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Chapter THREE: PHARMACEUTICAL SERVICES FOR SUBSTANCE MISUSERS: SUMMARY OF EXISTING SERVICES

Introduction

41. Pharmacists in Scotland are currently involved in dispensing medication for the treatment of substance misuse, providing needle and syringe exchange schemes, nicotine replacement therapy, and the provision of advice on better health to substance misusers. These services are part of a multidisciplinary approach to prevent the spread of diseases such as HIV infection and Hepatitis B and C, to stabilise and normalise the lives of misusers, improve their health and integrate them back into the community.

42. This chapter gives a brief description of each of these services and summarises the main areas where pharmacists contribute to the treatment and care of substance misusers.

43. Examples of agencies working in partnership are included in Appendix X. Not all of the examples are necessarily unique and their widespread adoption would be beneficial to patients and other members of the healthcare team.

Summary of Services Provided by Pharmacists to Substance Misusers

Health Promotion and Health Education

44. Community pharmacists provide advice to the public on healthy lifestyles. They are ideally placed to support national and local community projects aimed to disseminate information about the misuse of a range of substances, including drugs, prescription and "over-the-counter" ( OTC) medicines, volatile substances, alcohol and tobacco. They are uniquely placed to prevent the misuse of both "over the counter" ( OTC) and prescription medicines.

45. Pharmacists are involved in activities that encourage the safe use of medicines. These take the form of advice at the point of sale or dispensing, as well as talks or lectures to parents' groups in schools and community groups. Specially trained pharmacists offer advice to parents on signs and symptoms of drug misuse, as well as advice to young people on the risks of drug misuse. This advice is in line with national and local policies.

46. Community pharmacists make available to the public a wide range of educational booklets and leaflets produced by the Scottish Executive. These include:

• a new parents' guide to drugs
• a club owner's guide to drugs
• new material on psychostimulants, such as cocaine and crack
• a cannabis guide for young people
• a guide to reducing risks from drug-related sexual assault
• Know the Score ( KTS) booklets on drink and drugs (including volatile substance abuse, overdose and Hepatitis C).

Copies are available to the public through a number of outlets including GP surgeries and community pharmacies.

Prescription Monitoring

47. Community Pharmacists and Pharmaceutical Prescribing Advisers undertake an important role by identifying excessive prescribing by individual prescribers. They must also be prepared to challenge inappropriate prescribing. Recommendations from the Fourth and Fifth Reports of the Shipman Inquiry will doubtless have an impact on future practice with regard to the monitoring of prescribing patterns of Controlled Drugs ( CDs) ^38,39.

Medication Review

48. Community Pharmacists and Primary Care Pharmacists working within general practice also monitor prescribing and how patients use their medications when undertaking medication reviews. The pharmacist assesses the patient's use of prescribed medications when taking a patient's medication history, and gives appropriate advice to prevent the inappropriate use of products containing ingredients with the potential for misuse.

Substitute Medication and Detoxification

49. Substitute medications can be prescribed to substance misusers for a variety of reasons. These include stabilization, maintenance, detoxification and harm reduction.

50. Pharmacists have led the way in expanding the supervised self-administration of methadone ^40,41,42. Participation is not obligatory but the large majority of pharmacists provide this service, [see Appendix VI]. There are well recognized procedures for the supply of multidose medication before weekends and public holidays when pharmacies are closed, but an increasing number of pharmacists are now able to offer late evening and weekend services.

51. The benefits of supervised self-administration or ingestion of methadone are now well documented ^40,43,44 and include:

• Frequent contact with a health care professional
• Opportunity for contact with other appropriate services
• Adherence to the prescribed dosage
• Reduced risk (to the individual and/or other people, including children) of accidental poisoning
• Stabilization of chaotic lifestyles
• Continuity of treatment
• Reducing an individual's contact with drug dealers
• Removing the need for individuals to support a drug habit through crime.

52. Methadone is addictive but it is less addictive than heroin and certain other opiates. Some substance misusers may only ever use methadone maintenance as a form of harm reduction and be unable to move to abstinence, but others, with support, are able to make adjustments in their lives towards a more organised existence that eventually leads to abstinence. This goal is manageable if it is backed up by the provision of advice and counselling and if there is a willingness on both sides to achieve abstinence. This provides the prescribing doctor and the pharmacist with an opportunity to build up a professional relationship with the substance misuser and to monitor changes in attitude or behaviour. It is a major challenge for substance misusers to maintain an opiate-free life and appropriate support is essential. This may include the use of antagonist drugs, such as Naltrexone, and counselling.

53. The definition of "success" should not, however, be confined to abstinence. A broader definition should be applied that encompasses those elements which lead to stabilisation, a reduction in problems related to drug use and a reduction in drug intake.

54. In addition to methadone, there is the potential for pharmacists to become involved in the dispensing and supervised consumption of other substitute medications for the treatment of opiate dependence, such as dihydrocodeine and buprenorphine (Subutex).

55. Some pharmacists have been involved in supervising the consumption of other medications that have been prescribed for patients with drug misuse problems, including doses of benzodiazepines such as diazepam.

56. Hospital pharmacists are also involved in the care of drug misusing patients. As the number of patients on substitute prescribing programmes increases it is inevitable that some will be admitted to the secondary care sector for non-drug related reasons. Such patients should have their treatment continued and be provided with adequate pain relief.

57. Hospital-based Medicines Information Pharmacists play an important role in advising both community and secondary care colleagues on treatment regimens, as well as assisting in the identification of tablets following accidental poisoning.

Care Management

58. Hospital and community Pharmacists are involved in the development of integrated care plans and pathways which take cognisance of the pharmaceutical needs of the patient. Monitoring the implementation of care pathways should always include an assessment of the pharmaceutical needs of the patient and it is crucial that compliance with medication regimens is taken into account when assessing the patient's condition. In the absence of pharmaceutical involvement at this stage the patient's adherence to his/her medication regimen, or inappropriate use of OTC medications, may be missed. Pharmacists dispensing daily medication are ideally placed to monitor the patient's physical condition.

Drug Testing

59. Pharmacists have a valuable role to play in the provision of advice on the increasing range of "near-patient" drug testing now on the market. However, it is important that they do this in collaboration with biochemistry departments that have specific expertise in the identification of drugs in urine, saliva, or buccal fluid. There is an opportunity for these new technologies to be used in community pharmacies, providing a convenient and effective means of monitoring patient compliance with the care programme.

Needle and Syringe Exchange Schemes

60. A needle and syringe exchange scheme is a facility that enables an injecting drug user to obtain clean needles and syringes and return used ones for safe disposal and destruction. They serve to limit the spread of blood-borne infections, such as HIV and Hepatitis B and C, which can be transmitted by the sharing of injecting equipment. They can also provide an opportunity for clients to gain access to mainstream drug services for longer term help. Depending upon where the exchange is located, additional services such as advice and counselling may also be provided.

61. The first needle exchanges began in Britain in 1986 but only one of these was pharmacy-based. Different models of service were developed following a pilot scheme in 1987. These were established alongside existing schemes based within hospitals or drug agencies. Pharmacy-based schemes emerged as a result of the pilot and in recognition of the fact that there was considerable potential for more injectors (such as young people and women) to be reached. The Royal Pharmaceutical Society of Great Britain issued guidelines for pharmacists taking part in needle exchange schemes in 1987 ⁴⁵. Further, more detailed, guidance was issued in 1989 ⁴⁶,1991 ⁴⁷ and 1993 ⁴⁸ and a comprehensive resource pack was produced by the National Pharmaceutical Association ( NPA) in 1998 ⁴⁹.

62. The involvement of Scottish community pharmacies in the provision of needle exchange is at a much lower level than that in England or Wales. This is due to the fact that, prior to their official, funded introduction in Scotland in 1992, most Scottish pharmacies that were selling clean injecting equipment to injecting substance misusers did not remove contaminated syringes from circulation and did not therefore fulfil the true definition of an "exchange". Some of the used equipment was returned to "fixed" nurse-led exchanges instead. Nevertheless, those pharmacies that are involved in needle exchange schemes [see Appendix VIII] have demonstrated that they are capable of providing a valuable and attractive low-threshold service to drug injectors.

63. Two Scottish documents have highlighted the need for the expansion of needle exchange provision: the Scottish Needs Assessment Programme ( SNAP) report on Hepatitis C ⁵⁰ and the Health Promotion Strategy Review Group Report on HIV⁵¹. Recent Scottish Executive advice to Drug and Alcohol Action Teams requires an increase in the number of outlets for needle exchange in order to reduce sharing of injecting equipment. An increase in the provision of clean injecting equipment and its safe return for disposal is essential if the prevalence of the viruses HIV, Hepatitis B and C, are to be contained and reduced.

64. Pharmacists who participate in needle exchange schemes may well be asked to sell citric acid. Citric acid is used by heroin injectors to help dissolve some types of street heroin in water. Until recently, Section 9A of the Misuse of Drugs Act made it an offence for anyone to supply anything that could be used for the preparation and administration of a "controlled substance". The Home Office has recently agreed to a change in the law ⁵² and, with effect from 1 August 2003, it is no longer an offence for doctors, pharmacists and drug workers to supply swabs, filters, sterile water, certain mixing utensils ( e.g. spoons, bowls, cups and dishes) and citric acid to drug users who have obtained controlled drugs such as heroin and cocaine without prescription.

Treatment of Overdose

65. Naloxone is the specific antidote for opiate poisoning, yet it is not presently included in the list of Prescription Only Medicines [ POMs] that anyone can administer in an emergency to save lives.

66. Several publications have addressed the issue of the distribution of naloxone to substance misusers ^53,54,55,56 and a survey of substance misusers shows extensive support for the provision of supplies to take away ⁵⁶. Preliminary results of two pilot schemes in Germany and the Channel Islands are encouraging ⁵⁷ and a study of the wider distribution of take home naloxone is now required. Home treatment by an acquaintance is a controversial programme that is being tried out in a number of countries outwith the UK but research is needed to measure its effectiveness and safety ⁵⁸.

67. Naloxone can be administered safely to people who have taken overdoses of opiates and without harm to those who have not. At present, the only way to provide naloxone for administration in an emergency, other than on the prescription of a doctor, is by way of a Patient Group Direction ( PGD).

68. PGDs can be used for the supply and administration of medicines to a patient that cannot be previously identified, provided the following conditions are met:

• The multidisciplinary team that draws up a PGD must include a pharmacist and a doctor.
• The PGD must include the following:
• • specification of the drug and its dose,
  • the conditions under which it can be supplied and/or administered,
  • the professionals to whom the PGD applies,
  • the circumstances in which it can be used.
• The relevant Operating Division or authorising body must approve its use.
• There must be training for all concerned and a clear audit trail.
• The PGD's use must be documented and reviewed.

69. Three such Directions have been developed for use in Glasgow ⁵⁹ and since their introduction at least one life has been saved. Surveys of pharmacists undertaken in Glasgow, Aberdeen, and Edinburgh have indicated the willingness of pharmacists in those cities to supply and be trained to administer naloxone in the case of an emergency ⁵⁹.

Detection/Management of Solvent Misuse

70. At present, the pharmacist's role in the detection and management of solvent misuse and the misuse of volatile substances is limited. This is because the effects of solvents wear off quickly, within 30 minutes or so, and are therefore difficult to detect. Furthermore, symptoms such as nausea, headaches and dilated pupils can be misleading as they may have many causes unrelated to the misuse of volatile substances. Pharmacists are, however, alert to certain signs and symptoms such as a chemical smell on clothing, hair or breath; or "drunken" behaviour, such as a lack of co-ordination and coherence. They have established useful links in certain areas for the reporting of suspected cases of solvent abuse. NHS Boards should seize the opportunity to make use of the skills and aptitudes of pharmacists so that they can join forces with Local Authority Education Departments to warn parents and schools about the dangers of solvent abuse. Pharmacists also have a duty to prevent the inappropriate sale of solvent-based products from their premises.

Misuse of Over-The-Counter ( OTC) Medicines

71. The RPSGB Code of Ethics ⁶⁰ states that pharmacy services are concerned with ensuring the safe, effective and appropriate use of medicines. However, there is potential for the misuse of all medicines including those bought over the counter at a community pharmacy. Although clear guidance on the use of OTC medicines is given with the medicine, patients may inadvertently or deliberately take more than the recommended dose or use the medicine for longer than recommended. Most people who misuse OTC medicines are unlikely to view themselves as "substance misusers".

72. Surveys of community pharmacies in Scotland have found a consistently high rate of suspected misuse of OTC medicines with 67.8% in 1995 and 69% in 2000 believing OTC medicines were misused in their area ⁶¹. The most widely suspected products of misuse were those containing antihistamines, opiates or mild stimulants, and laxatives. Although most OTC medicines that are misused fall into one of these categories, it is important to remember that almost any drug has the potential to be misused. Often these are only documented by a few case reports or are generally acknowledged as current "street" trends ⁶².

73. Pharmacists take this matter seriously and work to a variety of protocols to maximize benefit and minimize harm to patients. These include the control of particular products using registers of sales, refusing sales (in line with the RPSGB Code of Ethics), and ceasing to stock certain products where misuse is suspected ^61,63.

74. An increased awareness of OTC medicines and their potential for misuse would help all health workers to be more alert to, and able to spot, patients with these problems. This will be of even greater importance as Internet sales may increase the supply of both OTC medicines and POMs beyond the current network of providers. Pharmacy referrals on to support groups, community-based drug teams or other health professionals could be a key aspect of supporting a patient suspected of misusing non-prescription medicines.

Smoking Cessation Schemes ( SCS)

75. Nicotine Replacement Therapy ( NRT) is regarded as the pharmacological treatment of choice in the management of smoking cessation. The term NRT is used to refer to a number of products such as nicotine patches, high strength chewing gum, nicotine inhalation devices, tablets, lozenges and nasal sprays. It supplies the body with nicotine at a level that controls withdrawal symptoms, leaving the person free to concentrate on breaking their addiction.

76. Since April 2001, all forms of NRT are now available on prescription under the NHS⁶⁴. This will benefit less affluent people who wish to give up smoking. Most are now available on general retail sale or over-the-counter in community pharmacies. Its enhanced profile as a medical treatment should also encourage those able to afford it to buy it from their pharmacist.

77. However, there is good evidence that NRT by itself is not sufficient to make a large difference in the numbers of people who successfully give up smoking each year. To succeed, smokers need education, support and motivation ⁶⁵. This type of intervention ranges from low intensity support such as self-help materials and telephone helplines to more intensive interventions including individual and group counselling. In general, the more intensive the intervention, the greater the success rate.

78. Bupropion (Amfebutamone or Zyban) was licensed for use as an aid to smoking cessation in June 2000. NICE guidance states that bupropion is not recommended for smokers under 18 years or those who are pregnant or breastfeeding and that there is currently not enough evidence to recommend the use of NRT and bupropion together ⁶⁶.

79. Most community pharmacists provide some form of smoking cessation service. These range from the locally funded supply of NRT under a PGD with structured counselling and motivational support to opportunistic interventions associated with the sale of NRT or other products to aid smoking cessation ⁶⁷. This type of service has the potential to reduce nurse/ GP workload. Learning resources on smoking cessation are available for pharmacists from NHS Education for Scotland.

80. Pilot evaluations have demonstrated the benefits of hospital initiation of NRT in selected high risk patients ⁶⁸. However, these developments have typically been small scale and short term. The emphasis here is on continuity of treatment/motivation after discharge. A further pilot, referred to as the Breathe Project, has just been launched throughout Greater Glasgow as a means to help pregnant women to give up smoking. The project, which is being led by two specialist midwives, will forge links with pharmacies participating in the Starting Fresh stop smoking scheme across Glasgow. The results of the pilot will be evaluated in due course.

Alcohol Counselling

81. With the recent emphasis on the spread of illegal drugs there has been a greater tendency to play down alcohol which, when misused through heavy and binge drinking, can lead to addiction and have a detrimental effect on health. Pharmacists can, however, play an important part in the management of alcohol problems ^69,70

82. The main role that pharmacists currently play in relation to alcohol is one of education and advice. Many people drink alcohol but forget that it is a drug. When it is combined with certain types of medicine, such as anti-depressants, antihistamines, drugs used to treat epilepsy, etc., it can be dangerous. As well as asking patients about their drinking habits and encouraging them to reduce their consumption, pharmacists are alert to the signs of alcohol-related disease, counsel on the appropriate use of medicines in known alcohol misusers, and act as a signpost to services for specialist help.

83. Pharmacological interventions used in alcohol dependence for prevention of relapse include deterrent medication such as disulfiram (Antabuse), acamprosate (Campral) and naltrexone (Revia) although the latter is currently unlicensed for this indication in the UK.

84. A Health Technology Assessment by NHS Quality Improvement Scotland has found evidence in favour of the efficacy of supervised disulfiram and acamprosate in the prevention of relapse ⁷¹.

85. All NHS Specialist Alcohol Services in Scotland use disulfiram or acamprosate and a few use named patient/off license prescribing of naltrexone. For example, in NHS Lothian, the Area Drug and Therapeutics Committee has approved the use of acamprosate on a shared care basis with Primary Care. NHS Lothian has also produced a protocol for prescribing oral naltrexone for alcohol dependence. NHS Greater Glasgow has a shared care protocol in place for acamprosate.

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