AJP Summer 2022

BOARD OF DIRECTORS 2021–2022

OFFICERS

President Darren Clonts

President Elect Dawn Gerber

Past President Jacob Schwarz

Treasurer Stephanie Spark Secretary Nancy Costlow Director/CEO Kelly Fine

DIRECTORS AT LARGE

Community Pharmacy

Phillip Ieng Health System Pharmacy Christopher Edwards Technician Melinda Browning Directors at Large Reasol Chino Laura Carpenter Erin Epley Kimberly Langley Nina Vadiei

LIAISONS

University of Arizona Student Chapter Raman Kaur Dean’s Designated Representative Nancy Alvarez

Midwestern University Student Chapter David Halterman Dean’s Designated Representative Michael Dietrich

Creighton University Dean’s Designated Representative Jane Stein

LEGAL COUNSEL

Roger Morris

Membership & Volunteer Services Hanna Wooldridge Digital Marketing & Engagement Irma Settle Administrative Services Melina Esquer The interactive digital version of the Arizona Journal of Pharmacy is available for members only online at www.tinyurl.com/azjournal (480) 838-3385 admin@azpharmacy.org EDITOR’S NOTE: Any personal opinions expressed in this magazine are not necessarily those held by the Arizona Pharmacy Association. “Arizona Journal of Pharmacy” (ISSN 1949-0941) is published quarterly by the Pharmacy Network of Arizona at: 1845 E. Southern Avenue, Tempe, AZ 85282-5831.

Dear AzPA Members,

president’s message

Darren Clonts, PharmD, MBA, BCACP

As the Pharmacy Performance Quality Lead at Cigna Medical Group (CMG), Darren Clonts has responsibility for valuebased pharmacy quality across Medicare, Medicaid, and Commercial lines of business. Throughout his career at CMG, he has been involved in the design and implementation of novel clinical pharmacy programs including collaborative practice diabetes management, transition of care services, centralized refill services and quality measure performance. Following graduation from the University of Arizona College of Pharmacy, he received a Master’s in Business Administration from the University of Phoenix School of Business and was certified as a Lean Six Sigma Greenbelt in process improvement. Prior to becoming President of the Association, he served on the Board of Directors as the Managed Care Academy Chair.

As my term as AzPA President comes to an end, I want to thank all of you for allowing me to have this opportunity to serve and give back. I want to thank those who also have dedicated their time in the past or who are currently volunteering their time in the service of our profession. I am so grateful that people are willing to give up their discretionary time to improve our ability as a profession to care for our patients. Our healthcare system needs pharmacy professionals working at the top of their abilities to improve the safe use of medications for all.

Recently I had the opportunity to reflect on an experience that happened early on in my pharmacy career. I had a distressed looking elderly man visit my pharmacy and dump a sack full of medications onto the counter that had fallen out of his pill box. He was confused and did not know what to do and did not have any one at home who could help him. He humbly asked if I could help him sort his medications. I gladly agreed and reorganized his pill box. He thanked me and was truly grateful for the help I gave him. He left and not long after he returned with that same concerned look, but now slightly embarrassed. He again had spilled all of his medications. My heart went out to him and I agreed to help him organize his pill box again.

I know many of you share similar stories of helping others. I like reflecting on this experience because it reminds me why I became a pharmacist in the first place – to help others. Also, it is a reminder of the sheer number of patients out there who need a pharmacy professionals help.

All of us have a “why” I’m a pharmacy professional. I would invite you to reflect on that “why”, and as you do, it will be a motivation and a focus for you each day. I would also invite you to be involved with the profession. We need your help and are working diligently to organize ways for more people to be engaged in promoting our profession.

Thank you for all that you do.

Sincerely, Darren Clonts

Welcome New Members AzPA news

1st Year Practitioner

Courtney Coombe

2nd Year Practitioner

Andrew Vogler

Pharmacist

Zaira Balmaceda

Nicole Christofferson

Jaclyn DeStefano

Nicole Evans

Susan Follis

Kirsten Hayes

Vanthida Huang

William Kennedy

Brian Kopp

Courtney McKinney

Thu Nguyen

Jacob Northrup

Tho Pham

Janet Prom

Hannah Shorb

Brianne Spaeth

Danielle Villa Mary Wagoner

Amy Wilson

Andrew Wirick

Premium Pharmacist

Jovencio Domingo

Patrick “Sean” Duffy

Yvonne Johnson

Mark Labash

Resident

Weiqing Chen

Brittany Cooper Michaela D’Angelo Brenna Darling

Mikali Shedd

Ada Zheng Alice Zheng Retired Don Yeats

Kwong Lun YIM

Student Pharmacist

Amy Aboalam

India Bhatia

Ashley Colby Noemi Cole

Denise Dang David Elias-Campa

Vano Ghaderi Masihi Donya Goharian

Sarena Hamid

Madison Herber

Heather Hotchkiss

Michael Javadi

Marquise Jeffery

Rhianna Miller

Noah Myers

Zinah Oraibi

Vandan Patel

Kishen Rathod

Sharon Ruditser

Robin Skaf

Kinsey Smith

Sherina Smith Mana Tabar Marjan Talle

Yu Tung Tan

Cindy Thai Rebekah Torchon

Jennifer Weiss

Setareh Zakikhani Stephanie Zidar

Technician

Lourva Begay

Sylvia Gomez

Justine Hisel

Michael Machado

Michaelina Peterson Racquel Robertson Nicolas Ruiz

Alberta Tsinnijinnie Carmen Vasquez 

Awards Ceremony

AZPA ANNUAL CONVENTION AWARD RECIPIENTS 2022

DISTINGUISHED YOUNG PHARMACIST OF THE YEAR

Matthew Gotfryd

This award recognizes an Arizona pharmacist who is licensed to practice for 5 years or less, who has demonstrated significant leadership in Arizona pharmacy in the previous year. Contributions can relate to AzPA participation, activities within his/her professional practice, or community service.

EXCELLENCE IN INNOVATION

Christopher Edwards

This award recognizes and honors a pharmacist who has demonstrated significant innovation that directly or indirectly results in improved patient care and/or advancement of the profession of pharmacy.

EXEMPLARY PATIENT CARE

Jing Li

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

PHARMACEUTICAL ASSOCIATE OF THE YEAR

Danielle Gilliam

This award recognizes a pharmaceutical industry representative, who serves Arizona pharmacy, routinely demonstrates a very high level of professionalism, and is committed to improving medication use by supporting their customer’s patient care goals.

STUDENT OF THE YEAR

Ramandeep Kaur

This award recognizes an Arizona PharmD candidate who has demonstrated significant leadership in Arizona pharmacy in the previous year.

RPD/PRECEPTOR OF THE YEAR

Brian Kopp

This award recognizes a Residency Program Director/ Preceptor who has actively demonstrated outstanding leadership qualities and has a history of significant contributions to residency training in the role of preceptor and mentor.

TECHNICIAN OF THE YEAR

Michaelina Peterson

This award recognizes an Arizona pharmacy technician who has excelled in the field of pharmacy and has demonstrated a high level of service and professionalism in pharmacy during the previous year.

PHARMACIST OF THE YEAR

Tenille Davis

This award honors an Arizona pharmacist who has actively demonstrated outstanding leadership and service for AzPA or for the profession of pharmacy in Arizona during the previous year.

HALL OF FAME

This award is given to a member of AzPA with at least 10 years of practice experience in Arizona who has demonstrated innovation or excellence in practice, education, or research. This person is an Arizona pharmacy pioneer who has been instrumental in advancing the profession of pharmacy by promoting the importance of innovation and integrity in the field.

ELIAS SCHLOSSBERG

Ed Stein

This award is the highest level of recognition for an Arizona pharmacist who has made significant contributions to health system pharmacy in the form of sustained exemplary lifetime service that reflects positively on the profession of pharmacy.

BOWL OF HYGEIA

This award is the highest level of recognition provided to an Arizona pharmacist who has compiled an outstanding record of community service. This service, which apart from his/her specific identification as a pharmacist, should reflect well on the profession.

Michael Dietrich

Joe Leyba Ysenia Rios

Ron Woodbeck

John Saliba

FELLOWS PHARMACY APPRECIATION

Awarding Fellowship in the Arizona Pharmacy Association fosters and rewards demonstrated excellence in pharmacy through outstanding service to the profession and sustained involvement in AzPA.

CORPORATE APPRECIATION

This award is given to a corporation or business who serves Arizona pharmacy, routinely demonstrates a very high level of professionalism, and is committed to improving the profession of pharmacy by supporting AzPA in a significant way.

This award is given to an individual who has demonstrated very special or unique interest and concern for the advancement of Arizona pharmacy, as reflected by dedicating significant personal time and effort in completion of one or more special activities or services for AzPA and/or the profession of pharmacy.

Jessica DiLeo

Melinda Browning

Senator Pace

Brianne Spaeth

Nicole Early

Eman Kirolos

Senator Shope

Maura Jones

The AzPA Board of Directors consists of Officers and Directors that are elected by the membership. These dedicated volunteers are committed to ensuring you have a voice in the matters that impact your profession.

President Dawn Gerber President-Elect Kimberly Langley

Immediate Past President Darren Clonts

Treasurer Jacob Schwarz Secretary Nancy Costlow CEO Kelly Fine

Roger Morris, RPh, JD

Student Liaison University of Phoenix

Jose Espinoza

Student Liaison Midwestern University Lyndy Abdelsayed

Student Liaison Creighton University Sharon Ruditser

V I R T U A L S E S S I O N S I N C L U D E :

O p i o i d U p d a t e

I m m u n i z a t i o n U p d a t e

P h a r m a c y L a w P a t i e n t S a f e t y T o b a c c o C e s s a t i o n M o r e d e t a i l s c o m i n g s o o n

C a n ' t a t t e n d l i v e ? N o w o r r i e s ! A l l s e s s i o n s w i l l b e r e c o r d e d .

Arizona State Board of Pharmacy Update editorial advocacy

Board Members

Joseph Leyba, RPh, President

Lorri Walmsley RPh, Vice President

Cedar Lahann, PharmD, RPh, Member

Ted Tong, PharmD, RPh, Member

Kevin Dang, PharmD, RPh, Member

Mohammad (Mo) Salari, RPh, Member

Kristen Snair, CPhT, Member

Frank Thorwald, Member (Public)

Randy Schoch, Member (Public)

The Board Is on Facebook

Follow the Arizona State Board of Pharmacy for the latest news and updates at https:// www.facebook.com/Arizona-State-Board-ofPharmacy-396869467321193

Update Your Profile

In an effort to communicate more effectively with its licensees and permittees, the Board noticed that contact information in its system is not always current and up to date. You are required to update your personal contact information and pharmacy employer within 10 days after a change pursuant to Arizona Revised Statutes (A.R.S.) §32-1926. Please use your online profile to update your contact information.

License Processing Time

The Board continues to receive applications that are incomplete. The main items missing include:

1. Fingerprint clearance cards. Prior to applying with the Board, please have your fingerprint clearance card ready to upload with your application. Submitting your Board application and then submitting your fingerprint clearance card at a different time will delay your application from being processed.

2. Proof of authorized presence in the United States under federal law (See A.R.S. §411080). For example, a driver’s license, a nonoperator ID issued by a state located in the US, or other documentation that verifies lawful presence. The following states do not verify lawful presence when issuing a driver’s license or a non-operator ID: California, Colorado,

Connecticut, Delaware, District of Columbia, Hawaii, Illinois, Maryland, Nevada, New Jersey, New Mexico, New York, Oregon, Utah, Vermont, and Washington. If your driver’s license is from a state listed above, you will have to submit another form of identification showing lawful presence in the US.

3. If you have encountered legal issues and were charged, regardless of the outcome, you must provide a police report and court records, if applicable.

For pharmacist application: The Board has been authorized to release your test for your examination(s) prior to the Board reviewing your application. When you pass the examination(s), your license will be issued only after your application and all the supportive documents have been provided and appropriately reviewed. If your application is incomplete, or your appearance is needed before the Board, your license will not be issued until those matters are resolved and Board staff has approval to issue your license. Board staff is encouraged that this new process will speed up the licensing process by several weeks.

Disciplinary Actions and Updates Health Boards Disciplinary actions for the Arizona State Board of Pharmacy, Arizona Medical Board, Arizona Naturopathic Physicians Medical Board, Arizona Board of Osteopathic Examiners, and Arizona Regulatory Board of Physician Assistants can be found at https://pharmacy.az.gov/ quarterly-updates

Upcoming Board Meetings

• Complaint Review: August 2, 2022 - 8:30am

• Board Meeting: August 10, 2022 - 8:30am

• Board Meeting: August 11, 2022 - 8:30am

• Complaint Review: September 27, 2022 - 8:30am

• Board Meeting: October 5, 2022 - 8:30am

• Board Meeting: October 6, 2022 - 8:30am

• Complaint Review: November 29, 2022 - 8:30am

• Board Meeting: December 7, 2022 - 8:30am

• Board Meeting: December 8, 2022 - 8:30am

editorial preceptor corner

This article was previously published in the Wisconsin Journal of Pharmacy and is reprinted with permission from the original publisher and authors.

The Mindful Preceptor: Tips for Incorporating Well-being and Mindfulness into Pharmacy

Rotations

Beth Buckley, PharmD, CDCES Concordia University Wisconsin School of Pharmacy

Rachele Harrison, PharmD Medical College of Wisconsin School of Pharmacy

Mathew Letizia, PharmD

Medical College of Wisconsin School of Pharmacy

Disclosure

The author(s) declare no real or potential conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honorarium.

Funding

This research was not funded.

As stress, burnout, and mental health issues appear to be on the rise in the United States, efforts to improve wellness have increased. The alarming rates of burnout in healthcare professionals of all settings have been shown to have serious, wide-ranging consequences that range from reduced job performance to medical error and clinician suicide.1 As a possible intervention strategy to reduce perceived stress and decrease the risk of burnout in healthcare workers, including pharmacists, mindfulness training has received recent attention.2

What is mindfulness?

Given our current climate, the ability to pause, breathe, and self-reflect amid peripheral noise is more important than ever before. Developing the skills to achieve this can be obtained through the practice of mindfulness. According to mindful.org, mindfulness is “the basic human ability to be fully present, aware of where we are and what we’re doing, and not overly reactive or overwhelmed by what’s going on around us.” We all possess the ability to be mindful; we just have to learn how to access that part of ourselves.3 As we learn to get into this present state of mind, we feel better, think more clearly, and appreciate more about our daily lives. Mindfulness has been practiced for centuries, with a more recent mainstream acceptance as many have searched for new coping skills to deal with these long years of pandemic changes, uncertainty, and changing home and work lives. The purpose of this article is to describe the advantages of mindfulness-based practices and provide ideas for how preceptors can incorporate mindfulness into pharmacy rotations.

The Advantages of Mindfulness:

Mindfulness has over three decades of evidencebased research helping people to shift their focus to the present and deal more effectively with anxiety, stress, and the demands of everyday life.4,5 Studies conducted to examine the impact of mindfulness-based training on healthcare professionals, and trainees have provided strong evidence to support the efficacy of mindfulness practice to reduce job burnout, perceived stress, depression, and promote resilience in healthcare professionals.2,6,7 The mountain of evidence behind the value of mindfulness continues to grow, with

exponentially positive results within the studies of this decade.8

The 2019 National Consensus Conference brought together several national pharmacy associations to evaluate factors that contribute to well-being and develop strategies to fuel improvements in resilience.1 Based on recommendations from this conference, pharmacy students at the Medical College of Wisconsin (MCW, since 2020) and Concordia University Wisconsin (CUW, since 2018) are familiar with these practices, as the first year Patient Skills Labs at both schools include a weekly practice with reflection. Survey results from the first two years of this incorporation into the skills laboratory curricula were impressive. The results affirmed that students were receptive to the incorporation of mindfulness techniques. Student responses revealed that mindfulness creates a positive and engaging culture; helps professors build warm, empathetic, and trusting relationships with students; and provides students with valuable resources to aid in their resiliency and well-being. After learning mindfulness practices, students from both schools reported a plan to use some type of mindfulness tool when working with patients in their future practice, with common themes of breathing exercises, active listening, mindfulness of thought, and the use of empathy and self-compassion. For these reasons, we believe that pharmacy preceptors should be aware of these remarkable skills that students have learned and are currently practicing in both their professional and personal lives. Pharmacy preceptors now have the opportunity to also embed mindfulness techniques into their rotations to nurture positive and engaging relationships with their students and help to keep the focus on patient-centered care.

Overcoming Barriers:

Precepting, in addition to the responsibilities of clinical practice, can be labor intensive. Additionally, the thought of embedding yet another activity into a learner’s rotation can seem intimidating. Fortunately, the process of integrating mindfulness into a learner’s daily regimen is easier than anticipated. Most mindfulness techniques, such as the practice of gratitude, guided deep-breathing, or selfreflection, take only a few minutes and can have a valuable impact on mindset. Although the type

and duration of activity may vary, data shows that even short duration interventions elicit positive outcomes related to stress and anxiety levels.8

If you are not already using these skills, the foreign nature and fear of leading these activities can seem daunting. However, comfortability and confidence with mindfulness develops with practice, and these negative feelings quickly diminish. Moreover, many students are already aware of these techniques and have developed these skills. The reinforcement of mindfulness practice throughout their rotations would allow learners to transform their skills into proven abilities as they engage in patient-centered care. Keep in mind that leading these skills does not require you to be an expert. And, there are many ways to practice mindfulness. If you are not comfortable taking the lead to initiate these tools, there are many evidencebased meditation apps that can be used for your own practice, with your family, your patients, and students (Tables 1-3).

Incorporating Mindfulness:

To incorporate mental health and well-being into rotations, look for natural places where a pause can give the preceptor and learner a chance to connect, ground, re-center, and set a mindset for being fully present in the moment. The most common place to take a needed pause for reflection is before or after an encounter, or at the beginning or end of the day.

A few potential times of day with specific examples are outlined here (see Table 1 for specific activity resources):

1. Start of the workday: As you outline the flow and objectives for the day, consider setting an intention. An intention is “a determination to act in a certain way”9 or “a purposeful awareness of how you want to experience something: how you want to act and feel.”10 The intention can be for yourself or can include the learner. It can be something simple, like using the Maui Habit to establish that “it’s going to be a great day.”11 It can also be more involved such as taking some breaths, connecting with how you are feeling, and then setting an intention for the day’s focus. This is not a goal with an outcome but instead allows the individual to set the tone for the day. For example: “This morning is going to be busy; let’s take it one patient at a time, with a smile on our face and an open, patient-centered heart.”

2. Lunchtime: This is a great time to purposefully promote and role-model the importance of breaks to rejuvenate ourselves and build energy and resiliency. An example would be to use the mindful acronym P.R.O.: both you and the student sit down together to practice Pause, Relax your body, and be Open to what matters most in the moment. Another example would be to practice mindful eating. This is simply savoring your food by noticing the smell, the complexity of taste, and taking a moment of gratitude for all the work it took to get this nourishment from seed to your plate. After eating, a refreshing walk with mindful awareness of the beauty around us (even better if you can go outside) is another way to relieve unnecessary tension from your mind and body.

3. End of the Day: Preceptors know how much an end of day debrief can enhance learners’ insight and solidify unsure concepts. Mindful reflection questions can be added to this interaction. For example, consider using G.L.A.D. to address learning, build gratitude, and enhance resiliency through the development of positive mindfulness with less bias and judgment. When the intention is to practice GLAD at the end of the day, your brain searches for these positive moments to remember for later.

G = GRATITUDE

What are you grateful for today?

L= LEARNING

What was the most profound/interesting/ surprising thing you learned today?

A = ACCOMPLISHMENT

What did you accomplish today?

D= DELIGHT

What brought you a sense of delight today?

4. Preparation for communication: Before entering a room for a patient encounter, preparing to talk with another health care professional, or answering the phone, a simple pause to connect with the breath can be encouraged. For example, S.T.O.P.: “Stop, Take a few deep breaths, Observe your thoughts, emotions, body, then Proceed with awareness.”

5. To de-escalate stressful moments: When you have an overwhelmed learner or patient, one of the easiest ways to engage mindfulness is to focus on the breath. For example, diaphragmatic breathing or “belly breathing” involves taking slow, deep inhalations, followed by an extended exhalation.12 This is a recommended technique to help with shortness of breath from COPD and asthma. It stimulates the vagus nerve and enables the

Table 1: Resources for Suggested Activities

Activity Name

parasympathetic nervous system to affect a state of calm in the body.13 Other examples include “breath micropractice” (take 3 deep, intentional and attentive breaths), “counting breaths” (breathe naturally and count one for breath in, two for breath out, up to the count of 10), or “square/box breathing” (breath in for count of 4, hold or count of 4, breath out for count of 4, hold for count of 4, and repeat for 1 minute).

Timing: Duration Resources

The Maui Habit 10 seconds

Book: BJ Fogg. Tiny Habits: the small changes that change everything. Thorndike Press. May 2020.

You tube: https://www.youtube.com/ watch?v=2L1R7OtJhWs&t=420s

PRO: Pause, Relax, Open to what matters in this moment 10 seconds https://elishagoldstein.com/less-stress/

Mindful Eating Varies https://www.mindful.org/6-ways-practicemindful-eating/

Mindful Walking ~ 10 minutes

G.L.A.D. Technique, or G.L.A.D. Daily Snapshot practice ~ 5 minutes

https://ggia.berkeley.edu/practice/walking_ meditation

https://www.psychologytoday.com/us/blog/ practical-mindfulness/201908/get-glad-andscrub-away-rumination-and-anxiety

Breath Micropractice: Stop and take 3 deep, intentional breaths < 30 seconds https://siyli.org/resources/category/guidedmeditations/

Video: https://elishagoldstein.com/videos/thestop-practice/

STOP: Stop, Take a breath, Observe, Proceed ~ 2 minutes

Mindful breathing: Many techniques available: square/box breathing, body scans, guided imagery

~ 1 minute

Diaphragmatic Breathing ~ 2 minutes

5-4-3-2-1 Coping Technique for Anxiety < 5 minutes

Source: https://elishagoldstein.com/audio/ mindful-solutions-for-success-and-stressreduction-at-work/

http://www.freemindfulness.org/download https://www.anahana.com/wellness-blog/ breathing/square-breathing

https://www.lung.org/lung-health-diseases/ lung-disease-lookup/copd/patient-resourcesand-videos/belly-breathing-video

https://www.urmc.rochester.edu/behavioralhealth-partners/bhp-blog/april-2018/5-4-3-2-1coping-technique-for-anxiety.aspx

Table 2: Suggested Apps

App Name WHY the authors love and recommend

The Mindfulness App

Headspace

Insight Timer

Beginners: 5 day guided practice and introduction to mindfulness. Various meditations with different timings available.

Beginners: 10 day basics course with animations. Easy to use courses based on user needs. Available on app and website. See Netflix series for more information.

The largest variety of free guided meditations for a wide range of experiences. Constantly adding new resources - daily habits, discussion groups, learning series.

Smiling Mind

CALM

Healthy Minds Program

Completely free (no in-app purchases). Developed as a school program in Australia, then expanded to include a wide breadth of exercises on both the app and website. Organized by groups: Adults, Kids, Youth, Families, Classroom, Work, Healthcare. Includes “bite size” meditations.

Includes a large variety of calming exercises, breathing techniques, and a Calm Kids section with options for sleep, music, scenes, and relaxing sounds.

Beginners: 5 part Foundations course with self-assessment for awareness, connection, insight, and purpose. UW Madison developed and evidence based. Easy to follow “learn” and “practice” sessions.

Table 3: Suggested Websites

Website Name Resources

Mindful.org

https://www.mindful.org/ meditation/mindfulnessgetting-started/

Mindfulness Exercises. com https://mindfulnessexercises. com/mindfulness-exercisesfor-beginners/

National Academy of Medicine: The Clinician Well-being Knowledge Hub

UW Madison Center for Healthy Minds

https://nam.edu/ clinicianwellbeing/solutions/ individual-strategies/

https://centerhealthyminds. org/

Berkeley Greater Good in Action https://ggia.berkeley.edu/

AACP Wellness and Resiliency in Pharmacy Education

https://www.aacp.org/ resource/wellness-andresilience-pharmacy-education

American Mindfulness Research Association https://goamra.org/

Action for Happiness

https://www. actionforhappiness.org/

APhA Well-being index https://app.mywellbeingindex. org/login?id=60

The Free Mindfulness Project

https://www.freemindfulness. org/download

WHY the authors love and recommend

An excellent place to start and then to expand learning: filled with resources and practices

A variety of exercises for beginners - can choose by topic

Includes resources and publications specifically related to health care clinicians

A great resource for the science behind wellbeing and the current research in Wisconsin

A large variety of practices in addition to a monthly “happiness calendar” with daily ideas for creating joy

Excellent supportive resource to incorporate well-being into academia

A professional resource with current, evidence based research on mindfulness and its applications

Programs and actionable suggestions to create a happier and kinder world

Free resource for pharmacists to assess current levels of well-being, and then utilize resources to improve

Free to download mindfulness meditation exercises

6. Direct patient care: In addition to helping our COPD and asthma patients, mindful breathing can be an essential tool to teach our patients to overcome stress and anxiety as they face difficult challenges. Mindful breathing can also be helpful for patients making positive, yet difficult, lifestyle changes such as smoking cessation and weight loss. Another technique to use is focusing on the senses for grounding and to decrease anxiety in the moment. The 5-4-3-2-1 Coping Technique includes acknowledging: ○ 5 things you can see ○ 4 things you can touch

3 things you can hear

2 things you can smell ○ 1 thing you can taste

To help sort through the abundance of valuable resources to explore, Tables 1, 2, and 3 provide the authors’ favorite resources to explore mindfulness.

7. Anytime: Explore the apps, and then use it to lead you through a short (from 1 to 5 minute) practice based on what you are feeling or needing. This is an excellent way to learn the practices, get comfortable with the thought process, and find go-to meditations that work for you. Suggested times to listen to an app guided meditation include: in the morning while waiting for coffee to brew, while eating, during your commute, during breaks/downtime/any time you want to center yourself and learn something new. The app practices can be used to connect with family by listening to a practice and then discussing it: after school/work, dinner time, bedtime. If you are a beginner, Headspace, Healthy Minds, and Smiling mind all have beginner foundation curriculum. Table 2 includes free apps with descriptions of their basic functions. Choose one and get started! In addition, Table 3 provides some of the authors’ favorite website to further explore mindfulness.

Conclusion:

Mindfulness is a practice that helps us learn to pay attention and be present in our lives. Though it cannot eliminate life's stresses, it has been shown to improve the well-being of healthcare professionals, including pharmacists and pharmacy students. Therefore, it would be advantageous for preceptors to embrace

mindfulness as a tool for themselves and to coach learners on how to use mindfulness throughout the workday to stay centered and provide quality patient care. Preceptors can consider integrating mindfulness into their rotations through specific activities or consider adapting their precepting style to include mindful elements to reduce perceived stress, decrease the risk of burnout, and build resiliency in our future pharmacists. 

REFERENCES

1. Action Collaborative on Clinician Resilience and WellBeing. National Academy of Medicine. https://nam.edu/ initiatives/clinician-resilience-and-well-being/. Accessed February 14, 2021.

2. Luken M, Sammons A. Systematic Review of Mindfulness Practice for Reducing Job Burnout. American Journal of Occupational Therapy. 2016;70(2). doi:10.5014/ ajot.2016.016956

3. Jaret P, Pal P, Zuo M, Calechman S, Willard C, Domet S, Goldstein E, Gerszberg C. What is mindfulness? https:// www.mindful.org/what-is-mindfulness/. Published July 2020. Accessed February 14, 2021.

4. Kabat-Zinn J. The original, Jon Kabat-Zinn, M.B.S.R. Training Program. Mindfulness Based Stress Reduction. https:// mbsrtraining.com. Updated December 9, 2020. Accessed December 9, 2020.

5. Potter D. Online Mindfulness-Based Stress Reduction (MBSR). Palouse Mindfulness. https://palousemindfulness. com/index.html. Updated December 9, 2020. Accessed December 9, 2020.

6. Kinser P, Braun S, Deeb G, Carrico C, Dow A. "Awareness is the first step": An interprofessional course on mindfulness & mindful-movement for healthcare professionals and students. Complement Ther Clin Pract. 2016;25:18-25. doi:10.1016/j.ctcp.2016.08.003

7. Lomas T, Medina JC, Ivtzan I, Rupprecht S, Hart R, EiroaOrosa FJ. The impact of mindfulness on well-being and performance in the workplace: an inclusive systematic review of the empirical literature. European Journal of Work and Organizational Psychology. 2017;26(4):492-513. doi:10 .1080/1359432x.2017.1308924

8. American Mindfulness Research Association. https:// goamra.org/. Accessed October 1, 2020.

9. Definition of Intention. Merriam-Webster. https://www. merriam-webster.com/dictionary/intention. Accessed February 14, 2021.

10. Morley G. How to Set Intentions & Why I Like Intentions More Than Goals. Georgie Morley: personal growth & accessible self-care. http://georgiemorley.com/how-to-setintention/. Published January 2, 2020. Accessed February 14, 2021.

11. Fogg BJ. Tiny Habits: the small changes that change everything. Thorndike Press. May 2020.

12. Belly Breathing. American Lung Association. https:// www.lung.org/lung-health-diseases/lung-disease-lookup/ copd/patient-resources-and-videos/belly-breathing-video Accessed February 20, 2021.

13. Gerritsen RJS, Band GPH. Breath of Life: The Respiratory Vagal Stimulation Model of Contemplative Activity. Front Hum Neurosci. 2018;12:397. Published 2018 Oct 9. doi:10.3389/fnhum.2018.00397

Continuing Education Information:

Target Audience: Pharmacists

Activity Type: Knowledge-Based

Learning Objectives:

1. Describe the current recommendations regarding the use of aspirin for primary prevention of cardiovascular disease.

2. Analyze the findings of recent clinical trials that studied the use of aspirin for primary prevention of cardiovascular disease.

3. Discuss patient specific recommendations regarding the use of aspirin for primary prevention of cardiovascular disease.

Aspirin Therapy for Primary Prevention of Cardiovascular Disease

Elizabeth K. Pogge, Pharm.D., MPH, BCPS-AQ Cardiology, BCGP, FASCP, FAzPA, Professor

Desiree Smith, PharmD Candidate 2022, Midwestern University College of Pharmacy - Glendale Campus

Andy Lo, PharmD Candidate 2022, Midwestern University College of Pharmacy - Glendale Campus

Adrian Salazar, PharmD Candidate 2022, Midwestern University College of Pharmacy - Glendale Campus

Tony Huang, PharmD Candidate 2022, Midwestern University College of Pharmacy - Glendale Campus

Acknowledgement

None

Funding

This research was not funded.

Conflict of Interest

The authors declare that there are no conflicts of interest.

Abstract

Cardiovascular disease is the leading cause of death in the United States. Two common causes of cardiovascular death are strokes and ischemic heart disease. As such, the prevention of these events from occurring has received a lot of focus. This brings attention to one of the oldest drugs in the pharmacy arsenal, aspirin. This pharmacologic agent works by inhibiting platelet activation and decreasing the risk of clot formation, while at the same time increasing the risk of bleeding.

Summary of articles: Routine use of aspirin for the primary prevention of cardiovascular disease has been debated after three large randomized, controlled trials were published. These trials concluded that aspirin for the primary prevention of cardiovascular disease in patients with a low to moderate ASCVD risk score provided minimal efficacy while increasing the risk of bleeding. The results of these trials were quick to be implementing into several guidelines that recommended against the routine use of aspirin for primary prevention of cardiovascular disease especially in patients at an increased risk of bleeding or > 70 years of age. This new data prompts shared decision making to occur between the patient and the provider when considering aspirin for the primary prevention of cardiovascular disease.

Summary: Pharmacists can be an integral part of the interprofessional team by providing patient education and counseling related to aspirin use. Furthermore, pharmacists can educate providers and the public about the evolving role of aspirin for primary prevention of cardiovascular disease.

Introduction

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality globally.1 According to the American Heart Association (AHA), the two most common cardiovascular-related deaths are ischemic heart disease (IHD) and stroke, followed by high blood pressure and heart failure.2 Modifiable risk factors leading up to these events are smoking, physical inactivity, nutrition, overweight/ obesity, elevated cholesterol, diabetes mellitus, and high blood pressure.1 As such, the 2019 American College of Cardiology (ACC)/AHA guidelines strongly recommend (Class I) primary prevention interventions through lifestyle modifications such as exercise, healthy diet, and smoking cessation.1 In addition to lifestyle changes, pharmacotherapy to reduce other modifiable risk factors such as blood pressure and cholesterol is strongly recommended for those at high risk.1 For the first time in decades, these guidelines recommend aspirin should be used infrequently in the routine primary prevention of ASCVD.

Acetylsalicylic acid or aspirin was produced in 1897 by German Chemist Felix Hoffman as an analgesic extracted from the willow bark tree.3 Aspirin is commonly used for fever, inflammation, and pain at higher doses; however, its use is limited due to gastric side effects.4 Aspirin works by irreversibly inhibiting two isoforms of the COX enzyme. COX-1 is responsible for TXA2 production causing platelet aggregation in the arterioles. COX-2 promotes vasodilation through the up-regulation of prostaglandins. By inhibiting TXA2, aspirin inhibits platelet activation that decreases the risk of clot formation, however, increases the risk of bleeding. Aspirin use for primary prevention of cardiovascular disease is common practice among adults. The 2017 National Health Interview Survey (NHIS) found that 29 million (23.4%) United States (US) adults without cardiovascular disease over the age of 40 reported taking daily aspirin and 6.6 million (22.8%) started aspirin without a physician recommendation.5 When looking at older adults specifically, this survey found that 46.2% of adults without cardiovascular disease 70 years or older reported using aspirin.5 While aspirin use for secondary prevention of ASCVD is consistently recommended, data on primary prevention continues to evolve.6 The 2019 ACC/ AHA primary prevention guidelines mentioned above provide several new recommendations regarding aspirin for primary prevention.1 These guidelines suggest that low-dose aspirin might be reasonable (Class IIb, LOE: A) in adults 40 – 70 years of age with a higher ASCVD risk who are not at an increased risk of bleeding. Furthermore, they recommend against (Class III: harm) the routine use of low-dose aspirin for primary prevention among adults > 70 years of age or any adult who is at an increased risk of bleeding. Furthermore, the US Prevention Services Task Force is in the process of updating their recommendation regarding aspirin for primary prevention.7-8 The current draft states that adults who are 60 years or older should not be initiated on low-dose aspirin for primary prevention and adults 40 to 59 years with a 10% or greater 10-year ASCVD risk may be considered for low-dose

aspirin on an individualized basis.7 This represents a shift in thinking surrounding the use of aspirin for primary prevention of ASCVD, with recent evidence pointing to a lack of benefit with routine use. The purpose of this article is to review several recently published trials that have laid the foundation for this change in aspirin recommendation and provide suggestions to pharmacists regarding counseling related to aspirin use for primary prevention.

Clinical Trial Summaries

Three large randomized, controlled trials, ARRIVE, ASCEND, and ASPREE trial are responsible for many of the changes we are seeing in the guidelines regarding aspirin for primary prevention.9-12 A summary of these three trials can be found in Table 1.

All three of these trials are a strong study design, randomized, double-blind, placebo-controlled,

Table 1 – Comparison of Aspirin Primary Prevention Trials

Male: 44%

Median age: 74 years

Male: 71%

Male: 63%

Baseline Characteristics

Primary Outcome

White race: 95% Current smoker: 4% HTN:** 74% Statin use: 34% Type 2 diabetes: 11%

Primary endpoint: Death from any cause, dementia, and persistent physical disabilities9

Secondary endpoint: Cardiovascular disease (defined as fatal coronary heart disease, nonfatal MI, fatal or nonfatal stroke, or hospitalization for heart failure)

Safety endpoint: Major hemorrhage

Mean age: 64 years White race: 98% Current smoker: 29% HTN:** 65% Statin use: Not reported Type 2 diabetes: 0%

Primary endpoint: Composite of time to first occurrence of cardiovascular death, MI, unstable angina, stroke, or TIA

Safety endpoint: Hemorrhagic events

Protocol Intention-to-treat

Median follow-up 4.7 years

Primary endpoint: HR 1.01 (0.92 - 1.11)9

Median follow-up 5 years

Primary endpoint: HR 0.96 (95% CI 0.81-1.13)

Results

Secondary endpoint: HR 0.95 (95% CI 0.83-1.08)10

Safety endpoint: HR 1.38 (95% CI 1.18-1.62)*

Safety endpoint: Gastrointestinal bleeding HR 2.11 (95% CI 1.36-3.28)*

Mean age: 63 years White race: 97% Current smoker: 8% HTN:** 62% Statin use: 75% Type 2 diabetes: 94%

Primary endpoint: Time to first serious vascular event (composite including non-fatal MI, non-fatal stroke, TIA, or death from any vascular cause)

Safety endpoint: First occurrence of any major bleeding event

Median follow-up 7.4 years

Primary endpoint: RR 0.88 (95% CI 0.79-0.97)*

Safety endpoint: RR 1.29 (95% CI 1.09-1.52)*

Abbreviations: ASCEND = A Study of Cardiovascular Events in Diabetes ASPREE = Aspirin in Reducing Events in Elderly, ARRIVE = Aspirin to Reduce Risk of Initial Vascular Event, ASCVD = atherosclerotic cardiovascular disease, CI = confidence interval, CVD=cardiovascular disease, HTN= hypertension, HR = hazard ratio, MI= myocardial infarction, RR = rate ratio, TIA = transient ischemic attack

* Statistical significance

**Hypertension was defined differently between the three trials. ASPREE included those taking an anti-hypertensive agent or blood pressure >140/90 mmHg, ARRIVE included those taking an anti-hypertensive, and ASCEND included those with self-reported hypertension.

multinational trials, looking at aspirin enteric-coated 100mg daily versus placebo. Each trial included a low number of participants in the US, which could limit the applicability of these studies to US patients. Each trial was conducted to evaluate the benefits and risks of aspirin in primary prevention so patients with baseline cardiovascular disease were excluded. Baseline characteristics between the two groups were similar in each study. Each study did an intention-to-treat analysis, with the ARRIVE trial also including a per-protocol analysis.11 The statistics in this paper will include just the intention-to-treat analysis as this data is generally considered more applicable to real life clinical practice. Each study is summarized below with important take home points.

The ASPREE trial included adults ≥ 70 years old and White or ≥ 65 years old if Black or Hispanic.10 Participants were excluded if they had dementia, a disability, or were at a high risk for bleeding. For Black and Hispanic individuals, they used a lower age due to the higher risk of cardiovascular disease seen in these ethnicities. At baseline, 30% of participants were obese (body-mass index (BMI) > 30 kg/m2), 70% had 2 or more cardiovascular risk factors, and 11% had previously used regular aspirin. This trial was multicenter and included 34 sites in the US and 16 in Australia, most participants being Australian (87%). It is important to note that the primary outcome of this study was the composite of death, dementia, or persistent physical disability, while the secondary outcomes were cardiovascular and bleeding. The primary outcome was not statistically significant, with a limitation related to this outcome being the follow-up of only approximately five years. This paper focuses on the secondary outcomes, with there being no significant benefit for the use of aspirin for primary prevention of cardiovascular disease (defined as fatal coronary heart disease, nonfatal myocardial infarction (MI), fatal or nonfatal stroke, or death or hospitalization for heart failure), with a statistically significant 38% increased risk of major hemorrhage (defined as hemorrhagic stroke, symptomatic intracranial bleeding, or clinically significant extracranial bleeding). These results were consistent when looking at each endpoint of the cardiovascular outcome, with no benefit for the use of aspirin seen in any subgroup. In terms of major hemorrhaging, any intracranial bleeding and upper gastrointestinal bleeding were both increased with the use of aspirin, while fatal bleeding was not statistically significantly different between the two groups. Several limitations to this trial were noted by the authors. The trial had a low adherence rate, with only two-thirds of the participants still taking the assigned intervention at the end of the trial, which could have led to an underestimation of any benefit seen with aspirin. Furthermore, since only

a small number of participants were taking aspirin prior to the trial, the results cannot give guidance on continuing or discontinuing healthy elderly individuals who have been taking aspirin for primary prevention.

The ARRIVE trial studied men ≥ 55 years with two to four risk factors for cardiovascular disease and women ≥ 60 years with 3 or more risk factors.11 At baseline, the mean estimated ACC/ AHA 10-year ASCVD risk score was moderate for these participants at 17.3%. The median BMI of participants was 28 kg/m2, with 58% of participants having high total cholesterol (defined as ≥ 200 mg/ dL). Patients were excluded if they were at high risk of bleeding or had comorbid diabetes. This study was multicenter, with 90% of patients from Germany, Poland, and the United Kingdom, and only 4% from the US. The primary composite outcome of the first occurrence of MI, cardiovascular death, unstable angina, stroke, or transient ischemic attack (TIA) was not statistically significant between the aspirin and placebo group at a median follow-up of five years. These results were consistent when looking at each endpoint of the cardiovascular outcome, with no benefit for the use of aspirin seen in any subgroup. In the safety analysis, gastrointestinal bleeding was significantly higher in the aspirin group (0.97% vs 0.46%; p = 0.0007) with total serious adverse events not differing between the two groups. One limitation to this study was the low overall incidence of gastrointestinal bleeding as well as cardiovascular events. These lower event rates show some of the challenges with doing primary prevention studies, including differences in other primary prevention measures among providers, low compliance among participants, as well as difficulty in capturing events in a primary care clinic which could underestimate the actual event rate.

The ASCEND trial included 15,480 participants, ≥ 40-year-old, from the United Kingdom with diabetes and without baseline cardiovascular disease.12 They excluded patients with a contraindication to aspirin. At baseline, 47% of participants were obese (BMI > 30 kg/m2), 35% were using regular aspirin before screening, and the median duration of diabetes among participants was seven years. The primary efficacy endpoint was the time to first serious vascular event, a composite of non-fatal MI, non-fatal stroke, TIA, or death. The primary safety endpoint was the first occurrence of any major bleeding event, defined as intracranial hemorrhage, sight-threating bleeding in the eye, gastrointestinal bleeding, or any other serious bleeding that resulted in hospitalization, transfusion, or death. Over a mean follow-up of 7.4 years, there was a 12% lower risk of serious vascular event in

the aspirin group compared to placebo, but also a statistically significant 29% increased risk of major bleeding. The majority of first major bleeding events included gastrointestinal bleeding followed by sight threatening bleeding events in the eye and intracranial bleeding events. ASCEND was unique in the fact that recruitment, treatments, and follow ups were all done by mail, which allowed this trial to have almost complete follow-up with all patients randomized. Limitations included low adherence to aspirin in the treatment group (70%) which decreased over time while the placebo group had an increase in use of aspirin during the study which could have led to an underestimation of aspirin effectiveness.

Clinical Implications

The risk and benefits of taking aspirin for primary prevention is a duality that needs to be assessed on an individualized basis. When summarizing these three recent trials, aspirin provided a benefit in decreasing serious vascular events (vascular death, non-fatal MI, non-fatal strokes, and TIA) in diabetic men and women at least 40 years of age but did so at the expensive of increased bleeding risk.12 For adults > 70 years of age or those at moderate cardiovascular risk without diabetes, aspirin was not able to reduce cardiovascular events and consistently showed higher rates of bleeding.10 It is important to note that during all three of these trials, the cardiovascular endpoint occurred less commonly

than was expected. One theory as to why this occurred is related to the increased use of other effective primary prevention strategies, most notability statins, antihypertensives, and anti-diabetic agents. With more effective primary prevention strategies, we could continue to see less benefit from aspirin therapy.

The main adverse effect of aspirin that should be considered when prescribing is bleeding, which is variable based on patient demographics. Specifically, patients with diabetes mellitus and/or moderate cardiovascular risk were at an increased risk of gastrointestinal bleeding, and major bleeding with aspirin therapy.12 In addition, aspirin has shown to have an increased risk of a major hemorrhagic events in the elderly (70-years of age or older).10 In all three trials safety endpoints, gastrointestinal bleeding was statistically significantly higher in the aspirin group, reinforces the fact that gastrointestinal bleeding is a concern with aspirin therapy.10-12

When considering aspirin for primary prevention of ASCVD, a one-size-fits-all strategy is clearly not optimal. The risk of bleeding needs to be weighed against the benefit aspirin can provide. Pharmacists can play a role in screening patients for appropriate aspirin use and making patient specific recommendations regarding aspirin therapy. Additionally, pharmacist can counsel patients taking aspirin on strategies to mitigate bleeding risk, such as reducing concomitant medications that increase bleeding risk. It is important to remember that patients may not report over-the-counter medications, such as aspirin, as well as supplements or non—

steroidal anti-inflammatory drugs to their providers due to perceptions that these products are benign and safe. Therefore, pharmacists working as part of the interprofessional team can be an important tool in providing aspirin counseling to patients. A current systematic review of the US prevention service task force found that older age, male sex, and diabetes mellitus all increase the risk of serious bleeding in patients.13 Several reversible risk factors were also identified, including smoking, elevated blood pressure, and concomitant medications with antiplatelet effects. Pharmacists can assist in providing a thorough review of patient specific risk factors of aspirin associated bleeding and provide counseling related to risk factor modification.

Conclusion

Historically, aspirin has been used for many decades for a variety of therapeutic uses. While historical data showed aspirin was beneficial for the primary prevention of cardiovascular disease, newer studies have consistently shown no benefit for most adults. The increased risk of bleeding, however, remains consistent and bleeding risk should be weighed against the potential benefits of aspirin therapy in all patients. Emphasizing nonpharmacologic primary prevention strategies is important in all patients, as they have no known adverse effects, and may provide significant benefits. Still, aspirin plays a role and may be considered in some high-risk individuals. Pharmacists play an integral role in screening patients for aspirin therapy and deprescribing aspirin therapies for patients who are low to moderate ASCVD risk or at a high risk of bleeding. As new data emerges, pharmacists can continue to educate patients and providers on the benefits and risk of aspirin therapy. 

REFERENCES

1. Arnett D, Blumenthal RS, Albert MA, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019 Sep, 74 (10) e177–e232

2. Benjamin EJ, Muntner P, Alonso A, et al. Heart Disease and Stroke Statistics – 2019 Update: A report from the American Heart Association. Circulation. 2020 Jan, 14; 141(2).

3. Singal AK, Karthikeyan G. Aspirin for primary prevention: Is this the end of the road? Indian Heart J. 2019 MarApr;71(2):113-117.

4. Raber I, McCarthy C, Vaduganathan M, et al. The rise and fall of aspirin in the primary prevention of cardiovascular disease. Lancet 2019; 393: 2155-67.

5. O'Brien CW, Juraschek SP, Wee CC. Prevalence of Aspirin

Use for Primary Prevention of Cardiovascular Disease in the United States: Results From the 2017 National Health Interview Survey. Ann Intern Med. 2019;171(8):596-598.

6. Antithrombotic Trialists’ (ATT) Collaboration, Baigent C, Blackwell L, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomized trials. Lancet. 2009;373:1849–60.

7. US Preventive Services Task Force. Aspirin use to Prevent Cardiovascular Disease: Preventive Medication. https:// uspreventiveservicestasksforce.org/uspstf/draftrecommendation/aspirin-use-prevent-cardiovasculardisease-preventive-medication. Accessed October 16, 2021.

8. Guirguis-Blake JM, Evans CV, Senger CA, et al. Aspirin for the primary prevention of cardiovascular events: a systematic evidence review for the US Preventive Services Task Force. Ann Intern Med. 2016; 164:804–13.

9. McNeil J.J., Woods RL, Nelson MR, et al. Effect of aspirin on disability-free survival in the healthy elderly. N Engl J Med. 379(16): 1499-1508.

10. McNeil, J. J., Wolfe, R., Woods, et al. (2018). Effect of aspirin on cardiovascular events and bleeding in the healthy elderly. N. Engl. J. Med. 379 (16), 1509–1518.

11. Gaziano, J. M., Brotons, C., Coppolecchia, et al. (2018). Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet 392 (10152), 1036–1046.

12. Bowman, L., Mafham, M., Wallendszus, et al. (2018). Effects of aspirin for primary prevention in persons with diabetes mellitus. N. Engl. J. Med. 379 (16), 1529–1539.

13. Whitlock EP, Burda BU, Williams SB. Bleeding risk with aspirin use for primary prevention in adults: A systematic evidence review for the US prevention services task force. Ann Intern Med. 2016;164(12):826-835.

14. Lexicomp Online, Lexi-Drug. Aspirin. Available at: www. online.lexi.com. Accessed February 8, 2022.

CE Questions

1. Which of the following is a strong (class I) recommendation by the 2019 ACC/AHA guidelines for primary prevention of atherosclerotic cardiovascular disease (ASCVD)?

a. The intake of trans fat should be increased to reduce ASCVD risk

b. Adults should engage in 300 minutes of vigorous aerobic activity per week

c. All adults should take 1 gram of over-the-counter omega-3 fatty acid

d. Tobacco abstinence is recommended for all adults to reduce ASCVD risk

2. Which of the following is a risk factor for the development of atherosclerotic cardiovascular disease?

a. Obesity

b. Hyperlipidemia  c. Hypertension   d. All the above

3. What is the mechanism of action of Aspirin?

a. Irreversible inhibitor PGY12 receptor  b. Reversible inhibitor of Factor Xa  c. Irreversibly inhibits COX-1 and COX-2 enzymes  d. Irreversibly inhibits COX–2 enzymes

4. Which of the following is a correct recommendation regarding aspirin for the primary prevention of ASCVD according to the 2019 ACC/AHA guidelines?

a. Low-dose aspirin might be reasonable in adults 40 – 70 years of age with a higher ASCVD risk who are not at an increased risk of bleeding  b. Low-dose aspirin should be routinely recommended for the primary prevention of ASCVD in all adults > 70 years of age who are not at an increased risk of bleeding

c. Low-dose aspirin should be routinely recommended for the primary prevention of ASCVD to adults 40 – 70 years of age with a higher ASCVD risk

d. Low-dose aspirin might be reasonable for adults > 18 years of age with comorbid diabetes

5. Which of the following is a limitation of the ARRIVE trial?

a. Low incidence of gastrointestinal bleeding and cardiovascular events

b. The study only included adults > 70 years of age   c. The study only included men  d. Patients were excluded if they had a higher risk of bleeding

6. Which of the following is a true statement regarding the results of the ASPREE trial?

a. This trial found a statistically significant benefit in utilizing aspirin over placebo for the primary outcome of death from any cause, dementia, and persistent physical disabilities   b. This trial found a statistically significant benefit in utilizing aspirin over placebo for the secondary outcome of cardiovascular disease  c. This trial found a statistically significant increase in major hemorrhage in patients utilizing aspirin as compared to placebo  d. This trial found a statistically significant benefit in utilizing aspirin over placebo for the primary outcome of cardiovascular death

7. What comorbidity was the focus of the ASCEND trial? a. Smoking  b. Obesity  c. Cancer  d. Diabetes mellitus

8. Which of the following accurately represents the results of the primary safety outcome related to bleeding in the ASCEND, ARRIVE, & ASPREE trials when comparing aspirin to placebo? a. Statistically significant higher bleeding risk with aspirin  b. Statistically significant lower bleeding risk with aspirin  c. No difference in bleeding risk with aspirin vs. no aspirin therapy  d. Statistically significant higher gastrointestinal bleeding with aspirin but no difference in other types of bleeding between the two groups

9. Which of the following reversible risk factors increases a patient’s risk for bleeding? a. Black race  b. Moderate cardiovascular risk  c. Adults > 70 years of age  d. BMI < 30 kg/m2

10. Which of the following is a counseling point to tell patients to be aware of while taking aspirin? a. Notify your provider if you experience black tarry stools  b. Take 1 tablet by mouth three times daily  c. Take 1 tablet by mouth 30 minutes before food  d. May crush enteric-coated tablets in patients with gastrostomy tube (G-tube)

editorial member spotlight

Brandy DeChellis

B.S. Microbiology PharmD, CSP College of Pharmacy: University of Pittsburgh School of Pharmacy, Graduating Class of 2008

AzPA Membership Type: Pharmacist

Banner Family Pharmacy-MD Anderson Cancer Center Associate Director, Retail/Specialty

Instagram- @bmdechel | LinkedIn - @BrandyDeChellis | Facebook - Brandy DeChellis

How long have you been an AzPA member?

2 years

What do you enjoy most about being an AzPA member?

As an AzPA member, I enjoy the professional connection. The field of pharmacy is a constantly changing landscape which can be difficult to keep up on the new information. AzPA brings a diverse pharmacy group together to help promote change and learning! I love the positivity and the helping hands to elevate one’s knowledge.

How were you first introduced to the world of pharmacy?

I was first introduced to the world of pharmacy as a child. My godfather had owned and operated an independent pharmacy in Western Pennsylvania. I remember his big smile, warmth and compassionate demeanor when visiting! I knew at that moment that I wanted to be just like him. Making people feel cared for and supported but also experiencing the ‘familyoriented’ atmosphere.

Explain what a typical work day looks like for you.

A typical work day includes clinical monitoring when refilling oral oncology medications, compounding magic mouthwashes and administrative tasks. My work day is changing on a weekly basis to include rounding with our Stem Cell team at Banner Gateway Hospital!

In your opinion, what is the most rewarding part of practicing pharmacy?

The most rewarding part of practicing pharmacy is the customer feedback! We celebrate the positive comments but also are rewarded when we can brighten up a patient’s day. There is no bigger reward than bringing comfort and joy to a patient.

How do you give back to the profession?

I give back to the profession by mentoring! I enjoy being the advisor for technicians, pharmacists and students. Along my own pathway in pharmacy, it was the mentors who I am reminded of when pharmacy becomes challenging.

What do you enjoy doing in your free time?

In my free time, I love spending it with my family! My kids keep me busy with all of their activities which include gymnastics, swimming and soccer! I am their biggest cheerleader! I also have volunteered to be an assistant soccer coach for Gilbert Youth Soccer Association.

What's something about you (a fun fact) that not many people know?

I am a Reebok Certified Indoor Spin Instructor.

Retirement Blindspots

Some life and financial factors that can sometimes be overlooked. Pat Reding and Bo Schnurr

This series, Financial Forum, is presented by PRISM Wealth Advisors, LLC and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

We all have our “blue sky” visions of the way retirement should be, yet our futures may unfold in ways we do not predict. So, as you think about your “second act,” you may want to consider some life and financial factors that can suddenly arise. You may end up retiring earlier than you expect. If you leave the workforce at “full” retirement age (FRA), which is 67 for those born in 1960 and later, you may be eligible to claim “full” Social Security benefits. Working until 67 may be worthwhile because it will reduce your monthly

Social Security benefits if you claim them between age 62 and your FRA.1 Now, do most Americans retire at 67? Not according to the annual survey from the Employee Benefit Research Institute (EBRI). In EBRI’s 2020 Retirement Confidence Survey, 16% of pre-retirees expected to retire between ages 66-69, and 31% thought they would retire at age 70 or later. The reality is different. In surveying current retirees, EBRI found that only 6% had worked into their seventies. In fact, 70% percent of them had left work before age 65, and 33% had retired before age 60.2

You may see retirement as an extension of the present rather than the future. This is only natural, as we all live in the present – but the future will arrive. The costs you have to shoulder later in retirement may exceed those at the start of retirement. As you may be retired for 20 or 30 years, it is wise to take a long-term view of things.

You may have a health insurance gap. If you retire before age 65, what do you do about health coverage? You may shoulder 100% of the cost. Looking forward, you may need extended care, and it seems to get more expensive each year. Wealthy households may be able to “self-insure” against extended care, but many other households struggle. In Genworth’s 2020 Cost of Care Survey, the median monthly cost of a semi-private room in a nursing home is $7,738. In California, it is $9,023; in Florida, $8,803.3 Suppose you become disabled or seriously ill, and working is out of the question. How do you make ends meet?

Age may catch up to you sooner rather than later. You may stay fit, active, and mentally sharp for decades to come, but if you become mentally or physically infirm, you need to find people to trust to manage your finances.

You could be alone one day. As anyone who has ever lived alone realizes, a single person does not simply live on 50% of a couple's income. Keeping up a house, or even a condo, can be tough when you are elderly. Driving can be a concern. If your

spouse or partner is absent, will there be someone to help you in the future?

These are some of the blind spots that can surprise us in retirement. They may quickly affect our money and quality of life. If you age with an awareness of them, you may have the opportunity to manage the outcome better. 

CITATIONS

1. Social Security Administration, December 1, 2020

2. Employee Benefit Research Institute, December 1, 2020

3. Genworth Cost of Care Survey, March 30, 2020

Pat Reding and Bo Schnurr may be reached at 800-288-6669 or pbh@berthelrep.com.

Registered Representative of and securities and investment advisory services offered through Berthel Fisher & Company Financial Services, Inc. Member FINRA/SIPC. PRISM Wealth Advisors LLC is independent of Berthel Fisher & Company Financial Services Inc.

This material was prepared by MarketingPro, Inc., and does not necessarily represent the views of the presenting party, nor their affiliates. This information has been derived from sources believed to be accurate. Please note - investing involves risk, and past performance is no guarantee of future results. The publisher is not engaged in rendering legal, accounting or other professional services. If assistance is needed, the reader is advised to engage the services of a competent professional. This information should not be construed as investment, tax or legal advice and may not be relied on for the purpose of avoiding any Federal tax penalty. This is neither a solicitation nor recommendation to purchase or sell any investment or insurance product or service, and should not be relied upon as such. All indices are unmanaged and are not illustrative of any particular investment.

AzPA presents an innovative podcast intended for pharmacists and pharmacy technicians to obtain continuing education credit. The podcast also provides current health information and hot topics in the evolving world of pharmacy.

www.azpharmacy.org/education/azpa-podcast/

and the law

Patient Waivers

Don R. McGuire Jr. 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.

We received a number of questions through the years about patients signing a waiver to protect the pharmacy and its pharmacists. These questions usually arise when looking for protection from mis-filling prescriptions, delivering prescriptions to the incorrect patient, or dispensing unapproved medications (like ivermectin). This article explores waivers, their content requirements, and the likelihood of enforcement.

A waiver is an agreement between a patient and the pharmacy. The patient agrees to give up a legal right to sue the pharmacy if he or she is injured as

the result of an activity or due to goods or services provided by the pharmacy.

Waivers are contracts and are interpreted by the courts using contract law. Courts generally do not look favorably on waivers and will strictly construe them against the drafter. Waivers are governed by state law, so there are no national requirements that this article can provide. However, there are a handful of states where waivers are unenforceable and will not be useful.

Your first step in deciding whether to use waivers in your pharmacy is whether your state will enforce them.

There are some general requirements to consider. The waiver must be clear, unambiguous, and avoid legalese. Waivers should stand alone and should not be made part of other documents where they could be overlooked. The risks that the patient is waiving their right to must be complete and clearly listed. The waiver should only address ordinary negligence and inherent risks.

Waivers are not enforceable when waiving intentional or reckless behavior or gross negligence. They do not absolve the pharmacy of the duty to exercise due care and take appropriate safety measures for the protection of the patient. Failure to take basic, industry-standard safety steps could be seen as gross negligence and therefore not waived by the agreement.

Because waivers are contracts, there must be consideration given to make the contract legally enforceable. Consideration is the benefit that each party gets from the contract. This benefit can be a promise to do something you are not legally obligated to do or a promise not to do something you have a right to do. What consideration or benefit is the patient receiving in this bargain? If that cannot be identified, the waiver will be invalid and unenforceable.

Even if you have a well-drafted waiver, there are still hurdles to overcome. Courts will not enforce waivers that are contrary to public policy or that are seen as unconscionable. Each state has its own criteria for determining what is against public policy. However, some common unenforceable waivers involve a highly-regulated activity (pharmacy practice arguably is one) or a service upon which the public depends (pharmacy practice again). A waiver could be deemed unconscionable if it is too one sided or if one party is in a superior bargaining position that leaves the other party with no choice but to agree. This leads us back to the consideration concern.

You need to be able to articulate what benefit the patient receives by signing the waiver. Providing pharmacy services to the patient may not be sufficient consideration.

The existence of the waiver does not prevent the pharmacy from being sued. The waiver is a defense that can be raised. Even if it is raised successfully and there is an early dismissal, the pharmacy incurs expenses. For this reason, a waiver can never replace an insurance policy. One of the benefits of an insurance policy is the defense expenses coverage resulting from a covered claim.

Another factor to consider is the impression a waiver may give to your patients. Asking them to sign a waiver in case they ever receive a mis-filled prescription that leaves them injured and without legal recourse will reduce their confidence and loyalty in your pharmacy and pharmacists.

The waiver is not a panacea. In the right jurisdiction, it can be a legally enforceable agreement. However, when drafting a waiver, several factors have to be considered when determining its enforceability. The ability to draft an enforceable waiver is difficult for a pharmacy operation because of public policy reasons. If the idea of a release like this was viable, every professional would use one with every transaction or encounter. The effort is probably more effectively spent on a patient safety program.

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.

© Don R. McGuire Jr., R.Ph., J.D., is General Counsel, Senior Vice President, Risk Management & Compliance at Pharmacists Mutual Insurance Company.

A waiver is an agreement between a patient and the pharmacy. The patient agrees to give up a legal right to sue the pharmacy if he or she is injured as the result of an activity or due to goods or services provided by the pharmacy.

Cash Copay Collection

By Trenton Thiede, PharmD, MBA, President at PAAS National®, expert third party audit assistance and FWA/HIPAA compliance.

Numerous PBMs are conducting audits and asking for proof of copay collection. This is relatively easy to respond to (albeit annoying) when patients have paid by check or credit card as there is a “paper trail” of the financial transaction. PAAS National® analysts have seen some pharmacies struggle to provide evidence of cash transactions as they do not have sophisticated point-of-sale systems that record the method of payment or they lack consistent cash handling policies and procedures, or both.

Of particular concern recently has been Caremark, who requires that pharmacies provide bank deposit slips as evidence of cash copays (the final step in the “paper trail” evidence). While, clearly, individual bills received from a patient at the register cannot be linked to a particular transaction, Caremark may be suspicious of large copays paid in cash and will demand to see bank deposit slips that exceed (in the aggregate) the amount of the individual copay.

If your pharmacy cannot provide sufficient evidence of copay collection, then PBMs may recoup claims during audit and potentially terminate your pharmacy agreement.

Consider the PAAS tips below to strengthen your cash handling procedures where needed.

PAAS Tips:

• Don’t wait for an audit, with Proof of Copay Collection requirements, to upgrade to an integrated Point-Of-Sale system. Benefits may include:

o Creation of itemized sales receipts with date and time of sale, individual items sold, dollar amount of each item (e.g. copay) and method of payment received

o Additional features often include:

Incorporate electronic signatures as proof of dispensing and acknowledgement of HIPAA notice of privacy practices

Link to OTC inventory levels for reporting and automatic reorder points

Link to pharmacy dispensing software to update a work queue, mark prescriptions as “sold” or even hard-stop prescriptions if trying to sell a certain number of days after fill date (may prevent dispensing beyond PBM return-to-stock window)

Query transactions such as when responding to a PBM audit or if a customer disputes payment amount or receipt of a medication at a later date

• Develop or revise cash handling policies that include:

o Making deposits to the bank at regular intervals (e.g., weekly)

o Avoid taking money out of the register to run the business (e.g., buying stamps, staff lunch, etc.)

o Balance the register at the end of every business day

Breakdown cash by denomination and document for comparison against the next deposit

Leave a set minimum amount for open of next business day

Additional funds should go into a safe until the next scheduled bank deposit

If you have a point-of-sale system, it should be able to reconcile every transaction of the day to ensure you have the right amounts on-hand and identify any lost payments or theft 

PAAS National® is committed to serving community pharmacies and helping keep hard-earned money where it belongs. Contact us today at (608) 873-1342 or info@ paasnational.com to see why membership might be right for you.

©2022 PAAS National® LLC All Rights Reserved

Beware and Be Ready! In-Person Onsite Audits Are Resuming

By Trenton Thiede, PharmD, MBA, President at PAAS National®,

expert third party audit assistance and FWA/HIPAA

compliance.

OptumRx and Express Scripts recently sent notices to pharmacies informing them in-person onsite audits will be starting back up in April. PAAS National® has also reviewed audit notices from Caremark and MedImpact with intentions of visiting the pharmacy in person to conduct the audit. We would expect other PBMs to follow this trend as well.

COVID-19 restrictions lead PBMs to conduct their audits virtually since early 2020. Pharmacies would respond to the audit request by submitting documents in for review and having a compliance phone interview with the auditor. With COVID-19 numbers decreasing, PBMs feel now is the time to resume audits onsite.

PAAS analysts have years of experience assisting pharmacies through onsite audits. Pharmacies can receive a pre-audit consultation with an analyst, in addition to specific PBM trends, state laws that

are being targeted, and many other tips that can be provided to support you through your audit. We also offer our Onsite Credentialing Guidelines1 located on the PAAS Member Portal, to help our members prepare for potential questions that may be asked during the auditor’s visit.

PAAS Tips:

• Engage PAAS2 as soon as possible after receiving an any audit notification (including onsite)

• PAAS Audit Assistance members can log on to the Member Portal to search past Newsline articles3 for safe filling and billing tips, or submit a question online4

• PAAS FWA/HIPAA Compliance members should review their compliance tasks5 to ensure the pharmacy is up to date

o MedImpact is specifically looking for written policies and procedures for FWA when onsite 

REFERENCES 1. https://portal.paasnational.com/Paas/Resource/Tools

PAAS National® is committed to serving community pharmacies and helping keep hard-earned money where it belongs. Contact us today at (608) 873-1342 or info@ paasnational.com to see why membership might be right for you.

©2022 PAAS National® LLC All Rights Reserved

University & Alumni News

Midwestern University College of Pharmacy

Mitchell R. Emerson, PhD Dean, Midwestern University CPG

Greetings from the Midwestern University College of Pharmacy. We have many reasons to celebrate this past quarter as we welcome the summer.

In April, Dr. Suzanne Larson, Midwestern University and Dr. Janet Cooley, The University of Arizona hosted a free Continued Education program where attendees learned about technology used on rotations including tools for both in person and remote learning. Thank you to all our alumni, preceptors and friends who joined us.

On June 2nd, we celebrated our newest graduates, the Class of 2022! We wish our newest alumni our sincerest congratulations as they start their next journey. Prior to graduation, on May 13th, we recognized many from the Class of 2022 on their accomplishments and awarded the Faculty Mentor of the Year to Dr. Titilola Afolabi. Additional honors included the Preceptors of the Year awarded to Kevin Carrasco, Pharm. D., MPH, Banner University Medical Center Phoenix (Preceptor of the Year), John (Sean) McHale, Pharm. D., Soleo Health (Rookie Preceptor of the Year), and Kelsey Buckley, Pharm.D., BCACP, Associate Professor and Ambulatory Care Pharmacist (Faculty Preceptor of the Year). A sincere thank you and congratulations to those who make such a difference for our students.

The end of May and beginning of June are a whirlwind of activity at the college as the same week we celebrated the Class of 2022

we welcomed Class of 2025. Orientation and “Bootcamp” were hosted the week of May 30th and classes began June 6th. Our newest class comes from diverse backgrounds and nearly every state and several foreign countries. We’re looking forward to helping them become exceptional pharmacists and health care providers.

Rounding out a busy month, on June 17th, we hosted the Midwestern University Alumni and Friends Dessert Reception in conjunction with the AzPA Annual Meeting. The cherished event made a triumphant return after a two-year hiatus due to the pandemic. As always, we enjoyed plenty of sweet treats and reconnecting with our alumni, preceptors, and friends. We also celebrated many of our faculty and alumni who are making an impact in pharmacy in Arizona through presentations at the meeting:

• Roger Morris – Adjunct Faculty

• Ariane Guthrie – PGY-2 Resident

• Dawn Gerber – Presenter and Leadership Track Coordinator

• Mark Boesen – Adjunct Faculty

• Suzanne Larson – Director OEE

• Matt Cheung – Community Partner

• Sophia Galloway – Alumni

• Kelly Fine – Adjunct Faculty

• Holly Van Lew – Alumni

• Erin Raney – Faculty

University & Alumni News

• Vanthida Huang – Faculty

• Andrew Vogler – ID Fellow

• Tho Phan – ID Fellow

• Maura Jones Wolken – Faculty

• Melinda Burnworth – Faculty

• Adrienne Waibel – Alumni

The College is well represented on the AzPA Board of Directors as the following were sworn in for 2022-2023:

• Dawn Gerber – President

• Mike Dietrich – College of Pharmacy Representative

• Lyndy Abdelsayed – MWU Student Liaison

The College looks forward to another outstanding year for AzPA under the leadership of Dr. Gerber!

continued from page 34

In addition to presentations and leadership, several members of the MWU family were recognized. Maura Jones received an AzPA Appreciation Award, and Ron Woodbeck and Mike Dietrich were inducted into the AzPA Hall of Fame for their years of dedicated service to AzPA and the profession.

We are looking forward to catching up with all of you and connecting at a future event.

To follow us and learn more about our events and wins, join the CPG social media community:

Like us on Facebook

Follow us on Twitter Follow us on Instagram 

Creighton University School of Pharmacy

Amy Wilson, PharmD Dean, Creighton University SOP

Health care partnership a win-win

Creighton health sciences students are finding they benefit as much as those they serve through a partnership the University has with an organization in Phoenix dedicated to fostering independence for adults with autism and other neurodiversities.

Through the agreement between Creighton University Health Sciences Campus–Phoenix and First Place AZ, Creighton health care providers offer services and education to residents of First Place–Phoenix, an innovative residential community.

Many adults with autism spectrum disorder (ASD), Down syndrome, traumatic brain injury and other neurodiverse abilities face unique challenges in daily living. First Place–Phoenix is designed to nurture a sense of community, independence and interdependence within a supportive and caring environment. It also offers sites for education, training and creative expression.

"This collaboration helps build a supportive community culture so that health care providers not only understand autism but also people with autism through its many forms and expressions," says Denise Resnik, founder and president/CEO of First Place AZ. "Our partnership with Creighton offers valuable insights into the lives of health science students while providing them with experiences that deepen their understanding of neurodiverse populations and appreciation for the challenges inherent in navigating systems of care."

Residents received flu shots last fall from pharmacy faculty in a familiar setting at First Place–Phoenix, with students offering additional support to help them understand more about the vaccine and possible side effects.

In 2022, pharmacy and occupational therapy faculty and students have begun working with First Place residents to provide medication history and education, as well as how to improve daily activities with OT support. Students review residents' medications and learn about their daily activities. Throughout the conversation, the residents and students work together to set goals and recommendations to work toward more lifestyle independence.

In one case, after the medication review, an occupational therapy student identified that a resident was having trouble opening a pill case. The pharmacy student then noted

University & Alumni News

that the medication was being filled and mailed from another state. Together, their recommendation was to find a physician in Arizona to support the person's medication needs and to acquire a different, larger pill case for easier opening.

The School of Medicine offers an innovative elective rotation with First Place–Phoenix called "Minding the Gap." Randy Richardson, MD, regional dean of the School of Medicine in Phoenix, says the goal of the course is to improve the continuity of care for adolescents and adults with autism and other intellectual and developmental delays.

"There is often a well-organized pediatric team that cares for these patients during their childhood, but their care often is nonexistent or poorly coordinated as they move from pediatric to adult care," Richardson says, "which is the 'gap' mentioned in the title of the course."

continued from page 36

He says Caroline Kim Kupfer, MD, assistant professor of medicine who directs the course, helps students understand the challenges and opportunities in the health care system for treating and caring for "this underserved, underrepresented and often underestimated cohort of patients."

Amy Friedman Wilson, PharmD'95, dean of the School of Pharmacy and Health Professions, says the partnership with First Place has given students a "fantastic" opportunity to serve the community in an interprofessional manner alongside health sciences colleagues.

And students are finding satisfaction in helping empower the residents to become more independent. Says Sarah White, a first-year occupational therapy student: "Independence–that's the key word." 

Rick G. Schnellmann, PhD Dean, University of Arizona COP—Tucson

Celebrating 75 Years of Excellence!

The University of Arizona R. Ken Coit College of Pharmacy is celebrating its 75th anniversary during Homecoming this October.

Much has changed since the first class of 84 students started in September 1947. When the school opened, it was housed in Temporary Barracks Building T-3, a surplus army prefabricated hut located just west of Bear Down Gymnasium, where the ScienceEngineering Library now stands.

Today, the Coit College of Pharmacy resides on two campuses. In Tucson, Roy P. Drachman Hall and Skaggs Pharmaceutical Sciences Center. In Phoenix, the Phoenix Bioscience Core. Between both campuses, the College of Pharmacy has contributed to science and advancing health through its world-class scientists, educators, and alumni.

To help celebrate the 75th anniversary, the College of Pharmacy has been collecting and sharing memories of the college and highlighting some of the achievements and events of the school, its students, faculty, staff, alumni and friends. One of the first memories shared was from Steven Dudley, PharmD, DABAT. Dr. Dudley is a 2015 Pharmacy School graduate, a clinical toxicologist and the Director of the Arizona Poison and Drug Information Center.

“One of my favorite things from pharmacy school was actually being able to apply what we learned in the classroom to real life scenarios. I remember participating in the Pharmacy Day on the Capitol event and meeting with Senator Steve Farley to discuss the value of pharmacists and the impact we can have in healthcare. It was great to see his and his staff's eyes light up when they recognized all the ways pharmacist involvement improve patient care. It felt great to advocate because if we don't fight for our profession, who will?"

If you have a memory and photograph to share about your experience with the Coit College of Pharmacy, please send them to jjavier@pharmacy.arizona.edu. Collected memories and photos will be shared with the PharmCat family in newsletters, social media and through the website.

AzPA state advocacy

AzPA Legislative Affairs Update

55th Legislature - Second Regular Session Summary

Adjourned “sine die”: June 25, 2022

General Effective Date: September 24, 2022

Days in Session: 166

Total Bills Introduced: 1,851

Bill Number/Sponsor Action

HB 2490: Pharmacists; Providers; Collaborative Practice Agreements (Rep. Wilmeth)

Governor Ducey signed this bill on March 30th. PASSED

Bills Passed: 392

Bills Signed by Governor: 387

Bills Vetoed by Governor: 4

Bills Not Signed but Allowed to go into law: 1

Summary and Notes

Summary: Licensed pharmacists are authorized to enter a "collaborative practice agreement" with a "provider or providers" to initiate, monitor, and modify drug therapy or provide disease management assistance. Collaborative practice agreements are required to outline the duties that the provider is delegating to the pharmacist to perform and specify the medical conditions to be managed by the pharmacist. A provider who enters into a collaborative practice agreement is required to have a previously established provider-patient relationship with a patient for that patient to be eligible to be included under the collaborative practice agreement. Repeals statute regulating a pharmacist initiating, monitoring, and modifying drug therapy and use.

Note: We worked with the Arizona Medical Association, Arizona Osteopathic Medical Association and other pharmacy stakeholder groups to finalize language that everyone was supportive of with the goal of modernizing and clarifying some of the language.

SB 1016:

Public Health Emergency; Pharmacists; Off-label Use (Pharmacies; Off-label Use; Refusal Prohibition) (Sen. Townsend)

This bill FAILED the Senate 14-15. DEFEATED

Summary: During a proclaimed public health state of emergency, a pharmacy is prohibited from refusing to fill a prescription order for a prescription-only drug that is being prescribed for an "off-label use" (defined) and that is potentially lifesaving.

Note: This bill was a top priority to kill due to the interference with the ability of a pharmacist to use professional judgement in the practice of pharmacy.

SB 1161:

Prescription Drug Coverage; Steering Prohibition

(Sen. Barto)

This bill passed out of the Senate committee 7 to 1. However, the Senate President intervened on behalf of the insurers and did not allow the bill to go to the Senate floor.

WITHDREW

Summary: A pharmacy benefit manager is prohibited from steering or directing a patient to use the pharmacy benefit manager's affiliated provider through any oral or written communication, from requiring a patient to use the pharmacy benefit manager's affiliated provider in order for the patient to receive the maximum benefit for the service under the patient's health benefits plan, and from requiring or inducing a patient to use the pharmacy benefit manager's affiliated provider, including by providing for reduced cost sharing if the patient uses the affiliated provider. A pharmacy benefit manager, health insurer or third-party payor is prohibited from requiring a clinician-administered drug to be dispensed by a pharmacy, including by an affiliated provider, as a condition of coverage.

Note: We built a large stakeholder group in support with hospitals, doctors, and patients. We were going to run a strikeeverything amendment on a bill in the House Appropriations committee, but insurers were able to get the unions to oppose the bill and we withdrew the bill due to concerns about the vote and not wanting to harm the cause for the next legislative session.

SB 1374:

Immunizations; Pharmacists

(Sen. Shope)

Governor Ducey signed this bill on July 6th. PASSED

Summary: Licensed pharmacists are authorized to order and administer immunizations or vaccines recommended by the U.S. Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices to a person who is at least six years of age without a prescription order, and to a person who is at least three years of age with a prescription order or under a collaborative practice agreement. A pharmacist who administers an immunization, vaccine, or emergency medication is required to provide vaccine information materials and follow the standard operating procedures based on vaccine administration protocols and immunization practices published in the CDC's morbidity and mortality weekly report.

Note: Senate Health Chair, Nancy Barto refused to hear our original bill SB1373 in committee, so we put the language on SB1374 as a strike-everything amendment. We worked with the Arizona Medical Association, Arizona Osteopathic Medical Association, Arizona Family Physicians Association, and the Arizona Pediatric Association on the final language to get the doctors to neutral.

SB 1413:

Pharmacists; Prescriptions; Refusal; Prohibition (Sen. Rogers)

This bill was never heard in committee. DEFEATED

Summary: A pharmacist is prohibited from refusing to fill any valid prescription order written by any licensed health care provider. A pharmacist's refusal to fill a valid prescription order is an act of unprofessional conduct.

Note: This was another legislative priority for defense. We were able to keep the bill from being heard.

SB 1569: Pharmacy Technician Trainees; Pharmacists; Compounding (Sen.

Barto)

Governor Ducey signed this bill on July 6th. PASSED

Summary: Effective July 1, 2023, pharmacy technician trainees are required to register with the Arizona State Board of Pharmacy, instead of being licensed by the Board. The maximum pharmacy technician trainee registration application fee is $25. Pharmacy technician trainees are no longer required to have a high school diploma or the equivalent. Also modifies requirements for a “remote hospitalsite pharmacy” (defined) permittee. A remote hospital-site pharmacy permittee is required to ensure that the pharmacy is supervised by a pharmacist located in Arizona who is employed by the hospital. The pharmacist in charge is required to develop and implement procedures for obtaining, storing, and dispensing drugs for inpatient administration and devices and recordkeeping requirements. Remote hospitalsite pharmacy permittees are required to maintain a perpetual inventory of controlled substances, and to ensure that there is continuous video surveillance of the pharmacy and that videos are maintained for at least 60 days. A pharmacist is authorized to engage simultaneously in the practice of pharmacy at a reasonable number of remote hospital-site pharmacies as determined and approved by the Board.

Note: This was a legislative priority of the AzPA. The bill originally dealt with changing the pharmacy technician trainees from a license to a registration in order to help relieve the staffing delays due to licensing delays. In addition, the bill was amended in committee to deal with conflicting statute around remote hospital pharmacies.

SB 1176:

340B Drug Programs; Prohibitions

(Sen. Gowan)

Your Team

Governor Ducey signed this bill on June 13th. PASSED

Summary: All insurance contracts that are issued, delivered, or renewed on or after January 1, 2024 for a third party that reimburses for "340B drugs" (defined) are prohibited from discriminating in reimbursement on the basis that the pharmacy dispenses a 340B drug, and from taking other specified actions on the basis that a pharmacy dispenses a 340B drug.

Dianne McCallister AzPA Lobbyist

Kelly Fine AzPA CEO

Ken Bykowski AzPA Legislative Affairs Committee Co-Chair

Mark Boesen

AzPA Legislative Affairs Committee Co-Chair