These facts and other amazing little delights can be found on the EPA-USA FAQ page. The EPA-USA said they have been looking into this problem since 1999. You can read a doozy of a 41 page report quaintly titled errata.pdf.

Should you be worried about your health? Again we refer to the EPA-USA FAQ page: Studies have shown that pharmaceuticals are present in some of our nation’s water bodies. Further research suggests that there may be some ecological harm when certain drugs are present. To date, no evidence has been found of human health effects from PPCPs in the environment.

The American Pharmacists Association produced a press release in February of 2007 on how to correctly dispose of pharmaceuticals. Here’s a few highlights.

DO NOT FLUSH unused medications. Consumers were once advised to flush their expired or unused medications

When tossing unused medications…..Crush solid medications or dissolve in water and mix with kitty litter or a solid kitchen substance….. then place in a sealed plastic bag …before tossing in the trash.

Check for approved state and local collection programs or with area hazardous waste facilities. In certain states, you may be able to take your unused medications to your community pharmacy.

This year the EPA-US Great Lakes ran the Great Lakes 2008 Earth Day Challenge with one of the aims to collect “1 Million Unwanted Pills”. To reinforce the point here’s a quote from the same page:

Traces of medicines have been found in streams and the Great Lakes where we get our drinking water and have also been detected near wastewater treatment outflows. Some of these medicines can lead to reproductive and developmental problems in fish and other animals. We often treat leftover medicine as a common household waste. More than half of people surveyed throw their unused medicines in the trash while a third flush them down the drain. In both cases, the medicines have the potential to be released into our rivers and lakes

August 6th 2008: Another press release from the EPA titled “EPA Continues Work to Understand Potential Impacts of Pharmaceuticals in Water”

The agency’s work to increase industry stewardship and scientific understanding of pharmaceuticals in water continues,” said Benjamin H. Grumbles, EPA’s assistant administrator for water. “By reaching out to the National Academy of Sciences and requesting information from the health care industry, EPA is taking important steps to enhance its efforts.

There’s a lot more words in that press release but I think you will agree that there is an adhoc approach in the USA for dealing with pharmaceutical waste, with a lot of nice words thrown in.

What’s happening in Australia?

It really is as easy as 1,2,3. July 2008 marked the 10 year anniversary of the Return of Unwanted Medicine Program. Simply walk into any retail pharmacy in Australia with your out of date or unwanted medications and they are accepted and placed in a yellow 20 litre sealable container. They are returned to the pharmaceutical wholesalers and from there collected by the waste disposal experts for high temperature incineration which is the safest way to destroy this sort of waste. Drivers are accredited and random audits are carried out. There is the chance for diversion but in 10yrs there have only been a handful of instances.

The RUM Project is funded by the Commonwealth Department of Health & Ageing.

Over 400 Tonnes (440t US)of unwanted and out of date medicines are collected every year.

( As an aside, Australia has about 22 million people. The USA had 305 million or so when I checked at the population clock. Would 6100t (US) of pharmaceutical waste really be stopped from going into normal waste in the States?)

If I’m writing this there has to be a bush slant. There is.
Our clinics are in one state, our head office and a lot of logistics come from another state (still one of the closest towns to us). When a pharmaceutical item goes out of date and put in the bin it becomes waste. This is then legally not allowed to cross state borders! Several years ago pharmaceutical waste was sometimes placed in the correct containers but most often not as it was difficut to have empty buckets supplied by plane. It was then driven back in the back of a troopie by anyone going into town to one of our suppliers, repacked (i.e. now double-handling waste) into the appropriate containers then entering the RUM process.

To improve this process we now deal direct with RUM. Our environmental health bloke and myself move around the lands and we are the ones who remove waste and sharps sealed in approved containers to a central point. The pharmaceutical waste is then placed into metal crates supplied by RUM and locked and trucked to Perth using a driver accredited to handle waste (again done by RUM for us). I have a key and the contracted waste management company in Perth has a key.

Now all we need is for the roads to be capable of taking trucks again and I can get some trucked out.

The system we run is probably the best, and simplest in the country and I hope can be emulated by other remote health services.

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I could not attend the last camp Ngaanyatjarra Health held, but attended and presented at the camp in 2005. A great few days, but the relationships with youth and family I developed then continue on to today. FWPA produce a Mooditj newsletter and there is also a video presentation that explains what it is all about.

we have gone a bit further this year. A while ago I posted a job ad for a male youth health educator. This is to work on a program called officially the “Improving the Sexual health of Aboriginal and Torres Strait Islander Youth Demonstration Project”, but we call it the “Kungkaku Yangupalaku Healthy Relationships Project”.

This is one of six prgrams being run across Australia. These will be evaluated by the Australian Institute of Health and Welfare (AIHW) at the conclusion of the programs. If found to be successful I hope funds continue to be made available, rather than just another piece of research.

The first newsletter from the project is available here (600kb file - I apologise for the white blocks around the text - these appeared while shrinking the file from 2MB).

Click on the image below to see the ad in full size.

The award had four winners from two categories. Ngaanyatjarra Health was the only winner in the category, A significant increase in, or commendable, immunisation coverage in populations of hard-to-reach children and/or adolescents.

Below is an extract from the article that appeared in Australian Doctor on 30th September.

THE AWARDS

THIS year’s GlaxoSmithKline childhood immunisation awards highlight some of the innovative approaches taken around the country to boost childhood immunisation coverage. They range from a city council’s overhaul of its clinic-based immunisation program, to ensure a more parent-friendly appointment-based service, to a GP network’s use of a mascot called “Grubsy” to sell the benefits of vaccination to parents and children.

Awards were granted in two categories

1) A significant increase in, or attainment of, high immunisation coverage in children over 12 months; or

2) A significant increase in, or commendable, immunisation coverage in populations of hard-to-reach children and/or adolescents.

The four winning teams, profiled below, chosen from 27 commendable entries, each receive a grant of $12,500 to support a local immunisation-related activity.

NGAANYATJARRA HEALTH SERVICE

Winner: Significant increase in, or commendable, immunisation coverage rates in populations of hard to reach children and/or adolescents.

The initiative: Under logistically challenging circumstances, Ngaanyatjarra Health Service revised its immunisation program, setting up a computerised patient recall system and addressing issues of vaccine storage.

The setting: The health service covers 12 Aboriginal communities spanning a vast tract of remote WA. Geographic, cultural and staffing issues had seen overall childhood immunisation rates fall to less than 75% in 2007.

The result: The initiative exceeded the 90% overall childhood immunisation target, achieving rates of 96.9%.

Ngaanyatjarra Health Service had a formidable task on its hands, given the challenges of providing immunisations to communities that are at least 1000km from a regional centre.

Communication between clinics and with external organisations was difficult, with the vagaries of satellite phone links, unreliable power supplies and the absence of a central computerised record system. Add in problems with ensuring delivery and storage of vaccines, and difficulties finding and retaining suitably qualified staff, and it is hardly surprising that immunisation rates in children were below par (72.5% across all cohorts in 2007).

The self-imposed target of 90% might have been considered ambitious under these circumstances, but the Ngaanyatjarra team were undeterred, setting in place a multidisciplinary plan of action. Doctors, pharmacists, remote area nurses and child health coordinators were all involved, as were health information and IT co-ordinators.

Targeting immunisation delivery and information management, the health service liaised with nursing staff regarding immunisations due, educated and informed parents and guardians, purchased specialised pharmaceutical refrigerators for each clinic and implemented a service-wide computerised patient information recall system. They also monitored Medicare immunisation reports to assess their progress.

Fifteen months after the start of the initiative, results were impressive, with overall coverage having steadily risen to 96.9%.

However, the Health Information Manager, Lesley Clay, said much of the recognition should really go to the nurses on the ground. Operating at full stretch, often with only one remote area nurse per settlement, she said their dedication and resourcefulness continued to be admirable. Given the remoteness and the degree of transience of the population, it could be quite a challenge even to locate a particular family, she said.

Preferring not to give out lollies after immunisations in view of the high prevalence of diabetes among the adult population, the health service plans to spend its award money on a new approach — beanies to give children as a reward for having their needles. As well as keeping kids warm in the cold desert winters, the beanies will help promote Ngaanyatjarra’s ear health program.

The Ngaanyatjarra team believes its results can be maintained, as the new strategies have been integrated into everyday practice

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Modification is required to the current HMR process before it will be viewed as a workable and useful process for clinicians and clients in remote Aboriginal communities. Below are suggested opportunities for modification. These comments are based on my experiences as a remote pharmacist in the Kimberley.

Referral Process

Comment: The current referral process requires a preferred community pharmacy. This concept is largely foreign to many members of Aboriginal communities who access medicines through the S100 supply scheme. Often access to pharmacy services is limited to the supplying community pharmacy and the visiting pharmacist (often an outsourced arrangement). The pharmacist may or may not be an accredited pharmacist.

Suggestion: The opportunity for a doctor to refer a patient to an accredited pharmacist who is known to be familiar with the community is essential.

Comment: The referral process is based on the doctor seeking consent from the patient. In many remote communities, a doctor visit may be once a week and it is usually the resident nursing and Aboriginal Health Worker (AHW staff) who are more familiar with the patients.

Suggestion: Remote area nursing staff and AHWs to be able to refer patients to pharmacist for HMRs. I would strongly recommend that the referral is done in consultation with the prescriber (ie the prescriber is phoned to alert them to this). However, consent and explanation of the process can be done by the nursing staff & AHWs.

Comment: The current referral process means that there will always be a delay between referral and actual HMR interview. This is often exaggerated in remote communities, because the pharmacist may only be visiting once every 3 months. Opportunistic care is often a very successful option for patients in remote area communities and this concept can be extended to HMRs for Aboriginal people.

Suggestion: The ability of remote area nursing staff and AHWs to refer patients will allow patients to be referred more promptly. For example, patients can be referred opportunistically on the day the pharmacist is in the clinic.

Referral form

Comment: With agreement from the clinic and patient (and as part of the clinic team), I was often able to access the patient’s information from their file. This included their progress notes, lab results and medication chart (as well as old medication charts). As the prescriber knew I had access to this information, they were often in the position to reduce the amount of medical history they had to provide me with.

Suggestion: The workload of the clinician writing the HMR referral can be reduced by a form where the referring clinician signs that themselves and the patient have given the accredited pharmacist permission to access the patient’s file (and electronic data if a patient information recall sheet exists). This means that the referring clinician need not provide lab results etc.

HMR interview

Comment: Frequently, the visiting pharmacist is largely unfamiliar with the client base of a remote AMS. Therefore, they are often reliant on the patient knowledge, community knowledge and cultural knowledge of the local staff, in particular the AHWs. The delivery of the HMR interview can be enhanced enormously by this local knowledge.

Suggestion: The financial recognition of the participation of AHWs and nursing staff in the HMR process is essential. Not only do these staff add to the outcomes of the HMR process, but they also usually expend a lot of energy and time co-ordinating the pharmacist visit. Therefore, there should be an opportunity for the AMS to claim for their involvement in the process.

Comment: I know that I used different HMR resources for different people. In particular, I used a large human body to show where all the tablets were working. I imagine there are many other pharmacists with useful tools for delivering HMRs.

Suggestion: I believe that many pharmacists (particularly new pharmacists) would benefit from a centralised location for accessing information about HMRs for remote populations.

Increased Prescriber Familiarity with the HMR Process

Comment: In my experience, there are a large number of prescribers who do not consider the option of HMRs for their patients. This may be due to lack of familiarity or due to the complexity associated with participating in this process.

Suggestion: There is a need for increased publicity of the HMR service to clinicians in remote area practice. There also needs to be an update on claiming process for those involved in MBS claiming at AMSs.

Cathy Larkin is an accredited pharmacist who has worked in the Kimberley as the Rural Pharmacist Academic and with the Kimberley Aboriginal Medical Service. She has now “turned to the dark side” and is studying medicine at Flinders University.

This is the third guest post in a series on Home Medicine Reviews in remote aboriginal Australia.
The first was by Chris Phillips and the second by Lisa Crisp.

Published in conjunction with my friends at Auspharm

For those non-pharmacists, a home medicine review is designed to “assist consumers living at home to maximise the benefits of their medication regimen and prevent medication related problems.”

* achieve safe, effective, and appropriate use of medications by detecting and addressing medication-related problems that interfere with desired patient outcomes
* improve the patient’s quality of life and health outcomes using a best practice approach, that involves cooperation between the general practitioner, pharmacist, other relevant health professionals and the patient (and where appropriate, their carer)
* improve the patient’s, and health professional’s knowledge and understanding about medications
* facilitate cooperative working relationships between members of the health care team in the interests of patient health and well being.”

This section is from the Medicare Australia website.

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CRANA’s aim is to “promote the development and delivery of safe, high quality health care to remote areas of Australia and her external Territories”. This is enshrined in their constitution.

At their just completed conference CRANA members voted overwhelmingly to change its constitution and accept other health professionals as members.

The Central Australia Rural practitioners Association (CARPA) has long been a loose association of all health professionals whose aim mainly has been the CARPA Standard treatment Manual which is the main guidelines followed by Remote Area Nurses.

CRANA runs a lot of training courses and of course the CRANA Procedures Manual is a mainstay out bush.

We then have SARRAH - Services for Australian Rural and Remote Allied Health, which is recognised as a peak body representing rural and remote allied health professionals. SARRAH is a ‘grassroots’ organisation whose membership consists of individual allied health professionals across rural and remote Australia.

I guess we’ll all fit into remote health. The CRANA press release is below.

MEDIA RELEASE : CRANA Comes of Age
Members of CRANA, previously an organisation solely representing the remote area nurses of Australia, have overwhelmingly voted to open the doors to other health professionals.

CRANA recently proposed sweeping changes to its constitution, copies of which were widely publicised and circulated to members. This lengthy process was followed by a postal vote seeking approval to make the changes that would change the face of CRANA and welcome all remote health professionals wishing to join.
At the 26th Annual Conference just last week, votes were counted, unveiling a massive 98% approval for change.
In line with that direction, members later also voted for our first Indigenous non nurse Board member. Jo Appoo is an Aboriginal health worker who has worked extensively in remote areas and is a staunch supporter of the Aboriginal Health Worker Program.

“We are very excited to have Jo on the CRANA board of Directors”, said Christopher Cliffe, President of CRANA, “she will bring a whole new perspective to the organisation and help us expand our training for this group of health professionals.”

Carole Taylor, CEO commented that there is currently a review of the plethora of organisations working in rural and remote Australia, and CRANA has been approached by a number of organisations from the rural sector seeking various forms of amalgamation or co-location.

“We have thought about this for some time and made the decision that, as the only organisation with purely a remote focus, we have a responsibility to widen our scope and embrace all remote health professionals”, she added, “there is a need for the remote health sector to be treated differently as the remote workforce has very different pressures than other sectors.”

“Our members work in the most challenging and geographically diverse locations to be found anywhere. Our members work in remote Indigenous communities, in the mining industry, on remote islands, holiday and ski resorts and on ocean liners. They are very often resource poor and have limited or no access to GP’s or specialists,” Ms Taylor said.

Ms Taylor continues, “Remote people are our specialty and remote training and support our focus. We may not be in a position to join permanently with our rural colleagues, but we will continue to work with them when the need arises. What we can now do, however, is represent all those dedicated health workers working in remote Australia and ensure that this sector continues to have a strong voice and an organisation that fully understands their needs.”

For further information, contact Carole Taylor, CEO 0429 649 226

- I write the occasional drug newsletter for CRANA and I am on the CARPA executive. -

The Kimberley presents some unique challenges for pharmacy practice, but as I have found, the greater the challenge, the greater the reward. The distances are vast and the patients often unsure and mistrusting of this new service. But providing a valuable service to people in remote locations has been one of the best jobs I have ever done.

For the past two years I have been fortunate enough to work across the Kimberley region of Western Australia. It is one of the most beautiful offices in the world and this is the story of how I established a career in this wonderful workplace.

Before moving to the Northern Territory in 2007 I contacted as many different pharmacists and others with an interest in pharmacy practice as I could find in the area. Initially the response to my call for employment was slow, but once word spread that there was a pharmacist willing to travel to rural and remote NT and WA, the work flowed. One of the first (and best) positions I took up was working with the Kimberley Division of General Practice (KDGP) to provide a HMR service to the Kimberley region of WA.

With the support of KDGP I am able to travel to the Kimberley and the towns within it at no cost to me. Without this support it would not be economically feasible to make the trip. With KDGP funding my travel, I am also able to venture out to aboriginal communities to provide some patients with the first pharmacy service of their lives. Because many indigenous Australians collect (or have delivered) their medications directly from the aboriginal health service (AHS), they may never enter a pharmacy or come into contact with a pharmacist. While AHS staff are competently trained, it is rare that an AHS staff member would have the time to provide the type and quantity of medicines education that can be passed on during a home medicine review. Over and over again I find myself spending much time providing medication counselling and education to remote patients, but it is this basic medicine information that allows people to better self-manage their medications and avoid adverse outcomes and medication misadventure. For these patients, the education provided at the HMR interview is easily the most valuable part of the process and is always wonderfully rewarding for me.

Each time I visit an aboriginal community I am accompanied by an aboriginal health worker who introduces me to the patient to rapidly establish a level of trust that would otherwise be unachievable in a single visit. I vividly remember my first visit to a remote aboriginal community in the Kimberley. We were so far out of town that we were almost back in the NT and we were completely isolated. Although there were several houses in the community, it felt completely deserted. In the middle of nowhere, with no mobile phone coverage, in a community where I was not known or trusted, I was especially grateful to have a health worker with me that day. It’s a very different place to do a HMR as compared to my home town of Launceston that’s for sure!

I have also found that I have been able to establish much closer working relationships with the GPs that I report to. At some AHSs I spend time discussing the patients face-to-face with the GP both before and after the interview; a luxury very rarely found elsewhere. Remotely located GPs (AHS or other) also seem even more grateful for the service than urban doctors – I figure that they are so used to facing barriers to service provision that to have a willing pharmacist provided through KDGP at no extra work or cost for the GP, is an absolute dream!

The community pharmacies should also receive a mention here. Without their cooperation and support the process would cease. Across the Kimberley community pharmacists have been nothing but helpful and supportive, which makes the process that much easier for me.

It takes a lot more planning to conduct HMRs in the Kimberley. It’s many phone calls and time for KDGP to arrange the logistics of getting me to the Kimberley, and accommodating me there (they provide a hire car, flights, hotel room etc). There’s more preparation to be done at my end for a week on the road, and of course it’s a day’s travel each way to get there, but at the end of a busy week I am always happy to reflect on how much has been achieved and how great it has been to provide home medicine reviews for remotely located patients that otherwise would have missed out on such a service.

For any accredited pharmacist willing and able to travel, there is unmatched reward waiting in rural and remote Australia. With the support of local divisions of general practice, a two week working “holiday” to remote Australia may just be the best thing you ever did! And once you’ve been once, I’m sure you’ll be back because it’s very hard to give up once you get the taste for it!

Lisa Crisp is an accredited pharmacist based in Katherine, NT. She graduated from the University of Tasmania in 2004 and achieved DMMR accreditation with AACP in 2006. Despite living in the Top End, Lisa continues to work in Tasmania, across the Kimberley and the Top End in many roles; accredited pharmacist, locum pharmacist in both community and hospital pharmacies as well as consulting for divisions of general practice and other pharmacy-linked groups.

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For those non-pharmacists, a home medicine review is designed to “assist consumers living at home to maximise the benefits of their medication regimen and prevent medication related problems.”

* achieve safe, effective, and appropriate use of medications by detecting and addressing medication-related problems that interfere with desired patient outcomes
* improve the patient’s quality of life and health outcomes using a best practice approach, that involves cooperation between the general practitioner, pharmacist, other relevant health professionals and the patient (and where appropriate, their carer)
* improve the patient’s, and health professional’s knowledge and understanding about medications
* facilitate cooperative working relationships between members of the health care team in the interests of patient health and well being.”

All the above is from the Medicare Australia website.