The Tablet: December 2013 - January 2014

Informed Consent • Methadone Maintenance Treatment • Hangover Cures

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Flu Season Launch Health Minister Dr. Terry Lake receives his u shot from BCPhA president Don Cocar

In this issue: A Year in Review 2012/13

A voice for community pharmacy

THE RIGHT MIX Evolution happens and we’ve been there!

Pharmacy practice continues to expand in scope. Wynward is here to support that progress. In collaboration with BCPhA, Wynward recognizes the need to be responsive on emerging trends, while at the same time delivering The Right Mix on product, price, and service experience for your insurance needs.

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THE TABLET

DEC/JAN

2014

Editor-in-Chief Kathie Taylor 604.269.2863, kathie.taylor@bcpharmacy.ca

|

VOLUME 22. NO. 6

contents 22 methadone maintenance treatment

Senior Editor Elise Riedlinger 604.269.2866, elise.riedlinger@bcpharmacy.ca Advertising Sales Shannon Ward, OnTrack Media 604.639.7763, tablet@ontrackco.com

10 informed conssent

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Features

Columns

Regulars

5

Meet Dr. Nigel Murray President and CEO, Fraser Health

6

President’s Message Services worth paying for

9

Government Relations Update Budget 2014 submission

10

Informed Consent When a 3 is not enough

7

14

DPIC The elusive hangover cure

16

Feature Article: A Year In Review

CEO’s Message The contribution of members is invaluable

21

8

Pharmacy Practice Support Increasing adaptations to demonstrate our value

Product in Focus Glycopyrronium for COPD maintenance therapy

25

Clinicare Pharmacists The “poopâ€? on treating C. difďŹ cile

28

Career Listings Find a job in pharmacy

2012/13 22

Methadone Maintenance Treatment What you need to know

Got a suggestion for an article in The Tablet?

Email info@bcpharmacy.ca with your story ideas.

www.bcpharmacy.ca

Dec/Jan 2014

A voice for community pharmacy

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3

SMALL TALK

In the news Policy and procedure manuals

The BCPhA launches flu season with Ministry of Health

The BCPhA has developed manuals to support pharmacies in documenting policy and procedures that ensure operational activities are compliant with the regulatory framework governing pharmacy practice.

On November 7, BCPhA president Don Cocar gave Health Minister Dr. Terry Lake his flu shot at an event at Vancouver General Hospital to kick off the official start of the flu season.

Manuals on Administration of Injections, Dispensary Activities and Operation of a Community Pharmacy are now available for download by Pharmacy (Corporate) members. As of November 2013, members have already completed more than 650 downloads.

Minister Lake and Provincial Health Officer Dr. Perry Kendall urged British Columbians to get the flu vaccine this year to protect themselves and their loved ones from influenza.

Annual General Meeting The BCPhA’s Annual General Meeting was held on November 23 and included the passing of a special resolution to amend the BCPhA By-laws to create a new official position of past president. Past president Ralph Lai and CEO Geraldine Vance presented their respective annual reports, and new Board members Alex Dar Santos, Nemanja Filipovic, Randy Konrad and John Tse also received their BCPhA pins at the meeting.

More than 2,700 pharmacists across BC are now trained and authorized to provide injections this flu season.

Reminder: The designated Pharmacist member of an active Pharmacy member can access these manuals!

Additional manuals will be released in the future. Please visit www.bcpharmacy.ca/ regulatory-compliance-support to learn more.

eTraining: Expanded Access to Publicly Funded Vaccines More than 250 members have successfully completed our first eTraining program, Expanded Access to Publicly Funded Vaccines. The program is accredited for 1.25 CEUs and provided as a complimentary member benefit.

Health Minister Dr. Terry Lake receives his flu shot from BCPhA president Don Cocar.

Until February 1, 2014, BCPhA Pharmacy members can also share this eTraining program with pharmacy staff. If an employee of a Pharmacy member would like to use eTraining and is not in our member database, their pharmacy manager will need to email the BCPhA to confirm employment status. Visit www.bcpharmacy.ca/etraining for more information or to start your training.

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Dec/Jan 2014

www.bcpharmacy.ca

BCPhA past president Ralph Lai (right) gives new Board member Alex Dar Santos his BCPhA pin.

MEET THE PRESIDENT AND CEO, FRASER HEALTH

Meet... Dr. Nigel Murray President and CEO, Fraser Health Authority Board; and general manager, Health Services Delivery Plan. In 1995, he was named a Member of the Order of the British Empire for services to health in the New Zealand Defence Force.

Murray has a Bachelor of Arts degree from Dartmouth College; a Bachelor of Medicine and Surgery, University of Otago Medical School; a Masters of Occupational Medicine from Harvard University School of Public Health; and an Associate Fellow, Faculty of Occupational Medicine from Royal College of Physicians.

What do you consider your greatest achievement?

The unique opportunities I have had to serve the public health system in a number of countries and settings.

What would you like to accomplish in the next five years?

Dr. Nigel Murray leads the overall management and delivery of health programs and services in one of the largest and fastest-growing health networks in Canada, overseeing acute care hospitals as well as community-based residential care, home health, mental health services, public health services and chronic disease management.

Murray was previously the interim CEO of the Southland District Health Board and the lead CEO for New Zealand Health Sector Industrial and Employee Relations.

Before that, he worked in senior health administration roles including acting general manager, National Women’s Hospital; general manager, planning and development, Auckland District Health

I’d like to foster an environment that produces fundamental health care transformation, as opposed to just incremental changes.

Which talent would you most like to have?

Is patience a talent?

Which words or phrases do you most overuse?

Who is your favorite writer?

Dr. Seuss.

What is your motto?

Just do it.

What is your idea of perfect happiness?

Watching my four children grow and have happiness.

What is your most marked characteristic?

Impatience to achieve the outcomes we need for our health system.

Who has been the greatest influence on you?

The health care team that we have working in our publicly funded health system demonstrates a level of passion and commitment I truly admire.

What role do you see for pharmacists in the delivery of health care in our province?

In addition to advising on the most effective and efficient use of pharmaceuticals, pharmacists play a critical and growing role as health care providers in alternative settings, in part, managing poly-pharmacy in the community.

“What’s next?”

What do you most value in your colleagues?

Their critique.

www.bcpharmacy.ca

Dec/Jan 2014

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DON COCAR

|

PRESIDENT

Services worth paying for

It’s hard to believe

we’re already nearing the end of 2013, and by the time this publication reaches you, we’ll be right in the midst of flu season as well.

As of November 2013, there are more than 2,700 pharmacists in British Columbia authorized to provide injections – and I’m proud to say the BCPhA trained more than 2,200 of them! I was pleased to help launch this year’s flu season campaign with the Ministry of Health, and give Health Minister Dr. Terry Lake his flu shot at the event. I think it’s a great message that pharmacists are accessible and trusted immunizers, and one that has really caught on with the public.

Although community pharmacists are not mandated to be vaccinated or wear a mask during the flu season, it only makes sense for those of us who are health care professionals to do so.

I’ve had my flu shot and hope you’ve had yours as well. Getting immunized is still the best way to protect you and your patients from the flu.

This year the publicly funded program includes anyone planning to visit a loved one in a health care facility, or who takes family members to outpatient appointments. With this expansion, a significant percentage of British Columbians are eligible for a publicly funded flu shot and you can expect it will be even busier at pharmacies across the province.

Speaking of what is often referred to as a “free” flu shot in the media and by the public, I believe that in our own conversations with patients, stakeholders and government, we should move away from phrasing any of our pharmacy services as “free.” In a way, using this terminology devalues pharmacists and the services we are trained to provide.

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www.bcpharmacy.ca

Rather than referring to “free” flu shots or “free” Medication Review Services, let’s use the term “publicly-funded services” instead. This emphasizes that these are value-added services for patients, and that although the cost doesn’t come out directly of their pockets, these services – and pharmacists’ expertise – are worth paying for, and the government does just that.

Although we are well-known for being convenient and accessible, pharmacists are also health care professionals who spend a great deal of time training to become medication experts. Particularly as we look to secure funding for our proposed new clinical services – ranging from expanding the trial prescription program to treating minor ailments – the public needs to see the true value of our profession. It’s important that we all remind patients and others of the value of our existing and proposed services, and our worth to the health care system.

Unfortunately we are somewhat hampered by previous strategies that link clinical services investments to decreased generic pricing.

We are now working towards gaining support for clinical services funding independent of pricing decisions.

We also want to revisit and advocate for fair compensation for our current pharmacy services, and are seeking funding outside of the traditional prescription drug budget managed by the medical beneficiary and pharmaceutical services division.

Our message to government, stakeholders and the public needs to be consistent: expanding the role of pharmacists in health care enhances cost-effectiveness, increases access to care, and most importantly, helps improve patient outcomes.

For a full list of the BCPhA Board of Directors, visit www.bcpharmacy.ca/bcpha-board-pha.

GERALDINE VANCE

|

CEO

The contribution of members is invaluable

This issue of The Tablet provides members with a

look back over the past fiscal year (ending August 31, 2013) and follows the Annual General Meeting that was held on November 23.

When I look back at the year that was, I am struck by the commitment so many pharmacists have made to their profession. Each year the Association hosts a past presidents’ dinner that honours the outgoing president and all those that came before them. This year we were fortunate enough to have 11 former presidents with us. We unveiled a past presidents’ plaque that is now on display at the Association as a token of respect and acknowledgement for the countless hours these men and women made in service of their profession.

Like all similar associations, we depend on the volunteer efforts of members. In this past year, we had members work with staff on a wide range of issues that made a tangible difference for community pharmacy. Things like the development of a new compounding policy and rate schedule, input into the PharmaNet Modernization project, and hundreds of meetings with elected provincial government officials and other stakeholders wouldn’t have happened without the volunteer efforts of members.

And of course, each year the Board of Directors makes a commitment to take time away from their businesses, jobs and families to work for the advancement of pharmacy in BC. I think our hard-working Board members and members who sit on committees and participate in programs like our MLA outreach program are unsung heroes.

In an organization as small as the BCPhA, staff simply couldn’t do the work we need to do without the ongoing contribution each Board and other members make. As pharmacy continues through a time of change and tumult, we need to engage with as many members as possible and tap into the incredible resources we have amongst them.

As I come to the end of my second year with the Association I am thankful for the generous support I have received from the Board and many members. We work hard every day to earn your trust and advance the needs of pharmacy in BC. Wishing you and your families a safe and happy holiday season and all the best for 2014.

Current BCPhA president Don Cocar (third from left) and past-presidents (left to right) Shakeel Bhatti, David Hill, Geoff Squires, Chuck Willett, Ralph Lai, Ken McCartney, Ron Stein, Bill Heese, Derek Desrosiers, Fred Wiley and Greg Shepherd. www.bcpharmacy.ca

Dec/Jan 2014

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DEREK DESROSIERS | ACTING DIRECTOR, PHARMACY PRACTICE SUPPORT

Increasing adaptations to demonstrate our value The last time I wrote a column for The

Tablet I was president of the BCPhA Board of Directors and it was July 2010. It’s been more than three years since then and a lot of water has passed under the bridge in that time. What is amazing, however, is that some of the issues we are dealing with are the same now as they were back in the summer of 2010.

Our relationship with government has been a topic of discussion for many years as it has tended to be an on-again, off-again relationship depending on the issues of the day and the players on both sides of the table. There have been many changes within the Ministry of Health as we’ve been through a few ministers, and there have also been many changes within the pharmaceutical services division (now the medical beneficiary and pharmaceutical services division). Those changes coupled with the ongoing changing face of pharmacy as a profession means we’re constantly trying to educate government about pharmacists, pharmacy and our contribution to the health care of British Columbians. It’s no small feat but our MLA outreach program has made tremendous strides in building support for pharmacy within the political ranks of BC’s government and opposition parties.

Another challenge we have with government is helping them see the value in the pharmacy services for which they are paying.

Specifically, we need to step up collectively and do a much better job of using the expanded scope opportunities that are available to us.

Adaptations is an area that is very much underutilized from a broad provincial perspective. In the 12 months ending March 31, 2012, pharmacies in BC billed PSD for 183,149 adaptations, the huge majority of which were prescription renewals. I suspect many more adaptations were actually done but not billed. There are a variety of reasons why pharmacists do not bill for all the adaptations they do, including: • not wanting to incur the wrath of a physician • not wanting to take the time to complete the documentation • not wanting to take the time to complete the billing process.

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www.bcpharmacy.ca

Help optimize drug therapy and ensure your patients receive timely access to care by employing your authority to adapt prescriptions where appropriate. British Columbians support improved access to health services and greater choice about where they receive those services. Increased use of this authority when it benefits the patient is critical to demonstrating that pharmacists are hearing and responding to the needs of the public. If government sees no value in the services they pay for, they will ultimately discontinue the funding.

Adaptations claims reminders: • In the PRACT ID Ref field, enter P1 (for College of Pharmacists of BC) • In the PRACT ID field, enter your College ID • At the beginning of the sig (“directions”) field, type “Adapted” • Include the appropriate intervention code listed below to flag the claim as eligible for clinical services fee payment.

Category

Fee

Renewals

$10

Change: dose or regimen Therapeutic Substitution

Intervention Code NL - Renewal of prescription NI - Dosage change

$10

NJ - Formulation change NK - Directions for use modified

$17.20

NM - Therapeutic substitution

Please visit www.bcpharmacists.org for the College of Pharmacists of BC’s PPP-58 Orientation Guide.

BCPhA support materials are available at www.bcpharmacy.ca/prescription-adaptation.

GOVERNMENT RELATIONS

BC finance committee recommends government explore better use of pharmacists

By Coco Lefoka

Every year the provincial government presents a budget to British Columbians, traditionally delivered in February or March before the start of its new fiscal year.

During the budget development process, the government seeks input from stakeholders and citizens on ideas to improve programs and services. For Budget 2014 this process included a province-wide public consultation.

The BCPhA offered recommendations on ways BC can secure the long-term fiscal sustainability of the Province’s health care system. Our submission addressed how the Province can improve health care service delivery, achieve cost avoidance and broaden the role pharmacists play in the health care system.

We recommended the Province immediately eliminate the silo approach to managing PharmaCare budgets that involves breaking up health care costs into compartments. Notably, the elimination of these silos was called for in 2008 by a pharmaceutical task force created by the ministry of health.

The task force rightly observed that a silo approach fails to fully recognise the positive impact of pharmaceutical treatment on other areas of the health care system.

In the budget submission, we also called for improving the approach to spending on immunizations to better manage costs. By implementing the BCPhA’s recommendation, the Province would put immunization spending in one area of the health care budget instead of multiple, so costs could be tracked more effectively. This would enable spending to be directed to health providers like pharmacists who provide immunizations at the lowest cost for taxpayers.

Another area the BCPhA addressed is chronic disease care, recommending the Province integrate spending on programs and services for patients with chronic disease to manage these costs more effectively.

We also called on the Province to continue to invest in pharmacy services to manage drug costs. It is well recognized that pharmacy-based medication management and adherence programs increase proper

medication use by patients, so British Columbians stand to benefit by the government continuing to invest in medication adherence services such as Medication Reviews.

The BCPhA advocated for the government to renew a minimum investment commitment of $1.6 million for the Enhanced Rural Incentive Program to maintain pharmacy services for rural British Columbians. In addition, we recommended the government invest in the clinical services the Association has proposed for the health care system.

When the Select Standing Committee on Finance and Government Services released its report on the consultations, we were pleased they heard how pharmacists can be better utilized to improve patient care and achieve overall cost savings. The report recommended that further consideration of these proposals is warranted, and that work be undertaken with pharmacists and other health care professionals to explore innovative new service delivery models.

The Association is focused on acting on opportunities to work with the provincial government on the implementation of the recommendations provided in the submission. To learn more, visit www.bcpharmacy.ca/advocacy-govt-relations-public

We’re recruiting members to join our MLA Outreach Program in the following communities: 1.

2.

3.

4.

5.

6.

Surrey-White Rock Coquitlam-Burke Mountain Abbotsford South Port Moody-Coquitlam Nechako Lakes Surrey-Tynehead

To get involved or for more information, please contact BCPhA public affairs manager Coco Lefoka at 604.269.2868 or coco.lefoka@bcpharmacy.ca.

www.bcpharmacy.ca

Dec/Jan 2014

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INFORMED CONSENT

When a is not enough – What is informed consent?

Ey 6aUa $ LeYLQe $OOLaQceLe[ LaZ CoUSoUaWLoQ CyULO LoSe] CKLef 2SeUaWLQJ 2fÂżceU BC3K$ This column seeks to translate the legal requirements of informed consent to provide members some key practical steps towards compliance. It is not meant to override or contradict the standards of the College of Pharmacists of BC or applicable legislation.

It does not constitute legal advice.

Consent.

Informed consent.

Express consent. Implied consent. Inferred consent. What’s the difference? Just as long as the patient signs the form, you’ve got the consent, right?

Not so fast. When it comes to consent, we are ďŹ elding a lot of questions, in particular regarding its documentation. So we’ve put together this little primer to help you distinguish between these concepts and understand your obligations. There are four key take-aways from this article: 1. Informed consent is always required for the provision of health care services.

2. The words “express�, “implied� and “inferred� all describe the way the consent is given, not whether it is informed.

3. It is the pharmacist’s responsibility to ensure the patient has given informed consent, no matter how it is communicated.

4. Keeping a record of the encounter is recommended.

What is “consent�?

Basically, consent is agreement. If a patient consents, the patient agrees. The law1 says that a health care provider must not provide any health care to an adult without the adult’s consent (except in certain very limited circumstances).

elements exist, we say that the patient has given informed consent to receive health care. There are slightly different elements of consent for adults and for minors or people of lesser capacity who are incapable of providing informed consent.

What is informed consent?

There are four basic elements that make up an adult’s informed consent to health care: 1. It must relate to the proposed health care, be given voluntarily, and not be obtained by fraud or misrepresentation.

2. The adult must be capable of making a decision about whether to give or refuse consent to the proposed health care. The law allows providers to presume that an adult is capable of giving or refusing consent until the contrary is shown.

3. The provider must give the adult the information a reasonable person would require to understand the proposed health care, including information about the condition, the nature of the proposed health care, its risks and beneďŹ ts and alternative courses.

4. The adult must be given an opportunity to ask questions and get answers about the proposed care.

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1. Explain to the individual and be satisďŹ ed that he or she understands the nature and consequences and the reasonably foreseeable beneďŹ ts and risks of the health care and 2. Make reasonable efforts to determine and must conclude that the health care is in the individual’s best interest.

The parent or guardian cannot overrule the individual’s decision and is not entitled to disclosure of the information.

In short, no matter how old they are, the patient has to have been told – and the pharmacist must be satisďŹ ed that the patient understood – the information that is relevant to the patient’s decision whether or not to consent.

The capable patient (adult, mature minor or parent of infant) – and no one else – makes the decision.

If the patient is under 19, the health care provider must also take steps to determine that the health care is in the individual’s best interest. Please refer to the legislation for speciďŹ c details in this area.

Only when the patient makes an informed decision, can he or she give informed consent. Informed consent is always required for the provision of health care.

That same law also explains the elements of consent. This is important, because consent to health care will only exist if all the elements of consent exist. When all the

10

For people under the age of 19, the requirements are slightly different. The health care provider must:

www.bcpharmacy.ca

Duty to communicate clearly Providers have a duty to communicate clearly when seeking consent or deciding whether an adult is not capable of consenting. This means providers must communicate with the adult in a manner appropriate to the adult’s skills and abilities, and may allow the adult’s spouse, or any near relative or close friend who accompanies the adult to help the adult to understand or show an understanding of the relevant information.

How do I judge whether the patient is capable?

When deciding whether an adult is incapable of giving, refusing or revoking consent to health care, a health care provider must base the decision on whether or not the adult demonstrates that he or she understands the information given, and the information applies to his or her situation.

Okay, so what is express, implied or inferred consent?

Is the consent process to be documented for every pharmacy service?

The terms express consent and implied or inferred consent describe the way in which consent is communicated: the patient may expressly communicate informed consent verbally, or by signing a form, or checking a box. The patient impliedly communicates consent when his or her behaviour implies that they consent, such that you can infer from their behaviour that they consent.

It depends, and here is why. Pharmacy practice is overseen by the College of Pharmacists of BC under the authority of BC and federal laws.

The College prescribes pharmacy practice rules, requires informed consent be obtained and leaves it to the registrants’ judgement regarding documentation.

Regardless of whether the consent is communicated expressly, or inferred from conduct, the elements of consent must exist in order for the consent to be informed, as required by law.

www.bcpharmacy.ca

Government and other pharmacy benefits payers require that pharmacy comply with the College rules. However, some payers may also require that informed consent be documented in a particular way as a prerequisite for payment.

Even if the College or payers do not require documentation, it is recommended to do so. Documentation establishes accountability and will support how you exercised your professional judgement when questioned by your peers. It can also support your defense in a negligence legal case and against payer-audit recoveries.

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INFORMED CONSENT

How does the pharmacist document informed consent?

Any form of documentation is acceptable provided it documents that the four elements of consent existed and that it is documented in compliance with the applicable standards of care. The documentation must also comply with payers’ requirements if the payer requires documentation as a pre-requisite for payment.

Some organizations use standard forms that may require the patient to indicate by signature their expressed consent. Others make notes on the paper or the digital patient file. Whichever way you document, these two critical steps must be taken in sequence:

Step 1: Obtain informed consent fulfilling the four elements of consent.

Communicate with the patient.

Step 2: Document your communication process with the patient as required for that service by CPBC and payer.

By doing both of the above, you have obtained and documented informed consent, performed your professional obligation and protected your service fees.

A patient’s signature on a consent form without or before the pharmacist communicates with the patient using the four elements of consent is not documentation of informed consent.

What are the current documentation requirements?

Dispensing: The College requires counselling and its documentation under the Health Professions Act Bylaws, Schedule F, Part 1,section 6(4) (f)(iii) (documentation), section 6(5) (prescription dispensing); and Section 12 (consultation). These requirements are consistent with the four elements of informed consent.

The College does not specify a documentation format. The Ministry/ PSD has not specified a format. Patient signature to evidence informed consent not required.

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Adaptation: The College provides a recommended documentation and notification template that may be used by the provider for documenting a patient’s informed consent, in which the pharmacist attests that he or she obtained informed consent fulfilling the four basic elements (see PPP-58 Adapting a Prescription - Appendix D).

The Ministry/PSD has not specified a format. Patient signature to evidence informed consent not required.

Medication Reviews: The College has not specified a format. The Ministry/ PSD form uses the same approach as the College set out for Adaptation. Patient signature to evidence informed consent not required.

Immunizations: The College has not specified a format. The Ministry/PSD has not specified a format. The College has specific consent requirements described under Part 4 of the Health Professions Act - Bylaws, Schedule F. Patient signature to evidence informed consent not required.

www.bcpharmacy.ca

There is no legislation that precludes pharmacists from exceeding existing standards and obtaining the patient’s signature to evidence informed consent.

The key is that consent was obtained using the four basic elements and using the two-step process.

What about later? Can a patient change her mind?

Yes. Re-visit patient consent if you are ever in doubt as to the patient’s wishes, or when the treatment plan changes.

Refusal or revocation of consent should be documented. It is advisable to have a process in place to handle such requests.

Is consent for health care reasons different than for privacy reasons?

Yes. Consent for privacy reasons is about consent to the collection, use and disclosure of the patient’s personal health information, not about the provision of health care.

A detailed discussion is beyond the scope of this article, but the basic principle is that patient consent may be implied for the collection, use, and disclosure of the patient’s personal information, within the circle of care, for the purposes of ongoing care and treatment. Hospital pharmacies and government agencies are covered by the Freedom of Information and Protection of Privacy Act (the FOIPPA), but community pharmacies are covered by the BC Personal Information Protection Act (PIPA), and the HPA Bylaws, Part VII. See those laws for more detail about the requirements.

Implied consent must be “informed and knowledgeable” so under the PIPA, community pharmacies are permitted to rely on written notices about the pharmacy’s information handling practices to communicate to patients the reasons for the collection, use and disclosure of patient information and the ways in which the pharmacy respects patient privacy.

Remember, this applies only to consent for the collection, use and disclosure of personal information. For health care, you must communicate with the patient and ensure the four elements exist. This is a key difference.

If the pharmacist wishes to collect, use or disclose the patient information for some purpose not consistent with direct patient care (a “secondary purpose”),

the pharmacist should obtain express consent, which involves fully informing the patient of the secondary purpose.

There are certain legal exceptions to this requirement – see HPA Bylaws Part VII.

Informed consent for health care requires that the patient have the information that is relevant to the health care, the treatment and the risks and benefits.

This requires the pharmacists to exercise professional skill and judgment, and to communicate with the patient.

Informed consent for the collection, use and disclosure of personal information requires that the patient have the information relevant to the information handling practices.

A pharmacy’s obligation to personal information is also described under HPA2, PODSA3 and the PSA 4, which have additional requirements. These are not discussed here. Please refer to those laws to ensure your understanding and compliance.

Most organizations already have a Privacy Policy statement detailing how they will handle personal information. Those who do not are well advised to do so. The Office of the Information and Privacy Commissioner for British Columbia provides very good resources.

References 1. Health Care (Consent) and Care Facility (Admission) Act 2. Health Professions Act (HPA) 3. Pharmacy Operations and Drug Scheduling Act (PODSA) 4. Pharmaceutical Services Act (PSA)

This requires the pharmacist to, at minimum, have appropriate notices posted.

Informed consent for one is not sufficient for the other.

>LSJVTL [V [OL )*7O( Pharmacist (General) members: Briana Bapty, Melissa Bleier, Chengyuan Bo, Joshua Brady, Dreena Dabels, Joseph Frketic, Lori Holtorf, Jason Huber, Sidney Jin, Sukhjeet Kalar, Mounir Khalil, Ping Lee, Lesya Lyseiko, Akshita Mangalam, Michael Matys, Hineshkumar Patel, Gary Peng, Sina Pirooz, Nasheena Poonja, Elahe Rahimi, Hamid Saebi, Pardeep Sandhu, Harpreet Sidhu, Karen Sullivan, Loann Tan, Taisa Trischuk, Ken Michael, Boyang Xia and Allan Yee Pharmacy (Corporate) members: Coal Harbour Pharmacy, Medical Centre Prescriptions, Pharmacists Clinic, Pharmacity Drugstore, Pharmacity Drugstore #2, Pharmacity Drugstore #3, Rexall #7161 and Wescana Pharmacy #3

www.bcpharmacy.ca

Dec/Jan 2014

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DRUG AND POISON INFORMATION CENTRE

The elusive hangover cure By 5ayPoQG LL B 6c 3KaUP 0 6c

Recent news

reported that a common soft drink was the best remedy for alcohol hangovers, based on in vitro observations that it accelerated the metabolism of both ethanol and its toxic product, acetaldehyde.1 However, though hangover cure reports surface periodically, the perfect cure for hangovers remains elusive. With winter holidays approaching, pharmacists are likely to encounter patients seeking relief from alcohol overindulgence.

symptoms is unclear, and “no two hangovers are the same6�. The relative roles of ethanol, its metabolite acetaldehyde, congeners (other alcohols and organic compounds produced during fermentation or introduced during beverage production), co-exposures such as tobacco smoke, other substances and dancing are also unclear. Psychosocial factors, personality traits and individual biology may play a role – roughly 25 per cent of the population appears to be resistant to developing hangovers.7

Veisalgia – aka hangover Hangovers are a diverse constellation of unpleasant signs and symptoms that occur as blood alcohol concentrations (BAC) fall.

They include both physiological, affective and cognitive effects generally beginning six to eight hours after consumption of an intoxicating amount of alcohol, peaking when the BAC reaches zero, and typically lasting about 24 hours.2 There is no accepted consensus on what constitutes a hangover.2-5 In the largest survey of hangover symptoms, fatigue was the most common symptom (reported by almost 96 per cent), followed by thirst, drowsiness, sleepiness, headache, dry mouth, nausea, weakness, reduced alertness and concentration problems (symptoms reported by at least 75 per cent).5 These also tended to be the most severe symptoms, in addition to vomiting, apathy and reduced appetite.

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Though there are several prevailing theories, the pathophysiology of hangovers is not fully understood. During hangovers there are many biological changes – dehydration; pH and electrolyte imbalance; hypoglycemia; sleep disturbances; increases in various hormones, serotonin, histamine, prostaglandins and cytokines; increased inammatory state and gastric irritation.2-5 The correlation between these effects and

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The economic burden of hangovers is signiďŹ cant. One estimate is that alcohol-related short-term disability (days in bed and days with reduced activity) costs the Canadian economy roughly $40 million,8 while estimated costs of lost productivity in other countries are in the billions.9 Studies have shown impaired cognitive and psychomotor performance in the hungover state; in one study attention performance was similar between the acute intoxication and hangover states, while reaction times were actually worse in the hangover state, raising safety concerns.10

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Treatments Home treatments, folk-cures, herbal and homeopathic hangover remedies abound, as do anecdotes of their effectiveness. While rehydrating, refuelling, and resting are good things, very few specific hangover treatments have been scientifically studied (Table 1).

Treatments have diverse purported mechanisms, the few studies that are available tend to be small and methodologically flawed (a consensus document on best practices in hangover research has recently been published11), and overall there is little evidence that specific treatments are effective for preventing or treating hangovers.

Safety concerns While most remedies are likely to be relatively harmless, some treatments are potentially hazardous. “Hair of the dog” (more alcohol) only delays the onset of hangover symptoms, may enhance the existing toxicity of alcohol already consumed, and may increase the likelihood of continued drinking. Analgesics may provide relief from headache, but care must be taken not to overuse. Some

hangover remedies available for purchase on the internet contain analgesics – patients should check labels. NSAIDs may worsen gastric irritation, and the rare patient may be at increased risk for developing liver toxicity from acetaminophen due to depleted glutathione stores and induction of hepatic metabolism. Caffeine may create a false sense of safety, but data shows that judgement and psychomotor performance can remain impaired during acute intoxication, and evidence for improved performance during hangovers is lacking.

Summary Few hangover remedies have been proven to be helpful. Pharmacists can help patients avoid worthless and potentially dangerous treatments. However, the best prevention is avoiding overindulgence in the first place, and the most effective cure is likely the tincture of time.

References available upon request; please contact the BCPhA communications team.

Table 1. Purported mechanisms and effects of some hangover treatments Soft drinks (Sprite); fructose or glucose beverages (Outox®, RU21, others)

Raises activity of alcohol dehydrogenase and aldehyde dehydrogenase, increasing clearance of ethanol and acetaldehyde. Fructose enhances regeneration of NAD+, a cofactor in the metabolism of ethanol. No clinical studies; effect on hangover symptoms unknown. 1, 12

Borage oil

Basis of treatment unclear – likely related to mediation of prostaglandin synthesis. No effect on overall hangover symptom score. (RCT n=18) 9

Artichoke extract

Antioxidant and choleretic activity. No effect on physiological changes, cognitive function test scores, symptom ratings; subjects could not reliably identify treatment vs. placebo. (xo RCT n= 15) 13

Prickly pear (Opunta ficus indica) (NOHO, PreToxx, others)

Antioxidant; increases protective stress proteins. Extract reduced nausea, anorexia, and dry mouth but no other symptoms. Reduced risk of a severe hangover and markers of inflammation. (xo RCT n=55) 14

After Effect® (borage oil, prickly pear, milk thistle extract, fish oil, vitamins and magnesium)

Combined antioxidant, prostaglandin, immune system and miscellaneous effects. Symptom scores appeared to show benefit, but there was no placebo control (only subjects’ expected severity scores if treatment had not been used). (n=103) 15

Party Smart® (Himalayan Drug Company)

Mechanism unknown. Contains date palm, chicory, Indian gooseberry, grape, and other Ayurvedic herbs. Four small trials (n=10 to 19) conducted by the manufacturer showed better mood and reduced hangover symptoms compared to competing products (various vitamins, minerals, extracts etc.).

Ethanol and acetaldehyde clearance also increased. Another Himalayan Drug Co product, Liv.52, was also reported to do the same. 16-20

Tangerine pith/ginger/ sugar

Unclear; traditional Chinese remedy, regulates “qi”. Reduced gastrointestinal symptoms when taken before alcohol consumption but no effect if used after (xo RCT n=10). 21

Kudzu (Pueraria lobata; Drinkwel, Last Round, others)

Kudzu flower increases elimination of acetaldehyde. However, some remedies contain kudzu root which reduces acetaldehyde clearance similar to disulfiram. No clinical studies on hangover symptoms. 22

B vitamins and derivatives (pyridoxine, metadoxine, pyritinol) (Hangover Guardian, Modjo Synergy, others)

Pyridoxine and metadoxine are purported to increase alcohol metabolism, protect the liver and balance the immune system. Equivocal effects on alcohol clearance but largest studies show pyridoxine does not affect ethanol clearance or level of consciousness during intoxication; hangover symptoms not assessed. Pyritinol is a pyridoxine derivative touted as nootropic; may reduce prostaglandins, promote glucose uptake into the brain. One small study reported reduced hangover symptoms. 23

Cysteine and other “biologically active” sulphur compounds (Xo3, others)

Cysteine, N-acetylcysteine, and glutathione are supposed to replenish hepatic glutathione stores, but relation to hangover symptoms is unclear. One patent application for methylsulfonylmethane (MSM) as a hangover cure purports that MSM softens cell walls, allowing alcohol to be flushed out faster and increasing cell oxygenation. No clinical trials on relieving hangover symptoms. 24

Caffeine

Caffeine has alerting and analgesic effects. Subjects given caffeinated beer reported better perceived sleep quality, but there were no significant differences in morning sleepiness, hangover incidence, or hangover severity. (RCT n=54) 25

Propranolol

Increased adrenergic tone may cause hangover symptoms. 160 mg long-acting propranolol taken before drinking reduced HR but no effect on BP; no benefit for tremor, headache, overall severity (xo RCT n=10). 26

NSAIDs

Inhibition of prostaglandin synthesis. 200 mg tolfenamic acid taken before drinking and before bed reduced headache, dry mouth, thirst, tremor, nausea and vomiting. (xo RCT n=30) 27

Tropisetron (plus diazepam)

Tropisetron aimed at GI symptoms; diazepam for withdrawal. Tropisetron did not have any effect on GI symptoms or headache. (RCT, n=11) 28

xo = crossover RCT = randomized controlled trial www.bcpharmacy.ca

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ON THE COVER | A YEAR IN REVIEW

A Year In Review

By Kathie Taylor The Association’s fiscal year goes from September 1 to August 31. The operations of the Association are governed by a number of key objectives and priorities that are set through a Board strategic planning process. The BCPhA Board of Directors meets each April and works with staff to review its overarching strategic goals and set priorities for the year ahead.

For the 2012/2013 fiscal year, the Board set the following key objectives related to three major priorities: Advocacy • Build relationships with provincial MLAs to ensure they know the value community pharmacy brings to the health care system.

• Build alliances with other stakeholders that are influential with the provincial government and can support pharmacy’s role in the health care system.

• Ensure pharmacy is a participant in the public policy debate on key issues – scope of practice, health human resources and primary care renewal.

• Increase pharmacy’s profile in the media on key policy and patient care issues.

• Be visible in the next provincial election – ensure candidates know pharmacy’s story.

Expanding technical and other training opportunities for members • Evaluate what additional opportunities exist for the Association to develop and deliver pharmacist training programs – clinical and non-clinical.

• Leverage the government funding for primary care alignment and pharmacist training in expanded scope of practice activities to explore additional funding opportunities in these areas.

• Explore opportunities to deliver/manage CEU programs as a value-add for members.

Expanding member services and benefits • Enhance and brand goods and service offerings to members.

• Explore opportunities for new non-dues revenue generation that adds to the organization’s value proposition.

• Support member recruitment and retention efforts with comprehensive research.

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Advocacy and government relations The 2012/13 fiscal year began with the government’s appointment of Dr. Margaret MacDiarmid, a general practitioner and former president of the BC Medical Association, as Minister of Health. During her tenure, the Association’s relationship with the minister was productive and we were able to meet with her a number of times to raise issues of concern to community pharmacy and to demonstrate how pharmacists could help respond to many of the access issues facing our health care system.

We were pleased to once again participate in the government’s annual flu season media kick-off. One of our members provided Minister MacDiarmid with her flu shot at the event in November 2012.

In January 2013, the minister also participated in the launch of the BCPhA’s annual medications return campaign.

The 2013 campaign was made possible through the support of the Post-Consumer Pharmaceutical Stewardship Association, as well as the regional districts of AlberniClayoquot, Capital, Comox Valley, Metro Vancouver, North Okanagan, Squamish Lillooet, Thompson Nicola and the Northern Environmental Action Team (on behalf of Peace River and Northern Rockies).

The Association’s MLA outreach program, created the previous year to match local pharmacists with their MLAs, was expanded with the goal of continuing to build working relationships between local pharmacists and their MLAs.

There are now 110 pharmacists that are part of the MLA outreach program, providing contact in about 90 per cent of the ridings in BC. In addition, Board members and senior staff of the Association maintain frequent contact with officials within the health ministry on a range of issues.

Clinical services proposals In March 2013, as part of Pharmacy Awareness Month, the BCPhA released seven clinical services proposals designed to help community pharmacists increase access to primary care and reduce costs to the health care budget.

The clinical services proposals include initiatives that can be implemented in a variety of pharmacy environments from rural communities to urban areas: • Trial Prescription Program • Treatment of Minor Ailments • Medication Adherence Services • Self-monitoring of Blood Glucose in Type 2 Diabetes

The response has been encouraging.

Meetings with key stakeholders – including patient groups, health authorities and others – brought positive feedback and support for community pharmacy’s role in health care.

Our Asthma Consultation Service proposal was endorsed by the Asthma Society of Canada, and the proposals earned a front page story and supportive editorial from The Vancouver Sun. One of the Association’s objectives in releasing the proposals was to ensure pharmacy was prepared to participate in the public policy debate associated with the provincial election campaign in May 2013. Our MLA contacts were provided with materials to use with candidates running in the election. Our previous MLA outreach efforts meant that when Premier Clark appointed Dr. Terry Lake as Minister of Health on June 7, he was already aware of the role and importance of community pharmacy. Our MLA contacts in his riding had worked hard to establish a working relationship with him and to serve as a resource for questions he might have on pharmacy issues.

• Community Pharmacist-led Anticoagulation Management Service

Existing patient care services

• Pharmacist-led Smoking Cessation Services

Administration of Injections

• Asthma Consultation Service

The BCPhA’s clinical services proposals were featured on the front page of The Vancouver Sun on March 12 and in its March 15 editorial.

It’s been more than four years since BC’s community pharmacists were authorized to administer injections.

Their response during the annual flu season as well the outbreak of pertussis at the end of 2012 and measles in August 2013 (particularly in the Fraser Health area) demonstrated how quickly pharmacists can respond to a crisis by immunizing large numbers of patients in a short period of time.

More than 2,700 pharmacists are authorized to administer injections in BC, and 84 per cent of all BC pharmacies have at least one authorized pharmacist. The BCPhA has trained more than 2,200 pharmacists to administer injections in workshops held around

www.bcpharmacy.ca

Table 1. Number of authorized community pharmacists in BC as of November 1, 2013

BCPhA trained, not authorized: 114 Not authorized: 1,513 Authorized to administer injections: 2,728

Table 2. BC community pharmacists’ authorization by year 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0

2009

2010

2011

2012

2013*

Not authorized community pharmacists Authorized community pharmacists

the province. In May 2013 the BCPhA’s training program was accredited as a CCCEP Certificate program.

During the current flu season, a pilot project in Vancouver Island Health Authority is exploring a new distribution model for supplying publicly funded flu

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vaccine to pharmacies. It’s hoped this pilot program will demonstrate the efficiencies of pharmacists ordering and receiving supply directly from the distributor instead of through their local health authority.

ambiguous wording. A revised manual is expected to be released before the end of 2013 and will include a checklist of steps pharmacists need to take to ensure they have completed the process and documentation of the service properly.

Expanded Access to Publicly Funded Vaccines

Regulatory compliance support The Association continued the development of policy and procedure manuals mandated by the College of Pharmacists. The template manuals are available at no cost to our Pharmacy (Corporate) members.

As a result of the Association’s efforts with the Ministry of Health, BC Centre for Disease Control, College of Pharmacists of BC and others, authorized pharmacists can now administer a wider range of publicly funded vaccines including Td (tetanus diphtheria) and MMR (measles, mumps, rubella) and most other publicly funded vaccines by specific request. In addition, authorized pharmacists can offer vaccines for purchase, such as shingles and travel vaccines.

Expanded access was one of most popular sessions presented at the BCPhA’s 2013 conference in Kelowna. That presentation has now been translated into the Association’s first eTraining program, developed as a member benefit.

Medication Reviews The Association was successful in advocating for the retention of funding for the Medication Review Service. The government agreed to continue the $10 million funding for its 2013/14 fiscal year (ending March 31, 2014).

BCPhA staff has also been involved in reviewing and recommending changes to the Medication Review Manual to clarify potential inconsistencies and

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These manuals, required by the College of Pharmacists of BC to satisfy the Pharmacy Operations and Drug Scheduling Act Bylaws Part II Section 10, can be easily downloaded and modified according to each pharmacy’s individual practice.

The templates now available on the BCPhA website are Dispensary Activities, Operation of a Community Pharmacy and Administration of Injections.

Other manuals under development include Adaptation and Prescription Renewal, Centralized Prescription Processing, Compounded Prescriptions, Medication Review Services, Methadone Maintenance, Residential Care Facility, and Telepharmacy.

PharmaCare and third-party payers The BCPhA’s Professional Services team responds to members who contact us on a daily basis with questions about

www.bcpharmacy.ca

claims adjudication, product supply and other payer issues. We also work with PharmaCare on a regular basis to ensure, as much as possible, that planned changes have minimal negative impact on community pharmacy.

For example, when PharmaCare decided to revise the Compounded Prescription Policy, the BCPhA established a working group that made recommendations to the Ministry of Health’s pharmaceutical services division on fees and to delay implementation to give pharmacies more time to work with software vendors for claims submission assistance.

When a PharmaNet service interruption was planned, the BCPhA worked with ministry representatives to mitigate the disruption for patients and pharmacists.

We also communicated with Pharmacy and Pharmacist members to ensure they were prepared for what was estimated to be a 20-hour service interruption.

The impact of PharmaCare audits on pharmacies across the province has grown significantly over the last year.

Many questions have arisen about the implementation of PharmaCare audit policies and procedures. As a result, the BCPhA Board approved the creation of an Audit Task Force. This group, with the assistance of senior staff at the Association, is working to develop recommendations to government on what changes need to be made to current policies and practices to ensure the audit process is fair and transparent. The group’s work will continue into 2014.

collaboration

B C P hA A nnua l Co nfe re nce 20 13

At this year’s conference, the Future of Pharmacy panel discussion included (let to right) Bob Nakagawa, registrar of the College of Pharmacists of BC; Geraldine Vance, BCPhA CEO; and Dr. Peter Zed, Associate Dean, Practice Innovation, UBC Faculty of Pharmaceutical Sciences.

Annual conference The 2013 conference was a great success, with more than 240 delegates meeting at the Delta Grand Okanagan Resort and Conference Centre from May 30 to June 1.

The theme was Collaboration: Working together for improved patient care, which focused attention on the importance of pharmacists working collaboratively with other health care professionals for the benefit of all British Columbians.

The conference gave members the opportunity to hear from many key stakeholders including two former health ministers, third-party payers, pharmacists from other provinces and our keynote speaker from New Zealand about ways in which community pharmacy can find new opportunities in this current tough environment. Highlights of the conference were as always the trade show, with delegates and exhibitors joining in the fun of the “tacky tourist” theme, and the awards dinner honouring outstanding pharmacists.

is happening in pharmacy in BC and elsewhere.

In April 2013 the BCPhA conducted the bi-annual online Wage & Benefit Survey.

The response rate was 648 members (24 per cent of the membership) and 13 non-members. Although there was no significant change in the standard work week or average wage rates by region from the 2011 survey, more respondents said they are working unpaid overtime. The total number of full-time and part-time vacancies increased significantly, from 15 in 2011 to 152 in 2013, although the number of respondents reporting a vacant pharmacist position at their pharmacy decreased from 15.6 per cent in 2011 to 10.3 per cent.

More pharmacies are providing smoking cessation, administration of injections, diabetes counseling, and methadone maintenance programs, while fewer are providing long-term care. Although job satisfaction was rated as very satisfied or satisfied by 67.9 per cent of respondents, this is down slightly from the 74.9 per cent who responded the same way in 2011.

Both surveys are expected to be repeated in two years.

Membership retention Despite mounting financial pressures on both pharmacies and pharmacists, membership in the BCPhA remained strong. As of August 31, 2013, there were 2,785 Pharmacist (General) and 809 Pharmacy (Corporate) members, representing 64 per cent and 70 per cent respectively of the total licensed pharmacists and pharmacies in the

Membership

2,785 registered pharmacists in BC are BCPhA members.

809 licensed pharmacies in BC are BCPhA members.

64%

70%

Hearing from members In September 2012, the BCPhA Member Survey was conducted by Ipsos Reid, one of Canada’s leading survey-based marketing research firms. The response rate was very good, with 541 members (18 per cent of the membership) responding.

Members said the things they valued most were the liability insurance offerings, support for scope of practice, advocacy the Association does on behalf of the profession, and information about what

Membership Growth Membership Growth Last Decade 03-04

04-05

05-06

06-07

07-08

08-09

09-10

10-11

11-12

12-13

Pharmacies

100%

108%

112%

118%

121%

123%

121%

137%

151%

148%

Pharmacists

100%

102%

106%

109%

111%

120%

125%

134%

143%

148%

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ON THE COVER | A YEAR IN REVIEW

province. The ongoing challenge for the Association is to continually grow member benefits while maintaining the individual Pharmacist membership fee of $400 that is still the best membership fee value of all pharmacy associations in Canada.

Affinity Rx One of the newest member benefits is the Affinity Rx program that offers BCPhA

members exclusive discounts and value-added services.

Job Board

Launched in June 2012, the program has already generated more than $200,000 in savings passed on to the more than 1,200 members as well their friends and family who have taken advantage of the offers. These include 4,600 movie tickets, 1,300 PNE and Playland tickets, 450 hotel nights booked at discounted rates, and 500 Telus Mobility smartphones and plans.

Another popular benefit is the BCPhA’s Job Board, providing Pharmacist members the opportunity to post their resumes on the Hire-A-Pharmacist section of the website, and Pharmacy members to advertise positions online and in The Tablet, as well as view posted resumes.

The Job Board is the most-viewed section of our website, with Career Opportunities one of the most valued sections of The Tablet.

Financial Statements

BCPhA Board of Directors

Summarized Statement of Financial Position* August 31, 2013 2013 ASSETS CURRENT ASSETS $ 2,530,788 LONG TERM INVESTMENTS 2,200,000 LONG TERM PREPAIDS 33,900 CAPITAL ASSETS 74,189 $ 4,838,967

2012 $ 3,105,293 1,900,000 34,416 46,759 $ 5,086,468

LIABILITIES AND NET ASSETS CURRENT LIABILITIES Accounts payable and accrued liabilities $ 128,050 Deferred revenue 2,807,211

$ 235,139 2,971,718

$ 2,935,261

$ 3,206,857

$ 400,000

$ 400,000

74,189 1,429,517

46,759 1,432,852

$ 1,903,706

$ 1,879,611

$ 4,838,967

$ 5,086,468

Summarized Statement of Operations Year Ended August 31, 2013

REVENUES$ (including deferred project revenues) EXPENDITURES EXCESS (DEFICIENCY) OF REVENUE OVER EXPENDITURES FOR THE YEAR

The Board of Directors for 2012/13 was comprised of:

2013

2012

3,139,784

$ 3,931,048

3,115,689

3,999,657

Ralph Lai, President Don Cocar, Vice President Shakeel Bhatti Bill Bright Derek Desrosiers

$ 24,095

$ (68,609)

Julie Ford Caren Heughan Victor Ikari Allison Nourse

NET ASSETS Unrestricted net assets Internally restricted in capital assets Internally restricted

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www.bcpharmacy.ca

David Pavan Greg Shepherd Nadeem Zia Four members left the Board of Directors as of August 31: Bill Bright, Derek Desrosiers, Caren Heughan and Victor Ikari. Joining the 2013/14 Board are: Alex Dar Santos, Nemanja Filipovic, Randy Konrad and John Tse.

PRODUCTS IN FOCUS

Glycopyrronium for COPD maintenance therapy Glycopyrronium bromide (SEEBRI* BREEZHALER*) is a once-daily, long-acting anticholinergic (LAAC) approved for maintenance therapy for patients with chronic obstructive pulmonary disease (COPD). LAAC agents are indicated as first-line therapy for symptomatic patients with moderate to severe COPD, as well as those with mild COPD and persistent symptoms despite short acting anti-cholinergics or beta agonists.

Glycopyrronium in COPD (GLOW2 Study) The Glycopyrronium bromide in COPD airways clinical study 2 (GLOW2) was a double-blind, placebo-controlled study comparing glycopyrronium bromide 50 ug once daily versus placebo in patients with moderate to severe COPD (FEV1 30-80% of predicted and post-bronchodilator FEV1/FVC <70 %) for 52 weeks. There was also an open-label tiotropium (Spiriva®) 18 ug daily parallel study group. A total of 1066 patients participated in the study, randomised at 2:1:1 ratios for glycopyrronium, placebo, and tiotropium respectively. Patients taking inhaled corticosteroid/long acting B2 agonist (ICS/LABA) medications were switched to an equivalent dose of ICS for the duration of the trial.

the reports of dry mouth were suspected to be drug related and of mild degree; none were severe. Like other anticholinergic drugs, caution is advised in patients with known narrow-angle glaucoma, prostatic hypertrophy and urinary retention as glycopyrronium may exacerbate these conditions.

Drug interactions There are potential additive interactions with concomitantly used anti-cholinergic medications, which should be avoided with the use of SEEBRI*.

Cimetidine potentially inhibits renal excretion of glycopyrronium by 23% but this is unlikely to be of clinical significance.

Patient selection Glycopyrronium is a suitable alternative to tiotropium in the treatment of mild, moderate and severe COPD. This is appropriate in patients who are symptomatic despite the use of short-acting bronchodilators. It is not indicated as a rescue medication for the treatment of acute exacerbations of COPD.

At 52 weeks, the glycocopyrronium group showed an 8.2% improvement in trough FEV1 and 34% reduction in rates of moderate to severe COPD exacerbations compared to placebo.

These rates were comparable to the tiotropium group.

No dosage adjustment is required in elderly patients, those with hepatic disease, or those with mild to moderate renal dysfunction.

Patients with end-stage renal disease have not been formally evaluated and glycopyrronium is not recommended routinely in this population.

Administration

Summary

SEEBRI* BREEZHALER* is supplied as a dry powder contained in a single dose capsule. This is administered in the proprietary patientactivated BREEZHALER*. There is rapid onset of action with FEV1 increases documented after five minutes of inhalation.

Glycopyrronium is useful addition for the management of symptoms and maintenance therapy for mild, moderate and severe COPD. It is comparable to tiotropium in clinical endpoints and side effect profile.

Adverse effects

Submitted by Dr. Edgar Lau, MD, FRCP (C) Staff Respirologist, Richmond Hospital

The most common reported side effects of glycopyrronium were nasopharyngitis, gastroenteritis and dry mouth. The majority of

Note: Glycopyrronium is now listed on PharmaCare as a Limited Coverage Drug that is covered with an approved Special Authority (SA).

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METHADONE MAINTENANCE TREATMENT

Methadone Maintenance Treatment: What you need to know methadone 10 mg/ml solution. The College has mandated the following timeline:

As community pharmacies throughout BC now know, significant changes are being made to the standards and guidelines for delivering Methadone Maintenance Treatment (MMT) services.

By February 1, 2014 All pharmacy managers, staff, relief pharmacists and pharmacy technicians employed in a community pharmacy that provides pharmacy services related to MMT must:

In October 2012, Health Canada approved a new commercially available methadone 10 mg/ml solution (Methadose®) for sale in Canada (although British Columbia has been using a compounded methadone 1 mg/ml, it is currently the only province doing so).

• have successfully completed the mandatory CPBC MMT live or online training program, and

With a new commercially available product now on the market and available for purchase by pharmacies, patient safety can be improved through a significant reduction in the risk of incorrect compounding.

However, because the new Methadose® solution is 10 times the concentration of the compounded methadone 1 mg/ml solution, there is certainly a potential for measuring error in the early stages of the conversion period as pharmacists move their patients to the new product and adjust to the change. Pharmacists must ensure they talk to methadone patients about the upcoming transition and educate them on the new solution (a much smaller volume, but stronger).

The College of Pharmacists of BC collaborated with various working groups including the BC Pharmacy Association to identify areas within Professional Practice Policy 66 (PPP-66) Methadone Maintenance Treatment (MMT) and the Policy Guide that required significant changes due to the new

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• have implemented all necessary practice requirements identified in the CPBC Methadone Maintenance Treatment Policy Guide (2013). (www.bcpharmacists. ists. org/about_us/key_initiatives/index/ articles/144.php) February 1, 2014 – February 28, 2014 During this transition period, pharmacists will be allowed to dispense both methadone 10 mg/ml solution (Methadose®) and compounded methadone 1 mg/ml. During this period, new MMT prescriptions must be written on the new form, and pharmacists must: • transition their patients from 1 mg/ ml to the commercially available 10 mg/ml methadone oral preparation • educate patients about safety concerns (e.g., 10 times concentration) • educate patients about appropriate security and storage (e.g., does not require refrigeration and must be

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stored securely because of increased strength), and • manage inventory, create plan and appropriately document methadone powder inventory. (Note that wholesalers will likely only accept returns of full, unopened bottles of powder. They cannot accept part bottles of any narcotic for return.)

Documentation of the above must be available for review by College inspectors.

Effective March 1, 2014 • All MMT prescriptions must be dispensed with the commercially available 10 mg/ml methadone oral preparation.

FAQs Q: Do the new policies apply to patients taking methadone for pain?

A: No. PPP-66 is specifically for Methadone Maintenance Treatment.

In addition to the timeline, there are a few key points we’d like to highlight for members.

1. As stated in principle 3.3.1 of the Policy Guide, when preparing a methadone prescription, “Methadone doses must be accurately measured in a calibrated device with an error rate of no greater than 0.1 ml.” We recognize that the volume dispensed will now be very small. You may need to buy specialized equipment in order to meet the 0.1 ml accuracy required by the College.

2. Another key point is from principle 4.1.6 of the Policy Guide, which states that patients getting carries must receive each day in an individually labelled, separate bottle: “With respect to take-home doses the first dose, unless otherwise indicated in writing, must be a witnessed ingestion with all subsequent take-home doses dispensed in child-resistant containers … Each dose must be dispensed in an individual, appropriately sized, childresistant container (bottle).”

3. Note that the College will be strict on the requirement that as of February 1, 2014, any new MMT prescription must be written on the correct form. Please see principle 2.1.1 for more details on the new Methadone Maintenance Controlled Prescription form.

4. As of February 1, 2014, the Professional Practice Policy-71: Delivery of Methadone for Maintenance also comes into effect, enforcing federal legislation that prohibits the delivery of methadone. PPP-71 also provides clarity for delivery under extraordinary circumstances, for example, if severe restrictions on mobility have been identified. Because of the new PPP-71, some pharmacies may have to adjust their hours of operations. If your pharmacy does not provide deliveries, you can refer the patient to another pharmacy (if the physician signs an exemption because of mobility). PPP-71 also enforces that pharmacists are responsible for secure transportation – direct from the dispensing pharmacy to patient – and must witness ingestion.

We know that many of our members are critical to maintaining patient care for those on methadone maintenance treatment, and will be affected by this transition to Methadose®. During this time, the Association aims to provide support to our members, and will continue to provide updates as more information is confirmed.

If you have any questions before you proceed with the changes, please contact the College of Pharmacists of BC. The full PPP-66, Policy Guide, and PPP-71 are available on the College’s website at www.bcpharmacists.org.

Because pharmacies may need to buy specialized equipment to meet the 0.1 ml accuracy required by the CPBC, the BCPhA has secured funding to help offset a portion of these costs. This grant has been made possible through a contribution by Mallinckrodt Canada ULC to the BCPhA’s Pharmacy Innovation Fund.

Details regarding the amount available for each pharmacy and the application process are being announced mid-December.

www.bcpharmacy.ca

Q: Is it now mandatory to lock up Methadose® (since it won’t be refrigerated)?

A: Store Methadose® as you would any other narcotic. The College is currently working with the Vancouver Police Department and a working group to review pharmacy security recommendations.

Q: How do I ensure accuracy of dispensing?

A: Use a device that can provide an error rate of 0.1 ml or less.

Q: What happens if there is a shortage?

A: As per the Policy Guide principle 6.3.1, Compounding in Exceptional Circumstances, the only situation that would constitute consideration of exceptional circumstances is when a commercially available 10 mg/ml oral preparation is not available.

Methadone for maintenance must be at the strength of 10 mg/ml to ensure minimization of errors.

A compounding log must be established to record when methadone solutions are prepared, how much was prepared, and who prepared the product.

Q: What if a patient is allergic?

A: The patient’s physician may request an exemption from PharmaCare.

Q: What do I need to know about the new form?

A: If not specified, the default is Daily Witnessed Ingestion (DWI), not carries.

Patients must sign the bottom of the form when receiving their first dose.

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3 FOR SOME, IT CAN MEAN EXCRUCIATING AND POTENTIALLY DEBILITATING PAIN. * 1,2,

SELECTED IMPORTANT SAFETY INFORMATION ZOSTAVAX® is not a treatment for zoster or postherpetic neuralgia (PHN). If an individual develops herpes zoster despite vaccination, active current standard of care treatment for herpes zoster should be considered. Vaccination with ZOSTAVAX® may not result in protection of all vaccine recipients. ZOSTAVAX® is contraindicated in patients with a history of hypersensitivity to any component of the vaccine, including gelatin; a history of anaphylactic/ anaphylactoid reaction to neomycin; primary and acquired immunodeficiency states due to conditions such as: acute and chronic leukemias; lymphoma; other conditions affecting the bone marrow or lymphatic system; immunosuppression due to HIV/AIDS, cellular immune deficiencies; immunosuppressive therapy (including high-dose corticosteroids); active untreated tuberculosis; pregnancy. In clinical trials, ZOSTAVAX® has been evaluated for general safety in more than 32,000 adults 50 years of age or older. ZOSTAVAX® was generally well tolerated. Vaccine-related injection-site and systemic adverse experiences reported at an incidence ≥1% are shown below. The overall incidence of vaccine-related injection-site adverse experiences was significantly greater for subjects vaccinated with ZOSTAVAX® versus subjects who received placebo (48% for ZOSTAVAX® and 17% for placebo among recipients aged ≥60 (Shingles Prevention Study [SPS]) and 63.9% for ZOSTAVAX® and 14.4% for placebo among recipients aged 50-59) (ZOSTAVAX® Efficacy and Safety Trial [ZEST]). Vaccinerelated injection-site and systemic adverse experiences reported in ≥1% of adults who received ZOSTAVAX® (N=3,345) or placebo (N=3,271) (0-42 Days Postvaccination) in the Adverse Event Monitoring Substudy of the SPS were: erythema† (35.6%, 6.9%), pain/tenderness† (34.3%, 8.6%), swelling† (26.1%, 4.5%), hematoma (1.6%, 1.4%), pruritus (7.1%, 1.0%), warmth (1.7%, 0.3%), headache (1.4%, 0.9%). Most of these adverse experiences were reported as mild in intensity. The remainder of subjects in the SPS received routine safety monitoring, but were not provided report cards. The types of events reported in these patients were generally similar to the SPS subgroup of patients in the Adverse Event Monitoring Substudy. Vaccine-related injection-site and systemic adverse experiences reported in ≥1% of adults who received ZOSTAVAX® (N=11,094) or placebo (N=11,116) (1-42 Days Postvaccination) in the ZEST were: pain† (53.9%, 9.0%), erythema† (48.1%, 4.3%), swelling† (40.4%, 2.8%), pruritus (11.3%, 0.7%), warmth (3.7%, 0.2%), hematoma (1.6%, 1.6%), induration (1.1%, 0.0%), headache (9.4%, 8.2%), pain in extremity (1.3%, 0.8%).

ARE YOUR PATIENTS PROTECTED?

INDICATED FOR THE

PREVENTION OF HERPES ZOSTER

IN INDIVIDUALS 50 YEARS OF AGE OR OLDER.

Please visit our website at: www.merck.ca

* ZOSTAVAX® is not indicated to reduce the morbidity and complications associated with herpes zoster. † Designates a solicited adverse experience. Injection-site adverse experiences were solicited only from Days 0-4 postvaccination in SPS and from Days 1-5 postvaccination in ZEST. ®

References: 1. Data on file, Merck Canada Inc. Product Monograph. ZOSTAVAX , 2011. 2. Clinical Manifestations: Chickenpox. In: Mandell G, Bennett J, Dolin R eds. Principles and Practice of Infectious Diseases, 6th ed, vol 2. Philadelphia: Elsevier; 2005.

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www.bcpharmacy.ca

®

Registered trademark of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. Used under license. © 2012 Merck Canada Inc., a subsidiary of Merck & Co., Inc. All rights reserved.

VACC-1039532-0007-E-CDN-APR-14

See prescribing prescribingsummary summary on pages 26-27 See prescribing summary on page24-25 xxx See on pages

CLINICARE PHARMACISTS

The “poop” on treating C. difficile Ey -aVoQ 0iQ aQG Larry LeXQJ We have all experienced this before: a patient has read or heard about some radical new treatment in the media and wants to know what their pharmacist thinks about it. Recently, we had several physicians and patients ask us about one therapy that has been making headlines in the news: an oral medication made of stool (or “poop”) in the treatment of Clostridium difficile (C. difficile). Reports of this new treatment were seen in major publications such as The Vancouver Sun, CBC News, and USA Today. This was particularly relevant, as over the past year we have seen many patients suffering from C. difficile-associated diarrhea with recurrent, severe symptoms despite standard treatment with metronidazole or vancomycin.

There are multiple different regimens that can be tried; one method includes:

C. difficile is an anaerobic, gram-positive bacteria that normally colonizes the intestinal tract. It can overpopulate the gut after normal gastrointestinal flora is altered, commonly after antibiotic use. It can cause a range of illnesses from mild diarrhea to severe pseudomembranous colitis. Relapsing C. difficile occurs in up to 25 per cent of patients treated with either metronidazole or vancomycin. Ten per cent of patients will unfortunately suffer from multiple relapses.

Patients who experience multiple relapses of C. difficile will usually follow a familiar timeline of repeated antibiotic courses for longer durations of treatment.

A recent meta-analysis showed that FMT can be effective in the treatment of recurrent C. difficile-associated diarrhea with benefits that may last up to nine years after therapy. Unfortunately it seems that the available evidence is not enough to support routine FMT at this time.

The idea of using stool in an oral preparation is currently being studied through innovative research in Calgary. The capsules contain material from stool of healthy donors, which are processed to isolate the bacteria within the fecal matter. The resulting concentration of isolated bacteria is then formulated into capsules, which are encased in three layers of gelatin. The gelatin layers are designed to protect the capsule past the acidic stomach environment and into the colon where the payload can be delivered. Despite promising observational evidence that suggests a 100 per cent cure rate with minimal side effects, the capsules are still in the experimental phase and are unfortunately not yet commercially available. There is a need for ongoing research and randomized controlled trials to support the use of this therapy at this time.

A similar alternative in the treatment of recurrent C. difficile is the use of fecal microbiota transplantation (FMT). FMT is the transplantation of donor stool into the bowel of the patient, usually via enema or a colonoscope by a specialist.

1. Pre-treatment with vancomycin 500 mg twice daily for seven days, followed by oral lavage with an electrolyte purgative (such as GoLYTELY).

2. 300 gms of donor stool suspended in 300 mL of sterile normal saline, then homogenized in a blender to liquid consistency.

3. Enema administered once daily for five days. Patients are encouraged to retain the enema for at least six hours. Loperamide 2 mg can be given to help facilitate retention of the enema.

Since oral stool medications are not yet available for purchase, we had to recommend alternatives for our patients, which included a second course of antibiotics as well as a course of Saccharomyces boulardii (yeast probiotic). Oral rehydration solution was always encouraged to prevent dehydration.

What experience have you had with treating C. difficile, and would you be willing to try a course of oral stool medications? Visit us on Facebook at Clinicare Pharmacists to join the discussion.

Larry Leung and Jason Min are directors of Clinicare Pharmacists Inc. and lecturers at UBC. They have a passion for interdisciplinary care and the development and implementation of innovative clinical pharmacy services in the community.

References 1. UpToDate Topic: Fecal microbiota transplantation in the treatment of recurrent Clostridium difficile infection. Accessed from: http://www.uptodate.com/contents/ fecal-microbiota-transplantation-in-the-treatment-of-recurrent-clostridium-difficileinfection?source=search_result&search=fecal+transplant&selectedTitle=1~5 2. http://www.cbc.ca/news/canada/calgary/poop-pills-can-treat-c-difficile-calgary-doctorsays-1.1895079 3. Kassam Z, Lee CH, Yuan Y, Hunt RH. Fecal microbiota transplantation for Clostridium difficile infection: systematic review and meta-analysis. Am J Gastroenterol. 2013;108(4):500.

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Prescribing Summary Patient Selection Criteria THERAPEUTIC CLASSIFICATION Live, attenuated virus varicella-zoster vaccine INDICATIONS AND CLINICAL USE ZOSTAVAX® is indicated for the prevention of herpes zoster (shingles).

ZOSTAVAX® is indicated for immunization of individuals 50 years of age or older.

SPECIAL POPULATIONS For use in special populations, see Supplemental Product Information, WARNINGS AND PRECAUTIONS, Special Populations.

CONTRAINDICATIONS History of hypersensitivity to any component of the vaccine, including gelatin. History of anaphylactic/anaphylactoid reaction to neomycin (each dose of reconstituted vaccine contains trace quantities of neomycin). Neomycin allergy generally manifests as a contact dermatitis. However, a history of contact dermatitis due to neomycin is not a contraindication to receiving live virus vaccines.

Primary and acquired immunodeficiency states due to conditions such as: acute and chronic leukemias; lymphoma; other conditions affecting the bone marrow or lymphatic system; immunosuppression due to HIV/ AIDS; cellular immune deficiencies. Immunosuppressive therapy (including high-dose corticosteroids); however, ZOSTAVAX® is not contraindicated for use in individuals who are receiving topical/inhaled corticosteroids or low-dose systemic corticosteroids or in patients who are receiving corticosteroids as replacement therapy, e.g., for adrenal insufficiency.

Active untreated tuberculosis.

Pregnancy (see WARNINGS AND PRECAUTIONS - Pregnant Women in the Supplemental Product Information).

Safety Information WARNINGS AND PRECAUTIONS General The health care provider should question the patient about reactions to a previous dose of any varicella-zoster virus (VZV)-containing vaccines (see CONTRAINDICATIONS).

As with any vaccine, adequate treatment provisions, including epinephrine injection (1:1000), should be available for immediate use should an anaphylactic/ anaphylactoid reaction occur. Deferral of vaccination should be considered in the presence of fever >38.5°C (>101.3°F). ZOSTAVAX® does not protect all individuals against the development of Herpes Zoster or its sequelae.

See ACTION AND CLINICAL PHARMACOLOGY and CLINICAL TRIALS in the product monograph.

The duration of protection beyond 4 years after vaccination with ZOSTAVAX® is unknown. The need for revaccination has not been defined.

ZOSTAVAX® has not been studied in individuals who have previously experienced an episode of herpes zoster.

Transmission In clinical trials with ZOSTAVAX®, transmission of the vaccine virus has not been reported. However, postmarketing experience with varicella vaccines suggests that transmission of vaccine virus may occur rarely between vaccinees who develop a varicella-like rash and susceptible contacts. Transmission of vaccine virus from varicella vaccine recipients who do not develop a varicella-like rash has also been reported and is therefore a theoretical risk for vaccination with ZOSTAVAX®. The risk of transmitting the attenuated vaccine virus to a susceptible individual should be weighted against the 26

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risk of developing natural herpes zoster and potentially transmitting wild-type VZV to a susceptible contact.

ADVERSE REACTIONS Adverse Drug Reaction Overview In clinical trials, ZOSTAVAX® has been evaluated for general safety in more than 32,000 adults 50 years of age or older. ZOSTAVAX® was generally well tolerated.

ZOSTAVAX® Efficacy and Safety Trial (ZEST) in Subjects 50 to 59 Years of Age In the ZEST study, subjects received a single dose of either ZOSTAVAX® (n=11,184) or placebo (n=11,212) and were monitored for general safety throughout the study. During the study, a vaccine-related serious adverse experience was reported for 1 subject vaccinated with ZOSTAVAX® (anaphylactic reaction).

All subjects received a vaccination report card (VRC) to record adverse events occurring from Days 1 to 42 postvaccination in addition to undergoing routine safety monitoring throughout the study.

Vaccine-related injection-site and systemic adverse experiences reported at an incidence of ≥1% are shown in Table 1. The overall incidence of vaccine-related injectionsite adverse experiences was significantly greater for subjects vaccinated with ZOSTAVAX® versus subjects who received placebo (63.9% for ZOSTAVAX® and 14.4% for placebo).

Table 1: Vaccine-Related Injection-Site and Systemic Adverse Experiences Reported in ≥1% of Adults Who Received ZOSTAVAX® or Placebo (1-42 Days Postvaccination) in the ZOSTAVAX® Efficacy and Safety Trial ZOSTAVAX® Placebo (N = 11,094) (N = 11,116) Adverse Experience % % Injection-Site Pain† Erythema† Swelling† Pruritus Warmth Hematoma Induration

53.9 48.1 40.4 11.3 3.7 1.6 1.1

9.0 4.3 2.8 0.7 0.2 1.6 0.0

Systemic Headache Pain in extremity

9.4 1.3

8.2 0.8

†

Designates a solicited adverse experience. Injection-site adverse experiences were solicited only from Days 1-5 postvaccination.

Within the 42-day postvaccination period in the ZEST, noninjection-site zoster-like rashes were reported by 34 subjects (19 for ZOSTAVAX® and 15 for placebo). Of 24 specimens that were adequate for Polymerase Chain Reaction (PCR) testing, wild-type VZV was detected in 10 (3 for ZOSTAVAX®, 7 for placebo) of these specimens.

The Oka/Merck strain of VZV was not detected from any of these specimens.

Within the same 42-day postvaccination reporting period in the ZEST, varicella-like rashes were reported by 124 subjects (69 for ZOSTAVAX® and 55 for placebo). Of 23 specimens that were available and adequate for PCR testing, VZV was detected in one of these specimens from the group of subjects who received ZOSTAVAX®; however, the virus strain (wild type or Oka/Merck strain) could not be determined.

Shingles Prevention Study (SPS) in Subjects 60 Years of Age and Older In the largest of these trials, the Shingles Prevention Study (SPS), 38,546 subjects received a single dose of either ZOSTAVAX® (n=19,270) or placebo (n=19,276) and were monitored for safety throughout the study. During the study, vaccine-related serious adverse experiences were reported for 2 subjects vaccinated with ZOSTAVAX® (asthma exacerbation and polymyalgia rheumatica) and 3 subjects who received placebo (Goodpasture’s syndrome, anaphylactic reaction, and polymyalgia rheumatica).

In the Adverse Event Monitoring Substudy, a subgroup of individuals from the SPS (n=3,345 received ZOSTAVAX® and n=3,271 received placebo) were provided vaccination report cards to record adverse events occurring from Days 0 to 42 postvaccination in addition to undergoing routine safety monitoring throughout the study.

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Table 2: Number of Subjects with ≥1 Serious Adverse Events (0-42 Days Postvaccination) in the Shingles Prevention Study Placebo ZOSTAVAX® n/N n/N Relative Risk Cohort % % (95% CI) Overall Study Cohort All ages

255/18671 1.4%

254/18717 1.4%

1.01 (0.85, 1.20)

60-69 years old

113/10100 1.1%

101/10095 1.0%

1.12 (0.86, 1.46)

≥70 years old

142/8571 1.7%

153/8622 1.8%

0.93 (0.74, 1.17)

AE Monitoring Substudy Cohort All ages

64/3326 1.9%

41/3249 1.3%

1.53 (1.04, 2.25)

60-69 years old

22/1726 1.3%

18/1709 1.1%

1.21 (0.66, 2.23)

≥70 years old

42/1600 2.6%

23/1540 1.5%

1.76 (1.07, 2.89)

N=number of subjects in cohort with safety follow-up n=number of subjects reporting an SAE 0-42 Days postvaccination

The incidence of death was similar in the groups receiving ZOSTAVAX® or placebo during the Days 0-42 postvaccination period: 14 deaths occurred in the group of subjects who received ZOSTAVAX® and 16 deaths occurred in the group of subjects who received placebo. The most common reported cause of death was cardiovascular disease (10 in the group of subjects who received ZOSTAVAX®, 8 in the group of subjects who received placebo). The overall incidence of death occurring at any time during the study was similar between vaccination groups: 793 deaths (4.1%) occurred in subjects who received ZOSTAVAX® and 795 deaths (4.1%) in subjects who received placebo.

Vaccine-related injection-site and systemic adverse experiences reported at an incidence ≥1% are shown in Table 3. Most of these adverse experiences were reported as mild in intensity. The overall incidence of vaccine-related injection-site adverse experiences was significantly greater for subjects vaccinated with ZOSTAVAX® versus subjects who received placebo (48% for ZOSTAVAX® and 17% for placebo).

Table 3: Vaccine-Related Injection-Site and Systemic Adverse Experiences Reported in ≥1% of Adults Who Received ZOSTAVAX® or Placebo (0-42 Days Postvaccination) in the Adverse Events Monitoring Substudy of the Shingles Prevention Study Placebo ZOSTAVAX® (N = 3345) (N = 3271) Adverse Experience % % Injection Site Erythema† Pain/tenderness† Swelling† Hematoma Pruritus Warmth

35.6 34.3 26.1 1.6 7.1 1.7

6.9 8.6 4.5 1.4 1.0 0.3

Systemic Headache

1.4

0.9

†

Designates a solicited adverse experience. Injection-site adverse experiences were solicited only from Days 0-4 postvaccination.

The remainder of subjects in the SPS received routine safety monitoring, but were not provided report cards. The types of events reported in these patients were generally similar to the subgroup of patients in the Adverse Event Monitoring Substudy. Within the 42-day postvaccination reporting period in the SPS, the number of reported noninjection-site zoster-like rashes among all subjects was small (17 for ZOSTAVAX ®, 36 for placebo; p=0.009). Of these 53 zoster-like rashes, 41 had specimens that were available and adequate for PCR testing. Wild-type VZV was detected in 25 (5 for ZOSTAVAX®, 20 for placebo) of these specimens. The Oka/Merck strain of VZV was not detected from any of these specimens.

The number (n=59) of reported varicella-like rashes was also small. Of these varicella-like rashes, 10 had specimens that were available and adequate for PCR testing. VZV was not detected in any of these specimens.

The results of virus testing in subjects with varicella-like and zoster-like rashes should be interpreted with caution due to the number of samples that were not available for testing.

The numbers of subjects with elevated temperature (≥38.3°C [≥101.0°F]) within 7 days postvaccination were similar in the ZOSTAVAX® and the placebo vaccination groups [6 (0.2%) vs. 8 (0.3%), respectively].

Other Studies In other clinical trials conducted prior to the completion of the SPS, the reported rates of noninjection-site zoster-like and varicella-like rashes within 42 days postvaccination were also low in both zoster vaccine recipients and placebo recipients. Of 17 reported varicella-like rashes and non-injection site zoster-like rashes, 10 specimens were available and adequate for PCR testing, and 2 subjects had varicella (onset Day 8 and 17) confirmed to be Oka/Merck strain.

To address concerns for individuals with an unknown history of vaccination with ZOSTAVAX ®, the safety and tolerability of a second dose of ZOSTAVAX® was evaluated. In a placebo-controlled, double-blind study, 98 adults 60 years of age or older received a second dose of ZOSTAVAX® 42 days following the initial dose; the vaccine was generally well tolerated. The frequency of vaccine-related adverse experiences after the second dose of ZOSTAVAX® was generally similar to that seen with the first dose.

Descriptive study P017 is an estimation study with no hypothesis testing. In this double-blind, placebocontrolled, randomized clinical trial, ZOSTAVAX® was administered to 206 subjects 60 years of age or older who were receiving chronic/maintenance systemic corticosteroid therapy at a daily dose equivalent of 5 to 20 mg of prednisone for at least 2 weeks prior to enrollment, and 6 weeks or more following vaccination to assess the immunogenicity and safety profile of ZOSTAVAX®. In this clinical trial, the safety profile was generally similar to that seen in the Adverse Event Monitoring Substudy of the SPS (see CONTRAINDICATIONS regarding corticosteroids).

Post-Marketing Adverse Drug Reactions The following additional adverse reactions have been identified during post-marketing use of ZOSTAVAX®.

Because these reactions are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to the vaccine.

Gastrointestinal disorders: nausea.

Skin and subcutaneous tissue disorders: rash.

Musculoskeletal and connective tissue disorders: arthralgia; myalgia.

General disorders and administration site conditions: injection-site rash; injection-site urticaria; pyrexia; injection-site lymphadenopathy.

Immune system disorders: hypersensitivity reactions including anaphylactic reactions.

If a patient experiences an adverse event following immunization, please complete the appropriate Adverse Events following Immunization (AEFI) Form and send it to your local Health Unit in your province/territory.

To report a suspected adverse reaction, please contact Merck Canada Inc. in any of the following ways: – Call toll-free 1-800-567-2594 – Complete a Canada Vigilance Reporting Form and fax toll-free to 1-800-369-3090 – Mail to: Merck Canada Inc., Pharmacovigilance, P.O. Box 1005, Pointe-Claire – Dorval, QC H9R 4P8 DRUG INTERACTIONS Overview ZOSTAVAX® must not be mixed with any other medicinal product in the same syringe. Other medicinal products must be given as separate injections and at different body sites.

Concurrent administration of ZOSTAVAX® and antiviral medications known to be effective against VZV has not been evaluated.

Use with Other Vaccines ZOSTAVAX ® and PNEUMOVAX ® 23 (pneumococcal vaccine, polyvalent, MSD Std.) should not be given concomitantly because concomitant use resulted in reduced immunogenicity of ZOSTAVAX® (see CLINICAL TRIALS in the product monograph).

Administration DOSAGE AND ADMINISTRATION (see Product Monograph for complete information) Recommended Dose and Dosage Adjustment FOR SUBCUTANEOUS ADMINISTRATION. Do not inject intravascularly.

Individuals should receive a single dose consisting of the entire content of the vial (approximately 0.65 mL).

ZOSTAVAX® is not a treatment for zoster or postherpetic neuraligia (PHN). If an individual develops herpes zoster despite vaccination, active current standard of care treatment for herpes zoster should be considered.

At present, the duration of protection after vaccination with ZOSTAVAX® is unknown. In the Shingles Prevention Study (SPS), protection was demonstrated through 4 years of follow-up. The need for revaccination has not yet been defined.

Reconstitute immediately upon removal from the freezer.

To reconstitute the vaccine, use only the diluent supplied, since it is free of preservatives or other antiviral substances which might inactivate the vaccine virus.

Vial of diluent To reconstitute the vaccine, first withdraw the entire contents of the diluent vial into a syringe.

To avoid excessive foaming, slowly inject all of the diluent in the syringe into the vial of lyophilized vaccine and gently agitate to mix thoroughly. Withdraw the entire contents into a syringe, and using a new needle, inject the total volume of reconstituted vaccine subcutaneously, preferably into the upper arm - deltoid region.

IT IS RECOMMENDED THAT THE VACCINE BE ADMINISTERED IMMEDIATELY AFTER RECONSTITUTION, TO MINIMIZE LOSS OF POTENCY. DISCARD RECONSTITUTED VACCINE IF IT IS NOT USED WITHIN 30 MINUTES. Do not freeze reconstituted vaccine.

CAUTION: A sterile syringe free of preservatives, antiseptics, and detergents should be used for each injection and/or reconstitution of ZOSTAVAX® because these substances may inactivate the vaccine virus.

It is important to use a separate sterile needle and syringe for each patient to prevent transfer of infectious agents from one individual to another.

Needles should be disposed of properly.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. ZOSTAVAX® when reconstituted is a semi-hazy to translucent, off-white to pale yellow liquid.

70-79 years of age, and 1,263 were 80 years of age or older. ZOSTAVAX® was demonstrated to be generally safe and effective in this population.

Pregnant Women: There are no studies in pregnant women. It is also not known whether ZOSTAVAX® can cause foetal harm when administered to a pregnant woman or can affect reproduction capacity. However naturallyoccurring varicella-zoster virus infection is known to sometimes cause foetal harm. Therefore, ZOSTAVAX® should not be administered to pregnant women; furthermore, pregnancy should be avoided for three months following vaccination (see CONTRAINDICATIONS).

Nursing Women: It is not known whether VZV is secreted in human milk.

Therefore, because some viruses are secreted in human milk, caution should be exercised if ZOSTAVAX® is administered to a nursing woman.

Pediatrics: ZOSTAVAX® is not recommended for use in this age group.

HIV-AIDS Patients: The safety and efficacy of ZOSTAVAX® have not been established in adults who are known to be infected with HIV with or without evidence of immunosuppression (see CONTRAINDICATIONS).

Immunocompromised Subjects: Data are not available regarding the use of ZOSTAVAX® in immunocompromised subjects (see CONTRAINDICATIONS). ®

Registered trademarks Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. Used under license.

13-02_153682 VACC-1039532-0007-E-CDN-APR-14 PRODUCT MONOGRAPH AVAILABLE AT www.merck.ca OR UPON REQUEST AT 1-800-567-2594

www.merck.ca

MERCK CANADA INC. P.O. BOX 1005, POINTE-CLAIRE DORVAL, QUEBEC H9R 4P8

OVERDOSAGE There are no data with regard to overdose.

For management of a suspected drug overdose, contact your regional Poison Control Center.

STORAGE AND STABILITY Storage ZOSTAVAX® SHOULD BE STORED FROZEN at an average temperature of -15°C or colder until it is reconstituted for injection (see DOSAGE AND ADMINISTRATION).

Any freezer, including frost-free, that has a separate sealed freezer door and reliably maintains an average temperature of -15°C or colder is acceptable for storing ZOSTAVAX®. The diluent should be stored separately at room temperature (20 to 25°C) or in the refrigerator (2 to 8°C). Do not store the diluent in a freezer.

Before reconstitution, protect from light.

DISCARD IF RECONSTITUTED VACCINE IS NOT USED WITHIN 30 MINUTES. DO NOT FREEZE THE RECONSTITUTED VACCINE. Supplemental Product Information WARNINGS AND PRECAUTIONS Special Populations Geriatric: The mean age of subjects enrolled in the largest (N=38,546) clinical study of ZOSTAVAX® was 69 years (range 59-99 years). Of the 19,270 subjects who received ZOSTAVAX®, 10,378 were 60-69 years of age, 7,629 were

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CAREER OPPORTUNITIES

diploma from an accredited institution and have excellent customer service skills. Cantonese speaking ability is highly preferred. Mostly weekdays; no evenings, no stats. Please send resumes to crystalpharmacy@hotmail.com or fax 604.433.2830.

ARE YOU MAXIMIZING THE VALUE OF YOUR MEMBER BENEFITS? Pharmacy members can place free Career Opportunities listings in this section and on the BCPhA website. Job postings for pharmacy technicians and assistants are also distributed by the Pharmacy Technician Society of British Columbia (PTSBC). A new enhancement to the best pharmacy job board in BC!

CAMPBELL RIVER Pharmacist – part-time

Pharmacist members looking for new career opportunities can post their resumes for free on the Hire-aPharmacist page. To learn more, visit the Recruitment section of bcpharmacy.ca ABBOTSFORD Pharmacist – part-time

Overwaitea Food Group, a Canadian-owned company, is one of Western Canada’s leading food and consumer-goods retailer, and operates more than 100 pharmacies in BC and Alberta including Save On Foods, PriceSmart Foods, Coopers Foods, Urban Fare and Overwaitea. At this time we are looking for a part-time pharmacist (32 to 40 hours). We provide a very professional pharmacy practice environment and are committed to: challenging and growing our staff, caring for people, healthy living for our shoppers and patients, innovation and investing in our future.

Applicants must have a BC license and be in good standing with the College of Pharmacists. Good communication skills and knowledge of Kroll software are considered an asset. Only shortlisted applicants will be contacted. Please send resumes to Gary Go, regional manager, pharmacy operations, at gary_go@owfg.com.

at missagh@manshadipharmacy.com. Fax 250.372.2224 or phone 250.574.0111. Only qualified applicants will be contacted. Thank you for your interest.

Pharmacist – part-time London Drugs has a part-time opportunity in Kamloops. Join a clinical and patient-focused team using the latest robotic dispensing machines plus counseling booths and counseling rooms.

Competitive salary and compensation packages, scheduled meal breaks and opportunities to advance to roles such as travel medicine, longterm care, pharmacy management, CDE, injection pharmacist and patient care pharmacists. Please send resumes to Shawn Sangha, Rx operations manager, at ssangha@londondrugs.com or fax 604.448.1075.

KELOWNA Pharmacist – part-time

Pharmacy technician – full-time

CHILLIWACK

We are presently accepting applications for a full-time registered pharmacy technician. The opening is for Monday to Friday with no evenings or weekends. We offer a very competitive compensation package. Please send resumes to info@pharmasaveabby.com, fax 604.870.2955 or please call 604.870.5600.

Pharmacy technician – full-time Chilliwack Rexall has an immediate opening for full-time pharmacy technician. We offer a very competitive compensation package ($28/hour).

Please send resumes to Neerav Joshi, manager, pharmacy recruitment & retention, at njoshi@ rexall.ca or apply online at www.rexallcareers.ca.

Dedication to the health and well-being of our customers and patients is at the core of our business. We offer excellent base salary rates, annual bonus opportunities, a full benefits package, educational allowance, paid med checks and career growth opportunities. Qualifications: pharmacy license to practice in BC, experience in retail pharmaceutical systems and dispensing procedures, exceptional communications and organizational skills, strong patient satisfaction orientation, ability to maintain optimum balance between the profession and business of pharmacy, strong proble- solving and analytical skills, and the ability to work productively as part of a dynamic, fast-paced team. Please send resumes to Neerav Joshi, manager, pharmacy recruitment & retention, at njoshi@rexall.ca.

ALDERGROVE

GIBSONS

Pharmacist – part-time

Pharmacy technician or assistant – full-time and part-time

Pharmacist – full-time

Part-time pharmacist position in Kelowna (Winfield). Key responsibilities of a Shoppers Drug Mart pharmacist include: checking prescriptions for accuracy; counseling on prescription medications and OTCs; health management consulting; participating in cognitive/enhanced services and programs; and collaboration with other health professionals to ensure accuracy of dispensed prescriptions. Qualifications: Bachelor of Pharmacy; license to practice in BC; superior interpersonal skills; strong verbal and written communication skills; exceptional customer service and computer proficiency.

Desired qualifications: experience with Kroll software and providing medication review services, and injection certification. Please send resumes to Sarah Pelka, associate owner, at asdm2153@shoppersdrugmart.ca or please call 250.766.2345.

Pharmasave is looking for a part-time pharmacist (for weekends) who has been practising for at least two years. The pharmacy is located inside the Abbotsford Regional Hospital. Remuneration paid according to experience. Please send resumes to info@pharmasaveabby.com, fax 604.870.2955 or please call 604.853.6696.

London Drugs has a full-time opportunity in Gibsons. Join a clinical and patient-focused team using the latest robotic dispensing machines plus counseling booths and counseling rooms.

Competitive salary and compensation packages, scheduled meal breaks and opportunities to advance to roles such as travel medicine, longterm care, pharmacy management, CDE, injection pharmacist and patient care pharmacists. Please send resumes to Shawn Sangha, Rx operations manager, at ssangha@londondrugs.com or fax 604.448.1075.

In business since 1922, Otter Co-op is a successful $160M retail operation, located minutes east of Langley. Due to our tremendous growth and expansion plans, we are accepting applications for a full-time and part-time pharmacy technician or pharmacy assistant. We provide an excellent pharmacy practice environment. If you are highly motivated to provide excellent pharmacy care and customer service, please apply to Hisham Metwally, pharmacy manager, Otter Co-op, Box 4200, 3600 - 248 Street, Aldergrove, V4W 2V1.

Please send resumes to pharmacymgr@ottercoop.com or fax 604.856.3101.

KAMLOOPS Pharmacist – full-time

BURNABY Pharmacy assistant – full-time Pharmacy assistant position available in a neighbourhood-oriented retail pharmacy in Crystal Mall, Metrotown area. We are proud of our top level of customer service, hence, we have very good rapport with our clients. Potential candidate must possess a pharmacy assistant program

28

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Dec/Jan 2014

Open Monday to Friday 9am-5:30pm, no weekends or holidays. Full benefit package, RRSP contribution, College fees, and liability insurance included. We are looking for someone who is compassionate, empathetic, patientfocused, and inter-collaborative with other health care providers. Please send resumes to Missagh Manshadi, owner/pharmacy manager

www.bcpharmacy.ca

Pharmacy technician – full-time The role of the pharmacy technician is to aid the pharmacy in the production of prescriptions, provide optimal customer service, and participate actively in growing prescription and OTC sales. Candidates must have registered

pharmacy technician certiďŹ cation and maintain registration with the CPBC. Please send resumes to kay.sajid@loblaw.ca or apply online at www. drugstorepharmacy.ca. Fax 1.866.628.5329 or please call 1.905.216.6010.

LADYSMITH Pharmacist â&#x20AC;&#x201C; full-time Full-time pharmacist position available in our busy community dispensary on Vancouver Island.

Full technician coverage and double pharmacist coverage most hours during weekdays. Full clinical services offered. Varied duties including medication reviews and community presentations.

Competitive salary and beneďŹ ts including potential for ownership. Please send resumes to Steve Robinson, owner, at steveer217@gmail.com or please call 250.714.5590.

MAPLE RIDGE Pharmacy manager â&#x20AC;&#x201C; full-time We have an immediate opening for a pharmacy manager with great prospects. We are a compounding pharmacy attached to a medical clinic with great opportunity to perform many clinical tasks and work closely with doctors. This is a very good position for someone with at least two years of pharmacy experience in Canada and experience with Kroll computer software. We are open until 6pm and closed on Sunday and

statutory holidays. We have a very professional and friendly work environment and offer a great compensation package including proďŹ t sharing with the right candidate. We believe only a win/win formula with all staff is sustainable so if you want to talk more about this, please send your resume via email to info@medlandia.com or please call 604.465.3375.

NANAIMO Pharmacist â&#x20AC;&#x201C; full-time London Drugs has a full-time opportunity in Nanaimo. Join a clinical and patient-focused team using the latest robotic dispensing machines plus counselling booths and counselling rooms.

Competitive salary and compensation packages, scheduled meal breaks and opportunities to advance to roles such as travel medicine, longterm care, pharmacy management, CDE, injection pharmacist and patient care pharmacists. Please send resumes to Shawn Sangha, Rx operations manager, at ssangha@londondrugs.com or fax 604.448.1075.

NEW WESTMINSTER Pharmacy manager â&#x20AC;&#x201C; full-time Medicine Shoppe Pharmacy #142 is looking for a pharmacy manager to lead our dynamic team.

The pharmacy is the designated renal pharmacy for New Westminster and works very closely

with the renal department at Royal Columbian Hospital. The pharmacy manager is responsible for managing pharmacy operations and maintaining a professional working relationship with pharmacy staff as well as doctors and nurses both in the building as well as in the dialysis unit at Royal Columbian Hospital. The pharmacy manager will be required to work Monday to Friday, 9am to 6pm. See attachment at www.bcpharmacy.ca/jobs for responsibilities and required skills. BeneďŹ ts include competitive salary and bonus structure.

Interested applicants should send their resume by fax to 604.521.9614 or email nimishavirani@gmail. com. Applicants will be contacted for interviews.

PENTICTON Pharmacist â&#x20AC;&#x201C; part-time London Drugs has a part-time opportunity in Penticton. Join a clinical and patient-focused team using the latest robotic dispensing machines plus counselling booths and counselling rooms.

Competitive salary and compensation packages, scheduled meal breaks and opportunities to advance to roles such as travel medicine, longterm care, pharmacy management, CDE, injection pharmacist and patient care pharmacists. Please send resumes to Shawn Sangha, Rx operations manager, at ssangha@londondrugs.com or fax 604.448.1075.

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www.bcpharmacy.ca

Dec/Jan 2014

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POWELL RIVER Pharmacist – full-time Westview Pharmacy, a locally owned and operated independent pharmacy adjoining a medical clinic, is seeking an enthusiastic, motivated, adaptable and customer-centred pharmacist.

Working in unison with our team, you will provide professional advice and knowledge to customers on their prescriptions and OTC products. We offer a professional and well-respected work environment with competitive wages and a comprehensive benefit package, not to mention great work hours – closed evenings and Sundays.

For further information or to submit your resume, please contact us at westviewpharmacy@shaw.ca.

We thank all candidates for their interest and wish to advise that only those applicants selected for an interview will be contacted.

PRINCE GEORGE Pharmacist – full-time

Pharmacy manager needed for independent community pharmacy. Friendly environment. We offer a competitive wage. Must be able to work some weekends. Please send resumes via fax to 604.543.4433 or please call 604.543.6677.

Pharmacist – part-time Part-time pharmacist needed for independent community pharmacy. Friendly environment, flexible shifts and no evenings. We offer a competitive wage. Must be able to work some weekends. New grads welcome! Please send resumes via fax to 604.543.4433 or please call 604.543.6677.

Part-time or full-time pharmacist position, Monday to Friday, no evenings. Wages commensurate with experience. East End Pharmacy in Vancouver. Please fax 604.255.9815 or call Raj at 604.255.9890.

Pharmacy assistant – full-time We are looking for a self-motivated, wellorganized, efficient pharmacy assistant to join our team. Must work well under minimal supervision; handle pressure well and be able to work as a team player; take initiatives and prioritize your workload; and work independently. Duties include handling cash register. Second language preferred, but not required as long as fluent in English. Must have strong and efficient technical skills as this position is fast-paced. Experience in compounding and auto/pac med is an asset. Must be willing to work between two stores if required (Cambie and 41st and a new location opening December on Main St. at 1st). Skytrain stations within one block of both locations. No phone calls about this job posting. Please send resumes to ymm@yyoung.com or fax 604.324.1727.

London Drugs has a full-time opportunity in Prince George. Join a clinical and patient-focused team using the latest robotic dispensing machines plus counseling booths and counseling rooms.

Competitive salary and compensation packages, scheduled meal breaks and opportunities to advance to roles such as travel medicine, long-term care, pharmacy management, CDE, injection pharmacist and patient care pharmacists. Please send resumes to Shawn Sangha, Rx operations manager, at ssangha@londondrugs.com or fax 604.448.1075.

SALMON ARM Pharmacy assistant – full-time Pharmasave in Salmon Arm is actively seeking the right individual to join our dispensary team as a full-time pharmacy assistant. Candidates must have outstanding communication and customer service skills. The position is for a Tuesday to Saturday schedule and is available immediately.

Please call 250.832.2111.

SALT SPRING ISLAND Pharmacist – full-time Pharmasave on Salt Spring Island has an opening for a full-time pharmacist. If you dream about living in one of the most vibrant and beautiful Gulf Island communities in British Columbia while still maintaining an interesting and rewarding career, then you should consider joining our team of experienced and dedicated professionals. We offer a competitive compensation and benefits package and the opportunity for a truly great lifestyle.

Our standards are high and we aim to offer our customers the best service and pharmacy counseling available. Come and find out why The

Dec/Jan 2014

Pharmacy manager – full-time

Pharmacist – full-time or part-time

Pharmacist – full-time

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SURREY

VANCOUVER

We’re seeking an enthusiastic, self-motivated pharmacist to join our dispensary team.

Additionally the applicant will be licensed, injection certified and have operational knowledge of the HWNG computer system. We are an 8am to 10pm, seven day a week operation, so a flexible working style is necessary. If you are interested in this opportunity, please email your application to Steve Leong, associate owner, at asdm2226@shoppersdrugmart.ca; fax 250.964.1884 or please call 250.964.1888.

30

New York Times calls Salt Spring Island one of the “gems” of the Pacific Northwest. Please send resumes to gary@saltspringpharmasave.com or please call 250.537.5534.

VERNON Pharmacy technician – full-time The role of the pharmacy technician is to aid the pharmacy in the production of prescriptions, provide optimal customer service, and participate actively in growing prescription and OTC sales.

Candidates must have registered pharmacy technician certification and maintain registration with CPBC. Please send resumes to kay.sajid@loblaw.ca or apply online at www.drugstorepharmacy.ca. Fax 1.866.628.5329 or please call 1.905.216.6010.

VICTORIA Pharmacist – full-time Dedication to the health and well-being of our customers and patients is at the core of our business. We offer excellent base salary rates, annual bonus opportunities, full benefits package, educational allowance, paid med checks and career growth opportunities. Qualifications: pharmacy license to practice in BC, experience

www.bcpharmacy.ca

in retail pharmaceutical systems and dispensing procedures, exceptional communications and organizational skills, strong patient satisfaction orientation, ability to maintain optimum balance between the profession and business of pharmacy, strong problem solving and analytical skills, and the ability to work productively as part of a dynamic, fast-paced team. Please send resumes via email to Neerav Joshi, Manager, pharmacy recruitment & retention, at njoshi@rexall.ca.

Pharmacist – full-time We are seeking a full-time pharmacist to join our Peoples Drug Mart location in Victoria, BC. Our store has an elderly population base and is located adjacent to physicians’ offices and walk-in medical clinics. We are seeking the following skills: ability to work collaboratively with physicians and staff; ability to counsel patients on the use of OTCs; ability to perform medication reviews; and ability to communicate effectively with elderly patients. Candidates with injections authority are encouraged to apply. Please send resumes to sunil@sparklit.com or please call 250.818.1468.

Pharmacist – part-time Pharmacist required to work at Victoria Peoples Pharmacy, owned and operated by Naz Rayani.

We are looking for an engaged, clinically-oriented outgoing, part-time pharmacist to work at our unique community pharmacies. Our focus is on patient-centered practice with a desirable and friendly population. All applications are confidential. Compensation is commensurate with experience. Please send resumes to jobs@victoriapharmacy.com.

Pharmacy technician – full-time Pharmacy technician required to work at Victoria Peoples Pharmacy, owned and operated by Naz Rayani. Our focus is on patient-centered practice with a desirable and friendly population. All applications are confidential. Compensation is commensurate with experience. Please send resumes to jobs@victoriapharmacy.com.

Pharmacy technician – full-time Victoria Rexall has an immediate opening for full-time pharmacy technician. We offer a very competitive compensation package. Please send resumes to njoshi@rexall.ca or apply online at www.rexallcareers.ca.

WEST VANCOUVER Pharmacy assistant – part-time Pharmasave in The Village at Park Royal is seeking a reliable, outgoing pharmacy assistant to greet customers, receive prescriptions/ obtain client information, and assist with compounding, compliance, packaging, cash and other duties as required. Previous experience or recent graduation from a pharmacy assistant program is essential, along with excellent written and spoken English. Experience in Kroll and specialty compounding is beneficial but not mandatory. Candidates must possess strong interpersonal skills and have a commitment to providing exceptional customer service in a team environment. We offer competitive compensation and an excellent work environment. Please send your resume via email only to pharmacist@prvpharmasave.com.

OPPORTUNITIES ACROSS BC

BUSINESS OPPORTUNITIES

FRASER VALLEY

Rewarding ownership opportunity â&#x20AC;&#x201C; Surrey

Pharmacist â&#x20AC;&#x201C; full-time

Enjoy the best of both worlds and be in business for yourself instead of by yourself. Unique business opportunity for the right person.

Seeking a pharmacist/partner for Surrey, BC area.

Phone 604.543.6677 for further details.

Forewest Holdings is currently recruiting for a staff pharmacist for the Fraser Valley region. We are looking for a pharmacist with an entrepreneurial spirit who is detail-oriented and committed to clinical pharmacy practice.

Pharmacists with injection training and a commitment to performing medication reviews and other pharmacy services are encouraged to apply. Interested applicants are requested to send their cover letter and resume by email to Sameer Premji, pharmacy operations coordinator, at spremji@forewest.ca. Short-listed candidates will be contacted for interviews.

NORTHERN BC Pharmacist â&#x20AC;&#x201C; full-time, relief Dedication to the health and well-being of our customers and patients is at the core of our business. We offer excellent base salary rates, annual bonus opportunities, full beneďŹ ts package, educational allowance, paid med checks and career growth opportunities. QualiďŹ cations: pharmacy license to practice in BC, experience in retail pharmaceutical systems and dispensing procedures, exceptional communications and organizational skills, strong patient satisfaction orientation, ability to maintain optimum balance between the profession and business of pharmacy, strong problem solving and analytical skills, and the ability to work productively as part of a dynamic, fast-paced team. Please send resumes via email to njoshi@rexall.ca or apply online at www.rexallcareers.ca.

Are you thinking of selling your pharmacy?

OVERWAITEA FOOD GROUP may be interested.

If you would like more information contact us at pharmacybuyer1@gmail.com.

At PHARMASAVE we understand that you want to be in business for yourself, not by yourself.

You can have the best of both worlds! Maintain your freedom and independence while having access to Pharmasaveâ&#x20AC;&#x2122;s proven products, programs and strong national brand. Pharmasave is a true cooperative, 100 per cent member owned and governed. BeneďŹ t from owning your own business and share in the economic advantages of a 400+ strong group of stores. Be an owner in an organization that delivers all of its proďŹ ts directly back to you, the shareholder.

Pharmasaveâ&#x20AC;&#x2122;s only priority is you and your success! If you are interested in purchasing a pharmacy or planning to sell your business, please contact Dave Reston, CEO Pharmasave PaciďŹ c, phone 604.575.5730 or 1.800.665.3344 or email dreston@pharmasavebc.ca.

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BCPhA Director, Pharmacy Practice Support The BCPhA is seeking a Director of Pharmacy Practice Support (formerly the Director of Professional Services). A member of the Associationâ&#x20AC;&#x2122;s leadership team, the Director develops and implements strategies and programs that support pharmacy practice in BC. The candidate must have a track record in ongoing risk assessment, and be able to lead the development of policy recommendations related to the delivery of pharmacy services that will be presented to public and private payers.

They must be a registered pharmacist with the CPBC and conversant in all aspects of community pharmacy including senior operational experience, negotiations and panCanadian pharmacy initiatives.

Pharmacy is in a time of great change, and the BCPhA is seeking a passionate professional who can hit the ground running in taking on the challenge of providing leadership for members.

In response to the changing environment and based on input from BCPhA members, the department of Professional Services has been re-named Pharmacy Practice Support.

This better reďŹ&#x201A;ects the departmentâ&#x20AC;&#x2122;s work, ranging from leadership on the development of strategic opportunities in pharmacy to providing direct assistance to members dealing with adjudication issues.

To learn more, visit www.bcpharmacy.ca.

Deadline for applications closes December 31.

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A voice for community pharmacy