Preventing misuse of medicines Dr

. marwa salih al-naimi

 PharmacyEthics
Pharmacy Ethics
LEC:6
Dr . marwa salih al-naimi

Preventing misuse of medicines

Understanding the Patient's Medication Experience
There are three dimensions to the patient's medication experience, and all
three are important in pharmaceutical care practice: the patient's description
of the medication experience, the medication history, and the current
medication record.
II. The Medication History
A comprehensive medication history is conducted for very specific reasons.
The record of medications used in the past to treat or prevent medical
conditions or illnesses provided information that is essential when making
current therapy decisions. Effectiveness of therapies used in the past can
direct future drug selections. Safety issues from the patient's history serve as
warnings to avoid re-exposing the patient to harm. Medications, primarily
vaccines used to immunize the patient against communicable diseases, are
the mainstay of preventive drug histories.
Following is a list of the components of a comprehensive medication history.
Not all of this information will be available or useful in every case.
The Second Dimension of the Patient's Medication Experience Contains a
Comprehensive Medication History and Includes:
1.An immunization record;
2- A history and quantification of social drug use;
3- Medication allergies and characteristics of the allergic response;
4- A description of any adverse reactions to medications;

Page1
 Pharmacy Ethics
Pharmacy Ethics
5- Health alerts and/or special needs of the patient;
Dr . marwa salih al-naimi
6- A historical account of relevant medication use (success/failures).
Keep in mind, you are trying to identify drug-related needs (for example, the
patient requires an immunization), identify a drug therapy problem (patient is
allergic to penicillin,) or gather information that will help you select
medications that will be effective in the future (hydrochlorothiazide did not
work in the past). Medication histories focus on the discovery of information
that is most likely to be relevant to improving your patient's future medication
experience. Collect only that information you will use to make decisions for
and with your patients.
1-Immunizations
The immunization record includes the documentation of childhood and/or
adult vaccinations received and a plan to meet current guidelines.
Pharmaceutical care practitioners should be aware that guidelines for
vaccinations change quite frequently so it is important to keep an up-to-date
protocol. This record can become very useful for the patient because there
are few health care professionals or institutions who maintain a current
record of all of the patient's vaccinations, and yet it is frequently required for
travel, school enrollment, participation in athletics, or emergency care.
Maintaining accurate immunization records for patients and their family
members is a valuable service.
2-History of Social Drug Use
Social drug use in the context of pharmaceutical care includes tobacco,
caffeine, alcohol, and drugs of abuse. It should be made clear to the patient
that this information is important because all of these compounds can alter
the absorption, distribution, metabolism, and elimination of many other

Page2
 Pharmacy Ethics
Pharmacy Ethics
prescription and nonprescription products, in addition to causing a number of
health problems themselves. Care must be taken not to be judgmental about
Dr . marwa salih al-naimi
the behavior of patients nor to introduce any personal beliefs or prejudices
with regard to the use of these substances.
Practitioners will assess the impact of the social drug use on the selection,
dosing, and safety of the patient's pharmacotherapies.
3-Medication Allergies
Medication allergies can be confusing to patient and practitioner alike.
Frequently, patient been told they had an allergic reaction, or they suspect
an allergic reaction themselves, he/she actually experienced an adverse
reaction to a drug product.
Definition Allergic drug reaction:
Unfavorable physiological response to an allergyen to which the patient
develops an immune response (antibodies) and through the release
chemical mediators (immunoglobulins, complement, cytokines) experiences
urticaria, eczema, dyspnea, bronchospasm, diarrhea, rhinitis, laryngospasm,
and analphylaxis Subsequent exposure can result in more serious
symptoms and consequences. The resolves after the drug is discontinued,
but may require emergency treatment.
Adverse drug reaction:
A harmful, undesirable, or unintended effect of a drug administered at
dosages normally used in patients for prophylaxis, diagnosis, or therapy.
Type A adverse drugs reactions are most commonly extensions of the
known, but undesirable pharmacology of the drug. Type B reactions are
idiosyncratic and unrelated to the pharmacology or dosage and are therefore
unpredictable.
Page3
 Pharmacy Ethics
Pharmacy Ethics
Care should be taken to be specific when gathering drug allergy information
from the patient. Be sure to include the nature of the allergic response, the
Dr . marwa salih al-naimi
product that caused the reaction, and the timing of the reaction. Patients
should not be exposed to a product that has produced a true allergic
reaction, so a portion of your responsibility is to separate true allergic
responses from adverse drug reactions. This may be difficult with the limited
history and/or memory the patient has of the event. In all cases, the reaction
should be noted with documentation to describe the circumstance. This
information will directly impact your choice of drug products to be used in a
patient.
4-Adverse Drug Reactions
Adverse reactions to past medications can manifest themselves in a number
of ways: gastrointestinal problems (nausea, vomiting), dermatological
problems (rashes, hives), central nervous system changes (drowsiness,
irritability), and many others. Again, it is important to be specific about the
product and the dosage regimen that resulted in the adverse outcome. The
timing of the problem in relation to taking the medication, the severity, the
duration, and the resolution of the problem should all be noted.
5-History of Relevant Medication Use
Patients often can provide tremendously useful information about previous
medication use. What has been effective, what has failed? It is likely that this
will be the case again. What the patient will not take"and what does the
patient feel good about taking due to previous experience? This information
can save a significant amount of time and energy, but more importantly, it
can save the patient suffering and inconvenience. Take time to elicit this
information and listen closely. Be sure to include the original reason the
patient was taking the medication, the product, the dosage regimen, the start

Page4
 Pharmacy Ethics
Pharmacy Ethics
and stop dates, and the response the patient experienced. In general,
practitioners use 6 months as a guide to

Dr . marwa salih al-naimi

determine how far back to investigate medication histories in patients with
extensive past treatments.
Some patients may have difficulty providing specific drug names, dosages,
and dates due to memory loss or the complexity of the information. This is
frequently the case when the patient speaks a different language and/or has
acquired the medication in a different country.
III. The Current Medication Record
The third component of the patient's medication experience is the current
medication record.
Note
The current medication record includes all of the patient's current medical
conditions or illnesses and how well they are being managed with drug
therapy. The current medication record includes the indication, drug product,
dosage regimen, duration of therapy, and clinical results to date.
Patients frequently interpret a question about current medications to mean
only those medications written as prescriptions by a physician. Time and
care should be taken to assess all the products a patient is currently taking
for therapeutic purposes (regardless of source and category of product). All
of the products being taken can impact other products as well as the medical
condition of the patient.
There is a specific way to organize the information describing your patient's
current drug therapies. Practitioners establish the connections between the
clinical indication, the specific drug product, the dosage regimen actually
Page5
 Pharmacy Ethics
Pharmacy Ethics
taken by the patient, the length of therapy, and the response the patient has
experienced from each drug regimen. All of these data are necessary to
make clinical decisions. The relationship between indication, drug product
marwa salih al-naimi
and dosage, and response is among the most important clinical information
the pharmaceutical care contributes to care
Indication
Indication is the clinical reason the patient is taking the medication.
Patients take medications for a variety of reasons. Treating a disease that
has been diagnosed by a physician is only one of several categories of
indications for drug therapies. Drugs are often used before a formal
diagnosis can be established. Medications are frequently used to prevent a
medical condition or illness from developing. Manyforms of pharmacotherapy
are used to simply alleviate uncomfortable signs or symptoms.
The current medication record serves as the basis for practitioners to make
clinical judgments as to the appropriateness of the indication for each
medication the patient is currently taking. Patients have many personal
reasons for taking supplements, alternative products, and non prescription
medications. Symptoms, prevention, and medical problems can all be
indications for medications. When you record your patient's current
medication record, drug therapies are grouped by indication.
Drug Product
The drug product should be noted by generic and brand names (if
applicable). The color or appearance of products in generic products and
this can be very confusing to the patient, so you may need to include the
manufacturer of generic products.
Dosage Regimen
Page6
 Pharmacy Ethics
Pharmacy Ethics
The dosage regimen is made up of several components. Each of these can
influence the outcomes, and practitioners must be exact and complete when

Dr . marwa salih al-naimi

describing the dosage regimen the patient is actually taking. The dosage
regimen includes the dose (usually in milligrams (mg]) of the medication, the
frequency of administration (usually times per day), and the duration of
treatment (for 2 weeks). It will be difficult to evaluate the appropriateness of
the medication regimen if any of this information is missing.
The dose most often represents the amount of active ingredient that the
patient takes or applies each time he or she self-administers the drug
product. The dose could also be administered by a nurse or some other
health care provider. However, in general, the dose is the amount of drug
the patient takes (or is given) each time. The strength is how much active
drug is contained in the dosage form (tablet or capsule, liquid). For injectable
medications, strength is usually described in terms of concentration of
active drug per volume of liquid.
Example
An aspirin tablet containing 325 mg of acetylsalicylic acid provides a dose of
325 ml of aspirin. The strength of the tablet is said to be 325 mg. If the
patient takes two of these tablets taken was 650 mg. In the United States,
aspirin tablets commonly have a strength of 81 or 325 mg.
Example: 1 milliequivalent (mEq) of potassium chloride (KCI) per milliliters
(ml) of 5% dextrose in water would be expressed as a concentration of 1
mEq/ml.
dosage

Page7
 Pharmacy Ethics
Pharmacy Ethics
The term dosage is used to describe the total amount of drug the patient
takes over a given amount of time.

Dr . marwa salih al-naimi

Example
If your patient takes two aspirin tablets containing 325 mg each, and takes
the same dose four times each day, then the dosage would be described as
650 mg four times a day (or a daily dosage of 2600 mg).
Example Every 12 hours or every 6 hours. In some cases, dosing intervals
can be measured in days, weeks, or months.
The duration of therapy describes the total time (most often expressed in
days, weeks, or months) the patient has been taking the same medication.
Example Many antibiotic drug regimens instruct the patient to complete a full
10-day course of therapy to ensure effectiveness. This would be described
as a duration of therapy of 10 days.
When describing the patient's dosage regimen of a medication currently
being taken, all of the components (product, dose, dosing interval, and
duration) are important in order to make valid clinical decisions about how to
optimize your patient's medication experience.
It is also important to emphasize that the dosage regimen recorded here
must be the one the patient is actually taking. If this is not the one prescribed
by the physician then that difference is noted. Be aware of both, but your
clinical decisions are always based on what the patient is actually taking.
Start Date

Page8
 Pharmacy Ethics
Pharmacy Ethics
The start date of medications is especially important if you are assessing the
possibility of an allergic reaction or the onset of an adverse reaction to a
medication. It is also important in assessing whether a certain drug therapy
has had enough time to produce the desired response. Treatment failures
are a significant drug therapy problem, and time to response is an important
item of information in assessing treatment failures.
Dr . marwa salih al-naimi
Response
The patient's response to a medication should be evaluated relative to the
desired goal of therapy for the specific medical problem. Pharmaceutical
care practitioners use a standard set of definitions for terms to describe the
patient's response to drug therapy (refer to ). The terms stable improved,
partially improved, worsened, resolved, and failed all have specific meaning
when used to describe the patient's response to current medications.
Standard terminology will allow a colleague (or even yourself over time) to
understand exactly what is occurring in patient. The description of the
patient's response needs to include both positive and negative resonses
if applicable. For example, how well is this drug therapy working for your
patient at the time you are gathering the current medication record?
This is a good time to emphasize that no information should be elicited from
a patient unless you are going to use it. Each item of information you collect
needs a purpose and a specific reason to apply it to make better decisions
for the patient. describes the relevant patient information required to make
an assessment of the patient's drug-related needs.
CASE (HIV and Natural Remedies)
Sophie was as regular as clockwork regarding when she came to the
pharmacy clinic to pick up her maintenance drugs of didanoisine,
zidovudine, and nelfinavir. She had become HIV+ from using intravenous
Page9
 Pharmacy Ethics
Pharmacy Ethics
drugs. Garth Wardworth, Pharm. D., was surprised when she placed several
bottles of various vitamins and herbal remedies, including a garlic
supplement, omega 3 oil, St. John's Wort, and Echinacea on the counter
instead of her usual prescriptions. "Where are your prescriptions?" Dr.
Wardworth asked, "Oh, I've got them right here in my pocket, but I'm not
going to need them. I know the right thing to do now. Only natural products
can go into my body.
Dr . marwa salih al-naimi
No more artificial chemicals for me. I've abused my body long enough," Ms.
DuBois responded. Dr. Wardworth immediately reacted to Ms. DuBois's
statement by reciting all of the reasons she should continue with her triple
combination antiretroviral therapy but to no avail. He emphasized that her
decision need not be limited to either prescription drugs or natural products
since she could take both at the same time. Still Ms. DuBois insisted that
she did not want the prescriptions filled. She had been reading numerous
articles and books on "alternative" healing and was convinced that this was
the right decision for her.Was this sudden change in her attitude toward her
medications a sign of in capacity? Even though she didn't seem disoriented
or confused, her decision to stop taking the medications that were most
likely going to save her life struck Dr. Wardworth as irrational.
If Dr. Wardworth is going to treat her as incompetent to consent or refuse
consent for her prescribed medications, he needs to be able to show how
she lacks capacity. If, for example, she could give no reason why she was
afraid of the medication or why she believed the natural products were
better, that might be reason to suspect a lack of capacity. however, hardly
seems to be evidence that she is not sufficiently autonomous to make her
own choices. What would count as an adequate reason for Dr Wardworth to
treat her as lacking sufficient capacity for autonomous choice in this
important decision, and what should he do if she persists in claiming she has
that capacity?
P a g e 10
 Pharmacy Ethics
Pharmacy Ethics

P a g e 11