How did you become interested in pharmacy, particularly behavioral health and teaching?
I’ve always been fascinated by substances and how they work. I remember learning about neurotransmitters when I was very young. I didn’t know what I wanted to do when I entered undergrad. I was a physics major for a while, which is cool, but I didn’t feel like it related as much to people or life. So, after my freshman year of college, I took several jobs. I went around the town where I grew up, applied for many jobs, and got hired as a gas station attendant during the day. In the afternoons, I was a soda jerk at the local pharmacy when pharmacies still had soda fountains. I did that for a while. Kids would come after school, and I would scoop that flavored frozen ice. It was a good time. Then, one day, Michael Tidd, who was a year ahead of me in school and was the pharmacy technician, called in sick. The pharmacist, Joe LaMonica, said, “Come on, Stephanie, I need you to come out back and do technician work. We’re not going to have a soda jerk today.” I was like, all right, sure, let’s do it. I went out back, and that forever changed everything for me. I loved it. I loved learning about different substances, their doses, and their forms.
This independent pharmacy had a contract with the local psychiatric institute, Baldpate Mental Institution. Twice a day, we would deliver medications to patients in that hospital, which had inpatient and partial outpatient programs. I would volunteer every night to deliver the medications to the patients in the hospital. Even one time, in a snowstorm, my little Toyota Camry got caught on the way up this hill, but it didn’t deter me. I loved going there. I loved seeing patients. Sometimes, I would see them waiting in line to go out to smoke cigarettes; it was a different time. They would always smile at me, and I would smile at them, and it really brought a lot of joy to my day. I was also fascinated by Joe’s large pharmacy book – the AHFS Drug Handbook. It was all about drug information. I remember highlighting the pages. One thing I noticed is that we would often fill the same medications. We would fill a lot of clonidine; we’d fill a lot of clonazepam; there were certain medications we would always fill. I remember asking Joe what was going on with this. Why do we always use the same medication? And he was like, “Oh, that’s the cocaine detox protocol.” I flagged each of those drugs in that book for my reference, and I literally brought the drug information resource book home night after night and read it. I read about the absorption, distribution, metabolism, and elimination of these substances. After that, I realized that I should probably go to pharmacy school; it is a calling that probably fits me.
So, I applied to pharmacy school, exactly one pharmacy school, the University of Buffalo, where I was an undergraduate. It turns out it was a really good pharmacy school. They accepted me, I went there, and it was great. In pharmacy school, I learned a lot. It was at a time when PharmD was becoming the norm. It was a transition time in our profession where we were moving more from dispensing and chemistry to patient care. I did this clinical elective in psychiatry, and then I did my APPEs (advanced pharmacy practice experiences), which made up our fourth year of pharmacy school. I did an elective clinical rotation at the Buffalo Psych Center and an informatics rotation at the Rochester Psych Center. My focus this last year on caring for patients with psychiatric needs solidified my interest in that area. I came to Maine after graduating and did a residency at Maine Medical Center. Matt Hart and I were the first two pharmacy residents in Maine and the first ever pharmacy residents at Maine Medical Center. During that experience, I also had the opportunity to do an elective rotation in psychiatry. We didn’t have any psychiatric pharmacists at the time at Maine Medical Center. We now have Nikki Centanni, who’s absolutely fantastic, but at the time, we didn’t. I did a rotation with one of the physicians, John Campbell, on P-6, and it was awesome. So, that’s my education.
How did I get into teaching? I loved teaching as a child, as a student, and as a peer. I loved teaching other pharmacists around me at Maine Medical Center, for example, much to their chagrin, some let me do it, but you could tell they weren’t super excited. You could tell others were a little more annoyed, and some leaned into it and couldn’t get enough. When I learned a new pharm fact, I wanted to share it. I realized that I liked teaching and started precepting more and more students. About five years into practice, I took an inventory of what I liked in what I did and what brought me joy. A lot of what brought me joy was, in fact, teaching, whether it was formally precepting or otherwise. That’s when I decided to join academia.
How do you envision pharmacists as part of the hospital and community treatment team?
My vision is twofold. First, every rounding team in hospitals has a pharmacist assigned to them. I don’t mean just assigned to them, but devoted to them, ideally a different pharmacist for each rounding team. The pharmacist would literally do bedside rounds with the team, whether for one hour or four hours in the morning. Second, my vision is that each patient speaks to and sees a pharmacist on the inpatient side at least once. That’s a very low bar, but that’s a good place to start.
Sometimes, not as much as it used to be, I have patients surprised when I go into their room and say, “Hey, I am a pharmacist in the hospital here.” They’re surprised that pharmacists work in hospitals. I would love for that not to be a surprise and for the general public to know that we are essential members of the hospital care team, just like nurses, physicians, social workers, physical therapists, occupational therapists, and every other care member of the team.
On an outpatient basis, my vision is similar. I envision an ambulatory care pharmacist, at least one, in every ambulatory care clinic and a psychiatric pharmacist in every ambulatory care clinic. That could be an opportunity for a health system to start with one pharmacist for the health system and broaden from there. It is important because ambulatory care pharmacists might be akin to what you think of as a family provider. A Board Certified Ambulatory Care Pharmacist (BCACP) is a credential for an ambulatory care pharmacist. For psychiatric and substance use disorder pharmacy, it is a Board Certified Psychiatric Pharmacist (BCPP). There are a lot of synergies when a psychiatrist and a BCPP are embedded in a family practice, as well as when a BCPP and BCACP are both available in a practice.
That is my big-picture vision. These provide lots of benefits. On the inpatient side, pharmacists on every rounding team offer the ability to do that just-in-time teaching right there. Everything changes constantly; there are new guidelines, evidence, and warnings. As medication experts, pharmacists can devote their time and focus on those new warnings and things related to the medicines. We don’t have to think as much about all the new stuff related to diagnostic testing or other issues that are not directly medication related.
A pharmacist on every rounding team allows the pharmacist to know the patients to a greater degree and at different levels. That will enable us to provide more information when assessing drug-related problems. For example, in my world, when I get the question, “This patient’s confused. Can you look at their medications and come up with what you think might be happening?” I can’t do that on the computer. I mean, I can, and I can pull out this patient on diphenhydramine that’s likely to contribute like this or that medication, but seeing the patient first provides a more comprehensive and accurate assessment. Talking to the patient can help determine the type of altered mental status based on clinical presentation (e.g. hypoactive vs hyperactive delirium) and possible causes. A pharmacist rounding every day can appreciate the evolution of possible acute delirium, for example. It might be more of an anticholinergic type of picture or more dopaminergic. Did we start this patient on this medication or whether they might be withdrawing from a GABAergic agent, or whatever the case may be. We are thinking about it with the pharmacological lens at all times.
On the outpatient side, to round that off, ideally, you’ve got two pharmacists, one ambulatory and one psychiatric. My vision is that they each have a panel of patients. They are there for provider and walk-in patient consultations, but they also have a panel of patients, so they have direct appointments with patients. So maybe a patient comes in, maybe it’s in a family medicine clinic, perhaps it’s a patient who has either treatment-resistant depression or bipolar disorder. They’re on an antipsychotic and meet with their psychiatric nurse practitioner, family nurse practitioner psychiatrist, or primary care provider about every six months or every year. In addition, they come in and see the psychiatric pharmacist every one to three months. During that visit, not only does the pharmacist assess things like the dose, how it works for the patient, and the common adverse effects like metabolic effects, sedation, et cetera, but also things like doing AIMS screening, looking for abnormal involuntary movements that can happen insidiously over time with antipsychotics. Catching symptoms early could prevent that patient from progressing into more overt tardive dyskinesia, which we know can sometimes be irreversible. That is one concrete example of how it can be beneficial to integrate pharmacists into patient care.
We’ve been using the term behavioral health; how does that also include substance use disorders? How do substance use disorders fit into the pharmacy field?
The best home for substance use disorders in pharmacy is in the field of psychiatric pharmacy. Within the blueprints for our specialty board certifications, substance use disorders, including gambling disorders, most clearly are in the psych blueprint, but they fall a bit in many other blueprints. You will see it as part of the blueprints for acute substance withdrawal in ambulatory care and internal medicine. Comprehensive substance use disorders and all of the different substances, I would say, are most affiliated with psychiatric pharmacy. It is an umbrella; however, it’s a wiggly umbrella, and there is a cross-over between psychiatric and substance use disorders, whether it is a psychiatric condition like trauma, PTSD, or another psychiatric condition.
How can others best utilize the pharmacists’ expertise in the multidisciplinary team and their roles?
The biggest thing is remembering the pharmacist and remembering us at the beginning, where we can best incorporate our expertise. We’re also incredibly thorough, comprehensive, and reliable in general. We are great partners for new initiatives. Make sure the pharmacist’s voice is included. For example, if it’s a traditional bedside rounding physician team, pick a time in the presentation to invite the pharmacist to share; it doesn’t matter whether it is the beginning, middle, or end, but before the team transitions to the next patient. For example, say, “Stephanie, do you have any thoughts about this patient?” Once it becomes part of the workflow, it will remind everyone about the pharmacist’s role on the interprofessional team.
When you call us, use SBAR (situation, background, assessment, recommendation) communication. Share the situation, background assessment, and your question. Knowing the question and situation up front will help the pharmacist formulate which questions to ask or what to think about. If I don’t know your question until after receiving a whole patient presentation, we will have to go back to review key info again (e.g. sCr or WBC) once the question is known. Instead, if you share the question (situation) up front, and I know the question is about lithium dosing, I can listen closely to the current sCr and trend, Na value, TSH etc. during the initial presentation. It essentially couches the question so that the presentation can be listened to with this in mind.
Utilize consults. For example, ask what you want answered but don’t add your theory or thoughts about it yet. The reason is that this is the best way to use us as an independent resource. We don’t want to be biased by your thinking – you called us as an independent consultant, and we want to analyze the data from our lens. Otherwise, being biased by your thinking might result in us not giving you exactly what you’re looking for – an unbiased consultation. A great way to ask is something like “Hey, can you look into this and see if anything here needs to be dose adjusted?” Or: “This patient had a major change in renal/hepatic function. Can you please assess and provide recommendations?”
We spend a lot of time in school educating and talking about educating both patients and providers. We’re good at explaining the same thing depending on someone’s health literacy up to a doctoral specialist in that area, to someone who may be very unfamiliar with most health terms. So, utilizing us in that way is important. We’re also good at drug information searches – finding the papers, reading them, summarizing them, and providing that summary. We’re also good at finding and interpreting new guidelines, finding new practice changes, and anything that might help your team be a better team. Pharmacists can be a source not only of patient care delivery and optimization but also of staff and provider care optimization, which evidence shows helps to impact levels of burnout. If we feel more competent in what we do because we’re constantly learning with high-quality evidence, we are less likely to feel burned out.
What challenges do pharmacists face in treating individuals with SUDs? Any suggestions on how those can be addressed?
There are many challenges, and many of them will depend a little bit on where the pharmacist is. In the community pharmacy, the biggest challenges will be time and competing priorities. Another challenge in community pharmacies is information. Some community pharmacists have access to the whole chart. For example, if a community pharmacist works at the community pharmacy at Maine Medical Center, the outpatient pharmacy, they can access the entire Epic medical chart. While information in a non-health system, community pharmacy, is often lacking because we don’t have access to the electronic health record. However, some things can help bridge that gap. For example, the Health Information Net is a platform that provides information across the state. Some organizations provide more information to it than others. However, the absence of data doesn’t mean that it doesn’t exist.
Another limitation on the outpatient side is related to organizational limitations. For example, some organizations have stances or policies regarding response in an emergency or policies regarding where certain things can be stored in the pharmacy. Where things are stored can matter. For example, storage of naloxone, if it’s seen or not seen, could make a difference in whether someone feels comfortable asking for it. If someone sees it in front of them, that person’s more likely to feel like they can ask for it and not be stigmatized. Right or wrong, it doesn’t mean a pharmacy with it in the back will stigmatize that person. But it’s perception, right? Especially when we’re talking about patients who have, as a population, historically been discriminated against and stigmatized throughout healthcare.
Other inherent barriers, such as wearing white coats, happen on the inpatient and outpatient side. We wear white coats partly because we used to make coal tar and nasty, gross things, and we didn’t want ’em to get on our clothes. They got on our white coat when we were making drugs, but that’s not the case if you’re rounding with patients (and not doing procedures). It also doesn’t make sense to have a white coat in psychiatry. On the MMC psychiatry inpatient and consult services, we don’t wear white coats at all. We want to break down barriers and increase trust and rapport with patients who as a group have historically been discriminated against. Like white coats, most pharmacies in the past had elevated floors, literally to elevate the ‘expert.’ In 2025, we are working to bring down the barriers for people who have been marginalized and discriminated against over and over again and elevated pharmacy floors are a relic of the past, much like soda fountains with soda jerks.
Another challenge is establishing relationships with patients. That can be difficult if it’s a community pharmacy where there are often many floaters or there’s not a consistent pharmacist. In that case, it’s hard to develop relationships with patients and for a community member to develop a relationship with the pharmacist. They don’t know who will be there and whether it’s someone who has stigmatizing attitudes about something like purchasing syringes.
Pharmacy leadership needs to support innovation. Sometimes, it is easier done on the inpatient side and a bit harder on the outpatient side but is maybe even more important on the outpatient side right now. Pharmacists are permitted by law to enter into a collaborative therapy agreement with a physician for things like prescribing medications. At the community level, pharmacists could administer long-acting injectable medications and potentially help with dose optimization at the pharmacy level. Pharmacists can currently administer long-acting injectable medications by law if they have engaged in additional medication administration training and maintain it annually. Pharmacists with board approval to administer medications can be publicly found on the licensure website under individual pharmacist licenses. Currently, there are two different long acting injectable buprenorphine forms and one long acting injectable naltrexone form. Outside of the world of substance use, we’ve got a whole host of long-acting injectable antipsychotics that are often indicated for people who have substance use disorders for other co-occurring conditions, like bipolar disorder, schizophrenia, or major depressive disorder (adjunctive tx), which could be administered in the pharmacy.
How can pharmacists be involved in innovative ways to provide treatment for people with SUDs, initiating or dispensing methadone or buprenorphine in the pharmacy? What might it take to implement those in Maine?
While pharmacies aren’t 24 hours a day like they may have been before COVID, we’re still pretty accessible and often have longer hours than health clinics in general. We are still located in some of the most rural areas of Maine. Life can be more unstable and variable in early substance use recovery, so having pharmacies with longer than banker’s hours is a real benefit, and there are a few cool things on the horizon for pharmacies and pharmacists.
One is methadone administration. A study that was published through Brandis, the Heller School for Social Policy and Management about pharmacy based methadone. Basically, there’s a huge opportunity for community pharmacies to partner in several ways. One model would be pharmacies partnering with an OTP that allows the OTP to operate a medication methadone unit in the pharmacy. Another model would be for the pharmacy to allow an OTP to put a mobile medication unit in the parking lot of that pharmacy. Then, a third model they talk about is where the pharmacy dispenses methadone, like any controlled substance prescribed. This third model right now is not permitted by law but may be permitted by law in the future, depending on the legislation, Modernizing Opioid Treatment Access (MOTA) Act.
These options can help remove the stigma that might occur for some people who find it stigmatizing to go to a clinic every day to receive care for their chronic disease, whereas someone with hypertension doesn’t have to do that. It is also an option for those who find it hard to get to the clinic daily because of transportation barriers. However, I do want to say that for some people, going to the methadone clinic every single day and the structure of the clinic with counseling is a really important part of their recovery and is an essential part of their treatment. Another benefit of pharmacy dispensing is that we know methadone has a ton of drug interactions, so having the methadone happening within the pharmacy and keeping all of the medications together allows the pharmacist and the rest of the healthcare team to look at the full list and make sure there aren’t clinically significant interactions that are happening as well as make sure the dose is consistent.
I think that’s a huge opportunity. We talked a little bit ago about the long-acting injectable administration and initiating buprenorphine in pharmacies. There are a lot more community-based initiation protocols that exist. The newer low dose initiation is often a multi-day low dose initiation starting at maybe 0.5 milligrams per day and working up. That could be done at a pharmacy because the patient could come back every day. Macro dose initiation also could occur when someone takes a high dose, and if they have symptoms, they continue to take more of that same very day. Again, there would need to be collaborative practice agreements to do all of these things.
Both of those things could happen at a pharmacy. That said, a major thing a pharmacy needs for any of these things is a private place for patients to receive care. We can’t be doing that in the aisle, or it can’t be just like an extra booth. There has to be a door; it has to be a room, and it needs to be a private place. That is a limitation for some pharmacies but not insurmountable. Another initiative we talked about is hiring a board-certified psychiatric pharmacist, which would address some of these challenges, but sometimes it can be difficult for organizations to justify the cost upfront, even though we know the return on investment is great. The USPHS found the return on investment for clinical pharmacists was 12:1.
If anyone is interested in looking at who is a Board Certified Psychiatric Pharmacist (BCPP), there’s a website, the Board of Pharmacy Specialties (BPS), and if you click on find a board certified pharmacist: https://bpsweb.org/find-a-board-certified-pharmacist/ you can click on the BCPP or psychiatric pharmacist, and that can give you a list of who in any given location. You can click like Maine and see all of us in Maine that have that credential. There are other certifications as well.
What is your passion related to substance use or behavioral health?
My first passion is helping us all understand and continue to understand that substance use disorders are diseases, and they’re almost always symptoms of something else. Something else is often trauma or undertreated other psychiatric conditions, pain, and sometimes a blurring of chronic emotional and physical pain. Once people can understand more and that they could be in those shoes too, I think that inherently reduces some of the attitudes and behaviors that can serve to stigmatize and discriminate against people with substance use disorders. I think talking about the importance of language, of being real and about harm reduction, really thinking about harm reduction, not just saying it, but really what this means are my passion.
I’m also passionate about innovation because I’ve been practicing for almost 20 years, and what we’ve been doing for most of this time hasn’t worked, and I don’t want the status quo to continue. Finally, what we’re doing is starting to work. It’s taken a lot of innovation and will continue to take more innovation to get there. I’m so heartened when I hear some of my students talk about substance use disorders and other psychiatric conditions and speak openly and with empathy; it heartens me. It brings a lot to my soul.
We need people who want to be innovative and challenge the status quo. What keeps you engaged in your passions?
It’s so interesting because when I was thinking about this, what brought me into this field was the neurotransmitters and the science. I loved the people visiting the pharmacy, but the neurotransmitters brought me in. But it’s the people that keep me here. It’s the patients and the students, and I use the word ‘students’ broadly. It’s the patients and learners that I interact with. Those are the ones that invigorate me and reinvigorate me. When I have a challenging day, week or sometimes a month, those are the two groups that really make it better for me. I’ll add a third group, my colleagues, who are doing this work. I love and feel inspired by our conversations every day. The people are what keep me engaged.
Is there anything else I haven’t asked that you would like to share?
I would reiterate that for leaders, if you’re a decision maker, whatever those decisions look like, think about pharmacists, and while we can and do dispense, we do a lot more. Whether we are in a dispensing role in a community pharmacy or have no dispensing roles for some people on the inpatient side, it doesn’t matter. We all also have clinical knowledge, expertise, and training and have a lot to offer. And for any pharmacists, pharmacy students, pharmacy learners, or prospective pharmacy students, feel free to email me, and we’ll chat. I encourage you to step into this work into the psychiatric substance use disorder work. It is so gratifying. Our patients are so grateful, and it’s tremendous to see someone move from being so ill with their disease to moving into this place of glorious recovery. You can see people in this remarkable place glow-up, change the whole way they carry themselves and turn around their entire lives. You don’t see that as much in other areas of medicine, maybe a little bit, but that’s routine here in our work. I would encourage you all to step into this work. Lean in.