Major changes are on the way for pharmacy in Ireland, the chair of the Government’s Expert Taskforce to Support the Expansion of the Role of Pharmacists in Ireland told the 2024 Annual Education Conference of the Hospital Pharmacists Association of Ireland (HPAI).
Prof Pat O’Mahony, Chair of the Board of the Health Information and Quality Authority (HIQA) and former Deputy Secretary General and Head of Governance and Performance at the Department of Health, was appointed to chair the taskforce in July 2023.
He said the group expects to present its final recommendations to the Minister for Health by the end of May 2024. Included in these will be a recommendation to permit and support prescribing by pharmacists for a defined list of common conditions.
“It’s not a question of will there be an expansion in the role of the pharmacist. That decision has already been made and confirmed. This is something real. It is actually happening,” Prof O’Mahony said.
“We’re not pushing the boulder up hill. We’re trying to facilitate it rolling down hill in an appropriate way and in the appropriate directions. It’s a very exciting time to be involved in an initiative around pharmacy,” he said.
On April 16, the Government approved the drafting of an amendment to the Health (Miscellaneous Provisions) Bill 2024 which will lay the groundwork for the introduction of pharmacist prescribing. The amendment will make provision in primary legislation for the further expansion of the role of pharmacists. The matter has now been referred to the Office of the Attorney General for drafting.
The taskforce is currently completing an initial list of common conditions for which pharmacist prescribing will be permitted.
“We will also be recommending a mechanism to amend, delete or add to that list and there will be a formulary of permitted medications,” he said.
He said the change will necessitate additional training and this will be provided at undergraduate and post-graduate level. However, he added, “there will be recognition of qualifications that people already have. Many have this already from post-graduate work or have a qualification from outside the Irish jurisdiction. And I am pushing for the recognition of prior experience if [the individual] is 25 years qualified.”
The expert taskforce, which was established in July 2023, is made up of 13 experts with experience in pharmacy education and practice, healthcare policy and delivery, and other related disciplines. The first recommendation of the Expert Taskforce was implemented on 1 March 2024, when the maximum legal validity of prescriptions was extended from six to 12 months.
Prof O’Mahony expects the final set of recommendations to be completed within weeks. He gave assurances that the taskforce would consider issues specific to hospital pharmacists, including the prescribing of over-the-counter products.
“We now have an opportunity to move things on in a way that we have all looked for over an extended period of time. Let’s seize the moment,” he said.
With these additional duties on the horizon, the question is, can the current hospital pharmacy service bear this additional demand. A survey of heads of departments, conducted by the HPAI recently, found significant understaffing in hospital pharmacy departments across the country.
Of the 11 hospitals who participated in the survey, more than a third (36%) had 1-2 pharmacy technician posts unfilled and another third (36%) had 3-4 vacant technician posts.
In relation to staff grade hospital pharmacist positions, more than half of the hospitals had 1-2 vacant posts and 9 per cent had 3-4 vacancies at this grade.
All of the hospitals who responded to the survey had at least one vacant senior pharmacist position. A third (36%) had 1-2 posts unfilled, 27 per cent had 3-4 posts unfilled and 18 per cent had 5-7 unfilled posts. One hospital had between eight and 10 vacant senior pharmacist posts.
In five of the seven HSE hospitals surveyed, the recruitment freeze had severely impacted services.
Sustainable prescribing
A presentation by Dr Sharon Pfledger, a consultant in pharmaceutical public health with the NHS Highlands in Scotland, left jaws on the floor as she presented the evidence on levels of pharmaceutical pollution.
Dr Pfledger has qualifications in pharmacy and public health and is a visiting professor at the Robert Gordon University, School of Pharmacy and Life Sciences in Aberdeen. She has dedicatwed much of her career to tackling the issue of healthcare pollution. She is a founding member and NHS lead of the One Health Breakthrough Partnership, which is focused on the sustainable use of medicines and reducing antimicrobial resistance. She sits on various Scottish and UK government committees to tackle healthcare’s impact on the environment.
“The Hippocratic Oath – first do no harm – was developed with the patient in mind, but I would put it to you that that is now out of date. We are actually doing harm to our patients and our planet through the use of medicines,” she told the conference.
A 2022 study of 258 rivers in 104 countries found concerning levels of 61 pharmaceuticals. The most commonly detected drugs were analgesics, antibiotics and anticonvulsants. In more than 25 per cent of the rivers analysed, the concentrations were high enough to be considered a threat to the environment and/or human health.
Similar contamination has been identified in Irish rivers. A study by Dublin City University (DCU) published in 2023 examined the levels of 16 specific pharmaceuticals in rivers across Ireland. A total of 53 high risk and 64 moderate risk concentrations were identified during the study period. Sulfamethoxazole and venlafaxine were most commonly detected. Diclofenac, metformin, trimethoprim, ciprofloxacin and carbamazepine were also frequently identified. The study also found regional differences, with the River Suir having elevated levels of sulfamethoxazole, while the River Nore showing the lowest concentrations of venlafaxine.
Research has already shown that this contamination is having an effect on the ecosystem. Fluoxetine contamination has been linked to delayed tadpole development and 17-alpha-ethinylestradiol has resulted in the collapse of the fathead minnow population due to the feminisation of male fish. Paracetamol is acutely toxic to nearly all species in aquatic environments, resulting in neural, behavioural, and physiological adverse effects.
What is not known, Dr Pfledger said, is if accidental daily exposure to sub-therapeutic doses of medications over a long period of time will have negative human health impacts. The interaction between different pharmaceutical-derived chemicals in the environment and the toxicity of metabolites are also unknown. She pointed out that the water treatment processes can actually metabolites that are more toxic to the environment than the original medicine. This is known to happen with carbamazepine.
The scale of pharmaceutical pollution is significant and this has the potential to dramatically increase antimicrobial resistance. In the Indian city of Hyderabad, which plays host to 90 pharmaceutical factories, exceptionally high levels of ciprofloxacin were found in local lakes. Enough ciprofloxacin entered the waterflow every day to treat 90,000 people at therapeutic doses.
However, she pointed out that only 5 per cent of pharmaceutical waste comes from industry processes. Close to 90 per cent is generated by patient use and excretion, and the remaining 5 per cent is generated by people disposing of unused medicines down the toilet.
Pharmacists have a crucial role to play in reducing pharmaceutical waste, Dr Pfledger said. Research suggests that up to 60 per cent of patients do not take their medicines as prescribed, and one in 10 primary care prescriptions are inappropriate
“I call it the merry go round of care,” she said. “Because if the patient doesn’t take their medicine and they feel sicker, what are they going to do? They're going to go back to their GP for more interventions, probably more prescriptions. Adherence is a huge area for us as pharmacists but how often do we really take time to understand what the issues are with somebody's medicine. That's a key area that we can all get better in.”
She highlighted the importance of talking to patients about a medication’s side effects.
“I think we're good at discussing the benefits - the drug will do this for you, it will make you better - but we're not as good at discussing the risks. So the patient goes to pharmacy. They get their medicine. They go home. They take it out of the bag. They get the leaflet out. They look at it and they say ‘Oh my God, look at all those side effects. I'm not taking that’. So the drug sits in the cupboard and they don't take it. If we had that conversation with them about the side effects before the drug was given to them it might have been different,” she said.
She pointed out that pharmacists have been ranked by patients as the second most trusted source of health advice, after nurses. This affords pharmacists an opportunity to make a real difference in health promotion, she said.
“This is something I've been trying to change now for over 20 years in the Highlands, to get secondary care pharmacists to understand that they have a real public health role. It might only take one sentence to the patient to get them to start thinking about things. So ask the patient if they are up to date with their vaccinations? Do they smoke? If they do, could you help them with smoking cessation?”
Furthermore, she said, pharmacists have a direct link to prescribers and are a trusted source of pharmacological information. This puts pharmacists in the ideal situation to spread the message of eco-friendly prescribing, and with pharmacist prescribing on the way, there is also an opportunity to put this into practice.
However, in order to prescribe with the planet in mind, prescribers need to have access to the relevant information.
Seven years ago, Dr Pledger co-founded the One Health Breakthrough Partnership - a collaboration between researchers, academics, water providers and regulators, environment agency representatives, and public health specialists from across Scotland which is working to reduce pharmaceutical pollution in the environment. The group has been impactful in driving the message of sustainable prescribing. In response to a dearth of information on the environmental impacts of different medications, the partnership is calling for this information to be included in prescribing formularies.
“It essentially means bringing environmental data alongside clinical and cost-effectiveness data. I might have two drugs in my formulary, drug A and drug B, and they are both clinically effective and both cost the same, but one of them is really eco-toxic. The prescriber doesn't know which one is eco-toxic because we don't have that information. What I'm trying to do is to put that into formularies,” she explained.
“Eventually I see this work informing formulary development across the world. I want to help, every prescriber, every pharmacist to understand the impact of a drug on the environment and on their patient, and help them to pick the best one for both,” she said.
Further information on eco-friendly prescribing and pharmaceutical waster is available on the One Health Breakthrough Partnership website (https://ohbp.org/).
Research
Close to 70 research abstracts were presented at this year’s conference. Four of these were selected for oral presentation, including a report on the outcomes of a pharmacy-led polypharmacy review in an intellectual disability service.
Staff at the Phoenix Pharmacy reviewed 42 residents at St Ita’s Hospital in north Dublin, which provides long-term care to adults with intellectual disability and a mental health diagnosis. The hospital has two consultant psychiatrists on site, as well as a visiting GP.
Medication was reviewed according to the seven-step iSympathy tool which requires consideration of what matters to the patient; the appropriateness of medicines; the necessity for each medicine; the effectiveness, potential harm and cost-effectiveness of the medicines; and the development of an agreed shared plan for the patient.
Presenting the research on behalf of the study group, Helen Danaher gave examples to demonstrate the outcomes.
She presented the case of a 58-year-old man with mild intellectual disability and a diagnosis of epilepsy. He was receiving carbamazepine, a statin, a proton pump inhibitor, and supplementary vitamins.
After the medication review, it was recommended to the GP that long-term prescribing of lansoprazole should be considered and that the need for dietary supplementation should be review, as the patient had gained weight since this was initially prescribed.
In a second example, Ms Danaher presented the case of a female patient with severe intellectual disability, bipolar affective disorder, autism, pica, and epilepsy.
The review revealed that the patient was receiving just 200mg of lithium and, based on the fact that her blood levels were sub-therapeutic, it was deduced that the drug was probably not delivering a benefit. Laboratory tests indicated that the medication was having a detrimental effect on the patient’s kidney and thyroid function. The consultant agreed with the pharmacist’s recommendation that the patient should be tapered off lithium.
“There was a lot of hesitancy among the nursing staff,” Ms Danaher said. “They are looking after the patient all the time. It's very difficult for them to see change in medicines. Starting a medicine is fine, but stopping a medicine is very different. A lot of reassurance was needed. We had to reassure them that this is going to be tapered really slowly and it's not going to be stopped immediately and we don't envisage any major withdrawal effects from it because she has lots of other medicines that will help her bipolar. She's on an antidepressant. She's on two mood stabilisers, and she is also on an antipsychotic.”
“This review was done in October. It's now April and I’m glad to say she is now off the lithium and it hasn't had any impact on her behaviour,” she reported.
Among the 42 patients who were reviewed, the average number of different medications was 14 per patient. The initiative achieved a 3.2 per cent reduction in medication use and delivered cost savings of €174 per month.
Ms Denehan said buy-in from other healthcare professionals and adequate resources are essential to the success of medication review initiatives such as this.
The other three abstracts selected for oral presentation were a review of anticholinergic burden in hospitalised older adults with cancer, presented by Emer Cronin from the School of Pharmacy at University College Cork; Where to start? The Irish Emergency Department Antimicrobial Discharge (EDAD) study: A multi-centre, prospective cohort analysis, which was presented by Aisling Rafferty, from Children's Health Ireland; and Planning the implementation of a new oncology compounding information system in an aseptic compounding unit: a mixed methods study, which was presented by Mahreen Khosa from the Mater Private Network Dublin.
Report from Irish Pharmacist, May 2024, Page 16
https://irishpharmacist.ie/digital/irish-pharmacist/irish-pharmacist-may-2024/
