Alcohol outlets,drug paraphernalia sales,and neighborhood drug overdose

BackgroundAlcohol outlets have been associated with various forms of injury and may contribute to neighborhood disparities in drug overdose. Few studies have examined the associations between alcohol outlets and drug overdose. This study investigated whether alcohol outlets were associated with the neighborhood drug overdose rate and whether the sale of drug paraphernalia contributes to this association.MethodsA cross-sectional ecological spatial analysis was conducted within census block groups in Baltimore City (n = 653). Outcomes were counts of EMS calls for any drug overdose in 2015 (n = 3,856). Exposures of interest were counts of alcohol outlets licensed for off-premise and on-premise consumption and the proportion of off-premise outlets selling drug paraphernalia (e.g., blunt wrappers, baggies, pipes). Negative binomial regression was used to assess the relationship between outlet count and overdose rate, and if paraphernalia sales altered this relationship, controlling for other neighborhood factors. Spatial autocorrelation was assessed and regression inference adjusted accordingly.ResultsEach additional off-premise alcohol outlet was associated with a 16.6% increase in the neighborhood overdose rate (IRR=1.17, 95%CI=(1.11, 1.23)), adjusted for other neighborhood variables. On-premise alcohol outlets were not significantly associated with overdose rate when adjusting for off-premise alcohol outlets (IRR=1.01, 95% CI=(0.97, 1.06)). The proportion of off-premise outlets that sold drug paraphernalia was negatively associated with overdose rate (IRR=0.55, 95% CI=(0.41, 0.74)) and did not alter the relationship between off-premise outlets and overdose.ConclusionThis study provides preliminary public health evidence for informing policy decisions about alcohol outlet licensing and zoning. Alcohol outlets could be potential community partners for harm reduction strategies such as health communication in identifying overdose symptoms or Good Samaritan Laws.     

Distances to on- and off-premise alcohol outlets and experiences of alcohol-related amenity problems

Introduction and Aims. There are a number of studies in recent years that have examined the relationship of alcohol outlets to the incidence of alcohol‐related problems. Only a small number of these studies examine the types of alcohol‐related problems which may be considered amenity problems, such as neighbourhood disturbance, litter and noise. This paper examines the association between the proximity of someone's home to alcohol outlets and their experience of public amenity problems. Design and Methods. Data came from an Australian general population survey: the Alcohol's Harm to Others Survey (2008). Two thousand six hundred and forty‐nine Australians aged 18 years and over were asked about their experiences of a number of amenity‐type problems and the distance they lived to the nearest on‐ and off‐premise alcohol outlet. Results. Bivariate results showed that respondents living closer to on‐ and off‐premise outlets reported more problems, with minor differences by distance to on‐ and off‐premise outlet. In multivariate logistic regression analyses, controlling for possible confounding effects of the respondent and neighbourhood characteristics, living closer to on‐premise outlets was independently associated with reporting being kept awake or disturbed at night and living closer to an off‐premise outlet was independently associated with reporting property damage. Discussion and Conclusions. A possible interpretation of the results is that respondents living close to on‐ and off‐premise outlets experience more amenity problems than those living further away, but that these experiences are concentrated among demographic groups who live in these areas. Direction of influence cannot be inferred from these cross‐sectional findings.[Wilkinson C, Livingston M. Distances to on‐ and off‐premise alcohol outlets and experiences of alcohol‐related amenity problems. Drug Alcohol Rev 2012;31:394–401]     

Population pharmacokinetic–pharmacodynamic modelling to describe the effects of paracetamol and N‐acetylcysteine on the international normalized ratio

Paracetamol is one of the most common pharmaceutical agents taken in self‐poisonings, and can increase the prothrombin time (PT) through liver injury, and in overdose without hepatic injury by reducing functional factor VII. PT is a measure of hepatic injury used to predict and monitor hepatotoxicity, reported as the international normalized ratio (INR). The antidote for paracetamol poisoning, N‐acetylcysteine (NAC), has been reported to have an effect on the PT. This analysis included patients from a retrospective case series, a prospective inception cohort of paracetamol and psychotropic (control) overdoses, and a cross‐over clinical trial. A population pharmacokinetic–pharmacodynamic model describing the pharmacodynamic effects of paracetamol and NAC on the INR was developed in Phoenix NLME. The dataset included 172 patients; the median age was 22 years (range 13–71 years). A one‐compartment model with first‐order input and linear disposition best described paracetamol pharmacokinetics. The population mean estimate of the concentration that induced a response halfway between the baseline and maximal pharmacological effect of paracetamol was 1302 μmol/L (242), the maximum effect of paracetamol was 0.534 (202; from baseline) and the maximum effect of NAC was 0.325 (9.03; from baseline). Both paracetamol and NAC contributed a pharmacological effect to the elevation of INR. The estimated paracetamol concentration that induced a response halfway between the baseline and maximal pharmacological effect was within the range of plasma paracetamol values studied, fivefold greater than the maximum therapeutic concentration, suggesting that an elevated INR would not be expected within the therapeutic range. Simulated 24 and 48 g paracetamol overdoses with NAC administration produced INR values (50th percentile) that reached the upper limit of, or exceeded, the reference range.     

The Analgesic Concentration of Oxycodone with Co‐administration of Paracetamol – A Dose‐Finding Study in Adult Patients Undergoing Laparoscopic Cholecystectomy

We have previously shown that paracetamol has an opioid‐sparing effect in tonsillectomy, and now, we evaluated the analgesic efficacy of paracetamol i.v. in early post‐operative pain after laparoscopic cholecystectomy (LCC). Twenty‐four patients with LCC were randomized to receive paracetamol i.v. 1 g (group 1) or 2 g (group 2) at the end of surgery. All patients were provided 0.1 mg/kg of oxycodone i.v. 15 min. before the end of surgery. At the recovery room when the wound pain at rest was ≥3/10 and/or ≥5/10 during the wound compression, plasma sample was taken for the determination of oxycodone (minimum effective concentration, MEC), its metabolites and paracetamol. After that the patients were titrated with further doses of oxycodone i.v. to wound pain < 3/10 at rest and < 5/10 during wound compression, plasma sample was taken for the determination of minimum effective analgesic concentration (MEAC) of oxycodone. The total oxycodone dose needed for pain relief was similar, about 0.3 mg/kg (range 0.2–0.5), in both groups (p = 0.80). At the onset of pain, P‐oxycodone (MEC) was similar in both groups, 25 ng/ml (19–32) in group 1 and 24 ng/ml (16–34) in group 2. The pain relief (MEAC) was achieved in group 1 with P‐oxycodone 70 ng/ml (30–131) and in group 2 with 62 ng/ml (36–100) (p = 0.48). In conclusion, in the early‐phase after LCC, there was no significant difference between the effect of paracetamol doses of 1 g and 2 g i.v. on the need of i.v. oxycodone.     

Smoking cessation advice provided in 53 Norwegian pharmacies

Objective To investigate the quality of the smoking cessation advice on over‐the‐counter (OTC) nicotine replacement treatment (NRT) provided by community and hospital pharmacies in Norway and to assess any change in customer services and pharmaceutical smoking cessation advice after a change in legislation deregulating NRT from pharmacy‐only to general sale. Method A mystery shopper made 106 visits to 53 pharmacies in Oslo, Norway. The first visit was when NRT was a pharmacy‐only medicine and the second when it had become available from any outlet as a general sales product. The pharmacies were scored on 12 observation parameters regarding customer service and pharmaceutical advice (score 0–4, total possible score was 48). Key findings There was considerable inter‐ and intra‐pharmacy variation in scores. The pharmacies' total score ranged from 3 to 45. On only 14.2% of the visits was the service categorised as ‘Good’. There was no statistically significant difference in total score between the two test periods (P = 0.56), and hence no measurable difference in customer services and pharmaceutical advice as a result of increased competition after the switch to general sale. A scatter plot showed no relationship between the individual pharmacies' total score at the two visits. Conclusions Pharmacies' scores for the quality of their smoking cessation advice were generally low. There was no measurable change in pharmacies' customer service and pharmaceutical advice following the deregulation of NRT. There was little consistency in the total score between the first and the second visit to the same pharmacy. Improvement is needed in the smoking cessation advice provided by Norwegian pharmacies.     

The characteristics of acute non‐fatal medication‐related events attended by ambulance services in the Melbourne Metropolitan Area 1998–2002

Introduction and Aims. To describe the characteristics of non‐fatal medication‐related ambulance attendances in Melbourne. Design and Methods. A retrospective analysis of 16 705 patient care records completed by ambulance paramedics in Melbourne where medications had a causal role in the attendance. Results. A single medication only was implicated in 11 765 cases (70% of the total). Of these, 85% involved one of six types of medication: benzodiazepines (52%), paracetamol (15%), selective serotonin re‐uptake inhibitors (6.5%), combination paracetamol and opioids (4%), phenothiazines (3.4%) and tricyclic antidepressants (TCA) (3.7%). Cases involving benzodiazepines were significantly (P < 0.001) older (Average = 37 years) than those involving paracetamol (Average = 30 years). Thirty‐four per cent of cases involved concurrent alcohol use, and this varied according to drug type (paracetamol 26%, benzodiazepines 40%, selective serotonin re‐uptake inhibitors 35%, paracetamol and opioids 35%). An abnormal Glasgow Coma Scale score was found in 19% of cases, again varying according to drug type (paracetamol 10%, TCA 39%, benzodiazepines 21%, paracetamol and opioids 17%, phenothiazines 15%). Ten per cent of cases were not transported to hospital ranging from 3% for TCA to 13% for benzodiazepines. Discussion and Conclusions. The majority of non‐fatal medication events attended by ambulance paramedics involve one of six substances. Benzodiazepines were most commonly implicated and, as management may require only simple supportive treatment, significant numbers are not transported to hospital. The unique clinical population is identified in this study and the ongoing medical and psychiatric treatment of these patients not transported to hospital in the study period needs to be considered. [Hutton J, Dent A, Buykx P, Burgess S, Flander L, Dietze P. The characteristics of acute non‐fatal medication‐related events attended by ambulance services in the Melbourne Metropolitan Area 1998–2002. Drug Alcohol Rev 2009]     

Changing the density of alcohol outlets to reduce alcohol-related problems

Increasingly, it seems, legal and political debates regarding the granting of new liquor licences are turning to the issue of whether the number and density of alcohol outlets makes a difference in rates of alcohol consumption and alcohol‐related harm. But what is the state of the evidence on this question? In this Harm Reduction Digest Livingston, Chikritzhs and Room review the research literature on the effects of density of alcohol sales outlets on alcohol consumption and alcohol‐related problems; suggest a new way of conceptualising the relationships; and discuss the implications for reducing alcohol‐related harm.     

Agranulocytosis attributed to metamizole: An analysis of spontaneous reports in EudraVigilance 1985‐2017

Despite ongoing debates about its safety, the use of metamizole (dipyrone) is still increasing in many countries. In this study, we analysed spontaneous reports of suspected metamizole‐associated agranulocytosis recorded in EudraVigilance database from 1985 to 2017 with regard to patient and treatment characteristics as well as fatal vs non‐fatal outcomes and compared these findings among countries. A total of 1448 reports from 31 different countries were included (Germany 42.0%; Spain 29.6%; Switzerland 13.1%; other countries 15.3%). Mean age of patients was 53.6 years (63.4% females). Differences among countries were observed, for example with respect to patient age, route of administration and daily doses. Overall, median time between starting metamizole and developing an agranulocytosis was 13 days with 34.7% of cases occurring up to 7 days. This time was much shorter in patients who had already received metamizole before (median: 6 vs 15 days). About 16% of cases ended fatally. Patients with fatal outcomes were older and more often had also received methotrexate compared to those with non‐fatal outcomes. When adjusting for age and sex in a multivariable logistic regression, methotrexate was associated with an increased risk of fatal outcomes (odds ratio: 5.18; 95% confidence interval: 3.06‐8.78). In conclusion, metamizole‐associated agranulocytosis is still a life‐threatening condition, especially in the elderly and those also receiving methotrexate. As agranulocytosis can develop weeks after last administration and independently of dose and duration of treatment, prescribers and patients should be aware of its signs and symptoms.     

Levothyroxine Poisoning – Symptoms and Clinical Outcome

Levothyroxine (LT), T4, poisoning is rarely associated with a severe outcome. However, cases with significant complications have been reported. The aim of this study was to identify factors associated with symptoms of poisoning including late‐onset symptoms. All enquiries to the Danish Poison Information Centre (DPIC) concerning LT poisoning between March 2007 and September 2012 were reviewed and the following parameters were recorded: age, dose, time from ingestion, multiple drug intake and symptoms. To evaluate the frequency of late‐onset symptoms, a subgroup of patients without initial symptoms were contacted. A total of 181 patients were registered (112 children). Ingested LT dose ranged from 10 to 9000 mcg (median 275 mcg). A total of 29 of 181 (16%) patients were symptomatic at the time of enquiry, and there was no difference in ingested LT dose between asymptomatic and symptomatic patients, neither in children nor in adults (age 16–92 years) (p < 0.68 and p < 0.47, respectively). In total, 153 of 181 (85%) patients did not have symptoms of poisoning at the time of enquiry; however, in 9 of 21 (43%) patients, we were able to contact, late‐onset symptoms existed. In none of the cases, hospital contact was needed and there were no reports of long‐term sequelae. Acute LT poisoning often follows a benign course. The occurrence of symptoms appears not to be dose dependent. Late‐onset symptoms seem to be common. However, all symptoms resolved spontaneously without need of medical care.     

Knowledge of medicine outlets’ staff and their practices for prevention and management of malaria in Ghana

Objective To obtain information about the staff resources available in licensed medicine outlets, assess their knowledge about malaria illness, current policy initiatives for malaria control, and the practices for prevention and management of malaria. Setting Hospitals/clinics and retail medicine outlets (community pharmacies and licensed chemical shops) from urban and rural areas in Southern and Northern Ghana. Method A cross section of medicine outlets (n = 121) in the two geographic and socio-economically diverse settings in Ghana were sampled. Data on staff resources, their knowledge about malaria, and current initiatives for malaria control were obtained through structured interviews. Staff practices for prevention and management of malaria were assessed through observation of their practice during counseling, selection, and dispensing of anti-malarial. Main outcome measures Professional status of staff in the outlets, the proportion of staff with adequate knowledge on malaria illness and the initiatives for malaria control; skills and practices for the recognition, prevention, and management of malaria. Results 56% of the staff (n = 269) were non-professionals, whereas 44% (n = 212) were professionals. The hospitals/clinics had more professional staff per outlet than the retail outlets. One hundred and fifty four staff members, including those in-charge of the outlets at the time of data collection (n = 121), and others recommended by the in-charges or outlet owners (n = 33) were assessed. Of these, 83% knew the mode of malaria transmission, 81% could advise clients on practices for malaria prevention, 88% recognized signs/symptoms of uncomplicated malaria, and 64% those of complicated malaria. Less than 40% had adequate knowledge about current initiatives for malarial control, and only 21% could manage malaria cases as recommended by national guidelines. Conclusion Most of the staff, particularly those in the retail outlets were not professionally trained. The staff assessed could recognize malaria illness and counsel clients on practices for disease prevention. The majority, however, lacked knowledge on the current initiatives for malaria control and the skills to manage malaria cases appropriately. In order to achieve public health objectives, interventions to strengthen skills and improve practices for malaria case management are needed. Training on current initiatives for malaria control should also be considered a priority.     

Effects of active and passive smoking on the development of cardiovascular disease as assessed by a carotid intima‐media thickness examination in patients with type 2 diabetes mellitus

Carotid intima‐media thickness has been widely used as a surrogate end‐point for cardiovascular disease, myocardial infarction, and stroke. This study aimed to assess the effects of active and passive smoking exposure on the development of cardiovascular disease in patients with type 2 diabetes mellitus. Seven hundred twenty‐two patients with type 2 diabetes mellitus were recruited for the study. A standardized questionnaire on smoking status, pack‐years of smoking, and the number of years of smoking cessation was provided to the patients, and their responses were collected for analysis. The carotid intima‐media thickness, carotid plaque, and the internal diameter of the common carotid artery were determined by high‐resolution B‐mode ultrasonography. Compared to non‐smokers, passive female smokers had a higher risk of cardiovascular disease (odds ratio = 3.50, 95% confidence interval: 1.29–9.49, P = 0.009); they also had a significantly larger common carotid artery (P = 0.041) and risk of carotid plaque (odds ratio = 2.20, 95% confidence interval: 1.1980–4.0505, P = 0.01). Both active and passive male smokers had a significantly greater carotid intima‐media thickness than non‐smokers (P = 0.003 and P = 0.005, respectively). Male active smokers had a significantly higher risk of carotid plaque (odds ratio = 2.88, 95% confidence interval: 1.4788–5.6094, P = 0.001). In conclusion, cumulative active and passive smoking exposures are significant risk factors for carotid atherosclerosis in patients with type 2 diabetes mellitus. Our results highlight the importance of endorsing a smoke‐free environment for patients with type 2 diabetes mellitus.     

Children's over‐the‐counter medicines pharmacoepidemiological (COPE) study

Objective To quantify the extent and types of minor ailments in children that were presented at community pharmacies and the types of over‐the‐counter (OTC) medicines purchased in response to these ailments. Method Data on all requests and sales of OTC medicines for children (aged 16 years and under) and consultations for minor ailments in children were recorded in eight community pharmacies for one week every month over a 12‐month period. Participants were members of the public who consulted the pharmacists or other pharmacy staff in the community pharmacies. Key findings A total of 976 consultations was recorded with 61.5% requesting an OTC medicine by name and 38.5% by symptom presentation. An average of 10.2 consultations was made per pharmacy per week. Requests for treatment were usually made within five days of symptom occurrence (86%). Most of the consultations were made by mothers (75%), although 17% were by fathers. The most commonly purchased OTC medicine was paracetamol. There were five requests for aspirin and one was for a 2‐year old child. A total of 62 cases (6%) was referred back to the child's primary care physician (general practitioner). Conclusions Symptoms related to cough and cold were the most common problems in children presenting to community pharmacies for treatment. Paracetamol was the most widely used OTC medicine in children. Pharmacy staff do question the request for OTC medicines such as aspirin, to ensure its safe use. Community pharmacies play an important role as the first port of call for advice on minor ailments in children and have an opportunity to provide health promotion to carers of children.     

An evaluation of a rural community pharmacy‐based smoking‐cessation counselling and nicotine replacement therapy initiative

Objective To evaluate the efficiency and the effectiveness of a rural community pharmacy‐based smoking‐cessation counselling and nicotine replacement therapy (NRT) initiative. Setting Community pharmacies in NHS Highland in the north of Scotland. Key findings Most clients (77%) smoked cigarettes for an average of 34 pack‐years ranging from 1 to 174 pack‐years. Almost three‐quarters (73%) of the NRT prescribed was in the form of patches. Most respondents (91%) claimed pharmacists' advice was useful, and most (65%) thought that the pharmacist was their preferred healthcare professional for smoking‐cessation advice because of ease of access. At the end of week four, 45% of clients reported that they had stopped smoking, this fell to 35% at the end of week 12, and at 44 weeks the point prevalent abstinence rate was 15.8%. Of those that did not stop, 19% reduced their smoking level. This initiative cost £525 for each quitter. Thirteen quality criteria were defined in the assessment framework of which six were achieved. Conclusions There are no established criteria for evaluating community pharmacy‐based smoking‐cessation initiatives currently available, neither are reductions in smoking levels reported. Enhancing the role of the community pharmacist to include health improvement improves the interface between healthcare and the consumer, and helps to meet the national recommendations. Community pharmacy‐based smoking‐cessation initiatives impact on smoking‐cessation targets, allow for the variety of services relevant to the needs of the population and are part of the key to making a difference. Methods A review of the literature on community pharmacy‐based smoking‐cessation initiatives informed a performance assessment framework. Data for evaluation were collected through client records, questionnaires and semi‐structured interviews of the stakeholders, and a cost‐effectiveness analysis was undertaken.     

Work readiness scale for pharmacy interns and graduates: A cross-sectional study

IntroductionAs the number of unemployment among pharmacy graduates increases, the Saudi Ministry of Labor implemented extra measures to facilitate their training and hiring by the private sectors. Nevertheless, there is a paucity of data regarding pharmacy graduates’ work readiness (WR). Hence, we aim to assess their WR and identify predicting factors associated with WR among pharmacy graduates’ in Saudi Arabia.MethodsA 46-item self-reported pre-validated anonymous work readiness scale (WRS) survey with a 5-point Likert scale was administered to pharmacy senior students and graduates using Qualtrics XM® survey tool over the month of May 2020. The main outcome was to assess WRS for pharmacy interns and graduates and identify factors associated with work readiness.ResultsA total of 617 participants have participated in this survey, out of which 46.5% were freshly graduated pharmacists and 19.6% were pharmacy interns. Most participants (82.3%) were PharmD candidates or graduates. Around two-third of participants (63%) have successfully completed all survey items. The maximum points scored was 223 out of 230, and the median overall score was found to be 175. There was no significant association with gender, age, or type of university regarding overall scores. However, a statistically significant odds ratio was observed with PharmD program type and previous pharmaceutical marketing training (OR = 1.778, 95% CI = 1.143–2.765: OR = 0.618, 95% CI = 0.432–0.884, respectively).ConclusionThe overall median score shows a good work readiness level among pharmacy students/graduates in Saudi Arabia; however, PharmD program graduates exposed to advance pharmacy training, including the pharmaceutical marketing experience, have higher work readiness odds than Bpharm graduates. Further studies involving other related perspectives, such as stakeholders, employers, and preceptors, would give a clear image of pharmacy graduates’ job readiness levels.