Background:Buprenorphine/naloxone (Suboxone) is an emerging option for chronic noncancer pain (CNCP), but evidence on transitioning patients from full opioid agonists remains limited. At the University of Saskatchewan Chronic Pain Clinic (UCPC) in Saskatchewan, Canada, pharmacists support these transitions within a unique interdisciplinary model. Aim:The aim of this study was to explore patient perspectives on transitioning to and using buprenorphine/naloxone for CNCP. Methods:This qualitative study involved one-on-one semistructured interviews with current and former UCPC patients who had transitioned to buprenorphine/naloxone for CNCP. Participants were invited by email to complete semistructured interviews via Zoom or telephone with a trained facilitator. The interview guide was informed by a literature review and pretested. Recorded interviews were transcribed using an artificial intelligence-supported platform, reviewed for accuracy, and analyzed in NVivo 14 using thematic analysis. Results:Seven participants (five females, two males; average age 57 years) were interviewed. Most had used opioids long term for pain prior to transition. Experiences varied: some transitioned easily, whereas others required more time or experienced discomfort. Buprenorphine/naloxone tablet size and taste were the most common negative experiences. Side effects were mild (e.g. drowsiness, constipation). Some expressed concern about long-term use and desired clearer communication during transitions. Although buprenorphine/naloxone was not uniformly experienced as effective for pain relief, most would recommend buprenorphine/naloxone to others. Conclusion:Patient experiences at UCPC suggest that though buprenorphine/naloxone is not a universal solution for CNCP, it may be an effective option for carefully selected individuals. Side effects were tolerable, and most would recommend the treatment. Improved communication during transitions may enhance patient experiences.

Background:Pharmacists are essential to team-based care, contributing knowledge and expertise that positively impact patient care. However, it is less clear how interprofessional collaboration is enacted by pharmacists in single-disciplinary outpatient practice environments. Methods:We recruited pharmacists from 3 university-affiliated, pharmacist-led primary care clinics in Canada. Employing a social network analysis approach, the data collection encounter explored the nature and composition of collaboration in patient care. We conducted semistructured interviews, including participant drawings (sociograms), to illustrate their network experiences caring for specific patients. Transcripts from the data collection encounters were systematically coded and analyzed in an iterative process. Initial codes were generated inductively and broader categories refined through constant comparison and finalized by author discussion. Results:Eleven (78%) pharmacists were interviewed and drew 28 sociograms. Pharmacist networks encompassed a wide array of health professionals and patient family members. Despite the physical distribution of interprofessional members, pharmacists formed and maintained relationships to support patient care through conscientious communication and medication management decision-making. Network relationships and system factors influenced collaboration and patient care, often resulting in practice paralysis and/or the need to re-emphasize patient self-advocacy. Interpretation and conclusion:Our findings underscore the dynamic nature of pharmacist networks and how they are navigated to support pharmacist-led medication management. Primary care pharmacists attempt to overcome encountered barriers to implementing patient care plans through various strategies, including leveraging new and existing network relationships. System obstacles impeding effective and efficient patient care could in part be overcome through pharmacist scope of practice expansion.

BackgroundBuprenorphine may provide superior analgesia to full opioid agonist therapy and reverse the effects of opioid-induced hyperalgesia, while having a favorable safety profile and fewer adverse effects, in chronic non-cancer pain treatment. Low-dose initiation of buprenorphine is a useful strategy for patients on long-term opioid therapy because it avoids the need for moderate opioid withdrawal required for traditional buprenorphine initiations. However, there are few published reports of low-dose initiation regimens in the setting of chronic pain.AimsThe aim of the study was to describe a case series of individuals living with chronic pain who were transitioned from long-term full opioid agonist therapy onto sublingual buprenorphine/naloxone using low-dose initiation regimens.MethodsThis study is a retrospective case series that included all patients who received care at an outpatient chronic pain clinic and were scheduled for low-dose initiation of buprenorphine/naloxone between March 2020 and December 2022. Data were collected through a retrospective review of electronic medical records and results were analyzed using descriptive statistics.ResultsEighteen patients underwent transitions from their baseline opioids onto buprenorphine/naloxone using a low-dose initiation regimen. Of those patients, 17 successfully completed the initiation (94.44%), 12 experienced adverse effects during the initiation (66.67%), with only one patient requiring treatment discontinuation, and all adverse effects resolved once maintenance doses of buprenorphine/naloxone were established. The mean Clinical Global Impression-Improvement score after initiation was 2 (1-5).ConclusionLow-dose initiation is an effective approach to transition patients with chronic non-cancer pain from long-term opioid therapy to buprenorphine/naloxone without major complications or worsening pain. Contexte: La buprenorphine peut offrir une analgesie superieure a celle d'un traitement par agonistes opioides complet et inverser les effets de l'hyperalgesie induite par les opioides, tout en presentant un profil d'innocuite favorable et moins d'effets indesirables dans le traitement de la douleur chronique non cancereuse. L'initiation a faible dose de la buprenorphine est une strategie utile pour les patients sous traitement opioide a long terme, car elle evite le besoin de sevrage des opioides modere necessaire pour les traitements traditionnels a base de buprenorphine. Cependant, il existe peu de rapports publies sur les regimes d'initiation a faible dose dans le cadre de la douleur chronique.Objectifs: L'objectif de cette etude etait de decrire une serie de cas d'individus vivant avec une douleur chronique qui sont passes d'un traitement opioide complet a long terme a un traitement par buprenorphine sublinguale/naloxone en ayant recours a des regimes d'initiation a faible dose.Methodes: Cette etude est une serie de cas retrospective incluant tous les patients pris en charge dans une clinique externe de traitement de la douleur chronique et pour lesquels un schema d'initiation a faible dose de buprenorphine/naloxone a ete programme entre mars 2020 et decembre 2022. Les donnees ont ete collectees par le biais d'un examen retrospectif des dossiers medicaux electroniques et les resultats ont ete analyses a l'aide de statistiques descriptives.Resultats: Dix-huit patients ont fait la transition des opioides de base a la buprenorphine/naloxone en utilisant un regime d'initiation a faible dose. Parmi ces patients, 17 ont termine l'initiation avec succes (94,44 %), 12 ont presente des effets indesirables pendant l'initiation (66,67 %) et un seul patient a du interrompre son traitement. Tous les effets indesirables ont disparu une fois les doses d'entretien de buprenorphine/naloxone etablies. Le score d'impression clinique globale-amelioration moyen apres le debut du traitement etait de 2 (1-5).Conclusion: L'initiation a faible dose est une approche efficace pour faire passer les patients souffrant de douleur chronique non cancereuse d'un traitement opioide a long terme a la buprenorphine/naloxone sans complications majeures ni aggravation de la douleur.

Pharmacists can have an essential role in providing care for patients with mental illness. There are gaps in the understanding of the current extent of pharmacists’ involvement in caring for patients with mental illness and their readiness to effectively provide this care. To describe the current practices, attitudes, and beliefs of pharmacists in providing care to individuals with mental illness, and to assess factors that may impact these practices. An electronic questionnaire was emailed to pharmacists in Saskatchewan, Canada. Likert scale questions were utilized, and data were analyzed using descriptive statistics and content analysis for free-text responses. The response rate was 9.1

Background: Chronic noncancer pain (CNCP) is a common condition that affects individuals at a biopsychosocial level and can significantly impair function and quality of life. Referral to an interprofessional CNCP program is recommended for most patients; however, these clinics are limited in number and capacity. Expanding access by testing new service delivery models would be of value. The purpose of this study was to measure the impact of a new pharmacist-led, interprofessional model of care developed at the University of Saskatchewan Chronic Pain Clinic. Methods: A retrospective chart audit was conducted using data that included adult patients referred for CNCP management between May 2020 and December 2021. Medication use, overall health status (using the Clinical Global Impression of Change–Improvement [CGI-I] scale) and patient readiness to change (using the Transtheoretical Model) were measured 6 months after the initial appointment. Results: The study included 138 patients. Of the 80 patients taking an opioid, 22.5% were switched to buprenorphine/naloxone and the remainder had their mean morphine-equivalent dose reduced by a mean of 41.7 mg/d. Overall patient health status was minimally improved and many patients moved into the Action stage of change. Discussion: Changes in opioid use demonstrate a clinically important shift toward safer medication regimens that are less likely to lead to toxicity and unintended overdose. CGI-I data suggest that these patients, whose health status is typically very difficult to change, did not deteriorate but slightly improved after attending the clinic. Conclusion: The unique pharmacist-led, interprofessional model of care used by the University of Saskatchewan Chronic Pain Clinic may offer a viable alternative to traditional physician-led models.

Background One in 5 Canadians experience chronic pain, with increased prevalence in older adults, females, Indigenous peoples and populations affected by social inequities. Chronic pain is a complex biopsychosocial condition, and management is influenced by the intricate relationship between pain, mental health and physical well-being. Unmanaged chronic pain negatively affects all aspects of an individual’s life and society as a whole. Chronic pain management is challenging due to the number of people affected and the significant time and resources required to provide comprehensive, integrated care. Specialized care may be offered in interprofessional chronic pain clinics, but wait lists in many regions are exceptionally long, and in some areas, these clinics are nonexistent. The management of chronic pain has been complicated by the opioid crisis and the subsequent increased societal awareness of opioid use. Opioids play an important role in treating pain, but the risk of harm related to opioid use is also high. Between January 2016 and June 2020, there were more than 17,602 opioid-related deaths within Canada, and at least 1 pharmaceutical opioid was involved in 33% and 16% of opioid toxicity deaths among females and males, respectively. The 2017 Canadian Guideline for Opioids for Chronic NonCancer Pain provides recommendations regarding the safe and appropriate use of opioids to manage chronic pain. In addition, other strategies have been implemented to address the opioid crisis. Unfortunately, some of these strategies have created barriers for patients with chronic pain to access care, including difficulty obtaining opioid prescriptions. Health professionals must work collaboratively and in a patientcentred manner to develop individualized treatment plans, to provide education on how to minimize opioid risk and to offer support and follow-up. In an effort to provide better access to interprofessional chronic pain management, the Medication Assessment Centre (MAC) has recently launched the Medication Assessment Centre Interprofessional Opioid Pain Service (MAC iOPS), using an innovative, pharmacist-led, interprofessional approach. This new service aims to use pharmacists’ unique knowledge and skills to implement and evaluate a new way to manage chronic pain in Saskatchewan. This article provides an overview of the MAC iOPS and offers insight into the establishment of this unique model of care.

Experiential education is a critical component of any pharmacy undergraduate curriculum. Establishing new, high-quality practice sites can be challenging. We designed a new advanced pharmacy practice experiential rotation suitable for implementation in most community pharmacy settings. The aim of this article is to describe the design of this rotation entitled the Targeted Pharmacy Intervention in Inflammatory Bowel Disease (TPI-IBD) and to determine its impact on student knowledge and confidence using a before-after survey design. The TPI-IBD utilizes a student-delivered intervention as a platform for experiential learning in community pharmacy practice. The TPI was focused on patients with IBD, and implementation was guided by a co-preceptor from the university in collaboration with onsite-preceptors at each pharmacy. The TPI-IBD rotation was delivered from 6 community pharmacies during 5 weeks in 2018. Students conducted standardized monitoring on patients with IBD and met weekly with the university preceptor for case presentations and therapeutic discussions. Electronic charts were maintained by students who were responsible for ensuring detailed documentation on each patient. Knowledge, confidence, and overall satisfaction were assessed by a survey given to students before and after the rotation. Students were highly satisfied with the learning experience and improvements in knowledge and confidence were clearly demonstrated. The TPI strategy was an effective way to expand rotation options in community pharmacy sites with minimal burden on local preceptors.

ABSTRACT Overdoses of prescription medications continue to be a significant concern for health systems around the world. Medical regulators in several jurisdictions have started generating personalized prescribing profiles for individual physicians as an audit and feedback tool to reduce the sub-optimal prescribing of high-risk drugs such as opioids, benzodiazepines and stimulants. However, little is known about how to most effectively communicate the data in these prescriber profiles to the intended recipients. The aim of this study was to collect the opinions of physicians in Saskatchewan, Canada, regarding their personalized prescriber profiles. One-on-one semi-structured interviews were completed in January 2019 with 17 physicians who were given access to personalized profiles containing their prescribing information on opioids, benzodiazepines, stimulants and gabapentin. Interviews were recorded and data was analyzed using thematic analysis. Respondents thought the profiles were a useful tool that had significant potential to improve their prescribing practices. However, many physicians also thought the profiles were confusing and difficult to interpret. Several recommendations were made to improve the prescriber profiles, which may be applicable to other jurisdictions currently using, or planning to develop, similar quality improvement tools. These recommendations include: limiting the use of abbreviations and acronyms; being explicit regarding the intent of the profiles; ensuring comparator data is relevant to the individual recipient; using a combination of numbers and visuals to display data; and providing detailed context regarding what the data means.

Canada’s universal public health care system provides physician, diagnostic, and hospital services at no cost to all Canadians, accounting for approximately 70% of the 264 billion CAD spent in health expenditure yearly. Pharmacy-related services, including prescription drugs, however, are not universally publicly insured. Although this system underpins the Canadian identity, primary health care reform has long been desired by Canadians wanting better access to high quality, effective, patient-centred, and safe primary care services. A nationally coordinated approach to remodel the primary health care system was incited at the turn of the 21st century yet, twenty years later, evidence of widespread meaningful improvement remains underwhelming. As a provincial/territorial responsibility, the organization and provision of primary care remains discordant across the country. Canadian pharmacists are, now more than ever, poised and primed to provide care integrated with the rest of the primary health care system. However, the self-regulation of the profession of pharmacy is also a provincial/territorial mandate, making progress toward integration of pharmacists into the primary care system incongruent across jurisdictions. Among 11,000 pharmacies, Canada’s 28,000 community pharmacists possess varying authority to prescribe, administer, and monitor drug therapies as an extension to their traditional dispensing role. Expanded professional services offered at most community pharmacies include medication reviews, minor/common ailment management, pharmacist prescribing for existing prescriptions, smoking cessation counselling, and administration of injectable drugs and vaccinations. Barriers to widely offering these services include uncertainties around remuneration, perceived skepticism from other providers about pharmacists’ skills, and slow digital modernization including limited access by pharmacists to patient health records held by other professionals. Each province/territory enables pharmacists to offer these services under specific legislation, practice standards, and remuneration models unique to their jurisdiction. There is also a small, but growing, number of pharmacists across the country working within interdisciplinary primary care teams. To achieve meaningful, consistent, and seamless integration into the interdisciplinary model of Canadian primary health care reform, pharmacy advocacy groups across the country must coordinate and collaborate on a harmonized vision for innovation in primary care integration, and move toward implementing that vision with ongoing collaboration on primary health care initiatives, strategic plans, and policies. Canadians deserve to receive timely, equitable, and safe interdisciplinary care within a coordinated primary health care system, including from their pharmacy team.

Introduction Medication reviews (MRs) have become an integral part of pharmacists’ practice in many countries. In this study, MR was defined as a structured assessment of patients’ pharmacotherapy whose aim is to optimize drug use and to improve health outcomes. These MR services are typically part of government-funded programs that are not always designed based on published pharmacist intervention studies linked with improvements to patient outcomes. There is evidence regarding the benefits of pharmacist-led MRs, including improvements in chronic disease management, quality of life, patient knowledge and satisfaction, resolution of drug therapy problems and reduced medication costs. However, there have been no large multinational randomized, controlled trials measuring the impact of MRs on patient morbidity or mortality, and reviews or syntheses of studies often come to inconclusive results. This knowledge gap may be, in part, due to a possible lack of standardization regarding the activities performed during an MR in various regions of the world, making it impossible for researchers to combine and analyze MR data from different countries. A previously published comparison of the standardization or consistency of activities performed by pharmacists during MR in various countries was not identified; however, it is clear that the primary aims of MR programs vary widely around the world. For example, the British Medicines Use Review (MUR) targets adherence, whereas comprehensive medication management (CMM) in the United States includes an intensive workup of pharmacotherapeutic and patientoriented goals. Several different national or regional guidelines on MR have been developed, tailoring MR activities to individual health systems. Examples include the Pharmacist Guide for the Saskatchewan Medication Assessment Program (SMAP), which has recently been evaluated, and the Australian guidelines for pharmacists providing Residential Medication Management Reviews (RMMR), Home Medicines Reviews (HMR) and MedsCheck. The existence of multiple locally developed guidance documents, funding models and policies suggests that there may be significant inconsistencies regarding the specific activities that are performed by pharmacists during an MR in different countries. The aim of this policy review was to compare the specific activities of pharmacists who provide MRs in a convenience sample of 6 countries. The primary objectives were to determine if there are inconsistencies in how the service is provided internationally and to identify if key components of MRs (based on known best practices) are being omitted.

Background: Chronic insomnia is a common medical condition that negatively impacts quality of life and daytime function. Access to the first-line treatment for insomnia, cognitive behavioural therapy (CBT-i), is limited. Pharmacists are well positioned to provide this service, but evidence regarding pharmacist delivered CBT-i is sparse. The aim of this study was to evaluate the effectiveness of CBT-i delivered by pharmacists practicing in an outpatient clinic setting. Methods: This study was a retrospective chart audit of adult patients with chronic insomnia who received CBT-i from a pharmacist at one of two outpatient clinics in Canada. The primary endpoints were the differences between patient self-reported sleep diary parameters and utilization of hypnotic medications before and after CBT-i was delivered. The differences in patient reported sleep parameters were compared using Wilcoxon Signed Rank test and paired samples t-test and changes in hypnotic utilization was compared using McNemar Chi-square test. Results: 183 patients were referred for CBT-i and attended an initial appointment with a pharmacist. Of these, 105 did not receive the CBT-i. This resulted in 78 patients who met the inclusion criteria. Changes in sleep diary parameters were all statistically significantly improved after patients received CBT-i, except for total sleep time. Hypnotic medication use was also reduced. At baseline, 71.8% (n=56/78) of patients were taking one or more hypnotic medications compared to 52.6% (n=41/78) after CBT-i (p=0.0003). Discussion: The results of this study provide preliminary evidence that pharmacists working in an outpatient clinic setting may be able to effectively deliver CBT-i for patients with chronic insomnia. The external validity of these results is limited by the observational study design and the inclusion of pharmacists practicing in outpatient clinics, which is not the setting where most pharmacists currently practice. Conclusion: This observational study found improvements in sleep quality and efficiency, as well as, a reduction in hypnotic medication use, in patients who received CBT-i from pharmacists practicing in an outpatient clinic setting. Future randomized, controlled trials should evaluate the impact of CBT-i in a larger sample of patients, provided by pharmacists practicing in both outpatient clinics and community pharmacies. Original Research

Objective: To determine the impact of the SIMPL-SYNC refill synchronization (SSRS) service compared with that of usual care (UC) on medication adherence when applied as an opt-out strategy among patients receiving chronic medications. Design: This was a pragmatic randomized controlled trial. Setting and participants: The study was conducted in 2 community pharmacies located in Saskatchewan, Canada. Eligible patients were chronic medication users visiting the study pharmacies. Outcome measures: The primary outcome was the percentage of individuals achieving optimal adherence to all eligible study medications. Eligible study medications included 22 commonly used medication classes used to treat diverse conditions. Adherence was assessed for each medication class after 300 days using the proportion of days covered (PDC). Optimal adherence was defined as PDC >= 80%. Results: A total of 488 patients were screened for eligibility, and 190 patients were included in the intention-to-treat analysis (95 in SSRS, 95 in UC). The mean age of participants was 59 years, and 34% (65/190) were older than 65 years. A total of 574 individual adherence observations representing the 22 eligible study medication classes were generated from the 190 study participants. The percentage of individuals achieving optimal adherence to all their eligible study medications was 50.5% (48/95) in the SSRS group versus 44.2% (42/95) in the UC group (P = 0.383). Similarly, no statistically significant difference was observed in a per-protocol analysis assessing people who participated fully in the service; the percentage of individuals achieving optimal adherence to all their eligible study medications was 55.1% (38/69) in SSRS versus 40.7% (33/81) in UC (P = 0.080). Patient refusal of the refill synchronization services was common among randomized patients. Conclusion: SSRS service failed to detect a robust improvement in medication adherence when delivered using an opt-out strategy. However, small improvements in adherence or benefits to specific subgroups of patients could not be ruled out. (C) 2020 American Pharmacists Association (R). Published by Elsevier Inc. All rights reserved.

Individuals who take medications may benefit from using vitamin and/or mineral supplements (VMS) yet excess supplementation can lead to overuse (daily intake exceeding the tolerable upper intake level (UL)). This study assessed VMS use of medically complex, community-living, older adults. A chart review of 229 patients ≥50 years with new medication assessments between 2014 and 2017 indicated that 76.9% of patients used ≥1 VMS daily. The UL for one or more nutrients was exceeded by 39.8% of supplement users.

Background: The Saskatchewan Medication Assessment Program (SMAP) is a publicly funded community pharmacy-based medication assessment service with limited previous evaluation. The purpose of this study was to explore community pharmacists' experiences with the SMAP. Methods: Online, self-administered questionnaire that consisted of a combination of 53 Likert scale and free-text questions. All licensed pharmacists who were practising in a community pharmacy setting in Saskatchewan were eligible to participate. Results: Response rate was 20.3% (n = 228/1124). Most respondents agreed that the SMAP is achieving all of its intended purposes. For example, 89.7% agreed that the SMAP improved medication safety for patients who receive the service. Most pharmacists enjoyed performing the assessments (84.6%) and were confident in their ability to identify drug-related problems (88.3%). Pharmacists reported lack of time, patients having difficulty coming to the pharmacy and restrictive eligibility criteria as the top barriers to the SMAP. Good teamwork, employer support and personal professional commitment were the top recognized facilitators. Respondents made several suggestions to improve the SMAP in the free-text areas of the questionnaire. Conclusions: Community pharmacists in Saskatchewan were positive and confident about performing medication assessments, and most agreed that the SMAP is achieving all of the intended purposes. Respondents also identified several barriers to providing SMAP services, which have resulted in specific recommendations that should be addressed to improve the program.

BACKGROUND AND PURPOSE:Pharmacy schools would benefit from new models of experiential education. The University of Saskatchewan (Canada) recently opened a patient care clinic called the Medication Assessment Centre (MAC) as new experiential education model. The purpose of this paper is to describe the structure and function of the MAC and to report program evaluation data.EDUCATIONAL ACTIVITY AND SETTING:The MAC is a unique application of an existing experiential education model in that it is an pharmacist-run ambulatory clinic (which is common) that is physically located on campus amongst the classrooms and supervised by pharmacy faculty (which is unique). Students are all required to participate in the clinic on a regular basis, in between lectures, throughout the four years of the pharmacy program.FINDINGS:Students were invited to participate in one of five focus groups to assess the value of the experience. Transcripts were analyzed using thematic analysis, and the results identified strong satisfaction amongst students. The overall themes fell into three categories: (1) aspects that students liked, (2) aspects that students found challenging, and (3) positive impact on student learning. Previously published studies have found strong support for the MAC amongst patients and physicians.SUMMARY:Students felt that a faculty supervised experiential education clinic that is physically located within their pharmacy school was a valuable learning experience. This paper provides a description of how the MAC has been integrated into an existing pharmacy curriculum, which may be valuable to schools contemplating a similar addition to existing experiential learning.