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CPD 41: HAVING THE CONVERSATION ‘SEXUAL HEALTH’ Biography - Rozamond McElwee graduated with a First Class Honours MPharm Degree from the University of Brighton in 2011. She subsequently completed her pre-registration year in The Royal Brompton Hospital, one of the largest specialist heart and lung centres in Europe. This included training in world-leading cancer centre, The Royal Marsden. A particular highlight of Rozamond's training in London was being selected to present her audit assessing the compliance of the management of chronic heart failure patients with NICE guidelines to London Pharmacy Education and Training group. Having spent some time abroad, Rozamond has relocated to Ireland and is Module currently working for Ryans Pharmacies, Kildare & Offaly.

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June 2012

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Chronic Pain – assessment and management in primary care

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Having the conversation ‘Sexual Health’

60 Second Summary

Sexually Sheehan et al reported in 1996 that the estimated cost of transmitted pain for 95 patients to (STIs) the Irish Health Services when added infections Pain is one of the commonest reasons for patients to seek to the amount Social by Welfare payments received and areofcaused 1 medical attention. A recent survey has shown that as many infections (more the lost earnings of each patient amounted to 1.9 million as 8.3 visits per year to primary care physicians in Ireland than 30 different 6 pounds at the time of referral. The recent data from PRIME bacteria, viruses were due to symptoms of pain.2 A large scale survey carried survey showand thatparasites) the mean cost per chronic pain patient out in 15 European countries and Israel in 2006, screening are passed fromacross all grades of pain, is estimated that at €5,665 per year countries are not always reliable and complete. INTRODUCTION 46,394 respondents reported that the prevalence of chronic one person to This is due to a number of factors including which was extrapolated to another €5.34 billion or 2.86% of Irish The World Health Organisation sexual pain of defines moderate to severethe intensity in adult was predominantly during unprotected fact that STI’s Europeans are often asymptomatic and 7 GDP per year. Thiscontact demonstrates urgent need for cost health as ‘a state of physical, 3mental and sexual (vaginal,an anal and oral). STIs that appropriate diagnostic tools are often not 19%. effective strategies to manage chronic pain effectively. social well-being in relation to sexuality. It are an important public health problem and available. In addition under reporting is a major

Introduction

2 requires a positive and respectful approach to can give rise to complications such as pelvic problem in assessing the total More recent survey data from another study, carried out issue of STI’s. sexuality and sexual relationships, as well as the inflammatory disease and infertility. Early in 2,019and people chronic pain and 1,472 primary Understanding chronic pain of STIs is important. possibility of having pleasurable safewith sexual detection and treatment Ireland experiences, free of coercion, discrimination care physicians across 15 European countries, have Chronic painFrom is defined as 2012, pain that outlasts normal healing 1995 to there has been overall and violence.’1 has changed with demonstrated that chronic Little pain affects 12-54% ofregards adult to the incidence in STI notifi cations. This may be of STIs in Ireland since 2000.2 Three STIstime (usually increase three to six months), and is most frequently Europeans, in Ireland is up to 13%. Sexually transmitted infections (STIs)and are its prevalence due to a number of factors: improvements in comprise approximately 90%The of notifications; associated with musculoskeletal disorders such as low caused by infections (more than(Prevalence, 30 different Impactano-genital testing methods, improved access to testing PRIME and Cost of Chronic Pain) study, warts, Chlamydia trachomatis and back pain and arthritis. However, can alsosystems be associated bacteria, viruses and parasites) that are passed and screening, better itreporting and non-specific urethritis of the on the other hand, determined the prevalence of(inflammation chronic 3 from one person to another predominantly simplifi ed processes, as well as ongoing with other disorders such as depression or metabolic urethra, cause unknown). pain to be as high as 35.5% in Ireland.4 The PRIME study during unprotected sexual contact (vaginal, anal sexual behaviours. Young people, disorders or unsafe neurologic conditions such as multiple was designed investigateAccording the prevalence of chronic pain Surveillance and oral). STIs are an important publicto health to the Health Protection particularly those in the 20 to 29 year age problem and can give rise to complications Centre (HPSC), were 12,719 STI sclerosis. group are most affected by STIs. In 2012, in Ireland; compare the psychological and there physical health such as pelvic inflammatory disease and notifications in 2012, a crude incidence rate over 70% of all STIs notified were in those profiles of those with and without chronic pain; and explore chronic) can 30 be years categorised nociceptive infertility. Early detection and treatment of STIs (CIR) of 277.2 per 100,000 population. Pain (acute or aged less than of age: as 59% in the 4 pain-related disability. is important in order to protect the health of theResponses to survey questions were 20-29 year age group, 11.3% or neuropathic. Nociceptive pain isand caused by inanthose active Chlamydia was the most common STI in population. 19inflammatory and under. process associated with obtained from 1,204 people. illness, injuryaged and/or Ireland in 2012, accounting for 48.4% of actual or potential tissue that damage i.e. Nociceptive EPIDEMIOLOGY all STI notifications (CIR 134.3 per 100,000 Many forget a barrier method is pain Despite the magnitude of the problem, chronic pain is population). In the space of ten2,5 years, there hasfrom activity requiredininneural order pathways to greatly reduce the risk of results secondary to actual both under-recognised andbeen undertreated in primary Globallypharma approximately 700%care. increase in cases of acquiring STI’s. Nociceptive Condoms actpain as aisbarrier to or potential tissue damage. mediated Chlamydia in being Ireland. keep blood, semen and vaginal fluids from Indeed, up to 38% of patients reported inadequately STI’s are the most common group of notifiable by pain receptors located in skin, musculoskeletal system, 2 passing from infected person to uninfected managed in primary care for their pain symptoms. In infectious diseases in most countries. The 8 The rise in cases of gonorrhoea as seen bone, over and joints. Neuropathic on thecondoms other hand, person. When usedpain, correctly, are addition, peopleand with chronic reported up toexplained by worldwide incidence of major bacterial thepain years (Table 1)waiting is primarily effective in preventing men and women from results from direct injury to a peripheral or central sensory viral STI is estimated at 2.2 overyears 125 million cases between seekingincreasing help and diagnosis, andresistance 1.9 antimicrobial which contracting HIV, gonorrhoea, chlamydia and nerves do not produce transduction at yearly. However, the exact magnitude of threatens themanaged. treatment2and control of nerve; the affected trichomoniasis. years before their pain was adequately STIs worldwide is unknown. Data collated by nociceptors.8 Pain characteristics and associated conditions gonorrhoea.

for both types of pain are shown in Table 1. use by Healthcare Professionals in the Republic of Ireland only Learning, Evaluation,For Accredited, Readers, Network | www.learninpharmacy.ie © Copyright 2012 Pfizer Healthcare Ireland Date of Preparation: Module 1 June 2012 EPBU/2012/XXX

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CPD 41: HAVING THE CONVERSATION ‘SEXUAL HEALTH’

FIGURE 1. STI NOTIFICATIONS BY YEAR, 2000-2012. HEALTH PROTECTION SURVEILLANCE CENTRE STI

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

3735

3993

3992

3981

4174

3456

3494

3283

2134

2464

2556

2605

2003

16

1

1

0

1

0

1

1

0

0

0

0

0

1343

1649

1922

2258

2803

3353

3144

5023

6290

5781

5399

6407

6221

290

349

214

186

270

342

431

417

444

434

625

834

1110

Herpes Simplex (genital)

269

331

358

375

411

441

455

988

394

469

877

1263

1339

Lymphogy analoma venereum

0

0

1

0

0

1

0

2

0

0

3

2

3

Non specific Urethrisis

1726

1634

2025

2332

2746

2106

2161

1870

1636

1209

1657

1603

1542

Syphilis

46

279

303

235

144

282

134

212

312

570

614

653

565

Trichomoniasis

78

64

73

59

60

83

52

94

70

79

84

75

81

8300

8829

9426

10610

10064

9872

11890

11280

11006

11815

13442

12864

Ano- Genital Warts

Module 1 June 2012

Chancroid

sionals in Ireland Chlamydia trachomatis

anagement in primary care Gonnorrhoea

ehan et al reported in 1996 that the estimated cost of n for 95 patients to the Irish Health Services when added Total 7503 he amount of Social Welfare payments received and lost earnings of each patient amounted to 1.9 million nds at the time of referral.6 The recent data from PRIME vey show that the mean cost per chronic pain patient stimated at €5,665 per year across all grades of pain, From 1995 toto2012, there hasor been an overall ch was extrapolated €5.34 billion 2.86% of Irish increase in STI notifications. This may be 7 P per year. This demonstrates an urgent need for in cost due to a number of factors: improvements ctive strategies to manage chronic access pain effectively. testing methods, improved to testing

and screening, better reporting systems and simplified processes, as well as ongoing unsafe derstanding chronic pain sexual behaviours. Young people, particularly those in the 20 to 29 year age group are most onic painaffected is defined as pain that outlasts normal by STIs. In 2012, over 70% of allhealing STIs e (usuallynotified three towere six months), and is most frequently in those aged less than 30 years of age: 59% in the 20-29 year age group, and ociated with musculoskeletal disorders such as low 11.3% in those aged 19 and under.4

k pain and arthritis. However, it can also be associated h other disorders such as depression or metabolic THE IRISH STUDY OF SEXUAL HEALTH AND 5 (ISSHR) orders orRELATIONSHIPS neurologic conditions such as multiple rosis. The first national study of sexual health took place in 2006 called the Irish Study of Sexual

n (acute or chronic) can be categorised as gave nociceptive Health Relationships (ISSHR). This us information on the levels of sexual europathic. Nociceptive pain is caused byknowledge, an active assessed attitudesprocess and behaviours among ss, injuryand and/or inflammatory associated with the 18-60yr olds. ual or potential tissue damage i.e. Nociceptive pain ults from Irish activity in neural pathways secondary to actual people are culturally less comfortable with sexuality Nociceptive etc than some other European otential nudity, tissue damage. pain is mediated counterparts, as it is a society still deeply pain receptors located in skin, musculoskeletal system, influenced by a Roman Catholicism. However 8 e, and joints. Neuropathic pain, on the other hand, this influence has weakened considerably over the last to fewa decades and key finding of ults from direct injury peripheral or acentral sensory the ISSHR study showed increasingly liberal ve; the affected nerves do not produce transduction at attitude towards sex, particularly in the last 10 iceptors.8 Pain characteristics and associated conditions both types of pain are shown in Table 1.

years. This can be viewed as both positive and negative progress.

Contraception protects against pregnancy but not against STI’s, which tends to be overlooked.

The study found that those with lower levels of educational qualifications had lower levels of sexual health knowledge. Thus, these groups, in addition to a high probability of having early sexual intercourse were less likely to use contraception, and also significantly less likely to have good knowledge of STI’s.

Many forget that a barrier method is required in order to greatly reduce the risk of acquiring STI’s. Condoms act as a barrier to keep blood, semen and vaginal fluids from passing from infected person to uninfected person. When used correctly, condoms are effective in preventing men and women from contracting HIV, gonorrhoea, chlamydia and trichomoniasis. However, a condom does not provide a full barrier to the transmission of ulcerating STIs (Herpes simplex virus, genital warts) because they are spread by contact between infected skin and mucosal surfaces, unlike other STIs which are transmitted through vaginal fluids and semen. To protect against herpes, total abstinence is the only protection that is 100% effective but condoms can reduce the risk of contracting the virus, and avoiding sex when the virus is at its most contagious (when symptoms are evident) is advised.

Another concern relating to sexual health is the role of alcohol and illicit drugs on influencing behaviour. The ISSHR study demonstrated that intoxication from alcohol and/or illicit drugs was one of the major reasons for not using contraception and condoms. The ISSHR survey also included questions on whether an individual had ever sought advice on STI’s. Results showed no significant difference between men and women. Younger people were more likely to have sought advice, as were those with higher levels of education, particularly third-level. PROTECTION AND CONTRACEPTION, PREVENTION IS BETTER THAN CURE There is a strong need to address the issue of protection as well as contraception.

Female condoms were developed as a female initiated barrier method for STI prevention, and provide an equally effective barrier to STIs as male condoms. Due to the cost to produce and mechanical difficulties, female condoms are unpopular.

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CPD 41: HAVING THE CONVERSATION ‘SEXUAL HEALTH’

HIGH RISK GROUPS6 Groups at high risk of contracting STIs include: • men who have sex with men

Module 1 June 2012

• people who have come from or who have visited areas of high HIV prevalence and behaviours such as:

Educational distance learning content for healthcare professionals in Ireland

• misuse of alcohol and/or substances • early onset of sexual activity

Chronic Pain – assessment and management in primary care

• unprotected sex and frequent change of and/or multiple sexual partners. COMMON STI’s

The Health Protection Surveillance Centre (HPSC) is responsible for the collation and analysis of data of STI notifications from all over the country. Once analysed, reports are put together to outline trends of STI occurrence in Ireland4. The following STIs are those that medical practitioners must report to the Director of Public Health. This information is used to investigate cases thus preventing spread of infection and hence further cases.

The deregulation of the emergency hormonal England, some pharmacies offer free chlamydia contraceptive (EHC) Norlevo in February 2011 screening kits, under Patient Group Directives al reported in confidence 1996 that the estimated cost of Introduction in the pharmacy (PGD’s) to those under the age of 25 thatSheehan etdemonstrated profession to make the clinical decision receive emergency hormonal contraception Chancroid (Haemophilus ducreyi), Granuloma pain for 95 patients to the Irish Health Services when added Pain is one of the commonest reasons forcontraceptive patients to seek regarding its supply. also opened up and inguinale (Klebsiella granulomatis), or their regular pill. The young to the amount of Social WelfareThis payments received 1 opportunities to discuss contraception surveyishas shown that many medical attention. A recentperson Lymphogranuloma venereum (Chlamydia given advice onas how to use the the lost earnings of each patient amounted to 1.9It million and protection methods with patients. is trachomatis) and non-specific kit and instructions oninhow to return it and as 8.3 urethritis. visits per year to primary care physicians Ireland 6 pounds at the time of referral. Thethat recent data frommust PRIME opportunities like these pharmacists what2 will happen once results are available. were dueTHE to symptoms of pain. A large scale survey carried POSSIBLE WAYS TO REDUCE utilise sexual andpain provide Some pharmacies, in addition, offer partner survey show that to thepromote mean cost perhealth chronic patient and Israeland in 2006, screening INCIDENCE OF STIs out in 15 European countries information regarding STIs as well as the notification, provide treatments as part is estimated at €5,665 per year across all grades of pain, provision of EHC. 46,394 respondents reported that the prevalence of chronic of their PGD’s. The overall aim of this service which was extrapolated to €5.34 billion or 2.86% of Irish 1) Making a strong, clear policy on the isintensity to detect chlamydia in the early stages, pain of moderate to severe in adult Europeans was 7 negative impact of alcohol and drugs: Encouraging use of condoms is of need utmost This demonstrates an urgent for cost thus preventing the development of longGDP termper year. 19%.3 importance and can be promoted by listing its complications and reducing the spread of effective strategies to manage chronic pain effectively. Demonstrating the effect that alcohol and advantages disease.9 drugs have on contraceptive safe-sex Moreand recent survey data from another study, carried out practices by all sectors that provide information 1. Many contain lubricant in 2,019 people with chronic and 1,472 primary 3) pain Reducing the cost of contraception: Understanding chronic pain and advice relating to sexual health and care physicians across 15 European countries, have contraception. 2. 92-98% effective 20% men and women agreed that the cost OTHER NOTIFIABLE DISEASES INCLUDE

Chronic pain is defined as pain that outlasts normal healing demonstrated that chronic of pain affects would 12-54% of adult their use of condoms discourage time (usually3.three to six months), 2) Making STI screening more readily Prevention of STI’s and is most frequently 2 Europeans, and its prevalence in predominantly Ireland is up tothe 13%. Thethat have less them, groups available: associated with musculoskeletal disorders such as low with lower level education and a PRIME (Prevalence, Impactincome-those and Cost of Chronic Pain) study, 4. Only contraception males have control of 5 back pain and arthritis. However, it can also be associated manual The Irish Family Planning 2012determined onAssociation’s the other hand, the occupation. prevalence of chronic with other disorders such or metabolic 5. Females canasbedepression prepared and carry them report stated they encountered ‘persistent 4 pain to be as high as 35.5% in Ireland. The study and protection Hence the cost of PRIME contraception barriers to testing remain for individuals in disorders oralso neurologic conditions such as multiple contributing somewhat was designed to public investigatemay thebe prevalence of chronic painto the sexual remote areas who do not have access to sclerosis. A survey of more than 600 university students health concerns. While some hospitals, as well as those on low income, in Ireland; compare the psychological and physical healthuniversities provide free condoms to students, these are around the country (conducted on behalf of especially young people,profiles for whom the cost of those withofand without chronic pain; and explore Painthat (acuteUniversity or chronic)College can beCork) categorised as two nociceptive often in short supply and only benefit those found that thirds STI screening at private clinics is prohibitive.’84 pain-related disability. Responses to survey questions were attend university. had not been tested forisan STI but of or neuropathic. Nociceptive pain caused by10% an active those whoinflammatory had, had contracted STI. 90%with obtained from 1,204 people. Making the relatively inexpensive and accurate illness, injury and/or process an associated ROLE OF COMMUNITY PHARMACIST – students said that they had had unprotected STI screening test more readily available and actual or potential tissue damage i.e. Nociceptive pain ‘’HAVING THE CONVERSATION’’ oral sex. In addition, more people gave as a affordable to the public would a costDespitebethe magnitude of the problem, chronic pain is results from activity inusing neuralcontraception pathways secondary reason for the desiretotoactual effective way of managing the public health both under-recognised andAs undertreated in primary care.2,5 professional, the most accessible healthcare opposed to wishing not issue which is worsening due to more risky or potentialavoid tissuepregnancy damage. as Nociceptive pain is mediated Indeed, up to 38% of patients reported are being pharmacists an inadequately important resource for STI to contract an STI. This highlights the need to behaviours and lower incomes. by pain receptors located in skin, musculoskeletal system, prevention control. 2The emphasise the need for use of barrier protection managed in primary care for their painand symptoms. In large number of 8 bone, and joints. pain, oncontraception. the other hand, pharmacy outlets, and the trust shared between There is the potential for community as well Neuropathic as regular long term 10 addition, people with chronic pain reported waiting up to pharmacists and the public combine to afford pharmacies to become involved in the delivery results from direct injury to a peripheral or central sensory years between seekingahelp andopportunity diagnosis, to and 1.9 patients and unique reach of sexual health services2.2 in the future with the Pharmacists aredo experienced in discussing nerve; the affected nerves not produce transduction at 2 their managed. sexual health. support of adequate training guidance. In wasdiscuss yearsand before their pain adequately personal details with patients and giving 8

nociceptors. Pain characteristics and associated conditions for both types of pain are shown in Table 1.

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CPD 41: HAVING THE CONVERSATION ‘SEXUAL HEALTH’ 4. Health Protection Surveillance Centre. (2014). Trends in Sexually Transmitted Infections in Ireland, 1995 to 2012. Available: http://www.hpsc.ie/ hpsc/A-Z/HIVSTIs/SexuallyTransmittedInfections/ Publications/STIReports/. Last accessed Mar 2014.

Module 1

5. Dr Richard Layte et al. (2006). The Irish Study of Sexual Health and Relationships. Available: http://www.dohc.ie/publications/pdf/ISSHR_Main_ Report.pdf?direct=1. Last accessed March 2014.

June 2012

6. NICE. One to one interventions to reduce the transmission of sexually transmitted infections (STIs) including HIV, and to reduce the rate of under 18 conceptions, especially among vulnerable and at risk groups; 2007 [cited 2014 March]; Available: http://www.nice.org.uk/nicemedia/pdf/ PHI003guidance.pdf. Last accessed March 2014.

sionals in Ireland

anagement in primary care

7. British National Formulary, March 2014 8. Irish Family Planning Association (2013). IFPA annual report 2012. Available: http://www.ifpa.ie/ sites/default/files/ifpa_annual_report_2012.pdf. Last accessed March 2014.

them advice in a non-judgemental manner. Pharmacists need to be confident in discussing topics such as sexual health in order to develop a level of trust with the patient. Sexual health topics need to be dealt with in a sensitive manner:

ehan et al reported in 1996 that the estimated cost of • Greettothe n for 95 patients thepatient Irish Health Services when added he amount Social payments received and • of Bring theWelfare patient into the consultation room lost earnings of each patient amounted to 1.9 million • time Maintain eye contact 6 nds at the of referral. The recent data from PRIME vey show• that the mean costbody per chronic pain patient Use appropriate language stimated at €5,665 per year across all grades of pain, • Ask open-ended questions ch was extrapolated to €5.34 billion or 2.86% of Irish 7 P per year. This demonstrates an information urgent needremains for cost • Reassure them that all confidential, as always ctive strategies to manage chronic pain effectively. All of these factors are fundamental to ensure

patient feels at easepain and comfortable in your derstanding chronic

presence. There are some key opportunities

onic paintoispotentially defined asbroach pain that normal healing the outlasts subject and promote health. One such occasion when e (usuallysexual three to six months), and is mostisfrequently emergency hormonal disorders contraception ociated with musculoskeletal suchisas low required. Advice about long term methods k pain and arthritis. However, it can also be associated of contraception and information regarding h other disorders as depression or metabolic STI’s are such standard practice throughout the orders orconsultation. neurologic conditions such as multiple rosis. A patient asking about irregular periods, spotting or genital warts is a signal that

n (acute or chronic) can be categorised as nociceptive demonstrates the patient requires more europathic. Nociceptive is to caused by an active knowledge and ispain open any information that ss, injurycan and/or inflammatory process associated be provided. A patient presenting with with their first prescription for a contraceptive is another ual or potential tissue damage i.e. Nociceptive pain to utilise, to counsel on sexual ults from opportunity activity in neural pathways secondary to actual health and how to reduce the risk of contracting otential STIs. tissue damage. Nociceptive pain is mediated pain receptors located in skin, musculoskeletal system, 8 Patients are increasingly toother present at e, and joints. Neuropathic pain, likely on the hand, pharmacies for advice on their sexual health as ults from direct injury to a peripheral or central sensory appointments aren’t necessary, opening hours ve; the affected nerves do produce transduction and weekends are not often more convenient andat 8 iceptors.private Pain characteristics and conditions consultations are anassociated option. both types of pain are shown in Table 1.

Pharmacists can aid patients in a number of ways including: •

Signposting and referral when necessary

Sale of OTC items (pregnancy tests, condoms, self-care products)

Advice and information on STI’s

Supply of EHC where necessary and appropriate

Information on long term contraception options

SUMMARY/CONCLUSION Ultimately the pharmacist can play a central role on the promotion of sexual health and knowing when referral is necessary. The key to reducing the incidence of STIs is by encouraging safer sex and using fundamental opportunities that arise in the pharmacy to provide advice. In order to accomplish these goals, it is imperative that pharmacists and their staff are at ease discussing sexual health issues and are adequately trained to provide advice. Leaflets or cards could be supplied to patients receiving their regular contraceptive medication or if supplying emergency hormonal contraception. REFERENCES 1. World Health Organization (2006). Sexual and reproductive health. Available: http://www. who.int/reproductivehealth/topics/sexual_health/ sh_definitions/en/. Last accessed Mar 2014 2. De Schryver, A. Meheus, A.(1990). Epidemiology of sexually transmitted diseases: the global picture. World Health Organization. 68 (5), 639-654. 3. Shiely F, Hayes K, Horgan M (2014). Comparison of risk factors for prevalent sexually transmitted infections based on attendees at two genitourinary medicine clinics in Ireland. Int J STD AIDS. 25 (1), 29-39.

9. Pharmaceutical Services and Negotiating Committee. (2010). EN 14, Chlamydia screening and treatment. Available: www.psnc.org.uk/pages/ en14_chlamydia_screening_treatment_.html. Last accessed Apr 2014. 10. Baker, N. (2014). Sex lives of students survey reveals high levels of unprotected sex. Available: http://www.irishexaminer.com/ireland/ sex-lives-of-students-survey-reveals-high-levelsof-unprotected-sex-262143.html. Last accessed March 2014.

Pfizer Healthcare Ireland are committed to supporting the continuous professional development of pharmacists in Ireland. We are delighted to be supporting Irish Pharmacy News in order to succeed with this. Pfizer’s support of this programme is the latest element in a range of activities designed to benefit retail pharmacy. Other initiatives include the Multilingual Pharmacy Tool, Pharmacy Dietitian programme, host your own website with www.mylocalpharmacy.ie and the support of Pfizer for a year, pharmacy Consultation Room brochures and posters as well as a host of other patient-assist programmes including the Quit with Help programme and www.mysterypain.ie. If you would like additional information on any of these pharmacy programmes, please contact Pfizer Healthcare Ireland on 01-4676500 and ask for the Established Products Business Unit. Supported by Pfizer through an unrestricted educational grant. The opinions expressed are the authors and not the sponsors.

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