Gary E. DeLander

Center for the Advancement of Pharmacy Education 2013 Educational Outcomes

An initiative of the Center for the Advancement of Pharmacy Education (formerly the Center for the Advancement of Pharmaceutical Education) (CAPE), the CAPE Educational Outcomes are intended to be the target toward which the evolving pharmacy curriculum should be aimed. Their development was guided by an advisory panel composed of educators and practitioners nominated for participation by practitioner organizations. CAPE 2013 represents the fourth iteration of the Educational Outcomes, preceded by CAPE 1992, CAPE 1998 and CAPE 2004 respectively. The CAPE 2013 Educational Outcomes were released at the AACP July 2013 Annual meeting and have been revised to include 4 broad domains, 15 subdomains, and example learning objectives.

Increased nociceptive response in mice lacking the adenosine A1 receptor.

The role of the adenosine A1 receptor in nociception was assessed using mice lacking the A1 receptor (A1R−/−) and in rats. Under normal conditions, the A1R−/− mice exhibited moderate heat hyperalgesia in comparison to the wild‐type mice (A1R+/+). The mechanical and cold sensitivity were unchanged. The antinociceptive effect of morphine given intrathecally (i.t.), but not systemically, was reduced in A1R−/− mice and this reduction in the spinal effect of morphine was not associated with a decrease in binding of the μ‐opioid ligand DAMGO in the spinal cord. A1R−/− mice also exhibited hypersensitivity to heat, but not mechanical stimuli, after localized inflammation induced by carrageenan. In mice with photochemically induced partial sciatic nerve injury, the neuropathic pain‐like behavioral response to heat or cold stimulation were significantly increased in the A1R−/−mice. Peripheral nerve injury did not change the level of adenosine A1 receptor in the dorsal spinal cord in rats and i.t. administration of R‐PIA effectively alleviated pain‐like behaviors after partial nerve injury in rats and in C57/BL/6 mice. Taken together, these data suggest that the adenosine A1 receptor plays a physiological role in inhibiting nociceptive input at the spinal level in mice. The C‐fiber input mediating noxious heat is inhibited more than other inputs. A1 receptors also contribute to the antinociceptive effect of spinal morphine. Selective A1 receptor agonists may be tested clinically as analgesics, particularly under conditions of neuropathic pain.

Interdependence of spinal adenosinergic, serotonergic and noradrenergic systems mediating antinociception.

The present investigations examined possible interdependence among serotonergic, noradrenergic and adenosinergic pathways as spinal antinociceptive systems. ED50 values for antinociception induced by intrathecal injections of noradrenergic, serotonergic or adenosinergic agonists in mice were determined. These results were compared to ED50 values determined when an antagonist or a sub-antinociceptive dose of a second agonist was coadministered i.t. with agonists. Interactions observed when serotonergic and adenosinergic agents were coadministered suggest that antinociception induced by serotonin (i.t.) is mediated, in part, via serotonin-stimulated release of adenosine. The mechanism by which norepinephrine administered i.t. induced antinociception, however, appeared to be independent of serotonergic and adenosinergic pathways.

Altered sensory behaviors in mice following manipulation of endogenous spinal adenosine neurotransmission

Adenosine or adenosine analogs injected intrathecally (i.t.) induce significant antinociception. Recent studies support the existence of an endogenous spinal system that can modulate nociceptive input by releasing adenosine. Inhibition of adenosine metabolism by administration of an adenosine kinase inhibitor, in the present study, decreased behavior induced by putative pain neurotransmitters providing additional support for an endogenous purinergic system. Conversely, administration of high doses of methylxanthines (i.t.), adenosine receptor antagonists, induced behavior similar to that induced by pain neurotransmitters. Methylxanthine (i.t.)-induced behavior was partially inhibited by antagonists of receptors for pain neurotransmitters. These observations are consistent with the hypothesis that an endogenous purinergic system tonically modulates nociceptive input involving a variety of chemical mediators. Preliminary studies also revealed methylxanthine-induced allodynia and suggested spinal purinergic systems may have a broader role in discriminating sensory input.

Falls prevention education: Interprofessional training to enhance collaborative practice

ABSTRACT The gap between the complex health care needs of older adults and the availability of geriatrics-trained health care professionals is widening. Interprofessional education offers an opportunity to engage multiple professions in interactive learning and clinically relevant problem solving to achieve high-quality patient-centered care. This article describes a project that engaged an interprofessional teaching team to support interprofessional practice teams to reduce falls in older adults via implementation of evidence-based practice guidelines. Ninety-five participants from 25 teams were trained on multiple strategies to decrease the risk of falls in older adults. The intervention facilitated increases in knowledge, confidence in skill performance, and team commitment to change practice patterns to support the health and safety of older adults. Findings suggest that community-based practices can successfully support the training of interprofessional teams and that training may lead to improved care processes and outcomes for older adults.

Synthesis and opioid activity of conformationally constrained dynorphin A analogues

Several cyclic lactam analogues of Dyn A-(1-13)NH2 were prepared in order to reduce the conformational flexibility in different regions of the native linear peptide. Cyclo[D-Asp(i),Dap(i+3)]Dyn A-(1-13)NH2 (Dap = alpha,beta-diaminopropionic acid) analogues were designed on the basis of molecular modeling using AMBER, which suggested that this constraint may be compatible with an alpha-helix. The cyclic portion of these constrained analogues spanned from residues 3 to 9, a region proposed by Schwyzer (Biochemistry 1986, 25, 4281) to adopt a helical conformation at kappa receptor sites. Analogues containing Dab (alpha,gamma-diaminobutyric acid) or Orn in position i + 3 were also synthesized to examine the effects of larger ring size. The cyclic peptides exhibited marked differences in binding affinities for kappa, mu, and delta receptors and in opioid activity in the guinea pig ileum (GPI). Cyclo[D-Asp6,Dap9]Dyn A-(1-13)NH2 showed both high kappa receptor affinity and potent agonist activity in the GPI, while cyclo[D-Asp3,Dap6]Dyn A-(1-13)NH2 exhibited very weak binding affinity at all opioid receptors as well as very weak opioid activity in the GPI. Cyclo[D-Asp5,Dap8]Dyn A-(1-13)NH2 showed moderate binding affinity for kappa receptors and was the most kappa selective ligand in this study, but this peptide exhibited very weak agonist activity in the GPI assay. Compared to the corresponding linear peptides, all of the cyclic peptides exhibited decreased mu receptor affinity, while kappa receptor affinity was retained or improved. Therefore the corresponding linear peptides were generally mu selective while the cyclic constrained peptides demonstrated slight selectivity for kappa vs mu receptors or were nonselective. Increasing the ring size by incorporating Dab or Orn in positions 6, 8, or 9 did not significantly affect the binding affinity for the three opioid receptor types nor the opioid activity observed in the GPI. Circular dichroism spectra of the cyclo[D-Asp(i),Dap(i+3)] derivatives in 80% trifluoroethanol at 25 and 5 degrees C suggested differences in the stability of a helical structure when the constraint was incorporated near the N-terminus vs in the middle of the peptide.

An Interprofessional Approach to Reducing the Risk of Falls Through Enhanced Collaborative Practice

Falls are the leading cause of accidental deaths in older adults and are a growing public health concern. The American Geriatrics Society (AGS) and British Geriatrics Society (BGS) published guidelines for falls screening and risk reduction, yet few primary care providers report following any guidelines for falls prevention. This article describes a project that engaged an interprofessional teaching team to support interprofessional clinical teams to reduce fall risk in older adults by implementing the AGS/BGS guidelines. Twenty‐five interprofessional clinical teams with representatives from medicine, nursing, pharmacy, and social work were recruited from ambulatory, long‐term care, hospital, and home health settings for a structured intervention: a 4‐hour training workshop plus coaching for implementation for 1 year. The workshop focused on evidence‐based strategies to decrease the risk of falls, including screening for falls; assessing gait, balance, orthostatic blood pressure, and other medical conditions; exercise including tai chi; vitamin D supplementation; medication review and reduction; and environmental assessment. Quantitative and qualitative data were collected using chart reviews, coaching plans and field notes, and postintervention structured interviews of participants. Site visits and coaching field notes confirmed uptake of the strategies. Chart reviews showed significant improvement in adoption of all falls prevention strategies except vitamin D supplementation. Long‐term care facilities were more likely to address environmental concerns and add tai chi classes, and ambulatory settings were more likely to initiate falls screening. The intervention demonstrated that interprofessional practice change to target falls prevention can be incorporated into primary care and long‐term care settings.

Descending systems activated by morphine (ICV) inhibit kainic acid (IT)-induced behavior

Modulation of spinal systems activated by N-methyl-D-aspartate (NMDA) and substance P administered IT have been an area of interest in several laboratories. In the present investigations, behavior induced by the excitatory amino acid kainic acid, but not quisqualate, is demonstrated to be modulated in a manner similar to that previously observed for NMDA. Biting, scratching and licking behavior was induced by IT injections of excitatory amino acids or substance P in mice. Behavior induced by kainic acid (IT) injection was inhibited in a dose-dependent manner by coadministration of morphine (ICV), norepinephrine (IT), N-ethyl carboxamidoadenosine (NECA) (IT) and agonists interacting at PCP receptors (IT). Kainic acid and NMDA differed, however, in that a dopaminergic agonist, apomorphine, inhibited kainic acid-, but not NMDA-induced behavior and a selective NMDA receptor antagonist inhibits NMDA-, but not kainic acid-induced behavior. Behavior induced by quisqualate (IT) was not inhibited by any treatment and may have nonspecific actions in this type of assay. Our observations support independent spinal sites of action for behavior induced by kainic acid and NMDA, but several similarities were observed in the modulation of spinal systems activated by these agents.

Opportunities and Responsibilities for the Academy in the Medical Home

The Patient Protection and Affordable Care Act has created significant traction for the delivery of team-based, interdisciplinary care. New care delivery models such as medical homes, accountable care organizations (ACOs), and coordinated care organizations (CCOs) are examples of integrated care models growing at an accelerating rate among public and private payers. These models are based upon the conceptual framework that a patient or family should have a “home” where health care is provided, and through which this care is coordinated, all in an effort to enhance quality of care while managing the costs of health care. The academy must work to ensure pharmacists and student pharmacists are prepared to fulfill critical roles and provide leadership, as providers, policy makers, and payers explore ways to achieve the triple aim1 through coordinated, high-value care. The Pharmacy Workforce Commission has made its pharmacist workforce projections based on traditional dispensing roles that are largely centered around the consumption of pharmaceuticals.2 The commission’s report acknowledges that the demand for pharmacists will be higher should pharmacists assume a larger role in patient care management. Further, employers in community, hospital, and managed care pharmacy are interested in hiring pharmacy graduates with collaborative, interprofessional, and team-based care skills.3 Colleges and schools of pharmacy are well positioned to model and expand the role of pharmacists as new primary care delivery models are implemented. Pharmacist faculty members have a long tradition of serving as role models for progressive services. Faculty placements in institutional settings have contributed to the expansion of clinical pharmacy services and postgraduate residencies.4 Faculty members can dedicate the time required to demonstrate the value of clinical pharmacy services separated from traditional distributive functions. Unfortunately, while pharmacists in community pharmacy settings are considered the most accessible healthcare professionals, the percentage of faculty members integrated into interprofessional team practices or community pharmacy clinical positions is low. The academy must intensify efforts to identify opportunities for faculty placement within innovative community pharmacy and primary care settings seeking to develop or modify current practice models to meet patient care delivery goals outlined in the current health care legislation. Practice settings should embrace experimentation and evaluation of novel ideas that aim to enhance patient outcomes and provide cost-effective care. Faculty members will provide the added benefit of keeping community pharmacy colleagues informed about current and evolving developments in health care policy, and emerging opportunities for pharmacy integration into new practice models. Community-based pharmacists in states with collaborative drug therapy agreements, in particular, can initiate clinical services with physician practices to monitor and manage patients with chronic conditions and complex regimens between primary care physician office visits. Physicians participating in new collaborative care models increasingly see value in clinical pharmacy services, and consumers who may be reluctant to interrupt the workflow of a busy community pharmacy will likely find their pharmacist to be more accessible for questions and medication management. There are clearly multiple opportunities for the academy and employers to partner in the development of cost-effective care models and innovative educational programs. These will, in turn, increase the visibility of a pharmacist’s role as a medication management expert to patients, health care colleagues, payers, and policymakers. The responsibility for providing a robust, well-prepared cadre of pharmacists to fulfill expanded expectations for clinical pharmacy services also falls upon the academy. We need to seriously consider how we can best prepare future students, and retrain current practitioners, for new direct patient care medication management roles.5 Pharmacy has advocated for meaningful roles in collaborative interprofessional care, while we have concurrently sought educational strategies and existing practice models required to develop in students the knowledge, skills, attitudes, and values required for a pharmacist to operate at the “top of their license.” Acceptance of pharmacists as full members of high functioning, collaborative, interprofessional healthcare teams will be dependent upon the capacity of the academy to guarantee consistency in the abilities of all graduates through curricular revision and assessment. Now a decade past, the requirement of an entry-level doctor of pharmacy degree stimulated by work of the American Association of Colleges of Pharmacy Commission to Implement Change in Pharmaceutical Education6 has helped to standardize the content of pharmacy curricula. Colleges and schools of pharmacy have worked to integrate foundational sciences into an expanded treatise and application of clinical sciences. The 2004 Center for Advancement of Pharmacy Education (CAPE) outcomes, in turn, brought more focused attention to direct patient care and involvement of pharmacists in discussions of public health and wellness.7 Increasingly, the integration and application of knowledge, skills, attitudes, and values in team-based care are at the center of collaborative care efforts in these new models of care. Our efforts begin with a responsibility to identify mature students with a breadth and depth of preparation and experiences that allow them to be competent and confident in dynamic team settings. The CAPE 2013 outcomes highlight a need to build upon that base and redouble our energy to lead students in building collaborative team skills, leadership abilities, and habits of self-reflection that complement the knowledge and capacity for patient care expected of a medication expert.8 As a first step, many curricula now include greater emphasis on communications, patient assessment and monitoring, and problem-solving skills using common chronic diseases for case studies. Accompanying the opportunity for community-based faculty practices in expanding the role of pharmacists is a critical need to model collaborative patient-centered care for current pharmacy students through experiential education. Emerging medical home, ACO, and CCO models create greater urgency for interprofessional education and involvement in interprofessional practice models throughout the educational process that will establish a routine of participation in team-based problem solving and patient care. Students need to experience innovative, collaborative practice models to learn how pharmacists can contribute their expertise both in health systems and community-based practice settings. Clinical pharmacy services in community pharmacies offer a wealth of experiences for students both in introductory pharmacy practice experiences as well as longer advanced pharmacy practice experiences. Similarly, the medical home model can be expected to catalyze new opportunities for community-based postgraduate residency training and be a rich source for health services research by pharmacy faculty members. Health services research (HSR) is a multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health and well-being.9 Its research domains include individuals, families, organizations, institutions, communities, and populations. HSR opportunities include research that focuses on medication use and safety in primary care, new team-based care delivery and payment models, use of health information technology, and health care policy changes. HSR impacts patient care quality and medication safety initiatives, expands professional practice opportunities (eg, direct patient care roles in chronic disease management, community-based health care teams), and informs health care policy. Faculty members in colleges and schools of pharmacy are ideally positioned to lead HSR initiatives that assess clinical and economic outcomes of linking pharmacists and clinical pharmacy services to medical homes, ACOs, and CCOs. Credible, peer-reviewed research will be key to demonstrating the value proposition for the overall health system and to expanding the role of pharmacists in new, collaborative, interprofessional models of care. Integrated, interprofessional care models represented by medical homes, ACOs, and CCOs outline a new vision for healthcare delivery in the United States. Clinical pharmacy services will be required in order to fulfill this vision, but the pharmacy profession is responsible for demonstrating that pharmacists are best equipped to meet that need. Health services research conducted by faculty members in colleges and schools of pharmacy should be at the center of an iterative development process for implementation of healthcare reform. Incorporation of faculty members in collaborative care models will be critical in continuing efforts to demonstrate pharmacist involvement is a sound investment economically and therapeutically. Sustaining an expanded role for pharmacy is dependent upon a strong cohort of pharmacists prepared to contribute fully and, when appropriate, lead interprofessional healthcare teams. Ensuring consistent strength of graduates through curricular redesign and opportunities to experience problem solving in these emerging collaborative settings remains a primary responsibility of the academy.

Rules of the Road

Discussions at the American Association of Colleges of Pharmacy (AACP) interim meeting in February 2012 highlighted some of the challenges faced by prospective students as they evaluate options for professional education. As an academy, we present an exciting, but often confusing array of education models from which students can choose. It is time to establish guidelines by which institutions will cooperate to facilitate the best possible match between student and professional program. In admissions vernacular, these guidelines are referred to as “traffic rules.” The ease by which students can indicate interest in multiple professional programs, coupled with an increasing diversity of educational models, has provided both students and institutions a chance to discover and learn about each other more effectively than previously seen in the academy. On one hand, this is an exciting opportunity that should facilitate the best match between institution and student. Conversely, it creates an unpredictable landscape characterized by students “hedging their bets” as colleges and schools scramble to fast-track evaluation processes, and institutions vainly attempt to control a dynamic environment using a combination of “carrot” (marketing) and “stick” (admissions deposits). Proposed “traffic rules” would establish a date before which a student could not be required to commit to an institution with a deposit. Colleges and schools of pharmacy would still be allowed to make offers of admission at any time. Students could voluntarily choose to accept an offer of admission and provide a deposit as soon as they were comfortable with their selection. Colleges and schools of pharmacy, however, would agree not to require deposits, or provide other enticements, prior to a specific date. While students could still choose to accept multiple offers of admissions, they would be advised that efforts to retrieve deposits after the specific deposit date would be considered a violation of the PharmCAS Applicant Code of Conduct. Traffic rules are not new to higher education. Residency programs accredited by the American Association of Medical Colleges,1 the Council of Graduate Schools,2 and the American Society of Health-System Pharmacists,3 among others, have long-established guidelines that describe processes similar to those proposed for pharmacy admissions. The guidelines are valued because they allow institutions to conduct a deliberative admissions process without artificial time constraints. A well-defined playing field allows all institutions to use interview processes that recognize that both the student and institution have an opportunity to distinguish themselves based on their unique merits. Adequate time is available to evaluate recent academic performance or request additional information from potentially outstanding students whose strengths are less evident. Perhaps most importantly, institutions can actively recruit those students identified in interviews as being a strong fit for their program. The student perspective is simply one of fairness and respect. Where to pursue a degree is likely one of the most important decisions a student will make. It has significant professional and financial implications that extend well beyond their years in the program. We should respect the significance of their decision, provide a reasonable amount of time for students to explore unique aspects of individual professional programs, and then encourage them to make the decision that is best for them. It is simply unfair to require a student to commit to a program before they can assemble the data needed to make an informed decision, and it is difficult to imagine that an admissions deposit would drive the behavior of an informed consumer making a