The Profession of Pharmacy Chapter 1 The Profession of Pharmacy

Chapter 1 Topics Ancient Origins Pharmacist Pharmacy Technician Pharmacy Workplace of Today

Learning Objectives Describe the origins of pharmacy Describe the four stages of development of the pharmacy profession in the twentieth century Enumerate the functions of the pharmacist Discuss the educational curriculum for today’s pharmacy student Explain the licensing requirements for pharmacists Identify the duties and work environments of the pharmacy technician Differentiate among the various kinds of pharmacies

Ancient Origins Pharmacy comes from the Greek word pharmakon, meaning drug Scientific approach to medicine began with the ancient Greeks Hippocrates Proposed that disease came from natural, not supernatural causes Established the theory of humors (blood, phlegm, black bile, yellow bile)

Ancient Origins Galen Conducted animal experiments Produced a systematic classification of drugs for treatment of disease Galenical pharmacy described the process of creating extracts of active medicinals from plants Diascorides First century A.D. De Materia Medica (standard text on drugs for 1500 years)

Ancient Origins Dr. John Morgan Eighteenth Century Supported the separation of the professions of pharmacy and medicine

Terms to Remember pharmakon theory of humors galenical pharmacy De Materia Medica Learn more at American Institute of the History of Pharmacy (AIHP)

Discussion How has the profession and practice of pharmacy evolved since ancient times?

Pharmacist The profession of pharmacy exists to safeguard the health of the public The pharmacist is one who is licensed to prepare and dispense medications, counsel patients, and monitor outcomes pursuant to a prescription from a licensed health professional The role of the modern pharmacist evolved from compounder and dispenser to providing medication information and preventing medication-related problems

Evolution of the Pharmacist’s Role During the twentieth century, the pharmacy profession has evolved through four stages. Traditional Era Scientific Era Clinical Era Pharmaceutical-care Era

Traditional Era Early twentieth century Formulation and dispensing of drugs from natural sources Pharmacognosy The study of the medicinal properties of natural products of animal, plant, and mineral origins Galenical pharmacy Techniques for preparing medications

Scientific Era Began after World War II Emergence of the pharmaceutical industry Drugs made in factories, not apothecary shop Pharmacy education emphasized sciences Pharmacology The scientific study of drugs and their mechanism of action including side effects Pharmaceutics Release characteristics of drug dose forms

Clinical Era 1975: Millis Report, Pharmacists for the Future New educational emphasis on clinical (patient-oriented) pharmacy Pharmacokinetics the activity of a drug within the body over a period of time; includes absorption, distribution, metabolism, and elimination Pathophysiology the study of disease and illnesses affecting the normal function of the body

Pharmaceutical-Care Era 1990: Hepler and Strand defined Pharmaceutical care a philosophy that expanded the pharmacist’s role to include appropriate medication use to achieve positive outcomes with prescribed drug therapy includes Monitoring response to therapy Educating patients and dispensing prescriptions Visit the American Pharmacists Association (APhA)

Discussion How does the pharmaceutical care model affect the duties of pharmacists in the 21st Century? medication outcomes?

Terms to Remember pharmacist pharmaceutics pharmacognosy pharmacokinetics galenical pharmacy pathophysiology pharmacology pharmaceutical care

Role of the Pharmacist Today’s pharmacist: Compounds and dispenses drugs Gathers information about patients Counsels on possible side effects and adverse reactions Monitors for drug interactions Screens, monitors, and advises for self-treatment with over-the-counter (OTC) products sold without a prescription Provides drug information to other healthcare professionals Advises on home healthcare supplies and medical equipment

Community Pharmacist Dispenses drugs for exiting disease Involved in patient care initiatives to prevent or identify disease Administration of immunizations screening for and educating about hypertension, diabetes, and other conditions providing education about lifestyle choices and dietary supplements Runs a business hires and supervises employees deals with insurance companies maintains inventory

Hospital Pharmacist Dispenses oral medications Prepares and dispenses parenteral medications Sometimes specializes, with advanced training in an area of patient care Educates and counsels patients Provides drug information Administers a department develops policies and procedures purchases drugs and supplies monitors drug use in the hospital Learn more about hospital pharmacy at the web site of the American Society of Health-System Pharmacists (ASHP)

Home Healthcare Pharmacist Prepares medications and IVs for home delivery and use including IV nutrition and antibiotics cancer chemotherapy pain medications Educates patient or caregiver on appropriate and safe medication use Monitors patient’s response to prescribed therapies

Other Pharmacy Settings Health maintenance organization (HMO) Long-term care facilities Specialized practice psychiatry drug abuse Nursing homes geriatrics

Nuclear Pharmacy Nuclear pharmacist Procures, stores, compounds, dispenses, and provides information about radioactive pharmaceuticals used for diagnostic and therapeutic purposes Learn more about nuclear pharmacy at the Cardinal Web site

Education and Licensing Requirements 6 year program 2 years prePharmacy calculus, chemistry, biology Pharmacy College Admission Test (PCAT) Doctor of Pharmacy (PharmD) degree basic science courses practice setting experience Residency in specialty area is optional For a listing of accredited schools of pharmacy, visit the Web site for the American Association of Colleges of Pharmacy (AACP)

Education and Licensing Requirements required by all states overseen by board of pharmacy involves graduation form an accredited college of pharmacy passing state board certification examination serving an internship continuing education for license renewal

Discussion What are the differences and similarities between and among the various pharmacy practice settings? How does specialized training affect the role of the pharmacist?

Terms to Remember compounding over-the-counter (OTC)

Pharmacy Technician A pharmacy technician, also called the pharmacy tech, is an individual working in a pharmacy who, under the supervision of a licensed pharmacist, assists in pharmacy activities that do not require the professional judgment of a pharmacist. Regardless of practice setting, the pharmacy tech can assist with workload. The pharmacist provides the final check on the original prescription with the medication bottle and label before counseling the patient.

Evolution of the Pharmacy Technician’s Role Without pharmacy technicians, pharmacists would not have sufficient time for the duties involved in “pharmaceutical care.” counseling patients reviewing medication profiles monitoring for side effects and adverse reactions screening patients for disease discussing cost-effective drug therapy options with the prescriber

Evolution of the Pharmacy Technician’s Role Safety Note! Pharmacy technicians play a valuable role in reducing the risk of medication errors.

Evolution of the Pharmacy Technician’s Role Originally, many pharmacy techs were trained as medics in the military. returned after service to take positions in hospitals In community pharmacy the pharmacy tech evolved from clerk or cashier to a pharmacist’s assistant.

Evolution of the Pharmacy Technician’s Role A pharmacy technician assists the pharmacist with routine functions. leaves professional decision making and judgment calls to the pharmacist Technician activities may range from ordering, stocking, and inventorying drugs to preparing the IV order to assisting in the dispensing process. the pharmacist must always check his or her work the pharmacist is responsible for patient counseling the technician functions in strict accordance with standard written procedures and guidelines

Evolution of the Pharmacy Technician’s Role Safety Note! The pharmacy technicians works under the direction of the supervising pharmacist.

Evolution of the Pharmacy Technician’s Role Central defining feature of the technician’s job is accountability to the pharmacist for the quality and accuracy of his or her work. The essential differences in the duties of a pharmacist and a technician involve: accountability making decisions about the patient’s healthcare

Education and Licensing Requirements Most state boards of pharmacy recognize the existence and importance of the pharmacy technician. Each state board of pharmacy regulates: the activities of pharmacy technicians sometimes the ratio of pharmacy techs to pharmacists

Education and Licensing Requirements In the past, on-the-job training was sufficient for the tech working in a pharmacy. Now formal technician training programs train pharmacy technicians for their expanded roles. Initially centered in hospitals to train staff in the necessary functions of the hospital pharmacy. Now many programs are offered by community colleges and technical schools.

Education and Licensing Requirements ASHP developed a model curriculum to meet the needs of all practice settings. In some states pharmacy technicians must be certified to practice. Academic programs help to prepare the student to pass the certification exam For an up-to-date list of states requiring certification of pharmacy technicians, see the Pharmacy Technician Certification Board Web site

Discussion What is the relationship between the duties of the pharmacy technician and those of the pharmacist? How do the education and licensure of technicians and pharmacists relate to those duties?

Work Environments and Conditions Pharmacy technicians are employed in most of the same settings as pharmacists community pharmacies (i.e., drugstores) hospital pharmacies home healthcare and long-term care facilities specialized area of practice (e.g., nuclear pharmacy) with additional training

Work Environments and Conditions Pharmacy technicians usually work in clean, well-lighted, and well-ventilated environments. To ensure a sterile environment and minimize infectious disease, many techs in the hospital and other practice settings work either in a “clean room” or under specialized ventilation cabinets called laminar flow hoods when they prepare infusions, total parenteral nutrition, or cancer chemotherapy. Gowns, masks, hairnets, foot booties, and gloves are often needed in this environment.

Work Environments and Conditions Pharmacy tech work requires standing, often for long hours. Pharmacists and pharmacy technicians may be on call or work days, nights, weekends, and holidays. At any time, 24 hours a day, some number of the estimated 250,000 pharmacy technicians currently employed are on the job.

Characteristics broad knowledge of pharmacy practice A successful pharmacy technician must possess a wide range of skills, knowledge, and aptitudes. broad knowledge of pharmacy practice dedication to providing a critical healthcare service to customers and patients high ethical standards willingness to follow instructions eagerness to learn an eye for detail manual dexterity facility in basic mathematics excellent communication skills good research skills ability to perform accurately and calmly in hectic or stressful situations ability to multi-task or work on several projects at the same time

Discussion What makes each of the listed characteristics of a pharmacy technician important?

Terms to Remember Pharmacy technician Multi-task

Pharmacy Workplace of Today Pharmacists work primarily in community and hospital pharmacies Some go on to pursue further education and higher degrees, residencies, or fellowships Other fields include managed care, mail-order pharmacy, home healthcare, long-term care, nuclear pharmacy, academia, drug information, sales, marketing, or research. The need for both pharmacists and pharmacy technicians is expected to continue. new life-saving drugs increase in the aging population in the United States

Community Pharmacy Three fifths of all pharmacists in the United States work in a community pharmacy (retail pharmacy). an independent or chain pharmacy that dispenses prescription medications to outpatients

Community Pharmacy Most community pharmacies are divided into a back prescription area offering prescription merchandise and related items a front area offering over-the-counter (OTC) drugs, toiletries, cosmetics, and greeting cards Community pharmacies may be independently owned small businesses part of large retail chains franchise operations The recent trend is toward fewer independent pharmacies

Community Pharmacy A chain pharmacy is a community pharmacy that consists of several similar pharmacies in the region (or nation) that are corporately owned. May be national or regional in department stores (e.g., Wal-Mart, Target) grocery stores (e.g., Kroger, Publix) typical corner drugstores (e.g., Walgreens, Eckerds, CVS, Rite-Aid). Located to allow for large-volume dispensing with heavy use of both pharmacy techs and automation Administrative decisions are made at the corporate level

Community Pharmacy An independent pharmacy is a community pharmacy that is privately owned by the pharmacist. May be owned and operated by a group of pharmacists (rather than a corporation) A pharmacist owner makes his or her own decisions regarding the practice of pharmacy more attention and time spent to keep customers Most compounding of prescriptions is done in this type of pharmacy

Community Pharmacy A franchise pharmacy is member of a small chain of professional community pharmacies that dispense and prepare medications but are independently owned; sometimes called an apothecary. Combines characteristics of independent business and large retail chain A large retail company, the franchiser grants exclusive use of the company name and rights to sell company products to a store owner/operator, the franchisee Most sell only medication and health-related products/services Visit The Medicine Shoppe

Community Pharmacy Pharmacy technicians employed in a community pharmacy typically aid the pharmacist in the filling, labeling, and recording of prescriptions operate and are responsible for the pharmacy cash register stock and inventory prescription and over-the- counter (OTC) medications maintain computerized patient records prepare insurance claim forms order and maintain parts of the front-end stock

Community Pharmacy A mail-order pharmacy is a large-volume centralized pharmacy operation that uses automation to fill and mail prescriptions to the patient. somewhat related to retail pharmacy Run by a centralized operation using both automation and pharmacy techs dispense and mail large volumes of prescriptions every day more and more prescriptions are being filled by mail-order pharmacies

Community Pharmacy Mail-order pharmacy Economies of scale allow lower acquisition costs savings to insurers and customers Limitations: if the patient experiences a side effect or adverse reaction, or the physician changes the medication, then the drug savings could be offset by drug wastage impersonal counseling, which is limited to a drug printout or calling a toll-free number time delay safety of delivery of pain medications through the mail

Discussion What are the advantages and disadvantages of each type of community pharmacy operation?

Terms to Remember community pharmacy chain pharmacy independent pharmacy franchise pharmacy mail-order pharmacy

Institutional Pharmacy Institutional pharmacies are organized under a corporate structure, following specific rules and regulations for accreditation. A pharmacy associated with any organized healthcare delivery system hospital pharmacy is the most common example more recent examples of places where institutional pharmacies can be found include : home healthcare long-term care facilities managed-care organizations

Institutional Pharmacy A hospital pharmacy is an institutional pharmacy that dispenses and prepares drugs and provides clinical services in a hospital setting. One fourth of all pharmacists work in a hospital setting an institution that offers 24-hour healthcare service; that has six or more beds, a governing authority, and an organized medical staff; and that offers nursing and pharmacy services carries out the functions of maintaining drug treatment records and ordering, stocking, compounding, repackaging, and dispensing medications and other supplies

Institutional Pharmacy The pharmacy technician in a hospital setting takes part in functions involving delivery, stocking, or inventorying of medications anywhere in the hospital may operate manual or computerized robotic dispensing machinery Typical hospital pharmacy staff may include: administrators with master’s degrees or PharmD degrees staff pharmacists with Bachelor of Science (BS) degrees staff and clinical pharmacists with PharmD degrees pharmacy technicians

Institutional Pharmacy Hospital pharmacies (and drugstore chains) are more likely than community pharmacies to require that pharmacy technicians be certified. Some pharmacy employers encourage technicians to become certified by paying for the certification exam by giving raises to those who pass it

Institutional Pharmacy A home healthcare pharmacy is a pharmacy that dispenses, prepares, and delivers drugs and medical supplies directly to the home of the patient. Spiraling hospitalization costs, regulatory changes, and advances in parenteral therapies have created an explosion in this field The home healthcare market continues to grow because of our aging society and as an alternative to the higher cost of hospitalizations Many hospitalized patients are discharged as soon as possible to continue their recovery at home with IV solutions.

Institutional Pharmacy Pharmacists and pharmacy technicians working in home healthcare provide educational materials carry out traditional compounding and delivery functions prepare and provide infusions and infusion equipment often must be available for emergencies on a 24-hour basis

Institutional Pharmacy A long-term care facility is an institution that provides care for geriatric and disabled patients. An extended-care facility (ECF) provides institutional services predominantly to older adults or disabled “residents” who unable to provide for routine or medical care for themselves includes adults who suffer from chronic (long-lasting) or such debilitating illnesses as stroke or Alzheimer’s disease both medical and residential care is provided with very few discharges

Institutional Pharmacy Skilled-care facilities (SCF) are limited to patients requiring more round-the-clock nursing care (such as IV infusions) or recovery after a recent hospitalization most patients are discharged from SCF to home when they have adequately recovered Other long-term care facilities include patients with acute or chronic psychiatric disorders or rehabilitation facilities for those with serious traumatic brain or spinal cord injuries

Institutional Pharmacy Some long-term care facilities have an “in-house” pharmacy others contract with a community pharmacy or allow each resident to choose his or her pharmacy Licensed pharmacists establish record-keeping systems related to controlled substances review drug regimens monitor repackaging and storage of pharmaceuticals ensure that medications are uncontaminated and have not expired note medication errors and adverse reactions or interactions educate residents on drug therapies and self-medication provide medications to outpatients or residents on weekend leave

Institutional Pharmacy The pharmacist may play a crucial role in ensuring regulatory compliance a licensed pharmacist must do a monthly check of each patient profile in a long-term care facility The professional organization for “geriatric” pharmacists is the American Society of Consultant Pharmacists (ASCP) Visit the ASCP Web site

Institutional Pharmacy A pharmacy technician in a long-term care facility may: log prescriptions and refill orders via computer prepare billings maintain drug boxes or trays for emergencies package and label medications deliver medications to the nursing home maintain records, retrieve and organize patient charts conduct inspections of drugs in inventory and in nursing stations repackage drugs in unit doses labeled for each patient

Institutional Pharmacy In-house pharmacies may provide a 7-day supply of medication in “blister packs.” Community pharmacies fill medication carts or trays with a 30-day supply of medication medication orders rarely change in this environment

Managed Care Managed care is a type of health insurance system that emphasizes keeping the patient healthy of diseases controlled to reduce healthcare costs. A relatively new form of healthcare that has grown dramatically over the past 35 years One of the first managed-care organizations was Kaiser Permanente Another name for managed care is health maintenance organization (HMO)

Managed Care HMOs encourage patients to take an active role in their own healthcare by: eating right exercising often avoiding negative life-style choices HMOs encourage patients to: have annual checkups get all their immunizations on schedule get necessary laboratory (like a cholesterol or sugar test) and diagnostic tests (like a pap smear or mammogram) to detect early diseases, which may be surgically correctible

Managed Care Most HMOs have their own staff physicians who are on salary Patients who need a specialist must first get a referral HMOs have been successful in slowing the pace of the inflationary increases in healthcare without compromising the quality of care Many employers now include an HMO option on their health plans

Managed Care Most HMOs are centralized primary-care clinics they serve patients with pharmacy, x-ray, and laboratory departments under one roof An HMO, like a hospital, usually has an approved drug list or formulary that has been recommended by a drug information pharmacist and approved by the medical staff

Managed Care The formulary plus the use of low-cost generic drugs allows the organization to volume purchase select drugs to lower operational and patient cost unlike a community pharmacy, an HMO pharmacy does not stock every brand of drug available Many HMO pharmacies have a tiered pricing plan so that patients pay one price for a generic drug, a higher price for a “preferred” brand name drug, and an even higher price for a “nonpreferred” brand name product most patients and physicians use the lower-cost alternatives whenever possible

Managed Care After the patient sees the physician, the patient may go to the HMO pharmacy to fill a prescription Patients needing refills may call an automated telephone number to expedite processing and reduce waiting times this “time savings” also allows the pharmacist to spend more time reviewing the computerized medication profile and counseling the patient

Managed Care The pharmacy technician in managed care performs similar functions to those in the community pharmacy although insurance billing and cashiering are minimal Clinical pharmacists may work closely with the primary-care physicians to better control chronic disease educating monitoring adjusting doses of medications per physician-approved protocols

Discussion What are the similarities between and among the various institutional pharmacy environments? What are the differences?

Institutional Pharmacy Terms to Remember Pharmacy Workplace: Institutional Pharmacy institutional pharmacy hospital pharmacy home healthcare pharmacy long-term care facility managed care health maintenance organization (HMO) formulary