News

2003

1.12.03 - Glan Clwyd Hospital - Directorate of Pharmacy - Consultant pharmacist Glan Clwyd, opened in 1980, is a 750 bed district general hospital complex between the national portrait gallery near St Asaph (city of international music) and Abergele, with easy access to recreational facilities eg water & mountaineering sports in Snowdonia and on the North Wales coast. A number of staff commute from Chester and Liverpool.

Substantial investment in pharmacy has been initiated - Automation - live in December 03, Sterile Products Unit £1.3m - work commences March 04 & also major investment in staffing, primarily at ward level. Posts are:

Interested ? Then feel free to contact Ann Slee or Uttam M Chouhan for an informal discussion - 01745 534098 or e-mail uttam.chouhan@cd-tr.wales.nhs.uk. Eighty pharmacy staff play a key role working with medical and nursing colleagues in developing and maintaining a wide range of acute specialties and community services. The pharmacy has an MCA (specials) licence, and includes the North-East Wales Medicines Information Centre. The North Wales Cancer Centre, with its own satellite pharmacy, opened in June 2000. Pharmacy has rolled out medicine management to all wards including POD; good progress achieved on accredited checking technician & one stop dispensing supported by clinical pharmacy technicians. Opportunities for continuing professional development and research are a priority within the department with every pharmacist now guaranteed half a day per month. Support to allow staff to attend meetings is available. This year we have had representatives at GHP (award & poster presentations), BOPA weekend, BPC conference, and are sending representatives to the ASHP MidYear and San Antonio Breast Conference. The department has Trust support for the introduction of supplementary prescribing. In addition to regular in-house study days our staff are also involved in external teaching including WCPPE and the clinical diploma. Temporary hospital accommodation can be provided free of charge if required. On site child care facilities, staff gym and free chiropody are just some of the local facilities available to employees. For more information on the area visit www.nwt.co.uk. Closing date for the post: 15 December 2003
For an application pack contact: Human Resources Department on 01745 534582/534578

18.11.03 - Technician post in Cardiff
For anyone out there interested in coming to work in Wonderful Wales we have a vacancy for an MTO 3 in Whitchurch Hospital which is the mental health hospital in Cardiff.

We provide services to both the mental health units in Cardiff and the Vale and the Community Services. We're a progressive and friendly department and are looking for someone to take this department forward with us. Our aim is to have all technicians qualified as ACT's so that they can manage the day to day running of the department which will allow the pharmacists to spend more time on the wards engaged in clinical activity.

We are a department committed to CPD and opportunities exist to increase your knowledge and participate in medicine management courses. For further information contact Wendy Davies on 02920336535 or email wendy.davies@cardiffandvale.wales.nhs.uk, or write to Wendy Davies, Principal Pharmacist, Pharmacy Department, Whitchurch Hospital, Park Road, Whitchurch, Cardiff CF14 7XB

18.11.03 - UKPPG committee: Your committee met in Cardiff on Friday 14th November, a particularly wet and windy day in Wales, as anyone who stood on Cardiff station waiting for a delayed train will testify.

Present: new Chairman Graham Newton, plus Celia, Graham P, Wendy, Morag, Robert and Steve

Apologies from Denise, Ian, David Taylor, Gill H, Diane, Fiona

Items discussed included:

20.9.03 - UKPPG committee - Your UKPPG committee met on 18th-19th September at Wokefield Park, both as a committee meeting and as a pre-conference planning meeting. People who attended were Celia, Robert, Fiona, Morag, Graham Parton, David Taylor and Liz Ebner (Thurs), Steve (Friday) and Wendy Davies. Mostly this involved conference planning but other news includes that the UKPPG Helpline appears to be about to restart in the next few days on the same number as before. Problems with dealing effectively with persistent callers have been addressed and the funding is to come from NIMH-E, through Prof. Anthony Sheehan.

1.8.03 - The United Kingdom Psychiatric Pharmacy Group (UKPPG) - what the Mental Health Review 2003 said about our growing group of specialists working in mental health

The Past
In 1970, a small group of pharmacists working in some of the large mental institutions of the time, before the advent of Community Care (The Department of Health 1989), met on a Saturday afternoon in Hertfordshire. They were concerned by the fact that at that time, pharmacy services to in-patients suffering from serious mental illness, were generally provided by unsupported, under-resourced staff, frequently working in isolation with no peer support and no opportunity for further training or personal development in the field of mental health. Later an informal group was set up which held similar meetings throughout the UK; in Birmingham, Leeds, Derby,Wales and Scotland. From that small beginning over thirty years ago, grew the United Kingdom Psychiatric Pharmacy Group (UKPPG), which now numbers some 400 members mostly working in secondary care. The Group is self-financing from membership fees and the proceeds of various educational activities and is organised on a voluntary basis by an active committee. It produces a quarterly bulletin, runs an e-mail discussion group, maintains an extensive website and organises an annual international conference which attracts speakers and delegates from all over the world, as well as supporting further training and education for both pharmacists and technicians working in mental health. Full membership is open to all pharmacists in the UK with associate membership being available to any non-pharmacist and those working abroad. The overall aim of the Group is "to promote better pharmaceutical care for people with mental health needs through education, liaison and accreditation."

Appropriate medication helps treat mental illness, minimises relapse and reduces suicide. Mental health pharmacists' aim is the safety of their patients by making sure that people who need medication get it, take it at the optimum dose and are provided with appropriate information about it and that those that don't need medication don't get it. All health service users should have the support of and access to, independent, education, information and advice about medication, this is clearly stated in the National Service Framework for Mental Health (Department of Health.1999) The ideal person to provide this is a specialist mental health pharmacist.

The Present
With these aims in mind the Group set about providing one day and weekend residential training courses and developing the annual conference into a forum where delegates could hear about the latest developments in treatment strategies from internationally renowned speakers and exchange news and views with colleagues from all over the world. The UKPPG also supports more formal postgraduate specialist education. This was initially provided from De Montfort University but since 2000 has taken the form of the postgraduate Certificate and Diploma in Psychiatric Therapeutics and Pharmacy distance learning programmes from Aston University in Birmingham. These are all open to any pharmacist but are particularly targeted at those working in secondary care. In 1997, 229 secondary care centres were identified as employing pharmacists dedicated to mental health. At that time it was accepted that these pharmacists were providing a wide ranging standard and breadth of service, with many continuing to work in small specialist departments or finding themselves, as a result of the advent of community care and the closure of the large institutions, equally isolated in large departments in general hospitals. (Taylor & Donoghue 2000). Additional initiatives have included the setting up of a medication help-line for patients and carers accessible by the general public, together with the provision of a range of user-friendly patient advice leaflets on medication (PALs) available on CD-ROM, plus a variety of publications to aid the professional in their optimal use of medication. The annual international conference has facilitated co-operation with other groups out-side the UK. The post graduate Certificate in Psychiatric Therapeutics distance learning programme is undertaken by students all over the world and past students include nurses as well as pharmaceutical industry personnel. More formal links have been developed across Europe with the European Pharmacists for Psychiatry and Neurology (EPPN) a group established in 1995.

These initiatives have clearly helped to develop the practice of at least some pharmacists working in mental health. However two major deficits were apparent. First, attendance at conferences and postgraduate education opportunities were only available to a minority of pharmacists, perhaps paradoxically those who were already well supported in their place of work. Second, there remained no practicable method of assuring the quality of the practice of pharmacists working in mental health. Coincidental with the realisation of these shortfall was the introduction of clinical governance in the National Health Service by the white paper, the New NHS - Modern Dependable (Department of Health 1997) and the mental health strategy, Modernising Mental Health Services - safe, sound and supportive (Department of Health 1998). Clinical governance demands professional peer review, life-long learning and the assurance of best practice - exactly those factors identified as deficits of the existing system.

Pharmacists are health care practitioners whose ultimate objective is to ensure the optimum use of medicines. Mental health is no different in this respect, but no body existed to ensure that pharmacists were adequately trained in the specialty of mental health and performing to the standards necessary to ensure optimal use of medicines. This was the situation in a climate of increasing availability of new and by definition expensive agents for the treatment of serious mental illness and the consequent escalation of the drug bill unsurpassed in the past forty years. The UKPPG therefore put forward the idea of a college which would ensure competence through an accreditation scheme that supported pharmacists' development through to formally recognised status as "specialist mental health pharmacists". Thus, the College of Mental Health Pharmacists (CMHP) was formed in October 2000 with the aim of establishing pharmacists as recognised expert practitioners in medicines use in mental health and to assure their competence.

The CMHP is viewed as an essentially facilitative body which will ultimately ensure the optimal use of medicines in mental health - wholly in accordance with the essence of clinical governance. Accredited membership is available via practice and academic routes, each requiring the submission of a portfolio which, if acceptable, is followed by a viva voce. Such accreditation is valid for five years with the requirement for annual evidence of continual professional development. To date twelve full members have been accredited and the expectation is to have an initial complement of twenty-five by October 2003.

Being recognised as experts in the use of medication in the treatment of mental illness has led to involvement of members of the Group in consultation processes surrounding various Government initiatives. To date contributions have been made to the consultation on the New Mental Health Act, Independent Specialist Advocacy in England and Wales, the Control of Medicines in Nursing Homes, the Extension of Prescribing Powers to Pharmacists and Nurses, the National Suicide Prevention Strategy for England and the Working Well programme for Mentality which considered the stigma attached to those professionals working in mental health. The group was a stakeholder with the National Institute of Clinical Excellence (NICE) in the production of the guidance on the use of atypical antipsychotics in the treatment of schizophrenia (NICE June 2002) and members sat on the guideline group for the development of the clinical guideline on core interventions in the treatment and management of schizophrenia (NICE December 2002). Currently members are continuing to work with NICE on the development of the anxiety and depression guidelines as well as the management of disturbed (violent) behaviour in in-patient psychiatric settings and the health technology appraisal of newer drugs in bipolar affective disorder. The group is registered as a stakeholder for all future NICE guidelines and technology appraisals involving the use of pharmacological interventions for the treatment of mental illness and its members will be closely involved in the production of any subsequent publications. Members are additionally working with the Royal College of Psychiatrists and British Association of Psychopharmacology on a joint statement on the use of high dose and combination antipsychotic medication. As well as other professional bodies, the UKPPG actively works with voluntary user and carer groups. Collaborating when invited to do so in research and providing speakers for local meetings. Members of such groups are also regularly invited to take part as speakers in the annual conference to give a "service- users perspective".

The Future.
The future looks bright in terms of the fact that there now exists a steadily growing group of highly qualified health care professionals with specialist knowledge in the use of medicines to treat mental illness whose main aim is to improve patient care. The potential is enormous, however the future is not without problems, with recruitment, in common with many other areas of the NHS, being a serious cause for concern. The opportunity for continuous professional development within psychiatric pharmacy is considerable but such opportunities are unavailable to even the most highly motivated if they are not fully resourced and supported by management. Similarly, enthusiasm and motivation needs to be rewarded with an appropriate grading system suitably remunerated. Recruitment into hospital pharmacy is currently dire with vacant posts in psychiatry more than most. It is still seen as an under-resourced specialty without the necessary career structure in the clinical field that the young graduate with a four year degree course behind them has been led to expect. Instead, recruitment of new graduates is largely into primary care, where the large multiples are able to offer attractive packages to newly qualified pharmacists to work in the community.

The government aims to have up to 1,000 pharmacists and up to 10,000 nurses trained as supplementary prescribers by the end of 2004. The plan is to make better use of highly skilled pharmacists and nurses by giving them delegated powers to prescribe medicines for patients in partnership with GPs and hospital doctors This is in order to "provide better and quicker patient care" and "help to improve patient access to medicines and increase the opportunity for patients to get advice about their medicines" ( Root G. 2003). The UKPPG contributed to the consultation process on supplementary prescribing and with the College of Mental Health Pharmacists (CMHP) supports the general concept. The main opportunity here is the potential to improve patient care - merely improving access to medicines and increasing the amount of information and advice to patients is not enough. Many mental health pharmacists already undertake roles that are compatible with this concept, so becoming supplementary prescribers will, for them, merely legitimise their current practice. Such activities include an involvement in lithium, depot and memory clinics together with general treatment reviews. Future activities could include initiating therapy for in-patients as well as out-patients, adjusting dosage according to response, rationalising treatment and dealing with side-effects, all of which will definitely contribute to improved patient care.

It is envisaged that supplementary prescribers in mental health will operate in a variety of situations: as a member of a ward multidisciplinary team headed up by a consultant psychiatrist, as a member of the community mental health team or in the out-patient clinic. It is the opinion of the UKPPG and CMHP that any pharmacist prescribing for patients suffering from mental illness should be clinically capable in the field of mental health and psychiatric therapeutics. The competencies of such pharmacists must be appropriately assessed and assured. It is hoped that trusts providing services to mental health patients will consider it prudent to have at least one accredited specialist pharmacist in their employ who can then be responsible for pharmaceutical care under the requirements of clinical governance. It is also hoped that those applying to be supplementary prescribers within the field of mental health will also be required to be similarly, suitably accredited.

Further information about the UKPPG and CMHP may be accessed from the website www.ukppg.org.uk which contains many links to other mental health sites useful to both professionals and the service user.

27.7.03 - Dave Branford off to New Zealand
In July, Dr Dave Branford issued this statement:
"From the beginning of September 03 until July 04 Dave Branford will be living and working in Auckland , New Zealand. During this career break I will be working as a member of a community mental health team in a newly developed role. During my absence the Derbyshire Mental Health Services Trust Pharmacy service will be managed by my deputy Mrs Beverley Thompson. For the first time for over 20 years I will not be attending the annual conference and I have resigned my post as registrar of the College of Mental Health Pharmacists. The wonders of e mail though mean that I will never be far away so I will continue to remain in touch.
Dave Branford, Pharmacy Dept, Kingsway Hospital, Derby, Tel: 01332 362221 Extn 3567 Fax: 01332 623588

21.6.03 - UKPPG committe meeting on 19th June 2003.
Your committee met before the Lilly conference in Brighton. Those present were Celia, Wendy, Graham N, Morag, Trudi (for CMHP), Robert, Denny, Steve, Fiona and Ian. Apologies from Graham Parton and Juliet. No information on Gill or Lynn.
Declarations of interest:

Items discussed included:

News:

Supplementary prescribing by pharmacists: the UKPPG joint position statement on supplementary prescribing by pharmacists is now in late draft stage. A working party (led by Graham Newton and consisting of Wendy Ackroyd, Dave Branford, Stephen Guy, Wendy Davies, Steve Bazire and Lynn Haygarth) has completed this draft and now needs comments as soon as possible. You can access the draft by clicking here and e-mail comments to Graham Newton at graham.newton@merseycare.nhs.uk by Friday 4th July.
(At this point I had to leave to the rest will be revealed in due course).

31.3.03 - UKPPG-AstraZeneca psychiatric medication helpline closed on 31st March 2003, due to loss of on-going funding. AstraZeneca have been looking at other ways of providing this support to users, and we thank them on behalf of the UKPPG and all those users who benefitted from the advice. The Maudsely are trying to get another source of funding for the helpline and things look cautiously optimistic at the moment. There is a message on the ansaphone letting patients know that the line is closed if they continue to call. Anne Connolly, Maudsley MI

29.3.03 - UKPPG committee met on 21st March 2003
Present: Celia, Wendy, Morag, David T, Juliet, Graham N, Steve (apologies from the rest)

17.3.03 - Congratulations to committee member Ian Maidment and wife Alison on the birth of a baby boy on Sunday morning (16th March 2003).

20.1.03 - UKPPG committee met Thursday 16th and Friday 17th January 2003
with thanks to Kim Heppinstall and Lundbeck for support. Members present included Celia, Graham N, Graham P, Wendy, Fiona, Robert, Steve, Ian, Juliet and Denny, plus Dave Branford (Thursday) and David Taylor (Friday). Items discussed included:

20.1.03 - Loxapine discontinuation
We also understand from the Pharmaceutical journal that loxapine (Loxapac) will be gradually discontinued between now and summer 2004.

14.1.03 - Nefazodone discontinuation advice
Dutonin (nefazodone) is indicated for the symptomatic treatment of all types of depressive illness, including depressive syndromes accompanied by anxiety or sleep disturbances. In adults the usual therapeutic dose is 200mg twice daily, up to a maximum dose of 300mg twice daily (1).

Nefazodone has a plasma elimination half-life of 2-4 hours.1 Steady state is reached within 3-4 days after initiation or dosage changes.1 After oral administration of radiolabelled nefazodone, the mean half-life of total label ranged between 11 and 24 hours (2).

Nefazodone is extensively metabolised after oral administration by n-dealkylation and aliphatic and aromatic hydroxylation, and less than 1% of administered nefazodone is excreted unchanged in urine.2 Attempts to characterise three metabolites identified in plasma, hydroxynefazodone (HO-NEF), meta-chlorophenylpiperazine (mCPP), and a triazole-dione metabolite, have been carried out (2). The elimination half-lives for these three metabolites, for nefazodone dosed at 100mg twice daily, were as follows:

Metabolite and Elimination Half Life (hours)

HO-NEF possesses a pharmacological profile qualitatively and quantitatively similar to that of nefazodone. MCPP has some similarities to nefazodone, but also has agonist activity at some serotonergic receptor subtypes. The pharmacological profile of the triazole-dione metabolite has not yet been well characterised. In addition to the above compounds, several other metabolites were present in plasma but have not been tested for pharmacological activity (2).

Nefazodone is eliminated within 24 hours of discontinuing treatment1, however because of the presence of metabolites with longer half-lives the washout period should be regarded as 3-4 days (the time to reach steady state).

The Summary of Product Characteristics for Dutonin (1) states that "withdrawal reactions have been reported in association with serotonin re-uptake inhibitors (SRIs) and to date have rarely been reported with Dutonin. Symptoms include dizziness, paraesthesia, headache, anxiety and nausea. Abrupt discontinuation of treatment with Dutonin should be avoided. The majority of symptoms experienced on withdrawal of SRIs are non-serious and self-limiting."

Switching from Dutonin™ to Other Antidepressants:

Abrupt discontinuation of Dutonin should be avoided as withdrawal reactions have been reported rarely with Dutonin (1).

The Maudsley Prescribing Guidelines (3) advise that all antidepressants have the potential to cause withdrawal phenomena and should be withdrawn slowly, preferably over four weeks, by weekly decrements. If withdrawal symptoms occur then the rate of drug withdrawal should be slowed or (if the drug has been stopped) the patient given reassurance that symptoms rarely last more than 1-2 weeks. The British National Formulary also advises that withdrawal should not be abrupt, with the dose being reduced gradually over 4 weeks (4).

When switching from one antidepressant to another, abrupt withdrawal should usually be avoided. Cross-tapering is preferred in some cases, where the dose of the drug being withdrawn is slowly reduced while the new drug is slowly introduced. No clear guidelines are available on switching antidepressants, so caution is required.(3) Potential problems include drug interactions or discontinuation effects from the first drug being interpreted as side effects of the second drug.(5)

The Maudsley Prescribing Guidelines gives the following advice on switching from nefazodone to other antidepressants (3):

Antidepressant Advice on switching from nefazodone:

When switching from Dutonin (nefazodone) to another antidepressant, consider contacting the specific manufacturer for advice on initiation following nefazodone. Summaries of Product Characteristics for Dutonin (nefazodone) and other antidepressants can be found on the Electronic Medicines Compendium at http://emc.vhn.net.

References:
1. Summary of Product Characteristics, Dutonin™ (nefazodone), June 2002
2. US Prescribing Information, SerzoneÒ (nefazodone), April 2002
3. The Maudsley Prescribing Guidelines, 6th EditionTaylor D, McConnell H, Duncan-McConnell D, Kerwin RMartin Dunitz, 2001
4. British National Formulary, 44Published by the British Medical Association and the Royal Pharmaceutical Society of Great Britain, September 2002
5. Psychotropic Drug Directory 2001/02, Bazire S, Quay Books, 2001