The Official Publication Of The Florida Pharmacy Association APR. 2016
INTERN PHARMACISTS IMMUNIZING The Views of Pharmacists on Intern Pharmacists Being Permitted to Immunize
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FLORIDA PHARMACY TODAY
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florida PHARMACY TODAY Departments 4 Calendar 4 Advertisers 5 President’s Viewpoint
VOL. 79 | NO. 4 APRIL 2016 THE OFFICIAL PUBLICATION OF THE FLORIDA PHARMACY ASSOCIATION
Features
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7 Executive Insight
Intern pharmacists immunizing: The Views of Pharmacists on Intern Pharmacists Being Permitted to Immunize According to the Florida CS/HB 279 Act
17 FPA News & Notes 29 Buyer’s Guide
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Does a Benzodiazepine a Day Keep Anxiety Away?
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FPA 126th Meeting & Convention
MARCH 2016
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Mission Statements:
FPA Calendar 2016
of the Florida Pharmacy Today Journal
MAY
JUNE
1 - 3
NASPA Leadership Retreat Denver, Colorado
10
Last day to register for the Marriott Harbor Beach Hotel
6
Deadline for FPA Resolutions
10
6
Deadline for Vice Speaker and House of Delegates Board of Directors nominations
Last day for convention pre-registration
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APhA Diabetes Certificate Program
7
FPA Leadership Retreat Orlando, Florida
6/30 - 7/3 FPA Annual Meeting and Convention Ft. Lauderdale, Florida
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House of Delegates Board of Directors Conference Call
JULY
21-22 FPA CE Conference Jacksonville
17 - 24 FPA CE at SEA Barcelona Spain
24 - 25 NCPA Congressional Summit Washington D.C.
29 - 31 SE Officers Conference Williamsburg, Virginia
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Memorial Day - FPA Office Closed
For a complete calendar of events go to www.pharmview.com Events calendar subject to change CE CREDITS (CE cycle) The Florida Board of Pharmacy requires 10 hours’ LIVE Continuing Education as part of the required 30 hours’ general education needed every license renewal period. There is a new 2 hour CE requirement for pharmacists on the dispensing of controlled substances effective this biennial renewal period. Pharmacists should have satisfied all continuing education requirements for this biennial period by September 30, 2017 or prior to licensure renewal. Consultant pharmacists and technicians will need to review their licenses and registrations by December 31, 2016. For Pharmacy Technician Certification Board Application, Exam Information and Study materials, please contact the FPA office. For more information on CE programs or events, please contact the Florida Pharmacy Association at (850) 222-2400 or visit our website at www.pharmview.com
The Florida Pharmacy Today Journal is a peer-reviewed journal which serves as a medium through which the Florida Pharmacy Association can communicate with the profession on advances in the sciences of pharmacy, socio-economic issues bearing on pharmacy and newsworthy items of interest to the profession. As a self-supported journal, it solicits and accepts advertising congruent with its expressed mission.
of the Florida Pharmacy Today Board of Directors
The mission of the Florida Pharmacy Today Board of Directors is to serve in an advisory capacity to the managing editor and executive editor of the Florida Pharmacy Today Journal in the establishment and interpretation of the Journal’s policies and the management of the Journal’s fiscal responsibilities. The Board of Directors also serves to motivate the Florida Pharmacy Association members to secure appropriate advertising to assist the Journal in its goal of self-support.
Advertisers EPIC PHARMACY............................................. 13 THE HEALTH LAW FIRM............................... 13 KAHAN HEIMBERG, PLC............................... 15 PHARMACISTS MUTUAL................................ 2 PHARMACY QUALITY COMMITMENT....... 6
CONTACTS FPA — Michael Jackson (850) 222-2400 FSHP — Tamekia Bennett (850) 906-9333 U/F — Art Wharton (352) 273-6240 FAMU — Leola Cleveland (850) 599-3301 NSU — Carsten Evans (954) 262-1300 DISCLAIMER Articles in this publication are designed to provide accurate and authoritative information with respect to the subject matter covered. This information is provided with the understanding that neither Florida Pharmacy Today nor the Florida Pharmacy Association is engaged in rendering legal or other professional services through this publication. If expert assistance or legal advice is required, the services of a competent professional should be sought. The use of all medications or other pharmaceutical products should be used according to the recommendations of the manufacturers. Information provided by the maker of the product should always be consulted before use. 4 |
FLORIDA PHARMACY TODAY
E-MAIL YOUR SUGGESTIONS/IDEAS TO dave@fiorecommunications.com
The President’s Viewpoint TIM ROGERS, RPh, FPA PRESIDENT
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A Call to Action
e have been too passive for too long. For years, pharmacists were the shakers and movers of our profession. We took the knowledge that we had and put it to use to better the healthcare of our patients, to better our profession and to ensure that the Florida Legislature passed the required laws to allow our profession to grow and practice at its peak. What happened? Where is the drive that once kept us at the forefront of all the states’ pharmacy practices? Where are the voices in Tallahassee advocating for our profession? Where are our young and old pharmacists when we need to rally? Our students are phenomenal. While in school, they advocate for our profession; they are enthused about their future practices; they come out in force for Legislative Days, and not too long ago were instrumental in getting a law passed that allows Florida pharmacists to immunize patients. But two years out of school, 80 percent are no longer FPA members. We, as more established practitioners, are failing in our responsibility to keep them involved. Involvement starts at the grass roots of our organizations, the unit associations. We need to let them know that we need to organize and work together to continue the growth of the pharmacy profession that we have known in the past. It has been 14 years since we had a pharmacist in the Florida Legislature. For years, we have recognized the need to have a pharmacist to edify other legislators in what pharmacists can do to increase the level of healthcare for our patients and how these pharmacy services save money in the healthcare budget. We need voices of both phar-
macist representatives and pharmacist senators to speak for us. I have accepted the challenge and am now announcing that I am running for state representative for the 21st Dis-
We, as more established practitioners, are failing in our responsibility to keep them involved. Involvement starts at the grass roots of our organizations, the unit associations. We need to let them know that we need to organize and work together to continue the growth of the pharmacy profession that we have known in the past.
Tim Rogers, RPh 2015-2016 FPA President
will need lots of support and help, from seeking petition signatures to be on the ballot to holding signs and opening checkbooks. I challenge other pharmacists to follow my lead, get involved in politics and run for office. It is through efforts of many, to help a few, that we will once again restore our practice to where it should be and assure that it will be around for the service of our patients in the future. n
trict, which includes part of Alachua County and all of Gilchrist and Dixie counties. This has not been an easy decision; I am not an experienced politician, but this was the decision that I made. In order to be successful, I am going to need the support of pharmacy around the entire state. See my webpage at www.votetimrogers.com. I, and other pharmacists running for office, MARCH 2016
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FLORIDA PHARMACY TODAY
Executive Insight BY MICHAEL JACKSON, RPH BY GUEST COLUMNIST ANDREA MURZELLO, PHARM.D. CANDIDATE AND FPA INTERN
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FPA Working to Advance the Practice of Pharmacy
e are at the forefront of change for the profession of pharmacy. Back in the 1900s, we were a profession grown by mentors and apprenticeships. As time went on, we transitioned from a profession taught by example to a profession taught in schools. The first school of pharmacy was Philadelphia College of Pharmacy, which was founded in 1821.1 The available degree was a bachelor’s degree and this remained the norm for years. Then, the pharmacy curriculum was reevaluated and the Pharm.D. became standard. If you graduated from pharmacy school in 2003 or later, the doctorate became the entry-level degree.2 Now there are 135 colleges and schools that offer the Pharm.D. as a first professional degree. 3 The type of pharmacy degree wasn’t the only way pharmacy was changed. The role of a pharmacist has been expanding, and we are striving to make this a reality. A major buzz phrase these days is “provider status for pharmacists.” I urge you to ask yourselves what this means to you. How far does provider status go, what do you think the expanded role of a pharmacist should be, and what steps need to be taken to attain this status? During my time at the Florida Pharmacy Association, I was fortunate enough to go to state House and Senate floor meetings toward the end of session. There were a number of bills that expanded the role of a pharmacist. One of the main bills that piqued my interest was House Bill 941. Some areas of this bill directly affected pharmacy, including emergency medication situations such as prescription refills and opioid antagonists. The bill took into account
the difficulties in obtaining prescription refills at times. Currently, a pharmacist can dispense a three-day supply to a patient in need of a refill but nothing more. This can also be an issue with the packaging of certain medications. A pharmacist is unable to dispense insulin on an emergency basis because the packaging is meant for longer than three days. The bill retains the three-day emergen-
Currently, a pharmacist can dispense a threeday supply to a patient in need of a refill but nothing more. cy supply, but now allows a pharmacist to provide a one-time emergency refill of one vial of insulin to treat diabetes mellitus. Interestingly enough, House Bill 1241 allows pharmacists to dispense another type of medication during an emergency. Emergency opioid antagonists can be dispensed to patients or caregivers with a non-patient specific standing order. Emergency opioid antagonists are important, especially in a state such as
Andrea Murzello, FPA Intern
Florida. Prescription drug abuse has been a big problem in the state. Florida was known for its extensive number of pill mills. A pill mill is a doctor’s office or clinic that continuously prescribes and dispenses controlled substances outside of medical standards and violates the laws in the state of Florida that relate to the prescribing or dispensing of controlled prescription medications. There are many signs that can indicate if a physician office or clinic is a pill mill. These locations typically will only accept cash payments, no physical exam will be needed, multiple people will be in the parking lot or lined up to enter in the building and multiple patients will walk in and out too fast to have had a full examination from the physician. In 2010, prescription drug abuse hit an all-time high in Florida. Florida led MARCH 2016 |
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FPA STAFF Executive Vice President/CEO Michael Jackson (850) 222-2400, ext. 200
Director of Continuing Education Tian Merren-Owens, ext. 120 Controller Wanda Hall, ext. 211
Educational Services Office Assistant Stacey Brooks, ext. 210 Coordinator of Membership Christopher Heil, ext. 110
the nation in diverted prescription drugs. Seven Floridians (and many others throughout the nation) would die every day from prescription drug abuse.5 The reason why Florida was at the forefront of this drug abuse problem was because Florida did not have a strong oversight of physician prescribing practices and there was no prescription drug monitoring program. In that same year, there were over 900 pain management clinics in
through the timely administration of an opioid antagonist. In order to get the fastest administration of such a medication, it is only logical to allow the most accessible health care professional to provide the medication. An interesting change found in the previously mentioned House Bill 941 deals with sexually transmitted diseases. The change allows for the partner of patients with sexually transmitted diseases (STDs) to have quicker
FLORIDA PHARMACY TODAY BOARD Chair..................................... Carol Motycka, St. Augustine Vice Chair................................Cristina Medina, Hollywood Treasurer...............................Stephen Grabowski, Tampa Secretary.........................Verender Gail Brown, Orlando Member..................................... Joseph Koptowsky, Miami Member..............................Rebecca Poston, Tallahassee Member.............................................. Patricia Nguebo, Ocala Member................................. Norman Tomaka, Melbourne Member..............................Stuart Ulrich, Boynton Beach Member.......................Don Bergemann, Tarpon Springs Executive Editor.........Michael Jackson, Tallahassee Managing Editor.........................Dave Fiore, Tallahassee
This is a peer-reviewed publication. ©2016, FLORIDA PHARMACY JOURNAL, INC. ARTICLE ACCEPTANCE: The Florida Pharmacy Today is a publication that welcomes articles that have a direct pertinence to the current practice of pharmacy. All articles are subject to review by the Publication Review Committee, editors and other outside referees. Submitted articles are received with the understanding that they are not being considered by another publication. All articles become the property of the Florida Pharmacy Today and may not be published without written permission from both the author and the Florida Pharmacy Today. The Florida Pharmacy Association assumes no responsibility for the statements and opinions made by the authors to the Florida Pharmacy Today. The Journal of the Florida Pharmacy Association does not accept for publication articles or letters concerning religion, politics or any other subject the editors/ publishers deem unsuitable for the readership of this journal. In addition, The Journal does not accept advertising material from persons who are running for office in the association. The editors reserve the right to edit all materials submitted for publication. Letters and materials submitted for consideration for publication may be subject to review by the Editorial Review Board. FLORIDA PHARMACY TODAY, Annual subscription - United States and foreign, Individual $36; Institution $70/year; $5.00 single copies. Florida residents add 7% sales tax. FLORIDA PHARMACY ASSOCIATION
610 N. Adams St. • Tallahassee, FL 32301 850/222-2400 • FAX 850/561-6758 Web Address: http://www.pharmview.com 8 | FLORIDA PHARMACY TODAY
In 2010, 98 of the top 100 oxycodone dispensing physicians in the nation were from Florida. Today, there are no physicians in the state of Florida on the top 100 dispensing physicians list. Florida. Laws and regulations have since changed, and there are now fewer than 400 pain management clinics registered in Florida. The DEA has a report called the Automation of Reports and Consolidated Orders System (ARCOS). It lists the top oxycodone dispensing physicians. In 2010, 98 of the top 100 oxycodone dispensing physicians in the nation were from Florida. Today, there are no physicians in the state of Florida on the top 100 dispensing physicians list.5 Now that Florida has cracked down on prescription drug abuse, many users have found themselves unable to obtain enough prescription drugs to sustain their addiction. As a result, many have turned to street drugs such as heroin. Opioid antagonists will help with heroin overdose as well.6 A non-specific standing order for the dispensing of these opioid antagonists is a step in the right direction for pharmacy. In a sense, it makes the pharmacist the primary provider for the patient. The pharmacist continues to be the most readily accessible health care professional. Opioid overdose-related deaths are generally avoidable
access to treatment. Pharmacists will be allowed to dispense medications to persons diagnosed with STDs as well as medications to treat the partner, even if the partner has not been examined by the prescribing practitioner. This is a big step forward for pharmacists. This can prevent the vicious cycle of a patient getting treated for a sexual transmitted disease and then getting re-infected because their partner never received treatment. Pharmacists will be required to check for allergic reactions before dispensing the medications, and more guidance will be needed to make this a success. There have been preliminary economic analyses that suggest that expedited partner treatment is a cost-saving and cost effective partner management strategy for the health care system as a whole.7 These bills allow for an expansion of the role of the pharmacist. They place added responsibility on the pharmacist, as they would be providing primary care. Despite these expanding roles for pharmacists, there are some roadblocks to making this more successful. Many insurance companies are limiting access by employing the use
of preferred narrow networks. Many local pharmacies cannot compete in this narrow network when compared to the larger chains and PBMs. A high-performing network would be more ideal where services offered, health quality and long-term savings are valued. Such services include medication therapy management and specific disease state management. These programs can be further evaluated on a quality level with programs such as EQuIPP. Â It is a performance information management platform that makes performance data available to health plans. EQuIPP standardizes the quality of medication use and makes this information readily available.4 Performance management platforms such as this lead to increased emphasis on quality of care for our patients and customers. This is the right direction for the future of healthcare. I urge you to consider the growing world of pharmacy, where the possibilities are endless, but support is needed. Expanded pharmacy roles in the profession can be attainable with proper legislation and support. Think about where you see pharmacy going and the steps to get there. You, too, can be the force of change the profession needs. 1. http://schoolpages.pharmcas.org/ publishedsurvey/491 2. http://edtheory.blogspot.com/2011/12/ pharmacists-education-bspharm-topharmd.html 3. http://www.aacp.org/about/pages/ vitalstats.aspx 4. http://www.pharmacyquality.com/ 5. http://myfloridalegal. com/pages.nsf/Main/ AA7AAF5CAA22638D8525791B006A30C8 6. http://www.therecoveryway.com/drugabuse-facts/pill-mills-doctor-drug-dealer 7. http://www.cdc.gov/std/treatment/ eptfinalreport2006.pdf
2015-16 FPA Board of Directors The Florida Pharmacy Association gratefully acknowledges the hard work and dedication of the following members of the FPA leadership who work diligently all year long on behalf of our members.
Suzanne Kelley..................................................................................................Board Chair Timothy Rogers..........................................................................................FPA President Alexander Pytlarz.................................................................................... FPA Treasurer Scott Tomerlin...........................................................................................President-Elect Jackie Donovan........................................................................Speaker of the House Carol Motycka................................................................Vice Speaker of the House Thomas Johns......................................................................................... FSHP President Jennifer Raquipo................................................................................. Region 1 Director Michael Hebb.........................................................................................Region 2 Director Tom Cuomo.............................................................................................Region 3 Director Linda Lazuka.........................................................................................Region 4 Director Robert Parrado...................................................................................Region 5 Director Luther Laite IV.....................................................................................Region 6 Director David Mackarey.................................................................................. Region 7 Director Humberto Martinez..........................................................................Region 8 Director Mitchell Fingerhut.............................................................................Region 9 Director
Florida Pharmacy Today Journal Board Chair.............................................................. Carol Motycka, motycka@cop.ufl.edu Vice Chair....................................................Cristina Medina, cmmedina@cvs.com Treasurer....................Stephen Grabowski, sgrabowski@seniormmc.com Secretary.............. Verender Gail Brown, brownvgrx4304@hotmail.com Member.................................................Joseph Koptowsky, docjik1215@aol.com Member.............................. Rebecca Poston, Rebecca.Poston@flhealth.gov Member.................................................Patricia Nguebo, notablep@hotmail.com Member................................................................Norman Tomaka, FLRX9@aol.com Member........................................................................Stuart Ulrich, Stuarx@aol.com Member............................................................. Don Bergemann, don@bceinfo.com Executive Editor................Michael Jackson, mjackson@pharmview.com Managing Editor...................Dave Fiore, dave@fiorecommunications.com Journal Reviewer....................... Dr. Melissa Ruble, mruble@health.usf.edu Journal Reviewer....................................Dr. Angela Hill, ahill2@health.usf.edu
MARCH 2016
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FLORIDA AGRICULTURAL & MECHANICAL UNIVERSITY COLLEGE OF PHARMACY & PHARMACEUTICAL SCIENCES
INTERN PHARMACISTS IMMUNIZING:
The Views of Pharmacists on Intern Pharmacists Being Permitted to Immunize According to the Florida CS/HB 279 Act Authors Margareth Larose-Pierre, Pharm.D. Kyle Brown, Pharm.D. Candidate Brittany Dutton, Pharm.D. Candidate Alyssa Munns, Pharm.D. Candidate Margareth Larose-Pierre is Associate Dean and Associate Professor of Pharmacy Practice at the Florida Agriculture & Mechanical University College of Pharmacy Durell Peaden, Jr. Center. In addition to teaching and training Doctor of Pharmacy students, Larose-Pierre has been an active member of multiple professional organizations. In her professional affiliations and in academia, Larose-Pierre remains a strong advocate for pharmacy students’ involvement in community activities. With the passing of CS/HB 279, she sees a groundbreaking opportunity for pharmacists and intern pharmacists to improve patient care through the education and training of students and through administering immunization to the community. Brittany Dutton is a fourth-year Doctor of Pharmacy candidate from Florida Agricultural and Mechanical University’s College of Pharmacy and Pharmaceutical Sciences. She has interests in retail and consulting pharmacy positions upon graduation. She is a member of Rho Chi and Phi Beta Kappa National Honor Societies, as well as the Florida Pharmacy Association and American Society of Health System Pharmacists. She recently completed the APhA Immunization course to become a certified immunizer. Alyssa Munns is a fourth-year Pharm.D. candidate at Florida A&M University’s College of Pharmacy and Pharmaceutical Sciences. She is a member of the Florida Pharmacy Association, American Society of Health-System Pharmacists, Rho Chi Society, Phi Theta Kappa and Phi Sigma Theta. With the passing of the CS/HB 279 act, she recently acquired certification as an immunizer in Florida through the APhA Pharmacy-Based Immunization Training Program. 10
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FLORIDA PHARMACY TODAY
Kyle D. Brown is a fourth-year Pharm.D. candidate at Florida A&M University’s College of Pharmacy and Pharmaceutical Sciences. Kyle is originally from New Mexico and moved to Florida in 2007 and began his pre-requisite to pharmacy school at Eastern Florida State College. He has been a member of the Florida Pharmacy Association through his matriculation through pharmacy school. Kyle was also recently certified as an immunizer in the state of Florida and is looking forward to graduating in April 2016. Abstract PURPOSE
The purpose of this study is to assess the views, attitudes and beliefs of practicing Florida pharmacists regarding intern pharmacists being able to legally provide immunizations to patients under licensed pharmacist supervision. Methodology-Florida pharmacists were provided access to a 12-question survey either electronically via the web-based site “Survey Monkey” or physically in-person. This survey was used to assess the opinion pharmacists have regarding intern pharmacists being able to provide immunizations to patients under their supervision. Prior to completing the survey, an informed consent statement was provided to the participant either electronically or physically in-person. This study took place from Aug. 12, 2015, to Nov. 13, 2015. RESULTS
Florida pharmacists had an overwhelmingly positive view toward intern pharmacists being able to legally immunize in Florida and felt CS/HB 279 will ultimately have a positive impact. When questioned about training students, the majority agreed that students should undergo the recommended training by the state (20 hours), and they are believed to have the ability to immunize in their P3 and P4 years. Additionally, more than half of the pharmacists felt that they were qualified to train intern pharmacists and would feel most comfortable with a student previously trained by their pharmacy school. The majority of pharmacists displayed concerns about students because of a greater liability posed to their license. A similar percentage of pharmacists had no concern with intern pharmacists immunizing as it is the law.
CONCLUSION
The CS/HB 279 Act has great implications for increasing the number of Florida pharmacists and intern pharmacists trained to administer immunizations. The results confirm that while there are uncertainties of allowing intern pharmacists to immunize, it is certain that the training resources, pharmacists willing to supervise and the positive outlook support this new responsibility of intern pharmacists. KEY WORDS:
Immunization, Vaccination, Vaccines, Intern pharmacist, CS/ HB 279 Act Background Pharmacists have been involved with vaccines since the mid-1800s, when Edward Jenner developed the small pox vaccination. During several outbreaks through the years, pharmacists have been instrumental in supplying vaccines without any direct administration of vaccines to patients on any grand scale. However, within the past 20 years, pharmacists have come to play a more active role in providing routine vaccinations to patients. In 1994, the Washington State Pharmacists Association became the first organization to implement an immunization training program for pharmacists.1 Following their example, the American Pharmacists Association (APhA) developed its nationally recognized Pharmacy-Based Immunization Delivery Certificate Program in 1996, which has provided training to over 15,000 pharmacists and intern pharmacists to date, allowing them to provide immunization to their patients.3, 4 On Jan. 1, 2015, a general bill was filed under the Health Innovation Subcommittee of the Florida Legislature to allow registered intern pharmacists to be able to administer select adult vaccinations under a registered pharmacist’s supervision in the State of Florida. This bill will allow an intern pharmacist, registered under the Florida Board of Pharmacy, to administer the same vaccinations applicable under pharmacist licensure. The intern administering the vaccination should have completed a certification program approved by the Florida Board of Pharmacy. This certification program should include a minimum of 20 hours of board-approved coursework. This coursework shall contain information regarding the safe and effective administration of vaccinations, along with potential allergic reactions resulting from the vaccines.5 The bill was passed by the Florida House of Representatives on April 9, 2015, and was later passed by the Florida Senate on April 24, 2015. The law went into effect on July 1, 2015, making Florida the 36th state in the union to allow intern pharmacists to provide immunizations.6
Objectives The primary objective of this study was to assess the views, attitudes and beliefs Florida pharmacists have regarding intern pharmacists being able to legally provide immunizations to patients under licensed pharmacist supervision. Secondary objectives included an assessment of the pharmacists’ perception of the CS/HB 279 Act in terms of how pharmacists will accept, train and prepare intern pharmacists to administer immunizations in a variety of healthcare environments. Methodology A survey study was conducted to include Florida pharmacists regardless of their immunization provider status to assess the views of pharmacists registered in the State of Florida on intern pharmacists being permitted to immunize according the passing of the CS/HB 279 Act. Pharmacists not registered in the state of Florida were excluded. This study was approved by the Institutional Review Board of Florida Agricultural and Mechanical University. Florida pharmacists were provided access to a 12-question survey either electronically via the web-based site “Survey Monkey” or physically in-person. This survey questionnaire, presented in table 1, assessed the opinion pharmacists have regarding intern pharmacists being able to provide immunizations to patients under their supervision. Prior to completing the survey, an informed consent statement was provided to the participant either electronically or physically in-person. This study took place from Aug. 12, 2015, to Nov. 13, 2015.
DURING SEVERAL OUTBREAKS THROUGH THE YEARS, PHARMACISTS HAVE BEEN INSTRUMENTAL IN SUPPLYING VACCINES WITHOUT ANY DIRECT ADMINISTRATION OF VACCINES TO PATIENTS ON ANY GRAND SCALE. MARCH 2016 |
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Table 1: Survey Questions Provided to Participating Pharmacists Question
Answer Selections (Participants could select more than one answer)
1. What is your age range?
A. 20-30 B. 31-40 C. 41-50 D. 51-60 E. 61-70 F. 71-80
2. What degrees/additional training have you obtained (Check all that apply or circle one)?
A. B. C. D.
B.Pharm. Pharm.D. Residency/Fellowship Other _______________
3. How would you characterize your area of pharmacy practice (Check all that apply or circle one)?
A. B. C. D. E.
Hospital Retail Nursing Home Retired Other _______________
4. How long have you been practicing as a licensed pharmacist?
A. B. C. D. E. F.
0-10 years 11-20 years 21-30 years 31-40 years 41-50 years 51-60 years
5. Do you agree with the passing of the CS/HB 279 Act to allow intern pharmacists to immunize in the state of Florida beginning July 1, 2015?
A. Yes B. No C. N/A
6. How long should intern pharmacists receive training in school in order to be prepared to administer immunizations (Check all that apply or circle one)?
A. B. C. D. E.
7. My chief concern regarding the CS/HB 279 Act would be (Check all that apply or circle one):
A. Possible harm to my patients B. Patients will not accept intern pharmacists immunizing instead of me C. Intern pharmacists are practicing immunizations under my license D. Greater liability is posed to my license E. No concern, it’s the law
8. In what year of pharmacy school do you consider an intern pharmacist to be capable of giving vaccines safely under pharmacist supervision (Check all that apply or circle one)?
A. B. C. D. E.
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The recommended training by the state (20 hours). 40 hours 80 hours 120 hours or greater No training at all
P1 P2 P3 P4 I do not feel like intern pharmacists should be able to immunize
Question
Answer Selections (Participants could select more than one answer)
9. Do you feel like you could spend adequate time training intern pharmacists to immunize?
A. Yes B. No C. I am not qualified to train intern pharmacists
10. Would you feel most comfortable with an intern pharmacist trained from (Check all that apply or circle one):
A. Their pharmacy school B. The organization that trained you/place of employment C. One on one training from you, the R.Ph./Pharm.D.
11. If and when intern pharmacists are permitted to immunize A. Yes at your pharmacy or healthcare location, do you feel that B. No your patients will be receptive to them providing these C. We do not provide immunizations services?
12. Do you believe the CS/HB 279 Act will potentially have a positive or negative impact?
A. B. C. D.
Positive Negative I am neutral I don’t know
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MARCH 2016
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Table 2: Demographic Characteristics of the Study Population Pharmacist Degrees/Certifications B.Pharm. Pharm.D. Residency/Fellowship Other Degree Area of Pharmacy Practice Retail Practice Setting Hospital Practice Setting Nursing Home Practice Setting Retired Other Practice Setting Pharmacist Age Ranges Age Range 20-30 Age Range 31-40 Age Range 41-50 Age Range 51-60 Age Range 61-70 Total Years of Pharmacy Practice 0-10 Years of Practice 11-20 Years of Practice 21-30 Years of Practice 31-40 Years of Practice 41-50 Years of Practice *Total Participants: 120 Pharmacists The data was collected and analyzed to determine the overall viewpoint pharmacists have on an intern pharmacists providing immunizations according to the CS/HB 279 act, the level of education they feel the intern should have received prior to providing these immunizations and if any differences in opinion are presented based on pharmacist demographics. Concerns about the new law were also addressed in the survey. Results During the three month period that the survey was administered, 120 pharmacists provided consent and completed the survey. Table 2 shows the demographic characteristics of the study population. The majority (56 percent) of the pharmacists that completed the survey reported that they had a Pharm.D, and 76 percent reported that they work in a retail practice setting. In regards to age range of 20 to 80 years surveyed, 25 percent of participants reported being within the age of 51 to 60 years old. Thirty-seven percent of participating pharmacists reported practicing pharmacy for zero to 10 years. When pharmacists were questioned about the CS/HB 279 act, many were unaware that interns could now immunize in the state of Florida (Figure 1 and 2). An overwhelming 91 percent agreed with the passing of the act, with 75 percent re14
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51 (42.86%) 67 (56.30%) 6 (5.04%) 14 (11.76%) 91 (75.83%) 25 (20.83%) 2 (1.67%) 2 (1.67%) 16 (13.33%) 22 (18.49%) 24 (20.17%) 27 (22.69%) 30 (25.21%) 16 (13.45%) 44 (36.67%) 20 (16.67%) 24 (20.0%) 26 (21.67%) 6 (5%)
porting a positive impact and 17 percent reporting they were neutral. Pharmacists were asked to choose all years of pharmacy school in which interns were considered capable of immunizing. The majority of pharmacists reported that third and fourth year pharmacy students, 54 percent and 29 percent respectively, had more clinical knowledge and experience and would be better prepared to provide immunizations (Figure 3). Because interns will be practicing under the pharmacist’s license and supervision, it was not surprising that 48 of the participants expressed that their major concern was a greater liability posed to the supervising pharmacist’s license. This concern was closely followed by 45 participants stating that they did not have any concerns, as it is the law. (Figure 4) The state requires that interns and pharmacists immunizing take part in a board-approved immunization program for a minimum of 20 hours.7 Ninety-Four (94) respondents representing 78 percent of the participating pharmacists agreed that students should complete a 20-hour program, as is required of pharmacists, to obtain immunization certification. (Figure 5) When evaluating pharmacists’ opinions on where the interns should be trained, 93 participants reported that the interns should be trained through the pharmacy school in con-
junction with the APhA immunization training program. Likewise, 45 participants reported that the intern should be trained by the supervising pharmacist’s place of employment. (Figure 6) Fifty-Four percent of participating pharmacists reported that they would be willing to train intern pharmacists to immunize, while 32 percent reported that they would not agree to train intern pharmacists. The majority of those that were unwilling to train cited lack of time as a reason. (Figure 7) In terms of patient perception, 83 percent of pharmacists agreed that patients would accept interns providing immunizations, while 7 percent felt their patients would be opposed to an intern providing immunizations (Figure 8). The other 10 percent of pharmacists reported that they work at sites that do not provide patients with immunizations. Discussion There was limited research available on intern pharmacists providing vaccination in the United States. While this is a pioneer study in terms of immunization research in Florida, several studies conducted in Canada showed that intern pharmacists providing immunizations yielded a positive impact on patient care. These Canadian studies showed positive patient reception, enhanced access to vaccinations and improvement in the intern pharmacists’ skill levels.8, 9, 10 Baseline data collected in our current study provided a framework for the initial integration of intern pharmacists into Florida’s immunization effort. Only 1 percent of the participating pharmacists felt the act would have a negative impact. This shows that some pharmacists might be unsure or unaware of the CS/HB 279 Act’s influence on pharmacy practice, but that they were not completely against it. Analysis of the data collected and the numbers reported indicate a need for a greater number of qualified immunizing pharmacists to mentor the intern pharmacists enrolled at any of the six colleges and schools of pharmacy in the state of Florida. Based on the results of this survey, the majority of the pharmacists prefer only third and fourth year interns be trained to provide immunizations. This is likely because students in the third and fourth year have more clinical knowledge and experience than students in the first and second years. In the future, retail pharmacy chains and other clinical settings will have to regulate an appropriate protocol by which interns can provide immunizations to patients in Florida. With retail chains already in other states allowing interns to immunize, corporate offices will likely transfer these protocols from these other states to Florida and possibly make some adaptation to comply with Florida laws. The main concern of the participating pharmacists was that there will be greater liability posed to their license. Regardless of any health-related profession providing training to students, liability will be a major concern. However, pharmacy schools in the state of Florida could implement training programs and immunization technique laboratory classes throughout the didactic curriculum years to improve students’ immunization skills to better prepare the intern to provide immunizations in practice. The students should also be
given the opportunity to improve upon their confidence and skills in school-affiliated immunization clinics. This additional training may allow both the supervising pharmacist and intern pharmacist to feel more comfortable with the intern providing vaccinations to patients. There was no difference among the results when comparing the age of the pharmacists and their experience level to whether they agreed or disagreed with the CS/HB 279 Act and its impact on pharmacy practice. In regards to the age range of survey participants, 90 percent, regardless of age, agreed with the passing of CS/HB 279 Act, and 75 percent reported that they felt the act would have a positive impact on the profession of pharmacy. In terms of their level of experience, 92 percent of the respondents, regardless of the number of years of experience they possessed, agreed with the passing of the act, and 78 percent reported that they felt the act would have a positive impact. This shows that, regardless of age and experience level, the majority of pharmacists agreed with the passing of the act and believe that it will have a positive impact on the pharmacy profession as a whole. Thirty-two percent of pharmacists reported that they are not willing to train intern pharmacists to provide immunizations. That will pose a significant challenge in the quest to increase the number of supervising pharmacists. Will their minds change when more pharmacists are made aware of the potential positive impact of CS/HB 379 on health care and disease prevention and the pharmacist’s role in immunizing? With pharmacy schools in the state of Florida educating
A Pharmacist And A Lawyer Board of Pharmacy Licensure Disciplinary Proceedings Compounding Violations, DEA Investigations Mergers and Acquisitions Pharmacy Risk Assessment/Management Evaluations KAHAN ◆ HEIMBERG, PLC
Pharmacist Attorney Brian A. Kahan, R.Ph., J.D. Licensed Florida Pharmacist and Attorney
STATEWIDE REPRESENTATION 561-392-9000 bkahan@kahanlaw.com 2300 N.W. Corporate Blvd., Suite 123 Boca Raton, FL 33431 The hiring of a lawyer is an important decision that should not be based solely upon advertisements. Before you decide, ask us to send you free written information about our qualifications and experience.
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and training their students, it is possible that will potentially bring the number of supervising pharmacists unwilling to train interns in immunization to decrease significantly in the near future. More initiative needs to be taken by pharmacists to train the next generation and enhance the intern’s performance while administering immunizations. Ultimately, this may require a corporate initiative by chain pharmacies, hospitals, and clinics to allow the pharmacists more time to provide training to intern pharmacists. Because only 54 percent of pharmacists reported their willingness to train, a comparison was made to see how the age factor and experience level influenced their response. The results show that the higher the age and experience level of the pharmacists, the more they reported a willingness to train intern pharmacists. More of the younger and less experienced pharmacists reported to be unwilling to train intern pharmacists. Interns providing immunizations will likely lead to a positive impact on pharmacy practice in that it will: 1) enhance patient access to vaccines, 2) allow pharmacists and intern pharmacists to work as a more cohesive unit to improve patient care and 3) provide the intern with immunization experience prior to graduation.11, 12, 13 The State of Florida requires that, in order to be certified as an immunizer in the state, both pharmacists and intern pharmacists must have completed training in cardiopulmonary resuscitation (CPR) and basic cardiac life support (BCLS) in addition to the 20-hour Immunization Delivery training program. The major limitation of this study was the small size of the population surveyed, with only 120 participants, despite attempts to distribute the survey through hand delivery, survey monkey and a link through the Florida Pharmacy Association (FPA) member emails. Additionally, as with all self-reported surveys, a potential for bias in the collected data cannot be ruled out. Conclusion The CS/HB 279 Act has great implications for increasing the number of Florida pharmacists and intern pharmacists trained to administer immunizations. The results confirm that, while there are a few uncertainties in regards to allowing intern pharmacists to immunize, it is certain that the training resources, pharmacists willing to supervise and the positive outlook support this new responsibility of intern pharmacists.
Disclosure The authors of this presentation have nothing to disclose concerning possible financial or personal relationships with commercial entities. References
1 Hogue MD, Foster SL, eds. Pharmacy-based immunization delivery: a national certificate program for pharmacists, 9th ed. Washington, D.C.: American Pharmacists Association; 2004 2 Pharmacy-Based Immunization Delivery. American Pharmacists Association. Available at: http://www.pharmacist.com/ pharmacy-based-immunization-delivery. Accessed on 8/11/2015. 3 Hogue, MD, Grabenstein JD, Foster SL, et al. Pharmacist involvement with immunizations: a decade of professional advancement. J Am Pharm Assoc. 2006; 46(2):168-179. 4 Immunization Action Coalition. Historic Dates and Events Related to Vaccines and Immunization. Available at: http:// www.immunize.org/timeline. Accessed on 9/26/2015. 5 Health Innovation Subcommittee. Committee Substitute for House Bill No. 279. The Florida Senate. Available at: http:// laws.flrules.org/2015/108. Accessed on 11/18/2015 6 Pharmacist Administered Vaccines: May student interns administer vaccines? American Pharmacist Association. Available at: http://www.pharmacist.com/sites/default/ files/files/PharmacistIMZAuthority_June18_2012%20 %5BRead-Only%5D.pdf. Accessed on 11/18/2015. 7 Section 465.189, F.S. Administration of vaccines and epinephrine autoinjection. The Florida Senate. Available at: http://www.leg.state.fl.us/statutes/index. cfm?App_mode=Display_Statute&URL=0400-0499/0465/ Sections/0465.189.html. Accessed on 11/18/2015. 8 Cheung, W., Tam, K., Cheung, P., et al. Satisfaction with student pharmacists administering vaccinations in the University of Alberta annual influenza campaign. Can Pharm J. 2013; 146(4):227-232. 9 Poulose S, Cheriyan E, Cheriyan R, et al. Pharmacistadministered influenza vaccine in a community pharmacy: A patient experience survey. Can Pharm J (Ott). 2015; 148(2):6410 Papastergiou John, Folkins Chris, Li Wilson, and Zervas John. Community pharmacist administered influenza immunization improves patient access to vaccination. Canadian Pharmacists Journal. 2014; 47: 359-365. 11 Conway, S., Johnson, E., Hagemann, T. Introductory and Advanced Pharmacy Practice Experiences Within Campusbased Influenza Clinics. Am J of Pharm Educ. 2013; 77(3): 61. 12 Madhavan SS, Rosenbluth SA, Amonkar M, Borker RD, Richards T. Pharmacists and immunizations: a national survey. J Am Pharm Assoc. 2001:41(1):32-45. 13 Malvey D, Fottler MD. The retail revolution: who will win and who will lose. Health Care Manage Rev. 2006; 31(3):168–78.
INTERNS PROVIDING IMMUNIZATIONS WILL LIKELY LEAD TO A POSITIVE IMPACT ON PHARMACY PRACTICE IN THAT IT WILL: 1) ENHANCE PATIENT ACCESS TO VACCINES, 2) ALLOW PHARMACISTS AND INTERN PHARMACISTS TO WORK AS A MORE COHESIVE UNIT TO IMPROVE PATIENT CARE AND 3) PROVIDE THE INTERN WITH IMMUNIZATION EXPERIENCE PRIOR TO GRADUATION. 16
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FPA News & Notes Board of Pharmacy Inspection Standards Pharmacy permits in Florida undergo routine inspections. Under rule 64B16-28.101, a pharmacy will be inspected twice during its first year of operation, followed by an annual inspection. If a pharmacy has had a passing inspection for the most current three years, as well as no discipline during that three-year period, the inspection will be done every two years instead of annually. The exception will be for a failed inspection or any discipline received. Members may need to be aware that some board rules have been revised that change what inspectors may be looking for. This includes changes to rule 64B1627.410. We have received many questions on the requirements for technician ratio, as well as the new obligations to show documentation on technicians’ understanding of policies and procedures. This includes being able to produce those policies and procedures (See Jan. 5, 2015 Stat News). Members will need to be aware that the Department of Health will be inspecting for compliance to this rule. Such review will include but not be limited to: ■■ Requirement to produce a written policy and procedure manual regarding the number of technician positions and their utilization ■■ Documentation signed by pharmacy technician acknowledging review of the policy and procedure ■■ Documentation that pharmacy technician has been trained in the established job description Members may also need to make sure that the licenses of pharmacists, technicians and interns are on display and readable by the pharmacy patrons (64B165-27.100). Make sure that you have your continuous quality improvement (CQI) policies and procedures available for inspection, as well as a summary of quality-related events that may have occurred in your pharmacy. DEA form 222s must be properly completed or records of receipt of Controlled Substance Ordering System (CSOS) orders must be available for review. Controlled substance prescriptions should have the date dispensed and the name of the dispensing pharmacist in the record. Also, the Department will be checking for an audit trail of your receipt of drugs. You may expect to see increased enforcement in this area, especially with the recent changes in Florida law (see 2016 legislative report). The FPA has installed a link to the DOH website that contains the various inspection forms used by Inspection Services. You will find that link in the “laws and rules” portal on pharmview.com.
Technician National Certification As of Dec. 31, 2015, there were 18,216 PTCB-certified pharmacy technicians in Florida. Our state is ranked third behind Texas and California. Forty-five states and the District of Columbia regulate pharmacy technicians, with 24 states (DC included) requiring national certification. Since 1995, the Pharmacy Technician Certification Board (PTCB) has granted 587,536 certifications. What is interesting is that 10 states actually include technicians on their boards of pharmacy. Currently, Florida only requires technicians to be registered. This registration can be applied for only after completing a Florida Board of Pharmacy technician training program. By the year 2020, those candidates seeking PTCB certification will be required to successfully complete an ASHP/ACPE accredited training program. The FPA has longstanding policy to support PTCB certification. For more information, please visit www.ptcb.org. 2016 Legislative Session Report We are again pleased to report another winning legislative session with a number of pharmacy projects presented to members of the Florida Legislature for their consideration. With this being a significant election year, the possibility to get bills to the governor’s desk was quite a challenge. There were 937 bills filed in the Florida Senate and 877 bills that were filed in the House. One hundred ninety-six bills passed the Florida Senate and of those bills 116 passed the House as well. The House passed 251 bills and of those 163 passed the Senate as well. This means that of the 1,814 bills that were filed in the House and Senate, 279 (15 percent) were approved in both chambers. A comprehensive legislative report has been filed on Pharmview.com. A sampling of information in the report includes the following: ■■ Revisions to the Florida Drug and Cosmetic Act related to track and trace ■■ Redefining what distribution of drugs may be ■■ Office-use wholesaling ■■ Alleviating temporary shortages in pharmacies— what to do when you run out of something ■■ Revising the threshold that requires wholesalers to review controlled substance orders ■■ Requirements for a Department of Health pamphlet on controlled substances ■■ Pharmacist dispensing of opioid antagonists by standing order ■■ Advanced registered nurse practitioner and physician
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FPA News & Notes ■■ ■■ ■■ ■■ ■■
assistant prescribing of controlled substances Sexually transmitted disease partner therapy and the role of the pharmacist Requirement to respond to a Department of Health survey on telehealth Inspection requirement changes on dispensing practitioners Delegation of the authority for pharmacy designee (such as technicians) to query the PDMP database New requirements for the retail sale of dextromethorphan products
To view the 2016 legislative report, visit this link. You will need your username and password to see the report. Joint Florida Board of Pharmacy - Board of Medicine Meeting A joint meeting of the Florida Board of Pharmacy and the Board of Medicine took place in Altamonte Springs on April 7, 2016. This was the first joint meeting of these two regulatory bodies. The purpose was to engage in collaborative dialog with open discussion on patient care. This session was initiated through the issues surrounding controlled substance prescribing and dispensing in Florida. During meetings of the Board of Pharmacy Controlled Substance Standards committee, there was interest in convening a joint session between the two boards. At the conclusion of this event, there was a commitment to continue further dialog at future meetings. FPA to Host Diabetes Certificate Program The FPA is pleased to inform our members that we have partnered with the American Pharmacists Association in bringing the Pharmacist and Patient-Centered Diabetes Care Certificate Training Program to Florida. This offering will be available in Fort Lauderdale on June 29, 2016, just prior to the start of the 126th Annual Meeting and Convention. This educational event includes intensive educational experiences designed to equip pharmacists with the knowledge, skills and confidence needed to provide effective, evidence-based diabetes care. For more information or to register, visit this link. Seating is limited, so please register early. Florida Pharmacy Foundation Announces Scholarship Recipients
JAMES A. MINCY INDEPENDENT PHARMACY SCHOLARSHIP
This award, named in memory of James A. Mincy, a third-generation independent pharmacist, recognizes a pharmacy student who has demonstrated outstanding academic achievement, made contributions through volun-
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teer work, participated in professional or student organizations and shown an interest in independent pharmacy. Farima Raof is the winner of the 2016 scholarship. Farima is a third year student pharmacist at Nova Southeastern University College of Pharmacy. She has been extremely involved and has held leadership positions in several professional pharmacy associations and organizations such as APhA-ASP, FPA, NSU President’s 64 Prestigious Group, CPFI, Phi Lambda Sigma Pharmacy Leadership Society and Rho Chi Honor Society. Farima currently serves as APhA-ASP Chapter President for the Fort Lauderdale Campus. She is also an active member of the Florida Pharmacy Association, serves as a member of FPA Student Affairs Council and is a new student trustee to the Florida Pharmacy Foundation. JAMES B. AND PATSEY POWERS SCHOLARSHIP
This award was established in 1992 in honor of Powers’s achievements as the Florida Pharmacy Association executive vice president. In 2003, the Board of Trustees voted to include Patsey, his wife, for her involvement in Florida Pharmacy Association affairs for more than 30 years. The award recognizes a pharmacy student who has demonstrated outstanding academic achievement, made contributions through volunteer work and participated in professional or student organizations. Umima Baig is the recipient of the 2016 scholarship. Umima is a fourthyear student pharmacist at Palm Beach Atlantic University. She was actively involved in organizations as the president of Rho Chi and the student chapter of ACCP, as well as involvement in other organizations, such as FPA and FSHP. After graduation, she will be pursuing a PGY-1 residency at the West Palm Beach VA. Practitioner Survey on Use of Stroke and Bleeding Risk Tools Researchers at Nova Southeastern University are asking for assistance with a survey related to practitioner involvement in the use of stroke and bleeding risk tools. A drawing for a $50 gift card may be available for those who respond. To view an introductory letter and take the survey, enter here. If you wish to go directly to the survey, select this link. AHCA Notice to Providers on Inspections The Agency for Health Care Administration (AHCA)
FPA News & Notes has issued an advisory notice to Medicaid providers that employees from the Agency are authorized to have access to a Medicaid provider’s place of business and their Medicaid-related records, without prior notice. For more information about this authority, please see Section 409.907(3) (e), Florida Statutes, which requires providers to permit access to all Medicaid-related information. Employees from several organizational units within AHCA may present themselves at your offices, seeking the opportunity to conduct an on-site review. AHCA employees all carry an AHCA-issued identification badge that states their name and the organizational office.
Editor’s Note: Members may need to be aware that in Florida Statutes 465.188, there is a Medicaid standard that describes how routine audits are to be performed in pharmacies. While Agency staff may have full access to pharmacy businesses, there may be some limits and exceptions. These audit standards in F.S. 465.0188 are not applicable to Medicaid managed care patients. They are also not applicable to any investigative audit conducted by the Agency for Health Care Administration when the agency has reliable evidence that a claim that is the subject of the audit involves fraud, willful misrepresentation or abuse. Please consult your attorney for more information.
In MemoriAm Richard Lloyd Wagner passed away on April 19 at the age of 76. He was born and raised in Brooklyn, New York, and attended Stuyvesant High School and Columbia University, where he studied pharmacy. “Richie” moved to Miami in November 1963 and shortly thereafter purchased Milton Medical and Drug Company, where he proudly served the Miami Beach community for 52 years. He was active in founding Nova Southeastern College of Pharmacy and is a past president of the Dade County Pharmacy Association. Richie was committed to lifelong Jewish learning, a long-time member of Temple Samu-El Or Olom and Bet Shira Congregation. He was a loving husband to his “precious bride” of almost 47 years, Sheila. He was a truly wonderful man, full of life and laughter, loved by all who had the privilege to know him. He is survived by his wife, Sheila; his loving daughters Elissa (Joseph) Newman and Sari (Alan) Lennick; his adoring grandchildren Zachary Eli, Dylan Albert, Halle Charlotte and Olivia Wagner; his beloved brother Allan (Debbie) Wagner; loving nieces and nephews; amazing cousins; so many treasured friends and colleagues; and his devoted staff of over forty years. The funeral was held at Lakeside Memorial Park in Miami on Thursday, April 21. Donations in Wagner’s honor can be made to Bet Shira and Beth Torah Congregations and the Florence Melton School at the Miami Center for Advancement of Jewish Education, 4200 Biscayne Blvd, Miami, Fla. 33137.
SAVE THE DATE 126TH ANNUAL MEETING AND CONVENTION OF THE FLORIDA PHARMACY ASSOCIATION Marriott Harbor Beach 3030 Holiday Drive Fort Lauderdale, Florida 33316 June 30 - July 3, 2016
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Does a Benzodiazepine a Day Keep Anxiety Away? Melanie Smith, Pharm.D. Ereka Managan, 2016 Pharm.D. Candidate An xiet y disorders are becoming increasingly common in the United States. The 12-month prevalence has risen to 40 million adults age 18 or older, or approximately 18 Melanie Smith, percent of the popuPharm.D. lation.1 According to a study conducted by the Anxiety and Depression Association of America, anxiety disorders cost the U.S. more than $42 billion per year, about one-third of the total $148 billion spent on mental health.2 People suffering from anxiety are three to five times more likely to visit a doctor and six times more likely to be hospitalized for psychiatric disorders than those who are not.2 Anxiety encompasses a large variety of specific disease states, including generalized anxiety disorder, panic disorder, social anxiety disorder and specific phobias. The treatment of these disorders varies according to etiology of the disorder. Unfortunately, unlike many other disease states, there is not a concise set of treatment guidelines published in the United States for the treatment of all anxiety disorders. The most wellknown treatment guidelines for generalized anxiety are from the National Institute for Health and Clinical Excellence (NICE). These are published in the United Kingdom and were last updated in 2011.3 The American Psychiatric Association (APA) last published guidelines on the treatment of panic disorder in 2009.4 The Canadian clinical practice guidelines published in 2014 address the treatment of panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder, as well as obsessive-compulsive disorder, and posttraumatic stress disorder.5 20
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So do our treatment practices in the U.S. follow the direction of these clinical practice guidelines? Unfortunately, the answer is no. The NICE guidelines recommend anti-depressants as first line in the treatment of generalized anxiety disorder, and the APA guidelines for the treatment of panic disorder recommend the same. Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibi-
ti-depressants. They carry risks of dependency, cognitive impairment, abuse and withdrawal that are not as significant for other treatments of anxiety. Dependency and abuse stems from the gratifying sensations that materialize when the brain’s reward center receives a surge of dopamine. This occurs when BZDs weaken the inhibitory influence of cells in the ventral tegmental area of the brain that normally prevents excess dopamine. The addictive nature
ANXIETY ENCOMPASSES A LARGE VARIETY OF SPECIFIC DISEASE STATES, INCLUDING GENERALIZED ANXIETY DISORDER, PANIC DISORDER, SOCIAL ANXIETY DISORDER AND SPECIFIC PHOBIAS. tors (SNRIs) are the best-tolerated and most efficacious anti-depressants for the treatment of anxiety. A recent metaanalysis compared the efficacy of pharmacological, psychological and combined treatments for panic disorder, generalized anxiety disorder and social phobia and found that medications were significantly more efficacious than psychotherapies, with the highest efficacy being SNRIs, followed by benzodiazepines (BZDs), SSRIs and tricyclic anti-depressants.5 Benzodiazepines (BZD), though not recommended as first-line therapy, are the most commonly prescribed drugs in the treatment of anxiety disorders. No studies have looked at their longterm (greater than eight months) effectiveness, and they come with significant risks when used inappropriately.6 BZDs are known for their rapid relief of the somatic and autonomic symptoms of anxiety, but they do nothing for the psychic symptoms of worry and apprehension that are relieved by an-
of BZDs is due to long-lasting changes in the brain’s reward system via activation of the GABAA receptor. In addition to the risks of dependency and abuse, when used concomitantly with other medications or substances that decrease respiratory function, the risk of overdose increases significantly. We know that abuse of prescription medications is on the rise in the U.S. A recent study found that between 2004 and 2011, drug overdose involving opioids and BZDs increased significantly. There was a 19.1 percent increase in emergency department visits related to the combined use of BZDs and opioids over the seven-year study period, compared to an increase of 11.4 percent for BZDs alone and 12.6 percent for opioids.7 Additionally, another study conducted in Veterans Affairs Medical Centers across the U.S. found that in 2,400 veterans who died of drug overdose while prescribed opioid pain relievers, 49 percent were also concurrently prescribed BZDs. Patients currently being pre-
scribed BZDs and opioids had more than three times the risk of overdose. Interestingly, a history of previous BZD prescriptions increased the risk of overdose by more than two times. The study also found that risk of overdose increased with daily opioid dose, daily BZD dose and dosing schedule that included both scheduled and as-needed doses.8 The NICE guidelines suggest that BZDs not be offered for the treatment of generalized anxiety except as a shortterm measure during crisis. For panic disorder, they state that BZDs are associated with worse outcomes and should not be prescribed.3 The Canadian guidelines for the management of anxiety suggest that BZDs only be used as adjunctive therapy early in treatment during times of acute crisis or while waiting on the onset of SSRIs or SNRIs. They suggest only short-term use with dosing as scheduled rather than as needed to prevent possible dependency, sedation, cognitive impairment and other side effects.9 The APA recommends SSRIs, SNRIs and tricyclic anti-depressants over BZDs for panic disorder in patients with comorbid depression or substance abuse disorders. When BZDs are prescribed, the APA recommends prescribing limited dosing intervals and prescribing as scheduled rather than as needed.4 Recently, the Centers for Disease Control (CDC) released the 2016 guidelines for treatment of chronic pain with opioids. Due to the lack of evidence of long-term efficacy and the risks of abuse, dependency, and overdose, the CDC felt it necessary to offer concise recommendations to improve communication about benefits and risks of opioids for chronic pain, improve the safety of pain treatment, and reduce risks associated with long-term opioid therapy. They recommend non-opioid therapy as first line in treating chronic pain and using opioids only when benefits outweigh risk. They also recommend using the lowest effective dose, reassessing benefits and risks every three months, monitoring for abuse, and avoiding concurrent BZDs and opioids.10 Considering the fact that BZDs carry many of the same questions of long-term efficacy and many of the
same serious risks of opioids, prescribers need the same guidance for the use of BZDs and a systematic review of the literature regarding treatment with BZDs in addition to publication of standards for the use of BZDs in anxiety disorders needs to be completed. As pharmacists, we must advocate for the safe and effective use of all medications, especially those that carry high risk of abuse and dependency, such as BZDs. It is important to remember that BZDs are not recommended as first line treatment for anxiety disorders. SSRIs and SNRIs should be our mainstay treatments and BZDs should only be considered as adjunctive therapy for short-term use. It would be appropriate to offer BZDs in the short duration (four to six weeks) that it takes to see the effects of SSRIs and SNRIs. Scheduled dosing intervals have been proven to be more safe and efficacious, and a patient should never be on both a scheduled interval and as needed dosing. Additionally, patients who receive both BZDs and opioids are at a much higher risk of abuse and overdose and this practice should be limited. We must be vigilant in screening for abuse and misuse of these medications, including carefully utilizing resources like the prescription monitoring program and assessing patients for efficacy or potential abuse. We all have patients who come to fill their BZDs and opioids every month and have been filling them for long periods of time. I would encourage a careful evaluation of these patients. Does a BZD a day really keep the anxiety away, or is this a dangerous situation just waiting for a poor outcome? As pharmacists, it is our duty to protect our patients from unsafe medication prescribing even in situations that require tough conversations and extraordinary diligence. Protecting our patients is worth that fortitude and diligence and will ultimately lead to safer prescribing practices and better outcomes. REFERENCES
Kessler RC, Chiu WT, et al. Prevalence, severity, and comorbidity of twelvemonth DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of
General Psychiatry, 2005;62(6):617-627. Greenberg PE, Sisitsky T, et al. The economic burden of anxiety disorders in the 1990s. J Clinical Psychiatry, 1999; 60(7):427-435. National Institute for Heath and Clinical Excellence. National Clinical Guideline Number 113. Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults. January 2011. Available at www.nice. org.uk/CG113. Stein MB, Goin MK, et al. Practice guideline for the treatment of patients with panic disorder. American Psychiatry Association (APA). January 2009. Katzman MA, Bleau P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry, 2014;14(Suppl 1):S1. Bandelow B, Reitt M, et al. Efficacy of treatments for anxiety disorders: a met-analysis. International Clinical Psychopharmacology, 2015;(30):183192. Perna G, Alciati A, et al. Long-Term Pharmacological Treatments of Anxiety Disorders: An Updated Systematic Review. Curr Psychiatry Rep, 2016;18:23 DOI 10.1007/s11920-0160668-3 Jones C, McAninch J. Emergency Department Visits and Overdose Deaths from Combined Use of Opioids and Benzodiazepines. Am J Prev Med, 2015;49(4):493–50. Park TW, Saitz R, et al. Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study. BMJ,2015;350:h2698. Dowell D, Haegerick TM, et al. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep, 2016;65(1):1-49. doi: 10.15585/mmwr.rr6501e1.
Author Bio: Melanie Smith is a PGY1 pharmacy resident at UF Health Jacksonville. She graduated with a Pharm.D. in 2015 from the University of Arkansas for Medical Sciences in Little Rock, AR. She has pharmacy interests in critical care, infectious diseases, research, and academia, and after completion of her PGY1, she will be going to the Medical University of South Carolina in Charleston, S.C., to complete a PGY2 specialty residency in critical care. MARCH 2016
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CALL FOR ABSTRACTS FOR POSTER PRESENTATIONS For Florida Pharmacy Students
FLORIDA PHARMACY ASSOCIATION 126th ANNUAL MEETING AND CONVENTION
June 29-July 3, 2016 Marriott Harbor Beach Resort & Spa ♦ Ft. Lauderdale, Florida Poster Session: Friday, July 1, 2016 ♦ 11:00AM-1:00PM
The FPA Poster Presentations are open to PHARMACY STUDENTS ONLY. Complete and submit this COVERSHEET for each abstract submission. Submissions must be received no later than Friday, May 6, 2016. Abstracts will NOT be accepted after this date. Mail or E-mail this application along with the abstract submission to: Tian Merren Owens, MS, PharmD, Director of Continuing Education Florida Pharmacy Association 610 N. Adams Street Tallahassee, FL 32301 tmerren@pharmview.com
PLEASE TYPE
Contact Information: Presenter's Name (MUST BE A STUDENT):________________________________________________________________
□Entry Level Pharm.D. □ Post B.S. Pharm.D. Address: ________________________________________________________________________________________
City, State, Zip: ___________________________________________________________________________________ Telephone No: _____________________E-Mail Address: _________________________________________________ Abstract Title: ____________________________________________________________________________________ Poster Type:
□Clinical Research □Basic Science Research □Translational Research (Basic Science and Clinical Research)
Primary Author: __________________________________________________________________________________ (Students must be listed first to be considered for the Award. Presenter will be notified by mail of acceptance). Co-Author(s): _________________________________________________________ Student
□YES □NO
Awards:
Posters will be eligible for 1st, 2nd, and 3rd place prizes to be presented at Convention. (Only one prize is given for each winning poster)
Free Registration:
Three entry level students from each Florida College of Pharmacy will be eligible for a complimentary Florida Pharmacy Association Convention Student registration. (Student Registration does not include CE or hotel accommodations) I am interested in being considered for this registration:
College:
□YES
□NO
_____________________________________________________________________________
ABSTRACT FORMAT The abstract form submitted should be the equivalent of one page. The abstract should include: Title (Include authors’ names and name of College of Pharmacy), Purpose, Methods, Results, and Conclusions. Abstracts will not be accepted if it is not in this format. Do not include figures or graphs.
Please direct all questions and concerns to:
Tian Merren Owens ♦ (850) 222-2400 ext. 120 ♦ tmerren@pharmview.com DEADLINE DATE: FRIDAY, MAY 6, 2016 22
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CALL FOR RESOLUTIONS TO THE 2016 HOUSE OF DELEGATES The House of Delegates Board of Directors will meet in May 2016 to review and approve resolutions for the Annual Meeting. The deadline for submitting resolutions is May 6, 2016! PLEASE NOTE THIS DEADLINE. The following information will be needed when submitting resolutions: 1. Name of organization: The name of the organization submitting the resolutions(s); 2. Name and telephone number of individuals: A contact in the event clarification or further information is needed; 3. Problem: A statement of the problem addressed by the resolution; 4. Intent: A statement of what passage of the resolution will accomplish; 5. Resolution Format: Please type and use double spacing. TITLE OF RESOLUTION NAME OF ORGANIZATION WHEREAS , AND
WHEREAS :
THEREFORE BE IT RESOLVED (THAT THE FPA OR SUBDIVISION OF FPA)
CONTACT NAME AND PHONE #: PROBLEM: INTENT:
Return this form to: Membership Coordinator, Florida Pharmacy Association, 610 North Adams Street, Tallahassee, Florida 32301 or fax (850) 561-6758
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HELP SUPPORT THE ADOPT-A-STUDENT PROGRAM Florida Pharmacy Association (FPA) 126th Annual Meeting & Convention June 30-July 3, 2016 Marriott Harbor Beach Resort & Spa – Ft. Lauderdale, Florida Again this year, students from Florida Colleges of Pharmacy will be “Adopted” for the FPA Annual Meeting and Convention. Pharmacy students will benefit from the interaction with practicing pharmacists, learn first hand how FPA actually operates and how they can become involved in their chosen profession. As you remember, college students are on a tight budget and most of them cannot afford to attend convention. Here is how you can help! Be a Bronze, Silver or Gold Sponsor! The donation amounts are Bronze ($150), Silver ($250), and Gold ($500) Level Mentor Sponsors and will help offset the costs of the AAS program. You also have the option to give any amount you prefer. The FPA offers Adopted students complimentary registration, which includes tickets to the Exhibit Hall, Student Luncheon, Awards Banquet, President’s Breakfast, hotel accommodations for 3 nights at the host hotel, and special programs designed for them. Your generous support of the FPA’s programs and services are keys to our success in advocating for our profession, supporting our pharmacy students and promoting quality patient care services. Thank you for giving back to your profession. Make a contribution yourself, ask your local unit association or get together with friends to Adopt-A-Student. Remember, these are the future leaders of pharmacy! Mentor Program. Each of the adopted students will be assigned a pharmacist who may invite them to attend meetings, CE programs, and share their knowledge and pharmacy experience with them. If you plan to attend the convention and would like to be a mentor, please contact the FPA office. Please donate online or complete the form below and fax or mail with your check to: Florida Pharmacy Association 610 North Adams Street Tallahassee, FL 32301 Fax: (850)561-6758 Please make your check payable to the Florida Pharmacy Foundation Sponsor Name: _________________________________________________________________________ Address: ______________________________________________________________________________ City: _______________________________________ State: __________ Zip: _______________________ Phone: ____________________________________ Amount of Contribution: _______________________ Charge to the following (please circle): AMEX
DISCOVER
MASTERCARD
VISA
Account #:_____________________________________Security Code: ________ Exp. Date: __________ Signature: _____________________________________________________________________________ q Yes, I would like to serve as a Mentor. q Contact me with more information on Mentoring. Contributions to the Florida Pharmacy Association Foundation are tax deductible as a charitable contribution for federal income tax purposes. Consult your CPA for complete details. 28
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florida BUYER’S GUIDE PHARMACY TODAY
ADVERTISERS: This is a special section designed to give your company more exposure and to act as an easy reference for the pharmacist.
PHARMACY RESOURCES PPSC Retail Pharmacy Purchasing Program (888) 778-9909
LEGAL ASSISTANCE Kahan ◆ Heimberg, PLC Brian A. Kahan, R.Ph., Attorney at Law (561) 392-9000 The Health Law Firm George F. Indest III, J.D., M.P.A., LL.M. (407) 331-6620
PHARMACEUTICAL WHOLESALER McKesson Drug Company Jim Springer (800) 804-4590 FAX: (863) 616-2953
FREQUENTLY CALLED NUMBERS AHCA MEDICAID PHARMACY SERVICES 2727 Mahan Drive Tallahassee, FL 32308 (850) 412-4166 www.fdhc.state.fl.us/medicaid/ pharmacy AMERICAN PHARMACISTS ASSOCIATION (APhA) Washington, D.C. (800) 237-2742 www.pharmacist.com AMERICAN SOCIETY OF HEALTH SYSTEM PHARMACISTS Bethesda, MD (301) 657-3000 www.ashp.com/main.htm DRUG INFORMATION CENTER Palm Beach Atlantic University (561) 803-2728 druginfocenter@pba.edu FLORIDA BOARD OF PHARMACY 4052 Bald Cypress Way Bin #C04 Tallahassee, FL 32399-3254 (850) 245-4292 www.doh.state.fl.us/mqa FLORIDA POISON INFORMATION CENTER NETWORK (800) 222-1222 www.fpicn.org NATIONAL COMMUNITY PHARMACISTS ASSOCIATION 100 Daingerfield Road Alexandria, VA 22314 (703) 683-8200 (703) 683-3619 fax info@ncpanet.org
Advertising in Florida Pharmacy Today Display Advertising: please call (850) 264-5111 for a media kit and rate sheet. Buyers’ Guide: A signed insertion of at least 3X per year, 1/3 page or larger display ad, earns a placement in the Buyers’ Guide. A screened ad is furnished at additional cost to the advertiser. Professional Referral Ads: FPA Members: $50 per 50 words; Non‑members: $100 per 50 words; No discounts for advertising agencies. All Professional Referral ads must be paid in advance, at the time of ad receipt.
RECOVERING PHARMACISTS NETWORK OF FLORIDA (407) 257-6606 “Pharmacists Helping Pharmacists”
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