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[post_content] => Medicinal cannabis prescribing in Australia has risen sharply in recent years, with the Therapeutic Goods Administration (TGA) recording thousands of approvals each month under the Special Access Scheme (SAS) and Authorised Prescriber pathways.
Following the expansion of these pathways in 2016, over 700,000 prescription approvals have been issued.
TGA data show that the most common indications for SAS Category B approvals to prescribe medicinal cannabis are for chronic pain, anxiety and sleep disorder.
For pharmacists, this presents an obligation to critically assess the evidence of benefit, weigh potential risks and interactions and apply rigorous professional standards when dispensing.
What’s the leading indication for medicinal cannabis prescribing?
Chronic non-cancer pain. But the quality of supporting evidence is far less robust than the demand for treatment suggests.
Evidence shows that medicinal cannabis may provide a small benefit for a subset of patients who live with chronic pain, said Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne.
[caption id="attachment_10405" align="alignright" width="318"]
Professor Suzanne Nielsen MPS[/caption]
‘And of those people who find it efficacious, the benefits are often quite small,’ she said.
Concerns also remain about the safety of long-term use.
‘We already know that the pattern we saw with opioid [dependence] has been replicated with medicinal cannabis, with recent studies showing around one in four people using medicinal cannabis meets criteria for cannabis dependence,’ Prof Nielsen said.
Alongside evidence-based pharmacological approaches, some of the most effective treatments for chronic pain is typically multidisciplinary care, including behavioural and physical therapies.
‘This helps to avoid some of the serious [adverse] effects we see with some medicines,’ she said.
Some studies show that medicinal cannabis is beneficial for patients with comorbid conditions, such as chronic pain and depression, Prof Nielsen said.
But when patients are assessed for therapeutic interventions for these conditions, it’s integral that healthcare professionals who are familiar with the whole person’s care are involved.
‘Someone with comorbidities alongside their chronic pain is likely to be on multiple medications where there's risk of interactions,’ Prof Nielsen said.
‘Ideally, this should be assessed and managed by a GP, perhaps with specialist input – and less ideally by a cannabis clinic that's not necessarily managing the rest of a patient's care.’
Does the evidence support medicinal cannabis for anxiety?
Not at this point, Prof Nielsen said.
‘While the evidence signals there's a possible effect for cannabidiol (CBD), the studies we're looking at often have really important limitations,’ she said.
‘They're often very small, might only have a one-off dose of CBD, and may be looking at experimentally-induced stress – not necessarily treatment of an anxiety condition.’
And for some patients, tetrahydrocannabinol (THC) containing medicines can worsen symptoms of anxiety.
‘We've seen reports of acute psychosis, particularly when people are using higher concentration THC products,’ she said. ‘So there are a number of factors we need to consider, particularly for individuals who might be predisposed to those risk factors.’
There is a range of both psychological and pharmacological treatments available to treat anxiety, including cognitive behavioural therapy and antidepressants, such as selective serotonin reuptake inhibitors.
‘It's really about remembering the therapeutic hierarchy and going with the first-line medicines, which are safest to try first before unapproved, experimental medications,’ Prof Nielsen said.
Can cannabis improve sleep or worsen insomnia?
Sleep disturbances such as insomnia are another frequent driver of medicinal cannabis prescribing. Yet, here too, the evidence base is ‘mixed’, Prof Nielsen said.
‘There are often significant weaknesses in study designs, and medicinal cannabis is often not compared against the most effective treatment,’ she said.
THC can induce drowsiness and create a perception of improved sleep among people taking it for insomnia.
‘But actually, when we look at objective measures of sleep for people, there's often nothing that's statistically or clinically different to placebo,’ Prof Nielsen said.
Furthermore, tolerance can develop with ongoing use, and cessation may trigger rebound insomnia.
‘People who have tried medicinal cannabis and then have stopped using it often find their sleep is much worse,’ she said. ‘And there is that risk of the person developing cannabis use disorder and dependence as well.’
Is medicinal cannabis the first-line therapy for any conditions?
No. There are more than 1,000 medicinal cannabis products, and most are unregistered and have not undergone safety, quality or efficacy assessment by the TGA, said Myfanwy Graham, NHMRC Postgraduate Scholar, Monash University, Fulbright Alumna in Public Health Policy, and appointed member of the TGA’s Medicinal Cannabis Expert Working Group.*
[caption id="attachment_30412" align="aligncenter" width="400"]
Myfanwy Graham[/caption]
‘TGA guidance on medicinal cannabis states that it is not a first-line treatment strategy and standard, registered treatments should be trialled or deemed inappropriate before consideration of medicinal cannabis on a case-by-case basis,’ she said.
When standard treatments prove ineffective in patients with conditions such as multiple sclerosis or rare forms of epilepsy – there is ‘good evidence’ to support the use of medicinal cannabis as an appropriate option, Prof Nielsen said.
‘And we have TGA-approved products for those conditions too.’
‘[These are] Sativex (nabiximols; Schedule 8) and Epidyolex (CBD; Schedule 4),’ Ms Graham added.
What are the potential risks and adverse effects?
Patients who are interested in trying these medicines should be made aware of the risks, including the potential for dependence, so they can make an informed decision, Prof Nielsen said.
This includes informing patients about potential adverse effects of medicinal cannabis, including:
- sedation and drowsiness
- confusion
- tachycardia
- dry mouth
- anxiety, nausea and vomiting
- appetite changes.
‘Older patients may be more susceptible to adverse effects and there are neurocognitive considerations with the use of THC-containing medicinal cannabis products in individuals under 25 years of age,’ Ms Graham said.
When dispensing ongoing prescriptions of medicinal cannabis, pharmacists should also check in with patients about the effectiveness of therapy and if they are experiencing any adverse effects. This approach is similar to the ongoing risk assessment applied to patients on long-term opioid therapy.
‘There should be an ongoing conversation around whether people are developing signs of cannabis use disorder, having difficulty controlling the amount they use, or if they tend to use it to address other symptoms as well,’ Prof Nielsen said.
‘If they are experiencing cravings and spending a lot of time thinking about using medicinal cannabis, this is suggestive that there should be an assessment of developing cannabis use disorder.’
Next steps include having a discussion with the prescriber. ‘There are drug and alcohol clinical advisory service hotline numbers in every state that they can call as well,’ she said.
Are there any contraindications and interactions to be aware of?
Pharmacists play an important role in terms of screening and counselling patients on medicinal cannabis use before dispensing, Ms Graham said.
This includes looking out for contraindications such as:
- people with a current or past psychotic disorder, or an active mood or anxiety disorder
- women who are pregnant, planning to become pregnant or breastfeeding
- people with unstable cardiovascular disease.
‘There are also cannabinoid-specific considerations such as liver function, and driving and occupational considerations,’ she said.
There are also a host of interactions between cannabidiol and other medicines, including:
- warfarin
- tacrolimus
- valproate
- methadone
- lithium.
What are pharmacists’ professional obligations?
The Australian Health Practitioner Regulation Agency (Ahpra) recently released guidance on professional responsibilities with medicinal cannabis, said Ms Graham.
‘The first port of call for pharmacists is being really well informed about the current state of evidence and regulations, both at a state and federal level, and being able to engage with patients about any questions they have [around] medicinal cannabis,’ she said.
While the dose titration of medicinal cannabis used is product and condition specific, Ms Graham said the general rule of thumb is to ‘start low and go slow’.
‘Pharmacists should have an awareness of maximum daily doses of THC, patients’ overall THC intake if they have a number of different prescriptions dispensed, and [any] dose escalation over time,’ she said. ‘And ensure that supply is in line with therapeutically appropriate quantities.’
As most medicinal cannabis approvals are for Schedule 8 products, pharmacists must complete Schedule 8 prescriber verification processes before dispensing medicinal cannabis, along with checking TGA prescription approvals. ‘[This must be done] in line with what’s required in their state or territory,’ Ms Graham added.
*Myfanwy Graham’s contributions do not represent the views of the TGA or the Medicinal Cannabis Expert Working Group
[post_title] => As medicinal cannabis prescriptions climb, does the evidence hold up?
[post_excerpt] => Medicinal cannabis prescribing in Australia has risen sharply in recent years, with the TGA recording thousands of approvals each month.
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[title_attribute] => As medicinal cannabis prescriptions climb, does the evidence hold up?
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[post_content] => The International Pharmaceutical Federation (FIP) Congress opened overnight in Copenhagen by honouring some of the world’s leading pharmacists and challenging the profession to embrace new opportunities.
‘Embrace new opportunities’
The theme of the FIP Congress this year is ‘Pharmacy Forward: Performance, Collaboration, and Health Transformation’ – aiming to explore the evolving role of pharmacists in the context of modern healthcare challenges.
Reflecting on this theme in his opening address, Paul Sinclair MPS – Australia’s first FIP President – called on pharmacists, pharmaceutical scientists and educators to be strong advocates for new opportunities.
‘Last May, FIP launched the global “Think Health, Think Pharmacy” campaign to highlight pharmacies as an underused resource in primary care. Our shared message is clear: we want everyone – and policymakers – to include pharmacy when thinking about health and universal coverage,’ he said.
‘The global pharmacy field is rapidly evolving with technology, changing healthcare, and growing recognition of pharmacists’ key role in patient-centred universal health coverage … Now is the time for pharmacists to embrace these opportunities. Our new strategic plan calls for bold action to harness pharmacists’ diverse skills and redefine the profession for a bright future.’
Professor Lisa Nissen FPS, new FIP Fellow
The opening ceremony also saw Professor Lisa Nissen FPS awarded an FIP Fellowship for her contribution to the work of the federation, and for her global and domestic impact on pharmacy practice.
This sizeable contribution has stretched more than 25 years, and has included leading:
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[post_content] => New research has found that ibuprofen and paracetamol may be contributing to antimicrobial resistance – particularly when used in combination.
Researchers from the University of South Australia conducted a study in residential aged care facilities (RACFs) on antimicrobial resistance, looking at the interactions between organisms such as Escherichia coli, non-antibiotic medicines and the broad-spectrum antibiotic ciprofloxacin, Lead Researcher Associate Professor Rietie Venter told Australian Pharmacist.
‘We also looked at an antibiotic-sensitive microorganism we isolated from a resident and we treated this microorganism with nine medications which are frequently used in the older population,’ she said.
The microorganisms were treated with the medicines – including ibuprofen, diclofenac, paracetamol, furosemide, metformin, atorvastatin, tramadol, temazepam and pseudoephedrine – both individually and in combinations of two.
Paracetamol and ibuprofen were found to increase ciprofloxacin resistance in this gut bacterium separately, and even more so when combined.
‘When bacteria were exposed to ciprofloxacin alongside ibuprofen and paracetamol, they developed more genetic mutations than with the antibiotic alone, helping them grow faster and become highly resistant,’ A/Prof Venter said.
‘Worryingly, the bacteria were not only resistant to the antibiotic ciprofloxacin, but increased resistance was also observed to multiple other antibiotics from different classes.’
How do paracetamol and ibuprofen increase antimicrobial resistance?
Sequencing in follow-up studies revealed how the organism acquired mutations, A/Prof Venter said.
‘Evolution is turbocharged in these little microbes; under ideal conditions, organisms like the one we used double every 20 minutes,’ she said.
‘If they get stressed by the addition of paracetamol and an antibiotic, they mutate. While some of those mutations make them more vulnerable, many might actually make them resistant.’
Mutations conferring resistance to ciprofloxacin were identified, along with efflux pumps – membrane proteins that expel antibiotics before they can reach their targets.
‘When used in combination, a synergy between the two medicines causes increased mutations, leading to higher levels of resistance.’
On a positive note, none of the other nine medicines analysed in the research increased antimicrobial resistance in the gut bacteria.
‘None of the other medications, when combined with ibuprofen, were worse than ibuprofen by itself,’ she said.
Are there certain populations who could be more at risk?
Older Australians, particularly those in RACFs, are a reservoir for antimicrobial resistance.
‘Older people are more likely to be prescribed multiple medications – not just antibiotics, but also medicines for pain, sleep, or blood pressure – making them an ideal breeding ground for gut bacteria to become resistant to antibiotics,’ A/Prof Venter.
While more research is needed before any policy change may be considered, A/Prof Venter thinks it’s important to understand why these analgesics are being taken together and to consider alternative options.
‘We would love to do more research to see if there is a way we can exchange an [analgesic] for another pain medication that doesn't cause the enhanced antimicrobial resistance, or if there's a certain time between taking them that’s better.’
What advice should pharmacists provide to patients?
It’s common for antibiotics to be combined with over-the-counter analgesics. For example, a woman with a urinary tract infection who is taking an antibiotic might also take an analgesic for pain relief, or a child with a bacterial infection such as tonsillitis who is prescribed azithromycin could be administered ibuprofen and paracetamol to manage a high fever.
The research provides an opportunity for pharmacists to raise awareness among patients about the risks of antimicrobial resistance, A/Prof Venter said.
‘It’s well known that the use of antibiotics may cause antimicrobial resistance,’ she said. ‘But it’s not considered that these frequently used medications can also increase antimicrobial resistance.’
The paracetamol scheduling changes introduced earlier this year are also an important step in building public awareness that these medicines are not as harmless as they might appear, A/Prof Venter believes.
‘Compared to many other medications, people tend to think of [paracetamol and ibuprofen] as completely harmless,’ she said. ‘So strategies such as smaller pack sizes can lead to changes in behaviour.’
PSA’s Medicine safety: Child and adolescent care report found that pharmacists have an increasing role in helping patients use common analgesics safely, with approximately 16% of pharmaceutical poisoning hospital admissions in children under 5 years of age being attributed to paracetamol.
‘By limiting the maximum pack sizes of paracetamol, we are opening the door to have a conversation about the risks and benefits of these medicines – both in the pharmacy and at home – and take steps as a community to promote the safe use of medicines,’ said PSA National President Associate Professor Fei Sim FPS.
‘By involving pharmacists in the supply of paracetamol in larger pack sizes, we strike the right balance between access and safety, giving pharmacists the opportunity to help patients manage their pain effectively while reducing the risk of misuse and harm.’
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[post_content] => On Monday (25 August) PSA introduced the new crop of leaders for the Early Career Pharmacist (ECP) Community of Specialty Interest (CSI) – a dynamic group dedicated to empowering the next generation of pharmacists across Australia.
Dr Ayomide Ogundipe MPS has been re-appointed for a third term as Chair of the Early Career Pharmacist Leadership Group and ECP Director on the PSA National Board.
For the first time the ECP CSI will also include a representative practising in the Northern Territory.
The 2025-26 Early Career Pharmacists CSI is led by:
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[post_content] => Patients often find creative ways to remember to take their medicines. These might include alarms and reminder apps or placing medicines in visible locations like kitchen benches or
bedside tables. However, some patients remove medicines from their original packaging to make their medication routine more convenient.
They might transfer them into pill organisers, plastic bags or leave them loose in pockets or
handbags. While these strategies may help with adherence, they can also compromise
medicine stability and effectiveness.1
Challenges of repackaging medicines
While manufacturers test the stability of medicines in original packaging, this assurance of stability over the shelf life is lost once medicines are removed from the original packaging.2,3
A national study of community pharmacists found that 88% had observed visible changes
in repackaged medicines, including discolouration, softening and enteric coat rupture. These changes were most frequently reported in humid and hot climates.1
In these high-risk climates, sodium valproate, telmisartan, and aspirin were found to be particularly susceptible to physical instability.1
Patient storage practices: a critical factor
Despite pharmacist recommendations, patients may unknowingly compromise their medicines’ safety by exposing them to heat, moisture or light, leading to degradation and reduced effectiveness. Common storage locations (e.g. bathroom cabinet, car) can contribute to degradation.
For instance, enteric-coated tablets, designed to resist stomach acid, were found to rupture prematurely when exposed to moisture. Softening of tablets and capsules was also frequently noted, leading to crumbling or loss of integrity. These changes can compromise drug efficacy and patient safety, particularly for medicines with a narrow therapeutic index.4
Best practices for medicine storage at home
To maintain medicine stability and effectiveness, patients should follow key storage principles:
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[post_content] => Medicinal cannabis prescribing in Australia has risen sharply in recent years, with the Therapeutic Goods Administration (TGA) recording thousands of approvals each month under the Special Access Scheme (SAS) and Authorised Prescriber pathways.
Following the expansion of these pathways in 2016, over 700,000 prescription approvals have been issued.
TGA data show that the most common indications for SAS Category B approvals to prescribe medicinal cannabis are for chronic pain, anxiety and sleep disorder.
For pharmacists, this presents an obligation to critically assess the evidence of benefit, weigh potential risks and interactions and apply rigorous professional standards when dispensing.
What’s the leading indication for medicinal cannabis prescribing?
Chronic non-cancer pain. But the quality of supporting evidence is far less robust than the demand for treatment suggests.
Evidence shows that medicinal cannabis may provide a small benefit for a subset of patients who live with chronic pain, said Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne.
[caption id="attachment_10405" align="alignright" width="318"] Professor Suzanne Nielsen MPS[/caption]
‘And of those people who find it efficacious, the benefits are often quite small,’ she said.
Concerns also remain about the safety of long-term use.
‘We already know that the pattern we saw with opioid [dependence] has been replicated with medicinal cannabis, with recent studies showing around one in four people using medicinal cannabis meets criteria for cannabis dependence,’ Prof Nielsen said.
Alongside evidence-based pharmacological approaches, some of the most effective treatments for chronic pain is typically multidisciplinary care, including behavioural and physical therapies.
‘This helps to avoid some of the serious [adverse] effects we see with some medicines,’ she said.
Some studies show that medicinal cannabis is beneficial for patients with comorbid conditions, such as chronic pain and depression, Prof Nielsen said.
But when patients are assessed for therapeutic interventions for these conditions, it’s integral that healthcare professionals who are familiar with the whole person’s care are involved.
‘Someone with comorbidities alongside their chronic pain is likely to be on multiple medications where there's risk of interactions,’ Prof Nielsen said.
‘Ideally, this should be assessed and managed by a GP, perhaps with specialist input – and less ideally by a cannabis clinic that's not necessarily managing the rest of a patient's care.’
Does the evidence support medicinal cannabis for anxiety?
Not at this point, Prof Nielsen said.
‘While the evidence signals there's a possible effect for cannabidiol (CBD), the studies we're looking at often have really important limitations,’ she said.
‘They're often very small, might only have a one-off dose of CBD, and may be looking at experimentally-induced stress – not necessarily treatment of an anxiety condition.’
And for some patients, tetrahydrocannabinol (THC) containing medicines can worsen symptoms of anxiety.
‘We've seen reports of acute psychosis, particularly when people are using higher concentration THC products,’ she said. ‘So there are a number of factors we need to consider, particularly for individuals who might be predisposed to those risk factors.’
There is a range of both psychological and pharmacological treatments available to treat anxiety, including cognitive behavioural therapy and antidepressants, such as selective serotonin reuptake inhibitors.
‘It's really about remembering the therapeutic hierarchy and going with the first-line medicines, which are safest to try first before unapproved, experimental medications,’ Prof Nielsen said.
Can cannabis improve sleep or worsen insomnia?
Sleep disturbances such as insomnia are another frequent driver of medicinal cannabis prescribing. Yet, here too, the evidence base is ‘mixed’, Prof Nielsen said.
‘There are often significant weaknesses in study designs, and medicinal cannabis is often not compared against the most effective treatment,’ she said.
THC can induce drowsiness and create a perception of improved sleep among people taking it for insomnia.
‘But actually, when we look at objective measures of sleep for people, there's often nothing that's statistically or clinically different to placebo,’ Prof Nielsen said.
Furthermore, tolerance can develop with ongoing use, and cessation may trigger rebound insomnia.
‘People who have tried medicinal cannabis and then have stopped using it often find their sleep is much worse,’ she said. ‘And there is that risk of the person developing cannabis use disorder and dependence as well.’
Is medicinal cannabis the first-line therapy for any conditions?
No. There are more than 1,000 medicinal cannabis products, and most are unregistered and have not undergone safety, quality or efficacy assessment by the TGA, said Myfanwy Graham, NHMRC Postgraduate Scholar, Monash University, Fulbright Alumna in Public Health Policy, and appointed member of the TGA’s Medicinal Cannabis Expert Working Group.*
[caption id="attachment_30412" align="aligncenter" width="400"] Myfanwy Graham[/caption]
‘TGA guidance on medicinal cannabis states that it is not a first-line treatment strategy and standard, registered treatments should be trialled or deemed inappropriate before consideration of medicinal cannabis on a case-by-case basis,’ she said.
When standard treatments prove ineffective in patients with conditions such as multiple sclerosis or rare forms of epilepsy – there is ‘good evidence’ to support the use of medicinal cannabis as an appropriate option, Prof Nielsen said.
‘And we have TGA-approved products for those conditions too.’
‘[These are] Sativex (nabiximols; Schedule 8) and Epidyolex (CBD; Schedule 4),’ Ms Graham added.
What are the potential risks and adverse effects?
Patients who are interested in trying these medicines should be made aware of the risks, including the potential for dependence, so they can make an informed decision, Prof Nielsen said.
This includes informing patients about potential adverse effects of medicinal cannabis, including:
- sedation and drowsiness
- confusion
- tachycardia
- dry mouth
- anxiety, nausea and vomiting
- appetite changes.
‘Older patients may be more susceptible to adverse effects and there are neurocognitive considerations with the use of THC-containing medicinal cannabis products in individuals under 25 years of age,’ Ms Graham said.
When dispensing ongoing prescriptions of medicinal cannabis, pharmacists should also check in with patients about the effectiveness of therapy and if they are experiencing any adverse effects. This approach is similar to the ongoing risk assessment applied to patients on long-term opioid therapy.
‘There should be an ongoing conversation around whether people are developing signs of cannabis use disorder, having difficulty controlling the amount they use, or if they tend to use it to address other symptoms as well,’ Prof Nielsen said.
‘If they are experiencing cravings and spending a lot of time thinking about using medicinal cannabis, this is suggestive that there should be an assessment of developing cannabis use disorder.’
Next steps include having a discussion with the prescriber. ‘There are drug and alcohol clinical advisory service hotline numbers in every state that they can call as well,’ she said.
Are there any contraindications and interactions to be aware of?
Pharmacists play an important role in terms of screening and counselling patients on medicinal cannabis use before dispensing, Ms Graham said.
This includes looking out for contraindications such as:
- people with a current or past psychotic disorder, or an active mood or anxiety disorder
- women who are pregnant, planning to become pregnant or breastfeeding
- people with unstable cardiovascular disease.
‘There are also cannabinoid-specific considerations such as liver function, and driving and occupational considerations,’ she said.
There are also a host of interactions between cannabidiol and other medicines, including:
- warfarin
- tacrolimus
- valproate
- methadone
- lithium.
What are pharmacists’ professional obligations?
The Australian Health Practitioner Regulation Agency (Ahpra) recently released guidance on professional responsibilities with medicinal cannabis, said Ms Graham.
‘The first port of call for pharmacists is being really well informed about the current state of evidence and regulations, both at a state and federal level, and being able to engage with patients about any questions they have [around] medicinal cannabis,’ she said.
While the dose titration of medicinal cannabis used is product and condition specific, Ms Graham said the general rule of thumb is to ‘start low and go slow’.
‘Pharmacists should have an awareness of maximum daily doses of THC, patients’ overall THC intake if they have a number of different prescriptions dispensed, and [any] dose escalation over time,’ she said. ‘And ensure that supply is in line with therapeutically appropriate quantities.’
As most medicinal cannabis approvals are for Schedule 8 products, pharmacists must complete Schedule 8 prescriber verification processes before dispensing medicinal cannabis, along with checking TGA prescription approvals. ‘[This must be done] in line with what’s required in their state or territory,’ Ms Graham added.
*Myfanwy Graham’s contributions do not represent the views of the TGA or the Medicinal Cannabis Expert Working Group
[post_title] => As medicinal cannabis prescriptions climb, does the evidence hold up?
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[post_content] => The International Pharmaceutical Federation (FIP) Congress opened overnight in Copenhagen by honouring some of the world’s leading pharmacists and challenging the profession to embrace new opportunities.
‘Embrace new opportunities’
The theme of the FIP Congress this year is ‘Pharmacy Forward: Performance, Collaboration, and Health Transformation’ – aiming to explore the evolving role of pharmacists in the context of modern healthcare challenges.
Reflecting on this theme in his opening address, Paul Sinclair MPS – Australia’s first FIP President – called on pharmacists, pharmaceutical scientists and educators to be strong advocates for new opportunities.
‘Last May, FIP launched the global “Think Health, Think Pharmacy” campaign to highlight pharmacies as an underused resource in primary care. Our shared message is clear: we want everyone – and policymakers – to include pharmacy when thinking about health and universal coverage,’ he said.
‘The global pharmacy field is rapidly evolving with technology, changing healthcare, and growing recognition of pharmacists’ key role in patient-centred universal health coverage … Now is the time for pharmacists to embrace these opportunities. Our new strategic plan calls for bold action to harness pharmacists’ diverse skills and redefine the profession for a bright future.’
Professor Lisa Nissen FPS, new FIP Fellow
The opening ceremony also saw Professor Lisa Nissen FPS awarded an FIP Fellowship for her contribution to the work of the federation, and for her global and domestic impact on pharmacy practice.
This sizeable contribution has stretched more than 25 years, and has included leading:
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[post_content] => New research has found that ibuprofen and paracetamol may be contributing to antimicrobial resistance – particularly when used in combination.
Researchers from the University of South Australia conducted a study in residential aged care facilities (RACFs) on antimicrobial resistance, looking at the interactions between organisms such as Escherichia coli, non-antibiotic medicines and the broad-spectrum antibiotic ciprofloxacin, Lead Researcher Associate Professor Rietie Venter told Australian Pharmacist.
‘We also looked at an antibiotic-sensitive microorganism we isolated from a resident and we treated this microorganism with nine medications which are frequently used in the older population,’ she said.
The microorganisms were treated with the medicines – including ibuprofen, diclofenac, paracetamol, furosemide, metformin, atorvastatin, tramadol, temazepam and pseudoephedrine – both individually and in combinations of two.
Paracetamol and ibuprofen were found to increase ciprofloxacin resistance in this gut bacterium separately, and even more so when combined.
‘When bacteria were exposed to ciprofloxacin alongside ibuprofen and paracetamol, they developed more genetic mutations than with the antibiotic alone, helping them grow faster and become highly resistant,’ A/Prof Venter said.
‘Worryingly, the bacteria were not only resistant to the antibiotic ciprofloxacin, but increased resistance was also observed to multiple other antibiotics from different classes.’
How do paracetamol and ibuprofen increase antimicrobial resistance?
Sequencing in follow-up studies revealed how the organism acquired mutations, A/Prof Venter said.
‘Evolution is turbocharged in these little microbes; under ideal conditions, organisms like the one we used double every 20 minutes,’ she said.
‘If they get stressed by the addition of paracetamol and an antibiotic, they mutate. While some of those mutations make them more vulnerable, many might actually make them resistant.’
Mutations conferring resistance to ciprofloxacin were identified, along with efflux pumps – membrane proteins that expel antibiotics before they can reach their targets.
‘When used in combination, a synergy between the two medicines causes increased mutations, leading to higher levels of resistance.’
On a positive note, none of the other nine medicines analysed in the research increased antimicrobial resistance in the gut bacteria.
‘None of the other medications, when combined with ibuprofen, were worse than ibuprofen by itself,’ she said.
Are there certain populations who could be more at risk?
Older Australians, particularly those in RACFs, are a reservoir for antimicrobial resistance.
‘Older people are more likely to be prescribed multiple medications – not just antibiotics, but also medicines for pain, sleep, or blood pressure – making them an ideal breeding ground for gut bacteria to become resistant to antibiotics,’ A/Prof Venter.
While more research is needed before any policy change may be considered, A/Prof Venter thinks it’s important to understand why these analgesics are being taken together and to consider alternative options.
‘We would love to do more research to see if there is a way we can exchange an [analgesic] for another pain medication that doesn't cause the enhanced antimicrobial resistance, or if there's a certain time between taking them that’s better.’
What advice should pharmacists provide to patients?
It’s common for antibiotics to be combined with over-the-counter analgesics. For example, a woman with a urinary tract infection who is taking an antibiotic might also take an analgesic for pain relief, or a child with a bacterial infection such as tonsillitis who is prescribed azithromycin could be administered ibuprofen and paracetamol to manage a high fever.
The research provides an opportunity for pharmacists to raise awareness among patients about the risks of antimicrobial resistance, A/Prof Venter said.
‘It’s well known that the use of antibiotics may cause antimicrobial resistance,’ she said. ‘But it’s not considered that these frequently used medications can also increase antimicrobial resistance.’
The paracetamol scheduling changes introduced earlier this year are also an important step in building public awareness that these medicines are not as harmless as they might appear, A/Prof Venter believes.
‘Compared to many other medications, people tend to think of [paracetamol and ibuprofen] as completely harmless,’ she said. ‘So strategies such as smaller pack sizes can lead to changes in behaviour.’
PSA’s Medicine safety: Child and adolescent care report found that pharmacists have an increasing role in helping patients use common analgesics safely, with approximately 16% of pharmaceutical poisoning hospital admissions in children under 5 years of age being attributed to paracetamol.
‘By limiting the maximum pack sizes of paracetamol, we are opening the door to have a conversation about the risks and benefits of these medicines – both in the pharmacy and at home – and take steps as a community to promote the safe use of medicines,’ said PSA National President Associate Professor Fei Sim FPS.
‘By involving pharmacists in the supply of paracetamol in larger pack sizes, we strike the right balance between access and safety, giving pharmacists the opportunity to help patients manage their pain effectively while reducing the risk of misuse and harm.’
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[post_content] => On Monday (25 August) PSA introduced the new crop of leaders for the Early Career Pharmacist (ECP) Community of Specialty Interest (CSI) – a dynamic group dedicated to empowering the next generation of pharmacists across Australia.
Dr Ayomide Ogundipe MPS has been re-appointed for a third term as Chair of the Early Career Pharmacist Leadership Group and ECP Director on the PSA National Board.
For the first time the ECP CSI will also include a representative practising in the Northern Territory.
The 2025-26 Early Career Pharmacists CSI is led by:
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[post_content] => Patients often find creative ways to remember to take their medicines. These might include alarms and reminder apps or placing medicines in visible locations like kitchen benches or
bedside tables. However, some patients remove medicines from their original packaging to make their medication routine more convenient.
They might transfer them into pill organisers, plastic bags or leave them loose in pockets or
handbags. While these strategies may help with adherence, they can also compromise
medicine stability and effectiveness.1
Challenges of repackaging medicines
While manufacturers test the stability of medicines in original packaging, this assurance of stability over the shelf life is lost once medicines are removed from the original packaging.2,3
A national study of community pharmacists found that 88% had observed visible changes
in repackaged medicines, including discolouration, softening and enteric coat rupture. These changes were most frequently reported in humid and hot climates.1
In these high-risk climates, sodium valproate, telmisartan, and aspirin were found to be particularly susceptible to physical instability.1
Patient storage practices: a critical factor
Despite pharmacist recommendations, patients may unknowingly compromise their medicines’ safety by exposing them to heat, moisture or light, leading to degradation and reduced effectiveness. Common storage locations (e.g. bathroom cabinet, car) can contribute to degradation.
For instance, enteric-coated tablets, designed to resist stomach acid, were found to rupture prematurely when exposed to moisture. Softening of tablets and capsules was also frequently noted, leading to crumbling or loss of integrity. These changes can compromise drug efficacy and patient safety, particularly for medicines with a narrow therapeutic index.4
Best practices for medicine storage at home
To maintain medicine stability and effectiveness, patients should follow key storage principles:
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[post_content] => Medicinal cannabis prescribing in Australia has risen sharply in recent years, with the Therapeutic Goods Administration (TGA) recording thousands of approvals each month under the Special Access Scheme (SAS) and Authorised Prescriber pathways.
Following the expansion of these pathways in 2016, over 700,000 prescription approvals have been issued.
TGA data show that the most common indications for SAS Category B approvals to prescribe medicinal cannabis are for chronic pain, anxiety and sleep disorder.
For pharmacists, this presents an obligation to critically assess the evidence of benefit, weigh potential risks and interactions and apply rigorous professional standards when dispensing.
What’s the leading indication for medicinal cannabis prescribing?
Chronic non-cancer pain. But the quality of supporting evidence is far less robust than the demand for treatment suggests.
Evidence shows that medicinal cannabis may provide a small benefit for a subset of patients who live with chronic pain, said Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne.
[caption id="attachment_10405" align="alignright" width="318"] Professor Suzanne Nielsen MPS[/caption]
‘And of those people who find it efficacious, the benefits are often quite small,’ she said.
Concerns also remain about the safety of long-term use.
‘We already know that the pattern we saw with opioid [dependence] has been replicated with medicinal cannabis, with recent studies showing around one in four people using medicinal cannabis meets criteria for cannabis dependence,’ Prof Nielsen said.
Alongside evidence-based pharmacological approaches, some of the most effective treatments for chronic pain is typically multidisciplinary care, including behavioural and physical therapies.
‘This helps to avoid some of the serious [adverse] effects we see with some medicines,’ she said.
Some studies show that medicinal cannabis is beneficial for patients with comorbid conditions, such as chronic pain and depression, Prof Nielsen said.
But when patients are assessed for therapeutic interventions for these conditions, it’s integral that healthcare professionals who are familiar with the whole person’s care are involved.
‘Someone with comorbidities alongside their chronic pain is likely to be on multiple medications where there's risk of interactions,’ Prof Nielsen said.
‘Ideally, this should be assessed and managed by a GP, perhaps with specialist input – and less ideally by a cannabis clinic that's not necessarily managing the rest of a patient's care.’
Does the evidence support medicinal cannabis for anxiety?
Not at this point, Prof Nielsen said.
‘While the evidence signals there's a possible effect for cannabidiol (CBD), the studies we're looking at often have really important limitations,’ she said.
‘They're often very small, might only have a one-off dose of CBD, and may be looking at experimentally-induced stress – not necessarily treatment of an anxiety condition.’
And for some patients, tetrahydrocannabinol (THC) containing medicines can worsen symptoms of anxiety.
‘We've seen reports of acute psychosis, particularly when people are using higher concentration THC products,’ she said. ‘So there are a number of factors we need to consider, particularly for individuals who might be predisposed to those risk factors.’
There is a range of both psychological and pharmacological treatments available to treat anxiety, including cognitive behavioural therapy and antidepressants, such as selective serotonin reuptake inhibitors.
‘It's really about remembering the therapeutic hierarchy and going with the first-line medicines, which are safest to try first before unapproved, experimental medications,’ Prof Nielsen said.
Can cannabis improve sleep or worsen insomnia?
Sleep disturbances such as insomnia are another frequent driver of medicinal cannabis prescribing. Yet, here too, the evidence base is ‘mixed’, Prof Nielsen said.
‘There are often significant weaknesses in study designs, and medicinal cannabis is often not compared against the most effective treatment,’ she said.
THC can induce drowsiness and create a perception of improved sleep among people taking it for insomnia.
‘But actually, when we look at objective measures of sleep for people, there's often nothing that's statistically or clinically different to placebo,’ Prof Nielsen said.
Furthermore, tolerance can develop with ongoing use, and cessation may trigger rebound insomnia.
‘People who have tried medicinal cannabis and then have stopped using it often find their sleep is much worse,’ she said. ‘And there is that risk of the person developing cannabis use disorder and dependence as well.’
Is medicinal cannabis the first-line therapy for any conditions?
No. There are more than 1,000 medicinal cannabis products, and most are unregistered and have not undergone safety, quality or efficacy assessment by the TGA, said Myfanwy Graham, NHMRC Postgraduate Scholar, Monash University, Fulbright Alumna in Public Health Policy, and appointed member of the TGA’s Medicinal Cannabis Expert Working Group.*
[caption id="attachment_30412" align="aligncenter" width="400"] Myfanwy Graham[/caption]
‘TGA guidance on medicinal cannabis states that it is not a first-line treatment strategy and standard, registered treatments should be trialled or deemed inappropriate before consideration of medicinal cannabis on a case-by-case basis,’ she said.
When standard treatments prove ineffective in patients with conditions such as multiple sclerosis or rare forms of epilepsy – there is ‘good evidence’ to support the use of medicinal cannabis as an appropriate option, Prof Nielsen said.
‘And we have TGA-approved products for those conditions too.’
‘[These are] Sativex (nabiximols; Schedule 8) and Epidyolex (CBD; Schedule 4),’ Ms Graham added.
What are the potential risks and adverse effects?
Patients who are interested in trying these medicines should be made aware of the risks, including the potential for dependence, so they can make an informed decision, Prof Nielsen said.
This includes informing patients about potential adverse effects of medicinal cannabis, including:
- sedation and drowsiness
- confusion
- tachycardia
- dry mouth
- anxiety, nausea and vomiting
- appetite changes.
‘Older patients may be more susceptible to adverse effects and there are neurocognitive considerations with the use of THC-containing medicinal cannabis products in individuals under 25 years of age,’ Ms Graham said.
When dispensing ongoing prescriptions of medicinal cannabis, pharmacists should also check in with patients about the effectiveness of therapy and if they are experiencing any adverse effects. This approach is similar to the ongoing risk assessment applied to patients on long-term opioid therapy.
‘There should be an ongoing conversation around whether people are developing signs of cannabis use disorder, having difficulty controlling the amount they use, or if they tend to use it to address other symptoms as well,’ Prof Nielsen said.
‘If they are experiencing cravings and spending a lot of time thinking about using medicinal cannabis, this is suggestive that there should be an assessment of developing cannabis use disorder.’
Next steps include having a discussion with the prescriber. ‘There are drug and alcohol clinical advisory service hotline numbers in every state that they can call as well,’ she said.
Are there any contraindications and interactions to be aware of?
Pharmacists play an important role in terms of screening and counselling patients on medicinal cannabis use before dispensing, Ms Graham said.
This includes looking out for contraindications such as:
- people with a current or past psychotic disorder, or an active mood or anxiety disorder
- women who are pregnant, planning to become pregnant or breastfeeding
- people with unstable cardiovascular disease.
‘There are also cannabinoid-specific considerations such as liver function, and driving and occupational considerations,’ she said.
There are also a host of interactions between cannabidiol and other medicines, including:
- warfarin
- tacrolimus
- valproate
- methadone
- lithium.
What are pharmacists’ professional obligations?
The Australian Health Practitioner Regulation Agency (Ahpra) recently released guidance on professional responsibilities with medicinal cannabis, said Ms Graham.
‘The first port of call for pharmacists is being really well informed about the current state of evidence and regulations, both at a state and federal level, and being able to engage with patients about any questions they have [around] medicinal cannabis,’ she said.
While the dose titration of medicinal cannabis used is product and condition specific, Ms Graham said the general rule of thumb is to ‘start low and go slow’.
‘Pharmacists should have an awareness of maximum daily doses of THC, patients’ overall THC intake if they have a number of different prescriptions dispensed, and [any] dose escalation over time,’ she said. ‘And ensure that supply is in line with therapeutically appropriate quantities.’
As most medicinal cannabis approvals are for Schedule 8 products, pharmacists must complete Schedule 8 prescriber verification processes before dispensing medicinal cannabis, along with checking TGA prescription approvals. ‘[This must be done] in line with what’s required in their state or territory,’ Ms Graham added.
*Myfanwy Graham’s contributions do not represent the views of the TGA or the Medicinal Cannabis Expert Working Group
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[post_content] => The International Pharmaceutical Federation (FIP) Congress opened overnight in Copenhagen by honouring some of the world’s leading pharmacists and challenging the profession to embrace new opportunities.
‘Embrace new opportunities’
The theme of the FIP Congress this year is ‘Pharmacy Forward: Performance, Collaboration, and Health Transformation’ – aiming to explore the evolving role of pharmacists in the context of modern healthcare challenges.
Reflecting on this theme in his opening address, Paul Sinclair MPS – Australia’s first FIP President – called on pharmacists, pharmaceutical scientists and educators to be strong advocates for new opportunities.
‘Last May, FIP launched the global “Think Health, Think Pharmacy” campaign to highlight pharmacies as an underused resource in primary care. Our shared message is clear: we want everyone – and policymakers – to include pharmacy when thinking about health and universal coverage,’ he said.
‘The global pharmacy field is rapidly evolving with technology, changing healthcare, and growing recognition of pharmacists’ key role in patient-centred universal health coverage … Now is the time for pharmacists to embrace these opportunities. Our new strategic plan calls for bold action to harness pharmacists’ diverse skills and redefine the profession for a bright future.’
Professor Lisa Nissen FPS, new FIP Fellow
The opening ceremony also saw Professor Lisa Nissen FPS awarded an FIP Fellowship for her contribution to the work of the federation, and for her global and domestic impact on pharmacy practice.
This sizeable contribution has stretched more than 25 years, and has included leading:
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[post_content] => New research has found that ibuprofen and paracetamol may be contributing to antimicrobial resistance – particularly when used in combination.
Researchers from the University of South Australia conducted a study in residential aged care facilities (RACFs) on antimicrobial resistance, looking at the interactions between organisms such as Escherichia coli, non-antibiotic medicines and the broad-spectrum antibiotic ciprofloxacin, Lead Researcher Associate Professor Rietie Venter told Australian Pharmacist.
‘We also looked at an antibiotic-sensitive microorganism we isolated from a resident and we treated this microorganism with nine medications which are frequently used in the older population,’ she said.
The microorganisms were treated with the medicines – including ibuprofen, diclofenac, paracetamol, furosemide, metformin, atorvastatin, tramadol, temazepam and pseudoephedrine – both individually and in combinations of two.
Paracetamol and ibuprofen were found to increase ciprofloxacin resistance in this gut bacterium separately, and even more so when combined.
‘When bacteria were exposed to ciprofloxacin alongside ibuprofen and paracetamol, they developed more genetic mutations than with the antibiotic alone, helping them grow faster and become highly resistant,’ A/Prof Venter said.
‘Worryingly, the bacteria were not only resistant to the antibiotic ciprofloxacin, but increased resistance was also observed to multiple other antibiotics from different classes.’
How do paracetamol and ibuprofen increase antimicrobial resistance?
Sequencing in follow-up studies revealed how the organism acquired mutations, A/Prof Venter said.
‘Evolution is turbocharged in these little microbes; under ideal conditions, organisms like the one we used double every 20 minutes,’ she said.
‘If they get stressed by the addition of paracetamol and an antibiotic, they mutate. While some of those mutations make them more vulnerable, many might actually make them resistant.’
Mutations conferring resistance to ciprofloxacin were identified, along with efflux pumps – membrane proteins that expel antibiotics before they can reach their targets.
‘When used in combination, a synergy between the two medicines causes increased mutations, leading to higher levels of resistance.’
On a positive note, none of the other nine medicines analysed in the research increased antimicrobial resistance in the gut bacteria.
‘None of the other medications, when combined with ibuprofen, were worse than ibuprofen by itself,’ she said.
Are there certain populations who could be more at risk?
Older Australians, particularly those in RACFs, are a reservoir for antimicrobial resistance.
‘Older people are more likely to be prescribed multiple medications – not just antibiotics, but also medicines for pain, sleep, or blood pressure – making them an ideal breeding ground for gut bacteria to become resistant to antibiotics,’ A/Prof Venter.
While more research is needed before any policy change may be considered, A/Prof Venter thinks it’s important to understand why these analgesics are being taken together and to consider alternative options.
‘We would love to do more research to see if there is a way we can exchange an [analgesic] for another pain medication that doesn't cause the enhanced antimicrobial resistance, or if there's a certain time between taking them that’s better.’
What advice should pharmacists provide to patients?
It’s common for antibiotics to be combined with over-the-counter analgesics. For example, a woman with a urinary tract infection who is taking an antibiotic might also take an analgesic for pain relief, or a child with a bacterial infection such as tonsillitis who is prescribed azithromycin could be administered ibuprofen and paracetamol to manage a high fever.
The research provides an opportunity for pharmacists to raise awareness among patients about the risks of antimicrobial resistance, A/Prof Venter said.
‘It’s well known that the use of antibiotics may cause antimicrobial resistance,’ she said. ‘But it’s not considered that these frequently used medications can also increase antimicrobial resistance.’
The paracetamol scheduling changes introduced earlier this year are also an important step in building public awareness that these medicines are not as harmless as they might appear, A/Prof Venter believes.
‘Compared to many other medications, people tend to think of [paracetamol and ibuprofen] as completely harmless,’ she said. ‘So strategies such as smaller pack sizes can lead to changes in behaviour.’
PSA’s Medicine safety: Child and adolescent care report found that pharmacists have an increasing role in helping patients use common analgesics safely, with approximately 16% of pharmaceutical poisoning hospital admissions in children under 5 years of age being attributed to paracetamol.
‘By limiting the maximum pack sizes of paracetamol, we are opening the door to have a conversation about the risks and benefits of these medicines – both in the pharmacy and at home – and take steps as a community to promote the safe use of medicines,’ said PSA National President Associate Professor Fei Sim FPS.
‘By involving pharmacists in the supply of paracetamol in larger pack sizes, we strike the right balance between access and safety, giving pharmacists the opportunity to help patients manage their pain effectively while reducing the risk of misuse and harm.’
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[post_content] => On Monday (25 August) PSA introduced the new crop of leaders for the Early Career Pharmacist (ECP) Community of Specialty Interest (CSI) – a dynamic group dedicated to empowering the next generation of pharmacists across Australia.
Dr Ayomide Ogundipe MPS has been re-appointed for a third term as Chair of the Early Career Pharmacist Leadership Group and ECP Director on the PSA National Board.
For the first time the ECP CSI will also include a representative practising in the Northern Territory.
The 2025-26 Early Career Pharmacists CSI is led by:
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[post_content] => Patients often find creative ways to remember to take their medicines. These might include alarms and reminder apps or placing medicines in visible locations like kitchen benches or
bedside tables. However, some patients remove medicines from their original packaging to make their medication routine more convenient.
They might transfer them into pill organisers, plastic bags or leave them loose in pockets or
handbags. While these strategies may help with adherence, they can also compromise
medicine stability and effectiveness.1
Challenges of repackaging medicines
While manufacturers test the stability of medicines in original packaging, this assurance of stability over the shelf life is lost once medicines are removed from the original packaging.2,3
A national study of community pharmacists found that 88% had observed visible changes
in repackaged medicines, including discolouration, softening and enteric coat rupture. These changes were most frequently reported in humid and hot climates.1
In these high-risk climates, sodium valproate, telmisartan, and aspirin were found to be particularly susceptible to physical instability.1
Patient storage practices: a critical factor
Despite pharmacist recommendations, patients may unknowingly compromise their medicines’ safety by exposing them to heat, moisture or light, leading to degradation and reduced effectiveness. Common storage locations (e.g. bathroom cabinet, car) can contribute to degradation.
For instance, enteric-coated tablets, designed to resist stomach acid, were found to rupture prematurely when exposed to moisture. Softening of tablets and capsules was also frequently noted, leading to crumbling or loss of integrity. These changes can compromise drug efficacy and patient safety, particularly for medicines with a narrow therapeutic index.4
Best practices for medicine storage at home
To maintain medicine stability and effectiveness, patients should follow key storage principles:
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[post_content] => Medicinal cannabis prescribing in Australia has risen sharply in recent years, with the Therapeutic Goods Administration (TGA) recording thousands of approvals each month under the Special Access Scheme (SAS) and Authorised Prescriber pathways.
Following the expansion of these pathways in 2016, over 700,000 prescription approvals have been issued.
TGA data show that the most common indications for SAS Category B approvals to prescribe medicinal cannabis are for chronic pain, anxiety and sleep disorder.
For pharmacists, this presents an obligation to critically assess the evidence of benefit, weigh potential risks and interactions and apply rigorous professional standards when dispensing.
What’s the leading indication for medicinal cannabis prescribing?
Chronic non-cancer pain. But the quality of supporting evidence is far less robust than the demand for treatment suggests.
Evidence shows that medicinal cannabis may provide a small benefit for a subset of patients who live with chronic pain, said Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre in Melbourne.
[caption id="attachment_10405" align="alignright" width="318"] Professor Suzanne Nielsen MPS[/caption]
‘And of those people who find it efficacious, the benefits are often quite small,’ she said.
Concerns also remain about the safety of long-term use.
‘We already know that the pattern we saw with opioid [dependence] has been replicated with medicinal cannabis, with recent studies showing around one in four people using medicinal cannabis meets criteria for cannabis dependence,’ Prof Nielsen said.
Alongside evidence-based pharmacological approaches, some of the most effective treatments for chronic pain is typically multidisciplinary care, including behavioural and physical therapies.
‘This helps to avoid some of the serious [adverse] effects we see with some medicines,’ she said.
Some studies show that medicinal cannabis is beneficial for patients with comorbid conditions, such as chronic pain and depression, Prof Nielsen said.
But when patients are assessed for therapeutic interventions for these conditions, it’s integral that healthcare professionals who are familiar with the whole person’s care are involved.
‘Someone with comorbidities alongside their chronic pain is likely to be on multiple medications where there's risk of interactions,’ Prof Nielsen said.
‘Ideally, this should be assessed and managed by a GP, perhaps with specialist input – and less ideally by a cannabis clinic that's not necessarily managing the rest of a patient's care.’
Does the evidence support medicinal cannabis for anxiety?
Not at this point, Prof Nielsen said.
‘While the evidence signals there's a possible effect for cannabidiol (CBD), the studies we're looking at often have really important limitations,’ she said.
‘They're often very small, might only have a one-off dose of CBD, and may be looking at experimentally-induced stress – not necessarily treatment of an anxiety condition.’
And for some patients, tetrahydrocannabinol (THC) containing medicines can worsen symptoms of anxiety.
‘We've seen reports of acute psychosis, particularly when people are using higher concentration THC products,’ she said. ‘So there are a number of factors we need to consider, particularly for individuals who might be predisposed to those risk factors.’
There is a range of both psychological and pharmacological treatments available to treat anxiety, including cognitive behavioural therapy and antidepressants, such as selective serotonin reuptake inhibitors.
‘It's really about remembering the therapeutic hierarchy and going with the first-line medicines, which are safest to try first before unapproved, experimental medications,’ Prof Nielsen said.
Can cannabis improve sleep or worsen insomnia?
Sleep disturbances such as insomnia are another frequent driver of medicinal cannabis prescribing. Yet, here too, the evidence base is ‘mixed’, Prof Nielsen said.
‘There are often significant weaknesses in study designs, and medicinal cannabis is often not compared against the most effective treatment,’ she said.
THC can induce drowsiness and create a perception of improved sleep among people taking it for insomnia.
‘But actually, when we look at objective measures of sleep for people, there's often nothing that's statistically or clinically different to placebo,’ Prof Nielsen said.
Furthermore, tolerance can develop with ongoing use, and cessation may trigger rebound insomnia.
‘People who have tried medicinal cannabis and then have stopped using it often find their sleep is much worse,’ she said. ‘And there is that risk of the person developing cannabis use disorder and dependence as well.’
Is medicinal cannabis the first-line therapy for any conditions?
No. There are more than 1,000 medicinal cannabis products, and most are unregistered and have not undergone safety, quality or efficacy assessment by the TGA, said Myfanwy Graham, NHMRC Postgraduate Scholar, Monash University, Fulbright Alumna in Public Health Policy, and appointed member of the TGA’s Medicinal Cannabis Expert Working Group.*
[caption id="attachment_30412" align="aligncenter" width="400"] Myfanwy Graham[/caption]
‘TGA guidance on medicinal cannabis states that it is not a first-line treatment strategy and standard, registered treatments should be trialled or deemed inappropriate before consideration of medicinal cannabis on a case-by-case basis,’ she said.
When standard treatments prove ineffective in patients with conditions such as multiple sclerosis or rare forms of epilepsy – there is ‘good evidence’ to support the use of medicinal cannabis as an appropriate option, Prof Nielsen said.
‘And we have TGA-approved products for those conditions too.’
‘[These are] Sativex (nabiximols; Schedule 8) and Epidyolex (CBD; Schedule 4),’ Ms Graham added.
What are the potential risks and adverse effects?
Patients who are interested in trying these medicines should be made aware of the risks, including the potential for dependence, so they can make an informed decision, Prof Nielsen said.
This includes informing patients about potential adverse effects of medicinal cannabis, including:
- sedation and drowsiness
- confusion
- tachycardia
- dry mouth
- anxiety, nausea and vomiting
- appetite changes.
‘Older patients may be more susceptible to adverse effects and there are neurocognitive considerations with the use of THC-containing medicinal cannabis products in individuals under 25 years of age,’ Ms Graham said.
When dispensing ongoing prescriptions of medicinal cannabis, pharmacists should also check in with patients about the effectiveness of therapy and if they are experiencing any adverse effects. This approach is similar to the ongoing risk assessment applied to patients on long-term opioid therapy.
‘There should be an ongoing conversation around whether people are developing signs of cannabis use disorder, having difficulty controlling the amount they use, or if they tend to use it to address other symptoms as well,’ Prof Nielsen said.
‘If they are experiencing cravings and spending a lot of time thinking about using medicinal cannabis, this is suggestive that there should be an assessment of developing cannabis use disorder.’
Next steps include having a discussion with the prescriber. ‘There are drug and alcohol clinical advisory service hotline numbers in every state that they can call as well,’ she said.
Are there any contraindications and interactions to be aware of?
Pharmacists play an important role in terms of screening and counselling patients on medicinal cannabis use before dispensing, Ms Graham said.
This includes looking out for contraindications such as:
- people with a current or past psychotic disorder, or an active mood or anxiety disorder
- women who are pregnant, planning to become pregnant or breastfeeding
- people with unstable cardiovascular disease.
‘There are also cannabinoid-specific considerations such as liver function, and driving and occupational considerations,’ she said.
There are also a host of interactions between cannabidiol and other medicines, including:
- warfarin
- tacrolimus
- valproate
- methadone
- lithium.
What are pharmacists’ professional obligations?
The Australian Health Practitioner Regulation Agency (Ahpra) recently released guidance on professional responsibilities with medicinal cannabis, said Ms Graham.
‘The first port of call for pharmacists is being really well informed about the current state of evidence and regulations, both at a state and federal level, and being able to engage with patients about any questions they have [around] medicinal cannabis,’ she said.
While the dose titration of medicinal cannabis used is product and condition specific, Ms Graham said the general rule of thumb is to ‘start low and go slow’.
‘Pharmacists should have an awareness of maximum daily doses of THC, patients’ overall THC intake if they have a number of different prescriptions dispensed, and [any] dose escalation over time,’ she said. ‘And ensure that supply is in line with therapeutically appropriate quantities.’
As most medicinal cannabis approvals are for Schedule 8 products, pharmacists must complete Schedule 8 prescriber verification processes before dispensing medicinal cannabis, along with checking TGA prescription approvals. ‘[This must be done] in line with what’s required in their state or territory,’ Ms Graham added.
*Myfanwy Graham’s contributions do not represent the views of the TGA or the Medicinal Cannabis Expert Working Group
[post_title] => As medicinal cannabis prescriptions climb, does the evidence hold up?
[post_excerpt] => Medicinal cannabis prescribing in Australia has risen sharply in recent years, with the TGA recording thousands of approvals each month.
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[title_attribute] => As medicinal cannabis prescriptions climb, does the evidence hold up?
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[post_content] => The International Pharmaceutical Federation (FIP) Congress opened overnight in Copenhagen by honouring some of the world’s leading pharmacists and challenging the profession to embrace new opportunities.
‘Embrace new opportunities’
The theme of the FIP Congress this year is ‘Pharmacy Forward: Performance, Collaboration, and Health Transformation’ – aiming to explore the evolving role of pharmacists in the context of modern healthcare challenges.
Reflecting on this theme in his opening address, Paul Sinclair MPS – Australia’s first FIP President – called on pharmacists, pharmaceutical scientists and educators to be strong advocates for new opportunities.
‘Last May, FIP launched the global “Think Health, Think Pharmacy” campaign to highlight pharmacies as an underused resource in primary care. Our shared message is clear: we want everyone – and policymakers – to include pharmacy when thinking about health and universal coverage,’ he said.
‘The global pharmacy field is rapidly evolving with technology, changing healthcare, and growing recognition of pharmacists’ key role in patient-centred universal health coverage … Now is the time for pharmacists to embrace these opportunities. Our new strategic plan calls for bold action to harness pharmacists’ diverse skills and redefine the profession for a bright future.’
Professor Lisa Nissen FPS, new FIP Fellow
The opening ceremony also saw Professor Lisa Nissen FPS awarded an FIP Fellowship for her contribution to the work of the federation, and for her global and domestic impact on pharmacy practice.
This sizeable contribution has stretched more than 25 years, and has included leading:
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[post_content] => New research has found that ibuprofen and paracetamol may be contributing to antimicrobial resistance – particularly when used in combination.
Researchers from the University of South Australia conducted a study in residential aged care facilities (RACFs) on antimicrobial resistance, looking at the interactions between organisms such as Escherichia coli, non-antibiotic medicines and the broad-spectrum antibiotic ciprofloxacin, Lead Researcher Associate Professor Rietie Venter told Australian Pharmacist.
‘We also looked at an antibiotic-sensitive microorganism we isolated from a resident and we treated this microorganism with nine medications which are frequently used in the older population,’ she said.
The microorganisms were treated with the medicines – including ibuprofen, diclofenac, paracetamol, furosemide, metformin, atorvastatin, tramadol, temazepam and pseudoephedrine – both individually and in combinations of two.
Paracetamol and ibuprofen were found to increase ciprofloxacin resistance in this gut bacterium separately, and even more so when combined.
‘When bacteria were exposed to ciprofloxacin alongside ibuprofen and paracetamol, they developed more genetic mutations than with the antibiotic alone, helping them grow faster and become highly resistant,’ A/Prof Venter said.
‘Worryingly, the bacteria were not only resistant to the antibiotic ciprofloxacin, but increased resistance was also observed to multiple other antibiotics from different classes.’
How do paracetamol and ibuprofen increase antimicrobial resistance?
Sequencing in follow-up studies revealed how the organism acquired mutations, A/Prof Venter said.
‘Evolution is turbocharged in these little microbes; under ideal conditions, organisms like the one we used double every 20 minutes,’ she said.
‘If they get stressed by the addition of paracetamol and an antibiotic, they mutate. While some of those mutations make them more vulnerable, many might actually make them resistant.’
Mutations conferring resistance to ciprofloxacin were identified, along with efflux pumps – membrane proteins that expel antibiotics before they can reach their targets.
‘When used in combination, a synergy between the two medicines causes increased mutations, leading to higher levels of resistance.’
On a positive note, none of the other nine medicines analysed in the research increased antimicrobial resistance in the gut bacteria.
‘None of the other medications, when combined with ibuprofen, were worse than ibuprofen by itself,’ she said.
Are there certain populations who could be more at risk?
Older Australians, particularly those in RACFs, are a reservoir for antimicrobial resistance.
‘Older people are more likely to be prescribed multiple medications – not just antibiotics, but also medicines for pain, sleep, or blood pressure – making them an ideal breeding ground for gut bacteria to become resistant to antibiotics,’ A/Prof Venter.
While more research is needed before any policy change may be considered, A/Prof Venter thinks it’s important to understand why these analgesics are being taken together and to consider alternative options.
‘We would love to do more research to see if there is a way we can exchange an [analgesic] for another pain medication that doesn't cause the enhanced antimicrobial resistance, or if there's a certain time between taking them that’s better.’
What advice should pharmacists provide to patients?
It’s common for antibiotics to be combined with over-the-counter analgesics. For example, a woman with a urinary tract infection who is taking an antibiotic might also take an analgesic for pain relief, or a child with a bacterial infection such as tonsillitis who is prescribed azithromycin could be administered ibuprofen and paracetamol to manage a high fever.
The research provides an opportunity for pharmacists to raise awareness among patients about the risks of antimicrobial resistance, A/Prof Venter said.
‘It’s well known that the use of antibiotics may cause antimicrobial resistance,’ she said. ‘But it’s not considered that these frequently used medications can also increase antimicrobial resistance.’
The paracetamol scheduling changes introduced earlier this year are also an important step in building public awareness that these medicines are not as harmless as they might appear, A/Prof Venter believes.
‘Compared to many other medications, people tend to think of [paracetamol and ibuprofen] as completely harmless,’ she said. ‘So strategies such as smaller pack sizes can lead to changes in behaviour.’
PSA’s Medicine safety: Child and adolescent care report found that pharmacists have an increasing role in helping patients use common analgesics safely, with approximately 16% of pharmaceutical poisoning hospital admissions in children under 5 years of age being attributed to paracetamol.
‘By limiting the maximum pack sizes of paracetamol, we are opening the door to have a conversation about the risks and benefits of these medicines – both in the pharmacy and at home – and take steps as a community to promote the safe use of medicines,’ said PSA National President Associate Professor Fei Sim FPS.
‘By involving pharmacists in the supply of paracetamol in larger pack sizes, we strike the right balance between access and safety, giving pharmacists the opportunity to help patients manage their pain effectively while reducing the risk of misuse and harm.’
[post_title] => Common analgesics may be contributing to antimicrobial resistance
[post_excerpt] => New research has found that ibuprofen and paracetamol may contribute to antimicrobial resistance – particularly when used in combination.
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[post_content] => On Monday (25 August) PSA introduced the new crop of leaders for the Early Career Pharmacist (ECP) Community of Specialty Interest (CSI) – a dynamic group dedicated to empowering the next generation of pharmacists across Australia.
Dr Ayomide Ogundipe MPS has been re-appointed for a third term as Chair of the Early Career Pharmacist Leadership Group and ECP Director on the PSA National Board.
For the first time the ECP CSI will also include a representative practising in the Northern Territory.
The 2025-26 Early Career Pharmacists CSI is led by:
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[post_content] => Patients often find creative ways to remember to take their medicines. These might include alarms and reminder apps or placing medicines in visible locations like kitchen benches or
bedside tables. However, some patients remove medicines from their original packaging to make their medication routine more convenient.
They might transfer them into pill organisers, plastic bags or leave them loose in pockets or
handbags. While these strategies may help with adherence, they can also compromise
medicine stability and effectiveness.1
Challenges of repackaging medicines
While manufacturers test the stability of medicines in original packaging, this assurance of stability over the shelf life is lost once medicines are removed from the original packaging.2,3
A national study of community pharmacists found that 88% had observed visible changes
in repackaged medicines, including discolouration, softening and enteric coat rupture. These changes were most frequently reported in humid and hot climates.1
In these high-risk climates, sodium valproate, telmisartan, and aspirin were found to be particularly susceptible to physical instability.1
Patient storage practices: a critical factor
Despite pharmacist recommendations, patients may unknowingly compromise their medicines’ safety by exposing them to heat, moisture or light, leading to degradation and reduced effectiveness. Common storage locations (e.g. bathroom cabinet, car) can contribute to degradation.
For instance, enteric-coated tablets, designed to resist stomach acid, were found to rupture prematurely when exposed to moisture. Softening of tablets and capsules was also frequently noted, leading to crumbling or loss of integrity. These changes can compromise drug efficacy and patient safety, particularly for medicines with a narrow therapeutic index.4
Best practices for medicine storage at home
To maintain medicine stability and effectiveness, patients should follow key storage principles:
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
