Ralph E. Small

Pharmacists' Knowledge and Attitudes toward Herbal Medicine

OBJECTIVE The use and sales of herbal medications have increased dramatically over the past several years. Pharmacists are in an ideal position to educate patients about herbal medicines. This study was intended to determine the knowledge and attitudes of pharmacists regarding herbal medications. METHODS A survey was distributed to pharmacists at several state and regional meetings in Virginia and North Carolina between August and October 1998. The survey evaluated demographic data, attitudinal scales, and a 15-item herbal medicine knowledge test. Pharmacists immediately returned the surveys to the distributor on completion. RESULTS Of the 217 surveys distributed, 164 met the inclusion criteria for further evaluation. Of the pharmacists surveyed, 68.0% practiced in a community pharmacy, 45.1% had previous continuing education on herbal medications, and 73.6% sold herbal medications in their practice settings. The average score on the herbal knowledge test was 6.3 (maximum score of 15). Pharmacists with previous continuing education scored significantly higher than those without prior continuing education (p < 0.001). Of the 15 questions, the five that pharmacists were most likely to answer correctly assessed the uses of herbal medications. Additionally, pharmacists with prior continuing education or with access to herbal medication information at their practice site were more likely to agree that providing information about herbal medication is a pharmacists professional responsibility (p = 0.02 and p = 0.01, respectively). CONCLUSIONS The findings from this study demonstrate that pharmacists were more likely to answer correctly about the uses of herbal medications than about drug interactions, adverse drug effects, and precautions of herbal medications. Additionally, pharmacists with previous continuing education on herbal medications were more knowledgeable about these products. With the increasing use of herbal medications, there is a greater need for pharmacy training programs in this area.

Results of a Smoking Cessation Clinic in Community Pharmacy Practice

OBJECTIVES To describe and assess the effectiveness of a smoking cessation clinic. DESIGN Single group, unblinded study. SETTING Seven chain (mass-merchandise) community pharmacies in Virginia. PARTICIPANTS Forty-eight patients who were smokers when admitted to the study. INTERVENTIONS Fifteen community chain pharmacists were trained using a smoking cessation training manual developed at the Virginia Commonwealth University School of Pharmacy. From April 1, 1997, through December 31, 1999, interested patients met individually with a study pharmacist during scheduled clinic times in semiprivate counseling areas. A patient chart was maintained at the site and updated after each visit. The first 30 patients completed a questionnaire after the third visit to the smoking cessation clinic to assess satisfaction with pharmacists and the overall program. MAIN OUTCOME MEASURE Rate of long-term smoking cessation. RESULTS Of the 48 patients, 12 (25.0%) abstained from smoking cigarettes for 12 months or more beyond their predetermined quit dates. Abstinence rates for 1, 3, and 6 months were 43.8%, 31.3%, and 25.0%, respectively. Women were nearly five times more successful in attaining long-term abstinence than were men (33.3% versus 6.7%; P= .047). No significant differences were observed in cessation rates related to age, number of cigarettes smoked per day, level of nicotine dependence, number of previous quit attempts, or method of cessation. Increased appetite and weight gain were the most frequently reported withdrawal symptoms (16.7% of patients). Patients expressed satisfaction with the pharmacists and the smoking cessation program. CONCLUSION Compared with other types of previously reported interventions, a community pharmacist-managed smoking cessation clinic achieved greater long-term smoking cessation rates.

Development and implementation of a smoking cessation clinic in community pharmacy practice.

OBJECTIVE To describe a pharmacist-operated program to help people stop smoking. SETTING Community chain (mass-merchandise) pharmacy practice sites in Virginia. PARTICIPANTS Faculty at the Virginia Commonwealth University School of Pharmacy (VCU) and 15 practicing pharmacists. PRACTICE DESCRIPTION Smoking cessation clinics within the pharmacy departments of seven Target stores. PRACTICE INNOVATION With input from the practicing pharmacists and using the most current strategies reported in the literature, faculty at VCU developed a training manual for smoking cessation counseling. This manual was used to facilitate a 4-hour training session and also served as a resource for pharmacists in the smoking cessation clinics. Pharmacists were taught about behavioral modifications, the Transtheoretical Model of Change as applied to smoking cessation, documentation, the Fagerström Test for Nicotine Dependence, smoking cessation therapies, patient counseling techniques, physical assessment skills, and how to develop an individualized action plan for smoking cessation. As pharmacists established smoking cessation clinics, issues such as workflow, continuous quality improvement, and marketing were addressed by the faculty members and practitioners. RESULTS Using the process and tools described in this article, pharmacists successfully established and operated smoking cessation clinics. CONCLUSION The process and materials developed for this demonstration project can serve as templates for other pharmacy faculty members and community pharmacists who wish to offer smoking cessation clinics.

Modeling the Cost-Effectiveness of a Smoking-Cessation Program in a Community Pharmacy Practice

Objectives. To describe some of the costs of providing a smoking‐cessation program in a community pharmacy practice, and to model the programs cost‐effectiveness compared with that of a self‐directed quit attempt.

Liver Function Assessment by Drug Metabolism

Liver function can be assessed by administering an exogenous substance to quantify changes in hepatic blood flow, uptake, biotransformation, and excretion. Characterization of drug half‐life, clearance, and product formation rates are possible methods for measuring hepatic efficiency. Allopurinol and caffeine have been used to measure metabolite formation followed by renal elimination of both parent substance and metabolite. Sorbitol, a substance with high intrinsic clearance, can reflect liver blood flow, while trimethadione, a low‐extraction drug, has been used to measure liver enzyme capacity. Metabolites from lidocaine, methacetin, and aminopyrine have been measured in serum, urine, and breath tests. Salivary clearance measurements of caffeine and antipyrine are reported as suitable for routine use. Genetic diversity of isoenzymes and the many metabolic processes used by hepatocytes make it extremely difficult to quantify functional changes with one substance. Combinations of model substrates have been suggested to assess the many hepatic processes.

Clinical Use of Methadone

Methadone hydrochloride is a mu-opioid agonist that has been used for the treatment of pain and for the management and maintenance of opioid withdrawal for over 50 years. Several characteristics make methadone a useful drug. However, these same characteristics and wide interpatient variability can make methadone difficult to use safely. A MEDLINE search was conducted on publications between January 1996 and May 2001 to identify literature relevant to this subject. Those publications were reviewed, and from them, other literature was identified and reviewed. Published studies demonstrate methadones efficacy in pain management and in opioid withdrawal. However, interpatient variability in pharmacokinetic variables of methadone produces difficulties in developing guidelines for methadone use. Clinicians should not be deterred from use of this drug which has been shown to benefit patients in both pain management and methadone maintenance, but an individualized patient approach must be taken to use methadone safely.

Home Blood Glucose Monitoring

OBJECTIVE: To provide a review of self-monitoring blood glucose including home blood glucose meters and patient education. DATA SOURCES: A MEDLINE search (January 1966–January 1998) was conducted to identify original and review articles. Search terms included self-monitoring blood glucose and blood glucose monitoring. Owners manuals and package inserts were reviewed to determine specific characteristics for each glucose meter. DATA EXTRACTION: All current original and review articles about self-monitoring blood glucose and home blood glucose meters were included if they contained information about benefits of self-monitoring blood glucose, technology and performance of blood glucose meters, quality control, selection characteristics of blood glucose meters, and patient education. DATA SYNTHESIS: Self-monitoring of blood glucose has become an increasingly vital component of the care of the diabetic patient. Many glucose monitors are available with various features that may be confusing to pharmacists. Pharmacists need to be able to aid patients in the selection of an appropriate glucose meter and provide the education necessary for proper use and follow-up. Patient education is a key component in optimizing the potential benefits of self-monitoring. CONCLUSIONS: Self-monitoring of blood glucose, if used properly, can have a positive effect by increasing patient involvement in overall diabetes care. Pharmacists are accessible and can teach patients necessary skills that will enhance their ability to self-manage blood glucose.

Migraine: a comprehensive review of new treatment options.

Headaches are among the most common complaints reported to health care professionals and are classified by the International Headache Society as migraine, tension‐type, or cluster, with additional subtypes. Classification and etiology of headache should be determined after thorough review of the patients history. Once diagnosed, migraine can be treated by preventive or abortive measures. Recent developments add new options, including availability of drugs for intranasal administration (sumatriptan, dihydroergotamine) and 5‐HT1B/1D agonists (rizatriptan, zolmitriptan, naratriptan, eletriptan). Although placebo‐controlled trials are available, few comparative clinical trials of these agents have been conducted; however, important pharmacologic, pharmacokinetic, and clinical differences exist among the drugs.

Chemistry, pharmacology, pharmacokinetics, and clinical applications of mesalamine for the treatment of inflammatory bowel disease.

Mesalamine is the therapeutically active moiety of sulfasalazine used to treat inflammatory bowel disease. A controlled‐release mesalamine capsule (Pentasa) is designed to release the agent continuously, and largely unaffected by intestinal pH, throughout the small and large bowel due to a diffusion‐dependent, semipermeable ethylcellulose coating. It is a safe and efficacious single agent for inducing remission and producing therapeutic benefit in patients with mild to moderately active ulcerative colitis (UC) (2 or 4 g/day) or Crohns disease (4 g/day), as well as for significantly enhancing quality of life for patients with mild to moderately active UC (2 or 4 g/day). It is also effective for maintaining remission in patients with quiescent UC and Crohns disease (4 g/day). Disease location (left‐sided UC or pancolitis) did not affect the agents effect in active disease or maintaining remission. Fewer treatment‐related adverse events were reported with mesalamine than with placebo in treating UC. In the treatment of active Crohns disease, data showed no statistically significant differences in response for patients with ileitis, ileocolitis, or Crohns colitis. This formulation of mesalamine may also be a possible steroid‐sparing agent for patients with either active or quiescent Crohns disease.

Implementing disease management in community pharmacy practice

Disease management (DM) is a comprehensive approach to preventing and treating disease that: (1) targets patients with specific diseases; (2) provides integrated services across organizational and professional boundaries; (3) utilizes services based on the best scientific evidence available; and (4) focuses on outcomes. DM differs from pharmaceutical care in that pharmaceutical care targets not only patients with specific diseases but also those with risk factors for drug-related problems, a history of nonadherence, and frequent changes in medication regimens. Steps to starting a DM program include: (1) identifying a target population based on the populations strategic importance to the goals and aims of the organization; (2) assessing the organizations available resources, both internal and external; (3) defining key indicators with which to assess the program for the purposes of internal quality control and of obtaining compensation from third-party payers; (4) implementing the program using the best scientific methods available; and (5) assessing the impact of the program. The development of a smoking cessation program at a nationwide retail pharmacy chain is used as an example of a DM program initiated in community pharmacy practice. Pharmacists are well positioned to take a major role in DM, because they are accessible to the community and because DM frequently involves drug therapy. DM is also widely used in managed care. It is important that community pharmacists be closely involved in the DM approach as it evolves.