Gray matters

BY Alaric DeArment

According to the Administration on Aging, the United States is similar to many other countries in the developed world — and even a few in the developing world — in that the population is getting older. According to the AOA, people in the United States ages 65 years and older numbered 39.6 million in 2009, a number expected to reach 72.1 million by 2030. In 2000, the elderly represented 12.4% of the population in the United States, but will constitute 19% of it in 17 years.

With aging comes a rise in the associated health problems and the need to take medications to address them. According to a 2006 Boston University study, more than 25% of patients ages 65 years and older use five or more prescription drugs per week. A Centers for Disease Control and Prevention survey of 2010 Medicare beneficiaries found that 68.4% of Medicare beneficiaries had two or more chronic conditions and 36.4% had four or more chronic conditions.

With more chronic conditions and more medications come an increased risks of falls and drug interactions, not to mention the pain associated with many health problems.

Following are three key issues that pharmacists and clinicians should be talking about with elderly patients.

Many of the drugs taken by seniors can increase their risk of becoming drowsy or dizzy — and in turn increase the risk of falling.

According to the Centers for Disease Control and Prevention, the risk of falls resulting in injury increases dramatically after age 75. The overall rate for all age groups is 43 falls per 1,000 people, and it’s still less than 60 at age 74; but after age 75, the rate increases to 115 falls per 1,000.  The second highest rate, slightly above 60-per-1,000, is found among people ages 12 to 17 years.

According to Emily Hensley, a Safeway pharmacy manager in Chicago, medications that elderly people take can greatly increase the risk of falls, making it an important topic to discuss with patients. These include opioids like oxycodone and fentanyl; anti-anxiety benzodiazepines like clonazepam, lorazepam and diazepam; such antihistamines as cyproheptadine, diphenhydramine and meclizine; and gastrointestinal drugs like ranitidine, atropine and loperamide.

“We tend to start talking about how medication affects you before you drive, but also let them know that if they get too drowsy or sleepy, they may risk falls,” Hensley told DSN Collaborative Care.

Important things patients should do, Hensley said, are make sure they don’t have bumps in their rugs, hold onto something like the armrest of a chair or a counter when standing up quickly, make sure their shoes fit correctly and take measures to avoid slipping in the shower.

Pain management
Pain among elderly people can result from a variety of causes — arthritis, circulation problems, shingles and cancer to name a few. Many elderly people with chronic pain may use such prescription drugs as opioids or such OTC medications as ibuprofen and acetaminophen.

But other treatments also exist, such as acupuncture and homeopathic remedies, which tend not to have drug interactions. “From a homeopathic point of view, those could be introduced without having to change the dose of a prescription drug,” Hyland’s homeopathic medical and scientific director Iris Bell said.

Similar issues that affect the elderly include restless legs syndrome, also known as Willis-Ekbom disease, and muscle spasms — both of which are treatable with homeopathic remedies. According to the Willis-Ekbom Disease Foundation, RLS affects 7% to 10% of Americans. Meanwhile, muscle spasms can result from a wide range of problems, such as electrolyte disturbances and calcium deficiency.

“The first step is always appropriate medical evaluation to rule out any causes that should be treated,” Bell said.

Drug interactions
Use of drugs by elderly people also increases the risk of interactions between prescription drugs, OTC drugs and supplements. 

A 2005 Kaiser Permanente study published in the journal BMC Geriatrics found that 84% of elderly women had used more than one dietary supplement, and 25% had used an herbal.

St. John’s wort can interact with non-steroidal anti-inflammatory drugs, or NSAIDs; anti-clotting drugs; antidepressants; anesthesia; HIV antivirals; and chemotherapy drugs. For other common interactions, see the chart to the right.

In terms of depletions, many drugs can leech essential nutrients from the body. For example, thiazide-type diuretics can deplete potassium from the body, as well as magnesium, zinc and sodium, according to the Chiropractic Resource Organization. Meanwhile, cholesterol-lowering statins can deplete Co Q-10, which can cause an increased risk of heart failure, muscle pain and mood disorders.


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Techs as heroes

BY Jim Frederick

Millions of Americans struggle daily with the cost of their prescription drug medications, leading to drop-offs in adherence and, all too often, a reduction in health outcomes and quality of life.

Financial help is available from many sources, including public and private grant programs and community organizations — and from drug companies themselves in the form of discounts and co-pay assistance. But many patients are unaware of such programs or struggle to find one that fits their needs.

Pharmacy technicians can help. Armed with information about funding sources and patient assistance programs, they can step into the knowledge void and be a key resource for patients at their most vulnerable — when they’re dealing both with disease and with the newfound financial burdens that come with their condition.

A vast arsenal of financial assistance programs from pharmaceutical companies, community assistance programs and other sources of funding and defrayed costs is out there, much of it accessible via the Web. The question, say pharmacy leaders, is where to look.
“Many adults older than 55 years need help paying for prescription drugs, health care, utilities and other basic needs,” the National Council on Aging reported. “There are more than 2,000 federal, state and private benefits programs available to help. But many people don’t know these programs exist.”

The issue resonates loudly with lower-income and fixed-income patients beset by rising out-of-pocket costs for their prescription medicines, and plays a very real part in the failure of millions of patients to adhere to their drug regimens. Even though IMS Health estimates that 72% of all U.S. prescriptions cost patients only $10 or less out-of-pocket in 2012, much of that is due to the “increasing use of generics, typically costing less than $10 for a prescription,” the healthcare research firm reported.

What’s more, that doesn’t take into account overall out-of-pocket health expenses, which are rising dramatically for insured Americans. Despite the rapid rise in lower-cost generics at the prescription counter, patients are feeling the squeeze as insurance companies, employers and other health plan payers, and pharmacy benefit managers shift more of the cost of prescription therapy onto their plan members. “Payers have been shifting more of the burden of insurance and prescription drug costs to patients,” IMS noted in its 2012 U.S. Medicines Report. “Patient out-of-pocket cost increases have been seen in both PPO [preferred provider organization] plans and CDHPs [consumer-driven health plans].

“Patients with insurance are paying higher deductibles and higher co-pays or co-insurance, and those with newer kinds of health plans have much greater visibility and responsibility for the overall costs of their care,” IMS reported. “Many traditional insurance plans also now carry a high deductible, and patients face a much higher portion of costs than in the past.”

Indeed, said IMS researchers, “patient out-of-pocket costs have risen three times higher than they were five years ago, and seven times higher in consumer-driven health plans.”

Average annual out-of-pocket health costs for Americans will likely approach $1,200 in 2013, according to IMS projections.

As costs go up, patients tend to stray from needed health services, including prescription therapy. “Patients’ exposure to rising out-of-pocket costs may be having an effect on their utilization of healthcare services,” IMS reported. “Rising co-pays or co-insurance are linked to increased abandonment and poorer adherence, while conversely, patients who pay less out of pocket are less likely to abandon medication and more likely to stay on therapy.”

Chris DuPaul, director of strategic development for CVS Caremark, cited the out-of-pocket cost burdens of some prescription therapies — particularly for patients who are uninsured or underinsured and on very restricted drug formularies — as one of the key “factors predictive of primary nonadherence.”

“Compared to preferred medications, non-formulary medications were 17% less likely to be filled and non-covered medications were 86% less likely to be filled, as those medications translated into higher out-of-pocket costs for patients,” DuPaul said. Given those findings, he added, it’s no surprise that “patients who live in higher-income areas [are] more likely to fill prescriptions for new medications.”

The issue of prescription costs, of course, is even more pressing for patients not covered by any insurance plan. “More than 46 million people in this country [are] without health insurance, and countless millions [have] substandard health insurance,” noted RxHope, an organization that provides information on financial resources for patients with limited financial resources or no health coverage.

This “growing uninsured population,” coupled with a near doubling of prescription drug dispensing in hospital outpatient pharmacies in recent years and “declining reimbursement rates” that “threaten traditional dispensing models,” is posing significant challenges to outpatient pharmacies, according to Stephen Eckel, PharmD, a long-time champion for boosting the role of technicians as assistant director of pharmacy and residency programs director at the University of North Carolina’s Eshelman School of Pharmacy.

The rapid growth of specialty pharmacy and its array of complex, high-cost drug treatments also is sure to drive community pharmacy’s need for technicians who can help serve as a bridge between cash-strapped patients and financial assistance programs. Costing, on average, far more than traditional branded drugs in both total price per dose and in the out-of-pocket portion of the cost for which patients bear the burden, specialty medications accounted for 26.7% of the $235 billion spent on brand-name drugs last year in the United States, according to IMS.

“Spending on new specialty medicines increased dramatically, with almost two-thirds of 2012 total new brand spending driven by specialty products,” IMS noted.

As “high-cost specialty drugs consume a growing portion of the pharmacy dollar,” to quote a report from pharmacy benefit management company and specialty pharmacy provider Catamaran, Americans’ sticker shock at the pharmacy counter will only increase. So, too, will their need for advice from pharmacy staff, including both pharmacists and technicians, on where to go for financial assistance and manufacturer-sponsored discount programs to allay the sometimes staggering out-of-pocket costs of complex, newer-generation specialty medicines, some of which can cost patients and their health plan payers a combined total of $100,000 or more each year.

However, help is available, including manufacturer-sponsored discount and co-pay assistance programs. Indeed, said Kevin James, VP managed markets at Avella Specialty Pharmacy in Phoenix, “it seems that most any new specialty drug that comes out now is going to have some form of patient assistance tied to it. It’s become very common.”

Financial assistance, he added, “absolutely improves adherence rates. If the patient can afford the medication, certainly it drives adherence to the medication.”

Besides the range of financial help available to qualifying patients, pharmacy techs also shouldn’t forget another source of very low-hanging fruit when it comes to helping prescription customers save money — and it’s much closer to home. That’s the availability, in many cases, of lower-cost generics and alternative drug therapies that sit on the pharmacy shelves. Working side-by-side with pharmacists, techs should be aware that “$55.8 billion was spent unnecessarily on higher-priced medications” in 2012, according to a recent Drug Trend Report from Express Scripts, “when more affordable, clinically equivalent alternatives were available.”


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CRN revises membership requirements, dues structure

BY Michael Johnsen

WASHINGTON — The Council for Responsible Nutrition on Wednesday announced changes to its bylaws, offering new classes of membership and a revised dues structure. The move allows more kinds of companies to join the association "to more fully recognize the evolving nature of the dietary supplement industry."

“CRN has been fortunate to see a steady stream of membership growth in recent years, and with these changes to our membership categories and dues structure, we are poised to welcome even more companies who manufacture or market dietary supplements or functional foods," stated Steve Mister, CRN president and CEO. "In addition, our new dues structure recognizes that many industry players have multiple roles, and more fairly reallocates the obligations of membership. Together these revisions will strengthen CRN and the future of our industry.”  

CRN now recognizes four categories of voting members — branded finished product manufacturers, contract manufacturers, ingredient manufacturers and ingredient representatives/distributors — each with different dues rates.

In addition, CRN now offers a four-tiered dues structure in the associate member category, dependent on the size of the company, making membership more affordable for single practitioners. “The bottom line,” Mister said, “is we value the role of our associate members and their continued contribution to the industry, and we needed to recognize that one-size-fits-all dues was not the ideal model for this category.”  

The revised by-laws also address the functional food category. Unlike dietary supplements, there is no regulatory definition for functional foods. Although CRN has welcomed functional food companies for over a decade, the new by-laws create a definition as “any product that is properly labeled as a ‘food’ (i.e., uses a Nutrition Facts label) under the U.S. Food, Drug & Cosmetic Act, that is formulated specifically to increase the intake of certain nutrients or other compounds and for which the manufacturer makes structure/function or health claims in its labeling.”

CRN will continue to represent store brand retailers of all sizes — those who market their own unique store brands of dietary supplements or functional foods, both brick and mortar and online. The change clarifies that these firms pay dues based only on the dietary supplements and functional foods they market under their own labels and allows them to have a voice in directing the future of the industry through CRN membership.

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