Florida Pharmacy Today October 2020 by Florida Pharmacy Today

The Official Publication Of The Florida Pharmacy Association OCT. 2020

THE IMPACT OF COVID-19: MAKING THE BEST OF YOUR P4 YEAR

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florida PHARMACY TODAY Departments 4 Calendar 4 Advertisers 5 Executive Insight

VOL. 83 | NO. 10 OCTOBER 2020 THE OFFICIAL PUBLICATION OF THE FLORIDA PHARMACY ASSOCIATION

Features

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The Impact of Covid-19: Making the Best of Your P4 Year Physician-Assisted Suicide In The State of Florida: What Pharmacists Can Do to Prepare Pharmacists: Visible and Yet Invisible Part II CDC Recommends Flu Vaccines for Health Care Personnel

OCTOBER 2020

FPA Calendar 2020

NOVEMBER 11

Veterans Day FPA Office Closed

25-28 Christmas Holiday FPA Office Closed JANUARY

14 - 15 FPA Committees, Councils and Board meeting 26 - 27 Thanksgiving FPA Office Closed DECEMBER 3

Pharmacy Based Immunization Delivery Training Program Webinar

Florida Board of Pharmacy meeting (pending approval)

5-6

Regulatory and Law Conference Sarasota and available via webinar

Diabetes Care Training Program webinar

New Years Day, FPA Office Closed

23-24 FPA Law and Regulatory Conference Sandestin 31

FPA election ballots due FEBRUARY

FPA awards nominations due MARCH

Legislative Session Begins

12-15 APhA Annual Meeting

FOR A COMPLETE CALENDAR OF EVENTS GO TO WWW.FLORIDAPHARMACY.ORG

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 two-hour CE requirement for pharmacists on the dispensing of controlled substances effective this biennial renewal period. Pharmacists and pharmacy technicians must also complete a one-hour Florida Board approved continuing education on human trafficking by Jan. 1, 2021. Pharmacists should have satisfied all continuing education requirements for this biennial period by Sept. 30, 2021, or prior to licensure renewal. Consultant pharmacists and technicians will need to renew their licenses and registrations by Dec. 31, 2020. For the 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.floridapharmacy.org CONTACTS FPA — Michael Jackson (850) 222-2400

FSHP — Tamekia Bennett (850) 906-9333 UF — Emely McKitrick (352) 273-5169

FAMU — Leola Cleveland (850) 599-3301 NSU — Carsten Evans (954) 262-1300

Note: The views of the authors do not necessarily represent the views or opinions of the Florida Pharmacy Association, Florida Pharmacy Today or any related entities.

Mission Statements: Florida Pharmacy Today Journal 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.

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..................................................................... 18 FOR SALE BY OWNER..................................... 10 MICRO MERCHANTS........................................ 2 PARTNERSHIP FOR SAFE MEDICINES......... 7 PHARMACEUTICAL DIMENSIONS............. 11 PQC...................................................................... 19 PHARMACISTS MUTUAL.............................. 20

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.

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FLORIDA PHARMACY TODAY

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Executive Insight BY MICHAEL JACKSON, RPH MICHAEL JACKSON, BPHARM, EVP & CEO, FLORIDA PHARMACY ASSOCIATION

America’s Highest Court Looking at PBMs

n Oct. 6, the United States Supreme Court heard arguments on the issue of states ability to regulate pharmacy benefit managers. In the case Rutledge v. PCMA, the attorney general of the state of Arkansas advocated for legislation adopted in that state to have oversight over PBM practices. The argument against the legislation by the Pharmaceutical Care Management Association is that states cannot regulate PBMs that are covered under ERISA. What is ERISA? ERISA was originally designed to protect the interests of employee retirement plan participants and their beneficiaries. It requires plan sponsors to provide plan information to participants and establishes standards of conduct for plan managers and other fiduciaries. It establishes enforcement provisions to ensure that plan funds are protected and that qualifying participants receive their benefits, even if a company goes bankrupt. ERISA stands for Employee Retirement Income Security Act of 1974 and was adopted by Congress, who wanted to bring more uniform standards, accountability and fiduciary responsibility to certain retirement plans across state lines. Over the years, this expanded into health plans. With ERISA, the argument by the PBM industry is that states cannot and should not regulate plans that provide services across state lines. Their claim includes concerns that various state laws make it impossible to comply with ERISA and service their beneficiaries who may be utilizing their benefits through the various jurisdictions.

This issue had been challenged in lower courts and so far the results have been mixed. It is the Arkansas case that is high on the radar for pharmacy. In this issue, a lower court (8th Circuit) ruled against the state of Arkansas. Arkansas Attorney General Leslie Rutledge raised the stakes and, work-

ERISA was originally designed to protect the interests of employee retirement plan participants and their beneficiaries. It requires plan sponsors to provide plan information to participants and establishes standards of conduct for plan managers and other fiduciaries.

ing with the Arkansas Pharmacy Association, the National Alliance of State Pharmacy Associations and with the National Community Pharmacy Association, decided to take this argument to the highest court in the land. The Florida Pharmacy Association signed on an amici curiae, essentially lending our name in support of Arkansas’ efforts.

Michael Jackson, B.Pharm

What is interesting is that the United States solicitor general filed a brief arguing that the 8th Circuit’s decision was wrong and urged the Supreme Court to take the case. It is the job of the solicitor general to supervise and conduct government litigation in the United States Supreme Court and their action suggests that this is an issue worthy of its day in court. What is in the Arkansas law that is interesting? The main parts of what Arkansas did included: ■ Restrict so-called “negative reimbursements” by requiring PBMs to demonstrate that a drug could have been purchased at a lower price through a wholesaler who does business in the state, and if the PBM fails to meet this burden, mandating that the PBM reimburse the pharSee Executive Insight, continued on page 6 OCTOBER 2020

FPA STAFF Executive Vice President/CEO Michael Jackson (850) 222-2400, ext. 200

Director of Continuing Education Tian Merren-Owens, ext. 120

Continuing Education Coordinator Stacey Brooks, ext. 210 Coordinator of Membership Christopher Heil, ext. 110

FLORIDA PHARMACY TODAY BOARD Chair............................... Carol Motycka, St. Augustine Vice Chair.........................Cristina Medina, Hollywood Treasurer.................................... Eric Jakab, Gainesville Secretary............................. Julie Burger, Pensacola Member.........................Michael Finnick, Jacksonville Member.............David Mackarey, Boynton Beach Member....................................... Matt Schneller, Tampa Member............................Teresa Tomerlin, Rockledge Member...................................... Greta Pelegrin, Hialeah Technician Member..........Julie Burger, Pensacola Executive Editor.......Michael Jackson, Tallahassee Managing Editor...................Dave Fiore, Tallahassee Journal Reviewer........................... Dr. Melissa Ruble Journal Reviewer....................................Dr. Angela Hill This is a peer-reviewed publication. . ©2020 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: www.floridapharmacy.org.

Executive Insight, from Page 5

macy at the cost of acquisition. Require PBMs to update their MAC pricing lists based upon changes in average wholesale prices; and. ■ Permit pharmacies to decline to dispense in the face of negative reimbursement. A few of the above items, in addition to other regulations, were adopted in Florida. However, there is little to no enforcement mechanism in place. We would like to see this changed, but much will depend upon which way the Supreme Court will rule in the Arkansas case. If they agree that the 8th Circuit Court was incorrect, then it creates an opportunity for us to become more successful in Florida and in other states to fix problems with the PBM marketplace. The case has been presented to the Supreme Court and is under review. We understand that a ruling will come out sometime late spring or early summer of next year. It is truly interesting that all this is happening during American Pharmacist Month. This is not an issue that the PBM industry is taking lightly. We are seeing their investment in the bombardment of negative social media posts and in the media disparaging services provided by our community pharmacies. You may recall that during the 2020 state legislative session, the FPA and a coalition of other pharmacy groups commissioned a study on the Medicaid managed care program which revealed very questionable practices by PBMs. This study proved that pharmacies both big and small were being unfairly reimbursed in favor of the PBMs own affiliated pharmacy providers. After the Nov. 3 election we will see a new state legislature. Now is the time to have conversations with candidates to prepare them for what they need to do. Putting this issue off for another year is not a viable option for state of Florida, its people or the profession of pharmacy. ■

1. https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/ fact-sheets/what-is-erisa

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THE IMPACT OF COVID-19: MAKING THE BEST OF YOUR P4 YEAR By Dâ&#x20AC;&#x2122;Andra Gill, Pharm.D. Candidate 2021 | Florida A&M University

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FLORIDA PHARMACY TODAY

When this year began, there was no way for me to know that it would turn out this way. What I thought was going to be a week off in March for my final spring break in pharmacy school turned into a sevenmonth-long â&#x20AC;&#x201C; and counting â&#x20AC;&#x201C; pandemic that completely shifted the end of my P3 year and the start of my P4 year. D'Andra Gill My last semester of didactic coursework unexpectedly ended with classes being held strictly via Zoom. Learning the already difficult material became even more challenging due to the sudden shift to online lecturing. I was forced to figure out how to complete three group presentations, as well as countless quizzes and exams, from the comfort of my home. Thankfully, I succeeded and I was able to move on to begin my advanced pharmacy practice experience rotations in May. This pandemic has definitely impacted academic life for pharmacy students, professors and preceptors. These unprecedented times have caused everyone to adjust very quickly to change. Unfortunately, for many fourth-year pharmacy students like me, the reality of rotations did not meet the expectation. Some rotations have been canceled, while others have been changed to virtual experiences. Many of my peers had to be switched to rotations with any preceptor who was willing to take students. However, every experience can be a learning experience. Regardless, as a student, it is up to you to make the best of these fourth-year experiences as you prepare to enter the job market as a newly practicing pharmacist. There are a plethora of things that can be done to ensure that you have a great experience on all of your rotations and throughout your last year of school, despite the unusual circumstances. It starts with remaining optimistic and being flexible. Moreover, building rapport, being honest and being creative will guarantee that your rotational experiences are tailored to your liking as much as possible. Build Rapport To begin with, due to many rotations being held virtually, preceptors and students are unable to interact as they have in the past. Midyear is approaching and many students are interested in pursuing residencies and fellowships. In order to obtain either, you will probably need recommendations from your preceptors. It is critical to make a great impression and build a positive relationship with preceptors whether your rotation is virtual or in-person. I am consistently communicating with one of my preceptors, even though the rotation ended over a month ago. We schedule one-on-one sessions each month just to stay in contact with one another and remain updated about my career plans. She has assisted me with editing my curriculum vitae and we are making plans to host mock interview sessions before midyear. None of this would have been possible if I had not first made a great impression, and, secondly, expressed interest in remaining in contact even after the rotation concluded. Likewise, it is not only important to build relationships

with preceptors, but also with anyone else you may come in contact with during your rotations. As a future health care professional, you must become acclimated to working on interprofessional teams. No matter what your future plans are, making connections and building your network will be beneficial. Sometimes it is not about what you know, but who you know. It is equally important to seek advice from pharmacists working in the roles you desire. The world of pharmacy is large, yet small, at the same time. Your future employers may know people who you may have come in contact with at some point. It would be very unfortunate to miss out on an opportunity due to making a negative impression. Therefore, strive to make the best of every situation you encounter and remain positive about every connection you make. Make sure that you are willing to bring something to the relationship as well and are not only interested in what you can gain from being connected with others.

THERE ARE A PLETHORA OF THINGS THAT CAN BE DONE TO ENSURE THAT YOU HAVE A GREAT EXPERIENCE ON ALL OF YOUR ROTATIONS AND THROUGHOUT YOUR LAST YEAR OF SCHOOL, DESPITE THE UNUSUAL CIRCUMSTANCES. IT STARTS WITH REMAINING OPTIMISTIC AND BEING FLEXIBLE. Be Honest Second, it is imperative to be honest with yourself, your preceptors and your advisers about your interests. If you foresee that you will not be able to handle something or enjoy an experience, then speak up about it. In addition, be sure to let your preceptors know in the beginning what you hope to gain from your experience. They may be able to create opportunities for you based upon your interests. I recently reached out to my adviser about changing my final rotation. It was a critical care elective rotation at the same hospital where I am completing my hospital practice rotation. Unfortunately, pharmacy students are required to remain within the central pharmacy for the duration of this rotation. It is unknown right now if and when that restriction will be lifted. I am not interested in having the exact same experience twice. Additionally, if the restriction is lifted by February 2021, I do not think that I will be able to handle completing a critical care rotation. Unexpectedly, my father passed away in January. This has made it difficult to maintain my focus and motivation at times while trying to finish the requirements for this degree. I know that potentially being surrounded by death each day on a rotation would not be best for me emotionally. I had to be honest with myself, and others, about my strengths and weaknesses. I am grateful that my adviser was very receptive and open to changing my rotation without a problem. Ultimately, communicating is the only way to guarantee that your experience will be enjoyable and beneficial. OCTOBER 2020

AS A FUTURE HEALTH CARE PROFESSIONAL, YOU MUST BECOME ACCLIMATED TO WORKING ON INTERPROFESSIONAL TEAMS. Be Creative Finally, with virtual rotations, it is very unlikely that you will have a preceptor monitoring you for 40 hours each week. This creates an opportunity to do more work independently. Once assignments given to you by your preceptor are complete, use your free time to work on projects that will benefit you in the long run. There are so many things that you can do during your downtime. Work on manuscripts for publication focused on disease states that you may be interested in specializing in. Edit your curriculum vitae and create your letter of intent. Reach out to professors about opportunities for research. Ask to complete additional presentations and projects on your rotation. Read articles about pharma news if you are interested in the pharmaceutical industry. Overall, do not always wait for an opportunity to fall in your lap; create one. Fortunately, I have been able to work on various manuscripts and projects while on rotations. I reached out to professors seeking opportunities and they immediately gave me something to work on. Also, I had some ideas of my own and things that I was working on, unassisted, that I wanted professors to look over. I am truly grateful that my professors

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have been so willing to help me with accomplishing my goals. Furthermore, I am interested in working in academia. So, I have made it my mission to have some form of teaching component during my rotations, if possible. Thankfully, patient counseling and presentations have been incorporated into all of my experiences. Besides that, on my current rotation I have the opportunity to facilitate an in-service training for the pharmacy technicians. All of these opportunities are helping to sharpen my public speaking skills as well as my confidence in educating others. On top of completing my rotations, working on additional projects, and preparing for post-graduate training, I am volunteering to tutor students in the P3 class at my school. I remember being in their position last year and not having assistance in some of the more challenging courses. Helping them has allowed me to retain the information I learned during my P3 year. It brings me so much joy to know that I can help others learn some of the most difficult material in the curriculum. It would be extremely selfish of me to withhold the knowledge that I have and not pay it forward. Someone helped me along the way, so I wanted to make sure that I did the same. It is not necessary to know everything in order to help someone else. It is absolutely acceptable to lift others as you continue to climb. Conclusion In closing, having to learn and complete rotations through a pandemic has proven that my peers and I have the ability to adapt to change and still be successful. Although, the future is uncertain, we are charged with the task to make the best of what we can now. None of us were aware at the start of this year that we would have to experience our long-anticipated APPE rotations in the midst of the COVID-19 pandemic. However, this experience will be a testament to our future success. Although I have been uncomfortable at times, I am truly grateful for the experiences I have had so far and the numerous connections I have made. In spite of the challenges, I am still growing professionally and personally. I am more motivated to help patients however I can. I am looking forward to finishing the second half of my APPE rotations and graduating so that I can begin making an even larger impact in health care.

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PHYSICIAN-ASSISTED SUICIDE IN THE STATE OF FLORIDA: What Pharmacists Can Do to Prepare By Emma Lodl

FLORIDA PHARMACY TODAY

Introduction Physician assisted suicide has been at the center of many legal and ethical discussions since the 1980s. Oregon, Washington, California, Colorado and Vermont legalized PAS, but there are several other states actively discussing PAS as part of the legislative agenda.1 PAS, also known as pharmaceutiLodl, 2020 UF cally assisted death or death with dignity, graduate and is a practice in which a physician prescribes member of the FPA Professional Affairs a lethal dose medication upon request of a terminally ill patient in order to facilitate a Council “good death” or “dignified death” of a patient who is enduring unbearable and prolonged suffering related to his or her condition.1 Despite the fact that this topic has been discussed in literature for 30 years, there remains a noticeable ambiguity and lack of emphasis regarding the role of the pharmacist within PAS legislation.2 The purpose of this review is to define the practice of PAS, summarize legislation and provisions for the pharmacist, and provide future directions for pharmacists in Florida in the case that PAS is legalized in this state. Aid-in-Dying Practices In general, aid-in-dying practices can be categorized as either euthanasia, in which the physician takes measures to directly end a patient’s life; or PAS, where a lethal-dose prescription is provided to a patient who self-administers the drug. Although a few European countries have legalized certain forms of euthanasia, legislation in the U.S. only allows PAS.1,2 There are several other terms that are used interchangeably for PAS, such as dignified death, pharmaceutically mediated death and medical assistance in dying. Regardless of the terminology used, the legal requirements remain the same. Each state that has legalized PAS has a unique set of provisions in place to determine eligible candidates and provide guidance to physicians.3,4 Unfortunately, there is a consistent lack of guidance for pharmacies and pharmacists within these laws. The Death With Dignity Act, passed in Oregon in 1997, was the first legislation passed on PAS. The DWDA requires patients to make two separate oral requests to the physician at least 15 days apart in addition to a written request. Following these requests, the patient must undergo a screening and evaluation process by two independent physicians to con-

IN GENERAL, AID-IN-DYING PRACTICES CAN BE CATEGORIZED AS EITHER EUTHANASIA, IN WHICH THE PHYSICIAN TAKES MEASURES TO DIRECTLY END A PATIENT’S LIFE; OR PAS, WHERE A LETHAL-DOSE PRESCRIPTION IS PROVIDED TO A PATIENT WHO SELF-ADMINISTERS THE DRUG.

firm a terminal diagnosis, defined as imminent death within 6 months, and the capacity to make health care decisions. At various points throughout this process, the physician is required to provide the patient with information on alternatives to PAS, such as hospice care and pain management services. Once a patient is deemed eligible, the attending physician may write a prescription for a lethal dose of medication (usually nine grams of secobarbital or 10 grams of pentobarbital) which can be dispensed from the physician’s office or from a community pharmacy. Since most physicians do not possess the appropriate licensure to dispense medications, the prescriber must utilize a community pharmacy to dispense the drug to the patient and must notify the pharmacy of the indication for the prescription prior to sending it.2,3 This notification provides transparency between the prescriber and the pharmacist and allows for the opportunity to refuse to fill the prescription based on moral objections.2 The clear advantages of PAS are patient autonomy and separation of the physician from the actual event of the patient’s death. There are also several disadvantages, such as adverse drug effects, increased grief and stress placed on family members, and the stigma associated with the act of suicide. Patients who self-administer the lethal dose medication are usually not under direct medical supervision and therefore may experience adverse effects such as severe nausea and vomiting or seizures, which can lead to prolonged suffering and even hospitalization. The physician may prescribe an antiemetic such as metoclopramide to be taken one hour before the lethal dose medication, but this is not a requirement.3 It should be noted that even though patients who participate in PAS may be at risk for adverse effects, there is much less risk compared to illegal means of ingesting a lethal dose medication.5 This process can also increase stress for family members compared with death in a health care facility, because the burden is placed on the next of kin to facilitate removal of the body and other preparations that would normally be the health care facility’s responsibility.3 Finally, the act of suicide may conflict with beliefs or morals, which is why physicians and pharmacists in these states are not obligated to participate in PAS.3-5 Pharmacists who conscientiously object to PAS may refuse to accept a lethal dose prescription from a physician. Conscientious objection can become complicated when a pharmacy technician objects to the filling of a PAS prescription or when a company supports PAS prescription services but the pharmacist employed by the company objects. In these cases, it is up to the company that owns the pharmacy and the individual objecting to PAS to determine the best course of action due to the minimal provisions within the law to address these issues.2,3 Therefore, it is essential that pharmacists and pharmacy technicians of every practice setting rely on statements put forth by national pharmacy organizations (such as the APhA or ASHP) and prioritize an open dialog with other pharmacists in their jurisdiction in order to prepare for a PAS bill within their state.

OCTOBER 2020

Florida Legislation and the Role of the Pharmacist Other than the five states mentioned in the introduction, no other states in the U.S. have legalized PAS. A handful of states have considered PAS legislation, but none have successfully passed these bills into law. The same is true in Florida, which proposed a bill to legalize PAS in January 2020 that was indefinitely postponed and withdrawn from consideration. The proposed bill was an adaptation of Oregon’s DWDA and had just as few provisions for pharmacists as the original DWDA.6 Although this bill was terminated, this does not eliminate the possibility for future discussions on this topic. Taking a reactionary approach in which pharmacists and pharmacy organizations are passive until a bill is passed into law will only result in additional challenges that could have been minimized by being proactive. So how do pharmacists in the state of Florida prepare for the next PAS bill? The answer is simple. Pharmacists need to talk about this issue and collaborate to form a position statement when the time comes to defend or object.

OTHER THAN THE FIVE STATES MENTIONED IN THE INTRODUCTION, NO OTHER STATES IN THE U.S. HAVE LEGALIZED PAS. A HANDFUL OF STATES HAVE CONSIDERED PAS LEGISLATION, BUT NONE HAVE SUCCESSFULLY PASSED THESE BILLS INTO LAW. THE SAME IS TRUE IN FLORIDA, WHICH PROPOSED A BILL TO LEGALIZE PAS IN JANUARY 2020 THAT WAS INDEFINITELY POSTPONED AND WITHDRAWN FROM CONSIDERATION. Amongst the various pharmacy practice settings and specialties, it should come as no surprise that palliative care and hospice pharmacy specialists are a useful resource for initiating and guiding dialog on this topic because of their familiarity with end-of-life care and terminal disease and involvement in a variety of inpatient and outpatient practice settings. While these pharmacists should be present in the conversation, it would be most beneficial to create a taskforce made up of pharmacists and stakeholders from a variety of pharmacy practices. There are two important questions that must be answered prior to recruitment for this taskforce and development of surveys. The first question is, which pharmacists will be most affected if PAS was legalized? The second question is, what role would the affected pharmacists have in the provision of PAS services to patients? 14

FLORIDA PHARMACY TODAY

Hospital pharmacists, industry pharmacists and ambulatory care pharmacists may also have an active role in working with these patients and processing insurance claims for lethal dose prescriptions. Because PAS services would extend into several practice settings, it is critical that the role of each pharmacist is defined within the scope of PAS and each pharmacist take up a position on whether he or she would participate or conscientiously object. If the pharmacist would participate, what type of activities would he or she be comfortable with? Should only terminally ill cancer patients qualify for PAS? What about patients with ALS or Alzheimer’s disease? These are examples of questions that need to be posed to pharmacists and it is encouraged that pharmacists utilize statements released from national pharmacy organizations such as APhA and ASHP as well as their interpretation of the Pharmacist’s Code of Ethics in order to develop their opinions on this topic.7 The Pharmacist’s Code of Ethics, which was published by APhA in 1994, provides a set of statements that describe the pharmacist’s professional role in relation to patient care. These statements emphasize the concepts of trust, respect and empathy, which are the foundation of the profession of pharmacy.7 While this code of ethics is beneficial when considering the obligations of the pharmacist to the patient, it is purposefully ambiguous and thus open to interpretation when applied to controversial issues such as PAS. In addition to this code, APhA recognizes the pharmacist’s obligation to self through the right to conscientious objection. To provide further guidance and clarity on the issue, ASHP released a statement in 1999 (last reviewed in 2013) which described the pharmacist’s obligation to the patient, to oneself and to the health care team. The statement emphasized the importance of knowledge and the pharmacist’s duty to “make a personal, professional commitment to learn more about end-of-life care.” The publication also described the role of the pharmacist in end-of-life care stating that “pharmacists should support appropriate drug therapy to ensure that palliative care and aggressive pain management are available for all patients in need.”8 Although there is still room for interpretation, these principles are intended to serve as the basis for decision-making amongst pharmacy organizations in individual jurisdictions. By utilizing the resources from national pharmacy organizations as a guideline, state pharmacy organizations can form their own position statements on this topic. Having a taskforce dedicated to consolidating individual opinions into a comprehensive position statement from pharmacists within the state would be an excellent way of ensuring that pharmacists are heard when the time comes to assess a PAS bill. Once assembled, this taskforce should aim to discuss provisions for the pharmacist that should be included in legislature in the case that PAS is legalized in the state of Florida. The consensus should be put into writing (e.g. a position statement) that is based on the discussions of the taskforce and opinions from pharmacy personnel based on surveys and questionnaires. The taskforce should also develop a set of pharmacy-specific provisions that they would like to see put in place if the

law were to be passed. There should be open communication between this taskforce and the state medical association in order to enhance collaboration prior to the bill being passed. Development of this taskforce may seem premature but, like any major controversy in the field of pharmacy, it is crucial to take a proactive approach instead of being reactionary. Conclusion At this time, PAS is legal in five of the 50 states, but it has been proposed within several other state legislatures, including Florida, and is still a relevant topic of discussion amongst medical professionals. Although Florida has denied the Death With Dignity bill, it is not unlikely that another bill will take its place in the future, a scenario for which pharmacists should be prepared. It is the obligation of each pharmacist in the state whose practice may be affected by legalization of PAS to avoid taking a passive stance. By proactively discussing this issue and involving Florida pharmacy organizations, pharmacists in Florida can have a collective voice on this issue and may be able to influence whether a bill is passed as well as the provisions for pharmacists within a PAS legislation. This commitment to being proactive is not just an obligation to the profession of pharmacy but as stated in the Pharmacist’s Oath, an obligation to the well-being of the patient.

References

1. Woods, P, Schindel TJ, King MA, et al. Pharmacy practice in domain of assisted dying: a mapping review of the literature. Research in Social and Administrative Pharmacy. 2020;16:267-276 2. Fass J, Fass A. Physician-assisted suicide: ongoing challenges for pharmacists. Am J Health-Syst Pharm. 2011;68:846-49 3. Varadarajan R, Freeman RA, Parmar JR. Aid-in-dying practice in Europe and the United States: legal and ethical perspectives for pharmacy. Research in Social and Administrative Pharmacy. (2016);12:1016-1025 4. Dixon KM, Kier KL. Longing for mercy, requesting death: pharmaceutical care and pharmaceutically assisted death. Am J Health-Syst Pharm. 1998;55:578-85 5. Allen WL, Brushwood DB. Pharmaceutically assisted death and the pharmacist’s right of conscience. J Pharm & Law. 1995;5:1-18 6. Florida Senate SB 1800. 2020. https://www.deathwithdignity. org/wp-content/uploads/2015/10/2020-FL-SB-1800.pdf 7. American Pharmacists Association. (1994). Pharmacist’s Code of Ethics. 8. American Society of Health-System Pharmacists. ASHP statement on pharmacist’s decision-making on assisted suicide. Am J Health-Syst Pharm. 1999;56:1661-4

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Pharmacists: Visible and Yet Invisible Part II By William Garst

My previous column featured the work of pharmacists in acute care (hospital) settings, emphasizing their work behind the scenes in hospitals compared to the visibility of pharmacists in the community pharmacy. In addition to being in community pharmacies and hospitals, one can also find a pharmacist in a long-term care facility. Pharmacists William Garst that work in LTCFs or skilled nursing facilities are called consultant pharmacists. The history of consultant pharmacy can be traced to the enactment of Medicare and Medicaid programs in 1965. The first regulations were known as Conditions of Participation – 16

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conditions LTCF’s must meet to receive reimbursement. It was not until 1974 that a monthly review of each resident’s medication regimen became a requirement of CoP. When this occurred, the result is what we know as a consultant pharmacist. In fact, the state of Florida has an additional licensure category for a consultant pharmacist (CPh). A Florida CPh must pass a three-day initial certification class in consultant pharmacy and acquire an additional 12 hours of continuing education each year in addition to the required 15 hours of CE to maintain the traditional pharmacist license. A consultant pharmacist takes a minimum of 27 CE hours each year to maintain a license. A consultant pharmacist is responsible for the entire medi-

A CONSULTANT PHARMACIST IS RESPONSIBLE FOR THE ENTIRE MEDICATION SYSTEM IN AN LTCF. THEY DEVELOP AND MAINTAIN POLICIES AND PROCEDURES THAT ADDRESS MEDICATION DELIVERY, HOW TO HANDLE MEDICATION ISSUES, STORAGE AND THE RETURN OF UNUSED MEDICATIONS TO THE VENDING PHARMACY, WHICH IS THE PHARMACY THAT DISPENSES THE DRUGS FOR THE RESIDENTS. cation system in an LTCF. They develop and maintain policies and procedures that address medication delivery, how to handle medication issues, storage and the return of unused medications to the vending pharmacy, which is the pharmacy that dispenses the drugs for the residents. One of the main functions of a consultant pharmacist is the medication regimen review. During this process, the CPh will make certain there are no unnecessary medications by confirming: ■ Each drug has a corresponding diagnosis in the chart. ■ There are no duplicated medications. ■ Each drug used as p.r.n (Latin for pro re nata meaning “as the occasion arises”) has a specific indication for use. If duplications are found, the CPh will contact the prescriber for clarification and request that unnecessary duplications are discontinued. Many medications require routine laboratory testing, such as digoxin, furosemide, potassium chloride, blood thinners and thyroid medications. These medications must have periodic laboratory testing for appropriate dosing. The CPh ensures there are orders for routine testing for these drugs and that the results are reported to the prescribers for their review. The CPh will make sure the prescriber acts on a result that is not in the therapeutic range. During the medication review, the CPh checks the medication administration record. Certain drugs need parameters (blood pressure or pulse) recorded before the drug is given. Examples are drugs for hypertension that affect blood pressure and heart rate, which should not be given if the blood pressure or pulse are below certain values. These drugs affect the heart rate and require that the pulse is recorded on the MAR. If the pulse is below a certain level the medication is withheld. The recording of the information on the MAR helps to ensure the drugs are having their intended therapeutic effect, and if there are multiple times a drug must be withheld this would be an indication for a reduction in dose. If the parameters are consistently above normal, this could indicate an increase in dose or a change of medications. As in the hospital setting, the CPh chairs the Antimicrobial Stewardship Committee to monitor the use of antibiotics in the facility to safeguard their appropriate use, to reduce the incidence of antimicrobial resistance and to monitor any

trends in usage. The CPh observes medication administration passes each month to confirm that nurses are using the proper procedures and techniques required for specific medications, including making sure medications are administered in a timely manner. They are involved in other activities, such as serving as a medication educator for nursing by providing in-service training. The CPh prepares monthly and quarterly reports for the director of nursing and administration. These reports include all the specific findings from each review, and, in the case of the quarterly report, a summation of findings and any observation of trends to monitor. They are also expected to keep abreast of any regulatory changes that might affect the facility. The consultant pharmacist is an integral member of the health care team in an LTCF. It was reported in 1997 that consultant pharmacists improved therapeutic outcomes by 43 percent and saved 3.6 billion dollars from avoided medication-related problems. William Garst is a consultant pharmacist who resides in Alachua, Florida. He received his bachelor’s degree in pharmacy from Auburn University in 1975. He earned a master’s degree in pharmacy from the University of Florida in 2001. In 2007, he received his doctor of pharmacy from the University of Colorado. Dr. Garst is a member of many national professional associations as well as the local Alachua County Association of Pharmacists. He serves on the Alachua County Health Care Advisory Board. He works part-time at the UF Health Psychiatric Hospital. He retired from the VA in 2016. Dr. Garst enjoys golf, reading (especially history) and family. He writes a blog called The Pharmacy Newsletter (https://thepharmacynewsletter.com/). William Garst can be contacted at communitypharmacynewsletter@gmail.com.

OCTOBER 2020

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