CPSUD Certification Review

Certified Pharmacist in Substance Use Disorders (CPSUD) Review

A Review Guide for the Certified Pharmacist in Substance Use Disorders (CPSUD) Exam

Block 1: Foundations of Addiction Pharmacy

A-C

  • 42 CFR Part 2: Federal Confidentiality Regulations for SUD Records.
  • AA: Alcoholics Anonymous.
  • ASAM: American Society of Addiction Medicine.
  • AUD: Alcohol Use Disorder.
  • AUDIT: Alcohol Use Disorders Identification Test.
  • BZD: Benzodiazepine.
  • CAGE: Cut down, Annoyed, Guilty, Eye-opener (Screening Tool).
  • CBT: Cognitive Behavioral Therapy.
  • CIWA-Ar: Clinical Institute Withdrawal Assessment for Alcohol, Revised.
  • COWS: Clinical Opiate Withdrawal Scale.

D-L

  • DEA: Drug Enforcement Administration.
  • DSM-5: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.
  • DTS: Delirium Tremens.
  • EHR: Electronic Health Record.
  • EPT: Expedited Partner Therapy.
  • FWA: Fraud, Waste, and Abuse.
  • GABA: Gamma-Aminobutyric Acid.
  • HCV: Hepatitis C Virus.
  • HIV: Human Immunodeficiency Virus.
  • LAI: Long-Acting Injectable.

M-O

  • MAT: Medication-Assisted Treatment (now MOUD).
  • MME: Morphine Milligram Equivalents.
  • MOUD: Medications for Opioid Use Disorder.
  • NA: Narcotics Anonymous.
  • NRT: Nicotine Replacement Therapy.
  • OAS: Opioid Agonist Scale.
  • OTP: Opioid Treatment Program.
  • OUD: Opioid Use Disorder.
  • PCP: Primary Care Provider / Phencyclidine.
  • PDMP: Prescription Drug Monitoring Program.

P-S

  • PEP: Post-Exposure Prophylaxis.
  • PrEP: Pre-Exposure Prophylaxis.
  • PTSD: Post-Traumatic Stress Disorder.
  • PWID: People Who Inject Drugs.
  • REMS: Risk Evaluation and Mitigation Strategy.
  • SAMHSA: Substance Abuse and Mental Health Services Administration.
  • SBIRT: Screening, Brief Intervention, and Referral to Treatment.
  • SDoH: Social Determinants of Health.
  • SUD: Substance Use Disorder.
  • SSP: Syringe Service Program.

T-Z

  • TCA: Tricyclic Antidepressant.
  • THC: Tetrahydrocannabinol.
  • TDM: Therapeutic Drug Monitoring.
  • UDT: Urine Drug Test.
  • VHA: Veterans Health Administration.
  • WHO: World Health Organization.
  • X-Waiver: DEA waiver for prescribing buprenorphine (no longer required).
  • CRAFFT: Car, Relax, Alone, Forget, Friends, Trouble (Adolescent SUD Screen).
  • DAST: Drug Abuse Screening Test.
  • NIDA: National Institute on Drug Abuse.

Addiction as a Chronic Brain Disease

  • The modern understanding is that addiction is a chronic, relapsing brain disease, not a moral failing.
  • Repeated substance use causes long-lasting changes in the brain's structure and function.
  • These changes affect key circuits involved in reward, stress, and self-control.
  • This brain-based model is essential for a non-stigmatizing, medical approach to treatment.
  • A CPSUD must be a champion of this model.

The Biopsychosocial Model of Addiction

  • This model recognizes that addiction is a complex condition influenced by multiple factors.
  • Bio (Biological): Genetics, neurobiology, and co-occurring medical conditions.
  • Psycho (Psychological): Co-occurring mental illness, trauma history, and coping skills.
  • Social: Family, community, and environmental factors (SDoH).
  • Effective treatment requires addressing all three domains.
  • A CPSUD understands that medication is just one part of a comprehensive treatment plan.

The Pharmacist's Role in SUD Care

  • Pharmacists are key members of the SUD treatment team.
  • They are medication experts, responsible for dispensing and managing Medications for SUD (MOUD).
  • They play a crucial role in harm reduction, especially through naloxone dispensing and syringe services.
  • They screen for unhealthy substance use and provide brief interventions.
  • They are a key resource for patient education and for connecting patients with treatment.
  • A CPSUD has advanced, specialized knowledge to lead these efforts.

Stigma and Person-First Language

  • Stigma is a major barrier that prevents people with SUDs from seeking care.
  • A CPSUD must be a champion for reducing stigma.
  • This involves using person-first, non-stigmatizing language.
  • For example, say "a person with a substance use disorder," not "an addict" or "an alcoholic."
  • Say "a person who uses drugs," not "a drug user."
  • This language shift reflects the understanding of addiction as a medical condition.

The Continuum of Care

  • SUD treatment occurs across a continuum of care.
  • This ranges from prevention and early intervention to outpatient treatment, intensive outpatient, and residential treatment.
  • The ASAM Criteria provide a framework for matching patients to the appropriate level of care.
  • A CPSUD must be familiar with this continuum and the different levels of care available in their community.
  • They play a key role in facilitating smooth transitions between these levels.

Block 2: Screening, Assessment & Neurobiology

The Reward Pathway

  • The mesolimbic dopamine pathway is the key reward pathway in the brain.
  • All drugs of abuse cause a large and rapid surge of dopamine in this pathway, particularly in the nucleus accumbens.
  • This produces a powerful feeling of pleasure and euphoria.
  • The brain remembers this experience and is strongly motivated to repeat it.
  • This dopamine surge is much larger and faster than what is seen with natural rewards like food or sex.

Tolerance and Withdrawal

  • With repeated use, the brain adapts to the presence of the drug.
  • Tolerance: The brain becomes less sensitive to the drug, and a higher dose is needed to achieve the same effect.
  • Withdrawal: When the drug is stopped, the brain's adaptations are unopposed, leading to a negative physical and emotional state.
  • This withdrawal syndrome is a powerful motivator to continue using the drug to avoid feeling sick.
  • Tolerance and physical dependence are normal physiological responses; they are not the same as addiction.

Craving and Relapse

  • Long-term use of drugs also causes changes in the brain's learning and memory circuits (e.g., in the hippocampus and amygdala).
  • Environmental cues (people, places, things) become strongly associated with drug use.
  • When a person is exposed to these cues, it can trigger intense craving.
  • These changes in the brain can persist for years after a person stops using.
  • This is why addiction is a chronic, relapsing disease.

The Role of the Prefrontal Cortex

  • The prefrontal cortex is the part of the brain responsible for executive functions like decision-making, impulse control, and judgment.
  • In addiction, the "go" signal from the reward pathway becomes much stronger, and the "stop" signal from the prefrontal cortex becomes weaker.
  • This leads to a compulsive, uncontrollable drive to seek and use the drug, despite negative consequences.
  • A CPSUD understands this neurobiology to better empathize with and treat their patients.

Genetics and Environment

  • Addiction is a complex disease that arises from an interaction between a person's genes and their environment.
  • Genetics are thought to account for about half of a person's risk for developing an SUD.
  • Environmental factors, such as early life trauma, stress, and social influences, also play a major role.
  • A CPSUD understands that addiction is not a choice, but a complex illness.

The SBIRT Model

  • SBIRT is an evidence-based, public health approach to delivering early intervention and treatment services for people with or at risk of developing SUDs.
  • It is a comprehensive, integrated approach.
  • Screening: A universal screening for all patients to assess for risky substance use.
  • Brief Intervention: A short conversation with those who screen positive to provide feedback and enhance motivation to change.
  • Referral to Treatment: For patients who need more extensive treatment.
  • Pharmacists are ideally positioned to perform SBIRT.

Screening Tools for Alcohol

  • Single-Question Screen: "How many times in the past year have you had X or more drinks in a day?" (X=5 for men, 4 for women). A response of ≥1 is a positive screen.
  • AUDIT-C: A 3-question screening tool that is a component of the full AUDIT. It is scored from 0-12.
  • CAGE Questionnaire: A 4-question tool that is easy to remember but less sensitive than the AUDIT-C.
  • A CPSUD must be an expert at using these tools.

Screening Tools for Drug Use

  • Single-Question Screen: "How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?". A response of ≥1 is a positive screen.
  • DAST-10 (Drug Abuse Screening Test): A 10-item, yes/no questionnaire.
  • CRAFFT: A screening tool specifically designed for adolescents.

Brief Intervention

  • A brief intervention is a short, patient-centered conversation.
  • It is not about confronting the patient or telling them what to do.
  • It uses the principles of motivational interviewing.
  • The goal is to raise the patient's awareness of their substance use and its consequences.
  • It helps the patient to explore their own reasons for wanting to make a change.
  • It can be as short as 5-10 minutes.

Referral to Treatment

  • For patients who have a more severe SUD or who are ready to seek formal treatment, a referral is needed.
  • This requires the pharmacist to be knowledgeable about the treatment resources available in their community.
  • A "warm handoff," where the pharmacist actively helps the patient to make the first contact with the treatment program, is more effective than a passive referral.
  • The SAMHSA treatment locator is a key resource for finding local programs.

The DSM-5 Framework

  • The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) is the standard classification of mental disorders used by clinicians.
  • It provides a set of diagnostic criteria for each Substance Use Disorder (SUD).
  • A pharmacist does not make a formal diagnosis, but they must be familiar with the criteria to understand the condition.
  • The DSM-5 combines the previous categories of "substance abuse" and "substance dependence" into a single disorder.

The 11 Criteria

  • The diagnosis of an SUD is based on a problematic pattern of use leading to clinically significant impairment or distress, as manifested by at least two of the following 11 criteria, occurring within a 12-month period.
  • These criteria are grouped into four categories.

Impaired Control (Criteria 1-4)

  • 1. Taking the substance in larger amounts or for longer than you're meant to.
  • 2. Wanting to cut down or stop using the substance but not managing to.
  • 3. Spending a lot of time getting, using, or recovering from use of the substance.
  • 4. Cravings and urges to use the substance.

Social Impairment (Criteria 5-7)

  • 5. Not managing to do what you should at work, home, or school because of substance use.
  • 6. Continuing to use, even when it causes problems in relationships.
  • 7. Giving up important social, occupational, or recreational activities because of substance use.

Risky Use and Pharmacological Criteria (Criteria 8-11)

  • 8. Using substances again and again, even when it puts you in danger.
  • 9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.
  • 10. Tolerance: Needing more of the substance to get the effect you want.
  • 11. Withdrawal: Development of withdrawal symptoms, which can be relieved by taking more of the substance.
  • The severity of the SUD is based on the number of criteria met: Mild (2-3), Moderate (4-5), or Severe (6 or more).

Block 3: Pharmacotherapy for SUDs

Management of Alcohol Withdrawal

  • Alcohol withdrawal can be life-threatening and often requires medical management.
  • The goal is to manage the symptoms and prevent the progression to seizures or delirium tremens.
  • Benzodiazepines are the first-line treatment. They are a form of cross-tolerant replacement therapy.
  • Long-acting BZDs like chlordiazepoxide or diazepam are often preferred.
  • In patients with severe liver disease, lorazepam or oxazepam are safer.
  • Dosing can be done on a fixed schedule or based on the patient's symptoms using the CIWA-Ar scale.
  • Thiamine supplementation is also essential to prevent Wernicke's encephalopathy.

Naltrexone

  • Naltrexone is a first-line medication for the treatment of moderate to severe AUD.
  • It is an opioid antagonist that is thought to reduce the rewarding effects of alcohol and reduce cravings.
  • It is available as a daily oral pill or a monthly long-acting injection (Vivitrol).
  • It is contraindicated in patients taking opioids, as it will precipitate withdrawal.
  • It can cause hepatotoxicity at high doses, so liver function should be monitored.

Acamprosate

  • Acamprosate is another first-line medication for AUD.
  • Its mechanism is not fully understood but is thought to restore the balance between GABA and glutamate neurotransmission.
  • It is designed to help patients maintain abstinence after they have stopped drinking.
  • The dose is two tablets three times a day, which can be a barrier to adherence.
  • It is cleared by the kidneys and requires dose adjustment in renal impairment. It is contraindicated in severe renal disease.

Disulfiram

  • Disulfiram is a second-line agent.
  • It works by blocking the enzyme aldehyde dehydrogenase.
  • If a person drinks alcohol while on disulfiram, they will have a severe and unpleasant reaction (flushing, nausea, vomiting, palpitations).
  • It is an aversion therapy.
  • It is only effective in highly motivated patients who can be supervised.
  • It has a risk of hepatotoxicity.

The Pharmacist's Role in AUD Management

  • A CPSUD is an expert in the use of all three of these medications.
  • They are responsible for counseling patients on the risks and benefits of each option.
  • They help to select the best agent based on the patient's goals (harm reduction vs. abstinence) and comorbidities.
  • They play a key role in monitoring for adherence and side effects.
  • They can work under a CPA to dose and manage these medications.

Management of Opioid Withdrawal

  • Opioid withdrawal is intensely unpleasant but not typically life-threatening.
  • Symptoms include nausea, vomiting, diarrhea, muscle aches, and anxiety.
  • The Clinical Opiate Withdrawal Scale (COWS) is a tool used to assess the severity of withdrawal.
  • Withdrawal can be managed with symptom-specific medications (e.g., for nausea) and alpha-2 agonists like clonidine or lofexidine.
  • The most effective way to manage withdrawal is to start a medication for OUD like buprenorphine.

Methadone

  • Methadone is a long-acting full opioid agonist.
  • It is a highly effective medication for OUD.
  • Due to its risk of QT prolongation and respiratory depression, its use is restricted to federally-regulated Opioid Treatment Programs (OTPs).
  • Patients must go to the OTP daily to receive their dose.
  • A CPSUD working in or with an OTP would be an expert in the complex pharmacology and regulations of methadone.

Buprenorphine

  • Buprenorphine is a partial opioid agonist.
  • This gives it a "ceiling effect" on respiratory depression, making it safer than full agonists like methadone.
  • It can be prescribed from an office setting and dispensed by a community pharmacy.
  • The requirement for a special "X-waiver" to prescribe it was eliminated in 2023, expanding access.
  • It is most often co-formulated with naloxone (Suboxone) to deter injection.
  • A key counseling point is that it must be started when the patient is in a state of mild withdrawal to avoid precipitated withdrawal.

Naltrexone

  • Naltrexone is an opioid antagonist.
  • It works by blocking the effects of opioids.
  • It is available as a daily oral pill or a monthly long-acting injection (Vivitrol).
  • The patient must be fully detoxed from all opioids for 7-10 days before starting naltrexone to avoid precipitated withdrawal.
  • It is a good option for highly motivated patients or for those in situations where any opioid use is prohibited (e.g., certain professions).

The Pharmacist's Role in OUD Management

  • A CPSUD is a key leader in expanding access to MOUD.
  • They are an expert on the pharmacology and clinical use of all three medications.
  • They play a critical role in the induction and monitoring of buprenorphine.
  • They are the primary providers of naloxone for overdose prevention.
  • In some states, pharmacists can now initiate and manage MOUD under a CPA.
  • This is a rapidly expanding area of advanced pharmacy practice.

The Public Health Burden of Tobacco

  • Tobacco use is the leading cause of preventable disease, disability, and death in the United States.
  • Nicotine is a highly addictive substance.
  • A comprehensive public health approach is needed to combat the tobacco epidemic.
  • Pharmacists are a key part of this approach.

The 5 A's Model for Counseling

  • The 5 A's is an evidence-based framework for brief tobacco cessation counseling.
  • Ask: Ask every patient about their tobacco use status.
  • Advise: Advise every tobacco user to quit in a clear and personalized manner.
  • Assess: Assess the patient's willingness to make a quit attempt.
  • Assist: For patients willing to quit, provide counseling and pharmacotherapy.
  • Arrange: Arrange for follow-up contact.
  • A CPSUD can train other pharmacists on how to effectively use this model.

Nicotine Replacement Therapy (NRT)

  • NRT is a first-line pharmacotherapy for cessation.
  • It works by reducing the withdrawal symptoms associated with quitting.
  • It is available in many OTC and prescription forms (patch, gum, lozenge, inhaler, nasal spray).
  • Combination therapy (e.g., the patch plus the gum) is more effective than monotherapy.
  • A CPSUD is an expert on the proper use of all forms of NRT.

Non-Nicotine Pharmacotherapy

  • There are two main non-nicotine prescription medications.
  • Bupropion SR: An antidepressant that also reduces cravings and withdrawal symptoms.
  • Varenicline: A partial nicotinic receptor agonist that both reduces cravings and makes smoking less pleasurable. It is the most effective single agent.
  • A CPSUD must be an expert on the use, side effects, and contraindications of these medications.

E-Cigarettes and Vaping

  • E-cigarettes are a controversial topic in tobacco control.
  • While they are likely less harmful than combustible cigarettes, they are not harmless.
  • Their long-term health effects are still unknown.
  • There is a major public health concern about the epidemic of vaping among young people.
  • The FDA has not approved e-cigarettes as a smoking cessation device.
  • A CPSUD must be able to provide evidence-based, nuanced counseling on the potential benefits and risks of these products.

Stimulant Use Disorder

  • This involves the problematic use of stimulants like cocaine and methamphetamine.
  • It is a growing public health problem, often co-occurring with opioid use.
  • The intoxication syndrome includes euphoria, agitation, and psychosis.
  • The withdrawal syndrome is characterized by severe fatigue, depression, and craving.
  • Currently, there are no FDA-approved medications for the treatment of stimulant use disorder.
  • The mainstay of treatment is psychosocial therapy, especially contingency management.

Cannabis Use Disorder

  • With the increasing legalization of cannabis, rates of cannabis use disorder are also increasing.
  • It is characterized by a problematic pattern of use leading to distress or impairment.
  • A withdrawal syndrome can occur upon cessation.
  • The potency of modern cannabis products is much higher than in the past.
  • This increases the risk of both addiction and psychosis.
  • The primary treatment is psychosocial therapy (e.g., CBT, motivational interviewing).
  • There are no FDA-approved medications for cannabis use disorder.

Benzodiazepine Use Disorder

  • This involves the long-term, problematic use of benzodiazepines.
  • It is often iatrogenic, starting from a legitimate prescription.
  • The primary treatment is a very slow and gradual taper.
  • Abrupt cessation can be life-threatening.
  • A CPSUD is an expert at designing and managing these complex tapers.
  • Psychosocial support is also essential.

Sedative-Hypnotic Use Disorder

  • This includes a range of drugs like barbiturates and the "Z-drugs" (e.g., zolpidem).
  • Similar to benzodiazepines, these drugs can cause tolerance and a dangerous withdrawal syndrome.
  • The management is also similar, involving a slow taper.
  • A CPSUD must be able to manage the withdrawal from all types of sedatives.

Gambling Disorder

  • Gambling disorder is now included in the DSM-5 as a behavioral addiction.
  • It is characterized by persistent and recurrent problematic gambling behavior leading to significant impairment.
  • The neurobiology is thought to be similar to that of substance use disorders.
  • The primary treatment is psychotherapy (e.g., CBT, Gamblers Anonymous).
  • There are no FDA-approved medications, but some have been studied off-label, including naltrexone.

The Prevalence of Co-Occurring Disorders

  • The co-occurrence of a substance use disorder and another mental illness is the norm, not the exception.
  • Approximately half of all people with a severe mental illness also have a co-occurring SUD.
  • This is sometimes referred to as a "dual diagnosis."
  • The most common co-occurring conditions are depression, anxiety disorders, and PTSD.
  • A CPSUD must be an expert in both addiction and general psychiatry.

Integrated Treatment

  • The evidence-based standard of care for co-occurring disorders is integrated treatment.
  • This means that both the SUD and the mental illness are treated at the same time, by the same team, in the same location.
  • This is much more effective than the older, sequential model where a patient had to get "clean" before their mental illness could be treated.
  • A CPSUD is a key member of this integrated treatment team.

SUD and Depression/Anxiety

  • There is a strong bidirectional relationship between these conditions.
  • People with depression or anxiety may use substances to self-medicate their symptoms.
  • Substance use can also cause or worsen depression and anxiety.
  • The treatment plan must address both conditions.
  • This often involves a combination of MOUD (if applicable), an antidepressant, and psychotherapy.

SUD and PTSD

  • The co-occurrence of PTSD and SUD is very common, especially among veterans.
  • The treatment must be trauma-informed.
  • This involves providing care in a way that is sensitive to the patient's trauma history.
  • Trauma-focused psychotherapy is a key part of the treatment.
  • Medications for both conditions are also used. Prazosin for nightmares can be particularly helpful.

SUD and Severe Mental Illness (SMI)

  • This includes conditions like schizophrenia and bipolar disorder.
  • These patients are at a very high risk for SUDs, especially tobacco use disorder.
  • The management is very complex and requires a specialized, integrated team.
  • Long-acting injectable formulations of antipsychotics can be a key strategy to improve adherence in this population.
  • A CPSUD working in a community mental health center would be an expert in managing this complex comorbidity.

Block 4: Specific Pain Conditions & Patient Populations

Diabetic Peripheral Neuropathy (DPN)

  • DPN is a common complication of diabetes, causing nerve damage, typically in the feet and legs.
  • It often presents with a "stocking-glove" distribution of symptoms.
  • Symptoms include burning, tingling, numbness, and shooting pains.
  • The cornerstone of management is optimal glycemic control to prevent progression.
  • Pharmacotherapy is aimed at symptomatic relief.
  • A CPMP plays a key role in managing the complex pharmacotherapy for this condition.

Postherpetic Neuralgia (PHN)

  • PHN is a complication of shingles (herpes zoster).
  • It is defined as pain that persists for more than 90 days after the onset of the shingles rash.
  • The pain is often severe and debilitating, described as burning or stabbing.
  • The risk of PHN increases with age.
  • The most effective prevention strategy is vaccination against shingles.
  • A CPMP is an advocate for and provider of the shingles vaccine.

First-Line Pharmacotherapy for Neuropathic Pain

  • The first-line agents for most types of neuropathic pain fall into two main classes.
  • Gabapentinoids (gabapentin and pregabalin): Work by modulating calcium channels.
  • SNRIs (duloxetine, venlafaxine): Work by enhancing the descending inhibitory pain pathway.
  • Tricyclic antidepressants (TCAs) are also a first-line option but are used less frequently in older adults due to side effects.
  • The choice between these agents is based on the patient's comorbidities and the side effect profiles.

Second- and Third-Line Agents

  • Topical Lidocaine: A first-line option specifically for localized PHN.
  • Capsaicin Patch: Can be effective for localized pain but often causes significant application site reactions.
  • Tramadol and Tapentadol: Can be considered as second-line agents due to their dual mechanism of action.
  • Strong Opioids: Generally considered third-line agents for neuropathic pain due to limited efficacy and significant risks.
  • A CPMP must be an expert at sequencing these therapies.

Counseling and Management

  • Patient education is critical for managing neuropathic pain.
  • It is important to set realistic expectations; complete pain relief is rare.
  • The goal is a 30-50% reduction in pain and an improvement in function.
  • All of the first-line agents require slow dose titration to minimize side effects.
  • A therapeutic trial of a medication may take several weeks at an optimal dose.
  • A CPMP is skilled at guiding patients through this titration and trial process.

Pathophysiology (Central Sensitization)

  • Fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain.
  • It is now understood to be a disorder of central pain processing, or "nociplastic" pain.
  • The central nervous system becomes amplified and hypersensitive to both painful and non-painful stimuli.
  • There is no peripheral tissue damage or inflammation.
  • This pathophysiology explains why traditional analgesics like NSAIDs and opioids are ineffective.

Clinical Presentation

  • The hallmark symptom is widespread pain, often described as a constant, dull ache.
  • It is almost always accompanied by severe fatigue and unrefreshing sleep.
  • Cognitive symptoms, often called "fibro fog," are also common.
  • Many patients also have co-occurring conditions like depression, anxiety, and irritable bowel syndrome.
  • A CPMP must be able to recognize the classic symptom cluster of fibromyalgia.

Non-Pharmacologic Therapy: The Cornerstone

  • Non-pharmacologic therapy is the foundation of fibromyalgia management.
  • Patient Education: Helping the patient to understand that their pain is real but is due to a sensitized nervous system, not tissue damage.
  • Exercise: A graded exercise program, especially low-impact aerobic exercise, is the most effective treatment.
  • Cognitive Behavioral Therapy (CBT): Helps patients to change their thoughts and behaviors related to pain.
  • Sleep Hygiene: Essential for managing fatigue.
  • A CPMP must be a strong advocate for these non-drug approaches.

FDA-Approved Pharmacotherapy

  • There are three drugs that are FDA-approved for fibromyalgia.
  • All of these agents work on the central nervous system.
  • Pregabalin (Lyrica): A gabapentinoid.
  • Duloxetine (Cymbalta): An SNRI.
  • Milnacipran (Savella): Another SNRI.
  • The efficacy of these drugs is modest, providing about a 30% reduction in pain for about half of patients.
  • They are considered an adjunct to, not a replacement for, non-pharmacologic therapy.

Inappropriate Therapies

  • A key role for the CPMP is to help deprescribe inappropriate medications for fibromyalgia.
  • Opioids: Are not effective for fibromyalgia and may even worsen the pain through opioid-induced hyperalgesia. Their use should be strongly discouraged.
  • NSAIDs and Acetaminophen: Are generally not effective, as fibromyalgia is not an inflammatory condition.
  • Benzodiazepines: Should be avoided due to risks and their negative impact on sleep architecture.
  • Educating both patients and providers about these inappropriate therapies is a critical function.

Osteoarthritis (OA)

  • OA is a degenerative joint disease, the most common type of arthritis.
  • It is characterized by the breakdown of cartilage in the joints.
  • It is a leading cause of chronic pain and disability, especially in older adults.
  • The pain is nociceptive and often related to activity.
  • Non-pharmacologic therapy, including exercise and weight loss, is the cornerstone of management.

Pharmacotherapy for OA

  • The choice of medication is guided by a stepwise approach.
  • First-line: Topical NSAIDs for knee or hand OA, and oral acetaminophen.
  • Second-line: Oral NSAIDs, used at the lowest effective dose for the shortest duration.
  • Third-line: Tramadol, duloxetine.
  • Intra-articular corticosteroid injections can provide short-term relief.
  • Opioids are generally not recommended for chronic OA.
  • A CPMP helps to create a safe and effective multimodal regimen.

Acute Low Back Pain (LBP)

  • Acute LBP is defined as pain lasting for less than 4 weeks.
  • Most cases are non-specific and will resolve on their own.
  • The key is to encourage the patient to remain active. Bed rest is not recommended.
  • First-line pharmacotherapy is with non-pharmacologic measures and, if needed, NSAIDs.
  • Skeletal muscle relaxants may be used for a short course but cause sedation.
  • Opioids should be avoided.

Chronic Low Back Pain (LBP)

  • Chronic LBP is pain lasting for more than 12 weeks.
  • Non-pharmacologic therapies are the foundation of management.
  • This includes exercise, physical therapy, and cognitive behavioral therapy.
  • First-line pharmacotherapy is NSAIDs.
  • Second-line agents include duloxetine and tramadol.
  • Opioids are not a preferred therapy for chronic LBP due to a lack of evidence for long-term benefit and significant risks.
  • A CPMP is an expert at designing non-opioid regimens for chronic LBP.

Topical Analgesics

  • Topical agents are a key part of the multimodal approach for localized musculoskeletal pain.
  • They have the major advantage of minimal systemic absorption and fewer side effects.
  • Topical NSAIDs (e.g., diclofenac gel): A first-line option for OA of the knee and hand.
  • Topical Capsaicin: Can be effective but causes a burning sensation.
  • Topical Lidocaine: While approved for PHN, it is often used off-label for musculoskeletal pain.
  • A CPMP should be an expert on the evidence and proper use of these agents.

Tension-Type Headache

  • This is the most common type of primary headache.
  • It is typically described as a bilateral, "band-like" pressure.
  • The pain is usually mild to moderate.
  • Acute treatment is with simple analgesics like acetaminophen or NSAIDs.
  • Frequent use of acute medications can lead to medication-overuse headache.
  • For chronic tension-type headache, the first-line preventive treatment is amitriptyline.

Migraine Headache

  • A migraine is a disabling primary headache disorder.
  • It is typically unilateral, pulsating, and moderate to severe in intensity.
  • It is often accompanied by nausea, photophobia, and phonophobia.
  • About one-third of patients experience an aura before the headache.
  • A CPMP must be an expert in the acute and preventive treatment of migraine.

Acute Migraine Treatment (Abortive Therapy)

  • The goal is to treat the attack early to relieve pain and restore function.
  • First-line for mild/moderate attacks: NSAIDs.
  • First-line for moderate/severe attacks: Triptans (serotonin 1B/1D receptor agonists).
  • Newer options: CGRP antagonists ("gepants") and ditans.
  • Opioids and butalbital-containing products should be avoided.
  • A key counseling point is to avoid overuse of acute medications to prevent medication-overuse headache.

Preventive Migraine Treatment

  • Preventive therapy is considered for patients with frequent or disabling migraines.
  • Traditional oral options include beta-blockers (e.g., propranolol), antidepressants (e.g., amitriptyline, venlafaxine), and anticonvulsants (e.g., topiramate, valproic acid).
  • The choice is guided by the patient's comorbidities and the side effect profile.
  • It can take several months to see the full benefit of a preventive medication.

CGRP Antagonists for Prevention

  • The newest and most significant advance in migraine prevention is the development of monoclonal antibodies that target Calcitonin Gene-Related Peptide (CGRP).
  • These are highly effective and well-tolerated biologic agents.
  • They are given as a monthly or quarterly subcutaneous injection.
  • There are also oral CGRP antagonists ("gepants") that can be used for prevention.
  • These drugs are very expensive and often require a prior authorization.
  • A CPMP must be an expert on the use and place in therapy of these new agents.

Geriatric Patients

  • Pain is very common in older adults, but its management is complex.
  • Older adults are at a much higher risk for adverse drug events due to age-related pharmacokinetic and pharmacodynamic changes.
  • The principle of "start low, go slow" is essential.
  • NSAIDs should be used with extreme caution due to their renal, GI, and cardiovascular risks.
  • Opioids cause more sedation and constipation in older adults.
  • A multimodal, non-pharmacologic approach is preferred.
  • A CPMP is an expert in safe analgesic prescribing for this population.

Pediatric Patients

  • Pain assessment in children, especially pre-verbal infants, is a major challenge.
  • Dosing of analgesics in children is almost always weight-based.
  • Safe dosing requires careful calculation to avoid errors.
  • Codeine should not be used in children due to the risk of ultra-rapid metabolism, which can lead to a morphine overdose.
  • A CPMP should be familiar with the principles of pediatric pain management.

Pregnant Patients

  • Pain management during pregnancy is a delicate balance between treating the mother's pain and protecting the fetus.
  • Acetaminophen is generally considered the safest analgesic during pregnancy.
  • NSAIDs should be avoided, especially in the third trimester.
  • Opioids should be used cautiously for a short duration. Chronic use can lead to neonatal abstinence syndrome.
  • A CPMP can be a key resource for managing pain in this complex population.

Patients with Renal or Hepatic Impairment

  • The dosing of many analgesics must be adjusted in patients with kidney or liver disease.
  • NSAIDs should generally be avoided in patients with significant renal impairment.
  • Acetaminophen is the preferred analgesic for these patients, but the dose must be limited in severe liver disease.
  • Many opioids and adjuvant analgesics require dose adjustment for renal dysfunction.
  • Morphine has an active metabolite that can accumulate in renal failure. Hydromorphone or fentanyl are often preferred.

Patients with a History of Substance Use Disorder

  • Managing pain in patients with a history of or active SUD is a major challenge.
  • These patients have a right to effective pain management.
  • A multimodal, non-opioid approach should be maximized.
  • If opioids are necessary for acute pain, they should be prescribed for a short duration with a clear plan.
  • Collaboration with the patient's addiction treatment provider is essential.
  • For patients on MOUD (e.g., buprenorphine), special strategies are needed to manage acute pain.
  • A CPMP is an expert in navigating these complex clinical and ethical situations.

Block 5: Opioid Stewardship & Risk Management

History of the Opioid Crisis

  • The current crisis began in the late 1990s with a dramatic increase in the prescribing of opioid analgesics.
  • This was driven by a push to treat pain as the "fifth vital sign" and by aggressive marketing from pharmaceutical companies.
  • This first wave led to a rise in addiction and overdose deaths from prescription opioids.
  • A second wave began around 2010 with a rise in deaths from heroin.
  • The third and current wave, which began around 2013, is driven by illicitly manufactured synthetic opioids, primarily fentanyl.
  • A CPMP must understand this history.

The CDC Guideline for Prescribing Opioids for Chronic Pain

  • In 2016, the CDC published a landmark guideline to promote safer opioid prescribing.
  • It emphasizes that non-opioid therapies are preferred for chronic pain.
  • When opioids are used, it recommends starting with the lowest effective dose of an immediate-release formulation.
  • It provides specific recommendations on dose thresholds (use caution at >50 MME/day, avoid >90 MME/day).
  • It also emphasizes the importance of risk mitigation strategies like PDMP checks and UDT.
  • A CPMP is an expert on implementing this guideline.

Opioid Stewardship

  • Opioid stewardship is a coordinated set of interventions designed to improve, monitor, and evaluate the use of opioids.
  • It is a key strategy for both improving patient safety and combating the opioid crisis.
  • The pharmacist is a key leader of the opioid stewardship program in a hospital or health system.
  • The program focuses on promoting safe prescribing, monitoring for high-risk use, and providing education.
  • A CPMP is often the person who leads these stewardship initiatives.

Harm Reduction

  • Harm reduction is a pragmatic public health approach that aims to reduce the negative consequences of substance use.
  • It is a key part of a comprehensive response to the overdose crisis.
  • Key harm reduction services include:
  • Naloxone Access: Dispensing the opioid overdose reversal drug.
  • Syringe Service Programs (SSPs): Providing sterile syringes to prevent the spread of HIV and Hepatitis C.
  • Fentanyl Test Strips: Allowing people to test their drugs for the presence of deadly fentanyl.
  • A CPMP should be a strong advocate for these life-saving services.

Medication-Assisted Treatment (MAT) / MOUD

  • The evidence-based standard of care for Opioid Use Disorder (OUD) is Medications for OUD (MOUD), formerly known as MAT.
  • The three FDA-approved medications are methadone, buprenorphine, and naltrexone.
  • A key public health goal is to expand access to MOUD.
  • Pharmacists are playing an increasingly important role in this, including initiating buprenorphine in some states.
  • A CPMP is an expert on the pharmacology and clinical use of these medications.

Universal Precautions for Opioids

  • The concept of "universal precautions" for opioids is an approach that applies a standard set of risk mitigation strategies to all patients on chronic opioid therapy.
  • This is because it is difficult to predict which individual patient will develop a problem.
  • This approach moves away from just trying to identify "problem patients."
  • The core components are a thorough assessment, a treatment agreement, regular monitoring, and documentation.

Risk Assessment Tools

  • Validated screening tools can be used to assess a patient's risk for opioid misuse or addiction before starting therapy.
  • The Opioid Risk Tool (ORT) is a brief, self-report screening tool for use in primary care.
  • The Screener and Opioid Assessment for Patients with Pain (SOAPP) is another commonly used tool.
  • These tools can help to stratify patients by risk (low, moderate, high) and to guide the intensity of the monitoring strategy.

Prescription Drug Monitoring Programs (PDMPs)

  • PDMPs are state-level databases that track the dispensing of controlled substances.
  • They are a critical tool for identifying patients who may be receiving prescriptions from multiple providers ("doctor shopping") or filling at multiple pharmacies.
  • Most states now mandate that prescribers and/or pharmacists check the PDMP before prescribing or dispensing an opioid.
  • A CPMP must be an expert user of their state's PDMP.

Urine Drug Testing (UDT)

  • UDT is another key tool for monitoring patients on chronic opioid therapy.
  • It is used to verify that the patient is taking their prescribed opioid (an expected positive result).
  • It is also used to screen for the use of non-prescribed or illicit drugs (an unexpected positive result).
  • The results of a UDT must be interpreted carefully.
  • A CPMP must understand the limitations of the test and the metabolic pathways of different opioids to avoid misinterpretation.

Patient-Provider Agreements (Pain Contracts)

  • A patient-provider agreement is a formal document that outlines the expectations and responsibilities of both the patient and the provider.
  • It is a tool for promoting communication and informed consent.
  • It typically includes the goals of therapy, the plan for monitoring, and the policies on issues like early refills and lost prescriptions.
  • The agreement should be used to facilitate a conversation, not just as a contract to be signed.
  • A CPMP can help to develop and implement these agreements.

Rationale for Tapering

  • Opioid tapering is the process of gradually reducing a patient's long-term opioid dose.
  • It should be considered for any patient on chronic opioid therapy who is not having a clinically meaningful improvement in pain and function.
  • It is also indicated for patients who are on high doses (>50 MME/day) or who are experiencing adverse effects.
  • The goal is to reduce the risks of long-term opioid therapy while minimizing withdrawal symptoms.
  • A CPMP is an expert in managing this complex and challenging process.

The Shared Decision-Making Conversation

  • The decision to taper must be made in collaboration with the patient.
  • Many patients are very fearful of a dose reduction.
  • The conversation must be empathetic and non-judgmental.
  • It should focus on the shared goal of improving the patient's safety and quality of life, not on simply reducing a number.
  • The pharmacist can use motivational interviewing techniques to help the patient explore their own reasons for wanting to taper.

Developing a Tapering Plan

  • The tapering plan must be individualized.
  • There is no one-size-fits-all approach.
  • A general rule of thumb is to reduce the total daily dose by about 10% every 1-4 weeks.
  • The taper should be slower for patients who have been on opioids for a long time or who are very anxious.
  • The plan must be clear and provided to the patient in writing.
  • A CPMP is an expert at creating these patient-specific tapering schedules.

Managing Withdrawal Symptoms

  • A slow taper is designed to minimize withdrawal symptoms, but some may still occur.
  • Common symptoms include anxiety, insomnia, nausea, and muscle aches.
  • Adjunctive medications can be used to help manage these symptoms.
  • Clonidine is often used to treat the autonomic symptoms of withdrawal.
  • Other comfort medications can be used for nausea, diarrhea, and insomnia.
  • The CPMP can recommend and manage these adjunctive medications.

Monitoring and Support

  • Close follow-up and support are essential for a successful taper.
  • This involves regular check-ins with the patient, either in person or by phone.
  • The pharmacist should monitor for withdrawal symptoms and assess the patient's pain and function.
  • It is important to provide positive reinforcement and to celebrate small successes.
  • The plan may need to be adjusted based on the patient's response. The patient should be empowered to have control over the pace of the taper.

Defining OUD

  • OUD is a chronic, relapsing brain disease characterized by a problematic pattern of opioid use leading to clinically significant impairment or distress.
  • It is a medical diagnosis, defined by criteria in the DSM-5.
  • It is not a moral failing.
  • A key part of the CPMP's role is to reduce the stigma associated with OUD.
  • This includes using person-first, non-stigmatizing language.

Screening and Diagnosis

  • The pharmacist can play a key role in screening for OUD.
  • This involves being alert to "red flags" in the pharmacy, such as patients frequently requesting early refills or appearing sedated.
  • Validated screening tools can also be used.
  • A formal diagnosis is made by a qualified provider based on the 11 criteria in the DSM-5.
  • The pharmacist's role is to screen and refer for diagnosis.

Medications for OUD (MOUD)

  • MOUD is the evidence-based standard of care for OUD. It significantly reduces the risk of overdose death.
  • Methadone: A long-acting full opioid agonist. Can only be dispensed by a federally-regulated Opioid Treatment Program (OTP).
  • Buprenorphine: A partial opioid agonist. Can be prescribed from an office setting and dispensed by a community pharmacy.
  • Naltrexone: An opioid antagonist. Available as a long-acting injection (Vivitrol). The patient must be fully detoxed from opioids before starting.
  • A CPMP is an expert on these life-saving medications.

The Pharmacist's Role in Buprenorphine Therapy

  • Pharmacists are a key partner in expanding access to buprenorphine.
  • They are responsible for dispensing the medication and providing patient education.
  • They play a crucial role in the induction process, ensuring the patient is in a state of mild withdrawal before the first dose to prevent precipitated withdrawal.
  • They help to monitor for adherence and side effects.
  • In some states, pharmacists now have the authority to initiate buprenorphine therapy under a CPA.

Harm Reduction

  • Harm reduction is a pragmatic approach that aims to reduce the negative consequences of substance use.
  • It is a key part of a comprehensive approach to OUD.
  • Key harm reduction services that can be provided by a pharmacy include:
  • Naloxone Access: Dispensing the opioid overdose reversal drug.
  • Syringe Service Programs (SSPs): Providing sterile syringes to prevent the spread of HIV and Hepatitis C.
  • Fentanyl Test Strips: Allowing people to test their drugs for the presence of deadly fentanyl.
  • A CPMP is a strong advocate for removing barriers to these services.

The Importance of Non-Drug Therapies

  • For chronic pain, non-pharmacologic therapies are the foundation of management.
  • They are often more effective than medications in the long term and have fewer side effects.
  • A multimodal approach that combines these therapies with medication is the standard of care.
  • A CPMP must be an expert on these non-drug approaches and be able to refer patients to the appropriate providers.
  • They are a key part of a holistic, biopsychosocial treatment plan.

Physical and Rehabilitative Therapies

  • Physical Therapy (PT): A cornerstone of chronic pain management. It focuses on improving movement and function through a tailored exercise program.
  • Occupational Therapy (OT): Helps patients to perform their activities of daily living.
  • Massage Therapy: Can be helpful for musculoskeletal pain.
  • Acupuncture: Has evidence for several types of chronic pain, including low back pain and migraine.
  • TENS (Transcutaneous Electrical Nerve Stimulation): Uses low-voltage electrical current to provide pain relief.

Psychological and Behavioral Therapies

  • These therapies are essential for addressing the "psycho" part of the biopsychosocial model.
  • Cognitive Behavioral Therapy (CBT): The most well-established psychological therapy for chronic pain. It helps patients to change their thoughts, emotions, and behaviors related to pain.
  • Acceptance and Commitment Therapy (ACT): A mindfulness-based therapy that helps patients to live a meaningful life despite their pain.
  • Biofeedback: A technique that teaches patients to control physiological functions like muscle tension.

Mind-Body Practices

  • These practices focus on the interaction between the brain, mind, body, and behavior.
  • Yoga and Tai Chi: Combine gentle movement, breathing, and meditation. Have good evidence for conditions like low back pain.
  • Mindfulness-Based Stress Reduction (MBSR): A formal program that teaches mindfulness meditation.
  • These practices can help to down-regulate the sensitized nervous system in chronic pain.

The Pharmacist's Role in Promoting Non-Drug Therapies

  • The CPMP is a key advocate for and educator about these non-drug approaches.
  • They can provide basic counseling on things like the importance of exercise and sleep hygiene.
  • They can also make formal referrals to other providers on the interdisciplinary team, such as physical therapists and psychologists.
  • This integrated approach is the key to successful chronic pain management.
  • It helps to move beyond a purely medication-focused model of care.

Block 6: Program Management & Evaluation

Needs Assessment

  • The first step in developing any program is to conduct a thorough needs assessment.
  • This involves using data to identify the key health problems in a community.
  • The Community Health Needs Assessment (CHNA) is a formal process for this.
  • The assessment should also identify the community's assets and resources.
  • A CPHP uses their analytical skills to contribute to this data-driven process.

Logic Models

  • A logic model is a visual tool that shows the relationship between a program's resources, activities, and expected outcomes.
  • It is a roadmap for the program.
  • Inputs: The resources needed (e.g., staff, funding).
  • Activities: What the program will do (e.g., provide screenings).
  • Outputs: The direct products of the activities (e.g., number of screenings performed).
  • Outcomes: The changes that result from the program (short-term, intermediate, and long-term).
  • A CPHP should be able to develop a logic model for a pharmacy-based public health program.

Setting SMART Objectives

  • The program's goals and objectives must be clearly defined.
  • The SMART framework is used to create effective objectives.
  • Specific: What exactly will you do?
  • Measurable: How will you know if you have met the objective?
  • Achievable: Is the objective realistic?
  • Relevant: Does the objective align with the overall goal?
  • Time-bound: When will the objective be achieved?

Engaging Stakeholders

  • A successful program must have the buy-in of key stakeholders.
  • This includes community members, other healthcare providers, and potential funders.
  • Engaging stakeholders in the planning process is essential.
  • This ensures that the program is relevant to the community's needs and is culturally appropriate.
  • A CPHP is a skilled collaborator and relationship-builder.

Securing Funding

  • Public health programs are often funded through grants.
  • A CPHP may be involved in writing grant proposals.
  • This requires the ability to articulate the public health need, the proposed intervention, and the plan for evaluation.
  • A strong business case and a clear budget are essential.
  • This is a key skill for a public health leader.

Project Management

  • Implementing a new program is a complex project.
  • A CPHP must have strong project management skills.
  • This involves creating a detailed work plan with a clear timeline.
  • It requires managing a budget and a project team.
  • Tools like a Gantt chart can be used to track progress.

Marketing and Recruitment

  • Once a program is launched, participants must be recruited.
  • This requires a formal marketing and outreach plan.
  • The marketing materials must be culturally and linguistically appropriate for the target audience.
  • Working with community partners is a key strategy for recruitment.
  • A CPHP must be able to "sell" their program to the community.

Staffing and Training

  • The CPHP is often responsible for hiring and training the staff for the new program.
  • This includes developing clear job descriptions and providing a comprehensive orientation.
  • Ongoing training and competency assessment are also essential.
  • This ensures that the program is delivered with high fidelity.

Quality Assurance

  • A formal Quality Assurance (QA) program is needed to monitor the implementation of the program.
  • This involves regularly reviewing the program's activities to ensure they are being delivered as intended.
  • This is the focus of a process evaluation.
  • The QA program provides real-time feedback that can be used to make course corrections.

Budget Management

  • The CPHP is responsible for managing the program's budget.
  • This involves tracking all expenses and ensuring that the program is staying within its budget.
  • They must be able to provide regular financial reports to the program's funders.
  • This financial acumen is a key management skill.

The Purpose of Program Evaluation

  • Program evaluation is the systematic collection of information about a program to assess its effectiveness and make decisions.
  • It is the final stage of the policy cycle and a key part of the 10 Essential Services.
  • It answers the question: "Did the program work?"
  • The findings from an evaluation are used to improve, continue, or terminate a program.
  • A CPHP must be able to design and interpret program evaluations.

Types of Evaluation

  • Process Evaluation: Assesses how a program is being implemented. Is it reaching the target population? Are the activities being delivered as planned?
  • Outcome/Impact Evaluation: Assesses the extent to which a program has achieved its intended outcomes. Did the program actually improve health?
  • Economic Evaluation: Assesses the cost-effectiveness of the program. Were the benefits worth the costs?
  • A comprehensive evaluation often includes all three types.

Evaluation Design

  • The "gold standard" for an impact evaluation is the Randomized Controlled Trial (RCT).
  • However, RCTs are often not feasible in a real-world public health setting.
  • Therefore, quasi-experimental designs are often used.
  • This involves using a comparison group that is similar to the intervention group but did not receive the program.
  • A CPHP should be familiar with these common evaluation designs.

Data Collection and Analysis

  • The evaluation plan must specify what data will be collected and how.
  • This can include both quantitative data (e.g., from surveys or health records) and qualitative data (e.g., from focus groups or interviews).
  • The CPHP is responsible for the analysis of this data.
  • This requires skills in biostatistics and data management.

Communicating Findings

  • The final step of the evaluation is to communicate the findings to stakeholders.
  • This is typically done in a formal evaluation report.
  • The report should be clear, concise, and objective.
  • It should include a set of actionable recommendations based on the findings.
  • The CPHP must be skilled at translating complex evaluation results into a format that is useful for decision-makers.

Behavioral Risk Factor Surveillance System (BRFSS)

  • The BRFSS is a state-based system of health surveys that collects data about U.S. residents regarding their health-related risk behaviors, chronic health conditions, and use of preventive services.
  • It is a key source of data for Community Health Needs Assessments (CHNAs).
  • A CPHP uses this data to understand the prevalence of key risk factors (e.g., smoking, obesity) in their state or local community.
  • This data is essential for program planning and priority setting.

Youth Risk Behavior Survey (YRBS)

  • The YRBS is a CDC-led national survey that monitors health behaviors that contribute to the leading causes of death and disability among youth and young adults.
  • It provides key data on issues like substance use, sexual behaviors, and mental health in adolescents.
  • A CPHP would use this data to inform prevention programs for young people.
  • This tool is critical for understanding the health needs of the adolescent population.

Health-Related Quality of Life (HRQOL) Scales

  • Standardized, validated questionnaires used to measure a person's perception of their own health.
  • A common example is the SF-36 or SF-12, which measure various domains of physical and mental health.
  • These tools are used in program evaluation to measure the impact of an intervention on a patient's quality of life.
  • This is a key patient-centered outcome.
  • A CPHP uses these scales to demonstrate the holistic value of public health programs.

Health Literacy Assessment Tools

  • Tools used to assess an individual's or a population's health literacy.
  • REALM (Rapid Estimate of Adult Literacy in Medicine): A word recognition test.
  • TOFHLA (Test of Functional Health Literacy in Adults): A reading comprehension test.
  • Newest Vital Sign: A quick test that uses a nutrition label to assess both literacy and numeracy.
  • These tools are used in research and can be adapted for clinical screening to identify patients who may need extra support.

Community Health Needs Assessment (CHNA) Tools

  • There are a variety of frameworks and toolkits available to guide the CHNA process.
  • The CDC and the Catholic Health Association are key sources for these tools.
  • They provide guidance on how to collect and analyze quantitative and qualitative data.
  • They also provide frameworks for engaging community stakeholders and prioritizing health needs.
  • A CPHP participating in a CHNA would use these standardized tools to ensure a rigorous and valid assessment.

Prevalence

  • A fundamental measure of disease frequency. It represents the proportion of a population that has a disease at a specific point in time. It's a snapshot of the disease burden.

\( \text{Prevalence} = \frac{\text{Number of Existing Cases}}{\text{Total Population}} \)

Incidence Rate

  • Another fundamental measure of disease frequency. It measures the rate at which new cases of a disease develop in a population over a period of time. It is a measure of risk.

\( \text{Incidence Rate} = \frac{\text{Number of New Cases}}{\text{Person-Time at Risk}} \)

Relative Risk (RR)

  • A key measure of association from a cohort study. It compares the incidence of disease in an exposed group to the incidence in an unexposed group.

\( \text{RR} = \frac{\text{Incidence in the Exposed}}{\text{Incidence in the Unexposed}} \)

Odds Ratio (OR)

  • A key measure of association from a case-control study. It compares the odds of exposure in the cases to the odds of exposure in the controls. For rare diseases, the OR approximates the RR.

\( \text{OR} = \frac{\text{Odds of Exposure in Cases}}{\text{Odds of Exposure in Controls}} = \frac{ad}{bc} \)

Sensitivity and Specificity

  • These are measures of the validity of a screening test. Sensitivity is the ability of a test to correctly identify those with the disease. Specificity is the ability to correctly identify those without the disease.

\( \text{Sensitivity} = \frac{\text{True Positives}}{\text{All Diseased}} \) ; \( \text{Specificity} = \frac{\text{True Negatives}}{\text{All Non-Diseased}} \)

Block 7: Advanced Topics & Final Review

Principles of Environmental Health

  • Environmental health is the branch of public health concerned with all aspects of the natural and built environment that may affect human health.
  • It focuses on preventing disease and creating health-supportive environments.
  • Pharmacists have a role in addressing environmental exposures that impact health.
  • This includes issues like air and water quality, hazardous waste, and exposure to toxic substances.
  • A CPHP should understand these fundamental principles.

Pharmacists and Environmental Exposures

  • Pharmacists can be a key resource for patients with concerns about environmental exposures.
  • This can include counseling on how to reduce exposure to lead in the home.
  • It can also involve providing information on the health effects of air pollution, especially for patients with asthma or COPD.
  • They can also be a source of information during a chemical spill or other environmental emergency.

Pharmaceuticals in the Environment

  • A major environmental health issue is the presence of pharmaceuticals in the water supply.
  • This is primarily due to the excretion of drugs by humans and the improper disposal of unused medications.
  • While the levels are very low, there are concerns about the long-term ecological effects.
  • A CPHP is a key advocate for and organizer of drug take-back programs.
  • These programs are the best way to prevent the improper disposal of medications.

Principles of Toxicology

  • Toxicology is the study of the adverse effects of chemical, physical, or biological agents on living organisms.
  • A key principle is "the dose makes the poison."
  • Pharmacists, with their deep knowledge of pharmacology, have a strong foundation in toxicology.
  • A CPHP can apply these principles to environmental toxicology.
  • They can be a key resource for the local health department or poison control center during an exposure event.

Climate Change and Health

  • Climate change is a major public health threat.
  • It can impact health through a variety of pathways.
  • This includes more frequent and severe heat waves, worsening air quality, and changes in the patterns of infectious diseases.
  • Pharmacists have a role in helping patients to prepare for and adapt to these health threats.
  • For example, they can counsel patients with respiratory disease on how to manage their condition during a wildfire smoke event.
  • A CPHP should be an advocate for policies that address the health impacts of climate change.

The Importance of MCH

  • The health of mothers and children is a key indicator of the health of a nation.
  • Public health programs focused on MCH aim to improve the health and well-being of women, infants, children, and families.
  • This is a core focus of public health practice.
  • A CPHP can play a significant role in MCH programs.

Preconception and Prenatal Care

  • A key public health strategy is to ensure all women have access to preconception and prenatal care.
  • The pharmacist's role in this includes counseling on the importance of folic acid supplementation to prevent neural tube defects.
  • It also includes conducting a preconception medication review to ensure that a woman is on the safest possible medications before she becomes pregnant.
  • This is a critical primary prevention activity.

Medication Safety in Pregnancy and Lactation

  • A CPHP is an expert on the resources used to determine the safety of medications in pregnancy and lactation.
  • They can be a key resource for both patients and providers on this topic.
  • They can also be involved in public health surveillance programs that monitor for the potential teratogenic effects of new drugs.

Childhood Immunizations

  • Childhood immunization is one of the greatest public health achievements in history.
  • Pharmacists are playing an increasingly important role in administering these vaccines.
  • A CPHP is an advocate for policies that expand the pharmacist's scope of practice to include the full range of childhood immunizations.
  • They are also a key voice in combating vaccine misinformation and hesitancy.

WIC and Other Nutrition Programs

  • The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a key public health program.
  • It provides nutritious foods, nutrition education, and healthcare referrals to low-income pregnant women and young children.
  • A CPHP should be familiar with this and other key MCH programs in their community.
  • They can provide referrals to these programs for their patients.

Defining Global Health

  • Global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.
  • It emphasizes transnational health issues, determinants, and solutions.
  • In our interconnected world, a health threat anywhere can become a health threat everywhere.
  • A CPHP should have a basic understanding of the key principles and players in global health.

The World Health Organization (WHO)

  • The WHO is the directing and coordinating authority for health within the United Nations system.
  • They are responsible for providing leadership on global health matters.
  • They shape the health research agenda and set norms and standards.
  • They also provide technical support to countries and monitor and assess health trends.
  • The WHO's Model List of Essential Medicines is a key global health document.

Major Global Health Issues

  • The burden of disease varies significantly between high-income and low-income countries.
  • Key issues in global health include infectious diseases like HIV, malaria, and tuberculosis.
  • Maternal and child mortality are also major challenges in many parts of the world.
  • There is also a growing "double burden" of disease, as low- and middle-income countries are now facing a rise in chronic, non-communicable diseases as well.

The Pharmacist's Role in Global Health

  • Pharmacists play a key role in addressing global health challenges.
  • This includes managing the complex supply chains for essential medicines in resource-limited settings.
  • It also involves providing direct patient care and medication management for both infectious and chronic diseases.
  • Pharmacists are key leaders in building pharmacy capacity and training the pharmacy workforce in other countries.
  • A CPHP may be involved in global health work through NGOs or academic institutions.

Travel Medicine

  • Travel medicine is a key area where a CPHP can have a direct impact on global health.
  • This involves providing pre-travel consultations to international travelers.
  • Key services include providing all recommended and required immunizations.
  • It also involves prescribing prophylactic medications, such as for malaria.
  • Counseling on food and water safety and other travel-related health risks is also essential.
  • Many pharmacies now offer specialized travel health clinics.

Defining Public Health Informatics

  • Public health informatics is the systematic application of information, computer science, and technology to public health practice, research, and learning.
  • It is about using data to improve the health of populations.
  • A CPHP is a type of public health informatician who specializes in pharmacy data.

Key Data Sources

  • Public health informatics uses data from a wide variety of sources.
  • This includes clinical data from EHRs, administrative data from insurance claims, and surveillance data from public health departments.
  • Pharmacy data, especially from PDMPs, is a key source.
  • New sources of data, such as from social media and wearable devices, are also being explored.

Geographic Information Systems (GIS)

  • GIS is a powerful tool used in public health informatics.
  • It is a system for capturing, storing, analyzing, and displaying data related to positions on the Earth's surface.
  • It allows for the creation of maps that can visualize health data geographically.
  • For example, a CPHP could use GIS to map the locations of opioid overdoses in a community.
  • This can help to identify "hot spots" and to target interventions more effectively.

Health Information Exchanges (HIEs)

  • An HIE is a system that allows healthcare providers and patients to appropriately access and securely share a patient's medical information electronically.
  • They are a key piece of infrastructure for population health management.
  • They allow for a more complete, longitudinal view of a patient's care across different health systems.
  • A CPHP should be an advocate for the integration of pharmacy data into HIEs.

The Role of the CPHPA

  • The Certified Population Health Pharmacy Analyst is the person with the skills to do this work.
  • They are the ones who can manage and analyze these large, complex datasets.
  • They are the ones who can turn the raw data into the actionable intelligence that is needed to drive public health improvement.
  • This is a highly specialized and in-demand skill set at the intersection of pharmacy, public health, and data science.

Prevention is the Primary Goal

  • The core focus of public health is to prevent disease before it happens.
  • This requires an "upstream" approach that addresses the root causes of poor health.
  • While treatment is important, a public health perspective always prioritizes primary prevention.
  • A CPHP is a leader in preventive health, from immunizations to smoking cessation.

Focus on Populations, Not Just Individuals

  • While all healthcare is delivered to individuals, public health thinks in terms of populations.
  • The goal is to improve the health of the entire community, not just the patients who walk through the door.
  • This requires a different set of skills, including epidemiology and data analysis.
  • A CPHP must be able to move between the individual patient level and the broader population health level.

Health Equity is a Core Value

  • Public health has a fundamental commitment to social justice.
  • A core goal is to eliminate health disparities and achieve health equity.
  • This requires a focus on the Social Determinants of Health and the needs of the most vulnerable populations.
  • A CPHP must be a champion for health equity in all of their work.

Evidence is the Foundation

  • Public health is a scientific discipline.
  • All programs and policies must be based on the best available scientific evidence.
  • This requires a rigorous, data-driven approach to practice.
  • A CPHP is an expert in finding, appraising, and applying this evidence.
  • This commitment to science is what makes public health effective.

Collaboration is Essential

  • Public health is a team sport.
  • The complex problems we face cannot be solved by any one person or profession alone.
  • Success requires collaboration between a wide range of partners, including government agencies, healthcare providers, and community organizations.
  • A CPHP must be a skilled collaborator and relationship-builder.
  • They are a key bridge between the world of pharmacy and the broader public health community.
Return to CPHP Certification Hub