s Prescription Opioid Abuse - an Epidemic in the US | I2P: Information to Pharmacists - Archive
Publication Date 01/07/2014         Volume. 6 No. 6   
Information to Pharmacists


From the desk of the editor

Welcome to the July 2014 homepage edition of i2P (Information to Pharmacists) E-Magazine.
At the commencement of 2014 i2P focused on the need for the entire profession of pharmacy and its associated industry supports to undergo a renewal and regeneration.
We are now half-way through this year and it is quite apparent that pharmacy leaders do not yet have a cohesive and clear sense of direction.
Maybe the new initiative by Woolworths to deliver clinical service through young pharmacists and nurses may sharpen their focus.
If not, community pharmacy can look forward to losing a substantial and profitable market share of the clinical services market.
Who would you blame when that happens?
But I have to admit there is some effort, even though the results are but meagre.
In this edition of i2P we focus on the need for research about community pharmacy, the lack of activity from practicing pharmacists and when some research is delivered, a disconnect appears in its interpretation and implementation.

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Newsflash Updates for July 2014

Newsflash Updates

Regular weekly updates that supplement the regular monthly homepage edition of i2P. 
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Feature Contribution

Woolworths Pharmacy - Getting One Stage Closer

Neil Johnston

It started with “tablet” computers deployed on shelves inside the retailer Coles, specifically to provide information to consumers relating to pain management and the sale of strong analgesics.
This development was reported in i2P under the title Coles Pharmacy Expansion and the Arid PGA Landscape”
In that article we reported that qualified information was a missing link that had come out of Coles market research as the reason to why it had not succeeded in dominating the pain market.
Of course, Woolworths was working on the same problem at the same time and had come up with a better solution - real people with good information.

Comments: 5

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Intensive Exposition without crossing over with a supermarket

Fiona Sartoretto Verna AIAPP

Editor's Note: The understanding of a pharmacy's presentation through the research that goes into the design of fixtures and fittings that highlight displays, is a never-ending component of pharmacy marketing.
Over the past decade, Australian pharmacy shop presentations have fallen behind in standards of excellence.
It does not take rocket science - you just have to open your eyes.
Recently, our two major supermarkets, Woolworths and Coles, have entered into the field of drug and condition information provision - right into the heartland of Australian Pharmacy.

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The sure way to drive business away

Gerald Quigley

I attended the Pregnancy, Baby and Children’s Expo in Brisbane recently.
What an eye and ear opening event that was!
Young Mums, mature Mums, partners of all ages, grandparents and friends……...many asking about health issues and seeking reassurances that they were doing the right thing.

Comments: 1

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‘Marketing Based Medicine’ – how bad is it?

Baz Bardoe

It should be the scandal of the century.
It potentially affects the health of almost everyone.
Healthcare providers and consumers alike should be up in arms. But apart from coverage in a few credible news sources the problem of ‘Marketing Based Medicine,’ as psychiatrist Dr Peter Parry terms it, hasn’t as yet generated the kind of universal outrage one might expect.

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Community Pharmacy Research - Are You Involved?

Mark Coleman

Government funding is always scarce and restricted.
If you are ever going to be a recipient of government funds you will need to fortify any application with evidence.
From a government perspective, this minimises risk.
I must admit that while I see evidence of research projects being managed by the PGA, I rarely see community pharmacists individually and actively engaged in the type of research that would further their own aims and objectives (and survival).

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Organisational Amnesia and the Lack of a Curator Inhibits Cultural Progress

Neil Johnston

Most of us leave a tremendous impact on pharmacies we work for (as proprietors, managers, contractors or employees)—in ways we’re not even aware of.
But organisational memories are often all too short, and without a central way to record that impact and capture the knowledge and individual contributions, they become lost to time.
It is ironic that technology has provided us with phenomenal tools for communication and connection, but much of it has also sped up our work lives and made knowledge and memory at work much more ephemeral.

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Academics on the payroll: the advertising you don't see

Staff Writer

This article was first published in The Conversation and was written by Wendy Lipworth, University of Sydney and Ian Kerridge, University of Sydney
In the endless drive to get people’s attention, advertising is going ‘native’, creeping in to places formerly reserved for editorial content. In this Native Advertising series we find out what it looks like, if readers can tell the difference, and more importantly, whether they care.
i2P has republished the article as it supports our own independent and ongoing investigations on how drug companies are involved in marketing-based medicine rather than evidence-based medicine.

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I’ve been thinking about admitting wrong.

Mark Neuenschwander

Editor's Note: This is an early article by Mark Neuenschwander we have republished after the soul-searching surrounding a recent Australian dispensing error involving methotrexate.
Hmm. There’s more than one way you could take that, huh? Like Someday when I get around to it (I’m not sure) I may admit that I was wrong about something. Actually, I’ve been thinking about the concept of admitting wrong. So don’t get your hopes up. No juicy confessions this month except that I wish it were easier for me to admit when I have been wrong or made a mistake.
Brian Goldman, an ER physician from Toronto, is host of the award-winning White Coat, Black Art on CBC Radio and slated to deliver the keynote at The unSUMMIT for Bedside Barcoding in Anaheim this May. His TED lecture, entitled, “Doctors make mistakes. Can we talk about it?” had already been viewed by 386,072 others before I watched it last week.

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Dispensing errors – a ripple effect of damage

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

Most readers will be aware of recent publicity relating to dispensing errors and in particular to deaths caused by methotrexate being incorrectly packed in dose administration aids.
The Pharmacy Board of Australia (PBA), in its Communique of 13 June 2014, described a methotrexate packing error leading to the death of a patient and noted “extra vigilance is required to be exercised by pharmacists with these drugs”.
This same case was reported by A Current Affair (ACA) in its program on Friday 20 June

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Take a vacation from your vocation

Harvey Mackay

Have you ever had one of those days when all you could think was, “Gosh, do I need a vacation.”
Of course you have – because all work and no play aren’t good for anyone.
A vacation doesn’t have to be two weeks on a tropical island, or even a long weekend at the beach. 
A vacation just means taking a break from your everyday activities. 
A change of pace. 
It doesn’t matter where.
Everyone needs a vacation to rejuvenate mentally and physically. 
But did you also know that you can help boost our economy by taking some days off? 
Call it your personal stimulus package.

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Explainer: what is peer review?

Staff Writer

This article was first published in the Conversation. It caught our eye because "peer review" it is one of the standards for evidence-based medicines that has also been corrupted by global pharma.
The article is republished by i2P as part of its ongoing investigation into scientific fraud and was writtenby Andre Spicer, City University London and Thomas Roulet, University of Oxford
We’ve all heard the phrase “peer review” as giving credence to research and scholarly papers, but what does it actually mean?
How does it work?
Peer review is one of the gold standards of science. It’s a process where scientists (“peers”) evaluate the quality of other scientists' work. By doing this, they aim to ensure the work is rigorous, coherent, uses past research and adds to what we already knew.
Most scientific journals, conferences and grant applications have some sort of peer review system. In most cases it is “double blind” peer review. This means evaluators do not know the author(s), and the author(s) do not know the identity of the evaluators.
The intention behind this system is to ensure evaluation is not biased.
The more prestigious the journal, conference, or grant, the more demanding will be the review process, and the more likely the rejection. This prestige is why these papers tend to be more read and more cited.

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Dentists from the dark side?

Loretta Marron OAM BSc

While dining out with an elderly friend, I noticed that he kept his false tooth plate in his shirt pocket. He had recently had seven amalgam-filled teeth removed, because he believed that their toxins were making him sick; but his new plate was uncomfortable. He had been treated by an 'holistic dentist'. Claiming to offer a "safe and healthier alternative" to conventional dentistry, are they committed to our overall health and wellbeing or are they promoting unjustified fear, unnecessarily extracting teeth and wasting our money?

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Planning for Profit in 2015 – Your key to Business Success

Chris Foster

We are now entering a new financial year and it’s a great time to reflect on last year and highlight those things that went well and those that may have impacted negatively in the pursuit of your goals.
It's also a great to spend some time re-evaluating your personal and business short, medium and long term goals in the light of events over the last year.
The achievement of your goals will in many cases be dependent on setting and aspiring to specific financial targets. It's important that recognise that many of your personal goals will require you to generate sufficient business profits to fund those aspirations

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Attracting and Retaining Great People

Barry Urquhart

Welcome to the new financial year in Australia.
For many in business the past year has been described as a challenging period.
Adjectives are a key feature of the English language.  In the business lexicon their use can be, and often is evocative and stimulate creative images.  But they can also contribute to inexact, emotional perceptions.
Throughout the financial pages of newspapers and business magazines adjectives abound.
References to “hot” money draw attention and comment.  The recent wave of funds from Chinese investors, keen to remove their wealth from the jurisdiction and control of government regulations is creating a potential property bubble in Australia.

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Updating Your Values - Extending Your Culture

Neil Johnston

Pharmacy culture is dormant.
Being comprised of values, unless each value is continually addressed, updated or deleted, entire organisations can stagnate (or entire professions such as the pharmacy profession).
Good values offer a strong sense of security, knowing that if you operate within the boundaries of your values, you will succeed in your endeavours.

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Evidence-based medicine is broken. Why we need data and technology to fix it

Staff Writer

The following article is reprinted from The Conversation and forms up part of our library collection on evidence-based medicines.
At i2P we also believe that the current model of evidence is so fractured it will never be able to be repaired.
All that can happen is that health professionals should independently test and verify through their own investigations what evidence exists to prescribe a medicine of any potency.
Health professionals that have patients (such as pharmacists) are ideally placed to observe and record the efficacy for medicines.
All else should confine their criticisms to their evidence of the actual evidence published.
If there are holes in it then share that evidence with the rest of the world.
Otherwise, do not be in such a hurry to criticise professions that have good experience and judgement to make a good choice on behalf of their patients, simply because good evidence has not caught up with reality.

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Laropiprant is the Bad One; Niacin is/was/will always be the Good One

Staff Writer

Orthomolecular Medicine News Service, July 25, 2014
Laropiprant is the Bad One; Niacin is/was/will always be the Good One
by W. Todd Penberthy, PhD

(OMNS July 25, 2014) Niacin has been used for over 60 years in tens of thousands of patients with tremendously favorable therapeutic benefit (Carlson 2005).
In the first-person NY Times best seller, "8 Weeks to a Cure for Cholesterol," the author describes his journey from being a walking heart attack time bomb to a becoming a healthy individual.
He hails high-dose niacin as the one treatment that did more to correct his poor lipid profile than any other (Kowalski 2001).

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Culture Drive & Pharmacy Renewal

Neil Johnston

Deep within all of us we have a core set of values and beliefs that create the standards of behaviour that we align with when we set a particular direction in life.
Directions may change many times over a lifetime, but with life experiences and maturity values may increase in number or gain greater depth.
All of this is embraced under one word – “culture”.
When a business is born it will only develop if it has a sound culture, and the values that comprise that culture are initially inherent in the business founder.
A sound business culture equates to a successful business and that success is often expressed in the term “goodwill” which can be eventually translated to a dollar value.

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Pharmacy 2014 - Pharmacy Management Conference

Neil Johnston

The brave new world of health and wellness is not the enemy of Pharmacy, it is its champion.
Australian futurist, Morris Miselowski, one of the world's leading business visionaries, will present the Opening Keynote address on Pharmacy's Future in the new Health and Wellness Landscape at 2.00pm on Wednesday July 30.
Morris believes the key to better health care could already be in your pocket, with doctors soon set to prescribe iPhone apps, instead of pills.
Technology will revolutionise the health industry - a paradigm shift from healthcare to personal wellness.
Health and wellness applications on smartphones are already big news, and are dramatically changing the way we manage our personal health and everyday wellness.

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Generation and Application of Community Pharmacy Research

Neil Johnston

Editor’s Note: We have had a number of articles in this issue relating to pharmacy research.
The PGA has conducted a number of research initiatives over the years, including one recently reported in Pharmacy News that resulted from an analysis of the QCPP Patient Questionnaire.
Pharmacy Guild president, George Tambassis, appears to have authored the article following, and there also appears to be a disconnect between the survey report and its target audience illustrated by one of the respondent comments published.
I have asked Mark Coleman to follow through, elaborate and comment:

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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)

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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