td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30630 [post_author] => 3410 [post_date] => 2025-10-03 14:40:26 [post_date_gmt] => 2025-10-03 04:40:26 [post_content] => Last year, the Therapeutic Goods Administration (TGA) made an interim decision to reschedule this formulation of dihydrocodeine (Rikodeine) to a prescription medicine. Why hasn’t it happened yet? On 26 July 2024, the interim decision on dihydrocodeine was published, which was made in response to concerns about the potential for misuse, abuse, and dependence associated with the opioid derivative. The TGA Delegate's interim decision was to amend the Pharmacist Only entry for dihydrocodeine to restrict undivided oral liquid preparations to a maximum primary pack size of 100 mL from 1 October 2025. So, what happened?What were the reasons for the interim decision?
The interim decision to amend the Schedule 3 entry for dihydrocodeine was made to balance the potential risks of dihydrocodeine, including respiratory depression, addiction potential and severe adverse effects, against the need for timely patient access to dry cough medicines. The amendment would also align Australia’s regulations more closely with other jurisdictions such as the United States, Canada, and Europe.Where is the final decision?
Australian Pharmacist understands that the final decision on the scheduling of dihydrocodeine is yet to be published, despite the implementation date flagged in the interim decision having come and gone last week.
It is highly unusual for an interim decision not to have been followed by a final decision within the usual decision-making timeframe – and to see the proposed implementation date pass without any formal notice.
What’s the reason behind the hold up?
In August 2024, the TGA sought public submissions on the interim decision on dihydrocodeine. It was reported in September 2024 that, of the 7 submissions received, two were in partial support while five were in opposition of the interim decision. The TGA noted that final decisions on dihydrocodeine had been deferred while the submissions received from the consultation were further considered.What should pharmacists do in the meantime?
For now, the scheduling of dihydrocodeine remains unchanged. PSA has reached out to the TGA for confirmation on the final scheduling decision. Pharmacists report they continue to experience frequent queries for dihydrocodeine from patients, many of whom don’t appear to have symptoms of dry cough. If diversion, misuse or abuse is suspected, pharmacists should ask the patient further questions to establish the patient’s:
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30612 [post_author] => 11351 [post_date] => 2025-10-02 10:50:09 [post_date_gmt] => 2025-10-02 00:50:09 [post_content] =>Advice around flagging SABA-only asthma patients, guiding them to new therapies for optimal management, and correcting inhaler technique.
Ever had those red flags when a patient is having multiple short-acting beta2-agonist (SABA) inhalers dispensed within a short timeframe? Or they’re taking salbutamol alone on multiple days of the week? And what about older patients who were told it was okay to use salbutamol frequently – and now it’s not?
How can pharmacists help these patients gain control over their disease? Or prevent them reaching the 1 g lifetime limit of oral corticosteroid use?
Pharmacist and asthma educator Sherri Barden MPS – who runs her own asthma, hay fever, eczema and chronic obstructive pulmonary disease, APLUS Pharmacy Education business – has heard it all. Routine inquiries about symptom frequency, reliever use and adherence during each pharmacy encounter is a good method, she says, of recognising if suboptimal control is worthy of timely intervention or referral.
Long-term solo SABA users
Patients who ‘just want the blue puffer’ may be the subject of a difficult conversation, according to Ms Barden. ‘Community pharmacists can reframe the conversation by encouraging their staff to firstly explain to the patient that salbutamol or terbutaline are a Pharmacist Only medicine and that the pharmacist will be with them shortly to discuss.’
She encourages pharmacists to use ‘a patient-centred, non-judgemental approach that links the discussion to the person’s goals and wellbeing’. Opening lines for long-term SABA users such as ‘Is this for asthma?’ and ‘I see you’re here for your reliever. Can I check how your asthma has been going lately?’ are recommended.
Another approach could start as: ‘There are some important updates to asthma care in adults and adolescents that could help you breathe easier and prevent flare-ups.’
Using brief symptom assessment tools such as the Asthma Control Test (ACT) and offering a collaborative plan can help make the conversation supportive rather than confrontational, Ms Barden suggests.
Importantly, patients should be advised that SABAs will continue to be available over the counter from pharmacists, but that the newer recommendations require a prescription. MedsChecks or Home Medicines Reviews can also provide opportunities to assess or reassess control, look at triggers or comorbidities contributing to poor control, review adherence and technique, and perform the ACT to track progress over time.
Up to 80% of people with asthma also have allergic rhinitis, Ms Barden points out. So it’s essential to assess or ask people about the upper airway.
If rhinitis ‘is not adequately controlled with the right information and quality use of medicines, it may contribute to poor asthma control’.
Ms Barden recommends the teach-back method for correct inhaler technique using either a placebo device or, better still, suggest the patient have a dose of their medicine with the pharmacist watching, who could then build follow-up and monitoring into routine practice.
National Asthma Council instructional videos for home use and ancillary labels –“Quick and Deep” for dry powder inhalers and “Slow and Steady” for metered dose or soft mist inhalers – reinforce the correct breathing method, Ms Barden says. They also act as ongoing prompts and conversation starters regarding technique.
Clear criteria for escalation, she stresses, should trigger a timely referral to a GP, nurse practitioner or respiratory specialist. In this way, patient progress can be measured, trends identified early, and care escalated if needed.
AP spoke to two pharmacists about interventions with patients with sub-optimal asthma control.
Case 1
David Peachey MPS Partner/Pharmacist Hatton & Laws Pharmacy and Priceline Pharmacy Launceston Plaza, Launceston, TAS
Mr B, a regular patient, repeatedly presented earlier than expected for salbutamol purchased as a Pharmacist Only medicine. There was no evidence of preventer use. He described increasing breathlessness and wheeziness, finding it harder to manage everyday activities like walking up the street. He was relying heavily on his SABA inhaler and had not had a recent GP review. This was a clear red flag that his asthma was not under control. His inhaler technique may also have been a factor, especially if copied from someone using it incorrectly.
Approaching Mr B in a supportive, non-judgemental way, I said: ‘I can see you might be experiencing some worsening of your breathing. I’d like to help you improve this. Let’s have a quick catch up in the consult room.’
I find open-ended questions most effective, particularly when patients are struggling. For example: ‘Would you be able to show me how you use your inhaler?’ or ‘Have you used a spacer before? I can show you what it does and how it works.’ Framing it as a way to improve breathing capacity, rather than criticising technique, makes patients more receptive.
When patients are hesitant, I focus on curiosity and reassurance rather than criticism. I explained to Mr B: ‘There are better and easier treatments available now such as anti-inflammatory relievers and a maintenance preventer and reliever in one device.
‘Using a Ventolin inhaler every week may cause side effects to your heart and lungs without you noticing. That might mean talking to your GP about an asthma plan and working together on inhaler technique today.’
By showing patients I am available anytime, I keep the door open, even if they aren’t ready to change immediately. Through this process, I was able to review and improve Mr B’s inhaler technique. Once he gained confidence using a spacer and making small adjustments, his reliance on salbutamol reduced.
Over time, he engaged more with his GP, which led to spirometry and a step-up in therapy with a preventer. Each small success built trust and transformed his asthma management from sub-optimal to stable, effective therapy.
The key lesson is that inhaler technique checks and supportive communication can significantly improve asthma outcomes. Many patients don’t realise how much salbutamol they are using or the risks of long-term reliance.
By engaging with open questions, demonstrating devices, and linking patients back to their GP, pharmacists can guide safer, more effective asthma care while building enduring patient trust.
Case 2
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Joanna Luong MPS Community Pharmacist PSA Trainer and Assessor Brisbane, QLD
Poorly managed asthma in the pharmacy is a common presentation. One standout case involved a man requesting over-the-counter salbutamol for his 20-year-old son. When I checked the dispense history, I saw salbutamol had been supplied monthly, always as a Pharmacist Only medicine, with no preventer prescribed and no record of any past clinical interventions.
Frequent reliever use can indicate uncontrolled asthma and may implicate poor inhaler technique. Patient education and collaborative care with a doctor was evidently warranted, to support the quality use of medicines and optimise management.
The man waited impatiently. I was careful my tone didn’t suggest misuse or poor self-management ability by his son. In a friendly, conversational manner, I said: ‘I’ve had many people coming in lately with asthma flare-ups due to the recent weather change. Has your son found that certain triggers worsen his symptoms? I can see he’s had Ventolin dispensed several times over the last couple of months.’
The question was closed, but the context prompted an elaboration of the response, which was that his son ‘usually just uses his inhaler a couple of times a week and that keeps everything under control’.
While acknowledging their satisfaction with their current level of control, I emphasised that, commonly, asthma management can be optimised even in people who consider their asthma well-controlled, and that along with proper inhaler technique, quality of life could be much improved including fewer episodes of wheeziness disrupting their daily activities.
‘Would your son have time at some point to come in for a quick chat so we can check his technique and discuss the updated Australian guidelines for asthma management?’ I asked.
As expected, there was some resistance. I gently reminded the father that guidelines evolve with research, and advice received several years ago may no longer be current, which is why regular medical reviews are recommended, and that my role was to help guide patients in making informed decisions about their health care.
Even though the conversation did not lead to change that day, keeping the conversation supportive and respectful meant he left the pharmacy open to future discussions.
I documented the intervention in the son’s dispense record so my colleagues and I could continue the conversation on subsequent visits. This ongoing engagement helped build rapport, and the father eventually persuaded his son to see his doctor, who prescribed a preventer inhaler now used regularly.
How we communicate can be just as important as what we say.
[post_title] => How pharmacists can combat poor asthma control [post_excerpt] => How pharmacists can flag SABA-only asthma patients, guide them to new therapies for optimal management, and correct inhaler technique. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => combatting-poor-asthma-control [to_ping] => [pinged] => [post_modified] => 2025-10-08 11:58:34 [post_modified_gmt] => 2025-10-08 00:58:34 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=30612 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => How pharmacists can combat poor asthma control [title] => How pharmacists can combat poor asthma control [href] => https://www.australianpharmacist.com.au/combatting-poor-asthma-control/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 30620 [authorType] => )
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30604 [post_author] => 3410 [post_date] => 2025-10-01 09:56:20 [post_date_gmt] => 2025-09-30 23:56:20 [post_content] => Last year, it was reported that Australian poisons hotlines received almost 1,500 calls about child ingestion of melatonin. In Western Australia, calls to the poisons hotline about melatonin have nearly doubled from 175 in 2018 to 322 as of August this year, across all age groups – mostly related to gummy products. In the same month, online health retailer iHerb suspended the sale of melatonin supplements in Australia. But there are retailers selling these products online, said Sarah Blunden, Professor and Head of Paediatric Sleep Research, CQUniversity Australia. [caption id="attachment_30644" align="alignright" width="300"]Professor Sarah Blunden[/caption] ‘There are a lot of other companies from the United States that sell it,’ she said. AP investigates what melatonin toxicity looks like, why so many kids are taking it and how pharmacists can help to ensure safe and effective use of medicines for sleep.
Why have calls to poison hotlines about melatonin gummies doubled?
From Prof Blunden’s perspective, the drivers are straightforward. ‘They are not regulated, they've got sugar in them and they taste good,’ she said. ‘Children love them and parents think they're natural. And without dosage requirements, they might give them one, two or three, and there’s no pharmacist or doctor monitoring the dose.’ Independent analyses of melatonin gummies have shown large discrepancies between labelled and actual melatonin content. ‘Two research groups – one in Canada and one in the UK – found some had no melatonin at all, and some had up to 400% of what was on the label,’ Prof Blunden said.‘without dosage requirements, they might give them one, two or three, and there’s no pharmacist or doctor monitoring the dose.' Professor Sarah BlundenThe Therapeutic Goods Administration (TGA) recently conducted its own review, reporting significant variability between products. For example, The Smurfs Kids Gummies Melatonin 1 mg contained 155–170% variation from the labelled amount. Endogenous melatonin biology is also highly individual, with retinal light-sensing pathways modulating secretion with wide inter-child variability, and there’s no practical clinical assay to map a child’s secretion pattern outside of a research study. ‘A child who’s particularly light-sensitive might have higher endogenous levels at a certain time, and if they then take several gummies, toxicity could be faster and worse,’ she said. ‘That’s why, when they present to ED, it gets labelled as an “overdose,” but we don’t exactly know what that means.’What are the symptoms of melatonin toxicity?
Common reported effects of melatonin toxicity include headache, dizziness, nausea, and drowsiness. Children can also experience central nervous system (CNS) effects, including extreme sedation, nightmares and vivid dreams. ‘Parents might see a very drowsy or unwell child and seek care, or they may witness ingestion of multiple gummies and go to the emergency department (ED),’ Prof Blunden said. Sometimes, toxicity appears fatal. ‘In a review we conducted, two or three deaths of children who had ingested melatonin were reported, but they are not included in many systematic reviews – including ours – because we couldn’t confirm that melatonin was the cause,’ she said. ‘I also found a paper reporting seven infants who died with high levels of exogenous melatonin in the blood, but causation wasn’t established. It’s unknown – and that is really scary.’Why are so many kids taking melatonin?
Sleep is increasingly recognised as a crucial factor in community health, said Prof Blunden. ‘Traditionally the pillars were healthy eating and exercise,’ she said. ‘But in the last 20 years, sleep has edged in as equally important.’ This shift is especially relevant for Australian parents, who have long encouraged children to sleep alone. ‘Because we've always had that expectation, there have always been issues around children who don't want to sleep by themselves,’ Prof Blunden said. Controlled crying was previously the standard response for children resisting independent sleep, but now, behavioural sleep medicine recognises melatonin as another option. ‘The increase in dual-working families, the need for children to sleep independently, the broader community conversation about sleep, and greater availability of melatonin for children who are not typically developing has led to the use of melatonin sharply rising,’ she said. ‘I’m on the board of the International Pediatric Sleep Association. And at the last two conferences, physiologists and clinicians said melatonin prescriptions and use have skyrocketed over the last 5 years,’ Prof Blunden said.Who is melatonin indicated for and at what dose?
In Australia, melatonin is indicated for children aged 2–18 years with neurodevelopmental disorders including:
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30596 [post_author] => 3410 [post_date] => 2025-09-29 10:46:50 [post_date_gmt] => 2025-09-29 00:46:50 [post_content] => New research has indicated that adolescents prefer seeking reproductive health services from pharmacists, but there are barriers to accessing care that must be addressed. Adolescents face unique and at times greater challenges when accessing sexual and reproductive health (SRH) services than adults, including stigma, limited knowledge, out-of-pocket costs and restrictive legislative frameworks, said SPHERE Research Fellow and lead author of the study Dr Anisa Assifi. ‘Community pharmacies offer a promising, accessible alternative, but only if pharmacists are equipped and supported to meet adolescents’ needs,’ she said.What are the benefits of pharmacy for SRH?
The review pulled on 25 years’ worth of published research in high-income countries with similar healthcare settings and approaches to care, including Australia and the United States. Overwhelmingly, adolescents felt they received detailed, high-quality, trustworthy information about contraceptive products from pharmacists. ‘What we found is that adolescents find pharmacy a really accessible and acceptable source of information, and really easy to get into,’ Dr Assifi said. ‘They trusted the pharmacist's knowledge.’ Across Australia, reproductive health is an area pharmacists are increasingly involved in. With scope of practice broadening, pharmacists have been prescribing emergency contraception, resupplying the oral contraceptive pill and dispensing mifepristone/misoprostol (MS-2 Step). At the same time, barriers to general practice access have increased; declines in Medicare bulk billing rates coupled with long wait times to see a GP have made pharmacy a more favourable setting for seeking reproductive care, ‘You might wait 5–10 minutes to talk to a pharmacist, depending on the pharmacy and location,’ she said. Despite efforts to improve sex education in schools, Dr Assifi said students may still be missing the information they need. ‘It’s an amazing opportunity for adolescents to talk to a health professional and get accurate information they may not be getting elsewhere.’What are the barriers to care?
It’s not all roses, with adolescents still frequently experiencing embarrassment and judgement from pharmacists and pharmacy staff when seeking SRH services, alongside stigma related to being sexually active, Dr Assifi said. ‘Many went in expecting to be judged, so it was both their experience and perception that contributed to them feeling judgement.’ Adolescents also questioned whether pharmacists would maintain confidentiality, and were concerned that the layout of large, high-volume pharmacies could make private conversations at the counter difficult. ‘What did come out was that the difference between pharmacy and family planning or GP clinics is that you're in a consultation room, so confidentiality is more maintained,’ she said. ‘False barriers’ were also identified. ‘Sometimes pharmacists were not up to date with guidelines or regulations (e.g. age of access, parental consent, prescription requirements) or they created unnecessary hurdles – saying they didn’t stock a product, or that parental consent was required,’ Dr Assifi said. ‘So even though they were trusted, there were still some issues that would come up where they would block that access.’ When pharmacists were empathetic and non-judgmental, including adjusting their body language and lowering their tone of voice, this made a significant difference to patient experience. ‘Some pharmacists were very good at this and recognised the importance of not being judgmental or making assumptions when interacting with adolescents, recognising that they need to be treated with respect and empathy,’ she said.What’s pharmacists' perspective?
Most pharmacists found it acceptable to provide contraception to adolescents, including emergency contraception, and felt comfortable counselling this age cohort. However, their acceptability of providing emergency contraception declined as adolescents’ age decreased. ‘Pharmacists felt more comfortable interacting with older adolescents and were looking for further training and support about how to provide appropriate care to an adolescent that meets their needs, including how to interact with them through those discussions and encounters.’ Dr Assifi said more research was required to understand the training and support mechanisms that would better enable pharmacists to provide adolescent-friendly care. ‘Pharmacists, along with any other health professionals, have their own personal belief systems, and we did find in quite a few studies that this made them unwilling or unhelpful to provide care,’ she said. ‘So we need to ensure that if one pharmacist is uncomfortable, another is available to provide the service so adolescents receive appropriate information and sexual and reproductive healthcare. ‘I think it's an injustice to the young person if we can't provide them with the appropriate information and support required of an SRH that they've come to you as a health professional seeking.’What needs to be considered?
PSA’s Code of Ethics states that in the instance of conscientious objection, pharmacists must ‘inform the patient when exercising the right to decline provision of certain forms of health care based on the individual pharmacist’s conscientious objection, and in such circumstances, appropriately facilitate continuity of care for the patient’. ‘What’s important is ensuring adolescents don’t feel judged or embarrassed when seeking information or services, and that they still receive the care they need,’ Dr Assifi agreed. ‘Adolescent-friendly care isn't simply about mannerisms and the way a pharmacist interacts and talks with a young person. Pharmacy staff and dispensing technicians also need to be involved in how to have these conversations.’ The pharmacy environment also has a role to play. Consultation rooms should be the standard setting for conversations about contraception to take place. ‘The availability of private consultation rooms is a great step forward, and being able to offer that space to a young person to have those conversations in – whether they choose to take it or not – is really important.’Do not use a paper checklist!!
SPHERE is currently working on further research to identify the impact of the paper form and checklist still used by some pharmacists when supplying emergency contraception. While the checklist has been found to be a barrier to access, this is likely even more pronounced in adolescents. ‘We don't want young people to feel like their personal information is being taken and they don’t know what's being done with it,’ Dr Assifi said. ‘Alternative ways where a young person can signal or provide that information so it doesn't feel as jarring as saying it across the dispensing counter should be considered.’ PSA’s Non-prescription medicine treatment guideline: Emergency Contraception, found in the Australian Pharmaceutical Formulary and Handbook or PSA Resource Hub, advises pharmacists to ‘Gather patient information in a confidential, respectful and non-judgemental manner. Do not use a written checklist or form because the patient (or third party) can perceive it as a barrier to care’. [post_title] => Stigma hinders adolescent contraceptive care [post_excerpt] => Adolescents prefer seeking contraceptive care from pharmacists, says new research. But there are barriers to access that must be addressed. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => stigma-hinders-adolescent-contraceptive-care [to_ping] => [pinged] => [post_modified] => 2025-09-30 15:36:53 [post_modified_gmt] => 2025-09-30 05:36:53 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=30596 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Stigma hinders adolescent contraceptive care [title] => Stigma hinders adolescent contraceptive care [href] => https://www.australianpharmacist.com.au/stigma-hinders-adolescent-contraceptive-care/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 30598 [authorType] => )
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30588 [post_author] => 250 [post_date] => 2025-09-26 12:32:10 [post_date_gmt] => 2025-09-26 02:32:10 [post_content] =>When standard needles for vaccination shortchange patient immunity.
Vaccines are most effective when administered using correct technique – this includes injection site positioning, angle of the needle and needle length.
Most vaccines currently available are administered as intramuscular (IM) injections. With the breadth and depth of pharmacist-administered vaccination growing, it’s timely that pharmacists double check their depth.
What needle size should I use for IM injections?
A 25 mm needle is recommended for most people, including from infants to older adults.
There are two exceptions:
For very large or obese people, a longer needle of 38 mm length is recommended.1 With 32% of the Australian population being obese,2 around a third of vaccines likely should be administered using longer needles.
If a needle isn’t long enough, or used at an incorrect angle, the needle may not fully penetrate the deltoid fat pad and therefore be inadvertently administered subcutaneously.
For most vaccines, this risks a higher rate of local adverse events, such as redness, swelling, itching and pain.1,3 This is particularly noted with aluminium-adjuvanted vaccines (such as hepatitis B, dTpa or dT vaccines).2
Concerningly, it is also recognised as reducing immunogenicity.2 For example, Rabipur Inactivated Rabies Virus Vaccine (PCECV) is considered invalid if given subcutaneously.2
It’s hard to tell. There is limited contemporary data – and no Australian data was identified when researching this article.
However, overseas studies suggest 38 mm needles are drastically underutilised4 – with one US study suggesting the wrong length needle was used 75% of the time when administering vaccines to obese people.5
Consult the Australian Immunisation Handbook.1 The ‘Vaccine injection techniques’ section contains advice on inadvertent subcutaneous injection of intramuscular vaccines.
Error reporting to indemnity insurers and state/territory health department systems may also be required.
In the example of the Rabipur rabies vaccine, as a subcutaneous dose is invalid, the dose must be repeated – an undesirable situation given the cost and time-critical regimen for rabies vaccines.
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30630 [post_author] => 3410 [post_date] => 2025-10-03 14:40:26 [post_date_gmt] => 2025-10-03 04:40:26 [post_content] => Last year, the Therapeutic Goods Administration (TGA) made an interim decision to reschedule this formulation of dihydrocodeine (Rikodeine) to a prescription medicine. Why hasn’t it happened yet? On 26 July 2024, the interim decision on dihydrocodeine was published, which was made in response to concerns about the potential for misuse, abuse, and dependence associated with the opioid derivative. The TGA Delegate's interim decision was to amend the Pharmacist Only entry for dihydrocodeine to restrict undivided oral liquid preparations to a maximum primary pack size of 100 mL from 1 October 2025. So, what happened?What were the reasons for the interim decision?
The interim decision to amend the Schedule 3 entry for dihydrocodeine was made to balance the potential risks of dihydrocodeine, including respiratory depression, addiction potential and severe adverse effects, against the need for timely patient access to dry cough medicines. The amendment would also align Australia’s regulations more closely with other jurisdictions such as the United States, Canada, and Europe.Where is the final decision?
Australian Pharmacist understands that the final decision on the scheduling of dihydrocodeine is yet to be published, despite the implementation date flagged in the interim decision having come and gone last week.
It is highly unusual for an interim decision not to have been followed by a final decision within the usual decision-making timeframe – and to see the proposed implementation date pass without any formal notice.
What’s the reason behind the hold up?
In August 2024, the TGA sought public submissions on the interim decision on dihydrocodeine. It was reported in September 2024 that, of the 7 submissions received, two were in partial support while five were in opposition of the interim decision. The TGA noted that final decisions on dihydrocodeine had been deferred while the submissions received from the consultation were further considered.What should pharmacists do in the meantime?
For now, the scheduling of dihydrocodeine remains unchanged. PSA has reached out to the TGA for confirmation on the final scheduling decision. Pharmacists report they continue to experience frequent queries for dihydrocodeine from patients, many of whom don’t appear to have symptoms of dry cough. If diversion, misuse or abuse is suspected, pharmacists should ask the patient further questions to establish the patient’s:
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30612 [post_author] => 11351 [post_date] => 2025-10-02 10:50:09 [post_date_gmt] => 2025-10-02 00:50:09 [post_content] =>Advice around flagging SABA-only asthma patients, guiding them to new therapies for optimal management, and correcting inhaler technique.
Ever had those red flags when a patient is having multiple short-acting beta2-agonist (SABA) inhalers dispensed within a short timeframe? Or they’re taking salbutamol alone on multiple days of the week? And what about older patients who were told it was okay to use salbutamol frequently – and now it’s not?
How can pharmacists help these patients gain control over their disease? Or prevent them reaching the 1 g lifetime limit of oral corticosteroid use?
Pharmacist and asthma educator Sherri Barden MPS – who runs her own asthma, hay fever, eczema and chronic obstructive pulmonary disease, APLUS Pharmacy Education business – has heard it all. Routine inquiries about symptom frequency, reliever use and adherence during each pharmacy encounter is a good method, she says, of recognising if suboptimal control is worthy of timely intervention or referral.
Long-term solo SABA users
Patients who ‘just want the blue puffer’ may be the subject of a difficult conversation, according to Ms Barden. ‘Community pharmacists can reframe the conversation by encouraging their staff to firstly explain to the patient that salbutamol or terbutaline are a Pharmacist Only medicine and that the pharmacist will be with them shortly to discuss.’
She encourages pharmacists to use ‘a patient-centred, non-judgemental approach that links the discussion to the person’s goals and wellbeing’. Opening lines for long-term SABA users such as ‘Is this for asthma?’ and ‘I see you’re here for your reliever. Can I check how your asthma has been going lately?’ are recommended.
Another approach could start as: ‘There are some important updates to asthma care in adults and adolescents that could help you breathe easier and prevent flare-ups.’
Using brief symptom assessment tools such as the Asthma Control Test (ACT) and offering a collaborative plan can help make the conversation supportive rather than confrontational, Ms Barden suggests.
Importantly, patients should be advised that SABAs will continue to be available over the counter from pharmacists, but that the newer recommendations require a prescription. MedsChecks or Home Medicines Reviews can also provide opportunities to assess or reassess control, look at triggers or comorbidities contributing to poor control, review adherence and technique, and perform the ACT to track progress over time.
Up to 80% of people with asthma also have allergic rhinitis, Ms Barden points out. So it’s essential to assess or ask people about the upper airway.
If rhinitis ‘is not adequately controlled with the right information and quality use of medicines, it may contribute to poor asthma control’.
Ms Barden recommends the teach-back method for correct inhaler technique using either a placebo device or, better still, suggest the patient have a dose of their medicine with the pharmacist watching, who could then build follow-up and monitoring into routine practice.
National Asthma Council instructional videos for home use and ancillary labels –“Quick and Deep” for dry powder inhalers and “Slow and Steady” for metered dose or soft mist inhalers – reinforce the correct breathing method, Ms Barden says. They also act as ongoing prompts and conversation starters regarding technique.
Clear criteria for escalation, she stresses, should trigger a timely referral to a GP, nurse practitioner or respiratory specialist. In this way, patient progress can be measured, trends identified early, and care escalated if needed.
AP spoke to two pharmacists about interventions with patients with sub-optimal asthma control.
Case 1
David Peachey MPS Partner/Pharmacist Hatton & Laws Pharmacy and Priceline Pharmacy Launceston Plaza, Launceston, TAS
Mr B, a regular patient, repeatedly presented earlier than expected for salbutamol purchased as a Pharmacist Only medicine. There was no evidence of preventer use. He described increasing breathlessness and wheeziness, finding it harder to manage everyday activities like walking up the street. He was relying heavily on his SABA inhaler and had not had a recent GP review. This was a clear red flag that his asthma was not under control. His inhaler technique may also have been a factor, especially if copied from someone using it incorrectly.
Approaching Mr B in a supportive, non-judgemental way, I said: ‘I can see you might be experiencing some worsening of your breathing. I’d like to help you improve this. Let’s have a quick catch up in the consult room.’
I find open-ended questions most effective, particularly when patients are struggling. For example: ‘Would you be able to show me how you use your inhaler?’ or ‘Have you used a spacer before? I can show you what it does and how it works.’ Framing it as a way to improve breathing capacity, rather than criticising technique, makes patients more receptive.
When patients are hesitant, I focus on curiosity and reassurance rather than criticism. I explained to Mr B: ‘There are better and easier treatments available now such as anti-inflammatory relievers and a maintenance preventer and reliever in one device.
‘Using a Ventolin inhaler every week may cause side effects to your heart and lungs without you noticing. That might mean talking to your GP about an asthma plan and working together on inhaler technique today.’
By showing patients I am available anytime, I keep the door open, even if they aren’t ready to change immediately. Through this process, I was able to review and improve Mr B’s inhaler technique. Once he gained confidence using a spacer and making small adjustments, his reliance on salbutamol reduced.
Over time, he engaged more with his GP, which led to spirometry and a step-up in therapy with a preventer. Each small success built trust and transformed his asthma management from sub-optimal to stable, effective therapy.
The key lesson is that inhaler technique checks and supportive communication can significantly improve asthma outcomes. Many patients don’t realise how much salbutamol they are using or the risks of long-term reliance.
By engaging with open questions, demonstrating devices, and linking patients back to their GP, pharmacists can guide safer, more effective asthma care while building enduring patient trust.
Case 2
![]()
Joanna Luong MPS Community Pharmacist PSA Trainer and Assessor Brisbane, QLD
Poorly managed asthma in the pharmacy is a common presentation. One standout case involved a man requesting over-the-counter salbutamol for his 20-year-old son. When I checked the dispense history, I saw salbutamol had been supplied monthly, always as a Pharmacist Only medicine, with no preventer prescribed and no record of any past clinical interventions.
Frequent reliever use can indicate uncontrolled asthma and may implicate poor inhaler technique. Patient education and collaborative care with a doctor was evidently warranted, to support the quality use of medicines and optimise management.
The man waited impatiently. I was careful my tone didn’t suggest misuse or poor self-management ability by his son. In a friendly, conversational manner, I said: ‘I’ve had many people coming in lately with asthma flare-ups due to the recent weather change. Has your son found that certain triggers worsen his symptoms? I can see he’s had Ventolin dispensed several times over the last couple of months.’
The question was closed, but the context prompted an elaboration of the response, which was that his son ‘usually just uses his inhaler a couple of times a week and that keeps everything under control’.
While acknowledging their satisfaction with their current level of control, I emphasised that, commonly, asthma management can be optimised even in people who consider their asthma well-controlled, and that along with proper inhaler technique, quality of life could be much improved including fewer episodes of wheeziness disrupting their daily activities.
‘Would your son have time at some point to come in for a quick chat so we can check his technique and discuss the updated Australian guidelines for asthma management?’ I asked.
As expected, there was some resistance. I gently reminded the father that guidelines evolve with research, and advice received several years ago may no longer be current, which is why regular medical reviews are recommended, and that my role was to help guide patients in making informed decisions about their health care.
Even though the conversation did not lead to change that day, keeping the conversation supportive and respectful meant he left the pharmacy open to future discussions.
I documented the intervention in the son’s dispense record so my colleagues and I could continue the conversation on subsequent visits. This ongoing engagement helped build rapport, and the father eventually persuaded his son to see his doctor, who prescribed a preventer inhaler now used regularly.
How we communicate can be just as important as what we say.
[post_title] => How pharmacists can combat poor asthma control [post_excerpt] => How pharmacists can flag SABA-only asthma patients, guide them to new therapies for optimal management, and correct inhaler technique. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => combatting-poor-asthma-control [to_ping] => [pinged] => [post_modified] => 2025-10-08 11:58:34 [post_modified_gmt] => 2025-10-08 00:58:34 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=30612 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => How pharmacists can combat poor asthma control [title] => How pharmacists can combat poor asthma control [href] => https://www.australianpharmacist.com.au/combatting-poor-asthma-control/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 30620 [authorType] => )
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30604 [post_author] => 3410 [post_date] => 2025-10-01 09:56:20 [post_date_gmt] => 2025-09-30 23:56:20 [post_content] => Last year, it was reported that Australian poisons hotlines received almost 1,500 calls about child ingestion of melatonin. In Western Australia, calls to the poisons hotline about melatonin have nearly doubled from 175 in 2018 to 322 as of August this year, across all age groups – mostly related to gummy products. In the same month, online health retailer iHerb suspended the sale of melatonin supplements in Australia. But there are retailers selling these products online, said Sarah Blunden, Professor and Head of Paediatric Sleep Research, CQUniversity Australia. [caption id="attachment_30644" align="alignright" width="300"]Professor Sarah Blunden[/caption] ‘There are a lot of other companies from the United States that sell it,’ she said. AP investigates what melatonin toxicity looks like, why so many kids are taking it and how pharmacists can help to ensure safe and effective use of medicines for sleep.
Why have calls to poison hotlines about melatonin gummies doubled?
From Prof Blunden’s perspective, the drivers are straightforward. ‘They are not regulated, they've got sugar in them and they taste good,’ she said. ‘Children love them and parents think they're natural. And without dosage requirements, they might give them one, two or three, and there’s no pharmacist or doctor monitoring the dose.’ Independent analyses of melatonin gummies have shown large discrepancies between labelled and actual melatonin content. ‘Two research groups – one in Canada and one in the UK – found some had no melatonin at all, and some had up to 400% of what was on the label,’ Prof Blunden said.‘without dosage requirements, they might give them one, two or three, and there’s no pharmacist or doctor monitoring the dose.' Professor Sarah BlundenThe Therapeutic Goods Administration (TGA) recently conducted its own review, reporting significant variability between products. For example, The Smurfs Kids Gummies Melatonin 1 mg contained 155–170% variation from the labelled amount. Endogenous melatonin biology is also highly individual, with retinal light-sensing pathways modulating secretion with wide inter-child variability, and there’s no practical clinical assay to map a child’s secretion pattern outside of a research study. ‘A child who’s particularly light-sensitive might have higher endogenous levels at a certain time, and if they then take several gummies, toxicity could be faster and worse,’ she said. ‘That’s why, when they present to ED, it gets labelled as an “overdose,” but we don’t exactly know what that means.’What are the symptoms of melatonin toxicity?
Common reported effects of melatonin toxicity include headache, dizziness, nausea, and drowsiness. Children can also experience central nervous system (CNS) effects, including extreme sedation, nightmares and vivid dreams. ‘Parents might see a very drowsy or unwell child and seek care, or they may witness ingestion of multiple gummies and go to the emergency department (ED),’ Prof Blunden said. Sometimes, toxicity appears fatal. ‘In a review we conducted, two or three deaths of children who had ingested melatonin were reported, but they are not included in many systematic reviews – including ours – because we couldn’t confirm that melatonin was the cause,’ she said. ‘I also found a paper reporting seven infants who died with high levels of exogenous melatonin in the blood, but causation wasn’t established. It’s unknown – and that is really scary.’Why are so many kids taking melatonin?
Sleep is increasingly recognised as a crucial factor in community health, said Prof Blunden. ‘Traditionally the pillars were healthy eating and exercise,’ she said. ‘But in the last 20 years, sleep has edged in as equally important.’ This shift is especially relevant for Australian parents, who have long encouraged children to sleep alone. ‘Because we've always had that expectation, there have always been issues around children who don't want to sleep by themselves,’ Prof Blunden said. Controlled crying was previously the standard response for children resisting independent sleep, but now, behavioural sleep medicine recognises melatonin as another option. ‘The increase in dual-working families, the need for children to sleep independently, the broader community conversation about sleep, and greater availability of melatonin for children who are not typically developing has led to the use of melatonin sharply rising,’ she said. ‘I’m on the board of the International Pediatric Sleep Association. And at the last two conferences, physiologists and clinicians said melatonin prescriptions and use have skyrocketed over the last 5 years,’ Prof Blunden said.Who is melatonin indicated for and at what dose?
In Australia, melatonin is indicated for children aged 2–18 years with neurodevelopmental disorders including:
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30596 [post_author] => 3410 [post_date] => 2025-09-29 10:46:50 [post_date_gmt] => 2025-09-29 00:46:50 [post_content] => New research has indicated that adolescents prefer seeking reproductive health services from pharmacists, but there are barriers to accessing care that must be addressed. Adolescents face unique and at times greater challenges when accessing sexual and reproductive health (SRH) services than adults, including stigma, limited knowledge, out-of-pocket costs and restrictive legislative frameworks, said SPHERE Research Fellow and lead author of the study Dr Anisa Assifi. ‘Community pharmacies offer a promising, accessible alternative, but only if pharmacists are equipped and supported to meet adolescents’ needs,’ she said.What are the benefits of pharmacy for SRH?
The review pulled on 25 years’ worth of published research in high-income countries with similar healthcare settings and approaches to care, including Australia and the United States. Overwhelmingly, adolescents felt they received detailed, high-quality, trustworthy information about contraceptive products from pharmacists. ‘What we found is that adolescents find pharmacy a really accessible and acceptable source of information, and really easy to get into,’ Dr Assifi said. ‘They trusted the pharmacist's knowledge.’ Across Australia, reproductive health is an area pharmacists are increasingly involved in. With scope of practice broadening, pharmacists have been prescribing emergency contraception, resupplying the oral contraceptive pill and dispensing mifepristone/misoprostol (MS-2 Step). At the same time, barriers to general practice access have increased; declines in Medicare bulk billing rates coupled with long wait times to see a GP have made pharmacy a more favourable setting for seeking reproductive care, ‘You might wait 5–10 minutes to talk to a pharmacist, depending on the pharmacy and location,’ she said. Despite efforts to improve sex education in schools, Dr Assifi said students may still be missing the information they need. ‘It’s an amazing opportunity for adolescents to talk to a health professional and get accurate information they may not be getting elsewhere.’What are the barriers to care?
It’s not all roses, with adolescents still frequently experiencing embarrassment and judgement from pharmacists and pharmacy staff when seeking SRH services, alongside stigma related to being sexually active, Dr Assifi said. ‘Many went in expecting to be judged, so it was both their experience and perception that contributed to them feeling judgement.’ Adolescents also questioned whether pharmacists would maintain confidentiality, and were concerned that the layout of large, high-volume pharmacies could make private conversations at the counter difficult. ‘What did come out was that the difference between pharmacy and family planning or GP clinics is that you're in a consultation room, so confidentiality is more maintained,’ she said. ‘False barriers’ were also identified. ‘Sometimes pharmacists were not up to date with guidelines or regulations (e.g. age of access, parental consent, prescription requirements) or they created unnecessary hurdles – saying they didn’t stock a product, or that parental consent was required,’ Dr Assifi said. ‘So even though they were trusted, there were still some issues that would come up where they would block that access.’ When pharmacists were empathetic and non-judgmental, including adjusting their body language and lowering their tone of voice, this made a significant difference to patient experience. ‘Some pharmacists were very good at this and recognised the importance of not being judgmental or making assumptions when interacting with adolescents, recognising that they need to be treated with respect and empathy,’ she said.What’s pharmacists' perspective?
Most pharmacists found it acceptable to provide contraception to adolescents, including emergency contraception, and felt comfortable counselling this age cohort. However, their acceptability of providing emergency contraception declined as adolescents’ age decreased. ‘Pharmacists felt more comfortable interacting with older adolescents and were looking for further training and support about how to provide appropriate care to an adolescent that meets their needs, including how to interact with them through those discussions and encounters.’ Dr Assifi said more research was required to understand the training and support mechanisms that would better enable pharmacists to provide adolescent-friendly care. ‘Pharmacists, along with any other health professionals, have their own personal belief systems, and we did find in quite a few studies that this made them unwilling or unhelpful to provide care,’ she said. ‘So we need to ensure that if one pharmacist is uncomfortable, another is available to provide the service so adolescents receive appropriate information and sexual and reproductive healthcare. ‘I think it's an injustice to the young person if we can't provide them with the appropriate information and support required of an SRH that they've come to you as a health professional seeking.’What needs to be considered?
PSA’s Code of Ethics states that in the instance of conscientious objection, pharmacists must ‘inform the patient when exercising the right to decline provision of certain forms of health care based on the individual pharmacist’s conscientious objection, and in such circumstances, appropriately facilitate continuity of care for the patient’. ‘What’s important is ensuring adolescents don’t feel judged or embarrassed when seeking information or services, and that they still receive the care they need,’ Dr Assifi agreed. ‘Adolescent-friendly care isn't simply about mannerisms and the way a pharmacist interacts and talks with a young person. Pharmacy staff and dispensing technicians also need to be involved in how to have these conversations.’ The pharmacy environment also has a role to play. Consultation rooms should be the standard setting for conversations about contraception to take place. ‘The availability of private consultation rooms is a great step forward, and being able to offer that space to a young person to have those conversations in – whether they choose to take it or not – is really important.’Do not use a paper checklist!!
SPHERE is currently working on further research to identify the impact of the paper form and checklist still used by some pharmacists when supplying emergency contraception. While the checklist has been found to be a barrier to access, this is likely even more pronounced in adolescents. ‘We don't want young people to feel like their personal information is being taken and they don’t know what's being done with it,’ Dr Assifi said. ‘Alternative ways where a young person can signal or provide that information so it doesn't feel as jarring as saying it across the dispensing counter should be considered.’ PSA’s Non-prescription medicine treatment guideline: Emergency Contraception, found in the Australian Pharmaceutical Formulary and Handbook or PSA Resource Hub, advises pharmacists to ‘Gather patient information in a confidential, respectful and non-judgemental manner. Do not use a written checklist or form because the patient (or third party) can perceive it as a barrier to care’. [post_title] => Stigma hinders adolescent contraceptive care [post_excerpt] => Adolescents prefer seeking contraceptive care from pharmacists, says new research. But there are barriers to access that must be addressed. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => stigma-hinders-adolescent-contraceptive-care [to_ping] => [pinged] => [post_modified] => 2025-09-30 15:36:53 [post_modified_gmt] => 2025-09-30 05:36:53 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=30596 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Stigma hinders adolescent contraceptive care [title] => Stigma hinders adolescent contraceptive care [href] => https://www.australianpharmacist.com.au/stigma-hinders-adolescent-contraceptive-care/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 30598 [authorType] => )
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30588 [post_author] => 250 [post_date] => 2025-09-26 12:32:10 [post_date_gmt] => 2025-09-26 02:32:10 [post_content] =>When standard needles for vaccination shortchange patient immunity.
Vaccines are most effective when administered using correct technique – this includes injection site positioning, angle of the needle and needle length.
Most vaccines currently available are administered as intramuscular (IM) injections. With the breadth and depth of pharmacist-administered vaccination growing, it’s timely that pharmacists double check their depth.
What needle size should I use for IM injections?
A 25 mm needle is recommended for most people, including from infants to older adults.
There are two exceptions:
For very large or obese people, a longer needle of 38 mm length is recommended.1 With 32% of the Australian population being obese,2 around a third of vaccines likely should be administered using longer needles.
If a needle isn’t long enough, or used at an incorrect angle, the needle may not fully penetrate the deltoid fat pad and therefore be inadvertently administered subcutaneously.
For most vaccines, this risks a higher rate of local adverse events, such as redness, swelling, itching and pain.1,3 This is particularly noted with aluminium-adjuvanted vaccines (such as hepatitis B, dTpa or dT vaccines).2
Concerningly, it is also recognised as reducing immunogenicity.2 For example, Rabipur Inactivated Rabies Virus Vaccine (PCECV) is considered invalid if given subcutaneously.2
It’s hard to tell. There is limited contemporary data – and no Australian data was identified when researching this article.
However, overseas studies suggest 38 mm needles are drastically underutilised4 – with one US study suggesting the wrong length needle was used 75% of the time when administering vaccines to obese people.5
Consult the Australian Immunisation Handbook.1 The ‘Vaccine injection techniques’ section contains advice on inadvertent subcutaneous injection of intramuscular vaccines.
Error reporting to indemnity insurers and state/territory health department systems may also be required.
In the example of the Rabipur rabies vaccine, as a subcutaneous dose is invalid, the dose must be repeated – an undesirable situation given the cost and time-critical regimen for rabies vaccines.
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30630 [post_author] => 3410 [post_date] => 2025-10-03 14:40:26 [post_date_gmt] => 2025-10-03 04:40:26 [post_content] => Last year, the Therapeutic Goods Administration (TGA) made an interim decision to reschedule this formulation of dihydrocodeine (Rikodeine) to a prescription medicine. Why hasn’t it happened yet? On 26 July 2024, the interim decision on dihydrocodeine was published, which was made in response to concerns about the potential for misuse, abuse, and dependence associated with the opioid derivative. The TGA Delegate's interim decision was to amend the Pharmacist Only entry for dihydrocodeine to restrict undivided oral liquid preparations to a maximum primary pack size of 100 mL from 1 October 2025. So, what happened?What were the reasons for the interim decision?
The interim decision to amend the Schedule 3 entry for dihydrocodeine was made to balance the potential risks of dihydrocodeine, including respiratory depression, addiction potential and severe adverse effects, against the need for timely patient access to dry cough medicines. The amendment would also align Australia’s regulations more closely with other jurisdictions such as the United States, Canada, and Europe.Where is the final decision?
Australian Pharmacist understands that the final decision on the scheduling of dihydrocodeine is yet to be published, despite the implementation date flagged in the interim decision having come and gone last week.
It is highly unusual for an interim decision not to have been followed by a final decision within the usual decision-making timeframe – and to see the proposed implementation date pass without any formal notice.
What’s the reason behind the hold up?
In August 2024, the TGA sought public submissions on the interim decision on dihydrocodeine. It was reported in September 2024 that, of the 7 submissions received, two were in partial support while five were in opposition of the interim decision. The TGA noted that final decisions on dihydrocodeine had been deferred while the submissions received from the consultation were further considered.What should pharmacists do in the meantime?
For now, the scheduling of dihydrocodeine remains unchanged. PSA has reached out to the TGA for confirmation on the final scheduling decision. Pharmacists report they continue to experience frequent queries for dihydrocodeine from patients, many of whom don’t appear to have symptoms of dry cough. If diversion, misuse or abuse is suspected, pharmacists should ask the patient further questions to establish the patient’s:
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30612 [post_author] => 11351 [post_date] => 2025-10-02 10:50:09 [post_date_gmt] => 2025-10-02 00:50:09 [post_content] =>Advice around flagging SABA-only asthma patients, guiding them to new therapies for optimal management, and correcting inhaler technique.
Ever had those red flags when a patient is having multiple short-acting beta2-agonist (SABA) inhalers dispensed within a short timeframe? Or they’re taking salbutamol alone on multiple days of the week? And what about older patients who were told it was okay to use salbutamol frequently – and now it’s not?
How can pharmacists help these patients gain control over their disease? Or prevent them reaching the 1 g lifetime limit of oral corticosteroid use?
Pharmacist and asthma educator Sherri Barden MPS – who runs her own asthma, hay fever, eczema and chronic obstructive pulmonary disease, APLUS Pharmacy Education business – has heard it all. Routine inquiries about symptom frequency, reliever use and adherence during each pharmacy encounter is a good method, she says, of recognising if suboptimal control is worthy of timely intervention or referral.
Long-term solo SABA users
Patients who ‘just want the blue puffer’ may be the subject of a difficult conversation, according to Ms Barden. ‘Community pharmacists can reframe the conversation by encouraging their staff to firstly explain to the patient that salbutamol or terbutaline are a Pharmacist Only medicine and that the pharmacist will be with them shortly to discuss.’
She encourages pharmacists to use ‘a patient-centred, non-judgemental approach that links the discussion to the person’s goals and wellbeing’. Opening lines for long-term SABA users such as ‘Is this for asthma?’ and ‘I see you’re here for your reliever. Can I check how your asthma has been going lately?’ are recommended.
Another approach could start as: ‘There are some important updates to asthma care in adults and adolescents that could help you breathe easier and prevent flare-ups.’
Using brief symptom assessment tools such as the Asthma Control Test (ACT) and offering a collaborative plan can help make the conversation supportive rather than confrontational, Ms Barden suggests.
Importantly, patients should be advised that SABAs will continue to be available over the counter from pharmacists, but that the newer recommendations require a prescription. MedsChecks or Home Medicines Reviews can also provide opportunities to assess or reassess control, look at triggers or comorbidities contributing to poor control, review adherence and technique, and perform the ACT to track progress over time.
Up to 80% of people with asthma also have allergic rhinitis, Ms Barden points out. So it’s essential to assess or ask people about the upper airway.
If rhinitis ‘is not adequately controlled with the right information and quality use of medicines, it may contribute to poor asthma control’.
Ms Barden recommends the teach-back method for correct inhaler technique using either a placebo device or, better still, suggest the patient have a dose of their medicine with the pharmacist watching, who could then build follow-up and monitoring into routine practice.
National Asthma Council instructional videos for home use and ancillary labels –“Quick and Deep” for dry powder inhalers and “Slow and Steady” for metered dose or soft mist inhalers – reinforce the correct breathing method, Ms Barden says. They also act as ongoing prompts and conversation starters regarding technique.
Clear criteria for escalation, she stresses, should trigger a timely referral to a GP, nurse practitioner or respiratory specialist. In this way, patient progress can be measured, trends identified early, and care escalated if needed.
AP spoke to two pharmacists about interventions with patients with sub-optimal asthma control.
Case 1
David Peachey MPS Partner/Pharmacist Hatton & Laws Pharmacy and Priceline Pharmacy Launceston Plaza, Launceston, TAS
Mr B, a regular patient, repeatedly presented earlier than expected for salbutamol purchased as a Pharmacist Only medicine. There was no evidence of preventer use. He described increasing breathlessness and wheeziness, finding it harder to manage everyday activities like walking up the street. He was relying heavily on his SABA inhaler and had not had a recent GP review. This was a clear red flag that his asthma was not under control. His inhaler technique may also have been a factor, especially if copied from someone using it incorrectly.
Approaching Mr B in a supportive, non-judgemental way, I said: ‘I can see you might be experiencing some worsening of your breathing. I’d like to help you improve this. Let’s have a quick catch up in the consult room.’
I find open-ended questions most effective, particularly when patients are struggling. For example: ‘Would you be able to show me how you use your inhaler?’ or ‘Have you used a spacer before? I can show you what it does and how it works.’ Framing it as a way to improve breathing capacity, rather than criticising technique, makes patients more receptive.
When patients are hesitant, I focus on curiosity and reassurance rather than criticism. I explained to Mr B: ‘There are better and easier treatments available now such as anti-inflammatory relievers and a maintenance preventer and reliever in one device.
‘Using a Ventolin inhaler every week may cause side effects to your heart and lungs without you noticing. That might mean talking to your GP about an asthma plan and working together on inhaler technique today.’
By showing patients I am available anytime, I keep the door open, even if they aren’t ready to change immediately. Through this process, I was able to review and improve Mr B’s inhaler technique. Once he gained confidence using a spacer and making small adjustments, his reliance on salbutamol reduced.
Over time, he engaged more with his GP, which led to spirometry and a step-up in therapy with a preventer. Each small success built trust and transformed his asthma management from sub-optimal to stable, effective therapy.
The key lesson is that inhaler technique checks and supportive communication can significantly improve asthma outcomes. Many patients don’t realise how much salbutamol they are using or the risks of long-term reliance.
By engaging with open questions, demonstrating devices, and linking patients back to their GP, pharmacists can guide safer, more effective asthma care while building enduring patient trust.
Case 2
![]()
Joanna Luong MPS Community Pharmacist PSA Trainer and Assessor Brisbane, QLD
Poorly managed asthma in the pharmacy is a common presentation. One standout case involved a man requesting over-the-counter salbutamol for his 20-year-old son. When I checked the dispense history, I saw salbutamol had been supplied monthly, always as a Pharmacist Only medicine, with no preventer prescribed and no record of any past clinical interventions.
Frequent reliever use can indicate uncontrolled asthma and may implicate poor inhaler technique. Patient education and collaborative care with a doctor was evidently warranted, to support the quality use of medicines and optimise management.
The man waited impatiently. I was careful my tone didn’t suggest misuse or poor self-management ability by his son. In a friendly, conversational manner, I said: ‘I’ve had many people coming in lately with asthma flare-ups due to the recent weather change. Has your son found that certain triggers worsen his symptoms? I can see he’s had Ventolin dispensed several times over the last couple of months.’
The question was closed, but the context prompted an elaboration of the response, which was that his son ‘usually just uses his inhaler a couple of times a week and that keeps everything under control’.
While acknowledging their satisfaction with their current level of control, I emphasised that, commonly, asthma management can be optimised even in people who consider their asthma well-controlled, and that along with proper inhaler technique, quality of life could be much improved including fewer episodes of wheeziness disrupting their daily activities.
‘Would your son have time at some point to come in for a quick chat so we can check his technique and discuss the updated Australian guidelines for asthma management?’ I asked.
As expected, there was some resistance. I gently reminded the father that guidelines evolve with research, and advice received several years ago may no longer be current, which is why regular medical reviews are recommended, and that my role was to help guide patients in making informed decisions about their health care.
Even though the conversation did not lead to change that day, keeping the conversation supportive and respectful meant he left the pharmacy open to future discussions.
I documented the intervention in the son’s dispense record so my colleagues and I could continue the conversation on subsequent visits. This ongoing engagement helped build rapport, and the father eventually persuaded his son to see his doctor, who prescribed a preventer inhaler now used regularly.
How we communicate can be just as important as what we say.
[post_title] => How pharmacists can combat poor asthma control [post_excerpt] => How pharmacists can flag SABA-only asthma patients, guide them to new therapies for optimal management, and correct inhaler technique. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => combatting-poor-asthma-control [to_ping] => [pinged] => [post_modified] => 2025-10-08 11:58:34 [post_modified_gmt] => 2025-10-08 00:58:34 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=30612 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => How pharmacists can combat poor asthma control [title] => How pharmacists can combat poor asthma control [href] => https://www.australianpharmacist.com.au/combatting-poor-asthma-control/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 30620 [authorType] => )
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30604 [post_author] => 3410 [post_date] => 2025-10-01 09:56:20 [post_date_gmt] => 2025-09-30 23:56:20 [post_content] => Last year, it was reported that Australian poisons hotlines received almost 1,500 calls about child ingestion of melatonin. In Western Australia, calls to the poisons hotline about melatonin have nearly doubled from 175 in 2018 to 322 as of August this year, across all age groups – mostly related to gummy products. In the same month, online health retailer iHerb suspended the sale of melatonin supplements in Australia. But there are retailers selling these products online, said Sarah Blunden, Professor and Head of Paediatric Sleep Research, CQUniversity Australia. [caption id="attachment_30644" align="alignright" width="300"]Professor Sarah Blunden[/caption] ‘There are a lot of other companies from the United States that sell it,’ she said. AP investigates what melatonin toxicity looks like, why so many kids are taking it and how pharmacists can help to ensure safe and effective use of medicines for sleep.
Why have calls to poison hotlines about melatonin gummies doubled?
From Prof Blunden’s perspective, the drivers are straightforward. ‘They are not regulated, they've got sugar in them and they taste good,’ she said. ‘Children love them and parents think they're natural. And without dosage requirements, they might give them one, two or three, and there’s no pharmacist or doctor monitoring the dose.’ Independent analyses of melatonin gummies have shown large discrepancies between labelled and actual melatonin content. ‘Two research groups – one in Canada and one in the UK – found some had no melatonin at all, and some had up to 400% of what was on the label,’ Prof Blunden said.‘without dosage requirements, they might give them one, two or three, and there’s no pharmacist or doctor monitoring the dose.' Professor Sarah BlundenThe Therapeutic Goods Administration (TGA) recently conducted its own review, reporting significant variability between products. For example, The Smurfs Kids Gummies Melatonin 1 mg contained 155–170% variation from the labelled amount. Endogenous melatonin biology is also highly individual, with retinal light-sensing pathways modulating secretion with wide inter-child variability, and there’s no practical clinical assay to map a child’s secretion pattern outside of a research study. ‘A child who’s particularly light-sensitive might have higher endogenous levels at a certain time, and if they then take several gummies, toxicity could be faster and worse,’ she said. ‘That’s why, when they present to ED, it gets labelled as an “overdose,” but we don’t exactly know what that means.’What are the symptoms of melatonin toxicity?
Common reported effects of melatonin toxicity include headache, dizziness, nausea, and drowsiness. Children can also experience central nervous system (CNS) effects, including extreme sedation, nightmares and vivid dreams. ‘Parents might see a very drowsy or unwell child and seek care, or they may witness ingestion of multiple gummies and go to the emergency department (ED),’ Prof Blunden said. Sometimes, toxicity appears fatal. ‘In a review we conducted, two or three deaths of children who had ingested melatonin were reported, but they are not included in many systematic reviews – including ours – because we couldn’t confirm that melatonin was the cause,’ she said. ‘I also found a paper reporting seven infants who died with high levels of exogenous melatonin in the blood, but causation wasn’t established. It’s unknown – and that is really scary.’Why are so many kids taking melatonin?
Sleep is increasingly recognised as a crucial factor in community health, said Prof Blunden. ‘Traditionally the pillars were healthy eating and exercise,’ she said. ‘But in the last 20 years, sleep has edged in as equally important.’ This shift is especially relevant for Australian parents, who have long encouraged children to sleep alone. ‘Because we've always had that expectation, there have always been issues around children who don't want to sleep by themselves,’ Prof Blunden said. Controlled crying was previously the standard response for children resisting independent sleep, but now, behavioural sleep medicine recognises melatonin as another option. ‘The increase in dual-working families, the need for children to sleep independently, the broader community conversation about sleep, and greater availability of melatonin for children who are not typically developing has led to the use of melatonin sharply rising,’ she said. ‘I’m on the board of the International Pediatric Sleep Association. And at the last two conferences, physiologists and clinicians said melatonin prescriptions and use have skyrocketed over the last 5 years,’ Prof Blunden said.Who is melatonin indicated for and at what dose?
In Australia, melatonin is indicated for children aged 2–18 years with neurodevelopmental disorders including:
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30596 [post_author] => 3410 [post_date] => 2025-09-29 10:46:50 [post_date_gmt] => 2025-09-29 00:46:50 [post_content] => New research has indicated that adolescents prefer seeking reproductive health services from pharmacists, but there are barriers to accessing care that must be addressed. Adolescents face unique and at times greater challenges when accessing sexual and reproductive health (SRH) services than adults, including stigma, limited knowledge, out-of-pocket costs and restrictive legislative frameworks, said SPHERE Research Fellow and lead author of the study Dr Anisa Assifi. ‘Community pharmacies offer a promising, accessible alternative, but only if pharmacists are equipped and supported to meet adolescents’ needs,’ she said.What are the benefits of pharmacy for SRH?
The review pulled on 25 years’ worth of published research in high-income countries with similar healthcare settings and approaches to care, including Australia and the United States. Overwhelmingly, adolescents felt they received detailed, high-quality, trustworthy information about contraceptive products from pharmacists. ‘What we found is that adolescents find pharmacy a really accessible and acceptable source of information, and really easy to get into,’ Dr Assifi said. ‘They trusted the pharmacist's knowledge.’ Across Australia, reproductive health is an area pharmacists are increasingly involved in. With scope of practice broadening, pharmacists have been prescribing emergency contraception, resupplying the oral contraceptive pill and dispensing mifepristone/misoprostol (MS-2 Step). At the same time, barriers to general practice access have increased; declines in Medicare bulk billing rates coupled with long wait times to see a GP have made pharmacy a more favourable setting for seeking reproductive care, ‘You might wait 5–10 minutes to talk to a pharmacist, depending on the pharmacy and location,’ she said. Despite efforts to improve sex education in schools, Dr Assifi said students may still be missing the information they need. ‘It’s an amazing opportunity for adolescents to talk to a health professional and get accurate information they may not be getting elsewhere.’What are the barriers to care?
It’s not all roses, with adolescents still frequently experiencing embarrassment and judgement from pharmacists and pharmacy staff when seeking SRH services, alongside stigma related to being sexually active, Dr Assifi said. ‘Many went in expecting to be judged, so it was both their experience and perception that contributed to them feeling judgement.’ Adolescents also questioned whether pharmacists would maintain confidentiality, and were concerned that the layout of large, high-volume pharmacies could make private conversations at the counter difficult. ‘What did come out was that the difference between pharmacy and family planning or GP clinics is that you're in a consultation room, so confidentiality is more maintained,’ she said. ‘False barriers’ were also identified. ‘Sometimes pharmacists were not up to date with guidelines or regulations (e.g. age of access, parental consent, prescription requirements) or they created unnecessary hurdles – saying they didn’t stock a product, or that parental consent was required,’ Dr Assifi said. ‘So even though they were trusted, there were still some issues that would come up where they would block that access.’ When pharmacists were empathetic and non-judgmental, including adjusting their body language and lowering their tone of voice, this made a significant difference to patient experience. ‘Some pharmacists were very good at this and recognised the importance of not being judgmental or making assumptions when interacting with adolescents, recognising that they need to be treated with respect and empathy,’ she said.What’s pharmacists' perspective?
Most pharmacists found it acceptable to provide contraception to adolescents, including emergency contraception, and felt comfortable counselling this age cohort. However, their acceptability of providing emergency contraception declined as adolescents’ age decreased. ‘Pharmacists felt more comfortable interacting with older adolescents and were looking for further training and support about how to provide appropriate care to an adolescent that meets their needs, including how to interact with them through those discussions and encounters.’ Dr Assifi said more research was required to understand the training and support mechanisms that would better enable pharmacists to provide adolescent-friendly care. ‘Pharmacists, along with any other health professionals, have their own personal belief systems, and we did find in quite a few studies that this made them unwilling or unhelpful to provide care,’ she said. ‘So we need to ensure that if one pharmacist is uncomfortable, another is available to provide the service so adolescents receive appropriate information and sexual and reproductive healthcare. ‘I think it's an injustice to the young person if we can't provide them with the appropriate information and support required of an SRH that they've come to you as a health professional seeking.’What needs to be considered?
PSA’s Code of Ethics states that in the instance of conscientious objection, pharmacists must ‘inform the patient when exercising the right to decline provision of certain forms of health care based on the individual pharmacist’s conscientious objection, and in such circumstances, appropriately facilitate continuity of care for the patient’. ‘What’s important is ensuring adolescents don’t feel judged or embarrassed when seeking information or services, and that they still receive the care they need,’ Dr Assifi agreed. ‘Adolescent-friendly care isn't simply about mannerisms and the way a pharmacist interacts and talks with a young person. Pharmacy staff and dispensing technicians also need to be involved in how to have these conversations.’ The pharmacy environment also has a role to play. Consultation rooms should be the standard setting for conversations about contraception to take place. ‘The availability of private consultation rooms is a great step forward, and being able to offer that space to a young person to have those conversations in – whether they choose to take it or not – is really important.’Do not use a paper checklist!!
SPHERE is currently working on further research to identify the impact of the paper form and checklist still used by some pharmacists when supplying emergency contraception. While the checklist has been found to be a barrier to access, this is likely even more pronounced in adolescents. ‘We don't want young people to feel like their personal information is being taken and they don’t know what's being done with it,’ Dr Assifi said. ‘Alternative ways where a young person can signal or provide that information so it doesn't feel as jarring as saying it across the dispensing counter should be considered.’ PSA’s Non-prescription medicine treatment guideline: Emergency Contraception, found in the Australian Pharmaceutical Formulary and Handbook or PSA Resource Hub, advises pharmacists to ‘Gather patient information in a confidential, respectful and non-judgemental manner. Do not use a written checklist or form because the patient (or third party) can perceive it as a barrier to care’. [post_title] => Stigma hinders adolescent contraceptive care [post_excerpt] => Adolescents prefer seeking contraceptive care from pharmacists, says new research. But there are barriers to access that must be addressed. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => stigma-hinders-adolescent-contraceptive-care [to_ping] => [pinged] => [post_modified] => 2025-09-30 15:36:53 [post_modified_gmt] => 2025-09-30 05:36:53 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=30596 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Stigma hinders adolescent contraceptive care [title] => Stigma hinders adolescent contraceptive care [href] => https://www.australianpharmacist.com.au/stigma-hinders-adolescent-contraceptive-care/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 30598 [authorType] => )
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30588 [post_author] => 250 [post_date] => 2025-09-26 12:32:10 [post_date_gmt] => 2025-09-26 02:32:10 [post_content] =>When standard needles for vaccination shortchange patient immunity.
Vaccines are most effective when administered using correct technique – this includes injection site positioning, angle of the needle and needle length.
Most vaccines currently available are administered as intramuscular (IM) injections. With the breadth and depth of pharmacist-administered vaccination growing, it’s timely that pharmacists double check their depth.
What needle size should I use for IM injections?
A 25 mm needle is recommended for most people, including from infants to older adults.
There are two exceptions:
For very large or obese people, a longer needle of 38 mm length is recommended.1 With 32% of the Australian population being obese,2 around a third of vaccines likely should be administered using longer needles.
If a needle isn’t long enough, or used at an incorrect angle, the needle may not fully penetrate the deltoid fat pad and therefore be inadvertently administered subcutaneously.
For most vaccines, this risks a higher rate of local adverse events, such as redness, swelling, itching and pain.1,3 This is particularly noted with aluminium-adjuvanted vaccines (such as hepatitis B, dTpa or dT vaccines).2
Concerningly, it is also recognised as reducing immunogenicity.2 For example, Rabipur Inactivated Rabies Virus Vaccine (PCECV) is considered invalid if given subcutaneously.2
It’s hard to tell. There is limited contemporary data – and no Australian data was identified when researching this article.
However, overseas studies suggest 38 mm needles are drastically underutilised4 – with one US study suggesting the wrong length needle was used 75% of the time when administering vaccines to obese people.5
Consult the Australian Immunisation Handbook.1 The ‘Vaccine injection techniques’ section contains advice on inadvertent subcutaneous injection of intramuscular vaccines.
Error reporting to indemnity insurers and state/territory health department systems may also be required.
In the example of the Rabipur rabies vaccine, as a subcutaneous dose is invalid, the dose must be repeated – an undesirable situation given the cost and time-critical regimen for rabies vaccines.
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30630 [post_author] => 3410 [post_date] => 2025-10-03 14:40:26 [post_date_gmt] => 2025-10-03 04:40:26 [post_content] => Last year, the Therapeutic Goods Administration (TGA) made an interim decision to reschedule this formulation of dihydrocodeine (Rikodeine) to a prescription medicine. Why hasn’t it happened yet? On 26 July 2024, the interim decision on dihydrocodeine was published, which was made in response to concerns about the potential for misuse, abuse, and dependence associated with the opioid derivative. The TGA Delegate's interim decision was to amend the Pharmacist Only entry for dihydrocodeine to restrict undivided oral liquid preparations to a maximum primary pack size of 100 mL from 1 October 2025. So, what happened?What were the reasons for the interim decision?
The interim decision to amend the Schedule 3 entry for dihydrocodeine was made to balance the potential risks of dihydrocodeine, including respiratory depression, addiction potential and severe adverse effects, against the need for timely patient access to dry cough medicines. The amendment would also align Australia’s regulations more closely with other jurisdictions such as the United States, Canada, and Europe.Where is the final decision?
Australian Pharmacist understands that the final decision on the scheduling of dihydrocodeine is yet to be published, despite the implementation date flagged in the interim decision having come and gone last week.
It is highly unusual for an interim decision not to have been followed by a final decision within the usual decision-making timeframe – and to see the proposed implementation date pass without any formal notice.
What’s the reason behind the hold up?
In August 2024, the TGA sought public submissions on the interim decision on dihydrocodeine. It was reported in September 2024 that, of the 7 submissions received, two were in partial support while five were in opposition of the interim decision. The TGA noted that final decisions on dihydrocodeine had been deferred while the submissions received from the consultation were further considered.What should pharmacists do in the meantime?
For now, the scheduling of dihydrocodeine remains unchanged. PSA has reached out to the TGA for confirmation on the final scheduling decision. Pharmacists report they continue to experience frequent queries for dihydrocodeine from patients, many of whom don’t appear to have symptoms of dry cough. If diversion, misuse or abuse is suspected, pharmacists should ask the patient further questions to establish the patient’s:
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30612 [post_author] => 11351 [post_date] => 2025-10-02 10:50:09 [post_date_gmt] => 2025-10-02 00:50:09 [post_content] =>Advice around flagging SABA-only asthma patients, guiding them to new therapies for optimal management, and correcting inhaler technique.
Ever had those red flags when a patient is having multiple short-acting beta2-agonist (SABA) inhalers dispensed within a short timeframe? Or they’re taking salbutamol alone on multiple days of the week? And what about older patients who were told it was okay to use salbutamol frequently – and now it’s not?
How can pharmacists help these patients gain control over their disease? Or prevent them reaching the 1 g lifetime limit of oral corticosteroid use?
Pharmacist and asthma educator Sherri Barden MPS – who runs her own asthma, hay fever, eczema and chronic obstructive pulmonary disease, APLUS Pharmacy Education business – has heard it all. Routine inquiries about symptom frequency, reliever use and adherence during each pharmacy encounter is a good method, she says, of recognising if suboptimal control is worthy of timely intervention or referral.
Long-term solo SABA users
Patients who ‘just want the blue puffer’ may be the subject of a difficult conversation, according to Ms Barden. ‘Community pharmacists can reframe the conversation by encouraging their staff to firstly explain to the patient that salbutamol or terbutaline are a Pharmacist Only medicine and that the pharmacist will be with them shortly to discuss.’
She encourages pharmacists to use ‘a patient-centred, non-judgemental approach that links the discussion to the person’s goals and wellbeing’. Opening lines for long-term SABA users such as ‘Is this for asthma?’ and ‘I see you’re here for your reliever. Can I check how your asthma has been going lately?’ are recommended.
Another approach could start as: ‘There are some important updates to asthma care in adults and adolescents that could help you breathe easier and prevent flare-ups.’
Using brief symptom assessment tools such as the Asthma Control Test (ACT) and offering a collaborative plan can help make the conversation supportive rather than confrontational, Ms Barden suggests.
Importantly, patients should be advised that SABAs will continue to be available over the counter from pharmacists, but that the newer recommendations require a prescription. MedsChecks or Home Medicines Reviews can also provide opportunities to assess or reassess control, look at triggers or comorbidities contributing to poor control, review adherence and technique, and perform the ACT to track progress over time.
Up to 80% of people with asthma also have allergic rhinitis, Ms Barden points out. So it’s essential to assess or ask people about the upper airway.
If rhinitis ‘is not adequately controlled with the right information and quality use of medicines, it may contribute to poor asthma control’.
Ms Barden recommends the teach-back method for correct inhaler technique using either a placebo device or, better still, suggest the patient have a dose of their medicine with the pharmacist watching, who could then build follow-up and monitoring into routine practice.
National Asthma Council instructional videos for home use and ancillary labels –“Quick and Deep” for dry powder inhalers and “Slow and Steady” for metered dose or soft mist inhalers – reinforce the correct breathing method, Ms Barden says. They also act as ongoing prompts and conversation starters regarding technique.
Clear criteria for escalation, she stresses, should trigger a timely referral to a GP, nurse practitioner or respiratory specialist. In this way, patient progress can be measured, trends identified early, and care escalated if needed.
AP spoke to two pharmacists about interventions with patients with sub-optimal asthma control.
Case 1
David Peachey MPS Partner/Pharmacist Hatton & Laws Pharmacy and Priceline Pharmacy Launceston Plaza, Launceston, TAS
Mr B, a regular patient, repeatedly presented earlier than expected for salbutamol purchased as a Pharmacist Only medicine. There was no evidence of preventer use. He described increasing breathlessness and wheeziness, finding it harder to manage everyday activities like walking up the street. He was relying heavily on his SABA inhaler and had not had a recent GP review. This was a clear red flag that his asthma was not under control. His inhaler technique may also have been a factor, especially if copied from someone using it incorrectly.
Approaching Mr B in a supportive, non-judgemental way, I said: ‘I can see you might be experiencing some worsening of your breathing. I’d like to help you improve this. Let’s have a quick catch up in the consult room.’
I find open-ended questions most effective, particularly when patients are struggling. For example: ‘Would you be able to show me how you use your inhaler?’ or ‘Have you used a spacer before? I can show you what it does and how it works.’ Framing it as a way to improve breathing capacity, rather than criticising technique, makes patients more receptive.
When patients are hesitant, I focus on curiosity and reassurance rather than criticism. I explained to Mr B: ‘There are better and easier treatments available now such as anti-inflammatory relievers and a maintenance preventer and reliever in one device.
‘Using a Ventolin inhaler every week may cause side effects to your heart and lungs without you noticing. That might mean talking to your GP about an asthma plan and working together on inhaler technique today.’
By showing patients I am available anytime, I keep the door open, even if they aren’t ready to change immediately. Through this process, I was able to review and improve Mr B’s inhaler technique. Once he gained confidence using a spacer and making small adjustments, his reliance on salbutamol reduced.
Over time, he engaged more with his GP, which led to spirometry and a step-up in therapy with a preventer. Each small success built trust and transformed his asthma management from sub-optimal to stable, effective therapy.
The key lesson is that inhaler technique checks and supportive communication can significantly improve asthma outcomes. Many patients don’t realise how much salbutamol they are using or the risks of long-term reliance.
By engaging with open questions, demonstrating devices, and linking patients back to their GP, pharmacists can guide safer, more effective asthma care while building enduring patient trust.
Case 2
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Joanna Luong MPS Community Pharmacist PSA Trainer and Assessor Brisbane, QLD
Poorly managed asthma in the pharmacy is a common presentation. One standout case involved a man requesting over-the-counter salbutamol for his 20-year-old son. When I checked the dispense history, I saw salbutamol had been supplied monthly, always as a Pharmacist Only medicine, with no preventer prescribed and no record of any past clinical interventions.
Frequent reliever use can indicate uncontrolled asthma and may implicate poor inhaler technique. Patient education and collaborative care with a doctor was evidently warranted, to support the quality use of medicines and optimise management.
The man waited impatiently. I was careful my tone didn’t suggest misuse or poor self-management ability by his son. In a friendly, conversational manner, I said: ‘I’ve had many people coming in lately with asthma flare-ups due to the recent weather change. Has your son found that certain triggers worsen his symptoms? I can see he’s had Ventolin dispensed several times over the last couple of months.’
The question was closed, but the context prompted an elaboration of the response, which was that his son ‘usually just uses his inhaler a couple of times a week and that keeps everything under control’.
While acknowledging their satisfaction with their current level of control, I emphasised that, commonly, asthma management can be optimised even in people who consider their asthma well-controlled, and that along with proper inhaler technique, quality of life could be much improved including fewer episodes of wheeziness disrupting their daily activities.
‘Would your son have time at some point to come in for a quick chat so we can check his technique and discuss the updated Australian guidelines for asthma management?’ I asked.
As expected, there was some resistance. I gently reminded the father that guidelines evolve with research, and advice received several years ago may no longer be current, which is why regular medical reviews are recommended, and that my role was to help guide patients in making informed decisions about their health care.
Even though the conversation did not lead to change that day, keeping the conversation supportive and respectful meant he left the pharmacy open to future discussions.
I documented the intervention in the son’s dispense record so my colleagues and I could continue the conversation on subsequent visits. This ongoing engagement helped build rapport, and the father eventually persuaded his son to see his doctor, who prescribed a preventer inhaler now used regularly.
How we communicate can be just as important as what we say.
[post_title] => How pharmacists can combat poor asthma control [post_excerpt] => How pharmacists can flag SABA-only asthma patients, guide them to new therapies for optimal management, and correct inhaler technique. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => combatting-poor-asthma-control [to_ping] => [pinged] => [post_modified] => 2025-10-08 11:58:34 [post_modified_gmt] => 2025-10-08 00:58:34 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=30612 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => How pharmacists can combat poor asthma control [title] => How pharmacists can combat poor asthma control [href] => https://www.australianpharmacist.com.au/combatting-poor-asthma-control/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 30620 [authorType] => )
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30604 [post_author] => 3410 [post_date] => 2025-10-01 09:56:20 [post_date_gmt] => 2025-09-30 23:56:20 [post_content] => Last year, it was reported that Australian poisons hotlines received almost 1,500 calls about child ingestion of melatonin. In Western Australia, calls to the poisons hotline about melatonin have nearly doubled from 175 in 2018 to 322 as of August this year, across all age groups – mostly related to gummy products. In the same month, online health retailer iHerb suspended the sale of melatonin supplements in Australia. But there are retailers selling these products online, said Sarah Blunden, Professor and Head of Paediatric Sleep Research, CQUniversity Australia. [caption id="attachment_30644" align="alignright" width="300"]Professor Sarah Blunden[/caption] ‘There are a lot of other companies from the United States that sell it,’ she said. AP investigates what melatonin toxicity looks like, why so many kids are taking it and how pharmacists can help to ensure safe and effective use of medicines for sleep.
Why have calls to poison hotlines about melatonin gummies doubled?
From Prof Blunden’s perspective, the drivers are straightforward. ‘They are not regulated, they've got sugar in them and they taste good,’ she said. ‘Children love them and parents think they're natural. And without dosage requirements, they might give them one, two or three, and there’s no pharmacist or doctor monitoring the dose.’ Independent analyses of melatonin gummies have shown large discrepancies between labelled and actual melatonin content. ‘Two research groups – one in Canada and one in the UK – found some had no melatonin at all, and some had up to 400% of what was on the label,’ Prof Blunden said.‘without dosage requirements, they might give them one, two or three, and there’s no pharmacist or doctor monitoring the dose.' Professor Sarah BlundenThe Therapeutic Goods Administration (TGA) recently conducted its own review, reporting significant variability between products. For example, The Smurfs Kids Gummies Melatonin 1 mg contained 155–170% variation from the labelled amount. Endogenous melatonin biology is also highly individual, with retinal light-sensing pathways modulating secretion with wide inter-child variability, and there’s no practical clinical assay to map a child’s secretion pattern outside of a research study. ‘A child who’s particularly light-sensitive might have higher endogenous levels at a certain time, and if they then take several gummies, toxicity could be faster and worse,’ she said. ‘That’s why, when they present to ED, it gets labelled as an “overdose,” but we don’t exactly know what that means.’What are the symptoms of melatonin toxicity?
Common reported effects of melatonin toxicity include headache, dizziness, nausea, and drowsiness. Children can also experience central nervous system (CNS) effects, including extreme sedation, nightmares and vivid dreams. ‘Parents might see a very drowsy or unwell child and seek care, or they may witness ingestion of multiple gummies and go to the emergency department (ED),’ Prof Blunden said. Sometimes, toxicity appears fatal. ‘In a review we conducted, two or three deaths of children who had ingested melatonin were reported, but they are not included in many systematic reviews – including ours – because we couldn’t confirm that melatonin was the cause,’ she said. ‘I also found a paper reporting seven infants who died with high levels of exogenous melatonin in the blood, but causation wasn’t established. It’s unknown – and that is really scary.’Why are so many kids taking melatonin?
Sleep is increasingly recognised as a crucial factor in community health, said Prof Blunden. ‘Traditionally the pillars were healthy eating and exercise,’ she said. ‘But in the last 20 years, sleep has edged in as equally important.’ This shift is especially relevant for Australian parents, who have long encouraged children to sleep alone. ‘Because we've always had that expectation, there have always been issues around children who don't want to sleep by themselves,’ Prof Blunden said. Controlled crying was previously the standard response for children resisting independent sleep, but now, behavioural sleep medicine recognises melatonin as another option. ‘The increase in dual-working families, the need for children to sleep independently, the broader community conversation about sleep, and greater availability of melatonin for children who are not typically developing has led to the use of melatonin sharply rising,’ she said. ‘I’m on the board of the International Pediatric Sleep Association. And at the last two conferences, physiologists and clinicians said melatonin prescriptions and use have skyrocketed over the last 5 years,’ Prof Blunden said.Who is melatonin indicated for and at what dose?
In Australia, melatonin is indicated for children aged 2–18 years with neurodevelopmental disorders including:
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30596 [post_author] => 3410 [post_date] => 2025-09-29 10:46:50 [post_date_gmt] => 2025-09-29 00:46:50 [post_content] => New research has indicated that adolescents prefer seeking reproductive health services from pharmacists, but there are barriers to accessing care that must be addressed. Adolescents face unique and at times greater challenges when accessing sexual and reproductive health (SRH) services than adults, including stigma, limited knowledge, out-of-pocket costs and restrictive legislative frameworks, said SPHERE Research Fellow and lead author of the study Dr Anisa Assifi. ‘Community pharmacies offer a promising, accessible alternative, but only if pharmacists are equipped and supported to meet adolescents’ needs,’ she said.What are the benefits of pharmacy for SRH?
The review pulled on 25 years’ worth of published research in high-income countries with similar healthcare settings and approaches to care, including Australia and the United States. Overwhelmingly, adolescents felt they received detailed, high-quality, trustworthy information about contraceptive products from pharmacists. ‘What we found is that adolescents find pharmacy a really accessible and acceptable source of information, and really easy to get into,’ Dr Assifi said. ‘They trusted the pharmacist's knowledge.’ Across Australia, reproductive health is an area pharmacists are increasingly involved in. With scope of practice broadening, pharmacists have been prescribing emergency contraception, resupplying the oral contraceptive pill and dispensing mifepristone/misoprostol (MS-2 Step). At the same time, barriers to general practice access have increased; declines in Medicare bulk billing rates coupled with long wait times to see a GP have made pharmacy a more favourable setting for seeking reproductive care, ‘You might wait 5–10 minutes to talk to a pharmacist, depending on the pharmacy and location,’ she said. Despite efforts to improve sex education in schools, Dr Assifi said students may still be missing the information they need. ‘It’s an amazing opportunity for adolescents to talk to a health professional and get accurate information they may not be getting elsewhere.’What are the barriers to care?
It’s not all roses, with adolescents still frequently experiencing embarrassment and judgement from pharmacists and pharmacy staff when seeking SRH services, alongside stigma related to being sexually active, Dr Assifi said. ‘Many went in expecting to be judged, so it was both their experience and perception that contributed to them feeling judgement.’ Adolescents also questioned whether pharmacists would maintain confidentiality, and were concerned that the layout of large, high-volume pharmacies could make private conversations at the counter difficult. ‘What did come out was that the difference between pharmacy and family planning or GP clinics is that you're in a consultation room, so confidentiality is more maintained,’ she said. ‘False barriers’ were also identified. ‘Sometimes pharmacists were not up to date with guidelines or regulations (e.g. age of access, parental consent, prescription requirements) or they created unnecessary hurdles – saying they didn’t stock a product, or that parental consent was required,’ Dr Assifi said. ‘So even though they were trusted, there were still some issues that would come up where they would block that access.’ When pharmacists were empathetic and non-judgmental, including adjusting their body language and lowering their tone of voice, this made a significant difference to patient experience. ‘Some pharmacists were very good at this and recognised the importance of not being judgmental or making assumptions when interacting with adolescents, recognising that they need to be treated with respect and empathy,’ she said.What’s pharmacists' perspective?
Most pharmacists found it acceptable to provide contraception to adolescents, including emergency contraception, and felt comfortable counselling this age cohort. However, their acceptability of providing emergency contraception declined as adolescents’ age decreased. ‘Pharmacists felt more comfortable interacting with older adolescents and were looking for further training and support about how to provide appropriate care to an adolescent that meets their needs, including how to interact with them through those discussions and encounters.’ Dr Assifi said more research was required to understand the training and support mechanisms that would better enable pharmacists to provide adolescent-friendly care. ‘Pharmacists, along with any other health professionals, have their own personal belief systems, and we did find in quite a few studies that this made them unwilling or unhelpful to provide care,’ she said. ‘So we need to ensure that if one pharmacist is uncomfortable, another is available to provide the service so adolescents receive appropriate information and sexual and reproductive healthcare. ‘I think it's an injustice to the young person if we can't provide them with the appropriate information and support required of an SRH that they've come to you as a health professional seeking.’What needs to be considered?
PSA’s Code of Ethics states that in the instance of conscientious objection, pharmacists must ‘inform the patient when exercising the right to decline provision of certain forms of health care based on the individual pharmacist’s conscientious objection, and in such circumstances, appropriately facilitate continuity of care for the patient’. ‘What’s important is ensuring adolescents don’t feel judged or embarrassed when seeking information or services, and that they still receive the care they need,’ Dr Assifi agreed. ‘Adolescent-friendly care isn't simply about mannerisms and the way a pharmacist interacts and talks with a young person. Pharmacy staff and dispensing technicians also need to be involved in how to have these conversations.’ The pharmacy environment also has a role to play. Consultation rooms should be the standard setting for conversations about contraception to take place. ‘The availability of private consultation rooms is a great step forward, and being able to offer that space to a young person to have those conversations in – whether they choose to take it or not – is really important.’Do not use a paper checklist!!
SPHERE is currently working on further research to identify the impact of the paper form and checklist still used by some pharmacists when supplying emergency contraception. While the checklist has been found to be a barrier to access, this is likely even more pronounced in adolescents. ‘We don't want young people to feel like their personal information is being taken and they don’t know what's being done with it,’ Dr Assifi said. ‘Alternative ways where a young person can signal or provide that information so it doesn't feel as jarring as saying it across the dispensing counter should be considered.’ PSA’s Non-prescription medicine treatment guideline: Emergency Contraception, found in the Australian Pharmaceutical Formulary and Handbook or PSA Resource Hub, advises pharmacists to ‘Gather patient information in a confidential, respectful and non-judgemental manner. Do not use a written checklist or form because the patient (or third party) can perceive it as a barrier to care’. [post_title] => Stigma hinders adolescent contraceptive care [post_excerpt] => Adolescents prefer seeking contraceptive care from pharmacists, says new research. But there are barriers to access that must be addressed. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => stigma-hinders-adolescent-contraceptive-care [to_ping] => [pinged] => [post_modified] => 2025-09-30 15:36:53 [post_modified_gmt] => 2025-09-30 05:36:53 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=30596 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Stigma hinders adolescent contraceptive care [title] => Stigma hinders adolescent contraceptive care [href] => https://www.australianpharmacist.com.au/stigma-hinders-adolescent-contraceptive-care/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( ) [is_review:protected] => [post_thumb_id:protected] => 30598 [authorType] => )
td_module_mega_menu Object ( [post] => WP_Post Object ( [ID] => 30588 [post_author] => 250 [post_date] => 2025-09-26 12:32:10 [post_date_gmt] => 2025-09-26 02:32:10 [post_content] =>When standard needles for vaccination shortchange patient immunity.
Vaccines are most effective when administered using correct technique – this includes injection site positioning, angle of the needle and needle length.
Most vaccines currently available are administered as intramuscular (IM) injections. With the breadth and depth of pharmacist-administered vaccination growing, it’s timely that pharmacists double check their depth.
What needle size should I use for IM injections?
A 25 mm needle is recommended for most people, including from infants to older adults.
There are two exceptions:
For very large or obese people, a longer needle of 38 mm length is recommended.1 With 32% of the Australian population being obese,2 around a third of vaccines likely should be administered using longer needles.
If a needle isn’t long enough, or used at an incorrect angle, the needle may not fully penetrate the deltoid fat pad and therefore be inadvertently administered subcutaneously.
For most vaccines, this risks a higher rate of local adverse events, such as redness, swelling, itching and pain.1,3 This is particularly noted with aluminium-adjuvanted vaccines (such as hepatitis B, dTpa or dT vaccines).2
Concerningly, it is also recognised as reducing immunogenicity.2 For example, Rabipur Inactivated Rabies Virus Vaccine (PCECV) is considered invalid if given subcutaneously.2
It’s hard to tell. There is limited contemporary data – and no Australian data was identified when researching this article.
However, overseas studies suggest 38 mm needles are drastically underutilised4 – with one US study suggesting the wrong length needle was used 75% of the time when administering vaccines to obese people.5
Consult the Australian Immunisation Handbook.1 The ‘Vaccine injection techniques’ section contains advice on inadvertent subcutaneous injection of intramuscular vaccines.
Error reporting to indemnity insurers and state/territory health department systems may also be required.
In the example of the Rabipur rabies vaccine, as a subcutaneous dose is invalid, the dose must be repeated – an undesirable situation given the cost and time-critical regimen for rabies vaccines.
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.