Monday, June 11, 2018

Insomnia: A Dreamer's Nightmare

Sleep. We all want it but can never seem to get enough of it.

“I keep waking up in the middle of the night, what do you recommend for sleep?”
“I haven’t slept in three days, what can I take?”
“I have insomnia, what’s good for sleep?”

These are just some of the questions community pharmacists face every day, but are we clear on what insomnia is and what the options are?

What exactly is insomnia?1

We throw around the term insomnia all the time, but what is the clinical definition? To be diagnosed with insomnia, the following criteria must be met:
  • Dissatisfaction with sleep quality or quantity, this could be 1 or more of the following:
    • Difficulty in falling asleep (sleep latency) 
    • Difficulty staying asleep 
    • Early morning awakening without being able to return to sleep 
  • Sleep disturbance must cause functional impairment or distress 
  • It occurs at least 3 nights per week for at least 3 months 
  • It cannot be substance related (e.g. Medication or drug of abuse)

So, what can we recommend?

Over the counter pharmacotherapy is limited to antihistamines, namely, diphenhydramine (Nytol, Sleep-Eze, Unisom, ZzzQuil and any generics). The dosing ranges from 12.5 – 50 mg, optimally 50 mg, 30 to 60 minutes before bedtime. However, this is only a temporary solution and should only be used for a short, intermittent (less than 4 times weekly) basis.
Other pharmacotherapy measures require a prescription and include benzodiazepines and nonbenzodiazepine GABA agonists.

Natural Health Products
There are two common natural health products marketed for insomnia – melatonin and valerian.

Melatonin (N-acetyl-5-methoxytryptamine) has been reported to increase total sleep time, relieve or prevent daytime fatigue associated with jetlag, reduce sleep onset latency, help reset the body’s sleep-wake cycle and improve overall sleep quality. Although the absolute benefit of melatonin compared to placebo was less significant when compared to other pharmacological treatments, melatonin may still play a role due to it’s side effect profile.2

Valerian (Valeriana officinalis) has been reported to improve sleep quality but most of the studies had significant issues with methodology and numerous variations in dosing, preparation and length of treatment.

Clinical Tip: Always refer to a physician if any over-the-counter product is required for over 7 consecutive days.

Nonpharmacologic Therapy
Nonpharmacologic treatment is the first line option because it is a safe and effective alternative to pharmacologic therapy. This comprises of psychological and behavioural including stimulus control therapy, relaxation training and cognitive behavioural therapy (CBT). A combination of these techniques can be found below!

Image result for CLOCK insomniaTop 10 tips for battling insomnia1
  1. Avoid napping during the day
  2. Maintain a regular schedule – go to bed and get up at a consistent time every day (including weekends)
  3. Implement a winding down ritual before bed using relaxation techniques like stretching, taking a warm bath
  4. Use your bedroom only for sleep and sex. Avoid watching television and eating in the bedroom.
  5. Make your bedroom the most comfortable place to sleep by ensuring it’s an ambient temperature and cutting down on light and noise
  6. Pick a comfortable mattress and pillows!
  7. Exercise regularly (aim for the late afternoon and avoid 2 hours before bedtime)
  8. Avoid alcohol, caffeine, nicotine and eating heavy meals before bed
  9. Reduce your fluid intake before bed to avoid sleep disruption
  10. Try creating a sleep diary!

I hope you were able to gain some insight from my blog posts – I know I’ve learnt a lot but it’s time for me to hit the hay. Goodbye and good night rxBriefCase!


  1. Procyshyn, R., Barr, A., CTMA [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2018 [updated 2017 06; cited 2018 06 07]. Insomnia. Available from Also available in paper copy from the publisher.
  2. Ferracioli-Oda, E., Qawasmi, A., & Bloch, M. H. (2013). Meta-Analysis: Melatonin for the Treatment of Primary Sleep Disorders. PLoS ONE8(5), e63773.

Thursday, May 31, 2018

A Solution to Our Opioid Crisis?

Canada is one of the highest per capita consumers of opioids, second only to the United States.1 The opioid crisis has been a hot topic among healthcare professionals affecting every province from the east to west coast. According to Health Canada, there were 2,946 apparent opioid-related deaths in 2016 and at least 2,923 from January to September 2017. Of this rise, 92% were ruled as accidental or unintentional.2

The government has identified the need for intervention, and on May 2, 2018, they issued a two-step strategy: inform patients and implement risk management plans.3
  1. Under the Food and Drug Regulations divisions, all prescription opioids in Part A of the “List of Opioids” will require pharmacists to affix the warning sticker shown below as well as a patient information handout at the time of dispensing.
  2. Market authorization holders (MAH) of specific opioids will be required to submit a Canadian tailored opioid risk management plan to Health Canada. This plan will allow for categorization, monitoring, prevention and management of opioid-related adverse events.
The mandatory bright yellow warning sticker is to be implemented in October 2018 and will be accompanied by a mandatory single page patient handout informing them about:
  • The signs of opioid overdose
  • The signs of withdrawal
  • Warnings to not share the medication
  • Store safely away from the reach of children
  • Other serious warnings and potential side effects

Is this necessary?

Despite Health Canada’s initiative, many pharmacists feel that their solution is modest at best. A recent poll on the Canadian Health Care Network found that only 38% of pharmacy professionals support Health Canada’s mandated warning sticker on all opioids. Rather, pharmacists serve as the last healthcare professional that patients encounter before receiving their opioid medications, thereby providing a distinct opportunity for individualized counselling. Warning stickers can inform and remind patients of the risks associated with opioid misuse, but this could also lead to non-compliant therapy and pharmacists may be the best judge of whether or not the sticker is appropriate.4,5

"Would you attach the warning sticker for a methadone or suboxone patient who is trying to manage their addiction?"?

In addition, the CPhA has proposed that the government utilizes the clinical knowledge and accessibility of pharmacists by expanding our scope for designation as practitioners under the Controlled Drugs and Substances Act. This will allow for modifications to opioid prescriptions including:
  • Dose Reductions
  • Dosage form adjustment
  • Substitutions for non-opioid alternatives
  • Opioid tapering
Working in a community pharmacy, I know that every opioid prescription already has auxiliary warning labels affixed and each new prescription also has a patient information handout to reinforce the pharmacist’s counselling points. So, the question is, will this really make a difference?

Personally, I have mixed feelings, these stickers may be the catalyst for conversations with patients, but we shouldn’t be treating them homogeneously. Rather, we should be providing personalized care, and a regulatory change like the one above will allow for pharmacists to leverage their role and combat the crises more holistically.

Leave a comment below to let me know if you support Health Canada’s mandatory warning stickers.



  1. Special Advisory Committee on the Epidemic of Opioid Overdoses. National report: Apparent opioid-related deaths in Canada (January 2016 to September 2017) Web-based Report. Ottawa: Public Health Agency of Canada; March 2018
  2. Government of Canada. Health Canada. Opioid Warning Sticker and Patient Information Handout, and Risk Management Plans; May 2018. Accessed on May 30, 2018:
  3. Canadian Pharmacists Association. New mandatory opioid warning stickers not sufficient to address prescription opioid misuse; May 2018
  4. Ubelacker, S. Health Canada mandates warning sticker for all prescription opioids. The Canadian Press; May 2018

Friday, May 25, 2018

Probiotics - What You Need to Know

Should I take probiotics? Which one should I take? The higher the number, the more effective it is right? These are questions that community pharmacists are posed with daily.
Probiotics are defined as “live microorganisms, which when consumed in adequate amounts, confer a health effect on the host”.

Lactobacillus and Bifidobacterium are the most common bacteria found in the probiotics on your local pharmacy’s shelves. These two species differ in benefits, and even different strains within the same species can diverge

Lactobacillus Bifidobacterium
  • Inhibit growth of enteric pathogens
  • Produce antimicrobial compounds
  • Reduce inflammation
  • Inhibit growth of enteric pathogens 
  • Aid in lactose maldigestion 
  • Modulate the immune system 
  • Reduce allergy symptoms 
  • Hepatic encephalopathy

Probiotics are not equally created

There are many probiotic formulations on the market and they differ in several aspects including: composition, manufacturing, production, shelf life, strength of the formulation (measured in Colony Forming Units – CFUs), ability to deliver to the gut, clinical evidence and Health Canada approved indications.1

  • CFU refers to the number of viable (able to multiply) bacteria cells in a sample 
  • A minimum number of microorganisms must be delivered to the gut in order to have the intended health benefits 
  • E.g. A minimum of 10 billion CFU is required to reduce the risk of CDAD
Ability to deliver to the gut3,4
  • To bestow its clinical effects, the probiotic must be able to deliver to the gastrointestinal system.
  • Enteric coated probiotic capsules have shown to be the most effective in reaching the gut. Encapsulated and probiotic powders have limited resistance to stomach acid
  • Evidence from one US review suggests that there is a 20-40% survival rate of bacteria through the GI tract.
  • However, this same review also stated that there is no evidence that orally administered probiotic organisms adhere to intestinal cells – they seem to pass into the feces without adhering or multiplying. This implies, to construe benefit, the probiotic must be administered continuously.
  • Temperature variations and other environmental conditions can compromise the stability and viability of the bacteria
  • Some products make no claim at all, while others claim the amount only at the time of manufacture. Some products, such as capsules, require the bacteria to be freeze-dried and such processes may also affect viability.
  • One US study conducted by found that among 26 probiotic products, eight contained less than 1% of the claimed number of live bacteria or of the claimed minimum of 1 billion.5
  • Consumers may be misled, as the number of live bacteria in a probiotic at the time of purchase may be lower than the labelled amount

So what’s the evidence?
Working in a community pharmacy, I’ve heard indications ranging from allergic conditions to vaginal yeast infections, but most commonly, and where most of the evidence lies, is with antibiotic use and diarrhea. Some probiotics can prevent diarrhea associated with antibiotic use (AAD) and can reduce the risk of Clostridium difficile associated diarrhea (CDAD).

Health Canada lists over 1000 types of active probiotics on the market but only 15 are indicated for AAD management and/or prevention, and only one probiotic is approved for both AAD and CDAD. This just goes to show probiotics are not interchangeable and can have great disparity.

There are no probiotic containing foods (e.g. yogurt) that have approved health claims. The CFU count in these foods generally do not contain the minimum of 10 billion CFUs to confer health benefits. In addition, the ability of food to deliver bacteria to the gut has not been clinically studied.4

Five Key Criteria for Recommending an Effective Probiotic6
  1. Identifiable high-quality strains
  2. Synergy of strains
  3. Guaranteed bioactivity (live, health microorganisms)
  4. Gastrointestinal survival
  5. Clinical studies (on the finished product).
What do you tell your patient?6
  1. Not all probiotics are the same
  2. Select a specific and appropriate probiotic for intended effect. Refer to the Canadian guide to probiotic products if you are unsure what to recommend
  3. Always select a product with the highest level of evidence, especially look for those approved by Health Canada for specific indications
  4. Advise patients to take probiotics at least 2 hours apart from antibiotics (if AAD/CDAD is the indication)
All in all, probiotics can be used to support a healthy digestive tract and immune system but not all probiotics can be assumed to provide the same efficacy for other indications.

Final Thoughts: 
Only recommend products approved by Health Canada and do your research before prescribing. Health Canada approved labelling should be printed clearly on the packaging and should be searchable on Health Canada’s Licensed Natural and Non-prescription Health Products Database (LNHPD) using the product’s unique NPN number. For general information on the use of probiotics, Health Canada provides a useful guide that outlines acceptable claims and identifies the strains that have been most studied.7

If you’d like to learn more about Probiotics in AAD and CDAD – visit rxBriefCase for the program:

  1. Joint FAO/WHO Expert Consultation on Evaluation of Health and Nutritional Properties of Probiotics in Food Including Powder Milk with Live Lactic Acid Bacteria, October 2001. 
  2. Goldenberg JZ, Ma SSY, Saxton JD, Martzen MR, Vandvik PO, Thorlund K, Guyatt GH, Johnston BC. 2013. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database of Systematic Reviews.5:CD006095. 
  3. Grzeskowiak et al. 2011. Manufacturing process influences properties of probiotic bacteria. Br J Nutr. 105 (6): 887 -94
  4. Millette M et al. 2013. Gastrointestinal survival of bacteria in commercial probiotic products. International Journal of Probiotics & Prebiotics. 8 (4):149-56
  5. Mason, P. 2007.Probiotics: are they worth taking? The Pharmaceutical Journal (Vol 278)
  6. Probiotics: A Leading Role in Reducing the Risk of Antibiotic Associated Side Effects & C. difficile Associated Diarrhea;
  7. Doran S, Snydman DR. Risk and safety of probiotics. CID 2015; 60 (Suppl 2): S129-S134.

Thursday, May 17, 2018

Getting Ready for the Long Weekend!

Who doesn’t love long weekends? Whether you’re going hiking, camping or simply getting out of the city, there’s always something to do.
Here are some tips for your weekend getaways that will take you right through the summer.

1. Lather on that sunscreen
As most of us know, the sun can damage our skin, while sunscreen can act as a form of protection. The sun has two types of radiation: UVA and UVB. UVB rays damage the surface of the skin by causing sunburns and tanning. On the other hand, UVA rays penetrate deeper into the skin to cause signs of skin aging, such as wrinkles, uneven colour, and leathery skin. Broad spectrum sunscreens can protect us from both types of radiation.
Where many people tend to get confused is the different SPF (Sun Protection Factor) options available. SPF tells us how much time the sunscreen will protect us from UVB rays. For example: If it takes 30 minutes for your skin to start turning red without sunscreen, using a sunscreen with SPF 30 should theoretically take 30 times longer to get a sunburn. However, this does not consider sweating, swimming and other ways the sunscreen can be removed.
Fun Fact: SPF 15 absorbs 93% of UVB radiation while SPF 30 absorbs 97%! It’s not twice the protection.
So how do you choose a sunscreen?

The Canadian Dermatology Association (CDA) recommends sunscreens with SPF30 for daily use. Look for the CDA logo, as it indicates the sunscreen is perfume free, hypoallergenic and has a minimum SPF of 30.

Fun Fact: Sunscreen should be applied every day, not just during the summer.

How much should I use?
The average adult needs 1 oz (i.e. a shot glass) of sunscreen for their body and 1 teaspoon for their face and neck. This should be applied 20-30 mins before entering the sun to give sufficient time for absorption and reapplied throughout the day, preferably every 2 hours.

Other tips:
  • Wear long sleeves, wide brimmed hats and sunglasses
  • Avoid the sun between 10 am – 4 pm when the sun’s rays are strongest
  • Stay in the shade

But what if you get burned?

  • Apply cold cloth to sunburned areas to relieve pain
  • Wear loose clothing to prevent more irritation

  • Break or pick at blisters
  • Peel skin
  • Spend excess time in sunlight

2. Get away bugs!
With the great outdoors, there also comes a plethora of insects that bite and sting. Here are my top tips for avoiding the annoying, inflamed bump to follow.

  • Avoid using scented cosmetics, perfumes, hairsprays that can attract insects
  • Avoid or caution eating outdoors and cover drinks to avoid swallowing wasps or bees
  • Limit the time outdoors at dawn and dusk
  • Wear clothing that covers as much skin as possible and tuck in pant legs when near nesting areas
  • Avoid infested areas (tall grasses, marshes, swamps)
  • Dispose of any sources of standing water (rain barrels, bird baths, clogged gutters)
  • Avoid being outdoors at dawn and dusk because this is their peak times

But if you get stung..
  • Remove the stinger or insect to decrease local reaction.
  • Remove it by gently scraping side to side with a fingernail, tweezers or even a credit card 
  • Clean the site with warm water and soap to prevent an infection
  • Apply a cool compress to the site to reduce swelling
  • For pain, try acetaminophen, ASA or ibuprofen
  • For pain, itching and inflammation, try an oral antihistamine over a topical one (diphenhydramine, loratadine, cetirizine)
  • If you really want a topical option, try an over the counter local anesthetic like benzocaine, lidocaine or pramoxine

3.  Stay hydrated
When you’re so busy having fun in the sun, your water intake may not be keeping up with all the loss from activity. Each person has varying water intake recommendations depending on age, weight, activity level – but a general rule of thumb is 8x8, or 8 glasses of 8 ounces of water each day.
Some tips to increase your water intake are:
  • Invest in a reusable water bottle
  • Drink a glass of water before you eat
  • Eat fruits and vegetables filled with water (cucumbers, celery, watermelon)
  • Infuse your water with fresh fruit (lemon, berries, oranges)
  • Make a water schedule and stick to it

Well that’s all I have for you this week. Happy Victoria Day!


Friday, May 11, 2018

World of Uncertainty

Hi rxBriefCase!

My name is Ingrid and I'm the new pharmacy student here. This is the first rotation of my fourth year before I become a full-fledged pharmacist. As I enter my final year of pharmacy school, I'm frequently bombarded with questions of my future career – Do I want to work in hospital or community? Do I want to stay in Canada or move to the US? Do I want to stay in Toronto or move to a smaller city?

The truth is, I have no idea!

Pharmacy is a career option that has many opportunities: community, hospital, industry, consulting, government - the opportunities are endless and I want to explore it all. The APPE rotation system is fantastic in that it allows students to get a feel of areas we would otherwise never be exposed to (like my time here at mdBriefCase!). Alas, to my dismay, there is limited time and positions making it impossible for me to dip my feet into it all but I shall revel in each rotation as they come.

While my future may be filled with uncertainty, there are a few fun facts I am certain about: 

1.      Travelling - The act of travelling is a pain but immersing in the food and culture of the destination is indescribable (most recently South Korea and the peanut butter grilled squid!)
2.      I'm a major foodie - I love both cooking and eating. I'm open to trying just about any food/cuisine at least once (Curry fish balls in Hong Kong is one of my favourite street foods!)
3.      I absolutely love aerial yoga – “What if I fall? Oh, but my darling, what if you fly?”
4.      I'm starting to get into hiking - Don't let me fool you, I'm not as active as I may sound, I need to balance my eating habits somehow
5.      I enjoy knitting while watching Netflix – This is my true form, wrapped up in a warm blanket with my needles and my latest binge 

I'm looking forward to exploring the realm of continuing education here at mdBriefCase and I'll check in with you next week.


Friday, April 20, 2018

Top 3 Doubts Preventing You From Becoming a Hospital Pharmacist

Change is hard.

Contemplation is the first step towards making any change in your career path, but it can be easy to talk yourself out of it.

Venturing into the unknown world of hospital pharmacy can seem daunting, so why make the transition? Maybe it’s because you feel like you’re not being challenged enough in your current role or maybe you feel like you’re not making enough of an impact on your patients. Maybe you just feel that it’s time for a change.

Whatever your reasons, you’ve probably at one point or another, doubted your ability to succeed in an institutional environment. 

In this blog, we’ll explore the 3 top reasons that you may have convinced yourself a hospital isn’t for you and why you shouldn’t allow them to stand in your way.

1) I need a residency to work in a hospital

A hospital pharmacy residency is a 12-month, rotation-based learning experience intended to prepare pharmacists for institutional practice. Many pharmacists are under the impression that they can’t get a position in a hospital without a hospital residency.

This is not true.

A hospital residency can be a valuable way to gain specialized knowledge and clinical experience, while building confidence, and it can definitely give your resume an edge. Teaching hospitals in particular, often put weight on whether a candidate possesses this qualification.

But it is not a requirement to be a hospital pharmacist. Not yet.

The 2013/2014 Hospital Pharmacy in Canada Report showed that only 20% of pharmacists working in hospitals across Canada have completed a hospital pharmacy residency. Although the Canadian Society of Hospital Pharmacy’s (CSHP) goal is to ultimately make that 100%, at this time, the fact remains: there are not enough residency positions to meet the needs of hospitals in Canada. Consequently, making residency a requirement for hospital positions is not a reality of the immediate future. Currently, about 80% of pharmacists hired in hospitals within Canada do not have a hospital residency.

More importantly, a good employer will not only value your credentials but also your experience, your ability to adapt to a new and challenging environment, your desire to advance the practice and your fit within the team.

2) I don’t have enough clinical background to work in a hospital

Remember, you are a pharmacist. You already have the foundational knowledge and skill set required to make a sound clinical judgment and provide optimal patient care. The basics are the same in any pharmacy practice setting.

Regardless of where you practice, whether community or hospital, pharmacy is an ever-evolving area of health care and staying abreast on new and upcoming treatments or guidelines is always best practice. Unless you are transitioning into a highly specialized field, you likely already have most of the knowledge you need for an institutional position. Think about your current role - much of what you need to know, you probably learned first-hand on the job.

"You already have the foundational knowledge and skill set required to make a sound clinical judgment and provide optimal patient care."

That’s not to say that there won’t be a learning curve. Depending on the site and the unit, training can often range from several weeks to several months. This will not only serve as an orientation to the operational and clinical services of your site, but it also begins the process of integrating your prior knowledge into the provision of pharmaceutical care for a new patient population.

If you still feel unprepared, keep in mind that most hospitals, and especially teaching hospitals, foster an environment where learning is encouraged. Members of your healthcare team are accustomed to the myriad of students, residents and fellows of different disciplines on your unit, at any given time, and will keep education a priority. In addition to peer support, most hospitals have a multitude of educational opportunities and online resources at your disposal to support personal development and enhance your knowledge.

3) I will be undervalued by other healthcare professionals on the team

This thought has probably crossed the mind of every pharmacist at one point or another.

Historically, pharmacists have been dubbed as the “unseen” members of healthcare teams. Working behind the scenes, the impact of the pharmacists’ role is not always clearly visible to patients or even other healthcare professionals. Studies have shown that pharmacists’ perception of their value among other health care professionals is often negative.

"Pharmacists are an integral part of interdisciplinary teams."

But pharmacists are an integral part of interdisciplinary teams. Numerous studies have shown the impact pharmacists can have on patient outcomes in a variety of settings. And despite the belief of how they are perceived by their colleagues, pharmacists in the hospital setting are recognized by other health care professionals as a valued member of the team.
The traditional hierarchy of hospital teams and the notion that “physician knows best” have long been replaced with patient-centered models that focus on collaboration between all equal members of the healthcare team to achieve patient-specific goals.

As with any new position, there will always be a certain amount of “proving yourself” involved. But this is an opportunity to show your team what you’re really capable of and ensure they utilize the full scope of their pharmacist in a collaborative environment. 

It may seem like an impossible task to start a new path in hospital pharmacy, but don’t allow your doubts to dissuade you. With persistence and dedication, you can make the shift.

Hospital Pharmacy in Canada 2013/2014 Report. Hospital Pharmacy in Canada Editorial Board. 2015

Friday, April 6, 2018

The Beginning and the End

“Keep calm and welcome to the team” - the sign pinned to the bulletin board across from my desk, my new home for the next 5 weeks. This was only a small part of the warm welcome I’ve received since starting my rotation here at mdBriefCase Group!

My name is Sarah, and I am an APPE (Advanced Pharmacy Practice Experience) student at the Leslie Dan Faculty of Pharmacy at UofT.

I am also a pharmacist. 

So why is a fully-licensed pharmacist doing a pharmacy student rotation? Recall that years ago, Pharmacy Schools in Canada started the transition from the standard Bachelors of Pharmacy program to an entry-level PharmD program? This is one of the reasons why I'm here today. 

My stream however, is called the PharmD for Pharmacists. A program for individuals, such as myself, who graduated with a Bachelors in Pharmacy and want to step it up a notch. 

Related imageMany people ask me why I decided to take the plunge and return to school for my PharmD, having graduated 10 years ago. Although those 6 letters after their name are the driving force for many, the answer for me was quite simple; I wanted to broaden my knowledge base.  

For the majority of my career, I have been working in the oncology setting –  a very niche area. The PharmD for Pharmacists has allowed me to explore and experience areas of Pharmacy I had never considered before. From uncovering the inner workings of the Faculty and what’s involved in curriculum design & development to learning, first-hand, about health care and pharmacy practice in the Cayman Islands. Being able to practice what I love, with one of the most beautiful beaches in the world in my own backyard, has definitely been a highlight of my PharmD experience!

mdBriefCase Group will be my last rotation before I complete my PharmD (yay!) and I am so excited to dive into the world of Continuing Education!

Have you always wondered about going back to school or what it would be like to practice abroad? Share your dreams or success stories with us!

- Sarah