North Carolina Pharmacist Volume 99 Number 1

North Carolina Pharmacist

Volume 99 Number 1 Winter 2018 Advancing Pharmacy. Improving Health.

Official Journal of the North Carolina Association of Pharmacists ncpharmacists.org

Featured Articles North Carolina’s Opioid Action Plan Page 17 Impact of Naloxone Education on Healthcare Professionals’ Knowledge and Attitudes Page 21

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Official Journal of the North Carolina Association of Pharmacists 1101 Slater Road, Suite 110 Durham, NC 27703 Phone: (984) 439-1646 Fax: (984) 439-1649 www.ncpharmacists.org Click Here to Follow us!

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JOURNAL STAFF EXECUTIVE EDITOR Penny Shelton EDITOR/STAFF WRITER Ralph Raasch LAYOUT/DESIGN Rhonda Horner-Davis

North Carolina Pharmacist Volume 99 Number 1

Winter 2018

Inside • From the President .................................................................4 • From the Executive Director .............................................................5 • Chronic Care and Health-System Meeting Schedule............................7-15 • North Carolina’s Opioid Action Plan ................................................17-18

BOARD OF DIRECTORS

• Updates of Interest .....................................................................................19

PRESIDENT Stefanie Ferreri

• Impact of Naloxone Education on Healthcare Professionals’

PRESIDENT-ELECT Debra Kemp PAST PRESIDENT Stephen Eckel TREASURER Thomas D’Andrea

BOARD MEMBERS Olivia Bentley Jamie Brown Lisa Dinkins Kira Harris Kevin Helmlinger Macary Marciniak Cortney Mospan Jason Moss Dave Phillips Justin Reid Jennifer Wilson

NCAP STAFF Linda Goswick Sandie Holley Rhonda Horner-Davis Teressa Reavis Ron Williamson

Knowledge and Attitudes....................................................21-29 • Opportunities for Pharmacist Involvement on Medical Missions..........31-34 • Medipreneurs Summit 2018.....................................................................35 • 2018 NCAP Elections and Awards.............................................................38

North Carolina Pharmacist is supported in part by: • Smith Drug Company...................................................................................2 • Epic Rx.........................................................................................................6 • Pharmacists Mutual Companies..................................................................16 • Pharmacy Technician Certification Board..................................................20 • NCAP Career Center...................................................................................30 • Epic Rx.......................................................................................................36 • Pharmacy Quality Commitment..................................................................37 • VIP Pharmacy Systems...............................................................................40

North Carolina Pharmacist (ISSN 0528-1725) is the official journal of the North Carolina Association of Pharmacists. An electronic version is published quarterly. The journal is provided to NCAP members through allocation of annual dues. Opinions expressed in North Carolina Pharmacist are not necessarily official positions or policies of the Association.

Publication of an advertisement does not represent an endorsement.

Nothing in this publication may be reproduced in any manner, either whole or in part, without specific written permission of the publisher.

ADVERTISING For rates and deadline information, please contact

Rhonda Horner-Davis at rhonda@ncpharmacists.org

•From the President • Stefanie Ferreri, PharmD

Re-engaging in the Profession to Bring North Carolina to the Forefront Happy (upcoming) Spring! By now, many of you have probably changed out your wardrobe in anticipation of warmer weather. Some of you have probably started getting outside and interacting with neighbors and friends who you didn’t see much during the winter months. As you do this, I encourage you to interact with your profession. This is where I need your help! Every volunteer and service-minded organization struggles with membership from time to time.

NCAP is facing that challenge now, which is why our Board has decided to focus on membership for 2018.

Whether you work in acute care, ambulatory care, community practice, long-term care, academia, industry or any other part of pharmacy, we have a home for you! I need your help convincing others that this organization is an important voice helping influence public policy as it relates to our profession. If all of our members recruit-

ed one person to renew or join NCAP, our numbers would double. The math is that simple. Recently, I worked with Penny to identify all UNC faculty who did not renew their membership, and I sent them a personalized message to rejoin. This took minimal effort on my part. I encourage you to find one person you work with to renew or join.

As you encourage your colleagues to consider NCAP their professional home, remind them of our forum meetings. In March, we have our chronic and health-system practice meetings in Concord. In addition to educational sessions, continuing education programs, and a chance to connect with old friends and meet new ones, you can also splash around at the Great Wolf Lodge – the venue for this meeting. We have also secured our location and time for our annual meeting. We will be returning to the Benton Convention Center in Winston-Salem from September 21-22, 2018. Mark your calendars for a great event.

NCAP is open to new ideas and revitalizing the organization. During my presidency I want to hear from you and the priorities you need NCAP to focus on. So much is happening in health care these days. Some of us are battling DIR fees, others are focused on quality metrics, and some are try-

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ing to move from volume-based, feefor-service to value based, pay-forperformance. Whatever your interest is in pharmacy, I want to hear from you and the help NCAP can provide.

When I first moved to North Carolina, I was in awe of how pharmacy could be practiced in this state. I moved here from the northeast where pharmacy practice typically lags behind. I was and I am still inspired by the type of care that pharmacists could provide in this state. However, as time has passed (this year marks my 20th anniversary in the Tar Heel state), I feel that other states have caught up and some have surpassed our practice. I want to bring North Carolina to the forefront again, and the larger our membership, the more powerful our voice can be. Please share your pharmacy ideas with me on Twitter @stefanieferreri or email me at stefanie_ferreri@unc.edu

Letters to North Carolina Pharmacist – The Editorial Board and Editor welcome your comments regarding the journal and any of its contents. In particular, we would like to hear from you concerning professional issues related to practice/professional dilemmas/potential conflicts of interest. If you have comments, please send to Ralph H. Raasch, Editor, mail to: ralphhraasch@gmail. com.

Volume 99 Number 1 Winter 2018

•From the Executive Director• Penny Shelton, PharmD, BCGP, FASCP use disorders. However, these meetings and the subsequent follow-up conversations have frequently turned to all things behavioral health, including unmet needs and lack of resources. The needs are great and seemingly everywhere!

Behavioral Health -- The Need is Great: Pharmacists, Can We Make a Difference?

A couple of weeks after ringing in the New Year, early on a Saturday morning, my phone rang. The ring was followed by news filled with a harsh and painful reality. Our neighbor’s oldest son had committed suicide. A young man we had watched grow up from across the street was forever lost to those who loved him. As the initial shock began to fade, I found myself thinking about how someone who seems to have so much to look forward to in life, how is it that he experienced only abject hopelessness? This young man, a soldier and recent college graduate with a new job and home, how did he become swallowed up by despair and agony, to such a degree that he was blinded to any solution other than ending his own life?

As I type this column, our nation is reeling in the aftermath of the Stoneman Douglas High School shooting in Parkland, Florida. Parkland will be another mass shooting forever etched as a dark mark in U.S. history. Seventeen lives were cut short due to the deranged actions of a young man, whose troubled past and signs of mental illness are only now, when it is too late, being examined for what could have been done to prevent the tragedy.

Of late, many of the meetings that I have attended have been related to the behavioral health aspects of substance

Depression, anxiety, substance use disorders, and psychoses permeate much of the work of healthcare and pharmacy.

Unfortunately, there is still a great deal of stigma related to mental illness. Most find it awkward and difficult to engage in conversations about behavioral health needs with their patients. For many, unless the patient asks, we tend to turn a blind eye to these issues. On the other hand, most healthcare providers, including pharmacists, show no hesitation in taking a proactive approach with patients about such conditions as hypertension and diabetes.

I believe there is more that pharmacists can do to help with mental illness.

Pharmacists are strategically positioned to help bridge the gap between primary care and behavioral health. Pharmacists are underutilized in behavioral health, but with a concerted effort, this is a reality that we can change.

A few years ago, when I was serving as Associate Dean for Academic Affairs for the School of Pharmacy at Shenandoah University, I had the privilege of working with a number of amazing next-generation pharmacists. One of these students, who is now a pharmacist, found her path to pharmacy through a most unusual yet profound way. When she was in middle-school, she and her mother lived in fear of an alcohol-fueled step-father, who frequently physically abused her mother. One day, she and her mother were at a community pharmacy picking up some prescriptions. Her mother was wearing a pair of dark sunglasses, an all too often needed accesso-

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ry, to hide her bruises. The pharmacist, when handing her the prescription bag, said something similar to: “I put some information in your bag for you. If I am wrong, then I apologize for my error, but if I am right and I did nothing, then that would be an even greater injustice.”

The pharmacist had given her a brochure about domestic abuse and contact information for a community safe house for abused women. To this day, my ex-student credits that pharmacist, a stranger who cared enough to notice, with saving her mother’s life. The care and compassion of that pharmacist made a difference and left a lasting impression.

What if more pharmacists took on the simple act of reaching out with information or starting a conversation with individuals in need? What if pharmacists were equipped with the resources, skills and information to make the process of engaging in these delicate conversations less awkward? What if pharmacists provided patients with information about community resources for suicide prevention, domestic abuse, and substance use disorders?

NCAP, this past fall during our Annual Convention, provided a workshop on Mental Health First Aid. I’d like to offer NCAP as a mechanism for bringing this training to pharmacists regionally. Perhaps the Association can help develop tools and resources to help mobilize pharmacists for behavioral health intervention. I welcome your thoughts and comments. I’d like to know how you think pharmacists can make a difference. We will not be able to save everyone, but if we do nothing, then we perpetuate our underutilization as well as the current disparities in behavioral health.

Pharmacy Proud penny@ncpharmacists.org

Volume 99 Number 1 Winter 2018

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2018 NCAP Chronic Care and Health-System Practice Forums Meeting The Great Wolf Lodge Concord, North Carolina March 21-23, 2018 Developed with UNC Eshelman School of Pharmacy Co-Sponsored by Campbell University College of Pharmacy and Health Sciences Fred Wilson High Point University School of Pharmacy Wingate University School of Pharmacy

Wednesday, March 21 5:00-7:00

Networking Reception with Exhibitors

Thursday, March 22 7:00-8:15

Registration/Breakfast with Exhibitors

8:15-8:30

Welcome/Introductions – Grand Plenary Until 3:30 PM

Moderators:

Jason M. Moss, PharmD, BCGP

Assistant Professor, Pharmacy Practice

Campbell University College of Pharmacy and Health Sciences Clinical Pharmacy Specialist Durham VA GRECC

Chair, NCAP Chronic Care Practice Forum

Kira Brice Harris, PharmD, BCPS, CDC, CPP Associate Professor

Wingate University School of Pharmacy

Chair, NCAP Health-System Practice Forum 8:30-9:30

ACPE#: 0046-9999-18-056-L04-P (1.0 hr) ACPE#: 0046-9999-18-056-L04-T (1.0 hr)

“In Managing Change or Conflict, What is Needed”

Learning objectives for Pharmacists/Technicians: At the completion of this knowledge-based activity, the North Carolina Pharmacist

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Volume 99 Number 1 Winter 2018

participant will be able to:

1) Identify what is needed to manage change

and not create conflict

2) Identify and understand the five dysfunctions of a team

3) Apply change and conflict management

with staff, clients and contracts

Eric Miller President

Smart Performance Strategies, Inc.

9:30-10:30 ACPE#: 0046-9999-18-057-L04-P (1.0 hr)

ACPE#: 0046-9999-18-057-L04-T (1.0 hr) “Collaborative Practice Authority: An Update on Advocating for Change”

Learning objectives for Pharmacists/Technicians:

At the completion of this knowledge-based activity, the

participant will be able to:

1) Define the current status of NCAP advocacy agenda

on collaborative practice authority

2) Describe how the current collaborative practice

authority statute creates barriers to innovative

practice and patient care

3) List the elements of a new bill designed to broaden

collaborative practice in North Carolina

4) Create a personalized action plan for engagement on this issue (Pharmacist only objective) Penny S. Shelton, PharmD, BCGP, FASCP Executive Director

NC Association of Pharmacists 10:30-10:45 Break

10:45-11:45 ACPE#: 0046-9999-18-058-L01-P (1.0 hr)

ACPE#: 0046-9999-18-058-L01-T (1.0 hr) “Clinical Updates and Therapeutic Controversies

Related to the Use of Direct Oral Anticoagulants (DOAC)”

Learning objectives for Pharmacists/Technicians:

At the completion of this knowledge-based activity, the

participant will be able to:

1) Review role of DOAC pharmacotherapy in the

management of atrial fibrillation (AFib) and venous thromboembolism (VTE)

2) Appraise recently published literature outlining

clinical applicability of DOAC pharmacotherapy

3) Identify criteria for fringe DOAC candidacy and

available clinical data which drives decision-making North Carolina Pharmacist

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Volume 99 Number 1 Winter 2018

4) Analyze patient case scenarios to determine most

appropriate anticoagulant strategy and duration of selected therapy Robert Tunney, PharmD, BCPS Clinical Pharmacy Specialist ECHI Heart Failure Program

Vidant Medical Center

Clinical Assistant Professor, Pharmacy Practice

Campbell University College of Pharmacy & Health Sciences 11:45-1:15

Lunch Symposium UAN#: 0468-0000-18-001-L01-P (1.0 hr) UAN#: 0468-0000-18-001-L01-T (1.0 hr)

“Acute Coronary Syndrome: Getting to the Heart

of the Matter for Pharmacists”

Learning objectives for Pharmacists/Technicians:

At the completion of this application-based activity, the

participant will be able to:

1) Identify patients at risk for ACS

2) Explain the distinct phases of the continuum of

ACS: UA, NSTEMI, and STEMI in order to assist

the care team in managing patients as they progress through treatment

3) Summarize best practices to counsel patients on

the importance of adherence and follow-up care

while monitoring their ongoing health including

coordinating all their prescriptions Toby C. Trujillo, PharmD, FCCP, FAHA, BCPS-AQ Cardiology Associate Professor

University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences

University of Colorado Anschutz Medical Campus

Clinical Specialist – Anticoagulation/Cardiology

University of Colorado Hospital Denver, Colorado

The Medical Learning Institute, Inc. is accredited by The Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

1:15-2:15

ACPE#: 0046-9999-18-059-L01-P (1.0 hr) ACPE#: 0046-9999-18-059-L01-T (1.0 hr)

“Updates in an Oft Neglected Disease State”

Learning objectives for Pharmacists/Technicians:

At the completion of this knowledge-based activity, the

participant will be able to: North Carolina Pharmacist

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Volume 99 Number 1 Winter 2018

1) Compare and contrast GOLD 2017 with previous GOLD Guidelines

2) Assess the severity of a patient’s COPD and

recognize an acute exacerbation of COPD

3) Recommend patient specific interventions based

on risk factors, status/severity, and progression of COPD (Pharmacist only objective)

4) Develop and justify a patient specific

pharmacotherapy care plan for both the management

and acute exacerbations of COPD

J. Andrew Woods, PharmD, BCPS

Associate Professor of Pharmacy

Wingate University School of Pharmacy

Internal Medicine Clinical Pharmacy Specialist

Carolinas Medical Center - Main

2:15-3:15 ACPE#: 0046-9999-18-060-L01-P (1.0 hr)

ACPE#: 0046-9999-18-060-L01-T (1.0 hr) “Beyond Statins: Managing Hyperlipidemia and Reducing Cardiovascular Risk”

Learning objectives for Pharmacists/Technicians:

At the completion of this knowledge-based activity, the

participant will be able to:

1) Compare and contrast recommendations from

major guidelines for the management of Hyperlipidemia

2) Evaluate the cardiovascular benefits of alternative

treatment options based on current literature

3) Evaluate a patient case to determine cardiovascular

risk and appropriate treatment strategies

Kira Brice Harris, PharmD, BCPS, CDC, CPP Associate Professor

Wingate University School of Pharmacy

Chair, NCAP Health-System Practice Forum 3:15-3:30

Break

3:30-5:30

Concurrent Sessions:

(A) ACPE#: 0046-9999-18-061-L01-P (2.0 hrs) ACPE#: 0046-9999-18-061-L01-T (2.0 hrs)

“New Drug Update”

Learning objectives for Pharmacists/Technicians: At the completion of this knowledge-based activity, the participant will be able to: 1) Identify new FDA approved drugs that have been approved in the past 12 months that are pertinent North Carolina Pharmacist

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Volume 99 Number 1 Winter 2018

to long-term care

2) Discuss the indication, mechanism of action, side

effect profile, monitoring, dosing and special

administration instructions of each medication

3) If applicable - review any clinical trials or studies

comparing the new medication to similar drugs in its therapeutic class

4) Discuss cost and feasibility options of new drugs

Bobbie H. Hall, PharmD, CGP Consultant Pharmacist Pharmacy Education Coordinator

Neil Medical Group Pharmacy Services Division

(B) ACPE#: 0046-9999-18-062-L04-P (2.0 hrs)

ACPE#: 0046-9999-18-062-L04-T (2.0 hrs) “Health-System Round Tables”

Learning objectives for Pharmacists/Technicians: At the completion of this knowledge-based activity, the participant will be able to: 1) Describe current gaps in practice across North Carolina 2) Discuss pharmacy practices to empower pharmacists 3) Describe systems to improve patient care Round Table Topics and Facilitators Listed in APP

Friday, March 23rd 7:45-8:00

Welcome/Introductions – Grand Plenary Until 9:00 AM

Moderators:

Jason M. Moss, PharmD, BCGP

Assistant Professor, Pharmacy Practice

Campbell University College of Pharmacy and Health Sciences Clinical Pharmacy Specialist Durham VA GRECC

Chair, NCAP Chronic Care Practice Forum

Kira Brice Harris, PharmD, BCPS, CDE, CPP Associate Professor

Wingate University School of Pharmacy

Chair, NCAP Health-System Practice Forum

8:00-9:00 Breakfast Symposium UAN#: 0473-9999-18-001-L01-P (1.0 hr) North Carolina Pharmacist

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Volume 99 Number 1 Winter 2018

“The Challenge of Clostridium Difficile and Antimicrobial-Resistant Gram-negative Infections: Opportunities to Re-Evaluate Current Management Approaches” Learning objectives for Pharmacists: At the completion of this knowledge-based activity, the participant will be able to: 1) Explain current trends in antimicrobial resistance and identify patient risk factors for infection 2) Assess the role of newer antimicrobial agents as part of the armamentarium in the management of infections caused by multidrug-resistant Gram-negative bacteria and C.difficile 3) Evaluate the utility of novel approaches that reduce the risk of recurrent C. difficile infection in high-risk patients 4) Describe antimicrobial stewardship strategies that aim to minimize the burden of serious bacterial infections in healthcare institutions James S. Lewis, II, PharmD, FIDSA ID Clinical Pharmacy Coordinator & Adjunct Associate Professor Departments of Pharmacy & Infectious Diseases Oregon Health & Science University – Portland (A) Chronic Care Practice Forum Plenary 9:15-10:15

ACPE#: 0046-9999-18-063-L04-P (1.0 hr) ACPE#: 0046-9999-18-063-L04-T (1.0 hr) “Reform of Requirements for Long-Term Care Facilities: The Mega-Rule…Pharmacy Impacts” Learning objectives for Pharmacists/Technicians: At the completion of this knowledge-based activity, the participant will be able to: 1) Discuss pharmacy-related Phase 1 requirements 2) Discuss pharmacy-related Phase 2 requirements and associated guidance 3) Discuss other important pharmacy-related changes to Appendix PP and associated guidance 4) Briefly describe pharmacy-related Phase 3 requirements

Todd King, PharmD, CGP

Director Clinical Services, LTC

Omnicare, A CVS Health Company

10:15-11:15 ACPE#: 0046-9999-18-064-L02-P (1.0 hr)

ACPE#: 0046-9999-18-064-L02-T (1.0 hr)

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Volume 99 Number 1 Winter 2018

“Going Viral: HIV Update – 30 Years of Progress”

Learning objectives for Pharmacists/Technicians:

At the completion of this knowledge-based activity, the

participant will be able to: 1) Review the epidemiology of HIV in the United States

2) List the various classes and agents of antiretroviral therapy

3) Describe the initial recommended treatment options

for most adult patients with HIV

4) Identify which adult patients would be candidates

for pre-exposure prophylaxis (PrEP)

5) Summarize investigational treatment options for HIV Steven W. Johnson, PharmD, BCPS, CPP, AAHIVP

Assistant Professor, Department of Pharmacy Practice

Campbell University College of Pharmacy and Health Sciences

11:15-11:30 Break 11:30-12:30

ACPE#: 0046-9999-18-065-L01-P (1.0 hr) ACPE#: 0046-9999-18-065-L01-T (1.0 hr)

“De-Intensification of Disease Management at the End

of Life – When, Why and How”

Learning objectives for Pharmacists/Technicians:

At the completion of this knowledge-based activity, the

participant will be able to:

1) Discuss the stages that a terminally ill patient

will go through prior to death 2) Identify the disease states most likely in need of

de-intensification at the end of life

3) Describe the intersection between the

patient/HPCOA goals of care and appropriate disease management

4) Discuss medication tapering at the end of life

and which medication classes require it 5) Summarize creative medication administration

techniques employed by the hospice

provider for the dying patient Jeff Lynds, RPh Director of Pharmacy

Hospice & Palliative Care Charlotte Region

12:30-12:45 Closing Remarks and Farewell 12:45-until

Joint Executive Committee Working Lunch

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Volume 99 Number 1 Winter 2018

(B) Health-System Practice Forum Plenary 9:15-10:15

ACPE#: 0046-9999-18-066-L04-P (1.0 hr) ACPE#: 0046-9999-18-066-L04-T (1.0 hr)

“Innovative Practice Models Across the Care Continuum:

A Panel Discussion of a Substance Abuse Patient Care”

Learning objectives for Pharmacists/Technicians:

At the completion of this knowledge-based activity, the

participant will be able to:

1) Explore innovative pharmacy practice models in the

inpatient, outpatient and transitional settings

2) Identify barriers and solutions to optimal patient care

in all practice settings

3) Apply innovative practice solutions to a patient case

to discuss the opioid abuse epidemic

Ryan Owenby, PharmD

Clinical Pharmacy Specialist, Emergency Medicine

Durham VA Medical Center

Courtenay Gilmore Wilson, PharmD, CDE, BCACP, BCPS, CPP

Associate Director of Pharmacotherapy

Mountain Area Health Education Center

Assistant Professor of Clinical Education

UNC Eshelman School of Pharmacy PGY2 Residency Director

MAHEC/UNC Eshelman School of Pharmacy

10:15-11:15 ACPE#: 0046-9999-18-067-L04-P (1.0 hr)

ACPE#: 0046-9999-18-067-L04-T (1.0 hr) “Anatomy of a Medical Malpractice Case”

Learning objectives for Pharmacists/Technicians:

At the completion of this knowledge-based activity, the

participant will be able to: 1) Review the process leading to a medical lawsuit 2) Identify the three common motivations for medical malpractice cases

3) Discuss the legal implications of collaborative medicine

4) Compare and contrast policy and procedure vs. standard of care 5) Describe the importance of chain of command as

applied to pharmacist liability

6) Articulate the legal necessity of appropriate documentation

7) Review the legal aspects of the employer/ employee relationship North Carolina Pharmacist

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Volume 99 Number 1 Winter 2018

Tricia Morvan Derr, BA, J.D. Managing Member Lincoln Derr PLLC Charlotte, North Carolina

Click Here

11:15-11:30

Break

11:30-12:30

ACPE#: 0046-9999-18-068-L04-P (1.0 hr) ACPE#: 0046-9999-18-068-L04-T (1.0 hr)

“Standardized Concentrations for Oral Liquid Medications”

Learning objectives for Pharmacists/Technicians:

At the completion of this knowledge-based activity, the

participant will be able to:

1) Discuss the reason for a national standard for oral liquid medications

2) Review the process for choosing the recommended standard

3) Describe the ramifications from insurance

companies once a national standard is set

Elizabeth Farrington, PharmD, FCCP, FCCM, FPPAG, BCPS

Pharmacist III – Pediatrics

New Hanover Regional Medical Center Department of Pharmacy Elizabeth.farrington@nhrmc.org 12:30-12:45

Closing Remarks and Farewell

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Volume 99 Number 1 Winter 2018

Pharmacy

Tomorrow.

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North Carolina’s Opioid Action Plan

By Penny Shelton

North Carolina, like so many other states in the union, has been hit hard by the opioid epidemic. Substance use disorders are killing individuals, devastating families and communities, and overwhelming law enforcement and healthcare providers, as well as outpacing available prevention and treatment services across the state.

According to the NC Injury and Violence Prevention Branch with the NC Division of Public Health, from 2009 to 2017, there was a 100% increase (5,745 vs. 2,879) in opioid overdose emergency department visits. During the five-year time frame of 2012 to 2016, North Carolina’s statewide, unintentional opioid-related mortality rate was 9.2 deaths per 100,000 persons. In 2016, there were 1,518 opioid-related deaths.

In addition, data from the NC Division of Mental Health, Controlled Substances Reporting System found the 2016 statewide dispensing rate for outpatient opioid pills to be 66.5

pills per resident. In 2016, there were 8,417,748 prescriptions for opioids dispensed in North Carolina.

In 2017, there were 5,734 opioid overdose emergency visits, a 40% increase when compared to 2016. The majority of opioid overdose patients were Caucasian (85%), male (62%), and between 25-34 years of age (39%). In addition, the majority (68%) of the overdoses seen in the ED were due to heroin.

The highest rates of 2017 opioid overdose ED visits occurred in Pamlico, Swain, McDowell, Haywood, Craven, Cabarrus, Vance, Buncombe, Rowan, Yad-

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kin and Stokes counties. It appears opioid-overdose ED visits are not trending down. North Carolina DETECT indicated 437 ED visits were due to an opioid overdose in January 2018, compared to 385 ED visits in January 2017.

According to the North Carolina Harm Reduction Coalition, there were 4,176 community-based opioid overdose reversals with naloxone in 2017.

The majority of these reversals required only one dose. However, in January 2018, when the naloxone dosage amount was reported (n=137), 17.5%

Volume 99 Number 1 Winter 2018

of reversals required 3 or more doses.

Heroin use is on the rise, and with that rise communities see increases in Hepatitis C, HIV and endocarditis cases due to sharing of syringes. There is an increased need for needle exchange programs and the selling of clean syringes. As of February 2018, the NC Harm Reduction Coalition reported only 25 active syringe exchange programs covering 31 counties in North Carolina.

Last summer Governor Cooper and Secretary Cohen unveiled a plan to tackle the opioid epidemic in North Carolina.

In addition, our state has been using an Opioid Prescription Drug Abuse Advisory Committee since 2016, and a related workgroup since 2017, to generate solutions and to coordinate multi-agency efforts and resources. The NC Division of Health and Human Services, the Division of Public Health and the Injury and Violence Prevention Branch have taken on key roles for bringing stakeholders, such as the North Carolina Association of Pharmacists, to the table to help drive positive change for the seven strategic areas of the North Carolina Opioid Action Plan.

The Plan was developed with stakeholders and community partners input and provides a living document that will be updated as progress is made.

The strategic areas of the Plan include: • Coordinating the state’s

infrastructure to tackle the opioid crisis, • Reducing the oversupply of prescription opioids, • Reducing the diversion of prescription drugs and the flow of illicit drugs, • Increasing community awareness and prevention, • Making naloxone widely available, • Expanding treatment and recovery systems of care, and • Measuring the effectiveness of these strategies based on results.

The North Carolina Association of Pharmacists and the profession of pharmacy have been identified in the Plan to help with five of these areas.

Our partners at the state level, as well as within the community, have recognized that pharmacists are an underutilized but valuable resource capable of making a difference. In order to better prepare pharmacists and to help pharmacy’s involvement be more impactful, NCAP is currently working on three phases of opioid-related, educational and practice transformation initiatives. Phase I will provide fundamental e-learning content, which will deliver essential information regarding various aspects of the opioid epidemic.

Phase II will be regional workshops filled with practical information, skills, and resources designed to help pharmacists transform their practices. Phase III will provide certificate level

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education for pharmacists in recovery coaching and medication assisted treatment for addiction. Statewide stakeholders, external to pharmacy, are beginning to look to pharmacy for solutions. NCAP is mobilizing to help prepare pharmacists while simultaneously advocating that our profession can make a difference.

Poisoning Data. NC Division of Public Health. Injury and Violence Prevention Branch. http://ivp.ncpublichealth.info/DataSurveillance/Poisoning.htm.

Accessed: February 24, 2018.

NC Overdose Data NC Opioid Prescription Drug Abuse Advisory Committee. Injury and Violence Prevention Branch. https://sites.google.com/view/ ncpdaac/data. Accessed February 24, 2018.

NC Opioid Action Plan: Version 1, June 2017. NC Division of Health & Human Services. https://files.nc.gov/ncdhhs/ NC%20Opioid%20Action%20 Plan%208-22-2017.pdf. Accessed: February 24, 2018.

Volume 99 Number 1 Winter 2018

Updates of Interest to Readers of North Carolina Pharmacist

The December 2017 Comprehensive Medication Management Update (ACCP grant awarded to UNC Eshelman School of Pharmacy) can be found at: https://www.accp.com/report/index.aspx?iss=1217&art=4 The Pneumonia Knockout Campaign Newsletter (January 2018) from the North Carolina Quality Center can be found at: https://www.ncqualitycenter.org/initiatives/pneumonia-knockout/pneumonia-knockout-campaign-resources/january-2018/ New 2018 ACIP immunization schedule for children and adolescents aged 18 years and younger can be found at: https://www.cdc.gov/mmwr/volumes/67/wr/ mm6705e2.htm?s_cid=mm6705e2_e New 2018 ACIP immunization schedule for adults aged 19 years and older are available at: https://www.cdc.gov/mmwr/volumes/67/wr/mm6705e3.htm?s_

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Volume 99 Number 1 Winter 2018

Impact of Naloxone Education on Healthcare Professionals’ Knowledge and Attitudes

By Jacqueline Hagarty, Matthew Martin, Michael DeValve, Susan Miller

Abstract Background: Naloxone, a safe opioid overdose reversal agent, is now more accessible in North Carolina through a statewide standing order. However, general awareness about naloxone is low. Previous studies identified healthcare providers’ perceived barriers to prescribing naloxone due to lack of knowledge about naloxone dosage forms for use in the community, worries about encouraging drug abuse, and concern about legal liabilities. The purpose of this study was to determine if a targeted naloxone education program increases knowledge and positive attitudes of health care professionals concerning naloxone use in the community.

Methods: Educational sessions were held for healthcare professionals in one region of North Carolina.

The Opioid Overdose Knowledge Scale (OOKS) and Opioid Overdose Attitudes Scale (OOAS) were administered before and after each educational session to assess for immediate changes. The mean change in overall pre- and post-test scores were analyzed and compared based on demographic information.

Results: One hundred one participants completed surveys. There was a 15% increase in the average knowledge score (33 to 40 out of 45 points, p-value <0.0125), and a 9% increase (106 to 119 out of 140, p-value <0.0167) in the average attitudes scores indicating an increase in readiness and positive attitudes towards naloxone use.

Limitations: This study utilized a convenience sample of healthcare professionals who attended the education sessions. Retention of knowledge and attitudes or behavioral changes following education sessions were not measured.

Conclusion: Targeted naloxone education is associated with an increase in short-term knowledge and positive attitudes towards naloxone use in the community.

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Background According to the Centers for Disease Control and Prevention (CDC), the amount of opioid overdose deaths quadrupled from 1999 to 2015.1 Opioids (opioid analgesics and heroin) accounted for 28,647 fatalities in 2014, or 61% of all drug overdose deaths.2 Over 1300 of these overdose deaths occurred in North Carolina.2 The United States attempted to address the source of the problem with prescription monitoring programs and suggested daily limits of opioids. Some community organizations are focused on preventing harmful consequences of drug use, such as criminalization, incarceration, spread of HIV and hepatitis, and death from overdose.3 Naloxone is a safe opioid reversal agent; it is one harm-reduction strategy increasingly used by first responders and laypeople in the community to address overdose situations in a timely manner.3 Intranasal and injectable dosage forms of take-home naloxone are indicated for layperson use in the community.4 North Carolina joined other states in efforts to make naloxone more accessible by granting emergency responders and police departments access to naloxone in 2010, and further expanded access to patients by allowing preventative distribution with a prescription in 2015.5 In June 2016, the North Carolina State Health Director signed a statewide standing order allowing pharmacists to dispense naloxone to anyone in need.5 Prescriptions can also be dispensed to a third party, such as a friend or family member of someone at risk.5 Despite the increased access to naloxone across the country, recent evidence suggests that there are many barriers that prevent healthcare professionals from prescribing and dispensing take-home naloxone.

Physicians from varying specialties across the United States (including internal medicine, family medicine, pain management, general practice, and many more), Volume 99 Number 1 Winter 2018

medical students, and medical residents indicate that one of the biggest barriers to prescribing take-home naloxone is a lack of knowledge about naloxone’s role in the community.6-10 Other barriers stated in the literature include a lack of guidelines or strong evidence that identifies candidates who would benefit from take-home naloxone, perceived legal issues with dispensing naloxone, and a lack of awareness of intravenous drug users among their patient population.6,7,9,10 There are also concerns from physicians, medical residents, and students, that naloxone may encourage higher drug use, that it does not tackle the source of the opioid epidemic, and that it might offend patients, despite the evidence that says otherwise.7-9 Pharmacists and pharmacy staff identified additional barriers to dispensing naloxone, especially without a prescription. Studies of community pharmacists in West Virginia and Massachusetts indicated that a main barrier to dispensing naloxone without a prescription is a lack of training.11,12 Pharmacists who underwent naloxone training in New Mexico cited a few perceived barriers to dispensing naloxone under a statewide standing order, including reimbursement challenges, affordability for patients, and lack of patient interest.13 Evidence exists to support that naloxone education programs increase patient and family member knowledge and positive attitudes towards naloxone and managing overdose situations.14-17However, few studies evaluate naloxone education programs for healthcare professionals.

Two European studies associated naloxone education with an increase in provider knowledge and positive attitudes.18,19 One study evaluated general practice residents,18 and the other evaluated interdisciplinary healthcare workers at multiple facilities.19 These studies used the Opioid Overdose Knowledge Scale (OOKS) and the Opioid Overdose Attitudes Scale (OOAS) to assess the efficacy of education for healthcare professionals and patients on layperson administration of naloxone.20 The OOKS and OOAS were developed and validated to measure change in patient and healthcare professional knowledge and positive attitudes towards naloxone use and overdose situations in an immediate pre-post test model.20 There are no published studies that utilize these scales in the Unites States to measure the effects of naloxone education for healthcare professionals.

Previously discussed studies that identify providers’ perceived barriers to prescribing of naloxone for layperson administration indicate that more education is needed.5-9 Many healthcare professionals practice in a position where they could identify patients at risk for opioid overdose, including primary care providers and North Carolina Pharmacist

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emergency providers. In past studies, the take-home naloxone education was typically described as a live and active learning environment.15-19 At the time of this project proposal, there did not appear to be any published studies that assessed the efficacy of take-home naloxone education for healthcare professionals. The purpose of this study was to determine if naloxone education is associated with a change in knowledge and attitudes in healthcare professionals.

Methods This was a single-group, pre-post quasi-experimental study. The education sessions took place from November 2016 through March 2017 within a large health system in southeastern North Carolina and assessed healthcare professionals from a medical center and affiliated clinics, a family medicine residency program, and the local public health department.

Participants – A convenience sample of 130 healthcare professionals attended one of six live education sessions. The education sessions originally targeted healthcare professionals working in an emergency department, behavioral health, an inpatient hospitalist group, and residents and faculty of a family medicine residency program. As an incentive, several of the sessions were offered with continuing education credit for physicians and nurses and advertised throughout the health system. However, these education sessions were open for any healthcare professional to attend, and they were advertised through emails and posters. Healthcare professionals who did not complete both a pre-test and post-test were excluded from the study. Individual participants’ pre-test and posttest scores were matched up by utilizing the last four digits of their social security number.

Measures – The primary endpoints of this study were the mean overall changes from pre-test to post-test scores on the OOKS and OOAS. Secondary endpoints included mean scores within each OOKS and OOAS subsection, differences in primary endpoints and pre-test scores between each demographic group, and change in the number of naloxone prescriptions at the family medicine residency program before and after education. The OOKS and OOAS measured knowledge and positive attitudes towards opioid overdose and naloxone use immediately before and after educational sessions. The OOKS (45 points total) assesses opioid overdose risks (9 points), signs (10 points), actions (11 points), and naloxone use (15 points).20 The OOAS (140 points total) assesses competence (50 points), concerns (40 points), and readiness (50 points) to manage an overdose and Volume 99 Number 1 Winter 2018

use of naloxone.20 The scales were used with permission from the original author, but the wording on both scales was adapted to include the intranasal naloxone dosage form. The term “fitting” was changed to “seizures” to better align with the US medical terminology.

Demographic questions were also added to the end of the post-test. The time between pre-test and post-test administration varied with the lengths of the educational sessions, but they were administered no more than one hour apart. A retrospective report generated the number of naloxone prescriptions written or electronically prescribed at the family medicine residency program before naloxone education, from June 2016 through October 2016, and after naloxone education, from December 2016 through April 2017. Naloxone prescribing habits were not tracked at any other locations where education was provided.

Education Sessions – Educational sessions were planned for varying targeted audiences and, therefore, varied slightly in content, length of time, and teaching intervention. The OOKS and OOAS pre-tests were administered on paper immediately before the educational sessions. The educational sessions generally covered the opioid epidemic, opioid pharmacology and overdose, naloxone pharmacology and dosage forms, identification of candidates for take-home naloxone, patient education, and North Carolina state laws regarding naloxone prescribing and use. All education sessions utilized a PowerPoint presentation, demonstration videos, and hands-on demonstration of various naloxone dosage forms using training devices. Immediately following the education sessions, the OOKS and OOAS post-test with added demographics was administered on paper.

were held for the county public health department and one hospital owned outpatient clinic. Sessions were conducted on November 8, 2016, December 2, 2016 (as shown on figure 3), January 9 and 12, 2017, February 23, 2017, and March 2, 2017. Of 130 attendees, 101 sets of scales were collected. Although the OOKS and OOAS were administered as one test, some participants only completed either the OOKS or the OOAS. Therefore, we collected 100 complete sets of OOKS and 96 complete sets of OOAS (see Table 1 for demographic information). Students were from various healthcare professions and undergraduate areas of study, including medical, pharmacy, and public health. “Others” included various healthcare professionals such as mid-level providers, physical therapists, and paramedics. Eight participants who did not provide demographic information were also classified as others.

Cronbach’s alphas for the OOAS were 0.725 for the readiness subsection, 0.877 for competence, and 0.793 for concerns. All calculated alphas were in an acceptable range (0.70 or higher in most research situations), demonstrating good internal reliability. A confirmatory factor analysis for the OOAS showed fair construct validity overall. However, several items across all three subsections had questionable validity based on our analysis. One such item may not be worded clearly enough, and could be misinterpreted.

A few other items in question surveyed participants about actions taken during overdose that were shown by video, but participants did not practice these actions in any simulation settings.

Data Collection and Analysis – Before analysis, the data were sanitized so as to be fully anonymous.

Descriptive statistics were used to describe naloxone prescribing at the family medicine residency clinic.

Scales and subscales were examined for scalability using Cronbach’s alpha and confirmatory factor analysis. The mean change in both individual’s and overall scores, the mean change in scores within each subsection of both scales, and differences based on demographics were analyzed using paired sample t-tests. Multivariate linear regression models were constructed in order to examine the relationship of demographic variables on scale score changes.

A paired samples t-test was performed. The mean change in OOKS score was an increase of 6.9 points, or 15% (SD 4.3, p<0.001). The mean OOKS pre-test score was 33.6, and the mean post-test score was 40.5, out of 45 points. The distributions of pre-test and post-test OOKS scores are shown in Figure 1. The mean change in OOAS score was an increase of 12.7 points, or 9% (SD 8.4, p<0.001). The mean OOAS pre-test score was 106.4, and the mean post-test score was 119.2, out of 140 points. The distributions of pre-test and post-test OOAS scores are shown in Figure 2. The mean scores within each subsection of the OOKS and OOAS are shown in Table 2. The differences between pre-test and post-test scores within each subsection were also significant (p<0.001).

Results There were 130 attendees at a total of six educational sessions. Following the initial project proposal of four education sessions, two additional sessions

Several differences in scores based on demographic information were identified. Participants who identified as pharmacists and pharmacy technicians had lower competence subsection scores compared

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to all other job title groups. The mean pre-test score was 28.11 for pharmacists and pharmacy technicians, and mean pre-test scores ranged from 32.12 to 37.40 for nurses and nursing assistants, physicians and mid-level providers, students, and other healthcare professionals. The mean post-test score in the competence subsection for pharmacists and pharmacy technicians was 38.37, in comparison to a range of 41.40 to 43.25 for all other groups. There were no differences at baseline (in pre-test scores) and no differences in change in scores between participants who had self, friend, or family members with opioid addiction, abuse or overdose and those participants who did not. However, there were a few differences between participants who had previously witnessed any overdose and those who had not. Participants who had previously witnessed an overdose had higher pre-test scores in the following subsections compared to participants who stated they had not witnessed an overdose: naloxone use (10.19 and 8.76, p<0.001), competence (37.71 and 30.55, p<0.001), and concerns (34.34 and 29.97, p<0.001).

There was no clear pattern in the number of naloxone prescriptions written or e-prescribed at the family medicine residency clinic before and after their education session. There was an overall decline in the number of monthly prescriptions from June 2016 to November 2016. Following the education session in December, the number of naloxone prescriptions increased to 7, but remained low (2 or less) for the next 4 months. The number of prescriptions each month can be found in Figure 3.

A regression model was used to look at the readiness subsection score as a dependent variable with demographics, OOKS scores, and the other two OOAS subsections as independent variables. The R square was 0.276. The adjusted R square was 0.122, the standard error of estimate was 2.988, R square change = 0.276, F change = 1.788, df1 = 13, and df2 was 61. However, only the competence and concerns scores demonstrated a significant impact on the readiness score (p=0.044 and 0.023, respectively).

Discussion This study showed a statistically significant increase in knowledge and positive attitudes in healthcare professionals regarding naloxone and opioid overdose management immediately following education sessions. Furthermore, we found a significant increase in scores of each subsection of the OOKS and OOAS. However, the results did not reveal any overall patterns in baseline scores or change in scores based North Carolina Pharmacist

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on demographic groups or educational interventions.

Additionally, the clinical relevance of these changes may not be known until follow-up studies can assess behavioral changes related to the increase in knowledge and positive attitudes.

A majority of the participants had previously received “none” or only “some” training on opioid prescribing and opioid overdose. This situation indicates the need for more education about opioids in healthcare professional training programs, especially because half of the participants reported 0-5 years of practice, indicating student or recent graduate status.

There may also be a need for more continuing education opportunities regarding opioid prescribing and overdose.

Pharmacists, as the medication experts, are in a position to provide education to other healthcare professionals regarding the topics of opioids, medicationassisted treatment (MAT), and naloxone. A new opioid action plan in North Carolina includes collaboration between healthcare professionals, law enforcement, the North Carolina Harm Reduction Coalition, and state governmental departments to reduce diversion, increase both awareness and naloxone access, and expand treatment programs.21 Pharmacists are called upon to aid in drug take-backs, participate in public education campaigns that includes opioid safety, dispense naloxone per the statewide standing order, and work with physicians to increase MAT for opioid use disorders. The North Carolina Association of Pharmacists (NCAP) is one organization that will provide educational resources to prepare pharmacists to educate other healthcare professionals.

Pharmacists are also in a position to provide opioid safety education to the general public. One recent news story suggests that a lack of training, awareness, and perceived importance of take-home naloxone may prevent patients from asking for it and pharmacists from prescribing it.22 Our study demonstrates that pharmacists may lack confidence to prescribe and dispense take-home naloxone. Although pharmacists may not have to respond to emergencies themselves, they should be able to counsel a patient, friend, or family member on naloxone and its use during overdose situations. Specific naloxone and overdose training for pharmacists may lead to improved patient education and awareness, but more studies are needed in this area.

The number of naloxone prescriptions was collected from the family medicine residency program Volume 99 Number 1 Winter 2018

because most of the providers in the clinic were able to attend the education session. It should be noted, however, that patients in North Carolina can obtain naloxone from a pharmacy under the statewide standing order, and that this study did not track conversations where the provider recommended naloxone without creating a prescription. The number of naloxone prescriptions increased in the month following the education session compared to the previous two months. However, the total number of naloxone prescriptions in the 5 months following the education session was less than the number of naloxone prescriptions in the 6 months preceding the education session. It is possible that the education session increased immediate awareness and identification of patients eligible for take-home naloxone, but over time it became less of a priority for these physicians.

These results only reflect the prescribing habits of the attendees of one education session, and it is not known if there were any changes in prescribing habits as a result of other education sessions.

Physicians and pharmacists reported lack of knowledge about naloxone’s role in the community as one of the biggest barriers to prescribing or dispensing it in previous studies.6-12 Our regression model demonstrated that participants’ readiness to use naloxone and manage an opioid overdose was significantly dependent on their attitudes (concerns and competence), but not on their increase in knowledge or demographics. Therefore, the results of this study suggest that lack of knowledge may not be the biggest barrier to prescribing naloxone. Although a significant increase in scores was found in all three subsections of the OOAS, the competence subsection had the largest increase in score. The questions in the competence subsection assessed a person’s confidence in knowing what to do during an opioid overdose. The minimal improvement in the concerns subsection may have contributed to the minimal increase in the readiness subsection. Our results suggest that an increase in confidence and decrease in concerns may be necessary to increase readiness to use naloxone to manage overdoses.

There are several limitations to this study. This study utilized a convenience sample of healthcare professionals who attended the educational sessions.

Many of the participants were not required to attend.

It is possible that people who attended were more willing to learn about opioid overdose and naloxone.

Not all attendees turned in both the pre-test and the post-test. It is not known how their participation would have affected the results. Availability of healthcare North Carolina Pharmacist

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professionals and time restrictions placed on the educational sessions may have affected the educational interventions, the participants’ knowledge and attitudes, and the amount of completed scales turned in. Finally, the scales were not designed to measure retention of knowledge, and for various logistical reasons, follow-up beyond the education sessions was not attempted in this study. Surveys were kept anonymous to encourage participation, so no contact information was collected. Contact information was not pursued because online survey response rates are generally poor. This study did not measure behavioral changes including overall naloxone dispensing or use, or other outcomes such as overdose mortality. In the one setting where prescribing habits were tracked, education did not seem to have a lasting effect on rates of naloxone prescriptions.

Conclusion Targeted naloxone education programs may increase short-term knowledge and positive attitudes of healthcare professionals concerning opioid overdose and readiness to use naloxone. Pharmacists are in a position to provide naloxone and opioid overdose education to other members of the healthcare team.

It may be of interest to assess what concerns are not adequately addressed in current naloxone education for healthcare professionals. Additionally, more studies are needed to assess behavioral changes following naloxone education in order to determine optimal educational interventions for healthcare professionals.

Authors and affiliations at the time this study was conducted: Jacqueline Hagarty PharmD1,2, Matthew Martin PhD1, Michael DeValve PhD3, Susan Miller PharmD1,4 1 Southern Regional Area Health Education Center, Fayetteville, NC 2 Cape Fear Valley Health System, Fayetteville, NC 3 Fayetteville State University, Fayetteville, NC 4 University of North Carolina, Chapel Hill, NC Corresponding Author: Jacqueline Hagarty (former PGY1 Pharmacy Practice Resident at Cape Fear/SRAHEC) jacki.chorzempa@gmail.com Disclosures The authors have no conflicts of interest to disclose.

No financial support was required to complete this study.

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References 1. Opioid Overdose. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/data/statedeaths.html. Published December 16, 2016. Accessed April 21, 2017.

2. Rudd R, Aleshire N, Zibbell J, Gladden R. Increases in drug and opioid overdose deaths — United States, 2000–2014. Morb Mortal Wkly Rep [Overdose Stats]. 2016;64(51):1378-1382.

3. Hawk KF, Vaca FE, Onofrio G. Reducing fatal opioid overdose: Prevention, treatment and harm reduction strategies. Yale J Biol Med. 2015;88(3):235-245.

4. American Heart Association. Web-based integrated guidelines for cardiopulmonary resuscitation and emergency cardiovascular care - part 10: Special circumstances of resuscitation. ECCguidelines.heart.org. Updated 2015.

5. Naloxone overdose prevention laws. The Policy Surveillance Program Web site. http://lawatlas. org/query?dataset=laws-regulating-administration-of-naloxone. Published July 1, 2016. Updated 2016. Accessed September 10, 2016.

6. Beletsky L, Ruthazer R, Macalino GE, Rich JD, Tan L, Burris S. Physicians’ knowledge of and willingness to prescribe naloxone to reverse accidental opiate overdose: Challenges and opportunities. J Urban Health. 2007;84(1):126-136.

7. Binswanger IA, Koester S, Mueller SR, Gardner EM, Goddard K, Glanz JM. Overdose education and naloxone for patients prescribed opioids in primary care: A qualitative study of primary care staff. J Gen Intern Med. 2015;30(12):1837-1844. doi: 10.1007/s11606-015-3394-3.

8. Gatewood AK, Van Wert MJ, Andrada AP, Surkan PJ. Academic physicians’ and medical students’ perceived barriers toward bystander administered naloxone as an overdose prevention strategy. Addict Behav. 2016;61:40-46. doi: 10.1016/j. addbeh.2016.05.013.

9. Leece P, Orkin A, Shahin R, Steele LS. Can naloxone prescription and overdose training for opioid users work in family practice?: Perspectives of family physicians. Can Fam Physician.

2015;61(6):538-543.

10. Wilson JD, Spicyn N, Matson P, Alvanzo A, Feldman L. Internal medicine resident knowledge, attitudes, and barriers to naloxone prescription in hospital and clinic settings. Subst Abus. 2016:18. doi: 10.1080/08897077.2016.1142921.

11. Thornton JD, Lyvers E, Scott VG, Dwibedi N. Pharmacists’ readiness to provide naloxone in community pharmacies in West Virginia. J Am Pharm Assoc (2003). 2017;57(2S):S12-S18.e4.

12. Stopka TJ, Donahue A, Hutcheson M, Green TC. North Carolina Pharmacist

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13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

Nonprescription naloxone and syringe sales in the midst of opioid overdose and hepatitis C virus epidemics: Massachusetts, 2015. J Am Pharm Assoc (2003). 2017;57(2S):S34-S44.

Morton KJ, Harrand B, Floyd CC, et al. Pharmacy-based statewide naloxone distribution: A novel “top-down, bottom-up” approach. J Am Pharm Assoc (2003). 2017;57(2S):S99-S106.e5.

Albert S, Brason FW,2nd, Sanford CK, Dasgupta N, Graham J, Lovette B. Project lazarus: Community-based overdose prevention in rural north carolina. Pain Med. 2011;12 Suppl 2:S77-85. doi: 10.1111/j.1526-4637.2011.01128.x Barocas JA, Baker L, Hull SJ, Stokes S, Westergaard RP. High uptake of naloxone-based overdose prevention training among previously incarcerated syringe-exchange program participants. Drug Alcohol Depend. 2015;154:283-286. doi: 10.1016/j.drugalcdep.2015.06.023 Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in massachusetts: Interrupted time series analysis.

BMJ. 2013;346:f174. doi: 10.1136/bmj.f174 Williams AV, Marsden J, Strang J. Training family members to manage heroin overdose and administer naloxone: Randomized trial of effects on knowledge and attitudes. Addiction.

2014;109(2):250-259. doi: 10.1111/add.12360 Klimas J, Egan M, Tobin H, Coleman N, Bury G. Development and process evaluation of an educational intervention for overdose prevention and naloxone distribution by general practice trainees. BMC Med Educ. 2015;15:206-015-0487-y.

Madah-Amiri D, Clausen T, Lobmaier P. Utilizing a train-the-trainer model for multi-site naloxone distribution programs. Drug Alcohol Depend. 2016;163:153-156. doi: 10.1016/j.drugalcdep.2016.04.007 Williams AV, Strang J, Marsden J. Development of opioid overdose knowledge (OOKS) and attitudes (OOAS) scales for take-home naloxone training evaluation. Drug Alcohol Depend.

2013;132(1-2):383-386. doi: 10.1016/j.drugalcdep.2013.02.007 North Carolina’s Opioid Action Plan 2017-2021.

North Carolina Department of Health and Human Services. https://www.ncdhhs.gov/opioids.

Published June 2017. Accessed October 1, 2017.

Gorman A. Pharmacists Slow To Dispense Lifesaving Overdose Drug. Kaiser Health News. https://khn.org/news/pharmacists-slow-todispense-lifesaving-overdose-drug/. Published January 2018. Accessed January 12, 2018.

Volume 99 Number 1 Winter 2018

Table 1: Participant Demographics

Number (%)

Job Title Physician Pharmacist/Pharmacy Technician Nurse/CNA/CMA Student Other

23 (23) 20 (20) 9 (10) 18 (18) 31 (31)

Number of Years Practicing 0-5 6-10 11-20 21-30 30+

48 (53) 8 (9) 15 (17) 12 (13) 7 (8)

Previous Training on Opioid Overdose None Some Adequate Extensive

38 (41) 36 (39) 12 (13) 7 (8)

Previous Training on Opioid Prescribing None Some Adequate Extensive

34 (37) 32 (34) 18 (19) 9 (10)

Previously Witnessed an Overdose No Yes

61 (66) 32 (34)

Self/Friend/Family Opioid Dependence or Abuse No Yes

68 (73) 25 (27)

Self/Friend/Family Overdosed on Opioids No Yes

78 (84) 15 (16)

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Table 2: OOKS and OOAS Subsection Scores

Pre-Test

OOKS Risk Signs Action Naloxone Use OOAS Competence Concerns Readiness

Post-Test

Mean Change n (%)

P-value

Median

Mean

Std Dev

Median

Mean

Std Dev

7 7 10 11

6.60 6.79 9.62 9.21

2.34 1.87 1.08 2.18

9 9 11 14

7.48 8.67 10.41 12.15

2.22 0.92 0.92 1.05

0.9 (10) 1.9 (19) 0.8 (8) 2.9 (19)

<0.001 <0.001 <0.001 <0.001

32 31 43

32.86 31.38 42.41

7.13 4.69 4.15

41 33 45

41.25 33.97 44.36

5.33 4.57 3.94

8.4 (17) 2.6 (6) 1.9 (4)

<0.001 <0.001 <0.001

Abbreviations: Std Dev = Standard Deviation

Figure 1: Distribution of Pre-Test and Post-Test OOKS Scores

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Figure 2: Distribution of Pre-Test and Post-Test OOAS Scores

Figure 3: Number of Naloxone Prescriptions at a Family Medicine Clinic by Month

The number of naloxone prescriptions written each month at one family medicine clinic. Education was performed at this clinic on Dec 2, 2016. Naloxone prescriptions were not tracked at any other location where educations sessions were held.

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the community’s overall health in a meaningful way. Professionals in medical mission organizations promote gradual improvements in morbidity and overall quality of life in the community over time by providing access to basic medical care such as multivitamin use, treatment for bacterial and helminth infections, and management of chronic conditions such as diabetes and hypertension. Many By organizations provide volunteers with an international opportunity to Charlotte Morgan Forshay and Dennis Williams provide quality care to underprivileged populations. Service through medical missions can be personally Introduction and professionally rewarding while providing insights and understandIn October 2017, the authors (a pharmacist and a student pharmacist) ing of other cultures. participated in a medical mission trip to Honduras. The mission was affiliated with the Carolina Honduras Health Foundation (CHHF), Honduras Missions which is one of several organizations operating medical missions in Honduras, a Central AmeriHonduras. This paper’s purpose is to describe activities and oppor- can country with approximately tunities associated with medical missions and to encourage pharma- 8 million people, is a developing cists and pharmacy students to support and engage in these activities. country.1 Environmental-related Medical needs and opportunities exist in numerous countries, but this cause or conditions lead to sigdescription will focus on Honduras. nificant morbidity and mortality.

Key areas of health risk include unsafe drinking water, poor sanitaBackground opportunity for volunteers to travel tion, vector-borne diseases such Medical mission trips are and step outside of their comfort as malaria, and injury from road common among healthcare profes- zones, allowing them to gain a new traffic.2 In 2000, the World Health sionals, healthcare students, and perspective in their own lives and Organization (WHO) ranked Honnon-medical volunteers. Individu- practice. Mission trips provide duras as position 131 out of 191 als often seek involvement in medi- hands-on experiences and learning countries on overall health-system cal mission organizations because opportunities for professionals and performance.3 Due to the limited they view access to consistent students, while the team simultane- capacity of the healthcare system, and reliable healthcare as a global ously maintains quality services it is estimated that 18% of the concern where they can make a for the visited community. Finally, population does not have access to contribution. Volunteers are motimission trips result in lasting relahealth services.4 Government-fundvated to contribute to the efforts of tionships both within the volunteer ed healthcare services including a medical mission organization for team and the local citizens. These primary care, crucial medications, a number of reasons. Recognizlasting connections generate further and vaccinations seldom reach the ing that healthcare professionals involvement and funding for future residents of rural Honduras. Thereplay an important role in populamedical trips providing regular care fore, medical mission organizations tion health in developing countries to the community. that target the rural environments motivate individuals to join a mediOrganizations that offer supplement medical care in a sigcal mission effort. Additionally, consistent patient care in developnificant way. medical mission trips provide the ing countries significantly improve The Medical Mission

Opportunities for Pharmacist Involvement on Medical Missions

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Exchange (www.mmex.org) is a free, online database with information on medical mission organizations that serve a number of countries in Central America.5 With medical missions, strategies for care can be long-term, meaning that medical teams are present on a consistent basis for much of the year, or short-term, where teams travel either sporadically or periodically. Mission efforts can also be focused toward a general practice or a specialized practice, including ophthalmology, dentistry, general surgery, as well as others.

Healthcare professionals search this resource to identify mission experiences that fit their specific goals. Medical mission organizations utilize it to find volunteers for their planned trips. Volunteers can use this database to make patient-specific referrals to medical specialists. The Medical Mission Exchange currently lists 85 organizations in Honduras alone.5 The Carolina Honduras Health Foundation (CHHF) provides ongoing healthcare to the underserved population of Honduras through short-term mission trips. CHHF (www.chhf.org) began in 1987 with the purpose of providing free medical, dental, and ophthalmic services in the Department (state) of Colón, an area of the country with very little access to medical care. CHHF currently manages a primary clinic facility located in Limón, Department of Colón. The first medical mission trip to Limón occurred in 1995, and since then the organization has established a consistent presence in the area. CHHF organizes a total of 18 trips per year that are scheduled every other week from January through October.6

Our Experiences In October 2017, CHHF sent a medical mission team to Limón for a ten-day trip. The first two days consisted primarily of travel, with six hours of air travel from North Carolina to San Pedro Sula, Honduras, followed by a three-hour drive to the city of La Ceiba. The second day included a 4-hour drive to Limón. The team coordinated clinics in Limón, Department of Colón as well as the surrounding villages in the Department of Colón on the following six days. The final weekend of the trip consisted of travel back to La Ceiba, time to explore the local culture there, and then return to North Carolina.

Our healthcare team was comprised of two American physicians, two Honduran physicians, one pharmacist, one pharmacy student, one nurse practitioner, one physician assistant, four nurses, and three additional volunteers.

The primary clinic in Limón has a brick and mortar building equipped with a pharmacy, laboratory and examination rooms. Most of the remote clinic settings were staged in schools, churches or community centers. On several days, clinics were offered at remote locations and the volunteers were divided into two teams. On these clinic days, the team members worked in the facility located in Limón, or traveled up to two hours to provide clinical services in a nearby village.

During the October experience, our team saw a total of 1420 patients, and we filled a total of 5174 prescriptions throughout the week.

Overall, the treatment consisted of management of acute infections, chronic medication management, and initiation of referrals for more specialized care. The team

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also managed several emergencies during the week that occurred throughout the day, and sometimes at night.

On a typical clinic day, clinics operated from approximately 9:00 am until 4:00 pm, varying with number of patients waiting to be seen. However, the days were much longer as volunteers packed medications and supplies for remote clinics, prepared medications for easier dispensing, and assessed the day’s activities and experiences.

During clinics, local volunteers were responsible for patient intake with completion of necessary paperwork. Two nurses collected each patient’s blood pressure, heart rate, temperature, height, and weight at the triage station. Following triage, each patient was seen by one of the providers.

The provider (physician, nurse practitioner, or physician assistant) completed a patient examination form that detailed pertinent medical history, information from the physical exam, any labs that were collected, and the treatment plan. The provider was additionally responsible for completing the pharmacy form to indicate what medications were to be dispensed for each patient. The pharmacist or pharmacy student, with the help of one to two nurses or volunteers, dispensed the medications and provided a double check on medication selection and dosing. Local Honduran employees of the organization served as translators for both patient-provider interactions and extensive patient counseling on medications as instructed by the pharmacist.

The pharmacist played a unique and vital role by overseeing the operation of the pharmacy and providing clinical advice. For the travel clinic days, the pharmacist

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facilitated the packing of medications and supplies to ensure that each team was well stocked and prepared for the expected patient population. Throughout the clinic day, the pharmacist participated in the dispensing of the medications and checked prescriptions prepared by other team members. The pharmacist improved patient care through clinical decision-making, which included antibiotic dosing, pharmacotherapy adjustments based on patient-specific factors, and therapeutic substitutions. The pharmacist communicated through a local translator to provide patient counseling information for each medication to each patient. Finally, the pharmacist assessed inventory and communicated inventory needs to the next team arriving two weeks later. Overall, the pharmacist provided comprehensive medication therapy management for patients and educational training to the volunteer team regarding the dispensing process.

Another valued and appreciated aspect of this medical mission that was not initially anticipated was the engagement of Honduran citizens in making this experience a success. In the case of CHHF, the Honduran staff provided safe travel within the country, prepared two meals daily for the mission volunteers, and prepared laundry and maintenance services at the clinic facilities. Friendships and bonds were formed with these individuals, which enriched the experiences and expectations for future trips.

Scope of Pharmacist Responsibilities with Medical Missions Beyond clinic activities, there are opportunities for pharmacists and student pharmacists

to contribute to the quality of the medical mission experience. The expertise of pharmacists and pharmacy personnel can contribute to planning prior to travel and followup in assessing the success and ongoing needs for the mission.

A formulary is essential for quality and continuity of drug therapy for patients. Pharmacist participation in formulary development is critical as our perspective provides clinical information regarding safety and efficacy as well as recommendations related to cost and availability of medications.

With a direct role in dispensing medications, the pharmacist’s recommendations on inventory quantities ensure that the clinic is well stocked, while avoiding excess cost to the organization. The pharmacist directs the appropriate labeling for the medications dispensed.

Finally, the pharmacist provides a clinical consult role for the providers and organization leadership to advocate and guide appropriate medication selection and use across all mission trips.

Pharmacists collaborate with other clinicians to develop important recommendations regarding practice standards for chronic disease management and preferred therapies, while accounting for conditions unique to developing countries.

General Recommendations for Preparation In preparing for a medical mission trip, keep in mind several important requirements. Volunteers often need to use their own funds, or participate in encouraged fundraising, to support their travel. Local communities or churches may sponsor mission trips as outreach activities. Using CHHF as an ex-

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ample, funds necessary are $1500 to $2000 that covers travel (international and local), lodging and meals, and insurance. Additionally, a portion of the funds support the required medical and pharmaceutical supplies needed for the trip.

A valid passport is required, and individuals must visit a travel clinic to receive the necessary vaccinations and prophylactic medications specific to the country they are visiting. It is important to learn about the country’s culture and customs and understand access to local currency and what items are needed for the trip.

Depending on the specific location of the trip, volunteers should pack light and for warm/hot weather. There may be no air conditioning. It is not uncommon for volunteers to donate some clothes from the trip to the local community. Be prepared for housing with local living conditions, which likely entails sharing bedrooms and bathrooms with other team members. Meal preparation may or may not be provided, so plan ahead, especially if you have any food allergies. Finally, depending on the location and needs of the group, volunteers will work alongside local citizens from the area.

Summary Participation in a medical mission trip is rewarding and challenging. Pharmacy professionals and students have important roles in medical missions. If travel is not possible or desired, there are still many ways to get involved in medical mission efforts. Contributions to a global health initiative can include personal donations, raising awareness, organizing fundraising efforts, or volunteering services and expertise to a medical

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mission board. Regardless of the manner of participation, serving a medical mission can be a rewarding and enlightening experience.

Authors: Charlotte Morgan Forshay, 4th Year Student Pharmacist, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina.

Dennis Williams, PharmD, BCPS Associate Professor and Vice Chair Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina References 1. Countries: Honduras. World Health Organization website. http://www.who.int/ countries/hnd/en/. Updated

2017. Accessed October 28, 2017.

2. Environment and health in developing countries.

Health and Environment Linkages Initiative, World Health Organization website. http://www.who.int/ heli/risks/ehindevcoun/en/.

Updated 2017. Accessed October 28, 2017.

3. The World Health Report 2000, Health Systems: Improving Performance.

Geneva, Switzerland: The World Health Organization; 2000.

Arch Med. 2017; 9(4): 1-8. doi: 10.21767/19895216.1000222.

5. Medical Mission Organizations, Honduras. Medical Mission Exchange website. http://mmex.org. Published 2012. Accessed October 28, 2017.

6. Carolina Honduras Health Foundation website. https:// www.chhf.org/team-schedule.html. Published 2012.

Accessed October 28, 2017.

4. Carmenate-Milián L, Herrera-Ramos A, RamosCáceres D, et al. Situation of the Health System in Honduras and the New Proposed Health Model.

The NCAP On-Demand E-Learning library of offerings is expanding! These webinars are a member benefit as CE is FREE TO MEMBERS ONLY. Several clinical and other topics are now available. There is also a dedicated project team that is working this year to increase our E-Learning offerings.

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2018 NCAP ELECTION AND AWARDS ELECTION Deadline: May 1, 2018 NCAP members interested in serving on the NCAP Board and/or Practice Forum Executive Committees are invited to submit their bios by May 1.

NCAP Board of Directors NCAP will elect a President-Elect (to serve as President in 2020) and one At-large Board Member (3-year terms). Please send bio to Stephen Eckel (seckel@ unch.unc.edu) Chronic Care Practice Forum The Practice Forum will elect a Chair-Elect (3-year term) and four Executive Committee members (3-year terms). Please send bio to Jason Moss, 2018 Chair of the Practice Forum (mossj@campbell.edu).

Community Care Practice Forum The Practice Forum will elect a Chair-Elect (3-year term) and two executive Committee members (3-year terms). Please send bio to Cortney Mospan, 2018 Chair of the Practice Forum (cortneymospan@gmail.com).

Health-System Practice Forum The Practice Forum will elect a Chair-Elect (3-year term), two Executive Committee members (3-year terms) and two Delegates to ASHP (3-year terms).

Please send bio to Kira Harris, 2018 Chair of the Practice Forum (kira.brice@gmail.com) .

Cardinal Health Foundation Rx Champions Award (sponsored by Cardinal Health) This award recognizes a pharmacist for his/her work within the pharmacy community to raise awareness of the serious public health problem of prescription drug abuse.

Don Blanton Award Presented to the pharmacist who has contributed most to the advancement of pharmacy in North Carolina during the past year. This award was established by Charles Blanton in memory of his father, Don Blanton, who served the North Carolina Pharmaceutical Association as President 1957-58.

Excellence in Innovation Award (sponsored by UpsherSmith Laboratories) Presented to a pharmacist practicing in North Carolina who has demonstrated Innovative Pharmacy Practice resulting in improved patient care.

AWARDS

Deadline for Nominations: May 1, 2018 It is a privilege for the North Carolina Association of Pharmacists to recognize excellence within the profession. NCAP members are invited to nominate deserving members for the following awards to be presented at the Annual Convention. Nominations must be in writing (see nominations form is on the website www.ncpharmacists.org or you may request from Linda Goswick). Send nominations to the NCAP Awards Committee, c/o Linda Goswick, 1101 Slater Road, Suite 110, Durham, NC 27703; FAX 984-439-1649; or e-mail linda@ncpharmacists.org North Carolina Pharmacist

Bowl of Hygeia Award (sponsored by American Pharmacists Association Foundation and National Alliance of State Pharmacy Associations) Criteria for this award are: (1) Licensed to practice pharmacy in NC; (2) Has not previously received the Award; (3) Is not currently serving nor has he/she served within the immediate past two years on its awards committee or as an officer of the Association in other than an ex officio capacity; (4) Has compiled an outstanding record of community service, which, apart from his/her specific identification as a pharmacist, reflects well on the profession.

Distinguished Young Pharmacist Award (sponsored by Pharmacists Mutual Companies) Criteria for this award are: (1) Entry degree in pharmacy received less than 10 years ago (2008 or later graduation date); (2) Licensed to practice pharmacy in NC; (3) Actively practices retail, institutional, managed care or consulting pharmacy; (4) Participates in national pharmacy associations, professional programs, state association activities and/or community service. Please send nominations for this award to Kevin Helmlinger, 2018 Chair of the New Practitioner Network (kevin. helmlinger@gmail.com)

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