Perceptions of the influence of prescription medicine samples on prescribing by family physicians

Background: The provision of free prescription medicine samples is a common and traditional marketing strategy used by pharmaceutical companies, but concerns have been raised about their influence on physician prescribing behavior and patient safety. Objective: We sought to investigate the knowledge, attitudes, and behaviors of Australian family physicians regarding the use of sample prescription medications. Methods: Qualitative and quantitative techniques were used, including (1) mailed questionnaires to family physicians, (2) semistructured interviews with family physicians, and (3) sample cupboard inventories. Results: A number of issues about samples were identified by the questionnaires (208) and interviews (17 doctors), including insufficient labeling, poor record keeping, diversion of stock (personal use by doctors.. their families, practice staff and pharmaceutical representatives), and wasting of expired stock. Prescription medicine samples also influenced prescribing behavior. Australian doctors were less likely to provide samples to patients on financial grounds compared with a previous study in the United States on medical residents. Six sample cupboards were inventoried. Median wholesale value of sample cupboards was AUD $4959 (range $2395-$8709), with 6% of stock expired. Very little generic medicine was included in the sample cupboards. Conclusions: Better methods are needed to meet legislative requirements and to ensure quality use of medicines (and optimal public health) with respect to prescription medicine samples. Doctors and practice staff require training on the appropriate handling and storage of prescription medications. Alternative ways for distribution of sample medications need to be investigated.

Development of a quality use of medicines coding system to rate clinical pharmacists' medication review recommendations

Objective: To develop a 'quality use of medicines' coding system for the assessment of pharmacists' medication reviews and to apply it to an appropriate cohort. Method: A 'quality use of medicines' coding system was developed based on findings in the literature. These codes were then applied to 216 (111 intervention, 105 control) veterans' medication profiles by an independent clinical pharmacist who was supported by a clinical pharmacologist with the aim to assess the appropriateness of pharmacy interventions. The profiles were provided for veterans participating in a randomised, controlled trial in private hospitals evaluating the effect of medication review and discharge counselling. The reliability of the coding was tested by two independent clinical pharmacists in a random sample of 23 veterans from the study population. Main outcome measure: Interrater reliability was assessed by applying Cohen's kappa score on aggregated codes. Results: The coding system based on the literature consisted of 19 codes. The results from the three clinical pharmacists suggested that the original coding system had two major problems: (a) a lack of discrimination for certain recommendations e. g. adverse drug reactions, toxicity and mortality may be seen as variations in degree of a single effect and (b) certain codes e. g. essential therapy were in low prevalence. The interrater reliability for an aggregation of all codes into positive, negative and clinically non-significant codes ranged from 0.49-0.58 (good to fair). The interrater reliability increased to 0.72-0.79 (excellent) when all negative codes were excluded. Analysis of the sample of 216 profiles showed that the most prevalent recommendations from the clinical pharmacists were a positive impact in reducing adverse responses (31.9%), an improvement in good clinical pharmacy practice (25.5%) and a positive impact in reducing drug toxicity (11.1%). Most medications were assigned the clinically non-significant code (96.6%). In fact, the interventions led to a statistically significant difference in pharmacist recommendations in the categories; adverse response, toxicity and good clinical pharmacy practice measured by the quality use of medicine coding system. Conclusion: It was possible to use the quality use of medicine coding system to rate the quality and potential health impact of pharmacists' medication reviews, and the system did pick up differences between intervention and control patients. The interrater reliability for the summarised coding system was fair, but a larger sample of medication regimens is needed to assess the non-summarised quality use of medicines coding system.

Characteristics of older dietary supplement users: Review of the literature

Published literature reports rates of dietary supplement usage by individuals aged 60 years or more to be 16−60%. Prevalence figures are dependent on the population studied and the method of data collection. In general, older supplement users are female, Caucasian and well educated, with healthier lifestyle practices than non-supplement users, and they are less likely to be overweight or to smoke. Neither income nor self-rated health status are reliable predictors of supplement use in this group. In many cases older supplement users report higher intakes of several micronutrients from food than older non-supplement users. Current patterns of supplement use by the older person reveal that although they consume a range of products, they do not supplement with nutrients that are of particular benefit to them. The supplements most commonly consumed by individuals aged 60 years and over are multivitamins and minerals, vitamin C and vitamin E preparations. There is insufficient data to quantify the dosage, frequency and duration of supplement use by the older population. Obtaining this information and data about herbal medicine use is an important step towards minimising the risk of drug–nutrient–herbal interactions. Identifying the health professionals who monitor the appropriateness and safety of supplement use in older individuals, particularly given the already high use of medication in this population, also needs to be a focus of future utilisation investigations. This systematic review of the literature published between 1982 and 2003 aims to measure the patterns of dietary supplement use by community-living individuals aged 60 years and over and to profile the characteristics of older supplement users.

Psychotropic medication utilization in a child and adolescent mental health service

Objectives: This study aimed to identify rates and correlates of psychotropic drug utilization in children and adolescents in inpatient and outpatient settings. Methods: A retrospective chart review examined 122 inpatient and 126 outpatient charts from a metropolitan child and youth mental health service in Brisbane, Australia. Results: Inpatients received more psychotropic medication than outpatients (71% vs. 25%; p < 0.01). Patients receiving medication were older, had longer hospital admissions, and more complex presentations, including history of abuse or suicide attempts and more diagnoses (all p < 0.01). Selective serotonin reuptake inhibitors (SSRIs) were the most frequently used drug class (44% inpatients; 14% outpatients), primarily indicated for mood disorders (31%). SSRIs and newer antidepressants (ADs) were used more frequently in patients with a high suicide risk (p < 0.01). Atypical antipsychotics (APs) were also used (inpatients 23%; outpatients 3%), primarily for behavioral disturbances. Half of those receiving medication (51%) received polypharmacy (> 1 concurrent drug), with up to four drugs used at one time. Rates of polypharmacy were highest among patients receiving antipsychotics. Conclusions: Use of psychotropic medication is frequent in this population. Future research should initially focus on inpatients and intensive treatment settings and examine both safety and efficacy of interventions for depression in young people, atypical antipsychotics for behavioral disturbances, and polypharmacy.

Cannabis use and psychosis: a review of clinical and epidemiological evidence

Objective: This paper evaluates evidence for two hypotheses about the relationship between cannabis use and psychosis: (i) that heavy cannabis use causes a 'cannabis psychosis', i.e, a psychotic disorder that would not have occurred in the absence of cannabis use and which can be recognised by its pattern of symptoms and their relationship to cannabis use; and (ii) that cannabis use may precipitate schizophrenia, or exacerbate its symptoms. Method: Literature relevant to drug use and schizophrenia is reviewed. Results: There is limited clinical evidence for the first hypothesis. If 'cannabis psychoses' exist, they seem to be rare, because they require very high doses of tetrahydrocannabinol, the prolonged use of highly potent forms of cannabis, or a preexisting (but as yet unspecified) vulnerability, or both. There is more support for the second hypothesis in that a large prospective study has shown a linear relationship between the frequency with which cannabis had been used by age 18 and the risk over the subsequent 15 years of receiving a diagnosis of schizophrenia. Conclusions: It is still unclear whether this means that cannabis use precipitates schizophrenia, whether cannabis use is a form of 'self-medication', or whether the association is due to the use of other drugs, such as amphetamines, which heavy cannabis users are more likely to use. There is better clinical and epidemiological evidence that cannabis use can exacerbate the symptoms of schizophrenia.

Systematic review: Terlipressin in acute oesophageal variceal haemorrhage

Background: Controversy exists surrounding pharmacological therapy in acute variceal bleeding. Methods: To determine the efficacy and safety of terlipressin. Methods: Randomized trials were identified and duplicate, independent, review identified 20 randomized trials involving 1609 patients that compared terlipressin with placebo, balloon tamponade, endoscopic treatment, octreotide, somatostatin or vasopressin for treatment of acute oesophageal variceal haemorrhage. Results: Meta-analysis showed that compared to placebo, terlipressin reduced mortality (relative risk 0.66, 95% CI 0.49-0.88), failure of haemostasis (relative risk 0.63, 95% CI 0.45-0.89) and the number of emergency procedures per patient required for uncontrolled bleeding or rebleeding (relative risk 0.72, 95% CI 0.55-0.93). When used as an adjuvant to endoscopic sclerotherapy, terlipressin reduced failure of haemostasis (relative risk 0.75, 95% CI 0.58-0.96), and had an effect on reducing mortality that approached statistical significance (relative risk 0.74, 95% CI 0.53-1.04). No significant difference was demonstrated between terlipressin and endoscopic sclerotherapy, balloon tamponade, somatostatin or vasopressin. Haemostasis was achieved more frequently with octreotide compared to terlipressin (relative risk 1.62, 95% CI 1.05-2.50), but this result was based on unblinded studies. Adverse events were similar between terlipressin and the other comparison groups except for vasopressin, which caused more withdrawals due to adverse events. Conclusions: Terlipressin is a safe and effective treatment for acute oesophageal variceal bleeding, with or without adjuvant endoscopic sclerotherapy. Terlipressin appears to reduce mortality in acute oesophageal variceal bleeding compared to placebo, and is the only pharmacological agent shown to do so. Future studies will be required to detect potential mortality differences between terlipressin and other therapeutic approaches.

Organisational Factors Contributing to Violations by Rural and Remote Area Nurses during Medication Administration

Medication errors are a leading cause of unintended harm to patients in Australia and internationally. Research in this area has paid relatively little attention to the interactions between organisational factors and violations of procedures in producing errors, although violations have been found to increase the likelihood of these errors. This study investigated the role of organisational factors in contributing to violations by nurses when administering medications. Data were collected using a self-report questionnaire completed by 506 nurses working in either rural or remote areas in Queensland, Australia. This instrument was used to develop a path model wherein organisational variables predicted 21% of the variance in self-reported violations. Expectations of medical officers mediated the relationship between working conditions of nursing staff and violation behaviour.