Drug Information & Poison Information Services

Drug Information Services (DIS)

Scope and Contribution to Patient Care

• Fundamental Responsibility: Providing drug information is a fundamental responsibility of all pharmacists, regardless of the practice setting.
• Core Function: Traditionally seen as suppliers of medicines, pharmacists now focus on providing appropriate information support to prevent adverse outcomes.
• Definition: Drug information involves providing clinically relevant information on any aspect of drug use related to individual patients, or general information on how best to use drugs for populations.
• Optimising Drug Use: Pharmacists apply their knowledge to optimise the use of drugs in the treatment and prevention of disease.
• Information Across Spectrum: Pharmacists provide concise information to patients during counselling and basic drug information to other health professionals.
• Specialised Services: Pharmacists specialising in drug information refine skills, access more resources, and provide deeper analysis, interpretation, and responses more efficiently.
• Quality and Impact: Provision of drug information is a professional activity with responsibilities akin to direct patient care; poor-quality information can significantly harm public health.
• Drug Information Centre: A specialised area where pharmacists or other health professionals provide information to health professionals or the public, centralising resources and trained professionals.
• Terminology: “Medicines information” is sometimes preferred to avoid confusion with services limited to drugs of abuse.
• Evolution: DIS originated in the USA in the early 1960s, parallel to clinical pharmacy services, typically in hospitals or supporting training programs. There has been limited momentum in establishing DIS in developing countries.
• Additional Contributions: DIS can contribute to pharmacovigilance (ADR reporting), drug use reviews, health education programs, and clinical research.
• Internet Impact: The internet offers remote access to resources, but the quality of free information varies and requires careful interpretation. DIS are better equipped to afford and interpret high-quality resources.
• Basic Service: A basic DIS can include a selection of textbooks, internet access, and relevant journals, managed by a pharmacist with specific training.

Skills Required

• Core Knowledge: Knowledge of pharmaceutics, pharmacology, pharmacokinetics, and pharmacotherapy is essential.
• Information Expertise: Ability to locate reliable information, formulate written or verbal responses, and critically evaluate published studies.
• Critical Analysis: Essential for independently evaluating research findings and extrapolating results to patients.
• Clinical Acumen: Sufficient clinical experience to interpret information for patient care.
• Literature Searching: Knowing how to quickly access information using effective search strategies is an essential skill.

Nature of Drug Information Resources

Information sources are categorised by content and publication speed.

• Primary Resources:
  • Description: Original reports of unique experiences, including research results (molecular science to clinical trials) and clinical experience (individual responses, small case series).
  • Publication: Primarily in scientific journals as research, concise reports, and letters to the editor.
  • Examples: Adverse Drug Reaction (ADR) reports.
  • Role: Forms the building blocks of medical science and clinical practice; requires critical analysis of full text. Important to replicate research and carefully interpret initial reports.
• Secondary Resources:
  • Description: Electronic knowledge systems that provide a condensed and refined view of primary data, often with summaries and regular updates.
  • Examples: Drugdex (Micromedex), International Pharmaceutical Abstracts (IPA).
  • Usage: Used for rapid responses, but may not include recent primary reports or may reflect author bias.
  • Bibliographic Databases: Services providing published abstracts and indexed databases.
    • IDIS (Iowa Drug Information Service): Includes full text from ~200 journals.
    • Medline (PubMed): Produced by US National Library of Medicine, uses US indexing conventions, available free via PubMed.
    • Embase: European perspective, more comprehensive indexing (including drug terms), available by subscription.
• Tertiary Resources:
  • Description: Quick reference sources typically consulted first. Offer foundational content and background material.
  • Examples: AHFS Drug Information, Martindale, Goodman and Gilman’s, British National Formulary (BNF), Australian Medicines Handbook (AMH), Meyler’s Side Effects of Drugs, Drug Prescribing in Renal Failure, British National Formulary for Children, Drugs in Pregnancy and Lactation, Handbook of Injectable Drugs, Drugdex. Physicians’ Desk Reference (package inserts). Effects on Clinical Laboratory Tests: Drugs, Disease, Herbs, and Natural Products by D. S. Young.
  • Online Databases: Micromedex Solutions, DynaMed Plus, Lexicomp.
  • Limitations: Information may be brief, requiring further checks with secondary or primary sources. Compilations should be verified for reliability and completeness.
• Other Sources:
  • Journals: Publish important research and clinical experience. Open-access journals are increasing.
  • Internet: Reputable organisations, national libraries, clinical guidelines, drug assessments (e.g., NICE, NPC, NPS, CADTH, DailyMed, EMA, Medicines.org.uk).
  • Product Information: Available for approved drugs.
  • Retrospective Analysis: Analysing large databases for outcomes can identify potential problems but doesn’t provide direct cause-and-effect evidence.

Systematic Approach to Answering Drug Information Enquiries

A stepwise approach helps reduce search time, avoid overlooking information, and aid enquirer understanding.

1. Requester’s Details: Identify the enquirer, obtain contact details, gauge the required depth of response, and determine a deadline.
2. Background Information: Gather relevant details from medical records, patient health status, disease management, and medication history (including allergies, diagnosis, lab data).
3. Refine and Categorise the Question: Clearly state the question’s nature (e.g., interaction, dosage, adverse effect) to dictate the most efficient search strategy.
4. Develop a Strategy and Conduct a Search:
   • Select and prioritise information resources based on likelihood of containing desired information.
   • Use search patterns as a guide.
   • Search product information, drug interaction checkers (e.g., Medscape), and relevant literature databases.
   • Consult reputable websites for recent alerts or guidelines.
5. Identify and Interpret Evidence: Critically analyse retrieved information, considering the quality of the evidence base to support conclusions.
6. Formulate and Provide a Response:
   • Derive answers only after critical analysis.
   • Provide a timely, direct, and concise response.
   • Restate the question to confirm understanding.
   • Include necessary detail, potentially for follow-up questions.
   • Absolute answers are rare, so uncertainty should be summarised.
7. Follow-up and Document the Outcome:
   • Determine the consequences of advice and patient outcomes (possible in hospital/clinic settings).
   • Document all advice provided, resources used, question, and response.
   • Feedback is critical for skill development.
8. Quality Assurance:
   • An integral part of the service, aiming to improve techniques and efficiency.
   • Assess resources, operating procedures, and output through internal checks and external peer review.
   • Regularly compare to similar services and accepted standards.
   • Seek user feedback via questionnaires.

Computerised Databases (Indexing and Searching)

• Bibliographic Databases: Provide abstracts and indexed databases to locate relevant reports. Examples include Medline (PubMed) and Embase.
• Indexing Terms (Keywords): Articles are labelled with information, including indexing terms (keywords) to help users find material.
  • MeSH (Medical Subject Headings): Controlled and structured list of headings used in Medline, ensuring one term per concept. Allows broad or focused searches.
• Tree Structure/Explosion: Groups of related terms are linked in “trees,” listing general terms with specific branches. “Explosion” allows searching for specific terms or groups at any level, providing power and flexibility.
• Subheadings: Can be applied to modify the meaning of selected headings (e.g., “adverse effects” or “drug therapy”).
• Search Limits: Restrict output by subject (e.g., human), language (e.g., English), or publication type (e.g., review, letter).
• Boolean Operators: Combine concepts for focused searches.
  • “AND”: Narrows the search, combining two or more concepts.
  • “OR”: Expands the scope, linking related terms.
  • “NOT”: Rarely used, as it can exclude relevant articles.

Poison Information Services (PIS)

Importance and Usefulness

• Specialised Area: PIS is a specialised area within drug information.
• Growing Need: The increasing number of chemicals, household products, and medicines leads to a greater incidence of intentional and unintentional poisoning.
• Impact: PIS significantly impacts healthcare quality by preventing and managing morbidity and mortality from poisoning.
• Immediate Assistance: Services provide immediate, round-the-clock toxicity assessment and treatment recommendations.
• Goals: Reduce morbidity and mortality, improve patients’ health-related quality of life, prevent unnecessary healthcare visits, and ensure effective treatment.
• Support for Physicians: PIS are crucial for physicians in emergency departments who may lack time or resources to find information.
• Pharmacist’s Role: Pharmacists with clinical toxicology knowledge and information retrieval skills are strong assets as poison information specialists.
• Evolution: The first PIS emerged globally after WWII due to the explosion of new chemicals and medicines.
• Indian Context: PIS are essential in India due to high poisoning incidence and mortality, limited access to information, and lack of toxicology analysis services. As of 2010, there were only four WHO-recognised centres in India. There is a great need for more well-equipped and trained PICs.
• Public Awareness: PIS create public awareness about poisoning, prevention, first aid, and management.

Differences from Drug Information Centres (DIC)

Functions of a Poison Information Centre

PICs achieve their goals by performing several functions:

• Patient Management: Providing immediate information for the effective management of poisoning cases.
• Toxicological Analytical Services: May provide or liaise with services for identifying toxic substances.
• Toxicovigilance: Monitoring for toxic exposures.
• Education and Training: Conducting programs for healthcare professionals and outreach programs for smaller hospitals. Educating the public on prevention and first aid.
• Prevention of Poisoning: Developing and distributing educational materials.
• Research in Poisoning: Participating in research activities.
• Development of Therapeutic Guidelines/Protocols: Creating guidelines for poison management.
• Contingency Planning: Involved in developing plans and responding to chemical disasters.
• Antidote Stock Rationalisation: Assisting with the rationalisation of antidote stocks.

Organisation (Personnel, Facilities)

• Structure: Varies with anticipated “ideal human exposure call volume”. Most PICs are linked to hospitals, universities, or public health services. Networking with other PICs is essential.
• Financial Support: Requires reliable financial support, often government funding as part of a public health service.
• Personnel:
  • Staffing: Adequate staff for 24/7 operation.
  • Key Roles: Medical Director (physician), Technical Director (pharmacist), Administrator, Clinical Toxicologist, Poison Information Specialist, Public Education Coordinator, secretarial assistance.
  • Clinical Toxicologist: Qualified physician with experience in poisoning treatment and related fields (emergency medicine, paediatrics, public health, internal medicine, intensive care, forensic medicine). Provides expert advice and training.
  • Poison Information Specialist: Trained to provide information, prepare protocols, maintain records, participate in CPD, update resources, and conduct research.
  • Training: Essential for staff in clinical toxicology and communication skills. Includes updating knowledge, handling databases, information retrieval, interpretation, and analytical skills.
• Facilities:
  • Location: Ideally within or closely associated with a hospital offering emergency and intensive care, co-located with a clinical toxicology service. Liaison with a hospital/university medical library is wise.
  • Space: Spacious facility (200 sq ft per workstation recommended), separate offices, adequate lighting and ventilation.
  • Equipment: Basic furniture, vital communication equipment (at least two telephones with sufficient lines, toll-free numbers, fax, e-mail), computers, printers, photocopying machine, Uninterrupted Power Supply (UPS). Book shelves and filing cabinets for systematic storage of records, lockable cabinet for confidential data. Toxicological analytical services (in-house or liaison with a lab).
• Legal and Ethical Prerequisites:
  • Official recognition by government or WHO is recommended.
  • Requires independent status, stability, and neutrality.
  • Governing body for policy guidance and fund-raising.
  • Confidentiality of data is crucial.
  • Information is usually provided free of cost, but charges on a “no loss–no profit” basis may occur for viability.
• Policies and Procedures: Well-defined for personnel recruitment, operations (from query receipt to final documentation), escalation protocols, staff training, confidentiality, and quality assurance programs.

Key Resources

PIS requires a wide range of information sources.

• Tertiary Resources:
  • Medical and General Toxicology Textbooks: E.g., Toxicology Handbook, The five-minute toxicology consult, Paediatric Toxicology.
  • Occupational and Industrial Toxicology: E.g., Merck Index, Handbook of Pesticide Toxicology.
  • Analytical Toxicology: E.g., Disposition of Toxic Drugs and Chemicals in Man.
  • Formulary Manuals: E.g., American Hospital Formulary Service Drug Information, Indian Pharmacopoeia, United States Pharmacopeia, British National Formulary.
  • Medical Dictionaries: E.g., Stedman’s, Dorland’s, Oxford.
  • Local Data: Lists of medicines, agricultural/chemical products with ingredients in the local market.
• Secondary Resources:
  • Databases: POISINDEX, WikiTox, Toxbase, Intox, MEDLINE, Toxicology abstracts, Toxline, Excerpta medica, Index medicus. Many are available online or on CD-ROM.
• Primary Resources:
  • Journals: Human and Experimental Toxicology, Clinical Toxicology, Neurotoxicology, Pharmacology and Toxicology, Toxicology, Journal of Medical Toxicology, Indian Journal of Environment & Toxicology, Indian Journal of Toxicology, Journal of Indian Society of Toxicology.
  • Online Journal Scanning Services: E.g., AMEDEO, Current Awareness in Clinical Toxicology.
• Other: Developed treatment protocols for common poisoning types, and educational materials (posters, booklets, leaflets) on safe use and storage.

Systematic Approach in Handling Poison Information Queries

A poison information specialist must possess good communication skills and react calmly in emergencies.

1. Develop and Conduct a Search Strategy:
   • Select and prioritise information resources based on efficiency and likelihood of finding desired information.
   • Consult tertiary resources, then secondary databases (e.g., POISINDEX), and developed poison management protocols for immediate information.
   • Document resources used.
2. Evaluate and Provide the Information:
   • Critically evaluate information from a comprehensive search.
   • Provide timely, printed, or written information (e.g., on cypermethrin poisoning, treatment is symptomatic and supportive).
   • Inform enquirer about expected symptoms and necessary monitoring.
3. Conduct Follow-up and Document:
   • Follow-up is vital to assess patient outcome and determine if additional information is needed.
   • May involve personal visits (if co-located) or telephone/e-mail.
   • Document details of enquirer, query, and response for future reference and legal protection.
4. Maintain Confidentiality: All information related to queries must be kept confidential for socio-legal reasons; disclosure without consent is prohibited.

Quality Assurance

• Integral Component: QA activities are essential for PIS to improve service quality and patient health outcomes.
• Programme Elements: Includes performance indicators, evaluation methods for quality, appropriateness, timeliness of recommendations, and effectiveness.
• Staff Evaluation: Periodically assess staff knowledge, retrieval skills, and communication abilities.
• Assessment Options: User feedback questionnaires, reviews against predefined standards/checklists, and peer review of answered queries.
• Levels of QA: Applied to inputs (staff, resources, facilities, organisation), processes (receiving queries, search strategy, data collection, literature evaluation, response formulation, documentation, storage), and outputs (user satisfaction, patient outcome).
• Clinical Governance: Regular meetings to discuss quality improvement, review complaints, maintain statistics, and plan educational/prevention programs. Feedback from clinical toxicologists on referred cases is also part of QA.