America’s Medicine Cabinet...Medco Health Solutions. 2005 Drug Trend Report. Pressure to Receive a...

AmericaAmerica’’s Medicine Cabinets Medicine Cabinet

Supported through a grant from the Community Pharmacy Foundation

AmericaAmerica’’s s Medicine CabinetMedicine Cabinet

Proceed with Proceed with (Pharmaceutical) (Pharmaceutical)

CareCare

Presenter�

Presentation Notes�

Welcome to America’s Medicine Cabinet. Today, we are going to talk about prescription and over-the-counter (or OTC) medicines. This presentation was created by the American Pharmacists Association (APhA) and the Institute of Safe Medication Practices (ISMP) and was supported through a grant from the Community Pharmacy Foundation.�


AcknowledgementAcknowledgement

The presentation was developed for The presentation was developed for APhA by the Institute for Safe Medication APhA by the Institute for Safe Medication Practices Practices –– Donna Donna Horn,RPh,DPhHorn,RPh,DPh

Director, Patient Safety Director, Patient Safety –– Community PharmacyCommunity Pharmacy Institute for Safe Medication PracticesInstitute for Safe Medication Practices

Presentation reviewers included Mitchel Presentation reviewers included Mitchel Rothholz, RPh, MBA; Harry Hagel, RPh, MS; Rothholz, RPh, MBA; Harry Hagel, RPh, MS; Tara Tara WheatlyWheatly, , PharmDPharmD Candidate; Allen Candidate; Allen Vaida,RPhVaida,RPh; and Louis Sesti, RPh. ; and Louis Sesti, RPh. The presentation was made possible through The presentation was made possible through a grant from the Community Pharmacy a grant from the Community Pharmacy Foundation.Foundation.

Presenter�


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What we will discussWhat we will discuss……

Significance of Medication MisuseSignificance of Medication MisuseContributing Factors to Medication MisuseContributing Factors to Medication Misuse–– AdvertisingAdvertising–– Patient behaviorPatient behavior–– Populations at riskPopulations at risk–– Importance of Importance of ““reading the labelreading the label””

Brand name extensionBrand name extension–– Health literacyHealth literacy

Proper Medication Storage and DisposalProper Medication Storage and DisposalWorking with Your PharmacistWorking with Your Pharmacist

Presenter�


Today we are going to discuss the following. The significance of medication misuse and contributing factors Who is at risk for using medications incorrectly and why Why it is important to take medications correctly How to read an OTC medicine label Practice reading OTC labels How to properly dispose of unused medications How to interact with your pharmacist for the best results Why are we here today? Americans are able to buy many types of medications, both by prescription from a doctor and over the counter in many types of stores—grocery stores, deep discount stores such as Wal Mart, natural food stores, gas stations, and, of course, drug stores. This ready access of medications has led some people to take these medications for granted, resulting in their taking medications incorrectly, or, as we say, misusing medications. This can cause harmful reactions to people, including hospitalization and, in rare circumstances, death. Today, we are going to talk about how people incorrectly use medications and how the local pharmacist can help you to use your medications safely and effectively so that these medications will actually make you feel better, not worse. When it comes to using medicine, it is important to know that no medicine is completely safe. �


Medication Use TrendsMedication Use TrendsImportance of medication andImportance of medication andbeing an informed consumerbeing an informed consumer

Presenter�


(Transition Slide) Let’s talk about the value of medication and the importance of being an informed consumer.�


Unintentional medication misuse can lead to patient

harm and additional health care costs.

Unintentional medication misuse can lead to patient

harm and additional health care costs.

Presenter�


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WhatWhat’’s causing misuse s causing misuse of medicines?of medicines?

People take a lot of (legal) drugsPeople take a lot of (legal) drugs–– Lots of prescriptions writtenLots of prescriptions written–– Lots of new prescription, OTC, and Lots of new prescription, OTC, and ““naturalnatural””

meds and vitamins availablemeds and vitamins available–– TV adsTV ads–– OTC labels hard to readOTC labels hard to read–– Seniors, parents get confusedSeniors, parents get confused–– Written information is hard to readWritten information is hard to read

Presenter�


(Read slide) We are going to talk about how all of these reasons lead to people misusing medications. People take a lot of (legal) drugs. Many prescriptions are written. Large numbers of new prescription, OTC, and “natural” medicines and vitamins are available. Pharmaceutical companies run TV ads. OTC labels are hard to read. Seniors, parents get confused. Written information is hard to read.�


2006 2006 Institute of Medicine ReportInstitute of Medicine Report

4 of 5 US adults take 4 of 5 US adults take Rx, OTC, or dietary Rx, OTC, or dietary supplement every weeksupplement every week33% take 5 or more 33% take 5 or more medications weeklymedications weekly1.5 million injured by 1.5 million injured by medication errorsmedication errorsMedication errors cost Medication errors cost $3.5 billion$3.5 billion

Presenter�


(Read slide) 4 of 5 US adults take prescription (Rx), OTC, or dietary supplement every week 33% take 5 or more medications weekly 1.5 million injured by medication errors Medication errors cost $3.5 billion The more medications people take, the more the medicines can interact with each other and lead to unintentional misuse of medications Keep in mind that “medicines” include vitamins, minerals, and herbals products and OTC (aka nonprescription) medicines, or medicines you can buy without a prescription, such as antacids, laxatives, pain, fever, or cough/cold medicines.�


Two of three patients Two of three patients leave doctorleave doctor’’s office with s office with a prescriptiona prescription

3.4 billion prescriptions filled in 20053.4 billion prescriptions filled in 2005

40% of the US population receive four 40% of the US population receive four or more prescriptions every yearor more prescriptions every year

Source: Miller L, ed. Chain Pharmacy Industry Profile. 9th ed. Alexandria VA: NACDS Foundation; 2006, p. 8.

Scope of the ProblemScope of the Problem

Presenter�


Lots of prescriptions are being written and filled every year. How many of you have had a prescription written by your doctor and filled at a pharmacy? How many of you have had more than one prescription filled last year? Have you or has anyone in your family used an OTC medicine this week? (Read slide) Two of three patients leave doctor’s office with a prescription 3.4 billion prescriptions filled in 2005 40% of the US population receive four or more prescriptions every year Source: Miller L, ed. Chain Pharmacy Industry Profile. 9th ed. Alexandria VA: NACDS Foundation; 2006, p. 8.�


23 million antibiotic 23 million antibiotic prescriptions written forprescriptions written for–– ColdsColds–– BronchitisBronchitis–– Upper respiratory infectionsUpper respiratory infections

44% children given antibiotics for colds44% children given antibiotics for colds51% adults given antibiotics for colds51% adults given antibiotics for coldsCDC 70% bacteria causing infection are CDC 70% bacteria causing infection are resistant to at least one common drugresistant to at least one common drug

Source: Medco Health Solutions. 2005 Drug Trend Report.

Pressure to Receive a PrescriptionPressure to Receive a Prescription…… Experience with AntibioticsExperience with Antibiotics

Presenter�


When you have a cold, how many of you want an antibiotic for a cold for yourself or your child, thinking you will get better, faster? Antibiotics are powerful drugs but they are not the cure for all that ails you. Antibiotics are drugs that fight infections caused by bacteria. They are not effective against viral infections such as the common cold, most sore throats, and the flu, yet doctors write prescriptions for antibiotics because their patients want them. Today, almost all important bacterial infections in the United States and throughout the world are becoming resistant to antibiotics. Antibiotic resistance has been called one of the world's most pressing public health problems. The smart use of antibiotics is the key to controlling the spread of resistance. Source: Medco Health Solutions. 2005 Drug Trend Report. �


And More Drugs And More Drugs aare Comingre Coming……

25 to 35 new drug 25 to 35 new drug approvals possible in approvals possible in each of the next 3 yearseach of the next 3 years

350 new biotech drugs 350 new biotech drugs being tested for market being tested for market right nowright now

Source: Medco Health Solutions. 2005 Drug Trend Report.

Presenter�


The US Food and Drug Administration (FDA) is the part of our country’s government that makes sure our medicines are safe and do what they say they do. The FDA judges a drug to be safe enough to approve when the benefits of the medicine outweigh the known risks for the labeled use. People are living longer, but developing more diseases; therefore, more new drugs are needed. Last year alone, the FDA approved 20 biotech drugs, among them treatments for insomnia, multiple sclerosis, severe pain, chronic kidney disease, incontinence, mouth sores, and many types of cancer. Source and background information: Medco Health Solutions. 2007 Drug Trend Report. Franklin Lakes, NJ. Available online at: http://medco.mediaroom.com/file.php/129/2007+DRUG+TREND+REPORT.pdf �


106 million people use 106 million people use vitamins and minerals dailyvitamins and minerals daily44.6 million people use 44.6 million people use herbal remedies*herbal remedies*24.2 million people use 24.2 million people use specialty supplementsspecialty supplements*11.9 million people experienced a side effect or an adverse *11.9 million people experienced a side effect or an adverse reaction from using herbal remedies. (onereaction from using herbal remedies. (one--fourth of the 44 million fourth of the 44 million people using such productspeople using such products ))

Source: Eisenberg D, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the US, 1990-1997. JAMA 1998;280:1569–1575.

Alternative MedicinesAlternative Medicines

Presenter�


Vitamins and minerals also have the potential to interact with medications you're taking. Drug-drug interactions occur when a drug interacts, or interferes, with another drug. For example, ferrous sulfate (iron) can negate the effects of tetracycline, a commonly used antibiotic. -More than 40% of Americans have tried alternative medicines. -50% of people ages 35–49 use alternative medicines. Source: Eisenberg D, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the US, 1990-1997. JAMA 1998;280:1569–1575. As many as 40% of cancer patients take unconventional herbal and dietary supplements such as St. John's wort, shark cartilage, and megadoses of vitamins (without telling their doctor). Prevention Magazine survey of US adults. Ironically patients with poor lifestyle habits or nutrition are the least likely to take them; older patents and women are more likely to use these supplements. Source: Huang HY, Caballero B, Chang S, et al. The efficacy and safety of multivitamin and mineral supplement use to prevent cancer and chronic disease in adults: a systemic review for a NIH conference. Ann Intern Med 2006;145:372–385).�


Blood thinners:Blood thinners:–– Coumadin (Rx)Coumadin (Rx)–– Aspirin (OTC)Aspirin (OTC)–– Ginkgo biloba (herbal)Ginkgo biloba (herbal)–– Vitamin E (dietary supplement)Vitamin E (dietary supplement)

St. JohnSt. John’’s wort decrease effectiveness of:s wort decrease effectiveness of:–– HIV drugsHIV drugs–– Birth control drugsBirth control drugs–– Drugs for heart, cancer, depression, seizuresDrugs for heart, cancer, depression, seizures

Natural Natural ≠≠

SafeSafe

Presenter�


Herbal supplements, which have grown significantly in availability and popularity in recent years, can add to the risk of drug-drug interactions. For example, ginkgo, which inhibits blood clotting, may cause trouble if it's taken with anticoagulants or blood thinners, such as warfarin (Coumadin). Taking these two products together increases the risk of bleeding.�


Claims linked to happy, Claims linked to happy, smiling actors may result smiling actors may result in irrational demands in irrational demands for new drugsfor new drugsMay lead to overmedicatingMay lead to overmedicating

Source: Abramson J. Overdosed America: The Broken Promise of American Medicine. HarperCollins Publishers, 2004.

Impact ofImpact of DirectDirect--toto--Consumer Consumer (DTC) Advertising (DTC) Advertising

Presenter�


When people see commercials of happy people who are suffering from what they think is the same disease as they have, the TV watchers want those medications, too. Remember the people on TV are actors! Anyone who watches TV knows the "healing purple pill" Nexium is often touted as a cure for heartburn and "erosions in the esophagus." Do you really have erosions of your esophagus? Or just some mild heartburn? “I see it on TV all the time. All my friends are taking it.” People need to understand that no matter how many times they see a drug on TV, these medications need to be used appropriately. Source: Abramson J. Overdosed America: The Broken Promise of American Medicine. Copyright ©2004 HarperCollins Publishers.�


Source: Get better care from your doctor: what 39,090 patients and 335 doctors have to say about how to make the most of your next appointment. Consumer Rep 2007;72:32–36.

Consumer Reports SurveyConsumer Reports Survey

78% of primary care physicians were 78% of primary care physicians were asked by their patients for specific drugs asked by their patients for specific drugs advertised on TVadvertised on TV–– 67% of doctors granted their patients' request67% of doctors granted their patients' request

Presenter�


Direct-to-Consumer (DTC) advertising can impact requests for pharmaceuticals by patients (some being inappropriate for the patient). The Consumer Reports magazine reported 40% of doctors surveyed believe DTC ads (ads for prescription drugs on TV and in magazines) by the pharmaceutical industry are a disservice to the public. A total 335 doctors and 39,090 people around the nation were surveyed in this study. 78% of primary care physicians were asked by their patients for specific drugs advertised on TV 67% of doctors granted their patients' request Source: Get better care from your doctor: what 39,090 patients and 335 doctors have to say about how to make the most of your next appointment. Consumer Rep 2007;72:32–36.�


Prescription and Prescription and OTCOTC MedicinesMedicines How are they different? How are they the same?How are they different? How are they the same?

Both types Both types of medicine:of medicine:

•• Directions must beDirections must befollowed carefully followed carefully and correctlyand correctly

•• Children should use Children should use only with permission only with permission of a parent or of a parent or guardianguardian

•• A pharmacist canA pharmacist cananswer questionsanswer questions

1. Can buy without a doctor’s order

2. Bought off the shelf in store aisles

3. May be used by more than one person for the same symptom or problem

OTC

1. Ordered by a doctor

2. Bought at a pharmacy

3. Ordered for and used by only one person

Prescription

Presenter�


(Click through the differences over three clicks—compare and contrast) (Click once more to bring up the similarities) Any medicine can cause harm if you use too much of the medicine or use it incorrectly. This is true for prescription and OTC medicines. For all medicines, you must read and follow the directions. Children should use medicine only with permission from a parent or guardian. We have both prescription and OTC medications currently in the United States. More medications are moving from Rx to OTC status everyday: 700+ former prescription products now sold without a prescription (eg, Nizoral AD, Lamisil AT, Pepcid, Nicorette, Plan B). -Just because they are OTC doesn’t mean you can take the medication lightly. (Review bullets). If you have questions about a medicine, you can ask a pharmacist. �


Medication Use IssuesMedication Use IssuesFactors impacting appropriate Factors impacting appropriate

medication use and outcomesmedication use and outcomes……

Presenter�


Now we will talk about the kinds of things that cause people to use their medication, prescription and OTC medications, incorrectly. �


Common Causes ofCommon Causes of ““Medication MisuseMedication Misuse””

Taking incorrect dosesTaking incorrect dosesTaking doses at Taking doses at wrong timeswrong timesForgetting to take dosesForgetting to take dosesStopping medicine too soon Stopping medicine too soon

Presenter�


This is usually what people do wrong. (Read slide) Take Your Medications Safely Medicine is prescribed to help you. But it can hurt you if you take too much or mix medicines that don't go together. Know what the medicine is for and how to take it. Ask about side effects and what to avoid. Read the label and warnings when you get your medicine. Ask the pharmacist about your medicine if it looks different than you expected—we will talk more about this in a minute. If you want to stop a medicine your doctor told you to use or to use it in a different way than directed by your doctor or the label, talk to a pharmacist. Some medicines take longer to show that they are working. With some medicines, such as antibiotics, it is important to finish the whole prescription even if you feel better sooner. With some medicines, if you want stop using them, you must reduce the dose little by little to prevent unwanted side effects.�


Misuse Leads to Treatment FailureMisuse Leads to Treatment Failure

Missed doses of glaucoma Missed doses of glaucoma medicine can lead to optic medicine can lead to optic nerve damage and nerve damage and blindness.blindness.

Missing doses or suddenly Missing doses or suddenly stopping high blood stopping high blood pressure medicine can pressure medicine can cause a rebound rise in cause a rebound rise in blood pressure.blood pressure.

Presenter�


Understanding the importance your medication plays in your treatment will help you get the most benefit from your prescription. Your doctor prescribed your medication, but you must take the medicine correctly to see the benefits. If you don’t take your medications correctly or at the right time, your condition can get worse.�


700,000 patients treated each year 700,000 patients treated each year because of unintentional overdoses.because of unintentional overdoses.Five most common types of drugs Five most common types of drugs taken incorrectly:taken incorrectly:–– Insulin Insulin –– Blood thinnersBlood thinners–– Antibiotics Antibiotics –– Aspirin Aspirin –– Pain medicationsPain medicationsSource: Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug events. JAMA 2006;296:1858–1866.

Emergency Room VisitsEmergency Room Visits

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People end up in the hospital when they take the wrong amount of medication. Source: Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug events. JAMA 2006;296:1858–1866. The recent death of actor Heath Ledger (Brokeback Mountain) is raising awareness about the potential dangers of prescription drugs, especially sleep medications that are combined with other drugs. Deaths caused by unintentional poisoning, of which 95% are drug overdoses, jumped from 12,186 in 1999 to 20,950 in 2004, according to figures from the Centers for Disease Control and Prevention. �


Are depressed Are depressed Are going through a life changeAre going through a life changeFrequently drink alcohol Frequently drink alcohol Live alone and don't get out much Live alone and don't get out much Suffer from pain Suffer from pain Have language or hearing difficulty Have language or hearing difficulty or feel uncomfortable asking questionsor feel uncomfortable asking questions

Source: US FDA. FDA Proposes Program to Give Patients Better Medication Information. AARP survey. Available online at: http://www.fda.gov/fdac/features/995_medinfo.html

Americans with Increased Risk Americans with Increased Risk of Medication Misuse: of Medication Misuse:

Presenter�


Are you going through a life change such as death of a loved one, retirement, moving, divorce, or remarriage? Are you uncomfortable asking you doctor, pharmacist, or other health care professional questions? If not, then you may be at risk for taking your medications incorrectly. Source: US FDA. FDA Proposes Program to Give Patients Better Medication Information. AARP survey. Available online at: http://www.fda.gov/fdac/features/995_medinfo.html�


Source: Cost Overdose: Growth in Drug Spending for the Elderly, 1992-2010. Washington, DC: Families USA; 2000.

Seniors at RiskSeniors at Risk

Elderly (65+) are 13% of Elderly (65+) are 13% of US populationUS populationAccount for 34% of all Account for 34% of all prescriptions dispensedprescriptions dispensedAverage number of prescriptions Average number of prescriptions per elderly person was 28.5 in 2000per elderly person was 28.5 in 2000Estimated to reach 38.5 by 2010 Estimated to reach 38.5 by 2010 243,000 hospitalized/year from reactions 243,000 hospitalized/year from reactions between prescriptions and OTC drugsbetween prescriptions and OTC drugs

Presenter�


Elderly patients—75% of whom take prescription drugs and 82% of whom use OTC products regularly—are at greater risk because they take and combine more medications than younger individuals. As mentioned before, drug-drug interactions occur when a drug interacts, or interferes, with another drug: mixing prescription and OTC drugs without advice from a pharmacist can result in harm and lead to hospitalizations. In fact, 243,000 people were admitted to the hospital last year because of bad reactions when taking more than one medication. Source: Cost Overdose: Growth in Drug Spending for the Elderly, 1992-2010. Washington, DC: Families USA; 2000.�


Source: IOM report 2006.

Seniors at RiskSeniors at Risk

BarriersBarriers–– Visual, hearing, and Visual, hearing, and

cognitive impairmentcognitive impairment–– Slower organ functions, Slower organ functions,

more body fat (drugs in body more body fat (drugs in body longer, increase chance of side effects)longer, increase chance of side effects)

–– Labeling and packaging difficult to read or useLabeling and packaging difficult to read or use–– Lack of health insurance and cost of drugsLack of health insurance and cost of drugs

Presenter�


Senior citizens’ bodies look and act differently than those of younger adults. Changes in body weight can influence the amount of medicine you need to take and how long it stays in your body. Body (blood) circulation may slow down, which can affect how quickly drugs get to the liver and kidneys. In addition, the liver and kidneys may work slower, which can affect how a drug breaks down and is eliminated from the body. Because of these changes, medicine may remain in your body longer and create a greater chance of interaction. Source: IOM report 2006 (Self medicate with cheaper OTC products, Inability to act on own behalf, Complex medications leads to adverse drug events (side effects and complications) �


Source: French D, Werner D, Campbell R, et al. A multivariate fall risk assessment model for VHA nursing homes using the minimum data set. J Am Med Dir Assoc 2007;8:115– 122.

Example: Elderly OveruseExample: Elderly Overuse

Unnecessary use of antihistamines, Unnecessary use of antihistamines, antianti--anxiety, sleep aids, and minor anxiety, sleep aids, and minor tranquillizers tranquillizers –– Leads to avoidable injuriesLeads to avoidable injuries

FallsFallsFracturesFracturesMotor vehicle accidentsMotor vehicle accidents

–– $27.3 billion health care $27.3 billion health care expenses related to falls in 2005expenses related to falls in 2005

Presenter�


(Read slide) About 850,000 people each year misuse sedatives, including sleep aids, according to the Centers for Disease Control and Prevention. All told, 14 million people misuse prescription drugs, including pain relievers, tranquilizers, and stimulants.�


Source: Johnson P, Hayes M, “Medication Use in Schools,” Am J Health Syst Pharm 2006;63:1277–1285.

Medications at School Medications at School

6% children (13 million) receive 6% children (13 million) receive medication in schoolmedication in school–– 80% medication errors were 80% medication errors were

““missed dosesmissed doses”” (forgotten)(forgotten)–– Bad habits, poor disease Bad habits, poor disease

management, rapid disease management, rapid disease advancementadvancement

Presenter�


Children are affected by medication misuse, too, which includes not taking medication according to the directions, or skipping doses. Sometimes medication (antibiotics, asthma inhalers, allergy medication) needs to be given to a child during school hours; many school systems don’t have nurses or trained health care workers to help students. This results in children not getting the medications they need at the time their body needs it. What happens to the student that does not have access to his or her breathing inhaler in gym class? Informed students who are taught responsible behavior will be responsible patients and have good health habits for life. Source: Johnson P, Hayes M”Medication Use in Schools,”. Am J Health Sys Pharm 2006;63:1277–1285.�


OverOver--thethe--Counter (OTC)Counter (OTC) MedicationsMedications

What you should know What you should know before you buybefore you buy……

Presenter�


Now we will talk specifically about medications you can buy without a prescription and how to safely purchase the most appropriate medication for what you need to treat.�


One of six adults admit taking One of six adults admit taking three or more pills in single three or more pills in single dose, despite label dose, despite label recommendationsrecommendations47% children given wrong dose of OTC 47% children given wrong dose of OTC fever medicinefever medicineOTC labels Drug Facts hard to OTC labels Drug Facts hard to understandunderstand

Source: Consumer Healthcare Products Association, IOM 2006.

OverOver--thethe--Counter Medications Counter Medications Concerns with UsageConcerns with Usage

Presenter�


The term "misuse" refers to taking more than the recommended number of pills per dose or taking pills more often than the label directs. Approximately one in two Americans misuse common pain relievers such as ibuprofen, naproxen, and aspirin. The survey also found that more than three-quarters of respondents reported never speaking to a doctor or nurse about any potential risks associated with these medications, many of which can be purchased without a prescription, or "over the counter" (OTC). Source: Consumer Healthcare Products Association, IOM 2006, Results of a new survey released by the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA).�


Concentrated Liquid Concentrated Liquid Tylenol for InfantsTylenol for Infants

A parent almost gave her 27A parent almost gave her 27--monthmonth--old old child 2 teaspoonsful of Tylenolchild 2 teaspoonsful of Tylenol®® infant infant drops (acetaminophen) instead of 2 drops (acetaminophen) instead of 2 droppersful. droppersful.

She did not realize that the infant drops She did not realize that the infant drops are much more concentrated than the are much more concentrated than the children's elixir.children's elixir.

Presenter�


Know your child’s weight. Directions on some OTC medicines are based on weight. Never guess the amount of medicine to give to your child or try to figure it out from the adult dose instructions. If a dose is not listed for your child’s age or weight, call your doctor or pharmacist. �


Drug Facts Drug Facts

Presenter�


(Click through slide several times while explaining the items that get circled, and say—) This is why parent’s do not give correct doses—the label can be confusing, and when you look for the dose to give your baby, it says to “ask your doctor”—what does a Mom or Dad do in the middle of the night?” Always give infants and children OTC medicines that are especially formulated for their age and weight. Give the right medicine, in the right amount, to your child. Not all medicines are right for an infant or a child. Medicines with the same brand name can be sold in many different strengths, such as infant, children, and adult formulas. The amount and directions are also different for children of different ages or weights. Always use the right medicine and follow the directions exactly. Never use more medicine than directed, even if your child seems sicker than the last time. Unless labeled otherwise, adult-strength products should not be given to children; doing so could result in accidental overdosing. To be safe, don’t cut adult tablets in half or estimate a child’s dose of an adult-strength liquid product. �


Measuring Tools for MedicinesMeasuring Tools for Medicines

Use the measuring spoon, Use the measuring spoon, cup, or syringe that comes cup, or syringe that comes with your medicine. This is with your medicine. This is the most exact way to the most exact way to measure your dose.measure your dose.If your medicine doesnIf your medicine doesn’’t come t come with a special measuring tool, with a special measuring tool, ask for one at the pharmacy. ask for one at the pharmacy. A silverware spoon may hold the A silverware spoon may hold the wrong of medicine. wrong of medicine. Make sure the tool can measure the right Make sure the tool can measure the right dosedose——check the markings on the tool.check the markings on the tool.

Presenter�


Use the dosing tool that comes with the medicine, such as a dropper or a dosing cup. A different dosing tool, or a kitchen spoon, could hold the wrong amount of medicine. Kitchen silverware spoons are different sizes and will not give the exact dose. Know the difference between a tablespoon (tbsp) and a teaspoon (tsp). Do not confuse them! A tablespoon holds three times as much medicine as a teaspoon. On measuring tools, a teaspoon (tsp) is equal to “5 cc” or “5 mL.” It is important to wash these measuring tools with soap and water after using them so they don’t pass germs from one person in your family to another.�


Source: © 2002-2007 NCPIE - National Council on Patient Information and Education

Did you know?TYLENOL® and Nyquil®

contain the same active pain relief medicine

Did you know?TYLENOL® and Nyquil®

contain the same active pain relief medicine Did you know?

The popular prescription medications Percocet and

Vicodin also contain acetaminophen

Did you know?The popular prescription

medications Percocet and Vicodin also contain

acetaminophen

Presenter�


Source: © 2002-2007 NCPIE - National Council on Patient Information and Education Important Point is to read the label and recognize the Active Ingredients to avoid duplication of ingredients�


Source: The People’s Pharmacy. Beware brand name creep in the drugstore. October 9, 2006. Available online at: http://www.peoplespharmacy.com/archives/editorial/beware_brand_name_creep_in_the_drugstore.asp. Accessed 6/11/07.

Confusion in the OTC AisleConfusion in the OTC Aisle

Brand name Brand name extension productsextension products–– 50 different Tylenol50 different Tylenol©©

productsproductsExtra strengthExtra strengthArthritis strengthArthritis strengthPMPMVarious cold and flu Various cold and flu preparationspreparations

–– Look closely at ingredients Look closely at ingredients or overdose can occuror overdose can occur

Presenter�


You may be surprised to know that many OTC medicines may contain the same active ingredients in some prescription or common cold and flu medicines. Don’t combine pain relievers, prescriptions, or multisymptom medicines with the same active pain relief ingredient because this could result in taking too much of that ingredient, and too much of any one ingredient can lead to serious health problems. More is not better. Look closely at product labels and be aware that advertisements do not always list the active ingredients—don’t be fooled by product names.�


Brand Name ExtensionsBrand Name Extensions

Presenter�


Laxatives and stool softeners are different ingredients and used for different reasons but these two products have the same Name! – Dulcolax. If your doctor told you to buy Ducolax prior to a colonoscopy, how would you know which one to get?�


Presenter�


Does ‘Total stomach relief’ mean it is the same stuff but stronger than ‘regular’?�


Presenter�


NO- two different ingredients but they are both called Maalox! The one on the right ( the Total stomach relief one) contains an ingredient that makes your stools turn black and ‘hairy’ (Bismuth)- what if no one told you that and you bought it thinking it was just stronger Maalox?�


Presenter�


For many years, the well-known Kaopectate brand name has been used as an antidiarrheal (stops bowel movements) product. Now there is new Kaopectate product—a stool softener (increase bowel movements)! Thus the same brand name is used for products with opposing indications/actions. A stool softener is used when you are constipated, not when you have diarrhea! �


Presenter�


When buying an OTC, read the Drug Facts label carefully to make sure it is the right medicine for you. Prescription and OTC medicines don't always mix well with each other. Dietary supplements (such as vitamins and herbals) and some foods and drinks can cause problems with your medicines too. Ask the pharmacist if you have questions. Now, let’s look a little closer at the Drug Facts label.�


Active IngredientAn active ingredient is the chemical compound in the medicine that works with your body to bring relief to your symptoms. It can always be found as the first item on the label.

Active IngredientAn active ingredient is the chemical compound in the medicine that works with your body to bring relief to your symptoms. It can always be found as the first item on the label.

WarningsThis section will tell you what other medications, foods or situations to avoid (such as driving) when taking this medicine.

WarningsThis section will tell you what other medications, foods or situations to avoid (such as driving) when taking this medicine.

Presenter�


Know what active ingredients are in your medicine. An active ingredient is the chemical compound in the medicine that works with your body to bring relief to your symptoms; make sure that you aren’t using more than one medicine with the same active ingredient. Know what to avoid while taking an OTC medicine �Warnings (precautions)—safety measures to make sure the medicine is used the right way and to avoid harm (before, during, and after use). As with prescription medicines, some OTC drugs can cause side effects or reactions. Read the label to see what to avoid while you are taking an OTC drug. When using this product/possible interactions These are substances that should not be used while using the medicine. Find out if other prescription and OTC medicines, food, dietary supplements, or other items (such as alcohol and tobacco) could cause problems with the medicine Possible side effects (adverse reactions) Unwanted effects that the medicine can cause and what to do if you get them. Source: http://www.bemedwise.org/label/label.htm�


UsesSometimes also referred to as indications, this section tells you ONLY symptoms the medicine is approved to treat.

UsesSometimes also referred to as indications, this section tells you ONLY symptoms the medicine is approved to treat.

Presenter�


Uses (“indications” and “contraindications”) What the medicine is used to treat, (why it is being used), and when the medicine should/should not be used. Look for an OTC medicine that will treat only the symptoms you have The formulations of OTC drugs are very specific and should not be mixed and matched. Source: National Council on Patient Information and Education. The New Drug Facts Label. Available online at: http://www.bemedwise.org/label/label.htm�


DirectionsThe only recommended daily dosage and frequency of dosage will be listed here. You should follow this strictly. Its’ not just how much to take, but also how often.

DirectionsThe only recommended daily dosage and frequency of dosage will be listed here. You should follow this strictly. Its’ not just how much to take, but also how often.

Presenter�


Directions—the correct amount to use, or dose; how to measure it; how often to use it; what to do if you miss a dose; special directions on how to use the medicine, such as whether to take it with or without food. Taking too much of a nonprescription medicine can be harmful. Only take the recommended amount and at the exact intervals stated on the label. Source: National Council on Patient Information and Education. The New Drug Facts Label. Available online at: http://www.bemedwise.org/label/label.htm�


Inactive Ingredients

An inactive ingredient is a chemical compound in the medicine that has no effect on your body. Preservatives, items that bind the pill together and food colors are listed here.

Inactive Ingredients

An inactive ingredient is a chemical compound in the medicine that has no effect on your body. Preservatives, items that bind the pill together and food colors are listed here.

Presenter�


Inactive ingredients—(the part of the medicine that colors, flavors, shapes, preserves, or helps the medicine dissolve) have you had any problems with ingredients in medicines, such as colors, flavors, starches, sugars, preservatives? Check for allergies Example: red food coloring, gluten Check for tolerance Example: lactose intolerance http://www.bemedwise.org/label/label.htm�


Other InformationAny other important information about the product, such as how to store the medicine, will be listed in this section.

Other InformationAny other important information about the product, such as how to store the medicine, will be listed in this section.

Presenter�


Storage instructions—how and where to keep (or store) the medicine. Expiration—date after which the medicine may not work, or may be harmful to use. Source: National Council on Patient Information and Education. The New Drug Facts Label. Available online at: http://www.bemedwise.org/label/label.htm�


What Does this What Does this Medicine Treat?Medicine Treat?

Presenter�


Let’s look at the label you have in front of you. What does “Feel Better Cold and Fever Suspension” treat? What are the active ingredients? (Call on someone to provide one active ingredient and what it does. Call on a second person to provide the second active ingredient and what it does) (Can then click through 4 clicks to demonstrate all the places on the label that shows us what the medicine treats and with what ingredients.)�


This Medicine Treats:This Medicine Treats:FeverHeadacheMinor body aches and painsSore throatStuffy nose Nasal and sinus congestion

FeverFeverHeadacheHeadacheMinor body Minor body aches and aches and painspainsSore throatSore throatStuffy nose Stuffy nose Nasal and sinus Nasal and sinus congestioncongestion

Presenter�


(Confirm answers with this slide) Note difference on Drug Facts and what is on the main label.�


LetLet’’s Reviews Review

The new The new Drug FactsDrug Facts label appears on:label appears on:a) most prescription medicines.a) most prescription medicines.b) most OTC medicines. b) most OTC medicines. c) dietary and herbal supplements.c) dietary and herbal supplements.

Presenter�


Correct answer: B A- Rx drugs should come with consumer medication information printed at pharmacy and/or Med Guide, if required C- considered ‘food’ products so labeling not required- buyer beware Source: http://www.bemedwise.org/quiz_facts/quiz.htm �


What if you currently use an What if you currently use an OTC medicine for a cough?OTC medicine for a cough?

Before you buy headache medication, Before you buy headache medication, which section of the which section of the Drug FactsDrug Facts label label should you read and compare?should you read and compare?

a) Inactive ingredientsa) Inactive ingredientsb) Active ingredientsb) Active ingredientsc) Warningsc) Warnings

Presenter�


Answer: B http://www.bemedwise.org/quiz_facts/quiz.htm�


More ReviewMore Review

What kind of information will you find What kind of information will you find in the in the WarningWarning category on the new category on the new Drug FactsDrug Facts label?label?

a)a) When to ask a doctor or When to ask a doctor or pharmacist before using pharmacist before using

b)b) Possible side effects Possible side effects c)c) Directions for pregnant or Directions for pregnant or

breastbreast--feeding mothers feeding mothers d)d) All of the aboveAll of the above

Presenter�


Answer: D http://www.bemedwise.org/quiz_facts/quiz.htm�


Safe Medication UseSafe Medication UseUnderstanding and Understanding and

taking chargetaking charge……

Presenter�


Now we will discuss how you can take charge of the proper use of medication by yourself and those you care for�


What is Health Literacy?What is Health Literacy?

Health literacy is the ability to read, Health literacy is the ability to read, understand, and effectively use basic understand, and effectively use basic medical instructions and information. medical instructions and information.

Low health literacy can affect anyone of Low health literacy can affect anyone of any age, ethnicity, background, or any age, ethnicity, background, or education level. education level.

Presenter�


Read slide Health literacy is the ability to read, understand and effectively use basic medical instructions and information. Low health literacy can affect anyone of any age, ethnicity, background, or education level �


Health information can be Health information can be confusing at timesconfusing at times

Everyone wants help with Everyone wants help with health informationhealth information

Asking questions helps patients Asking questions helps patients understand how to prevent or understand how to prevent or manage illnessmanage illness

Presenter�


Let's face it. Medicine is prescribed to help you. But it can hurt you if you take too much or mix medicines that don't go together. If people can’t read or understand the label and written information given to them, they can be in trouble, have needless suffering, and end up costing the government or themselves more money to get better. Many people are harmed each year, some seriously, because of taking the wrong medicine or not taking the right medicines correctly. People who are confused about medication schedules don’t understand their disease or the reason to take their medicines prescribed to them and end up not taking their medications at all or taking them incorrectly. Source: Weiss BD. Assessing health literacy in clinical practice. Medscape Today. Available online at: http://www.medscape.com/viewprogram/8203�


Source: www.usp.org/pdf/EN/patient safety (accessed 8/06)

Link: Low Health Literacy Link: Low Health Literacy and Medication Misuseand Medication Misuse

A recent study shows that of people A recent study shows that of people with reading difficulty:with reading difficulty:–– 36% took more or less than prescribed dosage.36% took more or less than prescribed dosage.–– 28% completely omitted one or more prescribed 28% completely omitted one or more prescribed

medications.medications.–– 12% took an extra dose.12% took an extra dose.–– 8% used an unauthorized drug.8% used an unauthorized drug.–– 7% took medication at wrong time.7% took medication at wrong time.

Presenter�


Have you ever had a problem with your medicines? You are not alone. There are so many things to keep track of. For example, you may have asked yourself: -When exactly should I take my medicine? -Is it safe to take my vitamins when I am taking a prescription medicine? -Now that I feel better, can I stop taking my medicine? Follow Prescription Directions Always take medications as instructed by your doctor, pharmacist, or other health care professional, and do not change the way you take them unless instructed by them to do so. Monitor Your Reactions Side effects of prescription medicines can be due to many possible causes. If you experience unusual symptoms that begin after you start taking a new medication, contact your doctor, pharmacist, or other health care professional immediately. It is important to determine if a symptom was drug-related and whether or not you should continue taking the medicine. www.usp.org/pdf/EN/patient safety (accessed 8/06)�


Patients who understand Patients who understand health care information may:health care information may:

understand instructions andunderstand instructions andtake medications correctly.take medications correctly.–– visit doctors less often.visit doctors less often.–– have fewer hospitalizations.have fewer hospitalizations.–– have better health outcomes.have better health outcomes.–– have increased patient satisfaction have increased patient satisfaction

(feel better!).(feel better!).

Source: Wolf MS, Davis TC, et al. Misunderstanding of prescription drug warning labels among patients with low literacy. Am J Health Syst Pharm 2006;63:1048–1055.Weiss BD. 20 Common Problems in Primary Care. New York: McGraw Hill; 1999.Baker DW, Parker RM, Williams MV, et al. Health literacy and the risk of hospital admission. J General Intern Med. 1998;13:791–798.

Presenter�


(Read slide) If you don’t understand, it is important to ask to get better results! Patients who understand health care information may:�-understand instructions and take medications correctly. -visit doctors less often. -have fewer hospitalizations. -have better health outcomes. -have increased patient satisfaction (feel better!).�


CheckCheck--upup Prescription PickPrescription Pick--upup

Is this your medicine?Is this your medicine?State your address and date of State your address and date of birth; do you match the information birth; do you match the information on the prescription receipt? on the prescription receipt? Do pharmacy employees open the bag and Do pharmacy employees open the bag and compare the name on the receipt with the name compare the name on the receipt with the name on the prescription label?on the prescription label?Do pharmacy employees offer you the Do pharmacy employees offer you the opportunity to talk to the pharmacist?opportunity to talk to the pharmacist?–– Know what you are signing.Know what you are signing.

Presenter�


Ask for information about your medicines in terms you can understand—both when your medicines are prescribed and when you receive them. Read the label before you leave the pharmacy with your prescription; be sure you have the right medicine, know the right dose to use, and know how to use it. What is the medicine for? How am I supposed to take it, and for how long? What side effects are likely? What do I do if they occur? Is this medicine safe to take with other medicines or dietary supplements I am taking? What food, drink, or activities should I avoid while taking this medicine? If you have bought the medicine before, make sure that this medicine has the same shape, color, size, and packaging. Anything different? Ask your pharmacist. Do they offer you the opportunity to talk to the pharmacist? Know what you are signing. You may be signing a statement that says you didn’t want to talk to a pharmacist.�


Keep medications in original Keep medications in original containerscontainersNever take someone elseNever take someone else’’s s medicationmedicationRead the label every time you take a doseRead the label every time you take a doseKeep a current list of your medicationsKeep a current list of your medicationsList your allergies (food, herbal, drugs)List your allergies (food, herbal, drugs)Place medication in a safe locationPlace medication in a safe location

What to DoWhat to Do…… AT HOMEAT HOME

Presenter�


READ THE LABEL AND FOLLOW DIRECTIONS Read the label each time you buy an OTC medicine or fill your prescription. Using too much of any active ingredient may increase your chance of unwanted side effects. It helps to give a written list of all your medicines and treatments to all your doctors, pharmacists, and other team members. Keep a copy of the list for yourself and give a copy to a loved one. Teen “Pharming” Teens abuse prescription drugs to get high. Prescription pain killers are second—only behind marijuana—as the nation's most prevalent illegal drug problem. Teens “steal” medications from you; you may not realize how easy it is for them to get your prescription medications.�


Lock Up Your MedicinesLock Up Your Medicines

Prescription pain killersPrescription pain killersAntiAnti--anxiety medicationsanxiety medicationsMedications for sleepMedications for sleepYou play a big role in You play a big role in keeping these powerful keeping these powerful medicines out of the medicines out of the hands of those who hands of those who shouldnshouldn’’t have themt have them

Presenter�


Does anyone in your home have these prescription drugs? (Refer to slide). If so, lock them up and dispose of them properly when no longer needed. Store medications where children cannot see or reach them—for example, in a locked box or cabinet. Teach children that medications can be dangerous if misused. �


Source: SMARxT Disposal Campaign

Disposal of Unused/Expired MedsDisposal of Unused/Expired MedsTake medication as directed, including Take medication as directed, including length of time.length of time.Discard when too old or no longer needed Discard when too old or no longer needed –– See expiration date, beyond use date, or See expiration date, beyond use date, or ““EXPEXP””

on Rx label or OTC package.on Rx label or OTC package.Do not flushDo not flush unused medications.unused medications.–– UNLESS insert specifically says it is OK. UNLESS insert specifically says it is OK.

Check with your local government. Check with your local government. –– Household hazardous waste facilities. Household hazardous waste facilities. –– Ask your pharmacist about takeAsk your pharmacist about take--back locations that allow back locations that allow

the public to bring unused drugs to a central location for the public to bring unused drugs to a central location for safe disposal.safe disposal.

Presenter�


Dispose of all medicines promptly after their expiration date and be careful not to throw them away where children or pets may find them. �


Source: SMARxT Disposal Campaign.

Proper DisposalProper Disposal

Do not flushDo not flush unused medicationsunused medicationsBe proactive and dispose of unused medication yourself Be proactive and dispose of unused medication yourself in household trash. in household trash. –– For pills, pour into plastic bag before crushing or For pills, pour into plastic bag before crushing or

dissolve in water to prevent airborne particles.dissolve in water to prevent airborne particles.–– Crush medication.Crush medication.–– For liquid medications, pour into a plastic bag.For liquid medications, pour into a plastic bag.–– Mix kitty litter or coffee grounds in the plastic bag containingMix kitty litter or coffee grounds in the plastic bag containing the the

medication.medication.–– Seal the plastic bag to reduce the risk of potential poisoning.Seal the plastic bag to reduce the risk of potential poisoning.–– Place sealed plastic bag in household trash for disposal.Place sealed plastic bag in household trash for disposal.–– Remove and destroy ALL identifying personal information Remove and destroy ALL identifying personal information

(prescription label) from the medication container.(prescription label) from the medication container.–– Recycle empty medication container as allowed in the local Recycle empty medication container as allowed in the local

recycling area or throw it in the trash.recycling area or throw it in the trash.

Presenter�


Dispose of all medicines promptly after their expiration date and be careful not to throw them away where children or pets may find them. (Read slide) Do not flush unused medications Be proactive and dispose of unused medication yourself in household trash. For pills, pour into plastic bag before crushing or dissolve in water to prevent airborne particles. Crush medication. For liquid medications, pour into a plastic bag. Mix kitty litter or coffee grounds in the plastic bag containing the medication. Seal the plastic bag to reduce the risk of potential poisoning. Place sealed plastic bag in household trash for disposal. Remove and destroy ALL identifying personal information (prescription label) from the medication container. Recycle empty medication container as allowed in the local recycling area or throw it in the trash. Source: SMARxT Disposal Campaign (www.pharmacist.com). Traces of caffeine and byproducts of drugs -- including antibiotics, anticonvulsants, mood stabilizers and hormones -- were found in the drinking water of 24 major metropolitan areas, according to a five-month study conducted by the Associated Press. While some scientists say that the chemicals' presence in the water poses little human health risk, others have expressed concern that regular exposure to these "emerging contaminants" may cause health problems in the long run. �


Your PharmacistYour PharmacistHow to engage and work How to engage and work with your pharmacistwith your pharmacist……

Presenter�


How can your pharmacist help you?�


The Solution to Ensuring The Solution to Ensuring Safe Medication UseSafe Medication Use

Pharmacists are the key health care Pharmacists are the key health care professionals to talk with regarding professionals to talk with regarding medication use issuesmedication use issues–– Patients trust and respect themPatients trust and respect them–– They know what medications are being taken They know what medications are being taken

and how to identify problemsand how to identify problemsCommunity pharmacists Community pharmacists –– Available in locations close to you Available in locations close to you –– They dispense medications They dispense medications –– They provide patient education, counseling, They provide patient education, counseling,

and monitoring of drug therapyand monitoring of drug therapy

Presenter�


Pharmacists are the most widely accessible health care professionals—there is a pharmacy on many street corners. Ask how to use the medicine correctly Read the directions on the label and other information you get with your medicine. Have the pharmacist explain anything you do not understand. Are there other medicines, foods, or activities (such as driving, drinking alcohol, or using tobacco) you should avoid while using the medicine? Ask if you need lab tests to check how the medicine is working or to make sure it doesn't cause harmful side effects.�


Pharmacists have the skills to:Pharmacists have the skills to:

help you select the appropriate help you select the appropriate medication,medication,work with your physician and other health work with your physician and other health care team members on your medication care team members on your medication treatment plan,treatment plan,eliminate medication duplication, eliminate medication duplication, screen for drugscreen for drug--drug interactions, and drug interactions, and tailor your medication regimen to your tailor your medication regimen to your individual needs. individual needs.

Presenter�


Pharmacists work with you and your doctor to evaluate your medications and compare them to the disease or symptoms you are trying to treat. Refer to information on slide Pharmacists work with you and your doctor to evaluate your medications and compare them to the disease or symptoms you are trying to treat.�


Community pharmacies offer:Community pharmacies offer:

Preventive servicesPreventive services–– Blood pressure screeningsBlood pressure screenings–– Bone density screeningsBone density screenings–– Pulmonary function testing Pulmonary function testing –– Cholesterol testing Cholesterol testing –– Diabetes education Diabetes education –– ImmunizationsImmunizations

Presenter�


Does your pharmacy offer these services? Do you use them? Many times they are available free of charge�


And moreAnd more……

Professional services Professional services –– Education on new and refill medicationEducation on new and refill medication–– Assistance and advice on selection of Assistance and advice on selection of

OTC and herbal products OTC and herbal products –– TakeTake--home patient literature on home patient literature on

prescribed medicationsprescribed medications–– Compliance/persistency reminder programsCompliance/persistency reminder programs–– Health condition informationHealth condition information

Coordinate care with your other health Coordinate care with your other health care providerscare providers

Presenter�


Review slide with audience�


When taken correctly:When taken correctly:–– for every $1 spent on Rxfor every $1 spent on Rx

medication, there is $4 medication, there is $4 decrease in hospital costs.decrease in hospital costs.

–– for every $3 spent on for every $3 spent on asthma medication,asthma medication,

–– there is a $17 decrease in emergency there is a $17 decrease in emergency room spending.room spending.

Source: NACDS Practice Memo. It’s time to talk about value. Available online at: http://www.practicememo.com/Archives/html/2006/Nov06.html

Why Talk with Your Pharmacist? Why Talk with Your Pharmacist?

Presenter�


Rxs may be expensive, but consider the cost to the benefits value. When taken correctly, medications can lead to better disease state management and better quality of everyday life. If you need help paying for prescriptions, ask your pharmacist or doctor for government and pharmaceutical sources. Source: National Association of Chain Drug Stores. http://www.nacds.org/�


Solutions?Solutions?

Know your medicineKnow your medicine……know your pharmacistknow your pharmacistWritten information Written information should include:should include:–– name of medication.name of medication.–– purpose for taking it.purpose for taking it.–– how long to take it.how long to take it.–– possible adverse effects.possible adverse effects.–– how much and how often.how much and how often.

Presenter�


If you are not sure, ask the pharmacist. The pharmacist is there to answer your questions.�


PharmacistsPharmacists improving medication useimproving medication use……advancing patient careadvancing patient care

Presenter�


Any questions?�


Supported through a grant from the Community Pharmacy Foundation

AmericaAmerica’’s s Medicine CabinetMedicine Cabinet

Proceed with Proceed with (Pharmaceutical) (Pharmaceutical)

CareCare

Presenter�


Welcome to America’s Medicine Cabinet. Today, we are going to talk about prescription and over-the-counter (or OTC) medicines. This presentation was created by the American Pharmacists Association (APhA) and the Institute of Safe Medication Practices (ISMP) and was supported through a grant from the Community Pharmacy Foundation.�

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