Pharmacy Times® interviewed Allison Burns, PharmD, RPh, president and CEO of EMO Health, on the role of the pharmacist as the educator for non-pharmacists around medications and how the roles of the pharmacist in patient-facing settings has changed over the years. Burns addresses the evolving and critical role of pharmacists in various health care settings and the need for continued support and resources to help pharmacists manage their responsibilities effectively while maintaining work-life balance.
Pharmacy Times: What is the pharmacist’s role today as the educator for non-pharmacists around medications?
Key Takeaways
- Pharmacists as Educators: Pharmacists play an essential role as educators for non-pharmacists in various health care settings. This educational role has expanded significantly in recent years. Many health care professionals, such as nurses, certified nursing assistants, and medication technicians, rely on pharmacists to provide medication training. Pharmacists are not only responsible for clinical information but also for operational and logistical aspects of medication management, such as storage, workflow, and ensuring proper administration. The pharmacist's expertise extends beyond clinical knowledge to practical medication management.
- Expanding Roles in Patient-Facing Settings: The role of pharmacists in patient-facing settings has not necessarily changed but has expanded. Pharmacists now work in non-traditional settings beyond the pharmacy, such as with fire departments, police, drug courts, community outreach groups, and schools. They assist in various scenarios, including overdose response, substance use disorder treatment, and providing medication education to parents and first responders. This expansion of roles allows pharmacists to utilize their knowledge in diverse situations, taking their expertise out of traditional pharmacy walls.
- Challenges and Opportunities for Pharmacists: Pharmacists working in patient-facing settings, especially in substance use disorder treatment, face complex cases involving co-occurring conditions, including mental health and physical health issues. There is a significant demand for medication expertise in these settings due to the multiple medications patients are taking from different providers in this patient population. Pharmacists are essential in helping these patients transition between different care settings, ensuring medication adherence, and providing support to non-medical staff who may not have extensive medication training. This expanding role offers numerous opportunities for pharmacists to make a meaningful impact in complex patient care scenarios.
Allison Burns, PharmD, RPh: The pharmacist’s roles as an educator I think has really expanded over the last, not even just 10 years, the last 5 years. I would say that because pharmacists, we are drug experts, that's what we go to school for, you would assume that maybe other health professionals would have just as much medication training, but they don't. So in terms of educating the non-pharmacists, these could be anywhere from licensed individuals, it could even be certified nursing assistants, or medication technicians—people that administer meds all the way down to unlicensed folks who are in patient facing situations where they may be in charge of overseeing patient medications, like direct care staff, and they rely a lot, believe it or not, they really do rely, especially where I work in behavioral health and mental health, on the pharmacist knowledge to teach them about meds. And I think where sometimes people have questions around that is, well what are you teaching them? And that's even more interesting, because pharma says, our whole thing is meds, right? So, it's not just clinical information. Sure, if a nurse is calling you, or maybe even a doctor, or a health care professional, licensed medical professional, they might be asking you a clinical question about the drug, like, does this and this interact? Or how long does it work for? Or when can I see some sort of effect in my patient?
But then you have the nonmedical staff that have questions about medications. For example, they’re in an inpatient setting, or congregate care setting, and they don't have a medication fridge, or they have left medication out, and they have no idea how to store a med, or they have controlled substances. And they want to know, do I store the controls or the non-controls together? So there's this whole, I would say space for medication training, some of its clinical and the other half of it, is that non clinical, more operational and even logistical sense to it, like how do I in the setting that I'm in, whether it is a long term care facility, congregate care inpatient, residential, how do I as the professional as the patient facing direct care worker, get the medication from myself to the patient, and that's a whole other process. And that has to do with workflow. Like I said, operations, setting up a medication room, the design of that room, the workflow, who should be allowed to access the meds. There's just such, I would say, an area for pharmacists to share all that information. Because as we all remember correctly, the pharmacy is typically just staffed by pharmacists. So, you're in charge of all aspects of it, you're in charge of inventory of those meds, you're in charge of storing those meds correctly, you're in charge, of dispensing the meds, everything all the above record, keeping that as well. I would say there's a huge role for pharmacists when it comes to training other non-pharmacist professionals around medications.
Pharmacy Times: How have the roles of the pharmacist in patient-facing settings changed in recent years?
Burns: So, in terms of change, I don't know if I would say that they necessarily have changed, or rather, I would call it the role of the pharmacist in patient facing settings has possibly expanded. So, I think in terms of change, we still have places like a retail or community setting where you can go into a retail chain pharmacy, or maybe even an independent, you go in, you drop off your script, you wait, you pick up the script. Then we've expanded into hospitals, and there's outpatient settings and things like that. But in terms of how things have changed, I think those have remained the same, largely, but there are now expanded roles.
For example, we have pharmacists that are in patient facing settings that are nontraditional pharmacy. So, this is where I guess I would say it's not necessarily a change, but an expansion of the role of pharmacists outside of a pharmacy. And what I mean by that is we utilize pharmacists in these non-conventional settings. So, we'll put a pharmacist with for example, I just talked to someone yesterday, they work with the fire department of their city, and specifically why? Because the fire department responds to overdoses. They also send somebody the next day when an overdose happens to check on that person where that overdose happened, or if they're able to get the contact information for that person to maybe make sure they get locked in with resources. We have the same thing with the police, where pharmacists are now doing that. We also have the same thing in drug court, where they now understand if a urinalysis comes back, it's a positive, that is still a dip cup that needs to be sent for confirmation.
We have pharmacists who are working with community outreach groups helping—this was another interesting initiative that we had over the summer—getting ready for the new school year, there were many parents that don't have education around medications that weren't around when they were growing up. So, we had a parent—it was like a parent's committee or PTO, or parent teacher organization. I believe that's what it's called. But we have these parents’ organizations, and we had a couple of different school departments reach out to us and ask, would you mind sending a pharmacist? It wasn't even just to speak to the students, they speak to the parents, because they wanted to understand more about medications that their children are taking. For schools, one of the main questions was [dextroamphetamine-amphetamine (Adderall; Teva)]. And there was, as you know, a recent shortage around [dextroamphetamine-amphetamine]. They had questions about other drug shortages. Fall was coming, and they wanted to know what if there was a shortage on flu vaccines and or antibiotics; they had a lot of questions that they felt very comfortable asking a pharmacist. And then I think the point of that may be the change is taking a pharmacist out of a pharmacy, taking them out of those four walls out of that dispensing scenario, and putting them in a setting where they're able to utilize the knowledge that they've always had. So, it's almost the same as patient counseling, but it's just an expanded role. You're giving counseling, where you're giving it to parents, you're giving it to people who've experienced acute traumatic situations, maybe a suspected overdose, and then also to first responders that are likely responding to those situations.
Another initiative that was quite different was they had us go into a Boys and Girls Club—these are more community-based organizations. And it was interesting, because they had students that come there after school, and they hadn't dealt with this. They're sometimes well, we didn't deal with this 20 years ago, and there are school-aged children that take medications multiple times in a day, and we never had to like store medications. So, we wanted a pharmacist consultant to come in to let us know this is the student’s own medication, they keep it in their backpack, should this backpack be locked up in an office or go into a locker? Or how do they store medications that they weren't familiar with? So, it was very interesting to get these different types of requests, I would say from unlicensed individuals, or they may be licensed because, of course, first responders are licensed, but they aren't necessarily medication experts.
So, I would say that the role of the pharmacist, maybe like the baseline foundation of what we do, which I would say is namely dispensing medications, hasn't changed, but I think our role has expanded around what happens to those medications after they're dispensed, and what role do we have in that and making sure that those are taken correctly, people are adhering to them, and that all their questions are answered, so they can be active participants in their own health.
Pharmacy Times: Would you provide a bit more background into your focus areas as a pharmacist and the health care setting that you work in?
Burns: So, my setting is behavioral health and mental health. Specifically, usually the primary diagnosis is a substance use disorder. Many substance use disorders co-occur with mental health disorders. And that could be a number of different disorders, whether it is depression, anxiety, PTSD, but we also see other, I would say, physical states, because when you're under the influence of substances, you tend to not take great care of the rest of your body. It's just like not, you're not really thinking of your eyesight and your blood pressure and your cholesterol or what you're eating when you're under the influence of different substances that alter decision making. So, we see these individuals that are coming into my practice setting which really, like I said, it's substance use disorder, formerly known as addiction medicine, just depends how people want to term it these days and cooccurring with mental health disorders, but they're coming in with increasingly more complex health concerns. So, they're coming in with diabetes, they're coming in with uncontrolled blood pressure and high cholesterol and sometimes cardiac conditions and if they are using drugs by injection, we see a lot of soft skin tissue infections, and then you've got an infectious disease that needs to be on hand.
Of course, we have individuals that have hepatitis C, HIV, any of the blood borne pathogens. But I would say overall, the practice setting that I'm working in, is these individuals’ primary diagnosis as a substance use disorder with a lot of chronic conditions, which lends itself nicely to a pharmacist being able to again, not necessarily have a changed role, but expand their role from four walls of a pharmacy like physical pharmacy, whether it's a standalone or maybe in a hospital, or in an outpatient setting to work with patients that have multiple conditions that need specialists. So you're almost like their medical home, not their PCP, because they need somebody to help them with the, let's say, the psychiatric meds, and then all the other chronic conditions, and then throw on top of if they have some kind of acute affection infection that's going on.
I'm in Boston, and we're having a very difficult time with individuals using a drug supply that's contaminated with xylazine. And it's leading to these very complex and serious soft skin tissue infections that aren't like anything we've really seen before. It's not like when someone would, let's say use the same vein repeatedly, the vein would collapse—it's not like that. You see these almost like ulcers that form all the way sometimes down the vein. And they are like open wounds that are easily infected, and they're very hard to treat. So, it's an awful thing that's happening, but it is creating an opportunity again, now for pharmacists to get involved in the care of, I would say, the most complex patients. Because let's say they do have a PCP, even if they go into their PCP, that PCP might not feel comfortable looking at that patient, especially in a community health setting, because they have these open sores. And then the ER, they might give them some, I would say acute treatment, to get them on their way and give them a referral to see infectious disease.
In the world of addiction, you typically enter, whether this was right or wrong, it should really be fluid. But this is typically how it is in the American Medical Society of Addiction. So ASAM, there are levels of care, we try to call them service settings now, so you don't get trapped in a single level or think it needs to be a step down approach to really be fluid, meeting the patient where they're at. But let's say for the most part, many individuals, especially because it's probably substance use, they will start at an acute treatment setting or like a detox, and then they will go to the next level or step down we're trying to use. They will then transition to the next service setting, which in Massachusetts and across the United States, that's a CSS, which would be a clinical stabilization service. And then they go to residential. In Massachusetts, we have an additional one that's right in the middle that's called transitional support services, and that's just to help with bottlenecking, but it is still the same as a congregate care inpatient residential setting. So, you could compare it almost to like a nursing home, but these are for individuals in like a long term care, but these are for individuals where their primary diagnosis is going to be a substance use disorder. But in those settings, you have individuals again, very chronic disorders need to be managed with multiple medications, and you don't necessarily have a multidisciplinary team. At any of those settings, you're very lucky to even have a nurse, as a nurse isn't required in the 3.1 level of care, which is just adult residential level of care, and that's where you typically spend the longest period before you are discharged or transition to a community setting. So it is interesting how much they do rely on a pharmacist in those settings, but that's I would say that’s where we put most of our pharmacists.
We work in all levels of care but right now we're very focused on I would say where the highest need and the biggest gaps are. So by highest need, I mean you have patients that have chronic disorders, or even acute disorders that have not cleared up yet on multiple medications that are have to just by the nature of their disease state, they have to make these transitions. So, they're going to make 4 transitions in 6 months. And it goes to wherever the open bed is. So, you might not be trying to change your PCP. But in Massachusetts, such as, say, you're in the capital, you're in Boston, and the next bed that opens is in Worcester, you're going to Worcester, the next bed that opens is in Springfield, you're going to Springfield. So, by the nature of the treatment system, you're going to have 4 transitions. And it's highly unlikely that those 4 transitions are going to be even in the same zip code, let alone the same, I would say county in Massachusetts, leaving them with these huge gaps in care, where they need somebody that understands medications to be able to support each transition to not just help reconcile them, but to also be there as a support for the patient facing staff that are working with these with the patients. So the direct care workers that are in charge of case management, the social workers, the licensed drug and alcohol counselors, they didn't get the training like we do on medications, yet they've been tasked with the responsibility of creating a treatment plan for individuals who most likely have at least 4 medications that they're taking daily, at least usually, including, sometimes antibiotics for the socks and tissue infections, maybe hepatitis C medication, maybe medication for HIV, maybe they're taking PrEP, so they don't contract HIV, and they don't even understand the difference between those because they just see the medication name. And then on top of all the other psychiatric meds that someone would take, because whether it's a chronic condition that you've had for a long time, or you are just coming off very psychoactive medication—not psychoactive medications, I shouldn't say that because it could be RX misuse, it could be illicit drug use, but some kind of psychoactive substance, anytime you come off anything, whether it's legal, like it's alcohol, or it's something illicit, like heroin, which is usually at this point, fentanyl, you have this protracted withdrawal and an effect on the mental state of someone, their emotional state, their physical state. And so, you have these workers that are tasked with caring for individuals, very complex, haven't taken any care of anything else, probably haven't even brushed their teeth at some point when they come into detox. And now you need to provide them with dental care, you need to provide them with sight care, by the way, they're detoxing off meth, heroin, and some other substances. And you're supposed to stabilize them enough to get them to the next place where there's a bed. And by the way, that's 50 miles away. So, it's very complex, but a place I'd say where there's a ton of opportunity, a ton of opportunity, especially for people with medication expertise, because that is the one thing that I would say, across all the settings, all our service settings and levels of care, the number one continuing education or workforce development requests that they've been getting is can we get more information on how to handle medications within their own scope of practice, so they're not dispensing, they're not prescribing, but they're charged again, with caring for or creating treatment plans for individuals who are taking multiple medications from multiple doctors for multiple reasons, over the course of whether it's weeks to months, and by the way, they're coming off of incredibly psychoactive substances.
My organization, we are all about really placing pharmacists, in settings where you're utilizing your knowledge to the fullest that you can, because there's so much more knowledge than just dispensing medication. It's everything around that medication. So, we do hear about it, though there are other places because Massachusetts is small, the size of New England could probably fit inside of Texas for all I know, you know what I mean? So, I would say that Massachusetts because 45 minutes south of Boston 45 minutes or maybe an hour north us, you're in another state, right? So, we have all these other states that touch us, and we’re able to share that information back and forth. So you are seeing in, I would say in those like border towns, we do see that in Rhode Island, in—I don't know about Connecticut as much—but Rhode Island, New Hampshire, Vermont, we're just sharing a model that, to be honest, people in those situations when you are, let's say, a firefighter or a police officer, you didn't get medication training, and you didn't get information on how to how to deal with those situations around overdoses—they know how to use Narcan, but these are much more complex polysubstance situations that we're seeing.
We're also seeing a lot more 911 calls around, I would say, mental health crises, where someone may be off medications that help stabilize them, and they need to understand how to respond to those situations as well. Another perfect example of something that happened recently, and they had individuals, we just had that 3 day weekend, a couple of weeks ago in October, and one of the cities called us because they had a long weekend, and people sometimes don't make great decisions, and they get locked up for the weekend. And [the police officers] did not understand the importance of some of the medications that people need to take daily. So, there was a situation where there was some patient harm that occurred because police officers just didn't know this person kept asking for, well, they did know the insulin situation, but they didn't have any insulin to give them. So, they didn't know what to do, so they bring him to the hospital. But there were other situations where they didn't understand that the patient takes methadone every day. And being off methadone for 3 days is going to cause some serious withdrawal. They just assumed that it's not a lifesaving medication in their mind, like insulin, they don't understand the pharmacokinetics or dynamics and how those medications work and the duration of action in the body.
So, that police department asked us to come in and do—it’s not necessarily that I wouldn't say their scope of practice or clinical knowledge—but it is clinically based in the sense they wanted to know, is there a set of medications that we need to know about that we need to have somebody on staff that knows how to administer these things, or they're asking a lot of questions like that. And so, we gave them a presentation on medications that people can't be without for over 24 hours, and what that type of withdrawal syndrome looks like? And they might not think it's important, but it is and how to then also work with the local providers because we don't want to over utilize our ER. So, they need to set up these relationships with the community health centers to make sure that there's someone that can come over and administer these medications, if needed. If someone gets there on a Friday, they're not going to be released till Tuesday, we've got a problem.
Pharmacy Times: Pharmacists are overtaxed and overworked today, particularly in the community setting. What more needs to be done to value the efforts of pharmacists while putting less strain on their time and ability to achieve work-life balance?
Burns: So, I think this is a great question. And very timely, because I do hear from a lot of my pharmacy colleagues that are working specifically in community settings and retail settings that they just don't have the resources they need. And so, I think there's a couple of different things at play. I think that companies need to probably do a better job of allocating the correct resources they need to their staff. However, I think saying that is probably very naive, because there's multiple things at play when you're looking at these big corporations.
So, I would look at factors for a pharmacist—if you're feeling overtaxed, overworked, what are the things that are maybe in your control that you can change or adjust to relieve some of that. And what I would say to pharmacists is you've got to look at your work environment. So, this is one thing that's very interesting. I do hear a lot of complaints about retail settings, yet I've gone to one retail setting, and within the same chain, I've gone to another store that's down the street, and it's a completely different company culture. It's the same company. So, pharmacists need to do a lot better job, especially our managers of record, if you're stressed out, you need to lead by example. I'm former military, so we learned how to handle stress very well. But you can't lead a team if you're stressed out. Everything trickles down or can trickle up.
If you have a toxic team member, pharmacists need to do a better job of educating themselves and getting the skill set around people management, soft people skills, emotional intelligence, that stuff is not taught in pharmacy school and that's not really on the pharmacy schools. They're supposed to teach you how to be a pharmacist. Once you get out into the world, that's what continuing education is for, that is on you to get those skills to be able to manage people, to lead people.
Then the other thing I would say that if you truly are unhappy and feeling that you're underappreciated and overworked in these settings and you're not being given the resources and you've done everything you can in your power to change the people around you, the attitudes around you, the environment around you. Then possibly look at other community settings because there are community settings where it is a good work environment, it is a good company culture. Like I said, these nontraditional pharmacy settings, I would say again, like the setting, and what you want and the quality of life you want. So, this is what I always say—you wanted to be a nurse, if you don't want to deal with emergencies all day, don't be an ER nurse and don't blame the patients in the ER. If you didn't want that setting, find another setting, maybe that setting is not for you, maybe you have problems with the patients. The problem is your career goals are no longer aligning with your setting. So, you've got to then come back, take accountability for yourself, reevaluate where you're at in your career, and then find a setting that's most appropriate for what you want to do at that time because we all change over the course of the years.
