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Clinical Pearl: Student reflection on Pride Month & 2SLGBTQIA+ advocacy during pharmacy school

 

June 2, 2023

By: Holly Wingate 

This article was written and researched by a CSHP student member for Interactions, our biweekly newsletter. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the student to select topics that are of interest and utility to both the student and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca.

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With June being Pride Month, we have the opportunity to reflect on the history of Pride Month, and its importance in being celebrated each year. In reflecting, I hope to give my perspective as a student on Pride and share ideas on how pharmacy students can advocate for the 2SLGBTQIA+ population during school years, all year round.

Background: Pride month

Why is Pride Month Important to Celebrate Each Year? 

In a time where many individuals are incredibly vocal on their beliefs, regardless of which ‘side’ they stand on, I feel we can get caught up talking about issues such as homophobia or 2SLGBTQIA+ care discrepancies, but this is often where our learning ends. While Stonewall occurred more than 50 years ago, we still celebrate Pride Month each June, and for good reason. Firstly, Pride Month is a recurring opportunity for everyone to learn about the 2SLGBTQIA+ population and see the joy in finding a community that supports one and one’s happiness. This type of learning can change lives both as an observer and as the individual who is experiencing it. For other members of the community, Pride Month allows them to be visible to those who choose to deny the truth of their existence, and to commemorate those before them that were unable to celebrate, and live authentically.5 Finally, it can be a time for some 2SLGBTQIA+ members where extreme pride replaces the feelings of shame or fear, truly impacting self-confidence and self-worth. In this way, Pride Month can be life changing. As I reflect on my own experiences, I have always felt Pride Month to be extremely joyful. Each year, it reminds me that we’re still here, no matter how invisible some may want us to be. It gives me the confidence to be honest and open with those around me. It is also a time to showcase the issues 2SLGBTQIA+ members experience, such as conversion therapy, the right to marry, and health discrepancies. Though it may feel that these issues are far removed, I will remind readers that Bill C-4, which banned conversion therapy in Canada, was only passed in 2021 and took three attempts to be approved.6 It is incredibly important to keep one-self up to date with 2SLGBTQIA+ challenges, and Pride Month is a great time for such learning to occur. I feel Pride Month is incredibly important to celebrate, especially for those who do not identify as a member of the 2SLGBTQIA+ population. In celebrating Pride Month as a heterosexual person, one is creating a space in the community of support for 2SLGBTQIA+ members for yourself and others. You are in a unique position where you can offer a safe space to members when they need it most.  

As health care providers, I believe we have a duty to all our patients to ensure we are entering care without biases and ready to treat equitably, regardless of who is in front of us. While some individuals today may feel homophobia has ‘quieted’ in health care, I reflect that it may be quite contrary. In Jessica Sheard’s Clinical Pearl: Clinical considerations and creating safe spaces for 2SLGBTQ+ patients, we see care discrepancies that may occur from homophobia are still rampant in today’s health care system. I highly recommend readers refer to this Clinical Pearl to see the impact those discrepancies have on individuals accessing health care. I feel as a healthcare provider, it is important to stay active in educating oneself to provide culturally safe and up-to-date care. Celebrating Pride Month as a health care provider may allow one to confront unconscious biases, which is an important part of being able to provide equitable care. In my early days of pharmacy education, I learned that it is “okay” to have biases, but it is “not okay” to do nothing to change them. Health care providers are the people who individuals turn to address their health needs, and we must be able to care for them as best we can. 

A Students Perspective: Pride and Advocacy during Pharmacy School  

• Check in with your internal biases, and self-direct to online materials to stay educated. This can include courses, readings, or webinars. I recommend looking into national associations such as the CPhA, as they often offer free resources to supplement learning and are trustworthy sources.  
• Subscribe to online 2SLGBTQIA+ news outlets to stay up-to-date on 2SLGBTQIA+ issues. These online news outlets are great for providing bite-sized news on the go, or you can take the time to read through entire articles on their websites.  
• Use social media to advocate for care discrepancies and gender-inclusive care, as it is highly impactful in accessing 2SLGBTQIA+ youth. Use your platform to promote local resources, such as pharmacies, 2SLGBTQIA+ community centers, and more. 
• As you work in pharmacy, keep resources available for patients to take, such as brochures or information sheets of nearby community resources. Be aware of which local resources are near your pharmacy for your patients. 
• Keep 2SLGBTQIA+ care discrepancies in the forefront of our minds at students, and respectfully offer to educate preceptors and managers on 2SLGBTQIA+ issues, and ways to continue delivering gender-inclusive, safe and equitable care in the workplace. Some ways to provide this care include asking about and using correct pronouns, avoiding dead-naming, and more.  

References

1.  The First Pride Was a Riot: The Origins of Pride Month. American University, College of Arts & Sciences News; 2022 Jun 10 [cited 2023 May 29]. Available from: https://www.american.edu/cas/news/the-first-pride-was-a-riot.cfm 
2. Why Is Pride Month Celebrate in June? Encyclopedia Britannica; 2022 May 27 [cited 2023 May 29]. Available from: https://www.britannica.com/story/why-is-pride-month-celebrated-in-june 
3. The History of Pride: How Activists Fought to Create LGBTQ+ Pride. The Library of Congress; n.d. [cited 2023 May 29]. Available from: https://www.loc.gov/ghe/cascade/index.html?appid=90dcc35abb714a24914c68c9654adb67 
4. History of Canadian Pride. Queer Events; 2021 [cited 2023 Jun 1]. Available from: https://www.queerevents.ca/canada/pride/history  
5. Celebrating Pride Month: We asked readers to define why celebrating Pride is important to them. Here is what they said. The Washington post; 2021 Jun 23 [cited 2023 May 29]. Available from: https://www.washingtonpost.com/nation/2021/06/11/pride-month-2021-celebration/ 
6. Proposed changes to Canada’s Criminal Code relating to conversion therapy. Government of Canada; 2021 Nov 29 [cited 2023 May 29]. Available from: https://www.justice.gc.ca/eng/csj-sjc/pl/ct-tc/index.html 

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The CSHP Foundation is now accepting applications for education grants in the following categories:

• Thematic Conferences Development: organization of a targeted group that will focus on issues in pharmacy practice and/or education.
• Educational Programs or Materials Development for Pharmacists:  development of resources for pharmacists with a focus on optimizing pharmacotherapy.

Two education grants, maximum $5,000 each have been allotted for 2023.

Eligible education proposals will reflect CSHP members’ innovative approaches to identifying or developing opportunities for professional education, dialogue, and knowledge transfer for pharmacists. The ultimate goal of each program will be to advance pharmacy practice and patient care in hospitals and other collaborative healthcare settings.

Education Grant Applicant Criteria
The principal applicant must be a CSHP Member, Member-in-Training, or Student Supporter and have been a CSHP member for at least 12 months at the time of the grant application.  Only one grant application may be submitted each year, and the principal applicant may only be awarded a grant every two years. See Criteria and Submission Checklist for further criteria.
 
Full details on the education grant program and the application process are available on the CSHP Foundation website at: https://cshp-scph.ca/foundation-education-grants.
 
Submissions for the Education Grants require the following components:

1. Criteria and Submissions Checklist (checklist document on Foundation website)
2. Title page (see Checklist document for details on what the title page should contain)
3. Written proposal (see Checklist document for details on what the written proposal should contain)
4. Grant Budget and Justification (budget template on Foundation website)
5. Curriculum vitae of the Principal Applicant
6. Letter(s) of support from applicant’s employer(s).

Additional information is also available on the CSHP Foundation website:

• Criteria for Evaluation of Submissions
• Education Grant Program Description

APPLY: To apply for a 2023 Education Grant, please submit all application documents in PDF format to Rosemary Pantalone electronically at rpantalone@cshp.ca
QUESTIONS: Please direct inquiries to Rosemary at the above-noted e-mail address.
DEADLINE DATE: Submissions must be received by October 16, 2023.

Grant decisions will be announced in January 2024.

The CSHP Foundation supports research and educational programs that advance pharmacy practice and patient care in hospitals and other collaborative healthcare settings. The Foundation raises funds that are used to: promote research, advance pharmaceutical science and programs of pharmaceutical education.

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Resource Spotlight: Environmental sustainability of Inhalers

May 16, 2023
Written by Layne Liberty

 

This article was written and researched by a CSHP student member for Interactions, our biweekly newsletter. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the student to select topics that are of interest and utility to both the student and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca

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Background

Asthma and chronic obstructive pulmonary disease (COPD) are two of the most common respiratory diseases with 3.8 million Canadians over the age of one living with asthma and two million living with COPD.1 Both conditions require the use of inhaler therapies to reduce morbidity and mortality.2 Many medications for these conditions are delivered using a pressurized metered dose inhaler (pMDI) which contain potent greenhouse gases (GHG) called hydrofluoroalkanes (HFA), or also known as hydrofluorocarbons (HFC).2 The GHG emitted from pMDI devices contribute to the carbon footprint of healthcare, which is estimated to be responsible for 4.6% of Canada’s total GHG emissions (equivalent to over thirty-three million tonnes of carbon dioxide equivalents).3  Other options for inhaled medications include dry powder inhalers (DPI) and soft mist inhalers (SMI), which both do not contain HFCs, and therefore, have a lower carbon footprint.2 While reducing the use of pMDIs may have positive impacts on the environment, changing therapies has implications for patients; thus, considerations such as inspiratory flow rate, handling capabilities, individual preference and financial constraints must be kept in mind. This resource spotlight aims to provide awareness, evidence and education about the environmental impact of inhalers to help pharmacists begin implementing environmentally sustainable practices. To learn more about the environmental impact of inhalers, check out the Canadian Society of Hospital Pharmacist (CSHP) recent Clinical Pearl article here. 

External Resorces

Unless otherwise noted, the Canadian Society of Hospital Pharmacists (CSHP) does not endorse or imply endorsement of the resources provided here. These resources are provided without warranty of any kind, either expressed or implied. It is the responsibility of the user of the resource to judge its suitability for his or her particular purpose within the context of his or her practice and the applicable legislative framework. In no event shall CSHP or any persons involved in providing the resource be liable for damages arising from its use. Resources are free unless otherwise indicated.  

Canadian Resources

Creating A Sustainable Canadian Health System In A Climate Crisis (CASCADES) 

CASCADES is a national collaborative project supporting the transition to a net zero carbon emission and climate resilient Canadian health care system. The website has a repository of guides, patient friendly infographics and tools regarding environmentally sustainable prescribing of inhaled therapies, such as: 

1. The Inhaler Primer Series provides a detailed overview of the environmental impact of inhalers and outlines options to mitigate and reduce the carbon footprint of inhalers
2. The Inhaler Playbook provides a guide to sustainable inhaler use in primary care including a prescribing pathway with considerations for switching to alternative therapies, patient education and disposal
3. A detailed inhaler comparison chart that compares available inhalers in Canada by carbon footprint, cost prior to coverage and provincial and territorial coverage status to support ease of sustainable prescribing 
4. A quick reference chart to support the switch to alternative low carbon footprint inhalers for adults 
5. A webinar on the climate impact of inhalers that provides education on proper asthma diagnosis, current guidelines, appropriate patient specific inhaler prescribing and logical switches to lower carbon footprint inhalers 

Health Product Stewardship Association (HPSA) 

HPSA runs a free medication return program through community pharmacies in BC, Manitoba, Ontario and PEI. It provides guidance for community pharmacies on how to implement these programs and guidance to consumers on safe disposal practices. This program is not available for hospitals or long-term care facilities; however, it is a useful resource for hospital pharmacists to refer patients to when counselling on inhaler medications and discussing proper disposal practices.  

European Resources

National Institute For Health And Care Excellence (NICE) 
NICE provides guidance and develops evidence-based recommendations to support best practices for the National Health Services (NHS) in the United Kingdom (UK). NICE has published a patient decision aid to help healthcare professionals and patients with asthma choose an appropriate inhaler while also considering the carbon footprint of treatment. It provides answers to common questions about switching inhaler treatments and is meant to support the shared decision making between the patient (over 12 years old) and healthcare professional.

Prescribing Always Includes Consideration Of Quality, Innovation, Productivity And Prevention (PrescQIPP) 

PrescQIPP is a not-for-profit social enterprise with the aim of supporting quality prescribing in the NHS. PrescQIPP has a repository of information on Bulletin 295: Inhaler carbon footprint such as: 

1. A guidance document that provides suggestions for inhaler optimisation and support for healthcare professionals to start or switch patients to low carbon footprint inhalers. It also provides education around the impact and importance of proper inhaler disposal.  
2. A tool designed for patient understanding that compares the carbon footprint of inhalers using easy to understand symbols and visuals.

Inhaler Life Cycle Assessment  
A sustainability evidence review of Carbon Footprints and Life Cycle Assessments of Inhalers was published in 2022. This paper provides an overview of the carbon footprint of pMDIs, DPIs and SMIs from creation of the active primary ingredient (API) all the way to end of life and disposal phase. The results show that the carbon footprint varies depending on which DPI is used and that the carbon footprint from DPI and SMIs is primarily due to the API and manufacturing stages of the life cycle, while pMDI is from the use and end of life phase.  

References

1. Public Health Agency of Canada. Report from the Canadian chronic disease surveillance system: asthma and chronic obstructive pulmonary disease (COPD) in Canada [Internet]. Ottawa: Government of Canada Publications; 2018. 61 p. Available from: https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/asthma-chronic-obstructive-pulmonary-disease-canada-2018/pub-eng.pdf 
2. Pernigotti D, Stonham C, Panigone S, Sandri F, Ferri R, Unal Y et al Reducing carbon footprint of inhalers: analysis of climate and clinical implications of different scenarios in five European countries. BMJ Op Resp Res. 2021;8(1):1-11. Available from: doi: 10.1136/bmjresp-2021-001071 
3. Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis. PLOS Medicine. 2018;15(7):1-16. Available from: https://doi.org/10.1371/journal.pmed.1002623  

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Clinical Pearls: The environmental impact of inhalers 

May 9, 2023

By: Layne Liberty

This article is part of a series appearing in Interactions, our biweekly newsletter, written and researched by CSHP's students. We've created this series as a valuable learning activity for pharmacy students undertaking rotations at CSHP. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the students to select hot topics that are of interest and utility to both the students and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca.

Role Of The Pharmacist

Pharmacists are leaders in healthcare and with Canada’s recently updated nationally determined contribution to reduce emissions by 40-45% below 2005 levels by 2030 and to reach net zero carbon emissions by 2050, its essential that pharmacist begin advocating and incorporating environmental sustainability into their practice.13 There is a growing number of resources and education available to aid healthcare providers in transitioning to prescribing and suggesting alternative low carbon inhalers, one being the primer and playbooks supplied by Creating A Sustainable Canadian Health System In A Climate Crisis (CASCADES).  Pharmacists are in a unique position to educate prescribers, colleagues, and patients on environmentally sustainably practices including the proper use and disposal of inhalers, and alternative therapies available. Pharmacist led interventions in the hospital such as initiating smoking cessation, conducting medication reviews, inhaler technique training, and reviewing asthma and COPD action plans have all been proven to improve disease management, adherence, and quality of life outcomes.14,15,16 COPD and asthma are often primarily managed in the community; however, a patient admitted to the hospital presents an opportunity for the hospital pharmacist to make appropriate interventions.17Acute exacerbations of COPD, which are the main reason for unscheduled hospital admissions, exert a significant impact on patients’ quality of life as it accelerates disease progression and leads to increased mortality.17 Asthma exacerbations also have a negative impact on quality of life, as it contributes to lung function decline, systemic effects, and mortality.18 Pharmacists have the knowledge and ability to make interventions like education and training on inhaler technique and could take it one step further by implementing environmentally conscious practices like education on proper medication disposal, suggesting alternative low carbon inhalers and promoting de-prescribing where clinically appropriate. 

Pharmacist led interventions to reduce the environmental impact of inhalers include the following:

Life Cycle Assessment of Inhalers and Ensuring Proper Disposal
Life cycle assessments have been completed on the different inhaler devices to determine the amount of GHG emitted during each phase from manufacturing to patient use to disposal. As mentioned, the GHGs emitted from the propellants in pMDIs are very potent, and from data presented in Table 1, an inhaler regimen for one patient over one year (3 salbutamol pMDIs and 12 Advair pMDIs) can be estimated to be the same as driving a gas car 1498km (that’s equivalent to a roadtrip from Banff, AB to Winnipeg, MB).19 The use and the disposal phase for a pMDI makes up approximately 85% of the total CFP, while the main contribution to the CFPs for the DPI/SMI inhalers are from the API and during the manufacturing stages of the life cycle20. If the manufacturing phases are the only contributing factor considered, then on average, the inhalers with the largest CFP are still pMDIs.20 In a study that compared the CFPs of tiotropium bromide (Spiriva®) Respimat® (both disposable and reusable devices) and ipratropium bromide (Atrovent®) pMDI, it was noted that ipratropium had a CFP that was 20 times greater than the disposable Respimat® device.21 The disposal phase of the Respimat® is the largest contributor to its CFP, so refill cartridges have been introduced to help mitigate the impact.22 The reusable Respimat® device can be refilled up to 6 times before the device needs to be replaced.22For example, if a patient is prescribed the Spiriva Respimat®, then this would translate into reducing the number of inhalers per year per patient from 12 to 2. 

Incorrect inhaler technique reduces the delivery of medication into the patients' lungs which is associated with poor disease outcomes, increased hospital admissions, increased healthcare costs and medication waste, all contributing to a larger environmental impact.15 Assessing a patient's appropriate inhaler technique allows pharmacists to assess therapeutic safety and efficacy and provides an opportunity to suggest environmentally conscious alternatives. Pharmacist led inhaler training has been proven to be effective with improvement in patient disease management and maintenance of proper technique.24,25,26 Although study results on improper inhaler technique vary, a study conducted in Canada found that 59% of study participants made critical errors (removing cap/lid/opening mouthpiece before administration, shaking MDI before use and inhaling properly depending on type used), while using their inhalers.27 Patients using pMDIs were also more likely to make critical errors in administration (93%) compared to patients using DPIs/SMIs (39%).27 The main critical errors in pMDI use were the actuation of the device and proper inhalation, which are common mistakes as patients are consistently unable to coordinate these two steps.27Assessing a patient's inspiration ability and hand dexterity are essential as a major component of a pMDIs CFP comes from the patient use phase. Incorrect pMDI inhaler technique not only leads to uncontrolled disease, it also causes an excess in propellant outflow and a higher requirement of reliever and maintenance canisters per year, both contributing to pMDIs environmental impact.9 Utilizing a spacer device with a pMDI in patients that have difficulty inspiring at the correct speed and depth can help mitigate this issue by slowing down drug delivery and reducing medication waste.9 Another issue with pMDI that affects patients and the environment, is the lack of a dose counter on the device. Without a dose counter, patients are more likely to throw away half full canisters or continue to use empty inhalers.9  Many patients use methods to test for the presence of medication like spraying into the air to see if medication comes out, which is incorrect, as the spray may just be leftover propellant.28 Education and counselling on proper dose counting methods such as keeping track of the doses administered for maintenance inhalers (dividing the total doses in the inhaler (found on the box) by the total number of doses per day), and reliever inhalers (write down the doses used after every administration) can help mitigate these issues.28
 

Recommend Alternate Inhaler Therapies
The National Health Services (NHS) in the United Kingdom (UK) has done extensive research on the environmental impact of inhalers and is aiming to reduce the carbon impacts of inhalers by 50% by 2030.29 0The Canadian healthcare system and health care providers can learn from this plan and join the NHS in making strides towards reducing healthcare’s environmental impact. Metered dose inhalers comprise 75% of the total amount of inhalers prescribed in Canada and the United States.9 Reliever medications like salbutamol (short-acting beta-2 agonist (SABA)) and ipratropium (short-acting muscarinic-antagonist (SAMA)) come in pMDI canisters and are commonly prescribed due to their treatment versatility (e.g. used for symptom management caused by conditions other than asthma and COPD) and low cost. Reliever and maintenance therapy metered dose inhaler prescriptions account for approximately 0.03% of annual global GHG emissions.9 and the carbon footprint of two doses of a salbutamol pMDI has been estimated to be approximately 500 g CO₂e.19 In comparison, the CO₂e emissions of a nine-mile car trip (approximately 14km) is estimated to be 2610 g CO₂eq (only 5 puffs of a salbutamol pMDI).19 When these values are scaled up to a population level, one can understand how patients with uncontrolled respiratory disease are significantly contributing to GHG emissions. Metered dose inhaler use is a double-edged sword, because although it helps patients maintain control of their respiratory symptoms and disease, it also contributes to deteriorating air quality. Poor air quality is known to be a significant trigger for patients with respiratory disease and leads to increased risk of exacerbations and poor symptom control. Recommending alternative therapies is not as simple as just switching to a more environmentally conscious choice, there are other considerations to keep in mind such as commercial availability, economic burden, drug coverage and patient preference (e.g. ease of use, hand dexterity and strength of lungs). DPI and SMI devices carry a significantly lower environmental burden so switching to these devices when clinically appropriate is recommended.19 For example, fluticasone propionate/salmeterol combination is available as a pMDI and a DPI, so depending on the patients’ dose, this switch could help lower the carbon footprint. Other examples of switching to low carbon inhaler alternatives are described in Figure 119 and the CFP of commonly prescribed inhalers is found in Figure 2.19,20

 

Ensure Proper Diagnosis And Promote De-prescribing Where Clinically Possible

COPD requires spirometry testing before definitive diagnosis with a post-bronchodilator forced expiratory volume in one second to forced vital capacity (FEV1/FVC) ratio < 70%.30 Diagnosing COPD just based on symptoms contributes to unnecessary treatment, patient psychological stress and overprescribing of inhalers.30 Asthma is diagnosed based on respiratory symptoms in addition to evidence of variable expiratory airflow limitation, tested by either peak flow or spirometry.31  A Canadian study of 613 patients with an asthma diagnosis in the last 5 years were re-tested with home peak flow and symptom monitoring, spirometry, and serial bronchial challenge tests.32 It was discovered that 33% of the participants did not have asthma and after 12 months of follow-up, 30% patients still showed no clinical or lab evidence of asthma.32  Similarly, overdiagnosis of COPD is common and it has been estimated that 1 in every 3 patients do not have COPD.33,34,35 A population-based cohort study found that of 1403 randomly selected patients from Ontario (taken from the Canadian Cohort Obstructive Lung Disease (CanCOLD) study) 5.1% of patients did not have COPD, while only 3.7% had correctly diagnosed COPD.36  Additionally, the over diagnosed COPD patients had significantly higher rates of hospitalizations, emergency department visits and ambulatory care visits.36 Another study in Ontario from 2000-2010 of 491,754 patients with newly diagnosed COPD found that only about one-third received spirometry prior to diagnosis.37 The Canadian Thoracic Society emphasizes the importance of de-prescribing inhaler therapies if the patient has not had a clinical benefit or confirmation of reversible airflow limitation through spirometry or peak flow testing.30The misdiagnosis and overprescribing of inhaler treatments increases risk for patient adverse effects and contributes to the use of healthcare resource and waste production. Focusing on more thorough diagnosis practices, gathering in-depth patient medical history and inquiring about inhaler effectiveness to the patient can all contribute to decreasing the CFP of the healthcare sector. 
 

Summary

The prevalence of asthma and COPD is expected to increase as the population ages and people are exposed to more environmental pollutants due to climate change. Asthma and COPD carry a significant environmental burden due to pMDI use, misdiagnosis and incorrect inhaler use. The use and disposal phase for pMDIs make up approximately 85% of the total pMDI CFP, so switching to inhalers mentioned in this article that have a lower CFP, and ensuring proper medication disposal, will contribute to mitigating the environmental impact of inhalers. In addition, pharmacists should ensure proper inhaler techniques through education and training and question the diagnosis of COPD and asthma when clinically appropriate. Utilizing this information during practice and consistently considering the environmental impact of medications will help push for changes in practice, therapeutic guidelines, and organizational policy (e.g. purchasing practices and formulary choice).

Figure 1. Examples of common inhalers and their low carbon alternatives. Switching from one inhaler to another is only suggested when clinically appropriate and through patient shared decision making. All data presented below is adapted to Canadian equivalents from information provided in the NHS Devon Formulary Guide.19

Image designed by Layne Liberty using free access to canva.com

 

Figure 2. Carbon footprint comparisons of commonly prescribed inhalers. 

All data presented below is adapted to Canadian equivalents from information provided in the NHS Devon Formulary Guide19 and PrescQUIPP21   

Image designed by Layne Liberty using free access to canva.com

 

References

1.  Public Health Agency of Canada. Report from the Canadian chronic disease surveillance system: asthma and chronic obstructive pulmonary disease (COPD) in Canada [Internet]. Ottawa: Government of Canada Publications; 2018. 61 p. Available from: https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/asthma-chronic-obstructive-pulmonary-disease-canada-2018/pub-eng.pdf
2. Ehteshami-Afshar S, FitzGerald JM, Doyle-Waters MM, Sadatsafavi M. The global economic burden of asthma and chronic obstructive pulmonary disease. The International Journal of Tuberculosis and Lung Disease. 2016;20(1):11-23. Available from: https://doi.org/10.5588/ijtld.15.0472
3. Hurst JR, Siddiqui MK, Singh B, Varghese P, Holmgren U, de Nigris E. A systematic literature review of the humanistic burden of COPD. International Journal of Chronic Obstructive Pulmonary Disease. 2021;16:1303-14. Available from: https://doi.org/10.2147/copd.s296696
4. Starup-Hansen J, Dunne H, Sadler J, Jones A, Okorie M. Climate change in healthcare: exploring the potential role of inhaler prescribing. Pharmacology Research & Perspectives [Internet]. 2020;8(6). Available from: https://doi.org/10.1002/prp2.675
5. Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: an economic-environmental-epidemiological analysis. PLOS Medicine. 2018;15(7):e1002623. Available from: https://doi.org/10.1371/journal.pmed.1002623
6. D'Amato G, Cecchi L, D'Amato M, Annesi-Maesano I. Climate change and respiratory diseases. European Respiratory Review. 2014;23(132):161-9. Available from: https://doi.org/10.1183/09059180.00001714
7. Jiang XQ, Mei XD, Feng D. Air pollution and chronic airway diseases: what should people know and do? J Thorac Dis. 2016;8(1):E31-40. doi: 10.3978/j.issn.2072-1439.2015.11.50
8. Keeley D, Scullion JE, Usmani OS. Minimizing the environmental impact of inhaled therapies: problems with policy on low carbon inhalers. European Respiratory Journal. 2020;55(2):2000048. Available from: https://doi.org/10.1183/13993003.00048-2020
9. CASCADES Canada. Environmentally sustainable opportunities for health systems: Primer Series Inhalers. [Internet]. 2020 [updated 2021 Oct; cited 2023 Feb 22]. Available from: https://view.publitas.com/5231e51e-4654-42c2-accd-b722e21f3093/environmentally-sustainable-opportunities-for-health-systems-primer-series-inhalers/page/12-13
10. Woodcock A, Beeh KM, Sagara H, Aumônier S, Addo-Yobo E, Khan J, Vestbo J, Tope H. The environmental impact of inhaled therapy: making informed treatment choices. European Respiratory Journal [Internet]. 2022:60 (1) 2102106. Available from: https://doi.org/10.1183/13993003.02106-2021
11. Lindh A, Theander K, Arne M, Lisspers K, Lundh L, Sandelowsky H, Ställberg B, Westerdahl E, Zakrisson A. Errors in inhaler use related to devices and to inhalation technique among patients with chronic obstructive pulmonary disease in primary health care. Nursing Open [Internet]. 2019;6(4):1519-27. Available from: https://doi.org/10.1002/nop2.357
12. AL-Jahdali, H, Ahmed, A, AL-Harbi, A, Khan M, Baharoon S, Salih S, Halwani R et al. Improper inhaler technique is associated with poor asthma control and frequent emergency department visits. Asth Clin Immun 2013:9(8) Available from: https://doi.org/10.1186/1710-1492-9-8
13. Environment and Climate Change Canada. Government of Canada [Internet]. Canada’s enhanced nationally determined contribution; 2021. Available from: https://www.canada.ca/en/environment-climate-change/news/2021/04/canadas-enhanced-nationally-determined-contribution.html
14. Bridgeman MB, Wilken LA. Essential Role of Pharmacists in Asthma Care and Management. Journal of Pharmacy Practice. 2021;34(1):149-162. doi:10.1177/0897190020927274
15. Hudd TR. Emerging role of pharmacists in managing patients with chronic obstructive pulmonary disease. American Journal of Health-System Pharmacy. 2020;77(19):1625-30. Available from: https://doi.org/10.1093/ajhp/zxaa216
16. Jia X, Zhou S, Luo D, Zhao X, Zhou Y, Cui Y. Effect of pharmacist‐led interventions on medication adherence and inhalation technique in adult patients with asthma or COPD: a systematic review and meta‐analysis. Journal of Clinical Pharmacy and Therapeutics [Internet]. 2020 Feb 27 [cited 2023 Feb 23];45(5):904-17. Available from: https://doi.org/10.1111/jcpt.13126
17. Lin G, Zheng J, Tang PK, Zheng Y, Hu H, Ung COL. Effectiveness of Hospital Pharmacist Interventions for COPD Patients: A Systematic Literature Review and Logic Model. Int J Chron Obstruct Pulmon Dis. 2022;17:2757-2788.
18. Rennard SI, Farmer SG. Exacerbations and progression of disease in asthma and chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2004;1(2):88-92. doi: 10.1513/pats.2306026
19. North and East Devon Formulary and Referral. Northeast Devon Formulary Guidance NHS [Internet]. The environmental impact of inhalers. Available from: https://northeast.devonformularyguidance.nhs.uk/formulary/chapters/3.-respiratory/the-environmental-impact-of-inhalers#:~:text=Carbon%20footprint,can%20contribute%20to%20global%20warming.
20. Fulford B, Mezzi K, Aumônier S, Finkbeiner M. Carbon footprints and life cycle assessments of inhalers: a review of published evidence. Sustainability. 2022;14(12):7106. Available from: https://doi.org/10.3390/su14127106
21. PrescQIPP; Homan K. Inhaler carbon footprint 2.2 [Internet]. [place unknown: publisher unknown]; 2021;24 p. Available from: https://www.prescqipp.info/umbraco/surface/authorisedmediasurface/index?url=/media/5719/295-inhaler-carbon-footprint-22.pdf
22. Hänsel M, Bambach T, Wachtel H. Reduced Environmental Impact of the Reusable Respimat® Soft Mist™ Inhaler Compared with Pressurised Metered-Dose Inhalers. Adv Ther. 2019 Sep;36(9):2487-2492. doi: 10.1007/s12325-019-01028-y
23. Health Product Stewardship Association. Health Products Stewardship Association [Internet]. Returning Medications - Health Products Stewardship Association. Available from: https://healthsteward.ca/consumers/returning-medications/.
24. Nguyen TS, Nguyen TLH, Pham TTV, Hua S, Ngo QC, Li SC. Pharmacists' training to improve inhaler technique of patients with COPD in Vietnam. Int J Chron Obstruct Pulmon Dis. 2018;13:1863-1872
25. Katsurada, M., Nagano, T., Nakajima, T., Yasuda, Y., Miwa, N., Sekiya, R., Kobayashi, K., Hojo, D., & Nishimura, Y. Retrospective analysis of the effect of inhaler education on improvements in inhaler usage. Respiratory investigation. 2021; 59(3): 312-319 . 
26. Capstick TG, Burnley M, Higgins H. P234 Improving in inhaler technique: a community pharmacy service. 
27. Batterink J, Dahri K, Aulakh A, Rempel C. Evaluation of the use of inhaled medications by hospital inpatients with chronic obstructive pulmonary disease. Can J Hosp Pharm. 2012 Mar;65(2):111-8. doi: 10.4212/cjhp.v65i2.1118
28. Gerald L, Dhand R. Patient education: Inhaler techniques in adults (Beyond the Basics). In: Basow, DS editor. UpToDate. Waltham, MA: UpToDate; 2021.
29. NHS Greater Glasgow and Clyde Area Drug and Therapeutics Committee. GGC Medicines: Home [Internet]. GGC Medicines: sustainability: reducing the environmental impact of inhalers; 2021. Available from: https://ggcmedicines.org.uk/blog/medicines-update/sustainability-reducing-the-environmental-impact-of-inhalers/.
30. Canadian Thoracic Society. Choosing Wisely Canada [Internet]. Respiratory Medicine- Seven Tests and Treatments to Question. Available from: https://choosingwiselycanada.org/recommendation/respiratory-medicine/.
31. Reddel HK, Bacharier LB, Bateman ED, Brightling C, Brusselle G, Buhl R, et al. Global Initiative for Asthma (GINA) Strategy 2021 - Executive summary and rationale for key changes. Eur Respir J 2021; in press (https://doi.org/10.1183/13993003.02730-2021)
32. Aaron SD, Boulet LP, Reddel HK, Gershon AS. Underdiagnosis and Overdiagnosis of Asthma. Am J Respir Crit Care Med. 2018 Oct 15;198(8):1012-1020. doi: 10.1164/rccm.201804-0682Cl
33. Walters JA, Walters EH, Nelson M, Robinson A, Scott J, Turner P, Wood-Baker R. Factors associated with misdiagnosis of COPD in primary care. Prim Care Respir J. 2011;20(4):396-402. doi: 10.4104/pcrj.2011.00039
34. Zwar NA, Marks GB, Hermiz O, Middleton S, Comino EJ, Hasan I, Vagholkar S, Wilson SF. Predictors of accuracy of diagnosis of chronic obstructive pulmonary disease in general practice. Med J Aust. 2011;195(4):168-71. doi: 10.5694/j.1326-5377.2011.tb03271.x.
35. Starren ES, Roberts NJ, Tahir M, O'Byrne L, Haffenden R, Patel IS, Partridge MR. A centralised respiratory diagnostic service for primary care: a 4-year audit. Prim Care Respir J. 2012;21(2):180-6. doi: 10.4104/pcrj.2012.00013. 
36. Gershon AS, Thiruchelvam D, Chapman KR, Aaron SD, Stanbrook MB, Bourbeau J, Tan W, To T. Health services burden of undiagnosed and overdiagnosed COPD. Chest. 2018;153(6):1336-46. Available from: https://doi.org/10.1016/j.chest.2018.01.038
37. Gershon AS, Hwee J, Croxford R, Aaron SD, To T. Patient and physician factors associated with pulmonary function testing for COPD. Chest. 2014;145(2):272-81. Available from: https://doi.org/10.1378/chest.13-0790
    
     

Latest News

Latest News

Resource Spotlight: PTSD and trauma-informed care

April 21, 2023

 

Written by CSHP Student

This article was written and researched by a CSHP student member for Interactions, our biweekly newsletter. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the student to select topics that are of interest and utility to both the student and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca

---

Background

Canada has one of the highest rates of post-traumatic stress disorder (PTSD) in the world, with 8% Canadian adults meeting the criteria for probable PTSD. PTSD can have significant consequences on patients’ mental health, quality of life, and mortality. As a result of a growing awareness on the effects of trauma and PTSD, trauma-informed care (TIC) has emerged in recent years as a principle-based framework that aims to improve support and outcomes for those living with trauma. This “Resource Spotlight” contains links to associations and guidelines that help pharmacists learn more about PTSD and trauma informed care, along with helpful resources to share with patients. To learn more about PTSD and trauma informed care, check out CSHP’s recent Clinical Pearls article on PTSD and trauma-informed care.

External Resorces

Unless otherwise noted, the Canadian Society of Hospital Pharmacists (CSHP) does not endorse or imply endorsement of the resources provided here. These resources are provided without warranty of any kind, either expressed or implied. It is the responsibility of the user of the resource to judge its suitability for his or her particular purpose within the context of his or her practice and the applicable legislative framework. In no event shall CSHP or any persons involved in providing the resource be liable for damages arising from its use. Resources are free unless otherwise indicated.  

CAMH

The Centre for Addiction and Mental Health (CAMH) located in Toronto, is Canada’s largest mental health and addictions teaching hospital. Their website features a wealth of resources for PTSD patients and healthcare providers including clinical and self-assessment tools, a summary of pharmacotherapies for PTSD, trauma resources (Ontario based), and mental health resources for healthcare workers. This webinar posted on their site also offers a great introduction to trauma informed care and provides some strategies for healthcare providers on how they can be implement TIC in their practice. 

CMHA

The Canadian Mental Health Association (CMHA) is a non-profit organization that aims to advocate for and provide mental health resources and support for Canadians nationwide. Their website offers many resources for those struggling with PTSD and other mental health problems including links to national crisis services, online mental health courses, programs such as Resilient Minds™, which is a peer-to-peer skills development program that educates fire fighters on resilience and provides them with the skills to respond to trauma in their workplace, and information on various mental health conditions, including one on PTSD.

Government of Canada

This webpage on the Government of Canada website can direct patients with PTSD to resources across the country. Some of the notable resources include a help line for Indigenous peoples seeking mental health support or crisis intervention, substance use and harm reduction services, provincial and territorial resources for mental health support, and Wellness Together Canada, a 24/7 support program funded by the Government of Canada for people with concerns regarding mental health or substance use.

Alberta Health Services TIC Training Modules

The Trauma Informed Care (TIC) e-Learning Series is a series of seven self-study online modules developed by Alberta Health Services (AHS) for their Trauma Training Initiative. Each module can be completed in 30 minutes or less and covers foundational topics relevant to TIC such as how to understand and recognize trauma and how to implement TIC. Non-AHS staff can obtain a certificate of participation by completing all the modules, required pre- and post-competency surveys, and certificate request form. A second part of the Trauma Training Initiative exists as a series of five three-hour online workshops that serves to enhance healthcare providers’ knowledge of TIC and provide additional strategies for how they can better support patients living with trauma. These three-hour workshops are currently only available to AHS staff.

Trauma-informed.ca

The Manitoba Trauma Information and Education Centre has put together a useful trauma informed toolkit made for service organizations and providers. It features extensive information on trauma-informed practices and PTSD, offers guidelines, and shares links to provincial trauma resources. 

Federal Framework on Posttraumatic Stress Disorder (PTSD)

In 2019, the Government of Canada published the first Federal Framework on Posttraumatic Stress Disorder (PTSD) to recognize the great impact that PTSD has on Canadians. The document is extensive and guides future direction for how the government can support those affected by PTSD. Some useful information embed within the document include background information on PTSD in the Canadian context, insight on PTSD initiatives currently underway to support high-risk populations and individuals, and links to clinical practice guidelines, including the latest national guidelines for PTSD published by the Anxiety Disorders Association of Canada in 2014.

PTSD Coach

PTSD Coach Canada is a free mobile app developed by Veterans Affairs Canada. While originally designed for veterans and military service members, anyone affected by PTSD may find the education, Canadian based resources, and tools to help manage symptoms within the app beneficial. It is not a meant to be a substitute for psychotherapy or medication for PTSD; however, it can be recommended as a convenient resource to supplement professional care.  

Latest News

Latest News

Clinical Pearls: PTSD and trauma-informed care 

April 11, 2023

By CSHP Pharmacy Student

This article is part of a series appearing in Interactions, our biweekly newsletter, written and researched by CSHP's students. We've created this series as a valuable learning activity for pharmacy students undertaking rotations at CSHP. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the students to select hot topics that are of interest and utility to both the students and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca.

• Recurrent distressing memories, nightmares, and flashbacks related to the traumatic event(s).5
• Intense feelings of distress and/or physiological reactions to internal or external reminders of the traumatic event(s).5
• Avoidance of distressing thoughts or the avoidance of external reminders of the traumatic event(s) (e.g., people, locations, objects, situations) that arouse distressing memories, thoughts, and feelings.5
• Negative changes to cognition and mood (e.g., persistent negative beliefs of oneself, others, or the world, feelings of detachment, or inability to experience positive emotions).5
• Changes in arousal and reactivity (e.g., hypervigilance, exaggerated startle response, and insomnia).5

PTSD symptoms may vary in frequency and severity between individuals; however, prior to obtaining a formal diagnosis of PTSD, all individuals must have experienced their symptoms for at least one month, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).5

Canada has one of the highest rates of PTSD in the world, with 8% of Canadian adults meeting the criteria for probable PTSD.2,6 Worldwide, the prevalence of PTSD differs among certain populations. Some populations that may be at higher risk of PTSD include survivors of sexual violence, women, younger adults, military veterans, and racially and culturally marginalized individuals.2,3,7-10 Furthermore, PTSD has been associated with an increased risk of substance use disorders, chronic diseases, co-morbid mental health conditions, accelerated aging, hospitalization, and suicide.1,11,12 Despite this, a cross-national survey found that only half of respondents reported seeking any kind of treatment.1 

Treatments

Currently, there is no specific treatment, psychological or pharmacological, that promises a cure for PTSD. However, there are several different treatments available that can help alleviate symptoms and make PTSD more manageable for affected individuals. Initial treatment of PTSD usually involves the use of trauma-focused psychotherapy, as recommended by national guidelines.11,13 Meta-analyses of over 30 randomized controlled trials (RCTs) of psychotherapies have found trauma-focused cognitive-behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR) therapy, stress management, and group TFCBT to be effective for managing PTSD compared to control.11,14,15 Other approaches include prolonged exposure (PE) therapy and cognitive processing therapy (CPT).11 Efficacy between psychotherapies are comparable; thus, the choice of psychotherapy should be a shared decision between the patient and the healthcare provider.11,16

Although psychotherapy is the recommended first-line treatment for PTSD, depending on availability, patient preference and circumstances, pharmacotherapy may also be considered as first-line treatment.13,17 For example, patients with comorbid conditions such as depression may start with pharmacological treatment until their symptoms are stable.13,16 Following improvement of symptoms, psychotherapy may be introduced; however, the benefit of combining the use of psychotherapies and pharmacotherapies requires further research.11, 13,16 One RCT found there to be no difference in efficacy between combination therapy of sertraline plus PE therapy and PE therapy plus placebo.18

The mechanism by which PTSD manifests itself physiologically is not entirely clear; however, studies have linked the dysregulation of neurotransmitters, reduced hippocampal volume, and genetic differences, to its pathophysiology and susceptibility in individuals.19, 20 First-line pharmacologic treatments for PTSD attempt to reduce the total severity of core symptoms (e.g., intrusive memories, avoidance, and hyperarousal) by targeting neurotransmitter imbalances.13 Currently, there is evidence from RCTs and meta-analyses to support the use of the selective serotonin reuptake inhibitors (SSRIs) fluoxetine, paroxetine, and sertraline and the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine as first-line agents.11 See the table below for an overview of the current pharmacologic recommendations. 

Table 1. Examples of recommended pharmacologic therapies for PTSD 11

Antidepressants such as mirtazapine, fluvoxamine, and phenelzine have shown evidence of efficacy in reducing the total severity of the core intrusion, avoidance, and hyperarousal symptoms of PTSD in smaller RCTs and are considered second-line agents accordingly.11 For patients with suboptimal responses to first-line options, providers can consider the addition of second-generation antipsychotics such as aripiprazole, olanzapine, and quetiapine to treatment plans.13Furthermore, providers can consider augmenting first-line agents with medications such as prazosin and trazadone: Several studies have shown evidence for the use of the alpha1-adrenergic antagonist prazosin in reducing traumatic nightmares, and the antidepressant trazadone is recommended in a number of PTSD clinical guidelines to treat insomnia.11,13  

Despite evidence to support the use of these therapies for PTSD, many patients do not find success in available treatments.30 In one meta-analysis comparing psychotherapies and pharmacotherapies for PTSD, researchers found that the average drop-out rate across all 55 studies included in their search was 29%.30 Reasons for treatment discontinuation vary greatly, ranging from difficulties to tolerating the use of traumatic images in trauma-focused psychotherapy31, to adverse events in SSRIs.17,32 Because of these potential challenges to current treatments, there has been a push in recent years to explore different agents as possible alternatives.13,33,34 Cannabis has been proposed as an alternative treatment for PTSD for its ability to increase serotonin and dopamine levels in the brain.13,35 Similarly, MDMA, which is the active ingredient in the illicit drug Ecstasy/Molly, has been proposed for its ability to reduce activity in the amygdala, the structure in the brain that processes fearful memories and emotions, and increase serotonin release.33,34 However, due to the limited evidence to support these two agents, they currently cannot be recommended to treat PTSD.13,33 Benzodiazepines (BZDs), while not a newly explored agent in PTSD research, has historically been widely prescribed to treat anxiety and insomnia.36 However, like cannabis and MDMA, BZDs are not recommended; this is due to their lack of efficacy in improving core PTSD symptoms37, sleep disturbances38, and their addictive properties.13

What is trauma-informed care?

Trauma-informed care (TIC) is a term that has recently risen in popularity in various mental health and addiction, medical, educational, and correctional settings.3,39 TIC relies on the concept that integrating the knowledge of the impact of trauma into all levels of care and services leads to improved support and outcomes for people living with trauma.3,39 Essentially, TIC provides a way for understanding how trauma affects people which can then be used to create policies and programs that promote a culture of safety and empowerment for those affected by trauma.12 The four key elements of TIC, as outlined in a 2014 initiative by the Substance Abuse and Mental Health Services Administration, include: realizing the widespread impact of trauma, recognizing the common reactions to trauma in both patients and staff, and responding by integrating knowledge about trauma into all levels of organizational structure to resist re-traumatization.40

In the hospital pharmacy setting, one example of TIC could include recognizing how trauma can affect medication adherence.41 A recent meta-analysis found that PTSD is associated with increased non-adherence, especially within the context of medical-event induced traumas such as those stemming from stroke or cancer diagnoses.42 A TIC framework can aid pharmacists in realizing when trauma may be affecting treatment outcomes and help them work with patients to adjust their treatment plans and goals accordingly.39,43 In a real-world example outlined in the American Journal of Health-System Pharmacy, clinical pharmacist Jennifer Cocohoba at the University of California, Women’s HIV Program, shared how she approached developing a treatment plan for a patient whose husband had died from an adverse drug reaction.44 Because of the patient’s trauma regarding taking medication, instead of starting them on an optimal medication regimen, Cocohoba had them start with small doses until they were be comfortable with introducing the optimal antiretroviral therapy at a later date.44 Other examples of TIC that are non-exclusive to hospital pharmacy could include having a list of referral sources to trauma services readily available to all patients, using welcoming and inclusive language on all signage, and encouraging self-care practices among staff.39,45

Despite the rise in popularity of TIC3,12, evidence to support its role in improving patient outcomes to date has been limited.39,46 Nonetheless, it is well known that trauma and PTSD can have significant consequences on patients’ mental health, quality of life, and mortality.11 It is important that policymakers and pharmacists alike are aware of emerging trauma frameworks like TIC so that evidence-based best practices can be developed that will achieve positive patient outcomes.   

References

1. Koenen KC, Ratanatharathorn A, Ng L, et al. Posttraumatic stress disorder in the World Mental Health Surveys. Psychol Med. 2017;47(13):2260-2274. doi:10.1017/S0033291717000708 
2. Statistics Canada. Survey on Mental Health and Stressful Events, August to December 2021. Published May 20, 2022. Accessed January 16, 2023. https://www150.statcan.gc.ca/n1/daily-quotidien/220520/dq220520b-eng.htm 
3. Lee E, Kourgiantakis T, Lyons O, Prescott-Cornejo A. A trauma-informed approach in Canadian mental health policies: A systematic mapping review. Health Policy. 2021;125(7):899-914. doi:10.1016/j.healthpol.2021.04.008 
4. Trauma. Centre for Addiction and Mental Health. Accessed January 13, 2023. https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/trauma 
5. Diagnostic And Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association; 2013. Accessed January 13, 2023. https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596 
6. Dückers MLA, Alisic E, Brewin CR. A vulnerability paradox in the cross-national prevalence of post-traumatic stress disorder. The British Journal of Psychiatry. 2016;209(4):300-305. doi:10.1192/bjp.bp.115.176628 
7. Scott KM, Koenen KC, King A, et al. Post-traumatic stress disorder associated with sexual assault among women in the WHO World Mental Health Surveys. Psychol Med. 2018;48(1):155-167. doi:10.1017/S0033291717001593 
8. Public Health Agency of Canada. Federal framework on posttraumatic stress disorder: recognition, collaboration and support. Published January 22, 2019. Accessed January 16, 2023. https://www.canada.ca/en/public-health/services/publications/healthy-living/federal-framework-post-traumatic-stress-disorder.html#s1-3 
9. Jude Mary Cénat, Rose DD, Wina PD, Kogan CS, Guerrier M. Prevalence of current PTSD symptoms among a sample of black individuals aged 15 to 40 in canada: The major role of everyday racial discrimination, racial microaggresions, and internalized racism. Can J Psychiatry. :07067437221128462. https://doi.org/10.1177/07067437221128462. doi: 10.1177/07067437221128462 
10. Bennett A, Crosse K, Ku M, Edgar NE, Hodgson A, Hatcher S. Interventions to treat post-traumatic stress disorder (PTSD) in vulnerably housed populations and trauma-informed care: A scoping review. BMJ Open. 2022;12(3):e051079. http://bmjopen.bmj.com/content/12/3/e051079.abstract. doi: 10.1136/bmjopen-2021-051079. 
11. Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14 Suppl 1(Suppl 1):S1. doi:10.1186/1471-244X-14-S1-S1 
12. Alberta Health Services. Trauma-Informed Care. Published August 5, 2022. Accessed January 24, 2023. https://ahamms01.https.internapcdn.net/ahamms01/Content/AHS_Website/tms/amh/if-amh-tic-module-1-an-introduction-to-trauma-informed-care/story_content/external_files/if-pspp-tic-module-1-introduction.pdf 
13. Richardson JD, Marlborough M. Post-traumatic stress disorder. In: Compendium of Therapeutic Choices. Canadian Pharmacists Association. Updated April 16, 2021. Accessed January 13, 2022. https://www.myrxtx.ca 
14. Bisson JI, Ehlers A, Matthews R, Pilling S, Richards D, Turner S. Psychological treatments for chronic post-traumatic stress disorder: Systematic review and meta-analysis. The British Journal of Psychiatry. 2007;190(2):97-104. doi:10.1192/bjp.bp.106.021402 
15. Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2007;(3):CD003388. Published 2007 Jul 18. doi:10.1002/14651858.CD003388.pub3 
16. Stein MB. Management of posttraumatic stress disorder in adults. In: Roy-Byrne P, ed. UpToDate. UpToDate; 2022. Accessed January 16, 2023. https://www.uptodate.com/contents/management-of-posttraumatic-stress-disorder-in-adults 
17. Martenyi F, Soldatenkova V. Fluoxetine in the acute treatment and relapse prevention of combat-related post-traumatic stress disorder: Analysis of the veteran group of a placebo-controlled, randomized clinical trial. European Neuropsychopharmacology. 2006;16(5):340-349. doi: 10.1016/j.euroneuro.2005.10.007. 
18. Rauch SAM, Kim HM, Powell C, et al. Efficacy of Prolonged Exposure Therapy, Sertraline Hydrochloride, and Their Combination Among Combat Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2019;76(2):117-126. doi:10.1001/jamapsychiatry.2018.3412 
19. Sherin JE, Nemeroff CB. Post-traumatic stress disorder: the neurobiological impact of psychological trauma. Dialogues Clin Neurosci. 2011;13(3):263-278. doi:10.31887/DCNS.2011.13.2/jsherin 
20. Sareen J. Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis. In: Stein MB, ed. UpToDate. UpToDate; 2022. Accessed January 24, 2023. https://www.uptodate.com/contents/posttraumatic-stress-disorder-in-adults-epidemiology-pathophysiology-clinical-manifestations-course-assessment-and-diagnosis 
21. Antidepressant, selective serotonin reuptake inhibitors. In: Lexi-Tox. Lexi-Comp, Inc. Updated December 13, 2021. Accessed January 17, 2023. https://online.lexi.com 
22. Jensen B, Regier L. Anxiety disorder medication: Drug comparison chart. August 2021. Accessed January 17, 2023. Available from www.rxfiles.ca 
23. Venlafaxine. In: Lexi-Drugs. Lexi-Comp, Inc. Updated January 19, 2023. Accessed January 19, 2023. https://online.lexi.com 
24. Mirtazapine. In: Lexi-Drugs. Lexi-Comp, Inc. Updated January 19, 2023. Accessed January 19, 2023. https://online.lexi.com 
25. Phenelzine. In: Lexi-Drugs. Lexi-Comp, Inc. Updated January 19, 2023. Accessed January 19, 2023. https://online.lexi.com 
26. Phenelzine product monograph. Montreal (QC): Searchlight Pharma Inc; October 4, 2022. https://pdf.hres.ca/dpd_pm/00067659.PDF 
27. Aripiprazole product monograph. Sain-Laurent (QC): Otsuka Canada Pharmaceutical Inc; February 11, 2021. https://pdf.hres.ca/dpd_pm/00060025.PDF 
28. Quetiapine. In: Lexi-Drugs. Lexi-Comp, Inc. Updated January 19, 2023. Accessed January 19, 2023. https://online.lexi.com 
29. Trazodone. In: Lexi-Drugs. Lexi-Comp, Inc. Updated January 19, 2023. Accessed January 19, 2023. https://online.lexi.com 
30. Lee DJ, Schnitzlein CW, Wolf JP, Vythilingam M, Rasmusson AM, Hoge CW. PSYCHOTHERAPY VERSUS PHARMACOTHERAPY FOR POSTTRAUMATIC STRESS DISORDER: SYSTEMIC REVIEW AND META-ANALYSES TO DETERMINE FIRST-LINE TREATMENTS. Depress Anxiety. 2016;33(9):792-806. doi:10.1002/da.22511  
31. Lewis C, Roberts NP, Gibson S, Bisson JI. Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: systematic review and meta-analysis. Eur J Psychotraumatol. 2020;11(1):1709709. Published 2020 Mar 9. doi:10.1080/20008198.2019.1709709 
32. Friedman MJ, Marmar CR, Baker DG, Sikes CR, Farfel GM. Randomized, double-blind comparison of sertraline and placebo for posttraumatic stress disorder in a Department of Veterans Affairs setting. J Clin Psychiatry. 2007;68(5):711-720. doi:10.4088/jcp.v68n0508 
33. Smith KW, Sicignano DJ, Hernandez AV, White CM. MDMA-Assisted Psychotherapy for Treatment of Posttraumatic Stress Disorder: A Systematic Review With Meta-Analysis. J Clin Pharmacol. 2022;62(4):463-471. doi:10.1002/jcph.1995 
34. Feduccia AA, Jerome L, Yazar-Klosinski B, Emerson A, Mithoefer MC, Doblin R. Breakthrough for Trauma Treatment: Safety and Efficacy of MDMA-Assisted Psychotherapy Compared to Paroxetine and Sertraline. Front Psychiatry. 2019;10:650. Published 2019 Sep 12. doi:10.3389/fpsyt.2019.00650 
35. Rehman Y, Saini A, Huang S, Sood E, Gill R, Yanikomeroglu S. Cannabis in the management of PTSD: a systematic review. AIMS Neurosci. 2021;8(3):414-434. Published 2021 May 13. doi:10.3934/Neuroscience.2021022 
36. Lader M. Benzodiazepines revisited--will we ever learn?. Addiction. 2011;106(12):2086-2109. doi:10.1111/j.1360-0443.2011.03563.x 
37. Braun P, Greenberg D, Dasberg H, Lerer B. Core symptoms of posttraumatic stress disorder unimproved by alprazolam treatment. J Clin Psychiatry. 1990;51(6):236-238. 
38. Cates ME, Bishop MH, Davis LL, Lowe JS, Woolley TW. Clonazepam for treatment of sleep disturbances associated with combat-related posttraumatic stress disorder. Ann Pharmacother. 2004;38(9):1395-1399. doi:10.1345/aph.1E043 
39. Raja S, Hasnain M, Hoersch M, Gove-Yin S, Rajagopalan C. Trauma informed care in medicine: current knowledge and future research directions. Fam Community Health. 2015;38(3):216-226. doi:10.1097/FCH.0000000000000071 
40. Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of trauma and guidance for a trauma-informed approach. Published July 2014. Accessed January 24, 2025. https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4884.pdf 
41. Kronish IM, Edmondson D, Li Y, Cohen BE. Post-traumatic stress disorder and medication adherence: results from the Mind Your Heart study. J Psychiatr Res. 2012;46(12):1595-1599. doi:10.1016/j.jpsychires.2012.06.011 
42. Taggart Wasson L, Shaffer JA, Edmondson D, et al. Posttraumatic stress disorder and nonadherence to medications prescribed for chronic medical conditions: A meta-analysis. J Psychiatr Res. 2018;102:102-109. doi:10.1016/j.jpsychires.2018.02.013 
43. Fernandes O, Toombs K, Pereira T, Lynder C, Bjelajac Meijia A, Shalansky S, et al. Canadian consensus on clinical pharmacy key performance indicators: quick reference guide. Published 2015. Accessed January 17, 2023. https://www.cshp.ca/docs/pdfs/CSPH-Can-Concensus-cpKPI-QuickReferenceGuide_June_2017.pdf   
44. Traynor K. Clinic views patients through trauma-informed lens. Am J Health Syst Pharm. 2019;76(19):1454-1455. doi: 10.1093/ajhp/zxz177.  
45. Center for Health Care Strategies. Key ingredients for successful trauma-informed care implementation. Published April 2016. Accessed Feb 2, 2023. https://www.samhsa.gov/sites/default/files/programs_campaigns/childrens_mental_health/atc-whitepaper-040616.pdf 
46. Han HR, Miller HN, Nkimbeng M, et al. Trauma informed interventions: A systematic review. PLoS One. 2021;16(6):e0252747. Published June 22, 2021. doi:10.1371/journal.pone.0252747 
    
     
     
    
     

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CSHP is searching for our next CPRB Coordinator

April 3, 2023

 

 

Coordinator, Canadian Pharmacy Residency Board

 Apply now

 

 

Position Summary

 

The incumbent will coordinate the work of the Canadian Pharmacy Residency Board (CPRB) and CPRB-accredited pharmacy residency programs which operate within the Canadian Society of Hospital Pharmacists. The Coordinator is responsible for the operations of the CPRB Board and committee meetings; the workflows of the accreditation, standards and the Pharmacy and Residency Application and Matching Service (PRAMS) programs; and the information system and communications functions required. This role reports directly to the Chief Pharmacy Officer, but requires close collaboration with the Chair, as well as other CPRB members and sub-committee members.

 

Responsibilities

• Administer and support the operations of the Canadian Pharmacy Residency Board, its members and committees.
• Organize the workflow of pharmacy residency program support, including accreditation, standards-setting, and the residency matching program.
• Handle communications with a variety of internal and external stakeholders and be responsible for the relevant information systems.

 

Partial list of duties

CPRB board and committee operations

• Manage all meeting logistics, including developing board and committee work plans and calendars, timely preparation and distribution of agendas, notifications, and advance reading material.
• Attend and serve as a recording secretary for board and as required, committee meetings, preparing and maintaining minutes, policies, and other public and confidential documents of the board and its committees in a timely manner.
• Communicate all decisions, actions, directives, and important information following board and committee meetings to the appropriate individuals or stakeholders.
• Anticipate and follow up on outstanding agenda items, taking action to ensure information is provided to the board and committee members.
• Liaise with CSHP Board administration to support CPRB’s Chair’s participation in meetings and draft written report and PowerPoint presentations for CSHP Board meetings.

Program Management

• Compile and report key metrics regarding residency programs (e.g., number of programs, residency programs, and ratio of applicants to matched applicants)
• Annually update CPRB documents, in collaboration with CPRB members (e.g., CPRB Accreditation Standards, Policy and Procedures, Strategic Business Plan) and coordinate translation
• Accreditation Surveys
  • Maintain and update survey schedule and documents as required
  • Act as liaison between residency programs and CPRB surveyors on survey processes and accreditation
  • Ensure that accreditation decisions are communicated promptly and accurately through program survey letters and formal final survey reports
• Liaise with external information services provider regarding enhancements and updates to PRAMS program
• Communicate with applicants and programs on application and matching process
• Contribute to the resolution of issues that arise during the application-matching process
• Standards
• Accreditation Surveys
  • Maintain strict version control and updates for CRPB Accreditation Standards
  • Ensure annual updates are translated and published to the CPRB website

Communications and Information Systems 

• Act as the CSHP office point of contact for accredited pharmacy residency programs, program applicants, and CPRB members
• Maintain the CPRB section of the CSHP website
• Manage Sharepoint site for CPRB and committees, including membership rosters, documents, permissions, etc.
• Liaise with appropriate CSHP staff on material for Interactions, Avenues for Education, Annual Reports, event scheduling, publicity, and promotions. 

Administrative

• Assist with and verify travel expense claims for volunteers and staff
• Liaise with finance for invoicing and payments
• Handle logistical arrangements and/or liaise with other CSHP staff for webinars and special events, such as the Student and Residency Networking event

 

Education

• Postsecondary education required. Equivalent experience will also be accepted.  

 

Skills and Experience

• 5 years of senior administrative roles including specialized knowledge of board governance procedures and project management experience, ideally in a non-for-profit organization
• Extensive computer and software skills, especially in Excel, PowerPoint, Sharepoint and database programs
• Accurate, detail-oriented, and high-quality outputs
• Multi-tasking skills and ability to be flexible when priorities shift
• Excellent oral and written communication skills
• Proactive problem-solving skills
• Ability to work with confidential and sensitive matters
• Fluency in both official languages an asset

Location and travel

• The position can be housed in the CSHP National Office in Ottawa or staffed remotely.
• Occasional travel within Canada is required.

Applications will be accepted on a rolling basis until the position is filled.

About the CPRB:
An affiliated board of the Canadian Society of Hospital Pharmacists, the Canadian Pharmacy Residency Board (CPRB) establishes standards and conducts accreditation surveys of pharmacy residency training programs in Canada. It also establishes policies and procedures that support those processes and develops education and research initiatives related to residency programs and residency training.

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• Compounding formulations
• Beyond-use dating
• Drug-drug and drug-material stability 
• Sterility testing
• And much more

• Discuss quality gaps in different health care settings
• Share quality improvement ideas to address the gaps
• Foster engagement and collaboration in quality improvement initiatives

• Supporting Pharmacists Providing Breast Cancer Care
• Supporting Pharmacists Providing Prostate Cancer Care

• General drug information requests
• Drug therapy topic reviews
• Drug-related policies and procedures

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Resource Spotlight: Schizophrenia

March 21, 2023
Written byMaria Ahmed

 

This article was written and researched by a CSHP student member for Interactions, our biweekly newsletter. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the student to select topics that are of interest and utility to both the student and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca

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Bacground

Schizophrenia is a mental disorder that can negatively alter the trajectory of an individual’s emotional, cognitive, and social development and manifest in adolescence. The course of schizophrenia can vary among individuals, but symptoms can range from hallucinations and delusions to reduced expression and cognitive impairment. This “Resource Spotlight” contains links to associations, guidelines, and foundations that help pharmacists learn about the schizophrenia spectrum and its management, and additional resources required to support patients. To get a summary of schizophrenia, check out CSHP’s recent Clinical Pearls article on Schizophrenia: An Overview. 

External Resources  

Unless otherwise noted, the Canadian Society of Hospital Pharmacists (CSHP) does not endorse or imply endorsement of the resources provided here. These resources are provided without warranty of any kind, either expressed or implied. It is the responsibility of the user of the resource to judge its suitability for his or her particular purpose within the context of his or her practice and the applicable legislative framework. In no event shall CSHP or any persons involved in providing the resource be liable for damages arising from its use. Resources are free unless otherwise indicated. 

Keep in mind, some resources are not Canadian and may not be translated into Canadian practices.

The Canadian Guidelines for the Assessment and Diagnosis of Patients with Schizophrenia Spectrum and Other Psychotic Disorders gives an in-depth view of the schizophrenia spectrum. It dives into diagnosis and presents recommendations within this patient demographic. It used the ADAPTE1 process and takes into consideration of the National Institute for Health and Care Excellence (NICE) guidelines, the Scottish Intercollegiate Guidelines Network, the European Psychiatric Association, and the American Psychiatric Association in order to highlight the national interventions that can be implemented in Canadian practice. 

The Guidelines for the Pharmacotherapy of Schizophrenia in Adults outlines the recommendations based of the National Institute for Health and Care Excellence (NICE) guidelines, the Scottish Intercollegiate Guidelines Network, the European Psychiatric Association, and the American Psychiatric Association via the ADAPTE1 process. It elaborates on the selection of antipsychotics, acute treatment, antipsychotic continuation, antipsychotic dose/ trial duration, acute exacerbation, relapse prevention, and treatment-resistant schizophrenia given specific symptoms.

The Canadian Guidelines for the Pharmacological Treatment of Schizophrenia Spectrum and Other Psychotic Disorders in Children and Youth summarizes the main international and local guidelines focused on adolescents. Similar to the previous resources, it used the ADAPTE1 process and takes into consideration of the National Institute for Health and Care Excellence (NICE) guidelines, the Scottish Intercollegiate Guidelines Network, the European Psychiatric Association, and the American Psychiatric Association. It expresses the general principles of care, the first exposure of psychosis, and hospital care within the children and youth population.

The Clinical Handbook of Psychotropic Drugs is a textbook written by Ric M. Procyshyn et al. that highlights the psychotropic medications currently available. Published in 2019, it has a dedicated chapter on antipsychotics, where it elaborates on the pharmacology, dosing, switching medications, warnings, precautions, monitoring parameters and patient-related issues within this medication class. It goes into depth of explaining extrapyramidal symptoms caused by antipsychotics and their management. This textbook is also available online through a subscription here.

A Canadian website called SwitchRx is a practical tool used by healthcare professionals to guide clinical practice and adjust a patient’s psychotropic treatment regimens. This tool was developed by PsychedUp, a company where programs are certified by the College of Family Physicians of Canada. This tool develops tapering and titration schedules, clinical tips, and additional pharmacokinetic properties related to the medications. Keep in mind, you need to register for free and set up an account first before accessing their resources. It is a tool that allows switching between antipsychotics, and antidepressants and combining strategies between medications. It also has a tool that helps guide healthcare professionals in weight management and switching hypnotics. In addition, it gives access to psychiatric scales and treatment guidelines.

The Schizophrenia Society of Canada started as a non-profit, charitable organization in Toronto and now has grown in order to support research related to schizophrenia and early psychosis (biological, psychological, spiritual, and social determinants of health). They provide educational content for patients and provide support in cannabis and psychosis, family recovery journey, and have a podcast called Look Again: Mental Illness Re-examined to shine a light on the voices in the mental illness community.

Early Psychosis Intervention is an online tool that includes representatives from BC Health Authorities, the Ministry of Health, and family/caregivers to provide a resource for the community. It provides educational content that explains the definition of psychosis, the importance of early intervention, diagnosis and associated issues, what family members need to know, and the recovery process. It also has various informational pamphlets for patients that range from connecting to people, stress management to taking care of your health.

The Psychiatric Survivors of Ottawa is a non-profit member-driven platform located in Ottawa that offers Peer Support Programs. These include the Wellness Recovery Action Plan sessions, peer support groups, walking groups, and much more. They also cater to caretakers and incorporate Family Peer Support Programs which include Family Peer Support Group seminars, and Family Wellness Recovery Action Plan. They also have online workshops for non-local caretakers called Family Dialogue about Communication.

1 - ADAPTE process is a systematic approach to adapting guidelines from one cultural and organizational context to another. The overall aim of the process is to take existing guidelines and enhance them to ensure the final recommendations address specific health questions relevant to the context. Click here for more information on ADAPTE.

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