number of patients. This led to a giant change in the regulatory scrutiny that we face on a day to day basis, which in turn led to FDA inspections on virtually every sterile outsourcing compounder in the nation.

Our company was also affected. While we did not have any contaminated product, we ended up making a very difficult business decision to issue a nationwide voluntary recall of WWW.ARRX.ORG

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New Study Shows Pharmacists Support Increased Role

By John Vinson, Pharm.D., Jordan Foster, and Heather JC Flowers

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s medication experts, pharmacists use their unparalleled drug knowledge within the scope of their practice to help Arkansans live safer and healthier lives. Often pharmacists observe issues that patients throughout the state face, yet their hands are tied, bound by state laws that govern the practice of pharmacy, no matter the advanced level of their knowledge and training.

In 2014, one of those problems observed by pharmacists pushed Arkansas into a negative, national spotlight when a study found that the Natural State ranks last in the nation for teen pregnancy rates. Reducing unintended pregnancy and increasing access to contraception have recently been identified as top health priorities for our nation in the April 2015 issue of the Institute of Medicine’s Vital Signs publication.

When unintended pregnancies go unchecked, countless issues can arise that can affect both public health and the overall cost of healthcare. Nationally in 2010, teen pregnancy and childbirth accounted for $9.4 billion in taxpayer money for increased health care, lost tax revenue from teen mothers due to lower education level, and increased incarceration of children of teen mothers. Not only can teen pregnancy rates affect the mother’s educational attainment level, drastically lowering her income potential, but it also affects the children of teen mothers, creating a cycle of poverty, incarceration, and unintended pregnancy.1 Some pharmacists in other areas of the country have begun pushing their local legislatures to expand the scope of their practice to include pharmacist initiation of drug therapy

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for oral contraception. In January 2016, Oregon began pharmacist initiation of oral birth control in an attempt to increase access to these medications, as well as reduce unintended pregnancies. The Oregon legislation was well thought out and led to development and implementation of a rigorous pharmacist training program, screening tools, protocols, and billing support. Although Oregon is the first state to make this legislative change specific for contraception, California recently followed suit with broader laws allowing for pharmacist initiation of oral contraception, injectable contraception, contraceptive patches, and contraceptive vaginal rings. Lawmakers in other states (Tennessee, Hawaii, Missouri, South Carolina, New Mexico, and Washington) are currently looking into similar legislative initiatives. In some places like Washington state, broader collaborative agreement laws with physicians can allow pharmacist initiation of hormonal contraception.

In light of these expanded practice laws for pharmacists, the Arkansas Pharmacists Association (APA) conducted a survey to assess the current comfort level of pharmacists with pursuing similar expanded practice/pharmacist initiation of hormonal contraception legislation. A survey was electronically sent to all APA members and student members comprised of eight questions – three regarding demographic data, three focusing on the concept of pharmacist initiation of hormonal contraception, and two centering on other forms of pharmacist practice expansion that did not involve hormonal contraception access.

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THE ARKANSAS PHARMACIST

NEW STUDY SHOWS PHARMACISTS SUPPORT INCREASED ROLE

As results were compiled, the data showed several important reactions. When asked if Arkansas pharmacists should have authority to initiate hormonal contraception to female patients in a community pharmacy setting, the number of surveyed pharmacists who agreed with the statement outnumbered the pharmacists who disagreed by a three to one margin. Sixtyfour percent of respondents said they agreed that pharmacists should have authority to initiate hormonal contraception, while 20 percent said they disagreed. The data also showed that Arkansas pharmacists would be more likely in agreement with initiation of hormonal contraception with a physician protocol or collaborative agreement in place.

The survey also asked pharmacists to choose how they felt about having authority to initiate specific hormonal contraceptives, including oral combination estrogen and progestin contraception, oral progestin-only contraception, injectable long-acting medroxyprogesterone, vaginal ring contraception, and topical patch combination. With the exception of long-acting medroxyprogesterone (27 percent disagree), less than 25 percent of responding Arkansas pharmacists disagree with pharmacist offering of multiple forms of hormone contraceptives to patients. Many pharmacists do not commonly dispense long-acting medroxyprogesterone and are not as familiar with this contraceptive, which could be a contributing factor to higher hesitation with this contraception. An additional consideration is that Arkansas pharmacists are not currently allowed by Arkansas law to administer intramuscular injections of contraception.

The final questions revolved around barriers to implementation of Arkansas pharmacist authority to initiate contraception and authority to initiate additional drug therapies for conditions or medical situations that require very limited or no diagnosis. Of the choices presented to the respondents, increased liability, turf war battles with physicians, and billing were the top concerns with pharmacist authority to initiate contraception, although very few Arkansas pharmacists see barriers to pharmacist initiated hormonal contraception as being impossible to overcome. When presented with a variety of additional therapies, nicotine replacement, vaccinations, and medications for international travelers were the therapies of which respondents would most like to see pharmacists gain authority to initiate therapy.

The scope of practice that guides the profession of pharmacy continues to evolve. From the addition of administering vaccinations to the emergence of medication therapy management, the services that a pharmacist in Arkansas can provide have eclipsed a strictly dispensary role and include therapies that can make a marked improvement on the health of Arkansans. With the data from this survey, the Arkansas Pharmacists Association will continue to explore opportunities that benefit patients and pharmacists throughout the state. ยง 1 www.cdc.gov/teenpregnancy/about/

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Arkansas pharmacists should have authority to initiate, without a collaborative agreement with a physician, hormonal contraception to female patients in a community pharmacy setting.

FIGURE 2

Arkansas pharmacists should have authority to initiate the following hormonal contraceptives:

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MEMBER SPOTLIGHT

Chris Allbritton, Pharm.D. Veterans Healthcare System of the Ozarks Springdale

Photo credit: Nick Smith, Hiccup Design, Bentonville

Pharmacy/academic practice: Veterans Healthcare System of the Ozarks

pharmacists reimbursed appropriately for patient care has got to be high on the list.

Pharmacy school and graduation year: UAMS COP 2000,

Oddest request from a patient/customer: Patient

Ambulatory Care Resident UAMS 2001

Years in business/years teaching: Clinical Pharmacist

2001-2007, Director of Pharmacy 2009-present, UAMS Clinical Assistant Professor – 2001- present

How does working at the VA differ from other health systems settings: Our pharmacy never touches currency

requested 30 bottles of shea butter lotion for their peripheral neuropathy. Believe it or not this is a pharmacy item at the VA.

Recent reads: Fearless (third time to read), The Testament Fun activities/hobbies: Fly fishing, bicycling, coaching my son’s teams and supporting daughter in soccer.

however we deal with insurance now. Clinical pharmacists are utilized at a very high level in the VA, they work side by side with physicians and directly manage patient care.

Ideal dinner guests: John Elway, Harrison Ford, Jerry

Favorite part of the job and why: Taking care of Veterans

If not a pharmacist then…: Housing construction/

first and foremost. However, being able to hire great staff and watching them succeed every day is a close second.

I would argue the pharmacy service at our VA is the best service provided to Veterans at our hospital.

Seinfeld

developer. §

Least favorite part of the job and why: The amount of regulations and surveys; however, you learn to deal with it after 14 years.

What do you think will be the biggest challenges for pharmacists in the next 5 years? The traditional model is

changing so converting to a payment model that includes 8

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Moseying Along at the FDA This column, presented by the Harding University College of Pharmacy, aims to briefly highlight information on new molecular or biological entities, new indications, or significant new dosage forms recently approved by the FDA.

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hings seemed to move at a snail’s pace this past quarter with the approval of only five new molecular/biological entities; however, several new devices and dosage forms were brought to market. Instead, grabbing the headlines was intense public criticism over extraordinary price increases for the well-known EpiPen® and the promise of safe and affordable alternatives.

Also, long overdue in light of additive drug effects that result in CNS depression, difficult breathing and deaths, the FDA is adding black box warnings to drug labeling of prescription opioid products and benzodiazepines.

anesthesia; Qbrelis™ (lisinopril, oral solution) for hypertension, heart failure, and acute MI; Rayaldee® (calcifediol, extendedrelease capsule) for hyperparathyroidism; Sustol® (granisetron, extended-release injection) for chemotherapy-induced nausea/ vomiting; Syndros™ (dronabinol, oral solution) for AIDSassociated anorexia/weight-loss and chemotherapy-induced nausea/vomiting; Troxyca® ER (oxycodone/naltrexone, extended-release capsule) for severe pain; and Viekira XR™ (dasabuvir/ombitasvir/paritaprevir/ritonavir, extended-release tablet) for hepatitis C.

New Drugs: Adlyxin™ (lixisenatide) is a new GLP-1 receptor

New Devices: AspireAssist®, a device approved for obesity

agonist approved for once-daily injection for adults with type 2 diabetes. Post-marketing studies are being required to evaluate its immunogenicity and use in pediatric patients.

Xiidra™ (lifitegrast) received priority review as a first-in-class lymphocyte function-associated antigen antagonist approved for dry eye disease. The fixed-dose combination Epclusa® (sofosbuvir/velpatasvir) used along with ribavirin received an expedited priority review as the first drug to treat all six major forms of hepatitis C virus. Exondys 51™ (eteplirsen) underwent an accelerated rare pediatric disease priority review as the first drug approved to treat Duchenne muscular dystrophy, a rare genetic disorder characterized by progressive muscular deterioration and weakness. Cuvitru™ (immune globulin, human) was approved as replacement therapy for primary humoral immunodeficiency (PI) in adult and pediatric patients.

New Dosage Forms: Significant new dosage forms that were

approved this quarter include: Ameluz® (aminolevulinic acid, gel) for actinic keratoses; Belviq XR® (lorcaserin, extendedrelease tablet) for weight loss; Byvalson™ (nebivolol/ valsartan, tablet) a new combination for hypertension; Erelzi™ (etanercept-szzs, injection) a biosimilar to Enbrel®; Amjevita™ (adalimumab-atto, injection) a biosimilar to Humira®; GoNitro™ (nitroglycerin, sublingual powder) for angina; Kovanaze™ (tetracaine/oxymetazoline, nasal spray) for regional dental

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treatment, consists of a tube that is placed endoscopically through an incision in the skin into the stomach which will allow patients to drain part of their stomach contents after each meal, preventing the absorption of approximately 30% of calories consumed. Medtronic's MiniMed 670G hybrid closedloop insulin delivery system, the first-ever artificial pancreas that automatically monitors blood glucose and administers appropriate basal insulin doses, was approved for patients >14 years with type 1 diabetes. Tecnis Symfony®, a first-of-itskind intraocular lens, was approved for cataract treatment that provides vision at distances similar to a multifocal lens but with less of a halo and glare problem. Absorb GT1™ Bioresorbable Vascular Scaffold System, the first fully absorbable stent to treat coronary artery disease was approved. The stent is designed to be gradually absorbed by the body over 3-years and releases everolimus to limit the growth of scar tissue.

Rx-to-OTC Switch: Differin® (adapalene, gel) was approved as the first OTC retinoid treatment for acne.

Withdrawals: All OTC antibacterial soaps containing any of 19 specific active ingredients due to a lack of evidence that they prevent illness and infection any better than plain soap and water. This rule does not affect OTC alcohol handrubs/ wipes or antibacterial products used in healthcare settings. §

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Jeff Mercer Takes Role As New Harding Dean

By Jordan Foster

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I REALLY DIDN’T THINK I WAS GOING TO GO TO COLLEGE BECAUSE I WASN’T A HIGH-ACHIEVING STUDENT IN HIGH SCHOOL. THEN MY OLDER BROTHER CALLED ME ONE DAY AND ISSUED A SIMPLE CHALLENGE. HE SAID, ‘WHY DON’T YOU CHANGE YOUR LIFE?’ THAT WAS ALL IT TOOK. - Jeff Mercer

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ften times our careers are shaped by major milestones that guide us down life’s path and are easily distinguishable when looking back - getting into our college of choice, landing the dream job, earning that big promotion. Other times, however, entire shifts in our direction can be catalyzed by a small, nearly insignificant moment that’s almost undetectable in hindsight. For Dr. Jeff Mercer, a simple telephone call set him on a path from being an apathetic high schooler with little career aspirations to being the newest dean of the Harding University College of Pharmacy and an esteemed leader in the pharmacy community.

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to help others. School, however, wasn’t an area of his life that garnered much attention. Upon graduating from high school, Mercer suddenly found himself with few options for the future.

Course Correction

“I really didn’t think I was going to go to college because I wasn’t a high-achieving student in high school. Then my older brother called me one day and issued a simple challenge.

He said, ‘Why don’t you change your life?’ That was all it took… I ultimately decided to give college a try and realized quickly that it suited me very well. From that point forward, I challenged and applied myself academically and realized that I was capable of a professional career far beyond anything I had previously imagined.”

Growing up in Georgia and Alabama, Mercer gave much attention to certain qualities that many Southerners pride themselves on – fostering relationships and connections, prioritizing family above all else, and nurturing a strong drive

Mercer’s newfound dedication to his education ultimately led to stops at Faulkner University in Montgomery, AL, Mercer University in Atlanta, and Auburn University in eastern Alabama. The choice to attend Auburn was particularly

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THE ARKANSAS PHARMACIST

JEFF MERCER, PHARM.D.

rewarding because he graduated Summa Cum Laude with his Doctor of Pharmacy degree from the same school that had denied him admission coming out of high school.

Auburn was also where Mercer and his wife Emmie spent the first few years of their marriage. “She put me through school by working and sacrificing a lot with her education and career. At the same time, she worked tirelessly to get her BS in mathematics and MS in information system degrees while working full time. Together, we discovered that education was the key to our future.”

After graduation, Mercer chose a career in community pharmacy with Publix Supermarkets, Inc. “It was everything I wanted at the time. I was promoted quickly, starting as pharmacy manager on day one and soon elevated to pharmacy supervisor over 33 stores in two states. During that time, I opened 23 new stores and supervised more than 70 pharmacists. My goal was to become VP of Pharmacy Services, and I just knew that was the destiny for my career.

What I didn’t realize is that God had other plans for our family.”

By 2005, Mercer and Emmie had two sons, Jeffrey and Levi.

Life was idyllic by all accounts, but his job was beginning to take a serious toll. “I was being drawn so far into the corporate world that I was losing sight of family and other relationships.

I began to look around, and through a seemingly random email from Harding’s first dean of the pharmacy college, Julie Hixson-Wallace, I came across Harding University’s plans to start a college of pharmacy. Something about those plans spoke to the deeper parts of me and I realized right away that this was my true career calling.”

“We teach contemporary pharmacy practice, but we do so from a Christian worldview and challenge students to use that learning to help change the world for the better. I believe our mission mindset has matured over the last 10 years, and we have created a very intentional focus on service and helping others.

A Decade of Change Ten years into his tenure at Harding, Mercer has been instrumental in the growth and maturation of the College.

“We were one of the first colleges of pharmacy to begin our program under a new set of standards for ACPE accreditation.

Due to the changing landscape of pharmacy education, we encountered a lot of scrutiny about our legitimacy and need to be here. For seven or eight years, we systematically met the sequential milestones necessary for full accreditation as recognized by ACPE in 2012. All along the way, it was a continuous march toward defining the true heart of our College.

“Today, students have a lot more choices about where to go to school. They can go close to home, they can go to any number of states, and they can make choices based on what they want out of a college. Harding has embraced this new environment as an opportunity to define who we are and to be very intentional about our identity.”

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Part of the identity Harding has chosen is focusing on mission and a dedication to service in career and life. “We teach contemporary pharmacy practice, but we do so from a Christian worldview and challenge students to use that learning to help change the world for the better. I believe our mission mindset has matured over the last 10 years, and we

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JEFF MERCER, PHARM.D.

have created a very intentional focus on service and helping others. You see that with every Harding student. Even within our required pharmacy practice experiences, service is a key component of student engagement and learning. More than ever, we are doing true domestic and foreign mission activities that center around our capabilities as pharmacists and pharmacy students.”

about themselves yet. When I arrived at Harding, I realized very quickly that true satisfaction comes from empowering those we teach to help others. It’s a special place, and I am honored to play a part in the development of our pharmacists of tomorrow.” §

Laying the Path Ten years after he found his way to Harding and two decades since the phone call that changed the direction of his life, Mercer says he now finds himself at peace with career and family. His wife is a faculty member in the Harding University College of Business and his three boys (Jeffrey, Levi, and Anderson) attend Harding Academy. Mercer still exhibits the drive and passion to help others. Now, as dean, his is the voice calling to his students to change their lives and by extension change the lives of millions of future patients.

“I believe in people and want to help others find confidence in their abilities. I think that’s why I’m well suited to lead in a place where students may not have discovered those things

“I believe in people and want to help others find confidence in their abilities. I think that’s why I’m well suited to lead in a place where students may not have discovered those things about themselves yet."

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LEGISLATOR PROFILE

Representative Mathew Pitsch Fort Smith

Rep. Pitsch at the new Arkansas College of Osteopathic Medicine in Fort Smith

District: #76 Represents (Counties): Sebastian Years in Office: 1.5 years, finishing first term Occupation: Engineer/Executive Director of Regional

Members to basically do three things 1) strive to be more accessible to our citizens, 2) be better communicators to our citizens, and 3) to be organized in our approach so we can have a more productive outcome.

Your fantasy political gathering would be: Following a

to serve constituents is what it is all about for me.

dinner meeting held at the White House of the country's most brilliant scientists, mathematicians, and engineers, someone asked President John F. Kennedy if there hed ever been a gathering of people with a higher I.Q.? President Kennedy's response was, "Only when Thomas Jefferson dined alone!"

My fantasy political gathering would be to dine alone with President Jefferson.

What do you like least about being a legislator: The

Toughest issue of the past session: They are all tough!!!

Transportation Authority/Small Business Owner/Professor

Your hometown pharmacist: Keith Larkin/Justin Boyd What do you like most about being a legislator: The ability

beaurocracy that needs to be dealt with to make positive changes for our citizens and the time away from family inherent in the job.

Most important lesson learned as a legislator: A statement

by the past Governor Mike Beebe really made an impact on how I tried to conduct myself, "If you want to make changes single handily then run for Governor, because right now you are getting ready to be part of a 100 member team and that requires a whole different set of skills and motivation to accomplish things."

Most admired politician: George Washington, Thomas Jefferson, Dwight D. Eisenhower, and Ronald Reagan in that order.

Advice for pharmacists about the political process and working with the AR Legislature: Call us and let's discuss

Casting a vote is probably the most honorable thing I have done in my public/professional life. No matter which side of any legislation you select to cast your district's vote for, some will benefit and some will be hindered. It helps to always remember to understand, to the best of your ability, what it would take to defend/understand both sides of the issue. To be specific in my answer, the legislative process not having a long term solution to Highway Funding (the greatest job creator we can do as a State in my opinion) as we ended the 90th General Session was very disconcerting to me personally.

Fortunately, Governor Hutchinson convened a special session to deal with Highway Funding in the interim where we dealt with this issue.

Hobbies: Church Activities, Coaching Youth Sports, Hunting, Outdoor Sports, serving on Non-Profit Board of Directors. ยง

anything and everything. Great communication is how good legislation is developed and it is how the process is meant to work. As the new Majority Leader I have asked our Caucus

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WrongfulAdvocacy Conduct Rule This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

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o paraphrase John Godfrey Saxe; laws are like sausages, it’s better not to see them being made. I am not an expert on sausages, but I would disagree with this comment with regards to laws. Even if we don’t get involved in the making of laws, we will be subject to them nonetheless. Pharmacists can ill afford to be impacted by laws drafted by those who know nothing about pharmacy.

Unfortunately for many of us, lobbying is a word with very negative connotations.

It projects images of under the table dealings and improper exchanges of cash. So how do we inform lawmakers of the impact of proposed laws on the practice of pharmacy? Through advocacy.

Not all advocacy has to take place in Washington, D.C. or your state capital. Invite your lawmaker to visit your pharmacy while they are home in the district. Then they will get to see first-hand what you are doing for your patients, their constituents.

Advocacy is simply the act of supporting a cause, an idea, or a proposed policy.

Many state and national associations organize advocacy meetings for their members. While we can all do this individually, a group of concerned citizens visiting the lawmaker’s office together can certainly make a larger impact.

The purpose of these visits is to educate the lawmaker and their staff on proposed laws that impact our profession. We might be in favor of a proposal, opposed to it or want to amend the language as presented.

Lawmakers are serving because they want to make a positive difference in our society. However, they are not experts in every field. There is only one pharmacist, Buddy Carter of Georgia, in the 114th Congress. The other Senators and Representatives need pharmacists’ help to understand how proposals will affect pharmacy practice.

I have participated in advocacy meetings on both the state and national level. In my experience, the lawmakers and staffers are eager to hear how proposals will affect constituents in their districts. The meetings usually consist of an introduction, explanation of why you are there, what the real impact in their district will be, and what action you want them to take. For pharmacists, the potential impact is not always direct. The impact may be on our patients; denying access, increasing

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costs, or creating hurdles to care. Of course, these indirect impacts will have impact on your pharmacy practice. Many times the true impact on patients is not readily apparent.

Pharmacists can explain how a particular policy will make it more difficult for patients to get their medications. Don’t expect immediate action. It is always a pleasant surprise to get a commitment, but many times the materials that you provide are circulated in the office before decisions are made.

Not all advocacy has to take place in Washington, D.C. or your state capital. Invite your lawmaker to visit your pharmacy while they are home in the district. Then they will get to see first-hand what you are doing for your patients, their constituents. You can also advise them about how proposed laws will impact your ability to provide these services. First-hand knowledge and stories of real impacts (not just theoretical ones) will have the most influence on the process.

If pharmacists don’t educate lawmakers about the effects of the changes on their practices and their patients, who will? Don’t think of it as lobbying. We are really educating our lawmakers. Joining and participating in professional organizations is a good way to get started. In the end, the profession will benefit and ultimately, our patients will too. § ________________________________________________________________ © Don R. McGuire Jr., R.Ph., J.D., is General Counsel, Senior Vice President, Risk Management & Compliance at Pharmacists Mutual Insurance Company.

This article discusses general principles of law and risk management.

It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with policies and procedures of their employers and insurance companies, and act accordingly.

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Unacceptable Welcome to another issue of Safety Nets. This issue of Safety Nets highlights the potential hazards associated with E-prescriptions. Thank you for your continued support of this column.

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his column has been published in ARโ ขRx - The Arkansas Pharmacist for 20 years. The original purpose of this column was to "present actual cases showing how an Arkansas pharmacist prevented a medication error from harming a patient". That purpose has not changed. Thanks to the participation of Arkansas pharmacists, the column has illustrated original prescriptions containing a variety of errors including illegible handwriting, dangerous prescription abbreviations, potential look-alike, sound-alike mix-ups, and others. In most of these cases, alert pharmacists prevented these potential errors from reaching patients.

In the past year, the number of prescriptions submitted to us from Arkansas pharmacists has dramatically increased.

The vast majority of these have been electronic prescriptions.

This is interesting considering the Health Resources and Services administration (HRSA) statement "compared to paper prescriptions, e-prescribing improves medication safety along with prescribing accuracy and efficiency." This month's column illustrates four electronic prescriptions received by Arkansas pharmacists along with a brief description of how the pharmacist attempted to resolve the problem.

Figure One

The maximum daily dose of nortriptyline is 150 mg. The pharmacist who telephoned the prescriber's office for clarification was told "yeah, we forgot to take the second part of the Sig. out. It should just be 75 mg at bedtime." UNACCEPTABLE

Figure Two

This ERx for methadone contains two different Sigs. The ERx was for a hospice patient. The pharmacist who telephoned the prescriber's office for clarification was told to "ignore the TID directions." He was then instructed to dispense a four-day supply of methadone to the patient.

The pharmacist replied "so the patient is to receive 24 tablets instead of 90." The response was "yes - if you say so." UNACCEPTABLE

Figure Three

The maximum daily dose of Tussionex is 10 mL. If the patient had followed these ERx directions, they would have administered 90 mL in one day. The pharmacist who telephoned the prescriber's officer for clarification was told "we meant teaspoonful - those abbreviations are really close." When the pharmacist questioned the TID dosing interval, she was told "okay." UNACCEPTABLE

Figure Four

This ERx instructs the patient to administer four Enalapril 10 mg tablets daily. The pharmacist who telephoned the prescriber's officer for clarification was nonchalantly told "sorry, we meant one daily."

UNACCEPTABLE

The electronic prescriptions illustrated in this issue of Safety Nets clearly do not "improve medication safety along with prescribing accuracy and efficiency." Several questions about these prescriptions are in order. Who entered the prescription information into the electronic prescription software? Were they a health care professional or support personnel? Did the prescriber review the information before the prescription was transmitted to the pharmacy.

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Each electronic prescription illustrated in this column is UNACCEPTABLE. Each one caused the pharmacist to waste valuable time. As frustrating as this is, we must remember that we are patients' final safety net. We must ensure every prescription - both electronic and handwritten - is accurate before we dispense the medication. Our patients are depending on us. ยง

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State PharmacyWrongful Audits: Knowledge Conduct and RulePreparation is Key

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n 2013, the 89th General Assembly passed into law Act 1499, (ACA 20-77-2501 et al), which established the Office of Medicaid Inspector General (OMIG). The idea was the brain child of Senator David Sanders and its creation (along with the Private Option) helped establish Arkansas as one of the most forward-thinking states in the critical governmental space of Medicaid reform. According to the OMIG website, “The mission of the Office of Medicaid Inspector General (OMIG) is to prevent, detect, and investigate fraud, waste, and abuse within the medical assistance program.” As part of that mission, one of the programs rolled out by OMIG in 2015 utilizes a contract between the Department of Human Services (DHS) and Optum, a health services private contractor, to address fraud, waste and abuse in the Medicaid program.

The program conducts state program integrity audits for Medicaid that specifically target you – pharmacies. Any pharmacy that has a contract with the state as a Medicaid provider and has a provider number is subject to the audit.

Is there a way to avoid these audits? Not unless you don’t want to do any Medicaid business. As tempting as that might sound, and as much as some providers in all fields across the state might prefer to avoid Medicaid, the reality is that it is a necessity for most providers. With that being the case, the best line of defense is to learn about the state pharmacy audit process and to know what to expect.

OMIG began the auditing program in state fiscal year 2015 and the first audits took place in May 2015. The reviews are both desk reviews and on-site audits. Both types of reviews are randomly generated requests for documentation to support services billed during the audit period. Optum uses an analytics program that produces the request. Significant effort was undertaken in the development of the system to ensure that the audits were fair and not targeting expensive drugs to the Medicaid program. Another neutral safeguard was an agreement that the “look back period” or parameters would only cover two years. The Pharmacy Bill of Rights and Medicaid Fairness Act were also considered when developing the audit protocol. The latter, which has been legislatively amended in the past few years, establishes some fairly stringent requirements on OMIG in handling these audits.

Licensed pharmacists and pharmacy technicians, through outside contractor Optum, conduct the audits on behalf of OMIG. The audit begins with proper notice to the pharmacy.

A certified letter is sent to the address listed by the pharmacy 18

associated with the provider number. There are two types of audits conducted: desk reviews, or what I call “mail in your stuff” document review, and on-site or field audits, which entail an office visit. Generally, you have 30 days to respond and both OMIG and Optum are fairly flexible on extensions during each stage of the process, without penalty to you as the pharmacy. For an on-site audit, you are given ten days’ notice to prepare.

Following the on-site audit, OMIG will send a report of their findings and observations pursuant to the Medicaid manual.

The Medicaid manual governs the procedures and time requirements for the next stages after submission, including reconsideration and potential appeal. For comparison to federal audits conducted by federal contractors or pharmacy benefit managers (PBMs), the potential penalties for submitting documents late or supplementing after the initial request are different.

Here is the impact for the first full year of the program: for state fiscal year 2016 (July 1, 2015-June 30, 2016), slightly fewer than 80 audits were conducted with roughly onefourth conducted on-site. Roughly one-quarter of those have been closed and more than $70,000 collected/recouped and returned to the Medicaid program. The good news is that those numbers are not overwhelmingly punitive. As the program continues to grow and take root, I anticipate more audits and recoveries. OMIG is required to publish a Quarterly Report and an Annual Report in October (all on their website), which provide further specifics on the program and the office.

To wrap up, adequate knowledge and awareness of the OMIG state pharmacy audits will put you in a better position to save time and money down the road. Good-faith selfdisclosure for improper payments and familiarizing yourself with commonly reviewed billing errors are critical ways to improve future audits and minimize potential penalties. § About Jay Shue:

Attorney Jay Shue provides pharmacy and healthcare clients with strategic advice and counsel in federal and state government investigations, audits and enforcement matters. Jay’s experience includes serving as Arkansas’ first Medicaid Inspector General, serving for six years as the Deputy Attorney General of the Arkansas Attorney General’s Medicaid Fraud Control Unit and working 20+ years as a prosecutor, litigator and attorney. Today, he a member of the Government Relations team at Wright Lindsey Jennings.

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STAFF PROFILE

Debra Wolfe Sheppard Director of Government Affairs Arkansas Pharmacists Association Hometown: Searcy, AR. Education: Bachelor of Fine Arts Career Background:

My corporate career began in the JCPenny catalog department. I've created art for the Searcy Daily Citizen, directed the Searcy Arts Council, worked as a program coordinator for Searcy Parks and Recreation, served as the Marketing Director for Simmons First Bank of Searcy, Kensett and Beebe. I came to Little Rock as a contract lobbyist primarily for agriculture and education clients. In 2008 I began as Director of Government Affairs for APA.

Personal goal for APA:

To successfully advocate and educate legislators resulting in advancing the profession of pharmacy in Arkansas.

Best part about working at APA:

I love my job! It is very fulfilling to represent such honorable professionals dedicated to advancing healthcare. Not every lobbyist is fortunate to represent clients that are so well respected in their communities.

Biggest challenge pharmacists face in the legislature: The pharmacy reimbursement model is so complex and completely different from any other business. Educating legislators on our payment model and overcoming hurdles from the many PBM lobbyists and their seemingly endless budgets is challenging. Our major asset is that we have pharmacists in every county who can build relationships with legislators...or even run for office.

Dream job: Never in my wildest dreams did it occur to me to pursue lobbying. When a job as a contract lobbyist quite literally fell into my lap, I discovered lobbying was my dream job and I hadn't even known it!

Family:

A blind date arranged by a legislator introduced me to my now husband and also lobbyist, Courtney Sheppard.

(Yes, legislators really can make a difference) Our blended family includes a son, two daughters, three granddaughters, four dogs and a cat.

Most unusual/interesting job: Supervising a Saturday morning work release crew.

Best vacation:

A week's sail from the Bahamas to the Exumas even though we were "shipwrecked" a few days by Hurricane Sandy. Luckily we were able to weather the storm in the Atlantis marina.

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Favorite meal:

Fried chicken, mashed potatoes, gravy, chocolate pie and fresh brewed, unsweet iced tea.

Favorite quote:

new.”— Dali Lama

“When you listen, you may learn something

Recent Reads: Just finishing Truly Madly Guilty by Liane Moriarty

People would be surprised to find out that you: Would love to be able to train service dogs.

You are happiest when: Those in my life are healthy and

happy.

Favorite hobbies and why you like them: Art...it's my therapy and inspiration.

Best piece of advice you’ve ever received: "Don't be afraid to ask questions, that's how you learn."

— Ruth Ivy Gilliam, my grandmother §

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UAMS COLLEGE OF PHARMACY

What Does Provider Status Mean for Pharmacists?

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here’s a lot of exciting buzz around the nation as pharmacists are considered for addition to the Social Security Provider Status recognition list. Before we start doing back flips and counting the big pot of gold, let’s stop and consider what this really means through the lens of a SWOT analysis. Let’s consider our current Strengths, Weaknesses that place disadvantage, Opportunities that give reason to prosper, and external Threats beyond our control.

Keith Olsen Pharm.D., FCCP, FCCM Dean

Pharmacists have the Strength of years of clinical education and practice to understand and serve chronically ill patients who consume a significant percentage of our nation’s healthcare expenses. We understand comorbidity and complex needs that contribute to multiple medication-related issues.

Many pharmacists already make team recommendations to physicians in protocols and Collaborative Practice Agreements (CPAs), and provide patient education beyond the counter to improve outcomes. UAMS students are trained under the campus-wide Integrated Clinical Enterprise and understand Inter-professional Multi-Disciplinary practice. Pharmacist involvement in community and hospital patient care have proven to greatly reduce readmission rates. Health care reform recognizes the Strength of Pharmacists in mandating medication review management of geriatric patients in longterm care. The Strength of Pharmacy consultation has been demonstrated with numerous publications.

Weaknesses under discussion within the profession include addressing the adequacy of clinical education, and the responsibility of assessing performance practice credentialing and privileging for patient care services required for health care plan participation. On the flipside, patients experience Weaknesses in health service benefits when their accessible community Pharmacist is not Provider eligible to be reimbursed for a service they could or provide. Patients economically seek out where their insurance pays, often forcing them out of their community for services. Weaknesses in public perception that pharmacy services are free are prevalent. Even after states approve Pharmacy Provider Status, implementation Weaknesses systemically will prohibit progress until Pharmacists are named and included on federal listings and codes for CMS billing mechanisms are established. This will not happen overnight.

Yet we don’t have to look far to find Opportunities that support the need for Pharmacists to be recognized with Provider Status. With the national and Arkansas shortage of Primary Care Physicians, states generally do not deny or resist recognizing the accessibility of Pharmacists to improve patient’s quality of care. There are inherent political Opportunities in an election year with the Affordable Care Act under bipartisan debate. As we move toward all states gaining

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status, we can take advantage of learning Opportunities from other states’ successful models. Pharmacy intervention currently provides Opportunities to reduce hospital length of stay and readmission rates has been demonstrated to improve cost-efficiency through patient medication therapy management.

External Threats challenging all of the above include our health care systems’ lack of standardized electronic record platform to link patient history and incorporate community pharmacy. State limitations on protocols and collaborative practice agreements (CPAs) prevent forward motion of team relationships to benefit patient outcomes. Threats written into state laws governing compensation for Pharmacy direct patient care services slow momentum of Provider Status.

However, the ever-present Threats of our aging population’s unsustainable expenditure to our national budget exist.

So, what can we do right now? Congress is under pressure to address access to health care and to find savings for improved patient outcomes and quality of life. We can send an e-mail or meet with our representatives to educate them and ask for support of legislation to expand access to care for patients who need the critical services that pharmacists can provide on care teams. The Pharmacy and Medically Underserved Areas Enhancement Act (HR592 and S314) is the legislative catalyst addressing healthcare for our country’s “MUAs”.

(Seventy three of seventy five counties in the state of Arkansas are designated as medically underserved areas.) The National Governors Association has published a paper entitled “The Expanding Role of Pharmacists in a Transformed Health Care System,” concluding after summarizing strong evidence, that “the integration of pharmacists into team-based models of care could potentially lead to improved health outcomes…

Examining state-specific challenges and promising practices from other states will allow states to develop policies that permit pharmacists to practice within the full scope of their professional training across the health care continuum."

To identify your congressional district and representative contacts, access www.govtrack.us/congress/members/AR. “Achieving provider status is about giving patients access to the valuable care that you provide. Becoming a ‘provider’ means that patients and pharmacists can participate in Part B of the Medicare program and bill Medicare for services that are within their state scope of practice to perform.” Clearly with emphasis on “and”, this package includes the essential bottom line of reimbursement. As Pharmacists are able to get a seat at the table of team focused patient care, we will then be positioned to share in the pot of money to be reimbursed.

Although this sounds simple, there are many SWOT details of readiness we need to keep in mind. §

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HARDING UNIVERSITY COLLEGE OF PHARMACY

2016: A Year of Transition

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small plaque adorns the entrance to my new office. It acknowledges the contributions that our founding dean, Dr. Julie Hixson-Wallace, made toward the development and maturation of our college. It also reminds me of the legacy that I have inherited as the new dean for Harding University College of Pharmacy.

On June 1st of this year, Dr. Hixson-Wallace was promoted to a university cabinet position. She now serves as the Vice Provost for Accreditation at Harding University. As a result of Dr. Hixson-Wallace’s promotion, I have been awarded the honor of serving as the second dean of our college. Some of you may remember that I have been with the college since its inception. Being trusted with the opportunity to lead in this new role, especially at Harding, has special meaning to me. I appreciate those who have sent along kind words of encouragement and support.

In addition to the recent transition in deanship, I am delighted to share some additional news about our College. Dr. Rayanne Story has been promoted into my former position as the new Assistant Dean for Experiential Education. She brings many years of institutional and academic practice to this position and is well known throughout the state for her work with APA and AAHP. For those that know Dr. Story, I believe you will agree that she is well suited for this position.

Jeff Mercer, Pharm.D. Dean

Dr. Forrest Smith, who has served as our Associate Dean for Academic Affairs since 2007, was selected to replace Dr. Yates as the Chair for Pharmaceutical Sciences. He is a pharmacologist with many years of academic research, teaching, and administrative experience. I’m excited about his leadership for our department of pharmaceutical sciences and know that we are in capable hands.

Amid all the transition, I want to emphasize that some things simply should not change. Our commitment to graduate pharmacists who accept the responsibility of improving the spiritual and physical wellness of the world remains.

We believe in optimal patient outcomes and the highest standards of Christian Service. This is who we are, and we are bound to that core mission.

Being trusted with the opportunity to lead in this new role, especially at Harding, has special meaning to me. I appreciate those who have sent along kind words of encouragement and support.

Experiential Education accounts for more than 30 percent of our pharmacy curriculum and over 50 percent of the hours that students spend in the Doctor of Pharmacy program.

For that reason, Dr. Story is joined by two additional faculty members, Drs. Tim Howard and Jeanie Smith, who each serve as Experiential Education Directors. I’m very pleased with this new team of experiential professionals who join our administrative secretary, Mrs. Sherrie McAleese, in meeting the experiential needs of our preceptors and students.

One additional transition occurred within our college when Dr. Bill Yates, who has served as our Chair for Pharmaceutical Sciences, retired on August 1st. Dr. Yates was also one of the founding members of our leadership team and served ten faithful years. He leaves Harding for retirement but remains active as president and CEO of his own drug formulation company. We wish him all the

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best and will truly miss his great leadership.

Lastly, I want to mention our most recent entering class. We are blessed with a full class of 60 first-year pharmacy students. Many of them are from your hometowns. They speak of you as mentors, friends and family who advised them to seek pharmacy as a career. Upon hearing this, I tell them each that they have made a good choice. I believe in this great profession of pharmacy and its noble and compassionate roots. Thank you for encouraging the next generation of pharmacists. Please don’t stop, even if the future looks very different than the pharmacy we practice today or may remember in the past, I am convinced that medication experts have a unique place in healthcare and need to serve as true patient advocates.

I thank you for what you do each day and am blessed to be a part of the education for what your successors will do tomorrow! §

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APA CONSULTANTS ACADEMY REPORT

The Death Rattle and the Pharmacist

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s a person draws closer to the time of death, especially with the hospice patient, we as care givers become faced with palliative therapies to maintain the person's comfort and dignity. The pharmacist can play an important role with symptom management and can assist in the quality of life for that patient.

Anthony Hughes, P.D. President

Issues that can easily present themselves are constipation, nausea and vomiting, pain, and the Death Rattle. Some may say what is the Death Rattle?

The Death Rattle is sounds often produced by someone who is near death as a result of fluids such as saliva and bronchial secretions accumulating in the throat and upper chest. It occurs in about 92% of patients.

The mental changes happening in the dying process causes the patient to lose the capacity to clear these upper respiratory secretions. Somewhere between 11 to 28 hours are common from the onset of the Death Rattle and death. It has been suggested that symptom management started earlier with lower rattle intensity improved effectiveness over time. One of the most interesting things (blessing) that happens is that the patient normally does not express to others that these sounds or rattles are distressing. These sounds do produce anxiety and distress for the family members and the care givers.

During these final hours things such as frequent turns, repositioning and a reduction of parenteral fluids are not harmful and may be the appropriated course. There are a couple of studies that found levels of hydration did not change the prevalence of death rattle. Providing education about the Death Rattle could be as effective as the repositioning and medications. Some consider suction but unless secretions are visible in the mouth, suction should be avoided.

A review of the available literature in the management of the Death Rattle we quickly see that the studies are very limited and produce the need for a well planned and executed study.

After repositioning and turns what options do we have?

The answer is the anticholinergic medications atropine, glycopyrrolate, hyoscyamine and scopolamine. No one product is superior to the rest. It may come down to ease of administration and product availability. These situations should follow the palliative care guidelines to start low and go slow.

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An interesting bit of the history with atropine is that it was used by Cleopatra, Renaissance women, and in Paris at the turn of the 19th century to dilate their eyes in the hopes they would appear more alluring. Let’s hope they could see their prospective candidates.

Atropine is the easiest for the caregiver to use. Using the ophthalmic 1% drop with 2 drops under the tongue titrated up every 4-8 hours produces about 1mg of

Consultant Clinical Pearl What common class of medications has an increased adverse effect with GI issues and sleep disturbance?

Answer: SSRIs

atropine.

It is thought that glycopyrrolate may be better in patients who are more alert and bothered by the rattles.

Glycopyrrolate is usually doses at 1mg orally or 0.10.2mg SubQ/IV every 4-8 hours prn.

Hyoscyamine can also be administered sublingual at 0.125 to 0.5mg every 4 hours as needed. A tip for the caregiver is to provide a few drops of water with the sublingual tablet will greatly assist the dissolving of the tablet.

Scopolamine crossed the blood-brain barrier, causing more sedation and possible delirium and agitation in higher doses. It is suggested to apply 1-2 patches every 72 hours as needed. However, slow onset may reduce its effectiveness.

No one medication stands out as superior but comes down to the situation at hand and what is best at that time. Who knows? You may be one that can provide the education for all involved to ensure a quality of life at the time of death. §

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2016 Arkansas Pharmacists Association DISTRICT MEETINGS The Arkansas Pharmacists Association held its 2016 District Meetings in 11 cities across the state during the months of August and September. Members were able to engage with state pharmacy board and APA leaders, get updates from the colleges of pharmacy and AAHP, and enjoy camaraderie and fellowship with fellow pharmacists in the area. APA member participation is integral to the success of the association. Thank you to all who attended!

HOT SPRINGS - Courtney Hooker, Kay Smith, Lance Smith, Luke Morrison

LITTLE ROCK

LITTLE ROCK - Philip Deer, Wayne Padget

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HOT SPRINGS - Christi Amerson, Jesse Rucker, Randy Burks

HOT SPRINGS - Amy Babb, Theresa Thomas, Misty Huerkamp

LITTLE ROCK - Andy Roller, Mandi Roller, Greg Orlicek

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LITTLE ROCK - Daniel Cate, Heather JC Flowers, Talon Burnside

APA wishes to thank our District Meeting Sponsors: Amerisource Bergen, Cardinal Health, Harding College of Pharmacy, UAMS College of Pharmacy, McKesson, and Smith Drug.

LITTLE ROCK - Brandon Achor, Schwanda Flowers, Tyler Shinaberry

MONTICELLO - John Summers, Lynn Wilson, Shane Dixon, Daniel Bryant

MONTICELLO - Ronnie Norris, James Bethea, Johnny Roach, Craig Meek

MONTICELLO - Carolyn Cathey, Tricia Nicholson, Kacie Barnett

MONTICELLO - Sarah Jane Hancock, Brandy Bowen, Ben Johnson, John Nowlin

BENTONVILLE - Ron Curran, Victoria Hennessey, Kristyn Mikle

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BENTONVILLE - Carol Fisher, Kay Humbard, Lisa Whitaker

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BENTONVILLE - David Darter, Jim Milholen, Ron Wann

CAMDEN - Scott Pace, John Kirtley

BENTONVILLE

CAMDEN - Raymond Turk, Jeff Prince, WV Guff

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CAMDEN - Casey de Yampert, Jennifer Davis

CAMDEN - Anna Chandler, Teresa McCann, Donah Dumas

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FORT SMITH - Alex Brown, Andrew Coles

FORT SMITH - Scott Pace

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FORT SMITH - Margaret Sparkman, Dana Harrington, Nicole Joe

FORT SMITH - Debbie Cloud, Rayanne Story, Julie Stroh, Cheryl Scott, Pam Pixley

JONESBORO - Waylon Bullock, Joe Vincent

JONESBORO - Connie Bennett, Doug Baltz

JONESBORO - Natalie Bari, Stacy Ziegler

JONESBORO - Eddie Glover, Kristy Reed

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MOUNTAIN HOME - Dylan Jones MOUNTAIN HOME - Brenda Ward, Kim Harrison, Susan McNutt

MOUNTAIN HOME - Scott Bryant, Leo Zibert

MOUNTAIN HOME - Darla York, Lis Mathews

RUSSELLVILLE - Eddie Glover

RUSSELLVILLE - Greg Bell, Michael Baker, Bart Beggs

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RUSSELLVILLE - Jennifer Harrell, Susan Resinger, Galen Perkins

RUSSELLVILLE - Margie Smith, Mike Smith, Marsha Duvall, Richard Harmon, Gary Denton, Jill Sheets

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SEARCY - Kyla Feather, Emily Richardson, Beth Ackerman, Taylor Mertin

SEARCY - Frank Bradham, Wali Abdul, Kyler Vaughn, Clayton House, Trace Neaville, Lincoln Neal, Tanner Rogers

SEARCY - Carrie Steele, Kena Taylor, Seth Johnston

STUTTGART - Brandyn England, Lisa Buell, Nick Dziurkowski

STUTTGART - Cheryl Blansett, Andy Blansett, Woody Hill

STUTTGART - Kristi Whitmore, Brittany Sanders

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STUTTGART - Abby Staton, Karen Watts, Dean Watts, Holly Vansandt, Alton Chambless AR•Rx

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APA COMPOUNDING ACADEMY REPORT

Compounding Update

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he compounding world is an exciting place to be right now! It seems like changes are occurring at warp speed, and staying current means staying involved – and never being bored! Here are a few highlights from recent months: Becca Mitchell, Pharm.D. President

Ready or Not, Here Comes USP <800>!

Insanitary Conditions in Compounding Pharmacies Another recent publication from FDA outlined what it considers “insanitary conditions” in compounding pharmacies. Some of the conditions described include vermin (insects or rodents), visible bacteria or mold, and non-microbial contamination line rust, glass shavings, or hair. It also emphasizes the importance of appropriate personnel protective equipment during compounding, aseptic technique, and facility design. The publication is an easy read and serves as a good reminder to your staff that they play a critical role in ensuring patient safety by observing their workspaces and notifying management of any issues.

It is available at www.fda.gov.

USP has released General Chapter <800> Hazardous Drugs – Handling in Healthcare Settings to become effective July 2018. The chapter includes best practice updates to procedures and personal protective equipment as well as facility design requirements that The APA Compounding will require enhancements for most pharmacies. The chapter applies to We Want to Hear From You Academy is intended to all drugs defined as hazardous by the be a resource for Arkansas National Institute for Occupational The APA Compounding Academy pharmacists for all things Safety & Health (NIOSH), not just is intended to be a resource for compounding. In order to chemotherapeutic drugs, and is Arkansas pharmacists for all things applicable to all healthcare settings. compounding. In order to fulfill fulfill that mission, we need to Several organizations have tools that mission, we need to hear hear from you! What’s going developed specifically to assist from you! What’s going on in your on in your pharmacy? What pharmacists with USP <800>, pharmacy? Do you have a great challenges do you regularly including the facility design. The patient care testimonial we might Arkansas Board of Pharmacy has not feature in an upcoming publication? see? yet implemented compliance with What challenges do you regularly USP <800>, but the topic is on the see? How can the Academy and agenda for discussion at the October its members provide value to your 18-19 ARBOP meeting. practice and enhance the care you provide? We know you are making a positive difference for Arkansas patients Changes to Compounding Pharmacy Inspections every day – help us get that good word out by letting us know what’s happening. Compounding Academy FDA recently published a Notice indicating changes to members should have received an email from me in its policies regarding FDA inspection of 503A (traditional) late August – if you didn’t, then APA does not have your compounding pharmacies. Starting August 1, 2016, FDA correct contact info. Please reach out to APA or to inspectors will be making a “preliminary assessment” of bmitchell@uscompounding.com if there’s anything we can whether or not the pharmacy meets the requirements of do for you. § 503A and, if so, not cite the pharmacy for non-compliance with current Good Manufacturing Practices (cGMP). This Notice represents a change from past practice, where FDA would issue and publicize inspectional observations for non-compliance with cGMP even when the eventual determination was that the pharmacy was wholly compliant with 503A requirements. IACP noted in its memo to membership that FDA rarely publishes “course corrections” like this and attributed the change to grassroots advocacy work from members and Congressional allies. If you’re not involved, you should be!

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ARKANSAS ACADEMY OF HEALTH-SYSTEM PHARMACISTS

AAHP Celebrates 50 Years of Fall Seminar hashtags #LiveYourWhy #AAHP50. If you have not had a chance to view the many posts see our social media pages.

We continued the tradition of providing over 11 hours of live ACPE-accredited continuing education on a variety of topics specific for pharmacists, technicians, and students.

We were excited to have so many students and pharmacists present during the poster session and over 15 in state and out of state programs participate in the Arkansas Residency Showcase. Our committee was successful in developing new programming and activities including a social event with an Escape Room. Thanks to the Arkansas Pharmacists Association’s Jordan Foster for designing our escape room; teams that participated had a great time. New this year, residency preceptors from across the state were able to participate in the New Practitioners, Residents, and Students Council annual preceptor development training both in person and online. Additionally, our committee successfully introduced a Reverse Expo providing key decision makers dedicated time with industry representatives. To help commemorate our 50th annual meeting we hosted a social media campaign in which AAHP board members and meeting attendees used Instagram and Facebook to highlight the important role of health-system pharmacists using the

Clinician of the Year: Dr. Jessica Schnur, Washington

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harmacists, pharmacy residents, technicians, and students met at the Arkansas Association of Health-System Pharmacists 50th Fall Seminar September 29 – 30th at the Arlington Hotel and Resort in Hot Springs, Arkansas. We were fortunate to have Ms. Julie Moretz, Vice Chancellor of Patient and FamilyCentered Care at the University of Arkansas for Medical Sciences as our keynote speaker.

Kendrea Jones, Pharm.D. President

Thanks to our Fall Seminar Committee and other volunteers who worked so hard to again plan a great meeting. During the awards banquet, the following awards were presented:

Manager of the Year: Dr. Kim Young, Baptist Health System, North Little Rock

Regional Medical Center, Fayetteville

Staff Pharmacist of the Year: Brooke Irwin, St Bernard's Medical Center, Jonesboro

New Practitioner of the Year: Dr. Drayton Hammond, University of Arkansas for Medical Sciences, Little Rock

Residency Preceptor of the Year: Dr. Katie Lusardi, University of Arkansas for Medical Sciences, Little Rock

Technician of the Year: Rhonda Calkins, Central Arkansas Veterans Healthcare System, North Little Rock As we reflect on 50 years of AAHP and this year’s Fall Seminar theme - “Learning from the Past, Celebrating the Moment, and Changing the Future”, AAHP will use the momentum of the past to continue to move the profession of pharmacy forward through leadership, education, and advocacy. §

Keynote Address - Julie Ginn Moretz

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Manager of the Year - Dr. Kim Young, Baptist Health System, North Little Rock

Staff Pharmacist of the Year: Brooke Irwin, St Bernard's Medical Center, Jonesboro

New Practitioner of the Year: Dr. Drayton Hammond, UAMS, Little Rock

Residency Preceptor of the Year: Dr. Katie Lusardi, UAMS, Little Rock

Technician of the Year: Rhonda Calkins, Central Arkansas Veterans Healthcare System, North Little Rock

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2016/2017 Calendar of Events NOVEMBER

DECEMBER

JANUARY

November 4-6 American Society of Consultant Pharmacists Annual Meeting and Exhibition Dallas, TX

December 3 APA Committee Forum Crowne Plaza Hotel Little Rock, AR

January 25 Legislative Reception Trapnall Hall Little Rock, AR

December 4 APA Board Meeting Crowne Plaza Hotel Little Rock, AR

January 27* CE at the Races Oaklawn Gaming and Racing Hot Springs, AR

November 7-12 CPE at Disney Walt Disney World Resort Orlando, FL

Member Classifieds

*Tentative Date

Member Classifieds are free to APA members and $65 per issue for non-members. Contact communications@arrx.org for more information.

Relief Pharmacists Needed: If any retired pharmacists want to work an occasional Saturday to stay current, earn some extra spending money and for the love of the profession, call Chuck in Danville at 479-495-7673. (9/20/16)

Omnicare, a CVS Health company, is hiring Pharmacist in Charge for our Little Rock, AR pharmacy. Contact michelle. buckley@omnicare.com for more information, or www.omnicare. com/careers to apply directly (7/27)

EXPERIENCED PHARMACIST available for relief work; Would consider a permanent position for a great opportunity; MTM Specialist and Certified Immunizer; Organized, Efficient, and Customer Oriented; Proficient with various pharmacy software systems including QS1, Pioneer, PDX, and ComputerRx; Implementation of Medicare Contracts and Immunization programs.

Will travel. Call 501-730-4075.

Experienced RETAIL pharmacy technicians needed for Medication Reconciliation Tech positions at CHI St. Vincent Infirmary in Little Rock. Interview patients and document medication histories in the EMR. Identify medication issues/resolve discrepancies with pharmacy or physician?s offices. Bachelor?s, Associate?s Degree, or equivalent retail pharmacy tech experience (6+ years) required. 80% pass rate required on skills exam. FullTime Day and Evening Positions Available. Email resumes to brhopkins@stvincenthealth.com (7/22)

Ideal Pharmacy and DME location for lease in Malvern, AR. Adjacent to Baptist hospital and several doctor’s offices. Formerly Phelan’s Discount Pharmacy and Medical Rentals. Free standing building with approximately 1600 Sq. Ft., private parking lot and 800 Sq. Ft. heated and cooled storage building for DME or other use. Rent or lease for $1500/mo. Contact: Neil Phelan JR., P.D. 501-337-6456 or phelanneil@sbcglobal.net (8/8/16)

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ISOTECH Microsphere Glovebox for Sale. Interested parties should contact Chris Hutts for more informationchutts@cantrelldrug. com. https://cantrelldrug.sharefile.com/d-s5587501243043f1b

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