AJP Summer 2012

Summer 2012 Vol. 4, No. 2

Arizona Journal of Pharmacy

THE OFFICIAL PUBLICATION OF THE ARIZONA PHARMACY ASSOCIATION

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Arizona Journal of Pharmacy

THE OFFICIAL PUBLICATION OF THE ARIZONA PHARMACY ASSOCIATION

Vol. 4, No. 2

Summer 2012

In This Issue Columns

President’s Message CEO’s Message Academy News • Community Pharmacy Academy • Geriatric Care Academy

• Health-System Academy

• Managed Care Academy

• Technician Academy • Student Pharmacist Academy

2 3 26 26 27 28 28 29

Featured Articles

Estimation of Creatinine Clearance (CrCl) in Spinal Cord Injury The Age of Self Service A Look Back - Pap Boat Time Capsule The Road to Provider Status...Is a Bumpy One

Departments

New Members Association News PAPA Legislative Update Student Perspective • A Lifetime of Leadership Arizona State Board of Pharmacy In Memoriam Drug Information Question Feature Pharmacist • Collaborative Practice: A Look at the Modern Pharmacist Continuing Education

18 20 21 21 22

5 6 15 16 23 24 25 30

32 33

Editor

Kelly Ridgway, R.Ph, Chief Executive Officer

www.azpharmacy.org

Managing Editor

Janet Weigel Marketing and Communications Manager

Editorial Board

Leslie Rodriguez, Pharm.D. Whitney Rice, Pharm.D. Julie Hernandez, Pharm.D.

Tina Smith, Pharm.D., BCPS Nicholas Muscolino, Pharm.D.

Summer 2012 • Arizona Journal of Pharmacy • 1

President’s Message

Wait ‘Til Next Year! individuals who did not wait until next year.

Kevin Boesen, Pharm.D. AzPA President

It’s mid-June and the Cubs are in last place with the worst record in the majors. Wait ‘til next year!

For Cubs fans, there comes a time every year when the reality sets in that this is not going to be the year the Cubs finally win a World Series. When that time comes, we cling to the hope that next year brings. “Wait ‘til next year.”

That’s a saying Cubs fans know all too well. It’s been 104 years since our last World Series title in 1908.

I sometimes wonder when the first optimistic Cubs fan shouted, “wait ‘til next year.” Could it have been in 1912? After winning the World Series in 1907 and 1908, the Cubs were in the World Series again in 1910.

Unfortunately, they were beat that year by the Philadelphia Athletics. When the Athletics won again in 1911, maybe some crazy A’s fan was rubbing it in to a Cubs fan who finally said after months of harassment, “oh yeah, wait ‘til next year!”

Did that person really think they were going to wait ‘til next year for the next 100 years (and counting)? You could waste a lot of time waiting until next year. Would anything ever get done?

If “wait ‘til next year” really was first said in 1912, then it was first said the same year Arizona became a State. Arizona officially became a state on February 14, 1912. With this journal and our annual meeting held last month, we celebrate Arizona’s 100 years of history. One thing for certain is that Arizona’s history is filled with

A name familiar to many Arizona pharmacists, Carl T. Hayden, was Arizona’s first congressman. He served in Congress from 1912 to 1927 and then served in the Senate from 1927 to 1969. He has been called the single most important individual in transforming Arizona from a frontier territory to a modern state. Carl T. Hayden dedicated a life of service to Arizona. I bet Senator Hayden never waited until next year.

Patrick Tillman came to Arizona in 1994 to play college football for Arizona State University. Tillman excelled at Arizona State. He was voted Pac-10 Defensive Player of the Year in 1997 and graduated in three and a half years with 3.84 GPA. After college, Pat Tillman was drafted by and played for the Arizona Cardinals.

However, deeply affected by the events of September 11, 2001, Pat Tillman turned down a $3.6 million contract offer from the Cardinals and became an Army Ranger. In 2004, Pat Tillman was killed in Afghanistan while on a mission to disrupt and destroy the alQaida infrastructure. Pat Tillman paid the ultimate price for our great state and our great county. He definitely never waited until next year.

Rufus Lyman was a physician born in Nebraska in 1875. As professor of pharmacology at the University of Nebraska College of Medicine, Dr. Lyman pushed for the creation of a school of pharmacy and became the school’s first dean in 1908. He quickly became involved in pharmacy education nationally pushing for greater standards in education and licensure.

In 1946, after 38 years as dean at the University of Nebraska and a national leader in pharmacy education, Dr. Lyman retired at the age of 72. The following year, 1947, the University of Arizona Board of Regents voted to

2 • Arizona Journal of Pharmacy • Summer 2012

establish a school of pharmacy. Dr. Lyman was offered the position of directorship and became the school’s founding Dean. In 1950, the college graduated is first class and Dr. Lyman retired. Dr. Lyman began a tradition of excellence in pharmacy education by not waiting until next year.

These are three of many individuals that have inspired Arizonans to be great. While we can learn a lot from the examples of others, one specific thing I have learned is that to be great means that you can’t wait. You have to try.

You have to do.

This is my fourth and final message as your president. In my first message, I challenged you to let your passion for pharmacy do great things for your patients. Did you? In my second message, I asked you help prevent prescription drug misuse through participation in the association’s AWARxE program. Did you get involved? In my most recent message, I challenged you to find your voice. Did you find it? Did you share it with all who would listen?

I thank you for the opportunity you have given me to serve as your president this past year. It has truly been an honor. So many of my mentors are leaders in this organization. This association is filled with incredible individuals who have done great things for Arizona, for pharmacy, and for their patients. I have done my best this past year to continue that legacy. I hope all of you continue to follow their example and do great things. Most of all, I hope you do it this year. Because as this Cubs fan has learned, sometimes next year never comes.

CEO’s Message

We’ve Come A Long Way The Arizona Pharmacy Association is part of a tremendous legacy of pharmacy in our beautiful state. From the earliest Native American medicine men to today’s specialized pharmacists, Arizona’s pharmacy history is rich.

The first drug store in the Arizona Territory was opened in Tucson by Charles Meyer, a German immigrant, in 1858. By 1880 there were “druggists” in eight towns in Arizona, primarily attached to the mining industry.

Before statehood, the Arizona Territorial Board of Pharmacy was organized in 1903 with 150 pharmacists in the state. The Pharmaceutical Association of Arizona was founded in 1910 and counted all 270 pharmacists in the Arizona Territory as members.

Today there are nearly 10,000 pharmacists licensed to practice in the state of Arizona and almost 1700 pharmacies.

In November 1922, Fred Fleishman of Tucson, A. G. Hulett of Phoenix, and A. L. Boehmer of Phoenix, formed the Arizona Pharmaceutical Association.

The top photo on the cover of this issue of the Arizona Journal of Pharmacy is of the 44 pharmacists attending the First Annual Convention of the Arizona Pharmaceutical Association held in November 1923. Nearly 400 pharmacists, pharmacy technicians, and student pharmacists attended the 2012 AzPA Annual Meeting held last month.

The College of Pharmacy at the University of Arizona welcomed its first class of student pharmacists in 1947. In 1950, Elias Schlossberg, “the father of hospital pharmacy in Arizona,” organized the Arizona Society of Hospital Pharmacists (AzSHP). Dr. Albert Picchioni founded the Arizona Poisoning Control Information Center (now known as the Arizona Poison and Drug Information Center) at the University of Arizona College of Pharmacy in 1957. In 1998, Midwestern University opened its

Arizona campus in Glendale including the College of Pharmacy-Glendale.

Over the years, education requirements for pharmacy degrees ranged from none (up until 1913) to Pharm.G. (1826-1937) to Pharm.C. (1937-1950) to B.S. Pharm (19501992) to the current Pharm.D. Licensing of pharmacies in Arizona wasn’t mandated until 1935 and hospitals were added in 1950. By the 1970’s the Arizona Pharmacy Act was revised to include extensive definitions, fee changes, generic substitution, and Rx blanks standardization. The year 2000 brought the introduction of collaborative practice agreements.

Beginning in 2004 the state began licensing pharmacy technicians. That same year also saw the authority for pharmacists to administer immunizations with a prescription.

In 2009 immunization authority expanded to remove the prescription requirement for most adult vaccines and in 2011 children’s vaccines were added and certified pharmacy interns were allowed to administer vaccines under supervision. The 2011 legislation also redefined collaborative practice agreements to offer more opportunities for pharmacists to offer clinical services to their patients.

Pharmacy in Arizona has come a long way since territorial days and state associations have played an integral part in advancing the practice and the profession. The names and acronyms aren’t important – APA, AzSHP, ASCHP, SASHP, CACSHP, AzPA. What are important are the commitment and contributions of the Arizona pharmacy pioneers who formed these organizations and promoted their profession. From the first affiliation in 1910 to the current incarnation, pharmacy professionals have united for a common good: our patients.

Kelly Ridgway, R.Ph. AzPA CEO

The pharmacists of today are more than “druggists”. We are an integral part of the health care team. But there are still challenges ahead. As we are called upon to play an active role in prescription drug diversion prevention, maintain continuous quality assurance, and provide clinical services to our patients, the Arizona Pharmacy Association is committed to the effort to recognize pharmacists as health care providers under the Social Security Act. If you have not done so already, please go to the AzPA website to sign the petition and download talking points on this critical issue.

Yes, we’ve come a long way, but we have the potential and opportunity to go further and the Arizona Pharmacy Association - your state association will be there.

On the cover Past: First Annual Convention of the Arizona Pharmaceutical Association Present: Installation of the 2012-2013 AzPA Board of Directors Future: The 2012 Student Pharmacist Leadership Conference participants

Summer 2012 • Arizona Journal of Pharmacy • 3

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New Members

WELCOME NEW MEMBERS PHARMACISTS Eithu Zar Lwin Annette M McGee Mutiu Olusey Okanlawon Jens Timothy David Hill Kelly Holladay Benjamin Azizi Ying Baker Richard Bullard Matthew L Covert Rohit Deshmukh Lisa Dicks Jennie Do Elizabeth Dooling David L Gorneau Shelagh R Grosch Ha Hua Mohamed F Ismail Andy Kizer Ranjita J Kokje Wagma Komak David V Larson Julie M Lehn Reddy Srinivasa Male Donyaila McClendon Jairaj U. Mehta Cynthia Meyers Kenneth Morris James Moser

Joseph N Muise Jennifer Ann Ng Diana Nguyen Tram H Nguyen Pamela Piotrowski Anthony Rampersaud Sarah W Randolph Colin Richholt Garry L Roberts Michael Roman Venous Sadeghi Mark Sarnowski Carol Schneiderman Haissam Shiblak Quang B Truong Habibatu N Turay-Samura Matthew Varacallo Helen H Wang Arthur H West Rex Williams Mike Gruette Amira Mohamed Mohamed Salih Kal Stiles Mary Babico Shannon Davis Mark Harmon Jenna Houranieh Emily Lundeen Pratima Patel

Courtney E Pawula Steve Patrick Roberts Alan D Dobrowski ASSOCIATES Tamer A. Elbayoumi Andrew Esposito Elizabeth Hall-Lipsy Melanie A. Jordan Curt Maxfield Michael McDole Mark Olsen Joie Rowles Volkmar Weissig Tate Williams TECHNICIANS Lisa Abel James Andrew Candelaria Danielle Evans Judy Gielniak Andrea Merchant Tina Vo STUDENT PHARMACISTS Hillary Aphaisuwan Ashley R Brening Aleasha Brown Kenton Brown

Kirsten Butler Iris Chang Sophana Chhim Alejandra Cuevas Ashley DeStefano Nimat Fatohi Salvatore Foran Ryan Gries Benjamin Guthrie Sarah Heitland Matthew Joachim Heather L Lathim Renee Lee Matt Mahoney Whitney Morejon Jimmy Ngo Sharan Obregon Carly O’Neill Alen Pajazetovic Palna Suri Patel Sabrina Pennock Kristen Senson Jiten Sidhu Matthew Simpson Sandy Skouson Jessica Stiles Tyler Wonnacott

Do you know someone who is not a member of the Arizona Pharmacy Association . . . and should be?!

Invite them to join the only statewide organization that represents the pharmacy profession in Arizona.

Annual dues for a pharmacist are just $225 per year. This equates to: • Approximately 2/10 of 1% of the annual wage for a new practitioner pharmacist • Less than 5 hours of work per year, after taxes • Less than 62 cents per day Visit the AzPA website at www.azpharmacy.org to join online or to download a printable Membership Investment Statement.

Arizona Pharmacy Association

AzPA values its members and recognizes that your time is valuable. Monthly payment plans are available for pharmacist membership categories, as well as an automatic annual renewal option, when you provide your credit card information.

Summer 2012 • Arizona Journal of Pharmacy • 5

Association News Arizona Pharmacy Assocation Announces 2012-2013 Board of Directors The Arizona Pharmacy Association (AzPA) announces the election of the 2012-2013 Board of Directors. Beginning their oneyear terms in July 2012 are: Michael Dietrich, President Sandra Leal, President-Elect Kevin Boesen, Past President Dawn Knudsen Gerber, Treasurer Ray Clark, Secretary Kristen Calabro, Community Pharmacy Academy Chair Elizabeth Louton, Community Pharmacy Academy Chair-Elect Tara Storjohann, Geriatric Care Academy Chair Elizabeth Pogge, Geriatric Care Academy Chair-Elect Lindsay Davis, Health-System Academy Chair

Kristen Allison, Health-System Academy Chair-Elect Ann Sears, Managed Care Academy Chair Eric Luecht, Managed Care Academy Chair-Elect Joy Davis, Technician Academy Chair Judith Day, Technician Academy Chair-Elect Eric Wong, Student Pharmacist Academy Chair University of Arizona COP Sophia Galloway, Student Pharmacist Academy Chair, Midwestern University CPG Pritesh Patel, Student Pharmacist Academy Chair-Elect,University of Arizona COP Norbert Laskowski, Northwest District Director Mary Lou Brubaker, Northeast District Director OPEN, Southwest District Director

Ken Fletcher, Southeast District Director Kyle Linhardt, Industry Representative J. Lyle Bootman, Dean, University of Arizona COP Dennis McCallian, Dean, Midwestern University CPG Roger Morris, Legal Counsel Election of the Student Pharmacist Academy Chair-Elect for Midwestern University College of Pharmacy Glendale will take place in August 2012. The 20122013 AzPA Board of Directors were installed during the AzPA 8th Annual Meeting at the Wigwam Resort Spa in Litchfield Park, Arizona, during the AzPA Annual Awards Banquet on June 30, 2012.

Installation of the 2012-2013 Arizona Pharmacy Association Board of Directors.

Front Row (l to r): Dennis McCallian, Pritesh Patel, Judith Day, Elizabeth Pogge, Joy Davis, Sandra Leal, Kevin Boesen, Michael Dietrich, Sophia Galloway.

Middle Row (l to r): Norbert Laskowski, Eric Wong, Eric Luecht, Ann Sears, Ray Clark, Elizabeth Louton, Kristin Calabro, Dawn Knudsen Gerber.

Back Row (l to r): Tara Storjohann, Lindsay Davis, Kyle Linhardt, Ken Fletcher.

6 • Arizona Journal of Pharmacy • Summer 2012

Association News

Cheers for Volunteers!

The Arizona Pharmacy Association staff is here to support YOU - our members. We acknowledge the contributions of the volunteers who have made a difference for our organization and their fellow pharmacy professionals. Thank you for all you do!

Eric Perry Jon Glover Whitney Rice Nick Muscolino Julie Hernandez Ann Sears Dawn Knudsen Gerber Teresa Stickler Kristin Calabro Mark Boesen

Ken Fletcher Steve LeMahieu Terry Daane Ken Mahan Laura Hanson Dean Wright Hal Wand Stacy Haber Tina Smith Chris Meilinger Kim Cauthon Grace Akoh-Arrey Betty Louton Nicole Romney Sandra Leal Kelly Green Boesen Ken Baker Mindy Throm Burnworth Nicole Scovis Terri Warholak Bao Nguyen Lindsay Davis

Jon Merchen Kristin Allison Joy Davis Mike Severn Chris Lesaca Kevin Boesen Roger Morris Mitch Buckley Carol Rollins Martie Fankhauser Greg Morrill Cheryl Shafer Bob Lipsy Lyle Bootman Crane Davis Lindsay Huxtable John Murphy Alan Barreuther Elizabeth Pogge Erin Raney Kip Raney Mary Gurney

PharmPAC Sets New Record for Drawdown Ticket Sales The Pharmacists Political Action Committee of Arizona (PharmPAC) held the PharmPAC Drawdown Roundup to raise funds in support of pharmacy political action. A record $12,900 was raised with the total being split between the PharmPAC fund and 10 lucky winners. The winning tickets were drawn by Jacob Boesen during the AzPA Annual Awards Banquet on Saturday, June 30, 2012. Cash prizes totaling $6,450 were awarded: Betty Louton Kris Kaniski Lynn Patton Betty Louton Dawn Gerber Sandra Leal Whitney Shields/Kristin Calabro Dean Wright Jeremy Gerber Whitney Rice

$3225.00 $1612.50 $ 322.50 $ 322.50 $ 161.25 $ 161.25 $ 161.25 $ 161.25 $ 161.25 $ 161.25

The AzPA PharmPAC plays an important role in advancing the legislative interests of the pharmacy profession.

PharmPAC members must be AzPA members. PharmPAC contributions are not tax-deductible. To make a contribution go to www.azpharmacy.org/PharmPAC.

Jacob Boesen and Kelly Ridgway draw the PharmPAC Drawdown winning tickets.

PharmPAC Drawdown Winners (l to r): Lynn Patton, Betty Louton, Kristin Calabro, Whitney Shields, Dawn Gerber, and Sandra Leal.

Summer 2012 • Arizona Journal of Pharmacy • 7

Association News AzPA 8th Annual Meeting Annual Awards Presentations Outstanding Leadership Award In recognition of exceptional leadership qualities and vision displayed during the past year.

Presented to Kevin Boesen, Pharm.D. Outgoing President Award Sponsored by McKesson Presented to Kevin Boesen, Pharm.D. Pharmacy Leadership Award Sponsored by NCPA In recognition of accomplished leadership in the advancement of pharmacy.

Presented to Michael Dietrich, Pharm.D. Incoming President Award Sponsored by AmerisourceBergen Presented to Michael Dietrich, Pharm.D. Pharmacy Appreciation Awards Individuals who have demonstrated very special or unique interest and concern for the advancement of Arizona pharmacy as reflected by dedicating significant personal time and effort in completion of one or more special activities or services for AzPA and/or the profession of pharmacy.

Presented to: Roger Morris, R.Ph., J.D. Representative Ted Vogt Corporate Appreciation Award A corporation or business who serves Arizona pharmacy, routinely demonstrates a very high level of professionalism, and is committed to improving medication use by supporting AzPA in a significant way.

Presented to AmerisourceBergen/Good Neighbor Pharmacy and Safeway, Inc.

Exemplary Patient Care Award An Arizona pharmacist who provides or enables exemplary patient care, regardless of practice setting, by consistently providing exemplary patient care services, serving as a role model for contemporary pharmacy practice, or developing or fostering the development of an innovative pharmacy practice resulting in improved patient care.

Presented to Hanna Phan, Pharm.D. Excellence in Innovation Award Sponsored by Upsher-Smith Laboratories A practicing pharmacist in Arizona who has demonstrated significant innovations in their respective pharmacy practice.

Presented to Lindsay Davis, Pharm.D. Distinguished Young Pharmacist of the Year Sponsored by Pharmacist Mutual Insurance Companies An Arizona pharmacist who has demonstrated significant leadership in Arizona pharmacy in the previous year. Contributions can relate to AzPA participation, activities within his/her professional practice, or community service.

Presented to Stephen Perona, Pharm.D. Bowl of Hygeia Sponsored by APhA and NASPA with support from Boehringer-Ingelheim The highest level of recognition provided to an Arizona pharmacist who has compiled an outstanding record of community service.

Presented to Hal Wand, Jr., R.Ph. AzPA Hall of Fame Award In honor of a pharmacist member of AzPA with at least 10 years of practice experience in Arizona who has demonstrated innovation or excellence in practice, education, or research.

This person is an Arizona pharmacy pioneer who has been instrumental in advancing the profession of pharmacy by promoting the importance of innovation and integrity in the field.

Presented to Albert L. Picchioni, MS Pharm., Ph.D. Awarded posthumously

PHOTOS - THIS pAGE. 1. Dr. Mary Picchioni represents her family celebrating Dr. Albert Picchioni’s induction into the Arizona Pharmacy Association Hall of Fame.

2. Nicole Runge is recognized by Crane Davis as the Technician of the Year.

3. Ray Nelson Clark, Jr., receives the Pharmacist of the Year Award from Jon Glover.

PHOTOS - FACING pAGE 1. Rep. Ted Vogt (center) receives an AzPA Pharmacy Appreciation Award from Kevin Boesen and Kelly Ridgway.

2. Eric Perry (center) accepts the Corporate Appreciation Award on behalf of Safeway.

3. Eileen Telles and Julie Miramont represent AmerisourceBergen/Good Neighbor Pharmacy for the Corporate Appreciation Award presentation.

4. Hanna Phan receives the Exemplary Patient Care Award from Mike Dietrich.

5. Lindsay Davis, accepts the Excellence in Innovation Award from Mike Dietrich.

6. Stephen Perona is honored with the Distinguished Young Pharmacist Award by Ryan Goodrich from Pharmacists Mutual and Whitney Shields.

7. Hal Wand receives the Bowl of Hygeia Award from Bill O’Neill (Boehringer Ingelheim), Dean Wright, and Chayenne Cook (Boehringer Ingelheim).

8. Kevin Boesen accepts the Outgoing President Award from Jeff Marshall of McKesson.

9. Mike Dietrich is recognized as Incoming President by Phil Guillen of AmerisourceBergen.

10. AzPA 2012-2013 President Mike Dietrich accepts the gavel from 2011-2012 President Kevin Boesen.

8 • Arizona Journal of Pharmacy • Summer 2012

Technician of the Year Award An Arizona pharmacy technician who has excelled in the field of pharmacy technology and has demonstrated a high level of service and professionalism in pharmacy during the previous year.

Presented to Nicole Runge, C.Ph.T. Pharmacist of the Year Sponsored by Pfizer An Arizona pharmacist who has actively demonstrated outstanding leadership and service for AzPA or for the profession of pharmacy in Arizona during the previous year.

Accomplishments include providing significant AzPA organizational leadership and reflect ongoing personal time and effort to mentor and/or serve the needs of AzPA members and Arizona pharmacy.

Presented to Ray Nelson Clark, Jr., Pharm.D.

Association News

Association News

Thank you to our VIP Reception Sponsors AmerisourceBergen Boehringer Ingelheim Cardinal Health Celgene Johnson & Johnson McKesson Pfizer PhRMA

10 • Arizona Journal of Pharmacy • Summer 2012

VIP RECEPTION PHOTOS 1. Janice Ganann and Larry Ganann.

2. Betty Louton, Virginia Boomershine, Mark Harmon, Eric Perry, and Jim Louton.

3. Ken Cross and Joe Rowan.

4. John Murphy and Debbie Murphy.

5. Devi Anderson and Larry Anderson (seated), Mike Gibbons and Tom Van Hassel (standing).

6. Norbert Laskowski, Paul Smith, Mindy Burnworth, Ken Mahan, and Shelli Laskowski.

7. Christine Barreuther, Mike Kalsman, and Kathryn Kalsman.

8. Ed Hunter, Tom Branson, Marty Branson, and Cindi Hunter.

Association News Midwestern University Dessert Reception 1. Bao Nguyen, Erin Raney, Julia Liu, and Nhung Luong.

2. Maria Chase, Jim Chase, and Steve LeMahieu.

3. Joy Davis, Jenny Whitney, Lee Ellershaw, and Carla Rowe-Malcolm.

4. Tina Johnson, Bob Johnson, Amy Woodbeck, Ron Woodbeck, and Bonnie DiLorenzo.

5. Falene Fletcher, Ken Fletcher, and Jim Kloster.

University of Arizona Reception 1. Kelly Green Boesen, Sandra Leal, and Kresta Leal.

2. Kristin Calabro, Whitney Shields, and Jennifer Knutson.

3. Stephen Perona and Shayla Perona.

4. Kathleen White, Michelle Nemetz, Jenene Spencer, Newsha Sarmadnia, and Sara Azimian.

5. Laura Adams and Robert Squire.

Summer 2012 • Arizona Journal of Pharmacy • 11

Association News Thank you to our 2012 Annual Meeting Exhibitors and Sponsors EXHIBITORS Agency for Healthcare Research & Quality American Regent, Inc Ameridose AmerisourceBergen/Good Neighbor Pharmacy Amylin Pharmaceuticals APP Pharmaceuticals Arizona Health-e Connection Arizona Pharmacy Foundation Arizona Smokers Helpline B. Braun/CAPS BD Diabetes Boehringer Ingelheim Pharmaceuticals BTG, PLC Cardinal Health CSL Behring Cubist Pharmaceuticals CVS Caremark Daiichi Sankyo Express Scripts Forest Pharmaceuticals Freedom Pharmceuticals Fry’s Pharmacy

Grifols Humana RightSource Rx LifeScan, Inc. Lilly USA McKesson Merck Vaccines Midwestern University CPG Nephron Pharmaceuticals NIPRO Diagnostics, Inc. Novo Nordisk Otsuka Pharmaceutical Pharmacists Mutual Companies PharMEDIUM Services Roche Diabetes Care Rx Relief Safeway, Inc. Sanofi Pharmaceuticals U S Army Medical Recruiting University of Arizona COP University of Florida COP Watson Pharmaceuticals

AzPA Exhibitors and Sponsors 1. Cardinal Health: Brian Willis, Riley McLaughlin, and Joel Butler.

2. McKesson: Ruben Vital, Joe Kliegl, Tricia Robleto, Jeff Marshall, and Mike Gibbons.

3. Amerisource Bergen: Scott Dahlstrom, Eileen Telles, Joe Williamson, Phil Guillen, and Oscar Acosta.

4. Fry’s: Nicole Runge, Jenny Whitney, Shannon Gentry, and Crane Davis.

5. Express Scripts: Kevin Dominguez and Jack Lin. 12 • Arizona Journal of Pharmacy • Summer 2012

MEETING SPONSORS AmerisourceBergen/Good Neighbor Pharmacy BD Diabetes Boehringer Ingelheim Cardinal Health Celgene Fry’s Pharmacy Johnson & Johnson McKesson Pfizer PhRMA Truven Health Analytics GOLF SPONSORS Above & Beyond Delivery, Inc. AmerisourceBergen/Good Neighbor Pharmacy Berry/Kerr Prescription Packaging Cardinal Health Diamondback Drugs Express Scripts Fry’s Pharmacy Johnson & Johnson McKesson

Association News

Check out all the photos from the Arizona Pharmacy Association 8th Annual Meeting on the AzPA website at www.azpharmacy.org.

1. AzPA Past Presidents: (l to r) : Crane Davis, Mike Dietrich, Terry Daane, Bob Lipsy, Alan Barreuther, Tom Van Hassel, Brian Erstad, Kathryn Kalsman, Tom Batik, Mike Kalsman, Kevin Boesen, Kelly Ridgway, Jon Glover, Steve LeMahieu, Mark Boesen, and Sharon Roberson.

2. Ronald Obrique, Asal Azizoddin, and Kristen Senson.

3.

4.

5.

6.

7.

8.

Laurita Lipsy, Jon Glover, and Bob Lipsy.

Dean Wright in PharmPAC jail.

Denny McCallian and Terry Daane.

Elizabeth Pogge and Tara Storjohann.

Judy Lee and David Lee. Consuelo Pitpitan and Laurita Lipsy.

9. Jeremy Gerber and Dawn Gerber.

10. Crane Davis in PharmPAC jail.

11. Taylor Romney and Nicole Romney.

Summer 2012 • Arizona Journal of Pharmacy • 13

Association News APF News At its July 2012 meeting the Arizona Pharmacy Foundation confirmed the appointment of three members-at-large to the board of directors: Kenneth Berry, Mark Boesen, and Chris Lesaca. These members join President Steve LeMahieu, Vice President Terry Daane, Treasurer Ken Mahan, and Members-at-Large Kevin Boesen, Michael Dietrich, and Roger Morris.

APF Golf Tournament The Annual Arizona Pharmacy Foundation Golf Tournament was held Sunday, July 1, 2012 at The Wigwam Golf Course. More than 50 golfers participated in the four-person scramble event. In a very close contest, taking first place were Terry Daane, Matt Johnson, Ken Mulley, and Rod Shafer. Second place was won by Jeremy Gerber and Mike Murosky.

In third place were Rory Albert, Gary Atkinson, Matt Gentry, and Steve LeMahieu. Proceeds from the tournament benefit the Llyn Lloyd Service to Pharmacy Scholarship supporting student pharmacists at Midwestern University and the University of Arizona.

Many thanks to our tournament sponsors: Above & Beyond Delivery, AmerisourceBergen/Good Neighbor Pharmacy, Berry/Kerr Prescription Packaging, Cardinal Health, Diamondback Drugs, Express Scripts, Fry’s Pharmacy, Johnson & Johnson, and McKesson.

Silent Auction The Foundation also held its silent auction during the AzPA Annual Meeting. For the third year in a row Dr. Robert Kravetz, Phoenix gastroenterologist and pharmacy memorabilia afficiando, generously donated items from his personal collection to the Foundation for the auction. Items included a 1926 edition of Remington’s Practice of Pharmacy, a tyrian atomizer, assorted elixirs and tonics, and apothecary glassware.

The auction raised more than $800 for APF. Many thanks to Dr. Kravetz for continuing to support the Arizona Pharmacy Foundation with his contributions.

The Arizona Pharmacy Foundation is a nonprofit 501(c)3 charitable organization. Its mission is to educate the public concerning the delivery of pharmaceutical care.

14 • Arizona Journal of Pharmacy • Summer 2012

AzPA Calendar of Events September 8, 2012 PTCB Exam Prep Course Begins September 22, 2012 Community Pharmacy Academy Conference October 2012 Managed Care Academy Conference American Pharmacists Month November 2012 Technician Academy Conference Anticoagulation Certificate Program January 2013 Midyear Meeting January 23, 2013 Pharmacy Day at the State Capitol Visit www.azpharmacy.org for all upcoming events.

Arizona Pharmacy Association

The voice of pharmacy in Arizona.

SAVE THE DATE! COMMUNITY PHARMACY ACADEMY CONFERENCE

Saturday, September 22, 2012 8:30 am to 4:00 pm Crowne Plaza Phoenix Airport Hotel 4300 East WashingtonStreet Phoenix, Arizona 85034 AzPA Member Pharmacist Non-Member Pharmacist AzPA Member Allied Pharmacy Non-Member Allied Pharmacy

$55 $85 $25 $35

Go to www.azpharmacy.org to register.

PAPA My Experience at the Utah School on Alcoholism and Drug Addiction

by Anonymous

Amidst my own feelings of bewilderment and resentment, I received a chance to attend the annual Utah School on Alcoholism and Drug Addiction for pharmacists and other health care professionals. My experience was a personal journey of healing the pain surrounding my addiction. I hoped to find a new direction for my career, a way to combine pharmacy and addiction through networking with others in the addiction recovery and treatment community. Most importantly, I discovered gratitude for my current circumstances.

Despite the roughly one in ten odds of having the disease of addiction, I found myself two and a half years into a five-year monitoring program in order to keep my pharmacy license after being diagnosed with substance dependency. Being able to openly discuss my experience with other pharmacists who are currently or were previously in a monitoring program, significantly reduced my own shame and guilt over my past behavior. Additionally, I was informed about the latest research that shows which areas in the brain are affected and why I have an inability to stop or moderate alcohol or drug use in the face of terrible consequences. My shame has been lessened because others have given energy bringing people together to learn and share about the disease of addiction.

Throughout the weeks, we were introduced to various twelve-step groups, including Alcoholics Anonymous, Al-Anon, and Narcotics Anonymous.

This is the first professional conference I attended where I had tears in my eyes while listening to fellow attendees describe the pain and hurt from the affects drug addiction has had on them and their loved ones’ lives. I was reminded of my sadness and anger about the harm done to myself, my family, and my friends.

Thankfully I am in a twelve step program and have tools to help me process my emotions. I am grateful for a treatment that has saved my life and I can carry it to others who still suffer.

After this week (at the school), I am less worried about the causes of my addiction and more interested in what I can do with my experience. I felt a positive connection to the pharmacy profession that I

previously saw as more of a problem than a solution to drug addiction. As a retail pharmacist, I see many controlled substance prescriptions that I fear may be illegitimate or forged. I was relieved to hear that I can be assured that there is a place for pain and anxiety medications in health care even though they can be abused. Along with clinical pearls from an addictionologist, I received a booklet about drugs that can be used safely by those with a history of substance dependency.

Overall, I am grateful for my addiction because it has allowed me to express my emotions and examine what I ultimately want in my life. Because of hearing others’ stories, I am grateful I did not hurt more people in my addiction. I am grateful for my current employer for giving me a second chance at a career in pharmacy. After a week of learning, I still have plenty of unanswered questions, but I am content with that. I do not know where I will be in a year, but I know that at the moment I am helping others and myself. And for that I am grateful.

If you or someone you care about is suffering from an alcohol and/or chemical dependency problem…

“A Partnership in Caring”

Pharmacists Assisting Pharmacists of Arizona (PAPA)

is Available For Help and Information CALL LISA YATES AT 928-532-2293 ALL CALLS CONFIDENTIAL • CALLER REMAINS ANONYMOUS Summer 2012 • Arizona Journal of Pharmacy • 15

Legislative Update AzPA Final Report 50th Legislature, 2nd Regular Session (2012)

Prepared by Jeff Gray, R & R Partners, AzPA Contract Lobbyist Days of Session: 116 Adjourned, Sine Die: Thursday, May, 3, 2012 at 8:25 PM General Effective Date: Thursday, August, 2, 2012 Bills Posted: 1,395 Bills Passed: 387 Bills Signed: 362 Bills Vetoed: 26 Bills Filed Without Signature: 0 Special Sessions Called: 0 Ballot Measures Referred This Session: 5 2012 Session at a Glance The Second Regular Session of the 50th Arizona State Legislature convened on January 9, 2012 amid a host of changes in members and leadership in both chambers. Former Speaker Kirk Adams, R-Mesa, stepped down in late April of 2011 to begin his campaign for Congress. Former Senate President Russell Pearce, R-Mesa, lost in a recall election in November to political newcomer Jerry Lewis, R-Mesa. This marked the first successful recall election of a sitting Senate President in Arizona’s history.

Both Majority Whips in the House and Senate were elevated Speaker and Senate President respectively (Speaker Andy Tobin, R-Dewey, and Senate President Steve Pierce, R-Prescott).

Both leaders focused intensely on job creation and economic development this legislative session. Senator Kyrsten Sinema, D-Phoenix, also stepped down in early January to run for Congress and Senator Scott Bundgaard, R-Peoria, stepped down moments before his testimony in the Senate Ethics Committee over a domestic incident. In the House, Representative Richard Miranda, D-Phoenix (arrested for theft and fraud in a nonprofit he ran) stepped down and Daniel Patterson, D-Tucson, resigned after his Ethics Committee hearing where the committee recommended expulsion over several domestic incidents. The Arizona Legislature was one resignation away from breaking the state record of members leaving during session. At least 15 Arizona lawmakers have announced their retirement or plans to seek another office.

While last session had various immigration reform bills circulating the Legislature, this session Republicans focused on passing legislation to create a stronger work force and business friendly environment. Taking full advantage of the super majorities in both chambers and a Republican governor, various tax reform, tort reform, regulatory reform and workers’ compensation legislation successfully passed.

For the first time in years, the Legislature and Executive had a budget surplus. The big debate was how much revenue needed to be set aside to prepare the end of the 1 cent sales tax in fiscal year 2014 and implementation of federal health care reform. Budget talks became much more heated toward the end of session when Governor Brewer asserted that she would veto any bill that was sent up to her until they had created a budget.

16 • Arizona Journal of Pharmacy • Summer 2012

Specific Issues/Actions HB2035 medical marijuana (Yee) – AzPA SUPPORTED AzPA supported this bill, specifically the provision allowing for discipline for providers making medical marijuana recommendations without first checking the prescription monitoring database. The requirement of providers was a specific recommendation that was made by AzPA as the Dept of Health Services was drafting rules for the program shortly after the law was passed by the voters. AzPA was asked to testify in the Senate on the scope and use of the prescription monitoring database. The bill was signed by the Governor.

HB2263 meth precursor logging system (Carter) - AzPA SUPPORTED The bill was introduced by the Consumer Healthcare Products Association, manufacturers of pseudoephedrine products.

The Association is running this bill in a host of states as a measure to prevent law enforcement from requiring the sale of pseudoephedrine products to be prescription only. The bill replaces written pseudoephedrine logging requirements with an electronic version (NPLEx) paid for by manufactures of the drugs (i.e. there is no charge for the hardware or access to the system).

A key provision is that it prohibits redundant reporting to local governments. AzPA requested amendments to allow written logs in situations where the pharmacy/retailer did not have access to the internet, which were adopted in the House. The bill was signed by the Governor. Retailers must begin using the system by Jan. 1, 2013.

Synthetic Drugs HB2356 drugs definitions (Fann) - AzPA SUPPORTED HB2356 added the chemicals that constitute “bath salts” to the list of dangerous drugs and schedule IV drugs. The bill was signed by the Governor.

SB1073(L. Gray)/HB2388 (Pratt) pharmacy board; drug schedules; rules - AzPA SUPPORTED After several sessions of the Legislature passing bills banning chemical compounds that constitute various forms of synthetic marijuana, meth, cocaine, etc., Senator Linda Gray wanted to run legislation to allow the state to be more proactive rather than waiting to ban chemicals once they had become highly prevalent. AzPA participated in stakeholder meeting with Sen. Gray prior to the legislative session and worked closely with her staff and the AZ Prosecuting Attorneys Advisory Council on a proactive statutory mechanism. The method that seemed the most plausible was to allow the AZ Board of Pharmacy by rule ban the sale of certain substances, then allow the legislature the following session to add such chemicals to the Title 13 criminal statute, thus banning the possession. The concept had the support of many rank and file legislators, but was opposed by House Judiciary Chairman Eddie Farnsworth, who would not give SB1073 a hearing in the House after it passed unanimously from the Senate. A striker vehicle was used to move the bill (HB2388) in the Senate. By this time, Rep. Farnsworth had worked to bring several senators in opposition to the bill by arguing that the bill was an unconstitutional delegation of authority to the Executive.

Despite these arguments, the bill once again passed the Senate by an 18-11 vote. The bill was never placed on a final read calendar in the House.

Legislative Update HB2369 electronic medical records (Carter) - AzPA SUPPORTED The bill is a follow up to the electronic medical records legislation passed last year, mostly cleaning up a host of provisions. It also included an amendment to A.R.S. § 36-2525 regarding electronic prescribing of controlled substances. The language was included at the request of the Arizona Community Pharmacy Committee and supported by AzPA, to ensure that Arizona law does not prohibit e-prescribing of controlled substances as permitted by federal law. The federal DEA rules became effective on June 1, 2010 and revise DEA’s regulations to provide practitioners with the option of writing prescriptions for controlled substances electronically and also permits pharmacies to receive and dispense the electronic prescriptions.

The electronic prescription and the pharmacy application would need to meet DEA requirements. The language proposed is taken from model language from the NACDS. The bill was signed by the Governor.

HB2646 pharmacy board; transfer of monies (Vogt) - AzPA SUPPORTED The bill permits the Executive Director to transfer up to $1 million annually from the Fund to the UofA Poison Control Center and clarifies that the monies transferred will supplement, rather than supplant, any state General Fund appropriations the Center may receive. The supplement/supplant language was included at the request of AzPA so the Board of Pharmacy monies could not be permanently used to fund the center. AzPA supported the bill and testified in the House and Senate Appropriations committees. The message for support was threefold during testimony: 1) the accreditation of the UofA School of Pharmacy is tied to the poison control center, which is underfunded.

Without a healthy Center, the School would be at risk; 2) most UofA pharmacy students take a rotation through the Center, thus allowing them to gain significant professional development; and 3) this funding mechanism is meant to serve as a temporary bandaid until a longer term solution is determined. Pharmacy Board funding is not intended to be permanent. The bill was signed by the Governor.

HB2730 prescriptions; foreign pharmacies (Crandell) - AzPA OPPOSED The sponsor and staff reached out to AzPA before the bill was introduced to get initial feedback. AzPA assisted in an initial stakeholder meeting with the sponsor to determine if there was an administrative solution to assist the constituent pushing for the bill (a physician providing services via a monthly service fee rather that requiring health insurance). The constituent wants to provide his patients with access to affordable prescriptions. After it was determined that the constituent did not want to partner with local pharmacies, but simply wanted to run a foreign import bill, AzPA informed the sponsor of opposition to the bill in its current form. AzPA helped facilitate a second larger stakeholder meeting which included drug manufacturers, as well as the constituent.

After outlining the lack of safety protocols in place for drugs manufactured overseas, the sponsor agreed to hold the bill.

HB2739 (McLain)/SB1043 (L.Gray) vaccines; health insurance - AzPA SUPPORTED This bill would have mandated specific reimbursement for child vaccinations. It was the second year that House Banking & Insurance Committee Chair, Representative Nancy McLain (R-Bullhead City), ran such a bill on behalf of the AZ Chapter of the American Academy of Pediatrics. Last session, Rep. McLain pulled the legislation under the commitment from health plans to work with the pediatricians over the interim to address their concerns. After numerous meetings during the interim between physicians and health plans to discuss reimbursement for vaccination costs, several of the health plans did not respond or did not make any adjustments in reimbursement rates. United Healthcare and Blue Cross Blue Shield of Arizona did address many of the concerns raised. However, because some of the plans did not respond to the extent that UHC and BXBS did, Rep. McLain re-introduced the legislation. While the health plans tried to work out a compromise with Rep. McLain, no agreement was reached with the pediatricians. The original bill, HB2739 passed the House 45-12. Once it reached the Senate, the bill was only assigning to Rules, essentially killing it for the session. Rep. McLain then again attempted to have the legislation move forward by having the legislation amended onto SB1043 in the House Government Committee via a strike-everything amendment. During this time, those that had raised concerns with the bill began exploring whether Arizona should consider creating a vaccine association similar to what has been done in a handful of states (such as Washington) to address the issue of reimbursement. While stakeholders discussed the concept of an association in lieu of a bill, Rep. McLain and the Pediatricians continued to move forward SB1043, where it passed the House 43-16. In April, the Governor’s Office of Strategic Budgeting and Planning calculated the potential increase in costs of this bill on the state health insurance plan, which was estimated to be $800,000 per year. After learning of this cost, both Appropriations Chairs in the House, Representative John Kavanagh, and Senate, Senator Don Shooter, requested a fiscal note from the Joint Legislative Budget Committee who also estimated the cost at $800,000 annually. JLBC also concluded that the bill would increase the cost of private healthcare insurance premiums and estimated that an additional $80,000 would be collected in premium tax collections. Once Rep. McLain learned of the annual cost to the state, she pulled the bill and it was not final read in the Senate. At this point, she does not intend on introducing the same legislation next session.

Sunrise Applications – AzPA OPPOSED AzPA had opposed the proposed expansion of the scope of practice for chiropractors and psychologists during the sunrise process this past fall/winter. Consistent with statutory requirements, the proponents did not move forward with legislation in 2012, but will likely be back reintroducing a new sunrise application later this fall.

Summer 2012 • Arizona Journal of Pharmacy • 17

Featured Article Estimation of Creatinine Clearance (CrCl) in Spinal Cord Injury

by John Bouchard, Pharm.D. Candidate, Midwestern University College of Pharmacy-Glendale, Class of 2012

Patients with a spinal cord injury (SCI) are a unique population set that presents with complications beyond permanent sensory and motor defects from their chief disability. Complications of SCI include delayed gastric emptying, decreased organ and tissue perfusion, impaired immune functions, and increased volume of distribution.1 Higher rates of obesity, decreased lean tissue, and increased fat mass are also more prevalent in SCI patients compared to able-bodied patients of similar age, height, and weight.2 These factors add to the complexity of treating infections using medications which require renal dosing. Standard practice for renal dosing aminoglycosides and vancomycin use the Cockcroft-Gault equation to estimate creatinine clearance. However, the Cockcroft-Gault equation relies on serum creatinine (SCr) levels and body weight. Body weight can be ideal, actual, or adjusted (if the actual weight is 120% of the ideal weight).

Research has found that patients with SCI have a decreased muscle mass which results in lower SCr levels regardless of kidney function.1 Creatinine production in patients with SCI is often decreased due to muscle atrophy from muscle denervation.3 As a result, estimating creatinine clearance by using the Cockcroft-Gault equation in SCI patients leads to clinically unacceptable results with an overestimation averaging 36%.3 One study found the overestimation to be 64% in tetraplegics (quadriplegics) and 24% in paraplegics.4 With inaccuracies of this magnitude, there must be a modification to the Cockcroft-Gault equation or another method must exist that is more accurate and practical to use on a regular basis.

A literature search was performed using OVID and IPA with the following search terms: Cockcroft-Gault, CrCl, creatinine clearance, SCI, spinal cord injury, quadriplegia, tetraplegia, paraplegia, renal failure, AKI, acute kidney injury, BMI, body mass index, IBW, and ideal body weight. Studies were selected based on relevance and date of publication.

Three studies on estimating creatinine clearance (CrCl) and one study regarding body mass index (BMI) were selected for this topic. No studies regarding ideal body weight of patients with SCI were identified in OVID or IPA using the search terms aforementioned. However, IBW guidelines stated on the American Dietetic Association’s website was extracted for this drug information inquiry.

One study compared the creatinine clearances of 36 SCI patients using the Cockcroft-Gault equation and 24-hour endogenous clearances.3 The results differed by 36.2%.3 The authors stated that the Cockcroft-Gault calculations were clinically unacceptable when compared to the 24-hour endogenous calculations.3 Although 24-hour urine collection provides more accurate results when compared to the Cockcroft-Gault formula, it is not a practical testing method.

It requires 24 hours to pass before dosing can be calculated.

Also, it needs the cooperation of multiple personnel and can prove to be difficult to accurately obtain.1 18 • Arizona Journal of Pharmacy • Summer 2012

Another method involves the endogenous protein, cystatin C, to assess renal function.1 Cystatin C is freely filtered at the glomerulus and has been determined to be independent of muscle mass.1 The authors state that it is the most accurate estimation compared to the clearance values obtained by the CockcroftGault and 24-hour urine collection methods.1 However, the test is expensive in comparison to the other methods and may not be available at many practice sites.1 One article proposed a series of recommendations to estimating the creatinine clearance of patients with SCI.1 The first recommendation is to ensure that the renal-dosed medication is indicated and effective for the treatment of the infection or disease.1 Second, avoid these medications if suitable alternatives are available.1 If alternatives are unavailable, then use the cystatin C method or the 24-hour urine collection if possible.1 Otherwise, use the Cockcroft-Gault formula and understand that it will be an overestimation of the true clearance.1,4 In this case, use a correction factor of 0.8 for paraplegics or 0.6 for tetraplegics.1,4 The Cockcroft-Gault equation with correction factors are listed below (where ABW is the adjusted body weight):

The correction factor was identified after observing the creatinine clearance in 36 male tetraplegics and 22 male paraplegics.4 The study compared the Cockcroft-Gault results to the results of the 24 hour urine collection creatinine clearance.

There was an overestimation in the Cockcroft-Gault result by 67% compared to the patient’s 24-hour clearance calculation.4 It was noted that able-bodied patients had a 24-hour urinary creatinine production greater than SCI patients of similar height and weight by 34% in men and 54% in women.4 Finding articles on ideal body weight for the SCI patient was a challenge. However, BMI evidence was in bulk and all had a similar theme. SCI patients have a greater body fat percentage and have a reduced lean tissue mass than their able-bodied control groups.2 Total body fat percentage was significantly higher in paraplegics (31.4% ± 1.2%) compared to the control group (22.9% ± 1.1%).2 Lean tissue mass was reduced in paraplegics (37.6 ± 1.1kg)) and tetraplegics (32.8 ± 2.5kg) compared to the control group (46.2 ± 1.0kg P<0.001).2 It was noted that the overweight minimum threshold of 25 kg/ m2 in able-bodied patients is equivalent to 19 kg/m2 in patients with SCI.2 The pharmacist should understand that estimations of IBW and BMI will cause skewed results in the SCI population.

A correction factor was presented in the American Dietetic Association’s (ADA) guidelines for estimating IBW in patients with SCI. The guidelines recommend using the Metropolitan Life Insurance tables for IBW and reducing the value by 10-15% in tetraplegics and 5-10% in paraplegics.5 This correction makes sense since IBW in a patient with an SCI should be less than their able-bodied counterparts due to increases in total body fat and reductions in lean tissue mass.

In conclusion, there is no superior test that can be performed to accurately estimate renal function in SCI patients without limitations. Estimations based on the Cockcroft-Gault equation are inaccurate, grossly overestimating renal function. The

Featured Article Creatinine (continued from page 18) 24-hour urine collection test is troublesome and demands participation from the entire healthcare team to provide accurate results. Lastly, the cystatin C method is expensive and may not be available at many hospitals.

Based on the evidence reviewed, it is recommended to verify that the renal-dosed medication is indicated and that no suitable alternatives are available. If the above verification is met then renal function should be calculated with a range of values using the Cockcroft-Gault equation with the correction factors of 0.8 for paraplegics and 0.6 for tetraplegics. Careful monitoring of renal function using the recommendations above should be performed daily at baseline, during, and after therapy to ensure the safety and efficacy of the medication being dosed.

The IBW can be corrected using the ADA recommendations by using the Metropolitan Life Insurance tables for ideal weight and reducing the number by 10-15% for tetraplegics and 5-10% for paraplegics. Although these recommendations will lead to clinically acceptable estimates, practitioners must understand that these are estimates and accuracy can still be in question.

Practitioners must use these recommendations as a guide and in no way replace the clinical judgment and careful observation of patients and corresponding renal function.

With acknowledgement to Mindy (Throm) Burnworth, Pharm.D., BCPS, Associate Professor, Midwestern University College of Pharmacy-Glendale for her editorial comments and assistance.

References 1. Young M, Ensom MH. Pharmacokinetics of aminoglycosides in patients with chronic spinal cord injury. AJHP. 2011 September; 68(17): 1607-14.

2. McDonald CM, Abresch-Meyer AL, Nelson MD, et al. Body mass index and body composition measures by dual x-ray absorptiometry in patients aged 10 to 21 years with spinal cord injury. JSCM. 2007 May; 30:S97-S104.

3. Macdiarmid SA, McIntyre WJ, Anthony A, et al. Monitoring of renal function in patients with spinal cord injury. BJU International. 2000 February; 85:1014-8.

4. Mohler JL, Barton SD, Blouin RA, et al. The evaluation of creatinine clearance in spinal cord injury patients. The Journal of Urology. 1986 August; 136:366-9.

5. American Dietetic Association Evidence Analysis Library. SCI: Assessment of Body Composition: Estimation of Ideal Body Weight. ADA, Accessed 19 October 2011, http://www.adaevidencelibrary.com/template.cfm?template=guide_ summary&key=2305&auth=1.

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Candidates may apply to take the Pharmacy Technician Certification Exam online at www.ptcb.org.

—Laura Forbes, RPh, Director of Pharmacy Services, Gov. Juan F. Luis Hospital and Medical Center, Christiansted, U.S. Virgin Islands CONNECT ONLINE:

Summer 2012 • Arizona Journal of Pharmacy • 19

Featured Article The Age of Self Service

by Joe Rowan, R.Ph.

In November 1952, after being discharged from the United States Army, I returned to Gunning-Casteel in El Paso to become Store Manager and Pharmacist at Store #10, the store I had left in 1950. Nothing much had changed: salary was still $300 per month and it was still a 10 hour per day/7 days per week job.

We were still compounding suppositories, capsules, lotions, ointments, creams, and powder papers. The average prescription was now $2.75 and tranquilizers such as Librium and Valium were beginning to replace the use of barbiturates.

Gunning-Casteel prided itself in providing ultimate customer service. We maintained charge accounts and offered delivery service. We would deliver anything, anywhere (within reason), at anytime. This included not only prescription and over-thecounter medications, but six-packs of Coca Cola, cigarettes, and groceries. One customer frequently called on Sunday morning asking me to take $10.00 to her maid, who would be leaving the customer’s home before she could get back from church! Our delivery area extended about 10 miles from the store and we logged over 100 deliveries a day.

The year 1954 was a memorable one for me. In January of that year, a very startling redhead in high heels named Marian approached me seeking a job as a cashier at G & C #10.

After a short interview with this young lady, I knew she was overqualified for the job, but offered her the position at $95 per month, with two caveats. The first was she could no longer wear high heels in the store as they damaged the flooring. The second caveat was hers. Even though her given name was Marian, she was to henceforth be known as Mims. Not only did Mims become my new cashier, but on Friday, August 13, 1954, she and I entered into a fifty-six year contract that would last until September 19, 2010, when Mims journeyed into a world of no tears to spend eternity with her Creator.

That same year, I determined that the supermarket across the street - with its push cart and self-service selection - was selling many of the items that my customers should be buying from me such as dental needs, hair preparations, shaving needs, cosmetics, and home remedies. The shopper could browse up and down the aisles with a basket and select whatever they needed. Selfservice drug stores were unheard of at this time. In our store, we still had clerks retrieving all the requested items off the shelves behind the counter while the customer waited. Notions, appliances, and gift items were displayed on self-service shelves.

I wondered why couldn’t drug stores offer self service?

I spent about three months with waxed paper and crayon redesigning my store to convert it to self service. Every counter, table, and fixture was reconfigured into the plan to present a sensible diagram of what Gunning-Casteel #10 would look like.

I approached Mr. Gunning and Mr. Casteel with my proposed new self-serve store. My idea was not met with resounding enthusiasm. While they saw value in what I was presenting, they felt such a complete overhaul of the store would be far too expensive an experiment at that time. I assured them that based on my thorough calculations and with the help of my employees and my lovely wife, the entire redesign could be completed in one night starting after closing at 10PM and reopening the next morning at 7 AM as a self-service store. And all at a total cost of less than $150 including labor and electrical rewiring. The fact 20 • Arizona Journal of Pharmacy • Summer 2012

that the store would not need to be closed during regular business hours and there would be no loss of revenue to the company was the deciding factor and Mr. Gunning and Mr. Casteel gave their approval with the caveat that if the plan failed, I was to return the store to its original state. I had no worry that my plan would not work.

We successfully completed the reconfiguration of the store overnight and reopened the next morning on schedule. The glass showcases with cosmetics and high-end gifts formed a square bull ring in the center of the store. This area would be staffed by a cosmetic lady during store hours. Other counters were moved to the back of the store separating the prescription case from the retail section of the store. The soda fountain, of course, remained full-service only and cigarettes, film, and other items would remain behind the cashier stand which would be staffed by a full-time cashier who would now be handling the bulk of the self-service sales. Our store proceeds increased dramatically and I was honored by the El Paso Sales Executive Club as Salesman of the Year. Within a year all 18 Gunning-Casteel Drug Stores became self service. This experience taught me to go ahead and take a chance on change if you are convinced you are right.

This is the sixth installment in a series of reflections from Joe Rowan, R.Ph., longtime Arizona pharmacist and AzPA member.

Follow Joe’s memoirs in future issues of the Arizona Journal of Pharmacy or catch up on past installments by visiting the Arizona Journal of Pharmacy archives on the AzPA website.

Mr. Wyle Casteel, co-owner of Gunning-Casteel Drug Stores, and Joe Rowan.

Joe and Mims Rowan, partners forever.

Featured Article

A Look Back - Pap Boat

by Robert E. Kravetz, MD, FACP, MACG American College of Gastroenterology

Nutritional feeding of infants and invalids was as challenging a problem in the past as it is now, but Total Parenteral Nutrition (TPN) and other less invasive modalities were not available to our ancestors. Pap boats date from the late 17th century and were used until the end of the 19th century to provide the necessary feedings.

Pap boats were open or half-covered boat-shaped vessels with a spout or lip at one end to deliver the pap to infants, invalids, and other patients. A handle was present for convenience. The pap was prepared from bread soaked in wine to which sugar was frequently added. On occasion the mixture would first be chewed by the administering nurse. Other semi-liquid preparations could be also administered this way.

Anyone interested in pharmacy collectibles and memorabilia may contact Dr. Kravetz at bob@brownies.com .

Early pap boats were plain but with the passage of time they became decorative and highly attractive. Generally they were made of ceramic, less often of glass, and rarely from pewter or silver. This beautifully decorated Delft pap boat is typical in shape and decoration of the ones that have survived and remind us of our past heritage.

Pharmacy Time Capsules Second Quarter 2012 1987—Twenty-five years ago:

1912—One hundred Years Ago:

•

•

Public Health and Marine Hospital Service was renamed the Public Health Service (PHS) and the mission was expanded to include communicable diseases field investigations, navigable stream pollution, and information dissemination.

•

APhA House of Delegates was established as a forum for all branches of the profession to have a voice.

Petition requesting recognition of Nutrition Support Pharmacy Practice as a specialty was submitted to the Board of Pharmaceutical Specialties.

1962—Fifty Years Ago: •

New England College of Pharmacy affiliated with Northeastern University

•

The Indian Hospital at Crow Agency, Montana began filing outpatient prescriptions directly from the patient’s medical record. This was eventually adopted throughout the Indian Health Service.

1937—Seventy-five Years Ago: •

National Cancer Institute was established to conduct and support research relating to the cause, diagnosis, and treatment of cancer.

One of a series contributed by the American Institute of the History of Pharmacy, a unique non-profit society dedicated to assuring that the contributions of your profession endure as a part of America’s history.

Membership offers the satisfaction of helping continue this work on behalf of pharmacy, and brings five or more historical publications to your door each year. To learn more, check out www.aihp.org.

Summer 2012 • Arizona Journal of Pharmacy • 21

Featured Article The Road to Provider Status...

Is a Bumpy One.

By Kelly Green Boesen, Pharm.D., BCPS and Sandra Leal, Pharm.D., FAPhA, CDE Hopefully many of you have heard about the petition started on Change.org to garner support to recognize pharmacists as health care providers. Currently, there are over 20,000 signatures of support. The idea and petition originated with AzPA member, Sandra Leal, PharmD, FAPhA, CDE. She had recently watched the success of a couple of online petitions and their impact they made and thought it was worth a try. The petition was launched mid-November of 2011. Sandra began posting the link to the petition on the social media network, Facebook. Kelly Green Boesen, PharmD, BCPS, another AzPA member, helped to repost the link on Facebook to share with others. This continued on, getting reposted and talked about among “friends”. In the first couple of weeks, the number of signatures were doubling daily.

While Sandra and Kelly were preparing to leave for the ASHP midyear meeting they were discussing the petition and what a great venue the meeting would be to get the word out and garner more support. Two days before departing Sandra said, “It would be great if we had T-shirts or something!” With that Kelly was off and running with marketing ideas. Kelly found a place that would make business cards quickly and had some buttons made up to be delivered to the hotel in New Orleans. Sandra and Kelly began enlisting the help of their other pharmacist friends and pharmacy students to pass the materials out. At Sandra’s speaking engagements she announced the petition. The signatures began accumulating at a faster pace.

Upon returning from the meeting Sandra and Kelly compiled printed-and-bound copies of the petition and the comments that were posted. They made an appointment with a staff member of Gabriel Giffords, then congresswoman for the Tucson area.

He recommended seeking out the press to get the message out.

Sandra and Kelly spoke at length to a news reporter for the Arizona Daily Star who ran an article on the subject. This article was then picked up by ASHP and APhA who linked it on their web pages and email blasts. Following the newspaper article, a local anchorwoman interviewed Sandra for a piece on the local news.

When the number of signatures reached 10,000 supporters (from pharmacists, doctors, even a senator), Sandra turned on the feature to email members from Centers for Medicare & Medicaid Services (CMS) and Health Resources and Services Administration every time a signature was posted. Sandra was promptly called to cease and desist as they were getting several emails a minute. From this phone call, a teleconference was arranged with several key people from CMS and APhA to discuss the issue. It has been reiterated in all of these discussions that the ONLY way to get CMS to recognize pharmacists as health care providers is to introduce a bill to Congress to change the law, no easy feat.

At the end of January of 2012, AzPA started getting more involved in developing a strategy for how we might accomplish this task. AzPA worked to develop talking points to be used to educate politicians about the subject. They were also instrumental in surveying other state associations to gauge interest in this topic in preparation for the national APhA meeting in March.

22 • Arizona Journal of Pharmacy • Summer 2012

Coincidentally, at the end of January the U.S. Public Health Service released a report titled “Improving Patient and Health System Outcomes through Advanced Pharmacy Practice: A Report to the Surgeon General 2011” led by U.S. Assistant Surgeon General Scott Giberson. The Surgeon General, Regina Benjamin, MD, MBA released a letter publicly supporting the report.

In February, Sandra was asked to come to the White House as part of the White House Community Leaders Briefing. This program was designed for community grass-roots activists to actively engage with the Administration on important issues such as health care reform. While there, Sandra was able to personally hand over a copy of the petition to President Obama’s special assistant on the National Economic Council who was discussing the Affordable Care Act implementation. Quite an experience!

In March of 2012, Kelly and Sandra travelled to the APhA meeting in New Orleans. They met up with the Arizona delegates and representatives Kelly Ridgway, Mark Boesen, Kevin Boesen, Amy Kennedy, and Lisa Carpenter. They introduced an amended policy statement to APhA to propose this issue to be a priority. In addition, they continued to hand out cards and pins and discuss the petition with as many people as they could. At the second general session at APhA, Scott Giberson spoke about the report and emphasized that pharmacists need to be recognized as providers in order to be a full-fledged member of the healthcare team and be able to provide sustainable benefits to patients. At the conclusion of this general session, the petition was highlighted.

Again, signatures and support grew.

Following APhA, Sandra, Kelly (Green Boesen) and Kelly (Ridgway) met with the senior legislative assistant to Congressman Raúl Grijalva. This was a very informative discussion, looking at past bills to Congress and options for pushing forward. There is much work to be done and the attempt to change this will be difficult. It is still necessary to keep passing the message on to people to sign the petition if they have not, they do not need to be a health care provider. The great thing about the petition is it is an easy way for someone to show support. How else would pharmacists get 20,000 people to call and tell their representatives? Keep signing until the road is paved!!

Pharmacists as Providers Sign the petition!

Go to www.change.org

or visit the home page of the AzPA website at

www.azpharmacy.org

Student Perspective A Lifetime of Leadership

by Alen Pajazetovic, Pharm.D. Candidate, Midwestern University-College of Pharmacy, Glendale, Class of 2012 The Second Annual AzPA Student Pharmacist Leadership Conference was held on April 28th, 2012 at the Westin La Paloma Resort in Tucson, AZ. A total of 24 students from both Midwestern University and the University of Arizona attended this event. The students were asked to submit an essay in order to apply for the privilege of attending this conference. Two winners were selected from the essays submitted: Kate Murphy, Midwestern University, and Michael Biegelman, University of Arizona, were the winners each receiving a certificate and gift for their efforts.

The conference began with a group picture in the bright sun to ensure that no one looked comfortable; squinting seemed to be the primary theme of the portrait. Afterward, the students were herded back into the room and asked to don blindfolds for the impending “icebreaker.” This activity involved animals and random noises; I shall delve no further into this subject as it is too emotionally draining to discuss. If attempting to stifle your curiosity about this event proves futile, you need look no further than the AzPA Facebook website where a staff member has decided to post a video of said activity.

Upon completion of the icebreaker, the students were treated to a lively (Red Bull-fueled) presentation by Dr. Crane Davis, the assistant pharmacy director at Fry’s Pharmacy. Dr. Davis illustrated the leadership qualities inherent in some of the greatest leaders in human history: President Obama, Franklin D. Roosevelt, Steve Jobs, James T. Kirk, and, of course, Oprah.

He detailed the concepts of accountability, human relations, and inter-dependence as integral areas of knowledge for any leader.

In addition, he explained the notion of the Pharm.D. as a brand and the importance of each and every pharmacist promoting this brand in the highest manner.

Dr. Chris Meilinger, the senior director of pharmacy operations for Express Scripts-Tempe delivered the next presentation. He detailed his career path and explained the key traits he found to be irreplaceable in leaders. The main traits included knowing oneself, learning to utilize a “circle of influence,” and, most importantly, overcoming fear and learning how to use it to your advantage. He concluded his presentation by stressing that true leaders attempt to experience as much as possible as “there is no substitute for an experience.”

Dr. Jon Glover drew upon his background as a leader in the military, in addition to his current position with Pfizer, to deliver his presentation. He explained how important the ability to communicate is in any leader. Then he gave a rather unique viewpoint on leadership. In his current position he does not have any subordinates to lead. However, he takes pride in empowering other people to make the right decisions by providing them the tools they need to do so. This gave students a new facet of leadership to consider.

Following Dr. Glover’s talk, the speakers split up among the students’ separate tables. At this point, they either discussed any specific questions their group of students had, or they discussed predetermined management/leadership practice cases.

The speakers rotated between groups of students every fifteen to twenty minutes. This section of the conference allowed students to gain insights into how experienced leaders would handle

situations that are very likely to arise early in the students’ careers.

McKesson sponsored a delicious lunch which was served on the patio. Sandwiches and chips were had by all. What else can be said about lunch? It was scrumptious.

Representative Matt Heinz, an MD from district 29, gave a very inspiring speech following lunch. Explaining the desperate need for practicing health care providers in the legislature, he encouraged all the students to run for their local legislature at some point in their career. He reinforced this by reciting his rise to the representative level, detailing how he didn’t know how to run but showed up and submitted his bid anyway. The only reason for doing this was because he saw a need for health care representation sponsored by a practicing health care professional.

Finally, he explained that he continues to practice medicine parttime in order to keep up his knowledge and better understand the legislative needs of physicians and pharmacists alike.

Dave Johnson, the director of corporate marketing for Rain Bird Corporation, followed Rep. Matt Heinz’s speech. This was an interesting presentation because Mr. Johnson is not in any way affiliated with the pharmaceutical profession. However, he is a firm believer that general marketing transcends professions and gave a riveting presentation on the basics of marketing. A well known fact is that any good marketing presentation will have a copious amount of Dilbert comics dispersed throughout, and this one did not disappoint. Mr. Johnson finished his presentation by tying some of the basic marketing concepts to pharmacy.

The president of AzPA, Dr. Kevin Boesen, gave the closing remarks. He discussed the importance of stepping out of one’s comfort zone. He also explained that failure is a requirement for a leader to be successful. Failing allows people to learn and better themselves. Leaders must be willing to take risks and overcome fear.

Overall, the Second Annual Student Pharmacist Leadership Conference was a unqualified success. The students were given the chance to interact with some of our most distinguished local leaders. After a day of inspiring speeches and presentations, the students left the conference motivated and ready to take on the challenges their own leadership roles will be sure to throw at them.

The participants of the 2012 Student Pharmacist Leadership Conference held at the Westin La Paloma in Tucson, Arizona.

Summer 2012 • Arizona Journal of Pharmacy • 23

Arizona State Board of Pharmacy Disposal of Unused Medicines: What You Should Know Overview Medicines play an important role in treating many conditions and diseases, but when they are no longer needed it’s important to dispose of them properly to avoid harm to others. Below are disposal options and special disposal instructions for you to consider when throwing out expired, unwanted, or unused medicines.

Medicine Take-Back Programs On April 28, 2012, the National Prescription Drug Take-Back Day, coordinated by the Drug Enforcement Administration, collected a record-breaking 552,161 pounds (276 tons) of unwanted or expired medications for safe and proper disposal. There were more than 5,600 take-back sites across the United States, including nearly 100 sites in Arizona. Since the first National Prescription Drug TakeBack Day in 2010 more than 1.5 million pounds (774 tons) of medications have been removed from circulation.

Medicine take-back programs for disposal are a good way to remove expired, unwanted, or unused medicines from the home and reduce the chance that others may accidentally take the medicine. The next national take-back event is September 29, 2012. Check the DEA website at www.deadiversion.usdoj.gov/drug_disposal/takeback.

Disposal in Household Trash If no medicine take-back program is available in your area, consumers can also follow these simple steps to dispose of most medicines in the household trash:1 • Mix medicines (do NOT crush tablets or capsules) with an unpalatable substance such as kitty litter or used coffee grounds; • Place the mixture in a container such as a sealed plastic bag; and • Throw the container in your household trash Flushing of Certain Medicines There is a small number of medicines that may be especially harmful and, in some cases, fatal in a single dose if they are used by someone other than the person the medicine was prescribed for. For this reason, a few medicines have specific disposal instructions that indicate they should be flushed down the sink or toilet when they are no longer needed and when they cannot be disposed of through a drug take-back program. When you flush these medicines down the sink or toilet, they cannot be accidently used by children, pets, or anyone else.

You may have also received disposal directions for medicines when you picked up your prescription. If your medicine is on this list, and you did not receive information containing disposal instructions along with your dispensed prescription, you can find instructions on how to dispose of 24 • Arizona Journal of Pharmacy • Summer 2012

the medicines at the FDA DailyMed System by searching the drug name, and then looking in one of the following sections of the prescribing information: • Information for Patients and Caregivers • Patient Information • Patient Counseling Information • Safety and Handling Instructions • Medication Guide If you have additional questions about disposing of your medicine, please contact the Food & Drug Administration at 1-888-INFO-FDA (1-888-463-6332).

Frequently Asked Questions Why do the medications on the list have flushing directions for disposal?

The medicines on this list of medicines recommended for disposal by flushing are safe and effective when used as prescribed, but they could be especially harmful to a child, pet, or anyone else if taken accidentally. Some of the possible harmful effects include breathing difficulties or heart problems, possibly leading to death. For these reasons, FDA advises that when it isn’t possible to return these medicines through a medicine take-back program, flushing these medicines down the sink or toilet is currently the best way to immediately and permanently remove the risk of harm from the home. FDA continues to work with and encourage the manufacturers of these medicines to develop alternative, safe disposal systems.

All other expired, unwanted, or unused medicines should be disposed of by using a medicine take-back program, if available, or by throwing them away in the household trash.

Does flushing the medicines down the toilet or sink drain pose a risk to human health and the environment?

We are aware of recent reports that have noted trace amounts of medicines in the water system. The majority of medicines found in the water system are a result of the body’s natural routes of drug elimination (in urine or feces).

Scientists, to date, have found no evidence of harmful effects to human health from medicines in the environment.

Disposal of these select, few medicines by flushing contributes only a small fraction of the total amount of medicine found in the water. When a medicine take-back program isn’t available, FDA believes that any potential risk to people and the environment from flushing this small, select list of medicines is outweighed by the real possibility of life-threatening risks from accidental ingestion of these medicines.

For the FDA List of Medicines Recommended for Disposal by Flushing visit the Patients and Public page of the AzPA website at www.azpharmacy.org Consumers are advised to check their local laws and ordinances to make sure medicines can legally be disposed of with their household trash.

1

In Memoriam Dr. Albert L. Picchioni Ph.D., Founder and the first Executive Director of The University of Arizona Poison and Drug Information Center, passed from this life on April 16, 2012 in Green Valley, Arizona.

The Arizona Poison and Drug Information Center was the first of its kind in the state of Arizona and one of the first Centers in the United States. Dr. Picchioni was a Professor of Pharmacology and Toxicology, researcher, educator, pharmacist, and mentor. His life’s work was that of improving the human condition through neuropharmacology research in epilepsy, and toxicology research in poison interventions and poison prevention education. If you or a loved one has ever had the need to call the Arizona Poison and Drug Information Center for poison or drug exposure advice or even medication questions, you experienced a dedicated service which was the outcome of Dr. Picchioni’s conceptualization, intellect, and perseverance. He simply wanted to help his community and enrich the knowledge base of his profession.

Dr. Picchioni was born August 28, 1921 in Klein, Montana to Italian immigrant parents who taught him the work ethic, wisdom, and knowledge he practiced throughout his life as a professor, husband, father, and community leader. He earned his B.S in pharmacy, with honors, from the University of Montana in 1943. He served three years in the U.S. Army as a combat medic pharmacist in the 311th Medical Battalion of the 86th Division in the European and South Pacific Theaters, working out of a medicine cabinet in the back of a truck belonging to a mobile hospital behind the front lines in Germany, Belgium, Austria, and later during a redeployment to the occupied Philippines.

Subsequent to his military service, he worked as a community pharmacist in Harlowton, MT (1946-47), and completed a residency in hospital pharmacy at the University of Michigan in 1948. He received his M.S.from Purdue University in 1950 and Ph.D. in Pharmacology in 1952.

Also in 1952, he was appointed Professor of Pharmacology in the College of Pharmacy at The University of Arizona and for 35 years thereafter, served in multiple, often simultaneous capacities of Professor of Pharmacology and Toxicology, in formal research and teaching appointments, Head of the Department of Pharmacology and Toxicology, Associate Dean of Academic Affairs, Interim Dean of the College of Pharmacy, Founder and Executive Director of the Arizona Poison Control Program, and Director of the Arizona Poison and Drug Information Center.

He served on the editorial board of Journal of Toxicology – Clinical Toxicology, was a consulting editor for the American Journal of Hospital Pharmacy, worked on numerous Food and Drug Administration panels for over-the-counter drugs, and for several years on the National Academy of Sciences Toxicology Information Program Committee. He conducted funded research in the areas of neuropharmacology and toxicology and published over 50 peer-reviewed journal articles, all the while maintaining his administrative and teaching responsibilities noted herein. He received numerous national and regional honors and awards, including Robbins Bowl of Hygeia Award for Community Service in Pharmacy (the first Arizona recipient of this award), Honorary Bobcat (The University of Arizona), American Association of Poison Control Centers National Recognition Award for Contributions to Poison Control Center Development and Toxicology, University of Montana School of Pharmacy Award in

Recognition for Outstanding Service to the Pharmacy Profession, University of Montana Distinguished Alumnus Award, Findlay E. Russell, M.D., Ph.D. Distinguished Citizen Award (College of Pharmacy), and Tucson Daily Citizen of the Week.

He retired in 1987 as Professor Emeritus of Pharmacology and Toxicology at The University of Arizona. He came from small town America and with his devoted wife, Theresa, at his side, made significant and lasting contributions to his profession, the scientific community, and future pharmacists. While he was a very busy and accomplished man, he never failed to keep his family first.

Within his children, he and Theresa instilled honesty, integrity, hard work, and humility. He was a patient and kind father and the best mentor his children had. He was a man of strong faith, and God has called upon one of His best to now serve in a better place.

Surviving children and family members include daughter, Dr. Mary Picchioni (Tim Carmichael); sons, Joseph Picchioni (Kim) and Dr. Geno Picchioni (Darlene); grandchildren, Garret and Whitney; his adopted Tucson daughter, Midji Stephenson and numerous nieces, nephews and cousins throughout the US and Italy. Albert is predeceased by his wife (the love of his life), Theresa and cherished daughter, Annie Marie in addition to parents, Guglielmo and Josephine (Medici); sister, Anne Godley; brothers, Frank, Jeano, Dominick and cousin, Louie.

In lieu of flowers, the family humbly suggests gifts be made to the Albert L. and Theresa M. Picchioni Pharmacology and Toxicology Research and Teaching Endowment in the College of Pharmacy at The University of Arizona. This fund supports the Arizona Poison and Drug Information Center and the College of Pharmacy’s Department of Pharmacology and Toxicology for research and teaching in the areas of acute poisoning, drug information, and drug action and effect on the human body --all to benefit the professional and public communities at large.

To contribute, please make a check payable to the Picchioni Endowment/UAF and mail it to UA College of Pharmacy, P.O. Box 210202, Tucson AZ 85721 Attention: Picchioni Endowment. You may also contribute online at http://tinyurl.com/picchioni. Please type Picchioni Endowment in the Comments field of the donation form and indicate Albert Picchioni in the Tribute field.

A Memorial Tribute honoring Dr. Albert Picchioni November 9, 2012

The University of Arizona College of Pharmacy All are invited to attend.

Please contact Ms. Shannon Lejeune, The University of Arizona College of Pharmacy, at 520.626.3566 or lejeune@pharmacy.arizona.edu for further information.

Summer 2012 • Arizona Journal of Pharmacy • 25

Academy News Community Pharmacy Academy Greetings, Community Pharmacy Academy Members, This is my final message as Community Pharmacy Academy Chair but I will continue to be active within AzPA as we work to strenghten and protect the business sustainability of community practice. Kristin Calabro is the new Chair and Elizabeth (Betty) Louton is Chair-Elect. They are both committed to representing community pharmacy in our association.

I hope many of you were able to attend the AzPA 8th Annual Meeting and take advantage of great programming to enhance your community pharmacy practice. Of particulare note was the ABC’s of CPA’s: Developing a Collaborative Practice Drug Therapy Managed Agreement which provided valuable information and concrete tools for expanding your practice. Future offerings of this workshop are planned.

The Community Pharmacy Academy Conference is September 22, 2012, at the Crowne Plaza Phoenix Airport Hotel in Phoenix. The theme of the conference is Changes Ahead – Are you ready? Topics for the day-long event include Continuous Quality Assurance Workshop, Exposure to Drugs In Utero, MTM Update, and the Pharmacists’ Role in Diversion Prevention. Registration is available on the AzPA website.

Thank you for the honor of serving our Academy on the AzPA Board of Directors.

Sincerely, Teresa Stickler, R.Ph. Community Pharmacy Academy Chair melrosepharmacy@yahoo.com

Geriatric Care Academy Greetings, Geriatric Care Academy Members, The Geriatric Care Academy (GCA) Conference was held Friday, May 4, 2012 in the late afternoon at the Crowne Plaza Phoenix Airport Hotel in Phoenix. The CE sessions were presented in a unique and engaging format - think speed-dating for CE!. Thank you to the facilitators who made this conference a huge success: Christi Jen, Dyan Cherry, Jared Neeley, Laura Hanson, Lindsey Burgin, Todd Penn, Jeremy Gerber, and Dawn Gerber. A special thanks to Lynne Bastone, ASCP Director of Policy & Advocacy for presenting the 2012 Federal Legislative and Advocacy Initiatives for Pharmacists session.

Kelly Ridgway, AzPA CEO, and Dawn Knudsen Gerber, GCA Chair attended the American Society of Consultant Pharmacists Spring Conference in Anaheim, California, May 21-23, 2012. Dawn faciliated a session on Natural Products for Geriatric Gonditions: What Does the Data Say? Kelly and Dawn co-presented the program Collaborative Practice: The Times They are A-Changin’!

Congratulations to Elizabeth Pogge on her election as GCA Chair Elect for the 2012-2013 AzPA Board of Directors term.

Tara Storjohann has ascended to the role of GCA Chair for the 2012-2013 term. Please support her and Elizabeth as they represent you and your colleagues on the AzPA Board of Directors. Our Academy is in capaable and dedicated hands.

Sincerely, Dawn Knudsen-Gerber, Pharm.D., CGP, FASCP Geriatric Care Academy Chair dknuds@midwestern.edu

26 • Arizona Journal of Pharmacy • Summer 2012

Academy News Health-System Academy News Greetings, Health-System Academy Members, It has been another fantastic year for the Health-System Academy (HSA) and a wonderful experience for me as the Chair for the academy.

I’ve had the opportunity to work with an amazing group of people on the HSA Board, the Arizona Pharmacy Association (AzPA) Board of Directors and the AzPA staff. I look forward to working with the organization much more in the future. That being said, I would like to briefly recap the year reflecting on our progress and look forward on some things to come.

Over the past year, the health-systems in Arizona have dealt with several issues on the legislative front that have impacted pharmacy practice and will continue to create new obstacles in the future including medical marijuana legislation, drug shortages with pending legislation, and striving to gain recognition for pharmacists as providers. It is a very important time in the field of pharmacy and we need to collectively work hard and move forward to take the lead as a state speaking out on these issues. Additionally, this past month was an important time for health-system pharmacists at the ASHP Summer Meeting in Baltimore, Maryland where the ASHP House of Delegates met to discuss many of these issues and the report from those sessions will be provided to the membership in the near future so please follow closely and consider getting involved.

The HSA had big year with the edition of new programming, hosting an excellent annual conference in Mesa in April, and working to engage our new practitioners in the state. The Mentor Connection Program, a 6-month pilot developed by the HSA, is designed based on the premise that pharmacy students have much to gain outside of the classroom and rotations including leadership skills, networking opportunities, and learning through the experiences of practicing pharmacists. The program also provides an excellent opportunity for pharmacists to have a significant impact on the future practitioners and on the profession. An introduction to the program presented at the AzPA 8th Annual Meeting.

In closing, I would like to offer an open invitation to the pharmacists in Arizona to get involved in whatever way you are able whether it is volunteering time on committees or providing financial support that is required for our organization to continue to operate at a high level to provide opportunities and benefits for our members and successfully lobby on the legislative front. I have gained so much professionally from being apart of the Arizona Pharmacy Association in the way of networking, professional growth, and better understanding of how the practice of pharmacy can future impact patient care, and I strongly encourage you take advantage of what AzPA can do for you and pharmacy in the state and let us know what we can do better.

Lindsay Davis began her term as HSA Chair at the 2012 AzPA Annual Meeting. Joining the AzPA Board of Directors as HSA Chair-Elect is Kristen Allison. I know they will continue the legacy of strong leadership at AzPA for health-systems pharmacists. Thank you for allowing me to serve you this past year in this capacity and I hope I can serve the membership in the future.

Jon Merchen, Pharm.D. Health-System Academy Chair jonathan.merchen@va.gov

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JOIN PAAS TODAY! 888.870.7227 | PAASnational.com Summer 2012 • Arizona Journal of Pharmacy • 27

Academy News Managed Care Academy News Greetings, Managed Care Academy!

It’s been another fun and exciting year--we have had some great activities. Hopefully you all will be even more involved this coming year. Thank you to those who have served this year in our academy or as representatives to our academy for committees in the AzPA and other organizations. It’s wonderful to see, and we cannot do what we do without volunteers who give back to their profession. We have had some others recently volunteer for committees. If you didn’t get a chance to sign up, and are interested, please contact the AzPA office so they can get you plugged in.

It’s that time of year again - time to hand the baton to your next MCA Chair, Ann Sears. Also, please join me in welcoming our Chairelect, voted in by you, our members. Welcome and congratulations to Eric Luecht. I know Ann and Eric will be great leaders for our Academy.

Watch the AzPA Calendar for the next Managed Care Academy Conference scheduled for October 2012. Stay tuned for more information.

Thank you for a great year!

All the best, Julie Hernandez, RPh, Pharm.D. MCA Chair rxchica@cox.net

Technician Academy News Greetings, Pharmacy Technician Academy Members, Thank you for the privilege of serving as the Chair of the Technician Academy this past year. Our academy is in excellent hands with Joy Davis, Chair, and Judi Day, Chair-elect, at the helm. Please support them and their efforts on behalf of AzPA. Plans are underway for the Pharmacy Technician Conference in November 2012. Watch your email and the AzPA website for more information as details are confirmed.

AzPA continues to offer an excellent exam prep course for the PTCB exam. The 7-week next class begins September 8, 2012. Check the AzPA website for details.

The number of job openings for pharmacy technicians continues to grow. More and more employers are looking for certified technicians with enhanced skills. AzPA is the ideal resource to update your knowledge and skills. Although there are more than 15,000 pharmacy technicians licensed in Arizona, only about 100 are AzPA members. Dues are just $40 per year yet it is apparent that very few of our colleagues are taking advantage of the benefits of membership in our state association. Please encourage your friends and co-workers to join their state association. They will be glad they did.

Sincerely, Mike Severn, C.Ph.T. Technician Academy Chair amsevern@gmail.com

28 • Arizona Journal of Pharmacy • Summer 2012

Academy News Student Pharmacist Academy News Greetings, Student Pharmacists, Congratulations to the Class of 2012! The University of Arizona College of Pharmacy and Midwestern University College of Pharmacy Glendale graduated 95 and 126 new pharmacists, respectively! We wish all the graduates great success as you embark on your pharmacy career and hope you will remain active members of the Arizona Pharmacy Association as new practitioners.

We have been honored to represent our fellow students on behalf of our colleges of pharmacy. Please continue to support AzPA and the Student Pharmacist Academy (SPA) as your new Co-Chairs begin their terms: Sophia Galloway, Pharm.D. Candidate Class of 2014 for Midwestern University and Eric Wong, Pharm.D. Candidate, Class of 2014, for the University of Arizona. We are very excited to have you represent your schools on the AzPA Board of Directors.

As the Student Pharmacist Academy finishes its second year of existence, we have much to celebrate and many plans for this coming year. The AzPA SPA will be active with other student organizations on the colleges of pharmacy campuses and busy coordinating events throughout the year.

On April 28, 2012, the AzPA Student Pharmacist Leadership Conference offered leadership training to 24 student pharmacist leaders from both MWU-CPG and UofA COP. This prestigious program is offered to a select group of student leaders who apply to participate in the program. The next AzPA SPA Leadership Conference is planned for April 2013. Invitations will be extended in early 2013. If you are interested in participating, be sure to get involved with your student organizations and demonstrate your leadership.

During the Student Pharmacist Leadership Conference, two very special student pharmacists were honored with the AzPA Pharmacy Academy Award for the SPA for their outstanding leadership and service to the AzPA SPA during the previous year. The 2011-2012 recipients are Qian Julia Liu from Midwestern University and Nathan Smith from the University of Arizona. Thank you, Julia and Nathan, for all you do for AzPA. As the Co-Chairs of the AzPA Student Pharmacist Academy, we invite you to energize your pharmacy school experience by getting involved! Please contact us to find out how.

Sincerely, Valerie Bostel and Jessica DiLeo AzPA Student Pharmacy Academy Co-Chairs valerie.bostel@gmail.com dileo@pharmacy.arizona.edu

Photos from the Student Pharmacist Leadership Conference Upper Left: Valerie Bostel, SPA Co-Chair, presents the SPA Pharmacy Service Award to Qian Julia Liu, Midwestern University College of Pharmacy - Glendale.

Above: Kevin Boesen (left), AzPA President and Kelly Ridgway, AzPA CEO (far right), present Michael Biegelman, University of Arizona College of Pharmacy, and Kate Murphy, Midwestern University College of Pharmacy-Glendale, with their awards for winning the Student Pharmacist Leadership Conference Essay Contest.

Lower Left: Jessica DiLeo, SPA Co-Chair, recognizes Nathan Smith, University of Arizona College of Pharmacy, with the SPA Pharmacy Service Award.

Summer 2012 â&#x20AC;˘ Arizona Journal of Pharmacy â&#x20AC;˘ 29

Drug Information Question

Question: Is extended-interval dosing of rosuvastatin in patients previously intolerant to statin therapy safe and effective?

by Lindsey Ong, Pharm.D. Candidate, Class of 2012, and Elizabeth Pogge, Pharm.D., BCPS, Assistant Professor, Midwestern University College of Pharmacy-Glendale

Answer: Introduction Hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, otherwise known as statins, are recommended by the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP-III) as first-line medications when lipid-lowering therapy is indicated.1 Statins have been proven to significantly reduce mortality and the number of coronary events in both primary and secondary prevention trials. Some patients discontinue statin therapy due to adverse effects and lose the cardioprotective benefits of these medications. The lipophilicity and the varying dependence on cytochrome P450 metabolism theoretically could influence the relative risk of myalgia associated with different statins. Studies designed specifically to evaluate the rate of statin-related myalgia have found that about 22% of patients taking statins report some amount of musculoskeletal pain that can lead to discontinuation of statin use.2 Other cholesterol-lowering agents are not as potent as statins at lowering the low-density lipoprotein (LDL) and have not yet been proven to reduce mortality.1 Currently, the guidelines do not address maintaining statin use in patients who experience intolerance.1 Alternative dosing regimens of longer-acting statins such as rosuvastatin and atorvastatin have been used in some patients.2 Rosuvastatin has the longest half-life of all available statins and is one of the most potent statins at reducing LDL levels.3 There are several trials that have looked at the efficacy and safety of alternative dosing regimens of rosuvastatin.

Clinical Trials Three articles were identified that looked at the efficacy of rosuvastatin every other day versus once daily.3-5 When compared to once-daily dosing, these studies found that every-other-day dosing may be an alternative regimen for cost savings, without a major decrease in therapeutic benefit or increase in adverse events. The dose in these studies varied from 10 mg to 20 mg every other day. One additional chart review also concluded that every-other-day rosuvastatin therapy improves serum lipid levels.6 A case series done by Mackie et al. described how rosuvastatin 2.5 mg or 5 mg administered on Mondays, Wednesdays, and Fridays in 2 women who were previously intolerant to atorvastatin therapy resulted in reductions in their LDL levels.7 After 6 weeks of rosuvastatin therapy, 1 of the women had a reduction of 29% for total cholesterol (TC) and 38% for LDL (baseline LDL = 218 mg/dL), while the other woman had a reduction of 14% for TC and 20% for LDL (baseline LDL = 143 mg/dL). The effects on high-density lipoprotein (HDL) and triglycerides (TG) were variable. The authors concluded that three-times-weekly dosing of rosuvastatin might provide a reduction in serum LDL while avoiding previously encountered adverse effects of daily statin therapy.

30 • Arizona Journal of Pharmacy • Summer 2012

A case series of patients previously intolerant to once-daily statin dosing who were placed on rosuvastatin once weekly was described by Backes et al.8 A total of 10 patients were prescribed the once-weekly rosuvastatin regimen, but 2 patients reported the same side effects as previously experienced and discontinued therapy. Eight patients were included in the final analysis; most of the patients had previously experienced myalgias without elevated creatinine phosphokinase (CPK) levels, 1 had a history of elevated liver function tests >3 times the upper limit of normal, and 2 had gastrointestinal complaints. Patients were given once-weekly rosuvastatin and followed for an average of 4 months. Doses ranged from 5 mg to 20 mg, with the majority (6/8) of patients receiving 10 mg. Overall, the patients experienced a mean TC reduction of 23% and LDL reduction of 29% (LDL decreases ranged from 6% to 62%). The effects on HDL and TG were variable. The authors concluded that onceweekly rosuvastatin provided cost savings and helped achieve a significant LDL reduction in this patient population. Limitations to this report include a case series design with a small sample size and lack of control group.

Gadarla et al. described a retrospective chart review that reported on 40 patients previously intolerant to daily statin therapy who were switched to rosuvastatin 5 mg (n = 10) or 10 mg (n = 30) twice weekly on Monday and Thursday for at least 3 weeks.9 Patients were excluded if they had other changes in their lipid medications. After >3 weeks, the patients’ mean serum concentrations of TC, LDL, and TG were reduced by 48 ± 26 mg/ dL (19%), 43 ±¬ 26 mg/dL (26%), and 22 ± 58 mg/dL (14%), respectively (p < 0.01 for all). There was no significant change in mean HDL cholesterol levels. Eight patients (20%) discontinued rosuvastatin after the 3-week lipid measurement due to muscle aches but were still included in the final analysis. These authors concluded that low-dose rosuvastatin twice weekly is tolerated by most patients previously intolerant to daily statins and produces significant reductions in TC, LDL, and TG. Limitations to this study include its retrospective design, small sample size, lack of control group, and short length of follow-up.

Backes et al. also performed a retrospective chart review that reported on 51 patients treated with every-other-day rosuvastatin.10 Inclusion criteria included previous documentation of statin intolerance, on every-other-day statin therapy for at least 1 month, and reports of lipid levels immediately before and after treatment. The majority of documented intolerances were due to myalgias (76.5%) and elevated hepatic transaminases (19.6%).

Subjects receiving other lipid-lowering agents were included as long as no other changes were made to their cholesterol regimen that could impact the lipid profile. Primary outcomes for this study were percent of patients who tolerated the alternate-day dosing regimen, changes in serum lipid levels from baseline to the follow-up, percent of patients who achieved their NCEP ATPIII LDL goals, and percent of patients who achieved their NCEP ATP-III update 2004 LDL goals. Thirty-seven patients (72.5%) were able to tolerant alternate-day dosing with rosuvastatin and

Drug Information Question (continued from page 30) were included in the final analysis. The 14 patients who were unable to tolerate rosuvastatin every other day had a recurrence of their prior adverse effect. The primary effects of every-other-day rosuvastatin therapy were a mean LDL, TC, and TG reduction of 34.5%, 24.4%, and 19.5%, respectively (p < 0.001 for all). There was no significant change in mean HDL. Most patients (64.9%; 24/37) were able to meet their NCEP ATP-III LDL goal. When considering the more stringent ATP-III update 2004 LDL goal, 45.9% (17/37) of patients were still able to meet their goal of <70 mg/dL or <100 mg/dL. The authors concluded that many patients with a previous intolerance to statins could tolerate rosuvastatin every other day, attain significant LDL reductions, and achieve their LDL goal. However, this study has several limitations, including its retrospective and observational design, small sample size, and lack of control group.

Ruisinger et al. conducted another retrospective chart review of a lipid clinic to identify patients with previous statin intolerance who received rosuvastatin once weekly.11 The purpose of the study was to determine the efficacy of rosuvastatin dosed once weekly in patients with a previous statin adverse effect. The authors excluded patients if other significant changes were made to their lipid regimen or the length of once-weekly rosuvastatin therapy was less than 4 weeks. Fifty patients were identified with documented statin intolerances including myalgias (70%), elevated CPK (12%), elevated hepatic transaminases (14%), and gastrointestinal complaints (8%). Almost all of the patients (92%) were taking rosuvastatin in combination with other lipid-lowering agents throughout the study. Thirty-seven out of the 50 (74%) tolerated once-weekly rosuvastatin. The dose of rosuvastatin ranged from 2.5 mg to 20 mg weekly. Post-treatment levels were drawn approximately 4 months after initiating rosuvastatin. There were significant decreases in TC by 17%, LDL by 23%, and TG by 12% and a significant increase in HDL by 5% (p < 0.001 for all). The LDL decreased from 167 ± 45 mg/dL at baseline to 125 ± 31 mg/dL at follow-up. There was no significant difference (p = 0.714) between groups in LDL reduction among patients who had follow-up lipid levels drawn 1 to 3 days versus 4 to 7 days after their last dose. The authors concluded that once-weekly rosuvastatin can significantly improve the lipid profile. This study also had limitations, including a retrospective and observational design without placebo controls, a small sample size, and relatively short study period of 4 months.

Discussion In all of the studies done on alternative dosing regimens of rosuvastatin, at least 70% of the patients previously intolerant to statin therapy were able to tolerate the new frequency of dosing without significant adverse events. Most of the studies found that alternatively-dosed rosuvastatin significantly lowered LDL and TC. However, effects on HDL and TG varied. Dosing of rosuvastatin varied in all of the trials and there is no current consensus on the best dose to use in less-than-daily rosuvastatin therapy. There are several limitations to the trials on alternativelydosed rosuvastatin in the current literature that could affect the validity of the study findings. Most of the studies included patients with myalgia as a documented statin intolerance and the subjective nature and self-reporting of this adverse effect could influence study results. The studies allowed for alternative lipidlowering medications as long as the dosing remained consistent, but they did not account for changes in non-pharmacological

lipid-lowering therapies such as diet and exercise, which are potentially confounding factors. The same group of authors published 3 of the 5 studies and the patient population for these studies was very similar; this presents a limitation to translating the study results to the general population of statin-intolerant patients. Confounding factors and potentials for bias in all of the studies are lack of randomization and controls, small sample size, and short follow-up time. Because of these many limitations, more research is needed before definitive conclusions can be made. At this time, the evidence suggests that less-thandaily rosuvastatin may be effective at lowering TC and LDL while producing fewer adverse effects and myalgias in patients previously intolerant to daily statin therapy. However, there is no evidence yet to suggest that alternative dosing still confers the same mortality-reducing benefits of daily statin therapy.

References: 1. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002;106(25):3143421.

2. Reinhart KM and Woods JA. Strategies to preserve the use of statins in patients with previous muscular adverse effects. Am J Health-Syst Pharm 2012;69:291300.

3. Dulay D, LaHaye SA, Lahey KA, et al. Efficacy of alternate day versus daily dosing of rosuvastatin. Can J Cardiol 2009;25(2):e28-e31.

4. Wongwiwatthananukit S, Sansanayudh N, Dhummauppakom R, et al. Efficacy and safety of rosuvastatin every other day compared with once daily in patients with hypercholesterolemia. Ann Pharmacother 2006;40:1917-23.

5. Li JJ, Yang P, Liu J, et al. Impact of 10 mg rosuvastatin daily or alternate-day on lipid profile and inflammatory markers. Clin Chim Acta 2012;413(1-2):139-42.

6. Juszczyk MA, Seip RL, Thompson PD. Decreasing LDL cholesterol and medication cost with every-other-day statin therapy. Prev Cardiol 2005;8:197-9.

7. Mackie BD, Satija S, Nell C, et al. Monday, Wednesday, and Friday dosing of rosuvastatin in patients previously intolerant to statin therapy. Am J Cardiol 2007;99:291.

8. Backes JM, Moriarty PM, Ruisinger JF, et al. Effects of once weekly rosuvastatin among patients with a prior statin intolerance. Am J Cardiol 2007;100:554-5.

9. Gadarla M, Kearns AK, and Thompson PD. Efficacy of rosuvastatin (5 mg and 10 mg) twice a week in patients intolerant to daily statins. Am J Cardiol 2008;101:1747-8.

10. Backes JM, Venero CV, Gibson CA, et al. Effectiveness and tolerability of every-other-day rosuvastatin dosing in patients with prior statin intolerance. Ann Pharmacother 2008;42:341-6.

11. Ruisinger JF, Backes JM, Gibson CA, et al. Once-a-week rosuvastatin (2.5-20 mg) in patients with a previous statin intolerance. Am J Cardiol 2009;103:393-4.

MISSION STATEMENT The Arizona Pharmacy Association is committed to serving and representing all practice settings.

AzPA will foster safe and effective medication therapy, promote innovative practice, and empower its members to serve the health care needs of the public.

VISION Empowering pharmacy professionals to provide optimal patient care.

Arizona Pharmacy Association

Summer 2012 • Arizona Journal of Pharmacy • 31

Feature Pharmacist Collaborative Practice: A Look at the Modern Pharmacist

by Alen Pajazetovic, Pharm.D. Candidate, Midwestern University-College of Pharmacy, Glendale, Class of 2012

“Don’t you guys just take the pills from the big bottle and put them in the little bottle?” Did anyone else cringe after reading that question? Despite the advances the profession of pharmacy has made over the last few decades, it seems that some patients and health care providers still have the preconceived notion that pharmacists are good for dispensing medication and nothing more. Over the past decade or so, new ways of overcoming this gross misconception and demonstrating our value as health care providers have been evolving. One avenue in which a pharmacist can advance their practice and demonstrate their value as a health care provider is through the development of a collaborative practice agreement.

Collaborative practice agreements are a way for a pharmacist to become an extension of the physician’s services while utilizing his or her own expertise in pharmacotherapeutics. Once the physician has made the diagnosis, a collaborative practice agreement allows a pharmacist to provide drug therapy management and direct patient care based on the specific terms of said agreement.

I was given the privilege of interviewing a pharmacist who is currently practicing under such an agreement, Dr. Julie Lehn. She presently holds the title of clinical pharmacy specialist in palliative medicine at Banner Good Samaritan Medical Center in Phoenix, Arizona.

Tell us about yourself and your career.

I got a late start in this profession, as pharmacy is my 3rd career. I received my Pharm.D. from the University of IowaCollege of Pharmacy. I went on to do a PGY1 general practice residency at the Phoenix VA. I fell in love with the amazing weather and decided to stay in Arizona. After residency, my practice was in internal medicine, first at the VA for three years, then Boswell Memorial for another three years, and I’ve been practicing at Good Samaritan since then.

Tell us about the process of setting up your collaborative practice agreement.

It all started when I was asked to sit in on the palliative care physician interviews because of my interactions with a previous palliative care provider at our facility and my involvement and experience in pain management. Once the palliative care physician was hired, I began to work with her on a regular but informal basis. We began talking early on about how I could better serve the Palliative Care department by establishing a collaborative practice agreement. In doing so I would become more of a direct extension of the physician’s services, be able to participate in the on-call rotation with the NP and physician, and eventually play a role in providing care in an outpatient clinic. We found a pharmacist/physician team in California that had already set up a palliative care collaborative practice agreement and 32 • Arizona Journal of Pharmacy • Summer 2012

networked with them prior to establishing our own agreement.

I was blessed to have upper administration’s support which helped make the transition to my current practice successful.

What do you feel are key elements to success in the area of collaborative practice?

One key element for success is developing a solid working relationship with the physician. They must have faith and trust in your clinical judgment and ability. I think another key element is being motivated to learn and be proactive in seeking ways to educate yourself and further your knowledge base in your practice area.

What advice would you give a pharmacist looking to start a collaborative practice agreement?

First and foremost, research the literature and laws in your state. After that, I highly recommend networking with others who have established collaborative practices. Finally, make sure that you have a well-established relationship with the physician so that the agreement will be mutually beneficial with the overarching goal of improving patient care.

Where do you see the profession of pharmacy heading in the next decade?

I would like to see pharmacists obtain status as health care providers under the Social Security Act and obtain status as mid-level providers so that we can more effectively act as an extension of provider’s services. These advances will depend on our ability to unite as a profession and approach the legislative issues as a whole. Collaborative practice agreements are a great alternative career track for qualified pharmacists who have made specific career choices because of their passion to be involved in direct patient care. I would like to see more of them developed. We have the education; we have the outcomes data; it’s all about looking for these opportunities, seizing them, and not being afraid of the responsibility that comes with them. We have to be willing to accept risk and responsibility in order to advance our profession and ultimately increase our positive impact on patient care and outcomes.

Julie Lehn, Pharm.D.

Continuing Education

Where Does this Used Needle Go?

by Musselman, Kerri, Pharm.D., Sicat, Brigitte, Pharm.D., Herbert Thomas, Michelle, Pharm.D., Harpe, Spencer E, Pharm.D., Ph.D., MPH, Virginia Commonwealth University School of Pharmacy, Richmond Apothecaries, Inc., Virginia Commonwealth University School of Medicine Abstract Many patients do not know how they should dispose of their used sharps. It is not uncommon for patients to see their pharmacist on a monthly basis to pick up their medications and their syringes.

Pharmacists are in a unique position to provide information regarding syringe disposal. When patients obtain syringes, the pharmacist should speak with them about how to dispose of syringes after use. The United States Environmental Protection Agency has guidelines for sharps disposal, including several options available to patients; however, these may not be familiar to pharmacists or patients.

This article provides a discussion of various methods of used sharps disposal.

Objectives: 1. Discuss the importance of proper disposal and list the problems of current disposal methods.

2. Identify individuals in the community who are at increased risk for accidental needlesticks.

3. Compare and contrast the different options available for disposal and recommend an option for a patient.

Approximately 9 million syringe users will administer 3 billion injections each year for home health treatments such as diabetes, allergies, infertility treatments, arthritis, migraines, etc.1 In addition, between 900 million and 1.68 billion insulin injections and up to 1 billion illegal drug injections occur each year in the United States.2 With this many injections every year, where do the used sharps go?

Needlestick injuries (NSIs) continue to be a serious problem in our society today, both in healthcare and non-health care settings. Injuries from contaminated sharps present a potential risk of contracting blood-borne pathogens, including HIV, hepatitis B, and hepatitis C.3 According to data from the Centers for Disease Control and Prevention (CDC), approximately 385,000 NSIs are experienced by hospital-based healthcare personnel.4 Healthcare providers typically realize that NSIs occur and that every precaution should be taken to avoid them.

Consequently, the Occupational Safety and

Health Administration (OSHA) published the Bloodborne Pathogen Standards to protect workers in health care settings.5 Those same precautions are important to patients in the community and the public at large.

Needles have been found in many inappropriate locations, including trash cans, parks, playgrounds, and on sidewalks, while others are being flushed down the toilet.2 Two factors that contribute to these practices are a lack of knowledge about disposal guidelines and a lack of available sharps containers in public places.6 Furthermore, there are a number of potential consequences associated with improper used sharps disposal in the community.

Inappropriate disposal increases the risk of NSIs. The pain from the injury is topped by the uncertainty of the risk for transmission of bloodborne pathogens.

The risk in the community from these medical wastes is real.7 Under-reporting of community based incidents is inevitable, but incidents have been reported. A case of hepatitis C virus transmission by NSI in the community has been described.8 The individual experienced an accidental NSI in a park and had negative seroconversion for hepatitis B or C on the day of injury.

Follow up tests after three months were positive, suggesting that hepatitis C can be transmitted by accidental NSI.8 Some used needles are flushed down the toilet2 potentially causing accidental needlesticks for utility workers.

The risk of NSI among workers, both health professionals and non-health professionals, in healthcare facilities has been previously studied.9,10 Outside of healthcare facilities, those groups at increased risk of experiencing an accidental NSI include sanitation workers, custodial staff, housekeepers, and law enforcement personnel.2,11 Workers may have an accidental NSI but never report it for fear of getting into trouble or thinking it was their fault. While under-reporting is known to be a challenge,10 studies suggest that larger numbers of people from different walks of life such as children, adults, and non-health care workers in the community have had injuries as a result of exposure to discarded sharps in public

places.11 Previous recommendations by the Environmental Protection Agency (EPA) stated that used sharps should be placed in a hard, puncture-resistant container, such as a fabric softener container. When the container was full, the cap was to be closed tightly and securely taped, with “DO NOT RECYCLE” written on the container to prevent it from being sent to a recycling plant.12 Even if all of these guidelines were followed, several issues could still arise. The containers could be sent to recycling plants inadvertently despite appropriate labeling, or the “DO NOT RECYCLE” message could rub off resulting in recycling. This could lead to an increase in NSIs occurring in recycling facility workers. Additionally, containers with used sharps could break open in garbage trucks, placing waste management workers at risk for accidental NSIs.1 As of 2004, the EPA recommends one of five options for disposal of used sharps: drop boxes/supervised collection sites, mail-back programs, syringe/ needle exchange programs, at-home syringe destruction devices, and special waste pick-up.2 The potential advantages and disadvantages of each method are discussed in Table 1. Additionally, Table 2 provides some resources that may be useful in helping patients find appropriate disposal solutions.

Drop Boxes/Supervised Collection Sites Drop boxes/supervised collection sites are locations where full used sharps containers are accepted for disposal. The locations may include doctors’ offices, hospitals, health clinics, pharmacies, health departments, community organizations, police and fire stations, and medical waste facilities.13 Some states where this service is available include California, Florida, Michigan, New York, Rhode Island, and Wisconsin.13-17 One such program in San Francisco, California, is funded as part of the community garbage collection rate. Residents can pick up a free sharps container at a specific location, and once it is full, the container can be returned to the same location designated by the recycling company, SF Recycling & Disposal Incorporated.18

Summer 2012 • Arizona Journal of Pharmacy • 33

Continuing Education (continued from page 33) Mail-Back Programs Mail-back programs are designed to meet specific mailing and labeling requirements in order to ship used sharps via the United States Postal Service (USPS) to an organization for disposal.

This option is particularly useful for individuals in rural communities or those who do not have any other disposal options.1 However, the cost varies from $25 to $45 and even more for larger containers. Some examples of mailback programs include options provided

by Sharps Compliance Corporation , Medasend, Waste Management, and Stericycle.

Syringe/Needle Exchange Programs (SEPs) The North America Syringe Exchange Network (http://www.nasen.org/) allows users of syringes/needles to exchange used needles for new needles. Funding for these programs often comes from the state or local government, and they are usually run by community organizations.19 This option for disposal is available in California, Illinois, Massachusetts, Michigan, Minnesota, New York, North Carolina, Ohio, Oregon, Pennsylvania, and Washington.

At-Home Needle Destruction Devices At-home needle destruction devices destroy used needles to make them safe for disposal. The devices destroy needles by either snipping or breaking the needle (e.g., the BD Safe-Clip™ device

by Becton, Dickinson, and Company) or melting the sharp/needle into a nonhazardous pellet (e.g., the Disintegrator®

by American Scientific Resources or the NeedleZap® by E Med Future).13 If a device is used to clip or break the needle, the device must itself also be disposed by using one of the five options listed by the EPA to prevent an accidental NSI. A case report of a woman who utilized a needle clipping device underscores this fact. The report describes a woman with diabetes mellitus who was experiencing neuropathy in her feet. Upon examination, her healthcare providers found that needles from 2 clipped syringes were embedded in her foot.20 Special Waste Pick-Up Special waste pick-up allows patients to place full sharps containers at the curbside for collection. Participants

must set up the service individually for their home. The used sharps are treated as medical waste and will be collected by employees specifically trained in hazardous waste handling. This service may not be available in all areas so more investigation into your specific locality’s sanitation company or the locality’s government website is required before this option can be recommended to patients.

This disposal service may be paid for by the patient or supplemented by the local government. A service of this type is available in Salem, Virginia.21 Although recommendations by the EPA provide guidance22, state regulations do not consistently mirror them. For instance, Virginia regulations state that sharps should be placed in opaque, puncture-resistant containers. Once full, the lid should be securely taped onto the container and placed in a trashcan. These regulations do not specifically address any of the other options recommended by the EPA.23 Since each locality can specify how sharps should be handled, it is important to find out what special procedures are required and what is available in each area. More information can be obtained through state laws and regulations or by contacting the local waste management authority.

Conclusion Each year, millions of patients in the United States administer medications via injections at home. The majority of these needles are discarded into the public solid waste system or improperly discarded. This poses a risk of injury.

Needlestick injuries in the community are underreported thus the implications to public health underestimated. Monitoring mechanisms are not thorough and reporting compliance is low.

Collaboration is needed between the government, community, hospitals and the research community to address and monitor the problem more effectively.

The Coalition of Safe Community Needle Disposal is working with the EPA to increase awareness efforts. Current recommendations by the EPA for disposal include drop boxes/supervised collection sites, mail-back programs, syringe/needle exchange programs, at-home needle destruction devices, and resident special waste pick-up.

As a pharmacist, it is important to learn more about what your state or

34 • Arizona Journal of Pharmacy • Summer 2012

locality offers and talk with your patients about the options available for safe disposal. It is important to talk with patients about their options and find the one that fits them the best.

References 1. Coalition of Safe Community Needle Disposal. http://www.safeneedledisposal.org/genprob.html.

Accessed June 10, 2009.

2. United States Environmental Protection Agency (EPA). Community Options for Safe Needle Disposal. Oct. 2004. http://www.epa.gov/osw/ nonhaz/industrial/medical/med-govt.pdf. Accessed June 10, 2009.

3. Mallin AR, Sinclair D. Needlestick injuries and potential body fluid in the emergency department.

CJEM 2003; 5: 36-37.

4. Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program. Division of Healthcare Quality and Promotion. Atlanta, GA: Centers for Disease Control and Prevention (CDC): 2008. [Available online at http://www.cdc.gov/sharpssafety/pdf/ sharpsworkbook_2008.pdf.] Accessed June 10, 2009.

5. Occupational Safety and Health Administration (OSHA). Occupational exposure to bloodborne pathogens:needlesticks and other sharps injuries; final rule. Federal Register 2001; 66: 5317.

6. Center for Disease Control and Prevention.

Syringe Disposal December 2005. Accessed on January 18, 2010. http://www.cdc.gov/idu/facts/ aed_idu_dis.pdf.

7. Sandra C. Thompson. Blood-borne viruses and their survival in the environment: is public concern about community exposures justified? Aust and N Z J Public Health 2003; 27: 602-607.

8. Haber PS, Young MM, Dorrington L, Jones A, Kaldor J, Kanzow S, Rawlinson WD. Transmission of hepatitis C virus by needlestick injury in community settings. J Gastroenterol Hepatol 2007; 22: 18821885.

9. Jagger J, Bentley MB. Disposal-related sharpobject injuries. Advances in Exposure Prevention 1995;1:1-6.

10. Panlilio AL, Orelien JG, Srivastava PU, Jagger J, Cohn RD, Cardo DM. Estimate of the annual number of percutaneous injuries among hospitalbased healthcare workers in the United States, 19971998. Infect Control Hosp Epidemiol 2004;25:556562.

11. O’Leary FM and Green TC. Community acquired needlestick injuries in non-health care workers presenting to an urban emergency department.

Emerg Med 2003; 15: 434-440.

12. Handle with care: how to throw out used insulin syringes and lancets at home. EPA530-K-99-008.

Washington, DC: US Environmental Protection Agency, 1999.

13. Coalition of Safe Need Disposal. http://www. safeneedledisposal.org/gentypes.html. Accessed June 10, 2009.

14. Specifics of Local Jurisdictions Sharp Collection Programs. Accessed June 15, 2009. http://www. ciwmb.ca.gov/HHW/Sharps/LocalProgram.pdf.

15. New York State Directory of Community Sharps Collection Sites. Accessed June 15, 2009. http:// www.nyhealth.gov/diseases/aids/harm_reduction/ needles_syringes/sharps/docs/nassau.pdf.

16. Michigan Department of Environmental Quality, Waste and Hazardous Materials Division. Sharps Collection Programs for Michigan Residents.

Accessed June 15, 2009. http://www.michigan.

Continuing Education (continued from page 34) http://www.epa.gov/osw/nonhaz/industrial/medical/ gov/documents/deq/whm-stsw-sharps-collectionmed-home.pdf] Accessed June 10, 2009. list_196524_7.pdf.

23. Regulation 16VAC25-90-1910.1030(d)(4)(iii)(A) 17. Wisconsin Department of Natural Resources.

Sharps Disposal. Accessed June 15, 2009. http:// & 9VAC20-120-220. Practice GreenHealth. Virginia Regulations. Accessed June 10, 2009. http://cms. dnr.wi.gov/org/aw/wm/medinf/sharps.htm. h2e-online.org/ee/rmw/rmw-regulations/state-rmw18. SF Recycling & Disposal Inc. San Francisco regulations/virginia/ Needle/Syringe Disposal Program. Accessed January 20, 2010. [Available online at: http://www. sfrecycling.com/needles/index.php?t=d] ACPE UAN# 0100-9999-12-051-H04-P 19. Center for Disease Control and Prevention.

Prevention Among Injection Drug Users. “Appendix This continuing education activity was A: Key Strategies for Preventing Blood-Borne Pathogen Infection Among Injection Drug Users. developed by the Virginia Pharmacists Accessed January 20, 2010. [Available online at: Association and is reprinted with http://www.cdc.gov/idu/pubs/ca/appendixA.htm.] permission. No financial support was 20. Woolfrey, Paul and Kirby, R. Lee. “Hypodermic received for this activity. This activity needles in the neuropathic foot of patient with diabetes”. Canadian Medical Association Journal. may appear in other state pharmacy 1998, Edition 158, vol 6. association journals.

21. Solid Waste Disposal & Transfer Station.

Salem, Virginia. http://www.salemva.gov/depts/swd/ sharppup.html. Accessed June 10, 2009.

22. United States Environmental Protection Agency (EPA). Protect Yourself, Protect Others. Safe Options Table 1. Advantages and Disadvantages for Home Needle Disposal. [Available online at:

An additional continuing pharmacy education homestudy article titled Reviewing Diabetes Guidelines is available on the AzPA website in the AJP Archives.

Member login is required.

Free CPE credit from home study articles published in the Arizona Journal of Pharmacy is a member benefit for AzPA Members.

Not a member? Visit the AzPA website and join today!

Drop Boxes/ Mail-Back Supervised Programs Table 1. Advantages and Disadvantages Collection Drop Boxes/ Mail-Back Syringe/ At-Home Special Feature Sites Supervised Prevents Programs Needle Needle Waste Yes sharps being introduced Yes Collection into the solid waste Exchange Destruction Pick-up disposal Sites Programs Devices system Prevents sharps being introduced Yes Yes Yes to all No No Yes Yes Convenience of sites into the solid waste disposal consumers system Availability to most consumers No Yes Convenience of sites to all No Yessupported by Nolocal Yes No Yes No Costs consumers government or community Availability to most consumers No Yes No Yes No organizations Costs supported by local No Noof the program Yesto the No Low In some Cost High government or community areas consumer organizations Cost of the program to the Low High Moderate Low Moderate consumer (clipping devices) ModerateHighNo Privacy for the consumer Yes (destructio n devices) Privacy for the consumer No Yes No Yes Yes Feature

Syringe/ Needle Exchange Programs Yes

At-Home Needle Destruction Devices No

Special Waste Pick-up

No

Yes

Yes

No Yes

Yes No

No In some areas

Moderate

Low (clipping devices) ModerateHigh (destructio n devices) Yes

Moderate

No

Yes

Yes

Table 2. Resources Table 2. Resources Resources Organizations United States Environmental Protection Agency (EPA) Center for Disease Control and Prevention (CDC) Coalition of Safe Community Needle Disposal International Sharps Injury Prevention Society Syringe mail-back programs Waste Management Sharps Compliance Corporation Stericycle Medasend Syringe destruction devices Disentegrator® NeedleZap® BD Safe-Clip™ Device

Resources Website Organizations United States Environmental http://www.epa.gov/osw/nonhaz/industrial/medical/disposal.htm WebsiteProtection Agency (EPA) Center for Disease Control and http://www.cdc.gov/needledisposal/index.htm http://www.epa.gov/osw/nonhaz/industrial/medical/disposal.htm Prevention (CDC) Coalition of Safe Community Needle http://www.safeneedledisposal.org/ http://www.cdc.gov/needledisposal/index.htm Disposal International Sharps Injury Prevention http://www.isips.org/ http://www.safeneedledisposal.org/ Society Syringe mail-back programs http://www.isips.org/ Waste Management http://www.wm.com/products-and-services/residential-otherwaste-solutions/syringe-collection.jsp Sharps Compliance Corporation http://www.sharpsinc.com/disposal_mail_product_page.htm http://www.wm.com/products-and-services/residential-otherStericycle http://www.stericycle.com/consumer-needle-disposal.html waste-solutions/syringe-collection.jsp Medasend http://www.medasend.com/ http://www.sharpsinc.com/disposal_mail_product_page.htm Syringe destruction devices http://www.stericycle.com/consumer-needle-disposal.html Disentegrator® http://www.disintegratorplus.com/ http://www.medasend.com/ NeedleZap® http://www.needlezap.com/index.html BD Safe-Clip™ Device http://www.bd.com/us/diabetes/page.aspx?cat=7002&id=7416 http://www.disintegratorplus.com/ http://www.needlezap.com/index.html Summer 2012 • Arizona Journal of Pharmacy • 35 http://www.bd.com/us/diabetes/page.aspx?cat=7002&id=7416

Continuing Education Quiz

Where Does This Used Needle Go?

1. Approximately how many injections are administered each year by users of selfinjectable medications? a. 9 million b. 900 million c. 1 billion. d. 3 billion 2. Which of the following is a concern when needles are not disposed of properly? a. Needlestick injuries b. Transmission of bloodborne pathogens c. Potential physical and emotional pain associated with a needlestick d. All of the above 3. Which of the following statements regarding needlestick injuries (NSIs) is true? a. NSIs are only a concern for individuals working in health care facilities b. The EPA has produced recommendations for used sharps disposal c. Appropriate disposal of used sharps eliminates the risk of NSIs d. All of the above 4. Which of these groups may have the greatest risk of exposure after used needles that were inappropriately disposed enter the public solid waste management system? a. Recycling facility workers b. Health care workers c. Law enforcement personnel d. None of the above

5. Which of the following disposal options would be the most expensive for the patient but better-suited for patients who live in rural areas? a. Mail-back programs b. Syringe/needle exchange programs (SEPs) c. Special waste pick-up d. All of the above 6. Which of the following waste disposal options may not prevent introduction of contaminated sharps into the solid waste system? a. Drop boxes/supervised collection sites b. Needle clipping devices c. Mail-back programs d. Syringe/needle exchange programs (SEPs) 7. Which of the following options is the most widely available for consumers across the country? a. Drop boxes/supervised collection sites b. Mail-back programs c. Syringe/needle exchange programs (SEPs) d. Special waste pick-up 8. Which of the following disposal option descriptions or examples are correct? a. The NeedleZap® is a syringe mail-back program b. The BD Safe-Clip™ device is a needle destruction device c. The special waste pick-up service in Salem, Virginia is a type of syringe exchange program d. None of the above are correct.

Arizona Pharmacy Foundation

9. Where can you find information regarding sharps disposal? a. Center for Disease Control and Prevention Website b. Safe Needle Coalition Website c. Environmental Protection Agency Website d. All of the above 10. What are important factors when recommending a disposal option to a patient? a. Availability in your locality b. Convenience for the patient c. Cost to the patient d. All of the above This activity was developed by the Virginia Pharmacists Association (VPA) for pharmacists as a knowledge-based learning activity.

VPA and the Arizona Pharmacy Association are accredited by the Accreditation Council for Pharmacy Education as providers of continuing pharmacy education.

CPE MONITOR INSTRUCTIONS: Pharmacists and technicians are required to provide their NABP e-Profile ID, plus their birth date (MMDD,) to AzPA in order to receive credit for completed CPE. As a secure, central system, CPE Monitor will assist licensees by maintaining & tracking all ACPE-Accredited CPE units.

AzPA is required to transmit the CPE data to CPE Monitor by December 31, 2012 in order to continue to issue ACPE-accredited CPE units.

Licensees may obtain additional information and set up their NABP e-Profile at www.

MyCPEmonitor.net.

Where Does This Used Needle Go?

ACPE UAN#0100-9999-12-051-H04-P Certificates will be mailed within 60 days.

This activity is accredited for 0.5 hours of CPE credit (CEUs 0.05) This activity is a benefit to AzPA members. Non-members of AzPA must enclose a $25.00 check payable to the Arizona Pharmacy Foundation.

In order to qualify for ACPE credit, participants must achieve a grade of 70% or above on the quiz and submit a completed activity evaluation.

ACTIVITY EVALUATION – Please indicate if the activity met the stated learning objectives: 1. Discuss the importance of proper disposal and list the problems of current disposal methods.

2. Identify individuals in the community who are at increased risk for accidental needlesticks.

3. Compare and contrast the different options available for disposal and recommend an option for a patient.

AGREE AGREE AGREE

DISAGREE DISAGREE DISAGREE

Will the information presented cause you to make any changes to your style or method?

Yes No If you answered “yes” please list one or two things you will do differently: _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ Overall evaluation of the article content: (please circle one)

Name __________________________________________________________ Address ________________________________________________________

Poor

1

2

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4

5

Excellent

Activity accredited date: 07-01-2012 Expiration date: 07-01-2015.

Send this page to: APF, 1845 E. Southern Ave., Tempe, AZ 85282

Email ________________________________________________________

City, State, Zip ___________________________________________________ Birthdate (MM/DD only) ______________ NABP e-Profile ID# ________________

36 • Arizona Journal of Pharmacy • Summer 2012

D i Together, g n i t y H ewe a l t are h . oamazing. rg At Dignity Health, talent and respect go handin-hand. Here, we are deeply committed to

Together, we are amazing.

providing an environment where employees

At Dignity Health,and talent and respect to golearn hand- in- feel welcome are encouraged from hand. Here, we are deeply committed to providing one another. Because when our individual an environment where employees feel welcome and views and experiences put together, are skills, encouraged to learn from oneare another.

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Our focus on employee satisfaction hason helped us earn recognition as: Our focus employee satisfaction has helped usArizona’s earn recognition as: Companies, • 2011 Most Admired Az Business Magazine, BestCompaniesAz • 2012 Top 25 Workplaces for Women, • 2011 Top 25 Workplaces for Women, Az Magazine, BestCompaniesAz Az Magazine, BestCompaniesAz • 2011 Arizona’s Most Admired Companies, • 2011 The Valley’s Healthiest Employers, Az Business Magazine, BestCompaniesAz The Phoenix Business Journal • 2011 The Valley’s Healthiest Employers, The Phoenix Business Journal EOE. ©2012 Dignity Health.

EOE. ©2012 Dignity Health.

We’re Dignity Health, Catholic Healthcare Healthcare West.formerly Our Arizona region is West. The word “dignity” perfectly defines what comprised of Chandler Regional Medical our organization stands for: showing respect for Center,byMercy Gilbert Medical and all people providing excellent care.Center Our Arizona St. isJoseph’s Hospital and Medical Center. region comprised of Chandler Regional Medical Center, Mercy Gilbert Medical Center and To learn more about our culture and our St. Joseph’s Hospital and Medical Center.

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