Michigan Pharmacist Journal - Jan./Feb./March 2021

MICHIGAN T H E O F F I C I A L J O U R N A L O F T H E M I C H I G A N P H A R M A C I S T S A S S O C I AT I O N

MPA VIRTUAL ANNUAL CONVENTION & EXPOSITION FEB. 26-27, 2021

LESSONS OF COVID-19

2021 Jan./Feb./March | Vol. 59, Issue 1

How chronic disease management has fared in a year of pandemic (p. 18)

E-CIGARETTES EXAMINED The dangers of vaping and how COVID has complicated matters (p. 22)

MichiganPharmacists.org

SUE THE PHARMACIST Recent legal precedents may lead to greater liability for pharmacists (p. 24)

IN THIS ISSUE 2021 MPA ACE

14 3 President’s Platform

MPA President Heather Christensen charts a path of continuing growth in 2021.

10 Advocacy Update

MPA’s legislative priorities in 2021 build on the advancements the profession has made in a year of change.

CSPM FOCUS

PROFESSIONAL AFFAIRS

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4,7 C EO Corner

8 Student Focus

Outgoing and incoming CEOs reflect on the past and create a vision for MPA’s future.

20 CSPM President

Pharmacy professionals in many different practice settings bring unique value to the healthcare team.

Student pharmacists meet the challenges of advocating for pharmacy in a virtual world.

24 Legal Insights

Don’t forget to sue the pharmacist: New litigation in Michigan pharmacists need to know about.

EDITOR: Mark Glasper; ASSOCIATE EDITOR: Dianne E. Malburg; MANAGING EDITOR: Mary Beth Wardell Michigan Pharmacist (ISSN 1081-6089) is the official journal of the Michigan Pharmacists Association, published four times a year at 408 Kalamazoo Plaza, Lansing, MI 48933. Publication Number: USPS-345-600.

Phone: (517) 484-1466, Fax: (517) 484-4893 Website: www.MichiganPharmacists.org, E-mail: MPA@MichiganPharmacists.org, Advertising Information: Visit www.MichiganPharmacists.org/news/advertising or contact Mary Beth Wardell, MPA communications manager, at (517) 377-0232 or MaryBeth@MichiganPharmacists.org

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All opinions expressed in Michigan Pharmacist are not necessarily official positions or policies of the Association. Publication of an advertisement does not represent an endorsement. Michigan Pharmacist is subject to the standards established by the Association. Michigan Pharmacist is distributed as a regular membership service, paid for through allocation of membership dues.

Nonpharmacist subscriptions are $40 annually. Postmaster send address changes to: 408 Kalamazoo Plaza, Lansing, MI 48933.

Periodical postage paid at Lansing, Mich. Nothing in this publication may be reproduced in any manner, either in whole or in part, without specific written permission of the publisher. © Michigan Pharmacists Association, 2021

— PRESIDENT’S PLATFORM —

AFTER A YEAR OF CHANGE, MPA CONTINUING TO GROW IN 2021

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ogether, in 2020, we all have experienced changes – not only to our personal lives, but to our professional lives – that have led to growth. This growth through constant change has been hard for me at times, as I expect it has been for you, but when looking back over the last year, it would not make sense to simply go back to the way things were in a lot of instances. The pandemic and its impact on the world have demanded our laser focus to prevent pauses in the care we provide the communities we serve. In 2021, I see the most significant changes to the Michigan Pharmacists Association (MPA) in areas of leadership, population health and how practice in a virtual world will impact pharmacy professionals and our communities.

BY HEATHER CHRISTENSEN,

clinical pharmacy specialist, ambulatory care, Spectrum Health West Michigan; president, Michigan Pharmacists Association

We start with the bittersweet retirement of Larry Wagenknecht. During his tenure of 37 years leading MPA, he has helped to grow the organization in many sustainable ways that continue to serve us well. I applaud his dedication to the practice of pharmacy and patient care in Michigan. Retirement for Larry is well-deserved and I foresee he will continue to be a pillar within the profession. With Larry’s continued commitment to a smooth transition and ongoing support, we welcome Mark Glasper. As noted in the press release announcing Mark’s acceptance as the new chief executive officer of MPA, I applaud his significant experience leading nonprofit organizations and his most recent position leading the Kentucky Pharmacists Association, where he worked to positively impact reimbursement rates for the State of Kentucky. I look forward to working with Mark now that he has joined the team.

Although it has been a tumultuous year in politics, I would be remiss not to include political leadership as one of the significant changes for our state and country in this election year. Elections create opportunities for us to lobby and educate newly seated elected officials about issues relating to pharmacy and healthcare delivery. It is imperative that we continue the efforts of those that came before us to preserve the extraordinary work already accomplished as we continue to innovate and foster equality.

Politically speaking, the profession has grown a lot since the Omnibus Budget Reconciliation Act was approved in 1990 (OBRA90), which required pharmacists to help patients understand their prescribed medication and what to expect from it. Still, there are many opportunities to improve upon the delivery of care from pharmacy professionals, including point-of-care testing, mitigating illness by allowing administration of vaccines for all ages and cognitive services through medication therapy management. Current advocacy efforts are leading to growing acknowledgment from medical and public health professionals outside pharmacy making the prospect of how much we can achieve electrifying. Because we already have the benefit of being a membership organization in which all pharmacy practice settings work together with the common goal of equity for our patients, many opportunities may be realized.

to provide medication for our patients, along with empowering licensed pharmacy technicians to support such infrastructure, provides us an opportunity to expand direct patient care. The management of chronic disease such as hypertension in the community by pharmacists is no longer futuristic. The prevalence of hypertension in Michigan is 57.4 percent, which is 1.26 percent higher than the national average.1 By building strength and understanding within the profession, and by crafting and promoting the right legislation, we can make strides toward our goals. We can remove the barrier of provider status and implement practices supported by studies nationwide that show pharmacists decrease the burden on primary care settings by allowing pharmacists in the community to provide such care.2 This requires focus on the work that so many before us have done to change reimbursement processes to allow for sustainable workplace models.

Further understanding around the issue of lack of healthcare access is essential to shed light on how telepharmacy and regulation reforms allowing for direct care by pharmacy professionals can address this.

From finding ways to safely provide virtual care for our patients, to creating platforms to continue to provide education and networking opportunities to our members, MPA is working hard for pharmacy professionals. That’s why I am excited for the MPA Virtual Annual Convention & Exposition this year. The team at MPA is building an excellent virtual event that will allow us to grow professionally from the safety of our homes. I look forward to seeing you there.

MPA continues to prove a strong organization with leadership from each of you. It is with courage and curiosity that we will independently make a difference.

The challenge to improve the health of our families, however, lies in the collective collaboration of our Michigan pharmacy professionals to creatively break down barriers to allow meaningful work and engaged patients.

REFERENCES: 1. Chronic Conditions by prevalence, State/County https://cms-oeda. maps.arcgis.com/apps/MapSeries/index.html?appid=2653fc1758 474036a46c1a2f47d4d243 2. Pharmacists’ contributions to hypertension control go beyond dispensing, Surgeon General says. APhA October 20, 2020.

Pharmacist.Com

The continued recognition of the safe use of technology 2021 Jan./Feb./March | Vol. 59, Issue 1

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— CEO CORNER —

GLANCE IN THE REARVIEW MIRROR, FOCUS ON THE FUTURE

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have had the honor and privilege to write something for every Michigan Pharmacist journal published by the Michigan Pharmacists Association (MPA) since January 1983. Truth be told, it is often a struggle! This issue has been the most difficult, because I have written it multiple times in my head over the past several months, only to scrap it and start over again! So here goes – my last article...

BY LARRY WAGENKNECHT,

pharmacist, outgoing chief executive officer, Michigan Pharmacists Association

Note: Larry Wagenknecht has retired as the chief executive officer of the Michigan Pharmacists Association effective Jan. 17 after 37 years with the Association. He is succeeded by Mark Glasper, former CEO of the Kentucky Pharmacists Association.

Since my focus at MPA has always been on the future, looking in the rearview mirror is unusual. However, several of my friends have suggested that I touch on some of the things that have been most important to me over the past 37 years of “practicing” pharmacy at MPA. Here are a few of the relationships and events that come to mind.

Our excellent and dedicated staff are one of the most important factors contributing to what we have accomplished as an Association over the years. Each day, our staff come to work with the specific goal to make pharmacy a better profession. It is their passion and commitment to our members that constantly amaze me.

I truly thank all the current and former employees for the work they have accomplished, and for challenging each of us to improve and fix problems in the profession. I want to thank Dianne Malburg for her insights, her creativity and her extremely strong work ethic. Many of the successes at MPA are a direct result of her commitment and dedication to MPA, our members and the profession.

I am equally proud and thankful to have worked with the many individuals who have served in MPA leadership over these 37 years. These individuals have come from almost every pharmacy practice setting and have provided their special insights and diversity to the discussions during MPA Executive Board meetings. They have inspired and energized me by providing unique ideas and provided the horsepower and push to get things done. This, combined with the work of individual MPA members, resulted in great outcomes. Thank you to each of you for your commitment to MPA and the pharmacy profession.

Lobbying and development of health policy have been my major passions. Over the years, we have influenced many pieces of legislation and Board of Pharmacy Administrative Rules that impact pharmacists and pharmacies daily. High points include regulating physician dispensing, controlled substances, Medicaid reimbursement, opioid awareness and others.

In collaboration with many innovative individuals, I have had the opportunity to develop several unique programs. The top three efforts of which I am proudest are the creation and growth of the Pharmacy Technician Certification Board (PTCB), making Michigan one of the first in the country to allow pharmacist immunizations and the creation of the

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Michigan Health Information Network (MiHIN).

While the creation of a nationwide pharmacy technician certification program was the vision of my predecessor, Lou Sesti, I had the opportunity to work with national and other state pharmacy organizations to make it happen. Since PTCB was created in 1995, nearly 728,000 pharmacy technicians have been certified. PTCB has enabled pharmacists to become more involved in patient care activities and I believe it will allow further expansion of the role of pharmacists in the future.

Michigan was one of the first states in the country to empower pharmacists to immunize patients using a collaborative practice agreement. Thanks to the work of Dr. Ron Davis, Michigan’s chief medical officer at the time, and MPA staff, we were able to get clarification from the Michigan attorney general that the term delegation described in the Michigan Public Health Code extended to pharmacists. As a result, pharmacists across the state began using collaborative practice agreements to expand the role of the pharmacist in patient care. Michigan’s success has since spread across the country and will continue to be critical in resolving the COVID-19 pandemic.

Information is critical, especially in health care. I was appointed by Gov. Jennifer Granholm to serve on the Michigan Health Information Technology Commission.

While serving, I was asked to be a co-chair of a task force of the Michigan Department of Community Health to create the Michigan Health Information Network (MiHIN) in 2010. MiHIN is a non-profit corporation that is the state’s designated health information entity. I was appointed to the MiHIN Board and have served as chairman of the board since its creation. The value that MiHIN has brought to health care in this state and country is immeasurable.

Michigan continues to be the leader in the country in the sharing of health information. My only regret is that at this time we have not yet resolved the software issues of community pharmacy operating systems communicating with the electronic medical records of physicians and health systems. I believe this will be resolved in the near future!

I came to work for MPA with the desire to make a difference – to improve the profession. While there have been successes, there is still much more to do! I challenge the current and future leaders of MPA to continue working to establish systems for pharmacists to receive fair and adequate payment for the patient services they provide (especially in the area of primary care), work to integrate healthcare information into the pharmacist’s routine workflow and continue to find ways to maximize the use of technology that is available to us to improve patient care.

With your continued support – we will be successful!

— EVENTS CALENDAR —

EVENTS CALENDAR MPA, local association and national pharmacy organization events as well as health observances are included below.

For the most up-to-date information, please visit our online calendar at www.MichiganPharmacists.org/eventscalendar.

JANUARY 2021

1-31 1-31 20 21 22 28

Friday, Jan. 1 – Sunday, Jan. 31

National Birth Defects Prevention Month Nationwide

Friday, Jan. 1 – Sunday, Jan. 31

National Slavery and Human Trafficking Prevention Month Nationwide

FEBRUARY 2021

1-28 3 5

Wednesday, Jan. 20 PSI Board of Directors Meeting Virtual Only

Thursday, Jan. 21

MPA Professional Affairs Committee Meeting Virtual Only

Friday, Jan. 22

MPF Health Professional Leadership Academy Session Virtual Only

Thursday, Jan. 28

CSPM Board of Directors Meeting Virtual Only

5 22 23 26-27

Monday, Feb. 1 – Sunday, Feb. 28

American Heart Month Nationwide

Wednesday, Feb. 3

MSCP Board of Directors and Committee Meetings Virtual Only

Friday, Feb. 5

National Wear Red Day for the American Heart Association Nationwide

MARCH 2021

1-31 19 23

Friday, Feb. 5

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Monday, Feb. 22

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MSPT Board of Directors Meeting Virtual Only MPA Executive Board Meeting Virtual Only

Monday, March 1 – Wednesday, March 31 National Kidney Month Nationwide

Friday, March 19

MPF Health Professional Leadership Academy Virtual Only

Tuesday, March 23

American Diabetes Association Alert Day Nationwide

Wednesday, March 24 PSI Board of Directors Meeting Virtual Only

Monday, March 29

MPA Executive Board Meeting Virtual Only

Tuesday, Feb. 23

MSHP Board of Directors Meeting Virtual Only

Friday, Feb. 26 Saturday, Feb. 27

MPA Annual Convention & Exposition Virtual Only

MPA & PSI Executive Fellowship Program Accepting Applications The Michigan Pharmacists Association (MPA) and Pharmacy Services Inc. (PSI) are accepting applications for the 2021-2022 Executive Fellowship program. The application deadline is 4:30 p.m., Friday, April 9, 2021 with interviews conducted no later than April 23, 2021.

The year-long MPA and PSI Executive Fellowship program provides a unique opportunity to gain business, management and leadership skills that all pharmacists need for a successful and rewarding career in any pharmacy practice setting. Please visit www.MichiganPharmacists.org/fellowship for more information about the Executive Fellowship and share this information with any pharmacist(s) who you believe would be a great fit for the Executive Fellowship.

If you have any questions, please contact Dianne Malburg, fellowship director, at Dianne@MichiganPharmacists.org or Farah Jalloul, fellowship assistant director at Farah@MichiganPharmacists.org.

2021 Jan./Feb./March | Vol. 59, Issue 1

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ISABELLE JANE BROWN

GREG S. UMSTEAD

Born April 26, 1928, in Cresson, Pennsylvania to LeRoy and Catherine Durbin, she passed away Oct. 21, 2020, surrounded by her family and under the loving care of the staff at the Henry Ford Allegiance Hospice Home.

Dr. Greg Umstead passed away peacefully at his home in Huntington Woods, Mich. on Friday, Nov. 6, 2020, following a long battle with pulmonary disease. He received his B.S. in Pharmacy (Cum Laude) from The Ohio State University College of Pharmacy and his Doctor of Pharmacy degree from the Philadelphia College of Pharmacy. In 1978, he relocated to Michigan to join the faculty of Wayne State University College of Pharmacy and Health Sciences where he would continue to teach hematology/oncology for more than 40 years. He practiced as a member of the Department of Pharmacy at William Beaumont Hospital in Royal Oak, Mich. for 15 years and developed a collaborative oncology research program with the Department of Medicine’s Oncology Division there. He moved his practice to the Department of Pharmacy at Ascension Health’s St. John Hospital in 2007 and continued to care for patients there until just a few months prior to his passing.

He was formally recognized as an outstanding educator, preceptor and mentor many times during his career and his advice and expertise in hematology/oncology pharmacy practice

Isabelle (as well as her husband Denniston) attended the University of Michigan College of Pharmacy, where they both graduated with a Bachelor of Science degree in Pharmacy in 1949. Isabelle and Denniston owned and operated Brown’s Pharmacy for 35 years until their retirement in 1996. The business continues to be operated by Grant and Austin Brown.

She was a member of the Michigan Pharmacists Association for more than fifty years and an acknowledged innovator in the business of pharmacy and best practice models in the community and long-term care pharmacy settings. She was forever grateful for the opportunities and support she received from the community. Isabelle was known for her kindness, razor-sharp wit and unabashed observations. She traveled the globe – often with grandchildren – loved to cook, hunt partridge and play bridge.

were well known and frequently sought by colleagues throughout the region.

Dr. Umstead is survived by his wife Carlene, his son, Patrick Umstead, of St. Clair Shores, Michigan and his daughter, Dr. Meghan Umstead of New York City.

MEMORIES

MEMORIES

MEMORIES

— BIOS AND MEMORIES —

TYLER W. STEFFEY Dr. Tyler W. Steffey was called home to heaven on Nov. 16, 2020. He died peacefully with his wife and family at his side. He loved life and lived it to the fullest.

He leaves behind his wonderful wife Katy, his parents: Jeff and Michele, brothers: Nicholas (Danielle) and Brent, and his beloved dogs: Kona and Benelli.

Tyler received his doctorate in pharmacy from Ferris State University and was owner of Central Drug Store in Charlevoix, Mich.

NEW STAFF BIOS EDUCATION ASSISTANT Alisha Swanchara joins the Michigan Pharmacists Association (MPA) as the education assistant, with more than seven years of experience as a meetings professional. She graduated from Grand Valley State University with her bachelor’s degree in hospitality tourism management with an emphasis in meeting and event management. Prior to MPA, Alisha was a meeting and event manager for a third party planning company where she planned national conferences for association and corporate clients. When not engaged in planning, she enjoys spending time relaxing, traveling and camping with her family, including her husband, Gunnar, and Bernese mountain dog, Baxter. She is very excited to interact with and get to know the members of MPA and looks forward to assisting them in planning successful meetings, trainings and networking events.

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— CEO CORNER —

LET’S GET STARTED G

reetings MPA Members! I am truly honored and humbled to serve as your chief executive officer, succeeding longtime CEO Larry Wagenknecht. I appreciate the confidence your Executive Board has in my abilities and likewise with the search committee, whose members reviewed qualifications of many fine candidates before settling on only a few for the Executive Board to consider. I was impressed with the entire search process led by Immediate Past Chair Jessica Bessner and Search Committee Chair Chris Maksym.

Coming off three-plus years as the executive director of the Kentucky Pharmacists Association, I look forward to utilizing my pharmacy knowledge and lifelong association management experience to build on MPA’s past successes and take the organization to greater heights on behalf of our dedicated members throughout the great state of Michigan.

BY MARK GLASPER, chief executive officer, Michigan Pharmacists Association

So, why MPA? Your Executive Board asked me that very question during the interview process. For me, it was an easy answer.

MPA is a financially healthy, well-respected state pharmacy association. I’ve seen and heard firsthand the high regard other state pharmacy executives have for MPA due in large part to outgoing CEO Wagenknecht.

Larry and I first met at a National Alliance of State Pharmacy Associations (NASPA) meeting and it was easy to see how our peers at the event considered him a dean of the state pharmacy association execs. I have to thank Larry for making me feel at home at MPA while mentoring me over my first and his last couple of months on the job.

MPA has an engaged Executive Board with dedicated volunteers throughout the organization. Nothing is more important to an incoming association executive than to have members who understand the importance of having a member-driven organization. That culture starts at the top and permeates down through committees, local associations and the rank-and-file members. I saw this level of dedication and involvement during the interview process and it drove me to want the job even more.

Finally, all pharmacy practice settings are represented under the MPA umbrella. That is a huge plus. I had no such luck in Kentucky where all the practice settings were represented by separate organizations. Being united as we are in MPA allows us to lobby more effectively with legislators. We may still have our spirited discussions internally, but we present a united front to legislators.

What are you going to do first as CEO? Again, this was another easy question for me to answer during my interview process.

I always want to meet members first and foremost. I’ve always enjoyed getting out and meeting with members, especially in their work setting. It helps me understand what demands you face on a daily basis, and it allows you to get to know me better. Of course, COVID-19 has altered such plans but that doesn’t mean we can’t get to know each other better. I’ve been Zooming nonstop since I started my tenure at MPA Dec. 1, 2020. I’d be happy to Zoom with you or even just share a phone call or email as a get-to-know-you and, in time, I hope to meet every MPA member in person!

Strategic planning is one of my passions, and I want to revisit the current MPA Strategic Plan with the Executive Board to determine what updates, if any, are required. I had the opportunity to review the current Strategic Plan during the hiring process and I was impressed. It had what I consider to be the essential elements of any good strategic plan – mission, vision, goals, etc. However, it also had a timetable, budget and metrics to determine progress. Not all organizations have this level of detail in their strategic plans, so I took this as a good sign that MPA is serious about its strategic plan.

Surveying also is one of my interest areas that I believe is essential to good association management. I have a saying, “I can’t tell you where you’re going unless I know where you’ve been.” That’s what surveying does for you. Therefore, I want to be sure we survey members on an annual basis, so we are able to track your wants and needs and determine if there are any trends we need to address. Small focus groups about individual topics, whether in person or via Zoom, also will help us drill down to uncover specific interests or concerns to consider.

He’s from where?

You may have heard that I’m from Ohio. That’s true. I was born and raised in Toledo, similar to Larry who was born in Toledo but raised just across the state line in Michigan. I’ll wager we’re the first back-to-back CEOs anywhere in this country who were born in Toledo.

However, that’s where our geographical similarities ended until now at MPA. I graduated from The Ohio State University with a degree in journalism/public relations while Larry went to “that school up north” and became a respected pharmacist and association management professional.

I, too, found myself in association management via marketing and communications positions before becoming an executive director/CEO. So that brings me back to MPA and why I’m here. As I indicated in my interviews: • • •

I can grow MPA, I can improve MPA member satisfaction, and I can raise awareness of MPA and the profession.

That’s because I’ve accomplished these tasks in previous positions and I look forward to doing it with MPA! 2021 Jan./Feb./March | Vol. 59, Issue 1

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— STUDENT FOCUS —

STUDENTS GET INVOLVED

IN PHARMACY ADVOCACY, VIRTUALLY

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ith the current pandemic, the norms of education have shifted greatly. Wayne State University (WSU) graduate students in the field of pharmacy have had to adjust their studying habits.

Following the shutdown in Michigan announced in March 2020, professors around the state had to adjust to a new method of teaching. Zoom meetings are now becoming the standard way of instruction, and many precautions are set in place for limited onsite learning such as labs and clinicals.

BY RANEM KISHMISH, 2023 Pharm.D. candidate, Wayne State University College of Pharmacy and Health Sciences; member, MPA Student Pharmacist Executive Council

Leslie A. Hamilton, from the department of clinical pharmacy and translational science at the University of Tennessee Health Science Center College of Pharmacy, conducted a survey in June 2020 that collected the responses of nearly 1,900 students from 29 schools of pharmacy in the United States. The results of the survey showed that 47 percent of students preferred live lectures and 30 percent preferred a blended course. While students saw the value of online learning, it’s clear there are aspects of the profession that are best taught in person, such as immunization techniques, clinical visits, etc.

Inspired by the University of Tennessee study, I decided to survey the Wayne State University Pharm.D. class of 2023. More than two-thirds of the class responded.

According to the results, 57 percent of students stated that they preferred traditional in-class instruction, while 34 percent preferred the hybrid option, and 9 percent

said they preferred being completely online. Most of the surveyed students mentioned that they previously studied with others in libraries and coffee shops and had found that to be beneficial for fully understanding the material.

However, now these students have learned to adapt to studying at home and messaging or calling each other for further clarification. Organizations have also had to adapt to new ways of reaching potential members.

As the chair of the Student Michigan Pharmacists Association at WSU, I had to become creative in how I could promote and encourage membership for our student chapter. I created a PowerPoint presentation with voiceover to explain what the organization is, why it is important to join and how to become a member. This presentation was given to incoming first-year pharmacy students to convey the importance of being a part of this organization and educate them about its goal. In addition, I made a flyer about Pharmacy Day at the Capitol, which is one of our organization’s largest events, to inform students about how they could join the event virtually.

Overall, pharmacy students seem to be adapting well to the shift from live lectures to virtual learning. Many still have concerns about finding a quiet place to study or take exams, but most of us have found a way to cope with the circumstances and continue to work hard to support our future patients on the path to better health.

Student pharmacists, MPA staff and other pharmacy professionals gather outside the state Capitol Building in Lansing, Mich. during Pharmacy Day at the Capitol on Sept. 17, 2019.

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— MEMBER BENEFITS —

COMPLIMENTARY MEMBERSHIP OFFERED Local, Practice Section Membership Included When You Become an MPA Member

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BY SPENCER HIGGINS, membership development manager, Michigan Pharmacists Association

his year, the Michigan Pharmacists Association has seen many pharmacy professionals join our ranks. We welcome you with open arms as we have a much stronger membership with you among us. Being an engaged member in MPA is a great way to start networking, advocating and advancing the profession. Whether you have just joined MPA or you have been a part of our efforts to further the profession for years, we want to take this opportunity to help our members maximize the impact of their membership.

When you become a member of MPA, you receive complimentary local association membership. Local associations are local groups under the umbrella of MPA that provide an opportunity to foster relationships with fellow pharmacy professionals in your community.

When you designate yourself as a member of a local association (referred to as a “local”) with MPA and that local adopts approved bylaws and maintains compliant status, they are eligible for all privileges and services of an affiliated local association, including operational funding for each member like you. Members can review a state map of different local association areas across the state online at www.MichiganPharmacists.org/locals. If you don’t live in the area

of an existing local, you can still join one of them and you can even work with MPA staff to start a new local.

In addition to local associations, MPA members receive complimentary practice section membership. Practice sections are groups of members who operate in the same pharmacy settings, such as community or health-system pharmacy. Each practice section offers unique networking and collaboration opportunities with others working in similar pharmacy settings. The practice section options include the Consultant and Specialty Pharmacists of Michigan (CSPM), the Michigan Society of Community Pharmacists (MSCP), the Michigan Society of Health-System Pharmacists (MSHP), the Michigan Society of Pharmacy Technicians (MSPT) and the Student Michigan Pharmacists Association (SMPA). Build professional relationships within your practice section affiliations and take full advantage of your membership.

If you have any questions about your local association or practice section affiliation, please reach out to Membership Development Manager Spencer Higgins at Spencer@MichiganPharmacists.org or (517) 377-0259.

2021 Jan./Feb./March | Vol. 59, Issue 1

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— ADVOCACY UPDATE —

2021 MPA LEGISLATIVE PRIORITIES A

BY BRIAN SAPITA, government affairs manager, Michigan Pharmacists Association

new Michigan Legislature convened in January. All Michigan Pharmacists Association (MPA) members are encouraged to reach out to their state legislators and U.S. congresspeople to get to know them and identify yourself as a pharmacy resource. Educating our policymakers about pharmacy is essential to advancing our profession.

Michigan Legislative Agenda

• Pharmacy Benefit Manager (PBM) Transparency: Educate policymakers on healthcare reimbursement and work to facilitate fair business environments by promoting legislation that addresses issues such as prescription drug pricing and reimbursement, fair audit practices, mandatory-mail order programs and PBM transparency.

• Access and Implementation of Technology: Work with LARA, the Michigan Health Information Network (MiHIN) and other stakeholders to provide pharmacists access to patient electronic health information and enhance the ability of the pharmacist to utilize technologies that result in the improved health and safety of the patients pharmacists serve.

• Advance Pharmacy Practice: Work with Medicaid, Michigan Department of Health and Human Services (MDHHS), managed care plans and other stakeholders to implement strategies that further utilize the services of pharmacists to provide access and improve the health care of the people of Michigan.

• Workplace Environment: Educate policymakers on the importance of promoting and supporting a culture of safety and work with stakeholders to improve the workplace environment to enhance medication safety.

Federal Legislative Agenda

• Fair Pharmacy Reimbursement: Work with both MDHHS and the Department of Insurance and Financial Services (DIFS) and other stakeholders to address direct and indirect remuneration (DIR) fees and other issues to achieve fair reimbursement for pharmacy services.

• Rules Promulgation: Work with the Board of Pharmacy within the Department of Licensing and Regulatory Affairs (LARA) to create fair and equal rules governing the practice of pharmacy in the state.

• Opioid Epidemic: Work with stakeholders to create and pass public health policy to decrease diversion and keep patients safe while maintaining patient access to medications for appropriate use and advancing the pharmacists’ role in medication-assisted treatment.

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• Direct and Indirect Remuneration (DIR) Fees: Support national efforts to limit the inappropriate use of DIR fees as a method of recouping dollars from pharmacies after a claim has been adjudicated.

• Provider Status: Work with national organizations and pharmacy stakeholders to support access of pharmacy services to patients through the recognition of pharmacists as providers under Medicare Part B.

• Reimbursement: Support national efforts to improve the frequency of updates to drug pricing standards, expand upon Medicare’s any willing pharmacy provisions and increase transparency requirements for PBMs.

2021 Jan./Feb./March | Vol. 59, Issue 1

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— MEMBERSHIP —

MPA MEMBERSHIP: A Look Back at 2020 T his year has been a challenge for the pharmacy profession and all of our communities across Michigan. COVID-19 has pressured us all to adapt and find new ways to achieve our goals. The Michigan Pharmacists Association (MPA) is no different. We are continuing to innovate and adapt to the obstacles in our way and provide our members with the tools, resources, information and other support needed to advance the profession of pharmacy and provide quality patient care.

BY SPENCER HIGGINS, membership development manager, Michigan Pharmacists Association

Members of MPA continue to strengthen their practices and advance the profession through advocacy. The Michigan Pharmacy Political Action Council (PAC) and MPA have had major wins this year and continue to build and develop coalitions of pharmacy professionals influencing decision-makers in Lansing and Washington.

We had a successful virtual Pharmacy Day at the Capitol (PDAC), and we encourage members to continue to be a force for advocacy during these times as the profession is being altered so dynamically.

With so much changing so quickly, information is everything. MPA members have been kept informed with crucial information through special COVID-19 updates, in addition to the regular publications such as the bi-weekly electronic newsletter, Pharmacy Related News (PRN), the quarterly Michigan Pharmacist journal, and four regular practice section newsletters. Members have also received discounts on MPA publications such as Michigan Pharmacy Law: A Guide to the Statutes and Regulations and the Pharmacy Certified Technician Training Manual, assisting in further development of pharmacy professionals.

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MPA continues to be a resource for professional practice development. Members are entitled to free consultations with MPA staff on issues related to Board of Pharmacy actions, licensing, third-party payers, professional practice issues, legislation and employer/employee relations, as well as continuing education offerings, information about employment opportunities and more.

Networking is incredibly important, and during 2020, it was more difficult than ever. Local associations and practice sections have found safe ways to continue to provide opportunities to build connections with others in the profession to address the needs and concerns of their communities and practices. Membership in local associations and MPA practice sections is complimentary with MPA membership. If you have yet to make use of that benefit, we highly encourage you to do so. MPA is working now on our first ever virtual Annual Convention & Exposition (ACE) and remains committed to bringing the pharmacy profession together however we can to advance pharmacy in Michigan.

We at MPA are humbled and motivated by the perseverance, ingenuity and commitment of our members. Pharmacy professionals, and our communities, are stronger together. Thank you for trusting MPA. If you have any questions about your membership benefits or how to get more involved, please reach out to Membership Development Manager Spencer Higgins at Spencer@MichiganPharmacists.org or via phone at (517) 377-0259.

— MPA EXECUTIVE BOARD —

MPA EXECUTIVE BOARD

Elections for the 2021 Michigan Pharmacists Association Executive Board were held last October, and the president-elect and board members took office Jan. 1, 2021. Installation ceremonies will be held virtually at the MPA Annual Convention & Exposition’s award ceremony on the evening of Saturday, Feb. 27, 2021.

CHARLIE T. MOLLIEN

HEATHER L. CHRISTENSEN

MIKE W. CROWE

MARK GLASPER

Hudsonville

Rockford

Grand Blanc

Lansing Area

CHAIR

PRESIDENT

PRESIDENT-ELECT

HEATHER M. SOMAND

KATIE AXFORD

JOSEPH LEONARD

Ann Arbor

Rockford

Flushing

TREASURER

SPEAKER OF THE HOUSE

VICE SPEAKER OF THE HOUSE

SECRETARY/CEO

HOPE M. BROXTERMAN Traverse City

RYAN J. GREENLEY

JOSEPH HARONEY

SARAH E. HILL

JESSE H. HOGUE

Chassell

Chelsea

Fowlerville

Portage

DOREEN KERN

RYAN D. MOORE

JAMIE THARP

THOMAS TOMASKI

Traverse City

Zeeland

Ann Arbor

Gaylord

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— ON THE COVER —

MPA VIRTUAL ANNUAL CONVENTION & EXPOSITION FEB. 26-27, 2021

BY MARY FARRINGTON, CMP, director of education, Michigan Pharmacists Association

The Michigan Pharmacists Association (MPA) is pleased to offer the 2021 Annual Convention & Exposition from Friday, Feb. 26, to Saturday, Feb. 27, as a complete virtual experience. MPA is committed to including the primary elements that you’ve come to expect of the Convention in a visually-captivating, virtual environment. The virtual offering will be comprised of three important components – education, access to suppliers and products, and networking. This will allow you to make meaningful connections and learn about valuable tools to improve your practice at a time when the practice of pharmacy has proven to be particularly challenging.

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To enhance this engaging experience, you will first enter a virtual conference center lobby. Within the lobby, you can choose what you want to do next: go to the exhibit hall, attend educational programs, socialize at a networking activity, recognize award recipients, create a personalized schedule of events, obtain pharmacy resources and recognize award recipients at the awards reception.

As a registrant, you will be able to visit with exhibitors at various times on Friday and Saturday to learn of the latest in pharmacy-related products.

— ON THE COVER —

EDUCATIONAL PROGRAMS Opening Session Officially kicking off the Convention is Dr. Parker Crutchfield, Ph.D., associate professor of medical ethics, humanities and law at Western Michigan University’s Homer Stryker M.D. School of Medicine in Kalamazoo, Mich. In this role, Dr. Crutchfield conducts clinical ethics consultations, teaches medical students and residents, and conducts research in medical ethics.

Throughout the pandemic, Dr. Crutchfield was part of a group of medical ethicists that were consulted during the allocation and distribution process of therapeutics.

He will speak on the ethical allocation of vaccines specifically related to COVID-19.

His presentation will begin at 9:30 a.m. on Friday, Feb. 26.

Keynote Session Dr. Jason Wasserman, Ph.D., will deliver the keynote session on the timely topic of health equity in a program titled The Social Determinants of Health and Contemporary Pharmacy Practice. This session will take place on Saturday, Feb. 27 at 8:30 a.m.

Dr. Wasserman is an associate professor in the Department of Foundational Medical Studies at Oakland University William Beaumont School of Medicine in Rochester, Mich. His scholarly work focuses on the medicalization of homelessness, the sociological impacts of the epidemiological transition on medicine, and the influences of neighborhood infrastructures and community networks on health outcomes among the urban poor.

Closing Session The Convention’s closing session will feature Paul Osincup, a speaker and self-described positive workplace strategist who helps organizations create happier, healthier and more connected places to work. His presentation, “Burnout is a Laughing Matter: Using Humor to Decrease Stress & Boost Resilience”, will be on Saturday, Feb. 27 at 4:15 p.m.

Self-Care Challenge Organized by the National Alliance of State Pharmacy Associations (NASPA) and the Nonprescription Medicines Academy (NMA), the NASPA-NMA Self-Care Challenge is returning to the Convention with a few changes this year. The Self-Care Challenge provides student pharmacists an opportunity to showcase their extensive over-the-counter (OTC) knowledge against their rival student pharmacists in a lighthearted competition, while granting continuing education credits for attendees. This year’s competition will feature three student pharmacists from each college of pharmacy in Michigan: Ferris State University, Wayne State University and the University of Michigan. These three schools will compete virtually in a threeround, jeopardy-style competition for a chance to be crowned victor!

Continuing Education Careful attention has been paid to create pharmacy continuing education programs that not only help pharmacists and pharmacy technicians fulfill licensure and certification requirements, but also help you grow in your healthcare setting as a community, consultant, specialty or health-system pharmacist or as a pharmacy technician. General programs on the following topics will also be offered during the Convention: diabetes, workplace violence, United States Pharmacopeia (USP) updates, dealing with difficult coworkers, expanded roles of technicians, medication therapy management, precepting in a

virtual environment, opioid use disorder, vaccine trends, pharmacy law, ethics, pain management and patient safety.

You can earn up to 13 hours of live credit during the virtual event, plus an additional 15 hours of non-live credit after the event.

Networking Opportunities With a little creativity and lots of determination, MPA leaders and staff are working hard to make this year’s conference as memorable and fun as years’ past. Each day and night of the convention will offer a variety of customized networking and social events to give convention participants that familiar feel of the Convention.

Two coffee hours are being planned with CEO Mark Glasper and President Heather Christensen to offer members the chance to connect directly with each of these new MPA leaders.

The Michigan Society of Pharmacy Technicians will be hosting their Tech Connect Social Friday evening from 4:455:45 p.m. Activities are being planned to promote camaraderie and networking among pharmacy technicians across the state.

The Student Pharmacist Executive Council (SPEC) are planning a virtual student social at 6-7 p.m. Friday evening with games and a trivia challenge to create friendly competition among student pharmacists from each of the three Michigan colleges of pharmacy.

Student pharmacists can also participate in the Michigan Society of Health-System Pharmacists leadership networking program on Saturday. In past years, students from every college would sit together for lunch with a health-system pharmacy leader to talk about professional practice issues, career options and share fun stories. At our virtual conference, these valuable interactions will still take place. Students won’t want to miss it!

MPF Charity Auction Each year, the Michigan Pharmacy Foundation (MPF) hosts a Charity Auction in conjunction with the Convention. While the tradition will continue, MPF will be launching a new virtual format and the Charity Auction will be open for bidding Feb. 15 through March 1. The extended bidding period will 2021 Jan./Feb./March | Vol. 59, Issue 1

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— ON THE COVER —

MPA VIRTUAL ANNUAL CONVENTION & EXPOSITION FEB. 26-27, 2021

not only allow MPA registrants to bid during the Convention Feb. 26 to Feb. 28, but allow bidders from all over the state and even the world to bid on unique items.

The virtual nature of the auction means physical contributions must be delivered to the MPA office and then shipped to winning bidders. The additional shipping costs make some small, classic auction items less feasible. However, donors are getting creative with innovative prizes that require few, if any, shipping costs. The Charity Auction is a key part of the MPF’s ability to better communities throughout Michigan by advancing pharmacy leadership, education and research in order to promote the highest level of patient care. We encourage members not just to contribute auction items, but to help spread the information about the auction to their family, friends and colleagues.

To donate, fill out the donation form at www.MichiganPharmacists.org/education/ convention and indicate your contribution.

Your donation is tax deductible. For questions, please reach out to Spencer Higgins, MPA membership development manager, at Spencer@MichiganPharmacists.org or (517) 377-0259.

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Awards Recognition

House of Delegates

Traditionally, MPA has honored the many distinguished individuals who serve and advance the profession of pharmacy and the health of our patients at our Annual Awards Ceremony. MPA recognizes a number of worthy awardees, including our 25-, 40- and 50-year members with the Years of Membership Awards; our Pharmacy Hall of Honor inductees, as well as our elected boards, leaders and fellows for their service. MPA also honors scholarship recipients, practice section awardees, the MPA Pharmacist of the Year and other honorable awardees.

The MPA House of Delegates is the policyforming body of the Association, comprised of pharmacy professionals from across the state with delegates from the Executive Board, the Michigan Society of Pharmacy Technicians, local associations, regional societies and the Michigan colleges of pharmacy. The 2021 House of Delegates will convene virtually on Sunday, Feb. 28, to discuss proposed policy changes and resolutions and review the MPA Bylaws.

After discussion and voting on any proposed changes, resolutions are directed to the MPA Executive Board for review and recommendation.

While the realities of the pandemic prevent us from gathering for a banquet, our virtual platform will still provide our distinguished awardees and membership the excitement and ceremony they deserve. This is a unique opportunity to gather virtually to honor and thank those who have stepped up during a difficult and unusual year in our profession.

Registration Go to MPA’s website at www.

MichiganPharmacists.org/education/ convention to register. Reduced registration rates make this an affordable event.

Individuals registering for Friday and Saturday will also have access to the virtual conference platform post-Convention with the opportunity to earn additional continuing education credit.

— LEGISLATIVE UPDATE —

LAME DUCK ROUNDUP:

WHAT HAPPENED TO THE LAST BILLS OF 2020

BY BRIAN SAPITA, government affairs manager, Michigan Pharmacists Association

T

he 100th Michigan Legislature came to a close on Dec. 31, 2020, with a new group of legislators being seated for the new year. Any bills that were not sent to Gov. Gretchen Whitmer for her signature have “died” and will need to be reintroduced in 2021. Below is a rundown of bills that the Michigan Pharmacists Association (MPA) was tracking heading into the final weeks of 2020 and the outcomes for each.

2. Pharmacists may operate in an area that is not designated on the pharmacy license but may not prepare sterile drugs in this area.

Electronic Prescribing

4. Substitution of therapeutically equivalent medication is allowed when a critical shortage exists without authorization of a prescriber. Again, a pharmacist must inform a prescriber if such a substitution happens.

Legislation was signed into law in April 2020 with language that would require prescribers to electronically submit all prescriptions, including controlled substances, beginning on Oct. 1, 2021.

According to the law as written, prescribers can apply for a waiver to this law if they can prove the move will cause financial hardship, if there is not reliable internet or the prescription will be dispensed in the same facility as it is written. The bill also authorizes the Department of Licensing and Regulatory Affairs (LARA) to delay the implementation date if the federal Centers for Medicare and Medicaid Services (CMS) delayed the Medicare requirement for electronic transmission of controlled substance prescriptions beyond Oct. 1, 2021. The delay cannot exceed the implementation date of the Medicare requirement. Outcome: CMS delayed enforcement of E-prescribing until 2022, but is still encouraging prescribers to implement as soon as possible. No decision has been released by LARA on whether they will extend the enforcement date.

Public Act 332/Senate Bill 879 Sen. Peter MacGregor (R-Rockford) introduced language that would codify executive order 2020-124 requiring insurers and health maintenance organizations (HMOs) to cover any emergency refills of covered prescription drugs dispensed by a pharmacist. Contract provisions governing out-of-network benefits and cost-sharing may still apply. This law is in effect until the end of the pandemic.

Outcome: Signed into law.

3. Pharmacists may dispense and/or administer drugs to treat COVID-19, pursuant to protocols established by the Centers for Disease Control and Prevention (CDC) or the chief medical officer of the Michigan Department of Health and Human Services (MDHHS).

5. Preceptors may supervise student pharmacists remotely to fulfill eligibility for licensure and to avoid delaying graduation.

6. Pharmacists may supervise technicians and other staff remotely through a real-time audiovisual camera system (telepharmacy), but there must be a pharmacist present in the pharmacy during this time.

7. Pharmacists holding a license in good standing in a different state will be deemed to be licensed in Michigan to do business, though they may not deliver controlled substances.

8. Wholesale distributors holding a license in good standing in a different state will be deemed to be licensed in Michigan to do business, but they may not deliver controlled substances.

This law is in effect until March 31, 2021. Outcome: Signed into law.

House Bill 5938 Rep. Frank Liberati (D-Allen Park) has introduced language that would require pharmacy benefit managers (PBMs) to be licensed within the state. Additionally, the bill would require parity between a PBM-owned pharmacy and a pharmacy not under their ownership. A prohibition on gag clauses is also included. Outcome: Expired in the House Ways and Means Committee.

Public Act 324/Senate Bill 920

Senate Bill 612

Sen. Peter MacGregor (R-Rockford) introduced language that would codify executive order 2020-124 to apply during the COVID-19 state of emergency:

Sen. Curt VanderWall (R-Frankfort) introduced legislation that would require insurers to post information on prior authorization requirements on their website and provide statistics on approval and denial rates. For denials, the health professional would have to be notified of the reason for the denial and be provided with a remedy for steps moving forward on future requests. Urgent requests would have to be addressed within one business day and non-urgent requests within two business days. Outcome: Expired in the House Health Policy Committee.

1. Pharmacists may dispense emergency refills for up to a 60-day supply of non-controlled maintenance medication. When filling an emergency refill, the pharmacist must: • inform the patient they are doing so under EO 2020-93,

• inform the prescriber in writing within a reasonable time of refills dispensed,

• make a reasonable effort to communicate with the prescriber regarding the refill, and make note of efforts to reach the prescriber, and

• the prescriber will not incur any criminal or civil liability as a result of filled prescriptions.

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— CSPM FOCUS —

CHRONIC DISEASE MEDICATION MANAGEMENT DURING A PANDEMIC: LESSONS LEARNED FROM COVID-19

I

BY ADAM KING,

MPH, CPhT, PRS, presidentelect, Michigan Society of Pharmacy Technicians; MSPT liaison to the Consultant and Specialty Pharmacists of Michigan Board of Directors

n the early days of the SARS-CoV-2 (COVID-19) pandemic, healthcare resources became increasingly stretched thin. This was especially true in congregate care settings and clinics that specialize in managing patients with chronic illnesses. Clinics were closed to the general public, basic care appointments were cancelled, and healthcare providers were denied access to our most vulnerable patients. This absence of care created a vacuum for pharmacists that needed renewed prescriptions, and patients who no longer had access to care.1–4

Care Delay Impacts After the COVID-19 outbreak started in the middle of March 2020, the impacts on preventative care and elective procedures were swift, often with severe impacts to patients who require this care.5,6 In late March, after an emergency declaration was enacted by Gov. Gretchen Whitmer, all elective procedures and faceto-face routine care appointments were cancelled.1,2 The economic impact of these sweeping regulations forced health systems to furlough office staff and some practitioners as a cost-saving measure.7 Physicians quickly transitioned to telehealth to continue care. While many physicians considered this stopgap measure adequate, many physicians surveyed stated that the care was sub-standard, with mental health patients suffering worsening health outcomes.8,9 Japanese health agencies report that suicide completion deaths in November outpaced deaths

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related to COVID-19.10 Here in the U.S., substance use disorder has resurfaced as an epidemic of concern, worsened by the lack of social interaction for those recovering from the disease.11 The disease population that seems to have suffered the most from the COVID-19 pandemic is that of people with diabetes.6 Telehealth for diabetics actually improved access to care, but the continuation of preventative care has not resulted in improved clinical outcomes.

The continuation of care also did not reduce the susceptibility of diabetics from contracting severe and often fatal cases of COVID-19.8 As clinics closed and patient options to renew prescriptions dried up, many state governments permitted pharmacist-prescribing for non-controlled substances.12 This measure allowed current therapy to continue, which prevented bad situations from getting worse. The consequences were more dire for patients that lacked control with their current therapy.9,13,14

Executive Orders Temporarily Expand Pharmacist Practice Scope As COVID-19 ravaged our communities in March, many states enacted regulations to expand pharmacy services.12 This made sense from a health education standpoint. Pharmacists are often cited as the most available healthcare professionals.

Some of the services authorized by states in the early days of the pandemic included emergency extensions

— CSPM FOCUS — of prescriptions that didn’t contain a controlled substance. Other states authorized pharmacists to provide some urgent care needs. Federally, pharmacists are permitted to provide point-of-care testing for COVID-19.

At the time of publication, most executive orders are now rescinded, but some in Michigan have been replaced by health department orders and legislative actions.5,15 As public health agencies became increasingly stretched, pharmacists and pharmacy technicians that volunteer on various Medical Reserve Corps became involved in managing public health interventions.16 Some of the actions that involved pharmacists included using geographical information to inform health departments of outbreaks, performing contact tracing and tracking hospital capacity information. This pandemic has opened many doors for pharmacists to increase their scope of practice and have a greater impact on public health. Yet, as of Oct. 13, 2020, only eight states reported having enough contact tracers to meet the needs of another surge in cases.16 Furthering the crisis of care during this pandemic was the loss by our patients of their employer-sponsored health care. More than half of Michigan residents receive health insurance from their employer.17,18 When their employment stops, so does their health insurance. This can leave costly therapies out of the reach of our patients and reduces access to healthcare, a major social determinant of health.

Vulnerabilities in the Drug Supply Chain As the COVID-19 pandemic dragged into the summer, a new threat to the health of our patients with chronic ailments emerged as our global drug supply became strained from global manufacturing restrictions. Our excess supplies ran dry, which caused patients to stockpile already scarce resources. Pharmacists were forced to make ethical decisions on how to manage these problems with little legal backup from professional liability.19

Hydroxychloroquine’s original promise as a potential treatment for COVID-19 created additional unwarranted strain on scarce resources. An already twitchy medical community began stockpiling medication, leaving patients suffering from malaria, rheumatic diseases and lupus searching pharmacies across the country. This prompted licensing authorities to enact regulations that require prescriptions for scarce drugs to list a medically indicated diagnosis on the prescription.20 COVID-19’s impact on the drug supply is not just limited to the manufacturing side.

As cases ramp up and intensive care units from coast to coast continue to become inundated, the demand of hospitals is diminishing our current supplies for intubation drugs such as sedatives and neuromuscular blockades, along with ventilation equipment.21 The global supply chain and current goods manufacturing practices do not permit manufacturers to increase the supply of necessary medications in short periods of time.

What Have We Learned?

Pharmacists’ prescribing rights have been hotly contested in the United States. In the event of a public health emergency, these prescribing rights have become a cornerstone of the public health emergency response.

Other countries, such as the United Kingdom, have allowed independent pharmacists prescribing authority since 2006 with little noted change in patient safety.22 The scopes of practice for a pharmacist in prescribing involve a range of permitted activities. In some Canadian provinces, pharmacists can interpret a prescription and make a therapeutic substitution during times of drug shortage, while in some states, pharmacists can only work under very limited collaborative practice agreements.22

prescriptions during declared emergencies.

For instance, Senate Bill 1151 was introduced in September, but lost traction in committee and will need to be reintroduced in the next legislative session.23 This expansion of the pharmacist’s scope of practice can improve access to health care during times of emergencies.

Since people diagnosed with diabetes appear susceptible to infections, pharmacists and pharmacy technicians should also become trained in diabetes self-management and education. This value-added service is reimbursable from insurance companies and can fill gaps in patient care when patients are unable to seek care from their prescribers.

Studies show that these additional pharmacy services can improve health outcomes for patients in terms of diabetes control.

Drug supply stabilization is another critical element that must be addressed. Global drug supplies are already strained, and future pandemics are likely to exacerbate the situation. The Strategic National Stockpile is not adequate for a national emergency due to lack of investment. During the initial COVID-19 outbreak, many states only received enough supplies to supply hospitals for a few hours.24,25 In an attempt to secure scarce medical supplies, states had to bid against each other and other entities in the absence of a national coordinated plan.

Conclusion While the COVID-19 pandemic continues to ravage our state, there are many lessons we have learned about the pharmacist’s role in chronic disease management and their ability to expand a patient’s care options.

As we continue to work through this global health emergency, there are many more lessons we will learn.

References available upon request from the MPA office.

The Michigan Legislature has seen efforts to codify expanding the pharmacist’s scope of practice to allow the extension of

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— CSPM PRESIDENT —

WHAT’S ‘SPECIAL’ ABOUT PHARMACY PROFESSIONALS A

BY SISTER PHYLLIS KLONOWSKI,

R.Ph., M.S., president, Consultant and Specialty Pharmacists of Michigan; member, MPA Professional Affairs Committee

s this article is penned, 2020 is drawing to a close. It has been a time of transition made almost surreal by the compounded realities of natural disasters, wildfires wiping out communities and displacing thousands, and a pandemic sequestering family, friends and colleagues for nearly a year. It has interrupted gatherings for arts, business, sports and worship and challenged us to use virtual platforms to bring family and community together for holidays and other special events. In addition, warp speed has been applied to technology, manufacturing and transportation, bringing together the best and brightest to break records and norms to give us personal protective equipment, hand sanitizers, masks and up to three vaccines to combat an unseen, often unfelt viral enemy.

We are living in a time of significant healthcare challenges. The worldwide pandemic and environmental disasters have added sustained strain to personnel and supplies. Technology and medical advances in detection, monitoring and treating COVID-19 are moving at a speed almost beyond comprehension.

And you, pharmacists and technicians, are beacons of hope and light in the midst of all this change.

You are special, because you are present and accessible, and you can be depended upon. This carries through to emergencies and disasters, as well as daily pharmacy operations, as they are complicated by increased cleaning, decreased handling and social distancing, alongside changes demanded by aging, disability and injury.

You are special, because of your knowledge of the community you serve. By observing and listening, you ascertain what is required in a given situation. With knowledge and understanding, you network and obtain what is needed or a viable alternative. This is especially crucial in the face of the ongoing needs compounded by COVID-19’s ever-changing demands.

You are special, because you communicate. Each patient served is respectfully acknowledged and receives medication with information about its use, possible effects and how to take it effectively. You also prepare patients for changes in appearance, cautions and adjustments in storing, preparing, administering or

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taking a medication safely. You communicate with other medical professionals to advocate care, avoid possible complications or duplications, and to assure treatment.

You communicate with insurance companies, verifying coverage and helping keep medication therapy within both medical and insurance guidelines. You communicate with legislative and civic leaders, advocating for public policies that support access and safety in health care.

You communicate in-season and out-, in-person and live, via interpreter, phone, Skype, telehealth and Zoom (to mention a few means employed) to help everyone see, hear and engage to serve patients and improve outcomes in these difficult times.

You are special, because you are versatile and adaptable.

The uniqueness in your focus reflects a love of people you believe can live with good health. The rich variety in the settings where you bring medication include: the intensive care unit to radiation therapy, neonatal to centenarian, urban and rural, long-term care, assisted living, memory care, in-home, chain, hospital, independent, specialty and free clinic pharmacies, research, development, billing and quality assurance – all with education requirements constantly changing and adapting.

It is the eve of Thanksgiving as I complete this message. I am grateful for each of you in pharmacy. I am grateful for your presence, perseverance and dedication. Medication is manufactured with standards of quality that lead the practice worldwide. It is delivered, stored, prepared and administered with equal standards of care and quality.

Patients are educated and engaged daily. Diversity enriches our profession and practice. For all of this, I am grateful.

I invite you to pause to say thank you for the health, knowledge, strength and focus you have been given personally. Take a moment to say thank you to the person(s) sharing your service. We need each other, and together, we are better and stronger.

If your focus, practice site or patient grouping has a special need you are providing in an on-going manner, MPA’s Consultant and Specialty Pharmacists of Michigan is open to sharing and welcomes you. A shared membership with another group is possible.

Happy New Year. May it bring health and safety for all.

Are YOU Registered?

During the COVID-19 pandemic, many pharmacy professionals wanted to lend their expertise to help. However, with all the chaos that COVID brought, it was a challenge verifying volunteer eligibility and licensure without prior registration. The Michigan Volunteer Registry is part of a national network of State-based systems designed for the advanced registration and credential verification of volunteers needed to help augment patient care and surge capacity needs.

Pharmacists and pharmacy technicians wishing to volunteer in a public health or medical event to assist their communities should register through the website. Student pharmacists may also register as pharmacists with limited license.

Register Now. You can make a difference.

To learn more about the MiVolunteer Registry, scan the QR Code using your mobile device or contact State Pharmacy Emergency Preparedness Coordinator Farah Jalloul at Farah@MichiganPharmacists.org.

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— PROFESSIONAL AFFAIRS —

E-Cigarette or Vaping Associated Lung Injury (EVALI): A Brief Review

BY DENISE MARKSTROM, Pharm.D., clinical pharmacy specialist, adult and pediatric bone marrow transplant, Michigan Medicine, C.S. Mott Children’s Hospital;

O

chair, MPA Professional Affairs Committee

ver the last decade and a half, e-cigarette use, or vaping, has grown exponentially around the world. While originally intended for an adult population seeking an alternative to cigarette smoking, the addition of flavorings to the original nicotine products have made e-cigarettes more popular to adolescents and teens. In 2019, the Centers for Disease Control and Prevention (CDC) announced the investigation of an outbreak of cases of severe pulmonary disease in people using e-cigarettes or vaping devices.1 As of February 2020, the CDC reports that 2,807 hospitalizations and 68 deaths have been attributed to e-cigarette or vaping related lung injury (EVALI).2 This article provides a brief review of the history of e-cigarettes, as well likely causative agents, signs, symptoms and treatment of lung injury related to vaping.

Although inventors have been developing electronic cigarettes, or e-cigarettes, since the 1930s, the first was not patented and marketed until the early 2000s. Hon Lik, a Chinese pharmacist, developed it, after the death of his father from lung cancer, to be used as a smoking cessation aid.3 Shortly thereafter, e-cigarettes became available in the U.S. In 2008, the World Health Organization (WHO) stated in a press release that “the electronic cigarette is not a proven nicotine replacement therapy” and that the “WHO has no scientific evidence to confirm

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the product’s safety and efficacy.”4 They recommended that manufacturers “remove any suggestion that WHO considers it to be a safe and effective smoking cessation aid.” In 2009, many countries banned the sale and use of e-cigarettes, including Australia, Canada and Hong Kong due to safety concerns. In the same year, the U.S. Food and Drug Administration (FDA) attempted to block the sale of e-cigarettes, stating that the product is a drug delivery system. However, companies selling these products filed an injunction against the

FDA stating that regulation of e-cigarettes was outside of their jurisdiction.5 In 2010, a U.S. Appeals Court ruled that the FDA could only regulate e-cigarettes as tobacco products and not as drugs.6 In between the court filing and decision, President Barack Obama signed into law the Family Smoking Prevention and Tobacco Control Act, which gave the FDA the authority to regulate the tobacco industry.7 In 2017, the FDA issued the final ruling in which e-cigarettes are considered to be tobacco products and not medical devices as long as they are

— PROFESSIONAL AFFAIRS — not advertised as smoking cessation aids.8 Although e-cigarettes were intended for adult use only, a significant proportion of users are adolescents, driven by youthoriented advertising and the development of flavored vape pods. The 2020 National Youth Tobacco Survey reported that although there has been a significant decrease in e-cigarette use (down by 1.8 million users), current users remain staggeringly high at 3.6 million teens.9 Among high school students, almost 39 percent vape regularly, and over 22 percent vape daily. At the time of the survey, 4.7 percent of middle school students were currently using e-cigarettes.

Data from 2020 regarding adult use is not available; however, in 2018, 3.2 percent of adults currently used vaping products.10 Use decreased with age: 7.6 percent in people ages 18-24, 4.3 percent in ages 25-44, 2.1 percent in ages 45-64 and less than 1 percent in those over 65.

cough, pleuritic chest pain and occasionally, hemoptysis.13-16 Most patients also present with a history of gastrointestinal symptoms, such as nausea, vomiting and diarrhea, as well as constitutional symptoms such as fever, chills and fatigue. Initial evaluation of the patient includes a thorough history of tobacco and e-cigarette use, usually between 30 and 90 days prior to symptoms; however, symptoms may occur within days of first use.14-15 Physical exam findings reveal hypoxemia, fever and tachypnea.

Lab work often reveals severely high inflammatory markers, e.g., C-reactive protein and erythrocyte sedimentation rate, and leukocytosis. Chest x-rays reveal diffuse bilateral infiltrates and chest CT reveals one of the following: bilateral ground glass opacities, diffuse nodules or alveolar damage, bronchiolitis obliterans organizing pneumonia (BOOP), acute eosinophilic pneumonia or lipoid pneumonia.13 Although infection is often ruled out, co-infection

There is no definitive proof that vaping increases the risk of contracting COVID-19.

However, researchers at Stanford conducted a survey of more than 4,300 people across the United States aged 13-24 and evaluated their risk of contracting COVID-19 based on whether they smoked cigarettes, e-cigarettes or a combination of both compared to nonsmokers.18 The risk of contracting COVID-19 was seven times higher in subjects who had ever used both cigarettes and e-cigarettes than non-smokers; users of e-cigarettes alone had a five-time higher risk. More research needs to be done to verify this risk.

Although no standard guidelines have been developed for the treatment of EVALI, certain medications have become commonplace.

The backbone of treatment for EVALI is corticosteroids; doses vary based on the severity of symptoms.15,19 Antibiotics are often started until infection can be ruled out; antivirals may be started in suspected

“WHO has no scientific evidence to confirm the product’s safety and efficacy.”4 They recommended that manufacturers “remove any suggestion that WHO considers it to be a safe and effective smoking cessation aid.”

Although no one compound has been definitively linked to EVALI, the likely cause has been linked to vitamin E acetate, which is used as a diluent in THC-containing vape pens.11 One study compared bronchiolar lavage (BAL) fluids in EVALI patients with those of healthy volunteers and found that vitamin E acetate was detected in 94 percent of patients with EVALI.12 While more study is needed to prove the causative agent in EVALI, some states such as Washington have banned the sale of vaping products containing vitamin E acetate. The Michigan House of Representatives overwhelmingly passed three bills, House Bills 5159, 5160 and 5161 banning these products and, as of this writing, they are before the Michigan Senate.

Patients with EVALI often present with a specific cluster of symptoms. Almost all present with respiratory symptoms: dyspnea,

may be present. A case report described a 27-year old patient with a two-year vaping history who presented with EVALI symptoms and was diagnosed with influenza and methicillin-sensitive Staphylococcus aureus (MSSA) pneumonia.16 EVALI was diagnosed upon bronchoscopy when severely denuded tissue was found throughout the lungs, consistent with inhalation injury.

Despite aggressive treatment, the patient succumbed to his illness after a two-week hospital stay.

Diagnosis during the COVID-19 pandemic may present challenges as the symptoms of COVID-19 mimic those of EVALI, as dyspnea, cough, fever and diarrhea are common in both. It can be difficult to determine between the two as testing results for COVID-19 are often delayed. Patients were often initially considered to have COVID-19, and EVALI may not have been considered if the patient did not alert clinicians to their vaping history.17

influenza patients. Supplemental oxygen is often warranted; mechanical ventilation is often necessary for severe cases. Mild cases may be considered for outpatient treatment, as long as follow-up can be scheduled within 24-48 hours. Although e-cigarettes have been available in the United States for nearly two decades, it was only recently that the hazards of their use were realized.

Pharmacists can be instrumental in the initial assessment of EVALI by taking a thorough tobacco use history as well as any symptoms the patient may be experiencing.

This is especially important during the COVID-19 epidemic as the signs and symptoms of COVID-19 and EVALI mimic each other.

References available upon request from the MPA office.

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— LEGAL INSIGHTS —

DON’T FORGET TO

SUE THE PHARMACIST T he Michigan Court of Appeals recently released an unpublished1 opinion potentially impacting pharmacy. The case can be found at Estate of Kevin Carl Gottshalk v. Plumbrook Pharm., 2020 Mich.

App. LEXUS 6183.

BY KIM SVESKA, R.Ph.,

Pharm.D., J.D., Foley, Baron, Metzger, and Juip, PLLC

The information provided in this article does not and is not intended to constitute legal advice. The content in this article are for general information purposes only.

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The Estate filed a complaint in Macomb County Circuit Court, claiming that a physician and the pharmacy committed malpractice related to the prescribing of Flexeril with Methadone 10 milligrams, seven times a day, and Valium 10 milligrams at HS (“hora somni,” or at bedtime) to a 49-year-old male.

An autopsy was performed, and the pathologist’s diagnosis was “intoxication by the combined effects of Methadone and Diazepam associated with acute pneumonia.”2 The key point for this audience is that the pharmacy was able to be dismissed from the case, because plaintiffs failed to name individual pharmacists. This most certainly suggests that the plaintiff’s bar will be more careful in the future and make sure that individual pharmacists, as well as the pharmacy, are named in pharmacy malpractice cases in Michigan.

Procedurally, the pharmacy filed a Motion for Summary Disposition under Michigan Court Rules (MCR) 2.116(C) (8), arguing that since pharmacists were not named individually, the pharmacy could not be held liable based on Michigan statutes and prior case law. The trial court granted the Motion for Summary Disposition, and this appeal followed. The primary argument by the pharmacy was that the pharmacy itself was not a licensed healthcare professional subject to medical malpractice claims and that the pharmacy was not sued under ordinary negligence theories. The Michigan Court of Appeals agreed with the trial court and upheld their dismissal of the pharmacy. The claims against the pharmacy were basically that the pharmacy should have known about the potential serious side effects and potentiation with the combination that was prescribed, and not raising issues with either the prescriber and/or the patient was below the standard of care. The patient had been on the combination of Methadone and Valium for a number of years, so the pharmacy/pharmacist likely had standard of care defenses.

The case turned on the statutory definition of licensed

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healthcare professional or a licensed health facility or agency, neither of which prior caselaw supported a pharmacy would fit within.3 In the appeal, the plaintiff argued that they did not need to name the individual pharmacists, because the pharmacists were employees of the pharmacy, and that should still be within the

definition of a licensed healthcare professional, since the pharmacy was licensed as well. In the alternative, they claimed that they did not need to name the pharmacists individually, because they were agents of the pharmacy defendant that was sued, under vicarious liability theories.

It does not appear that the plaintiff is filing an Application for Leave to File an Appeal with the Michigan Supreme Court, likely in light of the fact that it would not be successful.

ANALYSIS While this case will likely not increase the number of pharmacy malpractice cases being filed, it certainly will ensure that individual pharmacists are named defendants, along with the pharmacy, when cases are brought.

REFERENCES: 1. Technically, unpublished appellate opinions do not have stare decisis (binding precedent) affect, but most trial courts will take them into consideration when ruling on the parties’ motions.

2. The post-mortem toxicology found 130 ng/ml of Diazepam, 86 ng/ ml of Nordiazepam, and 860 ng/ml of Methadone. The reported range of blood concentration in Methadone-related fatalities was noted to be 400 to 1800 ng/ml.

3. See MCL 600.5838A.

— MEMBER SPOTLIGHT —

Michelle Sahr: MPA Involvement has Paid Off

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BY MICHELLE SAHR, Pharm.D., associate professor, Ferris State University

ver since Dr. Jeff Bates, my professor at Ferris State University (FSU), promoted Michigan Pharmacists Association membership and the MPA Annual Convention & Exposition (ACE) to my first year pharmacy (P1) class in 2012, I have been a member of MPA, and every year, I look forward to the ACE. The family I have made through my involvement in MPA has been priceless in connecting me to practitioners, students, legislators, industry professionals and so many others from Michigan and across the country. My membership as a student was instrumental in connecting me with mentors through the “Adopt-a-Student” program, and I have been able to stay in touch with my mentors and work with them for years afterward. As a student pharmacist, I attended Pharmacy Day at the Capitol, where I was first exposed to talking with legislators and had opportunities to network with students from other schools of pharmacy.

From student to resident, I took a more active role in MPA by joining the Michigan Society of Health-System Pharmacists (MSHP) Public Affairs Committee, where I helped work on campaigns to promote pharmacy outside of our pharmacy bubble. Soon after, I joined the Michigan Society of Community Pharmacists (MSCP) Board of Directors, MSCP Clinical Practice Committee and the MPA New Practitioner Committee. I have also participated on the MSHP Educational Affairs and Ambulatory Care Committees in more recent years. In working on these committees, I have found exponential reward for my MPA membership by being exposed to the many facets of MPA and its corresponding partners. I have been exposed to resources provided by MPA, MSCP and MSHP that I was never aware of, but found to be extremely helpful in practice.

Sometimes, leadership and involvement in state- and national-level associations does not feel close or attainable, so one of the great benefits of MPA is the local association membership that is complimentary with MPA membership. Since 2014, I have been participating in Kent County Pharmacists Association (KCPA) meetings and events regularly, which allowed

me the opportunity to be elected as a member of the KCPA Executive Board in 2017 and as president-elect in 2019. This spring, I will succeed the current president of KCPA, and I am looking forward to continuing the great work that KCPA has been doing. KCPA has been running membership drives through events for continuing education, educational nights and social functions.

KCPA has also been working to impact our communities beyond health care by volunteering and donating resources to local shelters and supporting organizations whose mission is to help the underserved.

In addition to the connections with pharmacy colleagues around the state, MPA has also allowed me to share my passions within pharmacy by educating others on topics that are important for healthcare practitioners. By doing this, I have had great opportunities for personal and professional growth by learning from others who have similar passions. The exposure provided by MPA in these presentations has allowed for national organizations to see my passion and invite me to speak across the country.

MPA has allowed me to engage with my profession in ways that would not be possible solely at my job. MPA provides countless resources to stay in touch and upto-date on COVID-19, legislation, practice trends and so much more. The amount of available information surrounding pharmacy and health care is overwhelming, and I find that MPA helps to condense and highlight important topics.

I have always been a strong believer that what you will get out of anything is dependent on how much you put in. I think this statement is especially true with associations: they can provide us with many resources and opportunities, but it is up to you to take advantage of and use those! I would encourage you to find at least one way to become more involved with your MPA membership; it could be your local association, committees, boards, task forces or so much more.

I know you won’t regret it!

PICTURED LEFT: Sahr poses with Ferris State University (FSU) College of Pharmacy first-year (P1) student pharmacists for the MPA New Practitioner “Night on the Town” event at the 2020 MPA ACE. PICTURED RIGHT: Ferris State University College of Pharmacy student pharmacists pose in the MPA New Practitioner photo booth at the MPA ACE 2020.

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— THAT’S MY PHARMACIST —

New Year and New Opportunities to Provide Patient Care 2021 is a New Year and a new chance to help your patients optimize their medication therapy and get access to high-quality patient care. The first few months of this year are great opportunities to demonstrate to your patients how pharmacists can help improve their overall health outcomes and treatment. Take advantage of all your patient interactions and their time in the pharmacy by explaining the many ways pharmacists can help! Utilize the materials from the That’s My Pharmacist campaign to easily communicate with patients and provide essential information about your role as a healthcare provider.

In the New Year, remind your patients of the “10 Reasons To Talk To Your Pharmacist,” and provide them with the flyer from www.ThatsMyPharmacist.com. A few of those reasons include: • A patient might be wondering if there is anything that you should not eat or drink with a medication.

• A patient is curious where they might obtain a flu shot as well as other recommended vaccinations.

• A patient might be curious about stopping a medication therapy.

• And more!

Help them understand what you do best!

Oftentimes, patients have a disease or condition that pharmacists can help manage, but they don’t know it! Post the “10 Conditions Your Pharmacist Can Help With” flyer around the pharmacy to help those patients become more aware of where they can look for answers to their questions. Some of those conditions include: • Heart attack • Smoking • Diabetes • Asthma • And more!

Also use their time in the pharmacy to make patients more aware of monthly health observances so you have the opportunity to educate patients on important health concerns.

Upcoming monthly observances include: • January: National Birth Defects Month • February: American Heart Month • March: National Kidney Month The That’s My Pharmacist campaign is made available by Michigan Pharmacists Association and the Michigan Society of Health-System Pharmacists (MSHP) Public Affairs Committee.

Find all these great materials and more at www.ThatsMyPharmacist.com.

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— COVER YOUR ASSETS —

FROM BREAK-INS TO PANDEMIC FATIGUE HOW TO STAY SAFE AND SANE IN 2021

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020 was one for the record books! As we start 2021, let’s make good preparations to keep ourselves and our families safe, secure and happy. For our first article of the new year, I wanted to offer a few ideas in this regard.

BY RON DEVERS,

CIC, CPIA, manager, PSI Insurance Agency

First, make it a resolution to prioritize your family’s protection. When was the last time you reviewed your life insurance for the entire family? What do you want your insurance to do for you? These questions are important to consider in protecting your family’s longterm financial picture.

Lastly, pandemic fatigue is real. What can you do to reduce pandemic fatigue?

Secondly, do you know what to do after a home robbery?

If you hear a strange noise in the dark, or come home and find you’ve been broken into, what should you do?

Think safety first!

• • •

• •

Stay out of the house and get to a safe place.

Call the police.

Once safe to go into the house, take inventory of stolen items.

Call your insurance agent to file a claim.

Take steps to prevent future break-ins.

You can replace your stuff…human life, not so much.

Think safety first.

Do you know the difference between a robbery and a burglary? Robbery is when an intruder uses force or the threat of force to take your belongings. Burglary is when an intruder takes your belongings when you are not home. Either way, homeowner’s insurance will likely cover damages done by the intruder and most of the belongings they take.

• Create new traditions: So many things and traditions have changed in the last year and focusing on them can add to your stress level.

Take some time to create new traditions for you and your family.

• Positive self-talk: Be your own cheerleader. We control our attitudes, so choose to feed your attitude with positive mental reinforcement – focusing on the good things.

• Accept your feelings: Allow yourself to feel!

Don’t stay stuck in negative emotions but allowing yourself time to feel and process these feelings can make you stronger and more resilient.

• Stay connected to others: We still need people. It may look different than before, but technology is allowing us to stay in contact with others. Do it!

• Limit your news intake.

• Take care of your body: Exercise, proper sleep and lowering stress can be big helps in overcoming pandemic fatigue.

PSI Insurance wants to wish you all a happy and prosperous 2021. Please let us know how we can help you with your insurance needs.

PSI Insurance Agency wants to wish you all a happy and prosperous 2021. Please let us know how we can help you with your insurance needs. Contact PSI Insurance Agency Manager Ron Devers at (800) 678-2774 or visit www.PSIInsurance.net.

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— PDAC FEATURE —

A Virtual Success Story

One Student Pharmacist’s Remarkable Experience at Pharmacy Day at the Capitol 2020

A

BY JOSEPH PAUL JAVIER, pharm.D.

candidate, Wayne State University College of Pharmacy

s my classmates and I exited our car into a cool fall day in 2019, we were taken aback by the sea of white coats in the distance. Hundreds of student pharmacists from all parts of Michigan were making their way to the state Capitol Building for PDAC 2019. The opportunity to meet with senators and state representatives at MPA’s Pharmacy Day at the Capitol was an experience unlike anything we’d seen before. For newly admitted student pharmacists at Wayne State University’s Doctor of Pharmacy program, advocating for our future profession on such a grand scale left an indelible mark on our memories.

Fast forward one year: 2020, the infamous year when COVID-19 changed the world. Social distancing has become a way of life and Zoom meetings are now ubiquitous to school and the workplace. Although it was expected, the necessary shift of this year’s PDAC to an online platform left me curious as to what to expect.

Would it be as exciting and engaging for me as it was the year before? Or would it be just another virtual experience for students already weary of plodding through daily classes online? Little did I know that Pharmacy Day at the Capitol 2020 would, for me, be an unforgettable and transformative experience.

Participating in this year’s ‘Up to Us’ competition, which focuses on government spending and policy, I decided to attend the virtual PDAC 2020 hoping to speak with Michigan legislators about the important role that pharmacists and vaccines play in lessening the burden on the country’s healthcare system.

This is an issue that I am very passionate about.

Healthcare spending is a major driver of the growing national debt, and investing in preventative medicine like vaccines benefits the economy and saves lives.

I logged onto the PDAC Zoom meeting and after a short briefing about key points to talk about concerning

legislation affecting pharmacy and healthcare, I was put into a breakout room with Rep. Padma Kuppa of House District 41, which covers the cities of Troy and Clawson.

I had heard about Rep. Kuppa through my non-profit work with the Council of Asian Pacific Americans and her support for issues like access to health care, protections for the elderly and disabled, as well as advocating for lower costs for prescription drugs.

However, I was not prepared to be the only student pharmacist in the breakout room with Rep. Kuppa. I struggled to recall the talking points I was supposed to ask her, but Rep. Kuppa was friendly and understanding.

Our meeting became more of a personal conversation where I shared my personal experiences of losing friends and family, because they could not afford medical care and life-saving medicines like vaccines or simple antibiotics. Before I knew it, the breakout room closed, and our meeting abruptly came to end before I could even thank Rep. Kuppa for her time. That was the end of my virtual PDAC experience, or so I thought.

A few days later, while I was driving home from my internship at World Medical Relief’s Affordable Prescription Program, I received a call on my cell phone.

Not recognizing the number, I let it go to my voicemail.

A few minutes later, I received a text message. I peeked at the notification and read that it was none other than Padma Kuppa and that she was trying to get a hold of me. I immediately pulled to the side of the road and called her back. When she answered my call, Rep. Kuppa began to tell me how she was appointed to the Governor’s Prescription Drug Task Force, which addresses the problem of high-cost prescription drugs in Michigan. She explained how she was looking for a legislative intern to help her do research, take notes for the task force and reply to her constituents regarding issues related to medicine and health care. Rep. Kuppa then asked if I would be interested in the position.

Trying to mask my excitement, I immediately told her I was up for the challenge and accepted her offer.

I am now working under Rep. Kuppa with state lawmakers, as well as directors of the Michigan Department of Health and Human Services, Department of Insurance and Financial Services, and Licensing and Regulatory Affairs to help lower costs of prescription drugs while learning about legislation that affects the pharmacy profession. All of this, because of a personal passion and a 10-minute meeting at the first ever virtual Pharmacy Day at the Capitol.

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— CE HOMESTUDY —

OPIOID USE DISORDER

IN THE COMMUNITY PHARMACY SETTING

BY ZACHARY R. MUELLER, Pharm.D.,

MPA/PSI executive fellow, Michigan Pharmacists Association Target Audience: This program was developed specifically for pharmacists and pharmacy technicians.

Disclosure Statement: The author does not have any conflicts of interest or financial relationships with a commercial interest related to this activity.

Pharmacist Objectives: Upon completion of this article, participant should be able to: 1. D iscuss the impact of Opioid Use Disorder (OUD) 2. E xplain the Screening, Brief Intervention and Referral to Treatment (SBIRT) intervention technique 3. D escribe Medication for Addiction Treatment (MAT) therapy and pertinent patient counseling 4. L ist the challenges facing patients with OUD Pharmacy Technician Learning Objectives: Upon completion of this article, participant should be able to: 1. D iscuss the impact of Opioid Use Disorder (OUD) 2. E xplain the Screening, Brief Intervention and Referral to Treatment (SBIRT) intervention technique 3. D iscuss the role of Medication for Addiction Treatment (MAT) 4. L ist the challenges facing patients with OUD

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Medication misuse and illicit drug use persist in the United States. In 2019, a national survey on drug use and health reported approximately 20 percent of people aged 12 and older used an illicit drug.1 In that same year, more than 70,000 people died from a drug overdose, both illicit and medicinal.2 Ongoing data has illustrated that illicit drugs and the misuse of prescription opioids have both contributed to the opioid crisis.

The estimated economic cost of the opioid crisis in 2015 was over $500 billion.3 It was named a public health emergency in October 2017, and while progress has been made, rates of opioid-related overdose deaths remain largely unchanged three years later.2,4 Since 2015 prescriptions for opioids have been decreasing, but overdose deaths have been increasing.2,5 Increases in overdose deaths were shown with illicitly manufactured fentanyl (IMF) and concomitant drugs, such as methampethamine.6 As of October 2020, opioid-related mortality was reported as increasing in 40 states during the COVID-19 pandemic.7 However, despite lockdowns and stay-at-home orders, pharmacy professionals were still available to help and guide patients. Pharmacists, student pharmacists and pharmacy technicians are among the most accessible healthcare professionals, practicing within 5 miles of most Americans. That said, they remain underutilized when addressing and maintaining opioid use disorder (OUD). This continuing education article will address the role of pharmacists, student pharmacists and pharmacy technicians in OUD and patient care.

Terminology Before addressing the role of pharmacy professionals in tackling the opioid crisis, it is crucial to understand the definitions of tolerance, dependence and addiction. Tolerance refers to a diminished response to a drug with repeated use.8 This means a drug administered at a dose that produced an effect will require a higher dose to achieve or maintain that same effect over time. For example, when a person consumes alcohol regularly, their liver will increase the production of the CYP2E1 enzyme that metabolizes alcohol, accelerating the elimination of alcohol, requiring more alcohol to reach the same effect.

Dependence manifests when, in the absence of a drug, an individual experiences physical or mental symptoms such as nausea, vomiting, insomnia, anxiety, agitation or chills – a state often referred to as withdrawal. A person can be dependent, but not in the stage of addiction. Addiction, as defined by the National Institute on Drug Abuse (NIDA), is a

“chronic, relapsing brain disease that is characterized by compulsive drug-seeking and use despite adverse consequences.”9 Persons with addiction have a disease that is more than experiencing withdrawal symptoms; their brain chemistry has been altered, affecting their behavior.

Persons who experience tolerance, dependence or addiction can benefit from the help of a pharmacist’s advanced medication knowledge. Patients that may benefit from the assistance of pharmacists and pharmacy technicians are not all at the addiction stage and are not all using illegal drugs.

Understanding this area and addressing the real healthcare concerns of these patients must become standard practice, just like counseling a newly diagnosed person with diabetes. Every patient is at a different stage in their life and should be met at that stage to provide the best patient-centered care.

Substance Use Disorder and Opioid Use Disorder Substance use disorder (SUD) and opioid use disorder (OUD) are mental health disorders. SUD is a disease that affects a person’s brain and behavior, altering their ability to control the use of a legal or illegal drug or medication that results in health problems, disability and a failure to meet major life responsibilities.10,11 SUD involves substances that can lead to psychological or physical dependence such as: alcohol, cocaine, heroin, methamphetamine, stimulants, tranquilizers, sedatives and opiates.1 Specifically, this article focuses on opiates and OUD. Opioid analgesics, or opioids for short, are a class of drugs used to treat pain. This includes street drugs that are not used medically, like heroin or illicitly manufactured fentanyl (IMF) due to their high likelihood of abuse. Examples of opioids are hydrocodone, oxycodone, codeine and fentanyl.

Opioids cause analgesia but may also produce feelings of euphoria and sedation. Opioid misuse occurs when a patient takes opioids in a way or dose other than prescribed, takes someone else’s prescription, or uses opioids for the euphoric effect.

Repeated misuse can lead to OUD. OUD is a health condition with possible long-term complications, just like hypertension or diabetes. Some of these longterm complications include an increase in infectious disease through unsafe sex or sharing needles, seizures, risk-taking behavior that may lead to accidents, suicide, family problems, work issues, legal trouble and financial problems.10

— CE HOMESTUDY — Mental health disorders such as OUD, are diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), a handbook created by the American Psychiatric Association for healthcare professionals in the United States. A diagnosis for OUD is defined in the DSM-V as observing two of the following within a 12-month period:12

• Opioids are often taken in larger amounts or over a longer period than was intended.

• There is a persistent desire or unsuccessful efforts to cut down or control opioid use.

• A great deal of time is spent in activities necessary to obtain the opioid, use the opioid or recover from its effects.

• Craving, or a strong desire or urge to use opioids.

• Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school or home.

• Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.

• Important social, occupational or recreational activities are given up or reduced because of opioid use.

• Recurrent opioid use in situations in which it is physically hazardous.

• Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

• Exhibits tolerance.

• Exhibits withdrawal.

With clear diagnostic criteria, substance and opioid use disorders are just that: diagnosable medical conditions. OUD is a conglomerate of misusing illicit opioids and/ or prescription pain relievers. Out of the 20.4 million people in 2019 who were diagnosed with SUD, OUD accounted for approximately 1.6 million, or 7.8 percent.1

Screening, Brief Intervention and Referral to Treatment (SBIRT) While the DSM-V represents diagnostic criteria, screening, brief intervention, and referral to treatment (SBIRT) represents a process to identify misuse and educate

or refer the patient accordingly. Pharmacy professionals have a unique opportunity to screen patients for medication misuse in the community setting. SBIRT is one model of intervention recognized by the Center for Medicare and Medicaid Services (CMS).

SBIRT has been utilized to identify, assess, reduce and prevent a multitude of behavioral health conditions such as tobacco and alcohol use disorders.13 SBIRT is yet to be validated for OUD in the community pharmacy setting, although a study has shown that it is feasible for community pharmacists to utilize.14 It is useful as a universal screening in the primary care setting.

The ubiquity of pharmacy professionals can be leveraged to screen and educate, as well as refer and connect patients with substance use treatment professionals and other community resources. In a letter to the Michigan Medicaid Director, the National Association of Chain Drugs Stores shared that pharmacists can help the SUD population “by using Screening, Brief Intervention and Referral to Treatment (SBIRT)... an evidencebased practice used to identify, reduce and prevent problematic use, abuse and dependence on alcohol and other substances of abuse and includes referral to treatment for those in need.”15 A quick 5- to 15-minute SBIRT intervention has been shown to reduce healthcare costs and reduce complications of OUD.16 These healthcare costs are associated with an approximate return of up to $5.60 per $1 spent.17 In Washington state, it was calculated to save $2 million for each 1,000 Medicaid patients who received SBIRT, mainly due to a reduction in re-hospitalizations.14 SBIRT represents an opportunity to quickly screen patients and assess the severity of their condition, and it has been utilized in a variety of healthcare settings for this purpose. It also allows for a brief intervention that addresses motivation and increases awareness, as well as referring a patient to treatment that provides access to more comprehensive options when needed. Utilizing SBIRT interventions in the community pharmacy setting allows pharmacists to provide additional care and support to patients with OUD. Appendix 1 provides a sample SBIRT workflow process utilizing the Drug Abuse Screening Test (DAST), as defined under the screening section below. A screening that warrants further education is encouraged to reinforce patient-centered healthcare decisions or intervention and needs to be communicated

with the patient’s primary care physician.

Although not validated specifically for screening in a community pharmacy, studies are underway to assess the advantages and limitations of SBIRT integration into the community pharmacy. One study focused on retail pharmacy patients and screened for substance and alcohol use disorders and tobacco use utilizing the National Institute of Drug Abuse (NIDA) Quick Screen and NIDA Modified-ASSIST (NM-ASSIST) and the Alcohol Use Disorder Identification Test.14 This study had a total of 24 patients with a 67 percent response rate. SBIRT screening revealed that 20 percent of patients were at risk for SUD with 50 percent of subjects requiring education and/or an intervention based on their responses. Risk was also assessed by the prescription drug monitoring program (PDMP) risk score, which is an assessment of the risk for misuse based on a patient’s controlled substance fill history. There will be more discussion about utilizing a PDMP under “Screening.” In addition, the study demonstrated that 60 percent of patients who received a positive screen by SBIRT were also PDMP-risk positive. They concluded that SBIRT-based screening was feasible in a retail setting with hopes that larger studies can assess the efficacy of such intervention. SBIRT represented a quick and simple set of procedures with a potential to impact the public health burden of substance use disorders.

Please visit www.MichiganPharmacists.org/ education/online to read the rest of this article and view tables.

Important Information Regarding Continuing Education Credit Due to the length of this continuing education article MPA has posted the complete article online. Upon completion of this activity, participants must complete an evaluation and posttest with a passing score of 70 percent on the MPA Web site at www.MichiganPharmacists.org/education/online.

A failed test may be retaken only once without additional cost. There are no refunds for failed tests. If all requirements are met, participants will receive pharmacy continuing education (PCE) credit through CPE Monitor, a national, collaborative effort by ACPE and the National Association of Boards of Pharmacy (NABP) that went into effect on Jan. 1, 2013, to provide an electronic system for pharmacists and pharmacy technicians to track their completed PCE credits. MPA, as an ACPE-accredited provider, is required to report pharmacist and pharmacy technician PCE credit using this tracking system. Pharmacist and pharmacy technician participants must provide their NABP e-Profile identification number and date of birth (in MMDD format) when they register for a CPE activity or complete activity evaluations. It will be the responsibility of the participant to provide the correct information (i.e., e-Profile identification number and date of birth in MMDD format). If this information is not correctly provided, NABP and ACPE prohibit MPA from issuing CPE credit. Online access to their inventory of completed credits will allow pharmacists and pharmacy technicians to easily monitor their compliance with CPE requirements and print statements of credit. Therefore, MPA will not provide printed statements of credit to pharmacists and pharmacy technicians. Partial credit will not be awarded.

If you have yet to sign up for CPE Monitor, go to MyCPEMonitor.net. For more home study activity options for pharmacists and pharmacy technicians, please visit www.MichiganPharmacists.org/education/online.

Michigan Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. ACPE Universal Activity #0112-0000-20-011-H01-P & 0112-0000-20-011-H01-T, 1.0 contact hour. Initial Release Date: 12/7/20; Expiration Date: 12/7/23, Knowledge-based Activity

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