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Session GuideRole of Dispensers in Promoting Rational Drug Use

PURPOSE AND CONTENTOBJECTIVESPREPARATIONSESSION NOTESACTIVITIESCONCLUSIONVISUAL AIDSBACK TO TABLE OF CONTENTS

PURPOSE AND CONTENT

Physicians are often highlighted as the final pathway for nearly all professional decisionsabout the use of health resources. Yet with respect to drugs, pharmacists and otherdispensers are in many cases the final link between the medication and the patient.Community pharmacies have always been a major location for health care worldwide.Pharmacy employees are consulted for health advice on problems of all kinds, andremedies are sold or dispensed with almost every transaction. Some of the remedies aresafe and effective when used correctly but otherwise can be dangerous; others areineffective no matter how they are used.

The purpose of this session is to identify important factors that influence the dispenser'sbehavior and consequently, his or her impact on a patient's compliance with drug therapy.

OBJECTIVES

To develop your ability to:

1. Identify who can be dispensers.

2. Describe the dispensing process.

3. Identify factors that influence decisions dispensers make.

4. Describe methods that enhance dispenser/patient communications.

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5. Identify ways to influence a dispenser's behavior.

PREPARATION

Read Session Notes and Trainers Guide and review visual aids.

Read Chapter 32 of Managing Drug Supply, "Ensuring Good Dispensing Practices."

Read article by Ross­Degnan, et al, "The Impact of Face to Face EducationalOutreach Diarrhea Treatment in Pharmacies," Health Policy and Planning, vol.11, no. 3, Sept. 1996.

Note: This module has been developed by a number of people including Drs. KumudKafle, Farai Chinyanganya and Sri Suryawati. Photographs have been provided by Dr.Edelisa Carandang (Philippines), Fatima Suleman (South Africa), Prof. Willy Anockobongo(Uganda), and Dr. Farai Chinyanganya (Zimbabwe).

SESSION NOTES

Case report

A 20 yr. female student suffering from tonsilitis,seen by a doctor in a 600­bed hospital OPD. Sheobtained a drug from the hospital pharmacy, andtook as instructed. She felt very weak after takingthe drug, 3 days later she got severely comatoseand was admitted to the same hospital. She tookchlorpropamide 250 mg 4 times a day. The OPDdoctor claimed that he prescribed chloromycetine4x250 mg daily for her tonsilitis. The patienteventually died 2 weeks after hospital admission..

Inappropriate or incorrect dispensing can undo many of the benefits of the health caresystem. Regardless of the modern facilities, extensive education, and careful diagnosis,the proper medication must be dispensed to the patient and the patient must comply withtherapy for the health system to have accomplished its task.

Dispensing is often overlooked by health planners during the development of health caredelivery. It is usually considered of secondary importance to diagnosis, procurement,inventory control, and distribution. This oversight is unfortunate, because poor oruncontrolled dispensing practices can have a very detrimental impact on the health caredelivery system. All of the resources required to bring a drug to the patient may be wastedif dispensing does not ensure that the correct drug is given to the right patient in aneffective dosage and amount, with clear instruction, and in packaging that maintains theintegrity of the drug. Since the dispenser is often the last person to see the patient beforethe drug is used, it is important that the dispensing process be understood as it affectsdrug use.

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This session outlines specific considerations of dispensing that are not only factorsin rational drug use, but are also essential to the overall functioning of a health caredelivery system.

A. WHO IS A DISPENSER?

Most of this session will discuss dispensing as ifit were only performed by trained pharmacists,pharmacy auxiliaries or other qualified healthworkers. In many, if not most countries,dispensing is performed by a wide variety ofpersonnel, not all of whom have had formaltraining.

In the real world, a prescriber is anyone with a recommendation for treatment; a dispenseris anyone that gives out the treatment.

Formally, we think of a dispenser as a personwho has had special training in the art ofpreparing and giving out medicines. In a globalsense, however, a dispenser can literally be anyperson who prepares and gives out remedies,regardless of training. Thus, dispensers includenot only the qualified health workers(pharmacists, physicians, nurses, basic healthworkers, even veterinarians), but also self­appointed health workers who have access to

any substance that they believe can cure. These dispensers would include friends,relatives, store keepers, taxi drivers, etc.

Consider the scenario in most countries. The qualified pharmacist's role is often suggestedby the advertisement: "Drugs ­ Retail and Wholesale." In their retail role, druggists, or theiremployees, will provide medicines and advice on any number of health conditions. On thewholesale side, they provide drugs to the entire private, and often to the public, health caresystem. Many drugs are sold to small local village shops, where they might be sold toanyone who can buy them. The buyer, in turn, might resell the drugs to someone else whomight possibly resell them again, ... and so on. The informal private drug distribution andtrade network remains a mystery. But one thing is certain: where there is a demand fordrugs, there will be a supply ­ and "dispensers" will dispense them, hopefully in

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accordance with good dispensing practices that willenhance rational drug use.

In many health care institutions, especially in thedeveloped countries, the role of the pharmacist inpatient care, especially in dispensing drugs to patients,becomes more and more important. [Link to Picture]Pharmacists contribute the safe and effective use ofpharmaceuticals at times when drugs are dispensed.They also play a significant role in promoting rationaluse of drugs, e.g. providing drug information to patient,and carrying out drug utilization studies.

A safe dispenser needs knowledge about differentdrugs, the specific product being dispensed and to havecommunication/consultation skills. This person needs tobe aware of promotional and marketing techniques that

may be used. To be an effective dispenser he/she needs an adequate drug supply,dispensing equipment, a relationship with the prescriber and status in the community.

B. THE DISPENSING PROCESS

As shown below, there are eight important steps to assure the proper delivery of drugs tothe patient from the dispenser. Notice that each step carries with it a number of importantresponsibilities and/or considerations. For our purposes, we make the assumption that (1)the prescriber has made the correct diagnosis and has selected the correct drug, dosageand quantity, and (2) the patient has access to the dispensary (pharmacy).

1. The dispenser receives thecorrect prescription from thepatient or prescriber (written ororal).

• information on patient

• therapeutic appropriateness

• economic consideration

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• communicate with prescribers for dubiousor unclear instructions

2. The dispenser correctly interprets the prescription orinstructions on the prescription.

• check the name of drugs

• check the dosages, administration, and duration

• check the availability of drugs

• retrieve from storage area

3. The prescribed therapy is available at the pharmacy in a usable form (notexpired or damaged).

ensure proper drugstoragecheck expiry dates and

use older stock first (first infirstout;FIFO)

checkand

double check (if possible)the drug product foraccuracy of identity,strength, and dose form.

4. The dispenser has true knowledge of the medication and its proper use.

• precise preparation of products

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• re­check drugs and dosages

5. The dispensercommunicates thecorrect way to take themedication to thepatient.

• label withpatient's name,drug name,directions foruse, date ofdispensing,

identity of prescriber, and identity of dispenser

• symbolic instructions in case of illiteracy

• use of auxiliary labels

6. The patient understands the instructions fromthe dispenser.

• repeat orally the labeled instruction, ifpossible in laymen's terms

• patient should repeat the instructions backto the dispenser

• emphasize the need for compliance

• provide warnings and cautions

• give special attention to certain cases, e.g.:

­ pregnant women

­ those with visual or hearing impairment

­ functional illiterates

­ children and elderly patients

­ those taking multiple medications

7. The patient complies with the instructions for therapy.

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8. The dispenser keeps accurate records ofoperations.

• enter details of encounter on patient profilecard

• enter record in prescriptionregister• complete inventory records.

POTENTIAL FOR ERRORPROBLEMS

During any of the above activities there is potential for errors to be made and problems tooccur. A few of these have been identified below. See if you can think of others.

• Wrong interpretation of the prescription (or diagnosis)

• Retrieval of the wrong drug from stock

• Wrong dosages

• Inadequate packaging/labeling of proprietary drugs

• Inaccurate counting, compounding

• Inadequate or nonexistent labeling

• No knowledge of proper drug compliance

• Insufficient knowledge of the disease process

• Insufficient time to talk with patients about their drugs

• Inability to communicate to patients about therapy

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As can be seen from the above, there are many potential areas in which the dispenser canmake mistakes. Dispensing requires trained, conscientious, responsible individuals.Proper policies, practices, and incentives must be provided to attract such personnel.

PROPER DISPENSING TAKES TIME

There are many factors that influence dispenser behavior:

• Training and knowledge

• Professional compensation (salary, prestige, etc.)

• Economic incentives (markup and volume of sales)

• Supply (cannot dispense what is not in stock)

• Available product information

• Availability of dispensing equipment (counting trays, vials, bottles,syringes, labels, etc.).

• Public vs. private sector promotional and marketing techniques.

• The social status of a dispenser and his or her role in the healthcare system.

• Dispenser­prescriber relationship.

• Lack of communication skills.

C. DISPENSING PRACTICES TO ENHANCE RATIONAL DRUG USE

Below are a series of questions designed to help assess dispensing practices in a drugdelivery system.

• What conditions exist at dispensing points? How are drugs handled? How accurately andcleanly are drugs dispensed? How concerned are health officials and health workers aboutthe quality of compounding and dispensing practices?

• How long is normally spent for dispensing? How do dispensers communicate withpatients?

• How often are patients improperly treated because their medicines have been improperlycompounded or dispensed, or because drugs have deteriorated in inadequate packaging?

• At each level in the health care system, who is responsible for the compounding and

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dispensing of drugs? What training do these individualshave in the principles and practices of drug compoundingand dispensing? How much supervision do theseindividuals receive?

• What types of pharmaceutical training are available inthe country? Are there standardized education curriculafor pharmacy personnel? Are training requirements fordispensers spelled out and reasonable, given thenumbers and geographical distribution of individualsmeeting, or eligible for meeting, these requirements?

• What resources exist to attract individuals to pursuedispenser training and to what extent can theseindividuals expect satisfactory remuneration for the

services they provide?

• Are wages and salaries adequate to effectively discourage dispensers from engaging inthe illegal sale and distribution of pharmaceuticals?

• What kinds of packaging are used to dispense drugs to patients? Is there anymechanized repackaging into course­of­therapy packets? In light of losses from poorpackaging and the costs of proper packaging, are there cost­effective alternatives topresent packaging methods? Could more expensive containers be recycled?

D. ROLE OF PRESCRIBER AND DISPENSERS IN PROMOTING CORRECTDISPENSING

PRESCRIBERS

• Diagnosis ­ By ensuring a correctdiagnosis which is explained to thepatient, compliance is improved.

• Prescribing ­ By prescribing as fewdrugs possible and explaining to thepatient which drugs are for whichcondition, patient understanding isenhanced.

• Drug information ­ The prescribershould explain how each drug should betaken, what side effects may occur andwhat to do if there is an unexpectedeffect, or no response to the drug.

PHARMACIST/DISPENSER

The pharmacist/dispenser has a crucial function in the health care system in:

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• Drug Procurement ­ Ensuring that good qualitydrugs are available when needed.

• Drug Distribution ­ Moving the drugs safely towherever they will be dispensed; making sure thatstorage and transport conditions do not adverselyaffect the drugs.

• Drug Prescribing ­ Pharmacists and dispensers areoften asked to prescribe 'Over The Counter' (OTC)preparations. In some countries there may be nodistinction between OTC and prescription onlyproducts.

• Drug Monitoring ­ In some settingspharmacists/dispensers are being called on tomonitor long term treatment for chronic conditions

such as hypertension, diabetes, asthma, etc.

Additional roles which a pharmacist/dispenser may be called on to fill include:

• Communication with physician ­­ this may be to check a prescription or respond to aquestion.

• Ensure compliance with treatment guidelines, particularly in institutional settings. Hospitalpharmacists may be given the responsibility of ensuring that prescriptions comply withtreatment guidelines. This is particularly true of complex regimens such as cancertreatment.

Research on prescribing patterns and drug utilization. Thepharmacist/dispenser is in a good position to monitor and evaluate prescribingand drug use particularly in an institutional setting.

Consumer Education. The pharmacist generally is trusted by consumers andcan provide respected advice and education either to individuals or tocommunity groups.

METHODS TO IMPROVE COMPLIANCE WITH THERAPY

•Dispenser­patient communication ­Dispensers play a significant role incommunicating with patients on how to takethe drugs, and ensuring compliance withdrug therapy. This can be done duringdispenser­patient contact.

Packaging for Patient Use ­ Drugs areusually dispensed to patients in some form

of container. The type of container can affect the quality of the drug at the time it is

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consumed. It can also have an important impact on the patient's image of the healthsystem, and his faith in the medicine. Shoddy containers can give the indication of anunreliable system and ineffective medicine. It also might affect the patient's compliancewith therapy.

Labeling ­ Do patients read labels? How much influence does a label have on dispensereffectiveness and patient compliance? In countries where the illiteracy rate is high, howcan labeling communicate therapy protocol effectively? These are questions in search ofanswers. We do know, however, that some forms of printed communication to patients doenhance therapy.

In the United States, labels are typed and are often accompanied by auxiliary labels[picture of computer label with stickers] which provide such information as "do not drinkalcohol while taking this medication" or "shake well". However useful, this type of labelingrequires high literacy and might be too expensive or inappropriate for use in other cultures.The use of pictorial labeling is gaining favor in health programs. One of the most ingeniouslabeling schemes for both dispensers and patients uses symbols to match drugs withconditions, and instructions when to take the medications.

Whether public or private sector, the dispenser is usually considered to be available and issought after for "free" advice. It is rare that a dispenser will charge a consulting fee.

F. PUBLIC vs. PRIVATE SECTOR DISPENSING: A PATIENT'S CHOICE

The Public Sector Option: Health careand drugs are often "free", beingprovided by the government. However,the public health clinic is frequentlylocated some distance from the patient'shome or work. Granted, it is within 3kilometers, but that is a long distance towalk, especially since the clinic is onlyopen certain hours. Once there, ourpatient knows he will encounter longlines. After being seen by the doctor,there is another line to get theprescription ­­ if it is in stock. This is not

a pleasant situation for someone who is feeling ill to begin with.

The Private Sector Option:

Private pharmacies or chemists' shops are located in high traffic areas, right around thecorner, or they are on the way to work. It takes less time to get service and the vendorsprovide friendly advice on the products they sell. True, the medication is more expensive,but it is there, and the patient feels he is getting his "money's worth" with the slick,commercial packaging.

Which would you choose? Estimates are that in some countries as much as 80­90% of the

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money spent on drugs is in the privatesector. If we want to truly make a globalimpact on rational drug use, dispensingin the private sector must be addressed.

INTERVENTIONS

There have been a number ofinterventions aimed at improving dispensing. InGhana, View locally or access on the web athttp://www.who.int/dap­icium/posters/2b1_txt1.html researchers testedthree different educational interventions. Theresults of this study showed that posters wereeffective in improving dispensing time, adequatelabeling and patient understanding, albeit at a lowlevel.

In Uganda View locally or access on theweb at http://www.who.int/dap­icium/posters/2f3_text.html a large studyshowed that it was possible to improvedispensing.

In Kenya and Indonesia View locally or access on the web at http://www.who.int/dap­icium/posters/3C3_1.html studies were undertaken in commercial pharmacies to improvediarrhea treatment. In both of these countries, improvements in treatment occurred. (See

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Ross­Degnan, et al ­ "The Impact on Face toFace Educational Outreach on DiarrheaTreatment in Pharmacies," Health Policy andPlanning, Vol. 11, No. 3, Sept 1996, p. 308­318.

In the Philippines View locally or access on theweb at http://www.who.int/dap­

icium/posters/3C4_TXTF.html an intervention was focused at drug selling store keepers.Through a series of discussions with these store keepers changes were made in theirselling behaviors related to antibiotics.

Studies have also been done on dispensingdoctors in Zimbabwe. View locally or accessthe web at http://www.who.int/dap­icium/posters/4b4_fin.html

All of these interventions were aimed at improving dispensing at local levels. Majorimprovements occurred. What is not clear is whether regulatory or policy changes wouldhave similar effects.

CONCLUSION

Dispensing is a critical and integral part of the drug use process. Up to now, theimportance of dispensing has been neglected in training and in essential drugs programs.The incredibly short dispensing times seen in many of the country indicator surveysreflects the serious situation that exists. Of all the areas open to intervention, improvingdispensing is among the easiest. Whether regulatory, managerial, or educational methodsare used, the patient benefits and the health system benefits.

ACTIVITY ONE

Country Situation Review

Think about who is responsible for dispensing in your own country. Review what trainingdispensers have, formal or informal, and for how long they have been trained. Finally,discuss how the dispensing process is monitored. How do we know that drugs are being

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dispensed correctly?

Each group member should fill in Worksheet 1 below for his/her own country. Then thegroup should discuss their country situations together. If group members are from thesame country they can discuss the same questions.

Worksheet 1: Who Dispenses in Your Country?

Type of Dispenser Y/N Dispensing Training MonitoringProcess:

Formal or

Informal ?

Duration:

Yrs / Days / Hrs

Y / N

If yes, how?

Specialists

Doctors

Senior Nurses

Junior Nurses

Pharmacists

Pharm. Technicians

Dispensers

Cleaners

Businessmen

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Storekeepers

Street Vendors

Fathers

Mothers

Sisters

Brothers

Grandparents

Barmen

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