s Time For a Philosophical Review of S3 | 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. 
Access and click on the title links that are illustrated

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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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Time For a Philosophical Review of S3

Peter Sayers

articles by this author...

Peter Sayers is vitally concerned about pharmacy professional practice - its innovation, its research and development, and its delivery to create an ongoing revenue stream. Delivery of healthcare is increasingly involved with Information Technology systems. All perspectives in IT must be considered for the impact on pharmacy practice and its viability.

How many times have you been interrupted during the busiest prescription flow of the day to attend to an S3 request?
How many times have you thought “b**gger – I need this interruption like a hole in the head!”
Yet you dutifully attend to the request in a professional manner, asking all the relevant questions of a patient who looks at you if you are from outer space!
And you return to the dispensing mess that has piled up while you were talking to the patient.
Something is wrong here, as pharmacist mental health becomes a victim of the process.
It’s definitely time to adjust the workflow process and create roles within pharmacies designated “consumer health-partner pharmacist”, or similar title.
We have a legislated “pharmacist-in-charge” role to cover dispensary procedures, but no designated person to look after consumer cognitive services – both core activities in a pharmacy.

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Contemporary thinking in health direction says that we should be mentoring patients to take responsibility for their own health, or in other words, have patients make guided individual choices using the pharmacist as a health partner.
How can we achieve this when the environment at that moment is not conducive for a patient to receive that education?
No specialist manager appointed, no properly designated spaces, no proper marketing systems to guide and develop the process- no wonder there are gaps in service delivery.
Yet not to provide adequate information services leaves you open to charges of unprofessional conduct and lack of a “duty of care”.

The Auspharmlist blog recently had a list of Facebook postings (by pharmacy consumers) regarding privacy in questions asked (mostly by pharmacy assistants), and counselling given (by pharmacists), in transactions that obviously involved the sale of S3 products.
The complainants mostly appeared to be women and most appeared to be members of an allied health discipline of some sort.
For me, the comments illustrated not only the need for designated pharmacists, but also the creation and promotion of a new role “pharmacy clinical assistant”.
Possibly recruited from the ranks of  dispensary assistants, clinical assistants should evolve to a level where consumers recognise their value.

It is well known that a large number of patients in all walks of life download information from the Internet as a primary information source for their health, so the health literacy level in the community today is well above the level of say twenty years ago.

So have we as pharmacists adjusted our approach to patients sufficiently to be regarded as fully professional, even though current legislation impedes our progress in this regard?
Speaking for myself, I find that each S3 encounter I have, apart from those encounters initiated by the patient directly, I find that I become more disenchanted and disillusioned.

Commonly, I find that patients who have counselling forced upon them react by showing a lack of respect, disinterest and general rudeness ranging to levels of aggressiveness – exactly as illustrated in the Auspharmlist blog.
Occasionally, I find myself defending my actions in a correspondingly aggressive manner.
Will we really attract patients in this way, or can we turn it to an opportunity in some way?

Pharmacy is being manipulated and pressured from many directions, chief among those involved being Big Pharma, various levels of government, doctor groups and some lobby groups e.g. FSM.
I also believe that PGA members are not being adequately represented amongst all the above “noise” from the different groups. Has Australia’s strongest lobby group (PGA) lost its punch?
Take the recent changes to S3 cough mixtures as an example.
Cough mixture sales management, past and present, has been well managed by Australian pharmacists, yet changes to poisons regulations have occurred for no apparent reason.

Continuous supermarket pressure to be able to sell cough mixtures and similar medicinal products has been ongoing since 1969.
More recently, changes in the type of patients pharmacists could service with cough medicines was limited to age 2+.
When I investigated why this happened (there were no known adverse events reported to the then reporting agency ADRAC) I discovered that mishaps had occurred with cough mixtures in a number of US supermarkets, resulting in the deaths of some children under two years of age.
The US at that stage had no poisons regulations that resembled Australia’s, but has since put some controls in place. But the damage had been done!
Then for “harmonisation” reasons, Australian regulators fell into line with the US Food & Drug Administration and imposed restrictions on Australian pharmacists.
What a reward for doing an excellent job!
It beggars belief as to the intelligence levels of bureaucrats in their regulatory fortresses.

However, no amount of argument by pharmacy seemed to alter this now entrenched attitude, so new regulations have now been imposed on pharmacists recently, again for no apparent reason.
The following notice has appeared on the TGA site:

15 August 2012
The TGA has conducted a review of the use of cough and cold medicines in children. As a result of this review, new advice is being given on the use of these medicines in children.

The review concluded that there are no immediate safety risks with these products. However, there is evidence that they may cause harm to children. Furthermore, the benefits of using them in children have not been proven. On this basis:

* Cough and cold medicines should not be given to children under 6 years of age.
* Cough and cold medicines should only be given to children aged 6 to 11 years on the advice of a doctor, pharmacist or nurse practitioner.

The labels of these products are being changed to reflect the new advice, but such changes take time to implement and must be phased in. Stock with the new labelling will begin to appear in pharmacies and other retail stores from September 2012. However, existing stock with the older labelling will still be allowed to be sold for use in adults and children aged 6 years and older until it is exhausted.

No immediate safety risks and some ingredients may cause harm?
Even the intake of water has no immediate safety risk but has been known to cause harm.
When will this madness cease?

TGA decisions are supposed to be evidence-based – where is the evidence that pharmacists do not manage S3 (and other) risks adequately?
Note also another direction in political correctness, where the 6-11 age group must be only given cough mixtures on the advice of a doctor, pharmacist or a nurse practitioner.
Note the above in conjunction with another section of the TGA site where there is an advisory for parents that states:
“If you have any doubt about whether your child has a common cold or something more serious, consult a doctor or nurse practitioner.”

Note that the traditional advisory role of the pharmacist has been removed.
I do not believe that this is accidental, and is a deliberate move to obliterate pharmacists from primary care. This trend started about a decade ago when pharmacists disappeared from public primary health care initiatives.
Since time immemorial, the major markets for pharmacy have been the health needs of the 0-5 age group and the aged care group.
And since the arrival of the First Fleet, pharmacists have the main practitioners of primary health

I also note that the Pharmacy Guild of Australia has opted out of any argument to remove cough mixture sales restrictions on pharmacists and provides direct evidence that it is losing its “mojo” by not defending pharmacy market share. This attitude seems to be an “across-the-board” one affecting all levels of professional initiatives by pharmacists.
Pharmacy leaders from earlier generations would never let this type of activity go unchallenged.
Has the current lot tied itself up through granting "favours" that have to be repaid by avoiding hard decisions?
In the UK, regulators have decided to change the rules for the display of S3 type products to now being able to be displayed openly. This move has been loudly condemned by all UK pharmacy organisations.
In Australia over the past fortnight, a posting to the Auspharmlist blog illustrated what happens when medicines are sold by supermarkets.
Firstly, a Pfizer cough mixture (Robitussin) was displayed and sold from a Woolworths location accessible to children when the product was clearly labelled “Keep out of the reach of children”.
Secondly, it was sold for the purpose of administering to a child under the age of six, not currently approved by the TGA.
Thirdly, it was a discounted product sold either to clear existing supermarket stocks or stock being cleared by Pfizer.
Fourthly, although advice was requested by the purchaser, none could be given by the supermarket.
Fifthly, this probably duplicated the conditions in the US supermarket chain that caused the deaths of children under two years of age, and created the harmonisation garbage that has been spun ever since by government regulators.
This story should be retold through every major Australian media outlet ASAP to try and create a stop to this "harmonisation" and create some public relations kudos for pharmacists that is well-earned (but rarely recognised).

Return to home

Submitted by Peter Kennedy on Wed, 26/09/2012 - 13:22.

Any philosophical review would be worse than useless if it was based on the muddled misconceptions in this article.

The legislation requiring a pharmacist to be continually in charge of a pharmacy is NOT just to cover dispensing of S4 prescriptions!!! It is ALSO just as much, if not MORE, in order to have a pharmacist present to supply S3s and supervise the supply of S2s! Supply of S3s is not an “interruption” to a pharmacist’s “real” job of churning out dispensed prescriptions. Supply of S3s and to a lesser extent S2s is the most CORE part of pharmacy practice – these are powerful and potentially dangerous medicines and the pharmacist is the ONLY trained person involved in their supply.

There have been NO “changes to poisons regulations” regarding cough mixtures in recent years. Nor have there been any legal changes permitting supermarkets to supply any extra types of cough medicines in addition to what they have always been permitted to supply. Nor have “Australian regulators imposed” any new “restrictions on pharmacists” in regard to “the type of patients pharmacists could service with cough medicines”.

You correctly quote the TGA’s statement about the change in its ADVICE concerning these medicines, but you seem to not understand that it is just that, a change in the TGA’s advice.

Although product sponsors are not allowed to actively promote uses of a medicine outside the parameters of the TGA’s approved advice, pharmacists remain, as they always have been, perfectly free to supply any medicine outside of the parameters of the TGA’s advice about it, if it is therapeutically appropriate in the pharmacist’s professional opinion.

In fact it is estimated that 20% to 30% of the medicines supplied in Australia are supplied “off-label”, that is, outside the TGA’s officially “approved” parameters of use of the medicine. This is not illegal and in the vast majority of cases is therapeutically appropriate and nobody ever gets in trouble for it.

“Harmonisation with the USA” played no part in the change to the TGA’s advice about these medicines. Insofar as the actions of foreign governments had any influence at all on the decision, it was much more so the actions in New Zealand, the UK and Europe, which all do have equivalents of Australia’s “pharmacy medicine” and “pharmacist only medicines” categories of medicines, and which all took similar action several years ago.

The push for “harmonisation” comes not from drug regulators but from product sponsors who want to have only one set of rules to deal with, and it is only in the case of NZ that Australian regulators have, to a limited extent, acceded to the sponsors’ demands for harmonisation in some respects (and firmly rejected the idea in many other respects and on many other occasions and in regard to many types of medicines).

Finally the warning “Keep Out of Reach of Children” is directed at consumers, not retailers. A glance into any pharmacy reveals, sitting on low shelves, hundreds of Schedule 2 and other medicines labelled “Keep Out of Reach of Children”, many of them discounted in price and heavily advertised, so your apoplectic reaction to a supermarket so “endangering” children is rather hypocritical. Do you really think that children under six stroll into a supermarket alone and do their own shopping?

And in any case, unlike the Schedule 2 and 3 medicines whose sale is restricted to pharmacies (not in order to "defend pharmacy market share" but to try to protect public health!), the warning "Keep Out of Reach of Children" is actually NOT legally required on the NON-scheduled cough mixtures sold by supermarkets. Probably it is there on the Robitussin label because the company's lawyers wanted it as a "butt-covering" exercise, or because the marketing department thought that it made the product look more effective.

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