Adapting a community pharmacy intervention to improve medication safety

BACKGROUND

Community pharmacies are an ideal location to address challenges of over-the-counter medication safety, yet many successful interventions are only tested in a few pharmacies without expansion, creating unrealized opportunities to improve patient care on a larger scale. Scaling up to numerous pharmacies can be challenging because each community pharmacy has unique needs and layouts and requires individualized adaptation.

OBJECTIVES

This paper reports techniques for (a) adapting a community pharmacy intervention to fit the unique physical layout and patient needs of health system pharmacy sites without increasing staff workload, (b) identifying strategies to gather feedback on adaptations from stakeholders, and (c) developing materials to share with pharmacy champions for them to independently implement and sustain the intervention in their organization.

PRACTICE DESCRIPTION

The study team collaborated with Aurora Pharmacy, Inc to develop an intervention designed to increase awareness of safe over-the-counter medication use for older adults.

PRACTICE INNOVATION

Senior Safe, a community pharmacy-based intervention, was designed, implemented, and tested using the Exploration, Preparation, Implementation, and Sustainment implementation framework.

EVALUATION METHODS

Senior Safe was adapted through pilot testing and a randomized control trial. Feedback was collected from key stakeholders, including pharmacy staff, older adults, and a research advisory group.

RESULTS

A finalized version of Senior Safe, as well as an implementation package, was provided to Aurora Pharmacy to integrate into all 63 sites.

CONCLUSION

This multiphase study illustrated that refining an intervention is possible and welcomed by pharmacy staff, but it requires time, resources, and funds to create an impactful, sustainable community pharmacy intervention.

Over-the-Counter Medicine-Seeking Behavior in Patients With Dermatophyte Infections Across Various Socioeconomic Strata: A Cross-Sectional Study

BACKGROUND AND OBJECTIVE

In dermatology outpatient departments in India, dermatophytosis is the most commonly encountered dermatosis. The objective was to collect data regarding the prevalence of over-the-counter (OTC) medication, knowledge of the illness, and hygiene habits among people with dermatophyte infections across various socioeconomic classes.

METHODS

At a tertiary care facility in central India, a cross-sectional study was carried out over six months. Data about socioeconomic class, hygiene routines, prior history of any type of treatment, understanding of the condition, and family history of similar illnesses were noted. A total of 551 patients were included in the study. The correlation was evaluated using Spearman's correlation coefficient (rho).

RESULTS

Socioeconomic class had little impact on seeking dermatologist advice. Steroids were prescribed to approximately 81.8% of all patients. There was a positive correlation (rho = 0.237) between the use of steroids and the severity of the condition. Around 34% of patients took prescription medications, as recommended by a pharmacist. The use of steroids positively correlated (rho = 0.426, p<0.001) with prescriptions by pharmacists. Over-the-counter drug availability and individuals believing pharmacists were qualified to identify and treat illnesses were significant contributing causes.

CONCLUSIONS

People from all socioeconomic strata need to be made more aware of the risks associated with the inappropriate use of medications and skin problems in general. Strict regulations to control prescription drug sales and deter practitioners of alternative medicine from prescribing allopathic medications may be beneficial.

Development and Pilot Testing of the OTC Coach Software to Support Student Pharmacist Learning

Description of the problem: Pharmacy students are expected to learn how condition and patient-specific factors influence medication decision-making. Our objective was to create an interactive learning tool that would support students as they learn how individual factors change over-the-counter (OTC) medication recommendations. Description of the innovation: OTC Coach was created to allow student pharmacists to practice making recommendations about OTC medications. First year student pharmacists enrolled in a required self-care therapeutics course were given access to the optional OTC Coach, which included electronic decision algorithms for 10 topics. Student perceptions were collected via an online survey. Critical analysis: Two-thirds of the first-year students enrolled in the self-care therapeutics course activated their OTC Coach account (n=53/79, 67%). Among the students who completed the survey and reported using the tool (n=60/75, 80%), there was agreement that it help them learn the course material (78%), increased their confidence in making appropriate therapeutic recommendations (78%), increased their confidence when answering examination questions (63%), and improved their examination performance (61%). Next steps: Implementing an electronic tool positively supported student learning about OTC medication recommendations, according to student self-report. The tool is being expanded to include an option for students to generate a series of scenarios with randomized patient and condition factors to further allow students to efficiently practice making repeated patient-centered recommendations.

Evidence-Based Pharmaceutical Care in Community Pharmacies: A Survey of 595 French Pharmacists

We assessed the use of evidence-based practice (EBP) among pharmacists working in community pharmacies in France and the factors linked to this practice. During 3 months in 2018, an online survey was sent to over 7000 active pharmacists and posted on pharmacists' social media sites. In total, 595 pharmacists completed the questionnaire. The responders were on average younger than the general population of community pharmacists. The 40-item questionnaire described four fictional clinical cases reflecting typical situations (conventional medicine and complementary and alternative medicine) encountered daily by community pharmacists. Multiple-choice responses were proposed and scored according to whether they reflected EBP. A high total score indicated behaviour in line with EBP. We observed 344/595 participants with a positive EBP score (57.8% [53.7-61.8%]). Univariate and multivariate analyses were used to evaluate factors that might explain adherence to EPB (the pharmacy's characteristics, the pharmacist's status, the mode of continuing education and sources of information). The majority relied on pharmaceutical industry and other biased and/or non-evidence-based sources, particularly concerning information on homeopathic products. The consultation of independent reviews, health agency recommendations and peer-reviewed scientific journals was associated with evidence-based decisions. In contrast, reliance on pharmaceutical industry documents, personal experience and informal handbooks was linked to lower EBP scores. The level of EBP use by French community pharmacists needs to be improved to ensure that good-quality, science-based advice is given to customers.

Association Between Purchase of Over-the-Counter Medications and Ovarian Cancer Diagnosis in the Cancer Loyalty Card Study (CLOCS): Observational Case-Control Study

BACKGROUND

Over-the-counter (OTC) medications are frequently used to self-care for nonspecific ovarian cancer symptoms prior to diagnosis. Monitoring such purchases may provide an opportunity for earlier diagnosis.

OBJECTIVE

The aim of the Cancer Loyalty Card Study (CLOCS) was to investigate purchases of OTC pain and indigestion medications prior to ovarian cancer diagnosis in women with and without ovarian cancer in the United Kingdom using loyalty card data.

METHODS

An observational case-control study was performed comparing purchases of OTC pain and indigestion medications prior to diagnosis in women with (n=153) and without (n=120) ovarian cancer using loyalty card data from two UK-based high street retailers. Monthly purchases of pain and indigestion medications for cases and controls were compared using the Fisher exact test, conditional logistic regression, and receiver operating characteristic (ROC) curve analysis.

RESULTS

Pain and indigestion medication purchases were increased among cases 8 months before diagnosis, with maximum discrimination between cases and controls 8 months before diagnosis (Fisher exact odds ratio [OR] 2.9, 95% CI 2.1-4.1). An increase in indigestion medication purchases was detected up to 9 months before diagnosis (adjusted conditional logistic regression OR 1.38, 95% CI 1.04-1.83). The ROC analysis for indigestion medication purchases showed a maximum area under the curve (AUC) at 13 months before diagnosis (AUC=0.65, 95% CI 0.57-0.73), which further improved when stratified to late-stage ovarian cancer (AUC=0.68, 95% CI 0.59-0.78).

CONCLUSIONS

There is a difference in purchases of pain and indigestion medications among women with and without ovarian cancer up to 8 months before diagnosis. Facilitating earlier presentation among those who self-care for symptoms using this novel data source could improve ovarian cancer patients' options for treatment and improve survival.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03994653; https://clinicaltrials.gov/ct2/show/NCT03994653.

A Case of Severe Hypoxia Caused by Phenazopyridine-Induced Methemoglobinemia: A near Fatal Event from Over-the-Counter Medication Use

Methemoglobinemia is a rare blood disorder characterized by the oxidation of heme iron from ferrous (Fe²⁺) to ferric (Fe³⁺) state, which increases oxygen affinity and impairs oxygen release to the tissue causing hypoxia. It can be congenital or acquired; however, most cases are acquired and caused by exogenous substances such as medications, chemicals, and environmental substances. Phenazopyridine is an over-the-counter urinary analgesic medication commonly used for symptomatic relief of dysuria and has been reported to cause methemoglobinemia. However, only a handful of cases of phenazopyridine-induced methemoglobinemia have been reported. We present a case of an 89-year-old female who presented with severe hypoxia, shortness of breath, headache, nausea, and dizziness caused by phenazopyridine-induced methemoglobinemia. She was found to have a methemoglobin level of 21.5% and was treated with methylene blue, leading to a rapid improvement of her symptoms. She was taking one over-the-counter phenazopyridine 200 mg tablet three times daily for two weeks for her chronic dysuria. This case highlights the need to have a high index of suspicion of phenazopyridine-induced methemoglobinemia in a patient presenting with unexplained shortness of breath with a history of phenazopyridine use as it could lead to severe methemoglobinemia with hypoxia that could potentially be fatal if not promptly diagnosed.

Disease-Drug Interactions Requiring Special Attention

This short review addresses disease-drug interactions requiring special attention, namely interactions between common conditions and over-the-counter medication and interactions between rare conditions and drugs that are absolutely contraindicated. We specifically examine over-the-counter analgesics, antiemetics and drugs used to treat allergy symptoms and underlying disease conditions they can exacerbate. Resources for avoiding disease-drug interactions in patients with rare conditions, such as myasthenia gravis, glucose-6-phosphate deficiency, mitochondriopathies and long QT-syndrome are given. We also discuss methods for avoiding disease-drug interactions in clinical practice. These include awareness, regular diagnosis- and drug-history taking, consulting the product information, good communication between healthcare providers and patient education. Furthermore, pharmacovigilance activities help in the early identification and characterization of adverse drug reactions resulting from disease-drug interactions.

'I Was Present but I Was Absent': Perceptions and Experiences of the Non-Medical Use of Prescription or over the Counter Medication among Employed South African Women

BACKGROUND

The need for workplace substance use prevention programmes globally and in South Africa is driven by the growing problem of substance use and the associated burden on the health and welfare of employees, their families and organizations. Substance use, which include the non-medical use of medications (both prescription and over-the counter), remains widespread and is a major cause of mortality and a risk factor for non-communicable diseases (NCDs).

METHOD

Twenty in-depth semi-structured qualitative interviews were conducted with employed women in treatment or shortly out of treatment for the non-medically indicated use of over the counter or/and prescription medications (NMIU). These interviews were conducted face-to face with women residing in the Western and Eastern Cape provinces of South Africa. Thematic analysis using NVIVO was used to analyse data collected.

RESULTS

The findings from this study suggest that previous use of legal or illegal substances and challenging life experiences underpin pathways to the non-medical use of over-the-counter and prescription medications among employed women. Factors found to contribute to misuse relate to a lack of understanding on risks, and health professional prescribing practices, while mitigators to harmful use were related to increased awareness and understanding harmful practices, the need for improved access and referral to specialist treatment as well as prevention programmes for women.

CONCLUSION

With the improved understanding of the issues surrounding the NMIU of over-the-counter and prescription medications among employed women, the need for interventions to prevent misuse and inadvertently dependency is highlighted.

Prevalence and Predictors of Self-Medication Practices in India: A Systematic Literature Review and Meta-Analysis

BACKGROUND

Self-Medication (SM) is a practice of using medications to treat selfdiagnosed symptoms without a legitimate prescription by a health care professional. Alongside posing a burden on a patient, SM practices are associated with certain unfavourable health conditions such as drug-resistance, adverse effects, drug-interactions, including death.

OBJECTIVE

To systematically review and quantify the prevalence of SM practices and its associated factors in India.

METHODS

A comprehensive systematic search was performed using scientific databases such as PubMed and Cochrane library for the peer-reviewed research articles that were conducted in India without any language and date restrictions. Studies which were cross-sectional by design and assessing the prevalence and predictors of SM practices in India were considered for the review, and all the relevant articles were screened for their eligibility.

RESULTS

Of 248 articles, a total of 17 articles comprising of 10,248 participants were included in the meta-analysis. Overall, the mean prevalence of SM practices in India was observed to be 53.57%. Familiarity with the medication appears to be a major reason to practice SM (PR: 30.45; 95% Confidence Interval [CI]: 17.08-43.82; 6 studies), and the practice was noticed more among individuals from a middle-lower class family with a prevalence rate of 26.31 (95%CI: 2.02-50.60; P<0.0001). Minor ailments were the primary reason for practicing SM (PR: 42.46; 95%CI: 21.87- 63.06), among which headache was the most commonly reported (PR: 41.53; 95%CI: 18.05-65.02).

CONCLUSION

Self-medication practices are quite frequent in India. While NSAIDs and anti-allergens are the most frequently utilized self-medicated drugs used for headache and cold and cough.

Utilizing a cognitive engineering approach to conduct a hierarchical task analysis to understand complex older adult decision-making during over-the-counter medication selection

BACKGROUND

Adults aged 65+ (older adults) disproportionately consume 30% of over-the-counter (OTC) medications and are largely responsible for making OTC treatment decisions because providers lack awareness of their consumption. These treatment decisions are complex: older adults must navigate age-related body/cognitive changes, developed comorbidities, and complex medication regimens when selecting the right OTC. Yet little is known about how older adults make such decisions.

OBJECTIVES

This study characterizes older adults' cognitive decision-making process when seeking to self-medicate with OTCs from their community pharmacy, and demonstrates how hierarchical task analysis (HTA) can be used to evaluate a pharmacy intervention's impact on their decision-making.

METHODS

A pre-/post-implementation approach, using a think-aloud interview process, was conducted with older adults within a community pharmacy setting as they completed a hypothetical scenario to treat either pain, sleep, or cough/cold/allergy symptoms. HTA developed a conceptualization of older adult decision-making regarding OTC selection and use before/after Senior Section implementation.

RESULTS

An HTA constructed from 12 purposefully-selected interviews (pre-n = 9/post-n = 3), consisting of 8 goals/15 sub-goals. While selecting an OTC, older adults considered quantity, cost, form, regimen, safety, strength, appropriateness of OTC safety, generic/name-brand, past experiences, and ingredients. The intervention reduced by half the number of factors considered.

IMPLICATIONS

Older adult decision-making is more complex than just selecting OTC medication from a pharmacy shelf. HTA-informed decision profiles can provide pharmacists critical insights into safety issues that older adults may not be considering (e.g., factors related to safety, strength, or appropriateness of OTC for symptoms) so that pharmacists can support their decision-making.

Self-Medication for Sleep in College Students: Concurrent and Prospective Associations With Sleep and Alcohol Behavior

OBJECTIVE/BACKGROUND

College students are at an increased risk for poor sleep and associated sleep problems. Emerging evidence suggests that a substantial subset of college students self-medicate with alcohol, marijuana, or over-the-counter medications to help sleep. The current study identified demographic, psychosocial, and sleep- and alcohol-related correlates of self-medication for sleep, and assessed its concurrent and prospective associations with insomnia symptoms, alcohol drinking, and negative drinking consequences.

PARTICIPANTS

Undergraduate students (N = 171; mean age = 19 years [SD = 1.35], 32% male, 74% White) enrolled in a four-year university in the northeastern United States.

METHODS

Data were drawn from a short-term two-wave longitudinal study. Participants completed two online surveys, separated by an average interval of 68 days (SD = 10.22).

RESULTS

At Time 1, 25% of students reported using at least one substance (alcohol, marijuana, or over-the-counter medications) for sleep aid in the past two weeks. Male and older students were more likely to report using substances for sleep. Sleep aid use at Time 1 was concurrently associated with greater levels of alcohol frequency, negative drinking consequences, and insomnia symptoms. Further, sleep aid use at Time 1 was associated with an increase in negative drinking consequences from Time 1 to Time 2, but not with changes in alcohol frequency or insomnia symptoms.

CONCLUSIONS

These findings indicate that substances are widely used among college students for sleep aid. Sleep aid use is associated with greater concurrent drinking and insomnia symptoms, and increases in negative drinking consequences over a short time period.

Predictors of over-the-counter medication: A cross-sectional Indian study

Context:

The determinants of over-the-counter (OTC) medication need to be understood to design adequate drug information policies.

Aim:

To determine the prevalence and predictors of OTC medication among the adult population of Berhampur town in Odisha, India.

Settings and Design:

It was a prospective, cross-sectional, observational study carried out in the private retail pharmacy on a convenience sample of 880 adults over a period of 6 months at Berhampur, Odisha, India.

Materials and Methods:

Medication use behavior was explored using a data collection form that had three parts. The first part captured data on the sociodemographic characteristics of drug consumers. The second and third part collected data on drug history and attitude toward the available health-care facility, respectively.

Statistical Analysis:

Descriptive statistics was used to represent the prevalence of OTC medication. Odds ratio and 95% confidence intervals (CIs) were used to determine the predictors of OTC medication.

Results:

The overall prevalence of OTC medication use was 18.72% (95% CI: 15.34–47.16%). Younger age, male gender, lower income, and poor lifestyle were the predictors of OTC medication. Perception of poor accessibility to health care, the presence of chronic diseases and having a symptom count of more than two significantly increased the likelihood of OTC medication (P < 0.05).

Conclusions:

Sociodemographic profile, drug history, and attitude toward health-care availability in the locality can predict OTC medication behavior. Interventions aimed at changing the perceptions of the public regarding accessibility, affordability of the health care is likely to influence OTC medication behavior and make it safer.

Acute generalised exanthematous pustulosis and other severe drug eruptions from over the counter medications: A case report and review of the literature

We present a case of acute generalised exanthematous pustulosis in an 11-year-old girl who used Duro-Tuss, an over-the-counter cough mixture containing pholcodine, and present a comprehensive review of the literature on severe drug reactions resulting from using non-prescription medications. This case reinforces the importance of taking a complete medication history.

Over-the-counter medication patterns in households in Sharjah, United Arab Emirates

Background

Self-medication and acquisition of over-the-counter (OTC) medications are emerging community health issues. Besides being a cheap alternative for treating common illnesses, the behavior entails serious ramifications, such as medication wastage, increasing pathogen resistance, and adverse drug reactions. The present study was conducted to explore the extent of OTC medications in households in Sharjah, United Arab Emirates (UAE), including native UAE and expatriate families.

Methods

The study employed a population-based, cross-sectional, analytical study design. The study population included native and expatriate households residing in the Emirate of Sharjah, UAE. The snowball sampling technique was used, and the sample included a total of 335 households.

Results

Expatriate households acquired more OTC medications than did native households (adjusted odds ratio [aOR]=1.7). The demographic determinants for expatriate households were number of family members (aOR=1.6), age of children in the family (aOR=1.8), and annual income (aOR=0.5). Expatriate households purchased more OTC medication practices than did native households (aOR=2.2). In the statistical sense, expatriate household practices were buying medication upon relatives’ advice (aOR=0.3), storage condition of medication (aOR=2.4), and disposal of expired medication (aOR=0.6). The highest percentages of OTC medications in native and expatriate households were those related to gastric and ear, nose, and throat illnesses.

Conclusion

The presence of OTC medications in expatriate households was two-fold more common than in native households in Sharjah, UAE. There were significant associations for behaviors related to the reasons why OTC medications were purchased and stored within the household for both native and expatriate families.