Includes bibliographical references.

The evolution of pharmacists’ roles in disasters, from logistics to assessing and prescribing -- Patient-oriented pharmacy practice research: Why should we care? -- Professional identity in pharmacy: Opportunity, crisis or just another day at work? -- The journey begins: BC roadmap for pharmacist integration into team-based primary care -- CPS 2020 to focus on scope harmonization efforts in key therapeutic areas -- Cross-Canada updates -- Impact of pharmacist-led medication assessments on opioid utilization -- Use of low-dose acetylsalicylic acid for cardiovascular disease prevention: A practical, stepwise approach for pharmacists -- Pharmacists’ perceptions of their working conditions and the factors influencing this: Results from 5 Canadian provinces -- Costs and consequences of the Portuguese needle-exchange program in community pharmacies.

[Article Title: The evolution of pharmacists’ roles in disasters, from logistics to assessing and prescribing/ Kaitlyn E. Watson, Karen Horon and Ross T. Tsuyuki, p. 129-131]

Abstract: In terms of mitigating the health-related impacts of disasters, pharmacists are the unsung heroes. Without them, there would be no medications for patients in need during and following a disaster or emergency. These days, pharmacists offer more than just logistics and dispensing during emergencies, which parallels the evolution of the profession.
Pharmacists have always been assisting in emergencies but previously have rarely been recognized for their contributions. Before 2001, pharmacists were only acknowledged for their primary role in logistics—getting drugs to where they were needed in an emergency.1,2 Figure 1 illustrates the evolution of pharmacists’ roles in disasters as outlined in the literature.

https://doi.org/10.1177/1715163520916921

[Article Title: Patient-oriented pharmacy practice research: Why should we care?/ Yazid N. Al Hamarneh, Zahava Rosenberg-Yunger, Arti Saxena, Lisa Dolovich and Ross T. Tsuyuki, p. 133-136]

Abstract: Pharmacists deal with multiple competing priorities when practising to their full scope. Deciding on what services to implement, how best to implement them and whether care processes are effective are key questions requiring evidence to inform decisions. The routine involvement of patients and pharmacy practice researchers can help improve how the profession of pharmacy asks and answers these questions.

https://doi.org/10.1177/1715163520909122

[Article Title: Professional identity in pharmacy: Opportunity, crisis or just another day at work?/ Jamie Kellar, Jennifer Lake, Naomi Steenhof and Zubin Austin, p. 137-140]

Abstract: A pharmacist receives a prescription and believes there is a dosing error, so calls the physician to clarify. The office secretary takes a message to pass on to the physician. An hour later, the secretary calls back and says, “I spoke with the doctor and the prescription was written correctly. Dispense as it is written,” providing no other information or details. The pharmacist then documents “spoke with MD office and confirmed dose.”

https://doi.org/10.1177/1715163520913902

[Article Title: The journey begins: BC roadmap for pharmacist integration into team-based primary care/ Barbara Gobis and Peter J. Zed, p. 141-143]

Abstract: For the past 20 years, the profession of pharmacy has been changing to align pharmacist roles and scope with the growing needs of patients and society. Pharmacists today have the training, skills and abilities to meet these needs through the provision of comprehensive medication management, which includes patient assessment, identification and prioritization of drug therapy problems; collaborative care plans; and follow-up to resolve drug therapy problems and optimize drug therapy outcomes for patients.

https://doi.org/10.1177/1715163519880577

[Article Title: CPS 2020 to focus on scope harmonization efforts in key therapeutic areas, p. 144]

Abstract: Canadian pharmacists scope 2020 (cps 2020) was launched in 2017 as an initiative to define, describe and develop a national harmonized scope of practice for Canadian pharmacists. The goal: to define the benefits to patients and the health care system when pharmacists are able to work to their full scope.
The initial work undertaken was to evaluate evidence that demonstrates the value of pharmacy services in 4 domains of pharmacist-delivered services: prescribing, dispensing, health testing and medication administration authority.

“As work continued it became clear that there were challenges with completing such a broad evaluation of evidence across all 4 domains,” says Shelita Dattani, director, Practice Development and Knowledge Translation and lead on the CPS 2020 initiative. “The extent of the initiative proved too large and diverse to review at one time and would not be scientifically feasible or meaningful.”

Over the past few months, after reflecting on the overall purpose and vision of the initiative, it was evident that the best way to achieve success was to target the harmonization efforts on one therapeutic area first and then expand that approach (including lessons learned) across other therapeutic areas using a phased approach.

The initial area of focus chosen is opioid stewardship.

Pharmacists, among the most accessible health care providers, are often the first providers to observe signs of opioid-use disorder.
A full and harmonized scope of practice for pharmacists in opioid stewardship responds to both critical patient needs and challenges to accessing primary health care providers, says Dattani. Moreover, there are well-defined pharmacist opioid stewardship activities where the benefits of scope harmonization can be demonstrated.

“Through the next year, our intent is to map out an evidence-informed action plan for a broader pharmacists’ role in opioid stewardship. We will then build on this approach and expand it to the evaluation of full and harmonized scope in other therapeutic areas,” she says.

The focus on opioid stewardship aligns with CPhA advocacy efforts for improving the safe and effective use of prescription opioids by expanding prescription opioid monitoring programs and supporting provinces and territories to ensure they have the best tools and technologies for this task.

“We are establishing a new overarching Steering Committee whose objective will be to focus solely on strategic guidance for the implementation of CPS 2020. We are also forming multiple advisory/working groups to review and analyze the evidence, gaps in care and opportunities for pharmacists to fill those gaps in each therapeutic area,” says Dattani.

https://doi.org/10.1177/1715163520917137

[Article Title: Cross-Canada updates, p. 145-147]

https://doi.org/10.1177/1715163520917138

[Article Title: Impact of pharmacist-led medication assessments on opioid utilization/ Hishaam Bhimji and Derek Jorgenson, p. 148-152]

Abstract:

Background
Canadians are the second-highest users of opioids in the world, and the rate of opioid-related death in Canada has been increasing dramatically. The Public Health Agency of Canada recently reported that over 4000 people died of opioid-related overdoses in 2017.1 In an effort to reduce opioid-related harm, the Canadian Guideline for Opioids in Chronic Non-Cancer Pain recommends that health professionals meet regularly with patients who are prescribed chronic opioids to develop treatment plans to taper opioid doses, maximize use of nonopioid pain medications, provide education to minimize opioid risk and offer frequent follow-up.2 This recommendation is challenging to implement because it is time-consuming and resource intensive. Consequently, this service is often offered in interprofessional chronic pain clinics in Canada, where wait lists can be long. Some regions, such as Saskatchewan, do not even have such clinics.

Pharmacists are reported to be among the most underused health professionals in North America, and the US Department of Health recently noted that they are uniquely positioned to help in a more substantive way to address the opioid crisis.3 In 2019, an article was published that proposes a framework to help pharmacists implement opioid guideline recommendations into practice.4 Unfortunately, studies evaluating the impact of pharmacist interventions, targeting opioid use in chronic noncancer pain, are limited. One retrospective chart audit evaluated 148 patients taking opioids for chronic noncancer pain in a Veterans Health clinic in California.5 Pharmacists working in the clinic developed a telephone assessment service that included a monthly call to patients taking opioids. This study found that opioid prescriptions were changed in 32% of patients, and over half of the pharmacists’ recommendations were to reduce doses. A Belgian study evaluated the impact of a multidisciplinary pain team, which included a pharmacist, on analgesic utilization in 93 patients with chronic noncancer pain. This study found that 53% of patients had a medication change implemented after being assessed by the pharmacist.6 Another study that assessed the impact of a pharmacist-led chronic pain clinic in the United States found improvements in chronic pain scores and reduced overall health expenditures among 564 patients who attended the clinic.7
Pharmacist-led medication assessment programs are available as publicly funded services in 8 of the 10 Canadian provinces; however, none specifically include opioid use or chronic pain in the eligibility criteria.8 Since these programs focus on medication optimization and patient education, it is conceivable that they could be leveraged to focus on patients who are prescribed chronic opioids to reduce the risk of unintentional overdose and death. There is significant research published regarding the benefits of pharmacist-led medication assessment programs. Studies have found that the service can improve quality of life, medication appropriateness, patient knowledge, chronic disease management, patient satisfaction and medication cost9-15; however, there were no published studies identified that evaluated the impact of a contemporary pharmacist-led medication assessment program on opioid utilization. The aim of this study was to determine the impact of a publicly funded, Canadian pharmacist-led medication assessment program on opioid utilization among ambulatory patients with chronic noncancer pain.

Methods
This study was a retrospective chart audit of adult patients taking opioids for chronic noncancer pain who attended the Medication Assessment Centre (MAC) in Saskatoon, Saskatchewan. The primary outcomes were changes in mean morphine equivalent (MME) doses and utilization of nonopioid adjunctive pain medications, before and after a medication assessment with a pharmacist.
The MAC is a pharmacist-run teaching clinic located in the College of Pharmacy and Nutrition at the University of Saskatchewan that provides medication assessments. Patients can either be referred to the MAC by a health professional or they can self-refer. These assessments follow the policies and procedures of the publicly funded Saskatchewan Medication Assessment Program (SMAP), which remunerates community pharmacies for patient assessments. The MAC is a nondispensing pharmacist clinic, and it is similar to a community pharmacy only in that the pharmacist is not physically colocated with other health professionals and communicates with family physicians primarily via facsimile. The MAC pharmacist is not responsible for additional duties that are common in community pharmacy settings, such as dispensing, vaccinations or patient self-care requests. Medication assessments at the MAC are provided by a pharmacist with a Bachelor of Pharmacy Degree (BSP) and a 1-year hospital residency (ACPR) but no formal additional training in chronic pain management or addictions.
The medication assessments provided at the MAC and within community pharmacies in Saskatchewan require that the pharmacist meet with patients to create a comprehensive medication list, provide education and ensure medication appropriateness and safety. Medication changes suggested by the pharmacist are typically approved by the patient’s family physician prior to implementation. To be eligible for government reimbursement of this service, patients must be 65 years or older and taking 5 or more chronic medications, an anticoagulant, or a Beers criteria medication.16 The MAC also provides assessments for patients who do not meet these criteria since it is funded by research grants and charitable donations and does not rely on fee-for-service billings.

All patients, 18 years and older, who were referred to the MAC for the first time during the 2017 calendar year and who were taking an opioid for chronic noncancer pain were included in the study. Chart data of patients who met the inclusion criteria were extracted in August 2018. The patient medication lists compiled by the pharmacist at the initial appointment, which included prescription and nonprescription drugs, were compared with the medication lists compiled at the most recent MAC follow-up appointment. If there were any differences between the medication lists (e.g., medication additions/discontinuations, dose adjustments), the charts were reviewed to determine if the changes were directly related to a recommendation made by the MAC pharmacist. Only changes that were a direct result of a documented MAC pharmacist recommendation were included in the analyses.

After excluding any medication changes that were not initiated by the MAC pharmacist, the MME doses before medication assessment and after assessment were calculated using the opioid conversion tables from the National Pain Centre (for fentanyl) and the Canadian Guideline for Opioids in Chronic Non-Cancer Pain for all other opioids.2 The proportion of patients taking various adjunctive, nonopioid pain medications before medication assessment and after assessment was compared using the chi-square test. Changes in MME doses before medication assessment and after assessment were compared using the Wilcoxon signed rank test. Data analyses were completed using IBM SPSS Statistics software (Version 25.0; SPSS, Inc., an IBM Company, Chicago, IL). The protocol was approved by the University of Saskatchewan research ethics board.

Results
A total of 129 new patients were referred to the MAC in 2017. Of those, 27.9% (n = 36) met the inclusion criteria and were included in the study. All 36 patients were seen by the pharmacist for an initial assessment and an average of 2.8 additional follow-up appointments. The mean age of study subjects was 59.8 years, and patients were taking an average of 15.2 different medications (for any indication) at baseline. The most common indications for opioid use were unspecified chronic pain or migraine headaches. The most common opioids used were hydromorphone and codeine (Table 1).

https://doi.org/10.1177/1715163520908285

[Article Title: Use of low-dose acetylsalicylic acid for cardiovascular disease prevention: A practical, stepwise approach for pharmacists/ Arden R. Barry, William M. Semchuk, Ann Thompson, Marlys H. LeBras and Sheri L. Koshman, p.153-160]

Abstract: Low-dose acetylsalicylic acid (ASA) is recommended in patients with established cardiovascular disease. However, the role of ASA in those without cardiovascular disease (i.e., primary prevention) is less clear, which has led to discordance among Canadian guidelines. In 2018, 3 double-blind, randomized controlled trials were published that evaluated ASA 100 mg daily versus placebo in patients without established cardiovascular disease. In the ASPREE trial, ASA did not reduce the risk of all-cause death, dementia, or persistent physical disability in patients ≥70 years of age but increased the risk of major bleeding. In the ARRIVE trial, ASA failed to lower the risk of a composite of cardiovascular events but increased any gastrointestinal bleeding in patients at intermediate risk of cardiovascular disease. In the ASCEND trial, ASA significantly reduced the primary composite cardiovascular outcome in patients with diabetes for a number needed to treat of 91 over approximately 7.4 years. Yet major bleeding was increased with ASA for a number needed to harm of 112. Therefore, in most situations, ASA should not be recommended for primary cardiovascular prevention. However, there are additional indications for ASA beyond cardiovascular disease. Thus, a sequential algorithm was developed based on contemporary evidence to help pharmacists determine the suitability of ASA in their patients and play an active role in educating their patients about the potential benefits (or lack thereof) and risks of ASA. Can Pharm J (Ott) 2020;153:xx-xx.

https://doi.org/10.1177/1715163520909137

[Article Title: Pharmacists’ perceptions of their working conditions and the factors influencing this: Results from 5 Canadian provinces/ Nicole W. Tsao, Shahrzad Salmasi, Kathy Li, Larry D. Lynd and Carlo A. Marra, p. 161-169]

Abstract:

Introduction:
Our previous study in British Columbia (BC) indicated that pharmacists have a poor perception of their working conditions. The objective of this study is to assess pharmacists’ perceptions of their working conditions in 4 other Canadian provinces.

Methods:
This was a cross-sectional study across Alberta, New Brunswick, Prince Edward Island and Newfoundland and Labrador, using a survey adapted from the Oregon Board of Pharmacy. Data collected previously from BC were also included in the analyses. The survey was emailed to all pharmacist registrants. Respondents were provided with 6 statements and asked to rate their agreement with them, using a 5-point Likert scale. Statements were framed such that agreement with them indicated good perception of working conditions. Logistic regression analyses were used to study the relationship between workplace factors on perception of working conditions.

Results:
Pharmacists perceived their working conditions to be poor. Pharmacists indicated that they do not have time for break/lunch (48.3% of respondents), work in environments that are not conducive to safe and effective primary care (26.5%), are not satisfied with the amount of time they have to do their job (44.0%) and face shortage of staff (shortage of pharmacists: 33.7%, technicians: 36.4%, clerk staff: 30.3%). Significant factors associated with poor perception were workplace-imposed quotas, high prescription volume, working in chain pharmacies and long prescription wait times.

Conclusion:
A high percentage of Canadian pharmacists perceived their working conditions to be poor. Considering the patient-related consequences of pharmacists’ poor working conditions and the system-related reasons identified behind it, we call for collaborative efforts to tackle this issue.

https://doi.org/10.1177/1715163520915230

[Article Title: Costs and consequences of the Portuguese needle-exchange program in community pharmacies/ Margarida Borges, Francesca Fiorentino, Gonçalo Jesus, Maria Cary, José Pedro Guerreiro, Suzete Costa and António Vaz Carneiro, p. 170-178]

Abstract:

Background:
Needle-exchange programs (NEPs) reduce infections in people who inject drugs. This study assesses the impact community pharmacies have had in the Needle-Exchange Program in Portugal since 2015.

Methods:
Health gains were measured by the number of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections averted, which were estimated, in each scenario, based on a standard model in the literature, calibrated to national data. The costs per infection were taken from national literature; costs of manufacturing, logistics and incineration of injection materials were also considered. The results were presented as net costs (i.e., incremental costs of the program with community pharmacies less the costs of additional infections avoided).

Results:
Considering a 5-year horizon, the Needle Exchange Program with community pharmacies would account for a 6.8% (n = 25) and a 6.5% reduction (n = 22) of HCV and HIV infections, respectively. The present value of net savings generated by the participation of community pharmacies in the program was estimated at €2,073,347. The average discounted net benefit per syringe exchanged is €3.01, already taking into account a payment to community pharmacies per needle exchanged.

Interpretation:
We estimate that the participation of community pharmacies in the Needle Exchange Program will lead to a reduction of HIV and HCV infections and will generate over €2 million in savings for the health system.
Conclusions:
The intervention is estimated to generate better health outcomes at lower costs, contributing to improving the efficiency of the public health system in Portugal.

https://doi.org/10.1177/1715163520915744