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[post_content] => As the custodians of medicine safety, promoting the judicious, quality and safe use of medicines is key to pharmacists’ roles. But it is also important to work with other health professionals to improve outcomes for all Australians.
At the Medicine Safety Forum held in Canberra on Tuesday, leaders from the health sector, government, academia and members of the public came together to discuss medicine safety.
It was an opportunity to build on the momentum generated by medicine safety and the quality use of medicines being named the 10th National Health Priority Area last month.
https://twitter.com/PSA_National/status/1203801841844154368
Attendees included Painaustralia CEO Carol Bennett, who said the forum provided a good starting point for a conversation about the safe, quality use of medicines as part of Australia’s national health policy.
As participants discussed, a focus on the regulation of medicines in isolation, including their cost and availability, is not in the best interests of consumers, who also need support with non-pharmacological strategies to manage their conditions.
Ms Bennett was positive about discussion that allowed key health bodies to build on the National Medicines Policy to formulate links to wider health policy, acknowledging that the quality use of medicines is just one component.
'We need to get the balance right,’ she told Australian Pharmacist.
Different perspectives from a range of stakeholders were welcomed by Ms Bennett. In particular, she was pleased to see consumers included in the forum, as consumer bodies have been petitioning for. Responding to the needs of the consumer is essential to 'produce policy in the context of people's lived experience,’ she said.
The people’s perspective
Consumers Health Forum CEO Leanne Wells asked attendees to ‘think differently’ to improve medicine safety. This includes improving medicines literacy and providing fit-for-purpose information.
https://twitter.com/JacintaAdelaide/status/1203800923048308736
Consumer representative Jen Morris said she was heartened by this discussion.
‘I think it’s inevitable that any plan or process for trying to improve the healthcare system requires cooperation and understanding between all parties involved – including consumers,’ Ms Morris told AP.
‘It was encouraging to see people recognising the value of consumers and the importance of working together to contribute to medicine safety efforts.’
https://twitter.com/DrSuziNielsen/status/1203889449962065920
Ms Morris has been a consumer representative for 12 years and said she is passionate about improving the quality of care for all Australians.
She has seen the discussion around medicine safety shift over the past decade.
‘People are now putting consumers and patients at the centre of the conversation and accept that the consumer perspective needs to be considered,’ she said.
‘Myself and the other consumers at the forum weren’t the only people in the room bringing this up – healthcare professionals were doing it themselves. This didn’t use to happen.’
Collaborative care
Australian College of Nursing Research and Government Relationships Officer Dr Lexie Brans said attendees at the forum had a desire to do things differently.
'There was a real commitment to changing the current systems and processes surrounding the quality use of medicines for the benefit of patients and to do so using existing resources more innovatively,' she told AP.
'It was also heartening to hear of the genuine commitment to working collaboratively with all health care practitioners and respecting the contribution of the different roles of different practitioners.'
Ms Brans said more collaboration is needed between all areas of the health sector to further improve outcomes.
'This is crucial if medicines are to be used safely, effectively and wisely, not only by health care practitioners but also by consumers (the harms of the so-called "wellness" industry for instance) or consumers as patients,' she said.
Kate Reed, Nurse Practitioner National Clinical Advisor at Palliative Care Australia, echoed this, stating that improving medicine safety relies on healthcare teams supporting each other using their different skills, knowledge and expertise.
https://twitter.com/bonnie_w_tai/status/1203800582114435072
‘Patients are at the centre of our care, and the only way we can ensure safety in medication management is through collaboration to reduce the chance of patients being managed ineffectively or placed at risk,’ she told AP.
For palliative care patients, this includes a risk of underprescribing due to a lack of understanding or a concern about adverse outcomes.
‘Palliative care patients are also particularly vulnerable to polypharmacy issues,’ Ms Reed said.
‘Patients who are under the care of specialist palliative care teams may also be on medications prescribed off-label to provide complex symptoms management. Such plans may not be familiar to other members of the healthcare team.’
https://twitter.com/APharm68/status/1203891235280187392
She said nurses can play an important role in educating patients about their medication management.
‘In the community, it is essential that this involves the community pharmacist where possible,’ Ms Reed said.
‘[In palliative care] it is often nurses who will pick up management issues such as confusion or dysphagia and will be able to initiate conversations … about changes to the management plan to ensure that the patient’s safety and goals of care are maintained throughout their illness progression and in end-of-life care.’
[post_title] => Messages from the Medicine Safety Forum
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[post_content] => Better use of existing funding, leveraging digital health and empowering consumers are the keys to improving medicine safety.
These were the main themes to come out of discussions at the Medicine Safety Forum held in Canberra on Tuesday.
Convened by the PSA, Consumers Health Forum of Australia (CHF), the Society of Hospital Pharmacists of Australia (SHPA), NPS MedicineWise, Monash University and the University of Sydney, attendees were challenged to think differently about the safe use of medicines in Australia.
With the cost of medicine-related harm estimated at more than $1.4 billion each year, PSA National President Associate Professor Chris Freeman said each area of the health sector has a role to play in addressing what he called ‘one of Australia’s greatest healthcare challenges’.
‘It was inspiring to see the sector work together to proactively identify those measures we can cooperatively pursue to make a real difference and protect patients,’ he said.
‘Improving medicine safety is not just about spending more money but also about being more strategic with the money that is spent.’
The forum welcomed the Council of Australian Governments Health Ministers’ decision to make Medicine Safety and the Quality Use of Medicines the 10th National Health Priority Area (NHPA) last month.
This followed the release of PSA’s Medicine Safety: Take Care report in January, which found 250,000 Australians are hospitalised each year and another 400,000 present to emergency departments as a result of medication errors, inappropriate use, misadventure and interactions.
The ideas and recommendations raised by stakeholders at the event will formulated into a report that will be used to help inform the government’s response to the 10th NHPA.
CHF CEO Leanne Wells said conversations at the forum often returned to how important it is for patients to be actively engaged in their health care decisions and educated about the medicines they are prescribed.
‘Modern medication offers great benefits, but the rate of hospital admissions caused by avoidable medication errors shows the importance of ensuring consumers are informed about their medicines, which is an integral part of broader quality use of medicines,’ she said.
This was echoed by NPS MedicineWise CEO Steve Morris, who said it was important to ‘cherish the ethos of quality use of medicines’.
‘While Australia’s National Strategy for the Quality Use of Medicines requires an update, the principles of 20 years ago, including the primacy of consumers, is just as relevant today,’ he said.
A/Prof Freeman thanked the more than 100 delegates who took part and applauded them for thinking outside the box.
‘[There] was deep discussion of the actions we can take to reduce harm from medicines,’ he said.
‘The depth and number of participants at the forum shows how important the issue is and how committed the health care sector is to improve medicine safety.’
[post_title] => Health sector collaboration the key to improving medicine safety
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[post_content] => Most Australian GPs have used a placebo in practice at least once, with active placebos used far more than inert placebos, a new study has found.
Published this week in the Australian Journal of General Practice,1 the results of a national survey of physician use, beliefs and attitudes about placebos found that 77% of the 136 GPs recruited from a national database had prescribed an active placebo – most commonly antibiotics – while 39% had used an inert placebo, like saline injections.
An online questionnaire was emailed to 1543 GPs in February last year with a subsequent reminder two months later. Of the 641 GPs who opened the email, 18% took part.
In the questionnaire, inert placebos were defined as ‘inert treatments like a sugar pill or saline injection that are prescribed to enhance patient expectations and improve outcomes via the placebo effect’.
Active placebos were defined as ‘active treatments prescribed solely or primarily to enhance treatment outcomes by increasing positive expectations – rather than through any specific physiological or pharmacological treatment effect’.
‘Prescribing unnecessary drugs to patients is not good practice in terms of quality use of medicines,’ PSA National President, Associate Professor Chris Freeman, said. ‘The more medicines a person has to take and manage the more risk there is of a medication related problem.’
While international surveys indicate that placebo use by GPs is ‘remarkably high’ the study authors wanted to examine the situation in Australia, given mounting research showing ‘the placebo effect is an important psychobiological phenomenon in its own right’.2
GPs primarily used placebos because they believed placebos could provide genuine benefit and viewed themselves as having a strong role in shaping patients’ expectations, according to the study findings.
‘Unnecessary prescription of antibiotics can not only cause patients harm but impact on the future effectiveness of these vital medications,' A/Prof Freeman said.
According to the Australian Institute of Health and Welfare’s (AIHW) Australia’s Health 2018,3 unnecessary prescribing of antibiotics leads to a higher risk of adverse side effects and increased anti-microbial resistance in the population.
‘Anti-microbial resistance means when we get sick in the future, antibiotics will not be able to fight the bacteria causing the infection,’ A/Prof Freeman explained.
‘There is also a cost to the health system every time a placebo medication is prescribed.'
Government spending on PBS medicines increased by 11% between 2015–16 and 2016–17 to reach $12.1 billion.
'While the cost of placebo prescribing was not quantified by this research, it clearly places an additional burden on our health care system and may also leave patients out of pocket for no good reason,’ A/Prof Freeman said.
NPS MedicineWise is also encouraging consumers to talk to doctors about their medicines and their effects before starting treatment.
Choosing Wisely Australia has 5 questions for consumers to ask doctors or other healthcare providers about medicines and whether they are necessary.
NPS MedicineWise has online information on topics including pain management, depression, insomnia and the appropriate use of antibiotics.
According to A/Prof Freeman: ‘Safe and quality use of medicines was declared a National Health Priority Area last month. The regular prescribing of active placebos – real drugs that won’t address the underlying condition – seems to fly in the face of all we are trying to achieve.
‘Increased utilisation of pharmacists as part of a collaborative health care team, including within general practice, will improve medication management and help educate consumers about quality and safe use of medicines.’
References
-
- Faasse K, Colagiuri B. Placebos in Australian general practice: a national survey of physician use, beliefs and attitudes. Aust J Gen Pract 2019;48(12):876–82.
- Petrie KJ, Rief W. Psychobiological mechanisms of placebo and nocebo effects: pathways to improve treatments and reduce side effects. Annu Rev Psychol 2019;70:599–625.
- Australian Institute of Health and Welfare. Australia’s Health 2018. Canberra: AIHW; 2018. At: www.aihw.gov.au/getmedia/7c42913d-295f-4bc9-9c24-4e44eff4a04a/aihw-aus-221.pdf
[post_title] => GPs use antibiotics as placebos: study
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[post_content] => More than 62,000 hospital admissions for heart failure in Australia could have been prevented and more than 400,000 bed days avoided, according to new data released last week from the Australian Institute of Health and Welfare (AIHW).1
That equates to, on average, 171 admissions every day, or one every eight minutes.
Another AIHW report released on the same day found that the rate of antidepressant prescriptions dispensed to ex-serving Australian Defence Force (ADF) members was slightly higher (20%) than in the general population (15%) in 2017–18, while the rate for cardiovascular medicines was slightly lower at 22% compared to 24% of Australians.
The Medications dispensed to contemporary ex-serving Australian Defence Force members, 2017–18 report analysed the PBS and RPBS within the population of ex-serving ADF members who had served in the ADF since 2001.
Rates for the dispensing of anti-infectives were similar, whereas prescriptions dispensed for nonsteroidal anti-inflammatory agents (15%) were slightly higher compared to all Australians (12%). All figures were adjusted for age and sex differences.
This was the first time an analysis included contemporary ex-serving ADF members who were not Department of Veterans’ Affairs cardholders.
The new data on avoidable hospital admissions included admissions for congestive heart failure.
The AIHW report, Potentially preventable hospitalisations in Australia by age groups and small geographic areas, 2017–18, analysed 22 conditions for which hospital admissions could have been prevented by timely and adequate healthcare in the community.2
An estimated 110,000 Australians are living with heart failure and in 2018, on average, seven people died of heart failure every day. Despite medical advances, health outcomes and survival rates for heart failure are poor, and the cost to the health system has increased on average by 6.5% per year.1
The Clinical Evidence Manager for the Heart Foundation, Cia Connell, said preventable hospitalisations for heart failure refer to admissions that could have been prevented by timely and adequate care in both the community and at discharge from previous hospital admissions.3
‘Repeat and unnecessary admissions can make the emotional and financial costs of living with heart failure incredibly high, which is why it’s alarming to see so many people ending up in hospital with them,’ Ms Connell said.3
‘Health professionals, including doctors, nurses and pharmacists, provide continual, long-term care for Australians living with heart failure so they can stay alive, stay well and stay out of hospital,’ she added. ‘This includes supporting people with heart failure to manage their symptoms and medications and to make long-term lifestyle changes so that they can enjoy a better quality of life.’3
The data was published as the Heart Foundation released an animated video series designed to support Australians to live well with heart failure. The videos were created for consumers but intended to be introduced via health professionals as part of a meaningful conversation about how to manage heart failure.
References
- Australian Institute of Health and Welfare. Potentially preventable hospitalisations in Australia by age groups and small geographic areas, 2017–18 2019. Canberra: AIHW; 2019. At: www.aihw.gov.au/reports/primary-health-care/potentially-preventable-hospitalisations/contents/overview
- Australian Institute of Health and Welfare. Medications dispensed to contemporary ex-serving Australian Defence Force members, 2017–18 2019. Canberra: AIHW; 2019. At: www.aihw.gov.au/reports/veterans/medications-dispensed-contemporary-ex-adf/contents/introduction
- Media release: 60,000 hospital stays for heart failure are preventable: new data. Heart Foundation. 29 November 2019.
[post_title] => New data on Australia’s health and medicines use
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[post_content] => Evaluation overseas has found pharmacist prescribing to be safe, clinically appropriate and well-received by patients.
Pharmacy groups have long called for changes to allow pharmacists to prescribe specified medicines such as the oral contraceptive pill.
In countries where this extension to pharmacy practice has begun, the financial impact and effect on patient outcomes has been positive, according to an analysis by health economist Dr Greg Merlo, published in The Conversation1 last week.
A Postdoctoral Research Fellow in the Primary Care Clinical Unit at the University of Queensland, Dr Merlo analysed the financial and clinical impacts of pharmacist prescribing and doctor dispensing.
Prominent activist, general practitioner and short-term independent MP, Prof Kerryn Phelps, argued last month that perverse incentives for community pharmacists may lead to inappropriate prescribing, and that – conversely – GPs should be able to dispense. However, an accusation of inappropriate prescribing while also dispensing can also be levelled at doctors, Dr Merlo found.
Studies in the United Kingdom and Canada (where prescribing was limited to urinary tract infections and cardiovascular conditions) demonstrated the safety and clinical appropriateness of pharmacists doing the prescribing, along with positive feedback from patients. The Canadian study also demonstrated better clinical outcomes and cost-effectiveness.
In countries where doctors have dispensing rights, studies have shown evidence that financial profits had influenced prescribing behaviour. In Switzerland, a 34% increase in drug costs per patient resulted from doctors overprescribing and prescribing more expensive medicines.
To address the concerns of this extension to pharmacy practice, Dr Merlo looked at three economic concepts to help understand the benefits and risks of pharmacist prescribing: supplier-induced demand (supplier has greater knowledge and may manipulate the consumer into buying an unnecessary medicine); product-bundling (a doctor will provide a medical consultation with the prescription); and externality (impact on society e.g. antibiotic resistance, codeine rescheduling).
However, ‘There is no reported evidence of inappropriate prescribing by pharmacists in any countries that have introduced regulated, controlled models of pharmacist prescribing,’ Dr Merlo found. He concluded that pharmacists prescribing ‘has the potential to lower costs to the health system because of fewer GP visits, offer convenience to consumers, and free up busy GPs to spend time on high-value care'.
However, ‘any increase in pharmacists’ scope of practice needs to be introduced with caution, with clear protocols and limited prescribing rights'.
In a position statement released in October, the Pharmacy Board of Australia recognised there are no regulatory barriers to pharmacists prescribing ‘via a structured prescribing arrangement or under supervision within a collaborative healthcare environment’.
Dr Merlo told Australian Pharmacist that, as a health economist, he sees himself as an outsider.
‘I would hear arguments from both sides and not know who to believe. I think politicians and regulators face the same problem,’ he said.
Regarding the so-called doctor-pharmacist ‘‘turf war”, he said ‘neither side of the war is showing signs of giving up. Rather than sweeping statements about conflicts of interest, we need an evidence-based framework to determine where it’s appropriate to extend pharmacists’ scope of practice'.
Dr Merlo favours policy guidance for extending scope of practice that could be applied consistently to all health professions. ‘It needs to be developed by an organisation who is independent of any specific professional group but will need to canvas widely and consider the perspectives of all groups concerned,’ he added.
Ideally, extending the scope of practice needs to be done in a way that the value is seen by both patients and GPs. Concerns of safety and conflicts of interest need to be addressed, he said.
Reference:
- The evidence shows pharmacist prescribing is nothing to fear. The Conversation. 26 November 2019. At: theconversation.com/the-evidence-shows-pharmacist-prescribing-is-nothing-to-fear-127497
[post_title] => Pharmacist prescribing is a positive move
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[post_content] => Men who have sex with men and use the human immunodeficiency virus (HIV) prevention pill have lower anxiety, new Australian research has revealed.
Those who take the pre-exposure prophylaxis medication (PrEP) against HIV infection have significantly lower levels of HIV-related anxiety, according to a study from the Kirby Institute at UNSW Sydney, published last week in the Journal of Acquired Immune Deficiency Syndromes ahead of World AIDS Day.1
Anxiety about HIV transmission has affected sexual behaviours of men who have sex with men for more than 30 years, but this new research provides the strongest evidence globally that, as well as driving down HIV infection rates, PrEP may be enhancing the mental health and wellbeing of men at risk of HIV.1
PrEP refers to the biomedical prevention of HIV using antiretroviral agents. This includes a fixed-dose combination pill of tenofovir+emtricitabine (e.g. Truvada), which was listed on the Pharmaceutical Benefits Scheme (PBS) in April 2018. Only patients who are at least 18 years old and who are at medium to high risk of infection, as defined by the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) guidelines, are eligible for the treatment.2
The co-lead author on the paper, Phillip Keen [PhD candidate] at the Kirby Institute, said the findings had important implications for understanding the benefits of PrEP.
‘We’ve known for some time that PrEP is very good at protecting people from HIV. This new evidence suggests that another benefit of taking PrEP is improved mental health, through reduced anxiety about HIV,’ he said.1
Data was analysed from the ‘Following Lives Undergoing Change’ study, a national, online survey of the sexual and drug use behaviours of more than 2,500 men at risk of HIV in Australia in 2018.
An earlier 2018 Australian study (pre-PBS listing) showed that less than half of those at high risk for HIV were currently taking PrEP. The authors of the Kirby Institute study concluded that their findings could inform how PrEP is promoted to men and used to support higher PrEP use in Australia.1
This conclusion was endorsed by the Australian Federation of AIDS Organisations (AFAO) CEO Adjunct Associate Professor Darryl O’Donnell, who said the research represents a turning point in our understanding of how fear of HIV has influenced sexual relationships for many men who have sex with men.
‘[PrEP] has helped many gay men enjoy sex without being fearful of HIV,’ he said.
However David Crawford, Treatments Officer with Positive Life NSW, which has assisted people living with HIV since 1988, said this isn't the case for all people living with HIV.
'Prior to this new Kirby Institute study, the prescribing of PrEP has been recognised as a game changer as it had appeared to alleviate the anxiety of many who were taking it,' he said.
'[But] for people who were assessed as being ineligible for PrEP, this led them to exhibit or express higher levels of anxiety.'
Mr Crawford said pharmacists should keep in mind that for people living with HIV, assurances of privacy are paramount.
'The main concerns people living with HIV have, particularly in smaller communities, are the maintenance of their confidentiality and how they will be responded to and treated when they attend a community pharmacy to collect their medicines,' he said.
World AIDS Day, held every 1 December, raises awareness around the world about the issues surrounding HIV and AIDS. It is a day for people to show support for those living with HIV and to commemorate people who have died.3
The national World Aids Day theme for Australia in 2019 is ‘Every Journey Counts’. Australians are encouraged to educate themselves and others about HIV, promote HIV prevention strategies, be aware of and educate others that undetectable = untransmissable (U=U), and ensure that and ensure that people living with HIV can fully participate in the life of the community, free from stigma and discrimination.
In line with Australia's aim to be one of the first countries to eliminate new HIV transmissions – new diagnoses are now at the lowest level in 20 years – the federal Health Minister Greg Hunt announced yesterday an extension of almost $3 million in funding for six national peak organisations.
The funding for 2020–21 will support people living with HIV and other blood-borne viruses and sexually-transmitted infections.
And from next week an estimated 850 Australians living with HIV will save more than $8,500 a year with the Pharmaceutical Benefits Scheme listing of the once-daily combination medicine Dovato (dolutegravir with lamivudine).
A red ribbon is the international symbol of HIV awareness and support.
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[post_content] => With increasing overdose deaths from both prescription opioids and heroin, naloxone nasal spray – now listed on the Pharmaceutical Benefits Scheme – is a life-saving and easy-to-use opioid reversal agent to stock in your pharmacy.
And pharmacists this week have been urged to re-think social attitudes to reduce the stigma of drug use, addiction and overdose to ensure easy access to naloxone nasal spray.
Guidance for provision of naloxone is now available in the PSA document Guidance for provision of a Pharmacist Only medicine – Naloxone for the treatment of opioid overdose.1
As John Jackson, Chair of PSA’s Harm Minimisation Committee told Australian Pharmacist: ‘Naloxone is not a new drug. It has been used extensively in a parenteral form, especially in hospitals where pharmacists have a sound knowledge of its use as a narcotic antagonist.’
But there is growing recognition of its potential benefit for suspected opioid overdose in the community.
Deaths due to illicit drug overdose (e.g. heroin or diverted fentanyl) commonly occur in the presence of another person. There may be a reticence to call an ambulance because of possible police involvement. Broader availability of naloxone among users, their family and friends can save lives.
The potential for overdose also exists with opioids prescribed for chronic pain (e.g. oxycodone), particularly when used with other central nervous system depressants such as alcohol and benzodiazepines. Australian research has found that most chronic pain patients prescribed opioids either expect to be offered naloxone or would appreciate it.2
Human stories
The director of the Australian Research Centre in Sex, Health and Society at LaTrobe University, Professor Suzanne Frazer, led a recent research project into why naloxone was not accessed more widely. Researchers interviewed 37 health professionals and also 46 people in New South Wales and Victoria who take opioids and found that many were either unaware of how to obtain the reversal agent or were too embarrassed.
Yesterday (Tuesday) the experiences and stories collected through that research were shared on Overdoselifesavers.org, a website launched at the Australasian Professional Society on Alcohol and Other Drugs conference in Hobart.
‘Many people we interviewed were keen to know about naloxone, and access it, but were concerned about confidentiality when speaking to pharmacists, or didn’t want to bring it up with their GP in case it affected their relationship in the future,’ Professor Frazer said.
‘We need to rethink our social attitudes to opioid consumption and overdose if naloxone programs are to fully achieve their life-saving potential,’ she said yesterday.
Role of the pharmacist
Experience with naloxone may be limited in the community, but pharmacists are uniquely placed to identify people at risk of opioid toxicity and provide them with a reversal agent. Being alert for the signs of opioid overdose, and then facilitating access to naloxone and training for family and friends, presents a good opportunity for pharmacists to undertake early intervention.
And naloxone is safe with no abuse potential. Australian and international studies have demonstrated that supplying naloxone for a layperson to administer is safe, feasible and cost-effective.2
‘In the nasal formulation, a simpler, more convenient preparation is able to be readily administered without extensive training,’ Mr Jackson said.
Naloxone is a competitive antagonist at opioid receptors with a fast onset of action and a short half-life. When administered in the presence of an opioid, it displaces the opioid at the receptor and reverses its effects – importantly respiratory depression which can be fatal.
It works for all opioids, e.g. heroin, morphine and oxycodone as well as opioid substitution therapies such as methadone. It is also safe in nonusers. When given to healthy volunteers with no recent exposure to opioids, naloxone showed no adverse effects.2
In 2016, naloxone injection 400 microgram/mL became available as a Schedule 3 medicine, available over-the-counter (OTC) and on prescription. It is approved for intramuscular, intravenous and subcutaneous use in Australia, and has been used by ambulance and paramedical staff to treat overdose for over 40 years.2 Naloxone nasal spray, 1.8 mg/actuation, became available OTC and on prescription (PBS subsidised on 1 November), earlier this year.
Mr Jackson said that ‘pharmacists need to develop the capability to identify and assess high-risk individuals in a non-stigmatising manner’.
From the PSA guidance document, pharmacists can identify high-risk factors (e.g. high opioid dose (>100 mg morphine equivalents/day)), long-acting form (e.g. methadone) or extended-release preparation). The person may have a respiratory condition, or smoke or take other central nervous system depressants, or may be part of a methadone or detoxification program.
Pharmacists should discuss with patients/carers the risks associated with opioids, and supply naloxone where appropriate. Also, ensure the person has been provided with an emergency opioid overdose protocol.2
‘In training people to recognise the symptoms of opioid overdose and how to administer the nasal spray, pharmacists should ensure [they] understand it is not a substitute for professional medical care, and further doses of naloxone may be required,’ Mr Jackson warned. Although the nasal spray contains two single dose devices, ‘emergency assistance should be sought whenever an opioid overdose is suspected and the spray administered’, he added.
‘The [nasal] spray can be administered even if the person is not breathing.’ Inform users that ‘each device contains only one spray and should not be pumped or “primed” before use.’
Be mindful that naloxone has a half-life <1 hour, which is shorter than all the opioids. Observe the patient for 2–3 hours after naloxone administration for relapse. This is particularly important following methadone or controlled-release opioids, where narcosis may persist for >24 hours.3
Resources
Refer to the PSA guidance document for the use of naloxone nasal spray in children, pregnancy and while breastfeeding, where the infant needs to be monitored for opioid withdrawal symptoms. Also, refer to the recommendations when supplied to a third party and follow–up advice.1
A training resource is available at: www.penington.org.au/programs-and-campaigns/resources/cope-overdose-first-aid
Although the nasal spray formulation is expensive at present, Mr Jackson said we can expect to see a price reduction, especially as multiple brands are available overseas.
References
- Pharmaceutical Society of Australia. Guidance for provision of a Pharmacist Only medicine: Naloxone. Canberra: PSA; 2019.
- Jauncey ME, Nielsen S. Community use of naloxone for opioid overdose. Aust Prescr 2017;40:137–40.
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]As regulatory bodies restrict or ban carisoprodol, the highly addictive but effective muscle relaxant still dominates the US prescription drug market.
Carisoprodol, marketed in the United States1 as Soma and Vanadom, was one of the first anxiolytic drugs sold on the market. Soma was developed in 1950 by Frank Berger and Bernard John Ludwig at Carter Products.
The team at Carter Products also developed meprobamate (Early Elixirs, September) and felbamate, used in the treatment of epilepsy.2
In 1959 the US Food & Drug Administration approved carisoprodol for use and throughout the next two decades concerns about abuse of the drug spread.3 But it wasn’t until an explosion in its use in the 1990s and early 2000s that it was classified in America as a Schedule IV drug with a potential for abuse in 2012.4
Between 1996 and 2005 the number of emergency department visits caused by carisoprodol in the US increased from 6,569 to 19,513 with the drug listed as one of the 25 most dangerous in the country. Despite restrictions, carisoprodol is still widely prescribed with over 3 million prescriptions (a drop from the 10 million written in 2008) written in the US in 2016.5
How it works
The exact method of action of carisoprodol is unclear but laboratory studies on animals show the relief of painful musculoskeletal conditions is associated with changes in the interneural activity of the spinal cord and the descending reticular formation in the brain.
Carisoprodol’s effects are felt within 30 minutes and last for approximately six hours, bringing on feelings of drowsiness and mild to strong euphoria – albeit short-lived due to the rapid rate at which it is metabolised. The drug has powerful reactions with many opioids and analgesics (especially codeine) reducing the amount of the opioid required for effect.6 Researchers have described carisoprodol as producing an effect in users similar in some ways to alcohol intoxication.5
Prolonged use of carisoprodol can lead to physical dependence and withdrawal can be life threatening for high-dose users. Patients suffering from physical withdrawal can be given long-acting benzodiazepines such as diazepam or clonazepam as the dosage of carisoprodol is slowly reduced.6 Used illicitly, carisoprodol is mixed with opioids and benzodiazepines to accentuate a user’s high. This practice is referred to as ‘The Holy Trinity’.
A typical dose of carisoprodol is 350–700 mg but some take up to 1050 mg or more, per day.5
Use in Australia
Carisoprodol is no longer a licenced product in Australia but can be accessed via the Special Access Scheme. Globally, it has been removed from sale by authorities or heavily restricted in Norway, Sweden, the European Union, Indonesia and Canada.5
References
- Drug Enforcement Administration, Diversion Control Division, Drug & Chemical Evaluation Section. CARISOPRODOL (Trade Name: Soma®) 2019. At: www.deadiversion.usdoj.gov/drug_chem_info/carisoprodol/carisoprodol.pdf
- Tone A. The Age of Anxiety: A History of America’s Turbulent Affair with Tranquilizers. New York: Basic Books; 2009. At: https://www.amazon.com/Age-Anxiety-Americas-Turbulent-Tranquilizers/dp/046502520X
- Fass J. Carisoprodol legal status and patterns of abuse. Ann Pharmacother 2010;44(12):1962–7. At: https://www.ncbi.nlm.nih.gov/pubmed/21062909
- Reeves RR, Burke RS, Kose S. Carisoprodol: update on abuse potential and legal status. South Med J 2012;105(11):619–23. At: https://www.ncbi.nlm.nih.gov/pubmed/23128807
- The Drug Classroom. Carisoprodol 2016. At: https://thedrugclassroom.com/video/carisoprodol/
- US National Library of Medicine. PubChem. Compound summary, carisoprodol 2019. At: https://pubchem.ncbi.nlm.nih.gov/compound/Carisoprodol
- Fudin J. The perfect storm: opioid risks and ‘The Holy Trinity’. Pharmacy Times 2014. At: www.pharmacytimes.com/contributor/jeffrey-fudin/2014/09/the-perfect-storm-opioid-risks-and-the-holy-trinity
- Australian Government, Federal register of legislation. Poisons standard February 2017 made under paragraph 52D(2)(a) of the Therapeutic Goods Act 1989. At: www.legislation.gov.au/Details/F2017C00665
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[post_content] => When medication charting involves a pharmacist as well as a doctor, medication error rates in hospital admissions are significantly reduced, according to a new study.1
Researchers from Monash University’s Centre for Medicine Use and Safety (CMUS) at the Monash Institute of Pharmaceutical Sciences and Alfred Health evaluated the model of collaborative medication-charting in public hospitals in Victoria. Over 8,500 patients in general medical wards were included in the study, making it the largest of its kind.1
Generally, a doctor charts a patient’s medications on admission, after which a pharmacist reviews and reconciles the medication list. However, delays and review omissions can occur. This increases the risk of medication errors, potentially leading to patient harm and increased duration of hospitalisation.
The 2016 study aimed to see whether timely, collaborative care as soon as possible after admission would reduce medication errors.
Patients who had partnered pharmacist medication charting (known as PPMC) were found to have a reduced hospital stay from 4.7 (IQR* 2.8-8.2) days to 4.2 (IQR 2.3-7.5) days (p<0.001); a reduction of half a day on average.1
Also, the number of medication errors detected within 24 hours of admission was significantly reduced. Medications charts that had at least one error was reduced from 66% to 3.6%.The number-needed-to-treat to prevent one error was 1.6 (95% Cl:1.57-1.64).1
The PPMC model involved a pharmacist taking a medication history, reconciling medications, assessing risk of venous thromboembolism (VTE), collaboratively making decisions with the admitting medical officer and charting the medication.
A second pharmacist took the role of independent assessor, reviewing all medications charted by a pharmacist within 24 hours, to provide a second check and identify any medication errors.
A limitation of the study was that pharmacists were only available during normal working hours during the intervention phase, whereas in the pre–intervention phase all admitted patients were included in the study, no matter what time of day or night.
The Deputy Director of Pharmacy at Alfred Health, Erica Tong, praised the collaborative work with the medical team at the point of admission, and believes the partnered pharmacist model around the clock should be evaluated.
‘Implementation of this model to other clinical areas such as surgical and oncology services should be considered, and evaluation of the impact on electronic prescribing systems on this model should also be investigated,’ Ms Tong said.1
The Acting Director of Pharmacy Services at Brisbane’s Princess Alexandra Hospital (PAH) and Associate Professor at the University of Queensland’s School of Pharmacy, Michael Barras, welcomed the study findings and fully supports this model of care.
‘Prescribing is not currently in a pharmacist’s scope of practice, unless under a research framework, so that task remains with the medical officer,’ he added. Although not providing 24-hour care, Emergency Department pharmacists are available until 8.00 pm daily.
'Models of care like this pharmacist-led medicines charting initiative need to become normal care for all patients in all hospitals if we are serious about medicine safety. Whatever Australian hospital a patient is in, they deserve to receive access to high quality pharmacist care like this,' according to PSA National President Associate Professor Chris Freeman.
'We welcome this research as it adds further weight to PSA’s call in Pharmacists in 2023 for hospital pharmacists to be available at comparable levels regardless of location, timing or nature of stay to make patients in Australian hospitals safer.'
The Monash study on minimising medication errors on admission builds on a previous study conducted by Erica Tong and colleagues – Reducing medication errors in hospital discharge summaries: a randomised controlled trial. The study involved pharmacists completing the medical discharge summary, resulting in a reduction of medication errors from 60% to 15%. This study was published in the Medical Journal of Australia (MJA) and was independently judged to be the best paper published by the MJA in 2017.2
*IQR = interquartile range, or middle 50% – used as a measure of statistical spread of results
References
- Tong EY, Mitra, B, Yip, G, et al. Multi‐site evaluation of partnered pharmacist medication charting and in‐hospital length of stay. Br J Clinl Pharmacol 2019. Epub 2019 Oct 21.
- Tong EY, Roman C, Mitra B, et al. Reducing medication errors in hospital discharge summaries: a randomised controlled trial. Med J Aust 2017;206:36–39.
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[post_content] => In a move aimed at reducing antibiotic resistance, the Pharmaceutical Benefits Advisory Committee (PBAC) has recommended that four of the most widely prescribed antibiotics in Australia have the default repeat options removed.
Amoxycillin, amoxicillin–clavulanic acid, cephalexin and roxithromycin are the four antibiotics with the highest volume of repeats.
Pharmacists need to be prepared for consumer queries. With the right advice, fears can be allayed and changes can be seen in a positive light for both individuals and the community.
Australia's Chief Medical Officer, Professor Brendan Murphy said earlier this month that the federal Health Minister, Greg Hunt, was likely to endorse the changes.
'The Minister has to make a decision on the recommendation of the PBAC but the Minister has indicated he is supportive of these changes,' he told the ABC.
Antibiotic resistance is a growing problem, acknowledged by health professionals and increasingly understood by the public. However, this doesn’t always translate into individual expectations for an antibiotic when a patient believes one is needed.
At its latest meeting in August, the PBAC considered changes to listings of certain antibiotics to encourage antimicrobial stewardship (collective strategies to improve appropriateness and minimise adverse effects of antibiotic use).
The outcome was a recommendation to change antibiotic listings for high use items on the PBS with repeat prescription options.1
Specifically, the PBAC recommended: ‘The removal of repeat options for a range of listings where no repeats were deemed necessary as per the Therapeutic Guidelines. The PBAC also recommended aligning the listings for specific indications to the Therapeutic Guidelines where increased quantities are clinically indicated. The PBAC considered that the recommended changes, aligned as best possible with the current version of the Therapeutic Guidelines (version 16), would support antimicrobial stewardship and quality use of medicines as well as assist in the reduction of antimicrobial resistance.’1
Angus Thompson MPS, Lecturer in Therapeutics and Pharmacy Practice at the University of Tasmania, is a passionate advocate of antimicrobial stewardship in the community and for pharmacist involvement. He sees the proposed changes to repeat options for those antibiotics as an important step forward for individual patient safety and broader action on antibiotic resistance, which has been a long time coming.
Mr Thompson recalls a patient admitted to hospital after a course of amoxicillin-clavulanic acid for a diabetic foot ulcer. When the ulcer hadn't improved after 5 days, she had the repeat dispensed. After 9 days she presented to her GP, who arranged for an urgent hospital admission due to the significant risk of foot amputation. If a clinical review had taken place at Day 5, earlier intervention may have prevented such a critical outcome.
Mr Thompson says that while changes to repeats are welcome, other issues including changes to pack sizes to better align with course lengths recommended in Therapeutic Guidelines are necessary. He added: 'Most women taking trimethoprim for a UTI need a 3–day course so do not need to be given 7 days’ supply, as this means any remaining tablets could be used inappropriately down the track without clinical review. We also need more judicious use of the advice to complete the course, especially when pack sizes and recommended course durations often align poorly.'
'The proposed change to automatic repeats presents a huge opportunity for pharmacists at the first dispensing to advise patients – if symptoms haven't improved by the end of the first pack they need to consult with their GP, unless the GP has advised otherwise', Mr Thompson said. ‘Consistency in messages is important.' He would like to see GPs write the recommended duration of therapy on scripts so pharmacists can reinforce that instruction.
PSA recently convened a meeting to discuss improvements in antibiotic labelling and counselling by pharmacists, including a review of the instruction ‘until all taken’. The meeting was chaired by Emeritus Professor Lloyd Sansom, and representative stakeholders from a number of medical, government, pharmacy and consumer organisations attended the meeting. PSA representative Claire Antrobus said that ‘a communications strategy is being developed to relay the outcomes of the meeting to medical, allied health and pharmacy professionals and to consumers’.
Jack Muir Wilson MPS, pharmacist at Wilkinson’s Pharmacy in Burnie, Tasmania, also welcomes the proposed changes, although in his small community there can be difficulties getting in to see the GP promptly.
Mr Muir Wilson would like to see some flexibility in the changes, to allow for prolonged courses of antibiotics when needed for chronic conditions. He thought expiry dates on antibiotic scripts would be useful, as well as new PBS Streamline codes for high–use antibiotics.
Also, 'health literacy can be a problem in some rural areas, so education for patients on when antibiotics are needed would be useful, along with education for prescribers on the importance of antimicrobial stewardship', Mr Muir Wilson said.
Pharmacists are urged to work collaboratively with prescriber colleagues to help improve antimicrobial stewardship in the community, where the vast majority of antibiotics are used.
Reference
- August 2019 PBAC meeting – other matters. PBS. Commonwealth of Australia. At: www.pbs.gov.au/info/industry/listing/elements/pbac-meetings/pbac-outcomes/recommendations-made-by-the-pbac-august-2019
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]I want to implement SafeScript in my pharmacy. What do I do, and how long does the process take?
SafeScript is an initiative by the Victorian Government which has established a clinical decision-making tool in the form of a real-time record of all prescriptions for specific medicines.
SafeScript draws data from Prescription Exchanges Serivces (PES) when prescriptions for monitored medicines are issued or dispensed. Monitored medicines include all Controlled Drugs, all benzodiazepines, zopiclone, zolpidem, quetiapine and products containing codeine.
The service is available to all pharmacists in Victoria, and will be compulsory from April 2020. While not yet compulsory, pharmacists should be using this system now.
One of the effects evident in the 13 months of activity following its roll-out in April 2018, is that 11,000 clinicians have begun utilising the service and SafeScript has helped those clinicians identify 15,000 instances of a person visiting more than four health providers for monitored medicines within the specified time period.
SafeScript also helped to identify 13,000 people who were prescribed doses that could be excessive, or in combinations that could increase risks.
There is a clear advantage for a pharmacist to have access to this information when making a decision about the appropriateness or safety of supplying a medicine at a specific point in time, especially from the perspective of assisting a person to access different services that may be relevant to their circumstances.
Registration
The process of registering for SafeScript is relatively simple, and requires two specific activities to be completed:
- Individual registration:
Every pharmacist registers through the SafeScript portal at www.safescript.vic.gov.au. This will require your AHPRA registration, date of birth, and contact details for the pharmacy at which you will access SafeScript.
- Enabling software:
Visit vic.health1 for instructions on downloading SafeScript software for each terminal used within the pharmacy. You will also find instructions for ‘manual’ access via the portal for systems that do not yet have integrated software solutions.
Implementation tips
Implementing SafeScript in isolation from your colleagues is less than ideal. A discussion in the workplace about the ease of implementation and wealth of clinical information SafeScript provides can help to ensure that all staff within the pharmacy are aware of the role of SafeScript, correct processes for accessing a person’s record, and how to proceed in the instance where a pharmacist identifies a request to dispense what they consider unsafe.
Importantly, each pharmacist needs to register individually for SafeScript – accessing a person’s medical information under another heath professional’s credentials is not permitted. Pharmacists should familiarise themselves with referral pathways for allied health, specialist pain treatment options, specialist substance use disorder options, and the use of motivational counselling to overcome dangerous health choices.
Other states
The Federal Government has committed to a national Real Time Prescription Monitoring (RTPM) service, interoperability between state and territory systems. Most states and territories are now actively working towards implementing RTPM systems in their jurisdictions.
The impact of SafeScript as a clinical tool on medicine safety is clear. RTPM cannot come soon enough to the rest of Australia’s prescribers and pharmacists.
| Lodge your own question at editorial@australianpharmacist.com.au |
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Conducting research can be a daunting prospect. But by choosing a mentor and working intelligently, pharmacists can research and have their work published.
A study published earlier this year in the Journal of Pharmacy Practice and Research found that pharmacists have a keen interest in conducting research.1 Yet these same pharmacists had comparatively low levels of research confidence and experience. The lack of confidence is understandable, as research and publication can be a formidable, lengthy undertaking. Thankfully, no one expects early career pharmacists (ECPs) to launch straight into a randomised control trial by themselves.
But while practising pharmacists may not always seem themselves as researchers, leading academics say the opposite is true. ‘Pharmacists working in clinical practice are in an ideal position to identify opportunities to change health care for the better,’ says Professor Simon Bell MPS, Director at Monash University’s Centre for Medicine Use and Safety. ‘Doing research is a way to explore those opportunities for change, to generate evidence that’s necessary to bring about change in clinical practice or health policy.’
So picture an ECP at work, wanting to get involved in research, with the distant goal of publishing work – where do they start? ‘Simple audit processes of the way you do things in your clinical practice is important research, and that can lead on to publications,’ says John Coutsouvelis, Senior Oncology and Haematology Pharmacist at Alfred Health, and a Senior Lecturer at Monash University. ‘It could be clinical, it could be a process. Start with audits and drug usage evaluations in hospitals. If you’re in community pharmacy, start with an audit of customer satisfaction with services. It’s all simple research, but starts you thinking about how to set up a study and what you’re measuring.’
Meredith Wiseman, a Senior Lecturer at Monash University, also encourages practising pharmacists to start with their own scope of practice. ‘Question what you see around you, and if you have a question, raise it with the people you work with – that’s often the start of more discussion around potential research projects,’ she says.
Discussing practice with colleagues and seniors is not only useful in mapping out a research question, but often yields potential opportunities for participating or collaborating with other projects and researchers. ‘Researchers are passionate about what they do and are happy to discuss research opportunities with any pharmacist,’ says Professor Bell. ‘Make an appointment with academic staff at your university, or if you’re working in a hospital, approach the director of pharmacy for advice. Universities and hospitals often have ongoing research projects that pharmacists can get involved in. This is a great way to gain experience.’
Mr Coutsouvelis also recommends that those who are looking to conduct research attend conferences in their field. ‘They’re a great way to start understanding what you need to put in an abstract and the things that reviewers look for.’
When it comes to developing a research question, Ms Wiseman encourages pharmacists to read academic literature. ‘It provides a good background. Read, read, read, talk with collaborators, get involved, and put yourself out there,’ she says. ‘Hospitals and other institutions often run journal clubs that can be a great resource for keeping abreast of current research.’
Reading naturally leads into the next step of research – a literature review.
‘It’s important to understand what’s already been published,’ says Professor Bell. ‘Often people come up with good ideas, but when they look further into the research literature they find several other studies have covered the area. It’s important to think about what your research will add.’
Determining methods
After identifying a research topic, pharmacists need to determine the research methodology for their study. For those new to research, this can be the most daunting stage of a study.
‘People often want to do complex research, but it’s more important to pick a methodology that is suitable to your question and that may mean a simpler methodology,’ says Mr Coutsouvelis.
Professor Bell says one common reason studies are rejected for publication is due to concerns over methodological quality. ‘I would encourage people to have a discussion with their research mentor about the most appropriate methods before they start doing their research,’ he says. ‘That way, the time and resources they invest will produce the best returns on investment and a high-quality piece of evidence at the end.’
Looking at past research can also help. ‘Go back to the literature and see how people have studied a similar topic in a different area, or a similar thing with a different drug, and try and map your methodology out that way,’ says Mr Coutsouvelis.
Finding that journal
When it comes to publishing research, finding the right journal can be a challenge. ‘There are many different scientific journals out there, with different readerships,’ says Professor Bell. ‘It’s important to keep your readership in mind when writing your article and selecting a target journal. Work is often rejected because it’s outside the scope of the journal, so you need to target your work to the right readership.’
A good place to start, says Ms Wiseman, are the professional journals. ‘Australian Pharmacist, the Journal of Pharmacy Practice and Research – they’re obviously going to be good links.’ She also advises close collaboration with experienced researchers. ‘Work with them to identify the best journal, and then read those journals yourself to ensure they fit your theme.’
When it comes to identifying and submitting to journals, Professor Bell says an experienced research mentor can save time, avoid needless rejections, and help optimise the impact of your work.
‘Regardless of where you choose to publish your research, it’s important to have a good research mentor who can guide you through that process. Publishing doesn’t have to be a daunting experience.
‘It’s fantastic when a student or pharmacist comes to us with an idea for research – it’s the kind of innovation and enthusiasm we need. But it’s important to take the time to work with a research mentor to help ensure that your proposed work is novel and the methods are rigorous before getting started.’
Dealing with rejection
When it comes to the final step of publishing their work, should new researchers expect to be knocked back by journals? ‘Even experienced researchers have their papers rejected,’ says Professor Bell. ‘The good journals only accept a small percentage of the articles they receive. If you do receive a rejection, that doesn’t mean that the work wouldn’t be suitable to be published in another journal. It can be easy to feel disappointed when a manuscript is rejected, but people shouldn’t lose heart if that happens.’
Having a research mentor is important as they can help identify more suitable journals to submit work to, and it requires patience. ‘ECPs sometimes expect something straight away, which is not a criticism. But to really get a good paper published can sometimes take a year,’ says Mr Coutsouvelis.
Reaching publication is a consultative process between researchers, publishers and reviewers. ‘Any article will go through several rounds of peer review and editing before it’s submitted for publication, so don’t get disheartened,’ he says.
References
- Waddell J. Research confidence, interest and experience of an Australian hospital pharmacy population. Journal of Pharmacy Practice and Research. May 2019. doi.org/10.1002/jppr.1480. At: https://onlinelibrary.wiley.com/doi/abs/10.1002/jppr.1480
| Submit your research to AP at australianpharmacist@psa.org.au |
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It’s no longer plain sailing in Australian community pharmacy. Bruce Annabel helps navigate in this, the fourth instalment of our Future Health series.
Most have heard the saying, ‘You cannot direct the wind, but you can adjust the sails.’ The nautical analogy is helpful. Pharmacy has sailed along propelled by the winds of regulation; the exclusive distribution of PBS pharmaceuticals and scheduled medicines have generated patient visits and profit. In return, consumers have received a reliable, accessible medicine distribution network. But in an era of tectonic change, is that sufficient to maintain pharmacy’s financial returns and relevance in the health spectrum?
The winds of change are blowing hard on the traditional business model, requiring owners, peak bodies, industry and the profession to assess where community pharmacy now stands. Initiatives are needed to harness these forces, beginning with the forthcoming Seventh Community Pharmacy Agreement (7CPA).
Winds of change
1. Market and technology
The key to community pharmacy success has been location, maximising script throughput, and operating efficiently as a business. However, fundamental change in the competitive and technological landscape has resulted in flat script volumes and falling patient visits pressuring profitability and viability. One of the biggest concerns is falling patient visits, down 3.8% during the last five years including 1.9% last year,1 reflecting the reduced market relevance of the traditional business model.
Therefore, historical success factors have become ‘hygiene’, and it’s getting worse because few are responding appropriately to the changes.
2. Blown off course
Unfortunately, price discounting is the result, financed by cutting wages and pressuring suppliers for deals that no longer exist. Something has to change – net profit is down 22% compared with five years ago, while return on investment has fallen to 14% compared with 25% just 10 years ago.1
Pharmacists clinging to the script-processing role means ‘pharmacist professional service’ is inconsistently delivered to patients, who are left to interact with pleasant assistants. That is referred to as ‘service’, which is now a ‘hygiene’ factor too. But even though it has been blown off course, the old model is chugging along, made possible by dispensing profitability sufficient to hold the bottom line together … for the time being.
3. Commoditisation
Because of price discounting and wage cuts, pharmacists are working even harder processing scripts with less time for advice and professional services. The result is that patients and the community have been trained to value pharmacies based on price instead of health benefits i.e. an industry focused on ‘selling to customers’ instead of ‘helping patients’.
The majority of new medicines being listed on the PBS are highly specialised, usually high cost, and mostly delivered to patients in hospital or specialist practices.
Pharmacy has been left primarily dispensing cheap off -patent pharmaceuticals with an average cost of $25.1 Many of these medicines have become commoditised by competing for market share through price discounting in a flat market.
4. Federal government
PBS script volume fell by 2 million between 2013/14 and 2017/18 and net outlays have been flat in nominal terms for 10 years. That policy will continue, evidenced by the April 2019 budget forecasting expenditure of $9.7 billion in 2022/23 compared with the 2018/19 estimate of $9.6 billion. So the government expects costly new medicines to be paid for by the industry, manufacturers, distributors and perhaps even pharmacy. Perhaps that was the motivation behind the proposed extended 60-day script supply for 143 drugs. The proposal could resurface!
5. Cyclonic winds
Winds of change may turn cyclonic as the Fourth Industrial Revolution gathers pace. It has been written: ‘During the next three years, the Fourth Industrial Revolution will really take hold as technologies in the physical, digital and biological spheres begin to come together under the impetus of ‘the internet of things’, artificial intelligence, robotics and additive manufacturing.’2 Immunotherapy, gene and cell therapy, along with technological convergence, will fundamentally reshape the industry.
Adjusting the sails
There is much support for pharmacist-only ownership, although it should be capitalised on by utilising their skills and trust with patients.
Innovation in the quality of the patient offer is the key to a non-price competitive value equation aimed at holding existing patients, attracting new ones and giving them great reasons to return.
Some pharmacies have done this by offering patients innovative services. This includes minor ailments, mental health, medication management and condition management in addition to script supply and advice. These innovative pharmacies outperform the industry standard in most measures, including earning professional services income over $100,000 pa, some $300,000 pa, compared with the average of a touch above $30,000.1
Virtually every pharmacy is capable of operating that model but they lack the incentive and/or implementation assistance. The innovators model should be adopted as the industry framework. The key elements are:
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Faye McMillan is a pioneer, paving the way for other Aboriginal and Torres Strait Islander people who want to work in the pharmacy profession. When she’s not busy winning awards, she works as a community pharmacist, university lecturer and is a founding member of Indigenous Allied Health Australia.
Why did you decide to become a pharmacist?
Over 20 years ago, I was working as a pharmacy assistant in my hometown of Trangie (NSW) when I thought to myself, ‘I actually want to be the pharmacist.’ The pharmacist I was working with at the time was extremely supportive and encouraged me to apply to study. I ended up being part of the inaugural cohort of students when Charles Sturt University introduced their pharmacy program in Wagga Wagga, NSW in 1997.
What’s the main focus of your practice?
I’m a community pharmacist, and I also teach in the area of Indigenous health, mental health and pharmacy at CSU. But the main focus of my work is patient-centred care, and ensuring that I’m working with people, so that they feel engaged. That’s what really drew me to pharmacy in the first place – an opportunity to have a relationship and help people as they navigate their health journey.
You’re passionate about recruiting Indigenous Australians into healthcare. What work do you do in this area?
As a founding member of Indigenous Allied Health Australia (IAHA), we strive to recognise Aboriginal and Torres Strait Islander people in the allied health workforce. I sat on the board from its inception in 2009 until 2017 and I was also the chair from 2010–2016. We started with just seven members, now we have 1,500.
IAHA is seen as one of the key bodies representing Aboriginal and Torres Strait Islander people to government and was involved in the development and implementation of the National Aboriginal and Torres Strait Islander Health Plan. We also work with universities to ensure that when Aboriginal and Torres Strait Islander students undertake allied health courses, they are being provided with support, mentors and networking opportunities.
But at IAHA, it’s not just about how we recruit people, it’s how we retain them. We work to ensure they feel engaged, not just in their profession but as a part of their community in the form of a trained healthcare professional.
You were Australia’s first registered Indigenous pharmacist and won the 2019 NSW Aboriginal Woman of the Year Award. How do you feel about being a role model?
It didn’t sit comfortably at first, but I think I’ve settled into it and recognised that people do need role models. When I was starting out I looked around for role models, and I appreciated the journeys of the people who I looked up to. If I’m that to someone else, then that’s a wonderful thing. Sometimes you’re able to use the platform of being an award recipient to give a nuanced opinion or view, and we need people to take up those positions.
You’re also a member of PSA’s National Aboriginal Community Controlled Health Organisation Leadership Group. Why is pharmacist intervention in Indigenous health so important?
Pharmacists play an integral role in the lives of so many people, whether clinically, in the community, or in hospitals – there are so many touch points where pharmacists can be included to provide insight into the health of Aboriginal and Torres Strait Islander people. The knowledge and skills that pharmacists have through their education, their life experiences and by being a consistent presence in the community means that they are able to provide a point of reference for other health professionals.
The Leadership Group is making significant contributions by ensuring people have access to a highly skilled and trained workforce, as well as providing education around the medicines that are needed in these communities, while ensuring they are accessible and affordable.
What’s the next big project that you’re working on?
I’m putting the final touches on a mental health app that I’ve been developing over the past 18 months. I wanted to create something that would provide meaningful support to people – not in place of trained mental health professionals, of course. The app is an extension of an existing self-awareness app that keeps you connected with people you’ve identified in your contact list as your ‘caring community’. It assesses where people are sitting on the scale of mental wellness, followed by contact from someone who will reach out and have a conversation with you. It’s all about having real conversations – listening out for warning signs such as changes in the timbre of the voice, and pauses, things that are easily masked in social media use.
Get more news at www.australianpharmacist.com.au [/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row]
[post_title] => Pushing boundaries: the pioneer pharmacist
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A range of apps enable pharmacists and patients to see and/or manage their medical information.
As the benefits of My Health Record (MHR) become more widely known, its uptake and usage can be expected to grow. As pharmacists, we are well positioned to take a leadership role and guide patients on this topic, given our status as the most digitally enabled of all health professionals.
It is important for patients who wish to play an active role in their healthcare, or carers of vulnerable patient groups (e.g. children, disabled, elderly, mentally impaired), to understand what information is available to them and how they can access and control access to clinical documents (shared health summary, discharge summary, pathology, diagnostic imaging), prescriptions (prescriptions issued and dispense uploads), consumer documents (patient health summaries, patient notes) and Medicare documents (e.g. immunisation register, organ donor status, Medicare benefits).
How do patients access their MHR?
There are two ways for patients to access their My Health Record.
1. WEB PORTAL (myrecord.ehealth.gov.au)
This site:
| Using a great smartphone app with your patients? Share your insights with your colleagues. Email australianpharmacist@psa.org.au and tell us about your experience and the results you’ve seen. |
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[post_content] => Three outstanding pharmacists recognised at the 2019 Victorian Pharmacists Dinner in Melbourne last week represent the difference dedicated members of the profession make every day to healthcare in the community.
The executive officer of the Pharmacists’ Support Service (PSS), Kay Dunkley MPS, was awarded the PSA Victorian Excellence Award for her commitment to improving the wellbeing of health professionals, particularly through peer support.
[caption id="attachment_8788" align="alignright" width="219"]
Kay Dunkley MPS[/caption]
This includes her involvement with the PSS and her help in establishing the AMA Victoria Peer Support Service in 2008. She has also travelled extensively in Australia and the United Kingdom promoting the welfare of pharmacists and pharmacy students.
Ms Dunkley said a highlight of her work was ‘being able to make a difference to the lives of those we care for as pharmacists’.
‘PSS is about caring for each other within the pharmacy profession to ensure that as a profession we can care for the Australian community,’ she said.
‘I really value the generosity of the PSS volunteers in giving their time and energy to be there for their colleagues in times of stress.’
The inaugural Victorian Early Career Pharmacist (ECP) of the Year title was won by Amanda Cross MPS. A postdoctoral research fellow at the Monash Department of Clinical Epidemiology, Cabrini Institute, Dr Cross has already gained a high level of expertise in research and clinical practice and is an exemplary role model for other ECPs. She is also an Australian Pharmacist columnist.
[caption id="attachment_8791" align="alignright" width="219"]
Amanda Cross MPS[/caption]
Her PhD, awarded this year just months before giving birth to her second child, focused on the prevalence and impact of potentially inappropriate medication use in older people with cognitive impairment, which has implications for medicine safety in Australia.
Dr Cross said she chose to do a PhD to try and make a difference on a larger scale.
‘I would frequently see patients struggling with medicine adherence and commonly using inappropriate medicines,’ she said.
‘Medicine safety is important to me because as a pharmacist it is my responsibility to ensure people are taking the right medicines, at the right dose, for the right duration to ensure the medicine is creating more benefit than harm.’
[caption id="attachment_8782" align="alignright" width="219"]
Roslyn Stewart MPS[/caption]
The Victorian Pharmacist Medal was awarded to Roslyn Stewart MPS, in recognition of her wide-ranging, 40-year career which included time at the Fairfield Infectious Diseases Hospital during the AIDS epidemic and as a senior pharmacist at the Royal Melbourne Hospital before 20 years in community pharmacy.
She has also conducted medicines reviews in aged care facilities and the community, and does volunteer work as a Mental Health First Aid Instructor.
Reflecting on her career, Ms Stewart said being a pharmacist offered a wealth of options.
‘I have taken advantage of this, working in research, hospital and community pharmacy,’ she said.
‘I have enjoyed each new challenge. Few careers provide this type of flexibility.’
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Dimitra Tsucalas FPS, co-owner of Ascot Vale Supercare Pharmacy, has seen it all. From late-night triage, shift workers, opioid seekers and everything in between, she says the best thing about 24-hour trade is the ability for patients to access a healthcare professional at any time.
What are the patient benefits of Supercare 24-hour pharmacies?
The benefits are essentially that they can approach a health professional to ascertain whether they need to get something that can resolve their problem reasonably quickly or [whether] they need to get to the next level to an Emergency Department or see a doctor; whether it’s something they need to worry about or not.
Essentially, they are seeing a health professional to triage – to either treat at a primary care level or move into the next stage – and they’re accessible at all hours.
So, at 2am when the itch becomes absolutely intolerable they can come and see someone. Or if symptoms are so problematic that it’s causing them anxiety they can come and see someone and decide whether they need to go to the Emergency Department.
What are challenges you might face after hours?
One of the biggest challenges was managing patients seeking over-the-counter codeine products. Now that has shifted to codeine containing and/or other medicines that are dependence inducing or potentially dangerous.
This issue is addressed to a great extent by SafeScript. But the challenge with SafeScript is that the pharmacist then becomes a police officer.
Certainly at night, people will try to obtain medicines when they shouldn’t. A refusal to fill a script can create the potential for confrontation – both physical and verbal. For young graduates or new employees working overnight, it can be quite confronting.
How long has your practice been using SafeScript?
Since the beginning. We use FRED pharmacy software, so any SafeScript warnings pop up as an alert, urging us to look into the person’s supply history.
What are you most proud of from your involvement in a Supercare pharmacy?
It is a big job transitioning from eight staff to 28 staff. It introduces a lot of new learning opportunities and challenges and you’ve got to keep making it work. You are professionally stimulated. I think all after-hours work can be, especially if you are working on your own.
So, pharmacists working on their own of an evening and overnight have to make calls that they don’t make necessarily on their own through the day. They can’t call a doctor and they can’t call a colleague so they will have to make the call. I think it’s empowering. The best thing about 24-hour trade is professional accessibility.
Dimitra Tsucalas on a typical overnight shift11.00 pm Unsure about whether to go to hospital for stitches, a mum brings in her two-year-old boy with a minor gash over his eyebrow. It is a small, clean cut. The bleeding has stopped and there are no red flags in his behaviour or appearance. I suggest some Solosite® gel to keep it moist and promote healing, and tell her to monitor for redness, inflammation or easily visible pus. I tell her to come back in or see a GP for review in 1–2 days if the wound is not healing. Midnight A mother brings in her daughter, 17, who has an exam the next day. Unwell and unable to focus or study, she has urinary frequency indicating a possible urinary tract infection. Her options: call overnight doctor services for assessment and possibly an antibiotic script if indicated; purchase hexamine as a stop-gap until her GP can be seen next morning or after her exam; or try the Instant-Script® service which assesses and allows for a trimethoprim script so she can begin treatment before review by her GP. 1.00 am A pregnant lady is brought in by her partner with dizziness, weakness and fainting. She is unable to keep anything down so dehydration is possible. We provide a private consult room for her to lie down while taking her blood pressure and blood sugar, and then decide to call an ambulance. She is taken to the Emergency Department for assessment. 3.00 am A regular customer arrives with a script she forgot to fill earlier. She asks about an itchy eye corner for which she had already tried allergy drops numerous times in recent months. A slightly elevated area near her nose bridge is visible, which is still itchy. I don’t supply her a product. Instead, I suggest a referral to an ophthalmologist or at least an optometrist for triage. She calls a month later: it was a malignant growth which has been removed. She gives her thanks. Dawn The phone rings. It is a dad with an 18-month-old baby calling about a dose of paracetamol, but he only has a bottle of Panadol® 5–12 Years at home. He asks if this is ok, and about the size of the dose. I tell him that it’s fine and ask how much the baby weighs so I can calculate the dose. |
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[post_content] => Megan Tremlett MPS and Sue Carson MPS are two pharmacists forging new roles outside the norm in pharmacy.
At PSA Queensland’s Annual Therapeutic Update this month, participants heard how they are following their dreams by pursuing work that was not available to them when they graduated more than 25 years ago. They are making a difference to peoples’ lives, and their passion is infectious.
Based on the Sunshine Coast, Ms Tremlett is co–ordinating the Aboriginal integrating pharmacists within Aboriginal Community Controlled Health Service (ACCHS) to improve chronic disease management project (IPAC).
Ms Carson is working as a pharmacist in the Community Transition Care Program at the Brighton Health Campus of the Metro North Hospital and Health Service in Brisbane.
Ms Tremlett loves contributing to the evolution of an alternative career path for pharmacists, one that is much needed in the Aboriginal and Torres Strait Islander health sector. She also finds it rewarding to contribute to research needed to support the value of this emerging role for pharmacists. She works collaboratively with project partners, which extends her knowledge of research methodology.
‘It is immensely rewarding to coordinate 20 inspirational pharmacists doing the pioneering “on the ground” work to provide, not only a relatively new clinical service but also to collect extensive project-related data,’ she told Australian Pharmacist this week. ‘Hearing numerous testimonials from patients, doctors and others positively impacted by their work has been very satisfying.’
In Ms Tremlett’s 28-year career, she has deliberately sought job variety and new challenges to progress her professional capabilities, including hospital pharmacy (both in Australia and the United Kingdom), community pharmacy, and as an accredited pharmacist conducting RMMRs and HMRs.
Due to her previous work in the Northern Territory, and her ongoing interest in new clinical roles for pharmacists, she was approached by PSA for the role of IPAC Project Coordinator.
‘I have been extremely fortunate to share this role with a wonderful colleague, Hannah Loller, who is equally passionate about the health of Aboriginal and Torres Strait Islander Australians.’
Ms Tremlett wants to encourage pharmacists to consider participating in research to use their extensive skills and push existing boundaries in care delivery.
‘In particular,’ she added, ‘I am optimistic that the role of pharmacists working with Aboriginal Health Services will continue to gain momentum thanks to a combination of research projects such as IPAC and IMeRSe, and the shared experience of a number of pharmacists who have already been working in this sector for many years.’
‘While there are challenges associated with becoming integrated into a new practice setting, the rewards of being a valued member of a multidisciplinary team and making a genuine difference to patient care are limitless. For pharmacists who like to travel, I would urge you to seek a new adventure in regional or remote Australia,’ Ms Tremlett said.
Sue Carson jumped at the opportunity to work in a community transition care program with registered nurses, enrolled nurses, speech pathologists, physiotherapists, dieticians, occupational therapists and social workers using her skills as an accredited pharmacist.
‘It is very rewarding to see a client of community transitional care gain independence in their own home after an admission to hospital. The other health professionals value my knowledge as a pharmacist, and we learn from each other every day.’
She has ‘never felt so valued in my career in pharmacy’ because in the transitional care setting, pharmacists are greatly needed as a significant number of hospital readmissions occur due to medication errors at transitions of care.
‘There are an increasing number of opportunities for pharmacists to work in multi-disciplinary teams as we [not only] have pharmaceutical knowledge but also communication skills. So pharmacists should seek out the opportunities that our professional training can lend itself to,’ Ms Tremlett said.
‘As PSA is impressing upon government and medical professionals [and as highlighted in the Royal Commission into Aged Care Quality and Safety] pharmacists need to be involved wherever and whenever medicines are used.’
PSA’s Pharmacists in 2023 report encourages pharmacists to be embedded wherever medicines are used, and unlock their potential to improve healthcare access and outcomes for Australians and reduce variability in care.1
Reference
- Pharmaceutical Society of Australia. Pharmacists in 2023: For patients, for our profession, for Australia’s health system. Canberra: PSA; 2019.
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]The pharmacovigilance inspector role is fairly new to Australia. It requires tact, tenacity, excellent time management and travel. Sarah May became the Therapeutic Goods Administration’s first pharmacovigilance inspector in 2015.
How did you become a pharmacovigilance inspector?
It was by accident really. I moved to London for a one-year working holiday. Over there it wasn’t possible to work in my field as a hospital pharmacist as my Australian registration was not directly transferable. As an alternative, I ended up in the pharmaceutical industry in medical affairs and pharmacovigilance. I then applied for – and secured – a role as a pharmacovigilance inspector with the UK Medicines and Healthcare products Regulatory Agency.
How did you end up at the TGA?
We were thinking about moving back from the UK when the TGA advertised a position for someone to establish a pharmacovigilance inspection program in Australia. At the time I was probably the only Australian with experience as a pharmacovigilance inspector. So began my career in setting up Australia’s Pharmacovigilance Inspection Program.
What role does your job play in supporting medicine safety in Australia?
I ensure Australian sponsors of medicines are complying with Australian Pharmacovigilance requirements1 (and that) they are monitoring the risk-benefit balance of medicines in Australia, collecting and reporting adverse drug reactions to the TGA and communicating identified risks as required. This can involve physically inspecting medicines companies (sponsors), reviewing adverse drug reactions, reviewing periodic safety update reports and databases, requesting records of ongong monitoring activities inspecting quality management systems and reviewing contracts and agreements with partners.
POINTERSSarah May’s pointers for a career as a pharmacovigilance inspector.
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AN INSPECTION DAY IN THE LIFE of Sarah May7.00 am: Travel preparation After waking at 6am and grabbing a taxi to the airport, join other inspectors and squeeze in some pre-flight breakfast. 8.30 am: Arrrive for inspection After landing, travel to the inspection site – the company headquarters, a manufacturing site, shop or home office – the site of their pharmacovigilance system. 9.30 am: Set up and preparation Sign into the site, set up computers and documents. Start inspection with introduction to team, discussion about inspection and methods. 11.00 am: Collect data Undertake the first pharmacovigilance inspection session. Generally it’s an interview session on how the sponsor is collecting adverse drug reactions data and submitting cases to the TGA. 12.30 pm: Documentation Write up a list of documents required from the sponsor to corroborate interviews and compliance with legislation. Through a working lunch, start review of documents provided so far – often in the hundreds in the course of an inspection. 2.30 pm: Shift in focus Second pharmacovigilance inspection session. Focus could be ongoing monitoring, post registration regulatory commitments, quality management systems, maintenance of reference safety information, contracts and agreements with partners and contractors. 4.00pm: Database reviews Ask for more documents, review databases before hotel check-in and quick team dinner later. 8.00 pm: More work Back to the hotel for more document reviews and initial findings on non-compliance issues. Prepare for inspection day two. |
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Deirdre Criddle FPS is a complex care coordinator pharmacist at Sir Charles Gairdner Hospital in WA, and also a senior pharmacist steering professional services and development. It keeps her busy – and inspired.
Can you tell us what your complex care role entails?
It’s quite new. In 2012, an inter-disciplinary team of advanced practitioners – nurses, social workers, occupational therapists, physiotherapists – were charged with improving health system navigation for complex patients. They asked Bruce Williamson, an experienced clinical pharmacist, if he could upskill them. Bruce tried to draft a program, but basically said, ‘You don’t need upskilling – you need a pharmacist embedded in your team.’
So he started this journey and I have been fortunate enough to follow in his footsteps since 2014. It’s now three days a week in an inter-disciplinary team. I do a lot of intensive work in medication management for patients who are medically complex. It’s a fantastic position, I love it, and it’s growing. I think there’s a huge opportunity for progression in that area – hospitals are facing such difficulty with patients becoming more complex, and pharmacists are an integral part of the solution.
What got you started in hospital settings?
I’ve had a varied journey. I started as a hospital pharmacist, then was with NPS MedicineWise for 14 years as an educational visiting pharmacist, which was invaluable. I branched into being an independent accredited pharmacist doing medicines reviews, and I hoped to make a career of that. But the cap came along in 2014, and that killed it. That’s when I came back into hospital pharmacy at Sir Charles Gairdner. And I heard Bruce talking at a clinical pharmacy meeting about his role, and I just thought, ‘Oh, I so want that job.’ Everything that I had done to that point was consolidated in that role. That’s what brought me back.
But I’m a bit of a jack-of-all-trades. I see the value in every aspect of our profession. It’s not like this role is better than that role. I would never dream of doing anything else.
You’re also a Director of the Society of Australian Hospital Pharmacists (SHPA). What are today’s biggest challenges in hospital settings?
It’s a very challenging environment. The need to prioritise is paramount, and that’s a difficult thing. In my role as a care coordinator pharmacist you are dealing with stressed patients, and also stressed staff. They’re working with insufficient resources, staffing levels are not what they should be, patient complexity is increasing ... basically, they’re working in a very stretched system. If you’re spending all your time with your nose to the grindstone, there’s no opportunity to do the reflection to ask, ‘How can I do my job better?’ That can only come if you’re given room to breathe. Trying to get those in power to understand the value pharmacists bring to complex systems, especially to reduce medicine-related harm across the patient journey, that’s where we need to go.
How would you like to see pharmacists’ roles in complex care develop?
For my first two years in this role, people would say, ‘What’s a pharmacist doing in a complex care coordination team?’ My dream now is that everyone will say, ‘Where’s the pharmacist?’ There are people like me all across Australia, and that is so exciting. Sometimes you think you’re alone, but I can guarantee you you’re not.
If we have mechanisms to network, and to improve the collaboration and sharing across our profession, especially in these emerging areas of practice, it can only be a good thing.
A DAY IN THE LIFE of Deirdre Criddle, hospital pharmacist8.00am: The day begins Connect with the cardiology pharmacist, who updates the team on new guidelines. Take a phone call from a clinical pharmacist concerned about a patient. 9.00am: Stopovers Visit a ward with a family, telephone interpreter in tow. Consent gained for a visit with an on-site interpreter in two days. 10.00am: Drive by Home visit with a patient who is confused by medicine changes. I make a phone call to his GP and General Medicine Consultant to discuss. Arrange a visit with patient at GP clinic the following day to trial a dose administration aid. 12.30pm: Meetings Meet with Head of Pharmacy Gillian Babe and Clinical Pharmacist David Lui to discuss the results of the Medicines Management Mapping Project about facilitating early post discharge using community and hospital pharmacists. 2.00pm: More meetings Catch up with the clinical nurse leads for the Cognitive Impairment Committee to discuss content development for an education package dedicated to antipsychotics prescribed in the hospital setting. 3.00pm: And another ... Multidisciplinary team meeting with CoNeCT social worker, pain consultant and addiction specialist to discuss concerns for a patient. 4.00pm: Check in What’s new in the email inbox? Check new referrals, and plan visits for the coming week. Phone patients scheduled for an outreach visit. 9.00pm: Moonlighting Teleconference with the International Pharmaceutical Federation (FIP) Working Group, based in the Netherlands. Final review of The pharmacist’s role in beating noncommunicable diseases. High fives all round as we agree to final edits and submit to the FIP Council for approval. |
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
