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Passionate for the Appropriate Use of Medication

Volume 8 | Issue 2

News & Views

Current Information and Topics from the Market Leader in Hospice Pharmacy



Summary of Pharmacy-related CoPs

Education Corner

Palliative Medicine Matters: Fundamental Principles for Safely Using Methadone for Pain Alternative routes of administration

HP's Supporting Cast

HP's Team Member Corner

Hot Off the Press!

3 5 6 8 9 10 11 11 12

Dear Laura XerisMobile

Effects of the New Medicare Conditions of Participation: Focus on Pharmacy

[ Terri L. Maxwell PhD, APRN, BC-PCM ]

After 9 years in development, the new Medicare Conditions of Participation (CoPs) were published on June 5, 2008 and become effective December 2, 2008.These new patientcentered CoPs are founded on evidence and standards of practice and emphasize quality improvement and patient outcomes. One very notable change in the CoPs is a new and strong focus on pharmacy and medication management. This article will highlight the areas within the CoPs where pharmacy services may be leveraged to meet these new requirements and criteria. The revised CoPs require an initial and comprehensive assessment of each patient. The comprehensive assessment needs to include a thorough medication review of all of the patient's medications, including herbal remedies, over the counter medications (OTCs), and other alternative treatments that could affect drug therapy. In addition, hospices must complete a review of the patient's drug profile to identify any possible side effects, actual and potential drug interactions, duplicative or ineffective therapies, and therapies, such as warfarin, that require laboratory monitoring. The goal is to eliminate unnecessary or duplicative drugs to make it easier for patients to follow their treatment plans.

A new CoPs standard (Standard 418.106: Drugs and biologicals, medical supplies and durable medical equipment) contains medication service requirements to improve patient outcomes. This is accomplished by the supporting role of the pharmacist in preventing medication related problems by using drugs more effectively and safely. This new standard requires that hospices either employ or contract with a specially trained individual or pharmacist to ensure that drugs and biologicals meet each patient's needs. Further, hospices are required to have a policy for the disposal of controlled drugs maintained in the patient's home when those drugs have been discontinued by the physician or are remaining at the time of death. The hospice clinician needs to provide a copy of the hospice's medication disposal recommendations and discuss policies and procedures with the patient and family at the time that controlled drugs are ordered and document the discussion in the patient's chart. Another significant new requirement related to chemical restraints administered in IPUs is discussed in Section 418.110 (m). CMS defines a "drug restraint" as "drugs or medications that are used to manage the patient's behavior or restrict the patient's freedom of movement that is not standard treatment for the patient's condition". If


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restraints are used, certain stipulations must be met such as · a physician must assess the patient in person and document an order and the rationale for its use in the clinical record, · the order must be renewed every 4 hours for no more than 24 hours, and · the patient must be monitored closely by trained staff. CMS recognizes that there are drugs used in hospice for symptom management that can also be used appropriately as drug restraints under limited circumstances. The new CoPs accent the value of pharmacists in hospice and have a strong emphasis on pharmacy standards, medication management and appropriate drug therapy selection and monitoring. While your hospice works to adjust to the new requirements outline in the CoPs, challenge your pharmacy provider to support your hospice in this endeavor. HP has a fully engaged proactive process to support hospices to meet these standards. Whereas most pharmacies only have information about medications that they dispensed, HP requires documentation of a patient's full medication profile (prescriptions, OTC's, herbals, nonhospice related meds, etc) upon admission. HP's specially trained hospice pharmacists prospectively screen all new medication requests for duplicate therapies, medications that require monitoring, and for potential drug interactions. HP also has softwarebased tools that aid in the identification of drug interactions at the time of dispense. If an interaction is noted, depending upon the degree of interaction and the clinical situation, HP pharmacists notify the hospice clinician of the interaction with

recommendations to minimize risk. HP's 24/7 access to consultation from a team of hospice-trained PharmDs, including offhours access to a clinical and administrative PharmD, along with dedicated PharmD Client Relations Liaisons for direct onsite clinical, administrative and operational support ensures that the collaboration required between your hospice and their pharmacist is not only met, but exceeded. HP's Resource Manual includes a sample medication disposal policy, as well as a copy of federal guidelines for medication waste, along with a medication waste and destruction decision tree to assist our partners in meeting the new Medication Disposal Policy standard. HP has been very attentive to the information released on the CoPs and has been proactively creating a comprehensive model that will help your program have a smooth adoption of the new patient centered CoPs. HP's clinical pharmacists are available to our partners 24/7 to provide recommendations for appropriate drug selection to ensure optimal patient outcomes.

HP Newsletter Staff

EDITOR: Rebecca Lewis, PharmD, MBA Senior VP, Marketing and Corporate Accounts [email protected] ASSISTANT EDITOR: Nick Baranowski Marketing Project Manager [email protected] LAYOUT AND DESIGN: Melissa Morris Ivone Director, Creative Services [email protected]

See "Pharmacy-related CoPs Standards" on the next two pages.

To request additional copies of this newsletter, please email [email protected]

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Pharmacy-related CoPs Standards


§ 418.54 (c) Comprehensive Assessment: Drug Profile


Standard (c): When performing a drug profile review for the comprehensive assessment hospices are required to: · Include all prescription and OTC drugs including herbal remedies and other alternative treatments that could affect drug therapy. · Determine whether those drugs and remedies are related to the terminal illness or not. - Hospices are not required to document the relationship of a drug therapy to the terminal illness or related conditions.


Drug Profile Review: · Nurses provide a full medication profile to HP- the patient's full drug profile is available on Xeris. · Hospices can choose the manner in which they document the drug profile review.

Per standing procedures, HP supports this process: · HP pharmacists review the medication profile for duplicate/ ineffective therapies, medications requiring monitoring/ dosing adjustments and potential drug interactions. · HP's software-based tools aid in identifying drug interactions at the time of dispense. HP's QAPI reports can be used to assess various aspects of your program, including resource allocation, standards of care, etc.

As part of the drug profile review, hospices are responsible for reviewing the patient's drug profile for: · side effects, · documenting both actual and potential drug interactions, · identifying any duplicate or ineffective drug therapies, and · drug therapy requiring laboratory monitoring. § 418.58 Quality assessment and performance improvement (QAPI) (a) Standard: Program Scope · Must focus on indicators related to improved palliative outcomes and end-of-life services. · Must address all services, including those provided under contract (including pharmacy). (b) Standard: Program Data · QAPI is data-driven based upon opportunities and priorities to improve patient care. · Data are used to manage individual patients or events or aggregated for groups of patients or events.

§ 418.106 Drugs and biologicals, medical supplies and durable medical equipment

-(a) Standard: Managing drugs/biologicals · Ensure that IDG confers with individual with education and training in drug management to ensure that drugs and biologicals meet each patient's needs. · Inpatient care directly: Pharmacy services must be under direction of a licensed pharmacist.

Partnership with HP satisfies this new standard: · Access 24/7 to HP's team of hospicetrained PharmDs for consultation. · Off-hours access to a dedicated PharmD, plus an HP operations administrator. · HP's partners have a dedicated PharmD liaison (CRL) for direct onsite clinical, administrative and operational support. · IPU services supported by clinical and administrative pharmacists.


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§ 418.106 Drugs and biologicals, medical supplies and durable medical equipment

(b) Standard: Ordering of drugs · Ordered by physician or NP · Verbal or electronic orders given only to licensed nurse, pharmacist, or physician and must be recorded and signed in accordance with all regulations. (c) Standard: Dispensing of drugs (d) Standard: Administration of drugs and biologicals · IDG must determine if patient/family is able to safely administer drugs.

· HP conforms to this as part of standard practice · HP is in compliance and has a sophisticated system for CII reconciliation and documentation

§ 418.106 Drugs and biologicals, medical supplies and durable medical equipment

(e) Standard: Labeling, disposing, storing of drugs (cont'd) · Labeled in accordance with standard practice. · In IPUs- Stored in secured areas in locked compartments, only authorized personnel may have access. · Written policies and procedures for managing and disposing of drugs in patient's home, discussed with patient and family at the time when controlled drugs are first ordered, document discussion in clinical record.

· HP's "Patient Welcome Letter" encourages discussions of proper medication disposal · HP's Resource Manual provides a sample medication disposal policy, Federal guidelines for medication waste, and a decision-tree, as well as other resources.

§ 418.60 Infection Control

(a) Standard: Prevention (b) Standard: Control (c) Standard: Education

· HP's Antibiotic QAPI report helps track trends in AbX use for infection control.

§ 418.104 Clinical Records

(a) Standard: Responses to medications, symptom management, treatments and services · Requires hospices to note in the clinical record the effectiveness of drug therapy.

· Consultation with HP pharmacists aids in evaluation of therapeutic response.

§ 418.110 Hospices that provide inpatient care directly

(m) Standard: Restraint or seclusion · Clarified the term "drug restraint" as "drugs or medications that are used to manage the patient's behavior or restrict the patient's freedom of movement that is not standard treatment for the patient's condition". · Requires a physician's in person assessment and order (no standing orders) and a rationale for use documented in the clinical record. · No more than 24 hours total, renewed every 4 hours for adults. · Monitored by trained staff. · Face to face evaluation every hour for violent or selfdestructive behavior.

· CMS recognizes that there are drugs used in hospice for symptom management that can also be used appropriately as drug restraints under limited circumstances. · HP pharmacists provide recommendations for appropriate drug selection and dosing parameters when medications are indicated for restraint purposes.

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[ Jillian Baer, PharmD, CGP, BCPS, Senior Manager, Clinical Education ]

Hospice Pharmacia is committed to providing high quality, clinical education programs focused on palliative and end-of-life care. Our programs are developed for the beginner to advanced nursing and pharmacy professional however, all medical directors, nurses, social workers, and pharmacists of our partnering hospice organizations are invited to participate. The Education Department offers bimonthly CNE programs via web-based teleconferences. If you are an HP partner and are interested in participating in one or more of these educational offerings, program invitations are faxed to HP's partnering hospices approximately 4­6 weeks prior to the scheduled program date. We are excited to announce the incorporation of fellow Omnicare associates as guest speakers for our July Continuing Education program! Nancy L. Losben, R.Ph., CCP, FASCP, CG, Chief Quality Officer, Omnicare and Cynthia Seel, BSN, RN, Key Account Manager, Omnicare will be presenting this exciting topic along with Jillian Baer, PharmD, CGP, BCPS, Senior Manager Clinical Education, excelleRx Inc., an Omnicare company. Nancy and Cynthia have numerous years of experience in the long-term care arena and their expertise will be appreciated during this month's program! The program will provide a discussion on the practice of hospice care in the long-term care setting; specifically addressing the concept of shifting the focus from chronic care to end-of-life care. The goals of the program are to provide the audience with an overview of considerations encountered in the long-term care setting including various regulatory issues, assessment via the MDS, the role of the consultant pharmacist, clinical concerns regarding the geriatric and hospice populations and appropriate medication management for the above noted patient groups. If you have any questions or suggestions regarding HP's clinical education offerings, please email Jillian Baer at [email protected] All interested participants will find instructions of how to join this program on the faxed invitation. Hospice Pharmacia partners may also wish to participate in self-study CNE programs online. To do so, log into Xeris® and click the Education Materials icon left navigation bar. on the


(Specific dates and times to be announced)

JULY: SEPTEMBER: NOVEMBER: Hospice Care in the LTC Setting 7/30 @ 12pm & 3pm EDT (tentative) Anxiety, Agitation and Delirium TBA Medication Waste TBA


Pain Assessment in the Palliative Care Environment Introduction to Non-Opioid and Opioid Pain Therapy Pain Management: The Role of Adjuvant Drug Therapy Pain Pathophysiology: Nociceptive & Neuropathic Pain Palliative Sedation Therapy in Hospice: Principles, Guidelines & Therapeutic Approaches Quality Assurance/Performance Improvement (QAPI) Programs in Hospice Controlling Common Symptoms in End-Stage COPD Management of Nausea & Vomiting: A Pathophysiologic Approach A Review of End-Stage Liver Disease

Palliative Medicine Matters

Vol. 2, No. 2 · SUMMER 2008

Fundamental Principles for Safely Using Methadone for Pain

By: Kevin T. Bain, PharmD, BCPS, CGP, FASCP

Physical pain is a common health problem that undermines quality of life considerably. For more than a decade it has been well documented that suboptimal treatment of pain is common. Methadone has steadily gained popularity as a treatment option for moderate-to-severe pain because, in part, methadone improves pain control in a substantial proportion of persons, including those with difficult-to-treat pain. Recently, however, there have been a disproportionate number of reported methadonerelated adverse events, prompting scrutiny by regulatory agencies of the use of methadone for pain management. If healthcare practitioners and consumers do not take action to safeguard the use of methadone, regulatory agencies may take further action against this highly effective drug. This article discusses safe practice recommendations to prevent methadone-related adverse events and to avoid patient harm. Several of these recommendations have been adopted from the Institute for Safe Medication Practices (ISMP).1 After reading this article, the healthcare practitioner should be able to explain principles for safely using methadone for pain. and hospitals; thereby eliminating the use of methadone 40mg tablets for the treatment of pain ( methadone_advisory.htm). This decision was made in direct response to the reported increase in methadone-related adverse events.

How can I prescribe methadone safely?

Methadone has unique properties and differs from other opioids in several important ways. These differences necessitate a highly individualized approach to prescribing methadone for pain, with particular vigilance during treatment initiation, during conversion to or from methadone, during dose titration, and with the addition or removal of interacting medications. Before initiating treatment with methadone, be familiar with methadone's unique properties and toxicities and consider whether the benefit of treatment with methadone outweighs the risks. Several reviews have been written on the clinical use of methadone for pain.3-8 When selecting an initial dose of methadone, give attention to the age, general condition, and medical status of the patient; the type, severity, and expected duration of the patient's pain; the patient's degree of opioid tolerance; the total daily dose, potency, and specific characteristics of the opioid the patient had been taking previously, if any; and concurrent medications, particularly other CNS and respiratory depressants.2 For opioid-naïve patients, methadone is most safely initiated using small doses. The usual oral methadone starting dose for opioid-naïve patients is 2.5mg to 10mg every 8 to 12 hours.2 For opioid-tolerant patients, methadone is most safely initiated using conservative doses. The usual oral methadone starting dose for opioid-tolerant patients varies dramatically; therefore, methadone dosing for these patients should always be individualized. Be familiar with the various conversion methods and ratios associated with methadone,9 and consult published literature and manufacturer recommendations2 to determine the oral methadone starting dose for your patient. Follow appropriate pain management principles when titrating opioid doses. The complexities associated with methadone dosing, however, can contribute to cases of overdose, particularly during dose titration. Namely, the full analgesic effects of methadone may not be attained until after 3 to 5 consecutive days of use.2 Therefore, titrate methadone doses more slowly than other opioid doses. Do not adjust methadone doses more often than weekly to allow for the full analgesic and side effects of methadone to become clear.1

Why are there warnings about the use of methadone?

The United States Food and Drug Administration (FDA) and ISMP increasingly have received reports of adverse events involving methadone that have resulted in serious patient harm, including numerous fatalities. These adverse events have been reported in patients just starting methadone for pain control and those switched to methadone after being treated for pain with other opioids. Moreover, serious adverse events have occurred in patients prescribed large, multiple daily doses of methadone for pain as well as in patients receiving doses commonly used for methadone maintenance therapy.2

What actions have been taken by regulatory agencies concerning methadone?

In November 2006 (updated in July 2007), the FDA issued a Public Health Advisory to warn healthcare practitioners and consumers about reports of death and life-threatening side effects (e.g., respiratory depression, cardiac conduction effects) in patients taking methadone ( In January 2008, the Drug Enforcement Administration (DEA) and the pharmaceutical industry reached an agreement to restrict distribution of methadone 40mg dispersible tablets to state-approved methadone maintenance programs, pharmacies participating in a Narcotic Treatment Program,

To prevent life-threatening adverse events with methadone, consider these additional risk-reduction actions: · Be familiar with methadone-related drug-drug interactions. Avoid concomitant use of methadone with other drugs that significantly increase the risk of an adverse event, such as paroxetine or fluconazole.10 If a patient must take these drugs concomitantly then the dose of methadone and titration schedule may need to be adjusted. · Be familiar with methadone-related drug-disease interactions. Avoid use of methadone in patients with conditions accompanied by hypoxia, hypercapnia or decreased respiratory reserve (e.g., chronic obstructive pulmonary disease, cor pulmonale, severe obesity), or in patients at risk for development of prolonged QT interval (e.g., cardiac hypertrophy, concomitant diuretic use, hypokalemia, hypomagnesemia).2 For patients judged to be at risk but in whom the benefit of treatment with methadone has been considered to outweigh the risk, careful monitoring of respiratory and/or cardiovascular status should be performed.2 · Proactively take actions to avoid errors associated with methadone prescribing. For example, always write the indication for methadone to prevent confusion between methadone and other medications with look-alike or sound-alike names. · When prescribing the oral liquid form of methadone, always specify the dose in both mL and mg. · Before prescribing methadone, evaluate the patient's risk of abusing the drug. Patients at risk for drug abuse require judicious prescribing of methadone or the use of an alternative opioid for pain management.

· Closely monitor the patient. If methadone is not taken for three consecutive days, the patient may lose tolerance and be at risk for an overdose if the usual dose is taken. In this situation, the dose should be adjusted to prevent an overdose. · Be sure to ask the patient about side effects, especially before changing the methadone dose. Side effects of methadone typically occur later and persist longer than methadone's analgesic effects, particularly in the early dosing period.2 · Be aware of and monitor the patient for the signs of methadone overdose (e.g., respiratory depression, lethargy, dizziness, confusion).

What is the take-away message?

Methadone is a very effective drug for the treatment of pain. Because it differs from other opioids in several important ways, safely using methadone can be challenging. However, healthcare practitioners and consumers should not be deterred from the use of this drug. Following the principles outlined in this article will help keep patients safe from methadone-related adverse events.


1. Institute for Safe Medication Practices. ISMP Medication Safety Alert! Keeping patients safe from iatrogenic methadone overdoses. Huntingdon Valley, PA: ISMP; February 14, 2008. 2. Roxane Laboratories Inc. Dolophine Hydrochloride (Methadone Hydrochloride Tablets, USP). Columbus, OH; October, 2006. 3. Davis M, Walsh D. Methadone for relief of cancer pain: a review of pharmacokinetics, pharmacodynamics, drug interactions and protocols of administration. Support Care Cancer. 2001;9(2):73-83. 4. Bruera E, Sweeney C. Methadone use in cancer patients with pain: a review. J Palliat Med. 2002;5(1):127-138. 5. Layson-Wolf C, Goode JV, Small RE. Clinical use of methadone. J Pain Palliat Care Pharmacother. 2002;16(1):29-59. 6. Fishman SM, Wilsey B, Mahajan G, Molina P. Methadone reincarnated: novel clinical applications with related concerns. Pain Med. 2002;3(4):339348. 7. Manfredi PL, Houde RW. Prescribing methadone, a unique analgesic. J Support Oncol. 2003;1(3):216-220. 8. Manfredonia JF. Prescribing methadone for pain management in end-oflife care. J Am Osteopath Assoc. 2005;105(3 Suppl 1):18S-21. 9. Weschules DJ, Bain KT. A systematic review of opioid conversion ratios used with methadone. Pain Med. In press 2008. 10. Weschules DJ, Bain KT, Richeimer S. Actual and potential drug interactions associated with methadone. Pain Med. 2008;9(3):315-344. 11. Roxane Laboratories Inc. Patient Information: Dolophine Hydrochloride (Methadone Hydrochloride Tablets, USP). Columbus, OH; October, 2006. 12. De Simone L. Methadone information for patients and families. J Palliat Med. 2007;10(5):1-2.

How can I administer methadone safely?

Safely administering methadone begins before the drug is prescribed. First and foremost, evaluate the patient's ability to comply with methadone's administration instructions. Consider alternative opioids if the patient is deemed at risk for noncompliance. Also, educate the patient and their family about methadone to determine if there is an acceptable balance between pain control and side effects. There are various patient education materials available to healthcare professionals.11, 12 After methadone is prescribed, consider these risk-reduction actions: · Instruct the patient to take methadone exactly as prescribed. Specify the exact time(s) for scheduled administration and clearly outline instructions for "as needed" use. · Instruct the patient to avoid drinking alcoholic beverages when prescribed methadone. · Educate the patient to alert all of their healthcare providers when they start or stop taking other drugs, herbal products or supplements, and encourage the patient to have all of their prescriptions filled at the same pharmacy to facilitate complete screening for methadone-related drug interactions.

Additional copies of this newsletter can be downloaded from the Quality Outcomes section of


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Alternative routes of administration: Highlight on morphine PLO gel

[ Rachel Boyer, PharmD; Palliative Care Pharmacy Practice Resident, University of Maryland School of Pharmacy ]

Why are alternative routes of administration important in palliative care?

End-of-life care presents many unique challenges, including the frequent need to alter the route of administration of medications because of a patient's inability to swallow as his or her condition declines. When the oral route is no longer feasible, clinicians turn to alternatives such as the intravenous, rectal and topical routes of administration for medication delivery. Since not all medications are commercially available in various dosage forms, prescribers frequently turn to pharmacists for compounding in order to continue medication therapy. Frequently, the compounds requested are in the form of gels for topical administration. For example, prescribers sometimes request that morphine be compounded for transdermal use despite its availability in a variety of dose forms. However, morphine's physical and chemical properties may not be ideal for systemic absorption across intact skin, even when

placed in a special gel to assist in transdermal delivery.


analgesia from topical administration of morphine in patients with mild somatic pain.9 A study investigating the efficacy of morphine PLO in the treatment of chronic arthritis pain demonstrated satisfactory pain relief after 3 weeks of therapy by all 3 patients entered in the study10. Plasma morphine levels were not measured, but urine drug tests confirmed the presence of morphine. Despite these case reports suggesting clinical benefit, a recent randomized, placebocontrolled, double-blinded crossover study by Paice et al5 demonstrated negligible absorption in topically administered morphine PLO. This study compared the absorption of subcutaneously injected morphine to the absorption of topically applied morphine PLO in 5 healthy patients. Morphine administered subcutaneously followed expected absorption and elimination curves whereas topically administered morphine provided blood concentrations below a quantifiable level in 3 subjects and was undetectable in 2 of the subjects. Based on these findings, topical PLO morphine would not be expected to provide systemic pain relief. The reasons for the equivocal results of these studies are unclear, although the reports of pain relief in the studies by Krajnik, et al. and Wilken, et al. may be related to the placebo effect and they were performed under less controlled circumstances compared to the study by Paice and colleagues. 9,10,11

(continued on back)

What is PLO and why is it unique?

Pluronic lecithin organogel (PLO) was developed to enhance drug delivery across the skin's surface for systemic effects.



pluronic acid and lecithin components of PLO are thought to work together to disorganize the outer most layer of skin to provide maximum absorption of the drug.4 Morphine PLO is compounded by mixing morphine powder into a PLO base.5 Morphine in PLO differs from morphine Intrasite® gel in that the latter is specifically formulated to apply to a wound for local pain relief and is not intended to provide systemic pain relief.6,7 The benefits of PLO as a base for gels has not been fully determined, nor are the ways in which the properties of a given drug affect the systemic absorption from the PLO base when topically applied.2 For example, ABH (Ativan®-Benadryl®-Haldol®) gel appears to be effective and stable in PLO for systemic use, but ketoprofen in PLO appears to have only local effects.8,4

Is morphine PLO effective for pain relief?

Current literature supporting the use of morphine PLO in pain management is mixed. Several case reports suggest

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The Pharmacy Technician ­ Who they are and how they make a difference

Pharmacy Technicians play a crucial role in pharmacy practice settings; however it is generally a "behind the scenes" role. As a result, many are unaware of the responsibilities they hold. According to the Pharmacy Technician (PTCB) pharmacy Certification technicians Board As the role of the technician continues to grow and change, pharmacists are able to spend more time focusing on clinical matters, such as carefully reviewing your patient's medication profile for appropriateness and drug-drug/drug-disease interactions, and making clinical recommendations concerning complicated end-of-life symptom management issues. By leveraging the role of the Pharmacy Technician, HP's Pharmacists concentrate on important communications with hospice nurses and physicians. Although it is not an industry requirement for a technician to be certified, there are over 300,000 pharmacy technicians in the U.S. who have taken and passed the Pharmacy Technician Certification Examination to become a CPhT. This statistic speaks to the increasing professionalism and commitment Pharmacy technicians perform a wide array of functions and services which support the HP pharmacy team and thus the patients in your care. Their responsibilities at HP may include the following tasks: Updating and maintaining accurate patient information Creating medication lists for the pharmacist's review Assisting pharmacists in labeling and counting medications Verifying that patients receive the correct medications Compounding medications under the supervision of a pharmacist Processing requests for refills and to the advancement of patient care. Pharmacy technicians at HP play an important role in ensuring that your patients receive timely pharmaceutical care; you can expect that through on-going development and training, their knowledge base and responsibilities will continue to evolve to better meet the needs of HP's hospice partners. HP's staff boasts nearly 100 Certified Pharmacy Technicians (CPhTs) who are in contact with our partnering hospices' staff via phone or web-based data requests each and every day. Pharmacy technicians at HP are the catalysts in connecting you with a Clinical HP pharmacist who supports the hospice team in developing and refining the medication portion of the care plan. Once a technician is certified, they must stay up-to-date on the most recent literature by completing continuing education programs.

are "individuals working in a pharmacy, who under the supervision of a licensed pharmacist, assist in pharmacy activities not requiring the professional judgment of a pharmacist" ( A pharmacy technician's duties might vary from state to state, however a strong relationship based on teamwork must always exist between a pharmacist and a pharmacy technician. Their daily collaboration is essential for your patient's safety and for the provision of optimal pharmaceutical care.


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Dear Laura

Dear Laura, We just hired a new nurse and she is nervous about ordering CII medications for her patients since she is new to hospice. What is HP's standard operating procedure when there are questions about a CII prescription? Will the pharmacist call the nurse directly or call the hospice office? Marybeth Sherry Jack, Marybeth, That is a great question. HP obtains the nurses call back number, if possible, in case a call gets disconnected or the pharmacist has a question about a medication request. We encourage nurses and pharmacists to discuss a plan for contact in the event that follow-up is needed. However, if a specific plan is not discussed, the pharmacist will attempt to call the nurse directly. If HP is not able to reach the nurse, the pharmacist will contact the hospice office to obtain further direction. The most important thing is to make sure that the patient receives the medication, and we will try as hard as we can to make sure that it happens. Laura Sherry, There are several benefits to using a PIN. The first, and most important, is that using a PIN increases the security of access to patient information. When a nurse provides his/her 4-digit PIN, the system verifies the accuracy of the number and confirms that access to the patient has been authorized by hospice. Using a PIN also helps to expedite a call. When an accurate PIN is entered, the nurse's name will automatically populate in Xeris. This information remains in the system and can be retrieved in the event that a question arises. Lastly, HP has made several nurse-specific reports available to hospice administrators. Successful PIN entry allows these reports to be nurse-specific and can help administrators with managing hospice activities. Laura Yes! The HPWoundCare Guidelines, consultations, and therapies are now available to all HP hospices! The HPWoundCare Guidelines and consultation are included in your per diem and all dispensed products will be billed to hospice at a fee-for-service rate. HP's wound care team can be accessed for consultations by selecting Option 9 from the main menu. Laura Dear Laura, I recall reading a few articles you have written regarding the process for obtaining a Personal Identification Number (PIN) for HP, but I still have a few nurses who have not established one yet. What are the benefits of having and using PIN when calling HP? Dear Laura, Previously, wound care supplies and HP's WoundCare guidelines were only available to hospices that participated in the WoundCare program. I recently saw a letter saying these things are available to all hospices now, is that true? Jack

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HP's Team Member Corner

Putting a Face with the Voice

We would like to introduce you to Morissa Gilman. Morissa is a Certified Pharmacy Technician and has been working at Hospice Pharmacia for over 5 and a half years. She currently supports your hospice staff as a Long Term Care (LTC) Fax Team Leader. The LTC Fax Team at HP is responsible to enter the data for all faxed patient admissions and patient-related updates in the LTC area. This includes the important job of ensuring the accuracy of data entered for patients' medication profiles. Pharmacy Technician Team Leaders are the most tenured of the technician staff at HP and are responsible for the overall departmental work flow to ensure quick processing of all LTC fax requests. The work of the LTC fax team creates efficient systems for your staff and reduces the need for multiple calls related to simple updates to the patient's medication profile. Across the industry, technicians are taking on greater roles to support the clinical pharmacists in their practices sites. Highly trained and skilled Certified Pharmacy Technicians make it possible for the Clinical Pharmacists to be readily available for medication consultation and acute patient care situations. This is not a new concept to Morissa. Prior to joining the team at HP, Morissa worked in a retail pharmacy for 5 years, and then moved to a LTC Pharmacy where she held the position of Manager of Prescription Data Entry. Morissa enjoys working at HP because "there is so much unique talent concentrated here." When away from work, Morissa enjoys spending time with her family, especially her 6 years old daughter. "My family is definitely most important to me." Morissa also enjoys traveling, dining at new restaurants, reading and going to the movies as well as campaigning and volunteering with animal rights organizations.


In this feature of Hot Off the Press! we are pleased to announce three state-of-the-art publications authored by clinicians from Hospice Pharmacia. The first two, on methadone-related drug interactions and conversion ratios, are the most comprehensive evidence-based reviews of its kind. In addition to reviewing the complexities associated with prescribing methadone, the authors emphasize that the care process of prescribing methadone should involve assuring the patient is an appropriate candidate for the drug and monitoring the patient for both therapeutic and toxic effects. As a compliment to these articles, this month's Palliative Medicine Matters discusses principles for how to safely use methadone for pain, a must-read guide for the practicing hospice and palliative care clinician. The third publication is a large, cross-sectional study of 10,065 persons with end-stage dementia receiving hospice care. The purpose of the study is to describe the use of acetylcholinesterase inhibitors and memantine and to determine factors associated with their use among persons with a hospice-admitting diagnosis of dementia. The authors found that nearly a quarter of persons were prescribed these drugs at the time of hospice enrollment, despite their questionable efficacy in this population. This nationally representative study provides the impetus for further studies evaluating the role of these drugs in persons with end-stage dementia. This article is a must-read for hospice decision-makers, administrators, medical directors, and researchers.


Weschules DJ, Bain KT, Richeimer S. Actual and Potential Drug Interactions Associated with Methadone. Pain Med. 2008 Apr;9(3):315-344. Weschules DJ, Bain KT. A Systematic Review of Opioid Conversion Ratios Used with Methadone for the Treatment of Pain. Pain Med. 2008 Jun 18. [Epub ahead of print]. DOI: 10.1111/j.1526-4637.2008.00461.x. Weschules DJ, Maxwell TL, Shega JW. Acetylcholinesterase Inhibitor and N-Methyl-D-Aspartic Acid Receptor Antagonist Use among Hospice Enrollees with a Primary Diagnosis of Dementia. J Palliat Med. 2008 Jun;11(5):738-745.


Passionate for the Appropriate Use of Medication


Hospice Pharmacia, the leader in medication management for hospice patients has always been focused on using technology to enhance the lives of partnering nurses and patients. As part of this focus, HP is excited to announce the expanded availability of XerisMobile! XerisMobile is a software application that provides access to pharmacy-related patient information via a handheld BlackBerry device. XerisMobile can be used on hospice owned BlackBerries or BlackBerries purchased through HP. This mobile access allows hospice users to refill medications, track packages, view medication profiles, enter patient assessment data, view demographic and condition information, and perform discharges from the patient's home. Immediate access to patient information can decrease the number of phone calls and allow for more efficient time spent with your patient. If you are interested in XerisMobile or would like additional information and pricing please email [email protected]

Alternate routes of administration

Continued from page 8

When is it appropriate to use morphine PLO?

Based upon current research, morphine PLO has limited evidence to support its use for pain management. Its place in therapy is uncertain, and should only be considered after other known effective routes of administration of morphine (subcutaneous, intravenous, rectal) are exhausted.

Reference List

1. Roy SD, Flynn GL. Transdermal delivery of narcotic analgesics: comparative permeabilities of narcotic analgesics through human cadaver skin. Pharm Res. 1989;6:825-832. 2. Murdan S. A review of pluronic lecithin organogel as a topical and transdermal drug delivery system. Hosp Pharm. 2005;12:267-271. 3. Kumar R, Katare OP. Lecithin organogels as a potential phospholipid-structured system for topical drug delivery: A review. AAPS PharmSciTech. 2005;6:E-298-310. 4. Shah AK, Wei G, Lanman RC, Bhargava VO, Weir SJ. Percutaneous absorption of ketoprofen from different anatomical sites in man. Pharm Res. 1996;13:168-172. 5. Paice JA, Roenn JHV, Hudgins C, Luong L, Krejcie TC, Avram MJ. Morphine bioavailability from a topical gel formulation in volunteers. J Pain Symptom Manag. 2008;35:314-320. 6. Ribeiro MDC, Joel SP, Zeppetella G. The bioavailability of morphine applied topically to cutaneous ulcers. J Pain Symptom Manag. 2004;27:434-439. 7. Twillman RK, Long TD, Cathers TA, Mueller DW. Treatment of painful skin ulcers with topical opioids. J Pain Symptom Manag. 1999;17:288-292. 8. Bleicher J, Bhaskara A, Huyck T, Constantino, S,Bardia A, Loprinzi C. al. Lorazepam, diphenhydramine, and haloperidol transdermal gel for rescue from chemotherapyinduced nausea/vomiting: results of two pilot trials. J Support Oncol. 2008;6:27-32. 9. Krajnik M, Zylicz Z, Finlay I, Luczak J, van Sorge AA. Potential uses of topical opioids in palliative care--report of 6 cases. Pain. 1999;80:121-125. 10. Wilken M, Ineck JR, Rule AM. Chronic arthritis pain management with topical morphine: case series. J Pain Palliat Care Pharmacother. 2005;19:39-44. 11. Vase L, Riley J, Price D. A comparison of placebo effects in clinical analgesia trials versus studies of placebo analgesia. Pain. 2002;99:443-452.

Hospice Pharmacia is a service of excelleRx, Inc.

Copyright © 2008, excelleRx, Inc., All rights reserved. Medication Use Guidelines (MUGs), and all Xeris products and services and their respective logos are trademarks of excelleRx, Inc. MUGs® and Xeris® are registered trademarks of excelleRx, Inc. No part of the information contained herein may be reproduced, duplicated, or copied without permission. Please inquire if you are not sure.



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