North Carolina Pharmacist Volume 105 Number 2

North Carolina Pharmacist Volume 105 Number 2

Advancing Pharmacy. Improving Health.

Save The Dates June 23rd - 25th, 2025 NCAP Annual Convention Asheville, North Carolina

Official Journal Of The North Carolina Association Of Pharmacists ncpharmacists.org

Call for Articles North Carolina Pharmacist (NCP) is currently accepting articles for publication consideration.

We accept a diverse scope of articles, including but not limited to: original research, quality improvement, medication safety, case reports/case series, reviews, clinical pearls, unique business models, technology, and opinions.

NCP is a peer-reviewed publication intended to inform, educate, and motivate pharmacists, from students to seasoned practitioners, and pharmacy technicians in all areas of pharmacy.

Articles written by students, residents, and new practitioners are welcome. Mentors and preceptors – please consider advising your mentees and students to submit their appropriate written work to NCP for publication.

Don’t miss this opportunity to share your knowledge and experience with the North Carolina pharmacy community by publishing an article in NCP. Click on Guidelines for Authors for information on formatting and article types accepted for review.

For questions, please contact Tina Thornhill, PharmD, FASCP, BCGP, Editor, at tina.h.thornhill@ gmail.com.

North Carolina Pharmacist is the official journal of the North Carolina Association of Pharmacists Located at: 1101 Slater Road, Suite 110 Durham, NC 27703 Phone: (984) 439-1646 Fax: (984) 439-1649 www.ncpharmacists.org

Official Journal of the North Carolina Association of Pharmacists 1101 Slater Road, Suite 110 Durham, NC 27703 Phone: (984) 439-1646 Fax: (984) 439-1649

North Carolina Pharmacist Volume 105 Number 2

www.ncpharmacists.org EDITOR-IN-CHIEF Tina Thornhill LAYOUT/DESIGN Rhonda Horner-Davis

EDITORIAL BOARD MEMBERS Anna Armstrong Jamie Brown Lisa Dinkins Jean Douglas Brock Harris Amy Holmes John Kessler Angela Livingood Bill Taylor

BOARD OF DIRECTORS EXECUTIVE DIRECTOR Penny Shelton PRESIDENT Bob Granko PRESIDENT-ELECT Tom D’Andrea PAST PRESIDENT Ouita Gatton TREASURER Ryan Mills SECRETARY Beth Caveness Cassey Zendarski, Chair, SPF Micaela Hayes, Chair, NPF Cornelius Toliver, Chair, Community Tyler Vest, Chair, Health-System Kimberly Hayashi, Chair, Chronic Care Mackie King, Chair, Ambulatory Angela Livingood, At-Large Elizabeth Locklear, At-Large Macary Weck Marciniak, At-Large North Carolina Pharmacist (ISSN 0528-1725) is the official journal of the North Carolina Association of Pharmacists.

An electronic version is published quarterly. The journal is provided to NCAP members through allocation of annual dues. Opinions expressed in North Carolina Pharmacist are not necessarily official positions or policies of the Association. Publication of an advertisement does not represent an endorsement. Nothing in this publication may be reproduced in any manner, either whole or in part, without specific written permission of the publisher.

A Few Things Inside • From the President..................................................................................................4 • Contraceptition Awareness in Female Undergraduate Students................................6 • Myths, Misconceptitions, and Truths about Buprenorphine.................................14 • Wellness Events on Pharmacy Student Well-Being..............................................18 • Hydroxychloroquine Retitinal Toxicity: Taking a Closer Look............................22 • A Learn and Grow(th) Mindset........................................................................24 • Improve Health by Reducing PFAS in Drinking Water........................................26 • PAAS National Message ...............................................................................29 • NCAP News ........................................................................................................30 • NCAP Classifieds................................................................................................32

North Carolina Pharmacist is supported in part by: • Alliance for Patient Medication Safety ....................................................4 • Pharmacy Quality Commitment...............................................................5 • Pharmacy Technician Certification Board (PTCB) ...............................12 • NCAP Career Center .............................................................................13 • Pharmacists Mutual Companies ............................................................17 • Working Advantage................................................................................23 CORRECTIONS AND ADVERTISING For rates and deadline information, please contact Rhonda Horner-Davis at rhonda@ncpharmacists.org

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•From the President• Robert P. Granko, PharmD, MBA, FASHP, FNCAP

Embracing the Future: A Vision of Service and Innovation

Welcome to my second installment for the North Carolina Association of Pharmacists. As I write this, I am just over halfway through my presidency. Time is flying!

As I continue to build on my theme of being “Of Service,” I am reminded of the commitment I witnessed at the NCAP Annual Convention right here in my hometown of Cary, NC. Spending time with many of you and listening to the talented speakers from across the state and different practice settings was truly inspiring. Those conversations serve as the backdrop for this column and hopefully capture our collective commitment to advancing pharmacy practice through advocacy while maintaining our core value of service to our patients and communities.

Service has always been at the heart of pharmacy. As pharmacists, we are trusted healthcare providers, counselors, and advocates. Our roles encompass many facets of patient care, including educating patients, managing chronic diseases, and ensuring the safe and effective use of medications.

NCAP is the home for pharmacists and pharmacy technicians, regardless of practice setting. In the coming year, NCAP and its leadership will continue to work on behalf of its members and those who have not yet joined our association, uniting, serving, and advancing our profession.

To truly make a difference, we must also look to the future and embrace innovation. The healthcare landscape is rapidly evolving, and we must be proactive in shaping that change through advocacy efforts. This involves enlisting others in our vision – from fellow pharmacists and pharmacy technicians to healthcare professionals, policymakers, and the public. Collaboration and teamwork are essential in addressing the complex health challenges we face today.

tunities, and daring to experiment, we can elevate the practice of pharmacy and continue to make a lasting impact on the health and well-being of our communities. Together, we can create a brighter, healthier future for all.

In our pursuit of excellence, we must continually search for opportunities to advance our profession. This means staying abreast of the latest research, technologies, and best practices. It also means advocating for policies that support pharmacists in expanding their scope of practice, allowing us to utilize our full potential in delivering comprehensive care.

Experimentation and a willingness to take risks are crucial in this journey.

Innovation often requires stepping out of our comfort zones and exploring new ideas and approaches. This idea, “Off the Beaten Path: Trekking Toward Transformative Practice,” was illustrated well by our convention speakers, who encouraged us to be bold and adaptable across all patient care settings.

In closing, join me in a year of service and innovation. By envisioning a bold future, enlisting others, seeking opporPage 4

2530 Professional Road Suite 200 North Chesterfield, Virginia 23235 Toll Free: (866) 365-7472 www.medicationsafety.org

Using Community Engagement Approach to Enhance Contraception Awareness in Female Undergraduate Students By: Carson Helms, Doctor of Pharmacy Candidate, Emily Hiller, Doctor of Pharmacy Candidate, Yassmin Honeine, Doctor of Pharmacy Candidate, Josephine Ariella Lovings, Doctor of Pharmacy Candidate, Vidhi Shah, Doctor of Pharmacy Candidate, and Dr. Edward T. Chiyaka

Introduction Safe sex education is crucial to ensuring the health and development of youth, the reduction of unnecessary health risks, and the improvement of opportunities for education. (1) Sexual health-related issues are wide-ranging and involve many factors, including sexual orientation, sexual expression, and relationships. (2) The number of women seeking family planning has continued to rise since the early 2000s. (3) Despite increased numbers of women seeking out contraception, the total of unintended pregnancies continues to rise. According to the World Health Organization, 55% of unintended pregnancies in females aged 15-19 years old end in abortion. (2) This statistic and others have driven the creation of community programs that promote both contraception use and safe sex practices to become prevalent within the United States. (4) Research shows that individuals with lower levels of education have less knowledge of sexual health, including contraception, which leads to worse sexual health outcomes when compared to those with higher education. (5) In North Carolina, there are several counties with a large population with less than a high school diploma. (6) Statewide programs that seek to promote contraception knowledge and utilization have been implemented in counties with low high school graduation rates. (7) The effectiveness of these programs has been investigated by evaluating community knowledge and perceptions of promoting safe sex practices to increase both participants’ knowledge and confidence, leading to a reduction in unintend-

ed pregnancies and the spreading of sexu- tion. (19) In terms of financial stress, the average cost of pregnancy in the United ally transmitted infections (STI). (9-11) States is almost $20,000, not to mention the cost of raising a child that follows An earlier study highlights how the COVID-19 pandemic impacted the mental, afterward. (20) It also comes with the physical, and social health of adolescents potential for physical harm and can cause anemia, depression, and heart conditions and young adults ages 12-24 years. (12) that might not cease once the pregnancy While the strategy of increasing contraception knowledge to prevent unplanned is over. (21) Effective contraception use requires more than just the choice to pregnancies is typically discussed in adolescent education, this emphasis fades use one; every form of contraception is imperfect due to ease of misuse or varied quickly once people enter adulthood. effectiveness rates, so it is vital that the (13) According to the Sexuality Information and Education Council of the United users receive education on their chosen States (SIECUS), the COVID-19 pandemic method. Previous research on young caused a significant disruption in sex edu- adults aged 18-29 years old revealed a cation for female adolescents aged 17-18 troubling lack of knowledge, with nearly 25% of women having little awareness of years old from 2019 to 2021, increasing basic contraceptive methods such as conthe likelihood of unwanted pregnancies. doms, pills, injectables, and IUDs. (17) (14) SIECUS directly attributed this gap in education to the COVID-19 pandemic, which has led to increased unplanned Sexually transmitted diseases are another pregnancies within the past four years. health consequence that disproportion(15) Furthermore, the shift to virtual ately impacts college students because of learning during the COVID-19 pandemic a lack of information about contraception. also decreased the confidence and knowl- In 2020, only 51% of sexually active adoedge of contraception use. (16) lescents reported using a condom, which is one of the main STI preventatives. (22) College-aged students (between 18The highest rates of STIs are reported 29 years old) have the highest rates of among college students, with 61% of the unplanned pregnancy when compared to national chlamydia cases being made up other women in the United States. (17) of 15-24-year-olds. (23) Proper screening On a global scale, the number of unand education, specifically for adolesplanned pregnancies is significantly higher cents, are crucial in decreasing the spread in the United States when compared to of STIs, including efforts such as the HPV other developed countries. (18) This issue vaccine. (24) Due to the increase in telehas major implications, as unexpected health visits, the screening and treatment pregnancies account for approximately of STIs have decreased, even with the 7% of college dropouts nationwide, with increased focus on routine screening for an astounding 61% of these individuals younger females. (12) Research indicates declining to re-enroll to finish their educa- that the person who is teaching young Page 6

adults about contraception and how it can prevent STIs can affect how well the information is comprehended. School-based peer-led education increased the use of contraception in under-resourced settings.

(25) This gives students the opportunity to step up and help educate their peers and provide a safe space for discussion and learning.

The purpose of this study is to assess the current level of contraception knowledge and awareness among female undergraduate students and to evaluate the effectiveness of a community engagement program in increasing the same factors.

We hypothesized that providing contraception education to female undergraduate students would improve their knowledge and confidence about their use. Previous studies have examined the effect of educational intervention in larger communities, as mentioned earlier, leaving a gap in research on the effect in much more specific populations. Therefore, the results of this study could show the benefit of a brief educational intervention in a much more defined population of female undergraduate students.

Methods Undergraduate female students at least 18 years old enrolled at Wingate University were surveyed regarding their knowledge and confidence of contraception use using a pre-post study. Participants were asked to attend a 10-minute-long PowerPoint presentation that covered various types of contraception. Before the presentation, participants were instructed to complete an anonymous electronic survey. Within the survey, participants answered questions about their demographics, sexual experiences, attitudes towards, and knowledge of contraception.

Immediately after the completion of the presentation, participants were instructed to complete a post-survey that included the same demographic, attitude, and knowledge questions as the pre-survey.

The pre-survey and post-survey were both administered via QualtricsXM, which was accessible using a QR code or a shareable link. The study was approved by the Research Review Board of Wingate University.

Pre- and post-survey data collected from QualtricsXM was imported into Microsoft

Excel (Version 16.81) and combined into a singular dataset for data cleaning and analysis. The initial sample consisted of 43 undergraduate students. After the inclusion criteria were applied, the final sample included 33 participants. The 10 participants were excluded due to being male, under the age of 18 years, or not being a current Wingate undergraduate student.

Data Analysis The data was collected through two questionnaires that were composed of four sections. The sociodemographic section had five questions, including age, religion, sexual orientation, associated university organization, and marital status. The sexual initiation section had six questions regarding previous sexual experience, number of sexual partners in the past five years, previous contraception use, first contraception used, and reasoning for using or not using contraception.

There were five questions focusing on the participant’s attitude towards contraception that were answered on a scale from strongly agree to strongly disagree.

The contraception knowledge section consisted of 5 items assessed through multiple-choice questions, which were recorded during analysis as the number of correct responses.

Data were analyzed using Microsoft Excel software version 16.81. T-tests were used to assess differences in knowledge levels, while chi-square tests of proportions were used to assess the change in perceptions and attitudes. A p-value less than 0.05 established statistical significance in this study.

Results Most participants (78.8%) were between the ages of 18-20 years, identified as Christian (66.7%), heterosexual (68.8%), and were associated with the University Athletic Team (31.4%). All participants reported being unmarried. The characteristics of the participants are shown in Table 1.

Participants were asked to report previous sexual experiences, number of sexual partners in the past five years, previous contraception use, first contraception Page 7

method used, and reason for using/not using contraception. Out of the 33 participants, only 15 (45.5%) reported having a previous sexual experience. Of the participants who reported having previous sexual experience, 80% of them reported having used contraception. Additionally, the majority of the participants (73.3%) cited pregnancy prevention as the reason for using contraception. Moreover, the majority of participants (53.3%) reported using the barrier method as their first method of contraception. There were 3 participants who reported not using contraception due to respondent opposition, partner opposition, or lack of contraception access. Table 2 shows a summary of sexual patterns and contraception use of participants who reported having previous sexual experience.

Further analysis showed that heterosexual women used contraception for pregnancy prevention, whereas some homosexual or bisexual women used contraception to prevent sexually transmitted infections.

Women in the older age range, 21-25, reported the highest numbers of previous sexual partners over the past five years.

The survey results show a significant improvement in students’ attitudes and knowledge about contraception after the intervention. Notably, the percentage of students who felt competent in making contraception decisions increased significantly, from 87.9% to 93.9%.

Furthermore, perceptions of contraception accessibility in the community or on campus improved significantly, rising from 72.7% to 81.8%. Additionally, the number of students who knew where to purchase various contraceptives and students’ comfort levels in discussing contraception techniques with healthcare practitioners increased by about nine percentage points. Despite these gains, there was no substantial change in the fear of judgment about contraception, which remained stable at 42.4%. All reported p-values are above 0.05, suggesting that the observed changes in students’ attitudes and perceptions towards contraception may not be statistically significant. Table 3 shows a summary of pre- and post-intervention survey results on contraception attitudes and perceptions among students.

Changes in contraception knowledge were more substantial compared to changes in

attitudes, as shown in Figure 1. Pre-survey results showed that 93.8% of participants correctly answered the question about potential side effects of birth control pills, and post-survey results showed the same result to the same question. The questions addressing the length of time the vaginal ring is left in place, and the advantages of male condoms over other birth control methods received the fewest correct responses (18.2% and 27.3%, respectively) before the intervention. The question concerning the length of the vaginal ring was the one that received the most percentage of “unsure” responses.

There was an improvement in general awareness of contraception following the session. All the knowledge questions had a higher percentage of correct responses.

But with an increase of 46.5%, p = 0.002, the only question that had the biggest change and demonstrated statistical significance was “How long is the vaginal ring left in place?” Another big change following the intervention was noted for the question that sought to identify barrier methods of birth control with a change of about 25 percentage points.

Discussion The objective of this study was to assess students’ attitudes and perceptions on contraception as well as to assess the level of contraception knowledge and awareness among female undergraduate students while evaluating the effectiveness of a community health engagement program. The study analyzed participants’ knowledge of and attitudes towards contraception, noting positive improvements between pre- and post-surveys.

Approximately 46% of the participants indicated having a prior sexual experience.

This finding sheds light on the diversity of sexual experiences and behaviors among female college students and can help inform strategies for sexual health education. Prior to the intervention, the participants’ average knowledge level was about 44.8%, which rose to 66.4% thereafter. Meanwhile, the participants’ attitudes towards contraception increased from 70.3% to 76.3%.

Our study findings showed an increase in attitudes and perceptions towards contraception after the brief intervention.

However, the changes between pre- and

post-survey were not statistically significant. The inability of a short intervention to significantly improve a participant’s attitude towards contraception could be due to a multitude of reasons, such as the small sample size as well as participant characteristics, including the previous sexual education received, previous sexual experiences, and religion. Further analysis of participants’ religion and sexual behavior indicated that all Muslim women who were surveyed reported no previous sexual intercourse compared to Christians and Atheists. With Islam being a religion that disapproves of sex before marriage, it is not surprising that unmarried women might have worse attitudes and knowledge levels towards contraception as they have not necessarily had personal experience with them. It is already known that racial and ethnic minorities often have lower rates of contraception utilization compared to the general public.26 This shows the significance of making sure young women are receiving thorough and appropriate contraception education regardless of religious beliefs so they will be aptly prepared later on in life.

An intervention consisting of contraception education has been carried out before with similar results that involved peer education led by nursing students.27 After the education was carried out, a more statistically significant difference was seen in changes in knowledge versus attitudes towards contraception. These findings are in sync with our findings, where statistically significant differences were observed in knowledge level versus attitude. The study completed by Sanz-Martos et al. showed 81.04% of the sample as having sexual intercourse previously, whereas our study reports 45%. This could explain why the previous study had more success in seeing larger statistical significance, as people who are currently sexually active are going to be more interested in learning about contraception, whereas others will see that it doesn’t apply to them and not comprehend the knowledge as thoroughly.

Many practical applications can be drawn from this research. As mentioned previously, to promote positive changes in contraception use confidence levels, a longer intervention is needed. However, this study has shown that a very short intervention can also help improve contraPage 8

ception knowledge levels and potentially lead to changes in health behavior. This can be applied to other settings, such as medical offices, schools, or community programs, by showing that even education that lasts only a few minutes long can be comprehended and remembered by the participant, potentially leading to safer decisions down the road. Brief contraception education will be a simple thing to integrate into many scenarios to help improve sexual education.

While our study offers valuable insights into contraception knowledge and utilization among female undergraduate students, it also has some limitations.

Participants were only selected from one university and had to be involved in some kind of extracurricular activity. As a result, the findings may not be generalized to other universities or students who were not in any of the targeted groups. The survey also excluded males, so these results can only be applied to one gender, and the sample size that could be reached is restricted. Future research is needed to complete the understanding of the pathways connecting undergraduate students’ attitudes and knowledge to outcomes later in life, including potential change in attitude and knowledge as someone ages.

This study has shown the need for more research on contraception knowledge and use among college students. As this short study did not show a significant improvement, perhaps a study that spanned over a longer period with a large sample would produce a better result.

Conclusion A brief community engagement program was conducted among female undergraduate students to help enhance their understanding of contraception. Following the intervention, participants exhibited heightened confidence and knowledge levels on contraception use. The educational focus on contraception methods not only strengthened participants’ understanding but also influenced their attitudes toward contraception, increasing the likelihood of their utilization in future sexual encounters. Targeting female undergraduate students is crucial for mitigating the risk of unwanted pregnancies and sexually transmitted diseases.

Authors: Carson Helms, Doctor of Pharmacy Candidate, Wingate University School of Pharmacy; Emily Hiller Doctor of Pharmacy Candidate, Wingate University School of Pharmacy; Yassmin Honeine, Doctor of Pharmacy Candidate, Wingate University School of Pharmacy; Josephine Ariella Lovings, Doctor of Pharmacy Candidate, Wingate University School of Pharmacy; Vidhi Shah, Doctor of Pharmacy Candidate, Wingate University School of Pharmacy; Edward T. Chiyaka, Ph.D., Assistant Professor, Wingate University School of Pharmacy Email: e.chiyaka@wingate.edu

References 1.

2.

3.

4.

5.

6.

7.

8.

Sweya, M. N., Msuya, S. E., Mahande, M. J., & Manongi, R. (2016). Contraceptive knowledge, sexual behavior, and factors associated with contraceptive use among female undergraduate university students in Kilimanjaro region in Tanzania. Adolescent health, medicine and therapeutics, 7, 109–115. https://doi.org/10.2147/AHMT. S108531 World Health Organization. Sexual Health.

Geneva: World Health Organization; 2023.

[Accessed September 21, 2023]. Available from: https://www.who.int/health-topics/ sexual-health#tab=tab_1 United Nations Department of Economic and Social Affairs, Population Division (2022). World Family Planning 2022: Meeting the changing needs for family planning: Contraceptive use by age and method. UN DESA/POP/2022/TR/NO. Lopez, L. M., Bernholc, A., Chen, M., & Tolley, E. E. (2016). School-based interventions for improving contraceptive use in adolescents. The Cochrane database of systematic reviews, 2016(6), CD012249. https://doi.org/10.1002/14651858.

CD012249 Guzzo, K. B., & Hayford, S. R. (2018). Adolescent Reproductive and Contraceptive Knowledge and Attitudes and Adult Contraceptive Behavior. Maternal and Child Health Journal, 22(1), 32–40. https://doi. org/10.1007/s10995-017-2351-7 Future NC. NC Educational Attainment Dashboard. Demographic Information, 2018 [Accessed November 10, 2023] Available from: https://dashboard.myfuturenc.org/county-explorer/ Upstream USA. North Carolina - Upstream USA. [Accessed November 10, 2023].

Available from: https://upstream.org/ partnerships/north-carolina/ Coyle, K., Anderson, P., Laris, B. A., Barrett, M., Unti, T., & Baumler, E. (2021). A

Group Randomized Trial Evaluating High School FLASH, a Comprehensive Sexual Health Curriculum. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 68(4), 686–695. https://doi.org/10.1016/j. jadohealth.2020.12.005 9. Spach NC, Thach SB, Dellinger CB, Ritter EQ, Galvin SL. Using a Community Engagement Approach to Enhance Contraception Awareness in Rural Western North Carolina. N C Med J. 2021 NovDec;82(6):377-383.

10. Birgisson, N. E., Zhao, Q., Secura, G. M., Madden, T., & Peipert, J. F. (2015).

Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review.

Journal of women’s health (2002), 24(5), 349–353. https://doi.org/10.1089/ jwh.2015.5191 11. Lightfoot, A. F., Taboada, A., Taggart, T., Tran, T., & Burtaine, A. (2015). ‘I learned to be okay with talking about sex and safety’: assessing the efficacy of a theatre-based HIV prevention approach for adolescents in North Carolina. Sex education, 15(4), 348–363. https://doi.org/10.1 080/14681811.2015.1025947 12. Lindberg LD, Bell DL, Kantor LM. The Sexual and Reproductive Health of Adolescents and Young Adults During the COVID-19 Pandemic. Perspect Sex Reprod Health. 2020 Jul;52(2):75-79. doi: 10.1363/psrh.12151. Epub 2020 Jul 21.

13. Solomon D, Pantalone DW, Faja S. Autism and Adult Sex Education: A Literature Review using the Information-Motivation-Behavioral Skills Framework. Sex Disabil. 2019 Sep;37(3):339-351. doi: 10.1007/s11195-019-09591-6. Epub 2019 Aug 12.

14. Siecus. (2022, February 22). Siecus 2021 Sex Ed State Legislative Mid-year report.

SIECUS. https://siecus.org/siecus-2021sex-ed-state-legislative-mid-year-report/ 15. Stavridou A, Samiakou C, Kourti A, et al.

Sexual Activity in Adolescents and Young Adults through COVID-19 Pandemic.

Children (Basel). 2021;8(7):577. Published 2021 Jul 5. doi:10.3390/children8070577 16. Diamond-Smith N, Logan R, Marshall C, Corbetta-Rastelli C, Gutierrez S, Adler A, Kerns J. COVID-19’s impact on contraception experiences: Exacerbation of structural inequities in women’s health. Contraception. 2021 Dec;104(6):600-605. doi: 10.1016/j.contraception.2021.08.011.

Epub 2021 Aug 27.

17. Frost, J.J., Lindberg, L.D. and Finer, L.B. (2012) ‘Young adults’ contraceptive knowledge, norms and attitudes: Associations with risk of unintended pregnancy’, Perspectives on Sexual and Reproductive Health, 44(2), pp. 107–116. doi:10.1363/4410712.

18. Unintended pregnancy in the United States [Internet]. 2022 [Accessed 2024 Page 9

Feb 6]. Available from: https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states 19. The National Campaign to Prevent Teen and Unplanned Pregnancy. (2015, July).

Unplanned pregnancy among college students and strategies to avoid it. Power To Decide. https://powertodecide.org/sites/ default/files/resources/primary-download/briefly-unplanned-pregnancy-college.pdf 20. Rae, M., Cox, C., & Dingel, H. (2022, July 13). Health costs associated with pregnancy, childbirth, and postpartum care. Health System Tracker. https:// www.healthsystemtracker.org/brief/ health-costs-associated-with-pregnancy-childbirth-and-postpartum-care/ 21. Centers for Disease Control and Prevention. (2023, February 8). Pregnancy complications. Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/ pregnancy-complications.html 22. The Lancet Child & Adolescent Health.

Youth Stis: An epidemic fuelled by shame.

The Lancet Child & Adolescent Health. 2022;6(6):353. doi:10.1016/ s2352-4642(22)00128-6 23. Reeves, J. M., Zigah, E. Y., Shamrock, O. W., Aidoo-Frimpong, G., Dada, D., Batten, J., Abu-Ba’are, G. R., Nelson, L. E., & Djiadeu, P. (2023). Investigating the impact of stigma, accessibility and confidentiality on STI/STD/HIV self-testing among college students in the USA: protocol for a scoping review. BMJ open, 13(2), e069574.

24. Shannon CL, Klausner JD. The growing epidemic of sexually transmitted infections in adolescents: A neglected population. Current Opinion in Pediatrics. 2018;30(1):137–43. doi:10.1097/ mop.0000000000000578 25. Wondimagegene YA, Debelew GT, Koricha ZB. Effectiveness of peer-led education interventions on contraceptive use, unmet need, and demand among adolescent girls in Gedeo Zone, South Ethiopia. A cluster randomized controlled trial. Global Health Action. 2023;16(1). doi:10.1080/1 6549716.2022.2160543 26. Budhwani, H., Anderson, J., & Hearld, K. R. (2018). Muslim Women’s use of contraception in the United States. Reproductive health, 15(1), 1. https://doi.org/10.1186/ s12978-017-0439-6 27. Sanz-Martos, S., López-Medina, I. M., Álvarez-García, C., & Álvarez-Nieto, C. (2021). Educational program on sexuality and contraceptive methods in nursing degree students. Nurse Education Today, 107, 105114. https://doi.org/10.1016/j. nedt.2021.105114

Table 1: Characteristics of participants Characteristics

No. (%)

Age 18 – 20 years

26 (78.8)

21 – 25 years

7 (21.2)

Religion Christian

22 (66.7)

Muslim

4 (12.1)

Atheist

2 (6.1)

Prefer not to say

1 (3.0)

Other

4 (12.1)

Sexual Orientation Heterosexual

22 (68.8)

Homosexual

3 (9.4)

Bisexual

5 (15.6)

Pansexual

1 (3.1)

Prefer not to say/no answer

2 (6.1)

University Organization University Athletic Team (yes)

11 (31.4)

Club Athletic Team (yes)

2 (5.7)

Greek Life (yes)

4 (11.4)

Pre-professional Club (yes)

9 (25.7)

Other (yes)

7 (20.0)

Prefer not to say

2 (5.7)

Table 2: Sexual behavior and contraception use of participants with previous sexual experience (n = 15) Count (%) Previous number of sexual partners in the past 5 years 0–1

5 (33.3)

2–4

6 (40.0)

5 - 10

2 (13.3)

11+

2 (13.3)

Previous contraception use Yes

12 (80.0)

No

3 (20.0)

First contraception method used Hormonal contraceptive (yes)

7 (46.7)

Barrier method (yes)

8 (53.3)

Emergency contraceptive (yes)

2 (13.3)

Reasoning behind using contraception Prevention of STI/STD (yes)

4 (26.7)

Prevention of pregnancy (yes)

11 (73.3)

Other health concerns (yes)

1 (6.7) Page 10

Table 3: Summary of pre- and post-intervention survey results on contraception attitudes and perceptions among students Percentage of students that selected Agree or Strongly Agree Pre-survey

Post-survey

p-value

I feel confident in making decisions in regard to contraception

87.9%

93.9%

0.422

Contraception is easily accessible within my community/ campus.

72.7%

81.8%

0.325

I know where to obtain various contraceptives.

75.8%

84.8%

0.263

I feel comfortable discussing contraception methods with my primary care provider and/or the campus health center.

72.7%

81.8%

0.374

I fear judgment from my family, co-workers, peers, and/or members of my community in regard to using contraception.

42.4%

42.4%

1.000

Figure 1: Participants’ knowledge of contraception as assessed in both pre-survey and post-survey assessments.

Post-Survey Knowledge

Pre-Survey Knowledge

93.9% 93.8%

Which o f these is a po ssible side effect o f birth control pills?

73.5%

Which metho ds o f birth co ntrol need a prescriptio n?

51.5% 64.7%

How long is the vaginal ring left in place?

18.2% 58.8%

Which of the following are barrier methods of birth control?

33.3% 41.1%

What do male condoms o ffer that o ther forms of birth co ntro l do no t?

27.3%

World Contraception Day “The Power of Options”

Sep 26, 2024 Page 11

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Myths, Misconceptions, and Truths about Buprenorphine

By: Dr. Daniel M. Strickland and Dr. Cheryl Viracola

The Clinical Scenario From The Prescriber Recently, a pharmacist working in a North Carolina branch of a national chain pharmacy refused to fill an electronic prescription for buprenorphine mono-product (BUP, without naloxone) for a patient of mine. They claimed that the policy of the parent company was to decline prescriptions for the mono-product unless the patient was allergic to naloxone.

When I heard about the problem and called the pharmacy, another pharmacist was on duty. I explained that the patient experienced severe headaches for several hours after taking the combination product (buprenorphine plus naloxone - BUPNx) but had no problem with the mono-product. The pharmacist filled the prescription. When a representative of the NC Association of Pharmacists (NCAP) was later able to query the original pharmacist, the alleged company policy could not be verified. The NCAP representative also contacted the company’s Executive Director of Regulatory Affairs, who revealed that there was no such company policy - to wit: … The situation you described below to have documented allergy to dispense the mono-product is not (company) policy. The mono-product may be a potential red flag, but the pharmacist can resolve the red flag and dispense using their professional judgment (1).

Burson (2) also reported other recent problems with patients obtaining buprenorphine. “We have an urgent situa-

tion afflicting rural areas in North Carolina and across our nation. Patients new to buprenorphine treatment cannot find pharmacies willing to fill their prescriptions.”

For the record, I understand and respect the authority of the dispensing pharmacist to decline a prescription: SECTION .1800 - PRESCRIPTIONS 21 NCAC 46 .1801 EXERCISE OF PROFESSIONAL JUDGMENT IN FILLING PRESCRIPTIONS (a) A pharmacist or device and medical equipment dispenser shall have a right to refuse to fill or refill a prescription order if doing so would be contrary to his or her professional judgment. (b) A pharmacist or device and medical equipment dispenser shall not fill or refill a prescription order if, in the exercise of professional judgment, there is or reasonably may be a question regarding the order’s accuracy, validity, authenticity, or safety for the patient. (c) A prescription order is valid only if it is a lawful order for a drug, device, or medical equipment issued by a health care provider for a legitimate medical purpose, in the context of a patient-prescriber relationship, and in the course of legitimate professional practice as recognized by the occupational licensing board governing the health care provider (3).

I discussed the issue with the representative of NCAP, who, in their professional opinion, believes that the prescription and my call to the pharmacist should have satisfied any reservations about its accuracy and validity. They also highlighted the importance of avoiding reliance on Page 14

unconfirmed company policies, which in this case only resulted in patient distress and wasted time and effort on the part of the prescriber.

In today’s complex healthcare landscape, where patient care is paramount, it is crucial to foster an environment of trust and collaboration among healthcare professionals. Pharmacists play a vital role in ensuring patient safety and optimizing medication therapy, but it is imperative to prioritize effective communication and collaboration between prescribers and pharmacists. This includes respecting each other’s expertise and judgment and verifying any policies or guidelines before acting upon them.

Discussion The above anecdotes highlight a common problem in Appalachia (and possibly in other parts of the country): misconceptions about the synthetic opioid buprenorphine. Poliwoda et al. (4) provide an excellent overview of the compound.

Buprenorphine (BUP) is one of three Medications used in the treatment of Opioid Use Disorder (or dependence) – sometimes abbreviated MOUD. Buprenorphine, a Schedule 3 drug, has been available as an analgesic for many years. Still, the Drug Addiction Treatment Act of 2000 (DATA 2000) established the criteria for outpatient use of BUP as MOUD (5) in a setting commonly referred to as an Outpatient Based Opioid Treatment (OBOT) clinic.

Medical providers no longer need to ob-

tain a waiver from the Drug Enforcement Agency to prescribe BUP as a MOUD. Still, some states have exceeded the original requirements of DATA 2000 and inserted legislative and regulatory requirements between the patient and their medical provider and pharmacy of choice (6,7).

Some wholesalers have imposed limits on ordering all controlled substances, which seem to be arbitrary but may be related to well-publicized suits and actions against so-called “Big Pharma” manufacturers such as Johnson & Johnson, Teva, Purdue Pharma, and wholesalers such as AmerisourceBergen, Cardinal Health, and McKesson (8) However, a recent notice jointly issued

by DEA and HHS stated: “DEA supports collaboration amongst all DEA registrants to ensure an adequate and uninterrupted supply of MOUD products when these products are appropriately prescribed.

Distributors should carefully examine quantitative thresholds they have established to ensure that individuals with OUD who need buprenorphine can access it without undue delay.” (9) Further guidance was provided by the Diversion Control Division of the DEA (10): “Question: Do the CSA or DEA regulations require DEA-registered manufacturers or distributors to establish limits (quantitative thresholds) on the amounts of controlled substances, including MOUD, that another DEA registrant can order or dispense?”

“Answer: No. Neither the CSA nor DEA regulations establish quantitative thresholds or limits on the amounts of controlled substances, including MOUD, that DEA registrants may order or dispense, nor do they require registrants to set such thresholds or limits.”

Despite these clarifications, however, there are some myths and misconceptions associated with buprenorphine, which persist and often compound problems with access to treatment or the availability of medication.

Even among health care providers (HCP), there are misconceptions about BUP. For instance, a survey of HCPs in Ohio found that 48.41% of participants endorsed at

least one piece of misinformation. The most endorsed items were that buprenorphine is ineffective at reducing overdose deaths and that its use substitutes one drug for another. HCP endorsement of buprenorphine misinformation significantly and negatively predicted willingness to work with patients with OUD (11).

Major et al. (12) also discuss the need to educate pharmacists on evidence-based practices for treating OUD and increase communication between prescribers and pharmacists). We should now add that communication between pharmacists and distributors regarding the position of the DEA on buprenorphine stocks may be necessitated.

The purpose of this article is to assist with such communication.

Myths & Facts Myth: Buprenorphine is just substituting one addiction for another.

Fact: OUD is a chronic, relapsing brain disorder, not a moral failing (6). It is considered a medical disability under the ADA’s definition because it is a condition that substantially limits a significant life activity (13) Importantly, the treatment of OUD is called medication-assisted treatment (MAT) and not medication-curative treatment because it often requires counseling, as well as support from family and community, and sometimes intensive inpatient rehabilitation. But along with methadone, it is an important, nay critical, modality to reduce or eliminate cravings and withdrawal symptoms. Please note that there is often a stigma associated with the term MAT; however, it is an acronym routinely used in addiction medicine circles. MOUD is used when referring to the three approved medications for treating OUD. Myth: Buprenorphine is as dangerous as other opioids.

Fact: Unlike full agonist opioids such as fentanyl or prescription painkillers, buprenorphine is a partial opioid agonist, which means it has a ceiling effect on respiratory depression. This reduces the risk of overdose compared to full opiPage 15

oid agonists. Indeed, buprenorphine is rarely even associated with drug overdose deaths (14-16). Additionally, because it produces minimal euphoric effects, buprenorphine has a much lower abuse potential than full agonists.

Myth: Buprenorphine treatment is only effective for a short period.

Fact: Like any medication to control a chronic disease, buprenorphine may be required as a long-term maintenance treatment for opioid dependence, but treatment duration must be individualized based on the patient’s needs. Unlike some full agonists, no tachyphylaxis is observed for the therapeutic effects of buprenorphine, so once a stable dose has been reached, it can be maintained in the long term.

Myth: Buprenorphine has a long halflife, similar to that of morphine (24-48 hours).

Fact: Contrary to common belief, the plasma half-life of sublingually administered buprenorphine, which equates to clinical half-life, is only 4-6 hours (17).

This property requires that a daily dose be split into 2 or 3 doses so that the plasma concentration does not drop below a therapeutic level. This characteristic requires that Opioid Treatment Programs (OTP - daily dispensing programs) may require a higher daily dose for plasma concentrations to remain in the therapeutic range for 24 hours. Fortunately, because of the safety range of buprenorphine, this does not present a danger to patients (18-22).

Myth: Naloxone, the second component in “Suboxone” (buprenorphine/naloxone –BUPNx), is poorly absorbed via the sublingual route; therefore, it cannot cause unpleasant side effects.

Fact: In a study of urine drug screens in a large clinical practice, 93% of the patients prescribed the combination product had urine concentrations of naloxone over the “clinical cutoff” of 30 ng/mL (23). Intolerable side effects include headaches, muscle cramps, dyspepsia, and dysphoria.

Myth: Buprenorphine is often diverted for misuse, i.e., to get “high.”

Fact: Most of the diverted buprenorphine

is used to alleviate withdrawal symptoms, not to get “high” (24-27). It can almost be considered “therapeutic.” It is reported that most of the diverted buprenorphine is obtained from friends, but when purchased, it costs between $20-$30 per tablet. In the outpatient clinic where author DMS is a provider,100% of patients admitted show buprenorphine in their intake drug screen. When queried about why they spent so much on buprenorphine when fentanyl is so cheap, they uniformly answered something to the effect that they didn’t want to die.

Since 2010, NCAP has been dedicated to raising awareness, providing education, and offering advanced training in Opioid Stewardship to both its members and the wider pharmacy profession. To discover more about the resources available to you, please visit www.ncpharmacists.org.

Click on the Resources and Professional Development tabs on the homepage to access toolkits, videos, on-demand webinars, and certificate-level programs designed to enhance your knowledge and professional development in this area of pharmacy practice. Their staff are also available to assist you. For any questions related to opioids, feel free to contact cheryl@ncpharmacists.org.

Authors: Daniel M. Strickland, MS, MD, FACOG, High Country Recovery, Boone, NC; Cheryl Viracola, PharmD, FNCAP; Director of Practice Advancement, North Carolina Association of Pharmacists cheryl@ncpharmacists.org References 1.

2.

3.

4.

Personal communication between Cheryl Viracola, PharmD, FNCAP, Director of Practice Advancement, North Carolina Association of Pharmacists and Lauren Paul, PharmD MS, Executive Director, Pharmacy Regulatory Affairs, of the subject chain pharmacy Burson, J. Urgent Situation for Buprenorphine Patients. January 28, 2024. https:// janaburson.wordpress.com/2024/01/28/ urgent-situation-for-buprenorphine-patients/. Accessed 4/20/2024 NC Board of Pharmacy. 21 NCAC 46 .1801 EXERCISE OF PROFESSIONAL JUDGMENT IN FILLING PRESCRIPTIONS. http://www. ncbop.org/lawsrules/rules.1800.pdf.

Accessed 4/20/2024 Poliwoda S, Noor N, Jenkins JS, et al.: Buprenorphine and its formulations: A

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

comprehensive review. Health Psychol Res. 2022; 10(3): 37517.

Drug Addiction Treatment Act of 106th United States Congress: 2000. Available at https://www.congress.gov/106/bills/ hr2634/BILLS-106hr2634pcs.pdf.

Strickland DM, Sorboro J. Adverse effects of regulation on buprenorphine prescribing and its impact on the treatment of opioid use disorder. J Opioid Manag. Vol 17, No 7 (2021): Special Issue - “Buprenorphine: Clinical and Public Policy Implications” Strickland DM, Baker JT. Legislative and Regulatory Barriers to Pharmacies Dispensing Buprenorphine for OUD. J Opioid Manag, 2023 Special-Issue;19(7):135-140. doi: 10.5055/jom.2023.0807. https://www.npr. org/2022/02/25/1082901958/opioid-settlement-johnson-26-billion https://www.deadiversion.usdoj.gov/ pubs/docs/Dear_Registrant_MOUD.pdf https://www.deadiversion.usdoj.gov/ GDP/(DEA-DC-065)(EO-DEA258)_Q_A_ SOR_and_Thresholds_(Final).pdf Franz, B., Dhanani, L., Hall, O.T. et al. Buprenorphine misinformation and willingness to treat patients with opioid use disorder among primary care-aligned health care professionals. Addict Sci Clin Pract 19, 7 (2024). https://doi.org/10.1186/ s13722-024-00436-y Major EG, Wilson CG, Carpenter DM, Harless JC, Marley GT, Ostrach B. Factors in rural community buprenorphine dispensing. Explor Res Clin Soc Pharm.

2022 Dec 26;9:100204. doi: 10.1016/j. rcsop.2022.100204. PMID: 36703716; PMCID: PMC9871294. (https://www.ada.gov/topics/opioid-use-disorder/).

Drug Overdose Deaths in the U.S. Top 100,000 Annually. US Centers for Disease Control and Prevention. https://bit. ly/3yfs8Fb Paone D, Tuazona E, Stajicb M, et al.: Buprenorphine infrequently found in fatal overdose in New York City. Drug Alcohol Depend. 2015;155:298-301.

DOI:10.1016/j.drugal-cdep.2015.08.007 Strickland DM, Gale G. Buprenorphine and Drug Overdose Deaths. Ann Clin Toxicol. 2022;5(1):1036.

Strickland DM, Manandhar P: Buprenorphine Half-Life – Further Considerations. Acta Scientific Pharmacology 2021;2(2):03-10. https://actascientific. com/ASPC/ASPC-02-0086.php Gueye PN, Borron SW, Risède P, et al.

Lack of effect of single high doses of buprenorphine on arterial blood gases in the rat. Toxicol Sci 2001 Jul;62(1):148-54. doi:10.1093/toxsci/62.1.148.

Ahmadi J, Jahromi MS, Ghahremani D, London ED. Single high-dose buprenorphine for opioid craving during withPage 16

20.

21.

22.

23.

24.

25.

26.

27.

drawal. Trials. 2018 Dec 10;19(1):675. doi: 10.1186/s13063-018-3055-z. PMID: 30526648; PMCID: PMC6288888.

Van Petten LE, Levin RA, Graham TC, Sutton ML. Parenteral toxicity of Buprenorphine (Buprenex) in Beagle Dogs and Sprague-Dawley Rats. The Toxicologist 1983;3(1):10 Dahan A, Yassen A, Romberg R, Sarton E, Teppema L, Olofsen E, Danhof M. Buprenorphine induces ceiling in respiratory depression but not in analgesia.

Br J Anaesth. 2006 May;96(5):627-32. doi:10.1093/bja/ael051. Epub 2006 Mar 17.

Walsh SL, Preston K, Stitzer M, et al.: Clinical pharmacology of buprenorphine: Ceiling effects at high doses. Clin Pharmacol Ther. 1994;55(5):569-580. DOI:10.1038/ clpt.1994.71 Strickland DM, Burson JK: Sublingual Absorption of Naloxone in a Large Clinical Population. J Drug Metab Toxicol 2018, 9:3 DOI:10.4172/2157-7609.1000240 Cicero TJ, Ellisa MS, Chilcoat HD: Understanding the use of diverted buprenorphine. Drug Alcohol Depend.

2018;193:117-123. DOI:10.1016/j.drugalcdep.2018.09.007.

Chilcoat HD, Amick HR, Sherwood MR, et al.: Buprenorphine in the United States: Motives for abuse, misuse, and diversion.

J Subst Abuse Treat. 2019;104:148-57.

DOI: 10.1016/j.jsat.2019.07.005.

Lofwall MR, Walsh SL: A review of buprenorphine diversion and misuse: The current evidence base and experiences from around the world. J Addict Med. 2014;8(5):315-326. DOI:10.1097/ ADM.0000000000000045.

Bazazi AR, Yokell M, Fu JJ, et al. Illicit use of buprenorphine/naloxone among injecting and noninjecting opioid users. J Addict Med. 2011;5(3):175-180. DOI:10.1097/ ADM.0b013e3182034e3

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Evaluating the Impact of Wellness Events on Pharmacy Student Well-Being By: William Mossman, PharmD Candidate, and Dr. Carrie L. Griffiths Introduction Literature has established that students enrolled in pharmacy school meet clinical cut points for depression as often as medical students and anxiety more often than medical students. (1) Despite this, a 2019 scan of pharmacy school websites found that a majority (77%) did not list mental health resources on their websites. Of those that did, information was not easily accessible, requiring over five minutes to locate information regarding mental health. (2) Additionally, a survey sent out as a part of the same study found that mental health resources available to pharmacy students were often within the universities themselves and not a part of the pharmacy program. It was common for these resources to be offered only during business hours on weekdays, which was not ideal for pharmacy students who had classes during that time. (2) Pharmacy schools that have implemented pilot wellness programs have had promising results, such as a program that consisted of required hour-long wellness sessions and student-led in-class wellness breaks where a post-survey discovered students experienced an increase in weekly exercise and sleeping more than four hours per night. (3) Evidence suggests that wellness events can improve the well-being of pharmacy students. One study surveyed a group of pharmacy students about the sources of stress. Researchers found that the well-being of pharmacy students is impacted by multiple sources ranging from the learning environment and workload to personal traits and life circumstances. (4) A study by Chatterjee and colleagues surveyed medical students, and

results showed that students preferred organic student-organized wellness events over mandatory school-organized events.

(5) Since stressors arise from various student situations, pharmacy schools should evaluate common sources of perceived stress among students and tailor wellness events accordingly. The goal of this study was to evaluate the wellness events offered at Wingate University School of Pharmacy (WUSOP) over the last year and compare events to the sources of stress experienced by WUSOP students to assess if the offered wellness events adequately improved students’ well-being.

Methods The Wingate University Research Review Board approved this single-site cohort study. Participants in this study were current first- through third-year pharmacy students enrolled at Wingate University School of Pharmacy. Students enrolled in other programs were excluded from this study. Data was collected using a Qualtrics survey distributed electronically in an announcement on Wingate University’s learning management system. In addition to obtaining consent and unidentifiable demographic information, the survey gathered information on participant well-being using an adapted WHO-5 Well-Being questionnaire and perceived sources of stress. Options for sources of stress were identified and adapted from Garber et al. (6,7) A select-all-that-apply item was used to identify wellness events attended by participants (if any), and the perceived impact of attended wellness events was determined using a Likert scale that included options ranging from Page 18

“no impact on wellbeing” to “substantial impact on wellbeing.”

Results Of the 42 respondents to the survey, 17% did not enter demographic information.

For those that did provide demographic information (Table 1), 76% were female, and 7% were male. Regarding age, 57% were 18-24, 19% were 25-34, 2.3% were 35-44, and 4.7% were 45-54, 60% identified as white/Caucasian, 12% as black or African American, and 2% as Asian or Pacific Islander, Hispanic, and Other respectively. Among cohorts, 38% of respondents were first-year pharmacy students, 24% were second-year pharmacy students, 21% were third-year pharmacy students, and 17% did not provide this information. Across campuses, 64% of respondents were from Wingate’s main campus, 9% from Wingate’s Hendersonville campus, and 17% unknown. Compared to the cohort sizes, 33% of first-year and second-year pharmacy students and 16% of third-year pharmacy students completed the survey.

Using the adapted WHO-5 questionnaire, 69% of students rated their well-being as good (all the time, most of the time, more than half the time), 21% rated their well-being as poor (none of the time, some of the time, less than half of the time), and 10% did not rate their well-being. Additionally, respondents reported perceived sources of stress. In order of frequency, reported perceived sources of stress include coursework burden (e.g., the number of submissions, preparation for exams), outside-of-school responsibilities (e.g., partner/spouse/children,

work, etc.), extracurricular activities (e.g., leadership, volunteering, etc.), absences during the school semester (e.g., illness, death in the family), experiential burden (e.g., additional rotation responsibilities), and all of the write-in responses mentioned a financial burden (Table 2).

The survey also asked respondents to report wellness event attendance. Seventy-four percent of respondents participated in a food truck event, 57% attended a monthly coffee bar, 33% attended a therapy dog session, 33% participated in spirit week, 21% attended a Thanksgiving potluck, and 7% did not attend any wellness events (Table 3). Students often attended multiple events, and there were instances of partial respondents reporting attendance without reporting demographic information. Respondents were asked to rate the impact of attending wellness events on their well-being (Table 4). Nineteen percent of respondents indicated a substantial improvement, 53% showed some improvement, 9% indicated minimal improvement, and 19% did not respond to this portion of the survey. Respondents also had the option to write suggestions for future wellness events. Responses included coffee/food/drink-based wellness events, yoga/mindfulness-based wellness events, therapy dogs, financial counseling, volunteer opportunities, and wellness challenges.

Discussion This survey aligns with evidence from Holman and colleagues that correlates attending well-being events with improved perceived wellness. (3) Another study showed a negative correlation between perceived stress and the number of wellness sessions attended by fourthyear pharmacy students. (8) Aligning with results seen in Babal et al., this survey observed a range of reported perceived sources of stress. (4) Expectedly, coursework burden was the primary stressor, and stressors originating from outside of school were the second most reported perceived source of stress. Reports of stress caused by the above, extracurricular events, and financial burden correlate with a study performed by Minshew and colleagues that observed pharmacy students experiencing stress due to academic expectations, co-curricular activities, and paid employment. (9) These wellness events provide a number of opportunities

for pharmacy students. Not only do wellness events enrich a student’s well-being, but they also allow students to congregate and interact with each other outside of the classroom, building camaraderie and facilitating networking. A desire for this engagement can be seen with suggested well-being events, including means to congregate, such as food trucks and coffee bars.

In this survey, the two responses from fourth-year pharmacy students were excluded due to the research proposal for this survey not covering fourth-year pharmacy students. A possible explanation for the comparatively small number of third-year pharmacy student responses could be survey/notification fatigue, as many survey and learning management system notifications have been sent out over their three years of pharmacy school.

The limitation of this survey was that 17% of respondents did not provide demographic information, which prevented the study from reaching the full scope of the surveyed population. Additionally, the demographic data of the survey population does not accurately represent the pharmacy student population.

Future well-being events include coffee/ food/drink-based events, yoga/mindfulness, therapy dogs, financial counseling, volunteer opportunities, and wellness challenges. Although some of the suggestions would require a source of funding, possible sponsors may include the school of pharmacy’s student senate, student organizations, or a grant. One method of increasing attendance at the most popular event, the monthly coffee bar, would be to offer a wider range of drink options, as the bar only supplies iced coffee. Hot coffee or tea may appeal to more participants.

classmates and faculty at these events, as seen by the suggested well-being events.

In continuing the evaluation of wellness events, taking attendance during the wellness events could offer more insights into who is attending.

Authors: William Mossman, PharmD Candidate (Corresponding author); Wingate University School of Pharmacy; wi.mossman558@wingate.edu; Carrie L. Griffiths, PharmD, BCCCP, FCCM; Adjunct Professor of Pharmacy Wingate University School of Pharmacy; Wingate, NC 28174 References 1.

2.

3.

4.

5.

6.

7.

Conclusion When provided with wellness events, most students reported at least some improvement in well-being. Indeed, it is paramount that the well-being of pharmacy students is adequately supported by their institution. There are many avenues of ensuring wellness events are offered to pharmacy students, such as school or student organization-sponsored events, and tailoring wellness events to specific student populations to enrich their well-being is necessary. There is a desire among pharmacy students to engage with Page 19

8.

9.

Fischbein R, Bonfine N. Pharmacy and Medical Students’ Mental Health Symptoms, Experiences, Attitudes and Help-Seeking Behaviors. Am J Pharm Educ. 2019 Dec;83(10):7558.

Sun W, Alzouby H, Harris S. Mental health resources in pharmacy schools. Curr Pharm Teach Learn. 2021 Apr;13(4):333339.

Holman SK, Folz HN, Ford B, et al. Design and implementation of a pilot student wellness program at a school of pharmacy. Curr Pharm Teach Learn. 2021 Nov;13(11):1471-1477.

Babal JC, Abraham O, Webber S, et al.

Student Pharmacist Perspectives on Factors That Influence Wellbeing During Pharmacy School. Am J Pharm Educ. 2020 Sep;84(9): ajpe7831.

Chatterjee K, Edmonds VS, Girardo ME, et al. Medical students describe their wellness and how to preserve it. BMC Med Educ. 2022 Jun 28;22(1):510.

Garber MC, Huston SA, Breese CR. Sources of stress in a pharmacy student population. Curr Pharm Teach Learn. 2019 Apr;11(4):329-337.

WHO-5 Questionnaires [Internet], (Ed) Jesper Kvorning. Hillerod, Denmark. Psykiatric Center North Zealand, Psychiatric Research Unit; 1998 [cited: 2024 Mar 26].

Available from: https://www.psykiatri-regionh.dk/who-5/who-5-questionnaires/ Pages/default.aspx Mnatzaganian CL, Lee KC, Singh RF, et al. Implementation and impact of a fourth-year student pharmacist wellness series pilot on perceived stress and support. Curr Pharm Teach Learn. 2022 Dec;14(12):1549-1554.

Minshew LM, Bensky HP, Zeeman JM. There’s no time for no stress! Exploring the relationship between pharmacy student stress and time use. BMC Med Educ.

2023 Apr 24;23(1):279.

Table 1: Survey Respondent Demographic Information Total (n=42)

Wingate (n=34)

HVL (n=8)

Gender (n) Male

3

2

1

Age (%) 18-24 25-34 35-44 45-54 Did not Provide

57 19 2.3 4.7 17

55.9 14.7 2.9 5.9 20.6

62.5 37.5

Ethnicity (%) White/Caucasian Black or African American American Indian or Alaskan Native Asian or Pacific Islander Hispanic Other Did not Provide

59.5 11.9 4.7 2.3 2.3 2.3 17

50 14.7 5.9 2.9 2.9 2.9 20.6

100

Year in Pharmacy School (%) P1 P2 P3 Did not Provide

38 24 21 17

35.3 20.6 23.5 20.6

50 37.5 12.5

KEY: HVL = Hendersonville

Table 2: Reported Perceived Sources of Stress Across Cohorts

Perceived Source of Stress

Total (N=42)

P1 (N=16)

P2 (N=10)

P3 (N=9)

Coursework Burden (e.g., quantity of submissions, preparation for exams)

38

15

10

9

Experiential Burden (e.g., additional rotation responsibilities)

8

1

2

3

Extracurricular Activities (e.g., leadership, volunteering, etc.)

15

4

3

6

Absences During Semester (e.g., illness, death in the family)

12

3

6

3

Outside School Responsibilities (e.g., partner/spouse/ children, work, etc.)

21

8

7

5

Other

2

0

0

0

Page 20

Table 3: Reported Attendance of Wellness Events Across Cohorts Event

Total

P1

P2

P3

Coffee Bar

24

9

7

8

Food Truck

32

12

11

8

Thanksgiving Potluck

9

6

2

1

Therapy Dogs

14

5

6

2

Spirit Week

14

8

1

4

None

3

2

0

0

Other

1

0

1

0

Table 4: Impact of Wellness Events on Pharmacy Student Wellbeing Across Cohorts Effect on Wellbeing

Total*

P1

P2

P3

Substantial Improvement

8

3

2

3

Some Improvement

22

10

6

5

Very Little Improvement

4

1

2

1

Did not Attend Events

3

2

0

0

**5 respondents did not enter information for this survey, 3 respondents did not attend wellness events and could not rate the impact on their well-bei

Hydroxychloroquine Retinal Toxicity: Taking a Closer Look

By: Dr. Heather R. King, PGY1 Community-Based Pharmacy Resident, and Dr. Geena Eglin, BCACP, CSP, CPP Introduction

patient-specific factors. (3)

Hydroxychloroquine (HCQ) is a traditional (non-biologic) disease-modifying antirheumatic drug (DMARD) commonly used to treat rheumatoid arthritis, systemic lupus erythematosus, and several other autoimmune conditions. (1) Chronic use of HCQ has been associated with the development of retinopathy. It is theorized that HCQ may lead to retinopathy by damaging photoreceptors through binding to melanin in the retinal pigment epithelium (RPE). (2) However, the exact mechanism by which HCQ causes retinopathy is unknown.

A retrospective case-control study published in 2014 examined 2,361 patients taking HCQ for more than five years and found that the average prevalence of retinopathy was 7.5%. (4) The authors noted that this statistic varied widely based on dose and duration of use. Only 2% of patients who were within the recommended dosage range of 4.0 – 5.0 mg/kg/day were found to have retinopathy within five to ten years of initiating HCQ therapy. This finding increased to 20% after 20 years of HCQ therapy. Patients whose average daily dose was greater than 5mg/kg had a 10% risk of developing retinal toxicity within ten years and a 40% risk within 20 years. (4) Based on this study, the AAO recognizes long durations of use and higher doses of HCQ as leading predictors of the development of retinal toxicity.

Most individuals do not experience vision changes until more extensive retinal damage has occurred, after RPE has been affected and the foveal center is involved.

It is important to follow the AAO screening recommendations to discontinue HCQ at the first conclusive signs of toxicity, thus preventing irreversible loss of visual acuity. (3)

Retinopathy caused by HCQ increases in incidence with longer durations of use; therefore, the American Academy of Ophthalmology (AAO) recommends baseline retinal exams such as a fundus examination, automated visual fields, and spectral domain optical coherence tomography (SD-OCT) within the first year of HCQ initiation. After this, an automated visual fields exam and SD-OCT should be performed at 5-year intervals for the continuation of retinal toxicity monitoring. However, some patients may be at a high risk of developing retinal toxicity and should have annual retinal exams. Risk factors for increased risk of HCQ-induced retinal toxicity include concomitant use of tamoxifen, HCQ use greater than five years, subnormal eGFR (< 60 mL/min/1.73m2), pre-existing macular disease, and HCQ dose greater than 5 mg/kg/day (actual body weight). The aforementioned retinal examinations are not routinely performed as part of an eye exam; therefore, the ophthalmologist must be made aware that their patient is taking HCQ to appropriately administer such exams at the recommended time intervals based on

In clinical practice, HCQ-associated retinopathy is viewed as a rare occurrence, and therefore, the importance of compliance with retinal exam monitoring may be overlooked. (5,6) Despite available evidence for the importance of screening, several studies have displayed a lack of adherence to the 2016 AAO monitoring recommendations. A retrospective chart review evaluating adherence to HCQ monitoring parameters for patients at a large academic medical center showed that only 60.6% met the recommended Page 22

screening frequency recommendations.

(5) Another study that stratified results based on provider type (retinal specialists, non-retinal ophthalmologists, and optometrists) showed that retinal specialists were more likely to follow screening protocols, most likely due to increased awareness of recommendations. (6) A study by Braslow et al. showed that the 2016 revision of the AAO recommendations made no appreciable difference in HCQ dosing. The authors found that 50% of participants (according to the 2011 recommendations) versus 47% (according to the 2016 recommendations) were placed on an excess initial dose. (7) Methods A Medication Use Evaluation (MUE) was performed at a rheumatology clinic to determine the percentage of patients with a documented retinal exam within the first year of HCQ therapy. Secondary endpoints included determining the percentage of high-risk patients with a documented annual retinal exam and determining the percentage of patients (routine and high-risk) who developed retinal toxicity while on HCQ. The timelines for documented retinal exams were based on the AAO monitoring recommendations for patients who initiated and continued HCQ therapy.

The clinic comprised an interdisciplinary team with a physician and an advanced practitioner. This was an Institutional Review Board (IRB) exempt, retrospective MUE targeting patients initiated on HCQ at the outpatient rheumatology office between February 1, 2018, and December 31, 2021. The patient population included those over 18 years of age who were initiated on HCQ therapy during the

study period. As the goal was to assess this clinic’s adherence to AAO monitoring recommendations for retinal toxicity, patients taking HCQ for more than one year prior to establishing care at this site were excluded from the study. A total of 422 patient charts were reviewed, and 325 patients were deemed eligible for inclusion in the study. Descriptive statistics were utilized.

Results The primary endpoint outcome showed that 17% of participants (n=55) had a documented baseline retinal exam within their electronic medical record during their first year of therapy. Of the patients included in the MUE (n=325), 46% (n=151) met the criteria for high-risk categorization for retinal toxicity by having one or more risk factors at the time of HCQ initiation. Classifying these patients who met high-risk criteria: 64 patients (42%) had an eGFR of < 60 mL/min/1.73m2, 100 patients (66%) were on a dose of HCQ >5 mg/kg/day, 11 patients (7%) had macular disease before HCQ initiation, one patient (1%) was taking chloroquine > 5 years, and no patients were taking tamoxifen.

Many of the patients had more than one risk factor, resulting in a categorization of high-risk. When analyzing high-risk patients, 10% (n=15) were found to have annual retinal exams documented. Overall, three patients developed retinal toxicity while taking HCQ. Two of these patients had a documented baseline retinal exam, and one did not have a baseline retinal exam documented in their chart. All three of the patients who developed retinal toxicity while on HCQ did not meet the criteria to be considered high-risk.

Discussion The results of this MUE showcase the need for a standardized documentation process for HCQ monitoring parameters, not only at the study site but across all disciplines prescribing this medication.

Most patients at the rheumatology clinic did not have a documented baseline retinal exam within the first year of therapy, showing a lack of compliance with AAO monitoring recommendations. A noteworthy finding from this MUE was that most patients who were at high risk for developing retinal toxicity met this criterion due to taking an HCQ dose >5 mg/kg/

day. This finding represents an opportunity for pharmacists to optimize patient safety by ensuring patients are prescribed appropriate doses of HCQ.

6.

Conclusion These findings highlight the opportunity for pharmacists to assist in ensuring compliance with monitoring parameters for HCQ. There is a strong correlation between the duration of therapy, dose, and development of retinopathy. While retinal toxicity associated with HCQ is relatively rare, the resulting vision damage may be irreversible and is avoidable if toxicity is caught early on through routine monitoring. When working collaboratively with provider care teams, pharmacists can play an integral role in the safe and effective use of HCQ.

7.

medical center. Investigative Ophthalmology & Visual Science 2022;63(7):2491. https://iovs.arvojournals.org/article.aspx?articleid=2782297. Accessed 5/19/2024.

Kalaw F, Arnett J, Baxter SL, et al. Trends and practices following the 2016 hydroxychloroquine screening guidelines. Sci Rep 2023; 13, 15618. https://doi.org/10.1038/ s41598-023-42816-5. Accessed 5/19/2024.

Braslow R, Shiloach M, Macsai M. Adherence to Hydroxychloroquine Dosing Guidelines by Rheumatologists: An Electronic Medical Record–Based Study in an Integrated Health Care System. Ophthalmology 2017; 124 (5): 604-608. https:// doi.org/10.1016/j.ophtha.2016.12.021.

Accessed 5/19/2024.

Authors: Heather R King, PharmD, PGY1 Community-Based Pharmacy Resident, Novant Health New Hanover Regional Medical Center; heather.king@novanthealth.org. Geena Eglin, PharmD, BCACP, CSP, CPP, Specialty Clinical Pharmacist Practitioner, Program Director, PGY1 Community-Based Pharmacy Residency, Novant Health New Hanover Regional Medical Center, Wilmington, NC. References 1.

2.

3.

4.

5.

Cohen S. Mikuls TR. Alternatives to methotrexate for the initial treatment of rheumatoid arthritis in adults. In: UpToDate, Waltham, MA. (Accessed on July 23, 2023, Last updated February 23, 2022).

Wallace DJ. Antimalarial drugs in the treatment of rheumatic disease. In: UpToDate, Waltham, MA. (Accessed on July 23, 2023, Last updated March 24, 2023).

Marmor MF, Kellner U, Lai TY, et al.

American Academy of Ophthalmology.

Recommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy (2016 Revision). Ophthalmology.

2016 Jun;123(6):1386-94. doi: 10.1016/j. ophtha.2016.01.058. Epub 2016 Mar 16.

PMID: 26992838 Melles RB, Marmor MF. The Risk of Toxic Retinopathy in Patients on Long-term Hydroxychloroquine Therapy. JAMA Ophthalmology 2014;132(12):1453–1460. https://jamanetwork.com/journals/jamaophthalmology/fullarticle/1913588.

Accessed 5/19/2024.

Stroman R, Islam Y, Steigleman A, et al.

Compliance with hydroxychloroquine screening guidelines at a large academic Page 23

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COMMENTARY: A Learn and Grow(th) Mindset

preceptor, they explained how receiving feedback would be a regular occurrence during my APPEs—at least twice a month in a formal setting and through daily informal feedback. They emphasized that feedback is not given to tear someone down or make them feel dumb. It is meant to provide opportunities to make changes that will help going forward on current and future rotations and throughout employment. From then on, I consciously tried to see feedback as an opportunity to learn and grow rather than becoming frustrated. I started to see a difference and had preceptors thank me for incorporating their feedback.

By: Dr. Matt Conzola, PGY1 Pharmacy Resident

While this was a big first step towards a growth mindset, receiving and incorporating feedback was only a small portion of where my thought process needed to change. Throughout my APPEs, I worked as part of an interprofessional team in rounding and non-rounding settings. This provided me with experiences that helped me academically and showed me another area where a growth mindset would benefit me.

Have you ever felt frustrated, demoralized, or burnt out during pharmacy school or residency? Has not doing well on an assessment or project made you feel like you are not smart enough to be where you are? Do you dread getting feedback on your performance? If so, read on! I can relate to these scenarios and hopefully help by sharing my experience.

While in pharmacy school, not doing well on an assignment or test made me feel like I was not smart enough and that maybe I was not good at learning about pharmacy. I did not enjoy getting feedback on presentations or clinical skills assessments and tended to take this information personally. Being told I did not do well frustrated me, and I thought I was not as good as the other students in my class. Early in my 4th year of advanced pharmacy practice experiences (APPEs), a preceptor noted my frustration during my midpoint evaluation. He provided advice that helped during my 4th year and kickstarted my transition from a fixed to a growth mindset.

I first heard “growth mindset” and “fixed mindset” in an undergraduate social psychology class. People with fixed mindsets tend to be extrinsically motivated, meaning their drive comes from attempting to prove themselves or show that they are

“better” than others. Success is a result of talent. Failure is seen as a limitation of one’s abilities, so people with fixed mindsets usually avoid situations where they are likely to fail. (1,2) Conversely, people with growth mindsets tend to be intrinsically motivated. Their goals are usually to achieve mastery of a particular subject, which can be done by developing new abilities and skills. People with growth mindsets believe that success results from effort, and failure can be used as an opportunity to learn. (1,2) Interestingly, data suggests that a growth mindset can be taught. A study conducted in 2015 by Persky et al. found that when working in groups, PharmD students with self-identified growth mindsets reported overall higher satisfaction with the team experience and with the peer evaluations they received. (3) Similarly, a 2021 study by Bradley et al. found that PharmD students had higher growth mindset scores on a rating scale and better team communication after completing an educational workshop on growth mindset. (4) Due to the large number of interprofessional interactions that pharmacists have daily, it stands to reason that having a growth mindset would improve academic and professional success.

During the midpoint evaluation with my Page 24

I found it frustrating when a provider disagreed with my recommendations during rounds. I assessed clinical interventions as “right vs wrong.” This black-and-white “scorekeeping” behavior became evident to my preceptor towards the end of my P4 year. This prompted a discussion about how a growth mindset can help me in more ways than just receiving and incorporating feedback. We discussed how if I were to continue with the same thought process of “right vs wrong” for an entire year of residency, I would not have the best possible experience and would spend most of my time frustrated.

Again, this discussion was the wake-up call I needed, and it could not have come at a better time. As a PGY1 pharmacy resident, I have continued to try and keep a growth mindset when receiving feedback, using mistakes as an opportunity to learn for the next time. An example of this came when I interviewed for a PGY2 critical care residency position. I did not interview well and ultimately was not

extended an offer for early commitment to the program. While this was a very difficult experience for me, I used this as an opportunity to improve my interview skills. I used the feedback about what did not go well during the interview. I set up a practice interview session with my residency program director to get additional feedback to help in future job interviews.

I recently interviewed for a different position and received a job offer, mainly due to the new interview skills I developed after experiencing an unfortunate failure.

A growth mindset helps one accept criticism by acknowledging that while you may be working hard and trying your best, there is always more to learn! Tiger Woods best summed it up: “No matter how good you get, you can always get better, and that’s the exciting part.”

Author: Matt Conzola, PharmD, PGY1 Pharmacy Resident, Novant Health New Hanover Regional Medical Center; matt. conzola@novanthealth.org

NCAP Advocacy Fund Your support drives positive change in our profession!

Generous contributions have helped us to achieve huge success during the 2023 legislative session.

Click Here To Donate Today! ncpharmacists.org

References 1.

2.

3.

4.

Cook DA, Artino AR. Motivation to learn: an overview of contemporary theories. Med Educ. 2016;50(10): 983-1077. https://doi.org/10.1111/ medu.13074 Amstrong K. Carol Dweck on How Growth Mindsets Can Bear Fruit in the Classroom. Association for Psychological Science: The Observer.

2019;32(9). https://www.psychologicalscience.org/observer/dweckgrowth-mindsets AM, Henry T, Campbell A. An Exploratory Analysis of Personality, Attitudes, and Study Skills on the Learning Curve within a Team-based Learning Environment. Am J Pharm Educ. 2015;79(2): 1-12. https://doi. org/10.5688/ajpe79220 Bradley CM, Jeter E, Lee S, Cooper JB. A Teamwork Workshop to Improve Pharmacy Students’ Growth Mindset and Communication Skills.

Am J Pharm Educ. 2021;85(5): 363-373. https://doi.org/10.5688/ ajpe8269 Page 25

Improve Health by Reducing PFAS in Drinking Water

By: Dr. Jean B. Douglas What are PFAS?

Per- and poly-fluoroalkyl substances (PFAS), microparticles/nanoparticles are manufactured chemicals that have been widely used in industry and consumer products for over 70 years. They are long-lasting chemicals whose components break down very slowly over time, leading to accumulation in the body and environment. For this reason, they are often referred to as “forever chemicals.” These compounds are used in fast-food wrappers, takeout pizza boxes, microwave popcorn packaging, nonstick cookware, stain-resistant fabrics, carpets, cosmetics, seafood, and items that resist grease, oil, and water.

Tap water has been reported to have a 45% content, and they have also been found in some bottled water. (1,2) Many of our medical products contain PFAS, such as implants, orthopedic components, contact lenses, surgical gloves, catheters, tubing, and blood infusion bags. (3)

Because thousands of PFAS chemicals are found in various consumer, commercial, and industrial products, it is difficult to study and assess the potential human health and environmental risks.

However, current scientific research suggests that exposure to certain PFAS may lead to adverse health outcomes.

(4)

What does research tell us about how these forever chemicals interact with our bodies? Environmentalists are studying 15,000 – 20,000 compounds, but the original and primary chemicals include polyethylene and polyvinyl chloride. (5) PFAS have been found in blood and other body tissues. The impact of PFAS is known to affect changes in cholesterol, liver enzymes, and small changes in infant birth weight, to alter the immune status and response to certain vaccines, to signal pregnancy-induced high blood pressure/preeclampsia, and to cause cancer. (5) While we know that particles have been found in the blood and the body, recent research shows particles being captured in our cardiovascular system, leading to harm and the need for surgery. (6) The latest discovery that man-made FAS causes disease was published in the March 7, 2024, New England Journal of Medicine. (6) This study by Marfella et al. adds to the growing ‘call to action’ for documenting the impact of microplastics and nanoparticles (MNPs) on human life and disease and supporting the removal of these chemicals from the environment. Polyethylene was reported in 58.4% of patients, and polyvinyl chloride was seen in 12.1%. No other MNPs were reported in the study.

Municipal water facilities monitor the presence of these chemicals, and Page 26

numerous advances are being noted in this area. The study by Marfella et al. was not designed to answer all our questions since it is a prospective multicenter observational study; however, it may be the first document showing that microplastics from our environment can be found in the lining of human arteries, causing harm.

Regulation and Disclosure: What is needed? Companies are now required to report the presence of these chemicals.

Permits must be obtained to address air emissions and wastewater discharges for disclosure and monitoring, and all solid waste in sanitary landfills must be analyzed. While US companies have made some progress in removing these chemicals, products from other countries still pose a risk. It is time for a policy shift: manufacturers should disclose the impact of any chemicals or compounds BEFORE they are used in products for human consumption and use.

On April 10, 2024, the Environment Protection Agency (EPA) announced new lower standards for up to five chemicals in our drinking water. (7) This represents a start to improving health and is the most accessible area to reduce the chemicals. The new regulations will go into effect in 2025, allowing municipalities up to five years to meet these standards. Grant money will be available for those smaller communities without resources to comply with the standards.

The new requirements for these manmade chemicals are shown in Table 1.

What did the NEJM article (6) tell us, and why is this important? Marfella and his colleagues studied atheroma plaques removed from patients undergoing carotid endarterectomy. (6) The procedure was scheduled because plaque interfered with the patient’s quality of life. The atheroma that was removed showed degeneration of the walls of the arteries caused by accumulated fatty deposits and scar tissue, leading to restriction of circulation and risk of thrombosis. Analysis performed on the specimens noted both micro and nanoparticle-sized size fragments of PFAS. For the next 34 months, patients were followed to determine if any thrombosis-related events, such as myocardial infarction, stroke, and death,

were observed. Table 2 shows the incidence and occurrence of these events in the 257 patients studied.

Of the 150 patients in whom the particles were found in the atheroma plaque, 20% had worsening problems, leading to 6.1 events per 100 patient-years. These patients also had a higher incidence of chronic diseases.

In contrast, where PFAS particles were not found, only eight patients developed thrombosis, with only 2.2 events per 100 patient-years. In all the data, the thrombosis problems continued after the atheroma was removed in 20% of patients.

What can one do to prevent the absorption of forever chemicals into the body?

The Centers for Disease Control and Prevention (CDC) and the National Health and Nutrition Examination Survey (NHANES) have found PFAS present in the blood of 97% of Americans. It is known that it takes four or more years to reduce the amount in the blood by 50%, and we know that our absorption of these chemicals occurs continuously. (8) We also know North Carolina is the third highest state with PFAS levels found in our environment, especially in the Cape Fear River Basin and Haw River. (9) The EPA defined the maximum contaminant level in public water systems to be four parts per trillion, and this can be easily measured by laboratories. Several states have banned these chemicals, and other states are phasing them from food packaging, responding based on the amount of PFAS found in their state. The EPA guidance defines options for the states. (10) It is important to know that not all PFAS are harmful, but knowing as much as we can about the products we buy and use is important to reduce risk.

Considerations: Ø Ø Ø Ø

Use PFAS-free products. (11) Check labels for the major PFAS microplastics, ‘phthalates,’ etc., in products and food packaging.

Use stainless steel, enamel, glass, or cast-iron bakeware/ cookware.

Discard plastic and take-out containers used in microwave

Ø

Ø Ø

Ø Ø

ovens.

Do not drink boiled contaminated water since the chemicals will become concentrated and more hazardous.

Throw away cookware with a scratched, damaged, or flaking nonstick finish.

Consider using PFAS-free pitchers (not expensive) or installing reverse osmosis house water filtration systems (can be expensive) in your home. Do research on the products you buy!

Support major companies that remove these chemicals from their products.

Read and advocate for PFASfree products for society’s health and reduced levels in our water supply.

Conclusion

Research is ongoing to determine how different levels of exposure to different PFAS lead to health effects. Concern for these microparticles is growing as more research is published and identified in products. The EPA’s announcement of lowering the permissible amounts of these chemicals in water supplies is a start to address this problem. It will allow closer monitoring and PFAS elimination in our drinking water. As with the US, the European Union is debating plans to restrict these products, hopefully by the end of 2025. (12,13) A large USA manufacturer of these chemicals, 3M™, plans to cease producing these original harmful agents by the end of 2025. Product substitutes are being identified, and with increased monitoring, hopefully, they will not be as toxic. (14) While companies will replace some of their products with PFAS-free products, the older versions will most likely remain available until the inventory is depleted. Evidence of the harm these particles can cause is growing, and people want to know how to protect themselves for health and longevity. It is important to keep up with the literature and to advocate for safety with your legislators. Read labels, educate yourself and others, and decide to use current and new PFAS-free products as they become available.

Author: Jean B. Douglas, BS Pharm, Page 27

PharmD, RPh; Retired Associate Professor, High Point University; jjmdouglas@aol.com References: 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

Tap water study detects PFAS ‘forever chemicals’ across the US, July 5, 2023, accessed 5/29/2024, https://www.usgs.gov/ news/national-news-release/tap-waterstudy-detects-pfas-forever-chemicals-us.

Felton R: New Study finds PFAS in Bottled Water, as Lawmakers Call for Federal Limits, June 17, 2021, accessed by 5/29/2024, https://www.consumerreports.org/health/ bottled-water/pfas-in-bottled-water-newstudy-finds.

Babu S: Medical Devices and PFAS: Navigating Regulatory Compliance, October 20, 2023, accessed 5/29/2024, https:// www.medinstitute.com/blog/navigating-the-complex-world-of-pfas-regulation-for-medical-devices. https://www.fda.gov/food/environmental-contaminants-food/and-polyfluoroalkyl -substances-pfas, 4-29-2024, accessed 5/29/2024.

What are PFAS Chemicals? Accessed 5/29/2024, https://www.ewg.org/what-arepfas-chemicals, 2023.

Marfella R, Prattichizzo F, Sardu C et al: Microplastics and Nanoplastics in Atheromas and Cardiovascular Events, N Engl J Med, 390:10, March 7, 2024.

Per-and Polyfluoroalkyl Substances. Find PFAS National Primary Drinking Water Regulation Update. May 02, 2024, accessed 5/29/2024, https://www.epa.gov/sdwa/ and-polyfluoroalkyl-substances-pfas.

Niehs.nih.gov/health/topics/agents/pfc. https:www.Perfluoroalkyl and Polyfluoroalkyl Substances (PFAS), May 03, 2024, accessed 5/29/2024. https://www.axios.com/local/Raleigh/2024/05/03/regulating-forever-chemicals-in-north-carolina, accessed 5/29/2025. https://www.whitehouse.gov/briefing-room/statements-releases/2024/04/10/ fact-sheet-biden-harris-administration-takes-critical-action-to-protect-communities-from-pfas-pollution-in-drinking-water/accessed 5/29/2024.

Evans S: https://www.ewg.org/ research, June 20, 2024, accessed 5/29/2024,ewgs-guide-countertop-water-filters.

Scott A: The Battle over PFAS in Europe, C & EN, 101:i31, September 18, 2023.

Cullen L, Prero J, Fox: Arnoldporter. com/en/perspectives/blog/environmental-edge/2023/02/five-key-features-of-eusproposed-pfas-restrict, accessed 5/29/2024.

News.3m.com/2022-12-20-3m-to-exit-pfasmanufact-by-the-end-of-2025, St. Paul, Minn., accessed 5/29/2024.

TABLE 1: New Requirements for PFAS PFAS

Perfluoro octanoic (PFOA) Perfluoro octane sulfonic (PFOS)

Previous Contaminant Level

70 ppt

70 ppt

Enforceable Maximum Contaminant Levels

4 ppt 4 ppt

New Goal

0 ppt 0 ppt

Other compounds (HFPO-DA 130,000 ppt for GenX 10 ppt 10 ppt [GenX], PFBS, PFNA, and PFHxS) ppt = parts per trillion; PFOA is used in Teflon©, Gore-Tex©, wire coatings, and chemical resistant tubing. PFOS is used in stain-resistant products, food packaging, firefighting foam, Scotchgard©, and cardboard packaging (10)

TABLE 2: Cardiovascular Events Reported at 34 Months Results

Micro & nanoparticles (MNPs)

No MNPs found

Incidence

Occurrence/100 patient-years

30 of 150 patients (20%) 6.1 events

8 of 107 patients (7.5%)

2.2 events

needed.

Example Wound Calculation: Wound dimensions in centimeters and the duration of therapy = 6 cm x 2 cm for 30 days • •

• • Auditors Are Drawn to Santyl® Like Moths to a Flame Summer is here and so are the bugs!

While mosquitos, gnats, moths and the like have next to nothing to do with Santyl® ointment for debriding chronic dermal ulcers and severely burned areas, the visualization of auditors being drawn to claims for Santyl® ointment being akin to moths (or other bugs) being drawn to a flame is a parallel not to be ignored.

A pharmacy billing a claim for Santyl® ointment is likely to see the claim audited in the future because Santyl® ointment has a specialized online calculator1 developed by the ointment’s manufacturer to aid in appropriate dosing calculations and dispensing. When the ointment is being used for a chronic wound, prescriptions for Santyl® must include the wound length and width (in centimeters) and the treatment duration to appropriately utilize the online calculator. When prescribed for a burn, the total body surface area and number of applications is required. Prescriptions missing applicable measurements will be flagged for non-calculable directions and will face full recoupment. Auditors are drawn to these scripts because they are high dollar claims and prescribers, and pharmacy personnel, often forget to include or obtain the measurements. Without this critical information documented, the claim will meet its demise upon audit.

Another pitfall to avoid with Santyl® ointment claims is the inherent rounding with the online calculator that could inadvertently cause the pharmacy to bill an incorrect days’ supply. The dosing calculator rounds UP to the nearest tube size (packed as 30 or 90 grams), therefore, the true days’ supply must be calculated by the pharmacy to ensure you are not dispensing more medication than what is

• •

Manufacturer calculator results indicate a total of 62 g would be needed, and it suggests dispensing 90 g total The patient would need 3.6 cm per application if dispensing the 90 g tube (or 6.2 cm per application for the 30 g tube due to the tube opening diameter difference) The calculation details state 1.78 cm = 1 g for the 90 g tube size 90 g x 1.78 cm/g = 160.2 cm in the 90 g tube 160.2 cm / 3.6 cm = 44.5 days’ supply If the pharmacy were to dispense the 90 g tube for a 30-day supply, they would be dispensing too much medication

•

•

010-30) and 90 g (NDC 50484-010-90) tubes of Santyl® ointment in your pharmacy software system reminding pharmacy staff to review the prescription for the wound length and width (in centimeters) and treatment duration If more than one wound is being treated, be sure measurements and the treatment duration for each wound is documented Consider revaluating wound measurements periodically as the wound is (hopefully) decreasing in size during the course of therapy o o

The pharmacy should dispense two 30gram tubes in this example • • • • •

The 30 g tube needs 6.2 cm per application (tube opening is smaller than the 90 g tube) The calculation details state 3.04 cm = 1 g for the 30 g tube size 30 g x 3.04 cm/g = 91.2 cm in the 30 g tube 91.2 cm / 6.2 cm = 14.7 days’ supply Therefore, two 30 g tubes = 29.4 days’ supply

o

•

The SIMPLEST Method The calculation method above is accurate, but also time consuming! The simplest method for calculating the correct quantity and days’ supply for Santyl® for a chronic wound is utilizing the PAAS National® Rx Days’ Supply Calculator app2!

The wound(s) dimensions are still required but the user-friendly interface has been designed to enhance efficiency and empower pharmacy staff with confidence.

The PAAS Rx Days’ Supply Calculator app eliminates the inherent rounding issue seen with the manufacturer’s calculator and provides precise calculations.

Rather than getting zapped with a recoupment, be prepared; have all the appropriate documentation accounted for at the time the claim is billed and bill for an accurate days’ supply. When audited, the claim has a higher probability of passing with no discrepancies and sending the auditor buzzing off with zero recoupment.

PAAS Tips: • Add a flag to the 30 g (NDC 50484Page 29

•

Contact the prescriber’s office and obtain a new prescription if the wound size has changed Plug in the new measurements into the PAAS Rx Days’ Supply Calculator app or Santyl® online calculator and bill for the appropriate quantity and days’ supply Note: the Santyl® calculators will only allow a 30-day maximum duration of therapy, likely to reiterate the importance of wound revaluation

For the treatment of a burn, only the Santyl® manufacturer’s online calculator can be utilized for determining the appropriate quantity; just remember to back-calculate the correct days’ supply by following the method outlined above Download the PAAS Rx Days’ Supply Calculator app for a free 7-day trial ($5.99/year thereafter) by visiting the Apple App Store3 or Android Google Play Store4, or check out the website at PAASNational.com/app2

By Trenton Thiede, PharmD, MBA, President at PAAS National®, expert third party audit assistance, FWA/HIPAA and USP 800 compliance.

References: 1.

2.

3.

4.

https://santyl.com/hcp/dosing https://paasnational.com/app/ https://apple.co/48PyXy0 https://play.google.com/store/ apps/details?id=com.paasnational.paascalculators

Copyright © 2024 PAAS National, LLC. Unauthorized use or distribution prohibited. All use subject to terms at https:// paasnational.com/terms-of-use/.

July Sunday Evening Webinar The July Sunday Evening Webinar is this Sunday, July 21 and you can still register for it. Cori Shope, PharmD, BCACP, CPP will present Demystifying Demyelination – A Multiple Sclerosis Treatment Review.

Visit our webinar webpage to learn more and register to join us. This event is ACPE accredited for 1 hour of live CE for pharmacists and pharmacy technicians.

PLEX? Visit our resource page to find two options to help you prepare for the NC MPJE. Scroll down the same resource page for a link to a NAPLEX preparation source and tell them NCAP sent you!

The next NAPLEX Prep Webinar is Saturday, July 20th from 9:00 am - 3:45 PM. You can register at the following link: https://www.highpreptutoring. com/book-online.

Immunization Certification and Refresher Courses Available

2024 Anti-Infective Conference The 26th Annual NCAP Anti-Infective Conference will be Friday, October 25 at the Greensboro Country Club. Details are still being confirmed so watch our weekly newsletter, eNCAPsulated, for more information and when to register. This event is a favorite for all pharmacy professionals specializing in the area of infectious diseases and for those who just want to learn more about what’s new in the field. This event is ACPE accredited for pharmacists and pharmacy technicians.

Are you a pharmacist interested in becoming an immunizer? Perhaps you are an immunizing pharmacist who would really like a refresher course. You’re in luck! Campbell University is hosting two programs addressing both of those needs. On July 31 from 9 am to 5 pm will be APhA Pharmacy-Based Immunization Delivery for Pharmacists and on August 23 from 9 am to 12 pm, Enhancing Immunization Confidence: A Refresher Program for Certified Pharmacists. Visit Campbell’s Featured Activities page for more information and to register for either program.

NC MPJE and NAPLEX Review Resources

For more go to ncpharmacists.org

Are you looking for preparation resources and materials to help you study for the NC MPJE and NA-

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Thank you to our generous donors for supporting the NCAP Advocacy Fund!

Jordon Baker Monica Barber Arpit Bhatt Anna Brown Genelle Butz Olivia Caron Elizabeth Caveness Dakota Chavis Heather Coleman Wendy Cox Thomas D’Andrea Stephen Dedrick Melissa Dinkins Evan Drake Jon Easter Allie Fay Stefanie Ferreri Adreas Ford Leigh Foushee

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The above contributors made donations to the NCAP Advocacy Fund between January 1 and June 30, 2024. Their contributions have helped us with our grassroots work on H246 Reform Pharmacy Benefits Manger Provisions, which currently sits in the Senate awaiting a committee hearing. Please consider making a donation of any size to further support our advocacy team as they work to get this important legislation passed!

Your support drives positive change in our profession!

Click to Visit Givebutter.com/AdvocacyFund and Donate!

Or Text GIVE2NCAP to (202) 858-1233

CLASSIFIEDS Business TARHEEL FLAGS • Flags (American, Christian, State, College Logo, etc.)

• Clocks (Battery Operated with Logos, etc.)

• Crosses with US Flag Motif Made from Recycled Wooden Shipping Pallets See Photos at TarHeel Flags on Facebook/Market Place Contact Jim Knowles, PharmD (Retired) TarHeelFlags@PinevilleDSL.net 704-835-1042 – Please Leave Message

For Sale SYNMED 1SM9900 XF SYSTEM

Complete SynMed XF System including Calibrated Containers, Dell OptiPlex 7040 with monitor, Wireless Honeywell bar code scanner, Lexmark laser printer model MA810, Zebra thermal printer model TLP2824 Plus, 4 positioning tray for two sets of blister cards, complete set of calibrated covers for containers, SynMed Image Module, SynMed Assist with includes Touch screen 23" Dell Computer.

This unit was bought new when starting up a pharmacy in 2020.

It was never used! The unit and all are in pristine condition. This would be like buying a new unit for tens of thousands less. Total Cost new was over $300,000. For Sale for $190,000. Purchase price does not include shipping charges, any tax and site preparation.

Contact Tom D’Andrea tdandrea@cstpharmacy.com 919-629-4900

Order A Classified Ad Free For NCAP Members or $1.00 a word with a $25.00 Minimum Contact Rhonda Horner-Davis at rhonda@ncpharmacists.org