NEWSLETTER FOR NH PHARMACY PROFESSIONALS Prescription Drug Monitoring Program (PDMP)

NEWSLETTER FOR NH PHARMACY PROFESSIONALS Volume 4, Issue 3

2014

Distributed as a service to the professionals of pharmacy

Prescription Drug Monitoring Program (PDMP) Went Live October 16, 2014

than 20 states including our neighbors in Maine and Vermont.

The NH PDMP began operating on October 16, 2014. Based on RSA 318-B:31, this means that all prescriptions for Schedules II-IV that are dispensed, shall be reported to the program. The intent of the program is to reduce the abuse, overuse, and diversion of controlled substances. It will also assist prescribers and dispensers (pharmacist) determine the legitimate pain needs of their patients versus the increasing challenges surrounding diversion and abuse. When the program launched in October, data as far back as March 1, 2014 was preloaded into the system. New Hampshire is the 49th state to initiate this type of program, and its operational parameters are somewhat unique to this state.

HID began assisting with the registration process of pharmacists this Fall. This process involved the PDMP (through the vendor, HID) sending out credentials for each pharmacist. The pharmacist was then assigned a USER ID and initial password. The password was then personalized and changed in a fashion similar to the process used by online banking or other websites. Once established, the pharmacist is able to access the PDMP during the dispensing process, and use his or her best professional judgment regarding any intervention. Certain chain pharmacies may also have their own IT groups assist with registration centrally; however, that has not been finalized.

In May, the Board of Pharmacy’s Advisory Council interviewed interested candidates for the Director’s position and unanimously chose Michelle Ricco Jonas to lead the project. Ms. Ricco Jonas brings a wealth of project management skills and experience in health related state and local government initiatives. The PDMP office resides in Concord, NH at the Board of Pharmacy located at 121 South Fruit Street. You may contact by telephone (603) 271-6980, fax (603) 2712856 or by email at [email protected]. New Hampshire has contracted with Health Information Designs, LLC (HID) as a vendor to develop a prescription database and help move the project forward. HID is a nationally recognized leader in automated healthcare solutions and also serves more

What’s next? At this point, we need to look at ways to tweak the program due to the ongoing dynamics of the environment. Some grants and funding options dictate certain requirements for extension of the monies needed to sustain the program. This means that we need to look at ways to satisfy that grant requirement by including changes involving, for example, interstate data sharing. Most changes of this type will require the introduction of new legislation and additional rulemaking. The success of this program depends upon one factor, and that one factor is using it! If pharmacists use the program as it was intended, then its success will be assured.

The NH Med Bank, formerly known as NH Rx Connects, is New Hampshire’s only first and only charitable pharmacy. Their mission is to provide medication access to New Hampshire residents who cannot afford them and reduce medication waste. NH Med Bank is currently seeking volunteer pharmacists. If you wish to find out more information, please call or email the Program Coordinator, Dan Walsh, at (603) 415-4258 or at [email protected] NH Pharmacy News 1

NHPA Board Members:

Help us, help you! As an organization, NHPA is working on your behalf to ensure the protection and advancement of the pharmacy profession. This is only possible through membership dues from pharmacists like you. NHPA board members volunteer their time on behalf of YOU! On December 7, 2014 NHPA will sponsor a CE program at SERESC in Bedford, New Hampshire. Topics include: Drug Diversion, NH BOP Update, Update in COPD, Pediatric GERD and Therapeutic Monoclonal Antibodies.

Check out NHPA’s newly redesigned website at www.nhpharmacists.net

Jay Calabro, President Lorraine Radick, Past President Cheryl Durand, Vice President Joel Brown, Treasurer Amanda Morrill, Secretary Cheryl Abel Andrew Brueckner (student) Maryann Cooper Christopher Lopez Don Messina Amanda Morrill Regan Sevinsky (student) Michael Viggiano Visit our website at: www.nhpharmacists.net Contact us by phone: 603.229.0292, option 1

NHPA is proud to be a member of the National Alliance of State Pharmacy Associations (NASPA) NHSHP Board Members: Regina Kavadias, President Jennifer Towle, President elect Kerri Johnson, Immediate Past President Tom Algozzine, Secretary Linda Horton, Treasurer Paul Belliveau Denise Boulais (CPhT) Dave DePiero Tina Genovese Marylou Kosmatka Dave LaCoste John Mini Molly Mortimer Ed Rippe Jane Rippe Diane Sadoski (CPhT) Laura Stewart (CPhT) Bob Theriault Elizabeth Wade Susan Ware Kristine Willett Visit our website at :www.nhshp.org Contact us by email: [email protected]

Cabin Fever CE Weekend is coming!! March 13-15, 2015 North Conway Grand Hotel Book your room now!

603-356-4200

Attendees will earn 5 hrs of LIVE CE, including 2 hrs of law, a presentation on multiple sclerosis a new clinical pearls session!

NHSHP is proud to be affiliated with the American Society of Health-System Pharmacists

NH Pharmacy News 2

Hydrocodone Rescheduling By: Melissa Tutu, Pharm.D. Candidate 2015

On October 6, 2014 the rescheduling of hydrocodone and hydrocodone combination products (HCP) went into effect. These products have moved from a schedule III to schedule II in the US federal register. According to The Controlled Substance Act, medications and prescription products with abuse potential fall into one of the four classes of schedules with schedule II including products with highest potential for abuse. Schedule II requirements, including security protocols, packaging and labeling, documentation and reporting, inventory count, DEA registration requirements, and now apply to these hydrocodone products. The FDA has proposed this change of schedule for almost ten years due to the drugs

addiction and abuse risk. The rescheduling of this medication is predicated to save the lives of hundreds. Many people, including health care providers, have opposed this schedule change. The DEA has received over 600 statements in opposition of the rescheduling. Organizations including the American Pharmacist Association, American Academy of Consultant Pharmacists, American College of Clinical Pharmacy, Academy of Managed Care Pharmacy, American Society of Consultant Pharmacists, National Alliance of State Pharmacy Associations, National Association of Chain Drug Stores, and National Community Pharmacists Association openly opposed the rescheduling. Some believe that even with rescheduling, drug abuse may not decrease. Rather, it may make it more difficult for those individuals with legitimate pain to get access to necessary medications. Zyhydro, hydrocodone extended release, is already a schedule II product. It will not be affected by this change.

In Memoriam John R. Mulkerron (August 28, 1939 - June 20, 2014) John R Mulkerron, 74, of New London, NH, devoted husband and father, died peacefully June 20, 2014 surrounded by his family. John was born in Boston and raised in Winthrop, MA. John’s pursuit of higher education began at Massachusetts College of Pharmacy where he earned his BS in pharmacy and graduated with honors. He then went on to earn his MBA from Northeastern University. His career began at the U.S. Food and Drug Administration as an inspector and later opened several retail establishments throughout the Boston area including Prudential Center Pharmacy, Center Plaza and Park Plaza Pharmacy. In 1990, he moved to NH as Director of Outpatient Pharmacy for the Dartmouth-Hitchcock Medical Center in Lebanon. John facilitated and led the opening of a successful outpatient hospital based Pharmacy, and his model has been replicated in many

hospital outpatient pharmacies. After his retirement in 2007, John continued his to work in pharmacies throughout the Sunapee Region, acted as a consultant for Planned Parenthood, and taught Pharmacy Technician classes at Lebanon College. John was able to find the time to volunteer as an active member of the Board of Health for both Lynnfield and Boxford, MA. In addition, he lovingly spent thirteen years building a stunning Friendship Sloop sailboat with his father in law that is still sailing on the Chesapeake Bay. He was an active member of the NH Pharmacists Association, American Pharmacist Association, and the NH Society of Health-System Pharmacists. John also was an avid historian and expert on World War II. Although John’s business endeavors and other efforts were successful, his most notable legacy is the family that he was so immensely dedicated to; the lessons he left each member of his family about respect, loyalty, tolerance, and unconditional love will live on forever. Expressions of sympathy may be made in John’s name to the Jimmy Fund. NH Pharmacy News 3

Synthetic Marijuana

Summary of New Recommendations for Pneumococcal Vaccines

By: Melissa Tutu, Pharm.D. Candidate 2015

The use of synthetic marijuana has been increasing in the Granite State in the last several months. In response, Governor Hassan issued a state of emergency. Dozens of people have been seen in the emergency department due to overdoses of the popular drug. The item was originally created and marketed for its sweet fragrance as a potpourri. However, the item was found to create a feeling of euphoria when smoked or ingested. “Smacked” or “Spice”, as many call it, was available at many convenience stores. In the past month, law enforcement officials throughout the state have raided convenience stores and gas stations to search for the drug to make sure that this item was off the streets. What is Spice? “Smacked” or “Spice” is a mixture of spices and herbs covered and sprayed with a chemical compound that is similar in structure to tetrahydrocannabinol, the active ingredient in marijuana that causes the individual to be in the state of euphoria or altered mental status. Side Effects Inappropriate use of the product such as smoking or ingesting can cause various symptoms such as suicidal thoughts, hallucinations, confusion, seizures, agitation, paranoia, fatigue, nausea and vomiting, increase heart rate and blood pressure, pale skin color, bloodshot eyes, and tremors. In some severe situations, inappropriate use of the drug can cause brain damage and even blindness. The package of this product does indicate “NOT FOR HUMAN CONSUMPTION.” Spice binds to the same receptors as tetrahydrocannabinol but does so with stronger affinity, causing a greater pharmacologic effect. As a pharmacist, it is always wise to educate your patients on hazards to the community. For more information regarding clinical management, please call the Northern New England Poison Center at 1800-222-1222.

By: Hayam AlRasheed, Pharm.D. Candidate 2015

Pneumococcus (Streptococcus pneumoniae) is a leading cause of infectious disease and can lead to pneumonia, bacteremia, and meningitis. In order to reduce the number of infections, the 7valent pneumococcal conjugate vaccine (PCV7) has been used since 2000. Another vaccine, 13-valent pneumococcal conjugate vaccine (PCV13), has been in use since 2010. The two vaccines have resulted in a reduction of pneumococcal infections. According to Centers for Disease Control and Prevention (CDC), cases of invasive pneumococcal disease (IPD) have declined approximately 50% in adults over the age of 65 years of age for serotypes unique to PCV13 relative to what was observed before 2010 when PCV7 was replaced by PCV13 in pediatric immunization schedule. Despite the reduction, cases of IPD that occurred among adults of 65 years and above still came to approximately 13, 500, in 2013. According to the CDC, an estimated 20% - 25% of invasive pneumococcal disease (IPD) cases and 10% of community-acquired pneumonia cases in adults ages 65 years and above is as a result of PCV13 serotypes, which can be averted by using PCV13 for the population. In 2013, 38% of IPD cases in adults ages 65 years and older were also found to have been due to serotypes that were unique to 23-valent Pneumococcal Polysaccharide Vaccine (PPSV23). As a result, the Advisory Committee on Immunization Practices (ACIP) has changed their recommendations for pneumococcal vaccination in adults. ACIP now recommends that both PPSV23 and PCV13 should be administered routinely to all adults that are aged 65 years and above. This is a broad measure that aims to prevent IPD cases that are as a result of serotypes unique to either PCV13 or PPSV23. The vaccines should be given in a series. PCV, Continued on page 5

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Ebola Outbreak By: Melissa Tutu, Pharm.D. Candidate 2015

The 2014 Ebola outbreak is said to be one of the largest infectious disease outbreaks to hit the globe; it is also West Africa’s first outbreak. The US is known for its diverse and unique population, hailing citizens from all over the world, including the West African nations of Nigeria, Liberia, Ghana, Sierra Leone. Thousands travel back and forth from the US every year to visit their country of origin. This may pose a threat to the US. Already there have been missionaries returning to the US from their field work in West Africa who have been infected by the Ebola virus. What is Ebola? The Ebola virus causes hemorrhagic fever that can be deadly. The virus requires 8 to 21 days for incubation. Researchers believe that many patients became infected through direct contact with an infected animal or from consumption of meat from an infected animal. Once the virus has infected a human, it is easily transmitted via direct contact. This may include contact of broken skin or mucous membranes of the non-infected patient or mucous membranes come into contact with infected bodily fluids, such as urine, semen, feces, vomit, or saliva. Are you at risk? People such as family and friends of the Ebola infected individual along with healthcare providers are at the highest risk for the transmission of the virus because they may come into contact with the infected patients bodily fluids or blood. At a health care facility, the virus can be spread. Hence, proper protective equipment and sterilization procedures are essential. What’s the pharmacist’s role? Infected patients may come to the pharmacy seeking advice from a pharmacist on their symptoms. The patient

may report symptoms such as fever, diarrhea, vomiting, weakness, headache, abdominal pain, red eyes, bleeding, or raised rash. Pharmacists play an important role, as they remain the number one most accessible healthcare professional. Pharmacists also should follow safety procedures at their pharmacies. For instance, sterilizing blood pressure cuffs before and after each patient use. Be sure to educate your patients on how severe this infectious disease is. Simple educational poster boards go a long way. These boards can present information on what Ebola is, how it is contracted, and signs & symptoms that are usually exhibited. Other ways to educate patients include providing general Ebola information and prevention measures, which include avoiding contact with body fluids and blood, making sure to practice good hygiene such as washing hands frequently, using hand sanitizers, and proper food handling and preparation. PCV, Continued from page 4

In cases where adults at 65 years and above have not been previously vaccinated, or their pneumococcal vaccination history is unknown, a PCV13 dose should be administered first, followed by PPSV23 after 6-12 months. These vaccines should not coadministered; administration must be separated by a minimum of eight weeks. In the case where a patient has been previously vaccinated with PPSV23, a dose of PCV13 should also be administered if it had not been given. A dose of PCV13 should be given at least a year after receipt of the last PPSV23 dose. In cases where an extra dose of PPSV23 is indicated, a subsequent dose of PPSV23 needs to be given 6-12 months after the administration of PCV13, and not less than five years after the latest dose of PPSV23. The recommendations by ACIP for regular use of PCV13 among adults of ages 19 years and above with immunocompromised conditions, cerebrospinal fluid leak, cochlear implants, or anatomic asplenia remain the same.

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Medication Safety Corner By: Elizabeth Wade, PharmD, BCPS

Clinical scenario: A patient was admitted to the hospital with chest pain. His past medication history from a nursing home medication administration record (MAR) prior to admission indicated the patient’s home dose of Xarelto (rivaroxaban), a new oral anticoagulant, as 15 mg PO daily. The Discharge Summary from this hospital listed the home does of Xarelto as 50 mg PO daily. Upon admission to the hospital, the admitting provider used the nursing home MAR to dictate the medication list, dictating 15 mg. However, transcription heard and transcribed 50 mg. Additionally, the discharge summary from the nursing home was used to enter the home medications on the patient’s home medication list. In order to make a Xarelto 50 mg dose, it was entered as Xarelto 10 mg tablets, dosed five tablets oral once daily at bedtime. The medication was held while the patient was in the hospital, so the patient did not receive any incorrect doses.

On the day of discharge, two astute providers reviewed the admission medication list, noted the dosing error, and corrected the dose to 15 mg. It is important to remember that because reports such as History and Physicals, Consults and Discharge Summaries are generally transcribed from a recording or dictation, there may be errors present. Actions: Sources of home medication information are now prioritized when generating the home medication list such that nursing home MAR’s are the most reliable source of information. Other medications reported to have been involved in “15” versus “50” mix-ups include insulin, oxycodone, and olanzapine, where 50 mg or units may be a more commonly believed dose. ISMP SAFE PRACTICE RECOMMENDATION: Verbal communications for drug doses should be stated the way pilots state numbers (“15 mg” is “onefive mg”). This method is especially important when stating doses of critical medications such as insulin. Records of medical dictations must be carefully checked by the practitioner who dictates them, especially drug doses. Practitioners giving dictation should assume that medical records won’t always be transcribed correctly. Other care givers should also be aware of the potential errors during the transcription process and always question doses that seem out of range or medications that do not “fit” or make sense with the patient’s current condition.

An Update on Federal Provider Status (H.R. 4190) The H.R 4190 bipartisan legislation which will amend the Social Security Act has now increased its number of cosponsors to over 120. APhA, ASHP, along with other members of the Patient Access to Pharmacists’ Care Coalition (PAPCC) have been working together on bill, which will recognize pharmacist as providers under Medicare part B. The PAPCC consists of 20 pharmacy organizations and was created to support federal policy proposals to allow state-licensed pharmacist to perform

services in medically underserved communities. A national advocacy campaign has begun and will continue with a new bill once the session begins in January. We urge you to reach out to your Congressmen and Sentator in support of H.R. 4190!

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DEA Final Rule on Disposal of Substances

By: Hayam AlRasheed, Pharm.D. Candidate 2015

The United States Drugs Enforcement Administration (DEA), in its quest to expand the available disposal options of unused, unwanted, or expired pharmaceutical controlled substances, has published the Final Rule which sets forth the implementation of the Secure and Responsible Drug Disposal Act of 2010. The implementation of the Final Rule permits authorized entities, for example manufacturers, reverse distributors, retail pharmacies, distributors, hospitals with on-site pharmacies, and narcotic treatment programs (NTPs) to collect substances for disposal purposes. The Final Rule, implemented on October 9, 2014, aims to prevent and reduce prescription drug abuse. The DEA, under the Final Rule, required DEA registrants to modify their registration so that they become authorized collectors. The DEA has expanded its registrants to include NTPs as well as hospital or clinics with on-site pharmacies. The expanded registrant categories provided more options for ultimate users hence contributing to secure, safe, responsible and convenient disposal of unwanted controlled substances. NTPs are required to have collection receptacles in rooms that are securely locked, have controlled access, and do not have other controlled substances. The requirements are a security measure necessitated by the nature of health care provided in NTPs. NTPs and other collectors are not allowed to collect schedule 1 controlled substances, and the collectors have to ensure that illicit substances are not collected inadvertently. Clinics and hospitals with on-site pharmacies permitted to be collectors will be

required to maintain receptacles in their registered centers, and will conduct mail-back programs. DEA registrants are not allowed to use collection receptacles for disposal of unused controlled substances that are in their inventory. The security measures provided will discourage diversion in the unique circumstances of hospital/clinics and NTPs. Changes in the Final Rule also ensure that LongTerm Care Facilities (LTCFs) have enough disposal options that expand disposal opportunities for its residents. The law has permitted retail pharmacies and hospitals or clinics to have collection receptacles at affiliated LTCFs. For security purposes, the DEA requires retail pharmacies and hospital/clinics to store inner liners in secured rooms that have controlled access for up to three business days after removal from collection receptacles in LTCFs. The collectors can also make storage of inner liners unnecessary by scheduling medication deliveries to coincide with transfer of liners for destruction. To avoid transportation of large consignments of controlled substances, the collectors should deliver liners to a registered distributor’s location or a reverse distributor using a contract or common pick-up. Collectors should also appoint a supervisor-level employee of the LTCF to oversee the removal and transfer of inner liners with an employee of the collector. The 14-day destruction requirement has been extended to 30 days to give the distributors and reverse distributors’ ample time to collect and destroy the substances. For practitioner's physical security, a clarification has been added to the existing rule. The rule restricts the storage of inner liners and mail-back packages that contain the collected substances to secure cabinets and locked rooms that have controlled access. Institutional practitioners and pharmacies are not allowed to store mail-back packages and inner liners by dispersing them in the inventory of non-controlled substances.

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Place your ad here! Full, ½ or ¼ page space available, contact LorrainePharmacy by emailTime at [email protected] Capsule 2014 (Third Quarter) Pharmacy Time Capsule 1989 There were 74 accredited colleges of pharmacy in the United States (including Puerto Rico). 1989 graduates figures included: 5721, BS; 836 PharmD (1st professional degree); and 222 PharmD (2nd degree). The conservative Heritage Foundation published "Assuring Affordable Health Care for All Americans," which called for a mandate to purchase health insurance. Losec (omeprazole) was first marketed in U.S. by Astra. In 1990, FDA required name change to Prilosec to avoid confusion with Lasix. 1964 1964 graduates figures included: 2029 BS and 166 PharmD (1st professional degree). Keflin (cephalothin sodium, Lilly) was the first cephalosporin to be marketed in the Unites States. Average cost of prescription was $3.41 Luther L. Terry, M.D., Surgeon General of the U.S. Public Health Service, released the first report of the Surgeon General's Advisory Committee on Smoking and Health linking cigarette smoking to lung cancer and other lung problems. 1939 The first Blue Shield plan was begun as an insurance to cover physicians’ fees. 1914 Cocaine, used in many patent medicines and tonics, was widely available in pharmacies and other retail establishments until banned in 1914. By: Dennis B. Worthen, PhD, Cincinnati, OH One of a series contributed by the American Institute of the History of Pharmacy, a unique non-profit society dedicated to assuring that the contributions of your profession endure as a part of America's history. Membership offers the satisfaction of helping continue this work on behalf of pharmacy, and brings five or more historical publications to your door each year. To learn more, check out: www.aihp.org NH Pharmacy News 8