North Carolina Pharmacist Volume 99 Number 2

North Carolina Pharmacist Volume 99 Number 2 Spring 2018 Advancing Pharmacy. Improving Health.

Putting the Pieces Together Your Membership Matters Join NCAP or Renew Today at ncpharmacists.org

Inside this issue: Save the Dates • Call for Articles and Reviewers • Member Spotlights • The Asheville Summit • The Medipreneurs Summit • In the News Official Journal of the North Carolina Association of Pharmacists ncpharmacists.org

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 EDITOR & CHIEF Ralph Raasch ASSOCIATE EDITOR Tina Thornhill LAYOUT/DESIGN Rhonda Horner-Davis EDITORIAL BOARD MEMBERS Anna Armstrong Jamie Brown Lisa Dinkins Jean Douglas Brock Harris Amy Holmes John Kessler Angela Livingood Ronald Small Bill Taylor

BOARD OF DIRECTORS EXECUTIVE DIRECTOR Penny Shelton PRESIDENT Stefanie Ferreri 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 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.

North Carolina Pharmacist Volume 99 Number 2

Spring 2018

Inside • From the President .................................................................3 • From the Executive Director .............................................................4 • Call for Articles and Reviewers ............................................................................7 • Save the Dates 2018 NCAP Convention ........................................................8 • Member Spotlights..............................................................................10 • Pharmacist Impact on Provider Quality Measures ..........................................13 • Infective Endocarditis and Injection Drug Use.................................................15 • The Asheville Summit on Population Health 2018 .............................................17 • A Students Perspective: Integrating Into a Team .................................21 • Pharmacists Can Fight the Opioid Crisis by Selling Syringes ......................24 • Inaugural Medipreneurs Summit..................................................................30 • New Inhaler Devices and the Importance of Appropriate Technique ..............33 • Partnerships and Growth for NCAP’s Pharmacy Technician Members ..............35 • In the News .........................................................................................................37

North Carolina Pharmacist is supported in part by: • Epic Rx..........................................................................................................6

• MedsOnCue ................................................................................................12 • Pharmacists Mutual Companies..................................................................20

• Epic Rx........................................................................................................23

• Pharmacy Technician Certification Board...................................................29 • NCAP Career Center...................................................................................32 • VIP Pharmacy Systems...............................................................................34

• Pharmacy Quality Commitment..................................................................36 • Smith Drug Company..................................................................................38

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•From the President • Stefanie Ferreri, PharmD

Congratulations to Residency Preceptors and Graduates!

Just as life is unpredictable, so will likely be your journey in pharmacy. Part of the fun of our great profession Congratulations to the many is we can take advantage of residency program directors and opportunities that come our preceptors across the state who way. This year marks my 20th are celebrating outgoing and anniversary graduation from incoming residents this month! my first residency, which was Your mentorship and leaderin Connecticut. If you had told ship in training the next genera- me at that time that I would tion of pharmacy professionals be raising my family in North is critical to the future of our Carolina, be a professor at UNC profession and the leaders of or be the president of the state NCAP want to thank you for association of pharmacy, I don’t your service! Personally, I want think I would have believed to thank the leadership at Nov- you. However, I embarked on ant Health for inviting NCAP to my journey post-residency speak at its end-of-year residen- with an open mind and an cy celebration. I had the pleaadventuresome spirit. sure of addressing 21 outgoing residents as they transition to either a PGY2 position or to No matter where you are their first employment opportu- in your career, I hope you nity. will take advantage of the Graduation ceremonies and end of residency celebrations are a great time for graduates to reflect on our journey and celebrate the successes along the way. It is also a time to plan the next steps on your professional journey; however, it is important to realize that not everything can be planned.

professional opportunities that are presented to you. NCAP is working hard to help create and develop these opportunities, and we need your help!

This summer, the NCAP Board of Directors will be asking members to share successes within their practices. Day

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two of our Annual Meeting in September will focus on important pharmacy issues within different sectors of pharmacy. The sectors we want to highlight include healthsystem, ambulatory care, public health, academia, community, long-term care, technician and students. The format for this day will be a combination of facilitated discussions and short presentations to advance each of these sectors of pharmacy practice. These sessions will be highly interactive so we can network and engage with one another on these pharmacy issues. Information gleaned from these sessions will serve to shape NCAP’s strategic plan and advocacy agenda for 2019. In order for this day to be a success, we need people to volunteer for activities and to invite your co-workers and colleagues to attend. We want to hear from you.

Please consider being part of this day. Don’t hesitate to reach out to me via email (stefanie_ ferreri@unc.edu) or twitter (@ stefanieferreri).

Volume 99 Number 2 Spring 2018

•From the Executive Director• Penny Shelton, PharmD, BCGP, FASCP

Speaking Up, Being Present, and Getting a Seat at “the Table” Throughout my life, there have been times all along the way, when I have heard the expression “it’s not what you know, but who you know, that is important”.

stakeholder meetings, and by being present, other healthcare providers and policy makers have heard about the importance of how pharmacists can help with various Throughout my life, there to “be at the table” and how so needs in our state. By being have been times all along the many times we as a profession present and speaking up on way, when I have heard the missed out on an opportunity behalf of pharmacy, doors have opened, such as an inviexpression “it’s not what you or had been overlooked or tation to the Governor’s Manknow, but who you know, surpassed because we were sion to speak with Governor that is important”. Early on not present.

Cooper and Secretary Cohen as a dedicated student and about Medicaid expansion. new practitioner, I often My second-year anniversary Additionally, we have been questioned the validity of as Executive Director just st this adage. I mean certainly passed on June 1 . I have and invited to various meetings to discuss necessary protections will continue to serve NCAP working hard, accumulating for pharmacy as North Carowith three key initiatives in knowledge and experience, lina transitions our Medicaid mind: 1) building awareness well, that had to be more about the Association and the to a managed care model. valuable, right? Yet as the roles of pharmacists, 2) creat- NCAP was also present at the years continued to tick by, I table with the State’s Opioid ing value for members; and began to note both personal Action Plan. We worked hard and professional experiences; 3) generating a voice for our to make sure pharmacy was whereby, being present at the profession. In the two years not only included, but that that I have served as your right time, or the strength of Executive Director, I have paid pharmacists and our Associaone’s network or an individtion were specifically menwitness to the importance ual’s level of connectedness tioned as important resources seemed to be the often elusive of “who you know” and “the yet magical factor that opened invite to the table” on numer- in fighting this public health crisis. NCAP has had imporous occasions. Through the doors or led to new opporturoles of generating a voice and tant meetings with Medicaid nities. Similarly, throughout building awareness, NCAP has regarding payment for servicmy career, I have heard how es and enrollment of pharmahad a presence at important important it is for pharmacy North Carolina Pharmacist

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Volume 99 Number 2 Spring 2018

cists for such services. There have been meetings with other healthcare associations, Representatives, Senators and the Attorney General’s office throughout this past year.

The relationships developed over the past two years on behalf of NCAP have led to strong partnerships. In the past two months, NCAP has applied for three different grants, all of which were opportunities brought to us based on NCAP having been present and at the table. The grants I’ve written are all designed to help bolster the reach of the Association and the voice of our profession.

The grants all seek funding to help pharmacists provide innovative patient care. Did you know that North Carolina ranks a disappointing 36th among the 50 states in health outcomes; or that NC is among the worst states, ranked 46th, for the percent of low-income adults who go without care due to cost; or that North Carolina had four of the top twenty-five cities for opioid overdoses? Pharmacists are a well-educated, highly trained, yet far too often underutilized resource.

Our profession has the ability to make a difference. Through NCAP, and the key initiatives of building awareness and generating a voice, we are beginning to get the attention of important stakeholders

and we are beginning to open doors.

Our voice is only as strong as our Association. As we continue to struggle with finding innovative healthcare solutions, transitioning Medicaid to managed care, fighting for provider designation and fair business practices, as well as inclusion in existing payment structures and future valuebased care models, pharmacy needs to come together in support of NCAP. NCAP should be the conduit for yielding change and providing that all important voice and sense of community for our profession.

In my heart I have faith in my profession and my colleagues.

The phone at NCAP rings often with inquiries as to what the Association is doing to help with work environment, PBM transparency and claw back fees, provider status or ability for pharmacists to get paid for services, and so forth.

Pharmacists turn to the Association when they have a need. Our profession needs our Association to represent them all the time, not just when a crisis arises.

The Board of Directors and I are doing our part. We are getting us to the table. We are talking with the “who you know” folks that can help make a difference, but we

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need your help, too; therefore, I’m going to close my column this time with two important statistics and a challenge.

Did you know that the most effective state pharmacy associations are the ones that have at least 20% of pharmacists in their state as members? We say that pharmacists in North Carolina are involved, engaged, active, and are progressive with regard to patient care. We like to think that North Carolina leads the way when it comes to pharmacy; while this used to be true, our state is falling behind. Did you know that less than 1 in 12 pharmacists in North Carolina are members of NCAP? How can we protect our profession and how can we be active at every necessary table if we don’t have a stronger membership? My challenge to you, the reader, is to tell five pharmacists about the great work of our Association and recruit at least two of those five to join. I have found that the most successful means of growing our membership is via our members.

You have the power to make our Association more effective and influential. Take the challenge! I look forward to welcoming the new members.

Pharmacy Proud, Penny

Volume 99 Number 2 Spring 2018

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Call for Articles

Call for Reviewers

The North Carolina Pharmacist is the official journal of the North Carolina Association of Pharmacists that seeks to advance the care of patients and the pharmacy profession. It is published online quarterly. It is a peer-reviewed publication that is intended to inform, educate, and motivate pharmacists, from students to seasoned practitioners, and pharmacy technicians in all areas of pharmacy.

The North Carolina Association of Pharmacists is currently seeking pharmacists interested in serving as a peer reviewer for our journal, the North Carolina Pharmacist. We accept a diverse scope of articles, including but not limited to: original research, quality improvement, medication safety, case reports/case series, reviews, clinical pearls, unique business models, technology, and opinions.

The journal is published online quarterly and is intended to inform, educate, and motivate pharmacists, from students to seasoned practitioners, and pharmacy technicians in all areas of pharmacy.

North Carolina Pharmacist is currently accepting articles for publication consideration. We accept a diverse scope of articles, including but not limited to: original research, quality improvement, medication safety, case reports/case series, reviews, clinical pearls, unique business models, technology, and opinions.

We are looking for those with a strong interest and expertise in the following: · Compounding · Hematology

Click on Guidelines for Authors for information on format and article types accepted for review.

Articles written by students, residents, and new practitioners are also welcome. Mentors and preceptors – please consider and advise your mentees and students to submit their appropriate written work to North Carolina Pharmacist for publication.

· Hospice / Palliative care · Pharmacy Law / Legislation · Men’s Health · Nutrition · Oncology · Pharmacoeconomics · Surgery

· Toxicology Don’t miss this opportunity to share your knowledge and experience with the North Carolina pharmacy community by publishing an article in North Peer review helps to validate research and increases networking possibilities. Don’t miss this opCarolina Pharmacist. portunity to share your knowledge and experience with the North Carolina pharmacy community.

Click here for Peer Reviewer Application and send the completed form to Tina Thornhill, Editor, at tina.h.thornhill@gmail.com.

Any questions? Please contact Tina Thornhill, PharmD, FASCP, BCGP, Editor, at tina.h.thornhill@gmail.com.

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Volume 99 Number 2 Spring 2018

2018 NCAP Annual Convention “Positioning for Influence: From Patient Stories to Pharmacy Vision�

Come Join Us

September 21-22, 2018 at the

Benton Convention Center in

Winston-Salem, NC Click here to book your room at the Winston-Salem Marriott

by August 23 for the special rate of $149.00 a night

Exhibitors Click here for a registration form to reserve your spot by September 10 or contact Sandie Holley at sandie@ncpharmacists.org for details

Visit ncpharmacists.org for more details coming soon North Carolina Pharmacist

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Volume 99 Number 2 Spring 2018

Click Here

This study guide contains pertinent federal- and state-level statutes and regulations for the practice of pharmacy in North Carolina. There are 75 “Test Your Knowledge� questions spread throughout the sections of the study guide; and as an added bonus, the guide contains a mock test with 80 practice questions. The book will be shipped in the form of a binder with loose leaf pages, making it easy to highlight and take notes as you work through the material. Purchase your copy today for $99 plus $10 Shipping and Handling.

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Volume 99 Number 2 Spring 2018

Member Spotlights!

Community Care Practice Forum Member Spotlight Christina Nunemacher The NCAP Community Care Practice Forum is proud to showcase Dr. Christina Nunemacher, PharmD, BCGP for our quarterly member spotlight. Dr. Nunemacher earned her BSPharm from the Philadelphia College of Pharmacy and her PharmD from Shenandoah University. Currently, she serves as clinical pharmacist at Realo Discount Drug in Jacksonville, NC where she provides support for Realo’s clinical services program.

Dr. Nunemacher is also a student and PGY-1 CommunityBased Pharmacy residency preceptor. In her role at Realo, Dr. Nunemacher works with patients one-on-one, care managers, and providers in Realo’s transition of care, chronic care management, and medication therapy management services. These services expand outside of the walls of the pharmacy to also include hospital and home visits. Dr. Nunemacher works to expand the view of the pharmacist outside of the profession of pharmacy by collaborating with key community stakeholders such as health departments and provider groups. Further, she stresses to her learners at her site the importance of engaging outside of the profession. Not only does Dr. Nunemacher believe it is essential to inspire fellow colleagues to become actively involved in local, state, and national pharmacy organizations, she views a key cog in advancing the profession being engaged in non-pharmacy specific organizations as well. Dr. Nunemacher credits NCAP for helping her stay abreast of innovative and forward-thinking pharmacy services throughout the state and even beyond. Awareness of these innovations inspires her and helps prevent her from becoming stagnant in her own practice. As a result, she co-facilitated a roundtable at NCAP’s Annual Convention on transitions of care services. Prior to moving to North Carolina, Dr. Nunemacher practiced in her home state of Pennsylvania, where she didn’t participate in her state association. She states North Carolina Pharmacist

“Now that I’ve experienced NCAP, I understand why membership matters. It’s not only the best way to stay current on where the profession is at and where it is going, it encourages pharmacists to continually reflect on our practice and find innovative ways to improve.” In addition to her independent community pharmacy experience, Dr. Nunemacher has worked in hospital practice and chain community pharmacies and developed curriculum for Coastal Carolina Community College’s pharmacy technician training program. She highlights a key role of the community pharmacist, empowering patients in their healthcare. She states, “I enjoy getting to know the patients that I serve, learning about what’s important to them and helping them realize what they can accomplish as they work towards achieving their own healthcare goals.”

Health-system Practice Forum Member Spotlight Dwight Cowart The NCAP Health-system Practice Forum proudly lifts up Dr. Harry “Dwight” Cowart, PharmD, BCNSP in our Member Spotlight. After playing football for East Carolina University, he received his Bachelors of Science in Pharmacy in 1979 and his Doctor of Pharmacy in 1999, both from the University of North Carolina in Chapel Hill. He is currently on staff at Pender Memorial Hospital as the full-time pharmacist providing clinical pharmacy and nutrition support services. Dwight serves as a preceptor for IPPE and APPE pharmacy students from all North Carolina Schools of Pharmacy. Dr. Cowart was inspired to specialize in nutrition support by his father’s experience with colon cancer. His father was diagnosed with colon cancer in 1967, and medical therapy and nutrition support were much different than today. During his father’s treatment, he lost 130 pounds and was never able to speak with a pharmacist or dietician. Dwight

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decided that he would be available for both pharmacy and nutrition questions when needed. Above all else, he wanted to be knowledgeable and comfortable in talking with any patient or family member regardless of the clinical situation. Dr. Cowart has been a member of NCAP for many years. Along with the continuing education offered by the organization, he finds the opportunities to network at local, regional, and state-wide events beneficial. He states that “it is priceless to be able to see how other people handle situations and organize their pharmacy. That helps you develop your own operation.” In addition to practicing in a health-system pharmacy, Dr. Cowart has experience in retail and home health practice settings. Dr. Cowart would advise students or other health systems pharmacists to always be willing to share time and resources with people less fortunate, both at home and overseas. Dr. Cowart has extensive experience in medical mission work throughout the world. “You never know, you may be helping a future President.” Dr. Cowart’s willingness to share his experience with his current and future healthcare colleagues exemplifies his core values of teamwork and compassion. He looks forward to practicing and influencing our profession for many years to come.

centers, oncology services, and its specialty pharmacies. In this role, he focuses on strategic work to collaborate with facility and clinical teams to ensure patient care is optimized for all who receive services in these ambulatory care settings. He is also the Residency Program Director for a PGY1 Community Pharmacy Residency with a focus in Specialty Pharmacy.

Dr. Reichard is an active member of NCAP, the American Society of Health-system Pharmacists, Excelera, and the Hematology/Oncology Pharmacy Association, supporting initiatives focused on the oncology pharmacy and technician practice model, utilizing data for benchmarking in the ambulatory setting, and strategies for successful specialty pharmacy business models. Dr. Reichard resides in Winston-Salem, North Carolina with his wife, Elizabeth, a pediatrician, and two children, Margaret Anne and Scott. https://medicationsafety.org/

New Practitioner Network Member Spotlight Jef f Reichard

Jeff Reichard, PharmD, MS, BCOP, BCPS has received the honor of being the recipient for the Spring 2018 New Practitioner Network Member Spotlight. Dr. Reichard graduated from the University of North Carolina Eshelman School of Pharmacy in 2011. Upon graduation, he completed a combined residency and Master of Science degree in health-systems pharmacy administration at the University of North Carolina Hospitals.

After residency training, Dr. Reichard joined Novant Health as a pharmacy manager within their acute care healthsystems pharmacy. He has worked in a variety of leadership roles including operations, clinical management, and specialty pharmacy. Currently, Dr. Reichard is the Director of Pharmacy for Hospital-Based Infusion, Oncology, and Specialty Pharmacy Service Lines at Novant Health. He has oversight over the health-systems hospital-based infusion North Carolina Pharmacist

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Volume 99 Number 2 Spring 2018

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Volume 99 Number 2 Spring 2018

Pharmacist Impact on Provider Quality Measures

By Jessica Sinclair With the disparity between the supply of primary care providers and demand for care, many providers struggle to meet the requests of their patients.1 Furthermore, transitions to quality-based payment models have added a need for continuous improvement. These constitute some of the many pressure points for providers to meet expectations from patients, staff, and third parties. Pharmacists are in a unique position to fill this need.

Endeavors such as the Asheville project and other studies assessing the collaboration between physicians and pharmacists have proven a correlation between the collaboration and better patient outcomes.2,3 Now it is the responsibility of pharmacists, as members of the healthcare team, to communicate how they can impact physician payment models while also focusing on superior quality of care.

The Merit-Based Incentive Payment System (MIPS) serves as a prime example of a novel qualitybased payment model. The program was developed to replace the various Medicare programs for reporting on quality. In 2019, a positive, negative, or neutral payment adjustment will be made based on quality performance for each MIPS eligible provider.4 Likewise, the Patient-Centered Medical Home Model (PCMH) incorporates quality care to strengthen the providerpatient relationship and transitions of care.5 The deviation from the fee-for-service model to models

that focus on quality care introduces an opportunity for pharmacists to intervene.

In a study conducted in Pittsburgh, Pennsylvania, pharmacists assessed a model of pharmacist integration within a PCMH primary care practice. Through their business model, pharmacists received referrals for medication adherence, diabetes self-management education, weight management, and management of several other chronic disease states.

Berdine and Skomo assessed baseline A1c, lipid panels, and BMI to observe the impact of pharmacist involvement and found improvements in each of these clinical measures. This study assessed how pharmacists can play a role in the PCMH to improve patient outcomes that are included in the quality assessment of the practice.6 Preliminary results from another study conducted within a primary care clinic in North Carolina suggest that pharmacist integration in the practice improved quality measures. Within the clinic of interest, clinical community pharmacists completed face-to-face annual wellness visits (AWV) and chronic care management (CCM) calls through utilization of a clinical services agreement. Seven MIPS and PCMH measures were compared for the 193 Medicare patients seen by the pharmacist to the remainder of the Medicare population at the practice. Interestingly, each measure was improved in the

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pharmacist population with the most significant improvement seen in the hepatitis C screening (31%), influenza vaccination (29%), and colorectal cancer screening (23%).

Quality management was a significant component of the annual wellness visit and quality measures were also continually assessed during monthly CCM contact with the patient.7 From this study, it was concluded that pharmacists were able to fill the gaps in care and accept new responsibilities and alleviate pressures put on the providers.

The previously mentioned studies highlight the role that pharmacists can play in healthcare reform. By providing clinical services within primary care clinics, pharmacists can directly impact provider payment by bringing in additional revenue and indirectly through their impact on quality measures. Having pharmacists integrated within the primary care setting expands their scope of practice and provides them with the opportunity to practice at the top of their license.

As the most accessible healthcare providers, pharmacists are favorably placed to serve as extenders of primary care providers. In order to make this model successful, pharmacists must communicate their value as medication experts in improving quality of care and filling the need for highly trained healthcare professionals.

Jessica Sinclair, PharmD, is a

Volume 99 Number 2 Spring 2018

PGY1 Community-based Pharmacy Resident at the UNC Eshelman School of Pharmacy, and Rx Clinic Pharmacy in Charlotte, NC. Email: jessica@rxclinicpharmacy. com References 1. Bodenheimer TS, Smith MD. Primary Care: Proposed Solutions To The Physician Shortage Without Training More Physicians.

Health Aff (Millwood) 2013;32(11):1881-6.

2. Cranor CW, Bunting BA, Christensen DB, et al. The Asheville Project: LongTerm Clinical and Economic Outcomes of a Community Pharmacy Diabetes Care Program. J Am Pharm Assoc 2003;43(2):173-84.

3. Carter BL, Bergus GR, Dawson JD, et al. A Cluster-

4.

5.

6.

7.

Randomized Trial to Evaluate Physician/Pharmacist collaboration to Improve Blood Pressure Control. J Clin Hypertens 2008;10(4): 260-271.

Sayeed Z, El-Othmani M, Shaffer WO, et al. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015: What’s New? J Am Acad Orthop Surg 2017;25(6): e121-e130.

Stange KC, Nutting PA, Miller WL, et al. Defining and Measuring the Patient-Centered Medical Home. J Gen Intern Med 2010;25(6):601-12.

Berdine HJ, Skomo ML. Development and integration of pharmacist clinical services into the patient-centered medical home. J Am Pharm Assoc 2012;52(5):661-7.

Anson J, Bentley O, Abuba-

kar A, et al. Assessing the Impact of Pharmacists in Improving Quality Measures that Affect Physician Payment. Presented at: American Pharmacists Association Annual Meeting; March 17, 2018; Nashville, TN.

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 Tina Thornhill, Editor, at tina.h.thornhill@gmail.com.

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.

Go to ncpharmacists.org and log-in for full access North Carolina Pharmacist

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Volume 99 Number 2 Spring 2018

Infective Endocarditis and Injection Drug Use – Recent Trends in Healthcare

By Felicia R. Britt, PharmD

Provisional data from the Office of the Chief Medical Examiner for North Carolina has indicated a 1,119.1% increase in deaths involving heroin and an 803.4% increase in deaths involving fentanyl or fentanyl analogues between 2010 to 2017.1 Although death is an all too common outcome of drug overdose, another devastating impact of injection drug use (IDU) in the United States is the increased occurrence of infectious diseases in these patients. Specifically, from 2010 to 2015, North Carolina (NC) saw a 13.5-fold increase in the incidence rate of infective endocarditis (IE); and from 2007 to 2016, the state experienced a 900% increase in the number of acute hepatitis C cases.2 The CDC published data regarding patients in NC with drug dependence who were hospitalized with endocarditis between 2010 to 2015.3 This 6-year snapshot revealed an approximate 12-fold increase in hospitalizations for drug dependence combined with endocarditis with most patients being non-Hispanic, white men, between 18 to 40 years of age from rural areas. Approximately one-third of the patients were co-infected with hepatitis C virus.3 The hospitalization cost for drug dependence–associated endocarditis approximated $54,000 per admission, which leads to significant socioeconomic implications given that nearly 45% of these patients are either uninsured or on Medicaid. 3 Given these statistics, it is critical that pharmacists understand the general pathophysiology, disease process, clinical presentation, as well as the prevention and treatment for endocarditis associated with IDU.

Pathophysiology Infective endocarditis associated with IDU occurs primarily when bacteria on the skin or in the syringe is introduced into the bloodstream via injection followed by subsequent colonization of the endocardium, the lining of the heart chambers and valves. Bacterial adhesion to the valvular surfaces of the heart is more commonly seen in immunocompromised and/or IDU patients.4 In IDU patients, common precipitating factors for IE are trauma to the surface of the valve (likely due to direct injection of particulate matter from illicit drugs) followed by alteration of the endothelial cells.4 This disruption of the lining renders the valvular surface susceptible to colonization by circulating bacteria.4 Colonization of the valve leads to the deposition of platelets and fibrin that form encapsulated vegetations making drug access to the site of infection and treatment challenging.4 Clinical Presentation & Diagnosis Many IE patients present with classic Oslerian manifestations including bacteremia or fungemia, active valvulitis, peripheral emboli (Janeway lesions), and immunological vascular phenomena (Osler nodes, Roth spots), especially those with left-sided IE.5 Most patients who are current IDU, however, typically experience right-sided IE and rarely present with Oslerian manifestations.5 Instead, these patients present with multiple septic pulmonary emboli leading to non-specific signs and symptoms such as chest pain, dyspnea, cough, hemoptysis, fever, chills, malaise, murmur and cardiac deficits.5

often use the Duke criteria as a guide, which can be found in the American Heart Association guidelines for Infective Endocarditis in Adults at http://circ.ahajournals. org/content/early/2015/09/15/ CIR.0000000000000296.6 Developed at Duke University and vetted through multiple studies, the Duke criteria serve as a reference for clinicians to aid in determining the probability of diagnosis.6 The presence of 1 major plus 1 minor criterion or the presence of 3 minor criteria is indicative of “possible” IE; whereas a case is considered “definite” if vegetation is visualized or has embolized.6 For patients who have had IE in the past or are current IDU (high suspicion of IE), the presumption of IE is often made before blood cultures are drawn. Definitive diagnosis is made using a combination of the Duke criteria and cardiac imaging.6 Identification of the vegetation via transthoracic and transesophageal echocardiography is essential and is typically used to complete the diagnostic evaluation.6 The Guidelines recommend obtaining at least 3 sets of blood cultures from different venipuncture sites with the first and last samples drawn at least 1 hour apart (Class I; Level of Evidence A) and performing echocardiography expeditiously in patients suspected of having IE (Class I; Level of Evidence A).6 Treatment Treatment of IE is often challenging due to poor antibiotic penetration into the vegetation; thus, prolonged, parenteral, bactericidal agents are required to eradicate the infection.6 The most common cause of IE in much of the developed world is Staphylococcus aureus for which the cure rates are >85%.6 Other common microorganisms associated with IDU are oxacillin-resistant Staphylococcus aureus strains, coagulasenegative staphylococci, β-Hemolytic streptococci, fungi, and aerobic Gram-negative bacilli, including Pseudomonas aeruginosa.6

In order to diagnosis IE, clinicians

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General antimicrobial treatment recommendations follow several themes. First, it is recommended to obtain an infectious disease consultation at the time of diagnosis for appropriate treatment selection. Once antimicrobials have been selected, the clinician may begin counting duration of therapy on the first day on which blood cultures are negative (assuming a positive culture was initially identified). During that time, blood cultures may be collected every 24-48 hours until those cultures are negative for 48 hours. For infections that require more than one antimicrobial agent, it is reasonable to time the administration of these agents at the same time or temporally close together. These recommendations all range from Class I; Level of Evidence B to Class IIa; Level of Evidence C.6 The antimicrobial of choice may vary given renal function, location of the vegetation, type of valve, the need for surgery to remove the vegetation/repair damaged valves and other patient-specific factors.

For example, a patient with a native valve staphylococcal IE with normal renal function allergic to penicillin will be treated with cefazolin 6 g/24 h IV in 3 equally divided doses for a duration of 6 weeks.6 However, if the patient had a prosthetic valve with a resistant staphylococcal strain, the patient would require a combination of vancomycin, rifampin, and gentamicin.6 These subtle differences in patient characteristics make a huge difference in pharmacotherapy; therefore, it is beyond the scope of this article to address all treatment modalities, and emphasizes the recommendation for infectious diseases consultation. Practicing clinicians advise accessing and referring to the guidelines when treating a patient with IE due to the wide variability of treatment options. In hospitals where infectious disease pharmacy consults are not feasible, pharmacists take on a greater role in ensuring the appropriate therapy is selected.

Pharmacists can help providers navi-

gate the complex treatment guidelines and ensure the proper treatment modalities are selected based on individual patient parameters. In addition, given the lengthy nature of treatment for IDU-induced IE, pharmacists can also play a significant role in patient education surrounding treatment and prevention of reinfection.

3. Fleischauer AT, Ruhl L, Rhea S, Barnes E. Hospitalizations for Endocarditis and Associated Health Care Costs Among Persons with Diagnosed Drug Dependence — North Carolina, 2010–2015.

MMWR Morb Mortal Wkly Rep 2017;66:569–573. DOI: http://dx.doi.org/10.15585/ mmwr.mm6622a1

Prevention Strategies and Recommendations for Pharmacy The CDC recommends public health programs and health care systems consider collaborating to implement syringe service programs, harm reduction strategies, and opioid treatment programs to reduce the risk for morbidity and mortality related to opioid-associated endocarditis.3 A great place to learn more about how pharmacists can get involved with syringe exchange programs, see the article, Pharmacists Can Fight the Opioid Crisis by Selling Syringes,

by Tessie Castillo from the North Carolina Harm Reduction Coalition, published in this issue of the North Carolina Pharmacist.

4. Sullam PM, Drake TA, Sande MA. Pathogenesis of endocarditis. Am J Med 1985 78(6B):110-5.

References 1. Miller A, Winecker R. Fentanyl and heroin-related deaths in North Carolina.

North Carolina Office of the Chief Medical Examiner.

Available at: http://www. ocme.dhhs.nc.gov/annreport/ docs/FentanylandHeroinRelatedDeathsinNorthCarolina-040918.pdf. Accessed April 30, 2018.

5. Moss R, Munt B. Injection drug use and right sided endocarditis. Heart 2003;89(5):577-581.

6. Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals from the American Heart Association. Circulation. 2015;132(15):1435-86.

Erratum in: Circulation 2015; 132:e215.

Felicia R. Britt, PharmD, will be a PGY1/PGY2 Health Systems Performance Assessment (HSPA) Resident, at Massachusetts General Hospital, Boston, MA. She wrote this article while earning her Doctor of Pharmacy degree at UNC Eshelman School of Pharmacy and conducting an Association Management Advanced Pharmacy Practice Experience with NCAP in March 2018.

2. Injury and Violence Prevention Branch. North Carolina Summary Data: Core overdose data slides January 2018. NC Dept Health & Human Services Chronic Disease and Injury Section.

Available at: http://injuryfreenc.ncdhhs.gov/DataSurveillance/poisoning.htm. Accessed April 30, 2018.

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The Asheville Summit on Population Health 2018

By Erin Brown Bianca Burnette Judith Councell Anna Pfeiffer

On Saturday, March 10th, 2018, students from across the southeast United States gathered at the Mountain Area Health Education Center in Asheville, NC to attend the 4th Annual Asheville Summit on Population Health. The Asheville Summit is a one-day conference planned exclusively by students at the UNC Eshelman School of Pharmacy, with the majority of the planning committee originating from the Asheville campus. Each year, the goal is to give participants the opportunity to explore a theme, and this year’s theme was “Population Health.” Approximately 150 students, residents, and pharmacists attended the event. Student colleagues from many pharmacy schools including Auburn University, High Point University, Mercer University, MUSC, Samford University, University of South Carolina, and Wingate University attended.

Dr. Kelly Epplen, the keynote

speaker from the James L. Winkle College of Pharmacy in Cincinnati, kicked the day off by introducing population health. She gave a good primer for the overarching theme before students delved into more specific areas throughout the rest of the day. Next, Courtenay Wilson and Jon Easter from North Carolina led a panel discussion devoted to the opioid epidemic. The first half consisted of a fascinating look at the current realities of the epidemic, and the second half was devoted to a lively Q&A session with the audience. As one participant stated, “I think my favorite talk was definitely the one about the opioid epidemic because that is a very difficult situation to deal with.

Many of us are currently working as interns and are exposed to chronic users on a daily basis at work.”

populations we see clinically, and participants responded well to the breadth of topics offered.

They ranged from caring for the aging population to harm reduction via needle exchange programs. Also included were talks focusing on serving the underserved, pulmonary rehabilitation for patients with COPD, bridging cultural and linguistic divides to better serve the Latino community, and promoting better outcomes for patients with Types I and II diabetes mellitus.

In between the breakout sessions, Anne Lake, a nurse practitioner from Wake Forest Baptist Health, gave a wonderful plenary discussion on bone health and fracture prevention. Dr. Lake is a nationally recognized bone specialist, and participants appreciated hearing her perspective as a provider. Finally, Dawn After lunch, participants attended Pettus and her current resident, breakout sessions of their choice. Kelsey Combs, ended the day by The goal was to highlight patient talking about interventions they

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Volume 99 Number 2 Spring 2018

have made with Triad Healthcare Network.

Throughout the day, scheduled breaks gave participants opportunities to network or visit some of the booths, which included code cart medication education, pharmacy trivia, and naloxone training. A crowd favorite was an interactive board game personally designed and constructed by our planning committee. Visiting all of the booths allowed participants to accumulate raffle tickets, which could be used to enter into a drawing for a variety of prizes.

Prizes were garnered by members of the program planning committee from local and national entities, and included tickets for the Biltmore Estate, gift cards to CVS and local eateries, and many other prizes that speak to the generosity of our sponsors.

The day culminated in a special drawing for tickets to Walt Disney World in Orlando, FL. Attendees sat in suspense with fingers

crossed, grasping long trails of raffle tickets as the lucky winner was announced.

At the end of the day, we gauged participants’ experience of the day by utilizing index cards, where they could write their thoughts. One student said, “Thank you so much for putting together an amazing conference!

I feel that I have a better understanding of population health and some of the most overlooked disease states.” Another said, “I enjoyed the choice in speakers and topics. I feel like every speaker was relevant and applicable to current pharmacy issues.”

Overall, the response from participants was overwhelmingly positive, which was very encouraging after a year of planning. It was gratifying to see the desired outcomes: the profession of pharmacy was promoted, networking occurred, invaluable knowledge was gained, and a good time was had by all!

The 2018 Asheville Summit Steering Committee North Carolina Pharmacist

Mark your calendars for the 2019 Asheville Summit on March 9 at MAHEC in Asheville! Next year’s theme will be Women’s Health. To stay up-to-date on all things related to The Asheville Summit, please feel free to check out our website at http:// ashevillesummit.web.unc.edu/.

We will continue to update the website throughout the fall and early into next year. Registration for next year’s conference will open in January 2019. Pharmacy students, pharmacy technicians, and pharmacists (as well as all other healthcare disciplines) are encouraged to attend. CE credit is provided for pharmacists and technicians.

Erin Brown (Class of 2020), Bianca Burnette (Class of 2020), Judith Councell (Class of 2019) and Anna Pfeiffer (Class of 2020) are all current Pharm. D. students at the UNC Eshelman School of Pharmacy, Asheville Campus.

Michael Harney gives his opening remarks and a demonstration to attendees Page 18 Volume 99 Number 2 Spring 2018

Participants listening attentively to our panel on the Students take advantage of our photo booth during a break opioid epidemic

Our raffle sales team getting ready to sell tickets

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Students visiting our Trivia Booth

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Volume 99 Number 2 Spring 2018

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A Student’s Perspective: Integrating into Interprofessional Teams on Advanced Pharmacy Practice Experiences

By Tiffany T. Vu and Kim E. Kelly The first three years of pharmacy school have come and gone, and it is now time to start the Advanced Pharmacy Practice Experiences (APPEs). APPEs represent the time when knowledge gained in the classroom gets applied to patients in a realworld setting. For many student pharmacists, the transition from the classroom to the patient care setting can be a daunting experience. Accompanying this challenge comes the excitement of new environments, co-workers and mentors, as well as a plethora of clinical and professional development opportunities. As a pharmacy student completing APPEs, there are a multitude of patient care settings that require interprofessional collaboration.

Interprofessional collaboration is so important that the “Core Competencies for Interprofessional Collaborative Practice” was written by the Interprofessional Education Collaborative to help guide healthcare professionals on how to work together to provide safe, high quality, and accessible patient-centered care.1 A mutual

understanding of interprofessional collaboration is imperative to provide comprehensive, safe, and efficient patient care.

Throughout the pharmacy curriculum, the importance of interprofessional teams in healthcare settings is made clear. Integrating into these teams, however, can seem intimidating. One of the difficulties with team-based care and interprofessional collaboration for student pharmacists is the short length of each APPE. During APPEs, student pharmacists may be placed on upwards of four to five different teams in as many months.

Interprofessional teams vary in size and scope, but the purpose remains to collaborate with various professionals to improve patient outcomes. Learning in a new environment plus the challenges of remembering what has been taught, can be overwhelming especially being the new person placed into an existing team. The first few days may feel uncomfortable while attempting to quickly assimilate, understand

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the team dynamics, and find a way to bring value to the team’s interventions. These hurdles are common, so the sooner one can assuage fears and focus on navigating the stages of team development, the quicker the contribution to patient care can begin. This article will seek to help define some of the types of personalities on interprofessional teams and how best to form a collaborative and collegial working relationship.

The World Health Organization (WHO) has described four stages of team development as: forming, storming, norming and performing.2 Any or all of these stages may be experienced throughout the APPEs. The first stage, “forming,” describes a period of team building masked by ambiguity and confusion. Members of the team typically do not have a say in whom they are working with; therefore, the team is typically guarded, superficial, and impersonal in communication. In addition, all team members may be unclear about the task at hand and the desired outcomes. The second stage, “storming,” tends to be a difficult stage where there may be conflict between some team members and some rebellion against the tasks assigned. Members may compete for positions of power and show frustration at a lack of progress in the task. This stage may not be as prominent in all settings, but may be seen at the beginning of the residency year when new medical interns are navigating through their first weeks and months as newly minted physicians. The third stage, “norming,” is when communication

Volume 99 Number 2 Spring 2018

is established, and information is flowing freely between the team members. The team at this stage starts to confront the task at hand, and generally accepted procedures and communication patterns are established. The last stage, “performing,” is when the team is close and supportive, open and trusting, resourceful and effective. It is during this final stage that the team focuses their attention on achieving common goals for the betterment of patient care. The goal for every interprofessional team should be to progress quickly through the stages to reach the performing stage.

With an understanding of how teams develop, what can the student pharmacist do to help the team best achieve the performing stage? First, recognize that it will not happen overnight, but it can happen more quickly with some keen observational skills and knowledge of how to navigate the different personality types commonly identified in interprofessional teams. The different types of personalities that can be encountered may not be easily read; however, the ability to identify them is the next step in the development of a performing team. These team member types include: the driver, analytical, amiable, expressive, negative and overly competitive team members.3

Driver: This is the member of the group that loves a challenge. They are willing to take risks and work at a fast pace in hopes of getting results. Drivers are direct, decisive, and determined. Conversely, they

can also be impatient, insensitive, dictatorial, and domineering.

Drivers are vital members of the team as they work tirelessly until the work is done. The best approach to take with a driver is to cut out the small talk, pick up the pace, and get right down to business. By appealing to their sense of work ethic and demonstrating a willingness to do hard work for the team, the student pharmacist may be offered a larger role in the team dynamics.

Analyticals: Analyticals are the team members that believe slow and steady wins the race. They ensure that nothing slips through the cracks as they dot every i, cross every t, and adhere to the rules. They are precise, logical, careful, and methodical. Since they are striving for perfection, over-analysis paralysis may result. The ideal way to approach an analytical would be to ensure full preparation for rounds because an analytical needs hard proof for every decision. Be prepared to present recommendations with guidelines and good, peer-reviewed articles. This preparation is key to moving the decision-making process forward and keeping the team functioning smoothly.

Amiable: This team member is one that genuinely cares about others.

They strive to make people happy, avoid hurting anyone’s feelings, and try to keep the peace.

They are warm, approachable, friendly, inclusive, and an overall team player. Sometimes amiable team members focus too much on the people aspect and their relationships that they tend to

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lose sight of the task at hand, and in turn, fail to get things done in a timely manner. To collaborate with this team member, it is best to find common ground. It begins with connecting on a personal level and building trust along the way. Once trust is established, team members can be urged to focus on the task at hand to maintain a smooth-running team.

Expressive: This team member is not only energized but energizing! They think about the big picture, are optimistic, visionary, a cheerleader and juggler of numerous things all at once. Their weakness lies in trying to balance too much at once, losing focus on the task at hand This team member tends to lack clear focus and may cause frustration to the other team members due to perceived lost time. To connect with an expressive, the student pharmacist also needs a high energy level. By demonstrating good enthusiasm, an expressive may be excited by the student’s role on the team.

Negative: The negative team member is quick to criticize without providing constructive feedback or providing a solution to a given problem. After a while, other team members may ignore them or disregard their input; however, this is the opposite of what should be done. Negative comments raised by this team member tend to have valid points that should be considered. The best way to work effectively with this team member is to ask them to fully describe the problem they see and ask them to provide a solution. Once a change is attempt-

Volume 99 Number 2 Spring 2018

ed or implemented, this team member may exhibit a change in attitude reflected in one of the other member types described.

Overly competitive: This team member does not integrate fully as part of the team. They tend to repeatedly ask others for help, but they are not collaborative.

They may try to actively sabotage others on the team to make them look superior. They may even take credit for the work of others. Although it may seem counterintuitive, the best way to get through to this team member is to show willingness and interest in working with them and not against them. Competitive team members may be insecure, which leads them to feel threatened by the success of others. Becom-

ing an ally through collaboration and demonstration of working towards the same goal, a true performing level can be reached.

As the student pharmacist embarks on their APPEs, interprofessional collaboration is a given.

Having the awareness of teamdevelopment staging and some of the prominent personality types will help to facilitate collaboration with members of the team. Understanding how people work, act, and react is essential to pushing the team chemistry to the performing stage. Altering the approach to integrating into the team will create a high-performing team. An interprofessional team that is performing at the highest level is of the utmost importance for your learning ex-

perience and your patients’ care.

Tiffany T. Vu, PharmD, MBA, is a 2018 Doctor of Pharmacy graduate from the Campbell University College of Pharmacy & Health Sciences. She is currently a PGY-1 Resident at North Memorial Health, Robbinsdale, MN. Kim E. Kelly, PharmD, BCPS, is a Clinical Assistant Professor, Pharmacy Practice at the Campbell University College of Pharmacy & Health Sciences.

References: 1. Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel.

Washington, D.C.: Interprofessional Education Collaborative.

2. World Health Organization. Patient Safety Curriculum Guide: Multi-professional Edition. Malta: World Health Organization; 2011.

3. Merrill DW, Reid RH. Personal Styles & Effective Performance. Boca Raton, FL: CRC Press; 1981.

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Volume 99 Number 2 Spring 2018

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Pharmacists Can Fight the Opioid Crisis by Selling Syringes

By Tessie Castillo The opioid crisis has united a variety of community members and professionals to prevent drug-related deaths and to foster harm reduction and recovery programs. People impacted by drug use are teaming up with first responders, treatment providers, faith communities, medical professionals, and other allies to create practical solutions, but one key ally is sometimes overlooked – pharmacists.

Neighborhood pharmacists can play a key role in helping people impacted by drug use to access essential services, such as naloxone to prevent overdose, syringe disposal services, referral to treatment programs, or access to sterile syringes.

Although overdose deaths take up most of the headlines around the opioid crisis, another problem has rapidly emerged as more people begin injecting drugs. Lack of access to sterile syringes has led to an increase in behaviors such as reusing syringes and sharing syringes. As a result, injection-related infections and diseases, as well as the costs of treating these illnesses, are skyrocketing across the state.

Another injection-related disease is endocarditis, a bacterial infection of the heart valves. Costs of treating endocarditis increased 1350% in North Carolina between 2010 and 2015 (Figure 3).3 Cases of sepsis, an immune response to bacterial infection that can lead to organ failure, rose 400% over the same time period (Figure 3).4

In North Carolina, cases of acute hepatitis C, a blood-borne virus that spreads primarily through

Pharmacists are well positioned to confront this major public health crisis. Hepatitis B and C,

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sharing syringes between infected persons, have gone up 900% from 2007 to 2016 (Figure 1).1 Chronic hepatitis C is expensive to treat. In 2011, North Carolina Medicaid spent $3.8 million to treat patients for hepatitis C. By 2016, costs had risen to $85.6 million (Figure 2).2

Volume 99 Number 2 Spring 2018

endocarditis, sepsis, HIV, infected wounds, and more can be prevented simply through helping people access sterile syringes. Although North Carolina has taken recent steps to increase access to syringes, including the legalization of community-based syringe exchange programs in 2016, these programs are not enough. There are currently only 25 syringe exchange programs in North Carolina.5 There are 2,856 pharmacies.6 Pharmacies are ideally positioned to make a difference in reducing the spread of injection-related illnesses.

Current North Carolina law allows pharmacists to sell syringes to customers without a prescription.

However, pharmacists are granted discretion and may choose not to sell syringes if they believe the items may be used for illicit purposes.7 This ambiguity often puts pharmacists in a difficult moral dilemma. Some pharmacists choose not to sell syringes to people whom they believe will use them to inject drugs. While that attitude may be well-intentioned (based on a desire to avoid “contributing” to injection drug use), the outcome of increasing numbers of injection drug users with limited access to sterile syringes is troubling on a number of levels.

First, denying access to syringes does not stop anyone from using drugs.8 It only makes people more likely to re-use a syringe or to share someone else’s, putting them and others at increasing risk for disease and infection. Second, choosing whether to sell syringes to someone based on factors such as appearance, clothing, mannerisms, or a belief that the person may use syringes for illicit purposes opens up pharmacists to ethical issues. Both national and North Carolinafocused studies have shown that pharmacists are less likely to sell syringes to customers who are black, Hispanic, male, or have a disheveled appearance, which in addition to being an example of profiling, also contradicts data regarding the typical opioid user, who is white and affluent.9,10 Lastly, inability to access sterile syringes is a major contributing factor to the spread of the aforementioned diseases and the rise in associated costs.

One reason that some pharmacies may adopt a North Carolina Pharmacist

policy of not selling syringes without a prescription is that they do not want to attract people who use drugs to their store. Certainly there are practical concerns about people using drugs on the store premises or overdosing in the bathroom or parking lot. There are ways to alleviate these concerns, but first, it is important to understand that with the scope of drug use right now, no business can completely avoid these types of problems. Gas stations and fast food chains don’t sell syringes and they, along with many other businesses, occasionally have to deal with incidents of drug use or overdose on their property. There is no way to guarantee the absence of drugrelated activity taking place on pharmacy property, but some pharmacies who do sell syringes without a prescription have developed ways to lessen problematic behavior. For example, some pharmacies in North Carolina include a note in each package of syringes sold that explains that their policy of selling syringes without a prescription is contingent on people using the syringes off the property. This small action can help reduce the use of syringes on the pharmacy property because people using drugs do not want to lose access to syringes from that pharmacy. Improper disposal of syringes may be another concern for pharmacies. If used syringes are being discarded on the property, pharmacists can install biohazard containers in the bathrooms or outside the store so that customers have a safe place to dispose of syringes.

For some pharmacists, policies against the nonprescription sale of syringes are not just about practical concerns but are also deeply rooted in negative perceptions of people who use drugs.

Stigma is at the root of many policies that ironically only contribute to more people using drugs.

Stigma makes politicians and communities reluctant to invest in treatment facilities or harm reduction programs that can help people who want to manage or cease drug use. Stigma keeps employers from offering jobs to people with a history of substance use, even if that person has not used drugs for years or can function professionally while using – and lack of employment is a significant factor in increasing drug use. Stigma can also keep people who use drugs from seeking medical treatment or calling 911 to report an

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overdose for fear of mistreatment by law enforcement, paramedics, or hospital staff. Stigma from pharmacists works in the same way. Without access to clean syringes, people can develop and spread costly, painful and even fatal infections. The infections and diseases, coupled with a lack of access to treatment and medical care, often cause people to use more drugs to cope with pain, shame and a general deterioration in quality of life. The vicious cycle of lack of access to basic survival needs such as medical care and employment can fuel problematic drug use for entire families, even for generations. At some point, someone has to step in and try to stop the cycle, even with something as simple as a clean syringe.

simply aren’t enough of them to provide all the necessary tools that pharmacists have right at their fingertips. Pharmacists are the heroes we need right now!

For most pharmacies in North Carolina, concerns over attracting people who use drugs to their store, as well as concerns over the ethical dilemmas presented by allowing pharmacists to sell syringes without a prescription at their discretion, has led them towards the easiest answer – don’t sell syringes unless a customer presents a valid prescription. While it is true that this policy decision may be the path of least resistance for pharmacies and pharmacists, it is creating a disastrous public health crisis in our communities.

3. NC State Center for Health Statistics Hospital Discharge Data, 2010-2015. Analysis by NC DPH Epidemiology Section.

Imagine a hospital refusing care to patients without insurance. That saves the hospital the expense of providing care to patients who may have trouble paying, but what is happening to all those people who are turned away? How many infections, diseases, and injuries are going untreated?

The hospital staff may never know. That is the tricky thing about turning people away. You may never see the true consequences of that decision for other people.

In the midst of the greatest public health crisis of our time, pharmacists are crucial allies in efforts to prevent disease and save lives. Pharmacists can help simply by selling a product that already exists in the store to people who ask for it. It is not the easiest thing to do, but it is the right thing to do in communities that are struggling with infections and loss of life from injection-related causes. Syringe exchanges and other community-based programs may help the cause, but there North Carolina Pharmacist

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Tessie Castillo, BA, Advocacy and Communications Coordinator at the North Carolina Harm Reduction Coalition References 1. NC Electronic Disease Surveillance System 20002016. Analysis by NC DPH

Epidemiology Section, Communicable Disease Branch.

2. NC Medicaid surveillance data 2011-2016.

4. NC State Center for Health Statistics Hospital Discharge Data, 2010-2015. Analysis by NC DPH Epidemiology Section.

5. NC Health and Human Services. Syringe Exchange Programs in North Carolina. Accessed 4/18/17. https:// www.ncdhhs.gov/divisions/public-health/north-carolinasafer-syringe-initiative/syringe-exchange-programsnorth 6. NC Board of Pharmacies 2017 Statistics. Accessed 4/18/17. http://www.ncbop.org/PDF/2017Statistics.pdf 7. NC Statute 90-113-21. Article 5B Drug Paraphernalia: General Provisions 8. Fuller C, Ahern J, Vadnai L, et al. Impact of increased syringe access: preliminary findings on injection drug user syringe source, disposal, and pharmacy sales in Harlem, New York. J Am Pharm Assoc. 2002; 42:77– 82.

9. Janulis, Patrick. Pharmacy nonprescription syringe distribution and HIV/AIDS: A review. J Am Pharm Assoc.

2012; 52:787–797; 10. Costenbader E, Zule W, Coomes C. Racial differences in acquisition of syringes from pharmacies under conditions of legal but restricted sales. Int J Drug Policy.

2010:425–8.

A Note from the Editors – For additional information from the NC Board of Pharmacy on syringe sales, go to: http://www.ncbop.org/faqs/ FAQsNonPrescriptionSyringeSale Volume 99 Number 2 Spring 2018

Figure 1

Figure 2

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Figure 3

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Inaugural Medipreneurs Summit is a Success!

By Michelle Fritsch ”I’ve never been to an event where the organizers got a standing ovation!” ~Lisa Larter, Keynote Speaker The energy at the Inaugural Medipreneurs Summit was palpable. This was evident from the beginning of the first informal gathering on Friday night of the event. Eighty-six pharmacists from 19 states and Canada gathered in Asheville to share common dreams and motivations and to form a special tribe of trailblazers in the world of pharmacy.

As a career professor, I had many activities planned to encourage people to get to know each other, to share their ideas and help each other through current obstacles, and to get them out of their seats. We found ourselves improvising from the plans from the very beginning, because NONE of that encouragement was needed. I have honestly never seen pharmacists so excited to network with each other.

Our keynote speaker, Lisa Larter, set just the right tone and fed the excitement. She graciously stayed throughout the Summit and facilitated some of the final panel discussion. She even had her own posse of smart pharmacists who hung on her every word. Speakers addressed topics important to entrepreneurs with established businesses, those early in the process of developing businesses, those with creative ideas, and those who are innovative intrapraneurs in their place of employment.

North Carolina Pharmacist

Dan Garrett and Stephanie Kiser gave the history of the Asheville Project over lunch on Saturday.

North Carolina is truly the birthplace of pharmacy entrepreneurship. Attendees had the opportunity to attend a variety of small, interactive group workshops on Saturday afternoon so they could get more in-depth knowledge in their particular areas of interest.

On Sunday, participants navigated through 10 stations to consider stimulating questions in key aspects of business/practice development. Fifteen experts were then available to work with groups on the questions they struggled to answer on their own. Attendees heard from many experts, received books and numerous resources, and most importantly, met the tribe that will take them to their new levels of entre/intrapreneurial achievement.

UNC and NCAP were faithful partners in the planning and implementation. Wellness Works was a platinum sponsor and NICU Consulting and ZRT Laboratory were Silver Sponsors.

Co-founders Michelle Fritsch, Anna Garrett and Sue Paul are already hard at work planning next year’s conference. Lisa Larter will make a return appearance as keynote presenter, and we will be adding half-day workshops to allow innovators to take a deep dive into topics that are of particular interest.

Our 2019 event will once again be held in Ashe-

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ville on April 26-28. Seventy percent of the Inaugural Medipreneurs purchased their tickets for our 2019 event before they left the conference.

These trailblazers will be given the first opportunity to invite next year’s attendees with the remaining open spots. Any tickets that remain after their invitation period will be available at a reduced early bird rate during the summer. Attendance will be limited to 150 innovators. Keep track of registration details at www.medipreneurs.com.

You are invited to join us in forging the path to successful innovations to enhance patient care and improve healthcare. Change has to start somewhere. Why not start with you?

Pictured left to right: Michelle Fritsch, Anna Garrett, Sue Paul, Co-Founders of Medipreneurs, and Sandie Holley

Attendees from 19 states and Canada attended the inaugural Medipreneurs Summit.

Making new connections and sharing ideas for innovation

Medipreneurs building their tribe

North Carolina Pharmacist

Michelle Fritsch, Pharm.D. BCGP, BCACP Co-founder Medipreneurs CEO & Founder, Meds MASH, LLC Email: michelle@medsmash.com

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for 5 to 10 seconds before exhaling.

New Inhaler Devices and the Importance of Appropriate Technique

· After each inhalation the white cap should be replaced onto the canister.

A PHARMACIST INTERVENTION OPPORTUNITY

· If the patient requires a second dose, the cap must be replaced first and then removed again.

By Cameron J. McKinzie, PharmD, BCPPS, BCPS, CPP

In the past several months, many inhaler manufacturers have transitioned from traditional metered-dose inhalers (MDI) to new delivery systems that significantly impact how the drug is correctly delivered.

Three devices are now breathactuated delivery systems: Qvar® RediHalerTM (beclomethasone) (which replaces the traditional Qvar® MDI), ProAir RespiClick® (albuterol sulfate), and AirDuoTM RespiClick® (fluticasone propionate/salmeterol) and its authorized generic formulation (available in doses of 55/14 mcg, 113/14 mcg, and 232/14 mcg). Breath-actuated inhalers (BAI) require appropriate inspiratory force for dose delivery, and because of this necessity, patients cannot use a spacer as they have with a traditional MDI. Pharmacists are uniquely positioned to provide education to patients on how to properly use these new devices and to recognize when errors in administration technique leads to asthma exacerbations and other adverse outcomes – including

hospitalization.

Key Points in Patient Counseling with BAIs: · A BAI should not be shaken or primed. · Removing the cap from the mouthpiece prepares the inhaler to deliver the dose. · There is no canister for the patient to press to administer a dose which changes how the patient must hold the inhaler. · The patient should grip the inhaler like they are holding a cup. · The patient should not put their hand or fingers at the top of the inhaler.

The vents are on the top of the inhaler and will be blocked preventing appropriate administration of the medication. · After inhaling, the patient should hold their breath

North Carolina Pharmacist

· The back of the inhaler should be checked with each dose to ensure dose delivery via the dose counter. · If the actuation counter has not changed, another breath should be taken to get the full dose.

Children and patients with asthma may find holding their breath for the recommend time to be challenging. Also, patients who are developmentally delayed or neurologically impaired will not be able to use this inhaler type.

Qvar® RediHalerTM and ProAir RespiClick® are approved for patients 4 years and older, and AirDuoTM RespiClick® and its generic formulation are approved for patients 12 years and older. It is also important to note that ProAir RespiClick® is a dry powder inhalation, unlike its traditional MDI counterpart, which may not be appropriate depending on the severity of a patient’s symptoms.

Spiriva® Respimat® (tiotropium bromide) has recently been approved for patients 6 years and older for maintenance treatment of asthma. When a patient first

Page 33 Volume 99 Number 2 Spring 2018

uses their Spiriva® Respimat®, they will need to prepare the device. First, they will remove the clear base and insert the narrow end of the cartridge (which contains the medication) into the inhaler until they hear a click. Then, the clear base can be replaced, the base should be turned until it clicks, and the cap should be opened, and the dose-release button pressed.

Once a mist is seen, the cap should be replaced and the three previous steps should be repeated three times. Only then is the inhaler ready to use. In order to deliver a dose, patients should again turn the clear base in the direction of the arrows until it clicks, open the cap, place the inhaler in their mouth and close their lips around the mouthpiece without covering the vents, and press the dose-

release button while taking a slow, deep breath in. These steps must be repeated with each dose.

With any new device being dispensed to patients, it is imperative that the pharmacist ensure that the patient knows how to properly administer a dose.

There are resources available to aid in education in the product’s package information and the manufacturer’s website.

Pharmacists should also consider whether the new device is appropriate for the patient’s age and developmental stage. Pharmacists can play a key role in providing education to patients and their caregivers on these new drug delivery systems to ensure the best possible outcomes.

North Carolina Pharmacist

Cameron J. McKinzie, PharmD, BCPPS, BCPS, CPP is the PGY-2 Pediatric Pulmonology Residency Program Director at the University of North Carolina Children’s Hospital. Email: cameron.mckinzie@ unchealth.unc.edu For further information on how to use, go to these addresses for each product: Qvar Redihaler – https://www.qvar. com/globalassets/qvar/qvar-redihaler-pi.pdf#page=8 ProAir RespiClick – http://hcp.proair.com/About-Respiclick-Bai.aspx AirDuo RespiClick – http:// myairduo.com/Assets/Pdf/ PI.pdf#page=40 Spiriva Respimat --https://www. spiriva.com/pdf/copd/SPIRIVA_ Respimat_Instructions.pdf

Page 34 Volume 99 Number 2 Spring 2018

Partnerships and Growth for NCAP’s Pharmacy Technician Members

better gauge how NCAP could

practices. Plans are also under-

meet some of their professional

way to provide at least one CE

needs. Top responses included:

program for its NCAP members

providing continuing education

before the end of 2018. In ad-

(CE) programs specifically for

dition to working with NCPTEC,

pharmacy technicians, forums

the task force hopes to work the

NCAP’s Technician Affairs

for job opening announcements,

North Carolina Association of

Project Team (TAPT), consist-

and member opportunities for

Pharmacy Technicians and the

ing of pharmacy technician,

discounts to professional and

North Carolina Board of Phar-

pharmacist, and student phar-

educational meetings.

macy to enhance the benefits to

By Nita Johnston, PharmD, MS

macist members, held their first meeting on April 6, 2018. The committee was charged with partnering with organizations that would enhance opportunities for our pharmacy technician members and advance their professional growth. The TAPT surveyed pharmacy technicians throughout the state to

To help meet this request, one developing partnership is with the North Carolina Pharmacy Technician Educators Coalition (NCPTEC). Members of the TAPT and NCPTEC met on April 27 and preliminary plans th

include developing curriculum standardization (e.g., law and marketing) and sharing best

North Carolina Pharmacist

our valuable pharmacy technician members.

Nita Johnston, PharmD, MS, is the Transitions of Care Administrative Coordinator with the Department of Pharmacy at Moses Cone Hospital in Greensboro, NC. Her email is: Nita.Johnston@conehealth.com.

Page 35 Volume 99 Number 2 Spring 2018

In The

By Tina Thornhill

portaproblem/ucm055305.htm

In a recent study published in the New England Journal of Medicine, omega-3 fatty acid supplements were no better than placebo for reducing the symptoms of dry eye disease.

Ref: http://www.nejm.org/doi/ full/10.1056/NEJMoa1709691

The FDA warns about Lamictal’s (lamotrigine’s) link to serious immune system reaction, hemophagocytic lymphohistiocytosis (HLH). HLH, an uncontrolled immune response, can present with a high fever, skin rash, unusual bleeding, CNS disturbances (e.g., seizures, gait abnormalities, vision disturbances), jaundice, swollen lymph nodes, and hepatomegaly (pain, tenderness). The reaction can occur within days or weeks of starting therapy. The FDA recommends that anyone taking lamotrigine presenting with fever or rash should promptly discontinue the drug and seek prompt medical attention.

Ref: https://www.fda.gov/Safety/MedWatch/SafetyInformation/ SafetyAlertsforHumanMedicalProducts/ucm605628.htm

The FDA has recently issued new or updated Medication Guides for the following drugs: Opdivo (nivolumab), Pomalyst (pomalidomide), Pradaxa (dabigatran etexilate

mesylate), Brilinta (ticagrelor), Cimzia (certolizumab pegol), Samsca (tolvaptan), Ferriprox (deferiprone), Ilumya (tildrakizumab-asmn), Viberzi (eluxadoline), Kevzara injection (sarilumab), and Yervoy (ipilimumab).

Ref: https://www.fda.gov/Drugs/ DrugSafety/ucm085729.htm

The FDA encourages veterinarians and pet owners to report medication side effects in animals and veterinary product problems. The pharmacist, however, may be well-positioned to also issue a report.

There are two ways to file a report: (1) For medications that are FDA-approved, call the drug company and file a report.

The drug company is responsible for reporting all adverse drug reactions to the FDA. (2) For FDA-approved and unapproved drugs or devices, the pharmacist can complete FORM FDA 1932a found on the FDA’s website.

Ref: https://www.fda.gov/animalveterinary/safetyhealth/re-

North Carolina Pharmacist

A recent study showed the best way for small community hospitals to reduce antibiotic overuse was: to provide more advanced education to the prescribers, give prescribers hotline access to a 24/7 infectious disease specialist, and to collaborate with hospital and community pharmacists. Pharmacists reviewed antibiotic usage and provided recommendations for improvement as well as strictly monitored the use of certain broadspectrum antibiotics. Hospitals using this system showed total antibiotic usage decline by 11% and broad-spectrum antibiotic use reduced by 24%.

Ref: Stenehjem E, Hersh AL, Buckel WR et al. Impact of implementing antibiotic stewardship programs in 15 small hospitals: a cluster-randomized intervention. Clinical Infectious Diseases, ciy155, https://doi. org/10.1093/cid/ciy155

Tina H. Thornhill, PharmD, FASCP, BCGP Associate Editor

Page 37 Volume 99 Number 2 Spring 2018

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