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Count on generics. Now more than ever. Dr. Reddy’s generic medications have been making life more affordable for patients for over 40 years. Today, our commitment to providing access to high quality, more affordable medications that patients and their doctors can count on remains unchanged. Why? Just ask the more than 23,000 committed employees at Dr. Reddy’s who know that

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FEBRUARY 2024 DRUGSTORENEWS.COM

I N S I D E Issues Summit speakers tackle pharmacy tech, the age of AI and more

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GENERATION

How does retail pharmacy capture spending of millennials and Gen Z customers who seek convenience and digital connectivity?

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02.24 Vol. 46 No. 2

GENERATION NEXT

Facebook.com/DrugStoreNews linkedin.com/company/drug-store-news/ instagram.com/dsn_media

FEATURES 38

INSIDE BEAUTY: HAIR CARE

Social Media Rewrites Hair Care Rules

Content creators are firing up hair care sales; retailers must be ready 42

PHARMACY: GENERIC DRUGS

Nickel and Dimed

How does retail pharmacy capture spending of millennials and Gen Z customers who seek convenience and digital connectivity?

Rock-bottom pricing and product shortages are placing increasing pressures on the generic drug sector 48

HEALTH: DIABETES

Diabetes market faces disruption

Ozempic and the Inflation Reduction Act represent seismic shifts in what pharmacies can offer its customers 54

30 DEPARTMENTS

COLUMNS

EDITOR’S NOTE

INDUSTRY NEWS

ONE-ON-ONE With Hello Bello’s Will Righeimer

PRODUCTS TO WATCH

DSN ISSUES SUMMIT

ONE-ON-ONE With Allison Medical’s Brandon Faber

LAST WORD By Dae Y. Lee, Pharm.D., Esq. and Harini M. Bupathi, Esq.

PHARMACY: VITAMINS

6 trends in vitamins and nutritional products

Supplements that fit religious diets are forecasted to expand, gummies make waves across age groups and more

HEALTH: FEMININE-CARE PRODUCTS

A new era in feminine care

Increasingly knowledgeable, consumers are seeking out cleaner formulations, sustainable solutions and more

DSN (ISSN 0191-7587) is published monthly 12 times a year by EnsembleIQ, 8550 W. Bryn Mawr Ave, Suite 200, Chicago, IL 60631. Subscription rate in the United States: $150 one year; $276 two year; $17 single issue copy; Canada and Mexico: $204 one year; $390 two year; $20.40 single issue copy; Foreign: $204 one year; $390 two year; $20.40 single issue copy. Periodicals postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Please send address changes to DSN, 8550 W. Bryn Mawr Ave, Suite 200, Chicago, IL 60631. Vol. 46 No 1, January 2024. Copyright © 2024 by EnsembleIQ. All rights reserved.

6 February 2024 DRUGSTORENEWS.COM

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ADD

SEX sales@TriggLabs.com

EDITOR’S NOTE

Forecasting the Future Retailers have opportunities and challenges ahead in attracting younger consumers

MEMBERS OF GENERATION Z—THOSE BORN ROUGHLY BETWEEN 1997 AND 2012— ARE BECOMING A DRIVING FORCE IN THE ECONOMY. MAKING UP ABOUT 68.2 MILLION AMERICANS, THEY ACCOUNT FOR SLIGHTLY MORE THAN 20% OF THE U.S. POPULATION AND HAVE ABOUT $150 BILLION IN BUYING POWER.

Someone (Lincoln, maybe?) once said, “The best way to predict the future is to create it.” This doesn’t necessarily apply to business— but in many ways, it does. Everyone knows that the future (be it health, fashion, politics) is about the next collection of minds, consumers, leaders to advance it. But the next generation is vastly different from the one or two before it, so businesses and suppliers have their work cut out for them. The U.S. Chamber of Commerce said recently that if businesses haven’t paid much attention to (or taken the time to learn about) how they can attract younger consumers, they will want to start— and fast. Members of Generation Z—those born roughly between 1997 and 2012—are becoming a driving force in the economy. Making up about 68.2 million Americans, they account for slightly more than 20% of the U.S. population and have about $150 billion in buying power. Clearly, a large tech-savvy demographic with such vast spending power is important, but digital retail specialist Sherwen said this group also is important because “they have their own unique buying power and preferences, which retailers need to understand in order to stay relevant,” the U.K. firm said. “This generation has higher expectations when it comes to the retail experience compared to previous generations and value social platforms, organic content and personalisation.” Our cover story this month (page 30) looks at the opportunities and the challenges retail pharmacy has when it comes to attracting this important demographic. And it explores what retailers and suppliers need to do. As our reporter found out, retail drug stores are well-positioned to meet the healthcare demands of today’s young consumers, but other categories (such as beauty care and personal grooming) may pose more of a challenge as these young shoppers tend to gravitate toward (and favor) category specialists. “We know that consumer expectations are shifting across the board,” Garry Marshall, director of pharmacy strategy for clinical effectiveness at Wolters Kluwer Health, told our reporter. “However, the younger generation of healthcare consumers have grown up in a more ‘on-demand’ society. It is natural that they would have the same expectations of healthcare.” dsn

8550 W. Bryn Mawr Ave., Ste. 200 Chicago, IL 60631 773.992.4450 Fax 773.992.4455 www.drugstorenews.com BRAND MANAGEMENT Senior Vice President & Publisher John Kenlon 516.650.2064 jkenlon@ensembleiq.com EDITORIAL Editor-in-Chief, Editorial Director Nigel F. Maynard nigelmaynard@ensembleiq.com Managing Editor Julianne Mobilian jmobilian @ensembleiq.com Senior Editor Sandra Levy slevy@ensembleiq.com Online Editor Gisselle Gaitan ggaitan@ensembleiq.com ADVERTISING SALES & BUSINESS Northeast Manager Alex Tomas 212.756.5155 atomas@ensembleiq.com Regional Manager Steven Werner 312.961.7162 swerner@ensembleiq.com DESIGN/PRODUCTION/MARKETING Art Director Michael Escobedo mescobedo@ensembleiq.com Production Manager Jackie Batson jbatson@ensembleiq.com Marketing Manager Kathryn Abrahamsen kabrahamsen@ensembleiq.com SUBSCRIPTION SERVICES List Rental mbriganti@anteriad.com Subscription Questions contact@drugstorenews.com

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EDITORIAL ADVISORY BOARD

8 February 2024 DRUGSTORENEWS.COM

John Beckner, NCPA Becky Dant, Costco J. Jeremy Faulks, Thrifty White Pharmacy Doug M. Long, IQVIA Nancy Lyons, Health Mart Pharmacy Katie Scanlon, Publix Super Markets Heidi Snyder, Drug World Pharmacies

NEW! COLOR FETISH HYDRATING LIP STAIN APPLIES GLOSSY, TRANSFORMS TO A SOFT-MATTE STAIN

INDUSTRY NEWS

NationsBenefits launches direct point of sale integration at Publix

CVS Health adds 2 new renewable energy projects with Constellation CVS Health and Constellation have entered into two agreements that total 264,000-megawatt hours of zero-emission, renewable energy equivalent to the annual electricity use of nearly 1,000 CVS Health locations. “Investing in our planet and people’s health are interconnected,” said Sheryl Burke, chief sustainability officer and senior vice president of corporate social responsibility at CVS Health. “As our world continues to evolve, these sustainability investments we’re making right now are increasingly important to create a healthier future for the communities we serve.” CVS Health will purchase energy and renewable energy certificates through two separate long-term agreements with Constellation. These deals are made possible by Constellation’s long-term agreements with solar projects located in California and Maryland. The retailer will receive approximately 264,000 megawatt hours of energy per year through its retail agreement with Constellation, with that energy matched by Green-e Energy Certified RECs sourced from other renewable facilities throughout the United States. “CVS Health continues to be a leader in supporting newly constructed renewable resources and steadfast in its journey towards embracing sustainable energy,” said Jim McHugh, chief commercial officer at Constellation. “We are thrilled to work with CVS Health once again and provide solutions towards a carbon-free future.” The retailer has now made five renewable energy investments since 2022. These two new investments with Constellation, the company’s two agreements announced in 2023 and the first investment made in 2022 represent more than 500,000 MWh of clean, renewable energy.

10 February 2024 DRUGSTORENEWS.COM

NationsBenefits, which offers supplemental benefits and healthcare fintech solutions to the healthcare-managed care market, has announced a direct point-of-sale integration strategy and basket analyzer technology at Publix Super Markets. As a result of the new direct integration strategy and BAS technology implementation, eligible NationsBenefits Medicare Advantage members who want to spend their health plan-funded benefit dollars on pre-approved healthy products can do so at Publix. “Our direct point of sale integration and basket analyzer technology are designed to empower our health plan partners’ members to make healthier choices with ease,” said Glenn Parker, CEO of NationsBenefits. “This means we eliminate many of the grievances members typically experience when attempting to spend their healthcare benefit dollars. Product eligibility checks are accurate and seamless for our health plan customers and their members.” The company said the integration represents a significant milestone in NationsBenefits’ mission to build the most advanced, merchant acquirer agnostic retail network serving the healthcare benefits and managed care market.

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P R O D U CTS TO WATCH

New & Noteworthy HRG’s five notable products from January

Product introductions surged to start the new year, seeing the highest number of introductions in months. For the month of January, suppliers introduced 278 new products, which is 200 more items than the 78 products they released in the previous month. Waukesha, Wis.based HRG reviewed 28 products in the health category, 136 items in the wellness sector and 114 items in the beauty aisle to see which ones stood out as Products to Watch. Here are the ones they chose:

1. Option 2 Emergency Contraceptive 1.5 mg Tablet Perrigo’s Option 2 Emergency Contraceptive (levonorgestrel 1.5 mg) is the same hormone utilized in many birth control pills but at a higher dose. Perrigo claims it reduces the risk of pregnancy by up to 94% with one pill when taken within 72 hours after unprotected sex or birth control failure. Option 2 is formulated to be an emergency method for birth control to prevent pregnancy before it occurs, the brand said. One tablet comes in a pack.

2. Reese Pharmaceutical’s ColoTest Test Kit The ColoTest Immunochemical Fecal Occult Blood Test by Reese Pharmaceuticals is an at-home, self-test to detect blood in the stool in as soon as one minute. Reese claimed ColoTest is 98.8% accurate with no diet restrictions or prep required and no doctor consultation or prescription needed. The company also said the test makes use of the same technology that is used in the doctor’s office. A kit contains two tests.

12 February 2024 DRUGSTORENEWS.COM

3. Crest Scope Squeez Mouthwash Concentrate Outlast Icy Mint Procter & Gamble’s Crest Scope Squeez Mouthwash Concentrate provides consumers with the same benefits as the liquid form to kill bad breath germs but in a smaller bottle for use at home or on the go. Consumers will be able to control the strength of flavor using the squeeze dosage cap provided. Developed to reduce plastic waste and gain counter space, one bottle of Squeez is equal to 1 L of mouthwash. It comes in a 1.69-oz. bottle.

4. Children’s Daily Immune Support Chewable Tablets 28 ct Zarbee’s Inc. said its Children’s Daily Immune Support Chewable Tablet is an excellent source of vitamin C, D3 and zinc. The tablet is formulated to support childrens’ immune systems and keep them healthy with an alternative to sugarfilled gummies (This statement has not been evaluated by the Food and Drug Administration). One pack contains 28 tablets.

5. Nizoral Scalp Itch Relief Nizoral Scalp Itch Relief liquid from Arcadia Consumer Healthcare offers a final step in the clinical anti-dandruff hair care regimen, the brand said. It was developed to relieve scalp itch between hair washes with a no-drip formula to soothe and hydrate the scalp from conditions such as dandruff, seborrheic dermatitis, eczema and psoriasis. Formulated with hydrocortisone 1%, aloe, menthol and hyaluronic acid, the liquid is fragrance- and paraben-free and greaseless. One bottle is 2 oz. dsn

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*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.

ONE-ON-ONE

SPONSORED

Accessible Injectables Brandon Faber, Director of Sales at Allison Medical, shares why the brand’s diabetes supplies are a staple amongst retailers and diabetes patients Drug Store News recently caught up with Brandon Faber, Director of Sales at Allison Medical, to learn more about the company’s SureComfort brand of diabetes supplies, and why patient care is at the heart of Allison Medical. Drug Store News: Can you tell us a little about Allison Medical? Brandon Faber: Allison Medical is a longstanding business based in Littleton, Colo., with over 30 years of expertise in diabetes supplies. Our main pharmacy products Brandon Faber, Director of Sales, include Insulin Syringes and Pen Allison Medical Needles under the SureComfort brand name. Our commitment lies in providing high-quality products at competitive prices, ensuring accessibility and affordability for our customers. SureComfort is available in retail pharmacies across the United States, including Puerto Rico and Canada DSN: What’s new at Allison Medical? BF: We have just completed a packaging refresh and will be rolling that out in the next month or so. We are very excited about the fresh, bold, new look of SureComfort Insulin Syringes, Pen Needles and all ancillary products. DSN: In a very competitive diabetes space, how has Allison Medical been able to show continuous growth each year for the past five years? BF: Our SureComfort brand of Insulin Syringes and Pen Needles are a staple among diabetes patients who inject regularly. First and foremost, we focus on patient care and that has been very beneficial. We strive to create a true WINWIN-WIN benefiting end-users, retailers and Allison Medical in our everyday business and we have been very successful in doing just that. Secondly, our sales team has a tremendous amount of industry experience which our retail and wholesale partners can rely on. In many cases, our sales team is used as an “industry guide.” In other words, when a retailer or wholesaler has a question, they call us first. In addition to that, we have great relationships with our customers and have a very strong customer service team that works hand in hand with our sales team to ensure our customers are receiving the best customer experience possible. We ship on time and we ship complete.

16 February 2024 DRUGSTORENEWS.COM

DSN: You mention patient care. Regarding diabetes, please explain why patient care is your No. 1 priority. BF: We take the quality of our products very seriously. Our SureComfort Insulin Syringes and Pen Needles consistently exceed industry standards set by Six Sigma, emphasizing our dedication to ensuring the well-being of those relying on our diabetes supplies. DSN: Retail chain and independent pharmacies have had some challenges in staying profitable over the past few years. Why do the pharmacies continue to recommend and dispense SureComfort Insulin Syringes and Pen Needles? BF: Yes, pharmacies have had their challenges, so when a pharmacy can obtain substantially greater profits by dispensing SureComfort Insulin Syringes and Pen Needles to their customers vs. national brands, especially without having to go through a lengthy rebate process, it makes a lot of sense for them to offer SureComfort. The pharmacies see their profits immediately on every box of SureComfort they dispense. DSN: In addition to the SureComfort brand that is sold at retail, does Allison Medical have any other product lines? BF: Yes, we have CarePoint Vet brand, which is solely focused on Animal Health. Believe it or not, there are a lot of small animals that require daily injections. CarePoint Vet helps address the injection needs of vet clinics. We also have CarePoint Precision, our general or conventional syringe brand. These products are tailored for a medical and/or clinical setting. Lastly, we have CarePoint Safety. These products are also used in medical, clinical, acute, LTC and pharmacy settings where a safety syringe is required. DSN: The FDA recently released a safety communication regarding syringes manufactured in China. Does this affect SureComfort insulin syringes? BF: No, SureComfort brand Insulin Syringes and Pen Needles are manufactured in an MDSAP-certified facility in South Korea. MDSAP is the newest and most stringent quality program for medical devices. Achieving this quality standard provides independent verification of Allison Medical’s commitment to providing exceptionally high-quality Insulin Syringes and Pen Needles. dsn

Sure TM

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Quality & Profitability so exceptional...

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PRIORITIES RITIES

1 Patient Care 2 Product Quality 3 Profitability

• MDSAP certified facility • Exceeds quality standards set forth by Six Sigma • Stringent manufacturing process • Ownership in the manufacturing facility • Potential enhanced profits for each Insulin Syringe and Pen Needle dispensed

Controlling diabetes means controlling blood sugar, and for many people, that means regular testing and injections. Our diabetes products have been created to provide exceptional product quality and comfort while addressing the ever-changing needs of both patients and allied health professionals worldwide. Our wide range of insulin syringes, are designed for comfort and ease of use. Our pen needles and lancets feature a universal ISO standard fit and can be used with standard insulin pens and lancing devices.

SureComfort insulin syringes and pen needles are manufactured in a MDSAP certified facility. MDSAP is the newest and most stringent quality program for medical devices. Achieving this quality standard provides independent verification of Allison Medical’s commitment to providing exceptionally high quality insulin syringes and pen needles. Our SureComfort product lines offer a large variety of options for all specific needs and comes in tri-lingual packaging.

Trust and comfort. Every single customer. Every single time. allison medical inspired innovation

For questions regarding the SureComfort product line, contact our Allison Medical Customer Service at: Toll Free: 1-800-886-1618

DSN INDUSTRY ISSUES SUMMIT

2023 DSN Industry Issues Summit keynote: Retail pharmacy in the age of AI Sharon Gai’s keynote explored generative AI and its impact on health, wellness and beauty CPGs By Sandra Levy

Forty six percent of executives believe AI cognitive computing and cloud applications will be the areas of our greatest investment in the next three years. So said Sharon Gai, an expert in e-commerce, digital transformation and AI, during her keynote address at Drug Store News’ 25th annual Industry Issues Summit. The presentation, sponsored by The Emerson Group, was titled, “Generative AI Glow-Up: New Radiance in Health, Wellness & Beauty CPG.” Gai, who worked at Alibaba for a decade, shared insights from the Chinese market, which she noted is the world’s largest online consumer market. “In our $100 trillion world economy, it is the second largest economy, but it’s also the world’s largest developing economy,” Gai said. Pointing out that China’s population is about 1.4 billion people, Gai said, “You’re going to get a plethora of different brands. China also is the world’s most competitive market. When you have a lot of competition, you’re naturally going to have a lot more models that come out of that market.” Gai took the audience back in time to 1999, when Alibaba founder Jack Ma toured the United States. “China didn’t really have a search engine available, but he got his hands on the latest search engine at the time and when Ma searched for American products like beer and searched for German beer, there were a lot of results, but when he searched for Chinese beer, or anything else Chinese, the screen returned blank,” she said. When Ma realized the entirety of China was not online, he went back to China and picked 18 students who had no experience in the Internet, e-commerce or building web tools. They started to build the first product, Alibaba.

Sharon Gai is an e-commerce, AI and digital transformation expert.

* †

C ©

18 February 2024 DRUGSTORENEWS.COM

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Acne Foaming Cream Wash helps treat and prevent acne on the face and body

Resurfacing Retinol Serum helps reduce the appearance of post-acne marks

*IQVIA, ProVoice Survey, rolling 12-month data as of March 2023. †Based on an independent national survey of pharmacists. REFERENCE: 1. Lynde CW, Andriessen A, Barankin B, et al. Moisturizers and ceramide-containing moisturizers may offer concomitant therapy with benefits. J Clin Aesthet Dermatol. 2014;7(3):18-26. CeraVe is a registered trademark. All other product/brand names and/or logos are trademarks of the respective owners. ©2023 CeraVe LLC CVE.A.P.1255.1

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DSN INDUSTRY ISSUES SUMMIT

com, which is still standing today. Fast forward 20 years. Gai described how the Internet economy took off in China with a variety of different apps. “The Chinese Internet is really like a parallel universe to everything we have in America—the Amazons, the Googles, the LinkedIns and Twitters–but it’s a little more interconnected because of the amount of AI that’s embedded in these products,” she said. When these apps were being built the Chinese tech founders adhered to what Gai called, “first principles thinking,” which is breaking down very complex problems and rebuilding them. When this concept is applied to e-commerce, which is how a lot of different tech apps and tools were built in China, there are three components: your consumer, merchandise or service and the context with which you bring these two variables together. “The changes that happen with these three things create the mountain of different possibilities you can have in the e-commerce space,” Gai said. “This is how Alibaba went from one little web page, alibaba.com, to the entirety of its company.

20 February 2024 DRUGSTORENEWS.COM

AliHealth started as a cloud pharmacy, but its product managers recognized that people were searching for grocery and skin care items, OTCs or certain drugs.

Next, Gai took the discussion to Alibaba Health, noting that China only has about 1.8 doctors per every 1,000 people compared to 2.4 in the United States and 2.8 in the U.K. “This means that resources in health care are very strained in China. When there’s a lot of competition, it breeds innovation. That‘s exactly what Alibaba Health has in terms of its growth trajectory,” she said. AliHealth started as a cloud pharmacy, but its product managers recognized that people were searching for grocery and skin care items, OTCs or certain drugs. “Ali pharmacy was pulled out of Tmall and a separate app was created,” she explained “The product managers noted that there were people searching to buy contact lenses and prescription eyeglasses, they needed eye exams and physical exams, they were looking for sexual health products, or wanted to do STD tests or pregnancy tests. This became a snowball effect and the number of services this app started to cater to. Today Alibaba Health is a full fledged telehealth app.” Gai also discussed how a medical doctor app was created for traditional Chinese medicine, a huge Chinese sector that she described as “a very old school brick and mortar place to play.” “What this medical doctor app did

As a user, you’re constantly learning about health care in general. What AliHealth really did, the big innovation, is consumerization of healthcare services.

was digitize that entire process,” she said. “You open the app, consult with the Chinese medicinal doctor and he will tell you what you need and an entire packet of ingredients will be shipped right to your doorstep.” Addressing the last pillar of Alibaba Health, a business to business pillar in which the creators built out a health knowledge map and traceability code, Gai said, “AliHealth set a standard in creating a QR code that every single brand would need to stick on their packaging so when this product is shipped to the end customer, they can scan it and see exactly where this medicine came from. This is the interface of the telehealth app, where you also can see the balance on your health insurance card, nearby hospitals, a doctor for an online experience, get medicine delivered in around 30 minutes to an hour, order vaccinations, get eye exams, mental health services and medical beauty.” The app also features short-form videos that offer health advice from doctors, who are becoming influencers. “As a user, you’re constantly learning about health care in general. What AliHealth really did, the big innovation, is consumerization of healthcare services,” Gai said. Lastly, Gai said that AliHealth is good at “new retail,” a term developed by Jack Ma in 2016. “It’s basically the unification or the synchronization of online and offline services,” she said. dsn

T I’ 4 to p o th c im s th to p

F w m y

PET SPECIALTY

SUPPLIER PERSPECTIVES

The many impressive numbers behind Purina ONE Adding up the ways this cornerstone of the super premium category has spent a decade showing the power of science-backed nutrition on pet health. By Joe Toscano, Vice President, Trade & Industry Development at Purina They say numbers and data tell a story. So I’ll start with a noteworthy statistic. Roughly 40 percent of pet owners say they are willing to pay more for a pet food tailored to their pet’s needs. At this higher price point, pet owners want a food that does it all – a bowl that creates excitement at mealtime, not compromising on taste, but also has a positive impact on their pet’s health. That’s exactly why such outcome-based brands, like Purina ONE®, the largest pet food brand in the aisle, continue to drive tremendous growth in the super premium category.

A Difference From Day ONE

For a brand that has become so synonymous with just a single number, Purina ONE has many digits worth celebrating, especially this year: 28. Making a pet food selection, especially a change, can be a stressful decision for any pet owner. That’s why Purina ONE has championed the 28-Day Challenge: just 28 days to see a difference in your pet. From a shiny coat to bright eyes and strong muscles, including a healthy heart, this time frame is all it takes for dog and cat owners to see the impact a science-backed nutrition formula can have on the life of their pet. 10. It’s been an incredible decade – 10 years – since the 28-Day Challenge was first introduced to consumers in 2014. And for this super premium brand, created around powerful ingredients found in nature, the results have been a consistent proof point of what you can achieve when you bring nature and research together. 61. To ensure the positive difference that begins on day one continues for a lifetime, there are 61 different formulas of ONE available for dog and cat owners, allowing a diet to be customized for the unique needs of each pet as they grow. 500. At Purina, we proudly have more than 500 scientists, veterinarians and nutritionists on staff, who work tirelessly to uncover breakthrough nutrition, like Purina ONE, that helps dogs and cats live longer, healthier lives. These experts fuel the innovation we believe should be pursued relentlessly, always focusing on the

pet’s nutritional needs, safety and wellbeing. We apply our unrivaled scientific experience in pet nutrition, physiology and behavior to make new discoveries and push boundaries, creating real nutritional solutions for your shelves that can make a profound difference in the lives of pets. 2 million. Yes, million! Since its inception, nearly two million dog and cat consumers have registered to take the Purina ONE 28-Day Challenge. We never tire of hearing the success stories of families who signed up and became loyal customers after seeing the positive, visible differences in their beloved family pets. In fact, many of these stories come from our retailer partners like you, and we love when you share them with your Purina sales representatives. Zero. The number of ingredients in Purina ONE – and in any of our pet food brands – without a purpose. At Purina, we believe nutrition starts with understanding nutrients, not just ingredients. The best ingredients are the ones that work together to enhance one another’s performance. A smarter nutrient blend is more digestible and effective for a pet than

a single ingredient. That’s why we don’t formulate our pet food on an ingredient basis but instead measure how different formulations affect a pet’s overall health. Every ingredient in every Purina dog and cat food recipe was selected for a specific purpose, and with your pet’s health in mind. (You can visit purina.com/ingredients to see pictures and read ingredient descriptions and benefits of every ingredient in every Purina food.) All these numbers are important, but at the end of the day (or at least at the end of this page), we know the most important numbers to you are how many consumers are returning to your store for their pet needs. Ensuring the right mix of science-backed, proven formulas on your shelves converts shoppers to loyal customers. Your Purina sales rep can provide you with additional information on the many formulas available that are tailored for the specific needs of your customers’ pets, including the exciting expansions coming to our Purina ONE line this year.

Purina trademarks are owned by Société des Produits Nestlé S.A.

DSN INDUSTRY ISSUES SUMMIT

2023 DSN Industry Issues Summit: How retailers, pharmacy technology companies are redefining the modern healthcare experience The first panel at Drug Store News’ 25th annual Industry Issues Summit explored how retailers and pharmacy technology companies are changing the healthcare experience By Sandra Levy

How are retailers and pharmacy technology companies redefining and improving the modern healthcare experience? That was the question posed to executives during the first panel at Drug Store News’ 25th annual Industry Issues Summit. The panel, “Redefining the Modern Healthcare Experience,” moderated by Scott Miller, president of strategic, community and specialized pharmacy at McKesson, featured top executives from retailers and pharmacy technology companies. Panelists included Kevin Host, senior vice president of pharmacy at Walmart; Jeff Key, Pioneer Rx president; Julie Lenhard, Wegmans vice president of pharmacy; Craig Norman, H-E-B senior vice president of pharmacy; Dain Rusk, Publix senior vice president; and Tom Utech, iA CEO.

Miller opened the dialogue by asking Host to discuss how Walmart is driving the patient to the right care at the right time and in the right setting. Noting that Walmart has opened 48 clinics in Georgia and Florida and that several more will open in Dallas and Houston next year, Host said, “These clinics are multi-functional, multiservice clinics that will have behavioral health and dental and many will have imaging.” Host said Walmart is working in partnership with UnitedHealth group and Optum to provide value-based care for patients. Host cited the company’s immunization offerings that ensures everyone is protected from disease states, such as COVID and RSV. “We’ve also tried

to take it a step further. This year we launched in 1,100 pharmacies testing and treatment services provided solely by pharmacists for flu, COVID and strep throat.” Emphasizing that there’s a severe shortage of primary care physicians, Host said, “Somebody’s got to fill in that gap and when it comes to acute care, upper respiratory conditions like flu, COVID and strep are at the top of that list. About one third of all urgent care visits are for those type of ailments, so If I can get all my pharmacies and pharmacists able to assess, diagnose and prescribe treatments for those, we’ll create access that is much needed.” Walmart also has created specialty pharmacies of the community around sexual health, HIV care and HIV

Panelists engaged in discussions over the changing landscape of retail pharmacy: (L to R) Kevin Host, SVP of pharmacy at Walmart; Jeff Key, Pioneer Rx president; Craig Norman, H-E-B SVP of pharmacy; Julie Lenhard, Wegmans VP of pharmacy; Dain Rusk, Publix SVP; and Tom Utech, iA CEO.

22 February 2024 DRUGSTORENEWS.COM

THIS

I S A M O V E M E N T.

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DSN INDUSTRY ISSUES SUMMIT

prevention, and more recently it launched specialty pharmacies focused on autoimmunity. The discussion progressed with Norman describing the care delivery team that includes pharmacists, physicians, nurses, dietitians and physical therapists. Norman said that over the last eight to 10 years, H-E-B has gotten involved in primary care after learning that the majority of its more than 100,000 employees to whom the retailer is providing health care did not have a primary care physician or primary care home, but were using urgent care and ERs. “We set out a number of years ago with our benefits team to create an outlet for them,” Norman said. “That has now developed into H-E-B Wellness Primary Care. We have a dozen locations, scattered across Austin, San Antonio and the Houston market. They provide all of the services you mentioned, but in addition, we’ve focused most recently over the last few years on mental health counseling and mental health therapists.” Over the last year, H-E-B began offering a membership program for non H-E-B employees and is partnering with companies to provide this service for their employees. “This is a non-insured model. It’s cash pay. We have a couple of tiers of memberships, for individuals,” Norman said. “A monthly membership fee starts at $99 and goes to $119 a month, and there’s a number of services included under both of those categories. Our primary care doctors and NPs are spending on average about 30 minutes with each person, so this is truly a personalized health experience for them, and it is really making marked improvements in overall health.” The discussion proceeded with Utech addressing the potential evolution technology can play to free up pharmacists to practice at the top of their license. “Technology can be an enabler,” Utech said. “Taking that fulfillment activity that typically has been the pharmacists’ duty, and pulling that centrally so it frees up their time. Obviously, COVID pushed a lot more pressure upon pharmacists in providing patient care.

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There’s opportunity with technology to centralize more of that fulfillment.” Miller advanced the discussion, asking Lenhard, “We’ve heard about concierge care, where patients can pay a subscription and get a level of guarantee on demand attention and monitoring over a year. Where do you see and what could a retail pharmacy version of concierge look like for you? “Our personalized customer care program is going to start with a small pilot on a newly diagnosed diabetic,” Lenhard said. “Where we think we can continue to create value for our customers with our pharmacists engaging with them on a regular cadence, first by just assessing their overall health, their access to health, social determinants of health and quality of life measures, really setting up the preferences of our customers and ensuring they are able to interact with our pharmacy services in a way that’s most meaningful for them.” Lenhard went on to say that Wegmans’ pharmacists can create great connection points with customers based on their disease states. The retailer has been partnering with its nutrition team to help develop health content and webinars for its customers. Wegmans also has wellness keys to help alert customers when shopping what products are vegan, gluten free, lactose free and diabetic friendly. “We’re going to continue to work with Wegmans School of Pharmacy,” Lenhard said. “We see a day where we can be reimbursed and whether that’s with a health plan or employer, certainly we’re going to start similarly to H-E-B with our own employees as well.” Key weighed in on the future of a subscription model, stating, “We’re becoming a subscription society. We have to define what is going to be the model and that the consumer wants to participate, that they want a subscription service, and they want to talk to someone they can trust. Technology will enable some of those interactions. Everyone should be experimenting, figuring out what those consumers want and what

those [subscription] packages are based on age.” Scott shifted the discussion to learn how Walmart’s major store remodeling efforts include pharmacy fitting into the shopping experience. Host shared that for the next cohort of 800 stores this year, Walmart is looking at what that wellness room looks like now that it provides testing and treating and long-acting injectable administration. “Now that pharmacists are being recognized more as providers, now that we’re able to hire additional staff, for i.e., community health workers, we’re able to spend more time with our patients around healthy eating, healthy living,” Host said. “For Walmart, we do A1C screenings and cholesterol screenings in the wellness room. Historically those rooms have been little more than a carve out of a closet. Going forward, we’re looking at multiple wellness rooms, areas for sick people to wait in separately from healthy folks.” Lastly, Rusk discussed Publix’s model and how the retailer is working successfully with health systems. Rusk said Publix has 11 unique health systems it partners with and will announce a 12th this year. “When those partnerships started it was more about getting to the patient at bedside, meds to beds delivery,” Rusk said. “From the health system standpoint, they’re trying to improve their scores, trying to maximize their CMS reimbursement that is critical in driving adherence. The worst thing that could happen to a hospital is to discharge someone, and within 30 days they’re readmitted. It’s very critical that patients leave with those meds, especially patients who may live in a pharmacy desert or who don’t end up having easy access.” Rusk noted that 56% of people who leave the hospital with a medication in hand didn’t get their prescription from a Publix pharmacy previously. “It’s probably the best loyalty program we have today,” he said. “In Publix pharmacy we end up converting almost 37% of them to come on as Publix shoppers. dsn

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DSN INDUSTRY ISSUES SUMMIT

2023 DSN Industry Issues Summit: Integrating front end into pharmacy, state of Retail Media Networks Drug Store News’ 25th annual Industry Issues Summit explored a range of topics, including how retailers are integrating the front end into pharmacy and the state of Retail Media Networks By Sandra Levy

A panel, titled “Integrating the Front-End Into the Pharmacy’s Healthcare Model,” explored ways retailers are merging the front end with the pharmacy. Moderated by Lari Harding, senior vice president of business development at Inmar, the panel included Colette Heimowitz, vice president of nutrition and education at SimplyGood Foods Company; Alex Hurd, Walmart / Canada vice president, health; Sherri Keeth, Sam’s Club vice president, DMM Healthcare + OTC; John Reed, L’Oreal Dermatological beauty general manager; and Jake White, CVS vice president of consumer health and wellness.

White addressed Harding’s first question, why should front end suppliers embrace the development of pharmacy as a healthcare destination, head on: “Our strategy at CVS is authority, convenience and engagement. It’s about building trust with the consumer, building their convenience in healthcare services and then you’ll get traffic that flows through. It’s about frequency and keeping them engaged in their health. You’ll have a different set of conclusions across a number of different retail levers, whether store experience, labor, investment or even pricing.” Hurd took the discussion to Walmart

Canada, which has 400 pharmacies, OTC, 190 vision centers and 72 medical clinics. “Our teams’ purpose is to enhance access to affordable personalized care,” he said. Hurd identified several trends over the last decade, including the shift in customer and patient expectation towards easier access, more affordability and greater choice for healthcare products and services. “Another trend is that of traditional healthcare providers and payors looking to work much more closely with retailers to leverage insights and frequent customer touch points to

(L to r) Moderator Lari Harding, SVP of business development at Inmar; panelists Colette Heimowitz, VP of nutrition and education at SimplyGood Foods Company; Alex Hurd, Walmart/Canada VP, health; John Reed, L’Oreal Dermatological beauty GM; Sherri Keeth, Sam’s Club VP, DMM Healthcare OTC; and Jake White, CVS VP of consumer health and wellness.

26 February 2024 DRUGSTORENEWS.COM

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DSN INDUSTRY ISSUES SUMMIT

deliver health care more efficiently and more effectively,” Hurd said. Harding proceeded to ask, what can we do to utilize built-in advantages and connect the front and back ends of the store to drive more trips, grow the market basket and improve health outcomes? Reed noted that many of the most debilitating skin conditions—such as eczema, acne and psoriasis—are increasing either because of more underlying conditions or people are more aware of them and self diagnosing, but access to dermatology as a specialty is going down, particularly in rural communities. “That takes us to the pharmacist as a potentially very powerful source of healthcare advice direct to the consumer,” Reed said. “When it comes to front store, retailers like consumer product brands need to offer some level of differentiation. Price and convenience are important factors, and obviously the higher pricing the more expectation there is around convenience and service. To be able to deploy a pharmacist to give meaningful recommendations, for example, to recommend a moisturizer with some protection if they’re dispensing a drug that is photosensitive.” Next, Harding asked Keeth to discuss the complementary role front-end suppliers can play as new prescription categories like semaglutides become available at the pharmacy. “Understanding the trends in that space and chronic conditions that are happening in the prescription space is critically important to the complementary products you should be focusing on in the OTC space, even in the HBA space,” Keeth said. “Always make sure you have your finger on the pulse of what’s going on in that pharmacy space.” The discussion continued with Heimowitz addressing how the store should evolve to make it easier for healthcare shoppers to find products that promote their health and wellness. “We know through consumer research that nutrition snacking drives more purchases in frequency than pharmacy

in food and beverage,” Heimowitz said. “Consistent over the last couple of years we know that low sugar is a priority for some consumers. Offer something at the counter or close to the counter at time of purchase so you get that impulse buyer something that has low sugar.” Heimowitz also said protein is important, especially with the GLP-1 consumer, the athlete and the aging female. “The combination of low sugar, higher protein, nutritional snacking at the counter will surprise the consumer. Giving them that impulse buy occasion for nutritional snacking at the counter would help drive frequency in purchase.”

The retail media landscape Another discussion, focusing on Retail Media Networks, titled, “Merchant to Maestro,” featured Andy Murray of the University of Arkansas/Center for Retailing Excellence and chair of the University of Arkansas’s Walton College of Business Customer-Centric Leadership Initiative. Murray noted that Retail Media Networks is a tremendously fast growing media ecosystem that’s been growing about 30% year on year. “In 2024, it’s estimated to be around $61 billion business in the United States,

and $101 billion by 2029. If we continue to see this grow at this rate, by next year, end, we’ll see almost 50% of all digital marketing is going to be through RMNs.” Here are some findings from Coca Cola-sponsored research Murray and colleagues conducted among executives: • Executives see the promise of a better consumer experience and more effective way to connect with consumers through first party data. • RMN could close the loop on what part of my advertising is working and how can I get to consumers. • Executives were “fuzzy” when asked to define customer experience. • For retailers, the promise of incremental revenue is very compelling, but that incremental revenue stream also is very high margin. • This is going to open new avenues to change the relationship between supplier and retailer. • There’s a wide gap between the promise of reality with systemic challenges that need to get addressed strategically on technology, data trust and capabilities. • For the first time the retailer also is a seller. • Source of funding is unclear. • Trust and transparency is a big issue. dsn

28 February 2024 DRUGSTORENEWS.COM

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COVER STORY

GENERATION

NEXT W

How does retail pharmacy capture spending of millennials and Gen Z customers who seek convenience and digital connectivity? BY MARK HAMSTRA

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ith their expanding range of in-store and online healthcare offerings, retail drug stores are well-positioned to meet the healthcare demands of today’s young consumers, according to some observers. Other product categories, however, such as beauty care, may pose more of a challenge for drugstore retailers, who compete against category specialists that are favored by young shoppers. “We know that consumer expectations are shifting across the board,” said Garry Marshall, director of pharmacy strategy for clinical effectiveness at Wolters Kluwer Health, which provides a range of technology solutions for pharmacies. “However, the younger generation of healthcare consumers have grown up in a more ‘on-demand’ society. It is natural that they would have the same expectations of healthcare.” Given retail pharmacies’ abundant presence in their communities, it makes sense that young consumers will want to turn to these convenient locations to get a diagnosis for a minor ailment, for example, he said. Wolters Kluwer’s Pharmacy Next survey found that more than half of Gen Z and millennials (56% and 54%, respectively) have visited a pharmacy for care in the past year, compared with 40%

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of Gen X and 35% of baby boomers. The survey also found that 78% of younger consumers are open to having medications such as antibiotics prescribed by a trained pharmacist.

Providing an omnichannel experience Young consumers will expect their healthcare experience to be flexible, with a digital experience augmenting their in-person care, Marshall said. For example, younger customers have a digitalfirst mentality and are more video- and textcentric than older consumers, he pointed out. That means information provided to young consumers will potentially be more effective if presented in digital formats, he said. “Pharmacies that adopt ways for [consumers] to get their information on demand via QR codes, texts, or video … are going to see more traction and loyalty,” said Marshall. Younger generations are using technology to inform, influence and secure their purchases across all industries and product types, said Phyllis Houston, VP of pharmacy enablement and performance at Cencora (formerly AmerisourceBergen). Houston oversees the development and implementation of Cencora’s pharmacy quality performance and clinical strategies for community pharmacy customers, including those that comprise Cencora’s Good Neighbor Pharmacy network.

The younger generation of healthcare consumers have grown up in a more ‘on-demand’ society. It is natural that they would have the same expectations of healthcare. – Garry Marshall, director of pharmacy strategy for clinical effectiveness, Wolters Kluwer Health

According to the 2023 Good Neighbor Pharmacy Voice of the Consumer shopper research report, younger generations take an omnichannel approach to shopping. They value convenience and leverage technology to search for products and services through mobile apps and websites. The report found that social media, internet search and YouTube ads are the top ways that young shoppers discover new products. “We also know a large portion of Gen Z are buying products based on an influencer’s recommendation,” Houston said, citing research from Hubspot’s U.S. State of Consumer Trends Report. In addition, consumers want to use digital services to have 24/7 access to retailers, including pharmacies, according to GNP’s shopper research. “The quality and competitive price of products, as well as user experience, are also top of mind,” said Houston. “While price is important to everyone, today’s younger generations use technology to compare prices prior to making a purchase.”

Online education and information Pharmacists can use digital channels to engage with their local community by providing education and healthcare information around products and services to support health, wellness and prevention of disease, said Houston. “Being able to access this type of information, at their convenience and when pharmacies are closed, could also help earn the trust and loyalty of new, younger customers,” she said. Houston also agreed that offering more wellness services, such as health screenings, immunizations and point-of-care testing, presents a key opportunity to bring younger shoppers into the store. As pharmacies add more healthcare services, they will need to rethink their staffing and processes in order to meet the expectations of these young consumers around convenience, accessibility and the ability to schedule appointments online, for example, said Marshall of Wolters Kluwer. “We saw some concerns by Gen Z and millennials about whether pharmacies have the capacity to become the new primary care hub, so

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The DSN Top Women in Health, Wellness & Beauty program applauds and recognizes women for their exceptional contributions to both their companies and communities. Save the date and celebrate these extraordinary women who are influencing and transforming the health, wellness, and beauty industry.

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COVER STORY

Meeting Young Consumers Where They Are With younger consumers relying heavily on digital connectivity in nearly every aspect of their lives, some drug store operators have stepped up their online efforts to attract and retain these customers. “It’s no surprise that younger generations shop and engage with pharmacies differently than older generations,” said Shahida Choudhry, pharmacy manager at Palms Pharmacy, a Health Mart pharmacy in Tampa, Fla. “Not only do they rely heavily on social media for information, but it also has a huge influence on what they buy, who they trust and where they shop. You have to capture their attention in such a way that they will listen.” As a result, Choudhry, who has been featured in the Pharmacy Podcast Network’s 50 Most Influential Leaders in Pharmacy Awards, focuses on reaching younger customers via digital platforms, including social media and e-commerce. “We’re on all social media channels, though I would say our biggest push is on Instagram for younger customers and Facebook for older generations,” she said. “We work hard to provide education, but it has to be fun also. We’ve been successful posting about fun and trendy topics, and following with an informational post about weight loss or ADHD. These posts generate interest and questions, and then they’ll start following us, liking us—and ultimately, they start trusting us.” Young consumers are investing money in themselves and in their own wellness, and that provides opportunities for both in-store and online sales, Choudhry said. The retailer uses Shopify as its e-commerce platform, and includes a “Shop Now” link in every social media post and in notification text messages. “We also have a QR code on postcards in our delivery containers to make it as easy as possible,” Choudhry added. Palms Pharmacy’s recent post on energy supplements had more than 10,000 views in just three days. This led to questions for the retailer and engagement with the pharmacy, as well as increased sales, she said. “In order to attract younger customers, I would encourage other pharmacies to get out there,” said Choudhry. “Enlist a clerk, a technician or a younger person on your staff and give them ownership to create and maintain an online presence.” Young consumers are seeking the ease that online purchasing provides, and if retailers have an online store, these shoppers will use it, she said. “Pharmacists are known as one of the most accessible and trusted healthcare providers,” Choudhry said. “It’s my passion to connect with my patients and see their progression. The connection that starts online should in no way change the way I deliver my expertise or the accountability I have to their health and well-being.”

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providing such services for common ailments, such as testing for strep or sinus infections or administering flu shots, will require a bigger or realigned headcount,” he said. Creating workflow efficiencies using tools that support clinical decision-making and provide patient education and engagement can help with the staffing challenges that drug store retailers will face, Marshall said.

Opportunities for OTC products Given that young consumers are prioritizing the importance of living a healthy lifestyle, drug store retailers should stock health and wellness products that align with this desire, said Houston. She cited products such as vitamins, minerals, supplements, and organic and natural local products and noted that retailers should also promote the online availability of these products. Marshall said that the use of pharmacy-based healthcare services among young consumers should carry over into the OTC department as well. “Growth in these categories will likely organically accompany growth in consumer health market share,” he said. “With convenience as the name of the game, stopping in the community pharmacy for a quick strep test, prescription, and a few other needed items will appeal to all consumers, as well as online ordering for store pickup or home delivery. We are going to have a generation of consumers who are going to see this as a standard for shopping.” Consumers following up on healthcare appointments and following their doctors’ guidance could be interested in buying products such as vitamins and sunscreen to procedures such as Cologuard to support their treatment and recovery, Marshall said.

Beauty care and Gen Z Among younger consumers, Gen Z (those born between 1996 and 2010) has already emerged as a distinct group, especially when it comes to beauty and personal care products, said Alison Schilling, managing director and partner in L.E.K. Consulting’s consumer practice.“Gen Z has different values, they shop differently, and they’re getting information differently,” she said.

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A recent research report from L.E.K. Consulting found that Gen Z consumers clearly prefer to shop at beauty specialist Ulta for beauty care products, as cited by 82% of consumers. Amazon followed at 75%, and then Walmart and Sephora were close behind at 74%, and Target came in at 68%. Drug store chains CVS and Walgreens lagged these retailers by double digits, with scores of 55% and 54%, respectively. Claire Davies, managing director at L.E.K. Consulting, pointed out that despite their comfort with digital platforms, Gen Z consumers actually enjoy shopping in bricks-and-mortar stores. “The role of the store is still alive and well, and actually Gen Z wants to shop in-store almost more than the prior millennial cohort,” she said. Almost all Gen Z consumers, however, will start their shopping research online, even though they end up buying the products in-store. This is especially important in the beauty categories, where consumers want to experience the products in person after researching them online, but before they make their purchases, said Davies. “For drug stores, it becomes a matter of what your store is doing to win out for their footfall,” she said.

The value of personal recommendations A key point of differentiation for Gen Z shoppers in the beauty category is the value they place on personal recommendations, said Schilling. “Everyone wants a good value, but they actually want things that work, and they want to have proof that they work,” she said. “They believe social media, they believe the microinfluencers, and they believe their friends and family. They are really looking for that personal recommendation.” One of the challenges that drug store retailers face when it comes to attracting young consumers is the product assortment they offer, said Schilling. Gen Z shoppers are not always as interested in some of the mass market brands that drug stores tend to carry, she said, and are attracted

Gen Z has different values, they shop differently, and they’re getting information differently. – Alison Schilling, managing director and partner, L.E.K. Consulting’s consumer practice

to the wider range of brands and products available at retailers such as Ulta and Target. “Target has expanded their range, and made it more applicable to a wider variety of consumers,” she said. “I think we’ve seen some of the drug stores try and do that, but it just hasn’t been to the same degree that we’ve seen in places like Ulta and Target.” In addition, if a consumer’s online search experience begins with a retailer such as Sephora or Ulta, for example, it follows that the consumer will look to make its purchase at those retailers as well, said Davies. This reinforces the need for drug stores to provide the kinds of digital experiences that can drive young consumers to translate their online research into in-store visits and purchases.

The challenges of private label Companies such as Ulta also offer private label beauty care products that are outside the realm of what most drug stores are merchandising, said Schilling. “Drug stores do a great job with private label in the non-beauty categories,” said Davies. “But there’s a question in my mind around whether the [drug store] brand is going to resonate from a beauty perspective. A company like Sephora is known for beauty, so consumers trust it.” The challenge for drug stores seeking to attract young consumers with private labels in categories such as color cosmetics is that these products require significant investment, said Schilling. “It’s like a high-fashion business,” she said. “There’s a lot of churn. You need to reinvent your color scheme every season, and launch new products. There’s a lot of investment that goes behind all of that.” dsn

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I NS I D E HAIR CARE

Social Media Rewrites Hair Care Rules Content creators are firing up hair care sales; retailers must be ready

The hair care category is the latest to be impacted by the power of TikTok. The #hairtok has more than 100 billion views on the platform. Sales of various hair care products are getting a jolt in sales—much like the skin and makeup sectors experienced— thanks to social mentions. Retailers need a scorecard to keep up and ensure inventory is stocked when a post sends a brand or item’s demand into the stratosphere. It’s not always an easy balance, said Andrea Harrison, vice president of merchandising beauty and personal care at CVS. The retailer keeps an ear to the ground to hear of emerging product trends in an effort to be in stock. TikTok is changing how brands go to market in the category. “Social media has had a profound impact on the hair care industry, providing hair care brands with opportunities to expand their brand presence across various platforms. Brands are reevaluating marketing plans to integrate new social media strategies,” said Meagan Wos, senior category manager for The Emerson Group. “Social commerce, beauty influencers and celebrities regularly showcase diverse hairstyles, products and how-to tutorials inspiring individuals to experiment with their appearance,” Wos explained. “This revolution in the hair care industry is characterized by the ability of social media to connect brands with a broader audience and individuals with the latest trends.” Several mass market brands confirm they experience meteoric sales spikes from social exposure. For example, Firstline’s first viral post came

38 February 2024 DRUGSTORENEWS.COM

Consumers are having more honest and transparent conversations online about hair problems. Health and wellness companies have stepped up their offerings to meet these needs. – Jackie Lane, head of creative and influencer discovery, Popcorn Growth

in March 2023 from an Influencer Partner’s video reel featuring the brand’s Satin WideEdge Bonnet, Detangling Brush, Styling Brush and Triple Edge Styler—all top-selling Evolve items. The reel engaged viewers with more than 13 million accounts reached, 17 millionplus video plays and more than 556,000 likes, according to the company. Mielle’s Rosemary Mint Scalp and Hair Strengthening Hair Oil also flew out of stores after a mention from TikTok “it” girl Alix Earle. Other viral sensations that retailers said moved the needle on their hair sales included Suave Moroccan Oil Infusion, Kristin Ess and OGX Coconut Oil. Recently, TikTok decided to get in on the sales generated on its platform with the opening of a TikTok shop. At first blush, the shop would be considered a competitor. However, Bri Kennedy, director of social media and marketing for Maesa, noticed a halo effect at retail when Hairitage by Mindy

I NS I D E HAIR CARE McKnight debuted on the platform. “The real excitement and traction began once top TikTok Shop affiliate creators started posting tutorials with the Hairitage hair tools,” said Kennedy. Sales soared on the TikTok shop, but also rang up more than double the yearly average at Hairitage’s retail partner, Walmart. One of the biggest trends on TikTok in the hair category is scalp care and products to strengthen strands. Thousands of content creators chronicle their success with brands—both ingestibles and topics—such as Nutrafol, Wellbell, hers and Pura d’ Or. The latter brand received a considerable boost from Hailey Bieber’s TikTok post showing her using its Organic Castor Oil, which is associated with fuller hair. The video has more than 18 million views and “absolutely impacted sales,” the company said. People are more concerned than just washing their hair and are taking to social media to discuss problems and solutions. “Consumers are having more honest and transparent conversations online about hair problems. Health and wellness companies have stepped up their offerings to meet these needs,” said Jackie Lane, head of creative and influencer discovery at Popcorn Growth. CVS and Walgreens have deepened commitments on the shelves to brands that strengthen hair, according to representatives of both chains. Grande Cosmetics, known for its eyelash growth serums, recently expanded into hair thickening lines that are sold at Ulta Beauty. “The next few years will bring new technologies to hair health,” said Emerson’s Wos. “We will

40 February 2024 DRUGSTORENEWS.COM

see the continued rise of detailed hair and scalp analysis services, coupled with specialized hair spas addressing specific scalp issues. The focus on understanding the scalp microbiome and its influence on hair health is here to stay.” She also believes AI and machine learning are revolutionizing hair and scalp analysis with diagnostic tools offering personalized insights into individual hair health. “This opens the door to highly effective and personalized hair care solutions,” Wos said. “Scalp care and biotechnology-backed ingredient sourcing are now intertwined, with a growing preference for eco-friendly and efficient approaches to obtain the best ingredients for diverse hair types.” To meet the surge in demand for scalp health, Voesh introduced a Scalp Massager ($8) designed to stimulate the scalp, improve blood circulation and promote healthier hair. “With a decade of experience in professional beauty, we’re extending our line to cater to consumers seeking the best selfcare routine. Drawing from our professional insights, we understand the crucial role beauty tools play in enhancing the efficacy of skin care products,” said Vera Oh, CEO and cofounder of Voesh NY. “Our future plans include introducing a range of self-care products paired with innovative beauty tools to elevate skin care results.” Dupes have shaken up the makeup and fragrance categories. Now it is hair care’s turn. “TikTokers have been hugely helpful to drug store or more affordable brands with the rise of dupe content. More and more content is around the fact that you don’t need to pay high prices for the more elevated brands to get the same results,” said Popcorn’s Lane, citing TikToker Abbey Yung as an example. Some popular substitutions from on mass market shelves include L’Oréal Ever Pure Bond Strengthening Concentrate instead of Redken Acidic Bonding Concentrate, OGX Argan Oil of Morocco for Morrocanoil and Revlon’s One-Step Blowout Curls for the Dyson Airwrap. L’Oréal just announced it has a new hair dryer to take on the pricey Dyson Supersonic, which retails for $430. At the recent CES show, L’Oréal unveiled AirLight Pro, priced under $400, which is expected to take Dyson head-on. Tutorials for people with textured hair have also been a positive for mass market brands like Mielle, Devacurl, The Doux and Dippity Do, the legendary gel getting a new life under Pacific World. “It’s a curly-haired paradise watching all these creative tutorials featuring our Gelée Mousse and Detangling Spray. These posts have amplified our presence,” said Vera Iwanoff, brand manager for Dippity Do of the nostalgic undergoing a revival. Dippity Do is rolling out Hair Gels in 20-oz bottles— specially curated for the U.S. market to keep the momentum going. The gels have been a proven success in Canada. The industry awaits the biggest TikTok hair trends of 2024. dsn

PHARMACY: GENERIC DRUGS

Nickel and Dimed

Rock-bottom pricing and product shortages are placing increasing pressures on the generic drug sector By Debby Garbato

In recent years, the generic drug industry has been caught up in a vicious cycle of competitive pricing that has reached critical levels. While low prices may initially appease patients and retailers, joy can be short lived because low profits are causing manufacturers to exit categories. Drug shortages inevitably follow, forcing a handful of suppliers to scramble to fill voids left by absconders. Then, the cycle begins anew. Shortages can leave consumers without necessary medications–or substitutions may be made, opening the door for errors and other negative scenarios. With mega retailers demanding aggressive pricing, some drug suppliers have either shut their doors, been acquired or turned to making higher profit drugs. Epipen generics as well as ADHD drugs and certain vital cancer drugs are among categories most affected by shortages. “Generics deflation has been a fact of life for years,” said

42 February 2024 DRUGSTORENEWS.COM

Gambelli Funds portfolio manager Jeff Jonas. “But it’s built up to the point of being unsustainable.” Generics are vital for patients’ financial and overall well-being. The Association for Accessible Medicines said generic and biosimilar savings totaled $408 billion in 2022. Of that, Medicare savings amounted to $130 billion ($2,563 per beneficiary). Combined, generics and biosimilars represent 90 percent of all U.S. prescriptions—but less than 18 percent of savings, with prices of generics declining by about 20 percent since 2019. AAM found that many scarce drugs were in the lowest price tiers. “It’s a huge gripe for me,” said Amanda Samojedny, VP of operations, Amici Pharmaceuticals. “Generics save the U.S. healthcare system billions. They’re valuable to patients and physicians and are more affordable than ever. But really low prices don’t matter if

you can’t get your hands on products. It’s a threat to patient safety and health. The market doesn’t function on value-based pricing, with labor and materials costs increasing. You have shrinking margins because prices are so low. Producing the drug becomes financially unsustainable. Something must give.” When a manufacturer discontinues a drug, it takes months to fill the void, said Tony Rosa, VP of retail sales, Amneal Pharmaceuticals. “Last year, the supply was tight in the market overall,” he added. “It’s hard for manufacturers to fill the void without an impact to their existing business. It creates instability on the supply side. This happened throughout the year.”

Root causes Causes behind declining prices and product discontinuations include retailers’ desire to offer low prices, myriad companies producing the same products and

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acceleration of FDA facility inspections. “For several years, retailers have faced eroding prescription reimbursement and complicated, opaque PBM practices,” said Brad Leonard, VP, pharmacy commercialization, UpsherSmith Laboratories. “Obviously, this drives retail pharmacy’s efforts to utilize the least expensive generic products. They’re aided by limited and consolidated buying groups and the FDA’s multiple generic approvals of the same molecules.” During the past decade, some retailers have taken price cutting into their own hands: CVS and Cardinal Health have a 50/50 joint partnership for generics sourcing; Walgreens owns a stake in AmerisourceBergen; and Walmart partners with McKesson Corp. to source and distribute generics in the United States. Since 2006, Walmart has offered generic drugs for $4. It is also large enough to offer private labels in some categories, including insulin that retails for less than $30. On the supplier side, retail consolidation has made the duplicative manufacturing situation and subsequent low pricing worse. “You have a preponderance of market share residing with a small number of buyers or decision makers and it’s being chased by a much higher number of sellers,” said John Dillaway, EVP, Ascend Labs. “The result is an unbalanced market creating an unhealthy environment for manufacturers.” According to Rosa, there could be up to 10-12 manufacturers competing per product. Drug manufacturers’ decisions to discontinue low profit generics also have been prompted by debt resulting from a merger/acquisition cycle six or seven years ago. “Some took on way too much debt and had to eliminate unprofitable generics to chip away at it,” said Jonas. “I think they’re doing better today. But it’s been a tough decade.”

More site inspections Last year, the FDA increased site inspection frequency after a COVID-19 lull. This resulted in more observations and in some cases import bans. “Some pretty big issues popped up in recent years,” said Rosa. “This led to import bans to multiple manufacturers. Buyers were scrambling to find products. With buyers having consolidated so much, issues become bigger.” In April, the FDA told Sun Pharmaceuticals to take “corrective action” at its Mohall, India, plant following non-compliance with its Consent Decree, noted The Hindu Business Line. This caused a temporary pause in releasing batches until mandated measures were implemented. Specializing in generics, Sun’s offerings include dermatology, cardiology and neurology drugs. In 2023, the FDA also halted imports from India-based Intas Pharmaceuticals following multiple violations. Inta’s efforts to hide “evidence” was reminiscent of a conspiracy-type TV crime drama. According to Becker’s Hospital Review, the FDA found plastic bags of torn quality documents under a stairwell and in a truck and scrap room. It also uncovered manually altered documents and found an analyst pouring acid in a trash receptacle containing drug quality documents. Inta’s offerings include carboplatin and cisplatin therapies used to treat various cancers. These drugs were in severe shortage for months following the ban. “Import bans put much pressure on the market at the beginning of 2023,” said Rosa. “Many suppliers with good FDA track records helped resolve the issue, with some relaunching previously discontinued

44 February 2024 DRUGSTORENEWS.COM

Drugs Introduced to U.S. Market, 2023 & 2024:

In January 2024, Amneal Pharmaceuticals launched fluorometholone ophthalmic suspension. The product received 180-day competitive generic therapy exclusivity from FDA, a status that applies to first-marketed generics of key medicines. FML suspension is indicated for the treatment of corticosteroid-responsive inflammation of the palpebral and bulbar conjunctiva, cornea and anterior segment of the globe. In July, Amneal launched its authorized generic for Xyrem (Sodium Oxybate) oral solution CIII. Sodium Oxybate oral solution, 0.5 g/mL is a central nervous system depressant for treatment of cataplexy or excessive daytime sleepiness in patients with narcolepsy.

In 2023, Camber Pharmaceuticals introduced almost 40 new generic products (22 during the first half of the year) and obtained approval for 43 ANDAs. Its portfolio now encompasses more than 150 generics, with more than 600 SKUs across various therapeutic classes and formulation types. Introductions included Famotidine powder for oral suspension, USP (generic Pepcid), Bupropion HCl ER tablets, USP (SR) (generic Wellbutrin), Eplerenone tablets (generic Inspra), Darunavir tablets (generic Prezista) and Gabapentin capsules (generic Neurontin).

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PHARMACY: GENERIC DRUGS

products.” In April, Canada-based Apotex Inc. even received a Drug Shortage Assistance Reward from the FDA for its “substantial efforts” to resolve a U.S. shortage of varenicline tablets, a smoking cessation product.

Potential solutions Generic drug suppliers are concerned about their future. According to Dillaway, the industry is “at significant risk,” with some companies exiting the market. “We’ve started to see casualties with some manufacturers shutting doors and others showing poor financial results. If untreated, these will augment the number of closures or become acquisition targets.” Industry associations like the AAM, NASPA, NCPA, NACDS and HAD are shedding light on these issues, including the complexity of how patients access drugs and the care pharmacists provide, said Leonard. PBM reform, he believes, can also help. “We must shift focus away from just prescription reimbursement driving to the least expensive generic medications. PBM reform is an important movement that can strengthen pharmacy’s ability to provide care and shed light on the positive impact generics have on public health.” Jonas said pharmacies and PBMs want a cost-plus model under which customers are charged the drug’s cost plus a small profit margin. “This would bring more transparency and take some price pressure off generics. Now, retail pharmacies and PBMs are making more money off generics. If you smooth profits out across different drugs, you won’t squeeze generics as much.” The FDA also has gotten involved. Back in 2017, it announced the Drug Competition Action Plan to encourage “robust and timely competition for generics” and “greater efficiency and transparency” to the drug review process. While there has been some progress and updates to the plan, Samojedny said it is not enough. “The DCA was to make generics more accessible. But the system is set up so prices are pushed lower and manufacturers must discontinue drugs that are financially unfeasible to produce.”

In January 2023, Upsher-Smith Laboratories, LLC expanded its fluoxetine product family with the addition of Fluoxetine Oral Solution, USP, 20 mg/5 mL. It is a generic version of Prozac (fluoxetine) Oral Solution. The fluoxetine oral solution market had U.S. sales of approximately $14.2 million for the 12 months ending November 2022, according to IQVIA. In April, it introduced Fluphenazine Hydrochloride Tablets, USP in 1 mg, 2.5 mg, 5 mg, and 10 mg strengths. It is a generic version of Prolixin. The fluphenazine hydrochloride tablet market had sales of roughly $30 million for the 12 months ending January 2023. In November, Upsher-Smith launched Pitavastatin Tablets in 1 mg, 2 mg, and 4 mg strengths. Pitavastatin Tablets are an AB-rated, generic equivalent to the branded product LIVALO (pitavastatin). The Pitavastatin tablet market had sales of approximately $302 million for the 12 months ending August 2023. Sawai Group Holdings Co., Ltd.’s (Sawai) company, Sawai USA, Inc. holds the ANDA for Pitavastatin tablets. This marks Sawai’s first Paragraph IV product to be launched in the United States.

Harder to replicate Some suppliers are maintaining profits by producing more generics whose manufacturing uses specific equipment that cannot be used to make other drugs. While investments are significant, this makes products more expensive to replicate, eliminating numerous “me-too” scenarios. “Patients see little financial benefit by addition of 10 or more approvals of the same molecule versus other new generic approvals of more complex products where fewer manufacturers may be in the market,” said Leonard. This is true of many biosimilars, which Intas is now emphasizing. In 2024, Camber plans to offer a broader product range, including specialty and oncology medications. Transdermal, ophthalmic, inhalation and nasal technologies use specialized equipment. Amneal has created a dedicated facility to produce Naloxone, which it hopes will be approved soon. “Not many manufacturers are investing the capital or resources to make these products,” said Rosa. “And there’s not enough product in the market.” While measures hold promise, they cannot codify the whole industry, particularly when pricing and the entire supply chain is complex, highly regulated and has many parties involved. And patients still require the lowerpriced generics. But while the situation has been plaguing suppliers for years, price gouging is getting worse. “There’s been a gradual realization of the inflation these guys face,” said Jonas. “But the drug supply chain is so complicated and opaque that it’s tough.” dsn

46 February 2024 DRUGSTORENEWS.COM

S In May, Dr. Reddy’s Laboratories Ltd. introduced Regadenoson Injection, a generic therapeutic equivalent of Lexiscan (Regadenoson) injection. It is available in single-dose prefilled syringes, 0.4 mg/5 mL (0.08 mg/mL). August saw the launch of Saxagliptin and Metformin Hydrochloride Extended-Release Tablets, a therapeutic equivalent generic version of Kombiglyze XR (saxagliptin and metformin hydrochloride extended release) tablets. Tablets are supplied in a strength of 2.5 mg/1000 mg in bottle count of 60 and strengths of 5 mg/500 mg and 5 mg/1000 mg each in bottle counts of 30.

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HEALTH: DIABETES

Diabetes market faces disruption Ozempic and the Inflation Reduction Act represent seismic shifts in what pharmacies can offer its customers By Taffel Sturgeon

Diabetes is certainly making a name for itself these days. In 2023 two events supercharged the category and could radically change the treatment for the 38 million Americans—11.6% of the population–that the CDC estimates suffer from the disease. One event is the Ozempic phenomena (see sidebar), representing a relatively new class of GLP-1 receptor agonist drugs that help manage blood-sugar levels in people with Type 2 diabetes. In 2023, semaglutide (Ozempic) use soared when it was discovered to have an off-label side effect of weight loss. That some 70 million Americans are obese means semaglutide (Wegovy when used for obesity) could turn out to be the biggest blockbuster drug class of all time. “Many physicians are calling GLP-1s game-changers at battling obesity and prediabetes,” said Casey Pflieger, director of retail sales for Owen Mumford, which makes injection pens and needles, including the world’s first reusable automatic insulin delivery pen. “These experts believe we could reverse the T2D trend. This could alter the drug and device market permanently and dramatically lessen reliance on insulin and all devices related to its drug delivery.” Ozempic and Wegovy are administered via injection, which could be a boon for brands that supply these diabetes devices, such as syringes and pens. “Because it is an injection, that could prove beneficial to Allison Medical,” said Brandon Faber, the company’s director of sales, which markets a variety of disposable syringe and pen needle products. The second significant change in the

Drug stores play a vital role in the day-to-day life of Type 1 diabetic patients by offering a range of high-quality, useat-home pens and syringes that bring to patients a sense of ease.

diabetes market is the Inflation Reduction Act, signed into law by President Joe Biden on Aug. 16, 2022. Starting in 2023, the IRA has lowered insulin costs for 4 million seniors and other Medicare beneficiaries with diabetes by capping a month’s supply of each covered insulin product at $35. “We embrace this program,” said Faber, “as more affordable insulin, combined with the affordability and quality of the SureComfort brand, will help improve proper diabetes management.” Under Medicare Part B and Medicare Advantage, when insulin is delivered through a pump that is covered under the durable medical equipment benefit, cost sharing is capped at $35 for a month’s supply of insulin. Medicare Part D covers things like syringes used to inject insulin, according to the Centers for Medicare & Medicaid Services, a federal

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48 February 2024 DRUGSTORENEWS.COM

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go.embecta.com/pharmacypartner *N=230 patients with diabetes across Canada. Participants answered a survey as part of the cross-sectional observational behavioral study. BD helped fund this study. † The study used in-silico probability model of needle penetration depth for posted-hub 4mm pen needles and average human tissue thickness measurements across a range of injection forces and recommended sites, pooled across gender and BMI. REFERENCES 1. Bari B, Corbeil MA, Farooqui H, et al. Insulin injection practices in a population of Canadians with diabetes: an observational study. Diabetes Ther. 2020;11(11):2595-2609. . Rini C, Roberts BC, Morel D, et al. Evaluating the impact of human factors and pen needle design on insulin pen injection. J Diabetes Sci Technol. 2019;13(3):533-545. 3. Frid AH, Kreugel G, Grassi G, et al. New insulin delivery recommendations. Mayo Clin Proc. 2016;91(9):1231-1255. embecta, formerly part of BD. BD is the manufacturer of the advertised products. embecta and the embecta logo are trademarks of Embecta Corp. BD and the BD Logo are trademarks of Becton, Dickinson and Company. All other trademarks are the property of their respective owners. © 2023 Embecta Corp. All rights reserved. BD-85393

HEALTH: DIABETES

Berberine—“nature’s Ozempic”—sales soar Combine the always innovative supplements industry with trend-setting TikTok videos, and you’ve got the latest supplements boom, this time using the herbal ingredient berberine, touted as “nature’s Ozempic.” Semaglutide (Ozempic, Wegovy when used for obesity) is an injectable drug that works by acting as a GLP-1 receptor agonist, which helps the body produce insulin in response to high blood-sugar levels and slows gastric emptying after meals, with the weighty upshot being feeling fuller longer and thus reduced calorie intake and lower body weight. The way berberine works is less clear. It has been shown to act against inflammation in the liver as a means of improving insulin resistance. Other researchers postulated a decade ago that berberine exhibits antidiabetic effects through gut microbiota modulation. Berberine as an oral supplement was found in a 2008 study to be equivalent to metformin (Glucophage) in lowering blood-sugar levels, using 500 mg three times daily for 3 months. In a 2021 study, researchers used 1,000 mg twice daily for 18 weeks to beat a placebo in terms of blood-sugar control and weight loss. Researchers there used berberine in the context of diabetes and non-alcoholic fatty liver disease, which are often linked because excess fat on the liver is also common in those with excess weight. Diabetes and weight gain are so connected that the phrase “diabesity” is now used in patients who have both. In 2022, sales of berberine supplements percolated along at about $350,000 a month, according to bricksand-mortar product scan sales data from SPINS. Viral videos on TikTok linking berberine and blood-sugar control began emerging in January 2023, with attendant sales growing to about $500,000 a month. By March 2023 viral videos began linking berberine to weight loss, and by the start of summer mainstream media reports on the trend led to an additional surge, with berberine supplements sales topping out at about $850,000 a month. “In the age of social media, we’ve seen how viral videos on these platforms have been able to influence sales,” said Scott Dicker, market insights director at SPINS. “Even now, months after the peak of the trend, the supplement continues to see increased sales compared to the ‘pre TikTok trend’ period.”

50 February 2024 DRUGSTORENEWS.COM

agency within the U.S. Department of Health and Human Services. HHS estimates that 1.5 million Medicare beneficiaries will benefit from the new insulin provision in the IRA, with an approximate annual cost savings averaging $500 per person. “The Inflation Reduction Act hasn’t had a direct impact on our business, although it is causing disruption for some of our partners who purchased insulin at higher prices last quarter and are now being reimbursed low,” said Pflieger, who noted Owen Mumford is seeing strong growth with its safety pen needles across Medicare Part D plans. “This is another challenge for pharmacies that are already underwater in so many categories.”

Diabetes Types 1 and 2 Both Type 1 and Type 2 diabetes center around insulin—a vital hormone that is required by the body to properly use sugar, or glucose. Type 2 diabetes is by far the more common type; about nine out of 10 diabetics have Type 2, according to the CDC. Also known as “insulin resistance,” the body either does not make enough insulin in the pancreas or the insulin is not good enough to properly deal with the circulating glucose that happens when the body breaks down foods. Sometimes insulin injections are used to manage bloodsugar levels with Type 2 diabetics, though most of the time it is managed through smart dietary measures and exercise, beverages low in carbohydrates and sugar like the Glucerna brand, natural dietary supplements such as alpha-lipoic acid to improve insulin sensitivity and cinnamon to reduce bloodsugar levels after meals, or pharmaceuticals like metformin (Glucophage). The drug works by helping the body lower production and absorption of glucose, and it helps reduce insulin resistance. Type 1 diabetes, on the other hand, happens when a body just does not produce insulin. That means patients must take insulin or analogues via regularly occurring injections. Type 1 diabetes has long been a challenge for patients, what with the invasive regime of regular insulin injections.

Brands assisting pharmacies Drug stores play a vital role in the day-to-day life of Type 1 diabetic patients by offering a range of use-at-home pens and syringes that bring to patients a sense of ease in receiving the intravenous insulin their body requires to stay alive. “Diabetes management can be confusing and overwhelming for newly diagnosed patients, and injection therapy can be particularly frightening and intimidating,” said Pflieger. “Because of this, Owen Mumford provides complementary Injection Therapy Guides designed to reinforce good injection technique and advise patients of the risk factors of needle

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HEALTH: DIABETES

reuse. We provide these injection guides free of charge to pharmacies, along with complementary pen needle samples.” Owen Mumford’s Unifine SafeControl is emblematic of the company’s innovation mindset; a pen needle used by healthcare professionals, it activates a safety mechanism once professionals are completely confident the full dose has been delivered so that the complete insulin dose is delivered. Another brand, UltiMed, manufactures diabetic devices, pens, syringes and insulin delivery pens in 30-, 90- and 100 counts. It helps drug store staff educate customers with custom microsites containing product information, a short training video, pharmacist talking points and safe sharps disposal resources in both English and Spanish. “The consumer healthcare landscape is ever evolving and changing, what with the growth of high-deductible health plans, customer concerns around affordability, and the presence of cash patients, not to mention the development of e-commerce alternatives,” said Sarah Hanssen, vice president of sales and marketing at UltiMed. “We recommend an overthe-counter, cash pen needle option as an important way for pharmacies to diversify and continue to capture market share.” Allison Medical specializes in providing value to pharmacies as well as downstream to its customers through its SureComfort brand. This goes for both educational materials for pharmacists and affordability for diabetic customers. “While our quality exceeds the Six Sigma standards,” said Faber of Allison Medical, “we offer our items at an affordable cost to pharmacies, allowing them to make greater profits while providing proven quality care for their patients. When patients have access to quality delivery devices at a more affordable price, they are more inclined to manage their diabetes properly; that is, less likely to reuse needles.” Other brands help diabetics with blood glucose monitoring tools. The OneTouch brand helps diabetics know when to avoid highs and lows. Its OneTouch test strips are covered by Medicare Part B. “With Bluetooth-connected meters and our highly rated OneTouch Reveal mobile app, patients can also automatically log readings, track patterns and share data with their care team,” said David DeJonghe, VP, global head of marketing at LifeScan. “OneTouch test strips are also available at the lowest copay on the most health plans and also covered by Medicare Part B.” The OneTouch brand makes educational resources and materials available for healthcare providers, including drug store staff through its website at professional.lonetouch.com.

New studies could upend the market And the seismic shifts in the diabetes market keep on coming. Within Ozempic world, its maker, Novo Nordisk, received approval from the FDA in 2019 for an oral pill version of semaglutide to treat diabetes. In August 2023, provocative new research published in The Lancet using Novo’s 50 mg pill semaglutide (Rybelsus) found a once-daily provision in 667 overweight or obese patients for 68 weeks resulted in a statistically significant weight loss of 17.4% compared to placebo. An incredible 85% of those taking the pill achieved a weight loss of

52 February 2024 DRUGSTORENEWS.COM

5% or more, compared to about 26% for placebo. (Both groups also received lifestyle interventions including counseling on behavioral and physical activity as well as concomitant dietary strategies.) Side effects are mostly consigned to gastrointestinal issues such as nausea, vomiting, diarrhea, stomach pain and constipation. Other new research, published in September 2023 in the New England Journal of Medicine, indicates that taking semaglutide (Ozempic) orally could possibly obviate the need for insulin injections altogether—a finding that, if confirmed with more detailed research, could absolutely be a game-changer in quality of life for Type 1 diabetic patients. The research, conducted at the State University of New York at Buffalo, found that popping pills of semaglutide instead of injections led to the complete elimination of prandial insulin in all patients. Prandial insulin is taken before each meal and it is composed of either short-acting regular human insulin or fast-acting insulin analogues, such as lispro, aspart or glulisine. The researchers also discovered that semaglutide led to the elimination of basal insulin in most (but not all) patients. Basal is a longer-acting insulin, which patients can take just once or twice daily and generally acts in the body for up to 24 hours, though that frequency can change depending on age and weight. “If these findings are borne out in larger studies over extended follow-up periods, it could possibly be the most dramatic change in treating Type 1 diabetes since the discovery of insulin in 1921,” said Paresh Dandona, M.D., Ph.D., the lead author of the study. “Within three months, we were able to eliminate all of the mealtime insulin doses for all of the patients, and within six months we were able to eliminate basal insulin in 7 of the 10 patients. This was maintained until the end of the 12-month follow-up period.” Who wouldn’t rather take a pill than an injection, even with today’s modern pens and relatively comfortable injectables? dsn

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PHARMACY: VITAMINS

6 trends in vitamins and nutritional products Supplements that fit religious diets are forecasted to expand, gummies make waves across age groups and more By Patrick Williams

Keeping apprised of trends can offer retail pharmacies and their partners a glimpse into possible opportunities. From discoveries of new ingredient formulations to diversified product availability for various consumer groups, trends in vitamins and nutritional products will continue to develop in 2024. Miami-based Okay Pure Naturals, which specializes in beauty products, recently began selling gummy vitamins and mineral supplements. Marketing Director Christopher Lopez said the company takes a problem-solution approach when developing products. “The thing that we’re focusing on, really, is solving the problem, being more open-minded about what ingredients are used to tackle that,” Lopez said. “There are timeless ingredients, and there’s new stuff.” Beyond ingredients, classic and fresh product types and forms are resonating with consumers this year.

“Given the broad range of benefits they offer, multivitamins tend to be an entry point into the VMS space as many consumers quickly recognize the value of investing in their overall wellness and start exploring more holistic support through supplementation.” — Bryan Donaldson, chief sales officer, Pharmavite

Multivitamins and vitamin D sales stay strong

In vitamins and mineral supplements (VMS), multivitamins and vitamin D products have become synonymous with the category and remain sought after. A report published by the Centers for Disease Control and Prevention in April 2023 examined dietary supplement use among Americans, focusing on multivitamins and single-ingredient vitamin D supplements. Between 2017 and March 2020, 31.5% of adults and 23.5% of children and adolescents reported taking multivitamins in the past 30 days, according to the survey. Over the same period, 18.5% of adults and 3% of youth reported taking a single-nutrient vitamin D supplement in the past month. In total, 58.5% of adults and 34.8% of youth took a dietary supplement within 30 days of completing the survey. In 2024, consumers continue to take

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multivitamins for immune health, said Bryan Donaldson, chief sales officer at West Hills, California-based Pharmavite, whose brand umbrella covers Nature Made, MegaFood, Equelle, Uqora and Bonafide. “Given the broad range of benefits they offer, multivitamins tend to be an entry point into the VMS space as many consumers quickly recognize the value of investing in their overall wellness and start exploring more holistic support through supplementation,” Donaldson said. For Pharmavite, vitamin D products sales are seasonal, increasing in the winter months, Donaldson added. Ultraviolet rays from the sun produce vitamin D3, so people living in cloudy climates do not easily receive as much as those living in sunnier areas in the winter, according to UCLA Health.

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PHARMACY: VITAMINS

Third-party verifications and certifications help gain consumer trust The vitamin and nutritional product professionals with whom Drug Store News spoke for this story are focused on associating their brands with trust in ingredient sourcing and product manufacturing. One way to achieve this has been by seeking and gaining third-party verifications and certifications. For Okay Pure Naturals, in addition to halal and kosher certification of its gummies, the company’s vegan certification of gummies caters to consumers who do not eat animals or products from animals for various reasons. All of TruLabs’ consumable products are vegan, non-GMO, keto-friendly, gluten-free, soy-free, dairy-free, zero sugar, free of artificial flavors and colors and made in the United States with globally sourced ingredients. Addressing the decision to make products in the United States, Pogue said TruLabs values the country’s high-quality manufacturing processes. All of TruLabs’ nutrition products are manufactured in a facility approved by NSF International, the non-profit organization that tests, inspects and certifies health products, Pogue said. “If you have to source ingredients from all over the place, you want to make sure that those ingredients are third-party tested and independently verified, that you’re putting in there what you have to do,” Pogue said. He said TruLabs also sent its products through WERCS assessments, which test product compliance with various regulations and sustainability requirements for retail acceptance, inventory and sale. “They go through every individual ingredient in every product, from coloring on down, to make sure that it’s safe for the human body, which we already knew it was, but we’ve been verified many, many ways,” Pogue said. Donaldson shared that many of Pharmavite’s products have been stringently verified for quality by third-party organizations such as the non-profit organization United States Pharmacopeial Convention and published in its annual United States Pharmacopeia (USP). “In fact, Nature Made was first to earn the USP Verified Dietary Supplement mark—independent verification of purity and potency—for many of its products,” Donaldson said. Although USP verification takes time, cost and effort, he said consumers deserve the assurances it provides. Consumer trust is important in the business world, Donaldson added, stating that this is especially true for the vitamin and supplement industry. “Pharmavite was founded in 1971 to improve health and wellness by focusing on the basics—complete nutrition through essential vitamins and minerals,” Donaldson said. “Our culture has been rooted in delivering high-quality, science-backed vitamin and supplement solutions ever since, which has earned us the trust of consumers, healthcare professionals, and retailers for over 50 years.”

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Gummies on the upswing

Expanding in use beyond children and people who have trouble swallowing pills, gummies are the fastest-growing segment within vitamins and mineral supplements, Donaldson shared. “Approximately 45% of households now use vitamins in gummy form and we anticipate they’ll be a third of the category by 2025,” Donaldson said. “As such, Pharmavite recently broke ground on a new facility that will manufacture this form for its Nature Made and MegaFood brands and be the site of our Gummy Innovation Center of Excellence, which focuses on product research and development.” Okay Pure Naturals’ decision to break into gummies marks an extension from the business’s beauty specialization, which Lopez said consists of top-selling, one-ingredient products, including castor oil, coconut oil and shea butter. “The demand really first came about as an extension of our beauty line,” Lopez said. “The first ones that we came out with were biotin and collagen. It was just a very natural extension of the beauty offerings that we had. We did it with the same ethos within the company, which is natural, clean ingredients.” Lopez said Okay Pure Naturals’ biotin and collagen gummy products are best-sellers, as are the business’ hair, skin and nails gummies and its multivitamins for men, women and kids,” Lopez said. “It’s a pretty standard assortment at the moment because the thing that we’re using to distinguish them is the fact that they are halal, kosher and vegan as the stand out [qualities].”

PHARMACY: VITAMINS

Product options for religious groups forecasted to expand

Religious practices regarding food preparation and consumption, including kosher diets among Jews and halal diets among Muslims, can extend to vitamins and supplements. In 2021, the Pew Research Center published a report called Jewish Americans in 2020. The report states: “Fewer than one-in-five U.S. Jews (17%) say they keep kosher in their home, including 14% who say they separate meat and dairy and 3% who say they are vegetarian or vegan.” Of survey respondents, those within the following demographics said they keep kosher: 95% of Orthodox Jews, 24% of Conservative Jews, 5% of Reform Jews and 6% of Jews without a denominational association. In a 2007 story published in Drug Store News sister publication Progressive Grocer, Berkeley College marketing professor Dorothy Minkus-McKenna estimated that about 70% of Muslims worldwide follow halal food standards. Globally, between 2024 and 2032, Expert Market Research predicts a 6.7% compound annual growth rate (CAGR) for kosher foods, including supplements, as well as snacks, beverages and other categories. The market research company notes: “The United States has one of the largest kosher foodeating populations across the world.”

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Future Market Insights forecasts a 2.8% CAGR between 2023 and 2033 for the United States halal nutraceuticals and vaccine market. Okay Pure Naturals, whose customers comprise multiple demographics in the United States and internationally, have obtained certification for gummies as kosher, halal and vegan, Lopez said. Of the halal and kosher certifications, Lopez said: “It came about from a lot of our customers—[many] are either from Jewish or Muslim backgrounds. So, we wanted to fulfill those retailers with some sort of supplement option that they can trust.”

Hydration supplements gain popularity

The tides of interest are rising for hydration powder and tablet supplements and their availability for drug stores. These hydration products combine water with electrolytes such as sodium, potassium and magnesium to “help regulate and maintain fluid balance in the body,” Melissa Boufounos, a certified holistic nutritionist, told Fortune. Searches for hydration products on The Vitamin Shoppe’s website increased by 200% between April 2022 and March 2023, according to the retailer’s Health & Wellness Trend Report 2023. The publication states: “Industrywide, SPINS reports

that this category grew by 68% for the 12 months ended March 2023, on top of a 168% increase in the prior year, underscoring the enduring power of this trend.” The demographics of people purchasing hydration products run the gamut, said Brandon Pogue, founder and CEO of McKinney, Texas-based TruLabs. The company’s best-selling product is Hydrate electrolyte drink mix that contains 18 vitamins and minerals. “I think the hydration space is great because it’s everybody,” Pogue said. Pogue began researching nutrition before launching TruLabs in 2018. He said he and his team have been on a mission to help athletes and non-athletes achieve proper hydration, as well as assist them to gain better sleep, workouts, energy and focus through other products. Addressing dehydration, TruLabs outlined in one of its blog posts that athletes who lost fluid equaling 2% of their body mass experienced reduced mental reasoning, motor

“I think the hydration space is great because it’s everybody.” — Brandon Pogue, founder and CEO, TruLabs

coordination and attention spans, citing a 2018 study published in Medicine & Science in Sports & Exercise. Electrolyte imbalances can also cause headaches, fatigue and muscle cramps, according to the Cleveland Clinic. “One of the other things that is important about that is selenium and some of the other ingredients that we have actually have metal inside of them,” Pogue said. “When you’re drinking copper, you’re actually drinking something that’s going to help your electrons in your nervous system communicate better.”

Social media broadens business

Public figures on social media continue to influence vitamin and nutritional product sales. Wellness influencers on TikTok and elsewhere on social media have played a role in driving up magnesium sales for Pharmavite’s Nature Made brand, Donaldson said. “While not all TikTok trends have validity, magnesium is a great example of a trend that many nutrition experts are getting behind and, ultimately, the integration of TikTok and other social media platforms into mainstream culture has officially cemented VMS into today’s zeitgeist by providing more opportunities to educate and drive awareness of VMS uses and benefits,” Donaldson said.

DRUGSTORENEWS.COM February 2024

PHARMACY: VITAMINS

Companies Innovate With Tastier Products

Companies continue to work toward producing better-tasting nutritional products. At TruLabs, controversy surrounding one artificial sweetener led to a new breakthrough: the development of a monk fruit-based sweetener. Monk fruit is a perennial vine native to southern China, according to a 2019 paper published in Frontiers in Pharmacology. “We’re very big on the efficacy of our products, but also really big on flavor,” Pogue said. In its zero-sugar drink mixes, TruLabs currently uses the zero-calorie sweetener sucralose. Sucralose is approved as a food sweetener in the United States and regulated by the Food and Drug Administration as a food additive, according to the agency. However, Pogue said negative attention has surrounded sucralose over the past year. In May 2023, the World Health Organization issued guidance stating that non-sugar sweeteners (NSS), including sucralose, should not be used “to control body weight or reduce the risk of noncommunicable diseases.” According to WHO, a review suggested “use of NSS does not confer any long-term benefit in reducing body fat in adults or children” and that their use can lead to negative effects “such as an increased risk of Type 2 diabetes, cardiovascular diseases, and mortality in adults.” Pogue said he and his team have not seen problems with sucralose. However, he added: “Because of the pain points of people and our consumers talking about sucralose, it caused us to innovate to solve that problem. Doing that, we actually innovated something that we were completely surprised by, which is a natural-based sweetener that tastes better than sucralose.” Pogue said TruLabs will premiere its monk fruit-based sweetener in 2024. Changes, Donaldson said, will propel the vitamins and nutritional products industry forward. “In today’s world, as illustrated by consumers’ ever-evolving vitamin and supplement routines, moving the category forward requires agility and the understanding that we need to continuously test, learn, adapt and grow in order to support our consumers,” Donaldson said. dsn

PRODUCT PICKS Hydrate Trulabs

TruLabs Hydrate is a zero-sugar, non-GMO electrolyte drink mix that replenishes 18 vitamins and minerals, including five vital electrolytes and 1,082 milligrams of electrolytes. The brand said it contains five immune system boosters for daily wellness and six B vitamins for a natural energy boost. Hydrate is gluten-free, dairy-free, vegan and soy-free, with no artificial flavors or colors.

Vitamin D Extra Strength 5000 IU (125 mcg) GummiesNature Made

These gummies offer an extra-strength dosage of the body’s preferred form of vitamin D. The vitamin D3 supplement provides 5,000 IU (125 mcg) per serving to support bone, teeth, muscle and immune health. It comes in strawberry-, peach- and mango-flavored gummies.

Okay Gummies Collagen 60 Count Orange Flavor Okay Pure Naturals Okay Gummies Collagen 60 Count Orange Flavor contains 100 mg of marine collagen for hair and skin health and joint support.

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HEALTH: FEMININE-CARE PRODUCTS

A New Era in Feminine Care

Increasingly knowledgeable, today’s consumers are seeking out cleaner formulations, sustainable solutions and more By Kathie Canning

For a number of reasons, the global feminine hygiene products market is enjoying a growth spurt. According to a 2023 report from The Insights Group (whose U.S. headquarters is in New York), the market was valued at $26,733.3 million in 2022 and is forecast to register a compound annual growth rate of 3.9% between 2022 and 2030. One likely growth driver is the emergence of a “new era” in feminine care. “Women today have access to the knowledge and want the tools necessary to take charge of their own sexual wellness and vaginal health,” explained Jody Currie, director of innovation and business development for the vH essentials brand from Lake Consumer Products, a subsidiary of Pharmacal, Jackson, Wis. “There is a desire to shed the embarrassment historically associated with her period, her sex life and her vaginal health in pursuit of the best version of herself.”

Clamoring for ‘Clean’ In this new era of feminine care, many women also are demanding “cleaner” feminine-care products. As Deeannah Seymour, CEO and co-founder of Nashville, Tenn.-based pH-D Feminine Health, pointed out, interest escalated during the COVID-19 pandemic. “Many people embarked on a healthier lifestyle that included incorporating products into their routines that are naturally derived and holistic, but are also effective and backed by clinical data,” Seymour said. In line with this trend, Seymour’s company recently introduced boric acid vaginal moisturizing gel. The product, available exclusively at Walgreens stores, features hyaluronic acid and vitamin E to alleviate dryness and discomfort commonly experienced by women during menopause, postpartum recovery and other “feminine health journeys.” Kecia Gaither, M.D., a double board-certified physician in OB/GYN and Maternal Fetal Medicine and director of Perinatal Services/Maternal Fetal Medicine at NYC Health + Hospitals/Lincoln in New York, agreed there’s heightened interest in clean ingredients. “I think there has been a scientifically based media drive to understand and acknowledge the existence of the vaginal microbiome and how that plays into many things—from a baby’s immunologic competence postvaginal birth to vaginal health,” she said. “With that being said, products which have chemicals, perfumes, deodorants or powders aren’t readily desired for vaginal health as they may irritate and/or alter the vaginal

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The new Summer’s Eve travel-sized collection is “gynecologist tested, gentle enough to use every day and free from dyes and parabens.”

microbiome, [leading] to increased incidence of vaginal infections like bacterial vaginosis or yeast infections.” The Summer’s Eve brand from Tarrytown, N.Y.based Prestige Consumer Healthcare tapped into the clean trend with the summer 2023 launch of its travel collection. The travel-sized collection includes the Refresher mist, Simply Sensitive wash and individually wrapped Sheer Floral cleansing cloths. According to the brand, the products are “gynecologist tested, gentle enough to use every day and free from dyes and parabens.”

Prioritizing Sustainability The environment also is top of mind for many women when it comes to feminine-care products. A recent influx of sustainable products such as menstrual cups, discs and period underwear aims to meet their needs. Such products also help to lessen the financial burden of feminine-care products, Gaither suggested, as they “pay for themselves after a few weeks or months.” Heather Hughes—group vice president and general merchandise manager, beauty, personal care and seasonal for Deerfield, Ill.-based Walgreens—noted

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HEALTH: FEMININE-CARE PRODUCTS

that Walgreens is seeing more customers add these types of reusable products to their basket to reduce their environmental impact. What’s more, products to make such items easier to use are now available, said Trisha A. Miller, Pharm.D., MPH, BCACP. Miller is supervisor, Pharmacy Ambulatory Services for Pittsburgh-based UMPC and University of Pittsburgh Schools of the Health Sciences. “Steamers are now available to sterilize cups [and] discs instead of having to boil in water on the stove,” she explained. “Products, disposable and reusable, have also evolved to include more diverse options related to size, firmness, materials, shapes, etc.”

Seeking Life-Stage Solutions More informed than ever, today’s women also want feminine-care products that help them manage their vaginal health through various life stages. “An emphasis on odor-eliminating feminine hygiene is more central in the 20s, 30s and early 40s, when menstruation and sexual activity can frequently cause a shift in the vaginal microflora, resulting in elevated pH and increased vaginal odor,” Currie explained. Younger consumers also are “doing a great job” when it comes to educating themselves about the importance pH-balanced products play in vaginal health, Seymour added. But when a woman transitions through menopause and beyond, her focus might be more on vaginal “hydration, lubrication and conditioning to support continued comfort and healthy sex as she ages,” Currie noted. Speaking of menopause, the Clearblue brand from Cincinnati-based Procter & Gamble introduced its Menopause Stage Indicator last summer. It is touted as “the first and only product to combine a woman’s urine FSH (folliclestimulating hormone) measurements with her age and cycle history to indicate her likely menopause stage.” Walgreens recently launched the product in stores. “The reception by our customers has been amazing,” Hughes said. “Clearblue Menopause Stage Indicator will indicate the likely menopause stage as premenopausal, early perimenopause, late perimenopause or postmenopause. This product delivers exceptionally well when it comes to accuracy, which is a top priority for consumers and Walgreens.”

Addressing ‘Period Poverty’ There’s good news and bad news when it comes to the menstrual-care product space. The good news? There’s plenty of innovation tied to cleaner and more sustainable formulations. The bad news? Many people struggle to afford menstrualcare products. Woonsocket, R.I.-based CVS Health has been working to raise awareness of the The Clearblue Menopause Stage Indicator is touted as “the first and only product to combine a woman’s urine FSH (folliclestimulating hormone) measurements with her age and cycle history to indicate her likely menopause stage.”

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pH-D Feminine Health boric acid vaginal moisturizing gel features hyaluronic acid and vitamin E to alleviate dryness and discomfort commonly experienced by women during menopause, postpartum recovery and other “feminine health journeys.”

affordability issue—what’s commonly known as “period poverty.” “We believe that period health is part of holistic health and well-being for women of all ages and backgrounds,” said Sasha Harris, CVS Health’s director of merchandising, women’s health. “In 2022, CVS Health took bold actions to make period products and care more accessible, like reducing the cost of store-brand period products by 25%-plus, paying the tax on menstrual products on behalf of customers in certain states, helping to eliminate state taxes on menstrual products and increasing access to menstrual care by offering new services at MinuteClinic and virtual care.” The retailer built on that work in 2023 by donating period products—up to 1,000,000— to Feeding America through a “buy one, donate two” program tied to CVS Health brand products, she added. It also created the First Period Box to educate young women on, and prepare them for, the onset of menstruation. “The work is part of our broader ‘HERE, Healthier Happens Together’ initiative, which focuses on supporting women’s health,” Harris explained. dsn

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LAST WORD

PBM Trends in 2023, Outlook for 2024 PBMs conducted reviews, focusing on HUB arrangements, prior authorizations, deliveries and more, with anticipated trends for 2024 By Dae Y. Lee, Pharm.D., Esq. and Harini M. Bupathi, Esq.

As 2023 came to a close, Pharmacy Benefit Managers conducted thorough reviews to ensure that their network pharmacies operate in compliance with the PBM’s Provider Manual and Participation Agreement. These reviews consist of PBMs assessing various facets of pharmacy operations, including an examination of past audit performance and any past adverse actions taken against a pharmacy, including network terminations. In 2023, PBMs focused on several key areas during their audits. There was a focus on HUB Pharmacy Arrangements. PBMs increased scrutiny on pharmacies that enter into HUB arrangements, enforcing provisions of their Provider Manuals that relate to such arrangements. Certain types of drugs are more commonly affiliated with HUB arrangements than others. Even if a pharmacy does not disclose or request permission from the PBM prior to engaging in the HUB arrangement, PBMs can still discover that one exists based on the types of drugs the pharmacy is dispensing. As such, although HUB arrangements may not be of significant concern under relevant state regulations, pharmacies must ensure they are complying with the terms of their PBMs contracts before entering a HUB arrangement. Another area of focus was Prior Authorizations across many PBMs. For instance, some PBMs may prohibit a pharmacy from participating in the PA process altogether, while others may allow a pharmacy to fill out PA forms so long as the PA is ultimately submitted by the prescriber. PBM concentration on PAs has increased uniformly. To illustrate, in 2023, Frier Levitt encountered instances where PBMs possessed telephone call recordings where pharmacies represented themselves as members of the prescriber’s office to complete PAs or even check in on the status of a PA.

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Dae Y. Lee, Pharm.D., Esq., CPBS is a pharmacist attorney in Frier Levitt’s Life Sciences Group.

Harini Bupathi, Esq. is an attorney in Frier Levitt’s Life Sciences Group. Her practice focuses on counseling pharmacy providers on their relationships with Pharmacy Benefit Managers and other similar payors.

PBMs also have been focusing on Deliveries, Proof of Receipt and Mailing Restrictions. Following the expiration of the Public Health Emergency (the “PHE”) earlier this year, several PBMs reinstated pre-COVID-19 limitations on mailing and delivery. Thus, PBMs have taken routes to restrict pharmacies from delivering or mailing prescriptions. PBMs are also requiring pharmacies to provide proof of receipt for all mailed prescriptions and are imposing mailing restrictions on certain drugs. Another area of focus for PBMs is Drug Invoice Shortages. PBMs continued to conduct invoice reconciliations, which consist of a review of claims dispensed during a particular period and comparing the total amounts billed for a given drug during that time frame against the total amounts purchased for the same drug during the same timeframe. Drug Invoice Shortage discrepancies have always been a favorite discrepancy of PBMs to allege, but 2023 saw a particular focus on such discrepancies. PBMs have revised their Provider Manuals to impose terms that cause PBMs to misinterpret pharmacy dispensing and purchasing data. In addition to drug invoice shortage discrepancies, PBMs asserted a high number of copay collection, member denial and prescriber denial discrepancies as well. The increase in these discrepancy types can likely be tied to changes to PBM Provider Manuals, which require pharmacies to submit additional documentation to verify a prescription claim. PBMs are expected to maintain focus on HUB pharmacy arrangements, PAs, claims for COVID19 test kits and more. PBMs will likely increase their auditing practices in 2024. Pharmacies should be well-prepared to counteract the aggressive tactics of PBMs and take proactive measures to prevent negative repercussions. dsn

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