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Clinical

Positive Intervention

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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:

Do they have sufficient hand-breath coordination?
Are they able to form a good seal over the mouthpiece?
Are they able to open, manipulate, and prime the device?
Are they able to inhale at the correct speed?

* Source: Debbie Rigby FPS

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

inhale slowly, steadily and deeply
4–5 seconds in adults
2–3 seconds in children.

This minimises deposition in the upper airways and enhances delivery to the lungs. Dry powder inhalers

inhale quickly and deeply
inhale forcefully from the start.

This separates the active ingredient small particles from the large particle excipients.

Some interventions do take time – but these are often the most important. Whether in community, hospital, consultant or institutional pharmacy practice, nearly all pharmacists need to be at the top of their game to support patients with respiratory conditions.

Australian Pharmacist talked to a rural-based community pharmacist and a hospital pharmacist about their experiences with patients who needed their urgent respiratory help.

HANY AITA

Managing Pharmacist, Amcal Max, Devonport, Tasmania

With 6 years as a pharmacist in his native Egypt, and another 13 years solely in rural and outback community pharmacy in Western Australia, New South Wales and Tasmania, Hany Aita MPS has seen a lot of people living with asthma.

And with fewer opportunities to visit doctors, asthma and COPD are ’not as well managed as you would think’, he says. Some patients, who have never been diagnosed and use puffers when short of breath, eventually visit a doctor, get a diagnosis and sometimes, for financial, time, distance or other reasons never follow-up, he explains.

However, he has a golden rule for himself and staff when non-prescription requests for salbutamol relievers are made. Always ask about frequency. ‘How often do you need to use it?'

Last year a local woman in her early 30s, seemingly health literate but not a regular patient, admitted to him that she used salbutamol ‘every day’.

Mr Aita was stunned that she had no idea, in a town of six pharmacies, that this was abnormal and the recommended use of non-prescription relievers in well-controlled asthma was no more than 2 days per week.

‘I said: “How long you been doing that? [She answered] ‘Oh I’ve been doing that for the last few years. It actually keeps me going.'" Unlike some hostile responses to his ‘red flag’ initial questions, ‘she was open to talk more about it’.

Mr Aita explained her ‘condition’ was not properly managed and referred her to her GP for an urgent diagnosis, or otherwise, of asthma. ‘It was just amazing that this was all new for her,’ he relates.

Some weeks later she returned – with an asthma action plan, a preventer for daily use and prescription for low-dose fluticasone propionate/salmeterol (Seretide).

SARAH RISDALE

Clinical Pharmacist, Royal Brisbane and Women’s Hospital

At her hospital, Ms Risdale’s role supports patients with a variety of acute – as well as chronic – respiratory diseases.

Reviewing medicines for drug interactions in an outpatient clinic may involve her recommending alternate asthma medicines for people living with HIV. For example, she may need to find alternatives to fluticasone/salmoterol (Seretide) due to increased risk of Cushing syndrome from cobicistat CYP34A inhibition.

Similarly, for inpatient care, she could be involved in adjusting doses of antimicrobials for respiratory patients, such as IV Amikacin in non-tuberculous mycobacterial pulmonary infections when drug concentrations exceed expected levels – which can vary depending on patient factors and dose frequency – or kidney function declines significantly.

One of her more challenging patient interactions was with a younger patient who had no significant co-morbidities and was recovering from COVID-19.

The patient had developed an empyema infected with a multidrug-resistant bacteria – including resistance to penicillins, cephalosporins and carbapenems.

As the patient was struggling with an infective collection in the pleural space on one side of a lung, Ms Risdale provided clinical advice and support around monitoring and managing adverse effects from the IV sulfamethoxazole/trimethoprim used, which can include electrolyte disturbances.

And, as the patient continued to experience respiratory decline, Ms Risdale was tasked with acquiring stock of a more specialised antimicrobial from overseas – cefidericol.

‘I found this situation challenging for several reasons as I had to contend with COVID-19 delays, unavailability through standard Special Access Scheme routes, time differences (between suppliers and manufacturers in Australia, Europe and Japan), cold-chain requirements and the time-critical need for treatment.

'Thankfully, I was able to arrange some stock reallocation from other hospitals in NSW and Western Australia, and was able to get it successfully transported via cold-chain courier across the country – on a weekend no less.

'We received the product in time and the patient made a full recovery!'

Build your skills with PSA Short Courses at psa.org.au/practice-support-industry[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row] [post_title] => How to remedy incorrect inhaler use [post_excerpt] => How pharmacists can change the lives of people with lung diseases by taking every opportunity possible. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => how-to-remedy-incorrect-inhaler-use [to_ping] => [pinged] => [post_modified] => 2022-06-14 17:42:12 [post_modified_gmt] => 2022-06-14 07:42:12 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=18727 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => How to remedy incorrect inhaler use [title] => How to remedy incorrect inhaler use [href] => https://www.australianpharmacist.com.au/how-to-remedy-incorrect-inhaler-use/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 18730 )

How to remedy incorrect inhaler use

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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:

sleeping tablets
anti-reflux or anti-nausea medicine
muscle aches and pains – a script for pain medicine may be an indicator
propranolol, which may be used to treat physical symptoms of anxiety
requests for products that may help improve memory and concentration
generally, people with anxiety may need more reassurance, so they could have more questions and concerns about their medicines, which pharmacists may notice during counselling.

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, MPS

Principal 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 tips

Always 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.

Explain that first-line management is psychological therapy. Encourage at every dispensing.
Explain how non-pharmacological therapy helps change the way we think and behave, and is important (sometimes alongside medicine) for recovery.

Empathise and validate to help alleviate stress consumers may be experiencing and allow them to feel like they are being heard. Having a non-judgmental attitude can help patients open up and feel more comfortable. Suggested phrases:

‘I can see you are not feeling okay. This is not nice.’
‘With everything you just explained, no wonder you are feeling anxious/worried.’
‘Is it okay if I ask some questions to make sure this product is appropriate for you?’
‘How long have you been having trouble sleeping?’
‘Have you been experiencing stress or anxiety?’

Listen if someone is expressing frustration, disengagement or agitation. Ask yourself if anxiety is underlying this. Step back, rethink your approach. When people are anxious, they may become defensive. If we really listen to their concerns, we may be able to reach a better outcome. NEVER say:

‘Don’t worry.’
‘That’s nothing to worry about.’
‘Try and relax.’
‘Think of all the positives.’
‘Calm down.’
‘It’s not a big deal.’
‘There’s nothing to be afraid of.’

Source: Louise Edwards, Duha Nur Gide

For PSA Self Care Cards, including on anxiety, visit psa.org.au/programs/self-care[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row] [post_title] => High anxiety [post_excerpt] => Wherever pharmacists practise, there are patients with anxiety – patients who are managing well, patients who are managing not so well, and patients in crisis. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => high-anxiety [to_ping] => [pinged] => [post_modified] => 2022-06-24 06:52:49 [post_modified_gmt] => 2022-06-23 20:52:49 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=18867 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => High anxiety [title] => High anxiety [href] => https://www.australianpharmacist.com.au/high-anxiety/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 18868 )

High anxiety

chronic obstructive pulmonary disease (COPD)

Q&A: Use of antibiotics in COPD

CPD

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[post_content] => Case scenario
Callum, a 30-year-old engineer, presents to you in the pharmacy requesting pain relief. Callum reports worsening left shoulder pain following his COVID-19 vaccine. Upon investigation, Callum states his vaccination was several weeks ago and thought at the time the injection was delivered very high on his arm. He has had increasing shoulder pain, swelling and reduced range of motion in his left shoulder. He is seeking assistance now as he is struggling to perform simple activities such as cooking. As you suspect, Callum has sustained a shoulder injury related to vaccine administration. You refer Callum to his GP.

Learning objectives
After successful completion of this CPD activity, pharmacists should be able to:

Describe the symptoms of shoulder injury related to vaccine administration (SIRVA)
Describe structures at risk of incorrect vaccination technique
Describe common diagnoses associated with SIRVA
Explain how pharmacists can help prevent SIRVA

Competency Standards addressed (2016): 1.1, 1.4, 1.5, 2.2, 3.1, 3.5

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.
Introduction
Many pharmacists across Australia are currently administering vaccines. Shoulder injury related to vaccine administration (SIRVA) is a very rare iatrogenic condition causally linked to improper vaccine delivery.¹ All vaccinators, including pharmacists should be knowledgeable about this largely preventable condition. This article provides current evidence- based information on SIRVA and how to prevent its occurrence.

How does SIRVA occur?
SIRVA occurs when vaccinations are delivered into the upper arm too high, too laterally (towards the sides), or too low, causing damage to underlying anatomical structures of the shoulder.

Damage can result from inflammatory changes related to localised reactions to the vaccine, or from direct trauma from the needle itself.^2,3 At-risk structures include nerves, tendons, bursae and the joint capsule.
Background
Criteria

SIRVA is characterised by an acute reduction in shoulder function and loss of joint range of motion, occurring within 48 hours of vaccination.³

Diagnostic criteria for SIRVA are somewhat varied. The Medical Dictionary for Regulatory Activities (MedDRA) defines SIRVA following the framework set out by the US Vaccine Adverse Event Reporting Scheme (see Box 1).^4–6 However, this set of diagnostic criteria excludes any neurological injuries. Previous literature on SIRVA has attributed nerve damage and resulting neurological conditions to improper delivery of deltoid intramuscular injections, despite global pharmacovigilance data utilising the MedDRA definition.² In contrast, Australian criteria (see Box 2), has no exclusion criteria, and as such allows the inclusion of any condition deemed related to errors in vaccine administration.⁷

Box 1 – American/MedDRA criteria

pain occurs within 48 hours
pain and reduced range of motion limited to the limb of the injection site
no prior history of pain, inflammation, or dysfunction
no neurological injuries or abnormalities
no other differential diagnoses present

Box 2 – Australian criteria

onset of symptoms within 24–48 hours
pain on movement
restricted range of motion of affected limb
abnormalities present on medical imaging
suspicion of incorrect technique of vaccine administration

Shoulder anatomy

The shoulder is extremely complex in both structure and function. To allow for the large degree of movement that is available at this joint, numerous structures sitting within a confined space must work in synergy. Stability to the shoulder is provided by static stabilisers (bones, capsule and ligaments) and dynamic stabilisers (muscles).⁸ Should damage occur to any of these stabilisers, synergy is lost and capacity for functional movements is reduced.⁸

The humerus, scapula and clavicle interlock to form the four joints of the shoulder: the glenohumeral joint (GHJ), acromioclavicular joint, scapulothoracic joint and sternoclavicular joint.⁸ Ligaments connect bones and provide stability across joint spaces.⁸ Bony prominences further serve as attachment points for surrounding muscles. Some, such as the acromion process of the scapula and deltoid tuberosity of the humerus serve as landmarks for vaccinations.⁸ The joint capsule, comprised of a synovial inner layer providing vascular nourishment to the underlying tissues, and a fibrous outer layer, encompasses all these structures.⁹

Dynamic stability is provided by the muscles and their tendons. The rotator cuff muscles – the supraspinatus, infraspinatus, teres minor and subscapularis – play a key role in all shoulder movements (see Figures 1 and 2).⁸ These muscles actively rotate the humeral head, while also compressing and centralising it in the glenoid fossa of the scapula.⁸ The long tendons of these muscles blend into the GHJ capsule to attach onto the proximal humerus.⁸ Impairment of any of these muscles has a considerable effect on the functional capacity of the shoulder. The biceps brachii muscle, with a minor role as a shoulder flexor, is often considered the fifth rotator cuff muscle.⁸ The long head of biceps brachii tendon sits within the bicipital groove of the humerus, held in place by the transverse humeral ligament, and passes within the capsule over the humeral head to attach onto the supraglenoid tubercle.⁸ The short head of biceps brachii, which also aids flexion, attaches to the coracoid process of the scapula.⁸ The triangular-shaped deltoid muscle encompasses the GHJ with its anterior, posterior and middle fibres, contributing to movement in all directions.⁸ The muscle bulk narrows over the lateral aspect of the humerus, with the tendon attaching onto the deltoid tuberosity and along the midshaft of the humerus.⁸

Four bursae – the subscapular, subcoracoid, subacromial and subdeltoid – are found within the shoulder joint,⁹ with the latter two often conjoined due to their proximity.¹⁰ These fluid-filled sacs act as a lubricant for muscles, tendons and ligaments to slide over bony surfaces, thus reducing friction within a joint.9 The subacromial bursa sits superficially to the supraspinatus tendon and greater tubercule of humerus, and deep to parts of the deltoid, acromioclavicular joint and acromion process of the scapula.¹⁰

The entire upper limb receives its cutaneous and muscular innervation (nerve supply) primarily from the brachial plexus, which runs from the neck to the axilla (armpit).¹⁰ Multiple nerves branch from the brachial plexus, including five major peripheral nerves (see Figure 3).¹⁰

Of greatest importance to vaccinators are the axillary and radial nerves, due to their proximity to the deltoid vaccination site. The axillary nerve runs along the inferior border of the subscapularis, to the long head of triceps, exiting the axilla to wrap around the posterior aspect of the surgical neck of humerus and then beneath the deltoid.¹¹ The axillary nerve splits to form the anterior and posterior branches beneath the anterior and middle to posterior portions of the deltoid respectively.¹¹ Location of the axillary nerve is dependent on shoulder positioning, with abduction (the movement away from body midline) moving the nerve furthest from the deltoid midpoint.¹² The radial nerve runs inferiorly along the posterior humeral shaft between the long and medial heads of the triceps, emerging more superficially near the deltoid tuberosity.¹³ This point of transition between deep and superficial portions has been noted to occur primarily along the middle to distal thirds of the humerus.¹³

Box 3 – Common symptoms upon presentation to healthcare professionals

Presenting symptoms^{2, 14–17}

shoulder pain
stiffness
inflammation
weakness
reduced ROM – particularly abduction
inability to perform activities of daily living
burning, neuropathic pain
paralysis or neuropathy (in cases of delayed presentation)

Box 4 – Common diagnoses under the SIRVA syndrome

Common diagnoses^18–27

subdeltoid/subacromial bursitis
adhesive capsulitis (frozen shoulder)
rotator cuff tears
rotator cuff tendinopathy
axillary nerve palsy
radial nerve palsy
neuritis
shoulder impingement syndrome
synovitis

Sub-diagnoses of SIRVA

Previous literature describes the presenting symptoms of SIRVA as following broad patterns, typically involving pain and loss of function (see Box 3).

While presenting symptoms tend to follow similar broad patterns, common diagnoses have more variance due to differing injection sites (see Box 4). Damage to the radial or axillary nerves, associated with the injection site being too low or too lateral, can range from mild to severe.²⁸ Common neural symptoms include sensory deficits, neuritis, radicular pain and motor deficits; also, complete nerve conduction loss can occur, leading to paralysis of innervated muscles.^29,30

Palsy associated with SIRVA affecting either the radial or axillary nerves can be highly impactful on activities of daily living (ADLs) due to the high level of muscle innervation.³¹ Degree of palsy is strongly correlated with proximity of injection to the nerve, with greatest nerve destruction occurring with direct injection to the nerve.^26,29,32,33 Chemical irritation or localised reactions surrounding the nerve, direct injection to the neural sheath, or laceration injury to the nerve are proposed causes of nerve damage associated with injections.^26,32,34 Where damage to the nerve is observed after a period of latency, the cause is attributed to fibrotic changes and progressive inflammatory responses.^33,35

When the injection site is too high, there is a far greater variance in common diagnoses, due to the proximity of GHJ capsule structures. Shoulder injuries are difficult for clinicians to diagnose without specific imaging due to the complexity of the GHJ, as non-invasive tests have low specificity and sensitivity without grouping of tests.^36–39 Tendinopathy or tendon tears have been noted in cases where the needle point is assumed to have contacted the tendons of the rotator cuff muscles or biceps brachii. However, it must be noted that imaging of non-symptomatic individuals has high rates of tendon pathologies, especially in ageing populations.^40–42 While causation has not yet been confirmed, bursitis is assumed to result from direct injection of antigens into the bursa.^43–45 Similar inflammation occurs when the capsule is injected, and is assumed to be the main cause of synovitis, adhesive capsulitis, or shoulder impingement syndrome in SIRVA cases due to the localised inflammatory response within the capsule.^17,43,44 As these diagnoses can have other causes, there is an assumed level of underdiagnosis of SIRVA in reported data where the recent immunisation may not have been considered as the primary cause.¹⁶

Perhaps of most concern, multiple case reports of osteonecrosis (bone death) of the humeral head have been documented.^46–49 The pathophysiology of osteonecrosis of the humeral head in SIRVA is still unknown, possibly resulting from direct injection of antigens into the bone tissue or from the needle stick injury itself, ultimately resulting in restriction of blood supply to the bony tissue.⁴⁹ As osteonecrosis occurs very rarely, it is likely that in these documented cases the immunisation is the primary cause rather than degenerative causes.⁴⁹

Prevention
Landmarking technique

Complete exposure of the upper arm from the elbow to the superior shoulder is necessary for the safe vaccine administration into the deltoid.^50,51 It has been suggested that immunisations being administered too low is a result of long sleeve shirts being rolled up, while immunisations delivered too high could be a result of sleeves being pulled down over the shoulder. Both rolling up and pulling down the sleeves of a shirt do not allow adequate exposure of the arm to prevent misinjection.^2,52

Several landmarking techniques are commonly taught to healthcare professionals, with the intention of mapping out key landmarks to determine a safe injecting zone. The Australian Immunisation Handbook utilises the inverted triangle method using the acromion and the deltoid tuberosity as anatomical markers (see Figure 4).^50,51

A similar technique is palpation of the acromion, with the injection site 2–3 fingerbreadths below.^53,54 This method uses the practitioner’s fingers to cover the subacromial/subdeltoid bursae, preventing the immunisation being delivered too high into the GHJ. Three fingers are generally used when practitioners have small hands, and two fingers when they have large hands. Using landmarking techniques helps to ensure the site of delivery is in the middle of the deltoid, at the point of maximal muscle bulk.

The Australian Immunisation Handbook also recommends the placement of the patient’s hand on their hip, resulting in a relaxed deltoid with the shoulder in 60 degrees abduction. This shoulder abduction was noted in a cadaveric study to move the axillary nerve 1.3–1.4 cm away from the deltoid midpoint, demonstrating the efficacy of shoulder abduction as a method to protect nerves during vaccination.12 Vaccinations in which the patient’s arm remains neutral (hanging at side) are therefore not recommended.⁵⁵

However, despite landmarking techniques being considered imperative for safe vaccination practices, studies show low rates of consistent use among vaccinators.⁵⁶ Of 76 respondents to one survey, only three healthcare practitioners reported using landmarking techniques (specifically use of the acromion as a bony landmark).⁵⁶

Knowledge of at-risk anatomy in this population sample was also low.⁵⁶

Figure 4: Example of Australian Immunisation Handbook landmarking technique

[caption id="attachment_17643" align="alignnone" width="1000"] Source: Mackenzie L, Bushell, M.[/caption]
Intervention strategies
Treatment of SIRVA is highly individualised to case presentations, as no randomised controlled trials are available to guide practice. Initially, conservative treatment is undertaken in most cases, involving rest, pharmacology and/or physiotherapy interventions. No spontaneous recoveries have been reported in cases of bursitis, rotator cuff pathology, nerve damage or adhesive capsulitis.^14,15,34,57

Pharmacological

Standard conservative pharmacology interventions of analgesia (non-steroidal anti-inflammatories or opioids) and corticosteroid injections have been reported to be effective treatment options for SIRVA-related pain and inflammation, and increasing articular range of motion.^3,14,15,58 Corticosteroids have been proposed as an effective first-response treatment for SIRVA cases; however, further investigation is required, as treated cases primarily had a diagnosis of bursitis.^17,59 Due to the mechanism of injury, corticosteroid injections are highly unlikely to benefit cases of nerve damage and, while providing symptomatic relief, can even be detrimental in the treatment of rotator cuff tears.^32,60,61 Where injection into the bursa results in bacterial infection, antibiotics are recommended.⁶² However, while this has been widely accepted as a standard treatment for infectious/septic bursitis, there are no reports on how commonly it has been used as a treatment in SIRVA cases.

Physiotherapy

Physiotherapy is commonly prescribed as adjunct therapy with pharmacological interventions, but it has been prescribed in isolation with similar results.^3,14,15,63 Reports of physiotherapy interventions were noted in approximately 80% of claims to the US Vaccine Injury Compensation Program (VICP) between 2010 and 2016, and in similar case series; however, specific forms of physiotherapy interventions were not described.^14,17,61 While not specific to SIRVA, physiotherapy has been demonstrated as an effective form of treatment for bursitis, adhesive capsulitis, and rotator cuff pathologies.^64–67 When used in combination, physiotherapy has been shown to increase the efficacy of other treatment modalities such as corticosteroid injections or other analgesics.^68–70

Surgical

In cases of unremitting pain or severe loss of neuromotor function, as seen in some iatrogenic nerve injuries, conservative treatment is abandoned in favour of early surgical exploration, often resulting in neurolysis, excision of contused nerves or neuromas, or nerve resection involving grafting or repairs.^34,57 Surgical intervention has also been recommended in nerve injury cases where no improvement is seen after 3–6 months of conservative intervention.34 Surgical intervention has also been reported following failed conservative management or in severe cases of bursitis or tendon tears.^3,14,17,63 Reports of surgical intervention were noted in about a third of claims to the VICP between 2010 and 2016, with subacromial decompression, joint debridement, rotator cuff repair and arthroscopy forming the majority of surgical interventions.¹⁴

To date, no best-practice guidelines have been established for the treatment of SIRVA, with treatment strategy having little impact on time to symptom resolution.⁶³ The majority of interventions target bursitis and inflammation as the primary cause of symptoms; however, SIRVA is not just bursitis, and the treatment modalities recommended by healthcare practitioners must be appropriate to each injury.
Knowledge to practice
Each year, millions of vaccines are administered by appropriately trained pharmacists. All vaccines must be administered safely. To reduce the risk of SIRVA, pharmacists should have a strong understanding of the underlying anatomy of the shoulder. This enables the pharmacist vaccinator to understand why it is important to not deliver the vaccine too low, too high or too laterally into the arm. To ensure safe administration, landmarking techniques should always be used.

The pharmacist also can assist in the identification and reporting of SIRVA. All suspected cases of SIRVA and other adverse events following immunisation should be reported to the Therapeutic Goods Administration (TGA) using the National Adverse Events Following Immunisation reporting form and referred to a GP and/or physiotherapist.

Pharmacists and other healthcare professionals should refer to the Australian Immunisation Handbook for guidance on the prevention and management of SIRVA.50,51 Pharmacists should complete the Pharmaceutical Society of Australia Annual Immunisation Update every year.

As SIRVA is rare, there is a paucity of research and resources publicly available. Patients suspected of SIRVA should be directed to the TGA and the specific health service of their state or territory.⁷¹ Pharmacists can recommend and counsel patients on treatment options for SIRVA- related pain and inflammation (e.g. NSAIDs and paracetamol).

Case scenario continued

Callum returns to the pharmacy several days later with a prescription for naproxen and sustained-release paracetamol. Callum tells you he has been diagnosed with a SIRVA, with a sub-diagnosis of subacromial bursitis. His GP prescribed physiotherapy treatment in addition to his analgesia. You counsel Callum on the appropriate use of paracetamol and naproxen. Callum thanks you for your advice and for referring him to his GP for further investigation with a suspected SIRVA.

Conclusion

SIRVA is largely preventable. All vaccinators, including pharmacists, should be knowledgeable about and use landmarking techniques to prevent SIRVA.
Key points

Shoulder injury related to vaccine administration (SIRVA) is preventable through correct immunisation technique.
Understanding the underlying structures at risk in the shoulder region demonstrates the importance of using correct technique.
Common signs and symptoms indicating SIRVA include stiffness, reduced range of motion and pain in the shoulder.
Pharmacists should report any suspected case of SIRVA to the TGA as an adverse event following immunisation.

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References

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LAURA MACKENZIE BPsychSc is a Physiotherapy Honours candidate at the University of Canberra.

DR MARY BUSHELL BPharm (Hons), PhD, GCTLHE, AAPCA, AFACP, MPS is a Pharmacist and a Clinical Assistant Professor at the University of Canberra.

DR JAQUELIN BOUSIE PhD, Grad Cert TE, BPhty (Hons), BE is a Physiotherapist and an Assistant Professor in Physiotherapy at the University of Canberra.

DR PHILLIP NEWMAN PhD, Master Sports Physiotherapy, BAppSc Physio, GCHE is a Sports Physiotherapist and a Clinical Associate Professor in Physiotherapy at the University of Canberra.

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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 objectives

After successful completion of this CPD activity, pharmacists should be able to:

Explain the lifecycle of head lice
Identify the signs and symptoms of head lice infestation
Discuss evidence-based treatment recommendations for head lice
Describe how to treat head lice in pregnant patients.

Competency standards (2016) addressed: 1.1, 1.4, 1.5, 2.2, 3.1, 3.5

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Introduction

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.

What are the symptoms?

Head lice infestation can be asymptomatic, particularly in first-time cases or light infestations.^6–8The 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.^6,10–12While extremely rare, there are reports of iron deficiency anaemia from severe infestations.^13,14

What are the causes and risk factors?

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 life cycle of head lice

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.^6,7,9Lice 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

Identifying head lice infestation

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

Apply hair conditioner liberally to wet hair (conditioner immobilises lice for about 20 minutes).
Detangle the hair, divide it into 3–4 cm sections, and comb each section from close to the scalp through to the tips of the hair using a fine-tooth comb.
Wipe the conditioner from the comb onto a paper towel after each stroke and inspect for lice and eggs.
Repeat combing at least twice for each hair section.
Thoroughly rinse the hair.

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.

When is referral required?

The following are red flag symptoms that may require referral to a doctor:^7,11

Unclear diagnosis
Signs of secondary infection (e.g. weeping or crusting of skin, swollen glands, fever)
Infestation is affecting quality of life (e.g. sleep)
Treatment failure
Has occurred 3 or more times in a year.

Management of head lice infestation

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 lice^7,⁸:

Confirm the presence of live lice on the scalp using wet combing or visual identification method. Identify close contacts of the patient, and recommend daily screening by wet combing while infestation is active.
Recommend a treatment based on patient characteristics and preference. Neurotoxic insecticides are suitable from age >6 months.⁸
- See individual product information for specific instructions on how long product should be left in the hair.
- Protect the eyes, mouth and nose with a towel or face cloth.
- Do not apply insecticides to hair after conditioner or hair product has been applied.
- Apply the product over the entire head, coating all hairs from root to tip.
- Dry hair with a towel, not a hair dryer. Heat can inactivate the product.
- Avoid rewashing the hair for 1–2 days after treatment.
- Wash hands thoroughly after use.
- Close contacts with live head lice should be treated at the same time to prevent re-infestation.
Wet combing is an effective, labour intensive treatment for head lice and may be preferred in pregnant or breastfeeding patients.^{7, 8} Wet comb every 1–2 days until no lice are found for 10 consecutive days.^7,22 (See “Identifying head lice infestation” section for wet combing method)
Following each treatment, wet-comb hair daily to check for newly hatched or resistant lice.
Re-treat hair after 7–10 days and continue surveillance with wet combing and re-treatment, if necessary, until no more lice are found.
Resistant infestations may respond to a change in treatment. Recurrent treatment failure requires referral to a medical practitioner.

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

Non-pharmacological treatments

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 infestations^7,11:

Soak combs and brushes in very hot water (>60 °C) for 5 minutes.
Items used by the individual 2 days before the initiation of treatment (e.g. hats, scarves, pillowcases, bedding, clothing and towels) should be washed in hot water, and dried using the hot air cycle or hung in direct sunlight.
Dry-clean items that cannot be washed, or seal them in a plastic bag for 2 weeks.
Vacuum furniture and floors to remove hairs that may have attached nits.

Drug interactions

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

Prevention of infestation

There are no preventive treatments for head lice, though the following strategies can be used to reduce the transmission of head lice⁷:

Regularly inspect the hair using the wet combing method.
Avoid playing with other people’s hair.
Tie hair back or plait long hair.
Avoid head-to-head contact with other people.
Avoid sharing personal items (e.g. clothes, towels, bedding, pillowcases, hairbrushes, combs, hair accessories and helmets).
Avoid lying on beds, couches, pillows, carpets or stuffed animals that have recently come into contact with an infested person.

Exclusion periods

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 continued

Jane 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.

Key points

Head lice is a common health problem, most often affecting school-aged children, irrespective of their socioeconomic status and personal hygiene.
Head lice is transmitted through direct head-to-head contact. Indirect transmission through clothing or furniture is rare.
Diagnosis of head lice infestation is established by the identification of live lice on the scalp, which can be done through wet combing.
Repeated treatment application, at least 7–10 days apart, is required to eliminate the lice that did not hatch in the first application. Increasing resistance may require another treatment with a different neurotoxic medicine.

[cpd_submit_answer_button] References

Hatam-Nahavandi K, Ahmadpour E, Pashazadeh F, et al. Pediculosis capitis among school-age students worldwide as an emerging public health concern: a systematic review and meta-analysis of past five decades. Parasitol Res 2020;119(10):3125-43.
Speare R, Thomas G, Cahill C. Head lice are not found on floors in primary school classrooms. Aust N Z J 2002;26(3):208-11.
Currie MJ, Ciszek K, Kljakovic M, Bowden FJ. Prevalence of head lice among children entering school in the ACT 2006-08. Aust N Z J Public Health 2011;35(2):195–6.
Counahan M, Andrews R, Büttner P, et al. Head lice prevalence in primary schools in Victoria, Australia. J Paediatr Child Health 2004;40(11):616–9.
Speare R, Buettner PG. Head lice in pupils of a primary school in Australia and implications for control. Int J Dermatol. 1999;38(4):285–90.
Centres for Disease Control and Preventation. Head lice. 2013. At: cdc.gov/parasites/lice/head/index.html
Sansom L, ed. Australian pharmaceutical formulary and handbook. 25th ed. Canberra: PSA; 2021
Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited. 2021
Devore CD, Schutze GE; AAP, Council on School Health, Committee on Infectious Diseases. Head Lice. Pediatrics 2015;135(5):e1355–e1365
Lamb, S. Head lice. 2018. At: https://dermnetnz.org/topics/head-lice
Raising Children Network (Australia) Limited. Head lice. At: https://raisingchildren.net.au/guides/a-z-health-reference/head-lice
Whybrew C. Detection and recommended treatment of head lice. Prescriber 2017;28(1):32–6.
Guss DA, Koenig M, Castillo EM. Severe iron deficiency anemia and lice infestation. J Emerg Med 2011;41(4):362–5.
Lowenstein EJ, Parish LC, Van Leer-Greenberg M, et al. The darker side of head lice infestations. Clin Dermatol 2022;40(1):81–4
Children’s Health Queensland Hospital and Health Service. Head lice. 2018. At: childrens.health.qld.gov.au/fact-sheet-head-lice/
Government of South Australia. Head lice-including symptoms treatment and prevention. At: www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/conditions/bites+stings+and+pests/head+lice+-+including+symptoms+treatment+and+prevention
Healthy WA. Head lice. 2019. At: healthywa.wa.gov.au/Articles/F_I/Head-lice
Johns Hopkins Medicine. No-panic guide to head lice treatment. At: www.hopkinsmedicine.org/health/treatment-tests-and-therapies/no-panic-guide-to-head-lice-treatment
Department of Health. Pediculosis (head lice). At: www.health.vic.gov.au/infectious-diseases/pediculosis-head-lice
Canyon DV, Speare R. Indirect transmission of head lice via inanimate objects. The Open Dermatology Journal 2010;4(1):72–6.
Jahnke C, Bauer E, Hengge U, et al. Accuracy of diagnosis of pediculosis capitis visual inspection vs wet combing. Arch Dermatol 2009;145:309–13.
Rossi S, ed. Australian medicines Adelaide: AMH; 2021.
Government of South Australia, Department of Health. Healthy heads without headlice: Management guidelines for the control of headlice in South Australia. 2005. At: sahealth.sa.gov.au/wps/wcm/connect/e1dc4180458f95fe92c3ff4ba88a01d5/headlice-book-jan06-web.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-e1dc4180458f95fe92c3ff4ba88a01d5-nKNDYcv
Public Health Medicine Environmental Group. Head lice: evidence-based guidelines based on the Stafford Report 2012 update. At: www.nhsggc.org.uk/media/239960/stafford-head-lice-2012.pdf
Therapeutic Goods Administration: Australian Government, Department of Health. Database of Adverse Event Notifications (DAEN). At: www.tga.gov.au/database-adverse-event-notifications-daen
Therapeutic Goods Administration: Australian Government, Department of Health. Consumer Medicines Information (CMI). At: www.tga.gov.au/consumer-medicines-information-cmi
Therapeutic Goods Administration. A review of the regulation of head lice treatments in Australia. 2003. At: www.tga.gov.au/publication/review-regulation-head-lice-preparations-australia

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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Head lice

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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 objectives

After successful completion of this CPD activity, pharmacists should be able to:

Discuss the rationale for drug checking (pill testing) services in Australia
Describe what the drug checking (pill testing) process involves
Describe the role that pharmacists can play in drug checking (pill testing).

Competency standards (2016) addressed: 1.1, 1.2, 1.4, 1.5, 1.6, 2.2, 2.3

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Introduction

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 and adverse events in Australia

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 amphetamine^3,4methylenedioxymethamphetamine (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.¹⁰They 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

What are novel psychoactive substances?

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

What is MDMA?

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.²¹Hyperthermia may lead to complications, including rhabdomyolysis and disseminated intravascular coagulation.²²

Drug checking in Australia

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

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.

What is the evidence?

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

Knowledge to practice

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:

Alcohol and drug phone support services, such as the Alcohol and Drug Foundation drug information and advice line (https://adf.org.au)
Local drug and alcohol services, which can be found by searching the Alcohol and Drug Foundation services directory (https://adf.org.au/help-support)
On-site ‘chill out’ spaces at festivals and dance parties, such as those run by DanceWize in NSW and Victoria.

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 continued

You 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.

Conclusion

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.

Key points

Harm experienced by people who use drugs in Australia can occur as a result of taking drugs that do not contain what the user expects, instead containing different substances or a different dose.
Drug checking aims to reduce harm from illicit drug use by providing service users with an indication of chemical makeup and credible information on the risks associated with their use.
The specific information obtained from chemical analysis depends on the method used; each method has different advantages and disadvantages.
Pharmacists are able to assist with the healthcare consultation by interpreting and conveying the results of the chemical analysis and providing tailored harm reduction advice.

[cpd_submit_answer_button] References

Groves A. ‘Worth the test?’ Pragmatism, pill testing and drug policy in Australia. Harm Reduct J 2018. At: https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-018-0216-z
Barratt MJ, Kowalski M, Maier LJ, et al. Profiles of drug checking services in 2017. Drug Policy Modelling Program Bulletin No. 24. Sydney: National Drug and Alcohol Research Centre, UNSW Sydney; 2018. At: https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/Profiles%20of%20drug%20checking%20services%20in%202017.pdf
Pill Testing Australia. An Australian first – fixed site pill testing announced. Pill Testing Australia; 2021. At: https://pilltestingaustralia.com.au/an-australian-first-fixed-site-pill-testing-announced/
Pharmaceutical Society of Australia. PSA welcomes the ACT’s commitment to pill testing. At: www.psa.org.au/psa-welcomes-acts-commitment-to-pill-testing/
Pharmaceutical Society of Australia. Minimising harm from illicit drug use through pill testing and drug checking: position statement. Canberra: PSA; 2019. At: https://my.psa.org.au/servlet/fileField?entityId=ka17F000000cmhbQAA&field=PDF_File_Member_Content__Body__s
Australian Medical Association. AMA formally backs supervised pill testing trials. Canberra: AMA; 2019. At: ama.com.au/media/ama-formally-backs-supervised-pill-testing-trials
Royal Australian College of Physicians. RACP writes to nation’s leaders: there is sufficient evidence to support pill testing trials. Sydney: RACP. At: racp.edu.au/news-and-events/media-releases/racp-writes-to-nation-s-leaders-there-is-sufficient-evidence-to-support-pill-testing-trials
Australian Institute of Health and Welfare. National drug strategy household survey 2019. Canberra: AIHW; 2020. At: https://nla.gov.au/nla.obj-2917147095
Coroner’s Court of Victoria. Finding into death with inquest (File No. COR 2016 3441). 2021. At: coronerscourt.vic.gov.au/sites/default/files/2021-04/COR%202016%203441%20-%20Anson.pdf
State Coroner’s Court of New South Wales. Inquest into the death of six patrons of NSW music festivals. 2019. At: https://coroners.nsw.gov.au/coroners-court/download.html/documents/findings/2019/Music_Festival_Redacted_findings_in_the_joint_inquest_into_deaths_arising_at_music_festivals_.pdf
de Sousa Fernandes Perna EB, Theunissen EL, Dolder PC, et al. Safety profile and neurocognitive function following acute 4-fluoroamphetamine (4-FA) administration in humans. Front Pharmacol 2018;9. At: www.frontiersin.org/articles/10.3389/fphar.2018.00713/full
Hondebrink L, Nugteren-van Lonkhuyzen JJ, Rietjens SJ, et al. Fatalities, cerebral hemorrhage, and severe cardiovascular toxicity after exposure to the new psychoactive substance 4-fluoroamphetamine: a prospective cohort study. Ann Emerg Med 2019;71(3):294–305. At: annemergmed.com/article/S0196-0644(17)31382-3/fulltext#articleInformation
NSW Department of Health. ‘MDMA (ecstasy) POWDER’ found to contain: 25C-NBOMe, a synthetic hallucinogen; and 4-fluoroamphetamine, a stimulant - Public drug warnings. At: www.health.nsw.gov.au/aod/public-drug-alerts/Pages/mdma-containing-nbome-fa-jul21.aspx
WHO Expert Committee on Drug Dependence thirty-seventh meeting. 4-Fluoroamphetamine (4-FA) critical review report agenda item 5.4. Geneva: WHO; 2015. At: who.int/medicines/access/controlled-substances/5.4_4-FA_CRev.pdf
Laskowski LK, Elbakoush F, Calvo J, et al. Evolution of the NBOMes: 25C- and 25B- Sold as 25I-NBOMe. J Med Toxicol 2015;11(2)237–41. At: ncbi.nlm.nih.gov/pmc/articles/PMC4469725/
DanceWize NSW. MDMA Drug Information. 2021. At: dancewizensw.org.au/mdma
National Drug and Alcohol Research Centre. A quick guide to drugs and alcohol: ecstasy. Third edition. NSW: Drug Info State Library of NSW; 2017. At: https://druginfo.sl.nsw.gov.au/quick-guide-drugs-alcohol/ecstasy
Alcohol and Drug Foundation. MDMA-assisted therapy for PTSD edges closer. 2021. At: https://adf.org.au/insights/mdma-ptsd/
The Loop. Drug Alerts. 2019. At: https://wearetheloop.org/drug-alerts
NSW Health. 2021 Public drug warnings: High and variable dose MDMA (ecstasy) tablets and capsules. At: www.health.nsw.gov.au/aod/public-drug-alerts/Pages/drug-warning-qdance.aspx
Campbell GA, Rosner MH. The agony of ecstasy: MDMA (3,4-methylenedioxymethamphetamine) and the kidney. Clin J Am Soc Nephrol 2008;3(6):1852–60. At: https://pubmed.ncbi.nlm.nih.gov/18684895/
Carvalho M, Carmo H, Costa VM, et al. Toxicity of amphetamines: an update. Arch Toxicol 2012;86(8)1167-231. At: https://pubmed.ncbi.nlm.nih.gov/22392347/
Cook H, Priess B. Student union to hand out drug-testing kits at University of Melbourne campus. The Age. 2016. At: theage.com.au/national/victoria/student-union-to-hand-out-drugtesting-kits-at-university-of-melbourne-campus-20160920-grkh27.html
Sammut D, Craig C. Bitter pill: testing times for party drugs. At: https://chemaust.raci.org.au/article/septemberoctober-2019/bitter-pill-testing-times-party-drugs.html
Barratt MJ, Bruno R, Ezard N, et al. Pill testing or drug checking in Australia: Acceptability of service design features: Designing a drug-checking service. Drug Alcohol Rev.2018;37(2):226–36.
Alcohol and Drug Foundation. Pill testing: position paper. At: https://cdn.adf.org.au/media/documents/PillTesting_ShortPP_Final1.pdf
Maghsoudi N, Tanguay J, Scarfone J, et al. Drug checking services for people who use drugs: a systematic review. Addiction 2021;1–13. At: https://pubmed.ncbi.nlm.nih.gov/34729849/
Measham FC. Drug safety testing, disposals and dealing in an English field: Exploring the operational and behavioural outcomes of the UK’s first onsite ‘drug checking’ service. Int J Drug Policy 2019;67:102–107.
Measham F, Turnbull G. Intentions, actions and outcomes: A follow up survey on harm reduction practices after using an English festival drug checking service. Int J Drug Policy 2021; 95. At: sciencedirect.com/science/article/abs/pii/S0955395921001675?via%3Dihub
Brunt TM, Niesink RJM. The Drug Information and Monitoring System (DIMS) in the Netherlands: implementation, results, and international comparison. Drug Test Anal 2011;3(9):621–34.
International Pharmaceutical Federation. Reducing harm associated with drugs of abuse: the role of pharmacists. The Hague: International Pharmaceutical Federation (FIP); 2017. At: www.fip.org/files/fip/publications/Reducing-harm-associated-drugsabuse.compressed.pdf
Sansom LN, ed. Australian pharmaceutical formulary and handbook. 25th edn. Canberra: Pharmaceutical Society of Australia; 2021. At: https://apf.psa.org.au/

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.

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Drug checking in Australia: How pharmacists can be involved

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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 objectives

After successful completion of this CPD activity, pharmacists should be able to:

Describe the management options for lung cancer
Describe how genetics can affect treatment choice
Discuss the adverse effects of lung cancer treatments
Describe the mechanism of action of medicines for lung cancer.

Competency addressed: 1.1, 1.4, 2.1. 2.2, 3.1, 3.2. 3.3 3.5

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Introduction

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

Aetiology and pathophysiology

Risk factors for lung cancer include^3–5:

increasing age
history of or current tobacco use
exposure to cancer-causing substances (e.g. second-hand smoke)
occupational exposure (e.g. asbestos, arsenic, chromium, beryllium, nickel)
prior radiation exposure
air pollution
family history
Human immunodeficiency virus (HIV) infection
beta carotene supplements in heavy smokers.

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

Signs and symptoms

The most common symptoms at presentation include^3–5:

worsening cough
dyspnoea
hoarseness
chest pain
haemoptysis
malaise
weight loss.

In SCLC, infrequently patients may present with signs and symptoms of one of the following paraneoplastic syndromes due to various peptide hormone productions^3–5:

inappropriate antidiuretic hormone secretion
Cushing syndrome from secretion of adrenocorticotrophic hormone
paraneoplastic cerebellar degeneration
Lambert-Eaton myasthenia syndrome.

Diagnosis

At initial presentation, a thorough history is required, taking note of^3–5:

history of presenting complaint and symptoms
past medical and medication history and allergies
social history: occupational history (exposure to asbestos/radon), smoking (pack years)
family history
functional status.

Investigations to aid diagnosis and staging^3–5:

routine blood test
chest x-ray – investigate masses/rule out infections
computer tomography (CT) scan, including head, chest, abdomen and pelvis
positron emission tomography (PET) or magnetic resonance imaging (MRI) to investigate for metastases
endobronchial ultrasound (EBUS) bronchoscopy or mediastinoscopy to determine histopathology
respiratory function test (RFT)
molecular testing – EGFR, ALK, ROS1 and BRAF testing
tumour expression of PD-L1.

Staging

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:

size and extent of main tumour (T)
spread to nearby lymph nodes (N)
the spread of cancer to distant sites: metastasis (M).

Screening and prevention

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.

Smoking cessation

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

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:

First-generation EGFR TKIs – bind reversibly to the TKI domain.³
- erlotinib
- gefitinib
Second-generation EGFR TKIs – bind irreversibly with greater affinity to EGFR TKI domain.³
- afatinib (also inhibits human epidermal growth factor receptor 2 and 4 [HER2, HER4])
Third-generation TKIs – inhibit mutant eGFR, including the T790M positive EGFR (mutation causing resistance to first-and second-generation EGFR TKIs).³
- osimertinib.

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.¹⁶Afatinib 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:

diarrhoea (42%, severe 1%)
acneiform rash (papulopustular rash), drug eruption, folliculitis, rash erythematous and maculopapular rash (41%, severe <1%)
dry skin (31%)
fatigue (14%, severe <1%)
dry skin (31%)
nail effects/paronychia (17–25%)
QT interval prolongation (3–4%, severe <1%).

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.

Targeted therapy – monoclonal antibodies

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 NSCLC

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

Chemotherapy SCLC

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

Palliative care

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

Management of adverse effects of lung cancer treatment

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

Patient resources

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:

eviQ-Cancer Institute NSW (www.eviq.org.au)
Cancer Council (www.cancer.org.au)
Lung Foundation Australia (lungfoundation.com.au)
MacMillan Cancer Support UK (www.macmillan.org.uk).

Knowledge to practice

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 continued

You 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.

Conclusion

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.

Key points

An understanding of the pathophysiology of lung cancer, including common genetic mutations, is the cornerstone to management of advanced lung cancer.
There is a range of treatment options for lung cancer, and each has a different role in therapy.
Oral therapies targeting genetic mutations are emerging front-line therapy for management of advanced lung cancer in patients with identified mutations.
Pharmacists should be able to identify common side effects of oral anti-cancer therapy and recommend treatment within their scope of practice.

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Resources

Guidelines for pharmacists providing smoking cessation support: https://my.psa.org.au/s/article/Guidelines-for-pharmacists-providing-smoking-cessation-support
APF non-prescription medicine treatment guideline – Nicotine replacement therapy for smoking cessation: https://apf.psa.org.au/non-prescription-medicine-guides/nicotine-replacement-therapy-smoking-cessation/nicotine-replacement

References

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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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Lung cancer

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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 objectives

After successful completion of this CPD activity, pharmacists should be able to:

Describe the risk factors for developing post-traumatic stress disorder
Describe the symptoms of post-traumatic stress disorder
Discuss the management of post-traumatic stress disorder.

Competency Standards (2016) addressed: 1.1, 1.4, 1.5, 2.2, 3.1, 3.5

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Introduction

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.

What is PTSD?

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

Epidemiology

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

Insight into PTSD

‘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.‘

Aetiology

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 follows^9–11:

Exposure to actual or threatened death, serious injury or sexual violence in one (or more) of the following ways:

directly experiencing the traumatic event(s)
witnessing in person the event as it occurs to others
learning that the traumatic event(s) occurred to a close family member or close friend (in cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental)
experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g. first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

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

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

Symptoms

The DSM-V lists four symptom clusters of PTSD¹¹:

Intrusion symptoms
- Recurrent, involuntary and intrusive distressing recollections of the event(s)
- Recurrent distressing nightmares related to the trauma
- Dissociative reactions (e.g. flashbacks) where the individual feels the traumatic event is recurring; this may occur on a continuum from brief episodes to complete loss of consciousness
- Intense or prolonged distress or physiological reactivity after exposure to traumatic reminder.
Avoidance symptoms
- Effortful avoidance of distressing trauma-related thoughts or feelings
- Effortful avoidance of trauma-related external reminders (e.g. people, places, conversations, activities, objects or situations).
Negative alterations in cognitions and mood
- Inability to remember an important aspect of the traumatic event(s)
- Persistent and exaggerated negative beliefs or expectations about oneself, others or the world
- Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others
- Persistent negative emotional state (e.g. fear, horror, anger, guilt or shame)
- Markedly diminished interest or participation in significant activities
- Feelings of detachment or estrangement from others
- Persistent inability to experience positive emotions.
Arousal and reactivity symptoms
- Irritable behaviour and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects
- Reckless or self-destructive behaviour
- Hypervigilance
- Exaggerated startle response
- Problems with concentration
- Sleep disturbance.

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

Differential diagnosis

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: Re-experiencing and avoidance seen in PTSD and not TBI Persistent disorientation and confusion seen in TBI and not PTSD

Prognosis

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

Management

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:

Cognitive processing therapy (CPT)
Cognitive therapy (CT)
Eye movement desensitisation and reprocessing (EMDR)
Prolonged exposure (PE).

(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:

the person is unwilling or not in a position to engage in or access recommended psychological therapy
the person’s circumstances are not sufficiently stable to commence recommended psychological therapy
the person has a comorbid condition or associated symptoms where SSRIs are indicated
the person has not gained significant benefit from recommended psychological therapy
there is a significant wait time before psychological therapy is available.

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

Knowledge to practice

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.

Key points

PTSD is the result of being exposed to actual or threatened death, serious injury or sexual violence.
People with PTSD may experience intrusion, avoidance and arousal symptoms, and negative changes in cognition and mood.
Psychological therapies remain the forefront of PTSD treatment, which allow reprocessing of the trauma and treatment of any cognitive distortions associated with it.
Medicines are second-line; however, due to the limited evidence-based options and poor prognosis, PTSD can result in polypharmacy and off-label prescribing.

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.

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References

Stein MB, Rothbaum BO. 175 Years of Progress in PTSD Therapeutics. Am J Psych 2018;175:508–16.
Australian Pyschological Society. Postraumatic Stress Disorder. 2021. At: www.psychology.org.au/for-the-public/Psychology-topics/Posttraumatic-stress-disorder
Torres F. What is Posttraumatic Stress Disorder (PTSD)? 2020. At: www.psychiatry.org/patients-families/ptsd/what-is-ptsd
Wallace D. Post-traumatic stress disorder in Australia. Australas Psychiatry 2020;28:251–252.
Spaulding AM. A pharmacotherapeutic approach to the management of chronic posttraumatic stress disorder. J Pharmy Pract 2012;25:541–51.
McEvoy PM, Grove R, Slade T. Epidemiology of anxiety disorders in the Australian general population: findings of the 2007 Australian National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry 2011;45:957–67.
Australian Government. Australian Institute of Health and Welfare. Stress and Trauma. 2020. At: www.aihw.gov.au/reports/australias-health/stress-and-trauma
Brookes SK, Webster, RK, Smith LE, et.al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020;395:912–20.
Cooper J, Metcalf O, Phelps A. PTSD – an update for general practitioners. Aust Fam Physician 2014;43:754–7.
Sareen J. Posttraumatic stress disorder in adults: epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis. 2021. At: www.uptodate.com/contents/posttraumatic-stress-disorder-in-adults-epidemiology-pathophysiology-clinical-manifestations-course-assessment-and-diagnosis
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-V). Washington DC: American Psychiatric Association; 2013.
Phoenix Australia. The Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder and Complex PTSD. 2020. At: www.phoenixaustralia.org/australian-guidelines-for-ptsd/
Reisman M, PTSD Treatment for Veterans: what’s working, what’s new, and what’s next. Pharmacy and Therapeutics 2016;41(10):623–7, 632–4.
Davis LL. Exciting new developments in pharmacotherapy for PTSD. PTSD Research Quarterly 2021;32(4).

GABRIELLE HANSEN BPharm, Grad Cert Pharmacy Practice is Senior Clinical Pharmacist – Mental Health, Western NSW Health, Bloomfield Hospital, Orange. She has worked for 10 years as a mental health pharmacist and has experience in clinical governance and e-health deployment in one of the largest local health districts in Australia.

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Post-traumatic stress disorder (PTSD): an overview

People

Covering many bases

Public health leaders receive Queen’s Birthday honours

Career pathways: Fine wine and aged care blend in this Wood

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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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Behind the poisons hotline

How this pharmacist experiences the best of both worlds

Australian Pharmacist

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CONTACT

(02) 6283 4777
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Deakin West ACT, 2600

8.45am	School and day care drop off. My son’s school is across the road from the aged care facility, so it saves a lot of fuss in the mornings.
9.30am.	Question time. The morning is spent fielding queries from GPs, nurses and carers. I also liaise with community pharmacies to iron out discrepancies with medication charts or DAAs. Recently, we workshopped a way to make Schedule 4 medicines more distinguishable on sign-in sheets to ensure registered nurses (RNs) are contacted correctly.
10am	Psychotropic evaluations. Agitation and aggressive behaviour is often transient, so regular review of these medicines is necessary. This week, regular oxazepam was discontinued for one resident, and quetiapine for another – with no further issues.
1.30pm	Meeting of the minds. I catch up with the physiotherapists and RNs to look at whether falls are mechanical or chemical in nature, and discuss how they can be prevented.
2pm	Deep dive. I use this time to delve into medication charts to see if there are changes that need to be made. I do regular reviews and keep a list for the GP’s next monthly visit so nothing is missed. Recently, I reviewed a resident’s estimated glomerular filtration rate after his metformin was increased to 2 g daily. I advised the GP that his creatinine clearance is too low for this dose.
5.30pm	Home time. Cook dinner, help with homework and watch an episode of the latest series. I have decided to do my Diabetes Education Accreditation, so I will squeeze in a bit of study if I can!

Day 1 – Friday 29 July

Day 2 – Saturday 30 July

Day 3 – Sunday 31 July

1. They take a refreshed approach to Aboriginal and Torres Strait Islander healthcare

2. The importance of cultural safety is explained

3. Learn how to build an Aboriginal and Torres Strait Islander workforce

4. Figure out how to work around barriers to medication management

5. Understand how to communicate about medicines

Become a ‘deadly’ pharmacist

The morning after

Lessons in patient care

The future of pharmacist prescribing

Tales of poisons control

Goodbye for now

Role of aged care pharmacists

ANDREW KELLY MPS

DEE-ANNE HULL MPS

JAYLEE LEWIS

Duha Nur Gide

Louise Edwards BPharm(Hons), BA, MPS

Top tips

Smother the flare, but the bacteria is always there

When should flare-ups be treated?

Flare-up first-line: amoxicillin or doxycycline?

Prevention? Go for low-dose macrolides

CAL D? Yes! Five days is (usually) best

Review symptoms for post-dated prescriptions

Case scenario

Learning objectives

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Introduction

How does SIRVA occur?

Background

Prevention

Intervention strategies

Knowledge to practice

Case scenario continued

Conclusion

Key points

Case scenario

Learning objectives

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Introduction

What are the symptoms?

What are the causes and risk factors?

The life cycle of head lice

Identifying head lice infestation

When is referral required?

Management of head lice infestation

Non-pharmacological treatments

Drug interactions

Prevention of infestation

Exclusion periods

Case scenario continued

Key points

Case scenario

Learning objectives

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Introduction

Illicit drug use and adverse events in Australia

What are novel psychoactive substances?

What is MDMA?

Drug checking in Australia

The drug checking process

What is the evidence?

Knowledge to practice

Case scenario continued

Conclusion

Key points

Case scenario

Learning objectives

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Introduction

Aetiology and pathophysiology

Signs and symptoms

Diagnosis

Staging

Screening and prevention

Smoking cessation

Management of lung cancer