TSHP Journal - Vol 17 | 2018 by TSHP

TSHP Journal

October is American Pharmacists Month See page 16 for ways to celebrate all month long.

ADVANCING PHARMACY PRACTICE AND EDUCATION IN TEXAS

VOL. 17 | ISSUE 1 | 2018

Gabapentinoid Abuse: An Alarming Trend (CPE)

DIFFERENT SIDES OF THE OPIOID EPIDEMIC

The Other Side of the Epidemic: Pharmacists and Opioid Abuse

Awareness and Attitudes Regarding Gabapentinoid Abuse

Award Winning Poster Abstracts: 2018 Competition

Recognizing Outstanding Members: 2018 Award Recipients

A Look Ahead: Message from TSHP President, Tammy Cohen

Planting Seeds for Success: 2018 Scholarship Recipients

OFFICIAL JOURNAL OF THE TEXAS SOCIETY OF HEALTH-SYSTEM PHARMACISTS

WWW.TSHP.ORG/JOURNAL

TSHP Journal TSHP Journal Official journal of the Texas Society of HealthSystem Pharmacists www.tshp.org/journal Stacey Mather, CAE Executive Director Jenni Peters Membership & Communications Manager Leah Cody Professional Development Manager Katha Ferguson Receptionist / Administrative Assistant

About TSHP The Texas Society of Health-System Pharmacists (TSHP) has been supporting health-system pharmacy in Texas since 1949, becoming one of the leading health-system pharmacy societies in the country that fosters leadership and education in pharmacy. What began as a small group of twenty-five dedicated hospital pharmacists coming together to learn and discuss professional issues, has grown to a dynamic health-system pharmacy organization that includes pharmacists, technicians, residents, students, retired pharmacists, educators, industry associates, and others passionate about the mission, vision, and core values of TSHP. Pharmacy Leaders. Transforming Patient Care. For more information on TSHP, please visit www.tshp.org. TSHP Executive Committee President Tammy Cohen, PharmD, MS, FACHE, FASHP, FTSHP President-Elect Steven Knight, PharmD, BCPS, RPh, CMTM Immediate Past President Sidney Phillips, PharmD, RPh, MBA Secretary Latresa Billings, PharmD, BCPS Treasurer Jeffrey Wagner, PharmD, MPH, RPh, BCBS President-Elect Designee Sarah Lake-Wallace, MS, PharmD, FTSHP Treasurer-Elect Randy Martin PharmD, BCCCP

Hardware Requirements: Any computer capable of running an A-grade web browser. Typically, a minimum memory of 1GB, and a processor speed of 1Ghz Software Requirements: Any of the following A-grade browsers: • Chrome 45+ • Edge 38+ • Firefox 40+ • Opera 15+ • Safari 7+ No other plugins are mandatory. Adobe Flash is recommended. Connectivity: Minimum 1MB/s speed downstream, 512KB/s speed upstream For full CE information (UAN numbers, objectives, CEUs, type), see the end of the applicable article(s).

A very special thank you to the authors and contributors of this special issue, the TSHP Board of Directors, and the members of the 2017-2018 TSHP Editorial Advisory Board for their time and expertise in helping bring back the TSHP Journal better than ever. It is because of you that we can truly advance pharmacy practice and education in Texas.

Pharmacy Leaders. Transforming Patient Care.

Continuing Education Information The Texas Society of Health-System Pharmacists (TSHP) is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing education. To claim credit for CE, the participant must complete the course via the TSHP Education Portal (http://tshp.wcea.education/), pass an exam with a minimum score of 75%, and complete a session evaluation. Additional information on any available CE within this issue can be found at the end of each applicable article. Completion of this course requires access to an internet-enabled computer. Mozilla Firefox is the preferred browser for the TSHP Education Portal. For information regarding TSHP’s privacy policy, please visit http://tshp.org/privacypolicy.html. To view the privacy policy specific to the TSHP Education Portal, visit https://tshp.wcea. education/default/privacy. Questions? Contact TSHP at tshp@tshp.org.

TSHP Editorial Advisory Board / Peer Reviewers Paul Holder, MS, RPh, PharmD (Chair/Editor) Tina Beck, PharmD, MSCR, BCPS Jacqueline Bozick, PharmD, BCPS Amy Buesing, BS-Pharm, MBA Jeena Connor, RPh, PharmD Caitlin Gibson, PharmD, BCPS Bonnie Labdi, PharmD, BCOP Kathryn Pidcock, PharmD, BCPS

The TSHP Journal is the official publication of the Texas Society of Health-System Pharmacists (TSHP). TSHP is a membership-driven state society of pharmacists, technicians, students, and professional colleagues who advocate for optimized patient care, professional practice, and public health. Membership in TSHP is open to all pharmacists and others who support TSHPs mission and values. Annual membership dues are $180, of which $30 is for a subscription to the TSHP Journal. The annual subscription rate (minimum 2 issues) to non-members is $40. The cost for single copies is $25. Payments made to TSHP are not deductible as charitable contributions for federal income tax purposes. However, they may be deductible under other provisions of the IRS up to 33%. Requests for change of address should be sent to TSHP at least six (6) weeks before the change is effective.

ISSN: 2325-2804

TSHP payment processing can be reached at (512) 906-0546 Monday through Friday, 8:00 AM to 5:00 PM Central Time or by contacting tshp@tshp.org.

To view membership status, login at www.tshp.org/ login or contact the TSHP office. TSHP JOURNAL

C O NT E NT S 5

Message from the TSHP President

Gabapentinoid Abuse: An Alarming Trend (CPE)

Pilot Study: Pharmacist Awareness and Attitudes Regarding Gabapentinoid Abuse

The Other Side of the Epidemic: Pharmacists and Opioid Abuse

Poster Competition 2018 Winners TSHP Reseach & Education Foundation

27 2018 Award Recipients

TSHP Member Recognition

30 2018 Scholarship Recipinets

TSHP Research & Education Foundation

TSHP Journal 3000 Joe DiMaggio Blvd., Ste. 30A Round Rock, Texas 78665-3920 (512) 906-0546 TSHP President Tammy Cohen, PharmD, MS, FACHE, FASHP, FTSHP TSHP Journal Editor Paul Holder, MS, RPh, PharmD TSHP Journal Managing Editor Jenni Peters Questions/Comments: journal@tshp.org TSHP JOURNAL

SAVE THE DATE 2019 2019 TSHP Annual Seminar April 12-14 Frisco, TX

www.tshp.org/seminar #tshp2019 #pharmacystrong

A MESSAGE FROM TSHP PRESIDENT Tammy Cohen

hank you for a great 2017-2018 TSHP year! As I look back, itâ&#x20AC;&#x2122;s hard to believe that a year has already passed. A year ago, we set out with a few focus points which were membership growth, giving back to members, and expanding the TSHP and affiliate local chapter relationships. Giving back to members: This year, TSHP leaders have spent the year working with the Pharmacy Summit and our lobbyist, Brad Shields, on preparing for the upcoming legislative session and working to get a health-system pharmacist on Texas State Board of Pharmacy. Expanding the TSHP and local affiliate chapter relationships: This was a little more abstract, but vital to the TSHP and the local affiliates. I am pleased to report that great progress has been made on the local affiliated chapter agreements, which will wrap up this year. Together, the locals and TSHP will continue to grow. Additional areas of focus this past year included developing a new five-year strategic plan and hiring Stacey Mather as the new TSHP Executive Director. A full annual report is available on the TSHP website (www.tshp.org), highlighting the great activities that the councils and sections worked on over the past year. Thank you to the outstanding TSHP staff, Jenni, Leah, and Katha, for all your work, not only at Seminar but daily throughout the year to serve the members of the organization. This year has been particularly challenging with the changeover of Executive Directors. The staff did an amazing job in keeping the organization moving forward, not letting anything fall through the cracks. This is a unique year in TSHP history for executive officers. As you will recall, TSHP lost Rich Cadle unexpectedly last March. This was a big loss to TSHP and the pharmacy profession. Following the events of Richâ&#x20AC;&#x2122;s loss, the Council on Organizational Affairs was convened, and a review of policy was completed. The council recommended that I serve out a second term to the Board of Directors and the Board confirmed. Therefore, I will continue work for a second year as TSHP President and Sidney Phillips will serve a second year as Immediate Past President. In addition to the Presidential officer extensions, the TSHP Secretary officer will be extended. The secretary-elect has chosen to step down to focus on family matters. At which time, the Bylaws were reviewed, and the Board of Directors elected Latresa Billings to stay on as Secretary. Thank you to Sidney Phillips and Latresa Billings for your dedication and commitment to TSHP. In the 2018-2019 TSHP year, the focus will continue with membership growth, giving back to members, and expanding local/ state relationships and legislative preparation. The Council and Section Officer members have been appointed and work is already underway to allow a jump start to the upcoming year. Thank you for the opportunity to continue to serve as TSHP President for an additional year. I look forward to a busy and exciting upcoming year.

Tammy Cohen, PharmD, MS, FACHE, FASHP, FTSHP TSHP PResident 2017-2019

This is a unique year in TSHP history. Thank you for your dedication and commitment to TSHP. The focus will continue with membership growth, giving back to members, expanding local/state relationships, and legislative preparation.

TSHP President Tammy Cohen receives recognition from ASHP Board Member and long-time friend Todd Karpinski to celebrate the completion of a successful term of leadership at the 2018 TSHP Annual Seminar at The Woodlands Waterway Marriott Hotel & Convention Center. TSHP JOURNAL

Gabapentinoid Abuse: An Alarming Trend

Kirk E. Evoy, PharmD, BCACP, BC-ADM, CTTS Clinical Assistant Professor, University of Texas at Austin College of Pharmacy Adjunct Clinical Assistant Professor, University of Texas Health San Antonio School of Medicine Clinical Pharmacist, University Health System Emily A. Siegrist PharmD Candidate, University of Texas at Austin College of Pharmacy Yunle Huang PharmD Candidate, University of Texas at Austin College of Pharmacy

TSHP JOURNAL

rescription drug abuse has quickly become one of the most significant public health concerns in the United States (US), with annual rates of fatal overdoses nearly doubling over the past decade.1 In 2016, drug overdoses were responsible for more than 64,000 American deaths, the most in our country’s history, and now stand as the leading cause of accidental deaths in the US. Prescription and illicit opioids are predominantly responsible for this sharp rise and much effort has been put forth to combat this public health crisis. In particular, prescribers and policy makers have attempted to curb excessive opioid prescribing. As a result of this work, the number of opioids prescribed annually in the United States has begun to decrease for the first time since the early 1990s.2 Unfortunately, overdose deaths are still on the rise, as many prescription opioid abusers have simply turned to other drugs of abuse, particularly illicit opioids such as heroin. However, as prescription opioids become more difficult to obtain, it appears that some prescription drug abusers are also seeking highs from other prescription medications that are easier to access. Among these are the gabapentinoids, pregabalin and gabapentin. Though traditionally thought to have limited abuse potential, the number of reports of gabapentinoid abuse have multiplied in recent years.3 In response to a growing concern, the European labeling for pregabalin was updated in 2010 to include a warning for abuse potential, a 2016 recommendation from the United Kingdom Advisory Council on Misuse of Drugs identified both pregabalin and gabapentin as medications that should be reclassified as controlled substances in Europe, and Kentucky has become the first US state to re-classify gabapentin as a controlled substance under state law, with similar legislation being proposed in several others.4,5 Despite mounting evidence that gabapentinoid abuse is increasing significantly, publicity of the issue is limited compared to the larger opioid crisis, and as a result, many pharmacists are likely unaware of this concerning trend. This continuing education module was developed to increase awareness of the rise in gabapentinoid abuse by summarizing the current literature surrounding this topic and to help readers identify, prevent, and treat such abuse in their practice.

Why gabapentinoids?

Gabapentin (Neurontin®) was approved by the US Food and Drug Administration (FDA) in 1993, and is indicated for herpetic neuralgia and epilepsy.6 Howe-

Despite mounting evidence that gabapentinoid abuse is increasing significantly, publicity of the issue is limited compared to the larger opioid crisis, and as a result, many pharmacists are likely unaware of this concerning trend. ver, off-label prescribing of gabapentin is common, with reports indicating up to 95% of prescriptions are written for off-label indications.7 Gabapentin is not classified as a controlled substance by the US Drug Enforcement Administration (DEA) and inexpensive generic formulations are available. These dynamics, as well as the fact that prescribers are seeking lower-risk pain management options to replace opioid analgesics, likely contribute to the 64% increase in gabapentin prescribing in the US from 2012 to 2016.8 This is in stark contrast to the 34% decrease in prescribing of the most common opioid, hydrocodone/acetaminophen, over that timeframe. Pregabalin, still under patent protection and available only as brand name Lyrica®, is a Schedule V controlled substance according to the US DEA.6 It was approved in 2004 and carries several additional FDA-approved indications, including seizures, post-herpetic neuralgia, neuropathic pain, and fibromyalgia.9 Though overall prescription quantities of pregabalin are not as high as gabapentin, likely due to additional cost and regulatory hurdles, pregabalin prescribing is increasing significantly as well.8 Lyrica® now ranks eighth in the United States in terms of the annual invoice spending on a specific medication at $4.4 billion in 2016, up from $1.9 billion in 2012. Both gabapentin and pregabalin function as gamma-aminobutyric acid (GABA) analogues.10 Though the mechanism of abuse is not entirely understood, several drugs with known abuse liability, such as alcohol, benzodiazepines and Z-hypnotics, are also GABA-modulating. In comparing the two medications, pregabalin is absorbed from the gastrointestinal tract 3 times more rapidly than gabapentin and is 2.5 times more potent.11 Additionally, pregabalin is 90% bioavailable at all doses, while gabapentin displays saturable pharmacokinetics, with reduced absorption at increasing doses. Based on these properties, pregabalin is reportedly preferred by drug abusers; however, gabapentin can produce similarly desirable effects at escalated doses and several studies have identified higher rates of abuse for gabapentin than pregabalin.3,10 To identify what effects users are seeking from recreational gabapentinoid TSHP JOURNAL

use, we can find answers both in clinical studies and anecdotal reports from users. First, euphoria is a known adverse effect of pregabalin.9 In fact, a 2011 meta-analysis of 38 pregabalin clinical trials identified euphoria as the second most commonly reported adverse effect of pregabalin in terms of relative risk.12 In addition to euphoria, anecdotal accounts from recreational gabapentinoid users describe various effects, including: improved sociability, a marijuana- or benzodiazepine-like state of relaxation or conversely an amphetamine like high, sedation, dissociation, numbness and contentment.10,11,13-19 Three small clinical studies have been conducted to assess the abuse potential of pregabalin or gabapentin.9,20-21 Zacny, et al. did not identify an abuse liability when pregabalin 75 or 150 mg was administered to 16 patients without history of drug abuse.20 Conversely, a separate study revealed that 450 mg doses of pregabalin produced similar drug-liking effects to 30 mg of diazepam in a group of 15 recreational drug abusers.9 Finally, Lile, et al. found that gabapentin 600 mg and 1200 mg produced similar drug-liking when compared to THC (the active component of marijuana) in a cohort of 8 cannabis users.21 These studies corroborate epidemiological data indicating that at low doses in the general population gabapentin and pregabalin have little abuse liability, but at higher doses and/or in substance use disorder (SUD) populations they are more likely to produce desirable effects. However, the question remains as to why we are now seeing a rise in the abuse of medications that have been available for more than a decade. Interestingly this pattern of delayed understanding of the abuse liability of the gabapentinoids mirrors the benzodiazepines and Z-hypnotics as well.11,22 The recent increase in gabapentin and pregabalin abuse is likely multifactorial. One potential reason may include past or current opioid abusers seeking more readily available alternatives as opioids become more difficult to obtain.10,13 Gabapentin and pregabalin fit this bill. Both are commonly prescribed to chronic pain patients as providers attempt to reduce opioid prescribing. They also carry relatively little stigma with regards to prescribing or obtaining from the

pharmacy and are used to treat subjective symptoms that may be easily exaggerated or fabricated. These factors may facilitate obtaining high quantity prescriptions with relative ease. Beyond ease of access, it appears that some use gabapentinoids to potentiate the effects of other drugs, such as opioids, alcohol, benzodiazepines, marijuana, amphetamine, LSD, baclofen, and quetiapine, and thus may be used in combination with other prescription or illicit drugs.3,13,14,23-25 Several studies have identified high rates of gabapentinoid abuse in patients undergoing opioid abuse treatment, with some users taking gabapentinoids to potentiate a high from their methadone.25,26 Furthermore, gabapentin and pregabalin do not appear in standard urine drug screens, and may be ideal for those wishing to avoid detection.14 Finally, some patients may be misusing these medications simply to self-treat symptoms such as pain, anxiety, or withdrawal from other medications.10,23

Magnitude of the problem

Reports of gabapentin and pregabalin abuse in the published literature have risen sharply in recent years, as displayed in a 2017 systematic review published by our group, which identified 59 articles with original data describing gabapentinoid abuse, misuse or overdose, most of which were in the last few years.3 Schwan, et al. first identified a growing trend in pregabalin abuse reports in 2010.27 This study identified 16 reports of abuse, misuse, or dependence in the Swedish adverse event reporting system with the majority of the reports occurring from 2008 â&#x20AC;&#x201C; 2009. Shortly thereafter, Caster, et al. analyzed the World Health Organization Individual Case Safety Reports database and identified signals of pregabalin abuse dating back to 2005.28 Though these studies identified increasing trends, the total number of cases identified was quite small. Since that time, however, similar studies have identified far greater numbers of events reported in recent years. In 2016 Chiappini, et al. analyzed the European Medicine Agency (which plays a similar role in Europe to the US FDA with regards to medications) EudraVigilance adverse event reporting system from 2004-2015, identifying a staggering 7,639 reports of pregabalin abuse, misuse, or dependence in addition to 4,301 cases of gabapentin misuse, abuse or dependence.29 Alarmingly, more than 75% of those events had occurred since 2012, indicating a sharp rise in recent years. Based on inherent limitations of using a spontaneous adverse event reporting system to detect substance abuse events, the actual incidence of gabapentin and pregabalin misuse over that timeframe was likely significantly higher. Despite these concerning trends, it appears that in the general population,

overall rates of abuse are still fairly low. A 2014 study by Kapil and colleagues sought to assess life-time prevalence of gabapentinoid abuse and found that 1.1% and 0.5% of patients had misused gabapentin and pregabalin, respectively, among a cohort of 16-59 year olds representative of the general population in the United Kingdom.30 This was significantly lower than the lifetime prevalence of cocaine, MDMA (3,4-methylenedioxymethamphetamine, also known as ecstasy), and cannabis use identified in the same study (8.1%, 8.2%, and 28.1%, respectively). More recently, analysis of a US medical claims database identified a similar 2-3% rate of sustained overuse of gabapentin in a large, general population of commercially insured American patients aged 18-64 years, as defined by consistent receipt of greater-than-maximum-dose prescription quantities.31 While the rates of abuse in the general population appear to be relatively low, gabapentinoid abuse is reportedly much higher in patients with a history of or current SUD, with gabapentin abuse rates of 15-22% and pregabalin abuse rates of 3-68% identified across multiple studies in this population.3,22,25,32-34 In one of the largest studies of gabapentinoid abuse in SUD patients, Smith, et al. assessed 503 opioid abusers in Kentucky and demonstrated that 15% of this cohort had used gabapentin to get high within the last six months, which represented a 165% increase from the previous year, and a 2,950% increase from 2008.34 In another study of a US opioid abuse population, gabapentinoids were found to be misused more often than amphetamine salts and as often as clonazepam.33

Possible harms

Gabapentinoid â&#x20AC;&#x153;highsâ&#x20AC;? are typically achieved by taking supratherapeutic doses of the drug. One study describing 55 cases of pregabalin abuse noted a mean dose of 1,424 mg,35 while a median dose of 2,100 mg was observed among published case reports of pregabalin abuse.3 These are significantly higher than the maximum recommended dose of 600 mg daily.6 Among gabapentin abuse case reports, a median dose of 3,600 mg was identified.3 Although 3,600 mg is the maximum recommended daily dose for gabapentin, doses this high would typically be divided into 3-4 daily administrations.6 Despite these excessive doses, case reports indicate that the effects of high dose gabapentin or pregabalin alone are fairly benign. Acute overdose of gabapentinoids produces effects such sedation, mental clouding, dizziness, hypotension, and tachycardia but are generally not lethal.3 In fact, patients have reportedly survived TSHP JOURNAL

doses as high as 11.5 grams of pregabalin and 90 grams of gabapentin.36-37 However, a recent large-scale retrospective study identified significant increases in healthcare utilization and patient harm associated with sustained gabapentin overuse, indicating that these medications may not be as benign when abused as previously thought.38 In this study, sustained overuse of gabapentin multiplied the risk of all-cause inpatient hospital utilization (IHU) by 1.366 (95% CI=1.055-1.769), drug-related IHU by 1.440 (95% CI=1.0102.053), and IHU or emergency department utilization (EDU) for altered mental status by 1.864 (95% CI=1.324-2.624). Sustained overuse of both gabapentin and an opioid increased the odds of all-cause IHU, drug-related IHU, and IHU/IDU for altered mental status or respiratory depression by a factor of more than four. Furthermore, though the number of cases of deadly overdoses reported from gabapentinoids alone has been limited as they seem to rarely be the sole cause of overdose-related death, gabapentinoids have been linked as a contributing factor in a number of polysubstance abuse fatalities, likely due to additive central nervous system depressant effects.29,39-42 Though difficult to quantify exactly what role the gabapentinoids played in the fatalities given the retrospective nature of the study and the inherent limitations of spontaneous adverse event reporting systems, the 2016 analysis of the European Medicine Agency (EMA) EudraVigilance database described previously identified 27 deaths involving pregabalin and 86 associated with gabapentin abuse or misuse events since 2004, with more than 1/3 of those reported in the final two years of the study.29 Concurrent opioid use was implicated in most of these reported fatalities. Another concern with gabapentinoid abuse revolves around withdrawal and dependence. A well-established potential adverse effect of gabapentinoids is the risk of withdrawal if a patient abruptly discontinues the drug after consistently taking high doses.43-45 These withdrawal symptoms are reportedly similar to benzodiazepine or alcohol withdrawal. Surprisingly, despite the fact that both act through the GABA pathway, benzodiazepines reportedly provide no relief for gabapentinoid withdrawal symptoms, whereas resumption of the previously abused gabapentinoid provides rapid resolution of symptoms.46 Case reports also describe patients experiencing cravings, repeated self-titration, and drug-seeking behavior which may suggest dependence.18,43,47-48 While most gabapentinoid abusers seem to use high doses to achieve desired effects, the frequency of abuse seems to vary. A study of gabapentinoid misuse trends in the general population in the United Kingdom revealed that among

those reporting to have misused gabapentinoids in the past, 13% did so at least weekly, 50% between weekly and monthly, and 37% monthly or less.30 However, among a large American cohort of recreational opioid users, those abusing gabapentin did so nearly every day.34 This frequency of abuse may be an important factor in potential harm, as those using on a regular basis are likely at greater risk of withdrawal and dependence and given reported rapid tachyphylaxis associated with abuse of these medications, those taking on a regular basis often must continually escalate their dose in order to achieve the desired effects.10

How can pharmacists and pharmacy technicians mitigate the risks

As reports of gabapentinoid abuse continue to grow, we, as pharmacists and pharmacy technicians, must be vigilant in combatting this problem and there are several ways in which we can help.

Identify patients at risk The most commonly and consistently cited risk factor for gabapentinoid abuse is past or current opioid abuse.3, 22,32-33 As discussed previously, while the risk of gabapentinoid abuse is fairly low in the general population, within SUD populations gabapentin abuse rates have been reported to range from 15-22% whereas rates of pregabalin abuse in this population ranged from 3-68%.3 In the largest scale study assessing risk factors for gabapentin misuse, our group performed a retrospective analysis of the Truven Health MarketScanÂŽ Commercial Claims and Encounters database.49 Among the 44,148 patients included who received gabapentin without an opioid, only 2% used higher-than-max dose gabapentin for a sustained period versus 11.7% of the 15,335 patients who were also being treated with opioids. The top predictors of sustained gabapentin overuse in this population of patients using concomitant opioids were detoxification, altered mental status, and addiction. In the adjusted analysis, concomitant use of opioids multiplied the odds of sustained use of greater-than-max-dose gabapentin by 6.32 (95% CI=5.806.89), and the interaction of addiction with opioid use multiplied the rates of sustained overuse by 1.88 (95% CI=1.322.66). Surprisingly in patients prescribed gabapentin but not opioids, a history of addiction did not predict for sustained gabapentinoid overuse, once again pointing towards opioid abuse specifically as the greatest risk factor. To a lesser extent, recreational use of other drugs have been indicated as risk factors including cocaine, cannabis, and benzodiazepines, though these have been reported less consistently across the literature.10,25,27,34 Other factors that may increase

the likelihood of abuse appear to be young age, low socioeconomic status, and psychiatric comorbidities,32-33,39,50 and several studies have identified gabapentin abuse is common within the prison system.25,51-53 We should also be cognizant of drug-seeking behaviors. Case reports note various means of pharmacy and physician deception including filling prescriptions at more than one pharmacy, doctor shopping, requesting early refills, alleging medications were lost or stolen, asking that insurance not be billed, requesting specific drugs by name or continually requesting higher doses, and feigning symptoms to receive new or higher dose prescriptions.3,18-19 As pharmacy technicians often serve as the primary point of contact during prescription drop off and prescription pick-up and are largely responsible for data entry, they are in a position in which they may be most likely to identify suspicious patient behavior. If such behavior is identified, particularly in patients with the aforementioned risk factors for abuse, technicians should be vigilant in reporting these findings to the pharmacist prior to dispensing. Promote safe prescribing in those at risk Several studies indicate that those misusing gabapentinoids most commonly gain access to the medications through their health care providers.30,33-34 Kapil and colleagues identified that 63.1% of users obtain gabapentinoids from their health care providers, 57.8% from family or acquaintances, 47.3% from the internet, 13.1% from legitimate prescriptions, and 7.8% abroad.30 Similarly, Smith, et al. found that 52% accessed their gabapentin from physicians and 36% obtained it from drug dealers.34 Interestingly, Wilens, et al. studied gabapentinoid abuse trends among a cohort of American patients undergoing treatment for an opioid use disorder and assessed whether or not abuse rates differed between those who were prescribed a gabapentinoid and those who were not.33 In this population, about half the patients who actually had a prescription for pregabalin or gabapentin were misusing them whereas less than 20% of those without a prescription were misusing a gabapentinoid. Thus, we as health care providers play an important role in mitigating risk, particularly in our high risk patients. It is important to be especially careful when prescribing gabapentinoids to patients with a known history of substance abuse, as it seems that the easier access significantly increases their likelihood of abuse. Practitioners should also be cautious about escalating doses and prescription quantities. These medications should not TSHP JOURNAL

be thought of simply as a benign alternative to opioids. In addition, it is important to consider the data behind the many off-label indications these medications are used for and consider whether there is sufficient evidence for that indication, in order to accurately weigh the potential clinical benefits versus the risks of misuse or diversion. Finally, as these drugs have become more popular drugs of abuse, the black market for gabapentinoids has increased. Case reports indicate gabapentinoids are available from drug dealers and available for purchase on the internet.3,9 Gabapentinâ&#x20AC;&#x2122;s street value reportedly ranges from $1-7 per pill.25,34,54 As a result, these drugs may also have diversion potential, further increasing the need to investigate suspicious activity and cautiously escalate prescription quantities. Reduce the need to self-medicate Another important consideration may be identifying the underlying reason as to why the patient is misusing the gabapentinoid. Some reports describe patients misusing these medications to relieve symptoms such as pain, anxiety, or withdrawal from other drugs.10,23 Thus, if we can identify means to adequately treat these conditions, we may reduce their use of gabapentinoids to self-medicate. Finally, if misuse is suspected and discontinuation of the medication is desired, we should provide the patient an appropriate taper plan to avoid withdrawal and further need to seek relief. Consider policy changes Beyond our individual efforts, policy change aimed at mitigating this risk may be warranted as well. As of July 2017, 7 US states have required that gabapentin prescriptions be reported to local prescription drug monitoring programs to assist in identifying abuse signals.5 Furthermore, in 2017, Kentucky became the first US state to reclassify gabapentin as a Schedule V controlled substance and several other states are considering following suit. While efforts such as these would undoubtedly increase awareness of the issue at hand, it remains to be seen whether the benefits of this action justify the additional barriers to access for those using the medication therapeutically or the additional work required of prescribers and pharmacists in relation to a very commonly prescribed medication.

Conclusion

Reports of gabapentinoid abuse have risen sharply in recent years, and it is important to take action to mitigate the risks of this issue going forward. However, gabapentin and pregabalin are commonly prescribed medications and remain an important part of our therapeutic armamen-

tarium in the treatment of a variety of disease states. In the general population the abuse of these medications appears to be 5. significantly lower than many other typical drugs of abuse, so it is important that we do not condemn the use of gabapentinoids. However, efforts to increase awareness of their abuse liability and risk factors that may predispose patients to abuse, as well as development of policies to facili- 6. tate safe prescribing of gabapentinoids should be emphasized.

References 1.

3. 4.

National Institute of Health. Overdose Death Rates. Available at: www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed 2018 February 17. Goodnough A, Tavernise S. New York Times. Opioid Prescriptions Drop for First Time in Two Decades. Available at: http://www.nytimes.com/2016/05/21/ health/opioid-prescriptions-drop-for-first-time-in-two-decades.html?_r=0. Accessed 2016 June 16. Evoy KE, Morrison M, Saklad SR. Pregabalin and gabapentin abuse: a systematic review. Drugs 2017;77(4):403-426. Iverson L. Pregabalin and gabapentin advice [Internet]. London; 2016. Available from: https://www.gov.uk/government/uploads/system/uploads/attach-

ment_data/file/491854/ACMD_Advice_-_Pregabalin_and_gabapentin.pdf Peckham AM, Fairman KA, Sclar DA. Policies to mitigate nonmedical use of prescription medications: how should emerging evidence of gabapentin misuse be addressed? Expert Opin Drug Saf 2017; Oct 14:1-5. doi: 10.1080/14740338.2017.1390081. [Epub ahead of print] Lexi-Drugs. Lexicomp. Hudson: Wolters Kluwer Health, Inc. http://online.lexi. com. Accessed 2018 March 5. 7. Hamer AM, Haxby DG, McFarland BH, Ketchum K. J Managed Care Pharm. 2002;8(4):266-71. 8. Quintiles IMS Institute. Medicines use and spending in the U.S: a review of 2016 and outlook to 2021. Available from https://structurecms-staging-psyclone. netdna-ssl.com/client_assets/dwonk/ media/attachments/590c/6aa0/6970/ 2d2d/4182/0000/590c6aa069702d2d41820000.pdf?1493985952. Accessed 2018 February 2. 9. Pregabalin (Lyrica®) package insert. Pfizer, Inc., December 2016. 10. Schifano F, D’Offizi S, Piccione M, Corazza O, Deluca P, Davey Z, Di Melchiorre G, Di Furia L, Farré M, Flesland L, Mannonen M, Majava A, Pagani S, Peltoniemi T, Siemann H, Skutle A, Torrens M, Pezzolesi C, van der Kreeft P, Scherbaum N. Is there a recreational misuse potential for pregabalin? Analysis of anecdotal online reports in comparison with related

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gabapentin and clonazepam data. Psychother Psychosom. 2011;80(2):118-22. Schifano F. Misuse and Abuse of Pregabalin and Gabapentin: Cause for Concern? CNS Drugs 2014;28:491-96. Zaccara G, Gangemi P, Perucca P, Specchio L. The adverse event profile of pregabalin: A systematic review and meta-analysis of randomized controlled trials. Epilepsia 2011;52(4):826-36. Reeves RR, Burke RS. Abuse of combinations of gabapentin and quetiapine. Prim Care Companion CNS Disord. 2014 Sep 11;16(5). Reeves RR, Ladner ME. Potentiation of the Effect of Buprenorphine/Naloxone with Gabapentin or Quetiapine. Am J Psychiatry 2014;171(6):691. Spence D. Bad Medicine: gabapentin and pregabalin. BMJ 2013;347:f6747. Markowitz JS, Finkenbine R, Myrick H, King L, Carson WH. Gabapentin abuse in a cocaine user: implications for treatment? J Clin Psychopharmacol. 1997 Oct;17(5):4234. Halaby A, Kassm SA, Naja WJ. Pregabalin dependence: a case report. Curr Drug Saf. 2015;10(2):184-6. Gahr M, Franke B, Freudenmann RW, Kölle MA, Schönfeldt-Lecuona C. Concerns about pregabalin: further experience with its potential of causing addictive behaviors. J Addict Med. 2013 Mar-Apr;7(2):147-9. Carrus D, Schifano F. Pregabalin misuse-related issues; intake of large do-

To claim credit for this CE, the participant must complete the course via the TSHP Education Portal (http://tshp.wcea.education/), pass an exam with a minimum score of 75%, and complete a session evaluation. See page 3 for additional information on claiming credit. Gabapentinoid Abuse: An Alarming Trend UAN: 0156‐0000‐18‐159‐H05‐P & 0156‐0000‐18‐159‐H05‐T Credit Hours: 0.5 (0.05 CEUs) Type: Knowledge‐based Credit Available: June 1, 2018 – June 1, 2021 Pharmacist Objectives: At the completion of this activity, the participant will be able to: 1. Summarize the current literature regarding the epidemiology and prevalence of gabapentinoid abuse 2. Identify risk factors for gabapentinoid abuse and typical patterns of abuse 3. Define the potential harms of gabapentinoid abuse 4. Describe the role of pharmacists in identifying and reducing gabapentinoid abuse Technician Objectives: At the completion of this activity, the participant will be able to: 1. Summarize the current literature regarding the epidemiology and prevalence of gabapentinoid abuse 2. Identify risk factors for gabapentinoid abuse and typical patterns of abuse 3. Define the potential harms of gabapentinoid abuse 4. Describe the role of technicians in identifying and reducing gabapentinoid abuse

Thank you for being a TSHP Journal subscriber! Use promo code JRNL1 to redeem this CE credit for FREE. See claiming instructions above.

These speakers have no relevant conflicts of interest to disclose. The Texas Society of Health‐System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing education. Completion of this course requires access to an internet enabled computer. Mozilla Firefox is the preferred browser for the TSHP Education Portal. For information regarding TSHP’s privacy policy, please visit http://tshp.org/privacy‐policy.html. To view the privacy policy specific to the TSHP Education Portal, visit https://tshp.wcea.education/default/privacy. Questions? Contact tshp@tshp.org. TSHP JOURNAL

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21.

22.

23.

24.

25.

26.

27.

28.

29.

sages, drug-smoking allegations, and possible association with myositis: two case reports. J Clin Psychopharmacol. 2012 Dec;32(6):839-40. Zacny JP, Paice JA, Coalson DW. Subjective, psychomotor, and physiological effects of pregabalin alone and in combination with oxycodone in healthy volunteers. Pharmacol Biochem Behav. 2012 Jan;100(3):560-5. Lile JA, Wesley MJ, Kelly TH, Hays LR. Separate and combined effects of agabapentin and [INCREMENT]9-tetrahydrocannabinol in humans discriminating [INCREMENT]9-tetrahydrocannabinol. Behav Pharmacol. 2016;27:215-24. Grosshans M, Lemenager T, Vollmert C. Pregabalin abuse among opiate addicted patients. Eur J Clin Pharmacol. 2013 Dec;69(12):2021-5. Alblooshi H, Hulse Gk, El Kashef A, Al Hashmi, Shawky M, Al Ghaferi H, Al Safar G, Tay, GK. The pattern of substance use disorder in the United Arab Emirates in 2015: results of a National Rehabilitation Centre cohort study. Subst Abuse Treat Prev Policy 2016;11:19. Eastwood JA, Davison E. Pregabalin concentrations in post-mortem blood - A two year study. Forensic Sci Int 2016;266:197201. Baird CR, Fox P, Colvin LA. Gabapentinoid abuse in order to potentiate the effect of methadone: a survey among substance misusers. Eur Addict Res. 2014;20(3):115-8. McNamara S, Stokes S, Kilduff R, Shine A. Pregabalin Abuse amongst Opioid Substitution Treatment Patients. Ir Med J. 2015 Nov-Dec;108(10):309-10. Schwan S, Sundström A, Stjernberg E, Hallberg E, Hallberg P. A signal for an abuse liability for pregabalin--results from the Swedish spontaneous adverse drug reaction reporting system. Eur J Clin Pharmacol. 2010 Sep;66(9):947-53. Caster O, Edwards IR, Norén GN, Lindquist M. Earlier discovery of pregabalin’s dependence potential might have been possible. Eur J Clin Pharmacol. 2011 Mar;67(3):319-20. Chiappini S, Schifano F. A Decade of Gabapentinoid Misuse: An Analysis of the European Medicines Agency’s ‘Suspected Adverse Drug Reactions’ Database. CNS Drugs 2016;DOI10.1007/s40263-0160359-y.[Epub Ahead of Print]

30. Kapil V, Green JL, Le Lait MC, Wood DM, Dargan PI. Misuse of the γ-aminobutyric acid analogues baclofen, gabapentin and pregabalin in the UK. Br J Clin Pharmacol. 2014 Jul;78(1):190-1. 31. Peckham AM, Fairman KA, Sclar DA. Prevalance of gabapentin abuse: comparisons with agents with known abuse potential in a commercially insured US population. Clin Drug Investig. 2017;37:763-73. 32. Bastiaens L, Galus J, Mazur C. Abuse of Gabapentin is Associated with Opioid Addiction. Psychiatr Q. 2016;87(4):763-767. 33. Wilens T, Zulauf C, Ryland D, Carrellas N, Catalina-Wellington I. Prescription medication misuse among opioid dependent patients seeking inpatient detoxification. Am J Addict. England; 2015 Mar;24(2):173–7. 34. Smith RV, Lofwall MR, Havens JR. Abuse and diversion of gabapentin among nonmedical prescription opioid users in Appalachian Kentucky. Am J Psychiatry. 2015 May;172(5):487-8. 35. Gahr M, Freudenmann RW, Hiemke C, Kölle MA, Schönfeldt-Lecuona C. Pregabalin abuse and dependence in Germany: results from a database query. Eur J Clin Pharmacol. 2013 Jun;69(6):1335-42. 36. Braga AJ, Chidley K. Self-poisoning with lamotrigine and pregabalin. Anaesthesia. 2007 May;62(5):524-7. 37. Schauer SG, Varney SM. Gabapentin overdose in a military beneficiary. Mil Med. 2013 Jan;178(1):e133-5. 38. Peckham AM, Fairman KA, Sclar DA. All-cause and drug-related medical events associated with overuse of gabapentin and/or opioid medications: a retrospective cohort analysis of a commercially insured US population. Drug Saf. 2017 Sep 27. [Epub ahead of print] 39. Häkkinen M, Vuori E, Kalso E, Gergov M, Ojanperä I. Profiles of pregabalin and gabapentin abuse by postmortem toxicology. Forensic Sci Int. 2014 Aug;241:1-6. 40. Mowry JB, Spyker DA, Cantilena LR, McMillan N, Ford M. 2013 Annual report of the american association of poison control centers’ national poison data system (NPDS): 31st annual report. Clin Toxicol. Taylor & Francis; 2014 Dec 1;52(10):1032– 283. 41. Middleton O. Suicide by gabapentin overdose. J Forensic Sci. 2011 Sep;56(5):1373-5.

42. Lottner-Nau S, Ovguer B, Paul LD, Graw M, Sachs H, Roider G. Abuse of pregabalin – results of the postmortem toxicology from 2010-2012. Toxichem Krimtech 2013;80:339. 43. Filipetto FA, Zipp CP, Coren JS. Potential for pregabalin abuse or diversion after past drug-seeking behavior. J Am Osteopath Assoc. 2010 Oct;110(10):605-7. 44. Hellwig TR, Hammerquist R, Termaat. Withdrawal symptoms after gabapentin discontinuation. Am J Health-Syst Pharm 2010;67:910-912. 45. See S, Hendriks E, Hsiung L. Akathisia Induced by Gabapentin Withdrawal. Ann Pharmacother 2011;45:e31. 46. Mah L, Hart M. Gabapentin withdrawal: case report in an older adult and review of the literature. J Am Geriatr Soc 2013;61(9):1635–7. 47. Victorri-Vigneau C, Guerlais M, Jolliet P. Abuse, dependency and withdrawal with gabapentin: a first case report. Pharmacopsychiatry. 2007 Jan;40(1):43-4. 48. Kruszewski SP, Paczynski RP, Kahn DA. Gabapentin-induced delirium and dependence. J Psychiatr Pract. 2009 Jul;15(4):3149. 49. Peckham AM, Evoy KE, Covvey JR, Ochs L, Fairman KA, Sclar DA. Predictors of gabapentin overuse with or without concomitant opioids in a commercially-insured US population. Pharmacotherapy. 2018; doi: 10.1002/phar.2096. [Epub ahead of print] 50. Bodén R, Wettermark B, Brandt L, Kieler H. Factors associated with pregabalin dispensing at higher than the approved maximum dose. Eur J Clin Pharmacol. 2014 Feb;70(2):197-204. 51. Reccoppa L, Malcolm R, Ware M. Gabapentin abuse in inmates with prior history of cocaine dependence. Am J Addict. 2004 May-Jun;13(3):321-3. 52. Bicknell M. The pain of pregabalin prescribing in prisons. Br JGen Pract. 2013;63(613):405. 53. Del Paggio D. Bay area psychopharmacology. Newsletter. 2005;8(2):1–5. http:// www.acbhcs.org/Psychopharmacology/2005/June2005.pdf. 54. Smith RV, Havens JR, Walsh SL. Gabapentin misuse, abuse, and diversion: A systematic review. Addiction 2016;111(7):1160-74.

Call for Articles The TSHP Editorial Advisory Board welcomes article submissions for future issues of the TSHP Journal. www.tshp.org/journal

TSHP JOURNAL

PILOT STUDY

Pharmacist Awareness and Attitudes Regarding Gabapentinoid Abuse

Kirk E. Evoy, PharmD, BCACP, BC-ADM, CTTS Clinical Assistant Professor , University of Texas at Austin College of Pharmacy Adjunct Clinical Assistant Professor, University of Texas Health San Antonio School of Medicine Clinical Pharmacist, University Health System Stephanie L. Yin PharmD Candidate, University of Texas at Austin College of Pharmacy

Purpose: Gabapentinoids (gabapentin and pregabalin) have traditionally been thought to possess limited abuse liability. However, reports of gabapentinoid abuse have increased significantly in recent years. As opioid prescriptions are decreasing to mitigate the current abuse epidemic, gabapentinoids are increasingly being prescribed. This pilot study was conducted to assess pharmacist awareness of gabapentinoid abuse liability, and its influence on patient-care-related decisions before and after continuing education (CE) regarding gabapentinoid abuse presented at local Texas Society of Health-System Pharmacists (TSHP) meetings. Methods: A voluntary, anonymous, 10-minute, 15-question survey regarding pharmacist awareness and attitudes related to gabapentinoid abuse was administered before and after a live one-hour gabapentinoid abuse CE at two local TSHP affiliate chapter meetings in San Antonio and Dallas, Texas. Results: Twenty-seven pharmacists completed both pre- and post-surveys. The survey cohort was 59% male and 67% Caucasian, 100% practiced in an urban setting, and 71% had practiced for >6 years. Following the CE, pharmacist awareness of gabapentin and pregabalin abuse increased significantly (2.7/5 vs. 3.88/5, p=0.0021 and 2.9/5 vs. 3.88/5, p=0.0027, respectively, based on Likert Scale values of 1-5). Concern for abuse potential (2.59/5 vs. 3.38/5, p=0.0047) and the likelihood of altering prescribing/ verification practices (3.08/5 vs. 3.88/5, p=0.0016) increased significantly regarding gabapentin but not pregabalin. There was also a trend towards increased likelihood to alter pregabalin prescribing/verification patterns (3.42/5 vs. 3.92/5, p=0.0736). Conclusions: This pilot study identified a potential knowledge gap with regards to gabapentinoid abuse and indicated that CE on the subject may help remedy this gap. Larger and more generalizable studies are needed to confirm these results.

rescription drug abuse is a major public health concern with rates of drug overdose death in the United States reaching record levels.1 According to the Center for Disease Control and Prevention, more than 64,000 Americans died of drug overdose in 2016, with prescription and illicit opioids most commonly implicated. However, abuse of several other prescription medications not traditionally thought of as drugs of abuse have also been on the rise, including the gabapentinoids, pregabalin and gabapentin. Though their mechanism of action is not entirely understood, the gabapentinoids function as GABA-mimetics and thus act through the same GABA pathway as several other drugs with known abuse potential such as the benzodiazepines, Z-hypnotics, and alcohol.2-3 And while pregabalin is currently designated by the United States Drug Enforcement Administration (DEA) as a Schedule V controlled substance, indicating the lowest abuse potential among scheduled drugs, gabapentin is not labeled as a controlled substance.4-6 Likely, at least in part, due to increased emphasis on reducing opioid prescribing, coupled with their perceived limited abuse liability, the gabapentinoids are increasingly being prescribed for a variety of conditions.7 In fact, 64 million prescriptions for gabapentin were dispensed in the United States in 2016, representing a 64% increase since 2012. This is in stark contrast to the 34% decrease in prescriptions of the most com-

monly prescribed opioid, hydrocodone/ acetaminophen, over the same timeframe. Similar pregabalin trends have been described in the literature as well, including a 350% prescribing increase over a recent five-year span in the UK.8

t-care-related decisions before and after continuing education (CE) sessions regarding gabapentinoid abuse provided at local Texas Society of Health-System Pharmacists (TSHP) affiliate chapter meetings.

A 2017 systematic review highlighted this recent trend in gabapentinoid abuse, identifying 59 articles describing pregabalin and/or gabapentin abuse, the vast majority of which were published within the last 5 years.9 Though adverse effects are relatively benign when the gabapentinoids are abused on their own, several studies have pointed towards significant potential for harm when these medications are ingested concomitantly with other central nervous system depressant medications and they are increasingly being implicated as contributing factors in fatal overdoses.9-13

Survey Instrument A cross-sectional, non-experimental survey study was conducted. The 10-minute, 15-question survey consisted of eight demographic questions (collected only in the pre-education survey) and an additional seven questions assessing awareness of published literature regarding gabapentinoid abuse, level of concern for gabapentinoid abuse potential and liability, likelihood of altering prescribing or verification of medications, and personal measures utilized to stay up-to-date on drug abuse trends. These same 7 questions were collected both pre- and post-educational session. Responses were collected using Likert Scales for five questions, while the demographic data and two questions related to personal measures to stay up-to-date on drug abuse trends utilized multiple choice answers.

Based on the non-controlled status of gabapentin, the increasing gabapentinoid prescribing and frequency of abuse reports and harm, and personal conversations with colleagues, we hypothesized that relatively few pharmacists were aware of the abuse potential of the gabapentinoids and most were not factoring this into their patient care-related decisions. The objective of this pilot study was to assess pharmacist awareness of gabapentinoid abuse liability and its influence on their patienTSHP JOURNAL

Methods

Survey Cohort The study cohort consisted of pharmacists who attended one of two live, one-hour CE presentations regarding gabapentinoid abuse presented at a Central Texas Society of Health-System Pharmacists (CTSHP) meeting in San Antonio,

Texas or Metroplex Society of Health-System Pharmacists (MSHP) meeting in Dallas, Texas. Non-pharmacists in the audience were excluded from this study. The same CE presentation was utilized at both events and summarized current literature regarding epidemiology, prevalence, risk factors, patterns of abuse, and potential harms related to gabapentinoid abuse, as well as roles of pharmacists and technicians in identifying and mitigating gabapentinoid abuse. The pre- and post-education surveys were disseminated to attendees prior to the CE presentation via paper copy with an identical number to link the surveys without collecting respondentsâ&#x20AC;&#x2122; identifiers and were collected immediately after. Participation was voluntary and anonymous. A cover letter was distributed with the survey to explain the voluntary nature and implied informed consent by completing the survey. No cost or compensation was provided for participation. The study was approved by The University of Texas Health San Antonio Institutional Review Board. Statistical Analysis All data and statistical analyses were conducted using JMP 12.0ÂŽ (SAS Corp., Cary, NC, USA). Demographic information was assessed using descriptive statistics. Two-sided paired sample t-tests were used to compare pre- and post-education survey responses for gabapentin and pregabalin. A p-value of <0.05 was used to indicate statistical significance.

Results

Demographics A total of twenty-seven pharmacists completed both the pre- and post-CE surveys. Completion percentage could not be determined as total number of pharmacists in attendance at each talk was unknown. In brief, the cohort was 59% male and 67% Caucasian, 100% practiced in an urban setting (all practiced in Texas while two respondents practiced in multiple states), and approximately 71% had practiced for more than 6 years. Gabapentin Prior to the CE, the cohort surveyed felt there was little evidence of gabapentin abuse (mean 2.7/5), and that they were only slightly concerned with this issue (mean 2.59/5). In the post-education survey there was a significant increase in both their awareness of the level of evidence (mean 3.88, P=0.0021) and level of concern (mean 3.38, p=0.0047). After the CE, survey respondents were also significantly more likely to alter prescribing or verifying practices with regards to gabapentin in patients with a known history of drug abuse (mean 3.8/5 vs. 3.08/5, p=0.0016), but not in patients without a history of substance abuse (mean 2.12/5 vs. 2.52/5, p=0.2783). Overall, few participants had personally observed any signs of recreational abuse in practice (mean 1.87/6 in pre-education survey).

Pregabalin With regards to pregabalin, baseline awareness was slightly higher with regards to evidence of pregabalin abuse (mean 2.9/5) and concern with this issue (mean 3.08/5) compared to gabapentin. In the post test, however, there was still a significant increase in their awareness of the level of evidence (mean 3.88, P=0.0027), while their level of concern trended towards an increase (mean 3.46, p=0.1610) compared with baseline. Pharmacists were also more likely to alter their prescribing or verifying practices with pregabalin versus gabapentin in patients with a history of substance abuse (mean 3.42/5) and without a substance abuse history (mean 2.74/5). These measures both improved slightly after the continuing education (mean 3.92/5, p=0.0736 and mean 2.85/5, p=0.7702), but the differences were not statistically significant. Methods of Remaining Up-to-Date on Substance Abuse Literature This survey also assessed pharmacistsâ&#x20AC;&#x2122; methods of remaining up-to-date with the current literature regarding substance abuse and their perceived efficacy of these approaches. When asked what measures survey responders utilized to remain abreast of trends in prescription and nonprescription drug abuse, the most common responses were attending live CE (96%) and completing self-study CPE (48%), while 19% reported they do not consistently take measures to remain

Table 1. Knowledge, Awareness, and Concern Questions from Pre/Post Surveys Corresponding question number in Figure 1

Answer choice and corresponding score on Likert Scales

Question

Score: 1

Score: 2

Score: 3

Score: 4

Score: 5

Score: 6

To your knowledge, how much evidence regarding possible abuse potential of the following medications has been published regarding the following medications?

Unsure

None

Little

Some

Substantial

---

In practice, my level of concern as to the abuse potential/liability of the following medications can best be described as:

Not At All Concerned

Slightly Concerned

Somewhat Concerned

Moderately Concerned

Extremely Concerned

---

How likely are you to alter prescribing or verifying of the drug listed for a patient with a known history of drug abuse?

Extremely Unlikely

Unlikely

Neutral

Likely

Extremely Likely

---

Regarding patients without a current or prior substance abuse disorder, how likely are you to alter your prescribing or verifying practices when prescribing the drugs listed?

Extremely Unlikely

Unlikely

Neutral

Likely

Extremely Likely

---

In practice, I have personally observed signs of recreational abuse of the following medications in a patient I was caring for:

Unsure

Never

Rarely

Occasionally

Often

Always

Personally, how would you rate your understanding of recent trends in prescription and non-prescription drug abuse?

Not At All Aware

Slightly Aware

Somewhat Aware

Moderately Aware

Extremely Aware

---

*For questions 1-5, participants were asked each question separately with regards to gabapentin and pregabalin. TSHP JOURNAL

Figure 1. Pre- and Post-Education Survey Results

abreast drug abuse trends. And while there was an improvement in perceived awareness of recent drug abuse trends after completing this CE (3.38/5 vs. 3.03/5, p=0.2713), this difference did not reach statistical significance.

Discussion

concern regarding pregabalin abuse was slightly higher across the various measures compared to gabapentin, which is predictable given that only pregabalin is a controlled substance according to the DEA. As a result, a statistically significant improvement with regard to pregabalin was identified in only one of the five measures in the post-survey versus three of the five questions related to gabapentin. Based on the increase in reports of abuse, several states have recently passed legislation aimed at reducing gabapentin abuse, including adding gabapentin to prescription drug monitoring programs, imposing restrictions on the number of refills offered, and even reclassifying gabapentin as a controlled substance within their state.15 Data from this present study indicate that in addition to disseminating information through CE programs, measures such as this (e.g., reclassifying gabapentin as a controlled substance) may help increase pharmacist awareness of this issue.

This pilot study identified a possible knowledge gap with regards to gabapentinoid abuse. Despite the growing level of evidence that gabapentinoid abuse has significantly increased over the last several years, awareness, level of concern, and likelihood to alter prescribing or verifying practices in patients with a known history of substance abuse were low at baseline.9 Furthermore, significant improvement from baseline was observed in the post-education survey with regards to pharmacist knowledge of both gabapentin and pregabalin abuse potential, as well as concern for abuse, and likelihood to alter prescribing/verifying practices with regards to gabapentin, indicating that the continuing education session was There are several limitations to this stueffective in improving awareness of this dy that should be noted. The small samalarming trend. In comparing the speci- ple size and geographical limitations of fic medications, baseline awareness and the study significantly reduce its external

validity. Furthermore, the survey utilized was newly developed for this study and not previously validated. The response rate was not captured, and there are inherent limitations in the pre/post survey design as there is not a true control group present. Despite these limitations, no previous study assessing pharmacist awareness of gabapentinoid abuse has been published to date, and the results indicate that there may be an important knowledge gap present. This study was conducted as an exploratory pilot to assess the need for a larger, more generalizable assessment of pharmacist knowledge and awareness of this issue, as well as the potential value of disseminating information related to gabapentinoid abuse through additional education sessions.

Conclusion

This pilot study identified a potential knowledge gap with regards to gabapentinoid abuse and indicated that providing CE on the subject may improve pharmacist awareness of the issue, ultimately result in more cautious prescribing and verifying practices within vulnerable populations. Based on the results of this pilot

Table 2. Responses Regarding Means of Keeping Up-to-Date with Current Drug Abuse Research Question: Personally, what measures do you take to remain abreast of the most recent trends in prescription and nonprescription drug abuse? (Select all that apply)

Answer Choices Attend live continuing education programs related to prescription and nonprescription drug abuse Complete self-study continuing education programs related to prescription and nonprescription drug abuse Take part in personal study of current trends in prescription and nonprescription drug abuse Predominantly rely on observations in my current patients

Pre-Presentation Response Rates n = 26 (96%) n = 13 (48%) n = 3 (11%) n = 3 (11%)

I do not consistently take measures to remain abreast of the most recent trends in prescription and nonprescription drug abuse

n = 5 (19%)

Other (Describe)

Opioid Program n = 1 (4%) Son has ADHD n = 1 (4%) TSHP JOURNAL

study, larger and more generalizable studies are warranted to better categorize this potential knowledge gap and aid in development of effective continuing education tools to increase community awareness of these alarming gabapentinoid abuse trends. References 1.

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Pharmacy Leaders. Transforming Patient Care.

Happy Pharmacy Month from TSHP

Pharmacy Week 2018 October 21-27 #PharmacyStrong National Pharmacy Technician Day 2018 October 16 #RxTechDay Team Selfie Day 2018 October 19 #TeamSelfieDay TSHP JOURNAL

The Other Side of the Epidemic: Pharmacists and Opioid Abuse

THE PROBLEM

Since 1869, the problem of health professional substance abuse has existed in peer-reviewed literature. Literature shows that 10-15% of all medical professionals will cope with substance misuse at some point in their career. Despite its presence in the literature, the topic of health professional substance abuse, especially use among pharmacists, is rarely talked about. It’s whispered about at the water cooler but is not openly addressed. The recent opiate and benzodiazepine epidemics have had a major societal impact in the U.S.; prompting significant social and legislative changes. We all know the statistics. Among the more than 64,000 drug overdose deaths estimated in 2016, the sharpest increase occurred among deaths related to fentanyl and fentanyl analogs with over 20,000 over dose deaths attributed to those sources. Of the 20.5 million American 12 or older that had a substance use disorder in 2015, 2 million had a disorder involving prescription pain relievers. The pharmacy profession has been called upon to be part of the change, to help bolster the strength of the allied medical professions against opiate abuse. With the added stress of helping monitor pres-

“I am sober, with no temptations and the PRN requirements, which I at first resisted, have made me strong and well equipped to lead a sober and happy life. Plus, it has helped me save my career.” — PRN Participant

cription drug abuse, comes the increased risk for substance abuse itself. One in ten medical professionals will fall into addiction at some point in their careers. This is due to many factors including easy access to substances of abuse, stressful work environments, exposure to the trauma of others, and sleep deprivation . So, what about pharmacy professionals? The primary substances of abuse for pharmacy professionals are opiates. This poses a significant problem for the profession of pharmacy. Easy access to these substances paired with stressful work environments, little ability to practice self-care, poor work/life balance, and certain personality characteristics like perfectionism and care-taking create a perfect storm. For many people, all it takes is one pill to relieve some of that foot and back pain from long hours standing and they are hooked. Others take years to develop into diversion of substances from their jobs.

(PRN) with the Texas Pharmacy Association (TPA) has served over 1,000 allied medical professionals (including pharmacists and pharmacy students) in the state of Texas. PRN was one of the first physicians’ health programs (PHP) in the United States to address the needs of allied health professionals and continues to be a model for how supportive monitoring programs and PHP. PRN adheres to the dual philosophy that it is important to provide an opportunity for confidential recovery while also protecting the public from unsafe professional practice. PRN believes that pharmacists who have a substance use disorder or mental health problem should be offered a chance to enter recovery and confront their problems before having disciplinary action taken against their licenses. Thankfully, the state of Texas and the Texas State Board of Pharmacy recognizes the need for confidential and supportive recovery. PRN leads the path for non-punitive rehabilitation; providing referrals, monitoring, education, and advocacy to help professionals keep their licenses and continue to practice with integrity and safety despite their history of substance abuse.

To put further perspective on this issue, of the current participants in the Texas Professional Recovery Network (PRN), the peer assistance and support program for pharmacists in Texas, 45% have a primary addiction to opiates. It is currently unknown how many consider opiates to be their secondary substance of choice, Studies have shown that individuals usually secondary to alcohol. seeking to recover from substance abuse without the support of a PHP like PRN THE SOLUTION relapse (start using again) 40-60% of the Understanding the scope of the pro- time. However, individuals in a PHP like blem puts the profession in a good place PRN only relapse 20% of the time, and to begin supporting the solution: a robust when they do relapse, it is often only once. and supportive network to address addiction in pharmacy professionals. Since Why are the success rates of a PHP so 1981, the Professional Recovery Network much higher? PHPs offer something that

Brittany Lash, LPC Director of the Professional Recovery Network with the Texas Pharmacy Association TSHP JOURNAL

most recovery programs do not have: accountability. Individuals in PHP programs are required to participate in frequent un-scheduled drug screening to ensure that they remain totally abstinent from substances including alcohol. Throughout their tenure in the program, often five to ten years, professionals are provided the one-on-one support they require to stay sober and continue to practice safely.

REFERRALS

Referrals can be accepted by PRN in three ways. The first is for the individual living with addiction to contact PRN at 1-800-727-5152 and speak to one of our licensed clinical social workers. The other is for the Texas State Board of Pharmacy to refer an individual to PRN. The third, and most common, is for individuals to be referred to PRN by a concerned third party. In the case of third party referrals, this person’s identity and details about their report are kept strictly confidential. At no point will PRN release the details of this person’s report or identity to the addicted individual. After receiving the report from the concerned third party, PRN then provides a phone intervention for the individual believed to have an addiction. Our goal is to engage them as soon as possible in the PRN process, to identify any potential safety to practice concerns, and address those concerns in a meaningful and supportive way.

SIGNS AND SYMPTOMS

How would you know if someone you work with is potentially addicted to an opiate? The physical signs include: • Noticeable elation or euphoria • Drowsiness or sedation • Confusion • Constricted (small) pupils • “Nodding off”

If you notice these symptoms in a peer, please call PRN. That phone call could save their career and their life.

CONCLUSION

The unspoken truth about the opioid epidemic is that it impacts us all. From how we work to how we live; our families, our friends, and our coworkers. While Other signs might include: the pharmacy profession focuses its efforts • Dramatic shift in moods • Extra pill bottles showing up in the on helping others who may be living with opiate addiction, it is equally important trash that the profession helps itself. The sta• Evidence of drug diversion tistics speak for themselves. Should you • Financial problems or a peer need assistance with opiates or • Social withdrawal/isolation other substances of abuse, please contact Symptoms of opiate withdrawal include: the Professional Recovery Network (PRN) with the Texas Pharmacy Association • Headaches (TPA) at 1-800-727-5152. For more infor• Nausea and vomiting mation on our program, please visit our • Diarrhea website at http:www.txprn.com. • Sweating • Fatigue • Anxiety • Sleeping problems (or difficulties) References 1. Hazelden Betty Ford Foundation (June 2015) Health Care Professionals: Addiction and Treatment 2. Hazelden Betty Ford Foundation (June 2015) Health Care Professionals: Addiction and Treatment 3. Center for Disease Control 4. American Society of Addiction Medicine (2016) Opioid Addiction 2016 Facts and Figures 5. American Society of Addiction Medicine (2016) Opioid Addiction 2016 Facts and Figures 6. Hazelden Betty Ford Foundation (June 2015) Health Care Professionals: Addiction and Treatment 7. DuPont, Robert L.; et al (2009) Setting the standard for recovery: physicians’ health programs. Journal of Substance Abuse Treatment, 36 (2009), 159-171.

TSHP JOURNAL

TSHP Research & Education Foundation Poster Competition

2018 Winners TSHP JOURNAL

PRACTITIONER – ADMINISTRATIVE/PRACTICE MANAGEMENT

very year, the Texas Society of Health-System Pharmacists Research & Education Foundation holds a poster competition during the TSHP Annual Seminar. The Competition is an opportunity for new practitioners, students, technicians, and practitioners to submit and display original scholarly work in poster format in one of the followings seven categories: Resident/Fellow/Post-Graduate category includes posters submitted by pharmacists enrolled in a post-graduate residency, fellowship or other post-graduate educational programs. The category is divided into two sub-groups: PGY1 and PGY2. Student category includes posters submitted by students enrolled in pharmacy academic programs. Technician category is for posters submitted by practicing pharmacy technicians and technician students. Practitioner category is for posters submitted by registered pharmacists in one of three categories: • Administrative/Practice Management is related to professional practice management issues and leadership. • Clinical is related to patient care delivery, therapy and outcomes. • Education is related to patient, healthcare practitioner and community education and/or educational planning, development and conduct for professional practice.

The 2018 TSHP Research & Education Foundation Poster Competition took place at the 2018 Annual Seminar in The Woodlands, TX, April 6-8. The Foundation is proud to offer abstracts for the seven 2018 winning posters. Click on each poster thumbnail to view larger. The 2019 Call for Posters will open December 2018. For full competition details, visit www.tshp.org/poster.

Do the ‘Genes’ Fit? Starting a Pharmacogenetics Testing Service DA Pandya, LM Cuellar TIRR Memorial Hermann Houston, Texas Background: Pharmacogenetics is the study of how genes affect the body’s response to medications in terms of metabolic pathways and adverse effects. The role of genetic testing has yet to be fully integrated into practice despite considerable support in research. Several key components were identified in the process of establishing a pharmacist-managed pharmacogenetics testing service. Objective: To outline the steps taken to offer a pharmacogenetics testing service. Procedure: 8 steps were taken to start the service. Initially, we had to assess the need for the service by identifying patient needs and using a provider survey. Second, was the selection of a reference lab. There are many different type of tests available, so careful evaluation is necessary. Infrastructure needs were gauged which included labor, facility, and electronic medical records (EMR). Contracts with reference labs required legal review and laboratory leadership approval. Next is the development of documentation for pharmacists and posting of report in EMR. Additionally, educational needs were assessed and addressed for physicians, pharmacists and nursing. Reimbursement for the test is available for several indications. Adhering to the ICD-10 codes that are reimbursed is essential. Finally, outcome metric for pharmacogenetics has not been fully established; we plan to report impact of medication changes through interventions and quality of life surveys. Results: Not Applicable. Conclusion: As pharmacogenetics is a relatively new field, our outcome metrics will be useful to establish its place in practice. At our facility, we plan to expand these services for pain management, anticoagulation and refractory seizure management. Disclosure: DA Pandya and LM Cuellar have nothing to disclose.

Do the ‘Genes’ Fit?

Starting a Pharmacogenetics Testing Service Dehuti Pandya, PharmD, BCPS; Lourdes Cuellar, MS , FASHP Background: Pharmacogenetics is the study of how genes affect the body’s response to medications in terms of metabolic pathways and adverse effects. Genetic factors can account for up to 95% of drug-response variability and susceptibility. Pharmacogenetics testing demonstrates how genetic differences influence the variability in patients’ responses to drugs. The role of genetic testing has yet to be fully integrated into practice despite high levels of support in the research. Several key components were identified in the process of establishing a pharmacist-managed pharmacogenetic testing service. Purpose: To outline the steps taken to offer a personalized, precision medication service to improve patient outcomes. Assess Need

Documentation

• Provider survey • 80% of providers interested • Identify patient need(disease states) • High concern areas: neurological and behavioral health • Secure physician and leadership support • Physician within outpatient service line identified as champion

• Pharmacist EMR documentation template • Screening note • Results and counseling note • Posting report in EMR • Identify location for provider access • Search ability (access to results) • Categorization • Availability for lifetime encounters • ICD- 10 codes • Accuracy of charging/billing

Select Reference Lab

• Determine span of testing • Individual – test by gene (e.g. CYP340) • Disease state - test by medications used for disease/condition (e.g. depression) • Comprehensive – test for all available genotypes • Reference lab provider focus • physician vs. pharmacist • Rxpgx.com – reference guide - 75 reference labs

Education

• Assessment of knowledge gap • Physician • Pharmacist • Nursing • Pharmacist training & competency certification • Education for ISD team on impact of results and support to build necessary functions in EMR

Infrastructure

Reimbursement

• Labor (FTEs) – estimated pharmacist hours (testing, documentation of results, recommendations, and counseling) • Facility – Inpatient & outpatient • Electronic Medical Record (EMR) • Build clinical laboratory orders • Develop work flow process map • Notification in EMR of test results • Drug vs. gene interactions

• Medicare: Specific mental health and cardiovascular indications (4 medications covered) • - Amitriptyline - Nortriptyline • Tetrabenazine - Clopidrogel • Genetic tests & services are beginning to be addressed by a growing number of health plans

Outcome Metrics

• Impact of medication changes • Interventions • Trend pharmacogenetics of population tested • Quality of life survey

Provider-Reference Lab Contract • Legal review • Laboratory leadership approval • Billing structure (charge master)

Opportunities for Expansion & Improvement

• • • •

Disclosure: Authors have nothing to disclose.

TSHP JOURNAL

Pain management – opioid tolerance & abuse Anticoagulation (warfarin and DOAC) Seizure management - refractory seizures Identifying and building alerts in EMR

Acknowledgements: Sarah Lake Wallace for assistance in poster design

PRACTITIONER – CLINICAL Estimation of Glomerular Filtration Rate from Vancomycin Levels During Acute Kidney Injury Recovery Steven Knight, RPh, PharmD, BCPS1, Nicole Nguyen2, Benjamin Bolding3, Mario RoblesFranceschini, MD4, Carlos Pancorvo, MD5 1Methodist Charlton Medical Center 2University of Houston College of Pharmacy, Houston Texas, 3University of North Texas College of Pharmacy, Fort Worth Texas, 4Nephrology Fellowship, Methodist Dallas Medical Center, Dallas Texas, 5Dallas Nephrology Associates, Dallas TX Background: During the extension and recovery phase of Acute Kidney Injury the creatinine may give an unreliable estimation of GFR. Vancomycin is one of the most commonly used antibiotics which is primarily excreted via glomerular filtration, and its levels are monitored routinely during therapy. Objective: The primary objective of this exercise is to investigate if GFR calculated from the change in interval random vancomycin levels correlates with the actual GFR. Method: The patient is a 71 y/o woman on outpatient dialysis for a month due to Acute Kidney Injury over Stage 3 Chronic Kidney Disease. She was admitted to the hospital with a catheter related infection and treated with vancomycin. On admission it was noted that she had a normal urine output and creatinine of 1.4mg/dL, a day after receiving dialysis. However, the creatinine was rising, which did not reflect the improving renal function, as steady state had not been achieved. The patient was on Vancomycin therapy and drug levels were being monitored. Since Vancomycin is mostly excreted unchanged in the urine via glomerular filtration, GFR can be calculated from known pharmacokinetic equations to objectively determine renal function. Five Vancomycin concentration levels were taken approximately 6 hours apart during two Vancomycin dose administrations. The levels were entered into the elimination rate constant equation based on the difference in each serum vancomycin level [Ke = lnC1-lnC2/(t2-t1)] to estimate the patient’s vancomycin clearance [Cl= Ke x Vd]. Results: The results of the calculated GFR indicated an improvement in GFR between vancomycin doses, which reinforced the clinical assumption. The patient’s creatinine plateaued after and started decreasing and did not need further dialysis treatment. Conclusion: This exercise of calculating GFR from vancomycin clearance may indicate that random vancomycin levels can be utilized as another tool in estimation of renal function in patients which are not in steady state.

Estimating GFR from Random Vancomycin Levels Steven Knight,

RPh, PharmD, BCPS, CMTM,

Nicole Nguyen, PharmD Candidate*, Benjamin Bolding, PharmD Candidate**,

Mario Robles-Franceschini, MD, Carlos Pancorvo, MD Methodist Charlton Medical Center ● Dallas, Texas University of Houston College of Pharmacy ● Houston, Texas* University of North Texas College of Pharmacy ● Fort Worth, Texas**

Introduction

Patient Summary • The patient is a 71 year old female, hemodialysis patient readmitted due to a permacath infection • Past medical history includes diagnosis of acute renal failure superimposed on stage 3 chronic kidney disease • When the catheter was removed during infection treatment, the nephrologist noticed the patient’s renal function was improving • Per nephrologist request, patient agreed to participate in experiment comparing GFR calculated from random vancomycin levels to known improvement in patient’s renal function

Methods • Five vancomycin concentration levels were taken at intervals during the course of two vancomycin 750mg dose administrations • GFR trends were determined by inputting these labs values into known pharmacokinetic equations • Over the course of the study, nephrology and pharmacy personnel monitored patient status

Vancomycin Concentration Levels

Calculations

30 Vancomycin Concentration (mcg/L)

• Vancomycin is one of the most common IV antibiotics used for treatment and empiric therapy in clinical settings and is primarily excreted via glomerular filtration • Troughs are drawn to ensure adequate vancomycin concentrations to treat infections following the third dose • The Cockcroft-Gault equation is standard for estimating renal function and making dose adjustments accordingly • The objective of this study is to utilize random vancomycin levels to calculate GFR and compare the values to that of the patient’s known renal improvement

25 20

GFR= 8.892

Ke2→3:

ln (13.8/12.5) =0.01706 (10.00-4.20)

GFR= 15.25

Ke3→4:

ln (12.5/10.8) =0.02404 (16.08-10.00)

GFR= 23.66

y = -0.23(21.2) + 14.65

Average GFR: 8.892+15.25+23.66 = 15.93 3 mL/min

y = 9.774

We will refer to this as A = 9.774mcg/L

5 0

ln (14.5/13.8) =0.01178 (4.20-0.00)

Calculating trough before 2nd dose (A): Based on the values from 1 → 4 in the table, the the following best fit line equation was calculated: y = -0.23x + 14.65, where y = the vancomycin level and x = the relative time. Thus, the vancomycin trough before the 2nd dose was given can be calculated as follows:

Ke1→2:

2nd

Calculating level at time dose administered (B): Given the dose administered was 750mg and the patient weighed 72.1kg, the amount of vancomycin received from 2nd dose can be calculated as follows: We will refer to this as B = 14.86

Date & Time

20 30 Relative Time (Hours)

Vd = 0.7 x 72.1 Vd = 50.47

750 / Vd = Concentration 750 / 50.47 = 14.86

We will refer to this as B = 14.86mcg/L

2nd dose

7/26 1951

7/27 0003

7/27 0551

7/27 1156

7/27 1703

7/28 1555

Relative Time

0.00

4.20

10.00

16.08

21.20

44.07

Level

14.5

13.8

12.5

10.8

24.63

13.1

Calculating the total vancomycin concentration after the 2nd dose (C): The total vancomycin level at time the 2nd dose was administered can be calculated as follows: Total Concentration = A + B Total Concentration = 9.774 + 14.86 Total Concentration = 24.63 We will refer to this as C = 24.63mcg/L Calculating GFR after the 2nd dose: ln (24.36/13.1) Ke2nd dose → 5: = 0.02761 (44.07-21.20)

CrCl= 27.96mL/min

Results • Considering the patient’s known improvement in renal function, we expected the estimated GFR after the second dose of vancomycin to be equal to or greater than the GFR between the first and second dose • This expectation was met when comparing the calculated renal function values of 27.96 and 15.93mL/min for the second and first doses respectively • While this may indicate that random vancomycin levels can be used to estimate renal function, because these calculations were based on a single patient case, further studies are necessary in order to determine if this method has a role in clinical practice Disclosures and References • All authors have no potential conflicts of interests to disclose

Special Thanks • Pharmacy and Nephrology Department staff members at MCMC

TSHP JOURNAL

PRACTITIONER â&#x20AC;&#x201C; EDUCATION Economic Diversity in Advanced Pharmacy Practice Experiences (APPE) JT Copeland University of the Incarnate Word San Antonio, TX Background: In addition to the ACPE required community APPE, fourth year pharmacy students (P4) may participate in elective APPEs in a community practice setting. Historically, the majority of UIW students completed APPEs in affluent pharmacy practice settings. This limited student interaction with patients in an economically depressed area and resulted in underutilization of quality sites and preceptors in economically depressed areas. Objective: Enhance P4 participation in economically diverse practice settings. Methods: Prior to APPE assignments, the community practice area was divided into two economic areas: zip codes with less than 10% of households falling below the poverty level and zip codes with greater than 10% of households falling below the poverty level. If a student performs one or more elective Community APPEs, at least one APPE (required Community or elective Community) must be from a different socio-economic area. Results: Students provided patient care in economically diverse practice settings. Utilization of quality preceptors and sites in economically depressed areas increased. Conclusions: Diversification requirements will continue. Disclosure: None

Economic Diversity in Advanced Pharmacy Practice Experiences (APPE) Jeffrey T. Copeland, BS, Th.M., Pharm.D. Department of Pharmacy Practice, Feik School of Pharmacy, University of the Incarnate Word, San Antonio, Texas

Background

Objective Enhance P4 participation in economically diverse practice settings.

In addition to the ACPE required community APPE, fourth year pharmacy students (P4) may participate in elective APPEs in a community practice setting. Historically, the majority of UIW students completed APPEs in affluent pharmacy practice settings. This limited student interaction with patients in an economically depressed area and resulted in underutilization of quality sites and preceptors in economically depressed areas.

Methods Prior to APPE assignments, the community practice area was divided into two economic areas: zip codes with less than 10% of households falling below the poverty level and zip codes with greater than 10% of households falling below the poverty level. If a student performs one or more elective Community APPEs, at least one APPE (required Community or elective Community) must be from a different socio-economic area.

Results Students provided patient care in economically diverse practice settings. Utilization of quality preceptors and sites in economically depressed areas increased.

Conclusions Diversification requirements will continue.

Disclosure Author of this presentation have nothing to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation.

TSHP JOURNAL

RESIDENT/FELLOW/POST-GRADUATE (PGY1) Medication Use Evaluation of Intravenous Levothyroxine at a Large, Academic Medical Center S Michaud, A Sirisaengtaksin, RB Taylor Baylor St. Luke’s Medical Center Houston, Texas Background: The cost of IV levothyroxine at $97.28/vial led to the initiation of a protocol in May 2016 at Baylor St. Luke’s Medical Center (BSLMC) allowing pharmacists to hold IV levothyroxine orders for euthyroid patients who are NPO < 5 days. Exclusions include hypothyroid patients who are newly initiated on levothyroxine, refusal of withholding home dose, display of hypothyroidism, myxedema coma, cardiogenic shock or low cardiac output, and life gift donor patients. Objective: To evaluate the use of IV levothyroxine, assess compliance with automatic discontinuation protocol, and identify cost savings opportunities. Methods: Retrospective, observational study using electronic health records to identify patients ≥ 18 years admitted to BSLMC from May 2016 through December 2017 who received IV levothyroxine. Patient demographics, levothyroxine indication and dose, criteria for exclusion to protocol, and total cost of IV levothyroxine therapy will be recorded. Results: From 25 patients, preliminary data shows 32% patients were NPO for > 5 days, 4% had symptoms of hypothyroidism, 8% had myxedema coma, and 56% of patients did not meet criteria. 115 vials were used for patients who did not meet criteria, which cost $11,187.20. Conclusions: Equivalent oral levothyroxine would cost $50, indicating potential of $11,130 cost savings. Pharmacists should be re-educated on the IV levothyroxine safe withholding protocol criteria decrease cost of levothyroxine therapy. Disclosures: The authors of this presentation have no disclosures concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation.

Intravenous levothyroxine medication use evaluation at a quaternary academic medical center Amanda Sirisaengtaksin, PharmD; Ramsi Taylor, PharmD; Stephen Michaud, PharmD, BCCCP CHI St. Luke’s Health Baylor St. Luke’s Medical Center, Houston, Texas

BACKGROUND

METHODS

• Levothyroxine is a synthetic form of thyroxine (T4), a thyroid hormone, indicated for use in the treatment of hypothyroidism. T4 is endogenously secreted by the thyroid gland and converted to its active metabolite triiodothyronine (T3) to promote normal metabolic effects, including gluconeogenesis, utilization of glycogen stores, and protein synthesis

• Single-center retrospective chart review from May 1, 2016 through December 31, 2017 of at least 100 patients • A list of all patients receiving IV levothyroxine during this time period was obtained from the SharePoint Drug Utilization Report Tool and EPIC database

• Oral levothyroxine is widely used to achieve and maintain euthyroid state and to reverse clinical manifestations of hypothyroidism, including fatigue, cold intolerance, constipation, weight gain, and bradycardia, among other hypometabolic abnormalities

• For each eligible patient, data collected included patient’s medical record number (MRN), age, gender, prior to admission hypothyroidism diagnosis, criteria for intravenous formulation, hypothyroid or euthyroid state, duration of therapy, number of vials used, and total cost of therapy

• More serious consequences of systemic hypometabolism include pericardial effusion, hypertension, and hypercholesterolemia due to decreased heart rate and contractility, which leads to a decrease in cardiac output.1 Dose adjustments are based on changes in thyroid-stimulating hormone (TSH), and serum T4 and T3 levels

Patients newly initiated on levothyroxine, who have not achieved euthyroid

• Management of hypothyroidism in the inpatient setting for acutely ill patients may require the intravenous (IV) levothyroxine formulation due to mechanical ventilation, risk of aspiration, severe nausea or vomiting, or pre-procedural oral intake restrictions2

Table 2. Exclusions to Protocol

• Baylor St. Luke’s Medical Center (BSLMC) initiated a protocol in May 2016 allowing pharmacists to hold IV levothyroxine orders for euthyroid patients who are NPO for up to five days

STATISTICAL ANALYSIS • In this analysis, 25 patients who received levothyroxine were included. At least 100 patients will be collected at the time of study completion • Descriptive statistics will be used to summarize the data.

PRELIMINARY CONCLUSIONS

Patients who are NPO for longer than 5 days Patients who are displaying symptoms of hypothyroidism: Fatigue, cold intolerance, weight gain, constipation, dry skin, myalgias Patients presenting with myxedema coma Patients with cardiogenic shock or low cardiac output

• Equivalent oral levothyroxine therapy would cost approximately $50 total, indicating the potential for $11,130 in cost savings

PRELIMINARY RESULTS

• Education must be provided to pharmacists on exclusions to the IV levothyroxine safe withholding protocol

Table 3. Baseline Characteristics (n = 25) Male, n (%) 3 (12) 61.5 + 15 Age (years, mean + SD) Race, n (%) African American 5 (20) Caucasian 16 (64) Hispanic 4 (16) History of hypothyroidism, n (%) 24 (96)

60%

OBJECTIVES

40%

• Pharmacists should be proactive in ensuring patients meet criteria for exclusion to protocol before verification of IV levothyroxine and discontinue orders for patients who are not in critical need

LIMITATIONS

Figure 1. Criteria for Exclusions to Protocol (n = 25) 56%

50%

30%

• Assess cost of noncompliance with automatic discontinuation protocol

20%

Retrospective nature of study and subjective, observational notation of hypothyroidism symptoms in electronic medical record

FINANCIAL DISCLOSURES The authors of this presentation have no disclosures concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation

32%

• Evaluate the utilization and appropriateness of IV levothyroxine

• 56% of patients who received IV levothyroxine did not meet criteria for exclusion to the safe withholding protocol (n = 14/25) • The total cost of IV levothyroxine therapy for the 14 patients who did not meet criteria for exclusion to protocol was $11,187.20

Life gift donor patients

• To ensure safe withholding of levothyroxine without adverse effects to the patient, exclusion factors to the protocol were defined (see Table 2). If the patient is still NPO (nothing by mouth) after five days, the pharmacist may re-order the IV levothyroxine at 50% of the PO levothyroxine dose

Table 1. Inclusion Criteria Age > 18 years Patients who received at least one dose of IV levothyroxine

Table 4. Total number of vials, total cost (cost per vial = $97.28) Appropriate therapy NPO for longer than 5 days 111 ($10,798.08) Symptoms of 3 ($291.84) hypothyroidism Myxedema coma 3 ($291.84) Inappropriate therapy No criteria met 115 ($11,187.20)

Patients who refuse to have their home dose withheld

• Because the half-life of levothyroxine in euthyroid patients on chronic levothyroxine is 6-8 days, continuation of levothyroxine in the IV formulation may not be indicated immediately in acutely ill patients • Intravenous levothyroxine is also cost-restrictive at $97.33 per 100 mcg vial, while oral (PO) levothyroxine costs $0.34-0.50 per 100137 mcg tablet

PRELIMINARY RESULTS

10%

REFERENCES

NPO longer than 5 days

Symptoms of hypothyroidism

Myxedema coma

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No criteria met

1. Dillmann, W. H. (1990). Biochemical basis of thyroid hormone action in the heart. The American Journal of Medicine, 88(6), 626-630. doi:10.1016/0002-9343(90)90530-q 2. Hunter, K. A., & Dormaier, G. K. (1995). Pharmacist-managed intravenous to oral step-down program. Clinical Therapeutics, 17(3), 534-540. doi:10.1016/0149-2918(95)80119-7

RESIDENT/FELLOW/POST-GRADUATE (PGY2) Impact of Real-Time Prescription Benefit Information at Point of Discharge on a Provider-Sponsored Health Plan T Roduta, D Vu, R Cox, D Wallace, S Abughosh Memorial Hermann Health System, University of Houston Houston, Texas Background: Prescription medications account for nearly 10% of national healthcare expenditures ($3.4 trillion in 2016). Appropriate medication prescribing may reduce costly complications, impacting overall healthcare costs. Limited knowledge of the cost of medications coupled with the dynamic nature of prescription insurance formularies makes it difficult to ensure prescribing of cost-effective drug therapy. Patients are often discharged on inpatient medications when therapeutically equivalent medications with lower out of pocket costs are available. Objective: The objective of this study is to evaluate the impact of prescription formulary status availability at the point of discharge on patients’ ability to acquire and remain adherent to medications. Methods: Memorial Hermann (MH) has implemented a tool that provides real time prescription benefit information for patients with prescription insurance available in the electronic medical record (EMR). A multicenter, retrospective cohort study of all covered lives under the provider-sponsored health plan treated in a MH inpatient facility from July 1, 2016 through December 31, 2016 was performed. Patients with prescription benefits available were compared to those without to determine percentage of preferred medications prescribed and time to first/second fill. Criteria for appropriate versus delayed procurement were defined. Results: 1,148 patients were included in the study. Majority of prescriptions prescribed regardless of benefit availability were preferred. However, non-formulary prescribing was higher when benefits were not available (12% versus 26%, respectively; p = 0.05). Conclusions: Real-time prescription benefit availability does not affect prescribing behavior for tiered/preferred meds. However, the tool significantly reduced the amount of non-formulary medications prescribed. Disclosures: The authors of this presentation have nothing to disclose Impact of Real-Time Prescription Benefit Information at Point of Discharge on a Provider-Sponsored Health Plan Thomas Roduta, PharmD1; Dominic Vu, PharmD1; Rodney Cox, RPh, MS1; David Wallace, PharmD2; Susan Abughosh, PhD2 Memorial Hermann Health System1; University of Houston2

BACKGROUND • Prescription medications account for nearly 10 percent of national healthcare expenditures, estimated to be $3.4 trillion in 2016.1 • The ability of federal and state governments, employers, and patients to pay is difficult to maintain due to rising healthcare costs.2 • Appropriate medication prescribing may account for a reduction in costly complications and readmissions, impacting overall healthcare costs.3

RESULTS

METHODS Inclusion • Patients treated in a MH inpatient facility between 7/1/16 – 12/31/16 • Enrolled in the health plan for at least 6 months post discharge

Exclusion • Patients discharged with no prescriptions • Refill prescriptions

20%

49% 57%

22% Medicare

Primary Endpoint

9% Available (M)

Not Available (M)

Available(C)

Not Available(C)

% with Tier 1 63% Percent of preferred Tier 2,3 25% meds prescribed Non-formulary 12% % Secondary Endpoint Metric with Appropriate < 72 hours 82% Time to first fill Delayed > 72 hours 18% 73% Appropriate Time to second fill (maintenance) Delayed/No Fill 27%

• Patients are often discharged on inpatient medications when therapeutically equivalent medications that are covered by prescription insurance with lower out of pocket costs are available.5

Length of Stay

PURPOSE

• At MH, prescription insurance is not consistently available in the EMR at point of discharge.

43%

Commercial

• Limited knowledge of the cost of medications coupled with the dynamic nature of prescription insurance formularies makes it difficult to ensure the most cost-effective drug therapy at point of prescribing.4

• Memorial Hermann (MH) has implemented a tool that provides real time prescription benefit information for patients with prescription insurance available in the electronic medical record (EMR).

Benefit Availability

Coverage Breakdown

Drug class

Ethnicity

Sex

Age

Anticoagulation Drug Class

Prescriber /Service Line Facility

Primary and Secondary Endpoints

Med History

Orthopedic Service Line

Metric

COPD/Asthma

Pulmonary

% w/o 58% 16% 26% % w/o 79% 21% 72% 28%

Antidiabetic

Endocrine

p 0.72 0.06 0.05 p 0.62 0.81 0.46 0.33 Other

Other

CONCLUSION • Real-time prescription benefit availability does not affect prescribing behavior for tiered/preferred meds

OBJECTIVE

Multivariate Analysis

• To evaluate the impact of prescription formulary status availability at the point of discharge on patients’ ability to acquire and remain adherent to medications

• However, the tool significantly reduced the amount of non-formulary medications prescribed

BASELINE CHARACTERISTICS

• Multivariate analysis demonstrates a strong correlation among drug class, prescriber/service line, patients’ ability to acquire/remain adherent, and total out-of-pocket costs.

• To decrease medication costs through optimized prescribing of preferred medications

STUDY DESIGN • A multicenter, retrospective cohort study of all covered lives under the provider sponsored health plan

Medicare Commercial Variable (n = 488) (n=660) Average # of scripts 6.53 3.85 Age (Range) 75 (59 – 93) 44 (26 – 72) Female/Male 306/182 228/432 Ethnicity - Caucasian 64% 49% Average Length 5 4 of Stay

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p 0.032 0.051 0.622 0.093 0.835

REFERENCES 1. Centers of Medicare and Medicaid Services. National Health Expenditures Projections 2016 – 2025 . 2017 2. Keehan SP, Poisal JA, Cuckler GA, et al. National Health Expenditure Projections, 2015 – 25: Economy, Prices, and Aging Expected to Shape Spending and Enrollment. Health Affairs. 35(8). 2016 3. Shrank WH, Hoang T, Ettner SL, et al. Prescribing Generic or Preferred Pharmaceuticals Improves Medication Adherence for Chronic Conditions. Arch Intern Med. 166(1):332-337. 2006 4. Ornstein SM, MacFarlane LL, Jenkins RG, et al. Medication Cost Information in a Computer-Based Patient Record System. Arch Fam Med. 8(1): 118-121. 1999 5. Yousif W, Elkomy S, Soliman, M, et al. Improving the accuracy of electronic prescribing in West Bay Health Center in Qatar. BMJ Quality Improvement Reports. 5(1), 2016 DISCLOSURE Authors of this presentation have nothing to disclose concerning possible financial or personal relationships with commercial entities that may have direct or indirect interest in the subject matter of the presentation.

STUDENT Operation Naloxone: Interprofessional Overdose Prevention Service Learning L Groff, K Nguyen, K Tun, T Nguyen, K Evoy, L Hill The University of Texas at Austin College of Pharmacy Austin, Texas Background: Opioid overdose is the fastest growing cause of death in the U.S. Operation Naloxone is an overdose prevention program in which students are trained and subsequently lead trainings related to opioid overdose response, including the proper use of the opioid reversal agent naloxone, and to increase access to naloxone within the community. Objective: The goals of this project were to: 1) conduct train-the-trainer sessions open to all University of Texas Health San Antonio (UTHSA) students; 2) provide trainings and naloxone supply for vulnerable populations; and 3) assess the training effectiveness. Methods: UT Austin College of Pharmacy faculty members led two trainings for UTHSA students. Trained students participated in three interprofessional, student-led overdose prevention trainings for drug rehab center residents and staff. Pre- and post-training surveys were administered to student and rehab center training attendees to evaluate the impact on knowledge and attitudes regarding naloxone use and the interprofessional learning experience. Results: 84 UTHSA students were trained to provide naloxone education. Student-led trainings reached 272 rehab center residents and staff. Results displayed a significant increase (61% vs. 76%, p<0.0001) in mean knowledge, self-efficacy (median 3.5 vs. 5, p<0.0001) and attitude on harm reduction scores (4 vs. 5, p<0.0001). Interprofessional competencies of student participants also significantly increased (median 6 vs. 7, p=0.002). Conclusion: Through this project, UTHSA students were trained to provide opioid education and subsequently led trainings for vulnerable populations in Bexar County regarding appropriate opioid overdose response, and naloxone was provided to three rehab centers. Disclosures: The project was funded by the Center for Medical Humanities & Ethics at UT Health San Antonio.

Operation Naloxone: Interprofessional Overdose Prevention Service Learning Lindsey Groff1,2, Kimberly Nguyen1,2, Khine Tun1,2, Thuy Nguyen1,2, Lucas Hill, PharmD, BCACP1, Kirk Evoy, PharmD, BCACP, BC-ADM, CTTS, BCPS1,2,3 1

The University of Texas Austin College of Pharmacy, Austin, TX; 2 The University of Texas at Austin College of Pharmacy and University of Texas Health Science Center School of Medicine, San Antonio, TX; 3 University Health System

Methods

Background Drug overdoses are the leading cause of death in Americans under 50 years of age

•

Deaths from opioid overdose are rising rapidly

•

Among 9 largest TX counties, Bexar county had third highest rate of opioid overdose deaths

•

Naloxone can reverse an opioid overdose but it must be administered in a timely fashion for its life-saving potential

•

Unfortunately naloxone awareness, access and training are lacking and many overdose patients do not receive treatment

•

Operation Naloxone is an innovative overdose prevention program initiated at the University of Texas at Austin

•

It utilizes a “train the trainer” model in which healthcare students are prepared to train healthcare workers and community members to respond to opioid overdose

•

Training includes information regarding opioids, response to an overdose, and proper administration of naloxone

•

The goals of this CSL grant project were threefold: 1.

Lead train-the-trainer sessions, open to all UT Health San Antonio (UTHSA) students in order to equip these students with the knowledge necessary to appropriately administer naloxone and train others

Trained students including UTHSA healthcare students and UT Austin pharmacy students participated in three interprofessional, student-led overdose prevention trainings for residents, clients and staff at local drug rehabilitation centers, Lifetime Recovery and Alpha Home

The training presentation included the following: •

Background information on opioid overdose epidemic

•

Overdose risk factors

•

Opioid overdose prevention

• •

Objective

UT Austin College of Pharmacy faculty members led two trainings for students from multiple healthcare disciplines at UTHSA

•

Appropriate overdose response Naloxone access laws

Demonstration of naloxone administration technique for various naloxone formulations Small group case-based review sessions facilitated by students A stock of Nacran® Nasal Spray was provided to each training site

Conduct interprofessional, student-led trainings and provide naloxone supply for vulnerable populations in Bexar county

Assess the effectiveness of the trainings on trainee knowledge of opioid overdose prevention and perceptions on harm reduction

Evaluation

Figure 1. Student Participant Demographics Baseline Demographics Age, years < 25 25-34 45-54 >65 Gender Male Female Race/Ethnicity African American Asian Caucasian Hispanic/Latino Professional Affiliation College of Pharmacy Graduate School of Biomedical Sciences School of Health Professions School of Medicine School of Nursing Others

n (%), N = 41 21 (51) 17 (42) 1 (2) 2 (5)

15 (37) 26 (63)

1 (2) 9 (22) 20 (49) 11 (27)

2 (5) 1 (2) 8 (20) 23 (56) 4 (10) 3 (7)

Figure 2. Student Training Survey Pre-training (N = 43)

Post-training (N = 31)

P value

Knowledge, mean (SD) Self-efficacy, median (IQR)

50.8% (16%)

75.0% (14%)

< 0.001

2.75 (1.5)

4.5 (1)

< 0.001

Attitude, median (IQR) Interprofessional learning, median (IQR)

4.5 (1)

5 (0.9)

0.10

5 (1)

5 (0)

0.12

•

Baseline Demographics Training Facilities Alpha Home Lifetime Recovery Inpatient Center Lifetime Recovery Outpatient Center Age, years < 20 20-30 31-40 41-50 51-60 >60

n (%), N = 142 26 (18) 81 (57) 35 (25) 3 (2) 50 (35) 49 (35) 22 (15) 13 (9) 5 (4)

Gender Male Female Race/Ethnicity African American Caucasian Hispanic/Latino Others

94 (67) 47 (33) 11 (8) 48 (34) 79 (56) 4 (2)

Figure 4. Community Participants Demographics

For more information or a reprint, please contact Lindsey Groff via email at groff.lindsey@utexas.edu

Pre-training (N = 138) 61.4% (24.5%)

Post-training (N = 125) 76.2% (20.4%)

P value < 0.0001

Self-efficacy, median (IQR)

3.5 (2)

5 (1)

< 0.0001

Attitude, median (IQR)

4 (1.5)

5 (1)

< 0.0001

Interprofessional student-led training at Lifetime Recovery

Participants at student and drug rehabilitation center trainings completed surveys before and after the trainings. Surveys assessed the following: Knowledge related to opioid overdose and naloxone use (multiple choice question)

Self-efficacy regarding opioid overdose response based on five point Likert scales (1 = strongly disagree to 5 = strongly agree) Attitudes on harm reduction based on five point Likert scales (1 = strongly disagree to 5 = strongly agree) Interprofessional learning experience based on five point Likert scales (1 = strongly disagree to 5 = strongly agree) Interprofessional collaborative competencies attainment based on seven point Likert scales (1= strongly disagree to 7 = strongly agree)

Statistical Analyses •

Figure 3. Community Participants Demographics

Knowledge, mean (SD)

Pharmacy students conducting small group discussion at student trainings at UTHSA

•

Categorical variables were analyzed using x2 test

Continuous variables were analyzed using the unpaired or paired t test or Mann Whitney U test or Wilcoxon Signed Rank test All analyses were performed using SPSS 23.0® (IBM Crop, Armonk, NY, USA)

Figure 5. Interprofessional Competencies Attainment Survey

Total score, median (IQR)

Pre-training (N = 17)

Post-training (N = 17)

P value

6 (1)

7 (0)

0.002

Conclusion •

•

UTHSA students were trained to provide opioid overdose prevention education and subsequently led community trainings for vulnerable populations in Bexar County Post-community training surveys revealed improved knowledge and attitudes regarding opioid overdose and naloxone use The participating students at community trainings gained valuable interprofessional collaboration experience This “train the trainer” model proved to be an effective and valuable approach for the communities and participating healthcare students in order to deliver opioid overdose prevention education and increase naloxone access to those communities Funding provided by Center for Medical Humanities & Ethics at UT Health San Antonio

TSHP JOURNAL

TECHNICIAN Medication Compliance in Patients Admitted through a Community Hospital Emergency Room RA Ijax, EM Veltz, RA Forbess Houston Methodist Willowbrook Houston, Texas Background: Medication compliance is important both in determining good treatment outcomes and influencing healthcare costs. Studies have been conducted that have shown that non-compliance leads to adverse events, hospitalization and increased healthcare costs. They have also shown that compliance can improve treatment outcomes. Objectives: The objective of this project was to assess non-compliance in patients presenting to the emergency department of a community hospital over a 3-month period. Method: In the process of completing medication histories to facilitate physician admission reconciliation, the pharmacy technicians involved in this project completed a separate form documenting whether the patient was taking their medications as directed. If the patient was non-compliant with their medications, the medication reported was documented along with the reason cited for non-compliance. Emergency room visit and/or hospitalization within the previous 30 days was also assessed and documented for each patient. Results: A total of 905 patients were evaluated over the 3-month period, 743 of which were new admissions and 162 readmissions. Approximately 90-percent of the new admissions and 85-precent of readmissions were found to be compliant with their prescribed medication therapy. The most frequent medications that patients reported not taking as prescribed were cardiac, psychiatric/neurological and antidiabetic medications. Conclusions: The number of patients who were non-compliant with their medications was found to be approximately ten-percent, which was lower than expected based on the literature. There was a higher percentage of readmitted patients that were found to be non-compliant. Disclosures: RA Ijax has nothing to disclose. EM Veltz has nothing to disclose. RA Forbess has nothing to disclose.

MEDICATION COMPLIANCE IN PATIENTS ADMITTED THROUGH A COMMUNITY HOSPITAL EMERGENCY ROOM RA Ijaz, BS, CPhT, EM Veltz, CPhT, and RA Forbess PharmD, PhD Pharmacy Department, Houston Methodist Willowbrook Hospital, Houston, TX

Background Medication compliance is important both in determining good treatment outcomes and influencing healthcare costs. Medication compliance has been defined as a patient adhering to the directions prescribed by the provider for dose, frequency and timing. 1 When looking at adverse drug events leading to hospitalization, patient noncompliance was attributed with thirty-three percent of preventable causes in one review and as high as sixty-nine percent in another. 2,3 In 2012, Dr. Regina Benjamin, Surgeon General of the United States, estimated that approximately greater that 100,000 deaths per year could be attributed to non-compliance with estimated direct and indirect cost of $100 to $300 billion per year.4 In addition to increasing healthcare costs, patient noncompliance has also been shown to negatively affect treatment outcomes as well.5,6,7 A metaanalysis conducted to review research on patient adherence looked at more than 19,000 patients and found that patients were most likely to experience good outcomes when they adhered to treatment regimens. 8

The medications that were identified as being taken incorrectly are shown in Table 1. The most common medications reported were cardiac related drugs (40%), psychiatric/neurological drugs (21%), and antidiabetic drugs (10%). The remaining medications included antibiotics, respiratory drugs, anti-inflammatory drugs, antiparkinsonian drugs, steroids, etc. (Figure 3).

Table 1. Classification of medications identified as being taken incorrectly by interviewed patients

Categories Antibiotics

Objective The objective of this project was to assess non-compliance in patients presenting to the emergency department of a community hospital over a 3month period. During the admission process, data was collected on whether patients had been taking their medications as prescribed by the physician. If the patient was non-compliant, the medication reported was documented along with the reason cited for non-compliance. In addition, it was assessed if the patient had previously presented to the emergency room or other care facility within the last 30-days to see if trends exist in readmission of patients.

Method Currently, pharmacy technicians interview patients who are admitted to the hospital through the emergency department to obtain medication histories in order to facilitate accurate and timely medication reconciliation by admitting physicians. In the process of obtaining the medication history from the patient, the technicians involved in this project also completed a separate form documenting whether the patient was taking their medications as directed by the physician. If the patient was non-compliant, the medication reported was documented along with the reason cited for non-compliance. Emergency room visit and/or hospitalization within the previous 30 days was also assessed and documented for each patient. At the end of the 3-month period, the number of patients taking their medications differently from the prescribed directions were compared to the number of patients taking their medications correctly, and readmission rates were looked at between the two groups. In addition, medications that were identified as being taken differently than prescribed were categorized into therapeutic class to examine potential trends.

Cardiac

Antidiabetic Agents

Classification of Drugs Fluoroquinolones

Drug Name Ciprofloxacin, Levofloxacin

Tetracyclines

Doxycycline

Anticoagulant/ Antiplatelet

Clopidogrel, Warfarin, Rivaroxaban, Amiodarone

Nitrates Angiotensin-converting-enzyme inhibitor/Angiotensin receptor blocker

Calcium Channel Blockers

Isosorbide Dinitrate Lisinopril, Hydralazine, Losartan potassium, Valsartan, Sacubitril/valsartan, Telmisartan Carvedilol, Metoprolol Succinate, Metoprolol Tartrate, Atenolol Nifedipine

Diuretics

Furosemide, Hydrochlorothiazide,Spironolactone

Glycoside

Digoxin

Statins

Atypical Antidepressants

Rosuvastatin, Atorvastatin, Simvastatin Metformin, Canagliflozin/metformin, Glimepiride, Glipizide Exenatide extended-release, Insulin aspart, Insulin glargine Bupropion, Quetiapine

Anti-Convulsants

Oxcarbazepine, Gabapentin, Levetiracetam, Pregabalin

β -Blockers

Biguanides/ Sulfonylureas Pancreatic Islets hormones

Psychiatric/ Benzodiazepines Neurological Serotonin & Norepinephrine reuptake inhibitors/ Selective serotonin reuptake inhibitors Other Anxiolytic Drugs Bronchodilator/ Bronchodilator Respiratory Corticosteroid/ Leukotriene receptor antagonists Anti-inflammatory/ Analgesics

Others

Alprazolam, Chlordiazepoxide Citalopram, Fluoxetine, Escitalopram, Sertraline, Duloxetine Buspirone Ipratropium bromide/albuterol sulfate, Albuterol, Fluticasone/Salmeterol, Montelukast, Mometasone/Formoterol Hydrocodone/Acetaminophen, Celecoxib

Electrolyte/ Vitamins/ Renal Agents

Potassium Chloride, Calcium Acetate, Ergocalciferol

Antiparkinsonian Agents

Benign Prostatic Hyperplasia

Ropinirole, Benztropine Hydrocortisone, Levothyroxine, Prednisone, Triamcinolone Tamsulosin, Finasteride

Antimetabolites/ Immunosuppresives

Methotrexate, Cyclosporine Ophthalmic Emulsion

Anticholelithic/ Anticholinergics

Oxybutynin, Dicylomine, Ursodiol

Steroids/ Hormones

Figure 3. Percentage of medications by class reported as being taking incorrectly

Results A total of 905 patients were evaluated over the 3-month period, 743 of which were new admissions and 162 readmissions. Approximately 90percent of the new admissions and 85-precent of readmissions were found to be compliant with their prescribed medication therapy (Figure 1).

Figure 4. Reasons given for patients taking medications incorrectly

Antibiotics

Cardiac

18%

Diabetic

Figure 1. Breakdown of patients medication compliance and readmission

40% 21%

Psychiatric/Neurological Others

10%

Respiratory

Various reasons were stated by patients for their non-compliance. Misunderstanding the directions and side effects constituted 43-percent of the recorded reasons for non-compliance. Forgetting to take their medication, not wanting to take the medication, running out of refills, cost and not thinking the medication was working were among the other reasons stated by the patients for non-compliance (Figure 4).

TSHP JOURNAL

Conclusions Based on previous literature and background, it was expected that the number of patients who were non-compliant with their medications would be higher, but was found to be approximately ten-percent. One potential factor for this low number may be the fact that this project relied on patient self-reporting during the data collection phase. This makes the data subjective to the patient’s verbal history versus using an objective measure such as refill adherence and/or drug monitoring. In the patients interviewed for the project, there was a higher percentage of non-compliance seen in the readmitted patients versus the patients newly presenting to the emergency room which is consistent with the literature reviewed. 2,3

Future Steps •

Examine specific factors that can influence compliance to see if there is a correlation, i.e. age, complexity of drug regimen, number of medications, etc.

•

Identify specific patient populations that may benefit from inpatient pharmacy follow-up and determine effect on readmission

References 1. Cramer JA, Roy A, Burrell A et al. Medication compliance and persistence: terminology and definitions. Value in Health. 2008; 11:44-47. 2. McDonnell PJ, Jacobs MR. Hospital admissions resulting from preventable adverse drug reactions. Ann Pharmacother. 2002; 36:1331-1336 3. Senst BL, Achusim LE, Genest RP et al. Practical approach to determining cost and frequency of adverse drug events in a health care network. Am J Health Syst Pharm. 2001; 58:1126-32. 4. Benjamin RM. Medication adherence: helping patients take their medicines as directed. Public Health Rep. 2012; 127(1):2-3. 5. Hoorn R, Jaramillo E, Collins D et al. The effects of pyscho-emotional and socioeconomic support for tuberculosis patients on treatment adherence and treatment outcomes – a systemic review and meta-analysis. Hozbor DF, ed. PloS ONE. 2016; 11(4):e0154095.doi:10.1371/journal.pone.0154095 6. Cramer JA, Benedict A, Muszbek N et al. The significance of compliance and persistence in the treatment of diabetes, hypertension and dyslipidaemia: a review. Int J Clinical Practice. 2008;62(1):76-87. 7. Li BDL, Brown WA, Ampil FL et al. Patient compliance is critical for equivalent clinical outcomes for breast cancer treated by breast-conservation therapy. Ann Surgery. 2000;231(6): 883-889. 8. Dimatteo MR, Giordani PJ, Lepper HS et al. Patient adherence and medical treatment outcomes. A meta-analysis. Medical Care. 2002; 40(9):794-811.

Disclosures Authors of this presentation have the following to disclose concerning possible financial or personal relationships with commercial entities that may have direct or indirect interest in the subject matter of this presentation.

• Ruby Ijaz: Nothing to disclose • Edith Veltz: Nothing to disclose • Reba A. Forbess: Nothing to disclose

DATE

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enter enter

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Your support has impacted so many. Your continuted contribution will help many more. Since 1977, the TSHP R&E Foundation has been helping the future of pharmacy in Texas – students, practitioners, technicians, and leaders. With each passing year, the need increases. A student at a typical state-supported college of pharmacy pays: • $10,000 per semester for tuition and fees • An average of $250 per book • Approximately $1,200 per month for a dorm room

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scholarship Pharmacists allowed me to– focus on my Official Publication of the Texas Society of“The Health-System R&E Foundation studies and become more involved with my local and state chapter.” Rema Thyagarajan, PharmD, BCPS System Clinical Director of Pharmacy

TSHP JOURNAL

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TSHP MEMBER RECOGNITION 2018 Award Recipients

GLENDA LAWSON MCREE PHARMACY STUDENT AWARD

LARRY C. NESMITH PHARMACIST RECOGNITION AWARD

Laura Roccograndi

Reba A. Forbess, PharmD, PhD

Laura earned her Bachelor’s Degree from the George Washington University and worked as a cancer researcher at the University of Pennsylvania before enrolling at the University of Texas at Austin College of Pharmacy. As a third year student at the University of Texas, Laura is a member of the Rho Chi Honor Society as well as the Senate Representative for the College’s student government. Additionally, she currently serves on the Public Affairs & Advocacy Council for Texas Society Health-System Pharmacists. She has also served as TSHP Student Section Chair, the President for the University of Texas’s Student Society Health-System Pharmacy, and as the Chair of the Policy and Legislative Advocacy Advisory Group for the American Society of Health-System Pharmacists. For the past two years, Laura has worked as a Pharmacist Intern at the Dell Seton Medical Center. In these roles, Laura has a demonstrated her commitment to research, service, education and advocacy. Following pharmacy school, Laura hopes to pursue a career in Oncology Pharmacy.

LEO F. & ANN GODLEY RESIDENCY FELLOWSHIP AWARD Devlin V. Smith, PharmD

Devlin V. Smith is a 2016 graduate of the University of Tennessee College of Pharmacy. She is currently completing a Health-System Pharmacy Administration residency at MD Anderson Cancer Center in Houston, TX. Devlin is involved in multiple pharmacy organizations, including ASHP, TSHP (New Practitioner Section Committee Member), GCSHP, the Pharmacy Administration Resident Collaboration (Executive Council Member), and Phi Delta Chi. She also strives to stay fully engaged in developing the next generation of pharmacy leaders through mentorship and guidance of students at the University of Houston and the University of Tennessee College of Pharmacy. Her professional interests include health-system administration, oncology pharmacy management, strategic planning, and quality improvement science.

Reba Forbess completed the dual degree program at the University of Tennessee Health Science Center in Memphis, TN, receiving her Doctor of Pharmacy degree in 1997 and her Doctor of Philosophy degree in 1999. She worked as Clinical Supplies Manager/ Senior Scientist at Schering-Plough Healthcare Products and as a Clinical Pharmacist at several hospitals prior to moving to Houston in 2010. She currently works as a Clinical Pharmacist at Kingwood Medical Center and as a Pharmacist at Houston Methodist Willowbrook Hospital specializing in transitions of care. She serves as Secretary for the TSHP Communications and Marketing Council and as Member-at-Large for GCSHP heading the Council on Membership. She is also actively involved with Houston Childrens’ Charity.

LEWIS S. SMITH PHARMACY PRACTITIONER AWARD Christina Lane Tan, PharmD, BCPS

Christina Tan was born in Denver, CO, and raised in various countries, including Norway, Australia, Thailand, and the United States. She graduated Summa Cum Laude with a Bachelor of Science in Chemistry from Arcadia University in Glenside, PA, in 2006, and graduated Summa Cum Laude with a Doctor of Pharmacy degree from the University of Houston College of Pharmacy in Houston, TX, in 2012. She has been a clinical pharmacist at Kingwood Medical Center since 2013, and is a lead pharmacist for the neonatal intensive care, pediatric, and women’s units.

MIKE KNAPP PHARMACY TECHNICIAN AWARD Faith Burnett Rutherford, CPhT

Faith has been a serving the Kingwood area for 16 years as a pharmacy technician at Kingwood Medical Center. She has performed in and helped develop all technician roles Kingwood Medical Center has. Her passion for pharmacy and the advancement of the pharmacy technician profession shines when speaking with colleagues about being a pharmacy technician and the possibilities the technician role has to offer. TSHP JOURNAL

RESIDENCY PROGRAM EXCELLENCE AWARD Houston Methodist Hospital PGY1/PGY2/MS Health-System Pharmacy Administration Residency

The Houston Methodist Hospital (HMH) Postgraduate Year One (PGY1)/Postgraduate Year Two (PGY2)/Master of Science (MS) Health-System Pharmacy Administration Residency is a 24-month pharmacy residency training program that is offered concurrently with an MS degree in Pharmacy Leadership and Administration from the University of Houston College of Pharmacy. HMH is proud to be one of seven Texas Medical Center institutions that comprise “The Houston Program,” a premier platform dedicated to developing influential pharmacy leaders through the concurrent 24-month residency/Master’s Degree model. Residency training has played a significant role at the Houston Methodist Hospital (HMH) since 1987 when HMH supported one, two-year Hospital Administration resident. Today, HMH offers a total of nine post graduate training programs in the form of residencies and a fellowship program, accepting a total of up to 20 residents and two fellows each year. The current HMH PGY1/PGY2/MS Health-System Pharmacy Administration (HSPA) Residency began in 2009, initially onboarding one resident per year. The purpose of the program is to develop pharmacy leaders by providing the administrative and clinical skills necessary to lead a large health-system pharmacy or other healthcare organization in advancing patient care. The HSPA residency combines both a didactic and practical learning environment to train the pharmacy profession’s future leaders. Being a 24-month program, the first HSPA resident graduated in 2011. Due to the program’s success, HMH expanded the program to onboard two residents each year (for a total of four residents) in 2014. The program has had eight graduates, each of whom are leading in health care organizations throughout the United States. HMH, and specifically the PGY1/PGY2/ MS HSPA Residency Program is honored to be selected as the recipient of the 2018 TSHP Residency Program Excellence Award.

TSHP MEMBER RECOGNITION 2018 Award Recipients

NEW PHARMACIST AWARD

Linda Paul, PharmD, BCPS

Sara Wettergreen, PharmD, BCACP

Linda Paul received her Doctor of Pharmacy from The University of Incarnate Word - Feik School of Pharmacy in San Antonio, Texas. She did a PGY1 Pharmacotherapy Residency with Baptist Health System in San Antonio. She is current working at Baptist Health System as the Transitional Care Pharmacist for the San Antonio market of Tenet Health care. She is a Board Certified Pharmacotherapy Specialist and her areas of interest include ambulatory care, internal medicine and infectious disease. She was the president of Central Texas Society of Health-System Pharmacist.

PHARMACY LEADERSHIP AWARD Kevin Purcell, MD, PharmD, MHA

Kevin is a member of the regional pharmacy management team for Baptist Health System, which has six hospitals in the San Antonio area. He oversees the neonatal and pediatric pharmacy operations, antimicrobial stewardship program, clinical pharmacy services, pharmacy internship and residency training programs, academic partnerships, and pharmacy peer review committee. Kevin has a wide variety of experiences including pharmacy operations, clinical services, pharmacy and medical education, epidemiology and outcomes research related to pediatric infectious diseases, pharmacy program administration, business consulting, and leadership development and coaching. He has worked in various healthcare settings including freestanding children’s hospitals, health systems, universities, military bases, community pharmacies, psychiatric hospitals, long-term care pharmacies, and sole proprietorships. He also is a Past President of TSHP. He enjoys playing basketball, fishing, country-western dancing, barbequing, and watching westerns and martial arts movies. His wife Tram is also a hospital pharmacist.

Dr. Sara Wettergreen attended South Dakota State University, where she obtained her Bachelors in Pharmaceutical Science degree in 2012 and Doctor of Pharmacy degree in 2014. She completed her PGY1 Pharmacy Practice residency at the Michael E. DeBakey VA Medical Center in Houston, Texas and PGY2 Ambulatory Care residency at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. Dr. Wettergreen practices in an academic medical center with a clinic site in family medicine. She is dedicated to development and expansion of clinical pharmacy services. Over the past year, she has served as New Practitioner Liaison for the MSHP chapter, member of the TSHP New Practitioner Committee, and vice-chair of the TSHP Communications Council. She is passionate about professional organization service and encourages students to get involved as well.

PHARMACY MENTOR AWARD

INNOVATIVE COLLABORATIVE PRACTICE AWARD Memorial Hermann MSO-ISD Interlock Team

The creation of a clear work process in which the Medication Safety Officers from each of the Memorial Hermann Health System hospitals in collaboration with the Memorial Hermann Medical Informatics Team could review and approve requested changes to the electronic health record designed to improve medication safety. These changes include the creation of new rules and alerts, including drug route checking and dose range checking, as well discontinuing “nuisance alerts” that were responsible for significant alert fatigue.

Sondra Davis, PharmD, BCPS

Sondra Davis, PharmD, BCPS is the Residency Program Director and the Clinical Operations Specialist at Medical City Arlington. She earned her Doctor of Pharmacy degree from Midwestern University College of Pharmacy in Glendale, Arizona. Dr. Davis was pivotal in starting a new residency program where she is able to share her experience, knowledge and skills with new practicing pharmacists. Dr. Davis is dedicated to teaching excellence in the pharmacy profession as she precepts and guides over 20 students annually who are completing their advanced and introductory pharmacy practice experience rotations. Her passion for the profession is also evident as she supports and guides the clinical pharmacists at Medical City Arlington. In addition to mentoring students and residents, she serves on the Membership Development and Professional Affairs Councils for TSHP and the Section of Inpatient Care Practitioners Advisory Group on Pharmacy Practice Experiences for ASHP.

TSHP JOURNAL

Sara Wettergreen, PharmD, BCACP (middle), is presented the New Pharmacist Award by TSHP President-Elect Steven Knight, RPh, PharmD, BCPS (left) and TSHP President Tammy Cohen, PharmD, MS, FACHE, FASHP, FTSHP (right) at the 2018 TSHP Annual Seminar Welcome Session, April 6 in The Woodlands, TX.

TSHP MEMBER RECOGNITION 2018 Award Recipients

TSHP PHARMACIST PRACTITIONER RECOGNITION FELLOWS PROGRAM In 2012, the TSHP Board of Directors approved establishment of a unique Practitioner Recognition Program modeled after the ASHP Fellows program to recognize pharmacists who have made significant and sustained contributions to the Texas Society of Health-System Pharmacists and the profession. Through these presentations, we hope to honor excellence in health-system pharmacy practice and promote public awareness of pharmacists who have distinguished themselves in practice. At the 2013 Annual Seminar, the initial class of TSHP Fellows was recognized. A list of all past recipients can be found at www.tshp.org/fellows. At the 2018 TSHP Annual Seminar, we recognized our 2018 Class of TSHP Fellows.

FTSHP CLASS OF 2018 Lourdes M. Cuéllar, MS, RPh, FASHP

Títle: Administrative Director of Pharmacy Company: TIRR Memorial Hermann (TIRR) City: Houston, TX

Lourdes (Lou) M. Cuéllar serves as Administrative Director of Pharmacy at TIRR Memorial Hermann (TIRR) in the Texas Medical Center in Houston. She received her degree in Pharmacy and Masters in Pharmacy Administration from the University of Houston. She is a Past President of Texas Society of Health-System Pharmacists & Gulf Coast Society of Health-System Pharmacists, & past President and Chair of the TSHP R&E Foundation. Ms. Cuellar has also served and led several ASHP and TSHP councils, committees and task forces. She is currently serving on the Texas Statewide Health Coordinating Council by appointment from former Governor Perry. She is an adjunct Clinical Professor of Pharmacy Practice at the University of Houston & the University of the

Incarnate Word & serves as a preceptor for students & administrative residents. Ms. Cuellar has been the recipient of several leadership awards including the TSHP Distinguished Service Award and preceptor of the year award. The TIRR Pharmacy Department has been the recipient of the TSHP Collaborative Practice Award and the University of Houston Health-System Preceptor Site of the Year Award. TIRR pharmacists have been recipients of five Preceptor of the Year awards. Her professional interests are in pharmacy practice leadership & management, leadership development, health policy and advocacy, & alleviation of health disparities. Ms. Cuellar is an author and co-editor of the ASHP Preceptor’s Manual. She is recognized as a Fellow of ASHP.

Bradi L. Frei, PharmD, MSc, BCPS, BCOP

Bradi L. Frei, PharmD. MSc, BCPS, BCOP is an Associate Professor at University of the Incarnate Word and a Clinical Oncology Specialist at Mays Cancer Center at UT Health San Antonio since 2007. She is a graduate of The University of Texas at Austin College of Pharmacy. After earning her PharmD, she completed a combined Master’s Degree and specialty pharmacotherapy residency. Her areas of focus include breast cancer, palliative care, pain management, and gastrointestinal cancer. During her career at UIW, she

has presented at national meetings and published numerous papers and posters, including the Best Clinical Poster at TSHP Annual Seminar in 2013. Over the years, she has been involved in and held several leadership positions in several professional organizations, including ACCP, AACP, ASHP, TSHP, and CTSHP. She has served as president of CTSHP in 2011 and is currently serving as treasurer of TSHP Research and Education Foundation since 2015. Títle: Associate Professor\Clinical Oncology Specialist Company: University of the Incarnate Word\ Mays Cancer Center, UT Health City: San Antonio, TX TSHP JOURNAL

TSHP RESEARCH & EDUCATION FOUNDATION 2018 Scholarship Recipients

Paul Priebe - Texas Tech University Health Science Center School of Pharmacy TSHP Research & Education Foundation Arthur L. Davis Pharmacist Scholarship

Peter McKee - University of North Texas Health Science Center College of Pharmacy TSHP Research & Education Foundation Grace Dyan Coggin MSHP Memorial Scholarship

Lydia Halim Girgis - Texas Tech University Health Science Center School of Pharmacy TSHP Research & Education Foundation Metroplex Society of Health-System Pharmacists Scholarship

Austin Green - University of Texas College of Pharmacy TSHP Research & Education Foundation Austin Area Society of Health-System Pharmacists Scholarship

Anh Thu Tran - Texas A&M University Health Science Center Irma Lerma Rangel College of Pharmacy TSHP Research & Education Foundation Gulf Coast Society of Health-System Pharmacists Leadership Scholarship

Hayden Stewart - Texas Tech University Health Science Center School of Pharmacy TSHP Research & Education Foundation Michael Patry/Texas Tech University Health Sciences Center School of Pharmacy EPASHP Memorial Scholarship

Mary Tran - Texas Southern University College of Pharmacy & Health Sciences TSHP Research & Education Foundation Celso and Matiana M. Cuéllar Sr. Scholarship

Laura Roccograndi University of Texas College of Pharmacy TSHP Research & Education Foundation James T. Doluisio Scholarship

Bradley Endres - University of Houston College of Pharmacy TSHP Research & Education Foundation Micheline & Bourjois Abboud Scholarship

Lauren Laserna - Texas A&M University Health Science Center Irma Lerma Rangel College of Pharmacy TSHP Research & Education Foundation Eustacio Galvan Memorial Scholarship

Elizabeth Anatrella University of the Incarnate Word Feik School of Pharmacy TSHP Research & Education Foundation Jon Peyton Hudlow & Mark Tamble Memorial Scholarship

Niaz Deyhim - Texas A&M University Health Science Center Irma Lerma Rangel College of Pharmacy TSHP Research & Education Foundation Phyllis B. Ginsburg Memorial Scholarship

Susie Park - Texas Tech University Health Science Center School of Pharmacy TSHP Research & Education Foundation Gene Lake Scholarship

Pablo Saenz - University of the Incarnate Word Feik School of Pharmacy TSHP Research & Education Foundation Lourdes M. Cuéllar/ University of the Incarnate Word/El Paso Society of HealthSystem Pharmacists Scholarship

Mohammad Adil - University of Texas College of Pharmacy TSHP Research & Education Foundation Robert G. Leonard Memorial Scholarship

Jesus Camacho - University of Texas at El Paso School of Pharmacy TSHP Research & Education Foundation The University of Texas at El Paso School of Pharmacy/El Paso Society of Health-System Pharmacists Scholarship

Aimen Naveed - University of Houston College of Pharmacy TSHP Research & Education Foundation Glenda Lawson McRee Scholarship

www.tshp.org/scholarships

www.tshp.org/contributions TSHP JOURNAL

TSHP

Career Center

Connecting Talent with Opportunity

www.tshp.org/cc Authorship The Texas Society of Health-System Pharmacists Editorial Advisory Board welcomes manuscripts from any source that are pertinent to the practice of pharmacy in hospitals and health systems. Manuscripts are subject to review by the Editorial Advisory Board and Editor(s) and will be accepted for publication only if they are believed to represent an important contribution to the literature. Authors should follow the procedure checklist and submission instructions at www.tshp.org/journal. Authors without internet access may mail one (1) copy of their manuscript and a USB flash drive containing the manuscript file and supporting material to TSHP Journal, 3000 Joe DiMaggio Blvd, Ste 30A, Round Rock, Texas 78665-3920. Authors may call (512) 906-0546 for assistance. Accepted materials may not be published elsewhere without written permission from both the author and TSHP. The Editor(s) reserve the right to revise all manuscripts submitted, if necessary. The publisher assumes no responsibility for the statements and opinions advanced by contributors to the TSHP Journal. For guidance on style, authors should consult the manuscript checklist, recent issues of the TSHP Journal and American Journal of Health-System Pharmacy, and Scientific Style and Format: The CBE Manual for Authors, Editors, and Publishers, 6th edition. The AMAâ&#x20AC;&#x2122;s Manual of Style contain helpful advice on correct usage. The views expressed by authors of contributions in the TSHP Journal do not necessarily reflect the policy of TSHP or the institution with which the author is affiliated, unless otherwise specified. Authors, reviewers, Editorial Board members, and TSHP Journal Editors are required to declare potential conflicts of interest regarding manuscripts submitted for publication. TSHP JOURNAL

2019

TSHP 2019 Annual Seminar

Career & Residency Showcase CONNECT EXPLORE PREPARE

Friday, April 12 1:00-3:00 PM | Frisco, TX www.tshp.org/showcase TSHP JOURNAL