Tramadol: A Case of Misclassification?

Although tramadol was being considered for classification as a controlled drug back in 2007, it remained an uncontrolled drug.1 A decade later, Health Canada is reconsidering the decision and may re-categorize tramadol as an opioid.1

Tramadol is a painkiller that increases serotonin levels in the body like antidepressants do, leading to some analgesia.1 In addition, CYP2D6 in the liver then converts tramadol to a compound called M1, which is an opioid that provides pain relief similarly to morphine.1 One thing to remember is the pharmacogenomics involved with the conversion of tramadol to M1.1 Some individuals have weak CYP2D6 activity and do not receive the opioid effect, whereas, others may have rapid conversion and acquire a large opioid effect.1

The classification of Tramadol as an opioid is being contemplated due to multiple health care professionals voicing concerns as well as a report on opioid trends from the Canadian Institute for Health Information (CIHI) released last week.2 According to the report, tramadol prescriptions have increased 30% and daily doses have increased by 23% between 2012 and 2016.3 Despite the Canadian non-opioid classification, CIHI included tramadol in their report on opioids because the World Health Organization classifies it as an opioid, as does the United States’ Drug Enforcement Administration and the manufacturers' scientific description.2

Tramadol has the potential to be abused, misused, and can cause dependence especially at higher doses.2,4 Its classification as a non-opioid makes for minimal reporting requirements resulting in a lack of data to help us measure the extent of its abuse and misuse in Canada.2

The opioid crisis does not look like it will resolve any time soon as there is no simple solution for the problem. Therefore, making even the smallest of changes, such as modifying the classification of tramadol to an opioid and the resulting alterations in reporting requirements, could prove crucial.

Now we wait and see if Health Canada will make this change.

References:

1. Juurlink, D. (2017, November 27). Why Health Canada must reclassify tramadol as an opioid. The Globe and Mail. Retrieved from https://www.theglobeandmail.com/opinion/why-health-canada-must-reclassify-tramadol-as-an-opioid/article37089174/

2. Howlett, K. (2017, November 22). Health Canada eyes opioid restrictions for popular painkiller. The Globe and Mail. Retrieved from https://www.theglobeandmail.com/news/national/health-canada-eyes-opioid-restrictions-for-popular-painkillertramadol/article37048483/

3. Canadian Institute for Health Information. (2017). Pan-Canadian Trends in the Prescribing of Opioids. Ontario: Canadian Institute for Health Information. Retrieved from https://www.cihi.ca/sites/default/files/document/pan-canadian-trends-opioid-prescribing-2017-en-web.pdf

4. Purdue Pharma. (2016). PRODUCT MONOGRAPH INCLUDING PATIENT MEDICATION INFORMATION : Zytram XL®. Pickering. Retrieved from http://purdue.ca/wp-content/uploads/2015/12/Zytram-XL-PM-EN.pdf?4eb3c6

Being a Wise Pharmacist

The Canadian Pharmacist Association (CPhA) just released a campaign called Choosing Wisely Canada for pharmacists.¹ This campaign was created to help pharmacists have discussions with patients to identify if treatments are warranted, have evidence to support use, and/or can cause harm to patients.¹ The recommendations were made by asking Canadian pharmacists and pharmacy researchers to provide their input, which were then reviewed by an expert committee.¹ The final list was created considering the relevance to pharmacy practice, possible impact and supporting evidence.¹ The six evidence-based recommendations were made for pharmacists to help optimize patient care and safety.¹

1.   Don’t use a medication to treat the side effects of another medication unless absolutely necessary.²

It is important to clarify if a symptom is part of a medical condition or a side effect to a medication.² You do not want to initiate a prescribing cascade, as it can lead to polypharmacy.² The polypharmacy can then generate to more side effects, drug interactions, impact adherence and patient’s quality of life.²

For more information read: The prescribing cascade revisited.

2.   Don’t recommend the use of over-the-counter medications containing codeine for the management of acute or chronic pain.² Counsel patients against their use and recommend safe alternatives.²

According to evidence, use of over-the-counter pain medication containing codeine is not supported over non-opioid options.² Codeine has the potential to be abused and cause dependence.² Furthermore, the codeine containing medications tend to have high doses of the simple analgesics (acetaminophen, aspirin or ibuprofen) which can cause adverse effects with misuse (i.e. liver toxicity, peptic ulcers and renal damage).² 

For more information read: Misuseof non-prescription codeine containing products: Recommendations for detectionand reduction of risk in community pharmacies. 

3.   Don’t start or renew drug therapy unless there is an appropriate indication and reasonable expectation of benefit in the individual patient. ²

About 66% of Canadians over the age of 65 take five or more drugs.² Polypharmacy increases risk of adverse drug reactions and can lead to hospitalization.² Pharmacists should clarify the therapeutic indication for all medications and only renew prescriptions if benefits of therapy are known to be greater than the risks.²

A tool to help with this task: Check up on “checking”

4.   Don’t renew long-term proton pump inhibitor (PPI) therapy for gastrointestinal symptoms without an attempt to stop or reduce (taper) therapy at least once per year for most patients.²

PPIs are safe and well-tolerated for short term use in of gastroesophageal reflux disease, but can cause adverse effects if used long term, such as: increased risk of fracture, C. difficile infection and diarrhea, community-acquired pneumonia (CAP), hypocobalaminemia and hypomagnesemia.² Recommend H2-receptor antagonists or lifestyle changes for patients that have used PPIs for 4 weeks and are no longer symptomatic.² Note: This recommendation does not apply for Barrett esophagus, severe esophagitis grade C or D, or known history of bleeding gastrointestinal ulcers.²

Tools to help with this task: Bye-Bye PPI and PPI Deprescribing Algorithm

5.   Question the use of antipsychotics as a first-line intervention to treat primary insomnia in any age group.²

Many people have been using antipsychotics for an off-label indication of insomnia.² However, there is no evidence to support first-line use in guidelines and there are side effects to consider (i.e. weight gain and metabolic disorders).²

For more information read: Atypical antipsychotics for insomnia: a systematic review.

6.   Don’t prescribe or dispense benzodiazepines without building a discontinuation strategy into the patient’s treatment plan (except for patients who have a valid indication for long-term use).²

Benzodiazepines are often prescribed for anxiety disorders and insomnia.² Long term use in elderly patients can lead to tolerance, dependence, adverse effects (i.e. sedation, impaired memory, falls) and hospitalization.² Guidelines recommend using other options before benzodiazepines.² If prescribed they should not be used long term and a treatment plan should be developed (i.e. taper schedule).²

A tool to help with this task: Benzodiazepine and Z-drug Deprescribing Algorithm

These six changes have the potential to make a large impact on patient care and safety. What do you think about these new recommendations? Email me to share your success stories.

A video of the recommendations available as well: 6 Things Pharmacists & Patients Should Question - Choosing Wisely Canada

References

     1. Canadian Pharmacists Association. (2017, November 21). Choosing Wisely Canada. Retrieved from https://www.pharmacists.ca/pharmacy-in-canada/choosing-wisely-canada/

     2. Canadian Pharmacists Association. (2017, November). Six Things Pharmacists and Patients Should Question. Retrieved from https://choosingwiselycanada.org/pharmacist/

Medical Marijuana in Pharmacies - Will it Happen?

Hello rxBriefCase,

Marijuana has been in the news continuously for the past few months, with emphasis on the recreational marijuana deadline in July 2018. A couple weeks ago, the Liquor Control Board Ontario (LCBO) announced the first 14 cities to have shops that will be selling legalized recreational marijuana. Now that the recreational marijuana framework and dispensaries have been established, people have moved on to the next big thing - medicinal cannabis.
Shoppers Drug Mart just posted a job for a medical marijuana brand manager position, despite pharmacies not yet having the role of dispensing medical marijuana.¹ Handling medicinal cannabis dispensing has been a goal for Loblaw Companies Ltd., the company which also owns Shoppers Drug Mart, since they applied for a Health Canada license last year.¹ Other pharmacy companies are also looking to dispense  medicinal cannabis under the belief that pharmacies are ideal distribution locations, just like for any other prescription medication.¹

Based on a recent study, it appears it's not just the pharmacy companies who think this is a promising idea - so does the public.² The data from the new study done by the Ontario Pharmacist Association (OPA) shows that more than 7 out of 10 adult Ontario residents trust pharmacists to dispense medical marijuana.² Furthermore, 56% of the survey participants indicated preferring medicinal cannabis being dispensed at pharmacies, compared to other alternatives.²

This is not the way the medical marijuana dispensary framework is currently set up, and not using pharmacists in this process could create safety risks for patients.² This may be a missed opportunity for patients, as they forgo access to advice and information that could benefit their overall health. Pharmacists are the drug experts and can monitor for treatment effectiveness, side effects and identify potential risks (i.e. drug interactions or contraindications).²

Pharmacists are experts at reviewing prescriptions, dispensing medications, identifying drug interactions and counselling patients. We have a lot of practice with these activities, however, this may not be true when it comes to medical marijuana. Some pharmacists may see this new role as an opportunity to expand on our skill set and apply our drug expertise further. Others may feel uncomfortable dispensing medical marijuana as it will require developing new skills and obtaining new knowledge to provide patients the best care possible. 

With medicinal cannabis potentially being dispensed from pharmacies, it is very important that pharmacists receive education and training to help them prepare for a potential role in medical marijuana dispensing.

What are your thoughts? Do you feel prepared?

Note: There are medical marijuana continuing education options available for pharmacists and other healthcare professionals.

• Medical Cannabis Certificate Program (11 hours, $995 CAD)
• Medical Cannabis IQ: The Fundamentals (1.5 hours, $99 CAD)
• Core Knowledge of the Endocannabinoid System (11 hours, $995 CAD)   
• Medical Cannabis IQ: The Fundamentals (1.5 hours, $99 CAD)

Ontario pharmacists can have their continuing education costs subsidized with the help of allied health professional development funds from HealthForceOntario ($1,500 per year). 

References

1. The Canadian Press. (2017, November 13). Shoppers Drug Mart posts job for medical marijuana brand manager. CBC News. Retrieved from http://www.cbc.ca/news/canada/toronto/shoppers-marijuana-brand-manager-1.4400944

2. Baker, J. (2017, November 12). OPINION: Ontarians trust pharmacists to dispense medicinal cannabis, data shows. Toronto Sun. Retrieved from http://torontosun.com/opinion/columnists/columnist-ontarians-trust-pharmacists-to-dispense-medicinal-cannabis-data-shows

Installing Virus Protection Software

Hello rxBriefCase,

No, I am not referring to the software you install to protect your computer from a virus, but rather the influenza vaccination you provide patients to protect them from the flu. This blog post will provide an overview of important guideline recommendations and answers to common questions.

Recommendations to Remember

• Two Doses for Children to Start: Any child getting vaccinated for the first time between the ages of 6-months through-8 years-old, will requires two doses, at least four weeks apart.^1,2,3 It is recommended that children get their first dose as soon as the vaccine is available for the season.¹

• FluMist Recommendation Change: FluMist, the intranasal vaccine (LAIV4), is no longer the preferred vaccine for children.^1,2,3 This means that either the injection or the intranasal vaccination can be used for children, without preference.^2,3 Though more child friendly, the intranasal formulation is not considered to have superior effectiveness.² Alberta and Saskatchewan have stopped covering this intranasal option under their immunization program.⁹ Read more: Flu shot or nasal spray?

• Preferred Vaccine in Children: Children under the age of 18 are recommended to receive the quadrivalent vaccine.^2,3 The trivalent vaccine provides protection against three different flu viruses (2A, 1B), compared to the quadrivalent which protects from four strains (2A, 2B). The quadrivalent vaccine is recommended for kids under the age of 18 because the morbidity and mortality resulting from B strains is higher in that age group versus the adult population.^2,3

• Pregnancy and Flu Shots: Pregnant women may receive any licensed and recommended (consider age) influenza vaccine.^3,4 Data shows the influenza vaccination does not lead to any pregnancy complications or birth defects.⁴ Note: LAIV should not be used in pregnancy.³

• Egg Allergy and Flu Shots: An allergy to eggs is no longer a contraindication for flu shots. ^2,3 Studies have shown that the use of chicken embryos in the production of the vaccine do not create any issues for patients with egg allergies.⁵ Patients with an allergy to eggs, like all other patients, should be observed for 15 minutes after receiving the flu shot.^1,5 Read more: Algorithm for patients with egg allergies

• New Vaccine Available for Seniors: There is a new high dose trivalent vaccine (Fluzone High Dose) available for seniors (65+). This vaccine is currently not covered by any province, but it was just announced that it will be covered in Ontario next year.^2,3,6 The high dose vaccine is four times as potent. It is suggested for the elderly due to the high disease burden of influenza and their declining immune response.³ The high dose vaccine is predicted to help create a stronger immune response and be more effective for seniors.^2,3 Canadian Association of Retired Persons (CARP) supports the high dose vaccine: There’s a new flu vaccine available this year, just for Canadians 65+ (Video)

Common Questions from Patients

When is the best time for me to get the flu shot?

It is recommended to get the vaccine before the onset of influenza cases in the community or by the end of October.^1,3 However, getting the vaccine later in the flu season can still be beneficial.^1,3

Will the flu shot give me the flu?

No, it will not. You may experience a low-grade fever, aches, or some injection site soreness, redness and swelling.⁷ 

Why did I get the flu even though I got the flu shot?

The flu shot does not guarantee 100% protection, but it is the best way to try and protect yourself and others.⁸ There are a few possible reasons why you may have gotten the flu despite getting vaccinated. You may have been exposed to the flu virus before you got the flu shot or during the two weeks it takes your body to create antibodies which help provide the protection.⁸ Also, the virus you may have been exposed to might not have been included in the vaccine for that season.⁸ The vaccine provides protection for the most common circulating strains, but not all strains.⁸ Furthermore, the protection one gets depends on their overall health and age. ⁸

Helpful Links to Help Update Your Influenza Knowledge:

Giving the Flu Shot? Here's 5 Things to Know 5 Things to Know (Video)

Frequently Asked Flu Questions 2017-2018 Influenza Season

References

1. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2017–18 Influenza Season. MMWR Recomm Rep 2017;66 (No. RR-2):1–20. DOI: http://dx.doi.org/10.15585/mmwr.rr6602a1.
2. Bhaidani, S. [Hey Pharmacist]. (2017, October 4). Giving the Flu Shot? Here's 5 Things to Know
3. [Video File]. Retrieved from https://www.youtube.com/watch?v=F4P9kyOOY_Q&t=216s
4. National Advisory Committee on Immunization. Advisory Committee Review: Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2017-2018: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-statement-seasonal-influenza-vaccine-2017-2018.html
5. Centre for Disease Control and Prevention. (2017, September 19). Flu Vaccine Safety and Pregnancy. Retrieved from https://www.cdc.gov/flu/protect/vaccine/qa_vacpregnant.htm
6. Centre for Disease Control and Prevention. (2016, September 2). Flu Vaccine and People with Egg Allergies. Retrieved from https://www.cdc.gov/flu/protect/vaccine/egg-allergies.htm#algorithm-graphic
7. Ministry of Senior Affairs. (2017, November 7). Aging with Confidence: Ontario’s Action Plan for Seniors. Retrieved from https://news.ontario.ca/oss/en/2017/11/aging-with-confidence-ontarios-action-plan-for-seniors.html
8. Centre for Disease Control and Prevention. (2016, August 25). Seasonal Flu Shot Question and Answers. Retrieved from https://www.cdc.gov/flu/about/qa/flushot.htm
9. Centre for Disease Control and Prevention. (2017, October 26). Frequently Asked Flu Questions 2017-2018 Influenza Season. Retrieved from https://www.cdc.gov/flu/about/season/flu-season-2017-2018.htm
10. Mulholland, A. (2017, October 16). Flu shot or nasal spray? Conflicting studies lead to confusion. Retrieved from http://www.ctvnews.ca/health/flu-shot-or-nasal-spray-conflicting-studies-lead-to-confusion-1.3633892

Who Am I and What Am I Doing Here?

Hello rxBriefCase,

My name is Puja Modi and I am a final year student at the University of Toronto - Leslie Dan Faculty of Pharmacy. Like many students that preceded me, I am here completing a 5-week rotation as part of my Advanced Pharmacy Practice Experience (APPE) placements. These APPE rotations have offered me opportunities to apply my knowledge and gain experience that will help me with my future pharmacy career.

With graduation looming, everyone keeps asking me the same big question – where do you see yourself working? Currently, my answer is that I have not yet decided. The uncertainty stems from the fact that I have enjoyed all my past pharmacy placements and learned something valuable from each opportunity. My previous experiences include community pharmacy, hospital pharmacy, public health and safety research. This rotation at rxBriefCase is different from my former experiences and will allow me to expand my skill sets into the world of continuing education (CE).

No matter where I end up, I know that continuing education will always be a part of my career, as it is very important to stay up to date. This rotation will allow me to understand the landscape of CE in Canada, accreditation standards of the Canadian Council on Continuing Education in Pharmacy (CCCEP), and the role of pharmacists in CE development. I will also have the opportunity to refine my critical analysis and medical writing skills. I will be improving these skills by completing a critical appraisal of a CE program, writing an eNewsletter, developing a module for MedSchoolForYou and continuing to blog on my experiences and trending topics in the pharmacy world.

Some random facts about me:

• I love to travel - my most memorable trips were to India (3 months) and Europe (3 weeks)
• Hobbies of mine include dancing, photography and NETFLIX (next show: Stranger Things)
• I am a big foodie who is constantly eating – I am always open to suggestions for the best places to dine in Toronto

Keep an eye out for my next post!

- Puja Modi 

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

References

1. (n.d.). Retrieved September 20, 2017, from http://www.canadianhealthcarenetwork.ca/pharmacists/news/canadas-first-national-e-prescribing-platform-goes-live-40568
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 Informatics, 3(1), e2. http://doi.org/10.2196/medinform.3541

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:

• “Ouch! My back is killing me! Managing Mild to Moderate Pain 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

References

1. Beeby, D. (2017, September 11). Health Canada aims for prescription-only codeine pills, syrups. Retrieved September 15, 2017, from http://www.cbc.ca/news/politics/codeine-opiate-prescription-health-canada-juurlink-pharmacists-ban-sales-1.4284013

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 portions - Don’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:

• Advanced Obesity Management Program – An in-depth look at obesity management ($495 CAN)
• Canadian Obesity Network: Certified Bariatric Educator Final Exam – The Advanced Obesity Management Program is a prerequisite ($295 CAN)

- Ajay Chahal

References
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

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:

• “Medical Cannabis Certificate Program” – a comprehensive look at cannabis. ($995 CAD)
• “Medical Cannabis IQ: The Fundamentals” – a quick review of the fundamentals of cannabis. ($99 CAD)

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

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 5^th 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

References

1. Spolarich, A. E. (2015, April 18). Commonly Prescribed Medications and Managing the Oral Side Effects of Medication Use. Retrieved August 23, 2017, from http://www.sdha.ca/wp-content/uploads/2014/10/Pharmacology-Handout-Dr.-Ann-Spolarich.pdf

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”

-Unknown

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

-Mena

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.”

-Unknown

Thanks for reading. Until next time!

Mena

Natural Does Not Equal Safe

What is the number one reason some people choose a natural health product (NHP) over a pharmaceutical one? Safety!

It’s a common misconception that a natural product is safer than a “chemical/synthetic” one. There are several natural substances that are toxic and even deadly, like arsenic, lead and venom, just to name a few. Many people fall into this trap and end up choosing a product that is less effective for one they think is safer but it may not be as safe as they think.

 Recently an article was published in the Canadian Medical Association Journal criticizing Health Canada for its leniency when it comes to approving natural health products. The editor of the journal, Dr. Matthew Stanbrook, was quoted as saying "They simply have to show that someone, somewhere once used this as therapy for something". He went on to claim that manufacturers of NHPs have to stop advertizing  that their products are remedies because they have very little evidence for their actual efficacy.  Furthermore, the director of general of natural and nonprescription health products for Health Canada stated that “Health Canada has the power to recall a bag of chips, but does not have the power to recall an unsafe natural health product”.

There is clearly a big safety and efficacy gap that needs to be filled at Health Canada regarding NHPs. I used to think that even though NHP efficacy was questionable their safety was not, but now I’m not so sure.  Thankfully, Health Canada is currently reviewing the regulations that govern the sale of self-care products, which includes NHPs. All products, whether they are termed “natural” or pharmaceutical should follow the same strict and rigorous testing to ensure our safety.  Just because something is chemical doesn’t mean it isn’t natural and just because something is natural doesn’t mean it’s safe.

Link to CBC news article: http://www.cbc.ca/news/canada/toronto/medical-journal-takes-aim-at-natural-remedies-1.4174165

“Chemistry begins in the stars. The stars are the source of the chemical elements, which are the building blocks of matter and the core of our subject.”

Peter Atkins