Diagnosis and Treatment of ADHD in the United States: Update by Gender and Race.

Objective: The aim of this article is to update ADHD diagnosis/treatment trends by age, gender, and race. Method: National Ambulatory Medical Care Survey data were obtained for 2008-2009 to 2012-2013. Physician office visits including ADHD diagnosis and pharmacotherapy were measured per 1,000 population and per 1,000 office visits overall, and by demographic group. Logistic regression models controlled for demographics, psychiatric comorbidities, insurance type, and time period. Interactions of time, demographics, comorbidities, and insurance type were tested. Results: Diagnoses of ADHD increased by 36% in adults and 18% in youth, and diagnosis + drug by 29% in female and 10% in male youths. ADHD diagnosis was 77% less likely among Black than White adults but 24% more likely among Black than White youths in 2012-2013. Conduct disorder (CD) in youths multiplied odds of diagnosis + drug by 3.31; interaction of Black race × CD by 3.78. Conclusion: Upward trends in ADHD diagnosis and treatment have continued but vary markedly by group. Studies of undertreatment/overtreatment are needed.

Joint effects of advancing age and number of potentially inappropriate medication classes on risk of falls in Medicare enrollees.

BACKGROUND: Injurious falls among older adults are both common and costly. The prevalence of falls is known to increase with age and with use of fall-risk drugs/potentially inappropriate medications (FRD/PIM). Little is known about the joint effects of these two risk factors. METHODS: Data for 2013-2015 were obtained from the Truven Health MarketScan® Medicare database comprising utilization and eligibility (enrollment) data for approximately 4 million enrollees annually. A case-control design was used to compare enrollees aged 65-99 years diagnosed with > 1 fall event (n = 110,625) with enrollees without falls (n = 1,567,412). An exploratory analysis of joint age-FRD/PIM effects on fall risks was based on number needed to harm (NNH) calculations for each FRD/PIM therapy class count (compared with 0 FRD/PIMs), stratified by age group. Logistic regression analyses adjusted for demographics, comorbidities, and fracture history, measured in the 1 year prior to the fall date (cases) or a randomly assigned date (controls). RESULTS: For each FRD/PIM class count, NNH values decreased with older age (e.g., for 1 FRD/PIM class: from NNH = 333 for ages 65-74 years to NNH = 83 for ages 90-99 years; for 2 FRD/PIM classes: from NNH = 91 for ages 65-74 years to NNH = 38 for ages 90-99 years). NNH decreased to < 15 patients at > 6 classes for age 65-74 years, > 5 classes for age 75-84 years, and > 4 classes for age 85-99 years. Adjusted odds of falling were increased for age-FRD/PIM combinations with smaller NNH values: adjusted odds ratio (AOR) = 1.127 (95% confidence interval [CI] = 1.098-1.156) for NNH = 83-91; AOR = 1.427 (95% CI = 1.398-1.456) for NNH = 17-48; AOR = 1.983 (1.9034-2.032) for NNH < 15. CONCLUSION: FRD/PIM use and age appear to have joint effects on fall risk. Older adults at high risk, indicated by small NNH, may be appropriate for fall prevention initiatives, and clinicians may wish to consider decreasing the number of FRD/PIMs utilized by these patients.

Use of power-law analysis to predict abuse or diversion of prescribed medications: proof-of-concept mathematical exploration.

OBJECTIVE: To conduct a proof-of-concept study comparing Lorenz-curve analysis (LCA) with power-law (exponential function) analysis (PLA), by applying segmented regression modeling to 1-year prescription claims data for three medications-alprazolam, opioids, and gabapentin-to predict abuse and/or diversion using power-law zone (PLZ) classification. RESULTS: In 1-year baseline observation, patients classified into the top PLZ groups (PLGs) were demographically and diagnostically similar to those in Lorenz-1 (top 1% of utilizers) and Lorenz-25 (top 25%). For prediction of follow-up (6-month post-baseline) Lorenz-1 use of alprazolam and opioids (i.e., potential abuse/diversion), PLA had somewhat lower sensitivity compared with LCA (83.5-95.4% vs. 99.5-99.9%, respectively) but better specificity (98.2-98.8% vs. 75.5%) and much better positive predictive value (PPV; 34.5-45.3% vs. 4.0-4.6%). Of top-PLG alprazolam- and opioid-treated patients, respectively, 20.7 and 9.9% developed incident (new) Lorenz-1 in followup, compared with < 3% of Lorenz-25 patients. For gabapentin, neither PLA nor LCA predicted incident Lorenz-1 (PPV = 0.0-1.4%). For all three medications, PLA sensitivity for follow-up hospitalization was < 5%, but specificity was better for PLA (97.3-99.2%) than for LCA (74.3-75.4%). PLA better identified patients at risk of future controlled substance abuse/diversion than did LCA, but the technique needs refinement before widespread use.

Gabapentin use, abuse, and the US opioid epidemic: the case for reclassification as a controlled substance and the need for pharmacovigilance.

The abuse potential of gabapentin is well documented; with gabapentin having been noted as an agent highly sought after for use in potentiating opioids. When combined with opioids, the risk of respiratory depression and opioid-related mortality increases significantly. In the US, gabapentin was approved by the Food and Drug Administration as a non-controlled substance. To date, and in spite of empirical evidence suggestive of diversion and abuse with opioids, gabapentin remains a non-controlled substance at the federal level. This has forced individual US states and jurisdictions - often significantly impacted by the opioid epidemic - to forge ahead with legislative initiatives designed to reclassify and/or monitor the use of gabapentin. Since August 1, 2016, 14 of 51 US states and jurisdictions have either implemented legislative mandates requiring pharmacovigilance programs, amended rules and regulations, are in the throes of crafting policy, or are in the midst of gathering additional data for decision making. This fragmented geographic approach yields only a modest benefit in combating the abuse of gabapentin and/or the national opioid epidemic. Herein, we report state-by-state efforts to enhance pharmacovigilance and call for a re-evaluation of the schedule status of gabapentin at the federal level, and design and implementation of a national pharmacovigilance program.

Concomitant use of opioid medications with triptans or serotonergic antidepressants in US office-based physician visits.

BACKGROUND: Opioids are not recommended for routine treatment of migraine because their benefits are outweighed by risks of medication overuse headache and abuse/dependence. A March 2016 US Food and Drug Administration (FDA) safety communication warned of the risk of serotonin syndrome from using opioids concomitantly with 5-hydroxytryptamine receptor agonists (triptans) or serotonergic antidepressants: selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). Epidemiological information about co-prescribing of these medications is limited. The objective of this study was to estimate the nationwide prevalence of co-prescribing of an opioid with a serotonergic antidepressant and/or triptan in US office-based physician visits made by 1) all patients and 2) patients diagnosed with migraine. METHODS: National Ambulatory Medical Care Survey (NAMCS) data were obtained for 2013 and 2014. Physician office visits that included the new or continued prescribing of ≥1 opioid medication with a triptan or an SSRI/SNRI were identified. Co-prescribed opioids were stratified by agent to determine the proportion of co-prescriptions with opioids posing a higher risk of serotonergic agonism (meperidine, tapentadol, and tramadol). RESULTS: Of an annualized mean 903.6 million office-based physician visits in 2013-2014, 17.7 million (2.0% of all US visits) resulted in the prescribing of ≥1 opioid medication with a triptan or an SSRI/SNRI. Opioid-SSRI/SNRI was co-prescribed in 16,044,721 visits, while opioid-triptan was co-prescribed in 1,622,827 visits. One-fifth of opioid co-prescribing was attributable to higher-risk opioids, predominantly tramadol (18.6% of opioid-SSRI/SNRI, 21.8% of opioid-triptan). Of 7,672,193 visits for patients diagnosed with migraine, 16.3% included opioid prescribing and 2.0% included co-prescribed opioid-triptan. CONCLUSION: During a period approximately 2 years prior to an FDA warning about the risk of serotonin syndrome from opioid-SSRI/SNRI or opioid-triptan co-prescribing, use of these combinations was common in the USA. Studies on prescribing patterns following the March 2016 warning, and on the risk of serotonin syndrome associated with these co-prescriptions, are needed.

Predictors of Gabapentin Overuse With or Without Concomitant Opioids in a Commercially Insured U.S. Population.

OBJECTIVE: Research suggests the medical consequences of gabapentin overuse depend on whether gabapentin is abused alone or with opioids to potentiate an opioid "high." The objective of this study was to assess predictors of gabapentin overuse with or without concomitant opioids. METHODS: Data were obtained from the Truven Health MarketScan® Commercial Claims and Encounters database for 2013 through 2015. Eligibility criteria were gabapentin utilization, with or without opioids, for 120 days or longer throughout a 12-month observation period. Cohort identification was based on patterns of overuse exceeding thresholds of 3600 mg of gabapentin and/or 50 morphine-mg equivalents of opioids; sustained overuse was defined as three or more quarters exceeding threshold. Diagnostic predictors were measured in the 6 months pretreatment in inpatient (IP) or emergency department (ED) settings. Indications were measured in IP, ED, or ambulatory settings. Logistic regression analyses adjusted for age, sex, indication, use of benzodiazepine or z-hypnotics (i.e., zaleplon, zolpidem, eszopiclone) during gabapentin treatment, pretreatment ED/IP use, and pretreatment diagnoses of anxiety or depression. RESULTS: Criteria for sustained overuse were met by 2.0% of 44,148 patients treated with gabapentin without opioids and by 11.7% of 15,335 patients treated with concomitant gabapentin-opioid. The top three predictors of sustained overuse for gabapentin-only patients were insomnia (7.0%), euphoria (4.5%), and bipolar disorder (4.5%), and were detoxification (35.6%), altered mental status (26.3%), and addiction (21.6%) for gabapentin-opioid patients. In adjusted analyses, concomitant opioid use multiplied the odds of sustained misuse by 6.32 (95% confidence interval [CI] = 5.80-6.89) and the interaction of addiction with opioid use by 1.88 (95% CI = 1.32-2.66). Among gabapentin-only patients, sustained misuse was predicted by a history of anxiety (odds ratio = 1.56, 95% CI = 1.02-2.38) but not by a history of addiction. CONCLUSIONS: The likelihood of gabapentin overuse alone is low but significantly increases with concomitant opioid use, especially when coupled with a history of addiction. History of addiction does not appear to increase risk of gabapentin misuse among those with gabapentin alone.

Diagnoses of Cardiovascular Disease or Substance Addiction/Abuse in US Adults Treated for ADHD with Stimulants or Atomoxetine: Is Use Consistent with Product Labeling?

BACKGROUND: Among US adults, utilization of pharmacotherapy for attention-deficit hyperactivity disorder (ADHD) has increased more than ninefold since 1995-1996. Potential contraindications to ADHD pharmacotherapy include serious cardiovascular disease (CVD) and, for stimulants, addictions and bipolar disorder (BPD). OBJECTIVE: To assess the prevalence of potential contraindications among adults treated with ADHD pharmacotherapy. METHODS: A retrospective cohort analysis was performed using the Truven Health MarketScan® database. Subjects filled ≥ 1 prescription for atomoxetine or ≥ 1 stimulant in 2014-2015, were aged 18-64 years, commercially insured throughout observation, and diagnosed with ADHD on two or more medical claims. Diagnoses and medical procedures were measured in the 12 months prior to pharmacotherapy initiation. Metrics included serious CVD (cardiomegaly, cardiomyopathy, cerebrovascular occlusion, congestive heart failure, myocardial infarction, pacemaker, or valvular disorder) and any CVD (serious CVD, other atherosclerotic CVD, arrhythmia, congenital heart anomaly, or hypertensive heart disease). Rates of substance addiction or abuse were measured in a range to address nonspecific diagnostic coding. RESULTS: Only 2.0% of treated adults (n = 91,588) had one or more diagnosis indicating serious CVD. CVD prevalence increased monotonically with age. Of patients aged 55-64 years (n = 5,237), 7.2% had serious CVD; 15.9% had any CVD; and 1.9% had been hospitalized with one or more CVD. Of patients treated with stimulants (n = 87,167), 11.3-18.5% were diagnosed with addiction/abuse and 4.1% with BPD. CONCLUSIONS: CVD prevalence is generally low among adults using ADHD medication but increases with age. Although difficult to estimate precisely, the rate of addiction/abuse among stimulant-treated patients appears unexpectedly high. Further research should assess cardiovascular events and other potential harms associated with contraindicated use in high-risk adults.

All-Cause and Drug-Related Medical Events Associated with Overuse of Gabapentin and/or Opioid Medications: A Retrospective Cohort Analysis of a Commercially Insured US Population.

INTRODUCTION: Overuse of gabapentin and/or opioids occurs in a small percentage of patients at > 3-fold labeled dosages. Gabapentin may potentiate opioid effects. OBJECTIVE: The aim was to assess patient harm, defined as use of inpatient hospital (IPH) or emergency department (ED) services, associated with overuse of gabapentin with or without concomitant overuse of opioids. DATA SOURCE: Data were sourced from the Truven Health MarketScan® Commercial Claims and Encounters database, for the years 2013-2015. ELIGIBILITY CRITERIA: The eligibility criteria were two or more claims (billed encounters) and ≥120 days of treatment with gabapentin and/or opioids. METHODS: Cohort identification was based on daily-dosage thresholds of 50 morphine-milligram equivalents and 3600 mg of gabapentin in a 12-month follow-up: (1) no overuse; (2) mild overuse (two or more claims or two or fewer calendar quarters over threshold); and (3) sustained overuse (three or more over-threshold calendar quarters). IPH and ED use were measured for 6 months after the first overuse date (cohorts 2 and 3) or a randomly assigned date (cohort 1). Logistic regression analyses controlled for pre-treatment IPH/ED utilization, indication, addiction diagnosis, concomitant sedative/hypnotic use, and demographics. RESULTS: All-cause and drug-related IPH/ED utilization increased monotonically with degree of overuse, particularly of more than one medication. Sustained overuse of gabapentin multiplied odds of all-cause IPH by 1.366 [95% confidence interval (CI) 1.055-1.769], drug-related IPH by 1.440 (95% CI 1.010-2.053), and IPH/ED for altered mental status (e.g., euphoria, anxiety) by 1.864 (95% CI 1.324-2.624). Sustained overuse of both medications quadrupled odds of all-cause IPH, drug-related IPH, and IPH/ED for altered mental status or respiratory depression. CONCLUSION: Despite modest effects of gabapentin overuse alone, overuse of gabapentin with opioids may increase risk of harm and health-service utilization, supporting calls to make gabapentin a controlled substance in the USA.

Provision of Lifestyle Counseling and the Prescribing of Pharmacotherapy for Hyperlipidemia Among US Ambulatory Patients: A National Assessment of Office-Based Physician Visits.

BACKGROUND: An estimated 27.8% of the United States (US) population aged ≥20 years has hyperlipidemia, defined as total serum cholesterol of ≥240 mg/dL. A previous study of US physician office visits for hyperlipidemia in 2005 found both suboptimal compliance and racial/ethnic disparities in screening and treatment. OBJECTIVE: The aim was to estimate current rates of laboratory testing, lifestyle education, and pharmacotherapy for hyperlipidemia. METHODS: Data were derived from the US National Ambulatory Medical Care Survey (NAMCS), a nationally representative study of office-based physician visits, for 2013-2014. Patients aged ≥20 years with a primary or secondary diagnosis of hyperlipidemia were sampled. Study outcomes included receipt or ordering of total cholesterol testing, diet/nutrition counseling, exercise counseling, and pharmacotherapy prescription including statins, ezetimibe, omega-3 fatty acids, niacin, or combination therapies. RESULTS: Compared with previously reported results for 2005, rates of pharmacotherapy have remained static (52.2 vs. 54.6% for 2005 and 2013-2014, respectively), while rates of lifestyle education have markedly declined for diet/nutrition (from 39.7 to 22.4%) and exercise (from 32.1 to 16.0%). Lifestyle education did not vary appreciably by race/ethnicity in 2013-2014. However, rates of lipid testing were much higher for whites (41.6%) than for blacks (29.9%) or Hispanics (34.2%). Tobacco education was ordered/provided in only 4.0% of office visits. CONCLUSION: Compliance with guidelines for the screening and treatment of hyperlipidemia remains suboptimal, and rates of lifestyle education have declined since 2005. There exists an urgent need for enhanced levels of provider intervention to reduce the morbidity and mortality associated with hyperlipidemia.

Policies to mitigate nonmedical use of prescription medications: how should emerging evidence of gabapentin misuse be addressed?

INTRODUCTION: Over the past decade, increased prescription supply has facilitated an epidemic of nonmedical use of controlled substances, including predominantly opioids, as well as benzodiazepines, z-hypnotics, and stimulants. Areas covered: More recently, misuse of noncontrolled prescriptions, such as gabapentin, has been detected. Gabapentin misuse has been associated with drug-related harm and increased healthcare service utilization in a few studies, including a recent large-sample analysis of commercially insured enrollees in the United States (U.S.) Responding to this emerging base of evidence, a small number of U.S. states have acted to prevent or detect gabapentin misuse by requiring the inclusion of gabapentin utilization in reporting to local Prescription Drug Monitoring Programs (PDMPs) and/or imposing other restrictions on gabapentin prescribing (e.g., classification as a controlled substance, quantity limits). These efforts may result in unintentional harm by (1) encouraging 'doctor shopping' across state lines to seek lenient regulatory policies and (2) placing the burden for mitigating misuse on individual practitioners. Expert opinion: We call for a unified national approach, comprising federal regulation and enhanced PDMP reporting to address gabapentin misuse, while laying the groundwork for management of new medications of abuse that the healthcare industry may encounter in the future.

Real-world use of PCSK-9 inhibitors by early adopters: cardiovascular risk factors, statin co-treatment, and short-term adherence in routine clinical practice.

BACKGROUND: Inconsistency of real-world medication use with labeled indications may affect cost and clinical value of pharmacotherapy. PCSK-9 inhibitors are labeled in the US for use with statins to reduce low-density lipoprotein cholesterol in patients with atherosclerotic cardiovascular disease (ASCVD) or familial hypercholesterolemia (FH). OBJECTIVE: To assess consistency with labeled indications and treatment persistency for early (first 5 post-launch months) adopters of PCSK-9 inhibitor pharmacotherapy. METHODS: Retrospective analysis of commercially insured cohorts derived from the Truven Health MarketScan® database was performed. Subjects were aged 18-64 years, initiated PCSK-9 inhibitor or highest-intensity statin (rosuvastatin 40 mg/day or atorvastatin 80 mg/day) pharmacotherapy from August to December 2015, and were enrolled throughout 2015 and during separate baseline (pre-treatment) periods of 6 and 18 months. Baseline ASCVD, FH, and ASCVD events (myocardial infarction, transient ischemic attack, and cerebrovascular occlusion) were measured. Persistency was measured through December 2015 for subcohorts of patients initiating treatment from August to September 2015. RESULTS: Baseline disease rates were higher for patients treated with PCSK-9 inhibitors (n=390) compared with highest-intensity statins (n=26,306): ASCVD (68.5% vs 33.4%, respectively); FH (39.7% vs 15.5%); both P<0.001. In 18 months pre-treatment, 35.6% of PCSK-9 inhibitor-treated patients had ≥1 ASCVD event, and 87.9% had a labeled indication. Rates of 60-day nonpersistency for PCSK-9 inhibitors and highest-intensity statins were 33.3% and 39.8%, respectively (P=0.207). During PCSK-9 inhibitor pharmacotherapy, 33.8% of patients had evidence of statin supply and, of those initiating treatment from August to September, 40.9% filled ≥1 statin prescription. Of those with sustained pre-treatment statin use, 34.8% had no statin supply during PCSK-9 inhibitor pharmacotherapy. CONCLUSION: Among early-adopting PCSK-9 inhibitor-treated patients, the off-label diagnosis rate was 12%; a majority lacked statin co-treatment; and one third filled prescriptions for ≤60 days. Inconsistency with labeled uses may reflect prescriber/patient decisions, health-insurance coverage determinations, or statin intolerance not reported on claims.

Prevalence of Gabapentin Abuse: Comparison with Agents with Known Abuse Potential in a Commercially Insured US Population.

BACKGROUND: Despite international calls to make gabapentin a controlled substance, studies of gabapentin use/abuse patterns are limited to small/high-risk samples and adverse event reports. OBJECTIVE: The aim of this study was to conduct a systematic assessment of the abuse potential/prevalence of gabapentin in a large sample. DATA SOURCE: Truven Health MarketScan® Commercial Claims and Encounters database, years 2013-2015. ELIGIBILITY CRITERIA: Patients with two or more claims for one or more abusable drugs and ≥12 months' continuous enrollment were sampled for Lorenz curve analysis. Prevalence analysis was limited to those with ≥120 days of therapy. METHODS: Abuse potential was measured as Lorenz-1 (consumption of drug supply by top 1% of users) of ≥15%. Dose thresholds were morphine milligram equivalent (MME) standards for opioids, and maximum labeled doses in milligrams (mg) for other drugs. RESULTS: Lorenz-1 values were 37% opioids, 19% gabapentin, 15% pregabalin, 14% alprazolam, and 13% zolpidem. The top 1% gabapentin users filled prescriptions for a mean (median) 11,274 (9534) mg/day, more than three times the recommended maximum (3600 mg). Of these, one-quarter used or diverted ≥12,822 mg/day. The top 1% opioid and pregabalin users filled prescriptions for a mean (median) 180 (127) MMEs and 2474 (2219) mg/day, respectively. Of patients using opioids + gabapentin simultaneously, 24% had three or more claims exceeding the dose threshold within 12 months. LIMITATIONS: Established threshold criteria for gabapentinoid abuse are uncertain. Indications for gabapentinoid use (e.g. hot flashes, restless legs syndrome) were not measured. CONCLUSION: Gabapentin use patterns are similar to those of other abusable medications. High daily doses pose safety and/or diversion concerns, and investigation of the medical consequences of gabapentin abuse is needed.

Financial Impact of Direct-Acting Oral Anticoagulants in Medicaid: Budgetary Assessment Based on Number Needed to Treat.

BACKGROUND: Faced with rising healthcare costs, state Medicaid programs need short-term, easily calculated budgetary estimates for new drugs, accounting for medical cost offsets due to clinical advantages. OBJECTIVE: To estimate the budgetary impact of direct-acting oral anticoagulants (DOACs) compared with warfarin, an older, lower-cost vitamin K antagonist, on 12-month Medicaid expenditures for nonvalvular atrial fibrillation (NVAF) using number needed to treat (NNT). METHOD: Medicaid utilization files, 2009 through second quarter 2015, were used to estimate OAC cost accounting for generic/brand statutory minimum (13/23%) and assumed maximum (13/50%) manufacturer rebates. NNTs were calculated from clinical trial reports to estimate avoided medical events for a hypothetical population of 500,000 enrollees (approximate NVAF prevalence × Medicaid enrollment) under two DOAC market share scenarios: 2015 actual and 50% increase. Medical service costs were based on published sources. Costs were inflation-adjusted (2015 US$). RESULTS: From 2009-2015, OAC reimbursement per claim increased by 173 and 279% under maximum and minimum rebate scenarios, respectively, while DOAC market share increased from 0 to 21%. Compared with a warfarin-only counterfactual, counts of ischemic strokes, intracranial hemorrhages, and systemic embolisms declined by 36, 280, and 111, respectively; counts of gastrointestinal hemorrhages increased by 794. Avoided events and reduced monitoring, respectively, offset 3-5% and 15-24% of increased drug cost. Net of offsets, DOAC-related cost increases were US$258-US$464 per patient per year (PPPY) in 2015 and US$309-US$579 PPPY after market share increase. CONCLUSIONS: Avoided medical events offset a small portion of DOAC-related drug cost increase. NNT-based calculations provide a transparent source of budgetary-impact information for new medications.

Assessed Value of Consultant Pharmacist Services in a Home Health Care Agency.

OBJECTIVE: To report results of a survey administered to clinicians in a home health care agency regarding reasons for them to initiate consultation with a pharmacist working onsite at the agency and the perceived value of the interaction. DESIGN: The survey listed 16 reasons why an agency clinician commonly makes referrals and 9 questions assessing the perceived value of these services provided by the onsite consultant pharmacist. Responses were reported on a five-point Likert scale where 1 = Almost always/strongly agree and 5 = Almost never/strongly disagree. SETTING: Home health care agency in Spokane, Washington, with onsite and in-home consultant pharmacy services for 20 years via a partnership with Washington State University. PARTICIPANTS: All clinicians employed by the home health care agency. RESULTS: Twenty-eight of 101 part-time and full-time clinicians responded to the survey. Eighty-nine percent of respondents strongly agreed that it is valuable to have a consultant pharmacist onsite and pharmacy personnel serve as a helpful source of information. The most common reasons for referral were pain management, drug side effects, and drug interactions. CONCLUSION: Clinicians indicated consultant pharmacist services are beneficial and they used the consultant pharmacist primarily for pain management, drug side effects, and drug interactions, but made referrals for a wide range of reasons. This indicates that an onsite consultant pharmacist is valuable to home care providers. Further research regarding the benefit of an onsite consultant pharmacist in the home care setting is warranted.