Trazodone Prescribing for Children With Attention Deficit Hyperactivity Disorder on Medicaid in Oregon.

OBJECTIVE: To examine trazodone prescribing to Medicaid-insured children with a diagnosis of attention deficit hyperactivity disorder (ADHD) from 2012 to 2016 for patient-level factors, including coexisting diagnoses associated with trazodone prescriptions. METHODS: A retrospective cohort study used de-identified claims data from the Oregon Health Authority to analyze associations, frequency, and likelihood of new trazodone fills. RESULTS: A total of 16,547 trazodone prescriptions were identified, representing 8.4% (n = 2,705) of 32,134 children. Most were filled for children ages 10 years and older. Children with ADHD were predominantly male (70.7%); however, more female children had a filled trazodone prescription compared with males (10.1% vs 7.7%). Female and male children with a filled trazodone prescription shared common diagnoses in the top 10 rank, although episodic mood disorders, such as bipolar disorder (International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis code 296) were only noted for female children. Female children were significantly older at the time of the first filled trazodone prescription (12.5 years; 95% CI, 12.3-12.7) compared with male children (12.0 years; 95% CI, 11.8-12.1). Modified Poisson regression models found children with ADHD and a filled trazodone prescription were 3 times more likely to have a sleep-related diagnosis as their most common diagnosis (excluding ADHD), compared with those of the same age and sex without a trazodone prescription (RR, 2.94; 95% CI, 2.44-3.54). CONCLUSIONS: Children with ADHD are prescribed trazodone off label and for conditions with no national guidelines or clinical evidence of efficacy. Female children on Medicaid may be prescribed trazodone for concurrent mental health conditions, and further research is warranted regarding potential correlates.

A Pilot Study Regarding Pharmacy Law Education Across Doctor of Pharmacy Programs.

Objective. To describe the features of pharmacy law education in Doctor of Pharmacy (PharmD) programs in the United States. Methods. A review of the literature found no prior published data describing the delivery of pharmacy law education across PharmD programs in the United States. Members of the Pharmacy Law Educators Subcommittee of the American Society for Pharmacy Law (ASPL) developed questions for a survey. The survey was administered electronically to all 139 American Association of Colleges of Pharmacy (AACP) member institutions in the summer of 2016. A link to complete the 32-item online survey was distributed via email to the pharmacy law educator or associate dean at each AACP member institution. Results. Of the 139 PharmD programs surveyed, 49 completed the survey instrument, yielding a response rate of 35.2%. Variations between programs were found in the professional background of pharmacy law instructors and assessment strategies for pharmacy law courses, as well as in the structure and placement of the main pharmacy law course within the various curricula. Conclusion. This pilot study represents the first and only known attempt to examine delivery of pharmacy law education across colleges of pharmacy. The variations between programs found in this study highlight the need for further investigation into this area of pharmacy education.

Provider Education About Pneumococcal Vaccination Practices for Older Adults.

OBJECTIVE: To describe an interdisciplinary academic detailing project implemented to address low pneumococcal immunization rates. SETTING: Two medical clinics and four community pharmacies in rural Washington state. PRACTICE DESCRIPTION: The two medical clinics and four community pharmacies were all located in two rural counties and serve geographically large rural areas. PRACTICE INNOVATION: Academic detailing is an evidence-based approach designed to change clinical practice and improve decision-making. Our team utilized the academic detailing model to provide educational outreach to local rural health care providers. The detailing team visited each clinic and pharmacy on a defined schedule and provided information to physicians, clinic administrators, nurses, pharmacists, pharmacy technicians, medical assistants, and clinic front-end staff. MAIN OUTCOME MEASUREMENTS: The project team maintained detailed field notes from each academic detailing the visit and met to debrief about each encounter. From the field notes, through the process of thematic analysis and analytic memoing, the project team produced a list of "lessons learned" that could be used to guide other interprofessional teams wishing to embark on an academic detailing project. RESULTS: We have identified four key "lessons learned": Interprofessional team members bring different strengths to the project; using same-discipline team members paved the way for success; involving students aids in educating future practitioners in interprofessional practice; and scheduling meetings in advance is important. CONCLUSION: We described an approach to enhanced academic detailing using interprofessional team delivery, bringing interprofessional practice into the real-world practice setting.

Addressing Unmet Patient Care Needs Through Curricular Development of Student Pharmacist Leadership and Entrepreneurial Skills.

Objective. To develop, deliver, and evaluate an innovative curriculum designed to increase student pharmacists' skills and confidence in addressing unmet patient care needs and the Institute for Healthcare Improvement's (IHI) Triple Aim goals in the community pharmacy setting. Methods. Course modules developed collaboratively between the University of Washington and Washington State University focused on student pharmacist exposure to and direct application of leadership theory in addressing real world challenges. Both programs delivered the curriculum to all second-year student pharmacists during the fall 2015 and fall 2016 semesters. Student teams were asked to identify a new or enhanced service for a community pharmacy based on a needs assessment and the IHI's Triple Aim goals. Students completed precourse, postcourse, and retrospective assessments of their confidence, comfort level in leadership theory application, and project implementation. Effectiveness of the project pitch and team dynamics were assessed. Precourse, postcourse, and retrospective assessments of individual student progress in leadership, innovation, self-awareness, and professionalism also were completed. Results. For all confidence questions, a significant relationship was found between mean precourse and postcourse scores. A comparison of students' postcourse scores and their retrospective reflection scores indicated an increase in confidence to lead. At the conclusion of the course, the students reported improved confidence in their ability to communicate decisions (73%), create a vision (64%), and form a guiding coalition (55%). Conclusion. A five-module curriculum with corresponding project proposal successfully increased the confidence and comfort level of student pharmacists' in their leadership skillset.

Using Team-Based Learning to Train Student Pharmacists to Perform Tuberculin Skin Testing.

Objective. To evaluate the effectiveness of a team-based learning (TBL) model in training students to properly administer and interpret a tuberculin skin test (TST) in a laboratory course. Method. Team-based learning was used to deliver TST training to all second-year student pharmacists (n=120) in a patient care laboratory course. A 10-item TST Learning Opinion Survey was developed and administered to assess student pharmacists' self-perceived achievement of the class learning objectives, opinions about TBL learning experience, and interest in making TST a part of future practice. Results. All 120 student pharmacists achieved competency standards during skills evaluation. One hundred thirteen out of 120 students completed the survey instrument. The majority of respondents either agreed or strongly agreed that TBL helped them meet the TST training learning objectives of: demonstrating administration proficiency; demonstrating interpretation competency; proper reporting and patient counseling with a positive test result; and identifying when a second TST was necessary. Additionally, a majority of respondents agreed or strongly agreed that the TBL model improved their knowledge of pre-laboratory material, aided their confidence in practicing TST placement, and improved their communication skills through peer work in a TBL environment. Conclusion. Through this innovative model, student pharmacists met the TST learning objectives and developed knowledge and confidence. This activity can be replicated at other colleges, expanding the development of student pharmacists who are confident in their ability to provide TST services.

Somnolence-Producing Agents: A 5-Year Study of Prescribing for Medicaid-Insured Children With Attention Deficit Hyperactivity Disorder.

INTRODUCTION: Researchers evaluated the prescribing of medications that induce somnolence to children with attention deficit hyperactivity disorder (ADHD) insured by Medicaid. METHOD: An observational study of prescription claims for children ages 3-18 with ADHD-associated ICD 9 diagnoses filled between January 1, 2012 and December 31, 2016 in Oregon. RESULTS: There were 14,567 prescriptions written for a 30-day supply of sleep medication for 2,518 children. Most were written for males (66.3%) and to those ages 12-18 (63.8%). Trazodone, hydroxyzine, quetiapine, clonazepam, and amitriptyline were frequently prescribed. There were few prescriptions for zaleplon and zolpidem. DISCUSSION: Trazodone, hydroxyzine, and amitriptyline are commonly prescribed without clinical efficacy or guidance for children with ADHD. Quetiapine is prescribed off label in sub-therapeutic doses for its somnolence effect. Mental health drugs, which have voluntary formulary guidance in Oregon, and antihistamines on formulary, are more frequently prescribed for children with ADHD than drugs with FDA approval for insomnia.

Nurse practitioners' recommendations for pharmacotherapy in the management of adolescent concussion.

BACKGROUND AND PURPOSE: Nurse practitioners (NPs) frequently treat acute conditions presenting in children and adolescents in the outpatient setting. No evidence-based guidance exists pertaining to the treatment of concussion with medications. The purpose of this study was to examine recommendations by NPs for pharmacotherapy of acute symptoms for adolescent concussion. METHODS: This is a secondary analysis of data from a web-based census survey of all licensed NPs in Oregon and Washington State, where they practice as independent providers with prescriptive authority. Based on a standardized adolescent patient scenario video, NPs were asked to indicate prescription or nonprescription medication recommendations for concussion symptoms. Open-ended descriptions of medication recommendations were coded, summarized, and described. CONCLUSIONS: In narrative text, 78.4% of the 991 respondents recommended at least one type of prescription or nonprescription medication. Prescription medications (recommended by 17.2%) included antiemetics and antimigraine medications; nonprescription medications (recommended by 75.5%) included nonsteroidal anti-inflammatory drugs, over-the-counter pain relievers, and herbal medications. Pharmacotherapy recommendations varied by NP practice setting and rurality. IMPLICATIONS FOR PRACTICE: Nurse practitioners have full prescriptive authority in many states. No guidelines inform medication use in managing acute concussion symptoms, yet many providers recommend their use.

Assessing Pneumococcal Vaccination Availability in Under-Vaccinated Rural Counties: A Pharmacy Perspective.

OBJECTIVE: Vaccines are a low-cost, high-impact interventions that effectively and efficiently reduce the burden of infectious diseases. Many rural populations have vaccination rates well below nationally recommended levels. Community pharmacies may offer a solution to this problem. Under a collaborative drug therapy agreement (CDTA), pharmacists can prescribe and administer immunizations. The purpose of this study was to examine pneumococcal vaccine access in rural pharmacies in Eastern Washington state. DESIGN: A qualitative descriptive design was utilized in this study. The sample included all pharmacies located in two rural Washington state counties. Interviews were conducted with pharmacy staff. Every pharmacy in the two counties was surveyed over the telephone. Data analysis included directed content analysis and descriptive statistics. FINDINGS: Each of the 10 pharmacies identified participated. Pharmacy volume varied (weekly prescription counts of 300 to 2,500). Sixty percent of pharmacies currently provide vaccines. Quoted prices of the PCV13 varied between $65 and $228. Quoted prices of the PPSV23 varied between $64 and $120. Pharmacies that vaccinated made it convenient with "walk-in" scheduling practices. Some pharmacies required a prescription from a separate provider while others could prescribe on-site through CDTA. Pharmacies that chose not to vaccinate did so for a variety of reasons. CONCLUSIONS: Access to pneumococcal vaccines will be enhanced by pharmacist administration, resulting in improved availability, accessibility, accommodation, affordability, and acceptability for patients in rural Washington.

Teaching About Human Papillomavirus: Lessons Learned.

Occupational and environmental health nurses play a critical role in educating the public about human papillomavirus (HPV). With HPV vaccination rates remaining low, creative educational models should be explored.

The implementation of a naloxone rescue program in university students.

OBJECTIVE: Responding to the nationwide opioid overdose epidemic, Washington State University initiated a naloxone safety net project intending to increase awareness of opioid overdose, increase the availability of naloxone, and examine university students' perceptions regarding the usefulness of a novel, large-group audience-training model. SETTING: A Washington State University campus. PRACTICE DESCRIPTION: In September 2014, university students were recruited to attended a large-group audience training event which included opioid overdose prevention, recognition, and first response. All trained participants received an intranasal naloxone reversal kit. PRACTICE INNOVATION: Student pharmacists, who previously received naloxone rescue training and overdose education from the pharmacist lead researcher, acted as trainers. The training consisted of a large-group audience delivery with small-group practice sessions facilitated by the student pharmacists. EVALUATION: Participants who attended the recruitment event completed a pre-training survey to assess knowledge and perceptions about opioid use disorder and overdose. The following week, participants attended the training event. Participants were asked to complete a post-training survey to evaluate the usefulness of the program. RESULTS: Forty-three percent of the participants (65/150) who attended the recruitment event reported knowing someone who used prescription opioids to get "high." Seventy-four participants attended the training, and 92% of them (68/74) completed the post-training survey. The majority of respondents agreed that the training program met their expectations and the skills they learned could be used to intervene in an overdose situation. CONCLUSIONS: Before training, survey responses from recruited participates indicated the need to discuss opioid use disorder among university students is important. Use of a training model involving large-group audiences followed by small-group practice sessions offers an acceptable educational solution regarding opioid overdose and prevention. Our experience suggests using this training model to educate university students to recognize and provide first response is a feasible and acceptable approach.

Off-label Prescribing Trends for ADHD Medications in Very Young Children.

OBJECTIVE: This study examines off-label medication prescribing use and trends in children on Medicaid with ADHD with particular focus on the very young (under age 6 years). METHODS: This was an observational cohort study and retrospective analysis of ADHD medication prescriptions from Oregon Medicaid records (N = 83,190) in 2012. Manufacturer prescribing information was used to determine off-label designation. Children ages 3 to 18 years at the time of prescription who had continuous Medicaid enrollment of at least 10 months during the index year of 2012 were included in the sample frame. RESULTS: Children with ADHD were prescribed off-label medications primarily at the ages of 5 years and younger. Among children ages 3 to 5 years, 91.4% of prescriptions were off-label. After the age of 5 years, the percentage of off-label prescriptions dropped notably to 21%, reflecting the increase in availability of approved medications for the treatment of ADHD starting at age 6 years. In the 3- to 5-year-old age group, specific off-label and concerning medication-related observations included a high frequency of alpha agonist (e.g., guanfacine, clonidine) prescribing; the prescribing of untested formulations such as clonidine patches; prescribing of atomoxetine; and prescribing of large doses of stimulant medications. CONCLUSIONS: Most ADHD drugs prescribed for very young children are off-label, which is concerning owing to lack of safety and efficacy data in this vulnerable population.

Help Me Remember My Meds.

Nonadherence has led to increased health consequences and higher health care costs. A study surveyed subjects using either blister pack or a Philips Medication Dispenser machine to determine medication adherence. Although there is still a research gap associated with medication packaging, it has great potential to help patients who have difficulty managing their multiple medications.

Childhood Attention-Deficit/Hyperactivity Disorder Prescribing by Prescriber Type and Specialty in Oregon Medicaid.

OBJECTIVE: This study compares nurse practitioner (NP) and physician (MD/DO) prescribing patterns for treatment of children with an attention-deficit/hyperactivity disorder (ADHD)-related diagnosis covered by Oregon Medicaid from 2012 to 2013. METHODS: This study is a limited data set review of Oregon pharmacy claims for youth aged 3-18 at time of prescription fill, who were continuously enrolled for at least 10 months of the index year. Claims with selected ICD-9 codes (n = 197,364) were further defined by 30-day prescriptions and prescription drug events (PDE) linked to each prescriber type of interest. Descriptive statistical analysis of variables included prescriber type (NP vs. physician) and specialty (generalist vs. specialist), child age, and controlled versus noncontrolled drug type. RESULTS: A total of 82,754 complete 30-day prescriptions for 10,753 children from 1785 unique prescribers (78 NP specialists; 303 NP generalists; 162 physician specialists; and 1242 physician generalist prescribers) and 16,669 PDE were analyzed. Physicians prescribed more than 81% of all ADHD medications, and physician generalists prescribed nearly 60% of all prescriptions. Sixty-four percent of 30-day supply prescriptions (n = 52,678) were controlled substances. Generalists, both NPs and physician prescribers, prescribed controlled medications more often than specialists. Physician specialists consistently prescribed controlled substances for all age groups, while NP specialists prescribed more controlled substances as child age increased. Rates of controlled medications prescribed generally increased, as children got older, regardless of provider type. CONCLUSION: NPs overall prescribe in a similar pattern to physicians when given the authority to prescribe controlled substances for ADHD. Comparisons between prescriber types for controlled substance prescribing by age should be explored further to identify possible variance from national guidelines.

Secukinumab.

Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are sent in print and are also available on-line. Monographs can be customized to meet the needs of a facility. A drug class review is now published monthly with The Formulary Monograph Service. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, call The Formulary at 800-322-4349. The September 2015 monograph topics are cangrelor, lumacaftor/ivacaftor, brexpiprazole, talimogene laherparepvec, and lesinurad. The Safety MUE is on cangrelor.