Tobacco treatment practices of pharmacists in Montana.

OBJECTIVES: To assess the tobacco treatment practices of Montana pharmacists, evaluate pharmacist interest in addressing tobacco use, and identify perceived barriers to delivery of tobacco cessation services. DESIGN: Descriptive, nonexperimental, cross-sectional study. SETTING: Montana in February 2007. PARTICIPANTS: 192 pharmacists attending an annual continuing professional education program. INTERVENTION: Attendees at 11 meeting sites throughout the state completed the survey. MAIN OUTCOME MEASURES: Pharmacists' use of the U.S. Clinical Practice Guideline 5 A's (ask, advise, assess, assist, and arrange) in regard to tobacco cessation services. RESULTS: Of program attendees, 76% (192 of 253) completed the 35-item survey. More than one-half (58%) of respondents were men, and 90% were white. Respondents were licensed for a median of 22.5 years and dispensed a median of 1,000 prescriptions per week. The percent of pharmacists who treated one or more patients using the 5 A's in the preceding 30 days were as follows: asked about tobacco use, 39%; advised to quit smoking, 54%; assessed for readiness to quit smoking, 36%; assisted with quitting (i.e., cessation counseling), 46%; assisted with advice to use nonprescription cessation medication, 62%; assisted with advice to use prescription cessation medication, 54%; arranged for a follow-up appointment for additional counseling, 6%; and referred to a tobacco quit line, 23%. Most respondents (58%) reported that providing cessation services within routine practice was moderately or highly feasible. The most frequently cited barriers to providing cessation services included lack of time (52%), reimbursement (26%), and training (19%). CONCLUSION: Few Montana pharmacists are routinely asking patients about tobacco use in a typical month. However, the majority of pharmacists reported that it would be feasible to provide more tobacco cessation activities within routine pharmacy practice. Addressing barriers related to workload, reimbursement, and training would likely increase the number of pharmacists who provide tobacco cessation services.

Randomized trial assessing the effectiveness of a pharmacist-delivered program for smoking cessation.

BACKGROUND: As trained and accessible healthcare professionals, pharmacists are in an ideal position to provide tobacco cessation interventions. Of the 15 studies identified in the literature assessing the effectiveness of tobacco cessation interventions delivered by pharmacists, this is the first randomized controlled trial conducted in the US of a pharmacist-delivered program for smoking cessation using biochemical confirmation. OBJECTIVE: To assess the effectiveness on smoking cessation of a face-to-face group program conducted by the pharmacist team compared with a brief standard care session delivered by a pharmacist over the telephone. METHODS: An open-label, prospective, randomized, controlled trial was conducted at a Veterans Health Administration, community-based outpatient clinic in the Rocky Mountain region. Participants were randomly assigned to receive a 3-session face-to-face group program conducted by the pharmacist team or one 5- to 10-minute standard care session delivered by the pharmacist team over the telephone. Participants in both groups were offered either immediate-release bupropion or nicotine patch at no cost. The primary outcome of self-reported abstinence was biochemically confirmed by urinary cotinine at 6 months after the quit date. RESULTS: One hundred one smokers were randomized from October 3, 2005, to March 30, 2007, with the last 6-month follow-up survey completed on November 6, 2007. Analysis of data was completed in December 2007. Using intent-to-treat procedures, confirmed abstinence rates at the end of 6 months were 28% in the pharmacist-delivered face-to-face treatment group and 11.8% in the standard care telephone session control group (p < 0.041). CONCLUSIONS: This study demonstrates that pharmacists are effective providers of tobacco cessation interventions. Greater utilization of pharmacists in tobacco cessation efforts could have a significant impact on smoking rates, prevention of tobacco-related diseases, and overall improvement in public health across the US.

Tobacco interventions delivered by pharmacists: a summary and systematic review.

BACKGROUND: As one of the most accessible health care professionals, pharmacists are in an ideal position to provide tobacco-cessation and prevention services. Although there is growing interest in expanding the pharmacist's role in tobacco treatment, few published studies have assessed the efficacy or effectiveness of tobacco-cessation services delivered by pharmacists in the United States. OBJECTIVE: To summarize and critique studies that examined pharmacist-delivered tobacco-cessation services. METHODS: Articles written in English that appeared in peer-reviewed journals were identified from a systematic review of literature published from 1980-2006. Publications were selected for review if the interventions were delivered by pharmacists, if the intervention included United States Food and Drug Administration-approved drugs (if drug therapy was used), and if smoking-cessation rates could be calculated. RESULTS: Fifteen studies met inclusion criteria. Fourteen of the studies targeted smoking, and one targeted spit (chewing) tobacco. Five studies were controlled, and 10 were uncontrolled. One of the controlled studies (chewing tobacco) and eight of the uncontrolled studies were conducted in the United States. Findings of the uncontrolled U.S. studies suggest that pharmacists can deliver smoking-cessation services. Three of the controlled studies found statistically significant differences between the pharmacist-based intervention and the control group, and the trend in the other two studies was toward the effectiveness of the pharmacist-delivered intervention. Only six of the 15 studies reviewed used biochemical measures to verify self-reported cessation. CONCLUSION: The uncontrolled and controlled studies reviewed demonstrate that pharmacists can deliver tobacco-cessation interventions, and the evidence strongly suggests that they are effective in helping smokers to quit. Future studies conducted in the United States that are well controlled and include biochemical verification of smoking status are needed to provide definitive confirmation that pharmacist-delivered interventions are effective for smoking cessation. With the availability and expanded training of pharmacists, this is an opportune time for testing and disseminating evidence-based research evaluating the effectiveness of pharmacist-delivered tobacco-cessation services.

Pharmacy practice, research, education, and advocacy for older adults.

In the United States, older adults have become the fastest growing segment of the population and are expected to double in number to 70 million by 2030. As a whole, older adults have different health care needs than younger patients, and some of these needs should be met by pharmacists. Clinical pharmacy practice affecting older adults occurs in a variety of settings, including community, ambulatory care, primary care, hospital, assisted living, nursing home, home health care, hospice, and Alzheimer's disease units. Although specialty training in geriatrics or gerontology is not required for pharmacists to care for older adults, it is extremely helpful. Pharmacy education related to the care of older adults has improved slightly in the past several years but will need to increase even more to provide all pharmacists with the basic skills and knowledge to care for this unique group of patients. In addition, pharmacotherapy research targeting older adults needs to increase. Although it can be challenging, funding for this type of research is available. Patient and political advocacy is also important to support this growing population.

Pharmacist-managed tobacco cessation program in Veterans Health Administration community-based outpatient clinic.

OBJECTIVE: To describe an ongoing pharmacist-managed tobacco cessation clinic and assess the long-term effectiveness of the program. SETTING: Veterans Health Administration (VHA) community-based outpatient clinic in Missoula, Montana. PARTICIPANTS: Pharmacy professor/clinical pharmacy specialist, advanced pharmacy practice experience students, and tobacco cessation participants. PRACTICE DESCRIPTION: Ongoing, pharmacist-managed tobacco cessation program offered to veterans. PRACTICE INNOVATION: With use of the "Vets without Cigarettes" program developed by the Montana VHA and the most current strategies reported in the literature, the clinical pharmacy specialist and pharmacy students provide tobacco cessation services for Missoula Veterans Affairs Primary Care Center veterans. Activities include a three-session program using the Transtheoretical Model of Change, tobacco cessation pharmacotherapy, behavioral strategies, cognitive techniques, documentation, and follow-up survey. MAIN OUTCOME MEASURE: Percentage of veterans contacted reporting tobacco abstinence. RESULTS: Follow-up survey results were obtained for 130 (87.8%) of 148 veterans attending one or more sessions of the tobacco cessation class between November 1999 and December 2003. Of the 130 veterans contacted, 54 (41.5%) continued to be tobacco free. CONCLUSION: This program demonstrates that pharmacists are effective providers of tobacco cessation services. Furthermore, a comprehensive tobacco cessation program is provided that can serve as a model to guide pharmacists in assisting more patients to become tobacco free and live healthier lifestyles.

Establishing an on-site pharmacy in a community health center to help indigent patients access medications and to improve care.

OBJECTIVES: To describe the establishment of an on-site pharmacy in a community health center (CHC) to improve access to medications for indigent patients, the implementation of pharmaceutical care programs and clinical pharmacy services to improve patient care and therapeutic outcomes, and the development of an ambulatory care site for training pharmacy students. SETTING: Partnership Health Center (PHC), a federally funded CHC in Missoula, Mont. PRACTICE DESCRIPTION: Establishment of an on-site pharmacy and strategies for accessing medications for indigent patients, including participation in the U.S. Public Health Service pricing program, pharmaceutical manufacturers' assistance programs, and drug sampling, are described. The clinical pharmacy, disease management, and pharmaceutical care programs developed at the site to improve medication use and therapeutic outcomes are discussed. Development of an ambulatory care clerkship site at the CHC for training University of Montana pharmacy students is reviewed. PRACTICE INNOVATION: Partnership between PHC and the University of Montana School of Pharmacy and Allied Health Sciences (SPAHS) to establish an on-site pharmacy to help medically indigent patients access medications and to improve care. INTERVENTIONS: Programs to help indigent patients access, adhere, and appropriately use needed medications while decreasing clinic expenditures for medications. MAIN OUTCOME MEASURES: Number of prescriptions dispensed per month, clinic expenditures on medications per month, and number of clinical services and pharmaceutical care programs developed. RESULTS: Between November 1, 1999, and April 30, 2000, the average number of prescriptions filled for PHC clients increased from 219/month to 838/month and the average expenditure per prescription decreased from $16.55/month to $0.51/month. A pharmacist-assisted refill program was implemented. Programs in diabetes, hypertension, dyslipidemia, asthma, anticoagulation, and peptic ulcer disease were developed. CONCLUSION: Establishing an on-site pharmacy in a CHC in collaboration with a school of pharmacy significantly improved indigent patients' access to medications while decreasing clinic expenditures. Pharmaceutical care programs improved therapeutic outcomes, and clinical pharmacy services complemented the clinical activities of other health care providers in managing chronic diseases and resolving drug-related problems. The CHC provided an excellent setting for training pharmacy students in ambulatory care.

Citalopram-induced priapism.

Citalopram is a relatively new selective serotonin reuptake inhibitor (SSRI) that is becoming widely administered for the treatment of depression. Selective serotonin reuptake inhibitors generally are associated with mild adverse sexual side effects; however, more serious reactions may occur. A 58-year-old man experienced priapism several hours after inadvertently taking three tablets of citalopram 20 mg, which he had mistaken for aspirin, in addition to his usual dosage of 20 mg twice/day. Three days later, he was hospitalized and treated with intracavernous phenylephrine. He ultimately required surgical intervention. Although the citalopram overdose appears to be largely responsible for the patient developing priapism, he also was taking tamsulosin 0.4 mg/day at bedtime for benign prostatic hyperplasia. As alpha1-blockers have been associated with priapism on rare occasions, tamsulosin may have been a contributing factor. The patient also had a history of priapism associated with trazodone. Health care professionals should vigilantly monitor patients who take citalopram in high dosages or in combination with other drugs associated with priapism. Patients who have a history of priapism with other drugs may be more susceptible to citalopram-associated priapism.