Practical Approaches to Antidepressant-Associated QTc Prolongation: A Review of Cases

Brittany Weger, PharmD Candidate; Ali Goforth, PharmD Candidate; Alexandra Cunha, PharmD Candidate; Shaina Schwartz, PharmD, BCPP; Julie Cooper, PharmD, BCPS, BCCP

High Point University, High Point, NC

Type: Original Research. Background: Individuals with depression are at an increased risk of cardiovascular disease, which may be further complicated by antidepressant-associated QTc prolongation and Torsades de Pointe (TdP). Currently, there is no consensus guidance on QTc calculation, risk assessment, or post-incident management for such cases. Objectives: This review investigates documented cases of antidepressant-associated QTc prolongation and TdP to understand clinical decision-making in these patients. Methods: A structured literature search was conducted to identify case reports describing QTc prolongation or TdP in individuals taking an antidepressant. Reports published between January 2000 and March 2021 were eligible for inclusion. Articles describing patients with antidepressant overdose or omitting a diagnosis of depression, baseline QTc measurement, or maximum QTc measurement were excluded except in the event of sudden cardiac death outside the hospital setting. Bazett, Fridericia, Framingham, and Hodges formulas were used to calculate QTc. Mayo, Tisdale, and RISQ-PATH tools were used to calculate risk scores. Results: A total of 11 case reports met criteria for inclusion. The average patient was a 53.5-year-old female taking an SSRI with baseline and maximum QTc measurements of 420 msec and 535 msec, respectively. Four patients experienced TdP. The three risk scoring tools agreed in 4/11 (36%) cases. For the remaining 7/11 (64%) cases the Tisdale and RISQ-PATH scores identified risk as “low” whereas the Mayo score identified risk as “high”. Only one case specified the QT correction formula utilized. The most common intervention was to stop the antidepressant (45%, 5/11). Conclusions: Available case reports demonstrate a lack of consistency regarding QT correction formula used, risk evaluation techniques, and clinical management strategies. The Mayo risk scoring tool was the most conservative while Tisdale was the least conservative. Future research in this area can seek to develop a standardized approach for antidepressant-associated QTc prolongation in patients.

Antidepressant Prescribing Patterns in Transgender Individuals Diagnosed With Gender Dysphoria and Mood or Anxiety Disorders

Casey M. Tiefenthaler, PharmD1; Kelly C. Lee, PharmD, MAS, APh, FCCP, BCPP1,2

1 UC San Diego Health, San Diego, CA; 2 UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA

Type: Original Research. Purpose: Transgender adults are highly stigmatized members of society. Consequently, they are significantly more likely to be diagnosed with mood or anxiety-related disorders compared to cisgender individuals. Research efforts directed towards reducing adverse mental health outcomes are warranted. The purpose of this study was to investigate antidepressant prescribing patterns between gender identities and age groups. Methods: In this cross-sectional study, antidepressant prescribing data were collected from adults diagnosed with gender dysphoria (GD) during a 17-year timeframe between January 1, 2005 and October 31, 2021. Eligible patients had a concomitant diagnosis for mood or anxiety-related disorder at the time of their GD diagnosis. Patients with bipolar or obsessive-compulsive disorder were excluded. The primary outcome was to compare classes of antidepressants and number of prescriptions at the time of GD diagnosis between transgender females (MtF), transgender males (FtM), and non-binary (NB) individuals. Secondary outcomes included age group differences in prescribing patterns and gender identity differences in prevalence of comorbid psychiatric illnesses. Results: Of 131 patients who met inclusion criteria, 43% (n = 56) were identified as MtF, 41% (n = 54) as FtM, and 16% (n = 21) as NB. The most common concomitant diagnoses were mood disorders (n = 96, 73%) and generalized anxiety disorder (GAD) (n = 67, 51%). Approximately 37% (n = 48) of patients did not have an active antidepressant prescription at the time of GD and mood and/or anxiety disorder diagnosis. There was no significant difference in number of psychotropic prescriptions between gender identities (P = .357) or age group (P = .378). However, MtFs were prescribed bupropion at significantly higher rates than FtM and NB patients (16%, 11%, 0%, P = .046). Moreover, the prevalence of GAD was significantly greater among FtMs (P = .044) and those ≤ 40 years old (P < .001). Conclusions: Although there was no observable difference in the number of antidepressant prescriptions between gender or age groups, a staggering 37% of patients were not prescribed any antidepressants at time of their GD and mood and/or anxiety disorder. This serendipitous finding elucidates a potential gap in mental healthcare treatment among transgender adults. The study presents a potential opportunity for clinicians to address these health disparities faced by the highly marginalized population of transgender individuals.

Describe and Evaluate the Role of a Clinical Psychiatric Pharmacist in a Gender Health Program

Carolanne Wartman, PharmD1,2; David Butterfield, PharmD1,2; Lindsey Anderson, PharmD1,2; Michael Peters, PharmD1; Andrew Schmelz, PharmD1,3; Todd Walroth, PharmD1,2; Carol Ott, PharmD1,2

1 Eskenazi Health, Indianapolis, IN; 2 Purdue University, West Lafayette, IN; 3 Butler University, Indianapolis, IN

Type: Innovative Practices. Background: According to the 2015 US Transgender Survey, respondents reported experiencing serious psychological distress and attempting suicide at a rate significantly higher than the general population (39% vs 5% and 40% vs 4.6%, respectively). Identified barriers of care included costs of service, fear of being mistreated, and being refused care entirely. Psychiatric pharmacists provide a unique opportunity to deliver comprehensive care to these stigmatized individuals. To the best of our knowledge, there is no current literature describing the impact of a psychiatric pharmacist in an interdisciplinary gender health program. Description of Innovative Service: The Gender Health Program was established in March 2016 and provides primary and specialized care to transgender and nonbinary patients of all gender identities. A board-certified psychiatric pharmacist joined the team in May 2020 through a collaborative practice agreement. The pharmacist conducts patient interviews, medication management, laboratory monitoring, referrals to other healthcare providers, and a safe space for patients. Appointment types include mental health assessment and screening, mental health medication management, hormone therapy assessment and adjustment, and human immunodeficiency virus pre-exposure prophylaxis. Referrals to the pharmacist are made by the psychiatrists, psychiatry residents, family medicine providers and residents, a family medicine nurse practitioner, and mental health therapists. Impact on Patient Care: The pharmacist sees patients independently up to 15 hours per week. The clinical psychiatric pharmacist has seen a total of 94 patients, with a total of 158 appointments from May 2020 to December 2021. Patients ranged from 19 to 57 years of age. Depression and anxiety were the principle diagnosis discussed with patients (78% and 69%, respectively). Further data analysis will include baseline demographics, appointment details (eg, duration, medication changes, laboratory orders), and billing information. Conclusion: The gender diverse population experiences significant psychological distress and stigmatization in and outside of the healthcare setting. Given the high rate of depression, anxiety, and other mental health conditions, psychiatric pharmacists can provide positive health outcomes related to mental health assessments and medication management for this community. Dissemination of the details and impact of this innovative service will provide other institutions a roadmap to reproduce this service in their own health systems.

Optimizing the Role of the Clinical Pharmacist Practitioner in Collaborative Buprenorphine Management to Improve Rural Access

Haley Pals, PharmD, BCPP; Aruna Gottumukkala, MD

Tomah VA Medical Center, Tomah, WI

Type: Innovative Practices. Background: Despite the well-known morbidity and mortality benefit of buprenorphine for opioid use disorder (OUD), prescribing restrictions minimize widespread utility and disproportionally affect rural areas of the country. At a rural VA hospital, the outpatient mental health clinic had only two X-waivered psychiatrists to manage an increasing number of patients on buprenorphine. Psychiatric clinical pharmacist practitioners (CPP) had successfully helped the facility close the psychiatrist shortage gap before, thus an innovative collaborative approach was designed to expand CPP services into buprenorphine management. Practice Description: In June of 2020 they hired a psychiatric CPP to treat substance use disorders under a scope of practice with prescriptive authority. Existing buprenorphine patients were transferred to the CPP, where they took over primary management of all mental health conditions, medications, referrals, and lab monitoring. Patients see the X-waivered psychiatrist at least annually but are discussed after each CPP visit and buprenorphine prescription orders are placed for the psychiatrist's signature. New patients wishing to start buprenorphine are seen by the CPP in urgent access appointments and then staffed with an available X-waivered psychiatrist. Impact on Patient Care: From date of hire to December 31, 2021 the CPP has cared for over 80% (n = 53) of the facility's patients with OUD, of whom 34 received buprenorphine and the remaining received extended-release naltrexone injection or no longer needed medication. Those requesting urgent access appointments (n = 13) for buprenorphine assessment were on average seen same-day, compared with historically an average of about 6 days. Not all patients seen for assessment were appropriate for buprenorphine, representing an opportunity to avoid unnecessary psychiatrist intakes and prevent delays in care as wait time is currently 13.5 days. Psychiatrist time is saved by the CPP managing these buprenorphine patients, which allows them to focus on more complex patients or those needing diagnostic clarification. Conclusion: A collaborative approach to buprenorphine management utilizing a psychiatric CPP as the primary provider improved access to care at this rural facility. While collaboration decreases time burden for X-waivered psychiatrists, care could be more efficient and timely if a CPP could independently prescribe buprenorphine.

Successful Electroconvulsive Therapy After Failed Pharmacotherapies in an Older Female on Hemodialysis With Bipolar Mania

Ian McGrane, PharmD1,2; Robert Munjal, MD2; Shelby Skauge, PharmD Candidate1; Jason Molinaro, MD2

1 The University of Montana, Missoula, MT; 2 Providence St Patrick Hospital, Missoula, MT

Type: Therapeutic Case Report. Background: Bipolar disorder (BD) may be considered “late-stage” when the burden of disease is more treatment resistant and may require clozapine or electroconvulsive therapy (ECT). A common scenario is when a patient with BD had a preferential response to lithium, but can no longer take it due to end-stage renal disease. In this case, there are essentially three options – a) trial and error of novel or previously failed mood stabilizer or antipsychotics, b) cautious retrial of lithium, and c) ECT. Patient History: Our patient is a 75-year-old female who had her first episode of depression in her late twenties and episodes of mania in 2001, 2017 and 2020. These episodes of mania included grandiose and hyper-religious delusions. The patient had largely maintained psychiatric stability without psychiatric admissions while on lithium; but developed end-stage renal disease and required dialysis since 2018. Combination treatments of lamotrigine/quetiapine, divalproex/risperidone, and divalproex/olanzapine where previously attempted before she convinced her outpatient provider she did not have BD, and was treated with fluoxetine. Subsequently, she became manic and was admitted to our inpatient psychiatric hospital. We attempted combination treatments with quetiapine/divalproex, followed by quetiapine/lithium, and finally asenapine/lithium. Divalproex at 875 mg per 24-hour period yielded a pre-dialysis concentration of 57 mcg/mL. Quetiapine 300 mg nightly yielded a pre-dialysis concentration of 16 ng/mL. While taking 600 mg of lithium after dialysis and 300 mg on all other days except Sunday, pre- and post-dialysis lithium concentrations were 0.81 and 0.22 mmol/L, respectively. Mania was minimally abated, and after 46 days of hospitalization, bilateral ECT was initiated. After ECT #11 the patient was psychiatrically stable for discharge. She received weekly, then biweekly, and eventually monthly maintenance ECT until 2.5 months post-discharge for an additional 6 treatments. Review of Literature: An extensive PubMed search was performed to identify best practices for pharmacologic management of BD mania during hemodialysis. Our report reviews relevant literature surrounding these therapies and therapeutic drug monitoring. Conclusion: There is not a treatment guideline for BD in patients on hemodialysis and pharmacotherapy is challenging. This is the first report of ECT being effective in these patients.

Determining the Impact of High-Density Lipoprotein Cholesterol Levels and Their Influence on Movement Disorders in Patients Taking Antipsychotics

Carolyn O'Donnell, PharmD1,2; Tammie Lee Demler, PharmD, MBA, BCGP, BCPP1,2,3; Eileen Trigoboff, PMHCNS-BC, DNS, DABFN3

1 Buffalo Psychiatric Center, New York State Office of Mental Health, Buffalo, NY; 2 State University of New York, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York; 3 State University of New York, University at Buffalo School of Medicine, Department of Psychiatry, Buffalo, New York

Type: Original Research. Background: Recent studies have shown an association between a low level of high-density lipoprotein cholesterol (HDL-C) levels and increased risk for Parkinson disease, but it is unknown if lower HDL-C levels have the potential to increase Parkinsonian symptoms or other movement disorders in patients taking antipsychotics. Low HDL-C levels can impact the brain through different mechanisms including reduced myelin function, damage to the blood brain barrier, and potential cognitive impairment. However, it is unclear how this impacts movement disorders for patients taking antipsychotics. The objective of this study is to determine if low HDL-C levels lead to a higher risk of movement disorders in an inpatient state psychiatric facility. Methods: Adult patients at an inpatient state psychiatric facility were evaluated to determine if lower HDL-C levels were associated with more Parkinsonian symptoms or movement disorders. Patients were included if they were at the inpatient state psychiatric facility on August 31, 2021 and were taking at least one antipsychotic, had at least one HDL-C level, one history and physical, and at least one Abnormal Involuntary Movement Scale (AIMS) score. Patients were excluded if they had a criminal procedure law designation. Using a two-tailed t-test with unequal variance, patients were assessed to determine if low HDL-C levels influenced both movement disorders shown on initial physical exam, progress notes, and AIMS scores over a one-year period. Results: Of the 89 patients included in the study, there were eight patients with an AIMS score greater than zero and 34 patients with a low HDL-C level of less than 40 mg/dL for men and 50 mg/dL for women. There was no significance when comparing a patient's movements, AIMS scores, and HDL-C levels to suggest that lower HDL-C levels lead to more movement disorders in patients taking antipsychotics. Conclusion: From the results of this study, there is no clear association between patients with lower HDL-C levels and increased movement disorders or AIMS scores. Some of the patients were taking medications for movement disorders, which might have influenced their presentation, but in those patients, there was not a significant change in AIMS scores throughout their inpatient stay.

Utilization of Droperidol Versus Haloperidol for Acute Agitation in Psychiatric Patients Within the Emergency Department

Christie Costello, PharmD, BCPS; Caroline Crites, PharmD Candidate; Christine Rarrick, PharmD, MBA, BCPS, BCPP; Sophie Robert, BPharm, PharmD, BCPP; Erin Weeda, PharmD, BCPS

Medical University of South Carolina (MUSC) Health, Charleston, SC

Type: Original Research. Purpose: Droperidol is a butyrophenone antipsychotic used off-label to manage agitation. A black box warning emerged secondary to reports of corrected QT (QTc) interval prolongation and torsades de pointes causing a decrease in utilization. Droperidol was recently added to our institutional formulary for the management of agitation in the emergency department (ED) and usage has since increased. Patients commonly receive haloperidol, a similar butyrophenone antipsychotic, in combination with lorazepam and diphenhydramine at our institution. Lack of consensus exists regarding which agent to use based on effectiveness and safety in this patient population. Methods: A retrospective chart review was conducted of patients ≥ 18 years of age who presented to the ED from July 1, 2020 to June 30, 2021 with a psychiatric consult and received either parenteral droperidol or haloperidol. The primary outcome was to assess the efficacy of droperidol versus haloperidol in acute agitation based on additional medications required for sedation within 120 minutes. Secondary outcomes included the need for restraints, QTc > 500 milliseconds within 240 minutes post-administration, hypotension (systolic blood pressure < 90 and/or diastolic blood pressure < 50), respiratory depression (respiratory rate < 12), or bradycardia (heart rate < 60) post-administration. Results: A total of 298 patients were included (149 in each group). More patients presented with a chief complaint of psychosis in the droperidol group compared to haloperidol (33% vs 26%, respectively). The median doses of droperidol and haloperidol were 3.75 mg and 5 mg, respectively. There were more co-administered medications for agitation within 5 minutes for haloperidol (74%) compared to droperidol (44%) (P < .001). This largely included lorazepam and diphenhydramine for haloperidol and midazolam for droperidol. Patients requiring additional medications for sedation within 120 minutes were higher in the droperidol group (34%) than the haloperidol group (15%) (P < .001). There were no statistically significant differences in secondary outcomes. Conclusions/Future Directions: Patients in the droperidol group required further medications for sedation within 2 hours, however more patients in the haloperidol group received co-administered medications, likely driven by our institutions long-standing practice of combination agents with haloperidol. There were no differences in QTc prolongation or other adverse effects.

Understanding Pharmacy-Related Barriers to Care in Medication-Assisted Treatment Therapy: Perspectives From Peer Recovery Coaches

Katie H. Comanici, PharmD, MPH; Molly A. Nichols, PharmD, MATS; Stephanie Arnett, PharmD, CDCES; Catherine R. Scott, CPHQ; Carol A. Ott, PharmD, BCPP; Rakhi Karwa, PharmD, BCPS

Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN

Type: Original Research. Purpose: This study aims to understand how pharmacies and their personnel interact with medication for opioid use disorder (MOUD) current care practices by identifying barriers, facilitators, and opportunities through the perspective of peer recovery coaches. Methods: Ten peer recovery coaches were included, with five working in a rural or rural/mixed county in Indiana and five working in an urban county. A semi-structured interview was conducted individually with each participant. General topics covered in the interview were perspectives on their current role in MOUD therapy, their experiences at prescriber offices as well as at pharmacies regarding MOUD therapy, and how current MOUD care practices in those two settings could be improved upon. After all interviews were conducted, the data was analyzed using preconceived deductive codes as well as inductive codes that evolved with the project. One coder analyzed all ten transcripts, of which three were additionally analyzed by a second coder separately to confirm intercoder reliability. When the list of inductive codes was finalized after all transcripts were initially analyzed, each transcript was analyzed a second time to ensure all inductive codes were applied consistently. Results: Participants had been in recovery for a median of 4 years (range 1.6724) and had been working as a peer recovery coach for a median of 1.38 years (range 0.54). All peer recovery coaches identified themselves as facilitators in MOUD care. Within MOUD current care practices, frequent barriers identified included a lack of treatment standardization, stigma at the pharmacy, access to care, insurance or cost obstacles, and negative attitudes of society. All peer recovery coaches interviewed stated that the public considered using MOUD in one's recovery as trading one addiction for another. Peer recovery coaches viewed interactions with community pharmacies as either neutral or negative, as most participants were unsure of or not confident in pharmacists' knowledge of MOUD. Conclusions and Future Directions: There are many opportunities for community pharmacies to better engage in MOUD care practices. In the future, interviews will be conducted with community pharmacists and prescribers to obtain additional perspectives of those involved in MOUD practice.

Prevalence of Impostor Phenomenon Among Graduate Students in Pharmacy and Counseling Psychology

Logan T. Smith, PharmD Candidate1; Linda D. Logan, PharmD, BCPS, BCACP, BCPP1,2; Linda Campbell, PhD2

1 University of Georgia College of Pharmacy, Athens, GA; 2 University of Georgia Mary Frances Early College of Education, Athens, GA

Type: Work in Progress. Background: Mental health and wellbeing are increasingly recognized as important areas of emphasis for student support. Pharmacy and other graduate students are at increased risk of experiencing mental and emotional distress during their professional studies, including anxiety, depression, and academic concerns. Impostor phenomenon (IP) in higher education, also associated with generalized anxiety and depression, has been documented in the literature. Impostor phenomenon is associated with a lack of self-confidence and frustration due to inability to meet self-imposed standards of achievement. Furthermore, worsened physical health and diminished academic and professional success have been correlated with IP, potentially impacting healthcare professionals' ability to provide paramount patient care. Objectives: (1) Evaluate the degree of IP experienced by PharmD and graduate counseling psychology students. (2) Determine whether certain demographic variables correlate with IP. (3) Compare prevalence and degree of IP between PharmD and graduate counseling psychology students. Methods: Participants will be recruited from a public university, being eligible if currently enrolled in either the PharmD program or a graduate degree in counseling psychology and being ≥ 18 years old. Eligible students will receive an email inviting them to participate in an online survey including demographic data, the Clance Impostor Phenomenon Scale (CIPS), a validated IP instrument, the Perceived Stress Scale (PSS-10), and GAD-7. Responses will be anonymous. Outcomes: Reported outcomes will include degree of IP among respondents as average scores and number (%) of respondents falling within each of four intensity levels defined by the CIPS: “Few,” “Frequent,” “Severe,” and “Intense.” Pearson correlation analyses will be utilized to identify the relationships between CIPS score and variables including academic program, race/ethnicity, gender identity, PSS-10 score, GAD-7 score, and class year. Data collection has been completed among pharmacy students (182 respondents). Preliminary analysis revealed no statistical correlation in degree of IP and age, gender identity, or class year (P1 to P4). Non-White students had significantly lower scores on the CIPS, indicating fewer IP feelings (mean CIPS score 67.4 vs. 74.0, P = .002). Both an elevated PSS-10 and GAD-7 score were associated with higher CIPS scores (Pearson's r = .588 and .629 respectively; P < .001). Data collection is ongoing among counseling psychology students.

A Pilot Study Assessing Client Understanding and Use of Fentanyl Test Strips for Harm Reduction

Aleeya A. Barrolle, PharmD Candidate1; Kelly N. Gable, PharmD, BCPP1,2; Nathaniel Dell, AM, MSW, LCSW2

1 Southern Illinois University Edwardsville (SIUE) School of Pharmacy, Edwardsville, IL; 2 Authors located in St Louis, MO

Type: Original Research. Background and Purpose: The CDC has reported a sharp increase in overdose deaths from illicitly manufactured fentanyls (IMFs) occurring between April 2020 and April 2021 in the US. Approximately four in ten deaths involved stimulants. Fentanyl testing strips (FTS), when used to directly test drug product, can be a powerful harm reduction tool, promoting safer drug use behaviors and reduced overall overdose risk. This pilot study assessed treatment-seeking service users' knowledge and understanding of IMFs and motivation to use FTS as a method of harm reduction to prevent overdose. Methods: Clients actively engaged in residential-based or office-based treatment for a substance use disorder were recruited from a community mental health center in the midwestern US to complete a harm reduction-focused survey. With permission, survey questions were adapted from research conducted at Brown School of Public Health. Eligibility criteria included clients age 18 to 89 years of age with self-reported drug use in the past year (eg, heroin, cocaine, methamphetamine). A 20-question survey was administered verbally by a student investigator both in-person and via phone. Institutional Review Board (IRB) approval was obtained from both SIUE and Places for People. Results: Thirty clients completed the survey during the fall of 2021. Of respondents, 80% agreed that in Missouri, IMFs cause more overdoses than heroin. Seventy-three percent indicated concern about a friend overdosing due to IMFs, but only 47% expressed concern about personal risk for overdose. Most (73%) would like to be able to detect if there is fentanyl in their drug before use, but only 17% indicated that they feel confident in their ability to use FTS. Conclusions: Many respondents who were receiving services for past-year substance use lacked understanding of how to use FTS for harm reduction. Clients who primarily use non-opioid/stimulant drug products are at even greater risk for IMF overdose and would likely benefit the most from increased access and education surrounding use of FTS. Our healthcare system must rapidly continue to explore and expand upon overdose prevention efforts, including access to FTS, as urgent action is needed to reduce the continued rise in overdose deaths in the US.

A Qualitative Report of Fentanyl Exposure Among People Who Use Drugs in Austin, Texas

Sorina B. Torrez, PharmD Candidate 20221; Austin Buck, PharmD Candidate 20221; Lindsey J. Loera, PharmD1; Claire M. Zagorski, MSc, LP1; Jessica D. Cance, MPH, PhD2; Amanda Bingaman2; Heather Kane, PhD2; Sara Hairgrove2; Lucas G. Hill, PharmD1

1 The University of Texas at Austin, Austin, TX; 2 RTI International, Research Triangle Park, NC

Type: Original Research. Background: Deaths involving synthetic opioids in Texas have historically been lower compared to other US states because of the type of heroin available, black tar heroin, a tacky, tar-like substance. However, from 2020 to 2021, overdose deaths due to synthetic opioids increased in Texas by 170%. Little is known about the emergence of fentanyl in states where black tar heroin predominates and such research could yield valuable information to direct future harm reduction efforts. The purpose of this report was to understand the impact of increased fentanyl presence on the black tar heroin market in Austin, Texas. Methods: Adult patients accessing harm reduction services at two mobile outreach syringe services programs (SSP) in Austin, TX were invited to participate in an assessment interview examining their substance use. Potential participants were screened to determine if they met inclusion criteria, which required heroin or fentanyl use in the week prior. Data was collected from July 16, 2021 to July 23, 2021 from 30 participants via a semi-structured interview lasting 4 to 13 minutes and all participants received a $20 local grocery store gift card. Responses were analyzed using a deductive (via NVivo 12.0) and inductive hybrid approach to identify overarching themes discussed by participants. Results: Survey participants identified as male (n=17), female (n=10), and nonbinary (n=3) with a median age of 41.7 years. A majority identified as White (n=15) and were unhoused (n=16) or in temporary/transitional housing (n=4). Emerging themes discussed by participants included unintentional exposure to fentanyl, methods of detecting and identifying fentanyl in their drug supply, and harm reduction strategies to mitigate risks. Many respondents reported being able to identify fentanyl through use of fentanyl test strips, physical inspection, or by experiencing increased effects. Conclusions: Despite the predominance of black tar heroin in this region, people who use drugs in Austin, Texas report increased unintentional exposure to fentanyl. This emergence calls for public health initiatives that aim to reduce associated harms for people who use drugs. Initiatives that support SSPs and increase naloxone and fentanyl test strip access may be beneficial in this patient population.

An Assessment of Injection Site Reactions and Injection Site Pain of Once Every 6-Month and 3-Month Long-Acting Injectable Formulations of Paliperidone Palmitate

Karen Johnston, PharmD1; Dean Najarian, PharmD1; Sherry Fua, BSN, MSN, MBA, DNP1; Steven Wang, PhD2; Oliver Lopena, PharmD1; H. Lynn Starr, MD1

1 Janssen Scientific Affairs, LLC, Titusville, NJ; 2 Janssen Research & Development, LLC, Titusville, NJ

Type: Original Research. Background: Paliperidone palmitate 6-month (PP6M) long-acting injection was recently approved for the treatment of adults with schizophrenia. Dorsogluteal injection volumes range from 3.5 mL to 5 mL. Objective: Given the differences in formulation and injection volume of available paliperidone palmitate preparations, this post hoc analysis of a double-blind (DB) noninferiority study evaluated injection site reactions and pain following dorsogluteal injections of PP6M and paliperidone palmitate 3-month (PP3M). Methods: Following screening and an open-label transition and maintenance phase, clinically stable patients receiving “moderate/high” doses of paliperidone palmitate 1-month ([PP1M] 156 mg/mL; 234 mg/1.5 mL) or PP3M (546 mg/1.75 mL; 819 mg/2.63 mL) were randomized 2:1 to corresponding dorsogluteal injections of PP6M (1,092 mg/3.5 mL; 1,560 mg/5 mL) or PP3M (546 mg/1.75 mL; 819 mg/2.63 mL) during a 12-month DB phase. Patients receiving PP6M injections received alternating matching placebo injections every 3 months between active doses to maintain blinding. Results: In the DB phase, injection-site–related treatment-emergent adverse events (TEAEs) were reported in 59/478 (12.3%) PP6M patients and 11/224 (4.9%) PP3M patients, with injection site pain most common (37 [7.7%]) and 9 [4.0%], respectively). All other injection-site–related TEAEs, including induration, redness, and swelling, occurred in <2% of patients in both treatment groups. None of the injection-site–related TEAEs were reported as serious, resulted in treatment discontinuation, or required dermatological consultation. Mean [SD] patient-rated visual analog scale scores for injection site pain decreased from DB baseline to endpoint for subjects in both groups (PP6M: 17.22 [20.86] to 5.41 [10.76]; PP3M: 14.98 [18.98] to 4.54 [8.93]). Of the 895 active injections within the PP6M group, 2 instances of incomplete injections were reported. Both were related to increased resistance during injection; neither resulted in an adverse reaction. One instance was possibly related to insufficient shaking before administration. Conclusions: During the DB phase of a noninferiority study, injection-site–related TEAEs associated with PP6M injections up to 5 mL and PP3M injections up to 2.63 mL were mild to moderate in severity; none were reported as serious, resulted in treatment discontinuation, or required dermatological consultation.

Analysis of Psychiatric Care and Prescribing Patterns for Patients With PTSD Treatment in a Federally Qualified Health Center

Allison Wadlow, PharmD Candidate1; Leah Korte, PharmD Candidate1; Kelly N. Gable, PharmD, BCPP1,2; Jaron Asher, MD, ABPN2

1 SIUE, Edwardsville, IL; 2 Family Care Health Centers, St Louis, MO

Type: Original Research. Purpose: Psychotherapy remains the mainstay treatment recommendation within posttraumatic stress disorder (PTSD) guidelines. Consistency of pharmacotherapy treatment recommendations is lacking. The intent of this retrospective study is to explore PTSD pharmacotherapy prescribing patterns at a federally qualified healthcare center (FQHC). Methods: SIUE Institutional Review Board approval was obtained prior to project initiation. The FQHC selected for this project serves as a practice site for a psychiatrist, psychiatric pharmacist (BH providers), 25 primary care providers, and 18 family medicine residents (non-BH providers). Prescriber, prescribing data (from July 12, 2020 to July 12, 2021), patient demographics, and ICD-10 codes for depression, PTSD, and substance use disorders were extracted from the electronic health record. Psychiatric medication prescribing patterns were further analyzed based on concurrent diagnoses and type of prescriber (non-BH vs BH). Results: Within this FQHC, 490 patients receiving treatment over a one-year period had a diagnosis of PTSD. Depression (21%) and nicotine use disorder (20%) were the most common co-occurring psychiatric conditions. During this year, BH providers prescribed 430 psychiatric medications and non-BH prescribed 752 psychiatric medications. Selective serotonin reuptake inhibitors made up 11% of the 430 BH prescribed medications and 20% of the 752 non-BH prescribed medications, with sertraline used most frequently. Atypical antidepressants (mirtazapine, bupropion, duloxetine, and trazodone) made up 27% for BH and 17% for non-BH, with mirtazapine prescribed most frequently by BH. Quetiapine and aripiprazole were the most common antipsychotics and prescribed at comparable rates. Benzodiazepines made up 9.6% for non-BH and 6.7% for BH, with clonazepam prescribed most frequently. Prazosin was the most common medication for sleep-related PTSD symptoms, making up 8.1% for non-BH and 6.5% for BH. Conclusions: While PTSD guidelines lack consistency for pharmacotherapy, they all recommend SSRI treatments. The results of this study are likely reflecting the integrated healthcare model of this FQHC, in that non-BH providers are encouraged to initiate more common first-line treatments, while BH providers will often treat patients with more refractory symptoms. In this way, non-BH provider prescribing more closely matched current treatment guidelines. This study also demonstrated the need to reinforce the de-prescribing of benzodiazepines by non-BH providers.

Antipsychotic Efficacy of KarXT (Xanomeline-Trospium): Analysis of Positive and Negative Syndrome Scale Categorial Response Rates, Time Course of Response, and Symptom Domains of Response in a Phase 2 Study

Peter J. Weiden, MD1; Alan Breier, MD2; Andrew C. Miller, PhD1; Stephen K. Brannan, MD1; Steven M. Paul, MD1

1 Karuna Therapeutics, Boston, MA; 2 Indiana University School of Medicine, Indianapolis, IN

Type: Original Research. Background: KarXT (xanomeline–trospium) is an M1/M4-preferring muscarinic receptor agonist with no direct dopamine D2 receptor activity currently in phase 3 studies as a potential treatment for patients with schizophrenia. In a 5-week, randomized, double-blind, placebo-controlled, phase 2 study of acute psychosis in inpatients with schizophrenia (EMERGENT-1; NCT03697252), KarXT was associated with significantly greater reduction in Positive and Negative Syndrome Scale (PANSS) total score at week 5 compared with placebo as well as improvements on other key secondary efficacy measures. This current report provides additional information pertaining to PANSS categorical response rates, time course of response, and broader 5-factor PANSS symptom subdomains (positive symptoms, negative symptoms, disorganized thought, uncontrolled hostility, and anxiety/depression). Methods: Post hoc analyses included using categorical thresholds of PANSS total score reductions of ≥ 20%, ≥ 30%, ≥ 40%, and ≥ 50% between baseline and study end. Number needed to treat (NNT) for each categorical threshold was calculated. The proportion of KarXT- and placebo-treated patients achieving each response threshold at weeks 2, 4, and 5 was assessed. “Marder” 5-factor analysis of PANSS assessed response with KarXT across symptom domains. Results: A total of 83 patients in the KarXT group and 87 patients in the placebo group were included in the modified intent-to-treat analysis. Response rates with KarXT ranged from 59.0% for a ≥ 20% threshold to 15.7% for a ≥ 50% threshold. All response rates with KarXT were significantly higher than in the placebo arm, with NNTs ranging from 3 (≥ 20% improvement) to 11 (≥ 50% improvement). KarXT was associated with a higher response rate relative to placebo as early as 2 weeks for ≥ 20%, ≥ 30%, and ≥ 40% thresholds and 4 weeks for the ≥ 50% threshold. Each of the Marder 5-factor PANSS subdomains showed significant differences favoring KarXT over placebo by 2 weeks, which continued through week 5 (endpoint Cohens d effect sizes, 0.48-0.63). Conclusions: KarXT provided clinically meaningful responder rates on PANSS total score compared with placebo at each response threshold, providing further support of the successful primary and secondary endpoints. Response was demonstrated as early as 2 weeks relative to placebo. KarXT demonstrated improvements vs placebo in all 5 factors.

Assessing the Mental Health, Physical Health, and Well-Being of Doctor of Pharmacy Students

Mimi D. Nguyen, Pharm D Candidate1; Abby MacCauley Stocks, PharmD2; Heidi N. Anksorus, PharmD, BCPS1,3; Suzanne C. Harris, PharmD, BCPP, CPP1,4

1 University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC; 2 University of Kentucky Good Samaritan Hospital, Lexington, KY; 3 University of North Carolina Adams School of Dentistry, Chapel Hill, NC; 4 University of North Carolina Medical Center, Chapel Hill, NC

Type: Original Research. Introduction: Student well-being is a growing area of interest, though existing literature assessing multiple areas of well-being is lacking. This study aimed to evaluate the well-being of pharmacy students corresponding to three well-being domains (physical health, mental health, and personal well-being and burnout) and identify characteristics associated with these well-being domains in an attempt to gain a more well-rounded perspective of well-being and risk factors in pharmacy students. Methods: An online survey was disseminated to pharmacy students from 10 pharmacy programs. The survey was adapted from various instruments, including the Physical Health Measurements: Medical Outcomes Study Short Form-20 (SF-20); Patient Health Questionnaire-2 (PHQ-2); Generalized Anxiety Disorder-2 (GAD-2); World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (WHO-ASSIST); Well-being Index (WBI); and a non-proprietary, single-item burnout measure. Survey responses were compared using basic descriptive statistics and Pearson's χ2 was used for association analyses. Results: Students (N = 836) from 10 pharmacy programs responded to the survey (response rate 14.4%). For physical health, 59.3% of students reported sleeping < 7 hours per night and 60.4% reported exercising 1 to 5 hours per week. For mental health, 24.8% of students screened positive for depression and 42.1% screened positive for anxiety. Lastly, 65.9% of students were at risk for decreased well-being and 63.1% were at risk for burnout. Based on association analyses, “gender” and “pharmacy year” were associated with screening positive for anxiety and burnout (P = .001 and P = .044, respectively), while “gender” was associated with decreased well-being (P < .001), and “relationship status” was associated with screening positive for depression (P = .015). Conclusion: This study revealed pharmacy students are at risk for lack of sleep and exercise, depression or anxiety, decreased well-being, or burnout. In addition, several characteristics were found to be associated with these negative well-being outcomes. These findings help increase awareness about student well-being and inform pharmacy programs supporting well-being by better understanding student areas of concern.

Assessing the Use of Valproic Acid, Carbamazepine, Paroxetine, and Topiramate in Women of Childbearing Age

Carolina Liriano, PharmD; Hugh Franck, PharmD, BCPP, BCPS

North Florida South Georgia Veterans Health System, Gainesville, FL

Type: Original Research. Background: Women are the fastest growing group in the veteran population. Mental illnesses often occur during a woman's reproductive years, adding a complicating factor to treatment. Optimally, patients would have been taking a preferred pharmacological agent prior to pregnancy, but for women who decide to continue a potentially teratogenic medication the risks should be discussed. This study will focus on the use of valproic acid, carbamazepine, paroxetine, and topiramate. Objectives: (1) To examine the use of potentially teratogenic psychotropics in female veterans of childbearing age, including awareness of risks and contraceptive medication use. (2) To provide education and document contraceptive medication use as necessary. Methods: A report was generated for female veterans below the age of 50 years with active valproic acid, carbamazepine, paroxetine, or topiramate prescriptions within a portion of the Veterans Health System. Using the Computerized Patient Record System (CPRS), listed patients were assessed for use of these medications. Patient profiles were evaluated for documented history of infertility due to hysterectomy, tubal ligation, or menopause. These women were excluded from the study. Included women were contacted, surveyed, and educated. Results: Three patient lists were generated, no women of childbearing age were prescribed carbamazepine at the time. The number of female veterans assessed in each group were as follows: 39 on valproic acid, 48 on paroxetine, and 98 on topiramate. A total of 76 women were excluded and of the included women, 72 were able to be contacted, surveyed, and counseled. The majority of women reported being aware of the teratogenic risks of their medication but 44% were unaware. None were planning for pregnancy within the next year. Despite 68% of the women reporting use of contraceptive medication, only 45% were documented in the medication list. A total of 27 contraceptive medications were documented. The other 23 women not taking contraceptive medication were encouraged to and informed of the options available. Conclusions: Overall this study shows that there is a gap in teratogenicity awareness which may be lessened with routine discussion of risks, assessment of reproductive plans, and encouragement of effective contraceptive use.

Assessment of Oral Overlap With Antipsychotic Long-Acting Injectables Initiated in an Inpatient Setting

Jennifer Tran, PharmD; Katie Binger, PharmD, BCPP; Talia Miles, BCPS, BCPP

Veteran Health Indiana, Indianapolis, IN

Type: Original Research. Background: Long-acting injectable (LAI) antipsychotics are promising solutions to combat issues related to nonadherence. Prior to starting LAIs, oral antipsychotic overlap is used to establish tolerability and dose. After initiation of a LAI, oral overlap is continued to achieve therapeutic concentrations. Providers may prescribe additional overlap based on the presentation of the patient or misunderstanding of appropriate overlap. This may result in increased risk for polypharmacy, side effects, relapse, and nonadherence. Objectives: The aim of this study is to assess the appropriateness of oral overlap with LAIs. Additionally, this study aims to identify gaps in care with LAIs and how we can improve current prescribing practices. Methods: This retrospective, chart review will assess patients who were initiated on a LAI while admitted to the acute inpatient psychiatric unit from January 1, 2016 to December 31, 2019. Demographic variables were collected. Secondary outcomes include adherence to oral overlap, discontinuation of LAI within 4 months, and reason for discontinuation of LAI. Statistical analysis was completed using χ2 test for nominal variables and t-tests for continuous variables. Results: A total of 62 patients were included, 40 (65%) had appropriate overlap and 22 (35%) had inappropriate overlap. The most common LAI was paliperidone (82%, n = 50) and risperidone was the most common inappropriately used oral overlap (91%, n = 20). Patients were adherent to oral overlap in the appropriate (67%, n = 6) and inappropriate group (85%, n = 17). Discontinuation of a LAI in 4 months was in the appropriate group (48%, n = 19) and inappropriate group (41%, n = 9). Reasons for discontinuation of oral overlap include lost to follow-up, side effects, no injection visit scheduled, and inefficacy. There were no significant differences in secondary outcomes when comparing adherence to oral overlap (P = .26), discontinuation of LAI within 4 months (P = .62), and reason for discontinuation (P = .69). Conclusions and Future Directions: This study identifies gaps in our transitions of care process and whether prescribers are appropriately providing overlap to patients. This provides a new area of care where pharmacists may be instrumental in transitioning the patient from an inpatient setting to an outpatient setting.

Assessment of the Continuation Versus Discontinuation of Newly Initiated Antipsychotics for Delirium Treatment in Hospitalized Patients

Madison N. Holbrook, PharmD; Emily N. Gray, PharmD, BCPP; Amanda Hembree, PharmD, BCPS

Saint Francis Health System, Tulsa, OK

Type: Original Research. Purpose: Delirium occurs in up to 30% of hospitalized patients and 80% of critically ill patients. Antipsychotics are utilized for delirium treatment and have been associated with prolonged hospital stays and worse outcomes. This study evaluates patterns of newly initiated oral antipsychotics for the treatment of delirium and continuation upon discharge. Methods: A descriptive report identified 948 patients from multiple sites with routinely scheduled, newly initiated, oral antipsychotics and a concurrent diagnosis of delirium, altered mental status, or encephalopathy between January 1, 2020, and December 31, 2020, via the electronic health care record. Patients were excluded if they were admitted to hospice or a psychiatric care facility upon discharge, utilized an alcohol withdrawal order set, had an antipsychotic on their prior to admission medication list, or an antipsychotic prescribed by a psychiatrist. Two hundred patients were analyzed for antipsychotic utilization patterns, psychiatry consults, readmission within 30 days, reason for readmission, exposure to dexmedetomidine, opioids, or benzodiazepines, and utilization of the delirium prevention order set. Results: Demographics indicate the majority of patients who received antipsychotics were geriatric (n = 125) and male (n = 108). The documented indication for continued therapy upon discharge included acute metabolic encephalopathy (n = 41), delirium (n = 13), altered mental status (n = 10), and agitation (n = 9). Continuation was associated with prolonged duration of therapy, increased antipsychotic dose, and exposure to opioids. Newly initiated antipsychotics were discontinued 60% of the time. Factors that may have aided discontinuation were psychiatric consult (n = 42), use of the delirium protocol (n = 9), or admission to the stepdown unit (n = 17). In both groups, quetiapine (62.5%) was the most frequently prescribed antipsychotic with hospitalists (n = 137) as the most common prescriber. There were no significant differences found in readmission rates between groups. Conclusion: This study is limited due to the small sample size and inability to define a causal relationship. However, we can address trends throughout our health system, including a high rate of geriatric orders, prolonged duration of therapy, and increased dose with antipsychotics continued upon discharge. We identified our current safety tools are highly underutilized. Implementation of a medication discontinuation checklist upon discharge may increase accuracy, safety, and cost for patients.

Buprenorphine/Naloxone Film and Naloxone Nasal Spray Pharmacy Deserts in Harris County, Texas and Philadelphia County, Pennsylvania

Megan S. Yeung1; Lindsey J. Loera, PharmD1; Margaret R. Peterson, MSc2; Morgan L. Murchison1; Kami E. Johnston1; Chandler A. Prevatt1; Andrew M. Peterson, PharmD, PhD3; Kelly R. Reveles, PharmD, PhD, BCPS4; Lucas G. Hill, PharmD, BCPS, BCACP1

1 The University of Texas at Austin, Austin, TX; 2 The George Washington University, Washington, DC; 3 University of the Sciences Philadelphia, Philadelphia, Pennsylvania; 4 The University of Texas Health Science Center, San Antonio, TX

Type: Original Research. Background: Persons with opioid use disorder (OUD) must be able to obtain buprenorphine/naloxone films (BUP/NX) and naloxone nasal spray (NNS) in a timely manner to reduce risk for recurrence of use, morbidity, and mortality. This study was a focused assessment in two highly populated and demographically diverse counties in states where availability of BUP/NX and NNS was previously evaluated. Methods: A randomly selected 30% of community pharmacies in Harris County (n = 300) and Philadelphia County (n = 130) were audited via telephone from April 1, 2021 to September 30, 2021. Interviewers followed a standardized script to assess availability of BUP/NX and NNS. Primary outcomes included availability of a one-week supply of generic BUP/NX 8/2mg and a single unit of NNS overall and by pharmacy type. Secondary outcomes included willingness to order BUP/NX if unavailable and estimated timeframe to do so. Pharmacies were excluded if unreachable after three attempts, refused to disclose information, or were not a community pharmacy. Results: Forty-five pharmacies were excluded and 28 were non-responders, resulting in an 83% response rate. Data from 248 pharmacies in Harris County (145 chain, 103 independent) and 109 pharmacies in Philadelphia County (53 chain, 56 independent) were included in the final analyses. Overall, 89 (24.9%) had a one-week supply of generic BUP/NX and 131 (36.7%) had a single unit of NNS. Philadelphia County had greater BUP/NX availability compared to Harris County (38.5% vs 19.0%, P < .001), while Harris County had greater NNS availability (40.3% vs 28.4%, P = .032). Independent pharmacies were significantly less likely to have BUP/NX than chain pharmacies (17.6% vs 30.8%, P = .004) and NNS (16.4% vs 53.0%, P < .001). Of 268 pharmacies with generic BUP/NX unavailable, 97 (36.2%) indicated willingness to order with a median order time of 3 days. Conclusions: Few pharmacies in these metropolitan counties are prepared to dispense BUP/NX and NNS, with greater deficiencies in independent pharmacies. Further research is needed to identify underlying factors and effective solutions.

Characteristics of Inpatients Prescribed Dopamine Receptor Blocking Agents

Shaina Schwartz, PharmD, BCPP1,2; Lauren Dinkla1; Jocelyn Pullen1; Rachel Bernard1; Archana Kumar, MD2

1 High Point University, High Point, NC; 2 Cone Health Behavioral Health Hospital, Greensboro, NC

Type: Original Research. Purpose: Dopamine receptor blocking agents (DRBAs, also known as antipsychotics) are frequently used in hospitalized patients. These medications carry a significant risk of side effects and should be used judiciously. This purpose of this study was to examine patient, disease, and medication characteristics associated with the use of DRBAs in the inpatient setting in order to better understand current prescribing patterns and opportunities for optimization. Methods: A retrospective review of medical records was conducted at a moderately-sized non-profit community health network located in the Southeastern US. Those eligible for inclusion were inpatients ≥ 18 years of age with at least one DRBA medication order placed between January 1, 2018 and December 31, 2019.. Statistical testing was used to assess for relationships between patient characteristics (gender, ethnicity, marital status, health insurance type), disease characteristics (psychiatric diagnosis), and medication characteristics (DRBA, route of administration, adverse effects, medication non-adherence). Results: The study population (N = 17,224) contained those with (71.0%) and without (29.0%) psychiatric diagnoses, and the mean number of DRBA medications for each patient was 2.4 ± 1.1. The characteristics of single, male, government-sponsored health insurance, movement disorder, DRBA adverse effects, and medication non-adherence were associated with significantly greater mean total DRBA medications prescribed. Medication non-adherence and prescription of a long-acting injectable DRBA were greater in single and male patients, while suicidality was more likely in those with a movement disorder or DRBA adverse effect. Specific agents were also significantly associated with cardiovascular disease and metabolic disorder diagnoses. Conclusions and Future Directions: Based on the findings of this study, several patient, disease, and medication characteristics are related to the use of DRBAs in the hospital setting. It is important to further explore these associations in order to determine the appropriateness of DRBA prescribing and identify areas for improvement.

Comparison of Early Antipsychotic Metabolic Monitoring and the Development of Abnormal Hemoglobin A1c

Mitchell D. Crouch, PharmD1,2; Sarah A. Norman, PharmD, BCPS, BCPP1

1 Central Texas Veterans Health Care System, Temple, TX; 2 University of Texas at Austin College of Pharmacy, Austin, TX

Type: Original Research. Purpose: Patients treated with second-generation antipsychotics (SGA) are at risk for weight gain and glucose dysregulation increasing their risk of developing type 2 diabetes mellitus (DM2). Current guidelines recommend patients with schizophrenia be assessed for DM2 at baseline, 12 weeks after initiation of a new SGA, and yearly thereafter. In 2006 our institution implemented a clinical reminder to improve SGA metabolic monitoring. This tool includes body weight, blood pressure, lipid panel, and blood glucose, but does not include HbA1c monitoring. This study aimed to determine if early HbA1c monitoring in new start SGAs is a reliable predictor for future metabolic abnormalities. Methods: A single-site, retrospective, observational, quality improvement project identified veterans with a mental health diagnosis newly started on SGAs between January 1, 2015 and December 31, 2015. Veterans were followed for 5 years to assess changes in HbA1c. The primary outcome of this study was to compare rate of HbA1c ≥ 6.5% at 1-year post-SGA initiation for patients with and without early HbA1c monitoring. Early HbA1c monitoring was defined as baseline HbA1c (within 1 year before starting SGA) and repeat HbA1c 3 to 5 months after SGA initiation. Secondary outcomes include rate of HbA1c ≥ 6.5% at 5 years, proportion of days covered (PDC), HbA1c, BMI, and weight changes. Exclusion criteria included baseline HbA1c ≥ 6.5%, antidiabetic medication, SGA filled once, or deceased at the time of data collection. Results: Twenty-eight patients were reviewed, 14 with early HbA1c monitoring and 14 without. Rates of HbA1c ≥ 6.5% at 1-year were not statistically significantly different between early HbA1c vs no early HbA1c monitoring (2/14 [14.28%] vs 0/14 [0%], P = .482); or at 5-years (3/14 [21.43%] vs 1/14 [7.14%], P = .596). Proportion of days covered, HbA1c, BMI, and weight changes were similar between the two groups. Additionally, rates of early HbA1c monitoring were similar between SGAs considered high risk vs. low risk for metabolic abnormalities. Conclusions and Future Directions: Early HbA1c monitoring with initiation of a new SGA was not associated with improved outcomes for metabolic abnormalities for patients newly started on SGAs. Study findings are limited due to small sample size.

Comparison of Pharmacy Operations Across State Psychiatric Hospitals in the United States

Sara Huffman, PharmD; Albert Chira, PharmD, BCPP

Oregon State Hospital, Salem, OR

Type: Original Research. Background: In recent years, the role of pharmacists in the hospital setting has shifted from drug dispensing to independent medication management. Specifically, in the inpatient psychiatric setting, pharmacists have improved appropriate use of medications and outcomes in a particularly vulnerable population. Services provided by pharmacists vary due to differences in state regulations, billing complications, hospital infrastructure, and nature of pharmacist-prescriber relationships. Objectives: The objective of this study was to compare pharmacy operations across state psychiatric hospitals in the US. The main points of interest focused on availability of common medical technologies and specific clinical services offered. Methods: A telephone survey of state psychiatric hospitals was conducted from September 1, 2021 to December 31, 2021. Pharmacy contact was obtained from each hospital website or hospital operator. The survey included a total of 20 questions broken into five categories: general facility information, pharmacy structure, staffing model, systems, and clinical services. Survey answers were collected from an available pharmacist or manager at the time of the call. Collected data were analyzed using descriptive statistics. Results: Out of the 33 attempted surveys, 17 were completed, yielding a 51.5% response rate. Of respondents, 70.6% endorsed order processing via computerized physician order entry (CPOE) and 58.8% utilized automated dispensing cabinets (ADCs). Though only 29.4% had designated clinical pharmacists, 64.7% offered clinical services. Services commonly included medication management (82.3%), interprofessional team involvement (82.3%), lab monitoring (58.8%), patient education (58.8%), and committee participation (76.5%). Conclusion: Though clinical services were provided by most pharmacies surveyed, specific services varied. This could be due to differences in state laws, budget constraints, hospital infrastructure, pharmacist-provider relationships, and limitations due to COVID-19. Limitations of this study include small sample size, largely due to limited pharmacist availability. Additionally, the western region yielded most responses, therefore the sampling may not accurately represent other regions of the US. Further research should include more effective communication methods and a larger, more diverse sample. Other areas to assess include percentage of accepted pharmacist interventions, intervention documentation methods, rates of prescriptive authority or collaborative practice agreements (CDTMs), and medication error rates using CPOE versus other methods of order entry.

Competence, Concerns, and Readiness Regarding Opioid Overdose Management: A National Cross-Sectional Survey of the US General Public

Zach Krauss, MBA, BSPS, Student Pharmacist1; Lindsey Hohmann, PharmD, PhD2; Grace Trull, Student Pharmacist3; Jitisha Patel, Student Pharmacist4

1 Cedarville University School of Pharmacy, Cedarville, OH; 2 Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, AL; 3 University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC; 4 Shenandoah University School of Pharmacy, Winchester, VA

Type: Original Research. Purpose: Opioid misuse and overdose continue to be major public health issues in the United States. Given strains on healthcare resources during the COVID-19 pandemic, community-level responders are critical. Therefore, the purpose of this study was to better understand the general public's abilities (competence, concerns, readiness) regarding opioid overdose management and naloxone utilization. Methods: This cross-sectional survey study represents a sub-set of findings from a larger national survey exploring the general public's perceptions of community pharmacy-based opioid counseling and naloxone services. An Amazon Mechanical Turk (MTurk) online panel was utilized to recruit US adults and to distribute an anonymous electronic survey. Survey questions were adapted from Williams' et al (2013) Opioid Overdose Attitude Scale (OOAS). Outcome measures were assessed using 5-point Likert-type scales (1 = strongly disagree, 5 = strongly agree) and included: (1) competence in managing an opioid overdose (10-items); (2) concerns regarding intervening in an opioid overdose (8-items); and (3) readiness to intervene in an opioid overdose situation (10-items). Data were analyzed using descriptive statistics with Microsoft Excel 2021. Results: Approximately 49% of respondents were female and 82% White, with mean age of 43 years (N = 301). Overall, mean [SD] self-reported competence in managing an opioid overdose tended to be low (scale score: 2.61 [0.85]), with only 15.6% of respondents agreeing or strongly agreeing that they would be able to deal effectively with an opioid overdose and 13.6% stating they felt able to administer naloxone to someone who has overdosed. However, mean [SD] concerns regarding intervening in an overdose situation were fairly low/neutral (2.80 [0.66]), and readiness to intervene was high (4.11 [0.63]). Specifically, primary fears/concerns included accidentally hurting someone who has overdosed (50.9%) and doing something wrong in an overdose situation (76.7%). In terms of readiness, 92.0% indicated that they want to be able to help someone in an opioid overdose situation and 74.4% reported that they would do whatever was necessary to save the life of an overdose victim. Conclusions: The US general public is ready/willing to intervene in opioid overdose situations, but additional education is needed to increase naloxone administration competencies and allay specific concerns. Addressing these factors may increase community-level opioid overdose responder capacity.

Development of Attribute Statements for a Best Practice Model for Outpatient Psychiatric Pharmacy Practice

Jennifer Bean, PharmD, BCPS, BCPP1; Richard Silvia, PharmD, BCPP2; Gregory Payne, MBA3; Kelly Lee, PharmD, MAS, APh, BCPP, FCCP4; Elayne Ansara, PharmD, BCPS, BCPP5

1 VA-Tennessee Valley Healthcare System, Murfreesboro, TN; 2 School of Pharmacy-Boston, MCPHS, Boston, MA; 3 American Association of Psychiatric Pharmacists, Lincoln, NE; 4 Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California-San Diego, San Diego, CA; 5 Veteran Health Indiana, Indianapolis, IN

Type: Original Research. Background: A 2019 survey identified significant variability of practice characteristics among outpatient psychiatric pharmacists (OPPs), including prescriptive authority. In response to this variability, this project aimed to build consensus and develop practice model statements for psychiatric pharmacists providing direct care in an outpatient setting. Consensus of these attributes will promote a best practice model for consistent, effective care provided by OPPs. Objectives: The objective of this project was to develop attribute statements for a best practice model for psychiatric pharmacists providing direct patient care within the outpatient setting. Methods: Members from CPNP were questioned using a 5 phase (P1-5) survey and interview approach. The phases consisted of: (P1) an ideation survey to gather broad feedback; (P2) a 10-person summit to review P1 data and develop draft statements; (P3) a survey of the draft statements for acceptance, revision, or rejection; (P4) a summit to resolve review feedback; and (P5) a survey of CPNP membership to validate the finalized statements. The entirety of the project ran from June 2, 2020 to November 22, 2021. Results: Survey results from P1 indicated that attributes such as BCPP certification, PGY2 and/or PGY1 residency training, and years of practice are important characteristics for OPPs. The 143 attributes proposed in that survey informed the 28 statements that ultimately were studied in P5. The respondents of this final survey (n = 74; 6.1%) were licensed pharmacists for an average of 15.6 years (SD = 12.0) and had been practicing as psychiatric pharmacists for an average of 11.3 years (SD = 10.4). Slightly more than half (54.2%) of the respondents reported practicing in the outpatient setting and 74.3% were BCPPs. For each of the 28 statements, at least 90% of respondents either agreed or agreed with minimal reservations. Conclusions and Future Directions: With the high degree of agreement on the proposed practice model statements, they will be used as the basis for the Outpatient Psychiatric Pharmacist Best Practice Model. Next steps in developing this model include establishing implementation guidance and determining appropriate metrics for evaluation of these statements in practice. Appropriate field-testing methods will also be established.

Effects of Cannabidiol Products on In Vitro Metabolism of Clozapine

Alexandria Brinkmann, PharmD Candidate; Marshall E. Cates, PharmD, BCPP, FASHP, FCCP; Danielle L. Cruthirds, PhD; Lori U. Coward, BS; Greg S. Gorman, PhD

Samford University McWhorter School of Pharmacy, Birmingham, AL

Type: Original Research. Background: Patients receiving clozapine therapy could seek out cannabidiol (CBD) products for its various purported uses, such as anxiety, depression, and insomnia. Additionally, CBD has shown beneficial effects in a randomized controlled trial as an adjunctive therapy in schizophrenia. Concomitant use of CBD and clozapine could result in a potential drug interaction risk since CBD is an inhibitor of CYP1A2 and clozapine is primarily metabolized by this isoenzyme. Objectives: The purposes of this study were to determine the extent to which CBD inhibits the in vitro metabolism of clozapine and to determine whether various CBD products have differing effects in this regard. Methods: Five over-the-counter CBD products and one prescription CBD product were used in the project. Clozapine at a concentration of 10 μM was incubated with human liver microsomes over the corresponding physiological range of CBD concentrations derived from the recommended dosages of the various products. Each reaction was conducted in triplicate using control samples, containing no CBD. Concentrations of clozapine, norclozapine, and clozapine-N-oxide were measured after 30 minutes of incubation at 37 C° using high-performance liquid chromatography-tandem mass spectrometry. The degree of metabolic inhibition was determined by comparing the change in concentrations of clozapine and its metabolites at each CBD concentration versus control. Results: All CBD products over all concentrations tested modulated the in vitro metabolism of clozapine to some measurable degree. The maximum inhibition of clozapine metabolism expressed as the percent decrease in the formation of clozapine's two major metabolites norclozapine and clozapine-N-oxide versus a control reaction were approximately 67% and 79% for CBD #1, 62% and 81% for CBD #2, 59% and 70% for CBD #3, 49% and 42% for CBD #4, 45% and 56% for CBD #5, and 37% and 25% for CBD #6, respectively. Conclusions: Cannabidiol inhibits the in vitro metabolism of clozapine, the extent to which varies between individual CBD products. These findings need to be replicated in in vivo studies. Still, the practical implication is that clinicians should inquire about CBD use when patients are receiving clozapine therapy, and they should take appropriate monitoring measures in cases of concomitant use.

Evaluating the Utility of a Required Didactic Mental Health First Aid Training Course Among First-Year Pharmacy Students

P. Brittany Vickery, PharmD, BCPS, BCPP, CPP; Kendall Wick, PharmD Candidate 2023

Wingate University School of Pharmacy, Hendersonville Health Sciences Center, Hendersonville, NC

Type: Original Research. Background: There is a need for pharmacists to be trained to provide Mental Health First Aid (MHFA) and for students to provide peer support to each other. This research will aid in determining if MHFA should be required. Objectives: Evaluate (1) If MHFA training is beneficial. (2) If students find MHFA training valuable. (3) If MHFA reduces stigma and increases confidence in abilities to offer help to those with a mental health diagnosis or crisis. Methods: As part of a new curriculum of a PharmD program at a Pharmacy School in North Carolina students were required to participate in MHFA training during the fall (September 13, 2021 to November 18, 2021) of the first didactic year and study data was collected. The study was Research Review Board approved. The survey was administered anonymously online using Google Forms. The survey consisted of demographic information, questions that assessed stigma, and ability to offer help to those with a mental health crisis. Data were analyzed using IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA). Descriptive statistics were computed to describe the demographic characteristics. Differences between pre-training and post-training scores were assessed with t-tests for significance. Statistical significance was established at an alpha of P < .05. Results: A total of 69 students completed the pre-training survey, participated in the MHFA training, and 64 students completed the post-training survey. Most of the participants were female (71%) and White non-Hispanic (58%). The results from the pre-test and post-test indicate that the MHFA training had a positive impact on the students as there was increased confidence in ability to start a conversation with someone who may need mental health help (M = 4.4, SD = 0.7) compared to the confidence level before the training (M = 3.4, SD = 0.9), t (123) = 6.9, P < .001. Conclusions: Students were more confident in their ability to recognize a mental health diagnosis or crisis, felt they had a better knowledge base about options for treating a mental health disorder, and were able to identify stigmatizing words associated with mental health disorders.

Evaluation of Anticholinergic Medication Burden in Patients With Schizophrenia or Schizoaffective Disorder

Danial Chowdhury, PharmD1; Megan Maroney, PharmD, BCPP1,2; Germin Fahim, PharmD, BCPS1,2; A. Scott Mathis, PharmD1; Hoytin Lee Ghin, PharmD, BCPS1

1 Ernest Mario School of Pharmacy at Rutgers University, Piscataway, NJ; 2 Monmouth Medical Center, Long Branch, NJ

Type: Original Research. Background: Cognitive impairment is a key disabling feature of schizophrenia, with patients showing significant deficits in attention, learning, memory, executive functioning, and social cognition. Cognitive dysfunction may be further exacerbated by psychotropic medications which often possess strong anticholinergic properties. The Anticholinergic Cognitive Burden (ACB) Scale is available as an online tool that differentiates drugs based on anticholinergic properties to assess a patient's total anticholinergic medication burden. An ACB score of 3 or higher is associated with cognitive dysfunction and a 50% increased risk of developing dementia. Objective: The aim of this study was to assess the average anticholinergic medication burden of patients with schizophrenia or schizoaffective disorder at the time of admission to our hospital, using the ACB Scale. We also assessed the change in anticholinergic burden during the inpatient admission and if alternative treatment recommendations could have been implemented to reduce anticholinergic medication burden. Methods: This study retrospectively analyzed patients with a previous diagnosis of schizophrenia or schizoaffective disorder who were admitted to our institution between March 1, 2021 and September 30, 2021. Patient demographics, home medications, hospital-administered medications, documented adverse effects, and ACB scores for pre-admission and during admission were documented. All ACB score calculations were conducted by entering medications into an online ACB calculator. Only home medications filled consistently within the last 2 months prior to admission, according to outpatient pharmacy records, were included to account for medication adherence. Results: The majority of patients (79%) who met the inclusion criteria had an admission ACB score greater than 3, with the hospital on average increasing a patient's anticholinergic medication burden by 5.14 points. The most commonly administered medications were olanzapine, risperidone, trazodone and haloperidol. Medications with the highest anticholinergic burden were benztropine, diphenhydramine, hydroxyzine, and olanzapine. Anticholinergic adverse effects were not routinely documented. Conclusion: Our institution does not currently monitor anticholinergic medication burden while increasing the average patient's burden. Our preliminary recommendation is that all patients receive a baseline ACB score determination, and that patients with an ACB score greater than 3 have more active medication monitoring to assess for alternative therapy options with less anticholinergic burden.

Evaluation of Virtual Academic Detailing on Naloxone Prescribing at the US Veterans Health Administration

Sarah J. Popish, PharmD, BCPP; Mark Bounthavong, PharmD, PhD, MPH; Marcos K. Lau, PharmD, MS, BCPS; Daina L. Wells, PharmD, MBA, BCPP, BCPS; Chad L. Kay, PharmD, BCPS; Michael A. Harvey, PharmD, BCPS; Julianne E. Himstreet, PharmD, BCPS; Melissa L. D. Christopher, PharmD

US Department of Veterans Affairs, San Diego, CA

Type: Original Research. Background: Academic detailing (AD) has been reported to improve the naloxone prescribing rates among veterans at risk for opioid-related overdose. Conventional AD focuses on delivering educational outreach via in-person interactions. However, it is unclear whether other modes of communication (eg, virtual AD) are as effective. In 2018, a pilot virtual AD program was implemented at three VHA regional networks (VISNs), which provided an opportunity to perform an evaluation to compare virtual to in-person AD on naloxone prescribing rates. Methods: A retrospective quasi-experimental pretest-posttest design was used to compare the impact of virtual AD and in-person AD on naloxone prescribing rates 12 months before and after a naloxone-specific encounter. Providers who received an encounter for the first time between January 1, 2018 and May 31, 2020 were included for analysis. Monthly naloxone prescribing rates (naloxone prescriptions prescribed per 1000 patients) were averaged. Wilcoxon signed rank tests were used to evaluate the naloxone prescribing rates across the pre- and post-periods. Generalized estimating equation (GEE) model was performed to control for provider-level covariates. Results: A total of 253 providers were evaluated [in-person (n = 186; 73.5%); virtual (n = 67; 26.5%)]. Among providers who received in-person AD, the 12-month pre-post monthly naloxone rates were 1.9 and 4.0 per 1000 patients, respectively (P < 0.001). Among providers who received virtual AD, the 12-month pre-post monthly naloxone prescribing rates were 2.5 and 5.2 per 1000 patients, respectively (P = 0.004). In the GEE model, the difference in naloxone prescribing rates between the virtual and in-person AD was not statistically significant (difference in change in naloxone rates = +0.63; 95% CI: -2.23, 3.48). Conclusions: Among the three VISNs, significant increases in naloxone prescribing were reported for in-person and virtual AD. However, no differences in the change in naloxone rates were reported between the virtual and in-person AD. This study suggests that providers who received virtual AD have naloxone rate changes that are similar to providers who received in-person AD. As virtual AD expands, academic detailers will be able to reach a wider provider population that are challenging to access in-person.

Glutamatergic Dependence of the Ketamine-Like Rapid-Acting Antidepressant RO-25-6981 and Its Analogs

Nikki K. Ghazimorad, BS1; Jessica Wirtz, BS1; Mahdeed Raja, BS1; Eliza Talbot2; Tessa Spiger3; Robert D. Kirsh, BS4; Christopher H. So, PhD1; David B. Rawlins, PhD1; Jeffery N. Talbot, PhD1,5