Community Pharmacists' Views and Experiences with ADR Reporting for Complementary Medicines: A Qualitative Study in New Zealand.

INTRODUCTION: Detecting signals of safety concerns associated with complementary medicines (CMs) relies on spontaneous reports submitted by health professionals and patients/consumers. Community pharmacists are well placed to identify and report suspected adverse drug reactions (ADRs) associated with CMs, but pharmacists submit few CMs ADR reports. OBJECTIVES: The aim of this study was to explore New Zealand community pharmacists' views and experiences with ADR reporting for CMs. METHODS: Qualitative, in-depth, semi-structured interviews were undertaken with 27 practising community pharmacists identified through purposive and convenience sampling. Data were analysed using a general inductive approach. RESULTS: Participants were familiar with systems for reporting ADRs, believed ADR reporting for CMs important, and that pharmacists should contribute. However, few submitted reports of CMs ADRs and none encouraged patients/consumers to do so. Participants explained this was because they had never been informed by patients about ADRs associated with CMs. Participants said they would report serious ADRs; time pressures, lack of certainty around causality, lack of awareness of mechanisms for reporting CMs ADRs, and lack of remuneration were deterrents to reporting. Participants were aware of intensive-monitoring studies for prescription medicines, understood the rationale for considering this approach for CMs and recognised there would be potential practical difficulties. CONCLUSIONS: Participants used their knowledge of CMs safety concerns to minimise risk of harms to consumers from CMs use, but most had a passive approach to identifying and reporting ADRs for CMs. There is substantial potential for pharmacists to adopt proactive strategies in pharmacovigilance for CMs, particularly in recognising and reporting ADRs, and empowering CMs users to do the same.

Community pharmacists' professional practices for complementary medicines: a qualitative study in New Zealand.

Background Complementary medicines are a popular healthcare choice among patients/consumers, and most pharmacies sell these products. Pharmacists are well-placed to advise on complementary medicines, but their training and practices for these products are not optimal. Pharmacists' professional practices for complementary medicines ought to be influenced by professional codes of ethics and standards. Objective To examine community pharmacists' perspectives on complementary medicines in New Zealand, including motivations and justifications for selling these products, and professional and ethical issues complementary medicines raise for pharmacists. Setting Community pharmacists in New Zealand. Method Qualitative, semi-structured interviews with 27 New Zealand practising community pharmacists identified through purposive and convenience sampling. Main outcome measure Participants' views, experiences, and professional practices for complementary medicines. Results Participants struggled to clearly describe products they considered complementary medicines. Perspectives towards these products ranged from strongly supportive to somewhat sceptical; none was strongly opposed. Participants had several motivations for selling complementary medicines, particularly consumer demand and profits. Participants acknowledged ethical issues concerning complementary medicines, including lack of evidence of efficacy and pharmacists' limited training/knowledge. Few referred explicitly to complementary-medicines-related statements in the Pharmacy Council of New Zealand's Code of Ethics, or indicated these guided their practice. Conclusion Participants sold complementary medicines despite having limited knowledge on these products and concerns about efficacy; participants justified this as they believe they are providing an holistic option for patients, and/or ensuring complementary medicines do no harm. Participants were mindful of ethical/professional issues regarding complementary medicines, but were not necessarily aware of, or guided by, explicit statements in the Pharmacy Council of New Zealand's Code of Ethics.

Community pharmacists' views on the regulation of complementary medicines and complementary-medicines practitioners: a qualitative study in New Zealand.

OBJECTIVES: To examine community pharmacists' perspectives on CMs regulation in New Zealand, where proposals for CMs regulations had recently been suspended and where, currently, CMs are only weakly regulated. METHODS: Qualitative, in-depth, semi-structured interviews with New Zealand practising community pharmacists are identified through purposive and convenience sampling. Data were analysed using a general inductive approach. KEY FINDINGS: Participants held mixed views regarding harmonisation of CMs regulations across Australia and NZ; some supported an NZ national regulatory framework for CMs, based on the Australian system. Participants recognised the current CMs regulatory framework in NZ as inadequate, that regulation was required to some extent, and that mandatory regulation was not necessarily required. A key reason given in support of CMs regulations was the need for greater assurances around quality of CMs. Participants also supported a regulatory framework that incorporated assessment of the safety of CMs, but were less convinced of the need for, or feasibility of, requiring evidence of efficacy from clinical trials. Participants believed that regulation of CMs practitioners, such as herbalists, and CMs retailers was important, although there were mixed views as to whether regulation should be statutory or whether self-regulation would be adequate. CONCLUSIONS: On the basis of these findings, pharmacists would be expected to welcome proposals for national regulations for CMs in NZ: such regulations should address concerns regarding product quality, inappropriate health claims and supporting evidence, and therefore should support pharmacists in meeting their obligations under the NZ Pharmacy Council's Code of Ethics.

Atypical alliances: the potential for social work and pharmacy collaborations in primary health care delivery.

The growing prevalence of chronic conditions is a cause for concern globally, both in terms of its impact on the health of populations and also the strain it is predicted to place on health resources. There is a push to adopt more holistic and collaborative approaches to health care, and for the education of health care professionals to be reformed if these efforts are to be successful. A research project was undertaken in New Zealand in 2010-2011 aimed at exploring the perceptions of health care professionals on competencies in the field of chronic care. This article aims to highlight learning from the project regarding the "atypical alliance" between social work and pharmacy. Based on this, the authors argue that, with the growing expectations for interprofessional collaboration, effective primary and community health care delivery is increasingly dependent on relationships between educators in different health disciplines, between health professionals-in-training, and between education providers and health organizations.

The impact of New Zealand's 2008 prohibition of piperazine-based party pills on young people's substance use: results of a longitudinal, web-based study.

BACKGROUND: The last decade has seen the emergence of a new phenomenon in recreational substance use with the availability of herbal and synthetic, unregulated, psychoactive drugs in the market place; alongside this, international concern has developed in relation to their use and associated harms. New Zealand (NZ) was one of the first countries to experience this new phenomenon, with products containing chemicals of the piperazine group - mainly benzylpiperazine (BZP) and trifluoromethylphenylpiperazine (TFMPP). In 2008, the NZ Government prohibited these substances, but allowed a 6-month amnesty period for possession. Our study aimed to obtain a measure of change in BZP use over time. METHODS: This study used a longitudinal, web-based survey, with data collected at two time points from the same participants. The first survey was carried out 3 months after BZP prohibition, and included retrospective questions for the 6 months preceding the survey. The second survey was conducted 9 months after prohibition and also included retrospective questions for the 6 months preceding the survey. RESULTS: 273 sets of paired data were identified. The use of BZP party pills (p<0.0001) and legally available smokeable products (p=0.002) reduced over time. A majority of users of party pills obtained them from friends or from their own stockpiled supplies. The misuse of prescription drugs (p=0.02) increased over time, whereas statistically significant increases in stimulant or alcohol use were not noted. CONCLUSION: Following prohibition of piperazine-based party pills, we noted a significant reduction in the proportions of participants using them. The observed increase in the misuse of prescription medicines may relate to their perceived 'quality', or as being less 'illegal' than illicit drugs.

A qualitative evaluation of general practitioners' perceptions regarding access to medicines in New Zealand.

OBJECTIVE: The objective of this study was to evaluate general practitioners' (GPs) perceptions regarding access to medicines in New Zealand. DESIGN: Qualitative. SETTING: Primary care. PARTICIPANTS: GPs. MAIN OUTCOME MEASURES: GPs' views and perceptions. RESULTS: GPs were of the view that the current range of medicines available in New Zealand was reasonable; however, it was acknowledged that there were some drugs that patients were missing out on. When considering the range of subsidised medicines available in New Zealand, some GPs felt that there had been an improvement over recent years. It was highlighted that unexpected funding changes could create financial barriers for some patients and that administrative procedures and other complexities created barriers in receiving a subsidy for restricted medicines. GPs also reported problems with the availability and sole supply of certain medicines and claimed that switching from a branded medicine to its generic counterpart could be disruptive for patients. CONCLUSIONS: The research concluded that although there were some issues with the availability of certain drugs, most GPs were satisfied with the broader access to medicines situation in New Zealand. This view is to contrary to the situation presented by the pharmaceutical industry. The issues around sole supply, the use of generic medicines and the administrative barriers regarding funding of medicines could be improved with better systems. The current work provides a solid account of what GPs see as the advantages and disadvantages of the current system and how they balance these demands in practice.

Clinician experiences of employing the AmpliChip® CYP450 test in routine psychiatric practice.

These findings are from a qualitative study examining clinician experiences of employing the AmpliChip® CYP450 test in psychiatric practice. One hundred tests were made available to secondary care mental health service clinicians commencing patient treatment with risperidone across three District Health Boards within New Zealand. Feedback was sought on clinicians' (n = 33) experiences of ordering the test and receiving results, utilization of results, and perceived advantages and disadvantages. Difficulties were reported regarding ordering the test and receiving the results; however, real or perceived advantages of employing the test results in practice were widely reported. Analysis of the ways in which the test results were reportedly utilized revealed that they generally played a supporting role with regard to dosing decisions, rather than being the main influence on clinician behaviour. The test itself, and subsequent results, was viewed as potentially useful in facilitating the development of the doctor-patient relationship. Reported disadvantages of the test included potential over-reliance at the expense of clinical wisdom, cost, and challenges inherent in introducing a new clinical procedure into routine practice. These findings indicate that psychiatric clinicians are receptive to employing this test as a clinical support tool if its implementation is carefully considered and economically justifiable.

Prescription drug misuse in New Zealand: challenges for primary health care professionals.

BACKGROUND: Prescription drug misuse (PDM) is an international phenomenon. Prescription drugs sought for this purpose are often obtained through the primary health care network. OBJECTIVES: This study aimed to explore the challenges faced by community pharmacists (CPs) and general practitioners (GPs) when faced with the issue of "drug-seeking" and PDM. This forms part of a larger study of PDM issues for primary health care practitioners. METHODS: Qualitative interviews were carried out in New Zealand with 17 GPs and 16 CPs, purposively sampled to provide information from a variety of demographic and work environments. Interviews were tape-recorded, transcribed verbatim, and a thematic analysis conducted. Data collection took place between June 2007 and January 2008, and interviewees were offered an NZ$30 voucher in recognition of their contribution to the research. RESULTS: GPs and CPs faced a series of challenges in managing PDM, including identification of PDM, dealing with requests for inappropriate requests for psychoactive prescription drugs, verifying the legitimacy of requests and managing threatening behaviors. Specific issues were faced by rural practitioners, female practitioners and by locums and part-time staff. In particular, some participants reported feeling emotionally stressed after unpleasant drug-seeking incidents and some acknowledged that they may have missed identifying some drug-seeking because of lack of knowledge, "drug-seekers'" sophisticated strategies, or patients falling outside of their image of the archetypal "drug-seeker." CONCLUSION: This study demonstrated that PDM can be an issue for primary health care practitioners, and it can cause disruption to their work. Training in how to better manage threatening and escalating incidents may be useful as would increasing the level of awareness of PDM issues among health professional students.

A low-glycemic nutritional fitness program to reverse metabolic syndrome in professional firefighters: results of a pilot study.

BACKGROUND: The risk for cardiovascular events is higher for those with metabolic syndrome (MetS), and it is known that firefighters have a 4-fold risk for cardiovascular events. The purpose of this study was to quantify MetS prevalence and evaluate the effect of a low-glycemic nutritional fitness program on the reduction of MetS risk factors among firefighters. METHODS: Professional firefighters were screened for MetS then enrolled in a low-glycemic nutritional fitness program for a 12-week period. Anthropometric and physiological measurements were obtained at the start and end of the program. Subjects with 3 or more of the following were positive for MetS: waist-40-inches or greater (men) or 35 inches or greater (women), blood pressure 135 mm Hg or greater (systole) or 85 mm Hg or greater (diastole), fasting blood sugar 100 mg/dL or greater, triglycerides 150 mg/dL or greater, and high-density lipoproteins less than 40 mg/dL (men) or less than 50 mg/dL (women). Weekly sessions provided low-glycemic nutrition instruction, fitness training, and evaluation of individual progress. RESULTS: Seventy-five firefighters (aged 42 [SD, 8] years, mostly white men) had a total MetS prevalence of 46.7% (P<.05 vs normal population). One platoon (10 men, aged 48 [SD, 5] years) was enrolled in the 12-week program. Most (7/10) had MetS at the baseline, but this prevalence decreased significantly after 12 weeks to 3 subjects (P=.02). On average, subjects had 3.2 (SD, 1.6) versus 1.9 (SD, 1.7) MetS risk factors (P<.01) at baseline and the 12-week interval, respectively. CONCLUSIONS: The prevalence of MetS and MetS risk factors is higher among professional firefighters compared with the general population. A short-duration, low-glycemic fitness program can successfully improve anthropometric and physiological measures and reduce the prevalence of MetS.

BZP-party pills: a review of research on benzylpiperazine as a recreational drug.

BACKGROUND: BZP-party pills are yet another 'designer drug' which mimics the stimulant qualities of amphetamines and MDMA/Ecstasy. As legal markets for the substance have developed in the last decade (especially amongst young people) so has public and governmental concern. METHODS: This article provides a summary of the available international research on benzylpiperazine (BZP) and its popular use in the compound form known as 'party pills'. Through performing an analysis of the available medical and social scientific literature, the review outlines current knowledge on the compound, the prevalence of usage of BZP-party pills, as well as the associated harms, risks and rationales for use of the drug. RESULTS: Despite moves towards legislative control of BZP-party pills, the evidence presented suggests limited social and health harms associated with the drug, although research on long term effects is a significant gap in the literature. It also remains inconclusive as to whether BZP-party pills act as a 'gateway' to illegal drugs or, conversely, play a role in harm reduction with illegal drug users turning to legal alternatives; there is some evidence for both positions. CONCLUSION: With increasing controls of BZP-party pills, and with the increasing numbers of 'legal highs' and new designer drugs on the market, we conclude that new legal alternatives will continue to surface to replace the drug in the future. Considering a harm reduction approach to drug taking, it is suggested that policy makers consider the creation of a legal holding category which restricts and regulates the market in legal highs whilst the social and health harms associated with each drug can be thoroughly investigated.

Innocent parties or devious drug users: the views of primary healthcare practitioners with respect to those who misuse prescription drugs.

BACKGROUND: Many health professionals engage in providing health services for drug users; however, there is evidence of stigmatisation by some health professionals. Prescription drug misusers as a specific group, may also be subject to such judgment. This study aimed to understand issues for primary care health practitioners in relation to prescription drug misuse (PDM), by exploring the attitudes and experiences of healthcare professionals with respect to PDM. METHODS: Tape-recorded interviews were conducted with a purposive sample of general practitioners (17), community pharmacists (16) and 'key experts' (18) in New Zealand. Interviews were transcribed verbatim and a thematic analysis undertaken. Participants were offered vouchers to the value of NZ$30 for their participation. RESULTS: A major theme that was identified was that of two different types of patients involved in PDM, as described by participants - the 'abuser' and the 'overuser'. The 'abuser' was believed to acquire prescription medicines through deception for their own use or for selling on to the illicit market, to use the drugs recreationally, for a 'high' or to stave off withdrawal from illicit drugs. 'Overusers' were characterised as having become 'addicted' through inadvertent overuse and over prescribing, and were generally viewed more sympathetically by practitioners. It also emerged that practitioners' attitudes may have impacted on whether any harm reduction interventions might be offered. Furthermore, whilst practitioners might be more willing to offer help to the 'over-user', it seemed that there is a lack of appropriate services for this group, who may also lack a peer support network. CONCLUSIONS: A binary view of PDM may not be helpful in understanding the issues surrounding PDM, nor in providing appropriate interventions. There is a need for further exploration of 'over users' whose needs may not be being met by mainstream drug services, and issues of stigma in relation to 'abusers'.

"They're legal so they're safe, right?" What did the legal status of BZP-party pills mean to young people in New Zealand?

BACKGROUND: The legislation on psychoactive substances has a role to play with regard to shaping social values and influencing the normalisation of drug use. In New Zealand from 2005 to 2008, benzylpiperazine-containing 'legal' party pills (BZP-party pills) were legally available for purchase, subject to controls around a minimum purchase age of 18 years, and prohibitions on free of charge distribution and advertising in certain media. This paper explores what their legal status communicated to young users. METHODS: Interviews and group discussions with young people (n=58) who had used BZP-party pills in the preceding 6 months. RESULTS: Data were collected between June and December 2006 via a series of interviews with individuals, 'friendship' pairs, and groups comprised of participants known to each other. Young people saw BZP-party pills as 'safe' and of good quality as they were legal/government sanctioned, but also thus of inferior strength, suggesting they could take more of them. However, after using them they often reviewed their view of their safety and quality due to varied experiences. Being legal for some people meant they could use the substances without breaking the law, or having to go to 'dealers'. Their legal status also meant they were easily accessible and were seen to be 'socially acceptable', with some young people indicating they would be happy to discuss their use with their parents. However, social acceptability was, for some, a reason not to use them. CONCLUSION: These data provide a unique insight into the tension between positive and negative harm reduction messages relating to the legal nature of psychoactive drugs and as such begin to fill an information void in this area. The legal status of these 'party pills' conveys mixed messages to young people and whilst being seen as potentially safe and of good quality, this often leads to higher than 'recommended' doses being used. Nevertheless, not breaking the law or having to access BZP-party pills from 'dealers', and being able to discuss their use with their parents are all potentially positive harm reduction issues.

The CYP2D6 metaboliser status of patients prescribed risperidone for the treatment of psychosis.

AIM: To identify the distribution of CYP2D6 metaboliser status in patients who were being prescribed risperidone for the treatment of psychosis in a New Zealand-based clinical population. METHOD: 100 AmpliChip CYP450 Test kits were made available by Roche Diagnostics. Clinicians in mental health services across three Auckland District Health Boards were instructed that the tests were being made available for use with patients who were being prescribed risperidone for the first time. Test results were fed back to the prescribing clinician. Data analysis was descriptive in nature; however, chi-square and independent sample t tests were employed to examine differences in age, gender, and ethnicity. RESULTS: Data were obtained for 93 patients. Poor and intermediate metabolisers each constituted 10.6% of the sample. There were no ultra-rapid metabolisers. Statistical analysis revealed no significant between-group differences with respect to age or gender. The between-group difference in ethnicity status showed a trend towards statistical significance. CONCLUSION: Sample size limitations likely contributed to the finding that no statistically significant between-group differences were identified. In theory, though, for one in five patients a higher level of adverse effects might be predicted for a normal dose of risperidone, potentially leading to issues around treatment adherence or treatment failure.

Initiation into methamphetamine use: qualitative findings from an exploration of first time use among a group of New Zealand users.

Methamphetamine use has risen in many countries around the world in recent years, and New Zealand is no exception, with the substance having become well-established in the illicit drug market. While there is much published on the individual and social harms of this drug, limited data are available on methamphetamine use initiation. Understanding early patterns of behavior is important, given the potential risks involved at this stage of use. This article presents findings from a qualitative study which was undertaken with methamphetamine users, most of whom were in treatment at the time of the research. While the research primarily sought to investigate patterns of methamphetamine use and associated harms, a key issue explored was the way in which respondents came to use the drug. Findings revealed that most were experienced users of other substances when trying the drug for the first time, but lacked specific knowledge of methamphetamine. The majority were introduced to methamphetamine in a social situation by a friend or partner, who also played a key role in preparing the drug for administration. Several reported risk-taking behaviors on the first occasion of use. The findings have important implications for potential interventions and harm reduction strategies at first use.

Barriers to, and incentives for, the transfer of opioid-dependent people on methadone maintenance treatment from secondary care to primary health care.

AIM: To explore barriers to, and incentives for, clients on methadone-maintenance treatment (MMT) in Auckland, New Zealand to transfer from secondary care to general practitioner (GP) care. DESIGN: Surveys (with free text response sections) of MMT secondary care staff, stabilised clinic clients, authorised GPs and GP patients. RESULTS: High response rates from secondary care staff (77%) and GPs (74%). Barriers to stable clients' transfer included financial cost and attitudes of secondary care staff and clients. Incentives for patient transfer included confidentiality, a holistic approach to their care, continuity of care, increased patient control, convenience and avoidance of contact with other opioid-dependent people. Distrust in the quality of care provided by authorised GPs was a major barrier for some secondary care staff and their clients, despite prerequisite training for authorisation. In contrast, patients rated primary better than secondary care with none stating a likelihood to return to the secondary service within 6 months. CONCLUSIONS: Progression from secondary to primary care should be incorporated in MMT planning from the outset, with secondary services staff reassured about the quality of primary care. An integrated transition period and exploration of funding options to assist transfer from largely publicly funded secondary to largely privately funded primary care are also recommended.

Highs and lows: patterns of use, positive and negative effects of benzylpiperazine-containing party pills (BZP-party pills) amongst young people in New Zealand.

BACKGROUND: This study aimed to investigate patterns and context of use of BZP-party pills, function of use, and positive and negative effects experienced by a sample of New Zealand young people who had used the products. METHODS: A qualitative study comprised of semi-structured interviews and group discussions. RESULTS: The sample included 58 young people aged 17-23 years who had used BZP-party pills in the previous 12 months. Young people were using these substances in a range of settings--primarily during weekend social occasions--particularly as part of the dance party culture. They were mostly used for their stimulant properties and to enhance socialisation, and were often taken in combination with other legal and illicit drugs. Young people had suffered a range of physical and emotional negative effects, although none of these was reported as being life-threatening or long-term. Many participants had reduced the frequency with which they used BZP-party pills due to adverse effects. Potentially risky behaviours identified included taking large doses, mixing BZP-party pills with alcohol and other substances, and driving whilst under the influence of BZP-party pills. CONCLUSION: Findings suggest that young people in this study were not suffering excessive or dangerous adverse effects. However, potentially risky use of these products raises the issue of the need for developing harm reduction interventions.

The substances and choices scale (SACS)--the development and testing of a new alcohol and other drug screening and outcome measurement instrument for young people.

AIMS: To describe the development and evaluation of the Substances and Choices Scale (SACS), an adolescent alcohol and other drug (AOD) self-report instrument designed in a similar format to the Strengths and Difficulties Questionnaire (SDQ). DESIGN: A literature review, extensive consultation and discriminant analysis on a pilot sample (n = 61) of adolescents informed the development of the SACS. The psychometric properties of the SACS were then tested in a larger community and clinical sample. SETTING: Three youth out-patient AOD treatment services and three secondary schools in Auckland, New Zealand. PARTICIPANTS: 13-18-year-old males and females attending the services (n = 120) or schools (n = 531). MEASUREMENTS: The SACS was administered with the CRAFFT, the Problem Oriented Screening Instrument for Teenagers (POSIT) and the Strengths and Difficulties Questionnaire (SDQ). FINDINGS: Reliability of the SACS was sound, with coefficient alpha 0.91 and 3-week test-retest correlation 0.88. Congruent validity coefficients of the SACS versus the CRAFFT and the POSIT were 0.79 and 0.91, respectively. A ROC curve demonstrated the SACS as having a predictive value of 92%. Repeat SACS scores in a treatment sample indicated that the SACS had utility in measuring change. Feedback from participants indicated that the SACS was highly acceptable. CONCLUSIONS: The SACS is a simple AOD instrument that is reliable, valid and acceptable to young people. It has utility in screening and measuring outcome and should enhance the identification and treatment of AOD difficulties in adolescents across a range of health settings.

Legal piperazine-containing party pills--a new trend in substance misuse.

In this Harm Reduction Digest Sheridan, Butler, Wilkins and Russell address the emergent phenomenon of so-called 'legal party pills' which have become a significant drug issue in New Zealand and elsewhere. Although banned in a number of countries, they are currently legally available in New Zealand where they are marketed as 'safe' alternatives' to 'illicit' drugs often used in the dance scene such as MDMA and amphetamines. The authors describe the availability and use of these substances in New Zealand, summarize what is known about their effects, and speculate on harm reduction interventions and mechanisms of control and their possible sequelae. The paper provides a timely account of an emerging drug issue of relevance to harm reduction internationally.