First Issue 2021 Award-Winning Quarterly Publication of the Arkansas Pharmacists Association
COVID Vaccine Q&A Five Pharmacies Discuss the COVID Vaccine, How Their Workflows Changed, and What They Learned Along the Way
THE ARKANSAS PHARMACIST
Dear Colleagues, The Arkansas Pharmacists Ass ociation (APA) is your profess years, we have been looking ional statewide organization after the interests of Arkansas and for the past 138 pharmacists. Today, I want to your professional future by rene personally invite you to invest wing your APA membership in in 202 1. It's safe to say that no one cou ld have expected 2020 to unfo January with the United States ld the way it did. What started off as Supreme Court’s decision to celebratory in hear Arkansas’s pharmacy cas transitioned by March into unfa e Rutledge v PCMA quickly miliar and dangerous territor y with the onslaught of the CO throughout Arkansas, pharma VID-19 global pandemic. Yet cists and other healthcare pro fessionals stood steadfast and challenge of serving in a bra resilient, stepping up to the nd-new world and putting thei r lives on the line to protect patients. the health and wellbeing of thei r At the Arkansas Pharmacists Association, we pushed forw all the pharmacists of Arkans ard with an unw avering support for our mem as as we tirelessly strove to be bers and your central resource for CO and regulations. As the pandem VID-19 information, guidelines, ic continued to sweep across the state, APA faced further adv destroyed the Arkansas Pha ersity as a tragic fire in June rmacists Association offices in Little Rock. Before the smo members from around the stat ldering ashes could die dow e began calling and messaging, n, volunteering their time, money the Association get back on its , and elbow grease to help feet. 2020 was undoubtedly one of the most challenging years we has been there to fight and adv will ever remember, and every ocate for our profession. Des step of the way APA pite tragedies, hardships, and successful year and were rem immense challenges, we had inded of an unshakeable trut a h – none of APA’s success wou Now we are more than a month ld be possible without you. into the new year, and it is clear that 2021 will be another spotligh The key to success is your con t year for Arkansas pharmacist tinued membership in APA, fina s. ncial support, and professiona valuable time and presence so l engagement through your that we can keep advocating on your behalf. A few of APA’s successes in 2020-2021 include : • As Arkansas came face to face with the pandemic, APA quickly pivoted to become you Through our COVID Resources r central COVID-19 resource webpage and daily COVID ema . il update, we strove to keep the steadily changing flood of our members informed of information. As PPE became a commodity and worldwide with third-party companies to shortages ensued, we worked secure shipments of vital mas ks for Arkansas pharmacists compounding pharmacies to and teamed up with local produce essential hand sanitize r. • As the year rolled on, APA ente red uncharted territory as we shifted our annual events to an line with social distancing req online platform to keep in uirements. The Hosto Confere nce Center was transformed enjoyed an ambitious schedu into APA Studios as members le of events including the APA Virtual Summer Seminar, online with Arkansas pharmacy lead Regional Meetings, townhalls ers, a live Q&A with Governor Asa Hutchinson, the first eve Awards Show, student pharma r APA Excellence in Pharmacy cists’ pinning ceremonies and graduation celebrations, and • With two vaccines arriving more. at the end of 2020, APA coll aborated with Governor Asa Department of Health to crea Hutchinson and the Arkansas te a vaccine distribution plan that included pharmacists on wide reach across the state, thei the front lines due to their r ability to adapt to health cris es with innovative solutions, and experts. The plan launched Ark their role as medication ansas into the top 10 states in the country for administering stumbled and fell behind. vaccines while other states • APA submitted an amicus brief to the United States Sup reme Court in support of Ark Rutledge’s petition to the cou ansas Attorney General Leslie rt. The brief was also signed by NCPA, APhA, NASPA, and pharmacy associations. In the 51 other state and local days leading up to the case, APA provided live coverage from the Court and a post-case commen steps of the US Supreme tary webinar. • APA supported state legislat ors in their efforts to improve pharmacy by donating from the known as AP-PAC. Each elec APA political action committee tion cycle, AP-PAC gives betwee n $50,000-$100,000 to suppor have helped pharmacists. Tha t legislative champions that t money comes solely from gen erous APA member donations. • APA staff and members wer e interviewed by local news out lets such as Arkansas Busines Gazette, KARK, KLRT, KAIT, s, the Arkansas Democrat KTHV, KHOG, and KNWA, as well as national news organiz VICE News, and the New Yor ations including CNN, NPR, k Times and national pharma cy podcasts from the Americ Pharmacists United for Truth an Pharmacists Association and & Transparency. • APA continued to support its partnerships with the Arkansas Association of Health System Pharmacist Academy and Com s pharmacists, APA Consultant pounding Pharmacist Academ y. We appreciate the opportunity to serve the pharmacists of Arkansas. We are one of the associations in the nation bec strongest state pharmacist ause of our members and the passion they have for improvi the profession of pharmacy, ng the lives of their patients and but we can only move forward in strength and progress with engagement. If you’ve ever tho your active membership and ught about being a member of APA, now is the time. Please talented staff at 501-372-5250 do not hesitate to contact our if we can do anything to serv e you. We look forward to you in APA and to a great 2021! continuing your membership Warm regards, John A Vinson, Pharm.D. Executive Vice President & CEO PO Box 3798 | Little Rock, AR 72203 | p 501-372-5250 | f 501 -372-0546 | www.arrx.org
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APA Staff John Vinson, Pharm.D. Executive Vice President & CEO John@arrx.org
Nicki Hilliard, Pharm.D. Director of Professional Affairs Nicki@arrx.org Lynn Crouse, Pharm.D. Director of Pharmacy Practice Lynn@arrx.org Jordan Foster Director of Communications Jordan@arrx.org Susannah Fuquay Director of Membership & Meetings Susannah@arrx.org Celeste Reid Director of Administrative Services Celeste@arrx.org Debra Wolfe Director of Government Affairs Debra@arrx.org Office E-mail Address Staff@arrx.org Publisher: John Vinson Editor: Jordan Foster Design: Gwen Canfield - Creative Instinct Arkansas Pharmacists Association PO Box 3798 Little Rock, AR 72201-2923 Phone 501-372-5250 Fax 501-372-0546 AR•Rx The Arkansas Pharmacist © (ISSN 0199-3763) is published quarterly by the Arkansas Pharmacists Association, Inc. It is distributed to members as a regular service paid for through allocation of membership dues ($5.00). Non-members subscription rate is $30.00 annually. Periodical rate postage paid at Little Rock, AR 72201. Current edition issue number 92. © 2021 Arkansas Pharmacists Association.
POSTMASTER: Send address changes to AR•Rx The Arkansas Pharmacist PO Box 3798 Little Rock, AR 72201-2923 Opinions and statements made by contributors, cartoonists or columnists do not necessarily reflect the attitude of the Association, nor is it responsible for them. All advertisements placed in this publication are subject to the approval of the APA Executive Committee. Visit us on the web at www.arrx.org.
CONTENTS 6 Inside APA: The Land of Opportunity 7 From the President: NCPA Files Suit
Over DIR Fees: What Could It Mean for Arkansas?
8 FEATURE: COVID-19 Vaccine Q&A 14 Member Profile: Marco Middleton 15 Legislator Profile:
Representative Les Eaves
16 FEATURE: Baker’s Bears & Bulls
18 Safety Nets: E-Prescriptions: No
Guarantee to Be Error-Free
21 New Drugs: Antiviral Drugs and
Vaccine Take the Spotlight
22 UAMS: Listening through 2020
Cover Photo: Denise Roark of Collier Drug
23 Harding University: Changes on the
23 Upcoming Pharmacy Events 24 AAHP: Post Licensure Certification 25 Consulting Academy Report: Got
26 Compounding Academy: FDA Sends
Warning Letter to PCCA
ADVERTISERS 4 Pharmacists Mutual 8 Biotech Pharmacal, Inc. 17 Law Offices of Darren O'Quinn 19 UAMS College of Pharmacy 19 EPIC 20 Retail Designs, Inc. 20 Arkansas Pharmacy Support Group20 27 Pharmacy Quality Commitment
APA Board of Directors 2020 - 2021 Officers President – Kristen Riddle, Pharm.D., Greenbrier President-Elect - Max Caldwell, P.D., Wynne Vice President – Dylan Jones, Pharm.D., Fayetteville Past President – Dean Watts, P.D., DeWitt
Regional Representatives Region 1 Representatives - Kevin Barton, Pharm.D., Bentonville - John Hall, Pharm.D., Fort Smith - Spencer Mabry, Pharm.D., Berryville Region 2 Representatives - Erin Beth Hays, Pharm.D., Pleasant Plains - Greta Ishmael, Pharm.D., Cherokee Village Region 3 Representatives - Brandon Achor, Pharm.D., Sherwood - Brittany Sanders, Pharm.D., Little Rock - Lanita White, Pharm.D., Little Rock Region 4 Representative - Betsy Tuberville, Pharm.D., Camden Region 5 Representative - Lelan Stice, Pharm.D., Pine Bluff At Large Representatives - Stacy Boeckmann, Pharm.D., Wynne - Rick Pennington, P.D., Lonoke Arkansas Association of Health-System Pharmacists Kim Young, Pharm.D., Little Rock Academy of Compounding Pharmacists Brooks Rogers, Pharm.D., Little Rock Academy of Consultant Pharmacists Denise Robertson, Pharm.D., Little Rock
Ex-Officio APA Executive Vice President & CEO John Vinson, Pharm.D., Benton AR State Board of Pharmacy Representative John Kirtley, Pharm.D., Little Rock Board of Health Member Marsha Boss, P.D., Little Rock UAMS College of Pharmacy (Dean) Cindy Stowe, Pharm.D., Little Rock Harding College of Pharmacy (Dean) Jeff Mercer, Pharm.D., Searcy General Counsel Nate Steel, J.D., Little Rock Treasurer Richard Hanry, P.D., El Dorado UAMS COP Student Ashlyn Tedder Ward, Little Rock Harding COP Student Aritney 6 Cooper, Searcy
The Land of Opportunity John Vinson, Pharm.D. APA Executive Vice President & CEO
oday, the great state of Arkansas has the nickname, the Natural State. We see this nickname commonly displayed on state license plates, advertising campaigns, and souvenir t-shirts. This nickname was adopted in the mid 1990’s by the Arkansas state legislature as the state was experiencing a growth in the tourism industry from outdoor activities like hunting, fishing, hiking, boating, biking, and sightseeing that our state offers. As a native Arkansan, I remember the previous nickname for our great state. My first Arkansas license plate proudly displayed the nickname, the Land of Opportunity on the back of my 1983 red and white Ford Ranger pickup truck. This nickname had previously been used for over 50 years by Arkansas businessmen in promotional materials and on license plates. The phrase was used to describe emerging growth and economic opportunities in our state after the Great Depression and World War 2. Our state and nation were both recovering from very difficult economic hardships of the last 20 years in the 1920’s and 1930’s. Arkansas pharmacists and the profession has seen significant highs and lows over the last 20 years. The lows we experienced as a profession, especially in 2018, were not as significant overall in comparison to a World War or the worldwide financial collapse of the Great Depression, but they were still very challenging. In addition, the 2020 global pandemic c e r t a i n l y h a s b e e n e x t re m e l y emotionally and financially challenging times for both our professional and private lives. The pandemic has recently dramatically improved thanks to vaccination efforts but still is wreaking havoc on our ability to live
our lives the way we are accustomed to living. We also still have many significant challenges to overcome including misaligned incentives and self-dealing by middlemen in the broken pharmacy market as well as unsafe at worse and unhealthy at best working conditions for many employed pharmacists. Albert Einstein famously said, “in the middle of difficulty lies opportunity.” The silver lining of the COVID-19 pandemic has been the land of opportunity, the profession of pharmacy’s greatest moment to shine as the public health backbone of America, especially in rural and underserved areas of our country. Innovation and pharmacy services provided during the pandemic by pharmacists in nursing homes, hospitals, and community settings are changing the profession forever. Treatment protocol development, community and volunteer partnerships, home delivery, telemedicine, technology advancements, vaccination clinical services, immunization infrastructure, appointment-based models, digital patient engagement, medical billing, patient communication advancements and point of care testing are all emerging as the new norm for the next 20 years for the practice of pharmacy. The media attention, grass roots engagement with policy makers, and community recognition is changing the landscape for how our state association as well as national pharmacy associations can help pave the way for more opportunity for a better professional future. Very simply, I want to personally thank each of you for your role in helping our state, country and the world defeat the pandemic. Your heroic efforts are literally changing and saving lives in the world as well as changing the
THE ARKANSAS PHARMACIST
policy world for advancement of pharmacy services. The next year promises to be very exciting to support our great profession in the continued fight to end the pandemic through education and vaccination efforts. We have many new professional opportunities emerging from the recent success of the 2021 state legislative session. We also have a new future home to build for the Arkansas Pharmacists Association to thrive for the next 50 years. This project, The Phoenix Project, promises to provide a better pharmacy home for our profession
to gather, share ideas and advocate for a fair playing field for our profession to thrive. This exciting opportunity emerged from a dark time in our history and offers the chance to grow and rise from the ashes of 2020, with a fresh start at 417 South Victory next to our beautiful state Capitol. I ask for your continued presence, your financial gifts, your professional services, and your relationships with policy makers more than ever for us to succeed in the new land of opportunity. §
FROM THE PRESIDENT
NCPA Files Suit Over DIR Fees: What Could It Mean for Arkansas?
n January 15th NCPA filed a lawsuit against the government (HHS) to end retroactive pharmacy DIR fees. This suit is challenging a 2014 CMS rule which created a loophole allowing Part D plans and their PBMs to claw back exorbitant pharmacy DIR fees. Since 2014 NCPA has worked to persuade HHS to adopt new rules to stop DIR fees. We were all hopeful there was a remedy to the problem in 2019 but there was opposition and no solution was given. NCPA CEO Doug Hoey said “We’ve exhausted every effort to work through the legislative and regulatory processes. But we’ve had enough. We can wait no longer.” Retroactive pharmacy DIR fees make it difficult, if not impossible, for pharmacy owners and managers, to know actual costs and be able to plan. The DIR fee is recouped at a much later date (weeks or months) from the point of sale and arbitrary reports make it impossible to reconcile. There is no way to know how much was made or lost on individual Part D prescriptions. Mark Riley, former APA CEO, has been quoted explaining the PBM model as “it's like Visa telling Dillards how much to charge for the sweater.” However, with retroactive DIRs the PBM then months later comes back and pulls out arbitrary fees for DIR bringing the reimbursement below the cost of the drug. There is no way for pharmacies to plan and to control cash flow. No business can operate this way. Also, due to the lack of transparency they conceal the true cost of prescription drugs from the patient, taxpayers, and lawmakers, ultimately driving up the cost of prescription drugs and healthcare. As the pharmacist, you do not even know the true cost of that drug or what you were paid (or not paid) for the drug. On January 28th, NCPA held a webinar to educate pharmacists on the lawsuit. The recording is on the NCPA website. During the
Kristen Riddle, Pharm.D. APA President
webinar Doug Hoey made the point “DIR was never intended to have seniors, taxpayers, and pharmacy owners be reverse Robin Hoods, suffering while PBMs fill their pockets.” NCPA listed a study in the NCPA v Azar press release showing the increase in DIR fees since 2015 has been 1,600% with $4 billion in DIR fees being taken from pharmacies in 2017 alone. Pharmacists across the nation have felt this increase year after year and many have not been able to weather this storm leaving communities without a local pharmacy and patients without the resources of a local pharmacist. NCPA claims in the suit that the exception which allows DIR claw backs after the point of sale was inserted into a final rule in a manner that violated the legal process for proper rule making (NCPA v Azar Press Release-NCPA website). This exception is the loophole in which Plans and PBMs have used to claw back billions from independently owned pharmacies. “The goal of this lawsuit is to strike down a massive loophole in Medicare rules which Part D plans and their PBMs have used to pocket billions of dollars at the expense of patients and small business community pharmacies.” (NCPA Lawsuit to End DIR Fees- NCPA website) The lawsuit would eliminate retroactive claw backs and put all prescription price concessions at the point of sale. The suit however, would not prevent bad contracts. It will be up to the community pharmacy profession to make sure we have fair contracts. This suit would require re-contracting and give greater transparency and predictability at the point of sale. It is the first step to eliminate DIR all together. I am thankful NCPA has moved forward with this suit because doing nothing is not an option. §
Q &A By Jordan Foster APA Director of Communications
In December 2020, as COVID vaccines slowly began to trickle into the state, Arkansas pharmacists stood ready to administer not just the much-anticipated vaccine but also a dose of hope that “normal life” or something close to it would return soon. Within weeks, the number of pharmacies receiving shipments of vaccines soared from double to triple digits, but the supply wasn’t nearly enough to keep up with the astronomical demand. It was clear early on that pharmacies would need to innovate their practices to adapt to such an unprecedented event. APA asked five pharmacies across the state to share their stories of change and how they adapted to a brand new world.
Strike Team Pharmacy
Woodsprings Pharmacy, Jonesboro Describe Woodsprings involvement as a strike team pharmacy. Lacey Hoggard: Woodsprings Pharmacy was asked to be a strike team pharmacy to distribute vaccine to 12 hospitals around the state. We made over 30 deliveries to hospitals for their front line workers. We are proud to have been asked to be a member of this initial team in distributing vaccine to Arkansas. We have enjoyed being a part of history as we helped coordinate with ADH and APA to come up with a distribution plan. What made you decide to become a strike team pharmacy? LH: When we were asked to be a strike team pharmacy, the answer was immediately “yes!” The world was enduring a pandemic and we were given a chance to help with the beginning of the solution, so we were eager to help in any way we could. We had previously purchased an ultra cold freezer when we heard that the Pfizer vaccine would require one for storage, so we were excited to be able to put it to use. Small and medium sized hospitals needed a way to be able to receive vaccine in smaller quantities that were less than a whole Pfizer tray so we were thrilled to be able to help front line workers have access to the vaccine!
The strike team strategy involved an unprecedented level of collaboration between pharmacies. Are there any lasting effects from that collaboration? LH: Absolutely! When you have spent hours on calls and exchanged hundreds of text messages collaborating and planning strike team distributions, you have built relationships. We have reached out to several other strike team pharmacies multiple times since then about various COVID vaccine related questions (billing issues, mass clinic strategies, etc.) and also about other pharmacy related questions. It has been helpful to hear perspectives of other pharmacies and what is working well so we can see how we might adapt to better serve our patients and community. What do you know now that you wish you had known when you got your first shipment of COVID vaccines? LH: We knew that this was an unprecedented time in pharmacy and regulations/strategies were changing on a daily basis, but I think we underestimated how drastically the pharmacy dynamic would really change almost immediately. Woodsprings Pharmacy has been serving the Northeast Arkansas community for over 40 years and we were committed to still providing the best care to our patients and their medicine needs, even while taking on the new role of being a strike team pharmacy
THE ARKANSAS PHARMACIST
COVID-19 VACCINE Q&A
to serve hospitals, then as a HUB to provide vaccines to other pharmacies in our area, and also vaccinating members of our community. The new dynamic was challenging to provide excellent care to your patients, while fielding hundreds of calls each day about COVID vaccine questions. We are extremely proud of our staff who have risen to the challenge and put in a lot of extra time at night, weekends, etc. in order to make sure that everything was taken care of.
Off-Site COVID Clinics
The Pharmacy at Wellington, Little Rock How did your workflow change when you first started receiving the COVID vaccine? Brittany Sanders: When we first started receiving vaccine as a striketeam pharmacy, we did our immunizations off site, going to various hospitals across the state to immunize healthcare professionals, so it impacted us only in that we had fewer people in the store because part of our staff was gone offsite giving immunizations - so it just made things a little thinner in the store. Once the vaccine became available for people in the community, we quickly noticed that with the volume of vaccine that was going to be required and having people wait that 15 minute timeframe, it was going to be difficult due to space constraints in the store. We felt like people were on top of each other and us all day long and we knew we were going to need more space, so we began looking for an offsite space that could accommodate the vaccine part of our business.
were doing 50 or 75 shots in the pharmacy itself, our frontend sales were tremendous. When we got to more than 100 a day and decided to open our offsite clinic, we lost out on some of the opportunity to show people what a great service we offer in the pharmacy and maybe converting some of those vaccine patients to prescription patients or to OTC patients as well. Are there any changes that you have made - getting ready for the COVID vaccine and for the clinic - that you think will carry over into the pharmacy on a permanent basis? BS: I think we will still do a lot of vaccines on an appointmentbased model and offer that for flu season where we can have people sign up for an appointment time for a flu vaccine. The patients have really liked that, we have some predictability in terms of staffing and scheduling, so that's been a bonus. We've not done that in the past. Also, we've purchased additional laptops and scanners and things like that, and we will definitely take those off site with us to flu clinics in the fall to make those clinics easier. Our immunization operation has been incredibly streamlined.
Scheduling & Strategy
Collier Drug Stores, Northwest Arkansas Describe the scheduling software Colliers uses and the benefits it provides to Colliers.
Brenna Neumann: We made the decision to subscribe to a scheduling software early in the Phase 1A process due to the thousands of phone calls our stores were fielding. It was clear within the first week that a manual process for scheduling would not work as it had Looking back now that it has been open in the past for other vaccine services. for a while, what do you see as some of The scheduling software enabled me the pros and cons of having this specific to manage dose alotment across the Woodsprings Pharmacy's role as a striketeam offsite clinic? company. I determined a weekly base pharmacy meant they would deliver vaccines to smaller hospitals in the early days of the alottment and appointment schedule BS: It was wonderful in terms of reducing vaccine's availability. Above, Lacey Hoggard for each store based on their staffing and Dylan Dulaney prepare a delivery. stress in the pharmacy itself. Everybody and demand. Then, as more groups of could focus on their specific role. We could focus on filling people became eligible for the vaccine, we utilized the prescriptions in the pharmacy and then in the clinic we software to manage larger mass clinics. could focus on providing great care with the vaccines and getting people through safely and efficiently. Everybody Will this new scheduling strategy be a permanent fixture for had a clear role and there was no overlapping in terms of Colliers and if so, how will you use it in the future? what we needed people to do. BN: Collier's has decided to continue utilizing an online The cons were taking people out of the actual pharmacy scheduling program for vaccine services. In addition, we itself. During 2020, we hadn’t had people in the stores plan to utilize the scheduling platforms for other pharmacy consistently so when we started giving the vaccines and services such as compliance packaging requests, POCT,
Collier's pharmacist Jeremy Veteto administers a vaccine to John Luther of the Washington County Office of Emergency Management at a Collier's vaccine clinic at Central EMS during Phase 1A.
Woodsprings pharmacist Rian Snell answers questions from a KAIT News reporter. Television reporters across the state sought out pharmacists for several stories regarding the progression of COVID vaccination in Arkansas.
and pharmacogenomic testing. Implementing a new system for one pharmacy is difficult enough but you had to implement it across multiple locations. What was it like creating this new tool for all the Colliers stores and having to do it as quickly as possible? BN: The pharmacists and myself were overwhelmed with managing the clinical aspects of the program it wouldve been impossible for us to manage setting up a scheduling system. Luckily we have an administrative team that was able to manage the scheduling aspects. Amie Collier researched various platforms and selected SimplyBookMe as our primary scheduling software for in store appointments. The technician and pharmacy managers were trained on how to manage their store's appointments. We initially utilized a centralized scheduling system where the administrative staff managed appointments for all the stores working off of our waitlist. However, at the end of April as the waitlist was cleared the stores assumed responsibility for scheudling their own weekly appoitnments.
Doctor's Orders Pharmacy, Pine Bluff You had a different strategy when it came to scheduling patients for COVID vaccines by scheduling in groups instead of individually. Describe that strategy. Sarah Stephenson: After speaking with Brittany Sanders in December, we decided to use Acuity for our online scheduling tool. We developed a group scheduling system by creating classes that were specific to the current eligible phase. Our classes were scheduled every 10 minutes
Collier's Centerton pharmacist in charge Kathryn Stark and student pharmacists Tiffany Withrow and Matt Calhoun prepare vaccines for a COVID clinic.
throughout the day. Each 10 minute interval had a specific number of appointments available. We then worked with Allie Staton to develop questionnaires that pertained to the current phase. The questionnaires were attached to the classes and required to complete before the appointment could be booked. After the patient completed the appointment registration, a confirmation email was sent that clearly told the patient what was needed to prove their inclusion in the current phase, digital consent forms, and details about their appointment. By using class grouping, it allowed us to have better control of our scheduling without having to use our resources to maintain it. We later taught our scheduling process to the Arkansas Dept of Health and together we used it in mass clinics around the State. What made you decide to use this scheduling strategy for your COVID vaccinations and how did it change your workflow? SS: We knew an online scheduling system was necessary to lower our call volume so we could better use our resources to vaccinate more people. We also added volunteers to our call center to help those without internet access to schedule appointments as well. What do you see as the pros and cons of using this method? SS: The system is wonderful for allowing us to use our resources for vaccinating rather than scheduling. When we had the snow storm this winter, we needed to reschedule over a thousand people. We used the email addresses we had requested in the initial registration through Acuity to send mass emails to patients allowing us to inform them of their new appointment times. We ran a report for the classes that were scheduled that day, exported to Excel, and created a single email for each day that needed to be
THE ARKANSAS PHARMACIST
COVID-19 VACCINE Q&A
rescheduled. It took less than an hour to reconfigure the schedule and alert all of our patients. The downside of using online scheduling is that many people do not have internet access. For this reason we added volunteers to our call center to schedule these patients.
Vaccination Success Rison Pharmacy, Rison
Cleveland County has consistently been one of the most successful counties in Arkansas for COVID vaccination. For a long time, it was the county with the highest vaccination rate in the state and it has stayed at or near the top of the list. What did you and your staff do to contribute to the county’s leading vaccination rate?
DH & LW: At the beginning it felt like our workflow was complete chaos. We knew that we would be receiving the vaccine, but I do not think anyone could be prepared for the abrupt changes that began in January. When we initially began giving covid vaccines, we were giving them in the store during and after business hours. We quickly realized this would not be sustainable, and an off-site clinic was the best answer to increase the number of vaccinations we were able to provide each week. Diana came on board in April 2020 in anticipation that I would be spending more time in our Fordyce location and have more flexibility for time off. Without that change, we would not have been able to conduct off-site vaccination clinics during business hours.
Are there any changes you made within your pharmacy to prepare and adapt to the COVID vaccine that you expect to keep in place? Before we started giving covid vaccines, we completed the Diana Hill & Lynn Wilson: In the beginning, our county process with our software vendor to allow direct reporting numbers were really helped out by the number of residents to Arkansas’s WebIZ. Without this in place, our entire in our county who are healthcare workers and were able process would have been much more difficult. to get their vaccine at local hospitals. We are the only I do not know that there are any specific changes pharmacy in our county, and we started taking names down that we will make in our day-to-day pharmacy operations. on a waiting list a couple We have been fortunate of months before we to have a location where received our first vaccine. we can hold mass We called these patients vaccination clinics offas they were eligible to site, so that there is schedule vaccination minimal disruption to the appointments. We also pharmacy workflow. teamed up with our local Every person on our staff paper and our local county has really stepped-up medical officer, Dr. Mark during these hectic timesAttwood, to help get the there is not one person word out that we were on our staff who has not giving vaccines. come into work early or As different patient stayed late to get the job populations became done. As we’ve learned eligible, we contacted Congressman Bruce Westerman presents Lynn Wilson, owner/pharmacist of Rison to streamline vaccine Pharmacy, and staff with a "Hometown Hero" award for their role in vaccinating local businesses to inform Cleveland County. paperwork and reporting, them of their eligibility. other vaccines that we I really believe that our reaching out to these different administer in the future will seem like a piece of cake. patient populations have helped our vaccination rates. Our vaccination rate is helped by the fact that our county is What are you seeing as the biggest hurdle to a higher very small, and we received the same allotment as some vaccination rate overall? other counties. We have a significant portion of our population that are DH & LW: The biggest hurdle to a higher vaccination rate elderly, and a large population who do not have internet currently is vaccine hesitancy in a large portion of the access. I believe that it helped that we never utilized an population. We feel the problem to primarily be misonline platform for scheduling appointments in these information on social media and other internet platforms. particular populations. We pass on any questions that we receive to our county health officer, who works to provide accurate information How did your workflow change when you first started receiving with references to patients who have concerns about the COVID vaccine? vaccine safety and efficacy. §
Looking Back What moments from the past few months stick with you? Diana Hill & Lynn WIlson, Rison Pharmacy: I gave a patient a shot who immediately started crying tears of joy after receiving her shot. She told me that she had quit her job at the beginning of the pandemic to care for her elderly mother. She had hardly left her house in almost a year. Stories like this really stick with me. We have so many patients who finally felt like they could see their family again, our own families included. Sarah Stephnson, Doctor's Orders: I recently gave a vaccine to a young women. After the vaccine, she began to cry. I first thought she had anxiety about the vaccine, and I tried to comfort her. She took a minute and then told me that her mother and brother had both died from Covid-19 and this vaccine meant so much to her. I feel beyond honored to provide this service for our community. I am reminded daily the impact Covid has had on us all and how we are blessed to have a vaccine. Brenna Neumann, Collier Drug Stores: Aside from vaccinating thousands of Arkansas residents, probably the most memorable aspect of the pandemic vaccination efforts has been becoming integrated into the emergency services community. We have forged relationships with County Emergency management, local ADH units, nursing groups, physicians that previously did not exist. I have enjoyed working out in the community every week side by side with paramedics, fire departments, city and county officials, nurses and other community volunteers. I have learned so much about our counties in NWA that will be of benefit for years to come. Brittany Sanders, The Pharmacy at Wellington: We have one patient, she's a longtime regular patient with us, and she absolutely had not left her home in over a year before the vaccine was available. She waited her turn and was just so excited to be there and to be vaccinated that she broke down in tears. She was so happy to give me a hug. There’s been a feeling of relief that people get to finally be headed to a place where they don’t have to be afraid and it was such a great feeling to be part of getting her life back to normal. Lacey Hoggard, Woodsprings Pharmacy: We have had countless patients in tears because they were so excited to be vaccinated. Many have had jobs where they are highly exposed on a daily basis and were thankful for another level of protection, and many were thrilled to be able to visit a loved one who they have not been able to see during the pandemic. We did whatever we could to make the vaccine easily accessible to members of our community, including giving vaccinations in cars to make it easier for those with mobility issues and making in home visits for those who are confined to their homes. The countless kind words and thank you notes we have received remind you that the long hours are worth it and vaccination distribution efforts are providing hope to those around us.
What do you know now that you wish you had known when you got your first shipment of COVID vaccines? Lacey Hoggard, Woodsprings Pharmacy: We knew that this was an unprecedented time in pharmacy and regulations/ strategies were changing on a daily basis, but I think we underestimated how drastically the pharmacy dynamic would really change almost immediately. The new dynamic was challenging to provide excellent care to your patients, while fielding hundreds of calls each day about COVID vaccine questions. We are extremely proud of our staff who have risen to the challenge and put in a lot of extra time at night, weekends, etc. in order to make sure that everything was taken care of. Diana Hill & Lynn WIlson, Rison Pharmacy: Our biggest concern when we first started giving vaccines was that there might be an availability issue for second doses. As second doses began arriving and clarification was given during multiple zoom meetings, those fears subsided. The entire process has been a learn as you go experience. The association has been tremendously helpful with their zoom meetings and updates. Brittany Sanders, The Pharmacy at Wellington: How quickly demand would fall off. When we first started, we thought ‘we will still be vaccinating through the summer, maybe even in December we would still be getting those tail end groups of people with their first set of COVID vaccines.’ But then, around the first of April, demand really just hit a wall. And I think there are several pharmacies that were left with larger quantities of vaccines because demand went from 100 to 50 overnight and then from 50 to 25 the next day. Brenna Neumann, Collier Drug Stores: I wish we had the foresight to realize we were going to need to utilize a scheduling program so we could've planned and strategized ahead of supply. I knew pharmacy would play a key role in the adminsitration of Covid-19 vaccines in the state, I had no idea as to the scale! Absolutely blew my mind and do not think the implications willl fully be realized for months to come. I also wish I had a clue of the scale so I could have planned for increased staffing needs. Sarah Stephnson, Doctor's Orders: This is a hard question to answer because we knew basically nothing when we started. This had never been done before. As with most pharmacies, we learned from our mistakes and adapted as we went. We all worked 70-80 hour weeks striving to do better. The process was ever evolving and no one knew what to expect week to week. That all being said, I would do again in a heartbeat.
THE ARKANSAS PHARMACIST
Marco Middleton BRINKLEY FAMILY PHARMACY/ POLK PHARMACY CLARENDON
Pharmacy/academic practice: Brinkley Family Pharmacy/ Polk Pharmacy Clarendon
Pharmacy school and graduation year: I graduated from UAMS as a member of the Class of 2019.
Years in business/years teaching: I have 1.5 years in independent business serving Monroe County
Favorite part of the job and why: My favorite part of being a
pharmacist is the ability to help others and to have an impact on their health and well-being. In rural Arkansas, a pharmacist may be the only available provider for 20 miles and is easily the most accessible. So, having a local pharmacist that the community can trust is of utmost importance. I also enjoy the community of Central Arkansas Pharmacies as we work together to serve our local areas. Following other pharmacies to see how they accommodate their patients allows us to be most effective in Brinkley as we strive to be a pillar to our community. One of those pharmacies reside in Maumelle, Achor Family Pharmacy.
Least favorite part of the job and why: It may sound cliche,
but my least favorite part of the job doesn’t exist. I truly enjoy each area and challenge that we face because I know we are making a difference. I admit some days are tougher than others, and what gets me through those days is knowing that we are positively impacting the communities in which we serve.
What do you think will be the biggest challenges for pharmacists in the next 5 years? Over the next 5 years, I
think that one of the biggest challenges for pharmacists will be PBMs or Pharmacy Benefit Managers which have a large impact on patients access to medications. It is not a new phenomenon, but their impact on the practice of pharmacy has been well documented.
Oddest request from a patient/customer: After delivering
a wheelchair to a patient, I was called back to the residence shorty after leaving. Once I arrived, I was asked to take the packaging and some home trash to the dumpster. I of course agreed to do so, to the delight of the patient. Making an impact on the community sometimes calls for something different than vaccinations and prescriptions.
To best serve our community we must maintain the latest knowledge and information on research available.
Favorite activities/hobbies: I enjoy worshiping God and
spending time with my family. My wife Nicole, daughter Madison (17), and sons Marco Jr. (9) and Morgan (3) keep me busy with all the activities and hobbies that one man can handle. When I am not being a husband, father, or pharmacist I enjoy following college football and other sports.
Ideal dinner guests: As a sports fan I would have to say
Bobby Bowden, Nick Saban, LeBron James, Aaron Rodgers, Michael Jordan, and Jerry Jones.
If not a pharmacist then…: If I were not a pharmacist, I
would be a chemist. Pharmacy is actually my second career. I worked for Novus International, in Little Rock, from 20112019 as a full time Master’s degree chemist. Becoming a pharmacist was so important to me that I worked a full-time job and drove from Clarendon to Little Rock to pursue my dreams.
Why should a pharmacist in Arkansas be an active member of the Arkansas Pharmacists Association?
Every pharmacist in Arkansas should be an active member of the Arkansas Pharmacists Association. This association advocates for moving pharmacy forward in ever changing times. I am proud to be a member and the benefits I see are immense. If you are not a member please take the time to become one. §
Recent reads: As most of my peers, my most recent reads have been literature concerning the COVID-19 vaccinations. 14
THE ARKANSAS PHARMACIST
Representative Les Eaves SEARCY District: 46 (Searcy and Kensett) Represents (Counties): Part of White County Years in Office: Currently in my 4th term Occupation: Vice President of Delta Mfg., Inc.. We build horse,
livestock, flatbed, tilt and dump trailers and sell them through a nationwide network of independent dealers.
Your hometown pharmacist: Stanley Pharmacy (Scott and Kelly Stanley)
What do you like most about being a legislator: Its cliche
to say, but I really enjoying helping people. It is very rewarding to see the effect our actions have on the citizen of our state. But it’s even more rewarding to be able to help people who have encountered a rock block in government red tape. Its satisfying to solve these issues for people.
What do you like least about being a legislator: There isn’t very much I dislike about it.
Most important lesson learned as a legislator: Every bill
has a winner and a loser - it makes it difficult at times to figure out the right vote. But also, I’ve learned that everyone has a perspective, and that is important, and it should be respected even if we disagree. I get disappointed at times at the hyper partisanship that, at times, occurs.
Hobbies: Golf, Fishing, Camping, Private pilot, but the best times are with family.
Most admired politician: Hard to narrow it down to one but
modern-day favorite would be Senator John Boozman, state politician would be State Senator Jonathan Dismang, historical figure would be Ronald Reagan.
Advice for pharmacists about the political process and working with the AR Legislature: Don’t be afraid to engage in the process. Make the phone call, send the email. We appreciate your input and really need it in order to make better decisions. Also, be polite if we disagree, and understand that we serve the wishes of many industries and thousands of people.
Your fantasy political gathering would be: Ronald Reagan, John F. Kennedy, Thomas Jefferson and my grandfather Austin Glenn, just because I miss him. §
Arkansas State Board of Pharmacy
Executive Director...................Susan Newton, Pharm.D., Russellville President................................Kimberly Young, Pharm.D., Little Rock President-Elect............................Hye Jin Son, Pharm.D., Little Rock Immediate Past President..Erin Beth Hays, Pharm.D., Pleasant Plains Treasurer..................................Kendrea Jones, Pharm.D., Little Rock Secretary.........................................Melissa Shipp, Pharm.D., Searcy Board Member at Large................Chad Krebs, Pharm.D., Little Rock Board Member at Large.............Amber Powell, Pharm.D., Little Rock Board Member at Large....................Gavin Jones, Pharm.D., Benton Technician Representative...........BeeLinda Temple, CPhT, Pine Bluff
President................................Lenora Newsome, P.D., Smackover
Vice President/Secretary....Rebecca Mitchell, Pharm.D., Greenbrier Past President...............................Debbie Mack, P.D., Bentonville
Member................................Rodney Richmond, Pharm.D., Searcy Member.................................Lynn Crouse, Pharm.D., Lake Village
Member.............................................Brian Jolly, Pharm.D., Beebe Public Member...........................................Carol Rader, Fort Smith
Public Member..............................................Amy Fore, Fort Smith
BAKER’S BEARS & BULLS
Pharmacist Immunization Expansion by Joe Baker & Jason Lam
magine this: you’re sitting at home bored because there’s a pandemic outside. The economy has just crashed, and the unemployment rate is reaching a record high. You’ve decided to satisfy your boredom by scrolling on social media, and you’re surprised to see post after post about your favorite childhood store: GameStop. Everyone knows that in the digital world, GameStop is arguably one of the most obsolete companies, following in the footsteps of its fellow archaic companies. GameStop has been losing money for years and had even closed 462 stores in 2020. So, why did GameStop make the news internationally? Before we jump into the story, here’s some financial preface. When you buy a stock, you want the stock to go up: buy low, sell high. The worst thing that can happen as an investor is that the company goes to zero, and you lose your investment. When you short a stock, you “borrow” the stock from a brokerage firm at a high price, and ultimately, you want to “return” the stock at a low price, pocketing the difference.
Shorting a stock, however, is very risky because there’s no “safety net” per se. When you short a stock, you’re hoping it goes down, but if the stock goes higher than the price you shorted at, you actually owe the difference. The higher the stock goes, the more money you owe. Let’s say it has gone too high, and you want to get out. To sell your shorts, you must cover the stock AKA buy back the stock, and hence, reinforce the market algorithm to raise the stock price even more. When you have a scenario in which millions of dollars’ worth of shares are covered, this drastically raises the stock price, creating what’s called a “short squeeze.” Now, here’s the story: When you combine GameStop ($GME), hedge fund “knowit-alls”, and basement Reddit investing bros, you get the financial David vs Goliath battle of the century. Andrew Left, a short seller from Citron Research, bet that $GME would go to zero. Like other companies Andrew has shorted in the past, he publicly trashed the company so the stock would plunge.
THE ARKANSAS PHARMACIST
WallStreetBets (WSB), a Reddit community, took offense to this and collectively bought the stock, therefore “artificially inflating” the company’s stock from ~$20 to $483 in about two weeks. Without getting in the nitty gritty, Robinhood, a trading platform for novice investors, restricted their users from buying $GME and only allowed them to sell. Arguably, this caused the stock to tank to $50. Celebrities, politicians, and even financial figures like Elon Musk and Mark Cuban jumped in to voice their opinions on the fiasco. As a result of what transpired, Citron announced they will no longer publicly share their short positions after losing billions of dollars, WSB grew to almost 10 million but members lost millions in its wake, and Robinhood has plummeted to a one-star rating on Google Play as the CEO Vladimir Tenev continues to thank Congress for their questions during his congressional hearing. The only thing left for $GME investors to do now to get their tendies is to HODL with diamond hands as hedgies continue to bleed. The only questions that remain left are what meme will Roaring Kitty post next on Twitter and which executive talent will Ryan Cohen recruit next to the meme stock dream team?
This incident has been an excellent teaching moment for my personal finance students. Buying an individual company stock is inherently risky. Any company, no matter how big, can go under.
Personally, I have enjoyed watching the “game” (no pun intended) play out because I would rather be an observer than a participant. I don’t like the idea of “betting” that the market price of a company’s stock will go down in value; it smells too much like Vegas. It seems like the antithesis to free market capitalism in promoting the demise of a company, rather than an investment into its growth. My suggestion is to not get mixed up in it, or you risk losing a lot of money in its volatility. I adhere to the more tried and true approach to investing, “Get Rich Slowly but Surely.” This incident, however, has been an excellent teaching moment for my personal finance students. Buying an individual company stock is inherently risky. Any company, no matter how big, can go under. Just look at some of the companies that advertised during Tom Brady’s first Super Bowl in 2002: AOL, Blockbuster, Circuit City, Radio Shack, and Sears. So, if buying an individual company stock is risky (e.g., GameStop), how should I invest? A good option that you should consider is to purchase stock mutual funds or exchange-traded funds (ETFs) in either your employer sponsored retirement plan or your Roth IRA. If you purchase a large-cap stock mutual fund or an S&P 500 stock index fund, you are buying a mutual fund with hundreds of individual stocks in its portfolio, thus spreading out your risk also known as diversification. Want to learn more about investing? Order my book at: http://bit.ly/BakersDirtyDozenBook §
UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES COLLEGE OF PHARMACY
Melanie Reinhardt, Pharm.D. Eddie Dunn, Pharm.D.
E-Prescriptions: No Guarantee to Be Error-Free This issue of Safety Nets examines potential hazards associated with electronic prescriptions. Thank you for your continued support of this column.
The E-prescription illustrated in Figure One was transmitted from a prescriber’s office to a community pharmacy in Northeast Arkansas. The pharmacy technician entered the gabapentin patient directions into the computer as “take three capsules by mouth three times a day, then two capsules three times a day.” This information, along with the prescription image, was transmitted from the input queue to the pharmacist verification queue. While verifying the accuracy of the prescription, the pharmacist noticed a separate set of directions in the Admin Instructions section of the order instructing the patient to take “two gabapentin three times a day.” Confused by this discrepancy, the pharmacist telephoned the prescriber’s office for clarification. The prescriber’s nurse confirmed the patient was to administer two gabapentin 300 mg capsules three times a day. The nurse remarked “I’m not sure why those other directions were included.” After this, the prescription was correctly filled and the patient appropriately counseled.
This case clearly demonstrates the potential hazards associated with electronic prescriptions. While E-prescriptions may have certain advantages over traditional handwritten prescriptions, their use does not guarantee an error-free order. In this case, the electronic prescription itself is the problem. The order contains two separate, completely different directions to the patient. Whoever devised sections on medication orders such as Admin Instructions in addition to the traditional “Sig” section familiar to all pharmacists, has no knowledge whatsoever about what constitutes a safe prescription. Electronic prescriptions are not guaranteed to be error-free. In fact, the legibility and neatness of E-Prescriptions may actually increase the risk of error compared to handwritten prescriptions that may be more carefully examined by pharmacy staff. The authors of Safety Nets are not advocating a return to handwritten prescriptions – health care technology has forced 18
them into retirement. Many of these handwritten prescriptions had to be carefully scrutinized for a variety of reasons including poor handwriting. Today’s pharmacists must use the same degree of scrutiny when verifying the accuracy of electronic prescriptions. §
Inferior Healthcare in the United States Correctional System - Abigail Morrow Healthcare is a basic human right that is disproportionately administered to the different tiers of society: prisoners in the United States Correctional System experience this bias in the quality of care they receive every day. There is a massive amount of prisoners in the United States when compared to other countries, and the quality of care they receive is sub par in comparison. While my father was incarcerated, he experienced this negligence firsthand on multiple occasions. One incident occured when he was bitten by a spider, and was denied healthcare until he had a hole in his leg - on the brink of losing it completely. Another, more serious, incident occurred when he had requested a colonoscopy multiple times for years due to a family history of colon cancer, but it was not approved until his cancer had progressed to a stage IV diagnosis of colon cancer. On the flip side, once he was eventually transferred to a prison hospital with more optimal facilities, his team of providers worked with him as best as they could under the circumstances. These examples are indicative of the need to advocate to bring consistent and recommended care across the entire health care system from before diagnosis to end of life care for all patients. As human beings, and more importantly as health professionals, we are driven to help everyone regardless of our biases. My hope is to bring awareness about the sub-par health care that a portion of our citizens receive and that this awareness will lead to an improvement that will benefit all patients. It is time that we as health professionals advocate for prisoners, as every single individual deserves the best healthcare that can be delivered regardless of their circumstances. AR•Rx
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Antiviral Drugs and Vaccine Take the Spotlight at Year's End
n the final quarter of 2020, the FDA approved 13 new drugs and 7 new dosage forms. However, among those approvals were the first treatment for COVID-19 and emergency use authorization for two novel COVID-19 vaccines which may signal the COVID-19 pandemic is nearing its end and our lives may resume some degree of normalcy by the end of 2021.
Infectious Disease Treatment and Prevention:
Veklury (remdesivir), a SARS-CoV-2 nucleotide analog RNA polymerase inhibitor, became the first medication approved for the treatment of COVID-19 in October. PfizerBioNTech COVID-19 Vaccine and Moderna COVID-19 Vaccine, both novel mRNA vaccines, were issued emergency use authorization (EUA) for the prevention of COVID-19 in December. Inmazeb (atoltivimab/maftivimab/ odesivimab-ebgn), a combination of three recombinant human monoclonal antibodies, and Ebanga (ansuvimabzykl), a single IgG1 monoclonal antibody, became the first drugs approved for the treatment of Zaire ebolavirus, the virus that causes Ebola infection.
Imcivree (setmelanotide) is a melanocortin-4 receptor agonist which regulates appetite and fullness and increases resting metabolism approved for chronic weight management in obese patients whose obesity is due to certain genetic conditions including proopiomelanocortin (POMC) deficiency, proprotein subtilisin/ kexin type 1 (PCSK1) deficiency, or leptin receptor (LEPR) deficiency. Kesimpta (ofatumumab) is a CD20directed cytolytic antibody approved for relapsing forms of multiple sclerosis (MS). While not indicated for the treatment of an attack, Orladeyo (berotralstat), a plasma kallikrein inhibitor, was approved for the prevention of hereditary angioedema attacks. Oxlumo (lumasiran) is a small interfering ribonucleic acid (siRNA) for lowering urinary oxalate levels in patients with hyperoxaluria type 1. Zokinvy (lonafarnib) is a farnesytransferase inhibitor approved to treat rare conditions related to premature aging including Hutchinson-Gilford Progeria Syndrome. Gemtesa (vibegron), a beta-3 adrenergic agonist, treats overactive bladder symptoms including urgency, urge incontinence, and urinary frequency. Klisyri (tirbanibulin)
is a microtubule inhibitor for topical treatment of actinic keratosis of the face or scalp.
Danyelza (naxitamab-gqgk) is a GD-2 binding monoclonal antibody approved for relapsing or refractory neuroblastoma in the bone or bone marrow in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF). Orgovyx (relugolix) is a gonadotropin-releasing hormone (GnRH) receptor antagonist indicated for the treatment of advanced prostate cancer. Margenza (margetuximab) is a HER2/neu receptor antagonist approved to treat HER2+ breast cancer in combination with chemotherapy in patients with metastatic HER2+ breast cancer who have received two or more prior antiHER2 regimens.
Gallium 68 PSMA-11 (Ga 68 PSMA-11) became the first drug approved for positron emission topography (PET) imaging of prostate-specific membrane antigen (PSMA) positive lesions in men with prostate cancer.
New Dosage Forms:
Several new dosage forms were approved including: Alkindi Sprinkle (hydrocortisone, oral granule sprinkle) for pediatric patients with adrenocortical insufficiency; Bronchitol (mannitol, powder for oral inhalation) as addon maintenance therapy to improve pulmonary function in adults with cystic fibrosis; Eysuvis (loteprednol, ophthalmic suspension) a short-term symptomatic treatment for dry eyes; Onureg (azacytidine, oral tablet) for acute myeloid leukemia; Qdolo (tramadol, oral solution) for pain; Thyquidity (levothyroxine, oral solution) for hypothyroidism and pituitary thyrotropin suppression; and Xaracoll (bupivacaine, implant) for postsurgical analgesia following open inguinal hernia repair. §
UAMS SCHOOL OF PHARMACY
Listening through 2020
s we embark on 2021, I know that many of us spent the end Cindy Stowe, Pharm.D. of 2020 reflecting on this past year Dean and Professor UAMS College of Pharmacy and how our day-to-day routines may have changed based on our circumstances. I would like to share something that I did this past year that helped me embrace the craziness of 2020. Some of you know that I’m an avid ‘listener’. If you have read one of the Gallup books or done the CliftonStrengths assessment and learned about your Top 5 Strengths, you should know that my Top 5 are Learner, Individualization, Relator, Maximizer, and Self-Assurance. My Learner strength has always been at my core and drives how I interact with the world around me. This year approaching the day-to-day with an openness to learn, adapt, change, and move on has been particularly beneficial in the midst of a pandemic. I discovered audiobooks about five years ago, and over 2020 I became an avid podcast listener. The ability to listen while I drive or do routine things around my house has opened my world to different perspectives with current events and expert advice. I regularly listen to podcasts focused on COVID and here are a few that I think are pretty good: COVID-19 Q&A by JAMA, Social Distance by The Atlantic, and Osterholm Update from CIDRAP. If you have never tried listening to a book, I highly recommend giving it a try. All you need is a smartphone. I’m an Audible subscriber, but I also use the public library service which is free to rent audio books. There are some amazing narrators that make the books come to life! For people who are new to audio books, I recommend the Harry Potter series because of Jim Dale’s narration - it is AMAZING! In fact, I don’t really watch TV anymore with all this great listening. I’m always on the lookout for books or podcasts that will help me do my job better, help me enjoy the world around me, and help me escape reality just a little. I want to share with you six books to consider reading or listening to if you haven’t already done so and six podcast recommendations just in case you want to start with something shorter! These books and podcasts fall into my broadly defined category focused on helping me do my job better.
Books • • • • •
Apollo’s Arrow: the profound and enduring impact of coronovairus on the way we live by Nicholas A. Christakis Beyond Entrepreneurship 2.0: turning your business into an enduring great company by Jim Collins & Bill Lazier Hidden Valley Road: inside the mind of an American family (schizophrenia) by Robert Kolker Tightrope: Americans reaching for hope by Nicholas D. Kristof and Sheryl WuDunn How to be an Antiracist by Ibram X. Kendi
Together: the healing power of human connection in a sometimes lonely world by Vivek H. Murthy
Podcasts • •
• • •
TED Talks Daily: To future generations of women, you are the roots of change - Gloria Steinem Deep Questions with Cal Newport: Episode 39. David Epstein on skills, practice, and the subtle art of cultivating a meaningful career The Pharmacy Podcast Network: Episode 1063. Katherine Eban & A Bottle of Lies - SenioRx Radio Unlocking Us with Brené Brown: David Kessler and Brené on Grief and Finding Meaning Creative Classroom with John Spencer: The power of student check-ins during distant learning & hybrid courses A Bit of Optimism with Simon Sinek: Episode 24. The infinite game with Dr. James Carse
As we get into 2021, let me know what your best read/listen has been. I’m always looking for something to check out and if you have interest, I could even be convinced to do a virtual book club. I think book clubs are great ways to get to know people and share ideas. Let me know your thoughts by visiting tinyurl.com/y3c93ttf. With the start of 2021, pharmacists and their teams are hard at work delivering the COVID vaccine and preparing capacity to immunize the populace. Our faculty, staff, and students have been hard at work not only in the classroom and in the laboratory/research setting (benchtop, population, practice). We have been busy in the practice setting helping support pandemic initiatives. Student pharmacists have been volunteering, working, and learning by supporting COVID contact tracing, screening, and immunizing. Our faculty and staff have been helping in a hands-on capacity in the practice setting as well as helping manage the logistics of the immunization rollout in an effort to support practice needs. I’m incredibly proud of the creative and thoughtful ways that the UAMS COP students, staff, and faculty are supporting the efforts of pharmacists in all settings and roles, as we work to eradicate this virus. Here’s hoping that your 2021 lives up to all your hopes and dreams. For me, I hope our profession continues to capitalize on our strengths to solve the difficult problems, remove barriers, and show up for each other and our communities that we serve - we are better together. § (Note: For links to all the books and podcasts mentioned in this article, visit www.arrx.org/links)
THE ARKANSAS PHARMACIST
HARDING UNIVERSITY REPORT
Changes on the Horizon
n May of this year, the Harding University College of Pharmacy will graduate its tenth class of pharmacy students. These graduates will join alumni and other pharmacists throughout the nation who are caring for patients at a time when front-line health providers are needed the most. Pharmacy is a dynamic profession, and it is certainly expanding in the face of the pandemic. Harding recognizes the demands of our changing profession and is committed to providing the quality education and training needed for contemporary pharmacy practice.
Jeff Mercer, Pharm.D. Dean and Professor Harding College of Pharmacy
While Harding’s College of Pharmacy is well established and has produced excellent pharmacists over the years, the drive to innovate and adapt to new opportunities in pharmacy education is an important component of our program. An example of this is evident in our new 3 ½ year curriculum that was recently announced. This new curriculum offers incoming students the opportunity to save time and money by starting their pharmacy education sooner and finishing earlier. This unique program is designed to offer students hybrid modes of learning while integrating and aligning coursework in a student-centered approach to pharmacy education. Harding’s revised pharmacy curriculum is the first of its kind regionally and is unlike other pharmacy programs throughout the country. The first students in this innovative new curriculum will enroll this summer and will graduate in December 2024. Summer courses are online, customizable, and flexible enough to allow students to participate from home or elsewhere while working or completing pharmacy practice experiences. Courses in the fall and spring semesters remain traditional
and on-campus so as to maintain the special connection that Harding pharmacy students gain as a cohort. Breaks are also strategically built into the program for students to enjoy time with family and friends and to assure student health and wellness. Another important goal for our program is to provide opportunities for students to choose electives and experiences that are specific to their career goals. The revised curriculum offers students the opportunity to pursue a variety of focused educational tracks that offer extra training in advanced pharmacotherapy, management, medical missions, or public health. Dual degree options are also available in collaboration with Harding’s College of Business Administration, where students can pursue an online Masters in Business Administration or a Masters in Information Systems in conjunction with their Doctor of Pharmacy degree. With online options for these additional degrees as well as other elective and training opportunities available in the new curriculum, Harding’s pharmacy graduates will enter the workforce even more confident and prepared for their careers. As the profession of pharmacy continues to change and expand in scope, Harding is committed to preparing the pharmacists of tomorrow. Standing on the tradition of our graduates and alumni, we are striking out in an exciting new direction with our revised curriculum. With this change, Harding College of Pharmacy will offer one of the more unique educational pathways for students to consider when pursuing a pharmacy career. For more information about the program or details on how to apply, visit www.harding.edu/pharmacy or contact the office of pharmacy admissions at (501) 279-5528. §
Upcoming Pharmacy Events JUNE June 5-9 American Society of Health-System Pharmacists Summer Meeting Long Beach, CA June 8-9 AR State Board of Pharmacy Board Meeting Virtually/In-Person Little Rock, AR June 10 APA Board Meeting Doubletree by Hilton Little Rock, AR WWW.ARRX.ORG
June 11 APA Annual Convention (In-Person) Doubletree by Hilton Little Rock, AR June 17 APA Annual Convention (Virtual)
AUGUST August 5-6* APA Board Retreat and Committee Chair Orientation TBA
SEPTEMBER Every Thursday in September (2, 9, 16, 23, 30)* APA Regional Meetings Around the State In-Person/Virtual TBA September 23-24 AAHP Fall Seminar Wyndham Riverfront North Little Rock, AR
* denotes dates subject to change
ARKANSAS ACADEMY OF HEALTH-SYSTEM PHARMACISTS
Post Licensure Certification The Oath of a Pharmacist: Kim Young, Pharm.D. AAHP President
The revised Oath was adopted by the AACP House of Delegates in July 2007 and has been approved by the American Pharmacists Association. This revised version was used starting with the Class of 2009 and it is as follows. “I promise to devote myself to a lifetime of service to others through the profession of pharmacy. In fulfilling this vow: • I will consider the welfare of humanity and relief of suffering my primary concerns. • I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients. • I will respect and protect all personal and health information entrusted to me. • I will accept the lifelong obligation to improve my professional knowledge and competence. • I will hold myself and my colleagues to the highest principles of our profession’s moral, ethical, and legal conduct. • I will embrace and advocate changes that improve patient care. • I will utilize my knowledge, skills, experiences, and values to prepare the next generation of pharmacists. • I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.” In the Oath of a Pharmacist that we all take upon graduation, it says that “I will accept the lifelong obligation to improve my professional knowledge and competence.” One of the ways pharmacists can do this is through post licensure certifications or additional credentialing. The definition of a certification is an official document attesting to a status or achievement. The definition of a credential is a qualification, achievement, personal quality, or aspect of a person's background, typically when used to indicate that they are suitable for something. The opportunities for pharmacists are many, we just have to take advantage of the opportunities that are available to us. Many students are deciding on whether to pursue a PGY-1, PGY-2, or fellowship opportunity. Over the past 15 years the development of additional residency programs across the country and within Arkansas have made this a reality for multiple pharmacists. A traditional resident candidate enters a residency program upon graduation from pharmacy school, but that is not always the case. There are non-traditional residents that pursue a pharmacist position right out of school, and then decide they want to pursue a residency at a later date. It is less common, but definitely not unheard of. One could get an additional degree from a University. Pharmacists may choose to pursue a Juris Doctorate degree, Masters of Healthcare Administration, Masters of Business Administration, Master of Public Health, among countless others. Any of these can build upon and aid a pharmacist throughout his or her professional career. There are numerous training certifications programs available to pharmacists through various organizations an. Just a few of those are:
• Clinical Lipid Specialist Accreditation • Credentialed Pain Practitioner (CPP) • Certified Specialist in Poison Information (CSPI) • Diplomate of the American Board of Applied Toxicology (DABAT) • Advanced Cardiovascular Life Support (ACLS), • Pediatric Cardiovascular Life Support (PALS) • Credentialed Pain Educator (CPE) • Certified Geriatric Pharmacist (CGP) • Certified Professional in Electronic Health Records (CPEHR) • Certified Professional in Health Information Technology (CPHIT) • Certified Asthma Educator (AE-C) • Certified Nutrition Support Clinician (CNSC) • Certified Anticoagulation Care Provider (CACP) NCertified Diabetes Educator (CDE) National Certification Board for Diabetes Educators (NCBDE) • HIV Specialist (AAHIVS) or HIV Expert (AAHIVE) or HIV Pharmacist (AAHIVP) • Board Certified-Advanced Diabetes Management (BCADM) • Certified Professional in Healthcare Quality (CPHQ) The Board of Pharmacy Specialities (BPS) is one of the more well known organizations for post-licensure certifications. The organization began in 1976 as a division of APHA, and in 1978 the first speciality of Nuclear Pharmacy was established. Today, BPS recognizes 14 different specialities (ambulatory care pharmacy, cardiology pharmacy, compounded sterile preparations pharmacy, critical care pharmacy, emergency medicine pharmacy, geriatric pharmacy, infectious diseases pharmacy, nuclear pharmacy, nutrition support pharmacy, oncology pharmacy, pediatric pharmacy, pharmacotherapy, psychiatric pharmacy and solid organ transplantation pharmacy) and has over 49,000 active pharmacist certifications. BPS continually evaluates the needs for additional specialities to be acknowledged. These are just a few options that are out there for a pharmacist to continue his or her education. For many of the above certifications, they are not a one and done type item. You have to renew the certification at a defined interval either by examination or continuing education. This will ensure you continue to stay current with the most recent studies and guidelines related to your field of certification. Not only that, but the credentials/certifications highlight you as an expert in that field. Sometimes depending on your employer this may equate to a monetary advancement. But at the very least it will award you recognition among your peers. The certifications are not necessarily easy, but it is a process that will inertly cause you to grow within your profession/speciality. We are obligated as pharmacists to continue our education throughout the entirety of our profession, so why not get the recognition to go along with it? § References: Hillin, K., & Generali, J. A. (2005). Post-Licensure Certification and Credentialing. Hospital Pharmacy, 40(6), 472-472. doi:10.1177/001857870504000601 History. (n.d.). Retrieved January 03, 2021, from https://www.bpsweb.org/aboutbps/history/ Oath of a Pharmacist. (n.d.). Retrieved January 03, 2021, from https://www. pharmacist.com/oath-pharmacist Salahudeen, M. S., & Nishtala, P. S. (2015). Credentials for a PharmD graduate: The voyage never ends. SAGE open medicine, 3, 2050312115584228. https://doi. org/10.1177/2050312115584228
THE ARKANSAS PHARMACIST
CONSULTING ACADEMY REPORT
colleague sent me an article addressing negligence and malpractice that resulted in a fatal opioid medication administration error. The subject piqued my interest because I had recently discussed with this same colleague my observation of larger and more frequent dosing of high potency opioids in some of the nursing homes we service. In this particular article, an evening shift nurse mistakenly administered 120mg of Morphine to one resident that was actually prescribed for another. Denise Robertson, P.D. Consulting Academy President
it is administered. Administration of any medication to the wrong resident can have dire consequences. The same can happen with administration of prescribed medication to the right resident if proper attention is not paid. Whenever I have the opportunity for a teaching moment during medication pass, I draw attention to liquid opioid product concentrations, whether a solid dosage form is long acting or short acting, and what kind of measuring device is used to measure liquids. Morphine oral solution is available in 10 mg per 5 mL, 20 mg per 5 mL, and 100 mg per 5 mL (20 mg/ mL) concentrations. When I see the 100 mg per 5 mL (20 mg/mL) concentration prescribed, I take particular care to draw attention to avoid dosing errors due to confusion between different concentrations and between milligrams and milliliters, which could result in accidental overdose and death. The same holds true for oxycodone concentrated oral solution that is available as a 20 mg/mL concentration.
Opioid administration errors are preventable events. As pharmacists, we are well positioned to teach safe practices in prescribing, use and monitoring of all medication.
Realizing her mistake, the nurse followed proper protocol and the physician was notified. The physician ordered naloxone administration with instruction that if the resident did not respond to the naloxone administration, they were to transport the resident to the hospital. The resident became alert and verbally responsive, therefore the nursing home staff decided against sending the resident to the hospital and opted to monitor vital signs. The next morning, the resident was found unresponsive, transported to the hospital and passed away three days later. The cause of death was morphine intoxication. In this case, one dose of naloxone was not enough to save this resident. Proper education of nursing staff in the use of naloxone may have saved this resident’s life. With hospital stays becoming shorter, more residents are being discharged on high potency opioids for acute pain control. We consultants must be sure that naloxone is stocked in the emergency kit. We also need to educate our providers on proper use and follow-up of naloxone. Having naloxone as a safeguard in the emergency kit is comforting, but as we learn from the article, if not used properly, the outcome can be devastating. It is just as important to provide periodic education updates on opioid products, concomitant use with benzodiazepines and how potential administration errors can be made. I always teach the five RIGHTS of medication administration: Right resident, Right drug, Right dose, Right route and Right time. Most medication errors can be avoided by reading the prescription label of each medication every time
Concomitant use of opioids and benzodiazepines or other CNS depressants may result in profound sedation, respiratory depression, coma, and death. We know that avoidance is best practice but is not always possible. Always stress extra monitoring and vigilance when taken together. Don’t forget another teaching moment concerning fentanyl patches and fever. There is Increased delivery of medication from patches associated with increased temperature. This could be clinically significant for new users of the patch and requires extra monitoring for signs of opioid toxicity. Opioid administration errors are preventable events. As pharmacists, we are well positioned to teach safe practices in prescribing, use and monitoring of all medication. A little extra time spent with the nursing facility team will help to ensure safer resident outcomes. §
COMPOUNDING ACADEMY REPORT
FDA Sends Warning Letter to PCCA Brooks Rogers, Pharm.D. Compounding Academy President
hile Covid-19 vaccines are currently dominating your pharmacy landscape, it may have been easy to miss the warning letter that the FDA sent to Professional Compounding Centers of America (PCCA) this January which stemmed from a visit to PCCA’s Houston facility in October 2019. PCCA is one of the largest Active Pharmaceutical Ingredient (API) wholesalers in the compounding space and has been a pillar in compounding education for decades. Findings from the FDA are nothing to take lightly. The letter from the FDA had three main discoveries: 1. PCCA received drug ingredients from at least one API supplier whose drugs had been placed on “import alert” at the time they were imported by PCCA. 2. PCCA failed to ensure that the glycerin API it repackages corresponds to appropriate quality standards. This failure causes the glycerin API to be impure and misbranded. 3. FDA requested that PCCA publicly disclosure their manufacturers.
It may have been easy to miss the warning letter that the FDA sent to Professional Compounding Centers of America (PCCA) this January which stemmed from a visit to PCCA’s Houston facility... Findings from the FDA are nothing to take lightly.
PCCA’s initial response to each of these findings are as follows: 1. None of our current API manufacturers are on FDA Import Alert. When a manufacturer is issued an Import Alert, PCCA immediately disqualifies and eliminates that manufacturer. 2. PCCA has complete confidence in the quality of the glycerin we provide and our glycerin manufacturer. Our glycerin is of the highest quality and PCCA has thoroughly validated this U.S.-based manufacturer. This manufacturer is also an FDA-registered facility. The FDA has asked for additional testing, in which PCCA is reviewing. 3. PCCA product labeling has been revised to ensure products are not “misbranded.” FDA wants to make sure that PCCA’s customers understand that PCCA is not the original manufacturer of the chemicals and bulk substances we sell. They want this clearly “branded” on product labeling. PCCA has revised our product labeling to clearly state that PCCA is a repacker or repackager. This change became effective as of January 25, 2021. PCCA upholds that there are no quality issues with any of their products, all of their products are from FDA-registered facilities and this will not affect your pharmacy operations or patients. PCCA has yet to provide a more detailed response on this matter, but in the meantime, back to your regularly scheduled programming: Covid-19 vaccines. §
THE ARKANSAS PHARMACIST