1. New Zealand – Can we live up to the ‘clean-green’ image? Dr Rhiannon Braund School of Pharmacy University of Otago New Zealand

4. Pharmaceutical Policies In NZ Strong focus on ‘access’ to medications (and healthcare in general). Individuals and families with lower income have reduced costs to see a Dr or to collect medications. Pharmaceutical budget (~ $550 million p.a) maintained by a government agency (Pharmac) and they control the pharmaceutical schedule.

5. Collecting Prescription Medications A prescriber writes a prescription for three months. Historically this was issued as one month and two repeats. Patient paid a co-payment for first dispensing and the additional two were at no cost, but could not collect them until at least 20 days had passed. This co-payment was either $15, $3, $2 or $0 depending on income and number of items collected in a year.

6. What has changed? In 2004, introduction of ‘stat’ or ‘all-at-once’ dispensing. – Save ~$60 million in dispensing/professional fees – ~$24 million in wastage – Overall savings of ~$36 million p.a Recently (2007) the patient co-payment was reduced to $3 (NZD) for everyone.

7. ↑ Access = ↑ Excess ? If the obvious answer is yes, then the next question(s) are: – How much? – At what cost? (Clinical, Financial and Environmental) – Can we minimize this excess without compromising access?

8. Identification of returns (Study 1) ODHB pay for the destruction of medications returned to pharmacies A random sample of boxes for destruction were put aside for analysis Almost 1300 kg returned in 9 month period Analysed 160 kg (12%)

9. Braund et al 2007 NZFP

10. Conclusion (Study 1) All of the 20 most returned items = ‘stat’ but caution as ‘stat’ was intended to increase access One patient returned – 1198 paracetamol – 1157 paracetamol/codeine – 469 doxepin 25mg – 362 warfarin tablets – 7 100g tubes of hydrocortisone

11. Why are they being returned (Study 2) Previous overseas study found that those who returned medications brought back average of 60% of original prescription The reasons included – Bereavement(26%) – Expired medication(25%) – Person felt better(11%) – Doctor changed medication(11%) – Allergic reactions(8%) – Person did not want to take the drug (7%) Cameron S. 1996 Can Med Assn J

12. Situation in Dunedin (Study 2) Pilot study Two local pharmacies Five week collection Patients returning medication for disposal were asked to complete a brief questionnaire

13. Braund et al 2008 NZFP

14. Reasons for unused medications Braund et al 2008 NZFP

15. Conclusions (Study 2) Initiation of ‘trial’ prescribing Quantity of ‘prn’ medications – Amount vs period of supply One patient = ~ $15 000 worth of medication

16. Media Interest

17. Situation in Hutt (Study 3) Approached by HVDHB to assist Used our surveys ‘The main objective of this programme was to minimise the potential risk of household poisonings via safe and efficient methods of disposing unused medications.’ Question about medication storage added

18. 31 community pharmacies Four week collection period 1605 bags returned 653 completed questionnaires Sample analysed (329 with 149 questionnaires) All Qs were also analysed

19. Returns by quantity

20. Why was the medicine(s) not used?

21. Conclusions (Study 3) Trial prescribing ‘prn’ medications Inhaler returns Pharmac change in June 2008 – Susan Judd

22. Storage and disposal survey (study 4) Online Survey (via NZ poison centre) – Collecting medications – Collecting repeats – Storage – Disposal Over a three month period 516 people viewed the survey and it was completed by 452 individuals

23. Results 62 % said that they currently had leftover or unwanted medications at home. 48 % of people store their medications in the kitchen, 29 % bathroom, 13 % bedroom

24. Disposal of unused

25. Reasons for unused medication

26. Why do you keep unused medications

27. Where to from here? In 2009, will start analysis of different water systems to determine if trace levels of pharmaceuticals Also ‘life of a prescription’ study. This will investigate what types of medications are not collected, used etc

28. Acknowledgements Community Pharmacists Undergraduate Pharmacy Students NZPERF NZ National Poison Centre