California State Assembly has recently introduced a bill into legislation (Assembly Bill 186) that would provide safe facilities for drug users’ to inject illegal drugs such as heroin. The supporters feel that this type of program has the potential to decrease drug use in public areas, reduce syringes on the street, decrease HIV and hepatitis and lower overall overdose death rates.
Assembly Bill 186 applies to just 8 counties throughout California, including Alameda, Fresno, Humbolt, Los Angeles, Mendocino, San Francisco, San Joaquin and Santa Cruz counties. This program is being introduced as a test model as an attempt to decrease the sharp rise in opiate related adverse events and deaths.
As a pharmacist who practices in the center of one of these counties, I provide pharmaceutical services to many patients who live in a city that will most likely adopt a “safe haven” policy. This is an extremely contentious topic in our town; however, it is not my intent to debate the merits of faults of such a program.
More importantly, I would like to discuss a compelling concern that is not being addressed. Our particular town has an ever-growing homeless population. Just last night, a little after 9 pm, my wife and I drove from downtown to our house, about 2 miles from town center. As we were leaving town we passed not less than 10 encampments along the sidewalks; in front of the mayor’s office, the post office, the town clock, and city hall.
These were just the visible folks camping under tarps draped over shopping carts. Our town has a river that runs through town with many hidden embankments and treed areas that are home to many more individuals.
I practice in an out-patient pharmacy for the local community hospital, which also doubles for the county hospital. Any given day we are working with the social workers in the hospital to help expedite the discharge of a homeless person to the shelter downtown. Our goal is to assure the individual has 30 days’ worth of their medication with them as they head back out onto the street.
Over the last few months we have noticed a steep rise in our homeless diabetic patients coming back to the hospital. After a few interviews with patients, it happens that these homeless diabetic patients are regularly having their needles stolen. After a few days (and nights) on the street without their insulin, they end up back in the emergency room.
Patients are then treated for comorbid conditions, stabilized, then re-prescribed their medications and sent back to the shelter and onto the street. Unfortunately, our county Medicaid program does not offer the pen needles as a formulary alternative. Over the past couple months we have begun completing treatment authorization requests for these patients so they may be discharged with an insulin pen rather than a vial of insulin and a box of needles. This process may limit the possibility of stolen needles while allowing for the individual to treat their diabetes as required.
Of course, this is just a small point in the large problem. The first issue we come up against is storage of the pen needles. As we know, only the current pen needle may be kept out of the refrigerator. The others need to have safe storage at some location that will be accessible to the individual when they need it. Also, the individual will need to understand how to use the needles that are attached to the needle and, importantly, how to properly dispose of them.
My point here is this; why is the state not concerned about having a safe house for homeless diabetic patients to self-administer their insulin? Clients could come and go throughout the day and be assured that their diabetic supplies would be kept safe in the house for their return. Whether they are using insulin needles and vials, or insulin pens, their product would be stored in a clean and safe environment.
Assuredly, needles and syringes would be disposed of properly. Clients would have a table to sit at to check their blood glucose, rather than laying their supplies on a weather beaten blanket and tarp by the river. Their numbers could then be logged into a book that stays safely in the building and be available for their clinic visits when necessary. Patients would have the opportunity to wash their hands prior to handling the diabetic supplies, wipe the injection area with a sterile alcohol swab, and use a new needle with each injection.
If a state can go as far to create an assembly bill that strives to create a safe house for drug addicts to inject heroin, surely it is not too much to ask to have a safe house for homeless individuals to administer their insulin.
We all know that lack of literacy skills can pose a challenge for anyone navigating their way through every day obstacles. Place this person in a health care environment, and the problem increases significantly. Furthermore, discharge this patient from the hospital with current standards and they are sent home with stacks of paper that promptly get set aside with many questions left unanswered.
On average, individuals with low health literacy can read at a fifth-grade level, while consumer medication information is written at a tenth-grade level. Health professionals regularly overestimate patients’ level of understanding and commonly do not allow ample time for questions and answers. As well, it is not uncommon for hospitals to focus on meeting the regulatory requirements of the facility by sending patients home with all the required documents, rather than assuring a complete understanding of their discharge protocol.
As defined by the Institute of Medicine, health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.
In 2003, the US Department of Education National Assessment of Adult Literacy (NAAL) measured, among other items, health literacy. Based on the results of this study, it was found that over 36% of the adult US population was either basic or below basic health literacy. In 2007, an analysis of this report, Low Health Literacy: Implications for National Health Policy, attempted to define the impact of this astounding statistic.1 The US population in 2003 was approximately 242 million adults. This corresponded to an astounding 87 million US adults with at or below basic health literacy.
Empirical research on a conceptual model placed the cost of low health literacy between 7-17% of all healthcare expenditures. In 2003 this dollar amount was estimated to be between $106- $238 billion annually. In the year 2015, the annual health care expenditures are estimated to be $3.6 trillion, which would provide a cost of low health literacy at approximately $612 billion dollars.
Let’s take this a little farther and see the impact on individual hospital admissions. The 2007 analysis calculated that individuals with low health literacy cost, on average, an additional $993 per admission.
Furthermore, according to a Veterans Health Administration study, performed between 2007-2009 in northern Florida and southern Georgia, meeting the needs of those with marginal and inadequate health literacy could produce economic savings of approximately 8% of total hospital costs for this population.2This is a savings of $2480 per patient.
Currently, it is estimated there are approximately 35,000,000 hospital admissions per year in the United States.
Based on the NAAL 2003 study 36% rule, 12,600,000 of these admissions are challenged with Health Literacy. We have one study that estimates an additional $993 per admission and another study that estimates an additional $2480 per patient, so it would be considered conservative to use an average of $1000 for our calculations.
Based on an average of $1000 extra per admission for patients challenged with literacy, the increased cost to hospitals alone is $12.6 billion dollars per year. Your average mid-sized community hospital that sees 5000 admissions per year spends an additional $1.8 million dollars covering the costs associated with low health literacy.
One small portion of the answer lies in our profession as pharmacists. Take the time to help patients understand their medications. Listen to their concerns, address their obstacles, help patients achieve the understanding they need in order to obtain their best possible outcome of therapy.
1. Vernon JA, Trujillo A, Rosenbaum S, DeBuono B. Low Health Literacy: Implications for National Health Policy. 2007;
Accessed April 3, 2017.
2. Haun JN, Patel NR, French DD, Campbell RR, Bradham DD, Lapcevic WA. Association between health literacy and medical care costs in an integrated healthcare system: a regional population based study. BMC Health Services Res. 2015; 15: 249.
Gunda Siska, PharmD, has worked in various fields within the pharmaceutical industry as a licensed pharmacist for more than 20 years. She is currently a staff hospital pharmacist assisting nurses and doctors with drug prescribing, administration, and dispensing, as well as independently monitoring and dosing highly toxic and dangerous drugs. For 2 years, she was concurrently a consultant pharmacist for skilled nursing facilities and nursing homes. Dr. Siska is a member of the New Mexico Society of Health-System Pharmacists and the American Academy of Anti-Aging Medicine. Follow her on Twitter @GundaSiska
Recently Gunda wrote an article for Pharmacy Times, with her permission we are publishing it here as well, with a link back to the original article.
Metformin is a medication that I believe is underappreciated by the general public. Many people ttell me that their doctor prescribed this drug for them, but they took themselves off of it, but if they knew what I know about metformin, they would have stayed on the medication.
This is what I know: metformin extends life. It’s been proven in animal studies1 and in humans. A prospective observational study of nearly 20,000 people with type 2 diabetes mellitus (T2DM) and arteriosclerosis found that metformin use was associated with 24% lower all-cause mortality compared to patients who were not taking metformin.2
It is also the number one go-to medication for type 2 diabetes for several years, despite all the new designer medications coming on the market trying to replace it.
How does metformin save lives? Mainly through cardioprotection. Metformin reduces cardiovascular risk in humans.3 Most people with T2DM will most likely die from a cardiovascular event, especially if they are not on metformin.4,5,6
Metformin has so many positive effects on the body, no one really knows for sure all the ways it preserves life. It produces modest weight loss in the near term5 and blunts weight gain when given chronically.6 It normalizes hypertension,7 improves heart failure,8 preserves the kidneys,9 improves lipid levels,10 reduces the reoccurrence of colonic polyps and is being used experimentally in several different types of cancers.11 It reduces occurrence of strokes and atrial fibrillation.12,13 It helps in neurodegenerative diseases.14 There is no end to the life-preserving effects of this drug.
Why are so many people taking themselves off of metformin? Because it causes diarrhea. About 10% of metformin users get diarrhea. It’s the type of diarrhea that usually goes a way with time. It is often alleviated when the dose is slowly tapered up, when given in the delayed release form, and/or when taken with food.
It has recently been discovered that just like the newer diabetic medications, metformin also has activity in the gut to lower blood sugar.15 Thirty percent of metformin is excreted unchanged in the feces. It never even enters the bloodstream. It has activity in the lower gastrointestinal tract to produce satiety though a feedback mechanism to reduce consumption of food and ultimately sugar. Then it may have other activities to inhibit absorption of excess sugar into the blood stream. Then it regulates the liver and inhibits it from producing excess sugar through gluconeogenisis. Then once the sugar is actually in the bloodstream, metformin reverses insulin resistance, allowing the blood sugar to enter the cell and be used efficiently.
The medical experts at the National Institute on Aging, compare the longevity effects of metformin to calorie restriction. Both theories involve the way our bodies use energy.
When cells are no longer inundated with glucose and constantly being forcsfed, they wake up, become alive and vibrantly healthy.
The opposite is true. When we overeat chronically, our cells are forcefed glucose. Insulin resistance occurs as a result of protecting the internal cell functions from being overloaded with glucose. The cells shut down and are no longer as receptive to receiving new energy into the cell. It’s similar to a wooden stove being continually overloaded with wood. It cannot function properly under those circumstances and the door to the stove becomes difficult to open. The wood is analogous to glucose. The man opening the door is analogous to insulin. The stove door is analogous to the insulin receptor.
I tell all my patients that eating until we are 80% full is key to a healthy metabolism. I’m a strict advocate of this practice myself. But in reality, I know many people cannot accomplish this goal long term. Fortunately for drugs like metformin, people who are not as disciplined and motivated can still have a long healthy life. I wish the best for my patients, that is why I highly recommend that they take the medications that their doctors prescribe in addition to diet and exercise.
1. Martin-Montalvo A, Mercken EM Mitchell SJ, et al. Metformin improves health span and lifespan in mice. Nature Comm. 2013. doi; 10.1038/ncomms3192.
2. Roussel R, Travert F, Pasquet B, et al. Metformin use and mortality among patients with diabetes and atherlosclerosis. Arch Intern Med. 2010;170:1892–1899.
3.) Home PD. Impact of the UKPDS--an overview. Diabetic Med. 2008;25(suppl 2):2–8.
4.) Gu K, Cowie CC, Harris MI. Mortality in adults with and without diabetes in a national cohort of the US population, 1971–1993. Diabetes Care. 1998;21:1138–1145.
5.) UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes. Lancet. 1998;352:854–865.
6.) Holman R, Paul S, Bethel M, Matthews D, Neil H. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359:1577–1589.
7.) Landin K, Tengborn L, Smith U. Treating insulin resistance in hypertension with metformin reduces both blood pressure and metabolic risk factors. J Intern Med. 1991;229:181–187.
8.) Roumie CL, Greevy RA, Grijalva CG, et al. Association between intensification of metformin treatment with insulin vs sulfonylureas and cardiovascular events and all-cause mortality among patients with diabetes. JAMA. 2014;311:2288–2296.
9.) Hung, SC, et al. Metformin use and mortality in patients with advanced chronic kidney disease: national, retrospective, observational, cohort study. Lancet Diab Endocrinol. 3(8):605–614.
10.) Roumie CL, Huizinga MM, Liu X, et al. The effect of incident antidiabetic regimens on lipid profiles in veterans with type 2 diabetes: a retrospective cohort. Pharmacoepidemiol Drug Saf. 2011;20:36.
11.) Metformin Active in Reducing Colorectal Polyp Recurrence. Higurashi T, Hosono K, Takahashi H, et al. Metformin for chemoprevention of metachronous colorectaladenoma or polyps in post-polypectomy patients without diabetes: a multicentre double-blind, placebo-controlled, randomised phase 3 trial. Lancet Oncol. 2016;17:475-483.
12.) Cheng YY, Leu HB, Chen TJ, et al. Metformin-inclusive therapy reduces the risk of stroke in patients with diabetes: a 4-year follow-up study. J Stroke Cerebrovasc Dis. 2014;23:e99-e105.
13.) Chang SH, Wu LS, Chiou MJ, et al. Association of metformin with lower atrial fibrillation risk among patients with type 2 diabetes mellitus: a population-based dynamic cohort and in vitro studies. Cardiovasc Diabetol. 2014;13:123.
14.) Metformin Linked to Lower Neurodegenerative Disease Risk. American Diabetes Association 2016 Scientific Sessions; June 11, 2016; New Orleans, Louisiana. Abstract 72-OR/72.
15.) Buse JB, DeFronzo RA, Rosenstock J, et al. The Primary Glucose-Lowering Effect of Metformin Resides in the Gut, Not the Circulation. Diabetes Care. 2016;39(2):198-205.
Luka is our social media manager here at AudibleRx and recently wrote this blog about the digital world.
Morning, mortal enemy to some, or should I say everyone? In any case, we all know what that means; leaving the comfort of your warm fluffy bed and facing the reality of getting dressed up and going to work. However, you refuse to leave the comfort of your home until you have a nice cup of tea while reading your favorite newspaper. Everyone has their morning routine indeed. There is only one problem - you have no newspaper to read. Zero. Fortunately for you, there are two options; getting out as there is a convenience store next to your flat where you can buy it or simply checking out an online edition. Your legs are a bit sour from a football match you had yesterday and you are still in bed. Which one will you go for?
Digital is everywhere nowadays, а fact which is hard to deny. We do not even need to look that hard to notice it. Have you ever sat next to someone who listened to their music too loud? Would you check your Facebook or Twitter feed on a piece paper if you had chance? Maybe but probably not. Would you use a typewriter to start producing content or would you rather pick up your iPad? Again, it's a matter of personal preference for sure but what if you start an article at home and you would like to finish it during your daily commute to work? In that case, your cherished iDevice is a no-brainer. You can have your favorite songs at your fingertips; plug your headphones into the phone and you are good to go.
Technology has also changed the way we interact with each other. We can wish happy birthday to someone by making a video call to them or texting them. We can send emails instead of regular letters. There are loads of different ways to stay connected. Imagine yourself living on the opposite side of the globe than a very good friend of yours. It is fairly easy to keep in touch with them. Have you met someone new who you wanted to see again? Do you know their name and surname? Easy-peasy, find them online, plan something together and meet up. All of this would not have been possible without all those advancements in the digital field. However, all of this cannot and should not replace authentic human contact. Face-to-face conversations are still way better than lying on your bed and talking to your friend who happens to live next door through Skype. Go grab a coffee with them and fully express yourself. We all know this can be quite difficult online; even though there's an abundance of emoticons, they cannot fully replace the way we feel, thing or express ourselves.
On top of that, digital has greatly revolutionized a healthcare sector. You can book appointments with your doctor online. Surgeons use augmented reality to better perform surgeries and achieve better outcomes. Researches have a way to discover and predict new active compounds in silico (using sophisticated computer software) which means accelerated active compounds discovery and new treatment possibilities. Pharmaceutical representatives engage with healthcare professional in different, more engaging ways. Want to improve your knowledge about the medicines you take? Now you can listen to consumer medication information in a way that is the most convenient to you. Moreover, students can get an insight into the newest trends and discoveries by performing literature search of scientific articles online. Thinking of buying a new product but you are unsure if it's a good fit for you? Flying with an airline for the first time for your next holidays and you'd like to gain some insights? You get the picture. Furthermore, all sorts of wearable devices exist in the market, used to track our activity and overall health. These examples merely scratch the surface.
All those activities generate extensive amounts of data, information, which can provide unique insights and can be easily shared. This represents a great opportunity to expand and share your knowledge. However, pitfalls exist. Since everyone can create their own content and share it literally in the blink of an eye with the rest of the world we all need to possess some critical thinking. Not everything you read or listen is necessarily true. It is important to note who produces the content and what is its purpose. Is the purpose of an article to encourage everyone to get their flu jabs or is it to discourage them through the "facts" which have no real ground? Have you checked if information you consumed is scientifically proven? Do I even trust the source? Are there any science papers quoted? We need to be constantly vigilant and should not fall for everything we come across. The beauty of everything is that we can always double-check the information through some other, different and hopefully more reliable source. Do I use the information I get online to educate myself so I can pose more focused question to a professional in the field I am researching, for example my pharmacist or doctor? Or do I use it as the only source?
We live in an era dominated by digital and abundance of information. Armed with the knowledge we can now easily answer the question - yes, digital has profoundly changed our lives. Will it do that in the future? Absolutely! But how you might ask? I am sure in many more exciting ways, ways which are maybe beyond your or my imagination. Let's wait and see!
Social Media Manager at AudibleRx
Regularly I need to take pause and contemplate the evolution of our pharmacy profession. Recently I experienced a situation in our clinic pharmacy that caused me to question the meaning of units-of-service.
Late in the afternoon this young lady presented to our pharmacy with a couple of prescriptions from the local community hospital emergency room. This particular patient was from another county, so, when she was discharged from the emergency room earlier in the day she thought it would be reasonable to go to one of the familiar chain store pharmacies.
Throughout her afternoon she visited 2 of these stores, both times being turned away without her medications because her insurance was not currently active in this county. She was sick, needed medication, so she headed back to the hospital and found her way to our outpatient clinic pharmacy.
As expected, after processing the prescriptions, we also received a message that her insurance was inactive. At this point, we took a moment to ask the patient about her living status. She explained that she had just moved into this county and her insurance had not yet been transferred.
This sounded like a perfectly reasonable scenario so I asked my technician to make a phone call to the patients insurance and see if anything could be worked out. After a few minutes on the phone, the insurance had granted a one time override to cover the patient until her insurance could be transferred from the prior county to her new county of residence.
This was not a big deal for us. The entire process took 10 minutes and did not interfere with our normal workflow. Why had she gone to 2 other pharmacies and no one had offered to help her resolve her insurance situation?
It is my opinion that the pharmacies were just too busy to try and help her. This is certainly not the fault of the hard working pharmacists or technicians. As pharmacists we are all aware of pharmacy-metrics or units-of-service. During any given time frame we have work flow metrics that need to be met. We all have a que of prescriptions that need to be typed, verified, filled and dispensed.
Who has the time to help a patient who has just relocated into a new county and is having insurance difficulties? Any effort that takes the pharmacist and the technician away from performing the necessary functions of a well-run pharmacy will lessen the overall productivity and decrease the units-of-service for the day.
As a pharmacist in his 30th year of practice, I understand the pressure we face on a daily basis. Workloads are increasing, regulations never end, and it feels like a new medication enters the market place every single day. This is the time we need to remember the first sentence from the Pharmacist’s Oath we took on the day we graduated pharmacy school.
I promise to devote myself to a lifetime of service to others through the profession of pharmacy.
In July of 2007 the American Association of Colleges of Pharmacy adopted the new Pharmacist’s Oath. Reading through this document, there is mention of the welfare of humanity, optimal patient outcomes, ethical and legal standards, continuing knowledge, and a host of other excellent measures.
Nowhere in the Pharmacist’s Oath is there a discussion of units-of-service or pharmacy-metrics. Tomorrow when you go to work, give yourself a moment to pause before walking into the pharmacy. Reflect on what it might look like to practice in a world without metrics. Then, walk in the door and allow yourself the opportunity to be available.