Sunday, 11 May 2014

New Zealand

Figure 1: New Zealand (courtesy of Wikipedia)
New Zealand (NZ) is a country that I sometimes think of as miniature Australia, but I realise that this is a vast simplification as they do have a few significant points of difference from Australia, some of which I envy them for. They have a population of approximately 4.4 million people (compared to 22.5 million for Australia, 318.9 million for the U.S. and 63.7 million for the U.K.),  which funnily enough is roughly the population of the Australian city of Sydney, 1.36 million of which are found in Auckland (which is roughly the population of Adelaide and is found in the North Island), 400,000 of which are found in the country's capital, Wellington (which is roughly the population of Canberra and is also found in the North Island), 370,000 of which are found in Christchurch (found in the South Island) and 130,000 are found in Dunedin (Note: there are cities with a population greater than Dunedin but less than Christchurch that I omitted).1-6
Figure 2: New Zealand (courtesy of the CIA Factbook)

1. History

Figure 3: The Haast's eagle and
 its prey, the Moa
(courtesy of Wikipedia)
Similarly to Australia, NZ, in its current form, at least, started off as a British colony, although, also, similarly to Australia, it also had its own indigenous people that lived on the Islands for hundreds of years prior to the British settlement (or rather invasion as it wasn't exactly a peaceful settlement). The indigenous people of NZ are the Maori people and they are believed to have settled in the NZ circa 800 AD (compared to ~39,000 BC for when the Aboriginal Australians are believed to have settled in Australia). They also housed two of the largest birds of the modern era — the Moa (believed to have gone extinct ca. 1400 AD) and Haast's eagle (also went extent ca. 1400 AD as it fed on the Moa).1,2

2. Demographics

2.1 Ethnicity

About 71% of the New Zealand population is white (compared to 92% for Australia, 80% for the U.S., 87% for the U.K.), 14.1% is Maori (compared to <1% of the Australian population being Aboriginal), 11.3% is Asian (compared to 7% in Australia) and 7.6% is Pacific Islander.1-4

2.2 Religion

Figure 4: Symbols
 of Judaism,
and Islam
Approximately, 45.6% of their population is Christian (compared to 61.2% for Australia, 78.5% for the U.S. and 59.5% for the U.K.), 38.5% of the population is irreligious (compared to 22.3% for Australia, 12.1% for the U.S. and 25.7% for the U.K.), 2.1% of the population is Hindu (compared to 1.3% for both Australia and the U.K.), 1.4% is Buddhist (compared to 2.5% for Australia and 0.7% for the U.S.), 1.1% is Muslim (compared to 2.2% for Australia, 0.6% for the U.S. and 4.4% for the U.K.) and 1.4% of the population identifies as another religion (such as Jewish, for instance).1-4

2.3 Health

Figure 5: Medsafe's logo
The standard medical degree that Medical Schools in NZ (which number two — the University of Otago which is in Dunedin and the University of Auckland) give out is the M.B.Ch.B., which is pretty much the same as the M.B.B.S. (stands for: Medicinae Baccalaureus, Baccalaureus Chirurgiae in Latin) degree given by most Australian and British Medical Schools and takes about the same amount of time to complete (6 years). Healthcare in NZ is free, as in Australia and is funded via taxation. Their mean life expectancy is 80.93 years (compared to 82.07 years for Australia, 79.56 years for the U.S. and 80.42 years for the U.K.). Their rate of quacks per 1000 population is 2.74, compared to 3.85 for Australia, 2.42 for the U.S. and 2.77 for the U.K. Their prevalence of HIV/AIDS in adults (i.e. the percentage of adults with HIV/AIDS at the current time) is about 0.1%, which is about the same for Australia and less than said rate for the U.K. (0.2%) and U.S. (0.6%). Their rate of obesity, amongst adults, is 28.3%, compared to 26.8% for Australia, 33% for the U.S. and 26.9% for the U.K. Medsafe is the Government institution responsible for drug regulation in NZ. In NZ pharmacists are amongst the health professionals permitted to prescribe medications (as opposed to their sole role of dispensing in Australia), which is also true in the U.K. and U.S.1-4,7

The names they use for drugs are usually the International Nonproprietary Names (INNs), which are generic names set forth by the World Health Organization (WHO). Australia uses Australian Approved Names (AANs), the U.K. uses British Approved Names (BANs). AANs are what BANs used to be in 1999, mostly, because of the fact that they were last systematically updated in 1999.8,9

2.4 Education

Figure 6: The University of Otago, 
NZ's oldest university (courtesy of Wikipedia)
Their adult literacy rate is 99% (which is pretty much the same for Australia, the U.K. and U.S.), their average years of schooling (including university/TAFE training) is 12.5 years (compared to 12 years for Australia, 13.3 years for the U.S. and 9.4 years for the U.K.).

3. Miscellaneous other facts

Figure 7: Mt. Cook
(courtesy of Wikipedia)
NZ has the sixth highest human development index (HDI) of any country (compared to 2nd for Australia, 3rd for the U.S. and 26th for the U.K.), their highest mountain is Mt. Cook at 3,724 metres, compared to 2,228 for Mt. Kosciuszko, Australia's highest mountain. The combined land area of NZ is 267,710 km2, compared to Australia's 7,741,220 km2, the U.S.'s 9,826,675 km2 and the U.K.'s 243,610 km2.1-4,10

Figure 8: Metamfetamine

The chief class of drugs used illicitly there are amfetamines (most probably metamfetamine), according to the CIA Factbook (for Australia it is mostly cocaine and amfetamines, for the U.S. it's pretty much every illicit drug and for the U.K. it's a major consumer of heroin (especially from South East Asia), cocaine and producer of some synthetic drugs).1-4
Figure 9: Heroin
Figure 10: Cocaine

4. Therapeutic drugs

There's three drugs that make me jealous of New Zealanders as they're not marketed in Australia, or the U.S. for that matter; nefopam (Acupan), nabiximols (Sativex) and levomepromazine (Nozinan). They're also available in the U.K., amongst other countries.

4.1 Nefopam

Figure 11: Nefopam
Nefopam is a serotonin-noradrenaline-dopamine reuptake inhibitor (SNDRI), that's primarily used as a painkiller.11 SNDRIs are a class of drugs that increase the levels of serotonin, noradrenaline and dopamine in the body, especially in the brain and spinal cord. They most often achieve this by inhibiting three types of proteins
Figure 12: The Leucine Transporter, a type of SERT
 the serotonin transporters (SERTs), the noradrenaline transporters (NATs) and the dopamine transporters (DATs). Although exceptions do exist, such as hyperforin, the chief active ingredient in St. John's wort, which achieves its SNDRI effects by activating a receptor called TRPC6.12 Serotonin and noradrenaline are both implicated in the processing of pain in the brain and the transmission of pain signals through the spinal cord. SNDRIs also include cocaine; in the case of cocaine its action on dopamine levels in the brain is believed to be responsible for its addicting and euphoria-invoking effects. Despite this theoretical potential for abuse, nefopam abuse is actually pretty rare and it seldom ever causes patients to feel "high".11 Which is particularly impressive given the fact it's used as a painkiller, which are a class of drugs that are notorious for their ability to be abused, recreationally. My fellow pharm students might be interested to know it appears in schedule 4 of the Standard for the Uniform Scheduling of Medicines and Poisons (SUSMP).13 For the rest of you this is basically a legal document about the accessibility of drugs in Australia; schedule 4 is prescription-only medications, but unlike schedule 8 medications, possessing schedule 4 drugs without authority [like a prescription or because of your profession] isn't a criminal offence. If you're bored and want a look the most recent version of the SUSMP can be found here. It also seems to block the muscarinic acetylcholine receptors (mAChRs) which probably account for some of nefopam's side effects (such as constipation, dry mouth, blurred vision, dizziness, etc.).11 Nefopam may also interact with calcium and/or sodium channels in the spinal cord (which is an action it likely shares with the anti-seizure medications gabapentin and pregabalin), hence interfering with the transmission of pain signals down the spinal cord.14

Figure 13: Muscarinic acetylcholine receptor, M3

Nefopam has been in clinical use since the 1960s and produces pain relief that's said to be similar to that of intermediate-strength opioids (narcotic painkillers) like tramadol (when it's by itself it goes by the brand names: Durotram, Tradonal, Tramahexal, Tramal, Tramedo, Zydol; when in combination with paracetamol it's called Zaldiar in Australia), pentazocine (Talwin; not used in Australia) and hydrocodone (called Zohydro when it's by itself; Anexsia, Hycet, Lorcet, Norco, Vicodin, Xodol, Zamicet in combination with paracetamol, only available in North America), although some studies suggest it's significantly weaker and more akin to aspirin in strength.15 Nefopam is also used to treat shivering and intractable hiccups after surgery.16-18 It seems like as though it mediates its action on shivering by means of its effects on serotonin.16 It has also been used, successfully two I might mention, to treat chronic, persistent hiccups (which is a rare condition, but it can be quite distressing as it can make it difficult to sleep and hold a conversation).19

4.2 Nabiximols

Figure 14: Nabiximol's chief active constituents
Nabiximols is an alcoholic extract of the cannabis sativa (marijuana) plant that is sprayed into the mouth for the relief of treatment-resistant multiple sclerosis (MS)-related spasticity (muscle stiffness) and pain and severe treatment-resistant cancer pain. It contains cannabidiol (CBD) and Δ9-tetrahydrocannabinol (THC), in roughly equal portions. It works by activating the CB1 receptor, which is the single most abundant receptor in the human brain and is also found in the spinal cord and areas of the brain involved in pain processing. Unfortunately the evidence for the effectiveness of nabiximols is weak at best.20-21

4.3 Levomepromazine

Figure 15: Levomepromazine
Levomepromazine (called methotrimeprazine in Canada and older texts) is a drug that's quite popular in palliative care (like in people with terminal cancer) as it possesses painkilling, anti-emetic (nausea/vomiting-relieving), anxiolytic (anxiety-relieving), antidiarrhoeal (diarrhoea-treating) and sleep-inducing effects.22-26 Despite this the evidence behind these uses is weak at best.27 It was, originally, and still is sometimes, used as an antipsychotic. As an antipsychotic it is unremarkable, although it was once potentially the head of the pack for efficacy, prior to the introduction to clozapine and other atypical or second-generation antipsychotics.28


  1. "NEW ZEALAND". The World Factbook. The Central Intelligence Agency. 15 April 2014. Retrieved 12 May 2014.
  2. ^ "AUSTRALIA". The World Factbook. The Central Intelligence Agency. 15 April 2014. Retrieved 12 May 2014.
  3. ^ "UNITED STATES". The World Factbook. The Central Intelligence Agency. 15 April 2014. Retrieved 12 May 2014.
  4. ^ "UNITED KINGDOM". The World Factbook. The Central Intelligence Agency. 15 April 2014. Retrieved 12 May 2014.
  5. "2013 Census Usually Resident Population Counts". Statistics New Zealand. New Zealand Government. Retrieved 12 May 2014.
  6. "Subnational Population Estimates: At 30 June 2013 (provisional)" (PDF). Statistics New Zealand. New Zealand Government. 22 October 2013. Retrieved 12 May 2014.
  7. "Pharmacist Prescribing – Protocol Driven" (PDF). Pharmacy Guild of Australia. Retrieved 12 May 2014.
  8. Therapeutic Goods Administration (July 1999). "TGA Approved Terminology for Medicines – July 1999" (PDF). Department of Health and Ageing. Commonwealth of Australia. Retrieved 12 May 2014.
  9. Medsafe (3 May 2013). "International Non-proprietary Names (INN)". The Ministry of Health. Commonwealth of New Zealand. Retrieved 12 May 2014.
  10. "Table 1: Human Development Index and its components"United Nations Development Programme. The United Nations. 2012. Retrieved 12 May 2014.
  11. Heel, RC; Brogden, RN; Pakes, GE; Speight, TM; Avery, GS (April 1980). "Nefopam: a review of its pharmacological properties and therapeutic efficacy.". Drugs 19 (4): 249–67. doi:10.2165/00003495-198019040-00001. PMID 6991238.
  12. Leuner, K; Kazanski, V; Müller, M; Essin, K; Henke, B; Gollasch, M; Harteneck, C; Müller, WE (December 2007). "Hyperforin--a key constituent of St. John's wort specifically activates TRPC6 channels.". FASEB Journal 21 (14): 4101–11. doi:10.1096/fj.07-8110com. PMID 17666455.
  13. Therapeutic Goods Administration (July 2013). "POISONS STANDARD 2013". Department of Health and Ageing. Commonwealth of Australia. Retrieved 12 May 2014.
  14. Kim, KH; Abdi, S (April 2014). "Rediscovery of Nefopam for the Treatment of Neuropathic Pain." (PDF). The Korean Journal of Pain 27 (2): 103–111. PMC 3990817. PMID 24748937.
  15. Evans, MS; Lysakowski, C; Tramèr, MR (November 2008). "Nefopam for the prevention of postoperative pain: quantitative systematic review." (PDF). British Journal of Anaesthesia 101 (5): 610–7.  doi:10.1093/bja/aen267. PMID 18796441.
  16. Alfonsi, P (2001). "Postanaesthetic shivering: epidemiology, pathophysiology, and approaches to prevention and management.". Drugs 61 (15): 2193–205. doi:10.2165/00003495-200161150-00004. PMID 11772130.
  17. Park, SM; Mangat, HS; Berger, K; Rosengart, AJ (November 2012). "Efficacy spectrum of antishivering medications: meta-analysis of randomized controlled trials.". Critical Care Medicine 40 (11): 3070–82. doi:10.1097/CCM.0b013e31825b931e. PMID 22890247.
  18. Bilotta, F; Pietropaoli, P; Rosa, G (November 2001). "Nefopam for refractory postoperative hiccups.". Anesthesia and Analgesia 93 (5): 1358–60. doi:10.1097/00000539-200111000-00066. PMID 11682430.
  19. Bilotta, F (24 February 2007). "Nefopam for chronic persistent hiccups". British Medical Journal. BMJ Publishing Group Ltd. Retrieved 12 May 2014.
  20. Tanasescu, R; Constantinescu, CS (September 2013). "Pharmacokinetic evaluation of nabiximols for the treatment of multiple sclerosis pain.". Expert Opinion on Drug Metabolism & Toxicology 9 (9): 1219–28. doi:10.1517/17425255.2013.795542. PMID 23621668.
  21. Slof, J; Gras, A (August 2012). "Sativex® in multiple sclerosis spasticity: a cost-effectiveness model." (PDF). Expert Review of Pharmacoeconomics & Outcomes Research 12 (4): 439–41. doi:10.1586/erp.12.40. PMID 22681512.
  22. Guidelines & Protocols Advisory Committee (30 September 2011). "Palliative Care for the Patient with Incurable Cancer or Advanced Disease Part 2: Pain and Symptom Management" (PDF). British Columbia Ministry of Health. BRITISH COLUMBIA MEDICAL ASSOCIATION. Retrieved 12 May 2014.
  23. "Control of pain in adults with cancer A national clinical guideline" (PDF). Scottish Intercollegiate Guidelines Network. National Health Service. November 2008. pp. 64–67. Retrieved 12 May 2014.
  24. "Guidelines on Pain Management & Palliative Care" (PDF). UroWeb. European Association of Urology. 2013. p. 88. Retrieved 12 May 2014.
  25. "Levomepromazine in Palliative Care" (PDF). Palliative Care Guidelines. National Health Service. August 2013. Retrieved 12 May 2014.
  26. Joint Formulary Committee (2013). British National Formulary (BNF) (65 ed.). London, UK: Pharmaceutical Press. pp. 23–24,230. ISBN 978-0-85711-084-8.
  27. Darvill, E; Dorman, S; Perkins, P (April 2013). "Levomepromazine for nausea and vomiting in palliative care." (PDF). The Cochrane Database of Systematic Reviews 4: CD009420. doi:10.1002/14651858.CD009420.pub2. PMID 23633372.
  28. Sivaraman, P; Rattehalli, RD; Jayaram, MB (October 2010). "Levomepromazine for schizophrenia." (PDF). The Cochrane Database of Systematic Reviews (10): CD007779. doi:10.1002/14651858.CD007779.pub2. PMID 20927765.

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