ASHP InterSections ASHP InterSections

November 13, 2020

Pharmacists Take the Lead in Providing Vaping Interventions

Kimberly Novak, Pharm.D., BCPS, BCPPS, FPPA, with PGY2 residents Becca Wytiaz and Mara Rubin.

AN INCREASE IN THE USE OF E-CIGARETTES AMONG adolescents in the U.S. is erasing recent progress in reducing overall tobacco use in this population, according to alarming statistics from the Centers for Disease Control. Some 27.5% of high schoolers and 10.5% of middle schoolers reported current use of e-cigarettes, the CDC reported in a recent issue of the Morbidity and Mortality Weekly Report, creating an immense opportunity for pharmacists to get involved.

Vaping and COVID-19

In 2019, there was a surge in E-cigarette or vaping product use-associate lung injury (EVALI) which was particularly noted in adolescents and young adults. Interestingly, there was an observed decrease in EVALI cases early in 2020, explained Kimberly Novak, Pharm.D., BCPS, BCPPS, FPPA, an advanced patient care pharmacist in pediatric and adult cystic fibrosis at Nationwide Children’s Hospital in Columbus, Ohio. “This was originally attributed to increased public awareness of vaping and strategies aimed at reducing marketing and access of flavored vaping products of preferred by this population,” said Dr. Novak. “However, this decrease also corresponded with the initial surge in COVID-19 cases and many state-mandated stay-at-home rules as well as increased implementation of work-from-home and virtual school policies.”

As many of these policies were loosened in the summer months, health care practitioners have noted an increase again in EVALI cases, perhaps due to less supervision as parents returned to onsite work, she added.

Pharmacist roles

In general, e-cigarette usage in adolescents “has blown up among this population way more than people suspected, particularly because it’s so easy to hide, and it doesn’t smell,” said Dr. Novak. “This snuck up on us as a society with very little regulation, and now we’re working backward, trying to catch up to this epidemic that got out of the bag before we got a hold on it.”

Kyle Mays, Pharm.D., BCPPS, discusses cessation options with a teenage patient.

Pharmacists can play several important roles in patient care regarding e-cigarette usage and related lung injuries, said Dr. Novak, an ASHP member since 1998. In teaching hospitals like hers, pharmacists provide continuity where attending physicians and residents may change over. They also can monitor trends in nicotine usage, and, because patients view pharmacists differently than their physicians, they may share more information about medication histories with them.

Typical agents prescribed to help curb nicotine cravings, like varenicline (Chantix) and bupropion (Zyban, Wellbutrin), are not indicated for people under the age of 18, noted Justin Reinert, Pharm.D., BCCCP, a clinical assistant professor at the Ben and Maytee Fisch College of Pharmacy at the University of Texas at Tyler. This doesn’t mean physicians aren’t prescribing them for this population, he said, but pharmacists can employ motivational interviewing techniques and assess patients’ readiness to change.

Interventions to reduce usage

In addition, pharmacists can use their medication expert hat to advise primary care teams on different vaping products used by teens, said Kyle Mays, Pharm.D., BCPPS, a critical care pharmacist with SSM Health Cardinal Glennon Children’s Hospital in St. Louis. When his hospital saw a recent surge in illnesses among patients using THC-related vaping compounds, some of his colleagues weren’t aware these products were linked to lung injuries because of the solvents and vitamin E they contained. If patients are admitted with severe lung illnesses and are intubated and can’t speak, Dr. Mays and colleagues play detective, eliminating potential causes or ordering urine toxicology screens.

Justin Reinert, Pharm.D., BCCCP

In an effort to address e-cigarette usage in his area, Dr. Reinert is directing a two-fold intervention. Pharmacists and doctoral pharmacy students are providing educational in-services and assemblies in local schools, as well as surveying high school students about their use of nicotine products. Then, beginning this fall, pharmacy students will provide nicotine cessation programs in schools, targeted to high schoolers who may have violated a tobacco or nicotine use policy.

Among over 100 students they surveyed so far, about 78% reported using these products, said Dr. Reinert, an ASHP member since 2013. “Students are primarily into vaping, but it’s important to be cognizant of other things out there,” he noted. “Kids are still smoking cigarettes, they’re still using cigar wrappers for marijuana. The addictive component of the devices remains nicotine.”

Dr. Reinert tries to use shock value to educate the students, asking how many of them who drive and pump gas would stick the gas nozzle into their mouths and inhale. “There are components in these vaping cartridges that are identical to components of unleaded gasoline—lead, mercury, nickel, cadmium and heavy metals, etc.,” he said. “The students have no idea, which is terrible, but it also highlights the need for targeted education at this age group, which I think pharmacists are uniquely positioned to accomplish.”

Strategies for pharmacists    

The pharmacists offered advice on working with adolescent patients and their families:

  • Take an objective yet compassionate stance. “Don’t tell them they’re [doing something] wrong,” Dr. Novak said, as that can cause the patient to shut down and not disclose information. Instead, acknowledge that they may have made an unhealthy choice but keep the lines of communication open. “Your job is to treat the patient and make them better, not ridicule what they were doing that brought them in,” added Dr. Mays, an ASHP member for the past 10 years.
  • Put your message in terms relative to adolescents. Dr. Reinert’s cessation curriculum discusses the financial, health and psychosocial ramifications of nicotine use at a level appropriate for adolescents, not adults or younger children.
  • Offer resources for quitting. Educate adolescents that, similar to cigarettes, it’s hard to quit cold turkey, Dr. Mays noted. Encourage them to seek appropriate help through their pediatrician or another primary care provider, and work with them to develop a plan.
  • Try to talk to the patients without their parents. Patients may not want to fully admit to using these products, especially if their parents are present, Dr. Mays said.
  • Keep current on your knowledge. People tend to think JUUL devices are the e-cigarette of choice for teens, but new ones are popping up all the time, said Dr. Mays. “You have to stay trendy with what’s going on in a teenager’s mind,” he added.

Patient impact

Vaping devices essentially are nebulizers that deliver a drug, Dr. Novak said. But they haven’t yet been adequately studied to determine what products should go in them, what the safety margins are, or if chemicals put into them are altered by heat that the devices generate. Hopefully, with time, she said, the medical community will learn better safety information about these devices and their related products.

Meanwhile, pharmacists should stay involved, such as working with ASHP to advocate for more regulation around vaping and nicotine products. “The more we can do this on an individual level, whether in our own institutions, providing education or working with poison centers, we can make a pretty positive impact wherever our patients are,” said Dr. Novak.

 

By Karen Blum

 

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June 1, 2010

Achieving Balance in Today’s Connected World

Diane Ginsburg, M.S., FASHP

SOCIAL NETWORKING HAS BECOME such a standard part of my day that it’s hard to believe that just a decade ago, Facebook, Twitter, etc., were mere blips on the horizon. I have to admit that it’s easy to get a little compulsive about posting updates, keeping in touch with friends and colleagues, and sharing information and opinions on everything from my latest travel exploits to what’s happening in the classroom.
As a pharmacy educator, I am blessed to be surrounded by many soon-to-be practitioners. It’s fun to tap into their wealth of knowledge about this digital world and to see how creating a virtual identity is almost second nature to this generation.

But social networking is not without its perils. As you’ll see in this issue’s cover story (page 8), we all are navigating in uncharted waters. In this new world, we’re collectively trying to figure out how best to maintain our professionalism online while taking advantage of the many social benefits of this technology. I hope the tips and tools you’ll find in the story help you to chart your course online.
You may not be aware that a lion of our profession retired recently. Rear Admiral Robert Pittman, B.S.Pharm., M.P.H., U.S. Navy, recently spoke with InterSections about his service (page 14) with the U.S. Public Health Service Commissioned Corps and the Indian Health Service. RADM Pittman’s work to bring health care to rural patients and positively influence the federal pharmacy practice model is an inspiring story for us all.
I’m sure you’ve followed the aftermath of recent catastrophic events, such as the earthquakes in Haiti and Chile. The untold story is one that’s happening at the frontlines among patient-care providers. Pharmacists who are part of Disaster Medical Assistance Teams (DMATs) and International Medical Surgical Response Teams are stepping in and providing valuable patient care. Interested in learning more about DMATs? Check out the story on page 12.

Finally, as pharmacists move into more direct patient-care roles, they are finding many opportunities to influence the health of their patients. Take a look at page 19 to see how pharmacists are using the Rx for Change (Ask-Advise-Refer) program to help patients stop using tobacco products. It’s amazing what a simple question can do to get the ball rolling toward achieving better health!
Hope you enjoy this issue! If you have any questions or suggestions for future stories, please send me an e-mail at prez@ashp.org or intersections@ashp.org. Looking forward to hearing from you!

Diane Ginsburg, M.S., FASHP

Pharmacists Adopt Simple Tobacco-Cessation Tools

ROUGHLY ONE IN FIVE ADULTS in the U.S. uses tobacco products, according to the Centers for Disease Control and Prevention. That figure represents a tremendous opportunity for pharmacists to provide tobacco cessation counseling that can save lives, an opportunity not lost on the profession as a whole.

Karen S. Hudmon, Dr.Ph.

Indeed, roughly 85 percent of pharmacy schools train their students in techniques to help patients stop using tobacco products through Rx for Change, a shared curriculum being disseminated by the University of California-San Francisco Schools of Pharmacy and Medicine and promoted by the ASHP-supported Pharmacy Partnership for Tobacco Cessation (PPTC).

Initiating the Discussion
One of the most useful techniques featured in Rx for Change is a brief intervention called Ask-Advise-Refer (AAR). Using this intervention, pharmacists can ask patients about tobacco use, advise them to quit, and refer them to 1-800-QUIT NOW, a national quitline that connects to counselors located in each patient’s state.

“In many cases, it’s unrealistic for pharmacists to provide comprehensive counseling, from start to finish, so we are also promoting an approach where the pharmacist is the initiator of the quitting process,” said Frank M. Vitale, M.A., national director of PPTC and senior lecturer, pharmaceutical sciences, University of Pittsburgh School of Pharmacy.

“Most people have no idea how to quit,” Vitale adds. “They don’t understand that it’s more than just making yourself stop. So, pharmacists’ referring is a huge intervention because it gets people thinking about actual steps to take.”

Hospital and health-system pharmacists have unique opportunities to help change the tobacco-related behaviors of patients within their care, according to Karen S. Hudmon, associate professor in the Department of Pharmacy Practice at Purdue University, Indianapolis. Hudmon, along with her colleagues at UCSF, developed the Rx for Change curriculum.

“Any pharmacist who has contact with the patient has an opportunity,” she said. “Tobacco use should be addressed with all patients, including, but not limited to, cardiac patients, pulmonary patients, cancer patients, pregnant women, patients with mental illness, and patients undergoing surgery.”

Hudmon noted that hearing about tobacco cessation from a pharmacist reinforces what physicians have already tried to impart. “Studies show that people are more likely to quit when they hear the message through multiple providers,” she said.

A Touchy Subject
One of the challenges of using AAR is getting through the first step—asking a patient if he or she smokes or uses tobacco.

“In clinics, nurses tend to ask because it’s a routine part of their job,” said Alan J. Zillich, Pharm.D., associate professor in the Department of Pharmacy Practice at Purdue and research scientist at the Roudebush Veterans Administration Medical Center in Indianapolis. “But it’s not something that pharmacists have traditionally done, so there isn’t necessarily a routine for incorporating it into our patient interactions.”

Sometimes, the ability to conduct outreach comes down to a simple matter of personal comfort. “There’s a reluctance particular to community pharmacy when it comes to asking people about their tobacco use,” said Zillich. “But if you don’t ask, you can’t help patients quit.”

The approach should always be respectful of the patient, said Hudmon. “Before asking questions about smoking or imparting advice, ask for permission to do so. ‘Do you mind if I ask you a few questions?’ and ‘May I tell you what concerns me [about your smoking]?’ ”

Vitale added that pharmacists often have a ready-made reason for asking: namely, drug interactions. “In training students and clinicians, we provide them with a list of medications known to interact with smoking,” he said. “If a patient is taking a medication that is on the list, that’s a perfect opportunity to start the conversation.”

Vitale, who has counseled more than 15,000 patients about smoking cessation, said that he finds a common theme among tobacco users. “You discover very quickly that most smokers hate it and want to stop,” he said. “But many have that little voice that wants them to find an excuse to continue. If you, as a health professional, don’t say anything, you could be providing them with that excuse to continue.”

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