Impact of Up-Scheduling Medicines on Pharmacy Personnel, Using Codeine as an Example, with Possible Adaption to Complementary Medicines: A Scoping Review

Has the rescheduling of modified-release paracetamol in Australia affected the frequency of overdoses?

OBJECTIVES

In June 2020, modified-release paracetamol (paracetamol-MR) preparations were up-scheduled from schedule-2 (available in pharmacy) to schedule-3 (available by request to a pharmacist only). The present study aims to ascertain whether up-scheduling affected the frequency of paracetamol-MR overdoses.

METHODS

This is a retrospective cohort study of two data sets from 1 June 2017 to 31 May 2022. Monash Health data were extracted using the diagnosis of paracetamol overdose coding and electronic medical records data. Calls regarding paracetamol-MR overdoses to Victorian Poisons Information Centre (VPIC) were extracted from the Poisons centre call database. We used a quasi-experimental research design with interrupted time series analysis to evaluate the immediate impact and change in trend of poisoning-related calls and ED presentations before and after June 2020. The change in proportion of paracetamol-MR cases in both databases was analysed using the Χ2 test.

RESULTS

The proportion of paracetamol-MR cases in both data sets did not change. From Monash Health, there was no level change in monthly paracetamol-MR overdose-related presentations following re-scheduling (rate ratio [RR] = 1.08, 95% confidence interval [CI] = 0.57-2.01). There was no change in monthly paracetamol-MR overdose-related calls to VPIC following re-scheduling (RR = 1.05, 95% CI = 0.96-1.14).

CONCLUSION

The proportion of paracetamol-MR overdoses did not decrease after the up-scheduling to S3. Similarly, the frequency of overdoses by month remained similar. Further limitations on access to paracetamol products may need to be considered.

Towards defining and supporting pharmacists' professional role associated with traditional and complementary medicines - A systematic literature review

BACKGROUND

A review conducted in 2015 reported community pharmacists are willing to adopt a professional role in counselling consumers about the appropriate and safe use of traditional and complementary medicines (T&CM) but faced multiple barriers in doing so; including the role being poorly defined. This current review aimed to update and extend these findings, by identifying studies published since 2015 that reported on pharmacists across any setting.

METHODS

Eligible studies published between January 01, 2016 and December 31, 2021 were identified across six databases (PubMed, Scopus, Web of Science, EMBASE, ScienceDirect and MEDLINE). A grounded theory approach was used to thematically synthesize the data extracted.

FINDINGS

A total 64 studies representing pharmacists across 30 countries were included for review. Study designs varied including cross-sectional surveys (n = 36), qualitative studies (n = 14), and pseudo-patient studies (n = 3). Eight studies reported on practice and/or bioethical responsibilities and 19 studies reported on factors that would enable pharmacists to fulfill these responsibilities, while 37 studies reported about both.

CONCLUSION

These findings indicate research about pharmacists' responsibilities associated with T&CM is evolving from gap analysis towards research that is proactive in advocating for change in multiple areas. These findings can be used to inform a consensus discussion among pharmacists and key stakeholders regarding a set of professional responsibilities that would serve in the development of: a clearly defined role and associated practice standards, and competency requirements that inform educational learning objectives for inclusion in undergraduate, post-graduate and continuing professional pharmacy education.

A wastewater-based evaluation of the effectiveness of codeine control measures in Australia

BACKGROUND AND AIM

From 1 February 2018, codeine was rescheduled from an over-the-counter (OTC) to a prescription-only medicine in Australia. We used wastewater-based epidemiology to measure changes in population codeine consumption before and after rescheduling.

METHODS

We analysed 3703 wastewater samples from 48 wastewater treatment plants, taken between August 2016 and August 2019. Our samples represented 10.6 million people, 45% of the Australian population in state capitals and regional areas in each state or territory. Codeine concentrations were determined by liquid chromatography-tandem mass spectrometry and converted to per-capita consumption estimates using the site daily wastewater volume, catchment populations and codeine excretion kinetics.

RESULTS

Average per-capita consumption of codeine decreased by 37% nationally immediately after the rescheduling in February 2018 [95% confidence interval (CI) = 35.3-39.4%] and substantially in all states between 24 and 51% (95% CI = 22.4-27.0% and 41.8-59.4%). The decrease was sustained at the lower level to August 2019. Locations with least pharmacy access decreased by 51% (95% CI = 41.7-61.7%), a greater decrease than 37% observed for those with greater pharmacy access (95% CI = 35.1-39.4%). Regional areas decreased by a smaller margin to cities (32 versus 38%, 95% CI = 30.2-34.1% versus 34.9-40.4%, respectively) from a base per-capita usage approximately 40% higher than cities.

CONCLUSION

Wastewater analysis shows that codeine consumption in Australia decreased by approximately 37% following its rescheduling as a prescription-only medicine in 2018. Wastewater-based epidemiology can be used to evaluate changes in population pharmaceutical consumption in responses to changes in drug scheduling.

The provision of care provided by the pharmacy workforce in relation to complementary medicines in Australia

BACKGROUND

The use of complementary medicines (CMs) is prevalent across the world. Some CMs, such as St John's Wort, when taken with specific pharmaceutical medicines, may cause drug-herb interactions. In this context, pharmacists have the opportunity to play an important role in preventing harm to patients.

OBJECTIVE

The aim of this study was to explore real-life pharmacy practice in relation to CMs in New South Wales, Australia.

METHODS

The study design involved 'pseudo-patient' pharmacy visits while posing as a patient's relative requesting St John's Wort and using a standardized set of questions to document details of the interaction with a range of pharmacy staff.

RESULTS

Of the 110 metropolitan pharmacy visits made, the pharmacy workforce who were involved in assisting the pseudo-patient's request included 51 pharmacists (46.4%), 57 pharmacy assistants (51.8%) and 1 naturopath (0.9%). Advice that may have resulted in harm to the patient, was offered by pharmacists in 11.8% (n = 13) of the encounters, and 20.9% (n = 23) by pharmacy assistants. Conversely, advice that prevented harm was provided by only 17.3% (n = 19) pharmacists and 10.9% (n = 12) pharmacy assistants. History-taking was not attempted by 84 pharmacy staff.

CONCLUSION

The majority of pharmacy staff involved in this study did not manage a request for a CM with known drug-herb interactions in a way that would prevent harm. These findings highlight the need for the pharmacy workforce to engage in education and training in CMs, with a focus on how to consult evidence-based resources regarding interactions in the interest of patient safety.