td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 26036 [post_author] => 3410 [post_date] => 2024-05-06 12:37:31 [post_date_gmt] => 2024-05-06 02:37:31 [post_content] => Did you know a new Australian Cardiovascular risk calculator (AusCVDRisk) was released last year? If not, you’re not alone, said Karl Winckel, pharmacist at Princess Alexandra Hospital and the University of Queensland’s School of Pharmacy. [caption id="attachment_26040" align="alignright" width="222"] Karl Winckel[/caption] ‘It’s gone under the radar,’ he said. ‘Education about the new tool is mostly targeted at GPs rather than nurses or pharmacists.’ As it turns out, CVD risk has been ‘massively overestimated’ through use of previous CVD risk tables. With landmark studies such as ASPREE, ARRIVE, ASCEND all showing much lower benefit than expected for aspirin in primary prevention, it’s time to shift approach to preventative care. To kick off Heart Week (6–12 May 2024), Australian Pharmacist explains how to best wield the new tool to your patients’ advantage.What was wrong with the previous CVD calculator
Previous CVD risk assessments were based on the ongoing Framingham Heart Study, conducted in the small Massachusetts town of Framingham, dating back to the late 1940s. But cardiovascular risk has changed significantly since then, with people more aware of the risks, said Mr Winckel. ‘People are also exercising more and using preventative therapies,’ he said. The new AusCVDRisk tool uses QRISK3 risk prediction models, incorporating data from the United Kingdom and New Zealand, with baseline risk adjusted to suit the Australian context. ‘They looked at all the Australian Bureau of Statistics (ABS) and relevant surveys in New Zealand to dictate the number of strokes and heart attacks in different age and comorbidity brackets,’ he said. There was also lack of nuance when using the Framingham risk tables. For example, when users classified their smoking habits, they would simply click ‘smoker’ or ‘non-smoker’. ‘That means if you quit smoking a week ago, that classifies you as a nonsmoker, but you might have been smoking for 30 years,’ Mr Winckel said. While CVD risk reduces upon cessation, it never returns to baseline. With AusCVDRisk, users can include more details about their smoking history, including if they’re a never-smoker or ex-smoker. To demonstrate the variation in risk estimation between the Framingham and AusCVDRisk tools, Mr Winckel calculated his CVD risk using both. The former placed his risk at 5–10% over 5 years. Using AusCVDRisk, it was 2%. ‘That’s a big difference,’ he added.What are the benefits of the new calculator?
When it comes to calculating CVD risk, the devil is in the details. More information is included in AusCVDRisk about users' diabetes history to quantify a more accurate risk score, including:
Pharmacists should detect unnecessary and/or harmful uses of primary prevention, based on updated CVD risk, at any opportunity they have to review or consider a patient’s medicine profile.
This should be a key consideration for credentialed pharmacists conducting Home Medicines Reviews or Residential Medication Management Reviews.
Aside from antiplatelets, antihypertensives (which can lead to a significant drop in blood pressure among older patients) should also be investigated, along with beta blockers for primary hypertension, said Mr Winckel. ‘Beta blockers generally increase mortality for many frail elderly people by increasing risk of falls and subsequent fractures,’ he said. ‘When patients are not currently hypertensive, all hypertensives should be reviewed.’ But cessation of antiplatelets should only be considered when used in primary prevention, Mr Winckel warned. ‘If used for secondary prevention, lifelong antiplatelet therapy is required.’ [post_title] => New tool to counteract significant overestimate of CVD risk [post_excerpt] => Did you know a new Australian Cardiovascular risk calculator (AusCVDRisk) was released last year?If not, you’re not alone. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => new-tool-to-counteract-significant-overestimate-of-cvd-risk [to_ping] => [pinged] => [post_modified] => 2024-05-06 15:01:30 [post_modified_gmt] => 2024-05-06 05:01:30 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=26036 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => New tool to counteract significant overestimate of CVD risk [title] => New tool to counteract significant overestimate of CVD risk [href] => https://www.australianpharmacist.com.au/new-tool-to-counteract-significant-overestimate-of-cvd-risk/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 26038 )td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25965 [post_author] => 3410 [post_date] => 2024-05-01 13:01:56 [post_date_gmt] => 2024-05-01 03:01:56 [post_content] => New credentialing requirements announced as pharmacists prepare to take on aged care roles. The federal Department of Health and Aged Care has announced that pharmacists will need an Aged Care credential to become an aged care on-site pharmacist. Those who want to provide medication reviews such as Residential Medication Management Reviews and/or Home Medicine Reviews reviews will also need to complete a Medication Management Review (MMR). Kerri Barwick, PSA General Manager of Education and Training at PSA, explains what that involves.What’s the difference between accredited and credentialed pharmacists?
The change from ‘accredited’ to ‘credentialed’ pharmacist was initiated after the Australian Pharmacy Council was asked by the Department of Health and Aged Care to design accreditation standards for education providers, such as PSA, following the closure of the Australian Association of Consultant Pharmacy (AACP). In order to access government funding, a credential will be required that meets those standards for MMR and Aged Care.Why have these changes been made?
The AACP’s accreditation process was self-regulated and wasn't governed by an accrediting body. Standards are now in place to ensure the quality of the education delivered – including accreditation standards for educators and performance outcomes for learners, said Ms Barwick. Because ‘credentialed’ is now looked at from the perspective of meeting performance outcomes at the end of the program, the AACP-based assessment style – which entailed multiple choice questionnaires on clinical information and communication – doesn’t fit within this model. ‘To meet all those performance outcomes and accreditation standards, you couldn't run the same program,’ she said. ‘It wouldn't meet the standards.’ The skills required to provide MMR and Aged Care services also require additional specialisation, said Ms Barwick. ‘For the government to be able to pay pharmacists for those services, they want to guarantee the quality,’ she said.What will the new credentials involve?
PSA’s MMR and Aged Care credential programs, currently undergoing accreditation with APC, will involve case-based discussion and learning, along with simulations. ‘This will give learners as many real-life examples as we can without requiring a large amount of time learning on the job,’ explained Ms Barwick. ‘The PSA will also deliver both the MMR and Aged Care credential, so you'll be able to enrol in either or the whole package.’ PSA’s MMR and Aged Care credentials should be available for pharmacists in June 2024, pending the outcome of the next accreditation meeting.When do the changes take effect?
Not for a while. This week (29 April), the government announced an extension to Medication Review Numbers (MRNs) to support credentialed pharmacists to continue providing MMR services until 30 June 2025 during the transition to the new credentialing system. Pharmacists must transition to the new qualification within that 12-month period. PSA has been involved in discussions with the Department ‘for some time’ to ensure transition arrangements are in place to minimise disruption to patient services, and allow the existing workforce to continue providing MMR services in the immediate term, said PSA National President Associate Professor Fei Sim FPS. ’PSA continues to approach this fast-moving practice area with the intent to support our workforce, and to ensure the credentialing and recredentialing process is achievable and affordable,’ she said.Do I have to start credentialing from scratch?
No! PSA will have a process for recognition of prior learning for the MMR and Aged Care credential. PSA has also mapped the assessment delivered by AACP against the performance outcomes and assessed the existing gaps, said Ms Barwick. ‘For example, for the MMR credential, there's a performance outcome around cultural safety and cultural competence which pharmacists accredited by the AACP or PSA in the last 12 months will not have fulfilled,’ she said. To fill that gap pharmacists have the option to:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25567 [post_author] => 3919 [post_date] => 2024-05-01 11:01:36 [post_date_gmt] => 2024-05-01 01:01:36 [post_content] => Optimising proton pump inhibitor therapy in pharmacy Proton pump inhibitors (PPIs) are a widely used pharmacological treatment option for management of gastro-oesophageal reflux.1 [caption id="attachment_25337" align="alignright" width="233"] This activity is sponsored by Reckitt. All content is the true, accurate and independent opinion of the author and the views expressed are entirely their own.[/caption] While data on PPIs highlighted concerns about long-term use and the need for appropriate prescribing, an analysis of Pharmaceutical Benefits Scheme (PBS) data following the introduction of prescribing restrictions in 2019 suggests that a reliance on PPIs for management of reflux symptoms remains.2 Indeed, PPIs are an effective and well-tolerated pharmacotherapy for reflux and can be used confidently in the correct indications: first-line as a regular therapy for frequent/severe symptoms of gastro-oesophageal reflux disease (GORD), and second-line as an ‘on-demand’ therapy for mild/intermittent gastro-oesophageal reflux symptoms (see Therapeutic Guidelines for further information).1 However, for a variety of reasons, up to 40% of patients taking daily PPI for reflux symptoms are considered to have ‘PPI treatment failure’ or refractory GORD.3 Understanding the possible causes of persistent symptoms is important for pharmacists to efficiently troubleshoot next steps in management and/or recommend the appropriate course of action for the patient and their doctor to further investigate the issue. This article will provide an overview of 6 reasons why patients may find their PPIs failing — and courses of action to manage their concerns.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25351 [post_author] => 3387 [post_date] => 2024-04-29 12:14:39 [post_date_gmt] => 2024-04-29 02:14:39 [post_content] => Pharmacists encounter pregnant and new mums more often than most health professionals, and can have a bird’s-eye view when things go awry. At 20 weeks pregnant, PSA’s Queensland Pharmacist of the Year Jacqueline Meyer MPS, was diagnosed with intrauterine growth restriction, which severely impacted her fetal growth. A few weeks later, she stopped working – effective immediately. ‘I was put on immediate bed rest, even though I felt fine,’ she says. With her amniotic fluid diminished, Ms Meyer’s daughter, Fallon, was born at 28 weeks. Weighing only 520 grams, Fallon was placed in an incubator in the neonatal intensive care unit where she remained for the next 2 months. Ms Meyer is one of thousands of women who experience pregnancy complications, including gestational diabetes mellitus (GDM), affecting 1 in 6 pregnant Australian women.1 Perinatal depression (PND) is another prevalent complication, affecting up to 1 in 5 expectant or new mothers.2 However, there are significant gaps in pregnancy and early childhood support in Australia. With GDM diagnoses doubled within a decade,3 many patients are forced to rely on group education classes, says Anna Barwick MPS, credentialed pharmacist, and founder of remote access telehealth advisory service PharmOnline. Meanwhile, suicide is the third-highest cause of death among new mothers in Australia.4 After her turbulent pregnancy, Ms Meyer thinks pharmacists can help to fill these gaps. ‘We can recognise red flags, direct patients where to seek help, and provide emotional support about the importance of looking after your own health and nutrition.’Medicine use in pregnancy
While ‘every woman’ wants to avoid exposing their unborn child to risks associated with taking medicines for chronic conditions such as epilepsy, inflammatory bowel disease and arthritis, those risks can sometimes be overestimated, says Noor Al-Adhami, Women’s and Newborn Pharmacy Team Leader at Brisbane’s Royal Brisbane and Women’s Hospital (RBWH). ‘A gap we often see in RBWH’s Maternity Outpatient Clinic is lack of discussions around safety of medicines prescribed for depression and anxiety in pregnancy and breastfeeding,’ she says. ‘This can lead to women stopping their medicines abruptly without discussing with their GP or midwife, resulting in a deterioration in mental health that can negatively impact maternal and fetal outcomes.’ Pharmacists are in a good position to provide support and information regarding the safety of medicines in pregnancy and to address any concerns in a non-judgemental manner. ‘Advice regarding safety of antidepressant medicines involves discussing the benefit of continuation/initiation on maternal health, including improved function and quality of life, as well as risk to the fetus, which evidence shows is minimal with appropriate antidepressants,’ says Ms Al-Adhami.Health monitoring
While pregnancy is a short-term phase of life, significant ongoing effects can be experienced, particularly in children from pregnancies that are not well managed, says Ms Barwick. ‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.’ Gestational diabetes When expectant mums are diagnosed with GDM, community pharmacists can walk them through the process of monitoring blood glucose levels (BGLs). Where insulin is prescribed, pharmacists can inquire whether the dose is controlling blood glucose levels, and check their injection technique, says Ms Meyer. The use of insulin, considered a high-risk medication with APINCHs classification,5 Ms Barwick notes, provides justification for a Home Medicines Review (HMR). ‘There’s an advantage to going into the home to observe the patient’s diet, consider potential interactions, and educate patients on the best effects and outcomes,’ she says. Advice around cleaning blood glucose level (BGL) monitors to ensure accuracy can also be provided. ‘Pharmacists can explain how to put test drops through and clean blood spills on the monitor, common in pregnancy due to higher blood volume,’ says Ms Barwick. With only 50% of women diagnosed with GDM receiving tests for heart disease and type 2 diabetes post-pregnancy,6 HMRs can be beneficial at this stage of the journey, too. ‘Along with conversations around diet choices, exercise regimes and sleep, I also explain how often testing is required over the next 5–10 years, and how to monitor for signs of the development of diabetes,’ Ms Barwick advises. Nausea and vomiting in pregnancy The presence of iron in pregnancy multivitamins may exacerbate symptoms of nausea and vomiting in some pregnancies, according to Ms Barwick. ‘Pharmacists can recommend a trial cessation of the iron component of pregnancy vitamins, often unnecessary in pregnancy,’ she says. ‘A simple change in vitamin to focus on iodine and folate can make a big difference.’ Ms Barwick says community pharmacists may also recommend over-the-counter medicines such as doxylamine for symptoms of nausea and vomiting in pregnancy (NVP), and monitor its effectiveness.‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.' ANNA BARWICK MPSWhen women have symptoms of NVP, Ms Meyer points out that a family member might come into the pharmacy on their behalf if they are severely unwell. ‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency, such as vomiting to the point of severe dehydration, heart palpitations, blurred vision and cramping.’ When ondansetron is prescribed, pharmacists can recommend easy-to-consume forms, such as sublingual wafers, she adds. Preeclampsia Pregnant women who present with new hypertension after 20 weeks should be screened for preeclampsia.7 Community and credentialed pharmacists can assist patients with monitoring blood pressure, and look out for signs of preeclampsia, such as sudden oedema and weight gain, says Ms Barwick. ‘Patients can also be taught how to use a home blood pressure monitor appropriately and record the results. Women at high-risk of developing preeclampsia should consider treatment with low-dose aspirin,8 which can also be used to manage coagulation abnormalities in early pregnancy to prevent miscarriage. ‘A dose of around 75 mg has been shown to be effective for delivering a healthy baby, safely,’ notes Ms Barwick.9 Up to 150 mg can be used to prevent preeclampsia, she adds.10 Pharmacists should also keep a record of pregnant patients using aspirin to monitor for any potential adverse effects, such as bruising or bleeding. ‘While the risk of low-dose, aspirin-associated bleeding is low, reinforce the importance of looking out for any signs, either vaginal or rectal,’ Ms Barwick warns.Vaccinations
Australia has ‘dismal’ antenatal vaccination rates, with 15% vaccinated against influenza, 27% against pertussis, and only 12% against both among more than 591,000 pregnancies analysed in a population-based linked cohort study of data between 2012–2017.11 COVID-19 vaccine hesitancy has also been detected among pregnant Australian women.12 Overall, there is a lack of understanding of the benefits of antenatal vaccination, including providing immunity to both baby and mother against serious respiratory infections, says Ms Al-Adhami. Reduced access to vaccines is also an issue, particularly among vulnerable populations, such as those with mental health problems, and Aboriginal and Torres Strait Islander peoples. ‘Once we identified some women were having difficulties accessing antenatal vaccinations in the community, we recognised an opportunity to extend our scope of practice and improve our service delivery within the clinic,’ she says. This included credentialed training and the development of an opportunistic model of care, where ‘at-risk’ women were counselled and offered antenatal vaccinations during clinic visits. ‘Last year 546 vaccines were administered by our specialist antenatal pharmacists, adds Ms Al-Adhami.13 In Ms Meyer’s experience there has also been confusion among women about what vaccines are needed during pregnancy, and where to get them. ‘The states and territories all have different rules and regulations around who can provide National Immunisation Program (NIP) vaccines,’ she says. With most jurisdictions now increasing the number of vaccines pharmacists can administer, this should be used as an opportunity to initiate conversations with pregnant women about vaccination. ‘Ensure the mother is well educated on what vaccines she, and other family members, should receive according to current guidelines,’ says Ms Meyer.
All about birthing on country[caption id="attachment_25937" align="alignnone" width="500"] In 2020, photographer Bobbi Lockyer created a Birthing on Country project to highlight and create awareness around birthing issues and outcomes in Aboriginal women. For more, see www.bobbilockyer.com[/caption] Birthing on Country (BOC) is a holistic, integrated and culturally appropriate model of care, aimed at providing the best start in life for Aboriginal and Torres Strait Islander babies and their families.14 Broader than labour and delivery, BOC addresses socio-cultural and spiritual risk not dealt with through mainstream services. Guiding principles for a BOC program include respect for and incorporation of the knowledge and traditional practice of Aboriginal and Torres Strait Islander peoples, incorporate a holistic definition of health, respect for family involvement, women’s business, connection with Country and continuity of culturally safe care.15 Aboriginal and Torres Strait Islander mothers are 3–5 times more likely to die in childbirth than other mothers. Their babies are almost twice as likely to die in the first year of life – often due to premature birth.16 With research revealing access to community-governed, culturally safe birthing services is linked to a reduced risk of premature birth,17 pharmacists can advocate for and support BOC models of care. ‘BOC is so much broader than where a mother births – it is a social justice movement and system-wide reform. It’s an opportunity to Close the Gap in life outcomes for mums and bubs by recognising the impact of colonisation and the benefits of returning childbirth services to Aboriginal and Torres Strait Island community control,’ says Alice Nugent MPS, Aboriginal Community Controlled Health Organisation Pharmacist. Although not available everywhere, BOC can still involve birthing in a local hospital with the presence of an Aboriginal or Torres Strait Islander midwife or support worker throughout a woman’s pregnancy, birthing and post-natal journey. Once the baby is born, ongoing support is usually provided to the family, which may include cultural ceremonies for the mother and newborn. |
‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency.' Jacqueline Meyer MPSInfant formulas Formula manufacturers commonly use marketing that may feed into parental anxieties in claiming their products can prevent fussiness, help with colic, or improve night-time sleep.22 Pharmacists can emphasise the ‘antibodies, immunoglobulins and health benefits’ that breast milk can provide, along with advice on ensuring milk quality is at optimum levels, says Ms Meyer. ‘The number one thing is to eat before you feed,’ she says. ‘Mothers should also have a wholesome, balanced diet full of fresh nutrients and vegetables, so nutritional intake is at a premium.’ While breastfeeding should be encouraged, pharmacists can also guide mothers around selecting the right formulas when breastfeeding is not possible, says Ms Meyer. ‘We get a lot of questions around milk-free or dairy-free alternatives due to rising concerns of allergies and intolerances,’ she says. Factors to consider include the baby’s age, digestive issues, peptide profiles, short- or long-chain formula requirements, or whether specific formulas need to be prescribed. Pharmacists should also enquire how formulas are tolerated over a trial period – which ones and for how long, any reactions such as refusal, any reflux-type symptoms, changes in stool colour, irritability and any difficulty settling, suggests Ms Meyer. ‘Just trialling the formula for one day is often not enough. A longer period of time is required to identify a true intolerance.’ Medicines and breastfeeding Another reason why mothers opt to stop breastfeeding is medicine use.27 Pharmacists can reassure patients that very small amounts of medicines generally pass through breast milk, says Ms Meyer. ‘Medicine should never be a reason to stop breastfeeding, unless specifically advised to do so.’ Pharmacists can also advise patients when to take their medicines. ‘If the medicine is taken multiple times a day, recommend taking it directly after a breastfeed, so it reaches peak concentration in between feeding cycles,’ she says.
‘If your mum or dad had perinatal mental ill health, you’re more likely to have mental ill-health issues later on.' Lily Pham MPS
What's ailing pregnant and new mums?Pregnancy and the early stages of motherhood are fraught with discomfort. In addition to nausea and vomiting, some common ailments in pregnancy include constipation and indigestion, says Ms Al-Adhami. To overcome constipation, often due to hormone changes that slow down muscles in the bowel, patients should be advised to increase their fibre content by consuming fresh fruit and vegetables, wholemeal breads and breakfast cereals, nuts and legumes. Supplements such as psyllium husks can also be introduced. As iron tablets can also cause constipation, pharmacists can suggest another product for a trial period.23 Antacids for indigestion are safe to use in pregnancy. Calcium-based formulations are preferable to aluminium-containing antacids.24 When the baby arrives, back pain, incontinence and repetitive strain injuries are common. For mild to moderate pain, paracetamol is considered a safe analgesic during lactation, with the dose transferred through breast milk estimated to be 6% – much smaller than a child’s dose.25 Ibuprofen is also considered to be compatible with breastfeeding.25 Pelvic floor exercises can help to address post-birth incontinence, along with avoidance of persistent heavy lifting, repetitive coughing and straining.26 |
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25947 [post_author] => 3410 [post_date] => 2024-04-29 11:47:15 [post_date_gmt] => 2024-04-29 01:47:15 [post_content] => Nitazenes are becoming more common in the Australian illicit drug market, and are linked to an increasing number of overdoses and deaths. Last week, nitazines were detected in samples related to a cluster of 20 overdoses in the New South Wales Nepean Blue Mountains local health district. There have been 16 overdose deaths involving nitazenes in Victoria since 2021, prompting two coroners to recommend the implementation of drug checking services in the state. [caption id="attachment_10405" align="alignright" width="300"] Suzanne Nielsen MPS[/caption] Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne, explains how this little-understood drug entered the market and why pharmacists need to rethink harm minimisation.What’s the history of this synthetic opioid?
‘Nitazenes’ are a family of drugs. Substances within the class vary in potency, from lower in potency to significantly exceeding fentanyl’s strength. After nitazenes were synthesised in the late 1950s, development of the opioid as a therapeutic product was abandoned after early testing revealed high rates of adverse effects – including severe respiratory depression. In recent years, they have emerged as novel psychoactive substances, said Prof Nielsen. ‘Chemists who make illicit drugs [often] go back to drugs that didn't make it through the development pathway,’ she said. These drugs are therefore not internationally controlled, meaning their manufacture and distribution is ‘not necessarily illegal’. ‘It takes a while for national and international regulations to catch up and make them controlled substances,’ added Prof Nielsen. Most nitazenes that have been detected in Australia are also similar to, or stronger than fentanyl in potency. But while the pharmacology and effects of fentanyl are well profiled, the same can’t be said about nitazenes. ‘There are very few studies [that provide] a good sense of exactly how strong they are, how they work and how long they last,’ she said. ‘We do know they're very strong and have other negative effects we haven't fully characterised yet.’Where are nitazenes found?
Fentanyl and other novel synthetic opioids are commonly packaged and sold as substances such as oxycodone tablets, said Prof Nielsen. ‘Some people go online to find pharmaceuticals because they can be easier to access than through the healthcare system,’ she said. ‘Unless you're familiar with what to look for, these products look quite similar to pharmaceutical products.’ Some people, in the pursuit of a strong opioid, purchase nitazenes intentionally. But the majority of detections are in unintended purchases, when other substances are sought. ‘Sometimes [they are in] opioids such as heroin,’ said Prof Nielsen. ‘But we've seen detections in drugs being sold as ketamine, MDMA or other stimulants.’ These detections are cause for the most concern. ‘People seeking to use MDMA in a festival environment [likely] won't have any opioid tolerance, and will be very susceptible to an opioid overdose.’Is Australia at risk of a nitazene epidemic?
Nitazenes are causing large ‘clusters of deaths’ in England, Scotland and Ireland – where fentanyl has yet to emerge in the illicit market. There are concerns among addiction experts that Australia could similarly skip over fentanyl and head straight into a nitazene wave, warned Prof Nielsen. ‘There have been reports that the amount of heroin manufactured is dropping off,’ she said. ‘With the Taliban shutting down poppy production, an 80–95% reduction in heroin availability is expected.’ Programs such as real-time prescription monitoring and a tightening of regulations have also contributed to a ‘supply shock’ – which is historically associated with the entrance of potent substances into drug markets, said Prof Nielsen. With drug checking not widely accessible in Australia, it’s possible there are more nitazenes out there than we know. ‘Given overdose deaths have gone up fairly quickly in other parts of the world where these drugs have emerged, now is the time to raise the alarm.’What can pharmacists do to help?
With drugs such as MDMA or ketamine containing nitazenes, pharmacists need to broaden their approach to harm reduction, said Prof Nielsen. This includes anticipating requests for take-home naloxone (THN) from people who use drugs occasionally who have heard about the synthetic opioid – which should always be met with a positive response. Pharmacists could say, ‘it’s great you're asking for naloxone. I'm happy to provide it for you’, said Prof Nielsen. Follow-up questions could include:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 26036 [post_author] => 3410 [post_date] => 2024-05-06 12:37:31 [post_date_gmt] => 2024-05-06 02:37:31 [post_content] => Did you know a new Australian Cardiovascular risk calculator (AusCVDRisk) was released last year? If not, you’re not alone, said Karl Winckel, pharmacist at Princess Alexandra Hospital and the University of Queensland’s School of Pharmacy. [caption id="attachment_26040" align="alignright" width="222"] Karl Winckel[/caption] ‘It’s gone under the radar,’ he said. ‘Education about the new tool is mostly targeted at GPs rather than nurses or pharmacists.’ As it turns out, CVD risk has been ‘massively overestimated’ through use of previous CVD risk tables. With landmark studies such as ASPREE, ARRIVE, ASCEND all showing much lower benefit than expected for aspirin in primary prevention, it’s time to shift approach to preventative care. To kick off Heart Week (6–12 May 2024), Australian Pharmacist explains how to best wield the new tool to your patients’ advantage.What was wrong with the previous CVD calculator
Previous CVD risk assessments were based on the ongoing Framingham Heart Study, conducted in the small Massachusetts town of Framingham, dating back to the late 1940s. But cardiovascular risk has changed significantly since then, with people more aware of the risks, said Mr Winckel. ‘People are also exercising more and using preventative therapies,’ he said. The new AusCVDRisk tool uses QRISK3 risk prediction models, incorporating data from the United Kingdom and New Zealand, with baseline risk adjusted to suit the Australian context. ‘They looked at all the Australian Bureau of Statistics (ABS) and relevant surveys in New Zealand to dictate the number of strokes and heart attacks in different age and comorbidity brackets,’ he said. There was also lack of nuance when using the Framingham risk tables. For example, when users classified their smoking habits, they would simply click ‘smoker’ or ‘non-smoker’. ‘That means if you quit smoking a week ago, that classifies you as a nonsmoker, but you might have been smoking for 30 years,’ Mr Winckel said. While CVD risk reduces upon cessation, it never returns to baseline. With AusCVDRisk, users can include more details about their smoking history, including if they’re a never-smoker or ex-smoker. To demonstrate the variation in risk estimation between the Framingham and AusCVDRisk tools, Mr Winckel calculated his CVD risk using both. The former placed his risk at 5–10% over 5 years. Using AusCVDRisk, it was 2%. ‘That’s a big difference,’ he added.What are the benefits of the new calculator?
When it comes to calculating CVD risk, the devil is in the details. More information is included in AusCVDRisk about users' diabetes history to quantify a more accurate risk score, including:
Pharmacists should detect unnecessary and/or harmful uses of primary prevention, based on updated CVD risk, at any opportunity they have to review or consider a patient’s medicine profile.
This should be a key consideration for credentialed pharmacists conducting Home Medicines Reviews or Residential Medication Management Reviews.
Aside from antiplatelets, antihypertensives (which can lead to a significant drop in blood pressure among older patients) should also be investigated, along with beta blockers for primary hypertension, said Mr Winckel. ‘Beta blockers generally increase mortality for many frail elderly people by increasing risk of falls and subsequent fractures,’ he said. ‘When patients are not currently hypertensive, all hypertensives should be reviewed.’ But cessation of antiplatelets should only be considered when used in primary prevention, Mr Winckel warned. ‘If used for secondary prevention, lifelong antiplatelet therapy is required.’ [post_title] => New tool to counteract significant overestimate of CVD risk [post_excerpt] => Did you know a new Australian Cardiovascular risk calculator (AusCVDRisk) was released last year?If not, you’re not alone. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => new-tool-to-counteract-significant-overestimate-of-cvd-risk [to_ping] => [pinged] => [post_modified] => 2024-05-06 15:01:30 [post_modified_gmt] => 2024-05-06 05:01:30 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=26036 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => New tool to counteract significant overestimate of CVD risk [title] => New tool to counteract significant overestimate of CVD risk [href] => https://www.australianpharmacist.com.au/new-tool-to-counteract-significant-overestimate-of-cvd-risk/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 26038 )td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25965 [post_author] => 3410 [post_date] => 2024-05-01 13:01:56 [post_date_gmt] => 2024-05-01 03:01:56 [post_content] => New credentialing requirements announced as pharmacists prepare to take on aged care roles. The federal Department of Health and Aged Care has announced that pharmacists will need an Aged Care credential to become an aged care on-site pharmacist. Those who want to provide medication reviews such as Residential Medication Management Reviews and/or Home Medicine Reviews reviews will also need to complete a Medication Management Review (MMR). Kerri Barwick, PSA General Manager of Education and Training at PSA, explains what that involves.What’s the difference between accredited and credentialed pharmacists?
The change from ‘accredited’ to ‘credentialed’ pharmacist was initiated after the Australian Pharmacy Council was asked by the Department of Health and Aged Care to design accreditation standards for education providers, such as PSA, following the closure of the Australian Association of Consultant Pharmacy (AACP). In order to access government funding, a credential will be required that meets those standards for MMR and Aged Care.Why have these changes been made?
The AACP’s accreditation process was self-regulated and wasn't governed by an accrediting body. Standards are now in place to ensure the quality of the education delivered – including accreditation standards for educators and performance outcomes for learners, said Ms Barwick. Because ‘credentialed’ is now looked at from the perspective of meeting performance outcomes at the end of the program, the AACP-based assessment style – which entailed multiple choice questionnaires on clinical information and communication – doesn’t fit within this model. ‘To meet all those performance outcomes and accreditation standards, you couldn't run the same program,’ she said. ‘It wouldn't meet the standards.’ The skills required to provide MMR and Aged Care services also require additional specialisation, said Ms Barwick. ‘For the government to be able to pay pharmacists for those services, they want to guarantee the quality,’ she said.What will the new credentials involve?
PSA’s MMR and Aged Care credential programs, currently undergoing accreditation with APC, will involve case-based discussion and learning, along with simulations. ‘This will give learners as many real-life examples as we can without requiring a large amount of time learning on the job,’ explained Ms Barwick. ‘The PSA will also deliver both the MMR and Aged Care credential, so you'll be able to enrol in either or the whole package.’ PSA’s MMR and Aged Care credentials should be available for pharmacists in June 2024, pending the outcome of the next accreditation meeting.When do the changes take effect?
Not for a while. This week (29 April), the government announced an extension to Medication Review Numbers (MRNs) to support credentialed pharmacists to continue providing MMR services until 30 June 2025 during the transition to the new credentialing system. Pharmacists must transition to the new qualification within that 12-month period. PSA has been involved in discussions with the Department ‘for some time’ to ensure transition arrangements are in place to minimise disruption to patient services, and allow the existing workforce to continue providing MMR services in the immediate term, said PSA National President Associate Professor Fei Sim FPS. ’PSA continues to approach this fast-moving practice area with the intent to support our workforce, and to ensure the credentialing and recredentialing process is achievable and affordable,’ she said.Do I have to start credentialing from scratch?
No! PSA will have a process for recognition of prior learning for the MMR and Aged Care credential. PSA has also mapped the assessment delivered by AACP against the performance outcomes and assessed the existing gaps, said Ms Barwick. ‘For example, for the MMR credential, there's a performance outcome around cultural safety and cultural competence which pharmacists accredited by the AACP or PSA in the last 12 months will not have fulfilled,’ she said. To fill that gap pharmacists have the option to:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25567 [post_author] => 3919 [post_date] => 2024-05-01 11:01:36 [post_date_gmt] => 2024-05-01 01:01:36 [post_content] => Optimising proton pump inhibitor therapy in pharmacy Proton pump inhibitors (PPIs) are a widely used pharmacological treatment option for management of gastro-oesophageal reflux.1 [caption id="attachment_25337" align="alignright" width="233"] This activity is sponsored by Reckitt. All content is the true, accurate and independent opinion of the author and the views expressed are entirely their own.[/caption] While data on PPIs highlighted concerns about long-term use and the need for appropriate prescribing, an analysis of Pharmaceutical Benefits Scheme (PBS) data following the introduction of prescribing restrictions in 2019 suggests that a reliance on PPIs for management of reflux symptoms remains.2 Indeed, PPIs are an effective and well-tolerated pharmacotherapy for reflux and can be used confidently in the correct indications: first-line as a regular therapy for frequent/severe symptoms of gastro-oesophageal reflux disease (GORD), and second-line as an ‘on-demand’ therapy for mild/intermittent gastro-oesophageal reflux symptoms (see Therapeutic Guidelines for further information).1 However, for a variety of reasons, up to 40% of patients taking daily PPI for reflux symptoms are considered to have ‘PPI treatment failure’ or refractory GORD.3 Understanding the possible causes of persistent symptoms is important for pharmacists to efficiently troubleshoot next steps in management and/or recommend the appropriate course of action for the patient and their doctor to further investigate the issue. This article will provide an overview of 6 reasons why patients may find their PPIs failing — and courses of action to manage their concerns.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25351 [post_author] => 3387 [post_date] => 2024-04-29 12:14:39 [post_date_gmt] => 2024-04-29 02:14:39 [post_content] => Pharmacists encounter pregnant and new mums more often than most health professionals, and can have a bird’s-eye view when things go awry. At 20 weeks pregnant, PSA’s Queensland Pharmacist of the Year Jacqueline Meyer MPS, was diagnosed with intrauterine growth restriction, which severely impacted her fetal growth. A few weeks later, she stopped working – effective immediately. ‘I was put on immediate bed rest, even though I felt fine,’ she says. With her amniotic fluid diminished, Ms Meyer’s daughter, Fallon, was born at 28 weeks. Weighing only 520 grams, Fallon was placed in an incubator in the neonatal intensive care unit where she remained for the next 2 months. Ms Meyer is one of thousands of women who experience pregnancy complications, including gestational diabetes mellitus (GDM), affecting 1 in 6 pregnant Australian women.1 Perinatal depression (PND) is another prevalent complication, affecting up to 1 in 5 expectant or new mothers.2 However, there are significant gaps in pregnancy and early childhood support in Australia. With GDM diagnoses doubled within a decade,3 many patients are forced to rely on group education classes, says Anna Barwick MPS, credentialed pharmacist, and founder of remote access telehealth advisory service PharmOnline. Meanwhile, suicide is the third-highest cause of death among new mothers in Australia.4 After her turbulent pregnancy, Ms Meyer thinks pharmacists can help to fill these gaps. ‘We can recognise red flags, direct patients where to seek help, and provide emotional support about the importance of looking after your own health and nutrition.’Medicine use in pregnancy
While ‘every woman’ wants to avoid exposing their unborn child to risks associated with taking medicines for chronic conditions such as epilepsy, inflammatory bowel disease and arthritis, those risks can sometimes be overestimated, says Noor Al-Adhami, Women’s and Newborn Pharmacy Team Leader at Brisbane’s Royal Brisbane and Women’s Hospital (RBWH). ‘A gap we often see in RBWH’s Maternity Outpatient Clinic is lack of discussions around safety of medicines prescribed for depression and anxiety in pregnancy and breastfeeding,’ she says. ‘This can lead to women stopping their medicines abruptly without discussing with their GP or midwife, resulting in a deterioration in mental health that can negatively impact maternal and fetal outcomes.’ Pharmacists are in a good position to provide support and information regarding the safety of medicines in pregnancy and to address any concerns in a non-judgemental manner. ‘Advice regarding safety of antidepressant medicines involves discussing the benefit of continuation/initiation on maternal health, including improved function and quality of life, as well as risk to the fetus, which evidence shows is minimal with appropriate antidepressants,’ says Ms Al-Adhami.Health monitoring
While pregnancy is a short-term phase of life, significant ongoing effects can be experienced, particularly in children from pregnancies that are not well managed, says Ms Barwick. ‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.’ Gestational diabetes When expectant mums are diagnosed with GDM, community pharmacists can walk them through the process of monitoring blood glucose levels (BGLs). Where insulin is prescribed, pharmacists can inquire whether the dose is controlling blood glucose levels, and check their injection technique, says Ms Meyer. The use of insulin, considered a high-risk medication with APINCHs classification,5 Ms Barwick notes, provides justification for a Home Medicines Review (HMR). ‘There’s an advantage to going into the home to observe the patient’s diet, consider potential interactions, and educate patients on the best effects and outcomes,’ she says. Advice around cleaning blood glucose level (BGL) monitors to ensure accuracy can also be provided. ‘Pharmacists can explain how to put test drops through and clean blood spills on the monitor, common in pregnancy due to higher blood volume,’ says Ms Barwick. With only 50% of women diagnosed with GDM receiving tests for heart disease and type 2 diabetes post-pregnancy,6 HMRs can be beneficial at this stage of the journey, too. ‘Along with conversations around diet choices, exercise regimes and sleep, I also explain how often testing is required over the next 5–10 years, and how to monitor for signs of the development of diabetes,’ Ms Barwick advises. Nausea and vomiting in pregnancy The presence of iron in pregnancy multivitamins may exacerbate symptoms of nausea and vomiting in some pregnancies, according to Ms Barwick. ‘Pharmacists can recommend a trial cessation of the iron component of pregnancy vitamins, often unnecessary in pregnancy,’ she says. ‘A simple change in vitamin to focus on iodine and folate can make a big difference.’ Ms Barwick says community pharmacists may also recommend over-the-counter medicines such as doxylamine for symptoms of nausea and vomiting in pregnancy (NVP), and monitor its effectiveness.‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.' ANNA BARWICK MPSWhen women have symptoms of NVP, Ms Meyer points out that a family member might come into the pharmacy on their behalf if they are severely unwell. ‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency, such as vomiting to the point of severe dehydration, heart palpitations, blurred vision and cramping.’ When ondansetron is prescribed, pharmacists can recommend easy-to-consume forms, such as sublingual wafers, she adds. Preeclampsia Pregnant women who present with new hypertension after 20 weeks should be screened for preeclampsia.7 Community and credentialed pharmacists can assist patients with monitoring blood pressure, and look out for signs of preeclampsia, such as sudden oedema and weight gain, says Ms Barwick. ‘Patients can also be taught how to use a home blood pressure monitor appropriately and record the results. Women at high-risk of developing preeclampsia should consider treatment with low-dose aspirin,8 which can also be used to manage coagulation abnormalities in early pregnancy to prevent miscarriage. ‘A dose of around 75 mg has been shown to be effective for delivering a healthy baby, safely,’ notes Ms Barwick.9 Up to 150 mg can be used to prevent preeclampsia, she adds.10 Pharmacists should also keep a record of pregnant patients using aspirin to monitor for any potential adverse effects, such as bruising or bleeding. ‘While the risk of low-dose, aspirin-associated bleeding is low, reinforce the importance of looking out for any signs, either vaginal or rectal,’ Ms Barwick warns.Vaccinations
Australia has ‘dismal’ antenatal vaccination rates, with 15% vaccinated against influenza, 27% against pertussis, and only 12% against both among more than 591,000 pregnancies analysed in a population-based linked cohort study of data between 2012–2017.11 COVID-19 vaccine hesitancy has also been detected among pregnant Australian women.12 Overall, there is a lack of understanding of the benefits of antenatal vaccination, including providing immunity to both baby and mother against serious respiratory infections, says Ms Al-Adhami. Reduced access to vaccines is also an issue, particularly among vulnerable populations, such as those with mental health problems, and Aboriginal and Torres Strait Islander peoples. ‘Once we identified some women were having difficulties accessing antenatal vaccinations in the community, we recognised an opportunity to extend our scope of practice and improve our service delivery within the clinic,’ she says. This included credentialed training and the development of an opportunistic model of care, where ‘at-risk’ women were counselled and offered antenatal vaccinations during clinic visits. ‘Last year 546 vaccines were administered by our specialist antenatal pharmacists, adds Ms Al-Adhami.13 In Ms Meyer’s experience there has also been confusion among women about what vaccines are needed during pregnancy, and where to get them. ‘The states and territories all have different rules and regulations around who can provide National Immunisation Program (NIP) vaccines,’ she says. With most jurisdictions now increasing the number of vaccines pharmacists can administer, this should be used as an opportunity to initiate conversations with pregnant women about vaccination. ‘Ensure the mother is well educated on what vaccines she, and other family members, should receive according to current guidelines,’ says Ms Meyer.
All about birthing on country[caption id="attachment_25937" align="alignnone" width="500"] In 2020, photographer Bobbi Lockyer created a Birthing on Country project to highlight and create awareness around birthing issues and outcomes in Aboriginal women. For more, see www.bobbilockyer.com[/caption] Birthing on Country (BOC) is a holistic, integrated and culturally appropriate model of care, aimed at providing the best start in life for Aboriginal and Torres Strait Islander babies and their families.14 Broader than labour and delivery, BOC addresses socio-cultural and spiritual risk not dealt with through mainstream services. Guiding principles for a BOC program include respect for and incorporation of the knowledge and traditional practice of Aboriginal and Torres Strait Islander peoples, incorporate a holistic definition of health, respect for family involvement, women’s business, connection with Country and continuity of culturally safe care.15 Aboriginal and Torres Strait Islander mothers are 3–5 times more likely to die in childbirth than other mothers. Their babies are almost twice as likely to die in the first year of life – often due to premature birth.16 With research revealing access to community-governed, culturally safe birthing services is linked to a reduced risk of premature birth,17 pharmacists can advocate for and support BOC models of care. ‘BOC is so much broader than where a mother births – it is a social justice movement and system-wide reform. It’s an opportunity to Close the Gap in life outcomes for mums and bubs by recognising the impact of colonisation and the benefits of returning childbirth services to Aboriginal and Torres Strait Island community control,’ says Alice Nugent MPS, Aboriginal Community Controlled Health Organisation Pharmacist. Although not available everywhere, BOC can still involve birthing in a local hospital with the presence of an Aboriginal or Torres Strait Islander midwife or support worker throughout a woman’s pregnancy, birthing and post-natal journey. Once the baby is born, ongoing support is usually provided to the family, which may include cultural ceremonies for the mother and newborn. |
‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency.' Jacqueline Meyer MPSInfant formulas Formula manufacturers commonly use marketing that may feed into parental anxieties in claiming their products can prevent fussiness, help with colic, or improve night-time sleep.22 Pharmacists can emphasise the ‘antibodies, immunoglobulins and health benefits’ that breast milk can provide, along with advice on ensuring milk quality is at optimum levels, says Ms Meyer. ‘The number one thing is to eat before you feed,’ she says. ‘Mothers should also have a wholesome, balanced diet full of fresh nutrients and vegetables, so nutritional intake is at a premium.’ While breastfeeding should be encouraged, pharmacists can also guide mothers around selecting the right formulas when breastfeeding is not possible, says Ms Meyer. ‘We get a lot of questions around milk-free or dairy-free alternatives due to rising concerns of allergies and intolerances,’ she says. Factors to consider include the baby’s age, digestive issues, peptide profiles, short- or long-chain formula requirements, or whether specific formulas need to be prescribed. Pharmacists should also enquire how formulas are tolerated over a trial period – which ones and for how long, any reactions such as refusal, any reflux-type symptoms, changes in stool colour, irritability and any difficulty settling, suggests Ms Meyer. ‘Just trialling the formula for one day is often not enough. A longer period of time is required to identify a true intolerance.’ Medicines and breastfeeding Another reason why mothers opt to stop breastfeeding is medicine use.27 Pharmacists can reassure patients that very small amounts of medicines generally pass through breast milk, says Ms Meyer. ‘Medicine should never be a reason to stop breastfeeding, unless specifically advised to do so.’ Pharmacists can also advise patients when to take their medicines. ‘If the medicine is taken multiple times a day, recommend taking it directly after a breastfeed, so it reaches peak concentration in between feeding cycles,’ she says.
‘If your mum or dad had perinatal mental ill health, you’re more likely to have mental ill-health issues later on.' Lily Pham MPS
What's ailing pregnant and new mums?Pregnancy and the early stages of motherhood are fraught with discomfort. In addition to nausea and vomiting, some common ailments in pregnancy include constipation and indigestion, says Ms Al-Adhami. To overcome constipation, often due to hormone changes that slow down muscles in the bowel, patients should be advised to increase their fibre content by consuming fresh fruit and vegetables, wholemeal breads and breakfast cereals, nuts and legumes. Supplements such as psyllium husks can also be introduced. As iron tablets can also cause constipation, pharmacists can suggest another product for a trial period.23 Antacids for indigestion are safe to use in pregnancy. Calcium-based formulations are preferable to aluminium-containing antacids.24 When the baby arrives, back pain, incontinence and repetitive strain injuries are common. For mild to moderate pain, paracetamol is considered a safe analgesic during lactation, with the dose transferred through breast milk estimated to be 6% – much smaller than a child’s dose.25 Ibuprofen is also considered to be compatible with breastfeeding.25 Pelvic floor exercises can help to address post-birth incontinence, along with avoidance of persistent heavy lifting, repetitive coughing and straining.26 |
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25947 [post_author] => 3410 [post_date] => 2024-04-29 11:47:15 [post_date_gmt] => 2024-04-29 01:47:15 [post_content] => Nitazenes are becoming more common in the Australian illicit drug market, and are linked to an increasing number of overdoses and deaths. Last week, nitazines were detected in samples related to a cluster of 20 overdoses in the New South Wales Nepean Blue Mountains local health district. There have been 16 overdose deaths involving nitazenes in Victoria since 2021, prompting two coroners to recommend the implementation of drug checking services in the state. [caption id="attachment_10405" align="alignright" width="300"] Suzanne Nielsen MPS[/caption] Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne, explains how this little-understood drug entered the market and why pharmacists need to rethink harm minimisation.What’s the history of this synthetic opioid?
‘Nitazenes’ are a family of drugs. Substances within the class vary in potency, from lower in potency to significantly exceeding fentanyl’s strength. After nitazenes were synthesised in the late 1950s, development of the opioid as a therapeutic product was abandoned after early testing revealed high rates of adverse effects – including severe respiratory depression. In recent years, they have emerged as novel psychoactive substances, said Prof Nielsen. ‘Chemists who make illicit drugs [often] go back to drugs that didn't make it through the development pathway,’ she said. These drugs are therefore not internationally controlled, meaning their manufacture and distribution is ‘not necessarily illegal’. ‘It takes a while for national and international regulations to catch up and make them controlled substances,’ added Prof Nielsen. Most nitazenes that have been detected in Australia are also similar to, or stronger than fentanyl in potency. But while the pharmacology and effects of fentanyl are well profiled, the same can’t be said about nitazenes. ‘There are very few studies [that provide] a good sense of exactly how strong they are, how they work and how long they last,’ she said. ‘We do know they're very strong and have other negative effects we haven't fully characterised yet.’Where are nitazenes found?
Fentanyl and other novel synthetic opioids are commonly packaged and sold as substances such as oxycodone tablets, said Prof Nielsen. ‘Some people go online to find pharmaceuticals because they can be easier to access than through the healthcare system,’ she said. ‘Unless you're familiar with what to look for, these products look quite similar to pharmaceutical products.’ Some people, in the pursuit of a strong opioid, purchase nitazenes intentionally. But the majority of detections are in unintended purchases, when other substances are sought. ‘Sometimes [they are in] opioids such as heroin,’ said Prof Nielsen. ‘But we've seen detections in drugs being sold as ketamine, MDMA or other stimulants.’ These detections are cause for the most concern. ‘People seeking to use MDMA in a festival environment [likely] won't have any opioid tolerance, and will be very susceptible to an opioid overdose.’Is Australia at risk of a nitazene epidemic?
Nitazenes are causing large ‘clusters of deaths’ in England, Scotland and Ireland – where fentanyl has yet to emerge in the illicit market. There are concerns among addiction experts that Australia could similarly skip over fentanyl and head straight into a nitazene wave, warned Prof Nielsen. ‘There have been reports that the amount of heroin manufactured is dropping off,’ she said. ‘With the Taliban shutting down poppy production, an 80–95% reduction in heroin availability is expected.’ Programs such as real-time prescription monitoring and a tightening of regulations have also contributed to a ‘supply shock’ – which is historically associated with the entrance of potent substances into drug markets, said Prof Nielsen. With drug checking not widely accessible in Australia, it’s possible there are more nitazenes out there than we know. ‘Given overdose deaths have gone up fairly quickly in other parts of the world where these drugs have emerged, now is the time to raise the alarm.’What can pharmacists do to help?
With drugs such as MDMA or ketamine containing nitazenes, pharmacists need to broaden their approach to harm reduction, said Prof Nielsen. This includes anticipating requests for take-home naloxone (THN) from people who use drugs occasionally who have heard about the synthetic opioid – which should always be met with a positive response. Pharmacists could say, ‘it’s great you're asking for naloxone. I'm happy to provide it for you’, said Prof Nielsen. Follow-up questions could include:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 26036 [post_author] => 3410 [post_date] => 2024-05-06 12:37:31 [post_date_gmt] => 2024-05-06 02:37:31 [post_content] => Did you know a new Australian Cardiovascular risk calculator (AusCVDRisk) was released last year? If not, you’re not alone, said Karl Winckel, pharmacist at Princess Alexandra Hospital and the University of Queensland’s School of Pharmacy. [caption id="attachment_26040" align="alignright" width="222"] Karl Winckel[/caption] ‘It’s gone under the radar,’ he said. ‘Education about the new tool is mostly targeted at GPs rather than nurses or pharmacists.’ As it turns out, CVD risk has been ‘massively overestimated’ through use of previous CVD risk tables. With landmark studies such as ASPREE, ARRIVE, ASCEND all showing much lower benefit than expected for aspirin in primary prevention, it’s time to shift approach to preventative care. To kick off Heart Week (6–12 May 2024), Australian Pharmacist explains how to best wield the new tool to your patients’ advantage.What was wrong with the previous CVD calculator
Previous CVD risk assessments were based on the ongoing Framingham Heart Study, conducted in the small Massachusetts town of Framingham, dating back to the late 1940s. But cardiovascular risk has changed significantly since then, with people more aware of the risks, said Mr Winckel. ‘People are also exercising more and using preventative therapies,’ he said. The new AusCVDRisk tool uses QRISK3 risk prediction models, incorporating data from the United Kingdom and New Zealand, with baseline risk adjusted to suit the Australian context. ‘They looked at all the Australian Bureau of Statistics (ABS) and relevant surveys in New Zealand to dictate the number of strokes and heart attacks in different age and comorbidity brackets,’ he said. There was also lack of nuance when using the Framingham risk tables. For example, when users classified their smoking habits, they would simply click ‘smoker’ or ‘non-smoker’. ‘That means if you quit smoking a week ago, that classifies you as a nonsmoker, but you might have been smoking for 30 years,’ Mr Winckel said. While CVD risk reduces upon cessation, it never returns to baseline. With AusCVDRisk, users can include more details about their smoking history, including if they’re a never-smoker or ex-smoker. To demonstrate the variation in risk estimation between the Framingham and AusCVDRisk tools, Mr Winckel calculated his CVD risk using both. The former placed his risk at 5–10% over 5 years. Using AusCVDRisk, it was 2%. ‘That’s a big difference,’ he added.What are the benefits of the new calculator?
When it comes to calculating CVD risk, the devil is in the details. More information is included in AusCVDRisk about users' diabetes history to quantify a more accurate risk score, including:
Pharmacists should detect unnecessary and/or harmful uses of primary prevention, based on updated CVD risk, at any opportunity they have to review or consider a patient’s medicine profile.
This should be a key consideration for credentialed pharmacists conducting Home Medicines Reviews or Residential Medication Management Reviews.
Aside from antiplatelets, antihypertensives (which can lead to a significant drop in blood pressure among older patients) should also be investigated, along with beta blockers for primary hypertension, said Mr Winckel. ‘Beta blockers generally increase mortality for many frail elderly people by increasing risk of falls and subsequent fractures,’ he said. ‘When patients are not currently hypertensive, all hypertensives should be reviewed.’ But cessation of antiplatelets should only be considered when used in primary prevention, Mr Winckel warned. ‘If used for secondary prevention, lifelong antiplatelet therapy is required.’ [post_title] => New tool to counteract significant overestimate of CVD risk [post_excerpt] => Did you know a new Australian Cardiovascular risk calculator (AusCVDRisk) was released last year?If not, you’re not alone. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => new-tool-to-counteract-significant-overestimate-of-cvd-risk [to_ping] => [pinged] => [post_modified] => 2024-05-06 15:01:30 [post_modified_gmt] => 2024-05-06 05:01:30 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=26036 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => New tool to counteract significant overestimate of CVD risk [title] => New tool to counteract significant overestimate of CVD risk [href] => https://www.australianpharmacist.com.au/new-tool-to-counteract-significant-overestimate-of-cvd-risk/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 26038 )td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25965 [post_author] => 3410 [post_date] => 2024-05-01 13:01:56 [post_date_gmt] => 2024-05-01 03:01:56 [post_content] => New credentialing requirements announced as pharmacists prepare to take on aged care roles. The federal Department of Health and Aged Care has announced that pharmacists will need an Aged Care credential to become an aged care on-site pharmacist. Those who want to provide medication reviews such as Residential Medication Management Reviews and/or Home Medicine Reviews reviews will also need to complete a Medication Management Review (MMR). Kerri Barwick, PSA General Manager of Education and Training at PSA, explains what that involves.What’s the difference between accredited and credentialed pharmacists?
The change from ‘accredited’ to ‘credentialed’ pharmacist was initiated after the Australian Pharmacy Council was asked by the Department of Health and Aged Care to design accreditation standards for education providers, such as PSA, following the closure of the Australian Association of Consultant Pharmacy (AACP). In order to access government funding, a credential will be required that meets those standards for MMR and Aged Care.Why have these changes been made?
The AACP’s accreditation process was self-regulated and wasn't governed by an accrediting body. Standards are now in place to ensure the quality of the education delivered – including accreditation standards for educators and performance outcomes for learners, said Ms Barwick. Because ‘credentialed’ is now looked at from the perspective of meeting performance outcomes at the end of the program, the AACP-based assessment style – which entailed multiple choice questionnaires on clinical information and communication – doesn’t fit within this model. ‘To meet all those performance outcomes and accreditation standards, you couldn't run the same program,’ she said. ‘It wouldn't meet the standards.’ The skills required to provide MMR and Aged Care services also require additional specialisation, said Ms Barwick. ‘For the government to be able to pay pharmacists for those services, they want to guarantee the quality,’ she said.What will the new credentials involve?
PSA’s MMR and Aged Care credential programs, currently undergoing accreditation with APC, will involve case-based discussion and learning, along with simulations. ‘This will give learners as many real-life examples as we can without requiring a large amount of time learning on the job,’ explained Ms Barwick. ‘The PSA will also deliver both the MMR and Aged Care credential, so you'll be able to enrol in either or the whole package.’ PSA’s MMR and Aged Care credentials should be available for pharmacists in June 2024, pending the outcome of the next accreditation meeting.When do the changes take effect?
Not for a while. This week (29 April), the government announced an extension to Medication Review Numbers (MRNs) to support credentialed pharmacists to continue providing MMR services until 30 June 2025 during the transition to the new credentialing system. Pharmacists must transition to the new qualification within that 12-month period. PSA has been involved in discussions with the Department ‘for some time’ to ensure transition arrangements are in place to minimise disruption to patient services, and allow the existing workforce to continue providing MMR services in the immediate term, said PSA National President Associate Professor Fei Sim FPS. ’PSA continues to approach this fast-moving practice area with the intent to support our workforce, and to ensure the credentialing and recredentialing process is achievable and affordable,’ she said.Do I have to start credentialing from scratch?
No! PSA will have a process for recognition of prior learning for the MMR and Aged Care credential. PSA has also mapped the assessment delivered by AACP against the performance outcomes and assessed the existing gaps, said Ms Barwick. ‘For example, for the MMR credential, there's a performance outcome around cultural safety and cultural competence which pharmacists accredited by the AACP or PSA in the last 12 months will not have fulfilled,’ she said. To fill that gap pharmacists have the option to:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25567 [post_author] => 3919 [post_date] => 2024-05-01 11:01:36 [post_date_gmt] => 2024-05-01 01:01:36 [post_content] => Optimising proton pump inhibitor therapy in pharmacy Proton pump inhibitors (PPIs) are a widely used pharmacological treatment option for management of gastro-oesophageal reflux.1 [caption id="attachment_25337" align="alignright" width="233"] This activity is sponsored by Reckitt. All content is the true, accurate and independent opinion of the author and the views expressed are entirely their own.[/caption] While data on PPIs highlighted concerns about long-term use and the need for appropriate prescribing, an analysis of Pharmaceutical Benefits Scheme (PBS) data following the introduction of prescribing restrictions in 2019 suggests that a reliance on PPIs for management of reflux symptoms remains.2 Indeed, PPIs are an effective and well-tolerated pharmacotherapy for reflux and can be used confidently in the correct indications: first-line as a regular therapy for frequent/severe symptoms of gastro-oesophageal reflux disease (GORD), and second-line as an ‘on-demand’ therapy for mild/intermittent gastro-oesophageal reflux symptoms (see Therapeutic Guidelines for further information).1 However, for a variety of reasons, up to 40% of patients taking daily PPI for reflux symptoms are considered to have ‘PPI treatment failure’ or refractory GORD.3 Understanding the possible causes of persistent symptoms is important for pharmacists to efficiently troubleshoot next steps in management and/or recommend the appropriate course of action for the patient and their doctor to further investigate the issue. This article will provide an overview of 6 reasons why patients may find their PPIs failing — and courses of action to manage their concerns.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25351 [post_author] => 3387 [post_date] => 2024-04-29 12:14:39 [post_date_gmt] => 2024-04-29 02:14:39 [post_content] => Pharmacists encounter pregnant and new mums more often than most health professionals, and can have a bird’s-eye view when things go awry. At 20 weeks pregnant, PSA’s Queensland Pharmacist of the Year Jacqueline Meyer MPS, was diagnosed with intrauterine growth restriction, which severely impacted her fetal growth. A few weeks later, she stopped working – effective immediately. ‘I was put on immediate bed rest, even though I felt fine,’ she says. With her amniotic fluid diminished, Ms Meyer’s daughter, Fallon, was born at 28 weeks. Weighing only 520 grams, Fallon was placed in an incubator in the neonatal intensive care unit where she remained for the next 2 months. Ms Meyer is one of thousands of women who experience pregnancy complications, including gestational diabetes mellitus (GDM), affecting 1 in 6 pregnant Australian women.1 Perinatal depression (PND) is another prevalent complication, affecting up to 1 in 5 expectant or new mothers.2 However, there are significant gaps in pregnancy and early childhood support in Australia. With GDM diagnoses doubled within a decade,3 many patients are forced to rely on group education classes, says Anna Barwick MPS, credentialed pharmacist, and founder of remote access telehealth advisory service PharmOnline. Meanwhile, suicide is the third-highest cause of death among new mothers in Australia.4 After her turbulent pregnancy, Ms Meyer thinks pharmacists can help to fill these gaps. ‘We can recognise red flags, direct patients where to seek help, and provide emotional support about the importance of looking after your own health and nutrition.’Medicine use in pregnancy
While ‘every woman’ wants to avoid exposing their unborn child to risks associated with taking medicines for chronic conditions such as epilepsy, inflammatory bowel disease and arthritis, those risks can sometimes be overestimated, says Noor Al-Adhami, Women’s and Newborn Pharmacy Team Leader at Brisbane’s Royal Brisbane and Women’s Hospital (RBWH). ‘A gap we often see in RBWH’s Maternity Outpatient Clinic is lack of discussions around safety of medicines prescribed for depression and anxiety in pregnancy and breastfeeding,’ she says. ‘This can lead to women stopping their medicines abruptly without discussing with their GP or midwife, resulting in a deterioration in mental health that can negatively impact maternal and fetal outcomes.’ Pharmacists are in a good position to provide support and information regarding the safety of medicines in pregnancy and to address any concerns in a non-judgemental manner. ‘Advice regarding safety of antidepressant medicines involves discussing the benefit of continuation/initiation on maternal health, including improved function and quality of life, as well as risk to the fetus, which evidence shows is minimal with appropriate antidepressants,’ says Ms Al-Adhami.Health monitoring
While pregnancy is a short-term phase of life, significant ongoing effects can be experienced, particularly in children from pregnancies that are not well managed, says Ms Barwick. ‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.’ Gestational diabetes When expectant mums are diagnosed with GDM, community pharmacists can walk them through the process of monitoring blood glucose levels (BGLs). Where insulin is prescribed, pharmacists can inquire whether the dose is controlling blood glucose levels, and check their injection technique, says Ms Meyer. The use of insulin, considered a high-risk medication with APINCHs classification,5 Ms Barwick notes, provides justification for a Home Medicines Review (HMR). ‘There’s an advantage to going into the home to observe the patient’s diet, consider potential interactions, and educate patients on the best effects and outcomes,’ she says. Advice around cleaning blood glucose level (BGL) monitors to ensure accuracy can also be provided. ‘Pharmacists can explain how to put test drops through and clean blood spills on the monitor, common in pregnancy due to higher blood volume,’ says Ms Barwick. With only 50% of women diagnosed with GDM receiving tests for heart disease and type 2 diabetes post-pregnancy,6 HMRs can be beneficial at this stage of the journey, too. ‘Along with conversations around diet choices, exercise regimes and sleep, I also explain how often testing is required over the next 5–10 years, and how to monitor for signs of the development of diabetes,’ Ms Barwick advises. Nausea and vomiting in pregnancy The presence of iron in pregnancy multivitamins may exacerbate symptoms of nausea and vomiting in some pregnancies, according to Ms Barwick. ‘Pharmacists can recommend a trial cessation of the iron component of pregnancy vitamins, often unnecessary in pregnancy,’ she says. ‘A simple change in vitamin to focus on iodine and folate can make a big difference.’ Ms Barwick says community pharmacists may also recommend over-the-counter medicines such as doxylamine for symptoms of nausea and vomiting in pregnancy (NVP), and monitor its effectiveness.‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.' ANNA BARWICK MPSWhen women have symptoms of NVP, Ms Meyer points out that a family member might come into the pharmacy on their behalf if they are severely unwell. ‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency, such as vomiting to the point of severe dehydration, heart palpitations, blurred vision and cramping.’ When ondansetron is prescribed, pharmacists can recommend easy-to-consume forms, such as sublingual wafers, she adds. Preeclampsia Pregnant women who present with new hypertension after 20 weeks should be screened for preeclampsia.7 Community and credentialed pharmacists can assist patients with monitoring blood pressure, and look out for signs of preeclampsia, such as sudden oedema and weight gain, says Ms Barwick. ‘Patients can also be taught how to use a home blood pressure monitor appropriately and record the results. Women at high-risk of developing preeclampsia should consider treatment with low-dose aspirin,8 which can also be used to manage coagulation abnormalities in early pregnancy to prevent miscarriage. ‘A dose of around 75 mg has been shown to be effective for delivering a healthy baby, safely,’ notes Ms Barwick.9 Up to 150 mg can be used to prevent preeclampsia, she adds.10 Pharmacists should also keep a record of pregnant patients using aspirin to monitor for any potential adverse effects, such as bruising or bleeding. ‘While the risk of low-dose, aspirin-associated bleeding is low, reinforce the importance of looking out for any signs, either vaginal or rectal,’ Ms Barwick warns.Vaccinations
Australia has ‘dismal’ antenatal vaccination rates, with 15% vaccinated against influenza, 27% against pertussis, and only 12% against both among more than 591,000 pregnancies analysed in a population-based linked cohort study of data between 2012–2017.11 COVID-19 vaccine hesitancy has also been detected among pregnant Australian women.12 Overall, there is a lack of understanding of the benefits of antenatal vaccination, including providing immunity to both baby and mother against serious respiratory infections, says Ms Al-Adhami. Reduced access to vaccines is also an issue, particularly among vulnerable populations, such as those with mental health problems, and Aboriginal and Torres Strait Islander peoples. ‘Once we identified some women were having difficulties accessing antenatal vaccinations in the community, we recognised an opportunity to extend our scope of practice and improve our service delivery within the clinic,’ she says. This included credentialed training and the development of an opportunistic model of care, where ‘at-risk’ women were counselled and offered antenatal vaccinations during clinic visits. ‘Last year 546 vaccines were administered by our specialist antenatal pharmacists, adds Ms Al-Adhami.13 In Ms Meyer’s experience there has also been confusion among women about what vaccines are needed during pregnancy, and where to get them. ‘The states and territories all have different rules and regulations around who can provide National Immunisation Program (NIP) vaccines,’ she says. With most jurisdictions now increasing the number of vaccines pharmacists can administer, this should be used as an opportunity to initiate conversations with pregnant women about vaccination. ‘Ensure the mother is well educated on what vaccines she, and other family members, should receive according to current guidelines,’ says Ms Meyer.
All about birthing on country[caption id="attachment_25937" align="alignnone" width="500"] In 2020, photographer Bobbi Lockyer created a Birthing on Country project to highlight and create awareness around birthing issues and outcomes in Aboriginal women. For more, see www.bobbilockyer.com[/caption] Birthing on Country (BOC) is a holistic, integrated and culturally appropriate model of care, aimed at providing the best start in life for Aboriginal and Torres Strait Islander babies and their families.14 Broader than labour and delivery, BOC addresses socio-cultural and spiritual risk not dealt with through mainstream services. Guiding principles for a BOC program include respect for and incorporation of the knowledge and traditional practice of Aboriginal and Torres Strait Islander peoples, incorporate a holistic definition of health, respect for family involvement, women’s business, connection with Country and continuity of culturally safe care.15 Aboriginal and Torres Strait Islander mothers are 3–5 times more likely to die in childbirth than other mothers. Their babies are almost twice as likely to die in the first year of life – often due to premature birth.16 With research revealing access to community-governed, culturally safe birthing services is linked to a reduced risk of premature birth,17 pharmacists can advocate for and support BOC models of care. ‘BOC is so much broader than where a mother births – it is a social justice movement and system-wide reform. It’s an opportunity to Close the Gap in life outcomes for mums and bubs by recognising the impact of colonisation and the benefits of returning childbirth services to Aboriginal and Torres Strait Island community control,’ says Alice Nugent MPS, Aboriginal Community Controlled Health Organisation Pharmacist. Although not available everywhere, BOC can still involve birthing in a local hospital with the presence of an Aboriginal or Torres Strait Islander midwife or support worker throughout a woman’s pregnancy, birthing and post-natal journey. Once the baby is born, ongoing support is usually provided to the family, which may include cultural ceremonies for the mother and newborn. |
‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency.' Jacqueline Meyer MPSInfant formulas Formula manufacturers commonly use marketing that may feed into parental anxieties in claiming their products can prevent fussiness, help with colic, or improve night-time sleep.22 Pharmacists can emphasise the ‘antibodies, immunoglobulins and health benefits’ that breast milk can provide, along with advice on ensuring milk quality is at optimum levels, says Ms Meyer. ‘The number one thing is to eat before you feed,’ she says. ‘Mothers should also have a wholesome, balanced diet full of fresh nutrients and vegetables, so nutritional intake is at a premium.’ While breastfeeding should be encouraged, pharmacists can also guide mothers around selecting the right formulas when breastfeeding is not possible, says Ms Meyer. ‘We get a lot of questions around milk-free or dairy-free alternatives due to rising concerns of allergies and intolerances,’ she says. Factors to consider include the baby’s age, digestive issues, peptide profiles, short- or long-chain formula requirements, or whether specific formulas need to be prescribed. Pharmacists should also enquire how formulas are tolerated over a trial period – which ones and for how long, any reactions such as refusal, any reflux-type symptoms, changes in stool colour, irritability and any difficulty settling, suggests Ms Meyer. ‘Just trialling the formula for one day is often not enough. A longer period of time is required to identify a true intolerance.’ Medicines and breastfeeding Another reason why mothers opt to stop breastfeeding is medicine use.27 Pharmacists can reassure patients that very small amounts of medicines generally pass through breast milk, says Ms Meyer. ‘Medicine should never be a reason to stop breastfeeding, unless specifically advised to do so.’ Pharmacists can also advise patients when to take their medicines. ‘If the medicine is taken multiple times a day, recommend taking it directly after a breastfeed, so it reaches peak concentration in between feeding cycles,’ she says.
‘If your mum or dad had perinatal mental ill health, you’re more likely to have mental ill-health issues later on.' Lily Pham MPS
What's ailing pregnant and new mums?Pregnancy and the early stages of motherhood are fraught with discomfort. In addition to nausea and vomiting, some common ailments in pregnancy include constipation and indigestion, says Ms Al-Adhami. To overcome constipation, often due to hormone changes that slow down muscles in the bowel, patients should be advised to increase their fibre content by consuming fresh fruit and vegetables, wholemeal breads and breakfast cereals, nuts and legumes. Supplements such as psyllium husks can also be introduced. As iron tablets can also cause constipation, pharmacists can suggest another product for a trial period.23 Antacids for indigestion are safe to use in pregnancy. Calcium-based formulations are preferable to aluminium-containing antacids.24 When the baby arrives, back pain, incontinence and repetitive strain injuries are common. For mild to moderate pain, paracetamol is considered a safe analgesic during lactation, with the dose transferred through breast milk estimated to be 6% – much smaller than a child’s dose.25 Ibuprofen is also considered to be compatible with breastfeeding.25 Pelvic floor exercises can help to address post-birth incontinence, along with avoidance of persistent heavy lifting, repetitive coughing and straining.26 |
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25947 [post_author] => 3410 [post_date] => 2024-04-29 11:47:15 [post_date_gmt] => 2024-04-29 01:47:15 [post_content] => Nitazenes are becoming more common in the Australian illicit drug market, and are linked to an increasing number of overdoses and deaths. Last week, nitazines were detected in samples related to a cluster of 20 overdoses in the New South Wales Nepean Blue Mountains local health district. There have been 16 overdose deaths involving nitazenes in Victoria since 2021, prompting two coroners to recommend the implementation of drug checking services in the state. [caption id="attachment_10405" align="alignright" width="300"] Suzanne Nielsen MPS[/caption] Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne, explains how this little-understood drug entered the market and why pharmacists need to rethink harm minimisation.What’s the history of this synthetic opioid?
‘Nitazenes’ are a family of drugs. Substances within the class vary in potency, from lower in potency to significantly exceeding fentanyl’s strength. After nitazenes were synthesised in the late 1950s, development of the opioid as a therapeutic product was abandoned after early testing revealed high rates of adverse effects – including severe respiratory depression. In recent years, they have emerged as novel psychoactive substances, said Prof Nielsen. ‘Chemists who make illicit drugs [often] go back to drugs that didn't make it through the development pathway,’ she said. These drugs are therefore not internationally controlled, meaning their manufacture and distribution is ‘not necessarily illegal’. ‘It takes a while for national and international regulations to catch up and make them controlled substances,’ added Prof Nielsen. Most nitazenes that have been detected in Australia are also similar to, or stronger than fentanyl in potency. But while the pharmacology and effects of fentanyl are well profiled, the same can’t be said about nitazenes. ‘There are very few studies [that provide] a good sense of exactly how strong they are, how they work and how long they last,’ she said. ‘We do know they're very strong and have other negative effects we haven't fully characterised yet.’Where are nitazenes found?
Fentanyl and other novel synthetic opioids are commonly packaged and sold as substances such as oxycodone tablets, said Prof Nielsen. ‘Some people go online to find pharmaceuticals because they can be easier to access than through the healthcare system,’ she said. ‘Unless you're familiar with what to look for, these products look quite similar to pharmaceutical products.’ Some people, in the pursuit of a strong opioid, purchase nitazenes intentionally. But the majority of detections are in unintended purchases, when other substances are sought. ‘Sometimes [they are in] opioids such as heroin,’ said Prof Nielsen. ‘But we've seen detections in drugs being sold as ketamine, MDMA or other stimulants.’ These detections are cause for the most concern. ‘People seeking to use MDMA in a festival environment [likely] won't have any opioid tolerance, and will be very susceptible to an opioid overdose.’Is Australia at risk of a nitazene epidemic?
Nitazenes are causing large ‘clusters of deaths’ in England, Scotland and Ireland – where fentanyl has yet to emerge in the illicit market. There are concerns among addiction experts that Australia could similarly skip over fentanyl and head straight into a nitazene wave, warned Prof Nielsen. ‘There have been reports that the amount of heroin manufactured is dropping off,’ she said. ‘With the Taliban shutting down poppy production, an 80–95% reduction in heroin availability is expected.’ Programs such as real-time prescription monitoring and a tightening of regulations have also contributed to a ‘supply shock’ – which is historically associated with the entrance of potent substances into drug markets, said Prof Nielsen. With drug checking not widely accessible in Australia, it’s possible there are more nitazenes out there than we know. ‘Given overdose deaths have gone up fairly quickly in other parts of the world where these drugs have emerged, now is the time to raise the alarm.’What can pharmacists do to help?
With drugs such as MDMA or ketamine containing nitazenes, pharmacists need to broaden their approach to harm reduction, said Prof Nielsen. This includes anticipating requests for take-home naloxone (THN) from people who use drugs occasionally who have heard about the synthetic opioid – which should always be met with a positive response. Pharmacists could say, ‘it’s great you're asking for naloxone. I'm happy to provide it for you’, said Prof Nielsen. Follow-up questions could include:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 26036 [post_author] => 3410 [post_date] => 2024-05-06 12:37:31 [post_date_gmt] => 2024-05-06 02:37:31 [post_content] => Did you know a new Australian Cardiovascular risk calculator (AusCVDRisk) was released last year? If not, you’re not alone, said Karl Winckel, pharmacist at Princess Alexandra Hospital and the University of Queensland’s School of Pharmacy. [caption id="attachment_26040" align="alignright" width="222"] Karl Winckel[/caption] ‘It’s gone under the radar,’ he said. ‘Education about the new tool is mostly targeted at GPs rather than nurses or pharmacists.’ As it turns out, CVD risk has been ‘massively overestimated’ through use of previous CVD risk tables. With landmark studies such as ASPREE, ARRIVE, ASCEND all showing much lower benefit than expected for aspirin in primary prevention, it’s time to shift approach to preventative care. To kick off Heart Week (6–12 May 2024), Australian Pharmacist explains how to best wield the new tool to your patients’ advantage.What was wrong with the previous CVD calculator
Previous CVD risk assessments were based on the ongoing Framingham Heart Study, conducted in the small Massachusetts town of Framingham, dating back to the late 1940s. But cardiovascular risk has changed significantly since then, with people more aware of the risks, said Mr Winckel. ‘People are also exercising more and using preventative therapies,’ he said. The new AusCVDRisk tool uses QRISK3 risk prediction models, incorporating data from the United Kingdom and New Zealand, with baseline risk adjusted to suit the Australian context. ‘They looked at all the Australian Bureau of Statistics (ABS) and relevant surveys in New Zealand to dictate the number of strokes and heart attacks in different age and comorbidity brackets,’ he said. There was also lack of nuance when using the Framingham risk tables. For example, when users classified their smoking habits, they would simply click ‘smoker’ or ‘non-smoker’. ‘That means if you quit smoking a week ago, that classifies you as a nonsmoker, but you might have been smoking for 30 years,’ Mr Winckel said. While CVD risk reduces upon cessation, it never returns to baseline. With AusCVDRisk, users can include more details about their smoking history, including if they’re a never-smoker or ex-smoker. To demonstrate the variation in risk estimation between the Framingham and AusCVDRisk tools, Mr Winckel calculated his CVD risk using both. The former placed his risk at 5–10% over 5 years. Using AusCVDRisk, it was 2%. ‘That’s a big difference,’ he added.What are the benefits of the new calculator?
When it comes to calculating CVD risk, the devil is in the details. More information is included in AusCVDRisk about users' diabetes history to quantify a more accurate risk score, including:
Pharmacists should detect unnecessary and/or harmful uses of primary prevention, based on updated CVD risk, at any opportunity they have to review or consider a patient’s medicine profile.
This should be a key consideration for credentialed pharmacists conducting Home Medicines Reviews or Residential Medication Management Reviews.
Aside from antiplatelets, antihypertensives (which can lead to a significant drop in blood pressure among older patients) should also be investigated, along with beta blockers for primary hypertension, said Mr Winckel. ‘Beta blockers generally increase mortality for many frail elderly people by increasing risk of falls and subsequent fractures,’ he said. ‘When patients are not currently hypertensive, all hypertensives should be reviewed.’ But cessation of antiplatelets should only be considered when used in primary prevention, Mr Winckel warned. ‘If used for secondary prevention, lifelong antiplatelet therapy is required.’ [post_title] => New tool to counteract significant overestimate of CVD risk [post_excerpt] => Did you know a new Australian Cardiovascular risk calculator (AusCVDRisk) was released last year?If not, you’re not alone. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => new-tool-to-counteract-significant-overestimate-of-cvd-risk [to_ping] => [pinged] => [post_modified] => 2024-05-06 15:01:30 [post_modified_gmt] => 2024-05-06 05:01:30 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=26036 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => New tool to counteract significant overestimate of CVD risk [title] => New tool to counteract significant overestimate of CVD risk [href] => https://www.australianpharmacist.com.au/new-tool-to-counteract-significant-overestimate-of-cvd-risk/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 26038 )td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25965 [post_author] => 3410 [post_date] => 2024-05-01 13:01:56 [post_date_gmt] => 2024-05-01 03:01:56 [post_content] => New credentialing requirements announced as pharmacists prepare to take on aged care roles. The federal Department of Health and Aged Care has announced that pharmacists will need an Aged Care credential to become an aged care on-site pharmacist. Those who want to provide medication reviews such as Residential Medication Management Reviews and/or Home Medicine Reviews reviews will also need to complete a Medication Management Review (MMR). Kerri Barwick, PSA General Manager of Education and Training at PSA, explains what that involves.What’s the difference between accredited and credentialed pharmacists?
The change from ‘accredited’ to ‘credentialed’ pharmacist was initiated after the Australian Pharmacy Council was asked by the Department of Health and Aged Care to design accreditation standards for education providers, such as PSA, following the closure of the Australian Association of Consultant Pharmacy (AACP). In order to access government funding, a credential will be required that meets those standards for MMR and Aged Care.Why have these changes been made?
The AACP’s accreditation process was self-regulated and wasn't governed by an accrediting body. Standards are now in place to ensure the quality of the education delivered – including accreditation standards for educators and performance outcomes for learners, said Ms Barwick. Because ‘credentialed’ is now looked at from the perspective of meeting performance outcomes at the end of the program, the AACP-based assessment style – which entailed multiple choice questionnaires on clinical information and communication – doesn’t fit within this model. ‘To meet all those performance outcomes and accreditation standards, you couldn't run the same program,’ she said. ‘It wouldn't meet the standards.’ The skills required to provide MMR and Aged Care services also require additional specialisation, said Ms Barwick. ‘For the government to be able to pay pharmacists for those services, they want to guarantee the quality,’ she said.What will the new credentials involve?
PSA’s MMR and Aged Care credential programs, currently undergoing accreditation with APC, will involve case-based discussion and learning, along with simulations. ‘This will give learners as many real-life examples as we can without requiring a large amount of time learning on the job,’ explained Ms Barwick. ‘The PSA will also deliver both the MMR and Aged Care credential, so you'll be able to enrol in either or the whole package.’ PSA’s MMR and Aged Care credentials should be available for pharmacists in June 2024, pending the outcome of the next accreditation meeting.When do the changes take effect?
Not for a while. This week (29 April), the government announced an extension to Medication Review Numbers (MRNs) to support credentialed pharmacists to continue providing MMR services until 30 June 2025 during the transition to the new credentialing system. Pharmacists must transition to the new qualification within that 12-month period. PSA has been involved in discussions with the Department ‘for some time’ to ensure transition arrangements are in place to minimise disruption to patient services, and allow the existing workforce to continue providing MMR services in the immediate term, said PSA National President Associate Professor Fei Sim FPS. ’PSA continues to approach this fast-moving practice area with the intent to support our workforce, and to ensure the credentialing and recredentialing process is achievable and affordable,’ she said.Do I have to start credentialing from scratch?
No! PSA will have a process for recognition of prior learning for the MMR and Aged Care credential. PSA has also mapped the assessment delivered by AACP against the performance outcomes and assessed the existing gaps, said Ms Barwick. ‘For example, for the MMR credential, there's a performance outcome around cultural safety and cultural competence which pharmacists accredited by the AACP or PSA in the last 12 months will not have fulfilled,’ she said. To fill that gap pharmacists have the option to:
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25567 [post_author] => 3919 [post_date] => 2024-05-01 11:01:36 [post_date_gmt] => 2024-05-01 01:01:36 [post_content] => Optimising proton pump inhibitor therapy in pharmacy Proton pump inhibitors (PPIs) are a widely used pharmacological treatment option for management of gastro-oesophageal reflux.1 [caption id="attachment_25337" align="alignright" width="233"] This activity is sponsored by Reckitt. All content is the true, accurate and independent opinion of the author and the views expressed are entirely their own.[/caption] While data on PPIs highlighted concerns about long-term use and the need for appropriate prescribing, an analysis of Pharmaceutical Benefits Scheme (PBS) data following the introduction of prescribing restrictions in 2019 suggests that a reliance on PPIs for management of reflux symptoms remains.2 Indeed, PPIs are an effective and well-tolerated pharmacotherapy for reflux and can be used confidently in the correct indications: first-line as a regular therapy for frequent/severe symptoms of gastro-oesophageal reflux disease (GORD), and second-line as an ‘on-demand’ therapy for mild/intermittent gastro-oesophageal reflux symptoms (see Therapeutic Guidelines for further information).1 However, for a variety of reasons, up to 40% of patients taking daily PPI for reflux symptoms are considered to have ‘PPI treatment failure’ or refractory GORD.3 Understanding the possible causes of persistent symptoms is important for pharmacists to efficiently troubleshoot next steps in management and/or recommend the appropriate course of action for the patient and their doctor to further investigate the issue. This article will provide an overview of 6 reasons why patients may find their PPIs failing — and courses of action to manage their concerns.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25351 [post_author] => 3387 [post_date] => 2024-04-29 12:14:39 [post_date_gmt] => 2024-04-29 02:14:39 [post_content] => Pharmacists encounter pregnant and new mums more often than most health professionals, and can have a bird’s-eye view when things go awry. At 20 weeks pregnant, PSA’s Queensland Pharmacist of the Year Jacqueline Meyer MPS, was diagnosed with intrauterine growth restriction, which severely impacted her fetal growth. A few weeks later, she stopped working – effective immediately. ‘I was put on immediate bed rest, even though I felt fine,’ she says. With her amniotic fluid diminished, Ms Meyer’s daughter, Fallon, was born at 28 weeks. Weighing only 520 grams, Fallon was placed in an incubator in the neonatal intensive care unit where she remained for the next 2 months. Ms Meyer is one of thousands of women who experience pregnancy complications, including gestational diabetes mellitus (GDM), affecting 1 in 6 pregnant Australian women.1 Perinatal depression (PND) is another prevalent complication, affecting up to 1 in 5 expectant or new mothers.2 However, there are significant gaps in pregnancy and early childhood support in Australia. With GDM diagnoses doubled within a decade,3 many patients are forced to rely on group education classes, says Anna Barwick MPS, credentialed pharmacist, and founder of remote access telehealth advisory service PharmOnline. Meanwhile, suicide is the third-highest cause of death among new mothers in Australia.4 After her turbulent pregnancy, Ms Meyer thinks pharmacists can help to fill these gaps. ‘We can recognise red flags, direct patients where to seek help, and provide emotional support about the importance of looking after your own health and nutrition.’Medicine use in pregnancy
While ‘every woman’ wants to avoid exposing their unborn child to risks associated with taking medicines for chronic conditions such as epilepsy, inflammatory bowel disease and arthritis, those risks can sometimes be overestimated, says Noor Al-Adhami, Women’s and Newborn Pharmacy Team Leader at Brisbane’s Royal Brisbane and Women’s Hospital (RBWH). ‘A gap we often see in RBWH’s Maternity Outpatient Clinic is lack of discussions around safety of medicines prescribed for depression and anxiety in pregnancy and breastfeeding,’ she says. ‘This can lead to women stopping their medicines abruptly without discussing with their GP or midwife, resulting in a deterioration in mental health that can negatively impact maternal and fetal outcomes.’ Pharmacists are in a good position to provide support and information regarding the safety of medicines in pregnancy and to address any concerns in a non-judgemental manner. ‘Advice regarding safety of antidepressant medicines involves discussing the benefit of continuation/initiation on maternal health, including improved function and quality of life, as well as risk to the fetus, which evidence shows is minimal with appropriate antidepressants,’ says Ms Al-Adhami.Health monitoring
While pregnancy is a short-term phase of life, significant ongoing effects can be experienced, particularly in children from pregnancies that are not well managed, says Ms Barwick. ‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.’ Gestational diabetes When expectant mums are diagnosed with GDM, community pharmacists can walk them through the process of monitoring blood glucose levels (BGLs). Where insulin is prescribed, pharmacists can inquire whether the dose is controlling blood glucose levels, and check their injection technique, says Ms Meyer. The use of insulin, considered a high-risk medication with APINCHs classification,5 Ms Barwick notes, provides justification for a Home Medicines Review (HMR). ‘There’s an advantage to going into the home to observe the patient’s diet, consider potential interactions, and educate patients on the best effects and outcomes,’ she says. Advice around cleaning blood glucose level (BGL) monitors to ensure accuracy can also be provided. ‘Pharmacists can explain how to put test drops through and clean blood spills on the monitor, common in pregnancy due to higher blood volume,’ says Ms Barwick. With only 50% of women diagnosed with GDM receiving tests for heart disease and type 2 diabetes post-pregnancy,6 HMRs can be beneficial at this stage of the journey, too. ‘Along with conversations around diet choices, exercise regimes and sleep, I also explain how often testing is required over the next 5–10 years, and how to monitor for signs of the development of diabetes,’ Ms Barwick advises. Nausea and vomiting in pregnancy The presence of iron in pregnancy multivitamins may exacerbate symptoms of nausea and vomiting in some pregnancies, according to Ms Barwick. ‘Pharmacists can recommend a trial cessation of the iron component of pregnancy vitamins, often unnecessary in pregnancy,’ she says. ‘A simple change in vitamin to focus on iodine and folate can make a big difference.’ Ms Barwick says community pharmacists may also recommend over-the-counter medicines such as doxylamine for symptoms of nausea and vomiting in pregnancy (NVP), and monitor its effectiveness.‘There are many points, particularly during health crises, where pharmacists can intervene, monitor and provide recommendations.' ANNA BARWICK MPSWhen women have symptoms of NVP, Ms Meyer points out that a family member might come into the pharmacy on their behalf if they are severely unwell. ‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency, such as vomiting to the point of severe dehydration, heart palpitations, blurred vision and cramping.’ When ondansetron is prescribed, pharmacists can recommend easy-to-consume forms, such as sublingual wafers, she adds. Preeclampsia Pregnant women who present with new hypertension after 20 weeks should be screened for preeclampsia.7 Community and credentialed pharmacists can assist patients with monitoring blood pressure, and look out for signs of preeclampsia, such as sudden oedema and weight gain, says Ms Barwick. ‘Patients can also be taught how to use a home blood pressure monitor appropriately and record the results. Women at high-risk of developing preeclampsia should consider treatment with low-dose aspirin,8 which can also be used to manage coagulation abnormalities in early pregnancy to prevent miscarriage. ‘A dose of around 75 mg has been shown to be effective for delivering a healthy baby, safely,’ notes Ms Barwick.9 Up to 150 mg can be used to prevent preeclampsia, she adds.10 Pharmacists should also keep a record of pregnant patients using aspirin to monitor for any potential adverse effects, such as bruising or bleeding. ‘While the risk of low-dose, aspirin-associated bleeding is low, reinforce the importance of looking out for any signs, either vaginal or rectal,’ Ms Barwick warns.Vaccinations
Australia has ‘dismal’ antenatal vaccination rates, with 15% vaccinated against influenza, 27% against pertussis, and only 12% against both among more than 591,000 pregnancies analysed in a population-based linked cohort study of data between 2012–2017.11 COVID-19 vaccine hesitancy has also been detected among pregnant Australian women.12 Overall, there is a lack of understanding of the benefits of antenatal vaccination, including providing immunity to both baby and mother against serious respiratory infections, says Ms Al-Adhami. Reduced access to vaccines is also an issue, particularly among vulnerable populations, such as those with mental health problems, and Aboriginal and Torres Strait Islander peoples. ‘Once we identified some women were having difficulties accessing antenatal vaccinations in the community, we recognised an opportunity to extend our scope of practice and improve our service delivery within the clinic,’ she says. This included credentialed training and the development of an opportunistic model of care, where ‘at-risk’ women were counselled and offered antenatal vaccinations during clinic visits. ‘Last year 546 vaccines were administered by our specialist antenatal pharmacists, adds Ms Al-Adhami.13 In Ms Meyer’s experience there has also been confusion among women about what vaccines are needed during pregnancy, and where to get them. ‘The states and territories all have different rules and regulations around who can provide National Immunisation Program (NIP) vaccines,’ she says. With most jurisdictions now increasing the number of vaccines pharmacists can administer, this should be used as an opportunity to initiate conversations with pregnant women about vaccination. ‘Ensure the mother is well educated on what vaccines she, and other family members, should receive according to current guidelines,’ says Ms Meyer.
All about birthing on country[caption id="attachment_25937" align="alignnone" width="500"] In 2020, photographer Bobbi Lockyer created a Birthing on Country project to highlight and create awareness around birthing issues and outcomes in Aboriginal women. For more, see www.bobbilockyer.com[/caption] Birthing on Country (BOC) is a holistic, integrated and culturally appropriate model of care, aimed at providing the best start in life for Aboriginal and Torres Strait Islander babies and their families.14 Broader than labour and delivery, BOC addresses socio-cultural and spiritual risk not dealt with through mainstream services. Guiding principles for a BOC program include respect for and incorporation of the knowledge and traditional practice of Aboriginal and Torres Strait Islander peoples, incorporate a holistic definition of health, respect for family involvement, women’s business, connection with Country and continuity of culturally safe care.15 Aboriginal and Torres Strait Islander mothers are 3–5 times more likely to die in childbirth than other mothers. Their babies are almost twice as likely to die in the first year of life – often due to premature birth.16 With research revealing access to community-governed, culturally safe birthing services is linked to a reduced risk of premature birth,17 pharmacists can advocate for and support BOC models of care. ‘BOC is so much broader than where a mother births – it is a social justice movement and system-wide reform. It’s an opportunity to Close the Gap in life outcomes for mums and bubs by recognising the impact of colonisation and the benefits of returning childbirth services to Aboriginal and Torres Strait Island community control,’ says Alice Nugent MPS, Aboriginal Community Controlled Health Organisation Pharmacist. Although not available everywhere, BOC can still involve birthing in a local hospital with the presence of an Aboriginal or Torres Strait Islander midwife or support worker throughout a woman’s pregnancy, birthing and post-natal journey. Once the baby is born, ongoing support is usually provided to the family, which may include cultural ceremonies for the mother and newborn. |
‘Pharmacists can check how the woman is feeling and advise on the red flags that warrant a medical emergency.' Jacqueline Meyer MPSInfant formulas Formula manufacturers commonly use marketing that may feed into parental anxieties in claiming their products can prevent fussiness, help with colic, or improve night-time sleep.22 Pharmacists can emphasise the ‘antibodies, immunoglobulins and health benefits’ that breast milk can provide, along with advice on ensuring milk quality is at optimum levels, says Ms Meyer. ‘The number one thing is to eat before you feed,’ she says. ‘Mothers should also have a wholesome, balanced diet full of fresh nutrients and vegetables, so nutritional intake is at a premium.’ While breastfeeding should be encouraged, pharmacists can also guide mothers around selecting the right formulas when breastfeeding is not possible, says Ms Meyer. ‘We get a lot of questions around milk-free or dairy-free alternatives due to rising concerns of allergies and intolerances,’ she says. Factors to consider include the baby’s age, digestive issues, peptide profiles, short- or long-chain formula requirements, or whether specific formulas need to be prescribed. Pharmacists should also enquire how formulas are tolerated over a trial period – which ones and for how long, any reactions such as refusal, any reflux-type symptoms, changes in stool colour, irritability and any difficulty settling, suggests Ms Meyer. ‘Just trialling the formula for one day is often not enough. A longer period of time is required to identify a true intolerance.’ Medicines and breastfeeding Another reason why mothers opt to stop breastfeeding is medicine use.27 Pharmacists can reassure patients that very small amounts of medicines generally pass through breast milk, says Ms Meyer. ‘Medicine should never be a reason to stop breastfeeding, unless specifically advised to do so.’ Pharmacists can also advise patients when to take their medicines. ‘If the medicine is taken multiple times a day, recommend taking it directly after a breastfeed, so it reaches peak concentration in between feeding cycles,’ she says.
‘If your mum or dad had perinatal mental ill health, you’re more likely to have mental ill-health issues later on.' Lily Pham MPS
What's ailing pregnant and new mums?Pregnancy and the early stages of motherhood are fraught with discomfort. In addition to nausea and vomiting, some common ailments in pregnancy include constipation and indigestion, says Ms Al-Adhami. To overcome constipation, often due to hormone changes that slow down muscles in the bowel, patients should be advised to increase their fibre content by consuming fresh fruit and vegetables, wholemeal breads and breakfast cereals, nuts and legumes. Supplements such as psyllium husks can also be introduced. As iron tablets can also cause constipation, pharmacists can suggest another product for a trial period.23 Antacids for indigestion are safe to use in pregnancy. Calcium-based formulations are preferable to aluminium-containing antacids.24 When the baby arrives, back pain, incontinence and repetitive strain injuries are common. For mild to moderate pain, paracetamol is considered a safe analgesic during lactation, with the dose transferred through breast milk estimated to be 6% – much smaller than a child’s dose.25 Ibuprofen is also considered to be compatible with breastfeeding.25 Pelvic floor exercises can help to address post-birth incontinence, along with avoidance of persistent heavy lifting, repetitive coughing and straining.26 |
td_module_mega_menu Object ( [authorType] => [post] => WP_Post Object ( [ID] => 25947 [post_author] => 3410 [post_date] => 2024-04-29 11:47:15 [post_date_gmt] => 2024-04-29 01:47:15 [post_content] => Nitazenes are becoming more common in the Australian illicit drug market, and are linked to an increasing number of overdoses and deaths. Last week, nitazines were detected in samples related to a cluster of 20 overdoses in the New South Wales Nepean Blue Mountains local health district. There have been 16 overdose deaths involving nitazenes in Victoria since 2021, prompting two coroners to recommend the implementation of drug checking services in the state. [caption id="attachment_10405" align="alignright" width="300"] Suzanne Nielsen MPS[/caption] Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne, explains how this little-understood drug entered the market and why pharmacists need to rethink harm minimisation.What’s the history of this synthetic opioid?
‘Nitazenes’ are a family of drugs. Substances within the class vary in potency, from lower in potency to significantly exceeding fentanyl’s strength. After nitazenes were synthesised in the late 1950s, development of the opioid as a therapeutic product was abandoned after early testing revealed high rates of adverse effects – including severe respiratory depression. In recent years, they have emerged as novel psychoactive substances, said Prof Nielsen. ‘Chemists who make illicit drugs [often] go back to drugs that didn't make it through the development pathway,’ she said. These drugs are therefore not internationally controlled, meaning their manufacture and distribution is ‘not necessarily illegal’. ‘It takes a while for national and international regulations to catch up and make them controlled substances,’ added Prof Nielsen. Most nitazenes that have been detected in Australia are also similar to, or stronger than fentanyl in potency. But while the pharmacology and effects of fentanyl are well profiled, the same can’t be said about nitazenes. ‘There are very few studies [that provide] a good sense of exactly how strong they are, how they work and how long they last,’ she said. ‘We do know they're very strong and have other negative effects we haven't fully characterised yet.’Where are nitazenes found?
Fentanyl and other novel synthetic opioids are commonly packaged and sold as substances such as oxycodone tablets, said Prof Nielsen. ‘Some people go online to find pharmaceuticals because they can be easier to access than through the healthcare system,’ she said. ‘Unless you're familiar with what to look for, these products look quite similar to pharmaceutical products.’ Some people, in the pursuit of a strong opioid, purchase nitazenes intentionally. But the majority of detections are in unintended purchases, when other substances are sought. ‘Sometimes [they are in] opioids such as heroin,’ said Prof Nielsen. ‘But we've seen detections in drugs being sold as ketamine, MDMA or other stimulants.’ These detections are cause for the most concern. ‘People seeking to use MDMA in a festival environment [likely] won't have any opioid tolerance, and will be very susceptible to an opioid overdose.’Is Australia at risk of a nitazene epidemic?
Nitazenes are causing large ‘clusters of deaths’ in England, Scotland and Ireland – where fentanyl has yet to emerge in the illicit market. There are concerns among addiction experts that Australia could similarly skip over fentanyl and head straight into a nitazene wave, warned Prof Nielsen. ‘There have been reports that the amount of heroin manufactured is dropping off,’ she said. ‘With the Taliban shutting down poppy production, an 80–95% reduction in heroin availability is expected.’ Programs such as real-time prescription monitoring and a tightening of regulations have also contributed to a ‘supply shock’ – which is historically associated with the entrance of potent substances into drug markets, said Prof Nielsen. With drug checking not widely accessible in Australia, it’s possible there are more nitazenes out there than we know. ‘Given overdose deaths have gone up fairly quickly in other parts of the world where these drugs have emerged, now is the time to raise the alarm.’What can pharmacists do to help?
With drugs such as MDMA or ketamine containing nitazenes, pharmacists need to broaden their approach to harm reduction, said Prof Nielsen. This includes anticipating requests for take-home naloxone (THN) from people who use drugs occasionally who have heard about the synthetic opioid – which should always be met with a positive response. Pharmacists could say, ‘it’s great you're asking for naloxone. I'm happy to provide it for you’, said Prof Nielsen. Follow-up questions could include:
Get your weekly dose of the news and research you need to help advance your practice.
Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
Take a short survey about what you think of Australian Pharmacist and be in with the chance to win one of five $100 prizes.