The role of pharmacists in opioid stewardship: A scoping review.

BACKGROUND: The opioid epidemic is an international public health concern. Pharmacists are in a strategic position to promote and implement effective opioid stewardship due to both their central role on health care teams and frequent interaction with patients. Despite this integral role, pharmacists do not have harmonized scopes of practice in opioid stewardship. OBJECTIVES: This scoping review was conducted to identify and critically review the role of pharmacists in opioid stewardship and identify future areas of study. METHODS: The scoping review was conducted according to the methodological framework proposed by Arksey and O'Malley, which was further modified by the Joanna Briggs Institute. Six databases were searched for original, peer-reviewed research; PubMed (MEDLINE), Ovid Embase, Ovid International Pharmaceutical Abstracts, Scopus, Cochrane Library, and APA PsycInfo. RESULTS: In 92% of the included studies (n = 77), opioid stewardship interventions led by either a pharmacist or in an interdisciplinary team resulted in improvements in at least one outcome measure, with education and medication therapy adjustments being the most predominant activities. Other areas supported by evidence include community stakeholder education, policy and guideline setting, and risk assessment. CONCLUSION: This scoping review provides valuable insight into the various roles pharmacists can have in opioid stewardship. The findings from this review identified opioid stewardship activities that can make significant contributions towards reducing the impact of the opioid crisis. This review informs future research and has the potential to influence pharmacy practice on a national and international scale.

The role of pharmacists in opioid stewardship: Protocol.

BACKGROUND: The opioid crisis is a worldwide public health concern. In North America, evidence suggests that the increase in opioid prescriptions correlates with the observed increase in opioid-related mortality and morbidity. Pharmacists are in a strategic position to promote effective opioid stewardship as they have a central role on healthcare teams. However, in many contexts, pharmacists do not have a harmonized scope of practice and no standardized opioid stewardship approach has been implemented. OBJECTIVES: A scoping review will be conducted to identify and summarize evidence on the role of pharmacists in opioid stewardship and identify areas for future study. METHODS: The scoping review will be conducted according to the methodological framework proposed by Arksey and O'Malley, which was further modified by the Joanna Briggs Institute. Six databases will be searched which include PubMed, Embase, International Pharmaceutical Abstracts, Scopus, Cochrane Library, and APA PsycInfo. PROJECT IMPACT: The findings of this review will identify opioid stewardship activities that can contribute towards reducing the impact of the opioid crisis. Additionally, it will provide foundational strategies to promote policy level change and foster a harmonized scope of practice. This review has the potential to inform future research, impact pharmacy practice, and drive policy change.

A demonstration study comparing "role-emergent" versus "role-established" pharmacy clinical placement experiences in long-term care facilities.

BACKGROUND: Increasing challenges to recruit hospital sites with full-time on-site pharmacy preceptors for institutional-based Advanced Pharmacy Practice Experiences (APPE) has made it necessary to consider alternate experiential models. Sites with on-site discipline specific preceptors to supervise students have typically been referred to in the literature as "role-established" sites. In British Columbia, long-term care (LTC) facilities offered a unique opportunity to address placement capacity issues. However, since the majority of these facilities are serviced by off-site community pharmacists, this study was undertaken to explore the viability of supervising pharmacy students remotely - a model referred to in the literature as "role-emergent" placements. This paper's objectives are to discuss pharmacy preceptors' and LTC non-pharmacist staff experiences with this model. METHODS: The study consisted of three phases: (1) the development phase which included delivery of a training program to create a pool of potential LTC preceptors, (2) an evaluation phase to test the viability of the LTC role-emergent model with seven pharmacists (two role-established and five role-emergent) together with their LTC staff, and (3) expansion of LTC role-emergent sites to build capacity. Both qualitative and quantitative methods were used to obtain feedback from pharmacists and staff and t-tests and Mann-Whitney U tests were used to examine equivalency of survey outcomes from staff representing both models. RESULTS: The 76 pharmacists who completed the training program survey rated the modules as "largely" meeting their learning needs. All five role-emergent pharmacists and 29 LTC participating staff reported positive experiences with the pharmacy preceptor-student-staff collaboration. Preceptors reported that having students work side-by-side with facility staff promoted inter-professional collaboration. The staff viewed students' presence as a mutually beneficial experience, suggesting that the students' presence had enabled them to deliver better care to the residents. As a direct result of the study findings, the annual role-emergent placement capacity was increased to over 45 by the end of the study. CONCLUSIONS: This study demonstrated that role-emergent LTC facilities were not only viable for quality institutional APPEs but also provided more available sites, greater student placement capacity, and more trained pharmacy preceptors than could be achieved in role-established facilities.

Promoting direct patient care services at community pharmacies through advanced pharmacy practice experiences.

OBJECTIVES: To determine the relative benefits of three different models of advanced pharmacy practice experience (APPE) in successfully integrating the delivery of direct patient care into students' final year community pharmacy clerkships. METHODS: All fourth-year pharmacy students at the University of British Columbia were divided into one of three study arms for their community APPE: a 2 × 4-week rotation in a traditional format, a 1 × 8-week rotation where their preceptors had experienced a 2-day education course and a 1 × 8-week rotation with both preceptor education plus a 5-day pre-APPE in-store orientation and peer debriefing. KEY FINDINGS: All 123 students conducted patient consultations and documented their care. Students in the pre-APPE + preceptor education arm provided nearly double the number of direct patient consultations than did students in the preceptor-education-only arm or the traditional 2 × 4-week arm. Numbers of drug-related problems identified and interventions performed per patient consult did not differ across study arms. CONCLUSIONS: Pre-APPE orientation activities provided an enhanced learning environment, promoted greater student engagement, provided care to more patients, increased preceptor preparedness and enhanced in-store patient-centred care practice. Certain of these learning activities can also form part of third- and fourth-year introductory pharmacy practice experiences to prepare students for their final-year APPE.

An interprofessional Web-based resource for health professions preceptors.

OBJECTIVE: To develop a Web-based preceptor education resource for healthcare professionals and evaluate its usefulness. METHODS: Using an open source platform, 8 online modules called "E-tips for Practice Education" (E-tips) were developed that focused on topics identified relevant across healthcare disciplines. A cross-sectional survey design was used to evaluate the online resource. Ninety preceptors from 10 health disciplines affiliated with the University of British Columbia evaluated the E-tips. RESULTS: The modules were well received by preceptors, with all participants indicating that they would recommend these modules to their colleagues, over 80% indicating the modules were very to extremely applicable, and over 60% indicating that E-tips had increased their confidence in their ability to teach. CONCLUSION: Participants reported E-tips to be highly applicable to their teaching role as preceptors. Given their multidisciplinary focus, these modules address a shared language and ideas about clinical teaching among those working in multi-disciplinary settings.

An online module series to prepare pharmacists to facilitate student engagement in patient-centered care delivery: development and evaluation.

INTRODUCTION: Accreditation bodies across North America have adopted revised standards that place increased emphasis on experiential education and preceptors to promote and demonstrate patient-centered, pharmaceutical care practices to students. Since such practices are still evolving, challenges exist in recruiting skilled preceptors who are prepared to provide such opportunities. An online educational module series titled "A Guide to Pharmaceutical Care" (The Guide) was developed and evaluated to facilitate this transition. The objectives of this paper are: (1) to describe the development of the modules; and (2) to present the evaluation results from its pilot testing. METHODS: The Guide was developed as an online, self-directed training program. It begins by providing an overview of patient care (PC) philosophy and practice, and then discusses the tools that facilitate PC. It also provides a range of tips to support students as they provide PC during their experiential learning. Pharmacists participating in the pilot study were recruited using purposive and snowball sampling techniques. A pre-post quantitative survey with additional open-ended questions was used to evaluate the modules. RESULTS: THE MODULES INCORPORATED A VARIETY OF TEACHING STRATEGIES: self-reflection exercises, quizzes to review important concepts, quick tips, flash cards, and video clips to illustrate more in-depth learning. Thirty-two pharmacists completed the pre-post assessment and reported significant increases in their confidence because of this training. The most influenced outcome was "Application of techniques to facilitate learning opportunities that enable pharmacy students to practice pharmaceutical care competencies." They also indicated that the training clarified necessary changes in their teaching techniques as well as increased their own practice skills. CONCLUSION: The study results indicated that a series of self-paced online modules with appropriate content improved the pharmacists' confidence to nurture students' experiential learning for PC practice as well as enhanced their PC knowledge and skills within their own practices.

An enhanced community advanced pharmacy practice experience model to improve patient care.

OBJECTIVE: To quantify the benefits of an enhanced advanced pharmacy practice experience (APPE) community pharmacy model compared to the traditional program by comparing basic and comprehensive pharmaceutical care provided by students and assessing preceptors' perceptions of the APPE. METHODS: A pilot study consisting of 1 enhanced APPE arm and 2 traditional APPE (control) arms was conducted. The enhanced APPE consisted of a preceptor education program, a 5-day onsite student orientation, and an 8-week experience completed at 1 rather than 2 community sites. RESULTS: The level of interventions provided by students in the enhanced APPE arm significantly surpassed that of students in the control arms. In addition, preceptor questionnaires indicated overwhelming support for the enhanced model over the traditional APPE. CONCLUSIONS: The study's findings demonstrated that the enhanced APPE model enabled the participating pharmacies to provide increased level of patient care (as compared to the control sites) and improved preceptor satisfaction with the APPE.

Poloxamer 407-mediated alterations in the activities of enzymes regulating lipid metabolism in rats.

PURPOSE: Recently, the P-407-treated mouse was established as a useful animal model of hyperlipidemia and atherosclerosis. The present study was aimed to determine whether P-407-induced hyperlipidemia in the rat is associated with alterations in the activities of enzymes responsible for lipid metabolism. METHODS AND RESULTS: Rats were made hyperlipidemic by i.p. injection of 1.0 g/kg P-407 and blood samples collected 24 h after administration of P-407. Plasma from P-407-treated rats demonstrated 7- and 13-fold increases in cholesterol and triglycerides, respectively (p < 0.001). The plasma lecithin cholesterol acyl transferase (LCAT) activity in these animals was 4-5-fold greater than control animals (p < 0.05). Further, the plasma cholesteryl ester transfer protein (CETP) activity in P-407-treated rats was increased by approximately 25%, which was inhibited by > 50% in the presence of TP2, a monoclonal anti-CETP antibody (27.03 +/- 3.16 vs. 10.87 +/- 3.23; p < 0.05). The plasma CETP protein levels were also increased by 5-6-fold in P-407-treated animals (control 0.35 +/- 0.17 vs. P-407 treated 1.87 +/- 0.35 ug/ml, p < 0.05). However, the plasma hepatic lipase (HL) (control 49.2 +/- 3.1 vs. P-407-treated 2.0 +/- 0.38 umol/ml/h; p < 0.001) and lipoprotein lipase (LPL) (control 45.9 +/- 0.09 vs. P-407-treated 2.03 +/- 0.38 mol/ml/hr; p<0.001) activities in these animals were significantly inhibited. CONCLUSIONS: In summary, P-407-induced hyperlipidemia in rats is associated with alterations in plasma LCAT, CETP, HL and LPL activities.

Cyclosporine binds to the neutral lipid and potentially other binding sites of lipid transfer protein I.

PURPOSE: The objective of this study was to determine if cyclosporine (CSA) binds directly to the neutral lipid-binding site of lipid transfer protein I (LTP I). METHODS: This was accomplished by determining LTP I concentrations and cholesteryl esters (CE) and CSA radioactivity of eluted fast protein liquid chromatography (FPLC) fractions following an injection of different treatment groups (i.e., LTP I alone, 3H-CE liposomes alone, 3H-CSA liposomes alone, 3H-CE liposomes + LTP I, and 3H-CSA liposomes + LTP I) onto an FPLC column. Our hypothesis is that CSA will bind to the neutral lipid-binding site of LTP I because of its high solubility/interaction with cholesterol and triglycerides. RESULTS: Coincubation of LTP I with 3H-CE liposomes resulted in a significant decrease in the LTP I peak reported at fraction 10 and the appearance of a broad LTP I peak at fractions 30-34 compared to control. Coincubation of LTP I with 3H-CSA liposomes resulted in a significant decrease in the LTP I peak reported at fraction 10 and fraction 30 compared to control. In addition, 30% of the original radioactivity associated with 3H-CSA liposomes was found coeluted with the unbound LTP I peak at fraction 10. Taken together, these findings suggest that CSA does bind to the neutral lipid-binding site of LTP I but may also bind to other regions along the LTP I molecule. CONCLUSIONS: We have determined that LTP I mediated transfer of CSA between lipoproteins may be a result of the direct binding of CSA to LTP I at both its neutral binding site and potentially other binding sites along the molecule. These findings provide further evidence that the distribution/redistribution of drugs among plasma lipoproteins facilitated by LTP I may serve as a possible mechanism for determining the ultimate fate of drug compounds.

Cholesteryl ester transfer protein facilitates the movement of water-insoluble drugs between lipoproteins: a novel biological function for a well-characterized lipid transfer protein.

This review article addresses the recently discovered finding that cholesteryl ester transfer protein (CETP) can facilitate the transfer of water-insoluble drugs between different lipoprotein subclasses. This protein, which is often referred to as lipid transfer protein I (LTP I), is involved in the lipid regulation of lipoproteins. It is responsible for the facilitated transfer of core lipoprotein lipids, cholesteryl ester and triglycerides, and approximately one-third of the coat lipoprotein lipid, phosphatidylcholine, between different plasma lipoproteins. The human body appears to recognize exogenous water-insoluble drugs as lipid-like particles, which suggests that these compounds may interact with lipoproteins just like endogenous plasma lipids, and thus their transfer between lipoproteins may be facilitated by plasma CETP. Patients with a variety of diseases (i.e. diabetes, cancer, AIDS) often exhibit hypo- and/or hypercholesterolemia and triglyceridemia, commonly referred to as dyslipidemias, which result in changes in their plasma lipoprotein-lipid composition and concentration. The interaction of water-insoluble drugs with these dyslipidemic lipoproteins may be responsible for the differences seen in the pharmacokinetics and pharmacodynamics of the drug within different diseased patient populations. It is possible that these differences may be linked to the ability of CETP to transfer these compounds from one lipoprotein to another. This review examines the current understanding of the relationship between CETP activity and the lipoprotein distribution of a number of compounds (e.g. amphotericin B and cyclosporine A). It further suggests that additional research will expand our understanding of the role of CETP to explain other functions in lipophilic drug distribution and metabolism.

Role of plasma lipoproteins in modifying the toxic effects of water-insoluble drugs: studies with cyclosporine A.

Lipoproteins are a heterogeneous population of macromolecular aggregates of lipids and proteins that are responsible for the transport of lipids through the vascular and extravascular fluids from their site of synthesis or absorption to peripheral tissues. Lipoproteins are involved in other biological processes as well, including coagulation and tissue repair, and serve as carriers of a number of hydrophobic compounds within the systemic circulation. It has been well documented that disease states (eg, AIDS, diabetes, cancer) significantly influence circulating lipoprotein content and composition. Therefore, it appears possible that changes in the lipoprotein profile would affect not only the ability of a compound to associate with lipoproteins but also the distribution of the compound within the lipoprotein subclasses. Such an effect could alter the pharmacokinetics and pharmacological action of the drug. This paper reviews the factors that influence the interaction of one model hydrophobic compound, cyclosporine A, with lipoproteins and the implications of altered plasma lipoprotein concentrations on the pharmacological behavior of this compound.