IPA Journal - Apr/May/Jun 2018 by Iowa Pharmacy Association

A Peer-Reviewed Journal | Vol. LXXIV, No. 2 | APR.MAY.JUN 2018

LEADING OUTSIDE THE PHARMACY Series focusing on how pharmacists are becoming community leaders outside the pharmacy starts with a look at local government.

INSIDE: Peer Review: Dangers of Codeine Use in Children Midwest Pharmacy Expo & Legislative Day Recaps Responding to Drastic CVS Reimbursement Cuts

TABLE OF CONTENTS 8515 Douglas Avenue, Suite 16, Des Moines, IA 50322 Phone: 515.270.0713 Fax: 515.270.2979 Email: ipa@iarx.org | www.iarx.org

PUBLICATION STAFF David Schaaf, Managing Editor Kate Gainer, PharmD Anthony Pudlo, PharmD, MBA, BCACP Laura Miller Shannon Rudolph, PharmD

COVER STORY Leading Outside the Pharmacy pg. 14

A series on how pharmacists are becoming community leaders outside the pharmacy begins with a look at local government.

OFFICERS CHAIRMAN Rick Knudson, PharmD, BCPS, MS, MBA, Clear Lake PRESIDENT Craig Logemann, RPh, BCACP, CDE, Ankeny PRESIDENT-ELECT Cheryl Clarke, BS Pharm, RPh, FAPhA, Waukee TREASURER Sue Purcell, RPh, Dubuque SPEAKER OF THE HOUSE Steven Martens, PharmD, Grundy Center VICE SPEAKER OF THE HOUSE Jim Hoehns, PharmD, FCCP, BCPS, Cedar Falls

TRUSTEES REGION 1 Christopher Clayton, PharmD, MBA, Manchester REGION 2 Thane Kading, BS Pharm, RPh, Iowa City REGION 3 Rachel Digmann, PharmD, BCPS, Ankeny REGION 4 Carol Anderson, PharmD, Mason City AT LARGE Jessica Frank, PharmD, Winterset Deanna McDanel, PharmD, BCPS, BCACP, Coralville Heather Ourth, PharmD, BCPS, BCGP, Ackworth Nora Stelter, PharmD, CHWC, Urbandale HONORARY PRESIDENT June Johnson, BS, PharmD, FASHP, FCCP, BC-ADM, Des Moines PHARMACY TECHNICIAN Meg Finn, CPhT, North Liberty STUDENT PHARMACISTS Michael Harvey, Drake University Grant Jerkovich, The University of Iowa

The Journal of the Iowa Pharmacy Association is a peer reviewed publication. Authors are encouraged to submit manuscripts to be considered for publication in the Journal. For author guidelines, see www.iarx.org. “The Journal of the Iowa Pharmacy Association” (ISSN 1525-7894) publishes 4 issues per year: January/ February/March issue; April/May/June issue; July/August/ September issue; and October/November/December issue by the Iowa Pharmacy Association, 8515 Douglas Avenue, Suite 16, Des Moines, Iowa 50322. Periodicals postage paid at Des Moines, Iowa and additional mailing offices. POSTMASTER: Send address changes to: The Journal of the Iowa Pharmacy Association, 8515 Douglas Ave., Suite 16, Des Moines, IA 50322. Published quarterly, The Journal is distributed to members as a regular membership service paid for through allocation of membership dues. Subscription rates are $100 per year, single copies are $30. Printed by ColorFx; Graphic design done by the Iowa Pharmacy Association.

'Intense' Expo Clinically intensive programing kicks off a successful 2018 Expo. pg. 20

Energizing Day at the Capitol Pharmacy takes to the Capitol for IPA's Legislative Day. pg. 30

FEATURES

2018 IPA Annual Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Board of Trustee Election Results . . . . . . . . . . . . . . . . . . . . . . . 11 COVER STORY: Leading Outside the Pharmacy . . . . . . . . . . 15 Responding to Drastic Reimbursement Cuts . . . . . . . . . . . . . . 17 2018 Practice Advancement Forum . . . . . . . . . . . . . . . . . . . . . . 18 Midwest Pharmacy Expo Recap . . . . . . . . . . . . . . . . . . . . . . . . . 20 Peer Review: Dangers of Codine Use in Children . . . . . . . . . . 22 Student Column . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Legislative Day Recap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

IN EVERY ISSUE

President’s Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 CEO’s Column . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Health Care Hot Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Iowa Pharmacy News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Practice Advancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Public Affairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Technician’s Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 IPA Foundation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Member Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 IPA Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Calendar of Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Pharmacy Time Capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Mission Statement

The Iowa Pharmacy Association empowers the pharmacy profession to improve health outcomes. APR.MAY.JUN 2018 |

PRESIDENTâ&#x20AC;&#x2122;S PAGE

COLLABORATION IS CRITICAL TO COMBAT OPIOID ABUSE The opioid crisis continues to be an important topic for communities across Iowa. However, successful prevention, identification, treatment, and recovery regarding substance use disorders takes an interdisciplinary and communitywide effort. The following columns highlight perspectives from the leadership of the Iowa Pharmacy Association and Iowa Medical Society on how healthcare providers can work together to help patients and resolve this immediate concern.

Joyce Vista-Wayne, MD, DFAPA Des Moines President, Iowa Medical Society

e all know that Iowa has an opioid abuse problem. As two of the most trusted sources of information for patients, we are uniquely qualified to help combat this problem. To do so effectively requires collaboration. Our professions have a long history of working together to ensure appropriate use of medication in the treatment plan to prevent abuse. One of the most recent examples are the joint efforts over the past decade to help curb doctor shopping. Thanks to tools like the Prescription Monitoring Program (PMP), physicians and pharmacists have been able to more effectively share information about patientsâ&#x20AC;&#x2122; prescription habits. Since the PMP launched in 2010, these joint efforts have resulted in a 79% drop in the number of individuals filling prescriptions from more than five prescribers or at more than five pharmacies. As we look to further reduce prescription opioid abuse, the PMP will continue to be a valuable tool for physicians and pharmacists alike. The new PMP, scheduled to launch in early April, will have far greater functionality than the original system and will surely help to further facilitate communication between physicians and pharmacists.

| The Journal of the Iowa Pharmacy Association

Collaboration between our professions and our professional organizations will be absolutely critical if we are to be successful in addressing opioid abuse. In recent years, the Iowa Medical Society and the Iowa Pharmacy Association have worked hand-in-hand to craft legislation that has expanded access to the life-saving opioid antagonist naloxone. Thanks to these efforts, more individuals than ever before are obtaining this medication and successful overdose interventions are becoming more common. Unfortunately, the number of Iowans dying from an opioid overdose continues to climb. More must be done to reverse this alarming trend. Working together, I am confident that physicians and pharmacists can be successful in helping to reverse this tragic epidemic.

Dr. Vista-Wayne, MD, DFAPA, is the current president of the Iowa Medical Society. She is certified in both psychiatry and child and adolescent psychiatry with a practice site at Mercy Pediatric Neurology and Psychiatry Center in Des Moines, IA.

IOWA MEDICAL SOCIETY

PRESIDENT’S PAGE

HOW WE CAN WORK TOGETHER TO END THE OPIOID EPIDEMIC

he task of further combatting the opioid epidemic in Iowa will require a coordinated team effort. It will involve active engagement from health care professionals in tandem with law enforcement, legal team, rehab specialists and a variety of other community leaders. So, we should ask ourselves this question: How can pharmacists and prescribers collaboratively work together to combat the opioid epidemic? Electronic Communication: The time has come for widespread implementation of electronic prescribing for all controlled substances in an effort to curb fraud and abuse. In addition, we should adopt universal participation in the statewide Prescription Monitoring Program (PMP) for pharmacists and prescribers. The state is planning an upgrade to the PMP system, which should help better integrate the system into EHR workflow. Clinical decision support tools and proactive notification should be employed in our electronic databases to better identify patients at highest risk for controlled substance misuse. Sharing this type of information between pharmacy and medical databases in a meaningful way could help curb inappropriate controlled substance use (ex: diversion, drug seeking behaviors). Limiting the number of opioids dispensed and available in our communities: Here are some practical considerations: • Using adjuvant pain medications

and other treatment modalities to their fullest extent when treating chronic care patients. • Limiting the duration of opioid treatment in acute pain patients and using the smallest effective dose possible. • Encouraging patients to utilize partial fills for CII medications at the time of dispensing, as appropriate (ex: dispense 15 tablets instead of the 40 prescribed). • Promoting the National DEA Take Back Day and permanent medication disposal locations in an effort to minimize the number of unused controlled substances in our communities. https:// takebackday.dea.gov/; https:// odcp.iowa.gov/rxtakebacks • Promoting the use of pain contracts for all chronic opioid and benzodiazepine users (Ex: AAFP/FPM Medication Use Agreement). https://www.aafp.org/ fpm/2001/1100/fpm20011100p47rt1.pdf Awareness and Education: There are available online tools and guidelines which help shape how we manage our chronic pain patients. • CDC Guidelines for Prescribing Opioids for Chronic Pain https:// www.cdc.gov/drugoverdose/ prescribing/guideline.html • Promoting the statewide protocol which allows pharmacists to dispense Naloxone without a prescription to at-risk individuals or local agencies (ex: law

Craig Logemann, RPh, BCACP, CDE Ankeny IPA President

enforcement, fire department or EMS) www.iarx.org/naloxone • Advancing the number of pharmacist-physician collaborative arrangements in team-based care environments (ex: pain clinics, medication-assisted treatment clinics, etc.) https:// www.stepsforward.org/modules/ embedded-pharmacists Communication with our Patients: We should work together to identify patients with opioid use disorder and arrange for medication-assisted treatment, as indicated. We need to inform our patients about the potential risk of opioids at the time of prescribing and dispensing to mitigate future issues. Ongoing pain medication assessment is vital to minimize the incidence of opioid use disorders. The Iowa Pharmacy Association is committed to spreading the message that health care leaders should collaboratively implement solutions to curb the opioid epidemic in their communities. ■

APR.MAY.JUN 2018 |

CEO’S COLUMN

WE HEAR YOU

am a person that wears my heart on my sleeve. For better or worse I easily show emotion; and have always been that way. However something changed (I blame childbirth x4), and in addition to sharing emotions I now cry easily too. Not just with sadness, but with happiness, fear, pride, passion, or even just tiredness. Even though I am this way, it still surprises me when I see other people cry and express genuine emotions. At the recent APhA House of Delegates pharmacist delegates, in a room with 500+ professional colleagues, shared emotional stories that brought them to tears. The policy being debated related to “Pharmacist Workplace Environment and Patient Safety.” The tears came from pharmacists’ fear that they felt trapped between spending time with patients and workplace metrics that could jeopardize their employment. They felt the pressures created by the PBM payment model forced them to choose between meeting timeoriented metrics or following their professional judgement to provide patient care. Several email discussion threads followed the APhA House of Delegates that continued the conversation; one aptly noted that our profession is currently divided into two camps – those with “hope” and those with “despair.” After taking time to reflect on these discussions, and how it relates to IPA members (or

non-members) a few thoughts stood out to me. (and check out our student board member’s column on page 29 – thanks, Grant!) First, we hear you. To the pharmacists that feel “despair” – those who are burned out or on the path to professional burnout, the Iowa Pharmacy Association recognizes that this is a reality among health care professionals broadly. The IPA Board discussed the topic of professional burnout and resiliency at its recent meeting and is exploring ways to best serve our members that are on this path. IPA’s strategic plan and goals are set by pharmacists with “hope.” Theirs is a vision of pharmacy that is centered on patient care and recognized as a driver of positive health outcomes. Iowa is fortunate to have so many leaders and visionaries working, and at times sacrificing, for this hope. The association is a place that strives to make their hope infectious to the benefit of all in the profession. Both pharmacy “camps” represent the reality of the profession, and we as an association need to hear from both. Maybe more importantly, they need to hear from each other. Those looking to move forward will have difficulty when members of the profession are uninspired to do so. Those who are feeling burned out just may need to see and hear about what is happening in other settings to find energy. IPA

Kate Gainer, PharmD Executive Vice President & CEO Iowa Pharmacy Association

provides the space for these important interactions to happen through live meetings like Expo, IPA Goes Local, Practice Advancement Forum, and Annual Meeting. And yes, there is still strong value in face-to-face meetings. A debate that sparks tears at the microphone, followed by a round of applause supporting the delegate and then a vote to adopt their amendment would likely not occur in a virtual house of delegates. Additionally, the simple act of connecting with peers in an authentic, engaging way, is an important element of self-care to counter isolation and combat professional burnout. Finally, engage. Take advantage of the engagement opportunities your membership in IPA or other organizations affords you to expand your hope for our profession of pharmacy. ■

APR.MAY.JUN 2018 |

FRIDAY, JUNE 8 7:00 a.m.

REGISTRATION OPENS 7:15-8:15 a.m.

INDUSTRY SYMPOSIUM BREAKFAST 8:30-11:30 a.m.

HOUSE OF DELEGATES SESSION 1 KEYNOTE: Statewide Collaboration Panel Iowa Medical Society Leading Age Iowa Hospital Association Our first House of Delegates session will begin with a panel of leaders from Iowa healthcare organizations discussing how pharmacist and providers can work collaboratively to support a team-based model of care.

June 8-9, 2018 Des Moines Marriott Downtown The IPA Annual Meeting brings together Iowa pharmacists, pharmacy technicians and student pharmacists to shape policy, celebrate achievement and connect with colleagues. This year promises lively debate in the House of Delegates, fun and furious bidding at the IPA Foundation Silent Auction and plenty of opportunities to network and connect with colleagues from across the state!

House of Delegates Session 1*: IPA’s Speaker of the House, Steven Martens, will preside over delegate orientation, the report of officers, policy committee hearings and new business review. This is your opportunity to provide feedback and participate in the discussions that will shape the policy decisions at Saturday’s session.

Steven Martens

See this year’s policy topics at www.iarx.org/IPAAnnualMtg IPA will also present the Pharmacy Technician of the Year, Health-System Pharmacist of the Year, and Excellence in Innovation awards.

Questions? Contact IPA at 515-270-0713

PRE-MEETING CPE WEBINARS Don't forget - the Practice Advancement Forum will be held the day before Annunal Meeting. Bundle your Practice Advancement Forum and IPA Annual Meeting registrations and SAVE!

| The Journal of the Iowa Pharmacy Association

IPA has developed two 30-minute webinars that provide additional background on two policy topics for CPE credit. These webinars are free to registered Annual Meeting attendees. Visit www.iarx.org/AMCPE for details.

* Session accredited for CPE. Details at www.iarx.org/AMCPE

11:30 a.m.-1:00 p.m.

LUNCH & MOTIVATIONAL KEYNOTE KEYNOTE: Be Our Guest Dr. Jim Verlengia Director of Leadership Services Heartland Area Education Agency

SATURDAY, JUNE 9 7:00-8:00 a.m.

FUN RUN/WALK

Start the day off on the right (or left) foot! If you plan to participate, indicate your shirt size when you register. 7:30 a.m.

Walt Disney harnessed the talents of his “cast members” and inspired their hearts with his vision to create unparalleled entertainment experiences. He understood innately that his long-term success depended upon his ability to motivate people, one day and one innovation at a time. Dr. Jim Verlengia will outline proven Disney principles and processes to assist you in leading in your practice and delivering optimal patient care.

Following the lunch keynote, IPA will present its 2018 Appreciation Awards. 1:00-2:30 p.m.

DESSERT, POSTER PRESENTATIONS & EXHIBITS

Enjoy dessert as you learn about the exciting research projects that are advancing practice and improving patient care in Iowa. Exhibitors will also be on hand to showcase their latest products and services. 2:30-4:00 p.m.

OPEN NETWORKING & COMMITTEE MEETINGS

This time is set aside for you grow your professional network and meet pharmacy colleagues from across the state. Or, you are welcome to sit in on a committee meeting. 6:00-9:00 p.m.

PRESIDENT’S RECEPTION & ANNUAL BANQUET

Cheryl Clarke

The Annual Banquet is a celebration of the previous year for Iowa pharmacy. PresidentElect Cheryl Clarke will be installed as the 140th IPA President and give her inaugural address. The banquet will conclude with the presentation of IPA’s most prestigious awards.

9:00-10:30 p.m.

IPA FOUNDATION SILENT AUCTION Friday evening will conclude with the popular IPA Foundation Silent Auction to support the Foundation’s educational and student programs. Plan to bid on an impressive array of items and participate in the wine/beer ring toss and red envelope fundraiser. Remember to come early during the President’s Reception and preview the silent auction items before the doors open!

REGISTRATION OPENS 7:45-8:45 a.m.

INDUSTRY SYMPOSIUM BREAKFAST 9:00-11:30 a.m.

HOUSE OF DELEGATES SESSION 2 KEYNOTE: Pharmacy Standards – How They Impact Your Practice and the Profession Steve Mullenix, RPh SVP, Public Policy & Industry Relations National Council for Prescription Drug Programs

IPA welcomes Steve Mullenix back to Iowa to discuss the process of developing standards. Steve will provide several examples how several pharmacy-specific standards were developed and outline current priorities including PDMP, universal patient identifiers, and specialty pharmacy.

House of Delegates Session 2: Speaker Martens will preside over the final policy debate, nomination of the 2018 Honorary President, ratification of the Nomination’s Committee report and the installation of Jim Hoehns as the Speaker of the House. In addition, the 2018-2019 Vice-Speaker will be elected, and the Poster Presentation Award winner will be announced.

ADDITIONAL INFORMATION Silent Auction & Red Envelope Prize Donations

If you or your pharmacy would like to donate to the silent auction, please contact Laura at lmiller@iarx.org and provide a short description and approximate value (if available) of the item(s) you plan to donate. While items will be accepted up through the weekend of Annual Meeting, in order to have your item listed in the silent auction catalog, please notify Laura prior to June 1.

Present Your Poster

If you would like to present a poster, please submit an abstract at www.iarx.org/IPAAnnualMtg.

Hotel Information

Des Moines Marriott Downtown 700 Grand Ave, Des Moines, IA 50309 515-245-5500 Reserve your room by May 16 to secure room block rate of $129.00.

APR.MAY.JUN 2018 |

IPA BOARD ELECTION

IPAâ&#x20AC;&#x2122;S NEWLY ELECTED LEADERS Congratulations to the newly-elected IPA Board of Trustee members! These members will be installed into office at the 2018 IPA Annual Meeting on June 8-9 in Des Moines.

PRESIDENT

PRESIDENT-ELECT

Cheryl Clarke, BS Pharm, RPh, FAPhA

Connie Connolly, RPh, BCACP

Waukee

DeWitt

TRUSTEE - REGION 1

TRUSTEE - REGION 3

Sharon Cashman, RPh

Sally Haack, PharmD, BCPS

Waverly

Urbandale

TRUSTEE - AT LARGE

FOR TRUSTEE - AT LARGE

William Baker, BS Pharm

Craig Clark, RPh

Iowa City

Cedar Rapids

TECHNICIAN TRUSTEE

Jessica Burge, CPhT Des Moines

APR.MAY.JUN 2018 |

YOUR

PROFESSIONAL SKILLS

REPUTATION DONâ&#x20AC;&#x2122;T HAVE TO BE DAMAGED AS A RESULT OF IMPAIRMENT.

The Iowa Monitoring Program for Pharmacy Professionals (IMP3), a voluntary, confidential program of the Iowa Board of Pharmacy, is designed to assist pharmacists, pharmacist interns and pharmacy technicians in

P 3 I M

obtaining the necessary help for successful rehabilitation from substance abuse as well as mental and physical disabilities. This provides an opportunity for licensed professionals to receive proper treatment and maintain their professional status, while protecting the safety of the public.

O W A

IOWA MONITORING PROGRAM

for Pharmacy Professionals

To learn more about IMP3, visit imp3.iowa.gov. To self-report to IMP3, contact IMP3 staff at 515.725.2253.

HEALTHCARE HOT TOPICS

New HHS Secretary

Amazon Enters Healthcare Industry

MyHealthEData Initiative

Alex Azar II was appointed and confirmed as the U.S. Secretary of Health and Human Services in January. As secretary, Azar will be responsible for advising the president on matters related to health and income programs, overseeing a total of 11 federal agencies. He is a Yale Law School graduate and was formerly the president of Lilly USA (affiliated with Eli Lilly and Company).

In 2017, reports stated Amazon’s interest in expanding into pharmacy distribution. Earlier this year, multiple national reports confirmed that Amazon may partner with Berkshire Hathaway and JPMorgan Chase to form a healthcare company. While still in early planning stages, this move is likely to be a major healthcare disrupter. Initial plans are to provide healthcare for the three companies' own employees but may offer healthcare on a broader scale for more Americans in the future.

The MyHealthEData Initiative will allow Medicare beneficiaries to have electronic access to their healthcare records at all times. This initiative will use the “Blue Button” concept that has been successful in the federal Veterans Affairs (VA) system. The intent is for patients to truly be the center of the healthcare system and help them have a better understanding of their overall health. The platform will have information regarding prescriptions, doctor visits, procedures, lab values, and more. Consistent access to personal healthcare records is expected to help patients make more informed healthcare decisions.

CDC Supports Antibiotic Resistance Efforts Nationwide In January, the Centers for Disease Control and Prevention (CDC) released updated data regarding the AR Solutions Initiative. This project aims to reduce antimicrobial resistance (AR) by supporting state community efforts in detecting, responding to, containing, and preventing resistant infections. In Iowa, $1,302,228 was invested in these activities. Highlights included support for the University of Iowa Modeling Infectious Diseases in Healthcare Network virtual laboratory, genome sequencing of various bacterial isolates, and rapid response to emerging drugresistant Enterobacteriaceae.

Patients to Receive Benefit from Discounts and Rebates The pharmaceutical industry has received much scrutiny due to lack of transparency and rebates that falsely inflate medication costs. Often, health plans receive rebates from manufacturers making the list price much higher than actual. Rising medication costs can be detrimental to both the pharmacy profession and patients’ out-of-pocket costs. However, over the past several months, at least two major health plans have responded to these concerns. United Health and Aetna both have announced plans to pass on drug rebates to consumers starting in 2019.

CDC Leadership Change Brenda Fitzgerald, MD, resigned as CDC Director in January 2018. She had repeatedly recused herself from CDC activities and public health topics due to “complex financial interests” that may have been related to certain investments in cancer detection and health information technology. Anne Schuchat took on the role of acting director, but at the time of publication, it was presumed that Robert Redfield, MD, would be chosen as the CDC Director. Dr. Redfield’s background includes extensive HIV/AIDS research at the Walter Reed Army Institute of Research. This appointment does not require Senate confirmation.

White Paper to Lower Drug Costs Rising medication costs have received much national attention in recent times. In fact, the Council of Economic Advisors released a 30-page white paper entitled “Reforming Biopharmaceutical Pricing at Home and Abroad.” The paper states that many medication prices are artificially inflated due to “government policies that prevent, rather than foster, healthy price competition” as well as the lack of transparency in the pharmaceutical distribution system. The document explains reform that would curb raising medication costs while still allowing for innovation in healthcare.

Aligning with the launch of MyHealthEData, CMS plans to require providers to update their systems to ensure data sharing. At this time, outpatient pharmacy services will likely not be integrated into this model.

Trump Unveils Opioid Initiative On March 19, President Trump announced his administration’s plan to combat the opioid epidemic that includes education, awareness, research, enforcement, and treatment initiatives. The plan will look to reduce demand and over-prescribing through several methods including a Safer Prescribing Plan that calls for cutting nationwide opioid prescription fills by one-third within three years. The plan also calls for stronger enforcement to limit illicit drug supply chains, including the highly publicized death penalty for drug traffickers. The plan also looks to expand treatment access, particularly calling for a repeal of the rule the prohibits Medicaid from paying for addiction treatment at facilities with more than 16 beds. In addition, the plan will ensure all first responders are equipped with naloxone. ■

APR.MAY.JUN 2018 |

COVER STORY

LEADING OUTSIDE THE PHARMACY:

LOCAL GOVERNMENT Iowa has no shortage of pharmacy practice leaders. It’s baked into our cultural DNA and attracts leaders to practice and students to enroll and excel in our two colleges of pharmacy. Those leadership skills and abilities are vital to a thriving pharmacy practice, but they are also vital to a thriving community in which to practice. This series of articles will look at how pharmacists are utilizing their skills and abilities to be leaders in their communities. You will read about pharmacists who have pursued outside interests and passions to meet the needs of their community beyond the pharmacy. In addition to the personal satisfaction and positive impact on the community, it’s an opportunity to showcase the professionalism and compassion of pharmacists. Active involvement in the community elevates the profile of the profession, shifting the public’s perception to a contemporay view as a vital and accessible resource for the community’s health and well-being.

| The Journal of the Iowa Pharmacy Association

ach election cycle, we are inundated with messages from candidates promising to lead our nation and state to prosperity. Campaign promises are focused on fixing all of government’s problems and impacting everyone’s day-to-day life. The reality is that many of those national and state campaigns, while important and impactful in their own right, hardly affect that daily routine. How many presidents have run on the platform of fixing all of the potholes that you encounter on your daily commute? Your member of Congress may have voted to provide federal money for a recycling program, but are they reviewing the proposals to implement it? Those decisions are left to our local government officials. Mayors, city councils, boards, and commissions are the ones doing the “in the weeds” work of building and maintaining our communities. These are important positions that need strong leaders with a passion for serving their community.

him to the position last fall. His path to mayor started with an appointment to fill a vacancy on the Nevada City Council in January of 2010 and includes serving on the Nevada Planning and Zoning Commission, the Nevada Chamber of Commerce Board of Directors and currently the Nevada Economic Development Council. “I believe we are called to use our talents and skills to serve others,” explains Brett. “I have always had an interest and passion for public policy.” Bob Greenwood, RPh, who owns Greenwood Drug in Waterloo and Denver Drug in Denver, Iowa, was motivated to enter local government in Waterloo based on a single issue - the city was allowing open burning of yard waste within city limits. After beating the incumbent candidate, Bob served three terms from 2001 to 2013 as an at large member of the Waterloo City Council.

Enter the pharmacist.

“It was personally satisfying to be involved in the city business, made friends and a few enemies!” Greenwood says about his time on the council. “I absolutely believe I made a difference.”

Brett Barker, PharmD, is vice president of operations at NuCara Management Group. The people in his hometown of Nevada also call him mayor after electing

Carl Chalstrom, RPh, who practices at the Pharmacy Care Centre in Anamosa, is currently serving as the vice-president of the Anamosa Community Schools

COVER STORY

Board of Directors. His experience in community service involves several roles in local government in his current hometown of Anamosa, including mayor, and others while previously in Waterloo. “I think my attitude for being involved came from my parents, who both volunteered in the community,” Chalstrom explains on why he serves. “They modeled involvement as being a worthwhile endeavor.” Each of these pharmacists had their own motivation – passion, pet peeve, or personal conviction – and found their way to serve their communities through their local government. Communities are always looking for citizens to serve on committees or boards, and pharmacists, by their profession, are already looked upon as leaders in the community. It’s a natural fit. Pharmacists are well equipped for public service, particularly Iowa pharmacists who practice within a professional culture that focuses on building up leaders and collaboration.

“Pharmacists are naturally looked upon as trusted community leaders."

Brett Barker

“Pharmacists are naturally looked upon as trusted community leaders,” says Barker. His statement is backed by annual Gallup polls ranking pharmacists as one of the most honest and ethical professionals. As the most accessible healthcare professional, pharmacists are already in a position to impact their communities by caring for the health and well-being of their fellow citizens. In practice, they are there to serve the patient, guiding them through treatment, collaborating with their providers, and answering their questions in order to reach positive outcomes. They are looked up to for the knowledge, expertise, professionalism, and ability to engage people, all traits that make effective leaders within local government.

“We are trained to listen, and we are problem solvers,” explains Greenwood, who was able to move quickly to ban yard waste burning while providing an alternative disposal solution that included citywide composting, free yard waste dump, and curbside yard waste pick up.

"We are trained to listen, and we are problem solvers.” Bob Greenwood

While the outcomes of leadership in the community can be visible, like a curbside yard waste bin, the experience of serving others is often the most rewarding. For Greenwood, being on the city council meant also being a liaison to city departments. He found it personally satisfying helping citizens navigate the bureaucratic process and find resolution to their issues. Barker echoes that sentiment: “It’s greatly rewarding to see the positive impact that can be made on the community and on people’s daily lives.” Serving in local government is also a way to better understand the inner workings of your community. How many pharmacists know the intricacies of their local waste disposal process? Chalstrom found out more than he ever wanted to know during his second meeting serving on the city council, as the council was in the midst of renovating its waste disposal system. Don’t forget, as Greenwood describes, there is also labor union negotiations, water, sanitation, sewer and police and fire-rescue processes and polices – issues not normally addressed in the pharmacy. “But it is those things that have broadened my understanding of the world we live in, brings me into contact with people I normally wouldn't, and in the end, helps me learn more in order to relate with my patients better,” states Chalstrom. In addition to benefitting the community and the personally rewarding experiences, pharmacists choosing to pursue their interests in local government are also benefitting the profession of pharmacy

"But it is those things that have broadened my understanding of the world we live in, ... and in the end, helps me learn more in order to relate with my patients better." Carl Chalstrom

as a whole. In addition to seeing their leadership skills in action, the community gets to “know” their pharmacist as a person and a leader. Creating this connection outside the normal, often transactional, relationship patients have with their pharmacists progresses the profile of pharmacy from a simple dispensing role to that of the patient care leader role that the profession is seeking. That being said, it all comes back to the pharmacist having the desire to make their community a better place. “The citizens of the community trust you with their health and provide us a living doing something we love to do,” adds Chalstrom. “I think it's only right that we pay them back by using the skills we use while practicing pharmacy.” For those interested in stepping up and pursuing local government, Barker suggests checking with the local chamber of commerce or city entity to find out how to get started. Many communities are looking for new ideas and people willing to serve. While Barker, Chalstrom, and Greenwood served in high profile positions within local government, community leaders are needed on boards and commissions that do important work. Local government is not for everyone, but those who have the interest have found the work rewarding, both personally and to the communities they serve. “It’s easy to sit on the sidelines and talk about how things should be,” Barker explains, “but not many people actually step up and invest their time and talents to improving their community.” ■ APR.MAY.JUN 2018 |

IOWA PHARMACY NEWS

Amerigroup Accepting New Medicaid Members Again Last October, AmeriHealth Caritas pulled out of the Iowa Medicaid program, leaving 220,000 members to choose between the two remaining MCOs - Amerigroup and UnitedHealthcare. However, Amerigroup said it would not be able to accept new members at that time. On March 1, Amerigroup began accepting new Iowa Medicaid members, starting with the 10,000 members who initially chose to switch to Amerigroup and have since been managed by the State. On May 1, new Medicaid enrollees will be able to choose between the two MCOs. The Iowa Department of Human Services is currently seeking one or two additional MCOs to replace AmeriHealth Caritas with a target start date of July 1, 2019.

Updates to Iowa Prescription Monitoring Program The Iowa Board of Pharmacy launched a new Iowa Prescription Monitoring Program (PMP) on April 4, 2018. The new platform will utilize a NarxCare feature that quickly allows the user to see a patient’s overdose risk score and potential red flags to aid in clinical decision-making when prescribing or dispensing. The interface and clinical utility will be a benefit for all users and should help to make this important platform part of daily workflow. However, the Board of Pharmacy recognizes that to be fully utilized as a part of regular workflow, electronic integration is key. Therefore, they have recently implemented a pilot project with nine community-based pharmacies to have the PMP integrated directly into their pharmacy dispensing software. In April, the board’s Jen Tiffany, RPh, provided a review of the new platform for IPA’s 2/2/2 webinar. The recording of the webinar is available at www.iarx.org/222

| The Journal of the Iowa Pharmacy Association

Starting May 16, 2018, new Iowa Board of Pharmacy rules will require dispensers to report to the Iowa Prescription Monitoring Program (PMP) no later than the next business day following dispensing. The change in frequency is intended to provide more timely data to help providers and pharmacists using the PMP to make prescribing and dispensing decisions.

Iowa Immunization Coalition Dissolves In January 2017, the Iowa Immunization Coalition (IIC) announced that the organization would dissolve. The coalition was created in 2006 to promote immunizations for Iowans of all ages. IIC transferred its remaining assets to Iowa Public Health Association (IPHA), a long-standing partner of the coalition. IPA has been working with IPHA and IIC to expand access, knowledge and adoption of immunizations in Iowa.

340B Updates and Resources As part of the new Outpatient Prospective Payment System regulations, 340B funding was drastically cut by $1.6 billion and hospitals will now be reimbursed for 340B medications at average sales price (ASP) minus 22.5 percent as of January 1, 2018. Several pharmacy organizations wrote letters in opposition to these cuts, and the American Hospital Association filed a lawsuit against the regulations. However, a federal judge overturned the lawsuit on the basis that it was too preliminary to file a lawsuit. The lawsuit is expected to be refiled. The changes in the 340B program are in part due to the increased scrutiny the program has endured over the past several years. The program is executed through the Health Resources and Services Administration (HRSA) with the intention of allowing hospitals and clinics to purchase outpatient medications at a lower cost for uninsured or low-income patients. However, concerns have come

forward on the use of the saved dollars by various 340B entities. Due to this scrutiny, clinics or hospitals should prepare themselves for a potential audit. Experts suggest that sites walk through the process of an audit regularly to make sure proper documentation exists. If in fact a hospital or clinic receives notice of an audit, it’ll likely be too late to start preparing. During this process, auditors are generally looking for (1) evidence of diversion, (2) ineligible patients or prescribers, and (3) duplicate discounts. Practice sites must make certain to have outlined policy and procedures to avoid these errors. Furthermore, they must have a process to document how 340B savings align with programs and services offered to uninsured or low-income patients. IPA has two webinars located on our 2/2/2 webpage with more information. A presentation from Health Enterprises provides insight on how to prepare for an audit and ensure compliance. Furthermore, Apexus speaks to their contracting, distribution, and training resources as well as their HRSA-Aligned National Call Center staffed with experts in 340B program management.

Shingrix Comes to Market – Add it to your Immunization Protocol In January 2018, the CDC published its updated Advisory Committee on Immunization Practices (ACIP) guidelines for shingles vaccines. ACIP made three recommendations that related to the recombinant zoster vaccine, Shingrix (GlaxoSmithKline): • Recombinant zoster vaccine (RZV) is recommended for the prevention of herpes zoster and related complications for immunocompetent adults aged ≥ 50 years. • RZV is recommended for the prevention of herpes zoster and related complications for

IOWA PHARMACY NEWS

immunocompetent adults who previously received zoster vaccine live (ZVL). • RZV is preferred over ZVL for the prevention of herpes zoster and related complications. Shingrix was approved by the FDA in October 2017 and quickly recommended over Merck’s Zostavax by the CDC days after. Studies have shown that two-dose Shingrix reduces the risk of postherpetic neuralgia by nearly 90 percent and retains 90 percent of its effectiveness for over four years. The CDC recommends a shingles vaccine for adults aged 60 or older and that those who have received the older vaccine (Zostavax) get the new one (Shingrix). As a friendly reminder, don’t forget to add Shingrix to immunization protocols as part of an annual renewal to align with Board of Pharmacy rules (657 IAC 8.33(3)). In addition, IPA has been in communication with the Iowa Medicaid

IPA RESPONDS TO DRASTIC CVS/CAREMARK REIMBURSEMENT CUTS

Enterprise (IME) to understand the process and timeline to see Shingrix on the Medicaid preferred drug list (PDL).

Black Hawk / Bremer County Pharmacy Association Hosts 5th Annual Resident Night The Black Hawk / Bremer County Pharmacy Association hosted their 5th Annual Resident Night on March 22, 2018, at the Northeast Iowa Family Practice Center. The evening focused on presentations from the area’s eight PGY1 residents - Kiera Murray, PharmD, and Susan Voong, PharmD, from Covenant Medical Center presented on PCSK9 inhibitors; Julia Fifield, PharmD, and Jordann Kunkel, PharmD, from UnityPoint Allen Hospital discussed new lipid guidelines; Erin Schreiber, PharmD, and Amanda Waggett, PharmD, from UnityPoint Prairie Parkway Pharmacy presented on care for the LGBTQ population; and Robert Nichols, PharmD, from Greenwood Drug and Danielle Larson,

In mid-January, IPA received numerous notifications from members regarding unannounced and severe cuts to reimbursement for commercial claims submitted through CVS Caremark, which is the PBM for Wellmark and Medica. This concern quickly became a top priority for IPA, for which aggregate deidentified data was collected from pharmacies that confirmed these alarming reports. The data collected indicated that approximately 30% of these generic prescription claims were filled below cost for Iowa pharmacies. While Iowa pharmacies started experiencing these more aggressive cuts in January, we know that other states began to see these changes months prior, particularly in Medicaid managed care plans. Thankfully, Iowa

L to R: Erin Schreiber, Amanda Waggett, Jordann Kunkel, Julia Fifield, Danielle Larson, Robert Nichols, Kiera Murray, Susan Voong

PharmD, from NEIFPC/WHC discussed the Shingrix vaccine. The Black Hawk / Bremer County Pharmacy Association is a group of local pharmacists and pharmacy technicians who meet monthly for professional networking and for education in current pharmacy topics. The group is open to all pharmacists, pharmacy residents, and pharmacy technicians in Black Hawk and Bremer counties. For additional information on the association, contact Betsie Frey at BHBremerCoPharm@ gmail.com. ■

was partially insulated from the Medicaid managed care cuts since Iowa pharmacies are paid based on the transparent methodology - average acquisition cost plus a $10.02 dispensing fee. Quickly responding to our members, IPA has been in direct communication with CVS Caremark, Wellmark, Iowa Insurance Division, Iowa Attorney General’s Office, Governor’s Office, National Community Pharmacists Association (NCPA) as well as other key stakeholders regarding this important issue. As a direct result of IPA’s key communications, reimbursement rates were adjusted on March 1. While these adjustments were an improvement, the rates continue to be below the rates from 2017. IPA continues its efforts to resolve this issue.

APR.MAY.JUN 2018 |

June 7, 2018 | Des Moines Marriott Downtown Held 1 day before the 2018 IPA Annual Meeting, at the same location.

The 2018 forum will feature a revamped format that will showcase many of the projects that pharmacists and pharmacy residents are doing across the state to drive practice innovation. The day will feature two keynotes focused on advances in diabetes care, one by Erin Newkirk, PharmD, and the second by Jon Knezevich, PharmD, BCPS, and three breakout sessions. Each breakout session will feature three tracks, each covering a different theme. Each of those tracks will feature a 10-minute clinical pearl followed by focused presentations from Iowa pharmacy residents on their innovative research projects. We are excited about the new format that will provide a day filled with ideas to inspire, invigorate, and implement at your practice.

Schedule at a Glance 8:45-9:00 am

Welcome

9:00-10:15 am

Keynote: Advancements in Diabetes Care - Continuous Glucose Monitoring

10:15-10:30 am

Break

10:30-11:30 am

Breakout Session 1 Room 1: Transitions of Care & MTM (Employee-Based) Room 2: Antimicrobial Stewardship – Outcomes Room 3: Time & Inventory Management Strategies

11:30-12:30 pm

Lunch

12:30-1:30 pm

Keynote: Opportunities in Diabetes Stewardship

1:30-2:30 pm

Breakout Session 2 Room 1: Transitions of Care & MTM (Community-Based) Room 2: Antimicrobial Stewardship – Standards of Care Room 3: Adverse Drug Events

2:30-2:40 pm

Break

2:40-4:45 pm

Breakout Session 3 Room 1: Transitions of Care & MTM (Disease Management Programs) Room 2: Antimicrobial Stewardship – Outcomes Room 3: Behavioral Health

4:50 pm

Adjourn

Register at www.iarx.org/PracticeAdv Bundle your Practice Advancement Forum and IPA Annual Meeting registrations and SAVE!

PRACTICE ADVANCEMENT

Update: Making an IMPACT on Immunization Rates Fifteen community-based pharmacies across Iowa have partnered with IPA and the APhA Foundation to launch Project: IMPACT Immunizations. For the past several months, these pharmacies have been using a platform that communicates bi-directionally with IRIS, the state immunization registry. Based on the patient’s age and information from IRIS, an immunization “forecast” is generated to help pharmacists efficiently identify a patient’s unmet vaccination needs and start a conversation about immunizations. Preliminary data shows that pharmacists are able to improve adult immunization rates for their patients not just during flu shot season but throughout the year. The group involved in the study has developed innovative ways to incorporate this process into workflow and identify patients that benefit from this prospective immunization screening. This project will continue through May, and there is a possibility of involving a few more pharmacies later this year.

State Innovation Model Learning Community The State Innovation Model (SIM) is designed to bring together professionals across the healthcare continuum to aid in practice transformation within our evolving healthcare system. IPA continues to work closely with the Iowa Healthcare Collaborative (IHC) and other stakeholders on these efforts. This past March, IHC hosted a SIM Learning Community to provide resources and share best practices related to patient safety and health information technology. The morning focused on SIM strategies being implemented in Maine. Shaun Alfreds, CEO of HealthInfoNet in Portland ME, highlighted the importance of an interoperability framework to exchange health information between

all patient providers. The second half of the morning was Rebecca Lindberg and Cindy Winters discussing the Heart of New Ulm Project: a 10-year, communitywide health initiative focusing on reducing the number of heart attacks in patients between age 40-79 years old. The afternoon programming focused on methods to involve the patient in their own healthcare. Waverly Health Center was highlighted, as they include patients and patient consultants on many of their task forces. IPA highly encourages interested members to attend these free events. Watch the IPA Top 5 Events Edition for more information on future IHC events.

Iowa Pharmacists Positioned to Address HIV & Hepatitis C Disparities In collaboration with the Iowa Department of Public Health (IDPH), Iowa pharmacists will have an opportunity to showcase how pharmacy can serve as an access point and triage center for patients at risk for or diagnosed with HIV or hepatitis C. Through a multi-year initiative, IDPH is interested in replicating successful efforts from other areas of the country that utilize community-based pharmacists to screen patients for HIV and hepatitis C, refer atrisk patients for confirmatory laboratory testing, and initiate therapy for those with active infections. Objectives of this initiative, include: 1. Assess readiness to implement routine screenings in Iowa community-based pharmacies, 2. Provide technical assistance and trainings to support the implementation of HIV/HCV screening within Iowa communitybased pharmacies 3. Monitor preventive services guidelines and develop the framework for a best

practices manual for communitybased pharmacies While all communities have patients at risk for these infectious diseases, communities will be targeted based on criteria developed by IDPH. The goal will be to launch the initiative with 10 initial pharmacies and grow that number to 40 locations by the end of 2018. Watch for further communications from IPA for an invitation to participate if your community is identified.

IPA Partners with IHA on Antimicrobial Stewardship Efforts Over the past few months, IPA has been collaborating with the Iowa Hospital Association to develop resources and educational materials on implementing and expanding antimicrobial stewardship programs (ASP). An ASP creates an opportunity to provide a safer environment in the hospital and community from exposure to resistant bacteria and clostridium difficile. Additionally, a highly effective program can reduce the incidence and prevalence of resistant bacteria and clostridium difficile while preserving antibiotic efficacy for future generations. With input from several infectious disease pharmacists across the state, IPA is pleased to have been a key partner in developing the agenda for a day-long education program – occurring on Tuesday, April 17, 2018 in Des Moines. The education program will focus on a team-based approach to implementing stewardship programs in hospitals with additional assistance and focus for critical access hospitals (CAHs). This event will also spotlight and assist hospitals with developing their own program based on an Iowa toolkit, Iowa-based data, and other stewardship resources. These resources will be shared when available through IPA communications. ■

APR.MAY.JUN 2018 |

EXPO

INTENSE FRIDAY KICKS OFF ANOTHER SUCCESSFUL MIDWEST PHARMACY EXPO!

The weekend started strong and never let up for the nearly 300 pharmacists, pharmacy technicians and student pharmacists who attended the 2018 Midwest Pharmacy Expo on February 16-18. The event was held at the Holiday Inn Airport Des Moines for the second year and drew attendees from 13 different states. Expo kicked off on Friday with four clinically intensive workshops starting with biostatistics and followed by sessions covering chronic care topics, including mental health, cardiology and oral chemotherapy. The day wrapped up with an interactive physical assessment refresher for attendees to hone those clinical skills. Saturday was headlined by keynote speaker Jacques Turgeon, BPharm, PhD, associate dean of the Lake Nona Campus of the University of Florida College of Pharmacy and formerly the chief science officer of Tabula Rasa Healthcare. A full day of live continuing education followed the keynote, featuring speakers from across the country. Pharmacists enjoyed sessions focused on current topics, cardiology and medication optimization. Pharmacy technicians had their own track including sessions on common drug interactions and team building or they had the option to attend one of the dually accredited pharmacist topics each session. New this year was Expo Live - a live stream of several Expo sessions available for those who were unable to attend in person to participate live or view the recordings afterwards. Expo finished on Sunday with traditional favorites New Drugs and Gamechangers. Between them was a timely session with Don McGuire, Jr., RPh, JD, from Pharmacists Mutual on minimizing liability as pharmacist roles expand.

See also: Bill Wimmer Honored at the Midwest Pharmacy Expo Political Leadership Reception (pg. 35)

| The Journal of the Iowa Pharmacy Association

This was the fifth Midwest Pharmacy Expo, and the event is continuing to grow. The Clinically Intensive Workshops were the best attended Friday programming Expo has ever had. We look forward to building on this momentum and continuing to make Expo the must-attend event to learn, connect and be inspired with your colleagues from the Midwest!

EXPO

SAVE THE DATE:

February 8-10, 2019 NEW LOCATION!

The 2019 Midwest Pharmacy Expo will move to an exciting and very new location next year: the brand-new Hilton Des Moines Downtown. See you in 2019!

APR.MAY.JUN 2018 |

PEER REVIEW

DANGERS OF CODEINE USE IN CHILDREN FOR ANALGESIA AND COUGH RELIEF: IMPLICATIONS FOR THE PHARMACIST Edward A. Bell, PharmD, BCPS (corresponding author) Professor of Pharmacy Practice Drake University College of Pharmacy and Health Sciences 2507 University Avenue Des Moines, Iowa 50311 ed.bell@drake.edu 515-271-1841 (office) 515-271-4569 (fax) Brandon Boelts Doctor of Pharmacy Candidate, 2019 Drake University College of Pharmacy and Health Sciences Nicole Draker Doctor of Pharmacy Candidate, 2019 Drake University College of Pharmacy and Health Sciences No conflicts of interests were identified by the authors.

| The Journal of the Iowa Pharmacy Association

Abstract

History of Codeine Use

The use of codeine for the treatment of cough and pain has changed significantly over recent years. Codeine is subject to significant variations in hepatic biotransformation to active metabolites, and inter-subject genetic variabilities cause clinical efficacy and safety from codeine difficult to predict. Once a commonly prescribed pharmacotherapy in the pediatric population, recently published safety data and several recommendations from the Food and Drug Administration have significantly reduced the role of codeine as a safe and effective analgesic and antitussive agent. Codeine products are no longer indicated for treatment of cough in children less than 18 years of age and should not be used in this age group. Alternative analgesic and antitussive pharmacotherapies are recommended. For treatment of cough, honey, vapor rubs, fluids and humidity, and demulcents are safer, effective, and preferred in the pediatric population.

Pharmacology and Genetic Variation

Codeine is familiar to the medical community, especially those involved in pediatric care. For over 200 years codeine has commonly been used for post-operative analgesia, especially in tonsillectomy, and cough relief in children. Unfortunately, there are many underestimated risks associated with prescribing codeine to children.1 In addition to a lack of evidence for cough relief, severe adverse drug reactions have been reported with pediatric codeine use, with the most prominent being respiratory depression. There is also variability in how each individual metabolizes codeine to its active form, morphine, with safety and outcomes from patient-to-patient difficult to predict. Unfortunately, much of the risks associated with the use of codeine are not well known by providers and therefore are not taken into account when prescribing for children. This results in codeine being prescribed in unnecessary and unsafe situations. It is important that the medical community become more aware of the hazards and proper indications of codeine in an effort to protect children from its dangers.

The analgesic effect of codeine is the result of its biotransformation to the active form, morphine. This transformation is catalyzed by the hepatic cytochrome (CYP) P450 2D6 enzyme. Morphine then further undergoes glucuronidation to morphine-3-glucuronide and morphine6-glucuronide. The latter of these

PEER REVIEW

metabolites has been shown to have some analgesic effects in humans, while the first does not possess analgesic effects.2 Morphine’s affinity for muopioid receptors is responsible for its analgesia, and its potentially severe adverse effects. There are over 50 different genetic functional variations of the CYP 2D6 enzyme, with a wide array of metabolic capabilities of codeine biotransformation. The two most clinically important genotypes are the poor and ultra-rapid metabolizers. While poor metabolizers receive inadequate pain relief, ultra-rapid metabolizers have the ability to produce up to seven-fold more morphine. Approximately 5% of African Americans and Caucasians have the genotype for the duplicate CYP 2D6 enzyme, classifying as an ultra-rapid metabolizer, while Arabs and North Africans have a much higher prevalence at 30%. Poor metabolizers are most commonly seen in those of European Caucasian descent. Table 1 compares the relative prevalence and metabolic activity of CYP 2D6 phenotypes.3 There are many enzyme-inducing drug-drug interactions that can lead to toxic blood levels of morphine and increase risk for serious adverse effects. Many medications can induce CYP 2D6, leading to increased metabolism of morphine from codeine. Metabolism by CYP 3A4 is an alternative pathway to CYP 2D6. When codeine is metabolized by CYP 3A4 instead of CYP 2D6, an inactive metabolite, norcodeine, is formed. Therefore, inhibiting CYP 3A4, as some medications have an infinity, can shunt the drug towards CYP 2D6 metabolism, resulting in increased morphine production.4 Understanding the implications of inconsistent enzyme activity reveals why codeine is a dangerous therapy selection for children. Not only are they subject to the same degree of genetic variation, but children’s overall hepatic capacity continues to develop and mature with age. The risks of codeine extend beyond prescribing directly to this patient population. The active metabolite, morphine, has the ability to

Table 1: CYP2D6 Phenotype Variation3 Phenotype

Genotype

Ultra-rapid metabolizer

More than two copies of normal function alleles

Extensive (normal) Metabolizer

Two normal function alleles, one normal function allele and one decreased or non-function allele, or combinations that result in activity scores between 1 and 2.

Intermediate Metabolizer

One decreased function allele and one non-functional allele

Poor metabolizer

Two non-functional alleles

reach high serum levels in breast milk. This means that women possessing an ultra-rapid metabolizer phenotype are at increased risk of transferring high amounts of morphine to their child if receiving codeine while breastfeeding. The average concentration of morphine in breast milk of women receiving 60mg of codeine every 6 hours ranges from 1.9 to 20.5 µg/L. However, concentrations in the breast milk of mothers identified as ultra-rapid metabolizers receiving the same amount of codeine have been found to be significantly higher, at up to 87 µg/L. There is also a high correlation between infant and maternal adverse effects while taking codeine. According to one study, 58% of breastfeeding mothers with infants experiencing codeine-induced CNS depression experienced the adverse effects themselves, compared to 7% of the control population.5 This shows the notable ability of codeine to be easily transferred to the infant, especially when the mother herself is at an increased risk of adverse effects. Codeine should not be prescribed to nursing mothers due to its unpredictable and potentially harmful effects on the mother and the infant. One proposed solution would be to screen patients’ CYP 2D6 function, but unfortunately there are many barriers to implementing this into routine care. Although the effects are quite serious when toxicity does occur from CYP 2D6 duplication, the prevalence of those genetically most at risk, ultra-rapid metabolizers, is rare. This means that

Activity Score

Prevalence

> 2.0

1-2%

1.0-2.0

77-92%

0.5

2-11%

5-10%

the number of patients that would need to be screened before a toxic incident is prevented would be quite high. Furthermore, laboratory assessments for CYP activity screening are not routine for operations such as tonsillectomy. Implementing this screening for all patients undergoing this common procedure would be a clinical challenge that would require a significant increase in time and financial resources. The price of pharmacogenetic testing in the United States has been found to range from $33 to $710, with a follow-up appointment needed after approximately two weeks for discussion of results. However, efforts are underway to study and implement one-time pharmacogenomic testings, which have been shown to provide an incremental cost-effectiveness ratio of $43,165 per additional life-year, and $53,680 per quality-adjusted life years. Infrastructure and payment models for implementing this service are currently being evaluated.6-7

Codeine Ineffectiveness as an Antitussive

Codeine has also been historically used as an antitussive agent; however, there is no published evidence supporting codeine’s use as an effective antitussive agent in the pediatric population. Data indicate that codeine-containing products have no benefit over placebo in regards to cough suppression.1 Therefore, it is beneficial to provide recommendations for alternative antitussive agents, such as buckwheat honey, vapor rubs, or fluids

APR.MAY.JUN 2018 |

PEER REVIEW

and humidity. There have been promising studies of buckwheat honey products that showed significant benefit in symptom relief of cough in children one year of age and older.8 Applying small amounts of vapor rub can be effective for relief of many cough and cold symptoms, and children with a cough can additionally benefit from hydration, humidity from a vaporizer, or demulcents (e.g., cough drops products).9 These options should be considered first-line therapy for cough, while products containing codeine, dextromethorphan, guaifenesin, diphenhydramine or combination cough/ cold products should be avoided in pediatric populations for this indication, as they lack evidence for efficacy and safety in children.1

Case Studies and FDA Reports

In a Drug Safety Communication from April 2017, the Food and Drug Administration (FDA) described a review of the FDA’s Adverse Event Reporting System (FAERS) for codeine (1969 to May 2015). Identified in this review were 64 globally reported cases of respiratory distress, 24 of which resulted in death, due to codeine use in children < 18 years of age. Many of these cases have additionally been described in the published literature.10 Overall, 50/64 cases were reported in children < 12 years of age, and 21/24 of the deaths occurred in this age group. Respiratory distress occurred after a median of 5 codeine doses, with a range of 1-18 doses. Ten cases included information on hepatic metabolism profiles of the subject, with 7/10 cases reported as ultra-rapid metabolizers; 5/7 of these cases died from codeine use. The FDA has additionally reported that numerous cases of respiratory distress or excessive lethargy have occurred in infants of breastfeeding mothers where codeine was administered to the mother, leading to eventual distribution of codeine into breast milk and subsequently the feeding infant. One infant death due to breastfeeding and maternal codeine administration has been reported.11 This mother was determined to be an ultra-rapid hepatic metabolizer of codeine. These reported cases of adverse events due to codeine

use are likely a conservative estimate, as codeine is commonly prescribed and other cases may have occurred without reporting to the FDA or publication in the medical literature. For example, recent data demonstrate that in 2014, nearly 1.9 million individuals ≤18 years of age received a codeine-containing product from community pharmacies in the US.12 Due to the potential for codeine to result in significant harm, several medical organizations have recommended against the routine use of its for pain or cough in children. In 2011, the World Health Organization (WHO) removed codeine from its list of essential medicines.13 In 2013, Health Canada recommended against use of codeine in children < 12 years, and the European Medicines Agency issued a similar recommendation in 2015.14-15 The American Academy of Pediatrics published a document in 2016, Codeine: Time to Say No, recommending that use of codeine be restricted and re-evaluated.16 The FDA has issued several statements about the potential dangers of codeine use, beginning in 2012, with an additional warning published in 2013, when a “black box” warning was added to the labeling of codeine.16 The FDA published a Drug Safety Communication in April, 2017, including additional restrictive labeling changes: 1. Contraindication – codeine should not be used to treat pain or cough in children < 12 years 2. Warning (new) – recommendation against use of codeine in adolescents 12-18 years who are obese or have conditions such as obstructive sleep apnea or severe lung disease 3. Warning (strengthened) – breastfeeding is not recommended when taking codeine.10 In its most recent Drug Safety Communication (January 2018), the FDA is requiring new product safety labeling changes to curtail the use of prescription opioid cough and cold products containing codeine or hydrocodone in

children < 18 years of age by removing the indication for this use. The FDA’s Pediatric Advisory Committee has determined that the risks of using cough and cold prescription products containing codeine or hydrocodone outweigh their benefits in the pediatric population. In addition, product safety labeling will be revised to include added warnings of abuse, adverse effects, overdose, and death for individuals 18 years of age and older.17

Application to Pharmacy Practice

Codeine can still be purchased OTC in 28 states and the District of Columbia; however, the liquid formulation is considered a Schedule V narcotic in the state of Iowa and cannot be purchased without a prescription. If a parent or caregiver presents with a prescription for a codeine-containing product as analgesia for a child between the ages of 12 and 18 years, it is imperative that appropriate counseling be given. If a prescription for codeine is written for a patient less than 12 years, the prescriber should be contacted to communicate the FDA’s recommendation for contraindication in children 12 years and younger, and for the FDA’s warning for use in children 12-17 years who are obese or have co-morbidities of obstructive sleep apnea or lung disease. As has recently been stated by the FDA, antitussive products containing codeine or hydrocodone are contraindicated for use in the pediatric population. Because codeine is metabolized to morphine in varying amounts, it is imperative that pharmacists counsel parents with the same diligence as they would with morphine. The adverse effects that warrant immediate medical attention include excessive sleepiness, confusion, difficult/noisy breathing, or respiratory pauses during sleep. Both parents and older children should be counseled how to properly administer codeine. A study that assessed parental reports of morphine use at home after pediatric surgery found 14% of parents had received no counseling from the community pharmacist. Additionally, 13% of the caregivers reported they had not been taught APR.MAY.JUN 2018 |

PEER REVIEW

how to accurately measure the dose, and 11.6% of caregivers reported they received conflicting information from the pharmacist and another healthcare professional.18 As codeine may be inaccurately viewed by prescribers and patients as a safer alternative to morphine, there may be a greater risk of inadequate counseling regarding administration and adverse effects.

Alternative Medications

Replacing codeine with alternative analgesics is a step that has been taken by numerous institutions in the United States, many of which have completely removed all codeine products from their formularies. Most institutions have replaced codeine with acetaminophen, ibuprofen, hydrocodone, oxycodone, or morphine. A study found no statistical difference in level of pain, following a tonsillectomy, when comparing acetaminophen to acetaminophen with codeine.19 Ibuprofen was also shown to have superior efficacy when compared to morphine in treatment of pain following tonsillectomy, and was demonstrated to be potentially safer, as fewer patients receiving ibuprofen exhibited oxygen desaturation events as compared to children receiving morphine.20 When administering ibuprofen, some may believe there is an increased risk for gastrointestinal bleeds at high doses; however, a recent recommendation from a national otolaryngology professional organization stated that ibuprofen did not increase risk of bleeding following tonsillectomy, making it a viable option for pain management.21 Hydrocodone and oxycodone are other alternatives for analgesia. Oxycodone demonstrates good efficacy, with more pain reduction than codeine. It also is considered relatively safe for patients over six months of age.22-23 Nonetheless, hydrocodone and oxycodone are metabolized into active metabolites (hydromorphone and oxymorphone, respectively). Administration of these analgesic agents may have potential for increased adverse effects in children with genetic variations as well, with increased

| The Journal of the Iowa Pharmacy Association

risk of respiratory depression. Another replacement analgesic consideration is morphine, providing a lower risk of toxicity than codeine, as a known dose of the active drug can be given. Morphine can also be prescribed in newborns, providing a wide spectrum of treatable ages. Oral formulations have a low bioavailability, however, ranging from 17% - 33%. Caution must also be observed when oral solution dosage forms are used, as several concentrations are available, and vary by 1,000% (10x). This greatly increases a risk for medication errors. Despite these risks, experts at the Hospital for Sick Children in Toronto consider morphine the opioid of choice in pediatric patients.24

Recommended Approaches in Practice

Counseling regarding the dangers of codeine should not be limited to caregivers alone. Education of all members of the healthcare team on the potential dangers of codeine and its varying pharmacokinetic and pharmacodynamics profile is important. Providers may view codeine as a less potent analgesic, unaware that the patient is receiving the therapeutic effects and potential dangers of morphine. Open exchanges of information, regarding drug safety, through inter-professional dialogues and educational meetings, are a potential means to minimize improper use of codeine. There has been a significant effort to remove codeine from hospital formularies over the past decade and it is likely a more effective approach to limiting codeine use in pediatric populations rather than targeting specific providers. Blank Childrenâ&#x20AC;&#x2122;s Hospital, in Des Moines, removed acetaminophen with codeine from its formulary after the FDA required a black box warning for codeine use. The University of Iowa Stead Family Childrenâ&#x20AC;&#x2122;s Hospital continues to maintain codeine on its drug formulary, but has implemented best practice alerts for codeine, hydrocodone, and tramadol. These alerts notify providers of warnings and contraindications if a medication has been prescribed for a patient at risk. If education for specific providers is the

chosen approach, providing counseling points for both codeine and morphine is likely to be a more effective approach to providers who were resistant to eliminating codeine from hospital formularies.

Conclusion

The use of codeine as an antitussive and analgesic agent in the pediatric population has evolved significantly over recent years. From relatively common use as a post-operative analgesic and antitussive for acute symptomatic cough, codeine has been largely replaced by many institutions and providers. The FDA has most recently recommended labeling changes to curtail use of codeine for cough in children less than 18 years of age. The FDA has determined that the risks of codeine for this use are greater than the benefits. As most acute cough illnesses in children are self-limiting, prescribers and pharmacists should recommend safer treatments to parents and caregivers, including honey, vapor rubs, fluids and humidity, and demulcents.

References

1.American Academy of Pediatrics. Use of Codeine- and Dextromethorphan-Containing Cough Remedies in Children. Pediatrics 1997;99:918-920. doi:10.1542/peds.99.6.918. 2. Crews KR, Gaedigk A, Dunnenberger HM, et al. Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines for codeine therapy in the context of cytochrome P450 2D6 (CYP2D6) genotype. Clin Pharmacol Ther 2012;91:321-6. 3. Dean L. Codeine Therapy and CYP2D6 Genotype. In: Pratt V, ed. Medical Genetics Summaries. 1st ed. Bethesda, MD: National Center for Biotechnology Information, 2017;113. 4. Tremlett M, Anderson BJ, Wolf A. Pro-con debate: is codeine a drug that still has a useful role in pediatric practice? Paediatr Anaesth 2010;20:183-94. 5. Sistonen J, Madadi P, Ross CJ, et al. Prediction of codeine toxicity in infants and their mothers using a novel combination of maternal genetic markers. Clin Pharmacol Ther 2012;91:692-9.

PEER REVIEW

6. Verbelen M, Weale ME, Lewis CM. Cost-effectiveness of pharmacogeneticguided treatment: are we there yet?. Pharmacogenomics J. 2017;17(5):395-402 7. Bonner, L. Pharmacists’ role in pharmacogenomics increasing in an age of precision medicine. PharmacyToday 2016;22:40-43.

16. U.S. Food and Drug Administration. FDA Drug Safety Communication: safety review update of codeine use in children; new boxed warning and contraindication on use after tonsillectomy and/or adenoidectomy. February, 2013. https://www.fda.gov/ downloads/Drugs/DrugSafety/UCM339116. pdf (accessed 2017 Dec 18).

8. Paul IM, Beiler J, McMonagel A, Shaffler ML, Duda L, Berlin CM Jr. Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Arch Pediatr Adolesc Med 2007;161:1140-1146.

17. U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older, January 11 2018 https:// www.fda.gov/Drugs/DrugSafety/ucm590435. htm (accessed 2018 Jan 9).

9.Paul IM, Beiler JS, King TS, Clapp ER, Vallati J, Berlin CM. Vapor rub, petrolatum, and no treatment for children with nocturnal cough and cold symptoms. Pediatrics 2010;126:1-10.

18. Abou-karam M, Dubé S, Kvann HS, et al. Parental Report of Morphine Use at Home after Pediatric Surgery. J Pediatr 2015;167:599604.

10. U.S. Food and Drug Administration, April 20, 2017. FDA Drug Safety Communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children: recommends against use in breastfeeding women. www.fda.gove/ Drugs/DrugSafety/ucm549679.htm (accessed 2018 Jan 21). 11. IMS Health, Vector One: Total Patient Tracker. Year 2014. 12. World Health Organization. Codeine (deletion) – children. http://www.who.int/selection_medicines/ committees/expert/18/applications/Codeine/ en/ (accessed 2018 Jan 5). 13. Health Canada. Health Canada’s review recommends codeine only be used in patients aged 12 and over. Ottawa, Canada: Health Canada; 2013. www.http://healthycanadians. gc.ca/recall-alert-rappel-avis/hcsc/2013/33915a-eng.php (accessed 2018 Jan 5). 14. European Medicines Agency. Codeine not to be used in children below 12 years for cough and cold. London, United Kingdom: European Medicines Agency;2015 www.http://www.ema.europa.eu/ema/ index.jsp?curl=pages/news_and_events/ news/2015/04/news_detail_002316. jsp&mid=WC0b01ac058004d5c1 (accessed 2018 Jan 15).

19. Moir MS, Bair E, Shinnick P, Messner A. Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy. Laryngoscope 2000;110:1824-7. 20. Kelly LE, Sommer DD, Ramakrishna J, et al. Morphine or Ibuprofen for posttonsillectomy analgesia: a randomized trial. Pediatrics 2015;135:307-13. 21. Tunkel DE, Myer CM. Post-tonsillectomy analgesia: an old problem revisited. Kids ENT Health Month, May 2013. https:/www.entnet. org/kidsent (accessed 2018 Jan 12). 22. Traynor K. Hospitals don't miss codeine after it's gone. Am J Health Syst Pharm. 2014;71:979-80.

WANT TO GET PUBLISHED? Consider submitting your research manuscript to be peerreviewed by the Journal of IPA. Here is what we are looking for: Research Reports: Original research involving medication effectiveness, safety, pharmacoeconomics, pharmacokinetics, pharmacogenomics, interactions, adherence and use, and pharmacy practice. Meta-analyses are also considered research. Review Articles: Comprehensive, significant, critical, and analytical reviews that include essential information on a welldelineated subject. Reviews must synthesize and critically evaluate available data rather than simply describing the findings.

23. Jerome J, Solodiuk JC, Sethna N, Mchale J, Berde C. A single institution's effort to translate codeine knowledge into specific clinical practice. J Pain Symptom Manage 2014;48:119-26.

Case Reports: New or unusual events in one or more patients that expand the knowledge about common disease states or provide significant information about drug safety, adverse reactions, interactions, or usage.

24. Wong C, Lau E, Palozzi L, Campbell F. Pain management in children: Part 1 Pain assessment tools and a brief review of nonpharmacological and pharmacological treatment options. Can Pharm J 2012;145:222227.

Special Contributions: Articles on unusual, topical, or historical subjects concerning the profession of pharmacy. Contact IPA prior to submission. Submission guidelines can be found at www.iarx.org/Journal. Please send articles to IPA@ iarx.org.

15. Tobias JD, Green TP, Coté CJ. Codeine: Time To Say "No". Pediatrics 2016;138:e1-e8.

APR.MAY.JUN 2018 |

IT’S HERE! Your Guide to the Iowa MPJE Everything graduates and newto-Iowa pharmacists need to prepare for the Iowa Multistate Pharmacy Jurisprudence Examination, including: • Information on how to register for the exam • Questions in a table format to fill in your answers • Answers to each question with references to information in Iowa code and administrative code • Terminology section of key terms to know

IPA members enjoy a substantial discount!

Order & Download Yours at

www.iarx.org/MPJEStudyGuide

STUDENT COLUMN

STUDENT PHARMACIST PERSPECTIVE

HOPELESS TO EMPOWERED

harmacy school and pharmacy as a profession is a lot different than it used to be. Throughout my time at the University of Iowa, I heard about the steak dinners, a car as a signing bonus, and the general ease of landing your first job. To a student pharmacist graduating in 2019, that sounds like the distant past. Now I hear about “job saturation,” anxiety from seeking a residency, and the horror of not matching. Bear with me, this ends on a good note. With all the doom and gloom nowadays, it is pleasant to hear good news for a change. Learning about our fight for provider status, and how close we are, was that first silver lining that I encountered. It exposed me to a whole different world of pharmacy. It was nothing how I imagined. It was no 9 to 5. It was a lifetime of hard work, long hours, and justifying our existence in a clinical setting - which makes it that much more satisfying when we do.

“Provider status...was that first silver lining that I encountered. It exposed me to a whole different world of pharmacy.” Throughout the last year serving on the IPA Board of Trustees, I learned about the unique relationships between the Iowa Board of Pharmacy and Iowa Board of Medicine; IPA

and the Iowa Medical Society, and the American Medical Association and everyone else. I became comfortable talking with state legislators, pharmacists, doctors, etc. When ASHP reached out to students interested in their Advocacy Bootcamp in Washington, D.C., I immediately signed up. Without a doubt, if it were not for IPA, I would not have felt comfortable doing so.

“My experience with IPA changed me from being somewhat hopeless to feeling empowered.” My experience with IPA changed me from being somewhat hopeless to feeling empowered. When I look to the future, what I see is not bleak; it is exciting. I see clinical care in a community setting. I see seamless interdisciplinary teams. Most importantly, I see patients receiving every bit of care they need. All of this is due to the tireless work of over 300,000 pharmacists nationwide. Pharmacists who thanklessly take on extra work and ask for resources after proof. Pharmacists who turn the other cheek because they understand people are not always having the best day. Pharmacists who never stop pushing the envelope in a hundred different settings. This is the profession I did not expect, but I could not be more excited to join.

Grant Jerkovich 2019 PharmD Candidate The University of Iowa 2017-2018 IPA Board of Trustees

As I was driving back to Iowa City with a professor after the last board meeting, they casually mentioned going through Personnel Placement Service with another board member almost two decades ago. They then reminisced how they had either worked under or with almost every single board member. I heard pharmacy was a small world, but it was always within the context of making an impression. It never occurred to me that it’s so much more. I am truly blessed to have served on the board, to have my opinion heard as a student, and to join one of the most progressive pharmacy communities in the entire country. ■

"I am truly blessed to have served on the board, to have my opinion heard as a student, and to join one of the most progressive pharmacy communities in the entire country."

APR.MAY.JUN 2018 |

LEGISLATIVE DAY

AN ENERGIZED LEGISLATIVE DAY TAKES PHARMACY FORWARD

Equipped with a pharmacy-forward message, 180 Iowa pharmacists, pharmacy technicians, and student pharmacists went to the Iowa State Capitol to meet with their legislators during IPA’s Legislative Day. With white coats filling the Capitol Rotunda, members discussed IPA’s legislative priorities, including statewide protocols, immunization access expansion, and technician product verification. Members reported back that their message was well-received and that legislators were supportive of the profession. The relationships between legislators and IPA members that have been built and strengthened throughout the years were on display at the Capitol with members being invited into the House and Senate chambers and rare office meetings with legislative leadership. Those relationships and the face-to-face advocacy that happens on Legislative Day is vital to the association’s advocacy efforts. An energizing morning at the Capitol was followed by an afternoon focused on state and national level pharmacy and public health topics. Attendees heard from Ryan Burke, PharmD, from

| The Journal of the Iowa Pharmacy Association

APhA, on efforts across the country to implement statewide protocols. Both of Iowa’s pharmacist legislators, Rep. John Forbes and Sen. Tom Greene, provided their perspective on several issues facing the state legislature. A panel of experts discussed practical solutions to address the opioid crisis. The afternoon was capped off by Gov. Kim Reynolds, Lt. Gov. Adam Gregg, and Jerry Foxhoven, director of the Iowa Department of Human Services. Director Foxhoven gave an update on Iowa Medicaid through its managed care model. Gov. Reynolds thanked pharmacists for their work in caring for Iowans and outlined several initiatives to tackle some of the state’s public health needs. In addition to her remarks, she reminded everyone that her first job was at an independent pharmacy in Mt. Pleasant, Iowa. IPA’s Legislative Day is an important opportunity for members to engage with their legislators and learn about important pharmacy, public health and regulatory issues in Iowa. Mark your calendar for IPA’s 2019 Legislative Day on January 29, 2019. ■

LEGISLATIVE DAY

REP. DAVID HEATON RECEIVES IPA’S GOOD GOVERNANCE AWARD

IPA awarded State Representative David Heaton (R-Mount Pleasant) with its annual Good Governance Award in recognition of his work and strong support of pharmacy and public health. As chairman of the Health and Human Services budget subcommittee and a member of the Human Resources committee, Rep. Heaton has been a proud advocate for Iowa’s pharmacists on many legislative issues. He has worked to ensure fair reimbursement for pharmacies under Medicaid and has been a champion for small-town pharmacies throughout his tenure in the House. Recently, Rep. Heaton co-chaired the Opioid Epidemic Evaluation Study Committee, which brought together a diverse array of representatives from Iowa’s healthcare community to help find solutions to the growing opioid crisis in Iowa. IPA presented Rep. Heaton with the Good Governance Award during Legislative Day. APR.MAY.JUN 2018 |

BECOME A MEMBER OF THE IOWA PHARMACY ASSOCIATION

POSITION YOURSELF to lead and shape the future of your profession and join a network of pharmacists, pharmacy technicians and student pharmacists advocating the advancement of practice for the health and well-being of our patients.

ADVANTAGES FOR YOU Equipping you for today’s rapidly evolving health care system with free and convenient CPE and opportunities to connect with colleagues across the state.

ADVOCACY FOR YOUR PROFESSION Enabling you to confidently engage your elected officials while representing your interests with the Board of Pharmacy, state agencies, health care organizations, and provider groups.

of membership dues directly fund initiatives that advance the pharmacy profession

ADVANCEMENT FOR YOUR PRACTICE Creating opportunities for you and your colleagues to collaborate with healthcare teams and integrate pharmacy practice into emerging healthcare models.

IOWA PHARMACY NEEDS YOUR UNIQUE VOICE AND EXPERIENCE!

LEARN MORE & JOIN TODAY AT

WWW.IARX.ORG FREE CPE!

IPA members receive CEI’s Relicensure or Recertification CPE Libraries for FREE!

All the required CPE for relicensure or recertification conveniently bundled by CEI and free for IPA members!

LEGISLATIVE DAY

ENGAGING LEGISLATORS AT CAPITOL SCREENINGS Student pharmacists from Drake University and The University of Iowa gathered at IPA’s annual Legislative Day to offer health screenings and education to state legislators, capitol staff and other visitors. Over 100 screenings were performed, including blood pressure readings, bone density measurements, and blood glucose screenings. Furthermore, students were available to offer education on the importance of immunizations, smoking cessation, and the life-saving properties of naloxone. It was another successful year for the event, which tied-in very well to IPA’s legislative priorities for 2018. Students were excited to demonstrate pharmacists’ abilities and qualifications to provide clinical services to patients and further establish our value to the profession. Here are a couple testimonies from participating students. “I was able to connect with legislators and staff while demonstrating some of the services that pharmacists can provide, and this connection provided me with the opportunity to speak about legislative priorities as well. Legislative Day reminded me that legislators are accessible and concerned about healthcare issues, and want to hear what future pharmacists have to say about the future of pharmacy and how we can make a positive impact on the system.” -Kelli Jo Welter, PharmD Candidate 2020, Drake University “At the Capitol Screenings this year, I educated many legislators about naloxone and how pharmacists can provide this life-saving antidote as an effort to combat the opioid epidemic. I have a clinical interest in pain management, fostering my advocacy for naloxone co-prescribing and the naloxone standing order. Providing education regarding potential life-saving strategies and initiatives to both legislators and the public is essential in combatting this national crisis. Throughout the past four years, IPA has taught me to recognize issues impacting pharmacy practice, and Legislative Day has provided me with the opportunity to advocate potential solutions to my state lawmakers.” -Lorin Fisher, PharmD Candidate 2018, The University of Iowa APR.MAY.JUN 2018 |

PUBLIC AFFAIRS

BOARD OF PHARMACY: REGULATORY UPDATE The Iowa Board of Pharmacy convened for open session on January 17, 2018 and March 14, 2018, to discuss multiple requests, reports and informational items, and several proposed rules and pieces of legislation.

Collaborative Practice Agreement Requirement Waiver Approved

The Board reviewed a request from a pharmacist seeking a waiver from the requirements to participate in a collaborative practice agreement. The Iowa Administrative Code states an “authorized pharmacist” must meet one or more of the following criteria to perform collaborative drug therapy management: completion of a PharmD degree, BPS certification, CCGP certification, NISPC completion, completion of an ASHP accredited residency, or Board of Pharmacy approval. The Board approved this waiver given the pharmacist’s experience and expertise in the field, which also had to get approved by the Iowa Board of Medicine.

Updates to the Prescription Monitoring Program (PMP)

The Board of Pharmacy received an update from Board staff regarding the launch of the updated PMP, which will occur in April 2018. The new platform through Appriss Health will allow for additional services including the ability to view patient risk scores. The Board initiated a pilot program among nine pharmacy locations to test PMP integration into pharmacy software systems to improve workflow efficiency.

Discussion of IPA’s Proposed Legislation

IPA staff members presented IPA’s bill language to seek the Board’s ability

| The Journal of the Iowa Pharmacy Association

to register in support of the proposed legislation related to statewide protocols, immunization administration, technician product verification, and technicians performing prescription transfers. After much discussion and positive feedback, the Board voted to register in support of IPA’s proposed legislation.

Vote of Adoption of New Regulations

The Board voted to approve the adoption of these following regulatory changes. These rules should take effect on March 21, 2018. ITIN use for pharmacist license applications: The Board adopted the amendment to subrule 2.2(1) to allow for applicants who are not eligible for a social security number to use an individual tax identification number (ITIN) on the application for pharmacist licensure instead. The rule also clarifies that if an ITIN number is provided, the applicant must also provide acceptable proof of presence in the United States. Amendments to “General Pharmacy Practice” chapter: The Board adopted the amendments to chapter 6, which clarifies and rearranges content in a more efficient manner. Of particular note, it was amended that prescriptions and other records greater than 12 months old may be maintained in a secure storage area outside of the pharmacy, including a remote location, as long as the records can be retrieved within 48 hours of request by the Board. In addition, records less than 12 months old may be stored in a secure location outside of the pharmacy, including a remote location, as long as the pharmacy has an electronic copy of the records, and the original records can be retrieved within 48 hours of request by

the Board. Rules still stand that records must be maintained for a minimum of two years from the date of record. Amendments to “Valid prescriber/ patient relationship”: The Board adopted its amendment to rule 8.20 that clarifies pharmacists’ ability to continue to dispense remaining refills on a prescription order after the prescriber/patient relationship is broken until the patient is able to establish care with a new provider and a new order is issued. The dispensing of refills is up to the discretion of the pharmacist and should be determined based on the patient’s healthcare status and access to healthcare services. Rescind “Automated Medication Distribution Systems and Telepharmacy Services” and Replace with new “Electronic Data in Pharmacy Practice” chapter: The Board adopted the motion to rescind and reserve Chapter 9 to remove overlap and inconsistencies of rules for telepharmacy practice found in chapter 13. The Board also adopted the motion to rescind Chapter 21, and replace it with Chapter 21 “Electronic Data and Automated Systems in Pharmacy Practice.” This amendment aims to address minimum standards for automated systems to lessen the burden on pharmacies. Points addressed include system security and safeguards, storage and retrieval of prescriptions, the transmission of prescriptions, filling schedule II-controlled substances under special circumstances, the use of Automated Medication Distribution Systems (AMDS), and the tracking/ logbook maintenance of controlled substances. Amendments to pharmacy-based service programs: The Board adopted

PUBLIC AFFAIRS

the amendment to Chapter 11 stating that a pharmacy-based service program that is owned by and physically located at the same address as an Iowa-licensed and registered hospital is not required to obtain a separate CSA registration. A registrant must also submit a completed application and fee if/when a change of address of the registered pharmacy program site occurs.

IPA WORKING FOR YOU Addressing Your Iowa Medicaid & MCO Concerns

Upcoming Open Meetings of the Iowa Board of Pharmacy

55 Communicated up-to-date

Unless otherwise noted, all meetings are held at the board offices located at: RiverPoint Business Park 400 SW 8th Street, Suite E Des Moines, Iowa 50309

55 Resolved reimbursement concerns

May 23, 2018 July 25, 2018

announcements to pharmacies during AmeriHealth Caritas’ exit and MCO transition when pharmacies where being incorrectly reimbursed at FUL pricing for brand medications

55 Brought Preferred Drug List

BILL WIMMER HONORED AT POLITICAL LEADERSHIP RECEPTION

discrepancies to the attention of Iowa Medicaid Enterprise

55 Advocated for efficient processes that

do not put unnecessary financial burden on pharmacies when dispensing fee adjustments are implemented

55 Supported pharmacies through the audit appeals process

55 Ensure AAC reimbursement rates

are calculated fairly through Myers & Stauffer

55 Streamlined the processing of crossover claims for dual eligible patients

55 Helped pharmacies navigate the DME contracting process

55 Advocated for insulin pen needles to

be included as a pharmacy benefit for Medicaid patients

Bill Wimmer, IPA’s long-time legal and legislative counsel, was the featured speaker and guest of honor at the Midwest Pharmacy Expo Political Leadership Reception. The annual reception serves as a fundraiser for the political action fund and features a high level political speaker. Bill, who will retire in June, certainly fit the bill. He shared stories from representing Iowa pharmacy for the last 38 years, including his winding path to becoming a lawyer and his first client – Iowa pharmacy. Through his remarks, Bill implored the audience to work together through differences. He described the need to build trust back into government and between lawmakers that has been lost to partisanship. ■

Still Experiencing Issues? Tell Us Now! If you are experiencing an issue with one of the MCOs that does not reach adequate resolution through their respective helplines, please do not hesitate to contact IPA through our survey link on the IPA homepage.

APR.MAY.JUN 2018 |

TECHNICIAN CORNER

TECH TIDBITS Highlights from IPA’s monthly e-newsletter specifically for pharmacy technician members. How Technicians Can Handle Drug Shortages

Drug shortages seem to be a neverending problem in the world of pharmacy that can lead to workflow interruptions, using less effective therapies, and delays in treatment. According to the FDA, medication shortages can occur for a variety of reasons, such as lack of raw materials, increased medication demand, discontinuation of product, and quality issues. The cause of the most recent major drug shortages is the loss of manufacturing sites after hurricanes Irma and Maria devastated Puerto Rico. Puerto Rico produces roughly 10 percent of medications consumed in the United States and these natural disasters led to at least 40 medication and biologic product shortages. The Institute for Safe Medical Practices (ISMP) and the American Society of Health-System Pharmacists (ASHP) have outlined steps to take when preparing for and facing a drug shortage. First, assign one person, typically the employee responsible for ordering and inventory, to be in charge of monitoring drug shortages. Information regarding shortages can be found on the FDA’s website. Once aware of the shortage, determine expected duration and impact on the practice site, such as how much product is typically utilized and what is in current inventory. If the shortage will impact patient care, the following techniques can be used: recommend alternative therapies, restrict medications to specific populations, create partnerships with local pharmacies, or create new medication preparation workflows that reduce waste. Depending on the impact and severity of the shortage, the FDA, ASHP, or other governing bodies may outline

| The Journal of the Iowa Pharmacy Association

recommended alternatives. If this information is not available, the ISMP recommends to conduct a Failure Mode and Effects Analysis (FMEA) for alternative therapies recommendations to consider the safety, efficacy, and impact on work flow for these alternatives. Make sure to communicate this information with staff. Examples include having weekly or biweekly huddles or emails. Have a policy and procedure in place for the best way for your practice to communicate how shortages are being managed. It is also important to create a protocol on how to educate prescribers on how these shortages will impact their prescribing habits. It is important to avoid hoarding medications, since this can worsen or create drug shortages.

Million Hearts Update

Three years ago, we introduced you to the Million Hearts Campaign – a nationally driven initiative launched in 2012 with a goal to prevent one million heart attacks and strokes by 2017. In this initial campaign, it is estimated that Million Hearts was able to help prevent a half a million cardiovascular events from 20122016. The final number of impact will not be available until 2019. However, now that 2017 has come and gone, Million Hearts has been evaluated, analyzed, and revamped to present Million Hearts 2022. Million Hearts 2022 builds upon the experience, expertise, partnerships, and progress of the first five years and identifies three specific priorities for these next five years to reduce heart attacks and strokes. These include keeping people healthy, optimizing care, and improving outcomes for priority populations. Keeping People Healthy • Reduce the amount of sodium intake • Decrease tobacco use • Increase physical activity

Optimizing Care • Improve use of ABCS (Aspirin, Blood pressure control, Cholesterol Management, and Smoking Cessation) • Increase use of cardiac rehabilitation • Engage patients in heart-healthy behaviors Improving Outcomes for Priority Populations • African Americans • Patients aged 35-64 years old • Patients who have had a previous heart attack or stroke • Patients with mental illness • Patients with substance use disorders What can you do to make a difference? Pharmacy technicians can play an instrumental role in the Million Hearts 2022 Initiative. Talk to your patients – get to know them! When you see a patient picking up a prescription for heart-related medication, take the opportunity to educate them and provide resources. • Encourage your patients to get enrolled in medication synchronization (or a similar program) to help increase adherence to their medications • Discuss programs/services that your pharmacy may offer, such as smoking cessation classes, free blood pressure checks, cholesterol screenings, or dietician services • Consider a workflow that supports checking patients’ blood pressure with every vaccination or medication therapy management (MTM) sessioneven if they haven’t been diagnosed with hypertension! • Offer resources to your patients such as brochures on heart disease, information on the DASH diet, or website links (such as this Million Hearts Learn & Prevent tab)

TECHNICIAN CORNER

• Encourage your patients to talk with the pharmacist and ask questions about their medications and healthcare

Step 1: Make a tic-tac-toe grid.

• Provide your patient with support and empathy when they have changes in their medication regimens and/or health status

Alligation

Alligation is way to solve problems involving mixtures. This method of problem solving is more likely to be used in a hospital setting than a community setting, but it is a key component of certification examinations. Regardless of setting, as a pharmacy technician, it is important that you know how to work alligation problems. These problems may seem tricky at first glance, but really alligation is just basic math jazzed up a bit. So, let’s get started! A prescription is written for a 300 mL of a 40% solution. In your pharmacy, you stock a 60% solution and a 30% solution. Our task is to determine how to get the target strength of 40% that we “want” based on the strengths that we “have.” To the right is a step by step guide to do just that. The last tic-tac-toe board shows us that the total amount needed is 30 parts. We will need 10 parts of the 60% and 20 parts of the 30% solution to obtain a 40% solution. Next, we multiply the total amount of solution written in the prescription, in this case 300 mL, by the two fractions:

Step 2: Put the strength you “want” in the middle.

Step 3: Put the strengths you “have” on the left side. Always put the higher percentage on top and the lower percentage on the bottom.

Join IPA and receive CEI’s Technician Library for FREE!

40 30 Step 4: Find the differences by subtracting diagonally.

10 40

Amount of 60% solution needed: 10/30 reduces to 1/3 Step 5: Add up the differences in the right column. 1/3 * 300= 100 mL of 60% solution Amount of 30% solution needed: 20/30 reduces to 2/3 2/3*300= 200 ml of 30% solution

CPhT Recertification CPE for FREE!

Members: Login at www.iarx.org/cei_libraries to take advantage of your benefit and spread the word to your colleagues.

JOIN NOW & Receive Your Free CPE!

www.iarx.org/membership 515.270.0713 | ipa@iarx.org

40 30

The Technician Library includes pharmacy technician certification CPE activities in categories consistent with the PTCB Domains, including pharmacy law, patient safety, immunizations, and current drug therapy. Also included are live webinars to get those live credit hours.

APR.MAY.JUN 2018 |

Your Next Great Hire is Here The Iowa Pharmacy Association Career Center gives you access to Iowaâ&#x20AC;&#x2122;s top pharmacists and pharmacy technicians. Our members are highly engaged and dedicated to taking pharmacy practice to the next level. Post your next open position to reach our top-level talent pool of active and passive job seekers to join your practice today!

www.iarx.org/CareerCenter

TECHNICIAN CORNER

NEWLY PTCB CERTIFIED IOWA TECHNICIANS January 1 - March 31, 2018

Please join IPA in congratulating the following pharmacy technicians on becoming PTCB-certified! Morgan Allcroft Angela Anderson Sabrina Ash Douglas Baldus Kyle Bardenas James Bartlett Maribeth Bartruff Jimmal Battiste Kelsey Benson Maddison Berstler Tanya Black Aimee Blocker Debra Bownes Ashley Bredlow Jacob Buchheim Julia Cancino Molly Carlson Shelbie Christensen Therese Claeys Andrea Clifton

Bobbi Coleson Adilene Corona Kellie Craig Danielle Curtis Nicole Deeds Sara Dreyer Desirae Dupree Daniel Duryee Natalie Echtenkamp Austin Eckard Megan Fischer Natasha Folding Caitlin Forrester Cody Freiburger Deidre Funk William Galvin Rachel Garner Joann Gotto Elizabeth Hancock Chasity Hargrave

In a world where our patientsâ&#x20AC;&#x2122; health requires the best in care,

PTCB CHOOSES

EXCELLENCE. ptcb.org

Matthew Hartung Laura Haubrich Michaela Hays Samuel Hazlewood Cheyenne Hess Elizabeth Hunter Madelyne Iverson Mark Keller Cameron Keomanivong Allison Klein Melyssa Kleitsch Laura Larkin Amanda Lawrence Tabitha Liechty Kaitlin Luett Ashley Maas Lindsey Martin Michele Meier Kaitlin Melcher Samuel Melton

Olivia Mikarovski Hannah Miller Katelyn Miller Ashley Mulford Daniel Neff Autum Nelson Hoang Nguyen Zena Oweis Stacey Padilla Randee Peterson Sinh Phan Violet Piepmeier Laneshia Pledge Kristina Riley Taylor Roder Anna Rugama Jerri Sanger Taylor Schumacher Arnold Sengsirivanh Rachel Senica

Nicole Shinn Carmen Smith Erna Smlatic Erik Spencer Denise Steenhoven Rebecca Steine Jacob Taylor Teri Undis Brandi Van Gorp Kelli Vanegdom Forrest Vega David Vetter Kirstie Wagler Adam Weaver Serena Webb Kristen Wegmann Brandon Wheat Annette Yoder

PTCB is the leading certifying body for pharmacy technicians. We are most trusted. All 50 states, DC, Guam, and Puerto Rico accept PTCB Certification. We are the only certification that is nationally accepted. We specialize in pharmacy technicians. Our sole focus is on certifying technicians for their many roles across pharmacy settings.

We have nothing to hide. Our Pharmacy Technician Certification Exam (PTCE) is challenging, and we publish extensive detail about the exam.

We are informed by research.

We rely on evidence to evaluate the PTCB Program and strengthen its value.

Patient safety demands rigor.

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IPA FOUNDATION

BID FOR A GREAT CAUSE AT THE 2018 IPA FOUNDATION SILENT AUCTION

FOUNDATION AWARDS FOUR OUTCOMES INNOVATIVE PHARMACY GRANTS

Friends and friendly competition await at the 2018 IPA Foundation Silent Auction on Friday, June 8, at the Des Moines Marriott Downtown. Plan to bid on your favorite items and participate in the wine/beer ring toss and red envelope fundraiser.

The IPA Foundation has awarded $37,000 to four unique projects through the Outcomes Innovative Pharmacy Grant program. The grant program was established to provide financial support for research, education and promotion of innovative pharmacy practice initiatives within the state of Iowa. Congratulations to the recipients and their innovative projects!

The silent auction will conclude the Friday activities of the IPA’s 2018 Annual Meeting. Items can be previewed during the President’s Reception and the Annual Meeting app. Proceeds from the silent auction will support the foundation’s educational and student programs.

To Donate an Item

“Pharmacy Led Diabetes Management Using Bi-directional Text Messaging Reminders” submitted by Rachel Finkelstein, PharmD, BCACP, from the University of Iowa College of Pharmacy. “Creation and Implementation of a Pharmacy Performance Network in Iowa” submitted by Randy McDonough, PharmD, MS, CGP, BCPS, for CPESN-Iowa. “Community Provider-Pharmacist Collaboration to Improve Patient Outcomes through Electronic Medical Record (EMR) Sharing” submitted by Marla Tonn, RPh, BCACP, from CarePro Pharmacy – North Liberty. “Community Pharmacist Provision of Chronic Care Management Services for Medicare Beneficiaries with Uncontrolled Hypertension” submitted by Jim Hoehns, PharmD, BCPS, FCCP, from Northeast Iowa Family Practice Center Each recipient will present a poster on their project at the 2019 IPA Annual Meeting and the summaries will be published in a subsequent issue of The Journal of the Iowa Pharmacy Association.

SEPTEMBER 21, 2018

Brown Deer Golf Club, Coralville, IA Proceeds benefit the IPA Foundation’s support of student pharmacists at Drake University & The University of Iowa.

| The Journal of the Iowa Pharmacy Association

The grant program stems from the Outcomes Innovative Pharmacy Endowment that was established by the original investors of OutcomesMTM, a medication therapy management (MTM), service provider based in Iowa. In 1999, the Iowa Pharmacy Association provided seed money to support this innovative startup, which became a national leader in MTM services. Following the purchase of OutcomesMTM by Cardinal Health in 2015, the endowment was created as a way for those original investors to give back to the pharmacy profession and keep the innovative spirit and legacy of the company and Iowa pharmacy alive. Applicants must be an Iowa-licensed pharmacist or an Iowa-based researcher working with Iowa pharmacists in an innovative pharmacy practice. Applicants must also be active members of the Iowa Pharmacy Association. The application deadline for the next grant cycle is Dec. 1, 2018. Additional details and the application are at www.iarx.org/outcomesgrant.

Inspiring generosity and fulfilling the aspirations of the pharmacy profession through support of education, practice based research, and practice development

IPA WELCOMES WILL EVANS, 2018 EXECUTIVE INTERN

1960: The Iowa Pharmacy Foundation is established. The first student scholarships and loans are awarded by the foundation to student pharmacists at Drake University and The University of Iowa.

IPA is excited to introduce Will Evans as the 2018 Max W. Eggleston Executive Intern in Association Management. Will is a second-year student pharmacist at the University of Iowa and is originally from Grimes, Iowa. In his time at the University of Iowa, Will has been involved with organizations like SNPhA and the Free Mental Health Clinic of Iowa City. He has also worked at Hy-Vee for nearly two years. Will is passionate about research. During his undergraduate years at the University of Iowa, he was involved with a genetics research lab using fruit flies to investigate seizures. Now, in the college of pharmacy, he is researching community pharmacy access to electronic health records and is interested in understanding how healthcare can become more efficient while improving patient outcomes. “I have heard great things about IPA and the Max W. Eggleston Executive Intern position,” said Will. “IPA is truly advancing the field of pharmacy and I am excited to be a part of the association!” Will will be actively involved in several initiatives and events, including IPA’s 2018 Annual Meeting, throughout his 12week internship. When you see him, be sure to introduce yourself and welcome him to the IPA team. The IPA Foundation’s Max W. Eggleston Executive Internship in Association Management is a 12-week program held each year during the summer months at IPA’s office in Des Moines to provide student pharmacists with an educational experience in professional association management. ■

1978: Max W. Eggleston Executive Internship in Association Management is established to provide student pharmacists an educational experience in association management.

1989: The Leadership Pharmacy Conference is established to assist new practitioners with developing their leadership skills.

1994: Iowa Center for Pharmaceutical Care (ICPC) is established with the help of $300,000 and staff support from the foundation, Drake University and the University of Iowa colleges of pharmacy to allow community pharmacists to implement more patient care services.

2007: With support from both colleges of pharmacy and the IPA Foundation, the Collaborative Education Institute (CEI) was incorporated to serve continuing education needs of Iowa pharmacists and pharmacy technicians.

2010: The New Practice Model Task Force began meeting as a continuation of an unofficial discussion group started by the foundation in 2009. The task force leads to the creation of the New Practice Model pilot program to study tech-check-tech in 17 Iowa community pharmacies.

Since 1960, the Iowa Pharmacy Association Foundation has invested in the future of the pharmacy profession in Iowa by building strong leaders, investing in innovative practice initiatives and securing high quality education for tomorrow’s practitioners. The result has been, and continues to be, a progressive and innovative culture in Iowa that continues to lead in how pharmacy is practiced across the country. Consider investing in the future of your profession by donating to the IPA Foundation general fund today at www.iarx.org/IPAFWaystoDonate. Donations to the IPA Foundation are 100% tax deductible.

JEFFERSON

ONAWA

NEWTON DENISON

IOWA CITY

AMES DAVENPORT SIGOURNEY

JULY 21-28, 2018

JOIN THE 2018 RAGBRAI TEAM! It is not too late to be a part of the RAGBRAI team! This team is more than just riders. See where you fit in:

Ride

The deadline to join the team for the week-long ride has passed, but you can still register to ride for up to three days as a daily rider. For details and registration instructions, visit iarx.org/RAGBRAI. The deadline to register as a daily rider is May 31, 2018.

Drive

We are looking for volunteers to help get the team from the Missouri River to the Mississippi River. Volunteer to drive our support van for a day or two. If interested, contact Dawn Morse at dmorse@iarx.org or 515-270-0713.

Sponsor

Sponsorship opportunities are available to support the entire team or a specific rider. Visit www.iarx.org/ RAGBRAI for details.

Welcome Pharmacy Times!

Industry publication Pharmacy Times will be joining the IPA Foundation RAGBRAI time as a sponsor and sending a couple riders and writers to provide additional coverage of the teamâ&#x20AC;&#x2122;s activities.

| The Journal of the Iowa Pharmacy Association

THE TEAM (SO FAR) The team is taking shape and there is still time for daily riders to join. A special "thank you" to those who are volunteering to host the team each night!

Week-long Riders

Mark Adams, Drake Student Pharmacist Ashley Branham, PharmD Sarah Cashman Sharon Cashman, RPh Carter Chapman, Drake Student Pharmacist Ben Fox, Pharmacy Technician Christopher Fox, U. of Iowa Student Pharmacist Levi Gates, U. of Iowa Student Pharmacist Brian Haug Kevin Moores, RPh Anthony Pudlo, PharmD, MBA Mark Sorenson, RPh Troy Trygstad, PharmD, MBA, PhD Ben Urick, PharmD

Daily Riders

Matthew Cantrell, PharmD, BCPS

Overnight Hosts

Onawa: Scott North, RPh Denision: Tim Weber, RPh Jefferson: Victoria Riley Ames: Anne Stoever Garcia, PharmD Newton: Julie McCarey, RPh Sigourney: Jack Vallandingham, RPh Iowa City: Michael Brownlee, PharmD, MS, FASHP