Pharmacy Journal of New England-Winter 2019 by CT Pharmacists Association

VOL 16. NO 1 WINTER 2019

Winter 2019

PHARMACY JOURNAL OF NEW ENGLAND

PLUS

02 Nalxone 08 Preparing for the Holidays

09 Flu S eason Warm-Up Pharmacists of Yesterday, Today & Tomorrow

FIGHTING FOR PBM TRANSPARENCY

12 Flu Season Warm-Up

PAGE 4 Healing Patients with Trauma PAGES 2 & 6 PBM REFORM-THE FIGHT ISN'T OVER PAGE 21 FINDING THAT WORK-LIFE BALANCE

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Table of Contents From the Desk of New England................................................................PAGE 2 MPhA Pharmacist Spotlight......................................................................PAGE 3 Pharmacy on the Front Line......................................................................PAGE 4 Rx and the Law.........................................................................................PAGE 6 Legislative Update.....................................................................................PAGE 7 2019 MPhA Spring Conference Program…………………………………...PAGE 9 Marijuana As Medicine in New England………………….....................…..PAGE 11 PJNE Headlines........................................................................................PAGE 15 School Spotlights......................................................................................PAGE 16 CPA Mid-Winter Conference Recap.........................................................PAGE 18 Save the Date in New England.................................................................PAGE 20 Sneak Peek: Women in Pharmacy...........................................................PAGE 21

The Fight Continues for PBM Reform Dear Readers, We began 2019 with a critical milestone for PBM (pharmacy benefit manager) reform nationwide. On January 25, nearly 3,500 pharmacists and 170 patients voiced their support for parts of a proposed Centers for Medicare and Medicaid Services drug pricing rule that would eliminate the retroactive nature of direct and indirect remuneration (DIR) fees. What began as a years-long effort led by the National Community Pharmacists Association (NCPA) has grown into a movement that will help us gain momentum for moving pharmacy price concessions to point-of-sale. We recognize the challenges that DIR fees have created for community pharmacists to operate their small businesses, given the uncertainty of whether they will break-even on a transaction until months later. If passed, the new CMS drug pricing rule would create fairness for community pharmacists as well as patients. More than two dozen patient advocacy organizations supported the proposed rule on the premise that, if finalized, the pharmacy DIR fixes will result in a savings of $200-plus annually for the average patient’s out-of-pocket prescription drug costs. But the fight isn’t over for comprehensive PBM reform, especially here in New England. This issue of PJNE not only highlights how we are fighting for greater PBM transparency, but also the importance of pharmacists getting involved. It’s never too late to help your state and federal legislators better understand the impact of PBMs on your profession and patient care. There are a variety of resources you can share with them, including a PDF developed by the National Community Pharmacists Association (NCPA). Make your voice heard! Sincerely,

Lindsay De Santis Executive Vice President Massachusetts Pharmacists Association

Editors:

Lindsay De Santis, Nathan Tinker

Nathan Tinker, PhD CEO Connecticut Pharmacists Association

Design & Production: Kathy Harvey-Ellis

The Pharmacy Journal of New England is owned and published by the Massachusetts Pharmacists Association and the Connecticut Pharmacists Association. Opinions expressed by those of the editorial staff and/or contributors do not necessarily reflect the views or policies of the publisher.Readers are invited to submit their comments and opinions for publication. Letters should be addressed to the Editor and must be signed with a return address. For rates and deadlines, contact the Journal at (860) 563-4619. Pharmacy Journal of New England 35 Cold Spring Road, Suite 121 Rocky Hill, CT 06067-3167 members@ctpharmacists.org

Submitting Articles to the Pharmacy Journal of New England™

The Pharmacy Journal of New England™ is the product of a partnership between the Connecticut Pharmacists Association and the Massachusetts Pharmacists Association. The Journal is a quarterly publication. All submitted articles are subject to peer review. In order to maintain confidentiality, authors’ names are removed during the review process. Article requirements must conform to the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (Ann Intern Med 1982;96 (1part1):766-71). We strongly encourage electronic submissions. PJNE does not assume any responsibility for statements made by authors.

Please submit manuscripts to: PJNE 35 Cold Spring Rd., Suite 121 Rocky Hill, CT 06067 or email to: lcapobianco@ctpharmacists.org

Pharmacy Journal of New England • Winter 2019

MPhA Pharmacist Spotlight: Amy L. Vachon, PharmD Dr. Vachon has served as the Director of Clinical Pharmacy at Atrius Health since 2011. In that capacity, she is responsible for all services and staff providing formulary management, cost-saving prescribing initiatives, academic detailing, high-risk patient roster reviews, collaborative drug therapy management (diabetes, hypertension, hyperlipidemia, depression, anxiety, insomnia), drug information consult services, pharmacy benefit management and education, drug therapy guideline development, prescribing informatics, drug utilization reporting/analysis, pharmacist staff education and development, urgent drug news corporate response, and patient medication and drug therapy adherence education. Clinical Pharmacy was the first clinical department to be adopted across Atrius Health and has grown to include a large staff of clinical pharmacists deployed across almost every clinical site with central support from a clinical pharmacy technician team and analytics team. Dr. Vachon was the 2012 recipient of the MPhA Presidents Award and the MSHP 2011 Pharmacist of the Year. Outside of her pharmacy interests, Dr. Vachon and her husband Marc have penned a parenting book. What Made You Choose This Path in Pharmacy? I think choosing to complete a pharmacy residency opened many professional doors for me. It allowed me to try on various roles for a year, and then eventually I realized how much I loved educating clinicians, creating clinical guidelines, and managing the cost and quality of drug therapy. From there, I discovered managed care and ambulatory care clinical pharmacy. I especially love working in an accountable care organization, in which the incentive to provide the highest quality of care is appropriately balanced with managing the cost for that care. And I love how the ambulatory care environment allows a clinical pharmacist to directly help patients to succeed in understanding and managing their health over the long-term.

multi-disciplinary team. I am very fortunate to work with a highly talented and equally passionate group of clinical pharmacists who work hard every day to bring this mission to patients and clinicians. How Has Pharmacy Changed Since You Started Practicing? Most notably, pharmacy has moved into the realm of collaborative practice. Also, when I first moved to Boston, the PharmD degree was relatively new here; since then, I’ve seen it become the only new-graduate option. Today, the Clinical Pharmacy Department at Atrius Health is officially recognized as a medical specialty, alongside Cardiology, Nephrology, Dermatology and others. Where Do You See Pharmacy in the next 5-10 years? I think we will become recognized across the country as health care providers who can perform as midlevel prescribers. I believe that we will prove our value as drug therapy specialists, fitting into a common care model alongside nurses, nurse practitioners, physicians’ assistants, internists and specialists, in which each profession provides the services it does best and together the patient is surrounded and supported by a system of care. Why Do You Believe Professional Membership is Important? I think professional membership allows pharmacists to speak up, share ideas, support each other along the growth curve in our profession, and have a voice outside our profession. There are still many who do not understand the breadth of pharmacy services and what a pharmacist is trained to do, and our professional organizations can help us change that. Finally, if you were a drug, what would you be and why? I would be a disease modifying drug that had solid outcomes evidence. I’d like to be the hero changing the course of a disease rather than simply treating its symptoms.

In many ways, my current position has grown around me over the years I’ve been at Atrius Health – initially as one of only two clinical pharmacists providing formulary management, then piloting embedded clinical services within an internal medicine clinic, to developing full direct patient care under collaborative practice agreements with a much larger staff. All along, my passion has been to provide high quality, patient-centered medication management in a collaborative,

Pharmacy on the Front Line: Tom Buckley, Khmer Health Advocates, and the Role of the Pharmacist in Long-Term Trauma Treatment by Mary Lamothe Professor Thomas Buckley’s work with the KHA and UConn’s Institute of Collaborative Health combines clinical practice and advanced research with community engagement to bring new hope to trauma survivors from the Cambodian genocide. The program engages PharmD candidates on the front lines of public health and opens new frontiers in the battle against trauma-related illness and offers insight into treatments for diabetes, PTSD, and complex chronic disorders. In 2006, after spending the previous year in a Burmese refugee camp working as part of a Global Health Fellowship with the International Rescue Committee, UConn pharmacology professor Thomas Buckley was back in Connecticut. Perhaps recognizing that Buckley would jump at the chance to help people here at home, his wife, Cindy Kozak, Director of the Diabetes Prevention and Control Program of the CT Department of Public Health, sent him to check out Khmer Health Advocates (KHA), a group working with Cambodian refugees in southern New England. She was right, of course. Khmer Health Associates is a community-based health initiative that specifically supports Cambodian genocide survivors in Connecticut, Massachusetts, and Rhode Island. It is an affiliate program of the UCONN’s Institute for Collaboration of Health, Intervention, and Policy (InCHIP). The organizations had been working since the 1980s on multidisciplinary, whole-patient responses to seemingly insurmountable public health crises and offering a teambased approach to care that focuses on stress reduction and the social and behavioral determinants of health. Studies show that 60-70% of members of this community suffer PTSD, and 50% have chronic Depression. Chronic pain figures for survivors are four times the national average. Both the KHA, founded by survivors of the Cambodian genocide and the nurses who had treated them, and InCHIP, founded by two pioneering AIDS researchers, engaged clinicians and researchers from medicine, health care, and social work. But by 2006, it was clear that they needed a pharmacist. “They recognized that their patients had very complicated drug regimens and were mismanaging them frequently,”

Tom Buckley visits a health center in Cambodia. Buckley remembers. He had always been concerned with the medical, mental, social, and behavioral interactions of health, and, for KHA patients, who were experiencing medical problems that were the after-effects of surviving the Cambodian genocide, patients’ health problems proved to go way beyond drug management. Early on in what became the long-term relationship between Buckley and KHA patients, a fuller picture began to emerge of trauma survivors and the complex systems that might work to improve their health. As he got to know visitors to the clinic, Buckley was surprised to find that patients with significant chronic health problems had never even been asked about their backgrounds by their primary healthcare providers, so doctors usually knew nothing about the torture and starvation in their patients’ histories. One patient, Lila Plawecki, came to KHA with complex conditions, including diabetes and depression, and though she had had traditional medical care, she had never been asked by a doctor about her childhood experiences, 40 years ago, as a prisoner in Cambodia: abused, orphaned, and surviving on 600 calories per day. “Repeated exposure to torture/trauma causes chronic elevated cortisol levels, which overwhelms the negative feedback loop in our bodies,” which can explain many of the conditions refugees suffer today, Buckley explained. The health conditions brought on by such chronic suffering can appear decades after the abuse. KHA Executive Director Theanvy Kuoch, therefore, regularly visits area Buddhist temples and community centers in Connecticut,

Pharmacy Journal of New England • Winter 2019

western Massachusetts, and Rhode Island in her efforts to reach out and empower refugees to speak about their experiences, often for the first time. Speaking out helps the survivor to break the silence on torture and its aftereffects, but it also shows others that they are not alone. In many cases, silence was the key to people surviving their experiences, but that silence, over time, can lead to internalization of the trauma, and even to self-blame. The dehumanization that is central to the practice of torture, researchers and clinicians are finding, is best combatted by engagement with the community. According to Buckley, “social isolation is the number one predictor of PTSD” and related health conditions, and having escaped the crisis is not enough for an individual to recover long term. In essence, “the entire community has to heal.” Thus, for InCHIP and KHA, a major concern is the need for patients to share the stories of their experiences. Beyond meeting and sharing experiences, patients are taught to manage their conditions with such resources as the Eat, Walk, Sleep program. Each year, UConn’s School of Pharmacy students join with community health professionals to help KHA patients with the work of recovery. As part of their clinical rotations, senior students work directly with KHA patients and staff, including performing home visits or working in the community. Students also participate in the research and health advocacy projects and find that they can have a valuable impact on patient care as well as health policy. Buckley’s work brings together researchers from across the health fields, facilitating professional as well as community partnerships: “Everyone is working at the top of their license,” says Buckley, “my work with them has resulted in grant projects with faculty from numerous schools within the university, such as medical, nursing, and social work.” The work is reaping rewards in terms of treatment strategies and valuable research, including NIH projects, primary investigations into interrelationships among stress, violence, hunger, and chronic health conditions, including those that, Buckley says, “may interfere with the body's ability to properly absorb vitamins and minerals, and potentially some medications.” Buckley’s pharmacy students learn to work as part of an interdisciplinary, patient-centered team. “The team speaks the language of CARES,” says Buckley, referring to Communication, Access, Resources, Education, and Strategies. They learn to simplify healthcare to such essential questions as “What do we need to know” and “What do we need to do.” The team has developed a systematic approach to Medication Therapy Management (MTM), helping patients to understand their health conditions and manage their medications as well as their access

to medications. But students also learn to view their profession as public health beyond pharmacology. They learn firsthand about the basic access, health, and nutrition issues that patients face daily. Students even phone insurance companies to help patients access necessary medications. And they learn that, when it comes to chronic conditions, especially those triggered by trauma, there is actually, “not a lot of treatment that works,” and “meds are not usually the answer,” adds Buckley. Instead, a combination of drug therapy, including managing over-the-counter and prescription medications, with regular clinical therapy sessions and community and nutritional support seems to offer hope: “We know that medicines make up perhaps 10-20%, at most, of a person's total health - most of their health and wellness is affected by where they live and interact.” Time with patients might in fact prove to be the best indicator of success, and that puts pharmacists on the front line of health care: “We always tell our students as soon as they enter pharmacy school that the pharmacist is the most accessible health care provider. Data tells us that over 30 visits per year occur in a pharmacy on average, compared to three times a year with their physician.” Program graduates embrace their roles as community health professionals, and they apply their work with KHA as they help patients in their own professional practices access healthcare and deal with such challenges as follow-up care, all of which is key to public health because “seeing a patient 10 times more often than a physician gives the pharmacist the perfect vehicle for close monitoring of chronic diseases,” according to Buckley. Moreover, these young pharmacists tend to stay in touch with KHA staff and patients. Many students return to work with the patients and staff long after graduation. There is interest in how transferable this work can be to other traumatized communities, with hope for increased valuable implications for understanding the long-term consequences of war on chronic health conditions; the Veteran’s Administration, in particular, is concerned about the impact of multiple tours of duty on such conditions as PTSD. “Our curriculum is culturally and linguistically appropriate to Cambodian, but the concepts are readily transferable to other communities.” Although Buckley is back in Connecticut, his work is traveling abroad. Today, as part of a grant project, the teams are engaging technology to provide training for healthcare workers in Cambodia, who will deliver KHA’s curriculum to patients suffering diabetes and mental health conditions. This study will inform patient care and health policy in trauma communities worldwide.

Pharmacy Marketing Group Rx and the Law By: Don R. McGuire Jr., R.Ph, JD

Pharmacy Benefit Manager Regulation A first step in the regulation of Pharmacy Benefit Managers (PBMs) occurred at the quarterly meeting of the National Council of Insurance Legislators (NCOIL) in December 2018. That group’s Health, Long Term Care and Health Retirement Issues Committee passed a Model Act providing for the regulation of PBMs by state insurance commissioners. National Community Pharmacists Association’s (NCPA) regulatory affairs Vice President Ronna Hauser said, “We believe the act is a robust chassis that will put state insurance commissioners in a better position to regulate PBMs.” Many pharmacists may not have heard of NCOIL nor are they aware of how insurance is regulated in the United States. In 1944, Congress passed the McCarran Ferguson Act, which provided for the regulation of the insurance industry by the states rather than the Federal Government. As part of this regulatory design, Congress mandated that states must adopt an Unfair Trade Practices Act by 1948. The states did this through the adoption of a Model Act. Model Acts provide a template for state legislatures to review and adopt in their state. This eases the drafting burden on the legislatures while providing some uniformity across the several states. The National Association of Boards of Pharmacy provides the same service with its Model State Pharmacy Act. To facilitate the state regulation of insurance, there are two groups that provide assistance to the state legislatures and departments of insurance. The National Association of Insurance Commissioners (NAIC) was founded in 1871 and establishes standards, best practices, and coordination of regulatory oversight. NAIC also drafts and proposes Model Acts. NCOIL was founded in 1969 and brings together legislators from the states. NCOIL functions to educate legislators on insurance issues and to create Model Acts for states to adopt. So what does the adoption of this Model Act mean for pharmacy? There have been attempts by a few states to regulate PBMs. These attempts have not been consistent in their approach and some have not survived judicial scru-

tiny. The Model Act provides a consistent approach to PBM regulation. The Model Act specifically grants the state insurance commissioner the authority to regulate PBMs and to promulgate rules covering items such as network adequacy requirements, pharmacy compensation, and prohibited market conduct practices. Aside from the legal technicalities, the Model Act facilitates the passage of the law in the various states. The fact that a Model Act has been drafted highlights to state legislators the severity of the issue. The absence of a Model Act can sometimes be used by opponents to advocate that the issue isn’t that important simply because there is no Model Act addressing it. The drafting of a law takes a lot of research time and drafting effort. As mentioned earlier, the Model Act relieves the state legislators of this burden and makes it easier for them to pass the law. The passage of the Pharmacy Benefits Manager Licensure and Regulation Model Act is a positive step in the right direction for the profession of pharmacy. However, advances like this are not easy and are not free. NCPA worked with NCOIL members for more than nine months on the language of the Model Act to make sure that it addressed pharmacy owners’ concerns. This highlights again the need for pharmacists to be involved in the legislative process. As a previous article in this series said, “Even if we don’t get involved in the making of laws, we will be subject to them nonetheless. Pharmacists can ill afford to be impacted by laws drafted by those who know nothing about pharmacy.” The Model Act is available, but that is not the end of the story. Now the scene shifts to the state legislatures. The Model Act will likely face stiff opposition in each state where it is introduced. Pharmacists need to be prepared to get involved and advocate for passage of the Model Act. If you don’t, who will?

Legislative Update

Pharmacy Journal of New England • Winter 2019

Connecticut Governor Lamont Launches Budget, and Pharmacy is Part of the Equation They say elections have consequences—and (for better or worse) Connecticut’s pharmacy community is beginning to see the consequences of the state’s gubernatorial contest. Governor Ned Lamont’s election was narrow: Lamont captured 48.6 percent of the vote to his opponent Bob Stefanowski’s 46.9 percent. But Lamont brought with him a wave of Democratic House and Senate wins, giving Dems substantial majorities in both houses. On February 20, Lamont presented his first 2-year budget proposal, and since then a series of bills have been put forward to support that proposal. One thing that is conspicuously missing from the Lamont budget is the legalization (and potential tax revenue) of marijuana. Throughout his campaign, Lamont had said he favored legalization, and most people would have bet that it would appear in the budget. Instead, during his budget speech, Lamont simply said, “Legalizing recreational marijuana like our neighbors will make for a safer market that will be carefully regulated and taxed.” And that was it, nothing more, leaving it to the legislature to argue the issue separately. This is important because Connecticut is currently home to 18 approved medical marijuana dispensaries, of which 9 are currently operating (the other 9 were just approved a few months ago and have not yet opened their doors as of this writing). Four growers provide product to those dispensaries. There are some 30,000 medical marijuana patients in the state. As an organization, the Connecticut Pharmacists Association (CPA) does not support the legalization of recreational marijuana in Connecticut. We fear that “adult-use” program will damage the integrity and viability of the current, highly successful, medical model. It will be interesting to see how this now moves forward— there are literally dozens of lobbyists in Hartford working both sides of the legal marijuana issue. However it turns out, we hope that legislators and regulators understand and acknowledge the vital role pharmacist play, and have played, in Connecticut’s current program. A second major part of the Governor’s budget proposal is a new initiative entitled the “Connecticut Prescription Drug Program” (CPDP), a broad measure focused on driving down prescription drug costs through a variety of means. These include creating a regional drug buying consortiia with other states and expanding the state employee health

Connecticut pharmacists and pharmacy students celebrate a proclamation signed by Governor Ned Lamont that declared March 7th as “Pharmacist Day” in the state. program to include municipalities, libraries, and “large, selfinsured companies” in the state. For pharmacists, a key component of CPDP achieves a major goal—it prohibits PBMs and health carriers from contracting with pharmacists to “recoup, directly or indirectly, from a pharmacy or pharmacist any portion of a claim that [they] have paid to the pharmacy or pharmacist.” In other words, the bill would essentially wipe out delayed clawbacks. Pharmacy reimbursement reform is a major priority for our membership—the financial impact of clawbacks and direct and indirect reimbursement (DIR) protocols alone has been enough to force independent pharmacies in the state to close, an impact felt not only by the owners and employees of these pharmacies, but also by the thousands of patients they serve. Connecticut’s discussion of such reform is extremely timely. Just three weeks ago a years-long effort led by the National Community Pharmacists Association (NCPA) to build support for a proposal to move pharmacy price concessions to point-of-sale reached a critical milestone. On Jan. 25, 2019, CPA joined nearly 3,500 pharmacists and 170 patients in voicing support for parts of a proposed Centers for Medicare and Medicaid Services drug pricing rule that would eliminate the retroactive nature of pharmacy DIR. CPA believes that all such schemes should be eliminated, period. Doing so would have a clear and immediate effect: less uncertainty for pharmacies, lower costs for patients, and a more stable healthcare environment for both. There are a number of other bills and proposals affecting pharmacy practice working their way through the halls of Hartford. But it is clear that the Lamont administration is taking seriously the challenges facing the state’s budget, especially where drug pricing and access is concerned.

Massachusetts Legislative & Regulatory Update The 2019 Legislative Session has commenced and the Committee Chairs have been named. There have been a number of bills submitted for the upcoming session that impact the practice of pharmacy in Massachusetts. Please note the docket numbers below are temporary until bills are assigned to committees.

An Act Recognizing Pharmacists as Health Care Providers Sponsors: Senator Joan Lovely (SD846 ), Representative Christine Barber (HD549) The revised bill focuses on adding the word “registered pharmacist” to Section 1, Chapter 111 of the General Laws. Designation as Providers will be a first step in working towards reimbursement models.

An Act Relative to Smoking Cessation Agents Sponsors: Senator Michael Moore (SD103), Representative Danielle Gregoire (HD801) This legislation would grant registered pharmacists the authority to provide smoking cessation agents including nicotine replacement products and Varenicline/Bupropion. Under the provisions of the proposed bill, Pharmacists would be required to receive training and certification in the prescription of smoking cessation agents developed under the oversight of the Department of Public Health and the Board of Registration in Pharmacy.

An Act Relative to Hormonal Contraceptives Sponsor: Senator Michael Moore (SD102) The bill would allow registered pharmacists the authority to prescribe birth control. Under the provisions of the proposed bill, Pharmacists would be required to receive a Hormonal Contraceptive Certificate developed under the oversight of the Department of Public Health and the Board of Registration in Pharmacy in order to prescribe.

An Act to Ensure Access to Medications Sponsors: Sen. James B. Eldridge (SD884), Representative Gail Benson (HD1509) This legislation amends the “Any Willing Provider” law to allow community pharmacies to fill prescriptions for “spe-

cialty medications” as long as they can provide the required administrative, handling, and monitoring services required by the drug. Insurers and pharmacy benefit managers have been getting around the “Any Willing Provider Law” by designating a medication a “specialty medication” even when the drug requirements are minimal (e.g., Humira). This legislation will close that loophole. This will also assist patients by allowing them to obtain all their medication from one pharmacy instead of trying to coordinate mail shipments from a specialty pharmacy located in another state. The bill also sets a new category of registration at the Massachusetts Board of Pharmacy that would establish standards for specialty pharmacies and ensure the safe and efficient distribution of the medications in the commonwealth.

An Act to Reduce the Cost of Pharmacy Benefits Sponsor: Sen. Patricia D. Jehlen (SD1826) This legislation would allow for greater competition, increased transparency, and reduced prices by; • Prohibiting pharmacy benefit managers from creating artificial barriers for outside pharmacies in order to steer business to community, specialty, or mail-order pharmacies owned by the pharmacy benefit manager. This legislation would ensure the requirements set by the Massachusetts Board of Registration in Pharmacy are used. • Prohibit pharmacy benefit manager from charging insurers more than what was paid to the pharmacy • Require each pharmacy benefit manager to submit a transparency report to the Division of Insurance. The report will detail information about rebates, administrative fees and other revenue that is retained by the pharmacy benefit manager and sent to the insurer. The reports will then be sent to the Health Policy Commission and they will compile a publically available report that protects trade secrets.

Regulatory Update: Pharmacist Administration of Medications for the Treatment of Mental Illness and Substance Abuse Disorder. Via Circular : DCP 19-2-105, Recent amendments to 105 CMR 700.000 authorize pharmacists and pharmacy interns to administer medications for treating mental illness and substance use disorder, in accordance with Department guidance. There is no requirement for pharmacists or pharmacy interns to administer these medications. To administer, a pharmacist or pharmacy intern must first receive training that is accredited by the Centers for Disease Control and

Pharmacy Journal of New England • Winter 2019

Prevention, the American Council on Pharmaceutical Education or a similar health authority or professional body appropriate for the medications being administered and their respective patient populations. Such training shall include learning modules on techniques for administration by injection.

Requirement for Credits ✓ Program attendees can earn Continuing Pharmacy Education credits for this program by electronically logging onto the website: http://www.rxce.neu.edu, inserting the activity specific code number and successfully completing the activity learning assessment/evaluation form. ✓ Participant names will be checked against program attendance sheets for verification of attendance. ✓ Participants have 60 days to complete evaluations. After 60 days from April 25, 2019 no credit will be available for this program. ✓ Credits will be electronically transferred to the CPE Monitor System. No Statements of Credit will be issued by Northeastern University School of Pharmacy. ✓ Program participants can earn up to 7.25 contact hours of continuing education credits including 2.75 contact hours in pharmacy law. ✓ This program is not accredited for pharmacy technicians Evaluation All participants will have the opportunity to review the educational sessions and speakers and to identify future educational needs. Statement of Disclosure In accordance with the Accreditation Council for Pharmacy Education (ACPE) Standards for Continuing Pharmacy Education 2009, Northeastern University School of Pharmacy requires that faculty members disclose any relationship (e.g., shareholder, recipient of research grant, consultant or member of an advisory committee) that the faculty may have with commercial companies whose products or services may be mentioned in their presentations. Such disclosure will be made available on the day of the program. Accreditation Statement Northeastern University Bouvé College of Health Sciences School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Four Points by Sheraton 1125 Boston-Providence Turnpike Norwood, MA 02062 (781) 769-7900 Complimentary Self Parking

MPhA Spring Program 7:00 Registration and Networking Breakfast 7:50 am Welcoming Remarks by MPhA President Delilah Barnes, RPh, Sullivan’s Pharmacy 8:00 am – 9:00 am Pipeline Preview 2019 Maria Lowe, PharmD, RPh  Describe recent trends in the FDA approval process  Recognize emerging pipeline agents with currently available therapeutic options  Identify generic equivalents for commonly used brand name products that will be introduced to the market over the next two years ACPE UAN: 0027-9999-19-037-L04-P – knowledge based - 1 contact hour 9:00 am – 10:00 am Compounding: USP <800> – Where are We? Timothy Fensky, RPh, FACCP  Give examples of areas that might be overlooked in USP <800> Implementation Planning  Recall information contained in 247 CMR 19:00 ACPE UAN: 0027-9999-19-038 L03-P– knowledge based – 1.0 contact hour 10:00 am – 10:30 am Break - Visit Our Exhibitors! 10:30 am – 11:00 am CBD Oil – What You Need to Know Jane Tenaglia, RPh, Certified Aroma Therapist, Integrated Energy Therapy Advanced Practitioner, Reiki Master, Master Trainer Yoga Teacher  Identify market niches for CBD Oil  List important criteria for choosing safe and high-quality CBD Oil  Summarize legal and ethical concerns surrounding the sale of CBD Oil in Pharmacies ACPE UAN: 0027-9999-19-039-L04-P– knowledge based – 0.50 contact hour 11:00 am – 12:00 pm Benzodiazepine Best Practice Review and Approaches for Transitioning to Alternate Therapies Michael Angelini, RPh, PharmD, BCCP  List the expert recommendations for use of benzodiazepines primarily in anxiety and sleep disorders,  Compare the risks and benefits of benzodiazepines and non-benzodiazepines pharmacotherapy for anxiety disorders, and  Create a method of tapering/switching the benzodiazepine that is safe and effective. ACPE UAN: 0027-9999-19-040-L01-P– application based – 1.0 contact hour 12:00 pm - 1:00 pm Lunch & Exhibits 1:00 pm – 2:00 pm 2019 Regulatory Update Michelle A. Chan, RPh and Julienne Tran, RPh, Massachusetts Board of Registration in Pharmacy  Define the terms Advisories, Policies and Circular Letters as they relate to the Board of Registration in Pharmacy



Summarize Advisories, Policies and Circular Letters that affect the practice of pharmacy  Describe common deficiencies found upon inspection of pharmacies in Massachusetts ACPE UAN: 0027-9999-19-041-L03-P– knowledge based – 1.0 contact hour 2:00 – 3:00 pm National Drug Shortages and Strategies for Maintaining Quality Care Michael Cotugno, BS Pharm, RPh, Director of Patient Care Services, Brigham & Women’s Hospital  Explain the possible causes of drug shortages  Describe the impact of drug shortages  Identify possible solutions for drug shortages.  Summarize strategies for managing drug shortages. ACPE UAN: 0027-9999-19-042-L04-P– knowledge based – 1.0 contact hour 3:15 pm – 4:15 pm Hot Topics in Pharmacy Around the World in 60 Minutes New Hampshire’s Approach to Oral Contraception Certification for Pharmacists Michael Bullek, RPh, President, New Hampshire Board of Pharmacy  Describe hurdles overcome to pass legislation allowing pharmacists to prescribe oral contraceptives ACPE UAN: 0027-9999-19-043-L03-P – knowledge based – 0.25 contact hour Deprescribing- A New Buzz Word in Pharmacy Melanie Greer, PharmD, RPh, PGY2 Ambulatory Care Pharmacy Resident Boston Medical Center  Define deprescribing and how it relates to polypharmacy ACPE UAN: 0027-9999-19-044-L04-P – knowledge based – 0.25 contact hour Pharmacists as Harm Reductionists Alyssa Peckham, PharmD, RPh, BCPP, Clinical Assistant Professor of Pharmacy at Northeastern University and a Clinical Addiction Specialist at Massachusetts General Hospital  Explain what is meant by harm reduction in relation to reducing overdoses ACPE UAN: 0027-9999-19-045-L05-P – knowledge based – 0.25 contact hour Alliance Against Opioid Abuse  Explain the mission of the Alliance Against Opioid Abuse  Describe the purpose of the AAOA Pharmacy ToolKit ACPE UAN: 0027-9999-19-046-L04-P– knowledge based – 0.25 contact hour 4:15 pm – 5:00 pm MassPAT Update David Johnson, Director, Drug Control Program, MA DPH  List recent and upcoming enhancements to MassPAT  Describe trends in controlled substance prescribing  Identify risk indicators for SUD and overdose ACPE UAN: 0027-9999-19-047-L03-P – knowledge based – 0.75 contact hour 5:00 pm—6:00 pm MPhA Happy Hour! - Join us for complimentary food & cocktails

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Pharmacy Journal of New England â&#x20AC;˘ Winter 2019

Yankee Green: Marijuana as Medicine in New England by Al Domeika, RPh Dispensary Manager/Pharmacist Prime Wellness of Connecticut al@primewellnessofct.com Al Domeika is a founding member of Prime Wellness. He brings over 25 years of retail pharmacy experience, managing pharmacies in various regions with fluctuating volumes. A 1996 graduate of the University of Connecticut, Al is a long-standing member of the Connecticut Pharmacists Association. He specializes in patient-care, immunizations, diabetic care, and is CPR certified. Al is also the first pharmacist in Connecticut to receive a medical marijuana dispensary license.

MEDICAL MARIJUANA LAWS IN NEW ENGLAND In New England, each state has some sort of medical cannabis law on the books, although each state has plenty of differences. Here is a breakdown of each individual state in New England.

Connecticut is unique among New Englandâ&#x20AC;&#x2122;s medical marijuana programs, as the state has reclassified cannabis from a Schedule I drug to a Schedule II drug. Therefore, marijuana regulations mirror pharmacy law. Only pharmacy technicians may apply for a dispensary technician license, as they are the only ones to sell marijuana product to patients. Furthermore, only pharmacists may apply for a dispensary license, and only pharmacists may dispense product and counsel patients.

In order to dispense product, Connecticut pharmacists review the chemical composition of each marijuana product to predict how patients will react to different compounds. They must review a patient’s medical history and target the symptoms most affected by the patient. They monitor drug interactions, review expected effects with patients, and review the different ways patients may use cannabis, whether it be inhalation, sublingual, or ingestible. Once all this has been reviewed with the patient, the pharmacist suggests the appropriate product or products that will help the patient the best. They follow up with each patient and document effects, both positive and negative, and note any medication changes. Connecticut’s dispensary pharmacists have the opportunity to participate in research projects with different institutions as well. Other states have followed Connecticut’s lead in using pharmacists to dispense medical cannabis. Minnesota, New York, Arkansas, Pennsylvania, and now Oklahoma all are using or will be using pharmacists to help patients use cannabis in a responsible manner.

A HAZY FUTURE Where is all this headed? First, if the status quo remains—in which individual states will continue to defy federal law—sick patients in need will continue to have access to alternative medicine. However, since each state has different laws, it can be very confusing for patients, enforcement officers, and regulators. Patients are also limited to access medical cannabis only in the state in which they reside and have a card: they are forbidden to cross state lines with these products. Patients will continue to pay for their medicine out of pocket, as no insurance company will pay, as long as it is still federally illegal. There will remain significant limits on clinical research that can be done on the benefits of cannabis. Second, the federal government could deregulate cannabis altogether and treat it like alcohol, allowing it to be used recreationally throughout the country. This would eliminate the criminality of cannabis use and reduce incarcerations drastically. But, from a health care professional point of view, it will be hard to track patients’ usage and monitor potential drug interactions. In this scenario as well, insurance coverage will be unlikely, and this also will limit research.

Pharmacy Journal of New England • Winter 2019

Finally, the federal government could move cannabis from a Schedule I drug to a lower classification, like Connecticut has. In this case, patients would have safe access to the medicine, and it would open up a whole new field in pharmacy nationally. We would be able to track patients’ usage using PMP, and insurance companies would be free to pay for FDA-approved medicines, especially if we can prove that we are reducing patients’ other pharmaceutical drugs. Research opportunities would flourish. No matter where we go from here, pharmacists and other health care professionals should be aware of whether patients are using any cannabis products, medically or otherwise, to monitor symptom relief and drug interactions.

A BRIEF HISTORY

2018 Recipients of the “Bowl of Hygeia” Award

Ronda Lacey Alabama

Dennis McAllister Arizona

Cissy Clark Arkansas

Debby Johnson California

Catherine Jarvis Colorado

Marghie Giuliano Connecticut

Lisa Stonesifer Delaware

Michael A. Moné Florida

Sharon Sherrer Georgia

Starlin Haydon-Greatting Illinois

Bernadette Brown Indiana

Mickey Cooper Iowa

Brian Caswell Kansas

Pat Mattingly Kentucky

Nick LeBas Louisiana

Betty J. Harris Maine

Dixie Leikach Maryland

David Sencabaugh Massachusetts

Phil Hagerman Michigan

Laura Schwartzwald Minnesota

Ricky Cash Mississippi

Gene Forrester Missouri

Tricia Campbell Montana

Angie Svoboda Nebraska

Roseann Visconti Nevada

Jennifer Towle New Hampshire

Rupal Mansukhani New Jersey

Michael Raburn New Mexico

John Westerman, Jr. New York

Davie Waggett North Carolina

Robert Biberdorf North Dakota

Dan Karant Ohio

Don Ritter Oklahoma

Penny Reher Oregon

Richard Williams Pennsylvania

Abigail Vazquez Puerto Rico

Kelley Sanzen Rhode Island

Robert Hubbard South Carolina

Hugh Mack South Dakota

Larry Calhoun Tennessee

Carol Reagan Texas

Darryl Wagner Utah

Allen Huffman Virginia

Linda Garrelts MacLean Washington

Ivan Cephas Washington DC

Charles “Laddie” Burdette, Jr. West Virginia

Brook DesRivieres Wisconsin

Stephen Rogers Wyoming

The “Bowl of Hygeia”

The Bowl of Hygeia award program was originally developed by the A. H. Robins Company to recognize pharmacists across the nation for outstanding service to their communities. Selected through their respective professional pharmacy associations, each of these dedicated individuals has made uniquely personal contributions to a strong, healthy community. We offer our congratulations and thanks for their high example. The American Pharmacists Association Foundation, the National Alliance of State Pharmacy Associations and the state pharmacy associations have assumed responsibility for continuing this prestigious recognition program. All former recipients are encouraged to maintain their linkage to the Bowl of Hygeia by emailing current contact information to awards@naspa.us. The Bowl of Hygeia is on display in the APhA History Hall located in Washington, DC. Boehringer Ingelheim is proud to be the Premier Supporter of the Bowl of Hygeia program.

Pharmacy Journal of New England • Winter 2019

Kentucky Report Says PBMs Took $123.5 Million in Hidden Fees

FDA Continues to Advance Oversight of Drug Compounding

A recent report in Kentucky reveals that pharmacy benefit managers (PBMs) took $123.5 million in hidden fees from Kentucky health-insurance plans that cover the state’s poor. The report is the latest to examine a controversial practice known as spread pricing, in which PBMs pay pharmacies one price for a treatment while charging a higher one to their health plan clients. The difference, or spread, is used to stabilize drug costs, according to PBMs. Last year, four Kentucky insurers in Medicaid paid $957.7 million to four PBMs that use the arrangements. Of that, the PBMs kept 13 percent -- $123.5 million -- through spread pricing, according to the report. Kentucky officials found that those size of the spreads rose by more than a third from 2017. Source: bloomberg.com

The FDA has issued a final rule under section 503A of the Federal Food, Drug, and Cosmetic Act. This rule places six bulk drug substances on the 503A bulks list, which includes substances that compounders can use to compound drugs. The rule also identifies four bulk drug substances that are not on the list and therefore, cannot be used for compounding under section 503A. The final rule, which goes into effect on March 21 applies to compounding by licensed pharmacists in state-licensed pharmacies or federal facilities, and licensed physicians, according to the FDA. Source: fda.gov

U.S. Travelers Seek Cheaper Medicines in Mexico

According to a recent study in the American Journal of HealthSystem Pharmacy, more than half of health-system pharmacists have a high-degree of burnout. The study found that 53.2% of health-system pharmacists reported scores indicating a high degree of burnout on at least one subscale of the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). Christina Martin, PharmD, director of membership forums with the ASHP, said burnout is connected to compromised patient safety and a loss of productivity in the workforce. Erin Albert, PharmD, senior director for education for the American Society of Consultant Pharmacists, said among the factors for burnout in pharmacy include pressure to perform at better and faster rates, needing to do more with fewer resources and time, and more competition in the workplace with more pharmacy schools producing more pharmacists. Source: drugtopics.com

According to the U.S. government, nearly 1 million people in California alone cross to Mexico annually for health care, including to buy prescription drugs. Between 150,000 and 320,000 Americans a year cite health care as a reason for traveling abroad, citing cost savings as the motivating factor. Last year, Utah’s Public Employee Health Plan (PEHP) offered a voluntary Pharmacy Tourism Program. For certain PEHP members who use any of 13 costly prescription medications, the insurer will pay the bill to fly the patient and a companion to San Diego, then drive them to a hospital in Tijuana, Mexico, to obtain a 90-day supply of medicine. Source: npr.org

CVS Health Pilots “HealthHub” Stores in Houston After completing its $69 billion acquisition of Aetna in November, CVS Health is piloting three “HealthHub” stores in Houston with a suite of health care services that could be the drug store of the future. The new HealthHubs fit into CVS CEO Larry Merlo’s plan to turn his company’s 9,800 stores into a “health care destination.” For CVS, the goal is to arm its sprawling network of stores with a range of health services to protect against competition from Amazon and a wave of mergers in the industry. Equipped with on-site dieticians, nurse practitioners, lab services, and medical supplies on the shelves, the HealthHub stores will target patients with chronic conditions, such as diabetes and respiratory illnesses. Meanwhile, CVS reported a net loss of $421 million in the fourth quarter and set earnings expectations for 2019 well below Wall Street forecasts. Source: hartfordbusiness.com

Avoiding Pharmacist Burnout

FDA Approves First New Drug to Treat Postpartum Depression The FDA approved the first drug specifically targeted to treat postpartum depression. Developed by Massachusetts-based biotech company Sage Therapeutics, brexanolone will be marketed under the brand name Zulresso. The drug will be administered through an intravenous infusion over 60 hours. Because Zulresso can cause side effects like dizziness and sedation, the FDA will require women to receive treatment at an inpatient facility or hospital where they can be monitored. Specialists have praised the new drug because it works quickly and should help raise more awareness and diagnosis of postpartum depression, which 400,000 women in the U.S. experience every year. Source: statnews.com

UConn School of Pharmacy Honors Preceptors for Excellence in Teaching and Mentoring In conjunction with American Pharmacists Month last October, the UConn School of Pharmacy honored five individuals by naming them Dennis J. Chapron Preceptors of the Year. This year’s winners, all of whom were selected based on student nominations, included three preceptors representing Introductory Pharmacy Practice Experience (IPPE) and two representing Advanced Pharmacy Practice Experience (APPE). The IPPE Community Preceptor of the Year was John Del Debbio, Jr., a 1991 graduate of the UConn School of Pharmacy, with practice sites in Waterbury and Meriden, Conn. The Institutional Preceptor of the Year, Ellen Santoro, is a 1982 graduate of the UConn School of Pharmacy who recently retired from St. Francis Hospital in Hartford, Conn. where she was a staff pharmacist specializing in medical teaching, geriatrics, and rehabilitation. The award for Service Learning IPPE was earned by Annie Sanchez Krawiac who, for many years, has volunteered at summer and fall Migrant Farm Worker’s Clinics throughout the state. During these clinics, she has served as a mentor to many UConn School of Pharmacy students.

management specialist in the Department of Pharmacy Services at Hartford Hospital and an adjunct assistant clinical professor of pharmacy practice in the School of Pharmacy. He received his BS in pharmacy from UConn in 1976 followed by a Pharm.D. from the Philadelphia College of Pharmacy. Polomoff is assistant clinical professor of Pharmacy Practice in the School of Pharmacy and a Population Health Clinical Pharmacist at Integrated Care Partners/ Hartford Health Care in Wethersfield, Conn. She received her Pharm.D. from UConn in 2014. The person for whom the POY is named, Dennis J. Chapron, was also honored at the ceremony. He served as associate professor of Pharmacy Practice in the School of Pharmacy for 34 years prior to his retirement, where he was known for his excellence in teaching. He received the School of Pharmacy’s Teacher of the Year Award twice and was named Preceptor of the Year in 2001. Jill Fitzgerald, Director of Experiential Learning and Continuing Professional Development, said to the preceptors, “When we say, ‘We couldn’t do it without you,’ we mean it. Without your efforts, we couldn’t deliver the type of quality education we pride ourselves in providing. Our students are proof that all your hard work pays off, year after year.” UConn School of Pharmacy has honored preceptors in this manner for 17 years now.

Above, From left: John Del Debbio, Dennis Chapron, Jill Fitzgerald, Christina Polomoff, Richard Gannon, and Ellen Santoro

Richard Gannon was named APPE Adjunct Faculty Preceptor of the Year and Christina Polomoff was named APPE Faculty Preceptor of the Year. Gannon is a pain

Pharmacy Journal of New England • Winter 2019

USJ School of Pharmacy Honors Alumni and Scholarship Recipient The University of Saint Joseph (USJ) School of Pharmacy’s fall semester began with the matriculation of an exuberant class of Pharm.D. Students. USJ welcomed the Class of 2021 cohort, made up of 74 women and men from nine states and Puerto Rico, to the family and supportive environment for which USJSOP is known. USJ also welcomed new faculty members, Dr. Stephanie Zahn and Dr. Zhao Li. Ashley Bill (pictured left) is the recipient of a Gateway to Research Scholarship. Mentored by Dr. Ola Ghoneim, Ashley’s research is entitled, “Design, Synthesis, In-Vitro Evaluation, and Physicochemical Properties Enhancement of JOAB Series as Potential Pro-Inflammatory Mediator Suppressants.” Since 1974, the University’s Alumni Association has presented the distinguished alumni awards annually to outstanding alumni and University community members. Dayne Laskey (pictured right), PharmD, DABAT received the 2018 Winifred E. Coleman Service Award for his exemplary service and commitment to the University.

1-(877)-360-0095 www.buy-sellapharmacy.com

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Don’t Leave Money On The Table

when you transition the ownership of your pharmacy. • If you are talking with a buyer (particularly a chain buyer), have an offer on the table, haven’t signed anything yet, TALK TO US LAST!! •

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CPA Mid-Winter Conference 2019

The CPA Mid-Winter Conference brought 200 pharmacists from all practice settings in Connecticut to the Aqua Turf Club on February 7, 2019.

CPA would like to thank many Mid-Winter supporters, including Bristol-Myers Squibb and its alliance partner, Pfizer, who provided a generous CE grant.

CPA President Lisa Bragaw highlights the Association's "resiliency" over the past year during the business meeting, which kicked off the Conference.

The Mid-Winter Exhibit Hall was filled with a variety of companies and organizations from Connecticut and beyond, including Lilly USA, LLC.

Pharmacy Journal of New England â&#x20AC;˘ Winter 2019

CPA Mid-Winter Conference 2019

CPA CEO Nathan Tinker (left) and Lisa Bragaw (right) recognize James Zakszewski (center), a new Life Member of CPA. During the Conference, CPA honored 16 new Life Members, which are dedicated members of the Association for 40 years or more. CPA now has a total of 116 Life Members.

Keynote speaker Dr. Daniel Hussar traveled all the way from Pennsylvania again to engage the crowd with his program, "New Drugs of 2018."

Dr. Peter Buch, MD, kept the crowd entertained as he passed out candy to folks who answered his quiz questions correctly during the last program of the day, "Crohn's Disease: What You Need to Know."

Save the Date in New England! APRIL

Connecticut Compounding Conference

The largest compounding event in the Northeast, with a chance to earn up to 0.5 CEUs while networking with exhibitors! Visit ctpharmacists.org for more details about the conference, which will take place at the Red Lion Hotel in Cromwell.

APRIL

MPhA Spring Conference Join over 200 pharmacy professionals for a day of networking and continuing education. The 2019 conference will feature hot topics in pharmacy, including the ethical and legal considerations in the sale of CBD oil, and strategies to Cope with the Drug Shortage Crisis. Earn 7 hours of continuing education, including 2 law CEs at the Four Points Sheraton in Norwood, MA. Visit MassPharmacists.org to view the program and to register.

MAY

31 JUNE

Women in Pharmacy Summit Combining high level continuing education sessions with personal growth and development, this event is a unique opportunity to expand your knowledge while renewing your inner (and outer) self at the Spa at Norwich Inn. Visit ctpharmacists.org for more details.

Pharmacy Journal of New England • Winter 2019

Sneak Peek: Women in Pharmacy PM Group Supports Women Pharmacists Nationwide

www.pharmacistsmomsgroup.com

Suzanne Soliman is the founder of the Pharmacists Moms Group.

In 2017, soon after Suzanne Soliman, PharmD, had to miss her son’s baseball game because she was working late as a pharmacist, she decided to start a group called the Pharmacist Moms Group (PM Group). What started out as a group of about 50 has grown into 22,000-plus members on Facebook and over 70,000-plus followers/group members on all of the combined social media channels in less than two years. The mission of the PM Group is to provide support to women pharmacists across the country, to demonstrate leadership opportunities for women in pharmacy and other important issues impacting women pharmacists today. Suzanne, the current chief academic officer at the Accreditation Council for Medical Affairs, a company which offers the only Board Certification for Medical Affairs/MSLs (BCMAS) for pharmaceutical industry clinical professionals, has formed the largest virtual group of pharmacists in the United States and the most active with over 2 million posts in 2018. “I initially formed the group looking for personal support and did not expect it to grow this quickly,” said Soliman. “I formed it to so pharmacists could ask for tips about children, tips about landing a job, benefits of certain companies versus others, help each other since many of us work alone and not with another pharmacist and so many other issues.”

The group has changed the lives and helped support so many pharmacists. The rapid growth of the Pharmacist Moms Group on Facebook is due simply to word-of-mouth, according to Soliman. One of the most positive contributions to pharmacy took place on October 12, 2018—the first-ever Women Pharmacist Day. The organization founded this long overdue day to help recognize women pharmacists. The plan for this year is to recognize specific women pharmacists and to discuss women in leadership positions in pharmacy. The Pharmacist Moms Group is also partnering with certain colleges/schools of pharmacy to study women in pharmacy specifically related to leadership. From retreats to local meet-ups to partnering with professional organizations to support pharmacist moms in the workplace, Pharmacist Moms Group continues to grow in new directions. Soliman will be speaking at over 10 meetings this year to discuss women and pharmacy-related topics, including the Connecticut Pharmacists Association’s Women in Pharmacy Summit on June 1 at the Spa at Norwich Inn. Pharmacist Moms is leading the way and blazing a trail to improve the treatment of pharmacist parents. The group has now transformed into a force to advance women pharmacists worldwide.