Poster Presentations and Performance Paranoia

Stress

How to overcome performance anxiety from either stage fright or a poster presentation

Stage fright and the fear of public speaking are incredibly similar. Whether you are a dancer, painter, author, pharmacist, physician, or nurse you will more than likely be asked to get on stage and give a performance or presentation at some point. It is common to have performance anxiety.

For healthcare workers, most public speaking will be at conferences when presenting a research poster or lecture.  (Although why limit yourself to just that!) This environment, while traditionally low key, can still be anxiety inducing. As a dancer, the expectation of getting on stage is much higher, and so are the number of people watching you. This can make the situation equally as terrifying. So what are some healthy ways we can overcome this fear of public speaking?

Deep breathing:

Deep breathing may make you roll your eyes as one of those “wholistic” voodoo techniques that doesn’t really work, but trust me, it does. More importantly, trust the research behind it. A recent study out of australia evaluated Heart Rate Variability or HRV (one of the more negative and measurable side effects of performance anxiety) as well as self-reported anxiety. They had three groups of trained musicians. One control group, one group instructed to take 30 minutes of slow breathing before their performance, and another group using slow breathing and HRV target biofeedback. The slow breathing groups showed improvements in HF (High Frequency) heart rates, meaning their heart rates were lower. They also showed less variability if LF/HF (low frequency/high frequency) ratio measures, meaning they did not have as much heart rate variability when compared to controls. The addition of the biofeedback did not provide any statistical benefits than just the slow breathing alone.

So why does deep breathing work?

Deep breathing works because when you use your diaphragm to breathe, you are activating your parasympathetic nervous system. The sympathetic nervous system is responsible for your flight or fight response. Your parasympathetic nervous system, is responsible for you rest and digest response, and directly contradicts your sympathetic nervous system. So when you activate your parasympathetic nervous system right before a big performance, you have already activated all the rest and digest pathways. So the fight or flight pathways have a much harder time overcoming this and you don’t have the heart rate increases typical of the nerves associated with performance anxiety.

Tea:

The trick with tea is looking past the fancy labels and what they claim to do on the box, and read the actual ingredients.  There are many natural herbs that have proven medicinal benefits, and a lot of teas designed to take your money and may even cause you harm. To learn more about herbs in general, check out this article written by Rose all about cooking with herbs!

When it comes to tea and performance anxiety however, the real trick is avoiding caffeine. It pains me slightly to say this as I absolutely love my caffeine in any form, but the research is undeniable. Caffeine may give you a slight energy boost, though more than likely that energy boost is from the sugar in the caffeinated drink. That small energy burst will be short lived, and lead to a crash in the end. Caffeine can more than double the amount of stress hormones such as cortisol and epinephrine your body is producing. It also decreases your GABA neurotransmitter which acts as your bodies natural ‘brake’, and slows down and relaxes your body. I hate to be the one to tell you all of this. But it is true. Caffeine really should be avoided before a larger performance.

What you can find in tea however that will help, is camomile. Camomile is a common ingredient in ‘sleepy time’ tea, however it does more than just help with sleep. It contains many antioxidants including flavones. Flavones have been shown to lower blood pressure, something which is incredibly beneficial when you are about to get on a stage!

Practice Practice Practice:

Another simple technique is to make sure you are as prepared as possible, so nothing can cause you additional stress on your big day. Nothing is worse than getting ready to get on stage and realizing there is a large tear in your skirt. The number of times I have had to frantically search for push pins to mount my poster is higher than I care to admit.

By making sure to pack your performance bag the night before, you have the opportunity to check your costume for any last minute tears you may need to fix, or find some safety pins to make sure you have them on hand. Read your emails carefully to know what will be provided to set up your poster. Map out the location of where you are going and know how long it will take you so you won’t get stuck in traffic. Memorize your speech so it comes off as seamlessly as possible. Practice your choreography with and without music, with and without mirrors, and make sure you practice at least once in your full costume so you know if you can wear bangles without having them fly off your wrist and into the audience. (Nothing will ruin a performance faster than hitting an audience member in the head… trust me I’ve been there and you don’t want that to happen to you.)

When to talk to your doctor about medication?

Before I start talking about medication, please remember that while I am a pharmacist I am not YOUR pharmacist. This article is not intended to be taken as medical advice. Please consult your physician and your pharmacist before starting any medications.

If none of the above techniques work for you, it may be time to talk to your doctor about medication. Medication can be used in addition to any of the above techniques, but it should not e the sole technique used to overcome anxiety. Try different combination of both pharmacological, and non-pharmacological techniques. Deep breathing by itself may not be as helpful as you need, but deep breathing, tea, and lots of practice may work in combination. If there is one type of medication that should be added though, it should be a beta blocker.

Beta Blockers:

Beta blockers act on the Beta 1 and Beta 2 receptors and block adrenergic stimulation. This means they can decreases heart rate, myocardial contractility, blood pressure, and myocardial oxygen demand. Nonselective beta-adrenergic blockers (propranolol, nadolol) reduce portal pressure by producing splanchnic vasoconstriction (beta2 effect) thereby reducing portal blood flow.

No medication is FDA approved for performance anxiety, however propranolol has been the most studied. It comes in an immediate release formulation that will work quickly when used. This medication will not stop you from being nervous, but it will block the physiological response to nervousness. By not having the rapid increase in heart rate and blood pressure it is easier to focus on the performance itself, rather than your nerves.

Benzodiazepines:

Clonazepam (Klonopin), alprazolam (Xanax) and lorazepam (Ativan) all fall into a category of medications called benzodiazepines. These drugs can be used to reduce anxiety. However, they carry a high addiction potential, and are only recommended for short term use. Long term use of these agents has not been studied. If the beta blockers and other techniques do not work this could be considered, however this is an absolute last line agent and must be used in close collaboration with a physician and pharmacist. This drug class is one of the most abused controlled substances we have. That being said though, they may help with anxiety under the right conditions.

I hope this information has been helpful! Let us know how you overcome your nerves before a big presentation or performance! We would love to hear from you! You can contact us anytime here.

Performance Anxiety
Performance Anxiety

Speedy Recovery Breakfast Recipe

Speedy Recovery Breakfast

Speedy Recovery Breakfast

When I’m sick, I take my recovery very seriously. After all, you have to feed your body the best so it can be its best. Here’s a tasty, healthy, speedy recovery breakfast loaded with vitamins to give your immune system some of the tools it needs to heal.

Ingredients

Meal

🍊1/2 orange

🍏1/2 apple

🍌1/2 banana

Tea

🍵Green tea

🍯Honey

🍋1/4 lemon

This recipe brought to you with love from:

Rose Auflick of Mingled Vitality

https://www.mingledvitality.com/

Original post on Instagram

https://www.instagram.com/p/BqsUixNFL11/?hl=en

For more recipes, click here!

https://poiseandpotions.com/recipes/

Non-Scientists Guide to PharmacoGenomics

Pharmacogenomics

What is Pharmacogenomics?

The world of medicine is constantly changing, and new drugs are being approved in record numbers. The FDA approved a total of 59 new drugs in 2018. This may not seem like a high number but the last year that the FDA approved over 50 drugs in one year was 1996, making this the highest in at least 25 years. What is more astounding than the number of drugs approved however, is the type of drugs. More and more of the drugs being approved are drugs for personalized medicine, or what is known as pharmacogenomics.

Pharmacogenomics is the study of how a person’s genes affect their response to drugs. This new and emerging science is an area that pharmacists can make a huge role in a patient’s healthcare. This article hopes to explore pharmacogenomics in a little more detail, that way no matter who you are you can understand how pharmacogenomics affects you.

History:

Pharmacogenomics was first identified in 510 BC by Pythagoras. The same guy who was responsible for creating the pythagorean theorem we all blocked from memory as soon as we learned it as teenagers.. He did not call it pharmacogenomics at the time of course. He simply noticed that when some people ate fava beans they had a severe, potentially fatal, reaction, while others did not. It wasn’t until the 1950s that modern science identified this reaction as due to a G6PD deficiency.

After Pythagoras, in 1866, Mendel established the rules of heredity by using pea plants to test for genes. Known as the father of genetics he was able to coin the idea of dominant and recessive traits in plants by creating punnett squares. These squares were another of the many items we forgot during our schooling. While these squares may bring back memories of being back in a classroom for some, they also show just how simple pharmacogenomics can be. These basic principles are still used today. So if you could grasp the concepts behind these squares in school than you can understand pharmacogenomics now.

After Mendel created the idea of genetics, it took several trials and many years until Vogel coined the term pharmacogenetics in 1957. Since this time the expansion of this scientific field has grown exponentially. We have identified the structure of DNA, and know that it is made up of different bases. These bases are largely the same, however variation in the genome is seen every 500-1,000 bases, thus accounting for the difference between humans. These differences can come in many different forms, but the most well studied are known as SNPs or single nucleotide polymorphisms.

These SNPs are a large part of why a drug that works for one person may not work for someone else. In 2000 we were able to complete a map of the human genome sequence variation identifying 1.42 million SNPs. The information we learned from this was invaluable. Now that we know what the differences between the genes are, we can compare those to responses to medications and thus form the basis of pharmacogenomics. Because of this, the first pharmacogenomics test was approved by the FDA in 2005. This tested for variations in two alleles, CYP2D6 and CYP2C19.

Currently:

To date we have multiple pharmacogenetic tests available that test over 50 genes for potential interactions. According to the FDA, currently there are 214 drugs that have proven, documented drug-gene interactions. When a drug has such a strong drug-gene interaction that it must be included in the package labeling, that means there is a plethora of peer reviewed, researched, and published information out there proving the drug-gene interaction. The majority of this research is only 10 years old.

Some medications can only be prescribed after pharmacogenomic testing has been done. For example, abacavir is used to treat HIV patients, and can only be prescribed after testing for the HLA-B biomarker. If a patient is positive for HLA-B*5701 allele, they could have a potentially fatal hypersensitivity reaction.

Some medications may need to have their doses adjusted based on the results of pharmacogenetic testing. For example Warfarin has drug-gene interactions with both CYP2C9 and VKORC1. The package insert uses a chart that shows how both these genes can cause alterations in the starting dose.

So What Is Next?

This field is so new, and the amount of information we are learning every day is astounding. If you want to keep up with this field I highly recommend checking out the FDA’s website on pharmacogenomics. They are a great resource on this emerging field.

Your physician or your pharmacist should know if you are taking a medication that would require pharmacogenomic testing. However, if you are interested in having yourself tested than simply schedule an appointment with your healthcare provider. These tests are not cheap, however they are becoming so prevalent that they are getting cheaper very quickly. It is also important to consider the privacy of your pharmacogenomic information. Popular home testing kits have had data breaches in the past. So by going through your healthcare provider your information will be more protected than if you did it at home, as it would be part of your protected health information.

Our team member Catlina will be presenting a poster about her research on Pharmacogenomics at the College of Psychiatric and Neurologic Pharmacists Annual Meeting next month! If you have any questions about pharmacogenomics you can always use our contact us page to reach out.

Be on the lookout for more information about this emerging field by signing up for our email list at the bottom of this page!

Resources/References:

1. https://www.fda.gov/Drugs/DevelopmentApprovalProcess/DrugInnovation/ucm592464.htm

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2014592/

3. https://www.fda.gov/drugs/scienceresearch/ucm572698.htm

4.https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/020977s033s034,020978s036s037lbl.pdf

5. https://www.admerahealth.com/faq-items/physician-faq/

6.https://oneome.com/rightmed-comprehensive#genes

7. https://oneome.com/rightmed-comprehensive#genes

St. Patty’s Day Recovery Smoothie

Vegan Friendly Recovery Smoothie

We all know what weekend is coming up, so we thought you might appreciate a new recovery option. If you prep this delicious green smoothie the day before, you’ll have a tasty treat that’s easy on a sensitive stomach if you drank too much green beer the night before! This vegan friendly St. Patty’s Day Recovery Smoothie comes courtesy of Rose Auflic of Mingled Vitality, and we’re happy to recommend it! The Vegan GO Smoothie!

Jokes aside, even once the holiday has passed, we hope this simple breakfast option will be something you can enjoy any time of the year!

So many nutrients! Potassium, vitamin C, iron…and more! All in this vibrant, vegan, 💚GREEN💚 breakfast smoothie. If you need something to start your day off right, this will certainly do the trick!

Photo and recipe by Rose Auflick of Mingled Vitality https://www.mingledvitality.com/

Ingredients

🍏Granny Smith apple

🍌Banana

🍊Orange juice

🍍Pineapple juice

🥑Avocado

💚Baby spinach

Simply blend the amount of each ingredient that sounds perfect to you in a blender or similar device. Let it chill in a fridge overnight, and you’ll have the perfect St Patty’s Day Recovery Smoothie waiting for you once the festivities have died down!

This recipe brought to you with love from:

Rose Auflick of Mingled Vitality https://www.mingledvitality.com/

Original post on Instagram

For more recipes, click here! https://poiseandpotions.com/recipes/

Gluten-Free Lemon Cupcakes

Gluten-Free Lemon Cupcake!

Happy Friday Everyone!

 

For this week’s recipe, we’d love to share a gluten-free cupcake option that we recently tried, and loved enough to spread the word!

This recipe comes from a site you’re likely already familiar with – AllRecipes

We made a few modifications to their recipe that we found improved it for us, which I’ll detail below. These changes may not be for everyone, however, so take them with a grain of salt (but don’t use more salt than the recipe calls for, that’s definitely not recommended).

The changes we recommend are as follows:

  • Almond flour instead of all purpose gluten free flour (unless you’re alergic, obviously)
  • Whole milk

We really hope you all will enjoy these cupcakes as much as we did!

Gluten-Free Lemon Cupcake!

Why Advocacy Matters

Texas State Capitol

Yesterday may have seemed like just an ordinary Tuesday, but in reality it was one of the most exciting days for Texas and Tennessee pharmacy! In a random coincidence of happenstance, yesterday was both the Texas and Tennessee Pharmacy Day on the Hill. Our team member Catlina is a pharmacist in both of these states. She has helped coordinate multiple hill visits and has been involved in advocacy her entire pharmacy career. But the real question is why does advocacy even matter?

Congress has historically been one of the least trusted professions. Gallup polls rate members of congress at the absolute bottom of the list even with used car salespeople. Healthcare workers however, are among the most trusted. Nurses, medical doctors, and pharmacists have consistently been the top three highest ranked professions in regards to trust. Yet even though there is such a large gap it is important for the professions to work together. Pharmacy is THE most regulated profession in the entire world. No other profession has the licensing requirements, board oversight, laws, rules, and regulations that dictate how pharmacists practice each and every day.

Picture any activity you do in a pharmacy. Patient counseling? Mandated by OBRA 90. Displaying licenses? Mandated by board of pharmacy rule. Verifying orders? Mandated by the most complex combination of laws and rules imaginable. These lawmakers do not work in pharmacies. While there may be a few pharmacists in the legislature (Tennessee has 3, one of which is the lieutenant governor), these individuals are the exception rather than the norm. They do not understand the typical workflow of a pharmacy, and how we operate.

Tennessee Advocacy

As an example, here in Tennessee we had a bill proposed that would make it illegal for a pharmacist (or anybody) to eat behind the counter of a pharmacy. A patient had come to the pharmacy counter to pick up her medication, and she saw a pharmacist eating some peanuts behind the counter. While she was not allergic to peanuts, she got very upset by this, and called her local congressman. He then introduced a bill that would make it where no food would be allowed in the pharmacy for fear of contamination. This was a valid concern, as it is estimated that anywhere from 0.6%-1.3% of all people are allergic to peanuts.

However, what was not understood by this individual and the congressman who introduced the bill, was the extensive process we go through in a pharmacy to ensure a safe environment. The workflow of a pharmacy was also not well understood. As it is very common for a pharmacy to have only one pharmacist. This pharmacist is typically working through their lunch due to the need to counsel patients. It is very possible that those few peanuts the pharmacist ate were the only food she was able to eat all day. She then would have been legally required to wash her hands before handling any medication, and would have sanitized any counting trays used before counting any more prescriptions. When viewed in this light, and with the already existing sanitation laws in place, a few peanuts may not seem so harmful.

One person was able to potentially change the practice of pharmacy forever. This individual did not have any special relationship with the congressman. She was simply a concerned citizen who made a phone call. This is exactly why days on the hill are so important. Both Texas and Tennessee pharmacists were able to meet their elected legislators yesterday, and discuss issues that were important to them. When we show up at the capitol building in numbers like we do on these days, it is hard to not notice.

Texas Advocacy

Let me give you another example from Texas. Texas is one of only 5 states that does not currently allow for physician dispensing. This means that all prescriptions have to go through a pharmacy, and meet the strict requirements placed by the board of pharmacy and our state and federal rules, ensuring that safety measures are in place such as washing hands and sanitizing counting trays. There was a bill 3 years ago that would have allowed for limited physician dispensing for certain medications, completely avoiding these safeguards. When this bill was brought up in committee, I organized a group of 33 student pharmacists to go to the capitol. All we did was sit in the back of the room, in our white coats, and register in opposition to the bill. One signature and one seat was all we needed. Because of our presence in that room the bill was voted down in committee, and physician dispensing was not passed.

Catlina and Congresswoman
Catlina having a terrible hair day as she meets with her San Antonio Congresswoman

What Can You Do?

These stories show just how much of a difference you can make on the legislative process. All it took was one phone call about peanuts to get a bill introduced. All it took was a few signatures and showing up to get a bill to fail. My current position has me following 26 bills, and going to committee and subcommittee meetings almost daily during our legislative season. I can tell you from experience the majority of meetings have no members of the public attend. The majority of legislators have not heard from the people they represent. When a member of the public does show up it is noticed, and it has a large affect. That one phone call, that one letter, that one meeting that you show up for, really do make a difference.

So to all the pharmacists who attended these inspiring events yesterday, we here at Poise and Potions congratulate you. The difference you make may not seem like much, but every chance we have to get our voices heard is critical. We have to start advocating for ourselves as a profession. Pharmacists must insist on getting fair lunch breaks, and reasonable drug prices for our patients. We cannot let those who are not pharmacists dictate the practice of pharmacy.

Every profession, no matter if it is dancing, medicine, painting, nursing, architecture, or anything else is regulated in some way. So why not control the way we practice our profession?

Catlina and Taylor
Catlina at the Texas Day at the Hill 2016

Even if it is not through an official event you can still meet with your legislator at any time. Don’t hesitate to make those calls, and stand up for what you need. You would be surprised just how easy advocacy is.

I hope this article is inspiring, and encourages you to reach out. You can also reach out to us at any time, by contacting Poise and Potions. We want to hear how you have interacted with the legislative process and advocated for YOUR profession!

 

Patient Counseling That Patients Will Want

Patient Counseling

Have you ever woken up one morning and thought “I am going to give eight years of my life and potentially go into $300,000 of debt to count pills behind a counter and not talk to a single person all day?” No? Me neither. I think it’s safe to say that nobody has ever had this thought. And the reason for that is while pharmacy school provides a great training and a doctorate level education it also requires a high amount of communication. Pharmacists talk to technicians, physicians, nurses, store managers, and of course patients all day long. And while being a doctor of pharmacy means we have a high degree of knowledge about medications, it doesn’t mean we have great communication skills.

OBRA 90

Pharmacists started formally counseling their patients due to OBRA 90. This was a huge law passed in 1990 (passed in 1990… OBRA 90… noticing a theme?) that changed the profession of pharmacy forever. Obra 90, among many other things, was the first ever to mandate patient counseling. Now pharmacists have been practicing since way before 1990, and of course they had been counseling patients since before this time too. However, this law was enacted to help the federal government (and thus the American taxpayers) save money. Their theory was that if pharmacists did more counseling, there would be fewer adverse drug events and interactions, better care for the patients, and less healthcare spending. This is absolutely true. This study shows that when pharmacists provide structured counseling:

  • Confusion about when to take medications declined from 4% to 2.5%.
  • The average number of prescription drugs and the number of doses taken per day decreased.
  • Hospitalization frequency decreased from 39.8% to 31.3%.

Numbers like this show that counseling really can work. Yet another study showed that only 47.3% of pharmacists and 34.0% of patients were satisfied with the current medication counseling service. How many times have you gone to pick up a prescription, and the pharmacist didn’t even counsel you? How many times have you gone and picked up a prescription, the technician asks if you want to speak to the pharmacist, and you say no? You rush out of the pharmacy and don’t even look back. Or worse, the pharmacist comes over, counsels you, and you end up even more confused than when you started. I have heard over and over again from patients that counseling with a pharmacist can be a waste of time.

My theory is that it really isn’t a waste of time, if we are doing the right type of counseling. Our counseling sessions are so inadequate that they often go like this:

Pharmacist: “Hi Mr. Smith Are you picking up your medication today?”

Joe Smith: “Yes, it’s right there.”

Pharmacist: “Great! What did the doctor tell you about the medication?”

Joe Smith: “She told me it is for my high blood pressure.”

Pharmacist: “Yep, this is lisinopril, you take it once a day, and it helps with hypertension. You can take it with or without food. Do you have any questions about your medication?”

Joe Smith: “No, not really.”

Pharmacist: “Okay, here you go. Have a nice day.”

Joe Smith: “Thanks, you too.”

 

 

This may seem like a perfectly good counseling session, but in reality it is absolutely terrible. Let’s look at a proper counseling session using motivational interviewing:

Pharmacist: “Hi Mr. Smith, are you picking up your medication today?”

Joe Smith: “Yes it’s right there.”

Pharmacist: “Great! What did your doctor tell you about this medication?”

Joe Smith: “She told me it is for my high blood pressure.”

Pharmacist: “Yes it is for high blood pressure. This medication is called lisinopril. Have you taken it before?”

Joe Smith: “Yes, I’ve taken it for at least a decade now.”

Pharmacist: “That’s a long time. How have you been taking the medication?”

Joe Smith: “I take it once a day.”

Pharmacist: “That’s good, have you had any side effects?”

Joe Smith: “No, it works well for me.”

Pharmacist: “Good, what have your blood pressure readings been like?”

Joe Smith: “I don’t know. I don’t check them. My doctor does.”

Pharmacist: “When you are on this medication, it is very important to know what your blood pressure readings are. If you know your blood pressure, you can know if you are meeting your goal. What is your goal with taking this medication?”

Joe Smith: “Well my goal would be to not take the pill. I don’t like taking pills.”

Pharmacist: “That’s a great goal, and one that I think you can reach if you work hard. Definitely let your doctor know before you stop taking this medication, but there are non-pharmaceutical ways that we can use to decrease your blood pressure so hopefully you won’t have to take this medication long term.”

Joe Smith: “Non-pharmaceutical ways? Like aromatherapy? I don’t believe in that stuff”

Pharmacist: “No, like eating right and exercising. I know it seems silly, but it really can make a difference. If you want, we have a blood pressure machine right over there. I can show you how to take your blood pressure, and once we know what your numbers are, I can help you come up with some ways we can possibly reduce your blood pressure.”

Joe Smith: “Yeah I’ve heard all the speil before about eating healthy and losing weight. Every time I go to the doctor, she tells me I need to lose weight.”

Pharmacist: “What do you think is keeping you from losing the weight?”

Joe Smith: “I drink too many sodas. I can’t give up my Dr Pepper.”

Pharmacist: “I totally understand. If losing weight is a goal of yours, we can come up with ways to lose weight that don’t involve giving up sodas.”

Joe Smith: “Really? My wife is always telling me I need to give up sodas. If I could lose weight and still drink my sodas, that would be great. My kids are running circles around me, and I just want to be able to keep up with them again.”

Pharmacist: “Keeping up with your kids is a great goal to work towards. Let’s check your blood pressure and brainstorm ways we can help get there.”

~ Then the pharmacist helps the patient take his blood pressure and sets a goal of walking with his kids around the block after dinner to increase his exercise. ~

See how much different those two counseling sessions were? Now, I know what you are thinking. Of course they are different; one is longer. I would love to be able to help more patients, but I can’t afford the time to help every patient take their blood pressure, and not every patient is going to want to anyways. These are the typical arguments that a pharmacist, especially at a large chain store, is going to give. But I would argue that you can’t afford NOT to take the time. You may not always get a positive response, but I have seen patients break down and cry in the pharmacy because a pharmacist took 5 minutes out of their day to listen to a patient. Sometimes this is the first time a healthcare professional has done that for a patient ever. When I was in pharmacy school working for a large chain pharmacy, I made so many changes to a patient’s medication regimen just by talking to them and calling their doctors office. I would never do anything without their prescriber being notified, but it made such a difference in my patients lives they were so thankful for it. I have come up with a few tips and tricks for motivational interviewing to help you better communicate with your patients.

There is a whole art to motivational interviewing and if your pharmacy school was anything like mine the chances of them teaching you motivational interviewing in a meaningful way is not exactly high. APhA has a great (and short) book on motivational interviewing (Get a copy here) that I highly recommend. There is also a great series of videos on motivational interviewing put out specifically on tobacco cessation here. But in case you are looking for something shorter let me give you the highlighted version.

Meet the patient at their level:

One of the most surprising moments for me was when I was talking to one of my professors, a Pharm.D., and she went on a 20 minute rant about how much she hated being counseled.

She is an adrenaline junkie, and had had an accident where she fractured her pelvis. An incredibly painful event by all accounts, leading her to spend an extended amount of time in the hospital. She eventually made it out of the hospital to pick up her pain medication from the pharmacy. When it came time to check out the pharmacist politely checked her out at the register, and began to counsel her. She politely explained that she was a pharmacist and understood how to take the medication.

The pharmacist continued to counsel her and kept her standing at the register with a line forming behind her. She finally had enough of the pain and said “Can I see that prescription for a moment?” The pharmacist said yes and handed her the bottle. She opened it, took out a pain pill, and put it in her mouth. She said “You have about 30 minutes before this kicks in and I can’t drive home anymore. Can you please finish so I can go home?”

If we cannot even get pharmacists to want counseling we are doing something wrong. In her case she had very clearly declined counseling (something patients have a right to do) however the pharmacist ignored her request and continued to talk about her personal medical record in a public space. This is not how counseling should be done. There is a reason in both counseling examples up above the first question asked was “What did your doctor tell you about this medication?” A large part of motivational interviewing is meeting the patient where they are at in their education level.

 

The pharmacist above did not need to know about the medication side effects, she already knew them. She needed to know if the doctor wrote for refills and what else she could do to control her pain besides the medication. In the example with the high blood pressure it was the same scenario. The patient knew how to take the medication and knew the side effects. They did not know how that medication affected their blood pressure and how they could use alternative therapies to reduce their blood pressure. This is critical to listen to the patient.

Treat the patient with respect and use their language:

You will notice that in the blood pressure example the pharmacist used the term high blood pressure instead of hypertension. This is important to use patient friendly terms. The pharmacist also used Mr., and showed respect for the patient. They did not get offended when the patient rejected their idea of alternative therapies as aromatherapy that they did not believe in. The pharmacist simply talked to them about therapies that may be a better fit for this particular patient.

Separate pharmacists from point of sale:

One idea that I would love to see happen would be to separate pharmacists from the point of sale. When we are having to worry about collecting a patient’s money (Something virtually no other doctor would ever do) as well as counseling a patient that has potentially just gotten out of the hospital and is in pain it’s no wonder we aren’t getting heard. We should be meeting the patient in a private area (not the cash register) and sit down with them. This would not only give pharmacists a chance to sit but would also let the patient sit. Setting the expectation that there is time to talk and making a comfortable environment instead of standing with a visible line forming behind you.

Ask open-ended questions:

When I wanted to go to prom with my boyfriend in high school. I knew getting my mom to agree was going to be a tough sell. I did not ask my mom if I could go to prom with my boyfriend for an evening of dancing at a hotel that was known for not checking IDs with it’s liquor sales. The answer would be an absolute no. So I came up with a pretty crazy scenario, where me, my boyfriend and some friends were going to camp on a beach all weekend in a large tent. Having a whole group of teenagers in a tent for a whole weekend sounded worse than me and my boyfriend who she knew and trusted dancing for one night. When presented with the two options, my mom was much more agreeable to one night than an entire weekend. It’s all about perspective. The exact same can be said about counseling patients.

Instead of asking “Just picking up the one medication?” you could ask “What brings you in today?” These completely different questions will yield completely different answers. One will give you a simple yes. The other will lead the patient to discuss their headaches, or ask you about over the counter medications. It can’t be answered with a simple yes or no. Asking “Do you have any questions?” is the equivalent of asking your mom if you can go to prom with your boyfriend with no parental supervision. The answer will almost always be no. Asking “What other questions do you have for me?” is forcing your mom to choose between letting you be gone for one night with one trusted person or a whole weekend with a wild group of teenagers. It forces her to think and give a much better answer.

I hope these tips have been helpful to you. Please feel free to comment below or contact us if you have any other counseling tips. We would love to hear more advice on connecting to our patients!

Catlina using motivational interviewing while on a medical aid trip to India
Catlina using motivational interviewing while on a medical aid trip to India

Do Drug Expiration Dates Really Matter?

Glitter Pills

I have been sick with the flu for almost an entire week now, and let me tell you, if you ever want a great abdominal workout just get the flu and cough up a lung for a week straight. I’m going to have a 6-pack by the time I am fully recovered! If you would literally do anything else then get the flu like a normal person, just get your flu shot. It’s much more fun than this ‘workout’ I promise. But in all seriousness, when I first got sick I did what everybody does, and looked at my medicine cabinet. I had a whole collection of pills and potions, half of which were expired. Has this ever happened to you? You are terribly sick and only have expired drugs, and debate if it’s worth going to the store to get new ones or just risk using the expired meds you already have? You’re not alone. As much as I would love to say the good pharmacist in me never let any expired drugs into my house I am still human. And this got me to wondering do drug expiration dates really matter?

I want to preface this article with a gentle reminder that while I am a pharmacist, I am not YOUR pharmacist. Medical advice over the internet is never a substitute for discussing your individual health needs with a physician or pharmacist face to face. It is never recommended to take expired meds, however I am fully aware that the temptation is there and I want to do my best to present the facts to you so that you and your medical team can make the best decision for you. This article is written more scientifically than most of our posts as it is my hope that you will print this out and take it to your pharmacist or physician to discuss with them, and use the resources listed to check the claims I make and come to your own conclusions. With that being said, let’s find out if drug expiration dates really matter.

Why Drug Expiration Dates Matter

Under section 501(a)(2)(B) of the federal Food, Drug and Cosmetic Act (FDCA), manufacturers of prescription drug products establish controls for the manufacture, processing, packing, and holding of drug products to ensure their safety. Requirements for these controls are known as current good manufacturing practices (CGMPs), and include the requirement of an expiration date as of 1979. Current requirements include medications to be within 90%-110% of their stated potency.1 The FDA defines an expiration date as “the date placed on the container/label of a drug product designating the time during which a batch of the product is expected to remain within the approved shelf life specifications if stored under defined conditions, and after which it may not be used.”

The expiration date is determined by a review of documentation submitted to the FDA in a New Drug Application (NDA). This includes a stability assessment of the new drug substance and product (dosage form). The stability assessment follows procedures agreed upon by the United States, European Union, and Japan established at the International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH). How the stability assessments are conducted varies based on the substance and its dosage form, however stress tests are performed evaluating the effects of elevated temperature and humidity, oxidation and photolysis, and hydrolysis over a wide range of pH values.1Expiration dates for prescription drugs (and over the counter drugs) that are subject to premarket approval requirements are based on the amount of real time data available at the time of FDA approval of the NDA.

However, the expiration date may be extended as long as adequate data is provided to the FDA. This is rarely done however, as there is traditionally no incentive to extending expiration dates and extension is strictly voluntary. According to PhRMA, the initial expiration dating for prescription drug products is usually between 18 and 24 months, and expiration dates can range from 12 to 60 months. As of 2006 no drug has an expiration date longer than 60 months. As a general rule, solid dosage forms tend to have longer expiration dates than liquid ones.2

Many studies have proven stability of medications beyond their expiration date. Reducing waste is a key way to reduce healthcare costs and extending expiration dates is one tool through which this can be accomplished. In 1986, the FDA and the Department of Defense (DoD) singed an interagency agreement to “conduct a comprehensive, scientifically sound testing and evaluation program that will determine whether there is justification for extending the shelf life of stored medical items owned by components of DoD or their authorized program partners.”3This created the Shelf Life Extension Program (SLEP) providing the FDA with the largest data source of expired medications to date. From this study, Robbe et al published in 2006 that 122 medications have been tested and 88% were extended past their original expiration date for an average of 66 months.4

Some manufacturers have extended expiration dates during times of drug shortages. In June, 2017 the FDA posted extended expiration dates for batches of injectable atropine, dextrose, epinephrine, and sodium bicarbonate manufactured by Pfizer. This resulted in one hospital, Newton-Wellesley, saving $7,500 in drugs that were in short supply.2

It is important to note that once the manufacturers container is opened and a drug product is transferred to another container for dispensing and repackaging the expiration date no longer applies. The United States Pharmacopeia (USP) and the American Pharmacists Association (APhA) provide guidance to pharmacists on placing a “beyond use date” on the label of the new container.2

The AMA has resolutions drafted by its house of delegates stating that the AMA “Urges the pharmaceutical industry, in collaboration with purchasers, the FDA, and the United States Pharmacopeia (USP), to determine whether lengthening of expiration dates will provide clinical and/or economic benefits or risks for patients and, if this is the case, to conduct longer stability testing on their drug products.”2They have written many letters and provided many public comments on this topic.T

The SLEP Study

The SLEP study contains the most comprehensive database of long-term stability data in existence. This study published its research on 122 medications (3005 lots) in 2006.5Of the 3005 lots tested, 2650 were extended past their original expiration date. 1237 lots were found to be still viable at 70 months past their expiration date, and were abated before failure and were not studied past this time. Of the 479 lots that eventually failed no lots failed prior to one year past their expiration date, and 312 lots were extended beyond 4 years.

The DoD maintains a stockpile of medications worth around $13.6 billion as of 2016.6Based on the SLEP program and their research the DoD has been able to extend the expiration dates of medications saving $2.1 billion in 2016.6The cost of running the SLEP program in 2016 was $3.1 million resulting in a return on investment of $677 per dollar spent on this program. It is important to note that while many states and hospitals also maintain stockpiles of medications the data used from this study are proprietary to federal agencies such as the DoD, the Center for Disease Control’s Strategic National Stockpile (SNS), and the Veterans Administration (VA).3Non-federal or civilian agencies (including state stockpiles) may not avail themselves of this program.

The medications included in the SLEP study are medications that have been selected specifically for their likelihood of being stable past their expiration dates and have been properly stored under conditions consistent with CGMPs and thus cannot be generalizable to medications that have not been stored under these conditions.3There is much interest in states access to SLEP study data. Kozak et all studied patient attitudes towards unused and expired medication (UEM) in Indiana, and discovered that 40% of patients were unaware of a medication take-back location in their community, and while 77% were willing to drive to a take-back location to return UEM, only 15% had utilized take-back locations.7 Kuspis et all surveyed patients and pharmacies, and out of the 500 people surveyed only 1.4% returned medications to a pharmacy, and out of 100 pharmacies only 5% had consistent recommendations for their customers on drug disposal.8

The SLEP study has evaluated over 500 medications however most of this data is unpublished. Even with the data being unpublished the FDA has used the data to improve manufacturing practices.2,3,9 One study conducted by the Office of Regulatory Affairs (ORA) field laboratory evaluated Mark 1 Nerve Agent Antidote Kits containing atropine sulfate. Five out of every six atropine autoinjectors failed the stability testing due to brown particulate matter or cloudy brown solution.3Further testing revealed that the discoloration was a result of leaching iron from the stopper. The FDA can now use this data to advise the use of non-iron containing stoppers as a potential method of increasing the shelf life of these autoinjectors.

Other Studies

Research on medication stability past it’s expiration date has also been done in the civilian sector. Cantrell et al evaluated 31 expired EpiPens and 9 EpiPen Jrs all of which were 1 to 50 months past their expiration date.10 19 of the EpiPens (65%) and 5 of the Epipen Jrs (56%) contained at least 90% of their stated amount of epinephrine and all of them contained at least 80% their stated amount of epinephrine. This study asked for consumers to donate their autoinjectors. By using donated auto injectors they were able to get a more realistic view, as these medications were commonly stored in cars, humid bathrooms, or other less than optimal settings,

Teder et al evaluated expired and non-expired nifedipine formulations from Estonia and Russia and used IR spectroscopy, HPLC analysis, and evaluation of dissolution rates to compare the drugs to current European Pharmacopeia Standards.11 All tested products had at least 80% nifedipine and did not exceed tolerance limits for impurities. Expired nifedipine formulations did however release faster than their non-expired counterparts.

Binkhathlan et al evaluated tacrolimus extracted from expired Prograf®capsules and established through multiple tests including gas chromatography-mass spectrometry (GC-MS), X-ray diffraction (XRD), and differential scanning that extracted/purified tacrolimus retains its purity and immunosuppressive action.12

Tetracyclines, and their safety past expiration dates, have been highly debated. One report in 1963 by Frimpter et all discovered three cases of Fanconi Syndrome and postulated that the either the tetracycline degradation product epi-anhydrotetracycline or anhydrotetracycline was responsible.13However the SLEP study encountered no toxicity with tetracycline and found batches effective more that two years past their expiration dates.9

Tricyclic antidepressants (TCAs) are one of the few medications that have not been studied past their expiration date. This is potentially due to newer drugs like SSRIs and SNRIs being more common in practice as they have safer toxicity profiles.14According to a review of antidepressant overdose cases gathered from calls to Poison Control Centers, tricyclic antidepressants account for the second highest mortality index of all anti-depressants (40.7 per 10,000 exposures).15Only combination products such as olanzapine/fluoxetine and perphenazine/amitryptyline has a higher mortality index (45.7 per 10,000 exposures). It is worth nothing that the perphenazine/amitriptyline combination product has the highest mortality rate out of the combination products listed (74.1 out of 10,000), and that out of the individual products the TCAs had the highest specifically Amoxapine (124.2 out of 10,000) and Desipramine (141 out of 10,000). This toxicity is due to the cardiac effects of tricyclic antidepressants including dysrhythmias, EKG changes such as prolongation of conduction time, prolonged PR intervals and increased corrected pre-ejection period interval.14

Conclusion

Overall, there is much evidence for the safety and efficacy of medications past their stated expiration date. Many factors are involved in the lack of testing for extension of expiration dates. These include a lack of incentives, the high cost of testing, and the high burden of proof required to be submitted to the FDA. Much can be done to change this, however pharmaceutical companies fiercely fight to keep expiration dates within the traditional two to three year window. Drug manufacturers use patient safety as a defense, due to creation of new marketing materials in that time-frame. They claim patients may get confused between the old and new labeling.

Solid dosage forms tend to be more stable than liquid ones, and many medications, both solid and liquid, have been studied 70 months past their stated expiration dates in the SLEP study. The SLEP study has lead to massive cost savings in the DoD, SNS, and VA systems. This information is proprietary however, and while there is much interest in extending this information to the private sector and states, they argue that such programs would not result in equitable cost savings due to the unique set-up of entities involved in SLEP.

The SLEP study has also provided the FDA with information that can be used in guiding manufacturing pharmaceutical products to improve stability, such as using non-iron containing stoppers. Tetracyclines and tricyclic antidepressants are just a few examples of the need for more research into the safety and efficacy of medication past their expiration dates, as evidence to their harm is inconclusive.

Many medications have been tested past their expiration date, however the FDA, USP, and APhA currently all advise against the use of medications past their expiration date. The AMA also advises against the use of medications past their expiration date, however the have urged the FDA, USP and the pharmaceutical industry to continue to explore the safety, efficacy, risk, and economic benefits of extending expiration dates.

So with all this being said, do drug expiration dates really matter? The answer is honestly, it depends on the drug. There are a few drugs that can become toxic when taken past their expiration dates, however most drugs simply lose potency This means they may not be as effective as usual but will still be marginally effective and may still provide some benefit. I hope this helps! Let us know if you like these types of articles and we will be happy to provide more!

References:

1.     Commissioner, O. of the. (n.d.). MCM Legal, Regulatory and Policy Framework – Expiration Dating Extension [WebContent]. Retrieved October 20, 2017, from https://www.fda.gov/EmergencyPreparedness/Counterterrorism/MedicalCountermeasures/MCMLegalRegulatoryandPolicyFramework/ucm411446.htm

2.     (ProPublica), M. A. (n.d.-a). AMA report_CSA Rep 1 (Pharmaceutical Expiration Dates) a 01 FINAL… Retrieved October 20, 2017, from https://www.documentcloud.org/documents/3671873-CSA-Rep-1-Pharmaceutical-Expiration-Dates-a-01.html

3.     Khan, S. R., Kona, R., Faustino, P. J., Gupta, A., Taylor, J. S., Porter, D. A., & Khan, M. (2014). United States Food and Drug Administration and Department of Defense shelf-life extension program of pharmaceutical products: progress and promise. Journal of Pharmaceutical Sciences, 103(5), 1331–1336. https://doi.org/10.1002/jps.23925

4.     Lyon, R. C., Taylor, J. S., Porter, D. A., Prasanna, H. R., & Hussain, A. S. (2006). Stability profiles of drug products extended beyond labeled expiration dates. Journal of Pharmaceutical Sciences, 95(7), 1549–1560. https://doi.org/10.1002/jps.20636

5.     (ProPublica), M. A. (n.d.). Stability Profiles of Expired Drugs. Retrieved October 20, 2017, from https://www.documentcloud.org/documents/3525372-Stability-Profiles-of-Expired-Drugs.html

6.     (ProPublica), M. A. (n.d.-c). Expired drugs research letter. Retrieved October 20, 2017, from https://www.documentcloud.org/documents/3516397-Expired-drugs-research-letter.html

7.     Kozak, M. A., Melton, J. R., Gernant, S. A., & Snyder, M. E. (2016). A needs assessment of unused and expired medication disposal practices: A study from the Medication Safety Research Network of Indiana. Research in Social & Administrative Pharmacy: RSAP, 12(2), 336–340. https://doi.org/10.1016/j.sapharm.2015.05.013

8.     Kuspis, D. A., & Krenzelok, E. P. (1996). What happens to expired medications? A survey of community medication disposal. Veterinary and Human Toxicology, 38(1), 48–49.

9.     Cohen, L. P. (2000). Drugs frequently potent past expiration. Wall Street Journal.

10.  (ProPublica), M. A. (n.d.-b). Epinephrine Concentrations in EpiPens. Retrieved October 20, 2017, from https://www.documentcloud.org/documents/3696595-Epinephrine-Concentrations-in-EpiPens.html

11.   Teder, K., Pepeloshev, A., Matto, V., & Meos, A. (2013). Pharmacopoieal quality of non-expired and expired nifedipine formulations from Estonian and Russian Federation medicinal products market. Acta Poloniae Pharmaceutica, 70(3), 539–546.

12.  Binkhathlan, Z., Badran, M. M., Alomrani, A., Aljuffali, I. A., Alghonaim, M., Al-Muhsen, S., … Alshamsan, A. (2016). Reutilization of Tacrolimus Extracted from Expired Prograf® Capsules: Physical, Chemical, and Pharmacological Assessment. AAPS PharmSciTech, 17(4), 978–987. https://doi.org/10.1208/s12249-015-0433-7

13.  Frimpter GW, Timpanelli AE, Eisenmenger WJ, Stein HS, Ehrlich LI. Reversible “Fanconi Syndrome” Caused by Degraded Tetracycline. JAMA. 1963;184(2):111–113. doi:10.1001/jama.1963.03700150065010

14.  Khalid, M. M., & Waseem, M. (2017). Toxicity, Tricyclic Antidepressant. In StatPearls. Treasure Island (FL): StatPearls Publishing. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK430931/

15.  Nelson, J. C., & Spyker, D. A. (2017). Morbidity and Mortality Associated With Medications Used in the Treatment of Depression: An Analysis of Cases Reported to U.S. Poison Control Centers, 2000-2014. The American Journal of Psychiatry, 174(5), 438–450. https://doi.org/10.1176/appi.ajp.2016.16050523

 

Supreme Pizza Pasta

🍕Supreme Pizza Pasta🍕

For a healthier take on a hearty classic, try this pasta dish that’s loaded with veggies! Obviously for our gluten intolerant readers, substitute the traditional pasta with your favorite gluten free substitute!

♦️8 oz radiatore pasta (uncooked)

🔸2 tbsp olive oil

♦️4 oz sliced baby bella mushrooms

🔸1/2 green bell pepper (diced)

♦️1/4 red onion (diced)

🔸2.25 oz sliced black olives

♦️2.5 oz mini pepperoni

🔸3 oz cooked Italian sausage pieces (not pictured)

♦️14 oz diced tomatoes (no salt)

🔸1/3 cup Parmesan ♦️black pepper

🔸shredded mozzarella (not pictured)

▪️Cook the pasta according to package directions.

▪️Sauté mushrooms, pepper, and onion in olive oil until softened.

▪️Add olives, meats, and tomatoes until heated through.

▪️Add mixture to pasta, and stir in Parmesan and black pepper.

▪️Serve topped with mozzarella.

~

Mingled Vitality, March 28, 2018

Starting a Dance Troupe

So, you and your friend are sitting in your room on a Saturday night dancing to music and looking up youtube videos like this one (Who doesn’t love Shakira?) and thinking, “We should start a dance troupe!” Have you ever had that thought? Have you ever wondered what you actually need to start dancing on a real stage? The answer to what all it takes may surprise you.

Here is everything you need to start a dance troupe:

People:

The first thing you need is actual dancers! This is typically the easiest to get since you probably know at least a few people who like to dance. When asking people to join your troupe, especially friends always consider group dynamics. If you’re going to have any type of leadership structure in your troupe, you will want to organize that ASAP. Establishing those roles, expectations, and responsibilities sooner rather than later can cut down on a lot of potential drama. The last thing you need is for your troupe to fall apart over an argument about a guy. (I’ve seen it happen, trust me, it’s ugly)

If you want to attract dancers that you may not personally know then that can be easy as well. In this wonderful world we live in social media makes it easier than ever to find others with similar interests. Post on Facebook, stalk Instagram accounts of local dancers in your area, or post flyers around your college. If you are in high school or college look into your schools already existing organizations. They may already have a belly dancing group established. If not you can look into starting one.

I know when I looked into starting a belly-dancing organization at Texas A&M it was surprisingly easy. They had me sign up for a class online, which gave me all the information I needed. They were also kind enough to offer to to connect me with an adviser to assist with any technical details. See if your school offers a similar service. You can also post a flyer offering auditions at local bars and coffee shops. Or anywhere else you think you may be able to find fellow dancers.


Practice Space:

Dace space is important, but a practice space does not necessarily need to be a dance studio. However, if you have access to one that would be the most ideal. For those of us who don’t live in mansions with a free dance studios in our basements, here’s some alternatives.

The best teacher I ever had taught out of our friend’s garage. She cleaned the garage, hung a few mirrors on the wall, used some curtains to hide the power-tools, and voila! Instant dance studio. The key to turning a garage (or any room) into a dance studio is the mirrors. Mirrors can be found at most large locations like Target or Walmart for only $20

It can be incredibly beneficial to see what you are doing as you practice. You also need space. If you are going to perform on any stage, even a small one, it will typically be at least as large as a standard room if not many times larger. That is why it is important to not practice in your bedroom where you are having to dance around a bed, but rather in a living room with your couch moved out of the way, or even in your backyard (or a friend’s backyard) with some free space that isn’t taken up by a pool (Falling into the pool is generally not recommended).

If you do not have access to any of those spaces, I know of one last option for you. Most gyms will have some sort of dance room or racquet ball court. One with a dedicated dance room that would be ideal, since they should already have mirrors on the wall. Check their class schedule, and see if you can use the room when there are no classes in there. If you cannot find a dance room, try looking for a racquet ball court. These tend to be a bit more spacious, however they do not have mirrors. You can bring some mirrors from home and lean them against the walls.

Just be aware if you do this option your rehearsals may not always be private, and you may get some onlookers or run into issues with the gym staff. Always be polite and respectful and ask before you bring in large pieces of equipment like a stereo or mirror into a gym. The last thing you want is to get kicked out of the middle of your practice by an angry staff member. In my experience though, especially if it is a small group, most gyms don’t mind you using their room as long as you are a member of the gym and don’t mind the lack of privacy.

You can also consider looking at martial arts studios as they typically also have an open space with mirrors on the wall. My troupe was able to work out a deal with a local martial arts studio where we were able to rent the space for only the cost of the lights as long as the owner’s wife could join our troupe. This was a great way to get another excited dancer AND a practice space all in one! This was a no-brainer decision, and she quickly became one of the best dancers in our troupe.

If none of these options are available to you, that is when you may have to look into paying for spaces. If you know where you want to perform, then you can potentially make a deal with the venue to let you practice there, in agreement for bringing in a large crowd on performance day. You can also ask about coming in during non-traditional hours and seeing if they may give you a discount for that. Most venues do not open until later in the day. So if you are your group are willing to come in early especially during the weekday than you may be able to get a better price on using the space. It never hurts to ask for a discount!


Music:

Besides the actual music, you also need a way to play that music. That is where most of the problems come in. While most professional venues will have a sound system, a lot of the smaller or outdoor venues that you may be starting out at will not. You may also want to consider a sound system if your practice space does not have one built in. Your phone will not and should not be able to provide the necessary sound for the large practice space you will need. (Can you imagine accidentally turning up your phone volume loud enough to be heard over an entire large outdoor venue? Ouch!) If your practice space is small enough that you can hear the music through your phone speakers, you need a larger space to practice.

What my troupe did was each chipped in a little bit towards the sound system. Our group collected tips at each performance, and we agreed as a group to not take home our tips, but instead save them to buy the sound system that we wanted. This worked fairly well for us.


Choreography:

Youtube is an excellent resource for choreography. There are countless videos ranging from the most basic how-to tutorial, to incredibly professional and beautiful performances. This can be a great (and free) starting place to begin learning choreography. You can also consider asking some of the local dancers in your area. When I wanted to connect with other dancers I found Victoria Teel. I was lucky enough to work with her when we were both still in college. She later went on to perform on BellyDance SuperStars. Now she teaches belly dance classes online, and sells the fans she uses for her Teel Fan Method. Taking classes with her, or any other professional bellydancer, is a great way to get choreography. The major drawback being that it won’t be free.

Don’t underestimate your own creativity though, you can do so much just by taking the time to practice. I would spend an hour or two before all of my training sessions with Victoria practicing by myself, and if I thought of a great move I wanted to remember I wrote it down so I wouldn’t forget it. There were so many times when I would just be playing around and think of some great choreography, but forget to write it down or record it. Your phones video camera can be your best friend when practicing choreography! Don’t underestimate the value of writing down and recording choreo like I did! Trust me my performances got so much better when I started watching my recordings and taking notes. I would suggest you do the same.

You do not need a fancy camera to record choreography, but having a tripod might not be a bad idea. There were many times when our troupe would have to find an innocent bystander to take a video of our practice because we didn’t have a way to prop up a phone properly. Asking a friend works, but man there were times when having a tripod would have really helped us. You can get them for cheap on amazon


Costumes:

We have talked a whole bunch about bellydancing costumes in our previous article “From Bedleh to Baladi”. For learning about all the differences between the different types of costumes definitely check that article out. We also have an article talking about the differences between making and buying a bellydancing costumeSo check out these articles to learn more about costumes.

Tip1

A name and brand for your troupe:

Coming up with names can be the most fun part of starting a dance troupe. There is a reason why people pick out baby names before they are even close to becoming parents. So it is very possible that you have names in mind already.

Your name doesn’t have to be perfect right off the bat though! Names, logos, and styles can all change. But what is most important however, is your brand. If you want to be known as the family friendly middle eastern dancers, rather than the sexy and sensual belly-dancers, that’s important to establish early on when forming your troupe. This will define your brand. Having a dancer who has a more sensual style can be a great thing! If that is what your
troupe wants. However, if they do not want seduction and instead want to be branded as more family friendly than there are now different brands within a troupe, making you look disjointed, and may cause some venues to not want to work with you.

This is not to say that any one brand or style of dance is better than the other. The exact opposite can be said about a troupe wanting to be more seductive, and a dancer in that troupe wanting to be more family- friendly. There should be no discrimination within a dance troupe. I am only offering experience from the perspective of someone who started a troupe in a relatively small town in south Texas, where everything is bigger in Texas including the differences in responses we would get from others about our troupe. We would have performance venues think we were strippers, and were not only okay with the idea but wanted it. (Needless to say- we didn’t work with those places). While other venues would only accept us if we were wearing certain, more conservative outfits.

What we did is have one group of dancers that was more engaged with our performances at bars and music events, and another group of dancers more engaged with our family friendly events. We were all part of the same troupe, we just branded ourselves differently for different events based on the nature of the crowd, venue, and performance. Being aware that venues may ask you about branding, and being prepared for an answer is important. If you are in a large city the style may not be as important as it was in Texas, but differentiating yourself from other troupes they might already know will be.

I would recommend picking one person from your troupe who will be the coordinator for your performances. This person (or people) will be responsible for representing your group. So pick somebody with appropriate social skills, who can ask the questions necessary to find out what type of branding is necessary and what the expectations of the venue are. Having that go to person is part of your brand, they are identified as one of you. So it can be completely appropriate to have one go to person for the bars and music event venues, and another for the community-oriented family-friendly events.

This is what we did and it worked well in part because it took the burden of being the single contact person off of one individual. However, once a venue has made a connection with a member of your troupe, I would not recommend changing this person often. As once venues gets to know a group, if they constantly are interacting with different people within the group they can get confused. They will want one person who is their go to person, so they know who to call.


Places to perform:

Whew! What a lot of work so far! But now that we’ve made it this far we’re finally ready to start talking about WHERE you’re going to perform! Finding venues is a simple matter of networking. Find local bars in your area that have local musicians come and perform. Look for community events, horse races, talent shows, campus-wide student activity events, or anything that you can think of really. The chances to perform are practically endless!

Once you have identified a list of potential places to perform. Spend some time preparing before you pitch to them. Know what dates you can perform on, how long you can perform, what your set list will be, if you will be open to recurring events or not, if you will be asking for tips or not, etc. These will be standard questions asked when starting to work with a performance venue. Just know that not every place that you may want to perform at will be a good fit for you. Be prepared to talk to 5 places, and even if 4 say no and one says yes, this means that you have your first performance venue for your very first dance performance as a troupe!


Drive and Passion:

There can be many logistical issues with starting a dance troupe, but if you have the energy, drive, and passion, there is no reason you can’t start your very own dance troupe. Even if you have 100 hurdles between you starting your troupe, and fail 99 times, just remember what Thomas Edison said: “I have not failed. I’ve just found 10,000 ways that won’t work.” Combine his resilience and the “Just keep swimming” attitude of Dory and you’ll have the winning combination of characteristics necessary to start a dance troupe.