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BASIC TRAINING Knowledge Guide Pharmacology, Toxicology and Addiction Medicine COMMON PRESENTATIONS AND CONDITIONS Basic Trainees will require a sufficient depth of knowledge of these presentations and conditions. LESS COMMON OR MORE COMPLEX PRESENTATIONS AND CONDITIONS Analgesia management Common poisonings (including severe types such as sodium channel blockade) Diseases and disorders associated with substance abuse Management of overanticoagulation Overdose/toxic effects of alcohol and illicit drug use: » alcohol » amphetamines » benzodiazepines » cannabis » cocaine » ecstasy » nicotine » opioids » other prescription medications » paracetamol » solvents » zolpidem » zopiclone Presentations associated with an adverse drug reaction (including severe cutaneous reactions) or adverse drug event Presentations associated with drug interactions Recognition of the withdrawal state and management of acute withdrawal of: » alcohol » benzodiazepine » nicotine » opioids Complex drug interactions Recognise unusual adverse drug reactions Uncommon poisonings Basic Trainees will need to have an awareness of, and an understanding of appropriate resources that should be used to help manage patients with these presentations and conditions. RACP Basic Training Curriculum Adult Internal Medicine For all common presentations, Basic Trainees will need to know how to: Synthesise » incorporate epidemiology, pathophysiology and clinical science » recognise the clinical presentation » take a relevant clinical history » conduct an appropriate examination » establish a differential diagnosis » plan and arrange appropriate investigations Manage » provide initial, evidence-based management » discuss the principles of ongoing management » apply quality use of medicines » recognise potential complications of the disease and its management, and initiate preventative strategies » refer appropriately Consider other factors » identify broader considerations and their impact on diagnosis and management For all less common and more complex presentations, Basic Trainees will need to know how to: Synthesise » incorporate epidemiology, pathophysiology and clinical science » recognise the clinical presentation » take a relevant clinical history » conduct an appropriate examination Pharmacology, Toxicology and Addiction Medicine Knowledge Guide Page 1 BASIC TRAINING Knowledge Guide Pharmacology, Toxicology and Addiction Medicine » establish a provisional diagnosis » plan and arrange appropriate initial investigations Manage » initiate therapy in consultation » discuss broad therapeutic options » recognise potential complications » refer appropriately Consider other factors » identify broader considerations and their impact on diagnosis and management EPIDEMIOLOGY, PATHOPHYSIOLOGY AND CLINICAL SCIENCE Basic Trainees will be able to describe the principles of the foundational sciences. Accepted healthy alcohol intake according to sex and age, including pregnant women Actions of neurotransmitters Appropriate drug dose adjustments in disease, ageing and pregnancy Best practice for self-monitoring in chronic disease e.g. diabetes, hypertension, respiratory disease Categories of drug safety in pregnancy and their impact on prescribing Common and life-threatening drug interactions and common presentations of drug-induced disease and adverse drug reactions Common interactions between prescription and non-prescription medications and complementary therapies Corticosteroid use » actions and indications » relative potencies » monitoring » adverse effects and prevention Delivery techniques for specific medicines Describe the mode of action, adverse effects, interactions, pharmacokinetics of antipsychotics, benzodiazepines, antidepressants Effect of ageing, pregnancy and lactation on pharmacokinetics Factors predisposing to polypharmacy including therapeutic cascade and reasons for overprescribing and de-prescribing Factors increasing the risk of medication error Factors that affecting adherence Indications for monitoring plasma concentrations or pharmacological effects of specific drugs Impact of organ dysfunction on pharmacokinetics and dose modification Importance of genetic alterations in drug metabolism Mechanism of drug actions at the receptor and intracellular level Mode of action, antimicrobial spectrum, adverse effects, interactions, pharmacokinetics of common classes of antimicrobials Nature and specific manifestations of addiction Non-pharmacological alternatives to psychotropic medication Patient factors impacting on prescribing, such as allergy, age, pregnancy Pharmacological basis of drug interactions Pharmacology of drugs of abuse including: RACP Basic Training Curriculum Adult Internal Medicine Pharmacology, Toxicology and Addiction Medicine Knowledge Guide Page 2 BASIC TRAINING Knowledge Guide Pharmacology, Toxicology and Addiction Medicine » » » INVESTIGATIONS AND PROCEDURES Basic Trainees will know how to select and interpret the results of these investigations and procedures. IMPORTANT SPECIFIC ISSUES Basic Trainees will be able to identify important specialty-specific issues and their impact on diagnosis and management. effects side effects and interactions toxicological aspects where relevant Pharmacology of opioid replacement drugs e.g. methadone, buprenorphine Principles of absorption, distribution, metabolism and excretion of drugs Principles of addiction and tolerance Principles of dose titration Techniques for enhancing medication safety Administer simple drug use screening tools Drug monitoring including development of common adverse drug reactions such as monitoring of renal or hepatic function Investigations identifying drug efficacy or toxicity, such as ECG in digoxin treatment/poisoning, ECG in tricyclic antidepressant poisoning Mental state examination Liver function and impact on drug clearance Renal function and impact on drug clearance Acquire history of drug use Adjust therapy to achieve target ranges and monitor therapy appropriately Conduct brief interventions to reduce harm from drug or alcohol use Describe actions and indications of anticoagulants both prophylactic and therapeutic Describe legislation regarding prescribing of controlled and restricted drugs Describe common adverse effects and drug interactions for specific drug classes Discuss classes of commonly available analgesics with respect to mode of action, pharmacokinetics, potency and efficacy in various pain syndromes Discuss drug interactions, adverse effects, pharmacokinetics, monitoring of anticoagulation Discuss strategies to enhance patient adherence and techniques for encouraging self-management of health and chronic disease Discuss the prevalence of substance use and abuse and their onset Initiate anticoagulation with appropriate agent at an appropriate dose taking patient factors into consideration e.g. age, comorbid conditions Initiate empiric antimicrobial therapy with appropriate agent at appropriate dose taking patient factors into consideration e.g. age, comorbid conditions Know when and how to use therapeutic drug monitoring Liaise and communicate with community, health, drug and alcohol, education and welfare practitioners as appropriate Monitor efficacy of treatment and adjust regimen appropriately Prescribe corticosteroid therapy appropriately including dose reduction and escalation of dose in acute illness Prescribe medications safely and accurately, and monitor for efficacy and toxicity Prescribe analgesia with reference to » underlying cause, severity, co-morbidities and co-medications RACP Basic Training Curriculum Adult Internal Medicine Pharmacology, Toxicology and Addiction Medicine Knowledge Guide Page 3 BASIC TRAINING Knowledge Guide Pharmacology, Toxicology and Addiction Medicine » » » » » LEARNING METHODS Suggested opportunities, activities, and resources to assist with learning. acute and chronic pain management non-pharmacological strategies adjuvant therapies use of pain-scoring tools safe prescribing of opioids Prescribe medications in patients with altered physiology e.g. age and pregnancy Prescribe adjuvant therapy where appropriate Prescribe psychotropic medications safely avoiding serious side effects including QT prolongation and serotonergic syndrome Prescribes medications in renal and/or liver failure Provide advice on judicious prescribing Recognise polypharmacy and strategies to de-prescribe Recognise signs of drug abuse on general history and examination and impact on presentation Recognise when steroids are not appropriate Obtain accurate medication history including drug allergies and complementary and alternative medicines Understand factors that can impact on compliance Understand local and national medication guidelines and their limitations Understand the regulatory and funding framework in which medicines are made available Clinical experience in Pharmacology, Toxicology and Addiction medicine in a range of settings Textbooks Birkett DJ. Pharmacokinetics Made Easy. 2nd ed. Australia: McGraw-Hill Education; 2010. Other American Geriatrics Society Beer’s criteria for Potentially Inappropriate Medication Use in Older Adults www.americangeriatrics.org Australian Commission on Quality and Safety in Healthcare-Medication Reconciliation www.safetyandquality.gov.au/our-work/medicationsafety/medication-reconciliation Interactive Clinical Pharmacology www.icp.org.nz/index.html National Prescribing Service –Prescribing Competencies Framework www.nps.org.au/health-professionals/cpd/prescribing-competenciesframework National Health and Medical Research Council (NHMRC) Alcohol Guidelines www.nhmrc.gov.au/your-health/alcohol-guidelines WHO Guide to Good Prescribing apps.who.int/medicinedocs/en/d/Jwhozip23e/3.html RACP Basic Training Curriculum Adult Internal Medicine Pharmacology, Toxicology and Addiction Medicine Knowledge Guide Page 4