Managing inappropriate use of non-prescription combination analgesics containing codeine: A modified Delphi study

'More of an art than a science'? The development, design and mechanics of the Delphi Technique

The Delphi Technique is a group judgement method which is typically used to reach agreement from a group of people with expertise in a particular area. It is an iterative process where panel members complete questionnaires over several rounds, often rating their agreement/disagreement against a statement, with changes made in later rounds based on the feedback received. It has been used widely in pharmacy-related studies relevant to education, research and practice. This paper provides a critical analysis of the various design choices which researchers may consider when planning a Delphi namely the panel of participants, the use of the Likert scale, the effect of feedback, what constitutes consensus and the number of rounds. It also gives an overview of the development and origins of the Delphi, and discusses the advantages and disadvantages of the technique. Advantages include that the Delphi can be conducted with panel members in different geographical locations in their own time, however the technique can therefore take longer to conduct and lacks face-to-face discussion. Patient experts may be less comfortable participating in a relatively complex survey, however the anonymous nature of the process can be more inclusive in allowing participants to feedback candidly. This paper shows the importance of careful planning of the design choices to ensure the reliability and validity of the Delphi.

Over-The-Counter Codeine: Can Community Pharmacy Staff Nudge Customers into Its Safe and Appropriate Use?

The misuse of opioids, including codeine which is sold over-the-counter (OTC) in United Kingdom (UK) community pharmacies, is a growing public health concern. An educational Patient Safety Card was developed and piloted to see if it nudged customers into the safe and appropriate use of OTC codeine. Exploratory analysis was conducted by (i) recording quantitative interactions for people requesting OTC codeine in community pharmacies; and (ii) a web-based pharmacy staff survey. Twenty-four pharmacies submitted data on 3993 interactions using the Patient Safety Card. Staff found the majority of interactions (91.3%) to be very or quite easy. Following an interaction using the card, customers known to pharmacy staff as frequent purchasers of OTC codeine were more likely not to purchase a pain relief medicine compared to customers not known to staff (5.5% of known customers did not purchase any pain relief product versus 1.1% for unknown customers (χ² = 41.73, df = 1, p < 0.001)). These results support both the use of a visual educational intervention to encourage appropriate use of OTC codeine in community pharmacy and the principles behind better self-care.

The attitudes and practice strategies of community pharmacists towards drug misuse management: A scoping review

WHAT IS KNOWN AND OBJECTIVE

Community pharmacists have a key role to play in addressing drug misuse. The objective of this research was to systematically review the current evidence and investigate the attitudes and practice strategies of community pharmacists towards drug misuse management.

METHODS

Data were extracted from 19 studies retrieved via a three-step search strategy using the Arksey and O'Malley methodological framework for conducting scoping reviews.

RESULTS AND DISCUSSION

The attitudes and practice strategies of pharmacists towards drug misuse management and relevance to years of practice experience were discussed in seven of the 19 studies. Pharmacists reported gaps in knowledge and insufficient education and training on drug misuse-related topics. Barriers to the effective management of drug misuse included lack of time and staff training. The most commonly reported strategy to address drug misuse was referral back to the doctor. Eight of the studies identified the benefits of real-time prescription monitoring systems. Pharmacists have a key role to play in addressing drug misuse. Opportunities exist in the development of new and innovative approaches for harm minimization led by pharmacists, and in the examination and evaluation of the pharmacists' role in referral services, interventions and screening.

WHAT IS NEW AND CONCLUSION

It is important to consider the role and contribution of early career pharmacists in the delivery of primary health care. They are the future of the pharmacy profession; therefore, it is critical that they are sufficiently trained and provided with the necessary resources to ensure high quality care in the management of drug misuse.

[Community pharmacists, students in pharmacy, and requests of codeine-based medicines: Observational study]

INTRODUCTION

The case of purple drank motivated a study to investigate the way community pharmacists and students in pharmacy managed, with patients, the abuse risk of non-prescription codeine-based medicines.

METHODS

This prospective descriptive study was conducted, between September and October 2016, within a 170 community pharmacies network of Aquitaine and 437 pharmacy students of Bordeaux university (fourth, fifth and sixth year students, without selection of the pharmacies where they were able to work). It used a common survey questionnaire, which was sent to students through their own "Facebook" (Facebook Inc.) groups.

RESULTS

Pharmacists advised codeine-based medicines in self-medication mostly as a second line pain treatment (96.2%), students also (72.1%). The opinions of pharmacists were almost equally shared concerning their ability to identify dependent patients or to raise the subject of addiction with them (57.7% and 53.8% of positive responses). This seemed to be more difficult for students (57.4% doubted about their ability of identification, 73.8% felt unable to address this issue with patients). Successful experiences concerning help to pharmacodependent patients were rare (11.5% of pharmacist, 4.9% of students). All were involved in patient information on these medicines use. Their opinions about an evolution toward a mandatory prescription status for all codeine-based medicines were almost equally split: 50% of pharmacists were favourable to it, 44.3% of students. They expressed the need for information tools in the care of these patients (46.2% of community pharmacists, 63.9% of students).

CONCLUSION

These results illustrated the interest of pharmacists, and students in pharmacy, toward pharmacodependent patients; they also showed the complexity of this relation. Thus, they could help the elaboration of information tools in the care of these patients, with an adaptation for students who nevertheless presented a good maturity about this question.

Implementation of a clinical tool to assess and address pain management requests in the pharmacy

BACKGROUND

Morbidity and mortality associated with inappropriate use of over-the-counter combination analgesics containing codeine (OTC CACC) in Australia resulted in it being upscheduled in 2010 from "Pharmacy Only" (Schedule 2) to "Pharmacist Only" (Schedule 3), and further to "Prescription Only" (Schedule 4) in February 2018. There have been a number of concerns and challenges identified by community pharmacists in the provision of OTC CACC. In practice, sub-optimal management of patients accessing these medications has been demonstrated. To assist the management of patients using OTC CACC, the development of a management and referral pathway would be advantageous.

OBJECTIVES

To evaluate the use of an online interactive clinical tool and/or clinical information via an online PDF-based platform for managing OTC CACC requests and codeine dependence.

METHOD

Two interactive online clinical tools to aid management of patients who presented requesting OTC CACC were developed. Evaluation of these tools was undertaken using responses to multiple choice questions and feedback from pharmacist surveys.

RESULTS

Of the 904 pharmacists who responded to the evaluation survey, 66.7% had not used the tool in the preceding 12 months. The most common reason why pharmacists did not access either the online interactive, or online PDF clinical tools was that they had no knowledge of them. Older age of the pharmacist (50 years or older compared to younger than 30) predicted tool access (adjusted proportional odds ratio = 3.16, 95% CI 1.72-5.80, p < 0.001). The access of the tool was positively associated with it being perceived as useful (adjusted odds ratio = 14.7, 95% CI 6.7-32.5, p < 0.001).

CONCLUSION

A number of pharmacists participating in the evaluation had never accessed either the online interactive or online PDF clinical tool, as they were not aware of them. Further research needs to be conducted into how to best promote and increase awareness of online clinical tools to pharmacists, especially younger pharmacists, and determine the best way to integrate online clinical tools effectively and efficiently into current practice.

Preparation, Characterization and Pharmacokinetics Evaluation of the Compound Capsules of Ibuprofen Enteric-Coated Sustained-Release Pellets and Codeine Phosphate Immediate-Release Pellets

The objective of this study was to prepare ibuprofen enteric-coated sustained-release pellets (IB-SRPs) and codeine phosphate immediate-release pellets (CP-IRPs) to play a synergistic role in analgesia. The pellets were developed by extrusion-spheronization and fluidized bed coating technology. The single-factor investigation was used to determine the optimal prescription and process. The sustained-release membrane of IB-SRPs was water-insoluble ethyl cellulose (EC), triethyl citrate (TEC) was used as plasticizer, and hydroxypropyl methylcellulose (HPMCP) was chose as porogen. Besides, the immediate-release layer of CP-IRPs was gastric-soluble coating film. The ibuprofen and codeine phosphate compound capsules (IB-CP SRCs) were prepared by IB-SRPs and CP-IRPs packed together in capsules with the optimum doses of 200 and 13 mg, respectively. The prepared pellets were evaluated by scanning electron microscopy and dissolution test. Pharmacokinetic studies in beagle dogs indicated that the optimized IB-CP SRCs had smaller individual differences and better reproducibility comparing with commercial available tablets. Additionally, IB-CP SRCs achieved consistency with in vivo and in vitro tests. Therefore, IB-CP SRCs could play a great role in rapid and long-term analgesic.

Non-prescription supply of combination analgesics containing codeine in community pharmacy: A simulated patient study

BACKGROUND

The inappropriate use of non-prescription combination analgesics containing codeine (NP-CACC) has become a significant health issue in Australia.

OBJECTIVE

To investigate the current management of NP-CACC direct product requests in community pharmacies located in Victoria, Australia.

METHODS

A covert simulated patient (SP) method was used to observe the responses of pharmacy staff during an NP-CACC request. Four SPs were trained to complete 1 of 2 scenarios. Each scenario involved a direct product request for Nurofen Plus (200 mg ibuprofen, 12.8 mg codeine) with identical reason for use, symptoms, and medical history but varied previous product use. Scenario One (Sc1) involved a first time NP-CACC user and in Scenario Two (Sc2) the SP had used NP-CACC regularly for the past month. Each visit was documented by the SP immediately after they left the pharmacy. A NP-CACC supply score, created from 4 outcomes (pharmacist involvement, establishment of therapeutic need, establishment of safety and provision of counselling), was given to each pharmacy visit (maximum of 8) during data analysis.

RESULTS

145 pharmacy visits were completed. Both scenarios were performed in most of the 75 pharmacies visited (73 Sc1 and 72 Sc2). Treatment was provided in the majority of visits but refused in 37(24%) because the SP was unable to provide photo identification. A pharmacist was involved (directly or indirectly) in 77% of visits. Adequate questioning to establish therapeutic need occurred in 50% of pharmacy visits, safety was established in 17% of visits, and adequate counselling provided in 17% of visits. The SP scenario did not significantly affect the NP-CACC supply outcomes. NP-CACC supply scores ranged from 1 to 8, (Md = 5) with only 1 pharmacy visit achieving the maximum score of 8.

CONCLUSIONS

The majority of pharmacy visits did not achieve a full score relating to NP-CACC supply, illustrating the need for improved awareness of how to assess and manage patients requesting NP-CACC.