Texas Pharmacy Ebook Continuing Education

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Elite Learning

TEXAS PHARMACIST Continuing Education

Need to complete the DEA’s new one-time Substance Use Disorder requirement? SEE INSIDE FRONT COVER FOR MORE DETAILS

Includes mandatory topics required for license renewal.

ELITELEARNING.COM/BOOK Complete this book online with book code: RPTX3024 30-hour Continuing Education Package $135.00


Overview of Texas Pharmacy Law, 2nd Edition (Mandatory)


[1 contact hour] This continuing education course provides important background information on the Texas State Board of Pharmacy, their role in revising and adopting changes to the law, and important Texas State Pharmacy Law updates from Early 2021 through the first half of 2023. THIS COURSE FULFILLS THE REQUIREMENT FOR TEXAS PHARMACY LAWS OR RULES Mental Health Concerns and The Older Adult (Mandatory) 7 [6 contact hours] The healthcare worker meeting mental health needs will be able to view the older adult within the context of aging theories and identify interpersonal connection, biopsychosocial elements, and the assessment and treatment for common mental health problems in the older adult. The target audience is any healthcare worker who will assess, intervene, or treat mental health needs of an older adult client. Registered nurses, mental health technicians, mental health providers, case managers, and primary care healthcare workers can benefit from the perspective provided by this course. [2 contact hours] Pain is not always curable, and there are a number of approaches to its treatment. The appropriate treatment plan can vary significantly, depending on the cause of pain, patient-specific factors, and personal preference. A comprehensive pain treat- ment plan is often a multimodal approach, requiring the use of both pharmacological and non-pharmacological treatment options. A thorough understanding of the available therapies is necessary to provide optimal care to a patient in pain. This course serves as an overview of pain, its evaluation, and treatment (US National Library of Medicine, 2021). THIS COURSE FULFILLS THE REQUIREMENT FOR PAIN MANAGEMENT Prescribing Controlled Substances Safely: A DEA Requirement (Mandatory) 44 [8 contact hours] THIS COURSE FULFILLS THE REQUIREMENT FOR MENTAL HEALTH AWARENESS Pain Management Awareness for Pharmacists, Second Edition (Mandatory) 34 Nurse Practitioners (NPs), Physician Assistants (PAs), Pharmacists, and Dentists care for patients with disorders in many health- care settings. Individuals may seek care for an acute illness or worsening of a chronic condition. Often, pain is the leading reason for seeking medical care. Appropriate prescribing practices are critical for all medications, but controlled substances require special attention. The Drug Enforcement Agency (DEA), the Food and Drug Administration (FDA), and the U.S. Department of Health and Human Services (HHS) all have a role in controlled medication schedules. Prescribers must under- stand federal and state requirements for all controlled substances. This course will provide a general review of federal and state-controlled substance regulations and the prescribing practices for controlled substances. Additionally, substance use disorders are complex phenomena affecting many lives. This course also reviews common substance use disorders, including alcohol, anxiolytics, stimulants, hallucinogens, and tobacco/vaping. However, the focus is on clinical safety considerations [1 contact hour] This course focuses on how human trafficking occurs, ways to identify those who may be trafficked, safety protocols, and victim resources. This course meets the Human Trafficking requirement for Texas Professionals and is approved by the Texas Health and Human Services Commission. THIS COURSE FULFILLS THE REQUIREMENT FOR HUMAN TRAFFICKING PREVENTION Heart Failure: Evidence Review and Management 89 [2 contact hours] Heart failure is a complex clinical syndrome associated with increasing morbidity, mortality, and economic burden. Despite evidence supporting guideline-directed therapy and management for reduction of morbidity and mortality, these medications are still underprescribed. According to the CHAMP-HF registry, among eligible patients, only 22% were prescribed essential heart failure medications per guideline recommendations ((Greene et al., 2018). Healthcare providers have an essential role in improving outcomes with heart failure by bridging the gap between guideline-directed recommendations and actual clinical practice. The learning outcomes of this activity will help clinicians understand this healthcare gap by reviewing the current evi- dence-based pharmacotherapy recommendations for HF treatment through analyzing clinical trials and guidelines. when prescribing non-cancer-related opioid medications for acute/chronic pain in adults. THIS COURSE FULFILLS THE DEA’S REQUIREMENT FOR PRESCRIBING AND MONITORING CONTROLLED SUBSTANCES Recognizing and Responding to Human Trafficking in Texas (Mandatory) 82




Book code: RPTX3024


Management of Drug Challenges: Generic vs. Branded Drugs, 2nd Edition [1 contact hour] Written program is designed to help healthcare professionals best understand the generic drug environment, recognize when substitution is warranted, and work with their patients to fully understand and appreciate the process. Monitoring Techniques for Optimal Diabetes Management and Control 108 [2 contact hours] 100 The purpose of this course is to assist in the successful management of diabetes, including blood glucose monitoring (BGM) and the ability of persons with diabetes to monitor the effectiveness of their diabetes treatment plan to understand better the interrelationships of food, activity, and medication-taking. In addition, BGM data can alert the person to hypoglycemia and hyperglycemia, inspiring lifestyle modifications that may help people with diabetes achieve their A1C goals. Diabetes technol- ogy has resulted in many improvements in blood glucose meters. Continuing advances in BGM have led to the development of continuous glucose monitoring (CGM) systems that enable people with diabetes to optimize glycemic stability and improve the quality of their lives. This course reviews the features and functionality of BGM with glucometers and CGMs in line with the 2022 [3 contact hours] This course will outline the risk factors, pathophysiology, and diagnostic criteria of type 2 diabetes. Goals of management, treatment options, and psychosocial barriers will also be addressed to guide successful multidisciplinary care of these patients. Rhinitis: Treatment Strategies for Healthcare Providers 134 [1 contact hour] American Diabetes Association (ADA) evidence-based guidelines integrated into clinical practice. Pharmacological Management: Type 2 Diabetes in Children, 2nd Edition 120 The purpose of this course is to explain the epidemiology of rhinitis, discuss the pathophysiology of allergic and nonallergic rhinitis, review assessment and diagnostic testing for rhinitis, and describe the pharmacological and nonpharmacological treatment strategies of allergic and nonallergic rhinitis. Shingles Disease Process and Vaccination for Pharmacists 142 [1 contact hour] Shingles causes a characteristic rash typically localized in one area of the body. Serious complications, which often depend on the rash location, can arise, such as pain that persists after the rash has cleared and even vision or hearing loss. Treatment typically focuses on antiviral therapy and symptom control. Shingles can be prevented through vaccination, which is recom- mended for adults over 50 since the immune system weakens with age. This course serves to review the disease process of shingles and the use of vaccinations to prevent shingles. The Complications of Chronic Kidney Disease, Second Edition 147 [2 contact hours] This course serves as a review of chronic kidney disease (CKD) and the medications used to prevent adverse effects of CKD and slow disease progression.

©2023: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.


Book code: RPTX3024


FREQUENTLY ASKED QUESTIONS What are the requirements for license renewal? Licenses Expire Contact Hours

Mandatory Subjects

1 hr Texas Pharmacy Laws or Rules 2 hrs related to Prescribing and Monitoring Controlled Substances (Pharmacists licensed on or after September 1, 2020 must complete this requirement not later than the first anniversary of their licensure) A Texas HHSC-approved course on Human Trafficking every renewal period 1 hr Mental Health Awareness (1 time requirement)

30 (All hours are allowed through home-study)

Renewal every two years, licenses expire during birth month.

How much will it cost? If you are only completing individual courses in this book, enter the code that corresponds to the course below online.



PRICE $9.95 $34.95 $14.95 $79.95 $11.95 $14.95


Overview of Texas Pharmacy Law, 2nd Edition (Mandatory) Mental Health Concerns and The Older Adult (Mandatory)

1 6 2 8 1 2 1 2 3 1 1 2



Pain Management Awareness for Pharmacists, Second Edition (Mandatory) Prescribing Controlled Substances Safely: A DEA Requirement (Mandatory) Recognizing and Responding to Human Trafficking in Texas (Mandatory)

Heart Failure: Evidence Review and Management

Management of Drug Challenges: Generic vs. Branded Drugs, 2nd Edition Monitoring Techniques for Optimal Diabetes Management and Control Pharmacological Management: Type 2 Diabetes in Children, 2nd Edition Rhinitis: Treatment Strategies for Healthcare Providers Shingles Disease Process and Vaccination for Pharmacists The Complications of Chronic Kidney Disease, Second Edition


$14.95 $19.95

$9.95 $9.95


Best Value - Save $111.40 - All 30 Hours


$135.00 RPTX3024

How do I complete this course and receive my certificate of completion? See the inside back cover for step by step instructions to complete and receive your certificate. Are you approved by ACPE?

Colibri Healthcare, LLC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. (Provider #0607). Your hours will be reported to CPE Monitor within 10 business days after course completion. Are my contact hours reported to my state board? Yes, we report your hours electronically to CPE Monitor as early as within 10 business days after course completion and no later than 60 days after the event. CPE Monitor is a national online continuing pharmacy education (CPE) tracking service that will authenticate and store data for completed CPE units and allow you to easily track your ACPE-accredited CPE units electronically. It is a collaborative effort between the National Association of Boards of Pharmacy® (NABP®), the Accredited Council for Pharmacy Education (ACPE), and accredited continuing pharmacy education (CPE) providers. Keep your certificate in a safe place for your records. Please provide your license #, date of birth, and NABP ID. This is necessary to report your completion. Missing information can delay reporting and result in additional fees after 60-days of completion. What information do I need to provide for course completion and certificate issuance? Please provide your license number on the test sheet to receive course credit. Your state may require additional information such as date of birth and/or last 4 of Social Security number; please provide these, if applicable. Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Pharmacy you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, e-mail us at office@elitelearning.com, or call us toll free at 1-888-666-9053,, Monday - Friday 9:00 am - 6:00 pm, EST. Important information for licensees: Always check your state’s board website to determine the number of hours required for renewal, and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file.

Browse our entire library to select your own courses, go to EliteLearning.com/Pharmacy. You may also read and complete the courses in this book online.



Book code: RPTX3024

Chapter 1: Overview of Texas Pharmacy Law, 2nd Edition (Mandatory) 1 Contact Hour

By: Patricia Weiser, PharmD Author Disclosure: Patricia Weiser, PharmD, and Colibri Health- care, LLC do not have any actual or potential conflicts of interest in relation to this lesson. Universal Activity Number UAN: 0607-0000-23-017-H03-P Target Audience: Pharmacists in a community-based setting. To Obtain Credit: A minimum test score of 75 percent is needed to obtain a credit. Please submit your answers either by mail, fax, or online at EliteLearning.com/Book Questions regarding statements of credit and other customer ser- vice issues should be directed to 1-888-666-9053. This lesson is $9.95. Activity Type: Knowledge-based Initial Release Date: 7/28/2023 Expiration Date: 7/26/2026 Learning objectives After completing this course, the learner should be able to: Š Describe the eligibility qualifications and make-up of the Texas State Board of Pharmacy. Š Explain the powers and duties of the Texas State Board of Pharmacy. Introduction The Texas State Board of Pharmacy is the regulatory and disci- plinary body responsible for management of the pharmacy pro- fession in the state of Texas. This organization is responsible for providing rules, regulations, and guidance regarding all areas of pharmacy practice. It is the responsibility of pharmacists, pharma- cy interns, and pharmacy technicians to maintain competency in understanding and applying these rules to their daily pharmacy practice. This continuing education course provides important background information on the Texas State Board of Pharmacy, its role in revis- ing and adopting changes to the law, and important Texas state pharmacy law updates from early 2021 through the first half of 2023. When the Board adopts changes or updates to Texas phar- macy law, these changes are enacted in the following locations:

Colibri Healthcare, LLC is accredited by the Accredita- tion Council for Pharmacy Education (ACPE) as a pro- vider of continuing pharmacy education. Participants of the session who complete the evaluation and provide accurate NABP e-Profile information will have their credit for 1 contact hour (0.1 CEU) submitted to CPE Monitor as early as within 10 business days after course completion and no later than 60 days after the event. Please know that if accurate e-Profile information is not provided within 60 days of the event, credit cannot be claimed after that time. The participant is ac- countable for verifying the accurate posting of CE credit to their CPE Monitor account within 60 days.

Š List the steps required to propose updates to Texas state pharmacy law and where to find information from the Board regarding confirmed and proposed updates. Š Discuss important updates to Texas state pharmacy law adopted between February 2021 and May 2023. ● Texas Administrative Code, Chapters 281–315: https://www. sos.state.tx.us/tac/index.shtml ● Texas Occupational Code, Chapters 551–569 (Texas Pharmacy Act): https://www.sos.state.tx.us/tac/index.shtml The Board publishes adopted revisions to the Texas state phar- macy law, as well as any proposed rule changes that are up for Board approval, in quarterly issues of the Texas Register , a weekly publication that presents news from various regulatory agencies across the state of Texas. The content of this course is current as of April 30, 2023. Because the Texas State Board of Pharmacy implements changes to state law on a quarterly basis each year, it is important to check each February, May, August, and November to learn about any up- dates.


Texas State Board of Pharmacy The Texas State Board of Pharmacy has 11 members and is re- sponsible for the management and regulation of the pharmacy profession within the state of Texas. The Board provides legisla- tive policy and guidance regarding practice, licensing, and inter- Who serves on the Texas State Board of Pharmacy? The Texas State Board of Pharmacy consists of 11 members. The governor appoints members, to be approved by the Senate, with the following guidelines: ● Seven of the members must be licensed pharmacists. ● One member must be a pharmacy technician. ● Three members represent community and public interest and are not pharmacists. Eligibility for Texas State Board of Pharmacy appointment Texas Occupational Code Sec. 552.002 breaks down the qualifi - cations and eligibility requirements for serving on the Texas State Board of Pharmacy. Sec. 552.002 explains the following require- ments:

professional collaboration. The Texas Occupational Code Chap- ter 552 describes the Texas State Board of Pharmacy, including membership, responsibilities, and powers.

Members of the Texas State Board of Pharmacy serve six-year terms staggered with three or four terms expiring every other year. Board members may not serve more than two consecutive full terms. In the case of a vacancy, the governor appoints a re- placement that will complete the term.

A pharmacist Board member must, at the time of appointment: ● Be a resident of the state of Texas. ● Have at least five years of pharmacy licensure. ● Be in good standing regarding pharmacy practice within the state of Texas.

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Book Code: RPTX3024


● Be actively practicing pharmacy in Texas. A pharmacy technician Board member must, at the time of ap- pointment: ● Be a resident of the state of Texas. Powers and duties of Texas State Board of Pharmacy Texas Occupational Code (TOC) Chapter 554 outlines the various powers held by the Texas State Board of Pharmacy. In general, this section discusses the legislative and regulatory power of the Board. TOC Sec. 554.001 permits the Board to: ● Administer and enforce the rules contained within the TOC and the Texas Administrative Code. ● Appoint committees from the Board’s membership, as well as an advisory committee from non-Board members of the phar- macy profession. Process for proposing updates to Texas Pharmacy Law Texas Administrative Code Chapter 281 describes Texas State Board of Pharmacy action requirements and procedures. TAC §281.5, specifically, focuses on the process for initiating proceed - ings before the Board. According to TAC §281.5: ● Any interested person may petition the Board requesting the adoption of a rule. ● Petitions must be sent to the executive director or secretary of the Board. ● Within 60 days of petition submission, the Board must either deny the suggested petition in writing with explanation regarding the denial or shall initiate rulemaking procedure. Where to find proposed and adopted changes Emergency, proposed, and adopted rule changes are published by the Board in the Texas Register , a weekly publication that con- tains bulletins regarding the state’s various rulemaking agencies, including the Texas State Board of Pharmacy. The Texas Register is managed by the Office of the Secretary of State and can be found here: http://www.sos.state.tx.us/texreg/index.shtml

● Have five years of registered pharmacy technician experience preceding the appointment date. ● Be in good practice standing as a pharmacy technician in the state of Texas. ● Be currently practicing as a pharmacy technician in Texas. ● Inspect facilities licensed as pharmacies to determine compli- ance with code. ● Suspend, revoke, retire, or otherwise restrict a pharmacist or pharmacy license when considered necessary. ● Adopt rules involved in promoting the health and safety of citizens of the state of Texas. UPDATES TO TEXAS STATE PHARMACY LEGISLATION Petitions are considered adequate if they contain all of the fol- lowing: ● The exact wording of the new, changed, or amended pro- posed rule. ● Specific reference to the existing rule that is proposed to be changed or amended in the case of a changed or amended rule. ● A justification for the proposed action, in narrative form, with specific detail and background to inform the Board, as well as other interested parties, of the reasons and arguments on which the petitioner is relying. This publication also includes any withdrawn or repealed rules, rule reviews, and other regulatory information deemed import- ant by the Texas State Board of Pharmacy. The Board welcomes all comments regarding proposed rule changes, and there is a deadline of five business days prior to any Board meeting for any submitted comments to reach the Board.


Pharmacist licensure eligibility In order to be eligible for pharmacy licensure in the state of Tex- as, the Texas State Board of Pharmacy outlines various minimum qualifications in Chapter 558 of the Texas Occupations Code. These eligibility requirements include being a minimum of 18 years of age, successful graduation from an accredited pharmacy practice program, and passing of the licensing exams selected by the Board. While most of this information reflects no change from previous Board policy, a few important updates have been adopted re- garding initial licensure eligibility. In August 2021, the Board adopted amendments to Texas Admin- istrative Code (TAC) §283.4, which pertains to internship require- ments. At this time, the number of internship hours required for license eligibility was altered to reflect Accreditation Council for Verifying and dispensing requirements The bulk of the pharmacy-specific aspects of the Texas Adminis - trative Code focus on elements of pharmacy practice, such as the responsibilities and obligations for providing safe and effective care to patients. While the role of the pharmacist varies depend- ing on the position they hold, the TAC contains information re- garding appropriate and approved practice for every pharmacist. An important role of a pharmacist is verifying the validity of a pre- scription. TAC §291.29 outlines various requirements for prescrip- tion validity, including determining script authenticity, medically legitimate reasoning for prescribing, and identifying potentially inappropriate prescribing patterns in the community. As pharma- cy practice scope and technology advance, however, pharmacists must adapt to continue performing this role successfully.

Pharmacy Education (ACPE) standards for intern hours. As of May 2023, ACPE requires 1,440 hours of APPE hours for successful ac- creditation; however, if the ACPE changes the requirements, then the hours requirement in Texas will also change. The Board updated their extended-internship policy, also found in TAC §283.4, in February 2022. An extended-internship position fills the time following professional program graduation but prior to taking the Board-mandated licensing exams. This position may be used to complete unfulfilled internship hours, among other situations. However, the Board updated this policy to prohibit an extended-internship position to be utilized by a pharmacy resi- dent who has not successfully passed their licensing exams in the time allotted by their residency program. In February 2022, the Board provided guidance on how to vali- date prescriptions originating from a teledentistry or telemedicine visit. An update to TAC §291.29 noted that teledentistry and tele- medicine prescriptions must follow all in-person-visit-originating prescription requirements. Therefore, these prescriptions must be issued for a medically appropriate reason and meet all other ap- plicable laws, such as the Controlled Substances Act, if necessary. Another aspect of pharmacy practice involves emergency refills of medication. If a prescriber is unable to be reached, a pharmacist may use professional judgement in determining the necessity of an emergency refill of medication.


Book Code: RPTX3024

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■ Before the expiration or within recommend use date of the drug. ■ After a licensed pharmacist has thoroughly inspected the medication and ensured acceptable integrity. Board updates to TAC §291.33 and §291.8 adopted this set of requirements for accepting returned medication, albeit in differ- ent situations than a charitable medical clinic. According to TAC §291.8, the requirements described in the Texas Food, Drug, and Cosmetic Act also apply to pharmacies accepting returned drugs from healthcare facilities and penal institutions. Assuming the aforementioned eligibility is met, such as remaining in an un- opened, tamper-evident manufacturer container, a medication returned from a healthcare institution or penal institution may be redispensed by the pharmacist following a thorough inspection and confirmation of medication integrity. Self-Assessment Quiz Question #1 For noninsulin emergency refills, what quantity of medication are pharmacists able to dispense?

According to TAC §291.34, an emergency refill may be issued when: ● Failure to refill the prescription could result in patient suffer - ing. ● Failure to refill the prescription may lead to a disturbance in a therapeutic regimen. ● The pharmacist does not dispense an amount of medication exceeding a 72-hour supply. ● The pharmacist informs the patient that the refill is provided without authorization, and practitioner authorization will be mandated for future refills. ● The pharmacist informs the prescriber of an emergency fill as soon as possible. ● The pharmacist maintains a record of the emergency refill, including all information regularly required for a prescription record. While these guidelines establish clear parameters for the emer- gency refill procedure, questions remained about specific scenar - ios related to deciding to dispense an emergency refill. Consider - ing the importance of insulin therapy to patient health, the Board updated TAC §291.34 to reflect specific instructions for managing insulin emergency refills. Similar to other emergency refills, the pharmacist must attempt to contact the prescriber and assess the patient’s remaining insulin to determine the necessity of an emer- gency refill. However, unlike other emergency fills, insulin may be filled with up to a 30-day supply rather than a 72- hour supply. This also applies to supplies needed for administration of insulin. November 2022 Board proceedings resulted in various updates to Texas Administrative Code §291.33 and §291.8 regarding the redispensing of medications returned to a pharmacy. Chapters 431 and 442 of the Texas Health and Safety Code outline require- ments for a returned medication to be redispensed to a charitable medical clinic. Chapter 431, which is the Texas Food, Drug, and Cosmetic Act, explains that for re-dispensing eligibility, a returned drug must: ● Be a drug that requires a prescription; however, no controlled substances are eligible for return and redispensing. ● Be a drug approved by the federal Food and Drug Adminis- tration. ● Be sealed in the manufacturer’s unopened original tamper-ev- ident packaging and meet the following (as appropriate de- ○ Be oral or parenteral medication in sealed single-dose containers designed with approval of the federal Food and Drug Administration. ○ Be a topical or inhalant medication in sealed units-of-use containers approved by the federal Food and Drug Ad- ministration. ○ Be a parenteral drug in a multidose container with no doses yet withdrawn. ○ Not be subjected to any recall initiated by state or federal agency, drug seller, or manufacturer. ○ Only be dispensed: Controlled substance management and dispensing The final update to controlled substance law in Texas went into effect in February 2023. TAC §315.6 reflects that, in conjunction with the Texas Prescription Monitoring Program, by the next busi- ness day following the dispensing, pharmacists are required to report each controlled substance dispensed. In an update to TAC §315.6, the Board included directions for what to report, which can be found in another Board publication, the Data Submission Guide for Dispensers. This guide explains the various steps for establishing regular reports through the Texas Prescription Moni- toring system. Following this guide ensures that pharmacies are in compliance with all Board requirements for controlled substance reporting. pending on the medication): ○ Be individually packaged. ○ Be packaged in unit-dose packaging.

a. 15-day supply. b. 30-day supply. c. 3-day supply. d. 1-day supply.

Pharmacy practice involving controlled substances represents the most heavily legislated and regulated aspect of patient care. This is designed to improve patient safety, as well as protect health- care practitioners from mismanaging these potentially dangerous medications. However, despite the vast set of rules regarding con- trolled substances, additions and alterations are routinely made to pharmacy practice legislation. At the federal level, prescriptions written for medications belong- ing to the Schedule II controlled substance class were considered valid for 30 days from the date the prescription was written. Some common medications in this class include oxycodone, hydro- morphone, and methylphenidate. In Texas, however, the period during which prescriptions for Schedule II controlled substances were valid was much shorter. In May 2021, the Texas State Board of Pharmacy adopted changes to TAC §315.3 and §315.5 to make Texas pharmacy requirements consistent with federal law. There- fore, prescriptions for Schedule II controlled substances are valid for up to 30 days from the written date. This update is also reflected in the dispensing of multiple con - trolled substance prescriptions. If a prescriber writes multiple pre- scriptions for a Schedule II substance to give the patient a 90-day supply, the prescriptions are valid only within 30 days of the date written on the prescription. More recently, the Texas State Board of Pharmacy updated the 30- day window for Schedule II prescription validity again. Previously, this legislation applied only to in-state prescribers; prescriptions for Schedule II medications written outside of Texas remained valid for the shorter period of time. Starting in February 2022, however, out-of-state practitioners were ncluded in the update, allowing for 30-day prescription validity for Schedule II controlled substances. Pharmacy Practice Consideration: It is important to verify the legitimacy of controlled substance prescriptions before dis- pensing them. The Texas State Board of Pharmacy provides a list of “Red Flags” that may assist in determining if a pharmacy has become a target for invalid prescriptions. For instance, if numerous people come to the pharmacy with the same con- trolled substance prescriptions written by the same provider, the lack of individualized drug therapy may indicate that these prescriptions are fraudulent. For a full list of Red Flags, visit https://www.pharmacy.texas.gov/files_pdf/You_might_be_a_ pill_mill_if.pdf

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Book Code: RPTX3024


Self-Assessment Quiz Question #2 When an out-of-state prescriber writes a prescription for a Schedule II controlled substance, how many days after it is writ- ten is the prescription valid for?

a. 30 days. b. 60 days. c. 14 days. d. 7 days. Drug disposal

● The waste disposal service abides by all rules of the Texas Commission on Environmental Quality and the U.S. Environ- mental Protection Agency. ● The pharmacist seals the container of disposal-ready medica- tions in the presence of an approved witness (administrator, director, etc.) and seals the container with tamper- resistant tape. ● Records of the container’s transfer to the waste disposal ser- vice, as well as subsequent proof of destruction, must be maintained for two years and include: ○ Date of transfer. ○ Name and address of the waste disposal service. ○ Signature of the individual transferring the container to the service. a timeline for continued education in nonsterile compounding methods and safety. The Board also updated requirements for the nonsterile com- pounding environment within the pharmacy. To this end, TAC §291.131. Pharmacies participating in compounding must have a specific, designated area for non- sterile compounding. This area must be adequately-sized and possess the correct equipment for safe and orderly compounding. Only personnel authorized by a phar- macist-in-charge or responsible pharmacist should be in the area during non-sterile compounding. Non-sterile compounding environments must include a clean, well-maintained sink with hot and cold running water, and must be exclusive from facilities in a rest room. Supplies necessary for adequate washing must be in the immediate area of the sink and include: ● Soap or detergent. ● Air-driers or single-use towels. If any drug product requires special attention to prevent con- tamination, such as penicillin, appropriate measures must be taken to avoid cross-contamination. This could include establish- ing drug-specific equipment for certain substances or diligently cleaning equipment following use of a potential contaminant drug. Cleaning and sanitizing of surfaces within the non-sterile compounding environment must occur on a regular basis, and should be specified in each pharmacy’s standard operating prac - tices. Further changes regarding automated pharmacy dispensing sys- tems were adopted in August 2021, as well. TAC §291.76 pro- vides guidelines for the management of institutional pharmacies (Class C) located in a freestanding ambulatory surgical center. TAC §291.151 refers to pharmacies located in a freestanding emergency medical care facility (Class F). Each of these subchap- ters were revised to include licensed nurses in the management and use of automated pharmacy dispensing systems. Following these updates, licensed nurses with pharmacist authorization may load medications into automated dispensing systems. In conjunction with automated pharmacy dispensing system changes, the Board provided direction regarding pharmacist ver- ification of automatically dispensed medication.

TAC §303.1 outlines the requirements that must be followed when disposing of dangerous drugs or controlled substances. In hospi- tals and other healthcare facilities, there are strict steps involving an inventory, a witness, and which medications may be destroyed. In a February 2023 update to TAC §303.1, the Texas State Board of Pharmacy adopted a new policy for healthcare facilities utiliz- ing an independent, third-party medical waste disposal service. This update removes inventory-keeping requirements and allows for disposal of both dangerous and controlled substances in the same container as permitted by the Drug Enforcement Agency as long as: Nonsterile compounding TAC §291.131 provides guidance for pharmacies participating in compounding nonsterile products. This rule includes important definitions, operational standards, and approved compounding situations. In August 2022, the Texas State Board of Pharmacy adopted a number of revisions focusing on training and the compounding environment. Regarding training, TAC §291.131 outlines: ● All training must be documented and covered by standard operating practices. ● All personnel involved in nonsterile compounding should be well trained and must undergo continued training, as is rele- vant. ● Training must include demonstration and education of the fol- lowing: ○ Hand hygiene. ○ Garbing. ○ Cleaning and sanitizing. ○ Handling and transporting components of and com- pounded nonsterile preparations. ○ Measuring and mixing. ○ Properly using equipment used in nonsterile compound- ing. ○ Completely documenting the compounding process. Each nonsterile compounding pharmacy location must have a pharmacist in charge, who is responsible for confirming the com - pleteness and adequacy of the training on an individual basis. This pharmacist should also determine appropriate content and Remote pharmacy practice Driven by technological advances and the coronavirus pandem- ic, the remote, or off-site, role of the pharmacist has greatly in- creased within the past five years. As a result, the Texas State Board of Pharmacy has adopted a number of revisions related to the remote practice of pharmacy. TAC §291.121 regulates various remote pharmacy services. Re- mote pharmacy services are defined as any aspect of pharmacy practice provided by a community pharmacy (Class A) or institu- tional pharmacy (Class C) that occurs in a facility separate from the actual pharmacy. In an August 2021 update, the Board approved pharmacy services that are provided via an automated pharmacy dispensing system, which is a mechanical system that dispenses drugs remotely and records all dispensing transactions.


Book Code: RPTX3024

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When a controlled substance is dispensed from an automated dis- pensing system, the pharmacist will verify this withdrawal as soon as reasonably possible, but no more than 72 hours following dis- pensing. When a dangerous drug is dispensed from an automat- ed dispensing system, the pharmacist will verify this withdrawal as soon as reasonably possible, but no more than one calendar week following dispensing. Pharmacists must verify all withdrawals at the soonest reasonable time, but no less than once every calendar week that the pharmacy is open. In some Class C pharmacies located in a freestanding ambulato- ry surgical center, a stock of controlled substances is maintained to provide quick and easily accessible medication when needed for emergent situations. TAC §291.76 overviews the requirements associated with maintaining this stock of controlled substances. While freestanding ambulatory surgical centers have always been required to maintain a log of controlled substance use, as of Feb- ruary 2023, pharmacists are now responsible for ensuring this per- petual inventory of controlled substances is both complete and accurately reconciled. Another remote service provided by pharmacies is emergency medication kits. These kits include specific medications required for life-saving measures and may reside in facilities without an es- tablished pharmacy. TAC §291.121 lists requirements for main- taining an emergency medication kit, including how to apply to provide an emergency kit, the process for stocking, and reporting use of the kit. Beginning in May 2022, the Texas State Board of Pharmacy removed restrictions on duplicating drugs within emer- gency medication kits, which allows pharmacies to place dupli- cate medications in the kit in the case of multiple crises or wasted doses of crucial medication. Conclusion Remaining competent and up to date with all Texas state phar- macy laws is an important part of providing safe and effective pharmacy care. The rules and regulations, while often revised and fine-tuned, are designed to encourage patient safety outcomes and protect the interests of pharmacists, pharmacy interns, and

Self-Assessment Quiz Question #3 When a controlled substance is dispensed from an automated pharmacy dispensing system, how long does a pharmacist have to verify the order? a. 7 days. b. 72 hours. c. 5 days. d. 24 hours. Self-Assessment Quiz Question #4 The Texas State Board of Pharmacy recently removed limitations on placing duplicates of medications in emergency medication kits located at remote sites. What was the reasoning behind this change? a. Save the pharmacist time by limiting the number of times medications need to be replaced. b. Allow for an adequate supply of medication in case of multiple crises or wasted drugs. c. Extend beyond-use dating of the kit by allowing remote staff to remove expired drugs and replace with duplicates. d. Expand the practice capabilities of the remote site and remove the need for pharmacist verification of drugs in nonemergent situations.

pharmacy technicians within the healthcare field. As such, fre - quently referring to both the Texas Administrative Code and Tex - as Pharmacy Act will further cement concepts of lawful pharmacy practice.

References •

Accreditation Council for Pharmacy Education (ACPE). (2016). Accreditation standards and key elements for the professional program in pharmacy leading to the Doctor of Pharmacy degree . https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf • State of Texas. (2019). Constitution and Statutes . 3 Tex. Occup. Code . §551-569. Texas State Government. https://statutes.capitol.texas.gov/?link=OC • State of Texas. (2019). Constitution and Statutes . 6 Tex. Health. Code. §431, 442. https:// statutes.capitol.texas.gov/Docs/HS/htm/HS.431.htm •

State of Texas. (2023). Constitution and Statutes. 22 Tex. Admin . Code. §281-315. https:// texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=3&ti=22&pt=15 • Texas Prescription Monitoring Program. (2020). Data submission guide for dispensers. Appriss Health . https://www.pharmacy.texas.gov/files_pdf/TX_PMP_AWARxE_ DispenserGuide.pdf • Texas State Board of Pharmacy. (February 2018). “ Red flags” checklist for pharmacists . https://www.pharmacy.texas.gov/files_pdf/You_might_be_a_pill_mill_if.pdf

OVERVIEW OF TEXAS PHARMACY LAW, 2ND EDITION Self-Assessment Answers and Rationales

1. The correct answer is C. Rationale: Pharmacists are allowed to dispense a 72-hour sup- ply in emergency refill situations for noninsulin medications. Tex - as Administrative Code §291.34 outlines that to protect patients from unnecessary refills, pharmacist emergency fills are capped at 3-day supplies. 2. The correct answer is A. Rationale: When the Texas State Board of Pharmacy updated Schedule II controlled substance prescription validity windows, they initially left out-of-state prescribers out of the 30-day window extension. However, in a February 2022 update to TAC §291.34, out-of-state prescribers were included in this provision to match federal Drug Enforcement Agency standards.

3. The correct answer is B. Rationale: In both institutional (Class C) pharmacies and free- standing emergency center (Class F) satellite pharmacies, phar - macists must verify controlled substance dispense orders from automated dispensing cabinets within 72 hours of the controlled substance being pulled. This information is found in TAC §291.76 and §291.151. 4. The correct answer is B. Rationale: Emergency medication kits are intended to provide healthcare professionals who are proficiently trained in life-saving measures with resources to perform emergency medicine without pharmacist oversight. In this case, earlier limitations prevented staff from effectively handling all potential emergency situations, and removing this limitation allows for best patient care outcomes.

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Book Code: RPTX3024


OVERVIEW OF TEXAS PHARMACY LAW, 2ND EDITION Final Examination Questions Select the best answer for each question and then proceed to EliteLearning.com/Book to complete your final examination. 1. How long is a Texas State Board of Pharmacy membership term?

7. When disposing of dangerous medications or controlled substances with a waste disposal service in a Class C phar- macy setting, which of the following is no longer required following Board revisions? a. Proof of destruction of drugs sent to waste disposal com- pany. b. Record of when disposed drugs were sealed in the dis- posal container. c. Proof of witness to drug disposal in waste service con- tainers. d. Inventory of each medication disposed of, including dates, disposer, and witnesses. 8. Which of the following are requirements listed under Texas Administrative Code regarding mandatory training for non- sterile compounding? a. Proper hand hygiene. b. Measuring and mixing procedures. c. Completing documentation of the nonsterile compound- ing process. d. Methods of cleaning and sanitizing compounding space. 9. Which healthcare staff member was granted expanded use of an automated pharmacy dispensing system in an August 2021 update to TAC §291.121? a. Physician assistants. b. Licensed nurses, with pharmacist authorization. c. Licensed nurses. d. Hospital or healthcare facility administration. 10. Which of the following is not an acceptable reason for place- ment in an extended internship position? a. An individual has received a pharmacy practice degree but has not taken necessary licensing exams. b. An individual has not successfully completed the re- quired internship hours required by the state of Texas but has completed a pharmacy practice degree program. c. An individual has completed a pharmacy practice degree but failed at least one required licensing exam. d. None of the above.

a. 9 years. b. 6 years. c. 12 years. d. 3 years. 2. How many hours of pharmacy internship experience does the state of Texas require? a. 1,880. b. 500.

c. 1,200. d. 1,440.

3. If a pharmacist determines a patient requires an emergency refill of an insulin product, what is the maximum days’ supply the pharmacist may dispense?

a. 14-day supply. b. 3-day supply. c. 7-day supply. d. 30-day supply.

4. Which of the following is not a requirement for a returned medication to be acceptable for redispensing under Texas Administrative Code? a. The returned medication is in the original manufacturer packaging with an intact tamper-evident seal. b. The returned medication is not a controlled substance. c. The returned medication is expired or past the be- yond-use date. d. The returned medication is thoroughly inspected by a pharmacist to ensure integrity. 5. How many days is a Schedule II controlled substance pre- scription valid for past the original written date? a. 7 days. 6. The reference pharmacists must use in Texas to ensure ac- curate reporting of controlled substance dispensing is called the: a. Texas Pharmacy Act. b. Data Submission Guide for Dispensers. c. Texas Controlled Substances Act. d. Texas Administrative Code. b. 21 days. c. 90 days. d. 30 days.

Course Code: RPTX01TL


Book Code: RPTX3024

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Chapter 2: Mental Health Concerns and The Older Adult 6 Contact Hours

Colibri Healthcare, LLC is accredited by the Accredi- tation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. Partici- pants of the session who complete the evaluation and provide accurate NABP e-Profile information will have their credit for 6 contact hours (0.6 CEU) submit-

By: Mary Perry, MSN, RN, PMHNP-BC Author Disclosure : Mary Perry and Colibri Healthcare, LLC do not have any actual or potential conflicts of interest in relation to this lesson. Universal Activity Number (UAN) : 0607-0000-23-013-H99-P Activity Type : Knowledge-based Initial Release Date : October 12, 2022 Expiration Date : June 1, 2026 Target Audience: Pharmacists in a community-based setting. To Obtain Credit: A minimum test score of 75 percent is needed to obtain a credit. Please submit your answers either by mail, fax, or online at EliteLearning.com/Book Questions regarding statements of credit and other customer ser- vice issues should be directed to 1-888-666-9053. This lesson is $34.95. Learning objectives Upon completion of this course, the learner will be able to do the following: Š Examine the most common theories on aging, developmental tasks, and reflection from the older adult perspective. Š Evaluate essential components of the therapeutic alliance with the older adult. Š Demonstrate verbal communication styles that enhance the interpersonal connection with the older adult. Aging is a normal biological process. It is a distinctive, often pro- gressive, natural decline in functioning that includes all body sys- tems— cardiovascular, endocrine, immune, and neurological, to note a few. Elderly is a term often used interchangeably with older adult , which the American Association of Geriatric Psychiatry (Lun- debjerg et al., 2017) defines as those age 65 years and older, which qualifies them for Medicare eligibility. This patient popula - tion is projected to double from 2015 to 2050 worldwide (World Health Organization, 2017). As the world population rapidly in- creases, so too do mental health needs. Everyone will experience aging on some level, but differing populations will advance at dif- The inevitability of aging and its developmental stages in asso- ciation with human health have been studied and debated over the years. What follows is a summarization of the most common theories on older adulthood, from Sigmund Freud, Heinz Kohut, Bernice Neugarten, Daniel Levinson, and Erik Erikson. Healthcare workers see aspects of each of these while assessing and caring for the older adult’s mental health needs. Sigmund Freud was fo- cused on the need to control the ego (part of the human psyche that operates in the real world) and id (part of the human psyche that strives to fulfill primal needs) with the superego (internalized values and morals that push the ego to act in a more virtuous way). Regression may induce rudimentary methods of coping to resurface in the older adult (Sadock et al., 2015). Heinz Ko- hut stated that the elderly are constantly faced with narcissistic injury as they cope and adapt to the biological, psychological, and social losses associated with the aging process. The central task of aging is preservation of self-esteem (Sadock et al., 2015). Bernice Neugarten theorized the major conflict of old age to lie in the release of autonomy and authority; the focus is on accom- plishments and previous victory. This time is for reconciliation with others and processing grief related to the death of others and the inevitability of death of self (Sadock et al., 2015). Daniel Levinson found that age 60 to 65 is a transition period. Older people, “late

ted to CPE Monitor as early as within 10 business days after course completion and no later than 60 days after the event. Please know that if accurate e-Profile information is not provided within 60 days of the event, credit cannot be claimed after that time. The participant is accountable for verifying the accurate posting of CE credit to their CPE Monitor account within 60 days.

Š Differentiate the social determinants of health and the barriers to care for the older adult. Š Select recommended assessment considerations for the older adult. Š Appraise biopsychosocial considerations for the assessment for the older adult. Š Analyze crisis, loss, grief, and bereavement for the older adult. Š Distinguish risk factors, treatment, and recovery for the older adult with a mental health diagnosis. ferent rates. However, increasing age is not proportionally associ- ated with declining intellectual and physical capacity. Older adults with mental health needs are a population subset with specific characteristics for the healthcare worker. The ability to thoroughly assess and diagnose, individualize care (whether lifestyle related or pharmacologic), and tailor mental health interventions for the older adult can improve quality care and safety. The unique pre- sentation of the older adult can provide a better understanding for assessment, intervention, and treatment considerations for the healthcare worker addressing the mental health needs of the older adult. adults,” become consumed by the thought of their death and are often narcissistic and heavily engrossed in their body appear- ance. He found that creative mental activity is recommended and is a healthy substitute for decreased physical activity (Sadock et al., 2015). All the above theorists have aspects of interest for the healthcare worker to note; however, Erik Erickson’s eight psycho- social stages of development are especially worthwhile to con- sume prior to working with an older adult. Erik Erikson created a framework that highlights tasks to be ac- complished, virtues to be gained, or—conversely—a crisis can occur throughout the life span. He expanded on Freud’s theory by recognizing the relationship between the individual and their environment to include a client’s customs and traditions (Sadock et al., 2015). The healthcare worker should approach each cli- ent’s meaning, acceptance, or toil with life and death with cultural awareness. Erikson’s stages from birth to older adult are a trajec- tory of development, an amalgamation of physical, cognitive, in- stinctual, and sexual realms (Sadock et al., 2015). An interruption or inability to accomplish the tasks in each stage may lead the client to undergo a decision point in their life. The older adult is influenced by each stage along the continuum. The healthcare worker can gain much by capturing the perspective of the older



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Book Code: RPTX3024


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