Characterizing acute and postsurgical pain management in patients receiving buprenorphine or buprenorphine/naloxone.

BACKGROUND: There is currently a clinical dilemma in treating acute pain in patients receiving long-term buprenorphine products. METHODS: This is a retrospective cohort review involving patients receiving long-term buprenorphine therapy who either underwent a surgical procedure or presented to an emergency department (ED) for acute pain between January 1, 2012 and January 1, 2022. Patients were excluded if opioids were prescribed 30 days before the index date. Chart reviews were conducted to characterize buprenorphine treatment strategies and the addition of new pain medications. Chart review revealed (1) incidence of opioid use disorder (OUD) relapse, (2) hospital re-presentation for pain or OUD, (3) fatal and non-fatal overdose, and (4) all-cause mortality and suicidality. Descriptive statistics were used to analyze results. RESULTS: A total of 70 of 259 screened patients met inclusion criteria. The mean (±SD) age was 50.3 ± 13 years, 92.9% male, 64.3% White, and 78.6% had an OUD diagnosis. While 84.3% presented to the ED, 15.7% underwent surgical procedures. For the primary endpoint, the total daily dose of buprenorphine or buprenorphine/naloxone from index date to discharge was continued in 90.0%, increased in 2.9%, decreased in 1.4%, and discontinued in 5.7% of cases. At discharge, 46.2% were prescribed an additional pain medication. A total of 7.1% re-presented for pain or OUD relapse, 15.7% experienced an OUD relapse, 1.4% experienced new-onset suicidality, and 1.4% experience all-cause mortality within 90 days of the index date. No fatal or non-fatal opioid overdoses were observed. CONCLUSION: The most commonly observed practice was continuing buprenorphine doses in patients with acute or postsurgical pain, which was effective and safe. Although further data is necessary to fully elucidate these findings, the data herein may suggest that clinicians can safely continue buprenorphine doses in the acute pain setting in patients receiving these products chronically.

Utilization of a "Diversity Index" to Assess Racial Diversity of US School of Pharmacy Graduates.

OBJECTIVE: Diversity in the training environment for health professionals is associated with improved abilities for graduates to care for diverse populations. Thus, a goal for health professional training programs, including pharmacy schools, should be to pursue representation among graduates that mirrors that of their communities. METHODS: We evaluate racial and ethnic diversity among graduates of Doctor of Pharmacy (PharmD) programs across the United States (US) over time. Using a "Diversity Index", we quantify the relative racial and ethnic representation of each program's graduates compared with that of college-age graduates nationally and within the geographic region of the respective pharmacy school. RESULTS: Over the past decade, the number of US PharmD graduates increased by 24%. During this time, the number of Black and Hispanic PharmD graduates significantly increased. Still, representation of minoritized populations among graduates continues to be significantly lower compared with US benchmark populations. Only 16% of PharmD programs had a Diversity Index that matched or exceeded their benchmark comparator Black or Hispanic populations. CONCLUSION: These findings highlight the significant opportunity that exists to increase the diversity of graduates of US PharmD programs to better reflect the diversity of the US population.

Efficacy and safety of hydroxyzine for sleep in adults: Systematic review.

OBJECTIVE: The purpose of this systematic review is to assess the efficacy and safety of hydroxyzine for insomnia in adults. METHODS: A comprehensive literature search of PubMed, Embase, and CENTRAL databases was conducted to identify relevant published studies through October 2022 using the search terms: hydroxyzine and sleep, insomnia, sleep disorder or sleep initiation and maintenance disorders. Studies identified for review included prospective, interventional designs or cohort trials that reported impact of hydroxyzine on sleep in adults. Animal studies, case reports, non-English articles, letters to the editor, case studies, and conference abstracts were excluded. Data were extracted using a standardized systematic process. RESULTS: Five articles were identified for inclusion, including 1 open-label and 4 randomized controlled trials, evaluating a total of 207 patients receiving hydroxyzine 25 mg, 50 mg, or 100 mg at bedtime. Mixed efficacy was demonstrated in the sleep measures of sleep onset, sleep maintenance, and sleep quality. The most common adverse drug effect was dry mouth, although 4 of the 5 studies did not report safety outcomes. CONCLUSIONS: The studies in this review suggest hydroxyzine could be considered as a short-term treatment option for adults with insomnia for whom previous therapy was ineffective, not tolerated, or contraindicated. Additional long-term studies with an active comparator are needed to further establish its role in insomnia treatment.

Slowed progression: The utility of Test to Treat initiatives in improving the neglected inequities of COVID-19 among racially/ethnically minoritized groups.

In the United States, coronavirus disease 2019 (COVID-19) has resulted in more than 95 million infections and 1 million deaths (as of September 2022), with individuals of racially/ethnically minoritized groups being disproportionately represented among these numbers. Despite the apparent pandemic fatigue in many communities, systemic and structural racism continue to place racially/ethnically minoritized groups at a disadvantage for overcoming the virus, especially as it relates to receiving vaccinations and COVID-19 targeted therapeutics. Test to Treat programs have the potential to mitigate these disparities by rapidly identifying the presence of a COVID-19 infection and readily offering treatment options. Nonetheless, Test to Treat programs must be optimized to adequately address the limitations to care within racially/ethnically minoritized communities.

Impact of a resident-driven wellbeing committee on resident-perceived wellbeing, burnout, and resilience.

BACKGROUND: Limited data exists to guide strategies that reduce risks of burnout amongst pharmacy residents. OBJECTIVE: The primary objective of this analysis was to characterize wellbeing, burnout, and resiliency among pharmacy residents. The secondary objective was to assess the impact of a resident-run wellbeing committee on wellbeing, burnout, and resiliency. PRACTICE DESCRIPTION: In 2018, a wellbeing committee was developed at an academic medical center with the aim of promoting wellbeing and resilience amongst pharmacy residents. PRACTICE INNOVATION: The wellbeing committee functions through 3 workgroups focused on resources, engagement, and advocacy. Collectively, these workgroups aim to facilitate wellbeing discussions, plan mindfulness events, and advocate for policies to enhance the wellbeing of residents. EVALUATION METHODS: Pharmacy residents were invited to participate in an electronic survey aimed at characterizing resident wellbeing and assessing the impact of a resident-led wellbeing committee on wellbeing, burnout, and resiliency. The Resident & Fellow Wellbeing Index (RFWI) and Brief Resilience Scale (BRS) were utilized to assess burnout and resiliency, respectively. Continuous and categorical endpoints were assessed utilizing student t tests and chi-square tests, respectively. RESULTS: A total of 16 of 38 residents participated in this analysis. Scores for RFWI and BRS remained stable throughout the 16-week period. RFWI scores demonstrated that up to 50% of residents scored as "at risk" at any point during the study period, while over 80% of respondents maintained high levels of resilience. More than 50% of respondents reported a positive impact of the wellbeing committee on their wellbeing, burnout, and resilience. CONCLUSION: A resident-led wellbeing committee demonstrated favorable impact on wellbeing, burnout, and resilience for majority of pharmacy residents. While this data suggests that such a committee may serve to protect residents from the negative impacts of burnout, future studies are necessary to further elucidate strategies to promote resident wellbeing.

Healthcare Equity and Leadership: Implementation of Diversity, Equity, and Inclusion Training for Pharmacy Residents.

BackgroundPharmacy training programs infrequently include formal training in the areas of diversity, equity, and inclusion (DEI). Hence, the purpose of this report is to offer perspectives gained from the delivery of a DEI curriculum within a pharmacy residency program aimed at expanding experiential learning focused on DEI and health equity. Program Implementation: Pharmacy residents at an academic medical center were invited to participate in a longitudinal DEI/equity seminar series that was thoughtfully and strategically developed by a team of residents and program leadership based on a six-step process. Residents were offered 9 individual seminars covering 4 major focus areas to facilitate enhanced awareness, learning, and vulnerability. Participants were invited to provide evaluations of each seminar and the overall series. Program Assessment: A total of 41 residents (100%) participated in at least one of the 9 seminars that were offered and approximately 50% completed the post-series survey. Resident-perceived benefit of each individual session was consistently favorable. Additionally, greater than 70% of participants responded favorably when asked about the impact of each session on their awareness, resources provided, and ability to apply the learnings to their practice. Conclusion: Our inaugural experience with the integration of a DEI seminar series into a pharmacy residency program suggests that there is a clear benefit to including DEI/health equity into pharmacy residency training. This data may suggest that adoption of DEI-focused experiential training may increase cultural awareness and the availability of resources to better equip pharmacy residents in applying concepts of DEI into their practice.

Assessing the Economic Value of Pharmacy Resident Participation in an Investigational Drug Service.

PURPOSE: Completion of postgraduate residency training gives pharmacists an opportunity to gain advanced practice experience, yet the availability of these positions is often limited. Through participation in an investigational drug service (IDS), residency programs may be able to expand learning experiences while demonstrating a financial benefit to the institution. The purpose of this assessment is to examine the economic value generated by pharmacy resident involvement within an IDS. METHODS: This was a single-center retrospective record review. All resident dispensations within the IDS from January 1, 2016, to December 31, 2017, were evaluated for cost avoidance, revenue, and waived revenue. Cost avoidance was defined as the cost of medications the institution would have incurred had the sponsor not provided therapies free of charge. Medical center contract acquisition costs were used to determine cost avoidance. Total economic value accounted for the personnel costs of resident dispensations. Descriptive statistics were utilized for all assessments. RESULTS: A total of 444 resident dispensations occurred during the study period on 15 IDS protocols. The total cost avoidance for resident dispensations was US$144 898. Total revenue for these dispensations was US$1424, and waived revenue fees totaled US$17 625. After accounting for the personnel cost of dispensations by the residents, the total economic value of resident participation in the IDS was US$159 150. CONCLUSION: Resident participation in the IDS contributed economic value to the institution. The IDS provides a unique learning experience for the pharmacy residents, cost savings for the institution, and supports the advancement of patient care.

Safety of Intravenous Bisphosphonates for the Treatment of Hypercalcemia in Patients With Preexisting Renal Dysfunction.

BACKGROUND: Although intravenous (IV) bisphosphonates are first-line medications for the management of hypercalcemia, studies examining their use in patients with preexisting renal dysfunction are limited. OBJECTIVE: The objective of this study is to describe the safety and efficacy of pamidronate and zoledronic acid in the treatment of hypercalcemia in patients with baseline renal dysfunction. METHODS: A retrospective analysis was conducted of IV pamidronate and zoledronic acid in adult patients with hypercalcemia and creatinine clearance (CrCl) <60 mL/min. The primary endpoint was incidence of all-grade serum creatinine (SCr) elevations. Secondary endpoints included refractory hypercalcemia, hypocalcemia, osteonecrosis of the jaw (ONJ), corrected serum calcium (CSC) decrease ≥1.0 mg/dL by day 7 of bisphosphonate administration, and normalization of CSC ≤10.5 mg/dL by days 10 and 30. RESULTS: A total of 113 patients were included (n = 55 pamidronate, n = 58 zoledronic acid). The primary endpoint of all-grade SCr elevation occurred in 28 (24.8%) patients. Grades 3/4 SCr elevations occurred in 10.9% of patients treated with pamidronate and 1.7% of patients receiving zoledronic acid. Approximately 16% and 14% of patients developed grades 1 and 2 hypocalcemia, respectively, and there were no cases of ONJ. Overall, 64.6% of patients achieved normalization of CSC by day 10, and there were no statistical differences between bisphosphonate type and renal function. CONCLUSIONS AND RELEVANCE: The analysis suggests an association between IV bisphosphonates and increased rates of SCr elevations among patients with preexisting renal dysfunction. Future prospective studies are necessary to elucidate these findings.

Assessment of pharmacy-driven transitional interventions in hospitalized patients with psychiatric disorders.

OBJECTIVE: Pharmacy-driven transitions of care (TOC) services for psychiatric patient populations have not been systematically evaluated. The primary objective was to assess pharmacy TOC services for patients hospitalized for psychiatric care at an academic medical center. The secondary objectives were to evaluate the incidence of psychiatric-associated readmission, emergency department (ED) presentations, or both and outpatient clinic follow-up 30 days after discharge, in addition to characterizing the types and frequencies of psychotropic medications prescribed at discharge. DESIGN: Retrospective, double-cohort study. SETTING AND PARTICIPANTS: This study compares adult patients who received at least 1 pharmacy-driven TOC intervention before discharge from a psychiatric unit between June 1, 2017, and June 30, 2018, with a historical control group that was discharged between June 1, 2016, and May 31, 2017. Interventions included discharge education on selected high-risk medications, medication barriers assessment, TOC notes to outpatient providers, postdischarge telecommunication, and bedside medication delivery. OUTCOME MEASURES: The percentage of pharmacy TOC services provided for patients hospitalized for psychiatric care at an academic medical center and the incidence of psychiatric-associated readmission, ED presentations, or both and outpatient clinic follow-up 30 days after discharge. RESULTS: Fifty-three and 104 electronic health records were reviewed within the control and intervention groups, respectively. The most common interventions were discharge education (22.7%), bedside delivery of medications (22.7%), and medication barrier assessments (22.2%). Adherence (26.8%) and cost (19.5%) were the most common medication barriers. Thirty-day psychiatric-associated readmissions, ED presentations, or both occurred in 32.4% and 15.4% of patients in the control and intervention groups, respectively (P < 0.001). Of the patients, 15.1% and 20.1% presented for outpatient follow-up in the control and intervention groups, respectively (P < 0.001). Statistically, more patients in the control group were prescribed antidepressants at discharge (41.8% vs. 13.1%), whereas more patients in the intervention group were prescribed lithium (10.9% vs. 4.3%) and antipsychotics other than clozapine (40.0% vs. 25.9%). CONCLUSION: The findings show significant differences in clinical outcomes between patients receiving and not receiving pharmacy-driven transitional interventions. Future prospective studies are warranted to further elucidate these observations.

A comprehensive review of chronic heart failure pharmacotherapy treatment approaches in African Americans.

BACKGROUND: Our aim was to review the published literature evaluating treatment approaches for chronic heart failure (HF), notably as it relates to African American patients. METHOD: We undertook a comprehensive database search (1986-2017) of PubMed, EMBASE, and Ovid/MEDLINE utilizing terms 'African American', 'black', 'chronic heart failure', 'heart failure', 'medication', 'chronic therapy', and 'clinical trials'. Additional notable studies were obtained from ClinicalTrials.gov . Studies published in English that examine treatment modalities of chronic HF in African American and non-African American patients were included. RESULTS: Examples of current gaps worthy of investigation include whether to maximize thiazides and calcium-channel blockers prior to adding renin-angiotensin system (RAS) inhibitors or beta blockers in HF with preserved ejection fraction; whether hydralazine/isosorbide dinitrate (ISDN) should be initiated during earlier HF stages; whether to prioritize hydralazine/ISDN over other agents such as RAS inhibitors; varying response of African Americans to different agents within drug classes; and the role of mineralocorticoid receptor antagonists. CONCLUSION: Further studies are needed in order for consensus guidelines to clarify how best to treat this population.

Economic outcomes associated with an investigational drug service within a Veterans Affairs health care system.

BACKGROUND: An investigational drug service (IDS) has a foundational role in ensuring the safe and efficient management of investigational drugs. The objective of this assessment is to determine economic value of an IDS within a Veterans Affairs health care system. METHODS: This assessment was a single-center retrospective record review. Study protocols managed by the IDS over a 2-year period were evaluated for cost avoidance, revenue, and waived revenue. Cost avoidance was defined as the cost savings generated when a research subject received sponsor-provided treatment in place of a therapy that would have been otherwise funded by the institution. Revenue from fees charged to investigators and waived revenue based on the standardized IDS fee schedule were also totaled. The total economic value to the institution accounted for the personnel costs of the IDS. RESULTS: Twenty-three investigational study protocols managed by the IDS resulted in economic outcomes. The total cost avoidance during the two-year period was $482,627.33. The total revenue and waived revenue associated with the IDS was $16,822 and $54,200, respectively. Oncology protocols had the highest contribution to the outcomes of cost avoidance and revenue and mental health protocols had the highest contribution for waived revenue. The overall economic value of the IDS to the institution was $393,649.33. CONCLUSIONS: Over a two-year period, the IDS demonstrated a substantial economic value that was largely driven by cost avoidance. Revenue generation from fees charged to investigators and cost savings to the investigator through waived revenue also contributed economic benefits to the institution.

Implementation of a Student-Developed, Service-Based Internship for Pharmacy Students.

PURPOSE: This article describes the development, implementation, and impact of a student-created pharmacy internship program with aspects of service-learning, professional development, and ambulatory care pharmacy practice. PROGRAM DESCRIPTION: As the pharmacy profession continues to evolve, pharmacy internships present valuable opportunities for student pharmacists to explore career pathways and develop personal and professional skills. While internships in clinical and industry settings support interns' professional development, service-based internships provide additional benefits to student pharmacists by promoting cultural awareness, community engagement, and commitment to serving underserved patients. Student leaders from the Student Health Action Coalition (SHAC) at the University of North Carolina Eshelman School of Pharmacy created a service-learning, ambulatory carefocused pharmacy internship for fellow student pharmacists. Two rising third-year students were selected to participate in the internship in the summer of 2018. Over the two-month program, the interns participated in various program components including direct patient care activities, faculty-led workshops and topic discussions, and quality improvement projects. In addition to supporting the interns' academic and professional growth, this program also furthered the mission of SHAC to promote positive health outcomes for underserved populations. SUMMARY: The SHAC Ambulatory Care in Underserved Populations Internship represents an innovative initiative by pharmacy student leaders to develop a service-focused internship for fellow student pharmacists. Participation in the internship provides unique opportunities not often available in conventional pharmacy curricula, including engagement with underserved patient populations and exploration of strategies to mitigate health disparities. Crafted by students for fellow students, this internship provides opportunities for personal and professional growth for both student developers and interns to carry into their future pharmacy careers.