Search Results for: sugary

Why Your Pharmacy Should Stop Selling Sugary Beverages

Two of the most common questions I get about my discontinuing of selling sugary beverages in September of 2014 is A) Did I notice a drop in income because of the lost sales of this line and B) Did I notice an increase in sales because of this move.

Before I stopped selling this line I would see perhaps $1000 on a good month in sales of these products. I don’t have a number of the extra sales made when customers came in to buy pop, juice, vitamin water, chocolate milk, or iced tea. This might be picked up by measuring a drop in sales beyond the regular amount of these beverages sold. Since there really wasn’t a drop in sales though, it is difficult to tell if these ancillary sales dropped or not.

One thing is for sure, the unexpected volume of free advertising it gave the store more than made up for anything lost on pop or any other extra product not being purchased with it. It elevated the reputation of the store to a destination where customers knew we were willing to try something bold to further their health, even if it meant less revenue.

One great offshoot of this event was the introduction it brought us to a key Canadian researcher, Leia Minaker at the University of Waterloo’s Propel Centre for Population Health Impact. She took notice of the activity in Baddeck and started a natural study to determine the effect this had in the selling of pop in Baddeck after that day in September. She collected sales data not only from us but from the two other major sellers in the Village and determined that there was no switching behavior in purchasing to these other outlets. The study was published in BMC Public Health in 2016. (Minaker LM, Olstad DL, MacKenzie G, et al. An evaluation of the impact of a restrictive retail food environment intervention in a rural community pharmacy setting. BMC Public Health. 2016;16:586. doi:10.1186/s12889-016-3281-9).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947263/

Another great find for me was Dr Yoni Freedhoff, one of this country’s most prominent voices not only on unhealthy marketing practices to everyone (especially children) but also on the larger topic of obesity.

After two and a half years I look back on this move as the best one I could have done for my Pharmacy. When I think of the doubt I had in the months or weeks leading up to this I now realize the worry was for nothing. In this day and age, we try to rock the boat as little as possible in our pharmacy models for fear of going out of business. I can assure you if by some stretch your pharmacy would close based on the lost sales of sugary beverages, then maybe you should be in a convenience store type of setting instead. If you know for a fact that the small amount of profit made on this loss leader (if any at all) won’t affect your store adversely, and you realize the huge price tag that the consumption of these beverages costs your country long term, what is the holdback in removing them from your business?  After all, shouldn’t we be partly responsible for this cost to the healthcare system by continuing to sell liquid calories and in effect promoting them? When asked about other snack foods, which we have overhauled as well at Stone’s, my response is that this is my contribution to educating the public on one of the most common sources of extra calorie consumption starting with children and moving right on up to older adults. If you own a pharmacy, make a mark by taking your own stand on something that you know is causing harm to your patients. You’ll feel better for it and so will your business.

 

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New Senate Proposed Sugary Beverage Tax – The Real Benefit Isn’t Lower Obesity Rates
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backgroundThe month of March ushered in news of a new report entitled “Obesity in Canada”. Submitted by the Senate, this report was a 21 recommendation paper to try and constructively address the growing concern of why Canadians are following its Southern neighbors in growing rates of obesity in both children and adults. In fact there are is a doubling in obesity in adults since 1980 and children’s obesity rates in this country have tripled in that time. This report was a breath of fresh air from a government group that many today look at with question of why they are even there.

As a Pharmacy owner that discontinued sale of such products in September of 2014, this story caught my eye. Anything having something to do with sugary beverages is a hot topic with the media, as I abruptly found out that day a year and a half ago. Even a small pharmacy in the middle of nowhere can make the national and international news by making “such a bold and forward thinking move” (as it was described) as stopping the sale of everything from pop, juice, vitamin water, sports drinks and chocolate milk.

Any talk of manipulating the sale of a staple in the Canadian diet will bring about cries of a “Nanny State move”. So when news hit that one of the recommendations from the Senate’s report was a proposed tax on such drinks, the naysayers came out of the woodwork, and along with them, the defenders of the plan. One of the first to press against the idea was Jim Goetz, the president of the Canadian Beverage Association who attempted to educate us in a biased way with stories of how this has been tried in other parts of the world and didn’t work, had no effect on obesity and resulted in lost jobs and increased grocery expenditures. Mr. Goetz is a name I learned back when I stopped selling these beverages and saw an article in rebuttal to this type of move. When I read of crazy claims that increased calorie intake had nothing to do with obesity, it really opened my eyes to the war that goes on in this category.

Granted there is no shortage of stories where an increase in tax on a target food group seemed to be a dud with respect to changes in obesity, even when the calorie intake did seem to drop. Denmark, Mexico, the United States, Finland, France, Hungary all are examples of stories where a tax was implemented with results that vary depending on who tells the story. In fact during a recent CBC Radio interview on the Senate report I gave recently, I was pressed on the success (or lack of) in such programs. I was quite persistent though on the complete irrelevance of the obesity outcome but rather we should focus on the fact that we need to pay for the adverse health issues that arise from the obesity that we know these beverages cause.

When I cross from Dartmouth to Halifax on either bridge, I expect to pay a toll. It doesn’t really cause me to take the long way around through Bedford, I pay the toll and drive over the bridge. I do it because I realize the upkeep of the bridge has to happen somehow and if I don’t pay it through tolls, I’ll sure as heck going to end up paying it some other way. It just makes sense for users to pay for that. When I buy tires for my car, I pay a fee that is to be used for the recycling of that tire at its end of life. You just do it because something has to happen to that tire when you’re done with it and that costs money to do.

If you agree that extra calorie intake results in obesity, then what is it that drains the healthcare budget of a country so quick when its population becomes more obese? Children with obesity are more likely to suffer from type 2 diabetes, hypertension and asthma. Adults with obesity have a higher incidence of depression, anxiety, heart disease and diabetes and also are more likely to be absent from work, pursue lower income jobs and earn lower overall wages (and in doing so pay less tax). Last year in the U.S., health care costs as a result of obesity reached $300 billion annually. A simple consideration in mathematics will show how this cost could be somewhat offset by a sugary beverage tax. Even though there are many reasons a nation becomes overweight, sugary beverages are one of them and you can consider it a user fee with that tax.

Lots of other great ideas came from the report, like an overhaul of the Canada Food Guide – without involvement from the food industry and one of my favorite recommendations, stricter controls on advertising unhealthy food and drinks for kids. Well done Canadian Senate!

Graham MacKenzie Ph.C.

IMG_2313[2] copyStone’s Pharmasave

Baddeck, Nova Scotia

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Stone’s Withdraws Sugary Beverages – One Year Later
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September 11, 2014 was a busy day at Stone’s Drug Store in Baddeck.  The week that followed was a similar pace.  After months of contemplation the trigger was pulled to remove the sale of all sugary beverages from the pharmacy on the second Thursday in September.  Before opening on that day I removed all of the pop, juice, chocolate milk, and sports drinks from the floor and coolers and put it in our counseling room for what I thought would be a normal day.  Perhaps there would be a few questions or even complaints about this but that would be all.  https://stonespharmasave.com/blog/?p=560

 

In response to an editorial by a group close to the beverage industry that this type of move is ineffective in changing overall health,  I responded with https://stonespharmasave.com/blog/?s=sugary

 

Turned out there was a lot of attention grabbed by this move, not just by local and national media, but also from a Scientist at the Propel Centre for Population Health Impact named Leia Minaker.  The Propel Centre is a research centre located at the University of Waterloo that aims for overall better health and cancer prevention.  Leia’s proposal was to undertake a natural experiment whereby the effects of a local retailer restricting the purchasing of (in this experiment) carbonated beverages in a small town might have effects like less purchasing of carbonated beverages or perhaps lead to switching of purchasing behavior of these products among stores in the village by its residents.

 

This study would not have been possible were it not for the amazing cooperation of the two other main retailers in the Village of Baddeck, the Coop (the local grocery store) and Needs (the local convenience store).  Along with our sales data Leia collected the sales data of these other two businesses for their carbonated beverages for a period of 88 weeks prior to the September 11 date and a total of 128 weeks of data was collected to give a before and after snapshot of sales.  The data showed that we at Stone’s sold just 6% of the carbonated sales in Baddeck.  With this in mind it is even more amazing to see that after controlling for summer peak sales, weekly carbonated beverage sales declined by 11.4% as a whole in Baddeck in the post intervention period.  In a separate statistical analysis, it was determined that after controlling for model specified seasonality, the sales decreased by 21.4%.  Not bad for a little store that sold only 6% of the carbonated beverages overall in Baddeck!  Another unexpected finding beyond this was that buying patterns did not appear to shift to the other retail outlets in the village

 

So congratulations to Leia, to Stone’s and to the residents of the Baddeck area for getting the message we drove out relentlessly about what sugary beverages do to you.

 

Leia and her team are now embarking on a longer term look at this data.  Part of this involves trying to determine the overall buying patterns of the Village before and after we stopped selling the beverages.  Natural studies can be rare opportunities for this type of evaluation and they certainly want to use as much data as possible in finding the effects of the sugary drink withdrawal.

 

Common questions asked of me during this time:

 

Was this something meant to inspire other retailers to do the same thing?   Not really, but that would be nice.  It was done for the sole purpose of showing my customers that if I stressed on a daily basis how bad a product is and how it so quietly sneaks into your diet and causes long-term health problems for you then I couldn’t sell it anymore.

 

You still sell bars and chips.  Isn’t this a nanny state move to grab headlines in the news?  “Haters gonna hate” I always say.  The point shows how much we think drinking juice is good for you, how sports drinks are important to increase athletic performance, how chocolate milk is as healthy as white milk and how pop is ok to have daily because of the sheer presence of these pop companies in sporting event advertising and sponsorship – when this is the exact opposite of the truth in all cases.

 

Who do you think you are controlling what I can or cannot buy?  Well, first of all it’s my store.  Second of all you can go for a 30 second walk and still purchase these sugary beverages if you need them.

 

What about all of the other unhealthy things you sell in the drug store?  This criticism ranged from homeopathic products, to vitamins and supplements, to weight loss programs, whatever was the last headline in the newspaper that was useless or dangerous.  As a pharmacist my number one thought process is to prevent harm as well as providing an effective product.   Any pharmacist will tell you of countless customers who take a product different from the one they spent the last five minutes recommending.  In that situation we realize they are buying that other product so we just want to make sure their choice will not result in harm, even if that product is homeopathic.  Some of the customer’s choices are unchangeable and part of their beliefs for whatever reason.   Often it is a part of a process of that patient determining on their own what works for them and what doesn’t.

And what of the hydromorphone capsules I sell and see addiction develop, the chemotherapy pills when they work sometimes and other times they lead to more suffering and therapeutic failure (try explaining the concept of a successful randomized controlled trial with this patient’s family), taking statins and have a heart attack, take NSAIDS and end up with a GI bleed, take a benzodiazepine for anxiety and get addicted?  Everyone has their story of something that went wrong in medicine.  I can’t remove everything from the store that has risk so I chose to remove the biggest offender.

 

So what about the bars – are you removing them also?  I’ll admit this was one I didn’t really have an answer for right away but I thought why not get rid of all of this.  As I described in the last question I needed to strike a balance between what I thought was completely crazy and acceptable in slightest moderation.  I believe that the sugary drinks put us in the hospital long-term and shorten our lives.  If everyone ate the bars like they consumed the sugary beverages then they would be gone also.

 

Have you noticed a change in your sales since you made this move?

Getting rid of these coolers and freeing floor space from pop led to a rearrangement of some of the merchandise in the pharmacy.  The organic food and gluten free section definitely was one of the first to expand.  So sales grew in this area that is largely driven by large consumer demand and we basically carry what they ask for.  The main areas that expanded beyond this were related to the nutraceuticals and compounding.  The unexpected exposure gained when the sugary drinks were dropped drew the attention of those who were interested in controlling their health and prevention on their own and for many this meant non-prescription means through evidence bases supplements and food that was free of pesticides and herbicides and were GMO free.  These are definitely consumer demand driven products and nutraceuticals require a fair bit of education beyond the Pharmacy degree education I received.  Compounding had led me to this area.  It turned out all of these “beyond ordinary” pharmacy services caught the eye of these preventative medicine patients out there, so this is where we saw the expansion.

 

What has been the overall reception from the public?

Overall the public’s response has been great and even a year later people come into the pharmacy that never set foot in here to congratulate us.  On social media where one’s backbone grows and anonymity is popular there were some comments that were less than complimentary but overall it seemed most people got it when it came to understanding the reason for this and the real message behind it.

 

Is it really that unsafe for someone to consume pop or juice?

I use the analogy of a person holding out their hands together to catch marbles that are falling.  At first they find it easy to catch the marbles but after a while their hands begin to fill with more and more marbles and they eventually let one drop.  This represents the tipping point where something happens to your health and the marbles are the insults over a lifetime, like heavy metal exposure, pesticides, herbicides, fertilizers, stress, processed food, and sugar.  Perhaps a little bit here and there doesn’t seem to matter, especially early on, but they all add up together.  With the growing mountain of evidence of what sugary beverages can do in even low consumption – it really is that unsafe!

 

Also a special thanks to Dr. Yoni Freedhoff, a family doctor and assistant professor at the University of Ottawa and author of The Diet Fix for sharing this with a guest blog on his ever popular Weighty Matters blog http://www.weightymatters.ca/2014/09/guest-post-pharmacist-who-refuses-to.html and for the Village of Baddeck and its surrounding area for making this study so successful.

 

Graham MacKenzie Ph.C.

Stone’s Pharmacy

Baddeck N.S.

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Pharmacy Sugary Drink Withdrawal and the New WHO Sugar Guidelines
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In response to my decision to remove sugary drinks from my pharmacy in September of 2014, there seem to be the odd lingering claim that “…targeting the sale of one particular category is not going to have a significant impact [on obesity]”, and that “information – not restriction – is key.”

While we agree with the point that obesity is a complex, multifactorial problem, it is completely baseless, in fact hovering on outright deception, that extra calorie intake does not increase your weight. In 2013, the journal PLOS Medicine published a systematic review of systematic reviews, which are the most comprehensive forms of evidence that we have. This review by Bes-Rastrollo and colleagues found that 83% of reviews not funded by the beverage industry a relationship between sugar-sweetened beverage consumption and weight gain. On the other hand, 83% of the reviews that were funded by the industry found insufficient evidence to support a positive association between sugar-sweetened beverage consumption and weight gain or obesity.

Also keep in mind metabolic disease which has also been shown to increase with consumption of these drinks and is one of the main reasons we pharmacists see our customers (high blood pressure, increased cholesterol, increased abdominal obesity, and insulin resistance). For example, a 2010 meta analysis in the Journal of Diabetes Care of over 300,000 subjects found that those that consumed the most sugary drinks, one or two per day (pop, juice, vitamin water, iced tea and energy drinks) had a 26% greater chance of developing type 2 diabetes than those that drank none or 1 serving per month. They concluded that weight gain and metabolic syndrome correlates positively with consumption of these drinks. The New England Journal of Medicine published a study in 2011 which followed over 120,000 people and concluded that one 12 ounce sugary beverage serving a day increased their weight more than those that did not consume this beverage. Finally, a 2012 study in Circulation followed 40,000 men and found a 20% higher chance of having a heart attack or dying from a heart attack when one can of sugary beverage per day was consumed compared to men that didn’t. This was verified by a second study.

Calorie consumption from all sugary beverages combined has continued to climb each decade, especially among children and teens. By coincidence, today, the World Health Organization is changing its recommendation for daily total consumption of sugar to 6-12 teaspoons daily. This would be exceeded by consuming even one can of soda. Finally, we are seeing revised recommendations on sugar that follows science. The new recommendation now recommends free sugars being as low as 5% of total calories, meaning a serving of orange juice is off limits – imagine, a recommendation that pushes you to eat the fruit instead of drinking the juice. Brilliant! There is now a separation of total sugars and free sugars. The total sugar concept meant you could gobble up your calories with juice and pop, but now it’s considered free sugar.

The withdrawal of sugary beverages from Stone’s Pharmasave in Baddeck was not meant to “ban” pop sales, and I certainly do not expect to see a drastic change in obesity levels in my town as a result of my decision. I made this decision to help educate my customers on the effects of sugary drinks. I therefore agree that education is an important component of healthy eating. However, in keeping with recommendations from world experts in obesity research (see the 2015 Lancet Obesity Series), I am also aiming to move beyond education by starting to create an environment in my store that is supportive of healthy food choices. As a pharmacist, I know I shouldn’t sell tobacco, no matter what the industry claims. I don’t feel I should sell sugary beverages, either.

 

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Press Release: Soft Drinks and Sugary Beverages

Nova Scotia pharmacy stops selling soft drinks and other sugary beverages

photo credit: kevin dooley via photopin cc

photo credit: kevin dooley via photopin cc

Pharmacist Graham MacKenzie says this is part of an overall move to sell healthier foods. Continue reading

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The Value of Pharmacy Research

Boost Your Professional Credibility & Contribute to your Profession with Research

Practicing pharmacy has proven for me to be much more than I had planned when I was accepted to Dalhousie University’s College of Pharmacy 30 years ago.  Of course it created a career where I used the most available evidence based treatments for just about any medical conditions that I was asked about.  This degree put myself and my colleagues on a level that resulted in more people listening to us and taking our recommendations than we had ever experienced in our lives before.  All of a sudden, with such a degree on our wall and a license to our name, people would follow our beliefs without question.  Pharmacy can be a powerful profession with regard to public credibility, even when it involves treatments that have very little evidence or no evidence (such as homeopathy).  The mere presence of a treatment in a pharmacy and the recommendation of a pharmacist is all the public needs to blindly follow us in many cases.

We normally aren’t asked or required to supply randomized placebo controlled trials to back up our recommendations in the front store nor is that commonly asked for in our prescription world either.  Most of us simply give recommendations without readily knowing off hand any particular study that backs up what we are saying at all.  Giving public presentations may be an opportunity to show an audience where the foundation of our claims come from in the scientific world.  It turns out that the public can be information nerds like we are sometimes and are quite interested in presentations like this.

As pharmacists, we are tied to the study designs of others when it comes to our recommendations.  The weakness of their designs becomes the weakness of our recommendations.  For years we recommended docusate sodium as a stool softener, only to hear that it really doesn’t do what we claimed all these years.  10 years ago I was lucky enough as an owner to pursue a niche in compounding, a subset of pharmacy I was exposed to as a student working in a pharmacy a block away from the College of Pharmacy in Halifax.  Pain compounding became the focus of my practice.  The evidence for these ingredients was positive but didn’t involve hundreds of thousands of patients.  It consisted of many smaller studies that together added up into a strong base from which to recommend this treatment modality.  Active ingredients like amitriptyline, clonidine, gabapentin, ketoprofen, ketamine and lidocaine were all mentioned in the literature, but something was missing for me.  In order to put some stronger faith from the public in this, I needed to show some way that I was in some way involved with the evidence base of treating people this way for pain.

Turns out, universities are eager to showcase their research and are very helpful in sourcing out grants to fund scientific studies.  It has always been a drawback for a situation to exist in scientific study whereby the “promoter” that stands to make money is funding and driving the study forward.  However when we consider that this is how most prescription meds came to market it becomes more acceptable.  I believed it would be a strong asset to show that I spearheaded a study through my pharmacy that proved for the first time the permeability of these six ingredients through the skin would happened simultaneously.  A visit to the local university and they helped us with the application procedure for a grant that covered the cost of the study, new equipment included.  The money went completely to the lab with our pharmacy handing over three sample creams in three different bases.  With very little effort on my behalf, I went from wanting to prove I could drive these molecules through the skin to having a typed manuscript with graphs showing flux over time that I could bring to prescribers and show to recipients of the cream to instill confidence in their medication.  This completed study is soon to be published.

As a follow up, we applied for and were accepted for a grant with the local pain clinic to use the same pain cream with the local pain clinic on 40 patients with nerve pain.  What better way to put your money where your mouth is than to put your own hand picked ingredients on the spotlight and test whether or not they actually work.  We were that confident based on hundreds of patient results.  

In another study, we partnered with The Propel Centre at The University of Waterloo to supply data on the aftermath of discontinuing the sale of sugary beverages at our pharmacy in 2014.  In this case they approached us on starting this study, which was finally published in 2016 and became the subject of a Thesis presentation after that. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947263/

My point is, based on the funding available out there, why not take a treatment concept you either feel strongly about or want to clarify that has been conventionally accepted for years (either prescription or non prescription) – lots of opportunities exist in the front store here without taking on big pharma. Meet with the university scientist that will design the study and share your thoughts on what you are trying to unveil. Allow them to introduce you to the grant application personnel, (or vice versa).  It becomes an incredible strength to refine your knowledge of study design you’ve learned from your pharmacy degree.  You don’t have to be an expert on study design.  Allow the researcher you are collaborating with to develop the study with your input.  Nothing beats having your name on a study that shows that you are so committed to your profession and your recommendations that you are willing to be involved in an actual study to clarify our understanding of a topic.  Being known as a research pharmacist gives extra credibility to your commitment to your profession as well as increases your knowledge base for your recommendations to your patients and your physicians.  Your contribution to your profession will not go unnoticed, and the next time a customer asks you if you are aware of any studies on a particular topic, you just might be able to quote one directly.

Graham MacKenzie Ph.C.


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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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Individual attempts at large scale health outcomes
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I find it amusing, especially in the world of preventative therapies, the cut-throat competitive atmosphere in what works and what doesn’t; what is a waste of money and what is positively proven.  Unfortunately, virtually all of these claims (positive or negative) come from a claim or conclusion from the latest study.  The study might or might not be well designed, it may or may not have the power to come to the conclusion that it does, and it may be just an opinion.

I am a firm believer in the concept that the sum of what we know is a result of all of the studies we have, not just from one or two studies.   When I stopped selling sugary drinks last year at my pharmacy or as some reported it, “banned sugary drinks”, some claimed I thought I could lower the weight of those in the village of Baddeck by “controlling” if they consumed these beverages.  Of course this is quite impossible an expectation and was never the intent.  Just last week a report of no change in obesity trends after a ban on new openings of fast food restaurants in South Los Angeles may have given many the impression that it didn’t matter if you ate there or not.  You were still going to stay obese anyway.

The messages that are lost on this are manifold.  First, there are people out there with good intentions that want to make a start or make some sort of statement if not to just remind you of the need to be healthier, even if there is no immediate measurable outcome.  Second, and perhaps more importantly, maybe the “measurable outcome” is that it spurs someone else to do something with the same intention.  Perhaps it isn’t directly related to the event that inspired the first act.  It could be that someone sees a ban on something and then they start a walking club because they want to be part of a solution to a problem that the first person wanted to fix.   Thirdly, no one is trying to control your lifestyle, regardless of how unhealthy it may be by taking these small steps.  These decisions that are being made are not micromanaging obscure trends, they are trying to apply general proven concepts of good diet and exercise to as large a group as possible.

It is easy to find fault with small measures when they don’t have the results we think they should have.  On their own however, individual changes do very little.  It just depends on how far back you step when you measure results.  One individual in my town getting healthy by my sugary drinks removal is huge.  You may not notice a significant difference when this is spread out over the entire population of the town.  A recent article in Science Daily had the title, “From soda bans to bike lanes: Which ‘natural experiments’ really reduce obesity”.  Being a part of a natural experiment with the Propel Centre at the University of Waterloo with the sugary beverage withdrawal this grabbed my interest.  The article stated that without before and after weight measurements of the population these studies may not have the rigor to come to meaningful conclusions on obesity related outcomes.  While this is probably true, it is difficult to argue the fact that a good diet helps to bring good health.  It is not rocket science at all to determine what diet gives you good health.  Of all of the scientific studies done today, there are very little out there that argue against the fact that calorie restriction and eating whole foods will improve your health.  Will the construction of a hiking trail in a community lower the obesity rate in that community, maybe or maybe not.  The only question is what is the tipping point that cumulative measures like this have a measurable effect.  What we should care about more is that it spurs others to push for ways that make others healthy, not just themselves.

There is a reason why many people don’t litter.  Not only was it driven into our heads as children and adults, but many get the fact that it is a cumulative measure in order to work.  It’s like the sand bag on the pile keeping a flood back.  Some bags aren’t even touching the water, but they all work to accomplish the job together.

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Pop Withdrawal From a Pharmacy and the new WHO Sugar Recommendations
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In response to my decision to remove sugary drinks from my pharmacy in September of 2014, there seem to be the odd lingering claim that “…targeting the sale of one particular category is not going to have a significant impact [on obesity]”, and that “information – not restriction – is key.”

While we agree with the point that obesity is a complex, multifactorial problem, it is completely baseless, in fact hovering on outright deception, that extra calorie intake does not increase your weight. In 2013, the journal PLOS Medicine published a systematic review of systematic reviews, which are the most comprehensive forms of evidence that we have. This review by Bes-Rastrollo and colleagues found that 83% of reviews not funded by the beverage industry a relationship between sugar-sweetened beverage consumption and weight gain. On the other hand, 83% of the reviews that were funded by the industry found insufficient evidence to support a positive association between sugar-sweetened beverage consumption and weight gain or obesity.

Also keep in mind metabolic disease which has also been shown to increase with consumption of these drinks and is one of the main reasons we pharmacists see our customers (high blood pressure, increased cholesterol, increased abdominal obesity, and insulin resistance). For example, a 2010 meta analysis in the Journal of Diabetes Care of over 300,000 subjects found that those that consumed the most sugary drinks, one or two per day (pop, juice, vitamin water, iced tea and energy drinks) had a 26% greater chance of developing type 2 diabetes than those that drank none or 1 serving per month.  They concluded that weight gain and metabolic syndrome correlates positively with consumption of these drinks. The New England Journal of Medicine published a study in 2011 which followed over 120,000 people and concluded that one 12 ounce sugary beverage serving a day increased their weight more than those that did not consume this beverage. Finally, a 2012 study in Circulation followed 40,000 men and found a 20% higher chance of having a heart attack or dying from a heart attack when one can of sugary beverage per day was consumed compared to men that didn’t.  This was verified by a second study.

Calorie consumption from all sugary beverages combined has continued to climb each decade, especially among children and teens.  By coincidence, today, the World Health Organization is changing its recommendation for daily total consumption of sugar to 6-12 teaspoons daily.  This would be exceeded by consuming even one can of soda.  Finally, we are seeing revised recommendations on sugar that follows science.  The new recommendation now recommends free sugars being as low as 5% of total calories, meaning a serving of orange juice is off limits – imagine, a recommendation that pushes you to eat the fruit instead of drinking the juice.  Brilliant!  There is now a separation of total sugars and free sugars.  The total sugar concept meant you could gobble up your calories with juice and pop, but now it’s considered free sugar.

The withdrawal of sugary beverages from Stone’s Pharmasave in Baddeck was not meant to “ban” pop sales, and I certainly do not expect to see a drastic change in obesity levels in my town as a result of my decision. I made this decision to help educate my customers on the effects of sugary drinks.  I therefore agree that education is an important component of healthy eating. However, in keeping with recommendations from world experts in obesity research (see the 2015 Lancet Obesity Series), I am also aiming to move beyond education by starting to create an environment in my store that is supportive of healthy food choices.  As a pharmacist, I know I shouldn’t sell tobacco, no matter what the industry claims. I don’t feel I should sell sugary beverages, either.

 

 

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WILL YOUR 12 YEAR OLD SELF BE TO BLAME FOR YOUR DEATH?
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There are few non-traumatic causes of death that happen as suddenly and without prior knowledge of any ill health more than myocardial infarction or a heart attack.  Certainly there are disease states or signs ahead of time that put you at risk for such an event.  Smokers (including secondhand smoke), high stress lifestyle, heavy metal exposure, air pollution, increased fat or sugar, diabetes, chronic infections, lack of exercise…does this fall into the heading of a 12 year old?  Sure it does.  In fact science has shown us that atherosclerosis has its beginnings in this age group.  Although we typically don’t screen this age group for any diseases unless symptoms arise, studies have shown that 1 in 6 teens already have atherosclerotic plaque in their coronary arteries.

So what is this atherosclerosis and what makes it such a ticking time bomb in so many of us? It is something that affects half of us (at least in this continent).  For reasons that are not completely understood, a fatty streak develops with the help of the above mentioned triggers, perhaps on a damaged or oxidized piece of endothelial cells which lines the inside of the blood vessel.  This causes the immune system to respond with white blood cells congregating to this area.   Cholesterol in the blood accumulates and a deposit begins to form in the lining of the blood vessel.  Calcium and fiberous tissue builds up forming a plaque and a noticeable hardening of the area occurs where the elasticity of the blood vessel is compromised.  As blood flows through the vessel, it expands and contracts and makes the plaque more unstable and prone to rupture.  A plaque can be stable or unstable.  Unstable plaques have more normal macrophages and foam cells (fat laden macrophages).  A fiberous cap develops that can rupture and expose the contents like collagen to the blood supply.  This results in a clot forming and breaking off, only to get lodged in a smaller blood vessel and the blood supply is blocked, like in the blood vessels supplying the heart or brain.  Or maybe the plaque grew to the point that it blocked off the vessel without rupturing at all.

So what does this have to do with a 12 year old.  All of this happens so slowly it can start at that age or earlier.  Plaques can change size and shape in only 6 weeks but the foundation of this structure have its beginnings in a child’s circulatory system.  We work so hard and pay so much in trying to eliminate cigarette smoke and to keep it from children today as opposed to 40 years ago – which is great.   Why not recognize the impact a sugary drink has on this highly influential blood vessel.  Removing sugary drinks from my pharmacy had many reasons, not the least of which are diabetes and obesity.  Sudden death from a heart attack later on in life with no warning should be a motivating factor in cutting back on or removing these beverages from everyone’s diet.

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