THE KENTUCKY PHARMACIST Vol. 12, No. 1 January/February 2017 News & Informat ion for Members of the Kentucky Pharmacists Ass ociation
Embrace & Advocate Change!
2017 Kentucky Legislative Session Guardian of the Profession in Frankfort
Table of Contents
January/February 2017 2017 KPhA Professional Awards Call for Resolutions for 2017 House of Delegates Meetings Feb. 2017 CE — Bacterial Pneumonia Feb. Pharmacist/Pharmacy Tech Quiz Answer Sheet Technician Involvement KPhA New and Returning Members Online Journal Government Affairs Contribution Pharmacy Policy Issues Pharmacy Law Brief Pharmacists Mutual Cardinal Health KPhA Board of Directors/KPERF Board of Directors 50 Years Ago/Frequently Called and Contacted/KPhA Staff
Table of Contents Table of Contents— Oath— Mission Statement 2 President’s Perspective 3 Campaign for Kentucky’s Pharmacy Future 4 Serve on the KPhA Board of Directors 5 From your Executive Director 6 KPERF Board of Directors 7 APSC 8 KPhA Emergency Preparedness 9 Naloxone Training 10 Jan. 2017 CE — CDC Guidelines for Opioid Use for Chronic Pain 11 Jan. Pharmacist/Pharmacy Tech Quiz Answer Sheet 18
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Oath of a Pharmacist At this time, I vow to devote my professional life to the service of all humankind through the profession of pharmacy. I will consider the welfare of humanity and relief of human suffering my primary concerns. I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy outcomes for the patients I serve. I will keep abreast of developments and maintain professional competency in my profession of pharmacy. I will embrace and advocate change in the profession of pharmacy that improves patient care. I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.
Kentucky Pharmacists Association Vision — We are a unified pharmacy profession empowered to maximize patient and public health as fully integrated members of the healthcare team. Mission — The mission of KPhA is to advocate for and advance the profession through an engaged membership.
Editorial Office: © Copyright 2017 to the Kentucky Pharmacists Association. The Kentucky Pharmacist is the official journal of the Kentucky Pharmacists Association published bi-monthly. The Kentucky Pharmacist is distributed to KPhA members, paid through allocations of membership dues. All views expressed in articles are those of the writer, and not necessarily the official position of the Kentucky Pharmacists Association. Editor-in-Chief: Robert McFalls Managing Editor: Scott Sisco Editorial, advertising and executive offices at 96 C Michael Davenport Blvd., Frankfort, KY 40601. Phone 502.227.2303 Fax 502.227.2258. Email ssisco@kphanet.org. Website http://www.kphanet.org.
The Kentucky Pharmacy Education and Research Foundation (KPERF), established in 1980 as a non-profit subsidiary corporation of the Kentucky Pharmacists Association (KPhA), fosters educational activities and research projects in the field of pharmacy including career counseling, student assistance, post-graduate education, continuing and professional development and public health education and assistance. It is the goal of KPERF to ensure that pharmacy in Kentucky and throughout the nation may sustain the continuing need for sufficient and adequately trained pharmacists. KPERF will provide a minimum of 15 continuing pharmacy education hours. In addition, KPERF will provide at least three educational interventions through other mediums — such as webinars — to continuously improve healthcare for all. Programming will be determined by assessing the gaps between actual practice and ideal practice, with activities designed to narrow those gaps using interaction, learning assessment, and evaluation. Additionally, feedback from learners will be used to improve the overall programming designed by KPERF.
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President’s Perspective
January/February 2017
PRESIDENT’S PERSPECTIVE Trish Freeman KPhA President 2016-2017
Welcome to 2017! Each new year brings new opportunities for us – as individuals in our own practices, and collectively as a profession – to improve patient and public health, and I encourage you to reflect on what you can do in 2017 to advance these goals. OUR KPhA has been working diligently to implement the new strategic plan that I shared with you in my last message. As part of the plan, the KPhA Board, with approval from the House of Delegates, voted to establish a new Board of Directors for the Kentucky Pharmacists Education and Research Foundation (KPERF). As a reminder, KPERF was established in 1980 and was created to institute, sponsor, establish, foster and promote education programs and research projects in the field of pharmacy, including career counseling and student assistance, postgraduation education, continuing education, professional utilization, and public health education and assistance, to ensure that pharmacy in Kentucky may sustain its continuing need for sufficient and adequately trained pharmacists whose training is used to its fullest extent possible in providing health care for the citizens of Kentucky. To accomplish this mission, the KPhA Board of Directors
appointed a group of dedicated pharmacy practitioners to oversee the activities of the Foundation. According to the amended bylaws, the KPERF Board shall consist of five to nine members and includes the current President and Treasurer of the KPhA Board to enhance communications and collaborative work between the two affiliated organizations. I am pleased to announce the following individuals as members of the KPERF Board of Directors:
Paul Easley
Patricia Freeman (KPhA President)
Melinda Joyce
Clark Kebodeaux
Robert Oakley
Chris Palutis (KPhA Treasurer)
Duane Parsons
Kelly Smith
The new KPERF Board of Directors met for its inaugural meeting on Jan. 5, 2017, and elected Duane Parsons as Chair of the Board and Clark Kebodeaux as Secretary. Chris Palutis will serve as Treasurer of KPERF as required in the amended bylaws. The KPERF Board will meet at least quarterly and will continue its long-standing role of offering ACPE-accredited continuing education programs and co-sponsoring the annual KPhA meeting. Please join me in thanking our colleagues for lending their time and expertise to the Board. If you don’t know these colleagues, a short bio and picture of each member is on page 7. The mission of KPERF is more important today than ever before as we work to accomplish our vision of becoming a unified pharmacy profession, empowered to maximize patient and public health as fully integrated members of the healthcare team. We look forward to the great work that KPERF will do in 2017 to assist us in accomplishing this vision.
The Campaign for Kentucky’s Pharmacy Future: The Next 50 Years Leave a legacy by participating in the campaign to replace OUR KPERF/KPhA Headquarters! Learn more about options for payment and levels of recognition at http://www.kphanet.org/?page=buildingcampaign or call 502-227-2303. 3
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Campaign for Kentucky’s Pharmacy Future
January/February 2017
The Campaign for Kentucky’s Pharmacy Future: The Next 50 Years
96 C Michael Davenport Blvd. The Campaign for Kentucky’s Pharmacy Future: The Next 50 Years http://www.kphanet.org/?page=buildingcampaign
Donors to the campaign as of Jan. 10, 2017
Jeff Arnold Ray Bishop Fred Carrico Matt Carrico Jessika Chinn J. Leon & Margaret Claywell Chris & Katy Clifton David Dubrock Paul Easley Brian Fingerson Joseph L. Fink III Matt Foltz Andrew & Virginia France Trish Freeman Robert Goforth Cynthia Gray
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George & Burnetta Hammons Christopher Harlow JCAP Don & Vicki Kupper Phil & Julie Losch Joe Mashni Bob Oakley Chris & Consuelo Palutis Duane Parsons Ron & Lisa Poole Richard & Zena Slone Leah Tolliver Sam Willett Lewis & Kim Wilkerson Michael & Mary Ann Wyant
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KPhA Board of Directors Election
January/February 2017
Get Involved — Volunteer 2017-18 KPhA Board of Directors Nominations Serve OUR profession by serving on OUR KPhA Board of Directors! The Kentucky Pharmacists Association Board of Directors is accepting nominations for the following positions to serve on the KPhA Board for the 2017-18 year:
President-Elect
Treasurer
Director (3 open spots)
For a description of the positions and a nomination sheet, visit www.kphanet.org and click on About, Board of Directors. Nominations may be submitted electronically to Scott Sisco at ssisco@kphanet.org or mailed to KPhA, Attn: Scott Sisco 96 C. Michael Davenport Blvd., Frankfort, KY 40601 no later than Feb. 15, 2017.
Reserve your room today! Griffin Gate Marriott Resort and Spa is the host hotel for the 139th KPhA Annual Meeting & Convention. Book your room now at a reduced rate of $139/night for single and double occupancy. Overnight accommodations can be made online through a link at http://www.kphanet.org/?page=AnnualMeeting, or by calling 1-800-266-9432 before May 31, 2017 to receive the group rate. The group name is Ky Pharmacist Association Annual Meeting 2017.
2017 KPERF Golf Scramble June 22, 2017 Griffin Gate Marriott Resort Golf Course Assemble your team now! Watch www.kphanet.org for details. 5
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From Your Executive Director
January/February 2017
MESSAGE FROM YOUR
EXECUTIVE DIRECTOR
Robert “Bob” McFalls
OUR KPhA Call to Action: It’s Time to Engage, Support, Advance and Advocate with YOUR Legislators throughout the 2017 Legislative Session Legislators returned to Frankfort on January 3 with a flurry of first-week activity as many new faces graced the halls of our state Capitol. Following the 2016 General Election, the General Assembly now includes two new state senators and 28 new state representatives, including OUR KPhA pharmacist member and the Representative from District 98, the Honorable Dr. Danny Bentley. We certainly experienced an historic election in 2016, and changes already are underway with even more expected. Collectively, with your active engagement and participation, OUR KPhA looks forward to working with the newly constituted General Assembly in advancing the profession’s legislative priorities.
sions. And, we are continuing to work directly with the Department of Insurance on the full implementation of SB 117 in terms of PBM compliance with our new legal protections.
As we continue to grow our relationships with the new legislature, the time for your active engagement is now. OUR KPhA is leading advocacy efforts to address several critical issues of importance. KPhA has worked to get a bill introduced that would expand authority for pharmacists to be able to administer all immunizations starting at age 9. Current law allows pharmacists to administer flu vaccines beginning at age 9 and all other immunizations beginning at age 14. Pharmacists have played a crucial role in improving Kentucky’s vaccination rates, and we believe this bill could help improve outcomes even more. OUR KPhA also is working on legislative strategies to address the specialty drug and mail-order issues that remain unresolved. Another responsibility is to monitor legislation in terms of potential harm to the profession, e.g., any expansion of dispensing role by other health care profes-
Some of you make your commitment to support KPhA Government Affairs and/or KPPAC at the time you pay your dues. Others of you take the time to write a check or make an online contribution to KPPAC. However you do it, know that your funds are being put to good use, and that your engagement is essential for our collective success in terms of advancing our legislative priorities.
We will keep you updated on the issues through our weekly Legislative Updates during the session. When the time is right, we also will issue Grassroots Call to Action — this is when your contact with your individual legislators makes the difference as we have seen with legislative successes for several years now.
Speaking of engagement, I also am asking for your consideration to supporting the work of our Government Affairs fund (GA). Your personal and/or business donations provide addiMost of the changes in the state legislature are within the tional financial support for the work of our lobbying efforts as House of Representatives, where leadership control switched we work on our legislative issues. Following last year’s dyto the Republicans for the first time in 95 years. Representa- namic election cycle, the KY Pharmacists Political Action tive Jeff Hoover (R-Jamestown) was selected by the new ma- Council’s fund balance is also low. Each year, KPPAC must jority to serve as the new Speaker of the House. Speaker carefully analyze where it should allocate its limited Hoover joined the House in 1997 and served as Minority resources in terms of candidates seeking elected office. Floor Leader since 2001. He replaces former Speaker Greg Where does KPPAC raise the much-needed funds to make Stumbo (D-Prestonsburg) who was defeated in his contributions on behalf of the profession? Unlike Government re-election bid. There are several new faces on the House’s Affairs where pharmacies may contribute, KPPAC must rely leadership team, and several changes in committee leaderentirely upon individual donors. KPPAC works diligently ship also have been made. OUR KPhA Government Affairs throughout the year to grow its resources in order to support team has already started our work in cultivating relationships those candidates who support our key issues. KPPAC and its with both the new and seasoned legislators. For a complete campaign account are funded by individuals — like you — report, I would direct you to a great background resource on who are true believers in the power of the collective voice of KPhA’s web site (Please see New Faces at the Capitol at pharmacy and what KPPAC is accomplishing. https://kphanet.site-ym.com/?page=28. Login required.) Many of you are compelled by duty to give at multiple levels.
As we continue this journey, I want to encourage everyone to remain focused on the opportunities that our strength represents when we are united in a way that undergirds all pharmacists, pharmacy technicians and our professional issues. Please contact me, President Trish Freeman, Government Affairs Co Chairs Richard Slone and Nancy Horn Barker, KPPAC Chair Matt Carrico and/or Scott Sisco with any questions and feedback as we advocate together. 6
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KPERF Board of Directors
January/February 2017
Welcome new KPERF Board of Directors Chair Duane Parsons, RPh, is a 1974 graduate of the University of Kentucky College of Pharmacy. He resides in Richmond with his wife of 46 years, Linda. They have three daughters, Dana (Luke) Wingfield, Erin (Kenny) Stewart and Keri (Kent) Robbins and six grandchildren. Parsons has worked in retail pharmacy for 45 years. The last 27 were with Kroger Pharmacy as a Pharmacy Merchandiser in charge of 157 pharmacies in Kentucky, Tennessee, Indiana and Illinois.
two-year ASHP Residency at Shands Teaching Hospital. He is a Fellow of ASHP and KSHP and a past president of KPhA, SHP, JCAP and served as a board member for all three organizations. Oakley won the KSHP Pharmacist of the Year Award (2015), the JCAP Pharmacist of the Year Award (2006) and was co-winner of the KPhA Professional Promotion Award (2001). He was Director of Pharmacy at Baptist Hospital East in Louisville from 1988 to 2013 and is now System Director of Pharmacy for Baptist Health.
Secretary Clark Kebodeaux, PharmD, BCACP, is a clinical assistant professor of pharmacy practice and science at the University of Kentucky College of Pharmacy. He graduated from the University of Kansas School of Pharmacy and completed a PGY1 community pharmacy residency at the University of Kentucky College of Pharmacy/Kroger Pharmacy.
R. Paul Easley, RPh., graduated from the University of Kentucky College of Pharmacy in 1977. He has worked in retail pharmacy settings since then, currently working for Value Market Pharmacy in Louisville. He has been very active with KPhA and JCAP, holding leadership positions, including Treasurer, for both organizations. He is married to Kathy Jean Easley, and they have four children: Taylor, Logan, Holden and Lucy.
President Patricia (Trish) Rippetoe Freeman, RPh, PhD holds several positions in the UK College of Pharmacy, including Director of the Center for the Advancement of Pharmacy Practice (CAPP); Clinical Associate Professor in the Pharmacy Practice and Science Department, and Faculty Associate in the Institute for Pharmaceutical Outcomes and Policy (IPOP). She represents KPhA as its delegate to the United States Pharmacopeia and has served as a Kentucky delegate at the APhA Annual Meeting. Dr. Freeman received a bachelor of pharmacy degree and a Ph.D. degree from the University of Kentucky.
Melinda Joyce, Pharm.D., FAPhA, FACHE is Vice-President, Corporate Support Services, for Med Center Health, the parent company for The Medical Center in Bowling Green. Her main responsibilities focus on the quality, population health management, survey readiness, patient safety, patient satisfaction and performance improvement initiatives of the corporation. Prior to this position, she was the Corporate Director of Pharmacy for The Medical Center. She also serves as a preceptor for students and teaches pharmacology to nursing students. Dr. Joyce is a 1983 graduate of the University of Treasurer Chris Palutis, BS, RPh, is originally from the north- Kentucky College of Pharmacy. She has held all elected offices within the Kentucky Pharmacists Association and was appointeast Pennsylvania area. He attended the ed to two terms on the Kentucky Board of Pharmacy, and has Philadelphia College of Pharmacy & Science served as a Trustee on the American Pharmacists Association and earned his Bachelor of Science Degree (APhA) Board of Trustees. in Pharmacy in 1995. Palutis has more than 20 years of innovative pharmacy management experience, including positions in retail, long term care as well as retail independent pharmacy ownership. He and his wife, Consuelo (who is also a pharmacist), opened C&C Pharmacy in Lexington in February 2009 and have seen positive growth year after year. The pharmacy now employs two additional full-time pharmacists (in addition to Chris and Consuelo) as well as UK Interns and other Pharmacy Technicians. Chris and Consuelo reside in the Lexington area. Robert Oakley, BS, RPh, is a 1977 graduate of the University of Kentucky College of Pharmacy. He also earned an M.S. degree from the University of Florida in 1982 and completed a
Kelly M. Smith, PharmD is Professor of Pharmacy Practice and Science and Associate Dean, Academic and Student Affairs at the University of Kentucky (UK) College of Pharmacy. A graduate of the University of Georgia, Dr. Smith completed drug information residency training at UFHealth/Jacksonville in Jacksonville, Fla. She began her career as a drug information clinical specialist and Board Certified Pharmacotherapy Specialist (BCPS) at UK Hospital, went on to become Director of the affiliated Drug Information Center and also served for 10 years as the PGY1 Pharmacy Residency Program Director for UK HealthCare.
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APSC
January/February 2017
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KPhA Emergency Preparedness
January/February 2017
Volunteer Volunteer Volunteer Pharmacist, pharmacy technician and student pharmacist recruitment is still underway for the Kentucky Pharmacists Association emergency preparedness program! Pharmacy professionals play a critical part in responding to emergency events such as a natural disaster or infectious disease outbreak. You may sign up as a volunteer on the KPhA website, completing a volunteer form below or simply sending an email directly to Leah Tolliver at ltolliver@kphanet.org. Please join the emergency preparedness program and help to recruit other volunteers! We need all of you! For more information on how you can be involved in the KPhA Pharmacy Emergency Preparedness Initiative, contact Leah Tolliver, KPhA Director of Pharmacy Emergency Preparedness at 502-227-2303 or by email at ltolliver@kphanet.org.
For more resources, visit YOUR www.kphanet.org and click on Resources—Emergency Preparedness.
KPhA Pharmacy Emergency Preparedness Volunteer Form Name: __________________
____
Status (Pharmacist, Technician, Student): ___________________
Email: ______________________________ Phone: ________________________ County: Interest in serving as a volunteer: Yes____ No ____ Interest in serving as a Volunteer District Coordinator: Yes____ No _____ You also may join the Medical Reserve Corps by following the KHELPS link on KPhA Website to register (www.kphanet.org under Resources) Please send this information to Leah Tolliver, KPhA Director of Pharmacy Emergency Preparedness via email at ltolliver@kphanet.org, fax to 502-227-2258 or mail at KPhA, 96 C Michael Davenport Blvd., Frankfort, KY 40601.
Donate online to the Kentucky Pharmacists Political Advocacy Council! Go to www.kphanet.org and click on the Advocacy tab for more information about KPPAC and the donation form.
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Naloxone Certification Training
January/February 2017
KPERF Naloxone Certification Training The online training program can be found at the following link on the KPhA website: http://www.kphanet.org/?page=NaloxoneCert2015 The cost of the training is $5 for KPhA members, and $10 for non-KPhA members. After successfully completing the course, credit will be applied to your CPE Monitor Profile and you will be emailed a certificate of completion.
Are you connected to YOUR KPhA? Join us online! Facebook.com/KyPharmAssoc Facebook.com/KPhANewPractitioners @KyPharmAssoc @KPhAGrassroots
KPhA Company Page
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Jan. 2017 CE — CDC Guidelines for Opioids for Chronic Pain
January/February 2017
Understanding the Centers for Disease Control’s 2016 Guidelines on Management of Opioids for Chronic Pain By: Vishal Patel, PharmD., PGY-1 Pharmacy Resident, Baptist Health Louisville The author declares no financial relationships that could be perceived as real or apparent conflicts of interest. Universal Activity # 0143-0000-17-001-H04-P&T 1.5 Contact Hours (0.15 CEUs) Expires 1/1/2020 Objectives: At the conclusion of this Knowledge-based article, the reader should be able to:
KPERF offers all CE articles to members online at www.kphanet.org
1. Identify current trends in opioid usage; 2. Define key clinical questions considered by the guidelines; and, 3. Recognize opportunities to apply these guidelines in their practice. pain that typically lasts more than 3 months or past the time of normal tissue healing while acute pain is defined by Opioids are a class of medication typically prescribed for shorter periods of time. Currently, opioids are being used to pain management. Usage of these medications has been treat both acute and chronic pain. Analysis of the 2012 Nadrastically increasing within the United States during the tional Health Interview Study showed that 11.2 percent of past few years. Prescription volume for opioids has risen from under 100 million scripts per year in the 1990s to well adults reported having pain every day and, in 2005, 11.5 million adults were prescribed long-term opioid therapy.4,5 over 200 million by 2013.1 This trend has been accompaLong term opioid use is not well defined within the guidenied by an increase in opioid related overdoses, deaths and diversion. Drug overdoses from all sources have been lines, however other studies have defined it as greater than day supply or 10+ opioid prescriptions on the rise with 47,055 lethal drug overdoses in 2014. Opi- 90 days with a 120+ 5 oids make up the majority of these cases with 18,893 over- in a given year. dose deaths related to prescription opioids and 10,574 The evidence levels for use of opioids with these two pain overdose deaths related to heroin.2 This problem has beindications are vastly different. There is strong evidence for come so large that the United States Department of Health the short term efficacy of opioids from clinical trials lasting and Human Services has declared opioid diversion, addic- shorter than 12 weeks while long term evidence is lacking.7 tion and overdose the fastest-growing drug problem in the A report published by the Agency for Healthcare Research United States, going as far as to call it an epidemic.3 and Quality (AHRQ) on the effectiveness and risks of longIntroduction
The diagnosis of pain can be divided into two groups based term opioid treatment of chronic pain found that the overall on the duration of the symptoms. Chronic pain is defined by quality of evidence for chronic usage was low on the GradTable 1. Interpretation of recommendation categories and evidence type (GRADE scale) Recommendation Categories Category A recommendation Category B recommendation
Applies to all persons; most patients should receive the recommended course of action. Individual decision making needed; different choices will be appropriate for different patients. Clinicians help patients arrive at a decision consistent with patient values and preferences and specific clinical situations.
Evidence Type Type 1 evidence
Randomized clinical trials or overwhelming evidence from observational studies.
Type 2 evidence
Randomized clinical trials with important limitations, or exceptionally strong evidence from observational studies.
Type 3 evidence
Observational studies or randomized clinical trials with notable limitations.
Type 4 evidence
Clinical experience and observations, observational studies with important limitations or randomized clinical trials with several major limitations. 11
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Jan. 2017 CE — CDC Guidelines for Opioids for Chronic Pain ing of Recommendations Assessment, Development and Evaluation (GRADE) scale (seen in Table 1).8 It is important to note that the AHRQ did not publish any recommendations based on its findings. The Centers for Disease Control and Prevention (CDC) built upon the AHRQ report to publish recommendations regarding the usage of opioids in managing chronic pain.7 Use and Limitations of the CDC’s Guidelines
January/February 2017
mendations. A comparison of the objectives both groups attempt to answer is included in Table 2. As can be seen, both papers assessed the same clinical questions, with the exception of the CDC’s inclusion of measures to assess the effects of opioid therapy for acute pain on long term use. The following is a short summary reviewing the findings of the questions as well as some of the evidence found to support the claims.
With regards to Key Question 1, the effectiveness of long The CDC guidelines were written for usage by primary care term opioid therapy, neither the AHRQ nor the CDC were clinicians in managing chronic pain for patients in outpaable to find any comparator controlled studies for opioid tient settings. However, with the shift towards more intertherapy lasting longer than one year. This finding plays a professional team based care, these guidelines also are large role in some of the weaknesses in the recommendaapplicable for pharmacists to promote collaborative intetions as well as in the evidence behind the current usage of grated pain management. Therefore, it is vital for pharmaopioids in chronic care. Further studies need to be percists, as well as other healthcare professionals, to be familformed in this area to obtain any clear evidence to support iar with and involved in the care of patients to combat the the usage of opioids for long term therapy. growing trends in opioid usage. In addition, the principles of these rules can be adapted to an inpatient setting to help When looking at the potential for harm caused by opioid assist with use, one eviTable 2. Primary Clinical Questions Comparison management 2014 Agency for Healthcare Research dence 3 retroCenter For Disease Control’s Guideline for in order to spective study, and Quality report on The Prescribing Opioids for Chronic Pain – Effectiveness and Risks of Long-Term utilizing claims decrease outUnited States, 2016 Opioid Treatment of Chronic Pain patient utilizadata, found that Key Question 1. Effectiveness and tion of opioids. Key Question 1. Effectiveness long term opioid Comparative Effectiveness use (defined as Key Question 2. Harms and Adverse These guideKey Question 2. Risk and Harm greater than 90 Events lines were day’s supply of Key Question 3. Comparative intended to Key Question 3. Dosing Strategies opioids within 12 cover patients Effectiveness of Dosing Strategies months of a new Key Question 4. Risk Assessment and who are older Key Question 4. Risk Assessment and chronic pain diRisk Mitigation Strategies Risk Mitigation Strategies than the age agnosis) versus Key Question 5. Effects of Opioid Therapy of 18 with no opioid prefor Acute Pain on Long-Term Use chronic pain scription was outside of palliative and end of life care. Palliative care coassociated with an increased risk of opioid abuse/ vers patients with serious advanced illness where care is dependence with adjusted odds ratios (ORs) ranging from centered on providing relief from pain while end of life care 14.9 (95 percent CI, 10.4 to 21.5) for low-dose therapy to involves patients with a terminal illness or at high risk for 122.5 (CI, 72.8 to 206.0) for high-dose therapy.9 In addition, dying in the near future. These two patient populations rea review of another 10 uncontrolled studies found that paquire unique considerations for their pain management and tients on opioid therapy for at least 1 year had rates of opihave differing therapeutic goals. Patients undergoing active oid abuse of up to 8 percent and an increase of dependcancer treatment also are excluded from the scope of this ence of up to 23 percent.6,7 These studies also demonstratguideline; the scope does include cancer survivors with ed increases in the risk of cardiovascular events, endocrinchronic pain who have completed cancer treatment, are in ological harm and odds of road trauma for patients with clinical remission and are under cancer surveillance only. long term opioid prescriptions.7 Road trauma is defined as codes V00 to V89 from the International Statistical ClassifiClinical Questions cation of Diseases, 10th Revision. Although many of these The CDC guidelines approach opioid usage by looking to studies had limitations, there is fair evidence connecting answer five major questions. The AHRQ report served as a the use of chronic opioids to harm in patients. basis for gathering evidence for the CDC’s guidelines. Newer evidence from studies performed after the 2014 re- Key Question 3 looked at comparing the effectiveness of port were included in the development of the CDC’s recom- different methods for initiating and titrating opioids as well 12
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Jan. 2017 CE — CDC Guidelines for Opioids for Chronic Pain as comparing immediate-release (IR) versus extended released (ER) and long acting (LA) opioids. AHRQ’s report found insufficient evidence to determine comparative effectiveness of ER/LA versus IR options and the CDC followed suit, even with the addition of newer studies. The 2014 report found a few randomized head to head trials comparing the harm caused by various ER/LA opioid options, but was unable to find any clear differences in pain management between these ER/LA options after one year of therapy.6 One of the newer cross-sectional studies found that initiation of therapy with an ER/LA opioid was associated with an increased risk of overdose versus initiation with an immediate-release opioid (adjusted hazard ratio 2.33, 95 percent CI = 1.26–4.32).10 No additional studies were found regarding dose escalation, and current studies were too limited to determine long term effects of dose escalation, ER/LA versus immediate dosing and scheduled dosing versus as needed dosing.6
January/February 2017
discussed in the following section. When determining to initiate or continue opioids for chronic pain, nonpharmacological and non-opioid therapy always should be considered first. Opioids should not be the first line therapy for chronic pain. Exercise therapy has been shown to produce both a decrease in pain and an increase in function in a wide variety of patients ranging from back pain to fibromyalgia.7 Cognitive behavioral therapy (CBT) is another option focused on helping patients modify situational factors. A systematic review of randomized controlled trials found that CBT has small positive effects on disability associated with chronic pain with maintenance at six months.13 Non-opioid pharmacological options also should be considered. Depending on the type of pain, these can include acetaminophen, NSAIDS, cyclooxygenase (COX) inhibitors as well as some anticonvulsants and antidepressants. Acetaminophen, NSAIDS and COX inhibitors have been recommended as first line options for nociceptive pain, such as that associated with osteoarthritis and back pain. However, it is important to consider the safety and side effects of these medications. Acetaminophen has been associated with liver failure and should be avoided in patients with hepatic failure or a history of alcohol abuse.14 Similarly, NSAIDS/COX inhibitors have potential harm related to gastrointestinal bleeding, renal damage and cardiovascular risks.14 For neuropathic pain, anticonvulsants, tricyclic antidepressants and SNRI’s can be used.7 Some of these medications also may be of use for treating depression, which is a common co-morbidity of patients with chronic pain.
Risk assessment and mitigation is important when attempting to manage opioid therapy. Various tools were analyzed in studies, including the opioid risk tool (ORT), the screener and opioid assessment for patients with pain-revised tool (SOAPP-R) and the brief risk interview. Results from the ORT were inconsistent while the other two tools had limited evidence available for conclusions. ORT results ranged from non-informative to moderately useful, while the SOAPP-R was non-informative in both studies.7 The last key question examined the effects of opioid therapy for acute pain on long-term use. Two studies were found pertaining to this question, both of them rated as evidence level 3. One study found that the use of opioids within 7 days of low-risk surgery was associated with an increased likelihood of opioid use at 1 year (adjusted OR 1.44, 95 percent CI = 1.39–1.50).9 Examples of low risk surgery in this study include cataract surgery, laparoscopic cholecystectomy, transurethral resection of the prostate or varicose vein stripping. The other study found that use of opioids within 15 days of onset of low back pain was associated with an increased risk of long term opioid use (adjusted OR 2.08, 95 percent CI = 1.55–2.78 for 1 to 140 morphine milligram equivalent(MME)/day and OR 6.14, 95 percent CI = 4.92–7.66 for ≥450 MME/day).12 Recommendations Recommendations made in the new CDC guidelines focus on three major categories: determining when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up and discontinuation; and assessing risk and addressing harms of opioid use. The recommendations are summarized in Table 3. Categories one and two will be discussed in this section. Portions of category three will be
Although each of these non-opioid options have their own side effect profile, these medications are considered safer than opioids due to the lower risks associated with substance abuse disorder and overdose. In 2010, deaths related to opioids were 16 times higher than deaths related to either acetaminophen or NSAIDs combined.7 However, there are cases where opioids may have to be used in patients, namely when the expected benefits outweigh the potential risks. In these cases, the opioids should be combined with non-pharmacological or non-opioid therapy. Step up therapy is not always advised and patients should fail non-pharmacologic and non-opioid pharmacologic therapy prior to proceeding to opioid therapy. When initiating opioid therapy, it is important to have treatment goals established for patients. The clinical evidence review performed by both the CDC and the AHRQ found that there is no strong evidence to support the long term use of opioids in chronic pain. In addition, a review of studies found that there is weak evidence to suggest that pa-
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Jan. 2017 CE — CDC Guidelines for Opioids for Chronic Pain
January/February 2017
Table 3. CDC recommendations for prescribing opioids for chronic pain outside of active cancer, palliative and end-of-life care Determining When to Initiate or Continue Opioids for Chronic Pain Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate.
Category A, Evidence 3
Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
Category A, Evidence 4
Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.
Category A, Evidence 3
Opioid Selection, Dosage, Duration, Follow-Up and Discontinuation When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.
Category A, Evidence 4
When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to ≥50 morphine milligram equivalents (MME)/day and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.
Category A, Evidence 3
Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.
Category A, Evidence 4
Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.
Category A, Evidence 4
Assessing Risk and Addressing Harms of Opioid Use Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day) or concurrent benzodiazepine use, are present.
Category A, Evidence 4
Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
Category A, Evidence 4
Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
Category A, Evidence 3
Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.
Category A, Evidence 2
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Category B, Evidence 4
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Jan. 2017 CE — CDC Guidelines for Opioids for Chronic Pain tients who needed opioid therapy for greater than six months found any clinically significant pain relief from these durations of therapy.15 For this reason, it is important to have clear goals established as well as a plan to discontinue opioids if these medications do not work for either pain reduction or improvements in physical function. Patient education on opioids is minimal according to some studies. A small survey of outpatients found that many patients do not know what opioids are and consider “narcotics” synonymous with “addiction.”16 Patients always should be counseled on these medications, so that they have a better understanding of what the potential risks and benefits are. Patient specific factors, such as prior medications and chronic disease conditions, also should be taken into account. Reassessments of pain management progress should be done to monitor the development of risks. Recommendations are to reevaluate progress within one to four weeks of starting opioids and re-evaluate the risk/benefits at least every 3 months, preferably earlier.7 Unique effects of opioids, such as tolerance and physical dependence, may decrease benefits over time making it important to ensure that the medications used continue to be appropriate. 14
January/February 2017
of overdose tends to grow higher beyond the 50 MME/day threshold, careful consideration should be assessed for using these dosages. Dosages higher than 90 MME/day should be avoided. Management of initiation of opioids in acute pain also should be carefully evaluated. Long term use tends to stem from an initial use for acute symptoms. Various guidelines regarding emergency room and other clinical settings’ usage of opioids agree that limitations in durations of opioids in acute pain help to prevent long term risk and chronic prescripitons.7 One study analyzing back pain found that there was little improvement in pain control for opioid usage beyond 4 days of therapy.20 For this reason, a 3 days’ supply should typically be sufficient to manage pain and a duration longer than 7 days should not be used. Management also can be attempted using non-opioid pharmacological options. Conclusion: A Pharmacists Role
Pharmacists can play an important role in helping to manage pain in both an outpatient and inpatient environment. One of the largest areas that can be focused on is patient education and monitoring. As previously mentioned, many patients are unaware what opioids are and have a large fear Immediate release (IR) medications are preferred over the of addiction to these substances. Pharmacists can help to use of ER/LA opioids. Studies have shown that the risk of review some of the risks and benefits of opioids by counseloverdose is much higher when patients are initiated with longer acting medications when compared to the immediate ing patients to ensure they understand their therapy. Patients should be cautioned that with long term use of these release alternatives.10 The FDA also has noted that ER/LA medications, they likely will not experience complete pain opioids are more appropriate for opioid-tolerant patients, relief as long-term efficacy has not been proven and toler(patients who have received 60 mg daily of oral morphine) 17 ance to the medication develops. In addition, side effects for at least 1 week. They also have made adjustments to the labeling, stating that ER/LA opioids should be reserved also should be explained to the patient and monitored by the pharmacist in both inpatient and outpatient settings. These for management of pain severe enough to require daily, around-the-clock, long-term opioid treatment when alterna- include severe reactions such as respiratory depression and development of a potentially serious lifelong opioid use distive treatment options are ineffective or not tolerated.17 If 14 considering to change a patient to ER/LA after an initial one order. More common side effects include constipation, dry week of IR therapy, dosage should be considered and likely mouth, nausea, vomiting, drowsiness, confusion, tolerance, physical dependence and withdrawal symptoms when stopreduced to account for incomplete opioid cross tolerance. ping opioids.14 If applicable, common methods to manage Opioids should be started at the smallest starting dose availside effects also should be discussed including maintenance able. The Joint Commission’s Sentinel Event database of proper hydration and usage of stool softeners and laxashows that 47 percent of opioid-related adverse drug events tives to prevent opioid induced constipation. in hospitals causing harm to patients were due to wrong Pharmacists also should assist in assessing the appropridose medication errors. Studies have shown that there is little difference between liberal dosage escalation and main- ateness of opioids when patients are initiated or continued tained current dosages in regards to pain control and quality on pain management. Doses and medication choice should be considered, as the lowest dose should be used and ER/ of life.18 Further studies have shown an increasing risk of LA products should not be used for opioid naive patients. In overdose when increasing pain control to higher dosages. When comparing the risk of overdose, 50-100 morphine mil- addition, duration of therapy should be limited to less than ligram equivalents/day (MME) was up to 4 times higher and one week if the opioids are being used to treat acute pain. doses greater than 100 were almost 9 times higher than 1- Management of inpatient usage and reduction of opioid prescribing at hospital discharge can help prevent future 20 MME/day.19 This evidence helps to solidify the notion chronic opioid use.21 Similar management in an outpatient that lower doses would be safer for patients to use. As risk 15
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Jan. 2017 CE — CDC Guidelines for Opioids for Chronic Pain
January/February 2017
setting may help move patients towards more appropriate and safer options to help reduce pain related symptoms.
DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.
4. Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. J Pain 2015;16:769–80.
Cochrane Database Syst Rev 2010:1:CD006605.
7. Chou R, Deyo R, Devine B, et al. The effectiveness and Drug interactions also should be monitored as many potenrisks of long-term opioid treatment of chronic pain. Evitially fatal adverse events can exist. These include interacdence Report/Technology Assessment No. 218. AHRQ tion with any other central nervous system depressants, Publication No. 14-E005-EF. Rockville, MD: Agency for benzodiazepines and alcohol. The use of state prescription Healthcare Research and Quality; 2014. drug monitoring programs (PDMP) (KASPER in Kentucky) http://www.effectivehealthcare.ahrq.gov/ehc/ can help to identify if patients are receiving opioid dosages products/557/1971/chronic-pain-opioid-treatment-report or combinations of medications that can increase the risk of -141007.pdf. an overdose. The CDC recommends to monitor PDMP data 8. Institute of Medicine. Dying in America: improving qualiat least every 3 months for patients on opioid therapy for ty and honoring individual preferences near the end of chronic pain.7 Patient specific factors also should be considlife. Washington, DC: The National Academies Press; ered, for example elderly patients may have reduced hepat2015. ic or renal function, either of which could lead to unintended 9. Elund MJ, Martin BC, Russo JE, DeVries A, Braden JB, overdose of opioids.7 Sullivan MD. The role of opioid prescription in incident In conclusion, there is a continued knowledge gap in eviopioid abuse and dependence among individuals with dence related to the use of opioids for chronic pain manchronic noncancer pain: the role of opioid prescripagement. While performing additional studies to gather this tion. Clin J Pain. 2014; 30:557-64. evidence would be the strongest method to establish effica10. Miller M, Barber CW, Leatherman S, et al. Prescription cy, health care professionals can utilize the recommendaopioid duration of action and the risk of unintentional tions within these guidelines to help monitor and reduce the overdose among patients receiving opioid therapy. JAcurrent usage of opioids in these patients. MA Intern Med 2015;175:608–15. References 11. Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink 1. IMS’s National Prescription Audit (NPA) & Vector One DN, Bell CM. Long-term analgesic use after low-risk ®: National (VONA). surgery: a retrospective cohort study. Arch Intern Med 2. Center for Disease Control and Prevention, National 2012;172:425–30. Center for Health Statistics, National Vital Statistics 12. Webster BS, Verma SK, Gatchel RJ. Relationship beSystem, Mortality File. Number and Age-Adjusted Rates tween early opioid prescribing for acute occupational of Drug-poisoning Deaths Involving Opioid Analgesics low back pain and disability duration, medical costs, and Heroin: United States, 2000–2014. Atlanta, GA: subsequent surgery and late opioid use. Spine (Phila Center for Disease Control and Prevention. Available at Pa 1976) 2007;32:2127–32. http://www.cdc.gov/nchs/data/health_policy/ AADR_drug_poisoning_involving_OA_Heroin_US_200 13. Williams AC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding 0- 2014.pdf. headache) in adults. Cochrane Database Syst Rev 3. Epidemic: Responding to America's Prescription Drug 2012;11:CD007407. Abuse Crisis. Washington, D.C.: 2011. [Accessed Jan. 5, 2013]. Office of National Drug Control Policy, Execu- 14. Lexicomp Online®, Pediatric & Neonatal Lexi-Drugs®, Hudson, Ohio: Lexi-Comp, Inc.; Oct. 1, 2016. tive Office of the President of the United States. 2011. Available at: http://www.whitehouse.gov/sites/default/ 15. Noble M, Treadwell JR, Tregear SJ, et al. Long-term files/ondcp/policy-and-research/rx_abuse_plan.pdf. opioid management for chronic noncancer pain.
5. Boudreau D, Von Korff M, Rutter CM, et al. Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf 2009;18:1166–75.
16. Mangione MP, Crowley-Matoka M. Improving pain management communication: how patients understand the terms “opioid” and “narcotic”. J Gen Intern Med 2008;23:1336–8.
6. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49.
17. Food and Drug Administration. FDA blueprint for prescriber education for extended-release and long-acting opioid analgesics. Silver Spring, MD: US Department of 16
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Jan. 2017 CE — CDC Guidelines for Opioids for Chronic Pain Health and Human Services, Food and Drug Administration; 2014.
January/February 2017
Epub ahead of print. 20. Coste J, Delecoeuillerie G, Cohen de Lara A, Le Parc JM, Paolaggi JB. Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice. BMJ 1994;308:577–80.
18. Naliboff BD, Wu SM, Schieffer B, et al. A randomized trial of 2 prescription strategies for opioid treatment of chronic nonmalignant pain. J Pain 2011;12:288–96.
19. Bohnert ASB, Logan JE, Ganoczy D, Dowell D. A de- 21. Calcaterra SL, Yamashita TE, Min SJ, Keniston A, tailed exploration into the association of prescribed Frank JW, Binswanger IA. Opioid Prescribing at Hospiopioid dosage and prescription opioid overdose deaths tal Discharge Contributes to Chronic Opioid Use. J among patients with chronic pain. Med Care 2016. Gen Intern Med. 2016;31(5):478-85.
January 2016 — Understanding the CDC’s 2016 Guidelines on Management of Opioids for Chronic Pain 1. What was the prescription volume for opioids in 2013? A. 100 million B. 150 million C. 200 million D. 250 million E. 300 million 2. Who do the CDC guidelines apply to? A. Primary care physicians B. Nurse practitioners C. Physician assistants D. Pharmacists E. All of the above 3. Which risk assessment tool had the highest level of evidence in the CDC guidelines? A. Opioid risk tool B. Screener and opioid assessment for patients with painrevised C. Brief risk interview 4. Which Key question was unable to be answered by the CDC guidelines? A. Key Question 1. Effectiveness B. Key Question 2. Risk and Harm C. Key Question 3. Comparative Effectiveness of Dosing Strategies D. Key Question 4. Risk Assessment and Risk Mitigation Strategies E. Key Question 5. Effects of Opioid Therapy for Acute Pain on Long-Term Use 5. Which key question was new to the CDC guidelines that was not mentioned in the AHRQ’s report? A. Key Question 1. Effectiveness B. Key Question 2. Risk and Harm C. Key Question 3. Comparative Effectiveness of Dosing Strategies D. Key Question 4. Risk Assessment and Risk Mitigation Strategies E. Key Question 5. Effects of Opioid Therapy for Acute Pain on Long-Term Use
6. Step-wise therapy should always be used in patients prior to initiating opioid treatment. A. True B. False 7. How long should immediate release opioids be used prior to initiation with longer acting agents? A. 3 days B. 5 days C. 7 days D. 14 days 8. What is considered the upper limit of MME/day dosage in patients? A. 10 B. 20 C. 50 D. 90 E. 100 9. What is the recommended maximum duration for opioids in acute pain? A. 3 days B. 5 days C. 7 days D. 14 days 10. How are opioids metabolized within the human body? A. Renal B. Hepatic C. Neither D. Both A & B 11. What is a serious side effect of opioid usage? A. Physical dependence B. Respiratory depression C. Withdrawal symptoms D. Constipation
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THE KENTUCKY PHARMACIST
Jan. 2017 CE — CDC Guidelines for Opioids for Chronic Pain
January/February 2017
This activity is a FREE service to members of the Kentucky Pharmacists Association. The fee for non-members is $30. Mail completed forms to: KPERF, 96 C Michael Davenport Blvd., Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile. Expiration Date: January 1, 2020 Successful Completion: Score of 80% will result in 1.5 contact hours or .15 CEUs. Participants who score less than 80% will be notified and permitted one re-examination. TECHNICIANS ANSWER SHEET. January 2016 — Understanding the CDC’s 2016 Guidelines on Management of Opioids for Chronic Pain (1.5 contact hours) Universal Activity # 0143-0000-17-001-H04-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D E 3. A B C 5. A B C D E 2. A B C D E 4. A B C D E 6. A B
7. A B C D 8. A B C D E
9, A B C D 10. A B C D
11. A B C D
Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet. Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature ____________________________________________Completion Date___________________________
Personal NABP eProfile ID #_____________________________ Birthdate ____________(MM/DD) PHARMACISTS ANSWER SHEET January 2016 — Understanding the CDC’s 2016 Guidelines on Management of Opioids for Chronic Pain (1.5 contact hours) Universal Activity # 0143-0000-17-001-H04-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D E 3. A B C 5. A B C D E 2. A B C D E 4. A B C D E 6. A B
7. A B C D 8. A B C D E
9, A B C D 10. A B C D
11. A B C D
Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet. Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature ____________________________________________Completion Date___________________________
Personal NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation Council for Pharmacy Education as a provider of continuing Pharmacy education.
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Quizzes submitted without NABP eProfile ID # and Birthdate cannot be accepted.
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2017 KPhA Professional Awards
January/February 2017
2017 KPhA Professional Award Nominations Open Bowl of Hygeia Award Criteria – To recognize an individual who has demonstrated outstanding community service in pharmacy. Eligibility – The recipient must be an Active or Honorary Life member of the Association. The recipient must be a pharmacist with a current valid license to practice in Kentucky. The recipient must be living; awards are not presented posthumously. The recipient has not previously received the award and is not currently serving nor has he/she served within the past two years on the selection committee or as an officer of the Association in other than an exofficio capacity. The recipient has compiled an outstanding record of community service that apart from his/her specific identifications as a pharmacist reflects well on the profession. Ron Poole 2016 Larry Stovall 2015 Jerry White 2014 Leon Claywell 2013 George F. Hammons 2012 William I. McMakin, III 2011 Kim Croley 2010 Patricia Thornbury 2009 Dave Peterson 2008 Charles Fletcher 2007 Gloria Doughty 2006 Larry Hadley 2005 Harold Cooley 2004 Brian Fingerson 2003 Simon Wolf 2002 Richard Ross 2001 Tom Houchens 2000 Phil Losch 1999 Lucy Easley 1998 Nick Schwartz 1997 Michael Cayce 1996
E IS N I DL 31 ! A DE RCH MA
Bill Borders Gerald Deom Kenneth Calvert Joseph G. Bessler Michel A. Burleson Lynn Harrelson William A. Conyers, Jr. Daniel R. Kovar, Jr. Martin W. Nie Ralph Schwartz Dwaine K. Green W. Vance Smith Richard L. Roeding William J. Farrell, Sr. Joseph L. Scanlon Joseph T. Elmes, Jr. H. Joe Russell Alvin R. Bertram Norman C. Horn H. Joseph Schutte D.H. "Sonny" Ralston Arthur G. Jacob James M. Brockman Richard E. Murray Randolph N. Smith Oliver E. Mayer Donald C. Morwessel James Phillip Arnold William D. Morgan Ernest M. Davis W.F. Bettinger Arvid E. Tucker Vernon B. Hager Sidney Passamaneck John H. Voige E. Crawford Meyer James J. Hamilton
1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959
fession at large over an extended period of time. Eligibility – Only Active or Honorary Life members of the Association shall be eligible for the award. No individual shall be a recipient of the award more than once. Kim Croley 2016 Michael A. Burleson 2015 William Grise & Judy Minogue 2014 Catherine Hanna 2013 Glenn Stark 2012 Kenneth Roberts 2011 Ann Amerson & Lynn Harrelson 2010 Larry Hadley 2009 Dwaine Green 2008 John Brislin 2007 Donnie Riley 2005 Gloria Doughty 2004 Coleman Friedman 2003 Joe Fink III 2002 Melinda Joyce 2002 David Jaquith 1999 R. Paul Easley & Jeff Osman 1998 Ralph Bouvette 1997 Pat Chadwell 1996 Jordan Cohen and Marty Nie 1995 Mike Montgomery 1994 Richard Ross 1993 Thomas Weisert 1991 R. David Cobb 1990 Joseph G. Bessler & Arthur G. Jacob 1989 Paul E. Davis 1988 Norman Horn & Robert E. Lee Sandlin 1987 Joseph V. Swintosky 1986 J.H. (Jack) Voige 1985 KPhA Distinguished Service Award Charles T. Lesshafft, Jr. 1984 Criteria- To recognize individual mem- Jerry Budde 1983 bers who have made significant contri- William H. Nie 1982 butions to the Association or the proR.N. (Randy) Smith 1981
Nominate your peers today! Nomination forms are more information is available at http://www.kphanet.org/?58
Submit nominations to: KPhA Awards, 96 C. Michael Davenport Blvd., Frankfort, KY 40601; or via email to ssisco@kphanet.org. 19
THE KENTUCKY PHARMACIST
2017 KPhA Professional Awards KPhA Pharmacist of the Year Award Criteria – To recognize a pharmacist for outstanding professional activities undertaken during the current or previous calendar year, which resulted in demonstrable benefit to the profession of pharmacy. Eligibility – Only Active or Honorary Life members of the Association shall be eligible for nominations and receipt of this award. Joel Thornbury 2016 Claire Love 2015 Jill Rhodes 2014 Trish Freeman 2013 Alyson Schwartz 2012 William Grise 2011 Holly Byrnes 2010 Dave Sallengs 2009 Kelly Smith 2008 Joseph Bickett 2007 Paul Easley 2006 John Anneken 2005 Kim Croley 2004 Ralph Bouvette 2003 David Jaquith 2001 Melinda Joyce 1999 Michael Wyant 1998 Phil Losch 1997 Tom Houchens & Bob Kuhn 1996 Don Ruwe 1995 Mark Edwards 1994 C. Dave Peterson 1993 Brian Fingerson 1992 Martin W. Nie 1991 Judy Minogue 1990 Paul Ruwe 1989 Joseph L. Fink III 1988 Steven R. Adams 1987 William J. Farrell 1986 Harold G. Becker 1985 Dwaine K. Green 1984 R. David Cobb 1983 Richard E. Murray 1982 Richard Rolfsen 1981 Gloria H. Doughty 1980 Joseph G. Bessler 1979 Emil Baker 1978 Robert L. Barnett 1977 Joseph L. Scanlon 1976 John B. Anneken 1975 Alvin R. Bertram 1974 Patricia A. Donahue 1973 H. Joseph Schutte 1972 Willard Alls 1971 Joe D. Taylor 1970 Richard L. Ross 1969 Ralph J. Schwartz 1968 George W. Grider 1967 Robert J. Lichtefeld 1966 E.M. Josey 1965
January/February 2017 Julius T. Toll Charles E. Otto Charles F. Rosenberg R.N. Smith E. Crawford Meyer Charles A. Walton Ernest C. Williams George W. Grider Ray Wirth Nathan Kaplin Marion Hardesty
1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954
KPhA Professional Promotion Award Criteria – To recognize individuals or organizations who have exhibited outstanding efforts to demonstrate the importance of pharmacy as a health care profession, and which promote proper application of pharmacists’ professional services. Eligibility – Open to persons or organizations. Suzanne Francis 2016 Kerry Hettinger 2015 Cassandra Beyerle 2014 Julie N. Burris & Walgreens Corporation 2013 SUCOP student chapter of APhA-ASP 2012 Lynne Eckmann 2011 Gloria Doughty & Lynn Harrelson 2010 Jordan Covvey 2009 Jeff Mills 2008 Trish Freeman 2007 Sherry DeCuir 2006 Pete Orzali 2005 John Armistead, Don Kupper & Willie Newby 2004 Kroger Pharmacy Mid South Division, Holly Divine, Randy Gaither, Bill Grise & Laura Jones 2003 JCAP & Dean Ken Roberts 2002 Paul Easley, Bob Oakley and Michael Wyant 2001 Judy Minogue 2000 Ralph Bouvette 1999 Rodger Smith, Barbara Woerner, Mary Ann Wyant, and Rick Vissing 1998 Larry Spears 1997 John B. Anneken 1996 Phil Losch 1995 Jordan Cohen 1994 Judy Minogue 1994 Kentucky Academy of Student of Pharmacy 1993 Celeste Flick & Clarence Sullivan III 1988 William H. Nie 1987 Student Kentucky APhA 1986 20
Northern KY Pharmacists Association 1986 Distinguished Young Pharmacists of the Year Award sponsored by Pharmacists Mutual Insurance Company Criteria – To recognize a young pharmacist’s outstanding contribution to the profession and/or community. Eligibility – The recipient must be an Active member of the Association. The recipient must be licensed to practice for nine years or less. The recipient must have a valid, active license to practice in Kentucky. The recipient must have demonstrated participation in a national pharmacy association, professional program(s) and/or community service. Matt Carrico 2016 Cassandra Beyerle 2015 Chris Harlow 2014 Brooke Hudspeth 2013 Stacy Rowe 2012 Aimee Ruder 2011 Karen Hubbs 2010 Matt Martin 2009 Tiffany Self 2008 Angela Parrett 2007 Janet Mills 2006 Alyson Schwartz 2005 Nancy Horn 2004 Jennifer O’Hearn 2003 Karen Altsman 2001 Kim Wilson 1999 Kim Harned 1998 Michael Box 1997 Dan Yeager 1996 Dan Minogue 1995 Pan Haeberlin 1994 Kim Croley 1993 Phillip Sandlin 1992 Jeffrey W. Danhauer 1991 Mark S. Edwards 1990 Susan Murray Kathman 1989 Melinda Cummins Joyce 1987 Excellence in Innovation Award Sponsored by Upsher-Smith Laboratories Criteria – To recognize a pharmacist who has demonstrated innovative pharmacy practice resulting in improved patient care in the previous year or over an extended period of time. Eligibility – A recipient must be a pharmacist who is an Active or Honorary Life member of the Association. A recipient may receive the award more than once.
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2017 KPhA Professional Awards Chris Harlow 2016 Matt Carrico 2015 Brooke Hudspeth 2014 Buddy Wheeler 2013 Lynn Harrelson 2012 James Nash & BC Childress 2011 Lynne Eckmann & Cathy Hanna 2010 Ann Albrecht 2008 Lisa Short 2005 Holly Divine, Amy Nicholas 2004 Judy Minogue 2003 Trish Freeman 2002 Mary Ann Wyant 2001 Joyce Korfhage Rhea 2000 Cathy Edwards 1999 Celeste Flick 1998 Jeanne Zeis 1997 Dave Wren 1996 Preston Art 1995 W. Michael Leake 1994 KPhA Technician of the Year Award Criteria – To recognize a Certified Pharmacy Technician for outstanding
January/February 2017 professional activities. Eligibility – Only active Pharmacy Technician members of the Association shall be eligible for nomination and receipt of this award. Heather Daniels 2015 Don Carpenter 2014 Leslie Lochner & Robin Lillpop 2013 Patricia Robinson 2012 Jessica Salmons 2011 Gwen Otter 2010 Lisa Sawvel 2008 Margaret Sinkhorn 2007 Charlotte Bowling 2006 Mary Jane Wathen 2005 Kent Williams 2004 Tammy Newsome 2003 Frank Ray 2002 Jane Woerner 2001 Cardinal Health Generation Rx Champions Award Criteria – This award program recognizes excellence in community-based
prescription drug abuse prevention at state pharmacy associations. This award honors a pharmacist who has demonstrated outstanding commitment to raising awareness of the dangers of prescription drug abuse among the general public and among the pharmacy community. The award also is intended to encourage educational prevention efforts aimed at patients, youth and other members of the community. In addition to the award, to honor the pharmacist’s work to fight prescription drug abuse, APMS, state pharmacy associations and the Cardinal Health Foundation will donate $500 to a charity of the award recipient’s choice. Trish Freeman 2016 Laurel Taylor 2015 Amber Cann 2014 Raymond Float 2013 Brian Fingerson 2012
Call for Resolutions for KPhA House of Delegates OUR KPhA House of Delegates will meet at the 139th KPhA Annual Meeting and Convention June 22-25, 2017 at the Griffin Gate Marriott Resort in Lexington. All active pharmacist members in attendance are considered delegates. Resolutions, formal statements expressing the opinion, will, or intent of a body of persons, may be submitted by individual members, district organizations, other associations or interests or committees. The most effective resolutions are carefully constructed to use as few words as possible to convey the basic issues and reasons for the stand. All proposed resolutions received prior to May 12, 2017 will be submitted to the KPhA Board of Directors, who will review them and make recommendations to the House of Delegates. The Board reserves the right to edit any proposed resolutions submitted and may, at its discretion and upon its own initiative, develop additional proposed resolutions. The Board will report all resolutions to the House of Delegates. Each resolution will carry with it the Board's action to recommend or not recommend, or with no recommendation. After the Board has considered all submitted resolutions, it will provide those resolutions for publication on the KPhA website (www.kphanet.org). These resolutions will be provided in writing to the Delegates. Following the action of the House of Delegates at the KPhA Annual Meeting, the resolutions adopted will be published on the website and in the next edition of The Kentucky Pharmacist. Submit resolutions to Scott Sisco (ssisco@kphanet.org) or Robert McFalls (rmcfalls@kphanet.org) or via mail to KPhA, 96 C. Michael Davenport Blvd., Frankfort, KY 40601 by May 12, 2017.
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THE KENTUCKY PHARMACIST
Feb. 2017 CE — Bacterial Pneumonia
January/February 2017
Bacterial Pneumonia: An Overview of Classification Criteria and Antibiotic Treatment By: Madison E. Vaughn, PharmD Candidate; Kayla N. Kreft, PharmD; Holly L. Byrnes, PharmD, BCPS; Julie Harting, PharmD – Sullivan University College of Pharmacy There are no financial relationships that could be perceived as real or apparent conflicts of interest. Universal Activity # 0143-0000-17-002-H01-P&T 1.0 Contact Hour (0.1 CEUs) Expires 1/5/2020 Goals: To assist pharmacists in understanding the recent changes to the classification of bacterial pneumonia and the recommended antibiotic treatment regimens. Learning Objectives
KPERF offers all CE articles to members online at www.kphanet.org
At the conclusion of this Knowledge-based article, the reader should be able to: 1. Summarize the 2007 IDSA/ATS consensus guidelines for the management of community-acquired pneumonia; (P&T) 2. Describe recent changes to the classification of bacterial pneumonia; (P&T) 3. Summarize the 2016 IDSA/ATS clinical practice guidelines for the management of hospital-acquired and ventilatorassociated pneumonia; and, (P&T) 4. Apply the 2007 CAP and 2016 HAP/VAP guidelines to the treatment of bacterial pneumonia. (P) Introduction Pneumonia is an infection of the lung that can be caused by bacteria, viruses or fungi. Despite advances in preventive measures, pneumonia is still a common cause of morbidity and mortality.1 Pneumonia is the leading cause of death worldwide in children under 5 years of age.2 In the United States, pneumonia is the most common hospitalacquired infection3 and the most common cause of sepsis and septic shock.2 Due to this potential severity, it is highly important to treat patients appropriately and quickly to prevent complications and mortality.4-6
factors to drive the recommendations for empiric therapy, expanded emphasis on the importance of local antibiograms, less emphasis on scoring systems and procalcitonin for determining presence of illness, removal of early vs. late categories for HAP/VAP, new recommendations for duration of therapy and utilization of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The GRADE system allows the guidelines to be more flexible and leaves treatment judgment up to the provider.
This article aims to review the major points of both the community-acquired and hospital-acquired/ventilatorThe Infectious Diseases Society of America (IDSA) and the associated guidelines, with additional attention given to the American Thoracic Society (ATS) collaborate on the develrecent update. opment of consensus guidelines on the management of pneumonia. These guidelines are divided into community- Community Acquired Pneumonia (CAP) acquired pneumonia (CAP),7 which was last updated in CAP is an infection of the lower respiratory tract that is ac2007, and hospital-acquired/ventilator-associated pneumoquired outside of a healthcare setting. Signs and symptoms nia (HAP/VAP),8 which underwent a recent update pubsuch as fever, shortness of breath, cough, tachypnea, leulished in July 2016. kocytosis or leukopenia indicate possible pneumonia. A The 2016 hospital-acquired/ventilator-associated guidechest X-ray or computed tomography (CT) scan must conlines detailed several noteworthy changes, the most promi- firm the presence of an infiltrate for the patient’s pneumonent of which is the complete removal of healthcarenia to be diagnosed, regardless of microbiological testing. associated pneumonia (HCAP) from the guidelines. The Infiltrates might not always be apparent early in the course rationale for this removal is further explained in the of infection. If a patient is hospitalized and is suspected of healthcare-associated pneumonia section. Other notewor- having pneumonia, even though initial chest radiography thy changes include the following: updated specific risk findings are negative, it may be reasonable to presumptive22
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ly treat with antibiotics and repeat the imaging in 24 to 48 hours.
Table 1. Criteria for classifying severe community-acquire pneumonia
The most common pathogens associated with CAP are Streptococcus pneumoniae, atypical bacteria (Chlamydia pneumoniae, Mycoplasma pneumoniae and Legionella species) and Haemophilus influenzae. However, newer data since the 2007 guidelines describe how viral respiratory tract infections are being acknowledged as common etiologies of CAP, credited to the emergence of new diagnostic technologies. Human rhinovirus and influenza are the two most common viral pathogens recovered from inpatients admitted with CAP.9
Major Criteria Septic shock requiring vasopressors Invasive mechanical ventilation
When developing a treatment plan and determining the location of treatment for CAP (inpatient vs. outpatient), infection severity plays a major role. CURB-65 and Pneumonia Severity Index (PSI) are two different tools that can be used to determine severity of infection. One severity tool is not preferred over the other according to the guidelines, however both tools have respective pros and cons. CURB-65 contains less criteria and is easily remembered but has not been as heavily tested in studies as PSI, which involves a longer process. CURB-65 scores are calculated by receiving one point for each of the following five criteria: confusion (new-onset disorientation to person, place or time), uremia (BUN level >19 mg/dL), elevated respiratory rate (³30 breaths/min), low blood pressure (systolic <90 mm Hg or diastolic £60 mm Hg) and age ³65 years. A CURB-65 score of ³2 indicates that inpatient treatment is recommended. PSI stratifies CAP patients into five mortality risk classes based on demographics, comorbidities, findings on physical examination and laboratory findings. Risk classes l and ll indicate outpatient treatment, risk class lll recommends the patient be placed in an observational unit or have a short hospitalization, while risk classes lV and V indicate inpatient treatment.10 Intensive care unit (ICU) resources may be limited; therefore, it is extremely important that these resources are reserved for high-mortality-risk patients. Due to the importance of conserving ICU resources, the CAP guidelines utilize specific criteria to determine the need for ICU treatment (Table 1). Having ≥1 of the two major criteria for severe CAP or ≥3 of the minor criteria for severe CAP requires direct admission into the ICU.
Minor Criteria
New-onset confusion/disorientation Uremia (BUN ³20 mg/dL) Respiratory rate ³30 breaths/min PaO2/FiO2 ratio 250 Hypotension requiring aggressive fluid resuscitation Multilobar infiltrates Leukopenia (White Blood Cells <4,000 cells/mm 3) Thrombocytopenia (platelets <100,000 cells/mm 3) Hypothermia (core body temperature <36°C)
A patient with at least one of the Major Criteria for severe CAP or at least three of the Minor Criteria for severe CAP requires direct admission into the ICU.
CAP caused by these organisms as this testing may allow for early de-escalation of empiric therapy. A list of clinical indications for additional diagnostic tests (Table 3) was developed on the basis of two criteria: when the result is likely to modify individual antibiotic treatment and when the test is likely to have the highest yield. The additional diagnostic testing that can be performed include blood culture, sputum culture, Legionella urinary antigen test (UAT) and pneumococcal UAT. The recommended empiric treatment agents for MRSA and Pseudomonas coverage when indicated can be found in Table 2. Treatment duration for CAP is a minimum of 5 days. If the patient remains febrile for 2-3 days or fails to meet more than one sign of clinical stability (Table 4), a longer treatment duration may be indicated. In clinical trials, the median duration of therapy in patients with CAP is 7 days.11 Healthcare-Associated Pneumonia (HCAP)
Before the 2016 update, the hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) guidelines were last updated in 2005. The primary difference between the 2005 guidelines and the 2016 update is the removal of healthcare-associated pneumonia (HCAP). The concept of HCAP was created with the assumption that The most common pathogens of CAP were considered patients in the community with frequent nosocomial expowhen creating the empiric antibiotic treatment for both inpa- sure were believed to be at higher risk for multidrug retient and outpatient CAP. Table 2 provides guidelinesistant organisms. HCAP criteria was defined as: hospitalrecommended empiric treatment regimens. Methicillinized for ≥2 days within 90 days of current infection, resided resistant Staphylococcus aureus (MRSA) and Pseudomoin a nursing home or long-term care facility, received IV nas aeruginosa rarely cause CAP and require additional antibiotic therapy within 30 days, received chemotherapy empiric antibiotics when suspected. Additional diagnostic within 30 days, received wound care within the past 30 testing may be indicated for patients suspected of having days or attended a hemodialysis clinic. The empiric treat23
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Table 2. Empiric antibiotic treatment for community-acquired pneumonia Outpatient Inpatient Previously healthy and no antimicrobial therapy in previous 3 months Macrolide OR Doxycycline
Comorbiditiesa or antimicrobial therapy in previous 3 months Respiratory Fluoroquinoloneb
Respiratory Fluoroquinoloneb
b-lactame + Azithromycin
OR
OR
OR
c
b-lactam + macrolide
Non-ICU
ICU
d
b-lactame + Respiratory Fluoroquinoloneb
b-lactam + macrolide
Penicillin Allergy: Respiratory Fluoroquinoloneb + Aztreonam MRSA Coverage Indicated: vancomycin OR linezolid Pseudomonas Coverage Indicated: Antipseudomonal b-lactamf + ciprofloxacin or levofloxacin OR Antipseudomonal b-lactamf + aminoglycoside + azithromycin OR
a
Antipseudomonal b-lactamf + aminoglycoside + anti-pneumococcal fluoroquinolone
Comorbidities including chronic lung, heart, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; and immunosuppression b
Respiratory Fluoroquinolones (Moxifloxacin, Levofloxacin and Gemifloxacin)
c
b-lactam considerations for outpatient treatment (Amoxicillin-Clavulanate, Cefpodoxime, Cefuroxime)
ment for HCAP included one antiMRSA antibiotic plus two antipseudomonal antibiotics from different classes. Since the 2005 HAP/VAP guidelines, studies have shown that many patients classified as having HCAP were not found to be at higher risk for multidrug resistant organisms, resulting in overprescribing of unnecessary broad spectrum regimens. A meta-analysis composed of 24 studies, which encompassed 22,456 patients, compared the frequency of multidrug resistant organisms in patients diagnosed with HCAP to patients diagnosed with CAP. Patients diagnosed with HCAP were associated with higher rates of multidrug resistant organisms; however it was revealed that the risk factors for HCAP were not specific enough to truly determine which patients were at higher risk for multidrug resistant organisms. It was believed that the mortalities documented in the HCAP group were more likely associated with comorbidities and age than multidrug resistant organisms.12
The updated guidelines now recommend that patients receive treatment for multidrug resistant e organisms only if proven risk facb-lactam considerations for ICU treatment (Cefotaxime, Ceftriaxone or AmpicillinSulbactam) tors for multidrug resistant organf Antipseudomonal b-lactam (piperacillin-tazobactam, cefepime, imipenem or meropenem) isms are present (Table 5). The 2016 HAP/VAP guidelines also Table 3: Indications for more extensive diagnostic testing mention that HCAP might be considered as a separate ICU admission entity in the upcoming update to the CAP guidelines. Failure of out-patient antibiotic therapy Since patients with HCAP originate from the communi Travel within the last 2 weeksa ty and are generally treated in emergency depart Recent alcohol abuse ments, it is believed that if HCAP needs to be a sepa Leukopenia rate entity, it would be more appropriate to include it within the CAP guidelines. Chronic severe liver disease d
b-lactam considerations for non-ICU inpatient treatment (Cefotaxime, Ceftriaxone or Ampicillin)
Asplenia
Severe obstructive/structural lung disease
Pleural effusion
Positive legionella urine antigen test result
a
Hospital-Acquired Pneumonia (HAP) and Ventilator -Associated Pneumonia (VAP) HAP is defined as pneumonia that presents at least 48 hours following hospitalization and VAP is defined as pneumonia that presents at least 48 hours after intubation. In order to diagnose HAP/VAP, the 2016 HAP/
Positive pneumococcal urine antigen test result Southeast, East Asia and southwestern United States
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Temperature 37.8°C
Heart rate 100 beats/min
Respiratory rate 24 breaths/min Systolic blood pressure ³90 mmHg Arterial oxygen saturation ³90% or pO2 ³60 mmHg on room air Ability to take oral medication Baseline mental status for patient
January/February 2017 Table 5: Risk factors for multidrug-resistant pathogens Hospital-acquired Pneumonia
Previous IV antibiotic use within 90 days
Ventilator-associated Pneumonia
Previous IV antibiotic use within 90 days
Septic shock
Acute respiratory distress syndrome prior to VAP onset
≥5 days of hospitalization prior to VAP onset
Acute renal replacement therapy prior to VAP onset VAP guidelines recommend collecting noninvasive respiratory samples such as spontaneous expectoration, sputum inducceived IV antibiotics in the past 90 days or if a patient has tion, nasotracheal suctioning and endotracheal aspiration. structural lung disease such as bronchiectasis or cystic fibrosis. The guidelines also recommend that all hospitals apply data from a local antibiogram. Ideally, antibiograms should be de- Empiric Therapy of VAP veloped that are specific to a hospital’s intensive care unit, An empiric antibiotic treatment regimen for patients suspected HAP patients and VAP patients. It may not be feasible to deof having VAP, similarly to HAP, should always include covervelop unit-specific antibiograms within certain healthcare setage for S. aureus, P. aeruginosa and other gram-negative tings due to reasons such as limited exposure or surveillance bacilli. The antimicrobial agents recommended for the empiric of patients with HAP/VAP. In those situations, it is recomtreatment of VAP can be found in Table 7. mended to refer to the most recent local antibiogram availaAn antibiotic with MRSA coverage only should be included in ble. the empiric treatment of VAP in patients with any of the folEmpiric Therapy of HAP lowing: a risk factor for multidrug-resistant pathogens (Table An empiric antibiotic treatment regimen for patients suspected 5), receiving treatment in a ICU where >10-20 percent of the of having HAP should always include coverage for S. aureus, S. aureus isolates are methicillin resistant or receiving treatP. aeruginosa and other gram-negative bacilli. When determent in a unit where the prevalence is not known. mining the proper empiric treatment for HAP, it is important to It is suggested to include two anti-pseudomonas antimicrobial understand which patients are at higher risk of mortality and the factors that warrant additional empiric antimicrobial cover- agents from different classes in the empiric treatment of VAP age (Table 5). The recommended empiric treatment for HAP if the patient has risk factors for multidrug-resistant pathogens, has structural lung disease, is being treated in a ICU can be found in Table 6. where >10 percent of the gram-negative isolates are resistant Patients that are at higher risk of mortality or acquiring MRSA to the antimicrobial being considered for empiric monotherapy should receive an antibiotic with MRSA coverage as part of or in facilities where susceptibility rates are not known for the their initial empiric therapy. The risk factors for mortality inantimicrobial agent being considered. clude: septic shock and pneumonia requiring ventilation support. The risk factors for MRSA infection include: IV antibiotics In general, aminoglycosides and colistin should be avoided in the treatment of HAP/VAP, unless the other recommended in the past 90 days, history of previous MRSA infection and hospitalization at facility where >20 percent of their S. aureus antimicrobial agents with sufficient gram-negative coverage isolates are methicillin-resistant or frequency of MRSA is not are not a possibility. Aminoglycosides are not recommended as monotherapy when alternative agents are available due to known. If MRSA coverage is indicated, the guideline recomtheir weak lung penetration abilities and enhanced risk of otomended agents with MRSA coverage are vancomycin and toxicity and nephrotoxicity. Colistin is not a preferred agent linezolid. due to adverse effects such as Clostridium difficile, the potenThe other considerations for empiric coverage of HAP is the tial for antibiotic resistance and high cost. need for two anti-pseudomonal antimicrobial agents. This is an important difference from previous guidelines that recom- Pathogen-Specific Therapy mended that empiric coverage always include two antiThe 2016 HAP/VAP guidelines include pathogen-specific pseudomonal agents. The current guidelines only recommend therapy recommendations for MRSA, P. aeruginosa, extendtwo agents when: a patient has a high risk of mortality, reed spectrum beta-lactamase (ESBL) producing gram-
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Table 6: Empiric antibiotic treatment for hospital-acquired pneumonia No risk factors for mortalitya No risk factors for mortalitya High risk of mortalitya, IV and no risk factors for with risk factors for MRSA antibiotics in the past 90 MRSA infectionb infectionb days or structural lung diseasec One of the following: One of the following: Two of the following (avoid two b-lactams): Piperacillin-tazobactam 4.5g Piperacillin-tazobactam 4.5g IV q6h IV q6h Piperacillin-tazobactam 4.5g IV q6h OR OR OR Cefepime2g IV q8h Cefepime or Ceftazidime 2g IV q8h Cefepime or Ceftrazidime OR 2g IV q8h OR Levofloxacin 750mg IV OR q24h Levofloxacin 750 mg IV q24h Levofloxacin 750mg IV OR Ciprofloxacin 400mg IV q8h q24h Imipenem 500mg IV q6h OR Ciprofloxacin 400mg IV q8h Meropenem 1g IV q8h Imipenem 500mg IV q6h Meropenem 1g IV q8h
OR
OR
Imipenem 500mg IV q6h
Aztreonam 2g IV q8h
Meropenem 1g IV q8h OR Amikacin15-20mg IV q24h Gentamicin 5-7mg/kg IV q24h Tobramycin 5-7mg/kg IV q24h OR
PLUS
Aztreonam 2g IV q8h PLUS
Vancomycind
Vancomycind
OR
OR
Linezolid 600mg IV q12h
Linezolid 600mg IV q12h
a
Risk factors for mortality: Septic shock, pneumonia requiring ventilator support Risk factors for MRSA infection: IV antibiotics in the past 90 days, history of previous MRSA infection and hospitalization at facility where >20 percent of their S. aureus isolates are methicillin-resistant or frequency of MRSA is not known c Structural lung disease (i.e. bronchiectasis, cystic fibrosis) d Vancomycin 15mg/kg IV q8-12h with goal to target 15-20mg/mL trough (for severe illness, consider a loading dose of 25-30mg/kg) b
negative bacilli, Acinetobacter species and carbapenemresistant pathogens, when positive culture results are attained.
It is recommended that antimicrobial susceptibilities guide antibiotic therapy selection for P. aeruginosa HAP/VAP. For patients diagnosed with HAP/VAP caused by P. aeruginosa that remain in septic shock, require ventilator support or the results of the antimicrobial susceptibility test are not available, it is recommended to utilize two anti-pseudomonal agents from two different antimicrobial classes. Once a patient in septic shock receives antibiotics that the isolate is susceptible to and the septic shock resolves, de -escalation to one antipseudomonal antibiotic is recommended. If a patient with HAP/VAP due to P. aeruginosa is not currently in septic shock or requiring ventilator support, it is recommended to treat with only one anti-pseudomonal antibiotic. It is important to select antibiotics that the P. aeruginosa isolate is susceptible to, excluding aminoglycosides for reasons previously stated. For patients with HAP/VAP caused by ESBL producing gram-negative bacilli, it is recommended that antibiotic therapy be guided by the antimicrobial susceptibilities and patient factors such as, co-morbidities, allergies and
possible side effects.
If a patient presents with HAP/VAP triggered by an Acinetobacter species, it is recommended that either a carbapenem It is recommended that HAP/VAP due to MRSA be treated or ampicillin/sulbactam is used for treatment if the isolate is with either vancomycin or linezolid. Patient-specific factors susceptible to these antimicrobial agents. If the Acinetobacsuch as renal function, blood cell counts, concomitant use ter species is only susceptible to polymyxins, it is recomof serotonin-reuptake inhibitors and cost should be taken into consideration when choosing between vancomycin and mended that colistin or polymyxin B be used with the addition of inhaled colistin as an adjunctive therapy. linezolid. 26
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Table 7: Recommended antimicrobial agents for the empiric treatment of ventilator-associated pneumonia Antibiotics with MRSA coveragea Vancomycin 15mg/kg IV q8-12h
b-lactam based antibiotics with Pseudomonas coverageb Piperacillin-tazobactam 4.5g IV q6h
Non b-lactam based antibiotics with Pseudomonas coverageb Ciprofloxacin 400mg IV q8h
(consider a loading dose of 25-30mg/kg with severe illness)
OR
Levofloxacin 750mg IV q24h
Cefepime 2g IV q8h
OR
Ceftazidime 2g IV q8h
Amikacin 15-20mg/kg IV q24h
OR
Gentamicin 5-7mg/kg IV q24h
Imipenem 500mg IV q6h
Tobramycin 5-7mg/kg IV q24h
Meropenem 1g IV q8h
OR
OR
Colistin 5mg/kg IV loading dose followed 2.5mg x (1.5 x CrCl + 30) IV q12h
OR Linezolid 600mg IV q12h
Aztreonam 2g IV q8h
Polymyxin B 2.5-3mg/kg/d divided into two daily IV doses a
An antibiotic with MRSA coverage should be included in the empiric treatment of VAP if the patient has a risk factor for multidrugresistant pathogens, if the patient is being treated in a ICU where >10-20 percent of the S. aureus isolates are methicillin resistant or if the patient is being treated in a unit where the prevalence is not known. b
It is suggested to include two anti-pseudomonas antimicrobial agents from different classes in the empiric treatment of VAP if the patient has risk factors for multidrug-resistant pathogens, has structural lung disease, is being treated in a ICU where >10 percent of the gram-negative isolates are resistant to the antimicrobial being considered for empiric monotherapy or in facilities where susceptibility rates are not known for the antimicrobial agent being considered.
Lastly, if a patient with HAP/VAP caused by a carbapenemresistant pathogen is only susceptible to polymyxins, it is recommended that colistin or polymyxin B be used with the addition of inhaled colistin as an adjunctive therapy. Duration of Therapy The updated guidelines recommend a shorter antibiotic course of 7 days for both HAP and VAP, regardless of microbial etiology. This recommendation was determined by the results gathered from two systematic reviews and an observational study. One of the systematic reviews included six randomized trials, which encompassed 508 patients with HAP/VAP and compared fixed durations of antimicrobial therapy. Patients receiving shorter courses of antibiotic therapy (7 to 8 days) showed reductions in recurrent VAP due to multi-drug resistant pathogens. When compared to longer courses of antibiotic therapy (10-15 days), there were no differences in length of hospital stay, mortality, treatment failure or duration of mechanical ventilation.13 If possible, antibiotic de-escalation also is recommended to avoid unnecessary side effects and to avoid contributing to future antibiotic resistance. There are situations that exist where a shorter or longer duration of therapy may be necessary based on the patient’s clinical improvement. The guidelines leave the definition of clinical improvement up to the clinician’s discretion. Monitoring The 2007 CAP and 2016 HAP/VAP guidelines only briefly 27
mention the monitoring of antimicrobials for efficacy, but as pharmacists, it is our responsibility to be aware of monitoring for both efficacy and safety when administering antimicrobials. The following paragraphs briefly describe monitoring considerations for the drug classes indicated for the treatment of pneumonia. All antimicrobials should be monitored for efficacy by monitoring the patient’s clinical response to the medication. A couple drug classes require further monitoring by the pharmacist. Aminoglycosides and vancomycin require pharmacokinetic dosing and monitoring to increase the probability of achieving serum drug concentrations within therapeutic range and the possibility of reducing cost.14 This also allows for safety monitoring as supratherapeutic levels increase the risk for adverse effects of these medications. When administering many antimicrobials, a major monitoring parameter is renal function through clinical markers such as serum creatinine and blood urea nitrogen (BUN). Many antimicrobials including vancomycin, colistin, polymyxin B, fluoroquinolones and all b-lactams except ceftriaxone and nafcillin requires some form of renal dose adjustment.15 For a couple antimicrobial classes, it is also highly important to monitor the QT interval on the electrocardiogram (ECG). Fluoroquinolones and macrolides both have the potential to prolong the QT interval. Prolonging the QT interval could produce a ventricular arrhythmia which could lead to sudden cardiac death.16 When a patient is on these medications, it is
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also important to monitor for other medications and electrolyte abnormalities that could enhance a patient’s risk of QT prolongation.
tions Program Healthcare-Associated Infections Antimicrobial Use Prevalence Survey Team. Survey of health care-associated infections. N Engl J Med 2014; 370:2542–3.
Conclusion
4. Kang C-I, Kim S-H, Park WB, et al. Bloodstream InfecIn conclusion, the recent update of the HAP/VAP guidelines tions Caused by Antibiotic-Resistant Gram-Negative made several significant changes, with the most noteworBacilli: Risk Factors for Mortality and Impact of Inapprothy being the removal of HCAP from the guidelines, leaving priate Initial Antimicrobial Therapy on Outcome. Antimithis topic to be addressed in the next CAP guideline upcrobial Agents and Chemotherapy. 2005;49(2):760date. The update to the CAP guidelines is currently in pro766. doi:10.1128/aac.49.2.760-766.2005. gress. It will be important to be familiar with the current CAP guidelines in anticipation of the guideline update 5. Kim S-H, Park W-B, Lee C-S, et al. Outcome of inapwhich may bring HCAP back into the clinical picture. propriate empirical antibiotic therapy in patients with Staphylococcus aureus bacteraemia: analytical strateIt is important to understand that these updated HAP/VAP gy using propensity scores. Clinical Microbiology and guidelines focus on specific risk factors and allow these risk Infection. 2006;12(1):13-21. doi:10.1111/j.1469factors to drive the decision for appropriate empiric therapy 0691.2005.01294.x. recommendations. Within these risk factors, the IDSA and ATS include antibiogram factors. This will make it increas- 6. Ramphal R. Importance of Adequate Initial Antimicrobiingly important for hospitals to keep an up-to-date antibioal Therapy. Chemotherapy. 2005;51(4):171-176. gram in order to allow their clinicians to practice in accorddoi:10.1159/000086574. ance with the guidelines. The other prominent change is 7. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious the shortened duration of therapy for all HAP/VAP patients, Diseases Society of America/American Thoracic Sociewhich may potentially shorten duration of hospital stays. ty Consensus Guidelines on the Management of ComThe pharmacy technician plays a vital role in the pharmacy, munity-Acquired Pneumonia in Adults. Clin Infect Dis. and therefore should be aware of the current guideline 2007;44(2). doi:10.1086/511159. changes in the treatment of pneumonia. A pharmacy tech8. Kalil AC, Metersky ML, Klompas M, et al. Management nician’s main role in the treatment of pneumonia is being of Adults With Hospital-acquired and Ventilatoron the front lines of helping prevent medication errors that associated Pneumonia: 2016 Clinical Practice Guidecould be detrimental to the patient’s health and safety. Enlines by the Infectious Diseases Society of America and suring that the patient receives the right formulation, dose the American Thoracic Society. Clin Infect Dis. 2016;63 and strength of a medication is vital to ensuring appropriate (5). doi:10.1093/cid/ciw353. care for the patient. 9. Jain S, Self WH, Wunderick RG, Fakhran S, Balk R, The 2016 HAP/VAP clinical guidelines included data Bramley AM, et al. Community-acquired pneumonia through November 2015. New data will continue to be pubrequiring hospitalization among U.S. adults. N Engl J lished in this area to assist clinicians to make the most apMed. 2015. 373(5):415-427. propriate choice in the treatment of bacterial pneumonia. As pharmacists, it is our responsibility to stay up-to-date on 10. The ohio state university college of medicine community-acquired pneumonia. Ohio State Wexner Medical new evidence and guidelines to ensure our patients are Center. https://internalmedicine.osu.edu/pulmonary/ receiving safe and appropriate drug therapy. cap/index.cfm. Published: unknown; accessed 2016 References Oct 24. 1. Pneumonia. Centers for Disease Control and Preven11. Li DX, Ferrada MA, Avdic E, Tamma PD, Cosgrove SE. tion. http://www.cdc.gov/nchs/fastats/pneumonia.htm. Sustained impact of an antibiotic stewardship intervenPublished June 2016. Accessed Nov. 5, 2016. tion for community-acquired pneumonia. Infect Control 2. Top 20 Pneumonia Facts—2015. American Thoracic Hosp Epidemiol. 2016;37:1243-1246. Society. https://www.thoracic.org/patients/patient12. Chalmer JD, Rother C, Salih W, Ewig S. Healthcareresources/resources/top-pneumonia-facts.pdf. Acassociated pneumonia does not accurately identify pocessed Nov. 5, 2016. tentially resistant pathogens: a systematic review and 3. Magill SS, Edwards JR, Fridkin SK; Emerging Infecmeta-analysis. Clin Infect Dis. 2014;58(3):330-339.
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13. Pugh R, Grant C, Cooke RP, Dempsey G. Short-course versus prolonged-course antibiotic therapy for hospitalacquired pneumonia in critically ill adults. Co-chrane Database Syst Rev 2015; 8:Cd007577.
dations for adult inpatients. The Johns Hopkins Hospital Antimicrobial Stewardship Program. Published 2015; accessed 2016 Oct 7.
16. D’lgnazio J, Camere MA, Lewis DE, et al. Novel, single14. Bond CA, Raehl CL. Clinical and economic outcomes of dose microsphere formulation of azithromycin versus 7pharmacist-managed aminoglycoside or vancomycin day levofloxacin therapy for treatment of mild to modertherapy. Am J Health Syst Pharm 2005; 62:1596. ate community-acquired pneumonia in adults. Antimicrob Agents Chemother 2005; 49:4035. 15. 2015-2016 Antibiotic guidelines: treatment recommen-
February 2016 — Bacterial Pneumonia: An Overview of Classification Criteria and Antibiotic Treatment 1. What is required for the diagnosis of communityacquired pneumonia? A. Culture results positive for bacteria B. Elevated serum biomarker levels C. Presence of infiltrate on chest X-ray D. Positive signs/symptoms of pneumonia 2. Given the following patient information and labs, calculate the patient’s CURB-65 score to help determine location of CAP treatment. Age 32, respiratory rate = 35 bpm, BUN = 15 mg/dL, negative signs of confusion, blood pressure = 100/55 and white blood cells = 16,000 cells/mm3. A. CURB-65 score of 0 – outpatient treatment B. CURB-65 score of 1 – outpatient treatment C. CURB-65 score of 2 – inpatient treatment D. CURB-65 score of 3 – inpatient treatment
6. Which situation warrants the use of two anti-pseudomonal agents when empirically treating VAP? A. Patient’s antimicrobial susceptibility test results are not available B. Patient history of cirrhosis and diabetes C. Patient received chemotherapy in the past 90 days D. Patient’s white blood cell count >25,000 cells/mm3 7. What is the recommended empiric antibiotic treatment for HAP if the patient has no risk factors for mortality, MRSA or pseudomonas? A. Two anti-pseudomonal agents from different classes and one agent with MRSA coverage B. Two anti-pseudomonal agents from different classes C. One anti-pseudomonal agent and one agent with MRSA coverage D. One anti-pseudomonal agent with MSSA coverage
3. A patient with a history of Type 2 Diabetes Mellitus is diagnosed with CAP and is calculated to have a CURB-65 score of 1. Patient has an allergy to Bactrim. Based on the provided information, which empiric antimicrobial therapy regimen is most appropriate? A. Azithromycin + Amoxicillin/Clavulanate B. Azithromycin C. Doxycycline D. Amoxicillin/Clavulanate + Levofloxacin
8. Which class of antibiotics should be avoided as monotherapy, when treating VAP due to their weak lung penetration and enhanced risk of adverse effects? A. Fluoroquinolones B. Aminoglycosides C. Carbapenems D. Macrolides
4. Which classification of pneumonia is no longer recognized in the new update to the pneumonia guidelines? A. Community-acquired pneumonia B. Healthcare-associated pneumonia C. Hospital-acquired pneumonia D. Ventilator-associated pneumonia
9. According to the 2016 HAP/VAP guidelines, what is considered a risk factor for multidrug-resistant pathogens? A. IV antibiotic use within past 90 days B. Wound care within past 30 days C. Chemotherapy within past 30 days D. Resident in a nursing home/long-term care facility
5. A patient is currently receiving empiric treatment with Cefepime 2g Q8H for HAP. Two days after initiating Cefepime, sputum cultures come back positive for Acinetobacter baumannii. Patient is unaware of any drug allergies. Assuming pathogen is susceptible to all antimicrobials with coverage, what changes would you make to their current therapy? A. Continue current antimicrobial therapy B. Decrease current dose of cefepime to 1g Q8H C. Discontinue cefepime and initiate Meropenem D. Discontinue cefepime and initiate Levofloxacin
10. A patient recently discharged from a hospital is readmitted and diagnosed with HAP. During the patient’s previous admission, no IV antibiotics were given. The patient is currently being treated at a facility where the frequency of MRSA is unknown. Based on the provided information, which of the follow empiric antimicrobial therapy regimen is most appropriate for the patient? A. Piperacillin-tazobactam B. Piperacillin-tazobactam + Vancomycin C. Levofloxaxin + Meropenem D. Cefepime + Gentamicin + Vancomycin 29
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This activity is a FREE service to members of the Kentucky Pharmacists Association. The fee for non-members is $30. Mail completed forms to: KPERF, 96 C Michael Davenport Blvd., Frankfort, KY 40601. Credit will be applied to your CPE Monitor Profile. Expiration Date: January 5, 2020 Successful Completion: Score of 80% will result in 1.0 contact hour or .1 CEUs. Participants who score less than 80% will be notified and permitted one re-examination. TECHNICIANS ANSWER SHEET. February 2016 — Bacterial Pneumonia: An Overview of Classification Criteria and Antibiotic Treatment (1 contact hours) Universal Activity # 0143-0000-17-002-H01-T Name _______________________________________________KY Cert. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C D 6. A B C D
7. A B C D 8. A B C D
9, A B C D 10. A B C D
Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet. Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature ____________________________________________Completion Date___________________________
Personal NABP eProfile ID #_____________________________ Birthdate ____________(MM/DD) PHARMACISTS ANSWER SHEET February 2016 — Bacterial Pneumonia: An Overview of Classification Criteria and Antibiotic Treatment (1 contact hours) Universal Activity # 0143-0000-17-002-H01-P Name ________________________________________________ KY Lic. # __________________________________ Address ______________________________________________Email_____________________________________ PLEASE CIRCLE THE APPROPRIATE ANSWERS: 1. A B C D 3. A B C D 5. A B C D 2. A B C D 4. A B C D 6. A B C D
7. A B C D 8. A B C D
9, A B C D 10. A B C D
Information presented in the activity: Met my educational needs ___Yes ___No Figures and tables were useful ___Yes ___No Achieve the stated objectives ___Yes ___No Posttest was appropriate ___Yes ___No Was well written ___Yes ___No Commercial bias was present ___Yes ___No Is relevant to my practice ___Yes ___No If yes, please explain on a separate sheet. Unmet Objectives:______________________________________________________________________________ I hereby certify that I completed this self-study program independently and without assistance from any other party. Signature ____________________________________________Completion Date___________________________
Personal NABP eProfile ID #_____________________________ Birthdate ___________________(MM/DD) The Kentucky Pharmacy Education & Research Foundation is accredited by The Accreditation Council for Pharmacy Education as a provider of continuing Pharmacy education.
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Quizzes submitted without NABP eProfile ID # and Birthdate will not be accepted.
THE KENTUCKY PHARMACIST
Technician Involvement
January/February 2017
Technician Involvement: A crucial piece of moving the profession forward Commentary by KPhA Past President and current Board Director Richard Slone Over the next few years, the profession of pharmacy must change in order to survive. The old model of dispensing medications will not be enough, especially for independent pharmacies, to keep the doors open. Part of that change is going to have to involve a greater role for our pharmacy technicians, and KPhA is poised to be the leader in providing the education for these new tasks. But, to involve the technicians, we must engage pharmacy technicians in Kentucky and encourage membership in KPhA. KPhA boasts a technician membership of just over 100. There are thousands of technicians registered to work in pharmacies in Kentucky, and 4,669 of those technicians are certified through PTCB and need continuing education to recertify. KPhA offers its members free CE that is approved for technicians as well as pharmacists through this journal. Technician membership is $50 per year. The Association also offers live CE at the Annual Meeting and the Legislative Conference, some of it directly for technicians.
As pharmacists, we must encourage our technicians to take advantage of these opportunities. We must allow them to get involved and actively participate in association activities. Encouraging KPhA membership for technicians is the first step, but the next step has to be encouraging those new members to get involved and educate themselves about what is happening in the pharmacy profession. And it takes pharmacist supervisors who will give technicians the time to be involved. Each year, the KPhA Technician Academy develops Technician specific programs for the Annual Meeting, but the same technicians come each year. The Academy needs more involvement from technicians from all areas of pharmacy to succeed in its mission to unite the pharmacy technicians throughout the Commonwealth to have one voice toward the advancement of our profession. And technicians must seek out opportunities. Ask your pharmacists what you can do to help. Attend meetings to learn about advances in pharmacy practice. Read the emails sent out by the association to keep up with national and state issues that will affect the profession. It takes all of us to deliver the best care possible for our patients: Pharmacists, technicians, cashiers. Weâ&#x20AC;&#x2122;re all in this together. And until we encourage more involvement from all of our members and potential members, we wonâ&#x20AC;&#x2122;t have the tools to innovate and develop new ways to care for our patients.
Make plans now to network with your colleagues, learn about the latest advances in the profession and recognize very deserving members.
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THE KENTUCKY PHARMACIST
KPhA New and Returning Members
January/February 2017
KPhA Welcomes New and Renewing Members Nov. â&#x20AC;&#x201D; Dec. 2016 Jamal Aboulhosn Louisville
William E. Clark Collierville, Tenn.
Michael Glenn Downs Lexington
John Bryan Anneken Edgewood
Jared Clay Cole Owensboro
Paul Easley Fisherville
Samuel T. Armes Crossville, Tenn.
Bonnie K. Collins Paris
Anna Eiler Louisville
Paul E. Arthur Huntington, W. Virg.
Heather Brooke Collins London
Suzanne Epley Russellville
Lisa K. Babb Guston
Stephanie Sue Collins Corbin
William Farmer Henderson
Keenan Charles Baker Beattyville
George M. Combs Louisville
Martha J. Ford Fort Thomas
To YOU, To YOUR Patients To YOUR Profession!
Verlon Banks Whitesburg
Charlotte Cornett London
Jason Fox Louisville
Peter W. Hovis Louisville
Holly A. Barber Central City
Hannah Marie Couch Lexington
Tom G. Frazier Salyersville
Taryn Howell Hagerhill
Jennifer Barker Morehead
Robert E. Cull Owenton
Aaron Gabbard Booneville
Travis Hudnall Smiths Grove
Susan R. Barrett Booneville
Dan Moore Daffron Monticello
Milton E. Gardner Jeffersontown
Melissa Hudson Villa Hills
Thomas M. Beringer Sparta
Lysette Daniels Smiths Grove
Eric T. Gibbs Corbin
Ricky Jackson Louisville
Kaleb Blair Whitesburg
Matthew Daniels Smiths Grove
Amy L. Glaser Alexandria
Stephanie Johnson Hagerhill
Diana Frances Bowles Sonora
Pamela Decker-Meadows Cynthiana
Robert Haney Bedford
Frederick Johnston Georgetown
Brenda G. Brewer Stanton
Alfred L. Diebold Louisville
Carol Sharpe Harper Louisville
Linda Johnston Georgetown
Jimmy W. Buchanan Lexington
Brad Doering Florence
Clara Herrell Lexington
Leigh Ann Keeton Flatwoods
Michael A. Burleson Lexington
Walter J. Doll Lexington
Jennifer Hibbs Louisville
Dhaval Kotak Oak Forest, Ill.
Phillip Ryan Cassaday Bowling Green
Brenda Lee Dooley Booneville
Amanda Holder Bowling Green
Don Kupper Louisville
Timothy P. Castagno Louisville
Jacob Dotson Grayson
Marylou Hoskins Owensboro
Sheila Diane Lee Simpsonville
Terri L. Chism Brandenburg
Donald Kenneth Dove Winchester
Marylou S. Hoskins Jr. Hawesville
Savannah Leigh Lindsey Glasgow
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MEMBERSHIP MATTERS:
THE KENTUCKY PHARMACIST
KPhA New and Returning Members
January/February 2017
Robert Little Berea
Angela Onkst Louisville
Amanda Louis Shimfessel Lexington
Laura Beth Wells Lexington
John Lutz Louisville
Chris Palutis Richmond
Stacie M. Silvers Pendleton
Sara Wells Gilbertsville
Calvin Lynn Manis Barbourville
Consuelo Palutis Richmond
Jamie R. Smith Booneville
Sandy Wethington Liberty
Craig Martin Georgetown
Duane W. Parsons Richmond
Jessica R. Smith Booneville
Jerrold White Russellville
Ronald D. McClish Simpsonville
Willie Patton Grayson
Lois Smith Blackey
Amy N. Wilder Booneville
Thomas McConnell Kuttawa
Mohan Petchimuthu Louisville
Wayne D. Sparrow Eminence
Lisa Williamson Nicholasville
Clayton Mckinney Shelbyville
David Peyton West Liberty
Larry Spears Dry Ridge
Laura Willoughby Hardinsburg
Parvin Wm. Mischel Kathleen, Ga.
Andrea Potter-Adams Isom
Nancy Stanton Holmes Mill
Christine Windham London
Lindsay Monroe Emmalena
Amanda D. Prine Bowling Green
Sandra Staton Albany
Randy Windham London
Jason Moore Corbin
Herbert Wayne Rice Grand Rivers
Quincy S. Stephenson Providence
Glenn B Wooden Leitchfield
Megan B. Morgan Manchester
Vendonna Rickard Madisonville
Amanda J. Sublett Lexington
Laban Young Louisa
Jerry B. Morris Louisville
Jesse L. Rudd Salyersville
Rebecca Thornbury Grundy, Virg.
Wayne Morris Frankfort
Paul Ruwe Covington
Geanie Umberger West Lafayette, Ind.
Stephanie Myers Louisville
Gregory John Sanders Lexington
Jonathan Gabriel Van Lahr Webster
Vinh Nguyen Louisville
Nicholas J. Schwartz Florence
Frank Vice Flemingsburg
Chasity Brooke Nichols London
Ginger Scott Morgantown, W. Virg.
Lorne Virgin Grayson
Edwin Nickell Eddyville
Terrence Seiter Burlington
Anthony Daren Warford Clay
Paul Nixon Tompkinsville
Susanna Sexton Cornettsville
Susan Weaks Paducah
KPhA Honorary Life Members Ralph Bouvette, Leon Claywell, R. David Cobb, Gloria Doughty, Ann Amerson Mazone, Kenneth Roberts
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Know someone who should be on this list? Ask them to join YOU in supporting OUR KPhA!
THE KENTUCKY PHARMACIST
Online Journal
January/February 2017
NEW in 2017! Two of the six editions of The Kentucky Pharmacist will be published online only. To access the online version, go to www.kphanet.org, click on Communications and then on The Kentucky Pharmacist link. Continuing Education articles are available to KPhA Members electronically under the Education tab on the KPERF CE Articles page (log-in required).
Would you rather receive all of the journals electronically? Email ssisco@kphanet.org to be placed on the KPhA Green List for electronic delivery. Once the journal is published online, you will receive an email with a link to the online version. Contact Scott Sisco at ssisco@kphanet.org or call the KPhA Headquarters at 502-227-2303 with questions. 34
THE KENTUCKY PHARMACIST
KPhA Government Affairs Contribution
January/February 2017
KPhA Government Affairs Contribution Name: _______________________________Pharmacy: _____________________________
Email: ______________________________________________________________ Address: _____________________________________________________________ City: ___________________________________________ State: _________ Zip: ____________ Phone: ________________ Fax: __--_______________ E-Mail: _____________________________ Contribution Amount: $_________ Check ____ (make checks payable to KPhA Government Affairs)
Mail to: Kentucky Pharmacists Association, 96 C Michael Davenport Blvd., Frankfort, KY 40601
KPhA sends email announcements weekly. If you arenâ&#x20AC;&#x2122;t receiving: eNews, Legislative Updates, Grassroots Alerts and other important announcements, send your email address to ssisco@kphanet.org to get on the list.
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THE KENTUCKY PHARMACIST
Pharmacy Policy Issues
January/February 2017
PHARMACY POLICY ISSUES: BARRIERS ASSOCIATED WITH IMPLEMENTATION OF HIV PRE-EXPOSURE PROPHYLAXIS (PREP) Author: Matthew Westling, a native of Hilliard, Ohio, is a PY1 student at the University of Kentucky College of Pharmacy. He completed his pre-professional education at UK as a chemistry major. Issue: I heard a discussion regarding implementation of Pre-Exposure Prophylaxis (PrEP) as an approach to further containing the transmission of HIV. The concept of using PrEP is controversial and generates a great deal of discussion. Several barriers to implementation exist. What is all that about? of the medication averages a cost of Discussion: Since the onset of the HIV/AIDS epidemic in the early approximately $10,000.3 Currently, Have an Idea? 1980s, researchers have been conmost third-party insurers will cover This column is designed to sistently searching for new and innocost of the medication when it is preaddress timely and practical vative ways to slow transmission of scribed for PrEP. However, about 10 issues of interest to pharmacists, HIV in at-risk populations. In 2012, percent of the population in Kentucky pharmacy interns and pharmacy the FDA approved the use of Truvais not covered by public or private technicians with the goal being to da® (emtricitabine/tenofovir) for health insurance and approximately encourage thought, reflection and prophylactic prevention of HIV in un22 percent of the population is on exchange among practitioners. infected individuals who are at a high Medicaid.3, 5 Medicaid can cover the Suggestions regarding topics for risk for acquiring HIV in the hopes of cost of PrEP but the medication must consideration are welcome. Please slowing transmission rates.1 Since be prior-authorized. The program send them to jfink@uky.edu. approval of use of this combination might, however, not cover the full cost medication in prophylaxis, several of the medication and any associated institutions and organizations have widely accepted and laboratory tests and other auxiliary activities needed to endorsed this approach.4 According to the CDC, it is estimaintain on-going medication therapy.3, 9, 7 In some states mated that in 2014 alone, just over 44,000 people were in- such as Washington and New York, strong PrEP assistance fected with HIV. With HIV infection and transmission rates programs have helped mitigate barriers associated with holding relatively constant, the adoption of this antiretroviral cost. In New York alone, following implementation of specifcombination as a prophylactic measure in at-risk communi- ic goals set by the New York State Department of Health, ties such as men who have sex with men (MSM) has recipients of PrEP increased by 338 percent from 2013gained popularity. However, many barriers exist to imple2014.4 mentation including cost, lack of awareness/practitioner Since Kentucky has many statewide issues associated with knowledge and the continuity of care required to maintain HIV transmission, including a high rate of injection drug use prophylactic medication therapy.3 In some instances, proand large areas of rural/impoverished communities where vider attitudes toward this controversial prevention method patients may not be able to access Truvada, some have also pose a barrier to medication acquisition. raised the issue regarding the potential of implementing a In terms of HIV prevalence, Kentucky currently ranks 26th detailed PrEP assistance program or, at a minimum, openamong the 50 states with regard to HIV diagnoses.6 Howev- ing a PrEP dialogue. Additionally, with the continuation of er, since Kentucky has a relatively high injection drug using care that is required for on-going PrEP therapy, concerns (IDU) population, a greater susceptibility to a potentially have been raised surrounding the role of community pharlarge outbreak similar to the episode that occurred in Ausmacists in dispensing and providing medication therapy tin, Ind., in 2015 does exist.8 This raises questions regardmanagement in areas where care might not be easily acing the application of PrEP to populations such as IDU and cessible. As use of PrEP becomes more widespread in the additionally the barriers that are encountered when attempt- U.S., pharmacists may begin to question how they can play ing to prescribe and acquire PrEP in rural and impoverished a more significant role in access and counseling. The next areas. installment will discuss the issue of pharmacists’ and physiAs previously mentioned, one of the main issues associated cians’ attitudes toward PrEP agents and the continuing care with Truvada use as PrEP is its expense. A one year supply required to maintain on-going therapy. 36
THE KENTUCKY PHARMACIST
EPIC Pharmacies References: 1. Food and Drug Administration. U.S. Department for Health and Human Services. FDA Approves First Drug for Reducing the Risk of Sexually Acquired HIV Infection. U.S. Food and Drug Administration. Food and Drug Administration, 17 July 2012. Web. 26 Oct. 2016.
January/February 2017 5. The Foundation for a Healthy Kentucky, www.kentuckyhealthfacts.org. 6. United States. Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Kentucky â&#x20AC;&#x201C; 2015 State Health Profile. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, 22 Dec. 2015. Web. 26 Oct. 2016.
2. Hood, Julia E., Susan E. Buskin, Julia C. Dombrowski, David A. Kern, Elizabeth A. Barash, David A. Katzi, and Matthew R. Golden. "Dramatic Increase in Preexpo7. United States of America. Department of Health and sure Prophylaxis Use among MSM in Washington Human Services. Center for Disease Control and PreState." AIDS 30.3 (2016): 515-19. Print. vention. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States, A Clinical Practice 3. Krakower, Douglas S., and Kenneth H. Mayer. "PreGuideline. Atlanta, GA: Center for Disease Control and exposure Prophylaxis to Prevent HIV Infection: Current Prevention, 2014. Print. Status, Future Opportunities and Challenges. " Drugs. 75.3 (2015): 243-51. Print. 8. WKYT News Staff. "Report Ranks Eastern Kentucky Counties at Highest Risk for HIV Outbreaks." Report 4. Laufer, Franklin N., Daniel A. O'Connell, Ira Feldman, Ranks Eastern Kentucky Counties at Highest Risk for and Howard A. Zucker. "Vital Signs: Increased MediHIV Outbreaks. WKYT, 26 Apr. 2016. Web. 26 Oct. caid Prescriptions for Preexposure Prophylaxis Against 2016. HIV Infection--New York, 2012-2015." Morbidity and Mortality Weekly Report: MMWR / 64.46 (2015): 1296- 9. "Advisory Council for Medical Assistance (MAC)." Ken301. Print. tucky: Cabinet for Health and Family Services. N.p., 10 Oct. 2016. Web. 26 Oct. 2016.
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THE KENTUCKY PHARMACIST
Pharmacy Law Brief
January/February 2017
Pharmacy Law Brief: Professional Degrees, Titles and Designations
Author: Joseph L. Fink III, B.S. Pharm., J.D., Professor of Pharmacy Law and Policy and KPhA Professor of Leadership, Department of Pharmacy Practice and Science, UK College of Pharmacy Question: When pharmacy education went to all graduates earning a professional doctorate in the year 2000 that was, in my view, a positive development for the profession. However, I’ve heard that some employers of pharmacists have directed their employees holding such degrees not to use the associated title, i.e., “Don’t answer the phone at the pharmacy saying ‘This is Dr. Miller. How can I be of assistance? ’” Further, someone told me that there’s a unique wrinkle in Kentucky addressing whether nurse practitioners who hold a doctoral degree may use the title associated with that degree. What’s the story on all that?
Submit Questions: jfink@uky.edu Disclaimer: The information in this column is intended for educational use and to stimulate professional discussion among colleagues. It should not be construed as legal advice. There is no way such a brief discussion of an issue or topic for educational or discussion purposes can adequately and fully address the multifaceted and often complex issues that arise in the course of professional practice. It is always the best advice for a pharmacist to seek counsel from an attorney who can become thoroughly familiar with the intricacies of a specific situation, and render advice in accordance with the full information.
Response: Recent developments in the professions have brought to the fore the issue of doctoral degrees and the attendant use of the title “doctor” by holders of such degrees. For example, the American Medical Association has launched an initiative it designates as “Truth in Advertising” under its “Patients Action Network.”1 An additional example was a publication by the Kentucky Medical Association. 2 Finally, this has been elevated to a matter of law or public policy through a statute enacted in Kentucky with an effective date of June 8, 2011, as follows: Advanced practice doctoral program in nursing Degree - Portrayal of credentials.
tification title such as FNP or CRNA, if the person wants to use those titles. (2) The academic degree (M.S.N., Ph.D., D.N.P., etc.) may be used; it is not required. If it is used, there is no law on where it is placed, i.e. before or after licensure title of APRN. An individual who holds a doctoral degree should be aware of KRS 164.298 (2) and KRS 311.375 which state that if a person uses the title Doctor or Dr., they must also use their doctoral credentials, i.e. D.N.P.4 Regarding the point about pharmacists’ employers getting in on the issue, Drug Topics, a national pharmacy news magazine, conducted an informal readership poll during the summer of 2012 on the topic of title and designation use. The main question posed was, “Does your employer allow the use of your doctor (sic) degree on your name tag?” With slightly over 2,000 responses tabulated by the end of July the breakdown was:
(2) Each university offering an advanced nursing practice doctoral program shall refer to the degree as the "doctor of nursing practice," with the degree being abbreviated as "DNP." Any advertisement about the advanced nursing practice doctoral program shall not refer to graduates using the term "doctor." Graduates of the program shall accurately portray their academic credentials as well as their registered nurse and advanced practice registered nurse credentials, if applicable, subject to sanction under KRS 311.375(4). [Emphasis added]3 The Kentucky Board of Nursing also addresses the issue this way: Required Title for Advanced Practice Registered Nurses (1) APRN is the legal, licensure title for all NPs, CNMs, CRNAs, and qualifying CNSs. (KRS 314.042). That title should always be used by any currently licensed APRN. It should precede any cer-
Yes, my employer allows PharmD after my name or the use of the title doctor before my name. 39% Yes, my employer allows PharmD after my name but not the title Dr. before my name. 36% No, my employer does not allow any doctor title before or after my name. 25%
It may be helpful to look at the origin of the title. History tells us that the first doctoral degree was conferred at the University of Bologna, the oldest university in the world. It was in the field of law. The title has its origins in the Latin word “docere,” meaning “to teach.” Medical education programs in the British system (Britain, Ireland and the Common38
THE KENTUCKY PHARMACIST
January/February 2017
Pharmacy Law Brief wealth Nations) do not confer Doctor of Medicine degrees. The degree conferred there is Bachelor of Medicine, Bachelor of Surgery [M.B., B.S.]. That degree is used because of the convention in academic circles that the first degree in a given field is the baccalaureate (Bachelor’s) degree. The curriculum leading to the first degree in allopathic medicine in the U.S. system, the M.D., is referred to as “undergraduate medical education.” That’s why a medical school graduate completing a medical residency is considered to be pursuing “graduate medical education.” Doctoral degrees can be classified into three categories. Professional Au.D. D.O. D.D.S./D.M.D. D.N.P. D.P.M. /D.S.C. D.P.T. Dr.P.H.
D.V.M./V.M.D. J.D. M.D. O.D. Pharm.D. Psy.D.
Research
Honorary
D.B.A. D.Eng. D.S.W. Ed.D. Ph.D. S.J.D. Th.D.
D.F.A. D.H.L. D.Litt. D.Sc. LL.D.
Further, it is noteworthy that other fields have changed their degree abbreviations to get the letters “M” and “D” juxtaposed: DDS → DMD, DVM → VMD. Finally, another distinction is worth mentioning. “Doctorate” is a noun whereas “doctoral” is an adjective, so a student is said to be pursuing a doctorate or a doctoral degree, not a doctorate degree. What is the source of this issue? Imprecision in communication that would not be tolerated when communicating about disease states or therapies has created this situation. Physicians and others refer to themselves and their activities with imprecision, e.g., doctor’s appointment, when it really is a physician appointment. There is an important difference between a title and a job description. Understanding the difference can help us all communicate more effectively with patients and other professionals. References and Resources:
1. https://www.patientsactionnetwork.com/issuesA note about the category known as honorary degrees overview/truth-in-advertising/. may be in order. An honorary degree is a degree honoris 2. Kentucky Medical Association. MD√ID – Know Who’s causa, meaning “for the sake of honor.” Use of the title Treating You. Check to Be Sure Your Family Receives “doctor” by those holding doctoral degrees, earned or honthe Best Possible Care. Louisville, KY (2011). Availaorary, is appropriate but not mandatory. Some do and ble at: http://mdidky.com/. some don’t. Think of Dr. Henry Kissinger, who always used it, versus two U.S. Senators with doctoral degrees who 3. K.R.S. 164.298. – State Universities and Colleges: never did – George Mitchell and George McGovern. Advanced Practice Doctoral Programs in Nursing – Degree – Portrayal of Credentials. Several other points may be of interest. First, when abbreviating an academic degree, there is no intra-abbreviation spacing; that is, all letters always run together. There are NEVER any spaces in the abbreviation for an academic degree. This is one of the very few absolute rules in life. Also, a distinction should be drawn between a title, say “Dr.,” versus a postnomial, “Ph.D.” Use one or the other; it is never appropriate to use both at once.
4. http://kbn.ky.gov/apply/Pages/APRN/aprn.aspx. 5. Drug Topics Voice of the Pharmacist: Surveys. Advanstar Communications, North Olmsted, OH (undated). Available at: http://drugtopics.modernmedicine.com/drugtopics/ survey/surveyList.jsp?id=758592.
Other sources: Further, it is appropriate to either use the periods between Szeinbach SL, Fink III JL. Identifying the pharmacist's prothe letters or not to do so, but one should be consistent. Some abbreviations may turn out to be too lengthy, say for fessional status. Am Pharm. 1984;NS24:624-7. a name tag, if periods are used. Think of: Fink III JL. Viewpoint – A matter of degree: Let’s get it right. Drug Topics. 2007(Mar 5);151:64. Julie Schwartz, Pharm.D., B.C.A.C.P. vs. Julie Schwartz, PharmD, BCACP
Join the Committee of 100! Each contributor who pledges at least $5,000 over the next 5 years will be counted among the Committee of 100. Add your name to the list today by calling 502-227-2303 or log on to http://www.kphanet.org/?page=buildingcampaign
Contributions are tax deductible. 39
THE KENTUCKY PHARMACIST
January/February 2017
Pharmacists Mutual
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THE KENTUCKY PHARMACIST
Cardinal Health
January/February 2017
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THE KENTUCKY PHARMACIST
KPhA Board of Directors/KPERF Board of Directors
KPhA BOARD OF DIRECTORS
January/February 2017
KPERF BOARD OF DIRECTORS
Chris Clifton, Villa Hills chrisclifton@hotmail.com
Chair
Duane Parsons, Richmond dandlparsons@roadrunner.com
Chair
Trish Freeman, Lexington trish.freeman@uky.edu
President
Clark Kebodeaux, Lexington clark.kebodeaux@uky.edu
Secretary
Chris Harlow, Louisville cpharlow@gmail.com
President-Elect
Chris Palutis, Lexington chris@candcrx.com
Treasurer
Brooke Hudspeth, Lexington brooke.hudspeth@kroger.com
Secretary
Trish Freeman, Lexington trish.freeman@uky.edu
KPhA President
Chris Palutis, Lexington chris@candcrx.com
Treasurer
Paul Easley, Louisville rpeasley@bellsouth.net
Jessika Chinn, Beaver Dam jessikachilton@ymail.com
Past President Representative
Melinda Joyce, Bowling Green MBJoyce@chc.net Bob Oakley, Louisville Boakley@BHSI.com
Directors Matt Carrico, Louisville* matt@boonevilledrugs.com Kevin Chen, Lexington kevin.chen@uky.edu
University of Kentucky Student Representative
Kelly Smith, Lexington ksmit1@email.uky.edu
KPERF ADVISORY COUNCIL
Chad Corum, Manchester pharmdky21@gmail.com
Christen S Bruening, Cincinnati, Ohio cmschenkenfelder@gmail.com
Matt Foltz, Villa Hills mfoltz@gomedcare.com
Matt Carrico, Louisville matt@boonevilledrugs.com
Cathy Hance, Louisville cathy@compoundcarerx.com
Kim Croley, Corbin kscroley@yahoo.com
Cassy Hobbs, Louisville cbeyerle01@gmail.com
Kimberly Daugherty, Louisville kdaugherty@sullivan.edu
Katherine Keeney, Louisville Sullivan University KKEENE6675@my.sullivan.edu Student Representative
Mary Thacker, Louisville mary.thacker@att.net
Chris Killmeier, Louisville cdkillmeier@hotmail.com
KPhA/KPERF HEADQUARTERS 96 C Michael Davenport Blvd., Frankfort, KY 40601 502.227.2303 (Phone) 502.227.2258 (Fax) www.kphanet.org www.facebook.com/KyPharmAssoc www.twitter.com/KyPharmAssoc www.twitter.com/KPhAGrassroots www.youtube.com/KyPharmAssoc
Jeff Mills, Louisville jeff.mills@nortonhealthcare.org Richard Slone, Hindman richardkslone@msn.com Sam Willett, Mayfield duncancenter@bellsouth.net * At-Large Member to Executive Committee
HOUSE OF DELEGATES Lance Murphy, Louisville lancemurphy84@gmail.com Amanda Jett, Louisville ajett@sullivan.edu
Speaker of the House
Vice Speaker of the House
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THE KENTUCKY PHARMACIST
50 Years Ago/Frequently Called and Contacted/KPhA Staff
January/February 2017
50 Years Ago at KPhA FROM KENTUCKY AT A GLANCE Hubbard & Curry, Inc., Lexington, recently suffered considerable fire and smoke damage to its grill and food service counter by an over-heated hot plate. The fire was discovered by a cruiser patrolman in the wee hours of the morning who saw flames through the store window. - From The Kentucky Pharmacist, January 1967, Volume XXX, Number 1.
Frequently Called and Contacted Kentucky Pharmacists Association 96 C Michael Davenport Blvd. Frankfort, KY 40601 (502) 227-2303 www.kphanet.org Kentucky Board of Pharmacy State Office Building Annex, Ste. 300 125 Holmes Street Frankfort, KY 40601 (502) 564-7910 www.pharmacy.ky.gov Pharmacy Technician Certification Board (PTCB) 2215 Constitution Avenue Washington, DC 20037-2985 (800) 363-8012 www.ptcb.org
Kentucky Society of Health-System Pharmacists P.O. Box 4961 Louisville, KY 40204 (502) 456-1851 x2 (502) 456-1821 (fax) www.kshp.org info@kshp.org American Pharmacists Association (APhA) 2215 Constitution Avenue NW Washington, DC 20037-2985 (800) 237-2742 www.aphanet.org
National Community Pharmacists Association (NCPA) 100 Daingerfield Road Alexandria, VA 22314 (703) 683-8200 info@ncpanet.org Drug Information Center Sullivan University College of Pharmacy 2100 Gardiner Lane Louisville, KY 40205 (502) 413-8638 www.sullivan.edu Kentucky Regional Poison Center (800) 222-1222
In Memoriam Rosana Aydt, 65, of Villa Hills, passed away Nov. 28, 2016. She attended the University of Tennessee where she earned her degree in Pharmacy. She was the cofounder of Faith Community Pharmacy which has served over 6,500 clients and distributed $37 million worth of free medication since opening in 2002.
KPhA Staff Robert McFalls, M.Div. Executive Director rmcfalls@kphanet.org
David S. Shipley, 77, formerly of Sturgis, Ky., died Dec. 13, 2016. David was a graduate of Sturgis High School and the University of Kentucky College of Pharmacy, Class of 1961.
Scott Sisco, MA Director of Communications & Continuing Education ssisco@kphanet.org Angela Gibson Director of Membership & Administrative Services agibson@kphanet.org
KPhA Remembers
Leah Tolliver, PharmD Director of Pharmacy Emergency Preparedness ltolliver@kphanet.org
KPhA desires to honor members who are no longer with us. Please keep KPhA informed by sending this information to eramey@kphanet.org. Deceased members for each year will be honored permanently at the KPhA office.
Elizabeth Ramey Receptionist/Office Assistant eramey@kphanet.org
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THE KENTUCKY PHARMACIST
January/February 2017
THE
Kentucky PHARMACIST 96 C Michael Davenport Blvd. Frankfort, KY 40601
SAVE THE DATE
Show your Pharmacist Pride with a KPhA Roamey Window Cling ($5) or your own personalized Roamey ($25)! All proceeds benefit the KPhA Building Fund
www.kphanet.org
Available at the KPhA Online Store www.kphanet.org, click on About Tab, Online Store 44
THE KENTUCKY PHARMACIST