s Prescription Opioid Abuse - an Epidemic in the US | I2P: Information to Pharmacists - Archive
Publication Date 01/09/2009         Volume. 1 No. 4   
Information to Pharmacists


From the desk of the editor

Welcome to the September 2009 issue of i2P E-Magazine - Information to Pharmacists.
In this edition I would point you to the Pharmedia link where trends in US pharmacy consumers are noted and matched to the Australian counterpart.
There is a strong similarity between the two countries.
In this commentary a direction and a strategy is suggested.
Please feel free to add your comment in the panel provided at the foot of this commentary, as it is a very important issue for Australian pharmacists.

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Another Step Back?

Neil Johnston

Anyone who has followed the story of convenience clinics in the US would have come to a simple conclusion very early in their investigations.

That conclusion would have been that with a few exceptions, the market being serviced in primary care was identical to that serviced by Australian pharmacists.

What was commonly known as “counter prescribing” in Australia became known as the “Minute Clinic” or Rediclinic in the US.

Now we have a development here in Australia where nurse-led clinics are being hosted by pharmacies, with the initial players being the Revive Clinic and the Pharmacy Alliance Group, consisting of 186 franchisees, all based in Perth, Western Australia.

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Pharmacies to write prescriptions? Yet another conflict?

Neil Retallick

The divide between who writes prescriptions in Australia and who dispenses them has traditionally been seen as an important construct in minimising any conflict of interest.
Will the evolution of nurse practitioners working in pharmacies mean that this protection mechanism for the average Australian (and their taxes) is dissolved?

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Location rules, regulation rules and money rules

Chris Wright

The National Competition Policy Review of Pharmacy has surely failed to protect the industry from itself.
The objectives of the restrictions include; “ Keeping pharmacy business small enough to facilitate the close personal supervision of their professional operation by the proprietor pharmacists.”
Oh, yeah, just how does that work?
And… “Protecting pharmacy businesses from perceived “unfair competition” and market dominance from large pharmacy-owning corporations and chains and, in some jurisdictions, Friendly Societies”.

Come on, let’s be serious!

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Advancing to garbage at the speed of light

Pat Gallagher

I am going to preach to you dear reader.
So what is new with that you will say?
Plenty, because I truly do believe in this creed, which is the belief that without rigorous control of core data integrity the whole e-health plot is flawed.
This boring subject has been raised in these pages several times and there is no doubt the message has sort of got through, but ‘sort of’ is way, way too far from being acceptable. You see this mishmash problem in the pharmacy daily as you use different PDE numbers for the same product when you buy from more than one wholesaler.
You cope with different proprietary product identification and then use the GS1 barcode, on the product pack, to close the sale at the POS (you do, you do use that barcode don’t you!).
All of this means you have to use the wetware technology tool to interpret and map information from one system to another; and the minute you introduce wetware you introduce errors.

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Pharmacy women’s Congress 2009 - Opportunities for learning

Karalyn Huxhagen

All of us have that neat stack of literature either beside our bed, under the desk or overflowing off the kitchen bench. If you are like me some are half read, bookmarked for later more in depth reads or stripped of relevant articles for pharmacy assistant training modules.
I also have a system with my emails and RSS feeds that categorises them to the ‘to be read when I have time file’. On a morning not so long back when I could lay in bed and clear this email in tray I completed a competition on the Pharmacy Daily website for the Pharmacy women’s Congress 2009. To my ultimate surprise I won!!

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The finish line of the Pharmacy Melbourne Cup is in sight…who will be the winners?

Garry Boyd

Comment about the future of pharmacy has been a daily occurrence for seemingly as long as Cook plotted a course up the eastern seaboard.
He hit the rocks, as will many of the so-called “players” attempting to seek proprietorship over parts of the pharmacy puzzle will.
Whether it be fact or Chinese whispers, a number of “core”(sorry Kev) “assets” have the attention of many.

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Paracetamol Problems in New Zealand

Staff Writer

Paracetamol overdosing is emerging as a problem in New Zealand similar to other western economies around the world.
In Australia we have seen some of larger chain pharmacies encouraging the sale of high volumes of paracetamol by deep discount, 
Despite protests from a range of pharmacists, little has been done to prevent the spread of irresponsible paracetamol sales.
Pharmacy Boards state they need an official complaint backed up with evidence of adverse events resulting from inappropriate selling.
Liver damage is one adverse event, sometimes requiring a liver transplant to rectify the damage.
There is no easy solution for paracetamol is such a useful drug.
However, there is a strong argument for confining all paracetamol sales to pharmacies irrespective of the potential inconvenience.
In fact, if the general principle applied that all medicines should be sold from a pharmacy, the need to sell other types of merchandise would dissipate.
It's worth a thought 

People overdosing on paracetamol

Source Otago Times

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Health IT Needs More Money - What's New About That?

Staff Writer

The consistent mismatch of approaches to Health IT continue to occur, even with the best efforts of Minister for Health and Ageing (Nicola Roxon) trying to uncover the best way forward.
Costs, both in the government and private sectors, have continually expanded to now stellar $ numbers.
Nicola Roxon's focus on the patient and building out from that point, will see her win the day.
Vendors (such as the Pharmacy Guild) who are canny enough to mould their systems to her view of the world, may eventually get a "nod" of some sort, provided the systems developed genuinely provide a scale of economy, saving development costs as well as delivering the specified benefits to health generally.
Commitment has been made to a National Broadband Network (NBN) and a 16-digit patient identifier so movement to shared health records is nearly possible, with the AMA making some "noises" towards a form of electronic health record (but not a full record).

Source: Australian IT


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UK Opposed to Direct to Consumer Advertising

Staff Writer

Proposals that would allow the pharmaceutical industry to provide drug information directly to consumers has been opposed by the Royal Pharmaceutical Society.
This against a EU background to develop an informational infrastructure that could be delivered to all of the European community.
A conflict of interest clearly exists between the public's interest to receive accurate and objective information and the pharmaceutical industry's objective of building revenue and market share. 

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NZ Considers Project Stop

Staff Writer

The New Zealand Pharmacy Guild has commented on the efficiency of Project Stop in Australia and wants to introduce it to NZ pharmacists.
They would also like to extend its use for other medication tracking.
NZ interest may further stimulate a faster uptake of the system in Australia, and by comparing notes in developing the use of the software, governments may be encouraged to fund a range of extensions.

Pharmacies Fight to Stop P-Runners
Source: Stuff.co.nz

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Health Insurers to feel the cold winds of change

Staff Writer

At last there is a move to sort out the high costs and inefficiencies inherent in Australia's private health insurance system.
Not that the private funds are totally to blame.
Government policies built around the Medicare levy (an extra tax, unless you take out private insurance), the limited range of benefits payable by private funds (because of government controls) has led to a high level of dissatisfaction by people privately insured.
It appears that an entity titled Medicare Select, may be utilised to negotiate and "bulk buy" health services, including those of the state-owned hospitals.
Private health funds, including Medibank Private, would be involved in managing the services on behalf of their members.
This new system has a real potential to reduce major health costs.

Medibank backs system shake-up

Mark Metherell
Source: BrisbaneTimes.com.au

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QUMAX –where to from here?

Karalyn Huxhagen

In April 2010 the current program for QUMAX (Quality use of medicine in aboriginal community controlled centres) will come to an end.
This was a pilot program and work is being done to look at where to from here?
Like all pilots the program took some time to achieve its goals but achieve them it did.
The evaluation process has been ongoing and the feedback from pharmacists and patients has been excellent.

Comments: 1

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UK Media Shutdown on Complementary and Alternate Medicine Information

Staff Writer

Will the issues revolving around complementary and alternate medicine (CAM) use ever be resolved?
Outcries from some respected science authorities deride all CAM as "witchcraft", yet most pharmacists would know of at least one good outcome from CAM.
For example, recent research into Traditional Chinese Medicine has uncovered the fact that some herbal remedies for the treatment of heart conditions, help to restore the nitrous oxide (NO) balance in the body, in part by converting nitrites and nitrates absorbed from foods, to beneficial NO (allowing proper dilation of blood vessels, subsequent reduction in blood pressure and gradual depletion of arterial plaque).
This information is now evidence-based, but will you see it appearing in mainstream medical publications?
It is my belief that while many critics of CAM definitely have a valid case for some complaint (particularly when patients are financially exploited), there are many "experts" that have been blind to information that could prove useful (and cheaper) for their patients, simply because they were unaware of the evidence available.
It is simply hidden from view under the sheer volume of total information that is being published and disseminated to health profesionals.
In February 2008 the respected BBC came under fire for providing information on CAM's and withdrew this popular service. I was unaware of this happening and have provided one of the media stories reporting the incident, for others who may have been unaware.
The BBC is a public broadcaster (like Australia's ABC) and serves the interests of the general population free from commercial pressure.
As 41% of people in the UK use CAM the decision to close down the service was certainly a controversial one.
A recent visit to the BBC site demonstrated some CAM news stories, mostly geared towards the potential problems that may be associated with its use.
This is a shame because the BBC are well placed to research evidence surrounding CAM's and provide a much needed and unbiased site for solid information.

Source: NaturalNews.com


The BBC Abandons Its Complementary Medicine Website Due to Pressure

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Software Licences Trigger Software Investment Review

Staff Writer

Many firms that licence key software programs are tightening up licencing conditions such as who is entitled to received free licences and what scale of charges apply.
Clients are reluctant to pay fee increases for basically the same software each year, but charitable and aged care organisations will be hit hard for licences that formerly were available to them free of charge.
Obviously there will be some hard negotiating coupled with a review of the actual software required.
One alternative may be to replace Microsoft with the Sun Open Office suite of programs that virtually duplicates the entire range of programs contained in Microsoft Office and comes entirely free of any cost. Open Office can also convert to any of the Microsoft formats.
Pharmacists may like to consider the change as well.

Source: Aged Care Guide


Aged Care IT Investment Put on Hold

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Supporting the Carers

Staff Writer

With the Baby Boomer retirement revolution due to start in 2010, one of the key needs will be an army of carers to provide home support needs.
Traditionally, this has fallen to family members, usually female.
And with a considerable number of carers being elderly themselves, there will be a human resource shortfall in this area.
One obvious solution is to elevate this activity to that of a career and the necessity to put training processes in place coupled with appropriate remuneration.
Government has made some moves in this regard, but not nearly enough nor in a timely fashion.
There is an opportunity for pharmacy to provide a support service in the form of "Pharmacy in the Home" services.
Creating the outreach is the difficult part, but pharmacies that do not try and participate will lose market share to those who do provide the service.

Carer at home issues raised by NHHRC reform proposals

Source: Aged Care Guide

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The Importance of Vitamin D3 in Aged Care

Staff Writer

A walk in the sun to generate a reasonable level of vitamin D3 is said to delay the need for a knee replacement.
But this vitamin is also implicated in heart health, cancer prevention, osteoporosis, arthritis and immune modulation, as in multiple sclerosis.
In fact, it is said that vitamin D3 is involved with over 1100 individual genes in an average person.

Even if you get sun exposure, if you utilise sunscreen preparations the conversion reaction in the skin is virtually negated, or if you have a shower 15 minutes after exposure, the vitamin washes away before being absorbed through the skin.
Old skin is also inefficient as a medium for generating and absorbing the vitamin.
While sun exposure is the cheapest and most optimal way of getting a daily dose of vitamin D3, a back up through oral supplementation is also recommended. 

Knee replacements delayed by sun

Source: Aged Care Guide


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Pharmacy in the Home Opportunity emerging

Neil Johnston

The following story published by Drug Topics mirrors a trend that has already commenced in Australia.
A more conservative customer/patient is emerging, in part driven by government attempts to convert branded drugs on the PBS to a cheaper generic version.
Harsher economic conditions have also played a major part.
As we all know, not all customer/patients are convinced of the value involved in changing from long established brands, no matter what arguments are offered.
That means two distinct classes of health consumers are forming up within Australian pharmacies.
Note also that the value-conscious health consumer illustrated in the article is less impulse driven and creates a shopping list before leaving home.
And in the background, high levels of government stimulus spending means that the ability for government to fund existing and future services is at risk, and resources will have to be rationed even more than they are currently.
But this trend opens up a range of opportunities for pharmacists to develop a range of services targeted for customers/patients within their homes.
Mark Coleman discusses a "Pharmacy in the Home" concept further along this article.

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Prescription Opioid Abuse - an Epidemic in the US

Con Berbatis

articles by this author...

Con Berbatis is a pharmacy researcher attached to Curtin University in Western Australia. For i2P, he identifies Australian and global research reports that may be useful for pharmacists to include in their own planning initiatives.

Editor: The US has more prescription opioid-related deaths than deaths due to heroin and cocaine.
Scary stuff in the USA and becoming so here in Australia!
Dr Alex Wodak from St Vincents Hospital chaired a committee of experts who recently wrote a report into prescription opioid policy. He joins Lateline to discuss prescription drug abuse. 
One point made by Dr Wodak was that the rate of opioid prescription abuse in the US had a strong correlation with direct to consumer advertising.
This point should not be lost on Australian regulators.
Some relevant reports written by Con Berbatis are also worth reading.
Go to:
http://archive.i2p.com.au/?page=site/article&id=318 ( Oct 2005) 


http://archive.i2p.com.au/?page=site/article&id=717 (June 2007)

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Prescription opioid expert discusses drug deaths

Australian Broadcasting Corporation

Transcript of Broadcast: 19/08/2009
Reporter: Leigh Sales

LEIGH SALES, PRESENTER: And earlier I was joined by Dr Alex Wodak from St Vincents Hospital.He chaired a committee of experts who recently wrote a report into prescription opioid policy.Dr Wodak, thank you for coming in.


LEIGH SALES: We've heard a lot about the heroin shortage in Australia in recent years. How much is that contributing to the illicit use of oxycodone?

DR ALEX WODAK: Well very significantly. We see both in time and space, we see the interaction of heroin and the use of prescription opioids by injection, so in the Northern Territory and Tasmania which always have the lowest availability of heroin in the country we see the highest rates of injection of prescription opioids. And over time we saw when heroin started becoming scarce after 2000, we saw a big increase in the injection of prescription opioids.

LEIGH SALES: So does it mean that the majority of those heroin users have switched to something else?

DR ALEX WODAK: Well a lot of people these days use a lot of different drugs. The days when people only used heroin are over and over in most countries too. And these days most drug users use heroin and alcohol and prescription opioids and cannabis and stimulant, a whole smorgasbord of drugs.
But the prescription opioids are really causing us a lot of concern in Australia and even more so in the United States.

LEIGH SALES: Tell us a little bit more about that? What is happening in the United States?

DR ALEX WODAK: Well, the prescription opioids were made into a new formulation, a sustained-release formulation which is a much better way of treating chronic pain. And that happened about 20 years ago, and consumption started really increasing very rapidly in the United States, possibly also connected with the marketing practices of the pharmaceutical companies particularly the direct consumer advertising.

And the increase in consumption was unfortunately mirrored since 2000 in the United States by an increasing drug overdose deaths. There are now more deaths from prescription opioids in the United States than there are from heroin or from cocaine.

LEIGH SALES: But that is not the case yet in Australia?

DR ALEX WODAK: No it is not the case yet in Australia, but we hope we don't follow those trends in Australia because consumption is certainly starting to increase and our consumption in Australia now is roughly at the levels that the United States was in the year 2000 when this trend became evident.

LEIGH SALES: Do you expect that - even though you hope we don't, that we will end up following that trend?

DR ALEX WODAK: Well, my colleagues and I at the College of Physicians have written a report which we hope will stimulate a debate and also stimulate government policy change so that we can avert going down the road that the United States has gone down. It really is quite alarming.

LEIGH SALES: I will ask you a little bit more about that report later. But can I ask first of all, there are a lot of drugs that are manufactured in such a way so that they can't be injected. Why can't a version of oxycodone like that come out?

DR ALEX WODAK: Well, oxycontin was supposed to be a drug that couldn't be injected and there are other morphine-based drugs that also were marketed with the claim that they couldn't be crushed and injected. When people are determined to do things that they really want to do, and they've got a lot of time on their hands, a lot of ingenuity and unfortunately they manage to overcome a lot of the technology that's gone into trying to make the whole formulation impregnable.

LEIGH SALES: Steve's story focused a lot on the black market in these drugs an illicit drug use, but isn't it a case that also a large part of the increase in oxycodone use is for legitimate reasons?

DR ALEX WODAK: Yes and for great benefit to Australian people who have malignant pain, pain from cancer or chronic non-malignant pain, pain from arthritis or from old occupational injuries and that sort of thing.

These drugs are much better than the previous drugs we had to give people, which were shorter acting and the shorter-acting drugs caused high peaks and low troughs, so when there were high peaks they had complete relief of pain and a little bit of euphoria. Then when they had the low troughs the pain came back and they started to feel some withdrawal symptoms which they wouldn't recognise as withdrawal symptoms. So those cycles really in some vulnerable people tended to result in ever increasing doses and then duplicitous behaviour in drug seeking. And the hope was that the sustained release formulations would overcome that because in theory there are ... not just in theory, in practice they're much better drugs for chronic pain.

But what's happened is that because of the apparent greater effectiveness and greater safety they've been used in ever-increasing quantities and unfortunately with the ever-increasing quantities we're now starting to see some significant problems.

That's been compounded by the heroin shortage and also the fact that there's been a cap on the methadone and buprenorphine programs for treating heroin dependence. So people who can't heroin, can't get on a methadone and buprenorphine program, the only other option for them is to buy the black market opiates and that's what they do.

LEIGH SALES: You mentioned that these drugs are used to help people who have chronic pain. How prevalent is the problem of chronic pain in Australia and has there been a lot of attention on the way that the medical community can deal with that?

DR ALEX WODAK: It's a very significant problem. It's going to ... there are about three million people in Australia with chronic pain, meaning pain every day for more than three months and that number of people with chronic pain is going to increase in Australia as the population ages and the fact that obesity and overweight ... people becoming more obese and overweight is also going to exacerbate that. Joints are going to wear out faster.

And we don't handle this problem of chronic pain well at all. We don't have enough specialists in the area, we don't have proper guidelines for general practitioners that have been developed for general practitioners. The whole area really needs a bomb put under it and the fact that it's not being as well handled as it should be has also exacerbated the problems that we have with these prescription opioids.

LEIGH SALES: You mentioned the lack of guidelines for GPs which I think is something in your report that you recommend should happen. Did it make other recommendations about the possible regulation of these types of drugs?

DR ALEX WODAK: Yes, there certainly is a lot that we could do on the supply side. We have - as in everything else, six states and two territories all doing different things and it's very hard to aggregate the data from the different states, in fact, you can't. And also you can't track people who move all that easily between one jurisdiction and another. So there's a lot of catching up to do and a doctor who really wants to find out what a patient's been up to, if he or she suspects that the patient has been doctor shopping, we make some provision for that doctor, but we should really be doing a lot more.

LEIGH SALES: It seems a little weird in this day and age when it's so easy to access things online and discover things, how is it that there isn't an easy system by which doctors can track where patients have been?

DR ALEX WODAK: Well, I agree that we should have an online system but it hasn't been developed as yet and privacy concerns are not a trivial consideration. They're an important consideration. But the experts in this area think they can be overcome and we really should have a national web-based system so that doctors and pharmacists can look up and see what other drugs have been prescribed to that patient in the last couple of months.

LEIGH SALES: Is there a risk that if there is further regulation of these drugs or a crackdown that it might, you know, help wean people off illicit drug use but harm those who are perhaps using the drug for legitimate reasons?

DR ALEX WODAK: That certainly is a great concern and crackdowns are very attractive to politicians and unfortunately to the media and some in the community. But the benefits of supplier restrictions are often over-exaggerated and the real cost like you're describing of supply constraints are really very considerable and we should be very wary of them. I am not saying we shouldn't do them but we have to have a balanced approach and I think the benefits of more retention on the demand side, that's where we really ought to put the effort.

And expanding the methadone buprenorphine programs, for example, would take a lot of pressure off the black market system of prescription opioids.

LEIGH SALES: Do we know whether the use of oxycodone has plateaued or is it still increasing all the time?

DR ALEX WODAK: It's still increasing and the morphine is also increasing, morphine-based, they're the two major drug types.

LEIGH SALES: What do we know about the long-term risks of consistently using these types of drugs? We saw the man in the story which had lost his arm, which I presume is an extreme.

DR ALEX WODAK: It is an extreme but unfortunately people like me do see that with monotonous regularity. It is not something you see every day but we do see people losing fingers and arms and legs. You don't have to see too much of that to be horrified.

LEIGH SALES: What are some of the other side effects of long-term use?

DR ALEX WODAK: Well, people become dependent on the drug and a lot of the people who are taking these drugs are not injecting them, they're taking them orally and we're seeing a different demographic of people who are dependent, increasingly becoming dependent on prescription drugs and many of them are functional people who have got jobs and stable relationships and stable addresses and so on and quite different from the people in trouble with heroin. And that difference is seen in very sharply in the United States and the United States started a system of providing buprenorphine outside the methadone clinics in doctor’s surgeries, so called office-based practice.

When they did that if the United States in 2001, the doctors were flooded with white employed stable people stuck on prescription opioids they were taking by mouth, not injecting.

So we don't want to see any of that in Australia and we're already seeing a little bit of it.

LEIGH SALES: Dr Wodak, thank you very much for joining us tonight.

DR ALEX WODAK: My pleasure.

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