..Information to Pharmacists
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Your Monthly E-Magazine
MARCH, 2004


CON BERBATIS

From a Researcher Perspective
Does it Cost or Does it Pay?
A Study in Progress Part 1

Editor's Note: Woolworths is pushing forward with its pharmacy concept, into rural areas.
A model is being established in a Woolworth's site on the far north coast of NSW.
It will not have a pharmacist, or scheduled drugs, but it will have the "look and feel" of a pharmacy (like a Priceline store in a Woolworths environment).
Like most pharmacists, I find the concept difficult to accept.
It struck me when I received this material from Con Berbatis, that the AIDS/HIV community would feel disadvantaged in such an environment.
This particular community is passionate about privacy and very sensitive as to how they receive their drugs, and health advice.
Out of my own experience I could not see this group of patients warming to a Woolworths pharmacy, and Con Berbatis asks this question in his article.
I make the point because the Northern Rivers Health Area, in which Ballina is situated, has the largest rural population of HIV/AIDS patients in NSW, possibly Australia (except for capital cities).
How then do the economic rationalists deciding competition policy in this country, evaluate fairly the economic savings made by pharmacy in the interventions with the AIDS/HIV community?
Surely the dollars saved in this process would more than offset some perceived discount that Woolworths may offer in the supply of drugs?
Well, corporates like Woolworths do not have a social conscience, and the shareholer's returns always rules at the end of the day.
Harm minimisation services would not give the desired return.
It is time a different form of accounting was introduced, so that like can be compared to like.

Con Berbatis is currently researching US and UK supermarket pharmacies to see exactly how many provide harm minimisation services, and to what depth.

His findings will be progressively published in i2P, and will provide economic arguments for governments, and others, to consider.

IHRA Conference in Melbourne April 20-24, 2004.


The 15th International Conference on the Reduction of Drug Related Harm organised by the International Harm Reduction Association (IHRA) will be held from 20 to 24 April at the Melbourne Convention Centre. The IHRA chairman is Dr Alex Wodak of Sydney's St Vincent's Hospital, a world authority on harm reduction (HR).
The Monash Pharmacy Practice Symposium: Innovations in teaching and learning practice
This will be held on 15th and 16th April 2004 in Monash University. Specialist HR pharmacists Assoc Prof Janie Sheridan formerly with London's National Addiction Centre and Kay Roberts the Co-ordinator of Glasgow's Pharmacy Needle Exchange Scheme are travelling to Australia to participate.

HYPOTHESIS

Decrease in HIV/AIDS mortality and morbidity in 2003 attributed to the harm reduction (HR) activities in community pharmacies in Oceania


Editor :
The following preliminary report by Con Berbatis is to make i2P readers aware of

(a) the latest statistics of HIV/AIDS in Oceania (Australia and New Zealand) and North America,
(b) the term 'harm reduction ' (HR) , its scope and importance in Australia's community pharmacies,
and
(c) a new approach to estimating community pharmacies' contribution to lowering HIV/AIDS morbidity and mortality by virtue of their known HR activities in Australia compared to North America .

This report has not been reviewed by experts.
If readers find flaws or omissions please email them directly to Con Berbatis so he may take these into account in developing this study.

1.0 BACKGROUND

Australia's community pharmacies are amongst world leaders in harm reduction (HR) practice .
Harm reduction aims to decrease the adverse health, social and economic consequences of drug use without necessarily diminishing drug consumption (Wodak,2003). Typical examples in pharmacies are (a) issuing sterile needle equipment in order to prevent the transmission of viruses and microbes in body fluids,
(b) participating in methadone maintenance programs and in particular supervising the dosing of oral liquid methadone, of buprenorphine and other drug dependence pharmacotherapies ,
(c) issuing condoms for preventing sexually transmitted diseases (STDs) often resulting from illicit drug consumption,
(d) providing information on HR, health promotion and preventing sexually transmitted diseases to affected individuals, those at risk or their carers and
(e) increasingly in Australia declining the dispensing or sale of licit prescribed or over-the-counter agents (OTCs) to consumers whose motives are dependence or diversion and not therapeutic drug use.

1.1 Quantifying the HR contribution of Australia's community pharmacies : processes

Curtin University's National Pharmacy Database Project found 40-50% of pharmacies in 2002 supervised dosing of liquid methadone or other agents and approximately 50% issued needle equipment which placed them second to pharmacies in Scotland in methadone dosing and first amongst pharmacies in the world for distributing needle equipment.
According to the results of Curtin University's National Pharmacy Database Project Australia's pharmacies in 2002 detected minimally 13,500 forged S8 prescriptions, 24,000 doctor or prescription shoppers and refused supply of dependence-producing OTCs to 0.63 million clients .
HR services in 2002 were charged for in 31.5% of pharmacies which represents the most widely remunerated specialist or enhanced service provided in Australia's community pharmacies (Berbatis et al, 2004).
Comparable HR data have been reported for just Scotland, England and Wales.

1. 2 Quantifying the HR contribution of Australia's community pharmacies : outcomes

While the above statistics quantify the HR activities or processes performed in community pharmacies , they give little idea of the outcomes of their HR involvement.
In 2000 , our Curtin University pharmacy research group with statisticians from the University of Western Australia, reported for the first time the higher retention of methadone maintenance patients in community or primary care methadone programs with community pharmacists issuing methadone compared to hospital clinic programs .
The costs were lower or similar to those in corresponding hospital or private clinics .
The retention of patients is regarded as the most practical quantitative indicator of the performance of methadone programs (Berbatis and Sunderland, 2000)
In the following we consider another approach to measuring the outcomes of community pharmacists' HR activities.

1.2.1 Oceania's community pharmacies' contribution to HIV/AIDS morbidity and mortality in 2003

The following quantitative approach to estimating community pharmacy's is based on the notional contribution to HIV/AIDS cases and lives prevented or saved through HR activities.
The latest data reflecting the international extent of HIV/ AIDS with statistics on the prevalence (current cases) , incidence (new cases) and mortality (deaths0 by region around the world including North America (the USA and Canada) and Oceania (Australia and New Zealand) were published by UNAIDS an agency of the United Nations in November 2003.
There are various causes of HIV/AIDS including transfusion with contaminated blood products, sexually transmitted disease and injection with infected equipment most commonly with shared needle equipment which is the most common cause in north America and Oceania.
If the contribution by our colleague community pharmacies in New Zealand is included and a modest overall attributable fraction is applied to the estimated numbers of cases and lives saved in Oceania compared with North America , a sizable contribution to the HIV-AIDS numbers and lives saved results. In the USA methadone dosing in pharmacies is negligible and the provision needles quite patchy throughout the 1980s and 1990s.
Population studies attribute most of the prevention in deaths and cases of HIV/AIDS to HR activities and in particular to the provision of sterile needle equipment and methadone maintenance programs (Wodak,2003).

2.0 METHOD

The methodology is divided into the following two parts .

2 .1 Decreases in HIV/AIDS in Oceania in 2003 due to harm reduction

It is assumed in the following estimates that the decreases in HIV/AIDS deaths, incidence and prevalence in Oceania in 2003 compared to North America were totally attributable to the higher rates of HR activities in Oceania compared to North America.

The stepwise calculations were as follows :

1. The ranges of estimated prevalence, incidence and mortality (deaths) due to AIDS/HIV in 2003 for 'North America' and 'Oceania' were drawn from UNAIDS statistics released in November 2003
(Table 1).
2. The estimates for North America were adjusted respectively to the population of Oceania by multiplying the mid-range figure by 25/315 based on the populations of North America and Oceania rounded to 315 million and 25 million respectively.
3. The UNAIDS estimates for Oceania were subtracted from the corresponding estimates for North America adjusted for Oceania in the 'standardised estimates' (Table 1) .
4. The resulting decreases in 2003 of 64,365 existing cases ( prevalence) , 2,721 new cases (incidence) and 1,115 mortalities (deaths) due to AIDS/HIV in 2003 in Oceania are attributed totally to HR activities and are designated ' Total cases or deaths prevented ' ( Table 1).
In 2003 Oceania would therefore have had the above additional cases and deaths due to HIV/AIDS if it were not for the HR policies adopted by Australia's and New Zealand's governments involving principally the widespread dosing of liquid methadone and issuing needle equipment by pharmacies.


2 .2 Decreases in HIV/AIDS in Oceania in 2003 due to harm reduction in community pharmacies

Curtin University's NPDP results reflected the numbers that were dosed in Australia's community pharmacies patients with methadone, buprenorphine and naltrexone during 2002 had risen to more than 40,000. A larger number of clients were provided with sterile needle equipment. The total numbers of clients who received HR activities exceeded 40,000 . The numbers of patients registered in Australia's methadone maintenance programs has exceeded 10,000 since 1991 and by May 2000 had increased to 30,752 patients.
In 1997-98 there were an estimated 74,000 Australian dependent heroin users and it unlikely the figure has increased substantially since then because of falls in the supply of heroin (Hall et al, 2000; Topp et al, 2002). These figures imply the rate of patients in treatment has grown rapidly . Community pharmacies provide even more clients with sterile needle equipment. The total number provided with either or both needle equipment and pharmacotherapies by Australia's community pharmacies exceeds 50,000 and may well be more than 60,000 people throughout Australia.

In this study community pharmacies in Oceania are assigned a notional attributable fraction of 0.1 (or 10%) of the decreases in HIV/AIDS cases or lives due to their contribution to the total HR activities in Oceania. That is, an estimated 272 new cases and 6,436 existing cases as well as 111 deaths due to HIV/AIDS may have been prevented by the HR activities of community pharmacies in 2003.

Table 1. HIV/AIDS deaths, incidence and prevalence in 2003 : North America and Oceania
(sources : The Australian Nov 27 2003 : page 7; The Washington Post Nov 27, 2003 : www.washingtonpost.com/wp-srv/health/daily/graphics/AIDS_112603.gif )

2003 AIDS/HIV indicators
North America
Oceania
Standardised figures
* Total cases or deaths prevented

Prevalence or current cases (mid-range)
0.79-1.2 x 10 6 (1.0 x 10 6)
12-18 x 1,000(15,000)
80,000-15,000
65,000 cases
Incidence or new cases (mid-range)
36-54 x 1,000(45,000)
700-1,000(850)
3,600-850
2,750 cases
Deaths in 2003(mid-range or estimate)
12-18 x 1,000(15,000)
<100( 75)
1,200-75
1,125 deaths
 

* to rounded populations estimated for mid-2003 ie N Am = 315million; Oceania = 25million
The figures for N America reduced by 25/315 or x 0.08 for standardising the estimates for Oceania

In 2003, the 10% of the total 65,000 cases prevented and attributed to community pharmacy ( Table 1) totalled 6,500 current cases of HIV/AIDS , 275 new cases of HIV/AIDS were avoided and 112 HIV/AIDS deaths were averted.

Question:
Would supermarket pharmacies play a part in this impressive contribution to population health by providing harm reduction services?
How many supermarket pharmacies provide these services in the UK?
Answer:
UK data is currently being explored for the respective percentages relating to methadone, buprenorphine and other pharmacotherapies provided by independent pharmacies and supermarket pharmacies.

3.0 DISCUSSION

These preliminary estimates of the decreases in HIV/AIDS cases and deaths in Oceania in 2003 have been estimated to be attributed by the harm reduction Australia's provided in community pharmacies.
The estimates may be affected by many factors including for example the high accessibility and implementation of AIDS chemotherapy may directly reduce the numbers of HIV/AIDS deaths.
Poor or defective blood transfusion practices may increase the incidence, prevalence and numbers of deaths suddenly and when the practices are improved the HIV/AIDS incidence will rapidly fall, followed by declines in prevalence and numbers of deaths.
The effectiveness of the HR activity will vary depending for example on the causes of HIV/AIDS.
For example in societies where HIV is most commonly caused by sexually transmitted disease such as Africa the provision of condoms is more important than the needle equipment or methadone.
The attributable fraction of 0.1 is a notional figure which does not attempt to distinguish between the contribution of other HR activities such as condoms, education and intervening in the diversion or misuse of licit drugs by injection (eg morphine).
The attributable fraction was based on a consideration of the following factors :
(a) data on the extent of pharmacies' HR activities including the numbers of client provided with sterile needle equipment and dosed with methadone and other opioid dependence pharmacotherapies ;
(b) the retention of methadone patients in community-based programs;
(c) the high proportions of Australia's dependent heroin users provided either or both methadone in 2003 (Hall et al, 2000);
(d) from 1991 to 2003 from 10,000 and 40,000 patients were registered in Oceania's methadone maintenance programs (Berbatis et al, 2000) ;
(e) the total national contribution to the decreased HIV/AIDS morbidity and mortality attributable as a fraction to HR activities by pharmacies.
An emerging issue is the role in HR provision by supermarket pharmacies who now comprise growing proportions of pharmacies in the USA and England and disproportionately higher components of total medicines issued and pharmacy sales in those countries.
The advent of supermarket pharmacies reduces the ratio of independent pharmacies.
Australia has no, and Scotland few, supermarket pharmacies, but they have the highest national participation rates internationally of pharmacies in methadone programs and Australia has the highest reported proportion of pharmacies issuing sterile needle equipment .
Given no provision by US pharmacies of maintenance methadone and little of sterile needle equipment US supermarket pharmacies it is speculated that HR activities in pharmacies will fall due to the displacement of independent by new supermarket pharmacies.
Data are needed on the numbers of supermarket pharmacies which provide these services in England and elsewhere in the UK and also the prevalence of pharmacist-owned in comparison to non-pharmacist-owned pharmacies providing HR services.
The comparisons will provide insight into relative contribution to HR activities.
In conclusion, we have applied a notional 0.1 or 10% of total HIV/AIDS cases or deaths prevented (Table 1) in Oceania compared to North America to estimate the contribution by Australia's community pharmacies to HIV/AIDS morbidity and mortality.
Community pharmacies' contribution was estimated to decrease HIV/AIDS in 2003 by 6,436 current cases, 272 less new cases per year and 111 fewer deaths prevented in Oceania by providing sterile needle equipment and dosing with methadone liquid , buprenorphine and naltrexone.
The relief in terms of psychological trauma and financial loss will be left to others.

Con Berbatis
6 February 2004.
Email : berbatis@git.com.au

References
Berbatis C, Sunderland VB. The role of the community pharmacy in methadone maintenance treatment. Final report. November 2000. Barton (ACT) : AACP, 2000.
Berbatis CG, Sunderland VB, Bulsara M, Lintzeris N. Trends in licit opioid use in Australia, 1984-1998: comparative analysis of international and jurisdictional data. Med J Aust 2000; 173: 524-527.
Berbatis C, Sunderland VB, Bulsara M, Mills C. National pharmacy database project. School of Pharmacy, Curtin University of Western Australia. www.guild.org.au/public/r&d.adpreports# accessed 10 January, 2004.
Hall WD, Ross JE, Lynskey MT, Law MG, Degenhardt LJ. How many dependent heroin users are there in Australia? Med J Aust 2000; 173: 528-531.
Topp L, Kaye S, Bruno R, et al. Australian drug trends 2001: findings of the Illicit Drug Reporting System (IDRS). Kensington (NSW): NDARC, 2002.
Wodak A. Harm reduction as an approach to treatment . In : Graham AW, Schultz TK, Mayo-Smith MF, Ries RK, Wilford BB. Principles of addiction medicine. Third edition. Annapolis Junction (MD,USA):
American Society of Addiction Medicine, 2003: 533-541.