A National Survey of Perceptions Around Conditions Associated With Pharmacy Faculty Workload Equity.

OBJECTIVE: To assess pharmacy faculty members' perceptions of conditions associated with workload equity and factors that can improve workload equity. METHODS: A 26-item survey instrument was developed and distributed via email to members of the American Association of Colleges of Pharmacy Council of Faculties. Questions pertained to the workload distribution, fairness in assignment, and perception of the conditions associated with workload equity (transparency, context, credit, clarity, norms, and accountability) as well as institutional and individual demographics. RESULTS: A total of 662 responses were obtained (response rate 15.9%). Respondents' demographics were comparable to available national data. Approximately 41% of respondents reported their institutions did not have a written faculty workload policy. Most respondents reported their workload assignment was fair (highest with research/scholarship) but reported only moderate alignment between assigned and actual workloads. The rating level for what domains the primary decision maker uses to assign workload was highest for context, followed by credit, clarity, and transparency. Transparency was reported as the most needed condition to improve faculty perception of workload equity. Respondents also rated increasing trust between leadership and faculty and increasing productivity and accountability as the most important reasons to minimize workload inequities. CONCLUSION: This was the first national survey of pharmacy faculty perceptions around the conditions associated with workload equity. Though additional research is needed in this area, programs can work to implement strategies associated with all of the conditions, particularly transparency, to improve faculty perceptions of equity.

Perceptions and Practices for Evaluating Faculty Workload by Pharmacy Education Administration/Leadership.

OBJECTIVE: To assess how department chairs/administrators define, measure, and evaluate faculty workload to better understand practices within the Academy. METHODS: An 18-item survey was distributed to department chairs/administrators via American Association of Colleges of Pharmacy Connect. Participants identified if they are a primary decision maker for faculty workload, whether their program has a workload policy, how workload is calculated, and how faculty satisfaction with workload equity is measured. RESULTS: Of 71 participants initiating the survey, data from 64 participants from 52 colleges/schools were eligible for analysis. Leaders of practice departments reported that their faculty spend an average of 38% of their time on teaching (compared to 46% for non-practice departments), 13% on research (vs 37%), 12% on service (vs 16%), and 36% on clinical practice (vs 0%). Most survey participants (n = 57, 89%) are at schools/colleges with a tenure system, and about 24 participants reported that faculty workload metrics differ across departments/divisions. Teaching assignments and service are reportedly negotiable between faculty and supervisors, and workload expectations are widely variable. The majority indicated they do not analyze faculty satisfaction with workload fairness (n = 35) and faculty do not provide evaluative feedback on how supervisors assign faculty workload (n = 34). Of 6 priorities considered when determining workload, 'support college/school strategies and priorities' ranked highest (1.92) and 'trust between the chair and faculty' ranked lowest (4.87). CONCLUSION: Overall, only half of the participants reported having a clear, written process of quantifying faculty workload. The use of workload metrics may be needed for evidence-based decision-making for personnel management and resource allocation.

Esketamine: A Novel Option for Treatment-Resistant Depression.

Objective:To review the pharmacology, pharmacokinetics, efficacy, safety, use requirements, and place in therapy of esketamine for treatment-resistant depression (TRD). Data Sources: A comprehensive PubMed search (1966 to October 2019) was conducted using the search terms depression, treatment-resistant, suicide, intranasal, esketamine, and JNJ-54135419. Additional data were obtained from references of identified articles, governmental sources, manufacturer product labeling, and Clinicaltrials.gov . Study Selection and Data Extraction: All English-language trials evaluating intranasal esketamine for TRD were included and discussed. Data Synthesis: Intranasal esketamine was approved by the US Food and Drug Administration, in conjunction with an oral antidepressant, for treating TRD in adults. Two short-term trials (TRANSFORM-1 and -2) found statistically significant reduction in the Montgomery-Asberg Depression Rating Scale score at day 28 for the fixed 56-mg dose (-4.1; 95% CI = -7.69 to -0.49; P = 0.027 [exploratory]) and flexible-dosed arms (-4.0; 95% CI = -7.31 to -0.64; P = 0.02), though the fixed-dose 84-mg arm (-3.2; 95% CI = -6.88 to 0.45; P = 0.088) of TRANSFORM-1 and TRANSFORM-3 did not (-3.6; 95% CI = -7.2 to 0.07; P = 0.059). Two long-term trials (SUSTAIN-1 and -2) suggested maintenance of response with continued use. Esketamine's adverse effects include dizziness, dysgeusia, somnolence, dissociation, suicidal thoughts and behaviors, and increased heart rate and blood pressure. Relevance to Patient Care and Clinical Practice: Although providing a novel antidepressant mechanism and formulation for TRD, esketamine's role in treatment will likely be limited by cost, administration, and diversion concerns. Conclusion: Intranasal esketamine significantly reduced depression symptoms in TRD, though with tolerability issues.

Identifying clinical net benefit of psychotropic medication use with latent variable techniques: Evidence from Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).

BACKGROUND: Poor medication adherence is common among individuals with Bipolar Disorder (BD). Understanding the sources of heterogeneity in clinical net benefit (CNB) and how it is related to psychotropic medications can provide new insight into ways to improve adherence. METHODS: Data come from the baseline assessments of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Latent class analysis identified groups of CNB, and validity of this construct was assessed using the SF-36. Adherence was defined as taking 75% or more of medications as prescribed. Associations between CNB and adherence were tested using multiple logistic regression adjusting for sociodemographic characteristics. RESULTS: Five classes of CNB were identified: High (24%), Moderately high (12%), Moderate (26%), Moderately low (27%) and Low (12%). Adherence to psychotropic medications did not differ across classes (71% to 75%, χ2 = 3.43, p = 0.488). Medication regimens differed by class: 57% of the High CNB were taking ≤2 medications, whereas 49% of the Low CNB were taking ≥4. CNB classes had good concordance with the SF-36. LIMITATIONS: Missing data limited measures used to define CNB. Participants' perceptions of their illness and treatment were not assessed. CONCLUSIONS: This novel operationalization of CNB has construct validity as indicated by the SF-36. Although CNB and polypharmacy regimens are heterogeneous in this sample, adherence is similar across CNB. Studying adherent individuals, despite suboptimal CNB, may provide novel insights into aspects influencing adherence.

Point/Counterpoint: Are Outstanding Leaders Born or Made?

The question of whether outstanding leaders are born or made has been debated for years. There are numerous examples of historical figures that came naturally to leadership, while others developed their leadership skills through tenacity and experience. To understand leadership, both nature (the genetic component) and nurture (the environmental influences) must be considered. This article represents the work of two Academic Leadership Fellows Program groups who debated each position at the 2016 American Association of Colleges of Pharmacy (AACP) Interim Meeting in Tampa, Fla., in February 2016.

Prevalence of Antidiabetic and Antilipidemic Medications in Children and Adolescents Treated With Atypical Antipsychotics in a Virginia Medicaid Population.

BACKGROUND: Atypical antipsychotic use among children and adolescents is a cause for concern secondary to metabolic adverse effects. There have been reports of weight gain, metabolic syndrome, dyslipidemia, glucose abnormalities, and decreased insulin sensitivity in children aged 4 to 19 years using atypical antipsychotics. OBJECTIVE: To determine the prevalence of antidiabetic and antilipidemic medication use among children and adolescents receiving atypical antipsychotics and to evaluate whether the odds of receiving antidiabetic and antilipidemic medication differs among atypical antipsychotic agents. METHODS: This retrospective cross-sectional study included Virginia Medicaid beneficiaries (2-17 years) continuously enrolled from August 1, 2010, to July 31, 2011. The participants were categorized into atypical antipsychotic exposed and unexposed. The prevalence of antidiabetic and antilipidemic medication use within the groups was computed. Logistic regression was used to calculate the odds of receiving antidiabetic or antilipidemic medication after controlling for age, sex, and race. RESULTS: A total of 299593 and 4922 beneficiaries were identified in unexposed and exposed groups, respectively. The prevalence of antidiabetic medication use was 0.32% in the unexposed and 1.40% in the exposed group (P < 0.0001). Prevalence of antilipidemic medication use was 0.09% in the unexposed and 0.35% in the exposed group (P < 0.0001). Risperidone and quetiapine users had lower odds than olanzapine users of receiving antidiabetic medication. No differences between the odds of receiving antilipidemic medication among the different antipsychotics (P = 0.1653) were observed. CONCLUSIONS: Prevalence of antidiabetic and antilipidemic medication use was significantly higher among children and adolescent atypical antipsychotic users in a Virginia Medicaid population.

The Effect of Sleep Medication Use and Poor Sleep Quality on Risk of Falls in Community-Dwelling Older Adults in the US: A Prospective Cohort Study.

BACKGROUND: Sleep complaints and the consumption of medications for sleep are common in older adults. Falls are also a significant concern for older adults and sedative use has been identified as a risk factor for falls. Sleep quality is a potential confounder in studies evaluating the relationship between sleep medication use and falls. However, very few studies have assessed the combined impact of sleep medication use and sleep quality on the risk of falls. OBJECTIVE: The objective of this study was to evaluate the association between sleep medication use, poor sleep quality, and falls in community-dwelling older adults. METHODS: This was a multicenter, 6-month prospective cohort study conducted in senior housings settings in central Virginia, USA. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and a medication review was conducted. Data regarding falls were collected over 6 months by use of a diary. Logistic regression modeling was used to examine the effects of poor sleep quality, sleep medication use, and both, on the risk of falls. RESULTS: Among 113 independently living older adults (mean age ± standard deviation 81.1 ± 8.6), 46.9 % fell at least once during a 6-month period; 62.8 % (n = 71) had poor sleep quality, and 44.2 % (n = 50) used medications or treatments to aid sleep. Compared with participants reporting good sleep quality and no sleep medication use, those who reported poor sleep quality and sleep medication use had an increased risk of falls after adjusting for covariates (odds ratio 3.23, 95 % confidence interval 1.05-9.91). The group with good sleep quality and sleep medication use, as well as the group with poor sleep quality and no sleep medication use had no significantly greater risk for falls compared with the group with good sleep quality and no sleep medication use. CONCLUSION: A combined effect of sleep quality and sleep medication use on the risk of falls suggests that medication effectiveness may be an important factor to consider in understanding the risk of falls associated with sedative medications.

Management of insomnia in elderly patients using eszopiclone.

Insomnia is a common sleep complaint in the elderly. The safety and efficacy of eszopiclone, a non-benzodiazepine hypnotic, in elderly patients with chronic insomnia has been established in two 2-week and one 12-week randomized, double-blind, placebo-controlled trials. Eszopiclone 1 mg was effective in reducing sleep latency. Eszopiclone 2 mg was effective in reducing latency to sleep and for increasing sleep maintenance. Eszopiclone doses of 1 mg and 2 mg reduced the number of daytime naps and decreased the duration of naps in elderly patients. Eszopiclone 2 mg improved the quality of life measures for mood, physical health, household activities, medication, leisure activities, and self-report of physical functioning and vitality in the 2-week trials, and vitality and general health in the 12-week trial. The most commonly reported side effects in the elderly included unpleasant taste, dry mouth, dizziness, and somnolence. The concurrent use of drugs that inhibit or induce the cytochrome P450 enzyme CYP3A4 can alter concentrations of eszopiclone and the dose may need to be adjusted. The recommended starting dose of eszopiclone for difficulty falling asleep is 1 mg at bedtime. For elders who complain of difficulty maintaining sleep, eszopiclone should be initiated at 2 mg at bedtime. Overall, eszopiclone is a safe and well-tolerated treatment option for elderly patients with insomnia.

An exploratory study of drug abuse and dependence information in package inserts.

Information about drug abuse and dependence from package inserts of centrally acting drugs was evaluated for content. Of the 77 labels reviewed, 40 were opiate agonists, 18 were stimulants, and the remainder fell into other selected categories. The amount of information ranged from 0-66 sentences, with greatest variability found in the opiate agonists (range 9-66). Information amount was significantly correlated with the year of drug approval (p < 0.001) but not with the latest label revision (p = 0.749). Information amount did not differ significantly with warning strength or schedule. While most package inserts explain physical dependence, tolerance, and withdrawal, there is a lack of information about psychological dependence. Variability in information about abuse and dependence potential is high and can affect prescribing by physicians and counseling by pharmacists, underscoring the need for further studies.

Zolpidem modified-release in insomnia.

Zolpidem modified-release (MR) is the first hypnotic agent to be marketed in an extended-release formulation. Zolpidem MR is a two-layered, biphasic release tablet indicated for the management of induction of sleep and sleep maintenance. The pharmacokinetics of the drug are similar to those of immediate-release zolpidem. Two double-blind, placebo-controlled, parallel-group trials demonstrated efficacy in adults and elderly patients treated with zolpidem MR for 3 weeks without significant impairment in next-day psychomotor functioning. The most common adverse effects with zolpidem MR were dizziness, somnolence, and headache. A starting dose of zolpidem MR 12.5 mg is recommended for adults and 6.25 mg for elderly patients.

Development of a competency-based assessment process for advanced pharmacy practice experiences.

OBJECTIVES: To develop and implement a competency-based assessment process for the experiential component of a pharmacy education curriculum. DESIGN: A consultative process was used in the development of new assessment forms and policies, and a survey regarding student and faculty satisfaction was conducted. Information received from the survey and from consultations with faculty preceptors resulted in revision of the forms in subsequent years. ASSESSMENT: Faculty and student perceptions of the assessment process were generally positive. We were moderately successful in reducing grade inflation. The new process also provides the school with data that can be used to evaluate the effectiveness of our curriculum in preparing students for practice. CONCLUSIONS: Development and implementation of a competency-based assessment process require a considerable amount of work from dedicated faculty members. With health professions schools under pressure to provide evidence of their graduates' clinical competence, this is a worthwhile investment.

Polypharmacy in a 75-year-old patient with schizoaffective disorder.

A 75-year-old white female with schizoaffective disorder was admitted to an inpatient psychiatry unit for uncooperativeness in refusing to take scheduled medications. She complained of anticholinergic adverse effects and had abnormal involuntary movements in the oral/buccal region. The patient had been prescribed six psychotropic medications (i.e., thiothixene, lithium, divalproex sodium, amitriptyline, benztropine, and trazodone effects. The treatment team determined that the patient was noncompliant and experienced the effects of polypharmacy. She had been prescribed two mood stabilizers and suffered from anticholinergic adverse effects and the movement disorder tardive dyskinesia (TD). Four medications were discontinued: thiothixene, amitriptyline, lithium, and benztropine. Quetiapine, a second-generation antipsychotic, was recommended, with a daily titration schedule to reach a target dose of 600 mg per day in divided doses. This agent has less propensity to cause movement disorders compared with first-generation antipsychotics. All medications with additive anticholinergic properties also were discontinued. Lithium was stopped secondary to subtherapeutic levels and potential drug interactions. The pharmacist educated the inpatient team on the additive anticholinergic effects of each medication, reduced the total number of medications prescribed, and assisted in appropriate conversion to quetiapine to reduce TD symptoms.

Eszopiclone for insomnia.

OBJECTIVE: To review the pharmacology, pharmacokinetics, efficacy data, and adverse effects of eszopiclone in the treatment of transient and chronic insomnia in adult and geriatric patients. DATA SOURCES: A MEDLINE literature search (1966-May 2005) was conducted to retrieve articles and abstracts involving eszopiclone. The manufacturer of the drug provided a general summary of clinical data and abstracts of unpublished Phase III clinical trials. STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were reviewed, and information deemed relevant was included for this review. DATA SYNTHESIS: Food and Drug Administration approval of eszopiclone was based on 6 double-blind, placebo-controlled trials. Five trials published in abstract or study form were reviewed. The sixth trial was not available for evaluation. An open-label continuation trial was also reviewed. All studies showed statistically significant improvements in sleep parameters in adult and elderly patients treated for insomnia with eszopiclone. CONCLUSIONS: The results of the 5 available double-blind, placebo-controlled studies (and 1 open-label, 6-month extension) showed that eszopiclone was safe and effective in the treatment of transient and chronic insomnia in adult and geriatric patients. Tolerance with long-term exposure (6 mo) and rebound insomnia were not observed. The results of the 6-month, open-label extension trial demonstrated that improvements in sleep parameters were sustained. Future studies comparing eszopiclone with other non benzodiazepine sedative-hypnotics (eg, zolpidem, zaleplon) are needed with cost data to clearly define the role of eszopiclone in the pharmacotherapy of chronic insomnia.

Advances in pharmacotherapy of psychotic disorders in the elderly.

OBJECTIVE: To evaluate the literature on the pharmacotherapy of psychosis in the elderly. DATA SOURCES: Searches of MEDLINE (1996-April 2002) and the Cochrane Database using the terms psychosis, elderly, geriatric, dementia, Alzheimer's disease, Parkinson's disease, antipsychotics, atypical antipsychotics, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, and haloperidol were performed. An updated search of psychosis, risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole occurred in April 2003. STUDY SELECTION: Reviews, case reports, and open-labeled and controlled trials were selected. DATA SYNTHESIS: Psychotic symptoms in the elderly can occur in the context of psychiatric disorders, medical conditions, or as a medication complication. Behavioral problems (e.g., agitation, aggression) can accompany psychosis and may not respond to nonpharmacological strategies. Pharmacological management of psychosis in the elderly with typical antipsychotics (e.g., haloperidol, chlorpromazine) can result in intolerable adverse effects (e.g., sedation, anticholinergic effects, extrapyramidal symptoms, tardive dyskinesia, and orthostatic hypotension). The atypical antipsychotic agents (e.g., risperidone, olanzapine, quetiapine, ziprasidone) and the dopamine-serotonin system stabilizer aripiprazole offer more tolerable adverse effects profiles. Most information supporting the use of the atypical antipsychotics is derived from open-label trials involving patients with dementia or Parkinson's disease; however, data from large randomized, controlled trials is emerging. In general, psychosis in elderly patients responds to low doses of antipsychotics. Patients must be monitored closely for adverse effects, especially in light of the new information associating cerebrovascular adverse events with risperidone in patients with dementia. Further trials are required to determine if this is a disease- or drug-specific phenomenon. CONCLUSION: Psychosis in elderly patients can be managed with antipsychotic agents. The atypical antipsychotics are effective and offer advantages over typical antipsychotics with regard to a reduced rate of adverse effects.