DRUG ABUSE AND MISUSE

Basic Terminologies:

Drug Abuse

If a person uses a medication as a habit, then it is called drug abuse.

To abuse is to use something in a way that will cause damage or harm.

Term drug abuse refers to consumption of psychoactive drug without medical

instructions.

Drug Misuse

If, somebody uses a drug without knowing its purpose, then it leads to drug misuse.

To misuse is to make a mistake and use something incorrectly.

Taking of drugs in damaging quantities or in quantities other than prescribed one

Difference between misuse and abuse:

It mostly has to do with the individual’s intentions or motivations. For example,

let’s say that a person knows that he will get a pleasant or euphoric feeling by
taking the drug, especially at higher doses than prescribed. That is an example of
drug abuse because the person is specifically looking for that euphoric response.

In contrast, if a person isn’t able to fall asleep after taking a single sleeping pill,
they may take another pill an hour later, thinking, “That will do the job.” Or a
person may offer his headache medication to a friend who is in pain. Those are
examples of drug misuse because, even though these people did not follow medical
instructions, they were not looking to “get high” from the drugs. They were
treating themselves, but not according to the directions of their health care
providers.

However, no matter the intention of the person, both misuse and abuse of
prescription drugs can be harmful and even life-threatening to the individual. This
is because taking a drug other than the way it is prescribed can lead to dangerous
outcomes that the person may not anticipate.
Dangers linked to misuse and abuse of prescription drugs:

It’s important to note that all drugs can produce adverse events (side effects), but
the risks associated with prescription drugs are managed by a health care
professional. Thus, the benefits outweigh the risks when the drug is taken as
directed.

However, when a person misuses or abuses a prescription drug, there is no medical

oversight of the risks. A person can die from respiratory depression from misusing
or abusing prescription painkillers; for example, opioids. Prescription sedatives
like benzodiazepines can cause withdrawal seizures. Prescription stimulants such
as medications for attention deficit hyperactivity disorder (ADHD) can lead to
dangerous increases in blood pressure. The risks from these drugs are worse when
they are combined with other drugs, or alcohol.

Additionally, when a person misuses a prescription drug, even on a single

occasion, that individual might enjoy the experience so much that they begin to
seek out the drug more often. Thus, drug abuse and drug dependence are serious
risks of misusing prescription drugs.

Why do people misuse and abuse prescription drugs:

Prescription drugs are often readily accessible in the home, so it’s easy to take
more of them than recommended for a therapeutic reason, or to sneak a few from
someone else’s bottle to see if you can “get high.”

One feature of prescription drug abuse is when a person continues to take the drug
after it’s no longer needed, medically. This is usually because the drug produces
euphoric responses. Prescription drugs are often preferred for abuse because of the
mistaken belief that the drugs provide a “safe high.” But as I mentioned before, all
drugs carry risks, and if these risks are not being managed by a health care
professional, people can get into serious trouble.

What is Addiction?

Compulsion to continue administration of psychoactive drug in order to avoid

physical and psychological withdrawal effects

“WHO”
A cluster of psychological, behavioural and cognitive phenomena of variable
intensity in which use of psychoactive drug takes on high priority, the necessary
descriptive characteristics or preoccupation with a desire to obtain and take the
drug and persistent drug seeking behaviour.

2. PHASES OF ADDICTION

Tolerance

Reduced effects of same dose of a drug … Increase dose

Habituation

Emotional and Psychological need felt for drug

Dependence

Psychological & physical need felt for drug and withdraw of drug produces
abstinence syndrome

HARMS RELATED TO PSYCHOACTIVE DRUGS

1. Health problems

th and lung problems

2. Social problems

3. Drug related crimes

LIST OF COMMONLY ABUSED DRUGS

DRUGS THERAPEUTIC MISUSE/ABUSE STRATEGY & REMEDY
& CLINICAL
USES
bromazepam
BROMAZEPAM  Insomnia addiction can 1. Detoxification
(Benzodiazepine)  Anxiety only develop as
 Muscle a result of the 2. Cognitive behavioral
relaxant repeated
 Anti-seizures consumption of therapy
bromazepam
over a length of 3. Sell drugs only on valid
time that cause
dependence. prescription.
bromazepam is
frequently 4. Presence of qualified
consumed
recreationally for person at pharmacy.
the pleasant
sedative “high” it 5. Minimizing
produces
 The longer prescription forgery
PENTAZOCINE  Analgesic someone use
(Opioid)  Used before pentazocine the 6. Inspection of drug
surgery with more likely they
anesthesia become addicted. selling stores
 Act on CNS When pentazocine
to relieve is used for a long 7. Narcotics register.
pain. time, it may
become habit- 8. Original prescription of
forming, causing
mental or physical patient at pharmacy
dependence
There are chances 9. Avoid temptation and
DIPHENOXYLATE  Anti- of abuse because
+ diarrheal. of the presence of peer pressure.
ATROPINE  Anti- opioid
(Lomotil) (diphenoxylate). 10. Keep track of
cholinergic.
The reasons of
 pain-relieving initiation of prescription drug.
diphenoxylate
were to relieve 11. Know yours teen’s
withdrawals, as a
cheap substitute activity.
opioid, curiosity,
and suggestion of 12. Develop self-
friends
 Severe Long term use of instructional techniques
TRAMADOL chronic pain. tramadol by
 Post-surgery patient built for behavioral self-
physical and
pain
emotional control.
dependence. So,
the withdrawal 13. Seek help for mental
effects are
maximum illness
When nalbuphine
NALBUPHINE  Severe pain injection used for 14. Keep well balanced
 Post labor long time, it may
pain become habit- life.
forming, causing
mental/physical 15. Effectively deal with
dependence.
 Alprazolam is peer pressure. The
Alprazolam  Anxiety frequently abused
 Panic because biggest reason teens
disorders commonly
prescribed. Due to start using illicit drugs
 Insomnia
its short action its
off-label use. effect wear off is because of their
quickly and
people want more friends
administration at
high doses.
Severe
withdrawal effect
make difficult for
people to stop
using it.
The widespread
DIAZEPAM  Anxiety availability of
(valium)  Muscle Valium, and the
relaxant pleasant calming
effects that it
 Restless legs
produces, have
 Withdrawal made diazepam a
syndrome common drug of
abuse. For most
people, valium
makes you
feel relaxed and
calm. Some
people say valium
makes them feel
emotionally numb
Many people
CLONAZEPAM  Anxiety become addicted
 Alcohol by only taking the
withdrawal amount prescribed
by doctor.
 Antiepileptic
Addicted persons
brain cannot
produce feeling of
relaxation and
calmness without
clonazepam.
PROMETHAZINE Tixylix is usually
HCL  Cough prescribed for the
+ suppressant children with dry
PHOLCODINE cough. Tixylix
(TIXYLIX) have some
sedative
properties due to
anti-histamine
effect.
Some parents
medicate their
babies with
allergy or cough
medicine say it
helps the children
sleep.
Frequent use of
 Anti- seizure the drug in a
 Sedative manner
PHENOBARBITAL inconsistent with
 Barbiturates
its prescribed
withdrawal purposes.
Developing
significant
tolerance to
phenobarbital
even though one
does not have a
prescription for it.
 Chapter 17

Role of Pharmacist as public educator in

drug information and monitoring
Introduction
• The volume complexity and cost of modern medicines are increasing. So need to compare the
therapeutic efficacy (i.e. benefit) of medicine with their potential to cause harm (i.e risks)
• The main aim of advising and drug monitoring are:
❖ Gain the maximum benefits from their medication to maintain or increase the quality
and duration of patient life
❖ Avoiding suffering from unnecessarily illness caused by excessive, inappropriate or
inadequate consumption of medicines
What information and advice giving in pharmacy
• Patients and customers have right to be involved in the decisions about their treatment and
their use and choice of medicines
• Thus pharmacists require effective communication skills to be able to identify the individual
need of patient
• In the UK, the veterinary medicine regulations 2007 require, to give information of following
advice
➢ Always advise on safe administration
➢ Advise as necessary on any warnings or contra indications on the label or packing
➢ Be satisfied that the person who will use the product is competent to use it safely and
use for intended purpose
• The British National Formulary (BNF) uses the term counseling rather than advice as a head-
ing in individual monographs to detail the type of advice to be given to the patients
• Such advice is above that require on the label of dispensed products and usually involves unu-
sual/ complicated methods or time for administration or potential interaction with foods.
• For example bulk forming laxatives have counseling statement “ Preparations that swell in
contact with liquid should always be carefully swallowed with water and should not be taken
immediately before going to bed.
The need of information and advice giving
• Some patients, especially geriatric population (50%), have difficulty in taking medicine and
complying dosage regimen
• It is estimated that 85% of over the 75 years old in UK takes at least one prescribed medicine
whereas 36% of them take 4 or more medicines.
• So, patient medicine compliance is a big problem, and a lot of medicines get wasted because
people don’t use them properly and they get expired.
• The one of the reason behind not to take medicine is that patient doesn’t understand how to
take medicine
• Evidences show that advice by the pharmacists can lead to better patient compliance
• All of medicines are supplied with patient leaflet but most of patients cannot understand it due
to medical terms as well as illiteracy
• Some of the patients who understand the information become scared by the side effects
• So, pharmacist is the best source of the information and appropriate patient counseling may
increase the patient compliance, maximize the efficacy and minimize the ADRs
The aims of information and advice
• Advice the patients, how to use the medicine
• Encourage patients to identify any problems they perceive from medicine and also advise the
solutions of these problems

69
• Encourage patients to make their own action plan for taking medicine correctly
• Gain an understanding of patient perspective
• Respect the patient beliefs and be non-judgmental of their use of medicines
Opportunities for giving information and advice
• The community pharmacy is the best place for giving patient advice and information
• It is integral that patient should be advised after dispensing the medicine
How to provide information and advice
• The information and advice giving should always be in thoughtful and structured ways
• Pharmacist not only have the sound knowledge of drugs but also should have excellent com-
munication skills
• Pharmacist should allow the patient to ask questions so that patient may understand the infor-
mation
• Information and advice may be considered successful, if it is two way communication
• It is important to provide the correct amount and type of information:
❖ Chunks and checks: The information needs to be given in suitable bite chunks. Observa-
tion of patient response should indicate whether chunks are too small or too large for pa-
tient understanding
❖ Access the patient starting point, how much they know, especially in the start of session
❖ Ask the patient what should be helpful. For example, a patient may be more concerned
about immediate effects of the drugs on their lifestyle rather than progression of disease
❖ Give explanation at an appropriate time
• In order to help the patient in with recalling and understanding, the advice or information that
you provide, the pharmacist should provide material
❖ Organize the explanation: Try to a logical sequences and discrete sections. Don’t
combine the information of side effects with how to administer the medicine.
❖ Use signposting- in other words to explain 3 points, we should say firstly, secondly
and thirdly before each point
❖ Use easily understandable and concise language- avoid jargons
❖ Use visual method of explanation. Demonstration method of pharmaceutical packag-
ing is useful e.g. aerosols
❖ Check patient understanding at regular interval
What information to include
o How to take or use medicine
o When to take medicine
o How to take medicine
o How long to continue to take medicine
o What to expect e.g. immediate relief or it may take several days for relief
o Why the medicine is being taken
o What to do if something get wrong e.g. if dose is missed
o How to recognize the side effects and minimize their incidence
o Lifestyle changes which needs to be maintained
o Dietary changes which need to be made
Who to counsel
• Consideration of the medication for counseling:
➢ A prescription with multiple medicines
➢ Medicines with complex dosage regimen, special delivery method and novel packaging
➢ A medicine with narrow therapeutic index (lithium, theophylline)
➢ A medicine having potential for interaction with other drug or food
➢ The medicines that have common potential to cause side effects. In this case not only pa-
tient should be informed how to recognize side effect but also tell him/her how to manage
it
➢ A recommendation in Appendix 9 of BNF that a cautionary or advisory label should be
used
• Consideration of the patient:

70
 o Is the patient is known at pharmacy and have they previously identified as having prob-
lems with drug therapy?
o What information has patient previously received
o What are patient comprehension level?
o What level of support patient need or have?
o The age of patient? In general all the patients who are elderly should have advice and for
child guardian should be advised
o Is patient is pregnant or nursing mother? In this case reassurance of safety of medicine
o Does patient has any physical or mental disability?
o Patient is known non-compliant of medicine
Other instances which should alert the pharmacist to need of counseling would be
➢ Purchase of an OTC medicine that has interaction with prescribed medicines
➢ A patient asking for medicine not to dispense indicating that patient is non-compliant
➢ A patient asking for an OTC medicine that is used to relieve symptoms of prescribed
medicine. e.g. a patient asking for the omeprazole while he has been prescribed for
NSAIDs may be using overusing the NSAID
Recognizing the need for information and advice
➢ Has the medicine been prescribed before to the pa-
tient?
➢ Are instructions clear?
➢ Is the prescription for drugs which have a compli-
cated or unusual regimen?
Assessing and prioritizing the needs
• Although all individuals should be considered for infor-
mation and advice, there will be some for whom little or
none is required
• For example a patient who ask for OTC medicine by
name and has used it on successfully for several previ-
ous occasions need less or no advice
• Giving information and advice is time consuming so
pharmacists should concentrate to those patients requir-
ing it
• This entails the assessing the needs and prioritizing, so that most needy patients should enter-
tained
• Pharmacist may have to be selective the what advice should be given to patient
• Information on cautionary labels should include the reason but in very easy way and no jar-
gon, technical term or detailed mechanism should be included. So emphasis should be on im-
portant point.
• If only two points are selected for prescription, it can be two different points for two people.
• e.g. for metronidazole counseling, the most important advise to the person who is non-alco-
holic will be to “swallow the whole tablet with plenty of water” instead of “avoid alcohol
consumption with medicine intake”, the most important advise for alcoholic person
Specifying assessment method
• Assessment should be made what the patient has been advised, he/she understands and is ad-
here to comply
• Assessment may be whether patient know how to take medicine or read the label.
• He/she is able to use inhaler in correct way or is able to open child resistant container
Implementation
• The appearance of the pharmacy is an important factor. The environment should be profes-
sional.
• Patient counseling at busy pharmacy can be difficult so a quite place may be required for pa-
tient counseling especially for DUR/MUR.
• If patient is unknown to pharmacist, it is important for beginning of conversation to estimate
not only amount of information that is required but also patient level of comprehension.

71
• The type of language is very important, simple language should be used
• The advice giving process must not be monologues by the pharmacist, giving a long list of
information points. There should be ample opportunity for the patient to ask questions
Assessing the success of the process
• Having given the information, it is then major importance to check if the process has been
successful or not?
• During the information and advice giving process the pharmacist should be checking if the
patient is understanding the information
• Watching the patient body language and maintaining eye contact can give useful clues,
whether the massage is easily understandable.

72
 HEALTH SYSTEM RESEARCH
Research Methods & Designs
 Research
• The systematic investigation into and study of
materials and sources in order to establish
facts and reach new conclusions.
• In the broadest sense of the word, research
includes any formal gathering of data,
information and facts for the advancement of
knowledge.
 Health System Research
• Health systems research aims to provide
information which will improve the
functioning of the health system, and
ultimately lead to improved health status.
 Why conduct studies
To describe
• Burden of disease
• Prevalence of risk factors
• Health behaviors
• Other characteristics of a population that
influences risk of disease
• Causes or risk factors for illness
• Relative effectiveness of interventions
 Epidemiology Methods

• Descriptive epidemiology

• Analytic epidemiology
• Descriptive epidemiology
– Helps the epidemiologist to
• become familiar with data,
• identify extent of public health problem,
• obtain a description of public health problem that can be
easily communicated,
• identify high risk population and
• provide clues to determinants of disease.

• In Descriptive Epidemiology, the hypothesis is

generated by studying the background of the
disease.
• Descriptive epidemiology in context of person,
place and time
– Person: describing data by person allows the
epidemiologist to identify frequency of disease and
who is at great risk.

– Place: describing data by place helps the

epidemiologist to understand geographical extent of
disease, where the causative agent resides and
multiplies and how the disease is transmitted.

– Time: epidemiologist can reveal the extent of public

health problem in context of when and whether the
disease is predictable.
Types of Descriptive Studies
 Descriptive Study Designs
• There are four major type of studies used in
descriptive epidemiology;

– Ecologic study

– Case studies and case series

– Cross-sectional studies

– Serial surveys
• Ecologic study
– An ecologic study involves aggregated data on the
population level.

– The ecologic study are mostly cross-sectional,

however, may be longitudinal in nature.

– When data are collected from a population overtime

to look for trends or changes, this type of study is
known as a TIME-TREND or a TIME-SERIES STUDY.

– Ecologic study may be analytic or descriptive.

• Case report
– Case report is a profile of single individual.

– (Find two case reports and discuss)

• Case series
– Involves small group of people with similar
diagnosis.

– (Find two case series and discuss)

• Cross-sectional studies
– In cross-sectional studies, the data is collected in a
single point of time.
– There is no follow-up period.
– Cross-sectional studies may be descriptive or analytic.
– For example, if a study is designed to assess
prevalence of a disease in a given population, it is
known as a descriptive cross-sectional study.
However, if we study associations between disease
and other , the study design would be analytical.
• Sometimes, cross-sectional studies are called

prevalent studies as these collect data at a single

point of time.
• Strengths of cross-sectional studies
– We can study several associations at once.
– Conducted over a short period of time.
– Produce prevalence data.
– Bias resulting from loss of follow-up does not exists.

• Weaknesses of cross-sectional studies

– Fail to explain whether an exposure preceded or
followed a health outcome (nothing about causal
direction).

– Method not feasible for studying rare condition and

has the potential for RESPONSE BIAS.
• Serial surveys
– Cross-sectional surveys that are routinely
conducted are called serial surveys.

– These surveys reveals changing pattern of health

states or events over time.
 Analytical Epidemiology
• Analytic Epidemiology is mainly concerned
with finding the causes of the infection or the
disease to identify the interventions of the
disease.
• Analytic Epidemiological studies are mainly
categorized as experimental and
observational studies.
• Analytic epidemiology studies are conducted
to obtain a relationship between different
exposures to the disease condition and to
obtain its outcome in a measurable manner.
• Analytic epidemiology incorporates a
comparison group in its study designs.
• Analytic epidemiology is important in deriving
conclusions on a particular disease state or an
infection to confirm the hypothesis tested
whether it can be accepted or it is rejected.
Analytical study Types
Cohort Studies:
• An “observational” design comparing
individuals with a known risk factor or
exposure with others without the risk factor
or exposure.
• Look for a difference in the risk (incidence) of
a disease over time.
• Best observational design.
• Data usually collected prospectively (some
retrospective).
• Characteristics are follow-up period can be
prospective or retrospective.
Cohort Study Design
• Advantages:
• No temporal ambiguity.
• Several outcomes could be studied at the same time.
• Suitable for incidence estimation.
• Disadvantages:
• Limitations of prospective type
• Expensive.
• Time-consuming.
• Inefficient for rare diseases.
• May not be feasible.
• Sub classes of cohort design
• Prospective Study:
• Looks forward, looks to the
future, examines future events, follows a
condition, concern or disease into the future.
• Retrospective Study :
• “To look back”, looks back in
time to study events that have already occurred.
One key point is that the data which is used was
not taken originaly for research purpose.
E.g: prescription evaluation.
Prospective Design
Retrospective Design
 Case Control Study:

• Also known as “Reteospective study”.

• Retrospective means that (like a detective) you begin at the end
with the disease & then work backwards to find possible causes.
looks at phenomena that has already happened an easy & quick
way of comparing treatments.
• Advantages:
• Fast & cheaper than prospective study.
• Disadvantages:
• Difficulty in collection of information on past exposures
• Poor in determining cause & effect relationship
• Cannot calculate incidence of disease nor can you calculate
prevalence.
• There may be other ways in which cases & controls differ.
Case Control Design
 Experimental Study design
• Definition
• “It involves the science and planning of
how an experiment will be conducted in order to
obtain valid and reliable result”.
• Theory
• It resembles controlled experiments performed in
scientific research. It involves two groups
• Control group (comparison group)
• Intervention group
• When experimental study includes randomization of
participants to the intervention and control group and
participant and evaluators are blinded, confounding and
bias may be effectively controlled.
• It is more powerful study design because the investigator
has more control over the level of exposure. Hence, the
randomized blinded experimental study is considered to
be the “gold standard” in epidemiology for basing
conclusions about causal relationship.
• They are most useful for establishing cause-effect
relationship and for evaluating the efficacy of prevention
and therapeutic interventions.
• Methodology
• It contains two types of methodology:
• Between group design
• In which outcomes’ are compared between two
or more groups of people receiving different
levels of intervention.
• Within group design
• It is used where the outcome in a single group is
compared before and after the assignment of an
intervention.
• In experimental study unit of analysis may be
on the individual or community level. When
experimental study is performed in a clinical
setting (also called clinical trial) unit of
analysis is individual while interventions apply
on a group level in population (school,
classroom, or city) also known as community
trial then the unit of analysis is community
level.
• Randomization
• When the study group is determined, in an ideal situation the
participants are then assigned to the intervention and control
groups by random assignment. Random assignment makes both
group look as similar as possible, thereby minimizing the potential
influence of confounding factors. Chance is the only factor that
determines group assignment.
• RCTs are most used in clinical setting.
• An important feature of randomization is balance out the effect of
confounding both known and unknown confounders.
• For example smoking is a confounding factor, so randomization of a
sufficient large no. of subjects will produced similar distribution of
smoker in both groups.
• Blinding
• The terms blind and masking are synonymous; both terms
describe methods that help to ensure that individuals do
not know which treatment or intervention is being
administered.
• Blinding is used in experimental studies to minimize
potential bias from placebo effect. Placebo effect is defined
as the effect on patient outcomes (improved or worsened)
that may occur because the expectation by patient (or
provider) that a particular intervention will have an effect.
• Placebo is independent of the true effect (pharmacological,
surgical).
• Types of blinding
• There are three types of blinding
• Single-blinded study
• Double-blinded study
• Triple-blinded study
Single-blinded study:
• In which the subject are blinded but the investigator
are aware of who is receiving active treatment.
• A classic example of a single-blind test is the Pepsi
Challenge. A tester, often a marketing person, prepares
two sets of cups of cola labeled "A" and "B". One set of
cups is filled with Pepsi, while the other is filled with
Coca-Cola. The tester knows which soda is in which cup
but is not supposed to reveal that information to the
subjects. Volunteer subjects are encouraged to try the
two cups of soda and polled for which ones they prefer.
Double-blinded study:
• In which neither the subject nor the investigators know
who is receiving the active treatment.
• Double-blind methods can be applied to any
experimental situation in which there is a possibility
that the results will be affected by conscious or
unconscious bias on the part of researchers,
participants, or both.
• For example, in animal studies, both the career of the
animals and the assessor of the results have to be
blinded; otherwise the career might treat control
subjects differently and alter the results
• Triple blind study:
• In which the treatment or intervention is
unknown to (a) the research participant, (b) the
individual(s) who administer the treatment or
intervention, and (c) the individual(s) who assess
the outcomes.
• The purpose of triple-blinding procedures is to
reduce assessment bias and to increase the
accuracy and objectivity of clinical outcomes.
Conducting a triple-blind study is difficult.
• Exception of blinding:
• In the following conditions blinding cannot be applied;
• FDA recommend (in 1970),do not require the blinding
in new drug trials
• In case of nondrug study, such as those involving in
behavior changes or surgery, it may be impossible or
unethical to blind.
• Treatment that having characteristics side effects
• If outcome measure was based on a urine sample or
blood test
• Non randomization
• There are the several reasons in which randomization
cannot be assigning;
• When large research population was not always
available
• Research is expensive
• Funds may not be adequate for research procedures,
follow-up treatments and testing of large study and
control group
• Lack of subjects with disease or condition or a desire to
participate
• If a large population is to be treated with a
preventive measure such as immunization, the
epidemiologist would not purposely have half the
population assigned at random to a control group
leave them at risk of getting the disease because
they were not immunized.
• When the entire population is to be affected or to
the treatment e.g. if fluoride is added to the
water supply of a city there is no way to include
or exclude certain individuals.
• Advantages:
• Randomization ensure that results are
accurate & have a lower risk of being biased.
• Disadvantages:
• Ambiguity in results due to different genetic
make up of individuals.
Pre & Post Marketing
Survey
 Pre Marketing Survey

• A Pre-Market Survey is to set goals for your

marketing research project by identifying what it
is you want to find out. Before you can begin
building your survey, you need to ask some
questions to guide you in the creation process.
• Your goal for the survey will help you decide what
questions to add, how many to add, and who to
target your survey to.
• Before you launch a product, you have to do
the survey to, not only see if it has a chance of
succeeding to begin with, but also to gather
crucial information from consumers
• There are many online survey
tools, which reduces the amount of work and
eliminates the need for field research
 Post Marketing Survey
• Post-marketing surveillance (PMS) is the
identification and collection of information
regarding medications after their approval by
the U.S. Food and Drug Administration (FDA)
• PMS provides valuable information on the use
of drugs in special patient populations, which
is information not easily obtainable from pre-
marketing studies.
• A post-marketing study is an integral part of
research that helps to ensure a favorable risk-
benefit profile for approved drugs used in the
market.
• Post-marketing trials are often done to
enhance sales, or are inconclusive.
Causality Assessment
• An evaluation performed by a medical professi
onal regarding the likelihood that a
therapy or product being assessed in a clinical
trial caused or contributed to an adverse even
t.
Causal Relationship
• A relationship between one phenomenon or event (A) and another
(B) in which A precedes and causes B. In epidemiology a risk factor
associated with a certain condition.
• A medicine causing an adverse reaction.
• Causality Assessment
• The evaluation of the likelihood that a medicine was the causative
agent of an observed adverse reaction. Causality assessment is
usually made according established algorithms
Sensitivity & Specificity Test
 Screening
Screening is the process in which we use a test
to determine whether an individual likely has a
particular health indicator or not or is likely to
develop a particular health indicator or not
Screening is not the same as diagnosis;
screening tests give us information about
whether the disease is likely to be present
 Example
• Physicians assess blood pressure and
cholesterol as screening tools for the
development of cardiovascular disease
• Women use home pregnancy tests to screen
for presence of an embryo or fetus
 When to screen
1. We screen for health indicators that affect population
health principally, not for rare diseases
2. There should be sufficient time between biological
onset of disease and appearance of signs and
symptoms of the disease exist so that screening could
detect the presence of the disease earlier than it
would come to clinical attention
1. There should be available treatment for the
disease so that early detection improves the
lives of affected
2. Screening tests should be cheaper and less
invasive than best available diagnostic tool
 Screening test evaluation
1. Sensitivity
2. Specificity
 Senstivity
• The sensitivity of a test is defined as the
proportion of people with disease who will
have a positive result.
• In defining sensitivity, we are only interested
in the proportion of people with disease who
test positive.
• Sensitivity can only be calculated from those
people who have the disease.
• Sensitivity of a test only tells us how good the
test is for identifying people with disease
when only looking at those with disease.
 Specificity
• The specificity of a test is the proportion of
people without the disease who will have a
negative result.
• In defining specificity, we are only interested
in the proportion of people without the
disease who test negative.
• Specificity can only be calculated from those
people who do not have the disease.
Enlist the sensitivity and specificity of different
screening test kits
 Chapter 19

Complementary and Alternative thera-

pies
Complementary and Alternative Medicines
➢ Alternative therapy is a broad domain of healing resources that encompasses all health
systems, modalities and practices and their accompanying theories and beliefs, other than
those intrinsic to the politically dominant health system of a particular society or a cul-
ture.
➢ Alternative therapies includes all such practices and ideas self-defined by its users as pre-
venting or treating illness or promoting health and well being
Background of complimentary and Alternative medicine
➢ Historically, complimentary and alternative therapy was the main form of medicine avail-
able to world’s population including those of western countries
➢ In many parts of the world, it is using still today.
➢ However, with the advent and expansion of discovery and production of mainly synthetic
medicines by pharmaceutical companies, usage of mainly plant based traditional medi-
cines declined
➢ Almost more 50 diverse complementary therapies have been listed
Description of alternative therapies
1. Therapies containing medicinal substances
2. Therapies not using medicinal substances
3. Therapies using both medicinal substances and other treatments
Therapies using medicinal substances
1. Aroma therapy
2. Bach Flower remedies and essences
3. Herbalism
4. Homeopathy
5. Nutritional Medicine
6. Traditional Chinese Medicines
Therapies not using medicinal substances
1. Acupuncture
2. Chiropractic
3. Healing
4. Osteopathy
5. Reflexology
Therapies using both medicinal substances and other treatments
1. Anthroposophical medicine
2. Ayurvedic medicine

76
Herbal Therapy
❖ Traditional herbal therapy and herbalism had a historic basis, partly based on the galeni-
cal model of four ‘humors’ and belief that an excess of any of the humors leads to dis-
ease.
❖ Today, treatment is aimed at ‘restoring balance’ and ‘strengthening body systems’.
Herbalists aim to treat patients in a holistic way by selecting a herb a combination of
herbs to treat a particular persons and his/ her unique set of symptoms
❖ One of the principal tenets is that the whole plant extract, and not an isolated constitu-
ents, is responsible for clinical effects
❖ It is claimed that herbal constituents of herbs, works synergistically to achieve benefit
and reduce the possibility of adverse effects.
❖ Rational phytochemical / phytomedicine has entirely different approach that is basis of
pharmacological activities
❖ Herbalism involves preparations made from plants or plant parts. In some instances, a
crude drug (e.g dried leaves) are used. Manufactured products use extracts of plants or
plant parts, formulated as, for obviously including numerous chemical entities.
Homeopathy
o Use of highly dilute, succussed substances to stimulate the body own healing activity
(vital force). One of the key principal is ‘like cure like’-a substance that in large quantity
causes a set of symptoms in healthy person can be used such symptoms in an ill person.
E.g. Homoeopathic preparations of coffee are used to treat insomnia.
o Treatment is holistic-two patients with same set of symptoms may be given different
remedies depending upon their personal characteristics, physical appearance and emo-
tional state.
o Although there are several hypotheses, there is not a explanation of MOA. And it is not
effective than placebo
Bach flower therapy
Developed by Dr Edward Bach, who believed that physical disease was the results of be-
ing at one’s spiritual purpose i.e negative state of mind induce illness.
His approach to health focused only on mental state of patient. He identified 38 negative
psychological state of mind (e.g. Jealousy, guilt, hopelessness).
He designed a remedy used for each state.
The Bach therapy comprises of 39 remedies, 37 out of them originates from flower/ tree,
one from natural spring water and a ‘Rescue therapy’ a combination of five of other 38
remidies.
Flower therapy are extremely dilute preparations but not homoeopathic remedies
Many countries have their own flower remedies/ essences depending upon their native
plants / trees
Aroma therapy
▪ The therapeutic use of medicinal substance, largely essential oils which typically contain
numerous chemicals constituents and extracted from plants
▪ Aroma therapists believe that essential oils is used for prevention or treatment of diseases
but also for their effects on mood, emotions and well being.
▪ Aroma therapy is claimed to be holistic therapy in that practitioner will select an essential
oil or combination of essential oils to suit each client's symptoms, personality and emo-
tional state

77
▪ The most common method for application of essential oils is massage using a carrier oil,
other methods used include the additions of essential oils to baths and footbaths, inhala-
tions, compresses and used in aromatherapy equipment e.g. Burners and vaporizers
Acupuncture
 This involves insertion of needles into specific point or set of points on the body for the
treatment of specific conditions
 Various forms exist such as auriculoacupuncture (needling on specific point on ear) and
electroacupuncture (electrical stimulation of inserted needles
 Two main types of acupunctures are as follows
➢ Medical acupuncture
➢ Traditional Chinese acupuncture
 Medical Acupuncture
❖ Usually practiced by the doctors who are trained in acupuncture and used this tech-
nique alongside with conventional medicines.
❖ Principles of neurophysiology and anatomy (i.e directed at stimulated nerve endings)
are used in this technique
 Traditional Chinese Acupuncture
❖ It is part of broader system of Chinese traditional medicines and uses the concept of
‘Yin-Yang’ and five elements (wood, fire, metal, water, earth) to explain the physio-
logical functions of human body and development of medical disorders in order to
guide diagnosis and treatment.
❖ Traditional Chinese Acupuncturists restore the balance of energy in the body by ‘un-
blocking meridians’ (pathways along which life energy flow)by inserting needle stra-
tegically in specific points along meridians
Acupressure
❖ Acupressure is a type of traditional Chinese massage therapy that focuses on stimu-
lating various pressure points around the body.
❖ Massaging these pressure points is believed to help control the flow of energy around
the body, as well as positively influence overall metabolism.
❖ Various diseases are believed to get treated by the acupressure such as GIT prob-
lems, bladder, gall bladder problems etc
Reflexology
 A form of treatment and diagnosis which involves the massage of specific points on
the feet (mainly on the soles but also on the top and sides)-Maps of areas on the feet
corresponding to different areas/ organs of body have been drawn up)
 It is made on belief that there are reflexes in the feet for all parts of body.
 Reflexologists claim to be able to identify sites of tenderness and lumps or granules of
crystalline material; which in reflexology is taken to represent remote organ disease

78
 The Top Ten Basic Counseling Skills
-- Kevin J. Drab, M.Ed., M.A., LPC, CAC Diplomate

Research is increasingly finding that the type of therapy used is not a important to outcomes as are
specific counselor behaviors such as (1) Enthusiasm, (2) Confidence, (3) Belief in the patient’s ability to change.
Although there is nothing which will ensure change, it would appear that clients are more likely to
achieve their goals when a good and positive relationship exists between them and their therapist. In essence the
counselor’s interactions with the client are a powerful tool in the helping relationship.

1. Listening

a. Attending - orienting oneself physically to the patient (pt) to indicate one is aware of the patient, and,
in fact, that the client has your full, undivided attention and that you care. Methods include eye
contact; nods; not moving around, being distracted, eye contact, encouraging verbalizations; mirroring
body postures and language; leaning forward, etc. Researchers estimate that about 80 percent of
communication takes place non-verbally.
b. Listening/observing - capturing and understanding the verbal and nonverbal information
communicated by that pt.

Two primary sources of information:

• CONTENT - what is specifically said. Listen carefully for, not only what a person says, but also the
words, expressions and patterns the person is using, which may give you a deeper insight.
Counselors should develop their ability to remember what was said, as well as to clarify what was
said or finding out what was not said.

• PROCESS - all nonverbal phenomena, including how content is conveyed, themes, body language,
interactions, etc. Smiling

2. Empathy
The ability to perceive another's experience and then to communicate that perception back to the
individual to clarify and amplify their own experiencing and meaning. It is not identifying with the pt or
sharing similar experiences-- not "I know how you feel"!

Primary skills associated with the communication of empathy include:

a. nonverbal and verbal attending
b. paraphrasing content of client communications
c. reflecting patient feelings and implicit messages

a. ATTENDING – involves our behaviors which reflect our paying full attention, in an accepting and
supportive way, to the client.

b. PARAPHRASING - Selective focusing on the cognitive part of the message – with the client’s key
words and ideas being communicated back to the patient in a rephrased, and shortened form. There are
four steps in effective [paraphrasing:
I. Listen and recall. The entire client message to ensure you recalled it in its entirety and do not
omit any significant parts.
II. Identify the content part of the message by deciding what event, situation, idea, or person the
client is talking about.
 2

III. Rephrase, in as concise a manner as possible, the key words and ideas the client has used to
communicate their concerns in a fresh or different perspective.
IV. Perception check is usually in the form of a brief question, e., “It sounds like...,” “Let me see if I
understand this,” which allows the client to agree or disagree with the accuracy of your
paraphrasing.

c. REFLECTING PT'S FEELINGS- Affective reflection in an open-ended, respectful manner of what

the client is communicating verbally and nonverbally, both directly through words and nonverbal
behaviors as well as reasonable inferences about what the client might be experiencing emotionally It is
important for the helper to think carefully about which words he/she chooses to communicate these
feelings back to the client. The skill lies in choosing words which use different words that convey the
same or similar. For example, if a poorly skilled helper reflected to the client that he/she was “very
angry and depressed,” when the client had only said they were irritated by a certain event, and had felt
very sad over the death of a family pet, the result could be counterproductive to the process of change.

3. Genuiness
Ability of counselor to be freely themselves. Includes congruence between outer words/behaviors and
inner feelings; nondefensiveness; non-role-playing; and being unpretentious. For example, if the helper claims
that they are comfortable helping a client explore a drug or sexual issue, but their behavior (verbally and
nonverbally) shows signs of discomfort with the topic this will become an obstacle to progress and often lead to
client confusion about and mistrust of the helper.

4. Unconditional positive regard

An expression of caring and nurturance as well as acceptance.
• Includes conveying warmth through:
• Also conveying acceptance by responding to the pt's messages (verbal and nonverbal) with
nonjudgmental or noncritical verbal & nonverbal reactions.
• Respect - ability to communicate to the pt the counselor's sincere belief that every person possesses the
inherent strength and capacity to make it in life, and that each person has the right to choose his own
alternatives and make his own decisions.

5. Concreteness
Keeping communications specific -- focused on facts and feelings of relevant concerns, while avoiding
tangents, generalizations, abstract discussions, or talking about counselor rather then the client.
Includes the following functions:

a. Assisting client to identify and work on a specific problem from the various ones presented.
b. Reminding the client of the task and redescribing intent and structure of the session.
c. Using questions and suggestions to help the client clarify facts, terms, feelings, and goals.
d. Use a here-and-now focus to emphasize process and content occurring in current session, which may of
help to elucidate the problem being worked on or improving the problem-solving process.

6. Open Questions -- A questioning process to assist the client in clarifying or exploring thoughts or
feelings. Counselor id not requesting specific information and not purposively limiting the nature of the
response to only a yes or no, or very brief answer.
a. Goal is to facilitate exploration – not needed if the client is already doing this.
 3

b. Have an intention or therapeutic purpose for every question you ask.

c. Avoid asking too many questions, or assuming an interrogatory role.
d. Best approach is to follow a response to an open-ended question with a paraphrase or reflection which
encourages the client to share more and avoids repetitive patterns of question/answer/question/answer,
etc.

8. Counselor Self-Disclosure
The counselor shares personal feelings, experiences, or reactions to the client. Should include relevant
content intended to help them. As a rule, it is better to not self-disclose unless there is a pressing clinical need
which cannot be met in any other way. Remember empathy is not sharing similar experiences but conveying in
a caring and understanding manner what the client is feeling and thinking

9. Interpretation
Any statement to the client which goes beyond what they have said or are aware of. In interpretation the
counselor is providing new meaning, reason, or explanation for behaviors, thoughts, or feelings so that pt can
see problems in a new way. Interpretations can help the client make connections between seemingly isolated
statements of events, can point out themes or patterns, or can offer a new framework for understanding. An
interpretation may be used to help a pt focus on a specific aspect of their problem, or provide a goal.

• Keep interpretations short, concrete (see concreteness), and deliver them tentatively and with empathy.
• Use interpretations sparingly and do not assume a pt's rejection of your insight means they are resistant
or that you are right.

10. Information Giving and Removing Obstacles to Change

Supplying data, opinions, facts, resources or answers to questions. Explore with client possible
problems which may delay or prevent their change process. In collaboration with the client identify possible
solutions and alternatives.
 PHARMACY
LAYOUT
DESIGN

• The location of a pharmacy, its management and sufficient capital are major
factors contributing to a pharmacy’s success. Another major factor in
determining the success of a pharmacy is its general appearance, including the
layout design of the pharmacy and the arrangement of the individual
departments. Before a pharmacist undertakes to design a layout or modernize
a pharmacy, be should consider the objectives of the layout design, the type of
pharmacy, the classes of consumer goods and purchases, and the principles of
layout design.
• Objectives of Layout Design
The major objectives in the design of the exterior of a pharmacy is to attract
more patrons into the pharmacy. The overall objective of interior layout design
is to increase the amount of the total purchases of each person who enters the
pharmacy.
In addition to the above general objectives, there are six specific objectives;

1. to enhance the general appearance of the pharmacy and to project a

professional image
2. to control payroll expenses through convenience and efficiency of the layout;
3. to improve patrons satisfaction and convenience;
4. to maximize the utilization of space;
5. to disperse and control the traffic pattern within the pharmacy; and
6. to provide surveillance and reduce pilferage.
• One other important factor to consider is the philosophy of the pharmacist
owner. Many pharmacists prefer to practice in a specific type of setting. Thus,
the design required by a service-oriented pharmacist would differ from that
needed by the pharmacist interested in using mass merchandising techniques.
 Types of community pharmacies
1) PHARMACEUTICAL CENTER
The pharmaceutical centre, designed and developed by McKesson &
Robbins and the American Pharmaceutical Association, is similar to the
perscription-oreinted pharmacy, but it must conform to certain standards.
The layout design of this centre is not so as critical as with the other types
because no merchandise of any kind is displayed. The inventory is confined
to legend and non-legend medication and few convenience goods. The
doctor, the atmosphere, and the uncluttered floor space are the hallmarks of
the pharmaceutical centre. The pharmaceutical centre usually has a separate
room for fitting orthopaedic and surgical appliances.

2) PRESCRIPTION-ORIENTED PHARMACIES
This type of pharmacy usually occupies up to 1500 square feet and is so
designed that the patrons will have a comfortable waiting area under the
prescription department. Health-related items, including drugs, home health
care appliances and supplies, and prescription accessories, are displayed
near this vicinity. The pharmacy may have a separate room for fitting trusses
and other orthopaedic and surgical appliances. Cosmetics, gifts, and a
limited member of other items are displayed in the other areas of the
pharmacy.

3) TRADITIONAL PHARMACIES
The traditional or conventional pharmacy usually occupies between 1500
and 6000 square feet. The major objective of the layout design for this type
of pharmacy is to disperse the customers and expose them to all areas in the
pharmacy. Those pharmacies also should have a pleasing appearance,
project a professional atmosphere, be convenient for both customers and
employees, and provide the opportunity for maximum sides at minimum
expense. Of course, surveillance for shoplifters must be included as one
objective in the design and layout process.
Although traditional pharmacies vary in design, it is generally agreed that
the best traffic flow can be achieved with 2.5:1 length-to-width ratio.
 4) THE SUPER DRUGSTORE
The super drugstore occupies more than 5000 square feet, generally 10000
square feet or more, with the design approximating a square. The basic
objective in a super drugstore is traffic control rather than traffic dispersal,
which is achieved by the merchandising techniques used. Many lines of goods
are sold in this type of drugstore, and the layout design is usually for the self-
service type to facilitate traffic control and to provide maximum sales at
minimum cost.

CONSUMER GOODS AND PURCHASES:

• Classification of Consumer Goods
Definitions of the classes of consumer goods are included to provide as
understanding of the relationship between consumer’s activity in the
purchase of various goods and good layout designs principles. In
addition to the classification of consumer goods, the manner in which
consumers purchase them is very important to the success of a layout
design.

• Convenience Goods:
Convenience goods normally have a low unit value and are purchased
frequently, with little effort on the part of the consumer. Convenience goods
make up the large majority of the stock of grocery stores, variety stores and
pharmacies.
1) Shopping Goods:
Goods in this class normally have a high unit value, are purchased
infrequently and required considerable effort on the part of the consumer.
For such purchases the consumer will compare prices, quality, special
features and required services among other features. Shopping goods are
found mostly in department, furniture, clothing and similar stores.
2) Specialty Goods:
• Specialty goods normally have a high unit value, possess unique qualities or
features and are purchased infrequently; consumers exert a great deal of effort
to purchase them. Rare antiques and exclusive brands of clothing are
examples of speciality goods.
• It should be noted that pharmacies stock predominantly convenience goods;
however, most pharmacies stock some shopping and speciality goods. The
prescription is a special case; it include attributes of all three classifications,
for example, some patients shop for expensive or maintenance drugs, while
other patients patronize only one pharmacist even at considerable expense and
effort because of the personal and special services provided.

Classification of Purchases:
1) Demand Purchases:
• When consumer enters a pharmacy, or any other place where goods or services
are sold, with deliberate intent of purchasing a particular item and/or service,
the purchase is considered to be a demand purchase. A prescription is a classic
example.
2) Impulse Purchases:
• Impulse purchases are purchases made after a consumer has entered the
pharmacy to purchase one or more other items, or are purchases made when the
customer has entered the pharmacy for no particular purpose. This type of
purchase frequently is suggested by an attractive display or price.
• Cosmetics, toiletries and sundries often are purchased on impulse.

• The percentage of pharmacy sales bought on impulse is not known. It can be

assumed that all prescription and most non-prescription drugs, prescription
accessories, surgical and orthopaedic appliances and supplies and other home
health care aids are purchased on demand. A significant percentage of other
types of products is bought on impulse. It should be noted that classes of
goods and purchases are not always mutually exclusive, but may be
integrated in varying degree in the mind of the purchaser.
 CLASSES OF LAYOUT DESIGNS
• Historic Types of Service Oriented Layout Design:
Historically, there are three basic types of layout: (1) Clerk or Personal service,
(2) Self-Selection, (3) Self Service. Each is designed to achieve the objectives
of the three basic types of pharmacies, Professional, Traditional and Super Drug
Store, respectively.
1) CLERK SERVICE:
The clerk service layout is the old traditional design used in most pharmacies
before the trend toward self-service and mass merchandising. It contains
primarily of complete clerk service with only a small part of the merchandise
exposed for patrons to handle.

• The modern example of this layout design is the pharmaceutical centre in

which no merchandise is on display. Traditionally, pharmacists have used the
clerk service design because it facilitates maximum interchange between
pharmacy personnel and patrons, one of the major reasons many independent
pharmacies have survived. Convenience and friendly service are still
important factors in the patronage of a specific pharmacy.
• However, the quality of clerk service has not been maintained in many
instances. In addition, prices of pharmaceutical products have risen and the
importance of price in relation to service has also increased. Therefore, this
combination of factors has caused many managers to reduce services and
seek an alternate type of layout design as a solution.

2) SELF-SELECTION:
In an attempt to provide adequate personal service in a more efficient
manner, and thus be more competitive with the larger super drug stores,
many independent pharmacists now use the self-selection layout design.
This type of layout design dictates that clerk service be maintained at all
service –oriented departments, such as cosmetics, photo supplies,
prescription and selected non-prescription drugs, surgical and
orthopaedic appliances and supplies and veterinary departments. Much
of the other merchandise however is displayed in a manner that the
patrons may see, handle and select themselves. This layout is most
frequently found in modern conventional pharmacies.
 • SELF-SERVICE:
The term self-service is restricted for those layouts that utilize minimum of
clerk service and expose the maximum amount of merchandise for patrons
to handle. It is not possible to have 100 % self-service in a pharmacy
because of the prescription department. Central check-out of all purchases
is the one criterion most commonly used to identify a truly self-service
layout, although some “experts” dispute the appropriateness of this basis of
distinction alone. This type of layout is most often used in the super
drugstores.

• Styles of Layout Design:

• Styles of layout design emphasize physical configuration of the layout
rather than the degree of service provided, although variations in services
will coincide with several of the styles as shown later. Four distinct
styles of layout design have been developed over the past several
decades. They include: (1) Centre Service, (2) Lobby Check-Out or Bull
Pen, (3) Off the Wall, and (4) Right Rea Service. The latter style is often
referred to as the “self-selection” style, but we have chosen not to use
this term in order to avoid confusion with the use of the term with regard
to the concept of a combination of clerk service and self- service.

1) CENTRE SERVICE STYLE:

This style features an elongated, two-sided wrapping counter and check-
out “island” located in or near the centre of the selling area of the
pharmacy. Usually convenience goods as well as things purchased on
impulse, such as tobacco, candy and sometimes magazines and photo
supplies are stocked in the island. The objective is to align the major
traffic-generating departments around the perimeter and then pull all the
traffic through the check-out island in the centre of the pharmacy. It has
been tried in several traditional pharmacies, especially those that are rather
wide or approximate a square configuration. The concept is good in theory,
but it has been less than satisfactory in practice in most instances.
2) LOBBY CHECK-OUT STYLE:
• This approach utilizes a square, clerk service check-out “island”, near the
front of pharmacy, but there is enough space between the check-out island
and the front window to form a “lobby”. Again candy, tobacco, photo
supplies, and men’s sundries are stocked in the island, while seasonal and
promotional merchandise are displayed in the lobby where the traffic is
heavy. Frequently, the check-out island is supplemented by a short wrapping
counter in the rear of the store in front of the prescription department.
• The major traffic-generating departments are located around the walls with
display counters or show cases placed in front of the wall shelves. Gondolas
are aligned front-to-rear in the centre portion of the pharmacy.

• This style is used in the larger traditional pharmacies with floor space of 5000
square foot or more. A modification of this style substituting several check-out
lanes for the “bull pen” and self-service for clerk service has been used
successfully in super drug stores. The main disadvantages of this style in the
traditional drug stores is the reduction of the depth penetration of the traffic
flow caused by the short wrapping counter and the check-out island.
3) OFF-THE-WALL STYLE:
This style features open display of merchandise on the wall shelving without
showcases or counters in front of the wall shelves. The main wrapping counter,
short or long, is placed across the rear of the store in front of the prescription
counter. One or two rows of gondolas are placed in the centre of pharmacy. This
style became popular for s time because of the ease and low cost of installing
fixtures. It is well adapted to a very narrow building, but is not conductive to
personal, clerk service.

4) RIGHT-REAR SERVICE STYLE:

This style frequently is called the self-selection style because it accommodates
this concept so well. The concept permits self-service where desirable, and thus
promotes efficiency and reduces costs. At the same time, it permits personal
clerk or professional services as appropriate. When this style is properly
designed and implemented, it has the twelve characteristics of optimum design
which are discussed below. The right-rear service style is well suited for most
traditional pharmacies, especially those that approximate a 2.5: 1 length to
width configuration.
 PRINCIPLES AND CHARACTERISTICS OF LAYOUT
DESIGN
• The principles of layout design include the selection of the appropriate service-
oriented design and style best suited to the type of pharmacy and location. They also
include the appropriate arrangement of departments and merchandise in order to
achieve optimum design characteristics traffic flow and shopping.
• Optimum design characteristics for the traditional pharmacy
1) All four corners of the merchandising and service area of the pharmacy should be
activated. This is achieved by strategic placement of clerk-activated service or special-
skills department, plus selected “self-Selling” departments such as greeting cards, gifts
and magazines.
2) All displays are departmentalized and well identified. Related departments and
merchandise are grouped adjacent or near similar departments and merchandise.

3) The main wrapping counter with a cash register is placed along the largest clear
wall—right side if walls are equal in length—and deep to the rear.
4) A selected assortment of the fastest selling non-prescription drugs, dental
products, and toiletries are displayed on the main wrapping counter.
5) The prescription department is located in the rear and adjacent to main
wrapping counter. The prescription department is dramatized with commanding
identification and floor elevation of seven inches. There should be a minimum of
150 foot-candles of light with in the prescription department.
6) An adequate waiting area with comfortable chairs and health related reading
materials should be provided near the prescription department. Sickroom supplies,
home health aids and prescription necessaries should be displayed near the
prescription department and waiting area.

7) The cosmetic and toiletries department is aligned with the non-prescription

drugs and prescription drugs departments from front-to-rear, respectively, along
the right or longest wall, pre-sold, nationally advertised advertised cosmetics and
toiletries, such as hair care products, lotion, and creams are place on open display
on gondolas across from the cosmetic department.
8) Special skill departments such as photography, imported gifts, costume
jewellery, veterinary drugs and pet supplies and orthopaedic and surgical
appliances and supplies should be given special treatment and well identified.
Clerk service should be provided in these departments.
9) Special care should be given to use of colour and special design features so
that the pharmacy is restful, pleasant place to shop and reflects professionalism
and pride of ownership.
10) The lighting lay out in the pharmacy must conform to the fixture layout,
highlighting the merchandise, not the fixtures. A minimum of 100 foot-candles
should be provided in the selling or merchandising area.
11) The fountain if one is installed is located across from the main wrapping
counter on the opposite wall deep in the rear of the pharmacy.
12) All clerk service stations must be self-supporting, that is, the service-
merchandise departments must produce gross sales at least ten times the weekly
pay roll.

Arrangement of departments and merchandise:

• The prescription department and other high skill or specialty department
should be located in the rear or towards the rear of pharmacy. if the
pharmacy has a fountain, it should be place in the rear of pharmacy
across from the main wrapping counter and the prescription department.
Ideally, the fountain should be separated from the prescription
department and the prescription waiting area by an attractive planter, a
partial partition perhaps made of pegboard on which home health care
products can be displayed, health information displayed or other
suitable means of separation. This type of arrangement maintains the
integrity of the professional atmosphere of the prescription and drug area.

• If the pharmacy has a surgical and orthopaedic department, a special fitting

room is a must. The door of fitting room and any intermediate door through
which a patient must pass should be adequately identified. Separate toilets for
men and woman should be located near the fitting room because in nearly
every instance, the patient will use the toilet after the fitting, especially the
fitting of trusses.
• If the pharmacy does not have a fountain, greeting cards and a gift department
are the best choices to replace the fountain in the rear of the pharmacy, a
photographic department or a veterinary drug department, if the development
of high skill department by highly competent clerks, provides another option.
A special room located in part of stockroom in the rear with the separate
outside entrance makes an ideal veterinary drug department, provided the
entrances are well identified.
 • The cosmetics, toiletries and non-prescription drug departments should be
arranged as described in characteristic number 7 described in the foregoing
section. The tobacco, candy and magazine departments are usually located
in the front of the pharmacy across from the cosmetic department.
Smoking accessories, photo supplies, and/or men’s toiletries are often
included in this area to provide greater sales potential, but more
importantly, greater gross margin. This is desirable in order to achieve
characteristic number 12 mentioned previously. Other major departments
can be used to fill the remainder of the wall space opposite the cosmetic
and drug side of the pharmacy. Gondolas normally are aligned lengthwise
in the centre portion of the pharmacy to complete the layout.

• Goods and services purchased on demand and specialty goods, should be

placed in or toward the rear of the pharmacy. This arrangement draws the
patrons deep into the pharmacy. Convenience goods generally are placed
near the front of the pharmacy. Selected convenience goods that are
purchased on impulse are displayed near the cash registers. Many
shopping goods and most products often purchased on impulse are
displayed in the middle portion of the pharmacy. Selected products of
both categories are displayed in the front part of the pharmacy and near
the cash register. Household products, school supplies and many sundries
are displayed on gondolas. Promotional merchandise frequently is
displayed on the gondolas, especially the ends of the gondolas and other
“hot” spots.

TRAFFIC FLOW ANALYSIS

• There are two types of traffic flow analyses, qualitative and quantitative. The first is
very simple to perform and can be done frequently, two or three times annually if
desired. The second, quantitative analysis, require more time and would be
performed no more frequently than once each year.
1) QUALITATIVE TRAFFIC FLOW ANALYSIS:
A qualitative traffic flow analysis is performed by tracing the path of each patron who
enters the pharmacy. First three layouts of the floor plan of the pharmacy are drawn on
graph or grid paper. Three time intervals representing morning, afternoon and evening
traffic, of either 30 min or one hour depending on the amount of traffic, should be
selected randomly over a period of a week. The path of each patron is traced on the
graph paper from the moment he enters the pharmacy until he leaves. Appropriate
marks are made at each point of purchase. It is useful to use three colours for tracing,
one representing ladies, another for men and third representing children under the age
of eighteen.
• The three tracings are then compared. Usually they have similar traffic
patterns with some variation due to different time of day the data were
taken. The primary purpose of the qualitative traffic analysis is to identify
“dead” areas in the pharmacy where few or no patrons shop. Dead areas are
an indication that the pharmacy needs to be modernized with significant
changes in the layout design.
2) QUANTITATIVE TRAFFIC ANALYSIS:
The following procedure is used to determine quantitatively whether the
present layout of the pharmacy is adequate. At the end of the study you will
be statistically confident that the results achieved are correct.

• STEP 1: Divide the pharmacy into major departments. In a traditional

pharmacy, these departments generally include: (1) Prescription Department,
(2) Non-prescription Drugs and Health related Items, (3) Cosmetics and
Toiletries, (4) Baby Department, (5) Feminine Hygiene (6) candy, tobacco and
accessories, and, magazines, and (7) in some instances, veterinary supplies,
Pharmacies containing less than 5,000 square feet generally can be divided
into fewer than ten departments, usually six or seven. The cash registers
should be keyed to each of the major department to record sales and number
of transactions.
• Step 2–Randomly select enough hours during a one-month period to be
assured that at least 400 patrons will be observed.

For example, if an average of 40 patrons entered the pharmacy each hour, ten one-
hour intervals or 20one-half hour intervals should be selected in order to conduct a
complete and quantitative traffic flow analysis.
• Step 3–Record the data from the cash register at the end of each sampling period
and label them with date and time of sampling.
• Step 4–Total the sales of each departments for all sampling periods and calculate
the average dollar value per transaction.
• Step 5–Conduct a quantitative traffic flow analysis as describes previously during
the same time interval used to obtain data in Step 2.
• Step 6–Compare the sales efficiency per transaction by department with
quantitative traffic flow to locate “dead” spots within the pharmacy and redesign
the layout based upon the data and space needed for each department in order to
maximize sales.
 • The procedure for selecting the times for sampling and may be demon-
started with the following examples, Assume the pharmacy is open from 9:00
a.m. until 9:00 p.m., Monday through Saturday. The sampling is to be
conducted during June. Since the month contain 30 days and five Sundays,
the pharmacy will be open 12 hours per day for 25 days, for a total of 300
hours. The number “1” is assigned to hour beginning at 9:00 a.m. on
Saturday, June 1, and each hour thereafter is numbered consecutively. This
means that the hour beginning at 8:00 p.m., Saturday, June 29, is assigned
the number “300”. Assume an average of 40 patrons per hour and 400
observations are to be made. A total of 10 hours should be selected–one hour
for each 30 hours the pharmacy is open during June (300 hours / 10 hours =
30 hours).

• Next place 30 slips of paper of equal size numbered 1 through 30 into a container, mix
them thoroughly and select one. Assuming number 13 was drawn, the traffic flow
analysis would begin at 9:00 am, on Monday, June 3 .Similar analysis would be
conducted each thirtieth hour the pharmacy was open in June.
• At the same time a traffic flow study is being conducted, determine the average dollar
amount per sales transaction for the entire pharmacy for each time interval and for each
department. This can easily be accomplished by means of a modern cash register,
which shows the number of transaction and sales by departments. This analysis will
provide a comparison of sales efficiency and the relative space needed for each
department when the pharmacy is renovated.
• When a complete renovation or any major change is made within the pharmacy,
another traffic flow analysis should be completed and the results compared with those
before renovation. In addition, it is suggested that the pharmacist complete a traffic
flow analysis on an annual basis.

• DIRECTIONS:
• 1. Sketch Flour plan on grid showing department locations.
• 2. Show each customer’s route by colored line
• 3. Terminate line at point of final purchase.
• Figure of traffic flow analysis
 APPLICATION OF TRAFFIC FLOW ANALYSIS
• A traffic flow analysis was conducted on a traditional prescription-oriented
pharmacy located in a medical building in a city of approximately 40,000
people. The pharmacy was approximately 40 years old and had not been
remodeled for the pat fifteen years. In addition to the street entrance in the
front of the pharmacy, patient could enter directly by side door from the lobby
after visiting the physicians in the building. Stock was stored in two rooms in
the rear of the pharmacy and in several rooms on the balcony level. It was
obvious that there was inappropriate use of all the space. The prescription
department was located on the balcony level and utilized a dumbwaiter to
transfer the prescription orders and the finished prescriptions between the
service area and prescription department.

• Thus, the pharmacist had very little patient contact. The pharmacy generally
was cluttered although it was kept clean. The cosmetic department, which had
several prestige lines and a large inventory for this particular size of pharmacy,
was kept fairly attractive.
• A qualitative description traffic flow analysis was conducted on several
occasions before remodeling. These revealed that only minor’s parts of the
pharmacy were active because large numbers of patrons were forced to
circulate throughout the store because of small waiting area in the prescription
department. However, inefficiencies did exist in several areas.
• The renovation included the following changes. The prescription department
was relocated on the first floor. A first level stockroom was converted into a
surgical and orthopedic fitting room.

• One of the second level stockrooms was converted into a physicians reading
lounge where physician could come to read the most popular medical journals,
inspect package inserts of new drugs, and drink free coffee. The ceiling of the
pharmacy was lowered and modern fluorescent lighting was installed. All
weather carpeting was placed on the floors. Wood paneling was installed
throughout the selling area, the prescription department, the physicians, reading
rooms, the fitting room. New fixtures were installed throughout the pharmacy.
• A quantitative traffic flow analysis was performed before and after the
renovation and revealed the following data: using random samples of time
intervals, approximately 31 percent of the patient entered the pharmacy from
the lobby through the side door before renovation. After renovation, 56 percent
of the patients entered the pharmacy by this entrance.
• This difference was statistically significant at the 0.01 confidence level -
in other words, the investigator was 99 percent confident that the
difference was not a result of chance. Each patron entering the pharmacy
before renovation made an average of 1.2 purchasing stops. After
renovation each made an average 1.4 purchasing stops.
• The annual sales increased by 14 percent over the previous year, taking
into consideration the sales decline rate of previous year. Prescription
sales increased an effective 16 percent on an annual basis–reversing a 14
percent decline trend, in addition to a net 2 percent absolute increase.
Most significant off all was the increase in new prescription, which
reversed a downward trend of 15 percent annually in addition to an actual
increase of 37 percent over the previous year.
 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

Community pharmacy
Community pharmacy:
Definition: Any place under the direct supervision of a pharmacist where the practice
of pharmacy occurs or where prescription orders are compounded and dispensed other than a
hospital pharmacy or a limited service pharmacy.
OR
A community pharmacy is a hybrid of professionalism & business.
OR
Establishment that is privately owned and whose function is to serve the society needs both for drug
products and Pharmaceutical services. It is often referred as retail pharmacy for retail drugs outlet.
OR
It is a place where medicine is dispensed or stored mostly the general population called community
retail medical store and drug outlet.
Hospital pharmacy
Definition: The health care service, which comprises the art, practice, and profession of choosing,
preparing, storing, compounding, and dispensing medicines and medical devices, advising healthcare
professionals and patients on their safe, effective and efficient use.
OR
A hospital pharmacy is a drug oriented one.
Clinical pharmacy
Definition: A health science discipline in which pharmacists provide patient care that optimizes
medication therapy and promotes health, and disease prevention.
OR
A clinical pharmacy is the one which is patient oriented one.
Public health:
Definition: The science and art of preventing disease, promoting health and prolonging life through
organized effort of the society.

History and background

The first medical store was established in Baghdad (Iraq) in 1754 AD. Madras College of Pharmacy first
of all started 2 years course of Pharmacy and then in Europe BSc pharmacy started in 1904.

Pharmacy in Indo-Pak: First pharmacy was established in 1863 by Sheikh Nabi bakhsh in Gujarat
(India) along with General Stores. In 1881 training of compounding started in Bengal where the first
ever degree course of Pharmacy was started in 1937 in Banaras Hindu University.

After independence: In 1948 Punjab University started three years course program of Pharmacy. In
1974 Gomal University started pharmacy department. So there the program of 3 years remained till
1978. Then from 1979 B-pharmacy 4 years’ program started and finally in 2003 doctor of pharmacy 5
years’ program started. In Pakistan there is round about 90,000 medical stores and 25,000
pharmacists. According to WHO for 2000 population there should be one pharmacist, but
unfortunately in Pakistan the ratio is 1: 8000

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

Types of community pharmacy

1. Independent pharmacy 2. Chain pharmacy

1. Independent pharmacy:
Definition: It is the public pharmacy owned by a single independent person and such type provide
prescription and health related services.
Advantages:
1. It provides the opportunity to practice pharmacy in according to one’s own personal style. So in
other words a community pharmacist can say ‘I am my own boss’.
2. As independent owner ‘I am the boss of everything’.
3. It requires less investment and has no profit sharing.
4. Freedom from control and restriction.
2. Chain pharmacy
Definition: It is the branched stores existing at various location but operating under common
ownership.
For example: Dewatson, Shaheen pharmacy, Umar pharmacy.
First Chain Pharmacy in Pakistan: Chain pharmacy concept in Pakistan for the first time initiate a
decade ago by pharmacia a subside Feroz son in Nowshehra. Then this concept become popular in
different big cities.

Advantages:
1. Chain pharmacy has wide geographical coverage.
2. Attracts qualified person due to the bulk purchase.
3. Provide better services as compared to independent pharmacy.
4. Use of employee promotional activities can be initiated in chain community pharmacy.

Difference between Chain and independent pharmacy

Feature Independent Pharmacy Chain Pharmacy

Ownership Privately owned Owned by a larger corporation
Size
Services Typically
May offersmaller with one or aservices,
more personalized few Larger
May withmore
have multiple locations
standardized
locations
such as compounding services and protocols
Pricing May have more flexibility with pricing Prices may be more standardized
and may offer competitive prices across locations
Inventory May have a more limited inventory, but Usually has a larger inventory with
may be able to order specialty items more standardized products
Customer May have a more personal touch and be May have more standardized
Service more connected to the local community customer service policies and
training
Technology May have less advanced technology Usually has more advanced
systems technology systems

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Branding May have a unique brand and image Usually operates under a larger
brand and image
Competition May face challenges competing with May have more resources to
larger chains compete with other chains

Establishment of community pharmacy

Different factors which are required for the establishment of community pharmacy are:
1. Organization 2. Site selection 3. Capital

1. Organization:
Introduction: The mechanism of determining and assigning the duties to the people that can work
together effectively.

Types of organization: There are three types of organization

a. Sole proprietor b. Partnership c. Corporation
a. Sole proprietor: Sole proprietor is the simplest form of SETUP and owned by one person. It is
geographically local and there are no legal formalities except license. The pharmacy is free to conduct
the enterprise any manner and owner receive all profit.

b. Partnership: If the resources of one individual are not sufficient and does not take complete risk so
partnership between two or more individual considered some matters
i. Investment ii. Division of profit and losses

c. Corporation: Corporation is a separate entity established by the authority of state. It is composed of

various stakeholders and capital is provided by civil individual. So it provides an individual opportunity
to invest without endangering their personal assets. Utility stores, Hospital pharmacies are called
Corporation. They are formed by the authorities of state.

2. Site selection:
a) Location of community pharmacy may be a critical factor in its survival.
b) Traditionally community pharmacy must be located in a close proximity of physician.
c) Community pharmacy must be located within Medical complexes and clinics.

3. Capital: The amount of capital required for the operation of successful community pharmacy
depends on:
1. Sale volume
2. Inventory requirement
3. Estimated operating expenses while capital needed
4. Projected sale volume should be considered minimum and the operating expenses should be
considered maximum.
5. Cash: Cash it is required in sufficient amount for pre-operating expenses
6. Different license fee:
a) Legal fee

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

b) Utility deposit
c) Operating expenses
d) sufficient cash is required to operate because mostly operations are extremely slow.

Furniture and equipment: These depend on structure of pharmacy in largely pharmacies more
equipment and fixtures are required.
Sources of capital
Equity capital: It comes from owner.
Borrowed: It comes from banks.
Credit: It comes from friends.

Management of community pharmacy

Definition: A set of activity directed for the effective utilization of resources in search of one or more
goals. Goals are profit in health services.
OR
It is an art and science of planning organizing, directing and human efforts within the organization
framework and economic environment of the form to achieve its objectives for effective running of
community pharmacy.

• There should be coordination among the people, materials, equipment and capital.

Management of community pharmacy concerned with some aspects:

1. Management of money
2. Management of inventory
3. Management of Facilities
4. Management of personal
1. Management of money:
It includes the ability to obtain money from varieties of sources in sufficient quantity to support the
necessary operation. It is the management function to employee the most appropriate way of money
management so as to get maximum return and minimum investment. So only those owners can
succeed who can manage the money effectively?

2. Management of inventory :
Inventory is an atomize list of goods along with their price. Major portion of inventory consists of
prescribed drugs. Management of inventory includes.
a) Required quantity of each item
b) Source of supply and price a good
c) A good inventory management should have implementation of well-organized stock central
system.

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3. Management of facility:
It includes the requirement for the furniture and equipment. It represents portion of capital. Its
management role is to make at economic use of all facilities.

4. Management of personal:
It required proper selection and proper training. So properly selected and well-trained employee can
assume many duties, otherwise it may be the responsibility of manager. Employee should be
compatible and must be minimum qualification. After selection the employee should put under
observation and supervision to pick up the knowledge and compensation. Compensation is the direct
return or award given to an individual per month based on individual performance is given to return
the qualified individual in industry, store, pharmacy.

General Role of community pharmacist

1. Role of community pharmacist is to provide public health education for maintaining health
problems and drugs information.
2. In all drug related problems like councelling proper use of OTC and prescribed medicines,
recording of drugs, medical problem history. Immunization schedule and referring of patient to
specific healthcare professionals.
3. Community pharmacist may involve actively in the area of Pharmacoepidemiology.
Pharmacoepidemiology is the post marketing phase of clinical trial of drug which concerned
with safety or risk assessment of new drug after coming in market.
4. Community pharmacist may involve in control of serious communicable disease by making
community aware through counseling. By this method a lot of disease i.e. TB, syphilis, herpes,
AIDs and hepatitis can be controlled.
5. Community pharmacist can encourage his/her patient to prevent themselves from various
chronic diseases by using various technologies of prevention, for example risk of stroke of heart
can be reduced by control of high blood pressure, check up to regulate the intake of prescribe
medicine lowering cholesterol intake and increase in physical exercise.
6. Community pharmacist may also involve in patient health education through the use of
pamphlet in Bulletins freely available on display.
7. Community pharmacist may provide counseling to pregnant ladies about the child health
hygiene, management of pregnancy diet and sub-nutritional state.
8. Community pharmacist can also play a major role by guiding the parents for the protection of
child against the disease of childhood by proper immunization schedule.
9. Community pharmacist may guide the patient about the nutrition intake according to
requirements of patient and their disease state.
10. Community pharmacist can make community aware about the environment health i.e. food
borne disease, local hazard carcinogen etc.
11. Community pharmacist provides counseling to the person involved in alcoholism and drug
abuse about the hazards and side effects.
12. Role of community pharmacist as public educator for monitoring health problem and drug
information.

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

Health

Definition: In 1948 WHO defined ‘health is a state of complete mental physical and social well being
and not merely in the absence of disease.’

Public Health:
Definition: The science and art of preventing disease promoting, protecting and improving health
through in organized effort of society is called public health.

Role of Pharmacist:
1. The primary concern of the pharmacist should be the Welfare of humanity and the relief of
human suffering from disease.
2. Very number of people ask the pharmacist about a health problem usually he or she should be
the first person in family member or friend who may consulted.
3. In order to be a truly effective member of healthcare. The pharmacist must be able to integrate
his pharmaceutical knowledge.
4. A pharmacist should prove himself as a drug information bank for the public as well as for the
member of health to fulfill the responsibilities, pharmacist must update his knowledge from
time to time in most cases public health can be maintained with proper health education but it
is only possible if the pharmacist is leading to share the wealth of his knowledge.
Ways through which pharmacist convey their knowledge:
1. Distribution of pamphlets.
2. Display free drug literature.
3. By arranging meeting with the different groups i.e. colleges, school, universities.
4. Personal contacts to public in pharmacy. Publicly health related data through local media. If
there is an outbreak of communicating disease, so it is the responsibility of community
pharmacist to get better related information and should provide it (related information)
directly to the patient at the time of medication purchase.
Main role of pharmacist in pharmaceutical care
In 1990 Hepler and strand defined pharmaceutical care but it is practically applied in 2003.
The responsible provision of drug to achieve different positive outcomes that improves the patient
quality of life, so there are different fields through which we can do patient care.
Patient care
Patient monitoring skill. Therapeutic planning skill
Communication skill. Knowledge of disease knowledge of
laboratory and diagnosis tests
Physical assignment skill Knowledge of drug therapy
Drug information skill Knowledge of non-drug therapy

What can expect people from community pharmacist:

1. Access 2. Safety 3. Communication 4. Privacy
5.Respect 6. Participation 7.Comments positive

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

Some common child hood diseases in our community

All children deserve high-quality medical care. As a parent, it is important to be aware of the most up-
to-date treatment guidelines so you can be sure your child is getting the best care possible.
The following information from the American Academy of Pediatrics (AAP) lists some of the most
common childhood illnesses and their approved treatments. The treatments discussed here are based
on scientific evidence and best practices. However, there may be reasons why your pediatrician has
different recommendations for your child, especially if your child has an ongoing medical condition or
allergy. Your pediatrician will discuss any variations in treatment with you. If you have any questions
about appropriate care for your child, please discuss them.
1. Asthma:
Asthma is a chronic condition that affects the airways. It causes wheezing and can make it hard to
breathe. Some triggers include exposure to an allergen or irritant, viruses, exercise, emotional stress,
and other factors. Asthma causes the inside walls of the airways, or the bronchial tubes, to become
swollen and inflamed. During an asthma attack, the airways will swell, the muscles around them will
tighten, and it becomes difficult for air to move in and out of the lungs. Around 7.9% of people in the
United States had asthma in 2017. There are many types of asthma, and several factors can cause
asthma or trigger an acute attack. Asthma is a long-term condition affecting the airways. It
involves inflammation and narrowing inside the lungs, which restricts air supply.

A person with asthma may experience:

1. Tightness in the chest
2. Wheezing
3. Breathlessness
4. Coughing
5. Increased mucus production
Types of Asthma: Asthma can occur in many different ways and for many different reasons, but the
triggers are often the same. They include airborne pollutants, viruses, pet dander, mold, and cigarette
smoke.
1. Childhood asthma: Asthma is the most common chronic condition in children. It can develop at
any age, but it is slightly more common in children than in adults.In 2017, children aged 5–14
years were most likely to experience asthma. In this age group, the condition affected 9.7% of
people. It also affected 4.4% of children aged 0–4 years.In the same year, asthma affected 7.7%
of people aged 18 years and over.According to the American Lung Association, some common
triggers of childhood asthma include:
a. Respiratory infections and colds
b. Cigarette smoke, including secondhand tobacco smoke
c. Allergens
d. Air pollutants, including ozone and particle pollution, both indoors and outside
e. Exposure to cold air
f. Sudden changes in temperature
g. Excitement
h. Stress
i. Exercise

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

It is vital to seek medical attention if a child starts to experience asthma, as it can be life
threatening. A doctor can advise on some of the best ways to manage the condition.In some
cases, asthma may improve as the child reaches adulthood. For many people, however, it is a
lifelong condition.
Physical exam: The doctor will focus on the upper respiratory tract, the chest, and the skin.
They will listen for signs of wheezing, which can indicate an obstructed airway and asthma.
They will also check for:
a. A runny nose
b. Swollen nasal passages
c. Any growths on the inside of the nose
Asthma tests: The doctor may also carry out a lung function test to assess how well the lungs
are working.A spirometry test is one example of a lung function test. The person will need to
breathe in deeply and then breathe out forcefully into a tube.
Other tests: Other tests for diagnosis include:
a. A challenge test. This test allows a doctor to assess how cold air or exercise affect a
person’s breathing.
b. A skin prick: A doctor can use this test to identify a specific allergy.

Tests to rule out other conditions:

1. Sputum tests, X-rays, and other tests can help rule out sinusitis, bronchitis, and other conditions
that can affect a person’s breathing.
2. Short-acting beta-agonists are the first choice for quick relief of asthma symptoms. They include
albuterol (ProAir HFA, Proventil HFA, Ventolin HFA), epinephrine (Asthmanefrin, Primatene Mist),
and levalbuterol (Xopenex HFA).
3. Anticholinergics such as ipratropium (Atrovent) lessen mucus in addition to opening your airways.
They take longer to work than short-acting beta-agonists.
4. Oral corticosteroids such as prednisone and methylprednisolone lower swelling in your airways.
5. Combination quick-relief medicines have both an anticholinergic and a short-acting beta-agonist.

2. Sore throat:
Introduction: A sore throat is a painful, dry, or scratchy feeling in the throat.Pain in the throat is one of
the most common symptoms. It accounts for more than 13 million visits to doctor’s offices each
year.Most sore throats are caused by infections, or by environmental factors like dry air. Although a
sore throat can be uncomfortable, it’ll usually go away on its own.

Types: Sore throats are divided into types, based on the part of the throat they affect:
1. Pharyngitis affects the area right behind the mouth.
2. Tonsillitis is swelling and redness of the tonsils, the soft tissue in the back of the mouth.
3. Laryngitis is swelling and redness of the voice box, or larynx.

Symptoms: Along with the sore throat, you can have symptoms like:
1. Nasal congestion 2. Runny nose 3. Sneezing
4. Cough 5. Fever 6. Chills

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7. Swollen glands in the neck 8. Hoarse voice 9. Body aches

10. Headache 11. Trouble swallowing 12. Appetite loss

Causes of sore throats: Causes of sore throats range from infections to injuries. Here are eight of the
most common sore throat causes.
1. Colds, the flu, and other viral infections 2. Strep throat and other bacterial infections
3. Allergies 4. Dry air 5. Smoke, chemicals, and other irritants
6. Injury 7. Tumor 8. Gastroesophageal reflux disease (GERD)

Home remedies for a sore throat: You can treat most sore throats at home. Get plenty of rest to give
your immune system a chance to fight the infection.To relieve the pain of a sore throat:
1. Gargle with a mixture of warm water and 1/2 to 1 teaspoon of salt.
2. Drink warm liquids that feel soothing to the throat, such as hot tea with honey, soup broth, or
warm water with lemon. Herbal teas are especially soothing to a sore throat
3. Suck on a piece of hard candy or a lozenge.
4. Turn on a cool mist humidifier to add moisture to the air.
5. Rest your voice until your throat feels better.

3. Ear Pain:
Causes: Ear pain is common in children and can have many causes
1. Ear infection (otitis media) 2. Swimmer's ear (infection of the skin in the ear canal)
3. Pressure from a cold or sinus infection 4. Teeth pain radiating up the jaw to the ear.

To tell the difference, your pediatrician will need to examine your child's ear. In fact, an in-office exam
is still the best way for your pediatrician to make an accurate diagnosis. If your child's ear pain is
accompanied by a high fever, involves both ears, or if your child has other signs of illness, your
pediatrician may decide that an antibiotic is the best treatment.

Amoxicillin is the preferred antibiotic for middle ear infections—except when there is an allergy to
penicillin or chronic or recurrent infections.

Many true ear infections are caused by viruses and do not require antibiotics. If your pediatrician
suspects your child's ear infection may be from a virus, he or she will talk with you about the best ways
to help relieve your child's ear pain until the virus runs its course.

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ROLE OF PHARMACIST AS PUBLIC HEALTH EDUCATOR

Introduction: Community pharmacists have always played a role in promoting, maintaining and
improving the health of the communities they serve.
First Point of Contact: Community pharmacists are often patients first point of contact, and for some
their only contact, with a healthcare professional.
Community Engagement: Engaging with communities through day to day activities, which might
include the provision of advice to parents of young children, the care and support of drug misuses,
visits to the homes of older and housebound people and advice on smoking cessation.
Significant contribution to public health: Pharmacists already make a significant contribution to public
health. However, there is a need for community pharmacists to understand the broader concept of
public health, which focuses on improving health at population level.

Public Health
Definition: The study and practice of how best to improve the overall health, and health gain, of
populations rather than individuals health.
OR
The most widely used definition of public health was coined by Sir Donald Acheson in 1988 as:
"The science and art of preventing disease, prolonging life and promoting, protecting and improving
health through the organized efforts of society."
This definition encompasses a very wide-range of activities and emphasizes the importance of a
strategies approach a public-health-a-well as collaboration between different groups and individuals to
achieve these aims.

SERVICES OF COMMUNITY PHARMACISTS

1. Smoking cessation.
2. CHD: lipid management, identifying risk factors for CHD, secondary prevention with aspirin,
anticoagulation, obesity and weight reduction.
3. Skin cancer prevention.
4. Individualization of Drug Therapy
5. Drug misuse
6. 4. Rational use of Drugs
7. Sexual Health (including emergency hormonal contraception)
8. Immunization
9. Family Planning
10. Oral health
11. Mental health
12. Accidental injury prevention
13. Folic acid and pregnancy
14. Asthm 15. Diabetes
15. Nutrition and physical activity.

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1. Smoking Cessation:
Obvious Area: Smoking cessation is an obvious area for community pharmacist involvement.
Most common health development activity: Indeed, a recent UK survey of current activities
showed that smoking cessation services are the most common health development activity in
community pharmacies at present.
Primary healthcare: Many Pharmacists are working as part of the wider primary healthcare
team and with the NHS Smoking cessation services to provide specialist advise.
Behavior Changes By Pharmacist: Published literature indicates that community Pharmacists
trained in behavior change methods are effective agents in helping clients to stop smoking.
2. Coronary Heart Disease
High Priority: CHD is seen as a high priority by the government, and community pharmacists
have a unique opportunity to demonstrate their skills and knowledge in dealing with this group
of people.
Potential contribution of pharmacists: The potential contribution of pharmacists in CHD is to:
1. Provide sound information, advice and support on stopping smoking, healthy eating and
physical activity.
2. Get involved in smoking cessation services
3. Establish and record smoking status, smoking cessation clinics
4. Patient group directions (PGDs) for nicotine replacement therapy (NRT)
5. Training on use of NRT for pharmacy staff and other health professionals.
6. Distribution of free NRT
7. Provide medicines management services to support people on medication (and their
careers) for the prevention or treatment of CHD and stroke.
8. Provide information on local screening services and the need for regular checks of:
For example, blood pressure and blood lipid levels.
9. Participate in initiatives to identify people at high risk of CHD and stroke.
10. Provide warfarin monitoring to reduce the incidence of second heart attacks and stroke.
11. Get involved in healthy schools or workplace initiatives (e.g, giving talks on the benefits
of stopping smoking)
12. Provide a smoke free environment in the pharmacy.
13. Learn to recognize a heart attack and what to do (including resuscitation skills)
14. Educate the public about the symptoms of a heart attack and what action to take.

Evidence that community pharmacists can be effective in providing CHD-related services

Pharmacy Health Link (PHLink): Pharmacy Health Link (PHLink) previously known as the pharmacy
healthcare scheme and the royal pharmaceutical society of Great Britain (RPSGB) review covered
several areas including:
a) Lipid management
b) Identifying risk factor for CHD
c) Secondary prevention with aspirin
d) Obesity and weight reduction.

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a) Lipid management: Evidence from US and Canadian RCTs (Randomized control trials) in
lipid management in the prevention of heart disease showed that lipid management
services provided by community pharmacists are effective in:
a) Helping clients to achieve target lipid levels.
b) Enhancing prescribing and use of lipid regulating medicines.
c) Reducing clients CHD risk scores.

b) Identifying risk factor for CHD: Community pharmacists can use patient medication
records (PMRS) to identify clients at high risk of CHD, by for example, searching for a range
of drugs that would indicate heart disease. The use of such data to target patients with risk
factors for CHD appears to be effective in identifying those at risk to provide follow up on
lipid management and advice.

c) Secondary prevention with aspirin: Community pharmacists could potentially perform an

important role in ensuring the appropriate of prophylactic treatment and intervening to
minimize potential harm from self initiated aspirin treatment in people with contra-
indications to its use.

Audits of aspirin: Two Audits of aspirin purchases in UK community pharmacies in 1996 and
1998 showed that 33% and 27% of patients respectively appeared to be taking prophylactic
aspirin without their GPS knowledge. This indicates that community pharmacy audits can
identify self-initiated aspirin treatment and encourage referral for medical advice.

d) Anticoagulation platelet: Another potential role for community pharmacists is in

monitoring of anticoagulant therapy and minimizing negative health outcomes in this high
risk patient group.

e) Obesity And Weight Reduction: The incidence of obesity is increasing dramatically and
there is potential for community pharmacists to advise clients on weight management and
offer weight reduction programs.

3. Skin Cancer Prevention:

Ideal place for Information: The community pharmacy is an ideal place for the public to obtain
information on skin cancer.
Pharmacy based information, such as sun screen technology, appears to be effective in raising
awareness of sun risk, and trained pharmacists are more likely to be proactive in counseling
clients.
However, the effect of this advice on the behavior of clients is currently unknown.
4. Individualization of Drug Therapy:
Latest concept in medicine: Today the latest concept in medicine is towards individualization of
drug therapy. Where judicious patient care is needed individualization of drug therapy becomes
a need, and a pharmacist can play a vital role in this.

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Counseling Patient: A physician who is preoccupied with patient diagnosis and treatment may
not spare time for patient counseling regarding pharmaco-economics, drug information,
alterative therapy, moral supporting etc. A pharmacist can set up a separate consolation room
and provide counseling to the patient.
He can store the details of patient history, allergies and other details necessary for therapy so
that the concept of individualization of drug therapy could be implemented.
Seven star pharmacist The ideal from pharmacist of the future has been described as a seven
star pharmacist some one who is equal in excellence to a five star hotel yet accessible to
everyone from the richest to the poor. The future 7 star pharmacies will have seven principal
roles to play:
1. Caregiver
2. Decision maker
3. Communicator
4. Leader
5. Manager
6. Lifelong learner and
7. Role Model
The community pharmacist with the above skills and attitudes should make himself an
indible partner in health care system of a nation

5. Drug Misuse & Abuse:

Role of Pharmacist: All pharmacists play a major part in limiting the illicit availability of drugs by
i. Controlling the supply of medicines
ii. Monitoring prescriptions to identify excessive prescribing
iii. Detecting and reporting forged prescriptions.
iv. Many pharmacists are involved in activities aimed at reducing the risk of harm from the
illicit use of drugs (e.g. Dispensing methadone and supervising consumption on the
pharmacy premises).
v. Community pharmacy-based supervised methadone administration services are
acceptable to clients and achieve high attendance rates.
vi. Pharmacists can also help to reduce the demand for drugs by providing information and
advice to the public on drug misuse and there is some scope to develop this role.
vii. Pharmacists can advise drug users on the risks of contracting blood borne viral
infections, particularly HIV, hepatitis B and hepatitis C usually from sharing needles
and/or syringes.
6. Rational the Of Drugs:
i. A community pharmacist can also advise on the administration of the medication
provide information on the storage of the medication and wherever necessary he can
counsel the patient.
ii. Education regarding the disadvantage of polypharmacy can also be given to the patient.
iii. Drug information system should be set up and access to adverse drug reaction system
should be made.

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iv. A community pharmacist should do therapeutic drug monitoring and he should have a
sound knowledge of genotype reporting ie, predictive pharmacology.
• Drug information awareness program: Drug information awareness program should be
conducted to make people aware of side effects of certain OTC drugs.
For Example:
i. Aspirin-a wonder drug also has many side effect like gastric ulceration, asthma and large
doses may cause tinnitus.
ii. Regular use of Paracetamol can cause harm to the liver.
iii. Drugs such as Coldarin can increase blood pressure in patients having hypertension.
iv. Pain shows difference between men and women. Where women respond better to the
opioids such as morphine, pentazocine and pethidine men respond better in the non-
steroidal anti-inflammatory drug, ibuprofen.
Considering the above examples in the best interest of public health a community pharmacist
can provide counseling to common people aware of these side effects

• OTC Product:
Definition: The Product which does not require the prescription of a registered practitioner but
which can be sold only under the supervision of a pharmacist.
In a nut shell there should be rationals use of drug i.e. Right drug to right patient in right does at
right time,
• Delivering Information About Drugs: A community pharmacist is one of the inevitable
members of the healthcare team who can help to achieve the goal of final use of drugs by
following good pharmacy practices. It is found that interventions by pharmacists in
explaining the patients about medicines prescribed to them can significantly enhance page
of correct use of medicine from 56 percent to 90 percent.
• Enhancing the availability of essential drugs in India: There is yet another role of the
community pharmacist in India and that is enhancing the availability of essential drugs.
Nearly 70 % population in India is deprived of essential drugs for a variety of reasons
including non availability of health professionals and improper professional advice about
the usage of drugs.

7. Sexual Health (including emergency hormonal contraception)

Pharmacists have a potential role in:
i. Promoting safer sex
ii. Contraception including Emergency hormonal contraception (EHC).
Published studies from the UK36: Published studies from the UK36 demonstrate that
pharmacists can effectively and appropriately supply EHC within the time scale required for
efficacy. In these and unpublished studies, users were satisfied with the service pharmacists
provided, although there were some concerns in about one-fifth of female about privacy and
confidentiality. Pharmacists were positive about their experience of providing EHC.

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8. Family Planning: A community pharmacist is the one who can control this rising population by
counseling with people and doing programs which exhibits the problems related with large
families.
i. He can tell the various family planning measures that are available in the market at
affordable prices.
ii. He can educate the people & convince them about the advantages of having small
families. So, like all other aspects community pharmacist plays a very important role in
this case also.

9. Immunization: Most pharmacists interact with the general public in relation to immunization,
either in the supply of vaccines for administration at local GP clinics or in the giving of advice
related to foreign travel. Community pharmacists should take every opportunity to emphasize
the importance of immunization and the risks associated with non-vaccination compared with
those of the possible side effects of the vaccines used.
Other potential roles for community pharmacists in immunization include:
i. Participating in the strategic planning of the managed introduction of immunization
programmers (influenza in the elderly).
ii. Advising on systems needed to optimize the use of vaccines in the event of emergencies.
iii. Providing information on the handling and storage of vaccines. These products are
particularly susceptible to changes in temperature and maintenance of the cold chain is
important.

10. Oral Health: Community pharmacists have several potential roles in oral health:
i. They may be asked questions about oral and dental problems (e.g. Toothache, Mouth
ulcer, Candida, Gingivitis). The outcome of such an encounter may be sale of a treatment
(e.g. a simple analgesic) or referral to another professional (e.g. Dentist or doctor).
ii. They can give information on nutritional issues in relation to oral health (e.g. Sugar in
foods, medicines and drinks) and oral hygiene (e.g., brushing, use of Toothpastes and
mouthwashes).
iii. They can give information about the side effects of medicines in relation to the Mouth.
Some medicines can alter taste or result in a dry or sore mouth.

11. Mental Health: The main point of interaction between community pharmacists and those with
mental health problems have traditionally been at the point of dispensing or in sales of
medicines. Drug therapy is, of course, a major part of mental health treatment. Pharmacists
also help to treat those suffering from drug addiction, a condition which is often associated
with mental health problems.
However, pharmacists are also ideally placed to
i. Recognize early symptoms of mental health problems;
ii. Spot signs of else in patients,
iii. Help with concordance
iv. Encourage good mental health practice in the local population
v. Help to change attitudes and perceptions towards mental health patients;

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vi. Provide information on stress management, including self help groups.

12. Accidental Injury Prevention

• Introduction: Accidents are a significant cause of morbidity and mortality, especially in the
young and Frail, elderly populations.
• Background: In 1998, there were more than 12,000 accidental deaths in the UK, including
3500 caused by road traffic accidents.
Each year in UK more than 3000 people over 65 years die as a result of falls.
Risk Factors For Fall: The risk factors for falls include disability, illness, visual impairment
and poly-pharmacy, with patients taking sedatives and anti- hypertensive being a particular
risk.
• Older People – More Vulnerable: Older people are particularly vulnerable as they are more
likely to be affected by osteoporosis, which puts them at risk of serious injury from broken
hips and wrists. Up to 14,000 people die annually in the UK as a result of osteoporosis hip
fracture.
Role Of Pharmacist: Community pharmacies are beginning to offer osteoporosis screening.
One report of a pharmacy-based screening service involving pharmacists and nurse input
was found to be feasible and identified women at risk of osteoporosis. Women using the
scheme valued the accessibility offered by community pharmacy.
• Awareness of medicine-related accidents: Pharmacists are ideally placed to raise
awareness of the risks of medicine-related accidents, which can occur:
i. Directly from over dosage or poisoning
ii. Indirectly from the medicines effects on the central serves system
iii. May be associated with tasks such as driving.
Preventive Measures: Measures to reduce the likelihood of accidents are routinely
implemented by pharmacists in the course of their work.
i. They control the supply of medicines
ii. They can educate the public and patients on safe storage and use of medicines
iii. They make arrangements for the safe disposal of medicines.

Data collected on unwanted medicines returned to community pharmacies showed that the
main reasons for returning medicines were a change in therapy, the death of the patient or
adverse reactions.
13. Folic Acid and Pregnancy: Community pharmacists and their staff are ideally placed to offer
advice to women about the use of folic acid before and during pregnancy. Evidence suggests
that pharmacy staffs are positive about this role, but replied studies showing the effects of
intervention on women's behavior.
14. Asthma: Community pharmacists are ideally placed to improve management of asthma. The
PHLink/RPSGB work investigated the role of pharmacists in only one area and that of improving
the management of asthma in school children by school teachers, where they found some
benefit. However, the conclusion was that further research in this particular area is needed.

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15. Diabetes: Diabetes is a significant cause of morbidity (e.g. blindness, cardiovascular disease)
and mortality, and Community pharmacists have a unique opportunity to demonstrate their
skills and knowledge in dealing with this client group. Pharmacists can potentially:
i. Promote healthy eating and physical activity to help reduce the risk of diabetes.
ii. Educate the public and pharmacy staff on the signs and symptoms of diabetes.
iii. Contribute to the early identification of diabetes.
iv. Ensure that diabetic patients are taking their medication regularly and attending.
v. Follow up visits at their GP practice or clinic.
vi. Provide medicines management services to patients with diabetes.
vii. Participant in multi-disciplinary teams to help in the management of diabetes.

16. Nutrition and Physical Activity: Community pharmacists have a role in advising the public
about nutrition, physical activity and general healthy living. Many of the conditions they deal
with in the pharmacy benefit from dietary change, increased physical activity and other lifestyle
changes.
In addition, community pharmacists see healthy, as well as sick people and by providing advice
to healthy diets, they can potentially contribute to the prevention of disease in later life.

Conclusion: Community pharmacists can make an important contribution to health development.

Evidence from the published literature is sufficiently strong in the areas of smoking cessation lipid
management, emergency contraception and immunization.

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Chapter: Public Health & Community Pharmacy

Dr. Rabeea sharif | Lecturer, Pharmacy Department | UOP
Public health:
Definition: The science and art of preventing disease promoting, protecting and improving
health through organized community measures is called public health.
Control of infections:
1. Sanitation 2. Health education 3.Health services 4. Epidemiology

Epidemiology:
Meaning: Greek word mean Epi= among/upon, Dimos= people, Logos= to study.
Definition: The study of distribution and determinants of health related state and events in
specialized population and application of these studies to the control of health problems.
OR
The science which is concerned with the factors and conditions which determines the
occurrence and distribution of diseases, defects, disabilities and death in the population.’
OR
Study of distribution, dynamics and determinants of the disease frequency in human
population.

Epidemiology: key words:

a. Population: Main focus of epidemiology is on the effect of disease on the population
rather than individuals.
b. Frequency: Epidemiology is quantitative science & concerned with the frequency
(occurrence) of diseases and other health related conditions.
c. Distribution: Distribution refers to the geographical distribution of diseases, the
distribution in time, and distribution by type of persons affected.
d. Determinants: Determinants are factors which determine whether or not a person will
get a disease.
Aims of epidemiology
1. To know distribution and size of disease (where it is happening and how many people
are suffering, their ages and occupation etc.)
2. To identify the etiological factors.
3. To provide data to planners and administrators for improvement.
Uses of epidemiology
1. To identify the factors that causes disease.
2. To identify the factors and conditions that can be used or modified to prevent the
occurrence and spreading of disease.
3. Explain how, when, where and why epidemics occur.
4. Evaluate the effectiveness of vaccines and different form of therapy to establish a
clinical diagnosis of diseases.
5. Evaluate the effectiveness of health programmed.
6. To identify health needs of community.
7. Predict the future health needs of population.

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Some Definitions related to Epidemiology

En-demic: Occurs routinely in a given area. Malaria is endemic to that part of Sout America.
Epi-demic: When a disease grows to an abnormally large population within a community or
region. The malaria outbreak was of epidemic proportions.
Pan-demic: When an epidemic gets huge... on the approach of being a region-wide or world-
wide problem and is infectious, it becomes pandemic.
Sporadic: Refers to a disease that occurs infrequently and irregularly

Types of Epidemiology
1. Descriptive Epidemiology:
• Examining the distribution of disease in a population, and observing the basic features
of its distribution
• Formulate the hypothesis, time , place and person
2. Analytic Epidemiology:
• Testing a hypothesis about the cause of disease by studying how exposures relate to the
disease
• Essential characteristics that are examined to study the cause of disease are host, agent
and environment
3. Experimental Epidemiology:
• To study the relationships of various factors determining the frequency and
distribution of diseases in a community.

Epidemiological triangle or Triad:

Introduction: The occurrence and manifestation of any disease are determined by the
interaction between the agent, the host and the environment. These three together constitute
epidemiological traid.
Use: The triad is used to determine the cause of infectious diseases, non-infectious diseases,
and accidents or injuries.
1. Agent
Biological agents: such as virus, bacteria, Protozoa, worms and insects etc.
Nutrients agents: such as carbohydrates, proteins, vitamins, minerals & water. Excess and
absence of these agent’s cause diseases.
Physical agents: like extreme of cold, X-rays, pressure, electricity etc.
Mechanical agents: i.e. motor vehicles, machines.

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Chemical agents: like carbon monoxide, pesticides, phenol, alcohol, fertilizer, fumes, dust,
gases etc. May cause illness by inhalation, injection or direct contact.
Social agents: smoking, poverty, social isolation etc.

2. Host:
Introduction: Human beings mainly acts as a host to a number of many diseases. The
microorganism attacks host when the immunity is lost.
Host Factors: The characteristics of human being that determined how he reacts to the
agent in the environment are called host factors. It includes age, sex, nutrition, humidity,
occupation, habits etc.
a. Age: Certain diseases like measles etc. are common in childhood. Cancer in middle age
and TB in older age are common.
b. Sex: Females are most affected from cancer as compared to males. Heart attack cases are
mostly found in males than females.
c. Nutrition: Essential hypertension, diabetics, mental disorders are due to nutrition
overeating, may lead to obesity and diabetes.
d. Habits: Certain habits like smoking may cause lung cancer. Open air defecation may
cause soil and water pollutions. Which ultimately cause various types of intestinal diseases.
e. Genetic : Genetic composition either increases the susceptibility to disease or may
protect against it e g diabetes, G-6PD deficiency, hemophilia etc

3. Environment
Introduction: Environment play a great role for safety of health. A healthy environment is
important for the wellbeing of individual and communities. So if the environment is
favorable for the agent, it causes disease.
Climate and seasonal factors: These may determine whether it may be suitable for a
particular disease or not, i.e. Malaria is more common in rainy season, whereas common
cold is common in winter.
Types of environment:
Physical: Non-living things man is in constant interactions: Air, Heat, Climate, Radiations
Biologic: Man, Animals, insects, rodents
Social: Smoking, Alcohol taking community, Poverty etc.

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Disease Transmission
Introduction: For Planning, Suitable prevention, control and control measures, its essential to
know about the modes of transmission of diseases. Here we will discuss the direct and indirect
transmission of disease.

Before this we see the major channels/routes of infection which are:

Skin and Mucous Membrane: Rabies, Gonorrhea and AIDS etc
Respiratory Tract: T.B, Influenza
GIT: Cholera, Diarrhea etc
Classifications for modes of transmission: An infectious agent may be transmitted from its
natural reservoir to a susceptible host in different ways. There are different classifications for
modes of transmission.
A) Direct Transmission B) Indirect Transmission
Direct contact Airborne
Droplet spread Vehicle borne
Animal Bite Vector borne (mechanical or biologic)
Vertical Transmission

A. Direct Transmission
Direct contact Occurs through person to person via skin-to-skin contact, kissing, and sexual
intercourse. Thus, infectious mononucleosis and gonorrhea are spread from person to person
by direct contact. Direct contact also refers to contact with soil or vegetation harboring
infectious organisms. Hookworm is spread by direct contact with contaminated soil.
Droplet spread refers to spray with relatively large, short-range aerosols produced by sneezing,
coughing or even talking. Droplet spread is classified as direct because transmission is by direct
spray over a few feet, before the droplets fall to the ground. Pertussis, Tuberculosis and
meningococcal infection are examples of diseases transmitted from an infectious patient to a
susceptible host by droplet spread.
Animal Bite: Direct biting of animals like Rabies
Vertical Transmission: From the infected mother to the fetus via placenta e.g AIDS, Hepatitis
etc.

B. Indirect Transmission: Refers to the transfer of an infectious agent from a reservoir to a

host by suspended air particles, in animate objects (vehicles), or animate intermediaries
(vectors).
Airborne transmission occurs when infectious agents are carried by dust or droplet nuclei
suspended in air.
Airborne dust includes material that has settled on surfaces and become resuspended by air
currents as well as infectious particles blown from the soil by the wind. Droplet nuclei are dried
residue of less than 5 microns in size. In contrast to droplets that fall to the ground within a few
feet, droplet nuclei may remain suspended in the air for long periods of time and may be blown
over great distances.

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Measles, for example, has occurred in children who came into a physician’s office after a child
with measles had left, because the measles virus remained suspended in the air.
Vehicles that may indirectly transmit an infectious agent include food, water, biologic products
(blood), and fomites (inanimate objects such as handkerchiefs, bedding, or surgical scalpels).

Vehicle: A vehicle may passively carry a pathogen — as food or water may carry hepatitis A
virus. Alternatively, the vehicle may provide an environment in which the agent grows,
multiplies, or produces toxin — as improperly canned foods provide an environment that
supports production of botulinum toxin by Clostridium botulinum.
Vectors: Vectors such as mosquitoes, fleas, and ticks may carry an infectious agent through
purely mechanical means or may support growth or changes in the agent.
Examples of mechanical transmission: are flies carrying Shigella on their appendages and fleas
carrying Yersinia pestis, the causative agent of plague, in their gut.
In contrast, in biologic transmission, the causative agent of malaria or guinea worm disease
undergoes maturation in an intermediate host before it can be transmitted to humans

General Methods to control the Diseases

1. Controlling the source of Infection (Agent):
• Early Diagnosis
• Notification: Reporting to the health authorities
• Isolation: Patients should be isolated to avoid the spread of disease.
• Home Isolation Hospital Isolation
• Treatment: Early and proper treatment with Antibiotics can help in prevention of
spread. Prophylactic treatment can be given.
2. Blocking the mode of Transmission:
Mode of transmission of infection should be controlled by adopting measures like
a) Drinking water should be properly disinfected
b) All food items should be protected from diseased agents
c) Human wastes should be exposed of in a sanitary way
d) Overall standards of living should be improved
e) Mosquitoes, flees, other insects, rodents and stray dogs should be destroyed
f) All discharges of the patient should be disposed off in proper way
g) All fomites of the patient should be thoroughly disinfected items should be burnt.
h) Transmission of STDs can be prevented by using mechanical contraceptives.
3. Protecting the susceptible Host:
a. Immunization: Disease like Pertussis, Diphtheria, Tetanus, Measles and T.B can be
controlled through proper immunization. It`s cheap, safe, easy and effective
method for control of majority of infectious diseases.
b. Health Education: Health education regarding mode of spread and method of
prevention of various diseases is imparted to public. With cooperation of public,
large number of diseases can be controlled easily, effectively and within short
period of time.

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NOTE: All the pregnant women, infants and children at specified time must be vaccinated
against communicable diseases so as to give protection against such diseases which include
diphtheria, pertussis, tetanus, polio, tuberculosis and measles. All the countries have their own
immunization schedule which is based on their local needs and feasibility. This schedule may
vary from region to region. While deciding immunization schedule following points must be
taken into consideration:
i. Age of the child ii. Availability of effective vaccines iii. Cost of the vaccines.
iv. Minimum number of visits to the health centre by the mother and the child.

National Immunization schedule is given in the following table. (Table A).

Expanded Programme of Immunization (EPI)

Starting: A programme named Expanded Programme of Immunization (EPI) was started by
WHO in the year 1974 throughout the world.

According to this programme:

• It was proposed to immunize all children by 1990 against six diseases viz., diphtheria,
pertussis, tetanus, polio, tuberculosis, and measles. But in the year 1990 the name of
this programme was changed to Universal Child Immunization (UCI- 1990).

• Every child must be immunized in the first year of age.

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Hospital Acquired Infection

Second Name: Hospital acquired infections are also known as nosocomial infections.
Definition: The infections acquired by the patient after they have been admitted to the hospital
or other health care center.
Source of Infection: Prior to admission in the hospital the patients do not have any such
diseases. They can get the diseases from different sources like
a) Patients, unsterilized instruments, infected hands of surgeons, nurses, ward boys and
other hospital staff who come in contact with the patients.
b) Contaminated food, water and other drinks may also be a good source of infection.
c) Articles like linen, bed clothes, fumiture, sinks, basin pots, door handles etc. are also a
source of infection.
d) Hospital dust, air and discharges of the patient which are highly contaminated with
micro-organisms, are the most important sources of infection.

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It includes: Hospital acquired infections include cross infection i.e.

a) Infection from person to person
b) Autoinfection Infections from one tissue to another tissue in the same patient eg.
discharging wounds, infected skin lesions, eczema, psoriasis, balls bed sones etc.

Pathogen Responsible: The common pathogenic micro-organisms responsible for hospital

acquired infection include staphylococcus, streptococcus, E. coli, corynebacterium diphtheria,
costridium tetani, hepatitis virus through infected blood etc.
Common Hospital Acquired Infections: The common hospital acquired infection include
infections of alimentary tract, infections of respiratory tract, infections of urinary tract, wound
infections, skin infections, viral infections etc.

Prevention and Control: Hospital acquired infections can be prevented by adopting following
measures:
i. Isolate the infectious patient.
ii. Doctors, nurses and other staff attending the patient must take precautions for personal
hygiene. They should wear face mark and apron. They must wash the hands with soap
and water after attending each infected patient specially after doing the wound
dressings. Sometime hand washing with soap and water may not be sufficient so a
disinfectant must be used for hand washing.
iii. The articles used by the patient should be thoroughly disinfected.
iv. Wound dressings and discharges of the patient like urine, faces, nasal secretions,
sputum etc should be destroyed in a sanitary manner.
v. Patients should not be allowed to spit here and there. They should spit only in the
sputum cup containing some disinfectant.
vi. There should be sufficient space in between the beds of two patients. The bed side pans
must contain some disinfectant and they must be cleaned immediately after use.
vii. Vaccum cleaning and wet cleaning of rooms should be done regularly and disinfectant
used to kill the micro-organisms.
viii. Rooms should be well ventilated, all doors and windows should be fitted with wire
gauge to prevent the entry of flies, mosquitoes and other insects in the rooms.
ix. All instruments, needles and syringes used should be properly sterilized, preferably
disposable needles and syringes should be used.
x. Staff working in the kitchen must observe strict hygienic habits and must be periodically
medically examined so as to ensure that they are free from infectious diseases.
xi. Laboratory personnel handling various specimens should observe all precautions to
prevent infections.
xii. Entry of visitors should be restricted in the rooms where patients with communicable
diseases are admitted.
xiii. Patients sufferings from communicable diseases should be properly treated with
antibiotics and measures should be taken to avoid the spread of the diseases to other
patients.

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

Pharmacoepidemiology / Drug Epidemiology

Definition: The study of the effects of drugs in populations of people.
OR
Study of uses and the effects of drugs in a large number of people.
Meaning: Pharmakon - Drug Epi – upon or among
Demos – People or district Logos - Study

Amalgam Of: This branch is an amalgam of:

Clinical Pharmacology, Clinical Epidemiology, Medical informatics and Biostat.
Potential contributions of PEp:
(A) Information that supplements premarketing studies information
(a)Higher precision
(b) In patients not studied prior to marketing, e.g. the elderly, children, pregnant women
(c) As modified by other drugs and other illnesses
(d) Relative to other drugs used for the same indication (standard drug v/s new drug)
(B) New types of information not available from premarketing studies
(1) Discovery of previously undetected adverse and beneficial effects
(a) Uncommon effects (b) Delayed effects
(2) Patterns of drug utilization
(3) The effects of drug overdoses
(4) The economic implications of drug use

(C) General contributions of pharmacoepidemiology

• Reassurances about drug safety
• Fulfillment of ethical and legal obligations

Types of Pharmacoepidemiological Studies:

There are two fundamental types of Pharmacoepidemiological studies
1. Experimental 2. Non-Experimental
These are distinguished by the methods in which subjects are assigned to the treatments.
Non-Experimental can be further divided as descriptive and analytic studies.

1. Experimental studies:
Introduction: The investigator assign treatments to the subjects or patients may be randomly
assigned to the treatments in some forms of experimental or analytic studies.
Randomized Clinical Trials: The gold standards in determining the beneficial and adverse
effects of drugs is prospective, blinded, randomized clinical trials. Patients enrolled in
randomized control trails have their treatments assigned at random.
Field trials are another form of experimental studies, used to study dietary factors and
vaccines. In field trials the investigator makes the treatment available and then determine how
well it works with careful follow up.
Examples: Studies of Ascorbic acid in preventing the common cold, study of poliomyelitis
vaccines.

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Community Intervention trails are similar to the field trials but the treatment intervention is
directed at a town or community like fluoridation of drinking water to prevent dental caries.

2. Non- Experimental Studies:

Introduction: In Non-Experimental studies, patients are not assigned to the treatments by the
investigator.
Most of these studies enroll patients who are receiving care, including medication, from
conventional settings of care such as clinic and hospitals.

1. Descriptive Studies: Non experimental studies are usually descriptive which are
conducted to describe or summarize data.
For example: An investigator may wish to know the types of the drugs prescribed at an
outpatient pharmacy by drug class. These data would help the investigator to determine
what types of drugs could be studied more rigorously using the prescription data from this
setting.
Hypothesis generation: Descriptive data are helpful in hypothesis generation and
determining whether there are sufficient numbers of patients, prescriptions, events etc. to
conduct a more rigorous study. Such studies might include profiles of drug use, drug
surveillance, patient types or disease types.

2. Analytic non Experimental Studies are often used to test hypothesis.

Example: We might find from our descriptive study that patients prescribed one type of
NSAIDs have a greater prevalence of gastropathy than those receiving other NSAIDs. We
might then ask whether this is because this NSAID is truly more gastrotoxic or whether
sicker patients who are more prone to develop gastropathy are also more likely to prescribe
this drug.
To find out the answer to this question would require a study that gives rates of gastropathy
that control for illnesses that increase the liklehood of gastropathy and use of other drugs
and foods that might also increase the risk of gastropathy among these patients.

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

Cohort Studies
Introduction: Cohorts are groups. Cohort studies are therefore studies of group of patients
having some common drug exposure of interest.
For example, we may wish to learn about the benefits and risks of the NSAIDs on the
population of the patients likely to be prescribed them. We would define our cohort or group
on the basis of patients exposure to NSAIDs.
Types: There are two types of cohort studies
1. Prospective Cohort
2. Retrospective Cohort

1. Prospective Cohort: In terms of scientific evidence and control over the factors of interest, its
preferred type of cohort study.
As name indicates, it looks forward in time. Doing so the investigator maximum control over the
study definition and its conduct.
2. Retrospective Cohort: As name indicates, it looks back on existing data. These data come
from large computer databases but can also come from paper charts or medical records.
Advantage of retrospective studies is lower cost as compared to prospective or clinical trial
studies.
Major disadvantage is that many forms of bias are possible.

The Case Control Study: Methodologically, case control studies are the diametric opposite of
cohort studies. Case control studies are generally conducted when the outcome of interest is
rare.
Instead of beginning with a group of patients using same drug and following them until they
have a specific event, as with the cohort study, in the case control study we first identify a
group of patients with a common event or disease. These are the cases.
For example: If we wished to know whether a certain drug caused aplastic anemia, first
patients with aplastic anemia will be identified. The controls will be the people who are
representative of the underlying population from which the cases came but who didn`t have
the outcome of interest. In the aplastic anemia example, the investigator would search for the
patients who came from the same settings of care as the cases or from the same community.
Sometimes controls are matched to cases on certain background factors that predict or
confound the outcome, such as age, gender or smoking status.
The idea of case control study is to compare the prevalence of exposure between the cases and
controls.

Case Reports: Presentation of the experience of a single patient.

Usually presented in a way that supports a hypothesis or an answer to a question.
Case reports are often referred to as Hypothesis generating because they bring forth evidence
supporting a hypothesis or conclusion.
For example, the presentation of the medications for a patient that were administered until the
development of aplastic anemia might suggest that one or more of these drugs could have
caused the aplastic anemia.

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Case Series: When the common experience of more than one patient are presented, this is
referred to as case series.
Greater the number of common experience, the stronger the evidences to support a
conclusion.
For example: If five patients developed aplastic anemia, after the exposure of the same
medicine, this would raise our suspicion beyond that for only one patient.

Cross Sectional Studies:

Definition: This is study conducted to obtain the prevalence of an outcome in a given set of
patients such as those being treated with a drug at single time point.
Also termed as SNAPSHOT STUDIES because data are collected all at once, the temporal
relationship between use of the drug and the outcome of interest cannot be determined in
such studies. This is a problem if investigator is trying to make cause and effect inferences.

The Ecological Study: There are times when data are not available at the patient level but there
is interest in getting a pre-liminary understanding of the relationship between the use of a drug
and an outcome. This may attract an investigator to use aggregate data to compare the gross
amount of drug used and the rate of occurrence of an event for a community, stat or country.
In other words, the unit of analysis in ecological studies is a population instead of a patient.
Example: Comparison of the no of prescriptions of beta adrenergic agonists inhalers dispensed
in a country and number of deaths from asthma.

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

Expanded Program on Immunization (EPI)

EPI means: Adding more disease controlling antigens of vaccination schedules.
Extending to all corners of a country and spreading services to reach the less privileged sector
of the country.
OR
The expanded Programme on Immunization (EPI) is a disease prevention activity aiming at
reducing illness, disability and mortality from childhood diseases preventable by immunization.
History:
• The World Health Organization (WHO) initiated the Expanded Program on Immunization
(EPI) in May 1974 with the objective to vaccinate children and eligible adults throughout
the world.
• Ten years later, in 1984, the WHO established a standardized vaccination schedule for
the original EPI vaccines:
1. Bacillus Calmette-Guérin (BCG)
2. Diphtheria- pertussis -tetanus (DPT)
3. Oral polio
4. Measles
Addition To EPI’s List: Increased knowledge of the immunologie-factors of disease led to new
vaccines being developed and added to the EPI's list of recommended vaccines: Later others
were added:
1. Hepatitis B (HepB),
2. yellow fever in countries endemic for the disease
3. Haemophilus influenzae meningitis (Hib) conjugate vaccine in countries with high
burden of disease

Global Alliance for Vaccines and Immunization (GAVI)

Created In: In 1999, the Global Alliance for Vaccines and Immunization (GAVI) was
created.
Purpose: GAVI was created with the sole purpose of improving child health in the
poorest countries by extending-the-reach- of the EPI.
GAVI brought together: The GAVI brought together a grand coalition, including the
1. UN agencies and institutions (WHO, UNICEF, the World Bank)
2. Public health institutes
3. Donor and implementing countries
4. Bill and Melinda Gates Foundation
5. The Rockefeller Foundation
6. The vaccine industry
7. Non-governmental organizations (NGOs) and many more.

GAVI Helped: The creation of the GAVI has helped to renew interest and maintain the
importance of immunizations in battling the world's large burden of infectious diseases.

GAVI’s Milestone: GAVI has set up specific milestones to achieve the EPI goals:

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1. By 2010 all countries have routine immunization coverage of 90% of their

child population,
2. HepB be introduced in 80% of all countries by 2007
3. 50% of the poorest all counties have Hib vaccine by 2005.
Starting in Pakistan: The Programme started in Pakistan in 1978 and is still continuing.
The programme is evaluated at intervals of 2-3 years.

Aim: I s to make immunization complementary to other Primary Health Care (PHC) services
in order to reduce morbidity, mortality and disability from the vaccine preventable diseases
of childhood and adults who require them.

Objectives: Specific objectives of the Programme are as follows:

1. To achieve 100% coverage with all EPI vaccines
2. Eradication of Polio
3. Elimination of Measles by 2010 because of measles deaths that occurred in 1999
4. Reduce HB to <1% among under 5 > Elimination of maternal and neonatal Tetanus
5. To maintain zero level of diphtheria
6. Prevention of severe forms of TB > To reduce the incidence of whooping cough
7. Achievement of 90/80 % immunization coverage by 2010
8. Introduction of new vaccines in the EPI immunization Schedule
9. Promote immunization programmes, including vaccine production and quality
control
10. Intensify implementation of the immunization activities for the maternal and child
health
services

Evaluation: In each country, immunization programs are monitored using two different
methods:
1. An administrative method : The administrative method involves using immunization
data from public, private, and NGO clinics. Thus the accuracy of the administrative
method is limited by the availability and accuracy of reports from these facilities.
This method is easily performed in areas where the government services deliver the
immunizations directly or where the government supplies the vaccines to the clinics.

2. Through community-based surveys: In countries without the infrastructure to do

this, community based surveys are used to estimate immunization coverage.

Application: Community-based surveys are applied using a modified cluster sampling survey
method developed by the World Health Organization.
• Vaccine coverage is evaluated using a two-stage sampling approach in which 30
clusters and seven children within each cluster are selected.
• Health care workers with no or limited background in statistics and sampling are
able to carry out data collection with minimal training.

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

Such a survey implementation provides a way to get information from areas where there is
no reliable data source. It is also used to validate reported vaccine coverage (for example,
from administrative reports) and is expected to estimate vaccine coverage within 10
percent.
Provide more detailed information: Surveys or questionnaires, though frequently
considered inaccurate due to self-reporting, can provide more detailed information than
administrative reports alone. If home based records are available, not only can vaccination
status be determined but also dates of vaccination can be reviewed to determine if
vaccinations were given at an ideal age and in appropriate intervals. Missed immunizations
can be identified and further improved.

EPI-Partners
1. International
i. WHO
ii. UNICEF
iii. Rotary International
iv. DFID (Department for International Development)
v. JICA (Japanese International Cooperation Agency)
vi. CDC Atlanta
vii. USAID (United States Agency for International Development)
viii. UNHCR
ix. Global Alliance for Vaccines and Immunization(GAVI)
2. National
i. Government of Pakistan
ii. Provisional government
iii. District government
iv. NGOs

CURRENT STATE OF EPI IN PAKISTAN

• Pakistan has made significant improvement in EPI coverage in comparison to India and
Afghanistan 47% of Pakistani children age 12-23 months had received all recommended
vaccines 1-2 years.
• 80% of children received BCG and Polio vaccine, fewer received some of doses of DPT,
Hep.B and measels
• 6% had not received any of vaccines
• Vaccination coverage is higher in urban areas than rural (54 Vs 44%)
• There is marked variation in vaccination coverage by province: 35% Balochistan, 53%
Punjab, 37% Sindh, 47% Khyber Pakhtunkhwa
Conclusion:
• Cost Effective: Immunization is the most cost-effective method of protecting children
from these Vaccine Preventable Diseases and therefore plays a vital part of community
healthcare. to VPDs.

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

• Vaccine preventable diseases (VPDs): 27% of deaths in <5 years age group are due to
VPD,s.
• Mortility in Pakistan: 15% deaths of children <5 years age contribute to mortality in
Pakistan as compared to 8-10% in developed world.
• Prior to the initiation of the EPI: Child vaccination coverage for tuberculosis,
diphtheria, pertussis, tetanus, polio and measles was estimated to be fewer than 5
percent. Now, not only has coverage increased to 79 percent, but it has also been
expanded to include other vaccinations such as for hepatitis B in 2001, Haemophilus
influenza B, rubella, tetanus and yellow fever.
• 80% children of world are being protected against childhood TB. .3 million children &
19.5 million CBAs are being protected against eight vaccine preventable diseases and
tetanus respectively.
• Measles deaths decreased by 60% worldwide between 1999 and 2005,
• 1000 deaths in less than 5 year children will daily occur in Pakistan, if EPI is discontinued.
It has eradicated small pox, lowered the global incidence of polio so far by 99% and
achieved dramatic reductions in Illness, disability and death from diphtheria, tetanus,
whooping cough and measles.
• VPDs rates in the United States are at very low levels. In 2007, only 43 cases of
measles, 12 cases of rubella, no cases of diphtheria, 28 cases of tetanus, and no wild-type
polio were reported to CDC.
• A survey conducted by the ministry of health in 2006, noted that 76.2% of children
in Punjab were fully immunized. This result, while-significant, shows that there is still
room' for improvement in order to achieve a target of 100%.
• A study conducted in Peshawar in 2007 found that only 37.6% of children were fully
immunized.
• There have also been increases in trained workers throughout the country, as
required, towards the aim of achieving full coverage.
• The impact of increased vaccination is clear from the decreasing incidence of many
diseases. Polio, although missed the goal of eradication by 2005, has decreased
significantly as there were less than 2000 cases in 2006.
• Therefore, not only is it necessary to evaluate the EPI as a whole, its implementation
must be studied in specific communities in order to pinpoint weaknesses, identify their
cause and most importantly find a solution.
• In past research studies, lack of motivation on the part of EPI staff, absence of
vaccinators, inconvenient locations and problems with the cold chain (It is the system of
storage and transportation of the vaccine at low temperature (cold condition) from the
manufacture till it is consumed) have been cited as common reasons for obstruction of
immunization.

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IMMUNIZATION BY VACCINATION
Immunization
Definition:
• It is the capacity of the body to resist infections.
• The study of immunity is called immunology.
Vaccination:
Definition: The process of developing immunity within the body with the help of vaccines
is called vaccination.
• Vaccines are actually the antigen-containing preparations.

The Schedule of Compulsory Vaccination

At birth
S.No Vaccines Diseases Types of Vaccines Dose ROA
01 BCG TB Live attenuated, 0.01 ml ID injection in left
deltoid
02 HBV Hepatitis B variant Recombinant yeast 0.5ml IM thigh
derived HBs antigen

2nd Month:
S.No Vaccines Disease Type of Vaccine Dose ROA
01 OPV Polio Live attenuated 2 drops Oral
02 HiB Hib Polysaccheride 0.5ml IM thigh
Disease Conjugate
03 HBV Hepatitis B Recombinant Yeast 0.5ml IM thigh
derived HBs Antigen
04 DPT Diptheria Toxoid (D) 0.5ml IM thigh
Tetanus Toxoid (T
Whooping Killed pertussic (P))
cough
4th Month:
S.No Vaccines Disease Type of Vaccine Dose ROA
01 OPV Polio Live attenuated 2 drops Oral
02 HiB Hib Polysaccheride 0.5ml IM thigh
Disease Conjugate
03 DPT Diptheria Toxoid (D) 0.5ml IM thigh
Tetanus Toxoid (T
Whooping Killed pertussic (P))
cough

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

6th Month:
S.No Vaccines Disease Type of Vaccine Dose ROA
01 OPV Polio Live attenuated 2 drops Oral
02 HiB Hib Polysaccheride 0.5ml IM thigh
Disease Conjugate
03 HBV Hepatitis B Recombinant Yeast 0.5ml IM thigh
derived HBs Antigen
04 DPT Diptheria Toxoid (D) 0.5ml IM thigh
Tetanus Toxoid (T
Whooping Killed pertussic (P))
cough
12th Month:
S.No Vaccines Disease Type of Vaccine Dose Mode of
Administration
01 MMR • Measles All Live attenuated 0.5ml Subcutaneous
• Mumps
• German
Measles
18th Month:
S.No Vaccines Disease Type of Vaccine Dose ROA
01 OPV Polio Live attenuated 2 drops Oral
02 HiB Hib Polysaccheride 0.5ml IM thigh
Disease Conjugate
03 DPT Diptheria Toxoid (D) 0.5ml IM thigh
Tetanus Toxoid (T
Whooping Killed pertussic (P))
cough
4-6 Years:
S.No Vaccines Disease Type of Vaccine Dose ROA
01 OPV Polio Live attenuated 2 drops Oral
02 MMR • Measles All Live attenuated 0.5ml Subcutaneous
• Mumps
• German
Measles
03 DPT Diptheria Toxoid (D) 0.5ml IM thigh
Tetanus Toxoid (T
Whooping Killed pertussic (P))
cough

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

Basic Principles to be considered in Immunization schedule

1. All EPI antigens are safe and effective if administered
2. The recommended interval between two doses of
• Live attenuated vaccine.
• Inactivated vaccines.
3. The only live attenuated vaccine given to HIV child is measles
4. Tetanus immunoglobulin (250 IU) must be given to babies:
a. Born outside hospital in unsanitary home conditions
b. Seen within 10 days after birth.
c. Whose mothers are not given two documented doses of TT.
5. Introduction of HB vaccine in 1990.
6. MMR vaccine is given not before the 12months not to be neutralized by maternal
antibodies

CONTRAINDICATIOS TO VACCINATION
1.ABSOLUTE 2.TEMPORARY
Contraindications to live attenuated vaccines:
Absolute:
1. History of anaphylactic reactions.
2. Subsequent doses of pertussis vaccines are absolutely contraindicated if the
child gets (within 48 hours of vaccination)
• Fever (40.5º),
• Collapse or shock.
• Persistent crying for 3 hours without apparent cause.
• Convulsion with or without fever within 3 hours after vaccination.
3. HIV infection is an absolute contraindication to administration of live
attenuated vaccines (OPV & BCG).
Temporary:
1. Pregnancy
2. 2- Severe illness that needs hospitalization.
3. Immunosuppression.
4. Recent receipt of blood.

The strategy for the vaccine delivery

1. The static immunization strategy.
2. The National Immunization Days (NIDs).
3. Mopping up Immunization.
4. Outreach immunization.

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1. The static Immunization strategy:

Advantages of integration of immunization services through (MCH):
a. Available resources.
b. Cold Chain maintenance.
c. Save time, effort and money.

2. The National Immunization Days (NIDs): It is periodic immunization of all the

eligible targets in a defined group over a large geographic areas within a short
period of time. It is one of the strategy for polio eradication and tetanus
elimination.

3. Mopping up Immunization:
a. It is house-to-house immunization with OPV in high risk districts.
b. It consists of two to three rounds 4-6 weeks apart.
c. Each round should be completed within a short period of time (3days).
d. High risk districts are those: Where the wild polio virus is still circulating
(polio case in the last 36 months).
e. Transient population, with overcrowding poor sanitary environment and
low access to health services.
f. With low immunization coverage.

4. Outreach Immunization: The outreach is carried during any time without

specific duration:
Limitations:
i. Expensive
ii. Cold chain failure.
iii. Difficulty to arrange the immunization schedule.
Missed opportunity: It occurs when a child or a woman in child bearing period
comes to the health facility or outreach site and does not receive any of the
vaccine doses for which he or she is eligible.
The reasons for missed opportunity are:
a. Health workers' practices.
b. Logistical problems.
c. Failure to administer simultaneously all the vaccines for which the child
is eligible.
d. False contraindications to immunization.

a. False contraindications to immunization:

Conditions that are wrongly considered as contraindications:
a. Minor Illness( respiratory tract infections,diarrhea, fever < 38.5°C).

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b. Prematurely or small for date infants.

c. Child being breast-fed.
d. Family history of convulsion.
e. History of jaundice at birth
f. Chronic health problems: Malnutrition,allergy, asthma, other atopic
manifestations; hay fever chronic diseases of heart, lungs, kidney or
liver, cerebral palsy & Down syndrome, dermatoses, local skin lesion.
g. .Treatment with antibiotics, low dose corticosteroids(local or inhaled)

The cold chain:

Introduction: It is the system of storage and transportation of the vaccine at low
temperature (cold condition) from the manufacture till it is consumed.
• Polio vaccine is the most sensitive vaccine to heat.
• Live attenuated vaccines are allowed to be frozen (OPV, Measles, MMR and BCG).
• Inactivated vaccines must not be frozen (DPT, DT, dT, TT and HB).
The levels of cold chain

The administrative levels of cold chain according to the duration of the storage and the
temperature required to keep the vaccine potent.

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

Administrative Level Storage Period Temprature Vaccines

Central & Regional Maximum three -20℃ to 30℃ OPV
Stores months +2℃ to +8℃ DPT, DT, dT, TT, HB,
HiB
District Stores & Maximum one 0℃ to +8℃ OPV, Measles,
Local Immunization month MMR, BCG
centers +2℃ to +8℃ DPT, DT, dT, TT, HB,
HiB

Refrigeration equipment for storage of vaccines:

a. Refrigerator
b. Cold boxes
c. Vaccine carriers
d. The ice packs retained in the freezer
• To stabilize the temperature of the refrigerator at the optimum level.
• Fully frozen ice-packs are used for lining the vaccines carriers and the cold boxes
during storing the vaccines

What damage the Vaccines?

1. Any defect in the cold chain.
2. Using skin antiseptic at the site of injection (e.g. BCG).
3. Using the reconstituted vaccine (MMR, measles, BCG) after the recommended
period (6 hours).
4. Exposure of the vaccine to unacceptable temperature during the immunization
session.
5. Exposure of the vaccine to direct sunlight (BCG).
6. Outdateexpiry.

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

Drug Utilization Review

Other Names: Drug Utilization Reviews (DUR), also referred to as Drug Utilization Evaluations
(DUE) or Medication Utilization Evaluations (MUE),
Definition: An authorized, structured, ongoing review of health care provider prescribing,
pharmacist dispensing, and patient use of medication.
OR
DURs involve a comprehensive review of patient’s prescription and medication data before,
during, and after dispensing to ensure appropriate medication decision making and positive
patient outcomes.
OR
Drug utilization review refers to a review of prescribing, dispensing, administering and ingesting
of medication.

Background
• A rising problem in our hospitals nowadays is the irrational use of medicines which has
disastrous effects on the health of the population.
• Problems like drug resistance, drug interactions, increased morbidity and mortality
rates, prolongation of treatment duration and cost, secondary infections and diseases,
recurrence of infections, are all on the rise due to irrational use of medicines. This
irrational use can be prevented by Drug Utilization Review studies.
• DUR studies helps to understand, interpret, evaluate and improve the prescribing,
administration and use of medicines. Pharmacists can contribute vastly to this due to
their extensive knowledge on medicines. This study will identify drug interactions and
provide solutions to the problems which will ultimately benefit the patient’s health.

Categories of DUR: DURs are classified into three categories:

1. Prospective - Evaluation of a patient's therapy before medication is dispensed
2. Concurrent - Ongoing monitoring of drug therapy during the course of treatment
3. Retrospective - Review of therapy after the patient has received the medication

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Steps in conducting drug utilization review:

1. Identify drugs or therapeutic areas of practice for possible inclusion in the program
2. Design of study
3. Define criteria and standards
4. Design the data collection form
5. Data collection
6. Evaluate results
7. Provide feedback of results
8. Develop and implement interventions
9. Reevaluate to determine if drug use has improved
10. Reassess and revise the DUR program
11. Feed back results

Indicators Suggesting a Need for DUR

1. Preventable adverse drug reactions, and toxicity
2. Medication errors
3. The medication is most effective when used in a specific way.
4. Signs of treatment failures
5. Pharmacist interventions to improve medication therapy
6. Formulary management
7. Patient dissatisfaction or deterioration in quality of life
8. Expensive medication
9. Frequently prescribed

Objectives:
1. Promoting optimal medication therapy
2. Assessing medicines to recognize problems
3. Evaluating the effectiveness of medication therapy
4. Conducting interventions to improve drug use
5. Identifying clinically significant drug interactions and providing interventions
6. Stimulating standardization in medication use process
7. Decrease the morbidity and mortality rates
8. Ensuring cost effective and timely treatment

Significance/Importance of DUR:
1. DUR programs play a key role in helping managed health care systems understand,
interpret, and improve the prescribing, administration, and use of medications.
2. Employers and health planners find DUR programs valuable because the results are used
to foster more efficient use of scarce health care resources. Pharmacists play a key role
in this process because of their expertise in the area of pharmaceutical care.
3. DURs offer the managed care pharmacist the opportunity to identify trends in
prescribing within groups of patients such as those with asthma, diabetes, or high blood
pressure.

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4. Pharmacists can then, in collaboration with other members of the health care team,
initiate action to improve drug therapy for both individual patients and covered
populations.
5. DURs serve as a means of improving the quality of patient care, enhancing therapeutic
outcomes, and reducing inappropriate pharmaceutical expenditures, thus reducing
overall health care costs.
6. DUR information also assists managed health care systems in designing educational
programs that improve rational prescribing.

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

Preventive health: Preventive health or prophylaxis includes

• Measures taken to identify and minimize risk factors for disease
• Screening for early detection of disease
• Improve the course of an existing disease
Levels of preventive health care
1. Primary level of PH
2. Secondary level of PH
3. Tertiary level of PH

1. Primary level of PH:

• It aims to prevent disease or injury before it ever occurs.
• Preventing exposures to hazards that cause disease or injury or altering unhealthy and
unsafe behaviors.
• Promoting healthy habits (seatbelts, helmets, exercise, not smoking) and immunization.
• It focuses to prevent disease among healthy people.

2. Secondary level of PH:

• It aims to reduce the impact of a disease or injury that has already occurred.
• Detecting and treating disease or injury as soon as possible to halt or slow its progress,
encourage health promotion , modification of the individual’s social circumstances and
lifestyles so that their health is improved and secondary disease is prevented.
• Screening tests to detect disease in its earliest stages.

3. Tertiary level of PH
• It aims to soften the impact of an ongoing illness or injury that has lasting effects.
• It is the early identification of high risk individuals prone to major life threatening illness
like heart diseases and cancer.
• It helps in taking timely, precautionary lifestyle modifications measures or treatment
which reduces the disability associated with the disease.

Important Preventive Health Measures: Following are some important preventive

health measures one must adopt in personal life:
1. Immunization of Children
2. Eat a proper, balanced diet
3. Avoid excess consumption of meat products
4. Routine checkup of hypertension or blood pressure.
5. Daily consumption of aspirin to prevent heart attack and stroke above age of 40.
6. Routine breast cancer screening in women above age 50.
There are 4 things you can do immediately without any medical knowledge
1. Don’t smoke or use other tobacco products/Stop Alcohol Consumption
2. Eat a proper, balanced diet
3. Exercise at least three days per week
4. See your doctor (also pharmacists) regularly for check ups and guidance

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Expanded program on immunization (EPI)

Introduction: The Expanded Program on Immunization is a World Health Organization program
with the goal to make vaccines available to all children throughout the world. It is a disease
prevention activity aiming at reducing the illness, disability or mortality from childhood disease
preventable by immunization.
Starting: In 1974, WHO started EPI programme while in Pakistan it was started in 1978 with
help of WHO that was only for six diseases.
As per WHO, Pakistan is 3rd most under vaccinated country.

Immunization
Introduction: According to WHO Immunization is the process whereby a person is made
immune or resistant to an infectious disease, typically by the administration of a vaccine.
ADVANTAGES:
1. Person Protection: Vaccines stimulate the body’s own immune system to protect the
person against subsequent infection or disease.
2. Controlling and eliminating life-threatening infectious diseases: Immunization is a
proven tool for controlling and eliminating life-threatening infectious diseases and is
estimated to avert between 2 and 3 million deaths each year.
3. Cost effective: It is one of the most cost-effective health investments, with proven
strategies that make it accessible to even the most hard-to-reach and vulnerable
populations.
4. Defined targets: It has clearly defined target groups.
5. No Lifestyle Changes Requirement: Vaccination does not require any major lifestyle
change.

Objective of EPI
1. The overall objective of the EPI is reduction of mortality and morbidity from the following
nine EPI diseases by offering immunization services:
a. Poliomyelitis
b. Neonatal Tetanus
c. Measles
d. Diphtheria
e. Whooping cough
f. Hepatitis-B
g. H.I. Pneumonia
h. Meningitis
i. Childhood TB
2. Optional Vaccines: Influenza, Hepatitis A and Typhoid Fever
3. Strengthen planning and management of NIP.
4. Facilitate countries improving their disease surveillance system.
5. Support regular evaluations and reviews of national EPI.
6. Provide support in micro planning to help countries deliver EPI.

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7. Strengthen the sustainability of services.

8. Maximization of benefits of the Global Alliance for Vaccines and Immunization.(GAVI)
9. Provide support to improve the quality of immunization services.
10. Assess new vaccines

Regional objectives
1. To maintain polio free status.
2. To eliminate measles.
3. Achievement and maintenance of more than 90% coverage with all vaccines by NIP.
4. To control Hepatitis B.
5. To eliminate neonatal tetanus.
6. To improve and maintain immunization safety.
7. To ensure vaccine safety.
8. To prepare National Immunization Programmes.

EPI in Pakistan
Introduction: Pakistan is a developing country with a population of 180 million and estimated
infant mortality rate (IMR) of 80/1000 live births.
EPI coverage: The EPI coverage is 80% for BCG 65% for DPT3 and polio3 and a mere 67% for
measles .
1. Tetanus Toxoid (TT) coverage The Tetanus Toxoid (TT) coverage of pregnant women is
56%-57% which is quite low.10-11% Tetanus neonatal is prevalent in Pakistan mostly in
the rural areas due to low TT coverage.
2. In a verbal autopsy study conducted in two provinces of Pakistan, the three main causes
of infant deaths were reported as diarrhea syndrome (21.6%), tetanus (11.7%) and
acute respiratory infections (11.6%).
3. A study conducted in KPK of Pakistan reported only 65% of under three year olds as fully
immunized. The reasons for non-compliance with the EPI schedule were:
4. Mother too busy and unawareness
5. Absence of vaccinator
6. Inconvenient places being utilized as EPI centers.

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Immunization Schedule in Pakistan:

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OPV (oral polio vaccine)

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BCG

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Measles Vaccine

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DPT ( Diphtheria-Pertussis-Tetanus ) Vaccine

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ADRS due to immunization:

1. Rare
2. Paralysis (OPV)
3. Injection Site abcess
4. Seizures
5. Sepsis
6. Minor
7. Fever (Should resolve within 24 hours
8. Local Reactions (Pain, redness, swelling etc)
9. Anaphylaxis

Strategies to improve immunization coverage

1. Increase priority of immunization for under 1 year population.
2. Acceleration of TT coverage for pregnant women.
3. Reduction of drop- out rates between first and last immunization by improving health
education of community with the help of public awareness and community participation
towards programme.
4. Strengthening the surveillance system to enable promote response for outbreak
investigation and monitoring the impact of programme in reducing morbidity of the six
targeted diseases.
5. Full integration of EPI in public health system with particular emphasis on improving
upon immunization services to the disadvantaged population residing in suburban
areas, deserts and hilly areas.

Herd immunity:
Introduction: Herd immunity happens when so many people in a community become
immune to an infectious disease that it stops the disease from spreading.
This can happen in two ways:
1. Many people contract the disease and in time build up an immune response to it
2. Many people are vaccinated against the disease to achieve immunity.
Herd immunity can work against the spread of some diseases. There are several reasons why it
often works.
Example: 19 out of every 20 people must have the measles vaccination for herd immunity to
go into effect and stop the disease. This means that if a child gets measles, everyone else in this
population around them will most likely have been vaccinated, already have formed antibodies,
and be immune to the disease to prevent it from spreading further. However, if there are more
unvaccinated people around the child with measles, the disease could spread more easily
because there is no herd immunity.
Goal: The goal of herd immunity is to prevent others from catching or spreading an infectious
disease like measles.

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Center For Disease Control (CDC)

Introduction: The centers for disease control and prevention (CDC) is one of the major
operating components of the department of health and human services (HHS), which is the
principal agency in the united states government for protecting the health and safety of all
Americans and for providing essential human services, especially for those people who are at
least able to help themselves.

Found In: It was founded in 1946 to help control malaria.

Forefront of Public Health Efforts: CDC has remained at the forefront of public health efforts to
prevent and control infections and chronic diseases, injuries, workplace hazards, disabilities and
environmental health threats.

Globally Recognized: Today CDC is globally recognized for conducting research and
investigations and for its action oriented approach. CDC applies research and findings to
improve people's daily lives and respond to health emergencies.

Centers Are:
• National public health institute of the United States.
• Federal agency under the Department of Health and Human Services.
• Headquarter located in Atlanta.
• On 1st July 1946 - The Communicable Disease Center Was organized in Atlanta, Georgia.
( to control malaria)
• Where as in 1970 - The Communicable Disease Center became the Center for Disease
Control.
• Today, CDC is one of the major operating components of the Department of Health and
Human Services and is recognized as the nation’s premiere health promotion,
prevention, and preparedness agency.

Role of CDC:
1. To Protect public health and safety through the control and prevention of infections and
chronic diseases, injuries, workplace hazards, disabilities and environmental health
threats.
2. Conducting research and investigations to improve people’s daily lives and respond to
health emergencies.

Goals of CDC:
1. Healthy People in Every Stage of Life
2. Healthy People in Healthy Places
3. People Prepared for Emerging Health Threats
4. Healthy People In A Healthy World
1. Healthy People in Every Stage of Life
Start Strong:

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• CDC works for improvement of infant growth.

• Increase the number of infants and toddlers that have a strong start for healthy and safe
lives. (Infants and toddler, ages 0-3 years).
Grow Safe and Strong:
• CDC also works for development of children to grow safe and healthy
• Increase the number of children who grow up healthy, safe, and ready to learn
(children, ages 4-11 years).
Achieve Healthy Independence:
• Increase the number of adolescents who are prepared to be healthy, safe, independent,
and productive members of society. (Adolescents,ages12-19years).
• Live a Healthy, Productive and Satisfying Life:
• Increases the number of adults who are healthy and able to participate fully in life
activities and enter their later years with optimum health. (Adults, ages 20-64 years).
Live Better, Longer:
• Increase the number of older adults who live longer, high quality, productive, and
independent lives. (Older Adults, ages 65 and over).
2. Healthy People in Healthy Places
Introduction: The places where people live, work, learn, and play will protect and promote their
health and safety specially those at greater risk of health disparities.
Healthy Communities: Increase the number of communities that protect and promote health
and safety and prevent illness and injury in all their members.
Healthy Homes: Protect and promote health through safe and healthy home environments.
Healthy Schools: Increase the number of schools that protect and promote the development,
health, and safety of all students and staff.
Healthy Workplaces: Promote and protect the health and safety of people who work by
preventing workplace related fatalities, illnesses, injuries, and personal health risks.
Healthy Healthcare Settings: Increase the number of healthcare settings that provide safe,
effective and satisfying patient care.
Healthy Institution: Increase the number of institutions that provide safe, healthy, and
equitable environments for their residents, clients or inmates.
Healthy Travel and Recreation: Ensure that environments enhance health and prevent illness
and injury during travel and recreation.

3. People Prepared for Emerging Health Threats

Introduction: People in all communities will be protected from infectious, occupational,
environmental and terrorist threats.
Preparedness goals will be developed to address scenarios that include natural and intentional
threats. The first round of these will include influenza, anthrax, plague, emerging infections,
toxic chemical exposure, and radiation exposure.

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Prevention: Increase the use and development of interventions known to prevent human
illness from chemical, biological, radiological agents, and naturally occurring health threats.
Detection and Reporting: Decrease the time needed to classify health events as terrorism or
naturally occurring in partnership with other agencies.
Decrease the time needed to detect and report chemicals, biological radiological agents in
tissue, food or environmental samples that causes threat to the public’s health.
Improve the timeliness and accuracy of communications regarding threats to the public’s
health.
Investigation: Decrease the time to identify causes, risk factors and appropriate interventions
for those affected by threat to the public’s health.
Control: Decrease the time needed to provide counter measures and health guidance to those
affected by threat to the health.
Recover: Decrease the time needed to restore health services and environmental safety to
prevent levels.
Improve the long term follow up provided to those affected by threat to the public’s health.
Improve: Decrease the time needed to implement recommendations from after action reports
following threat to the public’s health.

4. Healthy People In A Healthy World

Introduction: People around the world will live safer, healthier and longer lives through health
promotion, health protection, and health diplomacy.
Health Promotion: Global health will improve by sharing knowledge, tools and other resources
with people and partners around the world.
Health Protection: Americans at home and aboard will be protection from health threats
through a transnational prevention, detection and response network.
Health Diplomacy: CDC and the United States Government will be a trusted and effective
resource for health development and health protection around the globe.

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National Health Policy

Establishment: National health policy was established on 11 June 2001 by ministry of health
with national vision “HEALTH FOR ALL”.
Key features:
1. Implementing strategy of protecting people against hazard diseases, of promoting
public health, and of upgrading curative care facilities.
2. Enhancing equity, efficiency and effectiveness in the health sector .
3. Provincial Governments for improving health infrastructure and healthcare services.
4. The Federal Government will continue to play a supportive and coordinative role in key
areas like communicable disease control programs.

Ten Specific Areas of Reforms

1. To Reduce the Widespread Prevalence of Communicable Diseases
• Implementation Modalities: The Federal Government will assist in planning,
monitoring, evaluation, training and research activities. Provincial Governments
will undertake service delivery
a. EPI will introduce Hepatitis-B vaccine with effect from July, 2001.
b. Cold-chain equipment will be strengthened over the next 5 years.
c. Polio day will be observed annually to ensure WHO Certification by 2005.
d. Immunizing mothers against Neonatal Tetanus will be implemented in 57
selected Districts. Introduced DOTS (Directly Observed Treatment Short Course)
against Tuberculosis.
e. Malaria control program focusing on malaria microscopy and early
diagnosis with prompt treatment.
f. Prevention of HIV transmission through health education, surveillance
system early detection of Sexually Transmitted Infections.
• Targets and Time Frame:
a. Immunization coverage will be increased to 85% by 2003-2004 and full
coverage reached by 2010.
b. Polio cases will be reduced to less than 30 by end 2003 with WHO Certification achieved
by 2005.
c. Hepatitis-B Coverage will be available in 70% of districts by 2002 and 100% by 2003
providing 17.3 million doses annually over next 5 years.
d. Full DOTs coverage of TB will be achieved in all districts of the country by 2005.
The detection rate will be 70% and cure rate 85% by then. It will reduce TB prevalence
by 60% by 2010.
e. Malaria cases also will be reduced by 50% by 2010. Plasmodium Falciparum cases will be
kept at less than 40% of all malaria infections.

2. To Address Inadequacies in Primary/Secondary Health Care Services

The main inadequacies at BHU/RHC are the deficient state of equipment and medical
personnel, absenteeism. At the district/tehsil level (emergency care, surgical services,
anesthesia and laboratory facilities)

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• Implementation Modalities
a. 58,000 Lady Health Workers and 13,000 Village-based Family Planning Workers will
be utilized to cover the un-served population.
b. Improvement of District/Tehsil Hospitals. A minimum of 6 specialties (Medicine,
Surgery, Pediatrics, Gynae, ENT and Ophthalmology) will be made available at these
facilities.
c. District and Tehsil Hospitals will be reviewed and upgrade.
• Targets and Time Frame
a. 100,000 Family Health Workers will be recruited and trained by 2005 .
b. Rationalization study of RHCs/BHUs will be completed by 2002.
c. 58 District and 137 Tehsil Hospitals will be upgraded over a period of 5 years.

3. To Remove Professional and Managerial Deficiencies in District Health System

The ineffectiveness of the district health office is due to lack in essential qualifications and
management skills. Vacant post of male and female doctors and paramedics.
• Implementation Modalities
a. Adequate financial and administrative powers will be given to the DHO.
b. DHOs will be appointed on merit-based criteria, with a Masters in Public Health.
c. Improve the working/living conditions of doctors, nurses and paramedics in rural areas.
Rural Area Compensatory Allowance, Non-Practising Allowance, Anaesthesia Allowance
and Nursing Allowance.
d. After completing House Job will have to be posted on vacant posts in primary and
secondary facilities for a minimum period of one year. MOs cadre will serve for two
years to become eligible for promotion from BPS-17 to BPS-18. Specialists in non-
teaching hospitals will serve for a minimum period of 2 years in rural medical service for
promotion from BPS-18 to BPS-19.

4.To Promote Gender Equity in the Health Sector

• Implementation Modalities
a. Focused reproductive health services, enhancing child survival rates.
b. Expanding the Lady Health Workers Program at the grassroots level.
c. The establishment of ''Women-Friendly-Hospitals" in 20 Districts of Pakistan.
d. More job opportunities will be provided to women as WMO, Nurses, LHWs,
Midwifes and LHVs .
• Targets and Time Frame
a. By 2005, 100,000 Female Health Workers will be duly trained as
community workers and deployed in the field.
b. The nurses will increase from 23,000 to 35,000 by 2005 and 55,000 by 2010.

5.To Bridge the Basic Nutrition Gaps in the Target-population

• Implementation Modalities:
a. Vitamin-A Supplementation with OPV will be provided to all under-5 children.
b. Provision of iodized salt , fortified flour, vegetable oil, Iron and Vitamin-A.

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c. Provision of Health Nutrition Package through 100,000 Female Health

Workers which includes Vitamin-B Complex Syrup, Ferrous Fumarate and Folic Acid
to deserving persons.
d. Mass awareness/health education programs will be run through multi-media.
• Targets/Time Frame
a. Reduce Low Birth Weight babies from 25% in 2001 to 12% by 2010.
b. Vitamin-A Supplementation to approximately 30 million children a year.

6. To Correct Urban Bias in the Health Sector

• Implementation Modalities
a. Every Medical College, both in the public and private sectors will be required to
adopt at least one district /tehsil hospital or primary health facility in addition to
the Teaching Hospital affiliated to it.
b. The compulsory rural service of new medical graduates.

7. To introduce required Regulation in the Private Medical Sector

• Implementation Modalities
a. Draft laws/regulations on accreditation of private hospitals, clinics and labor
atories have been circulated to all Provincial Governments.
b. A law to ensure that private medical colleges adhere to PMDC approved
standards. The existing law on Tibb and Homeopathy will be amended to recognize
degree and postgraduate level courses in Traditional Medicine.
c. Each Provincial Government will develop an appropriate framework
for encouraging private-public cooperation in the health sector.

8. To Create Mass Awareness in Public Health Matters

• Implementation Strategy
a. Optimal use will be made of multimedia to disseminate health and
nutrition education.
b. TV/Radio Authorities will be asked to air programs dedicated to health
and nutrition, Anti-TB, Malaria and HIV-AIDS.
c. A Nutrition Cell will be established in the Ministry of Health through the Nutrition
Project with required nutrition experts and mass communication specialists.
d. Greater participation of NGOs and civil society in Mass Awareness programs.

9. Improvements in the Drug Sector with a View to Ensuring the Availability, Affordability and
Quality of Drugs in the Country
• Implementation Modalities
a. Local manufacture of required drugs both by multinational & national companies
will be encourage.
b. Imported drugs found to be in chronic short supply will be prioritized for
local manufacturing.
c. Balanced and fair pricing policies will be pursued.

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d. The drug control organization capacity for market surveillance and quality control
will be strengthened by posting additional staff and upgrading laboratories at
Karachi, NIH Islamabad.
e. The availability of life-saving drugs will be monitored in the market, the provision of
free life-saving drugs in the public sector hospitals will be limited to areas like
emergency/casualty.

10. Capacity Building for Health Policy Monitoring in the Ministry of Health
• Implementation Modalities
a. A Policy Analysis and Research Unit is proposed to be set up in the Ministry of
Health. This Unit will also be responsible for monitoring the progress of Health
Policy implementation in the key areas for submission to the Chief Executive/
Federal Cabinet periodically. The unit will also provide technical facilities to
Provincial Governments on need basis.

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Pharmacoeconomics
[ Pharmacoeconomic Modeling And Interpretation ]
Definition: Pharmacoeconomics identifies, measures, and compares the costs and consequences of drug
therapy to health care Systems and society.
OR
Pharmacoeconomics is the application of economic analysis to the use of pharmaceutical products,
services and programs, which frequently focuses on the costs (inputs) and consequences (outcomes) of the
use.
OR
Health economics is the science of assessing cost and benefits of healthcare.
OR
Pharmacoeconomics is a branch of health economics which compares the value of one drug or a drug
therapy to another.

First Published: Term Pharmacoeconomics was first published in 1986 by Townsend

Need of Pharmacoeconomic Analysis:

1. Help to decide which drug to develop.
2. To estimate and understand the full impact of new therapy.
3. To make an informed decision regarding appropriate use of drug which have been developed.

Pharmacoeconomic Analysis: Pharmacoeconomic analysis involves…

1. Identifying and measuring costs
2. Identifying and measuring consequences
3. Choosing a perspective

1. Cost:
Definition: The value of the resources consumed by a program or drug therapy of interest.
Costs are categorized as:
i. Direct medical costs.
ii. Direct nonmedical costs
iii. Indirect medical costs
iv. Intangible Costs
i. Direct Medical Costs: The costs incurred for medical products and services used to prevent,
detect, and/or treat a disease.
Examples of these costs include drugs, medical supplies and equipment, laboratory and
diagnostic tests, hospitalizations, and physician visits.
ii. Direct nonmedical costs: Any costs for nonmedical services that are results of illness or disease
but do not involve purchasing medical services.
These costs are consumed to purchase services other than medical care.
Examples: Include resources spent by patients for transportation to and from healthcare
facilities, extra trips to the emergency department, child or family care expenses, special diets,
and various other out-of-pocket expenses.
iii. Indirect medical costs: The costs of reduced productivity (e.g, morbidity and mortality costs).
Indirect costs are costs that result from morbidity and mortality and are an important source of
resource consumption, especially from the perspective of the patient.
Morbidity costs are costs incurred from missing work (i.e., lost productivity)
Mortality costs represent the years lost as result of premature death.
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iv. Intangible costs: Those of other nonfinancial outcomes of disease and medical care.
Examples include pain, suffering, inconvenience, and grief, and these are difficult to measure
quantitatively and impossible to measure in terms of economic or financial costs.
• In pharmacoeconomic analyses, frequently intangible costs are identified but not quantified
formally.
Direct Costs = Direct Medical Costs + Direct non-medical costs
Indirect Costs = Morbidity costs + Mortality costs
Total costs = Direct costs + Indirect costs + Intangible costs

2. Consequence:
Introduction: The effects, outputs, or outcomes of the program of drug therapy of interest. Similar
to costs, the outcomes or consequences of a disease and its treatment are an equally important
component of pharmacoeconomic analyses. Consequences are categorized as…
i. Clinical outcomes are the medical events that occur as a result of disease or treatment (e.g.,
safety and efficacy end points).
ii. Economic outcomes are the direct, indirect, and intangible costs compared with the
consequences of medical treatment alternatives.
iii. Humanistic outcomes are the consequences of disease or treatment on patient functional status
or quality of life along several dimensions (e.g., physical function, social function, general health
and well-being, and life satisfaction).
Assessing the economic, clinical, and humanistic outcomes (ECHO) associated with a treatment alternative
provides a complete model for decision making.
These consequences (outcomes) can be further categorized as
i. Positive: An example of a positive outcome is a desired effect of a drug (efficacy or effectiveness
measure).
ii. Negative: Example of negative outcome is ADR or toxicity of a drug.

3. Perspective:
Conduction from Different Perspective: A Pharmacoeconomic study may be conducted from
several different perspectives, each of which includes slightly different costs. These perspectives
may measure costs to society, the health care system, insurance, the government, patients and
their families.
Broadest Perspective: The perspective of society is the broadest of all perspectives because it is the
only one that considers the benefit to society as a whole. Theoretically, all direct and indirect costs
are included in an economic evaluation performed from a societal perspective.
• Patient perspective :Portion of cost not covered by Insurance.
• Provider perspective: e.g., Hospitals- Direct costs
• Payer perspective: e.g., Insurance companies, employers, or the government.
• Society perspective: All direct and indirect costs.

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Pharmacoeconomic methodologies
The methods are all similar in the way they measure cost (in dollars) and different in their measurement of
outcomes. The Economic evaluation methods are as follows.
1. Cost-of-illness (COI) evaluation
2. Cost Minimization Analysis (CMA)
3. Cost Benefit Analysis (CBA)
4. Cost Utility Analysis (CUA)
5. Cost Effectiveness Analysis (CEA)

1. Cost-of-illness (COI) evaluation:

Introduction: A cost-of-illness (COI) evaluation identifies and estimates the overall cost of a
particular disease for defined population.
This evaluation method is often referred to as burden of illness.

It involves measuring the direct and indirect costs attributable to a specific disease such as
diabetes, mental disorders or cancer.
COI evaluation is not used to compare competing treatment alternatives but to provide an
estimation of the financial burden of a disease.
For example if we want to estimate the cost of diabetes for six months in KTH. This includes both
direct and indirect cost attributed to diabetes i-e Cost of consultation, cost of hospitalization, cost
of drugs and investigations, cost of food and travelling. Indirect cost of diabetic patients includes
lost working days.

The costs of various diseases, including peptic ulcer disease, mental disorders, and cancer, in the
United States have been estimated. By successfully identifying the direct and indirect costs of an
illness, one can determine the relative value of a treatment or prevention strategy.

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2. Cost Minimization Analysis (CMA):

Introduction: Cost-minimization analysis (CMA) involves the determination of the least costly
alternative when comparing two or more treatment alternatives.

Alternatives must have an assumed or demonstrated equivalency: With CMA, the alternatives
must have an assumed or demonstrated equivalency in safety and efficacy (i.e., the two
alternatives must be equivalent therapeutically) . Once this equivalency in outcome is confirmed,
the costs can be identified, measured, and compared in monetary units (dollars).

Straightforward and simple method: CMA is a relatively straightforward and simple method for
comparing competing programs or treatment alternatives as long as the therapeutic equivalence of
the alternatives being compared has been established. If no evidence exists to support this, then a
more comprehensive method such as cost-effectiveness analysis should be employed.
Remember, CMA shows only a “cost savings” of one program or treatment over another.

For example: If drugs A and B are antiulcer agents and have been documented as equivalent in
efficacy and incidence of adverse drug reactions (ADRs), then the costs of using these drugs could
be compared using CMA. These costs should extend beyond a comparison of drug acquisition costs
and include costs of drug preparation (pharmacist and technician time), administration (nursing
time), and storage.
Another example would be prescribing a generic preparation instead of the brand leader.

3. Cost Benefit Analysis (CBA)

Introduction: Cost-benefit analysis (CBA) is a method that allows for the identification,
measurement, and comparison of the benefits and costs of a program or treatment alternative. The
benefits realized from a program or treatment alternative are compared with the costs of providing
it.
Convert Into Equivalent Dollar: Both the costs and the benefits are measured and converted into
equivalent dollars in the year in which they will occur.
For example, when a clinical pharmacy service is competing for institutional resources, CBA can
provide data to document that the service yields a high return on investment compared with other
institutional services competing for the same resources.

Costs and benefits are expressed as a ratio: These costs and benefits are expressed as a ratio (a
benefit to cost ratio). If the B/C ratio is greater than 1, the program or treatment is of value. The
benefits realized by the program or treatment alternative outweigh the cost of providing it.

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4. Cost Utility Analysis (CUA)

Introduction: Cost-utility analysis (CUA) is a method for comparing treatment alternatives that
integrates patient preferences and HRQOL. CUA can compare cost, quality, and the quantity of
patient-years.

Cost & Outcome Measuring: Cost is measured in dollars, and therapeutic outcome is measured in
patient-weighted utilities in terms of quality adjusted life years (QALYs) gained rather than in
physical units.

Appropriate Method: CUA is the most appropriate method to use when comparing programs and
treatment alternatives that are life extending with serious side effects (e.g., cancer
chemotherapy),those which produce reductions in morbidity rather than mortality.

Employed Less Frequently: CUA is employed less frequently than other economic evaluation
methods because of a lack of agreement on measuring utilities, difficulty comparing QALYs across
patients and populations, and difficulty quantifying patient preferences.

5. Cost Effectiveness Analysis (CEA)

Introduction: Cost-effectiveness analysis (CEA) is a way of summarizing the health benefits and
resources used by competing health care programs so that policymakers can choose among them.

Involves comparing programs or treatment alternatives: CEA involves comparing programs or

treatment alternatives with different safety and efficacy profiles.

Cost & Outcome Measuring: Cost is measured in dollars, and outcomes are measured in terms of
obtaining a specific therapeutic outcome in natural units (e.g years of life saved, ulcers healed).

Useful In Balancing Cost: CEA is particularly useful in balancing cost with patient outcome,
determining which treatment alternatives represent the best health outcome per dollar spent, and

Department Of Pharmacy | University of Peshawar

 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

deciding when it is appropriate to measure outcome in terms of obtaining a specific therapeutic

objective.

CEA may provide valuable data: In addition, CEA may provide valuable data to support drug policy,
formulary management, and individual patient treatment decisions. Globally, CEA is being used to
set public policies regarding the use of pharmaceutical products (national formularies) in countries
such as Australia, New Zealand, and Canada.

Compare Therapy: It compares therapies with qualitatively similar outcomes in a particular

therapeutic area.
For instance, in severe reflux esophagitis, using a proton pump inhibitor compared to using H2
blockers.

CEA does not allow comparisons to be made between two totally different areas of medicine with
different outcomes.

Results Expressed: The results of CEA are expressed as a ratio either as an average cost-
effectiveness ratio (ACER).

ACER: An ACER represents the total cost of a program or treatment alternative divided by its clinical
outcome to yield a ratio representing the dollar cost per specific clinical outcome gained,
independent of comparators.
Average cost effectiveness (ACER) = Net Cost / Net Health Benefit

Table V Summary of Pharmacoeconomic methodologies:

Key:
• CBA: Cost-benefit analysis
• CEA: Cost-effectiveness analysis
• CMA: Cost-minimization analysis
• COI: Cost-of-illness evaluation
• CUA: Cost-utility Analysis
• QOL: Quality of life; QALY / Quality-adjusted life-year.

Department Of Pharmacy | University of Peshawar

Patient Education and Counselling

Dr. Rabeea Sharif

Lecturer, Pharmacy department

UOP.

Patient Assessment
• The collection of data about an individual’s health state, the purpose of which is to make a
judgment or diagnose.

• Patient assessment is the process through which the pharmacist evaluate the patient
information (both objective and subjective) that was gathered from the patient and other
sources (e.g. drug therapy profile, medical record, etc.)

• The patient interview contains the subjective data, whereas the physical examination is geared
towards supplementary this information with objective finding.

• The finding of clinical signs and symptoms will then aid in the overall patient assessment and
outcomes.

Patient assessment in pharmacy perspective

• The pharmacy profession provides many levels of medical care. The challenges for professions
are to advance the patient assessment skills of pharmacists and to show their worth through
improved patient outcomes.Some pharmacist currently administer vaccinations, order
laboratory tests, and engage in disease management activities in which they perform physical
assessments and even make diagnosis of certain clinical conditions. In fact, pharmacists in the
community setting have used their skills in patient’s assessments for years in dispensing OTC
products.Pharmacists can use assessments skills together important clinical data that may aid in
referral, treatment or other primary care pathways.

• When a patient presents to the pharmacists with sudden symptoms of hypoglycemia, for
example, patient interview skills, a general survey, and a limited physical examination may be
used to obtain a clinical picture of illness. In turn, the pharmacists may make an initial judgment
on the patient’s condition that may require immediate referral and/or treatment, or other
primary care pathways.

• A pharmacist properly trained in assessing extra ocular muscle function, for instance, may be
able to detect phenytoin toxicity by observing excessive nystagmus during the examination. No
diagnosis is necessary, but a decision regarding a proper referral or serum drug level
measurement may be appropriate.

• Patient with diabetes who has not been seen by his or her primary care provider for 2 years but
continues to get medication refilled. The scenario increases the value of pharmacist’s physical
examination skills. If the appropriate environment in attainable (an examination room), the
pharmacist may ask to do a foot assessment. If trained well examination techniques, the
 pharmacist may be able to detect early signs of ulceration, callus, deformity, or peripheral
neuropathy.

How to Do Patient Assessment

1. Patient interview

• The pharmacists usually goes through a series of questions to identify and elaborate on the
problem.

• The set of 3 prime assessment questions in a medication consultation session is equally

important to learn for an initial patient interview,

• Successful and experienced pharmacists have found that beginning a patient interaction with
even a simple open ended question such as “What can I help you today?” establishes good
pharmacists-patient rapport.

• After receiving the patient answer, the follow-up statement can be,” Tell me more about it”.

• The pharmacist can then go into what can be called the “Basic Seven ”, an open ended line of
questioning to elicit a more detailed explanation. Following the “Basic Seven” line of
questioning, it is appropriate to summarize what the patient has reported to verify this subject
information with the patient. At this point, the pharmacist may choose to make an assessment
or proceed with more steps, such as a history, a review of systems, a general survey, and a
physical examination.

• Basic Seven lines of Questioning

The question about location, quality, quantity, timing, setting, modifying factors and associated
symptoms are called seven lines of questioning .
2. Physical examination

• When preparing for a physical examination, pharmacists should make sure that introduction
take place and that the patient is aware of the procedures.

• When initiating physical examination it may be useful for the pharmacists to ask following four
questions

i. What am I examining?

ii. How do I examine it?

iii. What am I looking for?

iv. What do I do about it?

i. What am I examining?

• The first question addresses 2 items. First, it assembles data from the patient interview into the
initial assessment possibilities. It identifies the area(s) of the body on which the pharmacist may
want to follow up with a physical examination.

• Second, it suggests an anatomical perspective and forces the pharmacists to focus on just that
anatomy.

ii. How do I examine it?

• The question “How do I examine it?” brings into consideration the various techniques, tests, and
more focused parts of the general physical examination. They include the basic techniques of
 • Inspection

• palpation

• Percussion

• auscultation

iii. What am I looking for?

• The third question,” What am I looking for?” is yet another open ended question that will focus
the pharmacist’s thought physical process. What are the possible causes of this condition? What
are the signs associated with them?

iv. What do I do about it?

• Fourth and final question, many factors are taken into consideration, including scope of practice,
urgency of condition.

• The answer to the question requires assimilation of the finding (signs and symptoms from the
assessment) with the pharmacist’s skills and the formulation of a decision.

DOCUMENTATION

• Documentation has both clinical and medical-legal implications. After documenting the patient
interviews and physical assessment, the pharmacist must remember to continue by describing a
plan of follow-up care(if needed).
 • It is an essential piece of the puzzle. Any provider should be able to look at the note and know
exactly what was accomplished, along with the appropriate follow-up. One should keep in
mind,” if it is not documented, it did not happen.

• Provides a permanent record of patient information.

• Provide evidence of pharmaceutical care activities by the pharmacist.

• Communicates essential information to other pharmacists and health care professionals.

• Serves as a legal record of patient care that was provided.

SUMMARY

• The profession of pharmacy is expending to include primary care delivered by pharmacists. In

many communities in the United States, the pharmacist may be the only locally available
medical professional.

• Pharmacists are now involved in many facts of the patients-centered health care system and can
utilize their unique knowledge based to improve outcomes.

• By building on this knowledge base, and obtaining expended training in patient assessment,
pharmacists can become more involved in a variety of roles. The most important outcomes of
these expended roles will be the optimization of patient.

Counseling
• Counseling is giving advice and making certain that the advice is understood after listening
sympathetically to the patient‘s doubts, problems or viewpoint.

• Giving clients the opportunity to explore, discover and clarify ways of living more resourcefully
and towards greater well being. It is a key competency element of Pharmaceutical care process

Patient’s compliance

Patient’s compliance may be defined as the extent to which a patient takes or uses their medication, in
accordance with the medical or health advice given.

Patient’s non- compliance

• Patient non compliance from doctor point of view may extend to the failure to keep an
appointment and non-participation in a screening programme which may relate back to a
patient’s behavior and acceptance of health care advice.

• Patient compliance from pharmacist’s point of view is largely dependent upon the
communication of information necessary for the correct use of medication in association with
supportive advice or counseling.
Communication

• Communication may be defined as the means by which information is passed from a sender to a
receiver. It is important to ensure that information received (understood) is the same as that
sent.

• Exchange of message between people for the purpose of achieving common meaning.

• Verbal communication:

Verbal communication includes use of actual words for communication. They denote the literary
meaning of actual words. Word selection.

• No n -‐ v e r b a l communication:

A large measure of how you relate to others and how they relate to you is not based on what is said ,
but on what is not said. Words normally express ideas, whereas non verbal expressions convey attitudes
and emotions. It involve that how the message is said

• Body language

• Gestures

• Facial expression

• Physical contact

• Body posture [closed position, feet position]

Characteristics of communication

• The purpose of communication is not just to deliver a message but to effect a change in the
recipient, in respect of his knowledge his attitude and eventually his behavior.

• The value of communication is to be judged not on its purpose or content, but on its effect on
the recipient.

• Communication must be matched to the knowledge, social background, interest, purposes and
needs of the recipient.

• Communication is effected not only by words, which must have the same meaning for giver and
receiver, but also by attitude, expressions and gestures.

• If communication is to change behavior, the required change in the recipient must be seen by
him to have more advantages than drawbacks.

• To make sure that communication has succeeded, information about its effect, both immediate
and subsequent, is needed

• Communication demands efforts, thought, time and often money.

Patient-pharmacist communication
Communication has three essential parts

i. Communicator or sender (Pharmacist)

ii. Communicatee or receiver (Patient)

iii. Message transacted between two (Information)

• Communicator has to use proper language, signs, symbols, examples and reinforcing techniques
to make message easily, fully and correctly understand by the patient.

• Effective communication requires complete understanding of patient by the pharmacist.

Information which should be considered as important by the pharmacist to convey to the patient

• The pharmaceutical form of the medicine and its identity.

• The intended use and expected action.

• The method of use.

• The dose or amount to be use.

• The frequency and correct time of administration or use.

• The maximum dose in 24 hours.

• The duration of treatment.

• Side effects to be minimized by the patient.

• Side effect s to be referred to the doctor.

• Medicine, food or activities the patient has to avoid during treatment.

• Action to be taken in the event of a missed dose.

• The storage of medication

• The discarding of unused medicine beyond a specified expiry date.

• The aim of treatment.

How to use the inhaler

To get the maximum benefit from your inhaler, make sure that you follow the these simple instruction

• Always shake the inhaler before use.

• Breath out as fully as you can just before placing the mouth piece in position.

• Tilt your head back slightly so that the medication ends up in your lungs. Not your mouth.
 • Now suck in air (if your inhaler is the pressurized type, you should spray it at the same time),
and continue to inhale so that the medication is taken deep into your lungs

• Hold your breath for as long as possible then breathe out slowly.

• It may help to first go through this procedure, without activating the inhaler, until you feel
confident about it.

• Always make sure that the inhaler is thoroughly dry before and dried after use. The mouthpiece
may be detached and washed after use but DRY THOROUGHLY

• Keep all medicines out of reach of children

How to use your eye ointment

• First wash your hands then gently clean the eyelids

• Next , gently pull the lower lid downwards, and direct your gaze upwards

• Carefully place a thin line of ointment along the inside of the lower eyelid. Avoid touching the
eyelid with the tube nozzle if possible

• Next close your eye, and move the eyeball from side to side. Gentle massage will also help to
spread the ointment

• Initially your vision may be blurred, but will soon be cleared by blinking. DO NOT RUB THE EYE
AT THIS STAGE

• Be sure to complete the course of treatment as directed

• Do not share the eye ointment with anyone else

• Store in cool dark place

• KEEP ALL MEDICINES OUT OF THE REACH OF THE REACH OF CHILDREN

Patient Counseling :
Dispensing process, to ensure that the patient receives and understands important
information. For example

• The name of the drug and the purpose of the medication

• To identify potential dispensing errors.

• Safe and effective drug therapy depends on patients being well informed about their
medication.

• Lack of information may lead to the therapeutic failure, adverse effects, additional expenditure
on investigations and treatment or even hospitalization.

• The information is usually given verbally , but may be supplemented with written materials.
 • During counseling, the pharmacist should assess the patients understandings about his or her
illness and treatment, and provide individualized advise and information which will assist the
patient to take their medication in the most safe and effective manner.

• To provide accurate advice and information , the pharmacist should be familiar with the
pathophysiology and therapeutics of the patients disease.

• Pharmacist should not only advise both the doctor and patients about prescribed medicines but
also

• Monitor adverse drug reactions

• Consult with doctor about prescribing and dispensing procedure

• Advise members of the public about ‘Over the Counter Drugs’

• Advice to patient in response to description of symptom

• Take part in health education

• Take part in diagnostic screening

Skills Required for Patients Counselling

1. Professional knowledge

• Provide drug education to the patient in a manner that the patient can understand and use to
benefit their therapy

• Convey accurate information concerning the patient’s medication therapy including medication,
indication, dosage form, route, duration, precautions, interactions, missed dose procedures,
storage recommendations, and specific techniques for self monitoring

• Discuss any potential therapeutic problems

• Correct any incorrect information relayed by the patient

• Recognize compliance problems and increase adherence

2. Communication Skills:

• Display effective verbal communication skills

• Use an interactive approach to assessing and verifying patient understanding through the use of
o p e n ‐ e n d e d questions

• Display effective nonverbal communication

• Use language the patient will be able to understand

• Demonstrate effective counseling techniques

3. Patient Interaction:

• Communicate to the patient why the counseling session and included information is important
 • Systematically think through problems and present medication information in a logical order

Factors effecting patient counseling

1. Patient education

• Patient education is the most important variable affecting compliance. Information provided to
the patient concerning medication must be understood. Faulty comprehension has been
reported to contribute to some two-third of compliance problem.

• Most patient are only able to recall about a third of what has been told to them and it
recommended that when counseling the more important points should be given initially and
finally as recall of interviewing items.

• The patient is too fearful or nervous to ask questions.

• The patient is unwilling to ask questions for fearing of appearing ignorant.

• The patient is confused by spate of medical terminology.

• The patient does not appreciate the importance of information conveyed.

• The doctor or pharmacist lack the time or devote insufficient time to explain instructions
adequately to the patient.

• The consultation is awkwardly terminated, e.g prescriber writing the prescription or the
pharmacist placing the medication in a bag and handing it to the patient.

• The pharmacist has the opportunity and responsibility, where such deficiencies exist in the
patient-doctor relationship, to ensure that the patient understands all immediately relevant
information relating to the prescribed medication regimen. The pharmacist should use suitable
verbal, written or audiovisual communication techniques in order to inform, educate or
reinforce the knowledge of the patient about his/ her medication.

2. Environment

• Space, furnishing, privacy and noise can be significant influences. Even a reduction in light at one
end can convey an impression of greater privacy.

• The counter itself can be a serious barrier and inhibit the patient from being receptive and
information.

• Pharmacist who have established counseling facilities engender and experience a heightened
awareness by the public of the pharmacist professional contribution to primary health care.

3. Personal

• To most people, a clean white lab coat or uniform or smart business-like dress gives a
professional image which helps to put the patient at ease and conveys confidence.

• The pharmacist behavior will also subconsciously as well as consciously contribute to the ease
and effectiveness of communication and counseling.
• Both verbal and nonverbal communications are effective.

• Physical positioning is important; the pharmacist should be a comfortable distance from the
patient, not too close so as to threaten him and not too far away to make a quite conversation
ineffective.

• The pharmacist voice level should keep low and personal. Avoid speaking down to the patient
while at the same time trying to speak in a manner, and using a vocabulary, which will be
understood. Eye contact is also important but should not be too excessive such that the patient
feels both stared at and uncomfortable.

• Both verbal tics for example, repeatedly saying ‘you know’ or ‘OK’ and physical tics, such
repeatedly scratching the nose or ear, should be avoided as they are irritating and distract the
concentration of the patient.

Patient Education
• Health information is complex, and patients can easily become confused. Without the proper
educational resources, doctors, clinical trial professionals, pharmaceutical reps, and other health
educators may find teaching patients about medical issues difficult.

• To help, we have put together our top five strategies for educating patients effectively.

• TOP 5 TIPS FOR BETTER PATIENT EDUCATION

1. Demonstrate Interest and Establish Trust

• When teaching patients about medical issues, it is important first to establish trust. Show them
that you are interested in more than just their physical well-being. Creating a rapport with your
patients will make it easier for them to hear your medical advice later, making it less likely that
they will tune out your words.

Some ways that you can demonstrate your interest in patients include:

• Ask how things are going with their work, hobby, home life, etc.

• See if they have been anywhere interesting recently or if they have upcoming travel plans.

• Find out if they have read any good books or watched any good TV shows or movies recently.

• Patients who feel cared for and heard will be more receptive to education provided to them. In
addition, investing a minute or two of non-medical conversation can help put patients at ease,
making them open up more about any problems, medical issues or worries they might be facing.
It can even give you clues about your patient’s preferred style of learning, which leads us to the
next strategy.

2. Adapt to the Patient’s Learning Style

• Even patients who want to learn may have difficulty doing so if the information is not presented
in a way conducive to their style of learning. Barriers can include language, culture, level of
 formal education, and even misinformation that patient received from a family member, friend,
or the internet.

• Some patients will already know what kind of learner they are (visual, auditory, etc.) and might
be able to tell you how they learn best. Remember: Teaching patients requires taking the time
to learn how your patients learn will improve patient outcomes in the long run.

3. Use Innovative and Age-Appropriate Education Materials

• Patient education materials come in all forms. Newer, more innovative formats are finding their
ways into the health education space, giving patients more opportunities to learn in fun and
unique ways. Some of these new formats include comic books and podcasts.

• Of course, you can still use the traditional tri-fold pamphlets or videos in the waiting room.
These do have some value, but fresh, individualized approaches to patient education are more
likely to be effective in the long run.

4. Ask Patients to Explain Information Back to You

• Far too often, patients will say that they understand what their doctor told them even if they
really don’t! The reasons why a patient may say they understand something when they don’t
are numerous:

• They might be in shock or overwhelmed by a diagnosis and just want to leave.

• They might be too embarrassed to admit that they don’t really understand it.

• They might genuinely think they understand it, but realize later they forgot some important
piece.

• One way to prevent patients leaving before they fully grasp what you are telling them is to have
them repeat the information back to you. When doing so, you can correct details they get wrong
or fill in gaps, helping to reinforce the information.

• If you suspect your patient is simply repeating what you said without actually understanding it,
you can also ask him or her to re-word it in a way that would help a family member or friend
understand the information.

5. Educate the Patient’s Family or Caretaker

• Two minds—and two memories—are better than one. Inviting a family member, friend, or
caretaker to join the education session will help to ensure that the medical information will be
retained. This is especially important for young children or individuals who have a learning
disability or special education needs.
• Inviting a caregiver to join the conversation can create a feeling of support and community. This
may be especially important when decision-making time comes, since then there will be at least
one other person who understands the issues at hand.
 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

MEDICAL COMLICATIONS OF DRUG TAKING

Introduction: Illicit drug uses associated with a multitude of serious adverse health, social and
economic consequences. Health complications of injecting drug use threaten individual's drug users,
their partners and families. In the case of HIV, complications of injecting drug use threaten the general
community.

Reasons: Complication of drugs use may be due to:

1. Particular pharmacological properties of a drug being consumed, related to the method of
administration
2. Caused by associated factors of drugs such as contamination or combination with other mood
altering substances taken at the same time.

Examples:
1. The sedative effect of opioids (such as heroin or morphine) which can cause death from
respiratory depression is an example of drug specific complication.
2. Amphetamine and cocaine, which are both stimulants, can induce a temporary psychotic state.
3. Benzodiazepines and barbiturates cause sedation and sometimes during withdrawal rebound
hyperactivity including convulsions can occur.

HEALTH OUTCOMES
1. MORTALITY RATES:
Estimate: The pooled standardized mortality rate of injecting drug use was estimated in 12
studies from several developed countries carried out between 1968 and 1993 to be 13.2.
13 times higher: This means that the mortality rate observed among injecting drug users is
about 13 times higher than expected for age and sex matched peers with no history of injecting
drug use.
1% per annum: In part of the world where the prevalence of HIV infection among injecting drug
users is still low, the mortality of injecting drug use is about 1% per annum.
2. MORBIDITY RATES:
Indirect Relation: Injecting drug use is also associated with considerable morbidity. Most of the
morbidity is indirectly related to drug injecting, Injecting drug use is often accompanied by
hazardous consumption of other legal and illegal drugs including
1. Alcohol 2. Cigarettes 3. Benzodiazepines,
4. Barbiturates 5. Amphetamine 6. Cocaine 7.Cannabis.
Illicit drug use is also often associated with other factors which independently contribute to
excess morbidity (and mortality) including:
1. Low socio economic status 2. Squalid living conditions,
3. An inadequate and irregular diet 4. Limited action,
5. High rates of unemployment 6. History of incarceration
7. Significant debt 8. Membership of minority ethnic groups.
Morbidity is more difficult to measure than mortality. Hospital bed utilization is often accepted
as a reasonable quantitative marker of morbidity.

Department Of Pharmacy | University of Peshawar

 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

SPECIFIC HEALTH PROBLEMS

1. DRUG OVERDOSE:
Major & Common Cause of Death: Drug overdose is the major cause of death among injecting
drug users and the second most common cause of death after AIDS in countries where HIV is
prevalent among injecting drug users.
Increasing Number Of Death:The number of death from drug overdose has been increasing
alarmingly in many countries of the world in recent years. It is not clear why these deaths are
increasing. An increase in population at risk because of illicit drug use (Especially drug injecting)
is likely to be a most important factors in many countries.
Drug overdose often occurs following ingestion of multiple substances.

Common Combination:
• A common combination in fatal overdoses is heroin accompanied by other central
nervous system depressant drugs, especially alcohol and benzodiazepines.
A poor correlation has been reported in many studies between the blood or biliary level
of morphine (as a marker of heroin) and fatal outcome.
This has led many to conclude that heroin exposure is not the only determinant of
outcome.
• Barbiturates have an even smaller margin of safety then other depressant drugs.
Respiratory depression Respiratory depression results from each drug and the result of
consuming a combination of depressant drugs is additive.
Terminal Event: Inhalation of vomitus sometimes occurs as a terminal event.

2. HEPATITIS:
Transmission: HIV, hepatitis B and hepatitis C are spread by blood-blood contact while HIV and
hepatitis B are also transmitted by sexual contact.
Global epidemic of overdose deaths The spectacular impact of HIV spreading among and from
injecting drug users has overshadowed the global epidemic of overdose deaths and rampant
infection with hepatitis B and hepatitis C in this population, so infection with hepatitis B and C is
common and carries a worse prognosis than either infection on its own consumption of
considerable quantities of alcohol over time in the presence of chronic hepatitis B or hepatitis C
is associated with poorer outcomes.

3. Sexually transmissible infections & Gynecological Complaints:

History: Although a history of sexually transmissible infections is very common among injecting
drug users, it is hard to know which group they should be compared with.
Experience of engaging in prostitution is common, especially among female injecting drug
users. This may account for the increase risk of sexually transmissible infections and pelvis
inflammatory disease (and also to some extent for the increased risk of hepatitis B).
Crack cocaine: Crack cocaine use is associated with increased risk of unsafe sexual practices
especially in sex for drugs. This practice has been linked to high rate of sexually transmissible
infections including HIV.

Department Of Pharmacy | University of Peshawar

 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

Menstrual irregularities: Menstrual irregularities including amenorrhea are common among

female injecting drug users. These problems usually resolve after enrolment in methadone
programmes, presumably reflecting improved nutritional status and a more stable life.

4. Bacterial Infections: Bacterial complications of injecting drugs include:

Infections with the agent which causes tetanus and botulism:
The former was one of the first serious complications described as far back as 1880s (Selwyn
1993). More recently outbreaks of botulism, a serious disease causing muscle paralysis and
possible death, have been linked to the use of heroine known because of its appearance as
Black Tar Heroin.
Cause of Infections: The infection occurs because of the contamination of the drug with plant
material and dirt in which these organisms dwell. It is not therefore, necessarily related to
sharing injecting equipment. The infections occurs when the drugs is injected subcutaneously
into the skin rather than into the bloodstreams.
Distal bacterial infections: Distal bacterial infections can result in septicemia, endocarditis,
lung, brain and joint abscesses. These were also probably more common in the era before
needle exchange.
Bacterial (or fungal) endocarditis resulting from drug injecting is said to be more common on
right side of the heart (especially tricuspid regurgitations). Injecting drug use accounts for an
estimated 14% of all cases of endocarditic (English et al 1995).

5. Violence: Injecting drugs users are often injured or killed by violent means. Some injuries and
deaths result from territory disputes between drug trafficking gangs.
Association Between Violence & Cocaine/ Alcohol:
• Violence appears to be more often associated with consumption of cocaine than heroin.
• There is a stronger association between the consumptions of alcohol and becoming a
victim or perpetrator of violence.
Road crash injuries: Illicit drug use appears to contribute little to road crash injuries or
fatalities. There may be some cross substitutions between alcohol and cannabis consumptions.
When minimum drinking age was raised from 18 to 21 in United States in 1980s, significant net
reductions in road crash fatalities occurred in this age group associated with reduced alcohol
consumptions and increased cannabis consumption.
• There appears to be increased incidence of violence among injecting drugs users who also
have a psychiatric condition.

6. Fungal Infections: Candida and other fungal endophthalmitis occur among injecting drug users.
Aspergilla endophthalmitis has been linked to contamination of lemon juice containers used to
acidify street heroin to facilitate the drug going into solution.

7. Tuberculosis: After several decades of declining incidence and prevalence, tuberculosis is once
again emerging as an international problem. Tuberculosis is more common in HIV infected
injecting drug users. The increasing incidence of tuberculosis is linked to HIV infected injecting
drug users become a public health problem in United States during in 1980s and 1990s.

Department Of Pharmacy | University of Peshawar

 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

8. Parasitic Infections: Malarial outbreaks linked to injecting drug use and sharing of injecting
equipment has been detected in temperate climates.

9. Venous And Areterial Problems:

• Damage to vein occurs from repeated venipuncture, often with blunt, previously used
needles.
• Chemical phlebitis results from adulterant commonly found in street drug samples such as
talc used to dilute street heroin or from injection of methadone syrup (which is very
viscous).
Use of Methadone Syrup: A methadone syrup formulations is used in some countries to
discourage injections.
Some injecting drug users also grind dup and inject tablets including benzodiazepines,
buprenorphines and other opioids.

Department Of Pharmacy | University of Peshawar

 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

CONTROL OF DRUG ABUSE AND MISUSE

Definition of Drug: The word drug has a dual meaning.
“It is a substance used in the diagnosis, treatment, or revention of a disease or as a component of a
medication",
Or
It is a chemical substance, such as narcotic or hallucinogen that affects the central nervous system,
causing changes in behavior and often addiction.

Medication Or Entertainment: Clearly, drug can be used either as medication, or as, in the second
case, a kind of entertainment or source of temporary relief from a stressful or unpleasant living
situation.

Explaination: People value some drugs as defined by first definition, a magical fix for their physical and
mental illness. The misuse and abuse of drugs arises under the second definition, and such abuse
changes people perception of drugs. They try to stay away from the second kind of drugs, and have a
hostile attitude toward groups who take them. In the view of many, drugs have become a Frankenstein
that will destroy the very pleasure and peace that people create them preserve. Depending on the
nature of the use, drugs can be either a Panacea, a cure for all inesses, or a Pano pathogen, a cause of
all illnesses.

Misuse:
1. The unintentional or inappropriate use of prescribed or over the counter (OTC) drugs.
2. One can label as "misuse" any episode when people take more drugs than prescribed.
3. Use OTC or psychoactive drugs to excess without medical supervision.
4. Take drugs improperly, such as taking them with alcohol.
5. Discontinue taking some drugs against a physician's recommendation.
6. Use human drugs for animals, or vice versa.
7. Pass on leftover drugs, especially antibiotics, to other people.

Drug abuse: Willful misuse of either legal or illegal drugs for recreation or convenience.
Generally, there are about 9000 legal or control drugs, and some of these drugs have potential for
misuses and abuses;
1. Antibiotics
2. Opiates
3. General brain depressant substances, which include alcohol, barbiturates, synthetic sedatives
and sleeping tablets
4. Stimulants or designer drugs, such as cocaine
5. Hallucinogenic drugs, which includes LSD (Lysergic acid diethylamide), mescaline, peyote and
any other plant-derived or synthetic substances

Reason of Misuse: The main reasons people misuse and abuse drugs are:
1. For pleasure, as stress or tension relief, or temporary escape
2. As mean to join specific groups

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3. For economic reason

SOME COMMON PSYCHOACTIVE DRUGS USED/MISUSED AND SELECTIVE
INFORMATION AND THEIR EFFECTS
1. Acid: Acid/LSD (Lysergic acid diethylamine) orally dissolved on the tongue. Hallucinogenic,
altered sensory perceptions e.g. visual hallucination, time distortion, detachment from reality.
Unwanted Effects: Panic attacks, frightening altered perceptions, dysphoria, delusions,
psychosis, tachycardia, After-effects include flashbacks.
2. Alcohol (Ethanol) Orally in drinks eg. wines, spirits, beers, etc. CNS depressant. Relation,
disinhibition, promotes, social interaction
Unwanted Effects: Aggressive mood, duress, dehydration, hypoglycemia, sedation, vomiting,
depression, anxiety, liver cirrhosis, acute hepatitis, gastric cancer.
3. Caffeine: Orally in drinks e.g tea, coffee and some soft drinks. CNS stimulation increased
alertness, combats fatigue, promotes stamina
Unwanted Effects: Duress insomnia, restlessness, anxiety, poor concentration, tremor,
headache Hashish Resin
4. Cannabis (Delta 9-tetrahydrocannabinol (THC) plus other cannabinoids), Hashish (resin) or
Marijuana (dried flower heads and leaves), both of which are smoked often with tobacco in
handled cigarettes. CNS depressant Relaxation, enhances mood, disinhibition sability.
Unwanted Effects: Anxiety, panic reaction, sedation, tachycardia, coughing, lung orders, loss of
motivation
5. Ectasy:(3,4 methylinedioxy-methamfetamine) Oral ingestion in tablets form often in action with
attendance at dance music event. CNS stimulation, hallucinogenic. Physical and mental
stimulation, confidence, sociability, happy, elevated mood, increased energy.
Unwanted effects: Sweating, tachycardia, headache, dry mouth, rhabdomyolysis, hyppyrexia,
hyponatremia, renal failure. After effects include depression, insomnia, anxiety, Lethargy.
6. Heroine (Damorphine): Inhalation of vapour produced when heated on tin foil, intravenous CNS
depressant Intense pleasure including euphoria, warmth, relaxation, detachment from
emotional distress.
Unwanted effects: Initially nausea and vomiting. constipation, drowsiness, confusion, dry
mouth, sweating in overdose-respiratory depression, monary oedemia, hypoxia, arrhythmias.
7. Tobacco (Nicotine): Cigarettes smoking, chewing tobacco. CNS stimulation. Social activity,
mood elevation, increases concentration, promotes relaxation.
Unwanted Effects: Various cardiac disease, chronic obstructive airways disease, cough,
halitosis.
8. Cocaine (Cocaine hydrochloride) “cocaine powder” cocaine base Crack. Nasal administration
through snorting, injecting smoking (free base) CNS stimulation. Euphoria, Alertness, increased
confidence, excitement, physical stimulation. Intense exhilaration (injection and crack)
Unwanted Effects: Cardiac toxicity, tachycardia, palpitations, hypertension, chest pain,
sweating, tremor, mental and anxiety, psychosis, After-effects include dysphoria, depression,
fatigue, intense carving.
9. Speed (Amphetamine): Nasal administration through snorting, orally, intravenous injecting
CNS stimulation, Physical and mental stimulation, confidence increased energy.
Unwanted Effects: Sweating, tachycardia, hypertension, anxiety, paranoia and psychosis.

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After-effects indude fatigue and depression.

THE HARMS RELATED TO PSYCHOACTIVE DRUG MISUSE AND ABUSE
1. HEALTH PROBLEM: These affect the individual drug user and include physical and psychological
health problems with problems may relate to the administration for example injecting drug
user is associated with damage to the circulatory system. Blood born virus infection for
example with HIV, hepatitis and hepatitis C is associated with the sharing of injecting
equipment. Skin infections are common among the drug user
2. SOCIAL PROBLEM: Social problem include poverty e.g social deprivation, exclusion or failure in
education, inability employment, spending of income on drug. Damage to family relationships,
society and homelessness
3. Drug Related Crime: Drug Related Crime include not only the criminal activities committed
against the misuse of drugs but also crime that impact on communities and society at large. The
latter may relate to the acquisition of drugs or the effects of drugs, e.g, burglary to obtain
money to buy drugs, robbery, prostitution, violence associated with drunkenness, drunk/ drug
drive.
Drug users are often at greater risk than non drug users of being victims of crime, eg violence
associated with debt to drug dealers, prostitution, robbery and mugging if homeless or
intoxicated.

THE MANAGEMENT OF DRUG USE AND DEPENDENCE

1. Primary Prevention:
Concerned With: Primary prevention is concerned with preventing people from starting to use
drugs.
Target groups: Target groups include vulnerable groups such as school children, looked after
children and young people who have left education.
It includes:
i. Warning of the harm that can result from drug use and dependence using health
promotion and education campaigns.
ii. Also includes legislation, as the illegal nature of many drugs may prevent some people
from using them.
Evaluation of Effect: It is difficult to evaluate the impact of primary prevention activities as so
many factors may influence the person's decision to use or not to use drugs. Reliable research
in this area can also be difficult to undertake. This does not mean that primary prevention
activities should not be used. They are very important for informing children and young people
about drugs and their effects. Such activities should not be scaremongering but need to be
factually accurate to give young people an informed knowledge base about drugs which reflects
what they may see within society.

2. Secondary Prevention:
Concerned With: Secondary prevention is aimed at people who use drugs by discouraging
further use.
Example:

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 PHARMACY PRACTICE-IIB (Community, Social & Administrative Pharmacy)

i. Giving advice to prevent problems such as overheating and dehydration to ecstasy users.
ii. Discouraging heroin smokers from progressing to injecting and warning on the risks and
guiding on the use of CNS depressant drugs (such as heroin and methadone by stimulant
users (such as ecstasy and amphetamine) when depressant drugs are used to assist with
the 'come down’ following CNS stimulation.

3. Drug Education:
Introduction: Drug education is a tool used in primary and secondary prevention campaigns and
includes leaflets, booklets, videos and posters.
Benefits:
i. People who are dependent on drugs may also benefit from drug education as they may
not be fully informed on the drugs they use or may consider using long-term risks and
overdose prevention.
ii. Drug education is also a key part of harm reduction, giving people information to assist
them in minimizing risk from drug taking e.g safer injecting information.
iii. Drug education may be provided by a range of people, e.g, teacher, community
pharmacist, youth workers, health promotion workers, medical and nursing staff and
police officers and should always be appropriate for the target group.
For example: Advice given to dependent heroin smokers would differ from that aiming
to prevent heroin use in school children.

Useful Lectures Should Delivered: Pharmacists may be asked to provide talks and should only
deliver such talks if they feel competent to do so and capable of answering question. Before
such talks are given it is advisable to get advice and information from a credible source such as
publication by drug charities and health promotion units. Seeking the support of the local drugs
service may be also prudent. Inaccurate advice can be harmful and discredited.
4. Social Support:
Introduction: Social support refers loosely to non-medical/pharmacological interventions that
can be made.
It Includes: These may include
i. Practical advice and assistance (e.g: seeking housing, benefit advice, provision of hostel
accommodation)
ii. Use of psychological tools such as motivational interviewing:
Motivational interviewing: Motivational interviewing aims to assist people in examining
their drug use and the impact it has on their lives and those of others to move people
towards a psychological state where they are motivated to change their behavior and
attempt to change their drug use.
Psychological tools: There are many psychological tools that are used by clinical
psychologists and counselors in the treatment and support of people with drug
problems.
Pharmacists should be aware of the need for a holistic approach to care, using not only
pharmacological therapies where appropriate, but non-drug treatments too. Some pharmacists

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with a special interest who have specialized in drug misuse have developed skills in
motivational interviewing and other psychological support tools.

5. Detoxification:
Introduction: Detoxification refers to the provision of treatment to help someone who is
dependent on a drug to stop using it.
Examples:
i. Use of diazepam at gradually reducing doses in benzodiazepine dependence
ii. Use of nicotine replacement therapy.
Aim: The aim of detoxification is for the person to become abstinent from the drug on which
they are dependent.

6. Rehabilitation:
It includes:
i. Rehabilitation may include a detoxification process followed by a period of social
support and Intensive psychotherapy to facilitate sustained change.
ii. Alternatively, it may comprise the social support and intensive psychotherapy phase
only, with successful detoxification being a requirement for entry on the program.
Provide in Therapeutic Community: Rehabilitation is usually provided within a therapeutic
community participants live in the environment where treatment is given, often for several
months. Often people who enter rehabilitation programs have serious, complex and chronic
drug dependency problems and may previously have experienced community.

Prevention:
1. Participating in or contributing to the development of substance abuse prevention and
assistance programs within health care organizations.
A comprehensive program should consist of (a) a written substance abuse policy, (b) an
employee and awareness pro- gram, (c) a supervisor training program, (d) an employee
assistance program, (e) peer support systems, such as pharmacist recovery networks, and f)
drug testing
2. Participating in public substance abuse education and prevention programs (e.g. in primary and
secondary schools, colleges, churches, and civic organization) and stressing the potential
adverse health consequences of the misuse of legal and use of illegal drugs.
3. Discouraging pharmacist involvement in the sale of alcohol and tobacco products.
4. Establishing a multidisciplinary controlled-substance inventory system that discourages
diversion and enhances accountability that complies with statutory and regulatory
requirements. Where helpful, for example, procedures might require the purchase of
controlled substances in tamper-evident containers and maintenance of a perpetual inventory
and ongoing surveillance system.
5. Working with local, state, and federal authorities in controlling substance abuse e.g. complying
with controlled-substance reporting regulations and cooperating in investigations that involve
the misuse of controlled substances, especially diversions from a health care organization.

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6. Working with medical laboratories to (a) identify substances of abuse by using drug and poison
control information systems, (b) establish proper specimen collection procedures based on
knowledge of the pharmacokinetic properties of abused substances, and (c) select proper
laboratory tests to detect the suspected substances of abuse and to detect tapering with
samples.
Education:
1. Providing information and referral to support groups appropriated to the needs of people whose
lives are affected by their won or another person's substance abuse or dependency.
2. Providing recommendations about the appropriate use of mood-altering substance to health
care providers and the public, including those persons recovering from substance dependency
and their caregivers.
3. Fostering the development of undergraduate and graduate pharmacy school curricula and
pharmacy technician education on the topic of substance abuse prevention education, and
assistance,
4. Providing substance abuse education to fellow pharmacists, other health care
professionals, and other employees of their health care organization.
5. Instructing drug abuse counselors in drug treatment programs about the pharmacology of
abused substances and medications used for detoxification.
6. Promoting and providing alcohol risk-reduction education and activities.
7. Maintaining professional competency in substance abuse prevention, education, and assistance
through formal and informal continuing education. 8. Conducting research on substance abuse
and addiction

Assistance:
1. Assisting in the identification of patients, coworkers, and other individuals who may be having
problems related to their substance abuse, and referring them to the appropriate people for
evaluation and treatment.
2. Participating in multidisciplinary efforts to supports and care for the health care organization's
employees and patients who are recovering from substance dependency.
3. Supporting and encouraging the recovery of health professionals with alcoholism or other drug
addictions. Major elements of an employer's support program might include (a) a willingness to
hire or retain employees, (b) participating in monitoring and reporting requirements associated
with recovery or disciplinary contracts, (c)maintaining an environment supportive of recovery,
(d) establishing behavioral standards and norms among all employees that discourage the
abuse of psychoactive substances, including alcohol, and (e) participating in peer assistance
programs.
4. Collaborating with other health care providers in the development of the pharmacotherapeuic
element of drug detoxification protocols.
5. Providing pharmaceutical care to patients being treated for substance abuse and dependency.
6. Maintaining knowledge of professional support groups (eg, state- and national-level pharmacist
recovery networks) and other local, state, and national organizations, programs, and resources
available for preventing and treating substance abuse (see "other resources").

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7. Refusing to allow any student or employee, including health professionals, practice, or be on-
site for rotations within the health care organization while his or her ability to safely perform
his or her responsibilities is impaired by drugs, including alcohol. The refusal should follow the
organization's policies and procedures, the principles of ethical and responsible pharmacy
practice, and statutory requirements. Practice should not be precluded after appropriate
treatment and monitoring, if approved by the treatment provider or contract monitor (or both,
when applicable).

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 CHAPTER 1

Role of community pharmacist in ensuring better healthcare

Health is a word very familiar to us but it also carries a lot of complications

and problems. According to the World Health Organisation, health is a state
of complete physical, mental and social well-being and not merely absence
of any illness. To make the above definition of health practical we have to
depend upon a "health care team".

A health care team is the group of people who share a common health goal
and common objectives determined by community needs. India with the
greatest cultural diversity, health though an important issue is being
neglected due to many hindrances. The condition is further worsened due to
insignificant drug use problems. On the spurge of many spurious, duplicate
and adulterated drugs, it is in the hands of the pharmacist particularly the
community pharmacist, to take up the challenge for providing better health
care and better outcomes economically.

Role of community pharmacist

A community pharmacist is the professional who would be in direct access

to the public and whose duties are widely sought after by the public and
patients. He dispenses medicines with a prescription and in certain cases
without a prescription where applicable (OTC drugs). As he is the person
who will be in direct contact with the public, he has to play an important role
in decreasing the mortality and morbidity in the public.

Community pharmacy practice evolved in the post second World War

period. A pharmacist not only began to perform functions that were new to
pharmacy, but they began to innovate functions and make original
contribution to literature. The popular motto of "patient oriented practice"
and "drug use control" came into practice. But unfortunately the role of
community pharmacist is not so much recognized till today especially in
India and needs strong efforts.

Although community pharmacist is of key importance in providing better

healthcare, it is the matter of shame for us that the Indian patient does not
find any difference between the grocer and the pharmacist. Despite of major
role of community pharmacy, the situation and condition of the community
pharmaceutical service has stood where it was like a man walking on a
treadmill. He walks and walks and sweats, but remains in the same place.
Until and unless the link between the people and physician i.e. the
pharmacist does not get its proper recognition any dreams of making India, a
healthier nation cannot be fulfilled.

The need of the hour is to make community pharmacist a key towards better
health care. The community pharmacist can take part in health promotion
campaigns, locally and nationally, on a wide range of drug related and health
related topics. A community pharmacist involvement could play an
important role in the following areas of health care.

Nutrition Counseling

Community pharmacist can make, significant contributions in assuring

adequate nutrition by advising his patients about basic food needs, keeping
to correct improper food habits in children, advising on special
requirements, suggesting special diet instructions for diabetic patients and
people with food allergy and participating in school lunch programs and
schemes like mid-day meals etc. in rural areas.

There are certain facts such as women who often eat fish or omega-3-fatty
acids are less likely to suffer stroke, symptoms of hyper vitaminosis result in
irregular menstrual cycle and excessive intake during pregnancy may cause
birth defects. The pharmacist can tell these facts to people to ensure better
health. Now a days designer foods i.e. nutraceuticals/ dietary supplements
have not only gained considerable acceptance but also have newfound use
and applications. They are considered to provide medical or health benefits.
The community pharmacist could explain these new innovative products and
their standardization.

Women Welfare-Pregnancy and Infant Care

A famous Sanskrit Shloka from Manusmriti scriptures goes as "Yatra

Nariyastu Poojayanta, Ramante Tatra Deva" which means, "where women
are worshipped Gods preside there".

Women are the corner stone for effective public health and investing in
women translate into investing in family, community and the Nation.
Against the backdrop of a hectic and demanding schedule, women's health
receives the least priority when it should be the first.

A woman goes through different stages throughout her life, each of which
has specific need and the presence of a counselor is needed in each one of
them. The pharmacist who understands the normal course of pregnancy and
infancy is at a distinct advantage as he or she can guide the mother in simple
matters of hygiene and management. The community pharmacist can
encourage breastfeeding and can play a major role by guiding the mother for
the protection of the child by following proper immunization schedule.
Efforts are definitely underway in this area.

The US FDA's office of women's health has created "women's health: take
time to care", a national public awareness campaign, where apart from
giving information about safe medicine use, they also hold local interactive
sessions led by pharmacists and other health care professionals.

Rational Use of Drugs

A community pharmacist can also advise on the administration of the

medication, provide information on the storage of the medication and
wherever necessary he can counsel the patient. Education regarding the
disadvantage of polypharmacy can also be given to the patient. Drug
information system should be set up and access to adverse drug reaction
system should be made. A community pharmacist should do therapeutic
drug monitoring and he should have a sound knowledge of genotype
reporting i.e. predictive pharmacology.

Drug information awareness programmes should be conducted to make

people aware of side effects of certain OTC drugs e.g. Aspirin - a wonder
drug also has many side effects like gastric ulceration; asthma and large
doses may cause tinnitus. Regular use of paracetamol can cause harm to the
liver. How many amongst the common people know that drugs such as
Action 500, Coldarin can increase blood pressure in patients having
hypertension. Even pain shows difference between men and women. Where
women respond better to the opiods such as morphine, pentazocine and
pethidine men respond better to the non-steroidal anti-inflammatory drug,
ibuprofen. Considering the above examples, in the best interest of public
health a community pharmacist can provide counseling to common people
unaware of these side effects.
Moreover the definition of an OTC product should be that "which does not
require the prescription of a registered medical practitioner but which can be
sold only under the supervision of a pharmacist". In a nut shell there should
be rational use of drug i.e. right drug in right patient in right dose at right
time. A community pharmacist is one of the inevitable members of the
health care team who can help to achieve the goal of rational use of drugs by
following good pharmacy practices. It is found that interventions by
pharmacists in explaining the patients about medicines prescribed to them
can significantly enhance patient knowledge of correct use of medicines
from 56 per cent to 90% per cent.

There is yet another role of the community pharmacist in India and that is
enhancing the availability of essential drugs. Nearly 70% population in India
is deprived of essential drugs for a variety of reasons including non-
availability of health professionals and improper professional advice about
the usage of drugs.

In India, one pharmacist for two thousand persons can improve access to
medicines and their safe utilizations. The existing pool of community
pharmacist can become an important instrument in bringing about this
change. For setting higher standard for pharmacy practice in the country the
essential drug list should be received by the government and the availability
of the essential drugs should be enhanced through the pharmacists.

Sexually Transmitted Diseases-AIDS

India has 3.5 million HIV positive cases, which is about 10% of the global
HIV cases and barely second to South Africa. HIV drugs are expensive and
beyond the reach of common man. Huge resource of community pharmacist
can educate people in the prevention and information of HIV/AIDS. For this,
Federation of Indian Pharmacists project in India on involvement of
pharmacist in fight against AIDS is very relevant.

Another sensitive issue is the increasing number of women patients suffering

from AIDS. The number rose from 7% in 1985 to 18% in 1995. Although
many classes of antiretroviral are available like protease inhibitors,
nucleoside reverse transcriptase inhibitors and non-nucleoside reverse
transcriptase inhibitors, patients need close monitoring and strict dietary
regimen. Explaining to what HIV is, its transmission, risk reduction, patient
counseling are the components of the counseling that a community
pharmacist can provide.

Alcohols, Drug Abuse and Smoking Cessation

The diseases of alcoholism and drug abuse also come under the preview of
the community pharmacist. The pharmacist has a key role to help individuals
who become dependent upon alcohol. Drug abuse is similar to alcoholism
yet different because it has been gaining more acceptances among young
people. Annual mortality from tobacco use exceeds that from all other
causes combined. Smoking is the greatest single preventable cause of
morbidity and mortality in India. It is the responsibility of a community
pharmacist to take an active role in helping the smokers to stop smoking.
Following a number of smoking policies through out the pharmacy, by
written information and posters, can do this. The pharmacist can advise on
the products available to assist the patient in giving up smoking. Counselling
sessions can be made by the community pharmacist to stop smoking.

Family Planning

One of the greatest needs of the hour is to control the tremendously

increasing population in India. A community pharmacist is the one who can
control this rising population by counseling with people and doing
programmes which exhibit the problems related with large families. He can
tell the various families planning measures that are available in the market at
affordable prices. He can educate the people and convince them about the
advantages of having small families. So, like all other aspects community
pharmacist plays a very important role in this case also.

Individualization of Drug Therapy

Today the latest concept in medicine is towards individualization of drug

therapy. Where judicious patient care is needed individualization of drug
therapy becomes a need, and a pharmacist can play a vital role in this. A
physician who is preoccupied with patient diagnosis and treatment may not
spare time for patient counseling regarding pharmaco-economics, drug
information, alternative therapy, moral supporting etc. A pharmacist can set
up a separate consultation room and provide counseling to the patient. He
can store the details of patient history, allergies and other details necessary
for therapy so that the concept of individualization of drug therapy could be
implemented.
The ideal frontline pharmacist of the future has been described as a seven
star pharmacist-some one who is equal in excellence to a five star hotel yet
accessible to everyone from the richest to the poor. The future 7 star
pharmacists will have seven principal roles to play:
-- Care giver;
-- Decision-maker;
-- Communicator;
-- Leader;
-- Manager;
-- Life long learner and
-- Role model.
The community pharmacist with the above skills and attitudes should make
himself an indispensable partner in health care system of a nation.

Conclusion

In the Indian health care system, pharmacist is under utilized because

community pharmacy and pharmacy practice are yet to be established
strongly and pharmacists working in community pharmacies do not provide
patient counseling in the usual situation. We need to work closely with the
pharmacist associations and share our common experiences and frame
appropriate guidelines for India so that community pharmacist who plays a
major role in providing better health care can be recognized.

In a nutshell, pharmacist in the health care system is like circumcenter of a

triangle with physicians, patients and nurses at the corners of the triangle. He
has direct contact with all health care professionals and patients. It is really
important to appreciate the fact that a patient finds himself to be much more
comfortable in a drug store than in a physicians dispensary. The role of
community pharmacist is indispensable in providing better health care. Steps
should be taken by the government and the pharmacist himself to make his
recognition in the community as a better health care provider. The National
pharmaceutical associations like Indian Pharmacists Organization,
Federation of Indian Pharmacists, Indian Hospital Pharmacists Association
and All India Organization of Chemists and Druggists etc. will have to be
committed to change and use their influence to convince community and the
government that pharmacists can play a significant role in national health
care programmes. The main driving force will have to come from
pharmacists themselves. They are best able to decide what can be achieved
and within what time scale. Every community pharmacist should always
remember, the following lines:
"Do all the good you can, In all the ways you can;
In all the places you can, At all the times you can;
To all the people you can, As long as ever you can".
 Chapter 16

Control of Drug Abuse and Misuse

Drug of Abuse
• Drug of abuse also called the illicit drugs refer to highly
addictive and illegal substances
• These substances are usually controlled at international,
national and community level
• Controlled drugs are any types of drugs that a regula-
tory authority includes in controlled drug list
• It usually includes substances which may be used for
the production or manufacture of narcotic drugs or psy-
chotropic substances.
Categories of controlled substances
• Narcotic Drugs (e.g. Morphine, codeine, pathidine)
• Psychotropic Substances (Alprazolam,Bromazepam,
Buprenorphine, Chlordiazepoxide)
• Precursor Chemicals (Ephedrine, Pseudoephedrine, Methyl Ergotamine)
International Regulations
• The International Narcotics Control Board (INCB) an independent, expert body with its head
Quarter in Vienna, Austria.
• It is an independent, quasi-judicial expert body established by the Single Convention on Narcotic
Drugs of 1961 by merging two bodies: the Permanent Central Narcotics Board, created by the
1925 International Opium Convention; and the Drug Supervisory Body, created by the 1931
Convention for Limiting the Manufacture and Regulating the Distribution of Narcotic Drugs.
• INCB has 13 members, each elected by the Economic and Social Council for a period of five
years. INCB members may be re-elected. Ten of the members are elected from a list of persons
nominated by Governments. The remaining three members are elected from a list of persons
nominated by the World Health Organization (WHO) for their medical, pharmacological or
pharmaceutical experience
• The INCB monitors and support government's compliance with International Drugs Control
Drug Treaties i.e. Single Convention 1961, Convention 1971, Convention 1988.
• Pakistan is signatory to following three UN Conventions which provide necessary guidelines
for regulation of controlled substances in the Country.
i. Single Convention on Narcotic Drugs of 1961 as amended by the 1972 Protocol.
ii. Convention On Psychotropic Substances, 1971.
iii. Convention against Illicit Traffic in Narcotic Drugs And Psychotropic Substances,
1988.
Single Convention on Narcotic Drugs of 1961 as amended by the 1972 Protocol
• This Convention aims to combat drug abuse by coordinated international action through
following interventions.
i. It seeks to limit the possession, use, trade in, distribution, import, export, manufacture and
production of drugs exclusively to medical and scientific purposes.
ii. It combats drug trafficking through international cooperation to detect and discourage drug
traffickers.
• This convention Consists of Four Schedules
1. Schedule I (Morphine, Pethidine, Fentanyl etc.)
2. Schedule II (Codeine, Pholcodine etc)
3. Schedule III (Preparations containing Narcotic Drugs)
4. Schedule IV (Chemicals used as Narcotics)
• Yellow List

58
 • The International Narcotics Control Board has prepared a list of Narcotic Drugs, in accordance
with the Convention On Narcotic Drugs of 1961.
• This list is revised and published by INCB each year and circulated to all member states.
Convention On Psychotropic Substances, 1971
• The Convention on Psychotropic Substances of 1971 is a United Nations treaty designed to
control psychoactive drugs such as amphetamine-type stimulants, barbiturates, benzodiazepines,
and psychedelics signed in Vienna, Austria on 21 February 1971.
• This convention Consists of Four Schedules
1. Schedule I (Chemicals used as Psychotropic)
2. Schedule II (Amphetamine, Methylphenidate etc.)
3. Schedule III (Buprenorphine, Pentazocin etc.)
4. Schedule IV (Alprazolam, Bromazepam etc.)
Green List
• The International Narcotics Control Board has prepared Psychotropic Drugs under international
control in accordance with the Convention On Psychotropic Substances, 1971.
• This list is revised and published by INCB each year and circulated to all member states.
Convention against Illicit Traffic in Narcotic Drugs And Psychotropic Substances, 1988
• The United Nations Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic
Substances of 1988 is one of three major drug control treaties currently in force. It provides
additional legal mechanisms for enforcing the 1961 Single Convention on Narcotic Drugs and
the 1971 Convention on Psychotropic Substances. The Convention entered into force on
November 11, 1990
• This convention Consists of Two Tables describing the precursors and chemicals under control
• Table I (Ephedrine, Pseudoephedrine, Ergotamine etc. )
• Table II (Solvents like Acetone, Ethyl ether, Hydrochloric Acid, Sulphuric Acid etc.)
Red List
• The INCB has prepared a list of Precursors and chemicals frequently used in the illicit
manufacture of narcotic drugs and psychotropic substances under International Control In
accordance with the United Nations Convention against Illicit Traffic in Narcotic Drugs and
Psychotropic Substances, 1988.
• This list is revised and published by INCB each year and circulated to all member states.
Regulation of Controlled Substances in Pakistan
• Controlled Substances being regulated under the umbrella of National Control and International
(UN).
National Control.
• The Control of Narcotic Substances Act, 1997 and rules framed there under.
• The DRAP Act, 2012 and rules framed there under.
• Ministry of Narcotics Control vide S.R.O. No.60(KE)/2014 dated 18th August, 2014, revised the
Committee for Allocation of Quota Of Controlled substances CAQCS comprising of three
members i.e.
• Secretary Ministry Of Narcotic Control • Chairman

• Director General ANF • Member

• Director Division of Controlled Drugs, DRAP • Member/ Secretary

• This committee is responsible for allocation of quota for import of all controlled substances for
different stakeholders in country including pharmaceutical industry
• Psychotropic Substances
List of Controlled Substances in Pakistan
• NARCOTIC DRUGS
Morphine Codeine Diphenoxylate Fentanyl

59
Oxycodone Pethidine Pholcodine

Alprazolam Loraze- Lormetaze- Midazolam Meprobamate Nimetazepam

pam pam

Bromazepam Cloraze- Clonazepam Nitrazepam Oxazepam Pentazo-

pate cine

Buprenor- Diazepam Methylphenidate Phenobarbital Pinazepam Prazepam

phine
Chlordiazepoxide Estazolam Temazepam Triazolam Zolpidem

Clobazam Fludiazepam Medazepam

Precursor Chemicals
• Ephedrine
• Pseudoephedrine
• Methyl Ergotamine
• Ergotamine Maleate
• Ergometrine Tratrate
• Acetone
• HCl
SOP FOR QUOTA ALLOCATION OF CONTROLLED SUBSTANCES
• The Committee for allocation of quota of controlled substances (CAQCS) has devised an SOP
for filling applications for quota allocation, which requires submission of information (as per
Checklist) like import, manufacturing and sale record of past three years , Validity of registra-
tion & DML, various undertakings etc.
• A Scrutiny Committee comprising of officer of DRAP, ANF and MNC scrutinizes the so eval-
uated application by Division Of Controlled Drugs, DRAP prior to presenting before the
CAQCS for allocation of quota of controlled substances
Drugs which require consumption certificate
Morphine Pathidine Codeine phosphateBuprenorphineFentanyl
PhenobarbitonealprazolamDiazepam Pentazocin

60
 Other activities performed by CAQCS
• Quota Allocation Of Controlled Substances for Export Purpose Only
• Destruction / Safe Disposal of Controlled Substances (Finished Products / APIs /Precursor
Chemicals).
• Quota Allocation of Pharmaceutical Products Containing Controlled Substances to
Tertiary Care Hospitals Located in Islamabad Capital Territory (ICT), Islamabad
Division of Controlled Drugs, DRAP
• Responsibility
• As per DRAP Act 2012, Division of Controlled Drugs in consultation with the Federal
Government be responsible for regulation and allocation of Quota of Narcotic Drugs,
Psychotropic Substances and Precursor Chemicals and to perform other functions connected
therewith
Functions of Division of Controlled Drugs, DRAP
• Scrutinize the application of Allocation of controlled substance (Active Pharmaceutical
Ingredient) and (Finished Form)
• Scrutinize the application for allocation of precursors chemicals
• Scrutinize the application for allocation of quota of narcotic drugs for hospital use only
• Scrutinize the application for allocation of quota of controlled substances for personal use
• Issuance of Import Authorization of controlled substances (API/Finished Form)
• Scrutinize the Application for export of finished drugs containing controlled substances
• Issuance of Export Authorization of finished drugs containing controlled substance
• Scheduling and Preparing agenda of meeting of scrutiny committee for quota allocation of the
meeting of scrutiny committee
• Execution of meeting and Preparation of the minutes of Scrutiny Committee
• Scheduling of the meeting of CAQCS meeting
• Preparation of agenda, executing of meeting and preparation of Minutes of CAQCS meeting
• Issuance of Allocation letter of controlled substances for complete cases
• Issuance of shortcoming letters of controlled substances for deferred cases
• Replies of the matter related to Anti Narcotic Force.
• Replies of the matter related to Ministry of Narcotics Control.
• Input/replies/feedback on reports of International Narcotic Control Board (INCB), The United
Nations Office on Drugs and Crime (UNODC) and Commission on narcotic Drugs (CND).
• Submission of Quarterly/Annual statistical report of Narcotics/Psychotropic substances and
precursors chemicals to International Narcotic Control Board (INCB) through Ministry of
Narcotic Control.
• Application for destruction of drugs containing controlled substances (finished form and raw
material).
Maintainace of sale record of Psychotropic, antidepressant and other controlled drug
• According to Punjab Drug Rules, 2007, for sale of specified in schedule B (psychotropic,
antidepressant and other controlled drug) shall be recorded at the time of supply in register
specially maintained for the purpose and the serial number of the entry in the register shall be
enter in the prescription and following particulars shall be entered in the register
i. S.No.
ii. Date of sale
iii. Name of patient
iv. Name of drug
v. Name of manufacturer
vi. Quantity sold
vii. Batch No.

61
 viii. Signature of qualified person
ix. Quantity purchased and balance
• Moreover, a substance specified in schedule B shall be store in
a) In a locked almirah, cupboard, or drawer reserved solely for the storage of drugs

62
 Hospital Pharmacy
• At hospital pharmacy, usually different protocols are established for controlled drug
management.
• The controlled drug is stored in lock and key under the supervision of hospital pharmacist.
• Register is maintained in which detail of patient, prescribers, name of drug, batch number, expiry
is mentioned
• Usually the empty ampules are stored for audit purposes
Elements of addiction
Physical tolerance:
❖ Physical withdrawal symptoms
❖ There is physical signs and symptoms experienced by the dependent when drug is removed or
withdrawal
❖ Examples:
i. Seizures with alcohol withdrawal
ii. Stomach cramps with severe influenza, constipation and diarrhea with opioids
withdrawal
iii. Insomnia with nicotine withdrawal
Psychological dependence
• There is a psychological disturbance experienced by addicted persons
• Feeling that they need drug in order to feel normal
• Examples
• Intense emotional experience
• Inability to cope
• Intense craving
• Altered mood & depression
Engage in illegal activities
• In order to obtain desired drug, they engage in illegal activities
• Taking wrong prescriptions etc
• Craving to continue to use the substance
• Association with peers indulged in substance abuse
The management of drug use and dependence
Primary prevention
• Primary prevention is concerned with preventing people from starting to drug use
• Targets groups include vulnerable groups such as school children and young people who left
education
• The awareness program about harms of drugs especially at community level, through social,
print and electronic media plays an important role in primary prevention of drug addiction
• Legislation to control and limit drug access to the persons who don’t require these medicines for
medical purposes is also included in primary prevention
• Primary prevention is very important for informing children and young people about drugs and
their effects
Secondary Prevention
• Secondary prevention is aimed at people who use drugs by discouraging further use.
• Examples of secondary prevention are giving advice to prevent problems such as overheating
and dehydration to MDMA users
• Discouraging heroin smokers from progressing to injecting
• Warning on the risks and guiding on the use of CNS depressant drugs (such as heroin and
methadone) by stimulant users (such as MDMA and amphetamine) when depressant drugs are
used to assist with come down following CNS stimulation
Drug education
Drug education is a tool used in primary and secondary prevention campaigns and include
leaflets, booklets, videos and posters

63
 • People who are drug dependent can also get benefit from this literature as the they are not fully
informed about aspects of drugs
• Already addicted persons can be educated about don overdose and long term risk of using drugs
• Health promotions among drug users reduces the risks of getting blood borne diseases and other
communicable diseases
Social support
• Refers loosely to non medical /pharmacological intervention that can be made
• Includes: practical advice and assistance
• Seeking housing
• Benefits advice
• Provides psychological tools such as motivational interviews
• Motivational interviewing aims to assist people in examining their drug use and the impact of
drugs on their lives so that they may change their behavior and drug taking process
• Some pharmacist with special interests who have with specialized in drug misuse have
developed skills in motivational interviewing and other psychological tools
Detoxification
• It refers to provision of treatments to help someone who is dependent on a drug to stop using it.
• Examples
• diazepam at gradually reducing doses in benzodiazepines dependence
• Use of nicotine replacement therapy for purpose of smoking cessation
Rehabilitation
• Rehabilitation may include a detoxification process followed by a period of social support and
intensive psychotherapy to facilitate sustained change.
• Rehabilitation is usually provided within a ‘therapeutic community’. Participants live in an
environment where treatment is provided, often for several months
• Often people enter in a rehabilitation programmes have serious , complex, chronic drugs
dependency
• National treatment outcome research study in UK evaluated the outcome of rehabilitation
program
• They found that after 4-5 years follow up , 47% of persons who were dependent on opiates were
abstinent whereas significant numbers of reminders were consuming opiate less frequently.
Harm reduction
• It describes the range of interventions used to reduce adverse consequences of drug dependence
experienced by both drug abuser and community
• Examples of harm reduction interventions include:
❖ Provision of sterile injecting equipment
❖ Informing the drug injectors about the harms of sharing needles (HIV, HBV & HCV ,
phlebitis etc) Provision of substitute therapy either at adequate maintenance dose or as a
detoxification dose with aim to reduce illicit drug use and drug related crimes
Pharmaceutical care to drug addict
• Responsible provision of the medicines or treatment to individual patient in a manner that
improves patient quality of life
• Role of pharmacist in drug dependence
• Community Pharmacist
• Hospital Pharmacist
• Pharmacist with special interest
Role of Community Pharmacist
• Ideally placed to contribute to the care of drug users. In
addition to health gains, there are following advantages
• Extended opening hours: Most pharmacies are open till late
hours and weekends so the people who are on detoxification
or maintenance therapy can access the pharmacy easily

64
• Accessibility: Pharmacies are located in communities so that it is easily accessible. Usually no
appointment is required for services in pharmacies
• Expert Advice: Pharmacist gives access to trained healthcare professional and free advice.
Advice may be sought by needle exchange users, people receiving substitute therapies and their
families. Alternatively, pharmacist may give advice proactively when required.
• Discretion: Pharmacist provides a confidential services to the patients
• Network of services: through widespread provision of services by many pharmacies, the
workload can be shared and a network of good practice developed. Joint training with other
pharmacists and GPs can develop professional relationships
• Job satisfaction: the pharmacist may be the only healthcare professional with whom some drug
users have regular contact. Over time and with an approachable, non judgmental service a strong
therapeutic relationship can develop between the pharmacist and service user. The pharmacist
may then be approached for advice and they can provide risk reduction information
• Harm reduction by community pharmacist
• Needle and syringe exchange program
• Dispensing services
Hospital Pharmacist
• Hospital should have clear guidelines for admission and discharge of drug users to ensure that
any ongoing prescribing is continued.
• Hospital pharmacist may contribute the designing of such guidelines
• Issues that hospital pharmacist may address includes
• Admissions: how to ensure the safe and prompt continuation of substitute prescribing when
someone comes to secondary care health department from community that require acute and out
of hour admissions. Methadone is a controlled drug, so pharmacy department must establish
procedures to supply methadone out of hours
• Discharge: how to ensure safe continuation of substitute prescribing on discharge without a
break in care or doubling up of prescribing. Contact with GP or community drug team is vital.
• Initiation of substitute therapy: For example a heroin dependent person is admitted to the ward
(unplanned) bcz of accident or emergency. It is important to control withdrawal symptoms that
onset quickly typically in 4-6 hours. If it is not performed, the person will be extremely anxious,
in severe discomfort, and very reluctant to remain in ward. And a result the care will be severely
compromised
• Appropriate referral: there are opportunities for identification of drug users not in contact
with service providers especially by accident and emergency staff. Knowledge of local service
providers and opening hours, including needle exchange program is important. The written detail
of contact numbers should be present in wards so that quick contact may be made.
• Hospital pharmacist play a key role in advising for co prescribing for people in substitute
therapy such as methadone. Many drug interactions can occur and change in doses may be
necessary with enzyme inducing or enzyme inhibiting drugs. Treatments for Epilepsy or
HIV/AIDS should be particularly considered
Pharmacist with specialized interest
• Pharmacist who specialize in drug dependency, come under the umbrella of ‘pharmacist with
special interests’.
• Some may provide services in community pharmacies whereas other ,may be based with
specialist drug services
• They provide support to clinical colleagues e.g. advising on prescribing or providing drug
information
• They may also oversee dispensing and make liaison with other community pharmacists
Needle and Syringe Exchange
• Before appearance of HIV/AIDS, availability of clean injecting equipment was limited due to
belief that this would prevent people injecting
• After appearance of HIV/AIDS in 1980----review health professional role including pharmacists
with supply of needle and syringes

65
• In mid 1980 increased awareness of cross infection danger due to injecting practices, needle and
syringe exchange program established
• These programs are studied in several research projects and found that these programs played a
vital role in reducing HIV/AIDS
• More liberal policy in 1988 approved selling syringes through pharmacies for harm minimizing
• In the early 1990s hepatitis C was identified. This blood borne virus is highly transmissible
among injecting drug users and research found that it may be not only transmitting through
contaminated syringes but also other equipment such as spoon or metal container in which drug
is mixed with water, the filter used to remove insoluble material and adulterants and swabs to
clean injecting sites
• Needle exchange program became a globally established schemes for professionals that
extended the role of pharmacist
• Training: Pharmacist and other staff should undertake training on issues relating to needle
exchange
• Vaccination: Although pharmacists and their staff don't handle the loose needles during needle
exchange process, it is wise health and safety precaution for all staff to be vaccinated against
hepatitis B. There is no vaccination for HIV and HCV
Needle exchange procedure
• Needle syringe exchange involves supplying free of cost clean, sterile injecting equipment in
exchange for used equipment, which is returned in sealed sharp container
• In addition, pharmacist also provide advice and check injecting sites and refers to medical
services when problem such as abscesses are identified
• Needle exchange schemes are usually coordinated within health locality, so local policies may
exist and provide guidance about minimizing risk
• Adequate storage facility is essential for needle exchange program. Used equipment returned to
the pharmacy in sealed bin by the client should be placed in large bin. This large bin should be
stored in separate area, away from clean equipment and other medicines
• These bin are sealed when full and collected for incineration by clinical waste management
companies.
• To maximize the public health benefits, every time a new needle should be provided to injecting
drug users, so adequate supply of equipment should be provided and every time a sharp bin
should be provided.
• The return of bin should be highly encouraged and motivation should be provided for doing it
again and again
• However, if a drug addict request for clean equipment but doesn't return the old equipment, it is
highly recommended to provide them clean equipment
• Pharmacy staff should never open the supply bins to count the syringes.
• Instead estimates of return numbers should be made by number of return reported by drug abuser
and size and estimated fullness of returned disposal bins
Record Keeping and Audit
• Record should be kept for audit purposes
• Record it how many syringes receive and give
• Name of receivers should be recorded if told voluntarily otherwise no need to record it
• Attractions of pharmacy based national syringe exchange are anonymity (no patient record) and
low threshold access as too many obstacles will discourage the needle syringe exchange
• In some schemes, pharmacies issue the card which give the service user an identification number
or code
• This can be used for record keeping, and it can be quickly seen if someone returns used
equipment or not.
• However, this system can be too time consuming in busy pharmacies, and some persons don’t
want to carry a card that identifies them as an injector.
Risk management
• A written procedure for needle exchange should be in place and followed

66
• Body fluid spillage kit should be kept in all pharmacies and staff should be trained about their
use
• In case of accident, where patient bleeds or vomit, this kit should be used
• Chain mail glove should be available in pharmacies where needle syringe program run, so that
if loose syringes are received that can be disposed off
Use of pharmacotherapy in drug dependence
• It refers to any drug treatment used to assist in management of drug dependence or symptoms
of withdrawal
• Substitute and non substitute therapy can be to drug addicts
• Substitute therapy is a drug treatment that replaces an illegal drug with a legal one of the same
pharmacological class e.g. methadone is substitute of opiates such as heroin
• Non substitutes drugs may also be used to control withdrawal symptoms (e.g. lofexidine for
opiates) and other symptoms secondary to withdrawal (e.g loperamide to manage diarrhea
associated with opiate withdrawal)
Role of pharmacotherapy:
• Pharmacotherapy can be mistaken both by the patients and professionals as an all encompassing
solution. However, it is one of several tools used in care of drug dependence.
• Alone it can’t stop someone using drugs but it can facilitate change in motivated people
• For example, substitute therapy can prevent withdrawal symptoms which helps the patients to
discontinue the link with drug suppliers
• It also reduce the need to commit crime to obtain money for drugs
• Substitute therapy, from a risk reduction point of view is also preferable to illicit drugs because
the quality and controlled of product is assured
• There are evidence base of literature that support the provision of pharmacotherapy in drug
dependence especially efficacy of methadone and buprenorphine
• Evidence shows the maintenance doses of treatment improves physical and mental health
outcomes, reduce drug related deaths and improves social life
• The psychoactive and non-psychoactive effects of substitute therapy are not usually the same as
illicit drug itself and it should be informed to patient
• e.g methadone is taken orally it does not euphoria and can cause lethargy and feeling of
heaviness not associated with heroin use
Methadone
• Methadone is used as a substitute drug in opiate dependence. Its long half life (24-48 hours),
making it possible to consume it once a daily.
• However, few patients prefer to consume drug in divided doses.
• The benefits of methadone therapy are following:
• Improves physical health
• Improves psychological health
• Reduced illicit drug consumption
• Reduced incident and frequency injecting episodes
• Reduced drug related crimes
• Benefits increase from individual to community. Less injecting will reduce the risk of blood
borne virus transmission and reduced drug related crimes
• Failure to reduce or prevent illicit drug consumption is usually associated with maintenance
doses of methadone less than 60mg.
• Before detoxification is considered, the maintenance dose of methadone is given for a longer
period of time
• Withdrawal of treatment can be begin only when patient is willing to attempt this
• In detoxification, the speed of dose reduction largely depend how well patient is coping
• For some people the small dose is most hard to reduce and usually people remain on small dose
of methadone (1-2mg) for months
• It is important to discuss the patient the potential overdose risk from combining methadone with
other CNS depressants including alcohol

67
• Health professional team may understand that sometimes the persons continue to take illicit drug
especially at the early stage of detoxification
• So, at early stage when there is greater risk of overdose of drug, due to concurrent use of illicit
drug with methadone, the patients must be informed risks and monitored closely
• If illicit drug use continues after methadone therapy, the methadone treatment may be
suboptimal or person is not ready to change their drug use
Safe storage of methadone at home
• Pharmacist should have good understanding of clinical aspects of methadone , before dispensing
of methadone.
• If take home doses are dispensed, pharmacist must discuss safe storage of methadone and other
drug
• As little as 5mg of methadone can kill a small child
Other Treatments
• Buprenorphine is a partial agonist, used as an opiate substitution therapy instead of methadone
• Its use is becoming more widespread as evidence develop
• As it is a partial agonist, it antagonizes the effects of other opiates
• The patient needs clear evidence on initiation and counseling on the risks of attempting to
overcome antagonist properties. This may present a overdose risk
• Buprenorphine is available in sublingual tablet and has a long half life and required once daily
dose
Lofexidine and Naltrexone
• Lofexidine and naltrexone are used in management of opiates withdrawal
• Lofexidine reduces some of physical withdrawal effects from opiates by acting on non adregenic
system.
• Naltrexone is an opiate antagonist drug used in relapse prevention
• There are also some drugs such as clopramide and Loperamide for prevention of diarrhea &
vomiting.
Urine screening and responding to symptoms
• People receiving treatment of drug dependence may have their urine screened to check
compliance of prescribed treatment and to check consumption of illicit drug.
• In some countries, these results determine whether treatment should be continued or not
• Pharmacists should undertake training in this area, as some over the counter and prescribed
medicines can interfere with test results, giving the false test reports.

68
 || SHIVAAY ||

THE PRESCRIPTION

Vishvajitsinh Bhati

@2016 by author
All right reserved. No parts and style of this book may be reproduced or
transmitted, in any form. Or by any means electronic, mechanical, photocopying,
recording or otherwise, without prior permission of the author.
Vishvajitsinh Bhati Page 1
 The prescription
 Definition: - a prescription is a written order from a
registered medicinal practitioner to pharmacist to
compounding and dispenses a specific medication for
the patient.
 The prescriptions are generally written in the English
language but Latin words or abbreviations are
frequently used in order to save time.
→ PARTS OF A PRESCRIPTION ←
1. Date
2. Name, age, sex and address of the patient
3. Superscription
4. Inscription
5. Subscription
6. Signa. Or signature
7. Renewal instruction
8. Signature, address and registration number of the
prescriber.

Vishvajitsinh Bhati
 1. Date: - it helps a pharmacist to find out the date of
prescribing and date of prescription for filling the
prescription.
 The prescription which prescribe narcotic or other
habit forming drug, must bear the date, so as to
avoid the misuse of prescription if it is presented
by the patient, a number of times for dispensing.

2. Name, age, sex and address of the patient: - must be

written in the prescription because it serves to identify
the prescription.
 In case, if any of this information is missing in the
prescription, the same may be included by the
pharmacist after proper enquiry from the patient.
 Also used in dose calculation of children.

3. Superscription: - it is represented by Rx symbol. It is

Latin word. It means you take.

3
Vishvajitsinh Bhati
  In older days, the symbol was considered to be
originated from the sign of Jupiter, god of healing.
This symbol was employed by the ancient in
requesting god for the quick recovery of the
patient.
4. Inscription: - this is the main part of the prescription
order, contains the names and quantities of the
prescribed ingredients.
 The name of each ingredient is written on a
separate line along with its quantity.
 In complex prescription in divided into following
parts…
i. Base: - the active medicaments which are
intended to produced the therapeutic effect.
ii. Adjuvant: - it is included either to enhance
the action of medicament or to improve the
palatability of the preparation.
iii. Vehicle: - it is included in the prescription
either to dissolve the solid ingredients or to
increase the volume of the preparation.
Vishvajitsinh Bhati
  Nowadays, the majority of the drugs are prescribed
which are already in a suitable formulation.
 The pharmacist is required to dispense the
readymade from of drugs. So, compounding of
prescription is almost eliminated.
5. Subscription: - this comprises direction to the
pharmacist for preparing the prescription and number
of doses to be dispensed.
6. Sidnatura or Signa:-this consists of the direction to be
given to the patient regarding the administration of
drug.
 It is usually written as ‘Sig’ on the prescription.
 The instructions given in the prescription are
required to be transferred to the container in which
the medicament is to be dispensed, so that the
patient can follow it. The instruction may include:

i. The quantity to be taken or amount to be used.

5
Vishvajitsinh Bhati
 ii. The frequency and timing of administration or
application.
iii. The rout of administration.
iv. The special instruction such as dilution
direction.
7. Renewal instruction: - the prescriber indicate on every
prescription order, whether it may be renewed and if
so, how many times.
 It is very important particularly in the prescription
containing the narcotic and habit forming drugs to
prevent its misuse.
8. Signature, address and registration number of the
prescriber: - the prescription must bear the signature
of the prescriber along with its registration number and
address.
 It is very important particularly in the prescription
containing the narcotic and habit forming drugs to
prevent its misuse.

Vishvajitsinh Bhati
 7
Vishvajitsinh Bhati
 HANDALING OF
PRESCRIPTION

The following procedure should be adopted by the

pharmacist while handling the prescription for
compounding and dispensing:-
1. Receiving
2. Reading and checking
3. Collecting and weighting the materials
4. Compounding, labeling and packaging

1. Receiving: - the prescription should be revised from

the patient by the pharmacist himself. While receiving
a prescription, a pharmacist should not change his
facial expression which gives an impression to the
patient that he is surprised or confused after seeing the
prescription.
Vishvajitsinh Bhati
 2. Reading and checking: - on receiving a prescription,
always check it that it is written in proper format.
 A prescription should always be screened behind
the counter. In case of any doubt regarding the
prescription ingredients or directions, the
pharmacist should consult the other pharmacist or
prescriber.
3. Collecting and weighing the material: - before
compounding the prescription, all the materials
required for it, should be collected on the left hand side
of the balance.
 After weighing the material it should be shifted to
right hand side of the balance. This gives a check
of ingredients which have been weighed. While
compounding the label of every stock bottle
should be read at least 3times in order avoid any
error.
i. When taken from the shelf or drawer.

9
Vishvajitsinh Bhati
 ii. When the contents removed for weighing and
measuring.
iii. When the containers are returned back to its
proper place.
4. Compounding, labeling and packaging: -
compounding should be carried out in a neat place. All
the equipment etc... Required should be thoroughly
cleaned and dried. Only 1 prescription should be
compounded at one time.
 The compounded medicament should be filled in
suitable containers depending on its quantity and
use.
 The filled containers are suitable labeled. White
plain paper of good quality should be used for
labeling the container.
 The container is polished so as to remove the
figure prints. While delivering the prescription to
the patient, the pharmacist should explain the
mode of administration, direction for use, and
storage.
Vishvajitsinh Bhati
 MODERN METHODS OF
PRESCRIBING
 Nowadays, the majority of the drugs are available
in the market as readymade formulation manufacturing
by different pharmaceutical companies.
 The drugs should be prescribed by its official
name and not by its proprietary or trade name.
 There are certain advantages and disadvantages of
prescribing the drugs by its proprietary name, which
are as under…

ADVANTAGES

1. It’s easy to remember proprietary because they are very

catchy.
2. It is easy to communicate with the patient.

11
Vishvajitsinh Bhati
 3. The continuity can be maintained by prescribing the
same proprietary name every time.
4. The bioavailability of drugs change with the change of
adjutants used in drugs formulation manufacture by
different
DISADVANTAGES

manufactures. So only those proprietary drugs can be

prescribed which have a better bioavailability.

1. It is cheaper to prescribe the drugs by its official

name.
2. It becomes difficult for a pharmacist to dispense
the substitute of the drug which is available in the
stock.

 There are 4 types of prescriptions which are

generally received by the retail drug store…
Vishvajitsinh Bhati
 I. Prescription in general practice.
II. Private prescription.
III. Hospital prescription meant for ‘out patients’.
IV. Hospital prescription meant for ‘in patient’.

CARE REQUIRED IN
DISPENSING
PRESCRIPTION
 Following precaution should be taken while
dispensing a prescription.
1) Always keep the prescription before you. Take the
prescription with you while taking out the medicine
from the shelf. It will serve as a constant reminder of
the name and strength of the preparation required
and helps to avoid mistakes.
2) Always check the dispensing balance before
weighing the ingredients which are required and help
to avoid mistakes.
13
Vishvajitsinh Bhati
 3) Replace containers of stock preparation or drugs in
their proper position after use.
4) Keep the label in upper position during weighing
solid ingredients especially the potent drugs such as
morphine hydrochloride to serve as a constant
reminder that the correct drug is being used.
5) When pouring or measuring the liquid ingredients,
keep the label upward in order to prevent surplus
running down of the bottle and staining the label.
6) Care should be taken to keep the dispensing balance
clean. The powder should be transferred from the
stock container by using a clean spatula. The scale
pan should be cleaned immediately after use.
7) Medicines which are uses externally such as lotions,
liniments, paints, etc...Should be supplied in
vertically fluted or fibbed bottles in order to
distinguish it by touch. They must be labeled in red
or against a red background.
8) Before handing over the medicine to the paints, again
check that the correct preparation, in the correct
Vishvajitsinh Bhati
 strength, has been supplied and correct direction has
been stated on the label.

15
Vishvajitsinh Bhati
 SOUECES OF ERROR IN
PRESCRIPTION

1. Abbreviation:-
 Abbreviation presents a problem in understanding
parts of the prescription order.
 Extreme care should be taken by a pharmacist in
interpreting the Abbreviation. Pharmacists should not
guess at the meaning of an ambiguous Abbreviation.

2. Name of the drug:-

 There are certain drugs whose name look or sound
like those of other drugs. Some of the example of such
drugs is as under: - Digitoxin and Digoxin

Vishvajitsinh Bhati
 3. Strength of preparation:-
 The strength of the preparation should be stated by
the prescriber. It is essential when various strengths of
a product are available in market.
4. Dosage form of the drug prescribed:-
 Many medicines are available in more than one
dosage form like as liquid, tablet, capsule, etc...

5. Dose:-
 Unusually high or low doses should be discussed
with the prescriber. Pediatric dosage may present. So
pharmacist should consult pediatric posology to avoid
an error.
 Sometime a reasonable dose is administered too
frequently.

6. Instructions for the patient:-

17
Vishvajitsinh Bhati
  The instructions for the patient which are given in
the prescription are incomplete or omitted.
 The quantity of the drug to be taken, the frequent
and timing of administration and route of
administration should be clearly given in the
prescription so as to avoid any confusion.
7. Incompatibilities:-
 It is essential to check that there are no
pharmaceutical or therapeutic incompatibilities in a
prescribed preparation and that different medicines
prescribed for the same patient do not interact with
each other to produce any harm to patient.
 Certain antibiotics should not be given with meals
since it significantly decrease the absorption of the
drug.

Vishvajitsinh Bhati
 Prescription handling
Dr. Jamshaid Sheikh
M. Phill (Pharmacy Practice)

Definition:
Prescription is a written document i.e. hand written, typed or computer generated issued
by the registered medical practitioner to individually named patients that contain
medicines.
OR
A prescription is a paper or electronic document detailing the medicine or medicines to be
dispensed for individually named patient and issued by an authorized prescriber.

A prescription is a three in one document

• Clinical document
• Legal document
• Invoice
CLASSIFICATION OF MEDICINES

• In general there are two types of medicines:

1. OTC (over the counter)
2. POM (prescription only medicines)

1. OTC :
• Any drug that can be taken by individual without prescription.
• These are the medicines those can be given to the individual without the prescription
from any pharmacy or retail outlet.
Criteria
The medicines declared on the basis of their previous history of efficacy and safety and
usually they have high therapeutic index and usually recommended in minor ailments.
Example:
• Dispirin
• Paracetamol
• Calpol
2. POM
All medicines that require a valid prescription for their issuance to the individual
patients.
Example
• Atenolol
• Alprazolam
 Prescriber

Medical professional that assess the patient, make diagnosis and prescribe the medicines
for the medicinal treatment is called Prescriber.
Types of Prescriber
More recently, the second Crown Report (1999) proposed two new classification of
prescribers:
i. Independent prescriber
ii. Dependent prescriber
1. Independent Prescriber
Any medical professional that assess the patient, make diagnosis and prescribe the
medicines for the medicinal treatment without dependent on other is called Independent
Prescriber.
2. Dependent Prescriber
Any medical professional that depend on independent prescriber is called Dependent
Prescriber.
• Mostly pharmacist are dependent prescriber. But not all the pharmacist are
dependent only specialized or clinical pharmacist that directly deal with the
patients
• They cannot prescribe the new medicines. In case of chronic ailments, when
patient taking long term therapy, the dependent prescriber, increase or decrease
the dose or change the product but not the active component.

ELECTRONIC PRESCRIPTION :
These are the prescriptions that contain the medicines name to the pharmacist sent by e-
mail from one computer to another for individual patient.
Merits
• Accuracy is more
• Save the prescription
• Save the history of patient
• Reliable method
• Get all the data about drug with software
• Drug interactions and contraindications are minimum
• Not damage the prescription
• Wrong prescription data is save and help in the identification.
• Easy order of the repeat medicines.
Demerits
• Expensive
• Difficult to avail
• More time consuming

PRESCRIPTION WRITING
Writing a prescription is a part of prescribing process. The stages in the prescribing process
are:
1. Define the patient’s problems (diagnosis)
2. Specify the therapeutic objectives
3. Verify the suitability of medicinal treatment
4. Write the prescription for medicinal treatment
5. Monitor the progress of patient

PARTS OF THE PRESCRIPTION

A complete prescription should have the following parts:
1. Date
2. Name, age, sex & address of the patient
3. Superscription
4. Inscription
5. Subscription
6. Signatura
7. Signature, address & registration number of the prescriber
8. Clinical history or diagnosis
Date
• Date must be written on the prescription by the prescriber when it is written.
• Prescription brought for dispensing containing the narcotic drug or other habit forming
drugs must bear the date.
• The prescription should be filled within a reasonable time after it’s written.
• Law defines the length of time from being written that a prescription remain valid.
• In UK prescription should be dispensed within 6 months of date except some drugs
like controlled substances where the requirement is within 28 days.
Name, age, sex & address of the patient
• If these information’s not written then pharmacist must ask the patient
• about these particulars and put down at the top of the prescription.
• This avoids the possibility of giving finished product to a person other than the patient.
• Patient full name must be written instead of surname or the family name.
• Age and sex of patient especially in case of children helps the pharmacist in checking
the medication and dose.
• Therefore there will be loss of danger of its being administered to the wrong member
of the family or the hospital ward having similar names.
• The address of the patient is recorded to help for any reference at a later stage, to
contact the patient or to deliver the medication personally
Superscription
• The superscription is represented by a symbol Rx which is always written on the top
left of the beginning of prescription.
• It was considered as the prayer to Jupietr, the God of healing, for quick recovery of the
patient.
• Abbreviation of Latin word “recip” meaning ‘taking thou’ or ‘you take’.
Inscription
 • This is the main part or body of the prescription, having following information:
i. Dose
ii. Dosage form
iii. Route of administration
• In past it contains the medicaments/active ingredients, bases or vehicles.
• But now-a-day only few prescription are compounded by a pharmacists.
• Majority of the prescription written for medications already prepared into dosage form
by industrial manufactures.
• The pharmacist is required only to dispense ready-made dosage form.
Subscription
• The part of the prescription that contains prescriber directions to the pharmacist
reading the dosage form to be prepared and a number of doses to be dispensed.
• Now-a-day only a few prescriptions are compounded therefore such directions are less
frequent.
Signatura
• It is usually abbreviated as ‘Sig’ on the prescription.
• It consists of directions given to the patients
i. Safe & appropriate usage
ii. Time, eating & use instructions
iii. Dilute it
iv. Not increase the dose
v. How many times a day
vi. Duration of treatment
vii. Route of administration
viii. Extra caring instructions
• These instructions should be mentioned on label of the container to ensure that patient
follow these instructions carefully.
Signature, address & registration number of the prescriber
• All other parts may be printed or typed written but the prescriber name must be hand
written and should be signed.
• This eliminates the danger of dispensing medicaments on a spurious order and it
authenticates the prescription.
• The prescription containing the narcotic and other habit forming drugs must bear the
address and registration number of the prescriber.
• This identifies the special licenses for prescribing the narcotics.
Clinical history or diagnosis
• This portion is on left side of the body of the prescription.
• This portion contains the history of the patients, i.e. blood pressure, allergy, interaction
or any problem .
• This also contains the diagnosis of the patients, i.e. asthma, CHF etc
HANDLING OF PRESCRIPTION
Receiving
The prescription should be received from the patient by the pharmacist himself.
Under no circumstances an unauthorized person should try to receive or read the
prescription.
Reading & Checking
 • A brief examination of each prescription should be made immediately upon receiving
it from the patient.
• This will tell the pharmacist about the nature of dosage form to be prepared and he can
estimate the time required for preparing it.
• If a long time is needed for compounding the prescription then he must tell the patient
about the time required to fill the prescription.
• In some cases patient’s name, age & address was not mentioned on the prescription in
such cases these information enquired from the patient.
• Careful examination of the prescription should be made only behind the counter, so
that if any error is present patient should not come to know about it.
• If there is any error or doubt he should consult the other pharmacists or the prescriber.
• Every prescription should be read and understood completely before compounding it.
• Every word and abbreviation must be read correctly, not guess any word otherwise
serious consequences are there.
Common Mistakes
• As number of drugs in the market are increasing, the mistakes, due to the similarities
or pronunciations and spelling are also increasing. So, pharmacist takes great care
especially when the prescriptions are received orally. Some drugs are given below:
• Apresoline , Priscoline
• Compocillin, Ampicillin
• Daricon, Darvon
• Digoxin, Digitoxin
• Prednisone, Prednisolone
• Quinine, Quinidine
Collection & Weighing Materials
• Materials to be used in compounding the prescription should be collected on the left
hand side of the balance and arranged in the order in which they are not to be mixed.
• The materials which are weighed should be shifted on right hand side of the balance.
• This gives a mechanical check of the ingredients which has been weighed.
• The label on every stock bottle should be read during the following three times:
• When taken from the shelf or drawer ii. When the contents are removed for weighing
or measuring iii. When the container are returned back to its proper place
Compounding
• This is the most important phase in handling the prescription.
• In this case proper drug is dispensed in a suitable form.
• This can be achieved only if accuracy, cleanliness and proper techniques are observed
in the preparation of any medication.
• Compound single prescription at one time.
• If two or more prescriptions are dispensed at the same time, one is likely to make
serious mistake by dispensing wrong drug.
• Attention should not be diverted by talking to the friends, attending the telephone or
engaging in other directions.
• Now majority of the prescriptions are return for the precompounding dosage forms
supplied by the pharmaceutical manufactures which required no compounding or
mixing by the pharmacist.
• Finishing
Containers
The compounded medicaments should be filled in a suitable containers.
Various type of containers are used in pharmacies:
• Round vials: For tablets & capsules
• Oval bottles: Low viscosity liquids
• Wide mouth bottles: High viscosity liquids, bulk powders
• Ointment jars & collapsible tubes: Ointments, creams & solid dosage form
• Dropper bottles: Eye drops, ear drops & other liquids administered by drops
• Sifter top container: powder to be sprinkled
Labelling
• The filled containers are suitably labelled, a good quality of paper and adhesives
should be used for labelling.
• The size should be proportion to the size of the containers.
• The label should be neatly hand written or preferably typed
• The following information should be written on the labels
i. Name of the prescribed medicines
ii. Name of the patient, age & sex
iii. Registration number
iv. Date of dispensing
v. Directions for its use
vi. Expiry date if any
vii. Storage conditions
viii. Name and address of pharmacy
Counseling
• Counseling is very important part of handling prescription.
• Pharmacist should hand over the medicines to the patient with counseling.
• He must guide the patient about safe and appropriate use of the medicines.
• He must tell about the drug interactions, contraindications and food interactions etc.
• He must guide the patient about timing of the drug to be taken, i.e. morning time,
evening time, bid, tid etc.
PRESCRIPTION PRICING MARK UP
It refers to difference between the cost of merchandise and selling price.
Types
It is of three types.
• Percent mark-up
• Percent mark-up + Minimum professional fee
• Professional fee
1. Percent mark up
In percent mark-up we use the following equation for the calculation of prescription pricing
(PP).
• PP = Cost of ingredients + (Cost of ingredients × Percentage Markup)
Percentage Mark-up is based on the ingredients cost.
Percentage Mark-up based on the assessment of all things (80% usually)
PP = 4Rs + (4Rs × 80%)
PP = 4Rs + 3.2Rs = 7.2Rs
2. Percent mark-up + Minimum professional fee
It is calculated by using following equation:
PP = Cost of ingredients + (Cost of ingredients × Percentage Markup) + Professional fee
In this case Percentage Mark-up is 50%.
Professional fee is also added in this but add minimum fee.
3. Professional fee
In Professional fee we use the following equation for the calculation of prescription pricing
(PP).
PP = Cost of ingredients + Professional fee
Cost of ingredients are added
More Professional fee is added because there is no additional Mark-up is there.
Calculation of Price
• According to the dose, price per dose is calculated.
• Then calculate the price for full treatment course.
• In case of syrups or creams or other things like this, the price of full bottle or tube is
calculated.
 by Robert V. Evanson*

formula for success •••

cost-pricing and
prescription pricing professional fee
P rescription pricing is one of the most
important current topics discussed
by everyone from executives of pharma-
therapeutic values of available prod-
ucts and physicians' primary pref-
erences. For cases wherein the patients'
pharmacist may be capable of com-
pounding any specialty item he dis-
penses (given proper equipment and
ceutical manufacturing companies to re- incomes are a real, limiting factor, the materials), to do so would increase pro-
tail pharmacists, from journal editors to prices of the primary preferences and duction costs for like grade and quality
college professors and students. Many the availability of suitable, less-expen- to such levels that the prices for which
ideas, facts and opinions have been ex- sive substitutes may be considered. he could offer prescriptions would find
pressed which find both agreement and Caplow and Raymond 1 reported a no buyers. Thus the manufacturer rep-
disagreement depending upon the study of 182 physicians in six midwest resents a form of economic substitution
writer's position. But there are certain states relative to the reasons for the for the factors of production which per-
factors of prime importance to be con- adoption of a drug. They found that mit a material cost within the limits of
sidered which lead to a rational ap- for 377 drug histories, 85.6 percent were sound, economic operation for indis-
proach to the pricing of all prescriptions. adopted and used by physicians because putable quality. The manufacturer truly
One basic concept to establish is of superior therapeutic and/or adminis- represents the greatest single factor in the
the nature of the consumer's personal trative qualities, but that only 2.4 per- reduction of pharmacists' supply prices
demand for prescription merchandise. cent were adopted and used because of rather than the greatest cause for high
Many writers relegate professional phar- price. Evidently price per se is of little prices as so often voiced by pharmacists
maceutical services and the resulting importance as a prime factor of the as a demurring defense or by others as a
products to the category of "something prescribing function and the patient complaint against drug prices.
that nobody wants." Granted that must be willing either to pay the price
some surveys show that not all pre- quoted (presumed to be the effective
scriptions written reach the pharmacy,
f or
demand price) or be denied the values of
but to say that prescriptions are some- specificity inherent in the drug of
thing unwanted is both a misstatement
PRESCRIBING
choice.
of fact and presumptuous. No rational Current reactions to prices of pre-
person "wants" to be ill, but a person so scription specialities seetn to indicate a
incapacitated has both the want and certain amount of resistance in demand
the need to be restored to his normal con- prices. Some relief may be possible
dition of health. He may choose one of through prescribing lesser quantities,
three actions-he may do nothing and but the extent to which this action can
permit the illness to run its course; he alleviate an actual or anticipated re-
may resort to self-medication; he may sistance is limited by the minimum
demand the services of a physician. quantities required to effect a cure or
Since prescriptions result from the lat- maintain a desired or continuing thera-
ter action, it can be assumed that the peutic effect.
patient choosing this action does both
nature of supply prices

~
need and want the drugs prescribed for
his particular condition. Supply prices are the prices which
dealers are willing to accept for different
nature of demand prices
amounts of output. Normally the ex-
2.4%
Important to the proper understand- penses of production, when any given
ing of demand prices-prices which con- amount of goods or services are pro-
sumers will pay for given quantities of duced, are the supply prices of the cor-
prescribed drugs-is a philosophy that responding factors of production. The Compounding and dispensing are also
prescriptions may be characterized by a _sum of these are the supply prices for production functions. The difference in
somewhat absolute demand on the part that amount of the commodity or man-hours to produce finished prescrip-
of patients. However, this demand is service. tions for specialities may be negligible
dependent upon, or is derived from, a What are these factors of production but a compounded prescription requires
relatively elastic commodity-physi- for the pharmacy? They include the individual attention and more than the
cians' services, or the kind, quality and complete cost of putting the materials on average time. Supply prices may in-
amount of pharmaceuticals deemed the shelf, plus the complete cost of com- clude an average time charge for all pre-
necessary by the physician to restore the pounding or dispensing, plus the over- scriptions with those compounded in-
patient to his normal condition of health. head costs incurred in operating the de- cluding charges in amounts equal to the
Thus the practice of pharmacy is partment, plus an addition for a fair re- additional costs for labor or each pre-
based not upon an uncalculated need or turn in a net or professional profit. scription may be charged as an indi-
unpremeditated impulse but rather It is necessary to establish a basic vidual event or a standard charge may
upon a calculated need which is de- philosophy regarding manufacturers' be added to all prescriptions.
pendent to a great degree upon the specialities. Although the individual Overhead represents all other opera-
1. Caplow, Theodore, and Raymond, John, tive expenses including indirect labor
* Presented to the section on pharmaceutical "Factors Influencing the Selection of Pharmaceu- costs related or incidental to produc-
economics at the 1959 convention of the AMERI- tical Products," Jl. of Marketing, 19 , 18 (July
CAN PHARMACEUTICAL ASSOCIATION in Cincinnati. 1954). tion functions. Although it may seem

700 JOU RNAL OF THE AMERICAN PHARMACEUTICAL ASSOCIATIO N