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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]As interviews for the Aged Care Royal Commission continue, medical experts have voiced concerns about the overuse of psychotropics as medical restraints in aged care facilities, but Department of Health secretary Glenys Beauchamp told the commission that the government is unlikely to become involved, citing doctor-patient confidentiality.
Ms Beauchamp told the commission that the government was committed to putting in place mandatory reporting requirements around the use of physical restraints in aged care facilities, but fell short of intervening in medical restraints.
‘In terms of the medical restraint, at the moment that's certainly something in terms of doctor-patient privilege that I wouldn't want to intervene (in). What we want to try and do is minimise the use of both forms,’ she said.
Her statement runs counter to the views of healthcare professionals who have spoken to the commission, some of whom have suggested that the use of medical restraints is a symptom of systemic problems in aged care.
Associate Professor Edward Strivens, president of the Australian and New Zealand Society for Geriatric Medicine, told the commission that psychotropics are, ‘a last resort, but too often we see them used as a first resort.’ His statement was supported by data revealed during the inquiry that 80% of dementia patients are taking psychotropic drugs.
A consultant pharmacist in the quality use of medicines for older adults, Dr Amy Page, echoed this view.
‘We know that [these medications] are overused, and cause significant harm. The HALT study and RedUSe studies have very recently shown that many people in Australian residential aged care facilities (RACFs) are able to be withdrawn from these medicines when pharmacist-led strategies are implemented., The current situation is harmful. We haven’t seen much in the way of improvements, so maybe something further is needed,’ she told Australian Pharmacist.
The Pharmaceutical Society of Australia’s (PSA) Medicine Safety Report also noted the challenges with prescription medication in aged care, citing a 2014 study in which pharmacists retrospectively assessed medication-related problems, and found that 98 per cent of residents in aged care facilities had at least one medication-related problem, while over 50 per cent are exposed to at least one potentially inappropriate medicine.
The inquiry has also investigated the use of psychotropic medication in managing patients who become violent. Dr Page agreed with healthcare professionals who advocated for the use of sedatives with aggressive patients, but questioned a statement made to the commission by Royal Australian College of General Practitioners president Harry Nespolan, who said psychotropics might be appropriate for patients spending ‘most nights screaming’.
‘Psychotropic medications only have any evidence for working when there’s physical aggression involved. The example that was given by Royal Australian College of General Practitioners about people not sleeping and calling out all night - these medicines don’t work for that,’ she said.
She said that pharmacists are able to support the appropriate review of these medicines, and supports the inclusion of pharmacists in multidisciplinary healthcare teams within aged care facilities, echoing the views expressed in PSA’s recently released Pharmacists in 2023 report, which called for the ‘full integration of pharmacists into collaborative, patient-centred models of care.’
‘A pharmacist at the facility or undertaking reviews can help identify people who may not be adequately managed on their current regimen because they are using potentially inappropriate medications and not taking indicated medicines,’ she said.
Dr Page recalled conversations with politicians in the early 1990s, who declined to be involved with the physical restraint of patients in aged care facilities, citing a reluctance to interfere with medical treatment.
‘I really hope it’s not going to take another 24 years to realise that using medical restraints to stop somebody from calling out or for vocalising is inappropriate,’ she said.
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[post_title] => Psychotropic medicines in the spotlight in Aged Care Royal Commission
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Pharmacists are underutilised in the Australian healthcare system and should be able to practise their skills to their full scope, says Dr Richard Di Natale, the leader of the Australian Greens.
Dr Di Natale, a GP before entering parliament, was speaking at last week’s launch of PSA’s Pharmacists in 2023 report.
‘Pharmacists have always played a critical role in the healthcare system, but the profession of pharmacy is underutilised, and we need to do everything that we can to ensure that one of the most highly trained and respected healthcare professionals in the community are able to utilise those skills much more broadly,’ Dr Di Natale said.
Referring to the Medicines Safety: Take Care report, Dr Di Natale said it was pretty remarkable that much of the burden of disease in our hospital system and emergency departments is the result of people experiencing adverse reactions from medicines.
Citing the $1.4 billion dollars spent annually due to medicine misadventure, Di Natale stated, ‘Everytime we talk about supporting pharmacists in playing a more active role in this space, we keep talking about the cost involved in doing that, but never about the costs of not doing that – $1.4 billion dollars, however, is a huge cost to our healthcare system.’
Dr Di Natale noted that 2023, in fact, isn’t that far away – and that the 11 key actions outlined in the Pharmacists in 2023 report need to be taken to allow pharmacists to do their job effectively.
‘Pharmacists are well respected and trusted by the community, as well as being strong advocates for evidence-based policy. The 2023 report shows that pharmacists have a much bigger role to play within our healthcare system, and we do support expanding the scope of pharmacists.’
This support, Dr Di Natale stated, extends to funding.
‘We do support the call in the report for additional funding to recognise the value that pharmacists bring, but we need to make sure that the funding model is transparent and makes it very clear what is being funded and the reasons behind it.’
Dr Di Natale said that he looks forward to a continued relationship with PSA, and acknowledges the organisation’s work in contributing to the national debate for evidence-based policy.
‘Your voice in the debate as trusted healthcare professionals – people trained in science with a strong evidence-base and wanting to advance the cause of good public health policy – is so critical. I look forward to continuing on in that journey over the coming years.’
Also speaking at the launch was Emma McBride, Labor Member for Dobell. Previously a pharmacist for ten years in Wyong Hospital on the NSW Central Coast, Ms McBride was the deputy director of pharmacy for the Central Coast local health district prior to her election to parliament.
‘I am delighted to join the launch of your report, Pharmacists in 2023: for patients, for our profession, for Australia’s health system,’ Ms McBride said.
‘Pharmacy is a dynamic profession. As the report highlights, the rapid pace of change and advances in treatment mean that medicines are now the most common medical intervention in healthcare. Diseases that were life-threatening when I set out in my career 20 years ago can now be safely treated and managed. This makes the role of pharmacists as medicines experts critical to the health and well-being of all Australians.’
Ms McBride said that there has been a lot of consultation and discussion around healthcare, but, as specified in the Pharmacists in 2023 report, it is now time for action.
As previously reported, Federal Minister for Health Greg Hunt also commended PSA for the report, while announcing the PSA would be first time signatories to the Seventh Community Pharmacy Agreement (7CPA)
In a post-launch statement, Leanne Wells, CEO of the Consumers Health Forum of Australia, also spoke highly of the report. Ms Wells said that the Pharmacists in 2023 report, ‘Advocates more patient-centric care which the Consumers Health Forum strongly supports. The role of the pharmacists as dispensers, quality use of medicines advisers and deliverers of aspects of primary health care is an important area of reform.’[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row]
[post_title] => Pharmacists in 2023 report embraced
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So you think you know your rights and obligations at work? Go to school on these employment fundamentals. Staff are the key to the success of any business. Putting efforts into recruitment, staff development and succession planning all contribute to an effective and efficient operation that should reward a pharmacy business operator with customer loyalty, staff satisfaction and ultimately business success.
But no matter if you are an employer or an employee, there are important fundamentals of the law which govern workplace relationships that every pharmacist should understand.
The Award
The employer-employee relationship in community pharmacy is governed by the Pharmacy Industry Award 2010 (Award) or the Health Professionals and Support Services Award 2010 (HPSS Award). The exceptions are employees (and their employers) covered by a modern enterprise award or instrument (e.g. many hospital pharmacists), and employees excluded from award coverage by the Fair Work Act 2009. The Award sets out the minimum requirements that employers must adhere to in relation to their employees’ wages, entitlements, allowances, uniform, hours of works, breaks, overtime and more. The terms of these arrangements can be varied between the employer and employee regarding when work is performed, overtime rates, penalty rates, allowances and leave loading.
Casual or permanent?
Defining an employee’s status is essential. An important, recent case centred around the definition of a casual versus a permanent employee – WorkPac Pty Ltd v Skene [2018] FCAFC 131.
Paul Skene, a truck driver, had been classified by his employer as a casual. But following termination of his employment, Mr Skene claimed payment of accrued annual leave – something casual employees are not entitled to. The Court concluded that Mr Skene had actually been a permanent employee, despite his employer’s classification – and therefore entitled to annual leave. The key factor was that Mr Skene had worked a regular roster over an extended period of time.
The Court found there was no evidence that Mr Skene had been paid a casual loading; but if an employer has paid loading anyway, such a payment doesn’t define that employee as casual.
The Award was amended in the last few years to disallow an employee being classified as casual if they work ‘reasonably predictable hours’. Further changes have been recently made to permit ‘casual conversion’, including a new clause permitting a regular casual employee to request that their employment be converted to full-time or part-time employment.
Other entitlements
The Award entitles part-time and full-time employees to various leave and allowances, superannuation and other entitlements under the National Employment Standards (NES).
It also details the circumstances in which agreements can be entered into by the employer and employee in addition to the minimum standards set by the NES. For example, an employer and employee can reach agreement for the employee to take excessively accrued annual leave; but if no agreement can be reached despite an employer’s genuine attempts, an employee may be required to take some of that leave.
When employment ends by termination or the transfer of a business, leave entitlements are treated as follows:
Overtime
The Award describes pay rates for overtime and penalty loadings for evening work and weekend hours. For example, penalty loading for an employee’s classification will apply if they are required to work before 8am, after 7pm, or on Saturday and Sunday. Overtime is paid if the employee works at the direction of the employer for more than 38 hours per week or 12 hours per day, between midnight and 7am, or outside any rostering arrangements.
Time off in lieu of overtime payment is allowed, but the time off must be of the same value of the overtime worked.
Annual leave
If an employee has excessive leave (that is, more than 8 weeks paid annual leave, or 10 weeks paid annual leave for a shiftworker), the employer or the employee may seek to reduce that excessive leave. If an employer has genuinely tried to reach agreement with an employee without success, the employer may direct the employee to take one or more periods of paid annual leave. However, an employer cannot give a direction if it will result in the remaining leave being less than 6 weeks; or requires the employee to take less than one week leave; or requires the employee to take leave within 8 weeks or more than 12 months after the direction is given.
If an employee has genuinely tried to reach agreement with an employer without success, the employee may give a written notice to the employer requesting to take one or more periods of paid annual leave. The same time restrictions apply as set out above.
Long service leave
Long service leave accrues from the commencement of employment. If the employee has completed 10 years (or 7 years in some States) with the business, the employee is entitled to their pro-rata value of long service leave accrued but not taken. Where the business is being transferred, State or Territory legislation determines whether or not long service leave is permitted to be paid out.
Personal leave and sick leave
Employees are not entitled to be paid out any accrued personal or carer’s leave.
Family and domestic violence leave
The Award now includes provision for 5 days’ unpaid leave to deal with family and domestic violence. The leave is available in full at the start of each 12-month period of the employee’s employment and does not accumulate year to year. This leave is available to casual employees as well.
Termination
Employment can end for many reasons. An employee may resign or can be dismissed. However it ends, it’s important to play by the book. These rules are set out by the NES.
Notice periods don’t apply to casuals, those on a fixed-term contract, or those fired because of serious misconduct.
Dismissal
When an employer dismisses an employee, they have to give them notice. This is the case even on the sale of a business.
Notice periods are generally 1 week for 1 year or less of continuous service; 2 weeks for 1–3 years; 3 weeks for 3–5 years; and 4 weeks for more than 5 years. An employee has to get an extra week of notice if they’re over 45 years old and have worked for the employer for at least 2 years.
An employer can let the employee work through their notice period; pay it out to them (also known as pay in lieu of notice); or give a combination of the two.
Resignation
The notice of termination required to be given by an employee is the same as that required of an employer, except that there is no requirement to give additional notice based on the age of the employee.
If an employee doesn’t give the required notice, the employer may withhold any monies due to the employee, but not exceeding the amount the employee would have been paid in respect of the period of notice.
Final pay
Final pay refers to what an employer owes an employee when their employment ends. Usually, an employee is to be paid on their last day of work or on the next scheduled pay day. An employee should receive any outstanding wages for hours they have worked, including penalty rates and allowances; any accumulated but not taken annual leave, including leave loading; accrued or pro rata but not taken long service leave; payment in lieu of notice; and redundancy pay (if it applies).
Redundancy
This happens when an employer either genuinely doesn’t need an employee’s job to be done by anyone, or becomes insolvent or bankrupt. Redundancy can happen when the business introduces new technology; slows down due to lower sales or production; closes down; relocates; or restructures.
If a business is sold, a new employer can choose not to recognise an employee’s service with the old employer for the purpose of redundancy entitlements. The old employer will then need to pay redundancy to the employee.
However, an employee will not be entitled to redundancy pay if they reject the new employer’s job offer and that offer was on terms and conditions no less favourable than the employee’s old job; the employee’s service with the old employer(s) for redundancy pay will be recognised; and there would have been a transfer of employment if the employee had taken the job.
Exceptions to redundancy pay include, but are not limited to: if the employee has not served at least 12 months continuous service with the employer; employees terminated for serious misconduct; employees of small businesses. A ‘small business’ is one that employs fewer than 15 employees.
Unfair dismissal
Unfair dismissal is when an employee is dismissed from their job in a harsh, unjust or unreasonable manner. Generally, employees have to be employed for at least 6 months before they can apply for unfair dismissal. However, employees working for a small business have to be employed for at least 12 months before they can apply.
If there was a change of business ownership, service with the first employer may count as service with the second employer when calculating the minimum employment period.
Small businesses have different rules. The Small Business Fair Dismissal Code provides protection against unfair dismissal claims.
Employment contracts
Employers and employees cannot contract out of the Award – except in relation to the limited circumstances the Award allows (as discussed earlier). Terms of pay, including employee entitlements, must be in accordance with the minimum standards set under the Award.
An employment contract does not have to be in writing. However, it is difficult to prove a verbal agreement existed. As an employee, if you reach agreement with the employer for employment conditions which vary from the Award in your favour, it is vital to have a written record.
Employers can learn from the Workpac case: set out in writing the agreed classification of the employee and benefits, including pay rates and entitlements, appropriate for that employee’s true classification, and conduct affairs in accordance with that agreement.
Any questions?
If you have a workplace dispute or query, the Fair Work Commission is Australia’s national workplace relations tribunal. It is an independent body with power to carry out a range of functions including, but not limited to, providing a safety net of minimum conditions, including minimum wages in awards; dealing with applications in relation to unfair dismissal; regulating industrial action; resolving workplace disputes through conciliation and, in some cases, tribunal hearings.
Usually, the Commission only becomes involved in a workplace dispute when a person makes an application with the Commission to initiate a matter.
The Commission cannot provide legal advice. You should obtain expert legal advice if you have a workplace dispute or any concerns about your rights as an employer (or potential new employer) or employee.
BILL SUEN MPS is the PSA Victorian State Manager, Adjunct Senior Lecturer at Monash University, and an examiner for the Pharmacy Board of Australia. STEPHANIE MCGRATH is a Senior Associate at Robert James Lawyers practising in commercial law with a focus on health, business and property across Australia.
This article is intended only to provide a summary and general overview on matters of interest. It does not constitute legal advice.[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row]
[post_title] => A fair day’s pharmacy – your rights and obligations
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[post_content] => In 2023 pharmacists will be the custodians of medicine safety, embedded wherever medicines are used, and more responsible and accountable for the safe and effective use of medicines, a new report reveals.
Pharmacists in 2023: For patients, for our profession, for Australia’s health system, developed by the Pharmaceutical Society of Australia (PSA), reveals the 11 system changes needed for healthcare evolution to deliver safety and quality improvements in the use of medicines, and better use of pharmacists to improve access to healthcare. Today also marks 11 years since PSA achieved national unification, further demonstrating just how far the organisation has come.
PSA National President Dr Chris Freeman launched the report today at a breakfast event in Parliament House attended by political leaders and pharmacy experts from across the country.
'Pharmacists in 2023 is the pharmacy profession’s response to the national medicine safety problem,' Dr Freeman said. 'The report unlocks the potential for pharmacists to improve healthcare access and outcomes for Australians and reduce variability in care.'
PSA recently showed in its Medicine Safety: Take Care report that 250,000 people are admitted to hospital each year as a result of medicine-related problems, costing the Australian health system $1.4 billion per annum.
Dr Chris Freeman at the Pharmacists in 2023 report launch
‘Medicine safety should be a national priority,’ Dr Freeman said. ‘The Pharmacists in 2023 report identifies the key actions needed to address this issue by unlocking more opportunities for pharmacists as the guardians of medicine safety.
‘Pharmacists must be empowered to do more than the current system allows them to do. As the only health professionals trained with a specific focus on the effective and safe use of medicines, pharmacists must lead a culture change to embed medicine safety at every point of healthcare delivery.
‘Rather than gazing into a crystal ball, we have laid out an ambitious agenda for change with tangible and practical actions to support all pharmacists to reach their full potential and provide more effective and efficient healthcare.
All of the actions in Pharmacists in 2023 aim to ensure pharmacists practise to the full extent of their expertise, are recognised for their key role in healthcare and are remunerated appropriately.
‘Our goal is to ensure any Australian, no matter where they live, can receive the best possible care from a pharmacist, and that pharmacists are supported to address their patients’ needs using the full extent of their training and expertise.”
The PSA report is the result of two years of consultation with a wide range of pharmacy, consumer and health stakeholders.
For pharmacists in 2023 to address the health needs of all Australians, the report identifies 11 actions for change:
- Empower and expect all pharmacists to be more responsible and accountable for medicine safety.
- Enhance the role of community pharmacists to have a greater level of responsibility and accountability for medicines management.
- Embed pharmacists within healthcare teams to improve decision making for the safe and effective use of medicines.
- Facilitate pharmacist prescribing within a collaborative care model.
- Improve pharmacist stewardship of medicine management to improve outcomes at transitions of care.
- Utilise and build upon the accessibility of community pharmacies in primary care to improve consumer access to health services.
- Equip the pharmacist workforce, through practitioner development, to address Australia’s existing and emerging health challenges.
- Establish additional funding models to recognise the value and quality of pharmacist care.
- Allow greater flexibility in funding and delivery of pharmacist care to innovate and adapt to the unique patient needs in regional, rural and remote areas.
- Develop and maintain a research culture across the pharmacist profession to ensure a robust evidence base for existing and future pharmacist programs.
- Embrace digital transformation to improve the quality use of medicines; support the delivery of safe, effective, and efficient healthcare; and facilitate collaborative models of care.
Dr Freeman said, 'I now look forward to working with pharmacy leaders, other healthcare groups, consumers and government to advance the role of pharmacists in 2023 – for patients, for our profession and for Australia’s health system.'
Read Pharmacists in 2023.
[post_title] => Broadening pharmacists' role to improve health
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[post_content] => Federal Minister for Health Greg Hunt has committed to PSA being a signatory of the Seventh Community Pharmacy Agreement (7CPA), due for commencement in 2020.
Mr Hunt, attending the launch of the PSA’s Pharmacists in 2023 report at Parliament House in Canberra, praised the work of the PSA – and flagged an important development in the governance of pharmacy remuneration in Australia.
‘As we look forward to pharmacy in 2023, and go through this report, the goal is the integrated role of pharmacists practising to their full scope. We will now work with you on these recommendations … and I make this commitment that you (PSA) will be the signatories for the first time for the 7CPA.
‘I would like to build in to that agreement the expanded scope of practice where pharmacy will be involved increasingly in preventive health ... to keep more people out of hospitals, keep more people healthy, save lives and protect lives.’
Greg Hunt at the Pharmacists in 2023 report launch.
Mr Hunt also praised the work of PSA in its advocacy for funding support for a number of pharmacy trials, in particular chronic pain MedsCheck.
‘What we do on these MedsChecks literally saves lives and protects lives, and that’s a united front we have to have,’ Mr Hunt said.
Mr Hunt also stated that real-time prescription monitoring would be rolled out across Australia in the coming year.
‘Real-time monitoring is something that the PSA has championed, (and we are) now working with the states to have a single standard on that. This is about protecting patients and protecting the broader community. I am very confident that it will be up and running across the nation for the course of this calendar year, and it would not have happened without the Society and without your support.’
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]As awareness of transgender people grows, so does the need for healthcare professionals to be educated in the area of transgender health . A recent article in Australian Prescriber draws on ‘decades of experience’ to give practitioners fresh insight into gender-affirming hormone therapy.
The article, authored by sexual health physician Dr Louise Tomlins, noted that, while not all transgender individuals chose to undergo gender-affirming therapy, interest in the therapy has increased. This makes it vital that educated healthcare professionals are available to provide support, both clinical and psychosocial.1
As awareness increases, the role of pharmacists in multidisciplinary healthcare teams supporting individuals undergoing gender confirmation therapy has been a topic of renewed discussion. In the UK, Caroline Dada is the medication safety officer and lead pharmacist for community mental health services and gender identity for the Leeds and York Partnership Foundation Trust. She believes she is the only pharmacist specialising in gender identity in the UK.
‘Community pharmacists and GP-based pharmacists are in a great position to support patients with gender identity issues,’ she said. ‘The service users for whom I prescribe will be on lifelong therapy, so community pharmacists will need to have a greater understanding of their health requirements and therapy.’2
The Australian Prescriber article outlines the different therapy options for individuals undergoing gender transition from male to female, and from female to male.
Transwomen
Estrogens in combination with an anti-androgen are the standard first-line gender-affirming hormone treatments for patients transitioning from male to female (transwomen).
Estrogen is the preferred treatment as it most closely resembles the hormone produced by the ovaries. The dose of estradiol valerate tablets starts at 2–4 mg daily, increasing up to 8 mg daily. Tablets can be given in divided doses if nausea occurs in higher doses. Patches or implants are preferred for transwomen over 40 years of age (although can be used in younger women) to minimise the risk of venous thromboembolism. Patches start at 100 microgram/24 hours. Implants of 50 mg and 100 mg are available from compounding pharmacies. Their duration of drug delivery is on average 6–12 months, but this needs to be monitored. Tachyphylaxis can develop with long-term implant use.1
Ethinylestradiol and conjugated equine estrogens are generally avoided because of an increased risk of venous thromboembolism. Also, blood levels may be inaccurate.
Anti-androgens suppress the production and effect of endogenous androgens, thereby reducing masculine characteristics. Cyproterone and spironolactone are the most commonly used agents. In combination with estrogen, they reduce the dose of estrogen required to achieve feminising effects.
Cyproterone is a synthetic progestogen with a potent anti-androgenic effect. The starting dose is usually 25–50 mg daily, which can be increased to 100 mg daily. Cyproterone has been associated with rare cases of fulminant hepatotoxicity when used for metastatic prostate cancer.
Spironolactone is a potassium-sparing diuretic, which in higher doses directly inhibits testosterone production and blocks androgen receptors. The usual starting dose is 100 mg daily in one or two doses, up to a maximum of 400 mg daily. Monitoring of blood pressure and potassium concentrations is required. Possible adverse effects include hyperkalaemia, polyuria, polydipsia and postural hypotension, particularly at higher doses.
Some clinicians add progesterone to improve breast development. However, evidence is limited, and adverse effects are possible e.g. depression, weight gain and higher lipid levels.
The impact of hormone therapy is variable in transwomen, ranging from breast growth and changes in the body fat distribution, to emotional changes and a decline in libido.
Transmen
Testosterone is the standard masculinising treatment for patients transitioning from female to male (transmen). Usually injections are used. Other formulations are available (tablets, gels and creams), but are generally unsuitable. Tablets don’t achieve adequate concentrations.
Testosterone enantate is given by intramuscular injection every two to three weeks. Some patients can self-inject. A starting dose of 125 mg is titrated up to 250 mg to achieve male physiological concentrations. Transmen may experience cyclical effects of aggression at the beginning of the hormone cycle and fatigue and irritability at the end, in addition to desirable outcomes of deepening of the voice, increased muscle mass and the cessation of menstruation.1
Alternatively, testosterone undecanoate injections are given in a dose of 1000 mg every 10–12 weeks. Cyclical effects occur, but less frequently. This formulation is associated with a risk of pulmonary microembolism, making it unsuitable for self-injection.
The impacts
In both transmen and transwomen, hormone concentrations are monitored at three month intervals throughout the first year of therapy, and at 6–12 month intervals thereafter. Patients can expect to see changes in the first few months of treatment, and reach a maximum after 3–5 years.
It is recommended that transmen, who still have female reproductive organs and breast tissue, continue to undergo cervical and breast screenings. Similarly, prostate cancer screenings should be discussed with transwomen.1
Starting treatment after puberty will reverse or regress many primary and secondary sexual characteristics. However some will persist to the extent that reassignment surgery might be sought by some individuals. These therapies are believed to be relatively straightforward and safe, and resemble therapies used for postmenopausal women or hypogonadal men.1
However, Bryan Bishop, a community pharmacist who has worked extensively with transgender patients, told Pharmacy Today that an understanding of the mechanics of hormone therapy is only one part of the role that healthcare professionals play in supporting transgender patients. Being open to communication with these patients is also an important part of delivering optimal healthcare outcomes.
‘You don’t have to shy away from communicating with a patient. Ask them their preferred name and if they have any preferred pronouns,’ he said.3
References:
- Tomlins L, Prescribing for transgender patients. Aust Presc 2019; 42(1). At: https://www.nps.org.au/australian-prescriber/articles/prescribing-for-transgender-patients#article
- Dada C, The gender identity guru. The Pharmaceutical Journal. Epub 2016 Jan 13. At: https://www.pharmaceutical-journal.com/careers-and-jobs/careers-and-jobs/career-qa/how-i-deliver-a-pharmacy-service-for-patients-undergoing-gender-reassignment/20200322.article?firstPass=false
- Bonner L. Pharmacists can be accessible trusted providers for transgender patients. Pharm Today 2016;22(3):57. At: https://www.pharmacytoday.org/article/S1042-0991(16)00356-X/fulltext
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[post_content] => In the fight against antibiotic resistance, shorter courses of antibiotics are now recommended for patients with common infections, but how short is long enough?
The optimal antimicrobial duration for common bacterial infections is outlined in a review paper recently published in Australian Prescriber 2019;42(1):5-9.1
'The key message for pharmacists is that when antibiotics are deemed necessary, there is increasing evidence that shorter antibiotic courses result in clinical outcomes that are similar to longer courses, with fewer adverse drug events,' said Dr Janet Sluggett, National Health and Medical Research Council (NHMRC), Early Career Fellow at Monash University, and Professional Services pharmacist at CPIE Pharmacy Services in Adelaide.
'The paper is useful for pharmacists because it summarises recommended treatment durations for respiratory, urinary and skin infections that are commonly encountered in the community setting.'
The Australian Prescriber paper highlights data that shows Australia has relatively high rates of antibiotic prescribing.
'In 2015, 30% of all patients attending a general practice received an antibiotic prescription,' the paper stated.
'Most are for acute respiratory infections, and in quantities several-fold more than recommended by Australian guidelines.'1
While the review paper is aimed at prescribers, particularly General Practitioners, pharmacists are 'uniquely placed to identify opportunities to support appropriate use of antibiotics', Dr Sluggett said.
'Prescribers are advised to document indication and duration for use on all antibiotic prescriptions, which provides us with more information and opportunity to contribute to patient care,' she said.
'Confirming treatment durations, breaking packs when dispensing and counselling patients that there may be tablets remaining at the end of treatment are all valuable interventions.'
It’s also important to remember that the Cautionary Advisory Label Additional Instruction D – ‘until all taken’ – may not be appropriate for inclusion on dispensing labels when the pack size is greater than the prescribed treatment duration, said Dr Sluggett, who is also a member of the Australian Pharmaceutical Formulary and Handbook (APF24) New Drug Advisory Group.
'Pharmacists are well placed to advise consumers on how best to take antibiotics, discuss why antibiotics are not always necessary, and provide general education regarding hand hygiene,' she said.
'This is also a good opportunity to reinforce the importance of appropriate medicines disposal through pharmacies.'
If pharmacists do identify problems relating to antibiotic use – such as inappropriate use, suspected adverse drug events, or signs that an infection may not be resolving – they should act.
'Steps that I might take in these situations could include a discussion with the patient, contacting the prescriber and/or referring to evidence-based resources such as the Therapeutic Guidelines: Antibiotic,' Dr Sluggett suggested.
'The other important role we play is in reassuring patients, particularly in those cases where antibiotics are not indicated, or may no longer be required.'
Useful resources for pharmacists include the PSA's new Choosing Wisely recommendation number three (do not dispense a repeat prescription for an antibiotic without first clarifying clinical appropriateness) and the latest Antimicrobial Stewardship in Australian Health Care publication.
Dr Sluggett also encourages pharmacists – including those working with aged care providers and in general practice – to support antimicrobial stewardship at a broader level.
‘This could mean contributing to local guideline development, education, audit and feedback, research, local drug formularies and infection control committees,' she suggested.
When it comes to customer education, pharmacists may find the PSA's printable Self Care Cards on antibiotics and colds and flu useful.
'Ensuring antibiotics are used in the best possible way requires a team approach,' Dr Sluggett said.
'We can advise prescribers on current guideline recommendations for treatment of infections, dosing regimens and switching from IV to oral therapy. Pharmacists can also identify people at risk and administer certain vaccinations.'
References
- Wilson HL, Daveson K, Del Mar CB. Optimal antimicrobial duration for common bacterial infections. Aust Prescr 2019;42:5-9. At: https://www.nps.org.au/australian-prescriber/articles/optimal-antimicrobial-duration-for-common-bacterial-infections#r1
[post_title] => Are antibiotics courses for common infections too long?
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[post_content] => Two additional targeted biologicals for severe chronic plaque psoriasis are now listed on the Pharmaceutical Benefits Scheme (PBS), offering relief for adults with the often underestimated condition.
Chronic plaque psoriasis (often referred to as psoriasis) is thought to affect between 2.3% –6.6% of Australians. Chronic plaque psoriasis is the most common form of the condition, accounting for approximately 90% of all psoriasis cases.1,2
Psoriasis is an immune mediated condition that can cause red scaly patches, itchiness and flaking of the skin.3 It is associated with higher rates of depression and anxiety; the psychosocial impact of psoriasis affects quality of life. Patients with psoriasis are also at an increased risk of conditions such as metabolic syndrome and cardiovascular disease.4 The two new PBS listed medicines, tildrakizumab (Ilumya) and guselkumab (Tremfya) could alleviate the condition in patients.
‘While psoriasis was once thought of as little more than “influenza of the skin”, our improved understanding of the immunological pathways involved in the disease has led to the development of ...biologicals with a more targeted mechanism of action,’ said Associate Professor Peter Foley, Clinical Dermatologist and Director of Research, Skin & Cancer Foundation Inc, in a statement.
In psoriasis, there is an increase in interleukin-23 (IL-23), a pro-inflammatory cytokine. Tildrakizumab and guselkumab, both monoclonal antibodies and inhibitors of IL-23, relieves inflammation and symptoms of psoriasis.5,6
The recommended dose of tildrakizumab is 100mg subcutaneously at week 0 and week 4, and every 12 weeks thereafter.5
Conversely, the recommended dose of guselkumab is 100 mg subcutaneously at week 0 and week 4, and every 8 weeks thereafter.6
Both tildrakizumab and guselkumab are immunomodulators and as such appropriate precautions prior to commencement of therapy should be taken (e.g. screening for tuberculosis and hepatitis B, immunisations etc.5,6
Professor Foley said that, while there is no cure for psoriasis, the development of biologicals is promising. However, there may still be barriers to widespread usage.
‘It would appear that a significant portion of patients are not presenting to their GPs because they are not aware that newer, less toxic therapies are available or they have been told years ago that there is no cure,’ he said.4
With tildrakizumab’s and guselkumab’s inclusion on the PBS and continued research and development of biologicals, more effective treatment could be within reach, he said.
References
- Griffiths CE, Christophers E, Barker JN, et al. A classification of psoriasis vulgaris according to phenotype. Br J Dermatol. 2007;156(2):258-262. At: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2133.2006.07675.x
- Parisi R, Symmons DP, Griffiths CE, Ashcroft DM. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. J Invest Dermatol 2013 133(2):377-85. At: https://www.ncbi.nlm.nih.gov/pubmed/23014338
- Victoria State Government Better Health Channel, Psoriasis. At: https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/psoriasis
- Woodley, M. PBS listing could save psoriasis patients tens of thousands a year. News GP 25 January 2019. At: https://www1.racgp.org.au/newsgp/professional/pbs-listing-could-save-psoriasis-patients-tens-of
- TREMFYA (guselkumab) Australian product information. At: https://www.tga.gov.au/sites/default/files/auspar-guselkumab-181105-pi.pdf
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[post_content] => There has been an increase in incidents of community-associated Staphylococcus aureus bloodstream infections (CA-SABs) in Victoria and Western Australia (WA). Pharmacists have a role to play in infection control and prevention.
A study, which surveyed 10,320 hospital-reported S. aureus bacteraemia (SAB) cases in Victoria and WA from 2011-2016, found that 6,800 cases were community-associated (CA), as opposed to healthcare-associated, with the number of CA-SABs increasing by eight and six per cent per year in Victoria and WA respectively.1 Methicillin-susceptible S.aureus (MSSA) was the cause of most CA-SABs.
Importantly, patients 60 years and over had higher incidences of CA-SABs, with men twice as likely to acquire the infection than women of the same age.
The study comes in response to hospital reports received by the Victorian Healthcare Associated Infection Surveillance System (VICNISS) and Healthcare Infection Surveillance Western Australia (HISWA) in 2016 and 2017, informing them of increased incidences of CA-SABs.
These increases may be due to virulent S. aureus strains or changes in host risk factors.1 Aged care facility residents may be at particular risk as infections in this group would have been classified as CA-SABs in the study.
Pharmacists’ role in infection control and prevention
According to Naomi Weier, Project Pharmacist at the Pharmaceutical Society of Australia (PSA), ‘pharmacists have a key role to play in counselling patients on infection control and prevention’.
‘This includes counselling patients on hygiene measures such as covering sores or wounds and correct use of dressings, counselling and promotion of the importance of correct handwashing techniques and washing hands regularly and providing education and advice on exclusion periods for infectious conditions if required,’ she said.
According to health.vic The incubation period is most commonly 4—10 days, although this can vary. Transmission is usually via direct or indirect contact with a person who has a discharging wound or clinical infection (e.g. respiratory or urinary tract), or who is colonised with S.aureus (e.g. approximately 50% of the population). Infection control and prevention is required for as long as the lesions are purulent and continue to drain or carrier state continues.
Weier also sees an opportunity for pharmacists to ‘educate patients with risk factors (e.g immunocompromised patients etc) for certain infections on symptoms to look out for and strategies for reducing the risk of infection’.
Recognising infection in patients
S. aureus is most commonly responsible for skin infections and will likely present with redness, swelling, pain, heat and pus-filled lesions such as boils and abscesses.2
However, S. aureus can also infect joints, bones, blood, the gastrointestinal tract and other major organs, with symptoms varying based on the infection’s location in the body.
Sepsis, symptoms include rapid breathing, an elevated heart rate, fever, chills and disorientation.3
Dangers of infection
While boils and abscesses are often relatively mild infections and can be easily treated with drainage and appropriate antibiotics, invasive S. aureus infections can be more difficult to treat and can often be life-threatening. In fact, S. aureus bacteremia has an in-hospital mortality of 20-30%, a 2018 review reported.2,4
S. aureus can cause complications such as endocarditis (infection and inflammation of the heart’s inner lining) and septic thrombophlebitis (clot/venous thrombus). Increased microbial load and a decrease in the body’s ability to fight the infection, if left unchecked, can lead to organ failure.4
Sources of infection should always be identified to decrease rates of mortality. Persistent fever should be monitored and blood cultures sampled.4
Further complications arise when patients have methicillin-resistant S. aureus (MRSA), as the bacteria will not be susceptible to the penicillins normally used to treat MSSA. Instead, patients will need to be identified as soon as possible and treated with the appropriate antibiotic(s) (e.g. vancomycin, teicoplanin, daptomycin etc.) in order to clear the infection.4 Further information can be found in eTG and AMH.
Referring patients to seek medical help
According to Weier, ‘pharmacists should refer patients presenting with symptoms of bacterial infection requiring antibiotics to their doctor immediately,’ while also taking the opportunity to explain the role of antibiotics, knowing what to expect and when they should be used. Repeat prescriptions for an antibiotic should only be dispensed after clarifying clinical appropriateness, in line with PSA’s Choosing Wisely Recommendations.
‘Also, when presented with a prescription for an antibiotic, pharmacists should review the prescription to assess its appropriateness for the patient – including the correct antibiotic, dose, directions, and duration – and counsel patients on the role of antibiotics and their correct use,’ she said.
This is in line with the International Pharmaceutical Federation’s views, suggesting that the pharmacist’s role is to encourage responsible use of antibiotics to achieve optimal patient outcomes and prevent antibiotic resistance.5
Finally, ‘pharmacists should refer patients back to their doctor if there is no improvement or if symptoms worsen’, Weier explained.
-
- Imam N, Tempone S, Armstrong P, et al. Increased incidence of community-associated Staphylococcus aureus bloodstream infections in Victoria and Western Australia, 2011-2016, 2019. The Medical Journal of Australia. At: https://www.mja.com.au/journal/2019/210/2/increased-incidence-community-associated-staphylococcus-aureus-bloodstream
- Staphylococcus aureus infection, Queensland Government. 2017. At: http://conditions.health.qld.gov.au/HealthCondition/condition/14/33/132/staphylococcus-aureus-infection
- Staph infections: What you should know, Penn Medicine. 2018. At: https://www.pennmedicine.org/updates/blogs/health-and-wellness/2018/may/staph-infections
- Jung N, Rieg S. Essentials in the management of S. aureus bloodstream infection. 2018. Infection. At: https://www.ncbi.nlm.nih.gov/pubmed/29512028
- Fighting antimicrobial resistance, International Pharmaceutical Federation. 2015. At: https://www.fip.org/files/fip/publications/2015-11-Fighting-antimicrobial-resistance.pdf
[post_title] => The rise of community-associated golden staph infections
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]A medication that promises to alleviate symptoms of severe asthma is now listed on the Pharmaceutical Benefits Scheme (PBS) under Section 100, giving patients access to the potentially life-saving treatment.
There are 2.5 million Australians (10% of the population) estimated to be living with asthma, and while many patients are able to manage their condition, severe asthma continues to challenge some of them. It is estimated that up to 10% of patients with asthma may have severe asthma.1,2
Benralizumab (Fasenra) was developed to treat eosinophilic-driven asthma, a factor in some severe asthma cases. This condition occurs when there is an excess of eosinophils, a type of white blood cell, in the blood and airways which increase the severity of asthma symptoms as well as the number of flare-ups.3
According to the data from a small sample to validate the Asthma Control Test (Asthma Score), conducted by The National Asthma Council Australia, 89% of sufferers report daily wheezing, 56% report daily cough, and 39% report experiencing phlegm and shortness of breath every day.4
Patients with severe asthma who are unable to control their symptoms with inhalers alone, may rely on oral corticosteroids to assist in symptom management during acute flare-up.
Chronic or long-term oral corticosteroid use increases risk of systemic adverse effects which includes weight gain, diabetes, coronary heart disease, depression, osteoporosis and fractures.5
Benralizumab promises to alleviate symptoms by working ‘with the body’s immune system to reduce the number of eosinophils in the blood and lungs,’ the medicine’s parent company, AstraZeneca, said in a statement.
Two Phase III asthma studies (SIROCCO and CALIMA) and one oral corticosteroid (OCS)-sparing phase III study (ZONDA) found benralizumab as an add-on therapy significantly benefited patients over the age of 12 years with uncontrolled severe asthma.6-8 Benefits observed were improved lung function, reduced asthma symptom score, improved quality of life and reduced number of asthma exacerbations.
‘Fasenra demonstrated significant reductions in annual asthma exacerbation rates of 51% and 28% versus placebo, when 8-weekly dosing, following the first 3 doses administered 4-weekly given as add-on maintenance treatment in patients with blood eosinophil count ≥300 cells,’ AstraZeneca’s statement said.
Even so, researchers note that the medicine is not free from adverse effects, which can include headaches, sore throats, fever/high temperature and injection site reactions – although these are considerably less severe than the long-term impacts of cortisol.9
Benralizumab’s inclusion in the PBS promises to greatly increase the number of people able to access the medicine.
‘Around 670 patients a year will now be able to access this medicine, which would cost more than $21,000 per year of treatment without the PBS subsidy. When this medicine is subsidised under the PBS, patients will pay $39.50 per script or just $6.40 a script for concessional patients,’ Health Minister Greg Hunt said in a statement.
The move has been praised by the National Asthma Council Australia.
‘The day-to-day burden of living with severe asthma can be considerable, including side-effects from frequent oral corticosteroid use, and new treatments provide additional options those affected,’ Siobhan Brophy, the Council’s Chief Executive Officer, said.
References:
- Chung KF, Wenzel SE, Brozek JL, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J 2014; 43: 343–73
- Hekking PP, et al. The prevalence of severe refractory asthma. J Allergy Clin Immunol 2015;135(4):896–902.
- Australian Institute of Health and Welfare. Asthma web report. Available from: https://www.aihw.gov.au/reports/asthma-other-chronic-respiratory-conditions/asthma/data Date accessed: August 2018.
- Nelsen LM, Kimel M, Murray LT, et al. Qualitative evaluation of the St George's Respiratory Questionnaire in patients with severe asthma. Respir Med 2017. Epub 2017 February 2018. At: https://www.ncbi.nlm.nih.gov/pubmed/28427547
- Lefebrve P, et al. Acute and chronic systemic corticosteroid–related complications in patients with severe asthma. J Allergy Clin Immunol. 2015;136: 1488–95.
- FitzGerald JM, et al. Benralizumab, an anti-interleukin-5 receptor α monoclonal antibody, as add-on treatment for patients with severe, uncontrolled, eosinophilic asthma (CALIMA): a randomised, doubleblind, placebo-controlled phase 3 trial. Lancet 2016;388(10056):2128–41.
- Bleecker ER, et al. Efficacy and safety of benralizumab for patients with severe asthma uncontrolled with highdosage inhaled corticosteroids and long-acting β2-agonists (SIROCCO): a randomised, multicentre, placebocontrolled phase 3 trial. Lancet 2016;388(10056):2115–27.
- Nair P, et al. Oral glucocorticoid-sparing effect of benralizumab in severe asthma. N Engl J Med 2017;376(25):2448– 58.
- Fasenra® (benralizumab) Product Information. August 2018.
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Psilocybin, a psychoactive compound found in ‘magic mushrooms’, is being trialled in the treatment of terminally ill patients to reduce symptoms of depression and anxiety at Melbourne’s St Vincent’s Hospital.
The treatment has proven to be successful in several international clinical trials, including US-based John Hopkins University in 2016 and Imperial College in London in 2017.
The St Vincent’s trial, headed by clinical psychologist Dr Margaret Ross, aims to provide relief for terminally ill patients – many of whom suffer from underdiagnosed mental health problems.
Major depression in terminally ill patients has been found to be common, ranging from 25% to 77%.1
While depression can diminish quality of life for patients, it has also been associated with a further decline in survival rate and treatment adherence in terminally ill cancer patients. A 2013 study found that about a third of patients with non-small cell lung cancer were suffering from depression. Those patients showed a median overall survival rate of 6.8 months, compared to that in non-depressed patients whose median survival rate was 14 months.2
Researchers from the John Hopkins University trial reported that the compound psilocybin is particularly effective at altering damaging thought processes.3
Serotonergic hallucinogens, including psilocybin (psilocin) and lysergic acid diethylamide (LSD) and mescaline, are a structurally diverse group of compounds that are 5-HT2A receptor agonists. They produce a unique profile of changes in thoughts, perceptions, and emotions.3,4,5
The John Hopkins trial administered psilocybin to cancer patients with a life-threatening diagnosis. Varying doses of psilocybin were given over a period of nine months, with five weeks between sessions. The study found that patients who received high doses of psilocybin (22 or 30 mg) reported decreases in symptoms of depression and anxiety as well as increased quality of life and optimism. Patient reports were echoed by psychiatrists who observed similar results.3
Furthermore, these changes were sustained with 80% of participants continuing to show ‘significant’ decreases in symptoms of depression and anxiety at a six-month follow-up.
Similarly, the Imperial College study found patients with severe depression experienced decreased symptoms after they were given two doses of psilocybin, 10 mg and 25 mg respectively, one week apart.3
fMRI scans revealed observable changes in their cognitive functioning.
‘Whole-brain analyses revealed post-treatment decreases in cerebral blood flow (CBF) in the temporal cortex, including the amygdala. Decreased amygdala CBF correlated with reduced depressive symptoms,’ researchers said in the subsequent paper.6
The St Vincent’s trial will commence in April, when a group of 30 patients will be given 25 mg of synthetic psilocybin alongside psychotherapy sessions.
‘We don't want it to be underwhelming, we don't want it to be overwhelming,’ Dr Ross said. ‘We know that higher doses are associated with anxiety but if it's too low a dose you're not really going to experience that psychological shift in the thinking that we're really looking for.’
While more trials need to be conducted, the positive results suggest that with more research, psilocybin could be offered routinely for relief of anxiety and depression in terminally ill patients.
References:
- Fine RL. Depression, anxiety, and delirium in the terminally ill patient. Proc (Bayl Univ Med Cent). 2001;14(2):130-3. At: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1291326/
- Arrieta Ó, Angulo LP, Núñez-Valencia C et al. Association of depression and anxiety on quality of life, treatment adherence, and prognosis in patients with advanced non-small cell lung cancer. Ann Surg Oncol 2013; 20: 1941-1948. https://doi.org/10.1245/s10434-012-2793-5
- Griffiths, R. R., Johnson, M. W., Carducci, M. A., Umbricht, A., Richards, W. A., Richards, B. D. Klinedinst, M. A. (2016). Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial. Journal of Psychopharmacology, 30(12), 1181–1197. https://journals.sagepub.com/doi/full/10.1177/0269881116675513#_i37
- Halberstadt AL. Recent advances in the neuropsychopharmacology of serotonergic hallucinogens. Behav Brain Res 2015; 277: 99–120. At: https://www.sciencedirect.com/science/article/pii/S0166432814004562?via%3Dihub
- Nichols DE. Psychedelics. Pharmacol Rev 2016; 68(2): 264-355 http://pharmrev.aspetjournals.org/content/68/2/264
- Carhart-Harris RL, RosemanL et al. Psilocybin for treatment-resistant depression: fMRI-measured brain mechanisms. Scientific Reports 2017. Epub 2017 October 13: https://www.nature.com/articles/s41598-017-13282-7#article-info
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[post_title] => How psilocybin can help terminally ill patients
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Lithium is an invaluable and lifesaving treatment for a range of psychiatric disorders, but its origins lie in patent medicine and the pioneering work of an Australian doctor.
People have been flocking to hot springs of lithium-heavy water for their perceived health benefits for millennia, but it was not until the second half of the 19th century that modern medicine put the element to use.
In 1859, an English physician described the use of lithium carbonate to treat gout by solubilising uric acid in the blood, as well as treating ‘brain gout’, or mental upset.
Over the next few decades, some US and Danish doctors reported that lithium carbonate could calm patients with ‘general nervousness’, mania or depression.1 However, its use in medicine remained rare, with most use instead in food products.
Until 1950, popular soft drink 7-Up2 contained lithium citrate and even beer3 was brewed with lithium-heavy water and promoted for its mood-enhancing abilities.
However, both the real and perceived health benefits of lithium were overshadowed when lithium was prescribed to patients with heart disease as a replacement for salt.4 The resulting overdoses and deaths led to the US banning lithium as an additive in 1950.
Elemental reactions
The exact action of lithium to manage mood remains unclear, though it is clear the molecule acts on the brain on multiple levels. It offers neuroprotective and neuroproliferative effects on brain structure, as well as plasticity.5 It also modulates neurotransmission, inhibiting excitatory neurotransmitters such as dopamine and glutamate,6 and promoting GABA-mediated neurotransmission.6
In 1949 in a Melbourne mental hospital for World War II veterans, Dr John Cade theorised the mania he witnessed in his patients might be linked to the high levels of uric acid he detected in their urine, in line with the 19th century theories about gout.
He experimented with injecting the urine collected from patients demonstrating mania into guinea pigs, which subsequently showed signs of agitation.1 Guinea pigs that were subsequently administered lithium following the urine injections rapidly calmed.
Dr Cade then experimented on himself and when he showed no ill effects after a dose of lithium, he started a trial on 10 patients.7 His trial showed significant positive results, but a mixture of poor timing (given lithium’s then-recent banning from food) and the then-obscurity of the Medical Journal of Australia where his article was published meant little acknowledgment.¹
Instead, Danish research published in 1954 detailing the results of a randomised trial kick-started lithium’s renaissance.1 By 1970, lithium had been widely approved for treating bipolar disorder and other mental health issues.1
Thinking big
In recent years, some studies have found a correlation between high levels of naturally occurring lithium in tap water and lower rates of suicide and mental health problems.2
However, these studies have had many limitations and there is no reliable evidence that says lithium addition to water or food would provide any health benefits.5
References
- Shorter E. The History of Lithium Therapy. Bipolar Disorders. 2009;11.
- Fels A. Should We All Take A Bit of Lithium? The New York Times. 2014 September 13. At: https://www.nytimes.com/2014/09/14/opinion/sunday/should-we-all-take-a-bit-of-lithium.html?_r=0.
- Shepherd R. Lithia Beer returns to West Bend, expands across Wisconsin. Isthmus. At: https://isthmus.com/food-drink/beer/lithia-beer-returns-to-west-bend-expands-across-wisconsin/.
- Hardman JG. Limbird PB. Gilman AG. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 10th Ed. New York. McGraw-Hill. 2001:507.
- Sachdev P. Let’s not put lithium in the drinking water just yet. Medical Republic. 2017 November 21. At: http://medicalrepublic.com.au/lets-not-put-lithium-drinking-water-just-yet/11998.
- Brunton L. Chabner B. Knollman B. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 12th Ed. New York. McGraw-Hill. 2010:445.
- Mitchell PB. Hadzi-Pavlovic D. Lithium treatment for bipolar disorder. [Reproduced from The Medical Journal of Australia]. Bulletin of the World Health Organization, 2000;78(4):515.
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]With community pharmacies feeling the squeeze, there has never been a more important time to provide continuity of care by building patient loyalty.
Self-serve checkouts, online stores and banking through phone apps: these days there’s often little need to talk to a person when making day-to-day purchases or transactions.
Pharmacy, however, remains one of the last bastions of good ol’ fashioned human connection. ‘Patients are looking for connection,’ said Capital Chemist’s Elise Apolloni MPS. ‘So often when people engage with services or businesses there’s nothing magical about the interaction.’
Fortunately, pharmacists can use these increasingly rare personal interactions to provide patient-centred service and foster continuity of care, bringing positive patient outcomes.
What customers want
The strength of a patient’s loyalty is primarily driven by the behaviour of the pharmacist treating them – not the price of the medication or the location of the pharmacy. And there’s no shortage of studies that reach this conclusion.
A 2013 Griffith University study found that patient-centred care, such as providing individualised medication counselling, continuity of care, development of relationships and respectful advice, emerged as the most important attribute when it came to retention of regular community pharmacy users.
Additionally, a US study published in the Journal of the American Pharmacists Association found that a pharmacist’s patient-centred communication style had a major influence on whether a patient would return to the pharmacy.
Associate Professor in Marketing at the QUT Business School Dr Gary Mortimer said while many customers seek pharmacies with lower prices, consumers are turning to pharmacy for healthcare solutions and triage prior to consulting their GP.
‘We see this mostly in consumers seeking access to flu jabs and health check-ups, possibly as a result of patients looking to avoid the high costs of seeing a GP for minor healthcare matters,’ said Dr Mortimer, who is currently working on the research topic ‘Clinical trials or pharmacist advice: The influence on health consumers’ perceptions of trust and decision making’.
PSA NSW Branch Vice President Krysti-Lee Rigby MPS said that consumers also wanted value. But that does not necessarily mean being the cheapest.
‘Value can come from having engaged and competent staff, service that meets or exceeds expectations, the pharmacist being accessible, being able to trust their pharmacist, and of course convenience,’ Ms Rigby said.
Holistic care benefits for patients
The relationship between pharmacist and patient should not be the transactional kind of relationship you have at your local convenience store, Dr Mortimer said.
‘Better patient healthcare outcomes result from ongoing, regular contact based on continuity of service and advice,’ he said.
Ms Apolloni said this was particularly apparent in the chronic disease space, where often a one visit solution wasn’t possible.
‘If a patient is not dazzled by your pharmacy and team, they may not return and you’ve missed an opportunity to build a therapeutic relationship with that person and contribute positively to their healthcare,’ Ms Apolloni said.
‘We’ve laughed with patients – and cried with them. I can’t see how that kind of connection and holistic care can be anything but great for the patient, the job satisfaction of the pharmacist, and the wider healthcare system.’
Ms Rigby added: ‘By building trust with patients, we can increase compliance of medications, create better health outcomes by educating patients on how to better manage their medications, and empower patients to take a proactive approach to their health.’
Ensuring continuity of care
Dr Mortimer suggests pharmacies take a five-stage approach to maximising holistic care opportunities, starting with establishing integrity.
‘Pharmacy must consistently deliver open and honest information across all touch points with consumers. Integrity cultivates trust between the patient and the pharmacy retailer,’ he said.
Pharmacists and assistants then need to provide expert advice around purchasing decisions.
‘Consumers have access to significant amounts of information today,’ Dr Mortimer said. ‘If a pharmacy assistant delivers inaccurate advice, or ill-informed advice that is not consistent, the patient-pharmacist trust relationship is damaged.’
The third ingredient for maximising holistic care opportunities is ensuring the security of personal data, said Dr Mortimer.
And fourth, pharmacies need to demonstrate competence.
‘Trust and continuity of care decrease when the consumer perceives that the pharmacy is incompetent in its dealings with them,’ he said.
‘For example, if the pharmacy is unable to perform transactions efficiently, loses prescriptions, has poor service, fails to offer a lower-priced generic alternatives, or fails to keep promises.’
Finally, and most importantly, said Dr Mortimer, the pharmacy must exhibit benevolence.
‘When a pharmacy demonstrates or promotes actions that indicate the support of the welfare of others over financial outcomes, consumers develop stronger levels of trust,’ Dr Mortimer said. ‘Benevolence is di cult to cultivate, as benevolent acts must be purely altruistic.’
Ms Apolloni added that being genuinely present and interested in a patient was another important precondition for holistic care.
‘We have many competing priorities, but it takes very little extra time to really listen and repeat back key pieces of information,’ she said.
Digital solutions
One way pharmacists can deliver more holistic care and maximise time with patients is by harnessing the power of technology.
Robert Read is CEO of MedAdvisor, a mobile and web app that manages all aspects of prescription medication use.
One of the advantages of this type of digital solution, said Mr Read, was that it prompted patients when it was time to re-order their medication. ‘And 50% of orders from the app go into the pharmacy outside of business hours,’ he said.
‘A pharmacy can then process those scripts before the doors even open so that when the patient comes in they can spend quality time counselling them.’
‘It’s really busy at the dispensary and pharmacists are doing all this processing work and not spending time talking to the patient about all the various things they might be eligible for,’ Mr Read said.
‘What MedAdvisor does is identify all the eligible consumers, and then helps you invite them to services they’re eligible for.’
Mr Read said their research showed more than 90% of patients stayed loyal to the pharmacy that signed them up to the app.
‘Not only does it play a big role in driving loyalty, but it improves a patient’s adherence to their medication,‘ he said.
Another way pharmacists are spending more time in front of patients is by purchasing an automated dispensing cabinet.
Pharmacy owner and technology consultant Robert Sztar MPS said the cabinets could free up your staff to deliver high-quality services, while the dispenser tackles the more routine tasks.
Avoiding poor patient service
Making patients aware of additional services they’re eligible for is an important part of providing holistic care, but Dr Mortimer said pharmacists need to be aware that not all up-sells are appreciated – especially product-based ones.
‘It frustrates consumers. They’ll pop in to collect a prescription and be up-sold OTC products, cosmetics or skincare products,’ he said.
‘While revenue and the bottom line is important, pushing sales is a short-term solution. If a consumer genuinely feels a pharmacy is taking the time to get to know them, really understanding their needs to develop healthcare solutions, they will keep coming back.’
Take a stand
While consumers do not necessarily become loyal to a particular brand or pharmacy, they do become loyal to what the business stands for, Ms Rigby suggested.
‘For community pharmacies to continue to be viable, they need to have clear missions and values, and ensure their staff align with them,’ she said. ‘Pharmacies need to show consumers what they stand for, besides making money.’
Ways to foster patient loyalty
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]A group of Melbourne pharmacists have developed a data aggregation and visualisation platform used for strengthening health supply chains, disaster response and improving health services throughout the South Pacific.
In June, the project won the People’s Prize at the the Australian Public Service Innovation Awards in Canberra.
The tool builds a map of every health facility within the countries that are participating in the project. Currently, six countries have partnered (Solomon Islands, Vanuatu, Kiribati, Cook Islands, Tokelau and Tonga) and that number is expected to grow further in 2018, with potential applications for Australia.
‘Kiribati has seen a 21% increase in the availability of medicines at the primary healthcare level since September 2017, which is a terrific result in a difficult geographic area,’ project member Kahlinda Mahoney said.
The project is named after Tupaia, a legendary Pacific Island navigator who joined Captain Cook’s crew as he sailed through Tahiti in 1769.
Using an app called Tupaia MediTrak to collect information from public health facilities, the tool syncs this information with data pulled from the pharmacy software used in each country – mSupply, used in about 30 countries around the world.
Tupaia also pulls data from the software used for disease tracking in many countries in the region (using open-source health information software DHIS2) and it presents this information in preconfigured dashboards and map overlays on a public website.
Password-enabled access allows higher-level users to see more data but the public can see the location of facilities, the services they provide and their opening hours. So far, the project has mapped all 600 facilities across the six partner countries.
‘Tupaia can be used for a huge range of programs. For example, it provides a map of the fridges in all the health clinics in Solomon Islands, showing whether they are working or not. This can be used by the national cold chain manager there to help plan their annual maintenance schedule,’ mapping team lead Susie Lake said.
‘The EPI program manager in Vanuatu might use it to map the availability of vaccines and pregnant mums might look up the location of the nearest facility that can handle emergency obstetric situations.’
The project is strongly focused on improving access to essential medicines. In Kiribati, Tupaia worked in partnership with mSupply to roll-out a mobile version of the widely used pharmacy software.
Ms Mahoney said the current version of mSupply Mobile was launched in 2016 and Australia’s Department of Foreign Affairs and Trade (DFAT) paid for it to be released ‘open-source’ in 2017.
‘This meant countries were able to roll it out more quickly and more widely than was possible before, as there are no longer licensing fees attached to it,’ she said.
‘We started this project to strengthen health supply chains in the Pacific, to make sure that medicines were getting to the right people at the right time – but it has grown to include disaster response, disease tracking, infrastructure, HR – it’s exciting but we’re always keen to do more,’ Ms Lake said.
‘There may be application here in Australia, particularly with recent commentary and events around medicines and vaccine stock-outs but we’ll just have to wait and see.’
Now 12 months old, the Tupaia project has been funded by the innovationXchange, part of the aid program at Australia’s DFAT. The focus on essential medicines in the region comes at a time when antimicrobial resistance, counterfeit medicines and medicines shortages are being recognised as serious regional health threats.
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[post_title] => Navigating South Pacific health care on a sea of data
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Pharmacist-led health interventions in Aboriginal communities came under the spotlight at PSA18 in Sydney yesterday, as delegates got early insight into some of the Pharmacy Trial Program (PTP) studies currently underway.
The 6CPA allocated $50 million to fund the program, aimed at gathering evidence to expand the role of pharmacy in delivering a wider range of primary healthcare services, with a particular focus on Aboriginal and Torres Strait Islander populations.
One trial currently in start-up is the Indigenous Medication Review Service Feasibility Study (IMeRSe), led by Griffith University’s Professor Amanda Wheeler.
‘The overall goal is to improve medication management and health and wellbeing for Aboriginal and Torres Strait Islander people through strengths-based collaborative and culturally appropriate pharmacy service,’ she said.
‘We know that medication reviews are funded but the research told us that for Indigenous people they have problems accessing medication reviews for many reasons. One of those is that talking to a pharmacist at a pharmacy or in their own home may not be a culturally safe space.’
‘That review service doesn’t involve anyone from the Aboriginal Health Service (AHS) – their trusted person who they work with and knows them so well. Only a GP may refer someone for a Home Medicines Review and that process may take several weeks.
‘They also tend to be a one-off and there is no ability for the pharmacist to check in in a funded way and see how things are going or tackle complex problems over a few months. There is also a lack of integration between pharmacists and Aboriginal Health Services.’
IMeRSe will involve up to 23 pharmacies across Queensland, the Northern Territory and New South Wales, and up to 540 AHS patients.
‘It’s a pharmacy service to promote health and wellbeing by optimising an individual’s medication management through a culturally responsive medication review service,’ Prof Wheeler said.
‘It will be delivered by community pharmacists but they are going to be integrated with Aboriginal Health Services as part of holistic care. We want to enhance existing services.’
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[post_title] => Greater pharmacist role in Aboriginal health trialled
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]The same day Jessica Chapman-Goetz MPS became a registered pharmacist in late 2015 she received a diagnosis for breast cancer. But she wasn’t about to step away from the job she loved, and has come to understand the integral role that pharmacists can play in providing supportive care for oncology patients.
How did you manage your treatment while working as an early career pharmacist?
It certainly wasn’t easy, but I made a decision that I wanted to try and limit the impact that breast cancer was going to have on my life. So I would organise treatment on a Friday afternoon, try to be back at work (at TerryWhite Chemmart Grange, in South Australia) by Tuesday, and then I was able to work full-time for about two and a half weeks before the next round of treatment. It was important for my mental health to work during treatment and be surrounded by my co-workers and beautiful community.
In what ways did your personal experience inform how you approach oncology care with patients?
As a patient I was observing what information was given at different stages and who provided it. I noticed that quite a lot was lacking. I also noticed that a lot of women were using online breast cancer forums to ask about the management of common chemotherapy adverse effects, and often the answers were not evidence-based. That prompted me to investigate how pharmacists feel about providing supportive care in the community for oncology patients.
I found that a lot of community pharmacists feel a bit apprehensive about it because they’re not sure exactly what treatment the person is on, or what it’s for. They more commonly refer to a GP because they feel more comfortable doing so than, say, managing basic mucositis themselves.
You said you noticed that quite a lot was lacking in terms of information. How can pharmacists help fill the gap?
Pharmacists can help make sure patients are getting information as they go through their journey, rather than all at once at the time of diagnosis, which is what commonly happens. Along the way, pharmacists can provide support and prompts by saying, ‘Okay, how is your mental health going? Have you thought about calling Cancer Council for services there? How are you going with side effects?’ Also, check what medicine information the oncology team has given the patient and, if there are gaps, offer to provide education from resources like EviQ (www.eviq.org.au). I didn’t receive anything from my oncology unit in terms of printed medication lists, and I know many other patients haven’t either.
What role could pharmacists be playing in assisting with treatment?
The biggest gap would be managing what would be termed ‘minor’ adverse effects from chemotherapy, whether it’s oral or intravenous. Often the oncology patient will feel like it’s too minor to bother the oncologist, or they’ll call the oncology nurse which takes them away from caring for inpatients. But often these minor adverse effects are something a pharmacist could really assist with.
If patients aren’t managing side effects such as small mouth ulcers, they can progress to the point where they can’t eat. And if you’re having multiple side effects at one time it really doesn’t take much for you to feel like everything’s too much. So pharmacists can make a big difference.
You’re now working as a hospital pharmacist at Flinders Medical Centre in Adelaide, but you’re continuing to explore ways of improving care for oncology patients. How?
I’ve done the Cancer Pharmacists Group Foundation Course with the Clinical Oncology Society of Australia (COSA). I could do stage two, which would make it easier for me to work in hospital oncology, but at the moment I don’t know that I want to do it full-time – it’s still a little bit close to home.
Instead I’m really enjoying empowering other pharmacists to provide supportive oncology care. I started off with a presentation here in Adelaide just with some peers. I’ve also spoken in Whyalla, Alice Springs and Darwin, and I’m going to be presenting at the TerryWhite Chemmart masterclass in April. I’ve also established connections with the Cancer Council to increase pharmacist involvement in allied healthcare for oncology patients.
Photography: Simon Casson [/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]A key tenet of PSA’s strategic intent is ensuring pharmacists are rewarded and recognised to reflect our high levels of training, our expertise and our contribution to the health system.
I know many pharmacists are greatly dissatisfied with how their efforts in improving patient care are currently recognised. Role fulfilment and acknowledgment of our integral place within the healthcare team are important, but many believe pharmacist remuneration is key to increasing professional satisfaction.
The funding frameworks used to remunerate pharmacist practice are largely governed by the Community Pharmacy Agreement (CPA). If individual pharmacist remuneration is to increase, we must seek an improvement in the application of the funding within the CPA to ensure a services or consultation model of pharmacy practice is worthy of genuine commitment by the community pharmacy sector.
But the CPA should not be seen as the only funding source; we must also look to diversify. The Medicare Benefits Schedule (MBS) presents an obvious funding pool which currently not only finances the services delivered by medical practitioners but an array of nursing and allied health practitioners. Many PSA members have been perplexed and disappointed that pharmacists have not been included through this mechanism. Given the funding freezes and relative low base of reimbursement, the MBS is no silver bullet. But it is a logical adjunct to the CPA.
The current review of the MBS provides a unique opportunity to drive this agenda. If we, as a profession, are to make claims of remuneration for services under the MBS, then we need to be specific about what this model might look like, what services should be funded, and how the health system will benefit from this investment. PSA has written to the MBS Review Taskforce, again calling for inclusion of pharmacists as eligible allied health professionals to access MBS items as part of Team Care Arrangements within Chronic Disease Management (CDM) items.
We remain highly concerned that pharmacists continue to be the only AHPRA-registered allied health professionals who are not eligible to provide allied health services through the CDM services. This exclusion causes major problems with integration and collaboration in primary care. Given the central role of medicines in the treatment of these patients, this exclusion doesn’t make sense, with the potential for sub-optimal health outcomes.
Inclusion of pharmacists (irrespective of setting) as eligible allied health professionals would have minimal, if any, impact on the budget for those MBS items, as GPs can only refer up to a maximum of five items within a 12-month period. But the inclusion of pharmacists as eligible allied health professionals would enable greater flexibility for the GP to engage with pharmacists to support patients with their chronic disease management.
Let me be clear: PSA is strongly advocating for inclusion of pharmacists on the MBS. It has been one of our major priorities in 2018, and continues to be so. PSA is highly concerned that pharmacists continue to be the only AHPRA-registered allied health professionals who are not eligible.
DR CHRIS FREEMAN FPS BPharm, GDipClinPharm, PhD, AACPA, AdvPracPharm, BCACP, MAICD [/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row]
[post_title] => From the President: Include pharmacists on the Medicare Benefits Schedule
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[post_content] => The new President of the Pharmaceutical Society of Australia (PSA) is Dr Chris Freeman – currently Clinical Senior Lecturer and the Director of the Centre for Optimising Pharmacy Practice-based Excellence in Research (COPPER) at the University of Queensland and Consultant Practice Pharmacist at Camp Hill Healthcare in Brisbane.
Chris’ professional contribution began in 2009 when he joined the PSA’s Early Career Pharmacist working group of the Queensland Branch – he was elected Chair soon after. By 2016 he had been elected National Vice President of PSA with significant contributions to the policy, advocacy and innovation at the organisation. His full biography is available here.
Australian Pharmacist sat down for a chat soon after his appointment.
AP: Congratulations on your new role, Chris. What can you say about those shoes you’re stepping into?
CF: It's been an absolute honour to serve as Shane Jackson's Vice President. I've not come across anyone who has invested his level of energy, enthusiasm and commitment – not only to the PSA but to the profession more widely. He has been a passionate advocate for moving the profession forward on a very positive pathway, and he's certainly set the platform for me. I hope I’m able to continue his great work.
AP: The trajectory of your career path seems to have been aimed towards this kind of leadership role.
CF: An opportunity came up to join the PSA Queensland Branch’s ECP working group and I thought I had something to offer. I felt compelled to try and do something about the issues that pharmacists were facing, rather than sitting on the sidelines. Over time, I found that I also wanted to contribute to the governance of the PSA given my interest in policy and innovation. I love my profession and want to see pharmacists respected and rewarded for the integral role we have in the health system. This continues to drive me today and stepping into the Presidency of the PSA provides me with an opportunity to do just that.
AP: Do you still plan to maintain your role as a consultant pharmacist in a general practice setting?
CF: Yes, the body of work that I've been focused on recently has been trying to further develop collaborative practice models and the evidence to support those practice models. I've tried to do that by example, not just within my own research work, but also in my own clinical practice. I plan to maintain my clinical activity moving forward – I think it provides a great touchpoint with consumers and a grounding so that I can have an understanding of the things that are going on within the profession. And it's an absolute pleasure to work alongside GPs and other allied health professionals who genuinely believe in interdisciplinary care, where they see a genuine role for pharmacists and community pharmacy in the care of patients.
AP: That is a big part of the PSA’s vision for the profession, and will be headlined in the Pharmacists In 2023 launch in March. How would you summarise that vision for the future of pharmacy in Australia?
CF: I want to see pharmacists practising to their full scope, filling genuine patient need, and this drives everything that we've done from the PSA point of view. The underlying philosophy is that whenever or wherever a medicine is being used or considered, a pharmacist should be involved to ensure the quality use of that medicine is being considered. This ensures that pharmacists are regarded by consumers, the public, by government and other health professionals as integral members of the healthcare team. Sometimes pharmacists are seen as nice to have but not a necessity. Pharmacists In 2023 will provide the platform from which we can say we are a necessity in the healthcare team. Patient outcomes are improved if pharmacists are provided with opportunities to meaningfully engage with their care and we can do this by delivering that care to our full scope of practice. Pharmacists In 2023 provides the action items – not only for the PSA, but for the profession more widely, to achieve that goal.
AP: What are the impediments to achieving these goals?
CF: We have to facilitate pharmacists to practise to the best of their ability, and that's done through professional support and tools led by professional organisations such as the PSA. It's through setting standards and enabling quality of practice. It’s also ensuring that we've got the right funding framework to allow pharmacists to meaningfully engage in a model of practice where patients are going to get the most out of the pharmacist’s care. And that might include things like external funding from Primary Health Networks, the Medicare Benefits Schedule (MBS) or it might be related to how the Community Pharmacy Agreement is structured.
AP: A bit about yourself. How do you achieve work/life balance?
CF: I've got a really young family – a six and a four-year-old. So a lot of my spare time is focused on the children and their activities. I love spending time at home here in Brisbane with them and my wife, and I try to make the most out of that. I've tried to manoeuvre things around my clinical practice as well as my practice at the university to really allow me to still dedicate genuine family time.
AP: And if you have any time to yourself?
CF: Exercise is my release. When I do get a bit of spare time I'm either out at the gym or on the bike. It gives me some thinking time, too, and is really important for maintaining the energy levels. I'm really focused on trying to maintain that energy in my role as President of the PSA.
[post_title] => Meet PSA's new President
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[post_content] => What happens when emotional pain becomes physical? Dr Anchita Karmakar and clinical pharmacist and PainWISE Director Joyce McSwan explore this concept.
When Dr Karmakar lost her daughter, abducted by the child’s father and taken to a foreign country, it began a decade-long quest for justice.
‘As a parent you never imagine that someday, you will not be able to see, hug and love your beautiful children,’ she said. ‘You assume that you will watch your children grow up, go through their milestones and ensure that they have the best shot in life with the support and love you provide for them.’
Dr Karmakar and Ms McSwan have a close working relationship, with Dr Karmakar often referring patients to PainWISE. But unbeknownst to Ms McSwan, Dr Karmakar was suffering from pain of her own.
At one point in her journey, Dr Karmakar began to experience tangible, debilitating physical pain in her hand. After having a series of tests including X-Rays for conditions such as carpal tunnel syndrome, no underlying physical causes for the pain were unearthed.
‘We were rather perplexed by her pain condition, because it wasn’t caused by anything physical as such. It turned out that it was actually emotional pain that turned into physical pain,' Ms McSwan said.
How the pain manifests
According to Ms McSwan, the progression of this type of pain is insidious. ‘People will complain of a pain of some kind – it could be whole body or limited to a certain limb,’ she said.
‘It has to do with how our brain expresses pain and the regions in the brain where this occurs and more importantly how our brain is massively connected with the rest of the body as a single entity. What has to be acknowledged here is that there are direct neural connections between all our body systems and each feedback and modulate the other. Whether we allow ourselves to be aware of it or not, the psychobiological connection is there and ongoing. And the expression of pain is real.
‘Pain is truly very complex. The neural, blood, and immune pathways between brain and body are tagged with body location information in the somatosensory part of our brain. The involvement of our communication pathways of the spinal cord, brain stem and thalamus, continues to add layers of complexities until the pain experience becomes conscious and grabs our attention. Our nervous system is a true marvel,’ Ms McSwan said.
‘Pain is protective for our survival so this alert can maladapt to stay on high alert. The nervous system, brain and body is just doing the job it is designed to do. And what we have to do is acknowledge that it is there, feel the pain (even if it is unpleasant) and seek treatment supportively to be able to help our system to modulate back again. There are many techniques these days to help with that.’
Ms McSwan said that the typical investigative routes of pain, such as MRIs and X-rays, will not reveal the underlying cause. She said it’s imperative that investigation extends beyond these limited methods.
‘We have to talk to the patients and look at the pain in a broader context, such as finding out when it began and some history of what kind of things were happening around the time the pain response started.
‘In Dr Karmakar’s case, we couldn’t see anything in the conventional tests, but the pain was incredibly real. On the hand she had the pain in, she used to wear a ring associated with her daughter. So, the emotional pain was expressed in that hand, almost to the finger that she wore it on,’ Ms McSwan said.
Once they worked out that it was emotional pain, the underlying trauma needed to be dealt with through therapy. Dr Karmakar’s recovery is ongoing, but she has healed through writing the book – and proven that despite the distress and despair she experienced, she could use the pain for greater good. She hopes it will help others who are faced with emotional pain that presents physically to be validated, acknowledged and assisted without judgement, Ms McSwan said.
Working together
Ms McSwan said that it’s important for doctors and physicians to collaborate through patients, and that in her experience, doctors appreciate the support in their understanding of pharmacology and pain management. It is simply impossible to manage such complex care needs on their own.
‘If they know your intention of care, they value that support. It’s vital to communicate – but it takes an investment of time and effort to cultivate these relationships,’ she said.
It all comes down to picking up the phone and figuring out the best way to communicate in order to express a concern, Ms McSwan said. When faced with a patient that has complex care needs, she recommended asking them who their doctor is so everyone involved in their care can be on the same page and can express any concerns. The initial effort expended saves time in the long run.
It’s equally important to bear in mind that pain is subjective, and that’s it’s vital to listen to patients, she said.
‘There are some good assessments that we as pharmacists can do – for example, asking patients about daily function, their barriers and their limitations. Before long, you will get a good idea of how pain is affecting their lives. If they say they have been screened and nothing indicates a reason for the physical pain, that's when it’s time to help them unpack some of their thoughts and emotions about the pain experience.’
Assessing the ‘yellow flags’ will highlight some important aspects of the patient’s beliefs about their pain. Catastrophisation or rumination, for example, will slow down healing process, Ms McSwan said.
She also said that it’s important not to judge, but to be empathetic, and recommended finding a psychologist that they can collaborate with and link the patient to. Patients who are taking analgesics for their physical pain will achieve so much more when it is combined with emotional support. Through the rapport pharmacists have with their patients, they can really help to facilitate the patient’s confidence to engage with this support.
‘Being able to use the right language to help the patient understand their pain is vital. Rather than saying, “I think you need to see a psychologist for your pain”, which can send the wrong message that you think their pain is in their head, perhaps let them know that the way they think about their pain can affect how they experience their pain. A psychologist can teach them some helpful tools on how to influence this.’
For further information on pain management, pharmacists can refer to PSA’s Chronic Pain MedsCheck CPD modules (Identifying patients and Using a chronic pain MedsCheck).
Joyce McSwan and Anchita Karmakar have authored the book, ‘With or Without your Smile’.
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Ravi Sharma’s credentials in pharmacy are formidable. Recently appointed the Royal Pharmaceutical Society’s (RPS’s) director for England, he was also National Clinical Lead for Clinical Pharmacy and Genomics for the National Health Service (NHS) while holding several honouree and advisory positions.
His key role has been focussed on the development of integrated/collaborative and innovative roles for pharmacists. He has published several articles in reputable journals and is involved in several research projects around the impact of clinical pharmacy within primary care.
He was recently invited to Australia on a speaking tour by PSA to share his insights, research and inspiration. Before his departure, Australian Pharmacist sat down with him to discover his impressions of Australian pharmacy – and what we need to do to catch up.
You were here in 2015 on a speaking tour. What changes are you noticing in the pharmacy landscape in Australia between then and now?
I’m really seeing some traction around integration and collaborative working. I’ve had some very interesting days catching up with internal and external healthcare stakeholders. I think there is now more open dialogue between the PSA and various healthcare organisations on the role and the clinical contributions that pharmacists can make being part of collaborative and integrated multidisciplinary teams – utilising the pharmacist’s expertise in medicines to help improve patient care and safety, and ensuring people get the best out of their medicines.
Integrated care and collaborative care are what I’m truly passionate about, and I feel that here in Australia it’s starting to be acknowledged that there is evidence out there. We’re not here in a silo, we’re here to work collaboratively as a team using pharmacists’ expertise. These teams will drive improvements in the healthcare system and most importantly patient quality of life.
You appear to be leading the way in the UK in the advancement of pharmacists’ roles and the integration of pharmacists into various models of primary care. How far behind is Australia?
I think it is fair to say there’s growing recognition and body of evidence around non-prescribing and prescribing pharmacists’ contribution to healthcare. The UK has been on a real journey to enable some of those models of care and practices to develop.
In the UK we are currently focussing on medicines value and safety. In the last five years there has been a real change in the landscape to enable greater multidisciplinary working to ensure members of the public get the best use out of their medicines. Subsequently, this has opened the door for pharmacists to go into many new and exciting roles.
We are not only seeing pharmacists work in community, hospital, industry or academia. We’re seeing non-dispensing pharmacist roles in general practice, aged care settings, urgent care, mental health services, prison services, and other community services such as homeless care or social care. Many of which are pharmacist prescribers. We are evaluating the impacts that many of these roles have on patient care and how they benefit the wider healthcare system.
I believe PSA are and continue to be strong advocates for positive change in the pharmacy profession in Australia. I see many new roles opening for pharmacists here, particularly in general practice and aged care settings. I am positive that in the future there will be many opportunities for pharmacists to be able to collaboratively prescribe within integrated teams alongside our medical colleagues.
Have you been able to discern the biggest obstacles to these advances in Australia?
It is important for healthcare professionals and the public to understand the knowledge and skills that pharmacists have. We undergo a significant amount of training in medicines and the application of medicines in real-life clinical practice. Furthermore, there is a growing evidence base showcasing the impacts that pharmacists can make on improving the delivery of care, improving patient care and safety, improving access to the medicines at the right time for the right individuals while improving greater collaborative multidisciplinary working between healthcare professionals. We do need to work on changing the culture, perceptions and behaviours of other healthcare professionals and help them understand the value that pharmacists bring to the management of people’s care.
Upon reflection, there’s something about the contracting and payment mechanism in Australia that is very different to the UK mechanisms. The UK mechanisms of funding and contracting enables greater collaborative and integrated working with multiple healthcare professionals. If that was to happen in Australia, I think it would enable further forward-thinking conversations around pharmacist role extension and collaborative prescribing.
What about yourself? Was there any single episode or patient interaction where you realised you could really advance pharmacy?
When working in general practice you have access to patient medical records, their histories and pathologies such as blood tests. I soon could see how I could make a huge difference to care by ensuring people were being prescribed the best medicines for their conditions.
One episode that comes to mind; I had a 65-year-old patient who was on three antihypertensive medicines. They had been on these medicines for a number of years. The patient came in for a clinical medication review with me in the GP practice. During the review, I measured his blood pressure and it was extremely low, something like 80/42 mmHg, suggesting that he was being overprescribed his current medication.
I was able to go through his medications and overall care in detail. He had clear signs and symptoms of hypotension and was at potential risk of falls. I suggested to the patient it would be appropriate to take them off one or two of his medications. I initially started off by taking off one of the antihypertensive medications and the plan was to follow him up within the next coming days. The patient was happy with the approach. Obviously working as part of the general practice team I can speak to the doctor about these decisions, but generally, the doctors appreciate that pharmacists know lots about medications and trust us to help improve patient care on a day-to-day basis.
After deprescribing one of the medicines, I followed up with the patient a week later and the blood pressure had improved to around 100/60 mmHg. I then decide to titrate the second antihypertensive medication down (i.e. a lower dose) and followed up the patient a week later. The patient returned with a blood pressure reading of around 120/75. The patient’s signs and symptoms of hypotension had resolved completely. Not only did the patient enjoy the conversation and approach to their care, the doctors were impressed by the pharmacist’s ability to manage, monitor and review the patients long-term condition.
I reflected on this one example and thought to myself, ‘This is me being an autonomous clinician with the support of a collaborative environment. The patient’s symptoms have been alleviated. I had monitored the patient, I’d reviewed their medications; I was able to educate the patient on their medicines and on how to take them. It was a detailed consultation that my GP colleagues respected – they really saw my ability to contribute.’’
There’s also work that I and my team of pharmacists have done in GP practices around complex polypharmacy – people on loads of medicines with lots of comorbidities, going through those medicines in detail and seeing if all of them are needed. And we’ve done some great work around patient safety deprescribing, as well as reducing medicine-related errors in general practice.
As an undergraduate, I really wanted to do this type of work. I’d learned about medicines, I’d learned about how they work. I’d applied my clinical knowledge, and this was unleashing that potential. It enabled me to work with colleagues around a person-centred approach to healthcare.
What advice would you give an early career pharmacist about their future?
I would tell them their profession is getting very exciting. Some advice I would give:
- Make sure you always put patient care first.
- Collaborate and work alongside other healthcare professionals. Be open and inclusive to those discussions.
- Develop your network in and outside of pharmacy. Many opportunities can come from broadening your network and connecting with new like-minded people.
- Seek new opportunities that goes beyond the traditional role of pharmacists e.g. artificial intelligence, genomics, health informatics and digital healthcare.
- Never burn bridges or ruin relationships. You never know when you will need work with people in the future.
Overall, be the change you want to see in the profession. I have met with some early career pharmacists during my trip and have been amazed by their enthusiasm, their vision for change and their will to make a difference to patient care. That’s the leadership we should be embracing and elevating. I am confident that the future of pharmacy in Australia is in safe hands.
What do you see are the most exciting new realms of pharmacy?
I would like pharmacists involved with collaborative prescribing – the ability to work as part of a team to improve patient care. The PSA has said that they want this happening by 2020. This holds great opportunity – to develop your clinical skills, to enable greater collaborative working with doctors, to work at the top of your scope, but also enhance your skills to extend your scope of practice. That is really exciting.
Other areas in the future? Artificial intelligence, digital medicine and genomics, particularly pharmacogenomics – being able to personalise medicines based on a person’s genomic makeup. This holds real opportunities for the pharmacy profession to ensure people get the best use of their medicines. We are the experts in medicine after all.[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row]
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
