Dr Rosie Nash
Dr Rosie Nash is a lecturer in Public Health at the University of Tasmania.
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[post_content] => Over 3 action-packed days, pharmacists gathered for a mix of clinical and practice updates, and social events at PSA22.
Here is a visual representation of the first in-person PSA national conference in 3 years. If you were unable to make it to the conference this year, catch up on all the highlights. If you were there, see if you can spot yourself in the crowd!
Day 1 – Friday 29 July
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Read Australian Pharmacist's coverage of Day 1 here:
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[post_content] => At PSA22 last week, new guidelines were launched to help pharmacists support Aboriginal and Torres Strait Islander peoples with medicines management.
Rather than focussing on clinical areas of practice, the guidelines help pharmacists understand how their clinical work informs the health outcomes for Aboriginal and Torres Strait Islander peoples, said co-author, Wiradjuri woman and 2022 PSA Pharmacist of the Year Dr Faye McMillan MPS.
‘It’s about [building] a level of reflexivity by checking what the other components are, [such as] unconscious bias or the socioeconomic environments in which Aboriginal Torres Strait Islander people might be engaging with services,’ she said.
‘The medications and how they work don't change, it's the thought processes and the implementation of policies and processes that inform how we respond.’
Whether you’re working in a community pharmacy setting in urban Australia, a hospital pharmacist or as an integrated pharmacist in a remote clinic – all pharmacists can learn from the guidelines, said Mike Stephens MPS, Director, Medicines Policy and Programs at the National Aboriginal Community Controlled Health Organisation (NACCHO).
‘[The guidelines] are a comprehensive platform to deliver better medicines management by supporting culturally safe practice for pharmacists and across the sector,’ he said.
Here’s why pharmacists should read the guidelines.
1. They take a refreshed approach to Aboriginal and Torres Strait Islander healthcare
The guidelines emphasise the importance of knowledge sharing between pharmacists and Aboriginal and Torres Strait Islander peoples and promote working with them to understand their healthcare needs, Mr Stephens said.
That could mean working with an individual, a group of Aboriginal and Torres Strait Islander patients or with the local community to come up with a strategy around health promotion in relation to medicines.
The guidelines also look at the use of culture as an agent of strength rather than a deficit, Dr McMillan said.
‘Many other documents [infer] that we were the cause of our ill health,’ she said.
[caption id="attachment_19668" align="aligncenter" width="400"]
Dr Faye McMillan MPS at PSA22[/caption]
‘It was all about behavioural [aspects], whereas this is about recognising the impact of historical traumas as well as contemporary challenges that Aboriginal and Torres Strait Islander peoples face.’
Aboriginal and Torres Strait Islander governance and authorship is imbued throughout the entire document, Mr Stephens said.
‘It’s responsive and consultative of Aboriginal and Torres Strait Islander voices.’
2. The importance of cultural safety is explained
In medicine management, cultural safety includes engaging with cultural knowledge around traditional medicines and the use of on-Country practices, and how these can blend with Western medicine.
‘This includes the concept of Country itself in the wellbeing of Aboriginal and Torres Strait Islander peoples,’ Dr McMillan said.
‘Medications in and of themselves won't change the overall health and wellbeing of the person.
‘When we don't understand what connection to culture and Country means, there are opportunities being missed through medication management.’
Medicines are a small but important part of healthcare for Aboriginal and Torres Strait Islander peoples, Mr Stephens said.
‘[Traditional healing methods] are diverse across the country, but they involve paradigms and ideas which are distinct from Western mainstream health ideas,’ he said.
‘Pharmacists should work with their local communities to understand how medicine fits into that and what its role is within that broader perspective on health.’
3. Learn how to build an Aboriginal and Torres Strait Islander workforce
Rather than citing statistics, the guidelines explain how to embed new policies and mechanisms, including the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan.
The guidelines help pharmacists understand the importance of having skilled Aboriginal and Torres Strait Islander people involved in all levels of organisations – from clinical governance to service delivery, Mr Stephens said.
This includes tips for securing scholarships through the Aboriginal and Torres Strait Islander Pharmacy Scholarship Scheme and exploring a range of practical programs that support Aboriginal and Torres Strait Islander employment or career development.
‘When Aboriginal and Torres Strait Islander people are in senior and leadership positions, it supports a more culturally safe and effective workforce [through] oversight and input from that perspective,’ he said.
4. Figure out how to work around barriers to medication management
While barriers to effective medicine management are multifactorial, Dr McMillan said they can include geography, fiscal environments, cultural contexts and the prioritisation of other activities.
‘That doesn't mean non-compliance,’ she added.
While some barriers are organisational and others structural, it’s about working with the individual through relationship building to identify any elasticity.
‘If finances are a barrier, have a conversation that isn't judgmental and builds on trust,’ she said.
For example, if it’s critical a patient starts taking their medicine immediately, but pay day is 3 days down the track, that could mean providing them with 3-day’s supply with payment settled upon their return.
‘That's an example of how relationships based in reality and non-judgment can really start to see change,’ Dr McMillan said.
Factors impacting health literacy are also important for pharmacists to understand, Mr Stephens said. This is related to the world views of patients, and the priorities, strengths and challenges they face.
[caption id="attachment_19674" align="aligncenter" width="300"]
Mike Stephens MPS, Director, Medicines Policy and Programs at NACCHO[/caption]
‘The English language may be the second, third or fourth language for a community,’ he said.
‘There could [also] be issues of institutional distrust, meaning people don't engage with or trust mainstream information.’
5. Understand how to communicate about medicines
To effectively communicate about medicines, pharmacists need to build a rapport through authentic conversations to understand a person’s circumstances.
‘It's not about speaking down to people, but making sure messages are clear and using the least technical language,’ Dr McMillan said.
This process begins in initial conversations with patients.
‘It’s starting the conversation with, “to ensure I'm being as respectful as possible, what would you like to be called when we’re having conversations about your health”, [for example] auntie or uncle?’ she said.
In all conversations about health and medicines, it’s essential to be clear about your intentions.
‘What we want is the intention to be a relationship to share our knowledge systems to ensure the best outcomes are achieved,’ Dr McMillan said.
This is crucial when approaching in-depth medicine management services such as medicine reviews.
‘You might be on multiple medications and all of a sudden the doctor or pharmacist says, “I'd like to refer you for a medication management review,”,’ she said.
‘If you don't know the context you might think, “they want to check what I'm doing because I've done something wrong”.’
The right approach would be saying: ‘I'm thinking of doing a medication review, because there may be a few medications that, when taken together, might not be working in the way that we'd like them to.’
Become a ‘deadly’ pharmacist
In Aboriginal language, ‘deadly’ means awesome or great. You might have noticed PSA staff and presenters at PSA22 wearing ’deadly’ scarves and ties.
Designed by artist Lani Balzan, the artwork highlights the multiple ways the pharmacy profession is engaged with Aboriginal Torres Strait Islander people.
There are three symbols representing Aboriginal and Torres Strait Islander people, Person Centred and Pharmacist.
‘The blue dots represent the pharmacist and pharmacy practices,’ Dr McMillan said. ‘You see how that is interwoven across the entire space of communities and individuals and what medicines means.’
To be a ‘deadly pharmacist’ means all of those things – engaging with the individual, the community and two-way knowledge sharing.
To complement the new guidelines and help you on that path, PSA and NACCHO co-designed the Deadly pharmacists foundation training course.
The eight-module online education program, released later this month, will equip pharmacists with the skills needed to work with Aboriginal and Torres Strait Islander primary healthcare services.
This includes developing an increased understanding of the holistic approach to wellness, taking into account connection to Country and culture and the importance of these inherent strengths when managing clinical conditions.
The program is free for all pharmacists. Enrol now to be the first to hear when the course opens.
[post_title] => Why you should read PSA’s new medicine management guidelines
[post_excerpt] => At PSA22, new guidelines were launched to help pharmacists support Aboriginal and Torres Strait Islander peoples with Medicines Management.
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[post_content] => At the final day of PSA’s national conference, attendees boosted their knowledge of poisons control, the latest Aboriginal and Torres Strait Islander healthcare policies and guidelines, and supporting transgender patients.
PSA22 FAST FACTS
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[post_content] => Two early career pharmacists who made presentations to PSA22 on research into pharmacist-delivered perinatal depression screening and opinions of pharmacists’ CPD requirements were presented with 2022 Australasian Pharmaceutical Science Association (APSA) awards during the closing luncheon on Day 3 today (Sunday).
Earlier this year, PSA renewed its partnership with APSA, which began in 2019, with the signing of a Memorandum of Understanding (MoU) for the next year.
The APSA Most Outstanding Oral Presentation winner was hospital pharmacist and Master of Philosophy candidate at the University of Sydney Lily Pham. The awards were presented to each winner by Dr Sarira El-Den MPS and Lisa Kalisch from APSA.
At PSA22 on Saturday, Ms Pham gave a presentation on the ‘Qualitative exploration of perinatal women’s views of pharmacist-delivered perinatal depression screening’ to a very interested audience.
https://twitter.com/truryAdelaide/status/1553573225937846272
Ms Pham who told Australian Pharmacist readers about her experiences at this year’s OnShore Refresher Conference in Darwin in the June issue news section, said afterwards that her presentation topic really ‘supports pharmacists working at their top of scope in mental health’.
The APSA Most Outstanding Poster Presentation winner was Oya Gulal. She is a New South Wales-based PSA Professional Practice Pharmacist, PSA Pharmacist Trainer, and a Subject Matter Expert at the Australian Pharmacy Council.
Ms Gulal was featured by AP on her 6-month stint as a pharmacist immuniser with the Royal Flying Doctor Service in New South Wales.
Her poster presentation was on ‘Australian pharmacists opinions of their CPD requirements’ which was watched by a sea of pharmacists and delegates wearing ‘silent disco’ headphones during numerous poster presentations on the afternoon of Day 2 (Saturday).
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The PSA22 'silent disco'[/caption]
On her award, Ms Gulal said: ‘Further education and emphasis on CPD will ensure Australian pharmacists understand and value their role in supporting the changes in practice scope for professional development, pharmacy practice and safety.’
So, start planning your abstracts for next year.
Meanwhile, find Lily Pham here and Oya Gulal here.
[post_title] => ECPs win big at APSA awards
[post_excerpt] => Two early career pharmacists were presented with 2022 Australasian Pharmaceutical Science Association awards at the PSA22 closing luncheon.
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[post_content] => It was a classic presentation – worsening flare-ups of osteoarthritis, poorly controlled with paracetamol, on top of a tangle of other health conditions and prescription medicines, including warfarin.
That’s the scenario faced at PSA22 on Friday by finalists in the 2022 Viatris Pharmacy Student of the Year (PSOTY) award. They were:
Haylee Shaw won the 2022 Vitaris Pharmacy Student of the Year award[/caption]
Ms Shaw says she has always had an interest in pharmacy and is excited to network and learn from other pharmacists.
‘I have always admired the accessible nature of the pharmacy profession. The ability to provide evidence-based advice and quality use of medicines to any member of the community without cost is something that really attracted me to this career path.
‘I entered this competition as I wanted to push myself and further my practical experience. I was also excited to be a part of the national conference and hear from like-minded peers and professionals.’
Chloe Woodward, who received the most votes from the competition audience, was chosen as the People’s Choice Award winner.
Ms Woodward told the audience, which was gearing up for the phenomenal “Dancing with the Pharmacists” show immediately afterwards, that she had learned ‘so much’ already at this, her first pharmacy conference, and was humbled and appreciated at the crowd support for her award.
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People's Choice award winner Chloe Woodward[/caption]
‘This competition provides students the opportunity to demonstrate important skills such as gaining patient insights and patient understanding, active listening and skills that support positive patient outcomes,’ said PSA National President Dr Fei Sim.
‘PSA is dedicated to making pharmacy an attractive career path for young people and celebrating success regardless of where you are in your career.
‘Each of the students who participated in the PSOTY competition has demonstrated impressive professionalism, skill, and dedication,’ she said.
Viatris Head of Business Development, Strategic Partnerships, Portfolio and Sourcing, Charbel Azzi reiterated the sponsor’s continued support for the next generation of Australian pharmacists.
‘They play a vital role in empowering Australians to live healthier at every stage of life, a mission we share,’ she said.
‘I was heartened by the drive and dedication of all the winners. I was particularly inspired by Haylee’s exemplary patient counselling skills, and congratulate her for winning this year.’
[post_title] => Tasmania top spot in pharmacy student showdown
[post_excerpt] => Haylee Shaw was crowned 2022 Vitaris Pharmacy student of the Year after winning the thrilling clinical competition at PSA22.
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[title_attribute] => Tasmania top spot in pharmacy student showdown
[title] => Tasmania top spot in pharmacy student showdown
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]A review of aged care patients’ medicines can reduce harm.
Welcome change is coming for government-funded residential aged care facilities (RACFs) with the investment in on-site pharmacists and pharmacy services from 1 January 2023.1 But what will pharmacists in these facilities do?
Role of aged care pharmacistsSupply of medicines
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Andrew Kelly MPS[/caption]
Dee-Anne Hull MPS[/caption]
Jaylee Lewis MPS[/caption]
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Many patients use fish oil in the hope of relief from inflammatory conditions or to reduce risks of cardiovascular disease. As non-prescription complementary medicines, it is likely many patients are not abreast of how to use fish oil in a way which will achieve therapeutic benefit.
Why supplement?
Mammals are unable to synthesise omega-3 acids and so dietary sources are important.1 Foods like cold-water fish, nuts, and plant oils provide the highest density of omega-3, although therapeutic doses from diet is unlikely to be achieved.2
How do omega-3 acids achieve a therapeutic effect?
Initially it was thought that omega-3 acids were important for cell membrane fluidity, with their weird, bent chains disrupting the sea of mostly saturated straight lipid chains.2 Maybe this did something for energy transduction and proton channels? Turns out – no.
A more contemporary view of fish oil involves anti-inflammatory activity and the prostaglandin system – potentially providing benefit in cardiovascular conditions and osteoarthritis.3
Do fish oil supplementations work?
Omega-3-containing fish oils have been extensively studied - the headline is that omega-3 supplements do not lower all-cause mortality4 or cardiovascular mortality,5 but may have some benefit in inflammatory conditions.6
There is also some evidence for cardiovascular benefit in patients with heart disease.7 The Mediterranean Diet Study had data extrapolated that suggested omega-3 supplementation may achieve the same longevity results, however it still appears that only food sources are associated with these benefits.6
Most people taking omega-3-containing fish oil supplements don’t take enough.
Guidelines for omega-3 supplementation in musculoskeletal conditions in adults recommend a minimum of 2.7g of fish oil per day, with 2-4g daily recommended for high triglycerides.3,9 This dose poses a significant pill burden and it is no surprise that so many patients do not achieve the required daily dose.
Persistence is also an issue
The high pill burden, and general issue of persistence means that many patients abandon treatment early, often before efficacy can be shown.10
Choosing formulations which reduce pill burden are important
The Therapeutic Guidelines suggests daily doses can range from 3-9 capsules depending on strength – using the highest tolerated dose will minimise pill burden and improve adherence.3
Liquid formulations are refined to have high concentrations of omega-3 and may be useful for those who cannot tolerate large capsules.
What if my patients don’t like the taste of fish?
Adverse effects such as reflux, fishy taste, or diarrhoea are common and may be the reason patients stop taking the supplement. These may be overcome by taking it with food to reduce the risk for reflux, or storing the medication in the freezer - which will reduce the oxidation of the fish oil and thus development of the fishy taste and anecdotally can help with GIT tolerability.8
References
- Lee JM, Lee H, Kang, SB, et al. Fatty Acid Desaturases, Polyunsaturated Fatty Acid Regulation, and Biotechnological Advances, Nutrients, 2016 Jan; 8(1) 23
- Omega-3 fatty acids. National Institute of Health. 2022. At: ods.od.nih.gov/factsheets/Omega3FattyAcids-Consumer/
- Cardiovascular Expert Group. Cardiovascular, Melbourne: Therapeutic Guidelines; 2010.
- De Santis A, Verela Y, Sot J, et.al, Omega-3 polyunsaturated fatty acids do not fluidify bilayers in the liquid-crystalline state, Nature, November 2018, 16240
- Aung T, Halsey J, Kromhout D, Associations of Omega-3 Fatty Acid Supplement Use With Cardiovascular Disease Risks, JAMA Cardiology, 2018 3(3) 225
- Katz J, Goldberg R, A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain, Pain, 2007 May;129(1-2):210-23
- Turner D, Shah PS, Steinhart AH, Zlotkin S, Griffiths AM. Maintenance of remission in inflammatory bowel disease using omega-3 fatty acids (fish oil): A systematic review and meta-analyses. Inflamm Bowel Dis 2011;17:336–45
- LeWine H, Fish oil: friend or foe?, Harvard Health Blog. 2020. At: health.harvard.edu/blog/fish-oil-friend-or-foe-201307126467
- Covington M, Omega-3 fatty acids, Am Fam Physician. 2004;70(1):133-140
- Loadsman P, Moses G, McGuire T, et.al Your questions about complementary medicines answered: fish oil, AFP, 2015 Volume 44, Issue 7, July 2015
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[post_title] => How much fish oil is enough?
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How pharmacists can change the lives of people with lung diseases by taking every opportunity possible.
For most pharmacists, respiratory health is a significant part of their practice.
Device counselling takes time and self-management is common. Yet people take their breathing for granted.
This can lead to significant undertreatment, unnecessary flare-ups, avoidable hospitalisations and sometimes even death.
Respiratory health is deceptively complex, with multiple medicines, different devices and under-recognised drug-drug interactions.
It is why patients need the support of pharmacists as their medicine experts – part of their wider healthcare team – to achieve good health.
Some interventions should be routine – checking inhaler use frequency (see Box 1), assessing stability in symptoms and active referral for reassessment. But others should happen much more often, particularly in checking inhaler suitability or optimising technique.
Box 1 – Selecting an inhaler device*
Essential questions for inhaler device choice for all patients:
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The starting point for these conversations is structuring in good practices, as Accredited Advanced Practice Pharmacist Debbie Rigby FPS outlines (see Box 2).
‘Inhaler device technique should be assessed and optimised at every opportunity. This means with initial dispensing plus repeats.’
Box 2 – Inhaler inspiratory flow rates
Many people inhale pMDIs too quickly. Assess technique at every opportunity.
Soft mist inhalers and pMDIs
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Some interventions do take time – but these are often the most important. Whether in community, hospital, consultant or institutional pharmacy practice, nearly all pharmacists need to be at the top of their game to support patients with respiratory conditions.
Australian Pharmacist talked to a rural-based community pharmacist and a hospital pharmacist about their experiences with patients who needed their urgent respiratory help.
HANY AITA
Managing Pharmacist, Amcal Max, Devonport, Tasmania
With 6 years as a pharmacist in his native Egypt, and another 13 years solely in rural and outback community pharmacy in Western Australia, New South Wales and Tasmania, Hany Aita MPS has seen a lot of people living with asthma.
And with fewer opportunities to visit doctors, asthma and COPD are ’not as well managed as you would think’, he says. Some patients, who have never been diagnosed and use puffers when short of breath, eventually visit a doctor, get a diagnosis and sometimes, for financial, time, distance or other reasons never follow-up, he explains.
However, he has a golden rule for himself and staff when non-prescription requests for salbutamol relievers are made. Always ask about frequency. ‘How often do you need to use it?'
Last year a local woman in her early 30s, seemingly health literate but not a regular patient, admitted to him that she used salbutamol ‘every day’.
Mr Aita was stunned that she had no idea, in a town of six pharmacies, that this was abnormal and the recommended use of non-prescription relievers in well-controlled asthma was no more than 2 days per week.
‘I said: “How long you been doing that? [She answered] ‘Oh I’ve been doing that for the last few years. It actually keeps me going.'" Unlike some hostile responses to his ‘red flag’ initial questions, ‘she was open to talk more about it’.
Mr Aita explained her ‘condition’ was not properly managed and referred her to her GP for an urgent diagnosis, or otherwise, of asthma. ‘It was just amazing that this was all new for her,’ he relates.
Some weeks later she returned – with an asthma action plan, a preventer for daily use and prescription for low-dose fluticasone propionate/salmeterol (Seretide).
SARAH RISDALE
Clinical Pharmacist, Royal Brisbane and Women’s Hospital
At her hospital, Ms Risdale’s role supports patients with a variety of acute – as well as chronic – respiratory diseases.
Reviewing medicines for drug interactions in an outpatient clinic may involve her recommending alternate asthma medicines for people living with HIV. For example, she may need to find alternatives to fluticasone/salmoterol (Seretide) due to increased risk of Cushing syndrome from cobicistat CYP34A inhibition.
Similarly, for inpatient care, she could be involved in adjusting doses of antimicrobials for respiratory patients, such as IV Amikacin in non-tuberculous mycobacterial pulmonary infections when drug concentrations exceed expected levels – which can vary depending on patient factors and dose frequency – or kidney function declines significantly.
One of her more challenging patient interactions was with a younger patient who had no significant co-morbidities and was recovering from COVID-19.
The patient had developed an empyema infected with a multidrug-resistant bacteria – including resistance to penicillins, cephalosporins and carbapenems.
As the patient was struggling with an infective collection in the pleural space on one side of a lung, Ms Risdale provided clinical advice and support around monitoring and managing adverse effects from the IV sulfamethoxazole/trimethoprim used, which can include electrolyte disturbances.
And, as the patient continued to experience respiratory decline, Ms Risdale was tasked with acquiring stock of a more specialised antimicrobial from overseas – cefidericol.
‘I found this situation challenging for several reasons as I had to contend with COVID-19 delays, unavailability through standard Special Access Scheme routes, time differences (between suppliers and manufacturers in Australia, Europe and Japan), cold-chain requirements and the time-critical need for treatment.
'Thankfully, I was able to arrange some stock reallocation from other hospitals in NSW and Western Australia, and was able to get it successfully transported via cold-chain courier across the country – on a weekend no less.
'We received the product in time and the patient made a full recovery!'
Build your skills with PSA Short Courses at psa.org.au/practice-support-industry[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row] [post_title] => How to remedy incorrect inhaler use [post_excerpt] => How pharmacists can change the lives of people with lung diseases by taking every opportunity possible. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => how-to-remedy-incorrect-inhaler-use [to_ping] => [pinged] => [post_modified] => 2022-06-14 17:42:12 [post_modified_gmt] => 2022-06-14 07:42:12 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=18727 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => How to remedy incorrect inhaler use [title] => How to remedy incorrect inhaler use [href] => https://www.australianpharmacist.com.au/how-to-remedy-incorrect-inhaler-use/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 18730 )
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Supporting patients starts with listening more.
Wherever pharmacists practise, there are patients with anxiety – patients who are managing well, patients who are managing not so well, and patients in crisis.
Mental Health Australia Chief Executive Officer Leanne Beagley says one of the best ways pharmacists can support patients is by recognising that anxiety often reveals itself in physical symptoms, such as difficulty sleeping, nausea and diarrhoea.
‘There’s a real interplay between people’s anxiety and how [the symptoms] are expressed in their body, and community pharmacists are in a great position to recognise that physical symptoms might have a mental health component and to encourage [people] to see a GP,’ she says. ‘It’s about understanding that physical symptoms might have an underlying mental health cause, and asking questions or encouraging people to think about that.’
Listening more is crucial to pick up on these signs, open up conversations and provide appropriate support.
AP spoke with two pharmacists who took the time to listen more.
Duha Nur Gide
Community Pharmacist and University of Sydney researcher, Sydney, NSW
Lessons from MHFA training
Mental Health First Aid (MHFA) training is extremely useful in identifying signs and symptoms of different mental illnesses, including anxiety, and the different ways that it may present, says Ms Gide.
‘It also explores the different types of anxiety, such as post-traumatic stress disorder (PTSD), panic disorder and social anxiety disorder. Additionally, and perhaps most importantly, it teaches pharmacists how to appropriately approach patients with anxiety and provides us with the knowledge and skill set to effectively offer support.’
The role-play for pharmacists, she says, is beneficial in gaining practical experience and increased confidence when interacting with patients experiencing anxiety, which optimises the outcome.
Tell-tale prescription presentations that may indicate underlying – or overt – anxiety, Ms Gide says, can include:
Most patients experiencing anxiety would be referred to their GP, who may then refer the patient to a psychologist or psychiatrist, for instance.
Patients with anxiety are also encouraged to seek support from other people, such as friends and family they trust, according to Ms Gide.
‘There are also often local mental health services that can help people with anxiety, so this is another referral option.’
Louise Edwards BPharm(Hons), BA, MPSPrincipal Master Mental Health First Aid Instructor, Perth, WA
Case 1 Anxiety and panic attack
Flustered, teary and struggling to enunciate her problem, Belinda* rushes into a busy street-front pharmacy, flapping her hands in front of her face as if to cool herself down.
‘I think I’m having a panic attack,’ the 20-something blurts out, while being moved quickly and calmly by Ms Edwards, the pharmacist in charge, to a nearby counselling room.
Belinda is asked if this has happened before. Yes, she replies, although it’s been a while. Due to meet estranged family members, she tells of suddenly becoming anxious and feeling hot, sweaty and shaky, and like she can’t breathe properly.
Ms Edwards sits with Belinda as she overtly slows her breathing, while a pharmacy colleague fetches cold water and jellybeans.
‘At all times, I was monitoring for physical alarms, such as loss of consciousness or Belinda expressing concerns with physical symptoms,’ Ms Edwards later recalls. Seeking help early, and starting previously learned breathing activity, prevented the attack from escalating, she believes.
After about 5 minutes with Belinda, Ms Edwards leaves her with a pharmacy assistant, clears some work in the busy dispensary, and asks for a print-out of the PSA ‘Anxiety’ Self Care Fact Card together with some ‘goodies’.
Not long after, Ms Edwards finds Belinda giggling with the pharmacy assistant. And while still somewhat red, Belinda feels ‘much better’ and apologises profusely, before wiping her face with the cold, wet paper towels provided for her.
Ms Edwards commends Belinda for ‘seeking help from us’ and presents her with the ‘Anxiety’ Self Care Fact Card. Belinda declines an offer for staff to take her to the nearby doctor and does not want anyone in the family to collect her.
She tells Ms Edwards of an imminent appointment with her GP for her oral contraceptive pill. ‘Although now,’ Ms Edwards later recalls, ‘she will discuss this episode to consider if she needs to return to psychology appointments, particularly as this family catch-up is likely to stir up anxiety.’
When presented with ‘our little goodies’ to help her feel better, ‘Belinda started tearing up with thanks’ again.
‘Belinda left about 10 minutes later with a fresh face and calmer disposition,’ Ms Edwards says, which was ‘a great experience for the PA to see how helping others really is personally rewarding – and she talked about it for weeks’.
Case 2 Methadone – Helen (pre-MHFA training)
Helen,* a regular methadone client, can be short with manners and appear defensive at times. A client for at least 6 months, she is on a larger dose of methadone and attends with her partner, who often appears intoxicated.
Helen presents alone one day with a prescription for diazepam 5 mg tds, to be collected every few days from the pharmacy. When she realises she will not be given the full supply, she becomes aggressive in tone and swears about how she is being distrusted.
‘At first, I was stern and clear regarding swearing and aggression and our contract relating to behaviour in the pharmacy,’ Ms Edwards later recalls.
While Helen rages that she will leave and find something else ‘to make her feel okay’, Ms Edwards notices she is tearing up.
‘I realised my attitude and approach were not leading to the best outcome, so I softened my demeanour and asked Helen if she wanted to step into a quieter area.’
Now in a quieter area, and out of breath from crying, Helen grabs Ms Edwards by the arm for support.
‘It was a rare show of vulnerability, so I talked softly and soothingly to make her feel comforted. It was clear that the façade we had seen for 6 months was hiding some significant anxiety.’
Helen explains that she is trying to avoid her often unkind partner, but her substance use problems and lack of family support have given her extreme anxiety about coping. Her GP has started her on a sample pack of sertraline before she returns in several days, and the diazepam is to help with her current extreme anxiety.
‘This person in front of me is suddenly more relatable,’ Ms Edwards recalls. ‘I understand why she presents the way she does. It shouldn’t have taken this show of emotion for me to change my thought processes regarding Helen, and I vow never again to make this mistake. I sit and chat with her while she calms.’
Helen is brought cold water and some jellybeans, and is made comfortable as she calms down with slow breathing.
And while there is a brief return to an embarrassed disengagement from Helen – manifested with no eye contact, fidgeting and mumbling – Ms Edwards talks her around (helped by some cool, wet paper towels and a ‘calm, caring tone’) expressing delight that Helen has trusted her with her personal information.
Helen responds well, particularly to Ms Edwards’s offer of local housing assistance and food provider numbers, as well as leaflets on anxiety.
‘Now that we have both had a good connection and I have really listened, Helen finds it much easier to understand the safety behind the limited supply,’ Ms Edwards says.
‘I work hard every visit to check in and make the staged supply interaction valuable for her. This not only reinforces our relationship, but also the benefits of medication supply.’
Case 3 Rescue Remedy – Maureen
One morning at the pharmacy, Maureen,* a young woman, asks Ms Edwards: ‘I’ve heard Rescue Remedy is good for nerves – do you have any?’
‘What kind of symptoms are you hoping to relieve?’ replies Ms Edwards. Helen lists ‘significant anxiety symptoms: not sleeping; emotional outbursts due to feeling anxious; an inability to stay on top of her university studies; disruption to function’, Ms Edwards recalls.
Ms Edwards tells her: ‘It sounds like you’re having a tough time at the moment, not being able to engage in all your usual activities.’
She tells Maureen there is no evidence that homeopathic preparations help with clinical anxiety, and that it appears some significant symptoms are interfering with her day-to-day life that need addressing with her doctor and perhaps warrant psychological intervention.
Maureen confides that this was a problem a few years back but that she had been helped by a good counsellor. Recently, however, she has moved, hasn’t had time to follow up, and doesn’t have a good GP.
‘We booked Maureen into a GP for a mental health plan and gave her Beyond Blue’s A Guide to what works for anxiety book, as well as PSA’s ‘Anxiety’ Self Care Fact Card,’ Ms Edwards says.
* Names are pseudonyms
Top tipsAlways recommend non-pharmacological intervention as first-line therapy Encourage patients to get a mental health plan, including booking double appointments. GPs require a double appointment for a mental health plan. Patients often need to return if a double is not booked – missed opportunities.
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COPD flare-up is a deterioration of symptom control in an otherwise stable patient, often involving a bacterial infection. Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis are primarily responsible (and sometimes Mycoplasma pneumoniae and Chlamydia pneumoniae).1
But when is it appropriate to use antibiotics, and when should patients be redirected to their doctor?
Smother the flare, but the bacteria is always there
Early initiation of an antibiotic for a COPD flare-up can prevent further damage to the airways, prevent hospitalisation, reduce the risk of further exacerbations, and allow people to regain symptom control.1,2
Antibiotic treatment aims to hasten recovery rather than eradicate the colonising organism, because most patients have persistent airway colonisation.2
Therefore, lower doses of antibiotics are used for treating fl are-ups of COPD than are used in community-acquired pneumonia.
Treatment is focused on improving the response to bronchodilator medicines rather than eradication.2
When should flare-ups be treated?
Antibiotics for COPD exacerbations are reserved for patients with all three of the following clinical features, which are suggestive of bacterial infection2:
Prophylactic antibiotics reduce COPD exacerbations for up to 3 years and may be appropriate for patients with recurrent infections and hospitalisations.1
Low-dose, long-term macrolides are preferred for preventive treatment.
Therapy should be reviewed after 6–12 months, and after each flare-up.1,2
Five days of antibiotic treatment for flareups is recommended,2 although in practice this may vary according to bronchodilator response.1 Duration of antibiotics for patients should be established during counselling or by contacting the prescriber.3 Cautionary advisory label (CAL) D should be endorsed with the length of treatment and added to the labelling to reinforce essential treatment advice provided in counselling.
Flare-ups can be community-managed according to a plan between the patient and prescriber; postdated antibiotic prescriptions can allow rapid treatment in the event of flare-up caused by bacteria.4
Delayed prescribing of antibiotics has been shown to reduce antibiotic use and resistance, and empowers the patient to be involved in their treatment.5,6
Pharmacists should review patient symptoms prior to supply. This will help pharmacists exercise professional judgement – based on knowledge and guidelines – to determine if supply (and/or referral) is appropriate.
ReferencesANDREW KRICH MPS is a Professional Practice Pharmacist in PSA’s NSW office.
Lodge your own question or advice at editorial@australianpharmacist.com.au
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[post_content] => Case scenario
Callum, a 30-year-old engineer, presents to you in the pharmacy requesting pain relief. Callum reports worsening left shoulder pain following his COVID-19 vaccine. Upon investigation, Callum states his vaccination was several weeks ago and thought at the time the injection was delivered very high on his arm. He has had increasing shoulder pain, swelling and reduced range of motion in his left shoulder. He is seeking assistance now as he is struggling to perform simple activities such as cooking. As you suspect, Callum has sustained a shoulder injury related to vaccine administration. You refer Callum to his GP.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
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Presenting symptoms2, 14–17
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Common diagnoses18–27
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Source: Mackenzie L, Bushell, M.[/caption]
Case scenario continued
Callum returns to the pharmacy several days later with a prescription for naproxen and sustained-release paracetamol. Callum tells you he has been diagnosed with a SIRVA, with a sub-diagnosis of subacromial bursitis. His GP prescribed physiotherapy treatment in addition to his analgesia. You counsel Callum on the appropriate use of paracetamol and naproxen. Callum thanks you for your advice and for referring him to his GP for further investigation with a suspected SIRVA.
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Case scenario
Jane and her 5-year-old son visit the pharmacy. Jane believes her child has head lice for the first time and needs advice. You comb through the child’s hair using a fine-tooth comb and find moving lice. After confirming the child has no allergies, you recommend KP24 (malathion) lotion, which is a first-line treatment for head lice. You explain how to use the treatment: apply to dry hair, massage the lotion in for 6 minutes and leave it on the scalp for 30 minutes before washing. You advise Jane not to use hot tools while using this product (e.g. a blow dryer), as it is flammable. You emphasise that at least two applications are needed, at least 7–10 days apart. It should be followed up with daily wet combing to identify remaining or newly hatched live lice.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.4, 1.5, 2.2, 3.1, 3.5 |
Head lice (Pediculus humanus capitis) infestation is a global public health issue — the prevalence estimates range from 5% in Europe to 33% in Central and South America.1 Prevalence of head lice infestation in Australian schools has been reported to be as high as 34%.1–5
Most head lice treatments are over-the-counter medicines, available without a prescription and readily available in pharmacies. It is essential that pharmacists have the knowledge and skills to assess, counsel and recommend appropriate evidence-based treatments for head lice.
Head lice infestation can be asymptomatic, particularly in first-time cases or light infestations.6–8 The main symptom is pruritus (itch) on the scalp, back of the neck and behind the ears, caused by an allergic reaction to louse saliva, which it injects while feeding.6,9,10 Individuals who have never experienced a head lice infestation can experience a delayed onset of itching, as sensitisation to louse saliva can develop over 4–6 weeks.6,9 Red to brown spots may be found on the scalp, which is blood excreted and digested by the lice.10 In rare cases, excessive scratching can lead to sores and secondary infections (e.g. impetigo), enlarged lymph nodes, alopecia, poor sleep and irritability.6,10–12 While extremely rare, there are reports of iron deficiency anaemia from severe infestations.13,14
Head lice can affect individuals of all age groups, irrespective of socioeconomic status, personal hygiene and hair type.15–17 It is mostly seen in children aged 3–11 years,15,18 and females (2.5 times higher risk).1
Head lice are commonly transmitted through direct head-to-head contact.6,9 Indirect transmission through sharing of clothes and personal care items is rare.6 Animals are not a vector for head lice transmission.9
The adult head louse is an arthropod insect (Phthiraptera), whitish grey to pale brown in colour, 2–3 mm in length, equipped with mouth parts to suck blood and 6 legs to attach to hair strands.6,7,9 Lice cannot jump or fly; they can only crawl from head to head,7, 9 and the average life span of an adult louse is 32–35 days.6,19 Lice can only survive 1–2 days away from the scalp but can become non-viable due to dehydration before death occurs.6,20
The louse requires a protein blood meal to produce eggs and will feed from its host every few hours.9 Its saliva aids feeding by acting as an anticoagulant and vasodilator.9
Nits (louse eggs) are 1 mm in size, oval, and yellow to white in colour.7 The louse produces a glue-like substance which allows the nits to stick firmly to hair strands; they are commonly found near the scalp margins, behind the ears and back of the neck.7,9,12 They are incubated by the heat of the scalp; eggs cannot hatch if they are not kept at temperatures close to the scalp and can die within a week.7,9 Nymphs (immature lice) hatch after 7–10 days.6,15,16 Once hatched, the nit shell becomes more visible, a dull yellow to white in colour, and remains attached to the hair shaft.6,15 Nymphs pass through three maturation stages, known as moults, which takes anywhere from 2 to 10 days.19 The female louse can mate and lay eggs about 1–2 days after becoming an adult and can lay 3–8 eggs per day.6,19
Diagnosis of head lice infestation can be challenging, as it can be easily misdiagnosed (see Table 1). Visual identification of a live louse on the scalp is required for diagnosis.6,7 Itching, or the presence of eggs, does not always indicate an active infestation.
Wet combing is a commonly used diagnostic tool and is preferred over visual inspection.7,21 Conditioner is applied to the hair to immobilise the lice, and a head lice comb (fine-tooth comb) is used to brush through the hair to collect the lice and eggs.7
Adapted from Therapeutic Guidelines and Australian Pharmaceutical Formulary (APF) 25. 6, 7
Other causes of head lice-like symptoms and their differentiating features are listed in Table 1.
Table 1 – Other causes of head lice-like symptoms
| CAUSE | DIFFERENTIATING FEATURE |
| Hair casts (pseudonits): remnants of inner root sheaths of hair follicles, encircling hair shafts of the scalp. | Casts can be easily dislodged from the hair. |
| Seborrheic dermatitis: can affect the scalp, eyebrows, nasolabial folds, central chest. It is a chronic relapsing condition. Commonly seen at puberty. Dandruff is the mildest form of this condition. | Scaling, ranging from mild to widespread thick crusts. Easily removed and can be accompanied with burning sensation and erythema. |
| Scalp folliculitis: an inflammatory disorder of the hair follicles. | Small, itchy pustules that become sore and crusted, and often occur on frontal hair line. |
| Trichorrhexis nodosa: can affect the scalp, pubic area, beard and moustache. Can be congenital or caused by trauma, either physical (e.g. excessive brushing) or chemical (e.g. hair dyes). Most commonly found in females. | Presence of white flecks in the hair, abnormally fragile hair, areas of alopecia. |
The following are red flag symptoms that may require referral to a doctor:7,11
Neurotoxic agents are the first-line treatment option for head lice infestation,22 though there are reports of increasing resistance.10,23 Physical insecticides like dimethicone are emerging to become favourable alternative options, and wet combing is an effective but labour-intensive mechanical approach.24
The treatment goals for head lice infestation are to eliminate the active infestation and prevent transmission of lice to others.7 Treatment choice should be guided by local patterns of insecticide resistance, prior use of treatments, patient characteristics (age, pregnancy, breastfeeding, history of hypersensitivity or adverse effects), and individual preference.7
Treatment should only be commenced if live lice are identified on the individual. Prophylactic treatment is not recommended and can contribute to insecticide resistance, treatment failure and adverse effects.7, 12
Close contacts of the infested individual should be screened using the wet combing method, repeated daily.⁷ Most treatments do not kill eggs and require a second or third application after 7–10 days to ensure the lice that have hatched since the first application are killed off.7,23 Dead eggs, lice or egg casings can be removed via fingernails or a fine-tooth comb.7
Treatment failure is defined as lice being present after the administration of treatment; this can be attributed to a variety of reasons: insecticide resistance, improper or inadequate application, re-infestation, failure to re-treat, or misdiagnosis.7
Treating head lice7,8:
Head lice treatment options are outlined in Table 2.
Table 2 – Head lice treatments
References: APF 257, TG8, AMH22, Department of Health23, Public health medicine environmental group24, TGA (DAEN)25, Consumer Medicines Information (CMI) for Ivermectin26
*Refer to product information for instructions on individual product use
As head lice can only survive 1–2 days away from the scalp, and there being little evidence of indirect transmission, the following interventions may be recommended; however, they have limited effectiveness in reducing infestations7,11:
Malathion can be absorbed through the skin, though risk of systemic exposure is low.22,27 If ingested, there is a risk of respiratory depression.19
Malathion when used in combination with anticholinesterases (e.g. donepezil, pyridostigmine) can result in additive toxicity.22
There are no preventive treatments for head lice, though the following strategies can be used to reduce the transmission of head lice7:
Children identified with active lice need to inform the school and close contacts to ensure appropriate screening can be implemented. Children should be excluded from school until the day after appropriate treatment has been administered and no live lice are detected.7
Case scenario continuedJane asks whether she also requires treatment, as she feels her scalp is itchy. After combing through Jane’s hair, you do not find any active lice or nymphs. In the absence of an active infestation, you suggest that Jane does not require treatment but can use wet combing daily for a week to screen for head lice. You further add, if lice are seen, Jane can use KP24 like her son, after confirming she is not pregnant or allergic to the product. |
SANDRA RAJU BPharm (Hons) is an intern pharmacist.
DR WUBSHET TESFAYE BPharm, MSc, PhD is a project manager and post-doctoral researcher at the University of Sydney.
DR MARY BUSHELL BPharm (Hons), AACPA, GCTLHE, AFACP, MPS, PhD is a Clinical Assistant Pharmacist and the Professional Practice Convenor for the pharmacy discipline at the University of Canberra.
DR JACKSON THOMAS BPharm, MPharmSc,PhD is a pharmacist, trialist, NHMRC-funded pharmaceutical scientist and Associate Professor at the University of Canberra.
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Craig, a 26-year-old male, enters your pharmacy and asks to speak to the pharmacist. He enquires about the use of ecstasy and explains that he will be attending a music festival on the weekend with friends. It is the middle of summer, and you know it’s going to be very hot on the weekend. Craig asks you for advice on the risks associated with ecstasy use and methods for reducing these risks.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.2, 1.4, 1.5, 1.6, 2.2, 2.3 |
Drug checking, also known as pill testing, is a process involving the chemical analysis of an illicit substance such as a pill or powder, followed by tailored feedback and counselling. The main aim of the service is to reduce drug-related harms, hospital admissions and deaths. Drug checking services have become well established overseas, with services set up in a number of countries including the Netherlands, Spain, the United States, Canada, the United Kingdom and New Zealand.1,2 These provide a mix of postal, fixed-site and on-site services, allowing people to anonymously post drugs for analysis, attend a permanent site, or visit a mobile facility such as those provided at festivals. In Australia, the first government-sanctioned on-site drug checking trial was conducted in 2018 at the Groovin the Moo festival in the ACT, followed by a second trial in 2019. In October 2021, the ACT Government approved and provided funding for Pill Testing Australia (PTA) and Harm Reduction Australia (HRA) to pilot a fixed-site pill testing service in the ACT. 3,4
The Pharmaceutical Society of Australia (PSA), Australian Medical Association (AMA) and Royal Australian College of Physicians (RACP) support further trials to inform the role of drug checking in Australia’s harm minimisation strategy.5–7 The 2019 National Drug Strategy Household Survey (NDSHS) found that 57% of Australians supported drug checking at designated sites, while 27% were opposed and the other 15% were unsure.8
Illicit drug use among Australians is common. The 2019 NDSHS found that 9 million people (43%) aged 14 years and over had illicitly used a drug (including pharmaceuticals for non-medical purposes) at some point during their lifetime.8
With respect to drug checking, the hallucinogenic amphetamine3,4 methylenedioxymethamphetamine (MDMA, or ecstasy) is of particular interest, as it is commonly used and tested for at music festivals and events. The 2019 NDSHS found that 2.6 million people (12.5%) aged 14 and over had used this drug during their lifetime, with 3% of people aged 14 and over (600,000 people) reporting use in the last 12 months.8
Between July 2016 and January 2017, several young Australians tragically lost their lives following the consumption of substances they believed to be MDMA or psilocybin (magic mushrooms).9 In April 2021, the Victorian Coroner released findings related to the examination of five of these deaths. Postmortem analysis revealed that what they had taken was not pure MDMA or psilocybin, but rather the novel psychoactive substances 4-fluoroamphetamine and 25C-NBOMe.9 As a result of these findings, the Victorian Coroner recommended that drug checking services be implemented in Victoria as a matter of urgency.9
Prior to the Victorian Coroner’s report, the New South Wales Coroner released findings into the deaths of six young people between December 2017 and January 2019.10 In these cases, deaths occurred as a result of MDMA toxicity, with each individual found to have had dangerously high plasma MDMA concentrations.10 The NSW Coroner also noted 29 pre-hospital intubations, 25 intensive care admissions and 23 drug-related hospital admissions during the festival season between 2018 and 2019, which encompassed 25 music festivals.10 They considered the difficulty in discussing issues such as drug checking due to the illegality of drug use, and raised the inadequate nature of the ‘just say no’ message that is currently promoted. In addition, the NSW Coroner determined that the individuals involved lacked understanding of the risks associated with high-dose MDMA and were unable to identify signs of MDMA toxicity.10
Drug use occurs in a wide variety of settings, including music festivals, nightclubs and at home. While the NSW Coroner’s report focused on music festivals, several of the Victorian cases involved taking the drugs at home with friends.9
Novel psychoactive substances (NPS), also known as ‘designer drugs’, have been designed to mimic the effects of popular recreational substances including amphetamines (such as MDMA), hallucinogens (such as lysergic acid diethylamide [LSD]), and cannabis. The NPS implicated in the Victorian Coroner’s report were 25C-NBOMe and 4-fluoroamphetamine.
25C-NBOMe is a stimulant and hallucinogenic substituted phenethylamine, part of a group of drugs commonly referred to as an ‘N bomb’. It is highly potent and can be taken orally, sublingually or insufflated (nasally inhaled). Mild toxicity manifests as hallucinations, tachycardia, hypertension, sweating, agitation and confusion.
In severe cases, seizures, rhabdomyolysis, hyperthermia and death can occur.9 4-fluoroamphetamine is a central nervous system (CNS) stimulant with dopaminergic and serotonergic effects. De Sousa et al noted elevations in blood pressure following administration of 4-fluoroamphetamine in volunteers.11 Several case reports exist of haemorrhagic stroke and other cardiovascular complications following recreational use.12 Both substances have since been the subject of public warning campaigns.13
Despite being considered a novel psychoactive substance, 4-fluoroamphetamine was first synthesised in the 1940s.14 NBOMes (including 25C-NBOMe) are newer, being first synthesised between 2008, when 25I-NBOMe was synthesised by a German chemist, and 2010, when they began to appear on the internet.15
The NPS seen on the market are highly variable, with substances disappearing and reappearing on the market.9,13
MDMA is a hallucinogenic amphetamine that produces effects such as euphoria, feelings of closeness and decreased fear, making it a popular party drug.16,17 It is also currently being investigated as a potential adjunct to psychotherapy for the treatment of post-traumatic stress disorder (PTSD).18 A standard recreational dose of MDMA is generally 75–125 mg, though higher strength pills are not uncommon.16,19,20
Toxicity manifests as hyponatraemia leading to cerebral oedema and seizures.21 Hyperthermia may lead to complications, including rhabdomyolysis and disseminated intravascular coagulation.22
Given the lack of professional drug checking services in Australia, at-home reagent testing is the primary method of drug checking currently available. This is a rudimentary method of checking drugs that can be done using a small set of reagents at home. These reagents are legally available for sale in Australia, and in some cases have been distributed to users by harm reduction organisations such as Students for Sensible Drug Policy (SSDP).23 Upon contact with the substance, a colour change will occur which can then be compared to a chart. This can provide an indication of the presence of a substance (expected or not), but gives no assurance as to its purity or dose.
In combination with the development of an early warning network, to alert the public to dangerous substances in circulation, drug checking has the potential to reduce harm and deaths associated with the use of drugs obtained from an unregulated market.9 Quality control in the illegal drug market is non-existent, leaving individuals at risk of unknowingly consuming a drug that is not what they expected, adulterated or a higher dose than intended. Worldwide there has been a trend towards the manufacture of high-strength MDMA pills. For example, in 2019 UK-based drug checking organisation, The Loop, discovered 300 mg MDMA pills (three times the usual dose).19 Of particular note is the prevalence of NPS, which are often mis-sold as other drugs such as MDMA.
The drug checking process usually consists of two components: chemical analysis of the substance to give an indication of content and purity, and a healthcare consultation to provide tailored harm reduction information and support to the service users. A number of different models are used to provide this service.2
Chemical analysis
Chemical analysis is a critical component of the drug checking process. It should be undertaken by professional chemists using specialised laboratory equipment and followed by a discussion with a harm reduction or healthcare worker, who interprets the result for the end user.
The most sophisticated method of analysis uses gas chromatography in combination with mass spectrometry (GCMS).24 This is a method that can be used to determine the concentration of the detected substance as well as any known adulterants or dangerous excipients.24 There are downsides to this method – it is expensive, requires a trained chemist, the equipment is difficult to transport, and the results can take time.24 Fourier-transform infrared spectroscopy (FTIR) is a somewhat more accessible method that is commonly used. It is cheaper and more portable, and can be used to identify known substances using a database.24 It only requires a small sample to be submitted, such as a scraping from a pill or a small amount of powder. This method also has its downsides: it is not able to detect substances that are not in its database, and it doesn’t provide information on dose.24 FTIR is used by The Loop and was used during the 2018 and 2019 Australian drug checking trials at Groovin the Moo in Canberra.
Research conducted by Barratt et al in 2018 revealed that only one-third of service users would be willing to give up an entire pill, which is required for a comprehensive quantitative result where the amounts of individual ingredients are determined.25 This type of analysis is particularly important where there is a trend towards pills of high potency, such as what has been seen with MDMA in both the UK and Australia.19,20 However, the study also found that service users were only slightly more interested in quantitative results than qualitative results.25 The limitations of the method of analysis used should be highlighted during the healthcare consultation phase.
Healthcare consultation
The healthcare consultation component of the drug checking process, also referred to as a brief intervention, is fundamental for the promotion of harm reduction.
Qualified and appropriately trained healthcare workers, including doctors and pharmacists, deliver individualised counselling to assist the service user in understanding the implications of the chemical analysis result. There is usually no charge for the consultation, and advice is provided in a non-judgemental manner.
The healthcare worker takes into consideration individual factors such as weight, gender, tolerance, mental state and presence of other drugs (including alcohol or prescription medicines), as well as the environment (for example, hot days can increase risk). Service users may be counselled individually or in groups. They are given the opportunity to ask questions, and harm reduction resources including fact sheets and contact details for drug and alcohol services are made available.
In the case of on-site facilities at festivals, attendees can be referred directly to medical services if deemed necessary. A survey of Australian festival and nightlife attendees who use drugs found that only 36% of respondents would use a service with no individualised feedback, highlighting the importance of this intervention and the willingness of users to engage with a health professional.25
An argument often highlighted by those opposed to drug checking is that the presence of these services equates to condoning drug use.26 It is important to note that regardless of the result, drug use is never stated as being safe, but rather the focus is on minimising harms associated with use. It is made clear to the service user that the only way to guarantee safety is to avoid use. The focus is on pragmatic strategies to reduce harm, such as taking a lower dose, taking it over a longer period of time, or in the case of known dangerous adulterants, encouraging disposal.
Research shows that when seeking information about the contents of a substance, friends are the most common source of information followed by the dealer.25 Drug check reporting websites that test substances and publish results are also frequently accessed by service users.25 Only a minority of people who use drugs in Australia have their drugs tested, either with at-home reagent kits or through a professional service (where these have been available).25
Despite critics of drug checking services citing a lack of evidence for harm reduction, a recently published systematic review suggests that the presence of drug checking services, in combination with healthcare consultations and an early warning system, is effective in reducing harms.27 A study conducted by The Loop found a 95% decrease in drug-related hospital admissions at a festival in 2016 compared with the previous year, where no drug checking was conducted, with the change attributed to increased awareness of mis-selling (for example, selling NPS as MDMA) and the presence of contaminants, as well as alerts made via social media and word of mouth.28
The results of chemical analysis, combined with a brief healthcare consultation, have been found to change consumption behaviours.28 For example, a survey conducted following on-site drug checking at three music festivals in the UK found that 20.8% of people whose drugs were found to be ‘not as expected’ discarded the drug on-site at the drug checking facility.29 A further 29.6% self-reported disposing of the drug after leaving the testing area.29 Another 20.1% took a smaller dose than originally intended, and 9.4% returned the drug to their supplier, potentially reducing demand for these particular substances and subsequently supply.29
Related to this is evidence to suggest that drug checking services can alter drug markets, so people can make more informed decisions about what they choose to purchase. For example, over the 30 years that the Netherlands’ DIMS service has been running, the contents of MDMA pills have been found to be increasingly more consistent with expectations, and there has been a decrease in poor quality, adulterated or dangerous substances.30
Pharmacists have played a role in drug-checking services overseas. Pharmacists possess a unique set of skills that make them particularly suited to delivery of healthcare consultations following drug checking. For example, a risk assessment is undertaken with consideration to the service user’s physical and mental health, environment, gender, weight and other consumed substances (prescription or recreational, including alcohol) to identify any ‘red flags’ that might require prompt referral or in-depth counselling.
A 2016 Australian survey found that 85% of respondents would be willing to use a fixed-site service, external to events, and 61% of respondents would wait one week for results if the results were reliable.25 As such, a model where fixed sites (such as pharmacies) are used as nominated drop-off points for off-site analysis could be considered.
Pharmacists in Australia and internationally have been involved in harm minimisation strategies.31 Currently, pharmacists in Australia are involved in the needle and syringe exchange and supply of pharmacotherapy for the management of opioid and nicotine addiction.32 The facilitation of drug checking services is in line with the harm minimisation work that pharmacists already do, and like other harm minimisation strategies, it is not intended to spread the message that illicit drug use is safe or without risk. Rather, it can be a way to provide support to hard-to-reach members of the population, including young people who use drugs. It is an opportunity for these people to engage with a health professional who is able to provide accurate and evidence-based advice and support without judgement. In some cases, referral to an external support service may be appropriate. Support services include:
While many on-site drug checking models utilise the skills of analytical chemists to operate laboratory equipment, pharmacists are able to interpret the results of testing and provide tailored advice to help the service user understand the result and its relevance.
Case scenario continuedYou ask Craig if he would like to join you in the private counselling room to discuss his queries, and ensure that advice is provided in a non-judgemental manner. You explain that there is no safe level of illicit stimulant use. You also explain that drugs sold as ecstasy do not always contain MDMA, instead they can be a mix of other substances; and if they do contain MDMA, the amount can vary. You outline a number of possible adverse effects, including seizures, cerebral oedema, arrhythmia, haemorrhage and death. Finally, you explain that the risk is also increased if other drugs (including alcohol) are taken at the same time, and that hot weather can contribute. You provide Craig with the details of the Alcohol and Drug Foundation website (and explain this has useful information on reducing the risks of drugs) as well as the Alcohol and Drug Foundation Drug information and advice line for further information. |
Drug checking is a harm-minimisation strategy that aims to provide service users with information on the chemical makeup of their drugs, and the risks associated with their consumption, to reduce drug-related harms, hospital admissions and deaths. Drug checking can also contribute data to early warning systems that can alert health professionals and law enforcement agencies to the current nature of illicit drug markets and enable them to tailor their response. Drug checking services are well established overseas with many utilising the expertise of health professionals, including pharmacists, to provide tailored and non-judgemental advice to service users based on the results of chemical analysis. With increasing local and international evidence supporting its use as a harm minimisation intervention, drug checking is expected to play an increasing role within Australia’s health system in coming years.
ALICE NORVILL BSc, BPharm is a pharmacist and specialist in poisons information working at the Victorian Poisons Information Centre, assisting in the management of unintentional and intentional exposures to various substances, including illicit drugs. In 2019 she volunteered with Pill Testing Australia to deliver brief interventions at the Groovin the Moo trial in the ACT.
The author would like to acknowledge: Rohan Elliott, BPharm, BPharmSc(Hons) MClinPharm, PhD, FSHP, and Dr Monica Barratt, BSc(Psych)(Hons), PhD, for their contribution to this paper.
[post_title] => Drug checking in Australia: How pharmacists can be involved [post_excerpt] => With increasing local and international evidence supporting its use as a harm minimisation intervention, drug checking is expected to play an increasing role within Australia’s health system in coming years. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => drug-checking-in-australia-how-pharmacists-can-be-involved-cpd [to_ping] => [pinged] => [post_modified] => 2022-05-05 20:48:22 [post_modified_gmt] => 2022-05-05 10:48:22 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=18377 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Drug checking in Australia: How pharmacists can be involved [title] => Drug checking in Australia: How pharmacists can be involved [href] => https://www.australianpharmacist.com.au/drug-checking-in-australia-how-pharmacists-can-be-involved-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 18500 )
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[post_content] => Case scenario
Mrs Ma, aged 60, presents with a prescription for osimertinib 80 mg once daily. It is a new medicine for her. She has a history of metastatic adenocarcinoma NSCLC with right-lung primary and bone metastasis. Mrs Ma returns to the pharmacy 2 weeks later complaining of a rash and tenderness to her arms. On examination, the rash looks pustular and erythematous and only extends to her right forearm. Mrs Ma denies any other rashes on her body or recent changes to her medicines or creams/body washes.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency addressed: 1.1, 1.4, 2.1. 2.2, 3.1, 3.2. 3.3 3.5 |
Lung cancer is the most common cause of cancer-related death both worldwide and in Australia.1,2 Lung cancer is the fifth most diagnosed cancer in Australia, with the highest mortality rate and a 5-year survival rate of around 18%.1,2 There are two major subdivisions of lung cancer: small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC).3–5
NSCLC accounts for approximately 85% of all lung cancers, with the remaining being SCLC.3–5 NSCLC arises from the epithelial cells of the lung situated within the central bronchi to terminal alveoli. The most common histologies are squamous cell carcinoma (30%), adenocarcinoma (30–40%) and large cell carcinoma (10–15%).3–5 Squamous cell carcinoma starts near a central bronchus, while adenocarcinoma and bronchioalveolar carcinoma usually originate from peripheral lung tissue.3–5 SCLC arises in peribronchial locations and tends to infiltrate the bronchial submucosa.3–5
Risk factors for lung cancer include3–5:
Although NSCLCs are associated with cigarette smoking, adenocarcinomas can be found in patients who have never smoked.3–5 Smokers have on average a 10-fold higher risk of developing lung cancer than lifetime non-smokers.3–5
The most common symptoms at presentation include3–5:
In SCLC, infrequently patients may present with signs and symptoms of one of the following paraneoplastic syndromes due to various peptide hormone productions3–5:
At initial presentation, a thorough history is required, taking note of3–5:
Investigations to aid diagnosis and staging3–5:
SCLC is defined by the spread of the cancer. Cancer that has spread beyond the supraclavicular areas is classified as extensive stage disease (ED), while cancer that has not spread is called limited stage disease (LD).6
The staging of NSCLC uses the American Joint Committee on Cancer (AJCC) TNM system, which stages cancer using these three key criteria7:
In July 2021 the Australian Government announced a $6.9 million budget to commence early scoping of a potential national lung cancer screening program to increase early diagnosis and survivorship of lung cancer.8 The screening program will target high-risk individuals by conducting 2-yearly low-dose computed tomography (LDCT) scans in these individuals.8
Primary prevention is still one of the most important strategies for reducing the burden of lung cancer in Australia. As primary healthcare professionals, pharmacists are integral in providing education and support for smoking cessation, preventing smoking uptake and providing counselling on minimising our patients’ exposure to second-hand tobacco smoke.
The pharmacist can play a major role in guiding patients through smoking cessation. Guidelines for smoking cessation are widely accessible and include the PSA’s counselling guideline for common aliments – smoking cessation.9 When assessing a patient, it is important to gather patient information, including medical history, current medications, readiness to quit, nicotine dependence and previous attempts to quit.
The PSA guideline outlines how to assess nicotine dependence and situations where patients may require referral, such as history of cardiovascular disease.9 When developing a quit strategy for patients, a combination of behavioural and medicinal interventions should be used. Patients should be provided with verbal and written information on the use of smoking cessation products and referred to Quitline for additional support packs and telephone counselling.9 It is important to consider the impact that smoking cessation may have on other medicines, as tobacco smoking induces CYP1A2 metabolising enzymes. As a result, smoking cessation can increase the levels of drugs metabolised by this enzyme.9
Management of lung cancer is multimodal and includes surgery, radiation therapy, chemotherapy and targeted therapy. These therapies can be used either alone or in combination, depending on the type of lung cancer, stage of lung cancer, molecular mutations, and the patient’s performance status.
These decisions are often made by multidisciplinary teams to help assess all aspects of the patient’s condition.3,11
Surgery
Patients with early-stage NSCLC disease have the best chance of cure if surgery is undertaken to remove the primary tumour.3 Surgery also allows for further testing to define the stage of cancer, and therefore guides the ongoing treatment decisions. The common surgical procedures include segmentectomy (removal of part of a lobe), lobectomy (removal of one of the lobes) or pneumonectomy (removal of part or all of lung).12 The type of surgery is determined by the extent of disease and the cardiopulmonary reserve of the patient.11
Radiation therapy
While not always a first-line option, radiation therapy has a potential role in all stages of NSCLC, as either definitive (intention of cure) or palliative therapy (end-of-life comforting therapy).
Radiation therapy is generally used in early-stage NSCLC in combination with chemotherapy as definitive therapy and in advanced stage NSCLC as palliative therapy.11,12
Pharmacotherapy
Recent advances in pharmaceutics have increased the availability of medicines to treat NSCLC. As a result, a range of targeted therapies and chemotherapy are used in the management of NSCLC. New therapies such as targeted mutation therapy have shown increased median survivals of around 25 months.3
Targeted therapies – tyrosine kinase inhibitors (TKIs)
NSCLC consists of molecular subtypes identified by genetic aberrations, which allows for use of targeted therapy. Targeted therapies produce higher response rates than immunotherapy in metastatic NSCLC, and patients should receive these agents first-line where indicated.13
TKIs are small molecule inhibitors which inhibit specific tyrosine kinases that are abnormally activated in some types of cancer.14 Activation of tyrosine kinases can increase survival and proliferation of malignant cells and increase angiogenesis, invasiveness, and metastatic potential of tumours.14 TKIs can target tumours harbouring targetable driver mutations.
Epidermal growth factor receptor (EGFR) tyrosine kinase Inhibitors
EGFR mutations cause uncontrolled cancer cell proliferation. EGFR has been shown to be over-expressed in more than 60% of NSCLC cases and is associated with a poor prognosis.15
EGFR TKIs inhibit EGFR-dependent tumour cell proliferation and can be further classified as3:
EGFR TKIs are indicated as first-line treatment for advanced stage NSCLC in patients with evidence in tumour of an activating EGFR gene mutation.16 The EURTAC study demonstrated that erlotinib had better progression-free survival (PFS) of 9.4 months versus 5.2 months with conventional first-line chemotherapy.16 Afatinib and osimertinib are indicated and PBS-listed for first-line treatment of Stage IIIB (locally advanced) or Stage IV (metastatic) NSCLC. The use of first-generation eGFR TKIs, erlotinib and gefitinib, is less favoured due to the availability of superior alternatives.23 Osimertinib is also available on the PBS as second-line EGFR TKI therapy for patients who have progressed on prior EGFR TKI therapy and have evidence of EGFR T790M mutation in tumour material.
Adverse effects of EGFR TKIs
As this is an emerging therapy, pharmacists should be aware of potential adverse effects of these agents.
Outlined below are some of the common adverse effects for osimertinib (EGFR TKI) and incidences of each adverse effect26:
Further information on side effects and management can be found in eviQ under individual agent treatment protocols.23
Pharmacists play a key role in management of EGFR inhibitor skin reactions. EGFR TKIs commonly cause skin reactions which present as a papulopustular rash, usually on the face and upper body, within the first 2–4 weeks of treatment.14 This could also present as itch, dry skin, paronychia, nail disorders and abnormal hair growth. It is important to note that this adverse effect occurs because of direct EGFR inhibition, and not as an allergic reaction to the therapy.23
These reactions are treated with topical corticosteroids (hydrocortisone 1% cream) and patients may be started on a tetracycline such as doxycycline. Pre-emptive prophylactic doxycycline may be used with initiation of EGFR TKI at the discretion of the prescriber.23 It is important to provide advice to patients on general measures to reduce skin reactions, including twice daily application of moisturiser and the use of sunscreen before going outdoors, as rash may be more severe in areas of skin exposed to sunlight.14,23 Patients should be advised to report within 24 hours any skin changes such as rash and itch to their oncologist.
Drug interactions – osimertinib
Osimertinib is metabolised by CYP3A4 and strong inducers of this metabolising enzyme such as carbamazepine, phenytoin, rifampicin and St John’s wort may decrease exposure of osimertinib. These drugs should be avoided, but if that is not possible the dose of osimertinib should be doubled.
Osimertinib is an inhibitor of P-gp, and drugs metabolised by P-gp with a narrow therapeutic index (e.g. digoxin and dabigatran) should be monitored for signs of increased exposure.
Anaplastic lymphoma kinase (ALK) fusion inhibitors
ALK gene mutation occurs in 2–7% of NSCLC resulting in constitutive activity and oncogenesis.3,5 Crizotinib is a first-generation ALK TKI which has activity against ALK mutations.15 It is also important to note that crizotinib has other molecular targets that are significant in NSCLC, such as the c-ROS oncogene 1 (ROS-1) and has recently also been approved for treatment of patients with evidence of ROS1 gene rearrangement in tumour material in Stage IIIB (locally advanced) or Stage IV (metastatic) NSCLC.23
Second-generation ALK inhibitors target ALK mutations with higher affinity and include ceritinib, alectinib and brigatinib. These are preferred agents for treatment of ALK positive Stage IIIB (locally advanced) or Stage IV (metastatic) NSCLC.23 Lorlatinib is a third-generation ALK TKI that was approved in November 2018 for patients who have progressed on crizotinib and another ALK inhibitor or after progression using alectinib or ceritinib as a first-line ALK inhibitor.3 This was based on the study by Solomon et al showing overall response rate (ORR) of 48% and median response rate of 12.5 months with lorlatinib in patients who previously received one or more ALK inhibitors.3
Emerging molecular targets
ROS, BRAF, RET, MET, NTRK and KRAS G12C mutations are other mutations that may initiate and maintain the growth of cancer cells. These gene mutations may be tested for in NSCLC due to emerging new TKIs being developed and approved for use in Australia that target these mutations.
Vascular endothelial growth factor (VEGF) receptor inhibitors
Bevacizumab is a monoclonal antibody (MAB) that targets the VEGF, inhibiting the formation of new blood vessels and reducing vascularisation and growth of tumours.14 Study E4599 (bevacizumab + carboplatin + paclitaxel vs carboplatin + paclitaxel) showed that the addition of bevacizumab resulted in a statistically significant improvement in overall survival and PFS.17 Consequently, bevacizumab is indicated for advanced or metastatic NSCLC in combination with carboplatin and paclitaxel and for continuing treatment, as monotherapy in a patient who does not have progressive disease.11
Immunotherapy PD1 and PDL1 inhibitors
The immune system is capable of anticancer activity; however, immune checkpoints or ‘brakes’ generated from the tumour can suppress the immune system’s activity.3 Immune checkpoint inhibitors release the ‘brakes’ of the immune system, allowing for full activity against the tumour.3 Pharmaceutical agents execute this through inhibition of T-cell antigen 4 (CTLA-4), program death ligand 1 (PDL-1) and its receptor (PD-1).14 Pembrolizumab, nivolumab (PD1 inhibitors), atezolizumab, and durvalumab (PDL-1 inhibitors) are immune checkpoint inhibitors approved for use in NSCLC. These agents may be used according to PBS restrictions for advanced stage disease in combination with chemotherapy, for patients with no targetable mutations, advanced stage disease following progression of first-line maintenance therapy for patients with locally advanced, un-resectable disease.11,12
The use of these agents in these settings is supported by several clinical trials. The IMpower150 trial, compared combination atezolizumab, bevacizumab, carboplatin and paclitaxel (ABCP) versus bevacizumab plus chemotherapy as first-line therapy.19 This study showed improved median overall survival in the ABCP arm compared to the bevacizumab plus chemotherapy arm (19.2 months versus 14.7 months).19
Adverse effects of PD1 and PDL1 Inhibitors
As immunotherapy boosts the immune response, an adverse effect of this may be over-stimulation of the immune system resulting in immune-related adverse events (irAE). These present as a range of autoimmune toxicities affecting any body system. Reactions may affect any organ system, including the liver, kidneys, skin (rash), endocrine (hypo- or hyperthyroidism), lungs (pneumonitis) and gastrointestinal tract (diarrhoea and colitis). Early identification and swift management are key in avoiding life-threatening severity.
Management of irAE requires referral to the patient’s medical oncologist without delay and will generally include treatment with corticosteroids and holding or permanently stopping the product depending on the grade of reaction.14 Further information on signs and symptoms of irAE can be found in eviQ.23
Chemotherapy in NSCLC generally includes the use of a platinum-based drug (carboplatin or cisplatin) in combination with another agent such as etoposide, pemetrexed, paclitaxel, gemcitabine or docetaxel.12 The role of chemotherapy in NSCLC varies significantly according to the stage of cancer and the ability to resect the cancer. To summarise, chemotherapy is generally used post- surgery in early-stage disease in combination with radiation for curative intent or in advanced-stage disease for patients without targetable mutations to increase survival and improve quality of life. Concurrent radiation and chemotherapy is more efficacious than sequential chemoradiation but increases the risk of adverse effects, particularly esophagitis.11
Patients diagnosed with SCLC often have extensive disease at the time of diagnosis.
As a result, the goal of treatment is the prolongation of survival and palliation of symptoms.12 In extensive disease, where patients are appropriate for chemotherapy, the standard regime is a platinum drug plus etoposide for 4–6 cycles in combination with radiation. These patients may also receive prophylactic cranial irradiation if disease responds well to chemotherapy.20 Patients who present with limited stage SCLC may be managed with concurrent chemotherapy and thoracic irradiation.12
The aim of palliative care is to improve the quality of life by reducing symptoms of cancer and slowing the spread of the cancer without the goal of curing the disease. These symptoms, which directly impact quality of life, include dyspnoea, cough, anorexia and fatigue.3 The involvement of a palliative care team can assist patients with advanced lung cancer in managing the symptoms as well as pain, nausea and end-of-life decisions.21
Each mode of therapy has significant adverse effects which are amplified by the use of these modalities in combination. Supportive care medications aim to prevent and manage these adverse effects. Pharmacists can play a role in the recognition of adverse effects of chemotherapy and immunotherapy and in ensuring appropriate referral and management. Patients experiencing adverse effects should be referred to their oncologist for further assessment.14
Patients undergoing treatment at a medical oncology centre are often supported by a team of doctors, nurses and allied health professionals who are willing to help. If patients have concerns regarding their treatment or adverse effects, they should be referred urgently to their treatment centre for direction.
Useful resources include:
The safe delivery of cancer treatment requires a multidisciplinary approach, and often care is shared between hospital specialists, hospital cancer care pharmacists, general practitioners and pharmacists.22 Communication between this team is key in ensuring best outcomes for the patient.
The accessibility of pharmacists allows them to play a key role in the care of patients with lung cancer. One of the most significant roles is that of encouraging smoking cessation. However, the emergence of oral therapies has resulted in the accessibility of cancer care medications in the community pharmacy. These medications require close clinical review for appropriateness, including screening for potential drug interactions and interactions with current medications, as well as complementary and alternative medicines. Patients commenced on these oral anti-cancer therapies in the community should be provided with detailed counselling and written information of treatment regime and adverse-effect management (accessible via eviQ).23 Patients receiving treatment from a cancer care centre may also present to community pharmacy, and therefore pharmacists can play a key role in early identification and management of adverse effects.
Case scenario continuedYou explain to Mrs Ma that the rash she has is common in people who take osimertinib and reassure her that prompt treatment with OTC hydrocortisone 1% cream and doxycycline will bring it under control. You emphasise that she should contact her oncologist without delay for assessment and prescription of the antibiotic so that the rash does not become worse. |
Lung cancer is the most common cause of cancer-related death both worldwide and in Australia.1,2 The identification of key mutations in NSCLC has allowed for emerging oral targeted therapy to be an integral part of NSCLC cancer management. Pharmacists have a key role in the education of patients on new targeted therapy and in the identification and management of adverse effects of treatment.
DANIELLE WOOLLEY BPharm (Hons) is pharmacist team leader at Royal Brisbane and Women’s Hospital and has practised in cancer care for the past 4 years.
VIVIAN DAY BPharm (Hons), GradDip (Clin Pharm) is a senior cancer care pharmacist at the Royal Brisbane and Women’s Hospital. She has been a pharmacist for 10 years, four of them in oncology, and is pursuing a postgraduate master’s degree in oncology.
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Case scenario
Emma is a 24-year-old paramedic who presents to your pharmacy with a prescription for paroxetine 20 mg daily and lorazepam 1 mg PRN for anxiety. She also requests a Fluvax. While you are giving Emma her flu shot, she mentions recent sudden anger and mood swings. She says she was actually in London last year at the height of the pandemic and witnessed her neighbour and one of her colleagues die. It took her months to get a flight home and she was all alone. Emma starts to cry and apologises.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency Standards (2016) addressed: 1.1, 1.4, 1.5, 2.2, 3.1, 3.5 |
Post-traumatic stress disorder (PTSD) first became a household name when it entered the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. This was as a result of the large number of veterans returning from the Vietnam War who were experiencing what was first termed ‘Post-Vietnam Syndrome’. Earlier conflicts had coined terms such as ‘shell shock’, ‘soldier’s heart’, and ‘war neurosis’. Other non-military terms for trauma such as ‘rape trauma syndrome’ and ‘railway spine’ also emerged in the 19th and 20th centuries.1
The definition of trauma has been debated for decades by clinicians, and the diagnostic signs and symptoms are constantly under scrutiny. These days, the term ‘PTSD’ is thrown around too often, which can take away from those who are suffering what can be a debilitating illness.
The Australian Psychological Society defines PTSD as a set of symptoms that can emerge following the experience of traumatic exposure to actual or threatened death, serious injury or sexual violence.2
Patients with PTSD have intense and disturbing thoughts and feelings related to the traumatic experience, persisting long after the event. Flashbacks, nightmares, sadness, anger and interpersonal detachment are common symptoms and may trigger avoidant or maladaptive behaviours that can cause further distress in the patient.3
In Australia, with worsening bushfire and natural disaster seasons, and the onset of the COVID-19 pandemic, we expect to see a rise in presentations of PTSD and other mental health disorders, such as depression, anxiety and substance abuse, due to the sudden and challenging nature of these events.4
With education, pharmacists can be aware of the signs and symptoms of PTSD and can play an integral role in providing medicines and advice to patients, along with advocating for non-pharmacological options for PTSD.5
Approximately two-thirds of Australians will experience events that are potentially traumatic.6 But only a small portion of these will go on to develop PTSD. The prevalence rate for PTSD in Australia is approximately 4.4% and is said to be increasing.5 However, the lifetime prevalence of PTSD in Australia is now 12%, with women being almost twice the risk of men.7
First responders and Australian Defence Force personnel were on the front line of the 2019 bushfire response, which led to an estimated prevalence rate of PTSD of 10% and 8.3% in these cohorts respectively.⁴ Yet, Australian veterans were recently reported to have higher rates of PTSD at 17.7% over the first 4 years following discharge from military services.4
The impact of rape trauma and child sexual assault has been well publicised in the Royal Commission into Institutional Responses to Child Sexual Abuse. Historical and recent trauma experienced as a result of separation from family, land and cultural identity has also had a serious impact on the social and emotional wellbeing of First Nations people.6
Finally, a review of the evidence of the psychological effects of the COVID-19 pandemic reported post-traumatic stress symptoms were higher in those who had been in lockdown, and in healthcare workers, compared to the general public.8
‘Imagine you are grocery shopping in a busy supermarket and you start having pervasive thoughts. Horrible images appear. They trickle in, flashbacks of being trapped and frozen. Suddenly, you cannot breathe and your heart is jumping out of your chest. You feel weird and embarrassed, as if everyone can see you struggling, but you are powerless to stop it. Your brain stops working and you cannot remember how to do simple tasks such as reading a shopping list or driving and following your normal route home. You somehow make it home and stare at yourself in the mirror. You feel as though you are not there, a feeling of numbness … of nothing. It is very frightening as it feels like a loss of your sense of self. You frantically grab at your face, trying to feel yourself, to make sure you are really there. Later in your bed, you are woken by the same violent twitching that wakes you every night. You get agitated, angry and resentful that even your serenity in bed has been hijacked.‘
The DSM-V definition of what constitutes a traumatic event is more tightly defined than those in previous editions, and the emotional response of intense fear, helplessness or horror during the traumatic event criterion has been removed.
The cause(s) of trauma are as follows9–11:
Exposure to actual or threatened death, serious injury or sexual violence in one (or more) of the following ways:
Note: Criterion 4 does not apply to exposure through electronic media, television, movies or pictures, unless this exposure is work-related.9,11
While much of the pathophysiology of PTSD is still unclear, recent research has revealed that trauma produces physiological and neurological change. Studies using magnetic resonance imaging (MRI) in patients with PTSD have shown that there is a decreased volume of the hippocampus, left amygdala, anterior cingulate and prefrontal cortex. This affects memory, fear, impulse control, emotions and the filtering of relevant information from irrelevant information.
Neurotransmitter activity can be affected where there is an increase in central noradrenaline levels, which can cause down-regulation of central adrenergic receptors. Stress hormones also play a part, with chronically decreased glucocorticoid levels and corresponding up-regulation of their receptors. This may account for the anecdotal observation that higher rates of autoimmune disease occur in patients with PTSD.10
Table 1 – Risk factors for PTSD
| PRE-TRAUMATIC | PERI-TRAUMATIC | POST-TRAUMATIC |
| Childhood trauma, adversity or emotional problems | Severity of trauma, injury, perceived life threat, interpersonal violence | Negative appraisals or inappropriate coping strategies |
| Lower socioeconomic status and poor education | Being a perpetrator, witnessing atrocities or killing the enemy (military) | Exposure to repeated upsetting reminders |
| Prior mental disorder or family psychiatric history | Dissociation that occurs during trauma and persists afterwards | Subsequent adverse life events, financial or other trauma-related losses |
| Genes, female sex/ younger age (at time of trauma) | Lack of social support following trauma |
Risk factors for PTSD are extensive and multifactorial. They can be divided into pre-traumatic, peri-traumatic, and post-traumatic risk factors (see Table 1).10
As primary healthcare providers, pharmacists should be particularly vigilant with persons who work in occupations such as law enforcement, the military, emergency services, communities that have been subject to natural disasters such as floods and bushfires, patients presenting with severe physical injuries or medical emergencies, and patients frequently presenting with non-specific somatic complaints.9
The DSM-V lists four symptom clusters of PTSD11:
Diagnosis of PTSD is made by identifying the presence of at least ONE symptom from the intrusion and avoidance clusters, and at least TWO symptoms from each of the remaining clusters. The duration of the symptoms must be more than 1 month, and cause clinically significant distress or impairment to the patient.11
Individuals with PTSD are 80% more likely to have symptoms that meet diagnostic criteria for at least one other mental disorder (e.g. depression, obsessive-compulsive disorder, substance use disorders).11
Not all mental disorders that occur in individuals exposed to trauma should necessarily be attributed to PTSD. The diagnosis requires that trauma exposure precedes the onset or exacerbation of pertinent symptoms.11
Furthermore, if the symptom pattern to the trauma meets the criteria for another mental disorder, these diagnoses should be given instead of, or in addition to, PTSD – they should not be ignored. If certain symptoms related to trauma are so severe, they may warrant a separate diagnosis and course of treatment (e.g. dissociate amnesia).11 Other common conditions to exclude after a traumatic event are listed in Table 2.
Table 2 – Other common conditions to exclude after a traumatic event11
|
DISORDER |
HOW IS IT DISTINGUISHABLE FROM PTSD? |
|
Adjustment disorder |
Trauma is of another type rather than that outlined by the DSM-V (e.g. divorce, being fired) OR, Trauma does meet the criteria outlined by DSM-V, but the symptom pattern does not (e.g. only a few symptoms are met) |
|
Acute stress disorder |
Symptom pattern is restricted to duration of 3 days to 1 month following trauma |
|
Traumatic brain injury (TBI) |
There may be significant symptom overlap. The two main differences:
|
PTSD can occur at any age, beginning after the first year of life. Symptoms usually begin within the first 3 months following trauma. However, symptoms can be delayed for months or even years, which is referred to as delayed expression.9,11
Prognosis for PTSD is variable. Recovery can be heavily influenced by other factors, especially in occupational trauma such as physical disability and loss of employment. Similarly, recovery from PTSD related to receiving financial compensation appears to be less likely, and is more associated with the compensation process itself. Elevated levels of anger may also affect the recovery trajectory.
Based on several studies, it is reasonable to assume PTSD is less likely to follow a chronic course with evidence-based treatment, and roughly a third of patients will make a good recovery, a third will do moderately well, and a third will be unlikely to improve.11
Routine psychological debriefing for those exposed to potentially traumatic events should NOT be offered – there is no evidence that psychological debriefing prevents PTSD, and it may be harmful for some. Instead, guidelines recommend providing information, emotional support and practical assistance in preference to individual or group psychological debriefing.11
The Australian Guidelines for the Prevention and Treatment of Posttraumatic Stress Disorder state that individual psychotherapy remains the recommended first-line treatment for PTSD.12
First-line recommendations for adults with PTSD12:
Trauma-focused cognitive behavioural therapy (TF-CBT) and its variants:
(A description of these can be found at www.apa.org/ptsd-guideline/treatments)
Medicines are second-line treatment, with limited evidence producing a short list of recommended antidepressants: sertraline, paroxetine, fluoxetine and venlafaxine. This evidence is not strong and has progressed very little over the years.4,12
Treatment with medicines is recommended only if one (or more) of the following circumstances apply12:
This short list of recommended antidepressants can be quickly exhausted when prescribers are faced with angry, agitated and highly distressed patients, which can lead to polypharmacy, off-label and idiosyncratic prescribing. Prescribing in such a manner can often result in medicine regimens similar to those seen in treatment-resistant depression.4 Using a prescribing algorithm like the one recommended by Phoenix Australia has been shown to result in better clinical outcomes than prescribing based on clinician preference.12
Emerging treatments for PTSD include MDMA or psychedelic-assisted psychotherapy, ketamine infusions, meditation, and cannabis and prazosin for minimising nightmares, although the evidence base is not yet robust enough for them to become regular practice. Veteran affairs organisations in countries such as the US, UK and Australia are at the forefront of investigating these options.13,14
Pharmacists can play a sentinel role in helping to manage patients with PTSD. Due to the prognosis of PTSD (and despite pharmacotherapy being second-line), patients will commonly present with at least one or more psychotropic medication. Medication adherence may be a problem due to mental state, reduced cognition and substance abuse, which commonly present in PTSD.
Patients with PTSD will often present with comorbid conditions requiring multiple medicines, ranging from chronic pain medications to medications to help abstain from alcohol. Thus, the need for pharmacist interventions, such as a medication review or referral for further investigation, is greater than ever.5
Case scenario continued
You recognise that, as a first-responder, Emma is at high risk of developing PTSD, and has recalled several traumatic events that cause her distress. You ask Emma about her symptoms, and she reports distressing nightmares and persistent negative thoughts. You undertake Mental Health First Aid with Emma to ensure her immediate safety and encourage support structures. You provide a referral for her GP for investigation for PTSD and explain treatment methods typically used, such as psychotherapies or medications.
|
Disclaimer
Although children may also be exposed to trauma, they are not included in this article due to space constraints. For more information about PTSD and children, please refer to the DSM-V and the Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder and Complex PTSD.
[cpd_submit_answer_button]GABRIELLE HANSEN BPharm, Grad Cert Pharmacy Practice is Senior Clinical Pharmacist – Mental Health, Western NSW Health, Bloomfield Hospital, Orange. She has worked for 10 years as a mental health pharmacist and has experience in clinical governance and e-health deployment in one of the largest local health districts in Australia.
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Dr Manya Angley FPS, 2021’s SA/NT Pharmacist of the Year and AACP MIMS Consultant Pharmacist of the Year, is Australia’s leading expert on disability cohort medicines and will speak at PSA22.
How did your childhood affect your adult life?
Growing up on a remote farm between Wilcannia and Bourke, NSW, I attended boarding schools in Ivanhoe, Cobar and later Adelaide, because there was no school for 100 miles. One of my jobs while waiting to be taken home on a Friday afternoon by the mailman, was to collect all the locals’ pharmacy supplies. They were never ready, so while inspecting all the shelves, reading the packets and studying the vitamins and remedies, I would eavesdrop on the pharmacist’s conversations. I loved the clinical environment, and that’s what sparked my interest. My mother, a registered nurse who ran the Royal Flying Doctor clinic and was first-on-scene at accidents near the farm, was also a strong advocate for better health and education for people with disability in the bush, particularly focusing on children with additional needs, as my younger sister had Down syndrome. So I had a caring role (with my sister) from the get-go and, with Mum’s work, it’s in my DNA to integrate, draw on your experiences and give back to the community.
How did the first 20 years of your career inform trajectories since?
I spent the first decade as a teaching academic, obtained my PhD and had three children. My PhD was lab-based and later my research steered toward expanding pharmacy models of practice. After my middle child was diagnosed with autism, a condition of unknown aetiology and prognosis, I spent a lot of spare time researching causes and management. I was well positioned to identify knowledge gaps and research opportunities, plus I had tapped into local disability and support networks. A passion to make a difference attracted interest from colleagues, thus the interdisciplinary Autism Research Group formed within the Sansom Institute for Health Research at the University of South Australia.
What is your favourite branch of pharmacy among your specialties?
Hospital, general practice, aged care, disability – I love them all in different ways and am passionate about exploring how consultant pharmacists can improve medicine safety in all these areas, especially for the very vulnerable at transitions of care.
What are your important medicine safety messages for PSA22?
The disability royal commission has shone a light on the disparity in health outcomes for people with disability. This cohort experiences high rates of physical and mental health problems, while access to appropriate healthcare is often poor. They have lower life expectancy, dying 27 years earlier than people without disability, and a relatively high rate of potentially avoidable death and hospital admissions.
It’s time for pharmacists to step up and claim their rightful role as medicines experts in this area of healthcare and make a big difference. Problematic use of psychotropics in people with intellectual disability concerns both the health and disability sectors, hence requires interdisciplinary collaboration to address it. Pharmacists can be a conduit between the sectors.
Would you do anything differently with your current knowledge and the profession’s evolution?
If I’d been more strategic with my career, no doubt I would have achieved more in terms of position and/or financial rewards. However, I have always been driven by my interests and circumstances and am grateful for the flexibility pharmacy has offered me. The fact that I‘ve changed tack at times has provided me with valuable opportunities and experiences. I’ve gained a unique understanding of the interplay between the various pharmacy sectors. I feel privileged to have played my part in the evolution of the profession and the journey has provided other rewards. I resigned from the University of South Australia in 2010 and started a private research and consulting business and became accredited at the same time. I also work as a contracted researcher. So I don’t switch off, just change gears and keep aiming for the horizon, which is very satisfying and doesn’t feel like work![/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row]
[post_title] => Covering many bases
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Public health leaders, a pharmacist and a former PSA CEO were honoured for their services to the community in this year’s Queen’s Birthday honours.
Victorian pharmacist George Greenberg was appointed a Member (AM) of the Order of Australia for ‘significant service to aged care, and to medical advisory roles’.
A former hospital and community pharmacist, Mr Greenberg was a member of PSA’s Victorian Ethics and Legislation Committee from 1997 to 2000.
He has been a Board Member of Emmy Monash Aged Care since 2005 and was a member of the Pharmacy Board of Victoria from 1994 to 2005.
The PSA’s National President Associate Professor Chris Freeman said Mr Greenberg deserved recognition for his work both as a pharmacist and as a member of numerous medical advisory boards.
‘Mr Greenberg has been an active member of our health community for many years, making significant contributions to the health sector across community and hospital pharmacy, as well as offering his expertise to further the pharmacy profession,’ he said.
‘I thank him for his dedication to advancing the pharmacy profession and for his years of service as a consumer and patient advocate.’
Professor Sarah Hilmer, Conjoint Professor of Geriatric Pharmacology Medicine at the University of Sydney, was also appointed an AM for ‘significant service to clinical and geriatric pharmacology’.
A clinical pharmacologist and geriatrician, Prof Hilmer has trained and educated countless pharmacy students and continues to provide training and education to pharmacists through conferences and educational programs.
She also led the Quality Use of Medicines to Optimise Ageing in Older Australians: Recommendations for a National Strategic Action Plan to Reduce Inappropriate Polypharmacy from 2015 to 2018.
Former PSA CEO Liesel Wett was awarded a Medal of the Order of Australia for ‘service to medical administration’.
Ms Wett has been CEO of Australian Pathology since 2014 and was PSA CEO from 2010 to 2014. She has also been Chair of Goodwin Aged Care Services since 2014.
Pandemic leadership celebrated
A number of high-ranking public health officials were also recognised for their leadership during the pandemic.
They include former Commonwealth Chief Medical Officer Dr Brendan Murphy, who was appointed a Companion (AC) of the Order of Australia for ‘eminent service to medical administration and community health, particularly as Chief Medical Officer, and to nephrology, to research and innovation, and to professional organisations’.
Speaking to Australian Pharmacist in November 2020, Dr Murphy, now the Secretary of the Commonwealth Department of Health, said it was a ‘privilege’ to help lead the country through the pandemic. He also thanked the nation’s pharmacists for their tireless work.
‘We could not be more appreciative of our pharmacists and the staff that support them in communities across the country,’ Dr Murphy said.
‘Our pharmacists play a pivotal role as our most accessible health professionals and their contribution on the frontline during this pandemic is to be greatly appreciated and admired.’
Queensland’s former Chief Health Officer, now Governor, Dr Jeanette Young was also appointed an AC for ‘eminent service to public health administration, to medicine and medical research, to the tertiary education sector, and as the 27th Governor appointed in Queensland’.
New South Wales Chief Health Officer Dr Kerry Chant was appointed an Officer (AO) of the Order of Australia for ‘distinguished service to the people of NSW through public health administration and governance, and to medicine’.
Dr Chant became a household name in NSW during the 2 years of the pandemic so far, providing daily COVID-19 updates at government press conferences. She has also made significant contributions to eliminate HIV, hepatitis B and hepatitis C, as well as holding a pivotal role in containing the spread of the swine flu.
She said the recognition went beyond her individual effort.
‘This honour is a tribute to my many colleagues in NSW Health for the outstanding work they have done and continue to do to keep the community safe throughout the COVID pandemic,’ Dr Chant said.
A/Prof Freeman extended his congratulations to all the health leaders.
‘I thank Dr Young, Dr Chant and Dr Murphy for their service and leadership throughout the COVID-19 pandemic and their ongoing support of health professionals,’ he said.
Other notable mentions include Dr Lucas De Toca, who oversaw the roll-out of the COVID-19 vaccination across primary care sites for the Department of Health and received the Public Service Medal (PSM) ‘for outstanding public service through leadership in managing the successful COVID19 vaccine rollout through primary health care’.
National Chair and President of the Heart Foundation Christopher Leptos, who also advises the pharmacy sector, was made an AO for ‘distinguished service to the not-for-profit sector through leadership and philanthropic support, to the public sector, and to education’.
Read the full list of 2022 Queen’s Birthday honours recipients.[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row]
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Working in aged care allows Amelia Wood MPS to improve prescribing practices while working flexibly for her childcare needs.
What led you to pharmacy?
Winemaking was my first career, taking me from my hometown of Adelaide to Coonawarra in South Australia’s rural south east. After 5 years, I switched wine for healthcare. I was always interested in pharmacy, so I found an external course through the University of New England and got a job as a pharmacy assistant in nearby Naracoorte.
How did you end up in aged care?
After a couple of years in community pharmacy and two stints of maternity leave, I became accredited. When I started providing medication reviews, I knew that was what I wanted to do. I prefer the pace and I enjoy improving patients’ quality of life by optimising their medicines. In 2019, when a funded opportunity at Longridge Aged Care came up through a project coordinated by PSA and the
Country SA Primary Health Network, I jumped at the chance. When the project ended, Longridge offered to keep me on.
What attracted you to the sector?
As a community pharmacist, I had a good relationship with Longridge. But I was frustrated that I couldn’t do more. I would see medicines that could be changed, but it was difficult to coordinate with the doctors. Now I have the chance to carefully review them and be on hand to answer any questions. Aged care is also really flexible. I work at Longridge 2 days a week, leaving me time to fit in medication reviews around school and childcare.
Why are aged care pharmacists an asset in residential facilities?
I take a lot of stress off the nurses so they can focus on patient care, while ensuring doctors are accountable for prescribing. They know what prescribing practices will be an issue and often consult me before making any medicine changes. Since I’ve been at Longridge, there have been less adverse incidents and decreased use of antipsychotics, benzodiazepines, antibiotics and high-dose PPIs.
What’s a positive improvement in a patient that stands out to you?
When I first started, one of the patients was hospitalised with hyperkalaemia. She also had a lot of ongoing mental health issues and was on a high sedative load. I worked with the doctor and the mental health nurse to simplify her medicines, taking her off sedatives like tramadol, amitriptyline, and pregabalin. When she got back to the facility, I was able to provide continuum of care. At 2 weeks post-discharge she was still feeling flat, so we reintroduced one of her antidepressants. After that, we were able to improve her pain management by working with the physiotherapist and temporarily introducing Palexia. When she saw the doctor a few weeks later, he said it was the best she had been in a long time.
What is your best advice for up and coming ECPs?
If you’re interested in aged care, accreditation is a great first step. It’s also important to get out there and let people know what pharmacists can do. I know some facilities were initially unsure of the benefits, but once they had a pharmacist on the team they couldn’t be without them.
A typical day for Amelia Wood MPS, Embedded Pharmacist, Longridge Aged Care, Naracoorte SA
|
8.45am |
School and day care drop off. My son’s school is across the road from the aged care facility, so it saves a lot of fuss in the mornings.
|
|
9.30am. |
Question time. The morning is spent fielding queries from GPs, nurses and carers. I also liaise with community pharmacies to iron out discrepancies with medication charts or DAAs. Recently, we workshopped a way to make Schedule 4 medicines more distinguishable on sign-in sheets to ensure registered nurses (RNs) are contacted correctly.
|
|
10am |
Psychotropic evaluations. Agitation and aggressive behaviour is often transient, so regular review of these medicines is necessary. This week, regular oxazepam was discontinued for one resident, and quetiapine for another – with no further issues.
|
|
1.30pm |
Meeting of the minds. I catch up with the physiotherapists and RNs to look at whether falls are mechanical or chemical in nature, and discuss how they can be prevented.
|
|
2pm |
Deep dive. I use this time to delve into medication charts to see if there are changes that need to be made. I do regular reviews and keep a list for the GP’s next monthly visit so nothing is missed. Recently, I reviewed a resident’s estimated glomerular filtration rate after his metformin was increased to 2 g daily. I advised the GP that his creatinine clearance is too low for this dose.
|
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5.30pm |
Home time. Cook dinner, help with homework and watch an episode of the latest series. I have decided to do my Diabetes Education Accreditation, so I will squeeze in a bit of study if I can!
|
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Genevieve Adamo MPS is the Senior Pharmacist – Poisons Information at the NSW Poisons Information Centre and a speaker at PSA22 next month.
Why choose pharmacy?
My father was a pharmacist, so I grew up working in his pharmacies every school holiday. After seriously considering economics, I felt a career as a pharmacist would combine my love of science with the family life I wanted, and it has not disappointed.
Where did you ‘learn the ropes’?
I was lucky enough to work part-time as a pharmacy assistant at Soul Pattinson, 160 Pitt Street, while a student at the University of Sydney, and then stay on as an intern and pharmacist. Working for Soul Pattinson allowed me to learn from different pharmacists and retailers and gave me an opportunity to develop a variety of clinical and management skills.
What attracted you to poisons info?
After my second child, I felt a bit rusty returning to work. A job at the Poisons Information Centre (PIC) provided an opportunity to use all my pharmacist skills with training to become a Specialist in Poisons Information (SPI). It was the most challenging and rewarding role with an amazing group of people. The shift-work of a 24/7 service, although unusual for a pharmacist, provides flexibility with juggling family unavailable in most pharmacy roles. I started with the Poisons Centre 18 years ago, and although I had a few years off to have more children, I kept returning because of the variety the role offers. Currently, my role in toxicovigilance incorporates providing advice on the phone service, as well as management of the website and media requests, development of fact sheets for public education, submissions for regulatory consideration and all things poisoning prevention.
What’s one ‘feel good’ situation where you made a difference?
We were consulted about a 1-year-old boy, very unwell with chronic salicylate poisoning from overuse of Bonjela teething gel. His mother had no idea it was toxic and, after recovery, was keen to collaborate on media messaging to ensure families knew the risks to prevent a recurrence. With more to be done, I used the case as part of the evidence to support an application to the Therapeutic Goods Administration for the rescheduling of choline salicylate. The application was successful. From February 2023, choline salicylate topical gels will be Schedule 2, requiring consultation with pharmacists and pharmacy assistants as well as cautionary warning labels. It is extremely rewarding to know I can help individuals and the community with the work we do at PIC.
What is a most unusual call to PIC?
There are so many it is hard to pick a stand-out. But there was a day when a child took a packet of flame colourant crystals to school thinking they were popping candy and shared them with friends. In fact, it was copper sulphate, which can be corrosive and cause severe toxicity, including renal and hepatic damage, metabolic acidosis, and death in small exposures. This resulted in many children requiring assessment and monitoring in hospital.
What would attract more pharmacists to PICs?
Poisons Information is a small specialty, with only about 60 SPIs nationwide, but the increasing complexity and call numbers mean we are often looking for pharmacists. It can be a stressful and demanding job, due to the fast pace and dealing with self-harm calls every day, but it is also clinically incredibly challenging and rewarding. There are often no set answers to the questions posed, so we are required to go back to first principles and evaluate available information. We are also fortunate to work on projects with amazing toxicologists and researchers to develop the latest information. Much of our call-taking is now done remotely, which means no commuting, as the job is no longer restricted to capital cities. Regular training sessions are a fantastic opportunity to catch up face to face, and it means you are always learning; it’s never boring.
Any advice for ECPs?
Get comfortable with the uncomfortable and practise problem-solving skills. We need to focus more on problem solving to find the best solution for our patients rather than what someone else has deemed the “right” answer. And take any opportunity to get involved in research.
Day in the life of Genevieve Adamo MPS, Senior Pharmacist – Poisons Information at the NSW Poisons Information Centre.8–11.30 am – Into the morning Get the kids to school and leisurely walk the dog before meeting with NSW PIC research team to finalise hand sanitiser exposure research paper. Radio interview on prevention of mushroom poisoning precedes work on a media campaign for carbon monoxide poisoning awareness. 2–6 pm – Disability medicines advice Review and analyse calls from disability workers to assess areas to potentially improve medication administration practices. Then it’s after-school activities and dinner until PIC time. 8 pm – Start call-taking shift at PIC In a 4-hour evening shift, I provide advice on 20–30 calls, each 3–5 minutes long. Call from mother of child, 18 months, found sucking on tube of home hair dye containing 12% hydrogen peroxide. Advise high-strength peroxide can cause a chemical burn, other systemic effects. Needs hospital monitoring, so referred immediately to the nearest hospital. 10.25 pm – Medicines non-compliance Call received from a group home regarding boy, 10 years, with autism refusing evening medicines including olanzapine 5 mg, amitriptyline 25 mg, aripiprazole 10 mg x0.5, clonidine 150 mcg x0.5, melatonin 2 mg. Has refused evening medicines for 2 weeks due to drowsiness in the mornings but takes morning doses of amitriptyline, aripiprazole and clonidine. Advise review by doctor tomorrow after 2 weeks of missed evening medicines. Doses of olanzapine or SR melatonin likely adverse effect cause. Suggest reduced dose/medicines change. 11.44 pm – Paracetamol overdose Woman calls about paracetamol clearance. Admits taking deliberate overdose of 20 tablets two nights prior, now has abdominal pain indicating liver involvement. After my compassionate explanation, woman says she will take more paracetamol and hangs up. Call police and I give her phone number so they can locate and transport her to hospital. 12 am – Bedtime, finally Complete all documentation, and review calls taken by other SPIs during the evening. |
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An only child of Vietnamese boat people, WA’s Pharmacist of the Year Phuong Nguyen MPS combines pharmacy with big business.
What first attracted you to the pharmacy profession?
I chose pharmacy as I felt that healthcare and business came together in community pharmacy. This comes from my parents, both teachers before they escaped Saigon in 1980, who instilled in me the importance of curiosity, education and community. My family also has strong roots in the business and healthcare industries with many doctors, nurses, optometrists and dentists. As the only pharmacist in the family, I love it because it allows me to connect and interact with patients to provide personalised advice and solutions by harnessing my listening and problem-solving skills.
Has the profession provided the impetus to get you where you are?
A background in pharmacy gave me the opportunity to work collaboratively in a multidisciplinary workforce and provided the foundation blocks for building professional working relationships – both in community pharmacy and then in a robust aged care pharmacy within a diverse team. It all provided valuable management and leadership skills, which are highly transferable in my consultancy work. A growth mindset has fuelled my quest for self-improvement and lifelong learning – hence my embarking on an MBA at the University of Western Australia.
I spent my final year living on campus at Harvard University. I met the brightest people, both in business and socially. It dragged me out of my (shy) comfort zone of largely pharmacy friends (and my extended family) and made me more ‘worldly’ and socially interactive. It was quite the life-changing experience – and I also saw a taping in New York of The Late Show with Stephen Colbert!
How did the job at PwC Australia come about?
While I was completing my MBA, the career option of consulting came up. Curious about what the job entailed, I applied for a summer internship. My generous and supportive pharmacy employer at the time allowed me to work for PwC Australia, and the internship exposed me to projects within the healthcare system. It was an opportunity to use my healthcare knowledge and MBA to serve the community.
What do you do with the company that benefits the health system and uses your pharmaceutical as well as business qualifications?
PwC Australia has given me the opportunity to be exposed and involved in interesting projects in healthcare and beyond – like implementing a digital transformation program. I’m able to utilise my knowledge of the healthcare system to build bridges and interact with other clinicians. For example, I was involved in COVID-19 preparedness within the healthcare system in relation to supplies and procurement. It allowed me to combine my understanding of healthcare needs with supply chain management.
Where do you see yourself in 5–10 years?
I would love a stint working in an emerging economy for an aid agency such as Médecins Sans Frontières. But I also want to maintain a close connection with community pharmacy – the heart of the pharmacy industry – and, through my consultancy work, influence health policies and systems to improve public health initiatives. Learning for professional and personal self-improvement is also in there. Ideally, as my mother always says, ‘Give your life purpose by giving back to others,’ so I would also love to provide mentorship in appreciation of this amazing and rewarding career.
What advice would you give to early career pharmacists?
Career mentors have helped me, so I encourage others to seek them. Mentors have imparted new perspectives and experiences and have helped guide, develop, encourage and empower my professional development, providing me with opportunities for self-reflection – and finally built my self-confidence.
And never underestimate the management and leadership skills that are built in pharmacy (let alone the skill to ‘read a room’ from all those tall tales you’ve heard at the dispensary). Learn and refine these skills, as they are valued in every relationship in any industry.
Explore new paths at psa.org.au/careerpathways
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CPD credits
Accreditation Number : CAP2206SYPRN
Group 1 : 0.75 CPD credits
Group 2 : 1.5 CPD credits
This activity has been accredited for 0.75 hours of Group 1 CPD (or 0.75 CPD credits) suitable for inclusion in an individual pharmacist's CPD plan, which can be converted to 0.75 hours of Group 1 CPD (or 1.50 CPD credits) upon successful completion of relevant assessment activities.
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
