Dispensing opioid substitution treatment: practices, attitudes and intentions of community-based pharmacists

INTRODUCTION AND AIMS: Community-based pharmacists (CPs) play a pivotal role in the provision of opioid substitution treatment (OST). This study examined practices, experiences, attitudes and intentions of a sample of South Australian pharmacists involved with the provision of OST. DESIGN AND METHODS: A random sample, stratified by geographic location, of 50 SA CPs were administered a telephone survey. The survey included pharmacist and pharmacy details, current practices, problems experienced, attitudes towards and future intentions in relation to the provision of OST. RESULTS: Pharmacists indicated high levels of support for the OST programme and most (98%) intended to continue providing OST. Sixty-four per cent of all pharmacists, and significantly more rural pharmacists (90%), indicated that they were willing to take on additional clients. Metropolitan pharmacists dosed greater numbers of OST clients (median = 7) than rural pharmacists (median = 4). There was a strong positive correlation between number of regular clients seen and problems experienced by pharmacists. Seventy per cent of pharmacists reported detecting no diversion of pharmacotherapy medication. DISCUSSION AND CONCLUSIONS: Despite reports to the contrary, pharmacists appear to be generally positively predisposed to providing OST. Policies aimed at retaining pharmacists, particularly in resource poor rural areas, could consider embracing a shared-care approach between general practitioners and pharmacists.     

Prescribers' perceptions of the diversion and injection of medication by opioid substitution treatment patients

Introduction and Aims. To examine Australian opioid substitution treatment (OST) prescribers' perceptions of (i) diversion and/or injection of methadone, buprenorphine, buprenorphine‐naloxone by patients; and (ii) effectiveness of current treatment policies in minimising the associated risks. Design and Methods. 1278 authorised OST prescribers, identified by each jurisdiction's health department records, were sent a postal survey in 2007. Reminder letters and additional copies of the survey were sent to non‐responders at weeks four and eight following the initial mail‐out. Respondents went into a draw to win one of ten $100 book vouchers. Results. Although the response rate was 26% (N = 291), participating prescribers served half (49%) of all OST patients in Australia. Prescribers perceived more buprenorphine patients removed supervised doses (7%) and diverted unsupervised doses (20%), compared with methadone patients (1% and 4% respectively) and buprenorphine‐naloxone patients (3% and 2% respectively). Prescribers reported significantly more buprenorphine and buprenorphine‐naloxone patients injected doses (5% respectively), compared with methadone patients (2%). Non‐adherence was identified through patient self‐report (51%), and the reports of pharmacists (49%) and other staff (34%). More prescribers were confident in assessing the risk of injection (54%) than diversion (37%). Many prescribers responded ‘don't know’ to quantitative survey items. Qualitative responses highlighted uncertainties in assessing diversion/injection and whether current responses constituted ‘best practice’. Discussion and Conclusions. Australian prescribers perceive most patients adhere with OST, although they may underestimate the levels of diversion. Prescribers' beliefs about patients' behaviours are important and influence decisions to prescribe, medication choice and suitability for unsupervised dosing. The uncertainties in assessing and responding to diversion/injection may be a factor deterring prescribers' participation in OST.[Larance B, Degenhardt L, O'Brien S, Lintzeris N, Winstock A, Mattick RP, Bell J, Ali R. Prescribers' perceptions of the diversion and injection of medication by opioid substitution treatment patients. Drug Alcohol Rev 2011;30:613–620]     

Evaluation of a five-day training programme on opioid substitution therapy in India

Aims: In India, opioid substitution therapy (OST) has been scaled-up in the recent years for HIV prevention among injecting drug users. This study aimed to assess the change in knowledge and attitude of the OST staff who underwent a five-day training programme on OST. Methods: Using a “pre-test post-test” design, routine data collected from 267 staff who underwent the OST training was analysed. The staff composition was: doctors (n?=?42, 15.7%), nurses (n?=?49, 18.4%), counsellors (n?=?45, 16.9%) and other programme staff (n?=?131, 49.1%). A 20-item, pen and paper questionnaire was administered right before the beginning of and immediately after the completion of the training. The questions were categorised into one of the five domains to assess whether changes in scores are confined to certain domains. Overall scores and scores in different domains were compared using paired-sample t-tests. The score difference in different cadres was compared using univariate general linear model with post-hoc comparisons. Findings: The difference between the total mean pre-test scores (9.24) (out of maximum possible score of 20) and post-test score (13.8) was significant. Comparison between various domains showed significant differences across all cadres. Doctors recorded significantly higher scores compared to other cadres. Conclusion: It is feasible to train different cadres of service providers together on OST in five days. The training was able to improve the participants’ knowledge and their attitude towards injecting drug users.     

High prevalence of constipation and reduced quality of life in opioid-dependent patients treated with opioid substitution treatments

Objectives To evaluate prevalence and severity of constipation and quality of life (QoL) in a cohort of opioid-addicted patients treated with opioid substitution treatments (OST).

Methods: A total of 1057 heroin-dependent patients treated with methadone or buprenorphine were enrolled in a multicenter observational study. Constipation was assessed by Wexner Constipation Scoring System (Wexner CSS), QoL by General Health Questionnaire (GHQ-12).

Results: 38.5% patients reported mild constipation, 33.3% reported moderate constipation, 14.8% severe constipation and 5.1% very severe constipation. Mean Wexner CSS score was 6.6 ± 4.8. 44.9% patients showed a GHQ-12 score ≥14; of these 18.3% patients showed a GHQ-12 score ≥20. Mean GHQ score was 13.8 ± 6.5. Mean Wexner CSS score was significantly higher in methadone patients (p = 0.004), in those taking psychoactive drugs (p = 0.0001) and in female (p < 0.0001) with respect to counterparts. Similarly, GHQ-12 mean scores were higher methadone group (p = 0.003), in those taking psychoactive drugs (p < 0.0001), and in female (p = 0.039) with respect to counterparts. ANOVA and ANCOVA showed a significant influence of methadone and female gender on Wexner CSS score while psychoactive drugs significantly influenced both tests.

Conclusions: The present study shows that patients affected by opioid-dependence in OST with methadone and buprenorphine have a high prevalence of constipation and reduced QoL.     

社区药学人员岗位技能培训探索

目的：探索如何开展社区药学人员岗位技能培训。方法2014年,该院药学部承担合肥市社区药学专业技术人员理论培训授课和实践培训任务。根据该地社区药学人员基本情况,按照国家卫计委《社区药学专业人员岗位培训大纲》等有关规定,制定岗位技能培训内容和方法并组织实施。结果多数学员较好地掌握了规范化药品调剂、特殊管理药品和高危药品管理、处方点评和药品不良反应（adverse drug reactions,ADR）／不良事件（adverse drug events,ADE）报表填写上报的基本技能,通过对学员的意见反馈统计,92％以上的学员认为参加岗位技能培训对实际工作很有帮助,95％以上的学员认为非常有必要加强特殊管理药品和高危药品管理、ADR／ADE 报表填写上报、处方点评等方面学习。结论只有定期参加岗位技能培训,加强药学专业继续学习,不断提高自身专业知识水平,才能满足社区居民、公众多层次的药学服务需求。     

Screening and brief interventions for alcohol: attitudes, knowledge and experience of community pharmacists in Auckland, New Zealand

Introduction . Screening and brief intervention (SBI) for alcohol consumption in primary care have been shown to be effective in reducing drinking. This role has not been taken up by community pharmacists. This study aimed to explore attitudes, knowledge, barriers and incentives towards involvement of community pharmacists in New Zealand with problem drinkers. Method . A postal survey (three mailshots) of community pharmacies was undertaken in Auckland, New Zealand, followed by a 10% random sample non‐responder‐follow‐up. Results . A response rate of 39.1% to the postal survey was obtained. In general, knowledge of alcohol content of drinks and recommended safe drinking limits was poor. Respondents were generally well motivated towards undertaking this role, but lacked knowledge, skills and confidence. On follow‐up, non‐responders were found to be less knowledgeable, but had similar attitudes to respondents, indicating potential for extrapolation with regard to beliefs and views on this subject. Discussion . This novel study has found that there is potential for involvement of community pharmacists in New Zealand in SBI for problem drinkers. Lack of knowledge can be remedied relatively easily; greater hurdles such as lack of skills, and lack of confidence may be offset by the high level of motivation of this group. This is an area where community pharmacists can further their professional scope of practice by being in an essential position to provide this service.     

Providing opioid substitution treatment to Indigenous heroin users within a community health service setting in Adelaide

In the late 1990s there was major concern regarding heroin use among the Nunga community in Adelaide. [Nunga is a generic term used for Aboriginal people from South Australia, similar to Koori's from Victoria and Nyungars from south-western Australia.] Heroin use was so common that community members reported that most families were affected by it in some way. There were few Nunga specific services provided, and those mainstream services available were not seen as culturally appropriate or for other reasons were difficult to access. In response to this, the Parks Community Health Centre, together with the Drug and Alcohol Services Council (DASC) [in 2005 the Drug and Alcohol Services Council (DASC) changed its name to Drug and Alcohol Services South Australia (DASSA)], and with the assistance of Nunkuwarrin Yunti Aboriginal Health Service [Adelaide's Aboriginal Community Controlled Health Service, based in the City Centre], commenced a programme offering treatment interventions for Nunga heroin users. The 'Way Out' Program commenced in March 1999. It is multi-faceted and includes an opioid substitution programme which is attracting and maintaining Nunga clients in greater numbers than ever before in South Australia. The programme locates the drug problem within a holistic view of the individual's health. It utilises networks throughout the Nunga community and in recent years has formed a strong working partnership with the Aboriginal Kinship Program [the Aboriginal Kinship Program (Department of Human Services, Metropolitan Health Division) works with Aboriginal families and individuals seeking support for family members in relation to illicit drug issues by providing support, referral, follow-up and advocacy services]. The 'Way Out' Program is succeeding in making essential treatment services available to Aboriginal people using heroin within Adelaide. This article provides an overview of the programme. [Williams N, Nasir R, Smither G, Troon S. Providing opioid substitution treatment to Indigenous heroin users within a community health service setting in Adelaide. Drug Alcohol Rev 2006;25:227 - 232]     

Participation in opioid substitution treatment reduces the rate of criminal convictions: Evidence from a community study

Objective

Positive outcomes associated with opioid substitution treatment include reduced illicit opioid use and lower risk of HIV and other blood-borne infections. The effect on the reduction of criminal activity remains unclear. Our aim was to investigate the impact of treatment on criminal activity using conviction register data.

Method

This observational retrospective study included all new patients (N = 169) enrolled in an opioid substitution treatment program in the Helsinki University Central Hospital Clinic for Addiction Psychiatry between 2000 and 2005. Psychiatric and psychosocial services were provided as part of the program. Patient treatments were followed up for 18 months. Data on criminal convictions were collected for approximately 3 years before and after the start of treatment.

Results

Mean rates of convictions decreased significantly during treatment. The effects were similar for total convictions, drug convictions, and property crime convictions. Although the numbers of violence and drunk driving convictions were too small to be analysed separately, on a bivariate level there was no indication of reduction in these crime types. Patients with amphetamine co-dependence fared best. Sex, age, other co-dependences or psychiatric diagnoses, negative urine analyses during the treatment, and dropping out from treatment had little impact on the outcomes.

Conclusions

Opioid substitution treatment seems to reduce criminal activity effectively. However, more information is needed to determine how treatment influences different types of criminality and which types of patients benefit most.     

Individual versus team-based case-management for clients of opioid treatment services: an initial evaluation of what clients prefer

Introduction and Aims. Case‐management is a client‐centred intervention to improve the coordination and continuity of delivery of services for people with complex needs. This service has been incorporated into opioid treatment programs in various ways. This study was undertaken to compare two case‐management models, termed individual case‐management (ICM) and team‐based case‐management (TBCM). This study aims to describe the new TBCM and client attitudes to, and acceptance of, this model compared with ICM. Design and Methods. Clients from two opioid treatment programs, one implementing ICM and one implementing the TBCM, were recruited to undertake a self‐complete survey examining satisfaction with case‐management during dosing hours over 7 months. Surveys took approximately 10 min to complete. Results. One hundred and sixty‐three clients were surveyed (62 ICM, 101 TBCM). Clients were demographically similar, but differed in terms of treatment and drug use characteristics. Significantly higher ratings of case‐management were reported from TBCM compared with ICM clients for help with opiate use (P < 0.001), other drug use (P < 0.001), mental health (P < 0.001), accommodation (P = 0.023), relationships/parenting (P = 0.003) and physical health (P = 0.002) and clinic services in terms of fairness and consistency, safety, respect, staff quality and confidentiality (P < 0.001). Compared with ICM clients, TBCM clients were more likely to report ease of access to case‐management (P < 0.001), wait significantly less time to see a case‐manager (38% vs. 7% seen same day) and 93% and 47% of clients, respectively, reported satisfaction with treatment (P < 0.001). Discussion and Conclusions. These initial data indicate client acceptance and satisfaction with the TBCM model. Further evaluation of the model, including cost‐effectiveness, is warranted.[Day CA, Demirkol A, Tynan M, Curry K, Hines S, Lintzeris N, Haber PS. Individual versus team‐based case‐management for clients of opioid treatment services: An initial evaluation of what clients prefer. Drug Alcohol Rev 2012;31:499–506]     

Characteristics of methadone maintenance treatment patients prescribed opioid analgesics

ABSTRACT

Background: Opioid analgesic use and disorders have dramatically increased among the general American population and those receiving methadone maintenance treatment (MMT). Most research among MMT patients focuses on opioid analgesics misuse or disorders; few studies focus on MMT patients prescribed opioid analgesics. We describe demographic, clinical, and substance use characteristics of MMT patients prescribed opioid analgesics and compare them with MMT patients not prescribed opioid analgesics. Methods: We conducted a cross-sectional secondary data analysis using screening interviews from a parent study. From 2012 to 2015, we recruited adults from 3 MMT Bronx clinics. Questionnaire data included patterns of opioid analgesic use, substance use, comorbid illnesses, and demographic characteristics. Our main dependent variable was patients' report of currently taking prescribed opioid analgesics. To compare characteristics between MMT patients prescribed and not prescribed opioid analgesics, we conducted chi-square tests, t tests, and Mann-Whitney U tests. Results: Of 611 MMT patients, most reported chronic pain (62.0%), hepatitis C virus (HCV) infection (52.1%), and current use of illicit substances (64.2%). Of the 29.8% who reported currently taking prescribed opioid analgesics, most misused their opioid analgesics (57.5%). Patients prescribed (versus not prescribed) opioid analgesics were more likely to report human immunodeficiency virus (HIV) infection (adjusted odds ratio [aOR] = 1.6, 95% confidence interval [CI]: 1.1–2.3) and chronic pain (aOR = 7.6, 95% CI: 4.6–12.6). Conclusion: Among MMT patients primarily in 3 Bronx clinics, nearly one third reported taking prescribed opioid analgesics. Compared with patients not prescribed opioid analgesics, those prescribed opioid analgesics were more likely to report chronic pain and HIV infection. However, between these patients, there was no difference in illicit substance use. These findings highlight the complexity of addressing chronic pain in MMT patients.