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Australia’s understanding and adoption of Quality Use of Medicines (QUM) principles across general practice and primary care has led to overall improvements in medicine use, such as curtailing high-dose use of proton pump inhibitors.
But the challenge has since changed, with Australians living longer – resulting in an older, sicker population who uses more medicines, said Professor Libby Roughead – Director of the QUM and Pharmacy Research Centre at the University of South Australia.
‘Now the game is to say, how do we go forward when we’ve got a frail older population, and lots of specialty medicine? she asked.
This is the question a panel of experts sought to answer at the National Medicines Symposium 2024 yesterday (19 November).
Be wary of using ‘wonder drugs’ in older patients
When clinical trials are conducted on new medicines, they’re not tested in the over 65 age group, said Steve Waller, Senior Advisor, Medication without Harm, Australian Commission on Safety and Quality in Health Care.
‘That creates complications, because we often don’t know what the impact in that older age group is … and pharmaceutical companies don’t have that information when they’re making an application for a new drug to be listed with the TGA [Therapeutic Goods Administration] and PBS [Pharmaceutical Benefits Scheme],’ he said.
Healthcare professionals must have awareness of the limitations of the data, thinks Professor Jennifer Martin, clinical pharmacologist and president of the Royal Australian College of Physicians.
‘Often, I say to people “why are you using a statin in [an older] population? We know the life expectancy when you go to a nursing home is less than 2 years, and you have to be on this drug at this dose for 5 years just to see a small reduction in a composite end point”,’ she said.
Healthcare professionals should rely on Australia’s ‘good sources of objective information’ such as Therapeutic Guidelines and the Australian Medicines Handbook, said Prof Roughead.
But more work needs to be done on increasing uptake of non-pharmacological interventions that are suitable for many conditions, including art therapy, music therapy, exercise and diet.
‘We know compassion practices are really helpful in some of the hard-to-treat conditions [such as] pain and depression, so we need to get better at involving the whole therapeutic armamentarium,’ she said. ‘The first definition of QUM is judicious selection of management options.’
Involve older patients in deprescribing decisions
Doctors, pharmacists, family members and carers typically talk among themselves about an older patient’s medicine regimen. But it’s the patient they need to focus on, thinks Prof Martin.
‘When you talk to an older person, they will typically say “I don’t know why they started those pills” or “I don’t think I was supposed to be on them long-term, but no one stopped them, so I just kept taking them”,’ she said.
‘So, come back to the patient and ask, “Why are you taking these medications? What are your goals of care? Do you want pain relief? What are you looking for?”’
As patients reach their final chapter, many are just after quality of life – which doesn’t necessarily entail losing cognitive function through heavy use of opioids.
‘Opioids may play some role in pain, but they certainly take away a lot of the quality of life for older people,’ said Prof Martin. ‘It’s not until you spend time talking to the person that you find out they actually want to be very sharp; they think they can cope with their pain by other measures, and we can probably reduce some of their opioids.’
Warranted distrust in medicines and healthcare needs to be built back up
While we live in an age where misinformation is rife, some of it stems from the health system and pharma model, said Prof Martin.
‘For example, we know with gabapentin, which some people use for pain, most of the information that got onto the market was fraudulent,’ she said. ‘[There] was then a big investigation, with lawsuits still ongoing.’
The same goes for opioids, ineffective for many of the conditions they are prescribed for – particularly chronic pain.
‘The public are looking at their health providers saying, “We now know this is misinformation, but you prescribed this”, so we’ve lost a bit of engagement with our community,’ said Prof Martin.
With many patients with chronic pain on high doses of opioids that are not treating their conditions and impairing their quality of life, Prof Martin thinks the healthcare sector has ‘something to answer for’.
‘That misinformation is coming from industry and from the fact that we’re too busy to actually go back to their source material,’ she said.
The good news is that opioid deaths have decreased over the last 5 years in Australia, thanks to tighter prescribing regulations and better resources such as the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, said Mr Waller.
Work on state formularies has also reduced the number of opioids that people can prescribe, said Prof Martin.
‘It has helped to get that conversation going of “Why do you need to have access to 10 different opioids in an in-patient setting?” and “Why do you need all these different concentrations?”’ she said.
However, more changes in practice are required to ensure that trend continues in the right direction, said Mr Waller.
‘We need to stop using opioids for chronic pain,’ he said. ‘There’s limited to no evidence to suggest that they work, and we need to be very judicious about our use of modified-release opioid analgesics.’
Yet as that work is done, it’s crucial to remember that these patients are suffering and compassion should be brought to the encounter – rather than simply saying ‘you can’t have that’, said Prof Roughead.
‘It’s not just ceasing a medicine. It’s ceasing a medicine and starting other things that you might need to help you be well, whether it be an exercise program or psychological services,’ she said.
Pharmacists can bridge communication and healthcare gaps in RACFs
With the Aged Care On-site Pharmacist (ACOP) program kicking off on 1 July 2024, pharmacists can improve the approach to healthcare by simply getting to know people – a skill well-honed by pharmacists in other settings, said Prof Roughead.
This includes understanding patient preferences and non-pharmacological activities that might support them.
‘If we can build a system where we can create relationships, particularly in a virtual world … we’re all going to be safer and we’re all going to feel better,’ she said.
‘That’s got to be the strength of an embedded pharmacist in aged care, that day-to-day knowledge of what the patient’s likes and dislikes are and how they’ve been managed over a continuum, as opposed to a visit that might happen once a year,’ added Mr Waller.
As the custodian of the pharmacy profession’s Professional Practice Standards and an education and training provider, PSA has continued to invest and embark into practice support training and education for pharmacists to become ACOP credentialed, said PSA National President Associated Professor Fei Sim.
The training covers all elements of this role – from professionalism, to understanding the governance of an RACF, collaborative practice, providing person-centred medication management and working within a multidisciplinary team to improve the safe and quality use of medicines.
‘Pharmacists undertaking the training program would then acquire the necessary credentials, qualifications and skill set to be able to undertake the role as an aged care on-site pharmacist,’ she said.
‘We’re also providing ongoing resources and clinical updates for credentialed pharmacists so they can be kept up to date with their knowledge and skills to undertake the role.’
With any new areas of practice, there is a great need for mentoring and networking for like-minded pharmacists who work in the same area to forge bonds, said A/Prof Sim. ‘That’s why PSA created the Consultant Pharmacists CSI group [and] an annual Consultant Pharmacist Conference, focusing on supporting and meeting the learning needs of credentialed pharmacists.’
