Objectives: This study describes community pharmacists’ opioid analgesic and medication for opioid use disorder (MOUD) practice behaviors and behavioral intentions in the context of primary, secondary, and tertiary prevention of opioid use disorder (OUD). Methods: The study sampling frame consisted of 2302 Tennessee community-practice pharmacists who were asked to complete a mailed, paper questionnaire. Behavioral intentions were elicited by asking pharmacists to indicate the number of times (0 to 10) they engage in a behavior, given 10 patients in 3 distinct vignettes. Perceptions of evidence-based MOUD and pain management patient care practices were also elicited. Results: A response rate of 19.7% was achieved. Pharmacists reported using a brief questionnaire to evaluate risk of opioid misuse with 2.1 ± 3.7 (mean ± SD) out of 10 patients, screening 2.1 ± 3.7 patients for current opioid misuse, discussing co-dispensing of naloxone with 2.9 ± 3.4 to 3.3 ± 4 out of 10 patients at a risk of overdose, and dispensing buprenorphine/naloxone to a mean of 4.6 ± 4.2 patients when they presented a prescription. Respondents perceived 38% of pain management and 30% of MOUD prescribers in their area to practice evidenced-based care. Conclusion: Pharmacists have an opportunity to improve the outcomes for patients prescribed opioids by increasing engagement across OUD prevention levels.

The Committee was charged with the responsibility for examining the need for change in pharmacy education and the models of leadership that would enable that change to occur across the academy. They also examined the question of faculty wellbeing in a time of change and made several recommendations and suggestions regarding both charges. Building upon the work of the previous Academic Affairs Committee, the 2018-19 AAC encourages the academy to implement new curricular models supporting personalized learning that creates engaged and lifelong learners. This will require transformational leadership and substantial investments in faculty development and new assessment strategies and resources. Recognizing that the magnitude of the recommended change will produce new stress on faculty, the committee identified the need for much additional work on student, faculty and leaders’ wellbeing, noting the limited amount of empirical evidence on pharmacy related to stress and resilience. That said, if faculty and administrators are not able to address personal and community wellbeing, their ability to support their students’ wellbeing will be compromised.

Objective. To examine the extent to which theory of planned behavior (TPB) constructs and demographic characteristics explain pharmacy students’ dispensing intentions in ethically or legally gray areas involving potential substance misuse or abuse. Methods. Two cohorts of third-year Doctor of Pharmacy (PharmD) students (n5159) were provided with five written cases describing common “gray area” dispensing scenarios in community practice involving medications and devices with potential for misuse or abuse (eg, long-term buprenorphine maintenance prescription without evidence of tapering, early refill of a narcotic for an out-of-town patient, non-prescription sale of pseudoephedrine). Students completed a 12-item survey instrument for each case. Items assessed whether the student would dispense the medication or device in the given scenario, how many times in 10 similar scenarios the student would dispense the medication or device, attitudes regarding dispensing, and subjective norm and perceived behavioral control beliefs. Results. Wide variation in the percentages of students who would dispense the medications or devices was noted across the five scenarios (14% in the buprenorphine scenario to 61% in the pseudoephedrine scenario). Attitude scores significantly predicted dispensing decisions in all scenarios (p,.001), whereas subjective norm and perceived behavioral control beliefs were significant predictors of dispensing only in select case scenarios. Gender and community pharmacy work experience did not consistently predict dispensing intentions. Conclusion. Student attitudes consistently predicted intent to dispense across five gray practice scenarios. These findings can be used to inform development of educational interventions that influence students’ attitudes and self-awareness in community practice decision-making scenarios involving potential substance misuse or abuse.

Abstract available in the American Journal of Pharmaceutical Education.

Cytochrome P450 (CYP) enzymes play a crucial role in the human body. These enzymes are responsible for the synthesis of steroid hormones and cholesterol, as well as the metabolism of external substances such as medications. While more than 50 CYP enzymes have been identified, just 6 are credited with metabolizing most drugs. Of note is CYP 3A4, which metabolizes ~34% of medications that use the CYP enzyme system. CYP enzymes are polymorphic, meaning there are different versions of the same enzyme; therefore there is variability from individual to individual in their ability to metabolize medications. In the oncology field tyrosine kinase has been identified as an important target controlling cell regulatory functions and proliferation. Thus, tyrosine kinase inhibitors have become widely used for a variety of malignancies. Many of these tyrosine kinase inhibitors rely on CYP 3A4 for metabolism and are subject to variable toxicities based on an individual patient’s genome. A 62-year-old female was diagnosed with Renal Cell Carcinoma (RCC). After undergoing a left nephrectomy, a surveillance scan 21 months after diagnosis was concerning for metastatic disease, which was then confirmed through biopsy. The patient was started on sunitinib 50 mg on days 1-28 of a six-week cycle for metastatic RCC. The patient suffered from Grade 3 myelosupression/mucositis within two weeks of the initiation of therapy. The early onset and severity of the toxicity lead to CYP 3A4 pharmacogenetic testing. She was subsequently found to have a 3A4 polymorphism (*1/*28). The dose of sunitinib was reduced to 25 mg followed by a further reduction to 12.5 mg due to toxicity. Eighteen months after starting sunitinib, a CT scan showed disease progression and therapy was changed to pazopanib. Due to her 3A4 polymorphism, the starting pazopanib dose was empirically reduced by 50% and was started at 400 mg/daily. Pazopanib was held for episodes of severe diarrhea and was further reduced to 200 mg/daily. Nine months after starting pazopanib, new imaging showed lesions in the patient’s liver, confirming disease progression. The patient was subsequently started on nivolumab but quickly progressed. She was then started on cabozantinib at a dose reduced 20 mg/daily. This initial dosing was tolerated well by the patient, so a decision was made to alternate between 20 and 40 mg/daily to increase to an average of 30 mg/daily. She is currently tolerating the 30 mg/daily and continues treatment for metastatic RCC. As described above, CYP 3A4 polymorphisms can result in severe toxicities that present earlier in the treatment course than traditionally expected. Moving forward there may be a role in testing for these polymorphisms to determine an individual’s optimal dose before initiating therapy with tyrosine kinase inhibitors. The advantage of performing such testing would be to limit the severity of toxicities experienced by this patient population, while retaining the overall benefit of these medications.

Drug-induced pancreatitis is a condition characterized by sudden inflammation of the pancreas that can be mild or severe but usually subsides. Signs and symptoms consist of abdominal pain, nausea/vomiting, low-grade fever and pain radiating to the lower back. The incidence of acute drug-induced pancreatitis is approximately 2% but in patients that have disease states that predispose them to the development of pancreatitis, such as malignancy, hypercalcemia, tumor lysis syndrome, and immunosuppression it is found to be much higher. Conditions that should be considered in the differential diagnosis are cholelithiasis, hyperlipidemia, pancreatic tumor and alcoholism. Additionally, several medications have been reported to have an association with inducing pancreatitis. The focused medications are cyclophosphamide, vincristine and prednisone. All three of these drugs come with a probable association of medications that can induce pancreatitis. Having risk factors and potential drugs that could induce pancreatitis make it challenging to pinpoint the cause. A 79-year-old male presented to the hospital with generalized weakness and altered mental status lasting approximately 5 days. A clinical diagnosis of angioimmunoblastic T-cell lymphoma was made and chemotherapy was started during the stay. CVP (cyclophosphamide, vincristine, and prednisone) chemotherapy was given along with a rasburicase for potential tumor lysis syndrome. All labs were within normal limits prior to chemotherapy except for calcium, which was 10.9mg/dL and 12.42mg/dL after correction for the albumin being 2.1gm/dL. The following day the patient complained of severe abdominal pain and had mild abdominal distention. A diagnosis of pancreatitis was made after labs revealed: amylase >600 U/L, corrected calcium 12.04mg/dL, glucose 260mg/dL, a bump in BUN from 34 to 50mg/dL and a normal lipid panel. The patient also had a CT scan that revealed cholelithiasis. Subsequently the chemotherapy was stopped and normal saline was given at 50mL/hr due to his heart failure with reduced ejection fraction. Upon discontinuation of the chemotherapy, the patients abdominal pain resolved within 2 days and labs started to return to normal. Labs revealed: corrected calcium 10.5mg/dL, glucose 98mg/dL and BUN 40mg/dL. The chemotherapy agent was switched to intrathecal methotrexate, in which the patient had no trouble tolerating and the abdominal pain never returned. Ultimately, the patient developed worsening heart failure and 20 days later expired. The complexity of pinpointing conditions, risk factors, or drug causes for pancreatitis is outlined in this case. This patient had several risk factors for developing pancreatitis such as malignancy and hypercalcemia but didn’t have any signs/symptoms. After CVP chemotherapy was started, the signs/symptoms matched the labs and clinical diagnosis but cholelithiasis revealed. Once the chemotherapy was stopped all signs/symptoms subsided and labs returned to normal. The most likely cause was the chemotherapy due to the timeline from initiation of therapy to the onset of pancreatitis symptoms but this case is extremely complex due to other conditions and risk factors.

Abstract available in the American Journal of Pharmacy Education.

Abstract available in the Clinical Pharmacology in Drug Development.

Background: Mannitol has been used in the past for the prevention of cisplatin-induced nephrotoxicity. Studies on its efficacy have conflicting results. An educational newsletter was designed for local oncologists on the conflicting data of mannitol use in preventing cisplatin-induced nephrotoxicity. Purpose: The purpose of this study was to determine whether a pharmacist-created newsletter intervention led to changes in the mannitol prescribing practices of local oncologists. Methods: A newsletter describing the paucity of evidence to support mannitol use to prevent cisplatin-induced nephrotoxicity was distributed via e-mail to local oncologists in October 2010. Mannitol prescribing rates were retrospectively evaluated before and after newsletter distribution. The Mann-Whitney U test was used to compare nonparametric continuous data. The chi-square test was used for nominal data. Descriptive statistics were performed for baseline demographics, and odds ratios were calculated for possible risk factors for acute kidney injury (AKI). The primary endpoint was a change in mean mannitol dose before and after the newsletter intervention. The secondary endpoint was the difference in the rate of AKI before and after the intervention. Data were collected for 67 patients with various malignancies. Results: There was a difference in the average mannitol dose before and after newsletter intervention (P = .02). The rates of AKI before and after newsletter were similar. Conclusion: A pharmacist-led newsletter intervention was associated with significantly decreased rates of mannitol usage after intervention.

OBJECTIVE: To describe a systematic approach to active learning using a lesson template with a graphic organizer activity. INNOVATION: The authors describe a tool that can be used to incorporate a graphic organizer activity into a traditional lecture class to promote active learning. This interactive template offers a step-by-step process to plan and implement a graphic organizer activity. The graphic organizer was used in a contact dermatitis lecture as part of a Nonprescription Medicines course for first year pharmacy students. CRITICAL ANALYSIS: A survey of students immediately after the activity identified that students agreed they were interested in the activity, were engaged with the activity, and perceived an understanding of the course material. An instructor reflection revealed that students were excited and identified some instructor challenges to executing the activity. NEXT STEPS: Instructors interested in using graphic organizers in lectures can refer to this approach for guidance. In addition to a graphic organizer, the structure of this template can be applied to different active learning activities, thus creating consistency in delivering active learning.