Healthy Aging in a 103 Year Old Customer
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Most Pharmacies have a patient (or more) that is a centenarian.  Living to the age of 100 is quite an achievement, considering these patients grew up and lived the prime of their lives in an era that had a healthcare model quite different from today.  Knowledge of how diet, exercise, nutrition and medicine interplay to result in a long life wasn’t as advanced as it is today.  Some may say the diet 100 years ago was superior to today’s diet.  They probably wouldn’t be wrong.  Sanitation, pasteurization, and crop control were at a different stage at this point in time than they are today.

I had the pleasure of sitting down with Margaret MacPhee, 103 years old from Baddeck, Nova Scotia recently to ask her what her life experiences that may have helped get her to this age.  In an interview that was hopefully not patronizing, she opened up about her life from childhood to today.

Margaret was born at home during the wintertime of 1915 and grew up in a house in Upper Baddeck (Big Baddeck) the fourth oldest child in a family of 11.  She wonders how she managed to be living at all growing up back then let alone survive to be 103.  Her house had no electricity or phone and was heated from one central stove.  Her father was a farmer and her mother “had lots to do with all the children”.  This was not uncommon for the families that grew up in the area as every family seemed to be large.  She went to school in Upper Baddeck for 11 years then went out working from home to home in the area doing housework.  She was married to Charles D MacPhee in 1946 until he passed away in 1992.  They had one daughter (Catherine), a large difference from her family size growing up.

Margaret didn’t smoke or drink alcohol during her life.  She didn’t recall taking any type of vitamin or herb growing up.  As a child she doesn’t directly recall most of the healthcare or medicine of the time.  She recalls early in her life coming home from Sydney and then coming down with Scarlet Fever.  She doesn’t remember what Dr MacMillan gave her at that point but she survived this.  She clearly tells about being quarantined alone in her room where her mother soaked a blanket and hung it in the doorway of the room to keep the germs from spreading to the rest of the house.  Given the lack of modern day entertainment sources for children back then, it must have been a lonely time for Margaret during the long hours of the days and nights while she recovered.  No one else came down with the disease in the house.  She also had measles and as well had whooping cough, which she recalls almost dying from.  She lost a brother to the whooping cough (a twin of another brother).  Another brother died from croup at a just a few months old.  There were no vaccines at this point for them of course and routine visits to the doctor weren’t all that common unless there was a need.  Given the lack of antibiotics and vaccines back then, childhood was a journey with pitfalls not seen today that made it more of an accomplishment to get to adulthood than it is now.

When asked of her sleep habits she says, “now I’m sleeping all the time.  If I lay down at all I’m asleep!”  She says living as a young girl on the farm you were up early to do your chores and then get ready for school.  When you came home you started into the chores again.  There were three meals a day, breakfast and supper and home and lunch was taken to school.  Food eaten back then was grown on the farm.  Herring and codfish were also staples as were beef and pork from the farm.  Whole food was the norm. Processed and ultra-processed food we see today weren’t the food choice back then living on the farm.

Margaret isn’t one for social media, and as mentioned,growing up they had no phone.  They burned kerosene lamps for light at night.  Electricity wasn’t something she had in a home until she got married and moved out on her own.  One of the biggest differences between then and now was the direct social network everyone had.  There wasn’t a night in the winter regardless of how stormy it was, that there weren’t people over at the house.  Family or friends and neighbors would visit until 11:00 at night every night.  A common activity was playing cards and it wasn’t uncommon for visitors to travel with snowshoes back home.  Picturing what it would be like with no power or contact with the anyone (TV, cell phone, social media, email or texting) makes it more understandable how long evenings were passed with groups of visitors every day. She says there isn’t anything like this today.  In fact we have seen survival rates from some diseases like cancer have a better survival rate when the patient has a better direct social network available to them.  If there was a storm, there were no plows but for two days after the storm everyone would be out with their horse and sleighs making a path on the road.

One of her earliest recollections in the house was a day when her father was out working, perhaps out in the woods, and her mother was out doing chores outside of the house briefly at noon.  She was left in the house with her two older brothers, one of them being in charge while she was out.  She recalls it being a stormy day, her mother was out feeding the animals and when she came out of the barn she smelled smoke.  Looking in the direction of the house her mother saw smoke coming from the house and chimney.  Her father smoked and instead of using matches he would use long thin sticks to light his pipe that he lit in the fire.  Her babysitting brother found some of these laying around and grabbed one and put it in the fire.  There was an open chimney behind the stove with bark, kindling, and papers in it.  He threw the stick in the chimney causing everything in it to catch fire.  By the time her mother made it back to the house, her brother had taken the younger brother out of the high chair and ran with him into the bedroom off of the kitchen and closed the door, leaving Margaret crawling around on the floor.  When her mother got to Margaret she was almost to the blazing chimney.  Her mother had her hands full.  

Today only two sisters, Agnes (Baddeck) and Marion (Sydney) are still alive.  Marion’s daughter was raised for a while by Margaret’s mother when Marion went to Sydney to work, so she thinks of her as a sister.  Her siblings lived to be in their 70’s for the most part.  Her mother died 4 months shy of her 100th birthday.  Margaret remembers her mother as being a hard working woman.  She wasn’t a nurse but she feels she could have been and would help deliver babies, was good around animals and people.  Her father passed away of a heart attack at 69 years of age.

In looking at what contributes to Margaret’s long life, we can certainly attribute her DNA passed down by her mother as being a major contributing factor.  There wasn’t a lot of money to go around the family growing up, but like the other families in the area they got through it.  Living on whole unpasteurized milk (not recommended today), curds, butter, cream, butter milk, vegetables and fresh farm raised meat.  Today she eats a little differently, margarine and 2% milk, and some processed food she might heat up in the microwave.  Aside from being forgetful with names, she is still quite active and comes into the pharmacy regularly.  A good sleep habit and regular physical activity are undoubtedly helping her to age in a healthy manner.  As a child and an adult, she had no cell phone to keep her up at night disrupting her sleep.  Finally, a strong network of other contacts that she regularly saw reflects the results we’ve seen in longevity from other studies.

Margaret has no major regrets looking back.  She supposes back growing up there were a lot of regrets of what she had to do but nothing lasting.  She recalls a story of two men in their 80’s for how she feels of this stage of life. One says to the other how great he feels and wakes up everyday wanting to take on the world.  The other one says he feels just the opposite.  He feels like a baby, “I have no hair, no teeth, and I just wet myself”.  Margaret also has a good sense of humor.

I’d like to thank Margaret for yet another down to earth talk with her and her willingness to share her experiences with everyone.  

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Pain Relief With Omega-3
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Omega 3 supplements have been taking a beating lately with regard to cardiovascular outcomes. One thing that we have seen is the questionable cause and effect of the wide variety of commercially available Omega 3 supplements available on the market and the dose required for any effect at all.

Clinically, one indication I see Omega 3 supplements used for successfully is pain relief. It works along the same pathway as anti-inflammatory medications. But what does the evidence tell us about the effectiveness of such supplementation in an era where vitamins, herbs and supplements are more and more becoming a punching bag for quackery? Is there hard evidence for treating pain without the use of (oral) NSAIDS, opioids, muscle relaxers, antidepressants, counterirritant rubs, and anticonvulsants? Transdermal pain compounding comes to mind, but is there an OTC product you can start today in giving your customers to begin safely reducing their pain?

First of all you need to set expectations. If you are someone in chronic daily pain, you need to be upfront with them as a pharmacist by telling them that 100% pain relief is not a concept that we entertain. Your discussion with goal setting with them should inquire what they want to get out of this. Most patients in chronic pain don’t necessarily need to be pain free, they have learned for years how to live and cope with pain. What they may share with you is the desire to play with their grandkids, to go to church with their spouse, to go for a walk with their dog every day, or to just simply get out of bed and make a meal for themselves.

There have been a number of pain patients I can recall who have claimed that by taking this one supplement, they are able to do some of these activities. As evidence-based healthcare practitioners, we must strike a balance between following anecdotal evidence we’re presented with in the pharmacy and using the invaluable clinical evidence we see as healthcare professionals that really no one else sees. This balancing act inevitably involves stumbles where we fall for an N of 1 to strongly and apply it to everyone we speak to. In other moments of clarity, we look back at the results of our recommendations and accumulate a non-trial-based clinical judgment that we feel strong enough about to make recommendations for in the front store.

Recommendations to use Omega 3 supplementation in relieving pain are based on good quality evidence. When we look at the use of Omega 3 with rheumatoid arthritis (RA) specifically, it is important to reinforce with patients (and to ourselves as pharmacists) that this is not meant to replace what we use conventionally. Disease modifying antirheumatic drugs (DMARDS)should not be dropped in favor of Omega 3 supplementations. In fact DMARDS can help induce the remission of the disease when used early. They can, however, be used in conjunction with them.

Being a disease connected with the immune system, rheumatoid arthritis treatments that work with the body’s immune system are an attractive way to combat the problem. Omega 3 has been shown to affect our immune system. Arachidonic acid, which is an omega 6 product, flows into pathways that create inflammatory molecules which are involved in rheumatoid arthritis, including inside immune cells. The EPA and DHA in marine Omega 3 supplements reduces arachidonic acid. They follow a pathway which results in anti-inflammatory products and affects dentritic cell and T cell function. Additionally, it reduces reactive oxygen species by leukocytes and inflammatory cytokine production by macrophages. But the work on this area and how it pertains directly to RA is less understood. (1)

In a systemic review of 23 studies of Omega 3 use, modest but fairly consistent benefits were seen in relation to joint swelling, pain, the duration of morning stiffness, and the global assessments of pain and disease activity.(1)  There was also a benefit in the amount of NSAID therapy used in these patients.

In explaining just how omega 3 has a cause and effect relationship with RA and how studies show that it helps to reduce pain, we look to the similarity in effect between NSAIDS and Omega 3 in the body. Prostaglandin E2 (PGE2) is involved in all processes leading to the classic signs of inflammation (redness, heat, swelling, pain and edema). (2) A typical NSAID blocks the production of Eicosanoids including several prostaglandins as well as thromboxane proinflammatory products involved in pain and inflammation. Omega 3 reduces the production of mainly PGE2. Therefore you get the benefit of reduced pain and inflammation while avoiding the other problems with NSAIDS on the stomach. Unfortunately, the blood thinning still occurs, so those at risk for bleeding or on blood thinners need to be mindful of this. In reducing the dose of Omega 3 to avoid this, patients may put themselves in a dose range that is ineffective for RA. As you may have guessed, Omega 6 supplements increase arachidonic acid which is responsible for the production of these pro-inflammatory products, so combination 3-6 or 3-6-9 products are not recommended.

Based on current data, doses above 2.7g per day of combined Omega 3 ingredients in the fish oil are required for this response, which may be delayed for two to three months before results are fully realized.(3)

A systematic review that looked at the effect of marine fish oil on the pain of arthritic disease determined that it did in fact reduce pain in that population (4). An excellent source for references comes from the Australian NPS MedicineWise from April of this year. Over all it lays out a number of encouraging studies that can put another tool in the pharmacist’s toolbox for helping your RA patient.

Looking back to our “front store experience N of 1 world,” Omega 3 supplementation and joint pain relief always remind me of my 101-year-old customer who reminds me that she wouldn’t be moving at all without this supplement.

Graham MacKenzie is a compounding pharmacist in Baddeck, N.S., and a graduate of Dalhousie College of Pharmacy.

References

  1. Miles EA, et al. Influence of marine n-3 polyunsaturated fatty acids on immune function and a systemic review of their effects on clinical outcomes in rheumatoid arthritis. Br J Nutr. 2012 Jun;107 Supp; 2:171-84
  2. Emanuela Ricciotti Et. al . Prostaglandins and Inflammation. Arterioscler Thromb Vasc Biol .2001 May; 31(5):986-1000
  3. Rees D, et al Dose-related effects of eicosapentaenoic acid on innate immune function in healthy humans: a comparison of young and older men. Am J Cin Nutr. 2006 Feb;83(2):331-42
  4. Senftleber NK et al Marine Oil Supplements for Arthritis Pain: A systematic Review and Meta_Analysis of Randomized Trials. Nutrients 2017.
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Stone’s Drug Store Discontinues Homeopathic Products

Stone’s Drug Store in Baddeck, Nova Scotia will no longer carry homeopathic products, citing a lack of clinical evidence about their effectiveness.

“Concerns have been raised about the effectiveness of homeopathic products,” said Graham MacKenzie, pharmacist and owner of Stone’s Drug Store. “This led me to review the clinical evidence and I came to the conclusion that these products should no longer be sold at our pharmacy.”

Homeopathy was founded in Germany in the late 1700s and is based on the principle that “like cures like”.  The basic concept is that the substances that cause illnesses such as the cold, flu, sleep disturbances, allergies, headaches and baby teething discomfort, will, in diluted form help the body to heal the condition.

“While I can accept the merit behind “like cures like”, as this is the basis for many vaccines, the fact that these substances are so diluted raises concerns,” said MacKenzie. “If homeopathy products can relieve symptoms of so many conditions, how can it do so in such diluted concentration?  Where is the evidence?”

Over the past twenty years, the Cochrane Database of Systematic Reviews has conducted reviews of the studies and trials of homeopathic treatments on seven different conditions and found a lack of evidence to support their effectiveness[i]. The Australian National Health and Medical Research Council came to the same conclusion in 2015, stating “[t]here was no reliable evidence from research in humans that homeopathy was effective for treating a range of health conditions.”[ii] Furthermore, the UK National Health Service stated in 2017 that there is “no clear or robust evidence to support the use of homeopathy.”[iii]

Homeopathy products do not require a prescription, are not classified as drugs by Health Canada and can be purchased in most pharmacies as self-selection in the over-the-counter aisles.

“As a pharmacist, my first priority is to provide a wide range of safe and effective health products but if I do not have a professional comfort level with a certain product, I have a duty not to sell it,” said MacKenzie. “I do not see the removal of homeopathic products as restricting the range of choice for patients. Rather, it is an invitation to discuss their health care concerns and to review other options that may be more appropriate, cost-effective and successful for them.”

Stone’s Drug Store had carried five homeopathic products – two for cold and flu, two for sleep and one for teething. These products are no longer available there.

Stone’s Drug Store is located in Baddeck, Nova Scotia. It is a full-service pharmacy that includes a compounding lab to tailor medicines to the needs of patients. Graham MacKenzie has been a pharmacist for 25 years.

 

[i] http://www.cochranelibrary.com/cochrane-database-of-systematic-reviews/

 

[ii] https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cam02_nhmrc_statement_homeopathy.pdf

 

[iii] https://www.england.nhs.uk/wp-content/uploads/2017/11/items-which-should-not-be-routinely-precscribed-in-pc-ccg-guidance.pdf

 

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My 11 Commandments of Weight
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The first of January inevitably brings on a list of common resolutions among your patients as well as yourself as a professional. Most of these are directed towards what we perceive as something that will lead to a healthier, if … Continue reading

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Common Holiday Season Drug Interaction Warning
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The holidays can increase the consumption of two drugs that we may use in a light to moderate fashion during the year, either at separate occasions or concurrently.   One of these drugs is alcohol and the other is acetaminophen. Sometimes … Continue reading

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Opioid Addiction from the Words of a Patient

Opioid addiction and misuse has been around since the earliest civilizations. Certainly when I graduated from Dalhousie College of Pharmacy 24 years ago and started working as a Pharmacist in Baddeck, we were all aware of such addiction. Based on what we were taught at the time, anyone who took an opioid dose of only the required amount for their pain and no more, would almost certainly avoid opioid misuse. This theory, largely fed to the medical community by the industry making these medications, has now proven to be untrue. The corporate deception has gone as far as to be prosecuted at a criminal level. Based on our centuries of using this class of medication it’s really a wonder it took us this long to figure out the truth.   Although the story behind that deception is too long to go into here, one thing is for sure, the opioid epidemic which has been gradually marching entirely across this continent eastward has become one of the most urgent medical crises of our time.

 

A few years ago I became involved with a group of medical professionals concerned with this topic called the Atlantic Mentorship Network, which has a focus on pain and addiction. It has turned out to be the best alignment in my career. Headed by Dr.’s Peter MacDougall and John Fraser, it is undeniably the best resource for anyone in working with pain or addiction treatment. They recently held a one day conference in September in Inverness that focused on the Challenges and Opportunities in the Delivery of Pain & Addiction Care in Rural Communities. Held this year at the beautiful Inverness County Centre for the Arts, it was a great collection of a dozen speakers that really educated and inspired those in attendance to take back to work helping those with pain and addiction and preventing addiction. All did an amazing job at educating from their own standpoint of doctor, pharmacist, counselor or Nurse.

 

Without a doubt, the absolute highlight of the day for me came not from any healthcare professional, but from a guest invited to speak on the topic of addiction by the name of John MacDonald. Accompanied by Laura Chapman MPH and Chera Clements RN, John quietly and modestly approached the podium as undoubtedly the bravest person in the room. Not used to speaking in front of the 60 plus people that were in attendance, he stated his name and openly announced himself as a recovering drug addict. John spoke for about 10 minutes, which probably seemed like an eternity for him. Little did he know the grasp he had on this group. In a day filled with Powerpoint presentations and laser pointers, he quietly stood in front of a group of strangers holding a hand written note in a simple scribbler and delivered an address that I don’t think I’ll ever forget. It took an experience like this to reinforce to me that the few brief interactions with patients I see every day at my work who have addiction issues did not choose to become that way. I later asked Laura for a transcript of his presentation so I could include it in the words he wrote with his permission, which he was happy to supply
. Without this, most of his effect would have been lost here. In listening and watching him that day, I was reminded of my own healthy children and how easily it is to have your life nearly destroyed by opioids. Remember that rescue Naloxone kits are provided free from pharmacies in Nova Scotia. If you are misusing opioids or are in regular contact with someone that is, you owe it to yourself to have a kit and learn how to use it. It may almost certainly help save a life.

Here is a transcript of John’s presentation:

 

Hello Everyone. My name is John MacDonald. I’ve been asked to speak to you today about substance abuse and addiction.

I’ve been using drugs since I was 13 years old. And in that 17 year period, myself, as well as our communities, went through different drug fads. First – it was cannabis, LSD, mushrooms, ecstasy and amphetamines and any other upper available. Then when I was 14, I started using oxys, cocaine, and crystal meth when available. Not all that long after, I found myself physically dependent on oxycontin and at that point, I had no idea what I was going through. I was never told before you could get sick without it. After a few days of waking up sick but getting better after I used, I googled side effects of oxys and that’s how I learned I was physically dependent. When I was a teen, we never learned about this kind of staff and never had programs at school geared toward drug prevention.

I started injecting drugs around the age of 15 and pretty soon, my addiction became even more out of control. I found myself becoming someone I couldn’t recognize. You see I didn’t set out wanting to become addicted to drugs or to be a junkie. No one does. It happens slowly over time. I experienced a lot of trauma in my early life and because it offered an escape from the horror of my home and public life while I was high nothing or no one could hurt me. However, after a while, it did more harm than good. Even today, I’m trying to reverse the damage drug addiction and substance abuse caused as I’m sure I will always have to do the rest of my life.

I spent years in and out of Detox but because I was there so often, when I would go, they would fast track me and turn a short time even shorter. I’d be discharged in the first week often leaving in withdrawal, which in turn would make my decision to use easy. The times I managed to stay off drugs for a few days after getting out, I would have everyone I used with constantly offering me free drugs and dealers calling trying to get me to use free stuff. They did it because they couldn’t clean up so they didn’t want me to but, whatever the reason, I always ended up giving in.

Drugs took everything from me, my dignity, health, family and friends. It made me homeless, sleeping under stairs, in ditch coverts, on benches. I even slept under the band shell in New Waterford one winter but more importantly, it made me lose myself and my love for myself and my happiness as it does and will continue to do to anyone that comes in contact with these substances.

Over the past 17 years, I have overdosed more than 20 times. I’ve witnessed more than anyone would be able to comprehend and I just lost my 28th friend from an overdose.

The Naloxone training program, I feel, is a god send because there are people alive today that probably wouldn’t be if Naloxone wasn’t readily available. I, myself, administered Naloxone on two separate occasions. The friends of those individuals were too scared to call 911 because they thought they would get arrested or in trouble with the police in other ways, so a person there knew I had a kit so he called me. I feel everyone who uses opiates should carry one and if someone you live with or a loved one uses them, you should also have one at hand in case they are using alone and overdose then you would be trained to administer the life-saving injection.

Anyway, thank you for listening and I hope you all have a great day.

 

This was followed by the largest round of applause we had heard all day, not to mention some encouraging support during his talk from those in attendance. Thanks again John for your insightful words and the best of luck with your future, which I am thinking might result in more than a few saved lives if he continues appearances such as this one.

 

Graham MacKenzie Ph.C.

Stone’s Pharmasave

Baddeck, NS

@grahamcmackenzi

graham@stonespharmasave.com

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Dispensing Pain Meds as a Specialty Service
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I have seen many changes happen to pharmacy in the last 24 years. One of the most career-shifting has been the change in the reimbursement model that has forced pharmacy to revisit how it makes money to remain afloat while continuing the important work of patient care. The traditional work I am referring to is not something that carries the business for most independent pharmacies.

Even before this adjustment to our financial model, we were criticized for not charging for other everyday services. Now, not only are many of us leaving money on the table for uncharged services that would easily have been charged by other professions and accepted by the public, but we are charging for dispensary services in unsustainable ways that fail to reimburse the business. Specialty services like methadone, travel clinics, injections, med reviews, compounding, nursing home filling, and others have helped relieve some of the financial strain on some pharmacy businesses. Some day soon I am sure medical marijuana will be one of those services.

Take two of these programs: methadone and medical marijuana. One currently runs in many Canadian pharmacies and one is on the horizon. Both of these have and will continue to gain popularity for the pain patient that has been prescribed opioids. In the case of methadone, it becomes a specialty rescue plan to give the patient back at least a small part of normalcy, even if there is no projected hard endpoint in sight. It can allow patients to stay off of street drugs and steer away from opioid addiction, and in addition keep their family, hold a job (at least one that allows them to go for a witnessed ingestion daily), keep some financial stability and make plans for the future. While this system has its share of abusers, the theory is sound.

In the case of medical marijuana, we try to remove opioids in a less proven method perhaps, and use a CBD/TCH combination to deal with pain in a way that has shown to work, even though we still have much to learn about long-term effects. Compounding can be included here as well, as studies have demonstrated and I have personally seen a regular pattern of reduced oral medications for pain when topical compounded products are introduced.

These demonstrate a practise we have shown in modern medicine for “a pill for every ill.” This is your symptom so this is your medication. In our defense we do try to project wellness campaigns into our profession surrounding eating right and physical activity—both with huge potential benefits. We actively run screening programs for cholesterol and blood glucose—again, often in free clinic formats without much evidence to back up clinical outcomes, such as death rate or disease prevention. This is all in the hope of reminding people to think about their health.

We have all pursued prevention programs in our pharmacies in one way or another. I removed sugary beverages a few years ago (a public health campaign that still resonates with my store today). I filmed a 40-minute healthy grocery shopping tour for YouTube for anyone to watch for free, and I have also done the blood pressure and glucose/cholesterol clinics in my store. In an era where evidence-based practitioners are claiming random screening in healthy populations proves questionable benefit, we push on despite costs to our businesses in both time and money.

What about the patient with either an acute need for a strong pain reliever or the one who is the long-term pain patient? You must be living under a rock if this hasn’t caused you to stop and think about where this patient will be in a few years (especially if they are not handled properly by both you and their doctor). Every time you fill a methadone prescription should make you think even harder. Why do we go through the trouble to screen for other diseases and prevent health complications while at the same time filling an opioid prescription while thinking “is this patient early for their refill?” Most of us have spent more time talking to a diabetic patients about their health than an oxycodone user about where their health is going. Is the potential impact of where that opioid patient could be headed any less drastic than the diabetic patient if not monitored properly? Even the patient on regular naproxen is probably not on our radar as someone who may get switched to an opioid and develop misuse issues down the road.

There are many responsible narcotic users out there who just don’t seem to be heading for any addiction or misuse problems. These patients are no less important when it comes to our vigilance though. We have tools available to us to help screen out those who are more likely to misuse. None of these tools are scientifically proven but they are based on our experience with various patient groups with opioids.

Realistically, any pain patient requires more time than the average patient even from day one. As specialized as methadone is today, it has become a regular fill commodity where a hundred or more patients come in for a witnessed ingestion and leave. With these numbers, there isn’t much time for a ”sit down” with each and every one. In stores with a more realistic number of patients, such as 10-20, it is conceivable that pharmacy staff is able to discuss how therapy is going each time, if they are showing subtle signs of drug use. A more one-on-one environment that isn’t rushed might bring out other signs of sub par therapy, drug diversion and other misuse.

If third-party payers reimbursed for such a specialized service, it would improve health outcomes in the long run. Each patient should be interviewed with each renewal of their opioid and as an initial consultation.  Pharmacists are in the best place to detect misuse. A patient that is yawning or restless in front of you, or perhaps agitated during the med review, may be showing signs of withdrawal from an opioid and could be a patient who is taking other sources of opiates along with their prescription. Urine drug testing should be discussed as a possibility early on with treatment as well so that it doesn’t offend patients later on when they are suspected of misuse.

It is estimated that 22% of patients will discontinue opioid therapy due to side effects. This may involve dose-limiting side effects that would require a dose reduction or even a discontinuation of the medication. This may include sedation, which should be assessed with high opioid doses (especially more than 200mg oral morphing equivalents) and with each dose increase. Although this will often resolve itself with tolerance, if suspected it should be monitored closely. Asking a patient to return to the pharmacy within a few hours after a dose may help.

Cognitive dysfunction follows the same warnings of dose increase and high dose as with sedation but can be trickier to pick out unless you take time to speak to the patient for a few minutes. It involves cloudy thinking, poor memory and diminished concentration. As with sedation, reducing the dose, discontinuing the drug or opioid rotation can help. Opioid-induced hyperalgesia is a side effect where this specialty service proves its worth. Again it tends to occur at higher doses and is a phenomenon where the pain threshold seems to drop, giving an increased sensitivity to pain as the opioid dose increases. Instead of a knee jerk increase in opioid dose, the dose should actually be tapered or a COX-2 inhibitor can be given concurrently. It has also been recommended that an NMDA receptor antagonist like Ketamine be tried. Quite often this molecule is used in our pain compounding.

A potentially serious side effect that can occur with opioids is sleep apnea, possibly due to the effect on sleep architecture. This may affect up to 30% of all patients on chronic opioid therapy and can significantly exacerbate a pre-existing sleep apnea condition. This is why it can be helpful for the partner of the patient to come with them to the interview with each fill. Extra information may be gleaned from this type of environment. Respiratory depression is a commonly known side effect of opioid use, however tolerance develops rather quickly and is often a problem only with patients with pulmonary disease like COPD or asthma. It can result in limiting the dose in these patients especially at higher doses.

Constipation, nausea, vomiting, dry mouth, pruritis, urinary retention, myoclonus, hormonal effects, immune suppression, and weight gain/sugar craving are all important side effects that should be addressed and monitored. It is difficult to do all of this with a typical prescription handout at the counter. Of course, the most important effect to monitor is addiction. Although the risk of this is low, it is still a real possibility and constant vigilant monitoring is important to cover your bases.

Tapering doses has become popular with recent warnings to keep patients below 90 oral morphine equivalents. The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain strongly recommends a coordinated multidisciplinary collaboration approach that involves several health professionals that are readily accessible to the physician. The Nova Scotia College of Pharmacists’ registrar Bev Zwicker released a communication to its members on June 26 explaining that the College of Physicians and Surgeons of Nova Scotia warning that the tapering of opioids needs to be done sensitively, collaboratively and with realistic expectations. It also confirmed that rapid withdrawal could be dangerous if done too quickly and that these high- -dose patients cannot be abandoned. These guidelines need to be reviewed by all involved especially pharmacists. Tapering should be considered if there are dose-limiting side effects that are intolerable, if the opioid trial is failed, if the pain has resolved itself, or if there is evidence of addiction or diversion. Most of these tapers are voluntary but the decision may be made by the physician unilaterally. Assessing the patient during the taper requires close monitoring for withdrawal symptoms.

This year, The Journal of the American Pharmacist Association published a paper where a pharmacist-led opioid exit plan for acute postoperative pain management can  have benefits when involved at the point of admission, during the post operative recovery period and on discharge. A 2013 BMJ Open paper outlined an RCT where regular GP care was compared to pharmacist-led management of chronic pain and demonstrated improved pain outcomes with the pharmacist-led management.

A 2014 study involving a pharmacist-initiated intervention trial in osteoarthritis showed that patients experience quantifiable benefits from interprofessional collaboration among pharmacists, physicians and physiotherapists. We have also seen pharmacists’ involvement in the co-management of acute pain and substance use disorder improves patient safety and pain control.

Creating your own niche market where you are the go to pharmacy for beneficial outcomes in acute and chronic pain patients becomes key where you are trying to prevent opioid misuse and abuse. It starts with one on one time with the pharmacist and patient each time they come into your pharmacy. It can make your pharmacy the safe place for patients, from their initial prescription for pain to managing a chronic condition while avoiding addiction. Hopefully a patient or their third-party plan would pay for that service.

References:

Ware et al CMAJ 2010; 182(4)

AMN The Prescribing Course—Safe Opioid Prescribing for Chronic Non-Cancer Pain 1st Ed Oct 2014 MacDougall/Fraser

Bruhn H, Bond CM, Elliott AM, et al. Pharmacist-led management of chronic pain in primary care; results from a randomized controlled exploratory trial. BMJ Open 2013;3:e002361

Marra, CA et al Cost-Utility Analysis of a Multidisciplinary Strategy to Manage Osteoarthritis of the Knee: Economic Evaluation of a Cluster Randomized Controlled Trial Study. Arthrit Care Res. 2014 June; 66 (6): 810-816

Andrews LB, et al, Implementation of a pharmacist-driven pain management consultation service for hospitalized adults with a history of substance abuse. Int J Clin Pract. 2013 Dec; 67 (12): 1342-9.

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Thank you Marijuana for taking the bad press off of bioidentical hormone therapy.
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  June 17, 2017 : looking back hardly a day or two goes by since this year began when a question about medical marijuana or as we call it out here “marijuana” and what is going to happen next July … Continue reading

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Preventing Medication Errors and the ISMP

One evening in late October of this year I sat down with a rep from a compounding pharmacy supply company to discuss how our compounding business was going.

One of the first topics he brought up was a story of a young Mississauga boy, Andrew, who had died from an apparent mix-up with a compounded medication.

The boy died of an overdose of baclofen after taking a prescription that was alleged to contain tryptophan for sleep. It was the first I had heard of the tragic story.

It is a scenario that mimics the worst possible case in the back of our heads each time we as pharmacists go to work each day.

As fallible human beings I consider us the strongest and weakest link in the chain of what has largely become an automated day—automated with humans that are capable of a momentary lapse of attention that can kill someone.

It not only focuses directly on errors but on almost any conceivable reason for them occurring

Almost exactly a month later, I am reading in Halifax’s Chronicle Herald of Ontario’s Health Minister Eric Hoskins desire to tighten the safety of his province’s pharmacy dispensing in the wake of this tragedy.

As part of that process he’s looking at how Nova Scotia has dealt with this issue (thechronicleherald.ca/novascotia/1416107-nova-scotia-pharmacies-lead-in-safe-medicine-practices, namely through an initiative called SafetyNET-Rx. ( http://www.safetynetrx.ca)

This story, of course, grabbed my attention, not only because I am a community pharmacist, but also because I also compound and live and practice in Nova Scotia.

I am further pulled into this story because the SafetyNET-Rx initiative mentioned was started at a former alma mater (St. Francis Xavier University in Antigonish, Nova Scotia), in part by a former classmate of mine from Dalhousie University College of Pharmacy (now Dean Neil MacKinnon at U of Cincinnati Winkle College of Pharmacy).

As a practising Nova Scotia pharmacist, I am fully involved with SafetyNET-Rx. Our pharmacy in Baddeck was part of the pilot project in 2010.

The Nova Scotia College of Pharmacists’ Standards of Practice (www.nspharmacists.ca/?page=standardsofpractice ) now outline that every pharmacy in the province must have a Continuous Quality Improvement (CQI) plan in place.

This is a requirement in the Practice Regulations to the Pharmacy Act of Nova Scotia.  For the first time we now have a monitored, effective QCI process that tracks quality related events (QREs).  It is the SafetyNet-Rx model we use now.

So what does this involve in our day-to-day work in the pharmacy? Mainly, anytime there is a QRE, we note it in a scribbler to be entered later into an online recording system.

These errors encompass everything that can go wrong, such as a prescription handed out for the wrong drug or directions or doctor (even if it exactly follows the actual prescription but was an unintended change).

Most of the recorded errors include mistakes made before the prescription actually gets to the patient’s hands. Every time we enter the wrong doctor, drug, strength or directions, it gets marked down. In a busy day we do the best we can to record these events but in reality some do get fixed and aren’t recorded.

These events are formally recorded online on the Community Pharmacy Incident Reporting site—ISMP (Institute for Safe Medication Practices).

Each pharmacy has its own username and login and can search based on several metrics the types of errors that occur, the days of the week they occur the most, who detected the error, contributing factors, degree of harm from the incident and what the error was—both for your pharmacy and combined aggregate of all pharmacies on the system.

It’s quite interesting to see these comparisons. All of this data is invaluable in helping to prevent future errors. Quarterly staff meetings are required and helpful in sharing this information.

Through this reporting system, we are keenly aware now of the most common source for errors, who is most likely to catch the error, why the error occurred and even when it is most likely to occur.

This allows us to plan staffing and make corrections that we would have normally made after a mistake is made; except now we can do it before the incident occurs.

We can see how we compare with all other community pharmacies and if a discrepancy occurs we can immediately make changes.

Knowing the most common errors prompts one to be extra careful in that field. For example, if you know your store has an inordinately high number of errors that involve number of doses dispensed compared to the aggregate, it becomes a focus until it is normalized.

If we find that many errors occur with incorrectly written prescriptions at the physician level, we would have that conversation with the physicians.

Along with this reporting system, there are several other checks in place.  Many of these are done by any other pharmacy in the country.  Staff emergency contacts are recorded, as are the numbers for all services used by the store from police and fire down to insurance, electrician, plumber, computer data and storage in case they are needed by any staff member.

Regular audits are done that range from removing outdated stock, adverse drug reaction reporting, monthly narcotic drug inventory reconciliation, equipment and facilities certification, adherence to standards of practice are recorded and annual staff performances.

Confidentiality agreements are signed, pandemic planning is completed, robbery and break-in procedures are made and reviewed and emergency response plans of all types are done (staff and customer accidents, fire, leaks, toxic spills and power outages).

For our pharmacy in Baddeck there were a few changes we made as a direct response from all of this monitoring.  We determined the time of day and day(s) of week that we were most likely to see an error and we adjusted staffing levels to be heavier at those times.

We also determined a certain physician that had a higher probability of making an error when writing a continuation prescription for a drug that the patient was already on. This alerted us to pay extra attention to this occurring with this physician.

We also added another satellite computer in the pharmacy, not only as a reminder to document but to allow easier, daily documentation of events.  When it wasn’t possible to do this we jotted them down for later entry.

Another interesting thing that came out from this was through the stringent narcotic self audits.  We started noticing that a certain brand of medication was short one tablet in each bottle we were getting so these bottles were counted upon opening and the rep was alerted to the problem.

We also realized that the most common “near miss” incidents were incorrect quantity and incorrect dose. Special attention was brought to this during the quarterly meetings so extra attention on filling the script would prevent the problem again.

Future reports of quality assurance demonstrate the effect of these changes, new problem areas are found and new targets are made. Regular Medication Safety Self Assessments are done. This is a valuable tool that assesses the pharmacy’s overall ability to function safely based on many parameters and is done on a regular basis.

It is really an environment full of information that was floating there unharnessed before that monumentally helps to improve the safety of our patients when acted on.

If it seems like a lot of extra work in an environment that has very little down time, then you are correct.  Personally though, I have always found a huge sense of calm knowing something extra was done to double check that a patient got what they were supposed to get when they leave my pharmacy.

The time involved though blends in with our work and is worth it.  Time management is a skill that becomes greater as a result.

Getting back to the original patient we spoke of, Andrew, would this event had occurred if all of this were in place?  It is difficult to speculate as the cause is before the courts right now.

One thing though is for certain, making an error is an opportunity to explore why that error occurred and make corrections so it won’t happen again.

In the December 1989 issue of the CAPSIL (The Canadian Association of Pharmacy Students and Interns), I wrote one of my first public articles (without the internet) on the topic of Medication Errors (http://capsi.ca/wp-content/uploads/2015/01/CAPSIL-JACEIP-1989-Dec.pdf ).

It is a subject that will never completely go away. It is a disservice to our patients to not act on each error as a learning experience. SafetyNET-Rx is an invaluable tool that really turbo charges your incident prevention and kudos to the Nova Scotia College of Pharmacists for implementing this requirement into their standards.

It not only focuses directly on errors but on almost any conceivable reason for them occurring. Hats off to my friend and Colleague Dean Neil MacKinnon for his role in its development.  This standard is a huge leap forward that has caught the attention of the rest of the country.

I had the pleasure of corresponding with Andrew’s Mom earlier this year who contacted me ahead of a meeting with the Ontario College of Pharmacists Task Force where a proposal for medication error reporting was on the agenda. The College also contacted me ahead of this meeting to share ideas on the ISMP and my experience with it. Andrew’s Mom was glad to see movement on this system and its potential introduction in Ontario and thanked me for writing about this topic for the national audience of Canadian Pharmaicsts on the Canadian Healthcare Network. Hopefully some good comes out of this tragedy.

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Essay on the life of J. Esmonde Cooke (1990)


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