Longitudinal research from Insightfully, commissioned by the Pharmacy Guild of Australia, found that more than 1 in 5 people have not filled a prescription in the past 3 years due to cost. This figure rises to 1 in 3 in regional Australia. Women, younger people, and those with dependents are most affected.

Pharmacy Guild National Councillor Mario Barone stresses the urgency of addressing this issue.

“We know what happens when people can’t afford their medicine – they get sicker,” he says. “Often there are complications that mean time off work, time in hospital and time recovering.”

Calls for government action 

Mr Barone urges the government to reduce the PBS general co-payment to ease financial pressure on patients.

“This non-inflationary measure would reduce out-of-pocket prescription costs for patients,” he says.

“Community pharmacists see patients struggling to afford their medicine every day.

“The government can, and should, take action to address these challenges and make sure medicine stops being a luxury item.”

Sydney pharmacist Claudia, echoes these concerns, explaining she sees multiple patients each week who are struggling to afford their medication.

“In the past 6 months I’d say 3-4 patients a week are struggling to afford their medication,” she says.

“We had a patient and realised he was only taking 50% of the medications he was meant to be taking just because he couldn’t afford to get all his medications.

“People are having to choose what they can and can’t get.”

Cost of living a top priority

With cost of living ranked as a top priority for voters, followed by healthcare, the Guild is calling on the government to act swiftly to improve medicine affordability.

“Australians are being forced to make tough choices between filling prescriptions and paying the rent, buying groceries and putting petrol in the car.

In the face of this evidence the government must act and make medicine more affordable by reducing the co-payment for general patients,” says Mr Barone.

For more information, visit: affordablemedicines.com.au.

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According to a statement released by the Guild, the current approach is not only making if harder for pharmacists to do their jobs but is also failing patients, with supply issues impacting vital medicines for diabetes, menopause and mental health.

‘Current approach too short-term and reactive’

Adding comment, the National President of the Guild, Trent Twomey says the current approach to the medicine shortage is too short-term and reactive.

“It doesn’t address the root cause of shortages, and patients continue to suffer,” he says.

“Information sharing and greater awareness of existing and forecasted supply disruptions is crucial to making sure Australian patients have the medicine they need.”

Since the disbanding of the Medicine Shortage Working Party in 2021, the Guild has consistently urged the government to reinstate the forum, which was formed during the COVID-19 pandemic.

This forum included representatives from all levels of the supply chain and provided for information sharing and
greater awareness of existing and forecasted shortages.

Unlike the Therapeutic Goods Administration (TGA) Medicine Shortage Action Groups, formed in response to critical shortages, the former Medicine Shortage Working Party facilitated broader discussions around general policies and mitigation strategies for anticipated or localised shortages.

Need to focus on the big picture

“The TGA’s reactive approach means that not all industry stakeholders are represented, leading to inconsistent information being shared across the supply chain,” says Mr Twomey.

“The Government can, and should, focus on the big picture – to reduce the impact being felt by vulnerable Australians who need these essential medicines.”

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“The gut-brain axis consists of complex bidirectional neural communication pathway between the brain and the gut, which links emotional and cognitive centres of the brain,” says Professor Nick Spencer from the College of Medicine and Public Health.

“As part of the gut-brain axis, vagal sensory nerves relay a variety of signals from the gut to the brain that play an important role in mental health and wellbeing.

“The mechanisms by which vagal sensory nerve endings in the gut wall are activated has been a major mystery but remains of great interest to medical science and potential treatments for mental health and wellbeing.”

Serotonin is a major hormone and neurotransmitter in the body and has been shown to play a major role in a range of bodily functions, including mental health and depression.

“The vast majority of serotonin is made in the gut in specialised cells, called enteroendocrine cells (EECs), within the gut wall but we still don’t understand how serotonin released from EECs activates the sensory nerve endings of the vagus nerve,” says Professor Spencer.

“It had once been proposed that EECs make physical synaptic connections with the sensory nerve endings of the vagus and use fast neurotransmitters to activate vagal sensory endings.

“However, the results of our new research uncover that any substances (including serotonin) released from EEC cells must communicate via a process of diffusion to the sensory nerve endings of the vagus nerve, that lie in colon (large intestine).

“We found that the distances between individual EECs that contain serotonin and vagal afferent nerve endings were too far apart to occur via a mechanism that involved synaptic communication and fast neurotransmission, as was previously thought.

“This is a major discovery for our understanding of gut-brain communication which has profound implications for drug developments, treatments of anxiety and depression and other digestive problems such as irritable bowel symptom (IBS), all of which involve serotonin in some way.

“It opens a whole new way of thinking and scientific enquiry for future drug development and investigation for control of the gut-brain axis and potential treatments for mental health and wellbeing, for instance the use of selective serotonin reuptake inhibitors (SSRIs), a widely used type of antidepressant,” he says.

“The majority of serotonin in the body, around 95%, originates in the gut, so there is great interest in how such large quantities of serotonin released from EEC cells act on the vagal sensory nerve endings in the gut wall.

“Understanding this mechanism can provide major new clues as to how serotonin not only communicates along the gut-brain axis, but how this serotonin may be involved in the control of health and wellbeing,” he says.

“Up until now, how different substances (like serotonin) released from EECs activated vagal nerve endings in the gut has been unresolved.  Recent literature suggests that that this communication occurred through physical connections known as synapses, and that EEC cells form very close junctions with vagal sensory endings.

“Our findings show that any substances released from EECs must act via diffusion onto vagal sensory nerve endings in the colon, which then relay sensory information to the brain,” says Professor Spencer.

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This first known large-scale review of international studies on the positive effect of blood pressure (BP) medicines across all classes in preventing migraine shows these common drugs could be used much more widely, at low cost, than is the case with current practice.

The meta-analysis was published in the journal, Cephalalgia and included 50 trials of more than 4300 people, with BP-lowering medication on average reducing the number of headache days experienced per month by about one day on top of the average placebo effect.

“For countries where new migraine medications are expensive, limited by prescribing criteria or not available at all – covering all countries to some extent – this study shows that common BP medicines, which GPs are comfortable prescribing, can be an important preventative measure for patients with migraine or severe headache episodes,” says the study’s Joint Principal Investigator, Dr Cheryl Carcel, Senior Research Fellow at The George Institute and Conjoint Senior Lecturer, Faculty of Medicine, UNSW Sydney.

“Moreover, while we can see from the analysis that the effect is true for almost all types of BP medicines, this is not reflected in the current clinical guidelines, which specify just one or two types (such as beta-blockers) but not the full range of therapies that could be useful.”

Joint Principal Investigator and former GP, Dr Faraidoon Haghdoost adds: “Around 90 per cent of people with migraine can be managed in general practice, where the goal is to prevent as many episodes as possible because of the disabling impact they have on the patient’s quality of life.

“The good news is that blood pressure medications are widely available at low cost, with many available in generic forms, presenting a trusted treatment option alongside other preventive measures such as avoiding triggers and making lifestyle changes.

“The number of people living with headache disorders is enormous and common treatments given once an episode has taken hold can have side effects that in themselves present problems, such as drowsiness or weight gain.

“Whereas BP meds can prevent episodes without a significant side effect burden.”

The results of the study also indicated that not all BP medications are equally effective in preventing migraine.

The George Institute team is soon to publish a further review to give more insight into which of the various mechanisms is best.

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However, when multiple medications are involved, the risks of adverse effects from medication interactions are heightened, meaning potential medicine-related harm can occur. This is why clear communication and medication review are important, especially in the population groups more likely to take multiple medications, such as the elderly.

When patients are given multiple medications, problems arise with adherence, sub-optimal prescribing, and medication interactions. The more medications a person takes, the more difficult it can be to obtain a medical history, and the greater the risk of adverse drug reactions.

When a person is taking five or more medications simultaneously, this is called polypharmacy, which is a significant barrier to medication adherence, due to the complexity of medication regimes and the increased risk of medication errors. ¹

The polypharmacy problem

Polypharmacy is common in older people as they often experience multiple chronic illnesses. According to the Australian Commission on Safety and Quality In Healthcare, two-thirds of those aged over 75 take five or more medications. Additionally, the commission provides that 49 per cent of people with polypharmacy had seven or more, and 11 per cent had 11 or more medications dispensed in 2018/19.² Another issue presents when more medicines are prescribed to treat symptoms that are caused by adverse effects of drugs. This is known as the prescribing cascade.¹ 

The most recent review of Australians aged over 70 taking five or more medications – the University of Western Australia (UWA) study in collaboration with UNSW Sydney in 2019, published in the <itals>Medical Journal of Australia<itals> – found a 53 per cent increase from 2006 to 2019 in the number of people taking five or more medicines.

“The medicines we looked at don’t include medicines purchased without a prescription, such as vitamins, minerals, herbal supplements or medicines not listed on the Pharmaceutical Benefits Scheme, meaning that the estimates in the paper may be conservative,” said lead researcher Dr Amy Page, from UWA’s Centre for Optimisation of Medicines.

“The rates in comparable years are also much higher in Australia than in the US or the UK.

“There have been many awareness-raising activities recently about the risks of taking multiple medicines, and there’s evidence of poor health outcomes in older people. However, the number of older people taking multiple medicines has increased.

“Strategies to increase people’s understanding of the potential risks involved in taking multiple medications are needed to target health professionals and the public.

“Taking multiple medications may be necessary, but it needs to be carefully assessed by a medical professional and balanced against the potential risks.”³

Risks

Certain combinations of medicines present a greater risk than others, including, according to NPS MedicineWise:

• When taking medications that affect the brain and nervous system, people are more prone to confusion, drowsiness, and memory problems. This can lead to falls and accidents.
• Older people are more susceptible to dizziness, light-headedness and confusion. In addition, some medications can cause these effects, such as those for blood pressure, and those for pain relief that contain opioids and drugs for psychotic conditions.
• Some medicines can interact with each other and affect existing medical conditions. For example, NSAIDs taken to relieve pain can worsen high blood pressure and kidney function.⁴

Managing the effects of polypharmacy 

Consumers can take control of their medications by implementing medication organisers and keeping a medicines list. Those taking proactive steps and working with their healthcare providers can more effectively manage their medications and mitigate the risks associated with polypharmacy.

Additionally, a home medicines review can be requested from a patient’s GP if the doctor believes the patient will benefit from such a review and an accredited pharmacist checks the medication the patient is taking at home, including any supplements. The pharmacist will check that the medicines are working correctly.⁵ If needed, two follow-up services can be offered to resolve medication-related problems.⁶

Pharmacists help to manage polypharmacy by asking follow-up questions when prescribing, and ensuring clear communication is given regarding medicines, and further, by encouraging the patient to involve a single prescriber and single pharmacist in managing their medication intake. Additionally, raising awareness regarding the harms associated with taking multiple medications means consumers can make informed decisions.²

Another method of managing the effects of polypharmacy is deprescribing, which refers to discontinuing drugs that may be harmful or no longer required. In older people, this has been linked to improved health outcomes. The process should be collaborative between the patient, doctor and pharmacist. Further, it should be carefully monitored, and the dose should be gradually tapered. Pharmacists can assist in the deprescribing process by helping to identify targets for deprescribing and planning the tapering of doses.⁷

The power of pharmacy-led interventions

Research from the University of South Australia indicates that regular visits to pharmacists for people in aged care can reduce problems with medication and improve health outcomes. The study involved 248 aged-care residents across 39 facilities in South Australia and Tasmania. Pharmacists met with the residents every eight weeks. The results showed that 60 per cent of residents had problems with their medication at each visit, and 309 recommendations were made to change residents’ medication. The study also showed that cognitive scores changed, with those residents monitored by pharmacists less likely to experience negative effects.⁸

“Medicines are the most prescribed health intervention for older people, yet they’re also the catalyst for concern for many aged-care residents,” lead researcher Professor Libby Roughead said in a 2022 media release.

“People living in aged-care homes rely on the support and care they receive, yet previously, residents have only received a medication review every two years, or earlier if required.”

“Our research highlights the need for personalised and continuing support by pharmacists more frequently.”

“It’s important to realise that the new on-site pharmacists will not only need to monitor and review medications but also be able to recognise the early onset of medicine-induced deterioration, such as changes in a person’s cognition or activity, to prevent harms such as injurious falls or delirium.

“More comprehensive support will not only avoid the many medicine-induced health issues currently experienced by aged-care residents but may also help in preventing frailty and declining cognition.”⁹

In March last year, before the election of an ALP-led government, the Coalition administration announced funding for on-site pharmacists to improve medication management in government-funded aged-care facilities, to begin in January 2023, after medication management was highlighted as a critical area of concern in the Royal Commission into Aged Care Quality and Safety.¹⁰

References 

1. NPS MedicineWise. ‘The dilemma of polypharmacy’. 2008. org.au/australian-prescriber/articles/the-dilemma-of-polypharmacy#r1
2. Australian Commission on Safety and Quality in Healthcare. ‘Polypharmacy, 75 years and over’. 2021 gov.au/our-work/healthcare-variation/fourth-atlas-2021/medicines-use-older-people/61-polypharmacy-75-years-and-over#:~:text=Polypharmacy%20is%20when%20people%20are,Atlas%20of%20Healthcare%20Variation%202021
3. University of Western Australia. ‘Older Australians taking multiple medicines may be putting health at risk’. 2019. <uwa.edu.au/archive/2019071511498/research/older-australians-taking-multiple-medicines-may-be-putting-their-health-risk/>
4. NPS MedicineWise. ‘Managing your medicines’. 2019. org.au/consumers/managing-your-medicines#risks-of-taking-multiple-medicines
5. ‘Home medicines review’. 2022. healthdirect.gov.au/home-medicines-review
6. Pharmacy Programs Administrator. ‘Home Medicines Review’. 2022. com.au/programs/medication-management-programs/home-medicines-review
7. NPS MedicineWise. ‘Deprescribing in older people’. 2020. org.au/australian-prescriber/articles/deprescribing-in-older-people#tools-to-support-deprescribing-decisions
8. Roughead E et al. ‘Effect of an ongoing pharmacist service to reduce medicine-induced deterioration and adverse reactions in aged-care facilities (nursing homes): a multicentre, randomised controlled trial (the ReMInDAR trial)’. 2022. ncbi.nlm.nih.gov/35460410/
9. University of South Australia. ‘In-house pharmacists essential for aged care’. 2022. edu.au/media-centre/Releases/2022/in-house-pharmacists-essential-for-aged-care/
10. Greg Hunt MP. ‘On-site pharmacists to improve medication management in RACFs’. 2022. health.gov.au/ministers/the-hon-greg-hunt-mp/media/on-site-pharmacists-to-improve-medication-management-in-racfs

This feature was originally published in the March issue of Retail Pharmacy magazine. 

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Published in Australian Prescriber, the review led by Flinders University pharmacologist Professor Arduino Mangoni highlights that while identifying and treating high blood pressure is important, elevated blood pressure when presenting to a hospital is relatively common and may not necessarily mean that a patient’s blood pressure has been an issue prior to admission.

Providing possible reasons for elevated blood pressure when presenting to a hospital, Professor Mangoni says this could be due to inaccurate measurements, and factors such as pain, anxiety, noise and interrupted sleep.

“The measurement of blood pressure in hospital patients significantly differs from the best practice recommended for primary care and outpatients,” says Professor Mangoni.

The review found recent studies suggest treating acute, asymptomatic, in-hospital elevations in blood pressure may have no benefit. Instead, they may increase the risk of in-hospital and post-discharge complications.

The authors say a significant problem in investigating in-hospital blood pressure elevations and their management is the lack of robust protocols.

“The industry needs to review the criteria used by hospital medical emergency teams in relation to blood pressure elevations,” says Professor Mangoni.

“Pending the development of robust measurement protocols in hospitalised patients, acute blood pressure elevations without additional symptoms or organ damage should not automatically equal treatment.

“Rather, such elevations should facilitate follow-up of blood pressure and other cardiovascular risk factors after discharge, including clear communication with GPs to appropriately plan investigations and management.”

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The authors of an article recently published in the Medical Journal of Australia’s Perspectives series support this notion, revealing that when it comes to medication management of older people, clear communication is even more important.

With older people often having complicated medication schedules, the researchers say communication breakdowns between the healthcare services they require may put them at risk of medication-related problems and hospitalisation.

Medication miscommunication, they add, may lead to patients not being fully informed about their medications or having the opportunity to ask required questions.

They say conversations about medications are needed more frequently, with more family involvement, while communication around medication also needs to be better tailored to what the individual patient needs to understand and remember.

Lead author Professor Elizabeth Manias, from the Centre for Quality and Patient Safety Research at Deakin University, and her colleagues say older patients are likely to have complex medication regimens that need to be carefully managed as they move across and within diverse settings, “including primary care, acute care, geriatric rehabilitation, and aged care facilities” and involving different health professionals across specialties.

“Discussions with older patients and families are often not prioritised across transitions of care. Instead, fleeting conversations take place at irregular time points and for short periods just before or after transfers,” Professor Manias and colleagues wrote.

“These conversations are rarely organised in a goal-directed way where medication communication is conveyed accurately, clearly, and comprehensively.

“The impact of fleeting conversations is that even if medication information is conveyed, patients and families may not be involved in key decisions about newly prescribed, ceased or changed medications, or may not voice their concerns and preferences about the medication regimen.

“There is a lack of recognition that ‘the one person who remains constant is the patient, who has the most to lose in a disconnected health system’.”

How to ensure clear communication 

Professor Manias and colleagues recommend the following principles:

• Communication about medication should occur throughout the duration of older patients’ care, rather than being limited to particular time points.
• Families should be included in medication communication at every opportunity, rather than waiting until medication counselling occurs just before hospital discharge or just before completing a primary care consultation.
• Communication needs to be tailored to each patient’s ability to comprehend, with clear, easy-to-understand language, using resources including diagrams, photographs of medications, audio and video recorded materials, simulations and patient case scenarios.
• Doctors, nurses, pharmacists and other health professionals need to acknowledge they all have important roles in communicating with each other about medication across transitions of care.
• Health professionals need to regularly seek outpatient and family priorities and preferences, especially if medication changes are made. Older patients and families should be encouraged to ask questions.
• Shared decision-making should be supported by communicating with patients and their families about the current medications they take, the consequences that may occur if medications are not consumed, the time when these are reviewed to decide if they will be continued, and the person who conducts the review.
• In facilitating informed consent to prescribing medications, decision aids can be helpful. Their use should be documented in medical records for future retrieval.

“Fostering engagement among older patients and families and creating opportunities for decision making about medications are crucial for improved safety and quality across transitions of care,” Professor Manias and colleagues wrote.

“Challenging fleeting conversations is key to reducing the risk of medication-related problems and patient harm.”

For more information, visit: doi.org/10.5694/mja2.51651

This feature was originally published in the September issue of Retail Pharmacy magazine. 

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Under the national program naloxone, which is said to rapidly reverse the effects of an opioid overdose or adverse reaction, will be available across Australia for free and without a prescription.

The national rollout of the THN program has been welcomed by the Pharmaceutical Society of Australia (PSA) who say pharmacists will be key to the success of this rollout due to their accessibility and expertise.

“Naloxone saves lives,” PSA National President Dr Fei Sim said.

“During the pilot, three lives were saved each day, but with wider access, we expect to see an even greater impact.”

Dr Sim says that previously one dose of naloxone cost approximately $40 but from 1 July two free doses of naloxone will be available, along with expert advice from pharmacists on how to administer the medication.

According to Dr Sim, the naloxone trial shows that by making medications such as naloxone more accessible, harm caused by excessive opioid use can be reduced.

Dr Sim says that anyone taking opioid medication for pain management, or anyone caring for someone using opioid medication, should collect naloxone from their local pharmacy.

Pharmacists are also available to provide advice on identifying opioid overdose, she says.

“Over recent years we have seen more cases of illicit party drugs being spiked with acetyl-fentanyl, which can cause opioid overdoses even in small amounts,” Dr Sim said.

“We are urging young people who use recreational drugs like cocaine to visit their local pharmacy and carry naloxone on a night out.

“Your pharmacist is there to provide judgement-free, expert advice, on when and how to use this life-saving drug.

“It could save your life or the life of a friend.”

Take-home naloxone will also be available through non-pharmacy sites such as alcohol and drug treatment centres and needle and syringe programs in New South Wales, South Australia, and Western Australia from 1 July 2022, and in Tasmania, Victoria, Queensland, and the ACT from 1 November 2022.

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Poor quality sleep is associated with ill health, including diabetes, high blood pressure, pain and depression, and health professionals often prescribe various medication to induce shut eye.

However, a US study reveals that medication to improve disrupted sleep may have little-to-no impact after one to two years.

The research published in BMJ Open, which sought to assess the effectiveness of medications used to tackle insomnia over the long term among ethnically diverse group of middle-aged women who developed sleep disorders found that long-term use of prescription medications for insomnia was not linked to better quality sleep.

The researchers looked at the data from 238 middle-aged women from the beginning of their usage of sleep medication alongside 447 women who had never used sleep medication.

Rating their level of sleep disruption out of five, the new medication users had similar scores at the start of their usage to the women who had never used sleep medication.

After a year, the results were reportedly still similar between the two groups and the researchers observed no statistically significant improvement in sleep in either group. After another year, the results were found to be the same.

“Sleep disturbances are common and increasing in prevalence. The use of sleep medications has grown, and they are often used over a long period, despite the relative lack of evidence from [randomised controlled trials],” the researchers conclude.

The researchers add that while insomnia medications may work well in some people with sleep disturbances over several years, the findings should give pause for those to prescribing clinicians and patients thinking about taking prescription medication for sleep disturbances in middle age.

For more information, visit: bmjopen.bmj.com/content/11/5/e045074

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Panic buying was not only seen in the toilet paper aisles of supermarkets but also in pharmacies with many people panic buying the medications they might need out of fear that supply of these products may run dry.

As a result, government-imposed dispensing limits on medications during the Covid-19 pandemic were introduced in a bid to offset panic buying and to safeguard medication supply.

But just how successful have these policies and limits been?

A recent study published in the Medical Journal of Australia (MJA), by Dr Mustafa Mian, a physician at Alfred Health in Melbourne, and colleagues, found that the number of prescriptions dispensed during March 2020 was significantly higher than predicted as a result of panic buying, but was then much lower in April and May when the government imposed dispensing limits and services to aid people who were isolating and needed medications.

“The number of prescriptions dispensed during March 2020, was significantly higher than predicted (4.80 million more prescriptions, +18.5%), but significantly lower in April (2.28 million fewer prescriptions, -9,2%) and May (2.08 million fewer prescriptions, -8.1%) – there was no significant difference in June 2020 (988,778 fewer prescriptions, -3.8%),” the researchers found.

Dr Mian and colleagues wrote that the increased dispensing of prescription medications in March 2020, was consistent with the general panic buying reported early in the Covid-19 pandemic.

In response to the March increase, the Australian government introduced dispensing limits of one month’s supply of medications if shortages would have serious health consequences.

That was balanced with services to assist susceptible patients to isolate themselves, including the Covid-19 home medicines service, which funded home delivery of prescription medications by community pharmacies and Australia Post – as well as funding for telehealth to facilitate remote prescribing.

“Our findings indicate that medication supply can be safeguarded from panic dispensing by a range of regulatory policies combined with medication services for vulnerable people,” Dr Mian and colleagues conclude.

“This may be particularly important for ensuring equitable access to medications for treating Covid-19. The risk of further Covid-19 outbreaks underscores the importance of maintaining these policies and services.”

For more information and to read the study, visit: onlinelibrary.wiley.com/doi/10.5694/mja2.51029

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