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Polypharmacy: The role of the integrative pharmacist with Jacqui Hagidimitriou

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Polypharmacy: The role of the integrative pharmacist with Jacqui Hagidimitriou

The term polypharmacy is usually defined as the use of five or more drugs, which can include both prescribed and over-the-counter medicines but what is often overlooked is the concomitant use of complementary medicines. Here in Australia, it's becoming more commonplace for pharmacists to intervene in patients with polypharmacy by conducting a medication review and working with their GP to determine if their medications are necessary.

What's increasingly evident that pharmacists are a trusted and readily accessible source of health information by the public and what comes with that is an expectation that they have a knowledge of complementary medicines too.

Today we're joined by Jacqui Hagidimitriou who shares her journey to becoming an integrative pharmacist with a passion for natural medicines and how using this knowledge alongside her pharmacy knowledge, she is able to better support patients burdened by polypharmacy. 

Covered in this episode

[00:35] Introducing Jacqui Hagidimitriou
[01:30] The journey to becoming an integrative pharmacist
[05:13] Is Complementary Medicine (CM) education for pharmacists sufficient?
[08:32] Pharmacists: trusted sources of health information?
[10:06] The role the integrative pharmacist can play in patient management?
[14:46] Examples of polypharmacy
[18:54] Barriers to safe use of CMs?
[26:03] Jacqui's own examples of collaborative and innovative health care in pharmacy

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us today on the line is Jacqui Hagadimitriou. Jacqui is an integrative pharmacist based in Samford, half an hour from Brisbane City, Queensland, Australia. 

In addition to her regular pharmacy duties, she consults regularly with clients in the business regarding safe and effective use of natural medicines. Jacqui regularly contributes to public education of natural medicine through health information nights, involvement in the Samford Health Expo, and other events run by the pharmacy. 

Her social media tag is The Natural Health Pharmacist and she runs a variety of blogs and tips through various forums. Jacqui was rewarded for her work in the natural medicine profession by winning the BIMA for Integrative Pharmacy in 2017. Welcome to FX Medicine, Jacqui. How are you?

Jacqui: I'm well. Thank you very much for having me on.

Andrew: So, today we're talking about persistent poly’s, the burden of medicines on patients and the health system. And this is never more evident than from February 2018, when the TGA decided to make codeine an S4, that is, doctor-only, prescribing-only drug because of a huge issue that reared its head certainly around the world and indeed in Australia. 

So, I guess though, to start off, we need to go back a little bit further and investigate your delving into natural medicines and not just pharmaceutical medicines. So, the overall impression about pharmacists is that they are quite sceptical about natural medicines. So, how did you come to be such an advocate?

Jacqui: Yeah. It's a good question because a lot of people that have, you know, house mates in the past have a kind of laugh about it now because I was so anti, definitely to their use and used to shut down anybody that used to think that it would do anything for them.

Andrew: You were like me.

Jacqui: Yeah. Well, I think we get trained that way.

Andrew: Yeah.

Jacqui: So, it's an interesting journey for me. Just that I started to go on different training events for natural medicines when I was left in charge of the pharmacy about five years ago. Because I was in charge of the whole store and I had this shelf of nutraceuticals that I was supposed to recommend and I didn't know what they did. And I'm a very thorough kind of person and I don't like giving out stuff that I don't know about. 

So, I thought I need to get some more information. So, that's kind of how I started. And as I delved down, I realised that there was a much larger body of evidence for their use than was portrayed both in my studies and in, I guess, the health media that kind of tries to stamp down on any use of natural medicines. And so I tried a few of them myself and I found them quite beneficial and I thought there's more to this than what I've been taught.

Andrew: Did you ever speak to colleagues about this, and what was their reaction? 

Jacqui: Like, even now, I still feel nervous when I tell them that I'm studying nutrition because I'm interested in the natural therapy side of things. Because yeah, you do get a varied response. 

But a lot of pharmacists now, I think, are actually quite interested and I think a lot of them believed similar to me. They've tried certain things and realised that there is a place for them. And that there is a place for further training and to actually learn how to utilise them properly.

Andrew: Yeah, indeed. I think one of the biggest travesties is the total denial and shutdown. Because patients will continue to use these things, and all that one is doing if you shut them down is furthering an unsafe use of that...or potentially unsafe use of that medicine.

Jacqui: Yes, it's definitely an issue and one that needs further thought. Because at the moment, people choose what they want to do, and if they're too afraid to talk to their pharmacist, to their doctor about what they're taking, then that's when we have drug interactions with over-the-counter herbal preparations and it doesn't serve them for them to be so judged for wanting to do that for their health.

Andrew: It's interesting that you said at the beginning that you didn't feel qualified. Do you think enough emphasis is placed on the vitamin shelves in pharmacies around training? And I'm talking here about not product-selling techniques. I'm talking here about safe and efficient use of those. Whether an adjunct or as a standalone.

Jacqui: Yeah. No. I think it's getting better and I think there's more available now. But, for instance, when I went through pharmacy… I can remember one lecture on complementary medicine, so we pretty much covered fish oil and glucosamine and... Well, my impression was the rest was rubbish. You know, that's the impression it left because they're the only ones that have the higher TGA rating or evidence. 

Andrew: Yep. 

Jacqui: Yeah. So, you don't really get trained in the pharmacy course. But as soon as you get out, the practical reality is that the public is looking to you, like as a pharmacist, for advice in all areas, and that includes complementary medicine. And yeah, you don't want your pharmacist guessing about whether it's safe, it's not safe. Any of that information.

Andrew: That's exactly right.

Jacqui: Yeah. It would be great seeing more training in the pharmacy degree. I think different universities do incorporate it more now than they used to. 

Andrew: Yep. 

Jacqui: But, yeah, I do think a lot of pharmacists are really interested. And because it does practically incorporate a large proportion of their business, they really need to take it seriously.

Andrew: Yeah. And I think I would, therefore, prefer those products that are not able to be self-selected by patients that they actually have to talk to somebody about, particularly, let's say, with somebody who has diabetes, they have either the beginnings of, or indeed further along kidney damage and you know, they've got leg cramps. And they can quite happily self-select off the supermarket shelves or any shelf a product which may really seriously affect their kidney function. And this is where I think it's critical that they get the appropriate support by a health professional that knows what they're doing.

Jacqui: And making the information easy for the health professionals to access as well. Because there's some texts that I use a lot now, but it wasn't easy to find them, if that makes sense.

Andrew: I remember. In fact, I am going to give a plug here. "Herbs and Supplements: An evidence-based review." I think it was...

Jacqui: That's the one.

Andrew: ...Braun and Cohen, Lesley Braun and Marc Cohen.

Jacqui: Yep. 

Andrew: Which at the NPS, that's the National Prescribing Service of Australia. I think this was 2009? It got the top four, in the top four places to go for evidence-based research, evidence-based information on supplements and herbs. And it was the only one that was in book form. The others were online.

Jacqui: Yeah. I love that resource. That's the one I was thinking of as the main one that I find very helpful.

Andrew: Yeah. It's quick to review as well, it's a very easily-read thing. I quite like that.

Jacqui: Yeah. It's got...

Andrew: Always have it at hand.

Jacqui: Yeah. Clear sections in it as well.

Andrew: I've seen pharmacists being rated as one of the most trusted professions by the public year after year. Why do you think this is?

Jacqui: I think it can be good and bad. I think sometimes it's because unfortunately, people are confused about their healthcare and pharmacists traditionally are an easy-access health professional that you can get to to ask questions. And so we spend a lot of our time explaining what medications do and even what their disease might mean for them. Because it's just part of our model, I think that people just expect that they can come and talk to a pharmacist and it's probably one of the most rewarding parts of our jobs as well. 

Yeah. So we’re trained, like, quality use of medication is something that we're trained in. So utilising medication for it's biggest benefit and reducing the side effects. So, having pharmacists to be able to critically evaluate patients' medications can be quite beneficial and it can develop that trust relationship as well.

Andrew: Okay. So, indeed, more and more patients are getting on more and more medications. And this is not uncommon these days. Indeed I, forgive me, listeners in Australia, you get on what's called the free list after 52 prescriptions.

Jacqui: Yeah. Well, it's equivalent to 60 prescriptions.

Andrew: Sixty now. Okay.

Jacqui: If they're on like a concession. A concessional card is different for people that are general patients.

Andrew: So, I remember, some years ago now, obviously, a lady that was on the free list by March, that means she had 52 prescriptions in 2 months and it was nothing more than polypharmacy. So, I'm really interested in your experience of polypharmacy as you've alluded to, and I think we've both seen people taking unwanted amounts of medication as well as unwanted or indeed sometimes suspicious amounts of nutraceuticals or vitamins. So, what do you think is the risk with this pattern and how do you combat this?

Jacqui: I think it's a big issue and it's always been a big issue and it probably always will be a big issue. Because the consequences of polypharmacy and taking extra supplements above and beyond what is needed increases the risk of all death as the worst case scenario, side effects, and I would even say the risk of being prescribed another medication that you possibly don't need because you're having side effects from the other ones that you're taking.

Andrew: Yes.

Jacqui: And I think it occurs because there's often multiple prescribers. Like, some people don't even go to the one GP. But even communication between specialists to GP to the pharmacy, if you shop around different pharmacies as well, there's no one central place you're actually looking at to see what are you actually taking. 

And people will have that fear of telling their doctor, their pharmacist what they're taking extra on top of what they've been prescribed. And I think they fear the judgment because doctors and pharmacists, we're obliged legally to warn them if we think they're doing something that might cause them harm. So, I think they're afraid of telling us what they're taking because we'll tell them to stop doing it.

Andrew: And do you find that this is easy to combat with your knowledge now of herbs and natural supplements? Do you find that you've got a way of opening up that conversation that you didn't have prior?

Jacqui: I think, well, definitely confidence. Because if you don't know what you're talking about, it's much harder to make them or help them understand the seriousness of the situation.

Andrew: Yeah.

Jacqui: So knowing whether you know, supplements, for instance, is going to cause a risk with their medication or whether indeed they're doubling up with their supplements. Because often people do take lots of different supplements and we know that lots will have the same ingredient in them. So, how do they know if they're having too much if they don't have someone that understands why they're taking it and the risks associated with different dosages? 

But I guess, we have ways to do medication reviews in the pharmacy which is probably where these things are the most...commonly do come out because we can spend the time to actually evaluate what's going on.

Andrew: Yeah. I think it's really interesting, like, how do you find out something that you don't know? How do you approach the questioning to uncover that they may be taking a vitamin supplement that they don't want to tell you about? Whereas if it's somebody who's going to shut them down, they'll just go, "I'm not going to even mention it." 

Whereas your demeanour being open and inclusive about natural supplements, and indeed, having some knowledge about them says, you know, "Hey, I'm here to help you. It's not just about judgment, I'm here to actually make sure that you're safe." Like, is… do you find that there's a difference in your demeanour the way they open up more easily?

Jacqui: Yeah. My demeanour or I think they feel more comfortable when they know that I support the use of natural medicines in an appropriate way. So, I think they can feel like they can discuss it with me and if I say I don't think it's a good idea it’s because I don't think it's the most appropriate thing for them, not because I think they're silly for trying something natural. 

But some people, I mean, in the end, people are responsible for what they do. Some people don't want a bar of it and you can't really do anything about that. You can… definitely, the way you approach people is very important. And I think especially if you've got to establish that trust relationship quickly. Yeah, you do have to be quite open and friendly, I think, to get people to feel like they can trust you.

Andrew: Yeah. Can you give me an example of polypharmacy that you've come across. Because like I've got one medication and one nutraceutical example in my history and they were both as bad as each other? Neither was better. They were both atrocious. But what one sticks out in your mind as being a catchphrase, if you like, or a poster child of polypharmacy?

Jacqui: Yeah. There was one patient actually, that I did a medication review on. And this was just pharmaceutical medications. He was on about probably six or seven medications. But when I sat down with him and it just didn't make sense to me. Like, a lot of them I couldn't figure out why the doctor was prescribing them and the patient certainly couldn't remember why. Because it was one simple problem I think he had initially and then he was on six or seven medications and each one was at a put-on because of a problem with the previous medication. 

So, I ended up sending the doctor a letter just explaining my concerns about that I think most of his symptoms and everything were due to the medications he was on. And I didn't hear anything after that, so I kind of forgot about it. But recently, he came back in, and this was probably a couple of years down the track after the review, to thank me because now he was feeling the best he'd felt in years and he was only on one appropriate medication.

Andrew: Wow.

Jacqui: And yeah. So it's interesting because a lot of the time, especially in pharmacy, you don't necessarily know the outcome of your intervention and what you've done. But it's really a good feeling when you realise you really helped someone. And something as simple as that, you know, a medication review, just to make sure that the medications are actually warranted.

Andrew: Yeah. So, the practitioner heeded your advice, changed their prescriptions, and monitored the patient for safe use and symptom relief.

Jacqui: Yeah.

Andrew: Polypharmacy doesn’t, as we've known, as we've elucidated now, doesn't just include prescription items. So, what else have you seen come through?

Jacqui: So, I had a... He's a lovely guy and he came in for a consultation with me for natural medicines just to help him out a bit with what he was taking. And he brought in about three massive bags of shopping bags full of different supplements and he was taking goodness knows what? 20 different things. And some of them were actually the same things just in a different guise and he didn't know why he was taking any of them. He hadn't seen anyone in a long time, so this was what he was doing off his own bat really.

Andrew: Yeah.

Jacqui: But the best thing I could have done for him was really just to explain what they all did, take away all the double-ups, try and figure out what was best and just let him on three to four things that he could keep doing. 

Because he was spending so much money on supplements he didn't know how he was going to continue to do so because he was a retired pensioner. So, that's probably one example of polypharmacy in the natural medicine sense, but we also see it, I guess, with prescriptions. Some practitioners too where people come in with a list of 10 items and they're not quite sure why they've been prescribed them.

Andrew: It's really interesting just how many elderly people really don't know that much about what their medicines are for you know? And that leads to a whole host of safety issues, particularly... I mean, let's talk about one called the triple whammy. So, let's say they've got blood pressure issue, so they're on an ACE inhibitor, they're on a fluid tablet, and then they get some arthritic pain. Take us through what happens.

Jacqui: Well, they get given a nonsteroidal which potentially can shut down their kidneys. But seems to be something, again, that we learn about in uni as a big no-no but happens all the time and nobody seems to worry about it.

Andrew: Yeah. What do you see are the main barriers to people being able to effectively use complementary medicines safely?

Jacqui: Yeah. I think there's a few barriers. Sometimes there's a question of wisdom. So, I think people being prescribed many, many supplements that they probably can't afford to take for a month let alone how ever long their practitioner thinks it's going to be useful for. So, I think that's one issue because if they'll prescribe maybe one or two things that were going to give them the most benefit with lifestyle change and dietary change which is probably a big contributing factor to a lot of people's issues, then they might see a longer-term benefit. 

But if they can’t comply, it’s a compliance issue, same as with pharmacy medication, prescribed medication, if somebody's not going to take what is prescribed as it's prescribed, then it's not going to have the intended benefit that it's being prescribed for.

Andrew: Yeah. And regardless of purported side effects and things like that, obviously, if people feel a great benefit now and immediately upon taking a medicine, I guess they're more likely to take it when they feel symptoms. But when you're taking a medicine for a silent condition, let's say cholesterol, and let's take statins, that controversial class of drugs, how do you get people to take their medicines more compliantly?

Jacqui: Well, I mean, there are different classes of patients too. Some people are just happy to do what their doctor's told them. But for the most part, people are increasingly wanting to know why. So, they have to know the perceived benefits of taking a certain medication, and they have to be aware of common side effects that might crop up initially. 

So, a lot of medications might cause some side effects initially but then go away after a little while as the body gets used to the medication. So, I think it's about managing expectations to how people take things in a compliant way.

Andrew: And I guess along that line and even harder would be natural medicines particularly when, A) they gain no benefit over the short-term and you've got to use them long-term and we've seen this with fish oils and multivitamins in cardiovascular disease. Anybody who wants a fish oil to work within a couple of weeks is doing a mischievous trial. And we've seen that recently with a meta-analysis. 

But the other thing is compliance about keeping them on the straight and narrow when the benefits aren't going to be seen for 6, 12, 24 months. I mean, in some cases it was five years before they saw benefit. How do you reinforce the benefit of staying on their judicious supplements?

Jacqui: Especially as well when it's going to cost them personally to keep taking a lot of supplements it because...

Andrew: Yeah. Very true.

Jacqui: They're not going to be on the PBS anytime soon.

Andrew: Nup.

Jacqui: So, yeah, I think, I don't know, I think it's probably an area that I'm very passionate about, interested in is public health. And how do we make preventative health actually work because everybody talks about prevention is better than cure, but prevention is often a lot more difficult and less obvious than treating something once it's cropped up.

Andrew: Yeah.

Jacqui: So, I think it's got to come from a lot of different sectors, from your natural health practitioners to even the doctors, pharmacists, they all have to work together, I think, to make sure we're actually delivering the right message about health for people. And that we can hopefully agree on it one day which is the best way to…

Andrew: …Ahh, we can dream.

Jacqui: And I would love to see more communication between practitioners as well. I think the rare times they do communicate with other practitioners, it's quite rewarding to be able to, you know, do what's best for the patient or the customer. Rather than trying to viciously protect your little sector of that client, if that makes sense.

Andrew: Yeah. I guess what I was thinking there is, do you find that natural or integrative practitioners are more open to a co-management of a patient?

Jacqui: I think I would like to say yes. I think it's hard to make the model work in a way, financially. So, I mean, I know that there's some really great integrative practices in the country and I've visited a couple of them just to see what they do. So I think it's definitely a good model. It's just whether...everybody's got to make some money, I guess, at the practical end.

Andrew: Oh, sure.

Jacqui: How to make that work.

Andrew: Yeah. Reality bite.

Jacqui: Yeah, that's right.

Andrew: So, the way to go forward, do you see any movement with your profession, with pharmacy?

Jacqui: I do see pharmacy changing, but I still think we're a little bit… you know, we can't say too much if there's no evidence base, then if the evidence isn't strong. It's still very much caught up by what evidence is available rather than how do we help these people manage their health to the best of our ability. 

So, I think... Yeah. I think there's a lot of pharmacists that are thinking along the lines of natural health, natural medicines, how can we incorporate that better and help people with it better. And I think we will see a change in the future. And I think even like in New South Wales, I believe, uni, they're doing like a graduate course in complementary medicine for pharmacists. 

Andrew: Good. 

Jacqui: So, I think we'll see some more… Pardon? 

Andrew: Good.

Jacqui: Yeah. I think we'll see some more programs like that coming through, so I do think it's a bit of a hard slog ahead as well.

Andrew: Oh, for sure. I mean, let's face it, evidence changes every day. I guess my issue is when the evidence is mischievous.

Jacqui: And that is a big problem because you almost need to have a degree in understanding trials, design, and statistical analysis to figure out whether the data is worth looking at or not for any trial. Drug, or natural medicines. It's very difficult even for people that are qualified in the health area.

Andrew: Yeah. Jacqui, you won the BIMA Award for Integrative Pharmacy in 2017. Tell us a little bit more about what you do in your Pharmacy Health Expo for the community?

Jacqui: Our Health Expo was developed by the owner of the pharmacy where I work and we do it every year. And it's a way for us to showcase all the health businesses in the area. 

So, different years will have a different focus. This year we're trying to let people know about our clinic in the pharmacy called The Clinic Hub where we have lots of allied health that work from the pharmacy clinic rooms. And I also develop, am developing, some programs for people to come and help them with their digestive health and menopause program. So, I'm developing two programs to run from the pharmacy. 

In addition, too, we often have health information nights. Like, I ran one last year on pain management in the event of the codiene coming off the pharmacy show to inform the public of their pain relief options. And we had... It was a collaborative approach with...I had a GP and a physio and myself talking through all the different pain options that people had available to them. 

So, yeah, we run lots of different things, we have in-store consultations, we have information nights and we run the Health Expo once a year. So, there's a lot going on all the time and each year it gets bigger and better. 

Andrew: Yeah. I've got to say, I love what you do, having that collaborative approach so that people can get the different aspects of different care that different professions offer. And each one might be slightly different, but they all overlap when they're treating one condition like pain, the various forms and the various presentations of pain. So well done to you. So proud of your win last year.

Jacqui: Thank you.

Andrew: And thanks for joining us today.

Jacqui: Thanks for having me on FX Medicine.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.

Additional Resources

Jacqui Hagidimitriou
The Clinic Hub
TGA: Codeine information hub
BOOK: Braun & Cohen: Herbs and Natural Supplements


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