PharmacyForward

Gender Identity & Transgender Care (III)

Cheyenne C. Newsome, PharmD, BCACP and Jessica Conklin, PharmD, BCACP, CDE, AAHIV — passionate advocates for the role of pharmacists in the care of transgender persons — talk with us about the need for patient and provider education and about the benefits and risks of gender-affirming treatment.

Key Lessons:

• Gender-affirming therapy is highly effective, improving the quality of life in more than 80% of patients.
• Hormonal therapy is the cornerstone of gender-affirming therapy. 
• Testosterone is used for masculinization by trans-men.  It is traditionally given by intramuscular injection but subcutaneous injections are easier to administered and may have a smoother effect (e.g. lower peak effect). 
• Side effects from testosterone are common including body and facial hair growth (you don't get to pick!), deepened voice (irreversible), clitoral enlargement, acne, menstrual irregularities, and weight gain from increased appetite.
• Estradiol (preferred estrogen) is used for feminization by trans-women. In addition, spironolactone is used in high doses for its anti-androgen effects.  Side effects are similar to those experienced by cisgender women.
• While trans-men often develop amenorrhea, pregnancy is still possible.  Frank discussions about the use of contraception, if sexually active, is important.
• A number of great resources are available to inform drug therapy decision making particularly the Endocrine Society Guidelines.
• Pharmacists can uniquely contribute to optimizing the care of trans-men and -women.

To learn more, view and download the Show Notes!

Gender Identity & Transgender Care (II)

Abby Frye, PharmD, BCACP, Dawn Fuke, PharmD, BCPS, and Justin Bachman, PharmD, BCACP — Clinical Pharmacist Specialists in Primary Care from the Providence Medical Group in Portland, Oregon — talk with us about creating gender-affirming care environments.

Key Lessons:

• Current estimates suggest that about 1 million adults in Adults in the United States don't identify with the gender assigned to them at birth  - but this is likely an underestimate.
• Transgender and gender non-conforming individuals face enormous and persistent stigma within our (and many other) cultures.
• Social stigma is associated with higher rates of anxiety, depression, and substance use disorders.
• Health professionals have a responsibility to take pro-active steps to counteract the discrimination that patients from vulnerable and marginalized populations face.
• Self-awareness and self-examination about communication practices are critical - this includes the information collected on patient intake forms and electronic health records as well as a patient's preferred name and pronoun. 
• Insurance coverage for gender-affirming therapies as well as health screening exams for transgender persons are sometimes denied and health professionals may need to advocate for coverage.
• A wide variety of resources are available to health professionals to learn more about the care of transgender and gender non-conforming individuals.

To learn more, view and download the Show Notes!

Gender Identity & Transgender Care (I)

Nicole Avant, PharmD, BCACP - Assistant Professor at the University of Cincinnati and Founder/CEO of Avant Consulting Group - and Tennille McKinney - HIV Educator and Consultant with Avant Consulting Group - talk with us about gender expression/identity, cis-privilege, and transphobia.

Key Lessons:

• Sex and gender are not synonymous.  Sex is based on biology and gender is a social construct. Sex is determined by genes and assigned at birth. Gender is influenced by cultural norms and internal sense of self.
• Transgender persons identify with a gender that is different from the sex that was assigned at birth.  Cis-gender persons identify with the gender that is congruent with the sex assigned at birth.
• Some transgender persons, but certainly not all, seek medical and/or surgical gender-affirming treatments to express their gender identity.
• Cis-privilege includes the rights and advantages that cis-gender persons enjoy.  This includes respect for one's gender identity and freedom from harassing comments or intrusive questioning.
• Deadnaming is the act of referring to and calling someone by their birth name rather than their chosen name which is congruent with their current identity.
• Transgender persons face social stigma from both the lay public and health professionals.  This sigma often results in transgender persons seeking care outside of traditional institutions and relying on self-care.

To learn more, view and download the Show Notes!

Social Determinants of Health and Healthcare Delivery (II)

Lea Eiland, PharmD, BCPS, BCPPS - Clinical Professor and Associate Department Head, Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy — talks to us about the impact of generational differences ... and why these differences influences our patients' communication perferences, beliefs, and expectations.

Key Lessons:

• Our patients and workforce are more diverse than ever - including their generational experiences that influence their expectations related to work, healthcare delivery, and communication.
• Generational differences are generalizations - so not all people within a generation fit the stereotype and we need to be careful to not make assumptions.
• The generations currrently in the workforce and healthcare delivery systems are Traditionalist, Baby Boomers, Gen-X, Millennials, and Gen-Z/iGeneration.
• Comfort levels with digital technology and communication formats vary by generation.  Older generations tend to prefer face-to-face and long-form written communications ... while more recent generations prefer short-form written communications.  But everyone can learn to adapt!
• Recent generations prefer short, action-oriented, on-demand learning methods.
• Feedback preferences are also generational. Older generations generally desire less frequent feedback and more recent generations prefer more.
• Learning how to function well as a team requires a shared vision about the goals and valuing the contributions of each person on the team.

Social Determinants of Health and Healthcare Delivery (I)

Magaly Rodriguez de Bittner, PharmD, BCPS, CDE - Professor and Associate Dean for Clinical Services and Practice Transformation, University of Maryland School of Pharmacy - talks to us about the impact of culture on behaviors and health outcomes ... and why healthcare practitioners need to develop cultural awareness and move toward cultural proficiency to achieve optimal outcomes for the patients they serve.

Key Lessons:

• Culture is the characteristics, knowledge, and beliefs of a group of people including their shared language, religious/spiritual beliefs, habits, and values.   Culture impact beliefs about diseases, medications, and healthcare.
• Many patients are reluctant to tell healthcare providers about their culturally-related health behaviors for fear of being judged or may believe such information is irrelevant.
• Behaviors and beliefs, regardless of source, can impact health outcomes and can augment, detract, or have no impact on the recommended treatment plan.
• Openly discussing beliefs and behaviors is critical.  Supporting patient decisions based on their beliefs builds trust.
• Communicating in the patient's preferred language is mandated by law. Use trained interpreters. Have written materials available in the patient's preferred language.
• Cultural awareness and moving toward cultural proficiency makes good business sense as you are better able to understand the needs of your patients.

Marijuana Use - Medical, Health, and Legal Issues (III)

William J Stilling, BS Pharm, JD - Founding Partner, Stilling & Harrison, PLLC and Clinical Associate Professor, Department of Pharmacy Practice at the University of Utah College of Pharmacy - talks to us about some of the legal issues related to the medical and recreational use of marijuana.

Key Lessons:

• Marijuana (in its raw form) is a schedule I substance under Federal Law.  However, the US Congress has prohited the Department of Justice from using its funds to enforce Federal law superceding State laws related to marijuana.
• Medical marijuana is typically legal to use under State laws only in specific "use cases" or "qualifying conditions."  Physicians and other prescribers can't legally prescribe marijuana because it would violate their DEA issued license but may "recommend" or "authorize" the use of marijuana.
• Healthcare instutitions need to consider the use of marijuana for therapeutic purposes by their patients and develop clear policies and procedures on how marijuana use will be accommodated in their facility.
• Pharmacists and pharmacies are subject to oversight by the board of pharmacy and most state boards require pharmacists to abide by Federal laws.  Thus, pharmacists who use marijuana, even for "legal" therapeutic purposes, may be subject to sanctions and lose their license to practice.
• Employers may terminate a pharmacist or health professional for marijuana use because it is a violation of Federal law.
• The FDA is unlikely to approve marijuana (in its raw form) for medical indications because it can not be easily studied or standardized.
• The legal status of marijuana in the years to come will be significantly impacted by political and economic forces.

View and Download the Show Notes

Marijuana Use - Medical, Health, and Legal Issues (II)

Laura Borgelt, Pharm.D., BCPS - Professor, Departments of Pharmacy Practice and Family Medicine at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences - talks to us about the recreational use of marijuana and its potential health consequences.

Key Lessons:

• Cannabis (marijuana) use has increased substantially in the past decade.  Young adults are the most likely to report using marijuana in the past year or month but use among older adults (age > 65 years) is growing as well.
• Its important to ask patients in a non-judgmental, open-ended manner about their cannabis use including the intended purpose(s), frequency of use, and forms used.
• Numerous cannabis products are available. Inhaling (smoking or vaping) remains the most common method for use.  Edible products are available in a wide variety of food-like delivery systems (e.g. baked goods, candies).  Topical products are more commonly used for medical purposes.
• The THC concentrations found in cannabis products today are much higher than years ago. This has resulted in higher rates of unintentional overdoses leading to paranoia and psychotic symptoms. Overdosing is most common with edible products due their delayed absorption.
• There are several short-term and long-term health consequences related to marijuana use. Regular cannabis use can lead to neurocognitive effects including impaired memory. Cannabis use is more likely to have a detrimental impact for adolescents and young adults. Cannabis use during pregnancy also appears to have detrimental neurocognitive effects on children.
• There are several potential drug-drug interactions with THC and medications metabolized through CPY2C9 and CPY3A4 as well as receptor interactions.
• Pharmacists have an important public health role by screening for cannabis use, educating patients about the potential risks associated with marijuana use, and identifying potential drug-drug interactions.

View and Download the Show Notes

Marijuana Use - Medical, Health, and Legal Issues (I)

Kari Franson, Pharm.D., Ph.D., BCPP - Associate Dean for Professional Education at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences - talks to us about the medical use of marijuana, THC, and CBD.

Key Lessons:

• Cannabis plants have been used for medical, recreational, and industrial purposes for thousands of years.
• The two active ingredients in cannabis plants include tetrahydrocannabinol (THC) and cannabidiol (CBD) - collectively known as cannabinoids.  They have distinctly different pharmacological properties.
• Cannabis plants that contain less than 0.3% of THC by dry weight are legally classified as hemp.  Cannabis plants can be cultivated to have more (or less) THC and CBD content.
• Prescription products containing THC have been available for more than 30 years. A buccal spray containing THC + CBD has been approved (but not in the United States) for the treatment of muscle spasms/stiffness associated with multiple sclerosis.  A purified CBD product was approved by the FDA for the treatment of rare childhood seizure disorders in 2018.
• There is a long list of claimed medical uses of marijuana (typically contains high concentrations of THC).  Not all claims are supported by sufficient evidence and some have been refuted by the evidence.  Far less is known about the medical uses of CBD.
• Cannabinoids are erratically and slowly absorbed from the GI tract.
• There are substantial legal barriers to studying cannabis and its health consequences in the United States.

View and Download the Show Notes

Credentialing & Privileging (III)

Brandon Shank, PharmD, BCOP - Clinical Pharmacy Specialist at the University of Texas MD Anderson Cancer Center - talks to us about credentialing & privileging from a front-line clinician's point of view.

Key Lessons:

• Building rapport and trust with your team is an essential first step from which clinical privileges follow.
• State laws vary.  Some authorize privileging of pharmacists at the institutional level.
• Obtaining and maintaining clinical privileges requires additional training ... and paperwork.
• Pharmacists have a unique understanding of the dosing and available dosage forms of drugs - this brings value to the patient care team.
• Privileging pharmacists to take on advanced clinical responsibilities can increase team efficiency and effectiveness.

View and Download the Show Notes!

Credentialing & Privileging (II)

Julie Groppi, PharmD - National Program Manager, Clinical Pharmacy Practice Policy and Standards, Department of Veteran's Affairs and Todd Nesbit, PharmD, MBA - Director of Pharmacy Patient Care Services, the Johns Hopkins Hospital - discuss the credentialing and privileging of pharmacists.

Key Lessons

• Credentialing is the process of verifying someone education, training, certifications, and experience. 
• Privileging is the process of determining an appropriate scope of practice based on the practitioner's credentials and granting authority to carry out specific patient care services/decisions.
• All health systems should credential the pharmacists they employ.
• Pharmacists can be privileged to initiate, modify, continue, or discontinue medication therapies as well as order tests and referrals as needed to achieve treatment goals.
• A pharmacist's privileges may be restricted to specific drugs and disease (e.g. collaboratory drug therapy management agreement) or may be service-specific (e.g. all patients enrolled in or assigned to a specific clinical service unit).
• The credentials necessary to be privileged to carry out advanced patient care services typically include residency training and board certification.

View and Download the Show Notes!