Old Habits Die Hard: Regression in Learning and Study Strategies Inventory Scores in PharmD Students.

OBJECTIVE: Prior studies have demonstrated that "learning to learn" (L2L) courses can lead to significant improvements in students' Learning and Study Strategies Inventory (LASSI) scores immediately following the course. This study aimed to analyze whether improvements in LASSI scores are sustained 1 year following an L2L elective course. METHODS: First-year pharmacy students in the classes of 2024 and 2025 completed the LASSI at the start of the fall semester and again immediately following an L2L course. One year later, during the second professional year, students completed the LASSI a third time. Repeated-measures multivariate analysis of variance was used to analyze within-participant differences in LASSI scores across each of the 10 LASSI scales. Univariate analysis of variance with Bonferroni correction was used for pairwise comparison. RESULTS: A total of 119 students completed all 3 LASSI assessments. LASSI scores improved in all 10 scales following completion of the L2L course. However, 1 year after the completion of the course, there was a statistically significant regression in all 10 scale scores (Wilks' Λ [20,98] = 8.7). Among the 10 scales, scores for the Attitude and Concentration scales were statistically significantly lower during the second professional year relative to baseline at the start of the first professional year. Selecting Main Ideas was the only scale with a higher score during the second professional year relative to baseline. CONCLUSION: Despite marked improvements in LASSI scores following the implementation of a "learning to learn" course for first-year pharmacy students, the improvements were not sustained after 1 year.

Cannabis Science and Therapeutics: An Overview for Clinicians.

Cannabis-based therapeutics have garnered increasing attention in recent years as patients seek alternative treatments for various medical conditions. This narrative review provides a comprehensive overview of the science behind the medical use of cannabis, focusing on the medical evidence for commonly treated conditions. In addition, the review addresses the practical considerations of using cannabis as a therapeutic agent, offering insights into dosing strategies, variations in cannabinoid formulation, and individual patient responses. Precautions, adverse consequences, and drug interactions are also discussed, with a focus on patient safety and the potential risks associated with cannabis use.

Opioid prescribing patterns in a commercially insured population.

BACKGROUND: Claims data evaluations have advanced our understanding about patient risk factors and predictors for opioid misuse and aid in patient identification. However, less evidence is available to guide the identification of prescribers with at-risk prescribing practices. Thus, an algorithm was developed to identify prescribers with outlying patterns of opioid prescriptions in a managed care organization. METHODS: A retrospective analysis used enrollment, prescription, and medical claims data from September-December 2019 to identify prescribers of schedule II, III or IV opioid analgesic medications. Criteria were used to characterize these prescribers as frequent, continuous, and/or high-dose prescribers of opioids. RESULTS: For prescribers with > 25 patients with any prescriptions, the algorithm identified 5136 prescribers who had prescribed at least one opioid. This group of prescribers accounted for 53.9% of the total opioids prescribed and wrote an average of 6.5 opioid prescriptions per prescriber during a 3-month period. There were 629 prescribers (12.2%) that had prescribed an opioid to ≥ 50% of their population (frequent prescribers); 493 prescribers (9.6%) that had prescribed >185 day-supply of opioids within 6 months to 10% or more of their population (continuous prescribers); 147 prescribers (2.9%) that had prescribed an average daily MME > 90 mg to ≥ 10% of their population in the most recent 90 days (high-dose prescribers); and 47 prescribers (0.9%) that met all three criteria. CONCLUSIONS: The algorithm identified a targeted prescriber group to employ resources to mitigate opioid misuse and abuse. Flexible criteria for frequent, continuous, and/or high-dose prescribing allows tailoring to the needs of different managed care organizations.

Patterns of opioid and benzodiazepine use with gabapentin among disabled Medicare beneficiaries - A retrospective cohort study.

BACKGROUND: Our goal was to describe specific patterns associated with co-prescriptions of gabapentin, opioids, and benzodiazepines among disabled Medicare beneficiaries. METHODS: Using 2013-2015 Medicare data, we conducted a retrospective cohort study among fee-for-service disabled beneficiaries continuously enrolled in Medicare Parts A, B, and D. The index date was defined as the earliest fill date for a gabapentin, opioid, or benzodiazepine prescription. Monotherapy, dual therapy, and tri-therapy were defined as utilization of one, two, and three medication classes, respectively. Augmentation was defined as a prescription for a different medication class in addition to prescription for initial medication; switching referred to a change in prescription for a different medication class with no subsequent fills of initial medication. We used descriptive statistics, Kaplan Meier analyses and Cox proportional hazards to examine the association between initial therapy and monotherapy, dual therapy, tri-therapy, switching and augmentation. RESULTS: Among 151,552 disabled beneficiaries, gabapentin initiators were more likely to augment therapy (50.1%) when compared to opioid (28.7%) and benzodiazepine (38.7%) users. When compared to opioid initiators, the risk of augmentation (HR[95%CI]: 1.85[1.82-1.89]) and switching (1.62 [1.51-1.73]) was significantly higher among gabapentin initiators. Risk of augmentation was also significantly higher among beneficiaries with co-morbid pain and mental health conditions (p < 0.01). Overall, the majority of beneficiaries augmented and switched within 2-months and 4-months after initiating therapy, respectively. CONCLUSIONS: Given safety concerns associated with gabapentin, opioids, and benzodiazepines, it is imperative that the benefits and risks of co-prescribing these medications be examined comprehensively, especially for those in vulnerable sub-groups.

Adverse outcomes associated with concurrent gabapentin, opioid, and benzodiazepine utilization: A nested case-control study.

Background: Gabapentin, opioids, and/or benzodiazepines are commonly prescribed for a variety of pain and psychiatric conditions. Despite the high likelihood of co-prescription of these medications, little is known about co-utilization of gabapentin (GABA), opioids (OP), and benzodiazepines (BZD) and associated public health outcomes. Methods: Using Medicare CCW Data, 2013-2016, we conducted a nested case-control study to examine the association between concurrent utilization of GABA, OP, and BZD and respiratory depression, opioid, and substance-related overdose among Medicare disabled beneficiaries. Cases and controls were Fee-for-service disabled beneficiaries who had a diagnosis of acute pain (AP), chronic pain (CP) or mental health conditions (MH) and received GABA, OP or BZD. Cases with respiratory depression, opioid or substance-related overdose were matched with up to 4 controls on socio-demographics, year of cohort entry and disease risk score. Primary exposure was concurrent medication utilization defined as an overlap of at least one day in prescriptions for GABA, OP and BZD. Findings: Across all cohorts, the majority of cases and controls were under 65, female, dually eligible and had prior histories of pain and mental health conditions. GABA+OP+BZD use was associated with increased odds of respiratory depression [AOR(95%CI)-AP: 1.35 (1.19-1.52), CP:1.24 (1.11-1.38) and MH: 1.16 (1.02-1.32) vs. OP only], opioid-related overdose [AP: 1.43 (1.04-1.98), CP: 1.47 (1.07-2.00) and MH: 1.44 (1.04-2.00) vs. OP only], and substance-related overdose [AP: 1.77 (1.26-2.50), CP: 1.70 (1.24-2.34) and MH: 1.92 (1.31-2.82) vs. GABA only]. While there were cohort differences in the association between GABA+OP and both respiratory depression and opioid-related overdose, GABA+OP and GABA+BZD use were associated with significantly higher odds of substance-related overdose across all clinical cohorts. Interpretation: Among Medicare disabled beneficiaries, concurrent utilization of gabapentin, opioids, and benzodiazepines is associated with multiple adverse outcomes. Given this, it is imperative that the benefits and risks of co-prescribing these medications be comprehensively examined. Funding: None.

Variation in Hospice Patient and Admission Characteristics by Referral Location.

BACKGROUND: Little is known regarding differences between patients referred to hospice from different care locations. OBJECTIVE: The objective this study was to describe the associations between hospice referral locations and hospice patient and admission characteristics. RESEARCH DESIGN: Cross-sectional analysis of hospice administrative data. SUBJECTS: Adult (age older than 18 y) decedents of a national, for-profit, hospice chain across 19 US states who died between January 1, 2012, and December 31, 2016. MEASURES: Patients' primary hospice diagnosis, hospice length stay, and hospice care site. We also determined the frequency of opioid prescriptions with and without a bowel regimen on hospice admission. RESULTS: Among 78,647 adult decedents, the mean age was 79.2 (SD=13.5) years, 56.4% were female, and 69.9% were a non-Hispanic White race. Most hospice referrals were from the hospital (51.9%), followed by the community (21.9%), nursing homes (17.4%), and assisted living (8.8%). Cancer (33.6%) was the most prevalent primary hospice diagnosis; however, this varied significantly between referral locations (P<0.001). Similarly, home hospice (32.8%) was the most prevalent site; however, this also varied significantly between referral locations (P<0.001). More hospital-referred patients (55.6%) had a hospice length of stay <7 days compared with patients referred from nursing homes (30.3%), the community (28.9%), or assisted living (18.7%), P<0.001. Hospital-referred patients also had the lowest frequency (58.4%) of coprescribed opioids and bowel regimen on hospice admission compared with other referral locations. CONCLUSION: We observed significant differences in hospice patient and admission characteristics by referral location.

Building confidence: Three-year evaluation of systematic progression of prescription verification on students' confidence during IPPE.

INTRODUCTION: To determine how a progression in community pharmacy prescription verification activities (PVAs) in a skills-based laboratory series impacts student confidence during community-based introductory pharmacy practice experiences (IPPEs). METHODS: Motivated by the 2016 Accreditation Council for Pharmacy Practice Education Standards, a progression of PVAs was implemented. As students progressed through three semesters of laboratory courses, the scope and verification error types expanded. A web-based survey was administered after students completed their IPPE. The survey was conducted over three years to collect data from students who completed one, two, or three semesters of PVAs. Two-way Analysis of Variance and Tukey-Kramer tests were used to analyze data. RESULTS: Over the three-year period, 395 students completed the survey. Students with two or three semesters of PVAs were significantly more confident than those with one semester of PVAs in verifying prescriptions on IPPEs, identifying legal concerns with prescriptions, and identifying and correcting prescription labels and expiration/discard dates. Students without professional pharmacy experience strongly agreed that PVAs prepared them for IPPEs compared to those with experience. CONCLUSIONS: This is the first study evaluating the impact of PVAs in the didactic curriculum on student confidence during IPPEs. Systematic progression of multiple semesters of PVAs may have helped students prepare for IPPEs and may have influenced student confidence in several aspects of prescription verification. This study lays the foundation for further investigation into the impact of building confidence and examining if confidence leads to improved accuracy in patient care.

Effect of a study skills course on student self-assessment of learning skills and strategies.

INTRODUCTION: The purpose of this study was to determine whether a study skills course taken by first professional year pharmacy students improved their self-assessment of study skills and strategies. METHODS: This study analyzed student responses to the Learning and Study Strategies Inventory (LASSI), an online assessment with questions in 10 subject areas: anxiety, motivation, concentration, test strategies, study aids, selecting main ideas, attitude, self-testing, information processing, and time management. Students in an elective study skills course in 2012-2017 completed the self-assessment prior to and at the end of the course. Wilcoxon signed-rank test was performed to compare class score pre- and post-course. RESULTS: Over a five-year period, 312 students completed both the pre- and post-course LASSI assessment. Average percentile scores increased significantly from the beginning to the end of the course in all 10 areas. Notably, average pre-course scores in seven subject areas (attention, concentration, self-testing, selecting main ideas, study aids, time management, and test strategies) were all below the 50th percentile, indicating a need for improvement in those skills to see increased academic success. Average post-course scores in each area increased to between the 50th and 75th percentile. CONCLUSIONS: This evaluation shows that a study skills course improves students' self-assessment of skills and attitudes associated with success in post-secondary education. Future studies will look at the effect of such a course on academic outcomes.

Anticholinergic Burden in Hospice Patients With Dementia.

BACKGROUND: End-of-life (EOL) patients with dementia have an increased risk for anticholinergic toxicities due to age-related pharmacokinetic and physiologic changes in conjunction with an increased susceptibility to drug-induced cognitive impairments. Despite this well-documented risk, the use of drugs with anticholinergic properties (DAPs) remains prevalent in EOL patients with dementia. OBJECTIVE: The aims of this study were to describe prescribing patterns and characterize anticholinergic burden among hospice patients with dementia, as measured by the Anticholinergic Cognitive Burden (ACB) scale. METHODS: This was a retrospective review of a national hospice patient information database. Patients included were admitted on January 1, 2016, discharged by death by December 31, 2016, and had a primary diagnosis of dementia. Patients' anticholinergic burden was calculated using ACB scores. RESULTS: A total of 1283 patients met the inclusion criteria. Of those, 37.1% (n = 476) were prescribed at least 1 DAP. Specifically, 28.9% (n = 371) were prescribed 1 DAP, 6.6% (n = 84) were prescribed 2 DAPs, 1.6% (n = 20) were prescribed 3 DAPs, and 0.08% (n = 1) were prescribed 4 DAPs. The majority of patients prescribed a DAP had an ACB score of 3 (n = 359, 75.4%) and an average ACB score of 3.8. The most common DAPs prescribed in patients with an ACB score of 2 or higher were quetiapine (n = 202, 42.4%), atropine (n = 155, 32.6%), hyoscyamine (n = 61, 12.8%), olanzapine (n = 46, 9.6%), and scopolamine (n = 35, 7.4%). CONCLUSION: Due to the limited benefit and increased harms with the use of DAPs, providers should aim to maximize nonpharmacologic options. By reducing the use of the top 5 DAPs identified in this study, the quality of life and care for EOL patients with dementia can potentially be improved.

Management of Opioid-Induced Constipation in Hospice Patients.

BACKGROUND: Constipation is a common symptom in patients with advanced disease taking opioids. Opioid-induced constipation (OIC) is commonly treated with laxatives and stool softeners. Recently, newer agents have come to market which broaden options for patients in whom first-line therapies are not effective. OBJECTIVE: To determine what pharmacologic regimens are currently used in hospice programs to prevent and treat OIC, whether those regimens have changed with the introduction of newer agents and evidence discouraging the use of docusate, and whether hospice programs are standardizing the management of OIC. METHODS: An online 10-item questionnaire was disseminated by the National Hospice and Palliative Care Organization. Questions addressed demographics; first-, second- and third-line pharmacologic treatments included in bowel protocols; whether prescribing practices have changed in the last 5 years; and percentage of patients receiving specific constipation therapies. RESULTS: The majority of organizations (68.8%) responded that at least 90% of patients were prescribed a bowel regimen on admission to hospice and 84.4% stated that they have a guideline or protocol for managing OIC. The most commonly used preparations for the treatment of OIC for patients during their length of stay in hospice were senna plus docusate, senna alone, docusate alone, bisacodyl, polyethylene glycol 3350, and lactulose. Over 75% of hospice organizations claimed they never used methylnaltrexone, linaclotide, lubiprostone, or naloxegol. CONCLUSION: This survey provides insight into recent practices of hospice organizations in the treatment of OIC. As more agents come to market, it is likely that management of OIC will continue to evolve.

Game on: The gamification of the pharmacy classroom.

BACKGROUND: Gamification is the use of game mechanics to promote engagement and enjoyment of problem-solving in non-game situations. Gamification has been used widely in recent years in industry and academia as a tool for training and education. OBJECTIVE: The aims of this paper are to provide an overview of gamification and digital game-based learning (DGBL), review the use of digital games in health professional education, and provide suggestions for future use in pharmacy curricula. DISCUSSION: Many examples of game-based learning in pharmacy and other health professional curricula have been published, however the body of literature on DGBL is less developed. Overall, evaluations of these techniques show that students find them engaging and enjoyable. A recent meta-analysis of studies comparing DGBL to non-game based learning in primary, secondary, post-secondary education found that DGBL significantly enhances learning. Challenges to implementing game-based learning are financial, cultural, and technological. CONCLUSION: Many areas of the pharmacy curriculum could be appropriate for digital gamification. With more students entering pharmacy school familiar with video games and game-based living the time has come for pharmacy educators to explore how these instructional technologies could benefit a new generation of pharmacy students. As serious games are developed and researched in pharmacy curricula, test scores, student confidence in knowledge and skills, and retention of knowledge and skills are all outcomes that, if published, will help advance the adoption of DGBL into the pharmacy school classroom.

State survey of medical boards regarding abrupt loss of a prescriber of controlled substances.

OBJECTIVES: The purpose of the study was to evaluate states' experiences with abrupt changes in controlled substances (CS) prescribing, to determine whether states have action plans in place to manage such situations, and describe the components of any such plans. METHODS: A survey of executive directors of 51 medical boards was conducted to evaluate states' experiences with abrupt changes in CS prescribing, the extent of consumer complaints attributed to these events, and the types of plans in place to manage these situations. RESULTS: Forty-six executive directors of medical boards responded. Twenty boards (43.5 percent) confirmed that their state had experienced abrupt loss of CS providers and 11 (55 percent) of these executive directors indicated that the loss resulted in increased consumer complaints. The majority of executive directors (86 percent) had no action plan. Six executive directors reported some type of action plan or process consisting of regulatory action, patient-provider connection, professional education, patient education, or public notice. CONCLUSIONS: Most states do not have operational plans in place. However, a few have key strategies that may be useful in addressing potential problems following abrupt loss of a CS prescriber. State medical boards can play a significant role in the development of comprehensive preparedness plans to mitigate damage from the loss of CS prescribers in the community.

Commonly Prescribed Medications Among Patients in Hospice Care for Chronic Obstructive Pulmonary Disease.

PURPOSE: End-stage chronic obstructive pulmonary disease (COPD) presents health care providers with challenges of providing optimal palliative care for patients who follow a less predictable trajectory. The objectives of this study were to evaluate medications being prescribed to patients with end-stage COPD, compared to recommendations made by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, and to determine which medications were provided by the hospice organization. METHODS: We retrospectively reviewed our database for medications pertaining to COPD management as stated in the GOLD criteria or those used for symptoms associated with end of life. RESULTS: A total of 745 patients met inclusion criteria, and approximately 63% were prescribed opioids. Prescribing rates for oxygen, short-acting ß2-agonists, and short-acting anticholinergics were 37%, 33%, and 31%, respectively. Systemic and inhaled corticosteroids were prescribed at higher rates of 20% and 18% compared to long-acting bronchodilators. DISCUSSION: Medications used for COPD exacerbation management were prescribed at higher rate than those used for maintenance treatment.

Prescribing practices in hospice patients with adult failure to thrive or debility.

OBJECTIVES: Despite being a common admitting diagnosis, there is very little published literature on medication management in hospice patients admitted with a diagnosis of failure to thrive or debility. The purpose of this study was to describe medication prescribing practices in hospice patients with either of these primary diagnoses by characterizing prescribed medications by name and by pharmaceutical class, and determining whether the patient or the hospice organization provided each medication. METHODS: A retrospective review of a patient information database compiled by a national hospice organization was conducted. Patients were included in this retrospective study if they were admitted to hospice care with a primary diagnosis of failure to thrive or debility, and if they were admitted on or after 1 January 2010, and discharged by death on or before 31 December 2010. RESULTS: Overall 293 patients and 6181 medication entries were evaluated. The most commonly prescribed drugs were acetaminophen, lorazepam, morphine, atropine, prochlorperazine, haloperidol, docusate, aspirin, and bisacodyl. The most commonly prescribed pharmacological classes were opioid and non-opioid analgesics, anxiolytics, anticholinergics, antihypertensives, laxatives, antidepressants, and supplements. The hospice organization provided over 90% of prescriptions for analgesics, antipsychotics, anticholinergics, and anxiolytics, and these medications were discontinued before death in less than 5% of patients. CONCLUSION: Recognized clinical components of failure to thrive syndrome include cognitive impairment, malnutrition, and depression. The hospice organization provided 80% of antidepressants, but infrequently provided appetite stimulants and drugs treating dementia. The most commonly provided drugs were those used for symptoms associated with most end-stage diseases.

Commonly prescribed medications in a population of hospice patients.

Although much attention has been placed on appropriate symptom management at the end of life, little is known about the medications actually prescribed to people in hospice care. The purpose of this study was to determine the most commonly prescribed medications in a population of hospice patients. A retrospective review of a patient information database was conducted. The 6 most common drugs (acetaminophen, morphine, haloperidol, lorazepam, prochlorperazine, and atropine) were included in emergency kits provided to patients at admission. Opioid and nonopioid analgesics, anxiolytics, anticholinergics, and antipsychotics were the most commonly prescribed pharmacologic classes. This description of prescribing practices could be useful in creating more informed care plans, educating health care personnel, and anticipating the changing medication needs of patients as they enter hospice care.

Pharmacokinetics and pharmacodynamic changes associated with aging and implications for drug therapy.

The population of older adults continues to increase, and polypharmacy in this population is more the rule than the exception. Physiologic changes that occur with aging result in multiple alterations to the pharmacokinetics and pharmacodynamics of drugs, which, in turn, increase the risk of adverse drug reactions. Consideration of initial dose adjustment, along with frequent medication reconciliation and analysis of the medication list, are keys to providing optimal pharmaceutical care for elderly patients.