How to Utilize Your Pharmacist In the Inpatient/Hospital Setting

1. How to Utilize Your PharmacistIn the Inpatient/Hospital Setting Julie Dopheide, PharmD, BCPP Associate Professor USC School of Pharmacy dopheide@usc.edu NAMI 2007 Annual Convention June 22, 2007

2. My experience…. • Psychiatric Pharmacist specialist at LAC+USC Inpatient Psychiatric service • 40 bed adult unit, 12 bed adolescent unit • 12 years of clinic experience (1988-2000) • Pharmacist Specialist at Kaiser Mental Health Center in Los Angeles, CA • 60 bed adult unit, partial hospitalization program • Consulting Clinical Pharmacist at BHC Alhambra Hospital in Rosemead, CA • 25 children, 15 adolescents, 40 adults general psychiatry • Eating Disorders inpatient, partial hospitalization unit

3. Psychiatric Hospitalization • Relief that treatment is underway in a safe place, with trained medical staff • Fear regarding an unknown medical team, medication changes, limited contact with loved one(s) • Concern that symptoms are not fully stabilized before discharge • Unaware that a pharmacist is actively participating in care and can be a resource

4. Role of the Pharmacist • Multidisciplinary treatment planning • Individual medication review, recommendations • Appropriate medication, dose, duration of tx • Drug intx screening, monitoring, simplify dosing • Fill prescriptions for routine and prn medications • Proper labeling, integrity, security of medications • Education of patients, treatment team, family • Individual counseling, medication group, discharge counseling, family meetings, new drug inservices

5. Medication Recommendations“Another pair of eyes….” • “Dose too low”, “Dose too high” • “Adequate trial has not been achieved yet, allow more time before change” • “Give at bedtime to minimize daytime sleepiness” or “Give in am to prevent insomnia” • “Check liver, kidney, thyroid, cholesterol, glucose, to ensure safety of medication” • Interpret lithium or valproate blood level

6. Individual Medication Review • JJ is a 22 year old hospitalized for running naked in the street; paranoid, not sleeping, Dx: Schizoaffective • Current medications: risperidone 4mg/d, olanzapine 30 mg/d, lithium 600mg/d, clonazepam 2mg • Lithium level 0.6 mEq/L • Recommendation: optimize lithium dose for maximum benefit, may not need 2 antipsychotics or clonazepam when lithium level is 0.8-1.2mEq/L • Use tylenol for pain instead of ibuprofen to avoid increase in lithium level and potential for toxicity

7. Individual Medication Review • FA is a 42 year old hospitalized after stopping olanzapine 30mg when told of Hep C, ↑ liver enzymes, ↑cholesterol, Dx: Schizophrenia, substance abuse • AH, VH, persecutory delusions, depression, isolation • Current meds: quetiapine 1200mg/d, citalopram 40mg/d, trazodone 200mg, temazepam 30mg at bedtime x 4wk • Recommendation: taper off quetiapine and start loxapine because it has > D2 blockade, evidence of liver safety • Psychosis greatly improved, trazodone, temazepam tapered off with ↓ daytime sedation, more socialization

8. Individual Med Consultation - SE • BB, a 36 yo engineer has + response to Abilify and Depakote but is concerned that coworkers will notice hand tremor or tremor will interfere with functioning at work. Discharge in 2 days • Recommend propranolol for tremor if related to Depakote, benztropine if tremor from Abilify • Discuss recommendations with physician, BB

9. Medication Education Group • 45 to 60 minutes, 6 – 12 patients • Interactive Discussion – structured format • Overview of psychotropics: thought organizers, mood stabilizers, antidepressants, sleep meds • Goals: de-stigmatize illness and medications, discuss med benefits, side effects/management • Answer questions and address concerns • Discuss consequences of alcohol & drugs

10. Medication Education Group • 22 yo newly diagnosed bipolar, resistant to meds hears from a 52 yo w/ bipolar x 30yrs, “Medication keeps you out of the hospital”. • 48 yo, obese person w/ diabetes learns there are meds w/ low to no weight gain and receives support from others struggling w/ weight issues • 36 yo, tells group “Taking medication helps keep me off drugs and alcohol”

11. Discharge Medication Counseling • PR is a 27 yo mother of 2 hospitalized after a suicide attempt, in hospital x 7 days • Diagnosis: Major depression w/ psychosis • Discharge medications: fluoxetine 20mg qam, olanzapine 15mg qhs • Question: “how come I don’t feel much better?” • Concern: “I don’t want to be addicted to drugs” • Family planning issues

12. Family Meetings • Family and friends provide encouragement and support to facilitate recovery, prevent relapse • How can refills be obtained? how often do blood tests need to be done? • What can risperidone liquid be mixed with? • Is it safe to take an antidepressant with blood pressure or pain medication?

13. Clinical Pharmacists Improve Care in Hospitals • 36 studies analyzed • General Medicine, Geriatrics, Psychiatry • Activities: interacting with health-care team, pt interviews, monitoring, discharge counseling • Improved med appropriateness • Improved med adherence • Decreased med errors • Decreased adverse drug events Kaboli P. Archives of Internal Medicine 2006;166:955-964

14. Outcomes of Clinical Pharmacist Interventions in Psychiatric Hospital • 93 participants • Compared usual care to regular pharmacist assessments, recommendations, education • Improved clinical response (↓ psychosis ↑ mood measured on objective rating scales • Decreased abnormal involuntary movements • Decreased restlessness (akathisia) • No sig. difference in med costs or length of stay Canales PL Am J Health-System Pharmacy 2001;58:1309-1316

15. Recommendations • Ask if hospital has a clinical pharmacist participating in treatment and med education • Ask for medication consultation with a pharmacist prior to discharge from hospital • Ask about clinic follow-up appointments • Verify discharge prescriptions include enough medication to last until clinic appointment • Utilize medication fact sheets and “Ask the Psychiatric Pharmacist” on NAMI.org