Maria Berbecaru extended interview
Just 3 years out of university, in 2019 Maria Berbecaru MPS made history by implementing Australia's first integrated community pharmacy-delivered medicine supply and on-site...
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Dr Shane Jackson presents at the 2022 ConPharm conference in Brisbane.[/caption]
With demand for pharmacists in aged care set to rise, there has never been a better time to broaden your scope of practice through accreditation.
The Australian Association of Consultant Pharmacy (AACP), which held its popular annual seminar ConPharm from Jun 17–19 over last weekend at Sea World on the Gold Coast, announced Dr Shane Jackson as new Chair of the AACP.
ConPharm 2022 comes as the profession celebrates 25 years of accreditation, with Debbie Rigby FPS, Lesley Taylor MPS and Roger Kilpatrick among the first pharmacists to be accredited by the AACP to conduct medication reviews in 1997. In the past quarter of a century, the role has evolved by improving the lives of patients and opening up new career paths for pharmacists, including in general practice, Aboriginal Community Controlled Health Organisations and aged care.
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Jaimie Hull MPS, Matthew Hoy MPS, Lucky Zeniou MPS, pharmacists from IUIH (Institute for Urban Indigenous Health) at ConPharm 2022[/caption]
With the news that government-funded residential aged care facilities will receive $345.7 million in funding to employ an on-site pharmacist or pharmacy services from next year, outgoing PSA National President Associate Professor Chris Freeman said accreditation is more important than ever.
‘Accredited pharmacists make up an important part of the pharmacy profession ecosystem, and medication management reviews are an evidence-based clinical service proven to enhance the safe and effective use of medicines,’ he said.
‘Quite simply, we need more accredited pharmacists and more medication reviews being done.’
AACP Board Member and accredited pharmacist Sue Edwards agreed, recommending pharmacists study pathways to accreditation offered via the AACP and the Society of Hospital Pharmacists of Australia (SHPA) by both looking at their websites and contacting them to ensure full understanding.
PSA offers Stage 1 accreditation, the first step in the two-stage accreditation assessment process.
‘Accreditation is important to demonstrate pharmacists meet standards for undertaking comprehensive medication review, in turn increasing trust and confidence in them among the medical profession and public,’ she said.
What accreditation offers
For consultant and general practice pharmacist Deborah Hawthorne MPS, gaining accreditation provided a much-needed boost to her career.
‘It reignited my love of pharmacy practice and has allowed me to focus on the clinical side of pharmacy within the primary care sphere,’ she said.
‘I get to create long-lasting relationships with patients, healthcare providers and other stakeholders, while at the same time improving health literacy, medication safety and health outcomes for the patients I encounter.’
The skills she has gained extend well-beyond aged care and Home Medicines Reviews. ‘[It] helps open up doors in community pharmacy, hospital pharmacy, research, public health, education and other embedded roles in GP and disability spaces,’ Ms Hawthorne said.
Ms Rigby, an Accredited Advanced Practice Pharmacist and Chair of PSA’s Interdisciplinary Team-Based Care Community of Specialty Interest, said accreditation is ‘essential’ to show pharmacists are ‘appropriately skilled and experienced to conduct comprehensive medication reviews’.
‘Completion of training and accreditation is a landmark event for pharmacists, which they are rightfully proud of,’ she said.
‘While pharmacists have a sound knowledge of medications, it is application of knowledge and clinical reasoning, together with interprofessional communication skills, that differentiate accredited pharmacists from some other areas of practice.’
For Toni Riley MPS, accreditation – and re-accreditation – is about pharmacists having a recognised role in medication management.
‘Most important is the ability of an accredited pharmacist to provide an in-depth clinical review, while being completely separate from the supply of medicines,’ she said.
Top tips to accreditation
The first step to gaining accreditation is to set a goal, Ms Rigby said.
‘In reality, accreditation could be achieved in as little as 2–3 months. But trying to fit accreditation into a busy professional and personal life can be challenging, and therefore setting a realistic timeline is essential,’ she said.
Identifying a mentor who can provide valuable advice and support is also important.
‘Finding an accredited pharmacist to shadow for real-life experience will reinforce whether this type of pharmacy practice meets your goals and professional satisfaction,’ Ms Rigby said.
Ms Riley said learning from others’ experience is ‘invaluable’. ‘[Also], be prepared to learn new skills beyond your current clinical knowledge and to embrace the concept of life-long learning enthusiastically,’ she said.
‘Whether you are fresh out of university or a seasoned pharmacist, the accreditation process is an educational experience that will enhance your pharmacy skills,’ Ms Hawthorne advised, saying ‘just do it!’.
Conducting medication reviews ‘enhances inter-professional relationships, improves the quality use of medicines and impacts positively on health outcomes,’ according to Ms Edwards, while accredited pharmacists can also use these skills and knowledge in other areas of practice.
She also recommended undertaking as much clinical CPD as possible, and attending face-to-face education sessions designed to build skills for medication review such as Pharmeducation masterclasses, PSA22 masterclasses as well as ConPharm.
Come to PSA22 for the Accredited Pharmacists Deep Dive and 3 days of high-quality robust Continuing Professional Development, platforms for innovative practice and strategic networking opportunities.
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2022 ConPharm Conference in Brisbane.[/caption]
ConPharm 2022
The 18th Annual Consultant Clinical Pharmacy Seminar ConPharm held over last weekend was an opportunity for newly-accredited pharmacists and those undergoing the usually 12-month accreditation process, to meet gain inspiration from more experienced colleagues involved in aged care.
Among topics for continuing education were improving medication review report writing, aged care, pain, antimicrobial, corticosteroid and anticonvulsant stewardship.
PSA National Board Vice-President and Chair of the AACP Board Dr Shane Jackson was among the presenters at ConPharm on aged care and the future of on-site aged care pharmacists.
'There has never been a more important time to be an accredited pharmacist,’ he told delegates and described the new funding of the on-site aged care pharmacist program as 'the single biggest investment in medicine safety in aged care, in Australia, ever.' He encouraged accredited pharmacists from across the country to support on-site aged care when it launches in January 2023.
And taking over the mantle of last year’s winner Dr Manya Angley FPS, this year’s AACP MIMS Consultant Pharmacist of the Year was announced as Robyn Saunders MPS who told ConPharm: ‘I encourage all pharmacists to elevate our standing. We are the medicines experts.’
[post_title] => Why pharmacist accreditation is important
[post_excerpt] => With demand for pharmacists in aged care set to rise, and the removal of the re-accreditation fee, there has never been a better time to broaden your scope of practice through accreditation.
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[post_content] => With the COVID-19 vaccine for children aged 6 months to 5 years given the green light in the United States, Moderna’s Chief Medical Officer Dr Paul Burton expects the infant vaccine to roll out in Australia next month.
The Therapeutic Goods Administration (TGA) announced in mid-May that it had received, and immediately commenced evaluation of an application from Moderna Australia Pty Ltd to extend the use of its COVID-19 vaccine, to children in this age cohort.
In an exclusive interview with Australian Pharmacist, Dr Burton, during a brief visit to Australia, said it is now down to the TGA and the Australian Technical Advisory Group on Immunisation (ATAGI) to review and assess the data.
‘If it is approved by the TGA, that will then go to our advisory group on vaccines to consider the way in which this should be rolled out to the community, so I’d expect it to be a matter of some weeks,’ Federal Minister for Health and Aged Care Mark Butler said in Canberra on Tuesday.
With young children differentially and disproportionately impacted by the Omicron variant, Dr Burton said building immunity is vital.
‘Data from Hong Kong [revealed] extremely high rates of paediatric ICU admission for kids with [Omicron], even compared to other variants of concern,’ he said.
Young children also act as a reservoir for COVID-19 infection.
‘The virus can go into that age group, [and] percolate because there’s no vaccination, no protection,’ Dr Burton said. ‘Then it goes back out to older people who are really vulnerable’.
The primary course of the infant vaccine is two 25 μg doses, 4 weeks apart, with recent clinical trials indicating that young children receive protection against COVID-19 6 weeks after their first dose, according to Moderna.
At this stage, the World Health Organization Strategic Advisory Group of Experts on Immunization (SAGE) does not recommend Spikevax for children under 12 years of age, pending the results of further studies.
New Omicron-containing bivalent booster available soon
Meanwhile, new clinical data on Moderna’s Omicron-containing bivalent COVID-19 booster candidate has revealed a 50 µg dose produces a significant jump in antibody levels.
‘People who have been exposed [to Omicron] got up to a 12-fold increase in antibody levels, and people who have not got up to a four-fold antibody increase,’ Dr Burton said.
‘We can probably get a good extended period of time, maybe up to a year between boosters, and that will provide protection against infection, severe disease and death.
‘Depending on TGA and ATAGI review and authorization, [we’re hoping] to have doses available for people in August.’
It is unknown if pharmacies will be the first port of call for the bivalent vaccine, but Dr Burton assumes it will follow the same channels as Spikevax boosters.
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‘We're [also] working on a study to test the bivalent booster in [children aged 5 months to 6 years] now,’ he said.
‘If they need boosting, we should be able to lead supply [with] that variant-adapted booster at the end of this year.’
Next in the works is a combined COVID-19 and flu vaccine that is currently in phase-one testing, and should be available in Australia in late 2023, Dr Burton said. A phase-one study for a triple combination – influenza, COVID-19, and respiratory syncytial virus (RSV) will begin soon, with the vaccine expected to roll out in Australia in late 2024.
With its recent 10-year agreement with the Australian Government to provide mRNA vaccines against COVID-19, influenza, RSV and other potential respiratory and latent viruses, Moderna’s manufacturing plant in Melbourne is also expected to open its doors by the end of 2024.
‘The aim of this plant is in Australia, for Australia,’ Dr Burton said. ‘[We want to] produce 100 million vaccine doses a year.'
‘This agreement and strategic partnership with Moderna and the Victorian Government is crucial insurance for the health of the Australian population,’ Former Minister for Health Greg Hunt said in March.
‘It means Australians will have access to the most cutting-edge vaccination technology available both now and into the future.’
Other pipeline therapeutic targets
Moderna is working to develop mRNA vaccines for a range of infectious diseases, which will likely be produced in the Australian plant, Dr Burton said. Studies are currently underway on vaccines for cytomegalovirus, which is the leading cause of birth defects in newborns, and Epstein-Barr virus (EBV).
‘There’s data that EBV contributes to multiple sclerosis (MS),’ he said. ‘There’s a burden of disease with MS in Australia, so I think there's a certainty that we will want to work on that here as well.’
Three Australian centres, the University of Queensland, the Burnet Institute and the Doherty Institute, are also collaborating with Moderna on its mRNA Access program, which focuses on the CEPI list of 15 priority pathogens, including Chikungunya, Crimean-Congo hemorrhagic fever, Dengue, Ebola, Malaria, Marburg, Lassa fever and Middle East respiratory syndrome.
But mRNA is the future of disease treatment more broadly, not just infectious diseases, Dr Burton told AP.
‘We have 46 programs in development, covering cancer, cardiovascular disease, rare disease, rare metabolic disease, and autoimmune disease,’ he said. ‘[And] we see Australia as a huge partner for us.’
Opportunities for pharmacists
With the Australian Moderna team rapidly growing, increasing from two to 20 in a 6-month period, the company is eager to recruit pharmacists in a range of roles – from medical affairs, global pharmacovigilance, safety monitoring and clinical development.
‘Some are now interested in moving into manufacturing and commercialisation,’ Dr Burton said. ‘The opportunities for pharmacists are extensive.’
Pharmacists are an asset because they understand complex science, diseases and how medicines are made, he believes.
‘They're also able to translate complex data into knowledge that patients, physicians and hospitals can use to improve [health] outcomes,’ Dr Burton said. ‘It's a particular skill that’s very valuable.’
PSA’s latest evidence and updates on mRNA vaccines in its CPD Roadshow are available to attend from 6 pm on the following dates:
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]The Pharmaceutical Benefits Scheme (PBS) Safety Net thresholds will be reduced from 1 July. Here’s what pharmacists need to know about the mid-year change.
25% fewer prescriptions needed for concession card holders to reach the PBS Safety Net
From 1 July 2022, the PBS Safety Net thresholds will be reduced by $80–85:
| Patient circumstance | Appropriate pharmacist action on or after 1 July 2022 |
| Patient reached the old (higher) threshold on or before 30 June 2022 and has already received a Safety Net card | Patient retains eligibility for the PBS Safety Net; dispense any PBS prescriptions with the patient’s CN or SN card Concessional co-payment (if applicable) amount remains the same ($6.80) No refunds to the patient relating to co-payments made prior to 1 July 2022 |
| Patient presents evidence (PRF) of having reached the new (lower) threshold prior to 1 July 2022 and requests a Safety Net card but does not require any prescriptions to be dispensed | Advise the patient that they will become eligible for a Safety Net card when their first ‘qualifying’ medicine is dispensed on or after 1 July 2022 A Safety Net card based on the new threshold cannot be issued without the dispensing of a qualifying PBS medicine |
| Patient has not reached the new (lower) threshold when they present (on or after 1 July) a prescription for two PBS medicines but reaches that threshold upon the first item being dispensed | The first item is dispensed as a general or concessional item (whichever applies); PBS co-payment amount remains the same The second item is the first ‘qualifying’ medicine dispensed; a CN or SN card (whichever applies) can be issued and the relevant PBS co-payment ($6.80 if CN card) applies |
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[post_content] => Six Australian jurisdictions enacted a free influenza vaccine program for patients 6 months and over this month, to stave off rising rates of the virus.
But the state-by-state rollout in GP clinics and pharmacies has caused confusion among patients, with some demanding refunds for previous vaccinations, and others presenting for immunisations outside their state’s eligible age bracket for pharmacist vaccinations.
When the Queensland government announced a fortnight ago that it would fund free influenza vaccines, Brisbane-based Ramsay Healthcare professional services pharmacist Rayana Alawie MPS said the phones were ‘ringing off the hook’.
‘Our first week of vaccine clinics was booked out,’ she said. ‘The demand now, however, has slowed down.’
To accommodate the influx of patients, Ramsay reduced the interval between appointments to 5 minutes.
‘Some of our stores stretched their vaccine clinic hours to accommodate children ages 5–10 during after-school drop-offs,’ she added.
Ms Alawie, who has administered more than 600 free influenza vaccines since the rollout began, said there had been some patient confusion.
‘We had patients aged under 5 and over 65 booking in for a free flu vaccine at a pharmacy when they weren't eligible,’ she said.
‘A handful rang up for a refund. We offered to print a tax invoice for the vaccine and directed them to phone 13HEALTH [Queensland health advice line] for further guidance.’
The rollout of the booking system also could have been better.
‘Our GuildCare booking link did not work until 1 week after the rollout was announced,’ Ms Alawie said.
‘By then, hundreds of vaccines were administered and uploaded on AIR [Australian Immunisation Register] but were not being claimed for.’
While this didn’t stop Ramsay providing the service, Ramsay pharmacies are still waiting for a resolution about claiming for the earlier vaccines.
‘When the GuildCare system did go live in our stores, AIR wasn't integrated for another 3 business days, so we had to endure double bookings while both GuildCare and MedAdvisor were running,’ she said.
‘The most tedious part of this lag was the double-entry of patient vaccine details on MedAdvisor to upload on AIR, and entering details on GuildCare for claiming.’
Pharmacists should also be remunerated more for the service, she believes.
‘At the very least, remuneration should be the same for all health professionals performing the same role,’ she said.
‘We should get the MBS [Medicare Benefits Schedule] fee that GPs claim for providing flu vaccinations.’
This is something PSA has called for in order to resolve issues around eligibility and claims.
Demand surges in metropolitan Sydney
Cabramatta-based pharmacist Quinn On MPS was at a pharmacy conference on the Gold Coast with four staff members when he found out that influenza vaccines would be provided free of charge in New South Wales.
‘I had to do everything remotely,’ Mr On told Australian Pharmacist. ‘Another pharmacist helped me organise by ordering stock and preparing our software so we could claim for the service.’
‘At the very least, remuneration should be the same for all health professionals performing the same role.'
Rayana Alawie MPS
Mr On, who owns several pharmacies in the area, said demand had sky-rocketed since the announcement was made last week.
‘We were doing 5–10 [vaccinations] a day, now we’re doing 50–100 a day,’ he said.
The biggest challenge for Mr On so far has been managing stock, with some pharmacies exhausting their supply within 2 days.
‘The concern at the moment is how much stock we [should] hold,’ he said. ‘It’s hard to estimate.’
‘We don't want to over-order, because people could become vaccine fatigued. Last year we threw out $10,000 worth of flu vaccines.’
While Mr On said pharmacists are well-placed to drive the influenza campaign, given their accessibility, longer hours of service and volume of vaccines they can administer, he believes there is an imbalance between healthcare professionals.
‘Pharmacists carry all the risk, we have to order stock at our own cost. Doctors get paid more for doing exactly the same job and they carry no risk,’ he said.
‘We [also] can’t access the MBS, we have to set up software, which [takes] a lot of time and involvement, and we have to pay for the service as well, to claim the money.’
Free flu vax allows for opportunities in Victoria
Victorian-based Sarah Venn MPS, from Camperdown Pharmacy, said demand for influenza vaccines had been steady throughout the flu season, with an uptick in patients following the Victorian government's announcement of free influenza vaccines last week.
While most patients are aware that the charge has been lifted, some are pleasantly surprised.
‘When I say there's no charge, they think it's Christmas Day,’ Ms Venn said.
Camperdown runs influenza clinics most days of the week, with Ms Venn estimating 300 free vaccines have been administered so far.
Like many other pharmacies, Camperdown is short-staffed, meaning they had to carefully plan their workflow to accommodate more vaccine patients.
‘We have got either a pharmacist or a nurse in our pharmacy with designated [vaccinating] times,’ Ms Venn said.
‘When we run a clinic, we might do 9.00 am–2.00 pm, choc-a-block.’
When Ms Venn heard about the funded influenza vaccines campaign last week, she instantly placed an order for more National Immunisation Program stock.
Luckily, the pharmacy had opted to order the usual amount of private vaccine stock, despite having to throw much of it away last year due to low demand.
‘[Our] rep said some people have only ordered 10% of what they [usually] would,’ she added.
Ms Venn said offering free influenza vaccines has also allowed for opportunistic COVID-19 vaccination – whether winter or first booster dose.
It has also alleviated confusion in these patients about the fee.
‘It takes away that complexity of explaining why the flu vaccine has a service charge and the COVID-19 one doesn't,’ Ms Venn said.
Camperdown recently applied for the Victorian government grant to support increased resources for small business, which Ms Venn said will be a helpful boost in light of staff shortages.
‘Yes, we get a remuneration for each vaccine given, but it's the extra time on the phone to take and field phone calls, [with] a lot of people still [booking] over the phone,’ she said. ‘It [should] give us a bit of a buffer for the other chores that are involved.’
Reports of mixed demand in Western Australia
Perth-based pharmacist Ron Stuurstraat MPS first found out about the funded influenza vaccine campaign the weekend before it began, when he sat down to scan the news on his lunch break.
'It all seemed to be done quite quickly, and then everyone was scrambling to figure out how to make it work.’
Ron Stuurstraat MPS
‘We didn't know what to expect,’ he said. ‘It all seemed to be done quite quickly, and then everyone was scrambling to figure out how to make it work.’
The morning after the announcement, Mr Stuurstraat did a stock check and decided they had enough to keep going without ordering any more.
That decision turned out to be the right one, with Mr Stuurstraat citing low community awareness of the free vaccines.
‘In the city, [demand] is not great,’ he said. ‘Most people don't even know it's happening. We're just getting the same number of people coming through.
‘When you [mention] it’s free, they say “Oh really, how come?”’
Other pharmacists, however, have had a different experience.
Keegan Wong MPS, PSA WA Branch President and pharmacy owner, said demand for influenza vaccines has been ‘unprecedentedly high’ since state-subsidized flu vaccines were announced.
‘Our systems in place since COVID-19 have prepared us for a strong uptake in vaccination delivery. However, the issue has been around supply shortage, much like what we have seen in Queensland and NSW,’ he said.
With many PSA WA members finding out about the program in the same way as Mr Stuurstraat, Mr Wong said improved communication about vaccination initiatives was vital.
‘More emphasis needs to be placed on delivering such a message to our community pharmacists first, ahead of the public, to ensure a smoother transition in healthcare delivery,’ he said.
‘Patients expect that after an announcement from WA Health, healthcare professionals will be advised and prepared from Day 1.
‘We are still working through our supply channels to receive more substantial stock, but we believe that we are able to get all our communities vaccinated on time for the peak of the winter flu season.’
Meanwhile, Mr Wong said he encountered some disgruntled patients requesting a refund after paying for their influenza vaccine pre-announcement.
‘[We explain] that the funding can’t be backtracked and most private health [insurers] provide full funding for the flu vaccine, so [we advise patients] to check with their health fund to see if they are able to claim the cost of the funding,’ he said.
While PSA congratulates the WA government for remunerating community pharmacists more than the other states for administering influenza vaccines, Mr Wong believes funding should stretch further.
‘More work needs to be done [through] funding for pharmacists to enable us to administer more vaccines and provide more injectables such as Vitamin B12 for our patients,’ he said.
[post_title] => Free influenza vaccine update
[post_excerpt] => Four Australian jurisdictions enacted a free influenza vaccine program for patients 6 months and over this month, to stave off rising rates of the virus.
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Ear disease in rural and remote communities is occurring at alarmingly high rates, with limited access to health services a significant contributing factor.
To address the issue, remote pharmacy academic Selina Taylor MPS devised LISTEN UP (Locally Integrated Screening and Testing Ear aNd aUral Program) for her PhD project through James Cook University.
The community pharmacy-based initiative, which was piloted in north-west and central-west Queensland pharmacies, trained pharmacists to conduct ear examinations on patients with ear complaints using video otoscopy and tympanometry.
Pharmacists were then able to make recommendations including no treatment, pharmacy-only products, or GP referral through a direct pathway.
Reducing pressure on the healthcare system
The project began with research into pharmacist, patient and health professional perspectives of expanded pharmacy services in rural and remote settings, which Dr Taylor said was positive across the board.
‘Patients wanted increased accessibility, pharmacists felt as though they should and could do more, and health professionals were also supportive, given that a lot of these regions [are short staffed],’ she said.
Pharmacists regularly had patients coming through with ‘blocked ear’ and ‘ear pain’ complaints, but they were unable to make a definitive diagnosis on a symptomatic description, and had a limited range of over-the-counter products to offer.
As a result, many patients presented to emergency departments (EDs) with ear complaints that could have been managed in community pharmacies.
By examining a patient’s ear canals and given a referral pathway to GPs, participating pharmacists could redirect patients away from EDs and into same- or next-day GP appointments.
‘Young mums described how great it was not having to take their child to ED and wait 6 hours to be seen.’
Selina Taylor MPS
‘It was [also] time saving for GPs, who were able to provide telehealth consults quite quickly after the pharmacist examination,’ Dr Taylor said.
‘They could make diagnoses and prescribe as required without having to bring patients into the practice.’
One otolaryngologist said that access to the video otoscope images saved his patients a 2,000–kilometre round trip for a 3-minute appointment.
Positive patient outcomes
From a patient perspective, the pilot provided convenience and improved knowledge about ear health.
‘Some people were travelling 600 kilometres, or waiting 2–4 weeks to see their GP,’ Dr Taylor said.
‘Young mums described how great it was not having to take their child to ED and wait 6 hours to be seen.’
For many, the visual aspect of the service improved their understanding of their ear condition.
‘Using video otoscopes meant patients could see inside the ear canal during their consultation,’ Dr Taylor said.
‘Some people said they have had ear disease for a number of years, and they've never been able to see inside their ear canal for themselves.'
Glory-Anne Leaupepe, a professional services pharmacist at Pharmacy First in Mount Isa, got involved in the project to address ear-health issues in her local community.
‘We see a lot of middle ear infections up here,’ she said. ‘It’s pretty hard to get into a GP, and even more frustrating to go to hospitals.’
Through the pilot, Pharmacy First helped 50 patients with their ear complaints. Ms Leaupepe said it was a useful educational tool which prevented patients from using the wrong medicine.
‘[Patients] would come in requesting ear wax drops because they felt blocked up, and then we’d have a look inside their ears and see they were perfectly clean,’ she said.
‘We also let them know that they don't need antibiotics straightaway, and that you can [often] treat an acute inner ear infection with analgesia.’
Other patients were saved from a long wait to see their GP.
‘Patients would come in, asking if there's anything they can do because they can't get into the doctor's [clinic],’ Ms Leaupepe said.
‘By looking inside the ear canal, we could say, “It doesn’t look like you have otitis media, all you need is pain relief for the next couple of days. It doesn't improve, then you should see your GP”.
‘But a lot of the time, it does resolve.’
Collaboration essential in rural and remote communities
All the health providers in rural and remote communities need to work together to provide the best care for patients, Dr Taylor told Australian Pharmacist.
‘Everyone's strapped, so having that continuity of care from a pharmacist into a GP practice was critical for this service,’ she said.
‘We can identify a problem, but without having a pathway to follow, there's nowhere for patients to go.’
Looking forward, Dr Taylor said pharmacists will continue to expand their range of services to meet the specific health needs of their local communities. But it is essential that these services are funded and remunerated.
Costs of providing the ear health service include training, pharmacist time, locum backfill and accomodation, and $10,000 worth of equipment per pharmacy.
While training and equipment costs were covered during the pilot, pharmacists had to provide consultations in their own time, which could take anywhere from 10–50 minutes.
‘That was one of the barriers [to uptake], Ms Taylor said. ‘If they were short on staff or busy with other pharmacy tasks, providing the service was less of a priority. That’s why we need funding.’[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row]
[post_title] => Expanded pharmacy services the remedy for ear health crisis
[post_excerpt] => Ear damage is rife in rural and remote communities. Providing pharmacists with training and diagnostic tools can have a dramatic impact.
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How pharmacists can change the lives of people with lung diseases by taking every opportunity possible.
For most pharmacists, respiratory health is a significant part of their practice.
Device counselling takes time and self-management is common. Yet people take their breathing for granted.
This can lead to significant undertreatment, unnecessary flare-ups, avoidable hospitalisations and sometimes even death.
Respiratory health is deceptively complex, with multiple medicines, different devices and under-recognised drug-drug interactions.
It is why patients need the support of pharmacists as their medicine experts – part of their wider healthcare team – to achieve good health.
Some interventions should be routine – checking inhaler use frequency (see Box 1), assessing stability in symptoms and active referral for reassessment. But others should happen much more often, particularly in checking inhaler suitability or optimising technique.
Box 1 – Selecting an inhaler device*
Essential questions for inhaler device choice for all patients:
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The starting point for these conversations is structuring in good practices, as Accredited Advanced Practice Pharmacist Debbie Rigby FPS outlines (see Box 2).
‘Inhaler device technique should be assessed and optimised at every opportunity. This means with initial dispensing plus repeats.’
Box 2 – Inhaler inspiratory flow rates
Many people inhale pMDIs too quickly. Assess technique at every opportunity.
Soft mist inhalers and pMDIs
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Some interventions do take time – but these are often the most important. Whether in community, hospital, consultant or institutional pharmacy practice, nearly all pharmacists need to be at the top of their game to support patients with respiratory conditions.
Australian Pharmacist talked to a rural-based community pharmacist and a hospital pharmacist about their experiences with patients who needed their urgent respiratory help.
HANY AITA
Managing Pharmacist, Amcal Max, Devonport, Tasmania
With 6 years as a pharmacist in his native Egypt, and another 13 years solely in rural and outback community pharmacy in Western Australia, New South Wales and Tasmania, Hany Aita MPS has seen a lot of people living with asthma.
And with fewer opportunities to visit doctors, asthma and COPD are ’not as well managed as you would think’, he says. Some patients, who have never been diagnosed and use puffers when short of breath, eventually visit a doctor, get a diagnosis and sometimes, for financial, time, distance or other reasons never follow-up, he explains.
However, he has a golden rule for himself and staff when non-prescription requests for salbutamol relievers are made. Always ask about frequency. ‘How often do you need to use it?'
Last year a local woman in her early 30s, seemingly health literate but not a regular patient, admitted to him that she used salbutamol ‘every day’.
Mr Aita was stunned that she had no idea, in a town of six pharmacies, that this was abnormal and the recommended use of non-prescription relievers in well-controlled asthma was no more than 2 days per week.
‘I said: “How long you been doing that? [She answered] ‘Oh I’ve been doing that for the last few years. It actually keeps me going.'" Unlike some hostile responses to his ‘red flag’ initial questions, ‘she was open to talk more about it’.
Mr Aita explained her ‘condition’ was not properly managed and referred her to her GP for an urgent diagnosis, or otherwise, of asthma. ‘It was just amazing that this was all new for her,’ he relates.
Some weeks later she returned – with an asthma action plan, a preventer for daily use and prescription for low-dose fluticasone propionate/salmeterol (Seretide).
SARAH RISDALE
Clinical Pharmacist, Royal Brisbane and Women’s Hospital
At her hospital, Ms Risdale’s role supports patients with a variety of acute – as well as chronic – respiratory diseases.
Reviewing medicines for drug interactions in an outpatient clinic may involve her recommending alternate asthma medicines for people living with HIV. For example, she may need to find alternatives to fluticasone/salmoterol (Seretide) due to increased risk of Cushing syndrome from cobicistat CYP34A inhibition.
Similarly, for inpatient care, she could be involved in adjusting doses of antimicrobials for respiratory patients, such as IV Amikacin in non-tuberculous mycobacterial pulmonary infections when drug concentrations exceed expected levels – which can vary depending on patient factors and dose frequency – or kidney function declines significantly.
One of her more challenging patient interactions was with a younger patient who had no significant co-morbidities and was recovering from COVID-19.
The patient had developed an empyema infected with a multidrug-resistant bacteria – including resistance to penicillins, cephalosporins and carbapenems.
As the patient was struggling with an infective collection in the pleural space on one side of a lung, Ms Risdale provided clinical advice and support around monitoring and managing adverse effects from the IV sulfamethoxazole/trimethoprim used, which can include electrolyte disturbances.
And, as the patient continued to experience respiratory decline, Ms Risdale was tasked with acquiring stock of a more specialised antimicrobial from overseas – cefidericol.
‘I found this situation challenging for several reasons as I had to contend with COVID-19 delays, unavailability through standard Special Access Scheme routes, time differences (between suppliers and manufacturers in Australia, Europe and Japan), cold-chain requirements and the time-critical need for treatment.
'Thankfully, I was able to arrange some stock reallocation from other hospitals in NSW and Western Australia, and was able to get it successfully transported via cold-chain courier across the country – on a weekend no less.
'We received the product in time and the patient made a full recovery!'
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Supporting patients starts with listening more.
Wherever pharmacists practise, there are patients with anxiety – patients who are managing well, patients who are managing not so well, and patients in crisis.
Mental Health Australia Chief Executive Officer Leanne Beagley says one of the best ways pharmacists can support patients is by recognising that anxiety often reveals itself in physical symptoms, such as difficulty sleeping, nausea and diarrhoea.
‘There’s a real interplay between people’s anxiety and how [the symptoms] are expressed in their body, and community pharmacists are in a great position to recognise that physical symptoms might have a mental health component and to encourage [people] to see a GP,’ she says. ‘It’s about understanding that physical symptoms might have an underlying mental health cause, and asking questions or encouraging people to think about that.’
Listening more is crucial to pick up on these signs, open up conversations and provide appropriate support.
AP spoke with two pharmacists who took the time to listen more.
Duha Nur Gide
Community Pharmacist and University of Sydney researcher, Sydney, NSW
Lessons from MHFA training
Mental Health First Aid (MHFA) training is extremely useful in identifying signs and symptoms of different mental illnesses, including anxiety, and the different ways that it may present, says Ms Gide.
‘It also explores the different types of anxiety, such as post-traumatic stress disorder (PTSD), panic disorder and social anxiety disorder. Additionally, and perhaps most importantly, it teaches pharmacists how to appropriately approach patients with anxiety and provides us with the knowledge and skill set to effectively offer support.’
The role-play for pharmacists, she says, is beneficial in gaining practical experience and increased confidence when interacting with patients experiencing anxiety, which optimises the outcome.
Tell-tale prescription presentations that may indicate underlying – or overt – anxiety, Ms Gide says, can include:
Most patients experiencing anxiety would be referred to their GP, who may then refer the patient to a psychologist or psychiatrist, for instance.
Patients with anxiety are also encouraged to seek support from other people, such as friends and family they trust, according to Ms Gide.
‘There are also often local mental health services that can help people with anxiety, so this is another referral option.’
Louise Edwards BPharm(Hons), BA, MPSPrincipal Master Mental Health First Aid Instructor, Perth, WA
Case 1 Anxiety and panic attack
Flustered, teary and struggling to enunciate her problem, Belinda* rushes into a busy street-front pharmacy, flapping her hands in front of her face as if to cool herself down.
‘I think I’m having a panic attack,’ the 20-something blurts out, while being moved quickly and calmly by Ms Edwards, the pharmacist in charge, to a nearby counselling room.
Belinda is asked if this has happened before. Yes, she replies, although it’s been a while. Due to meet estranged family members, she tells of suddenly becoming anxious and feeling hot, sweaty and shaky, and like she can’t breathe properly.
Ms Edwards sits with Belinda as she overtly slows her breathing, while a pharmacy colleague fetches cold water and jellybeans.
‘At all times, I was monitoring for physical alarms, such as loss of consciousness or Belinda expressing concerns with physical symptoms,’ Ms Edwards later recalls. Seeking help early, and starting previously learned breathing activity, prevented the attack from escalating, she believes.
After about 5 minutes with Belinda, Ms Edwards leaves her with a pharmacy assistant, clears some work in the busy dispensary, and asks for a print-out of the PSA ‘Anxiety’ Self Care Fact Card together with some ‘goodies’.
Not long after, Ms Edwards finds Belinda giggling with the pharmacy assistant. And while still somewhat red, Belinda feels ‘much better’ and apologises profusely, before wiping her face with the cold, wet paper towels provided for her.
Ms Edwards commends Belinda for ‘seeking help from us’ and presents her with the ‘Anxiety’ Self Care Fact Card. Belinda declines an offer for staff to take her to the nearby doctor and does not want anyone in the family to collect her.
She tells Ms Edwards of an imminent appointment with her GP for her oral contraceptive pill. ‘Although now,’ Ms Edwards later recalls, ‘she will discuss this episode to consider if she needs to return to psychology appointments, particularly as this family catch-up is likely to stir up anxiety.’
When presented with ‘our little goodies’ to help her feel better, ‘Belinda started tearing up with thanks’ again.
‘Belinda left about 10 minutes later with a fresh face and calmer disposition,’ Ms Edwards says, which was ‘a great experience for the PA to see how helping others really is personally rewarding – and she talked about it for weeks’.
Case 2 Methadone – Helen (pre-MHFA training)
Helen,* a regular methadone client, can be short with manners and appear defensive at times. A client for at least 6 months, she is on a larger dose of methadone and attends with her partner, who often appears intoxicated.
Helen presents alone one day with a prescription for diazepam 5 mg tds, to be collected every few days from the pharmacy. When she realises she will not be given the full supply, she becomes aggressive in tone and swears about how she is being distrusted.
‘At first, I was stern and clear regarding swearing and aggression and our contract relating to behaviour in the pharmacy,’ Ms Edwards later recalls.
While Helen rages that she will leave and find something else ‘to make her feel okay’, Ms Edwards notices she is tearing up.
‘I realised my attitude and approach were not leading to the best outcome, so I softened my demeanour and asked Helen if she wanted to step into a quieter area.’
Now in a quieter area, and out of breath from crying, Helen grabs Ms Edwards by the arm for support.
‘It was a rare show of vulnerability, so I talked softly and soothingly to make her feel comforted. It was clear that the façade we had seen for 6 months was hiding some significant anxiety.’
Helen explains that she is trying to avoid her often unkind partner, but her substance use problems and lack of family support have given her extreme anxiety about coping. Her GP has started her on a sample pack of sertraline before she returns in several days, and the diazepam is to help with her current extreme anxiety.
‘This person in front of me is suddenly more relatable,’ Ms Edwards recalls. ‘I understand why she presents the way she does. It shouldn’t have taken this show of emotion for me to change my thought processes regarding Helen, and I vow never again to make this mistake. I sit and chat with her while she calms.’
Helen is brought cold water and some jellybeans, and is made comfortable as she calms down with slow breathing.
And while there is a brief return to an embarrassed disengagement from Helen – manifested with no eye contact, fidgeting and mumbling – Ms Edwards talks her around (helped by some cool, wet paper towels and a ‘calm, caring tone’) expressing delight that Helen has trusted her with her personal information.
Helen responds well, particularly to Ms Edwards’s offer of local housing assistance and food provider numbers, as well as leaflets on anxiety.
‘Now that we have both had a good connection and I have really listened, Helen finds it much easier to understand the safety behind the limited supply,’ Ms Edwards says.
‘I work hard every visit to check in and make the staged supply interaction valuable for her. This not only reinforces our relationship, but also the benefits of medication supply.’
Case 3 Rescue Remedy – Maureen
One morning at the pharmacy, Maureen,* a young woman, asks Ms Edwards: ‘I’ve heard Rescue Remedy is good for nerves – do you have any?’
‘What kind of symptoms are you hoping to relieve?’ replies Ms Edwards. Helen lists ‘significant anxiety symptoms: not sleeping; emotional outbursts due to feeling anxious; an inability to stay on top of her university studies; disruption to function’, Ms Edwards recalls.
Ms Edwards tells her: ‘It sounds like you’re having a tough time at the moment, not being able to engage in all your usual activities.’
She tells Maureen there is no evidence that homeopathic preparations help with clinical anxiety, and that it appears some significant symptoms are interfering with her day-to-day life that need addressing with her doctor and perhaps warrant psychological intervention.
Maureen confides that this was a problem a few years back but that she had been helped by a good counsellor. Recently, however, she has moved, hasn’t had time to follow up, and doesn’t have a good GP.
‘We booked Maureen into a GP for a mental health plan and gave her Beyond Blue’s A Guide to what works for anxiety book, as well as PSA’s ‘Anxiety’ Self Care Fact Card,’ Ms Edwards says.
* Names are pseudonyms
Top tipsAlways recommend non-pharmacological intervention as first-line therapy Encourage patients to get a mental health plan, including booking double appointments. GPs require a double appointment for a mental health plan. Patients often need to return if a double is not booked – missed opportunities.
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COPD flare-up is a deterioration of symptom control in an otherwise stable patient, often involving a bacterial infection. Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis are primarily responsible (and sometimes Mycoplasma pneumoniae and Chlamydia pneumoniae).1
But when is it appropriate to use antibiotics, and when should patients be redirected to their doctor?
Smother the flare, but the bacteria is always there
Early initiation of an antibiotic for a COPD flare-up can prevent further damage to the airways, prevent hospitalisation, reduce the risk of further exacerbations, and allow people to regain symptom control.1,2
Antibiotic treatment aims to hasten recovery rather than eradicate the colonising organism, because most patients have persistent airway colonisation.2
Therefore, lower doses of antibiotics are used for treating fl are-ups of COPD than are used in community-acquired pneumonia.
Treatment is focused on improving the response to bronchodilator medicines rather than eradication.2
When should flare-ups be treated?
Antibiotics for COPD exacerbations are reserved for patients with all three of the following clinical features, which are suggestive of bacterial infection2:
Prophylactic antibiotics reduce COPD exacerbations for up to 3 years and may be appropriate for patients with recurrent infections and hospitalisations.1
Low-dose, long-term macrolides are preferred for preventive treatment.
Therapy should be reviewed after 6–12 months, and after each flare-up.1,2
Five days of antibiotic treatment for flareups is recommended,2 although in practice this may vary according to bronchodilator response.1 Duration of antibiotics for patients should be established during counselling or by contacting the prescriber.3 Cautionary advisory label (CAL) D should be endorsed with the length of treatment and added to the labelling to reinforce essential treatment advice provided in counselling.
Flare-ups can be community-managed according to a plan between the patient and prescriber; postdated antibiotic prescriptions can allow rapid treatment in the event of flare-up caused by bacteria.4
Delayed prescribing of antibiotics has been shown to reduce antibiotic use and resistance, and empowers the patient to be involved in their treatment.5,6
Pharmacists should review patient symptoms prior to supply. This will help pharmacists exercise professional judgement – based on knowledge and guidelines – to determine if supply (and/or referral) is appropriate.
ReferencesANDREW KRICH MPS is a Professional Practice Pharmacist in PSA’s NSW office.
Lodge your own question or advice at editorial@australianpharmacist.com.au
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[post_content] => A new standard of care will help to prevent long-term reliance on opioid analgesics used for acute pain.
The first national Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, developed by the Australian Commission on Safety and Quality in Health Care (ACSQHC), details appropriate opioid use in emergency departments and after surgery.
Released today, the standard suggests considering alternate analgesics and promotes cessation plans where opioids are required.
The aim is to recalibrate the opioid-first habit and provide a guideline to ensure all patients receive the same level of evidence-based safe and effective opioid prescribing.
‘We need to fine-tune our prescribing and use of opioid analgesics for acute pain, to reduce the harms associated with inappropriate prescribing and avoid short-term use becoming a long-term problem,’ said ACSQHC Chief Medical Officer and Conjoint Professor at the University of Newcastle Anne Duggan.
With around 2.5 million operations in Australia per year, PSA General Manager Policy and Engagement Chris Campbell MPS said the standard should help to improve opioid safety in acute care and beyond.
‘Too many Australians use opioids for far longer than intended post-surgery,’ he said. ‘PSA endorses the standard, which should be embedded in practice to improve the management of opioid use in acute care, and prevent harm upon discharge back into the community.’
Pharmacists’ role in opioid management
As medicines experts, pharmacists in all areas of practice play a big role in ensuring opioids are used appropriately, Prof Duggan said.
Hospital pharmacists in charge of stewardship programs should educate junior medical staff, who typically compile discharge summaries.
‘Around 70% of patients in hospitals are discharged on opioids, just in case,’ Prof Duggan said.
‘[Pharmacists] should be reminding clinicians that there is no role for modified-release opioids and clinicians should be prescribing the immediate-release medications,’ she said.
Pharmacists should also educate junior clinicians to not only test for pain, but also function.
‘They should be thinking, “How long does this patient need opioids? How do I calculate, based on the day before discharge, how much they need? How do I calculate what to give them when they get home? And how do I write to the GP?”’
When patients are assessed for opioid prescriptions, pharmacists should ensure clinicians know what other medicines they are taking.
‘[This will prevent] overdose in terms of sedatives, and ensure they're getting the right opioid,’ Prof Duggan added.
With many acute-care patients discharged to residential aged care facilities, on-site pharmacists play a significant role in ensuring opioids are used appropriately.
‘There are few other people with the same expertise to make sure that there’s a good indication for why the patient is on the medication, that the patient is on a sensible dose, that somebody has thought about their other medication and that there is a weaning plan,’ Prof Duggan said.
‘They can certainly raise the alarm with the GP that something's not right.’
Promoting the standard in a community setting
Patients may also be discharged back into the community with opioid scripts, making community pharmacists important gatekeepers in preventing opioid misuse and overdose.
‘When a patient goes to collect their script, pharmacists should educate them on the use of the drug and misuse, and [ensure] that they understand the side effects, risks and benefits of the opioids and what the [discharge] plan is,’ Prof Duggan said.
All patients discharged on opioids should eventually come off them, she warned.
With pharmacists often on the receiving end of prescribing, there are several checks they can conduct to ensure the guidelines have been followed.
Along with screening for modified-release opioids, pharmacists can pick up issues on prescriptions that don’t make sense.
‘[For example], the patient is X weeks postoperative and they are still on the same dose,’ Prof Duggan said.
‘Pharmacists can identify patients who haven't got a weaning plan, check the patient knows when to take it and why they're taking it, and identify and address [adverse] effects.’
Pharmacists can also assess patients in terms of the risk benefit.
‘If the patient is in trouble, pharmacists have a great role to play by ringing the GP and saying, “This patient's on this. I don't know why they're on it and they're having problems”.’
Real Time Prescription Monitoring (RTPM) can also be used to screen patients at risk of opioid misuse.
‘RTPM is another string to the bow with all the things we’re currently trying to do to reduce the harm from opioids,’ Prof Duggan said. ‘It's a great complementary initiative.’
Carefully dispensing opioids
To educate patients about the risks of opioids, pharmacists should take additional measures including labelling the medicines correctly, and providing take-home information and naloxone.
A fact sheet in the Australian Pharmaceutical Formulary Handbook (APF) digital issue, approved by the Therapeutic Goods Administration, outlines use of the Cautionary and Advisory Label 24 for opioid medicines.
Label 24, which states, ‘Use of this medicine has the risks of overdose and dependence’, is recommended for opioid medicines including buprenorphine, codeine, dihydrocodeine, fentanyl, hydromorphone, methadone, morphine, oxycodone, tapentadol and tramadol.
The risk of harm from opioids increases when patients use opioids in high doses, for longer than 90 days, or with medicines or substances with sedative or central nervous system depressant effects (including alcohol and illegal drugs). The risk of harm also increases when patients have complex comorbidities.
Harm from opioids includes overdose, physical dependence and opioid use disorder such as addiction and psychological dependence.
Pharmacists should provide the Opioid medicines patient information handout to patients receiving opioid medicines marked with Label 24. However, the label and handout may not be appropriate in some circumstances, such as when patients are using opioids for cancer or palliative care needs.
Pharmacists should also consider supplying take-home naloxone nasal spray or injection to patients receiving opioid medicines. For more information, see Naloxone for opioid overdose in the APF.
Opioid safety is everyone’s responsibility
Like most aspects of healthcare, the solution to opioid safety doesn’t lie with one root source, Prof Duggan said.
‘From the pharmacist point of view, they are the medication experts and they are in a fantastic position to influence prescribing practices,’ she said.
‘The doctor holds the pen, and the consumer is the one who is getting the medication and should be asking questions. They also know all the side effects [they are experiencing].’
Lastly, hospital pharmacists can ensure the standard is met by developing stewardship programs.
‘Everyone has a bit of expertise, so if everyone works together, you get a much better outcome,’ Prof Duggan added.
Read the full Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard here.
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[post_content] => Experts share vaccination advice for ensuring the community is protected against COVID-19 and influenza.
1. Perfect your co-administration technique
Co-administering the influenza and COVID-19 vaccines provides both convenience for the patient and protection against both types of viruses, said Dr Mary Bushell MPS, Clinical Assistant Professor at the University of Canberra and a contributor to the 2022 Immunisation Update.
‘Research also shows that being vaccinated against influenza provides some cross-protection to COVID-19, reducing hospitalisation and death,’ she added.
[caption id="attachment_18371" align="alignright" width="208"]
Dr Mary Bushell MPS[/caption]
GP Pharmacist Zachary Sum, who has just started co-administering the vaccines, said it is best to administer the COVID-19 vaccine in one arm and the influenza vaccine in another.
‘If the patient wants to receive both in one arm, they should be spaced horizontally 2.5 cm apart in the central and thickest part of the deltoid muscle,’ he said.
Pharmacists should ensure they use landmarking techniques so that both vaccines are administered into the deltoid mass, Dr Bushell said.
‘A vaccine given too high, too low or too far to the side may cause shoulder injury related to vaccination,’ she added.
It is crucial to check the patient's eligibility for the COVID-19 ‘winter dose’ in terms of timing, however.
‘Co-administering the vaccines is a good idea but it is equally important to ensure that eligible patients receive the COVID-19 winter booster dose at least 4 months after their third dose,’ Mr Sum said.
2. Patient care improves when barriers are removed
Queensland-based GP Pharmacist Catherine Laird MPS recently demonstrated why location-specific regulations should be removed to allow pharmacists to vaccinate patients in different settings.
‘Yesterday, one of our practice nurses had to go home sick unexpectedly, but we had patients waiting for flu and COVID-19 shots,’ she said.
‘I said, “I can help out”.’
While Ms Laird was able to see each patient who was booked in for a vaccination, she also provided extended protection to some patients through co-administration.
‘A couple of the people I spoke to were only there for a COVID-19 shot and they didn't realise the influenza shots were available,’ she said. ‘So I was able to [vaccinate them against influenza] as well.’
[caption id="attachment_18356" align="alignright" width="300"]
GP pharmacist Catherine Laird MPS vaccinating a patient[/caption]
This shows just how important pharmacists are in helping to keep the community safe.
‘Pharmacists are the medicines experts, so [we] have the knowledge to answer people's questions, for example around co-administration,’ Ms Laird said.
Removing barriers for pharmacists to provide other vaccines along with the locations for administration is in the best interests of the community, she believes.
‘There were patients booked in for other vaccines yesterday, and I got asked if I could help with those patients as well,’ she said.
‘I had to explain that pharmacists can't administer tetanus/whooping cough vaccines outside of a pharmacy, which was met with some bemusement.
‘The more access points to vaccination, [such as] in a GP practice like I did yesterday or expanding into aged care facilities, the more people are going to be able to get vaccinated.’
3. Remind overseas travellers to get vaccinated against flu at least 2 weeks before flying
The most common vaccine-preventable disease acquired by international travellers is Influenza. With overseas travel now permitted, it is essential prospective travellers arm themselves against the virus.
‘Individuals who are planning international travel should be vaccinated against influenza at least 2 weeks before their trip,’ said Dr Bushell.
4. Protecting children under 3 is a priority
Children are ‘superspreaders’ of influenza. According to research by the Infectious Diseases Society of America, Children aged 1−5 years have a higher total viral burden with prolonged virus shedding.
‘There is concern that they are at a higher risk of influenza and its complications this year,’ Dr Bushell said.
Dr Bushell said that more children under the age of 5 years old are hospitalised with influenza in Australia each year than any other vaccine-preventable disease – including COVID-19.
‘Vaccination provides children with protection against influenza and its complications,’ she said.
‘In an influenza season where there are more unknowns than usual, it’s the best way to keep your child protected.’
Children under 9 years of age who are receiving the influenza vaccine for the first time will need two doses, spaced 1 month apart.
5. Queensland-based pharmacists can vaccinate children 5 years and older
In an Australian first, it was announced last month that pharmacists in Queensland can vaccinate children aged 5 years and older against influenza.
Under emergency health orders, Queensland pharmacists are permitted to administer influenza vaccines to children in this age group in any Australian Government and Queensland Government controlled COVID-19 vaccination service.
This includes community pharmacies, medical centres, hospitals, Aboriginal Community Controlled Health Organisations, aged care facilities and disability centres.
‘Children can be influenza super-spreaders and vaccination is the best line of defence for themselves and those around them,’ said PSA’s Queensland Branch President Shane MacDonald.
‘The school holidays are a great opportunity for kids to come in for their COVID-19 and influenza vaccines on the same day.’
Looking to refresh your immunisation knowledge? Check out PSA's Immunisation Online Refresher Course.
[post_title] => Top tips for protecting patients against ‘flurona’
[post_excerpt] => New regulations and building back immunity to influenza are key to protecting the community this season and avoiding 'flurona'.
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Case scenario
Jane and her 5-year-old son visit the pharmacy. Jane believes her child has head lice for the first time and needs advice. You comb through the child’s hair using a fine-tooth comb and find moving lice. After confirming the child has no allergies, you recommend KP24 (malathion) lotion, which is a first-line treatment for head lice. You explain how to use the treatment: apply to dry hair, massage the lotion in for 6 minutes and leave it on the scalp for 30 minutes before washing. You advise Jane not to use hot tools while using this product (e.g. a blow dryer), as it is flammable. You emphasise that at least two applications are needed, at least 7–10 days apart. It should be followed up with daily wet combing to identify remaining or newly hatched live lice.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.4, 1.5, 2.2, 3.1, 3.5 |
Head lice (Pediculus humanus capitis) infestation is a global public health issue — the prevalence estimates range from 5% in Europe to 33% in Central and South America.1 Prevalence of head lice infestation in Australian schools has been reported to be as high as 34%.1–5
Most head lice treatments are over-the-counter medicines, available without a prescription and readily available in pharmacies. It is essential that pharmacists have the knowledge and skills to assess, counsel and recommend appropriate evidence-based treatments for head lice.
Head lice infestation can be asymptomatic, particularly in first-time cases or light infestations.6–8 The main symptom is pruritus (itch) on the scalp, back of the neck and behind the ears, caused by an allergic reaction to louse saliva, which it injects while feeding.6,9,10 Individuals who have never experienced a head lice infestation can experience a delayed onset of itching, as sensitisation to louse saliva can develop over 4–6 weeks.6,9 Red to brown spots may be found on the scalp, which is blood excreted and digested by the lice.10 In rare cases, excessive scratching can lead to sores and secondary infections (e.g. impetigo), enlarged lymph nodes, alopecia, poor sleep and irritability.6,10–12 While extremely rare, there are reports of iron deficiency anaemia from severe infestations.13,14
Head lice can affect individuals of all age groups, irrespective of socioeconomic status, personal hygiene and hair type.15–17 It is mostly seen in children aged 3–11 years,15,18 and females (2.5 times higher risk).1
Head lice are commonly transmitted through direct head-to-head contact.6,9 Indirect transmission through sharing of clothes and personal care items is rare.6 Animals are not a vector for head lice transmission.9
The adult head louse is an arthropod insect (Phthiraptera), whitish grey to pale brown in colour, 2–3 mm in length, equipped with mouth parts to suck blood and 6 legs to attach to hair strands.6,7,9 Lice cannot jump or fly; they can only crawl from head to head,7, 9 and the average life span of an adult louse is 32–35 days.6,19 Lice can only survive 1–2 days away from the scalp but can become non-viable due to dehydration before death occurs.6,20
The louse requires a protein blood meal to produce eggs and will feed from its host every few hours.9 Its saliva aids feeding by acting as an anticoagulant and vasodilator.9
Nits (louse eggs) are 1 mm in size, oval, and yellow to white in colour.7 The louse produces a glue-like substance which allows the nits to stick firmly to hair strands; they are commonly found near the scalp margins, behind the ears and back of the neck.7,9,12 They are incubated by the heat of the scalp; eggs cannot hatch if they are not kept at temperatures close to the scalp and can die within a week.7,9 Nymphs (immature lice) hatch after 7–10 days.6,15,16 Once hatched, the nit shell becomes more visible, a dull yellow to white in colour, and remains attached to the hair shaft.6,15 Nymphs pass through three maturation stages, known as moults, which takes anywhere from 2 to 10 days.19 The female louse can mate and lay eggs about 1–2 days after becoming an adult and can lay 3–8 eggs per day.6,19
Diagnosis of head lice infestation can be challenging, as it can be easily misdiagnosed (see Table 1). Visual identification of a live louse on the scalp is required for diagnosis.6,7 Itching, or the presence of eggs, does not always indicate an active infestation.
Wet combing is a commonly used diagnostic tool and is preferred over visual inspection.7,21 Conditioner is applied to the hair to immobilise the lice, and a head lice comb (fine-tooth comb) is used to brush through the hair to collect the lice and eggs.7
Adapted from Therapeutic Guidelines and Australian Pharmaceutical Formulary (APF) 25. 6, 7
Other causes of head lice-like symptoms and their differentiating features are listed in Table 1.
Table 1 – Other causes of head lice-like symptoms
| CAUSE | DIFFERENTIATING FEATURE |
| Hair casts (pseudonits): remnants of inner root sheaths of hair follicles, encircling hair shafts of the scalp. | Casts can be easily dislodged from the hair. |
| Seborrheic dermatitis: can affect the scalp, eyebrows, nasolabial folds, central chest. It is a chronic relapsing condition. Commonly seen at puberty. Dandruff is the mildest form of this condition. | Scaling, ranging from mild to widespread thick crusts. Easily removed and can be accompanied with burning sensation and erythema. |
| Scalp folliculitis: an inflammatory disorder of the hair follicles. | Small, itchy pustules that become sore and crusted, and often occur on frontal hair line. |
| Trichorrhexis nodosa: can affect the scalp, pubic area, beard and moustache. Can be congenital or caused by trauma, either physical (e.g. excessive brushing) or chemical (e.g. hair dyes). Most commonly found in females. | Presence of white flecks in the hair, abnormally fragile hair, areas of alopecia. |
The following are red flag symptoms that may require referral to a doctor:7,11
Neurotoxic agents are the first-line treatment option for head lice infestation,22 though there are reports of increasing resistance.10,23 Physical insecticides like dimethicone are emerging to become favourable alternative options, and wet combing is an effective but labour-intensive mechanical approach.24
The treatment goals for head lice infestation are to eliminate the active infestation and prevent transmission of lice to others.7 Treatment choice should be guided by local patterns of insecticide resistance, prior use of treatments, patient characteristics (age, pregnancy, breastfeeding, history of hypersensitivity or adverse effects), and individual preference.7
Treatment should only be commenced if live lice are identified on the individual. Prophylactic treatment is not recommended and can contribute to insecticide resistance, treatment failure and adverse effects.7, 12
Close contacts of the infested individual should be screened using the wet combing method, repeated daily.⁷ Most treatments do not kill eggs and require a second or third application after 7–10 days to ensure the lice that have hatched since the first application are killed off.7,23 Dead eggs, lice or egg casings can be removed via fingernails or a fine-tooth comb.7
Treatment failure is defined as lice being present after the administration of treatment; this can be attributed to a variety of reasons: insecticide resistance, improper or inadequate application, re-infestation, failure to re-treat, or misdiagnosis.7
Treating head lice7,8:
Head lice treatment options are outlined in Table 2.
Table 2 – Head lice treatments
References: APF 257, TG8, AMH22, Department of Health23, Public health medicine environmental group24, TGA (DAEN)25, Consumer Medicines Information (CMI) for Ivermectin26
*Refer to product information for instructions on individual product use
As head lice can only survive 1–2 days away from the scalp, and there being little evidence of indirect transmission, the following interventions may be recommended; however, they have limited effectiveness in reducing infestations7,11:
Malathion can be absorbed through the skin, though risk of systemic exposure is low.22,27 If ingested, there is a risk of respiratory depression.19
Malathion when used in combination with anticholinesterases (e.g. donepezil, pyridostigmine) can result in additive toxicity.22
There are no preventive treatments for head lice, though the following strategies can be used to reduce the transmission of head lice7:
Children identified with active lice need to inform the school and close contacts to ensure appropriate screening can be implemented. Children should be excluded from school until the day after appropriate treatment has been administered and no live lice are detected.7
Case scenario continuedJane asks whether she also requires treatment, as she feels her scalp is itchy. After combing through Jane’s hair, you do not find any active lice or nymphs. In the absence of an active infestation, you suggest that Jane does not require treatment but can use wet combing daily for a week to screen for head lice. You further add, if lice are seen, Jane can use KP24 like her son, after confirming she is not pregnant or allergic to the product. |
SANDRA RAJU BPharm (Hons) is an intern pharmacist.
DR WUBSHET TESFAYE BPharm, MSc, PhD is a project manager and post-doctoral researcher at the University of Sydney.
DR MARY BUSHELL BPharm (Hons), AACPA, GCTLHE, AFACP, MPS, PhD is a Clinical Assistant Pharmacist and the Professional Practice Convenor for the pharmacy discipline at the University of Canberra.
DR JACKSON THOMAS BPharm, MPharmSc,PhD is a pharmacist, trialist, NHMRC-funded pharmaceutical scientist and Associate Professor at the University of Canberra.
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[post_content] => Case scenario
Craig, a 26-year-old male, enters your pharmacy and asks to speak to the pharmacist. He enquires about the use of ecstasy and explains that he will be attending a music festival on the weekend with friends. It is the middle of summer, and you know it’s going to be very hot on the weekend. Craig asks you for advice on the risks associated with ecstasy use and methods for reducing these risks.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency standards (2016) addressed: 1.1, 1.2, 1.4, 1.5, 1.6, 2.2, 2.3 |
Drug checking, also known as pill testing, is a process involving the chemical analysis of an illicit substance such as a pill or powder, followed by tailored feedback and counselling. The main aim of the service is to reduce drug-related harms, hospital admissions and deaths. Drug checking services have become well established overseas, with services set up in a number of countries including the Netherlands, Spain, the United States, Canada, the United Kingdom and New Zealand.1,2 These provide a mix of postal, fixed-site and on-site services, allowing people to anonymously post drugs for analysis, attend a permanent site, or visit a mobile facility such as those provided at festivals. In Australia, the first government-sanctioned on-site drug checking trial was conducted in 2018 at the Groovin the Moo festival in the ACT, followed by a second trial in 2019. In October 2021, the ACT Government approved and provided funding for Pill Testing Australia (PTA) and Harm Reduction Australia (HRA) to pilot a fixed-site pill testing service in the ACT. 3,4
The Pharmaceutical Society of Australia (PSA), Australian Medical Association (AMA) and Royal Australian College of Physicians (RACP) support further trials to inform the role of drug checking in Australia’s harm minimisation strategy.5–7 The 2019 National Drug Strategy Household Survey (NDSHS) found that 57% of Australians supported drug checking at designated sites, while 27% were opposed and the other 15% were unsure.8
Illicit drug use among Australians is common. The 2019 NDSHS found that 9 million people (43%) aged 14 years and over had illicitly used a drug (including pharmaceuticals for non-medical purposes) at some point during their lifetime.8
With respect to drug checking, the hallucinogenic amphetamine3,4 methylenedioxymethamphetamine (MDMA, or ecstasy) is of particular interest, as it is commonly used and tested for at music festivals and events. The 2019 NDSHS found that 2.6 million people (12.5%) aged 14 and over had used this drug during their lifetime, with 3% of people aged 14 and over (600,000 people) reporting use in the last 12 months.8
Between July 2016 and January 2017, several young Australians tragically lost their lives following the consumption of substances they believed to be MDMA or psilocybin (magic mushrooms).9 In April 2021, the Victorian Coroner released findings related to the examination of five of these deaths. Postmortem analysis revealed that what they had taken was not pure MDMA or psilocybin, but rather the novel psychoactive substances 4-fluoroamphetamine and 25C-NBOMe.9 As a result of these findings, the Victorian Coroner recommended that drug checking services be implemented in Victoria as a matter of urgency.9
Prior to the Victorian Coroner’s report, the New South Wales Coroner released findings into the deaths of six young people between December 2017 and January 2019.10 In these cases, deaths occurred as a result of MDMA toxicity, with each individual found to have had dangerously high plasma MDMA concentrations.10 The NSW Coroner also noted 29 pre-hospital intubations, 25 intensive care admissions and 23 drug-related hospital admissions during the festival season between 2018 and 2019, which encompassed 25 music festivals.10 They considered the difficulty in discussing issues such as drug checking due to the illegality of drug use, and raised the inadequate nature of the ‘just say no’ message that is currently promoted. In addition, the NSW Coroner determined that the individuals involved lacked understanding of the risks associated with high-dose MDMA and were unable to identify signs of MDMA toxicity.10
Drug use occurs in a wide variety of settings, including music festivals, nightclubs and at home. While the NSW Coroner’s report focused on music festivals, several of the Victorian cases involved taking the drugs at home with friends.9
Novel psychoactive substances (NPS), also known as ‘designer drugs’, have been designed to mimic the effects of popular recreational substances including amphetamines (such as MDMA), hallucinogens (such as lysergic acid diethylamide [LSD]), and cannabis. The NPS implicated in the Victorian Coroner’s report were 25C-NBOMe and 4-fluoroamphetamine.
25C-NBOMe is a stimulant and hallucinogenic substituted phenethylamine, part of a group of drugs commonly referred to as an ‘N bomb’. It is highly potent and can be taken orally, sublingually or insufflated (nasally inhaled). Mild toxicity manifests as hallucinations, tachycardia, hypertension, sweating, agitation and confusion.
In severe cases, seizures, rhabdomyolysis, hyperthermia and death can occur.9 4-fluoroamphetamine is a central nervous system (CNS) stimulant with dopaminergic and serotonergic effects. De Sousa et al noted elevations in blood pressure following administration of 4-fluoroamphetamine in volunteers.11 Several case reports exist of haemorrhagic stroke and other cardiovascular complications following recreational use.12 Both substances have since been the subject of public warning campaigns.13
Despite being considered a novel psychoactive substance, 4-fluoroamphetamine was first synthesised in the 1940s.14 NBOMes (including 25C-NBOMe) are newer, being first synthesised between 2008, when 25I-NBOMe was synthesised by a German chemist, and 2010, when they began to appear on the internet.15
The NPS seen on the market are highly variable, with substances disappearing and reappearing on the market.9,13
MDMA is a hallucinogenic amphetamine that produces effects such as euphoria, feelings of closeness and decreased fear, making it a popular party drug.16,17 It is also currently being investigated as a potential adjunct to psychotherapy for the treatment of post-traumatic stress disorder (PTSD).18 A standard recreational dose of MDMA is generally 75–125 mg, though higher strength pills are not uncommon.16,19,20
Toxicity manifests as hyponatraemia leading to cerebral oedema and seizures.21 Hyperthermia may lead to complications, including rhabdomyolysis and disseminated intravascular coagulation.22
Given the lack of professional drug checking services in Australia, at-home reagent testing is the primary method of drug checking currently available. This is a rudimentary method of checking drugs that can be done using a small set of reagents at home. These reagents are legally available for sale in Australia, and in some cases have been distributed to users by harm reduction organisations such as Students for Sensible Drug Policy (SSDP).23 Upon contact with the substance, a colour change will occur which can then be compared to a chart. This can provide an indication of the presence of a substance (expected or not), but gives no assurance as to its purity or dose.
In combination with the development of an early warning network, to alert the public to dangerous substances in circulation, drug checking has the potential to reduce harm and deaths associated with the use of drugs obtained from an unregulated market.9 Quality control in the illegal drug market is non-existent, leaving individuals at risk of unknowingly consuming a drug that is not what they expected, adulterated or a higher dose than intended. Worldwide there has been a trend towards the manufacture of high-strength MDMA pills. For example, in 2019 UK-based drug checking organisation, The Loop, discovered 300 mg MDMA pills (three times the usual dose).19 Of particular note is the prevalence of NPS, which are often mis-sold as other drugs such as MDMA.
The drug checking process usually consists of two components: chemical analysis of the substance to give an indication of content and purity, and a healthcare consultation to provide tailored harm reduction information and support to the service users. A number of different models are used to provide this service.2
Chemical analysis
Chemical analysis is a critical component of the drug checking process. It should be undertaken by professional chemists using specialised laboratory equipment and followed by a discussion with a harm reduction or healthcare worker, who interprets the result for the end user.
The most sophisticated method of analysis uses gas chromatography in combination with mass spectrometry (GCMS).24 This is a method that can be used to determine the concentration of the detected substance as well as any known adulterants or dangerous excipients.24 There are downsides to this method – it is expensive, requires a trained chemist, the equipment is difficult to transport, and the results can take time.24 Fourier-transform infrared spectroscopy (FTIR) is a somewhat more accessible method that is commonly used. It is cheaper and more portable, and can be used to identify known substances using a database.24 It only requires a small sample to be submitted, such as a scraping from a pill or a small amount of powder. This method also has its downsides: it is not able to detect substances that are not in its database, and it doesn’t provide information on dose.24 FTIR is used by The Loop and was used during the 2018 and 2019 Australian drug checking trials at Groovin the Moo in Canberra.
Research conducted by Barratt et al in 2018 revealed that only one-third of service users would be willing to give up an entire pill, which is required for a comprehensive quantitative result where the amounts of individual ingredients are determined.25 This type of analysis is particularly important where there is a trend towards pills of high potency, such as what has been seen with MDMA in both the UK and Australia.19,20 However, the study also found that service users were only slightly more interested in quantitative results than qualitative results.25 The limitations of the method of analysis used should be highlighted during the healthcare consultation phase.
Healthcare consultation
The healthcare consultation component of the drug checking process, also referred to as a brief intervention, is fundamental for the promotion of harm reduction.
Qualified and appropriately trained healthcare workers, including doctors and pharmacists, deliver individualised counselling to assist the service user in understanding the implications of the chemical analysis result. There is usually no charge for the consultation, and advice is provided in a non-judgemental manner.
The healthcare worker takes into consideration individual factors such as weight, gender, tolerance, mental state and presence of other drugs (including alcohol or prescription medicines), as well as the environment (for example, hot days can increase risk). Service users may be counselled individually or in groups. They are given the opportunity to ask questions, and harm reduction resources including fact sheets and contact details for drug and alcohol services are made available.
In the case of on-site facilities at festivals, attendees can be referred directly to medical services if deemed necessary. A survey of Australian festival and nightlife attendees who use drugs found that only 36% of respondents would use a service with no individualised feedback, highlighting the importance of this intervention and the willingness of users to engage with a health professional.25
An argument often highlighted by those opposed to drug checking is that the presence of these services equates to condoning drug use.26 It is important to note that regardless of the result, drug use is never stated as being safe, but rather the focus is on minimising harms associated with use. It is made clear to the service user that the only way to guarantee safety is to avoid use. The focus is on pragmatic strategies to reduce harm, such as taking a lower dose, taking it over a longer period of time, or in the case of known dangerous adulterants, encouraging disposal.
Research shows that when seeking information about the contents of a substance, friends are the most common source of information followed by the dealer.25 Drug check reporting websites that test substances and publish results are also frequently accessed by service users.25 Only a minority of people who use drugs in Australia have their drugs tested, either with at-home reagent kits or through a professional service (where these have been available).25
Despite critics of drug checking services citing a lack of evidence for harm reduction, a recently published systematic review suggests that the presence of drug checking services, in combination with healthcare consultations and an early warning system, is effective in reducing harms.27 A study conducted by The Loop found a 95% decrease in drug-related hospital admissions at a festival in 2016 compared with the previous year, where no drug checking was conducted, with the change attributed to increased awareness of mis-selling (for example, selling NPS as MDMA) and the presence of contaminants, as well as alerts made via social media and word of mouth.28
The results of chemical analysis, combined with a brief healthcare consultation, have been found to change consumption behaviours.28 For example, a survey conducted following on-site drug checking at three music festivals in the UK found that 20.8% of people whose drugs were found to be ‘not as expected’ discarded the drug on-site at the drug checking facility.29 A further 29.6% self-reported disposing of the drug after leaving the testing area.29 Another 20.1% took a smaller dose than originally intended, and 9.4% returned the drug to their supplier, potentially reducing demand for these particular substances and subsequently supply.29
Related to this is evidence to suggest that drug checking services can alter drug markets, so people can make more informed decisions about what they choose to purchase. For example, over the 30 years that the Netherlands’ DIMS service has been running, the contents of MDMA pills have been found to be increasingly more consistent with expectations, and there has been a decrease in poor quality, adulterated or dangerous substances.30
Pharmacists have played a role in drug-checking services overseas. Pharmacists possess a unique set of skills that make them particularly suited to delivery of healthcare consultations following drug checking. For example, a risk assessment is undertaken with consideration to the service user’s physical and mental health, environment, gender, weight and other consumed substances (prescription or recreational, including alcohol) to identify any ‘red flags’ that might require prompt referral or in-depth counselling.
A 2016 Australian survey found that 85% of respondents would be willing to use a fixed-site service, external to events, and 61% of respondents would wait one week for results if the results were reliable.25 As such, a model where fixed sites (such as pharmacies) are used as nominated drop-off points for off-site analysis could be considered.
Pharmacists in Australia and internationally have been involved in harm minimisation strategies.31 Currently, pharmacists in Australia are involved in the needle and syringe exchange and supply of pharmacotherapy for the management of opioid and nicotine addiction.32 The facilitation of drug checking services is in line with the harm minimisation work that pharmacists already do, and like other harm minimisation strategies, it is not intended to spread the message that illicit drug use is safe or without risk. Rather, it can be a way to provide support to hard-to-reach members of the population, including young people who use drugs. It is an opportunity for these people to engage with a health professional who is able to provide accurate and evidence-based advice and support without judgement. In some cases, referral to an external support service may be appropriate. Support services include:
While many on-site drug checking models utilise the skills of analytical chemists to operate laboratory equipment, pharmacists are able to interpret the results of testing and provide tailored advice to help the service user understand the result and its relevance.
Case scenario continuedYou ask Craig if he would like to join you in the private counselling room to discuss his queries, and ensure that advice is provided in a non-judgemental manner. You explain that there is no safe level of illicit stimulant use. You also explain that drugs sold as ecstasy do not always contain MDMA, instead they can be a mix of other substances; and if they do contain MDMA, the amount can vary. You outline a number of possible adverse effects, including seizures, cerebral oedema, arrhythmia, haemorrhage and death. Finally, you explain that the risk is also increased if other drugs (including alcohol) are taken at the same time, and that hot weather can contribute. You provide Craig with the details of the Alcohol and Drug Foundation website (and explain this has useful information on reducing the risks of drugs) as well as the Alcohol and Drug Foundation Drug information and advice line for further information. |
Drug checking is a harm-minimisation strategy that aims to provide service users with information on the chemical makeup of their drugs, and the risks associated with their consumption, to reduce drug-related harms, hospital admissions and deaths. Drug checking can also contribute data to early warning systems that can alert health professionals and law enforcement agencies to the current nature of illicit drug markets and enable them to tailor their response. Drug checking services are well established overseas with many utilising the expertise of health professionals, including pharmacists, to provide tailored and non-judgemental advice to service users based on the results of chemical analysis. With increasing local and international evidence supporting its use as a harm minimisation intervention, drug checking is expected to play an increasing role within Australia’s health system in coming years.
ALICE NORVILL BSc, BPharm is a pharmacist and specialist in poisons information working at the Victorian Poisons Information Centre, assisting in the management of unintentional and intentional exposures to various substances, including illicit drugs. In 2019 she volunteered with Pill Testing Australia to deliver brief interventions at the Groovin the Moo trial in the ACT.
The author would like to acknowledge: Rohan Elliott, BPharm, BPharmSc(Hons) MClinPharm, PhD, FSHP, and Dr Monica Barratt, BSc(Psych)(Hons), PhD, for their contribution to this paper.
[post_title] => Drug checking in Australia: How pharmacists can be involved [post_excerpt] => With increasing local and international evidence supporting its use as a harm minimisation intervention, drug checking is expected to play an increasing role within Australia’s health system in coming years. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => drug-checking-in-australia-how-pharmacists-can-be-involved-cpd [to_ping] => [pinged] => [post_modified] => 2022-05-05 20:48:22 [post_modified_gmt] => 2022-05-05 10:48:22 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=18377 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Drug checking in Australia: How pharmacists can be involved [title] => Drug checking in Australia: How pharmacists can be involved [href] => https://www.australianpharmacist.com.au/drug-checking-in-australia-how-pharmacists-can-be-involved-cpd/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 18500 )
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[post_content] => Case scenario
Mrs Ma, aged 60, presents with a prescription for osimertinib 80 mg once daily. It is a new medicine for her. She has a history of metastatic adenocarcinoma NSCLC with right-lung primary and bone metastasis. Mrs Ma returns to the pharmacy 2 weeks later complaining of a rash and tenderness to her arms. On examination, the rash looks pustular and erythematous and only extends to her right forearm. Mrs Ma denies any other rashes on her body or recent changes to her medicines or creams/body washes.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency addressed: 1.1, 1.4, 2.1. 2.2, 3.1, 3.2. 3.3 3.5 |
Lung cancer is the most common cause of cancer-related death both worldwide and in Australia.1,2 Lung cancer is the fifth most diagnosed cancer in Australia, with the highest mortality rate and a 5-year survival rate of around 18%.1,2 There are two major subdivisions of lung cancer: small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC).3–5
NSCLC accounts for approximately 85% of all lung cancers, with the remaining being SCLC.3–5 NSCLC arises from the epithelial cells of the lung situated within the central bronchi to terminal alveoli. The most common histologies are squamous cell carcinoma (30%), adenocarcinoma (30–40%) and large cell carcinoma (10–15%).3–5 Squamous cell carcinoma starts near a central bronchus, while adenocarcinoma and bronchioalveolar carcinoma usually originate from peripheral lung tissue.3–5 SCLC arises in peribronchial locations and tends to infiltrate the bronchial submucosa.3–5
Risk factors for lung cancer include3–5:
Although NSCLCs are associated with cigarette smoking, adenocarcinomas can be found in patients who have never smoked.3–5 Smokers have on average a 10-fold higher risk of developing lung cancer than lifetime non-smokers.3–5
The most common symptoms at presentation include3–5:
In SCLC, infrequently patients may present with signs and symptoms of one of the following paraneoplastic syndromes due to various peptide hormone productions3–5:
At initial presentation, a thorough history is required, taking note of3–5:
Investigations to aid diagnosis and staging3–5:
SCLC is defined by the spread of the cancer. Cancer that has spread beyond the supraclavicular areas is classified as extensive stage disease (ED), while cancer that has not spread is called limited stage disease (LD).6
The staging of NSCLC uses the American Joint Committee on Cancer (AJCC) TNM system, which stages cancer using these three key criteria7:
In July 2021 the Australian Government announced a $6.9 million budget to commence early scoping of a potential national lung cancer screening program to increase early diagnosis and survivorship of lung cancer.8 The screening program will target high-risk individuals by conducting 2-yearly low-dose computed tomography (LDCT) scans in these individuals.8
Primary prevention is still one of the most important strategies for reducing the burden of lung cancer in Australia. As primary healthcare professionals, pharmacists are integral in providing education and support for smoking cessation, preventing smoking uptake and providing counselling on minimising our patients’ exposure to second-hand tobacco smoke.
The pharmacist can play a major role in guiding patients through smoking cessation. Guidelines for smoking cessation are widely accessible and include the PSA’s counselling guideline for common aliments – smoking cessation.9 When assessing a patient, it is important to gather patient information, including medical history, current medications, readiness to quit, nicotine dependence and previous attempts to quit.
The PSA guideline outlines how to assess nicotine dependence and situations where patients may require referral, such as history of cardiovascular disease.9 When developing a quit strategy for patients, a combination of behavioural and medicinal interventions should be used. Patients should be provided with verbal and written information on the use of smoking cessation products and referred to Quitline for additional support packs and telephone counselling.9 It is important to consider the impact that smoking cessation may have on other medicines, as tobacco smoking induces CYP1A2 metabolising enzymes. As a result, smoking cessation can increase the levels of drugs metabolised by this enzyme.9
Management of lung cancer is multimodal and includes surgery, radiation therapy, chemotherapy and targeted therapy. These therapies can be used either alone or in combination, depending on the type of lung cancer, stage of lung cancer, molecular mutations, and the patient’s performance status.
These decisions are often made by multidisciplinary teams to help assess all aspects of the patient’s condition.3,11
Surgery
Patients with early-stage NSCLC disease have the best chance of cure if surgery is undertaken to remove the primary tumour.3 Surgery also allows for further testing to define the stage of cancer, and therefore guides the ongoing treatment decisions. The common surgical procedures include segmentectomy (removal of part of a lobe), lobectomy (removal of one of the lobes) or pneumonectomy (removal of part or all of lung).12 The type of surgery is determined by the extent of disease and the cardiopulmonary reserve of the patient.11
Radiation therapy
While not always a first-line option, radiation therapy has a potential role in all stages of NSCLC, as either definitive (intention of cure) or palliative therapy (end-of-life comforting therapy).
Radiation therapy is generally used in early-stage NSCLC in combination with chemotherapy as definitive therapy and in advanced stage NSCLC as palliative therapy.11,12
Pharmacotherapy
Recent advances in pharmaceutics have increased the availability of medicines to treat NSCLC. As a result, a range of targeted therapies and chemotherapy are used in the management of NSCLC. New therapies such as targeted mutation therapy have shown increased median survivals of around 25 months.3
Targeted therapies – tyrosine kinase inhibitors (TKIs)
NSCLC consists of molecular subtypes identified by genetic aberrations, which allows for use of targeted therapy. Targeted therapies produce higher response rates than immunotherapy in metastatic NSCLC, and patients should receive these agents first-line where indicated.13
TKIs are small molecule inhibitors which inhibit specific tyrosine kinases that are abnormally activated in some types of cancer.14 Activation of tyrosine kinases can increase survival and proliferation of malignant cells and increase angiogenesis, invasiveness, and metastatic potential of tumours.14 TKIs can target tumours harbouring targetable driver mutations.
Epidermal growth factor receptor (EGFR) tyrosine kinase Inhibitors
EGFR mutations cause uncontrolled cancer cell proliferation. EGFR has been shown to be over-expressed in more than 60% of NSCLC cases and is associated with a poor prognosis.15
EGFR TKIs inhibit EGFR-dependent tumour cell proliferation and can be further classified as3:
EGFR TKIs are indicated as first-line treatment for advanced stage NSCLC in patients with evidence in tumour of an activating EGFR gene mutation.16 The EURTAC study demonstrated that erlotinib had better progression-free survival (PFS) of 9.4 months versus 5.2 months with conventional first-line chemotherapy.16 Afatinib and osimertinib are indicated and PBS-listed for first-line treatment of Stage IIIB (locally advanced) or Stage IV (metastatic) NSCLC. The use of first-generation eGFR TKIs, erlotinib and gefitinib, is less favoured due to the availability of superior alternatives.23 Osimertinib is also available on the PBS as second-line EGFR TKI therapy for patients who have progressed on prior EGFR TKI therapy and have evidence of EGFR T790M mutation in tumour material.
Adverse effects of EGFR TKIs
As this is an emerging therapy, pharmacists should be aware of potential adverse effects of these agents.
Outlined below are some of the common adverse effects for osimertinib (EGFR TKI) and incidences of each adverse effect26:
Further information on side effects and management can be found in eviQ under individual agent treatment protocols.23
Pharmacists play a key role in management of EGFR inhibitor skin reactions. EGFR TKIs commonly cause skin reactions which present as a papulopustular rash, usually on the face and upper body, within the first 2–4 weeks of treatment.14 This could also present as itch, dry skin, paronychia, nail disorders and abnormal hair growth. It is important to note that this adverse effect occurs because of direct EGFR inhibition, and not as an allergic reaction to the therapy.23
These reactions are treated with topical corticosteroids (hydrocortisone 1% cream) and patients may be started on a tetracycline such as doxycycline. Pre-emptive prophylactic doxycycline may be used with initiation of EGFR TKI at the discretion of the prescriber.23 It is important to provide advice to patients on general measures to reduce skin reactions, including twice daily application of moisturiser and the use of sunscreen before going outdoors, as rash may be more severe in areas of skin exposed to sunlight.14,23 Patients should be advised to report within 24 hours any skin changes such as rash and itch to their oncologist.
Drug interactions – osimertinib
Osimertinib is metabolised by CYP3A4 and strong inducers of this metabolising enzyme such as carbamazepine, phenytoin, rifampicin and St John’s wort may decrease exposure of osimertinib. These drugs should be avoided, but if that is not possible the dose of osimertinib should be doubled.
Osimertinib is an inhibitor of P-gp, and drugs metabolised by P-gp with a narrow therapeutic index (e.g. digoxin and dabigatran) should be monitored for signs of increased exposure.
Anaplastic lymphoma kinase (ALK) fusion inhibitors
ALK gene mutation occurs in 2–7% of NSCLC resulting in constitutive activity and oncogenesis.3,5 Crizotinib is a first-generation ALK TKI which has activity against ALK mutations.15 It is also important to note that crizotinib has other molecular targets that are significant in NSCLC, such as the c-ROS oncogene 1 (ROS-1) and has recently also been approved for treatment of patients with evidence of ROS1 gene rearrangement in tumour material in Stage IIIB (locally advanced) or Stage IV (metastatic) NSCLC.23
Second-generation ALK inhibitors target ALK mutations with higher affinity and include ceritinib, alectinib and brigatinib. These are preferred agents for treatment of ALK positive Stage IIIB (locally advanced) or Stage IV (metastatic) NSCLC.23 Lorlatinib is a third-generation ALK TKI that was approved in November 2018 for patients who have progressed on crizotinib and another ALK inhibitor or after progression using alectinib or ceritinib as a first-line ALK inhibitor.3 This was based on the study by Solomon et al showing overall response rate (ORR) of 48% and median response rate of 12.5 months with lorlatinib in patients who previously received one or more ALK inhibitors.3
Emerging molecular targets
ROS, BRAF, RET, MET, NTRK and KRAS G12C mutations are other mutations that may initiate and maintain the growth of cancer cells. These gene mutations may be tested for in NSCLC due to emerging new TKIs being developed and approved for use in Australia that target these mutations.
Vascular endothelial growth factor (VEGF) receptor inhibitors
Bevacizumab is a monoclonal antibody (MAB) that targets the VEGF, inhibiting the formation of new blood vessels and reducing vascularisation and growth of tumours.14 Study E4599 (bevacizumab + carboplatin + paclitaxel vs carboplatin + paclitaxel) showed that the addition of bevacizumab resulted in a statistically significant improvement in overall survival and PFS.17 Consequently, bevacizumab is indicated for advanced or metastatic NSCLC in combination with carboplatin and paclitaxel and for continuing treatment, as monotherapy in a patient who does not have progressive disease.11
Immunotherapy PD1 and PDL1 inhibitors
The immune system is capable of anticancer activity; however, immune checkpoints or ‘brakes’ generated from the tumour can suppress the immune system’s activity.3 Immune checkpoint inhibitors release the ‘brakes’ of the immune system, allowing for full activity against the tumour.3 Pharmaceutical agents execute this through inhibition of T-cell antigen 4 (CTLA-4), program death ligand 1 (PDL-1) and its receptor (PD-1).14 Pembrolizumab, nivolumab (PD1 inhibitors), atezolizumab, and durvalumab (PDL-1 inhibitors) are immune checkpoint inhibitors approved for use in NSCLC. These agents may be used according to PBS restrictions for advanced stage disease in combination with chemotherapy, for patients with no targetable mutations, advanced stage disease following progression of first-line maintenance therapy for patients with locally advanced, un-resectable disease.11,12
The use of these agents in these settings is supported by several clinical trials. The IMpower150 trial, compared combination atezolizumab, bevacizumab, carboplatin and paclitaxel (ABCP) versus bevacizumab plus chemotherapy as first-line therapy.19 This study showed improved median overall survival in the ABCP arm compared to the bevacizumab plus chemotherapy arm (19.2 months versus 14.7 months).19
Adverse effects of PD1 and PDL1 Inhibitors
As immunotherapy boosts the immune response, an adverse effect of this may be over-stimulation of the immune system resulting in immune-related adverse events (irAE). These present as a range of autoimmune toxicities affecting any body system. Reactions may affect any organ system, including the liver, kidneys, skin (rash), endocrine (hypo- or hyperthyroidism), lungs (pneumonitis) and gastrointestinal tract (diarrhoea and colitis). Early identification and swift management are key in avoiding life-threatening severity.
Management of irAE requires referral to the patient’s medical oncologist without delay and will generally include treatment with corticosteroids and holding or permanently stopping the product depending on the grade of reaction.14 Further information on signs and symptoms of irAE can be found in eviQ.23
Chemotherapy in NSCLC generally includes the use of a platinum-based drug (carboplatin or cisplatin) in combination with another agent such as etoposide, pemetrexed, paclitaxel, gemcitabine or docetaxel.12 The role of chemotherapy in NSCLC varies significantly according to the stage of cancer and the ability to resect the cancer. To summarise, chemotherapy is generally used post- surgery in early-stage disease in combination with radiation for curative intent or in advanced-stage disease for patients without targetable mutations to increase survival and improve quality of life. Concurrent radiation and chemotherapy is more efficacious than sequential chemoradiation but increases the risk of adverse effects, particularly esophagitis.11
Patients diagnosed with SCLC often have extensive disease at the time of diagnosis.
As a result, the goal of treatment is the prolongation of survival and palliation of symptoms.12 In extensive disease, where patients are appropriate for chemotherapy, the standard regime is a platinum drug plus etoposide for 4–6 cycles in combination with radiation. These patients may also receive prophylactic cranial irradiation if disease responds well to chemotherapy.20 Patients who present with limited stage SCLC may be managed with concurrent chemotherapy and thoracic irradiation.12
The aim of palliative care is to improve the quality of life by reducing symptoms of cancer and slowing the spread of the cancer without the goal of curing the disease. These symptoms, which directly impact quality of life, include dyspnoea, cough, anorexia and fatigue.3 The involvement of a palliative care team can assist patients with advanced lung cancer in managing the symptoms as well as pain, nausea and end-of-life decisions.21
Each mode of therapy has significant adverse effects which are amplified by the use of these modalities in combination. Supportive care medications aim to prevent and manage these adverse effects. Pharmacists can play a role in the recognition of adverse effects of chemotherapy and immunotherapy and in ensuring appropriate referral and management. Patients experiencing adverse effects should be referred to their oncologist for further assessment.14
Patients undergoing treatment at a medical oncology centre are often supported by a team of doctors, nurses and allied health professionals who are willing to help. If patients have concerns regarding their treatment or adverse effects, they should be referred urgently to their treatment centre for direction.
Useful resources include:
The safe delivery of cancer treatment requires a multidisciplinary approach, and often care is shared between hospital specialists, hospital cancer care pharmacists, general practitioners and pharmacists.22 Communication between this team is key in ensuring best outcomes for the patient.
The accessibility of pharmacists allows them to play a key role in the care of patients with lung cancer. One of the most significant roles is that of encouraging smoking cessation. However, the emergence of oral therapies has resulted in the accessibility of cancer care medications in the community pharmacy. These medications require close clinical review for appropriateness, including screening for potential drug interactions and interactions with current medications, as well as complementary and alternative medicines. Patients commenced on these oral anti-cancer therapies in the community should be provided with detailed counselling and written information of treatment regime and adverse-effect management (accessible via eviQ).23 Patients receiving treatment from a cancer care centre may also present to community pharmacy, and therefore pharmacists can play a key role in early identification and management of adverse effects.
Case scenario continuedYou explain to Mrs Ma that the rash she has is common in people who take osimertinib and reassure her that prompt treatment with OTC hydrocortisone 1% cream and doxycycline will bring it under control. You emphasise that she should contact her oncologist without delay for assessment and prescription of the antibiotic so that the rash does not become worse. |
Lung cancer is the most common cause of cancer-related death both worldwide and in Australia.1,2 The identification of key mutations in NSCLC has allowed for emerging oral targeted therapy to be an integral part of NSCLC cancer management. Pharmacists have a key role in the education of patients on new targeted therapy and in the identification and management of adverse effects of treatment.
DANIELLE WOOLLEY BPharm (Hons) is pharmacist team leader at Royal Brisbane and Women’s Hospital and has practised in cancer care for the past 4 years.
VIVIAN DAY BPharm (Hons), GradDip (Clin Pharm) is a senior cancer care pharmacist at the Royal Brisbane and Women’s Hospital. She has been a pharmacist for 10 years, four of them in oncology, and is pursuing a postgraduate master’s degree in oncology.
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Case scenario
Emma is a 24-year-old paramedic who presents to your pharmacy with a prescription for paroxetine 20 mg daily and lorazepam 1 mg PRN for anxiety. She also requests a Fluvax. While you are giving Emma her flu shot, she mentions recent sudden anger and mood swings. She says she was actually in London last year at the height of the pandemic and witnessed her neighbour and one of her colleagues die. It took her months to get a flight home and she was all alone. Emma starts to cry and apologises.
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency Standards (2016) addressed: 1.1, 1.4, 1.5, 2.2, 3.1, 3.5 |
Post-traumatic stress disorder (PTSD) first became a household name when it entered the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. This was as a result of the large number of veterans returning from the Vietnam War who were experiencing what was first termed ‘Post-Vietnam Syndrome’. Earlier conflicts had coined terms such as ‘shell shock’, ‘soldier’s heart’, and ‘war neurosis’. Other non-military terms for trauma such as ‘rape trauma syndrome’ and ‘railway spine’ also emerged in the 19th and 20th centuries.1
The definition of trauma has been debated for decades by clinicians, and the diagnostic signs and symptoms are constantly under scrutiny. These days, the term ‘PTSD’ is thrown around too often, which can take away from those who are suffering what can be a debilitating illness.
The Australian Psychological Society defines PTSD as a set of symptoms that can emerge following the experience of traumatic exposure to actual or threatened death, serious injury or sexual violence.2
Patients with PTSD have intense and disturbing thoughts and feelings related to the traumatic experience, persisting long after the event. Flashbacks, nightmares, sadness, anger and interpersonal detachment are common symptoms and may trigger avoidant or maladaptive behaviours that can cause further distress in the patient.3
In Australia, with worsening bushfire and natural disaster seasons, and the onset of the COVID-19 pandemic, we expect to see a rise in presentations of PTSD and other mental health disorders, such as depression, anxiety and substance abuse, due to the sudden and challenging nature of these events.4
With education, pharmacists can be aware of the signs and symptoms of PTSD and can play an integral role in providing medicines and advice to patients, along with advocating for non-pharmacological options for PTSD.5
Approximately two-thirds of Australians will experience events that are potentially traumatic.6 But only a small portion of these will go on to develop PTSD. The prevalence rate for PTSD in Australia is approximately 4.4% and is said to be increasing.5 However, the lifetime prevalence of PTSD in Australia is now 12%, with women being almost twice the risk of men.7
First responders and Australian Defence Force personnel were on the front line of the 2019 bushfire response, which led to an estimated prevalence rate of PTSD of 10% and 8.3% in these cohorts respectively.⁴ Yet, Australian veterans were recently reported to have higher rates of PTSD at 17.7% over the first 4 years following discharge from military services.4
The impact of rape trauma and child sexual assault has been well publicised in the Royal Commission into Institutional Responses to Child Sexual Abuse. Historical and recent trauma experienced as a result of separation from family, land and cultural identity has also had a serious impact on the social and emotional wellbeing of First Nations people.6
Finally, a review of the evidence of the psychological effects of the COVID-19 pandemic reported post-traumatic stress symptoms were higher in those who had been in lockdown, and in healthcare workers, compared to the general public.8
‘Imagine you are grocery shopping in a busy supermarket and you start having pervasive thoughts. Horrible images appear. They trickle in, flashbacks of being trapped and frozen. Suddenly, you cannot breathe and your heart is jumping out of your chest. You feel weird and embarrassed, as if everyone can see you struggling, but you are powerless to stop it. Your brain stops working and you cannot remember how to do simple tasks such as reading a shopping list or driving and following your normal route home. You somehow make it home and stare at yourself in the mirror. You feel as though you are not there, a feeling of numbness … of nothing. It is very frightening as it feels like a loss of your sense of self. You frantically grab at your face, trying to feel yourself, to make sure you are really there. Later in your bed, you are woken by the same violent twitching that wakes you every night. You get agitated, angry and resentful that even your serenity in bed has been hijacked.‘
The DSM-V definition of what constitutes a traumatic event is more tightly defined than those in previous editions, and the emotional response of intense fear, helplessness or horror during the traumatic event criterion has been removed.
The cause(s) of trauma are as follows9–11:
Exposure to actual or threatened death, serious injury or sexual violence in one (or more) of the following ways:
Note: Criterion 4 does not apply to exposure through electronic media, television, movies or pictures, unless this exposure is work-related.9,11
While much of the pathophysiology of PTSD is still unclear, recent research has revealed that trauma produces physiological and neurological change. Studies using magnetic resonance imaging (MRI) in patients with PTSD have shown that there is a decreased volume of the hippocampus, left amygdala, anterior cingulate and prefrontal cortex. This affects memory, fear, impulse control, emotions and the filtering of relevant information from irrelevant information.
Neurotransmitter activity can be affected where there is an increase in central noradrenaline levels, which can cause down-regulation of central adrenergic receptors. Stress hormones also play a part, with chronically decreased glucocorticoid levels and corresponding up-regulation of their receptors. This may account for the anecdotal observation that higher rates of autoimmune disease occur in patients with PTSD.10
Table 1 – Risk factors for PTSD
| PRE-TRAUMATIC | PERI-TRAUMATIC | POST-TRAUMATIC |
| Childhood trauma, adversity or emotional problems | Severity of trauma, injury, perceived life threat, interpersonal violence | Negative appraisals or inappropriate coping strategies |
| Lower socioeconomic status and poor education | Being a perpetrator, witnessing atrocities or killing the enemy (military) | Exposure to repeated upsetting reminders |
| Prior mental disorder or family psychiatric history | Dissociation that occurs during trauma and persists afterwards | Subsequent adverse life events, financial or other trauma-related losses |
| Genes, female sex/ younger age (at time of trauma) | Lack of social support following trauma |
Risk factors for PTSD are extensive and multifactorial. They can be divided into pre-traumatic, peri-traumatic, and post-traumatic risk factors (see Table 1).10
As primary healthcare providers, pharmacists should be particularly vigilant with persons who work in occupations such as law enforcement, the military, emergency services, communities that have been subject to natural disasters such as floods and bushfires, patients presenting with severe physical injuries or medical emergencies, and patients frequently presenting with non-specific somatic complaints.9
The DSM-V lists four symptom clusters of PTSD11:
Diagnosis of PTSD is made by identifying the presence of at least ONE symptom from the intrusion and avoidance clusters, and at least TWO symptoms from each of the remaining clusters. The duration of the symptoms must be more than 1 month, and cause clinically significant distress or impairment to the patient.11
Individuals with PTSD are 80% more likely to have symptoms that meet diagnostic criteria for at least one other mental disorder (e.g. depression, obsessive-compulsive disorder, substance use disorders).11
Not all mental disorders that occur in individuals exposed to trauma should necessarily be attributed to PTSD. The diagnosis requires that trauma exposure precedes the onset or exacerbation of pertinent symptoms.11
Furthermore, if the symptom pattern to the trauma meets the criteria for another mental disorder, these diagnoses should be given instead of, or in addition to, PTSD – they should not be ignored. If certain symptoms related to trauma are so severe, they may warrant a separate diagnosis and course of treatment (e.g. dissociate amnesia).11 Other common conditions to exclude after a traumatic event are listed in Table 2.
Table 2 – Other common conditions to exclude after a traumatic event11
|
DISORDER |
HOW IS IT DISTINGUISHABLE FROM PTSD? |
|
Adjustment disorder |
Trauma is of another type rather than that outlined by the DSM-V (e.g. divorce, being fired) OR, Trauma does meet the criteria outlined by DSM-V, but the symptom pattern does not (e.g. only a few symptoms are met) |
|
Acute stress disorder |
Symptom pattern is restricted to duration of 3 days to 1 month following trauma |
|
Traumatic brain injury (TBI) |
There may be significant symptom overlap. The two main differences:
|
PTSD can occur at any age, beginning after the first year of life. Symptoms usually begin within the first 3 months following trauma. However, symptoms can be delayed for months or even years, which is referred to as delayed expression.9,11
Prognosis for PTSD is variable. Recovery can be heavily influenced by other factors, especially in occupational trauma such as physical disability and loss of employment. Similarly, recovery from PTSD related to receiving financial compensation appears to be less likely, and is more associated with the compensation process itself. Elevated levels of anger may also affect the recovery trajectory.
Based on several studies, it is reasonable to assume PTSD is less likely to follow a chronic course with evidence-based treatment, and roughly a third of patients will make a good recovery, a third will do moderately well, and a third will be unlikely to improve.11
Routine psychological debriefing for those exposed to potentially traumatic events should NOT be offered – there is no evidence that psychological debriefing prevents PTSD, and it may be harmful for some. Instead, guidelines recommend providing information, emotional support and practical assistance in preference to individual or group psychological debriefing.11
The Australian Guidelines for the Prevention and Treatment of Posttraumatic Stress Disorder state that individual psychotherapy remains the recommended first-line treatment for PTSD.12
First-line recommendations for adults with PTSD12:
Trauma-focused cognitive behavioural therapy (TF-CBT) and its variants:
(A description of these can be found at www.apa.org/ptsd-guideline/treatments)
Medicines are second-line treatment, with limited evidence producing a short list of recommended antidepressants: sertraline, paroxetine, fluoxetine and venlafaxine. This evidence is not strong and has progressed very little over the years.4,12
Treatment with medicines is recommended only if one (or more) of the following circumstances apply12:
This short list of recommended antidepressants can be quickly exhausted when prescribers are faced with angry, agitated and highly distressed patients, which can lead to polypharmacy, off-label and idiosyncratic prescribing. Prescribing in such a manner can often result in medicine regimens similar to those seen in treatment-resistant depression.4 Using a prescribing algorithm like the one recommended by Phoenix Australia has been shown to result in better clinical outcomes than prescribing based on clinician preference.12
Emerging treatments for PTSD include MDMA or psychedelic-assisted psychotherapy, ketamine infusions, meditation, and cannabis and prazosin for minimising nightmares, although the evidence base is not yet robust enough for them to become regular practice. Veteran affairs organisations in countries such as the US, UK and Australia are at the forefront of investigating these options.13,14
Pharmacists can play a sentinel role in helping to manage patients with PTSD. Due to the prognosis of PTSD (and despite pharmacotherapy being second-line), patients will commonly present with at least one or more psychotropic medication. Medication adherence may be a problem due to mental state, reduced cognition and substance abuse, which commonly present in PTSD.
Patients with PTSD will often present with comorbid conditions requiring multiple medicines, ranging from chronic pain medications to medications to help abstain from alcohol. Thus, the need for pharmacist interventions, such as a medication review or referral for further investigation, is greater than ever.5
Case scenario continued
You recognise that, as a first-responder, Emma is at high risk of developing PTSD, and has recalled several traumatic events that cause her distress. You ask Emma about her symptoms, and she reports distressing nightmares and persistent negative thoughts. You undertake Mental Health First Aid with Emma to ensure her immediate safety and encourage support structures. You provide a referral for her GP for investigation for PTSD and explain treatment methods typically used, such as psychotherapies or medications.
|
Disclaimer
Although children may also be exposed to trauma, they are not included in this article due to space constraints. For more information about PTSD and children, please refer to the DSM-V and the Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder and Complex PTSD.
[cpd_submit_answer_button]GABRIELLE HANSEN BPharm, Grad Cert Pharmacy Practice is Senior Clinical Pharmacist – Mental Health, Western NSW Health, Bloomfield Hospital, Orange. She has worked for 10 years as a mental health pharmacist and has experience in clinical governance and e-health deployment in one of the largest local health districts in Australia.
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Case scenario
Mrs G, one of your regular customers, has type 2 diabetes and wants to take an active role in managing her health. While in the pharmacy, she asks if you can recommend some online sources for reliable health information that are easy to understand. She confides that she mostly trusts her sister for advice, as her sister is being treated for type 2 diabetes as well. You have always given Mrs G consumer product information leaflets with her prescriptions, and assumed that she understood the information, as she appears to be able to read the labels well. You now suspect she needs some help in interpreting written information. How would you assess her health literacy?
Learning objectivesAfter successful completion of this CPD activity, pharmacists should be able to:
Competency Standards addressed (2016): 1.1, 1.4, 1.5, 2.2, 3.1, 3.5 |
As one of the most accessible health professionals in Australia, pharmacists interact daily with patients and carers about their medicines and health choices. Also inherent in pharmacy practice is advice on health promotion, health education and disease prevention. Health promotion and education contribute to an individual’s ability to access, understand and use health information and health services, known as their health literacy.1
As pharmacists, we may take for granted our personal health knowledge, knowledge of the health system and health literacy, but it is important that we are aware that our community is composed of a diverse group of individuals all sitting along a health literacy spectrum.
There are hundreds of definitions of health literacy. However, an individual’s health literacy can be broadly defined as their ability to find, use, evaluate and apply information to access health services and manage their health.2 Health literacy is an essential lifelong skill that is highly transferable to multiple health conditions (mental health, cardiovascular disease, diabetes), considerations (vaccination, surgery) and contexts (home, community and hospital).
In the past, our understanding of health literacy was quite narrow: the patient was considered health literate or not based on their reading and numeracy skills. A patient was treated as an independent entity navigating their health journey in isolation.3 While public health and clinical definitions of health literacy still differ according to their origin, efforts have been made to bring these definitions closer together.3
Over time, our understanding has evolved to acknowledge that health literacy includes three important elements: the individual, their social networks (community), and the health and community services they are attempting to access (see Figure 1).
Source: Adapted from Nash, Elmer & Osborne4
An individual’s health literacy can be defined as “the ability to make sound health decisions in the context of everyday life: at home, in the community, at the workplace, the healthcare system, the marketplace, and the political arena. It is a critical empowerment strategy to increase people’s control over their health, their ability to seek out information and their ability to take responsibility”.5
Healthcare providers, and community and health service organisations, should ensure the health system is responsive to the health literacy needs of individuals and communities, and support individuals with health literacy challenges to develop the skills they need to manage their health.6
As pharmacists, we have the skills needed to identify different factors that influence the health literacy and health outcomes of our patients. Important factors to consider are the social determinants of health (SDHs), also referred to as the ‘causes of the causes’. The World Health Organization (WHO)7 refers to SDHs as the conditions in which people are born, grow, work, live and age. According to Whitehead and Dahlgren,8 SDHs include our individual lifestyle factors, community influences, living and working conditions, and more general social conditions.
External forces and systems also influence our SDHs on a daily basis. These include economic policies and systems, development agendas, social norms, social policies and political systems.7
Importantly, health literacy has been defined as an SDH in its own right.9 In other words, through developing and possessing health literacy assets, patients can overcome health inequities that exist in their life and community more broadly.
There are a number of tools and strategies pharmacists can employ to gauge the health literacy status of their patients and review the health literacy responsiveness of the pharmacy staff and services. To support quality use of medicines (QUM) and optimise patient health outcomes, pharmacists need to adapt their practice in response to the health literacy status of the local community. Many pharmacists may already be doing these things intuitively, but it is useful for pharmacists to have access to frameworks and theory to guide their practice in order to meet the needs of their patients, so they can access and understand the information needed to make appropriate health decisions.
The Shanghai Declaration on Promoting Health in the 2030 Agenda for Sustainable Development identified health literacy as a critical determinant of health and urged for global investment to enhance health literacy throughout the life course.10
In 2014, Australian state and territory health ministers endorsed the Australian Commission on Safety and Quality in Health Care’s National Statement on health literacy (HL) as Australia’s national approach to addressing HL.11 In the statement, the commission proposed a coordinated approach to HL based on: (1) embedding HL into systems (organisational HL), (2) ensuring effective communication, and (3) integrating HL into education for consumers and healthcare providers.
Reflective questions to consider:
It has been acknowledged that without health literacy we will struggle to overcome the non-communicable disease (NCD) burden. In 2019, NCDs such as cardiovascular disease, diabetes, cancer and stroke caused 278.5 deaths per 100,000 population in Australia.12 The associated risk factors are largely preventable. In addition, we need to manage the hysteria and misinformation being generated in response to COVID-19, leading to vaccine hesitancy and resistance to public health advice.
More than ever, it is important to build the health literacy capacity of our whole community to enhance self-sufficiency and self-care nationwide. Current health budgets and use of health services are unsustainable. A health literate Australia with health literacy responsive services will be vital if we are going to improve QUM and reduce the increasing burden on our health system.
A patient’s health literacy skills are often dispersed and shared across their social networks, including friends, family and other social supports.13 Each day pharmacists see examples of this in their practice. The concept of distributed health literacy was first described by Edwards et al in 2015,14 when they confirmed that accessing, understanding, evaluating and using health information was often not an individual task. It is important that we, as pharmacists, are aware of this and, where possible, seek permission to involve those supports in the provision of information and care.
Pharmacists respond to patients’ healthcare needs on a daily basis, and health literacy responsiveness is likely to be a familiar concept for pharmacists. It is defined as the “provision of services, programs and information in ways that promote equitable access and engagement, that meet the diverse health literacy needs and preferences of individuals, families and communities, and that support people to participate in decisions regarding their health and social wellbeing”.15
Tools such as the Optimising Health Literacy process (Ophelia) have been developed to enable health and community services to self-assess their service for health literacy responsiveness. Most have been derived from the US National Academy of Medicine’s Ten Attributes of Health Literate Health Care Organizations16:
A self-assessment tool such as the Organisational Health Literacy Responsiveness (Org-HLR) tool is useful for Australian pharmacy owners and pharmacists to review their current practice and services.15 Self-assessment tools also offer professional development, quality care and quality enhancement opportunities for the pharmacy, pharmacist/s, staff and patients.
As health professionals, we are known to overestimate the health literacy of our patients.17 We take for granted the health knowledge and insight we have gained from working within the health system each day. Therefore, it is important that we understand the true health literacy status of our patients and local community and respond appropriately.
Australians with low health literacy are more likely to have suboptimal health behaviours and health outcomes, resulting in increased healthcare costs to the individual, health payer and society.18 Low health literacy can be associated with less engagement with health services, including preventive services (e.g. cancer screening),19 higher hospital readmission rates,20 poorer understanding of medicine instructions21,22 and a lesser ability to self-manage care.23
In contrast, higher levels of health literacy are associated with greater patient involvement in shared decision making,24 which is important in patient-centred care. There is ample evidence that improving health literacy is associated with greater self-sufficiency, increased ability to self-care, adoption of positive health behaviours, increased preventive initiatives, better health outcomes and lower health care costs.25-27 Improved health literacy is therefore a key element of shared decision-making between patients and health professionals for their better health.
An individual’s health needs change across their life course – from birth to end of life. Pharmacists encounter patients from all stages of life and need to be responsive to their changing health needs. In addition, health literacy develops throughout life and is context-specific, varying according to different health issues (e.g. diabetes), life stages (e.g. maternal health) and different forms of communication (e.g. digital platforms, social media).28
Importantly, health literacy can support health and wellbeing throughout people’s lives.11 To be successful, this requires a whole-of-government strategy, whereby education, health and community work collaboratively to ensure health literacy is supported across the life course and in multiple contexts. A priority that cuts across all three sectors, health literacy provides us with an opportunity to activate the Health in All Policies agenda within our health service delivery.29 As pharmacists, we know that health doesn’t just happen in the pharmacy or the hospital and that our health literacy needs continually evolve with our health at any point in time. Health literacy therefore requires lifelong learning.
Preconception/conception: a mother’s role
It has been highlighted that pregnancy and early motherhood offer a window of opportunity to address the risk of NCDs earlier in the life course. Empowering women through improved health literacy may help reduce the intergenerational impact of NCDs.30 If pharmacists can determine the health literacy strengths and limitations of mothers who use their service, it may lead to tailored health solutions that effectively support women to achieve and sustain healthy lifestyle practices for themselves and their families. This approach may short-circuit the intergenerational health issues we observe. Furthermore, involving mothers in the design, development and implementation of solutions can also ensure that services are locally relevant, responsive, effective and sustained.
Children/adolescents
While health promotion activities are common in schools, the success and sustainability of these efforts rely on children possessing their own health literacy assets. The WHO has highlighted the importance of programs in schools to support the development of essential health literacy assets31,32 highlighting that we must start earlier in the life course in order to address the NCD burden. Also, ensuring health literate children for future pandemic responses should be a national priority. Useful when thinking about how to best develop a child’s health literacy, Nutbeam33 outlined three levels of health literacy: functional, interactive and critical health literacy. In 2016, five core components of health literacy were identified: theoretical knowledge, practical knowledge, individual critical thinking, self-awareness, and citizenship.34
In 2016, in recognition of a gap in HL development opportunities for children in schools,35,36 the HealthLit4Kids program was founded.37 HealthLit4Kids is an intervention co-designed with school communities and aligned with the Australian school curriculum which aims to increase health literacy of children, their families and communities. The program has been included in three WHO reports as an exemplar for how communities might address the increasing burden of NCDs globally.
Pharmacist involvement in Tasmanian HealthLit4Kids schools included school excursions to meet the pharmacist, pharmacist-led education on the health effects of smoking, attendance at school expos and promotion of the program to their local school community. In recognition of the health promotion, health prevention and health protection roles that pharmacists fulfil each day, this initiative may offer a potential extended care role for pharmacists in the future.
Adults
The impact of NCDs on the health, life expectancy and productivity of Australians has been highlighted. Health literacy also plays a fundamental role in medicine safety, especially in populations at risk of medicine-related harm.38,39 Each year in Australia there are 250,000 hospital admissions due to medicine-related problems, costing Australia $1.4 billion.40
Table 1 – Health Literacy Questionnaire results from National Health Survey 41
Domains 1–5 include 4-point scale (4 – ‘strongly agree’, 3 – ‘agree’, 2 – ‘disagree’, or 1 – ‘strongly disagree’)
Domains 6–9 include 5-point scale (5 – ‘always easy’, 4 – ‘usually easy’, 3 – ‘sometimes difficult’, 2 – ‘usually difficult’, or 1 – ‘cannot do or always difficult’)
Australia’s health literacy status
In 2018, the National Health Survey invited Australians to complete the Health Literacy Questionnaire (HLQ; see Table 1).41 The HLQ consists of 44 questions encompassing nine health literacy domains:
In 2018, some 5,790 Australians completed the HLQ in the national health survey.41 Of those:
While the majority of people (83%) felt that they are able to appraise health information, as many as 1 in 6 (17%) people disagreed or strongly disagreed that they are able to do so. Almost 2 in 5 people (39%) said they find it always easy to understand health information well enough to know what to do, with a further 54% stating that they usually find this easy.
So, while the majority of Australians who completed the survey suggested they are managing, there remain some priority populations who will require our support and a greater level of understanding and health literacy responsiveness.
As pharmacists, it is useful to consider how health literacy responsive our current practice is and how patients perceive their health professionals as part of the healthcare team. If we examine the findings against Domains 1, 6 and 7 specifically, we can identify potential areas for our practice improvement.
Case scenario continued
You suggest Mrs G complete the HLQ so you can see how to best support her needs. The results surprise you, as although she has good social supports, she doesn’t feel well supported by her healthcare providers. You arrange a consultation so you can provide one-on-one attention and resources that you go through together. She now feels that she has sufficient information to manage her diabetes and her general health.
|
DR ROSIE NASH BPharm (Hons), Grad Cert (Research), PhD, MPS, Senior Lecturer Public Health & Health Systems is a pharmacist and senior lecturer in public health specialising in health promotion interventions. She is Australia’s foremost researcher in children’s health literacy. Dr Nash co-founded HealthLit4Kids and established the cross-institutional Health Literacy & Equity Research Group. She has expertise in research and evaluation design, co-design and community-based research.
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Public health leaders, a pharmacist and a former PSA CEO were honoured for their services to the community in this year’s Queen’s Birthday honours.
Victorian pharmacist George Greenberg was appointed a Member (AM) of the Order of Australia for ‘significant service to aged care, and to medical advisory roles’.
A former hospital and community pharmacist, Mr Greenberg was a member of PSA’s Victorian Ethics and Legislation Committee from 1997 to 2000.
He has been a Board Member of Emmy Monash Aged Care since 2005 and was a member of the Pharmacy Board of Victoria from 1994 to 2005.
The PSA’s National President Associate Professor Chris Freeman said Mr Greenberg deserved recognition for his work both as a pharmacist and as a member of numerous medical advisory boards.
‘Mr Greenberg has been an active member of our health community for many years, making significant contributions to the health sector across community and hospital pharmacy, as well as offering his expertise to further the pharmacy profession,’ he said.
‘I thank him for his dedication to advancing the pharmacy profession and for his years of service as a consumer and patient advocate.’
Professor Sarah Hilmer, Conjoint Professor of Geriatric Pharmacology Medicine at the University of Sydney, was also appointed an AM for ‘significant service to clinical and geriatric pharmacology’.
A clinical pharmacologist and geriatrician, Prof Hilmer has trained and educated countless pharmacy students and continues to provide training and education to pharmacists through conferences and educational programs.
She also led the Quality Use of Medicines to Optimise Ageing in Older Australians: Recommendations for a National Strategic Action Plan to Reduce Inappropriate Polypharmacy from 2015 to 2018.
Former PSA CEO Liesel Wett was awarded a Medal of the Order of Australia for ‘service to medical administration’.
Ms Wett has been CEO of Australian Pathology since 2014 and was PSA CEO from 2010 to 2014. She has also been Chair of Goodwin Aged Care Services since 2014.
Pandemic leadership celebrated
A number of high-ranking public health officials were also recognised for their leadership during the pandemic.
They include former Commonwealth Chief Medical Officer Dr Brendan Murphy, who was appointed a Companion (AC) of the Order of Australia for ‘eminent service to medical administration and community health, particularly as Chief Medical Officer, and to nephrology, to research and innovation, and to professional organisations’.
Speaking to Australian Pharmacist in November 2020, Dr Murphy, now the Secretary of the Commonwealth Department of Health, said it was a ‘privilege’ to help lead the country through the pandemic. He also thanked the nation’s pharmacists for their tireless work.
‘We could not be more appreciative of our pharmacists and the staff that support them in communities across the country,’ Dr Murphy said.
‘Our pharmacists play a pivotal role as our most accessible health professionals and their contribution on the frontline during this pandemic is to be greatly appreciated and admired.’
Queensland’s former Chief Health Officer, now Governor, Dr Jeanette Young was also appointed an AC for ‘eminent service to public health administration, to medicine and medical research, to the tertiary education sector, and as the 27th Governor appointed in Queensland’.
New South Wales Chief Health Officer Dr Kerry Chant was appointed an Officer (AO) of the Order of Australia for ‘distinguished service to the people of NSW through public health administration and governance, and to medicine’.
Dr Chant became a household name in NSW during the 2 years of the pandemic so far, providing daily COVID-19 updates at government press conferences. She has also made significant contributions to eliminate HIV, hepatitis B and hepatitis C, as well as holding a pivotal role in containing the spread of the swine flu.
She said the recognition went beyond her individual effort.
‘This honour is a tribute to my many colleagues in NSW Health for the outstanding work they have done and continue to do to keep the community safe throughout the COVID pandemic,’ Dr Chant said.
A/Prof Freeman extended his congratulations to all the health leaders.
‘I thank Dr Young, Dr Chant and Dr Murphy for their service and leadership throughout the COVID-19 pandemic and their ongoing support of health professionals,’ he said.
Other notable mentions include Dr Lucas De Toca, who oversaw the roll-out of the COVID-19 vaccination across primary care sites for the Department of Health and received the Public Service Medal (PSM) ‘for outstanding public service through leadership in managing the successful COVID19 vaccine rollout through primary health care’.
National Chair and President of the Heart Foundation Christopher Leptos, who also advises the pharmacy sector, was made an AO for ‘distinguished service to the not-for-profit sector through leadership and philanthropic support, to the public sector, and to education’.
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Genevieve Adamo MPS is the Senior Pharmacist – Poisons Information at the NSW Poisons Information Centre and a speaker at PSA22 next month.
Why choose pharmacy?
My father was a pharmacist, so I grew up working in his pharmacies every school holiday. After seriously considering economics, I felt a career as a pharmacist would combine my love of science with the family life I wanted, and it has not disappointed.
Where did you ‘learn the ropes’?
I was lucky enough to work part-time as a pharmacy assistant at Soul Pattinson, 160 Pitt Street, while a student at the University of Sydney, and then stay on as an intern and pharmacist. Working for Soul Pattinson allowed me to learn from different pharmacists and retailers and gave me an opportunity to develop a variety of clinical and management skills.
What attracted you to poisons info?
After my second child, I felt a bit rusty returning to work. A job at the Poisons Information Centre (PIC) provided an opportunity to use all my pharmacist skills with training to become a Specialist in Poisons Information (SPI). It was the most challenging and rewarding role with an amazing group of people. The shift-work of a 24/7 service, although unusual for a pharmacist, provides flexibility with juggling family unavailable in most pharmacy roles. I started with the Poisons Centre 18 years ago, and although I had a few years off to have more children, I kept returning because of the variety the role offers. Currently, my role in toxicovigilance incorporates providing advice on the phone service, as well as management of the website and media requests, development of fact sheets for public education, submissions for regulatory consideration and all things poisoning prevention.
What’s one ‘feel good’ situation where you made a difference?
We were consulted about a 1-year-old boy, very unwell with chronic salicylate poisoning from overuse of Bonjela teething gel. His mother had no idea it was toxic and, after recovery, was keen to collaborate on media messaging to ensure families knew the risks to prevent a recurrence. With more to be done, I used the case as part of the evidence to support an application to the Therapeutic Goods Administration for the rescheduling of choline salicylate. The application was successful. From February 2023, choline salicylate topical gels will be Schedule 2, requiring consultation with pharmacists and pharmacy assistants as well as cautionary warning labels. It is extremely rewarding to know I can help individuals and the community with the work we do at PIC.
What is a most unusual call to PIC?
There are so many it is hard to pick a stand-out. But there was a day when a child took a packet of flame colourant crystals to school thinking they were popping candy and shared them with friends. In fact, it was copper sulphate, which can be corrosive and cause severe toxicity, including renal and hepatic damage, metabolic acidosis, and death in small exposures. This resulted in many children requiring assessment and monitoring in hospital.
What would attract more pharmacists to PICs?
Poisons Information is a small specialty, with only about 60 SPIs nationwide, but the increasing complexity and call numbers mean we are often looking for pharmacists. It can be a stressful and demanding job, due to the fast pace and dealing with self-harm calls every day, but it is also clinically incredibly challenging and rewarding. There are often no set answers to the questions posed, so we are required to go back to first principles and evaluate available information. We are also fortunate to work on projects with amazing toxicologists and researchers to develop the latest information. Much of our call-taking is now done remotely, which means no commuting, as the job is no longer restricted to capital cities. Regular training sessions are a fantastic opportunity to catch up face to face, and it means you are always learning; it’s never boring.
Any advice for ECPs?
Get comfortable with the uncomfortable and practise problem-solving skills. We need to focus more on problem solving to find the best solution for our patients rather than what someone else has deemed the “right” answer. And take any opportunity to get involved in research.
Day in the life of Genevieve Adamo MPS, Senior Pharmacist – Poisons Information at the NSW Poisons Information Centre.8–11.30 am – Into the morning Get the kids to school and leisurely walk the dog before meeting with NSW PIC research team to finalise hand sanitiser exposure research paper. Radio interview on prevention of mushroom poisoning precedes work on a media campaign for carbon monoxide poisoning awareness. 2–6 pm – Disability medicines advice Review and analyse calls from disability workers to assess areas to potentially improve medication administration practices. Then it’s after-school activities and dinner until PIC time. 8 pm – Start call-taking shift at PIC In a 4-hour evening shift, I provide advice on 20–30 calls, each 3–5 minutes long. Call from mother of child, 18 months, found sucking on tube of home hair dye containing 12% hydrogen peroxide. Advise high-strength peroxide can cause a chemical burn, other systemic effects. Needs hospital monitoring, so referred immediately to the nearest hospital. 10.25 pm – Medicines non-compliance Call received from a group home regarding boy, 10 years, with autism refusing evening medicines including olanzapine 5 mg, amitriptyline 25 mg, aripiprazole 10 mg x0.5, clonidine 150 mcg x0.5, melatonin 2 mg. Has refused evening medicines for 2 weeks due to drowsiness in the mornings but takes morning doses of amitriptyline, aripiprazole and clonidine. Advise review by doctor tomorrow after 2 weeks of missed evening medicines. Doses of olanzapine or SR melatonin likely adverse effect cause. Suggest reduced dose/medicines change. 11.44 pm – Paracetamol overdose Woman calls about paracetamol clearance. Admits taking deliberate overdose of 20 tablets two nights prior, now has abdominal pain indicating liver involvement. After my compassionate explanation, woman says she will take more paracetamol and hangs up. Call police and I give her phone number so they can locate and transport her to hospital. 12 am – Bedtime, finally Complete all documentation, and review calls taken by other SPIs during the evening. |
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An only child of Vietnamese boat people, WA’s Pharmacist of the Year Phuong Nguyen MPS combines pharmacy with big business.
What first attracted you to the pharmacy profession?
I chose pharmacy as I felt that healthcare and business came together in community pharmacy. This comes from my parents, both teachers before they escaped Saigon in 1980, who instilled in me the importance of curiosity, education and community. My family also has strong roots in the business and healthcare industries with many doctors, nurses, optometrists and dentists. As the only pharmacist in the family, I love it because it allows me to connect and interact with patients to provide personalised advice and solutions by harnessing my listening and problem-solving skills.
Has the profession provided the impetus to get you where you are?
A background in pharmacy gave me the opportunity to work collaboratively in a multidisciplinary workforce and provided the foundation blocks for building professional working relationships – both in community pharmacy and then in a robust aged care pharmacy within a diverse team. It all provided valuable management and leadership skills, which are highly transferable in my consultancy work. A growth mindset has fuelled my quest for self-improvement and lifelong learning – hence my embarking on an MBA at the University of Western Australia.
I spent my final year living on campus at Harvard University. I met the brightest people, both in business and socially. It dragged me out of my (shy) comfort zone of largely pharmacy friends (and my extended family) and made me more ‘worldly’ and socially interactive. It was quite the life-changing experience – and I also saw a taping in New York of The Late Show with Stephen Colbert!
How did the job at PwC Australia come about?
While I was completing my MBA, the career option of consulting came up. Curious about what the job entailed, I applied for a summer internship. My generous and supportive pharmacy employer at the time allowed me to work for PwC Australia, and the internship exposed me to projects within the healthcare system. It was an opportunity to use my healthcare knowledge and MBA to serve the community.
What do you do with the company that benefits the health system and uses your pharmaceutical as well as business qualifications?
PwC Australia has given me the opportunity to be exposed and involved in interesting projects in healthcare and beyond – like implementing a digital transformation program. I’m able to utilise my knowledge of the healthcare system to build bridges and interact with other clinicians. For example, I was involved in COVID-19 preparedness within the healthcare system in relation to supplies and procurement. It allowed me to combine my understanding of healthcare needs with supply chain management.
Where do you see yourself in 5–10 years?
I would love a stint working in an emerging economy for an aid agency such as Médecins Sans Frontières. But I also want to maintain a close connection with community pharmacy – the heart of the pharmacy industry – and, through my consultancy work, influence health policies and systems to improve public health initiatives. Learning for professional and personal self-improvement is also in there. Ideally, as my mother always says, ‘Give your life purpose by giving back to others,’ so I would also love to provide mentorship in appreciation of this amazing and rewarding career.
What advice would you give to early career pharmacists?
Career mentors have helped me, so I encourage others to seek them. Mentors have imparted new perspectives and experiences and have helped guide, develop, encourage and empower my professional development, providing me with opportunities for self-reflection – and finally built my self-confidence.
And never underestimate the management and leadership skills that are built in pharmacy (let alone the skill to ‘read a room’ from all those tall tales you’ve heard at the dispensary). Learn and refine these skills, as they are valued in every relationship in any industry.
Explore new paths at psa.org.au/careerpathways
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The former Director of Pharmacy at Adelaide’s Women’s and Children’s Hospital, Kingsley Coulthard FPS, is South Australia’s PSA Lifetime Achievement Award winner for 2022.
Why did you choose pharmacy?
Because my best mate from high school did. One of my best decisions! University life was a wonderful experience, especially learning and interacting with lecturers and other students . . . and it was face to face – regrettably ceased in many universities, a casualty of COVID-19.
What are you most proud of in your career?
Contributions to paediatric therapeutics, especially cystic fibrosis (CF), and the opportunity to mentor to some wonderful young pharmacists over many years. Many factors have contributed to the dramatic increase in survival for patients with CF, in particular the development of new therapies and the establishment of specialised CF clinics. The incorporation of pharmacists into these clinics is essential, and the opportunities for patient care and research are endless.
What about ‘the little people’?
Paediatric therapeutics have traditionally been neglected in favour of adults, especially in access to appropriate medicines/formulations and clinical trials. Although this has improved in recent years due to international pressure on the pharmaceutical industry and regulatory organisations, there is still a lot to do.
After your retirement in 2010, what links have you retained in pharmacy?
I have an active role in the profession as Adjunct Associate Professor at the University of South Australia and involvement with Asthma Australia as a member of the Professional Advisory Committee. And I was part of the National Asthma Council paediatric writing group for the latest edition of the Australian Asthma Handbook.
I have a close alliance to rural pharmacy and now locum, mainly on Yorke Peninsula. It is rewarding to see how country people in small towns value their local pharmacy. I am a strong believer in face-to-face education and organise such events on Yorke which are open to all health professionals.
What big changes have you have seen during your career?
The expansion of hospital pharmacy services – in particular ward-based, community services such as Home Medicines Reviews and integration into GP clinics/aged care and the impact of IT.
Pharmacy has established itself and been accepted as part of the health team.
What is the one thing you wish pharmacists could do better in respiratory care?
Pharmacists need more time to talk to and counsel patients with respiratory diseases, but the demands of inappropriate dispensing workloads are prohibitive. In areas such as CF, there needs to be specialised pharmacists who remain in those areas for extended periods of time to allow for the development of clinical and patient relationship skills.
What advice would you give to ECPs?
Seek out a mentor. If you’re frustrated with your current role, look at other areas of practice before abandoning the profession.
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Two slipped discs on a construction site led to Sean Richardson’s unusual career segue into the pharmacy profession.
Was pharmacy always your first choice as a career?
Not completing Year 10 led indolently into the laborious side of the construction industry. Years on, I injured my back and had 3 months of rehabilitation – a blessing in disguise. I was encouraged to attend a university open day, which led to a Foundation Studies course (UniSA College), uncovering an appetite for learning, which led to a Bachelor of Pharmacy (Honours).
How did you find your ‘mature age’ student experience?
Approaching tertiary study felt heavy – the age difference and sensation of being ‘behind’ helped shape how I managed my time. Networking with the university student group (South Australian Pharmacy Students’ Association), attending conferences by the National Australian Pharmacy Students’ Association and PSA, and becoming involved in the industry early was a priority. They were the building blocks to later career steps.
Employment early in my degree was key for the student-to-pharmacist transition while enjoying guidance from some of the best clinical, managerial and owner pharmacists in the profession.
Hear more from Sean in the podcast episode below:
What attracted you to locum work?
Two factors contributed: career progression options and remuneration. Looking at the role of a pharmacist in a logical sequence, experience is defined by environment, time and opportunity. So if I pursued constant new areas of learning, challenges and scope expansion, I would find myself upskilling quicker than working within the confines of one place.
Initially, it was confronting; the buck stops with you. In most locum roles, you are the sole pharmacist thrown in the deep end, expected to provide an accurate and professional service in a completely new setting. While challenging, your level of adaptability increases 10-fold, with new dispensing programs, medication familiarity and use patterns, servicing structures, team operation styles and pharmacy cultures.
Self-development as a pharmacist becomes constantly progressive, allowing positive change implementation. Locum positions are usually structured to allow convenience and a ‘slot in’ nature for the pharmacist. In most cases, travel costs, accommodation and car use are provided additional to fair remuneration ($45–$80 per hour plus superannuation, depending on urgency/location/duration/skill set and other factors).
What are some memorable experiences?
My first locum trip was to Coober Pedy via Greyhound bus (11 hours). I arrived late evening to no visible locals, no Vodaphone reception and a disappearing bus. I took the plane back on my return journey!
In Mt Isa one day, a very country-proud, Akubra-wearing customer wanted to know why I wasn’t wearing R.M. Williams boots, as he compared my brown generics with his polished black pair. I got some on my next trip back to Adelaide! No hat though.
What are the key challenges for pharmacy in regional Australia?
Access and consistency. Communication channels between community groups, hospitals, pharmacies and medical centres are crucial, with healthcare workers required to forward-think most decisions, especially for the Indigenous community, where patient location and movement timeframe plays a large role in medicines access.
Healthcare worker turnover is generally high, and adjusting to the setting can be difficult for new professionals.
Rather than position/employment satisfaction, recruiters need to dive deeper to a personal level.
Understand interests, lifestyle, social factors, family commitment/intentions and sense of community for an individual. Greater consideration needs to be taken to employ rurally, equal to that of those contemplating to venture.
What advice would you give to other early career pharmacists (ECPs)?
ECPs are commonly influenced by their immediate first experiences, but should note that their initial pharmacy may not be the staple representation of the industry – the diversity is extensive.
Challenges and constant developments await in the journey ahead. Don’t have any goals? That is step 1. Be resourceful. Seek opportunities, responsibility and be accountable. Aim to add your value.
Day in the life of Sean Richardson MPS, locum pharmacist in Bundaberg, QLD.Heading into a new position – 6.00 am Queensland sunrises (after moving from Adelaide) make exiting the pillow light work, even after trekking 620 kilometres the day before to accommodation. Bundaberg has a population of 93,000, but there’s minimal traffic, no line-ups and friendly service! Head start – 8.15 am Arrive 15 minutes early at the pharmacy to get acquainted with the new team; introductions and quick adaptions to follow. Navigate around the store, dispensing systems/POS, dispensary procedurals, staff roles, individual pharmacist expectations; become familiar with surroundings. Familiarisation process – 8.30 am Burrum Street Pharmacy (Bundaberg West) runs a tight boat with a Schedule 8 Maintenance and Opioid Replacement Therapy program providing suboxone services. Start the day with a stock check on the Schedule 8 safe and prepare for pick-ups. Staff guidance is crucial to getting up to speed to maintain expected level of service and accuracy. Ask lots of questions of the experienced team, which knows the community and customers and guides operations. Taste test – 9.30 am Discussions on antibiotic dosing for an extremely picky 2-year-old patient uneasy about the taste of medicines. ‘We’ve tried all of the flavours!’ Non-pharmacological advice is as important as medicinal; by placing the plastic syringe down the side of the tongue when administering to avoid tasting, junior had no time to think otherwise. Multitasking – 11.00 am It can be challenging to safely juggle the competing priorities of scanning over DAAs as well as script checking between two dispense technicians. Usually I dispense high script volume in other roles, but in this store technicians dominate. Lunch, as such – 12.00-2.00 pm Sole pharmacist lunches are as social as it gets – in the dispensary! Somewhere in between, I wolf down a quick microwave meal via fork or straw, whatever is at hand. Migraine medicine options – 3.00 pm Patient requested paracetamol/ibuprofen (Nuromol) for migraine, while taking eletriptan (Relpax). Discovered patient was directed to take additional Relpax even if first tablet failed (secondary dose unlikely to be effective if initial has failed). Further talks highlighted gastric stasis symptom of migraine and reduced tablet absorption. Recommended dissolvable aspirin and paracetamol as alternatives. Local culinary delights – 5.30 pm Time to close up with attempts to put the right code in the alarm. Head for the gym and dinner at a local restaurant. |
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