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A Painful PGx Codeine Controversy | Pain Pod · Pharmacy Podcast Network

• 0:05
  Speaker 1: You are listening to the global network of podcasters dedicated
• 0:09
  Speaker 1: to the pharmacy profession. Welcome to the Pharmacy Podcast Network.
• 0:34
  Speaker 2: Welcome to The Pain Pod, the podcast for all things
• 0:39
  Speaker 2: pain management, hosted by the pain guy, Dr.
• 0:43
  Speaker 1: Mark Groffoli.
• 0:48
  Speaker 2: We'll be collaborating with numerous pain management experts, talking about
• 0:52
  Speaker 2: substance usage disorders, the latest treatment modalities, and most important,
• 0:58
  Speaker 2: focusing on the pain of our patients as.
• 1:01
  Speaker 1: Leading providers of pain care.
• 1:05
  Speaker 2: And now here's our host, a man wanted in all
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  Speaker 2: 50 states, a suburban city.
• 1:12
  Speaker 1: Like mountain man. Without the beard.
• 1:16
  Speaker 2: From the hills of West Virginia and certified in weapons
• 1:21
  Speaker 2: of mass destruction response.
• 1:24
  Speaker 1: It's Dr. Mark Garofali. Welcome everyone to the Pain Pod.
• 1:34
  Speaker 1: Hopefully we're welcoming you back to the Pain Pod, of course.
• 1:38
  Speaker 1: Here today, yours truly, your host, Mark Pain Guy Garofali.
• 1:42
  Speaker 1: We're going to do, well, we can call it some
• 1:45
  Speaker 1: investigative reporting, but what we're going to do, we're going
• 1:46
  Speaker 1: to have ourselves a situation, okay? A la Jersey Shore,
• 1:51
  Speaker 1: of course. That one's for you, Mike. But anyways, we
• 1:54
  Speaker 1: got ourselves a situation. We've got a controversy, okay? What
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  Speaker 1: we've got here today on the pain pod is a
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  Speaker 1: painful pharmacogenetic codeine controversy. That's a mouthful, right? But in essence,
• 2:08
  Speaker 1: what we're going over here is, of course, the general
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  Speaker 1: idea of should a clinician or all of us clinicians
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  Speaker 1: ever shift practice based on one study or even one
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  Speaker 1: guideline or one case study, you name it, right? Deep
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  Speaker 1: thought there, folks. I'm going to follow up with a
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  Speaker 1: little bit more granular, specific question here for you. Y'all
• 2:30
  Speaker 1: see the Lancet, quote unquote, you can see my two
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  Speaker 1: peace signs with my hands indicating quotes right now. The
• 2:38
  Speaker 1: Lancet Expression of Concern back in February of 2026. So
• 2:44
  Speaker 1: the Lancet had that expression of concern regarding the original 2006.
• 2:48
  Speaker 1: So like two decades ago, the publication of a case
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  Speaker 1: study involving a newborn infant who very unfortunately died with
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  Speaker 1: a toxic post-mortem morphine concentration. So, very unfortunate situation, of course,
• 3:04
  Speaker 1: from decades prior. But did y'all see that in the Lancet? Well,
• 3:10
  Speaker 1: good golly, even the New Yorker. Yes, the general, lay
• 3:13
  Speaker 1: public for all of us publication, the New Yorker covered
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  Speaker 1: it this year too. Yet how many of us healthcare
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  Speaker 1: professionals didn't see or read that one either? Too many.
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  Speaker 1: That's how many. Too darn many. We're not going to
• 3:26
  Speaker 1: put the reading nerd caps on just yet, but in
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  Speaker 1: a very short period of time here in this episode,
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  Speaker 1: we're going to cover a couple articles. We'll highlight two
• 3:35
  Speaker 1: or three of them, but it'll involve some very important
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  Speaker 1: ones in the background. Let's dive in to save y'all
• 3:41
  Speaker 1: an hour or three, if not eight, of the reading
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  Speaker 1: and the research. It all starts with the OG case.
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  Speaker 1: The original 2006 case that was published in The Lancet
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  Speaker 1: in 2006. And it basically was describing a situation with
• 4:03
  Speaker 1: about a two week old baby. And that case report
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  Speaker 1: described a 13 day old breastfed infant boy who died, unfortunately, obviously,
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  Speaker 1: with a postmortem morphine concentration of 70. And that range
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  Speaker 1: could be debated, but typically between, say, 10 to 40.
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  Speaker 1: We'll go with that. The bottom line is elevated post-mortem
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  Speaker 1: morphine concentration. Which, by the way, of note, I think
• 4:30
  Speaker 1: it's probably important to mention that it took 12 weeks
• 4:33
  Speaker 1: to receive those results. Y'all ever heard of having to
• 4:36
  Speaker 1: wait 12 weeks, like three months, to get results from
• 4:39
  Speaker 1: the lab? Oh my goodness, if it's three minutes, we
• 4:42
  Speaker 1: lose our minds sometimes. But back to the case, right?
• 4:45
  Speaker 1: So the 32-year-old mother she had postpartum pain. It happens, right?
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  Speaker 1: She was prescribed and was utilizing codeine, acetaminophen, or maybe
• 4:58
  Speaker 1: some of you say acetaminophen codeine, or some might say
• 5:01
  Speaker 1: Tylenol with codeine. We'll say T3, okay? She was utilizing
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  Speaker 1: T3 at a dosage of two tablets twice a day.
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  Speaker 1: And that was after an uncomplicated pregnancy and delivery, of course.
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  Speaker 1: But the mom had developed some tiredness and constipation. So
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  Speaker 1: that dosage of the T3 was adjusted from two tablets
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  Speaker 1: twice a day to one tablet twice a day. So
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  Speaker 1: the dosage was cut in half, okay? Now, you know,
• 5:28
  Speaker 1: you got a two-week-old baby and, you know, they do
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  Speaker 1: a lot of things, but they delight families, right? It's
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  Speaker 1: such a joyous time. So for all of our fellow
• 5:38
  Speaker 1: parents out there and aunts and uncles and cousins and
• 5:41
  Speaker 1: you name it, it's a joyous time, right? So, you know,
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  Speaker 1: that baby boy was certainly delighting his family. And, you know,
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  Speaker 1: almost two weeks after birth was suddenly sleeping a bit
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  Speaker 1: more than usual. It was even noted by the parents
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  Speaker 1: that it was 20 hours in one day. Okay. And
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  Speaker 1: that one day that, you know, sleeping 20 hours in
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  Speaker 1: one day, it also happened to be the day of
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  Speaker 1: his routine peds appointment.
• 6:05
  Speaker 2: Okay.
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  Speaker 1: And that care team noted, you know, that he was somnolent,
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  Speaker 1: of course, but, you know, generally wasn't concerning. That night, however,
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  Speaker 1: that continued. So there was concern, and the mom sense
• 6:17
  Speaker 1: went off. So his mom called EMS, and they eventually
• 6:22
  Speaker 1: arrived and attempted CPR for a solid 40 minutes until
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  Speaker 1: confirming the infant's death. And that was actually despite his
• 6:30
  Speaker 1: parents noticing that he stopped breathing about a minute or
• 6:32
  Speaker 1: two before the ambulance even arrived. To say it's an
• 6:36
  Speaker 1: unfortunate situation comes up a bit short. It's an absolutely
• 6:40
  Speaker 1: horrid loss of life. you know, hopefully we as healthcare
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  Speaker 1: professionals can honor Tariq's life by striving to provide the
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  Speaker 1: safest and most effective postpartum pain management for mothers. And
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  Speaker 1: by the way, by association to their newborn little infant
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  Speaker 1: babies as well. So let's go a little bit deeper
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  Speaker 1: into this case, of course. So, you know, eventually, and many,
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  Speaker 1: if not all of y'all, know how this case unraveled afterwards, right?
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  Speaker 1: You know, genetic testing showed that the mom was a CYP450,
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  Speaker 1: so the liver enzyme, 2D6 ultra-rapid metabolizer, meaning basically that
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  Speaker 1: her body-specific liver metabolized or processed the codeine to morphine
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  Speaker 1: much more than an average person with a typical 2D6
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  Speaker 1: metabolic phenotype. Additionally, it was found that the mother's breast
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  Speaker 1: milk contained 87 nanograms per ml of morphine.
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  Speaker 2: Okay.
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  Speaker 1: So the general causation or timeline here, the proposed chain
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  Speaker 1: of causation here would basically be, well, there was maternal
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  Speaker 1: 2D6 ultra-rapid metabolism that increased the conversion of codeine to
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  Speaker 1: morphine in the mom, producing unusually high maternal morphine exposure,
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  Speaker 1: leading to high morphine concentration in the breast milk, leading
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  Speaker 1: to infant morphine exposure, neonatal opioid toxicity, and infant death overall. Now, pharmacologically,
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  Speaker 1: that's a very plausible pathway. But there's a huge difference
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  Speaker 1: between this pathway is possible and this pathway explains this death.
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  Speaker 1: And that's what we want to dive a little bit
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  Speaker 1: further into here. And the road's already been paved for
• 8:18
  Speaker 1: us with some subsequent updates and articles. Where we basically
• 8:24
  Speaker 1: have a little bit of a pharmacological plot twist. Okay? So,
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  Speaker 1: Fast forward to 2020, you know, during the pandemic, as
• 8:32
  Speaker 1: if anything else were going on in the world at
• 8:34
  Speaker 1: the time. Well, there was also basically two journals, Canadian
• 8:40
  Speaker 1: Family Physician and the Canadian Pharmacist Journal. Both of those publications,
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  Speaker 1: you know, formally retracted articles based on the case after
• 8:52
  Speaker 1: independent reviewers concluded that the findings were unreliable and met
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  Speaker 1: publication ethics criteria for retraction. The journals actually specifically cited
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  Speaker 1: concerns raised by the analysis that was performed in 2020.
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  Speaker 1: It was by two folks by the name of Zapersky
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  Speaker 1: and Drew Link. We'll have all the stuff in the
• 9:12
  Speaker 1: show notes for you folks for lots of additional reading
• 9:14
  Speaker 1: if you so choose. But anyways, they cited the concerns
• 9:17
  Speaker 1: from the analysis, including the toxicology findings. And generally, there
• 9:23
  Speaker 1: was implausibility of the proposed mechanism overall. So this is changing.
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  Speaker 1: This is big time, okay? A major issue discussed in
• 9:31
  Speaker 1: the subsequent criticism is the amount of drug that would
• 9:34
  Speaker 1: be expected to reach an infant through breast milk. Like,
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  Speaker 1: how much in the end, right? That 2020 analysis argued
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  Speaker 1: that the proposed explanation was highly implausible based on several factors.
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  Speaker 1: Let's go through a few, okay? The very small amount
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  Speaker 1: of opioid normally transferred into the breast milk. It's just
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  Speaker 1: not usually a large percentage, right? And then also the
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  Speaker 1: infant's ability to accumulate morphine. And finally, even the post-mortem
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  Speaker 1: toxicology findings that did not fit nice and packaged in
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  Speaker 1: neatly with the breast milk only hypothesis. And get this, okay,
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  Speaker 1: but wait, there's more. There was one particularly important finding,
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  Speaker 1: and it was that there was the reported presence of
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  Speaker 1: codeine itself in the infant's post-mortem blood, along with acetaminophen.
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  Speaker 1: Which does not necessarily make sense, given that the mother
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  Speaker 1: would have metabolized the codeine and morphine prior to breastfeeding
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  Speaker 1: the infant. The case study of the infant's last reported
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  Speaker 1: substantial feeding had taken place, said to be, 18 hours
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  Speaker 1: before his death. Considering, remember back, he slept for about
• 10:44
  Speaker 1: 20 hours that day, so he'd been sleeping the whole day,
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  Speaker 1: and his parents stated a lack of feeding that day.
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  Speaker 1: One would not expect much of anything in the infant's stomach, right?
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  Speaker 1: But the post-mortem examination revealed that the stomach had no
• 10:57
  Speaker 1: abnormalities or obstructions or anything like that, yet it contained
• 11:00
  Speaker 1: 2 mLs of white curdled material. Which forensic testing, by
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  Speaker 1: the way, from two independent analytical methods, detected codeine but
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  Speaker 1: not morphine. which could suggest actually direct administration. That took
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  Speaker 1: a turn, right? So let's think about that a little deeper.
• 11:18
  Speaker 1: Let's think it through. And at the time, the child
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  Speaker 1: would have been 12. So a 12-day-old infant, not 12 years,
• 11:25
  Speaker 1: a 12-day-old infant cannot crawl, cannot grab, can't put anything
• 11:29
  Speaker 1: in its mouth, then certainly could not swallow a T3 pill.
• 11:34
  Speaker 1: Yet direct administration would justify the staggering toxological findings, right?
• 11:41
  Speaker 1: Those considerations, though, did not automatically prove direct administration. It
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  Speaker 1: does create a major alternative hypothesis than the original PGX
• 11:50
  Speaker 1: explanation that that didn't adequately really resolve. And that's exactly
• 11:56
  Speaker 1: the type of finding that can change a causation interpretation.
• 11:59
  Speaker 1: It comes to causation, folks. Oh, my goodness. The Halloween times.
• 12:02
  Speaker 1: One of the scariest jack-o'-lanterns I could think of, right?
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  Speaker 1: Has the words carved in it. Causation from correlation. That's scary.
• 12:09
  Speaker 1: That's worse than any Halloween scary movie. I know. I
• 12:13
  Speaker 1: hope you have a little chuckle, even though we're talking
• 12:15
  Speaker 1: about scary stuff. And quite a heavy case here, by
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  Speaker 1: the way. Speaking of the case, by the way, the
• 12:20
  Speaker 1: dose makes the story even more complicated. The original report
• 12:24
  Speaker 1: described the mother's codeine regimen as initially two of the tablets,
• 12:29
  Speaker 1: and each tablet contained 30 milligrams of codeine. So two
• 12:33
  Speaker 1: tablets every 12 hours. That was subsequently cut in half
• 12:36
  Speaker 1: because of the tiredness and constipation. So then she was
• 12:38
  Speaker 1: getting one tablet that had 30 milligrams of codeine every
• 12:41
  Speaker 1: 12 hours. Okay. Let me throw a little side note
• 12:46
  Speaker 1: in here for you. So side note, a little pain pearl.
• 12:48
  Speaker 1: You know, the hydrophilic opioids are usual guys, the morphine, hydrocodone, codeine,
• 12:54
  Speaker 1: even oxycodone, you name it. can often facilitate, you know,
• 12:57
  Speaker 1: more constipation because they're hydrophilic. Again, the GI tract compared
• 13:00
  Speaker 1: to our lipophilic or heavy hitter prescription opioids. But codeine
• 13:05
  Speaker 1: actually can facilitate constipation in even lower dosages rather than
• 13:08
  Speaker 1: the respective higher dosages. Go figure. There's a pearl for you.
• 13:11
  Speaker 1: All right. Anyways, back to the case here. So, you know,
• 13:16
  Speaker 1: investigators interpreted the mother's symptoms as supporting that ultra-rapid metabolizer hypothesis,
• 13:22
  Speaker 1: which is reasonable as a hypothesis. Yet, maternal symptoms don't
• 13:27
  Speaker 1: prove that the infant received a lethal dose through breast milk. Similarly,
• 13:34
  Speaker 1: finding the very high morphine concentration in the infant establishes
• 13:37
  Speaker 1: opioid exposure, but in and of itself does not establish
• 13:42
  Speaker 1: the route of exposure, which is a distinction that is
• 13:46
  Speaker 1: fundamental in clinical toxicology. In addition to all that, the
• 13:51
  Speaker 1: evidence is not necessarily always reproducible, which is a concern.
• 13:56
  Speaker 1: You know, that original, the OG case from 2006 was
• 14:00
  Speaker 1: cited hundreds of times, if not more, quite frankly, and
• 14:04
  Speaker 1: had a substantial effect on postpartum analgesic prescribing. That 2020
• 14:10
  Speaker 1: retraction from the two journals, Canada, specifically noted that the
• 14:15
  Speaker 1: report has significantly influenced prescribing practices. The report from 2006,
• 14:19
  Speaker 1: that's 14 years of significance there. But the fact that
• 14:24
  Speaker 1: a clinical recommendation may have a reasonable safety rationale today
• 14:28
  Speaker 1: does not necessarily validate the evidence that originally drove that recommendation.
• 14:32
  Speaker 1: That's a really important distinguishment, folks. All right, so where
• 14:37
  Speaker 1: are we today? So our current conundrum. So on January
• 14:42
  Speaker 1: 6th of 2026, I alluded to this earlier, but the
• 14:44
  Speaker 1: New Yorker ran a story for the lay public, for everybody,
• 14:48
  Speaker 1: highlighting the concerns of this case. Did you read it? Well,
• 14:52
  Speaker 1: if not, how did that not come up in social
• 14:55
  Speaker 1: media for you? Me too, by the way. You know,
• 14:58
  Speaker 1: what's our algorithms giving us? Oh, cute animals, beautiful Hawaiian landscapes,
• 15:02
  Speaker 1: maybe some good food here and there. Who knows what else,
• 15:05
  Speaker 1: but it's all about the algorithms, baby, right? Well, the
• 15:10
  Speaker 1: New Yorker investigation described some additional concerns, okay, regarding the
• 15:14
  Speaker 1: toxicology and the interpretation of the infant's death, including the
• 15:17
  Speaker 1: significance of codeine acetaminophen concentrations, and even allegations surrounding the
• 15:23
  Speaker 1: broader research record. Those are reported allegations and investigative findings,
• 15:27
  Speaker 1: so they need to be distinguished from independently established pharmacological facts,
• 15:32
  Speaker 1: of course. So a couple weeks later, January 20th, 2026,
• 15:37
  Speaker 1: the Lancet was actually contacted, because they had the OG article,
• 15:42
  Speaker 1: with fresh allegations concerning data falsification. You know, thinking about
• 15:46
  Speaker 1: the tox data, right? along with ethical issues and authorship
• 15:50
  Speaker 1: problems tied to that OG 2006 report. So the Lancet
• 15:54
  Speaker 1: actually referred the new allegations to, let me get this
• 15:57
  Speaker 1: straight here, to the Research Integrity Office at Toronto's Hospital
• 16:01
  Speaker 1: for Sick Children, also known as SickKids, to initiate a
• 16:05
  Speaker 1: formal investigation, leaving open the possibility of a future retraction.
• 16:10
  Speaker 1: Onward to the next month, so February 14th, 2026, Valentine's Day,
• 16:15
  Speaker 1: What a love story, right? I wonder what Cupid's 2D6
• 16:18
  Speaker 1: phenotype was. Also, what would I do with that info? Well,
• 16:22
  Speaker 1: it's the same as you, right? Not too much. Anyways,
• 16:25
  Speaker 1: so Valentine's Day, the Lancet itself published, here comes my
• 16:28
  Speaker 1: two-piece signs on both sides of my skull here, going,
• 16:33
  Speaker 1: you know, for the quotes, Expression of Concern about the
• 16:37
  Speaker 1: original OG 2006 case study paper. By the way, that
• 16:42
  Speaker 1: is an important distinction from a retraction. It signals that
• 16:44
  Speaker 1: the journal has identified serious concerns requiring that further in consideration,
• 16:49
  Speaker 1: but had not, at that point, retracted the original article.
• 16:52
  Speaker 1: So that's where we're standing, right? So let's think about
• 16:55
  Speaker 1: this in the big picture. What's some concerns here? Okay,
• 16:57
  Speaker 1: we're gonna go into logic. It's not really philosophy, but logic, okay?
• 17:01
  Speaker 1: Let's do some, back in geometry times, some of us
• 17:05
  Speaker 1: learned about proofs back in elementary school, right? So here,
• 17:09
  Speaker 1: first statement, drug A can cause B Patient took drug A.
• 17:14
  Speaker 1: The patient developed B. Therefore, drug A caused B. Hmm.
• 17:21
  Speaker 1: That reasoning feels natural, right? But it's incomplete. It leaves
• 17:26
  Speaker 1: one thinking you got the answer, but it's not absolute.
• 17:32
  Speaker 1: What should happen, though, is in a case such as this,
• 17:37
  Speaker 1: us clinicians being propelled to ask questions. Like in this case,
• 17:41
  Speaker 1: was the exposure significant? Was the timing compatible? Was the
• 17:45
  Speaker 1: measured concentration consistent with the proposed exposure? Was the route
• 17:49
  Speaker 1: of exposure established? We beat that drum earlier, right? Are
• 17:52
  Speaker 1: there alternative sources of the medication? Are there alternative explanations
• 17:56
  Speaker 1: for the event? Are the lab results internally consistent? Can
• 18:02
  Speaker 1: the proposed mechanism reproduce the observed concentration? Have similar events
• 18:07
  Speaker 1: been observed independently? And in general, does the broader literature
• 18:11
  Speaker 1: support the proposed relationship? In this overall coding case here,
• 18:15
  Speaker 1: our situation we'd be facing, several of those questions became problematic.
• 18:20
  Speaker 1: And that's why we're discussing it on the pain pod.
• 18:22
  Speaker 1: This is where we push further. We push past the
• 18:25
  Speaker 1: limits of genuinely accepted information. Ask why. Repeatedly. PRN. So
• 18:32
  Speaker 1: in this overall situation, the pharmacogenetics may have been the
• 18:37
  Speaker 1: wrong answer to the right question, if you think about it, okay?
• 18:41
  Speaker 1: Back to the OG case. So the mother really did
• 18:44
  Speaker 1: have a 2D6 genotype that was an ultra rapid metabolizer, right?
• 18:48
  Speaker 1: So we have to distinguish between two things, if not more,
• 18:51
  Speaker 1: but two things, okay? One, the mother was an ultra
• 18:54
  Speaker 1: rapid metabolizer, period. That's it for one. And two, the
• 18:59
  Speaker 1: mother's ultra rapid metabolizer phenotype caused the infant's death. Big
• 19:04
  Speaker 1: difference there, right? The first is a pharmacogenetic observation, while
• 19:07
  Speaker 1: the second is a causal conclusion, and those are very
• 19:11
  Speaker 1: different claims. You know, the genotype may explain why the
• 19:15
  Speaker 1: mother experienced more pronounced opioid effects, that tiredness, constipation, or
• 19:18
  Speaker 1: why she generated more morphine than another patient. But that
• 19:22
  Speaker 1: does not automatically establish that enough morphine could have passed
• 19:25
  Speaker 1: through the breast milk to produce the observed lethal exposure
• 19:28
  Speaker 1: in the infant. And what about the coding in the
• 19:30
  Speaker 1: infant's post-mortem blood? Whoa! Real pharmacology. yet not universally causative overall.
• 19:39
  Speaker 1: So what do we take away from this case or
• 19:42
  Speaker 1: this situation overall? What's our key takeaways here? So the
• 19:46
  Speaker 1: OG case should probably no longer be presented as an
• 19:49
  Speaker 1: uncomplicated example of 2D6 ultra-rapid metabolism causing fatal morphine poisoning
• 19:55
  Speaker 1: through breast milk. As the causal interpretation is heavily disputed
• 19:59
  Speaker 1: and under formal journal scrutiny, some have been retracted. Rather,
• 20:07
  Speaker 1: it's actually a complicated case. including an academic pharmacological principle
• 20:12
  Speaker 1: potentially plausible in future patient care scenarios, right? So, you know,
• 20:19
  Speaker 1: what's our pearls here in the big picture? So, you know,
• 20:21
  Speaker 1: the classic teaching point was that 2D6 ultra-rapid metabolase can
• 20:25
  Speaker 1: convert more codeine to morphine, right? The real-life teaching point, though,
• 20:30
  Speaker 1: is yes, but does that explain the patient's outcome, okay?
• 20:36
  Speaker 1: We always want to just say no, right? And y'all
• 20:39
  Speaker 1: know me by now. I mean K-N-O-W. Know the pharmacology.
• 20:44
  Speaker 1: Know the genotype. Know the tox. Know that toxicology. Know
• 20:48
  Speaker 1: the limits of the evidence. And perhaps most importantly, know
• 20:52
  Speaker 1: what the evidence does and does not allow one to conclude.
• 20:57
  Speaker 1: After all, intelligence is knowing what one does not know.
• 21:02
  Speaker 1: So I'll leave us with that in this relatively rapid
• 21:05
  Speaker 1: rundown of this situation overall, okay? But I do invite
• 21:09
  Speaker 1: you all, PainPod Nation, join us next time on the
• 21:12
  Speaker 1: PainPod when we take a deeper dive into PGX and pain,
• 21:15
  Speaker 1: ironing out the details, removing the fluff, and giving you,
• 21:18
  Speaker 1: PainPod Nation, the clinical pearls that actually matter for your knowledge, expertise,
• 21:22
  Speaker 1: and patient care. And for all of our patients and
• 21:25
  Speaker 1: pain listening, for you, and for everyone else, lay public,
• 21:28
  Speaker 1: clinicians alike, the information is for all here on the PainPod.
• 21:33
  Speaker 1: And as always, folks, I thank you for your time,
• 21:36
  Speaker 1: and I wish you a great day every day.
• 21:40
  Speaker 2: If you'd like to join Mark on the PainPod, send
• 21:43
  Speaker 2: us an email to publisher at pharmacypodcast.com. And make sure
• 21:49
  Speaker 2: to share the show and subscribe on your favorite podcast directory.
• 21:53
  Speaker 1: Thanks for listening.