Missouri Board of Pharmacy Meeting: My Experience

I had the opportunity to attend a Missouri Board of Pharmacy meeting last week and I had no clue what to expect. It was eye-opening on how many people are involved in the well-being of pharmacy. Various topics were discussed at the meeting and for more information you can visit the Board’s website to see the complete agenda.1 The most interesting part of the meeting to me was when the board discussed the strategic planning for 2014. During this time period the public was able to voice their opinions and concerns.

MPA's July rotation student, Ashely Buehler, UMKC School of Pharmacy, Columbia campus.

MPA’s July rotation student, Ashely Buehler, UMKC School of Pharmacy, Columbia campus.

There were 10 things on the agenda for strategic planning and I will go into more detail about some of them below.1

1.)   Hospital Working Group:

The Board presented with this question “Does the Board want to continue active meetings of the Hospital Working Group?”1

2.)   Automatic Refills:

The Board presented with this question “Should the Board require additional safeguards prior to shipping automatic refills (i.e. – patient consent, patient notification)?”1 This topic was brought up due to the concern of sending refills to patients when the medication is unwanted or has been discontinued.1 Typically, automatic refills are used and implemented to help with adherence for patients.1 Centers for Medicare & Medicaid Services (CMS) wants beneficiaries to give consent for each new and refill prescription as they have been receiving more complaints about beneficiaries receiving medications they did not want.1 Overall, this topic brought about two sides different sides to argue. First, it was mentioned at the meeting the concern of decreasing adherence if automatic refills have more safeguards. Then, the second concern is voiced by CMS that patients are taking medications that have been discontinued or unwanted, which can increase health care costs.1 There was also issues expressed during the meeting about dangerous outcomes from patients taking medications that were discontinued.

3.)   Compounding for Office Use:

The Board requested that a discussion be held.1

4.)   Prescription Labeling:

The Board presented with this question “Should the Board amend Missouri law to clarify which pharmacy should be designated on the prescription label?”1 This is a concern when a prescription is filled in a different location than where the prescription is being picked up, for example a central fill pharmacy. The current statute about labeling (338.059) is phrased “the name and address of the pharmacy,” which does not specify which pharmacy.1 The Board discussed which pharmacy they believe should be liable and responsible, which would then be the pharmacy that should be on the label. A professional present in the meeting stated that Ohio had good phrasing on which pharmacy should be on the label if there was a central fill pharmacy used. The Ohio administrative code is 4729-5-16 that discusses the prescription label state rules.2

5.)   Charitable Services:

The Board presented with this question “Should the Board amend Missouri law to allow pharmacists to dispense prescriptions on the premises of a public health office or other charitable organization?”1

6.)   Automated Prescription Self-Service Devices:

The Board presented with this question “Would the Board like [to] address automated prescription self-service devices?”1 Since technology is advancing quickly today there have been discussions about having automated devices that receive prescriptions. Currently, the statute 338.095 is phrased as “it shall be an unauthorized practice of pharmacy and hence unlawful for any person other than the patient or the patient’s authorized representative to accept a prescription presented to be dispensed unless that person is located on a premises licensed by the board as a pharmacy.”1 Many ideas were discussed on how to move forward with this technology. California has implemented these automated prescription self-service devices with specific requirements for each device.3 Some of these requirements include, it can only be used for refill prescriptions, the device can identify the patient and only release the prescription to that specific patient, and has a telephone to talk with a pharmacy if necessary.3

7.)   Patient Safety Working Group:

The Board wanted to review the patient safety working group recommendations.1 “In 2013, the Missouri Board of Pharmacy initiated a statewide patient safety campaign entitled ‘MoSafeRx.’”1 In order to make this program work the Board created the patient safety working group and they defined what patient safety actually meant.1 Patient safety is defined as “the prevention and reduction of unnecessary harm caused by or associated with healthcare/pharmaceutical care.”1 The recommendation topics the working group determined were enhancing communication among healthcare professionals, enhancing communication among regulatory agencies, pharmacy technician training, quality assurance, scope of practice, and education and outreach.1

8.)   Revenue Sharing Agreements:

The Board presented with this question “Should the Board amend Missouri law to address prescription revenue sharing agreements between pharmacists and prescribers?”1

9.)   Drug Quality and Security Act:

The Board is concerned with implementation and has multiple questions to go along with this topic.1 These questions included 1

  • “How does the Board want to license outsourcers?”
  • “How does the Board want to license 3PLs?”
  • “Should we establish different inspection standards for outsourcers?”
  • “Can an outsourcer/pharmacy share the same space?”
  • “Discipline for compliance with federal requirements?”

10.) Sharing Pharmacy Space:

The Board presented with this question “Should the Board address sharing of pharmacy space with other healthcare providers [and] can a pharmacy store drugs for other healthcare providers?”1 This topic was brought up with the main concern of healthcare professionals storing medications in a pharmacy. An example mentioned at the meeting is when nurses store vaccines in a refrigerator in the pharmacy. The concern is should this be allowed and who accepts the responsibility of those particular drugs. The Board plans to look further into how to handle these situations.

Overall, I am glad I got the chance to attend a Missouri Board of Pharmacy meeting. It was a great experience and I was able to better understand the process of how rules and regulations get decided. I suggest that if you have the chance to attend a meeting to give it a whirl. The next Missouri Board of Pharmacy meeting will be held on October 16, 2014.4

Ashley Buehler
UMKC School of Pharmacy at MU
PharmD Candidate 2015
MPA Rotation Student, July 2014


1Revised meeting notice Missouri board of pharmacy. (2014, July 14). Retrieved from http://pr.mo.gov/boards/pharmacy/meetings/2014-07-15.pdf

24729-5-16 Labeling of drugs dispensed on prescription. (n.d.). Retrieved from http://codes.ohio.gov/oac/4729-5-16

3Board of pharmacy initial statement of reasons. (n.d.). Retrieved from http://www.pharmacy.ca.gov/laws_regs/1713_reasons.pdf

4Meeting information. (n.d.). Retrieved from http://pr.mo.gov/pharmacists-meetings.asp

A New Age for Tramadol

Big news has once again hit the world of pharmacy recently: Tramadol is now scheduled as a schedule IV controlled substance in all states according to the Drug Enforcement Agency (DEA).1 On July 2, 2014 the DEA announced this update in the Federal Register.2 Tramadol and any product containing the substance will require a “C-IV” notification on all its labels as of August 18, 2014.1 Schedule IV is “defined as drugs with a low potential for abuse and low risk of dependence” according to the DEA.3

In 1995, tramadol was approved as an opioid analgesic with monoamine reuptake inhibition used for the treatment of moderate to severe pain in adults.2 A typical dose of tramadol is one to two tablets (comes as 50 or 100 mg tablets) every four to six hours as needed for pain, with a maximum dose of 400 mg/day.2 Withdrawal symptoms, tolerance, dependence, and addiction to tramadol have all been reported before.2 Since tramadol is an opioid, immediately we would be concern with abuse or misuse. Tramadol is most often abused in these specific populations of narcotic addicts, chronic pain patients, and health professionals.2 According to the DEA, a report by IMS Health National Prescription Audit Plus, tramadol was dispensed 43.8 million times in the United States in just the year 2013.2 American Association of Poison Control Centers reported 13,067 contacts with tramadol with 6,589 contacts being single substance exposures, and nine reported deaths in 2012.2 Another report completed in 2012 by the National Survey on Drug Use and Health stated “3.2 million people in the U.S. aged 12 or older used tramadol for nonmedical purposes in their lifetime.”2

While several states had previously scheduled tramadol as a controlled substance1, Missouri has no state law scheduling tramadol as a controlled substance. Therefore, Missouri pharmacists need to know and take action on several things in order to be compliant with the August 18, 2014 effective date. Some of these actions required include:

  • All pharmacies and providers stocking tramadol or products containing tramadol must take inventory on or before August 18, 2014 and these substances must remain a part of all controlled substances inventories. 1, 4
  • All prescriptions for tramadol and products containing tramadol must follow the federal and state controlled substance prescription rules and regulations starting on August 18, 2014.1
  • Tramadol and products containing tramadol shall be marked as Schedule IV Controlled Substance in the pharmacy’s computer.
  • All prescriptions for tramadol must be changed over to reflect the specific pharmacy’s controlled numbering format for filing and record purposes.4
  • No electronic prescriptions shall be accepted for products containing tramadol, unless the pharmacy follows specific requirements in 21 C.F.R. §1311 set by the DEA.4
  • All prescriptions written for tramadol and products containing tramadol may only be refilled five times within a six month time period.4
  • All prescriptions written for tramadol and products containing tramadol will only be valid for 6 months.4
  • All prescriptions written for tramadol and products containing tramadol can only be transferred between pharmacies once.4 If pharmacies share an electronically, online, real-time database, then they may transfer the prescription as many times as allowed by the number of refills or expiration date.5

Some of these changes will cause confusion for patients and pharmacists will need to make sure their patients understand these changes in order to prevent misunderstandings in the future. For example, a prescription written for tramadol used to be valid for 12 months, with no restriction on the number of refills, and it could be transferred between pharmacies as many times as necessary.5 If you have any questions regarding the rescheduling of tramadol and products containing tramadol, contact the Missouri Board of Pharmacy. Overall, the addition of tramadol to a schedule IV will help prevent abuse and misuse, which will further protect our patients.

Ashley Buehler

UMKC School of Pharmacy at MU

PharmD Candidate 2015

MPA Rotation Student, July 2014


1DEA classifies tramadol a controlled substance. (2014, July 9). Retrieved from http://www.nabp.net/news/dea-classifies-tramadol-a-controlled-substance

2Tramadol (trade names: ultram®, ultracet®). (2014, July). Retrieved from http://www.deadiversion.usdoj.gov/drug_chem_info/tramadol.pdf

3Drug scheduling. (n.d.). Retrieved from http://www.justice.gov/dea/druginfo/ds.shtml

4Pharmacist’s manual an informational outline of the controlled substances act. (2010). Retrieved from http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/pharm_manual.pdf

5Rules of department of insurance, financial institutions and professional registration. (n.d.). Retrieved from http://www.sos.mo.gov/adrules/csr/current/20csr/20c2220-2.pdf

A Second Chance for Inhaled Insulin

Every pharmacy student has been told during their education that this profession is a forever learning field. For example, every pharmacist must obtain continuing education hours in order to renew their license. I do not think I fully understood how often or how much the world of pharmacy changes and one important thing pharmacists must stay on top of are new drug approvals. I would hate to be working in a pharmacy and get a new prescription for a drug I have never heard of. Therefore, I sometimes browse the FDA’s website to look at newly approved drugs and last week I saw a new approval that captured my attention.

Ashley Buehler, Pharm.D. Candidate 2015, UMKC School of Pharmacy - Columbia

Ashley Buehler, Pharm.D. Candidate 2015, UMKC School of Pharmacy – Columbia

According to the American Diabetes Association, there were 29.1 million Americans (9.3% of the population) with diabetes in 2012.1 This number has risen from 2010, when there were 25.8 million Americans with diabetes.1 Although, Type 1 diabetes can only be controlled with insulin, there are many different types of medications that can be used to control Type 2 diabetes.7 Insulin and some other Type 2 approved medications require a patient to inject themselves with a needle and personally I would not want to inject myself every day. Therefore, there has always been talk about trying to deliver insulin to patients by a different route of administration. This had been done before in 2006, when Pfizer made a drug called Exubera, which was the first inhaled form of insulin.2 But then in 2007 Pfizer took Exubera off the market due to lack of sales of the product.2

The FDA’s approval of Afrezza, an inhaled form of insulin,3 on June 27, 2014, is what caught my attention. Afrezza is manufactured by MannKind Corporation and approved for adult diabetic patients.3 This inhaled form of insulin is only to be used as a short acting control of glucose levels,3 and was approved with a Risk Evaluation and Mitigation Strategy (REMS).3

Now let’s dive into more specifics about Afrezza; it is a synthetic insulin that is inhaled by the patient.4 It comes in two different strengths, four units and eight units, which are dosed at mealtimes.4 Each strength comes as a different colored cartridge, the four units are blue and the eight units are green.4 Each cartridge must always be used with the Afrezza inhaler and the inhaler should be replaced every 15 days.4 Listed below are the steps to proper usage of the Afrezza inhaler.

Steps to Using Afrezza According to the Medication Guide4:

1.)   Select the correct number of cartridges needed based on your individual dose required. Some patients may need to use more than one cartridge of different or the same strengths.

  1. There will be a foil package that contains blister cards of the cartridges, so remove the correct number cartridges from the blister card by pressing the clear side.
  2. Important: Inhaler and cartridges must be at room temperature for 10 minutes before use.

2.)   Load the cartridge by holding the inhaler in one hand (white mouthpiece on top and purple base on bottom) and open the inhaler by lifting the mouthpiece with the other hand.

  1. Place the cartridge with the cup facing down and the pointed end of the cartridge should align with the pointed end of the inhaler.
  2. Close the mouthpiece and a snap should be heard when the inhaler is fully closed.
  3. Important: Make sure the cartridge lies flat within the inhaler and once in this flat position do not turn, point, or shake the inhaler as the drug powder may be lost.

3.)   Inhaling the powder requires multiple steps.

  1. First, remove the mouthpiece cover while still keeping the inhaler level.
  2. Exhale while the inhaler is away from your mouth.
  3. Put the mouthpiece in your mouth and tilt the inhaler down toward your chin, then close your lips to form a seal.
  4. Inhale deeply and hold your breath while removing the inhaler, then continue to hold your breath for as long as comfortable.

4.)   Remove the used cartridge by placing the mouthpiece back on the inhaler, then open the white mouthpiece, remove the cartridge, and then throw away the cartridge in the trash.

  1. Important: If you need to use more than one cartridge for your dose repeat steps two through four.
  2. Important: You can tell the difference of a new and used cartridge by the placement of the white cup. If the white cup is in the middle it is used and if it is to one side it is new.

Afrezza should be stored based on whether it has been opened or not.4 If the sealed foil packages have not been opened they should be stored within a refrigerator and can be used up to the expiration date.4 If the sealed foil package or the clear strips from the blister card have been opened they can be stored at room temperature.4 Although, the blister cards can last for 10 days, if removed from the foil package, and the clear strips only last for three days if they have been opened.4 The inhaler can be kept in the refrigerator, but do not keep the cartridges left in the inhaler.4 The inhaler can be cleaned by wiping it with a clean, dry cloth, but do not get the inhaler wet or wash it.4

Afrezza does come with a boxed warning of acute bronchospasms in patients with COPD or asthma.3 Therefore, it should not be used in patients with chronic lung conditions, such as COPD or asthma.4 It cannot be used in children under the age of 18.4 Patients should be informed to not operate heavy machinery, drink alcohol, or smoke while using Afrezza.4 The most common side effects seen with this new medication is hypoglycemia, cough, and sore throat.4 A list of warnings and precautions include: acute bronchospasm, change in insulin regimen, hypoglycemia, decline in pulmonary function, lung cancer, diabetic ketoacidosis, hypersensitivity reactions, hypokalemia, and fluid retention and heart failure with concomitant use of thiazolidinediones .5 Finally, Afrezza is pregnancy category C and there have not been studies on whether it is safe in lactating women.6

From this information it looks like Afrezza may have complicated steps to use and difficult storage directions, but it does provide the benefit of no needle sticks. Adherence is something pharmacists should worry about in their patients and Afrezza may provide an advantage as it is considered a painless route of administration when compared to injections. The FDA is requiring post-marketing studies to research safety and efficacy in pediatrics, pulmonary malignancy risks, and pharmacokinetic and pharmacodynamic studies.3 Currently, Afrezza is not yet available in pharmacies,5 but only time will tell if patients accept Afrezza or if it has the same fate as Exubera.

But I will leave you with a quote from the CEO of MannKind Corporation, Alfred Mann, the “approval of AFREZZA is an important milestone for MannKind, as today’s FDA action validates the years of clinical research and commitment that powered the development of this unique therapy.”5

Ashley Buehler
UMKC School of Pharmacy at MU
PharmD Candidate 2015
MPA Rotation Student, July 2014



1Statistics about diabetes. (2014, June 10). Retrieved from http://www.diabetes.org/diabetes-basics/statistics/

2Hitti, M. (n.d.). Sales of inhaled insulin exubera halted. Retrieved from http://www.webmd.com/diabetes/news/20071018/pfizer-quits-inhaled-insulin-exubera

3FDA approves afrezza to treat diabetes. (2014, June 30). Retrieved from http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm403122.htm

4Medication guide afrezza ® (uh-FREZZ-uh) (insulin human) inhalation powder. (2014, June). Retrieved from http://www.mannkindcorp.com/Collateral/Documents/English-US/Afrezza_MedGuide-IFU.pdf

5Mannkind corporation announces FDA approval of afrezza(R); a novel, rapid-acting inhaled insulin for the treatment of diabetes. (2014, June 27). Retrieved from http://www.news.mannkindcorp.com/phoenix.zhtml?c=147953&p=irol-newsArticle&ID=1943390&highlight=

6Label. (2014, June). Retrieved from http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/022472lbl.pdf

7Medication. (n.d.). Retrieved from http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/

MPA – My Pharmacy Association

In just one short month here at the Missouri Pharmacy Association (MPA), I have learned and experienced so much.

Lara Kerwin, MPA Rotation Student June 2014

Lara Kerwin, MPA Rotation Student June 2014

When I first arrived in Jefferson City for this APPE rotation, I did not know what to expect. I had several questions: What would working within the state pharmacy association be like? How are pharmacists integrated into the Association? What sorts of other activities and programming are going on in the Association?

Since my first day, I have been amazed at all of the great projects and services that M.P.A. provides, not only for the pharmacists, pharmacy students, and pharmacy technicians of Missouri, but for patients, too. Pharmacist members of MPA are involved in their communities and local government to advance of the profession. While in Jefferson City, I have been able to attend meetings and events with MPA pharmacists to see first-hand the passion and hard work that continue to drive the evolution of the scope of pharmacy practice in Missouri. In just one month, I attended meetings about implementing the “provider tax” and participated in a C.E. about implementing viable, pharmacy-driven “falls prevention” programs. I learned about SmartPA and DirectCarePro (and other programs within the Xerox suite) and Medicaid clinical edits at the Drug Prior Authorization Committee meeting. I even met with health care professionals of five federally qualified health centers as they developed a team-based, all-encompassing approach to transform pain management for Missourians. I feel like I have seen so much, and yet this is only a glimpse into the many projects of the pharmacist members of the Missouri Pharmacy Association.

I had no idea that the Missouri Pharmacy Association was involved in so many different areas! In addition to shadowing and meeting with pharmacist members of MPA this month, I have had the opportunity to work closely with MPA’s tight-knit, dedicated staff. MPA is currently planning their annual convention, this year with the Illinois Pharmacy Association to be held in St. Louis, Missouri (It is not too late to sign up – register here!). At the convention, there will be pharmacist, technician, and student programming – including the opportunity to present posters and participate in a patient counseling competition. It will be a great place to meet fellow pharmacy advocates and like-minded, patient-centered pharmacists from our neighboring states. Another big role MPA plays is in the affairs of our state government. Located just minutes from the capitol building, MPA is heavily involved in lobbying for expanding the roles of pharmacists in our communities; for example, this year, a bill was passed to expand our vaccination protocol abilities to include Hepatitis A and B administration, as well as Tdap, to our patients aged 12 and up. In this one act of legislation alone, MPA and other stakeholders have supported the evolving role of a pharmacist and increased access to care for thousands of Missouri citizens.

I have taken a lot away from this experience to drive my future practice. Most importantly, I take with me the importance of being an active member of My (Missouri) Pharmacy Association. As a student, I have attended the annual Legislative Day and met MPA members at Missouri receptions at annual conferences, but I see now that that is not the full experience. As students of both STLCOP and UMKC, there are enormous benefits of being active student members of MPA. In addition to being able to submit clinical and opinion content for their blog and magazine, MPA can help facilitate our patient care projects, publicize our community outreach, and teach us exactly how we can advocate and make an impact in our profession – the possibilities are endless. MPA not only will support us as students, but our first year of membership as graduated pharmacists is free! The MORx.com website offers us patient education resources, pharmacy legislation updates, and even free C.E. (Don’t forget, 2015’s – we have 30 hours to complete in one year after we graduate!) If there is a project you want to work on and really want to make an impact, reach out to MPA. To learn about opportunities, contact MPA staff Sarah Luebbert at sarah@morx.com or Brittiany Turner at brittiany@morx.com.

I have enjoyed my month as a student at MPA and being able to live in beautiful Jefferson City and see its local sites and attractions (*ProTip: Central Dairy and Thursday Night Live events in June are not to be missed). As I sign off my last MPA student blog, I want to thank the MPA and Dr. Oestreich for all of the learning experiences I have had. So long, Jefferson City!

Until next time,

Lara Kerwin
UMKC School of Pharmacy
Pharm.D. Candidate 2015
MPA Rotation Student, June 2014


“Show-Me” Vaccines

Lara Kerwin, PharmD Candidate 2015, UMKC School of Pharmacy

Lara Kerwin, PharmD Candidate 2015, UMKC School of Pharmacy

As a Kansas City (K.C.) native, I take pride in my hometown for several reasons:

1)     The Kansas City Royals are off to a great start this year! We fiercely love our Royals and root for them, no matter what.

2)     Two Sporting K.C. players are on the U.S. National soccer team this year and made key plays in our win over Ghana for the U.S. to remain in contention for the 2014 F.I.F.A. World Cup.

3)     Our barbeque, entertainment, and picturesque fountains are second-to-none. K.C. is a great place to live that offers the bustle of the city, quiet suburbia, and beautiful rural areas all wrapped into one.

Despite all of these amazing attributes of Kansas City, I heard news this week of home that left me feeling uneasy. As of June 9, The Kansas City Star reported 13 cases of the measles in town, along with two other suspected cases.1

As a Kansas Citian, certified immunizer, and future pharmacist, I was disheartened when reading this news because measles are a vaccine-preventable disease.

Once contracted, measles can lead to a whole body rash, fever, and even neurologic symptoms and death.2 Measles outbreaks, however, are not isolated to the Kansas City area. Several recent reports from the Centers for Disease Control and Prevention (CDC), including the Morbidity and Mortality Weekly Report from June 6, 2014, mention that there have been 477 cases of the measles reported in 20 states (including Missouri) between January 1 and June 13 this year alone.3 Also stated in these reports, “The majority of the people who got the measles were unvaccinated.” 2

The measles were eradicated in the United States back in 2000, so these outbreaks are raising serious concerns for the public.3 The CDC posits two reasons why the measles are making a comeback.

One, the measles is still endemic to other countries, so travelers from these regions are bringing the measles virus into the United States.

Two, people traveling to these endemic measles regions are not getting the necessary travel vaccinations or have never received the vaccine and become exposed.3

In a statement to The Star, the director of the Johnson County Department of Health and Environment declared, “The best way to prevent measles is what we have known for years; make sure that you and your children are up to date on your vaccinations.” 1

This got me thinking: Why are people not receiving these vaccines? The answer is multi-fold. Some avoid immunizations because of religious beliefs or ideals. However, others fear a link between vaccines (namely, MMR) and autism due to a plethora of misinformation.4 In 1998, a doctor from the U.K. purported a causal relationship between the measles-mumps-rubella vaccine and autism by way harmful, neurotoxic proteins entering circulation via MMR-induced irritable bowel disease.5 Since its original publication in The Lancet, it was released that this doctor did not reveal several conflicts of interest pertaining to his assertions about the MMR vaccine; his medical license has since been revoked, and The Lancet retracted the article in 2010.4 All the while, countless studies have found everything to the contrary of that original article: there is no causal link between the MMR vaccine and autism.5

Similarly, the evidence suggests that thimerosal, a preservative found in some multi-dose vaccine vials, does not cause autism, either. To further discredit the misinformation about MMR vaccines, the MMR vaccine does not and has never contained the thimerosal preservative).4, 5 In a newsletter addressing “Vaccines and Autism: What you should know,” the Children’s Hospital of Philadelphia decisively states, “… [D]elaying or withholding vaccines will not lessen the [autism] risk; it will only increase the period of time during which children are at risk for vaccine-preventable diseases.”5

The recent measles outbreaks across the United States, including Missouri, provide pharmacists with an opportunity to re-educate their patients on the importance of childhood, traveling, and catch-up immunizations, as well as an opportunity for pharmacists to expand their scope of practice.

This year in the Missouri state legislature, the Senate passed bills that supported by the Missouri Pharmacy Association and others about pharmacists providing immunizations. S.B.754 now provides that pharmacists in the state of Missouri can administer Hepatitis A, Hepatitis B, and Tdap in addition to influenza, pneumococcal, meningococcal, and zoster under protocol.6,7 This increases access to convenient care for patients who do not have a primary care provider. The bill also will protect against more vaccine-preventable diseases for Missourians. However, the aforementioned vaccines administered by pharmacists are restricted to patients aged twelve and older, and the bill does not provide for pharmacists to administer the MMR vaccine.8

Why does this matter? Nearly 30% of the measles outbreak cases were in people under the age of 19 (137/477).2 Presently, 27 states allow pharmacists to administer vaccines to patients under the age of 12, while 26 states ubiquitously allow pharmacists to administer every vaccine (including MMR).9 Therefore, precedent exists for pharmacists to be able to give the MMR vaccination to populations of all ages. But without proper legal provisions, Missouri pharmacists cannot actively provide these immunizations.8

What can Missouri pharmacists do in lieu of these measles outbreaks? According to pharmacist Mitchel Rothholz, RPh, MBA and chief strategy officer of the American Pharmacists Association (APhA), pharmacists must strive for the “Immunization Neighborhood.” 9 This concept includes advocating for immunizations through providing education and motivation for our patients and facilitating immunizations by inviting authorized immunizers into our pharmacies.9 If pharmacists honor the initiative, vaccine-preventable disease can be by and large eliminated.4 By “collaborat[ing], coordinat[ing], and communicat[ing]” with key players, the “Immunization Neighborhood,” concept can be achieved to meet the health needs of surrounding communities.9

Reimbursement plans for these services, as well as our current lack of provider status federally, may initially preclude Missouri pharmacists from providing the MMR vaccine.9 However, Missouri pharmacists can still play a definitive key role in resolving this health crisis. By correcting misinformation about vaccines, practicing at the top of their licenses with the implementation of S.B. 754, and continually advocating for increased access to care by way of expanding the scope of pharmacy practice, Missouri pharmacists can do their part to restore the health and safety of our Missouri hometowns and communities.

Lara Kerwin
UMKC School of Pharmacy
Pharm.D. Candidate 2015
MPA Rotation Student, June 2014



  1. Bavley A. KC area now has 13 measles cases, all apparently linked. The Kansas City Star. June 9, 2014.
  2. Centers for Disease Control and Prevention (CDC). Measles – United States, January 1 – May 23, 2014. Morbidity and Mortality Weekly Report Early Release. http://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.pdf June 6, 2014;63(22):496-9. Accessed June 17, 2014.
  3. Centers for Disease Control and Prevention (CDC). Measles Cases and Outbreaks, January 1 to June 13, 2014. http://www.cdc.gov/measles/cases-outbreaks.html June 16, 2014. Accessed June 17, 2014.
  4. Hensley E and Briars L. Closer look at autism and the measles-mumps-rubella vaccine. J Am Pharm Assoc. 2010;50:736-741.
  5. The Children’s Hospital of Philadelphia Vaccine Education Center. Q&A Vaccines and Autism: What you should know. http://www.chop.edu/export/download/pdfs/articles/vaccine-education-center/autism.pdf 2012;2. Accessed June 17, 2014.
  6. Missouri Senate. 97th General Assembly. Second Regular Session [Truly Agreed to and Finally Passed] Conference Committee Substitute for House Committee Substitute for Senate Substitute No. 2 for Senate Bill No. 754. http://www.senate.mo.gov/14info/pdf-bill/tat/SB754.pdf 2014. Accessed June 18, 2014.
  7. Missouri Board of Pharmacy. Immunization FAQ. http://pr.mo.gov/boards/pharmacy/SECURED_Immunization%20Brochure_10-6_.pdf Revised October 30, 2014;1-4. Accessed June 17, 2014.
  8. Carnahan R and Kander J. Rules of Department of Insurance, Financial Institutions, and Professional Registration. Division 2220 – State Board of Pharmacy, Chapter 6 – Pharmaceutical Care Standards. Code of State Regulations. http://www.sos.mo.gov/adrules/csr/current/20csr/20c2220-6.pdf April 30, 2013;1-11. Accessed June 17, 2014.
  9. Rothholz MC. The Role of Community Pharmacies/Pharmacists in Vaccine Delivery in the United States. [PowerPoint]. Atlanta, GA: CDC Advisory Committee on Immunization Practices (ACIP); 2013. Accessed June 18, 2014.