Thursday, September 21, 2017

I See the Light! – Canadian e-Prescribing Platform on the Horizon

A national e-prescribing system, removing the need to transcribe (and sometimes translate) written prescriptions?

Sounds too good to be true, but Canada HealthInfoway is working hard to make this a reality.

An e-prescribing system works by having the prescription electronically transfer from the physician’s office software, directly into the pharmacy software.  This isn’t a novel idea, with several pharmacies and doctor’s offices already having their own systems in place.  However, Canada Health Infoway is looking to create one national system, called PrescribeIT, to redefine the standard across all pharmacies and clinics.

PrescribeIT has one feature that other e-prescribing systems lack, the ability to communicate to the physician if the prescription has been filled1.  This may seem like a small feature, but doctors have generally been left in the dark, not knowing if their prescriptions are being filled.  Prescribers can become frustrated if they’re unsure the patient’s condition isn’t responding due to inadequate therapy or if the patient is non-adherent. PrescribeIT is a step forward to solving this problem and improving pharmacist-doctor communication.

E-prescribing can be a blessing and a curse to pharmacists.  On one hand, they no longer have to interpret (sometimes poor) doctor handwriting; this job will already be completed by e-prescribing. In a St. Johns study, e-prescriptions had an error rate of 0.66%, and hand written prescriptions 1.33%2.  The caveat is that errors will be far more difficult to catch.   If a doctor accidently inputs the wrong drug or patient into the e-prescribing tool, through a wrong click, it may be impossible to determine if it’s in error.  Therefore, it will be crucial that pharmacists communicate with patients to determine if the medication is appropriate.  This is a practice that pharmacists are already doing, but will now become even more important.

Don’t get too excited yet, as PrescribeIT is only just being trialed at Algonquin Family Health Team and the Muskoka Medical Pharmacy in Ontario1.  It will likely be a few years until we see it rolling out to other Canadian pharmacies.  This is an exciting new technology that will hopefully improve the standard of care in pharmacies.

- Ajay Chahal

  1. (n.d.). Retrieved September 20, 2017, from
  2. Phillips, J. L., Shea, J. M., Leung, V., & MacDonald, D. (2015). Impact of Early Electronic Prescribing on Pharmacists’ Clarification Calls in Four Community Pharmacies Located in St John’s, Newfoundland. JMIR Medical Informatics3(1), e2.

Monday, September 18, 2017

Painfully Common – Codeine Crisis?

Pain management can be complicated since there is no objective test to assess pain like in hypertension, and pain can be difficult to clearly articulate.  It’s also common for patients to ask for codeine containing products (schedule 2 in Ontario), to manage their pain.  Codeine is metabolized by the CYP2D6 enzyme into morphine, which then exerts its painkilling effects.  Patients metabolize codeine into morphine at different rates, therefore some patients may have a lot of pain relief and others may not experience anything at all.  To complicate things even further, codeine is an opioid that can cause addiction.

These factors contribute to why Health Canada is considering banning all non-prescription codeine1.  Health Canada is most concerned about the addictive potential of codeine, as they’ve noticed a significant number of patients entering rehab programs for non-prescription codeine substance abuse alone1.  From a pharmacist perspective, there are two predominant viewpoints:
  1. Schedule 2 codeine products have an important role in therapy and with the appropriate tools, they can be effectively monitored for abuse.
  2. Schedule 2 codeine products are too unsafe, due to their abuse potential, to be sold without a prescription.
Whether pharmacists can effectively monitor non-prescription codeine depends on the electronic tools available to them in each province.   For example, Alberta pharmacists have access to the patient’s electronic medical record (EMR) called NETCARE. They can use the software to identify when the patient last picked up codeine.  In this situation, schedule 2 codeine products can have an effective role in therapy and may not need to be prescription, since pharmacists are capable of monitoring for abuse.

However, Ontario pharmacists do not have access to an EMR and thus are unable to assess if the medication is being abused.  This can be dangerous since it is impossible to know how much codeine the patient is using.  In this instance, banning the sale of the non-prescription codeine products may be appropriate.

Health Canada should encourage provinces to make the appropriate regulatory changes based on their pharmacy infrastructure.  If the appropriate mechanisms are in place to monitor for abuse, the provinces should trust pharmacists to make the correct judgement to dispense codeine.

In either case, pharmacists must be competent to counsel patients on effective pain management strategies.  RxBriefCase offers an excellent program discussing mild to moderate pain management in primary care:
It will be interesting to see how Health Canada decides to regulate non-prescription codeine and how changes to the legislation will impact patients.

- Ajay Chahal

  1. Beeby, D. (2017, September 11). Health Canada aims for prescription-only codeine pills, syrups. Retrieved September 15, 2017, from

Friday, September 8, 2017

The Elephant in the Room – Obesity Management

Obesity is a tough topic to discuss with patients and many pharmacists may not feel they are adequately prepared to initiate the conversation.  It’s a daunting task because if it is not approached correctly, we risk alienating the patient and possibly making things worse.
There are many wrong ways to start the conversation: using scare tactics, generic advice, or guilt. However these approaches have shown not to be effective.1  Instead, start the conversation with an open question, something like “I’m sure you’re aware of how weight can affect your health. Do you have any concerns about your weight and health that you’d like to talk about?1.  This allows the patient to take control of the conversation and voice their concerns at the beginning of the interaction.

Once you’ve spent some time with the patient discussing their concerns, motivation and goals, it’s time to develop a plan.  Too often clinicians will give generic advice like “eat less and exercise more”, which is ineffective advice for a patient who may have already heard that a dozen times. Specific simple interventions are effective ways to help patients get started towards healthier living.   

Here are 10 simple tips that you can suggest to your patients:2
  1. Keep a meal routine - Eat at roughly the same times each day, whether this is two or five times a day.
  2. Go reduced fat - Choose reduced fat version of foods such as dairy products, spreads and salad dressings where you can. Use them sparingly as some can still be high in fat.
  3. Remember to Walk - Walk 10,000 steps (equivalent to 60-90 minutes moderate activity) each day. You can use a pedometer to help count the steps throughout the day.
  4. Pack a healthy snack - If you snack, choose a healthy option such as fresh fruits or low calorie yogurts.
  5. Look at the labels - Be careful about food claims. Check the fat and sugar content on food labels when shopping and preparing food. “Eat Right Ontario” has a great patient resource to help read nutrition labels.
  6. Caution with your portionsDon’t heap food on your plate (except vegetables).
  7. Up on your feet - Break up your sitting time. Stand up for ten minutes out of every hour.
  8. Think about your drinks - Choose water or sugar-free drinks. Unsweetened fruit juice is high in natural sugar so limit it to 1 glass per day (200mL). Alcohol is high in calories so try to limit the amount you drink.
  9. Focus on your food - Slow down. Don’t eat on the go or while watching TV. Eat at a table if possible.
  10. Don’t forget your 5 a day - Eat at least 5 portions of fruit and vegetables a day (400g in total).
If you are interested in learning more on obesity management, stay tuned for my eNewsletter, “Uncomfortably Common – Obesity Management”, which will be sent to rxBriefCase members early next year.  Advancing Practice also offers continuing education, and a Certified Bariatric Educator Exam:

- Ajay Chahal

1. Freedhoff, Y., & Sharma, A. M. (2010). Best weight: a practical guide to office-based obesity management. Canada: Canadian Obesity Network.
2. Beeken, R. J., Leurent, B., Vickerstaff, V., Wilson, R., Croker, H., Morris, S., . . . Wardle, J. (2016). A brief intervention for weight control based on habit-formation theory delivered through primary care: results from a randomised controlled trial. International Journal of Obesity, 41(2), 246-254. doi:10.1038/ijo.2016.206

Thursday, August 31, 2017

The Green Lottery – Who Will Distribute Recreational Cannabis?

The Federal government declared July 1, 2018 as the deadline to legalize recreational cannabis. The real tantalizing question is: how will it be distributed? The Provincial governments have the responsibility to make this decision.  Many investors, business owners and corporations are agonizing over this decision because recreational cannabis offers a significant earning potential.  Even pharmacists are eagerly waiting for the decision, as it could help revitalize the profession that has been hit with budget cuts over the past few years. Shoppers Drug Mart has already taken their first step into cannabis distribution by submitting an application to become a licensed medical cannabis distributor.

Who are the potential candidates for cannabis distribution? There are 3 viable options:
  1. Pharmacies
  2. Government owned dispensaries
  3. Privately owned dispensaries
From a clinical stand point there is no competition, pharmacies clearly are the best choice.  It’s logical for the medication experts (pharmacists) to dispense cannabis, especially as so many patients may be taking other medications concurrently that might interact.

However, the provincial governments will want to maximize their earnings. The best way to do this is by distributing cannabis through government owned dispensaries.  The issue with this option is that provincial governments will be too slow to set up distribution locations by the July 1, 2018 deadline.  This is why the Ontario government is considering combining LCBOs (Liquor Control Board of Ontario) with dispensaries.  This idea is absurd from a health care perspective because it encourages combining alcohol with cannabis; however, perhaps from a politician’s point of view, nothing is out of the question (just look at Donald Trump).

The last option, gaining a lot of traction recently, is privately owned dispensaries.  There are a number of illegally operating dispensaries throughout the provinces, which are hoping to legitimize when the provincial legislation passes.   They are already set up to dispense cannabis, which makes them an easy option for the provinces to certify as licensed cannabis distributors.  However, it may be difficult to regulate these dispensaries as many of these locations may not be using ethical business practices.  For those owners currently operating outside of the law, continuing to do so after legislation passes may not be a stretch.

Regardless of the provinces’ decision, pharmacists will need to be prepared to counsel and advise patients on the use of cannabis.

The following continuing education programs are an excellent way to learn more about cannabis:

For Ontario healthcare professionals only, there is a $1,500 government fund to help subsidize continuing education costs.  Therefore if you are a registered Ontario pharmacist, you may be eligible to be reimbursed! Visit Allied Health Fund for more details.

- Ajay Chahal

Thursday, August 24, 2017

The Journey Begins

 Hello rxBriefCase,

I’m excited to start my 5-week rotation with rxBriefCase and experience something completely different from the standard clinical rotations in community and hospital pharmacy clinics.  This is my fourth block, with six more to go until I’m finally finished school!  My previous rotations (block 1 and 2) were at Center of Addictions and Mental Health (CAMH), where I was part of the acute schizophrenia ward and outpatient mood/depression unit.  

Mental health is a topic that I have a passion for, and antidepressants are one of the most commonly prescribed medications in Canada.  Escitalopram was the 5th most commonly dispensed medication in 20131. If you are interested in furthering your understanding of the field, I’d suggest reading: 
  1. "A case of partial treatment response: what next?"
  2. "When treatment for depression doesn't work"
Both of these articles are in the rxBriefCase eNewsletter archive, and discuss therapeutic options in treatment resistant depression.

Having learned a lot about the nuances of communication during my time in hospital and community pharmacy, I’m excited to flip the script and focus on my written communication during my stay with the rxBriefCase team.

Stay tuned for future blog posts!

- Ajay Chahal

1. Spolarich, A. E. (2015, April 18). Commonly Prescribed Medications and Managing the Oral Side Effects of Medication Use. Retrieved August 23, 2017, from

Tuesday, July 11, 2017

Medical Abortion: A Woman’s Choice

Abortion has always been a controversial topic. There are very compelling arguments for both sides from all walks of life and professions. Some feel that ending the life of a fetus is still ending a life and it should be a very difficult decision to make and never to be taken lightly. Others feel that women have the right to decide what to do with their own bodies and sometimes bringing a child into a bad life situation will only do the child more harm than good. As a healthcare professional, whether you are pro-life or pro-choice, you are first and foremost pro-patient care.

Mifegymiso is a combination of two pills taken sequentially to induce a medical abortion up to 49 days into pregnancy. It was approved for use in Canada July 2016 but was only available to Canadian women in January 2017 whereas combination drugs of this nature have been available in over 60 countries for several years now. It is important to note that although medical abortion is more accessible and convenient than surgical abortion, it is does not carry less risk. Both methods have risks but if used correctly, this treatment will help so many women exercise their right to choose.

For more on information on this topic make sure to read my eNewsletter coming out soon. Even though it is a grim subject it is so important to educate ourselves on all options for women and learn to not judge or discriminate against people whether you are pro-choice or pro-life.

“If you’re against abortion, don’t have one”

Keep an open mind and an open heart. Take care!

Wednesday, July 5, 2017

Power over Your Period!

For some girls getting their first period is a rite of passage into womanhood while for others it’s an uncomfortable thing that happened that no one talked about. Lots of changes happen to your body once you start your period and many women have questions and concerns about their period but the right information is hard to find sometimes. Also, some women may find it embarrassing to ask these kinds of questions and therefore prefer to ignore them. Regardless of how you feel about your period every woman should have access to the right information so she can understand her body. Knowledge is power and you’re about to gain a whole lot of power over your period!
  1. Estrogen and progestin are the two main hormones that control your menstrual cycle
  2. Period cramps occur because during your period your uterus contracts to cause the bleeding of your period.  This tightening of the uterus is also what causes the painful cramps
  3. Having been pregnant and birthed a child reduces your risk of having menstrual cramps
  4. PMS goes away once you get your period
  5. Smoking is a huge risk factor for having PMS
  6. Midol® isn’t effective for menstrual cramps or PMS
  7. The time in your cycle that you are most likely to get pregnant is about 9-14 days into your cycle, if your cycle is 28 days. (Day 1 of your cycle is the day you get your period)
  8. It is possible to get pregnant while you’re on your period but the chance is not as high as on other days
  9. Douching is not good for vaginal health
  10. When you have not had your period for a full uninterrupted 12 months and you are otherwise healthy, then you are officially in menopause

Read my MedSchool for You program “Let’s Talk about Your Period” when it’s released in the near future, but for now here are the top 10 facts about your menstrual cycle and everything else that goes with it.

“Here’s to strong women. May we know them. May we be them. My we raise them.”

Thanks for reading. Until next time!