WHO Essential Drug Research Articles

1126P - The evolution of value with filgrastim in oncology

Background: The value of drugs will evolve over time as new evidence for risks and benefits emerge and the price of a drug changes. Methods: A NICE Evidence Search on March 1, 2017 revealed 25 systematic reviews and 55 economic evaluations of filgrastim.1 Results: Initial Health Technology Assessments (HTA) suggested low value due to high drug cost and no evidence for significant gain in Overall Survival (OS). More recent metanalyses of placebo-controlled randomized trial data show absolute OS gains of 3.2% (95% CI:2.1—4.2%) from filgrastim support of cytotoxic chemotherapy2 and falling costs due to biosimilar competition. Conclusions: Physicians and payers need to be aware that HTA decisions need constant re-evaluation, especially following the launch of biosimilar alternatives. This explains the first inclusion of filgrastim in the WHO essential Drug List for cancer more than 20 years after its original approval in 1991,3 and demonstrates the power of biosimilar medicines in transforming healthcare.

Study of drug utilization pattern in emergency medicine ward at a tertiary care teaching hospital

Background: The emergency department represents an important platform for conducting drug utilization studies as patients present with a wide spectrum of diseases in acute form. An irrational prescription adversely affects the prognosis and recovery of patients. Hence, the objective of our study was to evaluate the drug utilization pattern and to determine the rationality of prescription using WHO prescribing indicators in emergency medicine ward.Methods: After obtaining Institutional Ethical Committee approval, a prospective observational study was conducted over 2 months. The case records of 150 patients admitted to the emergency medicine ward, with a hospital stay of more than 24hrs were reviewed to analyze the prescription pattern during the initial 48hrs of admission. Case records of patients irrespective of age, sex and diagnosis were included in the study. Descriptive statistics were used to analyze the results (SPSS version 20).Results: A total of 1014 drugs were prescribed from 150 case records with a mean age of 47±18 years. An average of 6.76 drugs was prescribed per prescription; percentage of encounters with at least an antimicrobial was 115 (76.66%). Injections were prescribed in all patients (100%) and only 416 (41.02%) drugs were prescribed by generic name and 657 (64.79%) drugs abided to the WHO essential drug list. Majority of patients received anti-ulcerogenic drugs followed by antimicrobials.Conclusions: There was a tendency of polypharmacy with overuse of PPIs and antimicrobials. There is need to rationalize the drug therapy in terms of increasing prescription of drugs from essential drug list by generic name.

A study of drug utilization trends in acute coronary syndrome in intensive cardiac care unit at a tertiary care hospital, Mysore

Background: Acute Coronary Syndrome (ACS) is an emergency condition where usage of many drugs during its management in ICCU is common. This could be a potential cause for Polypharmacy, Potential Drug-Drug Interactions and increased Cost Burden on patients. The objective of the study was WHO criteria for prescription like, 1) Average number of drugs per prescription, 2) Percentage of drugs prescribed by Generic name, 3) Percentage of drugs with Injections prescribed, 4) Percentage of prescriptions with Antibiotics and 5) Percentage of drugs prescribed from the WHO Essential Drugs List.Methods: After obtaining approval from Institutional Ethics Committee, an observational study was carried out among 125 patients in a tertiary care hospital, Mysore. Patients diagnosed with ACS admitted in Intensive Cardiac Care Unit (ICCU) for initial 48 hrs were included in the study. The prescriptions were analyzed for WHO criteria for prescription. The results were analyzed using Descriptive Statistics and T- test.Results: In our present study the most common diagnoses were found to be ACS- Anterior wall myocardial infarction (36.8%) and ACS-Inferior wall myocardial infarction (32.8%). Hypertension (35.2%) and Type 2 diabetes mellitus (29.6%) were the frequently associated co-morbid conditions. Antiplatelet drugs (100%) and Hypolipidemic drugs (100%) were the most commonly prescribed, followed by Anti coagulants (94.4%). The average number of drugs per prescription was 9.09±2.17. Percentage of drugs prescribed by generic names was 37.29%. The percentage of drugs prescribed from essential drug list was 50.84%.Conclusions: The present study provides valuable insight about the overall pattern of drugs used in Acute Coronary syndrome. Physician should be encouraged to prescribe drugs with generic name.

Role of Zinc in childhood diarrhea management: a case of Nepal

<p style="text-align: justify;">Diarrhea is one of the leading causes of death among children less than five years of age around the world accounting for about two million child deaths annually. One of the recent strategies made to minimize the diarrhea associated mortality in children involves the use of oral zinc in diarrhea management. The inadequacy of dietary zinc uptake is exacerbated by the net loss of zinc during diarrhea. Zinc is enlisted in WHO essential drug list under medicine for diarrhea where it is indicated in acute diarrhea as an adjunct to oral rehydration salts. Zinc is usually well tolerated. It is necessary to explore public health applications, using zinc either as a preventive measure in children or therapeutically for diarrhea. <p style="text-align: justify;"><strong>Key words:</strong> Diarrhea, Dehydration, Mortality, Nepal, Zinc.

Drug Utilization Study in Ophthalmology Outpatients in a Tertiary Care Hospital

Aims: The present study was carried out to describe the patterns of prescription and drug use in Ophthalmology outpatients at GG hospital, Jamnagar, Gujarat, India. Methods: Total of 600 patients were included during 3 months duration and average number of drugs per encounter, percentage of drugs prescribed by generic name, percentage of encounters with antibiotics prescribed, percentage of encounters with an injection prescribed, percentage of drugs prescribed from the WHO Essential Drug List 2015, number of fixed dose combinations prescribed and percentage of antimicrobial agents prescribed were analyzed. Results: Prescription analysis showed that the average number of drugs per prescription was 3.20%. Eye drops were the most commonly prescribed (66.8%) dosage form, followed by ointment (18.4%), capsules (8.66%) and tablets (6%). Dosage forms were recorded in 99.2% drugs, information about the frequency of drug administration was present in 96% of the drugs and duration of therapy was recorded in 84.7% of the drugs prescribed. The drug classes that were used most frequently were Antibiotics (45%), Ocular lubricants (24.7%), NSAIDS (17.4%) and Anti-allergy medications (8.1%). Conclusion: Common prescription errors were minimum. However polypharmacy was common.

Investigation of Biowaivers for Immediate Release Formulations Containing BCS III Drugs, Acyclovir, Atenolol, and Ciprofloxacin Hydrochloride, Using Dissolution Testing.

The dissolution of several products containing Biopharmaceutical Classification System (BCS) class III drugs, acyclovir, atenolol, and ciprofloxacin hydrochloride, listed in the WHO essential drug list (EDL), was tested and compared with their respective comparator pharmaceutical products (CPPs) marketed in South Africa and India. US Pharmacopeia (USP) buffers of pH1.2, 4.5, and 6.8 were used as dissolution media and tested using USP apparatus 2 at 75rpm and 900ml. Nine acyclovir products were tested, and only three dissolved very rapidly in all media; i.e., they showed a release of >85% in 15min. Eight atenolol products tested were all very rapidly dissolving in all three pH media. Ten ciprofloxacin hydrochloride products were tested, and the results showed that only five products met the WHO biowaiver criteria. This study indicates that not all marketed products containing the same BCS III active pharmaceutical ingredient (API) in similar strength and dosage form are necessarily in vitro equivalent as per the WHO biowaiver criteria. Furthermore, selection and availability of an innovator product as CPP are important considerations that can affect the outcomes of such studies.

A Case Study on National List of Essential Medicines(NLEM)in India and WHO EML 2015-Overview

Availability of modern medicine increased all over the world due to huge expansion of the global Pharma market. At the same time misuse as well as accessibility of the most of essential drugs to majority of the population was denied due to cost-effectiveness of healthcare delivery combined with poor procurement policies and poor prescribing practices. During the recent years, the national list of India has assumed immense importance to improve access to medicines in India. It is therefore necessary to understand policies and guidelines followed in developing WHO essential drug list and national list of essential medicines. In this review article history of essential drug list and important inclusions in NLEM 2015 and WHO EML 2015 were highlighted.

Evaluation of corticosteroid use pattern in steroid responsive dermatological conditions

Background: Skin diseases account for 2% of the Out Patient Department based consultations in general practice worldwide, which includes diseases like, Dermatitis, Eczema, Acne, Urticaria, Psoriasis, skin allergy etc. Corticosteroids are one of the most commonly prescribed drugs in the skin diseases. Collection of data on the utilization of drugs at the hospital outpatient level has been shown to be an effective tool to constitute guidelines for improving utilization patterns. Objectives: Present study was designed to study utilization pattern of corticosteroid drugs with special emphasis on their adverse effects in a tertiary care teaching hospital. Materials and Methods: Prescriptions from department of dermatology were evaluated to know current trends. Results: Out of total 756 patients, 56.34% were male and 43.65 % were females. Corticosteroids were most commonly prescribed for Eczema (27.38%). 28.43 % of the drugs were prescribed from WHO essential drugs list. Corticosteroids were most commonly prescribed by topical route (86.48%). Diagnosis was included in 92.72 % of the prescriptions, while strength of the topical corticosteroidal was mentioned in 84.78 % of the prescriptions. Strength of the topical corticosteroidal was mentioned in 84.78 % of prescriptions. High potency topical corticosteroids were prescribed most frequently (63.72%). Total 32 steroid related adverse drug reactions were reported, Prednisolone was most commonly associated with adverse drug reactions. Conclusions: Present study reports use of High potency corticosteroids more frequently than others and emphasizes need of rational and complete prescribing of steroids in dermatology

Analysis of drugs prescribed in emergency medicine department in a tertiary care teaching hospital in southern Rajasthan

Background: Emergency medicine department of a tertiary care hospital is one of the busiest department and most challenging one for the attending physician. Patients here are in critical condition and treating doctors have to take fast decisions and actions so there are always chances of error in prescribing drugs. Therefore this study was planned with an intention to analyse drug utilization in patients admitted in emergency medicine department using WHO core prescribing indicators. Methods: A prospective observational study on drugs prescribed in emergency medicine department in a tertiary care hospital was conducted for a period of three months. Data was extracted from 450 patients’ case records in a preformed performa after taking approval from institutional ethics committee. Data was analysed by using Microsoft excel. 2010. Results: 1080 drugs were prescribed in the 450 prescriptions analysed, average being 2.40 drugs per prescription. Analgesics, proton pump inhibitors and antibiotics were the highly prescribed drugs and commonest routes of administration used were intravenous and intramuscular. Approximately 93% drugs belonged to either or both the WHO and National essential drug lists. Conclusions: The results of the study disclosed both rational and irrational drug utilization. No polypharmacy was observed but 80% drugs were prescribed by brand name. Utilization of drugs belonging to essential drug lists indicates judicious use of drugs by our clinicians. Smaller sample size and lack of estimation of cost of treatment are the limitations of this study. Hence more data must be generated for accurate analysis.

Development of Hospital Formulary as a Patient Safety Drug Delivery System in Promoting Rational use of Drugs in Tertiary Care Hospital

Objective: To constitute a Pharmacy Therapeutic Committee (PTC) and compile, design, develop and publish Owaisi Hospital and Research Centre (OHRC) Hospital Formulary for a tertiary care multi speciality hospital as a patient safety drug delivery system in promoting rational use of drugs. Methodology: PTC Committee was constituted and a descriptive form was designed for acquisition of data for drugs prescribed in respective departments and information pertaining to treatment modalities. The content of monographs to be incorporated was approved by PTC. The latest drug list was obtained from central pharmacy, respective departments/specialties and nursing stations. Subsequently, drugs were classified therapeutically along with USFDA pregnancy risk category; individual drug monographs were prepared, required ancillary information was added and lastly compared with WHO Essential Drugs List (EDL). Copies of the formulary were given to Medical Superintendent, Chief Medical Officer, and Chief Pharmacist and all the departments of Owaisi Group of Hospitals for implementation in the hospital as a tool to promote rational drug use. Results: PTC approved OHRC Hospital Formularyas a handy desk reference was compiled in 530 pages containing 306 generic drugs and FDCs. About 58 drugs were identified as Category A and B, 138 drugs as Category C, D, B/D, A/C and C/D and 7 drugs as Category X. Conclusion: Hospital formulary reflects the current clinical judgment of medical staff ensuring rational drug therapy, controlling drug costs, evidence based prescribing to reduce variation in the levels of treatment; additionally it helps in better inventory control by avoiding zero stock level and to limit the number of brands for each generic drug..

New costly treatments for hepatitis C and cancer added to WHO essential drug list

New costly treatments for hepatitis C and cancer added to WHO essential drug list

Trends of prescribing and utilisation of antibiotics in the paediatric out-patient population of a secondary care hospital in Gurgaon, India

ABSTRACT Background Antibiotics misuse is a global problem. To study the knowledge and practice regarding antibiotic use in care-givers of children and antibiotic prescription pattern in paediatrics out-patient department of a secondary care hospital at Gurgaon, Haryana, India. Methods The present study was undertaken to screen rational use of antibiotics among paediatric outpatient population in Gurgaon. As per WHO guidelines, 100 prescriptions were collected from paediatrics out-patient department and prescriptions containing antibiotics were analysed. One hundred caregivers were interviewed using a structured questionnaire to determine the knowledge of antibiotics. Results 45% of patients were prescribed antibiotics and out of the total antibiotics prescribed, 87% were generic drugs, 93% were from the WHO Essential Drugs List and 71% were as per National Formulary of India guidelines. 36% caregivers had knowledge of antibiotics and 14% knew that antibiotics are used for bacterial infections. Very few of the caregivers believed that antibiotics have side-effects (33%), 8% were aware of antibiotic resistance. Knowledge of antibiotics was significantly associated with high education and socioeconomic status ( p Conclusions Though the prescription of generic drugs and drugs from WHO Essential Drugs List is satisfactory, the low rate of rational prescriptions and poor knowledge of antibiotics among the caregivers and poor compliance to the given course of treatment is a matter of concern. Copyright © 2014, Indian Journal of Medical Specialities. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.

A retrospective study of prescription pattern of antimicrobials in an Urban Health Centre run by a medical college

Background: Antimicrobials are widely prescribed agents in clinical practice. Overuse of antimicrobials has led to emergence of drug resistance. Aims: The present study was aimed at knowing the choice of antimicrobial prescribing and to understand the rationality of antimicrobial usage . Materials and Methods: A retrospective prescription audit was done of all 655 prescriptions issued between 01/01/2012 and 31/12/2012 at the outpatient department of Urban Health Centre attached to a medical college. Demographic information, diagnosis, and medication details (dose, duration, frequency ) were recorded and analyzed, and data was expressed as percentages. Results: Of the total number of prescriptions, 46% prescriptions were containing at least one or more than one antimicrobial agent. Average number of antimicrobials prescribed per prescription was 1.35. Cotrimoxazole was the most common antimicrobial agent prescribed. Of the total 307 items of prescribed antimicrobials , 57% were prescribed by proprietary name and 43% by nonproprietary name. Out of the antimicrobial items prescribed, 44% were available at the pharmacy of the Urban Health Centre. Fifty eight percent of antimicrobials prescribed were from WHO Essential Drug List. Conclusion: Among the various antimicrobials prescribed at the Urban Health Centre, cotrimoxazole was found to be the most commonly prescribed antimicrobial agent in the year 2012. More than half of the antimicrobials were pres cribed by proprietary name. Less than half of the antimicrobials prescr ibed were available at the Urban Health Centre. Majority of the antimicrobials prescribed were from the WHO Essential Drug List.

Fixed dose combinations- to prescribe or not to prescribe: a dilemma of medical profession

Background: Fixed dose combinations (FDCs) refer to products containing two or more ingredients used for a particular indication in a single dosage form. Prescribing FDCs has become a routine affair in medical practice. There has been increase in the irrational FDCs in the recent past by leaps and bounds. The pharmaceutical companies are luring the physicians to prescribe their products even when they are not needed by the patients. The Indian laws too are not properly defined to grant marketing approvals of FDCs. Hence the rationality of a FDC has become one of the most controversial and debatable issues in general practice. Methods: We hence decided to analyze the existing FDCs in Indian market and study their rationality. Results: We observed that, although many brands of FDCs available are essentially rational as per WHO and Indian essential drugs lists, the irrational FDCs easily outnumber the rational ones. Hundreds of rational FDCs are also available which are not included in WHO or Indian essential drugs lists. A few FDCs with incorrect doses were also noted. Irrational FDCs not only cause more adverse drug reactions but the antibiotic FDCs are responsible for increasing the chances of resistance. A few of these are discussed for their irrationality. Conclusions: It is the need of the hour to raise our voice against the growing list of irrational FDCs and try to reduce the magnitude of this problem by sensitizing the undergraduates, the interns as well as the practitioners regarding their efficacy, safety, suitability, rationality and cost benefit.

Drug utilization in pediatric neurology outpatient department: A prospective study at a tertiary care teaching hospital.

Background:Neurological disorders are a significant cause of morbidity, mortality and adversely affect quality of life among pediatric patients. In India, more than 30% population is under 20 years of age, many of whom present late during the course of illness. Several drugs prescribed to pediatric population suffering from neurological disorders may be off label or unlicensed.Aims and Objectives:To study drug use pattern, identify off-label/unlicensed drug use and to check potential for drug-drug interactions in patients attending outpatient department of pediatric neurology at a tertiary care teaching hospital.Methodology:Prescriptions of patients attending pediatric neurology outpatient department were collected prospectively for 8 weeks. They were analyzed for prescribing pattern, WHO core prescribing indicators, off-label/unlicensed drug use and potential for drug-drug interactions.Result:A total of 140 prescriptions were collected, male female ratio being 2:1. Epilepsy was the most common diagnosis (73.57%) followed by breath holding spells, migraine and developmental disorders. Partial seizure was the most common type of epilepsy (52.42%). Average number of drugs prescribed per patient was 1.56. Most commonly prescribed drug was sodium valproate (25.11%) followed by phenytoin (11.41%). About 16% of the prescriptions contained newer antiepileptic drugs. More than 60% of the drugs were prescribed from WHO essential drug list. In 8.57% of cases drugs were prescribed in off-label/unlicensed manner. Twenty-six percent prescriptions showed potential for drug interactions.Conclusion:Epilepsy is the most common neurological disease among children and adolescents. Sodium valproate is the most commonly prescribed drug. A few prescriptions contained off-label/unlicensed drugs.

Prescription Analysis of Drugs Prescribed For Children in Some Towns of Maharashtra

Objective: To analyze the drug prescibed for the children in some towns of Maharashtra with reference to WHO Essential Drug List for Children, March 2011. Method: Data for this study collected by II MBBS students at their home towns like Jalna, Solapur and Chipulun with the help of prescription analysis form prepared by Department of Pharmacology. Rationality of prescription was evaluated as per WHO Model List for Essential Drugs for Children (2011). Results: Total 46 prescriptions of issued for children in Jalna, Solapur and Chiplun were analyzed. 31.48 % drugs prescribed for children in these towns were according WHO list of Essential Drugs for Children. Out of total 108 drugs prescribed 39.81 % were FDCs. 27.91% prescribed FDCs were rational. FDCs prescribed in this study were mainly from drug groups like antibiotics (25.58 %), vitamins/minerals (23.26 %), cough /cold (27.91 %) and analgesics (18.60 %) FDCs. Rational FDCs prescribed in this study were from the class of antibiotics. Conclusions: More than 68% prescribed drug for children in towns are not in accordance with WHO Model List of Essential Drugs for Children. Interventions to rectify over prescription of antimicrobials and cough/cold FDCs in children are needed. Vitamins/Minerals FDCs many times only add to the expenditure bill of the patient without giving any potential benefit. Vitamins and Minerals FDCs prescription should be based on deficiency status. Making availability of WHO/National Essential Drug List for children to all the prescribing physicians and organizing regular workshop/ educational campaign for rational prescribing may help in this regard.

A STUDY ON RATIONAL DRUG PRESCRIBING PATTERN IN GERIATRIC PATIENTS IN HYDERABAD METROPOLITAN

Objective: To describe rational drug prescribing in general practice for elderly patients, using patients age, sex, encounters and the occurrence of some predefined inappropriate drug prescribing, according to Beer’s criteria, drug-drug interaction of common OTC drugs and WHO essential drug list. Design: A retrospective study on rational drug prescribing patterns in geriatric patient was carried out using prescriptions issued to the geriatric patients, 65 years and above, attending the outpatient and inpatient department of various hospitals and clinics of Hyderabad. Results: Of the 150 prescriptions consecutively selected, Anti diabetics (142, 15.58%) were the most commonly prescribed medicines with metformin being the most prescribed anti diabetic. The medications prescribed by generic names were 92 (10.08%). 40% of medicines were prescribed from the WHO essential drug list. 17 (11.3%) prescriptions had one or more potentially inappropriate medicines from Beer’s criteria and in 16 (10.6%) prescriptions drug – drug interactions were ascertained according to drug - drug interactions of common OTC drugs. Conclusions: The drug prescribing pattern among the elderly is still suboptimal. Appropriate interventions are needed for both health care providers and patients alike. Key words: Geriatric patient, Drug-drug interactions, Essential drug list, Rational drug use.

Using the needs of WHO to prioritise Cochrane reviews: The case of antipsychotic drugs

BackgroundThis study aimed to investigate existing trialling activity relating to three antipsychotic drugs from the WHO List of Essential Medicines (chlorpromazine, fluphenazine decanoate, haloperidol), link existing trials to existing Cochrane reviews, identify gaps in reviewing activity on accessible treatments for people with schizophrenia.MethodsWe used the Cochrane Schizophrenia Group's register searching for all studies comparing the three antipsychotic drugs with each other and with all other pharmacological interventions listed on the Essential Medicines List (with the addition of 'placebo or no drug'). For each we also considered studies that focussed on administration, dose, withdrawal and use of that drug in specific circumstances administration. Data were then extracted on a number of studies, number of participants within those studies, and as to whether a maintained review already exists. Finally, every effort was made to consider as to whether there were possibilities for missing comparisons that no one had ever investigated.ResultsThere has been considerable research activity involving the three 'essential' antipsychotics and also comparing those three drugs to others on the 'essential' list. We found 490 studies with 77957 participants for haloperidol, 316 studies with 29179 participants for chlorpromazine and 33 studies with 4503 participants for fluphenazine decanoate. Reviewing activity has also been considerable in this area but there are notable omissions which would necessitate new reviews to comprehensively cover the area.ConclusionsWe have used the 'sample frame' of the WHO Essential drug list as a starting point. WHO prioritises for us those drugs that have universal accessibility but they may not be the compounds that are first choice if others are available. It is encouraging to see how many maintained reviews already exist to service those undertaking WHO guidelines. The needs of those guiding care can be taken as a means of prioritising research. For largest global impact WHO Essential Medicine list provides clear direction. By using this technique workload can be anticipated, prioritising can take place for new reviews and updates.

Chlorpromazine Dose for People With Schizophrenia

Chlorpromazine is one of the three antipsychotic drugs on the WHO Essential Drug List. It is used worldwide. The optimal dose has been the subject of evaluative research but summaries of this work are rare.To determine chlorpromazine dose response and dose adverse effect relationships for schizophrenia and schizophrenia-like psychoses.We searched the Cochrane Schizophrenia Group Trials Register (December 2008). References of all included studies were examined for further trials.All relevant randomised controlled trials (RCTs) comparing fixed doses of chlorpromazine for people with schizophrenia and reporting clinical outcomes.We extracted data independently. For dichotomous data we calculated fixed-effect relative risk (RR) and their 95% confidence intervals (CI). For continuous data, we calculated weighted mean differences (WMD) based on a fixed-effect model.We included four relevant studies (1012 participants) in this review. They are all hospital-based trials, have a duration of less than six months and are at moderate risk of bias. When low dose (</=400mg/day) was compared with medium dose (401-800 mg/day) mental state data were very few and difficult to interpret (n=22, 1 RCT, WMD 'withdrawal retardation' -2.00 CI -3.76 to -0.24). More people left for inefficacy of treatment in the low dose group (n=48, 1 RCT, RR 4.24 CI 0.24 to 74.01). In the short term, all measured extrapyramidal adverse effects tended to be lower in the low dose group (n=70, 2 RCTs, RR dystonia 0.20 CI 0.04 to 0.97). When low dose was compared with high (>800mg/day) data were taken from only one study (2gms chlorpromazine/day). Global state outcomes tended to favour the high dose group (n=416, 1 RCT, RR 'No clinically important improvement 1.12 CI 1.01 to 1.23). One case of death was reported in the high dose group (n=416, RR 0.33 CI 0.01 to 8.14) and a significantly greater number of people in the high dose group left early due to disabling adverse effects (n=416, RR 0.10 CI 0.04 to 0.27). Significantly less dystonia and unspecified extrapyramidal adverse effects were reported in the low dose group (n=416, dystonia RR 0.11 CI 0.02 to 0.45, unspecified extrapyramidal adverse effects RR 0.43 CI 0.32 to 0.59). People in both groups experienced akathisia (n=416, RR1.00 CI 0.55 to 1.83).The average dose of chlorpromazine given to people with schizophrenia has declined across time, but this has come about by long - and sometimes hard - experience rather than from direction from high-grade trial-based evidence. This progression towards gentler levels of dosing has taken six decades. We hope that, for modern compounds, data from relevant high-grade evaluative studies will be much more swiftly available to guide informed practice.

Review of Global Policy Architecture and Country Level Practice on HIV/AIDS and Drug Treatment

This review, funded by the U.K Department for International Development, provides an understanding of the gaps and opportunities for improving access to drug treatment, in particular opioid substitution treatment (OST), for drug users affected and infected by HIV. OST is effective in treating opioid dependency, reducing its individual and social costs. For HIV-infected, opioid-dependent injecting drug users, consistent participation in OST is associated with a higher probability of antiretroviral treatment and, amongst antiretroviral users, more consistent use of antiretrovirals. At the global policy level, there are few barriers to the introduction and expansion of OST with both methadone and buprenorphine now on the WHO Essential Drugs List, and all relevant international organisations approving and encouraging the use of OST for HIV prevention, treatment, care and support in countries where injecting drug use and HIV are found. Unfortunately, there are huge disparities in access to drug treatment, with participation in treatment in Asia and Africa being disturbingly low. Country reports from Vietnam, Kyrgyzstan and Kenya provide examples of the barriers and successes on the ground. Recommendations for donors, international organizations and public health champions include:1. Strengthen leadership at global level for access to drug treatment and, in particular, opioid substitution therapy as a key intervention in HIV prevention, treatment and care among injecting drug users. 2. Develop audit tools for donors to ensure that consideration of harm reduction interventions, prioritizing OST and needle-syringe programmes, becomes a standard part of all development work related to HIV/AIDS. 3. Support the implementation of drug treatment and, in particular, OST in country. 4. Integrate drug treatment and, in particular, OST with HIV treatment. 5. Establish comparable drug treatment programs within correctional institutions to those in the community.