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[post_content] => In February, the Federal Government substantially increased responsibilities around personal data for businesses who handle it, with healthcare providers given particular focus. So what does the new privacy regime mean on the ground?
As a pharmacy owner in 2018, you’ve committed yourself to building a prosperous future for your practice in an ever-changing physical and digital landscape.
The latter, with a specific focus on handling your patient’s data, is perhaps the most challenging, as our largely clinically focused training covers little on our obligations in securely handling personal information under the Australian Privacy Act 1988.
Now before your eyes roll back and you think to yourself, ‘Understanding my pharmacy’s data is just for the big ones who can afford an IT department’, you should know that not taking patient data privacy seriously could cost you and your business a fine of up to $1.8 million if you suffer a data breach – not to mention causing your patients serious harm.
What you need to know
The Mandatory Notifiable Data Breach scheme came into force on February 22, and means that any organisation covered by the aforementioned Privacy Act (which includes all pharmacies) is obliged to notify individuals whose personal information is involved in a data breach that is likely to result in serious harm.
This notification is to occur as soon as practicable after becoming aware of a breach.
What is a data breach?
A data breach happens when personal information (such as a person’s name, contact details, medical records, or banking details) is:
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]An Australian study indicates pharmacists should play a larger role in identifying and resolving drug-related problems (DRPs) as part of a collaborative general practice team.
A University of Technology Sydney study looked at six pharmacists that were co-located with GPs in 15 primary care practices across Western Sydney.
Helen Benson, a pharmacist and researcher on the study, believes pharmacists in these practices have made a real difference to patient care.
‘As far as chronic disease management and medication management goes, our skills and our knowledge mean that we can make a valuable contribution.
‘We understand how medicines work and how medicines work together, and are familiar with different disease states,’ Ms Benson said.
Pharmacists are especially valuable in helping people who have several co-morbidities and are taking multiple medicines. In this study alone, one person was taking 26 different drugs, and there was an average of 2.3 DRPs per patient.
‘When you think of all the things a GP has to do, it just makes sense that you have someone on the team who can help you manage those really complex patients. The main thing is making sure the medicine is the right drug for the right reason at the right time,’ she explains.
With an increased risk of DRPs in those cases, pharmacists can check medicines are indicated for a condition, are the right fit for a person and their family, and will bring the best outcome for them.
The research aimed to identify and classify DRPs detected by pharmacists during patient consultations, and compare the number of pharmacist recommendations with the number of recommendations GPs accepted and actioned.
GPs accepted and actioned 70% of pharmacist recommendations, indicating that pharmacists can effectively detect and resolve DRPs, and that most GPs are willing to accept pharmacist recommendations and collaborate with them as part of a general practice team.
The study’s findings were cited by Chair of the AMA Council of General Practice, Dr Richard Kidd as evidence of the importance of bringing 'pharmacists into the fold'.
‘With increasing evidence that where pharmacists are integrated within general practice patient care is improved, the AMA continues to advocate for Government funding to make this an everyday reality for general practice and for patients,’ said Dr Kidd.
References:
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[post_content] => The use of My Health Record is expected to ramp up in 2018, so how can pharmacists make sure they are properly prepared, and what benefits can they expect?
Every pharmacist knows the challenges of operating in an information vacuum.
Despite a less-than-rapid take-up, the Federal Government’s My Health Record (MHR) initiative holds the promise of delivering more patient information to pharmacists and this year is set to be the one in which that benefit is more widely felt.
Statistics from the MHR system operator – the Australian Digital Health Agency – show around 22% of Australians have registered for a MHR so far.1
Pilot trials suggest that number could soar to 98%2 by the end of 2018 when all Australians will have access to the system, unless they opt-out.
'Pharmacists are often trying to help patients without every piece of the jigsaw puzzle,' PSA President Shane Jackson said. 'MHR enables the pharmacist to apply their knowledge with an increased amount of verifiable clinical information.'
Currently almost 11,000 healthcare providers have registered for access to the records, including more than 6000 general practices and 1000 hospital organisations. Around 1500 community pharmacies1 have registered but an ADHA spokesperson said that number could soon jump significantly.
'By the end of 2018, all pharmacies will have access to conformant software to connect to MHR,' the spokesperson said. 'Every community pharmacy software vendor has now signed up to the Community Pharmacy Software Industry Partnership to connect to the MHR system.'
Benefits for pharmacists and patients
Through MHR, pharmacists can access a patient’s full prescription and dispense records, discharge summaries, medical history, information about allergies and immunisations, event summaries and health summaries – all in real time.
Already, more than 16 million prescription and dispense records have been uploaded to the system,1 giving pharmacists access to more information than ever before. ADHA Chief Medical Advisor Clinical Professor Meredith Makeham said: ‘There are a lot of efficiency and safety benefits that pharmacists will be able to support their patients with’.
How to register
To access the MHR, a pharmacy first needs to register with the MHR system, by applying for a Healthcare Provider Identifier for Organisations (HPI-O) and a National Authentication Services for Health Public Key Infrastructure (NASH PKI) Certificate.
Individual pharmacists, including consultants, need to apply for a Healthcare Provider Identifier for Individuals (HPI-I).
To simplify the process, ADHA's Dr Makeham said the agency had developed a 'fast-track' form specifically for community pharmacies.3
'It allows you to register for the healthcare identifier service, MHR system, and obtain your NASH digital certificate – that's a one-step process,' she said.
Help on navigating the registration process is available online at the ADHA website4 or PSA's Digital Health Hub (psa. org.au/digitalhealthhub). The latter also runs regular workshops for pharmacists bringing MHR into their operations.
If you're still baffled, you're not alone, said Rob Farrier, Pharmacist and Business Development Manager at National Pharmacies.
'The first piece of advice I would give is: go to one of the PSA or Primary Health Network education events around MHR – they can answer all of your questions, particularly if you've had a look at it and it made no sense,' Mr Farrier said.
'At face-value, there's a lot of acronyms and it sounds really complicated, but most of it's really easy.'
Dr Jackson said every PHN has Digital Health Officers who can assist pharmacies with registration.
'It takes a little bit of time but it's not an overly onerous process given that we need to make sure the security and integrity of the system remains intact,' he said.
PSA also has a Pharmacist Digital Health Leader Network5 which you're encouraged to reach out to.
'We have trained a number of digital health champions so they can talk to their peers about how to register, use MHR and overcome any hurdles in practice,' Dr Jackson said.
Making the software work
Once your registration has been processed you will receive confirmation letters from DHS. Your Medicare PKI Certificates and Personal Identification Code numbers for each HPI certificate will also be mailed separately.
You then need to add your HPI-Os and HPI-Is to your clinical software, providing it’s conformant.
‘Once your registration form has been processed and your software has been upgraded it’s simply a matter of installing your digital certificate and you’re away,’ Dr Makeham said.
‘All of the software vendors provide assistance to pharmacists to do that.’
Providers currently offering conformant versions of community pharmacy software include FRED Dispense, Minfos, POS Works, RxOne and Aquarius Dispense.
MHR champion and Founder of MyMedsHealth, Juliet Richards, encouraged: ‘once it’s set up it’s smooth sailing’.
Educating staff
To ensure you make the most of access to patient MHRs, there is a wide range of training on offer for pharmacists and pharmacy staff.
All around the country PSA is running two-hour introductory workshops6 that explore MHR’s features and functionalities, its benefits and uses in pharmacy practice.
For those unable to attend events in person there are plenty of training resources available online, said Coffs Harbour Clinical Consultant Pharmacist, Chris Braithwaite.
‘There are some really good training modules for all different areas of pharmacy practice on the ADHA and PSA websites,’ said Mr Braithwaite from Galambila Aboriginal Health Service.
PSA has MHR learning modules,7 it’s developing practice support tools8 and revising its Digital Health Guidelines.9
These resources provide examples of how and when to access a patient’s MHR, what to consider when integrating information from a MHR into clinical decisions, and how best to add to the record.
Additionally, ADHA has published five webinars10 covering topics from getting connected to MHR through to communicating with customers, and five CPD-accredited MHR training modules for pharmacists.11
Further opportunities
Enhancing your ability to engage with the system and integrate it into clinical workflows will be beneficial not only for your patients, but also for your business.
As such, Ms Richards recommended ‘getting onboard ASAP’. ‘Instead of resenting change you should be taking advantage of it and looking at services you could provide with access to all of that information,’ she said.
‘It’s a perfect opportunity for pharmacists to jump onto more meds checks, Home Medicine Reviews and diabetes checks.’
Mr Braithwaite added that there were real opportunities to provide more team-based care.
‘It’s really important you’re across how it works and the best way to utilise it because patients will expect pharmacies to have their MHR in the coming years,’ he said.
| The MHR in action: case study CONSULTANT PHARMACIST Juliet Richards, Founder of MyMedsHealth. I saw a patient the other day who was a bit confused. She was an elderly lady who was living alone and had been discharged from hospital. She thought she might have had a TIA but she wasn’t sure if she was meant to be taking a blood thinner or not. Her MyHealthRecord (MHR) discharge summary showed that she’d had an aneurysm and was meant to be followed up, but she had actually missed her appointment. Once we realised what was going on we referred her on to see the specialist again. |
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[post_content] => Buying expensive robotics could seem a counterintuitive way to boost profitability while increasing customer interactions but that is the promise of automated dispensing.
Could your pharmacy benefit from automated dispensing?
Purchasing an automated dispensing cabinet might seem like a somewhat impersonal solution to your pharmacy’s customer service problems; however, it may actually help you connect with your patients more than ever.
Pharmacy owner and technology consultant Robert Sztar said the cabinets can free up your staff to concentrate on delivering high-quality service – all while the dispenser is tackling the more robotic tasks.
‘The pharmacist has the capability to actually look after every need of that patient in their visit from one single point, as opposed to having to segment them through multiple touch points,’ Mr Sztar said.
The upfront costs
Gollmann International Sales and Project Manager Tobias Abromeit said one of their robots with an autoloader can be purchased for under $200,000.
With an average lifetime of more than 10 years, plus $1000 a month in service costs, this will cost roughly $320,000 over a decade. Breaking that down further, Mr Abromeit said it comes to about $9 per hour for a ‘colleague that manages your stock without any mistakes and is never on leave’. Meanwhile, Willach Pharmacy Solutions Managing Director John Koot said one of their automated systems can cost about $3000 per month over the first decade.
Calculating the benefits
Mr Koot said savings in costs and increases in revenue from higher script volumes, sales in other channels, and professional services can amount to $6000 per month.
He added that expected additional revenue over a five-year period can range from $250,000-$500,000, depending on your post-installation strategy.
Mr Abromeit said when you’re crunching the numbers, consider how much time you spend in the back office searching, fetching and controlling stock.
‘The reduced effort for physical labour, thanks to the robot, can be transferred into comprehensive consultation of customers by well-trained staff,’ Mr Abromeit said.
He added that automatic dispensers can also reduce missing or expired goods write-offs and cut down the time you spend searching for qualified staff.
Other factors
So how do you know if an automated dispensing cabinet is the right fit for your pharmacy?
Mr Abromeit said that compared with traditional shelving, an automated dispenser system generally offers more storage space, adding that all dimensions can be customised to individual stores.
Mr Koot added that benefits can also be achieved with a redesign of the dispensary and retail optimisation.
‘By increasing retail floor space, pharmacies can increase revenue by around $5000 per m2 due to increased dispensary space efficiencies,’ he said.
Final considerations
It’s worth noting that purchasing an automated dispenser isn’t totally without its risks.
For example, one supplier, Dose Innovations, went into administration in January, so it’s important to pick a provider that you’re confident will be around to service the machine for at least the next 10 years.
Also, make sure that the provider will service the machine in a timely manner if it breaks down.
‘You’ve got to make the assumption that something will go wrong at some point,’ said Mr Sztar, author of the book, magazine and podcast ‘Transpharmation’.
He added it will help if your pharmacy has a technologically literate person working a good portion of the time to limit the impact a breakdown would have on your pharmacy’s workload.
‘You don’t need a coder or a programmer,’ Mr Sztar said. ‘But you do need to make sure that you’ve got people who are there throughout the opening time of that pharmacy who are capable of interfacing with the support people.’
| Using technology to compete against discount pharmacies Pharmacist Robert Sztar: Scripts For You Somerville, Victoria ‘From the get go, two years ago, it’s been my wife and myself as just the two pharmacists. Because when you don’t have a patient base to start with, you don’t have the cash flow to bring on a big team from the beginning. That forced us to create a workflow that was not only scalable, but could be executed with the minimum of one pharmacist. So our workflow has heavily depended on automation both through software and through the hardware of the automated dispensing machine that warehouses and picks our prescription products. Also, when we began our practice, there were two very well-known discount pharmacies established nearby. So to differentiate ourselves we had to create a better experience, and not just by a few millimeters, but by a significant point that generated a ‘wow’ factor. So do I think our business would be where it is now without the automated dispenser? Without a doubt no. I couldn’t imagine creating the customer experience we do without it.’ |
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[post_content] => Community pharmacists in Victoria have less than three months to ensure they have an active connection with a Prescription Exchange Service (PES), so they can meet their obligations under the incoming SafeScript initiative.
Public consultation on the state’s real-time prescription monitoring system was completed last month, with new regulations set to take effect on 1 July, ahead of SafeScript’s implementation in October.
From July, all Victorian community pharmacies that have not activated the connection with a PES in their software need to turn on the connection by contacting their software vendor. This will ensure complete records are available in SafeScript.
It is free and the Victorian Government estimates almost nine in 10 community pharmacies in the state are already connected to a PES.
From the same date, pharmacists must ensure that when a monitored medicine is dispensed, the patient’s date of birth is recorded in the patient’s dispensing record. Dispensing software should prompt pharmacists to enter date of birth and vendors are being engaged to support this change.
Medicines to be monitored through the system include all Schedule 8 medicines and Schedule 4 benzodiazepines, z-drugs and quetiapine.
Prescription records will be automatically transmitted through the PES to SafeScript when a prescription is dispensed at a pharmacy. Through the PES connection, pharmacists will also receive pop-up notifications from their desktops to inform them whether it is necessary to review patient’s history in SafeScript and will be taken directly to the relevant record in SafeScript.
Pharmacists are also strongly encouraged to ensure their AHPRA registration details are up-to-date, especially primary place of practice and email address.
More information about the project can be found here.
[post_title] => Victoria's SafeScript means changes for pharmacists
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Key considerations and a recommended course of action when a pharmacist is asked to supply medication to a third party.
Scenario:
A 20-year-old man approaches a community pharmacist, requesting the emergency contraceptive pill (ECP) for his 18-year-old girlfriend.
The man tells the pharmacist his girlfriend is unable to come into the pharmacy in the next few days as she is working.
Upon questioning, the pharmacist identifies that the girlfriend has never taken this medicine previously.
Key considerations
Refusal of supply is not appropriate
A pharmacist is required to respond to patients, authorised representatives and other healthcare professionals in a timely manner to ensure patients or community healthcare service needs are met in a consistent manner (Professional Practice Standards (PPS) criterion 1.1.3).
Refusing to supply because the patient is not present in the pharmacy, without exploring other options to meet her needs, compromises the patient’s ability to access treatment in a timely manner.
Supplying without contacting the patient may not be appropriate
Pharmacists are required to ensure they have a thorough, accurate and systematic approach to history taking and, in particular, need to consider the reliability of any third party as an accurate historian (PPS criterion 4.6).
The pharmacist should use their professional judgment to consider whether the boyfriend is able to accurately provide the information required to ensure safe and appropriate use of the ECP.
Pharmacists should also ensure that the provision of the ECP to the boyfriend aligns with relevant clinical guidelines (PPS criterion 4.2.1).
Although there are no specific contraindications to the use of ECP, the boyfriend may not be able to provide specific information about the patient’s menstrual cycle, any regular oral contraceptives being taken and the patient’s other regular medicines.
This means the pharmacist may not be able to determine:
• the risk of pregnancy
• whether the ECP is the most appropriate treatment for the patient (e.g. if they are taking liver enzyme-inducing medicines, a higher ECP dose or copper intrauterine device may be more appropriate)
• what appropriate follow-up advice to provide (e.g. how to restart the regular oral contraceptive, how long to use an additional barrier method of contraception).
An additional concern related to third-party supply of ECP is the possibility of sexual assault or coercion.
Recommended course of action
Supply following communication with the patient is the most appropriate action
If the patient is unable to come into the pharmacy in a timely manner, the most appropriate method of communication would be to talk to her over the phone (PPS criterion 4.7.2).
This would enable the pharmacist to provide primary health care to the patient through accurate history taking (PPS criterion 4.6), assessment of risks and benefits (PPS criterion 4.7.3) and advising on the optimal use of this medicine (PPS criterion 4.8.2).
To ensure the quality use of medicines, the pharmacist should also facilitate appropriate patient follow-up (PPS criterion 1.7.5).
In this case, the pharmacist should encourage the patient to visit the pharmacy for follow-up when she is able. The pharmacist should confirm that the patient is aware of ongoing arrangements and access to healthcare professionals (PPS criterion 4.10.3).
Relevant Professional Practice Standards
Standard 1 – Fundamental Pharmacy Practice
Standard 4 – Provision of Non-prescription Medicines and Therapeutic Devices
Further resources
PSA Emergency Contraception: S3 guidance document
PSA Emergency Contraception Checklist
Visit apf.psa.org.au[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row]
[post_title] => Ethics case study: Supplying medication to a 3rd party
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[post_content] => More research has been urged after the creator of a breakthrough test for detecting Alzheimer’s disease said the test could be combined with daily doses of ibuprofen to eliminate the disease.
In a recently published Journal of Alzheimer's Disease paper, University of British Columbia’s Patrick McGeer detailed what he described as a potential ‘paradigm shift’ in the disease’s treatment.
Dr McGeer’s research has centred on the peptide amyloid beta protein 42 (Aβ42), finding that it is secreted in the saliva of those with – or at risk of – Alzheimer’s disease at a rate two to three times higher than the general population.1
He has developed an enzyme-linked immunosorbent assay (ELISA) test that he proposes could be used to detect Alzheimer’s risk by measuring Aβ42. Referencing studies that have shown a correlation between daily use of non-steroidal anti-inflammatory drugs (NSAIDs) and a reduction in the risk of developing Alzheimer’s, he said the test could be used to determine the best candidates for preventative therapy.
‘What we've learned through our research is that people who are at risk of developing Alzheimer's exhibit the same elevated Aβ42 levels as people who already have it; moreover, they exhibit those elevated levels throughout their lifetime so, theoretically, they could get tested anytime,’ Dr McGeer told ScienceDaily.
`Knowing that the prevalence of clinical Alzheimer's disease commences at age 65, we recommend that people get tested ten years before, at age 55, when the onset of Alzheimer's would typically begin. If they exhibit elevated Aβ42 levels then, that is the time to begin taking daily ibuprofen to ward off the disease.’2
However, University of Sydney researcher and pharmacist Dr Lisa Kouladjian O'Donnell told Australian Pharmacist more research in the field was needed before clinical practice was changed.
‘Dr McGeer and colleagues have stated that “17 epidemiological studies” have reported that there is a relationship between anti-inflammatory agents and Alzheimer’s disease,’ she said.
‘The next steps from this preliminary research would be to conduct some pre-clinical work, followed with randomised clinical trials, and systematic reviews.’ Although mainstream media reports suggest to readers that taking ibuprofen daily from age 55 could prevent Alzheimer’s disease, Dr Kouladjian O’Donnell has urged caution.
`If patients ask pharmacists’ advice on daily dosing of NSAIDs to prevent Alzheimer’s disease, I would recommend pharmacists explain to patients that the evidence for daily dosing of NSAIDs is lacking, and they should not be used,’ she said. `In Australia, NSAIDs are indicated for pain due to inflammatory arthropathies, pain due to inflammation and tissue injuries, and fever.3
‘NSAIDs have a high-risk side effect profile (for example common side effects include gastrointestinal ulceration or bleeding and hypertension) and there are various patient groups where many factors need to be considered before prescribing treatment with NSAIDs (e.g. patients with previous cardiovascular disease, gastrointestinal disease, and the elderly).3
‘A Cochrane review published in 2012 investigated aspirin, steroidal and non-steroidal anti-inflammatory drugs for the treatment of Alzheimer’s disease, and concluded that the efficacy of these drugs is not available, and therefore these drugs cannot be recommended for the treatment of Alzheimer’s disease.’4
References:
- McGeer PL, Guo JP, Lee M, et al. Alzheimer’s disease can be spared by nonsteroidal anti-inflammatory drugs. J Alzheimers Dis 2018; 62(3):1219–22.
- IOS Press, Neuroscientists say daily ibuprofen can prevent Alzheimer's disease. 2018. At: www.sciencedaily.com/releases/2018/03/180326140239.htm
- Rossi S, ed. Australian medicines handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2018.
- Jaturapatporn D, Isaac MG, McCleery J, et al. Aspirin, steroidal and non-steroidal anti-inflammatory drugs for the treatment of Alzheimer's disease. Cochrane Database Syst Rev 2012 Feb 15;(2):CD006378.
[post_title] => Alzheimer’s saliva test a potential breakthrough, but caution needed
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[post_content] => Pain caused by osteoarthritis (OA) is a common presentation in a community pharmacy, with many patients seeking advice on complementary and alternative medicines that can relieve pain. OA is the most common form of arthritis in Australia, occurring in about 9% of the population.
People with OA often seek pain-relieving medicines, including complementary and alternative medicines (CAMs), from a community pharmacy. Three CAMs options for osteoarthritis are devil’s claw, glucosamine and turmeric. What is the evidence for their efficacy in treating OA?
Turmeric
What is it?
Turmeric is the dried rhizome of Curcuma longa. It is commonly used as a spice and as a yellow-orange food colouring. Most research has focused on curcumin, one of the major constituents.4,6
Curcumin has been found to have anti-oxidant, anti-inflammatory, immunomodulatory, analgesic and anticancer properties.6,12
Evidence for OA
A 2016 systematic review of eight RCTs (n = 937) found evidence that 8–12 weeks of standardised turmeric extracts (typically 1000 mg curcumin) daily can reduce pain and inflammation-related symptoms of arthritis.
However, the evidence is not conclusive, because of the small number of RCTs, and their small sample sizes and heterogeneity.13
A 2017 systematic review of seven RCTs (n = 797) concluded that curcuminoids significantly reduce pain and improve quality of life compared with placebo in patients with primary knee OA. However, they are less effective than ibuprofen at relieving pain. Published RCTs vary in quality and have small sample sizes.14
Suggested counselling advice
`Use a product formulated to improve curcumin absorption.’11
Devil’s claw
What is it?
Also known as Harpagophytum procumbens, devil’s claw is a herb native to southern Africa, the root tubers of which are used medicinally.
Evidence for OA
A 2006 systematic review of 14 clinical trials (including four RCTs) concluded that, although the trials provided some support for efficacy of devil's claw in OA, their quality was poor.1
A 2007 review examined use in painful OA and chronic lower back pain. The reviewers concluded that the evidence of effectiveness was strongest for Harpagophytum preparations containing >50 mg of harpagoside per daily dose.2
A 2014 Cochrane review of two RCTs (n = 315) concluded that devil's claw, in a standardised daily dose of 50 mg or 100 mg harpagoside, may reduce non-specific lower back pain more than placebo (low-quality evidence). A third RCT (n = 88) found that 60 mg of harpagoside daily reduced pain to about the same extent as 12.5 mg rofecoxib daily (very low-quality evidence).3
Suggested counselling advice
‘Devil's claw may relieve back pain and osteoarthritis pain within 1–4 months of starting treatment.3,4 The safety of daily use for longer than 1 year is unknown.’3,4
Glucosamine
What is it?
Glucosamine is an endogenous aminomonosaccharide. It is essential for the synthesis of glycosaminoglycans (mucopolysaccharides), glycoproteins and glycolipids, which are components of many body tissues, including cartilage, tendons, ligaments and synovial fluid. Glucosamine for therapeutic use is derived from the exoskeletons of crustaceans or from corn.6,7 Some glucosamine supplements also contain chondroitin, an endogenous glycosaminoglycan.4
Evidence for OA
There is conflicting evidence regarding pain-relieving and structure-modifying effects of glucosamine in OA. There is also debate about whether glucosamine sulfate is more effective than glucosamine hydrochloride. Most trials have studied glucosamine sulfate for knee OA.5,8,9,10
Suggested counselling advice
‘The evidence is currently unclear on whether glucosamine (or glucosamine plus chondroitin) is of benefit in treating osteoarthritis. A suitable trial is 3–6 months of daily use. If your symptoms improve during this trial and you want these benefits to continue, you will need to continue to take glucosamine. Different brands and forms of glucosamine may vary in their effects.’5
Learn More
For more evidence-based information about these and other complementary medicines – including clinical notes on adverse effects, contraindications and dosages, as well as full references – refer to the Australian Pharmaceutical Formulary and Handbook 24th edition (APF24). APF is available in print or digital formats.
Digital APF is available at apf.psa.org.au (subscription required).
References
- Brien S, Lewith GT, McGregor G. Devil’s claw (Harpagophytum procumbens) as a treatment for osteoarthritis: a review of efficacy and safety. J Altern Complement Med 2006;12(10):981– 93.
- Chrubasik JE, Roufogalis BD, Chrubasik S. Evidence of effectiveness of herbal antiinflammatory drugs in the treatment of painful osteoarthritis and chronic low back pain. Phytother Res 2007;21(7):675–83.
- Oltean H, Robbins C, van-Tulder MW, et al. Herbal medicine for low-back pain. Cochrane Database of Systematic Reviews 2014, Issue 12.
- Gregory PJ. Natural medicines. 2017. At: https://naturalmedicines.therapeuticresearch.com
- eTG complete. Melbourne: Therapeutic Guidelines; 2017.
- Brayfield A, ed. Martindale: the complete drug reference. London: Pharmaceutical Press. At: medicinescomplete.com.
- Henrotin Y, Mobasheri A, Marty M. Is there any scientific evidence for the use of glucosamine in the management of human osteoarthritis? Arthritis Res Ther 2012;14(1):1–10.
- McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage 2014;22(3):363–88.
- Harrison-Muñoz S, Rojas-Briones V, Irarrázaval S. Is glucosamine effective for osteoarthritis?. Medwave 2017;17(Suppl1):e6867.
- Bruyere O, Cooper C, Pelletier JP, et al. A consensus statement on the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) algorithm for the management of knee osteoarthritis: from evidence-based medicine to the real-life setting. Semin Arthritis Rheum 2016;45(4 Suppl):S3–11.
- Gregory PJ. Natural medicines. 2017. At: https://naturalmedicines.therapeuticresearch.com
- Sahebkar A, Henrotin Y. Analgesic efficacy and safety of curcuminoids in clinical practice: a systematic review and meta-analysis of randomized controlled trials. Pain Med 2016;17(6):1192–202.
- Daily JW, Yang M, Park S. Efficacy of turmeric extracts and curcumin for alleviating the symptoms of joint arthritis: a systematic review and meta-analysis of randomized clinical trials. J Med Food 2016;19(8):717–29.
- Onakpoya IJ, Spencer EA, Perera R, et al. Effectiveness of curcuminoids in the treatment of knee osteoarthritis: a systematic review and meta-analysis of randomized clinical trials. Int J Rheum Dis 2017;20(4):420–33.
[post_title] => Complementary medicine: Osteoarthritis
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[post_content] => Schizophrenia is a chronic illness characterised by a range of symptoms including positive and negative symptoms. Examples of positive symptoms include hallucinations, delusions, and bizarre and inappropriate behaviour.
Negative symptoms include affective flattening, lack of speech, lack of motivation and inability to feel pleasure with any activity. In addition to these symptoms, patients also experience significant cognitive deficits and attention disorders. All these symptoms have a great impact on the person’s quality of life.2,3
Positive symptoms respond well to antipsychotics. However, the negative symptoms are usually hard to treat. Selective noradrenaline reuptake inhibitors (NRIs) such as atomoxetine and reboxetine are associated with improvement of the negative symptoms. Atomoxetine is used to treat attention deficit hyperactivity disorder (ADHD) symptoms and reboxetine is indicated to treat major depressive disorders. The most common side effects of both of these medications include loss of appetite, nausea, agitation, insomnia, dizziness, constipation, fatigue, dry mouth, sedation, sweating and palpitations. Reboxetine is associated with postural hypotension and atomoxetine with hypertension.4,5
NRIs increase prefrontal dopamine without significantly affecting subcortical dopamine levels, which makes them less likely to be abused and more suitable for managing the negative symptoms of schizophrenia. It is believed that positive symptoms are associated with excess subcortical dopamine, while deficits in the prefrontal dopamine contribute to negative symptoms.6 The aim of this review is to scope the literature on the effectiveness of NRIs for the management of negative symptoms of schizophrenia.
Characteristics of studies
Randomised controlled trials (RCTs) comparing NRIs with either a control treatment or placebo for people with schizophrenia or related disorders such as schizoaffective disorder. Participants were over the age of 18 years and were diagnosed by any means.
Quality of the research
Studies included in the report had a low or unclear risk of bias. Overall, the quality of the evidence ranged from low to very low depending on the measures reported in the studies. The main sources of bias were selective reporting and incomplete outcome of data.
Results
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[post_content] => A 76-year-old man with past medical history significant for a cerebrovascular accident, pacemaker insertion for sick sinus syndrome and transurethral resection for benign prostatic hyperplasia was rushed to the emergency department.1
The ambient temperature on the day of admission was 36.7°C. His medications included oxybutynin 5 mg tds. He had reported not feeling well and was light-headed.
When he arrived at the hospital car park, he started acting in a confused manner and attempted to get out of the car through the window. A few moments later, while still in the parking lot, he experienced a tonic-clonic seizure lasting only a few seconds.
The initial examination revealed that he was stuporous and responding only to painful stimuli, his skin was warm to the touch and dry, with a rectal temperature of 40°C, blood pressure of 160/88 mm Hg and heart rate 160 beats/min.
Within three hours of admission, the patient’s temperature was decreased to normal values by the use of ice packs, intravenous sodium chloride 0.9% infusions at room temperature (3 L) and bladder irrigations with cold sodium chloride 0.9%.
A review of the patient’s chart revealed that he had been admitted during the previous summer with a similar febrile episode and a rectal temperature of 41.1°C. The patient was also taking oxybutynin at that time. When he was discharged from this admission, he was instructed to refrain from taking oxybutynin and to keep a scheduled appointment with his urologist to discuss the need for continued use of the drug.
During one summer, a 48-year-old man with a history of diabetes mellitus and schizophrenia was twice admitted to hospital because of heat-related illnesses.2 On both occasions, he had been working under the sun in an open car park.
His medications included benzhexol 2 mg twice daily, chlorpromazine 650 mg at bedtime, and zuclopenthixol decanoate intramuscular injection 600 mg every 4 weeks.
The first admission, for heat stroke, was more severe. Upon arrival at hospital, the patient was comatose, with a temperature (measured via ear) of 42.4°C, hot dry skin, blood pressure of 66/27 mm Hg and heart rate 156 beats/min.
He was intubated. Fluid resuscitation and evaporative cooling by sponging with tepid water and fanning were initiated. He had metabolic acidosis, renal impairment, thrombocytopaenia, and rhabdomyolysis. Supportive care was required for 14 days, until recovery.
Heat stroke, an acute, life-threatening emergency, results from an overload or impairment of the body’s normal heat-dissipating mechanisms.3 The elderly (and infants) are most at risk and medications can be implicated.
Early recognition and rapid cooling plus cardiopulmonary support are essential. Antipyretics are contraindicated because they are ineffective in heat stroke and increase the risk of liver dysfunction. Unfortunately, temperature regulation disorders in the elderly are both relatively common and life-threatening, and they often go unrecognised.
One of the most direct health effects arising from global climate change is expected to be increased rates of mortality and morbidity associated with exposure to transient heat waves and high ambient temperatures.4-7 Many studies have shown that the elderly are among the most vulnerable to heat waves, with increases in cardiovascular and respiratory mortality, and hospital admissions for cardiac, respiratory and renal conditions during heat waves.4,6,8 Extreme heat-associated hospitalisations, especially amongst the elderly, have increased in recent decades.5
To illustrate the future impact of climate change, under a scenario of medium population growth, by the 2080s, Beijing is projected to experience 14,400 heat-related deaths per year in elderly individuals, which is a 265% increase compared with the 1980s.9 Modelling the effects of anticipated climate changes on the risks of heat disorder in Japan in the 2030s predicted increasing numbers of people transported by ambulance per day in summer by 63%.10 It is estimated that respiratory admissions alone in New York State due to excessive heat will be two to six times higher in 2080-2099 than in 1991-2004, due to climate change.11
Thermoregulation is largely a function of the temperature-regulating centre in the hypothalamus, which senses the temperature of the blood perfusing the brain and activates peripheral processes to bring core temperature to preset values. The major pathophysiologic mechanism underlying classic heat stroke is impaired heat dissipation because of compromised homeostatic mechanisms.1
The main ways in which the body eliminates heat during thermal stress are through sweat production (if the ambient humidity is below 75%), increased cardiac output to supply blood to the periphery, and redirection of blood flow to the skin (increases heat loss by radiation and conduction). When the environmental temperature is greater than the core body temperature, sweat production is the primary physiological way to lose heat.4 These responses can be diminished in elderly people, particularly in the presence of some drugs.
A range of physiological consequences of ageing contribute to the elderly’s sensitivity to heat. The lower a person’s body weight and total body water, as occurs with ageing, the sooner the loss of even a small amount of body water will cause symptoms and signs of dehydration.7
The inability to increase cardiac output, particularly if suffering cardiac disease, decreased peripheral blood flow and sweating, and reduced thirst sensation and capacity to conserve salt and water (e.g. with impaired renal function) are all important additional risk factors in the elderly.
Other contributing factors may include a reluctance to drink fluids because of concerns about bladder control problems, medical advice to restrict fluids or a lack of understanding of the importance of proper hydration or of perceived vulnerability to the effects of hot weather.13
Heat illness may be viewed as a continuum of illnesses relating to the body’s inability to cope with heat. Signs of heat-related illness in an individual often begin with heat exhaustion, a mild to moderate illness caused by water or salt depletion that results from exposure to high environmental heat or strenuous physical exercise.2,4,12
Affected subjects may experience intense thirst, weakness, nausea, vomiting, dizziness, fainting, headache, and muscle cramps. The temperature is typically normal but can be elevated; it is usually less than 41°C if elevated. Clinical signs and symptoms of dehydration are almost always present in the form of tachycardia, hypotension, and sweating.3,12
If unrecognised and untreated, heat exhaustion may progress to heat stroke. The latter is a medical emergency, with a core body temperature above 40°C, accompanied by hot, dry skin, multiple organ dysfunction and central nervous system abnormalities, such as confusion, delirium, ataxia, convulsions, or coma.
The key point in differentiating heat stroke from heat exhaustion is that central nervous system dysfunction is present in heat stroke but not in heat exhaustion. The prognosis depends on how early the diagnosis is made and how promptly cooling measures and active fluid and electrolyte resuscitation are started.2
Progression to death in an individual with heat stroke can happen rapidly (within hours), and even with prompt medical care, 10-15% of heat stroke cases are fatal; approximately 80% of deaths from heat stroke occur in persons more than 50 years old.2
Heat exposure is also a factor that can contribute to exacerbation of many pre-existing health conditions. In high-income countries, most heat-related deaths are likely to be from cardiovascular or respiratory causes.4 In many situations, however, heat exposure might not be confirmed as the underlying cause of death, and so heat-related illness is under-reported.
Rates of heat-related mortality and morbidity are highest in elderly and chronically ill individuals, particularly those with cardiovascular, respiratory, and renal diseases.2,4 The risk of heat stroke is also increased when patients take drugs that are known to impair thermoregulatory processes, either centrally via the hypothalamus or peripherally.14 These medications include diuretics, antipsychotics, or drugs with anticholinergic properties1-4,7,13-17:
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]An Australian study indicates pharmacists should play a larger role in identifying and resolving drug-related problems (DRPs) as part of a collaborative general practice team.
A University of Technology Sydney study looked at six pharmacists that were co-located with GPs in 15 primary care practices across Western Sydney.
Helen Benson, a pharmacist and researcher on the study, believes pharmacists in these practices have made a real difference to patient care.
‘As far as chronic disease management and medication management goes, our skills and our knowledge mean that we can make a valuable contribution.
‘We understand how medicines work and how medicines work together, and are familiar with different disease states,’ Ms Benson said.
Pharmacists are especially valuable in helping people who have several co-morbidities and are taking multiple medicines. In this study alone, one person was taking 26 different drugs, and there was an average of 2.3 DRPs per patient.
‘When you think of all the things a GP has to do, it just makes sense that you have someone on the team who can help you manage those really complex patients. The main thing is making sure the medicine is the right drug for the right reason at the right time,’ she explains.
With an increased risk of DRPs in those cases, pharmacists can check medicines are indicated for a condition, are the right fit for a person and their family, and will bring the best outcome for them.
The research aimed to identify and classify DRPs detected by pharmacists during patient consultations, and compare the number of pharmacist recommendations with the number of recommendations GPs accepted and actioned.
GPs accepted and actioned 70% of pharmacist recommendations, indicating that pharmacists can effectively detect and resolve DRPs, and that most GPs are willing to accept pharmacist recommendations and collaborate with them as part of a general practice team.
The study’s findings were cited by Chair of the AMA Council of General Practice, Dr Richard Kidd as evidence of the importance of bringing 'pharmacists into the fold'.
‘With increasing evidence that where pharmacists are integrated within general practice patient care is improved, the AMA continues to advocate for Government funding to make this an everyday reality for general practice and for patients,’ said Dr Kidd.
References:
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[post_content] => Australian laws requiring use of paper documents prevent new technological solutions that could inhibit prescription fraud.
That’s the diagnosis of Dr Tal Rapke, chief executive of an Australian blockchain script service who, during an interview with the Australian Pharmacist, described the legislative requirements as ‘embarrassing’ and an administrative burden for pharmacists and other health professionals.
Although the startup, ScalaMed, is currently running trials in three Australian locations, an inability to go fully paperless locally mean its efforts are being focused on the US, where it was the only Australian company accepted into this year’s digital accelerator program at the Texas Medical Center. The details of clinical trials of this nature are commonly posted to the clinical trials government website in the US.
‘The experience of paper in the healthcare system is annoying,’ Dr Rapke said.
‘For digital natives particularly, the use of paper is quite difficult for a whole lot of reasons – you can lose paper, you can damage paper, and paper can be quite easily defrauded.
‘If you actually look at the way pharmacies work today, for the most part, they don’t even use paper, all they do is clog up their store rooms with paper that gets randomly audited for administrative purposes rather than adding value to patients.’
Dr Rapke, a former pharmaceutical executive, said the use of blockchain technology could also prevent patients from tampering with prescriptions to increase the dosage or change the name of the intended recipient.
Blockchain is a continuously growing list of records, called blocks, which are linked and secured using cryptography. By design they are inherently resistant to modification of the data they contain making them ideal for electronic prescription use.
‘It’s much easier to add a zero onto the medicine you’re prescribed, or rub out a name or to print something onto a piece of paper than it is to take a blockchain and modify it,’ he said.
‘We’re firm believers in trying to create a system where patients are put at less risk because they don’t have access to the ability to change the script. It makes it easier for pharmacists to trust in the prescription they’ve received.’
While paper scripts are a legal requirement, ScalaMed and Holdsworth House Medical Practice, have established a trial to explore whether empowering consumers with their digital prescriptions in a digital format through a blockchain-based method of storing and accessing their data, will improve the flow of clinically important information, patient adherence and efficiency within the healthcare system.
‘Currently we’re restricted [to a limited number of sites] because of the requirements for paper,’ Dr Rapke said.
He added that unlike traditional centralised data repositories, blockchain uses a decentralised model, which is less attractive to hackers.
More on the trial can be read here.
[post_title] => Blockchain exec pushing for the end of paper prescriptions
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[post_content] => The new Pharmacy House – owned by PSA members, for PSA members – was officially launched in Canberra in March by Assistant Minister for Science, Jobs and Innovation Senator Zed Seselja.
Supported by donations from pharmacist members and organisations, the new Pharmacy House will enable PSA to better represent pharmacists and pursue its vision of improving Australia's health through excellence in pharmacist care.
Located in Deakin and close to Parliament House, the building is designed to ensure PSA continues to provide the best services, education and advocacy for members regardless of where they are located.
Senator Seselja unveiled a plaque with PSA leaders to mark the official launch of Pharmacy House during an historic ceremony, attended by around 120 people.
PSA National President Dr Shane Jackson said the new building embodied the future for all pharmacists in Australia.
'Pharmacy House is more than just a building; it's part of a drive into the future for all pharmacists, who are the most accessible healthcare professionals in Australia,' Dr Jackson said.
'I sincerely thank all of the pharmacists and supporters who have donated towards the building fund, which raised around $300,000 – we sincerely appreciate your generosity and support.
'Importantly, the name Pharmacy House has been retained and the location is on the site of the original Pharmacy House built in 1984, which was also supported by member donations.'
See images from the launch event below.
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PSA Chief Operating Officer Deb Bowden, Senator Zed Seselja and PSA National President Dr Shane Jackson.[/caption]
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[post_content] => Effectively managing the medication and health of elite athletes is always the right medicine for their sporting success.
However it’s often difficult when high-performance athletes – and support staff – are travelling overseas or need medication to treat medical or chronic conditions that can impact their performance.
Fortunately, Australia’s top athletes and coaches have expert medical and healthcare support, as well as pharmacy dispensary services, available through the Department of Sports Medicine at the Australian Institute of Sport (AIS) in Canberra.
The medical clinic helps manage the performance of Australia’s athletes in the international sporting arena by providing evidence-based and innovative sports medicine support.
Senior AIS sports physicians consult with athletes about injuries and illness, and help to manage and treat all aspects of injury and illness prevention.
The innovative Sports Medicine facility is designed to help prepare athletes to be at their optimum health to excel at their chosen sport.
Registered nurses also make a major contribution to athlete care by being responsible for dressing injuries, providing immunisations, taking blood and dispensing medications.
The nursing staff also supervise and maintain the AIS pharmacy, which is strongly supported by Capital Chemist at Lyneham in the ACT.
AIS Chief Medical Officer Dr David Hughes – who oversees the day-to-day functioning of Sports Medicine and its medical research program – spoke with Australian Pharmacist during a recent visit to the medical clinic.
Dr Hughes highlighted the integral role of health professionals – including pharmacists – to ensure peak performance for all the elite athletes based at the AIS.
‘We know that injury and illness have a significant impact on performance – particularly going into competition time,’ Dr Hughes told Australian Pharmacist.
‘When you’re competing, you don’t want to be knocked around by being unwell.
‘We also provide care for additional people – officials and other sporting administration people. ‘A lot of what we do is education around good hygiene, especially when large teams are travelling together.’
One of the main areas of the Department of Sports Medicine is the in-house pharmacy which operates a little differently to most mainstream community pharmacies.
AIS dispensary
The AIS pharmacy functions more like a dispensary utilising a unique in-house prescription system, where a doctor prescribes a medicine order that is then dispensed and electronically recorded on the athlete’s file.
‘It really functions more like a dispensary than a pharmacy – and we work really closely with Lyneham Capital Chemist,’ Dr Hughes said.
‘They are fantastic – they provide an excellent service – and are able to do things at short notice, including advice on the latest developments in medicines.’
While the AIS clinic stocks a fairly standard range of common medicines including for conditions like asthma, colds and flu, inflammation and minor ailments, Dr Hughes said the relationship with the local community pharmacy is imperative, especially when they need to stock medications that are specific to individual needs.
‘We value this collaboration with medicines experts and enjoy dealing directly with a pharmacist,’ Dr Hughes said.
The nursing staff at the AIS predominately manage the dispensary with Registered Nurse Ruth Fazakerley taking the lead.
Ms Fazakerley provides nursing support to athletes visiting the Sports Medicine Clinic as well as manages the handling and storage of medicines.
The high-tech facility has a two bed observation area, which is like a “sick bay” but the clinic and health centre is not open after hours or on weekends.
‘Our pharmacy is very much a dispensary – and that’s where it’s a little bit different to mainstream pharmacies,’ she said.
‘A lot of the athletes are quite young and this is the first time they’ve been away from home so the doctors won’t prescribe a full pack of any medicine. They are all short doses – and doctors will usually only give the amount until their next review of the athlete.
‘They don’t give a script with repeats – and they [athletes] are monitored closely.’
Ms Fazakerley said once the medication is dispensed, it’s recorded against an athlete’s file and they are given a receipt.
‘When we’re giving the medication we provide advice, and we remind them they can reduce their risks by going online and checking their substances through the Australian Sports Anti-Doping Authority (ASADA) website.’
Apart from the pharmacy, the clinic also provides a range of healthcare services including musculoskeletal ultrasounds, minor procedures, skin lesions, stitching lacerations and vaccinations.
Vaccination
To ensure athletes reach and perform at their peak, especially when travelling overseas, vaccination is critical to their success.
The sports medicine clinic provides a large number of vaccinations and travel vaccinations for athletes, especially in the lead-up to major international sporting events, including the Rio Olympics in 2016.
‘We provide all vaccinations that the athletes might need and for their support staff,’ Ms Fazakerley said.
‘We stock all the major vaccines and also provide expert advice on how to be safe and self-reliant in overseas countries to limit and reduce symptoms of travel illness.’
For vaccines, the clinic predominantly deals with the Canberra-based pharmacy as well as the Federal Government but ‘we did directly deal with vaccine companies before the Rio Olympics.’
In the lead up to Rio in 2017, it’s estimated the clinic vaccinated more than 850 people including athletes and support staff, who had to be vaccinated for a range of conditions including yellow fever.
Dr Hughes said there were also precautions taken following the outbreak of the Zika virus before the Olympics.
Medication Policy and travel medicines
To ensure all athletes take medication safely, the Sports Medicine clinic follows a strict Medication Policy – with a major focus on only dispensing the bare minimum amount of medication required for athletes.
‘We don’t like them wandering around with bags full of medication – fortunately not many athletes are on long-term medicines,’ Dr Hughes said.
It can often be challenging for the medical staff, especially when they are dealing with young athletes aged from about 14 years old.
There are also strict protocols around prescribing pain and sleeping medications.
‘Like any pharmacy, we potentially face the same issues with people doctor shopping, so we have pretty strict rules around the use of strong pain medicines and sleep medication,’ Dr Hughes said.
‘We have a Medication Policy around some of these issues and in all cases we try to address symptoms through non-pharmacological methods in first instance.
‘But if an athlete’s travelling, we have a general rule we will only hand out three days of any particular sleeping medication at a time.’
To help athletes self-manage conditions, they are also encouraged to meet with the doctor before travelling overseas.
‘We encourage athletes to check medicines before they leave – and in most cases, athletes come and check in with us beforehand,’ Dr Hughes said.
‘We put together a travel medical kit, which depends a lot on where they are travelling.’
These travel packs usually include small amounts of paracetamol, nasal spray, vitamin c, zinc supplements and a throat gargle – with some instructions so they can ‘self-manage their conditions’.
‘We do also operate a bit like a travel clinic,’ Ms Fazakerley said.
Anti-doping regulations
Another major focus of the medical clinic and pharmacy is ensuring athletes comply with Australian and world anti-doping regulations.
This is governed by the World Anti-Doping Agency (WADA) and ASADA, based in Canberra.
A key role for the clinic is educating athletes on which drugs and substances are banned for competition and keeping a close eye on the everchanging rules.
Dr Hughes said athletes are constantly reminded about the therapeutic use exemption system used by WADA as well as the Global Drug Reference Online (Global DRO) which provides athletes and support personnel with information about the prohibited status of specific medications based on the current World Anti-Doping Agency (WADA) Prohibited List.
‘With Global DRO – athletes can go there and tap in medication and see if it’s banned in sport,’ Dr Hughes said.
To also ensure prohibited medications really stand out, they are labelled with a bright pink label to show they are prohibited during competition.
‘We have to have them brightly labelled,’ Ms Fazakerley said.
During the year, the athletes are also regularly reminded about prohibited substances and the changes that come into effect on a national and global level. These updates are sometimes provided through information pamphlets and brochures.
Supplements and complementary medications can also be challenging for athletes to comply with antidoping regulations.
‘For anybody who comes here for a medication review, supplements can be an issue. We really try to educate them around that – but it’s difficult because there’s so many supplements on the market,’ Dr Hughes said.
He said the clinic generally tends to use the same brands of supplements which have been batch tested for compliance.
Mental health is another key practice area for the clinic, especially dealing with young adults and adolescents who are under pressure to perform at their best.
‘We do deal with mental health issues – it’s tricky as the athletes are away from home – and we’re discussing with parents who are distant so there’s an extra duty of care,’ Dr Hughes said.
The Department of Sports Medicine also works closely with other disciplines of Performance Support services to deliver integrated support services to Australia’s athletes.
[post_title] => Medication management gives athletes a sporting chance
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[post_content] => Antimicrobial resistance (AMR) has been ranked as serious a threat to society as terrorism. With millions of lives at risk, and trillions in GDP potentially lost, antibiotic misuse must be prevented to avoid widespread resistance.
Today, no-one expects a scratch from a rose thorn to be a fatal injury.
But this is precisely what happened to the first patient treated with penicillin, the first antibiotic, in 1941. While the patient initially responded well, British doctor Charles Fletcher didn’t have enough penicillin on hand to clear the infection, and the patient later died.
Since the advent of mass production, the use of antibiotics has expanded far beyond health care, into agriculture and household products.
Despite the development of successive generations of antibiotics, widespread overuse of antibiotics has seen bacteria rapidly develop resistance, leading to the evolution of superbugs such as methicillin-resistant Staphylococcus aureus (MRSA) that greatly tax hospitals.
Strains of bacteria resistant to all known antibiotics, including the polymyxins like colistin, have been present in the developing world for several years, but resistance is emerging in the developed world, including Australia.
‘What’s even more scary, is that in a patient in a two-week course of treatment, the resistance to the polymyxins can increase a thousand-fold,’ said Dr Mark Blaskovich, Senior Research Chemist at the University of Queensland.
Currently, 700,000 people die each year from antibiotic-resistant infections, and this is projected to rise as high as 10 million by 2050.1
Wins and losses
Australia is one of the world’s highest users of antibiotics in human health and while concerted efforts in recent years have reduced that somewhat, prescription rates remain much higher than guidelines recommend.
In fact, a five-year study published in the Medical Journal of Australia last year found antibiotics are prescribed for acute respiratory infections at rates four to nine times as high as those recommended by Therapeutic Guidelines.2
The key to combating AMR is of course limiting the use of antibiotics.
‘Australia is an excellent example of what happens if you control the use of new antibiotics,’ said Dr Blaskovich.
‘When fluoroquinolones were first used in Australia, they were under strict control, and Australia has one of the lowest rates of fluoroquinolone resistance in the world.’
Yet misuse remains an issue in Australian health care. The 2017 Antibiotic Use and Resistance in Australia (AURA) report found that more than 45% of hospital prescriptions for antibiotics were either not compliant with guidelines or considered inappropriate. In the community, AURA 2017 found antibiotics are still frequently prescribed for viral respiratory infections that cannot be treated with antibiotics.3
Mission creep
But antibiotic use and misuse isn’t limited to human health.
‘Of all the antibiotics used, generally, in any country, 20–30% are used in human health, and 70–80% are used in food animal health,’ said Professor Sabiha Essack, Director of the Antimicrobial Research Unit at South Africa’s University of KwaZulu-Natal. In animal health, most use is prophylactic and for growth promotion, but resistant bacteria can easily contaminate meat and other products when animals are slaughtered.
Resistant bacteria can also enter water and soil in the environment through animal faeces, eventually reaching other produce.
Various antimicrobials are also widely included in household soaps and cleaning products, and there are significant concerns that the mutations that allow bacteria to develop resistance to these antimicrobials could also make them resistant to prescribed antibiotics.
With antibiotic misuse spanning human and animal health, the World Health Organisation (WHO) is now prioritising a multi-sectoral approach to combating AMR. Known as One Health, it focuses on surveillance across human health, animal health and the environment.4
‘The arrangements for human AMR surveillance were reviewed in June 2017, with a number of recommendations for improvement, including moving to a One Health system with capacity to integrate human and animal health,’ said Australia’s Chief Medical Officer, Professor Brendan Murphy.
But there is currently still no comprehensive surveillance of AMR and antimicrobial usage in animal health. Some proof-of-concept surveillance projects and other research have been launched, but results from these studies are not expected until early 2018 through to 2020. Currently, animal and human surveillance data are not integrated.
Good stewards
In dispensing prescriptions and providing guidance on the use and prescribing of antibiotics, pharmacists are a crucial part of the battle to combat antibiotic misuse in human health.
In particular, pharmacist-led antibiotic stewardship programs appear to be having an impact on misuse and AMR.
‘We have evidence of improvement as stewardship programs are rolled out,’ said Dr John Turnidge, Scientific Secretary for the European Committee on Antimicrobial Susceptibility Testing. ‘In 2015, 40% of antimicrobial prescriptions for surgical prophylaxis were inappropriate. That dropped to 27% the following year.’
While there has been success in reducing misuse in hospitals, AURA data reveals inappropriate antibiotic prescribing in the community – particularly for respiratory tract infections – still poses a significant problem for Australia.
‘Australia’s weak point is finding the courage to directly address the problem of inappropriate prescribing in the community,’ Dr Turnidge said.
Australia’s National AMR Strategy calls for pharmacists to educate patients on appropriate antibiotic use, the dangers of resistance, how to prevent infections and manage symptoms without antibiotics.
While Dr Turnidge acknowledges the difficulty in finding a role for pharmacists in the community, where their job is seen as filling submitted prescriptions, he believes there are opportunities before people even visit a GP.
‘People visit the pharmacy looking for common cold remedies, and there’s an opportunity for pharmacists to intervene and offer them more information about their condition, saying “Here are the symptomatic treatments that work. [It] almost certainly doesn’t need antibiotics at any stage,”’ he said.
Providing patients with symptomatic treatment while also informing them about antibacterial resistance and the importance of restrained use may help address the considerable amount of inappropriate use in the community, but it is a difficult conversation to have.
GPs diagnose and prescribe medication; if pharmacists intervene before a patient visits a GP and advise against antibiotics, GPs could see it as impinging on their role. Dr Turnidge said the conversation needs to be had at a higher level, including such forums as the RACGP and Federal Government.
Community challenges
While antibiotic stewardship programs are mandatory for hospitals, many say that such programs are inadequate for GPs and primary care.
Dr Bastian Seidel, President of the Royal Australian College of General Practitioners, said a GP program is needed that would include not only GP training and educational resources for patients, but would establish treatment guidelines, antibiotic course duration and delayed prescribing.
‘We need to have more specific, real-world evidence informing the clinical decision making of GPs and literally anything should be up for grabs,’ he said.
Dr Blaskovich sees a role for stewardship pharmacists and AMR specialists to help develop a community AMR stewardship program and learning module for GPs, building off the experience in hospitals.
‘Hospitals are identifying doctors who are not following best practice, and they’re doing it in a way to try and educate, not penalise. We need to find a way to do this in the community,’ he said.
There is widespread recognition that GPs face considerable pressure from anxious patients to prescribe antibiotics in time-limited consultations.
Dr Blaskovich sees value in public awareness campaigns aimed at increasing health literacy among the public.
‘A still significant portion of the population believes that “antibiotic resistance” means that their body is becoming resistant to the antibiotics, not that the bacteria are becoming resistant,’ he said.
There is evidence that longer consultation times reduce antibiotic misuse and help change public attitudes. With consultations lasting an average of 24 minutes, Sweden has managed to successfully reduce overall antibiotic use.5 Worryingly, the average in Australia is 14 minutes, and is trending down.6
Many experts agree bans or limits on antibiotic use in other sectors should also be considered. While Australia has one of the most conservative approaches to antibiotic use in animals in the world, there has been no move to limit use in household products.
In 2016, the United States banned the use of 19 antibacterial substances, including triclosan, in consumer soaps as part of its AMR strategy.
‘Using one antimicrobial can cause resistance to other antimicrobial agents because they are carried along on the same DNA, so limiting their use like this is a step in the right direction,’ said Prof Essack.
Considering pharmacies often stock such antibacterial soaps, there may also be a role for pharmacists to advise against their widespread use, saving them for vulnerable and immunocompromised groups instead.
Ultimately, Dr Turnidge and others stress that pharmacists can see each interaction with a patient as a potential moment to raise awareness about AMR and promote the responsible use of antibiotics.
‘How to get some of the pharmacist’s time when they’re busy dispensing prescriptions and get them to counsel people looking for cold remedies is an interesting question, but is certainly worth answering,’ he said.
‘Pharmacists are particularly valuable at the level of respiratory infections, because they are the first port of call in those circumstances, not the GP.’
Timeline
| 1928 | Scottish scientist Alexander Fleming discovers Penicillium notatum mould kills Staphylococcus bacteria. |
| 1932 | German scientist Gerhard Domagk discovers sulfonamidochrysoidine. |
| 1938 | Howard Florey and Ernst Chain isolate penicillin from P. notatum mould, creating the first antibiotic. |
| 1940 | Penicillin-resistant Staphylococcus identified. |
| 1950 | Tetracycline introduced. |
| 1953 | Erythromycin introduced. |
| 1959 | Tetracycline-resistant Shigella identified. |
| 1960 | Methicillin introduced. |
| 1962 | Methicillin-resistant Staphylococcus aureus (MRSA) identified. |
| 1965 | Penicillin-resistant pneumococcus identified. |
| 1967 | Gentamicin introduced. |
| 1968 | Erythromycin-resistant Streptococcus identified. |
| 1972 | Vancomycin introduced. |
| 1979 | Gentamicin-resistant Enterococcus identified. |
| 1985 | Imipenem and ceftazidime introduced. |
| 1987 | Ceftazidime-resistant Enterobacteriaceae identified. |
| 1988 | Vancomycin-resistant Enterococcus identified. |
| 1994 | Vancomycin-resistant Enterococcus identified in Australian hospitals. |
| 1996 | Levofloxacin introduced. Levofloxacin-resistant pneumococcus identified. |
| 1998 | Imipenem-resistant Enterobacteriaceae identified. |
| 2000 | Linezolid introduced. Extensively drug-resistant tuberculosis (XDR TB) identified. |
| 2001 | Linezolid-resistant Staphylococcus identified. |
| 2002 | Vancomycin-resistant Staphylococcus identified. |
| 2003 | Daptomycin introduced. |
| 2004 | Pan-drug-resistant Acinetobacter and Pseudomonas identified. |
| 2009 | Ceftriaxone-resistant Neisseria gonorrhoeae identified. Pan-drug-resistant Enterobacteriaceae identified. |
| 2010 | Ceftaroline introduced. |
| 2011 | Ceftaroline-resistant Staphylococcus identified. |
| 2015 | Colistin-resistant bacteria identified. |
| 2016 | US FDA bans the use of triclosan and 18 other antibacterial substances from household soaps. |
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[post_content] => Having missed out on studying medicine at the university of her choice in India, Associate Professor Bandana Saini MPS thought she’d study pharmacy for ‘just a year’ while waiting to re-sit the medicine exams. More than two decades later, she’s a leading lecturer, researcher and asthma educator.
How did you find yourself in your current role at the University of Sydney?
I first studied pharmacy in India then came to Australia and completed an MBA.
I was about to return to India when I walked into the University of Sydney and thought, ‘I should see how pharmacy is taught here’. The then-Dean introduced me to a professor who asked, ‘If you were doing research, what would you do it in?’ I replied, ‘Asthma management’. And she said, ‘You’re on!’ That was 1997. I haven’t looked back.
What have you learned along the way?
My PhD focused on developing an asthma management model for community pharmacies. So I first had to learn a lot about community pharmacy because my original training had been very science and pharmaceutics-focused.
I had to register in Australia as a pharmacist and spent a lot of time in community pharmacies, which I loved. I got a lot of enjoyment talking to patients and listening to their stories.
Also, having asthma myself, I’ve realised I have a lot of personal motivation to work in this area.
What are your biggest challenges?
With teaching, you need a lot of passion. You also need a little bit of showmanship to engage pharmacy students not just in the lecture, but with the profession.
With research, the challenge is to make sure that, before I retire, respiratory disease management and my other research field, sleep, are remunerated parts of pharmacy services.
What’s the most satisfying part of your role?
If I go into a pharmacy almost anywhere in NSW, there’s a good chance someone will walk out and say, ‘Oh, Bandana, how are you?’
It’s very fulfilling to see people you’ve trained who are now professionals.
Where do you see yourself in 10 years?
I’d still like to be at the university because I really am passionate about teaching and research. But I want to take a bigger leadership role in terms of developing pharmacy services.
So far I’ve been a lone researcher. I do a project, get great results, publish it, publicise it and let the pharmacy profession know. But there’s a gap between that and actually making it happen. And that’s what I want to focus on.
What’s your plan to make that happen?
I’ll have to work with people outside pharmacy, people who are health policy experts.
I’ll learn and work with them towards making sure that there’s a channel for paying pharmacists for services they currently provide for free – in my case, asthma and sleep.
A typical day for Associate Professor Bandana Saini MPS, an Asthma Educator
| 8am | General preparation of respiratory kit. Prepare patient record file, print asthma education materials and action plans. |
| 9am | Arrive at pharmacy one to two hours before appointment. Check list of patient appointments. Request dispensed medication history and review asthma medications, as well as any notes from pharmacist. |
| 10am | Check which inhalers patient is using and prepare demonstration devices. Check who the patient’s GP or specialist is. Check with pharmacist for other issues. |
| 10.30am | Set up area for patient appointment. Ensure patient files, spirometer, lung models and dispensed medication history are ready. |
| 11am- 11.45am | Introduce myself to patients, make them comfortable, obtain patient consent, interview patient, conduct lung function test, inhaler check, vaccination status and action plan ownership checks. |
| 11.45am- 12.15pm | Go through three-step inhaler education plan, including patient demonstrating, giving a demonstration myself, and then getting the patient to demonstrate again correctly. |
| 12.45pm- 1pm | Explain action plan to patient. End interview with goals the patient would like to set. Discuss what I’ll recommend to their doctor and provide a copy of referral letter to them. |
| 1pm- 1.30pm | Complete documentation and send referral to GP. Make next pharmacy appointment for patient. Debrief pharmacist. Ensure patient notes are confidentially secured with pharmacy. |
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[post_content] => Pharmacist and runner Madeline Hills, applauded for her standout sportsmanship in the Commonwealth Games, tells AP how her pharmacy training set her up for athletic success.
Ms Hills' inspiring efforts on the track and at the 10,000m race-end on 9 April have been recognised and lauded internationally for showing the world what sportsmanship is all about.
Instead of leaving the track once her Commonwealth Games race was complete, as most competitors did, Ms Hills and her Australian teammates remained in place, compassionately awaiting the arrival of the last competitor Lineo Chaka from Lesotho, whom they cheered and clapped across the finish line.
Ms Hills is still to compete in the Women's 5000m Final on Saturday 14 April.
Before leaving to compete in the Commonwealth Games, Madeline talked to AP about the correlations between her pharmacy training and what it takes to be an Olympic athlete.
Q. You’re an Olympic and Commonwealth Games steeplechase veteran but you’ve made a late switch. Instead you’re contesting the 5000m and 10,000m flat – no hurdles or water pits. Why?
A. After the Olympics, I picked up a string of injuries that don’t really agree with all the jumping of steeplechase. Funnily enough, hurdling has always been the part I don’t like about the steeplechase. But it does seem strange to have left steeplechase; hopefully it’s not forever.
Q. What drew you to participating in the steeplechase originally?
A. In my second year as a pharmacy student the 2006 Commonwealth Games were on in Melbourne and we saw the steeplechase as an event I could qualify for. I’m quite tall and I’ve got very, very long limbs so I suppose people looked at me and thought I would effortlessly jump over things. To be fair, I actually don’t. I’m not the most coordinated but I get over them because I’m long.
Q. You did in fact qualify for the Melbourne Games, but three people qualified faster. You then parked the steeplechase for a while and focused on pharmacy?
A. Yes, I finished my study and had a really strong desire to travel. For the next four or five years I locumed around the country and did this cycle of working crazy hours, travelling overseas for months, then coming back to replenish the stocks. While I was working Adelaide, I studied a Masters in International Public Health – I wanted to see where pharmacy could take me. But then I started running again and community pharmacy worked for me because it’s so flexible.
Q. It was around this time that you started training towards the 2016 Rio Olympics. What has made your athletics career so satisfying?
A. The best moments are when I’m able to achieve something that once seemed impossible. I went into the Rio Olympics with a broken second metatarsal and all the specialists, the team doctor – everyone – was saying ‘we don’t want you to run on this’. So I emailed a family friend who’s a doctor for the Australian cricket team saying ‘What do you think?’ He wrote back ‘Mads, they’re right – you can’t run on this’. I remember getting that email and deleting it.
Q. You went on to run a personal best in Rio. What lessons has your sporting career taught you that you can apply to pharmacy and vice versa?
A. Pharmacists are quite meticulous with planning and executing things. Taking that to my running has helped me minimise complications from injury, plus train and work full-time relatively stress-free. Running has helped me be more flexible as a pharmacist. That can be as simple as adjusting when staff don’t turn up, thinking on your feet and accepting when things don’t go a certain way.
[post_title] => In the fast lane with Madeline Hills
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[post_content] => [vc_row][vc_column width="2/3"][vc_column_text]Since taking up the Chief Medical Officer post in 2016, Professor Brendan Murphy has made a number of strategic interventions in the pharmacy sphere, from directly admonishing the GPs with the highest rates of antibiotic prescribing to weighing in on pharmacies offering ultrasound screening for strokes.
Australian Pharmacist spoke to the Federal Government’s chief advisor on medical matters to gauge his thoughts on the future of pharmacy’s scope of practice and care.
Q How large a role do you think pharmacists can ultimately play in the broader healthcare system?
A The Government recognises the pivotal role of the community pharmacy sector – and pharmacists – in delivering medicines and vaccines to Australian patients. The Government also recognises the key role that community pharmacy plays as part of the primary health care team, and the assistance that community pharmacy can provide in achieving the whole-of-health system goals of providing the right care in the right place at the right time.
The Government entered into the Sixth Community Pharmacy Agreement (6CPA), which operates until 30 June 2020, to support the National Medicines Policy (NMP) and the sustainability of the Pharmaceutical Benefits Scheme.
The Compact includes a statement of intent to build on the collaborative primary health care arrangements in place within the Primary Health Networks (PHNs) that involve community pharmacies in the provision of support to patients, seeking to further improve their health outcomes.
In addition, PSA – and other pharmacy organisations – will continue to work cooperatively with the Government on the development of new and innovative ideas to expand the role of community pharmacy in supporting primary health care for patients. This will include appropriate evaluation of such measures, as well as working in partnership with the Australian Digital Health Agency to maximise the uptake and clinical use of the My Health Record by community pharmacies.
Q What are some of the looming health challenges where you see pharmacists playing a critical role in managing?
A The Government recognises the significant pressures on the health system, including a growing burden of chronic disease, an ageing population, and growing demand for high-cost, high-tech services and breakthrough medicines. Community pharmacy is an integral part of the Australian healthcare system through its role in the delivery of the PBS and related services.
Through the $50 million Pharmacy Trial Program (PTP), which was established under the 6CPA, trials of new and expanded community pharmacy programs are being undertaken, which seek to improve clinical outcomes for consumers and/ or extend the role of pharmacists in the delivery of primary health care services through community pharmacy.
Trials are underway looking at utilisation of pharmacist skills in medication management within Aboriginal Health Services. Trials are also underway in medication management and identification of risks in chronic disease, including diabetes and asthma.
A Chronic Pain MedsCheck Trial, recently announced by Minister Hunt (on 25 January), will assist patients who are taking medication to deal with ongoing chronic pain by supporting pharmacists to evaluate a patient’s medication use and develop a written action plan including education, self-management and referral to a general practitioner or other health professional where additional support is required.[/vc_column_text][/vc_column][vc_column width="1/3"][/vc_column][/vc_row]
[post_title] => Q&A: Chief Medical Officer Brendan Murphy
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[post_content] => As a supporter of pharmacists, Catherine King MP is a firm believer in having a ‘broader’ role for pharmacists in Australia’s health system.
During her speech at PSA17, Ms King said: ‘I want to recognise that pharmacists play a broader role in our healthcare system. For example, every State and Territory now asks you to help manage influenza by administering flu vaccines.’
She said pharmacists can play a role as medicines experts especially in the management of chronic conditions.
Q Why are you so passionate about improving healthcare in Australia?
A Healthcare is one of those unique issues that impacts Australians at every stage of their lives – from birth to death. And a person’s ability to access the healthcare they need – when they need it – is so intrinsically linked to their quality of life. We have a fantastic healthcare system in Australia but there’s growing inequality in access to healthcare and health outcomes. That’s why I’m so passionate about making sure our healthcare system is the strongest it can be.
Q How important is the role of pharmacists to improve Australia’s healthcare system?
A Pharmacists have unique knowledge about the role of medicines and play an important role in ensuring people are able to access them through the Pharmaceutical Benefits Scheme (PBS) – one of the most integral planks of our universal healthcare model. And for many Australians, a pharmacist will be their first port of call for advice when they are unwell.
Q What benefits are achieved by pharmacists working in collaboration with other health professionals including doctors?
A The role of pharmacy is changing – and will continue to change – as our entire health system changes. I’m a firm believer that there is a greater role for pharmacists to play as medicines experts especially in the management of chronic conditions. With a growing burden of chronic disease in Australia, we will need to find smarter ways to use our health resources. I think that closer collaboration between all health professionals will be integral to this.
Q What advice do you have for pharmacists to improve their engagements with medical professionals?
A Pharmacists are incredibly valuable resources not just for the community but for other health professionals. I think the key to interaction is ensuring pharmacists use their incredibly unique experience and skillset to show how they can improve the patient experience.
I’ve been on the record saying I don’t think pharmacists should expand into areas which will only increase duplication and double billing of Medicare. But likewise I don’t think there is enough recognition of the value that pharmacists can add in their own right. I think improving this recognition will help improve engagement between the industry and medical professionals. We all share a vision for patient-centred primary care where services are better integrated and coordinated. Pharmacists are critical to this.
Q As medicines experts, how can pharmacists play a greater role in community health?
A One in four Australians have a chronic condition and the social and economic costs of this are incredibly significant, something that will only continue to grow. If we are concerned about chronic disease and the strain it puts on our healthcare system, then the obvious answer is to keep people as well as possible for as long as possible. As key primary health providers, pharmacies play a dual role in both prevention and keeping people well and helping people access the primary care they need.
Q Would you recommend patients talking to their local pharmacists about minor illnesses, vaccination and medicines advice?
A Of course, pharmacists are incredibly important, knowledgeable health professionals and can be an excellent referral point for further health treatment, or on the spot advice.
[post_title] => Q&A: Shadow Federal Health Minister Catherine King
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[post_content] => Pharmacist Adrian Unger MPS was in his 50s when a young woman came into his pharmacy in Chatswood NSW, asked for bandages and set him on an unexpected path.
He assumed the bandages were for wound care, but she said she wrapped them around her hands for boxing. She trained at a gym down the road. Mr Unger liked the idea of a challenge, so he decided to try it out.
‘The owner looked me up and down and obviously thought I was too old for all that,’ Mr Unger said. ‘But I really enjoyed it and I’ve done it ever since.’
His interest in boxing took on a whole new meaning in 2004 when, at the age of 58, he was diagnosed with Parkinson’s disease.
‘My father had it, so I’d seen what it was like. He hadn’t done much to help himself and was wheelchair-bound for 20 years.’
Not knowing how long he’d remain physically independent, Mr Unger sold his pharmacy and did compounding for a while, but the work demanded a steady hand and he had to give it up. He decided to do as much exercise as possible to keep himself out of a wheelchair.
One day he saw a YouTube video about a gym in Indianapolis that offered non-contact boxing to control many of the symptoms of Parkinson’s. Soon after, the gym announced a course where people could learn how to run similar programs in their communities. The course was only intended for locals, but Mr Unger told the gym he and his wife were going anyway.
‘It was amazing. They had people up to 90 with gloves on, and if they couldn’t stand they were in a chair punching the bag, or their carer held them up.’
The two brothers who owned the gym in Chatswood had known Mr Unger since they were young, and they backed his idea to run the program, which he called Punchin’ Parko’s. Parkinson’s NSW provided a small grant. In 2014 a test run of the program kicked off with 12 people.
‘People told me how good they were feeling. One man couldn’t lean down and tie his shoes before the program, but afterwards it wasn’t a problem. We go go go the whole time, from warm ups to boxing moves to cool downs.’
Mr Unger explained that, to help with the symptoms of Parkinson’s, exercise needs to do three things: push you outside your comfort zone, force you to repeat movements, and be complex enough to kick-start neuroplasticity. Boxing – which he considered to be one of the hardest sports to master – ticks all the boxes.
‘People often say, “The best tablet I take for my Parkinson’s is exercise.” The day after a session, they notice all these little improvements, like their hands aren’t shaking as much. Some people come in with walking sticks and skip out without them.’
Participants attend sessions based on their level of symptoms, and must get a clearance from their doctor first. They are aged anywhere from 20 to over 90.
‘I like to say, “You don’t punch anyone, no one punches you, but there’s a whole lot of punches going on.” During the Olympics, two ladies told me they’d watched the boxing and it fascinated them because now they could see the tactics, the more technical side of the sport.’
Mr Unger said there is more literature to indicate this kind of exercise is beneficial and has been overlooked in the past. Neurologists have started referring people to Punchin’ Parko’s before they prescribe medication, to see if the exercise by itself will have an effect.
He has taken several qualified gym coaches under his wing and told them what to expect and how to introduce variations for people with Parkinson’s. He is now running his own Train the Trainers course so others can learn his secrets.
Mr Unger was honoured to receive a Medal of the Order of Australia in 2016 for his work with the program.
‘I accepted it on behalf of the Parko’s, because they’re the real stars. We have a great lot of people from all walks of life. We’re all in the same boat. If I walked into an ordinary gym, I’d be embarrassed to do anything, but here everyone’s the same, we’ve all been through it. If you make a mistake, who cares?’
[post_title] => Parkinson’s on the ropes
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For editorial inquiries, please contact editor Leisa Hayward.
02 9556 9110
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02 9556 9116
0449 042 577
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
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australianpharmacist@psa.org.au
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Deakin West ACT, 2600
