ARIZONA JOURNAL A JP OF PHARMACY THE OFFICIAL PUBLICATION OF THE ARIZONA PHARMACY ALLIANCE

WINTER 2010

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ARIZONA JOURNAL A JP OF PHARMACY Vol. 2, No. 4

WINTER 2010

IN THIS ISSUE BOARD OF DIRECTORS PRESIDENT Kelly Ridgway PRESIDENT-ELECT Kevin Boesen TREASURER Ken Mahan PAST PRESIDENT Mark Boesen SECRETARY Michael Dietrich COMMUNITY PHARMACY ACADEMY CHAIR Teresa Stickler HEALTH-SYSTEM PHARMACY ACADEMY CHAIR Butch David HEALTH-SYSTEM PHARMACY ACADEMY CHAIR-ELECT Jonathan Merchen MANAGED CARE PHARMACY ACADEMY CHAIR Ray Clark MANAGED CARE PHARMACY ACADEMY CHAIR-ELECT Julie Hernandez SENIOR CARE PHARMACY ACADEMY CHAIR Kimberly Cauthon SENIOR CARE PHARMACY ACADEMY CHAIR-ELECT Dawn Gerber STUDENT PHARMACIST ACADEMY CHAIRS Bonnie DiLorenzo, Midwestern University College of Pharmacy Glendale Kerry Redman, University of Arizona College of Pharmacy STUDENT PHARMACIST ACADEMY CHAIRS-ELECT Valerie Bostel, Midwestern University College of Pharmacy Glendale Jessica DiLeo, University of Arizona College of Pharmacy TECHNICIAN ACADEMY CHAIR Chris Lesaca TECHNICIAN ACADEMY CHAIR-ELECT Mike Severn NORTHWEST DISTRICT DIRECTOR Norbert Laskowski NORTHEAST DISTRICT DIRECTOR Chuck Dutcher SOUTHWEST DISTRICT DIRECTOR Lisa Keller SOUTHEAST DISTRICT DIRECTOR John Nicolais INDUSTRY REPRESENTATIVE Greg Morrill DEANS OF COLLEGES J. Lyle Bootman University of Arizona College of Pharmacy Dennis McCallian Midwestern University College of Pharmacy Glendale LEGAL COUNSEL Roger Morris, Quarles & Brady

COLUMNS President’s Message 2 CEO’s Message 3 Academy News • Community Pharmacy Academy 12 • Health-System Academy 12 • Managed Care Academy 13 • Senior Care Academy 14 • Student Pharmacist Academy 15 • Technician Academy 15 FEATURES AND ARTICLES An Adherence Message for Pharmacists 21 Taking the “Spice” Out of Life 22 Monitoring Controlled Substances - Are You Liable? 23 Closing the Coverage Gap 24 A Look Back - Toilet Tissue 27 Time Capsule 41 DEPARTMENTS New Members 4 Alliance News 5 Legislative Update 10 PAPA 11 Drug Information Questions 16 Feature Pharmacist • A Leader in Geriatric Pharmacy 18 • Not Your Typical Pharmacist 20 In Memoriam 30 Rx and the Law 31 Student Perspective • Is Marijuana Effective? 28 Continuing Education 32 Financial Forum 42 EDITOR-IN-CHIEF Mindy D. Smith, R.Ph., Executive Director/CEO MARKETING AND COMMUNICATIONS Janet Weigel EDITORIAL BOARD Leslie Rodriguez, Pharm.D. Tina Smith, Pharm.D., BCPS Whitney Rice, Pharm.D.

EDITOR’S NOTE: Any personal opinions expressed in this magazine are not necessarily those held by the Arizona Pharmacy Alliance. “Arizona Journal of Pharmacy” (ISSN 1949-0941) is published quarterly by the Arizona Pharmacy Alliance at 1845 E. Southern Avenue, Tempe, AZ 85282-5831. PHONE (480) 838-3385, FAX (480) 8383557, email info@azpharmacy.org. It is distributed to members as a regular member service paid for through an allocation of dues of $20.00 in advance.

Arizona Journal of Pharmacy 1

President’s Message The Pharmacy Revolution

Kelly Ridgway, R.Ph. AzPA President As I look to 2011 I see no more appropriate theme for this journal than the Pharmacy Revolution. This theme is opportune given our current economic and political landscape and is exactly what our profession needs in order to be a player on the future health care team. According to the Merriam-Webster dictionary, “revolution” means: • a fundamental change in the way of thinking about or visualizing something: a change of paradigm • a changeover in use or preference We as pharmacists need to assert ourselves as the medication experts, not just within our profession, but outside of our profession. We as pharmacists know this to be true but so many people outside our profession still do not realize this and do not understand how important our role is to patient care. As a profession we need to demand that pharmacists be present anytime medications are being discussed. We need to start bragging about our expertise and find creative ways to insert ourselves into the evolving health care arena. If we sit back and stick to our traditional roles of count, pour, lick and stick, we will continue to be left out of key decisions not because we don’t have value but because we have not demonstrated and shared our value to other health care providers and to our community.

2 Arizona Journal of Pharmacy

I recently read an article called “Bite Your Tongue?” written by David Miller, R.Ph., Executive Vice President of the International Academy of Compounding Professionals (IACP) in which he makes a call out to its members. Although I realize we are not all compounding pharmacists, his message resonates across all pharmacy practice settings, associations and affiliations. Since imitation is the sincerest form of flattery I would like to share with you his thoughts and put out the same message to all AzPA members as this is exactly what a “Pharmacy Revolution” needs to encompass. “How often do you pass up an opportunity to call a Congressman about an issue facing your practice? To respond to an IACP survey? To comment on an issue? To compliment or complain? To tell a colleague about our organization and invite them to join? To tell a patient about how important and unique your pharmacy and your services are? To go out and promote compounding in your neighborhood? To reach out to your local school of pharmacy and become a preceptor …? To say what’s right and what’s wrong both within pharmacy… I’m not blaming you. Not at all. We pharmacists aren’t very good at promoting ourselves…. “So. Here’s the deal. It’s time to start speaking up...... tell EVERYBODY about the value that you bring to the health care team as the medication experts that they so desperately need to deliver quality service to patients. Biting our tongues doesn’t help. It just hurts. And it only hurts ourselves. It’s time to open our mouths.” 2011 will bring about many changes both statewide and nationally: health care reform, the desire of physicians to move toward the medical home model, as well as many state specific changes such as expanding collaborative practice and immunization legislation. These all have

the potential to influence both positive and negative changes for our profession and that will largely depend on our voice, involvement and advocacy. I have never been more excited for our profession and the endless opportunities ahead but a part of me is also a little scared that as a profession we often do not exhibit the same gumption as other professions to fight for our rightful place within the health care team. Too often we step aside and permit others do what we were trained to do in order to avoid conflict and friction. We are already seeing this happen with other health professions such as nurses taking over medication counseling roles, MTM, and medication reconciliation. Medication management needs to stay within the practice of pharmacy and we need to protect, preserve and maintain it. We have to be willing to fight for this responsibility for the benefit of our patients, profession and health care as a whole. I challenge all of you to be an active member of AzPA and to encourage your colleagues to join and support this organization through membership, leadership, PharmPac contributions, and, most importantly, their voice. To conclude, I would like to end with a quote I have shared in every communication thus far as President and will continue to do so as it speaks volumes about our responsibility to AzPA as Arizona pharmacists.

“Every man owes a part of his time and money to the business or industry in which he is engaged. No man has a moral right to withhold his support from an organization that is striving to improve conditions within his sphere.” Theodore Roosevelt (26th President)

CEO’s Message Arizona Pharmacists and the Patient-Centered Medical Home At a recent stakeholders meeting on the sunrise application requesting modifications to change the location requirements in ARS 32-1972, it was requested that AzPA submit a statement outlining AzPA’s support of the patientcentered medical home (PCMH) concept. Details from that letter are below. AzPA strongly supports PCMH and believes that pharmacists can enhance the PCMH by focusing on medication management services through collaboration with the physician/clinician. Pharmacists do not wish to supplant the role of physicians, but to use our education, training and expertise to serve as a partner to physicians and a resource to patients. AzPA is also an advocate for expanding the use of health information technology, a critical principle behind PCMH. In Benefits and Outcomes from Integrating Medication Management in PCMH1 published on Patient Centered Primary Care Collaborative (http:// www.pcpcc.net), it states that effective medication therapy management (MTM) provides the physicians/clinicians with more time to diagnose patient problems, select appropriate treatment, formulate treatment goals, and effectively manage patient problems. Working with another clinician who is performing MTM services, the treating physician/clinician can gain confidence that the patient is receiving information about his conditions, medications, and care plan as well as encouragement and support to achieve his health goals. “Most patient care interactions involve medications, and the limitations both in knowledge and time on my part, makes the addition of a clinical pharmacist on the medical home team MANDATORY! I would have a difficult time maintaining our current standards without this person on board,” states James Bergman, M.D., Staff Physician, Group Health Permanente, Associate Professor, Family Medicine, University of Washington, Seattle1

The IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century2, identifies six aims for

health care system improvement: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity all important elements of the medical home concept. With these objectives in mind, two broad goals related to medication access and use are offered that should be integral parts of the medical home concept: 1. Recognizing the role of pharmacists to help ensure that medication therapy is safe, effective, equitable, patientcentered, and results in quality outcomes. 2. Expanding the use of health information technology to support full integration of pharmacists as part of the medical home partnership team. AzPA emphasized to the stakeholders how pharmacists are able to contribute measurable value directly to the care of patients through their expertise in medications, educating patients, helping to minimize interactions and side effects, and recommending drug therapy regimens to physicians/clinicians which move patients more quickly toward clinical goals. The data are positive about the delivery of these services, with a demonstrated return-on-investment (ROI) as high as 12:114, and an average of 3 to 5:1.15. The ROI reflects an ability to decrease hospital admissions, physician visits, emergency room admissions, and reduce use of inappropriate medications. Studies have indicated that pharmacists can improve clinical care outside of hospital settings. The Minnesota Experience study shows 637 drug therapy issues resolved among 285 patients with goals of therapy increased from 76% to 90%. The total health expenditures reduced from $11,965 to $8,197 per person. The ratio of reduction in total annual health expenditure to cost of providing MTM service is more than 12 to 1.1

AzPA’s employer-based patient selfmanagement program (PSMP), modeled after the Asheville Project, demonstrates how pharmacy care service for diabetic employees showed improvements in their outcomes over time. The methods implemented entailed long-term patient

Mindy D. Smith, R.Ph. Chief Executive Officer follow-up by a community pharmacist, monitoring, collaboration with physicians, clinical assessment and education. The figures indicate 50% reduction in employee sick days and a total saved of 5 million dollars of health care costs. All programs include collaboration with the patient’s primary care physician (PCP) and there is evidence that the patient has INCREASED PCP visits because the pharmacist refers the patient more often. In support of the patient-centered medical home, AzPA is working to change ARS 32-1972 to support the concept of the provider-pharmacist relationship and that the practice site and protocols are specific to the agreement between the pharmacist and provider. AzPA encourages constructive feedback from the physician association stakeholders as we continue to dialogue with them on the value of the pharmacist and ensure there are opportunities for pharmacists to be inserted in PCMH to improve outcomes related to drug therapy management. AzPA is committed to identifying ways we can better collaborate to strengthen the medical home and ensure that patients receive the best care in Arizona. References

1. “Benefits and Outcomes from Integrating Medication Management in PCMH”, Patient Centered Primary Care Collaborative, 2010. http://www.pcpcc.net/content/benefitsand-outcomes-integrating-medication-management-pcmh 2. William C. Richardson, et. al, Crossing the Quality Chas: A New Health System for the 21st Century, Institute of Medicine, Shaping the Future for Health, March 2001. http://www.nap.edu/html/quality_chasm/reportbrief.pdf

Arizona Journal of Pharmacy 3

New Members WELCOME NEW MEMBERS Jacquelyn Adkins Alejandra Aguilar Michael Anderson Golda Aranas Hugo Arias Allison Arterbury Valmira Asllani Tammie Austin Daniel Avery Yelena Babadzhanov Mina Baghzouz Brian Barkow Amy Bataoel Aundrea Bell Stacey Black Anthony Blackford Lauren Bodhaine Steven Boerner Steven Boyles Olga Boytsova Jacqueline Brody Sandra Brownstein Kristen Bunger Daniel Burgos Audrey Bushway Phalyn Butler Patrick Campbell Zak Cerminara Lawrence Chait Hout Chao Bach-Truc Chau Christopher Chavez Adam Chiappini David Choe Brooke Clark Mary Cradick Sarena DeBaca Thomas Deeren Shannon DeGrote Mary Dexter Derek Deyle Rafael Diaz Daniel Diggins Jr. Nandita Dinu

Van Do Sean Duffy Courtney Edel Frank Evans Echo Fallon Emily Fletcher Sarah Flocks Paul Frey Kristen Fyfe Kiel Gillette Ellen Gitt James Go Christa Goldie Helen Gruener Mary Guthrie Jennifer Hand Kirsten Haslett Jared Hatchard John Hayes Chelby Helmrich Michael Herman George Hernandez Stefanie Hollander Brian Hreniuc James Huang Shelly Hummert Michael Ivey Zac Johnson Stephen Karpen Amy Kennedy Tanya Kent Katrina Kittell Michael Klein Ifat Krase Kelly Krieger Matthew Kugelman Amelia Kwong Connie Kwong Yin Lai Rose LaMesjerant Brian Lamhong Marti Larriva Carolyn Lebet Ae Ri Lee

Yong Gu Lee Gia Leonetti Conchetta Lesser Shannon Li Shannon Lim Jennifer Lin Elizabeth Lu Dina Lynch Kyle Malhotra Heather Marrow Spencer Marshall Mary Beth Marten Loreae McCollum Bryanne McCown Krista McCoy Will McCracken Patrick McNeill Allan Miller Negin Mohebbi Lea Mollon Robert Montierth Saviena Moore Jazmin Moreno Clint Napier An Nguyen Cang Nguyen Carol Nguyen Danielle Nguyen Don Nguyen Linda Nguyen Natalie Nguyen Thu Nguyen Lameck Nyakweba Shanna Nyberg Dawne O’Brien Holly Paddock Kinjalben Patel Amber Pate-Mozroll Pankaj Patil Harold Perlman Eric Perry Lizabeth Petersen Tiffany Pham Tina Pham

Ngoc Lena Phung Doug Popham Misael Porras John Price Olivia Renner Randy Rhodes Traci Richards Edward Saksenhaus Alex Saliba Ashley Santa-Cruz Robert Sanzenbacher Scott Schmelder Clarissa Sema Victoria Sherbeck Forshad Shirazi Rijan Shrestha Caitlin Simonson Amelia Smith Jarrod Smith Lisa So Robin Staib Matthew Stevens Christina Summy Shadan Taban Natalee Tanner Trevor Thompson Kevin Tran Tina Tran Leah Tribbey Chris Valdiviez Tina Vallabh Beena Vemulapalli Hoang-Trang Vo Meghan von Schaumburg Peter Vu Abby White Amanda Wieman Riley Williams II Sue Wilson Eric Wong Andrea Woodard Shawn Yazza Lawrence York Yeh Ling Yuan Lee Jieyan Zhu

Thank you to McKesson for sponsoring the 2010 AzPA Membership Event. See page 8 for more information.

4 Arizona Journal of Pharmacy

Alliance News Cheers for Volunteers! The Arizona Pharmacy

Alliance staff is here to support YOU - our members. We acknowledge the contributions of the volunteers who have recently made a difference for our organization and their fellow pharmacy professionals. Thank you for all you do! Paul Smith Ken Mahan Terry Daane Julie Hernandez Kerry Redman Ken Frisard Peggy Khan Ray Clark Jessica DiLeo

Chris Lesaca Jon Merchen Teresa Stickler Mindy Burnworth Butch David Mike Dietrich Mary Martin Grace Akoh-Arrey Crane Davis Leslie Rodriguez Tina Smith Whitney Rice Mike Blaire Peter Vu Katie Schiraldi Bob Lipsy Jon Glover Valerie Bostel

Bonnie DiLorenzo Mark Boesen Greg Morrill Kelly Ridgway Kevin Boesen Keith Boesen Jayne Knott Lindsay Davis Martie Fankhauser Russ Newman Kim Cauthon Pam Coumans Jim Kloster Dawn Gerber Paul Smith Winnie Thi Mike Severn Norbert Laskowski Chuck Dutcher John Nicolais

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Rx relief ® Your Trusted Pharmacy Staffing Partner Arizona Journal of Pharmacy 5

Alliance News Do you know someone who is not a member of the Arizona Pharmacy Alliance . . . and should be?! Invite them to join the only statewide organization that represents the pharmacy profession in Arizona.

Membership Investment Statement Personal Information Name: Preferred Name: Address: City:

State:

Zip:

Home Phone:

(

)

Cell Phone:

Home Fax:

(

)

Referred by:

Birth Date (Month and Day only):

(

)

 Female

Gender:

 Male

Professional Information Company or Organization: Address: City: Phone:

State: (

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Please check the box of the practice academy that best represents your practice:  Community Practice

 Health-System

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MEMBERSHIP CATEGORIES

 Pharmacist – Individual

 Student

Licensed Pharmacists with at least two years of practice SINGLE PAYMENT MONTHLY PAYMENT OPTION: I authorize AzPA to charge my credit card $20 each month x 12 for a total annual payment of $240. See below. MONTHLY PAYMENT

$ 225.00 $ 340.00

 New Practitioner - 2 Yr

Husband and wife pharmacists SINGLE PAYMENT MONTHLY PAYMENT OPTION: I authorize AzPA to charge my credit card $30 each month x 12 for a total annual payment of $360. See below. MONTHLY PAYMENT Persons who are not licensed pharmacists and are interested in pharmacy or are associated with businesses or professions related to the pharmaceutical profession 50% reduction for Pharmacists who are within one year after graduation from a college or school of pharmacy 25% reduction for Pharmacists who are within two years after graduation from a college or school of pharmacy

 Retired Pharmacist

Licensed pharmacists who are no longer working

$

85.00

 Resident

Pharmacists currently enrolled in a residency program

$

65.00

 Technician

Persons employed as supportive pharmacy personnel

$

40.00

 Student

Persons who are matriculating full time in a college or school of pharmacy

$

20.00

 Pharmacist – Individual*  Pharmacist – Joint  Pharmacist – Joint*  Associate st

 New Practitioner - 1 Yr nd

$ $

20.00 30.00

$ 225.00 $ 115.00 $ 180.00

Please make checks payable to the

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Arizona Pharmacy Alliance

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Mail to: 1845 East Southern Avenue

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Payment Options  Single Annual Payment  Monthly Payment*

or fax to 480 838-3557 or call 480 838-3385

 Check Enclosed

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*Monthly Payment Option Available for Pharmacist-Individual, and Pharmacist-Joint. TERMS FOR MONTHLY PAYMENT: By checking the monthly payment option, I authorize AzPA to charge my credit/debit card as indicated for my membership dues payment. My credit card will be charged each month by AzPA $20 (for Individual ) or $30 (for Joint) x 12 months. Includes monthly administrative fee.

VISA ___ MasterCard ___ AMEX ____ Card # Expiration Date ____________________________

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Signature IMPORTANT INFORMATION REGARDING YOUR MEMBERSHIP DUES, TAXES AND DONATION TO THE APF. Of the "Membership Dues" payment, the amount listed below is deductible as a charitable contribution made to the Arizona Pharmacy Foundation (APF), a 501 (c) 3 non-profit corporation, Tax ID #86-0679270. The remaining portion is not deductible as a charitable gift, but may be deductible as a normal business expense. Membership payments to associations that are used for lobbying expenses are no longer deductible for federal income tax purposes. Of the membership dues payment to AzPA, 15% is non-deductible. Please consult your tax advisor on how these rules may apply to you. PHARMACIST Individual NEW PRACTITIONER 1st Year ASSOCIATE

$15 $10 $15

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Joint 2nd Year RESIDENT

$30 $15 $15

RETIRED

$10

TECHNICIAN

$ 5

STUDENT

$ 0

APF News The AWARxE Program The Arizona Pharmacy Foundation (APF) has become a licensee of the drug abuse awareness campaign, AWARxE. Founded by the Minnesota Pharmacists Foundation (MPF) after the death of a 24-year-old Minnesota resident who mixed drugs obtained online and from a local pharmacy, the AWARxE program’s mission is to increase awareness about prescription drug abuse in the United States and to provide medication safety information to the public. Pharmacists, students, and pharmacy staff have a critical role in educating the public and raising awareness of the dangers of medication abuse. AWARxE partners include the American Pharmacists Association (APhA), D.A.R.E., the Minnesota Pharmacists Association (MPhA), the Minnesota Board of Pharmacy, and now the Arizona Pharmacy Foundation. Medication Abuse Statistics Here are some key statistics on prescription and over-thecounter (OTC) drug abuse in the United States, according to the Substance Abuse and Mental Health Services Administration, the U.S. Drug Enforcement Administration, the Office of National Drug Control Policy, and the National Institute of Drug Abuse: • Everyday, more than 4,000 children and young adults begin experimenting with prescription and OTC drugs as a way to get high. • Between 1999 and 2004, nearly 21,000 people died from an overdose of prescription drugs - more than all deaths from cocaine and heroin overdoses. • 70% of persons 12 or older who abuse prescription drugs get them from family and friends for free. • In 2004-2005, ED visits involving abuse of prescription or OTC drugs increased 21%; nearly half of the patients

Alliance News • • • • • • • •

suppressant). In 2006, more than 2 million teens abused prescription drugs. 3 million 12 to 25 year-olds used OTC cough and cold medications at least once to get high. One-third of all new abusers of prescription drugs were 12 to 17 years old. Prescription drugs are the first choice among 12 and 13 yearolds. 13 is the average age for the first non-prescribed use of sedatives and stimulants. 1 in 7 boys and 1 in 5 girls has shared or borrowed a prescription drug. Nearly 1 in 10 high school seniors admits to abusing pain relievers. Girls 12 to 17 years of age are more likely than boys to misuse OTC medications, but the trend reverses with 18 to 25 year-olds.

Get Informed, and Get Involved! Visit awarerx.org for more information, including medication safety tips, trends on medication abuse, and resources for your patients about counterfeit medications, online pharmacies, and other related topics. Inform your patients about the dangers of prescription and over-the-counter drug abuse, especially parents or guardians of children and young adults. The Arizona Pharmacy Foundation is a 501 (c) 3 non-profit, charitable foundation. You can support APF by playing in or becoming a sponsor of the APF Annual Golf Tournament, participating in the APF Legacy Endowment program, designating APF in your workplace United Way or other charitable fundraising campaign, or making a donation in cash or kind. All donations are 100% tax-deductible.

younger than 20 had abused dextromethorphan (a cough

Arizona Journal of Pharmacy 7

Alliance News 2010 Membership Event Hits a Home Run!

On September 22, 2010, AzPA members gathered at Chase Field for the 2010 Membership Event. Four teams competed during the four-hour challenge recruiting 109 new pharmacist members. The winning team, The Avatars, brought in 36 new members. Butch David, of The Avatars, was the top producer, enrolling 28 new members for the Alliance. After the recruitment challenge, team members and guests enjoyed an Arizona Diamondbacks game from the comfort of one of the mini-suites. Thank you to McKesson for sponsoring this event and supporting AzPA! Thank you to all the teams! The Avatars – led by Chris Lesaca. Team members Jenny Whitney, Teresa Stickler, Jon Merchen, Mindy Burnworth, Albert Flores, Joy Davis, Mike Dietrich, and Butch David. The Mean Green Recruitment Machine – led by Ray Clark. Team members Penny Jastrzab, Kerry Redman, Jessica DiLeo, Kim Kelley, Scott Hall, Keri Tillman, and Adriana Kekic. The Rx Krushers– led by Kelly Ridgway. Team members Mark Boesen, Keith Boesen, Kevin Boesen, Greg Morrill, Kristin Calabra, Laura Hitchingham, and Bonnie DiLorenzo. The Rx Ruffriders – led by Kim Cauthon. Team members Dawn Gerber, Jim Kloster, Paul Smith, Pam Coumans, Martie Fankhauser, Emily Schmitz, Lindsay Davis and Winnie Thi.

Pharmacists Save Lives and Health Care Dollars Employers today are far too familiar with rising health care expenses and how chronic disease contributes to the associated high treatment costs and loss in productivity. The Pharmacy Network of Arizona (PNA) offers employers an opportunity to address these issues by empowering employees to successfully navigate the complexity of living with a chronic disease. PNA works with employers to offer consumer-incentive programs that focus on patient self-management education and techniques to help patients with chronic conditions improve health outcomes. Results from these patient centered programs show a 50% reduction in employee sick days and an average net savings of $1,600 to $3,200 per patient annually. By creating a collaborative team of employers, employees, pharmacists, and physicians, the program’s goal is self-care education. In private, faceto-face counseling sessions with a pharmacist, employees learn how to better manage their chronic conditions, such as diabetes, high blood pressure, and cholesterol, and reduce associated risks through the incorporation of medication therapy management. Incentives are aligned to focus on wellness, patient self management and workplace cost savings. The result for your employees: better health and a feeling of empowerment. The result for you: lower health care costs and improved productivity. For more information about how PNA can help you control health care costs, contact Mindy Smith, R.Ph., Executive Director, Arizona Pharmacy Alliance, at 480 838-3385 or mindy@azpharmacy.org

PNA The winning team - The Avatars! l to r: Teresa Stickler, Chris Lesaca, Jon Merchen, Albert Flores, Mike Dietrich, Mindy Throm Burnworth, Joy Davis, Jenny Whitney. 8 Arizona Journal of Pharmacy

• • • •

Patient-Centered Education & Support-Based Improved Health Outcomes Health Care Cost Savings

Alliance News Published Exclusively by the American Pharmacists Association The Leader in Providing the Most Comprehensive Line of Resources to Pharmacists and Health Professionals

APhA is pleased to offer The APhA Complete Review for the FPGEE® to members of the Arizona Pharmacy Alliance at a 20% discount off the list price The APhA Complete Review for the FPGEE® Dick R. Gourley The APhA Complete Review for the FPGEE® provides a comprehensive review of basic pharmaceutical principles covered in the Foreign Pharmacy Graduate Equivalency Examination (FPGEE®), a requirement for the Foreign Pharmacy Graduate Examination Committee (FPGEC) certification. Graduates of foreign pharmacy schools must pass this examination before proceeding to the NAPLEX and licensure in the United States. This review guide covers the four areas of the exam: basic medical sciences; social, behavioral, and administrative sciences; and the clinical sciences.

Key Features:  Comprehensive review of basic pharmacy education  Information summarized in user-friendly manner  Includes most important information in the four areas covered on the FPGEE®  Key points summarized  Pertinent references included  Self study questions and answers  Study tips ISBN: 978-1-58212-143-7 • 2010 • 650 pp • Softcover AzPA Price* $120.00 List Price $150.00 Purchase The APhA Complete Review for the FPGEE® for only $120.00, a savings of 20%!* Offer expires December 31, 2010. Be sure to mention offer code NASPA2010 in order to receive your discount. *Offer does not apply to orders of 10 units or more or to distributor orders. All prices are subject to change. For a list of current prices, please visit APhA’s online bookstore at www.pharmacist.com/shop_apha. To order: – Web: www. pharmacist.com/shop_apha – Call: 800-878-0729

Arizona Journal of Pharmacy 9

Legislative Update

Medical Marijuana

Proposition 203, Arizona’s Medical Marijuana Initiative, passed by 4,341 votes (50.13% to 49.87%) eleven days after the election. This makes Arizona the 15th state to legalize medical marijuana, not including the District of Columbia. The Arizona Department of Health Services (ADHS) is responsible for developing the rules and regulations to implement this change in state law. ADHS has 120 days to finalize all rules; however, implementation may not occur until late summer or early fall. The Arizona Pharmacy Alliance (AzPA) is working with ADHS to help define the role of pharmacy in the dispensing process and to ensure patient safety in the administration of medical marijuana. The Arizona Poison and Drug Information Center is also working with ADHS regarding post-marketing surveillance of the drug. The AzPA Board of Directors conducted a survey after the passing of Prop 203, and 117 members responded. Of the responders, 83.7% were pharmacist members, 8.5% student pharmacist members, and the remaining were pharmacy technician and associate members. When asked if a pharmacist should be involved in the dispensing of medical marijuana, 64.1% responded “yes” (see figure 1), and 65.9% feel that AzPA should take a position to advocate having pharmacists dispense medical marijuana. However, 17% of responding members believe that AzPA should advocate that pharmacists not be involved at all. Nearly 20% of respondents would want providers other than pharmacists dispensing medical marijuana, mainly prescribers with controlled substance dispensing privileges. Those participants who answered “yes” to having other personnel besides pharmacists dispensing medical marijuana made the following comments: “I would like to see specialized pharmacist dispensing in a clinic or office setting NOT at the typical community setting due to security. The hours should be during daytime with added security for theft prevention.” “State of Arizona Rules and Regs stipulate only a Pharmacist may dispense medication.” “Pharmacists and physicians only.” “Someone registered with Board of Health (like the owners of the dispensaries). There would have to be legal remedies such as we have with DEA and the State Board for problems with diversion and theft.” Seventy percent of responding members would like a pharmacist to be required on staff at a dispensary, and 87.1% believe that medical marijuana should be cultivated in a facility with Good Manufacturing Practices. When asked what type of facility should dispense medical marijuana, the response was divided: 37.6% said dispensaries only, 31.6% pharmacies only, and 26.4% responded both dispensaries and pharmacies (see figure 2). An overwhelming majority of responding members believe the city/ county zoning ordinances should be at least as stringent as Prop 203, and nearly 40% believe ordinances should be more stringent. More than two-thirds of responding AzPA members believe that the DEA should regulate medical marijuana, and nearly 90% 10 Arizona Journal of Pharmacy

feel that medical marijuana should require a prescription. When asked about under which schedule medical marijuana should be included, 58.9% responded C-II, 26.4% C-III to C-V, and 17% believe that it should remain a class-I controlled substance. Nearly 30% of respondents believe medical marijuana should be limited to smokeless dosage forms, whereas 40% believe it could be in the inhalant form and another 30% are undecided. Twothirds of responding AzPA members would like to see medical marijuana taxed, and more than 75% believe a medical marijuana clinic should not be allowed to dispense or have any financial interest in a dispensary facility.

Sunrise Application

Pursuant to section 32-3104 and 32-3106, Arizona Revised Statutes, the Arizona Pharmacy Alliance (AzPA) and the Arizona Community Pharmacy Committee (ACPC) submitted a request for an expansion of the scope of practice for the profession of pharmacy. The request consists of three items: 1. Permit licensed immunization-trained pharmacists to administer vaccines to persons less than 18 years of age. 2. Modify the location requirements in ARS 32-1970 so pharmacists are not limited as to where they can practice medication therapy management via physician-approved agreements, protocols and guidelines. 3. Clarify that immunization-trained pharmacy students may administer vaccines to persons under the direct supervision of a licensed immunization-trained pharmacist. During the sunrise hearing on December 9, 2010, the application received unanimous support from the committee of reference. Currently, AzPA and ACPC are working with various stakeholders, including family physicians, pediatricians, and doctors of osteopathy, to develop compromised bill language. AzPA will continue to keep you abreast of the progress of this proposed legislation.

Intervention Can Be the First Step of Recovery from Addiction

by Julian Pickens, Ed.D., Intervention and Recovery Specialists

After forty-two years in the alcohol/drug profession, I have learned that the Holiday Season brings on more alcohol and drug use. It has been the experience of the alcohol/drug rehab communities that we will see an increased number of admissions to treatment for alcohol/drug problems following the holidays. My experience is that often the family becomes more keenly aware of the problems that occur as a result of alcohol/drug use, due to the family member’s behavior and realizing something needs to be done. Families often try to intervene with the person having the alcohol/drug problem by themselves. We refer to such an intervention as a “simple” intervention. It is rare that such an intervention accomplishes the purpose of getting the person into treatment; rather, the simple intervention usually results in the person separating themselves from the family and them continuing even heavier alcohol or drug use. The second type of intervention occurs when someone or some entity, such as a court, becomes involved in a person’s life after demonstrating that they have an alcohol/drug problem. An example of this would be when the person gets a DUI. The judge may make a decision that either the person goes to treatment or they go to jail for a period of time. This is called a “crisis” intervention. Such an intervention can have a higher incidence of a person going to treatment, then with a simple intervention. However, fewer judges make such a decision to send the person to treatment rather than jail. The third type of intervention is when family, friends or work associates make the decision to involve a professional interventionist in helping with the intervention process. This type of intervention usually takes 6-12 hours for the preparation and then the actual intervention might take 2-6 hours. This “classic” intervention has the best chance of success if done with a professional interventionist. Approximately 8 out of 10 people end up getting the treatment they need when the intervention is conducted by a professional interventionist. Statistically, 2 out of 3 people who get the help they need from a quality treatment program maintain abstinence from alcohol or other mood-altering chemicals. The treatment center will give the individual a complete battery

PAPA

of psychological tests, a complete physical examination, and approximately 48-50 hours a week of individual and/ or group therapy. The person will also receive didactic presentations of alcoholism and drug dependence with a recommended plan of action for staying clean and sober. Addiction is a progressive fatal disease and if treatment does not occur, most people die as a result of the addiction or end up in some kind of institution. It is estimated that about 82% of people in penal institutions are there as a direct or indirect result of their alcohol/drug use. The people who receive good treatment for their addiction are considered to be the “fortunate few”. In summary, intervention can be a real key to helping a person get the treatment they need to learn how to live a life free of alcohol or drugs.

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

Arizona Journal of Pharmacy 11

Academy News Community Pharmacy Academy News

Health-System Academy News

By the time this goes to ‘press’ the ASHP PPMI Summit will be over. Rather than re-write the section Greetings, Community Pharmacy Academy Members, in ASHP about this initiative, here is the link for those with an interest: http://www.ashp.org/ppmi. I The 2010 Community Pharmacy Academy Conference like their catch-phrase, “Redefining, Reconstructing, was a tremendous success. More than 65 participants Reinventing”. It seems appropriate for our times. attended the event on September 17, 2010. Five hours We are in the midst of a health care revolution. If of continuing pharmacy education were presented, Pharmacy does not recreate itself over the next decade, including 2.0 hours of Law CE and 1.0 hour of someone else will, and we may not like the result. immunization update CE. The dinner symposium was sponsored by Eli Lilly. We are experiencing a higher rate of change than ever before in pharmacy. Rapidly evolving computer Thank you to Kelly Ridgway, R.Ph., Pharmacy Care programs, Computerized Physician Order Entry Manager, Safeway; David Searle, R.Ph., Director, (CPOE), more and more sophisticated robotics, and Pharmacy Development, Pfizer; Mike Severn, C.Ph.T., increasing reliability in bar codes show substantial Third Party Audit Manager, Apothecary Holdings potential for reducing the need for pharmacists’ time LLC; Heidi Ann Ecker, Director, Federal Govt. in dispensing and distribution as well as profile order Affairs, NACDS; and Joan Bailey, M.D. for your entry. This creates a compelling reason for change, presentations. and I believe we have a unique opportunity to recreate our profession over the next five to ten years. On Saturday, September 18, 2010, the Medication One of the reasons I feel we have a unique Therapy Management Certificate program was opportunity, is that coincidentally we are seeing presented. Sixty-two pharmacists and student a dramatic shortage in hospitalists, during a time pharmacists from across Arizona and out-of-state when the hospitalist model is rapidly becoming the participated. Many thanks to Grace Akoh-Arrey and preferred health delivery model for health systems. Russ Newman for facilitating this program. Also, So metaphorically, as one door is closing, another thank you to sanofi-aventis, Ken Frisard and Corina is opening, both for pharmacists and pharmacy Grancorvitz for providing the sponsored luncheon technicians. Pharmacists are uniquely poised to symposium. assume a number of functions that are traditionally physician responsibilities. With the passage of Proposition 203, medical marijuana, we continue to be interested in the implementation of this law. Please see the results of the AzPA member survey in the Legislative Update section of the journal. As 2010 comes to a close, our focus for the coming year includes collaborative practice agreements, prescription-transfer incentives, and medication takeaway programs. If you wish to become involved with any of these projects, please contact me. Catch the Beat: The New Pulse of Sincerely, Health-System Pharmacy HEALTH-SYSTEM ACADEMY CONFERENCE Teresa Stickler, R.Ph. Community Pharmacy Academy Chair SATURDAY, APRIL 2, 2011 melrosepharmacy@yahoo.com Banner Desert Medical Center

SAVE THE DATE!

12 Arizona Journal of Pharmacy

Pharmacists in health systems have more opportunity than ever before to assume authority in medication therapy management. Most hospital pharmacies provide pharmacokinetic dosing not only on request, but as a matter of course. In my own facility, Vancomycin dosing is done almost exclusively by pharmacists. We are seeing pharmacists expand their responsibilities in anticoagulation clinics, pain management consults, antibiotic consults, polypharmacy consults, and now pharmacy is becoming the primary discipline performing medication reconciliation (Med Rec). My pharmacy began performing pharmacy-based Med Recs last year. We found that pharmacy medication reconciliation was literally 200% more accurate than traditional med recs. We expanded our program from a demonstration unit to where we now cover the entire facility. Other hospitals are following and adopting this patient quality improvement process. There are a lot of other examples in our industry and it is time we begin to share our new programs so we all benefit. With that in mind, we are pushing two programs this year to help ‘spread the word’ about innovation: A new Director’s Forum and a Review/Gap Analysis on the Arizona progress to the ASHP 2015 Vision. The ASHP 2015 Vision was groundbreaking when it was conceived, as the PPMI summit is today. The $64,000 question is, how close are pharmacies getting to achieving the vision? We are going to begin a survey of Directors of Pharmacy in December to determine Arizona hospitals’ progress to the 2015 vision. We will report the results, along with the initial work on the new PPMI results, at the AzPA annual meeting in Tucson in July. Please be watching for notices of both the Arizona survey on the ASHP 2015 vision, as well as our Health-System Pharmacy Directors’ Forum on January 7, 2011 from 10 am to 1pm at the Grace Inn of Ahwatukee.

Academy News Managed Care Academy News Greetings, Managed Care Academy Members, I am very excited about this upcoming year and would like to introduce myself. I am Ray Clark and the Managed Care Academy (MCA) Chair for 2010-2011. I would also like to introduce Julie Hernandez as the Chair-Elect for 2010-2011. Julie has been very active in the Academy for the last several years and she will offer keen insight into the future of Managed Care Pharmacy. Our first priority is to start working on the annual MCA conference which will be held March 5, 2011. We welcome your input and are looking forward to building upon the outstanding work of our two past chairs, Kim Kelley and Elizabeth Wilmeth. We are still looking for volunteers to help us fill some empty spots on the AzPA committees. You would represent our academy at the committee meetings, then report back to the academy executive committee. Please check out our section on the AzPA website and feel free to contact me if you have any questions, comments, or want to get involved. Best regards, Ray Nelson Clark, Jr., PharmD Managed Care Academy Chair ray.nelson.clark@gmail.com

PLAN TO ATTEND! Managed Care Academy Conference Saturday, March 5, 2011 Location and time to be announced

Sincerely, Butch David, R.Ph. Health-System Academy Chair butch.david@bannerhealth.com Arizona Journal of Pharmacy 13

Academy News Senior Care Academy News

Happy Holidays from the Senior Care Academy! Thank you for being a member of AzPA and thank you to the wonderful AzPA staff! The Senior Care Academy news article in the journal’s fall edition reported on two major goals for this year: promote and increase membership in the academy and strengthen our affiliation with the American Society of Consultant Pharmacists (ASCP). For promoting and increasing membership in the Senior Care Academy during the past quarter, the academy put together a fantastic team for the September 22nd AzPA membership event. Our team was awarded second place for recruiting twenty-nine new pharmacist AzPA members and a majority joined the Senior Care Academy. Thank you to the following team members for their participation: Zina Berry Jim Kloster Justin Brock Dawn Knudsen-Gerber John Cerni Negin Mohebbi Pam Coumans Lisa Sims Lindsay Davis Paul Smith Martie Fankhauser Winnie Thi Ushma Kanzaria If you or other AzPA members are not members of the Senior Care Academy, consider choosing it as your second academy. This can be done under your membership page on the AzPA website. The academy is for anyone who is interested or provides pharmaceutical care to elderly patients. For the goal of strengthening our affiliation with ASCP, a draft affiliation agreement is being written and will be presented to the AzPA board members and ASCP. Benefits could include promoting membership

14 Arizona Journal of Pharmacy

in both organizations, sharing tools and resources for legislative affairs and continuing education, and enhancing communication. If you have any comments regarding the proposed ASCP affiliation agreement, email me. Other Senior Care Academy updates include the need for volunteers to represent the academy in the AzPA standing committees (legislative, continuing education, and annual meeting planning). Also, the Senior Care Academy educational conference is tentatively scheduled for May 2011. Please email me if you want more information or are interested in serving on a committee. Sincerely, Kim Cauthon, Pharm.D. Senior Care Academy Chair kbyrdx@midwestern.edu

SUPPORTING PHARMACISTS ADVANCING CAREERS Find the best jobs and highly qualified pharmacists Arizona has to offer.

ONLINE CAREER CENTER www.azpharmacy.org/jobs

Student Pharmacist Academy News

Greetings, Student Pharmacists! Congratulations to Valerie Bostel, Midwestern University College of Pharmacy Glendale Class of 2013, on her election as AzPA Student Pharmacist Academy (SPA) Chair-elect for MWU-CPG. With the creation of the SPA in 2010 and the election of the first chairs and chairs-elect, we are off to a strong start representing student pharmacists. Please mark your calendars for Wednesday, January 26, 2011 for Pharmacy Day at the State Capitol. This annual event, hosted by the APhA-Academy of Student Pharmacists Chapters of University of Arizona College of Pharmacy and Midwestern University College of Pharmacy-Glendale and the Arizona Pharmacy Alliance, offers an opportunity for state lawmakers to meet with pharmacy professionals and students, learn about the services pharmacists and pharmacies provide to our community, and discuss current issues relating to pharmacy and health care. Students from both colleges of pharmacy will also present information booths and screenings for immunizations, MTM, diabetes, smoking cessation, poison prevention, asthma, and more. The event will take place on the Senate Lawn at the Arizona State Capitol from 11:00 am to 1:30 pm. Lunch will be provided.

Academy News Technician Academy News Greetings, Pharmacy Technician Academy Members, Mark your calendars for the Pharmacy Technician Academy Conference on Saturday, February 19, 2011. The location is Scottsdale Healthcare-Shea. Cost is just $20 for AzPA Members and $30 for Nonmembers. The program will begin with registration at 8:30 am and include continental breakfast and lunch. The conference will provide 5.5 hours (0.55 CEUs) of continuing pharmacy education for technicians, including 1.5 hours of Law CE. • Role of the Certified Pharmacy Technician • Quality Assurance and Patient Safety • The Medical Home and the Role of the Pharmacy Technician • OTC/Herbal Updates • Pharmacy Audits: The fundamentals and strategic guidelines for preparation and prevention Technician Academy Conference The Certified Pharmacy Technician of the Future To register click on the link below http://m360.azpharmacy.org/event.spx?eventID=19624 or visit www.azpharmacy.org

Plans are underway for the first Student Pharmacist Academy Leadership Conference. Save the date for Saturday, April 30, 2011. Location and details will be forthcoming.

Sincerely,

We want you to be involved! Please contact the SPA Chair or Chair-elect for your college of pharmacy.

Chris Lesaca, C.Ph.T. Technician Academy Chair azclml@yahoo.com

Sincerely, Bonnie DiLorenzo and Kerry Redman AzPA Student Pharmacy Academy Co-Chairs bblorenzo@hotmail.com kredman@email.arizona.edu

Arizona Journal of Pharmacy 15

Drug Information Questions Question: Is HCG effective for weight loss?

by Kelly M. McKenzie, Pharm.D., and Stacy L. Haber, Pharm.D., Associate Professor, Midwestern University College of Pharmacy-Glendale Clinical Trials Answer: In 1973, Asher and Harper published the first Introduction randomized, double-blind trial to evaluate the effect of According to the most recent National Health and HCG on weight loss, hunger, and overall feeling of wellNutrition Examination Survey performed by the Centers for being.5 The researchers followed the protocol described Disease Control and Prevention, it is estimated that oneby Simeons.4 Forty female patients were randomized third of people in the United States are obese.1 Obesity is to receive 125 IU of HCG or placebo injections 6 days often accompanied by hypertension, hypercholesterolemia, each week for 6 weeks. At the end of the trial, 17 of 20 diabetes, respiratory problems, osteoarthritis, and (85%) from the HCG group and 13 of 20 (65%) from the other health issues that lead to increased morbidity placebo group had received 30 or more of the scheduled and mortality.2 While there is agreement throughout 36 injections. The mean weight loss was 19.96 pounds the medical community on the risks of obesity, there is for patients receiving HCG and 11.47 pounds for patients controversy over the use of diets, exercise programs, receiving placebo (p<0.001). Patients in the HCG group pharmacotherapy, and surgery. Because of the desire reported little or no hunger on 76.6% of their daily to be thin and the difficulty in losing weight, patients responses compared to 48.7% for patients in the placebo are attracted to options that promise quick and dramatic group (p<0.001). The HCG group described their mood results, and one of these options that has recently grown in as “good” or “excellent” on 86.5% of their daily surveys popularity is the use of HCG. compared to 70% for the placebo group (p<0.001). The HCG (human chorionic gonadotropin) was approved authors concluded that HCG was effective for promoting by the FDA in 1974 and is indicated for the treatment of weight loss by helping to suppress hunger and thus infertility and hormonal imbalances.3 The use of HCG increasing the ability of patients to comply with the strict for weight loss was first described by A. T. Simeons in diet. In this trial, there was a significant difference in the 1954. Simeons experimented with HCG in obese patients number of injections received between the groups, which based on his observation that their distribution of fat was may have affected the results. Additionally, all aspects of similar to that of patients with hormonal imbalances. In this trial were conducted at Harper’s weight loss clinic, his practice, he claimed that patients who received HCG, where HCG was routinely offered. while following a restricted diet, lost significantly more After publication of the trial by Asher and Harper, 2 weight than patients who followed the same diet but did not trials were performed with similar methods to evaluate receive HCG. He hypothesized that HCG made it easier to the efficacy of HCG for weight loss.6,7 The trials differed tolerate the restricted diet (by helping to control appetite) slightly in the number of patients and length. Stein et al. and caused a reduction in body fat (by making it easier included 51 women who underwent 32 days of treatment, to burn). He claimed that patients no longer responded while Greenway et al. included 40 women who underwent to HCG after about 40 days, but that courses could be 42 days of treatment. Stein et al. reported a dropout rate repeated after a 6-week break with equal efficacy, and that of about 20% in both groups; Greenway et al. reported he had successfully used HCG in over 500 patients during a dropout rate of 10% in the HCG group and 35% in the preceding 20 years.4 the placebo group. The average amount of weight loss The Simeons’ regimen involves injections of 125 IU for HCG versus placebo was 15.8 versus 15.5 pounds, of HCG 6 days a week, in addition to a restricted diet, for respectively, in Stein et al. and 8.8 versus 8.1 pounds, 6 weeks. For the diet, patients are given a list of foods respectively, in Greenway et al. Neither trial was able to that is divided into groups of protein, vegetable, bread, find a significant difference between the groups in weight and fruit, with corresponding serving sizes. During the loss or hunger. first 3 days, patients can eat all they want from the list. Shetty et al. performed a trial on HCG that was unique Beginning on the fourth day, patients are to consume 500 in that the 11 obese female patients were hospitalized.8 to 550 calories daily by eating 2 meals a day at any time, This allowed compliance to the diet to be monitored much with a meal consisting of 1 food from each group.4 In a more closely than in the trials performed in clinic settings, search of Medline (1950 to April 2010), 7 randomized, which relied on self-reports. The patients followed the controlled trials were found that evaluated the efficacy of 500-calorie/day diet recommended by Simeons and were this regimen; all of the trials were published in the 1970s, randomly assigned to receive 125 IU of HCG or placebo with the exception of 1 in 1990.5-11 injections daily for 30 days. The average amount of weight loss for HCG versus placebo was 9.3 versus 9.4 pounds, 16 Arizona Journal of Pharmacy

Drug Information Questions (continued from page 16) respectively. There were no significant differences between the groups in weight loss or tolerance to the restricted diet. Two crossover trials have been performed to evaluate the efficacy of HCG for weight loss.9,10 Both trials used the 500-calorie/day diet described by Simeons.4 Young et al. included 202 men and women who were randomly assigned to receive either 125 IU of HCG or placebo injections daily for 6 days each week for 6 weeks.9 This was followed by a 6-week washout period, during which patients were instructed to follow a diet that would help them maintain their weight, and then patients received the opposing treatment for 6 weeks. Of the 202 patients who began the trial, 106 (52.5%) dropped out before the end (57 while receiving HCG and 49 while receiving placebo). Miller et al. included 19 obese men and women who were randomly assigned to receive 125 IU of HCG or placebo injections daily for 4 weeks, then switched to the opposing treatment for 4 weeks with no washout period.10 Of the 19 patients who began the trial, 11 (57.9%) dropped out before the end (5 while receiving HCG and 6 while receiving placebo). The average amount of weight loss for HCG versus placebo was 13 versus 13.2 pounds, respectively, in Young et al.; Miller et al. did not specify the numbers. Neither trial was able to find a significant difference between the groups in weight loss; however, both trials found a significantly greater amount of weight loss during the first course of treatment, regardless of injection received, compared to the second. The most recent randomized, double-blind trial on HCG for weight loss was published by Bosch et al. in 1990.11 This trial was unique in that it used a diet of 1200 calories/ day, as opposed to 500 calories/day used in all of the previously mentioned trials, and that the injections were administered in the upper arm, as opposed to the gluteal muscle. Forty obese female patients were randomized to receive 125 IU of HCG or placebo injections daily on 6 days each week for 6 weeks. Seventeen of 20 patients (85%) in the HCG group and 16 of 20 patients (80%) in the placebo group completed the trial. The average amount of weight loss for HCG versus placebo was 7.0 versus 10.1 pounds, respectively. There were no significant differences between the groups in weight loss or hunger. Discussion Of the 7 randomized, controlled trials, 6 do not support the use of HCG for weight loss.6-11 Although the trial by Asher and Harper found HCG to be more efficacious than placebo, the uneven number of injections received between the groups may have affected the results.5 In the 2 crossover trials, the first series of injections resulted in significantly greater weight loss than the second series for both groups, which indicates a loss of effect with time.9,10 In all of the trials, HCG injections were as well-tolerated as placebo; however, there have been case reports of ovarian

hyperstimulation syndrome, a potentially life-threatening condition, associated with HCG.5-13 HCG was not included in the most recent edition of the Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. These guidelines state that patients should be placed on a diet that creates a deficit of 500 to 1000 calories/day, with a total intake of at least 1000 calories/day. They also state that a diet of only 500 calories/day has not been proven to be more effective for long-term weight loss than a typical low-calorie diet of 1000 to 1200 calories/day and may be associated with nutritional deficiencies and an increased risk of gallstones.2 Many weight loss clinics and medical spas are advertising HCG for weight loss on the radio, television, and internet. Patients in these programs may be asked to return to the clinic to receive the daily injections or given a prescription for HCG to be filled at a pharmacy for self-administration. It is important for pharmacists to know that HCG carries a black box warning that it “has no known effect on fat mobilization, appetite, sense of hunger or body-fat distribution” and that it “has not been demonstrated to be effective adjunctive therapy in the treatment of obesity.”3 Thus, based on the lack of evidence on its efficacy, HCG should not be used for weight loss. References: 1. Flegal K, Carroll M, Ogden C, Curtin L. Prevalence and trends in obesity among US adults, 1999-2008. JAMA 2010;303:235-41. 2. NIH, NHLBI Obesity Education Initiative. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. www. nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf (accessed 2010 Apr 26). 3. Drug Facts and Comparisons. Human chorionic gonadotropin monograph. Facts and Comparisons 4.0 (accessed electronically 2010 Apr 26). 4. Simeons AT, Heidelberg MD. The action of chorionic gonadotrophin in the obese. Lancet 1954;2:946-7. 5. Asher WL, Harper HW. Effect of human chorionic gonadotropin on weight loss, hunger, and feeling of well-being. Am J Clin Nutr 1973;26:211-18. 6. Stein MR, Julis RE, Peck CC, et al. Ineffectiveness of human chorionic gonadotropin in weight reduction: a double-blind trial. Am J Clin Nutr 1976;29:940-8. 7. Greenway FL, Bray GA. Human chorionic gonadotropin (HCG) in the treatment of obesity: a critical assessment of the Simeons method. West J Med 1977;127:461-3. 8. Shetty KR, Kalkhoff RK. Human chorionic gonadotropin (HCG) treatment of obesity. Arch Intern Med 1977;137:151-5. 9. Young RL, Fuchs RJ, Woltjen MJ. Chorionic gonadotropin in weight control: a double-blind crossover trial. JAMA 1976;236:2495-7. 10. Miller R, Schneiderman LJ. A clinical trial of the use of human chorionic gonadotrophin in weight reduction. J Fam Pract 1977;4:445-8. 11. Bosch B, Venter I, Stewart RI, Bertram SR. Human chorionic gonadotrophin and weight loss: a double-blind, placebo-controlled trial. S All Med J 1990;77:185-9. 12. Engel T, Jewelewicz R, Dyrenfurth I, et al. Ovarian hyperstimulation syndrome. Report of a case with notes on pathogenesis and treatment. Am J Obstet Gynecol 1972;112:1052-60. 13. Nwosu U, Corson S, Bolognese R. Hyperstimulation and multiple side-effects of menotropin therapy: a case report. J Reprod Med 1964;12:117-20.

Arizona Journal of Pharmacy 17

Feature Pharmacist

A Leader in Geriatric Pharmacy

Spend just a few minutes with Dr. Jeannie Lee and you will be inspired by her passion for geriatric pharmacy and patient care. I first met Dr. Lee when I participated in her “Perspectives in Geriatrics” course two years ago at the University of Arizona College of Pharmacy. During one of the afternoon sessions, we put cotton in our ears, mittens on our hands, foggy glasses over our eyes, and tied a loop of string around our legs. We were required to walk around the room, read and sign a patient agreement, and open a medication bottle. Easier said than done, right? After this activity, we understood first-hand how difficult it can be for an older adult to take their medications appropriately. I recently had the opportunity to join Dr. Lee at a “Take Back Rx” event in Oro Valley, where she was precepting pharmacy students performing medication reviews and hypertension screenings. When asked about the importance of these events to the geriatric population, she explained, “Polypharmacy is rampant. These patients usually have a stockpile of meds at home and don’t know how to dispose of them. They may try to take some of them when they’re feeling bad, just to see if it helps.” These events also give patients the opportunity to ask questions, as well as allow pharmacists to become involved in preventative care. “The first baby boomer will turn 65 next year,” Dr. Lee explained as she stressed the importance of pharmacists’ role in this aging population. “We’re one of the key members of the medical home model. The patient’s team cannot work without a pharmacist in dealing with polypharmacy, because we’re the drug experts. We need to develop our niche in the medical home model.” So what type of “team” is she referring to? “It must be interdisciplinary - not multidisciplinary - with the patient at the center of it all.” It is not about having multiple prescribers involved in a patient’s care. It is about having the right providers working as a team to care for the patient. Dr. Lee has extensive experience in setting up interdisciplinary clinics and coordinating the providers on a patient care team. While working at the Walter Reed Army Medical Center in Washington, D.C., she developed inpatient and outpatient anticoagulation services, as well as the Comprehensive Cardiovascular Clinic (CCC). At the CCC, she worked with cardiologists and other providers to evaluate a patient’s medication regimen and develop a care plan for each patient. In addition, Dr. Lee created the first-ever pharmacy geriatrics clinic at the Armed Forces Retirement Home in Washington, D.C. She held the clinic once weekly, available to over 900 patients, and developed a fall prevention program to assess a patient’s environment and medications after experiencing a fall. Dr. Lee also worked with a “Driver’s Clinic,” where an older patient’s care team will assess whether the patient can drive safely, considering factors such as reaction time, peripheral vision, and prescribed medications. These are only a few of the many clinics Dr. Lee has 18 Arizona Journal of Pharmacy

developed. Her most recent undertaking is the UPH Wilmot Geriatrics Clinic, sponsored by the Arizona Center on Aging. Every Friday morning, she meets with patients who are at least 65 years of age and who take five or more medications for chronic disease states. Dr. Lee assesses patients’ medication regimens, adherence, chronic disease state management, and possible adverse events. Providers may refer their patients to her for medication reconciliation, drug interaction screenings, allergy verification, renal dosing, lab follow-up, patient education, and other medication-related issues. There is a need for services like Dr. Lee’s clinic, especially with today’s aging population. “They’re the ones taking the most medications - both prescription and over-the-counter and who have the highest number of chronic conditions,” Dr. Lee explained. Furthermore, “older adults have the lowest health literacy level of all our patients, and it’s our job to help.” With the Institute of Medicine (IOM) reporting that less than one percent of graduating professional students (including pharmacy, nursing, and medical) are prepared to educate older adults, how can we hope to meet the needs of this growing population?1 “Get trained,” Dr. Lee advised. Through the Commission for Certification in Geriatric Pharmacy (CCGP), pharmacists having at least two years of experience can become a Certified Geriatric Pharmacist (CGP), a credential which must be renewed every five years. Dr. Lee is licensed as a Board Certified Pharmacotherapy Specialist (BCPS), a certification which she claims is also very helpful in caring for geriatric patients. In addition, she recommends getting involved in professional organizations such as the American Society of Consultant Pharmacists (ASCP) and AzPA’s Senior Care Academy, both of which are great resources for geriatric pharmacy. She also helps to develop geriatric programming for the annual American Society of Health-System Pharmacists (ASHP) Midyear Meeting.

Dr. Lee counseling a patient about blood pressure management at the Oro Valley “Take Back Rx” event.

Feature Pharmacist Opportunities in Geriatric Pharmacy (continued from page 18) You do not have to be CGP- or BCPS-certified to be of benefit to your geriatric patients. “Become aware of who your patients’ providers are and get connected with them,” Dr. Lee advised. “Let them know what you know; build rapport and relationships. This all starts with building relationships with your patients.” Starting in January 2011, Dr. Lee will be a faculty advisor in the Interprofessional Senior Mentor Program. Approximately 25-30 students from the Colleges of Pharmacy, Nursing, Medicine, Public Health, and Social Work at the University of Arizona will be chosen and assigned to a community-dwelling older adult. The goal of the program is to give students practical experience with older adults while working in interdisciplinary teams. “It’s all about experience,” Dr. Lee says. When asked what advice she gives her students on rotation, Dr. Lee explained, “Slow down. Meet them where they are, and don’t underestimate what you can gain from them.” She also emphasized the importance of education. “Sometimes

patients stop taking a medication because they forget what it’s for and it’s not making them feel any better.” She cited hypertension and dyslipidemia, two asymptomatic diseases, as being the most challenging in terms of medication adherence. The solution could be as simple as talking to patients about their medicines. If you are a pharmacist, technician, or student providing direct patient care to older adults, Dr. Lee offers the following advice: “Treasure your interactions with them. It’s not just you giving them something, but also them giving you wisdom from life’s lessons.” References: 1. Retooling for an Aging America: Building the Health Care Workforce. Committee on the Future Health Care Workforce for Older Americans, Institute of Medicine. Washington (DC): The National Academies Press; 2008.

By Katie Schiraldi, Pharm.D. Candidate Class of 2011, University of Arizona College of Pharmacy

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Arizona Journal of Pharmacy 19

Feature Pharmacist

Not Your Typical Pharmacist Hal Wand is more than your typical pharmacist. He is the Executive Director of the Arizona State Board of Pharmacy. Many are aware that the mission of the Arizona Pharmacy Alliance is committed to serving and representing all pharmacy professionals in all practice settings. In comparison, the mission of the Arizona State Board of Pharmacy (ASBP) is to protect the health, safety, and welfare of the citizens of the state by regulating the practice of pharmacy. AzPA works on behalf of pharmacists, while the Board focuses on protecting the public. Hal grew up in the north suburbs of Chicago. One day Hal’s mother, a nurse at the time, mentioned to him that “her friend is a pharmacist and really loves her job and she even makes more money than the nurses do.” Hal recalls that his mom’s friend was an early influence on his future profession in pharmacy. Subsequently, his pursuit to become a pharmacist began. In addition, Hal always wanted to be a lawyer, but at the time he did not know his career would incorporate both law and pharmacy. After he earned his Bachelor of Science degree in pharmacy from the University of Arizona in 1979, Hal worked as a hospital pharmacist at Boswell Hospital for nine years. Working in a hospital was a significant chapter in Hal Wand’s life, but he knew that that chapter would be ending soon. He felt something was missing. It was not merely the long nights and weekends, but rather his passion for law that was calling. Hal will never forgot how every year at the University of Arizona, the Director of the ASBP would come to inform students about the intern licensure process and introduce them to pharmacy law. After seeing the director, Hal recalls, “Wow. I really think he has a cool job. He is even wearing a suit and tie.” Hal met that same director during inspections and learned more about the director’s job. Hal knew right away that he wanted that job. Years later, Hal began his career with the ASBP in 1989 as a compliance officer, and in 1994 became deputy director. He was named executive director in 2003. Hal’s desire came to fruition and he got the job he always wanted. Hal was motivated and wanted to manage more responsibilities which inspired him to advance his career to that ultimate position. Hal states that an attractive aspect of his career is that “out of 21 years of working with the Board, no two days are exactly the same. It is full of variety.” There is no typical day in his line of work, which disallows boredom to creep into his day. His job description ranges from working on the state budget, writing consent orders, lobbying the legislature, keeping records (which have been kept since 1903), signing claims and documents, volunteering as a preceptor to pharmacy students, attending board meetings seven times a year, and presenting continuing education sessions on pharmacy law to faculty and alumni. Although a widerange of tasks, this list is not a complete description of Hal’s responsibilities. 20 Arizona Journal of Pharmacy

Hal’s favorite part of his job is meeting and talking to people and going to colleges to welcome students to the profession. Approximately seven years ago, before there was computerized testing, the NAPLEX exam was taken in big rooms that seated about 300 people. This gave Mr. Wand the opportunity to meet each pharmacist at least once, which in turn made him well known. When he Hal Wand, R.Ph. walked into a pharmacy, the ASBP Executive Director pharmacist would usually greet him by name. Hal states, “It was fun to be recognized and even more so to meet everyone who was a pharmacist in the state.” Working with the ASBP does not come without challenges. A difficult aspect of Hal’s job includes the state government’s bureaucracy. There are 210 agencies and many of the state’s rules are applied to all the agencies, but some do not fit every agency. It is difficult for Hal to see the ASBP treated the same as other agencies, especially when the goals are dissimilar. For example, the Arizona State Board of Pharmacy is not a tax-funded organization, but it is treated as one in some instances. With over two hundred agencies, this is why Hal’s main concern is “getting lost in the rush of those agencies.” Another difficult part of the job is revoking licenses, especially when an individual comes into the office crying and saying that they do not deserve it. Hal handles the situation well considering he does not vote on the outcome. Hal states, “You have to deal with someone at the worst time of their lives, but the good part is that years later they will come back when they realize why the board did what it did and are thankful for the board’s help. You deal with people at their worst but then you help them get back on track.” Hal also balances his time being an active member of the National Association of Boards of Pharmacy (NABP). Hal is serving the third year of a three-year term for NABP, representing District 8 on the Executive Committee. Hal enjoys being able to influence and participate in what happens nationwide. He can learn what other states are doing and can bring it home to Arizona. Mr. Wand participated in both meetings of the Task Force on Telepharmacy and the Implementation of the Medicare Drug Benefit Medication Therapy Management Provisions. In addition, he developed and reviewed questions for the NABP Multistate Pharmacy Jurisprudence Examination. When asked to share some words of wisdom for future pharmacists, Mr. Wand says the key is to “keep an open mind and be open to new ideas and thoughts. Be known as innovative. Do not think you know everything. Learn something from everyone you meet.” by Kamille Miles, Pharm.D. Candidate, Xavier University College of Pharmacy, Class of 2011.

An Adherence Message for Pharmacists

By: Jessica Baugh, Executive Resident – National Alliance of State Pharmacy Associations Pharmacists, as the medication experts and one of the most accessible health care professionals, can make a significant difference in their patient’s lives by ensuring they are taking their medications properly. Preventable deaths due to non-adherence are estimated to be at least 125,000 each year. Pharmacists must help their patients understand the severity of improper medication use and also the financial consequences. Poor medication adherence costs this nation $290 billion dollars which represents 13% of the total health care spending in this country. Adherence is so important an issue that if pharmacists do not step up to the plate and “own” it, someone else will. For patients, certain activities become routine such as setting an alarm clock, brushing teeth, and eating lunch and they no longer really have to think about doing them. They occur over the course of the day, and if missed they may or may not suffer consequences. If they wake up late, they could potentially be late to school or work, but likely will not be punished or fired for a very rare occurrence. While there are of course circumstances in which missing these activities could be harmful or severe, in most cases, it would be unlikely. It is important that patients understand that taking medications is a different story. While this may not be something that they have always had to do, or consider part of a daily routine, it is extremely important that you stress the importance of being adherent and taking medications as prescribed, and the potential consequences if they do not. You can focus on factors such as the reduction or alleviation of symptoms, increased quality of life, or slowing disease progression. As a pharmacist, you understand that each patient has different needs, and it is sometimes a challenge to find ways to best reach individual patients. As we know, the consequences of improper medication use can vary – some may be immediate, while some may take weeks or even years to notice. More importantly for patients, when it comes to medications, there is often no “I’ll get back on track tomorrow.” They need to understand that skipping medications can be harmful and should be taken very seriously. Pharmacists are the medication experts and are in a position to help. They have the ability to implement programs as part of their daily practice to help with patient non-adherence and are one of the most accessible health care professionals dealing with the patient’s medications. For example, the Appointment Based Model is a prescription synchronization program that many pharmacies are setting up to assist patients in refilling their medications at the same time every month. It has been shown that the pharmacists have a more efficient practice, resulting in expected improved medication adherence rates and decreased gaps in therapy. Especially with the increasing number of patients with chronic illnesses, there are increased numbers of prescription medications being prescribed. Those patients that are on multiple medications are more likely to miss doses and not take their medications properly. According to one study, people aged 75 years and older take an average of 7.9 drugs per day. There are numerous reasons for non-adherence and for each patient the reasons are different. However, pharmacists are part of a team of health care professionals that can make a significant

Features and Articles impact in these patients’ lives and should take every opportunity to talk to their patients about ways to improve their medication adherence. Dr. C. Everett Koop, former U.S. Surgeon General, said that “Drugs don’t work if people don’t take them.” And for some patients, missing their medications means there may not be a tomorrow. References: -Vermeire, E., et al. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther. 2001 Oct;26(5):331-42. -Marinker M, Blenkinsopp A, Bond C, et al. From Compliance to Concordance: Achieving Shared Goals in Medicine Taking. London, UK: Royal Pharmaceutical Society of Great Britain; 1997.

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Arizona Journal of Pharmacy 21

Features and Articles

Taking the “Spice” Out of Life

The recent buzz word “Spice” made the DEA’s priority list to ban five active compounds (JWH-018, JWH-073, JWH-200, CP-47,497, and cannabicyclohexanol) from the U.S. market for 12 months for further evaluation.1 Spice, also known as K2, Bliss, Black Mamba, Blaze, Red X Dawn, Bombay Blue, Fake Weed, Genie, and Zohai, have spread throughout the world since 2006.1,2,3 These products are not FDA approved, and do not have proper authority overseeing the manufacturing process. The commercial product Spice contains a blend of herbal products impregnated with compounds mentioned, and mimics the pharmacological effects similar to those of marijuana (THC: Δ9tetrahydrocannabinol) such as paranoia, giddiness, panic attacks, red eyes, impaired motor and verbal abilities, and cardiovascular symptoms. However, as depicted in Figure 1, they are not structurally related to marijuana’s active ingredient. One of the banned active ingredients, JWH-200 from the aminoalkylindole family, exhibits high CB1 and CB2 receptors affinity.4 The average commercial pack contains 3 grams of herbal blend with approximately 30mg of active ingredients. Consumers have been led to believe these herbal blends provide alternative effects to illegal drugs when in reality consumers ingest unknown substances coated with THC-like chemicals. Since last year, authorities, hospitals and poison control centers have reported the increase use of Spice and its cousins. Producers of such products continue to roll out several chemical analogues to bypass the law: JWH-073 replaced the banned JWH-018 on the German market.2 Weissman et al conducted a study of compound CP-47,497 in

22 Arizona Journal of Pharmacy

rodents for analgesic effects.5 It was shown to exhibit similar analgesic effect of THC; however CP-47,497 is 6 to 17 times more potent. The measurements were derived from tail-flick test, tail-pinch test, flinch-jump test, and vocalization of rodents. The rodents were administered subcutaneously with either CP-47,497 or THC. Rodents with CP-47,497 were observed to respond faster to pain stimulus (95% confidence interval). After searching medical database, studies of the banned compounds’ effects on humans were not located. Other sources such as WebMD indicate there are no related studies on humans. References 1. U.S. Drug Enforcement Administration. DEA Moves to Control Synthetic Marijuana. http://www.justice.gov/dea/pubs/pressrel/pr112410.html 2. Lindigkeit R, Boehme A, Eiserloh I, et al. Spice: A never ending story? Forensic Science International 191; 2009. 58-63 3 U.S. Department of Justice Drug Enforcement Administration. Drugs and Chemicals of Concerns. http://www.deadiversion.usdoj.gov/drugs_concern/spice/ spice_jwh073.html 4. Uchiyama N, Kikura-Hanajiri R, Ogata J, et al. Chemical analysis of synthetic cannabinoids as designer drugs in herbal products. Forensic Science International 198 (2010) 31-38. 5. Weissman A, Milne G, Melvin L. Cannabimimetic Activity of CP-47,497, A Derivative of 3-Phenolcyclohexanol. Journal of Pharmacology and Experimental Therapeutics. 1982; 223(2).

by Peter Vu, Pharm. D. Candidate 2011, University of Arizona College of Pharmcy

Monitoring Controlled Substances – Are You Liable?

by Victor Provencio R.Ph., Director of Pharmacy Sun Life Family Health Center, Casa Grande, AZ Controlled substances are medications that the DEA (Drug Enforcement Agency), an arm of the Department of Justice, has designated as habit forming, addictive, and having a high potential for abuse. They may have a legitimate medical purpose but that doesn’t mean they are not misused, abused, and used for no medical purpose at all. Controlled substances include narcotics (codeine, hydrocodone, morphine, and oxycodone), tranquilizers (diazepam, lorazepam, and alprazolam), sleeping pills (flurazepam, temazepam, zolpidem), stimulants (amphetamines, methylphenidate), and muscle relaxants (carisoprodol). This is just a small sampling. There are literally hundreds of controlled medications. The reason it is such a delicate topic is that a controlled substance prescription is not a legal prescription unless it is written for a legitimate medical purpose in the usual course of professional treatment. “The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist that fills the prescription,” CFR 1306.04. So there it is, pharmacists can be held responsible for prescription misuse by their patients but how is a pharmacist supposed to know which prescriptions are for a “legitimate medical purpose?” The truth is we are never absolutely sure but there are some red flags that can alert a pharmacist that a controlled substance is being abused. Here are some of the most common ones: • Early refills because the patient is taking more then prescribed • Multiple prescriptions from different prescribers • A patient swears they are allergic to codeine but they can take the stronger hydrocodone or oxycodone which doesn’t make sense because they are derivatives of codeine. • Chronic ailments or vague conditions for which there is no medical basis. • Lame excuses for having to get early refills (i.e., my roommate stole them, I dropped them down the toilet, I have to go to a funeral out of town and won’t be here when refill is due.) • Having someone else pick up their prescription and then claiming they never picked it up! • Offering to pay cash when they have insurance if the claim is rejected by their insurance or telling you not to process their prescription through their insurance in the first place. There are many more and some of them are so bad they are comical but the problem is not funny at all! Take for example hydrocodone. A startling statistic I found on the internet was that “Hydrocodone is the most frequently prescribed opiate in the United States with more than 136 million prescriptions for hydrocodone-containing products dispensed in 2008 (IMS Health™). There are several hundred brand name and generic hydrocodone products marketed. All are combination products and the most frequently prescribed combination is hydrocodone and acetaminophen (Vicodin®, Lortab®).

Features and Articles Imagine that, 136 million prescriptions! Prescribers and pharmacists can be vigilant and do their best and these drugs will still be abused. For a long time communication between prescribers and pharmacists was the major deterrent but more was needed. What was needed was a tool or a way to track ALL prescriptions for controlled substances prescribed by ANY prescriber and filled by ANY pharmacy! That would really cut down on doctor shopping or pharmacy shopping and ultimately the abuse. The state of Arizona started a prescription monitoring program (PMP) to meet that need. Legally licensed prescribers and pharmacists in Arizona can log onto the system and find out if their patients are getting controlled substances from other prescribers or pharmacies. Is it working? It seems to be; several prescribers at Sun Life have used the system and one doctor actually found out that someone was forging prescriptions in his name (be careful where you leave your prescription pads). If you are not using the system, here is a heads up - you should. These monitoring systems are fairly new but there are LEGAL cases RIGHT NOW where the prescriber or dispenser had the means to monitor the drug abuse and didn’t do it. Patients are suing their doctors and pharmacists! A recent article in Drug Topics by Kenneth R. Baker, BS Pharm. JD cites a case [Sanchez ex rel. Sanchez v. Wal-Mart Stores, Inc. 221 P.3d 1276 (2009)] in Nevada where a wife sued Walmart because they supplied the hydrocodone to the driver of the car that killed her husband. The driver had obtained 4,500 hydrocodone pills in one year at 13 different pharmacies! The lawsuit alleged that Walmart did not properly respond to the information on the state’s PMP system (which could also mean that it was not even used). We have the tool, if we don’t use it and our patient gets addicted or hurts someone we could be liable! Food for thought, isn’t it? Speaking of food, it is about my dinner time and, suddenly, I lost my appetite.

This article originally appeared in the STETH-O-SCOOP, the Sun Life Family Health Center monthly newsletter. It is reprinted with the author’s permission.

MISSION STATEMENT The Arizona Pharmacy Alliance 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 Journal of Pharmacy 23

Features and Articles

Closing the Coverage Gap

The Affordable Care Act includes provisions to close the Medicare Part D prescription drug coverage gap (also known as the “donut hole”) to make prescription drugs more affordable for people with Medicare. The first step in closing the coverage gap was the mailing of the one-time $250 rebate check to most people who reached the coverage gap in 2010. The second step to closing the coverage gap starts January 1, 2011. Starting in January 2011, people with Medicare who have Part D, but don’t get Extra Help (the low-income subsidy), will get a 50% discount under the Medicare Coverage Gap Discount Program on “applicable” drugs at the point-of-sale, and a 7% increase in coverage for all other covered Part D drugs (e.g., generic drugs and supplies associated with the delivery of insulin) while they are in the coverage gap. Over the next 10 years, prescription drug coverage will continue to increase for all covered drugs in the coverage gap so what people pay during the gap will continue to decrease until it reaches 25% in 2020. What are “Applicable” Drugs? Applicable drugs are Part D prescription drugs approved under new drug applications (NDAs) or licensed under biologics license applications (BLAs). These are generally covered brand-name Part D drugs including insulin and Part D vaccines. Applicable drugs also include Part D prescription drugs that are commonly considered generic drugs, but actually have been FDA approved under NDAs. These drugs must be covered by a signed discount agreement to be covered under Part D. Beginning in 2011, only those applicable drugs that are covered under a signed manufacturer discount agreement with the Centers for Medicare & Medicaid Services (CMS) will be covered under Part D. All other covered Part D drugs (e.g. generic drugs approved under abbreviated new drug applications (ANDAs) and supplies associated with the delivery of insulin) may continue to be covered by Part D plans irrespective of a signed manufacturer agreement. How will the Medicare Coverage Gap Discount Program work? Drug manufacturers must sign agreements with CMS to participate in the Medicare Coverage Gap Discount Program. The agreement specifies that all of the manufacturers’ applicable drugs will automatically be discounted by 50% at the point-ofsale for coverage gap claims beginning January 1, 2011. The discount doesn’t include the cost of the dispensing fee. The full cost of the drug will count as out-of-pocket spending for the purposes of reaching catastrophic coverage. Example: Mrs. Anderson reaches the coverage gap. She goes to her pharmacy to fill a prescription for an applicable drug. The price for the drug is $60 and the dispensing fee is $2. Once the 50% discount is applied, the cost of the drug is $30. The $2 dispensing fee is added to the $30 discounted amount. Mrs. Anderson will pay $32 for the prescription, but the entire $62 (both what Mrs. Anderson and the manufacturer pay) will be counted as out-of-pocket spending and will help Mrs. Anderson get out of the coverage gap. If a drug manufacturer doesn’t sign a discount agreement with CMS, its applicable drugs won’t be covered under Part D, 24 Arizona Journal of Pharmacy

and Part D sponsors won’t be allowed to grant an exception or provide a transition for such drugs. People may still buy the drug at its full price, but the cost won’t count toward getting out of the coverage gap. Medicare Part D plans will review coverage gap claims to determine the person’s eligibility and if the drugs are eligible for the discount. How will I know which manufacturers have signed a Coverage Gap Discount Program agreement with CMS? CMS has published a listing of companies that have signed an agreement along with the associated five-digit labeler codes on its website. The listing of labeler codes and manufacturers can be found at www.cms.gov/PrescriptionDrugCovGenIn. Select “Part D Information for Pharmaceutical Manufacturers.” How should pharmacies prepare for the Coverage Gap Discount Program? Pharmacies should do the following to prepare for the Discount Program launch on January 1, 2011: 1. Manage Supply Chain - Pharmacies should work with Medicare Part D contractors to review the list of labeler codes on the CMS Web site to determine if their inventories have applicable drugs. This can be done by comparing inventory against CMS’s list of labeler codes that are covered by a signed agreement in 2011. The Medicare Coverage Gap Discount Program labeler code list can be used to identify which manufacturers’ applicable drugs will continue to be covered under Medicare Part D in 2011. 2. Educate Staff - Pharmacy staff should be made aware of the Medicare Coverage Gap Discount Program and be prepared to answer patient inquiries about it. How will Medicare increase its coverage for all other Part D drugs? In 2011, Medicare will begin by increasing its standard coverage by paying 7% of the cost for all other non-brand name Part D drugs (e.g., generic drugs and supplies associated with the delivery of insulin) during the coverage gap, including the dispensing fee. This means people with Medicare who reach the coverage gap will pay 93% of the cost. Part D coverage will continue to increase each year and the amount people pay will decrease each year until 2020, when the amount eligible people pay for these drugs will be 25% of the cost. The standard rules for calculating the person’s out-of-pocket costs apply. Example: Mrs. Anderson reaches the coverage gap. She goes to her pharmacy to fill a prescription for a covered generic drug. The price for the drug is $20, and the dispensing fee is $2. Once the 7% coverage is applied to the $22, she will pay $20.46 for the covered generic drug and only $20.46 will be counted as outof-pocket spending that will help Mrs. Anderson get out of the coverage gap. Who is eligible for the new savings while in the coverage gap? People who meet all of the following criteria are eligible for discounts under the Medicare Coverage Gap Discount Program: • They are currently enrolled in a Medicare Prescription Drug Plan (including people enrolled in employer group health and waiver plans), or a Medicare Advantage Plan that includes prescription drug coverage

Features and Articles Closing the Gap (continued from page 26) • They don’t get Extra Help (a Medicare program to help people with limited income and resources pay Medicare prescription drug costs) • They have reached the coverage gap Note: Some people are in Medicare drug plans that don’t have a coverage gap, but they will still be eligible to get a discount on brand-name prescriptions once they reach the defined standard initial coverage limit (ICL). For 2011, the defined standard ICL is $2,840. How will someone know what discounts have been applied? The Explanation of Benefits (EOB) notice, that people with Medicare receive, will show the amount of the monthly prescription drug costs funded by the manufacturers. How do the discounts work if someone is enrolled in a State Pharmacy Assistance Program (SPAP)? People with Medicare who are eligible for the discounts and enrolled in a State Pharmacy Assistance Program (SPAP), or any other program that provides coverage or financial assistance for Part D drugs (other than Extra Help), still get the 50% discount on applicable drugs in the coverage gap. The 50% discount is applied to the price of the drug before any SPAP or other coverage. What if someone gets discounts from a drug manufacturer? Patient assistance programs offered by manufacturers don’t have the same rules as SPAPs. People should check with the manufacturer to determine if their assistance program will change. Does the discount apply to people who have enhanced Part D coverage? Yes. A discount may be applied after their coverage has been applied to the cost of the drug. The 50% discount will apply to the remaining amount they owe. For example, Mrs. Anderson is in an enhanced Part D plan. Her plan has an enhanced brandname drug benefit of 60%. After she reaches the initial coverage limit, she goes to her pharmacy to fill a prescription for a brandname drug. The negotiated price of the drug is $100. After the plan’s benefits are applied (60% off of $100 =$40), the 50% discount is applied to the remaining $40 amount. Mrs. Anderson will pay $20 for her prescription (plus any dispensing fee), but $40 will count as out-of-pocket spending and help Mrs. Anderson get out of the coverage gap. Who is responsible for handling disputes if someone believes they should have received a discount but didn’t? Part D plans must handle inquiries and complaints about the Medicare Coverage Gap Discount Program. Individuals who think they should get a discount need to call their Part D plan. The plan’s phone number is located on the individual’s plan membership card. If the individual and drug plan disagree on whether a discount is owed, the individual may use the existing coverage determination and appeals process to resolve the dispute. They can also call 1-800-MEDICARE (1-800-633-4227) to file a complaint. TTY users should call 1-877-486-2048.

Can someone file an exception for a drug if the manufacturer isn’t participating in the Medicare Coverage Gap Discount Program? No. If a manufacturer doesn’t have an agreement with CMS to participate in the Discount Program, no applicable drugs labeled by that manufacturer will be covered under Part D. All other covered Part D drugs (e.g. generic drugs and supplies associated with the delivery of insulin) by such manufacturers may continue to be covered by Part D plans. In 2011, manufacturers that produce over 99% of the brand-name drugs used by people with Medicare are participating in this program. Can retroactive adjustments affect the discount? Yes, if changes are made to an individual’s eligibility or benefit it could affect the discount. These adjustments would be reported on the monthly Explanation of Benefits (EOB) notice that people with Medicare receive. It will show the amount of the monthly prescription drug costs funded by the manufacturers. People should contact their plan if they think they are eligible for an adjustment. What happens if only a portion of the claim is in the gap? The 50% discount will only apply to the portion of the claim that’s in the coverage gap. For example, if someone fills a $100 prescription when he or she is $50 away from reaching the coverage gap, only the $50 in the coverage gap is subject to the discount. What additional discounts and savings will people with Medicare have over time in the coverage gap? • In 2011, people with Medicare will pay 50% for applicable drugs, and 93% for all other covered drugs. • Over the next 10 years, the benefits will increase for all covered drugs so that people with Medicare will pay less in the coverage gap. • By 2020, the coverage gap will close and people will pay only 25% for covered brand-name and generic drugs from the time they meet the deductible (if applicable) until they reach the out- of-pocket limit. This information appeared in the November 2010 CMS Update on Medicare Prescription Drug Coverage. It is reprinted as originally published. Please see page 26 for the charts associated with this article.

Arizona Journal of Pharmacy 25

Features and Articles

Closing the Gap

CMS Update on Medicare Prescription Drug Coverage (Article begins on page 24.)

26 Arizona Journal of Pharmacy

Features and Articles

A Look Back - Toilet Tissue by Robert E. Kravetz, MD, FACP, MACG American College of Gastroenterology

What could be more mundane then a roll of toilet tissue? Civilized society, particularly gastroenterologists’ patients, would be quite distressed if it was not readily available. What did people use before toilet paper was invented? Patrons of public restrooms in ancient Rome used a sponge soaked in salt on the end of a stick; wealthy Romans favored balls of wool soaked in rose water. During the Viking age in England, balls of discarded sheep's wool were also used. In 1391, the Chinese Bureau of Imperial Supplies began producing 720,000 sheets of toilet tissue per year for the emperor. Each sheet measured two feet by three feet. During the Middle Ages, balls of straw or grass were the method of choice. Later in England, British Lords used pages from books, while the King’s Navy subjected themselves to the frayed ends of anchor cable rope. In 1596, Sir John Harrington, a godson of Queen Elizabeth I, invented the first flush toilet (a distinction often attributed to the plumber Thomas Crapper.) Crapper actually revolutionized the toilet’s operation with a series of plumbing-related patents starting in 1861. Across the channel in France, royalty used lace and bidets, while ordinary citizens tried hemp. In

America, various objects such as corn cobs, leaves, sand, newspaper, and even mussel shells were utilized. Later, it was not uncommon for Sears Roebuck customers to tear sheets out of their catalogues and apply them toward a hygienic purpose. In 1857, the first tissue packaged for the bathroom was produced by Joseph Gayetty in New Jersey. It was called “The Therapeutic Paper” because it contained an abundance of aloe that was a curative addition. Gayetty had his name printed on every sheet. The Scott Paper Company, in 1880, was the first company to produce and manufacture a tissue on a roll specifically for use as toilet tissue. Large parent rolls of paper were converted into small rolls and they were marketed under private labels for drug stores. In 1896, Scott discarded the private labels and became the first company to sell toilet paper under its own name. The original roll of tissue illustrated here is a private label item dated 1920. As noted, it claims to be specifically efficacious for hemorrhoids. Whether it contained any “therapeutic” additives is not known. Most likely, the benefit of the tissue was its softness. Today, toilet tissue comes packaged in a variety of ply, scents, embossed patterns, etc. No matter how good the wipe, the end result is the same for all of them. Arizona Journal of Pharmacy 27

Student Perspective How Effective is Marijuana?

In November 2010, medical marijuana marked its chapter in Arizona’s history. With the passing of proposition 203, legalizing marijuana for medical use in Arizona has spawned many controversial questions, including marijuana’s clinical efficacy. At the beginning of the new millennium, worldwide prevalent use of marijuana reached approximately 163 million people.1 More recently in 2005, the National Survey on Drug Use and Health (NS-DUH) estimated 14.6 million illicit users in the U.S. This paper glances at the narrative history of marijuana with emphasis on its pharmacology as well as clinical trials. Native to Asia, the marijuana plant Cannabis sativa has been cultivated and utilized for millennia.2 An array of marijuana’s possible therapies encompasses analgesia, asthma, vomiting, nausea, depression, appetite stimulant, hiccups and many more.3 In addition to medicinal use, cannabis can be found in the recreational drink bhang in India and curries in Thailand. It was introduced to Europe by Scythian invaders and then made its way to the U.S. as an over-the-counter drug in the 19th century. The synthesis and identification of the first cannabinoid, Δ9tetrahydrocannibinol (THC), came in 1964.4 Six years later cannabis found its way onto Schedule I of the Controlled Substance Act. Despite its illegal use, cannabis peaks interests in both medical and non-medical communities. Cannabinoids can be categorized as phytocannabinoids, endocannabinoids and synthetic cannabinoids. The psychoactive compound in marijuana, THC, is one of many phytocannabinoids acting as cannibinoid (CB) receptor agonist where CB1 resides mainly in the central nervous system and CB2 prevails peripherally in cells of the immune system. Currently, more than 60 phytocannabinoids come from marijuana such as non-psychoactive extracts cannabinol and cannabidiol. Endogenously, anandamide is the first endocannabinoid known to exist as CB1 partial agonist with analgesic and antinociceptive properties. Other endocannabinoids (2-arachidonoylglycerol, N-arachidonoyl-dopamine) stem from arachidonic acid . Lastly, synthetic cannabinoid derivatives consist of CP55,940, HU-210, Ajulemic acid and Ab-cannabidiol. Some may have powerful psychoactive properties deemed too strong for human subjects. Spice, also known as CP-47,497, exhibits cannabis’ similar pharmacological action; however differs in chemical structure and exemplifies more potent synthetic cannabinoid.5 Ware et al conducted a randomized, double-blind, placebocontrolled trial in the treatment of chronic neuropathic pain.6 Of the 116 participants entered, 23 were selected for the study: 12 women and 11 men with the average age of 45.4 years. Over a period of four cycles (14 days per cycle), the employed method randomly assigned patients with postsurgical or post-traumatic neuropathic pain to four concentrations of THC (tetrahydrocannibinol): 0%, 2.5%, 6% and 9.4%. For each cycle, patients’ regimens included a 25 mg dose inhaled three times per day for five days then followed by a wash out period of 9 days. The pain measurement utilized an 11-point rating scale. Compared to 0% THC, patients administered with 9.4% THC experienced improved quality of sleep: degree of easiness (p=0.001), quick onset of sleep (p<0.001), and decreased wakefulness (p=0.01). Additionally, there was reported increase 28 Arizona Journal of Pharmacy

of drowsiness (p=0.003). During this trial, patients showed signs and symptoms of headache, burning sensation in the areas of neuropathic pain, dry eyes, dizziness, cough, and numbness. Most importantly, the primary outcome showed low average pain intensity with 9.4% THC (p=0.023). The limitation of this study entailed lack of generalizability with small sampling size and short duration of trial. The authors concluded supporting evidence for future research along with proposal of a vaporizer instrument. Collin et al introduced a randomized controlled cannabis trial in multiple sclerosis-induced spasticity.7 189 patients were screened to participate, consisting of 75 males and 114 females with an average of 12.6 years of MS. Patients were randomly assigned to receive either placebo or active preparation in a 6-week, double-blind study. 124 patients received the active preparation while 65 patients received placebo. This study utilized active preparation of oromucosal spray (Sativex) with a concentration of 2.7mg of THC per 100uL actuation and 2.5mg of cannabidiol. Subjects report daily assessment in their diaries on numerical scale from 0 to 10 in terms of severity of spasticity relative to baseline. In addition to this primary outcome, the secondary outcome includes Ashworth Scale, Motricity Index and PGIC (patient global impression of change) in disease. As a result, the CBM group (cannabis-based medicine) showed spasticity scores of 5.49—1.18 reduction from average baseline. The placebo group showed 0.63 point reduction. There were statistical differences between the two results (p = 0.048). However, the secondary outcome did not show statistical significance. Soderpalm et al studied a double blind trial of a small group of 13 patients to observe antiemetic property of smoked marijuana on nausea.8 In each of the four sessions, subjects were randomly given either marijuana cigarette or placebo, and either ondansentron capsule or placebo. Five minutes later, subjects were given 5mL syrup of ipecac mixed with 20mL of Ora-Sweet Syrup to induce nausea. The four treatment groups compared ondansetron (8mg) and placebo marijuana, moderate dose cigarette with 800mg of marijuana (16.9mg THC, 0.3% cannabinol & 0.05% cannabidiol) and placebo capsule, placebo capsule and placebo marijuana cigarette, and placebo capsule and low dose cigarette with 800mg of marijuana (8.4mg THC, 0.3% cannabinol & 0.05% cannabidiol). Smoking procedure dictated each puff required 15 seconds and one puff per minute until gone. The result showed suppression of queasiness with ondansetron (p<0.001), low dose marijuana (p<0.04) and moderate dose marijuana (p<0.01). Relative to placebo, low dose of marijuana and ondansetron showed lower emetic episodes (p<0.05). Comparing to ondansetron, marijuana’s antiemetic effect was modest. Low dose of marijuana decreased emetic frequency but not queasiness. Moderate dose of marijuana lowered queasiness but not the emetic frequency. Differences in subjective and physiological responses were observed. Ondansetron, however, did not present subjective and physiological emetic effects induced by ipecac. The limitations of this study include small sampling size, acute emetic episode, and single marijuana dose exposure. Therefore the findings in this study may not be generalized in patients with conditions such as chemotherapyinduced nausea and vomiting. Overall, therapeutic use of marijuana may offer some benefits to patients seeking alternative therapy to modern medicine. The

Student Perspective How Effective is Marijuana? (continued from page 28) clinical trials mentioned above, although small in size, pave paths for improved future studies. The oral formulation of a single synthetic marijuana component is available for treatment such as nausea and vomiting. Marijuana plant, however, in its natural form contains delta-9-tetrahydrocannibinol among other active ingredients with unknown possibilities. Therefore, many variables exist within this green plant waiting to be discovered and harnessed for therapeutic uses. References: 1. Elkashef A, Vocci F, Huestis M et al. Marijuana Neurobiology and Treatment. Substance Abuse 2008; 29:3, 17-29. 2. Martin-Sanchez E, Furukawa T, Taylor J. Systematic Review and Meta-analysis of Cannabis treatment for Chronic Pain. American Academy of Pain Medicine 2009; 10:8, 1353-1368. 3. Elikottil J, Gupta P, Gupta K. The analgesic potential of cannabinoids. Journal of Opioid Management 2009; 5:6. 4. McCarberg B, Barkin R. The Future of Cannabinoids as Analgesic Agents: A Pharmacologic, Pharmacokinetic and Pharmacodynamic Overview. Am J of Thera 2007; 14: 475-483. 5. Weissman A, Milne G, Melvin L. Cannabimimetic Activity of CP-47,497, A Derivative of 3-Phenolcyclohexanol. Journal of Pharmacology and Experimental Therapeutics 1982; 223:2. 6. Ware M, Wang T, Shapiro S, et al. Smoked cannabis for chronic neuropathic pain: a randomized controlled trial. CMAJ 2010; 182: 14. 7. Collin C, Davies P, Mutiboko IK et al. Randomized controlled trial of cannabis-based medicine in spasticity caused by multiple sclerosis. European Journal of Neurology 2007; 14:290-296. 8. Soderpalm A, Schuster A, de Wit H. Antiemetic efficacy of smoked marijuana. Subjective and behavioral effects on nausea induced by syrup of ipecac. Pharmacology, Biochemistry and Behavior 2001; 69:343-350.

AzPA Calendar of Events January 7, 2011 Health-System Directors of Pharmacy Forum Grace Inn of Ahwatukee January 26, 2011 Pharmacy Day at the State Capitol February 19, 2011 Technician Academy Conference Scottsdale Healthcare Shea Medical Center March 5, 2011 Managed Care Academy Conference TBD April 2, 2011 Health-System Academy Conference Banner Desert Medical Center Visit www.azpharmacy.org for all upcoming events. Empowering pharmacy professionals to provide optimal patient care

by Peter Vu, Pharm.D. Candidate Class of 2011, University of Arizona College of Pharmacy

PHARMACY DAY AT THE STATE CAPITOL 2011 On the Senate Lawn Wednesday, January 26, 2011 11:00 am to 1:30 pm Lunch will be provided. SPONSORED BY APhA â&#x20AC;&#x201C; Academy of Student Pharmacists Chapters of University of Arizona College of Pharmacy and Midwestern University College of Pharmacy â&#x20AC;&#x201C; Glendale and the Arizona Pharmacy Alliance Learn about the services pharmacists and pharmacies provide to our community.

Meet with pharmacy professionals and students.

Discuss current issues relating to pharmacy and health care.

Arizona Journal of Pharmacy 29

In Memoriam Edward Anthony Darbonne 1923-2010

The Lord has welcomed Ed into his kingdom on Monday, October 18, 2010. He was born on Oct. 20, 1923 to Semonia (Durousseau) and Anthony Darbonne. He is survived by his wife, Barbara (Greenway) Darbonne; his son, Brian A. and daughter-in-law, Lynne; his three grandchildren, two great- grandchildren, with a third on t he way; his brothers and sisters, John, Phil, Annette and Joan; and numerous nieces and nephews. He was preceded in death by his wife, Martha; his parents, brothers and sisters, Mel, Fr. Dudley, Tessie and Alberta. Being one of the eldest children, he helped with his younger brothers and sisters while teaching his parents English after his parents' family emigrated from Quebec, Canada to the States. He was in the Army Air Corp. and served his country proudly in WWII. Sergeant Darbonne was in battle in England and France where he was injured while being trapped behind enemy lines in a foxhole next to a German occupied foxhole. He recovered in Switzerland before coming back to America. He received three military medals; European-African-Middle Eastern service medal, Good Conduct medal, Victory medal. He received the Marksman M1 medal, and he reached the rank of Tech Sergeant grade five. After the Army, he came home to New York City where he went to The College of Pharmacy at Columbia University and graduated at the age of 28. With his Pharmacy degree, he moved to Phoenix, Ariz., where he met and married his wife, Martha (Franta) Darbonne. The two of them, with their son Brian, lived in the Phoenix area while he started his career with the Thrifty Drug Store chain. He was a Pharmacist and then promoted to a District Manager in which he managed many of the stores in California, New Mexico, Arizona, and Nevada. After the death of his wife in 1986, he moved to Rancho Bernardo, Calif., and married Barbara Greenway in 1989. Ed loved life, his family, and his extended family. He enjoyed his wife, Barbara's hobby of photography and was an excellent one man crew for her. Not having traveled previously, since being together, they traveled the country taking thousands of pictures and enjoying the many scenic and landscape photo opportunities. This made Ed very happy. He was a loving husband, devoted father and grandfather with a nickname of Pop and Grand Pop. His enjoyment of life was shared by his many friends of Phoenix, Ariz., the Rancho Bernardo Community and San Rafael Parish.

30 Arizona Journal of Pharmacy

Marian W. (Mims) Rowan 1927-2010

On Sunday September 19, 2010, Marian (Mims) Rowan embarked on her journey into a glorious life everlasting. Born in Scottsbluff, Nebraska and graduated from the University of Nebraska in 1948 with Mortar Board Achievement, Marian or Mims (as known by many) migrated to El Paso, Texas where she met her “temporary boss” and future husband of 56 glorious years Joe J. Rowan. Together Joe and Mims moved on to Flagstaff, Arizona in 1960 and established Rowan’s Flagstaff Pharmacy and later to Sedona, to open and operate “The Pharmacy”. Mims, along with being a devoted mother and wife, was an early pioneer in the capacity of pharmacy technicians better known in those days as wives and moms. Long hours and hard work did not keep Mims from fielding a staunch baseball team. Never mind said team was very co-ed with seven girls and two boys. The first six members made it look like possibly an all girl team was in the making, however two boys finally came upon the scene to join in the festivities. Mims’s trademark was a wonderful smile, a keen sense of humor accompanied by a kind word of encouragement as well as a positive assessment of everyone she met, be that person a beggar or wealthy entrepreneur or everyone in between. She always seemed to know the right words to employ at the correct moment to resolve situations for anyone she met. Mims remained a devoted friend of Saint Anthony and would always petition his assistance for anyone in distress. Upon retirement from the practice of pharmacy Joe became employed by the Arizona State Board of Pharmacy and Marian sought her future as a cashier in the Bursars Office at Scottsdale Community College where she continuously greeted every student with a warm smile, kindness and a sincere word of encouragement regarding their chosen fields of endeavor. Eventually Mims and Joe regrouped the dynamic tandem and became a team of volunteers at Scottsdale Historical Museum, The Old Adobe Mission in old town Scottsdale and Hospice of the Valley Thrift Store. Mims was the loving and encouraging mother of Anne Smith Rowan, Patricia McMillin, Kaye Bogue, Kelly Storch, Marty Ness, Meg Weber, Joe Jr., Tracy Rowan Cavanaugh, and Jack Rowan. She also lovingly provided a guiding and encouraging hand to 15 spectacular grandchildren scattered throughout the USA and Canada. She is further survived by husband Joe Sr., brother Charles Weeth of Abilene, Texas, and sisters Norma Echols of Mesilla, New Mexico and Emily LaScola of Saratoga, California. It was only fitting that Mims would be the center of attention at a family reunion of 52 members of the clan in Missoula, Montana on July 2nd, 3rd, a 4th of this year. Mims was a firm believer in life being only the journey to the destination where she will now reside with her smile, kindness and gift of confidence to cement her future bliss with her Almighty Creator. In lieu of flowers or gifts, Mims would sincerely suggest your donation or volunteer time to your own special and deserving charity.

Rx and the Law AND THE LAW by Don R. McGuire, R.Ph., J.D. This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

CAN YOU FILL IN ON SATURDAY? Joe, the owner of Town Drugs, called and asked his friend Sandy to fill in next Saturday so Joe could attend a wedding. Joe and Sandy’s friendship goes back many years, so Sandy agreed. Sandy has filled in for Joe maybe two to three times per year and Joe sends Sandy an IRS form 1099 at the end of the year. Unfortunately, Sandy misfilled a prescription on that Saturday and the patient was injured. Joe and Sandy had not contemplated what they would do in the event that an error occurred. What are the ramifications for this lack of planning? From the owner’s perspective: Joe has had a regular patient injured and he feels terrible about it. The patient may or may not want to transfer their prescriptions. Does Joe’s store insurance policy cover this claim? It depends on Sandy’s status. Joe’s store policy covers his employees, but clearly Sandy is not an employee here. Joes isn’t making any withholdings and isn’t giving Sandy a W-2 at the end of the year. Other types of workers may be covered under the store’s policy. They include temporary workers, leased workers and volunteer workers. Sandy is most likely an independent contractor, but Joe didn’t check his liability policy before the loss to see if his store’s policy covers independent contractors. If not, the store’s policy won’t cover this claim. From the relief pharmacist’s perspective: Sandy filled in at Joe’s assuming that Joe’s store policy would cover her while working there. More than likely, the policy covering Sandy’s regular employer will not cover Sandy while she is working at Joe’s. So, very easily Sandy could wind up with neither policy covering her. Sandy could have purchased her own policy, but didn’t think it was necessary since she was only filling in two or three times per year.

and Sandy could end up fighting about who is going to take care of the injured patient and their long friendship could dissolve. Now, what should Joe and Sandy have done? Planning for the unexpected takes a little time, but it is crucial in the event that something bad happens. Joe and Sandy should have been working under a written contract. The contract should clearly state Sandy’s status with Joe’s store (i.e., independent contractor, temporary worker, employee, volunteer, etc.). Depending on the agreed upon status, Joe should review his policy to verify coverage for Sandy’s activities. Joe should also make sure that Sandy has her own insurance policy as a fail-safe measure, regardless of whether he believes that his policy will cover her. Sandy would want to do this for her own peace of mind also. Joe and Sandy can also allocate risk in their contract and decide ahead of time who will be responsible should an error occur. This might have saved their friendship. Many times, such an allocation of risk could be covered under Joe’s policy if it meets the definition of a covered contract. This is more likely to be true when the contract deals with the conduct of Joe’s business. Which it does in this case. Many pharmacists view requests to fill in as minor, friendly exchanges. No one expects bad things to happen. Unfortunately, lack of planning could result in them being a stressful, life-changing event. Take some time and plan ahead. © Don R. McGuire Jr., R.Ph., J.D., is General Counsel at Pharmacists Mutual Insurance Company. This article discusses general principles of law and risk management. It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with policies and procedures of their employers and insurance companies, and act accordingly.

One possible result is that neither pharmacist has insurance coverage for this incident. Joe’s pharmacy will be held liable for this error because it was the pharmacy that dispensed the errant medication. Sandy is liable because she is the pharmacist who misfilled the prescription. Joe

Arizona Journal of Pharmacy 31

Continuing Education ADHD and Its Treatment in Adults by: Thomas A. Gossel, R.Ph., Ph.D., Professor Emeritus, Ohio Northern University, Ada, Ohio and J. Richard Wuest, R.Ph., PharmD, Professor Emeritus, University of Cincinnati, Cincinnati, Ohio

Goal The goal of this lesson is to explain attention-deficit/hyperactivity disorder (ADHD) in adults with focus on its clinical characteristics and confirmation, and its treatment. Objectives At the conclusion of this lesson, successful participants should be able to: 1. recognize epidemiologic information and characteristics relevant to ADHD; 2. identify symptomatology that characterizes ADHD and the principles that govern its clinical confirmation and management in adults 3. select from a list specific nonpharmacologic and pharmacologic measures that are reported to modify signs and symptoms of ADHD in adults. Attention-deficit/hyperactivity disorder (ADHD), which affects up to 12 percent of children and adolescents, persists into adulthood in up to 60 percent of cases. Four to 5 percent of adults worldwide are affected, making ADHD one of the most common psychiatric conditions in adulthood for which treatment is available. Only recently has the persistence of untreated ADHD in adults been recognized in primary care. Marked by inattention, distractibility and impulsivity, clinical features of adult ADHD are reminiscent of the symptoms of childhood ADHD; however, the condition evolves and changes as the individual matures. Work productivity loss in adults with ADHD is estimated at 35 days each year. Annual health care costs for adults with ADHD, compared with an age-matched cohort of unaffected adults, are three times higher, and annual health care expenditures for their family members are approximately 1.9 times higher compared with a matched cohort (group consisting of shared characteristics) of family members of non-ADHD patients. 32 Arizona Journal of Pharmacy

Background In adults, ADHD can lead to substantial social and occupational impairment and is associated with increased familial stress. Fewer adults with ADHD are employed full time, indicating that those with ADHD have a lower average income than control subjects, regardless of academic achievement or personal characteristics. Adults with ADHD have been shown to be more careless drivers, and more likely to receive multiple citations for speeding and have their driverâ&#x20AC;&#x2122;s license revoked. Adults with ADHD are twice as likely to have been arrested and convicted of a crime. Only 47 percent of adults with ADHD report being satisfied with their family life, compared with 68 percent of those without the condition. Adults with ADHD are twice as likely to be divorced. Only half of affected adults report contentment with their professional life. Adolescents with and without ADHD have the same rate of substance abuse; such is not the case for adults with ADHD. Between adolescence and adulthood, the rate of substance abuse increases substantially for individuals with ADHD. Although parents may worry that treating ADHD with psychostimulants will predispose their children to substance abuse later in life, treatment may actually protect against the development of substance abuse. If ADHD is consistently and effectively treated during the childhood and adolescent years, the risk of substance abuse later in life is no greater than in the general population. ADHD may affect sexual behavior. The Milwaukee Young Adult Outcome Study showed that sexually transmitted disease was four times more prevalent among persons with ADHD than their nonaffected peers. Affected persons also had far more children by age 20, but only half of the ADHD parents retained custody of their children. Executive functioning (the ability to maintain appropriate problem solving activity for attainment of a future goal) is an area of intense research in the study of

ADHD. Problems present clinically as deficits in time management, organization, and sequential and hierarchical thinking. Exceptionally intelligent adults are often able to compensate for their inabilities through adolescence and even young adulthood, but the cumulative challenges may eventually overwhelm their compensatory mechanisms. Data describing the likelihood that a child with ADHD will also have the disorder as an adult are conflicting. As definitions of ADHD subtypes improve, some subtypes will likely be found that cause more adult dysfunction than others. Pathogenesis As in childhood and adolescent ADHD, the most critical neurotransmitters in adults with ADHD are the catecholamines dopamine and norepinephrine, both of which appear to regulate inhibitory influences in the frontal-cortical processing of information. Specific neurobehavioral roles for these neurotransmitters remain unclear. Both dopamine and norepinephrine act upon relatively specific pathways that regulate attention, concentration and other cognitive functions. It is theorized that dopamine enhances signals and improves attention, acquisition, focus, on-task behavior and cognition, perception and vigilance. Norepinephrine may diminish â&#x20AC;&#x153;noise;â&#x20AC;? decrease distractibility and shifting; improve executive operations; and increase behavioral, cognitive, and motor inhibition. In terms of pathophysiology, it is postulated that neurotransmitter dysfunction causes dysregulation of the inhibitory influences of frontal-cortical activity, which is predominantly regulated by norepinephrine, and of lower striatal structures, which are predominantly dopaminergic. These striatal structures are driven by dopaminergic agonists controlled or modulated by higher inhibitory structures sensitive to adrenergic agents.

Continuing Education (continued from page 32)

Clinical Confirmation in Adults There are no efficient standardized assessment tools to specifically identify adult ADHD, which makes diagnosis confirmation challenging. Extensively studied in children, its persistence into adulthood was not recognized until the mid-1970s. These symptomatic adults were diagnosed retrospectively with ADHD following interviews with their parents and determination that symptoms of illness characteristic of the disorder had indeed been noticed during the affected adults’ early years. Current guidelines for both children and adults are that patients must meet the criteria established by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSMIV). Symptoms are categorized as follows: inattention (difficulty sustaining attention), forgetfulness and distractibility; hyperactivity (fidgeting, excessive talking and restlessness) and impulsivity (difficulty waiting one’s turn and frequent interruption of others). The DSM-IV criteria also include onset by age seven (confirmed, possibly, by retrospective analysis), impaired functioning in at least two settings (home, work, school), and persistence beyond six months. Symptoms. Symptoms in adults are similar to those in childhood except they are usually less disruptive and more along the lines of a sense of inner restlessness. Typically, adults with ADHD are unaware that they have the disorder. They may feel it is difficult to get organized, to stick with a job or keep an appointment. Everyday tasks of arising in the morning, getting dressed and ready for the day’s work, arriving at work on time and being productive on the job can be major challenges for the ADHD adult. Problems may intensify in adulthood when they begin an independent life with increasing challenges for organization associated with marriage, parenting, occupational planning and administration. Adults almost always self-refer for treatment rather than having a physician suggest its presence initially. This may occur when their children are diagnosed with the disorder and they begin to understand that some of the traits that have troubled them for years might point to ADHD as the root cause of their

problems. Other adults seek professional help for anxiety or other symptom(s) listed in Table 1. They may have a history of social inadequacy or problems at work, or they have been involved in frequent automobile accidents and they seek answers for the root cause of their “problem.” Gender distribution of selfreferring adults is nearly equal. A presenting comorbidity (concomitant, but unrelated illness) may be the first clue to the presence of adult ADHD. The majority of adults with ADHD have at least one additional psychiatric disorder such as anxiety, bipolar disorder or major depressive disorder; some adults may have more than one. Because there is considerable symptom overlap, this creates the potential for diagnostic confusion with consequent tendency to disguise a diagnosis of ADHD. It is also possible that many adult patients with ADHD have clinically significant but subthreshold symptoms. Hyperactivity symptoms may decrease with age because of developmental trends toward self-control. Adults with ADHD are generally less hyperactive than children. Whereas young children can often be seen in purposeless climbing, jumping and running about, adult variants of these characteristics include such raits as being a workaholic, feeling uncomfortable sitting through meetings or a movie, being unwilling to wait in line, and speeding while driving. Affected adults often work overtime and/ or hold more than one job. Symptoms of hyperactivity in adults may also be based not so much on motor behavior but on other aspects of functioning, such as talking. Adults may feel they need to talk excessively or they regularly talk out of turn, blurt out inappropriate comments, or feel compelled to talk endlessly on their cell phone during meetings or while driving. Such behaviors can lead to both personal and professional harm. Inattentive symptoms do not appear to have a similar developmental advantage and they tend to remain constant throughout adulthood. Adults with ADHD may be unable to understand which of their actions provoke irritation in others, but advancing age does have an advantage in that they may have better insight into monitoring the reactions of others and so they adjust their behavior accordingly. Traits that

were problematic in childhood may be adaptive to selective jobs by an adult. This does not imply that these adults no longer suffer impairment in quality of life, social relationships, personal planning, underemployment, motor vehicle safety and other dimensions of functioning. As one adult wisely said, “You don’t grow out of ADHD; you just get better at coping with it!” It stands to reason that adults with ADHD experience life differently from persons without ADHD.

Treatment Pharmacotherapy of adult ADHD is an effective means to manage symptoms of the disorder, with approximately two-thirds of adult patients experiencing moderate-tomarked improvement with drugs when combined with psychoeducational management. Clinical trials have confirmed that medications positively improve core ADHD symptoms by enhancing levels of dopamine and/or norepinephrine. Stimulants. The two major stimulant categories used to treat ADHD are the amphetamines and methylphenidates, compounds with a similar clinical effect. Stimulants comprise the majority of treatment protocols for both children and adolescents, and for adults. Seventyfive to 80 percent of adults with ADHD responded positively to stimulants in short-term trials. It is reported that 1.5 million adults in the United States now Arizona Journal of Pharmacy 33

Continuing Education (continued from page 33 take stimulants on a daily basis to treat short-term trials. It is reported that 1.5 their ADHD, with 10 percent of users older than 50 years of age. Amphetamines include dextroamphetamine (d-amphetamine; Dexedrine, etc.) and mixed amphetamine salts (Adderall, etc.). Recent advances have occurred with delivery systems rather than new and novel drugs. Long-acting formulations allow for more convenient and confidential administration of medication and eliminate the possibility of forgetting to take midday doses. They also reduce peak and trough adverse effects such as headache and moodiness, and eliminate afternoon wear-off and rebound. An extended-release form of mixed amphetamine salts (Adderall XR) provides 10 to 12 hours of activity. Lisdexamfetamine (Vyvanse), approved in 2007 for use in children, may become another alternative therapy for adults. Lisdexamfetamine is composed of d-amphetamine combined with the amino acid lysine that renders the molecule inert. Gastric enzymes cleave the lysine, which activates the molecule. Since gastric enzyme exposure is necessary for activation, this ensures that the medication cannot be misused if snorted or injected intravenously. Lisdexamfetamine is also long-acting and has consistent pharmacodynamic properties. Methylphenidate is available in immediate-release (four-hour duration of action), longer acting (six- to eighthour duration), and extended-release (10- to 12-hour duration) formulations. Osmoticrelease oral system (OROS) methylphenidate (Concerta ) releases the active ingredient slowly over 12 hours. Dexmethylphenidate (Focalin ) is comprised solely of the dextro- (active) portion of the methylphenidate molecule. Products are available in immediateand extended-release formulations. The methylphenidate transdermal system (Daytrana) is an alternative to orallyadministered drugs that delivers the active ingredient via skin patch. With optimal wear time of nine hours each day, its duration of action persists up to three hours after the patch is removed. Adverse effects of stimulants are generally mild and can be managed by adjusting the medication timing and dosage. The most common short-term effects are diminished appetite, GI 34 Arizona Journal of Pharmacy

disturbance, headache, insomnia and motor disturbance. Non-stimulants. Atomoxetine (Strattera) is a highly selective norepinephrine reuptake inhibitor in presynaptic neurons; it reduces reuptake of dopamine in prefrontal lobes to a lesser extent. It is of interest that development of atomoxetine was initially piloted in adults rather than children, although confirmation of benefit in children followed. At present, it is the only non-stimulant with FDA approval for treatment in adults. It often takes longer than the stimulants to chieve clinical effect, but has a powerful anxiolytic effect and minimal abuse potential. Atomoxetine is generally well tolerated with few mild side effects including appetite suppression and insomnia. Antidepressants are considered a second choice for treatment of adults with ADHD following a trial with the stimulants and atomoxetine. The older antidepressants (tricyclics) are sometimes used because they modify norepinephrine and/or dopamine. Venlafaxine (Effexor), a non-tricyclic antidepressant, is also used for its enhancement effect on norepinephrine. Bupropion (Wellbutrin, etc.), an antidepressant with an indirect effect to increase central dopamine, has been useful in treatment of ADHD in both children and adults. It has the added benefit of aiding reduction of nicotine dependence. Education and Psychotherapy. Although pharmacotherapy provides needed support, the individual must succeed on his own. To assist in this struggle, both education and individual psychotherapy can be helpful. Adults can learn how to organize their life by posting a large calendar where it will be seen each

morning that lists important tasks for the day. A special place can be set aside for keys, bills and the paperwork of everyday life. Tasks can be organized into segments such that completion of each part can give a sense of accomplishment. Above all, adults with ADHD should learn as much as they can about their disorder so they understand what is going on in their body and, thus, be better equipped to manage it. Psychotherapy can be a useful adjunct to medication and education, Therapy can help patients improve their poor self-image by examining experiences that produced it. The therapist can encourage patients to adjust to changes in their life by treatment â&#x20AC;&#x201C; the loss of impulsivity and desire for risk-taking, and the new feeling of thinking before acting. As patients begin to understand their new ability to organize the complexities of life, they can often begin to appreciate characteristics of ADHD that are positive, such as newfound energy, warmth, and enthusiasm. Focused therapies that incorporate cognitive-behavioral features have reportedly been effective in children, adolescents and adults with ADHD. The benefit of these treatments without concurrent pharmacotherapy has yet to be determined. Drug Holidays. Drug holidays, common in treatment of childhood ADHD, may also become part of the pharmacotherapy of adult ADHD. However, there is growing consensus that this practice of withholding medication one or more days each week in adults is inappropriate and that medication is most effective when taken consistently without interruption. Adherence. Poor adherence with treatment is common in the care of adult patients initiating stimulant therapy. In one

Continuing Education (continued from page 34) study, adults initiating pharmacological treatment for ADHD continued their medications for an average of only 50 days. Although early discontinuation of treatment commonly occurs in the care of adult ADHD, the factors that promote continuity of stimulant treatment remain largely unknown. Optimal management of ADHD includes pharmacologic and nonpharmacologic interventions. Support groups help persons of all ages with ADHD and their family members understand the disorder and available resources. Support groups can be located by calling an ADHD hotline (800.233.4050) or by contacting Children and Adults with Attention-Deficit/ Hyperactivity Disorder (CHADD) (Table 2). Other helpful websites on ADHD are also listed in Table 2. Summary and Conclusions Adult ADHD is one of the most common psychiatric disorders. It differs from ADHD in children and adolescents in that adults can often modify their daily routines to better match their temperament. It has been shown in most clinical trials that pharmacologic treatments effective in children and adolescents are also effective in adults. Although adults with ADHD are at higher risk for substance abuse than adults without the disorder, recent studies have shown that pharmacotherapy may reduce the risk of substance abuse in adults with ADHD. UAN #0100-0000-10-071-H01-P The content of this lesson was developed by the Ohio Pharmacists Foundation and reprinted with permission. No financial support was received for this activity. This

activity may appear in other state pharmacy association journals. Participants should not seek credit for duplicate content.

Meet me at the

Arizona Pharmacy Alliance 7th Annual Meeting July 7 – 10, 2011

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Register Now at the Early Bird Rate! ix, hoen

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The College of Psychiatric and Neurologic Pharmacists (CPNP) is a professional association of psychiatric and neurologic pharmacists. The CPNP Annual Meeting offers cutting-edge information ideal for the pharmacist, physician, nurse practitioner or other healthcare professional involved in the medication therapy management of psychiatric and/or neurologic patients.

Meeting Highlights Include: Pre-Meeting Workshop: A 3-hour workshop on Optimizing Cardiovascular Health in Psychiatric Patients will be offered on May 1. This workshop will provide hands-on experience in selecting first-line agents, identifying adverse effects and monitoring techniques to maintain safe and adequate care. Daily Keynote Addresses From: • Seizing the MTM Opportunity Linda Strand, PharmD, PhD • Drug Transporters and Psychiatry Lindsay Devane, PharmD, BCPP, FCCP • Management of Aggression in Children Lynn Crismon, PharmD, BCPP, FCCP • Glutamate: The Emerging Frontier of Psychopharmacology - Stephen Stahl, MD, PhD Programming: Registrants have 23 hours of ACPE and CME approved programming to choose from along with an anticipated five industry supported symposia opportunities. Research: Three hours of the meeting will be dedicated to networking with an anticipated 150+ poster authors. Abstract and Award submissions are open to all investigators with submissions due January 12, 2011.

Tucson, Arizona Registration and information available at cpnp.org/2011

Continuing Education Natural Products: Fumitory, Gamma Linoleic Acid, Garlic and Ginger

by: Thomas A. Gossel, R.Ph., Ph.D., Professor Emeritus, Ohio Northern University, Ada, Ohio and J. Richard Wuest, R.Ph., PharmD, Professor Emeritus, University of Cincinnati, Cincinnati, Ohio Goals The goals of this lesson are to present information on the claims, mechanisms of action, typical dosages used and other items of interest on natural products and nutraceuticals alphabetically from fumitory to ginger, and to provide background information for assisting others on their proper selection and use. Objectives At the conclusion of this lesson, successful participants should be able to: 1. exhibit knowledge of the claims, mechanisms of action, and typical dosages for natural products and nutraceuticals presented; 2. select from a list, the synonyms for these products 3. demonstrate an understanding of information that can be used when discussing these products with consumers. This lesson is part of a series that presents an overview of the common uses, proposed mechanisms of action, typical dosage regimens and other information of interest on natural products and nutraceuticals. Since natural products are somewhat controversial, the authors restate that the information presented is neither a promotion of nor a condemnation against their use. It is merely an overview of what has been reported in both the public and scientific literature, and certainly not an indepth treatise. FUMITORY (Fumaria officinalis), also known as beggary, common fumitory, earth smoke, fumiterry, hedge fumitory, herba fumariae, vapor and wax dolls, is an annual plant with varying characteristics. It usually resembles a bush, but can also appear as a low trailing shrub. It has gray pointed leaves that, at a distance, give the plant a wispy appearance of smoke (from which the synonym earth smoke is derived). It produces pink-purple flowers which bloom in the springtime. Fumitory is indigenous to the Mediterranean region and all of Europe, to parts of southern Siberia as well as northern Africa. The herb was long ago introduced to North and South America where it is widely dispersed in gardens, on slopes and in wastelands. The herb has reportedly been used since antiquity, and is described in records of herbal remedies from the European Middle Ages. Fumitory has been used as a laxative and diuretic, to treat arthritis and rheumatism, and as a blood purifier. Topically, it has been used to treat eczema and other skin disorders. More recently, its use has increased due to

36 Arizona Journal of Pharmacy

reports that extracts of fumitory may be useful in the management of cardiovascular diseases and disorders of the hepatobiliary tract. These include spastic discomfort in the area of the gallbladder and bile duct, as well as the gastrointestinal tract. The German Commission E (a European agency that oversees the promotion and use of natural products) approves its use for liver and gallbladder complaints. In homeopathic medicine, fumitory is used for chronic itching eczema resulting from liver disease. Fumitory has been found to have weak antispasmodic activity on the smooth muscle of the bile duct and upper gastrointestinal tract. The extracts of fumitory that are claimed to be useful for cardiovascular diseases include alkaloids, the major one being protopine. This substance has demonstrated antiischemic, bradycardic, hypotensive, sedative and antihistamine action in small doses. Large doses of protopine cause excitation and convulsions, and should not be used. The typical dose of fumitory is 2 to 4 grams of the above-ground parts of the plant daily. Alternatively, a tea, prepared by steeping 2 to 4 grams of the above-ground parts in 150 mL of boiling water for five to 10 minutes and then straining, is ingested three times a day. The usual dose for the liquid extract (1:1 ratio in 25 percent alcohol) is 2 to 4 mL three times a day. The tincture (1:5 ratio in 45 percent alcohol) is dosed at 1 to 4 mL three times a day. GAMMA LINOLEIC ACID is an omega-6 fatty acid, that is also known as gamolenic acid and GLA. It is present in the fatty acid fraction of several plant seed oils, including black currant, borage, and evening primrose. It is also produced naturally in the human body from the essential fatty acid linoleic acid. GLA is the precursor for dihomo-gamma linoleic acid (DGLA) which, in turn, is the precursor to the E-1 series of prostaglandins PGE-1) and arachidonic acid. These are the precursors to the E-2 series of prostaglandins (PGE-2), all of which are involved in many body functions. GLA is used for the treatment of diabetic neuropathy, heart disease, hyperlipidemia, rheumatoid arthritis and systemic sclerosis (hardening of tissue); to prevent cancer; and to enhance the activity of tamoxifen. It is also used for acute respiratory distress syndrome, allergic rhinitis, attention deficit hyperactivity disorder (ADHD), chronic fatigue syndrome, depression, eczema, hypertension, postpartum depression, psoriasis, Sjogrenâ&#x20AC;&#x2122;s syndrome and ulcerative colitis. In the body, the compounds into which GLA is converted have antiinflammatory, antiproliferative and vasoactive properties.

Research suggests that DGLA might act directly on T-cells to modulate immune response in diseases such as rheumatoid arthritis. Other reported, but not yet proven, activities of GLA include hastening the response to tamoxifen in patients with estrogen-sensitive primary breast cancer as well as other antiestrogen effects. It may also lower plasma triglycerides, increase HDL cholesterol levels and prolong bleeding time via an antithrombotic effect. GLA is usually well tolerated with no significant adverse effects. However, there are reports of it causing mild gastrointestinal effects such as nausea, vomiting, diarrhea, flatulence and belching. The typical dose of gamma linoleic acid for rheumatoid arthritis is 1.1 grams daily. For diabetic neuropathy, 360 to 480 mg daily is recommended. For treating hyperlipidemia, doses of 1.5 to 6 grams daily have been used. GARLIC (Allium sativum), also known as aged garlic extract, ail, ajo, allii sativi bulbus, allium, camphor of the poor, clove garlic, garlic oil, lasun, lasuna, nectar of the gods, poor manâ&#x20AC;&#x2122;s treacle, and stinking rose, is a perennial bulb plant with a tall, erect, flowering stem that grows two to three feet high. It produces pink to purple flowers that bloom from July to September in the northern hemisphere. The bulb has a unique odor and flavor. The botanical name for garlic, allium, reportedly comes from the Celtic word all, which means burning or smarting. However, garlic has been used and valued since ancient times. There are inscriptions on the Great Pyramid of Cheops describing its virtues. Central to southern Asia is considered to be the region of origin of garlic, but it is now cultivated worldwide. The medicinal parts of the plant are the whole fresh bulb, the dried aged bulb, and its oil. Garlic is taken orally to treat coronary artery disease, high blood pressure, hyperlipidemia, age-related vascular changes, atherosclerosis, myocardial infarction, chronic fatigue syndrome, earache and menstrual problems. It is used to prevent several types of cancer, including breast, colorectal, lung and stomach cancers; to treat bladder cancer; and to prevent and treat prostate cancer. It is used to treat allergic rhinitis, amoebic and bacterial dysentery, asthma and wheezing, atherosclerosis, bronchitis, colds and flu, diabetes, digestive disorders, enlarged prostate, fever, gout, headache, hypersensitive teeth, hypoglycemia, osteoarthritis, preeclampsia (hypertension and edema due to pregnancy), rheumatoid arthritis, sinus congestion, stomach ache, travelerâ&#x20AC;&#x2122;s diarrhea, tuberculosis,

Continuing Education continued from page 36) and vaginal trichomoniasis. Garlic is used as an aphrodisiac, cathartic, diuretic, stimulant and tonic; for enhancing circulation, fighting stress and fatigue; and to maintain healthy liver function. Topically, garlic is used for treating corns, ringworm infections and warts. The German Commission E approves the use of garlic in hyperlipidemia, hypertension and arteriosclerosis. In Indian medicine, garlic is used for treating bronchitis, constipation, joint pain and fever. In homeopathic medicine, garlic is used in conditions such as inflammation of the upper respiratory tract, digestive complaints and muscle rheumatism in the lumbar region. The following information is a compilation of reports on the effectiveness of the use of garlic for many conditions. It should be kept in mind that these reports do not represent the strenuous clinical trials required for FDA approval of labeled uses. Reports that are based on animal studies rather than human subjects have been omitted. Hypercholesterolemia. There are reports varying from no effects when compared to placebo in adults with mild to moderate hypercholesterolemia to studies in adult males that suggest garlic has beneficial effects on reducing total and LDL cholesterol, especially when added to therapy with lipid lowering HMG-CoA reductase inhibitors. One metaanalysis inferred that garlic was superior to placebo in moderately reducing (on average by 6 percent) total cholesterol. The authors, citing over two dozen studies, concluded that the majority of evidence suggests that garlic has modest benefits in decreasing total cholesterol, LDL cholesterol and triglyceride, but no effect on HDL cholesterol. Antithrombotic Effects. Limited clinical studies have suggested that inhibition of platelet aggregation has been observed after ingestion of both fresh and aged garlic. However, across the board, the overall results of other studies are inconsistent. Hypertension. No strong evidence for a beneficial effect of garlic in lowering elevated blood pressure was found. The trials reported were generally moderate to poor quality, and not all subjects had clinical hypertension. Gastrointestinal Effects. The effect of garlic in the gastrointestinal tract has long been debated. No human studies could be found regarding the effectiveness of garlic in treating gastrointestinal disorders. Blood Glucose Reduction. Claims have been made that garlic reduces elevated blood sugar levels, increases serum insulin levels and improves liver glycogen storage. A single report suggested that glucose levels decreased in healthy volunteers given garlic when compared to placebo. However, other reviews have reported that garlic has no effect on blood glucose levels. Antioxidant Activity. Researchers have demonstrated that allicin, a component of

garlic, increased the level of two important antioxidant enzymes in the blood – catalase and glutathione peroxidase. This discovery confirmed the antioxidant and free-radical scavaging potential of allicin. However, the clinical utility of garlic has not yet been determined. Antiseptic and Antibacterial Activity. Garlic had been used as an antiseptic long before bacteria and other microorganisms were known to exist. As recently as World War II, garlic extracts were used to disinfect wounds. The discovery of sulfonamides, penicillin and other antibiotics ended this use. However, clinical studies in humans have shown that garlic extracts inhibit the growth of gram-positive and gram-negative organisms. The potency of garlic is reported to be about 1 percent of that of penicillin. The consensus is that, even though garlic shows antibacterial and antifungal activity when tested in vitro, the concentrations needed for systemic activity would be too difficult to achieve. The extensive use of garlic for culinary purposes has shown essentially no ill effects. When used medicinally, adverse effects appear to be dose-related. These include bad breath and body odor, mouth and gastric burning and irritation, heartburn, flatulence, nausea, vomiting and diarrhea. Oral ingestion of excessive amounts of garlic has been associated with increased risk of bleeding, prolonged bleeding, bleeding behind the eye and spinal epidural hematoma. Asthma and other allergic reactions have been reported in people working with garlic. The typical dose of garlic extract for treating hyperlipidemia and hypertension is 600 to 1200 mg divided into equal doses given three times a day. Most studies reportedly have used a standardized garlic extract containing 1.3 percent allicin. Fresh garlic contains approximately 1 percent allicin. A major concern with both commercially marketed garlic extracts and the ingestion of fresh or aged bulbs of garlic is the lack of control and knowledge of the actual contents of the product. With “natural” products, this is complicated by the volatility and instability of important constituents. With commercial products, unless they are standardized to allicin, they may not contain enough of this important ingredient. One review of “odorless” and “deodorized” garlic products reported that some preparations did not contain any active components. GINGER (Zingiber officinale), also known as African ginger, ardraka, black ginger, cochin ginger, gan jiang, gimgembre, imber, Indian ginger, Jamaica ginger, jiang, kankyo, kanshokyo, nagara, rhizoma zingiberis, shen jiang, shoa, shokyo, srangavera, sunthi and zinzeberis, is a creeping perennial plant with thick, tuberous roots which spread underground. While the plant grows reed-like

stems that produce leaves and white, light purple or yellow flowers that resemble orchids, the medicinal and culinary parts of ginger are its roots. Ginger is indigenous to southeast Asia and is cultivated in tropical climates around the world. These include Australia, Brazil, Jamaica and other areas in the West Indies, India, west Africa and southern United States. References to the use of ginger for medicinal purposes are found in ancient writings of China, India, and the Middle East. Its use spread to Europe in the 13th century. Traditionally, the plant and its constituents are claimed to have antibacterial, antiemetic, antihepatotoxic, anti-inflammatory, antimutagenic, antioxidant, antithrombotic, antitussive, cardiotonic, carminative, diuretic, immunosuppressant, spasmolytic and stimulant activities. It has been used to increase gastric secretions, promote intestinal peristalsis, lower cholesterol levels, raise blood sugar levels, stimulate peripheral blood flow, and as a bitter to stimulate digestion. Current uses of ginger include prevention of nausea and vomiting (especially that of morning sickness, motion sickness and postoperatively); for loss of appetite, upset stomach and colic; and treatment of bronchitis, migraine headaches, rheumatism, and toothache. Topically, the fresh juice of ginger is used to treat burns. The German Commission E approves the use of ginger for loss of appetite, travel sickness and dyspeptic complaints. In China, it is used to treat colds, nausea, vomiting and shortness of breath. In Indian medicine, ginger is used for loss of appetite, upset stomach and pharyngitis. A definitive mechanism of action for ginger for motion sickness has not been determined. It was thought that the aromatic, carminative and absorbent properties of ginger lessen the effects of motion sickness in the gastrointestinal tract directly, rather than through the central nervous system. It has been postulated that ginger increases gastric motility and blocks the gastrointestinal reactions that are part of the nausea feedback system. More recent studies show that ginger does not influence gastric emptying time. Two constituents of ginger may act on serotonin receptors such as the 5-HT3 receptors in the ileum. These are the same receptors affected by the prescription antiemetics (Zofran, Kytril, etc.). While the predominant antiemetic effect of ginger is still believed to be localized in the gastrointestinal tract, there is limited evidence that its constituents may also have some central nervous system activity. There have been several human studies (with a very small number of subjects) comparing ginger root to the antiemetic dimenhydrinate and placebo. One doubleblinded study compared the effect of 940

Arizona Journal of Pharmacy 37

Continuing Education (continued from page 37) mg of powdered ginger root, 100 mg of dimenhydrinate, and a placebo in which the subjects were blindfolded and placed in a rotating chair. More of the subjects receiving the ginger root remained in the chair longer, averaging 5.5 minutes, compared to 3.5 minutes for the dimenhydrinate group, and 1.5 minutes for the placebo group. One-half of the group receiving the ginger root remained in the chair for the full six minutes of the test; none of the subjects in the other groups completed the test. In general, it took longer for the ginger group to begin to feel sick; but once the vomiting center was activated, sensations of nausea and vomiting progressed at the same rate for all groups of subjects. Another double-blinded, placebo-controlled study of seasick Marine cadets reported significant reduction of symptoms (vomiting and cold sweats), and noticeably suppressed dizziness following administration of 1 gram of ginger rhizome. A much larger study of over 1700 participants on an ocean sailing tour reported that the administration of 200 mg of ginger prior to departure was as effective as cyclizine, dimenhydrinate, meclizine, and scopolamine. Ginger (500 mg every four hours) and dimenhydrinate (100 mg every four hours) were compared in another double-blinded study with similar protective effects, but the ginger group experienced none of the side effects encountered by the other group. Other trials have shown no significant differences among ginger, the antiemetics,

and a placebo with regard to gastric as well as nongastric symptoms. One study, using blindfolded subjects in rotating chairs similar to the study mentioned earlier, compared powdered and fresh ginger against oral scopolamine. The conclusion of the authors of this report was that ginger provided no protection against motion sickness, while the scopolamine group was able to tolerate a significant increase in head movement. The bottom line to all this is that the jury is still out on whether ginger does, in fact, have therapeutic antiemetic effects, and if it does, what is its mechanism of action? Other proposed, but unproven, uses and mechanisms for constituents of ginger are inhibition of cyclooxygenase and lipooxygenase pathways, and inhibition of the synthesis of prostaglandin (PGE-2) and thromboxane B2. These are mediators of inflammation within the body. If this action is proven, ginger could be useful in treating osteoarthritis and rheumatoid arthritis. Laboratory tests (but not human clinical trials) have shown that ginger may increase the release of insulin and lower cholesterol levels; inhibit platelet thromboxane, providing an antiplatelet aggregation effect; block calcium channels to confer a blood pressure lowering effect; and exert negative inotropic and chronotropic activity, which could be helpful in treating heart disease. Ginger is well tolerated when taken orally in typical doses, except by individuals who do not like its taste and aroma. However, doses of

5 grams or more per day reportedly increase the risk of adverse reactions and decrease tolerability. Common adverse reactions at these levels include abdominal discomfort, diarrhea, heartburn, and a pepper-like irritant effect in the mouth and throat. The typical dose of ginger for motion sickness is 1 gram of powdered ginger root 30 minutes to four hours before travel. For morning sickness of pregnancy, 250 mg of powdered ginger root four times daily has been used. For post-operative nausea and vomiting, 1 to 2 grams of powdered ginger root one hour before induction of anesthesia is recommended. For chemotherapy-induced nausea and vomiting, the recommendation is 1 gram of powdered ginger root daily, starting on the first day of chemotherapy and continuing for five days. For migraine headache, 500 mg of powdered ginger root at the onset and repeated every four hours up to 2 grams per day for three to four days has been used. UAN #0100-0000-10-072-H01-P The content of this lesson was developed by the Ohio Pharmacists Foundation and reprinted with permission. No financial

support was received for this activity. This activity may appear in other state pharmacy association journals. Participants should not seek credit for duplicate content.

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38 Arizona Journal of Pharmacy

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Continuing Education Quiz ADHD and Its Treatment in Adults

This activity was developed by the Ohio Pharmacists Foundation for pharmacists as a knowledge-based learning activity. The Arizona Pharmacy Alliance and OPF are accredited by the Accreditation Council for Pharmacy Education as providers of continuing pharmacy education.

1. Work production loss in adults with ADHD is estimated at: a. 15 days each year. c. 55 days each year. b. 35 days each year. d. 75 days each year. 2. Between adolescence and adulthood, the rate of substance abuse for individuals with ADHD: a. increases. b. decreases. 3. The most critical neurotransmitters in adults with ADHD are dopamine and: a. acetylcholine c. norepinephrine. b. gamma-aminobutyric acid. d. serotonin. 4. Which of the following in NOT listed as a function regulated by dopamine and/or the neurotransmitter referred to in question # 3? a. Concentration c. Perception b. Attention d. Memory 5. Which of the following statements is true? a. Adults almost always self-refer for treatment of ADHD. b. Physicians almost always suggest the presence of ADHD in adults initially.

6. Which of the following statements is most likely to be true about adults with ADHD? a. They understand which of their actions provoke irritation in others. b. They are not able to adjust their behavior to the reaction of others. c. They do not suffer impairment to quality of life or social relationships. d. Traits that were problematic in childhood may be adaptive to selective jobs. 7. The percentage of adults with ADHD who responded positively to stimulants in short-term trials has been: a. 55 to 60 percent. c. 75 to 80 percent. b. 65 to 70 percent. d. 85 to 90 percent. 8. Which of the following products is comprised solely of the dextro(active) portion of the methylphenidate molecule? a. Strattera c. Dexedrine b. Focalin d. Concerta 9. Which of the following products is a non-stimulant drug? a. Strattera c. Dexedrine b. Focalin d. Concerta 10. There is growing consensus that the practice of withholding ADHD medication one or more days each week in adults is: a. appropriate. b. inappropriate.

Arizona Pharmacy Foundation ADHD and Its Treatment in Adults ACPE UAN# 0100-0000-10-071-H01-P This activity is accredited for 1.0 hours of CPE credit (CEUs 0.10) 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. recognize epidemiologic information and characteristics relevant to ADHD 2. identify symptomatology that characterizes ADHD and the principles that govern its clinical confirmation and management in adults 3. select from a list specific nonpharmacologic and pharmacologic measures that are reported to modify signs and symptoms of ADHD in adults.

AGREE DISAGREE

AGREE DISAGREE

AGREE DISAGREE

Will the information presented cause you to make any changes to your style or method? Yes If you answered “yes” please list one or two things you will do differently: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Overall evaluation of the article content: (please circle one)

Name __________________________________________________________

Activity accredited date: 01-01-2011 Expiration date: 01-01-2012. Send this page to: APF, 1845 E. Southern Ave., Tempe, AZ 85282

Address ________________________________________________________

Email ________________________________________________________

City, State, Zip ___________________________________________________

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Certificates will be mailed within 60 days.

Continuing Education Quiz This activity was developed by the Ohio Pharmacists Foundation for pharmacists as a knowledge-based learning activity. The Arizona Pharmacy Alliance and OPF are accredited by the Accreditation Council for Pharmacy Education as providers of continuing pharmacy education.

Natural Products: Fumitory, Gamma Linoleic Acid, Garlic and Ginger

6. The German Commission E approves the use of garlic for all of the following EXCEPT: a. hypertension. c. hyperlipidemia. b. arteriosclerosis. d. bronchitis. 7. Commercial garlic products may not contain enough of an important ingredient unless they are standardized to which of the following? a. Allicin c. Chinchona b. Berberine d. Zinzeberis 8. The German Commission E approves the use of ginger for all of the following EXCEPT: a. dyspeptic complaints. c. migraine headaches. b. loss of appetite. d. travel sickness. 9. Two of the constituents of ginger reportedly may act on which of the following types of receptors in the illeum? a. Acetylcholine c. Opioid b. Dopamine d. Serotonin 10. Laboratory tests (but not human clinical trials) have shown that ginger may have all of the following activities EXCEPT: a. exerting positive inotropic effect. b. lowering cholesterol levels. c. inhibiting platelet thromboxane. d. increasing the release of insulin.

1. Which of the following is NOT a synonym for fumitory? a. Ardraka c. Earth smoke b. Beggary d. Wax dolls 2. The German Commission E approves the use of fumitory for which of the following types of complaints? a. Arthritis c. Kidney b. Gallbladder d. Menstrual 3. Dihomo-gamma linoleic acid is a precursor to which of the following series of prostaglandins? a. PGA-2 c. PGE-1 b. PGC-4 d. PGG-3 4. All of the following are reported, but not yet proven, activities of gamma linoleic acid EXCEPT: a. prolonged bleeding time. b. lowered plasma triglyceride levels. c. hastened response to tamoxifen. d. increased LDL cholesterol levels. 5. Topically, garlic is used for treatment of all of the following conditions EXCEPT: a. corns. c. ringworm infections. b. ingrown toenails. d. warts.

Arizona Pharmacy Foundation Natural Products: Fumitory, Gamma Linoleic Acid, Garlic and Ginger

ACPE UAN #0100-0000-10-072-H01-P This activity is accredited for 1.0 hours of CPE credit (CEUs 0.10) 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. exhibit knowledge of the claims, mechanisms of action, and typical dosages for natural products and nutraceuticals presented. 2. select from a list, the synonyms for these products 3. demonstrate an understanding of information that can be used when discussing these products with consumers.

AGREE DISAGREE AGREE DISAGREE

AGREE DISAGREE

Will the information presented cause you to make any changes to your style or method? Yes If you answered “yes” please list one or two things you will do differently: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Overall evaluation of the article content: (please circle one)

Name __________________________________________________________

Activity accredited date 01-01-2011. Expiration date 01-01-2012. Send this page to: APF, 1845 E. Southern Ave., Tempe, AZ 85282

Address ________________________________________________________

Email_________________________________________________________

City, State, Zip ___________________________________________________

No

Poor 1 2 3 4 5 Excellent

Certificates will be mailed within 60 days.

Time Capsule Pharmacy Time Capsules Fourth Quarter 2010 1985 - Twenty-five Years ago:

1935 - Seventy-five Years Ago:

•

•

•

•

•

Prescription revenue in community pharmacies accounted for 62% of total sales. First Pharmacy in the 21st Century held in Millwood, VA. Attendees represented 8 pharmacy associations and 9 manufacturers. While no consensus developed, 3 later P=21 Conferences helped support the move to pharmaceutical care and the acceptance of the PharmD degree. Invitational Conference of Directions for Clinical Practice in Pharmacy (The Hilton Head Conference) focused on the role of clinical pharmacy primarily in the institutional setting. There were 72 accredited colleges of pharmacy in the US (including Puerto Rico)

1960 - Fifty Years Ago: • • • •

109 companies introduced 45 new chemical entities and 98 new dosage forms. In the first large scale use of Sabin oral polio vaccine in the US 180,000 school children were vaccinated. 50% of US hospitals lack the services of registered pharmacists. There were 75 accredited colleges of pharmacy in the US (including Puerto Rico).

Over 18% of community pharmacies were operating at a loss compared to 1932 when 34% were in the red.

1910 - One hundred Years Ago: • •

There was an average of 1500 pharmacy graduates annually. However, not all states required graduation as a prerequisite for licensure. There were 26 colleges of pharmacy represented at the annual meeting of the American Conference of Pharmaceutical Faculties (now the American Association of Colleges of Pharmacy).

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

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Arizona Journal of Pharmacy 41

Financial Forum

FINANCIAL FORUM This series, Financial Forum, is presented by Pro Advantage Services, Inc., a subsidiary of Pharmacists Mutual Insurance Company, and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

DISCOVER THE VALUE OF DOLLAR COST AVERAGING

Whether you’re a novice investor or you’ve been following the market for years, one thing you know is true: the market is constantly changing. The never-ending ups and downs can make it hard to determine when would be a good time to buy. Fortunately, there is an investment strategy that can help compensate for swings in the market and make the decision a little less troublesome for you. A widely recognized investment strategy known as dollar cost averaging offers a systematic approach to investing. By following this plan, you invest a specific dollar amount at set times, regardless of where the market may be at the time. One of the advantages of this strategy is that it can be applied to a wide variety of investment vehicles. As you know, the market price of an investment fluctuates. By using dollar cost averaging, you can buy more shares when the price is low, but you buy fewer shares when the price is high. While that seems fairly elementary, the interesting thing is that by spreading out your investment dollars this way, the average cost you pay per share can actually end up being lower than the average price per share over an extended period. The following example illustrates how this can happen. Let’s say you decide to invest $500 a month in a certain investment on the first of the month, and monitor that plan over a five-month period in the market. For illustrative purposes, we’ll say the market prices at the beginning of each of those months are $10, $8, $6, $5, and $8. Your steady $500 investments would buy you 50 shares the first month, 62 the next, and then 83, 100, and 62 again in the subsequent months. By the end of that five-month period, your total investment of $2,500 will have bought you a total of 357 shares. That amounts to an average cost per share of $7. However, if you take those five prices on your purchase date and divide, the average price per share over that same time period was $7.40. While a mere forty cents per share may not seem like a big difference, your $2,500 investment would only purchase 337 shares at the average price - a full 20 shares short of what you have accumulated through dollar cost averaging.* The key to this long-term investment strategy can be summed up in just one word - constant. You need to 42 Arizona Journal of Pharmacy

remember that you could still lose money if the investment you purchase declines in value, so dollar cost averaging is not a guarantee of profit. However, it can keep you from investing all of your money at one time, perhaps at a higher price. To follow this strategy, you need to consider your ability – both financial and emotional – to stick with the program in both rising and falling markets. Dollar cost averaging helps take the guesswork out of trying to time your investments, allowing you to focus on asset accumulation. As an additional benefit, because you buy more shares when the market is down, you’ll be in a better position for potential gains if the market rebounds. To find out whether this strategy would be appropriate, you need to evaluate your individual situation and your investment objectives. You may find, however, that this is just the right kind of plan to keep you on track and working toward your goals. *This example is for illustrative purposes only and does not reflect the performance of any particular investment.

Provided by courtesy of Pat Reding, CFPTM of Pro Advantage Services Inc., in Algona, Iowa. For more information, please call Pat Reding at 1-800-288-6669. Registered representative of and securities offered through Berthel Fisher & Company Financial Services, Inc. Member NASD & SIPC Pro Advantage Services, Inc./Pharmacists Mutual is independent of Berthel Fisher & Company Financial Services Inc. Berthel Fisher & Company Financial Services, Inc. does not provide legal or tax advice. Before taking any action that would have tax consequences, consult with your tax and legal professionals. This article is for informational purposes only. It is not meant to be a recommendation or solicitation of any securities or market strategy.

Kenneth R. Baker, RPh, JD Legal and Consulting Practice ƒ ƒ ƒ ƒ ƒ ƒ

Pharmacy Law Pharmacy Regulation Risk Management Insurance Pharmacy Quality Programs (CQI) Medication Error Reduction

Phelps Dodge Tower One North Central, Suite 900 Phoenix, AZ 85004 602-307-9900 Main 602-256-3086 Direct 602-307-5853 Fax kbaker@rcdmlaw.com

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Don’t get caught with your pants down!

Do you have a continuous quality improvement program in place or will you be caught ... Pharmacy Quality Commitment® (PQC) is a continuous quality improvement (CQI) program that supports you in responding to issues with provider network contracts, Medicare Part D requirements under federal law, and mandates for CQI programs under state law. When PQC is implemented in your pharmacy, you will immediately improve your ability to assure quality and increase patient safety. Don’t be caught in an audit without a continuous quality improvement program. Errors can injure your patients and put your pharmacy in financial jeopardy.

Call toll free (866) 365-7472 or go to www.pqc.net for more information. PQC is brought to you by your state pharmacy association.