Professional Documents
Culture Documents
Notes
PHAR1811 Notes
What do pharmacists do?
‐ Use expertise in medicines to optimise health outcomes and minimise medication misadventure
‐ Apply knowledge of poisons to promote their safe use and avoid harm to users and others
‐ Practitioner, caregiver, decision maker, scientist, teacher/educator, manager, leader,
communicator, lifelong learner, public health promoter, provide primary health care and advice
‐ Require sound pharmaceutical knowledge base, effective problem solving, organisation,
communication and interpersonal skills, ethical and professional attitude
Term Definition
Drugs Chemical entities which have some effect on the body, e.g. aspirin
Substance with narcotic or stimulant effects
Medicines/medication Drugs as they are given to the person, e.g. aspirin tablet
Poisons Drugs/medicines
Drugs work at the:
‐ Molecular level – chemical/biochemical reaction
‐ Level of organ/body part – e.g. strengthens heart/heartbeat
‐ Level of whole person – e.g. person able to walk and breathe more freely
Reasons for medicines
‐ Allow drugs to get to where they have their effect
‐ Drug doses often too small to be given as just the drug
‐ Different drugs given by different methods
o Get to where needed as quickly or slowly as possible
o Avoid being destroyed by body before arriving at site
o Ease and convenience for patients
o Avoid drug going to where it has unwanted side effects
Medicine examples Advantages and disadvantages
Tablets and capsules + Convenient, most drugs able to get into bloodstream
‐ Some are destroyed by enzymes/acid in stomach, cannot cross stomach or
intestine wall to enter bloodstream, cause irritation/damage to stomach/intestine
Inhalations + Fast‐acting – drug goes directly to where it acts, especially lungs
+ Helps avoid side effects – drug stays in lungs, does not go elsewhere in body
+ Comes in range of devices for people with different needs
Injections + Very fast‐acting if injected into blood (intravenous)
+ Can be slow‐acting and last for long time if injected into muscles (intramuscular)
+ Not destroyed by stomach acid or enzymes
‐ Inconvenient for patients
Research Activity which results in someone discovering something or understanding better
Primary Generation of new data or results
Secondary Using results generated by other researchers and summarising, analysing, interpreting
and evaluating them
Observational Observation of ongoing behaviour
Experimental Involves intervention
Scientific Uses scientific method; aim is usually to try and establish facts or laws
Historical Analyse historical source materials, use them to construct a historical account
Social May use scientific method, but also looks for patterns and generalisations
Market Looks for ways of understanding the behaviours and choices of consumers
Paradigms
‐ Paradigm – predominant worldview/accepted idea at a particular time, e.g. evolutionary paradigm
o Not ‘truth’, but accepted as being the best current approximation to explain observations
‐ Paradigm shift – cultures transform way of thinking from one thought system to another, pivotal
change in humanity’s way of thinking regarding a particular worldview
o E.g. Lamarckism vs. Darwinism, Ptolemaic geocentrism vs. Copernican heliocentrism, pre‐
and post‐Columbus and Magellan (flat vs. spherical earth)
‐ Medical paradigms
o Western diagnosis and treatment – biological/physiological/pharmacological perspective
o Traditional Chinese, Ayurvedic approaches
o Psychological treatments – ‘mind over matter’
o Historical – the four ‘humours’
o Alternative medicines – naturopathy, homeopathy, aromatherapy
‐ The nature of the paradigm dictates:
o What types of knowledge are important
o What sorts of research questions are valid to be pursued, and ‘experiments’ to carry out
o What sorts of evidence are considered relevant
o How results of research are interpreted and explained
‐ Scientific method:
o Decide on research question to be asked
o Look at previous information or results relating to the question
o Form a testable hypothesis
o Perform appropriate experiment/make appropriate observation, and collect relevant data
o Analyse data using appropriate (statistical) techniques
o Interpret data and draw conclusions which may evoke development of new hypotheses
o Publish results (journals, books)
o Replicate the results (usually done by other scientists)
Sources and Quality of Evidence
‐ REVIEW – relevance, expertise, viewpoint, intended audience, evidence, when published
‐ Book – author’s credentials (degree, professional affiliation), currency, peer‐review, intended
audience (academic or popular)
‐ Article – peer review, expected structure and content, contestable by others who repeat the
experiments
‐ Website – owner (government, organisational, individual, educational, commercial)
o Reason for existence – public information, product sales, personal experience
o Objectivity, use of advertising, accuracy, disclaimer, typos, references
‐ Advantages of using primary sources
o Closest to original event
o Specific to what you are researching/trying to answer
‐ Advantages of using tertiary sources
o Sources have already been analysed
o Gather a wider perspective/understanding/more interpretations of the information
Strength of evidence – level and quality (determine possible bias); statistical precision (chance)
Level of evidence Description
E4 (lowest) Case series, uncontrolled studies
E3 Efficacy demonstrated in case‐control (retrospective), cohort study (prospective),
non‐randomised concurrent control, or historical control trial
E2 Efficacy demonstrated in at least one randomised controlled trial (RCT)
E1 (highest) Efficacy demonstrated in systematic review of RCTs
Evidence‐based medicine (EBM)
‐ Process of locating and evaluating most relevant research findings and using results as the basis for
making clinical decisions
o Use scientifically generated evidence produces greatest likelihood of therapeutic success
o Recommending interventions in accordance with best available evidence may reduce
morbidity and mortality
o Patients have increasing access to scientific literature – expect health practitioners to
recommend treatments based on sound medical evidence
Type of study Description
Case series/ Characteristics of group of patients (series of cases) observed, described and
Observational published – slightly biased (no controlled variables)
Case‐control/retrospective studies
‐ Potential risk factors (e.g. diet) and exposure to treatment/intervention
of one group with the outcome/disease are compared with similar
information obtained from a control group – “looking backwards”
‐ Patients must recall info from past – responses influenced, aspects
omitted – less reliable; required data not obtained at the time
‐ Require fewer subjects and can be completed in a shorter time
Cohort/prospective studies
‐ Large group of individuals studied over a period of time to investigate
the outcome of a particular risk factor or exposure – “looking forwards”
‐ Know what you’re looking for, but may not have right people so large
group is required for statistical significance
Uncontrolled trials Post‐test studies – only outcomes of intervention are recorded (no comparisons)
Pre‐test/post‐test studies – outcomes are measured in subjects before and after
exposure to intervention (allows comparison)
Concurrent control Two or more groups – one acts as control (continue on normally), other receives
something new or varied – comparison made from each groups’ outcomes
Historical control Outcomes for a group of subjects exposed to the new treatment/intervention
are compared with a group treated in the past
Randomised Similar to concurrent control trail, but subjects are randomly allocated to
controlled trials (RCT) groups, e.g. placebo/control or intervention/treatment, to reduce bias
Systematic reviews Systematic location, analysis and synthesis of evidence from all available
published scientific studies
Meta‐analyses Quantitative statistical analysis of several separate but similar and comparable
studies, in order to test the pooled data for statistical significance
Eliminating bias
‐ Randomisation – relies on statistical principles to reduce bias
‐ Placebos – pharmacologically inert medication which looks, tastes and smells the same as the
active medication – in theory has no pharmacological effect
o Allows researcher to compare active drug with placebo – control
o Placebo effect – patient experiences response (therapeutic or side effects) to placebo as if
taking the real medication
‐ Blinding – Single blind trials – patients don’t know whether they receive active drug or placebo
o Double blind – patients and researchers don’t know who is getting the treatment
o Triple blind – patients, researchers and analysts unaware
‐ Crossover designs
o Each group receives one treatment for specific period
o Patients act as their own control, e.g. one treatment ‐> washout/break ‐> other treatment
Can be two treatments (e.g. different dosages) or treatment vs. control
o Ethical/practicality issues, e.g. cancer treatment
Sources of bias
‐ Non‐randomised trials
‐ Non‐comparability – 2 groups are initially different, e.g. people with higher cholesterol respond
better to drug (than mild cholesterol)
‐ Different co‐morbidity and co‐treatment – groups differ in the other treatments received
‐ Different measurement methods – e.g. historical controls or prolonged studies
Confidentiality and ethics
Scenario Issue
Person collecting ‐ Collector may be wrongly using medication for themselves
prescription is not the ‐ Clinical advice/details may not be passed on to patient
patient themselves ‐ Confidentiality – patient’s medical information is being accessed by others
! Provide printed information and place in paper bag along with medication
Some medications have ‐ Clear any pre‐conception of a patient’s condition or reason for medicine use
more than one use ‐ Clarify patient’s intended use prior to counselling
‐ Interact with patients in a discrete manner
‐ Health practitioners are unable to disclose a patient’s medical information to others, regardless of
the patient’s age
‐ Pharmacies may maintain the privacy of consumers by hiding name of medicines on tax printouts
‐ Releasing private information without the knowledge/consent of the patient is breaching the
patient‐pharmacist confidentiality code
Characteristics of a profession
‐ Code of conduct/professional code
‐ Autonomy – determines its own standards
‐ Specialised body of knowledge and skills primarily held by members of that profession
‐ Standards must be met through a form of assessment
‐ Public service
‐ Individuals of the profession identify with that profession (i.e. is part of their identity)
National Competency Standards Framework for Pharmacists in Australia 2010
‐ Competency Standards describes the skills, attitudes and attributes (e.g. values and beliefs) which
together enable an individual to practise effectively as a pharmacist
o Capacity and ability to perform tasks, including knowledge and communication skills
o Professional and ethical practice, leadership, communication, collaboration, preparing
pharmaceutical products, supplying prescribed medicines, delivering primary and
preventative health care, promoting optimal use of medicines, research, education
‐ Professional Practice Standards relate to the systems, procedures and information used by
pharmacists to achieve a level of conformity and uniformity in their practice
o Refers to the way the activities are performed
o Professionalism, ethical practice, maintenance of consumer privacy and confidentiality
‐ Personal competence and the adoption of quality standards are both required to ensure
professional services deliver optimal health outcomes for consumers
‐ Continuing professional development (CPD) – mandatory for all pharmacists seeking annual re‐
registration to practice – read relevant articles and answer questions to submit for assessment
Laws Sets of rules, imposed on each of us by our own community, which we must obey
Ethics Sets of standards which we impose on ourselves, either individually or as a group
Standards E.g. codes of conduct, professional standards
Activities pharmacies are expected to carry out competently
‐ Promote good health and wellbeing
‐ Interact with other health practitioners
‐ Utilise expert knowledge and provide care in a professional and compassionate manner
‐ Give advice on when and how to take medicines and inform consumers of side‐effects
o Ensure shared decision making through relevant communication and advice
o Ensure business practises are conducted primarily in the best interest of the consumer
‐ Respect consumer’s choice, compliance with consumer’s right to privacy, ensure confidentially of
patient’s information, not discriminate on any grounds
‐ Exercise professional autonomy, objectivity and independence, and manage situations of conflict
of interest
Reflection Process of thinking back on experiences, exploring them from hindsight, trying to
learn something as a result, formulating a plan to change something in the future
Reflective Writing in a manner that looks back on past experiences and seeks to explore
writing personal feelings, opinions and thoughts
o Self‐questioning – what has been achieved, what new questions have arisen?
Assessment Means of knowing what we have learnt, identification of misunderstandings,
strengths and weaknesses through provision of feedback, encourages future learning
Self‐assessment Ensuring correct dispensing of prescriptions, deciding whether to consult a colleague,
by pharmacists deciding on appropriateness, extent and content of counselling
Feedback Realistic, specific, descriptive, sensitive but direct, non‐judgemental, positive and
negative (if necessary), individual rather than comparative
Reflective writing Descriptive writing
Subjective information Fact and objective information
Looking back on past experiences, consideration of Looking at presently available facts and
practice, critiquing information
Personal thoughts and experiences No/limited bias
Descriptions, emotive language Order and sequence (logical)
Self‐analysis, self‐questioning Retelling an event
Focus on how event will influence future instruction Focus on what happened
Term Description
EBP (practice) Integration of best research results with clinical expertise and patient values
Hypothesis Statement that can be tested against reality (true or not?) and can then be
supported or rejected
Intellectual property Research, words and ideas generated by and owned by an author
Meta‐analysis Statistical technique allowing one to combine findings from several studies and
determine whether significant trends emerge
Peer review Set of procedures where one’s colleagues evaluate one’s contribution to the field
Random allocation Assignment of participants to different experimental groups on the basis of
chance and chance alone
Research Honest attempt to systematically study a problem, or add to its knowledge
Qualitative research Research technique that stresses the interpretation of language and context
Quantitative research Research technique that focuses on numerical calculations and statistics
Scientific method Use of investigative methods that are objective, systematic and reliable
Theories A collection of general principles which serve as an explanation of established
facts and observable data
History of medicine
Ancient Egypt
‐ 2700BC – ‘physicians’ and ‘dentists’ recorded
Edwin Smith papyrus Ebers papyrus
Primarily surgical Primarily medical
Cases of head injuries Medical textbook – eye, skin, internal, limbs – relatively advanced
approach to medicine
Techniques for stitching, splinting, Primitive understanding of human body – made up of fire, earth,
drilling air, water
Importance of observing patients Almost 900 pharmaceutical remedies
Supernatural dimension Magic played a key role – amulets, exorcisms, spells
highlighted Gods associated with healing, e.g. Isis, Re, Thoth, Imhotep
Most physicians were also priests
Ancient Mesopotamia
‐ Civilisations in the fertile area between Tigris and Euphrates rivers
‐ Evidence of medical practices – clay tablets (rather than papyri)
‐ Physician’s seals dated to 3000BC
‐ Code of Hammurabi (2250BC) – fees for medical services, punishment for malpractice
‐ Medicine intertwined with religion – gods of healing and disease, physician‐priests
‐ Disease was a punishment for sin
o If cause of sin not apparent, used methods of divination
Astrology, reading livers of sacrificial animals, interpreting dreams, abnormal
births of animals and humans, behaviours of animals, fire, rivers, plants and oil
o Also extensive use of plant remedies
Ancient Greece
‐ Disease seen as a disorder of the body, rather than the soul
‐ Magic/religion less prominent
‐ Original god of healing Apollo, replaced by Asclepius (5th century BC)
o Rod of Asklepios – staff and holy snake – symbol of medicine
‐ Disease believed to be caused by imbalance of humors
o Treatment – give the opposite qualities to restore humor balance
o E.g. treat yellow bile with ‘cold and wet’
Element Humor Origin of humor Qualities
Fire Yellow bile Liver Hot, dry
Earth Black bile Spleen Cold, dry
Air Blood Heart Hot, wet
Water Phlegm Brain Cold, wet
‐ Hippocrates (460‐379BC) – great physician
o Treatment of whole person, not just disease
o Nature intrinsically moves towards restoring balance – theory of natural healing
o Focused on progression of disease rather than speculating the causes
‐ Galen (130‐201AD) – physician to gladiators and emperors
o Contributions to anatomy and physiology – through extensive dissections
o Polypharmacy (‘many drugs’) – complex remedies with numerous ingredients
‘Theriac’ – universal remedy with 73 ingredients in honey
o Careful records of methods and dosages – recognised dose‐harm relationship
Arabic medicine
‐ 9th – 12th centuries
‐ Heavily influenced by Greek medicine but developed traditions beyond Greek model
‐ Provided link between Greek and early modern medicine
Persian medicine
‐ Important writers – al‐Razi (Rhazes), al‐Majusi, ibn Sina (Avicenna)
‐ al‐Majusi’s The complete book of the medical art
o General principles of elements and humors
o Symptoms of disease, causes and diagnosis from pulse, urine, fevers, saliva, perspiration
o General principles of hygiene, dietetics, cosmetics and therapy
o Different therapies for different diseases
o Surgery and recipes for medicaments
Developments in understanding Explanation
Anatomy ‐ Renaissance – increased interest in anatomy by artists, e.g. Vesalius
‐ Anatomy not perceived to be related to medicines
‐ Anatomy did not show physicians how to cure disease, only showed
the diseased and non‐diseased parts of the body
Physiology ‐ Theory of humors – used for many centuries
‐ Theory of circulation
‐ William Harvey (1628) – challenged the circulation theory
Understanding of disease ‐ Disease as a group or pattern of symptoms
‐ Disease as an altered anatomy
‐ Disease resulting from invasion by living organisms
Opium
‐ Common in Sumerian, Assyrian, Egyptian, Minoan, Greek, Roman, Persian and Arabic medicines
‐ Active part – gum extracted from unripe seed capsules of opium poppy – ‘poppy juice’
‐ Medicinal use – pain relief, anaesthetic (sedative and pain‐killing properties)
‐ Ritual use – used by priests and magicians, associated with deities, e.g. Isis, Apollo, Aphrodite
‐ Recreational use – smoking, probably began in China 15th century in opium dens
‐ Opium wars fought over opium trade between China and Britain
‐ Laudanum
o Tincture of opium (opium extracted with alcohol)
o Used recreationally as cheaper than wine or gin
o Used by many literary and political figures – Keats, Shelley, Dickens, Lewis Carroll, Edgar
Allan Poe, Samuel Taylor Coleridge
Coca
‐ Grows in South America (Andes Mountains) ‐ high, cold areas
‐ Used in medicine of Peru, Colombia, Ecuador, Venezuela, Bolivia
‐ Active part – leaves which are chewed with lime
‐ Major effects – mild stimulation, suppression of hunger, pain, thirst and fatigue
‐ Coca in Europe – used in ‘cocawine’
‐ Coca‐Cola
o Invented by American pharmacist John Pemberton, sold as medicine in Georgia 1886
o Non‐alcoholic alternative to cocawine – combined cocaine and caffeine
o Treat headaches, heartburn, lack of energy, impotence, morphine addiction
Belladonna (devil’s cherries, black cherry, deadly nightshade)
‐ Berry contains active ingredient
‐ Traditional use – dilate pupils
‐ Extremely toxic, causes hallucinations
Digitalis purpurea (Purple fox glove)
‐ Used by Dr William Withering in 18th century for ‘dropsy’ – oedema associated with heart failure
‐ Use of digitalis recognised as beginning of modern therapeutics
‐ Active ingredient – digoxin (still used today)
Importance of extraction of pure substances
‐ Standardised doses
‐ More widespread availability
‐ Able to by synthesised chemically
‐ Can be chemically modified to change therapeutic profile
o Cocaine ! anaesthetics
o Quinine ! anti‐malarials Pure substance Plant extracted from
o Atropine ! drugs for eyes, Morphine, codeine Opium
asthma, gastrointestinal tract
Cocaine Coca
Quinine Cinchona (bark)
Volatile anaesthetics and surgery
Atropine Belladonna
‐ Use of appropriate anaesthetics
Strychnine (causes muscle Nux vomica
transformed surgery
spasms, convulsions, death
‐ Volatile anaesthetics – produced altered
by asphyxiation)
consciousness
o Used CO2, nitrous oxide (laughing gas)
o Diethylether – effective, but flammable and caused severe post‐operative vomiting
o Chloroform – replaced diethylether in England, used by Queen Victoria in childbirth
More toxic than diethylether
Vaccination ‐ Prevention of infection
‐ Edward Jenner
o Noticed that milkmaids exposed to cowpox did not contract smallpox
o Smallpox declared eradicated in May 1980 by WHO
o Two small stocks remain in USA, Russia
Infection control ‐ Limited by poor understanding of transmission process
o Bacteria observed and described by Anton van Leeuwenhoek (18th century)
o Germ theory of disease – Louis Pasteur, Robert Koch
o Transmission of disease in hospitals through unclean hands – Oliver Wendell
Holmes and Ignaz Semmelweis in 1840s
‐ Importance of hygiene in limiting spread
Antibiotics ‐ Treatment of infection
‐ Alexander Fleming
o Accidental contamination of bacterial culture plates with mould (penicillin)
‐ Howard Florey and Ernst Chain
o Turned discovery into viable medicine
o Long and difficult process – culture vast quantities, determine structure,
synthesising from simpler molecules
‐ Albert Alexander
o Serious infection from scratch by rose thorn
o Recovered using injection of penicillin, but penicillin ran out and he died
Insulin
‐ Late 19th century – connection between pancreas and diabetes known
‐ Banting, Best, Macleod and Collip – isolated insulin from foetal calf pancreas
‐ Eli Lilly (drug company) – took over insulin production
‐ Originally all insulin from animal sources, e.g. cows, pigs
‐ Human insulin now synthesized by recombinant DNA technology
Oral contraceptives
‐ Allowed separation of intercourse from reproduction
‐ Gave women more choice – if, when, how frequently to have children
‐ Gave women, particularly married, more opportunity to pursue careers, lengthen professions
‐ Relaxed approach to sexual intercourse outside of marriage
Thalidomide and teratogenicity
‐ Thalidomide used to treat morning sickness
‐ Sold in 50+ countries, believed to be responsible for 10,000 children with severe birth defects
o Phocomelia – very short arms or legs, and flipper‐like hands or feet
o Damage to ears, eyes, internal organs
o Majority did not survive childhood
‐ 1961 – over 150 birth defects in babies whose mothers had taken thalidomide were reported
‐ US senate passed law requiring
o Evidence of safety AND efficacy before approval to market
o Accurate reporting of side effects and adverse effects
o Informed consent for patients in clinical trials
Modern medicines
Structure‐activity relationships
Enzymes Receptors
Enzyme substrate or inhibitor Receptor agonist or antagonist
Catalyse chemical reactions Cause physiological reactions
Drug (substrate) binds to active site – lock and key Lock and key concept
Enzyme catalyses reaction to metabolise substrate Agonists – stimulate receptor – causes
physiological response
Enzyme unable to catalyse – drug acts as inhibitor Antagonists – block receptor – blocks physiological
o Inhibitor competes with substrates, so response (and blocks other agonists)
substrate builds up in the body
‐ Concept of molecular targets for drug actions, e.g. proteins – enzymes, receptors
‐ Relationships developed between shape/structure and its nature and activity
‐ Quantitative structure‐activity relationships (QSAR)
o Synthesise large range of compounds of slightly different structure and shape
o Test for activity at receptor, and derive mathematical equations
o Predict response for as‐yet un‐synthesised compounds, and test predictions for accuracy
o Choose the most effective drug for further testing
‐ Hansch analysis – equations developed which relate drug activity to
o Partition coefficient
o Electron‐withdrawing or electron‐donating ability
‐ Computer modelling
o QSAR based on mathematical modelling
o Computer modelling allows visual analysis in 3D
o Model interactions of drugs and receptors based on shape and types of bonds
Biotechnology
‐ Technological application that uses biological systems, living organisms, or derivatives, to make or
modify products or processes for specific use
o Use of microorganisms to produce synthetic insulin
o Production of physiological treatments, e.g. growth hormone, blood clotting factors, EPO
o Genetic testing and screening
o Gene therapy
o Pharmacogenomics
Pharmacogenomics
‐ Examines the inherited variations in genes that dictate drug response and explores the ways these
variations can be used to predict if a patient will have a good, bad or no response to a drug
o Each individual’s genetic makeup influences their response to drugs
o If individual’s genetic makeup is known, it should be possible to tailor drugs for them
History of pharmacy
Ancient ‐ No clear distinction between physician and provider of medicines
civilisations ‐ No recognisable profession of pharmacy
‐ Some evidence of gatherers and preparers of medicine in Egypt – not distinct profession
Galen ‐ Physician and pharmacist – compounder of medicines
‐ Used iatreion and apotheca – rooms for receiving patients, and storing/preparing
medicines
rd
Damian and ‐ Twin brothers of Arabic descent, practised in 3 century in Asia Minor
Cosmos ‐ Damian – pharmacist, Cosmas – physician
‐ Canonised by Pope Felix IV in 6th century – patron saints of medicine and pharmacy
Medieval ‐ Pharmacy as distinct profession first emerged in Arabic/Persian culture
pharmacy ‐ First ‘pharmacy’ opened in Baghdad 754AD
‐ Pharmacists traded in medicines, spices, perfumes
‐ Part of public health system – subject to inspections
Pharmacy in Europe
‐ No clear distinction between medicine and pharmacy until 1240
‐ Pharmacy and medicine to be completely separated
‐ Venetian statuata prohibited practice of medicine and diagnosis by urine by pharmacists
Guilds
‐ Associations consisting of members of the same craft or trade
‐ Major roles:
o Care for poor and sick members of the community
o Control of locations of pharmacies – avoid high competitiveness
o Inspect pharmacies annually – ensure standards are met
o Determine which goods were pharmacy only
o Regulate prices, organise collection of taxes
‐ Surprisingly, pharmacists and physicians were often in the same guilds
Pharmacy in England
‐ Fluid relationships between physicians, apothecaries, traders, etc.
‐ Spicers – dominated retail trade of drugs, also compounded drugs
‐ Pepperers/grocers – dominated wholesale trade of drugs
‐ London Society of Apothecaries
o Apothecaries separated from grocers
o Exclusive rights to keeping of an apothecaries shop
o Illegal for grocers or other people to make, sell, compound, prepare, give, apply or
administer medicines
Changes in roles
‐ ‘Art’ and ‘mystery’ – original concepts of ‘education’ and ‘competency’
‐ Great Plague of London 1665
o Many doctors fled or died, apothecaries took over their role
‐ Apothecaries’ Act 1815
o Apothecaries formally recognised as medical practitioners
o Chemists and druggists given right to prepare and supply medicinal substances
Term Before After
Apothecaries Earliest formal title accorded to pharmacists – practitioners who made, Doctors
sold, compounded, prepared, gave, applied or administered medicines
Chemists Preparers and sellers or chemical substances (as distinct from medicinal Pharmacists
substances)
Druggists Traders and suppliers to apothecaries
Pharmacy in Australia
‐ Originally, considerable problems with supply of medicines
o Long delays in deliveries from England
o Spoilage on route, affected by heat, water and mould
o Theft on arrival
‐ Early attempts at local remedies were largely unsuccessful
‐ No clear role for specialised dispenser
‐ John Tawell – first pharmacist to be licensed in colony despite not having any actual qualifications
o First private retail pharmacy opened in 1820 – highly successful
Responsibilities of pharmacists
‐ Dispensing medicines involves assessing and evaluating prescriptions, and supplying medicines
‐ Verify prescriptions are authentic (written by registered health practitioner), legal and represent
intentions of prescriber
‐ Pharmacist shares legal responsibility with prescriber for errors or problems
‐ Must ensure that medicine will not cause harm to patient, and it will provide a potential benefit
‐ Must consider and understand
o Why a medicine has been described
o Disease/conditions the patient has
o Other medicines the patient is taking
o How likely the patient will use the medicine, and use it properly
‐ Supplying medicines involves
o Selecting the correct medicine from stock
o Applying appropriate labels
o Deciding on additional warning labels that are required or advisable
o Checking that the supplied and labelled medicine corresponds to prescription
o Ensuring that medicines are given to correct person
o Providing verbal and written advice to patient to ensure appropriate use of medicine
o Keeping the records required by law
Legislation – poisons and pharmacy practice
‐ Two main pieces of legislation which govern the day to day practice of pharmacy
‐ Poisons and Therapeutic Goods Act 1966
o Rules about regulation, control and prohibition of the supply and use of poisons
o Governs what medicines are pharmacy‐only, and where they can be stored/displayed
o Legal requirements for prescriptions, e.g. who can write them
o Who can hand out specific medicines
‐ Health Practitioner Regulation National Law (NSW) 2010
o Establishes a national registration and accreditation scheme for
Regulation of health practitioners
Registration of students undertaking programs of study or clinical training
o Defines unsatisfactory professional conduct
Not meeting expected professional standards for your level of experience
Supplying precursors to manufacturing of drugs
Unethical or improper criminal conduct
Providers of advice and education
‐ Retrieving, analysing and synthesising information
‐ Engaging in research (including participation in research programs)
‐ Educating students and colleagues
o Academic teaching programs, CPD activities, training sessions, student clinical placements
‐ Counselling, often involving use of CMIs
‐ Services to residential care facilities, Medicines Information Centres
‐ Health promotion
Providers of service
‐ Obtain patient histories
‐ Critically review treatment patients are receiving, and recommend any changes
‐ Help patients manage their own conditions
‐ Follow up particular patients who need ongoing care and assistance
Dose ‐ Specialised packaging of medicines by week/month, e.g. Webster packs
administration aids ‐ Patients and carers can see when medicines have/have not been taken
‐ Reduce problems with opening boxes and bottles, mistaking similar medicines
Disease State ‐ Focuses on whole patient
Management (DSM) ‐ Medicines, lifestyle, self‐management, monitoring of disease state
‐ E.g. how best to measure blood glucose levels and when; what to do themselves
if asthma occurs before seeing doctor; what to do if angina attack occurs
Home Medicines ‐ Initiated by doctor – refers patient to pharmacist
Review (HMR) o Patients taking many medicines
o Use of medicines may not be optimal
‐ Accredited pharmacist reviews medical and medicines history
‐ Arranges interview at home and collects relevant information
‐ Reviews findings using evidence‐based approaches
‐ Formulates recommendations
o E.g. stop/take new medication, see new specialist, administration method
‐ Writes to referring doctor about action needed to be taken
Australian health care system components
Hospitals ‐ Public
o Most hospitals and hospital beds
o Large hospitals offer complex and comprehensive range of services
o Teaching hospitals, e.g. RPA, Westmead, RNS
o Run by State governments with assistance from Commonwealth funding
‐ Private
o Run by either for‐profit or not‐for profit organisations
¥ E.g. large corporations, religions institutions, private health
insurance funds
o Historically tended to be smaller, less diverse – now large and diverse
Aged care ‐ Residential aged care
o Nursing homes
o Mostly provided by NGOs – many are charities, e.g. Anglicare
‐ Community aged care
o Provide services to assist older people to remain in their own homes
o Nursing services, day and respite care, home delivery of meals, assistance
with home activities, transport assistance
o Provided by State governments and charitable/religious organisations
Public health ‐ Programs which reduce incidence of illness and disease
programs ‐ Run mostly by State governments
‐ E.g. school health, dental health, child and maternal health, environmental health
(work health and safety)
Pharmaceuticals ‐ Regulated by Therapeutic Goods Administration & Pharmaceutical Benefits Scheme
Blood and organ ‐ Managed by Australian Red Cross
donations ‐ Funding from Commonwealth and State governments
Remote health ‐ E.g. Royal Flying Doctor Service
services o Not‐for profit charitable service
o Primarily funded by Commonwealth government, also raises funds from
supporters around Australia
Paying for health care
‐ National health care funding system involves governments, private organisations, consumers
‐ Medicare Australia
o Government agency that administers Medicare
o Also administers PBS, Australian Organ Donor Registry, Australian Child Immmunisation
Register, National Bowel Cancer Screening Register
‐ Medicare
o Program administered by Commonwealth Department of Human Services
o Universal health care program
o Provides affordable and accessible health care to all Australians
Pays for ‐ Patient services in public hospitals
‐ Costs of part or all of services provided by some private health care practitioners
‐ Subsidies of pharmaceuticals through PBS
‐ Grants to State governments and other bodies to fund particular services
Eligibility ‐ Living in Australia and are: Australian citizens, permanent residents or NZ residents
o Except if they live on Norfolk Island
‐ Reciprocal rights with visitors from NZ, UK, Ireland, Italy, Finland, Norway, etc.
o Free treatment at public hospitals
o Subsidised medicines under PBS
o Subsidised treatment by private health practitioners (except NZ, Ireland)
Services ‐ Public hospital care
o Public patients – free accommodation, meals, medical and nursing care, medicines
o Private patients – 75% of medicare fees for doctor services
‐ Non‐hospital care – funds or partially funds
o Costs of seeing GPs and specialists
o Range of tests and examinations for diagnosis and treatment of illness
o Eye tests by optometrists
o Most surgical and some other procedures by doctors or dentists
o Range of specialised services
‐ Private health insurance
o Allows choice of doctor in public hospitals, and choice of hospital
o Cover includes – dental treatment, chiropractic, home nursing, podiatry, physiotherapy,
occupational, speech and eye therapy, glasses, prosthesis, ambulance transport
o Over 40 providers, e.g. MBF, NIB, Medibank Private
o Regulated by Commonwealth government
Medicines in Australia
National Medicines Policy
‐ Published in 2000
‐ Collaboration between Commonwealth and State governments, health educators and
practitioners, healthcare providers, medicines industry, consumers, media
‐ Framework for the supply and use of medicines in Australia
‐ 4 Objectives
o Timely access to medicines, at affordable costs to individuals and community
o Medicines meet appropriate standards of quality, safety, efficacy
o Quality Use of Medicines
Judicious selection of management options – the place of medicines in treating
illness and maintaining health, if non‐drug therapies are the best option
Appropriate choice of medicines – selecting best option from range, considering
dosage, duration, benefits and risks, economic costs
Safe and effective use – by monitoring outcomes, minimising misuse
o Maintain a responsible and viable medicines industry
Availability of Medicines in Australia
‐ Requires approval of Therapeutic Goods Administration
o Unit of Australian Government Department of Health and Ageing
o Purpose – protect public health and safety by regulating therapeutic goods that are
supplied, imported, manufactured or exported from Australia
‐ Processes behind approval of medicines
o Determining chemical structure
Pharmacological testing to determine function
Modifications to find optimum activity
o Formulation into simple dosage form(s)
o Tests on organs and animals to ensure safety and efficacy
o Test on healthy human volunteers
o Optimise dosage forms
o Test in relevant patients
o Apply to TGA for registration
o Used by many patients
o Post‐marketing monitoring for adverse effects
o Apply for PBS listing
Regulation of supply of medicines to consumers
‐ State law
‐ NSW: Poisons and Therapeutic Goods Act 1966, Poisons and Therapeutic Goods Regulation 2008
‐ Poisons legislation – 8 schedules outlining restrictions on supply, storage and possession
Schedule Description Container heading
1 No longer exists
2 Medicinal Poisons Pharmacy
o Sold in pharmacies not supermarkets Medicines
o No restrictions on display in pharmacies
o Includes larger pack sizes of products which are available in
supermarkets e.g. paracetamol
3 Potent Substances Pharmacists Only
o Not on open display in pharmacies – no direct access Medicines
o Pharmacist intervention in supply is required (counselling)
o Some require recording of customer details
4 Restricted Substances Prescription Only
o Only available by prescription Medicines
o Stored in area where there is no customer access (dispensary)
o Prescriptions have legal status – valid for specific time only,
range of aspects required on valid prescription
o Special arrangement for emergency supply where there is an
absence of prescription (patient leaves vital medication at
home whilst on a trip)
5 Domestic Poisons Caution
6 Industrial and Agricultural Poisons Poison
7 Special Poisons Dangerous Poison
8 Drugs of Addiction Controlled Drug
o Only available by prescription (special requirements for
legality/validity)
o Must be stored in locked safe
o Strict stock control requirements – Drug Register
o Unauthorised possession is illegal
o Repeat intervals must be specified
o Repeats must be kept at original pharmacy (must be dispensed
from same place each time
Prescriptions
‐ In prescriber’s own handwriting
o Date of issue
o Patient’s name and address
o Name, quantity, strength of medication
o Adequate directions for use
o Maximum number of times prescription can be dispensed
o Prescriber’s signature
‐ Pre‐printed on form – prescriber’s name, address and telephone number
‐ Computer‐generated prescriptions
o Include all requirements as for handwritten
o Script must be pre‐printed with prescriber’s details
o Script must include statement about total number of items on the prescription, or bottom
part must be blanked out
o Script must be signed by prescriber immediately below last item on script
o No alterations allowed
The costs of medicines to consumers and to the Australian economy
‐ Pharmaceutical Benefits Scheme (1960)
‐ Provides afford prescription medicines to Australian residents and eligible overseas visitors
‐ Two methods of pricing in Australia
o Pharmaceutical benefits – specific list of approved products, quantities and repeat
quantities: price controlled by legislation
o Private prescriptions – products not listed on PBS: price controlled by market forces
How items receive PBS listing
‐ Research and development
‐ Approved by TGA
‐ Drug company applies for PBS listing
‐ Pharmaceutical Benefits Advisory Committee
‐ Pharmaceutical Benefits Pricing Authority
‐ Approval by Minister for Health
‐ Listing in PBS
‐ Item prescribed by doctor, and dispensed by pharmacist
‐ Cost reimbursement claimed by pharmacist to Medicare Australia
‐ Medicare Australia processes claim and pharmacist receives payment
Rural health and society
Social determinants of health
‐ Conditions in which people are born, grow, live, work and age
‐ Housing – dust and asthma, mould
‐ Employment and income
o Lower socio‐economic status associated with poorer health status
‐ Occupation – hazards, higher risks with machinery
‐ Education
‐ Transport
‐ Lifestyle choices – smoking, alcohol consumption, illicit drugs, nutrition, physical activity
‐ Age, culture and geographic location all affect health
‐ Person‐related – genetically determined diseases, birth defects
Rural view of health
‐ Based on absence of disease
‐ Wellbeing is associated with productivity and being able to carry out daily tasks
‐ Health services are viewed as curative services rather than preventative procedures
Rural Communities
‐ Anywhere outside the urban area
o Agricultural towns, mining towns, aboriginal communities, service communities
‐ Determining remoteness – RRMA, ARIA, ARIA+
o Remoteness affects health issues
o Used to determine levels of funding or as the basis for reporting of regional statistics
‐ Traditionally rural people are:
o Mutually supportive and close‐knit
o Believe family and location are very significant
o Strong sense of attachment – family, locality, occupation
o Very independent
o Possess significant ‘social capital’ – participation in networks, reciprocity, trust, common
interests, pro‐activity
Compared with urban Australia
‐ Lower life expectancy
o Decreases with increasing remoteness
o Regional Australia – 1‐2 years lower
o Remote Australia – up to 7 years lower
‐ Poorer health status – higher morbidity and mortality rates, hospitalisations, risk factors, fertility
‐ Higher rates of diabetes, obesity, mental health, cardiovascular diseases
‐ Poorer access to health care resources, facilities and services
o Increased reliance on telecommunications
o Longer waiting times
o Distance, time, cost, transport availability
‐ Services may be inappropriate or not accommodate needs
o Longer travelling distances to rural hubs and larger centres for specialised services
‐ Shortage of health care professionals – workforce shortage
‐ Ageing population
‐ Poorer education preparation
‐ Urban – refer patient to a specialist for treatment or follow up
o Rural – small rural hospital (non‐specialist as they are usually further away)
o Remote – RFDS – must wait hours/days for treatment and care
Weather and time factors affect how soon medical attention will be provided
Higher indigenous population
‐ Poorer health status – higher mortality rate, 10‐17 years lower life expectancy
‐ Higher burden of chronic illness
o Cardiovascular disease, tuberculosis, renal diseases, diabetes, mental illness, alcoholism,
child and maternal health
Rural health services should reflect health needs
‐ Move emphasis away from acute care to whole‐health model, particularly Primary Health Care
‐ Accessible, needs based, comprehensive, multidisciplinary, sufficiently flexible to respond to
changing needs
‐ Encouragement of communities to use local people/resources to help themselves
‐ Pharmacists should be
o Aware of cultural differences – deliver culturally appropriate services
o Aware of social and health issues faced by rural and Indigenous Australians
o Up to date with all new developments
Where pharmacists can work in rural Australia
‐ Community, hospital pharmacy
‐ Education (public health, school programs)
‐ Academia in rural universities
‐ Home Medicine Reviews
‐ Aged care facilities
‐ Aboriginal Health Services
‐ Consultant pharmacists
Role of remote pharmacists
‐ May need innovative ways to reach patients – boat, plane, RFDS
‐ May have no direct contact with patient
o Provision of products to Aboriginal Medical Service
o Staff training
o Ensuring QUM in remote sites
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Rural community pharmacies
‐ Regional pharmacies offer more services than urban pharmacies
o Asthma management, baby clinic, HMR, smoking cessation, methadone treatment, section
100 medicines
o Disease State Management – provide ongoing support in addition to medications
o Disease screening – cardiovascular disease (blood pressure, cholesterol), diabetes (blood
glucose), osteoporosis (bone mineral density), cancer (bowel scans)
‐ Larger – lower rents, less competition
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Royal Flying Doctor Service
‐ Founded by John Flynn; first flight in 1927
‐ Covers 2/3rds of the continent – doctors and nurses but no pharmacists
‐ Services – 24hr emergency service for life threatening illness or accidents
o Inter‐hospital transfers
o Comprehensive primary care
o Radio and telephone consultations
o Maintenance of >2500 medical supply chests
Aboriginal Community Controlled Health Services (ACCHS)
‐ Primary health care delivery to Indigenous Australians
‐ Primary clinical care and health advocacy, health promotion, referral support services
‐ Services planned in consultation with local communities, health professionals and governments to
meet local needs and priorities
‐ Improve coordination and access to increased range of services
o Housing, family and community services, employment, education
Aboriginal health Section 100 – National Health Act
‐ Supply of medicines to Aboriginal Health Services in remote areas
‐ List of basic drugs agreed for emergency supply
‐ No normal prescription necessary, and medicines supplied free
Regional Health Services
‐ Community identified problems
‐ Flexible mix of Commonwealth and State funded services
‐ Provide services to small rural and remote communities in a more cost effective way
o Multipurpose and regional health service centres
o Telemedicine
o Mobile services, e.g. RFDS, mobile intensive care services, visiting specialist services
Workforce dynamics
‐ Shortage of all health care practitioners
o More difficult to recruit and retain pharmacists
o Aging pharmacist population
‐ Much lower pharmacist/GP to population ratio in rural and remote areas
Reasons for shortage ‐ Feminisation of workforce – 70% of student intake is female
o Take time off to have children
‐ Insufficient students being trained
Predictors of rural ‐ People of rural/regional background more likely to practice in those areas
practice ‐ Rural experience or placements
Reasons for leaving ‐ Isolation of practitioners
rural/remote practice ‐ Shortage of locum or replacement
‐ Lack of continuing education
‐ Lack of preparation for rural/remote practice
Strategies to increase ‐ Rural and Remote Workforce Development Program
retention o Administered by Pharmacy Guild
o Student placement allowances and rural scholarships
‐ Practitioner retention – incentives
o Set‐up funds, succession planning, continuing education support
o Locum scheme
Strategies to increase ‐ Scholarships for students from rural background
recruitment ‐ Rural campuses and rural focus – students develop relationships in rural area
‐ Rural placement and placement support
Ethics
‐ Ethics – characteristic spirit or tone of a community
‐ Morals – social customs and habits of a community
‐ Ethical standards cannot exist without a moral framework
‐ Breaking the law is always unethical
‐ Every case must be considered on its own merits
‐ Ethical conduct always requires reflective evaluation of what is the proper course
‐ Ethical problems = ethical dilemmas
‐ Best interest of the patient are paramount at all times – go beyond commercial considerations
‐ Pharmacist has right to refuse to dispense a prescription, but has an obligation to inform patient
where else it can be dispensed
Misuse of medicines
‐ Drugs can be used medicinally, recreationally, or abused leading to dependency
‐ Use becomes misuse when behaviour results in harm
‐ Dependency (addiction) is a clinical state – results from regular use
o Tolerance – increased dose is required for same effects
o Withdrawal syndrome – effects associated with cessation of the drug
‐ Recreational use – usually non‐medical, does not necessarily involve harm or dependency
o However may lead to harm or dependency with regular use
‐ Substances which can be misused
o Caffeine, alcohol, nicotine, prescription drugs, amphetamines, marijuana, opioids
o 2010 most commonly used substances – alcohol > tobacco > marijuana/cannabis >
prescription medicines > ecstasy
Heroin
‐ Medicinal benefits – pain killer particularly in terminal cancer
o Available in early 1900s as OTC cough remedy – depresses respiration, sedative
‐ Semi‐synthetic derivative of morphine
‐ 1902 – reports appeared of tolerance, addiction and withdrawal
o 1954 – Made illegal in Australia
‐ Major effects – euphoria, sedation, respiratory depression, reduced BP, constipation
‐ Withdrawal symptoms
o Nausea, vomiting, diarrhoea, abdominal pain, bone, joint and muscle pain, hot and cold
flushes, disturbed sleep, intensive cravings for heroin
‐ Treatment of dependency
o Motivation to change
o Values and choices
o Dealing with related problems – medical, emotional, financial
o Medication
Methadone or buprenorphine maintenance
¥ Used to suppress withdrawal for current heroin users
¥ Produces similar effects but is orally or sublingually active
Detoxification – complete cessation of opiate use
Relapse prevention with naltrexone
Methadone
‐ Synthetic derivative of morphine
‐ Dispensing
o Patient must collect individual dose everyday from pharmacy
o Pharmacist prepares single doses, and must observe patient take and swallow dose
o After patient has proved reliable, is permitted ‘takeaway’ doses
Don’t have to visit pharmacy everyday
Advantages Disadvantages
Oral administration Still drug of addiction and dependence
Long‐acting – single dose lasts 24‐36 hours Can cause problems if combined with other opioids
Acts at same site (receptor) as heroin Psychological aspects of dependency not dealt with
Blocks effect of heroin and other opioids Possibility of diversion and street sales
Suppresses withdrawal symptoms – reduces For patient to become drug free, must be gradually
cravings but does not cause euphoria weaned from methadone
Legal and much cheaper Possible to overdose
Reduces disruptions to life – crime, infection from
sharing needles, social disruption, employment,
family responsibilities
‐ Support for treatment of dependency
o Together with the medical treatment, individuals also need
Non‐judgemental therapeutic relationship
Clarification of goals and values
Provision of relevant health information
Monitoring of progress and provision of feedback
‐ Role of the pharmacist
o Methadone dispensing
o Opportunity to develop relationship with individuals being treated
o Needle exchange schemes for injecting drug users
o Provision of health information
Misuse of legally available drugs
‐ Pseudoephedrine‐containing products
‐ Performance‐enhancing drugs in sport
‐ Prescription medicines
o Benzodiazepines and prescription painkillers
o Potential misusers – two main groups
Injecting drug users – use other drugs to replace heroin – potential misuse of both
types of prescription drugs
Elderly patients with chronic insomnia – potential misuse of benzodiazepines
based on clinical need, misuse may be unintentional and unwitting
o May engage in ‘doctor shopping’ and use of multiple pharmacy sources
‐ OTC cough mixtures
o Restriction to supply through rescheduling
o Inclusion of laxative substances in formula
‐ Alcohol
o Second greatest cause of drug‐related deaths and hospitalisations in Australia
o For men, risk of death from injury is greater than from disease
o Risk of alcohol‐related injury hospitalisation is higher in men than women
o Risks of harm from drinking alcohol increases with the amount consumed
o For children and people under 18 years, not drinking alcohol is the safest option
Delay initiation of drinking for as long as possible
o Maternal alcohol consumption can harm the developing foetus or breastfeeding baby
‐ Tobacco
o Smoking cessation
o Nicotine replacement to assist smoking cessation
o Pharmacological measures to assist smoking cessation
Performance‐enhancing drugs in sport
‐ Original Olympics – competitors ingested extracts of mushrooms and plant seeds
‐ Roman charioteers fed horses substances to go faster, gladiators given drugs to lose inhibitions
‐ Sport re‐emerged as a social, political and economic force in 19th century
o Big business, pressure to succeed is intense – temptation to achieve at all cost
‐ 1968 – list of banned substances produced, testing carried out at Mexico Olympics
‐ 1999 – World Anti‐Doping Agency (WADA) established
‐ Substances causing deaths, disqualification or banning – steroids, amphetamines, EPO
Prohibited substances and methods
‐ Androgenic anabolic steroids, anabolic agents – increase muscle mass, power and proteins
‐ Peptide hormones, growth factors
‐ Beta‐2 agonists
‐ Hormone and metabolic modulators
‐ Diuretics and other masking agents – dilute urine to decrease concentration of drugs
‐ Manipulation of blood and blood components
‐ Chemical and physical manipulation
‐ Gene doping
‐ Prohibited in competition (not outside of competition)
o Stimulants (exceptions include caffeine), narcotics, cannabinoids, glucocorticoids
Pharmacist roles
‐ Information for athletes
o Brand names and whether they contain banned substances
o What particular drugs do
o Where to find out what is banned, e.g. ASADA website
‐ Education – possible harmful effects of short and long‐term non‐medical use of drugs
Medicines and the internet
‐ Used by people who are busy, housebound, live in remote areas, embarrassed about condition
o Have been refused prescription by their doctor
o Have had medicine before and don’t want to revisit doctor (costs of visiting)
o Want to try something without asking doctor
o Want to access treatments not approved or marketed in Australia
‐ Legitimate businesses – run ethically, follow legal requirements for supply of prescription and
other restricted medicines
o Contact details, disclaimer, ordering restrictions conform with legal requirements, detailed
information about PBS and pricing, accreditation, privacy statement, disclosure and
transparency, ability to speak directly to pharmacists
‐ Doubtful and rogue sites
o False accreditation
o No requirement to forward a valid prescription
o No physical contact details
o Exaggerated claims without evidence – testimonials, claims from clinical trials
o Partial unreferenced data
o Quality not guaranteed – possible substitute or counterfeit ingredients
‐ Websites should be carefully regulated and monitored, and used appropriately by patients
Advantages Disadvantages
Convenience ‐ Available 24/7 – fits in with lifestyle ‐ Medicines may not arrive in time –
‐ No physical travel required, distance not an issue issue if required urgently
‐ Automatic reminders for repeats ‐ Some products cannot be sent by
‐ Stock large range of products mail, e.g. require refrigeration
‐ Easy to order and receive in mail
Anonymity ‐ Avoid embarrassment in ‘sensitive’ conditions ‐ May not receive complete advice
‐ Feel more comfortable in obtaining information
Price ‐ Convenient to compare prices ‐ Postage and shipping costs
‐ Reduced overheads – no bricks‐and‐mortar costs
International ‐ Wider range – access medicines unavailable in ‐ Risk of poor quality and service
access Australia
Reasons for using sources in academic writing
‐ Satisfy expectations of the academic community you are writing for
‐ Evidence of wide, informed and relevant reading – ability to integrate material from many sources
‐ To show your writing does not rely mainly on personal opinion
‐ To show the process by which you have arrived at your own conclusions about the topic
‐ To enable to reader to understand and evaluate the ideas and information you are presenting
‐ To show evidence of analytical and critical approach to your source material
‐ To enable readers to follow up references or perspectives of particular interest to them
Abbr. Translation Abbr. Translation
ac Before food/meal n At night
bd Twice a day pc After food/meal
cfm With first mouthful of food prn When necessary
d28 Discard contents 28 days after opening qid Four times a day
gw With glass of water qs A sufficient quantity
hs At bed time sp Sparingly
iaf Immediately after food stat Immediately
m In the morning tds/tid Three times a day
mdu Use as directed uaf Until all finished