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In Part 2a Con Berbatis reported on world pharmacy developments in the media in Europe and North America. In Part 2b. he reports on key findings and meetings held with pharmacy and medical leaders and practicing pharmacists from Washington DC, Baltimore and New York City ( 6-12 January) on the east coast, in Chicago and Toronto (13-14 January) and in Los Angeles and San Francisco ( 17-22 January) on the west coast (Table 1).
The topics discussed are summarised in Table 2.
Inferences made from the many observations from the trip together with the results of the National Pharmacy Database Project allow some interesting predictions for community pharmacy health-related practice.

From Washington DC (DC) I travelled by train to a snowing Baltimore on Monday 6th January to give a seminar on our recently published international and Australian analyses of psychostimulants.
My hosts in the School of Pharmacy were Dr Julie Zito the US expert on psychotropics prescribing in US children, Tony Tommassello (Ph D) a friend from 1998 who had won a $US 0.5million grant to study buprenorphine uptake in city settings and Dr Ed Johnson former pharmacy director and buprenorphine expert formerly at Johns Hopkins University .
Dr Zito reported over 10% of students in east coast regions were taking prescribed psychostimulants compared to NSW's 2-4%.
Dr Zito pointed to doubled or more use to the levels taken by 20-45 year olds of antidepressants , psychostimulants and other psychotropic drugs in US children down to toddlers .
The FDA estimates 70-80% of these drugs are used for unapproved indications and now requires full paediatric information on dosage and adverse effects in drug packages.
MRI brain scans are used to monitor effects in children (Table 2, Reference 1).
Drs Johnson and Tommasello will train and study pharmacists' buprenorphine dosing of opioid dependents after decades of being excluded from methadone maintenance

Washington DC - the active APhA in DC and ASHP seminar in Bethesda
On Tuesday 7th January I gave a morning and an afternoon seminar on our initial results of the National Pharmacy Database Project (NPDP).
In Bethesda 10 km north of DC , William A. Zellmer, the Deputy Executive Vice President of the American Society of Health-System Pharmacists chaired a meeting of 25 including ex-PSA man Dr Ross W Holland who now heads PharmEd Consultants.
A number said a survey like the NPDP would be almost possible to do because privacy laws and the dominance of the non-pharmacy corporate groups inhibited responses to much of the NPDP questionnaire.
In the afternoon I spoke to the American Pharmacists Association's executive director William Ellis and Anne Burns the director of practice development and research.
They showed me 82 impressive APhA publications (www.pharmacist.com ) adding to the 66 produced by the UK's Pharmaceutical Press ( www.pharmpress.com ) and handed me a dozen monographs in the two continuing education series 'Partners in self-care' and ' The dynamics of pharmaceutical care' ( Table 2, 2).

Next day Mitchel Rothholz the APhA's vice president of professional practice (picture) proudly spoke on the range of pharmacy activities recognised in the national medical position paper on 'Pharmacist scope of practice' ( Table 2, 3).
He said over 1,000,000 vaccinations yearly occurred in US pharmacies especially in the large pharmacy groups now competing for new professional services and increasingly over the internet with e-prescribing a reality (Table 2, 4).
US and Canadian national pharmacy authorities have struck an agreement to oppose internet sales of drugs (see Part 2a) because face-to-face counselling did not occur and the likely increased risk of adverse drug effects ( Table 2, 5).

The frequent television and radio advertising ( direct marketing) of pharmaceuticals we witnessed is known to produce higher pharmaceutical sales but has little impact on the health of consumers ( Table 2, 6).
That is, these forms of direct marketing drive the public to self- medication (naming the product) in pharmacies and other outlets but without appropriate interventions by pharmacists or other qualified health workers the health outcomes in consumers may not improve.
We have found in the National Pharmacy Database Project that more consumers seek advice for their minor health disorders than self-medication but the ratio of seeking advice to self-medication is higher in pharmacies in rural and remote than in urban areas.
We fear the frequency of self-medication in Australia's community pharmacies may soon surpass seeking health advice leaving pharmacists a declining role in primary health care .
When visiting large US city pharmacies the managing pharmacists in their inconspicuous dispensaries said consistently they received around 20-40 health queries each day implying the ratio of health queries to self-medication was much less than half and probably less than 1:4.
I concluded the frequency of pharmacist interventions in pharmacy medicines appears to have fallen so far in large US pharmacies that pharmacists' role in primary health care there is quickly becoming trivialised.
This is a poor omen for pharmacy's control of S3 and pharmacy medicines in other countries .

In Australia our national pharmacy bodies may need to reconsider the current emphasis on the processes of pharmacists providing S3 medicines to comparing the effectiveness of pharmacist- advised actions (both drugs and others) versus those of self-medication (with no pharmacist intervention).
In particular , to compare the rates of outcome indicators of S3 and other non-pharmacy medicines such as reports of misuse, safety and toxicity to poisons information centres in Australia.
Collating similar data from national registries of poisons centres in the USA where pharmacist-only medications exist just in Florida and comparing standardised rates with those from Australia.
Other indicators of drug-related morbidity such as statistics on OTC drug-related hospital admissions in both countries and reports to the Drug Abuse Warning Network (DAWN) in the USA need to be analysed.
Reports from the USA suggest misuse of OTC medications containing pseudoephedrine and dextromethorphan they have resulted in methods of or calls for restricting their access in pharmacies and other outlets (Table 2, 7a and 7b).

Table 1. World pharmacy and medical leaders in the USA and Canada : 6 - 22 January 2003.

New York City - methadone and pharmacy nurses

On 10th January I met Mark Parrino the dynamic president of the American Association for the Treatment of Opioid Dependence Inc (AATOD) and a longtime advocate of methadone maintenance (MMT) in a country where its use was pioneered in 1964 but has ironically resisted its use .
He said there were nearly 1000 accredited methadone treatment programs in the USA serving around 220,000 patients ( Table 2, 7), about half pro rata Australia's approximately 35,000 MMT patients, representing 27% increases in both US programs and patients since December 1998.
Just 1% of US MMT patients are assessed and managed in primary care.
Community pharmacies became involved on a trial basis in 2001.
AATOD instigated MMT in New York jails in 1987.
Mr Parrino has been a driving force in opening MMT programs in all but seven States, initiating MMT training programs for 24000 primary care doctors and other practitioners, compiling MMT accreditation standards, educating Drug Court judges and the public on the benefits of MMT.
He noted "…Recent oxycodone related admissions to methadone programs have strained existing resources…"
Mr Parrino blamed much of the 1999-2002 rise in methadone-related overdose deaths in Maine and Florida on questionable analgesic prescribing and misclassification of methadone-related deaths and not on diversion from methadone maintenance programs (Pharmacy Review April 2003, page 60).
He pointed to methadone deliveries to those States increased by 16% between 2001 and 2002 (DEA ARCOS data.
The majority of this increase was in 5 mg and 10 mg tablets to pharmacies.
An analysis of prescribing patterns showed a significant number of primary care doctors have switched from prescribing 'Oxycontin' to methadone as an analgesic (IMS data,2003) .
The majority of the methadone associated deaths appeared to originate in doctors in private practice who have no affiliation with methadone treatment programs.
One of the confounding variables, however, is the fact that no two medical examiners in the United States would agree on how to assess a methadone associated death.
There are no standard reporting criteria to follow and many of the medical examiners do not even agree on the kinds of post-mortem toxicology tests, which should be used in evaluating methadone toxicity deaths.
Australia and NSW particularly faced a situation from 1990-2000 when illicit heroin use and methadone peaked and was the highest in the world.
Forensic scientist Dr Olaf Plummer in Melbourne was the first to report a spate of methadone induction deaths and was a leader in characterising methadone-related deaths
Next day I met Sally Landsberger the manager of a small, busy, six-staff, mainly dispensing community pharmacy filled with Hispanic- and African- American patients near New York City's Columbia Hospital. Sally guided me to a separate room used by a nurse engaged to perform vaccinations, clinical testing for both screening purposes and monitoring purposes where patients with diabetes, asthma and cardiovascular diseases were educated in compliance and trained to use devices for monitoring.
I was impressed by the variety of information printed in Spanish and other languages to cater for the diverse ethnic minorities.

Chicago and Toronto - chain store pharmacies
The large group pharmacies visited in Chicago on 13th and 15th January and other cities days before on the east coast and on 19th to 21st January in San Francisco, typically had large areas of 200-400 square metres of shelves and modest dispensaries in the rear or on an upper floor.
Some pharmacy groups in Chicago and other cities engaged either nurses to regularly rotate amongst their member pharmacies or they contracted companies with nurses to provide specified services according to a program.
The most disturbing sight in the group pharmacies was the side-by-side display of Nicorettes and Nicabate and packets of cigarettes a practice which has largely but not totally disappeared from Australia's pharmacies since 1980 !
Some pharmacist managers were embarrassed but helpless to resist their pharmacy group's corporate commercial-anti-public health policy or they defended the cigarettes by saying pharmacies were a trivial supplier in the overall sales of tobacco-containing products !
On 14th January the University of Toronto's Associate Professor Linda D. MacKeigan hosted me for a pre-arranged address to a postgraduate seminar in the Faculty of Pharmacy on our research into psychostimulants.
I spoke to a part-time staff engaged to educate community pharmacists on the use and misuse of these agents.
Canada is the second highest licit stimulants consumer after the USA. Frank May and Debra Rowett the leaders of South Australia's Daw Park Hospital DATIS visit Dr MacKeigan to train 'academic detailers' for a project aimed at improving prescribing amongst Ontario's community doctors.

Table 2. Pharmacy themes discussed in USA and Canada in Dec. 2002 - January 2003

Los Angeles and San Francisco - licit opioid misuse and Walgreen's e-pharmacies
On 17th January in Los Angeles I renewed a friendship with Dr Walter Ling the UCLA's Professor of Psychiatry and head of the UCLA Integrated Substance Abuse Program .
He spoke on the medical recognition of the diversion, misuse and abuse of prescribed opioids by both patients , doctors and health workers in a chapter he had co-authored on 'Abuse of prescription opioids' (Table 2,8).
This issue has been highlighted nationally in Australia in May 2003 (Tobler H. Theatre of free dreams. The Australian 29 May 2003 : page 15).
The nonmedical use of prescription opioids occurs in over 1.6 million Americans (pro rata over 100,000 Australians) yearly. Oxycodone -associated deaths jumped from 49 in 1996 to 262 in 1999.
On 20th January in San Francisco I visited a number of group pharmacies (refer above section under Chicago).
On 21st January I met with Paul B Johnson a pharmacy manager of Walgreen's Pharmacy Fisherman's Wharf and a 1991 graduate of the UCSF Faculty of Pharmacy.
Paul managed a typical group pharmacy open from 8am to 9pm in winter and to midnight in summer (tourist season), consisting of 2500 sq m area of display shelves and retail counters adjacent to the entry doors in the control of non-pharmacist staff and a rear dispensary of similar area to dispensaries in this country.
He dispensed typically 200 items a day and had approximately 30 queries from clients about the treatment of minor ailments .
Neither Paul nor his contemporaries were likely to own their own pharmacies and he was content to follow a career path in group pharmacies.
Walgreen's pharmacies were on a website and offered a wide range of services including health information., prescription ordering, prescription refill (repeat) prompts , delivery of health equipment and non-health goods ( www.walgreens.com/pharmacy accessed 31 May 203) .
Doctors could be contacted by email and e-prescribing was planned to be commence by June 2003.
Paul referred me to Ruth Conroy, District Pharmacy Supervisor of Walgreen's Pharmacies in San Francisco who I met on 22nd January.
Ruth was a graduate of the School of Pharmacy in the University of the Pacific at Stockton, 100km east of San Francisco in 1982 .
She supervised over 40 pharmacies from Los Altos 20km south to San Francisco city.
Ruth ensured pharmacists and non-pharmacist staff attended Walgreen's external training and conducted in-house training programs according to Walgreen's requirements.
Walgreen's currently had approximately 3,800 pharmacies in the group and was aiming within a decade to have 5000 pharmacies - Australia's total number of pharmacies registered in 2003 with both State authorities and the Health Insurance Commission !
She thought Wal-Mart the biggest retailer in the USA would become the biggest group pharmacy by 2020 ( Table 2, 9).
Ruth confirmed the rapid growth of internet sales in the Walgreen group and predicted pharmacists activities would increasingly become e-pharmacies for most patient care and health-related activities.

My visit to the UK, USA and Canada sketched a map of the future of health-related processes and activities in pharmacies .

Predictions for community pharmacies to 2020 :
1. Groups of pharmacies will get bigger :
The trend towards membership of pharmacies into groups is undeniable with 50-55% of Australia's pharmacies already in groups.
This will result in greater efficiencies and increased rivalry for 'competitive edges' in both commercial and pharmacy practice activities such as free point-of -care screening in pharmacies.

2. e-pharmacies retain patients and enhance goodwill :
e-pharmacies will develop both as internet information receivers and internet providers of goods, information and service as part of pharmacy groups.
e-pharmacy services will reach community-wide into homes and health care facilities and will help pharmacies better retain patients.
For example, e-pharmacies with existing contracts with residential aged care facilities or rapidly expanding DMMRs and other types of medication reviews will be in a better position to retain these patients and enhance the value of their pharmacies.

3. From S8 dispensing jockeys to S8 online custodians :
The risk of Schedule 8 related misuse amongst children as well as adults will become so threatening to individual and public safety and increase medical and pharmacist insurance to such a degree that legislation will allow internet access by doctors and pharmacists to State (eg S8) and Commonwealth (eg HIC) -held patients' drug and medical histories before dispensing hence facilitating early interventions to prevent misuse .
That is, pharmacists will become online custodians to identify doctor and pharmacy shopping, forged prescriptions and misuse of prescribed Schedule 8 drugs and other dependence -producing agents such as the benzodiazepines.
National and State pharmacy bodies with or without their medical counterparts will unify for legislation to be enacted to compel
a) privacy release by patients receiving S8 drugs for doctors and pharmacists to access State and national government-held medication histories,
b) online access to HIC and State health department medication data on patients before prescribing and dispensing,
c) online access between dispensers and prescribers before prescribing or dispensing S8 drugs to suspected misusers and
d) limit S8 sources by patients to one prescriber-one pharmacy .

4. MediConnect system will be driven by S8 legislation :
MediConnect which has replaced the Better Medication Management System or BMMS will be driven by the above S8 legislation to overcome the constraint imposed by patients' 'opt-in' to MediConnect.
To facilitate MediConnect nationally, all medical offices and pharmacies will require standardised computer hardware, software and telecommunication (eg ADSL) to facilitate e-prescribing and the above legislated S8 activities which will extend to S4 and other schedules of drugs.
Encryption and other computerised security measures will be widely adopted for e-pharmacy activities

5. Algorithms for S4 to S3 to S2 to….S100 management :
the above model for S8 drugs will become so efficient and widely accepted that it will be modified for other schedules of therapeutic drugs and categories of patients.
Simple standardised health care algorithms for minor to serious health disorders will facilitate precise selection of S2s , S3s and better monitoring of S4s.

6. Pharmacies as screening resources :
screening in pharmacies will become recognised as the most efficient way of increasing new prescriptions for chronic disorders (eg type 2 diabetes and hypertension) and new profitable non-drug services for weight reduction will be developed in consultation either with experts with suitable internet programs and databases for recording managed overweight clients or in collaboration with successful weight reduction companies.
A range of efficient screening services will be provided.
Most pharmacies will provide a range of simple non-invasive screening services from simple anthropometric ( Body Mass Index) , blood pressure measurement, peak flow meter, bone density screening, ethanol and pregnancy testing .
More complex invasive testing of fluid specimens for cholesterol and glucose or immunological tests such as microalbuminuria and Helicobater pylori will be performed mainly in group pharmacies which engage nurses.
Additionally, external testing of more complex analytes such as therapeutic drugs in blood or illicit agents in hair samples will be sold in security packages as in US pharmacies.

7. Rural pharmacies as nuclear primary health care providers :
large pharmacy groups will replace existing government-funded health services in many rural and remote areas and develop private primary health care centres with doctors, nurses and other health professionals depending on demand.

8. Discharge patients with DAAs transferred to pharmacy care :
first-time and subsequent hospital patients with severe depression , bipolar and other mental disorders will be discharged with dose administration aids (DAAs) to the care of designated community pharmacies .
This will result in markedly improved compliance and lower readmission rates into high cost hospital beds which will facilitate enhanced fees for the pharmacies.

9. Client databases, retention of clients and value of pharmacies :
databases already exist in pharmacy groups in the USA and Australia with large client membership bases .
By linking point-of-sales with membership numbers they can measure the effectiveness of commercial promotions , professional innovations and other types of incentives and the retention of members. Quantitative markers of numbers of members , retention and POS per member will become the main determinants of valuing pharmacies.

Ends.

Con Berbatis
Lecturer
School of Pharmacy
Curtin University of Technology of Western Australia
Chief Investigator
National Community Pharmacy Database Project
3 June, 2003.
berbatis@git.com.au