The role of school characteristics in pre-legalization cannabis use change among Canadian youth: implications for policy and harm reduction

Reducing youth cannabis use in Canada is a public health priority with schools of interest as a potential modifier of behavior and as a venue for prevention programming. This work aimed to provide a basis for future policy and programming by evaluating pre-legalization cannabis use change patterns in schools and the impact of school characteristics on these patterns. Average rates of cannabis use behavior change (initiation, escalation, reduction, cessation) were collected from 88 high schools located in Ontario and Alberta, Canada participating in the COMPASS prospective cohort study. There was little variability in cannabis use behaviors between schools with intra-class correlation coefficients lowest for cessation (0.02) and escalation (0.02) followed by initiation (0.03) and reduction (0.05). Modest differences were found based on school province, urbanicity and student-peer use. Cannabis ease of access rates had no significant effect. Fewer than half the schools reported offering school drug use prevention programs; these were not significantly associated with student cannabis use behaviors. In conclusion, current school-based cannabis prevention efforts do not appear sufficiently effective. Comprehensive implementation of universal prevention programs may reduce cannabis harms. Some factors (urbanicity, peer use rates) may indicate which schools to prioritize.

Pharmaceutical policies: effects of educational or regulatory policies targeting prescribers

BACKGROUND

Pharmaceuticals make an important contribution to people's health. Medicines, however, are frequently not used appropriately. Improving the use of medicines can improve health outcomes and save resources. On the other hand, regulatory and educational policies may have unintended effects on health and costs.

OBJECTIVES

To assess the effects of pharmaceutical educational and regulatory policies targeting prescribers on medicine use, healthcare utilisation, health outcomes and costs (expenditures).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two trial registries in March 2018 and several other databases between 2014 and 2018. We reviewed the reference lists of included studies and other relevant reviews, contacted authors of relevant reviews and studies to identify additional studies, and did a citation search for all included studies using ISI Web of Science (searched 05 January 2016).

SELECTION CRITERIA

Randomised trials, non-randomised trials, interrupted time series studies, repeated measures studies and controlled before‒after studies of policies regulating who can prescribe medicines and other policies targeted at prescribers. We included in this category monitoring and enforcement of restrictions, generic prescribing, programmes to implement treatment guidelines, system-wide policies regarding monitoring medicine safety, and legislated or mandatory continuing education or quality improvement specifically targeted at prescribing. We defined 'policies' in this review as laws, rules, financial and administrative orders made by governments, non-governmental organisations or private insurers. We excluded interventions applied at the level of a single facility. For us to include a study, it had to include an objective measure of at least one of the following outcomes: medicine use, healthcare utilization, health outcomes, or costs.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and reference lists of relevant reports, assessed full-text studies for inclusion, extracted data, and assessed risk of bias and certainty of the evidence (GRADE). For all the steps in the above process we resolved disagreements by discussion.

MAIN RESULTS

We identified two studies that met our selection criteria: a controlled interrupted time series study evaluating a regulatory policy involving the monitoring of prescribing of benzodiazepines; and a controlled before‒after study of an educational policing involving mailed educational materials on prescribing for physicians and Health Maintenance Organization (HMO) members as well as an intervention to regulate drug reimbursement. We are uncertain about the effects on medicine use of a regulatory policy involving the monitoring of prescribing with triplicate prescriptions, compared with no regulatory intervention (very low certainty evidence). We are also uncertain about the effects on medicine use, assessed through doctors' prescribing, and costs of an educational policy involving mailed educational materials on prescribing for physicians and HMO members, compared to no educational intervention or an intervention to regulate drug reimbursement (very low certainty evidence). Neither of the included studies measured healthcare utilization, health outcomes, or additional costs, if any, to patients.

AUTHORS' CONCLUSIONS

We are uncertain of the effects of educational or regulatory policies targeting prescribers due to very limited evidence of very low certainty. The impacts of these policies therefore need to be evaluated rigorously using appropriate study designs. Evaluations are needed across a range of settings, including low- and middle-income countries, and across different types of prescribers and medicines.

Opioid prescribing in minimally injured trauma patients: Effect of a state prescribing limit

BACKGROUND

Opioid-prescribing practices for minimally injured trauma patients are unknown. We hypothesized that opioid-prescribing frequency and morphine-equivalent doses prescribed have decreased in recent years, specifically surrounding an acute prescribing limit implemented in August 2017 mandating opioid prescriptions not exceed 210 morphine-equivalent doses.

METHODS

A single-center retrospective study was performed in the month of May during the years 2015 to 2018 on minimally injured trauma patients in a level I trauma center. Minimally injured trauma patients included patients discharged within 2 midnights of trauma evaluation without surgical intervention. Primary outcomes were discharge opioid-prescribing frequency and dosing in morphine-equivalent doses. Secondary outcomes were occurrence and timing of postdischarge follow-up.

RESULTS

For 673 minimally injured trauma patients, opioid-prescribing frequency and morphine-equivalent doses prescribed decreased between 2015 and 2017 (49.3% to 31.5%, P = .006, mean 229 to 146 morphine-equivalent doses, P = .007). Decreases between 2017 and 2018 were not statistically significant. Acute prescribing limit compliance was 97% in 2018. After the acute prescribing limit was implemented, outpatient opioid prescribing did not increase and time to earliest follow-up did not decrease.

CONCLUSION

Opioid-prescribing frequency and morphine-equivalent doses prescribed to minimally injured trauma patients decreased dramatically between 2015 and 2018. These changes occurred primarily before the implementation of an acute prescribing limit; however, incremental improvement and high compliance since implementation are demonstrated. Patients did not have significantly earlier follow-up encounters for pain or additional opioid prescriptions. Prospective research on pain control for minimally injured trauma patients is needed.

State naloxone access laws are associated with an increase in the number of naloxone prescriptions dispensed in retail pharmacies

BACKGROUND

In response to the ongoing opioid overdose epidemic, many states have enacted laws increasing naloxone access by lay people, such as friends and family members of people who use drugs (PWUD), as well as PWUD themselves.

METHOD

We utilized Symphony Health Solutions' PHAST Prescription data from 2007 to 2016 to investigate whether naloxone access laws were associated with an increase in naloxone dispensed from retail pharmacies in the United States.

RESULT

Using a negative binomial regression, we found that naloxone access laws were associated with an average increase of 78 prescriptions dispensed per state per quarter. This represents an average 79% increase in naloxone dispensed from U.S. retail pharmacies, compared with states where there were no such laws.

CONCLUSION

Our study suggests that naloxone access laws can increase the availability and accessibility of naloxone.

Impact of Florida's prescription drug monitoring program and pill mill law on high-risk patients: A comparative interrupted time series analysis

PURPOSE

We quantified the effects of Florida's prescription drug monitoring program and pill mill law on high-risk patients.

METHODS

We used QuintilesIMS LRx Lifelink data to identify patients receiving prescription opioids in Florida (intervention state, N: 1.13 million) and Georgia (control state, N: 0.54 million). The preintervention, intervention, and postintervention periods were July 2010 to June 2011, July 2011 to September 2011, and October 2011 to September 2012. We identified 3 types of high-risk patients: (1) concomitant users: patients with concomitant use of benzodiazepines and opioids; (2) chronic users: long-term, high-dose, opioid users; and (3) opioid shoppers: patients receiving opioids from multiple sources. We compared changes in opioid prescriptions between Florida and Georgia before and after policy implementation among high-risk/low-risk patients. Our monthly measures included (1) average morphine milligram equivalent per transaction, (2) total opioid volume across all prescriptions, (3) average days supplied per transaction, and (4) total number of opioid prescriptions dispensed.

RESULTS

Among opioid-receiving individuals in Florida, 6.62% were concomitant users, 1.96% were chronic users, and 0.46% were opioid shoppers. Following policy implementation, Florida's high-risk patients experienced relative reductions in morphine milligram equivalent (opioid shoppers: -1.08 mg/month, 95% confidence interval [CI] -1.62 to -0.54), total opioid volume (chronic users: -4.58 kg/month, CI -5.41 to -3.76), and number of dispensed opioid prescriptions (concomitant users: -640 prescriptions/month, CI -950 to -340). Low-risk patients generally did not experience statistically significantly relative reductions.

CONCLUSIONS

Compared with Georgia, Florida's prescription drug monitoring program and pill mill law were associated with large relative reductions in prescription opioid utilization among high-risk patients.

Socioeconomic Determinants of Antibiotic Consumption in the State of São Paulo, Brazil: The Effect of Restricting Over-The-Counter Sales

BACKGROUND

Improper antibiotic use is one of the main drivers of bacterial resistance to antibiotics, increasing infectious diseases morbidity and mortality and raising costs of healthcare. The level of antibiotic consumption has been shown to vary according to socioeconomic determinants (SED) such as income and access to education. In many Latin American countries, antibiotics could be easily purchased without a medical prescription in private pharmacies before enforcement of restrictions on over-the-counter (OTC) sales in recent years. Brazil issued a law abolishing OTC sales in October 2010. This study seeks to find SED of antibiotic consumption in the Brazilian state of São Paulo (SSP) and to estimate the impact of the 2010 law.

METHODS

Data on all oral antibiotic sales having occurred in the private sector in SSP from 2008 to 2012 were pooled into the 645 municipalities of SSP. Linear regression was performed to estimate consumption levels that would have occurred in 2011 and 2012 if no law regulating OTC sales had been issued in 2010. These values were compared to actual observed levels, estimating the effect of this law. Linear regression was performed to find association of antibiotic consumption levels and of a greater effect of the law with municipality level data on SED obtained from a nationwide census.

RESULTS

Oral antibiotic consumption in SSP rose from 8.44 defined daily doses per 1,000 inhabitants per day (DID) in 2008 to 9.95 in 2010, and fell to 8.06 DID in 2012. Determinants of a higher consumption were higher human development index, percentage of urban population, density of private health establishments, life expectancy and percentage of females; lower illiteracy levels and lower percentage of population between 5 and 15 years old. A higher percentage of females was associated with a stronger effect of the law.

CONCLUSIONS

SSP had similar antibiotic consumption levels as the whole country of Brazil, and they were effectively reduced by the policy.

[The role of health regulations in the rational use of medicines]

The Federal Commission for the Protection against Sanitary Risk (COFEPRIS by its initials in Spanish) is the state body responsible for transversely regulating various sectors of the Mexican economy, among them health services and inputs. Both cases are related to the rational use of medicines. The pharmaceutical policy of the Mexican Government is to prevent health risks by strengthening the effective and timely access to a market supplied with safe, effective, and quality products at the lowest possible prices. To date, the regulatory mechanisms used by COFEPRIS to ensure access to medicines and quality health services have been effective. With the implemented measures, self-medication has been reduced and medical services provided by pharmaceutical clinics comply with the best practices. Finally, the regulatory framework has been strengthened to fight the illegal drug market and "miracle" products. So far, the present administration has increased seizures of illegal substances and, as of today, all advertising guidelines for health-related products comply with the regulations.

New start versus continuing users on aripiprazole: implications for policy

OBJECTIVES

To evaluate utilization of 90-day-supply prescriptions of aripiprazole.

STUDY DESIGN

One year (April 1, 2011, to March 31, 2012) retrospective cohort study from the Veterans Affairs San Diego Healthcare System.

METHODS

The primary outcome was to determine the difference in adherence for new starts versus continuing users on aripiprazole, as determined by medication possession ratio (MPR). Secondary outcomes included odds of adherence and refilling at least once associated with being a new start. Adherence was defined as MPR ≥ 0.8. Separate regression models (linear and logistic) were run for the entire population, as well as a subgroup analysis of 90-day prescription patients only.

RESULTS

A total of 749 patients, 328 of whom were new starts, were included in the analysis. Both new starts (41.2%) and continuing users (69.1%) had a large portion who received 90-day supplies. New-start patients had significantly lower MPR than continuing users (-0.13; 95% CI, -0.18 to -0.08). Logistic regressions showed that new starts also had lower odds of adherence (odds ratio [OR], 0.46; 95% CI, 0.33-0.65) and of refilling at least once (OR, 0.43; 95% CI, 0.28-0.66) compared with continuing users.

CONCLUSIONS

Patients who were continuing users of aripiprazole were more likely to be adherent and refill their medication. Overutilization of 90-day supplies of high-cost agents, particularly in new starts, may lead to waste. It is recommended that patients newly started on high-cost agents should initially be provided a 30-day-supply prescription until it is established that effectiveness and tolerance have been achieved.

[The judicialisation of health as a means ensuring access to medicines]

OBJECTIVE

A systematic review, focusing on the judicialisation of health regarding gaining access to medicines, was aimed at understanding the impact of lawsuits on the organisation of public health services.

METHOD

Original articles published between 2007 and 2011 in the pertinent national and international literature were analysed, resulting in 49,239 articles being found in Science Direct and BIREME databases. Results The survey indicated a predominance of literature from Brazil, mainly the southeast, as well as a study from Colombia.

DISCUSSION

The aforementioned chronic disease-related claims involved diabetes, high blood pressure, cancer and rheumatoid arthritis. Forming part of specific Unified Healthcare System programmes highlighted the difficulty in gaining access to the appropriate medicine and consequent health judicialisation demonstrated the fragility of existing public policy.

CONCLUSION

It was concluded that the courts (despite being a strategy for ensuring access to medicine) were unable to deal with the current spate of lawsuits, thereby leading to disruption regarding the flow of public systems.

[Surveillance of antibiotic consumption : clarification of the "definition of data on the nature and extent of antibiotic consumption in hospitals according to § 23 paragraph 4 sentence 2 of the IfSG"]

According to § 23 paragraph 4 of the German Infection Prevention Act (IfSG; July 2011), hospitals and clinics for ambulatory surgery are obliged to establish a continuous monitoring system of antibiotic consumption. This is aimed at contributing to an optimization of antibiotic prescription practices in order to confine the development and spread of resistant pathogens. The general requirements (restricted to hospitals) on the method and extent of data collection are provided by the national public health institution after discussion with representatives of various professional societies (Robert Koch-Institut, Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 59, 2013). The article aims to clarify these specifications and to provide background details. In agreement with national and European surveillance systems, the Anatomical Therapeutic Chemical (ATC)/Defined Daily Dose (DDD) classification system recommended by the WHO should be used as reference standard. Antibiotic consumption should be expressed as the number of DDDs per 100 patient days and per 100 admissions. The categories of antimicrobials and hospital organizational units to be monitored and the time intervals in which analyses should be conducted are determined. Furthermore, various approaches of data assessment are described.

[Ensuring of safety of the circulation of medicines in the current demographic situation]

The new millennium was manifested by principally new demographic situation characterized by an increase in the proportion of elderly population in the total population of the world and the spread of chronic non-communicable diseases. These changes have led to increased demand for health services, including safe and effective medicines. Creation of mechanisms ensuring international security of medicines circulation requires formation of an effective foreign policy and the reform of the regulatory framework at the national level, as well as improving the existing international and regional regulatory systems of all stages of the drug circulation to solve the most important challenges of the sector.

Impact of over-the-counter restrictions on antibiotic consumption in Brazil and Mexico

Background

In Latin American countries over-the-counter (OTC) dispensing of antibiotics is common. In 2010, both Mexico and Brazil implemented policies to enforce existing laws of restricting consumption of antibiotics only to patients presenting a prescription. The objective of the present study is therefore to evaluate the impact of OTC restrictions (2010) on antibiotics consumption in Brazil and Mexico.

Methods and Findings

Retail quarterly sales data in kilograms of oral and injectable antibiotics between January 2007 and June 2012 for Brazil and Mexico were obtained from IMS Health. The unit of analysis for antibiotics consumption was the defined daily dose per 1,000 inhabitants per day (DDD/TID) according to the WHO ATC classification system. Interrupted time series analysis was conducted using antihypertensives as reference group to account for changes occurring independently of the OTC restrictions directed at antibiotics. To reduce the effect of (a) seasonality and (b) autocorrelation, dummy variables and Prais-Winsten regression were used respectively.

Between 2007 and 2012 total antibiotic usage increased in Brazil (from 5.7 to 8.5 DDD/TID, +49.3%) and decreased in Mexico (10.5 to 7.5 DDD/TID, −29.2%). Interrupted time series analysis showed a change in level of consumption of −1.35 DDD/TID (p<0.01) for Brazil and −1.17 DDD/TID (p<0.00) for Mexico. In Brazil the penicillins, sulfonamides and macrolides consumption had a decrease in level after the intervention of 0.64 DDD/TID (p = 0.02), 0.41 (p = 0.02) and 0.47 (p = 0.01) respectively. While in Mexico it was found that only penicillins and sulfonamides had significant changes in level of −0.86 DDD/TID (p<0.00) and −0.17 DDD/TID (p = 0.07).

Conclusions

Despite different overall usage patterns of antibiotics in Brazil and Mexico, the effect of the OTC restrictions on antibiotics usage was similar. In Brazil the trend of increased usage of antibiotics was tempered after the OTC restrictions; in Mexico the trend of decreased usage was boosted.

["Off label" use of some medicinal products. Part I]

The review is devoted to the complex drug administrating process and the process of making decisions, both affected by the country official regulations, the established guidelines for good clinical practice and last but not least--the knowledge and discretion of the individual physician prescribing a medicine. The publication gives emphasis on the "off label use"--the practice of prescribing pharmaceuticals for an unapproved by official drug institutions indications or in an unapproved age group, unapproved dose or unapproved form of administration. Numerous cases of widespread and even routine practice of "off label use" made for the benefit of the patients are presented. Details of current drug regulations in Bulgaria are provided. Examples of drug prescriptions are drawn for indications other than those specified in the marketing authorization certificate, showing the gap between the established practices, the professionals opinions and the regulators delayed reactions, influenced by the policies of the pharmaceutical industry.

[Community antibiotic consumption in Chile, 2000-2008]

BACKGROUND

The Chilean Ministry of Health has implemented regulatory rules for the consumption of anti-biotics since September 1999, with sales restriction limited only with medical prescription.

AIM

To analyze the impact of established regulatory measures from 2000 to 2008.

MATERIAL AND METHODS

A retrospective analysis of antibiotics sales in pharmacies from 2000 to 2008 was performed. The information was obtained from the International Marketing System (IMS Health), an auditing system of pharmacy sales. The consumption unit used was the Defined Daily Dose per 1000 inhabitants/day (DDD).

RESULTS

From 2000 to 2002 the regulatory rules had a great impact, but since 2002 the antibiotic consumption increased, especially amoxicillin, returning to similar levéis observed in 1998.

CONCLUSIONS

The regulatory measures had an initial impact, but there was not reinforcement in the time and there was no further control. It is necessary to assume a permanent task and support of the authorities of health to edúcate the population about the implications of the inadequate use of antimicrobials and his effect on the microbial ecology.

Impact of safety concerns and regulatory changes on the usage of erythropoiesis-stimulating agents and RBC transfusions

PURPOSE

Safety concerns raised in the recent oncology trials with erythropoiesis-stimulating agents (ESAs) have led to regulatory restrictions on their use. We wished to determine the impact of these changes on the use of ESAs and RBC transfusions.

METHODS

In a retrospective observational study of patients treated at a comprehensive cancer center in 2006-2008, data on all ESA doses dispensed, RBCs transfused, and hemoglobin levels on the days of transfusions and ESA initiations were analyzed.

RESULTS

Compared with 2006, the total patients treated was 14% higher (28,339 versus 24,806) in 2007 and 22% higher (30,254) in 2008. Patients receiving ESAs decreased by 26% and 61%, and ESA units dispensed decreased by 29% (from 30,206 units to 21,409 units) and 80% (6,102 units) in 2007 and 2008, respectively. However, RBC transfusions increased by only 2% (from 38,218 units to 38,948 units) in 2007 and by 8% (41,438) in 2008. The mean hemoglobin on the day of transfusion was the same for each year (8.4 g/dl); however, an increasing proportion of patients initiated ESAs at lower hemoglobin (< 10 g/dl) levels. After adjusting for demographics and diagnostic variables for 3 years (n = 83,399), a multivariate logistic regression showed a significant decline in ESA use (p < .0001) without an increase in RBC transfusions.

CONCLUSIONS

Recent ESA safety concerns and regulatory restrictions have significantly decreased ESA use. The lack of a significant impact on transfusions may be related to a lower hemoglobin threshold used to initiate ESAs or treatment of patients less likely to respond.

Common sense in prescribing pain medications for the Louisiana physician

Louisiana physicians often face difficult predicaments in treating patients with chronic pain complaints. On the one hand, there is a greater appreciation for the debilitating impact of chronic pain on quality of life and better recognition that chronic pain is a disease in its own right deserving treatment. On the other hand, we regularly learn of arrests of physicians for prescribing these medications and read reports of exploding pain medication abuse. This article dispenses common sense advice for the Louisiana physician in approaching chronic pain issues such as defining your treatment population, obtaining independent corroborating records, prescribing extended-release pain medications when possible, considering adjunctive treatments to reduce total opiate use, collaborating with colleagues regularly, utilizing treatment agreements, employing sensible verification methods of proper medication use, opening the doctor-patient relationship to include concerned family or friends, using psycho-social indicators of good functioning, and reappraising the success of treatment at appropriate intervals. By employing these common-sense approaches Louisiana physicians can approach pain management prescribing with more assurance and confidence.

Examining the impact of Part D on nursing home residents

Key findings. (1) Even though 81 percent of eligible nursing home residents enrolled in Part D within the first year, they demonstrated no evidence of expanded drug coverage. (2) Medicare Part D lowered the out-of-pocket drug costs of nursing home residents by less than the amount in the community setting. (3) Nursing home residents who did not enroll in Part D exhibited characteristics of vulnerability: oldest-old, highest disease burden, and no previous drug coverage. (4) Disruptions in prescription drug use occurred after implementation of Part D.

Legal issues in prescription writing: a study of two health institutions in Nigeria

OBJECTIVES

This study examined the degree of deviation (from both World Health Organization (WHO) specifications and the particular institution's specifications) on the part of prescribers in adequately filling prescription forms and the legal implications of such deviations for the prescriber and the institution.

METHODS

The study was carried out at the Obafemi Awolowo University Teaching Hospital Complex (OAUTHC) and Obafemi Awolowo University Health Centre, Ife-Ife, Nigeria. The Teaching Hospital is a 1000-bed tertiary health care facility that serves as a training centre for health professionals. The Health Centre is a 25-bed health care facility. A random sample of prescriptions received from the Pharmacy Department of the OAUTHC and the Obafemi Awolowo University Health Centre were analysed.

KEY FINDINGS

For the Teaching Hospital, the prescriber's name and signature were on 80 and 96% of the prescriptions, respectively, whereas all prescriptions from the Health Centre contained this information. For the Teaching Hospital, 100, 1.8, 93.8 and 98.4% of prescriptions contained the patient's name, address and age, and the date, respectively, whereas 99.6, 86.4 and 99.9% of prescriptions from the Health Centre contained patient code number, age and the date respectively. The precentages of completely filled prescriptions for the Teaching Hospital and the Health Centre were 1.3 and 85.9% respectively. Prescription patterns for the major drug classes in both institutions were compared and related to the level of deviation from the ideal prescription-writing specifications of the WHO.

CONCLUSIONS

The legal implications of non-compliance with WHO standards in prescription writing are discussed, with appropriate recommendations.

The use of compound topical anesthetics

BACKGROUND

The author reviewed the history of, federal regulations regarding, risks of and adverse drug reactions of five compound topical anesthetics: tetracaine, adrenaline/epinephrine and cocaine (TAC); lidocaine, adrenaline/epinephrine and tetracaine (LET); lidocaine, tetracaine and phenylephrine (TAC 20 percent Alternate); lidocaine, prilocaine and tetracaine (Profound); and lidocaine, prilocaine, tetracaine and phenylephrine with thickeners (Profound PET).

TYPES OF STUDIES REVIEWED

The author reviewed clinical trials, case reports, descriptive articles, and U.S. Food and Drug Administration (FDA) regulations and recent public advisory warnings regarding the federal approval of and risks associated with the use of compound topical anesthetics.

RESULTS

Compound topical anesthetics are neither FDA-regulated nor -unregulated. Some compounding pharmacies bypass the new FDA drug approval process, which is based on reliable scientific data and ensures that a marketed drug is safe, effective, properly manufactured and accurately labeled. Two deaths have been attributed to the lay use of compound topical anesthetics. In response, the FDA has announced the strengthening of its efforts against unapproved drug products.

CLINICAL IMPLICATIONS

Compound topical anesthetics may be an effective alternative to local infiltration for some minimally invasive dental procedures; however, legitimate concerns exist in regard to their safety. Until they become federally regulated, compound topical anesthetics remain unapproved drug products whose benefits may not outweigh their risks for dental patients.

[Off-label use: update and relevance for urology]

The use of pharmaceuticals beyond the approved indication and conditions (off-label use) is of increasing public interest in times of necessary financial constraints in public health together with the high requirements for drug safety to protect the patient. Remarkably, more than half of the therapies in oncology are performed as off-label use. The discussion on off-label use is controversial and based on different points of interests. Evaluation of therapeutic agents by the pharmaceutical industry is predominantly driven by marketing and business requirements. As a consequence, treatment of rare diseases is often only possible by off-label use, creating more or less an off-label need. Reimbursement by health-care insurance is based on the approval of a pharmaceutical substance for a particular situation, because only the rigorous licensing process assures that the verified efficacy is higher than the, often severe, adverse side effects. It is a well known fact that the sometimes adverse events, which occur on administration of substances in an off-label fashion, are not included in the information on the regular use of a given drug. Finally, physicians request a controlled off-label use, which only allows experienced colleagues and (sub)-specialized oncologists to use pharmaceuticals in an off-label fashion. Up to date no legal documents exist that provide regulations for such an off-label usage.

Withdrawal of growth-promoting antibiotics in Europe and its effects in relation to human health

The glycopeptide avoparcin, bacitracin, the macrolides spiramycin and tylosin, and the streptogramin virginiamycin were withdrawn as growth promoters in the European Union between 1995 and 1999 on the basis of the Precautionary Principle. Relevant resistance thereupon diminished among enterococci (the indicator organisms) isolated from animal and human faeces. However, animal enterococci were shown to differ from those that caused human infections, although their resistance genes were sometimes indistinguishable and thus probably have a common origin. Before the ban, human clinical isolates of enterococci resistant to vancomycin or teicoplanin were uncommon in many, but not all, parts of Europe and resistance to quinupristin/dalfopristin in the case of Enterococcus faecium was very rare. After the ban, these resistances increased in prevalence almost universally, to the detriment of human health. Campylobacters, normally susceptible to macrolides, increased in prevalence before and after the ban. Analyses suggest that the added risk to human health from resistance among enterococci and campylobacters selected by growth promoter use is small, whilst the benefit to human health from their use, hitherto largely ignored, might more than counterbalance this.

Implementing changes to the state operations manual

For most consultant pharmacists, long-term care pharmacies, and nursing facilities, preparation for and implementation of the new Pharmacy Services and Unnecessary Medications guidelines in the State Operations Manual will be a multistep process. In the final guidelines released in December 2006, the Centers for Medicare & Medicaid Services made modifications to the "Advance Copy" version of the guidelines released in September 2006. Consultant pharmacists will play a key role in helping facilities interpret the newest version of the guidelines and determine whether they need to alter their processes to maintain regulatory compliance.

Antimicrobial resistance in Scandinavia after ban of antimicrobial growth promoters

The banned use of antimicrobial growth promoters resulted in a considerably decreased use of antimicrobials in food animal production in Sweden (65%), Denmark (47%), Norway (40%) and Finland (27%). The current prevalence of antimicrobial resistance in animal bacterial populations is also considerably lower than in some other countries in the EU. In the swine production, no or limited effect was found in the finisher production (>25 to 30 kg). Temporary negative effects occurred during the post weaning period (7-30 kg). In Denmark, the cost of production from birth to slaughter per pig produced increased by approximately 1.0 euro with a high variability between pig producers. In the broiler production the termination had no significant negative effect on animal health and welfare or on production economy.

Opioids in the Treatment of Chronic Pain: Legal Framework and Therapeutic Indications and Limitations

The most important message that physicians must communicate to persons with chronic pain is that, currently, no medication exists that will take away more than 30% of the pain they experience. Chronic pain is a chronic disease and, like diabetes or hypertension, requires chronic concessions and lifestyle modifications. In controlled trials of short duration and small sample size with highly selected patients, patients sustaining moderate-to-severe pain still experience moderate pain even on opioid medication. Adverse drug effects are predictable and common, and, in fact, long-term compliance with opioids is low owing to side effects. Screening for substance abuse by history taking, observing behavior, obtaining old medical records,and using UDS in patients before initiating opioid therapy is important to identify patients with comorbid addictive disease who require coincident or antecedent treatment. Familiarity with federal and state controlled substance legislation and state health care provider and pain treatment acts is a mundane but essential educational endeavor for all physicians prescribing opioids. If physicians educate their patients with chronic pain about the limited efficacy of the medications, patients' expectations for drug treatment can be more realistic.