tag:theconversation.com,2011:/global/topics/pharmacy-5018/articlesPharmacy – The Conversation2024-03-24T19:06:54Ztag:theconversation.com,2011:article/2260022024-03-24T19:06:54Z2024-03-24T19:06:54ZAustralia’s biggest chemist is merging with a giant wholesaler. Could we soon be paying more?<figure><img src="https://images.theconversation.com/files/582712/original/file-20240319-24-9w8vvm.jpg?ixlib=rb-1.1.0&rect=278%2C352%2C5095%2C1998&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sydney-australia-oct-11-2019-outside-1714118746">Dr. Victor Wong/Shutterstock</a></span></figcaption></figure><p>Corporate Australia loves a big merger. And amid a <a href="https://ministers.treasury.gov.au/ministers/andrew-leigh-2022/articles/opinion-piece-merger-policy-critical#:%7E:text=The%20data%20show%20that%20larger,patent%20than%20an%20average%20firm.">growing flurry</a> of them across the business scene, a new blockbuster has emerged.</p>
<p>All eyes are on two titans of the pharmacy industry – Chemist Warehouse and Sigma Healthcare. They are poised to join forces under an <a href="https://www.abc.net.au/news/2023-12-11/chemist-warehouse-sigma-healthcare-merger-deal-explained/103213384">A$8.8 billion deal</a>, which could radically reshape the way Australians access medication and other health products. </p>
<p>Mergers can lower business operating costs and make companies more efficient. But reduced competition in any sector typically leads to <a href="https://www.accc.gov.au/business/competition-and-exemptions/misuse-of-market-power">higher prices</a> for consumers. </p>
<p>What could this deal by “Australia’s cheapest chemist” mean for everyday Australians and their wallets? </p>
<h2>An unmatched pharmacy giant</h2>
<p>If the proposed merger goes ahead, the new entity will be enormous – far bigger than any of its individual competitors. </p>
<p>It will <a href="https://investorcentre.sigmahealthcare.com.au/static-files/d2c377b3-f487-4488-b34d-43c02330e6b7">combine</a> the market power of about 600 existing Chemist Warehouse outlets with <a href="https://sigmahealthcare.com.au/our-background/">more than 1,200 pharmacies</a> currently aligned to Sigma as a wholesaler, giving it more than 26% market share.</p>
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<p>Sigma is listed on the Australian Stock Exchange (ASX), meaning its shares can already be bought and sold by the public. </p>
<p>Through the merger, privately owned Chemist Warehouse, whose <a href="https://www.afr.com/companies/retail/chemist-warehouse-records-surging-sales-profits-ahead-of-asx-debut-20240320-p5fdyj">surging profits</a> have excited potential investors, will also get a backdoor entrance to the ASX without undergoing a lengthy initial public offering process. </p>
<h2>Who the players are</h2>
<p>Chemist Warehouse has earned a reputation as the “<a href="https://www.afr.com/markets/equity-markets/like-bunnings-fund-managers-bullish-on-chemist-warehouse-20231212-p5eqsy">Bunnings of pharmacies</a>”, famous for its perceived affordability. </p>
<p>It has established a strong retail presence nationally, with franchise outlets stocking not only prescription and over-the-counter medicines, but also a <a href="https://www.morningstar.com.au/insights/personal-finance/235983/the-rise-and-rise-of-chemist-warehouse">huge range of other health products</a> such as vitamins, cosmetics and toiletries.</p>
<figure class="align-right ">
<img alt="Amcal pharmacy storefront signage" src="https://images.theconversation.com/files/583622/original/file-20240322-28-4ouual.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/583622/original/file-20240322-28-4ouual.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=451&fit=crop&dpr=1 600w, https://images.theconversation.com/files/583622/original/file-20240322-28-4ouual.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=451&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/583622/original/file-20240322-28-4ouual.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=451&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/583622/original/file-20240322-28-4ouual.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/583622/original/file-20240322-28-4ouual.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/583622/original/file-20240322-28-4ouual.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sigma owns retail pharmacy brands, including Amcal.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/melbourne-australia-september-27-2015-allied-321194645">Nils Versemann/Shutterstock</a></span>
</figcaption>
</figure>
<p>Sigma Healthcare, on the other hand, operates retail pharmacy chains including Amcal and Discount Drug Store. </p>
<p>It is also one of <a href="https://www.afr.com/companies/retail/sigma-could-shed-customers-after-chemist-warehouse-merger-20231212-p5eqt6**">top three largest pharmaceutical wholesalers</a> in Australia, with a broad customer base.</p>
<p>This merger is a masterful blend of two <a href="https://www.masterclass.com/articles/horizontal-integration-explained">business strategies</a>: </p>
<ul>
<li>vertical integration – buying part of your own supply chain </li>
<li>horizontal integration – acquiring a competing business.<br></li>
</ul>
<p>The new entity will be able to independently source and sell its own products, fully controlling its own ecosystem of wholesale, distribution and retail pharmacies. </p>
<h2>How could this affect competition and consumers?</h2>
<p>Economic theory tells us that for consumers, mergers can be <a href="https://academic.oup.com/qje/article-abstract/120/2/701/1933966">a double-edged sword</a>. </p>
<p>On the one hand, they often increase business efficiency, scale and bargaining power. These cost savings may translate into lower prices for consumers.</p>
<p>In some industries, mergers have reduced prices by <a href="https://www.nber.org/papers/w31123">more than 5%</a>. </p>
<p>However, the decrease in competition brought about through a merger can allow companies to get away with charging <a href="https://www.brookings.edu/articles/the-consequences-of-increasing-concentration-and-decreasing-competition-and-how-to-remedy-them/">higher prices</a>, or even lowering the quality of their product offering.</p>
<p>Evidence from the US shows that in the <a href="https://www.investopedia.com/terms/c/cpg.asp">consumer packaged goods sector</a>, which includes drugs and other healthcare products, mergers <a href="https://www.nber.org/papers/w31123">increased prices</a> by 1.5% on average and lowered the total volume of goods sold by 2.3%.</p>
<figure class="align-center ">
<img alt="shelves containing various medications in Chemist Warehouse" src="https://images.theconversation.com/files/582715/original/file-20240319-16-xv7v5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/582715/original/file-20240319-16-xv7v5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/582715/original/file-20240319-16-xv7v5j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/582715/original/file-20240319-16-xv7v5j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/582715/original/file-20240319-16-xv7v5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/582715/original/file-20240319-16-xv7v5j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/582715/original/file-20240319-16-xv7v5j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The prices of many prescriptions in Australia are tightly regulated under the pharmaceutical benefits scheme (PBS).</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sydney-nsw-australia-march-20-2023-2277956295">Gerry H/Shutterstock</a></span>
</figcaption>
</figure>
<p>In Australia, tight regulation of prescription medications means there isn’t much leeway to increase prices for medicines covered under the <a href="https://www.pbs.gov.au/pbs/home">Pharmaceutical Benefits Scheme (PBS)</a>. </p>
<p>But Chemist Warehouse <a href="https://investorcentre.sigmahealthcare.com.au/static-files/d2c377b3-f487-4488-b34d-43c02330e6b7">earns</a> a whopping 67% of its revenue from its non-prescription “front of store” sales, compared to a rate of 27% at other Australian pharmacies. </p>
<p>This gives the giant a unique opportunity to capitalise on increased market power in the Australian context.</p>
<h2>Calls to increase competition</h2>
<p>There have long been <a href="https://www.pc.gov.au/research/supporting/competition-policy-review">calls</a> to enhance competition in Australia’s pharmacy sector. </p>
<p>The Harper <a href="https://www.pc.gov.au/research/supporting/competition-policy-review">National Competition Policy Review</a> singled out the <a href="https://www.guild.org.au/programs/seventh-community-pharmacy-agreement">Community Pharmacy Agreement</a> for stifling competition, saying its rigid location and ownership restrictions pose significant barriers for new players. </p>
<p>This has largely prevented Australia following in the steps of the United States and Europe, where deregulation in this industry has allowed consumers to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7911380/">buy over-the-counter medicines in supermarkets and gas stations</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-loaf-of-bread-and-a-packet-of-pills-how-supermarket-pharmacies-could-change-the-way-we-shop-122640">A loaf of bread and a packet of pills: how supermarket pharmacies could change the way we shop</a>
</strong>
</em>
</p>
<hr>
<p>This merger stands to further weaken competition in an industry already held back by such restrictions.</p>
<h2>Australian retail is already highly concentrated</h2>
<p>Australia’s high level of industry concentration – where markets are controlled by a small number of large players – has found itself in the spotlight amid a stubborn cost of living crisis.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/flying-under-the-radar-australias-silent-and-growing-competition-crisis-212116">Flying under the radar: Australia's silent and growing competition crisis</a>
</strong>
</em>
</p>
<hr>
<p>One way to assess market concentration is to measure the share of the market held by the top four companies. </p>
<p>In Australia, the top four players in the pharmacy sector collectively hold <a href="https://www.ibisworld.com/au/market-size/pharmacies/">over 50% of the market</a>.</p>
<p>As industry concentration has intensified across other sectors, many larger Australian corporations have been seen to <a href="https://treasury.gov.au/sites/default/files/2023-11/competition-review-mergers-background-note.pdf">increase their price mark-ups and suppress wage growth</a>.</p>
<p>If successful, this merger will further entrench the pharmacy sector among banks, supermarkets and petrol retailers in the ranks of <a href="https://theconversation.com/flying-under-the-radar-australias-silent-and-growing-competition-crisis-212116">the most concentrated Australian industries</a>. </p>
<h2>Will it go ahead?</h2>
<p>There are still significant hurdles for this merger to go ahead. </p>
<p>The move has to be approved by shareholders in both companies, and more importantly, receive a green light from the ACCC, Australia’s competition watchdog.</p>
<figure class="align-right ">
<img alt="A mobile phone open to the homepage of the ACCC website" src="https://images.theconversation.com/files/583624/original/file-20240322-20-tqaufc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/583624/original/file-20240322-20-tqaufc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/583624/original/file-20240322-20-tqaufc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/583624/original/file-20240322-20-tqaufc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/583624/original/file-20240322-20-tqaufc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/583624/original/file-20240322-20-tqaufc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/583624/original/file-20240322-20-tqaufc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The ACCC is not always able to block large mergers.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/stuttgart-germany-03252023-mobile-phone-webpage-2282182035">T. Schneider/Shutterstock</a></span>
</figcaption>
</figure>
<p>Submissions to the ACCC’s <a href="https://www.accc.gov.au/public-registers/mergers-registers/public-informal-merger-reviews/sigma-healthcare-limited-chemist-warehouse-group-holdings#:%7E:text=Submissions%20are%20invited%20from%20interested,Warehouse%20%E2%80%93%20attention%20Isobel%20Graham%22.">formal enquiry</a> into the merger will close this week. </p>
<p>However, the ACCC has struggled to block similar mergers in the past, such as the seismic <a href="https://www.afr.com/companies/financial-services/accc-admits-defeat-on-blocking-anz-s-4-9b-takeover-of-suncorp-s-bank-20240305-p5fa35">ANZ-Suncorp deal</a> that was finally approved in February. Regulatory obstacles alone may not be enough to prevent this consolidation.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/anzs-takeover-of-suncorp-will-reduce-bank-competition-but-will-that-be-enough-to-block-it-187279">ANZ's takeover of Suncorp will reduce bank competition – but will that be enough to block it?</a>
</strong>
</em>
</p>
<hr>
<p>Australians have a vested interest in a healthy competitive landscape. Reduced competition in the pharmacy sector will affect the pricing pressures on every store, not just the major players. </p>
<p>Don’t be surprised down the road if a visit to your local pharmacy shocks you with pricier cosmetics, sunglasses and even jellybeans!</p><img src="https://counter.theconversation.com/content/226002/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Angel Zhong does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The new retail giant will control more than 26% of the Australian pharmacy market.Angel Zhong, Associate Professor of Finance, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2114122023-08-31T21:39:50Z2023-08-31T21:39:50ZHere’s what new 60-day prescriptions mean for you and your hip pocket<figure><img src="https://images.theconversation.com/files/545417/original/file-20230829-19-mvx2g4.jpg?ixlib=rb-1.1.0&rect=1%2C0%2C997%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/customer-paying-bill-by-cell-phone-623126426">Shutterstock</a></span></figcaption></figure><p>From today, there are significant <a href="https://www.health.gov.au/our-work/60-day-prescriptions">changes</a> to how some common medicines are prescribed and dispensed in Australia. This means you could walk away from the pharmacy with 60-days’ worth of your usual medicine from a single prescription.</p>
<p>Until now, most long-term medicines were only available for 30 days at a time. So the price of these medicines for some patients may effectively halve. </p>
<p>You would also need fewer trips to the GP for a prescription and fewer visits to the pharmacy to have your medicine dispensed.</p>
<p>But not all medicines are yet eligible for 60-day scripts and not everyone is prescribed 60-days’ worth of medicine at a time. Here’s what the changes mean for you.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/last-year-half-a-million-australians-couldnt-afford-to-fill-a-script-heres-how-to-rein-in-rising-health-costs-178301">Last year, half a million Australians couldn't afford to fill a script. Here's how to rein in rising health costs</a>
</strong>
</em>
</p>
<hr>
<h2>Can I get a 60-day script today?</h2>
<p>If you have a current prescription, you need to use this prescription first before you get a new one. To be eligible for a prescription that provides medicine for 60 days your medication needs to be on the <a href="https://www.pbs.gov.au/industry/listing/elements/pbac-meetings/pbac-outcomes/2022-12/Increased-Dispensing-Quantities-List-of-Medicines.pdf">approved list</a>.</p>
<p>Your doctor also needs to assess if you are stable on it. This is to avoid wastage. We know new treatments can result in frequent changes to medication regimens, which would result in wasted medicines if they don’t end up being used.</p>
<p>Your doctor may also give you “repeat” prescriptions for 60-days’ worth of medicines at a time. Under the new rules, this could mean up to <a href="https://www.health.gov.au/resources/publications/60-day-prescriptions-information-kit-for-prescribers?language=ha">12 months’ supply</a> of medicine (the initial script plus five “repeats”). You would have to pay for each of these repeat scripts when your medicine is dispensed every 60 days.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-time-of-day-should-i-take-my-medicine-125809">What time of day should I take my medicine?</a>
</strong>
</em>
</p>
<hr>
<h2>Is my medicine on the list?</h2>
<p>The roll-out of 60-day scripts will be in three stages. The first stage, which begins today, <a href="https://www.health.gov.au/our-work/60-day-dispensing/pbs-medicines-current-item-codes">includes</a> medicines for cardiovascular disease (such as heart disease and stroke), heart failure, high cholesterol, gout, osteoporosis, and the gut conditions Crohn’s disease and ulcerative colitis.</p>
<p>This includes some of the most common medicines prescribed in Australia, such as atorvastatin for lowering cholesterol, and perindopril for lowering blood pressure.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person adding medications to pill organizer" src="https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Not all your medicines may be affected by the changes.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/1TL8AoEDj_c">Laurynas Mereckas/Unsplash</a></span>
</figcaption>
</figure>
<p>The following stages, set to be rolled out over the coming 12 months, include medicines for diabetes, epilepsy, glaucoma, asthma and Parkinson’s disease. </p>
<p>When fully implemented, these changes will affect more than 300 prescription medicines available on the Pharmaceutical Benefits Scheme (PBS).</p>
<p>These medicines have been chosen because they are appropriate treatments for people living with stable, chronic health conditions, they meet clinical safety criteria, and are considered cost-effective.</p>
<p>Medicines not available for 60-day dispensing are those only for short-term use and medicines known to be at risk of overuse. These <a href="https://www.nps.org.au/australian-prescriber/articles/pharmaceutical-drug-misuse-in-australia#information-sources-for-prescribers">include</a> pain medicines and some medicines for mental health conditions.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-why-pharmacists-are-angry-at-script-changes-and-why-the-government-is-making-them-anyway-204028">Here's why pharmacists are angry at script changes – and why the government is making them anyway</a>
</strong>
</em>
</p>
<hr>
<h2>Will I save money?</h2>
<p>The government has brought in these changes mainly to try to make medicines more affordable. We know people do not seek medical care or fill prescriptions <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/latest-release">due to cost</a>. </p>
<p>The <a href="https://www.pbs.gov.au/info/healthpro/explanatory-notes/front/fee">maximum price you pay</a> at the pharmacy for a PBS script (known as the co-payment) is not changing. <a href="https://www.pbs.gov.au/info/about-the-pbs">It’s still</a> A$7.30 for concession card holders and $30 for non-concession card holders. But by having 60-day dispensing, you’ll only be charged this every two months instead of every month.</p>
<p>But not everyone will save money from a 60-day prescription because in some cases your pharmacy may already be discounting your medicine. If the price for 60-days’ supply would not take the price over $30, you may not be getting two scripts for the price of one. </p>
<p>For example, a commonly discounted medicine is atorvastatin. In Australia, a non-concession patient generally pays between $8 and $22 for 30-days’ supply. But it’s likely that a 60-day supply would cost between $15 and $30.</p>
<p>The amount you or your family need to pay to reach the <a href="https://www.pbs.gov.au/info/general/faq#WhatisthePBSSafetyNet">PBS safety net</a> is also not changing. This is the threshold you need to reach before medicines become free (for concession card holders) or discounted (non-concession card holders) for the rest of the calendar year. In some instances, 60-day dispensing may result in you or your family reaching the safety net threshold later, or not at all.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Older woman looking into purse, holding coin" src="https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The changes are meant to make medicines more affordable.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hands-old-person-senior-hold-wallet-1844510152">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-the-pbs-safety-net-and-is-it-really-the-best-way-to-cut-the-cost-of-medicines-180315">What is the PBS safety net and is it really the best way to cut the cost of medicines?</a>
</strong>
</em>
</p>
<hr>
<h2>How should I store my medicine?</h2>
<p>If you don’t store your medicines correctly at home they can become degraded and not work so well. With a 60-day supply, correct storage is even more important. </p>
<p>As a general rule of thumb, never store your medicines in hot rooms or your car (even in winter) and don’t store them in direct sunlight. If your medicine needs to be stored in the fridge, your pharmacist will let you know.</p>
<p>One example is <a href="https://media.healthdirect.org.au/medicines/GuildLink_Information/58775/CMI/ujcxalae10320.pdf">latanoprost</a>, which are drops for the eye condition glaucoma. You can keep the bottle you are using in the cupboard but you need to store the unopened, second bottle in the fridge.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-what-should-you-do-with-your-unused-medicine-81406">Health Check: what should you do with your unused medicine?</a>
</strong>
</em>
</p>
<hr>
<h2>In a nutshell</h2>
<p>Remember, 60-day dispensing is only available for new prescriptions. When you next see your doctor, if your condition is stable and your medicine is suitable, you will be provided a 60-day script. Your pharmacist will then dispense a 60-day supply.</p>
<hr>
<p><em>If you have any questions about the new rules, ask your local pharmacist. Information is also available from the <a href="https://www.health.gov.au/our-work/60-day-prescriptions">Commonwealth health department</a> and the <a href="https://www.60dayscripts.com.au/">Consumers Health Forum</a>.</em></p><img src="https://counter.theconversation.com/content/211412/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Bartlett is a member of the Pharmaceutical Society of Australia, a previous director of Blooms the Chemist management services and remains a shareholder.</span></em></p><p class="fine-print"><em><span>Associate Professor Nial Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is a Fellow of the Royal Australian Chemical Institute, a member of the Australasian Pharmaceutical Science Association, and a member of the Australian Institute of Company Directors. Nial is the chief scientific officer of Vaihea Skincare LLC, a director of SetDose Pty Ltd a medical device company, and a Standards Australia panel member for sunscreen agents. Nial regularly consults to industry on issues to do with medicine risk assessments, manufacturing, design, and testing.</span></em></p>The price you pay at the pharmacy for your long-term medicines may effectively halve. But not all medicines or patients qualify.Andrew Bartlett, Associate Lecturer Pharmacy Practice, University of SydneyNial Wheate, Associate Professor of the Sydney Pharmacy School, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2114242023-08-23T20:09:26Z2023-08-23T20:09:26ZTaking more than 5 pills a day? ‘Deprescribing’ can prevent harm – especially for older people<figure><img src="https://images.theconversation.com/files/543368/original/file-20230818-21-ct0ux6.jpg?ixlib=rb-1.1.0&rect=23%2C15%2C5152%2C3430&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/many-multicolored-pills-seniors-hands-painful-548668765">Shutterstock</a></span></figcaption></figure><p>People are living longer and with more <a href="https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance/contents/health-functioning/health-disability-status">chronic health conditions</a> – including heart disease, diabetes, arthritis and dementia – than ever before. As societies continue to grow older, one pressing concern is the use of multiple medications, a phenomenon known as <a href="https://www.who.int/docs/default-source/patient-safety/who-uhc-sds-2019-11-eng.pdf">polypharmacy</a>. </p>
<p>About <a href="https://onlinelibrary.wiley.com/doi/full/10.5694/mja2.50244">1 million older Australians</a> experience polypharmacy and this group is increasing. They may wake up in the morning and pop a pill for their heart, then another one or two to control blood pressure, a couple more if they have diabetes, a vitamin pill and maybe one for joint pain. </p>
<p>Polypharmacy is usually <a href="https://www.safetyandquality.gov.au/sites/default/files/2021-04/fourth_atlas_2021_-_6.1_polypharmacy_75_years_and_over.pdf">defined</a> as taking five or more different medications daily. In aged care homes, <a href="https://doi.org/10.1016/j.archger.2022.104849">90% of residents</a> take at least five regular medications every single day. That can put their health at risk with increased costs for them and the health system.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/considering-going-off-antidepressants-heres-what-to-think-about-first-198880">Considering going off antidepressants? Here's what to think about first</a>
</strong>
</em>
</p>
<hr>
<h2>Adding up over time</h2>
<p>As people age, the effects of medications can change. Some medications, which were once beneficial, might start to do more harm than good or might not be needed anymore. About <a href="https://www.psa.org.au/wp-content/uploads/2020/02/Medicine-Safety-Aged-Care-WEB-RES1.pdf">half of older Australians</a> are taking a medication where the likely harms outweigh the potential benefits. </p>
<p>While polypharmacy is sometimes necessary and helpful in managing multiple health conditions, it can lead to unintended consequences. </p>
<p><a href="https://www.nps.org.au/living-with-multiple-medicines/costs">Prescription costs</a> can quickly add up. Taking multiple medications can be difficult to manage particularly when there are specific instructions to crush them or take them with food, or when extra monitoring is needed. There is also a risk of <a href="https://www.nps.org.au/consumers/understanding-drug-interactions">drug interactions</a>. </p>
<p>Medications bought “over the counter” without a prescription, such as vitamins, herbal medications or pain relievers, can also cause <a href="https://onlinelibrary.wiley.com/doi/abs/10.5694/mja11.10698">problems</a>. Some people might take an over-the-counter medication each day due to previous advice, but they might not need it anymore. Just like prescription medications, over-the-counter medications add to the overall burden and cost of polypharmacy as well as drug interactions and side effects. </p>
<p>Unfortunately, the more medications you take, the more likely you are to have <a href="https://www.nps.org.au/consumers/managing-your-medicines#risks-of-taking-multiple-medicines">problems with your medications</a>, a reduced quality of life and increased risk of falls, hospitalisation and death. Each year, <a href="https://www.psa.org.au/wp-content/uploads/2019/01/PSA-Medicine-Safety-Report.pdf">250,000 Australians</a> are admitted to hospital due to medication-related harms, many of which are preventable. For example, use of multiple medications like sleeping pills, strong pain relievers and some blood pressure medications can cause drowsiness and dizziness, potentially resulting in a <a href="https://betterhealthwhileaging.net/preventing-falls-10-types-of-medications-to-review/">fall</a> and broken bones. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/taking-an-antidepressant-mixing-it-with-other-medicines-including-some-cold-and-flu-treatments-can-be-dangerous-208662">Taking an antidepressant? Mixing it with other medicines – including some cold and flu treatments – can be dangerous</a>
</strong>
</em>
</p>
<hr>
<h2>Prescribing and deprescribing are both important</h2>
<p>Ensuring safe and effective use of medications involves both prescribing, and <a href="https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/silver-book/part-a/deprescribing">deprescribing</a> them. </p>
<p><a href="https://www.australiandeprescribingnetwork.com.au/474-2/">Deprescribing</a> is a process of stopping (or reducing the dose of) medications that are no longer required, or for which the risk of harm outweighs the benefits for the person taking them. </p>
<p>The process involves reviewing all the medications a person takes with a health-care professional to identify medications that should be stopped. </p>
<p>Think of deprescribing as spring cleaning your medicine cabinet. Just like how you tidy up your house and get rid of objects that are causing clutter without being useful, deprescribing tidies up your medication list to keep only the ones truly required. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543369/original/file-20230818-27-fo2qgf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="older couple sit at table looking at medications" src="https://images.theconversation.com/files/543369/original/file-20230818-27-fo2qgf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543369/original/file-20230818-27-fo2qgf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543369/original/file-20230818-27-fo2qgf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543369/original/file-20230818-27-fo2qgf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543369/original/file-20230818-27-fo2qgf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543369/original/file-20230818-27-fo2qgf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543369/original/file-20230818-27-fo2qgf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Deprescribing is the process of stopping or stepping down medications that are no longer needed.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/search/taking-medications">Shutterstock</a></span>
</figcaption>
</figure>
<h2>But care is needed</h2>
<p>The process of deprescribing requires close monitoring and, for many medications, slow reductions in dose (tapering). </p>
<p>This helps the body adjust gradually and can prevent sudden, unpleasant changes. Deprescribing is often done on a trial basis and medication can be restarted if symptoms come back. Alternatively, a safer medication, or non-drug treatment may be started in its place.</p>
<p>Studies show deprescribing is a safe process when managed by a health-care professional, both for people living at <a href="https://link.springer.com/article/10.1007/s11606-020-06089-2">home</a> and those in <a href="https://doi.org/10.1016/j.jamda.2018.10.026">residential aged care</a>. You should always talk with your care team before stopping any medications.</p>
<p>Deprescribing needs to be a team effort involving the person, their health-care team and possibly family or other carers. Shared decision-making throughout the process empowers the person taking medications to have a say in their health care. The team can work together to clarify treatment goals and decide which medications are still serving the person well and which can be safely discontinued.</p>
<p>If you or a loved one take multiple medications you might be eligible for a free visit from a pharmacist (<a href="https://www.nps.org.au/assets/NPS/pdf/NPSMW2390_Anticholinergics_HMR_Factsheet.pdf">a Home Medicines Review</a>) to help you get the best out of your medications.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/always-forgetting-to-take-your-medicines-here-are-4-things-that-could-help-193717">Always forgetting to take your medicines? Here are 4 things that could help</a>
</strong>
</em>
</p>
<hr>
<h2>What’s next?</h2>
<p>Health care has traditionally focused on prescribing medications, with little focus on when to stop them. Deprescribing is not happening as often as it should. <a href="https://www.australiandeprescribingnetwork.com.au/">Researchers</a> are working hard to develop tools, resources and service models to support deprescribing in the community. </p>
<p>Health-care professionals may think older adults are not open to deprescribing, but about <a href="https://academic.oup.com/biomedgerontology/article/77/5/1020/6352400">eight out of ten people</a> are willing to stop one or more of their medications. That said, of course some people may have concerns. If you have been taking a medication for a long time, you might wonder why you should stop or whether your health could get worse if you do. These are important questions to ask a doctor or pharmacist.</p>
<p>We need more <a href="https://shpa.org.au/news-advocacy/MedsAware">public awareness</a> about polypharmacy and deprescribing to turn the tide of increasing medication use and related harms. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/boomers-have-a-drug-problem-but-not-the-kind-you-might-think-127682">Boomers have a drug problem, but not the kind you might think</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/211424/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In the past five years, Emily Reeve has received funding from the National Health and Medical Research Council (NHMRC), Australian Association of Gerontology, Nova Scotia Health Research Foundation, Canadian Frailty Network, United States NIH, Australian Commission On Safety And Quality In Health Care, and US Agency for Healthcare Research and Quality. She has also received honorarium for writing and presentations from the US Deprescribing Research Network, Encyclopedia of Pharmacy Practice and Clinical Pharmacy (Elsevier), UpToDate (Wolters Kluwer), and Society of Hospital Pharmacists of Australia. She is Chair of the Australian Deprescribing Network (ADeN). </span></em></p><p class="fine-print"><em><span>Jacinta Lee Johnson is senior pharmacist for research within SA Pharmacy and Board Director for the Society of Hospital Pharmacists of Australia. In the last five years, she has received research funding or consultancy funds (for development and delivery of educational materials) from SA Health, the Medical Research Future Fund, the Hospital Research Foundation – Parkinson's, the Pharmaceutical Society of Australia, the Pharmacy Guild of Australia, the Society of Hospital Pharmacists of Australia, Mundipharma Pty Ltd, Aspen Pharmacare Australia Pty Ltd and Viatris Pty Ltd. </span></em></p><p class="fine-print"><em><span>In the last five years, Janet Sluggett has received research funding, prizes or consultancy funds from the National Health and Medical Research Council, Medical Research Future Fund, Australian Association of Consultant Pharmacy, Dementia Centre for Research Collaboration and various professional societies. In addition to her research appointments, she is a non-executive director of the Australian MedicAlert Foundation and Southern Cross Care SA, NT, Victoria. She is a registered pharmacist who is accredited to perform Home Medicines Reviews.</span></em></p><p class="fine-print"><em><span>Kate O'Hara is affiliated with the Society of Hospital Pharmacists of Australia (SHPA).</span></em></p>Health care has traditionally focused on prescribing medications, with little focus on when to stop them. But pills and potions can add up over time and do more harm than good.Emily Reeve, Senior Research Fellow in the Centre for Medicine Use and Safety , Monash UniversityJacinta L. Johnson, Senior Lecturer in Pharmacy Practice, University of South AustraliaJanet Sluggett, Enterprise Fellow, University of South AustraliaKate O'Hara, PhD student, Clinical Pharmacology and Toxicology, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2040282023-05-01T20:01:20Z2023-05-01T20:01:20ZHere’s why pharmacists are angry at script changes – and why the government is making them anyway<figure><img src="https://images.theconversation.com/files/523557/original/file-20230501-28-rxhhxq.jpg?ixlib=rb-1.1.0&rect=70%2C0%2C6639%2C3370&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-pharmacist-protective-mask-on-her-1734593969">Shutterstock</a></span></figcaption></figure><p>Australians will <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-press-conference-26-april-2023?language=en">soon be able to fill</a> two months’ supply of medicines at their community pharmacy, rather than one, for 325 common medicines. This change is expected to halve the cost of prescriptions for six million Australians.</p>
<p>The Pharmacy Guild of Australia has taken exception to the government’s policy change, <a href="https://www.guild.org.au/news-events/news/2023/8-in-10-australians-reject-federal-budget-proposal-due-to-medicine-shortages">warning</a> it will create medicine shortages and make pharmacies financially worse off.</p>
<p>The president of the guild <a href="https://www.sbs.com.au/news/video/pharmacy-advocate-in-tears-over-prescription-changes/mu92ka0aq">wept</a> at the thought of pharmacies going under because of reduced income from dispensing fees and co-payments. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1651443571981971457"}"></div></p>
<p>Mark Butler, the federal minister for health and aged care, was deft in his response, <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-press-conference-26-april-2023">advising Australians to</a>: </p>
<blockquote>
<p>take advice around medicine supply and medicine shortages from our medicines authorities rather than the pharmacy lobby group.</p>
</blockquote>
<p>This argy-bargy between the government and the guild is not uncommon.</p>
<p>What is uncommon is the public dismissal from a health minister of the guild’s views. This government is using its political capital to push health reform forward and doesn’t seem afraid to ruffle a few feathers.</p>
<h2>What is the Pharmacy Guild of Australia?</h2>
<p>The guild is an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4605468/">influential peak body</a> registered under the federal Fair Work Act 2009. It acts like a union for community pharmacy (also known as chemists) owners. It provides resources to help pharmacists improve their small businesses, but most of its membership value comes from advocating for community pharmacy owners.</p>
<p>The Pharmaceutical Society of Australia is a separate group which represents all pharmacists, including those who work in hospitals and those who don’t own the pharmacy they work in.</p>
<p>The guild and the Pharmaceutical Society of Australia negotiate five-year agreements with the government on remuneration and funding for supplying Pharmaceutical Benefits Scheme (PBS) medicines in the community and for delivering pharmacy programs to support patients.</p>
<p>Known as <a href="https://theconversation.com/explainer-what-is-the-community-pharmacy-agreement-38789#:%7E:text=Patients%20pay%20a%20contribution%20towards,patient%20contribution%20from%20the%20government.">Community Pharmacy Agreements</a>, the first was signed in 1990, while the most recent seventh Community Pharmacy Agreement was signed in 2020. That agreement is due to expire in 2025, potentially costing A$25 billion over five years. Of this, $16 billion will be paid for by the government and $9 billion will be paid for by patients.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-the-community-pharmacy-agreement-38789">Explainer: what is the Community Pharmacy Agreement?</a>
</strong>
</em>
</p>
<hr>
<h2>How does the guild wield its power?</h2>
<p>The guild is nearly 100 years old. It understands health care and how health policy is made. It has a reputation for shaping government health policy envied by many a health care peak body.</p>
<p>It doesn’t have authority over government policy. It asserts its influence through its soft power by shaping community preferences to get patients behind what it wants. This stems from community pharmacy’s reach into every corner of Australia and the inherent trust between a pharmacist and a patient. It undertakes its own research to generate ideas and to criticise government policy when it suits.</p>
<figure class="align-center ">
<img alt="Pharmacist explains a medicine to a mother holding a young child" src="https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pharmacies are found in all corners of the country.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cheerful-pharmacist-chemist-woman-giving-vitamins-211739305">Shutterstock</a></span>
</figcaption>
</figure>
<p>The guild also takes a more direct approach to influencing government policy. The Australian Electoral Commission <a href="https://transparency.aec.gov.au/Donor">reported</a> the guild was the 13th largest political donor in 2021–22, donating $578,000 to political parties across 88 separate donations. This was in an election year, which almost doubled its donations compared to the previous year.</p>
<h2>What policies has the guild influenced?</h2>
<p>The recent extent of the guild’s power is reflected in favourable policy outcomes for community pharmacies, despite these sometimes being unfavourable for taxpayers or patients.</p>
<p>The guild convinced the government to provide community pharmacies and pharmaceutical wholesalers with <a href="https://archive.budget.gov.au/2017-18/bp2/bp2.pdf">an extra</a> $225 million in the 2017–18 budget because prescription volumes were lower than expected within the sixth Community Pharmacy Agreement. This was a simple cash grab by pharmacies from taxpayers.</p>
<p>The guild also won a contentious policy back-flip in 2018 by getting the government to retain the Pharmacy Location Rules, <a href="https://www.guild.org.au/resources/business-conditions-survey">arguing</a> they provide “certainty and stability” for pharmacy small business. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-the-pharmacy-guild-of-australia-and-why-does-it-wield-so-much-power-127315">What is the Pharmacy Guild of Australia and why does it wield so much power?</a>
</strong>
</em>
</p>
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<h2>What are the Pharmacy Location Rules?</h2>
<p>The Pharmacy Location Rules are an <a href="https://www1.health.gov.au/internet/main/publishing.nsf/content/DDB409EBB18FCE8FCA257BF0001D3C0C/%24File/Pharmacy-Location-Rules-Applicants-Handbook-October-2018-v1-1.pdf">agreement</a> between the Australian government and the Pharmacy Guild of Australia. They place restrictions on where a new pharmacy can be established or where an existing pharmacy can be relocated. Pharmacies must meet location based criteria to be approved by the Australian Community Pharmacy Authority to receive pharmaceutical benefits. </p>
<p>The Pharmacy Location Rules <a href="https://www1.health.gov.au/internet/main/publishing.nsf/content/DDB409EBB18FCE8FCA257BF0001D3C0C/%24File/Pharmacy-Location-Rules-Applicants-Handbook-October-2018-v1-1.pdf">do not allow</a> new pharmacies to open within 1.5 kilometres or 10 kilometres of an existing pharmacy depending on the location, distance to the nearest pharmacy, and the number of supermarkets and medical practitioners in the area. Unless exempt, they do not allow pharmacies to be relocated from the town in which the approval was originally granted.</p>
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<img alt="shelf of common medicines" src="https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=445&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=445&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=445&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=560&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=560&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=560&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The Pharmacy Location Rules determine where new pharmacy retailers can set up.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/pyuOXgO951U">Unsplash/Franki Chamaki</a></span>
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<p>While no research has directly examined the impact, this policy has likely inflated consumer costs due to a restricted competitive pharmacy environment.</p>
<p>The Pharmacy Location Rules were introduced in the <a href="https://www.aph.gov.au/DocumentStore.ashx?id=523bbb1a-7e5f-485d-a8d5-d80b94a2c6d8&subId=561469">first Community Pharmacy Agreement</a> to help larger pharmacies generate efficiencies and profit through scale. The rules sweetened accompanying restrictions on PBS remuneration from the government. They have been included in each subsequent Community Pharmacy Agreement.</p>
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<strong>
Read more:
<a href="https://theconversation.com/relaxing-pharmacy-ownership-rules-could-result-in-more-chemist-chains-and-poorer-care-122628">Relaxing pharmacy ownership rules could result in more chemist chains and poorer care</a>
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<p>The Pharmacy Location Rules were meant to expire in 2015 after the government initiated Competition Policy Review <a href="https://treasury.gov.au/publication/p2015-cpr-final-report">recommended</a> they “should be removed in the long term interests of consumers”. Instead, the guild <a href="https://www.theguardian.com/australia-news/2015/may/27/pharmacy-guild-shelves-protest-plans-after-compromise-deal-with-government">pulled back on a threat</a> made to the government to launch a major campaign on another policy initiative, in exchange for delaying the removal of the location rules for five years. </p>
<p>Upon further lobbying, the Pharmacy Location Rules sunset clause <a href="https://www.pbs.gov.au/general/sixth-cpa-pages/cpsf-files/cpsf-progress-of-commitments-compact-between-the-guild-and-health.docx">was removed</a> after the guild formed a Pharmacy Compact with the government in 2017. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1638678308589305856"}"></div></p>
<h2>Pharmacy policies that benefit consumers</h2>
<p>Some government policy change has aligned guild and patient interests.</p>
<p>Community pharmacists are increasingly providing services traditionally delivered by GPs. Pharmacists can now administer flu and COVID vaccines, and state trials allowing pharmacists to dispense oral contraception and antibiotics without a prescription are gaining favour.</p>
<p>This push towards greater scope of practice is embedded in the current and prior Community Pharmacy Agreements. But it threatens GP revenues.</p>
<p>The Australian Medical Association, the peak body for doctors, recently took a swing at the guild. It <a href="https://www.aph.gov.au/DocumentStore.ashx?id=cecc2818-fb71-4e9e-b2df-203e8c7e4e27&subId=736754">outlined ways</a> to improve pharmacy competition in a government submission, which included removing Pharmacy Location Rules and getting pharmacies to compete on medicine prices through discounting. </p>
<h2>What does this all mean for patients?</h2>
<p>The government has assured the guild that the $1.2 billion savings from allowing patients to fill two months’ supply of medicines will be invested directly back into pharmacies.</p>
<p>Savings will be used to <a href="https://www.health.gov.au/sites/default/files/2023-04/summary-of-strengthening-medicare-policies.pdf">further expand</a> the scope of practice for pharmacists, potentially informed by a National Scope of Practice Review to start in 2023.</p>
<p>Despite this assurance, the guild will fight. It has <a href="https://www.guild.org.au/news-events/news/2023/8-in-10-australians-reject-federal-budget-proposal-due-to-medicine-shortages">already canvassed</a> 2,500 “voters” across Australia on the budget proposal. In addition to reduced dispensing fee revenue, having patients with chronic diseases reduce their pharmacy visits by half means the opportunity to sell other products sitting on shelves is also halved.</p>
<p>Substantial health reform is on the horizon, but it won’t be painless. Policy change can upset embedded business models. It can impact livelihoods if providers don’t respond to their new regulatory environment. In the coming whirlwind of power struggles, wouldn’t it be nice if the government and providers worked together to put the patient first?</p>
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<strong>
Read more:
<a href="https://theconversation.com/should-pharmacists-be-able-to-prescribe-common-medicines-like-antibiotics-for-utis-we-asked-5-experts-195277">Should pharmacists be able to prescribe common medicines like antibiotics for UTIs? We asked 5 experts</a>
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<img src="https://counter.theconversation.com/content/204028/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Henry Cutler does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Pharmacy Guild head wept at the thought of pharmacies losing income from a change that allows people with chronic diseases to halve their prescription costs. What’s going on?Henry Cutler, Professor and Director, Macquarie University Centre for the Health Economy, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2041632023-04-26T12:28:33Z2023-04-26T12:28:33ZMifepristone is under scrutiny in the courts, but it has been used safely and effectively around the world for decades<figure><img src="https://images.theconversation.com/files/522668/original/file-20230424-26-v5rdtr.jpg?ixlib=rb-1.1.0&rect=0%2C170%2C2915%2C1755&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Mifepristone is used together with another pill, misoprostol, in medication abortions.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AbortionPill/513c7c2f6d0346b9b9ddaa2c7344be46/photo?Query=mifepristone%20supreme%20court&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=39&currentItemNo=32">AP Photo/Allen G. Breed</a></span></figcaption></figure><p><em>A <a href="https://theconversation.com/the-supreme-court-rules-mifepristone-can-remain-available-heres-how-2-conflicting-federal-court-decisions-led-to-this-point-203623">flurry of court rulings</a> in April 2023 has left the <a href="https://www.reuters.com/world/us/us-abortion-providers-relieved-wary-supreme-court-preserves-pill-access-2023-04-22/">future of the abortion pill mifepristone in question</a>. For now, a U.S. Supreme Court decision on April 21 <a href="https://theconversation.com/how-will-the-supreme-courts-decision-on-mifepristone-affect-abortion-access-4-questions-answered-204172">allows the drug to remain accessible</a> <a href="https://www.nbcnews.com/health/womens-health/abortion-pill-lawsuit-mifepristone-questions-future-access-rcna79455">without additional restrictions</a> as the merits of the case are <a href="https://www.washingtonpost.com/politics/2023/04/21/mifepristone-abortion-pill-access-supreme-court/">weighed in lower court proceedings</a>.</em> </p>
<p><em>Depending on the outcome, the pill <a href="https://www.reuters.com/legal/government/us-supreme-court-preserves-access-abortion-pill-now-whats-next-2023-04-22/">could face a ban or tightened restrictions</a> on its usage, a possibility that has many health care providers concerned.</em></p>
<p><em>The Conversation asked Grace Shih, a family physician practicing in Washington state, to explain the science behind mifepristone as well as its safety and efficacy in medication abortions.</em></p>
<h2>What is mifepristone, and how does it work?</h2>
<p>Mifepristone is a pill that is <a href="https://theconversation.com/what-is-a-medication-or-medical-abortion-5-questions-answered-by-3-doctors-182646">used in medication abortion</a> during early pregnancy. It was initially <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-about-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation">approved by the Food and Drug Administration in 2000</a> and is approved by the FDA for medication abortion up to 10 weeks after the first day of the last menstrual period. </p>
<p>It can be taken as one part of a two-part pill regimen for medication abortion. Mifepristone is prescribed as a 200-milligram dose taken orally, followed by an 800-microgram dose of misoprostol, which is placed in the vagina or between the teeth and cheek, where it dissolves and is absorbed, usually 24 to 48 hours later. </p>
<p>Mifepristone acts by blocking the hormone progesterone, which is necessary for a pregnancy to develop. This stops the pregnancy growth and softens and dilates the cervix. It also prepares the uterus for contractions, increasing its sensitivity to medications such as misoprostol. </p>
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<figcaption><span class="caption">Mifepristone blocks the action of progesterone, a hormone that is needed for a pregnancy to develop.</span></figcaption>
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<p>Misoprostol is a synthetic <a href="https://www.yourhormones.info/hormones/prostaglandins/">prostaglandin</a>. Prostaglandin is a hormonelike substance that has multiple effects, including the stimulation of uterine contractions, which helps expel pregnancy tissue such as the thickened uterine lining and the tissues that are the precursor to the placenta. </p>
<p>Misoprostol is <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2002/19268slr037.pdf">currently FDA-approved</a> for reducing the risk of gastric ulcers in patients who are at high risk of complications from ulcers. But it is commonly used off-label for things like cervical ripening, or softening, to induce or help with labor. Mifepristone and misoprostol are also both used in the <a href="https://doi.org/10.1056/NEJMoa1715726">medical management of miscarriage</a>.</p>
<p>Medication abortion can also be done with misoprostol alone, an approach known as the misoprostol-only regimen. This <a href="https://doi.org/10.1097/aog.0000000000003017">regimen is safe</a> and has been <a href="https://www.washingtonpost.com/world/2023/04/19/abortion-pill-mifepristone-global-approved/">used widely by people around the world</a>. In the misoprostol-only regimen, an 800-microgram dose is placed in the vagina or between the teeth and cheek every three hours for up to three doses. </p>
<p>Both protocols are very effective, with the two-drug regimen <a href="https://doi.org/10.1097/AOG.0000000000000910">up to 99.6% effective</a> and the <a href="https://doi.org/10.1097%2FAOG.0000000000003017">misoprostol-alone regimen between 84% to 96%</a> in medication abortions.</p>
<h2>Why would a person opt for one regimen or the other?</h2>
<p>People usually don’t choose the type of medication abortion they receive. Because the availability of mifepristone and misoprostol is highly variable, whichever method is available to you is medically safe. Patients should feel assured that guidelines for medication abortion support the <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">safety and efficacy of both medication regimens</a>.</p>
<p>The <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">American College of Obstetricians and Gynecologists</a>, the <a href="https://doi.org/10.1016/j.contraception.2020.08.004">Society for Family Planning</a> and the <a href="https://www.who.int/publications/i/item/9789240039483">World Health Organization</a> all support both types of medication abortion. </p>
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<figcaption><span class="caption">Mifepristone and misoprostol work in tandem to terminate a pregnancy.</span></figcaption>
</figure>
<h2>How widely accessible is mifepristone?</h2>
<p>In January 2023, the <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/questions-and-answers-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation#">FDA updated its guidelines</a> to allow mifepristone to be dispensed through pharmacies with a prescription.</p>
<p>The change means that the drug is available both by mail or at brick-and-mortar pharmacies, as long as that retail pharmacy has been certified. In other words, people who live in states where abortion is not banned can take their mifepristone prescription and get it the way they pick up other medications. </p>
<p>For someone able to pick up mifepristone from a local pharmacy, the process is no different from picking up birth control pills or blood pressure medications. This allows mifepristone and its applications for abortion care and miscarriage management to be treated as typical health care. </p>
<p>While the January 2023 FDA ruling theoretically increases the ways that a person can get mifepristone, so far it has not been widely available at retail pharmacies.</p>
<h2>Can I still get mifepristone?</h2>
<p>The short answer is yes, mifepristone is still FDA-approved. The Supreme Court’s April 21, 2023, ruling means that there will be <a href="https://theconversation.com/how-will-the-supreme-courts-decision-on-mifepristone-affect-abortion-access-4-questions-answered-204172">no changes to mifepristone access for now</a>. However, for use in abortion care, mifepristone still faces restrictions depending on your state’s legislation.</p>
<p>As of April 2023, 27 states have <a href="https://www.guttmacher.org/state-policy/explore/medication-abortion">some restriction on medication abortion</a> according to the <a href="https://www.guttmacher.org/">Guttmacher Institute</a>, a reproductive health policy organization. This includes 12 states that have a near-total ban on abortion and one state that has stopped offering abortion care because of legal uncertainty. </p>
<p>Of the 15 states with restrictions specific to medication abortion, all of them require that medication be provided by a physician and not an advanced practitioner like a nurse practitioner. Six of the states require an in-person visit with a physician, one state requires that mifepristone be taken in the presence of a physician, and one state bans mailing medication abortion pills.</p>
<h2>Evidence-based health care</h2>
<p>As a practicing family physician, I follow the science and make medical decisions with my patients using the most up-to-date evidence. Medication abortion using mifepristone and misoprostol is <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">exceptionally safe and highly effective</a>, as is <a href="https://doi.org/10.1097%2FAOG.0000000000003017">medication abortion using misoprostol alone</a>. Side effects of the misoprostol-only regimen are similar to the combined regimen, though they may last longer because of the need for multiple doses of misoprostol.</p>
<p>Some news coverage has focused on comparing the efficacy of the two regimens. But percentage points mean very little to an individual’s health – what matters is that people get the care they need.</p>
<p>I will continue working, providing and advancing care that is based on science. Leading health professional organizations including the <a href="https://www.acog.org/clinical-information/policy-and-position-statements/position-statements/2018/improving-access-to-mifepristone-for-reproductive-health-indications">American College of Obstetricians and Gynecologists</a>, the <a href="https://policysearch.ama-assn.org/policyfinder/detail/mifepristone?uri=%2FAMADoc%2FHOD.xml-H-100.948.xml">American Medical Association</a> and the <a href="https://www.aafp.org/dam/AAFP/documents/events/nc/congress/nc18-ncfmr-actions-referrals.pdf">American Academy of Family Physicians</a> have all issued statements that call for removing all restrictions around mifepristone and/or support the safety of misoprostol-only medication abortion.</p>
<p><em>This is an updated version of an <a href="https://theconversation.com/what-the-fdas-rule-changes-allowing-the-abortion-pill-mifepristone-to-be-dispensed-by-pharmacies-mean-in-practice-5-questions-answered-197339">article originally published</a> on Jan. 11, 2023.</em></p><img src="https://counter.theconversation.com/content/204163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grace Shih does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Mifepristone’s safety in medication abortions has been well established over more than two decades, but legal wrangling leaves the future of the drug hanging in the balance.Grace Shih, Associate Professor of Family Medicine, School of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1973392023-01-11T13:26:42Z2023-01-11T13:26:42ZWhat the FDA’s rule changes allowing the abortion pill mifepristone to be dispensed by pharmacies mean in practice – 5 questions answered<figure><img src="https://images.theconversation.com/files/503684/original/file-20230109-13-cophlz.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7348%2C4407&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The rule change has little to no effect in states where abortion is banned or restricted.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/simplifying-the-dispensing-process-with-smart-apps-royalty-free-image/1138202173?phrase=pharmacist%20dispensing%20pills&adppopup=true">LaylaBird/E+ via Getty Images</a></span></figcaption></figure><p><em>In early January 2023, the U.S. Food and Drug Administration <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/questions-and-answers-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation#">modified its rules for mifepristone</a>, a drug used for medication abortion, allowing it to be offered with a prescription by certified pharmacies. Before this rule change, mifepristone could be dispensed only in person by providers at hospitals, clinics and medical offices, as well as by some mail-order pharmacies.</em></p>
<p><em>The Conversation asked Grace Shih, a family physician practicing in Washington, to explain the significance of this change for health care providers and their patients.</em></p>
<h2>What is mifepristone, and how does it work?</h2>
<p>Mifepristone is a pill that is <a href="https://theconversation.com/what-is-a-medication-or-medical-abortion-5-questions-answered-by-3-doctors-182646">used in medication abortion</a> during early pregnancy. It was initially <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-about-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation">approved by the FDA in 2000</a> and is FDA-approved for medication abortion up to 10 weeks after the first day of last menstrual period.</p>
<p>It can be taken as one part of a two-part pill regimen for medication abortion. Mifepristone is prescribed as a 200-milligram dose taken orally followed by an 800-microgram dose of misoprostol, which is placed in the vagina or between the teeth and cheek, where it dissolves and is absorbed, usually 24 to 48 hours later. </p>
<p>Mifepristone acts by blocking the hormone progesterone, which is necessary for a pregnancy to develop. This stops the pregnancy growth and softens and dilates the cervix. It also prepares the uterus for contractions, increasing its sensitivity to medications such as misoprostol. </p>
<p>Misoprostol is a synthetic <a href="https://www.yourhormones.info/hormones/prostaglandins/">prostaglandin</a>. Prostaglandin is a hormonelike substance that has multiple effects, including the stimulation of uterine contractions, which helps expel pregnancy tissue such as the thickened uterine lining and the tissues that are the precursor to the placenta. Mifepristone and misoprostol are also both used in the <a href="https://doi.org/10.1056/NEJMoa1715726">medical management of miscarriage</a>. </p>
<p>Medication abortion can also be done with misoprostol alone, known as the misoprostol-only regimen. In the misoprostol-only regimen, an 800-microgram dose of misoprostol is placed in the vagina or between the teeth and cheek every three hours for up to three doses. </p>
<h2>Why would a person opt for one regimen or the other?</h2>
<p>People usually don’t choose the type of medication abortion they receive. Either mifepristone is available where they are seeking care or it is not. </p>
<p>The American College of Obstetricians and Gynecologists <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">states that</a> “combined mifepristone-misoprostol regimens are recommended as the preferred therapy for medication abortion because they are significantly more effective than misoprostol-only regimens.” </p>
<p>The efficacy <a href="https://doi.org/10.1097/AOG.0000000000000897">of the two-pill regimen is approximately 95% to 98%</a>. However, because mifepristone is under the FDA’s <a href="https://www.fda.gov/drugs/drug-safety-and-availability/risk-evaluation-and-mitigation-strategies-rems">risk evaluation and mitigation strategy program</a>, which places <a href="https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm?event=RemsDetails.page&REMS=390">specific restrictions on mifepristone</a>, it can be difficult to obtain. </p>
<p>When mifepristone is not available, the American College of Obstetricians and Gynecologists considers the misoprostol-only regimen, which has an efficacy of 76% to 88%, to be an “<a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">acceptable alternative</a>.” Thus, the FDA’s permission to dispense mifepristone at retail pharmacies will help broaden access to the more effective combined mifepristone-misoprostol regimen of medication abortion. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/kzd4ABInBio?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Mifepristone and misoprostol work in tandem to terminate a pregnancy.</span></figcaption>
</figure>
<h2>What will the FDA’s rule change mean in practice?</h2>
<p>The recent FDA change means that retail pharmacies may dispense mifepristone by mail or at brick-and-mortar pharmacies, as long as that retail pharmacy has been certified. In other words, people who live in states where abortion is not banned can take their mifepristone prescription and get it the way they pick up other medications. </p>
<p>For someone able to pick up mifepristone from a local pharmacy, the process will be no different from picking up birth control pills or blood pressure medications. In this way, mifepristone and its uses for abortion care and miscarriage management will be treated as typical health care. </p>
<p>It is unclear whether or how the FDA’s rule will affect state restrictions on abortion care. If medication abortion is not permitted in a specific state, retail pharmacies in that state may or may not be able to dispense mifepristone for abortion care. However, mifepristone could be dispensed from certified pharmacies for reasons unrelated to abortion care, such as miscarriage management.</p>
<h2>What brought about the change?</h2>
<p>On Jan. 3, 2023, the FDA formally modified its <a href="https://www.acog.org/news/news-releases/2020/05/acog-suit-petitions-the-fda-to-remove-burdensome-barriers-to-reproductive-care-during-covid-19">regulations and guidelines around mifepristone use</a>, which were initially proposed during the COVID-19 pandemic. Previous guidelines required that mifepristone be dispensed in person.</p>
<p>These changes were brought about by a <a href="https://www.acog.org/-/media/project/acog/acogorg/files/advocacy/acog-v-fda-complaint-mifepristone-covid19.pdf?">civil complaint</a> that was sponsored by obstetrician-gynecologists, family physicians and reproductive justice advocates. It noted that “of the 20,000 drugs regulated by the FDA, mifepristone is the only one that patients must receive in person at a hospital, clinic or medical office,” even though the medication itself can be taken orally by a person unsupervised, at any location. </p>
<p>The in-person requirement meant that those seeking medication abortion or miscarriage care were required to face increased risk of COVID-19 exposure simply to obtain mifepristone. There has been <a href="https://www.acog.org/news/news-releases/2020/05/acog-suit-petitions-the-fda-to-remove-burdensome-barriers-to-reproductive-care-during-covid-19">no documented benefit</a> from this in-person dispensing requirement. </p>
<p>As a result of this complaint, the FDA placed a temporary pause on enforcement of the in-person dispensing requirement and subsequently <a href="https://www.fda.gov/files/drugs/published/Risk-Evaluation-and-Mitigation-Strategies--Modifications-and-Revisions-Guidance-for-Industry.pdf">conducted a formal review</a> of its regulations around the dispensing of mifepristone. The Jan. 3 decision is the FDA’s final decision.</p>
<p>Misoprostol has never been subject to the same restrictions. In addition to its use in the medication abortion regimen, misoprostol is FDA approved for management of gastric ulcers. And it is used, off-label, for cervical dilation and softening when doctors induce labor. People may continue to get their misoprostol at retail or mail-order pharmacies.</p>
<h2>How might this rule change affect medication abortion access?</h2>
<p>While this change is an important step in <a href="https://www.acog.org/news/news-releases/2023/01/statement-fda-announcement-regarding-changes-to-restrictions-on-provision-of-mifepristone">securing access to medication abortion</a>, it does not have a clear benefit for people who live in states where <a href="https://reproductiverights.org/maps/abortion-laws-by-state/">abortion is banned</a>. And it has limited benefit in states that have restrictions on medication abortion. </p>
<p>According to the <a href="https://www.guttmacher.org/">Guttmacher Institute</a>, a reproductive health policy organization, 29 states have <a href="https://www.guttmacher.org/state-policy/explore/medication-abortion">some restriction on medication abortion</a>, including 18 states that require that the clinician providing a medication abortion be physically present with the patient. Those restrictions therefore prohibit the use of telemedicine to prescribe medications for abortion.</p>
<p>It is unclear how many pharmacies will pursue certification and how quickly that certification can happen. Pharmacies that want to dispense mifepristone must comply with <a href="https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm?event=RemsDetails.page&REMS=390">FDA pharmacy agreements to achieve certification</a>. </p>
<p>This includes having systems in place to track and verify mifepristone prescribers, using a tracked shipping service and having the ability to report patient deaths to prescribers, <a href="https://www.accessdata.fda.gov/drugsatfda_docs/rems/Mifepristone_2023_01_03_Pharmacy_Agreement_Form_Danco_Laboratories.pdf">among other requirements</a>. CVS and Walgreens have already <a href="https://www.nytimes.com/2023/01/05/health/abortion-pills-cvs-walgreens.html">announced plans to become certified pharmacies</a>.</p>
<p>As a practicing family physician, I see the permanent removal of the in-person dispensing requirement as essential for normalizing abortion care and improving access to medication abortion. However, many obstacles remain, including specific patient consent forms, unique and required prescriber certification and the aforementioned pharmacy certification. </p>
<p>Leading health professional organizations including the <a href="https://www.acog.org/clinical-information/policy-and-position-statements/position-statements/2018/improving-access-to-mifepristone-for-reproductive-health-indications">American College of Obstetricians and Gynecologists</a>, the <a href="https://policysearch.ama-assn.org/policyfinder/detail/mifepristone?uri=%2FAMADoc%2FHOD.xml-H-100.948.xml">American Medical Association</a> and the <a href="https://www.aafp.org/dam/AAFP/documents/events/nc/congress/nc18-ncfmr-actions-referrals.pdf">American Academy of Family Physicians</a> have all issued statements that call for removing all restrictions around mifepristone, since there is no evidence that these restrictions improve patient care or safety.</p><img src="https://counter.theconversation.com/content/197339/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grace Shih does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The FDA’s allowance for pharmacies to dispense mifepristone will broaden access to the two-pill mifepristone-misoprostol regimen of medication abortion, which is 95% to 98% effective.Grace Shih, Associate Professor of Family Medicine, School of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1966462022-12-21T19:11:54Z2022-12-21T19:11:54ZDrinking alcohol this Christmas and New Year? These medicines really don’t mix<figure><img src="https://images.theconversation.com/files/502253/original/file-20221220-22-w0zd44.jpg?ixlib=rb-1.1.0&rect=8%2C17%2C5742%2C3811&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/champagne-glasses-hands-people-party-1377409880">Shutterstock</a></span></figcaption></figure><p>A glass or two of champagne with Christmas lunch. A cool crisp beer at the beach. Some cheeky cocktails with friends to see in the New Year. There seem to be so many occasions to unwind with an alcoholic drink this summer.</p>
<p>But if you’re taking certain medications while drinking alcohol, this can affect your body in a number of ways. Drinking alcohol with some medicines means they may not work so well. With others, you risk a life-threatening overdose.</p>
<p>Here’s what you need to know if you’re taking medication over summer and plan to drink.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-different-drinks-make-you-different-drunk-88247">Do different drinks make you different drunk?</a>
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</em>
</p>
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<h2>Why is this a big deal?</h2>
<p>After you take a medicine, it travels to the stomach. From there, your body shuttles it to the liver where the drug is metabolised and broken down before it goes into your blood stream. Every medicine you take is provided at a dose that takes into account the amount of metabolism that occurs in the liver.</p>
<p>When you drink alcohol, this is also broken down in the liver, and it can affect how much of the drug is metabolised. </p>
<p>Some medicines are metabolised <em>more</em>, which can mean not enough reaches your blood stream to be effective. </p>
<p>Some medicines are metabolised <em>less</em>. This means you get a much higher dose than intended, which could lead to an overdose. The effects of alcohol (such as sleepiness) can act in addition to similar effects of a medicine.</p>
<p>Whether or not you will have an interaction, and what interaction you have, depends on many factors. These include the medicine you are taking, the dose, how much alcohol you drink, your age, genes, sex and overall health. </p>
<p>Women, older people and people with liver issues are more likely to have a drug interaction with alcohol.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/women-are-50-75-more-likely-to-have-adverse-drug-reactions-a-new-mouse-study-finally-helps-explain-why-195358">Women are 50–75% more likely to have adverse drug reactions. A new mouse study finally helps explain why</a>
</strong>
</em>
</p>
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<h2>Which medicines don’t mix well with alcohol?</h2>
<p>Many medicines interact with alcohol regardless of whether they are prescribed by your doctor or bought over the counter, such as <a href="https://www.drugs.com/article/herbal-supplements-alcohol.html">herbal medicines</a>.</p>
<p><strong>1. Medicines + alcohol = drowsiness, coma, death</strong></p>
<p>Drinking alcohol and taking a medicine that depresses the <a href="https://adf.org.au/drug-facts/depressants/">central nervous system</a> to reduce arousal and stimulation can have additive effects. Together, these can make you extra drowsy, slow your breathing and heart rate and, in extreme cases, lead to coma and death. These effects are more likely if you use more than one of this type of medicine. </p>
<p>Medicines to look out for include those for depression, anxiety, schizophrenia, pain (except <a href="https://www.nps.org.au/australian-prescriber/articles/alcohol-and-paracetamol">paracetamol</a>), sleep disturbances (such as insomnia), allergies, and colds and flu. It’s best not to drink alcohol with these medicines, or to keep your alcohol intake to a minimum. </p>
<p><strong>2. Medicines + alcohol = more effects</strong></p>
<p>Mixing alcohol with some medicines increases the effect of those medicines. </p>
<p>One example is with the sleeping tablet zolpidem, which is <a href="https://www.tga.gov.au/news/product-recalls/zolpidem-stilnox">not to be taken with alcohol</a>. Rare, but serious, side effects are strange behaviour while asleep, such as sleep-eating, sleep-driving or sleep-walking, which are more likely with alcohol.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/i-cant-sleep-what-drugs-can-i-safely-take-102343">I can't sleep. What drugs can I (safely) take?</a>
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</em>
</p>
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<p><strong>3. Medicines + craft beer or home brew = high blood pressure</strong></p>
<p>Some types of medicines only interact with some types of alcohol.</p>
<p>Examples include some medicines for depression, such as phenelzine, tranylcypromine and moclobemide, the antibiotic linezolid, the Parkinson’s drug selegiline, and the cancer drug procarbazine.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two young women drinking alcohol sitting on bench outside bar" src="https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/502281/original/file-20221221-19-slbol7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Drinking craft beer this summer? This can interact with some drugs to raise your blood pressure.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/two-smiling-women-sitting-on-wooden-bench-1267696/">ELEVATE/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>These so-called <a href="https://www.mydr.com.au/medicine/monoamine-oxidase-inhibitors-maois-for-depression/">monoamine oxidase inhibitors</a> <a href="https://www.health.qld.gov.au/__data/assets/pdf_file/0020/145802/oncol_maoi.pdf">only interact with</a> some types of boutique and artisan beers, beers with visible sediment, Belgian, Korean, European and African beers, and home-made beers and wine.</p>
<p>These types of alcohol contain high levels of tyramine, a naturally occurring substance usually broken down by your body that doesn’t ordinarily cause any harm. </p>
<p>However, monoamine oxidase inhibitors prevent your body from breaking down tyramine. This increases levels in your body and can cause your blood pressure to rise to dangerous levels. </p>
<p><strong>4. Medicines + alcohol = effects even after you stop drinking</strong></p>
<p>Other medicines interact because they affect the way your body breaks down alcohol. </p>
<p>If you drink alcohol while using such medicines you may you feel nauseous, vomit, become flushed in the face and neck, feel breathless or dizzy, your heart may beat faster than usual, or your blood pressure may drop. </p>
<p>This can occur even after you stop treatment, then drink alcohol. For example, if you are taking metronidazole you should avoid alcohol both while using the medicine and for at least 24 hours after you stop taking it. </p>
<p>An example of where alcohol changes the amount of the medicine or related substances in the body is acitretin. This medication is used to treat skin conditions such as severe psoriasis and to prevent skin cancer in people who have had an organ transplant.</p>
<p>When you take acitretin, it changes into another substance – <a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2017-CMI-02034-1&d=20221221172310101">etretinate</a> – before it is removed from your body. Alcohol increases the amount of etretinate in your body. </p>
<p>This is especially important as etretinate can cause birth defects. To prevent this, if you are a woman of child-bearing age you should avoid alcohol while using the medicine and for two months after you stop taking it.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-we-dont-know-what-causes-most-birth-defects-78592">Why we don't know what causes most birth defects</a>
</strong>
</em>
</p>
<hr>
<h2>Myths about alcohol and medicines</h2>
<p><strong>Alcohol and birth control</strong></p>
<p>One of the most common myths about medicines and alcohol is that you can’t drink while using <a href="https://youly.com.au/blog/sexual-reproductive-health/does-alcohol-make-the-pill-less-effective/">the contraceptive pill</a>.</p>
<p>It is generally safe to use alcohol with the pill as it <a href="https://www.healthline.com/health/womens-health/birth-control-and-alcohol#:%7E:text=There's%20a%20bit%20of%20good,a%20less%20effective%20birth%20control.">doesn’t directly affect</a> how well birth control works. </p>
<p>But the pill is most effective when taken at the same time each day. If you’re drinking heavily, you’re more likely to forget to do this the next day. </p>
<p>Alcohol can also make some people nauseous and vomit. If you vomit within three hours of taking the pill, it will not work. This increases your risk of pregnancy. </p>
<p>Contraceptive pills can also affect your response to alcohol as the hormones they contain can change the way your body <a href="https://americanaddictioncenters.org/alcoholism-treatment/birth-control">removes alcohol</a>. This means you can get drunk faster, and stay drunk for longer, than you normally would.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman holding pack of contraceptive pills" src="https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=268&fit=crop&dpr=1 600w, https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=268&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=268&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=336&fit=crop&dpr=1 754w, https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=336&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/502282/original/file-20221221-16-n1zjeb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=336&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Yes you can drink while on the pill. But if you vomit within a few hours of taking it, the pill won’t work.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-hands-opening-birth-control-pills-2139091435">Shutterstock</a></span>
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</figure>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/always-forgetting-to-take-your-medicines-here-are-4-things-that-could-help-193717">Always forgetting to take your medicines? Here are 4 things that could help</a>
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</em>
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<p><strong>Alcohol and antibiotics</strong></p>
<p>Then there’s the myth about not mixing alcohol with any <a href="https://theconversation.com/mondays-medical-myth-you-cant-mix-antibiotics-with-alcohol-4407">antibiotics</a>. This only applies to <a href="https://www.healthdirect.gov.au/medicines/medicinal-product/aht,21161/metronidazole">metronidazole</a> and <a href="https://www.healthdirect.gov.au/medicines/brand/amt,1011571000168100/linezolid-apo">linezolid</a>. </p>
<p>Otherwise, it is generally safe to use alcohol with antibiotics, as alcohol does not affect how well they work.</p>
<p>But if you can, it is best to avoid alcohol while taking antibiotics. Antibiotics and alcohol have similar side effects, such as an upset stomach, dizziness and drowsiness. Using the two together means you are more likely to have these side effects. Alcohol can also reduce your energy and increase how long it takes for you to recover.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/mondays-medical-myth-you-cant-mix-antibiotics-with-alcohol-4407">Monday's medical myth: you can't mix antibiotics with alcohol</a>
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</em>
</p>
<hr>
<h2>Where can I go for advice?</h2>
<p>If you plan on drinking alcohol these holidays and are concerned about any interaction with your medicines, don’t just stop taking your medicines.</p>
<p>Your pharmacist can advise you on whether it is safe for you to drink based on the medicines you are taking, and if not, provide advice on alternatives.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dont-let-your-pet-accidentally-get-drunk-this-silly-season-sorry-tiddles-87671">Don't let your pet accidentally get drunk this silly season (sorry Tiddles)</a>
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</em>
</p>
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<img src="https://counter.theconversation.com/content/196646/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Associate Professor Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is a Fellow of the Royal Australian Chemical Institute, a member of the Australasian Pharmaceutical Science Association, and a member of the Australian Institute of Company Directors. Nial is the chief scientific officer of Vairea Skincare LLC and a Standards Australia panel member for sunscreen agents.</span></em></p><p class="fine-print"><em><span>Jessica Pace does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Drinking alcohol with some medicine means they may not work so well. With others, you risk a life-threatening overdose.Nial Wheate, Associate Professor of the Sydney Pharmacy School, University of SydneyJessica Pace, Associate Lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1885602022-08-17T19:25:57Z2022-08-17T19:25:57ZWhy letting Medicare negotiate drug prices won’t be the game-changer for health care Democrats hope it will be<figure><img src="https://images.theconversation.com/files/479678/original/file-20220817-12095-ynmg73.jpg?ixlib=rb-1.1.0&rect=26%2C164%2C4362%2C3347&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Drug prices have been soaring in recent years. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/prescription-royalty-free-image/155597284?adppopup=true">stevecoleimages/E+ via Getty Inages</a></span></figcaption></figure><p>Democrats hope their new <a href="https://www.nytimes.com/2022/08/16/business/biden-climate-tax-inflation-reduction.html">health care, tax and climate law</a> begins to rein in soaring prescription drug prices. </p>
<p>One of its most touted provisions allows <a href="https://www.medicare.gov/">Medicare</a>, America’s health insurance program for seniors, to negotiate some prescription drug prices for the first time, with some calling it “<a href="https://www.cbsnews.com/news/inflation-reduction-act-lower-drug-costs-medicare-seniors-cbs-news-explain/">game-changing</a>” and a <a href="https://www.biopharmadive.com/news/senate-passage-of-drug-pricing-bill-brings-major-defeat-closer-for-pharma-i/629096/">significant victory over the pharmaceutical industry</a>. Drug manufacturers had stubbornly opposed any governmental regulation of drug prices <a href="https://doi.org/10.1111%2Fj.0887-378X.2004.00311.x">for decades</a> and are <a href="https://news.bloomberglaw.com/health-law-and-business/big-pharma-likely-to-aim-legal-firepower-at-drug-price-measures">likely to challenge the measure in court</a>.</p>
<p>As a <a href="https://public-health.tamu.edu/directory/haeder.html">scholar</a> who has <a href="https://scholar.google.com/citations?user=QY68LSIAAAAJ&hl=en">published extensively on the politics of health policy</a>, I’m skeptical that giving Medicare the ability to negotiate prices on a handful of drugs will be as transformative as the law’s backers hope. While a good step, it is unlikely to make a significant difference in how much seniors pay overall for medicine.</p>
<p>Fortunately, there are several other provisions in the law that will do much more to meaningfully help seniors struggling with the high cost of prescription drugs. </p>
<h2>Why US drug prices are so high</h2>
<p>Pharmaceutical innovation over the past few decades <a href="https://theconversation.com/how-much-for-an-amputation-or-checkup-it-takes-a-complex-formula-and-a-committee-of-doctors-to-set-the-price-for-every-possible-health-care-procedure-182109">has been tremendous</a>. The <a href="https://doi.org/10.1038/d41586-020-03626-1">quick response</a> to the COVID-19 pandemic in terms of vaccine development and treatments perfectly exemplifies the incredible benefits that drug developers have brought to the world. </p>
<p>Yet these developments have come at a high price, particularly in the United States, where each person spends more than <a href="https://www.healthsystemtracker.org/chart-collection/how-do-prescription-drug-costs-in-the-united-states-compare-to-other-countries/">US$1,100 a year</a> on drugs – up from $831 in 2013. Indeed, Americans are paying substantially more than residents of <a href="https://www.healthsystemtracker.org/chart-collection/how-do-prescription-drug-costs-in-the-united-states-compare-to-other-countries/">similar countries like Germany, the U.K. and Australia</a> – who pay $825, $285 and $434 per person each year, respectively. </p>
<p>People who need specific high-priced drugs are even more adversely affected. </p>
<p>Dulera, an asthma drug, costs <a href="https://waysandmeans.house.gov/sites/democrats.waysandmeans.house.gov/files/documents/U.S.%20vs.%20International%20Prescription%20Drug%20Prices_0.pdf">50 times more in the U.S.</a> than the international average. Januvia, for diabetes, and Combigan, a glaucoma drug, cost about <a href="https://waysandmeans.house.gov/sites/democrats.waysandmeans.house.gov/files/documents/U.S.%20vs.%20International%20Prescription%20Drug%20Prices_0.pdf">10 times more</a>. Americans shell out, on average, <a href="https://www.rand.org/pubs/research_reports/RRA788-1.html">$98.70 for a vial of insulin</a>, compared with the $6.94 Australians pay. </p>
<p>These costs impose a <a href="https://www.commonwealthfund.org/publications/journal-article/2018/nov/whats-driving-prescription-drug-prices-us">big burden on Americans</a> – <a href="https://www.commonwealthfund.org/publications/journal-article/2018/nov/whats-driving-prescription-drug-prices-us">1 in 5 of whom</a> skip medications because of the cost. Seniors are <a href="https://www.kff.org/health-costs/poll-finding/kff-health-tracking-poll-february-2019-prescription-drugs/">particularly affected</a> by these problems.</p>
<p>The reasons for high prices are varied, including the <a href="https://theconversation.com/us-health-care-system-a-patchwork-that-no-one-likes-85252">overall complexity of the U.S. health care system</a> and the <a href="https://www.kff.org/other/report/follow-the-pill-understanding-the-u-s/">lack of transparency in the drug supply chain</a>. But as I noted in a 2019 <a href="https://theconversation.com/why-the-us-has-higher-drug-prices-than-other-countries-111256">article in The Conversation</a>, the biggest reason Americans pay so much more than people do elsewhere is simple: Pharmaceutical companies face no limits setting prices. </p>
<h2>Changing the game – a little</h2>
<p>The new law, known as the <a href="https://www.congress.gov/bill/117th-congress/house-bill/5376">Inflation Reduction Act</a> and signed into law on Aug. 16, 2022, seeks to change that. </p>
<p>The main mechanism to do it is by allowing Medicare to negotiate prices for some of the most expensive drugs. The act gives Medicare the ability to negotiate with drugmakers for 10 drugs starting in 2026 and 20 by 2029. </p>
<p>The law specifies that the medications Medicare is supposed to select must <a href="https://www.congress.gov/bill/117th-congress/house-bill/5376">account for most of its spending on drugs</a> and be name brands with no generic equivalents. Research has found that a relatively small number of drugs <a href="https://www.kff.org/medicare/issue-brief/relatively-few-drugs-account-for-a-large-share-of-medicare-prescription-drug-spending/?">are responsible for most spending</a>.</p>
<p>Importantly, pharmaceutical companies may face civil penalties and additional taxes on drug sales if they do not comply with the requirements to establish a “maximum fair price” as laid out in the law. </p>
<p>The provision is expected to <a href="https://www.cbo.gov/system/files/2022-07/senSubtitle1_Finance.pdf">save the U.S. government about $102 billion</a> by 2031 by allowing it to pay less on prescription drugs for Americans on Medicare – currently <a href="https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Medicare%22,%22sort%22:%22desc%22%7D">63 million people</a>. The annual savings amount to about 5% of what <a href="https://www.kff.org/medicare/issue-brief/relatively-few-drugs-account-for-a-large-share-of-medicare-prescription-drug-spending/">Medicare currently spends on drugs</a>. </p>
<p>There’s also a separate provision that requires pharmaceutical companies, under certain conditions, to provide Medicare with rebates if drug prices outpace inflation. That measure takes effect this year and is expected to <a href="https://www.cbo.gov/system/files/2022-07/senSubtitle1_Finance.pdf">yield $71 billion in savings</a> over a decade.</p>
<p>While the government savings are meaningful, I believe seniors themselves are likely to see only a minor drop in costs as a result of this provision, mainly through <a href="https://www.kff.org/medicare/issue-brief/how-would-drug-price-negotiation-affect-medicare-part-d-premiums/">slightly reduced premiums</a> and lower out-of-pocket costs. </p>
<figure class="align-center ">
<img alt="A Black female pharmacist shows Black senior woman some prescription meds." src="https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478839/original/file-20220811-8881-5qqn2f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Measures in the law Biden just signed should lower prices for many seniors.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-pharmacist-helping-a-senior-lady-choose-the-royalty-free-image/1352510394?adppopup=true">Marko Geber/DigitalVision via Getty Images</a></span>
</figcaption>
</figure>
<h2>Where the real savings are</h2>
<p>The provisions that will make a much bigger difference for seniors lie elsewhere. </p>
<p>Importantly, the new law limits seniors’ out-of-pocket expenses for prescription drugs to no more than $2,000 annually. Previously, there were <a href="https://www.healthline.com/health/medicare/medicare-out-of-pocket-maximum#medicare-out-of-pocket-costs">some restrictions but no limit</a>. This will directly help <a href="https://www.kff.org/wp-content/uploads/2022/08/Inflation-Reduction-Act-Web-Event-Slides.pdf">1.4 million seniors</a> who exceeded the $2,000 threshold in 2020. </p>
<p>The law also limits how fast premiums for Medicare Part D, which provides premium-based prescription drug insurance, can rise over the next few years and implements a number of other adjustments. </p>
<p>It also extends the Medicare Part D low-income subsidy to <a href="https://www.kff.org/wp-content/uploads/2022/08/Inflation-Reduction-Act-Web-Event-Slides.pdf">400,000 seniors</a> who previously earned too much to qualify. This program helps people pay for premiums, deductible and copays and has been valued at <a href="https://www.ssa.gov/benefits/medicare/prescriptionhelp.html">$5,100 a year</a>. </p>
<p>The legislation also limits the cost of insulin to no more than $35 per month for Medicare recipients only. This amounts to more than <a href="https://www.kff.org/medicare/issue-brief/insulin-out-of-pocket-costs-in-medicare-part-d/">$1 billion in annual savings for seniors</a>. Almost <a href="https://diabetes.org/about-us/statistics/about-diabetes">16 million American seniors have diabetes</a> and are likely to need insulin at some point in their lives.</p>
<p>Lastly, it also eliminates out-of-pocket costs for seniors for vaccines – a move that would have saved money for <a href="https://www.kff.org/wp-content/uploads/2022/08/Inflation-Reduction-Act-Web-Event-Slides.pdf">4.1 million people in 2020</a>. </p>
<h2>Broader impact</h2>
<p>There are real benefits in the bill President Biden signed into law. The government will save by negotiating prices. Seniors will save through the insulin cap and other provisions. </p>
<p>But I don’t believe Medicare’s ability to negotiate prices will be a <a href="https://www.cbsnews.com/news/inflation-reduction-act-drug-costs-medicare-seniors-cbs-news-explains/">game-changing reform</a>. </p>
<p>Besides affecting prices paid by only a slice of Americans, we do not know how aggressively the federal government will seek savings. This particularly applies to any future administration headed up by a Republican president. </p>
<p>The pharmaceutical industry may still manage to limit the impact of price negotiations, since it will be four years before the changes take effect. The industry has a history of <a href="https://www.amazon.com/American-Sickness-Healthcare-Became-Business/dp/1594206759">skillfully exploiting loopholes</a> and a <a href="https://theconversation.com/prescription-drug-costs-would-have-been-a-major-campaign-issue-so-what-will-happen-now-that-coronavirus-is-center-stage-132493">vast lobbying apparatus</a> to put into that effort. </p>
<p>As for Americans who aren’t covered under Medicare, drug prices <a href="https://rollcall.com/2022/08/10/senates-medicare-drug-pricing-may-ripple-into-private-market">may actually go up</a>. That’s because, if pharmaceutical companies do end up reducing drug prices for seniors, they may shift those costs to everyone else to make up for those lost profits.</p><img src="https://counter.theconversation.com/content/188560/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A new law will let Medicare bargain for the first time. But a health policy scholar explains why it’s unlikely to make much of a difference in how much seniors – or anyone else – pays for their meds.Simon F. Haeder, Associate Professor of Public Health, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1884122022-08-16T14:41:17Z2022-08-16T14:41:17ZThe key to treating TB may be in a common carbohydrate. What we know so far<figure><img src="https://images.theconversation.com/files/479161/original/file-20220815-25-i854zg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">New remedies are needed as rates of multi-drug resistant TB rise.</span> <span class="attribution"><span class="source">Jarun Ontakrai/Shutterstock</span></span></figcaption></figure><p><a href="https://link.springer.com/article/10.1007/s00289-021-03860-1">Curdlan</a> is a popular carbohydrate in the food industry. Its name is derived from the word “curdle”, and as it suggests, it’s widely used as a thickener and stabiliser in everything from sausages to milk substitutes.</p>
<p>More recently, it has caught the eye of the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8273257/">pharmaceutical industry</a>. That’s because curdlan, itself produced by bacteria, is able to trigger an antibacterial response in a range of environments and organisms. Among other uses, researchers are <a href="https://link.springer.com/article/10.1186/s13048-020-00626-7">looking at curdlan</a> as a possible treatment for cancers and <a href="https://www.sciencedirect.com/science/article/pii/S0144861714003828?casa_token=5A9L_uGxF5oAAAAA:56_9Q91nCk3cSJdLaXa0eZPp4iDXAs5b8XUUNQuwfhPdSl5Jg9w2wfxyjejHNCm7V8N5sH4iDrY">other diseases</a>.</p>
<p>One of those diseases is tuberculosis (TB), the infection responsible for <a href="https://www.frontiersin.org/articles/10.3389/fmicb.2017.02284/full">killing more people</a> than any other infectious disease in human history. <a href="https://www.nicd.ac.za/wp-content/uploads/2021/02/TB-Prevalence-survey-report_A4_SA_TPS-Short_Feb-2021.pdf">South Africa</a> has one of the world’s highest TB burdens – along with 29 other countries including India and China. These countries contribute 86% of the globe’s <a href="https://www.who.int/news-room/fact-sheets/detail/tuberculosis#:%7E:text=In%202020%2C%20the%2030%20high,Nigeria%2C%20Bangladesh%20and%20South%20Africa.">10 million annual TB cases</a>. South Africa’s combined burden of TB, TB/HIV and multi-drug resistant TB (MDR-TB), driven by socioeconomic factors and its high HIV <a href="https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&entity_type=%22country%22&lan=%22EN%22&iso2=%22ZA%22">numbers</a>, is especially worrying.</p>
<p>Existing remedies made up of cocktails of antibiotics are not effective against MDR-TB. This has sparked interest in finding alternative treatments. It’s why our research group at the School of Pharmacy at the University of the Western Cape, and others, are beginning to test the efficacy of curdlan as a potential drug candidate. </p>
<p>In a <a href="https://pubmed.ncbi.nlm.nih.gov/34534573/">recent paper</a>, for instance, we show very promising results for the potential treatment of TB using curdlan-based nanoparticles.</p>
<h2>How TB infects</h2>
<p>Our work centres on developing host-directed therapies using curdlan. Such treatments essentially let the human <a href="https://www.frontiersin.org/articles/10.3389/fmicb.2017.02284/full">immune system</a> do the heavy lifting. This is done by activating its natural antibacterial mechanisms while controlling the inflammation that results from such activation. Inflammation is a signal that the immune system is working. But if inflammation is out of control it can cause major damage to human tissue, as seen in severe <a href="https://www.frontiersin.org/articles/10.3389/fimmu.2020.01446/full#:%7E:text=Accumulating%20evidence%20suggests%20that%20some,%2C%20TNF%2D%CE%B1%2C%20and%20VEGF">COVID-19 infections</a>.</p>
<p>Research has already shown that host-directed therapies hold <a href="https://www.frontiersin.org/articles/10.3389/fcimb.2020.618414/full">immense potential</a> for the <a href="https://link.springer.com/article/10.1007/s11095-018-2528-9">treatment of TB</a>.</p>
<p>To understand how these therapies work, it’s important to understand how TB infection unfolds in the human body.</p>
<p>Primary TB infection occurs when a person inhales aerosol droplets, released by contagious individuals, that contain <em>Mycobacterium tuberculosis</em> (<em>M.tb</em>). This is the bacterium that causes TB. Once inhaled, <em>M.tb</em> quickly makes its way to the lung’s alveolar space, made up of tiny air sacs that sit at the end of the bronchioles, which are the air passages inside the lungs.</p>
<p>Here it is absorbed by what’s known as alveolar macrophages, the lung cells that are usually the first line of defence against pollutants and pathogenic organisms. Typically these macrophages would trigger an immune response in the body. But <em>M.tb</em> has evolved so cannily that it eludes or switches off this immune-triggering response in the macrophages. These alveolar macrophages become its infection headquarters; the bacterium remains concealed within these cells.</p>
<p>For any treatment to be successful, it has to navigate a <a href="https://www.frontiersin.org/articles/10.3389/fcimb.2020.618414/full">host of obstacles</a> to reach <em>M.tb</em>. It must make its way through complex lung lesions, then penetrate the cell membrane of macrophages and other host cells, and finally be taken up by the <em>M.tb</em> sitting within these cells.</p>
<p>That’s where nanoparticles enter the picture.</p>
<h2>Tiny ‘snipers’</h2>
<p>Nanoparticles are extremely small. They range from between one to 100 nanometres; for some perspective, there are a million nanometres in a single millimetre. In theory, and as is being shown in <a href="https://iopscience.iop.org/article/10.1088/1361-6528/ac7885/meta?casa_token=FjKJlNwJcFYAAAAA:CzLeHNZ_j9uFpGYgd9UnvJr-RBFnO8NoKhxymb8JcyrujuK0bISE6sP6vEIeYC8NvPcPJkLuIMA">laboratories</a> and existing treatments for other conditions like <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2720743/">cancer</a>, nanotherapies allow drugs to target pathogens with sniper-like accuracy. They also have the potential to tackle patient non-compliance that can lead to drug resistant TB.</p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4449995/">reasons</a> for non-compliance are varied and complex, but the duration of the therapy itself is a factor. Existing treatments require that, depending on the severity and progress of the disease, patients take many drugs over as many as six months. The <a href="https://www.who.int/news-room/fact-sheets/detail/tuberculosis">course of treatment</a> for MDR-TB lasts up to 24 months. </p>
<p>This high pill load, together with sometimes toxic side effects, has been shown to overwhelm patients. Many do not return to clinics and hospitals for check-ups, especially when they feel better after a few weeks. Some stop taking their medication. This could be behind the rise of drug resistant strains. Such non-compliance is also believed to be the cause of South Africa’s comparatively <a href="https://www.copenhagenconsensus.com/publication/south-africa-perspective-tuberculosis#:%7E:text=TB%20is%20South%20Africa's%20leading,to%20bring%20it%20under%20control.">high TB mortality</a>.</p>
<p>Traditional drugs are taken orally or intravenously. They travel throughout the body via the blood circulatory system. Many drug molecules do not reach their targets, staying in the body where they cause several negative side effects. That’s where nanoparticle-based treatments have the <a href="https://www.tandfonline.com/doi/abs/10.1517/17425247.2014.846905">upper hand</a>: they are extremely targeted and their release into the system is very controlled. Smaller doses are required and there is less dispersion around the body, meaning fewer side effects.</p>
<h2>Promising findings</h2>
<p>All these factors suggest that nanoparticle-based treatments may be the right approach to take against TB. And two interesting findings from our study bolster the case.</p>
<p>One, we observed the production of what’s known as pro-inflammation cytokines, a signalling molecule that triggers an antibacterial effect in immune cells. This meant that the nanoparticles were doing what they were meant to do.</p>
<p>Secondly, we found that the <em>M.tb</em> bacteria in the immune cells were considerably reduced over a 72-hour period. </p>
<p>These results suggest that curdlan nanotherapeutics are an avenue worth exploring in treating TB. There is much more work to be done, but it’s an important step towards tackling TB – in South Africa and everywhere else.</p><img src="https://counter.theconversation.com/content/188412/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Admire Dube receives funding from the Fogarty International Center of the National Institutes of Health (K43TW010371) and the National Institute of Allergy and Infectious Diseases (5R01AI152109). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.</span></em></p>As antibiotics lose their power to treat some forms of TB, interest in the antibacterial powers of curdlan is rising.Admire Dube, Associate Professor, Pharmaceutical Sciences, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1785032022-05-24T12:28:00Z2022-05-24T12:28:00ZScientists at Work: How pharmacists and community health workers build trust with Cambodian genocide survivors<figure><img src="https://images.theconversation.com/files/463796/original/file-20220517-13-z54dgh.jpeg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C766&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Community health workers assist patients as they gather their medications and supplements to discuss them during remote visits with pharmacists.</span> <span class="attribution"><span class="source">Photo courtesy of Khmer Health Associates</span></span></figcaption></figure><p>Wartime trauma paired with starting over in a new country make getting health care particularly challenging for immigrant refugees. Talking to a doctor or getting prescriptions filled in an unfamiliar language is hard enough. But for refugees, the physical and psychological scars of escaping war or genocide can complicate their health needs and getting them met.</p>
<p><a href="https://pharmacy.uconn.edu/person/christina-polomoff/">I am a clinical pharmacist</a> trained in improving medication safety and effectiveness in the outpatient setting. Starting in 2019, I was with a team of pharmacists serving Cambodian American patients in Connecticut and Rhode Island. I spent 15 months there studying the role of pharmacists and <a href="https://www.nhlbi.nih.gov/health/educational/healthdisp/role-of-community-health-workers.htm">community health workers</a> in helping disadvantaged immigrants get medications they need and learn to <a href="https://doi.org/10.1016/j.japh.2021.10.031">take them consistently and safely</a>. </p>
<p>Many of them had fled the <a href="http://doi.org/10.1001/jama.1993.03510050047025">Khmer Rouge</a>, a brutal political party and military force operating under the regime of <a href="https://www.history.com/topics/cold-war/pol-pot">Pol Pot</a> in 1970s Cambodia. They had witnessed executions, survived starvation or suffered <a href="http://cambodialpj.org/article/justice-and-starvation-in-cambodia-the-khmer-rouge-famine/">famine-related diseases</a>. </p>
<p>As pharmacists, we learned that the best way to care for these patients was by listening to and learning from the community members they trusted. It’s a lesson for health care providers that could prove useful as the U.S. <a href="https://www.uscis.gov/humanitarian/refugees-and-asylum/refugees">welcomes new refugees</a> from countries like Afghanistan, Sudan, Myanmar and Ukraine. </p>
<h2>Unsafe medicine</h2>
<p>As a traumatized population, Cambodian refugees might be wary of strangers. They may avoid anyone thought to be a government or other official. Consequently, they often rely on their own beliefs and assumptions, even about health. </p>
<p>Our research team learned that some Cambodians expect to receive medications for every illness. It reassures these genocide survivors that something is being done about whatever’s wrong.</p>
<p>If a doctor doesn’t give them a prescription, they might seek out one who will prescribe medicine. Still, they may take the medicine for only as long as they’re feeling sick. If side effects occur, they may decide the dose is too large and reduce how much they take. And medications are often shared among friends and family. </p>
<p>Limited English proficiency can keep immigrants from seeking medical care. When they do, language barriers make it difficult for health care providers to understand a patient’s symptoms and to prescribe the right medication, especially since interpreters are not always available. So, in immigrant communities, translating often falls to family members, sometimes children.</p>
<p>The presence of family members, especially children, can influence what patients and pharmacists say, particularly with sensitive subjects like mental illness or reproductive health. And translating in a medical setting can be a tremendous burden on children. During our research, we learned about a 7-year-old daughter who had been the one to translate her mother’s cancer diagnosis. </p>
<h2>Established relationships</h2>
<p>Locally based community health workers have been addressing these problems. With language interpretation skills and health information, they help residents in their own communities manage their mental and physical health.</p>
<p>Our research team of four pharmacists worked with five community health workers from <a href="https://khmerhealthadvocates.org/">Khmer Health Advocates</a>, a West Hartford, Connecticut-based organization for Cambodian American survivors of the Khmer Rouge genocide and their families. After four decades in the area, Khmer Health Advocates knew its community best. That’s why we followed the organization’s lead as it directed recruitment for our study.</p>
<p>The health workers introduced us and our research project at churches, temples and events like the Cambodian New Year celebration. They also went to health clinics Cambodians use and put up fliers at Cambodian businesses. </p>
<p>The health workers also reached out to residents individually, connecting with people on a personal level. As genocide survivors themselves with training in trauma-informed care, they met patients in safe, familiar locations like their homes. They ate together and discussed not just the study, but familiar concerns like the financial hardship of restarting life in a new country and having to accept low-paying service jobs. In all, the community health workers helped recruit 63 patients to work with the pharmacists.</p>
<figure class="align-center ">
<img alt="A man and two women sit at a table where health information, checklists and other papers are spread out." src="https://images.theconversation.com/files/462313/original/file-20220510-545-834gu.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462313/original/file-20220510-545-834gu.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=448&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462313/original/file-20220510-545-834gu.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=448&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462313/original/file-20220510-545-834gu.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=448&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462313/original/file-20220510-545-834gu.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=563&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462313/original/file-20220510-545-834gu.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=563&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462313/original/file-20220510-545-834gu.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=563&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">With training in trauma-informed care, the community health workers work directly with residents to help them improve their mental and physical health.</span>
<span class="attribution"><span class="source">Photo courtesy of Khmer Health Associates</span></span>
</figcaption>
</figure>
<h2>Cross-cultural problem solving</h2>
<p>The health workers schooled us in Cambodian culture, which greatly values showing respect. The “sampeah” greeting, for example, consists of palms pressed together in a praying gesture while bowing the head. The higher the hands and lower the bow, the greater the degree of respect being shown.</p>
<p>We also learned idioms to help us understand the patients’ descriptions of their symptoms. For example, “spuck” is what they call neuropathy or nerve damage. It’s a common symptom among those who <a href="https://doi.org/10.1177%2F1536504220920197">endured beatings</a> during the conflict. Another phrase is “kdov kbal,” meaning “hot head,” to describe a feeling of heat in the brain interfering with thinking. And “phleu” refers to losing the train of thought, like with cognitive impairment.</p>
<p>Community health workers also helped the patients trust us pharmacists to help them manage their medications.</p>
<p>When it was time to meet with pharmacists, the health workers had already interviewed the patients to document the medications, herbal products, traditional Khmer medicines and dietary supplements they were taking. The patient would gather them all in preparation to talk with the pharmacist as the health worker sat with them.</p>
<p>When I met with patients over video from my office, the health worker held each medication to the camera. Then I talked with the patient about doses, side effects and any questions they had. I explained ways to take medicine to avoid side effects, and I noted possible drug interactions for my recommendations to their doctors. Through all of this, the health worker translated from English to Cambodian, from medical jargon to culturally appropriate terminology and back again.</p>
<p>We helped the 63 patients resolve <a href="https://doi.org/10.1016/j.japh.2021.10.031">more than 80%</a> of their medication-related issues, a good resolution rate for any community, English speaking or not. Patients also got better at remembering to take medications, taking the correct doses and in taking them more consistently. Our study found that community health workers and pharmacists working together were crucial to these patients getting better at managing their medicines. </p>
<p>I saw up close how a cross-cultural team can effectively resolve medication-related problems in an immigrant community. With war and genocidal conflicts driving international migration, this model is applicable now when the health of the most vulnerable is increasingly at risk.</p><img src="https://counter.theconversation.com/content/178503/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The funding for this work was supported by the National Institutes of Health and National Institute of Diabetes and Digestive and Kidney Diseases (Grant DK103663).</span></em></p>Studying medication use in a traumatized population of immigrants required pharmacists to listen to and learn from trusted community health workers.Christina Polomoff, Assistant Clinical Professor of Pharmacy Practice, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1796072022-04-05T12:29:10Z2022-04-05T12:29:10ZHow the ‘test to treat’ initiative aims to get ahead of the next wave of COVID-19<figure><img src="https://images.theconversation.com/files/455661/original/file-20220331-20-adg2b6.jpg?ixlib=rb-1.1.0&rect=87%2C58%2C6403%2C4252&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pharmacies could play an increasingly important role in testing and treatment of COVID-19.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/help-from-a-pharmacist-a-female-pharmacist-with-royalty-free-image/1318290439?adppopup=true">dusanpetkovic/iStock via Getty Images Plus</a></span></figcaption></figure><p><em>Going into the third year of the pandemic, public health experts are developing strategies to work within communities to have a more nimble and rapid response to COVID-19 infection rates.</em> </p>
<p><em>C. Michael White, a professor of pharmacy practice, and Adrian V. Hernandez, a clinical epidemiologist, both from the University of Connecticut, explain how the Biden administration’s new “test to treat” initiative will make use of pharmacies in this effort. The strategy is to quickly identify those who are positive for COVID-19 and to provide oral antiviral treatments in the early days of illness when it is deemed necessary – all through the easy access of a local pharmacy. And they discuss how the strategy falls short of addressing the needs of underserved communities.</em></p>
<h2>1. What is the premise behind the initiative?</h2>
<p>In his March 2022 State of the Union address, President Joe Biden introduced the “<a href="https://www.hhs.gov/about/news/2022/03/08/fact-sheet-biden-administration-launches-nationwide-test-treat-initiative-ensuring-rapid-on-spot-access-lifesaving-covid-treatments.html#">test to treat” initiative</a>, a program designed to help reduce barriers to getting COVID-19 treatments in the early stages of illness. The goal is for people to be able to walk into a pharmacy with a health clinic staffed by nurse practitioners, physician assistants or physicians and to be tested for COVID-19 free of charge; if a person tests positive and treatment is deemed appropriate, oral antiviral therapy can be prescribed on the spot at no cost. </p>
<p>The premise is that the sooner people are tested, the sooner they can self-isolate to limit the spread of the disease while simultaneously receiving <a href="https://theconversation.com/could-oral-antiviral-pills-be-a-game-changer-for-covid-19-an-infectious-disease-physician-explains-why-these-options-are-badly-needed-169919">oral antiviral medications</a> to help prevent hospitalization and death from COVID-19.</p>
<h2>2. How might this initiative help curb the next wave of COVID-19?</h2>
<p>As of March 31, 2022, more than <a href="https://www.worldometers.info/coronavirus/country/us/">1 million</a> out of <a href="https://www.census.gov/popclock/">332.6 million people</a> or 3 in 1,000 people living in the U.S., have died from COVID-19. In contrast, <a href="https://www.worldometers.info/coronavirus/country/south-korea/">16,230 people</a> out of <a href="https://www.census.gov/popclock/world/ks">51.8 million</a> or 3 in 10,000 South Koreans have died from COVID-19.</p>
<p>Some countries, such as <a href="https://www.healthaffairs.org/do/10.1377/forefront.20210521.255232/full/">South Korea</a> and New Zealand, invested heavily in COVID-19 testing and <a href="https://ourworldindata.org/coronavirus-testing">contact tracing</a> early in the pandemic so those at higher risk of infection could be tested immediately and isolated early. And they implemented contract tracing – the process of identifying friends, family and co-workers who may have come into contact with the infected person – early on to help slow the spread of infection. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/455844/original/file-20220401-27-3ko9r7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A medical worker takes samples from a man during COVID-19 testing at a makeshift clinic." src="https://images.theconversation.com/files/455844/original/file-20220401-27-3ko9r7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/455844/original/file-20220401-27-3ko9r7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/455844/original/file-20220401-27-3ko9r7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/455844/original/file-20220401-27-3ko9r7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/455844/original/file-20220401-27-3ko9r7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/455844/original/file-20220401-27-3ko9r7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/455844/original/file-20220401-27-3ko9r7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Early on in the COVID-19 pandemic, South Korea implemented strategies to quickly test for COVID-19, isolate those who tested positive and trace people who may have come into contact with the infected person.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/APTOPIXVirusOutbreakSouthKorea/c572e19e09624d6cbefd71d4bc51c7a0/photo?Query=south%20korea%20covid&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=3879&currentItemNo=12">AP Photo/Ahn Young-joon</a></span>
</figcaption>
</figure>
<p>Another advantage of early COVID-19 testing is that infected people can be treated much sooner. A new meta-analysis of oral antiviral therapies found that such treatments reduced the <a href="https://dx.doi.org/10.1080%2F07853890.2022.2034936">risk of hospitalization and death from COVID-19 by nearly 67%</a>. </p>
<p><a href="https://www.ama-assn.org/delivering-care/public-health/what-doctors-wish-patients-knew-about-covid-19-oral-antivirals#">Starting therapy early</a> is key. Early studies with the injectable antiviral remdesivir found that people <a href="https://doi.org/10.1371/journal.pone.0258643">did not benefit</a> from the treatment at later stages of illness. Clinical trials for the newest oral antiviral therapies against SARS-CoV-2, the virus that causes COVID-19, required that patients be treated within <a href="https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-first-oral-antiviral-treatment-covid-19">five days of the beginning of their symptoms</a>. So combining early testing with immediate access to free oral antiviral therapy could make a huge difference, especially for those with limited access to traditional health care services. </p>
<p>A more rigorous and proactive testing program in the U.S. could especially benefit underserved communities with limited health care access. For instance, in the first half of the pandemic, a study found that for every 10,000 people who tested positive for COVID-19, more than <a href="https://doi.org/10.1001/jama.2020.26443">30 Hispanic patients and nearly 25 Black patients were hospitalized</a>, compared with only 16 Asian patients and seven white patients. </p>
<h2>3. What are the limitations of the initiative?</h2>
<p>Only about 2,800 of the <a href="https://doi.org/10.1371/journal.pone.0183172">approximately 50,000 retail pharmacies</a> in the U.S. <a href="https://www.rand.org/pubs/research_briefs/RB9491-2.html">have health clinics</a> staffed by nurse practitioners, physician assistants or physicians, and about a third of them are located in California, Florida, Illinois, Minnesota and Texas. And <a href="https://www.rand.org/pubs/research_briefs/RB9491-2.html">only 12.5%</a> of these retail clinics are located in medically underserved areas. </p>
<p>This leaves much of the country, and especially populations who suffer disproportionately from health disparities, left out of the “test to treat” initiative. But <a href="http://rximpact.nacds.org/pdfs/nacds-fact-sheet.pdf">95% of Americans</a> live within 5 miles (8 kilometers) of one of more than 41,000 community pharmacies. If those settings were part of the initiative, access and impact would be much more widespread and equitable. The pharmacy is often the sole health care setting that can alleviate the problem of <a href="https://assets.ctfassets.net/4f3rgqwzdznj/1XSl43l40KXMQiJUtl0iIq/ad0070ad4534f9b5776bc2c41091c321/GoodRx_Healthcare_Deserts_White_Paper.pdf">health care deserts</a> – areas that <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2015.1612">lack sufficient access</a> to medical offices in inner-city and rural communities.</p>
<p>At the height of the omicron surge, between <a href="https://www.worldometers.info/coronavirus/country/us/">890,000 and 904,000 people</a> in the U.S. were diagnosed with COVID-19 daily. <a href="https://www.ama-assn.org/practice-management/physician-health/omicron-pushed-doctors-brink-3-keys-get-them-back">Physicians’ offices</a> and <a href="https://www.npr.org/sections/health-shots/2022/01/13/1072902744/ers-are-overwhelmed-as-omicron-continues-to-flood-them-with-patients">emergency departments</a> were highly stressed. So adding only 2,800 retail health clinics – which are also dealing with heavy demands outside of COVID-19 – to rapidly test and disseminate oral antiviral drugs across the nation is unlikely to make a major dent in handling a COVID-19 surge. And there would be virtually no impact on COVID-19 outcomes in underserved communities, which would continue to have limited access.</p>
<h2>4. Could pharmacists play a bigger role in the initiative?</h2>
<p><a href="https://doi.org/10.1177/10600280211036160">Our research</a> shows <a href="https://doi.org/10.1177/1060028013511786">great variations</a> in how pharmacists are allowed to practice in the U.S. In hospitals across the country as well as federal health clinics run by the <a href="https://jcpp.net/wp-content/uploads/2015/09/Improving-Patient-and-Health-System-Outcomes-through-Advanced-Pharmacy-Practice.pdf">Department of Veterans Affairs, Indian Health Service and Department of Defense</a>, pharmacists are fully integrated health professionals who can order lab tests and interpret their results, order or alter drug therapy and actively monitor a patient’s drug response. </p>
<p>The data supporting the positive impact that <a href="https://doi.org/10.1177%2F1060028013511786">pharmacist-provided services</a> have on <a href="https://doi.org/10.1177%2F10600280211036160">patient health</a> is <a href="http://docplayer.net/395611-Improving-patient-and-health-system-outcomes-through-advanced-pharmacy-practice.html">undeniable</a>. For example, <a href="https://doi.org/10.1177%2F0897190020926841">pharmacist-run hypertension</a> and <a href="https://doi.org/10.2147/PPA.S180256">diabetes</a> clinics help patients achieve their blood pressure and blood sugar goals better than the standard treatment provided in physicians’ offices.</p>
<p>But pharmacists are not currently recognized as <a href="https://www.medicare.gov/coverage/doctor-other-health-care-provider-services">Medicare Part B providers</a> – health professionals allowed to bill Medicaid for clinical services. So pharmacists are limited in their ability to provide clinical services in the community.</p>
<h2>5. What can be done to address access issues?</h2>
<p>To broaden access, the Department of Health and Human Services authorized pharmacists to provide COVID-19 vaccines in community pharmacies or long-term care facilities in <a href="https://www.hhs.gov/sites/default/files/licensed-pharmacists-and-pharmacy-interns-regarding-covid-19-vaccines-immunity.pdf">September 2020</a>. Since that time, pharmacists from more than 41,000 pharmacies have administered <a href="https://www.cdc.gov/vaccines/covid-19/retail-pharmacy-program/index.html">233.4 million vaccine doses</a> as of early April 2022. This includes <a href="https://www.cdc.gov/mmwr/volumes/71/wr/mm7110a4.htm?s_cid=mm7110a4_w#">46% of all COVID-19 vaccinations</a> in children ages 5-11.</p>
<p>A similar authorization could be granted to allow <a href="https://www.ashp.org/news/2022/03/07/ashp-applauds-administrations-focus-on-covid-test-to-treat-opioid-treatment-in-state-of-the-union?loginreturnUrl=SSOCheckOnly#">pharmacists to provide oral antiviral drugs</a> to patients with positive COVID-19 tests who meet the criteria. </p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-likethis">Sign up for The Conversation’s daily newsletter</a>.]</p>
<p>Alternatively, a bill that has been proposed with bipartisan support in the <a href="https://www.pharmacist.com/Advocacy/Issues/Provider-Status/Equitable-Community-Access-to-Pharmacist-Services-Act-ECAPS">House of Representatives</a> aims to ensure that all communities have access to testing and drug treatment by a pharmacist.</p>
<p>However, the <a href="https://www.ama-assn.org/press-center/press-releases/ama-statement-administration-s-test-treat-covid-19-plan">American Medical Association</a> has taken a stand against “test to treat” in pharmacies, whether or not they have a health clinic with nurse practitioners and physician assistants in them. The organization states that the large number of drug interactions with these antivirals, the complexities of COVID-19 disease and the lack of full access to patients’ medical records suggests that patients testing positive for COVID-19 should solely contact their physician to discuss treatment options. </p>
<p>But this position does not take into consideration the <a href="https://doi.org/10.1177%2F10600280211036160">medical conditions pharmacists</a> already <a href="https://doi.org/10.1002/jac5.1051">successfully manage</a>, such as <a href="https://doi.org/10.1016/j.cardfail.2019.07.455">heart failure</a> and <a href="https://doi.org/10.18433/J3SQ0B">blood clotting</a>. And it does not address how to care for the <a href="https://creakyjoints.org/doctor-patient/americans-with-primary-care-doctor-declining/#">25% of patients</a> – largely in underserved communities – who do not have a primary care physician or access to a health clinic within a pharmacy.</p><img src="https://counter.theconversation.com/content/179607/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Earlier detection and treatment of COVID-19 by health care providers in pharmacies could help prevent surges in infection rates and severe illness.C. Michael White, Professor of Pharmacy Practice, University of ConnecticutAdrian V. Hernandez, Associate Professor of Comparative Effectiveness and Outcomes Research, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1651592021-09-21T12:35:12Z2021-09-21T12:35:12ZYou may soon be able to buy hearing aids over the counter at your local pharmacy<figure><img src="https://images.theconversation.com/files/420553/original/file-20210910-18-8slkhp.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The FDA Reauthorization Act of 2017 designated a new class of OTC hearing aids.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/hand-holding-hearing-aid-royalty-free-image/1271529622">Johner Images/Getty Images</a></span></figcaption></figure><p>Over-the-counter hearing aids may soon be <a href="https://www.nbcnews.com/health/health-news/cheaper-otc-devices-fill-void-left-fda-delay-hearing-aids-n1277294">hitting the shelves of community pharmacies nationwide</a>.</p>
<p>We are a <a href="https://scholar.google.com/citations?user=9Np7_DYAAAAJ&hl=en">pharmacist</a> and <a href="https://scholar.google.com/citations?user=c5UzXW0AAAAJ&hl=en">audiologist</a> who study the potential ways OTC hearing aids could be distributed and managed. In a market dominated by <a href="http://concentrationcrisis.openmarketsinstitute.org/industry/hearing-aid-manufacturing/">only a handful of manufacturers</a>, hearing aids that are available without a prescription will be more accessible to the estimated <a href="https://www.nidcd.nih.gov/health/statistics/quick-statistics-hearing">28.8 million U.S. adults</a> who could benefit from their use.</p>
<h2>A new class of hearing aids</h2>
<p>A <a href="https://www.nidcd.nih.gov/health/hearing-aids">hearing aid</a> is a device worn around the ear that makes desired sounds more audible for people with hearing loss. Hearing aid devices include a microphone, amplifier and a miniature loudspeaker to make sounds louder. Traditionally, these devices have been accessible only from licensed hearing aid dispensers or audiologists. </p>
<p>In 2017, the <a href="https://www.congress.gov/115/plaws/publ52/PLAW-115publ52.pdf">FDA Reauthorization Act</a> designated a new class of hearing aids that will be available over the counter to increase the accessibility and the affordability of hearing aids for U.S. adults. These hearing aids will be able to be purchased <a href="https://www.fda.gov/medical-devices/hearing-aids/how-get-hearing-aids">without a medical evaluation by a physician or a fitting by an audiologist</a>. However, OTC hearing aids are intended only for adults who believe they have mild to moderate hearing loss.</p>
<p>Implementation of these regulations is a year overdue, largely because of the COVID-19 pandemic. In July 2021, President Joe Biden <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2021/07/09/fact-sheet-executive-order-on-promoting-competition-in-the-american-economy/">directed the U.S. Department of Health and Human Services</a> to issue proposed rules within 120 days for how OTC hearing aids can be marketed and sold.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/420555/original/file-20210910-26-18azifn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Older adult wearing hearing aid." src="https://images.theconversation.com/files/420555/original/file-20210910-26-18azifn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420555/original/file-20210910-26-18azifn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420555/original/file-20210910-26-18azifn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420555/original/file-20210910-26-18azifn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420555/original/file-20210910-26-18azifn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420555/original/file-20210910-26-18azifn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420555/original/file-20210910-26-18azifn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Audiologist practices are often located in urban centers that tend to have a smaller population of older adults.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/ear-machine-royalty-free-image/88200782">cornaile photography/Moment via Getty Images</a></span>
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<p>How community pharmacies will sell these new devices is still unknown, but the law will undoubtedly increase public access to hearing aids. For one, pharmacies are more accessible to Americans than audiology practices. Audiologists <a href="https://doi.org/10.1016/j.socscimed.2019.01.015">tend to be located</a> in metropolitan areas with higher incomes, younger populations and greater insurance coverage, with a smaller proportion of people who need hearing aids most – namely, older adults. In contrast, <a href="https://www.nacds.org/news/nacds-issues-new-covid-19-report-on-reopening-america/">90% of Americans</a> live within 5 miles of one of the <a href="https://doi.org/10.1371/journal.pone.0183172">more than 60,000 community pharmacies nationwide</a>.</p>
<p>This will also get hearing aids into patients’ ears more quickly. It typically takes an average of <a href="https://www.hearingreview.com/uncategorized/marketrak-10-hearing-aids-in-an-era-of-disruption-and-dtc-otc-devices-2">four to five years</a> after individuals recognize their hearing loss before they see a health care provider, and sometimes an additional six years to obtain a hearing aid device. With this <a href="https://www.congress.gov/115/plaws/publ52/PLAW-115publ52.pdf">new law</a>, people will be able to purchase OTC hearing aids as soon as they become aware of their hearing difficulties.</p>
<p>OTC hearing aids will offer a do-it-yourself approach to addressing hearing loss. For example, a smartphone app may be used to guide users on how to <a href="https://dx.doi.org/10.1177%2F2331216518768958">self-measure and self-adjust</a> the hearing aid to best fit their ear. <a href="http://hearing.wustl.edu/Hearing-Aids/Hearing-Aid-Fittings">Traditional hearing aids</a> require a professionally administered hearing test and technical features that may allow more customized fine-tuning.</p>
<h2>Increased access at lower costs</h2>
<p>Only <a href="https://www.hearingreview.com/uncategorized/marketrak-10-hearing-aids-in-an-era-of-disruption-and-dtc-otc-devices-2">3.7% of people</a> reporting hearing difficulty own hearing aids. In addition to increasing accessibility, the 2017 federal law also intends to make hearing aids more affordable.</p>
<p>Traditional hearing aids cost an average <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2021/07/09/fact-sheet-executive-order-on-promoting-competition-in-the-american-economy/">more than $5,000 per pair</a>, while OTC hearing aids will likely be <a href="https://www.nbcnews.com/health/health-news/cheaper-otc-devices-fill-void-left-fda-delay-hearing-aids-n1277294">less than $1,000</a>. The charges and services associated with hearing aids, including the fitting process, which takes an <a href="https://www.hearingreview.com/practice-building/practice-management/marketrak-viii-the-impact-of-the-hearing-healthcare-professional-on-hearing-aid-user-success">average of 2.5 audiology visits</a>, are <a href="https://obamawhitehouse.archives.gov/sites/default/files/microsites/ostp/PCAST/pcast_hearing_tech_letterreport_final.pdf">not typically covered</a> by Medicare, Medicaid or private insurers. At prices similar to <a href="https://www.irs.gov/businesses/small-businesses-self-employed/local-standards-transportation">monthly car loan payments</a>, hearing health care services are often exclusive to people who have the means to pay high out-of-pocket expenses.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/420552/original/file-20210910-19-l2hsoo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Health provider using otoscope to examine a patient's ear." src="https://images.theconversation.com/files/420552/original/file-20210910-19-l2hsoo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420552/original/file-20210910-19-l2hsoo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420552/original/file-20210910-19-l2hsoo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420552/original/file-20210910-19-l2hsoo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420552/original/file-20210910-19-l2hsoo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420552/original/file-20210910-19-l2hsoo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420552/original/file-20210910-19-l2hsoo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Prohibitive costs and appointment hurdles can discourage patients from obtaining hearing aids.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/close-up-of-a-doctor-checking-the-ear-of-his-male-royalty-free-image/1310935018">Vladimir Vladimirov/E+ via Getty Images</a></span>
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<p>There are also <a href="https://doi.org/10.1177%2F0898264315585505">racial disparities in hearing aid use</a>. Although Black Americans are more likely to have had a recent hearing test, they are less likely to regularly use hearing aids than white older adults. Such disparities can have potential negative consequences for health and quality of life, including a higher risk of <a href="https://doi.org/10.1159/000485178">cognitive impairment, dementia</a> and <a href="https://doi.org/10.1002/lary.25927">falling</a>, as well as <a href="https://doi.org/10.1177%2F0194599820910377">social isolation, loneliness</a> and <a href="https://doi.org/10.1093/geront/gnz009">depression</a>.</p>
<h2>The pharmacist’s role in OTC hearing aid adoption</h2>
<p>While OTC hearing aids won’t require consultation with a medical professional, pharmacists are expected to play an important role in ensuring their safe and effective use.</p>
<p>As <a href="https://doi.org/10.1001/jamanetworkopen.2020.9132">among the most accessible types of health care providers</a>, community pharmacists are trained to identify, prevent and resolve medication problems. Pharmacists additionally have long helped patients purchase <a href="https://www.amcp.org/policy-advocacy/policy-advocacy-focus-areas/where-we-stand-position-statements/patient-care-services-provided-pharmacist">medical devices and equipment</a> like <a href="https://doi.org/10.1016/j.ptdy.2020.04.014">glucometers for diabetes testing</a> and <a href="https://doi.org/10.1038/s41371-020-0331-7">blood pressure monitors</a> for hypertension at their local pharmacy. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/420556/original/file-20210910-14-ocsq81.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Adult and young child talking to pharmacist at the counter." src="https://images.theconversation.com/files/420556/original/file-20210910-14-ocsq81.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420556/original/file-20210910-14-ocsq81.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420556/original/file-20210910-14-ocsq81.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420556/original/file-20210910-14-ocsq81.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420556/original/file-20210910-14-ocsq81.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420556/original/file-20210910-14-ocsq81.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420556/original/file-20210910-14-ocsq81.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Community pharmacists may soon be able to help patients pick out a hearing aid at their local pharmacy.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/small-family-being-served-by-chemist-at-local-royalty-free-image/1290302520">Tom Werner/DigitalVision via Getty Images</a></span>
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</figure>
<p>It is likely that community pharmacists will soon help patients select and purchase OTC hearing aids, and refer them to audiologists and physicians for additional screening, treatment and care when appropriate. They may also follow up with patients to ensure that the device works as expected. To prepare pharmacists for this new role, the University of Pittsburgh has developed the <a href="https://pittprofessional.catalog.instructure.com/courses/champ">first online program</a> to teach pharmacists and pharmacy technicians how to help patients safely choose OTC hearing aids.</p>
<p>By providing a lower-cost and more readily available option, OTC hearing aids have the potential to address significant barriers to hearing aid adoption and use.</p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>.]</p>
<p><em>An updated version of this article was published on Aug. 23, 2022. <a href="https://theconversation.com/over-the-counter-hearing-aids-have-been-greenlighted-by-the-fda-your-local-pharmacist-will-soon-be-able-to-sell-you-the-device-you-need-184890?notice=Article+has+been+updated.">Read it here</a>.</em></p><img src="https://counter.theconversation.com/content/165159/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lucas Berenbrok is an Associate Professor at the University of Pittsburgh and receives funding from the NSF I-Corps.</span></em></p><p class="fine-print"><em><span>Elaine Mormer is an employee at the University of Pittsburgh and has received funding from the NSF I-Corps.</span></em></p>Only 3.7% of people in the U.S. with hearing difficulty own hearing aids. Thanks to a federal law in progress of being implemented, OTC hearing aids may help bridge the gap.Lucas A. Berenbrok, Associate Professor of Pharmacy and Therapeutics, University of PittsburghElaine Mormer, Professor of Audiology, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1671782021-09-02T05:27:41Z2021-09-02T05:27:41ZThinking of trying ivermectin for COVID? Here’s what can happen with this controversial drug<figure><img src="https://images.theconversation.com/files/419019/original/file-20210902-18-njx5bl.jpg?ixlib=rb-1.1.0&rect=1%2C1%2C997%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/clamart-france-august-22-2021-box-2028959327">Shutterstock</a></span></figcaption></figure><p>Westmead Hospital in Sydney’s west says it has treated a patient <a href="https://www.news.com.au/lifestyle/health/health-problems/westmead-hospital-patient-overdoses-on-online-cure-for-covid19/news-story/d5cc0998a98791af3b43bcaef42578b9">who overdosed</a> after taking the drug ivermectin, an unproven and potentially dangerous treatment for COVID-19.</p>
<p>The person went to hospital seeking treatment for diarrhoea and vomiting side-effects, after taking the drug, which is usually used to treat parasites. The person had ordered this and other unproven COVID “cures” online.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1433020559349084160"}"></div></p>
<p>While the patient did not die, <a href="https://www.tga.gov.au/covid-19-treatments-information-consumers-and-health-professionals">health authorities are concerned</a> at the number of people taking ivermectin, and warn against it for anyone else who may have COVID symptoms or has been diagnosed with the virus.</p>
<p>Other known ivermectin side-effects range from mild to the life-threatening, including seizures and coma.</p>
<h2>Why are people taking it?</h2>
<p>Ever since researchers showed ivermectin could kill SARS-CoV-2 (the virus that causes COVID-19) in the laboratory, there has been interest in whether the drug would also work to kill the virus <a href="https://theconversation.com/head-lice-drug-ivermectin-is-being-tested-as-a-possible-coronavirus-treatment-but-thats-no-reason-to-buy-it-135683">in the human body</a>.</p>
<p>So far, there is <a href="https://theconversation.com/a-major-ivermectin-study-has-been-withdrawn-so-what-now-for-the-controversial-drug-164627">no clinical evidence</a> it works to treat or prevent COVID-19. And there is widespread consensus people should not take ivermectin at home for COVID-19. </p>
<p>Organisations that recommend against it include: the <a href="https://www.who.int/news-room/feature-stories/detail/who-advises-that-ivermectin-only-be-used-to-treat-covid-19-within-clinical-trials">World Health Organization</a>, Australia’s <a href="https://covid19evidence.net.au/faqs/#Ivermectin">National COVID-19 Clinical Evidence Taskforce</a> and <a href="https://www.nps.org.au/ivermectin-and-covid-19">NPS Medicinewise</a>, the United State’s <a href="https://www.fda.gov/animal-veterinary/animal-health-safety-and-coronavirus-disease-2019-covid-19/cvm-letter-veterinarians-and-retailers-help-stop-misuse-animal-ivermectin-prevent-or-treat-covid-19">Food and Drug Administration</a>, and the <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD015017.pub2/full">Cochrane Library</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-major-ivermectin-study-has-been-withdrawn-so-what-now-for-the-controversial-drug-164627">A major ivermectin study has been withdrawn, so what now for the controversial drug?</a>
</strong>
</em>
</p>
<hr>
<h2>How are people getting hold of it?</h2>
<p>Despite this, <a href="https://www.theguardian.com/australia-news/2021/sep/01/australian-pharmacists-report-rise-in-customers-refusing-to-say-what-ivermectin-prescription-is-for">community pharmacists</a> have reported increased demand for ivermectin, with people seeking the drug as a possible COVID treatment.</p>
<p>In Australia, ivermectin is <a href="https://www.tga.gov.au/covid-19-treatments-information-consumers-and-health-professionals">approved to treat parasite infections in humans</a>. It’s also widely used in veterinary medicine to treat and prevent parasite infections.</p>
<p>However, as a prescription-only human medicine (known as <a href="https://www.healthdirect.gov.au/medicines/brand/amt,3069011000036101/stromectol">schedule 4</a>), you can only access ivermectin legally in Australia after approval from a doctor.</p>
<p>This is because, like all medicines, ivermectin is not 100% safe. It does have possible harmful side-effects and a doctor’s judgement is necessary to decide if ivermectin is safe and appropriate for each patient.</p>
<p>So ivermectin is currently only recommended to treat and prevent COVID-19 when used <a href="https://covid19evidence.net.au/faqs/#Ivermectin">as part of a clinical trial</a>, where patients can be more safely selected and carefully monitored.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1432747015507779586"}"></div></p>
<p>As well as more patients presenting to pharmacies with scripts, the Therapeutic Goods Administration <a href="https://www.tga.gov.au/media-release/risks-importing-ivermectin-treatment-covid-19">warns</a> about the danger of importing ivermectin products of unknown quality, bought over the internet.</p>
<p>This is risky because products may not contain the stated drug, may contain dangerous contaminants or much more of the drug than thought, which may result in an overdose.</p>
<p>Of most concern are reports from <a href="https://www.abc.net.au/radio/programs/worldtoday/warnings-against-ivermectin/13524184">Australia</a> and <a href="https://www.theguardian.com/commentisfree/2021/aug/31/a-human-is-not-a-horse-so-why-is-a-livestock-drug-sweeping-america-covid-ivermectin">overseas</a> of people buying and taking ivermectin products intended for animal use. People may be resorting to these types of products where they have been unable to access a script for human formulations of ivermectin.</p>
<h2>What does it do to your body?</h2>
<p>We know very little about what the drug does to humans, and the little we do know mostly comes from <a href="https://pubmed.ncbi.nlm.nih.gov/34149064/">its use in animals</a>.</p>
<p>When taken at the recommended dose, the drug is generally well tolerated. But ivermectin is known to cause mild side-effects such as diarrhoea, nausea, dizziness and sleepiness. Less common, but serious, side-effects include severe skin rashes and effects on the nervous system (causing tremor, confusion and drowsiness). </p>
<p>In higher doses, and overdose cases, these side-effects can be <a href="https://www.fda.gov/consumers/consumer-updates/why-you-should-not-use-ivermectin-treat-or-prevent-covid-19">more severe</a>. These include low blood pressure, problems with balance, seizures, liver injury, and it can even <a href="https://www.nejm.org/doi/full/10.1056/NEJMc1917344">induce comas</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-misinformation-is-a-global-issue-but-which-myth-you-fall-for-likely-depends-on-where-you-live-143352">Coronavirus misinformation is a global issue, but which myth you fall for likely depends on where you live</a>
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<h2>The take-home message</h2>
<p>The public is understandably interested in medicines to treat and prevent COVID-19. However, <a href="https://theconversation.com/au/topics/covid-misinformation-103292">misinformation about ivermectin and others continues to circulate</a>. </p>
<p><a href="https://theconversation.com/how-well-do-covid-vaccines-work-in-the-real-world-162926">COVID-19 vaccination</a> remains the best way to reduce the risk of serious illness and death from COVID-19. Australia’s <a href="https://covid19evidence.net.au/">National COVID-19 Clinical Evidence Taskforce</a> provides the most up-to-date information about COVID-19 treatments and is a reliable source of information as new knowledge emerges.</p>
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<p><em>If you or a family member take ivermectin and have strong side-effects you should seek medical advice. Call the <a href="https://www.health.gov.au/contacts/poisons-information-centre">Poisons Information Centre</a> on 131 126. For life-threatening symptoms, call 000 for an ambulance.</em></p><img src="https://counter.theconversation.com/content/167178/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Associate Professor Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is Fellow of the Royal Australian Chemical Institute and a member of the Australasian Pharmaceutical Science Association. Nial is science director of the medicinal cannabis company Canngea Pty Ltd, a board member of the Australian Medicinal Cannabis Association, and a Standards Australia committee member for sunscreen agents.</span></em></p><p class="fine-print"><em><span>Andrew McLachlan receives research funding from the NHMRC and the Sydney Pharmacy School receives research scholarship funding from GSK for a PhD student under his supervision. Andrew has served as a paid consultant on Australian government committees related to medicines regulation. Andrew does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article.</span></em></p><p class="fine-print"><em><span>Slade Matthews has served the Australian Therapeutic Goods Administration as an external evaluator for the Therapeutic Goods Evaluation Panel. He also serves on the NSW Poisons Advisory Committee as the pharmacologist member. Slade does not work for, consult or own shares in or receive funding from any company of organisation that would benefit from this article.</span></em></p>Side-effects for this unproven and potentially dangerous treatment range from vomiting and diarrhoea to seizures and a coma.Nial Wheate, Associate Professor of the Sydney Pharmacy School, University of SydneyAndrew McLachlan, Head of School and Dean of Pharmacy, University of SydneySlade Matthews, Senior Lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1604542021-05-19T19:56:15Z2021-05-19T19:56:15ZFrom faith leaders to office workers: 5 ways we can all be COVID vaccine champions<figure><img src="https://images.theconversation.com/files/401464/original/file-20210519-3808-tzoar.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C997%2C633&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>Yesterday, we heard from <a href="https://www.theguardian.com/australia-news/2021/may/19/nurse-administers-one-covid-vaccine-in-eight-hours-at-victorian-hub-as-nsw-ramps-up-rollout">a nurse</a> at one of Victoria’s mass vaccination clinics who said she’d administered just one vaccine in an eight-hour shift. She said vaccine hesitancy was a factor in people not turning up to be vaccinated.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1394710882425389057"}"></div></p>
<p>So how do we handle people’s questions or concerns about the COVID-19 vaccines, to address vaccine hesitancy? How do we do this and boost the vaccine rollout, beyond the almost <a href="https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines/getting-vaccinated-for-covid-19#australias-vaccine-rollout">3.2 million doses</a> delivered in Australia to date?</p>
<p>GPs and practice nurses are ideally placed to answer specific questions about people’s personal health and vaccine eligibility. However, not everyone has a regular GP or <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1753-6405.13094">wants to get vaccinated at a GP clinic</a>. GPs are also being swamped with questions to address in limited time.</p>
<p>That’s why it’s essential to encourage other people in the community to be vaccine advocates.</p>
<h2>Why is this a good idea?</h2>
<p>People’s willingness to have a vaccine is influenced by <a href="https://journals.sagepub.com/doi/full/10.1177/1529100618760521">social norms</a> — what they think others are doing, and what they think trusted or influential people want them to do. </p>
<p>We have been regularly delivering vaccine communication training seminars, based on <a href="https://www.mja.com.au/journal/2021/communicating-patients-and-public-about-covid-19-vaccine-safety-recommendations">communication</a> and behavioural science, to people in all kinds of roles. These include cultural, faith and First Nations community leaders; health-care support staff, such as medical receptionists; and office and industrial workers. </p>
<p>These people don’t need all the answers. But if they have a role where people know and trust them, and might come to them with vaccine-related questions, these people can provide reputable information to increase vaccine acceptance or even help people book in to get the vaccine.</p>
<p>Here are a few strategies for these vaccine champions to help build vaccine confidence in their organisations or communities.</p>
<h2>1. Share your story</h2>
<p>When everyone knows a few people who have been vaccinated, vaccination starts to become the norm. Countries that had high hesitancy at the start of the COVID-19 vaccine rollout have generally seen <a href="https://yougov.co.uk/topics/health/articles-reports/2021/03/25/global-more-people-are-willing-take-covid-19-vacci">hesitancy go down</a> as vaccination rates go up. </p>
<p>If you’ve decided to get vaccinated, or if you’ve already received your vaccine, talk about your experience. Share your reasons for deciding to get vaccinated. For instance, what are the good things you think will come with vaccination? Post photos on social media (<a href="https://theconversation.com/pictures-of-covid-injections-can-scare-the-pants-off-people-with-needle-phobias-use-these-instead-157963">but avoid scary needles</a>) to normalise the experience.</p>
<p>We know from our <a href="https://www.mja.com.au/journal/2021/communicating-patients-and-public-about-covid-19-vaccine-safety-recommendations">current research</a> many people are concerned about side-effects. Talk about how you manage side-effects, if you get them, or if you needed some time off work to give people a sense of what to expect. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-telling-stories-could-be-a-more-powerful-way-of-convincing-some-people-to-take-a-covid-vaccine-than-just-the-facts-155050">Why telling stories could be a more powerful way of convincing some people to take a COVID vaccine than just the facts</a>
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</em>
</p>
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<h2>2. Work together with other vaccine advocates</h2>
<p>Find other people in your organisation who are willing to share their vaccination stories and work with them to brainstorm vaccine promotion strategies. For example, you can discuss what’s worked to promote flu vaccines in the past. </p>
<p>If you work in an office, make sure there are vaccine champions representing all levels of your organisation, not just managers. If you’re working in a diverse community, try to find and highlight vaccine champions of different genders, disability status and cultural background. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-elvis-to-dolly-celebrity-endorsements-might-be-the-key-to-countering-vaccine-hesitancy-152893">From Elvis to Dolly, celebrity endorsements might be the key to countering vaccine hesitancy</a>
</strong>
</em>
</p>
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<h2>3. Help people find answers</h2>
<p>It can be difficult for people to find answers to their questions about the vaccines and the vaccine rollout process. </p>
<p>We know people with lower levels of health literacy often have poorer health and <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30559-4/fulltext">say they are less likely</a> to get vaccinated. </p>
<p>Amid the whirlwind of information the pandemic has unleashed, people with lower levels of education and those who speak languages other than English are often left behind. These groups are also <a href="https://csrm.cass.anu.edu.au/research/publications/vaccine-willingness-and-concerns-australia-august-2020-april-2021-1">less likely to plan to get vaccinated</a>. </p>
<p>So if you feel confident finding reliable information, you can offer to help other people <a href="https://mvec.mcri.edu.au/references/covid-19-vaccines-frequently-asked-questions/">find</a> <a href="https://www.ncirs.org.au/covid-19/covid-19-vaccines-frequently-asked-questions">answers</a>. Understanding risk is hard; visual elements, such as pictograms, may help. Another option is to organise to bring in an expert to your work or place of worship for a live question and answer session. </p>
<p>You can also help people understand where to go to find out if they’re <a href="https://covid-vaccine.healthdirect.gov.au/eligibility">eligible for the vaccine</a>, or how to book an appointment.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-can-governments-communicate-with-multicultural-australians-about-covid-vaccines-its-not-as-simple-as-having-a-poster-in-their-language-156097">How can governments communicate with multicultural Australians about COVID vaccines? It's not as simple as having a poster in their language</a>
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<h2>4. Address vaccine misinformation</h2>
<p>Misinformation and conspiracy theories flourish in times of <a href="https://www.cambridge.org/core/journals/canadian-journal-of-political-science-revue-canadienne-de-science-politique/article/do-covid19-conspiracy-theory-beliefs-form-a-monological-belief-system/C9730961E7C7C37AA5E204A3EDD84965">uncertainty</a>, like the pandemic. </p>
<p>But before you jump in to correct every myth you hear someone share, it’s a good idea to consider if this myth is being shared widely, or if it is affecting behaviour. If it is, there are <a href="https://vaccinemisinformation.guide/">some strategies</a> you can use to <a href="https://hackmd.io/@scibehC19vax/home">address misinformation</a> without getting into a debate. </p>
<p>First, try and talk privately. Ask questions and acknowledge the emotions driving a person’s belief in misinformation. Offer to look for the truth together. And before you share information yourself, make sure it’s reliable: “<a href="https://www.unicef.org/ghana/stories/addressing-misinformation-and-rumours-about-vaccines-your-community">verify before you amplify</a>”. </p>
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Read more:
<a href="https://theconversation.com/religious-concerns-over-vaccine-production-methods-neednt-be-an-obstacle-to-immunisation-145046">Religious concerns over vaccine production methods needn't be an obstacle to immunisation</a>
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<h2>5. Encourage vaccination</h2>
<p>Not everyone will be comfortable or able to take a leadership role in building vaccine confidence. But even <a href="https://www.abc.net.au/news/health/2021-03-29/coronavirus-vaccines-concernes-conversation-guide/100018588">everyday conversations with friends and family</a> can have an impact. So can recommending vaccination. </p>
<p>A recommendation to vaccinate from a health-care professional is particularly <a href="https://onlinelibrary.wiley.com/doi/full/10.5694/mja12.11849">powerful</a>. Encouraging people in your network to vaccinate is also likely to have an influence. But this needs to be handled with respect and not done in a coercive or domineering way. </p>
<p>A simple phrase like “I hope you will get vaccinated” can make a big difference.</p><img src="https://counter.theconversation.com/content/160454/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jessica Kaufman receives funding from the Victorian Department of Health (C9824) and the National Health and Medical Research Foundation (Vaccine Barriers Assessment Tool, GNT1164200). She is a member of the Collaboration on Social Science and Immunisation (COSSI) network.</span></em></p><p class="fine-print"><em><span>Holly Seale is an investigator on a study funded by NHMRC and has previously received funding for investigator driven research from NSW Ministry of Health, as well as from Sanofi Pasteur and Seqirus. She is the Deputy Chair of the Collaboration on Social Science and Immunisation.</span></em></p><p class="fine-print"><em><span>Julie Leask receives funding from the World Health Organization.</span></em></p><p class="fine-print"><em><span>Margie Danchin receives funding from the NHMRC, WHO, Victorian and Commonwealth Departments of Health and holds a an MCRI clinician scientist fellowship. She is Chair, Collaboration on Social Science and Immunisation (COSSI). </span></em></p>Community leaders or trusted work colleagues can be COVID vaccine advocates and help boost vaccination rates. Here are some simple steps they can take.Jessica Kaufman, Research Fellow, Vaccine Uptake Group, Murdoch Children's Research InstituteHolly Seale, Associate professor, UNSW SydneyJulie Leask, Professor, University of SydneyMargie Danchin, Paediatrician at the Royal Childrens Hospital and Associate Professor and Clinician Scientist, University of Melbourne and MCRI, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1537962021-01-31T18:55:13Z2021-01-31T18:55:13ZDoctors must now prescribe drugs using their chemical name, not brand names. That’s good news for patients<figure><img src="https://images.theconversation.com/files/381267/original/file-20210129-21-1wumjzy.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6006%2C4007&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shuterstock</span></span></figcaption></figure><p>From today (February 1), when you receive a prescription in Australia, it will list the name of the medication’s <a href="https://www.pbs.gov.au/info/general/active-ingredient-prescribing">active ingredient</a> rather than the brand name. So, for example, instead of receiving a prescription for Ventolin, your script will say “salbutamol”. </p>
<p>This national legislation change, called <a href="https://www.safetyandquality.gov.au/sites/default/files/2020-12/fact_sheet_-_active_ingredient_prescribing_-_guidance_for_australian_prescribers_0.pdf">active ingredient prescribing</a>, is long overdue for Australian health care. </p>
<p>Using the name of the drug — instead of the brand name, of which there are often many — will simplify how we talk about and use medications. </p>
<p>This could have a range of benefits, including fewer <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/imj.12805">medication errors</a> by both doctors and patients.</p>
<h2>What is an active ingredient?</h2>
<p>The <a href="https://www.tga.gov.au/book/prominence-active-ingredients-medicine-labels">active ingredient</a> describes the main chemical compound in the medicine that affects your body. It’s the ingredient that helps control your asthma or headache, for example. </p>
<p>Drugs are tested to ensure they contain exactly <a href="https://www.tga.gov.au/publication/australian-regulatory-guidelines-prescription-medicines-argpm">the same active ingredients</a> regardless of which brand you buy.</p>
<p>There’s only one active ingredient name for each type of medical compound, although they may come in different strengths. Some types of medications may contain multiple active ingredients, such as Panadeine Forte, which contains both paracetamol and codeine.</p>
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<strong>
Read more:
<a href="https://theconversation.com/prescribing-generic-drugs-will-reduce-patient-confusion-and-medication-errors-77093">Prescribing generic drugs will reduce patient confusion and medication errors</a>
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<h2>There can be several brand names</h2>
<p>Until now, doctors and other prescribers have used a mixture of brand and active ingredient names when prescribing medicines. An Australian study found doctors used brand names for <a href="https://www.publish.csiro.au/AH/AH12009">80.5% of prescriptions</a>. </p>
<p>Different brands are available for most medications — <a href="https://www.mja.com.au/journal/2011/195/11/whats-name-brand-name-confusion-and-generic-medicines">up to 12</a> for some. Combined with active ingredient names, this equates to thousands of different names — too many for any patient, doctor, nurse or pharmacist to remember. </p>
<figure class="align-center ">
<img alt="A senior man taking a tablet. There are a variety of medications on the table." src="https://images.theconversation.com/files/381268/original/file-20210129-23-15x62ie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/381268/original/file-20210129-23-15x62ie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/381268/original/file-20210129-23-15x62ie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/381268/original/file-20210129-23-15x62ie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/381268/original/file-20210129-23-15x62ie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/381268/original/file-20210129-23-15x62ie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/381268/original/file-20210129-23-15x62ie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Older people are at higher risk of making medication errors, as they tend to take more medications.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Here’s an example of the problem.</p>
<p>I ask John, a patient whom I’ve just met, whether he takes cholesterol medications, commonly called statins. The active ingredient names for this group of medications all end in “statin” (for example, pravastatin, simvastatin).</p>
<p>“Ummm, I’m not sure, is it a blue pill?” John asks.</p>
<p>“It could come in many colours. It might be called atorvastatin, or Lipitor,” I reply. “Perhaps rosuvastatin, or Crestor, or Zocor?”</p>
<p>“Ah yes, Crestor, I am taking that,” John exclaims, after deliberating for some time.</p>
<p>This is a common and important conversation, but could be simpler for both of us if John was familiar with the active ingredient name.</p>
<p>And while we did eventually come to the answer, this medication could have easily been overlooked, by both John and myself. This may have significant implications and interact with other medicines I might prescribe.</p>
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Read more:
<a href="https://theconversation.com/ive-heard-covid-is-leading-to-medicine-shortages-what-can-i-do-if-my-medicine-is-out-of-stock-153628">I've heard COVID is leading to medicine shortages. What can I do if my medicine is out of stock?</a>
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<h2>Cause for confusion</h2>
<p>The main problem with using brand names for medications is the potential for confusion, as we see with John.</p>
<p>A prescription written using a brand name doesn’t mean you can’t buy other brands. And your pharmacist may offer to substitute the brand specified for an equivalent generic drug. So, people often leave the pharmacy with a medication name or package that bears no resemblance to the prescription.</p>
<p>When the terms we use to describe medicines in conversation, on prescriptions and what’s written on the medication packet can all be different, patients might not understand which medications they’re taking, or why. </p>
<p>This often leads to doubling up (taking two brands of the same medication), or forgetting to take a certain medication because the name on the package doesn’t match what’s written on your medication list or prescription.</p>
<p>Confusion resulting from using brand names has been associated with serious medication errors, including <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/211398?casa_token=hA41G4MI1ZQAAAAA:JJTT5NB6FOTsn-ZluZclU9Xxx942FN1mcbjcJ-zJlhJ6SNJc8GoIL0eyE1fdb55JV1s1gzu9aNg">overdoses</a>. Elderly people are the most susceptible, as they’re most likely to take multiple medications.</p>
<p>Even when the confusion doesn’t cause harm, it can be problematic in other ways. If patients don’t understand their medicines, they may be less likely to be proactive in making decisions with their doctor or pharmacist about their health care.</p>
<p>Health professionals can also get confused, potentially leading to <a href="https://www.ismp.org/resources/progress-preventing-name-confusion-errors">prescribing errors</a>.</p>
<h2>What are the benefits of active ingredient prescribing?</h2>
<p>The main benefit of the switch is to simplify the language around medications. </p>
<p>Once we become accustomed to using one standardised name for each medicine, it will be easier to talk about medicines, whether with a family member, pharmacist or doctor. </p>
<p>The better we understand the medications we’re using, the <a href="https://www.sciencedirect.com/science/article/pii/S0025619614003875?casa_token=s6dZMe3HH58AAAAA:ZEY1c6ltPyfJBMuOw6XHH6PdGdAuLpkn6s3WP0gmoSo8UwC7pD-vpwMwqqjp81V9KCbp6PcTtw">fewer errors we make</a>, and the more control we can take over our medication use and decisions.</p>
<figure class="align-center ">
<img alt="A pharmacist studies a woman's prescription." src="https://images.theconversation.com/files/381269/original/file-20210129-13-6xid6s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/381269/original/file-20210129-13-6xid6s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/381269/original/file-20210129-13-6xid6s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/381269/original/file-20210129-13-6xid6s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/381269/original/file-20210129-13-6xid6s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/381269/original/file-20210129-13-6xid6s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/381269/original/file-20210129-13-6xid6s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A pharmacist can let you know which brands of your medication are are available.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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</figure>
<p>This change will also serve to promote choice.</p>
<p>When you’re prescribed a medicine with a certain name, you’re more likely to buy that brand. In some cases there may be generic medicines that are cheaper and just as effective. Or there may be other forms of the medication that better suit your needs, such as a capsule only available in another brand.</p>
<h2>Not too much will change</h2>
<p>This new rule is not expected to lead to extra work for doctors, pharmacists or other health professionals who prescribe medicines, as most clinical software will make the transition automatically.</p>
<p>Doctors can elect to still include the brand name on the prescription, if they feel it’s important for the patient. But aside from some limited exceptions, the active ingredient name will need to be listed, and will be listed first.</p>
<p>Some active ingredient names may be a bit longer and more complex than certain brand names, so there might be a period of adjustment for consumers. </p>
<p>But in the long term, this change will streamline terminology around medicines and make things easier, and hopefully safer, for everyone.</p>
<p>Next time you receive your prescription, have a look at the name of the active ingredient. Remember it, and use that name when you talk to your family, doctor and pharmacist.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/boomers-have-a-drug-problem-but-not-the-kind-you-might-think-127682">Boomers have a drug problem, but not the kind you might think</a>
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<img src="https://counter.theconversation.com/content/153796/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Matthew Grant received funding from the National Health and Medical Research Council.</span></em></p>The language used to describe medications is confusing, with multiple names for the same drug. A change to prescribing rules from today should go a long way to addressing this issue.Matthew Grant, Palliative Medicine Physician, Research Fellow, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1536282021-01-20T19:07:54Z2021-01-20T19:07:54ZI’ve heard COVID is leading to medicine shortages. What can I do if my medicine is out of stock?<figure><img src="https://images.theconversation.com/files/379646/original/file-20210120-15-1rkrr09.jpg?ixlib=rb-1.1.0&rect=0%2C5%2C1000%2C660&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/middle-eastern-male-pharmacist-wearing-protective-1827869804">from www.shutterstock.com</a></span></figcaption></figure><p>You’ve just come from your monthly GP appointment with a new script for your ongoing medical condition. But your local pharmacy is out of stock of your usual medicine. Your condition is serious, and without it, your health is likely to suffer. What can you do?</p>
<p>While <a href="https://www.tga.gov.au/hubs/medicine-shortages">medicine shortages</a> happen from time to time, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7235598/">researchers</a> and <a href="https://www.abc.net.au/news/2021-01-20/australia-post-coronavirus-medication-shortage/13065076">the media</a> report COVID-19 is causing more shortages than normal for many life-saving medicines. In Australia, <a href="https://www.abc.net.au/news/2021-01-20/australia-post-coronavirus-medication-shortage/13065076">media reports indicate</a> this includes some medications used to treat hyperthyroidism, high blood pressure, or allergies.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1351605107289296896"}"></div></p>
<p>Unfortunately, you’ll only likely find out if this applies to you when you reach the pharmacy. If that happens, there are a few ways you may be able to obtain your prescription.</p>
<p>But if the stock shortage will last for an extended period of time, and you cannot find a supply, your doctor may need to consider prescribing a different medication. </p>
<h2>Why are there shortages?</h2>
<p>Unfortunately, medicine shortages are an all too common problem of the modern health-care system. When our medicines come from a global supply chain — where raw ingredients are made in one country, processed into medicines in another, then freighted by sea or air to Australia — a single break in the supply chain can result in medicines going out of stock.</p>
<p>So there have been calls for Australia <a href="https://www.afr.com/politics/federal/australia-looks-to-boost-drug-manufacturing-20200413-p54je6">to set up its own medicines manufacturing base</a>. But even if we do, that doesn’t help now during COVID.</p>
<p>Medicines shortages is a <a href="https://www.who.int/medicines/publications/druginformation/WHO_DI_30-2_Medicines.pdf?ua=1">growing issue globally</a>. That’s because of increasing demand, higher quality standards and fewer manufacturing sites. </p>
<p>Shortages have also been exacerbated in 2020 due to COVID-19. When workers are <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30459-1/fulltext">locked out of the factory</a> because of a local outbreak, medicines don’t get made. And when we <a href="https://www.freightaustralia.gov.au/annual-report/the-year-that-was/covid-19-impacts-on-freight">restrict the number of flights into Australia</a>, that prevents medicines from arriving.</p>
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<strong>
Read more:
<a href="https://theconversation.com/new-law-wont-safeguard-medicine-supply-itll-only-ensure-we-know-theres-a-shortage-103100">New law won't safeguard medicine supply – it'll only ensure we know there's a shortage</a>
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<p>When a manufacturer knows there is likely to be a medicine shortage, for any reason, they are required to inform the Australian Therapeutic Goods Administration (TGA) so pharmacies can make other arrangements, such as stocking up on alternatives or sourcing supply from other companies.</p>
<p>When the medicine shortage is considered to have a critical patient impact, or if it is in the interest of the public to know about the shortage, then the information is added to the TGA’s <a href="https://apps.tga.gov.au/prod/MSI/search">shortages website</a>, which the public can search.</p>
<p>But this information is only useful at the government and wholesaler level; local GPs and community pharmacists don’t have the time to check the site every day.</p>
<p>Dealing with shortages efficiently is important because their impacts are wide ranging. Shortages <a href="https://doi.org/10.1371/journal.pone.0215837">result in</a> higher costs to patients when they have to buy branded rather than generic formulations; more drug errors due to the different strengths and brands dispensed; more side-effects and higher death rates because of changes to less appropriate medicines; and more complaints from patients.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/379676/original/file-20210120-19-ot4pnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Pharmacist taking medicine off shelf" src="https://images.theconversation.com/files/379676/original/file-20210120-19-ot4pnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/379676/original/file-20210120-19-ot4pnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/379676/original/file-20210120-19-ot4pnl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/379676/original/file-20210120-19-ot4pnl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/379676/original/file-20210120-19-ot4pnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/379676/original/file-20210120-19-ot4pnl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/379676/original/file-20210120-19-ot4pnl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">There’s not always enough medicine to go round. And shortages can affect a patient’s health.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pharmacist-filling-prescription-pharmacy-drugstore-1281072733">www.shutterstock.com</a></span>
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<h2>What if your local pharmacy is out of stock?</h2>
<p>It is best to speak to your pharmacist about your options when your medication is out of stock. There may be other brands still available and appropriate to swap. Alternatively, your pharmacist could dispense a different strength of the same medication. <a href="https://www.psa.org.au/coronavirus/regulatory-changes/">Regulations</a> brought in during the pandemic have allowed pharmacists to do this to help with medicine supply. </p>
<p>If there are no appropriate substitutes, in rare instances a local compounding pharmacy can manufacture certain products in store.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-manage-your-essential-medicines-in-a-bushfire-or-other-emergency-127516">How to manage your essential medicines in a bushfire or other emergency</a>
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<p>If none of your local pharmacies stock your medicine, your next option is for an <a href="https://mymedkit.com.au/">Australian online pharmacy</a> to fill your script. It may be able to ship your medicine from another city or state.</p>
<p>It is not legal or safe for you personally to order prescription medications from online overseas suppliers. This is because they may not have been manufactured to Australian standards, and may be unsafe. But your pharmacist may do so on your behalf, under a special provision called <a href="https://www.tga.gov.au/ws-s19a-index">section 19A</a>.</p>
<p>If all else fails, you may need to contact your doctor about changing to a different medication. There are often many alternatives in the same drug class that work in the same, or very similar, way.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-what-should-you-do-with-your-unused-medicine-81406">Health Check: what should you do with your unused medicine?</a>
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<p>Finally, and especially during COVID-19, for a large number of medicines pharmacists are only allowed to provide a <a href="https://www.tga.gov.au/media-release/limits-dispensing-and-sales-prescription-and-over-counter-medicines">maximum of one month’s supply</a> to each patient. </p>
<p>So if your medicine is actually in stock and you want extra, just in case, then by law they may not be able to dispense it to you. This is to prevent panic buying and to ensure the wider community has steady access to medicine; that is, to prevent further shortages.</p>
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Read more:
<a href="https://theconversation.com/why-are-people-stockpiling-toilet-paper-we-asked-four-experts-132975">Why are people stockpiling toilet paper? We asked four experts</a>
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<img src="https://counter.theconversation.com/content/153628/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Associate Professor Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is Fellow of the Royal Australian Chemical Institute and a member of the Australasian Pharmaceutical Science Association. Nial is science director of the medicinal cannabis company Canngea Pty Ltd, a board member of the Australian Medicinal Cannabis Association, and a Standards Australia committee member for sunscreen agents.</span></em></p><p class="fine-print"><em><span>Elise Schubert is funded by a scholarship from the University of Sydney and Canngea Pty Ltd. </span></em></p>COVID-19 has resulted in higher than normal levels of medicine shortages. Here’s what to do if your local pharmacy is out of stock.Nial Wheate, Associate Professor of the Sydney Pharmacy School, University of SydneyElise Schubert, Pharmacist and PhD Candidate, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1532742021-01-14T20:07:04Z2021-01-14T20:07:04ZThe simple reason West Virginia leads the nation in vaccinating nursing home residents<figure><img src="https://images.theconversation.com/files/378834/original/file-20210114-18-1agp4nj.jpg?ixlib=rb-1.1.0&rect=8%2C48%2C5355%2C3337&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">By mid-January, only about a quarter of the COVID-19 vaccines distributed for U.S. nursing homes through the federal program had reached people's arms.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/pharmacist-gives-the-pfizer-biontech-covid-19-vaccine-to-a-news-photo/1295381204"> Paul Bersebach/MediaNews Group/Orange County Register via Getty Images</a></span></figcaption></figure><p>The urgency of vaccinating nursing home residents is evident in the numbers. The COVID-19 pandemic has claimed the lives of more than <a href="https://www.nytimes.com/interactive/2020/us/coronavirus-nursing-homes.html">136,000</a> residents and employees of long-term care facilities in the U.S. alone, accounting for nearly 40% of all U.S. deaths linked to the disease. </p>
<p>Echoing that urgency, Secretary of Health and Human Services Alex Azar <a href="https://www.cbsnews.com/news/covid-19-vaccine-alex-azar-face-the-nation/">declared in mid-December</a>, “We can have every nursing home patient vaccinated in the United States by Christmas.” Yet, by Christmas, most states had barely begun.</p>
<p>Other states were still <a href="https://www.providencejournal.com/story/news/coronavirus/2020/12/21/cvs-begins-vaccines-long-term-care-centers-12-states/3988430001/">far behind</a> when West Virginia became <a href="https://www.aarp.org/caregiving/health/info-2021/nursing-home-vaccines-slow-start/">the first state to finish</a> round one of the two-dose vaccine series in nursing homes on Dec. 30.</p>
<p>What did West Virginia do differently?</p>
<p>The numbers tell a story. As a professor who specializes in <a href="https://scholar.google.com/citations?user=cpd3_bYAAAAJ&hl=en">health care operations management</a>, I believe they hold some important lessons for other states and the rest of the vaccine rollout.</p>
<h2>The pharmacy math problem</h2>
<p>The first important point is that West Virginia opted out of a federal partnership program that relies on the giant CVS and Walgreens pharmacy chains to deliver vaccines to nursing homes. Instead, the state is relying on a network consisting mostly of <a href="https://wvmetronews.com/2020/12/29/local-pharmacies-playing-key-role-on-vaccine-distribution/">local pharmacies</a>.</p>
<p>West Virginia has also been praised for how it used <a href="https://wvmetronews.com/2020/12/29/local-pharmacies-playing-key-role-on-vaccine-distribution/">the time</a> between when <a href="https://theconversation.com/when-can-children-get-the-covid-19-vaccine-5-questions-parents-are-asking-150721">authorization for the first vaccines</a> became evident and when the first doses arrived to plan the rollout.</p>
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<p>The big difference is in the numbers. Under the federal partnership program, CVS planned to have <a href="https://www.wsj.com/articles/cvs-walgreens-gear-up-to-deliver-covid-19-vaccines-to-nursing-homes-11606921201">about 1,000 of its pharmacies</a> as vaccine hubs to serve some 25,000 nursing home facilities across the nation, a CVS official told The Wall Street Journal in early December. Similarly, a Walgreens official said his company would have 800 to 1,000 Walgreens pharmacies to serve as hubs for about 23,000 nursing home facilities.</p>
<p>That meant each CVS and Walgreens pharmacy on average planned to serve about 25 nursing homes.</p>
<p>West Virginia chose to mobilize independent and chain pharmacies alike, rather than relying just on CVS and Walgreens. Over <a href="http://wvpharmacy.org/">250 pharmacies</a> offered to help in vaccinating people at <a href="https://wvmetronews.com/2020/12/28/justice-all-nursing-homes-long-term-care-facilities-will-have-received-covid-19-vaccine-by-monday/">214 nursing homes</a>. In other words, each nursing home on average is served by more than one pharmacy.</p>
<p>Vaccinating nursing homes is a very labor-intensive operation. Getting consent from residents and staff is <a href="https://www.nytimes.com/2020/12/16/business/covid-coronavirus-vaccine-nursing-homes.html">time-consuming and confusing</a>. Some people also decline the vaccine. By Jan. 14, only <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations">about one-quarter</a> of the vaccines distributed to nursing homes through the federal program had reached people’s arms, while West Virginia had started vaccinating <a href="https://dhhr.wv.gov/COVID-19/Pages/Vaccine.aspx">new groups</a> and administering second doses.</p>
<h2>Incentives are another issue</h2>
<p>In addition to lopsided math, there is a story of incentives.</p>
<p>Under the contracts signed with the U.S. Department of Health and Human Services, CVS and Walgreens essentially won the right to vaccinate about <a href="https://www.aarp.org/caregiving/health/info-2021/nursing-home-vaccines-slow-start/">99%</a> of U.S. nursing homes that registered with the program. They had little incentive to commit a large number of pharmacies and workers to the daunting task of vaccinating people in nursing homes.</p>
<p>In West Virginia, however, hundreds of local and other chain pharmacies were involved, and each had every incentive to provide speedy services so nursing homes would not walk away from the vaccination deals. Local pharmacies also often have existing relationships with nursing homes – relationships they want to keep. </p>
<figure class="align-center ">
<img alt="Jeanne Peters, 95, received the first COVID-19 vaccination at a nursing home on Dec. 18, 2020, in West Hartford, Conn." src="https://images.theconversation.com/files/378843/original/file-20210114-13-afefmr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/378843/original/file-20210114-13-afefmr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/378843/original/file-20210114-13-afefmr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/378843/original/file-20210114-13-afefmr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/378843/original/file-20210114-13-afefmr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/378843/original/file-20210114-13-afefmr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/378843/original/file-20210114-13-afefmr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The amount of paperwork complicates the vaccination process.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakConnecticutVaccine/73288bee68404e06adf9d808c10bb5d1/photo">AP Photo/Stephen Dunn</a></span>
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<h2>Lessons for the rest of the country</h2>
<p>What can other states learn from West Virginia’s success story?</p>
<p>First, to speed up the vaccine rollout, the U.S. needs to address <a href="https://hub.jhu.edu/2021/01/08/tinglong-dai-stalled-vaccination-rates-covid-19/">the bottlenecks</a> – the shortages of resources, especially staffing and points of distribution, needed for vaccination. </p>
<p>Second, incentives matter. In designing vaccination programs, it is important to ensure providers are motivated to commit resources to speed up vaccination. Market competition is a powerful mechanism to achieve that.</p>
<p>Third, state and local leadership can make a difference. While <a href="https://nymag.com/intelligencer/article/americas-vaccine-rollout-disaster.html">a lack of federal leadership</a> has been cited as a reason for the slow vaccine rollout, West Virginia succeeded in vaccinating nursing homes because it could be more nimble outside the federal program. State and local leaders can succeed when they are held accountable and when they proactively manage the process.</p>
<p>The U.S. is only at the beginning of the COVID-19 vaccination process. Just over <a href="https://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution/">3% of the country’s population</a> had been vaccinated as of Jan. 13, and there are many challenges on the road ahead. The <a href="https://hub.jhu.edu/2020/12/04/tinglong-dai-vaccine-distribution-logistics/">complex cold storage requirements</a> of mRNA vaccines can make <a href="https://theconversation.com/getting-covid-19-vaccines-to-rural-americans-is-harder-than-it-looks-but-there-are-ways-to-lift-the-barriers-152377">reaching rural areas</a> difficult without careful planning and logistical support. More health care staff and residents have also <a href="https://www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/">rejected getting the vaccine</a> than public health professionals would like to see. In West Virginia, about <a href="https://apnews.com/article/coronavirus-vaccine-health-workers-676e03a99badfd5ce3a6cfafe383f6af">half the nursing home staff members declined</a>. These all have implications as vaccinations go on.</p><img src="https://counter.theconversation.com/content/153274/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tinglong Dai does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>West Virginia’s success holds some important lessons for other states and the rest of the COVID-19 vaccine rollout.Tinglong Dai, Associate Professor of Operations Management & Business Analytics, Johns Hopkins Carey Business School, Johns Hopkins University School of NursingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1485262020-10-22T04:35:04Z2020-10-22T04:35:04ZE-prescriptions are coming. But what are they? And is this the end of paper ones?<figure><img src="https://images.theconversation.com/files/364884/original/file-20201022-16-nddiip.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnancy-medicine-pharmaceutics-health-care-people-316712879">Shutterstock</a></span></figcaption></figure><p>Electronic prescriptions (or e-prescriptions) <a href="https://www.digitalhealth.gov.au/news-and-events/news/electronic-prescriptions-roll-out-expands-across-metropolitan-sydney">are being rolled out</a> in stages across Australia after being used in Victoria during the pandemic.</p>
<p>E-prescriptions have been common in countries such as the <a href="https://www.sciencedirect.com/science/article/pii/S1386505613000233?via%3Dihub">United States</a> and <a href="https://link.springer.com/chapter/10.1007/978-3-642-23315-9_8">Sweden</a> for more than ten years. In Australia, a fully electronic paperless system has been planned for some time. </p>
<p>Since the arrival of COVID-19, and a surge in the uptake of <a href="https://theconversation.com/telehealth-in-lockdown-meant-7-million-fewer-chances-to-transmit-the-coronavirus-141041">telehealth</a>, the advantages of e-prescriptions have become compelling. </p>
<p>So what are they? How does it all work? And is this the end of paper prescriptions?</p>
<h2>How do e-prescriptions work?</h2>
<p>Now, most doctors use a function in a patient’s electronic medical records to print out their prescription in the surgery. Patients then take it to the pharmacy for dispensing. The pharmacy needs to store this paper prescription <a href="https://www.health.nsw.gov.au/pharmaceutical/pharmacists/Pages/faq-recordkeeping-storage-privacy.aspx#:%7E:text=All%20records%20of%20prescriptions%20dispensed,where%20the%20prescription%20was%20dispensed.">for two years</a>.</p>
<p>However, with e-prescribing, doctors can use <a href="https://www.psa.org.au/ep/">their medical software package</a> to write and transmit that prescription as a “token” to the patient’s phone. This can be as an SMS or email, containing a QR code. </p>
<p>Patients are then free to choose which pharmacy to take the token to for dispensing. They can present their phone to be scanned, or forward the SMS or email to the pharmacy.</p>
<p>The pharmacy imports the code into its dispensing program, unlocks the prescription, checks it, and dispenses the medication.</p>
<p>If patients accidentally delete the email or SMS, they will have to contact their doctor to have their token cancelled and reissued. This is not that different to someone losing a paper prescription.</p>
<p>Although e-prescribing has been used during telehealth consultations in Victoria, for instance, it can also be used during a normal face-to-face consultation, once it rolls out in your area. </p>
<h2>What are the benefits of going paperless?</h2>
<p>Telehealth initially involved a lot of extra paperwork. Doctors would fax or email a prescription to a particular pharmacy for the script to be dispensed, then medication was delivered to patients at home.</p>
<p>The pharmacy needed to wait for the doctor’s surgery to mail the paper prescription, or had to collect it from the doctor’s surgery. It also had to store the prescription for two years after dispensing.</p>
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Read more:
<a href="https://theconversation.com/video-and-phone-consultations-only-scratch-the-surface-of-what-telehealth-has-to-offer-146580">Video and phone consultations only scratch the surface of what telehealth has to offer</a>
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<p>However, regulations have now <a href="https://www.pbs.gov.au/pbs/news/2019/09/electronic-prescribing">changed</a> to legalise e-prescriptions with no need for paper.</p>
<p>This allows an efficient, contactless system for distributing medication, improving pharmacy workflows, and removing storage requirements.</p>
<p>For patients, it means not having to worry about paper copies, and offers the convenience of being able to send a code to the pharmacy of their choice.</p>
<h2>Is it accurate? Does it save time?</h2>
<p>When researchers evaluated other benefits of e-prescriptions, they had mixed results.</p>
<p>A <a href="https://www.sciencedirect.com/science/article/pii/S1386505613000233?via%3Dihub">review of 19 studies</a> showed e-prescriptions may be clearer or more complete than paper handwritten prescriptions, reducing the need for pharmacists to contact doctors to clarify their instructions.</p>
<p>Another advantage is that e-prescriptions for addictive drugs, such as opioids, do not need doctors to write any details by hand (as is <a href="https://www.legislation.nsw.gov.au/view/whole/html/inforce/current/sl-2008-0392">currently required for paper scripts</a> for drugs of addiction).</p>
<p>However, e-prescriptions may <a href="https://pubmed.ncbi.nlm.nih.gov/18445369/">not reduce the time</a> it takes to process the prescription, as <a href="https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/1472-6947-9-8">new errors</a> may be introduced.</p>
<p>For instance, a <a href="https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/1472-6947-9-8">Swedish study</a> compared the number of times pharmacists had to contact the doctor to clarify information from new e-prescriptions, compared with computer-generated or faxed prescriptions. </p>
<p>The study found e-prescriptions were nearly eight times more likely to have issues about the dosage or how to take the medication. The authors believed this may be due to some electronic systems misinterpreting common shorthand doctors use (for example, lt3d for “one tablet three times daily”). </p>
<h2>Is this the end of paper scripts?</h2>
<p>About <a href="https://www2.deloitte.com/au/en/pages/technology-media-and-telecommunications/articles/mobile-consumer-survey.html#:%7E:text=91%25%20of%20Australians%20have%20a,and%2036%25%20market%20share%20respectively.">10% of Australians</a> do not have a smart phone. So paper prescriptions are still available and you can choose a paper one if you prefer or you don’t feel comfortable using the technology.</p>
<p>Some patients might find it a bit fiddly handling multiple e-prescriptions for multiple medications. At present, individual prescriptions are sent as separate emails or SMS messages and patients need some familiarity with searching their device to retrieve the right one.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/364885/original/file-20201022-21-10edtse.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person handing paper prescription to pharmacist" src="https://images.theconversation.com/files/364885/original/file-20201022-21-10edtse.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/364885/original/file-20201022-21-10edtse.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/364885/original/file-20201022-21-10edtse.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/364885/original/file-20201022-21-10edtse.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/364885/original/file-20201022-21-10edtse.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/364885/original/file-20201022-21-10edtse.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/364885/original/file-20201022-21-10edtse.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Some people may prefer to stick with paper prescriptions.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/confident-asian-young-female-pharmacist-lovely-1714542475">Shutterstock</a></span>
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<p>However, in the near future, you will be able to store all of your current prescriptions electronically in an “<a href="https://www.digitalhealth.gov.au/get-started-with-digital-health/electronic-prescriptions">Active Script list</a>”. This will allow a patient to have all their medications in one file and choose to give a doctor or pharmacist access to either add more prescriptions or dispense medication. Once this is in place, using an app to aggregate all this information may make this more usable.</p>
<p>Until then, some patients with multiple medications might prefer to stick with keeping their paper prescriptions together in a folder as it helps them keep their current medication list up to date.</p>
<h2>How about privacy and security?</h2>
<p>When it comes to their health data, people are often understandably concerned about privacy and security.</p>
<p>The Australian Digital Health Agency, the federal agency that oversees e-prescriptions, requires providers to conform to rigorous standards when managing sensitive data. </p>
<p>E-prescriptions must meet the <a href="https://www.liebertpub.com/doi/full/10.1089/omi.2020.0085">legal privacy requirements</a> in Australia’s <a href="https://www.legislation.gov.au/Details/C2014C00076">Privacy Act 1988</a> and <a href="https://www.qcert.org/sites/default/files/public/documents/au-bp-national_eauthentication_framework-eng-2009.pdf">eAuthentication framework</a>.</p>
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Read more:
<a href="https://theconversation.com/instant-prescriptions-might-be-the-way-of-our-digital-future-but-we-need-to-manage-the-risks-first-131308">Instant prescriptions might be the way of our digital future, but we need to manage the risks first</a>
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<p>Countries that have had e-prescriptions for some time, such as Greece, have explored the issues around <a href="https://www.diva-portal.org/smash/get/diva2:1129929/FULLTEXT01.pdf">privacy</a>. Australia, being much later to adopt e-prescriptions, has had the opportunity to address these concerns as part of the implementation process. </p>
<p>And a review <a href="https://www.liebertpub.com/doi/full/10.1089/omi.2020.0085">comparing digital security of e-prescription systems</a> in eight countries showed Australia (with the US) had the highest level of digital security.</p><img src="https://counter.theconversation.com/content/148526/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Penm is is a member of the International Pharmaceutical Federation (FIP) Pharmaceutical Technology Forum. FIP is the the global body representing over 4 million pharmacists and pharmaceutical scientists. FIP is a non-governmental organisation that has been in official relations with the World Health Organization since 1948.</span></em></p><p class="fine-print"><em><span>Andrew Bartlett does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Another use for your smartphone, this time to present to the pharmacists rather than a paper prescription.Andrew Bartlett, Associate Lecturer Pharmacy Practice, University of SydneyJonathan Penm, Lecturer (Pharmacy), University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1445692020-08-18T05:16:59Z2020-08-18T05:16:59ZIvermectin is still not a miracle cure for COVID-19, despite what you may have read<p>The head lice drug ivermectin has <a href="https://www.skynews.com.au/details/_6179108952001">yet again been touted in the media</a> as a possible treatment for COVID-19. But despite the <a href="https://www.biospectrumasia.com/news/91/16457/australian-develops-effective-triple-therapy-to-treat-covid-19.html">favourable headlines</a>, huge uncertainty remains about whether this treatment can be safely and effectively repurposed to tackle the coronavirus.</p>
<p>In recent weeks the media has been awash with <a href="https://www.trialsitenews.com/well-respected-australian-researcher-consider-triple-therapy-ivermectin-zinc-doxycycline-for-covid-19/">claims</a> ivermectin, when given in combination with the common antibiotic doxycycline and zinc supplements, is effectively a “cure” for COVID-19. </p>
<p>Yet there has been no definitive clinical trial so far showing this is the case. All we have are <a href="https://www.researchgate.net/publication/343305357_A_Case_Series_of_100_COVID-19_Positive_Patients_Treated_with_Combination_of_Ivermectin_and_Doxycycline">observational studies</a> and <a href="https://www.trialsitenews.com/well-respected-australian-researcher-consider-triple-therapy-ivermectin-zinc-doxycycline-for-covid-19/">clinicians’ opinions</a>. </p>
<p>The World Health Organisation’s <a href="https://clinicaltrials.gov/ct2/who_table">database of clinical studies for COVID-19</a> shows there are currently 16 trials investigating ivermectin. Even these studies are unlikely to provide the high-quality data necessary to show ivermectin can actually provide its touted benefits. </p>
<p>Many of the current studies have low numbers of participants, weak study designs, and inconsistent (and relatively low) ivermectin dosing regimes, with ivermectin frequently given in <a href="https://en.irct.ir/trial/48444">combination</a> with other drugs.</p>
<p>The <a href="https://www1.racgp.org.au/newsgp/clinical/insufficient-evidence-to-currently-support-ivermec">Royal Australian Council of General Practitioners</a> and the <a href="https://www.safetyandquality.gov.au/sites/default/files/2020-05/Potential%20medicines%20to%20treat%20COVID-19%20%281%20May%202020%29.pdf">Australian Commission for Quality and Safety in Health Care</a> have warned there is insufficient evidence ivermectin is a safe and effective treatment for people infected with the coronavirus.</p>
<h2>What do we know about ivermectin for COVID-19?</h2>
<p><a href="https://www.sciencedirect.com/science/article/pii/S0166354220302011">Laboratory studies</a> using monkey cells in a test tube (as opposed to clinical studies in human patients) have shown ivermectin can shut down the replication of SARS-CoV-2, the coronavirus that causes COVID-19, within 24-48 hours of exposure to the drug.</p>
<p>Ivermectin is thought to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3327999/">inhibit the virus</a> by preventing viral proteins moving in and out of the host cell’s nucleus, which is essential for replication of the coronavirus. </p>
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Read more:
<a href="https://theconversation.com/head-lice-drug-ivermectin-is-being-tested-as-a-possible-coronavirus-treatment-but-thats-no-reason-to-buy-it-135683">Head lice drug Ivermectin is being tested as a possible coronavirus treatment, but that's no reason to buy it</a>
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</p>
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<p>The problem is this process requires very high concentrations of ivermectin – well above the <a href="https://www.sciencedirect.com/science/article/pii/S0166354220302199#bib3">recommended dose for humans</a>. This means ivermectin’s virus-killing powers would be unlikely to be harnessed inside the human body. </p>
<p>A <a href="https://www.sciencedirect.com/science/article/pii/S0166354220302199#bib3%22%22">detailed analysis</a> of the relationship between dose and concentration of ivermectin suggests none of the currently used ivermectin dosing regimens would deliver high enough concentrations of ivermectin inside the body to activate its virus-killing effects.</p>
<p>Another <a href="https://www.tandfonline.com/doi/full/10.1080/13102818.2020.1775118">review</a> backs this up, suggesting all of the ivermectin doses being investigated in current clinical trials would fall well short of achieving drug concentrations high enough to wipe out SARS-CoV-2.</p>
<p>Even a 120 mg dose of ivermectin, which would be regarded as excessive (compared with the <a href="https://www.tga.gov.au/sites/default/files/auspar-ivermectin-131030-pi.pdf">recommended dose of 3-15mg</a> for treating parasitic infections) resulted in blood concentrations several orders of magnitude times lower than those needed to inhibit the virus.</p>
<figure class="align-center ">
<img alt="Head louse on human hair" src="https://images.theconversation.com/files/353309/original/file-20200818-16-yiitpt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/353309/original/file-20200818-16-yiitpt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/353309/original/file-20200818-16-yiitpt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/353309/original/file-20200818-16-yiitpt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/353309/original/file-20200818-16-yiitpt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/353309/original/file-20200818-16-yiitpt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/353309/original/file-20200818-16-yiitpt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Great for killing head lice, but the jury’s still out on coronavirus.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Male_human_head_louse.jpg">GillesSM/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>How much ivermectin is too much?</h2>
<p>While ivermectin generally doesn’t cause problematic side effects at the currently used doses, there is limited information about whether much larger doses would also be safe.</p>
<p>Repurposing ivermectin as a “cure” for COVID-19 would require massive doses, which would substantially increase the risk of <a href="https://www.tandfonline.com/doi/full/10.1080/13102818.2020.1775118">side effects</a> such as nausea, rash, dizziness, immune suppression, abdominal pain, fever, raised heart rate and unstable blood pressure. </p>
<p>Ivermectin at usual doses <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2885.2008.01007.x">does not enter the central nervous system</a>, but after large doses of the drug it may <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5929173/">enter the brain</a>, potentially causing impaired vision, hampering the central nervous system (which could in turn affect breathing, heart rate and consciousness), and exaggerating the effects of other sedative medicines such as benzodiazepines.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/tested-positive-for-covid-19-heres-what-happens-next-and-why-day-5-is-crucial-143687">Tested positive for COVID-19? Here's what happens next – and why day 5 is crucial</a>
</strong>
</em>
</p>
<hr>
<p>Ivermectin is a hugely useful medicine in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043740/">treating parasitic illnesses</a> such as lice, worms and scabies, particularly in developing countries. But as we have already seen in the <a href="https://theconversation.com/could-taking-hydroxychloroquine-for-coronavirus-be-more-harmful-than-helpful-139309">case of the malaria drug hydroxychloroquine</a>, just because a medicine is useful for one purpose, it cannot automatically be considered a miracle cure for COVID-19. </p>
<h2>Repurposing drugs as COVID-19 treatments</h2>
<p>Repurposing existing drugs as possible COVID-19 treatments is a smart strategy, but requires <a href="https://www.sydney.edu.au/news-opinion/news/2020/06/10/for-successful-covid-19-treatments-pharmacological-benchmarks-ar.html">several key principles</a> to be addressed. The drug must have antiviral effects in cells and animals at doses relevant to humans. The drug must be able to get to the site of infection in the body (or reduce the inflammation associated with the infection). It is best if the antiviral mechanism is understood. And finally, <a href="https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/bcp.14416">well designed clinical trials are needed</a> to be sure the drugs works in people with the infection and it is safe to use (especially in older, vulnerable unwell people). </p>
<p>Thankfully, Australia’s National COVID-19 Clinical Evidence Taskforce continually assesses and updates the best evidence-based advice for treating COVID-19, which you can read <a href="https://covid19evidence.net.au/#living-guidelines">here</a>.</p><img src="https://counter.theconversation.com/content/144569/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew McLachlan receives research funding from the NHMRC and the Sydney Pharmacy School receives research scholarship funding from GSK for a PhD student under his supervision. Andrew has served as a paid consultant on Australian government committees related to medicines regulation and anti-doping. Andrew does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article.</span></em></p>The head lice drug ivermectin is being touted as a coronavirus killer. But studies suggest it would need to be taken in mega-doses far higher than those currently used, with unknown side-effects.Andrew McLachlan, Head of School and Dean of Pharmacy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1415232020-06-30T19:10:38Z2020-06-30T19:10:38ZThe updated deal for pharmacists will help recognise their role as health experts, not just retailers<p>Australia’s <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/New-7th-Community-Pharmacy-Agreement">7th Community Pharmacy Agreement</a>, which comes into force today and lasts five years, will see the government provide A$16 billion for dispensing subsidised medicines and A$1.15 billion for other services such as diabetes support.</p>
<p>The agreement was struck between the federal government, industry peak body the Pharmacists’ Guild and, for the first time, the <a href="https://www.psa.org.au">Pharmaceutical Society of Australia</a>, which represents Australia’s <a href="https://www.pharmacyboard.gov.au/About/Statistics.aspx">31,000 registered pharmacists</a>.</p>
<p>If you are a consumer, the new deal is a reassuring continuation of essential existing subsidies. Prescription medications accessed under the Pharmaceutical Benefits Scheme (<a href="https://www.pbs.gov.au/pbs/home;jsessionid=4jsuwyz06dyu1dhj761nqmhc5">PBS</a>) will still be available from your local chemist. There will be a bit more government support for some other services provided by pharmacies, especially to Indigenous people. There is continuing recognition of the need to locate a community pharmacy within reach of most people. </p>
<p>If you are a pharmacist, the agreement finally gives you a little recognition as a professional with years of training and high standards, as distinct from corporations with chains of chemist stores.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-the-community-pharmacy-agreement-38789">Explainer: what is the Community Pharmacy Agreement?</a>
</strong>
</em>
</p>
<hr>
<h2>What’s in the agreement?</h2>
<p>The <a href="https://theconversation.com/explainer-what-is-the-community-pharmacy-agreement-38789">Community Pharmacy Agreement</a> is one of the building blocks of the Australian health system, which is notably fairer and more effective than that in the United States. The underpinning expectation is that the federal government will <a href="https://theconversation.com/explainer-how-is-the-price-of-medicine-decided-in-australia-83633">subsidise</a> prescription medicines under the PBS. We all benefit if everyone can afford those treatments. </p>
<p>Markets are imperfect. In an <a href="https://theconversation.com/relaxing-pharmacy-ownership-rules-could-result-in-more-chemist-chains-and-poorer-care-122628">unregulated</a> environment we would see pharmacies clustering in areas of high population – just like fast food shops – and not serving other areas such as outer suburbs and rural Australia.</p>
<p>The succession of Community Pharmacy Agreements, authorised under the <a href="https://austlii.edu.au/cgi-bin/viewdb/au/legis/cth/consol_act/nha1953147/">National Health Act</a>, uses regulation to avert this kind of market failure. The rules mean you cannot set up a pharmacy to compete with another nearby pharmacy, apart from under exceptional circumstances, thus ensuring the commercial viability of each pharmacy.</p>
<h2>Where’s the community?</h2>
<p>The “community” label is sometimes misunderstood. It doesn’t mean your local chemist is run by volunteers, the local council, or the federal government. Instead, it means the pharmacy operates on a commercial basis for people in the community. It is distinct from dispensing of medications by hospitals, which typically restrict what they offer to current patients and have a different business model.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/344695/original/file-20200630-103661-15ynk9w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/344695/original/file-20200630-103661-15ynk9w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/344695/original/file-20200630-103661-15ynk9w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/344695/original/file-20200630-103661-15ynk9w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/344695/original/file-20200630-103661-15ynk9w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/344695/original/file-20200630-103661-15ynk9w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/344695/original/file-20200630-103661-15ynk9w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pharmacies are a vital part of the community.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Elliston_Pharmacy,_2017_(01).jpg">Bahnfrend/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Each pharmacy serving the community must be supervised by a pharmacist – a health practitioner who has undergone extensive training and meets the relevant professional criteria. Pharmacists are supervised under the <a href="https://www.ahpra.gov.au/About-AHPRA/What-We-Do/Legislation.aspx">National Health Practitioner Regulation Law</a> and associated <a href="https://www.pharmacyboard.gov.au">Pharmacy Board</a>.</p>
<p>The dispensing of medicine in community pharmacies needs to be supervised by pharmacists, although pharmacies can be owned by non-practitioners. The ongoing shift to corporate ownership is contentious, as pharmacies move away from being analagous to the “friendly family doctor” and towards a business model that emphasises selling jelly beans, “wellness” products and fluffy toys alongside medications. That model is not good for public health, and not necessarily good for the pharmacists themselves (more on this point later).</p>
<h2>What’s the significance of the new agreement?</h2>
<p>The agreement is important for three reasons. </p>
<p>First, and most importantly, it retains existing arrangements regarding distribution of pharmacies. Those arrangements have been criticised by entrepreneurs, often represented by the <a href="https://www.guild.org.au/news-events/news/2020/the-seventh-community-pharmacy-agreement">Pharmacy Guild</a>, which is the equivalent of industry peak bodies such as the Minerals Council of Australia.</p>
<p>The latest version of the agreement provides for updating of government payments to wholesalers and retailers of prescription medications – in other words, continued subsidisation of products under the PBS and support for the pharmaceutical supply chain. </p>
<p>There is little point in subsidising payments by consumers if there are no supplies in the warehouses for distribution to the pharmacies. That is an issue of concern amid a pandemic. Streamlining of processes under the agreement will make it easier for pharmacies to receive payments to dispense medicines subsidised under the PBS and the <a href="https://www.dva.gov.au/health-and-treatment/help-cover-healthcare-costs/manage-medicine-and-keep-costs-down/concessional">Repatriation Pharmaceutical Benefits Scheme</a>, which helps Australia’s veterans and predates the wider PBS.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/pay-pharmacists-to-improve-our-health-not-just-supply-medicines-124641">Pay pharmacists to improve our health, not just supply medicines</a>
</strong>
</em>
</p>
<hr>
<p>There will be support for pharmacy services in regional, rural and remote areas, although past <a href="https://ajp.com.au/news/community-pharmacies-in-rural-and-remote-australia-are-on-the-brink-of-extinction/">concerns</a> about the viability of pharmacies in the bush mean it is uncertain whether this support will be sufficient.</p>
<p>Second, the agreement also provides support – mainly in the form of payments under the <a href="https://www.ndss.com.au/">National Diabetes Services Scheme</a> and the <a href="https://www1.health.gov.au/internet/publications/publishing.nsf/Content/nmp-guide-medmgt-jul06-contents%7Enmp-guide-medmgt-jul06-guidepr3">Dose Administration Aids</a> program – for advice by pharmacists regarding ongoing testing by consumers with diabetes and assistance to seniors. </p>
<p>There is also increased funding of programs aimed at boosting Aboriginal and Torres Strait Islander peoples’ access to medicines. </p>
<p>Finally, the agreement belatedly and weakly acknowledges the Pharmaceutical Society of Australia.</p>
<p>The society’s involvement in the agreement is important because health services are not just about profit. Corporate imperatives to maximise the use of floor space by selling <a href="https://theconversation.com/government-decision-not-to-ban-homeopathy-sales-from-pharmacies-is-a-mistake-96114">non-therapeutic</a> products are potentially at odds with both professional practice and consumer benefit. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/pharmacists-should-drop-products-that-arent-backed-by-evidence-12646">Pharmacists should drop products that aren't backed by evidence</a>
</strong>
</em>
</p>
<hr>
<p>The latest agreement expands the existing remuneration to pharmacy owners for pharmacists to provide health advice. This is likely to be a useful supplement, rather than a major revenue source. In the coming years we can expect to see claims by health economists and calls for greater support.</p>
<p>The Pharmaceutical Society’s involvement is more broadly relevant because the latest agreement provides for remuneration of advising by professionals. Community pharmacists are a first port of call for many people with health issues. Problems with the interaction of multiple medications mean we need accessible professional expertise. </p>
<p>Rewarding such service to the community means pharmacists, self-employed or otherwise, can concentrate on health, not jellybeans and complementary products.</p><img src="https://counter.theconversation.com/content/141523/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bruce Baer Arnold does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The new Community Pharmacy Agreement will make it easier for Australia’s pharmacists to spend time providing expert health advice to customers rather than focusing on retail revenues.Bruce Baer Arnold, Assistant Professor, School of Law, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1400702020-06-15T01:55:41Z2020-06-15T01:55:41ZGetting vaccinated at the pharmacy? Make sure it’s recorded properly<figure><img src="https://images.theconversation.com/files/341425/original/file-20200612-93521-ezks13.jpg?ixlib=rb-1.1.0&rect=0%2C14%2C1000%2C651&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/vaccination-242399758">Shutterstock</a></span></figcaption></figure><p>Pharmacists are vaccinating more and more people, but those shots are not always ending up in your immunisation record, our <a href="http://ncirs.org.au/reports">report</a> out today shows.</p>
<p>This means your records could be incomplete, leading to unnecessary repeat vaccinations, or it could affect your eligibility for government benefits or work. </p>
<p>Incomplete records also mean health authorities cannot accurately monitor vaccination uptake across the population. </p>
<p>And if we have a vaccine for COVID-19 delivered through pharmacies, accurate record keeping will be important for both individuals and health authorities.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-why-the-who-says-a-coronavirus-vaccine-is-18-months-away-131213">Here's why the WHO says a coronavirus vaccine is 18 months away</a>
</strong>
</em>
</p>
<hr>
<h2>Pharmacy vaccination is popular and becoming more so</h2>
<p>Our report, by the National Centre for Immunisation Research and Surveillance, shows pharmacy vaccination is becoming more popular. </p>
<p>In 2017, it accounted for 0.1% of all vaccinations reported to the <a href="https://www.servicesaustralia.gov.au/individuals/services/medicare/australian-immunisation-register">Australian Immunisation Register</a>. However, by 2019, that had risen to 2.7%, the vast majority (95%) of those influenza vaccine.</p>
<p>Pharmacists have also been allowed to give a wider range of vaccines to younger people over recent years. For instance, appropriately trained pharmacists in all states and territories can give:</p>
<ul>
<li><p>influenza vaccine to anyone aged 10 years or over</p></li>
<li><p>measles-mumps-rubella (MMR) or diphtheria-tetanus-pertussis (dTpa) vaccine to anyone aged 16 years or over.</p></li>
</ul>
<p>The rules for other vaccines vary depending on the <a href="http://ncirs.org.au/sites/default/files/2020-06/NCIRS%20Information%20Sheet-%20Vaccines%20from%20community%20pharmacy_updated%2010%20June%202020_final.pdf">state or territory</a> you live in.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/pharmacists-can-vaccinate-adults-against-whooping-cough-measles-and-the-flu-but-it-might-cost-you-more-122191">Pharmacists can vaccinate adults against whooping cough, measles and the flu, but it might cost you more</a>
</strong>
</em>
</p>
<hr>
<h2>What we found</h2>
<p>In <a href="https://www.health.nsw.gov.au/immunisation/Documents/pharmacist-new-standard.pdf">NSW</a> and the <a href="https://www.legislation.act.gov.au/View/di/2020-88/current/PDF/2020-88.PDF">ACT</a> it’s mandatory for pharmacists to report vaccinations to the Australian Immunisation Register. It’s strongly encouraged in other states and territories.</p>
<p>However, we found substantial under-reporting of pharmacist vaccinations. </p>
<p>Pharmacies are said to have administered <a href="https://www.psa.org.au/pharmacists-protecting-australians-from-the-deadly-flu-virus/">over one million</a> influenza vaccinations in 2018. That’s ten times more than the number we found recorded in the Australian Immunisation Register that year.</p>
<p>In 2019, there were reported to be <a href="https://ajp.com.au/news/give-us-the-nip-guild/">over two million</a> influenza vaccinations in pharmacies, four times more than actually recorded.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/341401/original/file-20200612-38695-zl08jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/341401/original/file-20200612-38695-zl08jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/341401/original/file-20200612-38695-zl08jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/341401/original/file-20200612-38695-zl08jo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/341401/original/file-20200612-38695-zl08jo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/341401/original/file-20200612-38695-zl08jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/341401/original/file-20200612-38695-zl08jo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/341401/original/file-20200612-38695-zl08jo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Not all pharmacy vaccinations are properly reported.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pharmacist-making-prescription-record-through-computer-483541759">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Why does this matter?</h2>
<p>Under-reporting of pharmacy vaccines is less of an issue for influenza vaccination, which is needed every year. But it is more important for vaccines only needed in one or two doses or at long periods apart, such as the two doses of MMR vaccine.</p>
<p>And as pharmacy vaccination expands to travel vaccines – such as cholera and hepatitis A (which can both now be given by pharmacists in Queensland) – having an accurate immunisation record is important when travel restrictions ease.
It’s likely a long time between overseas trips and remembering which vaccinations you’ve had can be difficult.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/prepare-for-a-healthy-holiday-with-this-a-to-e-guide-69552">Prepare for a healthy holiday with this A-to-E guide</a>
</strong>
</em>
</p>
<hr>
<p>As pharmacist vaccination expands to include younger ages and vaccines on the <a href="https://www.health.gov.au/health-topics/immunisation/immunisation-throughout-life/national-immunisation-program-schedule">National Immunisation Program</a>
(the series of vaccinations given at specific times throughout your life) there’s greater potential for confusion if records are not complete. Any unrecorded vaccinations could affect certain <a href="https://www.servicesaustralia.gov.au/individuals/topics/what-are-immunisation-requirements/35396">government support</a> or access to child care under <a href="http://www.ncirs.org.au/public/no-jab-no-play-no-jab-no-pay">No Jab No Pay or No Jab No Play policies</a>. </p>
<p>An accurate record of vaccinations can also be important to meet requirements for some university courses and jobs, particularly related to health care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-which-vaccinations-should-i-get-as-an-adult-81400">Health Check: which vaccinations should I get as an adult?</a>
</strong>
</em>
</p>
<hr>
<h2>It’s not just pharmacists</h2>
<p>Generally, vaccines given to young children (who are mostly vaccinated in GP clinics) are reliably recorded, but our <a href="https://cdn.theconversation.com/static_files/files/1068/2018_AIR_data_tranfer_report_FINAL_0.pdf?1591918206">2018 report</a> found some reporting errors. So it pays to check.</p>
<p>Reporting of adult vaccinations has been less reliable. Another of our <a href="https://cdn.theconversation.com/static_files/files/1069/Analysis_of_adult_vaccination_data_on_AIR_Nov_2019.pdf?1591918354">recent reports</a> showed true vaccination uptake for the shingles vaccine, largely given in GP clinics, could be up to twice as high as that recorded in the Australian Immunisation Register.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-rivalries-between-doctors-and-pharmacists-turned-into-the-turf-war-we-see-today-122534">How rivalries between doctors and pharmacists turned into the 'turf war' we see today</a>
</strong>
</em>
</p>
<hr>
<p>Many vaccinations given in workplaces – for instance hospitals and commercial providers of workplace influenza vaccination programs – are also not currently captured in the Australian Immunisation Register, although such vaccination providers can now register to report them.</p>
<h2>How can you check your immunisation record is accurate?</h2>
<p>If you are getting a vaccination from a pharmacist, or any other vaccination provider, you can check they will be reporting it to the Australian Immunisation Register and ask for a paper record of the vaccination.</p>
<p>You can then later request an immunisation history statement, which shows all the vaccinations recorded on the Australian Immunisation Register. You can <a href="https://www.servicesaustralia.gov.au/individuals/services/medicare/australian-immunisation-register/how-get-immunisation-history-statement">do this</a> via your Medicare online account (through myGov), the Express Plus Medicare mobile app, the Australian Immunisation Register help line (1800 653 809) or your vaccination provider. </p>
<p>If vaccinations are missing, you can contact the relevant vaccination provider and ask them to update your Australian Immunisation Register record.</p>
<h2>What can we do about it?</h2>
<p>Ultimately, it shouldn’t be your responsibility to regularly check your immunisation records are accurate and up to date. It should be the responsibility of the vaccination provider to report your vaccinations to the Australian Immunisation Register.</p>
<p>So we recommend further <a href="https://www.servicesaustralia.gov.au/organisations/health-professionals/subjects/air-education-vaccination-providers">education and training</a> for pharmacists, legislation to make Australian Immunisation Register reporting by pharmacists compulsory in all states and territories; and increasing and improving use of <a href="https://www.servicesaustralia.gov.au/organisations/health-professionals/subjects/web-services-digital-health-and-aged-care-channels">electronic reporting methods</a>.</p>
<h2>How about a vaccine for COVID-19?</h2>
<p>If a COVID-19 vaccine becomes available, we will likely need a mass immunisation program to vaccinate as many people as possible. Pharmacists may be part of this program. Legislation in Queensland <a href="https://www.abc.net.au/news/2020-04-11/coronavirus-queensland-pharmacists-medication-dispensing/12141376">is being amended</a> to allow for this. </p>
<p>Hopefully, by then, we will have addressed some of these issues.</p>
<hr>
<p><em>Kaitlyn Vette, Lauren Dalton and Kristine Macartney, from the National Centre for Immunisation Research and Surveillance, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/140070/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Frank Beard is employed by the National Centre for Immunisation Research and Surveillance, which receives funding from the Australian Government Department of Health, NSW Health, and the Sydney Children's Hospitals Network </span></em></p>If your immunisation record is incomplete, you might repeat a vaccination unnecessarily, or miss out on government support, child care, or work. So it pays to check.Frank Beard, Senior Lecturer, School of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1197642020-05-23T08:32:29Z2020-05-23T08:32:29Z3D-printed drugs could be a godsend for those on multiple pills a day – and potentially life saving<figure><img src="https://images.theconversation.com/files/337013/original/file-20200522-124845-188hi72.jpg?ixlib=rb-1.1.0&rect=163%2C303%2C4431%2C3194&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/daily-drug-dose-pills-organized-pill-1042487806">Szasz-Fabian Ilka Erika/Shutterstock</a></span></figcaption></figure><p>As the population ages and rates of chronic disease rise, an increasing number of people are taking <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008165.pub4/abstract">multiple pills</a> for several conditions, often at different times throughout the day. Taking the right pill at the right time can be a hassle and potentially dangerous if a mistake is made. It is especially tough for people with dementia, for obvious reasons. It would be convenient and safe if people could take just one pill a day – a pill that delivers all the right medication at the right time in the right dose.</p>
<p>Pills normally work by releasing drugs into the body when their outer shell is dissolved in the digestive system. The drug inside then enters the bloodstream. But a cleverly designed pill could have many layers. After the first drug has been released, the next shell of the pill is exposed, which then dissolves, releasing a different drug. This would continue until the entire pill is dissolved. </p>
<p>It would also be possible to time the delivery of each drug by placing the drugs in layers that dissolve at different rates. This is not a future dream. These “polypills” are already being made, mostly for type 2 diabetes, high blood pressure and heart conditions.</p>
<p>It is not difficult to mass produce these polypills. But there is a drawback. A polypill with a specific combination of drugs doesn’t necessarily help all patients. Some people might not need one of the drugs or they might need them in different doses to those in a mass-produced polypill.</p>
<p>Making personalised polypills through the usual drug manufacturing techniques is very expensive as they are produced in very small amounts – often for just one patient. A much cheaper way of making these polypills is 3D printing, in which thin layers of materials are built up according to the design to make a final product.</p>
<h2>Printed pills</h2>
<p>A 3D-printed drug has already been <a href="https://link.springer.com/article/10.1007/s11095-016-1933-1">approved</a> by the US Food and Drug Administration (FDA), but it is not a polypill. The FDA-approved pill is made of a water-soluble drug, but many drugs are not water soluble. Drugs either need to readily dissolve after entering the body or need to be dissolved before, for efficient absorption. And these limitations also apply to polypills.</p>
<p>We have <a href="https://www.sciencedirect.com/science/article/pii/S0927775720305070">recently published research</a> on a type of material that has been used to contain water-insoluble drugs in the past, but that has never been 3D printed before. These materials are known as “surfactant-polyelectrolyte complexes”. These materials are gels made mostly of water, but their chemistry allows them to carry drugs that cannot be dissolved in water.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/287677/original/file-20190812-71926-ljjquj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/287677/original/file-20190812-71926-ljjquj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/287677/original/file-20190812-71926-ljjquj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/287677/original/file-20190812-71926-ljjquj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/287677/original/file-20190812-71926-ljjquj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/287677/original/file-20190812-71926-ljjquj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/287677/original/file-20190812-71926-ljjquj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">3D printer for making polypills.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Surfactants are molecules with two parts: one part that likes to mix with water and the other that doesn’t. This means that surfactants tend to clump together with other molecules of the same type when they are placed in water so that the parts that don’t like water are shielded from it. These structures can store drugs inside them.</p>
<p>The surfactants in our study had a negative electrical charge, and the polymers (polyelectrolytes) had a positive electrical charge. So when the oppositely charged surfactants and polyelectrolytes came into contact, they were attracted to one another to form a “complex” (hence “surfactant-polyelectrolyte complexes”). That is to say we, they formed a 3D drug-carrying system.</p>
<p>We 3D printed alternating layers of polyelectrolyte and surfactant to make these complexes. These have the potential to store and deliver drug molecules in the form of pills. The pill can be made into a polypill simply by printing different layers with different drugs.</p>
<h2>Not there yet</h2>
<p>Although lots of research has already been done, this new form of drug delivery has much further to go, especially as it requires regulatory approval. These approvals take up to five years, after passing clinical trials.</p>
<p>Maybe in five years, some of us will get a prescription for customised polypills made on a 3D printer at our local pharmacies. People with multiple conditions will take one 3D-printed pill a day instead of a complex schedule of many pills, or perhaps even have the drugs implanted in their bodies.</p>
<hr>
<p><em>To find out more about the personalisation of healthcare listen to Medicine made for you, a series from The Conversation podcast The Anthill. Listen wherever you get your podcasts.</em></p>
<iframe src="https://open.spotify.com/embed/playlist/6pMpd8nUDPuHT4jj1JSB79" width="100%" height="250" frameborder="0" allowtransparency="true" allow="encrypted-media"></iframe>
<p><a href="https://itunes.apple.com/gb/podcast/the-anthill/id1114423002?mt=2"><img src="https://images.theconversation.com/files/321534/original/file-20200319-22606-q84y3k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=182&fit=crop&dpr=1" alt="Listen on Apple Podcasts" width="268" height="68"></a> <a href="https://www.google.com/podcasts?feed=aHR0cHM6Ly90aGVjb252ZXJzYXRpb24uY29tL3VrL3BvZGNhc3RzL3RoZS1hbnRoaWxsLnJzcw%3D%3D"><img src="https://images.theconversation.com/files/233720/original/file-20180827-75978-3mdxcf.png" alt="" width="268" height="68"></a></p>
<hr><img src="https://counter.theconversation.com/content/119764/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The author has been employed through an EPSRC grant (EP/N024818/1) 'Formulation for 3D printing: Creating a plug and play platform for a disruptive UK industry'. His work discussed in the article constitutes the project funded through the above grant.</span></em></p>New manufacturing processes will revolutionise the way we take our medicines.Saumil Vadodaria, Research Fellow, Chemical Engineering, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1374362020-05-13T13:36:39Z2020-05-13T13:36:39ZHow coronavirus is contributing to drug shortages in Canada<figure><img src="https://images.theconversation.com/files/333581/original/file-20200508-49550-lpw8di.jpg?ixlib=rb-1.1.0&rect=355%2C102%2C2676%2C2038&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A lab technician prepares a prescription at a pharmacy in Quebec City on March 8, 2020. </span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Jacques Boissinot</span></span></figcaption></figure><p>COVID-19 has exposed and magnified weaknesses within health-care systems. Drug shortages, which are a growing problem in Canada, may be one example of this. </p>
<p>Shortages hinder patients’ ability to effectively manage chronic diseases, leading to unnecessary harm. They also complicate the work of health-care providers, such as pharmacists, who must spend considerable time trying to find difficult-to-obtain drugs, and physicians, who have to prescribe alternative drugs to replace those that are unavailable. Shortages may also increase costs if alternative treatments are more expensive.</p>
<h2>Potential contributors to shortages</h2>
<p>Disruptions in the supply chain due to COVID-19 may cause shortages because <a href="https://dx.doi.org/10.1503%2Fcmaj.120416">many</a> drugs and the raw ingredients used to produce them come from India and China. India has started to <a href="https://doi.org/10.1503/cmaj.1095862">ban</a> some drug exports due to shortages in its own country. </p>
<p>Supply-side pressures are also caused by <a href="https://doi.org/10.1186/s12992-017-0285-x">increasing consolidation</a> in the pharmaceutical industry, which means fewer suppliers and manufacturing facilities and thus fewer alternative sources for drugs. Given that <a href="https://www.cdhowe.org/sites/default/files/attachments/research_papers/mixed/Commentary_515.pdf">most shortages</a> are of less expensive <a href="https://doi.org/10.1016/j.jval.2018.04.1826">generic drugs</a>, some speculate that manufacturers intentionally <a href="https://www.canadadrugshortage.com/causes/">limit the production of less profitable products to drive up sales of expensive brand name drugs</a>. </p>
<p>COVID-19 may also produce demand-side shortages. Manufacturers are struggling to keep up with demand for the sedatives required by patients on ventilators. Large volumes of these drugs will also be necessary when Canadian hospitals catch-up on elective surgeries cancelled due to COVID-19. For example, two manufacturers of one such sedative, propofol, <a href="https://www.drugshortagescanada.ca/search?term=propofol&date_property=&date_range%5Bdate_range_start%5D%5Bmonth%5D=3&date_range%5Bdate_range_start%5D%5Bday%5D=1&date_range%5Bdate_range_start%5D%5Byear%5D=2020&date_range%5Bdate_range_end%5D%5Bmonth%5D=5&date_range%5Bdate_range_end%5D%5Bday%5D=1&date_range%5Bdate_range_end%5D%5Byear%5D=2020&filter_type=_all_&filter_status=_all_&_token=kQ8C-BJS6Ha4u-oi7EfrYcXN7f-2Rf5_PvzqhACpLww">have reported recent shortages</a>. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/333584/original/file-20200508-49584-190lrw5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/333584/original/file-20200508-49584-190lrw5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/333584/original/file-20200508-49584-190lrw5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/333584/original/file-20200508-49584-190lrw5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/333584/original/file-20200508-49584-190lrw5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/333584/original/file-20200508-49584-190lrw5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/333584/original/file-20200508-49584-190lrw5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hydroxychloroquine has been in high demand since it was touted as a possible COVID-19 treatment.</span>
<span class="attribution"><span class="source">(AP Photo/David J. Phillip)</span></span>
</figcaption>
</figure>
<p>Hydroxychloroquine and azithromycin, which were <a href="https://doi.org/10.1503/cmaj.200528">touted</a> as treatments for COVID-19, are in sufficiently high demand that professional regulatory bodies have issued <a href="https://rnao.ca/news/media-releases/2020/03/23/joint-message-ontario%E2%80%99s-doctors-nurse-practitioners-and-pharmacists">warnings</a> about inappropriately prescribing these products. Since March 15, six azithromycin <a href="https://www.drugshortagescanada.ca/search?term=Azithromycin&date_property=&date_range%5Bdate_range_start%5D%5Bmonth%5D=3&date_range%5Bdate_range_start%5D%5Bday%5D=1&date_range%5Bdate_range_start%5D%5Byear%5D=2020&date_range%5Bdate_range_end%5D%5Bmonth%5D=5&date_range%5Bdate_range_end%5D%5Bday%5D=1&date_range%5Bdate_range_end%5D%5Byear%5D=2020&filter_type=_all_&filter_status=_all_&_token=kQ8C-BJS6Ha4u-oi7EfrYcXN7f-2Rf5_PvzqhACpLww">products</a> and one hydroxychloroquine <a href="https://www.drugshortagescanada.ca/search?term=hydroxychloroquine&date_property=&date_range%5Bdate_range_start%5D%5Bmonth%5D=3&date_range%5Bdate_range_start%5D%5Bday%5D=1&date_range%5Bdate_range_start%5D%5Byear%5D=2020&date_range%5Bdate_range_end%5D%5Bmonth%5D=5&date_range%5Bdate_range_end%5D%5Bday%5D=1&date_range%5Bdate_range_end%5D%5Byear%5D=2020&filter_type=_all_&filter_status=_all_&_token=kQ8C-BJS6Ha4u-oi7EfrYcXN7f-2Rf5_PvzqhACpLww">manufacturer</a> have reported shortages in Canada. The latter of these affects patients who take hydroxychloroquine to treat arthritis and lupus.</p>
<h2>Prevalence of shortages</h2>
<p>In order to enhance tracking of and responsiveness to drug shortages, Health Canada has required manufacturers to report shortages since 2017. Shortages have been steadily increasing over the past two years, with <a href="https://www.drugshortagescanada.ca/">2,023 products in shortage as of April 2020</a>. </p>
<p>Some of this effect may be attributable to the increasing number of products that are added to the pharmaceutical market each year. This suggests that Health Canada must continue to increase its capacity to monitor and address shortages to correspond with the growing number of products in active use. In its role as federal drug regulator, Health Canada may help drug manufacturers address shortages by reviewing alternative suppliers, processes, facilities and production locations. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/332524/original/file-20200504-83745-1awagdz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/332524/original/file-20200504-83745-1awagdz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=454&fit=crop&dpr=1 600w, https://images.theconversation.com/files/332524/original/file-20200504-83745-1awagdz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=454&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/332524/original/file-20200504-83745-1awagdz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=454&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/332524/original/file-20200504-83745-1awagdz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=571&fit=crop&dpr=1 754w, https://images.theconversation.com/files/332524/original/file-20200504-83745-1awagdz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=571&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/332524/original/file-20200504-83745-1awagdz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=571&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Anticipated or actual shortages, April 2018-April 2020.</span>
<span class="attribution"><span class="source">(Lorian Hardcastle and Reed Beall)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Although the full effects of COVID-19 on drug shortages are not yet known, it is notable that manufacturers <a href="https://www.drugshortagescanada.ca/">reported 221 new shortages in April 2020, compared to 148 in March, 59 in February and 104 in January</a>. In other words, a recent increase in shortages, which could be attributable to COVID-19, may worsen existing problems with shortages.</p>
<h2>Response to shortages</h2>
<p>Pharmacists reported a rush to fill prescriptions when physical distancing measures took effect, with some patients <a href="https://www.thestar.com/business/2020/03/19/please-stop-stockpiling-prescriptions-pharmacies-urge-canadians.html">requesting</a> a six-month supply. In response, Health Canada <a href="https://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2020/72661a-eng.php">discouraged</a> drug stockpiling and the <a href="https://www.pharmacists.ca/news-events/news/covid-19-and-the-responsible-allocation-of-medications-to-patients/">Canadian Pharmacists Association</a> and <a href="http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/exec_office_20200320.pdf">provincial governments</a> strongly encouraged pharmacists to limit patients to a 30-day supply of their prescriptions. </p>
<p>Although this may help to address shortages by moderating demand, it increases the cost of drugs for individuals who may incur additional dispensing fees with each visit. This disproportionately affects those who are unemployed and who have lower incomes. It may also require more frequent visits to pharmacies, which can be dangerous for seniors who are at increased risk for COVID-19 and tend to use more prescriptions. When this 30-day restriction is lifted, the elevated demand may further contribute to shortages.</p>
<p>The federal government has implemented several measures to address COVID-related shortages. On March 25, it <a href="https://www.parl.ca/DocumentViewer/en/43-1/bill/C-13/royal-assent">authorized</a> the passage of regulations necessary for “preventing shortages … or alleviating those shortages or their effects, in order to protect human health.” </p>
<p>This legislation also allows the government to grant a manufacturer a license to produce a drug, even if another manufacturer holds the patent for that product. Although these licences could theoretically increase supply, practical challenges may limit their utility. For example, alternative suppliers may similarly be unable to obtain raw ingredients from the same foreign suppliers. </p>
<p>A more practicable solution may be the import and sale of drugs that have not yet met all Canadian regulatory requirements, which is permissible following an <a href="https://www.canada.ca/en/health-canada/services/drugs-health-products/compliance-enforcement/covid19-interim-order-drugs-medical-devices-special-foods.html">order</a> by the minister of health. However, this exceptional process is only available for <a href="https://www.canada.ca/en/health-canada/services/drugs-health-products/compliance-enforcement/covid19-interim-order-drugs-medical-devices-special-foods/information-provisions-related-drugs-biocides/tier-3-shortages.html">particular drugs</a> that meet certain manufacturing standards.</p>
<p>While the federal government’s efforts may help to mitigate shortages during COVID-19, it should also seize this opportunity to develop long-term solutions to shortages, which have affected the Canadian drug market for years. Due to the globalization of pharmaceutical manufacturing, the government must work with both industry and other countries to rapidly identify and respond to disruptions in the supply chain, so that Canadians have uninterrupted and reliable access to safe drugs. Given the pressures caused by COVID-19, now is a pivotal time for the government to act.</p><img src="https://counter.theconversation.com/content/137436/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>This is a pivotal time for policymakers to be vigilant about drug shortages and to ensure that Canadians have reliable access to safe drugs.Lorian Hardcastle, Assistant Professor, Faculty of Law and Cumming School of Medicine; Member, AMR One Health Consortium, University of CalgaryReed F Beall, Assistant Professor, Community Health Sciences, Cumming School of Medicine, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1376712020-05-13T09:21:43Z2020-05-13T09:21:43ZCOVID-19 pandemic is our chance to learn how to reuse old medicines<figure><img src="https://images.theconversation.com/files/334114/original/file-20200511-49558-palxym.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>It’s usually illegal to reuse leftover medicines in the UK for any purpose. But as a result of the coronavirus pandemic, the government has released <a href="https://www.gov.uk/government/publications/coronavirus-covid-19-reuse-of-medicines-in-a-care-home-or-hospice?utm_source=09d3c6e9-e7c7-4867-a197-d2a68e01f4be&utm_medium=email&utm_campaign=govuk-notifications&utm_content=immediate">guidance</a> that allows this to happen in care homes and hospices, under very strict guidelines. </p>
<p>The guidance is to be welcomed. For the past two years, <a href="https://research.reading.ac.uk/research-blog/medicines-is-it-time-to-challenge-the-throw-away-culture/">we have been calling on</a> the government to consider changing the rules on reuse to prevent the massive amounts of waste that takes place when we throw away medicine. </p>
<p>The UK wasted an estimated £300 million a year of medicines <a href="https://discovery.ucl.ac.uk/id/eprint/1350234/1/Evaluation_of_NHS_Medicines_Waste__web_publication_version.pdf">in 2009</a>, £110 million of which related to medicines returned to community pharmacies for disposal. </p>
<p>People are more likely to <a href="https://link.springer.com/chapter/10.1007/398_2016_3">dispose of their unwanted residential medication</a> in the household bin or down the drain than return these to pharmacies, <a href="https://ehp.niehs.nih.gov/doi/full/10.1289/ehp.8315">contaminating</a> water and soil. Prescribed medicinal waste can also harm the environment by unnecessarily inflating our <a href="https://www.sduhealth.org.uk/policy-strategy/reporting/nhs-carbon-footprint.aspx">carbon footprint</a>.</p>
<p>A safe, sustainable system for reusing unwanted medication could make a huge difference in addressing these problems, beyond the current pandemic.</p>
<h2>What is medicine reuse?</h2>
<p><a href="https://onlinelibrary.wiley.com/doi/full/10.1111/ijpp.12391">Medicine reuse</a> is the idea that medication given to one patient can be taken back if it’s no longer needed and given to someone else to use instead. </p>
<p>Under normal circumstances, medicines dispensed in the community are not allowed to be reused, mainly because <a href="https://archive.bma.org.uk/collective-voice/committees/patient-liaison-group/resources/dispensed-but-unopened-medications">health officials worry that</a> drugs that come back from people’s homes will have declined in quality.</p>
<p>Medicines, after all, are not the same as other recycled goods — to work properly, the right amount of active drug is needed, but <a href="https://archive.bma.org.uk/collective-voice/committees/patient-liaison-group/resources/dispensed-but-unopened-medications">this could potentially decrease</a> if the medicine has been kept at the wrong temperature, or under too much light or moisture, away from the pharmacy.</p>
<p>The question of whether it is safe to reuse medicine is not an easy one to answer. We know <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2710.2009.01129.x">from our own work</a> on a small sample of tablets that if you take medicines out of their packaging and store them in hot and humid conditions for a month, there are at least some subtle changes. </p>
<p>But no one has ever fully looked at where and how medicines are generally stored when they leave the pharmacy. And we don’t actually know what (if anything) happens to medicines that are kept inside their original packaging. Because of this uncertainty, medicines returned to community pharmacies have to be <a href="https://psnc.org.uk/services-commissioning/essential-services/disposal-of-unwanted-medicines/">disposed of instead</a> of being reused.</p>
<p>Some countries including the <a href="https://www.ncsl.org/research/health/state-prescription-drug-return-reuse-and-recycling.aspx">United States</a> and <a href="https://givmed.org/en/">Greece</a> do operate medication reuse schemes, mainly for benevolent reasons – the idea being that suitable medicines can re-enter the supply chain and be re-issued to others who might not otherwise afford them.</p>
<h2>The environmental case for reuse</h2>
<p>Medicine shortages were a growing <a href="https://www.who.int/medicines/publications/druginformation/WHO_DI_30-2_Medicines.pdf?ua=1">global problem</a> even before the pandemic began.</p>
<p>In 2019 alone, the UK <a href="https://www.pharmaceutical-journal.com/news-and-analysis/news/confidential-government-documents-reveal-names-of-209-medicine-shortages-in-2019/20207603.article">identified supply issues</a> for 209 medicines, including heart medicines, anti-epilepsy tablets and treatments for cancer.</p>
<p>Now, the pandemic has added to an existing problem, by <a href="https://www.pharmaceutical-journal.com/news-and-analysis/opinion/comment/ways-to-safeguard-uk-drug-supplies-during-covid-19-and-beyond/20207897.article">reducing supplies</a> from overseas manufacturers while <a href="https://www.which.co.uk/news/2020/03/medicine-shortages-whats-going-on/">demand for medicines has naturally increased</a>.</p>
<p>The current government’s decision on the reuse of medicines, then, is a way of trying to deal with <a href="https://www.theguardian.com/commentisfree/2020/mar/19/will-coronavirus-lead-to-drug-shortages-for-the-nhs">drug shortages</a>. </p>
<h2>Medicine reuse in care homes</h2>
<p>What the <a href="https://www.gov.uk/government/publications/coronavirus-covid-19-reuse-of-medicines-in-a-care-home-or-hospice?utm_source=09d3c6e9-e7c7-4867-a197-d2a68e01f4be&utm_medium=email&utm_campaign=govuk-notifications&utm_content=immediate">government is suggesting</a> now is that care homes and hospices draw up <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/881838/medicines-reuse-in-care-homes.pdf">standard operating procedures</a> in case they have to reuse some medicines. </p>
<p>The proposals are quite complex and need careful reading. If a medicine that is urgently required is out of stock, an alternative must be prescribed and dispensed if at all possible. If not, then the pharmacy can explore the possibility of reuse. </p>
<p>Importantly, the proposed medicine should no longer be needed by the original recipient, and both parties (or their representatives) must consent to the reuse. Added to this are <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/881489/COVID-19_Infection_prevention_and_control_guidance_complete.pdf">measures to stop</a> the possibility of cross-contamination with the coronavirus during repackaging of the reused medicine.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/334116/original/file-20200511-30864-18uuma1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/334116/original/file-20200511-30864-18uuma1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334116/original/file-20200511-30864-18uuma1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334116/original/file-20200511-30864-18uuma1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334116/original/file-20200511-30864-18uuma1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334116/original/file-20200511-30864-18uuma1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334116/original/file-20200511-30864-18uuma1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The new guidance on reusing medicine in care homes addresses a genuine need.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>The new guidance addresses a genuine need within care homes and hospices which are already struggling on the frontlines of the pandemic, and where <a href="https://www.ft.com/content/aadf1825-4cad-4c8e-ad2d-5ecae186ca60">urgent demand for medication</a> is likely to be for the purpose of managing someone’s pain or breathlessness <a href="https://apmonline.org/wp-content/uploads/2020/04/priority-meds-for-end-of-life-care-290420-final-2.pdf">at the end of their life</a>. </p>
<p>Such a scenario is clearly an example where the benefit of reusing a medicine reasonably outweighs the potential risks.</p>
<h2>A more sustainable future</h2>
<p>It is vital that we learn from our experiences reusing medicine in care homes as we dare to look beyond the current pandemic. </p>
<p>At the moment, a registered health professional currently has <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/881838/medicines-reuse-in-care-homes.pdf">to inspect medicines</a> to make sure they are suitable for reuse. But whether completed in person or virtually, these checks can only provide a physical assessment, which does not guarantee the quality or amount of the medicines inside. So it will be important to find out how these inspections work in practice. </p>
<p>Our own ambition is to develop a <a href="https://www.mdpi.com/2226-4787/8/2/58">technology ecosystem</a> for the packaging of pharmaceuticals that will allow for the safe reuse of medicines in the future. This would involve creating a novel digital time temperature and humidity indicator to help with quality assurance of medicines. We have already developed a prototype using smart sensors which connect to the cloud to verify safety and enable the reuse of returned medicines.</p>
<p>This would provide an opportunity to explore medicine reuse not only during a pandemic but as a standard part of running a sustainable pharmacy.</p><img src="https://counter.theconversation.com/content/137671/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Parastou Donyai receives funding from Alzheimer's Society. </span></em></p><p class="fine-print"><em><span>Simon Sherratt works for the University of Reading as an academic, and has received research grants from the EPSRC .</span></em></p><p class="fine-print"><em><span>Rachel McCrindle and Terence Hui do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The UK government is allowing care homes and hospices to reuse leftover medicines during the pandemic. Here’s why that’s a good thing.Parastou Donyai, Professor and Director of Pharmacy Practice, University of ReadingRachel McCrindle, Professor of Computer and Human Interaction, University of ReadingRobert Simon Sherratt, Professor of Biosensors, University of ReadingTerence Hui, Postdoctoral research associate, University of ReadingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1364942020-04-21T12:47:29Z2020-04-21T12:47:29ZHow much coronavirus testing is enough? States could learn from retailers as they ramp up<figure><img src="https://images.theconversation.com/files/328947/original/file-20200419-152591-4p1h0f.jpg?ixlib=rb-1.1.0&rect=6%2C6%2C2032%2C1342&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">To control the coronavirus spread, the U.S. needs to get the most value out of the limited testing capacity it has.</span> <span class="attribution"><a class="source" href="http://gettyimages.com">Steve Pfost/Newsday RM via Getty Images</a></span></figcaption></figure><p>As states develop plans to restart their economies, the big fear is that coronavirus cases will <a href="https://www.reuters.com/article/us-health-coronavirus-china-toll/china-reports-rise-in-coronavirus-cases-most-from-abroad-idUSKCN21T012">surge again</a>. To keep the pandemic under control, strategic testing systems will be needed, and they will need to be scaled up fast.</p>
<p>But how many people should be tested? Who should be tested? And what should that testing system look like?</p>
<p>There isn’t one simple answer. The notion of “widespread testing” has a different meaning for big metropolitan areas, such as New York City and Detroit, than for rural areas like Montana or Alaska. For testing systems to be efficient, they need to be tailored to the demographics, circumstances and disease spread patterns for each.</p>
<p>As policymakers figure out the best design for each state or county, they could learn a lot from the retail industry, where strategic decisions such as where to locate warehouses and distribution centers are being made by companies like Amazon in the face of uncertain customer demand.</p>
<p>I have been <a href="http://www-personal.umich.edu/%7Esiqian/projects.html">researching complex systems design</a> in health care, transportation and energy supply management and have found that good models using mathematics and data can help design such systems, even with the kind of information uncertainty we see with the new coronavirus spread.</p>
<h2>It isn’t as simple as ‘test everyone’</h2>
<p>Policymakers and researchers have floated several <a href="https://www.vox.com/2020/4/10/21215494/coronavirus-plans-social-distancing-economy-recession-depression-unemployment">plans for reopening the country</a>, with a range of ideas for how to conduct coronavirus testing. On one end of the spectrum, a plan <a href="https://paulromer.net/covid-sim-part2/">sketched out by Nobel Prize-winning economist Paul Romer</a> calls for 7% of the U.S. population to be tested at random daily. That’s roughly 23 million people every day.</p>
<p>Another plan, released Monday <a href="https://ethics.harvard.edu/files/center-for-ethics/files/roadmaptopandemicresilience_updated_4.20.20.pdf">by a team coordinated by Harvard University’s center for ethics</a>, recommended 5 million tests per day by early June and 20 million a day by August.</p>
<p>While random testing of that magnitude can provide a broad snapshot of the disease, it is not realistic for a country the size of the U.S. in the short term. Countries that are conducting random testing on large percentages of their populations, such as <a href="https://www.nytimes.com/2020/04/14/upshot/coronavirus-singapore-thinking-big.html">Singapore</a>, <a href="https://nordiclifescience.org/covid-19-first-results-of-the-voluntary-screening-in-iceland/">Iceland</a> and <a href="https://www.sciencemag.org/news/2020/03/coronavirus-cases-have-dropped-sharply-south-korea-whats-secret-its-success">South Korea</a>, have far fewer people and less complex demographics than the U.S.</p>
<p>The U.S. also has had serious challenges with its testing system, including <a href="https://www.washingtonpost.com/investigations/2020/04/03/coronavirus-cdc-test-kits-public-health-labs/">a flawed diagnostic test approved by the CDC</a>, <a href="https://www.nytimes.com/2020/03/11/health/coronavirus-testing-shortages.html">scarce supplies for manufacturing test kits and running tests</a>, and <a href="https://www.nytimes.com/2020/04/13/nyregion/coronavirus-testing.html">limited access to screening</a>.</p>
<p>As of mid-April, <a href="https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/testing-in-us.html">U.S. public</a> and <a href="https://www.acla.com/covid-19/">corporate labs</a> together were only testing about 150,000 coronavirus samples a day. In all, some <a href="https://covidtracking.com/data">4 million tests had been conducted in the U.S.</a>, about 20% of them positive.</p>
<p>That high rate of positive tests, 20%, suggests that many COVID-19 cases probably aren’t being identified. The World Health Organization recommends conducting enough tests that <a href="https://twitter.com/WHO/status/1244637360706342917">no more than 10% come back positive</a>. In the U.S., that would require <a href="https://globalepidemics.org/2020/04/18/why-we-need-500000-tests-per-day-to-open-the-economy-and-stay-open/">more than 500,000 per day</a>, according to recent estimates from Harvard public health researchers.</p>
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<p>At this point, the U.S. needs to get the most value out of the limited testing capability it has. Some options include prioritizing states with the most infections and deaths from COVID-19; areas where health systems are overwhelmed; or groups that have the most contact with others, such as health workers and grocery store clerks.</p>
<h2>Who should be tested?</h2>
<p>One purpose of the mathematical models I work with is to help policymakers determine which population groups should be prioritized and how.</p>
<p>There are different reasons to prioritize different groups. For example, older adults and <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6915e3.htm?s_cid=mm6915e3_w#contribAff">people with chronic illnesses</a> have a higher likelihood of developing severe conditions if they get COVID-19. First responders, health workers, teachers and others who have close contact with large numbers of people also have a high chance of getting and spreading the disease. People living in close quarters such as nursing homes or prisons also run a high risk of infection.</p>
<p>Once priority groups are identified, models can show where to locate testing facilities and how to allocate the tests kits and other resources most efficiently.</p>
<h2>Learning from retail</h2>
<p>There is a large body of research that has traditionally been used to site retail stores, optimize inventory and production and manage stock levels as demand for products fluctuates by season. </p>
<p>Establishing a testing system for COVID-19 presents a similar set of challenges. The same <a href="http://www-personal.umich.edu/%7Esiqian/docs/or-ie-fighting-covid19_v1.pdf">mathematical models used to help retail companies</a> like Amazon meet demand quickly for a wide range of products could incorporate test-manufacturing capacities, the needs of different populations and goals such as increasing testing speed and coverage.</p>
<p>One question is where to conduct COVID-19 testing. Another set of questions involves the capacity of those facilities, such as how many test kits they need and what their staffing levels should be to process enough tests while minimizing people’s travel distance.</p>
<p>There is one big point of uncertainty, and it’s the same question that widespread testing is helping to clarify: How will the disease spread?</p>
<p>Retail companies know the demand patterns for most of their products quite well, given repeated orders and seasonal trends. But U.S. public health officials have only a few months of partial data on the spread and impact of this new coronavirus.</p>
<p>Adding to the complications, test results can create a biased picture of the pandemic depending on how many tests are done in each area and who was tested.</p>
<p>An iterative process is necessary to learn to analyze the data and predict the disease’s spread. </p>
<p>Whether the U.S. can scale up testing fast enough to keep the coronavirus spread under control mainly relies on strategic testing capabilities and how well we can design that testing system.</p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/136494/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Siqian Shen does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Testing everyone for COVID-19 isn’t realistic in a country the size of the US, but there are ways to design testing systems that can catch most of the cases.Siqian Shen, Associate Professor of Industrial and Operations Engineering, University of MichiganLicensed as Creative Commons – attribution, no derivatives.