Over the counter medicines: proceed with caution

Australian pharmacy perspectives on increasing access to medicines through reclassification

OBJECTIVES

Availability of medicines without prescription can increase consumers' timely access to treatment and promote self-management of minor ailments and adherence to long-term medications. Globally, access to relevant medicines has improved through increased reclassification of medicines from prescription to non-prescription availability. However, Australian reclassification lags behind countries with comparable health systems, and the factors influencing this are poorly understood.

METHODS

Semi-structured interviews were conducted during May 2015 to explore the perspectives of Australian pharmacists and support staff on future reclassification. Interview responses were transcribed verbatim, and the data were analysed thematically, primarily informed by the general inductive approach.

RESULTS

Participants identified a broad range of medicines as candidates for future reclassification by applying risk versus benefit judgements, assessing any medicines with potential for misuse and hazardous medicines as unsuitable. Key drivers for change in classification were underpinned by participants' desire to support consumers' management of minor ailments and adherence for those on long-term therapy. Barriers to reclassification were identified by pharmacy staff as internal, negatively impacting pharmacists' readiness for reclassification and external, negatively impacting the overall progress of change.

CONCLUSIONS

While the research provided valuable insights to inform the ongoing discussion on future reclassification, a larger, more representative sample is needed to confirm these findings.

Anticholinergic and sedative drug burden in community-dwelling older people: a national database study

OBJECTIVES

The Drug Burden Index (DBI) tool quantifies individual exposure to anticholinergic and sedative medications. The DBI has been internationally validated against adverse health outcomes in older people. DBI exposure has not been reported in the Irish older population. This study aimed to: (1) develop a list of drugs with clinically significant anticholinergic and/or sedative effects (DBI medications) relevant to Ireland; (2) examine, using the DBI formula, the prevalence of exposure to DBI medications in Irish older people and (3) explore patient factors associated DBI exposure.

DESIGN

A cross-sectional national pharmacy claims database study.

SETTING

Community setting using the General Medical Services (GMS) scheme pharmacy claims database maintained by the Health Service Executive Primary Care Reimbursement Services.

PARTICIPANTS

Irish older individuals (aged ≥65 years) enrolled in the GMS scheme and dispensed at least one prescription item in 2016 (n=428 516).

MAIN OUTCOME MEASURES

Prevalence of exposure to DBI medications and patient factors associated with DBI exposure.

RESULTS

282 874 (66%) of the GMS population aged ≥65 years were exposed to at least one DBI medication in 2016. Prevalence of exposure to DBI medications was significantly higher in females than males (females 71.6% vs males 58.7%, adjusted OR 1.65, 95% CI 1.63 to 1.68). Prevalence of DBI exposure increased progressively with the number of chronic drugs used, rising from 42.7% of those prescribed 0-4 chronic drugs to 95.4% of those on ≥12 chronic drugs (adjusted OR 27.8, 95% CI 26.7 to 29.0). The most frequently used DBI medications were codeine/paracetamol combination products (20.1% of patients), tramadol (11.5%), zopiclone (9.5%), zolpidem (8.5%), pregabalin (7.9%) and alprazolam (7.8%).

CONCLUSIONS

The majority of older people in Ireland are exposed to medications with anticholinergic and/or sedative effects, particularly females and those with multiple comorbidities. The high use of low-dose codeine/paracetamol combination products, Z-drugs and benzodiazepines, suggests there are opportunities for deprescribing.

Over-the-Counter Codeine-from Therapeutic Use to Dependence, and the Grey Areas in Between

Codeine is a widely used analgesic, that is available for sale in pharmacies over the counter (OTC) in a number of countries including the UK, South Africa, Ireland, France and Australia. In these countries with OTC codeine sales there has been emerging concerns about misuse of and dependence on codeine containing combination analgesics, with increasing numbers of people presenting for help with codeine dependence at primary care and addiction treatment services. This has led to many countries reviewing availability of codeine in OTC available preparations, and considering possible measures to reduce harms from misuse of OTC codeine containing combination analgesics.

“Doctor shopping and pharmacy hopping”: practice innovations relating to codeine

Purpose

– The misuse of pharmaceutical opioid analgesics is identified as a global public health concern. Codeine represents an interesting quandary in terms of its regulated status, with individuals varying in their metabolism of codeine, estimation of safe dosages, risk of adverse health consequences and abuse potential. Efforts to quantify and address hidden non-compliant medical codeine use, overuse and intentional misuse is compromised by availability to the public in prescribed and over the counter forms. The paper aims to discuss these issues.

Design/methodology/approach

– A review of literature on codeine use, misuse and dependence, and associated innovative medical and pharmacy interventions is presented, and was conducted as part of a larger scoping review on codeine.

Findings

– The review highlights the complexities associated with monitoring public health awareness of codeine's abuse potential, and customer/patients trends in non-compliant codeine use for therapeutic and recreational purposes. Aberrant codeine behaviours centre on visiting multiple doctors for prescriptions, repeated lost or stolen prescriptions, forging prescriptions and use of multiple pharmacies. Innovations to monitor misuse of codeine include national prescription databases and recent developments in real-time monitoring of dispensing activity.

Practical implications

– Further development of real-time monitoring processes with process evaluation is advised.

Originality/value

– This viewpoint is intended to demonstrate how efforts to quantify and address codeine use are compromised by its availability. It intends to encourage further policy and practitioner dialogue on how to monitor, support and intervene with consumers misusing codeine.

Swedish teenagers and over-the-counter analgesics - responsible, casual or careless use

BACKGROUND

Teenagers in Sweden were given greater access as consumers of OTC drugs in 2009 after the reregulation of the pharmacy market, which allowed for the establishment of private pharmacies and sale of specific over-the-counter (OTC) drugs in retail stores and gas stations. Increased access to OTC drugs could provide new opportunities for self-care but attenuates the opportunity for the traditional expert surveillance of pharmacists, thus increasing the possibility of inappropriate OTC drug use.

OBJECTIVES

Views of 16-19 year old Swedish teenagers on OTC drugs, with special regard to analgesic drugs were explored and described, based on the following questions: How and where did they acquire their knowledge and attitudes regarding OTC drugs? What perceptions did they have about the use of OTC drugs?

METHODS

A qualitative approach with a descriptive design was chosen. Data were collected in 2011 with 10 focus group discussions with high school students aged 16-19 years from different parts of Sweden. A total of 77 teenagers participated, 33 males and 44 females. A manifest qualitative content analysis was performed.

RESULTS

While most teenagers appeared to have responsible attitudes toward OTC drugs and their use, some teenagers had attitudes that ranged from casual to careless. The focus group discussions also revealed knowledge gaps among teenagers regarding OTC drugs, and the significant influence of parents and peers on their OTC drug use.

CONCLUSIONS

This study provides insight into how vulnerable some teenagers could be as new consumers of OTC drugs and suggested that educational efforts could be geared toward parents as well as teenagers.

Five years of non-prescription oseltamivir: effects on resistance, immunization and stockpiling

Objectives

In 2007 New Zealand (NZ) became the first country to make oseltamivir (Tamiflu®) available off-prescription. This study investigated the extent of pharmacist supply of oseltamivir over 5 years, including during the influenza A(H1N1) pandemic, and the impact of pharmacist supply of oseltamivir on influenza virus oseltamivir susceptibility, personal stockpiling and influenza vaccine uptake.

Methods

Randomly selected community pharmacies in NZ reported oseltamivir provision by prescription and through pharmacist supply from 1 January 2007 to 15 September 2011. Oseltamivir resistance data on influenza viruses isolated during influenza surveillance from 2008 to 2011 were obtained, along with influenza vaccine uptake data from 2005 to 2011 and influenza detection data.

Results

Seventy of 85 eligible pharmacies completed the study (82% response rate). Most supplies of oseltamivir throughout the 5 years were dispensed against a prescription rather than pharmacist supplied, with pharmacist supply responsible for 11% of supplies during the pandemic years (2009–10) versus 27% and 31% during 2007 and 2008, respectively. Pharmacist-supplied oseltamivir did not appear to be associated with the development of resistance, with identified likely stockpiling or with a decline in influenza immunization. Pharmacist supplies largely matched the timing of influenza in the community and peaked in June 2009, as did prescription supplies.

Conclusions

Five years of non-prescription oseltamivir in NZ has resulted in no significant change in the development of resistance or rates of influenza immunization. Supplies remained modest and significant consumer stockpiling through pharmacist supply has not occurred, even during the influenza A(H1N1)pdm09 pandemic in 2009 and 2010. Pharmacists could be better utilized in ensuring fast distribution of antivirals to influenza sufferers during a pandemic.

Current management and recommendations for access to antiviral therapy of herpes labialis

Herpes labialis is a common skin infective condition, worldwide, which is primarily caused by HSV-1. Recurrent episodes of herpes labialis, also known as cold sores, can be frequent, painful, long-lasting and disfiguring for infected patients. At present, there are two types of antivirals for the treatment of herpes labialis, topical and oral, which are available over the counter or as prescription-only. The aim of antiviral therapy is to block viral replication to enable shortening the duration of symptoms and to accelerate healing of the lesions associated with herpes labialis. This review examines the evidence for the effectiveness of current topical and oral antivirals in the management of recurrent episodes of herpes labialis. In most countries, oral antivirals for herpes labialis are available as prescription-only. However, in early 2010, the oral antiviral famciclovir was reclassified from prescription-only medicine to pharmacist-controlled status in New Zealand. The benefits and risks associated with moving an antiviral therapy for herpes labialis from prescription-only to pharmacist-controlled status are reviewed here, and the implications for patients, general physicians and pharmacists are considered.

Results of a national survey on over-the-counter medicines, Part 1: Pharmacist opinion on current scheduling status

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BACKGROUND

OTC medicines make up an important part of the community pharmacy world. As with most aspects of practice, however, hurdles exist that prevent an optimal level of care.

OBJECTIVE

To gauge pharmacist agreement on the scheduling status of various OTC medicines.

METHODS

Pharmacists across Canada were surveyed by mail.

RESULTS

Of the 5037 surveys mailed, 2403 were returned, with 2305 being usable for analysis (response rate of 49.4%). Across 25 agents, pharmacists tended to support existing control for pharmacies (such as Nix crème rinse and minoxidil topical solution) and returning control to pharmacies for unscheduled agents (such as ranitidine 75 mg tablets and nicotine patches).

CONCLUSIONS

Pharmacists generally favour tighter control of OTC agents, especially those that are unscheduled. This hopefully reflects pharmacist desire to ensure their proper selection and use.

Oral ingestion of a topical benzydamine hydrochloride-containing gynaecological preparation in association with television advertising in Italy: analysis of cases managed by a National Poison Control Centre

Objective To evaluate the impact of a television advertising campaign on the risk of oral ingestion of a topical non-prescription gynaecological preparation containing benzydamine hydrochloride. Design An interrupted time series design with data routinely collected. Setting A National Poison Control Centre. Participants 215 cases of hazardous exposure to the preparation under study occurred in Italy from January 2005 to December 2010. Primary and secondary outcome measures Mean daily rate of cases of exposure by gender in three different periods, that is, pre-advertisement period, before the advertisement was broadcast (from 1 January 2005 to 19 December 2009), advertisement period, when the advertisement was repeatedly launched (from 20 December 2009 to 27 February 2010), post-advertisement period (from 28 February 2010 to 6 March 2010); observed/expected ratios of cases, with expected cases based on data from the pre-advertisement period, adjusted for estimated variations in the number of users. Comparison of the distribution of the main characteristics of cases in the three different periods by means of Pearson's χ(2) test or Fisher's exact test. Results The adjusted observed/expected ratio of cases in women was 7.48 (95% CI 5.76 to 9.56) in the advertisement period and 2.97 (95% CI 2.24 to 3.85) in the post-advertisement period. Regarding the characteristics of cases, there was an increased proportion of cases of exposure due to confusion about the correct administration route in the advertisement and post-advertisement periods (81% and 55%, respectively, compared to 16% for the pre-advertisement period.) and of individuals with clinical effects (55%, 52% and 27%, respectively). Conclusions In Italy, an advertisement for a non-prescription medicine seems to have confused consumers regarding the administration route. This effect was observed even after the advertisement had stopped being broadcast. These results highlight the need for the monitoring of medication errors and adverse effects before, during and after advertising.

Nature and frequency of drug-related problems in self-medication (over-the-counter drugs) in daily community pharmacy practice in Germany

PURPOSE

To quantify drug-related problems (DRPs) in self-medication (over-the-counter [OTC] drug use) identified by community pharmacists (CPs) in Germany at the time the drug is dispensed.

METHODS

One hundred CPs were asked to document 100 consecutive customers presenting symptoms or requesting OTC drugs using a standardized documentation form. The number of 10,000 encounters seemed reasonable to evaluate the set objective. For each encounter, data such as age, sex, and first or repeated request and the availability of a patient file in the pharmacy including drug history were documented. Furthermore, identified DRPs, problem descriptions, and solutions were documented. Data were transcribed electronically, coded, checked for validity, and analyzed.

RESULTS

In total, 109 CPs documented 12,567 encounters identifying DRPs in 17.6% of all cases. Four indications comprised more than 70% of all DRPs: pain, respiratory, gastrointestinal, and skin disorders. Four DRPs were responsible for almost 75% of all DRPs identified: self-medication inappropriate (29.7%), requested product inappropriate (20.5%), intended duration of drug use too high including abuse (17.1%), and wrong dosage (6.8%). If a drug history was available, significantly more cases with wrong dosage (p < 0.05) and drug-drug interactions (p < 0.001) were detected. All patients with identified DRPs were counseled accordingly. Furthermore, the most frequent interventions were referral to a physician (39.5%) and switching to a more appropriate drug (28.1%).

CONCLUSIONS

In nearly one of five encounters, a direct pharmacist-patient interaction about self-medication revealed relevant DRPs. Having access to patient files including data on prescription and OTC drugs may increase patient safety.

Sex, drugs and gender roles: mapping the use of sex and gender based analysis in pharmaceutical policy research

BACKGROUND

Sex and gender sensitive inquiry is critical in pharmaceutical policy due to the sector's historical connection with women's health issues and due to the confluence of biological, social, political, and economic factors that shape the development, promotion, use, and effects of medicinal treatments. A growing number of research bodies internationally have issued laws, guidance or encouragement to support conducting sex and gender based analysis (SGBA) in all health related research.

METHODS

In order to investigate the degree to which attempts to mainstream SGBA have translated into actual research practices in the field of pharmaceutical policy, we employed methods of literature scoping and mapping. A random sample of English-language pharmaceutical policy research articles published in 2008 and indexed in MEDLINE was analysed according to: 1) use of sex and gender related language, 2) application of sex and gender related concepts, and 3) level of SGBA employed.

RESULTS

Two thirds of the articles (67%) in our sample made no mention of sex or gender. Similarly, 69% did not contain any sex or gender related content whatsoever. Of those that did contain some sex or gender content, the majority focused on sex. Only 2 of the 85 pharmaceutical policy articles reviewed for this study were primarily focused on sex or gender issues; both of these were review articles. Eighty-one percent of the articles in our study contained no SGBA, functioning instead at a sex-blind or gender-neutral level, even though the majority of these (86%) were focused on topics with sex or gender aspects.

CONCLUSIONS

Despite pharmaceutical policy's long entwinement with issues of sex and gender, and the emergence of international guidelines for the inclusion of SGBA in health research, the community of pharmaceutical policy researchers has not internalized, or "mainstreamed," the practice. Increased application of SGBA is, in most cases, not only appropriate for the topics under investigation, but well within the reach of today's pharmaceutical policy researchers.

Use of simulated patients to assess the clinical and communication skills of community pharmacists

OBJECTIVE

To investigate the quality and appropriateness of Emergency Hormonal Contraception (EHC) supply from community pharmacies.

SETTING

Community pharmacies in the southwest of England during 2007.

METHOD

Two simulated patient ('mystery shopper') scenarios to each participating pharmacy, one where the supply of EHC would be appropriate (scenario 1) and one where there was a drug interaction between EHC and St John's Wort, and the supply inappropriate (scenario 2). Pharmacy consultations were rated using criteria developed from two focus groups: one with pharmacist academics and one with female university students. Feedback to pharmacists to inform their continuing professional development was provided.

MAIN OUTCOME MEASURE

Scores on rating scales encompassing the clinical and communication skills of the participating community pharmacists completed immediately after each mystery shopper visit.

RESULTS

40 pharmacist visits were completed: 21 for scenario 1 and 19 for scenario 2. Eighteen pharmacists were visited twice. Five pharmacists visited for scenario 2 supplied EHC against professional guidance, although other reference sources conflicted with this advice. Pharmacies which were part of the local PGD scheme scored higher overall in scenario 1 (P = 0.005) than those not part of the scheme. Overall the communication skills of pharmacists were rated highly although some pharmacists used jargon when explaining the interaction for scenario 2.

CONCLUSION

Formatively assessing communication skills in an integrative manner alongside clinical skills has been identified as an important part of the medical consultation skills training and can be incorporated into the routine assessment and feedback of pharmacy over-the-counter medicines advice.

Review: Taking care of yourself in later life: A qualitative study into the use of non-prescription medicines by people aged 60+

The last 40 years have witnessed substantial changes to the experience of later life. Health and life expectancy have improved and the emergence of a putative third age has allowed post-working life to move beyond being a residual social category to become an arena in which later life lifestyles can be constructed. Greater emphasis is now placed on expectations of self-agency and choice. Allied to this is the growing role of consumerism as a way of organizing key aspects of social life. Not only do these changes place increased emphasis on individual responsibility for health, but they also engage individuals in various forms of health consumerism.This study draws on these aspects of contemporary society to provide an explanatory framework for understanding older people’s engagement with, and consumption of non-prescription medicines. We present a qualitative study in which we interviewed 22 men and women aged 60 plus who were purchasing or interested in purchasing non-prescription medicines, including complementary and alternative medicines. Our findings suggest that the use of non-prescription medicines is both pluralistic and makeshift. Moreover, while this pluralism led to tensions with conventional bio-medicine, conventional bio-medicine still maintained the legitimacy of its knowledge base. Self-care using non-prescription medicines appeared more governed by hope than by evidence or knowledge of the treatments concerned.We conclude that such pluralism of approach reflects the growing consumerism in health and self-care and that older people may in fact be similar to other age groups in terms of their approach to such commodification.

[Over the counter medication in pregnant women]

A prospective survey is conducted in a population of pregnant women in order to evaluate the prevalence of pregnant women using over the counter medication, to define their profile and to evaluate the information received about prenatal drug exposure and teratogen risk. During the study period, 223 women were interviewed, 23.3% of them use over the counter medication. In most cases, the drugs are "comfort drug". One woman, only, had taken anti-inflammatory during the first trimester. Only 51% had received information on drug and teratogen risk. Self medication is not frequently used by the pregnant women. The information provided by health professionals, about the risk and OTC medications during pregnancy, is insufficient.

From prescription-only to over-the-counter medicines ('PoM to P'): time for an intermediate category

BACKGROUND

Increasing numbers of medicines are being made available over the counter in the UK, by purchase in a pharmacy or from other less well-regulated outlets. When this is allowed by the Licensing Authority, it is often subject to certain restrictions. However, some drugs that could usefully be converted from prescription-only medicines (PoM status) to over-the-counter sales in a pharmacy (P status) are not suitable for full over-the-counter status, even with restrictions; and in some cases restrictions vitiate the usefulness of the medicine.

AREAS OF AGREEMENT

Drugs that can acceptably be switched from PoM status to P status include those that are used in the treatment of minor ailments or injuries, for health promotion or in palliative care.

AREAS OF CONTROVERSY

However, not all drugs that are being switched fall into these categories. Ready availability of antimicrobial drugs over the counter, one of which (azithromycin) has recently been switched, could encourage the emergence of resistant organisms. Drugs that are used for long-term treatment and lifestyle drugs are also controversial, particularly if their adverse effects are of potential concern. On the other hand, the availability of many drugs via the internet removes the ability of regulators to control the supply of such drugs. A POSSIBLE SOLUTION: A new category of purchase, Pharmacist Consultation and Supply, with built-in safeguards, could improve the availability of some medicines under more careful control than is currently available for over-the-counter medicines.