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Yes / The purpose of this paper is to determine how best to reduce, reuse and dispose of household waste medicines in the National Health Service (NHS) (UK). Through a combination of literature review and empirical work, this research investigates the existing household waste medicines reverse logistics (RL) system and makes recommendations for improvement by benchmarking it against household waste batteries RL. The viability and feasibility of these recommendations are evaluated through in-depth interviews with healthcare professionals and end user surveys. The batteries RL system appears to be a more structured and effective system with more active engagement from actors/stakeholders in instigating RL practices and for this very reason is an excellent comparator for waste medicines RL practices. Appropriate best practices are recommended to be incorporated into the waste medicines RL system, including recapturing product value, revised processing approaches, system cooperation and enforcement, drivers and motivations and system design and facilitation. This study offers academics and professionals an improved insight into the current household waste medicines RL system and provides a step towards reducing an existing gap in this under-researched area. A limitation is that only a small sample of healthcare professionals were involved in subjectively evaluating the feasibility of the recommendations, so the applicability of the recommendations needs to be tested in a wider context and the cost effectiveness of implementing the recommendations needs to be analysed. Reducing, reusing and properly disposing of waste medicines contribute to economic sustainability, environmental protection and personal and community safety. The information retrieved from analysing returned medicines can be used to inform prescribing practice so as to reduce unnecessary medicine waste and meet the medicine optimisation agenda. This paper advocates learning from best practices in batteries RL to improve the waste medicines RL design and execution and supports the current NHS agenda on medicine waste reduction (DoH, 2012). The recommendations made in the paper not only aim to reduce medicine waste but also to use medicines effectively, placing the emphasis on improving health outcomes.

Yes / In recent years, diverse scholars have addressed the issue of the chemosensory perceptions associated with traditional medicines, nevertheless there is still a distinct lack of studies grounded in the social sciences and conducted from a cross-cultural, comparative perspective. In this urban ethnobotanical field study, 254 informants belonging to the Gujarati, Kashmiri and English ethnic groups and living in Western Yorkshire in Northern England were interviewed about the relationship between taste and medicinal perceptions of five herbal drugs, which were selected during a preliminary study. The herbal drugs included cinnamon (the dried bark of Cinnamomum verum, Lauraceae), mint (the leaves of Mentha spp., Lamiaceae), garlic (the bulbs of Allium sativum, Alliaceae), ginger (the rhizome of Zingiber officinale, Zingiberaceae), and cloves (the dried flower buds of Syzygium aromaticum, Myrtaceae). The main cross-cultural differences in taste perceptions regarded the perception the perception of the spicy taste of ginger, garlic, and cinnamon, of the bitter taste of ginger, the sweet taste of mint, and of the sour taste of garlic. The part of the study of how the five selected herbal drugs are perceived medicinally showed that TK (Traditional Knowledge) is widespread among Kashmiris, but not so prevalent among the Gujarati and especially the English samples. Among Kashmiris, ginger was frequently considered to be helpful for healing infections and muscular-skeletal and digestive disorders, mint was chosen for healing digestive and respiratory troubles, garlic for blood system disorders, and cinnamon was perceived to be efficacious for infectious diseases. Among the Gujarati and Kashmiri groups there was evidence of a strong link between the bitter and spicy tastes of ginger, garlic, cloves, and cinnamon and their perceived medicinal properties, whereas there was a far less obvious link between the sweet taste of mint and cinnamon and their perceived medicinal properties, although the link did exist among some members of the Gujarati group. Data presented in this study show how that links between taste perceptions and medicinal uses of herbal drugs may be understood as bio-cultural phenomena rooted in human physiology, but also constructed through individual experiences and culture, and that these links can therefore be quite different across diverse cultures.

Yes / Ancient Chinese herbal texts as far back as the 4th Century Zhou hou bei ji fang describe methods for the use of Qing Hao (Artemisia annua) for the treatment of intermittent fevers. Today, the A. annua constituent artemisinin is an important antimalarial drug and the herb itself is being grown and used locally for malaria treatment although this practice is controversial. Here we show that the ancient Chinese methods that involved either soaking, (followed by wringing) or pounding, (followed by squeezing) the fresh herb are more effective in producing artemisinin-rich extracts than the usual current method of preparing herbal teas from the dried herb. The concentrations of artemisinin in the extracts was up to 20-fold higher than that in a herbal tea prepared from the dried herb, but the amount of total artemisinin extracted by the Chinese methods was much less than that removed in the herbal tea. While both extracts exhibited potent in vitro activities against Plasmodium falciparum, only the pounded juice contained sufficient artemisinin to suppress parasitaemia in P. berghei infected mice. The implications of these results are discussed in the context of malaria treatment using A. annua infusions.

No / Croton membranaceus is used by herbalists and traditional healers in Ghana for the management of various cancers, especially prostate cancers. A methanolic extract of the roots showed cytotoxic activities against two cancer cell lines, and bioassay-guided fractionation of this extract revealed that the cytotoxic activity resided mostly in the ethyl acetate fraction. Six compounds were isolated from this fraction, including a new furano-clerodane diterpenoid (1), for which the trivial name crotomembranafuran is suggested. This compound exhibited an IC50 value of 4.1 microgram/mL (10.6 microM) against human prostate (PC-3) cells, providing some support for the traditional use of C. membranaceus in the treatment of cancers

Yes / The health supply chain within the United Kingdom follows a traditional model adopted by many countries globally. This is typically the sourcing of products from manufacturer to pharmacy (hospital and community) via wholesaler or direct. New models of delivery are being piloted and evaluated to improve supply chain efficiency and effectiveness

Yes / The increase in pharmaceutical waste medicines is a global phenomenon and financial burden. The Circular Economy, as a philosophy within the pharmaceutical supply chain, aims to promote waste reduction, maximise medicines value, and enable sustainability within this supply chain (increasing circularity). Circularity strategies for pharmaceuticals are not currently implemented in many countries, due to quality and safety barriers. The aim of this study was to determine whether the application of circular economy principles can minimise pharmaceutical waste and support sustainability in the pharmaceutical supply chain; Methods: a detailed narrative literature review was conducted in order to examine pharmaceutical waste creation, management, disposal, and the application of circular economy principles; Results: the literature scrutinised revealed that pharmaceutical waste is created by multiple routes, each of which need to be addressed by pharmacists and healthcare bodies through the Circular Economy 9R principles. These principles act as a binding mechanism for disparate waste management initiatives. Medicines, or elements of a pharmaceutical product, can be better managed to reduce waste, cost, and reduce negative environmental impacts through unsafe disposal. the study findings outline a Circular Pharmaceutical Supply Chain and suggests that it should be considered and tested as a sustainable supply chain proposition.

Yes / Implementation and uptake of novel and cost-effective medicines can improve patient health outcomes and healthcare efficiency. However, the uptake of new medicines into practice faces a wide range of obstacles. Earlier reviews provided insights into determinants for new medicine uptake (such as medicine, prescriber, patient, organization, and external environment factors). However, the methodological approaches used had limitations (e.g., single author, narrative review, narrow search, no quality assessment of reviewed evidence). This systematic review aims to identify barriers and facilitators affecting the uptake of new medicines into clinical practice and identify areas for future research. A systematic search of literature was undertaken within seven databases: Medline, EMBASE, Web of Science, CINAHL, Cochrane Library, SCOPUS, and PsychINFO. Included in the review were qualitative, quantitative, and mixed-methods studies focused on adult participants (18 years and older) requiring or taking new medicine(s) for any condition, in the context of healthcare organizations and which identified factors affecting the uptake of new medicines. The methodological quality was assessed using QATSDD tool. A narrative synthesis of reported factors was conducted using framework analysis and a conceptual framework was utilised to group them. A total of 66 studies were included. Most studies (n = 62) were quantitative and used secondary data (n = 46) from various databases, e.g., insurance databases. The identified factors had a varied impact on the uptake of the different studied new medicines. Differently from earlier reviews, patient factors (patient education, engagement with treatment, therapy preferences), cost of new medicine, reimbursement and formulary conditions, and guidelines were suggested to influence the uptake. Also, the review highlighted that health economics, wider organizational factors, and underlying behaviours of adopters were not or under explored. This systematic review has identified a broad range of factors affecting the uptake of new medicines within healthcare organizations, which were grouped into patient, prescriber, medicine, organizational, and external environment factors. This systematic review also identifies additional factors affecting new medicine use not reported in earlier reviews, which included patient influence and education level, cost of new medicines, formulary and reimbursement restrictions, and guidelines. PROSPERO database (CRD42018108536). / This work presents research funded by the Pharmacy Research UK (grant reference: PRUK-2018-GA-1-KM) and Leeds Teaching Hospitals NHS Trust.

Yes / Introduction: There are risks to the safety of medicines management when patient care is transferred between healthcare organisations, for example when a patient is discharged from hospital. Using the theoretical concept of resilience in healthcare, this study aimed to better understand the proactive role that patients can play in creating a safer, resilient medicines management at a common transition of care. Methods: Qualitative interviews with 60 cardiology patients six weeks after their discharge from two UK hospitals explored patients’ experiences with their discharge medicines. Data were initially subjected to an inductive thematic analysis and a subsequent theory-guided deductive analysis. Results: During interviews twenty-three patients described medicines management resilience strategies in two main themes: identifying system vulnerabilities; and establishing self-management strategies. Patients could anticipate problems in the system that supplied them with medicines and took specific actions to prevent them. They also identified when errors had occurred both before and after medicines had been supplied and took corrective action to avoid harm. Some reported how they had not foreseen problems or experienced patient safety incidents. Patients recounted how they ensured information about medicines changes was correctly communicated and acted upon, and identified their strategies to enhance their own reliability in adherence and resource management. Conclusion: Patients experience the impact of vulnerabilities in the medicines management system across the secondary-primary care transition but many are able to enhance system resilience through developing strategies to reduce the risk of medicines errors occurring. Consequently, there are opportunities – with caveats – to elicit, develop and formalise patients’ capabilities which would contribute to safer patient care and more effective medicines management.

Yes / Avoidable harm associated with medicines is widespread – particularly at care transitions – and unintended discrepancies in patients’ medicines after discharge from hospital affect more than half of all patients. Patients with heart failure are frequent service users (including readmission to hospital), and susceptible to deficiencies in medicines management. Heart failure is responsible for approximately 5% of medical admissions and the readmission rate within 3 months of discharge may be as high as 50%.[1] The Improving Safety and Continuity of Medicines management at Transitions of care (ISCOMAT) study is an NIHR-funded programme of research in patients with heart failure. The first work package, described here, aimed to map and evaluate current medicines management pathways across care transitions, describing the core characteristics of best practice and effective systems at each stage. Mixed-methods research collecting data centred on patients’ journey out of hospital and back home exploring current practice relating on heart failure. NHS REC approval was obtained (16/NS/0018). Following a process of informed consent, data were collected from patients (n=16) in four health economies in England using semi-structured interviews conducted shortly after their discharge from hospital and again after two and six weeks and included video recording. Non-participant observation was conducted on cardiology wards in the four areas to understand predominant systems employed by the hospitals to deliver information to patients and to primary care. Interviews with staff in hospitals and primary care explored policy, practice and systems across the transition. Data were analysed using integrative ‘parallel mixed’ analysis. Several themes emerged that described the resilience of the system that manages patients’ medicines across the whole pathway. Spatial dimensions – including local working conditions – impacted on staff who managed transfers. Process efficiencies and effectiveness, including the degree of staff training and policy awareness, both enhanced and hindered communication with patients and health care professionals (HCPs) in primary care. The system did not allow staff to assess the impact of the management of medicines at discharge across the transition into primary care. Patients themselves were found to have different levels of knowledge and confidence in their medicines once back at home and, where their pathway included this, to value the care co-ordination functions of heart failure nurses. Primary care staff operated varying systems for managing discharge communication and implementing recommendations and some reported positive outcomes from integration of practice pharmacists into the system. To our knowledge this is the first UK study of medicines management along the patient’s journey from hospital into primary care for patients with heart failure. A whole pathway analysis has enabled a detailed understanding of resilience in each part of the healthcare system. These findings will be used in the co-design of an intervention to improve medicines management in the next phase of the research.