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Background: Lithium is a popular mood stabilizer. Anecdotally, it is an underutilized medication in primary care. We conducted a survey of family physicians (FPs), pharmacists and psychiatrists in Saskatchewan to examine attitudes towards and knowledge of lithium use in bipolar disorder (BD). Methods: FPs, psychiatrists and pharmacists within Saskatchewan were contacted via email addresses provided by the Saskatchewan Medical Association, Pharmacy Association of Saskatchewan and Canadian Society of Hospital Pharmacists – Saskatchewan Branch and a link to an online survey provided. Results: Responses were obtained from 209 participants – 30 psychiatrists, 103 FPs and 76 pharmacists. Lithium was considered a specialist medication by 63.11% of FPs and 70% of psychiatrists. Lithium was the first choice for maintenance treatment of BD by 31.03% of psychiatrists and 13.68% of FPs, atypical antipsychotics being preferred by both (37.93 and 44.21%, respectively). 72% of the FPs were hesitant to initiate lithium and yet 73.79% felt comfortable monitoring patients already on it. FPs hesitancy could be related to a lack of knowledge in initiating or adjusting lithium doses (53.9%), how the medication works (28.7%), need for blood tests (34.95%), concern about suicidal ideas (11.5%) and the feeling of needing more education on prescribing lithium (79%). 33.69% of FPs were unsure about reference lithium levels or did not use it for monitoring. Limitations and conclusions: Limited by small sample size, we observed significant apprehensions about prescribing lithium in this study, more should done in encouraging its use in BD management.

Background Neuropsychiatric symptoms associated with long COVID are a growing concern. A proposed pathophysiology is increased inflammatory mediators. There is evidence that typical serotonergic antidepressants have limited efficacy in the presence of inflammation. Although ketamine has shown promise in MDD, there is limited evidence supporting the use of ketamine to treat depressive symptoms associated with long COVID. Case Report This case took place on an inpatient psychiatry unit in a Canadian hospital. The patient was admitted with a 10-month history of worsening depression and suicidality following infection with COVID-19. Depressive symptoms and suicidal ideation were assessed throughout treatment using the Montgomery-Asberg Depression Rating Scale (MADRS). Written informed consent was obtained prior to data collection. This patient received 4 doses of intranasal ketamine which resulted in rapid improvement of depressive symptoms and complete resolution of suicidality with no major adverse events. Discussion There is evidence to support long COVID symptoms result from dysregulated inflammatory processes. The presence of inflammation in patients with MDD has correlated to poor outcomes with first-line antidepressants. It has been demonstrated that IV ketamine is associated with decreased inflammatory mediators and proportional decrease in depressive symptoms. Conclusions Intranasal ketamine in this case was effective at treating depressive symptoms and suicidal ideation associated with long COVID. This is consistent with available data that demonstrates ketamine's efficacy in reducing inflammatory mediators associated with neuropsychiatric symptoms. Therefore, ketamine may be a potential therapeutic option to treat long COVID and persistent depressive symptoms.

Background: In older adults, the use of antipsychotics to treat delirium or the behavioural and psychological symptoms of dementia is potentially inappropriate and may be associated with adverse effects. Antipsychotics newly initiated in hospital may be inadvertently continued after discharge. In the Saskatchewan Health Authority (SHA) - Regina area, the frequency and duration of antipsychotic continuation for older adults after initiation during a hospital stay is unknown., Objectives: To describe potentially inappropriate antipsychotic use in older adults after discharge from hospital, specifically rates of postdischarge antipsychotic therapy after initiation in hospital and continuation up to 180 days after discharge; prescribing regimens used; risk factors associated with continuation; pharmacist involvement; and plans for antipsychotic discontinuation, tapering, and/or follow-up., Methods: This retrospective chart review included inpatients 65 years of age or older who were discharged from medicine units at SHA - Regina area hospitals between September 30, 2021, and June 28, 2022. Outpatient dispensing histories were also gathered., Results: Of the 189 patients included in the analysis, 60 (31.7%) had continuation of antipsychotic therapy at discharge. Of these, 48 (80.0%), 33 (55.0%), and 24 (40.0%) had continuation of antipsychotic therapy at 30, 90, and 180 days after discharge, respectively. Of the patients with continuing antipsychotic therapy, 53 (88.3%) were 75 years of age or older, and 9 (15.0%) had documentation of an outpatient antipsychotic follow-up plan., Conclusions: Postdischarge continuation of antipsychotics was similar to that reported in the literature. Patients continued on antipsychotics after discharge were at a greater than 50% risk of continuation at 90 days and were unlikely to have a follow-up plan. Future quality improvement efforts should include standardized prioritization of medication reviews, documentation of indications, and regular reassessment of therapy., Competing Interests: Competing interests: For projects unrelated to the work reported here, Katelyn Halpape has received grants from the Health Canada Substance Use and Addictions Program and from Indigenous Services Canada; she also received an honorarium from Hogrefe Publishing for serving as co-editor of a chapter in the Clinical Handbook of Psychotropic Drugs. Zack Dumont is a past president of the Canadian Society of Hospital Pharmacists. No other competing interests were declared., (2024 Canadian Society of Hospital Pharmacists. All content in the Canadian Journal of Hospital Pharmacy is copyrighted by the Canadian Society of Hospital Pharmacy. In submitting their manuscripts, the authors transfer, assign, and otherwise convey all copyright ownership to CSHP.)

Objective: To explore barriers and facilitators for family physicians in Saskatchewan prescribing opioid agonist therapy (OAT)., Design: Self-administered postal survey., Setting: Family medicine practices in Saskatchewan., Participants: A total of 218 Saskatchewan family physicians who were not authorized to prescribe OAT as of June 2022., Main Outcome Measures: Descriptive and inferential statistics of physicians' self-reported barriers to and facilitators of prescribing OAT for opioid use disorder (OUD)., Results: Most respondents (84.8%) had some comfort with diagnosing OUD. However, more than half (58.3%) did not feel confident or knowledgeable about prescribing OAT. Barriers to OAT prescribing included lack of time, incomplete training requirements, lack of interest, insufficient funding or support, feeling overwhelmed, and perceiving that OAT does not work and thus is not necessary. Physicians working in core neighbourhoods and those receiving fee-for-service compensation reported the least available time to prescribe OAT. Conversely, physicians working in interdisciplinary team settings had increased time for OAT prescribing compared with physicians in other settings. Having a close personal relationship with someone with OUD was correlated with increased comfort in diagnosing OUD as well as with knowledge about and confidence in prescribing OAT. Themes identified as facilitators to increasing OAT prescribing included the addition of resources and supports, increased training, more awareness about OUD and OAT, enhanced compensation, and altered prescribing regulations., Conclusion: Despite the presence of several real and perceived barriers limiting OAT prescribing by Saskatchewan family physicians, there are family physicians interested in providing this therapy. Increased clinical resources and support, including increased interdisciplinary practice, are actionable steps that should be considered by policy decision makers to address this issue. Additionally, increased OUD and OAT education, which includes the perspectives of those with lived experience of OUD, would help address physician confidence, knowledge, and awareness in this area., (Copyright © 2024 the College of Family Physicians of Canada.)

Background: Opioids are a common treatment for older adults living with pain. Given high rates of polypharmacy and chronic comorbidities, older adults are at risk of opioid overdose. Evidence is now available that take-home naloxone (THN) supports reduction of opioid-related harms. It is unknown what THN initiatives are available for older adults, especially those living with chronic pain., Objective: To summarize the literature regarding THN, with a focus on older adults using opioids for pain, including facilitators of and barriers to THN access, knowledge gaps, and pharmacist-led initiatives., Data Sources: A scoping review, guided by an established framework and PRISMA-ScR guidelines, was performed. Methods involved searching 6 bibliographic databases (MEDLINE, Embase, Scopus, APA PsycINFO, Web of Science Core Collection, and PubMed), reference harvesting, and citation tracking. Searches were conducted up to March 2023, with no date limits applied; only English publications were included., Study Selection and Data Extraction: Study eligibility was determined according to preset criteria, including age; discrepancies were resolved by discussion and consensus. Data were extracted and categorized through thematic analysis., Data Synthesis: Four studies met the eligibility criteria. All 4 studies detailed THN programs in primary care settings involving older adults taking opioids for pain management. Two of the studies highlighted patient-specific risk factors for opioid overdose, including concomitant use of benzodiazepines and/or gabapentinoids, mean morphine milligram equivalents per day of at least 50, and previous opioid overdose. Two of the studies assessed patient knowledge of opioid overdose management and attitudes toward THN. Educational programs increased patients' interest in THN., Conclusions: The literature about THN for older adults living with pain is limited, and no literature was found on pharmacist-led initiatives in this area. Future research on THN provision for older adults, including pharmacist-led initiatives, could help to optimize care for older adults living with pain., Competing Interests: Competing interests: For activities unrelated to the study reported here, Ryan Chan received undergraduate research funding (in the form of an Interdisciplinary Dean’s Summer Research Project Award) from the University of Saskatchewan’s College of Medicine and College of Pharmacy and Nutrition and has received speaking honoraria for community-based presentations with Big Brothers Big Sisters; he is also Vice President, Communications with the National Executive Council of the Canadian Association of Pharmacy Students and Interns, which receives sponsorship from the Canadian Society of Hospital Pharmacists. For activities unrelated to the study reported here, Katelyn Halpape has received grant funding from Health Canada’s Substance Use and Addictions Program and Indigenous Services Canada. She also received an honorarium from Hogrefe for work as a chapter editor on the Clinical Handbook of Psychotropic Drugs. No other competing interests were declared., (2024 Canadian Society of Hospital Pharmacists. All content in the Canadian Journal of Hospital Pharmacy is copyrighted by the Canadian Society of Hospital Pharmacy. In submitting their manuscripts, the authors transfer, assign, and otherwise convey all copyright ownership to CSHP.)

Competing Interests: Intérêts concurrents:: Evan Wood est médecin; il travaille à l’Autorité de la santé du littoral de Vancouver pour la prise en charge du sevrage et entreprend des travaux sur la médecine des toxicomanies en milieu professionnel. Le Dr Wood est également professeur de médecine à l’Université de la Colombie-Britannique, un poste appuyé par une chaire de recherche du Canada de niveau 1 des Instituts de recherche en santé du Canada (IRSC) et il a reçu une subvention pour un projet R01 de l’Institut national des États-Unis sur l’abus de drogues, versée à l’Université de la Colombie-Britannique. Le laboratoire de recherche du Dr Wood est en outre appuyé par des subventions des IRSC versées à l’Initiative canadienne de recherche sur l’abus de substances. Il a également entrepris des travaux de consultation sur les enjeux juridiques liés aux troubles d’utilisation des substances et pour une société qui se consacre à la santé mentale appelée Numinus Wellness, dont il a été médecin-chef. Le Dr Wood a aussi reçu une rémunération sous forme d’actions ordinaires de Numinus. Il déclare avoir reçu des honoraires pour des conférences et des présentations non liées à l’industrie (p. ex., conférences universitaires ou éducatives), y compris une allocution pour la Société médicale canadienne sur l’addiction (SMCA), rémunérée à même le budget de la conférence de la SMCA; une série de séances scientifiques à l’Université Dalhousie (payée par l’université); et une conférence pour la plateforme éducative des équipes soignantes, des liens avec les services administratifs (indépendamment des travaux soumis et sans liens financiers avec l’industrie pharmaceutique). Le Dr Wood a aussi reçu une rémunération pour des rapports et témoignages d’expert sur des questions juridiques ayant trait au trouble d’utilisation des substances psychoactives, y compris de l’Association canadienne de protection médicale et de syndicats représentant des travailleurs souffrant de possibles troubles d’utilisation des substances. Il a reçu des bourses de déplacement des IRSC. Jessica Bright, Nirupa Goel et Josey Ross déclarent avoir reçu des bourses salariales du Centre sur la toxicomanie de la Colombie-Britannique, en appui à l’élaboration du présent manuscrit. Katelyn Halpape déclare avoir reçu des subventions du Programme sur l’usage et les dépendances aux substances de Santé Canada et du ministère canadien des Services aux Autochtones pour la Clinique de la douleur chronique de l’Université de la Saskatchewan. La Dre Halpape déclare aussi avoir reçu des honoraires en tant que rédactrice d’un chapitre du manuel intitulé The Clinical Handbook of Psychotropic Drugs. Aucun autre intérêt concurrent n’a été déclaré.

Competing Interests: The authors have no conflicts of interest to report.

Competing Interests: The authors have no conflicts of interest to report.

Background: In Canada, low awareness of evidence-based interventions for the clinical management of alcohol use disorder exists among health care providers and people who could benefit from care. To address this gap, the Canadian Research Initiative in Substance Misuse convened a national committee to develop a guideline for the clinical management of high-risk drinking and alcohol use disorder., Methods: Development of this guideline followed the ADAPTE process, building upon the 2019 British Columbia provincial guideline for alcohol use disorder. A national guideline committee (consisting of 36 members with diverse expertise, including academics, clinicians, people with lived and living experiences of alcohol use, and people who self-identified as Indigenous or Métis) selected priority topics, reviewed evidence and reached consensus on the recommendations. We used the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II) and the Guidelines International Network's Principles for Disclosure of Interests and Management of Conflicts to ensure the guideline met international standards for transparency, high quality and methodological rigour. We rated the final recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool; the recommendations underwent external review by 13 national and international experts and stakeholders., Recommendations: The guideline includes 15 recommendations that cover screening, diagnosis, withdrawal management and ongoing treatment, including psychosocial treatment interventions, pharmacotherapies and community-based programs. The guideline committee identified a need to emphasize both underused interventions that may be beneficial and common prescribing and other practice patterns that are not evidence based and that may potentially worsen alcohol use outcomes., Interpretation: The guideline is intended to be a resource for physicians, policymakers and other clinical and nonclinical personnel, as well as individuals, families and communities affected by alcohol use. The recommendations seek to provide a framework for addressing a large burden of unmet treatment and care needs for alcohol use disorder within Canada in an evidence-based manner., Competing Interests: Competing interests: Evan Wood is a physician who works for Vancouver Coastal Health in the area of withdrawal management and undertakes work in the area of occupational addiction medicine. Dr. Wood is also a professor of medicine based at the University of British Columbia (UBC), a position supported by a Canadian Institutes of Health Research (CIHR) Tier 1 Canada Research Chair, and has received salary support from an R01 from the US National Institute on Drug Abuse, paid to UBC. Dr. Wood’s research lab is further supported by CIHR grants to the Canadian Research Initiative in Substance Misuse. Dr. Wood has also undertaken consulting work in legal matters related to substance use disorders and for a mental health company called Numinus Wellness, where Dr. Wood is former chief medical officer; Dr. Wood has also received compensation in the form of equity in Numinus. Dr. Wood reports receiving honoraria for non-industry related lectures and presentations (e.g., at academic or educational conferences), including a talk at the Canadian Society of Addiction Medicine (CSAM) paid by CSAM conference; a Rounds Presentation at Dalhousie University (paid by the University); and an educational talk for the allied health educational platform, Executive Links (all outside the submitted work and did not involve funding from the pharmaceutical industry). Dr. Wood has also received payment for expert reports and expert testimony in legal matters pertaining to substance use disorder, including from the Canadian Medical Protective Association and from trade unions representing workers with possible substance use disorder. Dr. Wood has received travel support from the CIHR. Jessica Bright, Nirupa Goel and Josey Ross report receiving salary support from the British Columbia Centre on Substance Use, in support of the present manuscript. Katelyn Halpape reports receiving grant funding from the Health Canada Substance Use and Addictions Program and Indigenous Services Canada for the University of Saskatchewan Chronic Pain Clinic. Dr. Halpape also reports receiving an honorarium as chapter editor of The Clinical Handbook of Psychotropic Drugs. No other competing interests were declared., (© 2023 CMA Impact Inc. or its licensors.)

Background: Pharmacists can have an essential role in providing care for patients with mental illness. There are gaps in the understanding of the current extent of pharmacists' involvement in caring for patients with mental illness and their readiness to effectively provide this care., Aim: To describe the current practices, attitudes, and beliefs of pharmacists in providing care to individuals with mental illness, and to assess factors that may impact these practices., Method: An electronic questionnaire was emailed to pharmacists in Saskatchewan, Canada. Likert scale questions were utilized, and data were analyzed using descriptive statistics and content analysis for free-text responses., Results: The response rate was 9.1% (n = 146/1596). Fewer than 20% of respondents reported they were providing the clinical services listed to most or all patients with mental illness, except for providing basic medication education (61%). Almost all agreed it is a pharmacist's role to provide all the services (61-98% for different services) and many were motivated to provide them (47-91%). The factors most frequently selected as having the greatest impact on service provision were insufficient knowledge (27%, n = 34) and competing priorities (19%, n = 24)., Conclusion: Consistent with international trends, Saskatchewan pharmacists reported low provision of clinical services for individuals with mental illness, despite a readiness to provide these services. There is an opportunity and a need to better utilize pharmacists internationally in the provision of mental health care., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Chronic noncancer pain (CNCP) is a common condition that affects individuals at a biopsychosocial level and can significantly impair function and quality of life. Referral to an interprofessional CNCP program is recommended for most patients; however, these clinics are limited in number and capacity. Expanding access by testing new service delivery models would be of value. The purpose of this study was to measure the impact of a new pharmacist-led, interprofessional model of care developed at the University of Saskatchewan Chronic Pain Clinic., Methods: A retrospective chart audit was conducted using data that included adult patients referred for CNCP management between May 2020 and December 2021. Medication use, overall health status (using the Clinical Global Impression of Change-Improvement [CGI-I] scale) and patient readiness to change (using the Transtheoretical Model) were measured 6 months after the initial appointment., Results: The study included 138 patients. Of the 80 patients taking an opioid, 22.5% were switched to buprenorphine/naloxone and the remainder had their mean morphine-equivalent dose reduced by a mean of 41.7 mg/d. Overall patient health status was minimally improved and many patients moved into the Action stage of change., Discussion: Changes in opioid use demonstrate a clinically important shift toward safer medication regimens that are less likely to lead to toxicity and unintended overdose. CGI-I data suggest that these patients, whose health status is typically very difficult to change, did not deteriorate but slightly improved after attending the clinic., Conclusion: The unique pharmacist-led, interprofessional model of care used by the University of Saskatchewan Chronic Pain Clinic may offer a viable alternative to traditional physician-led models., Competing Interests: The authors have no conflicts of interest to report., (© The Author(s) 2023.)

Most research describing ketamine as a treatment for depression has relied on intravenous dosing. There remains a need for more research to support this treatment with other routes of administration. This was a retrospective chart review of 30 patients hospitalized with unipolar or bipolar treatment-resistant depression who were treated with up to four doses of compounded intranasal racemic ketamine (50 mg or 75 mg). Treatment courses lasted up to 7 days. Symptom improvement was measured with either the Hamilton Depression Rating Scale or the Montgomery-Åsberg Depression Rating Scale. Ketamine was well tolerated with no severe adverse events or treatment discontinuations due to adverse effects. Blood pressures increased by 4-6 mmHg on average with no patients requiring medication to lower blood pressure. Twenty patients (66.7%) were classified as treatment responders based on depression scores decreasing by more than 50%. Among the 27 patients with moderate to severe suicidal ideation scores at baseline, these decreased by 68.5% on average. Overall, the results suggest that compounded intranasal racemic ketamine was safe and effective in the treatment of depressive symptoms and suicidal ideation in a real-world sample of patients hospitalized with treatment-resistant depression. Additional research comparing intranasal ketamine to esketamine and intravenous racemic ketamine is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Background: Clinical pharmacists have a significant role in optimizing pharmacotherapy for patients admitted to acute care settings. Patients with mental health disorders are especially vulnerable to polypharmacy, adverse drug effects, medication nonadherence, and misconceptions about medication use. The Royal University Hospital in Saskatoon, Saskatchewan, currently lacks resources to provide optimal clinical pharmacy coverage for mental health inpatients., Objectives: To determine the optimal clinical role for a pharmacist providing specialized care to mental health inpatients and to evaluate the potential impact of the pharmacist on medication use and patient care., Methods: A pharmacist with 5 years of mental health-related pharmacy practice experience was temporarily assigned to the Mental Health Short Stay Unit as a practical component of a Master's program in pharmacy. Clinical activities to be completed by the pharmacist were defined on the basis of available evidence, existing performance and quality assurance indicators, and prior experience. The pharmacist's activities and recommendations during each shift were tracked and reported., Results: The pharmacist saw 94 patients over a total of 88 hours. The pharmacist made a total of 61 recommendations, of which 55 (90%) were accepted by the psychiatrist, and initiated 42 medication changes. Forty-one patients (44%) received a thorough medication assessment, and individualized, often specialized, education was provided to patients 39 times. The pharmacist was consulted by the psychiatrist 19 times., Conclusions: Pharmacists have an important role in medication management and patient education for psychiatric inpatients, and the health care team values pharmacists' unique expertise. Additional resources dedicated to defining and expanding clinical pharmacy services on inpatient psychiatry units could further optimize patient care., Competing Interests: Competing interests: For activities unrelated to the study reported here, Katelyn Halpape has received honoraria from Hogrefe Publishing for contributions to the 23rd edition of Clinical Handbook of Psychotropic Drugs, as well as honoraria for educational presentations from the British Columbia and Saskatchewan branches of the Canadian Society of Hospital Pharmacists (CSHP), the Saskatchewan College of Physicians and Surgeons, and the Pharmacists Association of Saskatchewan. Amy Soubolsky has received honoraria for educational presentations from the Saskatchewan branch of the CSHP. Amy Soubolsky and Katelyn Halpape have served in voluntary positions for the Saskatchewan Branch of CSHP. No other competing interests were declared., (2022 Canadian Society of Hospital Pharmacists. All content in the Canadian Journal of Hospital Pharmacy is copyrighted by the Canadian Society of Hospital Pharmacy. In submitting their manuscripts, the authors transfer, assign, and otherwise convey all copyright ownership to CSHP.)

Background: The opioid epidemic is an international public health concern. Pharmacists are in a strategic position to promote and implement effective opioid stewardship due to both their central role on health care teams and frequent interaction with patients. Despite this integral role, pharmacists do not have harmonized scopes of practice in opioid stewardship., Objectives: This scoping review was conducted to identify and critically review the role of pharmacists in opioid stewardship and identify future areas of study., Methods: The scoping review was conducted according to the methodological framework proposed by Arksey and O'Malley, which was further modified by the Joanna Briggs Institute. Six databases were searched for original, peer-reviewed research; PubMed (MEDLINE), Ovid Embase, Ovid International Pharmaceutical Abstracts, Scopus, Cochrane Library, and APA PsycInfo., Results: In 92% of the included studies (n = 77), opioid stewardship interventions led by either a pharmacist or in an interdisciplinary team resulted in improvements in at least one outcome measure, with education and medication therapy adjustments being the most predominant activities. Other areas supported by evidence include community stakeholder education, policy and guideline setting, and risk assessment., Conclusion: This scoping review provides valuable insight into the various roles pharmacists can have in opioid stewardship. The findings from this review identified opioid stewardship activities that can make significant contributions towards reducing the impact of the opioid crisis. This review informs future research and has the potential to influence pharmacy practice on a national and international scale., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Pharmacists' roles and services for patients with substance use are not well defined and inconsistent from site to site. Several barriers have been identified that hinder pharmacists' care for people who use substances, such as a lack of training and resources. Clinical practice tools can aid in transferring evidence-based approaches to the practice sphere., Objectives: The aim of the study was to develop a substance misuse management toolkit for community pharmacists to help them manage their encounters with people who use substances., Methods: A focused literature review was conducted and 2 needs assessment studies, one for community pharmacists and one for patients informed the development of the toolkit. The toolkit is an adaption of the screening, brief intervention, and referral to treatment (SBIRT) approach, which is one of the most well-defined and effective strategies for substance use management. However, SBIRT is a novel care model in community pharmacy settings. Therefore, a substance misuse management toolkit with 20 items was created for community pharmacists incorporating evidence-based strategies and clinical algorithms. Delphi procedure was used to validate the toolkit., Results: Two rounds of questions were sent to experts in the field of substance misuse, some of whom were pharmacists. In both rounds, these experts were asked to rate the appropriateness and clarity of items in the toolkit and provide comments and suggestions. Items with a median rating of 7 or more out of 10 were included in the toolkit. In the second round, the experts were asked to rerate the revised version and provide additional feedback. After the second round, agreement was reached for almost all items of the toolkit., Conclusion: A Delphi procedure was successfully used to provide evidence of the validity of the new guiding toolkit for community pharmacists. The toolkit will be implemented and evaluated to provide additional evidence of validity in practice., (Copyright © 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Ketamine has been safely used as an anesthetic for over 50 years. More recently sub-anesthetic doses have shown benefit for treatment-resistant depression (TRD). The majority of data on ketamine for depression is based on intravenous administration which is resource intensive and logistically challenging. Due to these concerns, novel modes of administration, including intranasal, are being explored. In 2019, the U.S. Food and Drug Administration (FDA) approved a commercially formulated intranasal s-enantiomer ketamine product, esketamine, for TRD. The cost of intranasal esketamine is significant and phase III clinical trials have not consistently demonstrated benefit over placebo. We describe a case of a patient with major depressive disorder (MDD) and acute suicidality who achieved rapid remission following three treatments with intranasal racemic ketamine. The associated drug cost was $42 USD, significantly cheaper than commercially available esketamine, and treatment was administered on an inpatient psychiatry ward with basic hemodynamic monitoring. Intranasal ketamine was not associated with significant adverse drug effects and facilitated a relatively short hospital admission. The case report provides support for the use of intranasal racemic ketamine as adjunctive treatment for MDD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Competing Interests: Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Introduction: Academic faculty are evaluated on their service, teaching, and research performance with the reward of tenure, promotion, and self-fulfillment. Triathletes spend numerous hours building their swim, bike, and run endurance in aspiration of crossing the finish line on race day. Given the workload required for academic and triathlon success, effective time and task management is essential. In this commentary, the authors posit that academic faculty can effectively structure their day-to-day "training" to achieve their career ambitions similarly to how a triathlete structures their training plan in preparation for a race., Perspective: Triathlon requires mastery of three disciplines - swimming, biking, and running - each of which requires specific training approaches, skills, and techniques. Likewise, the service, teaching, and research pillars of academia involve planning, development, and application of diverse knowledge, skills, and techniques. The authors apply the fundamental aspects and lessons learned of triathlon training to the planning and execution of faculty academic work., Implications: Through the adaptation of a triathlete training framework to an academic position, the reader will be prepared to cross the finish line and realize their career goals as an academic triathlete., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The opioid crisis is a worldwide public health concern. In North America, evidence suggests that the increase in opioid prescriptions correlates with the observed increase in opioid-related mortality and morbidity. Pharmacists are in a strategic position to promote effective opioid stewardship as they have a central role on healthcare teams. However, in many contexts, pharmacists do not have a harmonized scope of practice and no standardized opioid stewardship approach has been implemented., Objectives: A scoping review will be conducted to identify and summarize evidence on the role of pharmacists in opioid stewardship and identify areas for future study., Methods: The scoping review will be conducted according to the methodological framework proposed by Arksey and O'Malley, which was further modified by the Joanna Briggs Institute. Six databases will be searched which include PubMed, Embase, International Pharmaceutical Abstracts, Scopus, Cochrane Library, and APA PsycInfo., Project Impact: The findings of this review will identify opioid stewardship activities that can contribute towards reducing the impact of the opioid crisis. Additionally, it will provide foundational strategies to promote policy level change and foster a harmonized scope of practice. This review has the potential to inform future research, impact pharmacy practice, and drive policy change., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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

Background: Proton pump inhibitors (PPIs) have proven clinical efficacy for a variety of indications. However, there is emerging evidence of adverse events associated with their long-term use. The emergence of these adverse events has reinforced the need to regularly evaluate the appropriateness of continuing PPI therapy, and to use only the lowest effective dose for the minimally indicated duration., Objectives: To characterize the appropriateness of PPI orders continued or initiated in the internal medicine and family practice units of Vancouver General Hospital, to detect adverse events associated with PPI use, and to explore the impact of multidisciplinary teaching and provision of educational resources on health care practitioners' views about PPI use., Methods: A chart review was conducted for patients admitted (for at least 24 hours) between January 1 and December 31, 2015, for whom a hospital formulary PPI was prescribed. An educational initiative, which included interprofessional in-service sessions, a PPI prescribing infographic, a PPI prescribing card, and a patient counselling sheet, was implemented. The impact of these interventions was assessed using a qualitative survey of health care practitioners., Results: Of the 258 patients whose charts were reviewed, 175 had a PPI prescription before hospital admission, and 83 were initiated on PPI therapy during their hospital stay. Overall, 94 (36%) of the patients were receiving PPIs without an appropriate indication. Community-acquired pneumonia and Clostridium difficile infections were the most common adverse events potentially associated with PPI use. In-service sessions and educational resources on PPI prescribing were reported to affect the clinical practice of 24 (52%) of the 46 survey respondents., Conclusions: The results of this study emphasize the need for ongoing re-evaluation of long-term PPI therapy at the time of admission, during the hospital stay, and upon discharge. Implementing multidisciplinary teaching and providing educational resources may encourage more appropriate prescribing., Competing Interests: Competing interests: None declared.

Background: Pneumonia is the eighth leading cause of death in Canada. Use of guideline-concordant therapy tempers the development of resistance, decreases health care costs, and reduces morbidity and mortality., Objectives: The purpose of this study was to optimize the treatment of patients with pneumonia under hospitalist care by focusing on best practice and local antibiogram data. The objectives were to collaborate with a hospitalist representative to optimize in-hospital treatment of patients with community-acquired, hospital-acquired, and health care-associated pneumonia; to complete a baseline audit to determine the proportion of antibiotic orders adhering to the strategy; to present the strategy and baseline audit findings to the hospitalists; to perform a post-intervention audit, with comparison to baseline, and to present results to the hospitalists; to expedite de-escalation to a narrower-spectrum antibiotic; to expedite parenteral-to-oral step-down therapy and promote appropriate duration of therapy; and to determine if a pneumonia scoring system was used., Methods: An audit and feedback intervention focusing on pre- and post-intervention retrospective chart audits was completed. Review of pneumonia guidelines and the local antibiogram assisted in identifying the study strategy. A presentation to the hospitalists outlined antimicrobial stewardship principles and described the findings of the baseline audit. Pre- and post-intervention audit results were compared., Results: Local best-practice treatment algorithms were developed for community-acquired pneumonia and for hospital-acquired and health care-associated pneumonia. The pre-intervention audit covered the period December 2011 to January 2012, with subsequent education and audit results presented to the hospitalists in November 2012. The post-intervention audit covered the period December 2012 to January 2013. Adherence to the treatment algorithms increased from 10% (2/21) in the pre-intervention audit to 38% (5/13) in the post-intervention audit. There was a trend to reduced duration of therapy in the post-intervention group., Conclusion: An audit and feedback intervention related to hospitalists' prescribing for pneumonia increased adherence to local best practice.