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Welcome to Canada

By now, everyone has heard of the Syrian refugee crisis. The Syrian people, having witnessed unspeakable tragedy and horror, are fleeing their home country in the hopes of finding a new, safer, more prosperous life elsewhere.

The Government of Canada has committed to resettling 25,000 Syrians here in Canada. It may have been naive of me but I didn’t think many of them would be coming to our humble little province. I assumed they would be heading west, to Ontario, or Quebec or even further west. How very wrong I was.

I should have known that Nova Scotians would step up to the need. Mosques, church groups and government agencies have sponsored families. They are supporting them as they enter their new lives and helping them with things we all take for granted. As of February 5 of this year, over 500 refugees have arrived in our wonderful little province and I have had the pleasure of meeting a few of them in my capacity as their new pharmacist.

My first meeting came when a gentleman and his interpreter arrived at our store asking for help with itchy skin. He didn’t have his paper that would allow him to go to the doctor, and as myself, my manager and my student all worked to find out how to get him his paper and if he could see a doctor, his interpreter kept telling us that he was saying over and over “Canada is the best country in the world.” At the end of our interaction, we all welcomed him to Nova Scotia and wished him well. We felt we did very little for him – a Google search, a phone call. But to both men, it seemed this little act of kindness was huge and brightened their day. It certainly brightened ours.

The next time I met a refugee was when a gentleman and his son arrived at the pharmacy with the proper papers in tow but not a single syllable of English. Through mime and drawings, we were able to convey to him that his son was to take his amoxicillin three times daily until they were finished. Once they finally understood, they smiled and said thank you. Apparently, in a super Canadian fashion, thank you was the one phrase they had learned.

After both of these scenarios, I was able to go home to my warm house, snuggle my fluffy cat and make a nice meal for myself. I was able to call my friends and family and ask how their days were, read a good book have a cup of tea and go to bed. As I went through the motions of my day, I was struck by how brave these people truly are. I tried to imagine myself in a country in which I didn’t understand the language. I imagined trying to navigate a doctor’s visit, a trip to the grocery store, a walk down the street. I couldn’t imagine what it would be like to have to do all of those things that I take for granted in a totally new country after having fled a war zone. And these folks are doing it with a smile on their faces! They’re so glad to be out of the war zone and starting fresh. They will have lots of healing to do, and lots of learning to do. And so will we. We have to learn how to help these people. How do we communicate effectively? How can we make them feel welcome? How can we tell them where the nearest grocery store is? These are all things that we will learn as they learn to adjust to this new, snowy place.

Despite the fact that their English was broken at best, at the end of both of my interactions with the above mentioned folks, I left them with a sentence they understood right away. As soon as I said it, either alone or through an interpreter, their faces split into some of the brightest smiles I’ve ever seen- Welcome to Canada!

For more information on refugees and what we as health professionals can do, visit www.isans.ca or your pharmacy college website!

 

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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Life Outside Work

The nature of a job in a health profession is that we care for a living. If you ask anyone in the health field to define their job, most definitions will include some iteration of “I take care of my patients.” This is the most rewarding and exciting part of our job. It can also be the part that wears us out the fastest.

I remember finding out that one of my patients had had a resurgence of breast cancer. Her partner came in to pick up her pain meds and told me the terrible news. I cried with her and hugged her and told her I’d be there through it all to help them both. When that patient passed away, I cried and hugged her partner again. This is the sort of stuff that I bring home. Third party issues, doctors calls, injections and med reviews can all be left at work;  it’s the emotional side of caring for my patients that often makes its way into my psyche and hitches a ride home with me at the end of the day.

It is well-documented that health professionals often put themselves last. We do a great job of caring for other people but are not so great of taking care of number one. I can also attest to the fact that if a pharmacist (i.e. myself) is not in top emotional and mental health, work will suffer. A bout of depression does not bode well for accuracy and enjoyment at work.

So, how can we wage war against burn out?

I would argue the answer to the question is not more vacation time or shorter work weeks. It’s having a hobby. Recently, I have taken up wine as a hobby. Not in the “come home and drink a bottle of wine” sense. I have been taking wine education classes and am currently enrolled in the sommelier program put on by the Canadian Association of Professional Sommeliers. Once a week I have a four-hour class on the history of wine, how grapes are grown, grape physiology, how wine is made, etc. I also have papers to write and exams for which to prepare. I love absolutely everything about this course. It is so very different from my daily work experience. It is giving me a totally new and different set of skills. I am meeting new, like-minded people who share my passion for the history, science, and art of wine making.

Now, you’re probably reading this and asking, “but Laura, what does this have to do with me?” No, dear readers, I do not suggest that the key to happiness at work is to enrol in wine school. The point of sharing my story with you is this: having a hobby gives you an out. It allows your mind to escape into a place that has nothing to do with the wonderful world of pharmacy.  As a bonus, pharmacists pride themselves on being lifelong learners. A hobby has the ability to massage a different part of the brain that has been left dormant for too long. New skills can be learned and enjoyed. It gives you something to look forward to that is different from the day to day grind of getting up and going to work.

Do you have a hobby? Do you like to cook, or go to karaoke, or take in Zumba classes twice a week? Do you paint? Is there something you’ve always wished you could do? If you are looking at this article and thinking that you’ve always wanted to take an art history class then I say do it, friends. Join the running club you’ve been thinking about. Sign up for the pottery class you’ve been eyeing. Yes, it will take extra time out of your schedule. Yes, you may have to miss a class every so often. But I can tell you from personal experience that the richness a hobby will add to your life is worth any investment.

Here is a link to HRM recreational programs: http://www.halifax.ca/rec/documents/online.pdf

This would be a great place to start if you’re looking for a new hobby. Programs tend to be inexpensive and cater to any ability level. So here’s to getting out there and having a life outside of work!

 

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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Opiate Addiction in NS

Since graduating pharmacy school in 2009, I’ve noticed the problem of opiate addiction has had heavy media coverage in Nova Scotia. It feels like once a month we hear of yet another horrible story. Someone overdosed. Someone committed suicide because they couldn’t handle their addiction anymore. Someone is arrested because they are selling prescription narcotics on the streets. The problem is growing every week.

Recently, I took a course on opiate addiction and its treatment through the Centre for Addiction and Mental Health (CAMH). This course highlighted just how vast this problem is, not only in Nova Scotia, but across Canada. The coursework included the physiology of addiction,  pharmacology of opiates in addiction and how to treat people with the disease. I learned many valuable lessons from this course and I’d like to share a few with you.

1) Addiction is a brain disease. It is not a choice.

In pharmacy school, I was taught that if an opiate was prescribed for the right patient in the proper circumstances, people could not possibly become addicted to them. The implication here is that the people who are given these prescriptions must CHOOSE to become addicted or they must have a predisposition to addiction. If Mary breaks her leg and is given oxycodone IR to manage the pain,  she will be able to come off of those pills without issue unless she decides otherwise.

In the CAMH course, we were shown several videos where patients in methadone and buprenorphine treatment programs discussed how they became addicted. One person broke her leg and was given oxycodone. Another had dental pain and was given Percocet to help her cope. Another guy had chronic back problems. All of them were prescribed these drugs for legitimate reasons by doctors who just wanted to help their patients feel better. Every single one of these patients became addicted. Not because they wanted to, or chose to become addicted. Not because they had underlying mental health issues (though some did, not all) and were self medicating. They became addicted because of the drugs themselves.

With opiates, euphoria sets in during the first dose. Patients feel great when they take them, not only because their pain improves but because they work directly on the reward pathway. Because of this, the person taking an opiate feels fantastic. It’s that same reward pathway that leads to all the trouble. When the euphoria leaves, the patients feel awful.  Actually, they feel even worse than before starting drug therapy. And so, they reach for more. In this way, the cycle of addiction begins.

The take home message here, for me anyway, is to change the way I discuss these medications with people. The goal of course, is not to scare them away from proper pain management. Rather, if someone asks me if they can become addictive, to change my answer from the one above learned in pharmacy school to yes, they can be addictive. Therefore, use them when you need to and at no other time. And, if you feel like it is becoming a problem or you’re losing control of your use, talk to someone you can trust.

2) Addiction is a lifelong disease.

I’ve known this for awhile but this course really hammered the point home for me. Addiction is something to be managed, not cured. It is unrealistic to expect that the patient that comes to your pharmacy with their first prescription for methadone will ever discontinue maintenance treatment. It should be looked at like hypertension or diabetes. A chronic illness that we can manage very well and, in doing so, allow our patients to have normal, happy, productive lives.

In that same vein, it is unrealistic to expect that our patient on methadone will never relapse. Addiction waxes and wanes. The patient who was stable for years on 50 mg may have to have a dose increase to 70 mg for a while because they started using again for whatever reason. Just like your patient with hypertension may need a medication adjustment every once in a while, so too will your opiate-addicted patient.

3) Counselling, in all its forms, is essential. 

In this course, I learned of the incredible value that case managers, social workers and addictions counsellors give to the treatment of addicted patients. Studies have shown that regular counselling, even if it is simply a 5 minute chat, improves outcomes for these patients. The counsellor speaking to us at the course said that this applies to any health care provider who has contact with these patients. In fact, he pointed to the huge potential role pharmacists have to play in counselling. We see these patients much more often than any other member of their care team. In the beginning, we see them every single day. When they have been stable for some time, we will see them at a minimum of once weekly.

I have used this information to change how I dispense methadone. It is very easy to say “ok John Doe, here is your dose, have a good day.” I’ve started asking how they are feeling. Are they having any side effects, do they notice any withdrawal symptoms? I’ve begun to ask them how they are sleeping, and if they have any pain anywhere. These conversations do not take much longer than the “here’s your dose” conversation but they provide so much information. They also make the patient feel like they can come to me with any issues. One patient mentioned to me that they start sweating 3 hours after their dose. This points to the fact that the dose might be a bit high because sweating is a side effect of increasing methadone doses. Both the patient and myself discussed the issue with the prescribing physician and the issue was resolved.

Conversations like that show the patient that we are on their team and there to help them. They are also the main reason I wanted to be a health-care professional in the first place.

In closing, the problem of addiction in this country is not going to go away any time soon. We need more health care professionals trained to deal with the ever increasing population of patients who need our help. We need more doctors to get their methadone and/or buprenorphine exemptions. We need more pharmacies to dispense methadone. We need to educate the public on the benefits of treating patients who have addictions. We need to help quell the fears of people who are terrified of clinics and pharmacies who are involved in addictions treatments. The studies are there to prove success can be achieved and communities can be saved from this awful disease. We all need to pull together to make that happen.

If you’re looking for more information on this course or addiction material, check out the CAMH website www.camh.ca

Also, previous posts have discussed the More Than Meds project that is ongoing in Nova Scotia. People with addictions need people like pharmacists to help them navigate the healthcare system.  Check out the More Than Meds project at http://www.morethanmeds.com

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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Mobile Outreach Street Health (MOSH)

In any pharmacy practice, the diversity of the patients seen is huge. There are people with diabetes, mental illness, or cancer. People who can’t come to the store themselves and have to send family members or friends. People just coming out of the hospital. People going into nursing homes. I could go on for days about what we see in pharmacies.

I work on a busy downtown Halifax street. The population I serve is unique and extremely varied. We have a large immigrant population. We have a large elderly population due to several big apartment buildings in the area. We also have a population of people who live in shelters or on the streets.

The homeless in most cities are marginalized. The public walks past them as they beg for money without even a look. I myself have been guilty of this in the past. It wasn’t until I started working at my store that I really started to see these people. I don’t mean see with my eyes alone. I mean truly understand their plight; how they got there, and how they suffer.

Many of these people are addicted to drugs, some recreational but mostly prescription narcotics. How they got to that place was innocent enough. They may have had an injury, or a kidney stone, or a friend who was on the medication and offered to share.  Some have a problem with alcohol that has robbed them of their livelihoods and they are left to try to steal Listerine to quell their withdrawal symptoms.

Some have mental illness. Depression which leads to self medication with alcohol or drugs. Schizophrenia or bipolar disorder which lead people to run away from them in the street or tell them they are “crazy.”

Many times these patients end up in the legal system due to their addictions or mental illness because the public often doesn’t know what else to do but call the police. There are not enough resources in this town to help fix the root of these problems.

There is one group of people who are working very hard to change that: Mobile Outreach Street Health.

MOSH is a programme run through the North End Community Health Clinic and Capital Health. They have set up a group of nurses with a big van stocked with medical supplies, blood requisition sheets and HIV and Hep- C testing kits, and much more.

MOSH advocates for people who need a champion but don’t have one. I have worked with them many times. They have helped my patients get into a free dental clinic. They have paid for medications that were desperately needed but unaffordable. I have called them when concerned about a patient’s mental state and suicide risk. I have called them to ask if they have had contact with a patient I haven’t seen in a while. Each and every time I talk to MOSH, I am impressed by their programme and what they are achieving.

As a result, more homeless patients have health cards. More have access to medications and addictions counselling. More are receiving dental and wound care. More have access to clean needles and sharps containers.

As a health care professional and a proud Haligonian, I am so glad this service exists. The MOSH team saw a huge void in the healthcare system and they work every day to make sure it is filled. If we all tried to do this on some small scale in our practice daily, our patient care, and indeed our patients, can only get better.

For more information on MOSH, click on the link below.

http://www.cdha.nshealth.ca/primary-health-care/mobile-outreach-street-health-0

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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Comfort

Apparently this is my M.O. Title an article with one word then expand on the word using 500 other words. Whatever, I’m comfortable with that. (See what I did there?)

Anyway, as pharmacists, we are in the business of providing comfort. We have to do so within our own comfort zones. It’s all very “Inception-esque.” How to help our patients to the best of our ability while being comfortable in the act and with the results. It’s a balancing act, a thin line, a dance with heavy consequences if we have a misstep.

Recently, my comfort zone has been stretched with our new found ability to prescribe. Before the new regulations, I always took solace in the following sentence: “let me call your doctor to double check this.” That sentence holds comfort. Call the doctor, have her tell you everything is fine or she’d rather change to drug X. Then document all over town and everything is good. I’ve helped the patient and provided care, all very much within my comfort zone.  Now, we have many other ways that situations can be resolved. We can adapt a prescription. We can substitute one drug for another. We can prescribe for a situation where we would normally have to refer (hello, hemorrhoids).  So, we are now faced with a decision. Do we refer? Do we call the doctor? Do we offer one of these new services? If we are all being honest, we would all love to stay in our previous comfort zone. Call the doctor, refer, whatever. Problem solved, patient happy, move on. However, this would not allow for progress in our profession, nor is it in the best interest of the patient.  So, we expand our comfort zone.

The first time I offered one of these new services, I was extremely nervous. I broke out in a cold sweat, my hands were shaking and it took me 45 minutes to assess my patient and decide that yes, it was appropriate to substitute Fucidin H for Hyderm and Fucidin creams to allow the prescription to be covered by MSI. I was decidedly not comfortable. Like, lost sleep that night, called the patient for the next three days to make sure she was ok kind of not comfortable.

The patient was fine. Her wound healed up nicely. She was thrilled that I was involved in her care and able to get her prescription covered without having to wait to hear back from her notoriously hard to contact doctor. Everything was A-OK.

Since that first shaky experience outside my comfort zone, I’ve had lots of experiences with prescribing and I find myself shaking and sweating less each time. This is a classic sign of an expanding comfort zone.

The moral of the story? Dive in, my friends. Dive in. It will suck the first time. It will be hard. You may not be able to eat your lunch due to nausea. But you will do it. You will provide the patient with comfort even though you distinctly lack comfort at the time. Then, you will look back at the experience and realize it didn’t suck as much as you thought. The patient is happy and healthy and you lived to tell the tale. What you’re left with is a new definition of personal and professional comfort and a happy patient. What’s wrong with that? Absolutely nothing.

 

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.

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Time

      Time has come up a lot in recent months. Will we have time to administer injections? Do medication reviews? Assess for minor ailments? Will we have time to do all of these things and still have good relationships with our patients? All of these questions are legitimate and require careful thought to ensure solutions are realized and sustainable  for everyone.
      In thinking about these questions, I have been pondering the concept of time. Specifically our time as practitioners. For example, in the run of a day at many community pharmacies, there is not a lot of spare time. We could be at work for eight hours or more and are often running  from the time our shift starts. We run from one end of the counter to the other, answering the phone, ringing people in, counselling, recommending OTC’s. Unfortunately, it’s often difficult to have an extra minute to eat, let alone administer a flu shot.
      When I do have that extra minute, I try to spend it with my patients. I take an extra minute to talk to a mother about her son’s ADHD.  Perhaps the diagnosis was thrown at her and she doesn’t understand what is happening to her child. All it may take is three extra minutes and she leaves with more knowledge and comfort than when she arrived. Maybe you choose to spend it with a patient who has depression and has finally gotten up the energy and nerve to ask for help. Or perhaps with the elderly lady who can’t understand why her doctor has her on a stomach pill when she hasn’t had gastrointestinal problems for years.
      All of these little minutes add up. It may not seem like much, but I truly believe they cultivate our relationships with patients. Now we are faced with a changing scope of practice. When this expanded scope first came on my radar, I was scared. I was nervous that my relationships with my patients would suffer. Now I realize that I could choose to be scared and not do anything, which does no one any good,  or I can take the little minutes I have with patients and form them into an appointment to administer a flu shot, do a medication review or an assessment. I believe it will strengthen our bonds with our patients. Just because I’m giving a flu shot doesn’t mean I can’t ask the mother about her son’s ADHD, or the man about his depression, or the lady about her stomach. We can ask these questions, and we will, because they are still our patients and it is still their time. We’re just squeezing a few more services into it. Let’s face it- in the end, it’s just multi-tasking. And pharmacists are champion multi-taskers.
      We can do this.
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A Whim

I went into the profession of pharmacy on a whim. I always thought I wanted to be a paediatrician. I loved kids and loved helping people. I thought those two things melded perfectly into being a doctor for children. I envisioned having a super cute office filled with stuffed animals and clouds painted on the ceiling. It was going to be perfect…

Fast-forward to my first year of undergraduate sciences and Dalhousie University. I hated everything about that year. I hated going to classes with hundreds of other students. I hated that the professors had no idea who I was or what I could become. And I hated the exams. Very high pressure, very low expectation. Generally awful.

It was during that year that I met my best friend. I knew her from high school but we weren’t very close at that tenuous time in our lives. She was the only person I recognized in my first year chemistry class and we gravitated towards each other so we wouldn’t have to sit alone in a giant classroom of freshmen. We became fast friends and during the first few months of term she revealed to me that she was applying to pharmacy school, as many in her family had done before her. She said I should look into the program. I did just that and found it to be exactly what I wanted. It meant I could be in the health professions, have a well paying job and a large amount of knowledge. It also meant I didn’t have to go to school for 12 more years or mop up blood. Both of those items were extremely appealing.

And so, my friend and I worked vigilantly to get into pharmacy school that year. We got in after our first try. The two of us (along with another good friend who had been trying to get in and was successful) celebrated that June when we found out we were in the same class.

As I went through my pharmacy degree, I was so thankful. I LOVED the programme. I couldn’t wait to start new courses. I thrived on the stress of studying and learning and absorbing. And when I wrote my licensing exams, I felt Dalhousie had prepared me as best any college could.

I started working as a staff pharmacist in 2009 and to this day still love this profession. On a daily basis I help customers. I help them find toilet paper and hair brushes. But I also help them with getting their milk to let down after they’ve given birth to a beautiful baby boy and are terrified he’s not getting enough to eat. I help them with their addictions and blood pressure. I help them with their blood glucose meters and their hearing aids. I help them when they feel no one is listening. I hug them when they lose a loved one. I help them with their health, both physical and mental. That is what I signed up for when I became a pharmacist. And I love every second of it. Even if it started as a whim.