Managing complex medication regimens: perspectives of consumers with osteoarthritis and healthcare professionals

BACKGROUND: Managing medications is complex, particularly for consumers with multiple coexisting conditions for whom benefits and adverse effects are unpredictable and health priorities may be variable.

OBJECTIVE: To investigate perceptions of and experiences with managing drug regimens from the perspectives of consumers with osteoarthritis and coexisting chronic conditions and of healthcare professionals from diverse backgrounds.

METHODS: Using an exploratory research design, focus groups were formed with 34 consumers and 19 healthcare professionals. Individual interviews were undertaken with 3 community medical practitioners.

RESULTS: Consumers' management of medications was explored in terms of 3 themes: administration of medications, provision of information, and the perceived role of healthcare professionals. In general, consumers lacked understanding regarding the reason that they were prescribed certain medications. Since all consumer participants had at least 2 chronic conditions, they were taking many drugs to relieve undesirable symptoms. Some consumers were unable to achieve improved pain relief and were reluctant to take analgesics prescribed on an as - needed basis. Healthcare professionals discussed the importance of using non-pharmacologic measures to improve symptoms; however, consumers stated that physicians encourage them to continue using medications, often for prolonged periods, even when these agents are not helpful.

CONCLUSIONS: Consumers were dissatisfied about the complexity of their medication regimens and also lacked understanding as to how to take their drugs effectively. Dedicated time should be devoted during medical consultations to facilitate verbal exchange of information about medications. Pharmacists must communicate regularly with physicians about consumers' medication needs to help preempt any problems that may arise. Instructions need to be revised through collaboration between physicians and pharmacists so that "as needed" directions provide more explicit advice about when and how to use such drugs. Future research, using large, generalizable samples, should examine trends related to consumers' experiences of symptomatic relief from chronic conditions and their understandings about medications.

The epidemiology of ecstasy use and harms in New South Wales, Australia

Aims:This paper examines the epidemiology of ecstasy use and harm in Australia using multiple data sources.

Design: The data included (1) Australian Customs Service 3,4-methylenedioxymethamphetamine (MDMA) detections; (2) the National Drug Strategy Household and Australian Secondary Student Alcohol and Drug Surveys; (3) data from Australia's ecstasy and Related Drugs Reporting System; (4) the number of recorded police incidents for ecstasy possession and distribution collated by the N.S.W. Bureau of Crime Statistics and Research; (5) the number of calls to the Alcohol and Drug Information Service and Family Drug Support relating to ecstasy; (6) the Alcohol and Other Drug Treatment Services National Minimum Dataset on number of treatment episodes for ecstasy, and (7) N.S.W. Division of Analytical Laboratories toxicology data on number of deaths where MDMA was detected.

Findings: Recent ecstasy use among adults in the general population has increased, whereas among secondary students it has remained low and stable. The patterns of ecstasy consumption among regular ecstasy users have changed over time. Polydrug use and use for extended periods of time (>48 h) remain common among this group. Frequent ecstasy use is associated with a range of risk behaviours and other problems, which tend to be attributed to a number of drugs along with ecstasy. Few ecstasy users present for treatment for problems related to their ecstasy consumption.

Conclusions: Messages and interventions to reduce the risks associated with polydrug use and patterns of extended periods of use are clearly warranted. These messages should be delivered outside of traditional health care settings, as few of these users are engaged with such services.

Herb-drug interactions: a literature review

Herbs are often administered in combination with therapeutic drugs, raising the potential of herb-drug interactions. An extensive review of the literature identified reported herb-drug interactions with clinical significance, many of which are from case reports and limited clinical observations.
Cases have been published reporting enhanced anticoagulation and bleeding when patients on long-term warfarin therapy also took Salvia miltiorrhiza (danshen). Allium sativum (garlic) decreased the area under the plasma concentration-time curve (AUC) and maximum plasma concentration of saquinavir, but not ritonavir and paracetamol (acetaminophen), in volunteers. A. sativum increased the clotting time and international normalised ratio of warfarin and caused hypoglycaemia when taken with chlorpropamide. Ginkgo biloba (ginkgo) caused bleeding when combined with warfarin or aspirin (acetylsalicylic acid), raised blood pressure when combined with a thiazide diuretic and even caused coma when combined with trazodone in patients. Panax ginseng (ginseng) reduced the blood concentrations of alcohol (ethanol) and warfarin, and induced mania when used concomitantly with phenelzine, but ginseng increased the efficacy of influenza vaccination. Scutellaria baicalensis (huangqin) ameliorated irinotecan-induced gastrointestinal toxicity in cancer patients.
Piper methysticum (kava) increased the 'off' periods in patients with parkinsonism taking levodopa and induced a semicomatose state when given concomitantly with alprazolam. Kava enhanced the hypnotic effect of alcohol in mice, but this was not observed in humans. Silybum marianum (milk thistle) decreased the trough concentrations of indinavir in humans. Piperine from black (Piper nigrum Linn) and long (P. longum Linn) peppers increased the AUC of phenytoin, propranolol and theophylline in healthy volunteers and plasma concentrations of rifamipicin (rifampin) in patients with pulmonary tuberculosis. Eleutheroccus senticosus (Siberian ginseng) increased the serum concentration of digoxin, but did not alter the pharmacokinetics of dextromethorphan and alprazolam in humans. Hypericum perforatum (hypericum; St John's wort) decreased the blood concentrations of ciclosporin (cyclosporin), midazolam, tacrolimus, amitriptyline, digoxin, indinavir, warfarin, phenprocoumon and theophylline, but did not alter the pharmacokinetics of carbamazepine, pravastatin, mycophenolate mofetil and dextromethorphan. Cases have been reported where decreased ciclosporin concentrations led to organ rejection. Hypericum also caused breakthrough bleeding and unplanned pregnancies when used concomitantly with oral contraceptives. It also caused serotonin syndrome when used in combination with selective serotonin reuptake inhibitors (e.g. sertraline and paroxetine).
In conclusion, interactions between herbal medicines and prescribed drugs can occur and may lead to serious clinical consequences. There are other theoretical interactions indicated by preclinical data. Both pharmacokinetic and/or pharmacodynamic mechanisms have been considered to play a role in these interactions, although the underlying mechanisms for the altered drug effects and/or concentrations by concomitant herbal medicines are yet to be determined. The clinical importance of herb-drug interactions depends on many factors associated with the particular herb, drug and patient. Herbs should be appropriately labeled to alert consumers to potential interactions when concomitantly used with drugs, and to recommend a consultation with their general practitioners and other medical carers.

Using bioinformatics techniques for gene identification in drug discovery and development

As more and more evidence has become available, the link between gene and emergent disease has been made including cancer, heart disease and parkinsonism. Analyzing the diseases and designing drugs with respect to the gene and protein level obviously help to find the underlying causes of the diseases, and to improve their rate of cure. The development of modern molecular biology, biochemistry, data collection and analysis techniques provides the scientists with a large amount of gene data. To draw a link between genes and their relation to disease outcomes and drug discovery is a big challenge: How to analyze large datasets and extract useful knowledge? Combining bioinformatics with drug discovery is a promising method to tackle this issue. Most techniques of bioinformatics are used in the first two phases of drug discovery to extract interesting information and find important genes and/or proteins for speeding the process of drug discovery, enhancing the accuracy of analysis and reducing the cost. Gene identification is a very fundamental and important technique among them. In this paper, we have reviewed gene identification algorithms and discussed their usage, relationships and challenges in drug discovery and development.

Prevalence, detection and drug treatment of hypertension in a rural Australian population : the Greater Green Triangle Risk Factor Study 2004

Background: Hypertension is an important risk factor for cardiovascular disease; however, limited findings are available on its detection and management in rural Australia.

Aim: To assess the prevalence, awareness and treatment of hypertension in a rural South-East Australian population.

Methods: Three cross-sectional surveys in Limestone Coast, Corangamite Shire and Wimmera regions during 2004–2006 using a random population sample (n = 3320, participation rate 49%) aged 25–74 years. Blood pressure was measured by trained nurses. Information on history of hypertension and medication was obtained by questionnaires. Hypertension was defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg and/or on antihypertensive drug treatment.

Results: Overall, one-third of participants had hypertension; of these, two-thirds, 54% (95% confidence interval (CI) 47–60) of men and 71% (95% CI 65–77) of women, were aware of their condition. Half of the participants with hypertension were treated and nearly half of these were controlled. Both treatment and control were more common in women (60%, 95% CI 54–67 and 55%, 95% CI 47–64) compared with men (42%, 95% CI 36–49 and 35%, 95% CI 26–44). Monotherapy was used by 55% (95% CI 48–61) of treated hypertensives. Angiotensin-converting enzyme inhibitors were the most frequently used class of antihypertensive drugs in men, whereas angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists and diuretics were all widely used among women.

Conclusion: This study emphasizes suboptimal detection and treatment of hypertension, especially in men, in rural Australia.

Common structural basis for central nervous system drug design

The main theme of this thesis is that there is a common structural basis for drugs acting on the central nervous system (CNS), and that this concept may be used to design new CNS-active drugs which have greater specificity and hence less side-effects. To develop these ideas, the biological basis of how drugs modify CMS neurotransmission is described, and illustrated using dopaminergic pathways. An account is then given of the use of physicochemical concepts in contemporary drug design. The complete conformational analysis of several antipsychotic drugs is used to illustrate some of these techniques in the development of a model for antipsychotic drug action. After reviewing current structure-activity studies in several classes of CNS drugs (antipsychotics, anti-depressants, stimulants, hal1ucinogens, anticonvulsants and analgesics), a hypothesis for a common structural basis of CNS drug action is proposed- This is based on a topographical comparison of the X-ray structures of eight representative CNS-active drugs, and consists of three parts: 1.there is a common structural basis for the activity of many different CNS-active drug classes; 2. an aromatic ring and a nitrogen atom are the primary binding groups whose topographical arrangement is fundamental to the activity of these drug classes; 3. the nature and placement of secondary binding determines different classes of CNS drug activity. A four-Point model for this common structural basis is then defined using 14- CNS-active drug structures that include the original eight used in proposing the hypothesis. The coordinates of this model are: R1 (0. 3.5, 0), R2 (0, -3.5, O), N (4.8. -0.3, 1.4), and R3 (6.3, 1.3, 0), where R1 and R2 represent the point locations of a hydrophobic interaction of the common aromatic ring with a receptor, and R3 locates the receptor point for a hydrogen bond involving the common nitrogen, N. Extended structures were used to define the receptor points R1, R2 and R3, and the complete conformational space of each of the 14 molecules was considered. It is then shoun that the model may be used to predict whether a given structure is likely to show CNS activity: a search over 1,000 entries in the current Merck Index shows a high probability (82%) of CNS activity in compounds fitting the structural model. Analysis of CNS neurotransmitters and neuropeptides shows that these fit the common model well. Based on the available evidence supporting chemical evolution, protein evolution, and the evolution of neurotransmitter functions, it is surmised that the aromatic ring/nitrogen atom pharmacophore proposed in the common model supports the idea of the evolution of CNS receptors and their neurotransmitters, possibly from an aromatic amine or acety1cho1ine acting as a primaeval communicating molecule. The third point in the hypothesis trilogy is then addressed. The extensive conformation-activity analyses that have resulted in well-defined models for five separate CNS drug classes are used to map out the locations of secondary binding groups relative to the common model for anti-psychotics, antidepressants, analgesics, anticholinergics, and anticonvulsants. With this information, and knowledge derived from receptor-binding data, it is postulated that drugs having specified activity could be designed. In order to generate novel structures having a high probability of CNS-activity, a process of drug design is described in which known CNS structures are superimposed topographically using the common model as a template. Atoms regarded as superfluous may be selectively deleted and the required secondary binding groups added in predicted locations to give novel structures. It is concluded that this process provides the basis for the rational design of new lead compounds which could further be optimized for potent and specific CNS activity.

The regulation of research by funding bodies : an emerging ethical issue for the alcohol and other drug sector?

The degree to which funding bodies can and do control the content and dissemination of research products raises important issues which need to be openly debated by the alcohol and other drug (AOD) sector. Current policies relating to censorship and other means of controlling research topics or output are explored alongside an examination of how some institutions, particularly some academic journals, deal with such issues. We argue that regulation of research by funding bodies clearly contravenes the scientific ideal of freedom of information and open access to knowledge. Using international ethical guidelines, we also demonstrate that regulation raises concerns in relation to the ethical concept of beneficence. A number of examples specific to harm reduction strategies are presented in order to demonstrate how censorship might conceivably increase the harms associated with drug use. The commentary closes with recommendations concerning the establishment the prevalence of censorship and other forms of control over research in the AOD sector, and the role that ethics committees, journal editorial boards and professional societies might play in resisting the imposition of unacceptable conditions on publication of findings.

Client-reported reasons for non-engagement in drug and alcohol treatment

Introduction and Aims.To examine client-reported reasons for missed early appointments at a drug and alcohol treatment service and to compare characteristics of those who missed appointments with those who attended. Design and Methods. Clients who missed a first or second appointment between 1 May and 31 August 2007 at a public community-based outpatient treatment facility were invited to participate in a semistructured telephone interview.This consisted of an open-ended question asking the reason(s) for nonattendance, followed by a questionnaire of items for therapeutic alliance and service satisfaction, perceived impact of substance use and previous treatment experience, mostly rated on Likert scales. Database information on demographic and clinical variables was gathered for all clients who were accepted for treatment within the study time frame. Characteristics of those who missed a first or second appointment (n = 66) were compared with those who attended at least their first two appointments (n = 97). Results. Of clients who missed their appointments, 80.6% provided reasons for nonattendance, which included extraneous factors (50.0%), service shortcomings (29.7%), no further need for service (16.2%) and motivational ambivalence (4.1%). They generally had high ratings of therapeutic alliance and service satisfaction and identified their substance use as having a negative impact on their lives. Clients who missed appointments were more likely to be male, unmarried and have a history of polysubstance use. Discussion and Conclusions. Extraneous issues relating to the client may be a dominant obstacle in early treatment engagement. Efforts to overcome these issues may therefore improve early engagement.

Exploring in-hospital adverse drug events using ICD-10 codes

 Abstract
Objective Adverse drug events (ADEs) during hospital admissions are a widespread problem associated with adverse patient outcomes. The ‘external cause’ codes in the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) provide opportunities for identifying the incidence of ADEs acquired during hospital stays that may assist in targeting interventions to decrease their occurrence. The aim of the present study was to use routine administrative data to identify ADEs acquired during hospital admissions in a suburban healthcare network in Melbourne, Australia.

Methods Thirty-nine secondary diagnosis fields of hospital discharge data for a 1-year period were reviewed for ‘diagnoses not present on admission’ and assigned to the Classification of Hospital Acquired Diagnoses (CHADx) subclasses. Discharges with one or more ADE subclass were extracted for retrospective analysis.

Results From 57 205 hospital discharges, 7891 discharges (13.8%) had at least one CHADx, and 402 discharges (0.7%) had an ADE recorded. The highest proportion of ADEs was due to administration of analgesics (27%) and systemic antibiotics (23%). Other major contributors were anticoagulation (13%), anaesthesia (9%) and medications with cardiovascular side-effects (9%).

Conclusion Hospital data coded in ICD-10 can be used to identify ADEs that occur during hospital stays and also clinical conditions, therapeutic drug classes and treating units where these occur. Using the CHADx algorithm on administrative datasets provides a consistent and economical method for such ADE monitoring.

What is known about the topic? Adverse drug events (ADEs) can result in several different physical consequences, ranging from allergic reactions to death, thereby posing a significant burden on patients and the health system. Numerous studies have compared manual, written incident reporting systems used by hospital staff with computerised automated systems to identify ADEs acquired during hospital admissions. Despite various approaches aimed at improving the detection of ADEs, they remain under-reported, as a result of which interventions to mitigate the effect of ADEs cannot be initiated effectively.

What does this paper add? This research article demonstrates major methodological advances over comparable published studies looking at the effectiveness of using routine administrative data to monitor rates of ADEs that occur during a hospital stay and reviews the type of ADEs and their frequency patterns during patient admission. It also provides an insight into the effect of ADEs that occur within different hospital treating units. The method implemented in this study is unique because it uses a grouping algorithm developed for the Australian Commission on Safety and Quality in Health Care (ACSQHC) to identify ADEs not present on admission from patient data coded in ICD-10. This algorithm links the coded external causes of ADEs with their consequences or manifestations. ADEs identified through the use of programmed code based on this algorithm have not been studied in the past and therefore this paper adds to previous knowledge in this subject area.

What are the implications for health professionals? Although not all ADEs can be prevented with current medical knowledge, this study can assist health professionals in targeting interventions that can efficiently reduce the rate of ADEs that occur during a hospital stay, and improve information available for future medication management decisions.

Internet content regulation, public drug websites and the growth in hidden Internet services

Governments have traditionally censored drug-related information, both in traditional media and, in recent years, in online media. We explore Internet content regulation from a drug-policy perspective by describing the likely impacts of censoring drug websites and the parallel growth in hidden Internet services. Australia proposes a compulsory Internet filtering regime that would block websites that ‘depict, express or otherwise deal with matters of… drug misuse or addiction’ and/or ‘promote, incite or instruct in matters of crime’. In this article, we present findings from a mixed-methods study of online drug discussion. Our research found that websites dealing with drugs, that would likely be blocked by the filter, in fact contributed positively to harm reduction. Such sites helped people access more comprehensive and relevant information than was available elsewhere. Blocking these websites would likely drive drug discussion underground at a time when corporate-controlled ‘walled gardens’ (e.g. Facebook) and proprietary operating systems on mobile devices may also limit open drug discussion. At the same time, hidden Internet services, such as Silk Road, have emerged that are not affected by Internet filtering. The inability for any government to regulate Tor websites and the crypto-currency Bitcoin poses a unique challenge to drug prohibition policies.
Read More: http://informahealthcare.com/doi/full/10.3109/09687637.2012.745828

Fabrication of high specificity hollow mesoporous silica nanoparticles assisted by Eudragit for targeted drug delivery.

Hollow mesoporous silica nanoparticles (HMSNs) are one of the most promising carriers for effective drug delivery due to their large surface area, high volume for drug loading and excellent biocompatibility. However, the non-ionic surfactant templated HMSNs often have a broad size distribution and a defective mesoporous structure because of the difficulties involved in controlling the formation and organization of micelles for the growth of silica framework. In this paper, a novel "Eudragit assisted" strategy has been developed to fabricate HMSNs by utilising the Eudragit nanoparticles as cores and to assist in the self-assembly of micelle organisation. Highly dispersed mesoporous silica spheres with intact hollow interiors and through pores on the shell were fabricated. The HMSNs have a high surface area (670m(2)/g), small diameter (120nm) and uniform pore size (2.5nm) that facilitated the effective encapsulation of 5-fluorouracil within HMSNs, achieving a high loading capacity of 194.5mg(5-FU)/g(HMSNs). The HMSNs were non-cytotoxic to colorectal cancer cells SW480 and can be bioconjugated with Epidermal Growth Factor (EGF) for efficient and specific cell internalization. The high specificity and excellent targeting performance of EGF grafted HMSNs have demonstrated that they can become potential intracellular drug delivery vehicles for colorectal cancers via EGF-EGFR interaction.

Online information seeking by patients with bipolar disorder: results from an international multisite survey

BACKGROUND: Information seeking is an important coping mechanism for dealing with chronic illness. Despite a growing number of mental health websites, there is little understanding of how patients with bipolar disorder use the Internet to seek information.

METHODS: A 39 question, paper-based, anonymous survey, translated into 12 languages, was completed by 1222 patients in 17 countries as a convenience sample between March 2014 and January 2016. All patients had a diagnosis of bipolar disorder from a psychiatrist. Data were analyzed using descriptive statistics and generalized estimating equations to account for correlated data.

RESULTS: 976 (81 % of 1212 valid responses) of the patients used the Internet, and of these 750 (77 %) looked for information on bipolar disorder. When looking online for information, 89 % used a computer rather than a smartphone, and 79 % started with a general search engine. The primary reasons for searching were drug side effects (51 %), to learn anonymously (43 %), and for help coping (39 %). About 1/3 rated their search skills as expert, and 2/3 as basic or intermediate. 59 % preferred a website on mental illness and 33 % preferred Wikipedia. Only 20 % read or participated in online support groups. Most patients (62 %) searched a couple times a year. Online information seeking helped about 2/3 to cope (41 % of the entire sample). About 2/3 did not discuss Internet findings with their doctor.

CONCLUSION: Online information seeking helps many patients to cope although alternative information sources remain important. Most patients do not discuss Internet findings with their doctor, and concern remains about the quality of online information especially related to prescription drugs. Patients may not rate search skills accurately, and may not understand limitations of online privacy. More patient education about online information searching is needed and physicians should recommend a few high quality websites.