Pharmacy customers' views and experiences of using pharmacies which provide drug misuse services

This study aimed to determine whether pharmacy customers are deterred from using a pharmacy that offers services to drug misusers. If patients are deterred, what are their specific concerns? The study was qualitative and three different groups were interviewed about their views on pharmacies providing services to drug misusers (i) pharmacy customers, (ii) local community councils and (iii) local drug forums. This paper focuses on pharmacy customer interview results. Interviews were conducted in 10 pharmacies, five in Aberdeen and five in Glasgow, both areas of high drug misuse. The pharmacy customers were attending pharmacies with high, medium and low involvement with drug misusers and were located in city centre, suburban and rural locations. Pharmacy customers were generally supportive of pharmacies offering services to drug misusers. However, their support was often qualified by a wish to see a private area provided for methadone consumption. Pharmacy customers were more knowledgeable of the rationale for and supportive of needle exchange services compared to methadone maintenance and supervised consumption. The results of the study demonstrate that the majority of pharmacy customers are supportive of drug misuse services, provided there is adequate privacy in the pharmacy. These results should be used to encourage more pharmacists to provide drug misuse services.     

Pilot randomised controlled trial of community pharmacy administration of buprenorphine versus methadone

Objectives The established regime for opiate substitute prescribing for drug misusers is daily methadone administered under supervision in community pharmacies. Buprenorphine has recently been introduced as an alternative. However there is a lack of evidence of the effectiveness of buprenorphine maintenance therapy (BMT) in the UK treatment setting. This study aimed to assess methods for a randomised controlled trial (RCT) and the feasibility of pharmacy‐based supervised self‐administration (SSA) of buprenorphine compared to methadone. Setting Specialist substance misuse service, general practices and community pharmacies in Aberdeen, Scotland. Method The design was a pilot RCT. Opiate‐dependent drug misusers, newly referred for maintenance treatment were randomised to receive BMT or methadone maintenance therapy (MMT). Clients and pharmacists were interviewed at baseline and at the end of a 12‐week intervention period. Clients completed the quality of life measure EQ‐5D. Pharmacy activities were timed. Key findings Twenty‐one opiate‐dependent clients were recruited (BMT = 11, MMT = 10). Recruitment levels improved as the trial progressed. Clients' treatment preferences were evident. Withdrawals occurred early with BMT. Clients found SSA of buprenorphine acceptable, but found daily administration more manageable than three times weekly. Pharmacists found the dispensing of buprenorphine to be an acceptable role, but felt less certain of ensuring against diversion with buprenorphine than they were with methadone. Pharmacy activities associated with buprenorphine took longer than those associated with methadone (mean = 7 min 25 s versus mean = 3 min 27 s, respectively). Conclusion Recruitment to a trial comparing MMT to BMT for opiate‐dependent clients within a UK treatment setting is feasible. Clients and pharmacists found buprenorphine acceptable.     

National and local guidance on services for drug misusers: do they influence current practice?— results of a survey of community pharmacists in South East England

Objective — To investigate levels of awareness of national and local guidance about services for drug misusers and their effect on pharmacy practice. Method — A postal survey in 1997 to collect data on current involvement in services for drug misusers, awareness of and receipt of key documents pertaining to drug misuse, effects of guidelines and protocols on practice, and influences on decisions to provide services. Setting — A random one in two sample (n=1,582) of community pharmacies in the South East of England (North and South Thames regions). Key findings — A 65.1 per cent response rate was achieved. Just over half (54.7 per cent) were dispensing Controlled Drugs for the management of dependence, 47.2 per cent were selling clean injecting equipment and 15.5 per cent were offering a needle exchange service. Most respondents were unaware of key government documents, with the exception of “Health of the nation,” and only a small minority had received copies. The most influential factors on current position on service provision were “personal experience,” “local need” and “Royal Pharmaceutical Society of Great Britain (RPSGB) policy.” New local guidelines and initiatives mainly related to supervised consumption of methadone in pharmacies and pharmacy needle exchange. Conclusion — Community pharmacies are substantially and increasingly involved in providing*** primary care services for drug misusers. However, there is a disturbing lack of awareness of key government initiatives, possibly due to the lack of dissemination of such documents. RPSGB policy as a key influencing factor points to an opportunity for the profession to take a more influential position.     

Development,implementation and evaluation of a pilot project to deliver interventions on alcohol issues in community pharmacies

Objective The aim was to evaluate the feasibility and acceptability of the provision of brief interventions on alcohol misuse in community pharmacies. The objectives were to: train community pharmacists to initiate discussion of alcohol consumption with targeted pharmacy clients and screen, intervene or refer as appropriate; and to explore with pharmacists and clients the feasibility, acceptability and perceived value of screening and delivering the intervention. Setting Eight community pharmacies in Greater Glasgow. Method After a two‐day training course for pharmacists (n = 9) and one day for pharmacy assistants (n = 13), the eight pharmacies recruited clients over 3 months. Standardised protocols were prepared to screen clients for hazardous or harmful drinking using the Fast Alcohol Screening Tool (FAST) and to guide the intervention. Clients were recruited from specific target groups and via posters highlighting the service. Following completion of the recruitment phase, pharmacists and clients were followed up by the research team, using a combination of focus groups and semi‐structured telephone interviews. Key findings During the study period 70 clients were recruited, 30 screened as drinking hazardously (42.9%) and 7 (10%) screened positive for harmful drinking. Interventions commonly included explanation of sensible drinking and units in clients' preferred drinks (n = 33), feedback on screening and risks to health (n = 27) and discussion of pros and cons of current drinking pattern and link with presenting issue (n = 23). Of the 40 clients agreeing to be followed up, 19 could be contacted and most were generally positive about the experience. On follow‐up the pharmacists were positive and felt the project worthwhile and, importantly, noted no strong negative reactions from clients. Conclusion This project has been successful in training community pharmacists to discuss alcohol with 70 clients. Further work is required to test the generalisability of our findings and to measure the impact on alcohol consumption.     

The role of the community pharmacist in drug abuse: a comparison of service provision between Northern Ireland and England/Wales

Aim: The aim of the present research was to establish the current extent of pharmacists' contact with illicit drug users in Northern Ireland, their willingness to provide services for this group and to compare the findings with data from a 1995 national survey of community pharmacies in England and Wales. Method:The questionnaire developed by the National Addiction Centre for research in England/Wales was used to collect data. It was mailed on two occasions (March and April 1999) together with a covering letter and a prepaid return envelope to all community pharmacies in Northern Ireland (n=507). A final reminder letter was included in the local wholesalers' medical delivery for the attention of the pharmacist in May 1999.Main Outcome measure: The extent to which Northern Ireland pharmacists had contact with and provided services to illicit drug users compared to pharmacists in England/Wales.Results: A response rate of 67.5% was achieved. Respondents in Northern Ireland were providing fewer services to drug users than those in England/Wales. Respondents reported dispensing methadone for the treatment of addiction/misuse to only 9 patients, while only 17 pharmacists had been asked to sell injecting equipment in the previous week and no pharmacist was participating in a needle exchange scheme. However, most respondents indicated their willingness to provide such services. Barriers towards the provision of services were, however, highlighted e.g. the need for training and the establishment of support systems. Conclusion: Pharmacists in Northern Ireland are in a position to contribute to the policy agenda in Northern Ireland for drug misuse, prevention, treatment and harm minimisation roles which the survey indicates they are willing to embrace. However, training programmes, support systems and adequate remuneration packages must be established before they will be in a position to participate fully.     

Involvement of community pharmacists in the care of drug misusers: pharmacy-based supervision of methadone consumption

This article examines the feasibility and acceptability of a supervised consumption of methadone service from local community pharmacies. It builds upon the British Department of Health's recommendations to increase the involvement of community pharmacists in the care of addicted drug users and to expand the range of services they offer to drug users. The article also takes up the ongoing debate on regulating the structure of prescribing and dispensing of methadone and the Department of Health's suggestion to consider methods to reduce the diversion of methadone, for example via supervised consumption of methadone. The pharmacy-based supervised self-administration of methadone scheme (SSA) at the Camden and Islington Community Health Services Trust Substance Misuse Services (CTDS) in London has been found to be valuable by clients, pharmacists and keyworkers. All pharmacists involved regarded the project as workable and expressed their willingness to continue with the provision of supervised dispensing of methadone in the future. Clients stated as main advantages: local access, which saved them time and travelling, and the longer opening hours enabled them flexibility in managing their time. The main negative comments were related to lack of privacy when drinking their methadone within the pharmacy. Most keyworkers welcomed the SSA scheme as another dispensing option available. The fact that another responsible and accountable health professional was involved was positively perceived by the key workers. The Camden and Islington pilot project of providing a supervised consumption of methadone service from local community pharmacies has successfully put into practice the Department of Health's recommendations to increase the involvement of community pharmacists in the care of addicted drug users and to expand the involved health range of services they offer to drug users. This suggests a positive future for the practice and implementation of pharmacy-based self-administered provision of methadone.     

Methadone prescribing under supervised consumption on premises: a Scottish clinician's perspective on prescribing practice

Introduction and Aims. Specialist services have increased their capacity considerably in recent years to initiate and/or provide ongoing treatment for drug misuse. Consequently, methadone prescribing has substantially increased and over 17 000 patients are currently receiving methadone. Clinical guidance promotes consumption on the premises (COP) initially to ensure patients take medication as prescribed and also to prevent diversion. Diversion poses two risks: the patient may remain under‐treated and continue illicit heroin use; diverted drugs put others at risk. However, COP can be restrictive. Current UK guidance is vague and not evidence‐based recommending ‘around three months subject to assessment of compliance and individual circumstances’. The overall aim of this study was to describe clinical practice regarding prescribing methadone under COP in Scotland, and reasons for this. Design and Methods. A structured, postal questionnaire was sent to all lead clinicians in specialist drug treatment centres in Scotland in 2009 (n = 42). The questionnaire explored current practice, influence of supervision on retention, views of best practice and contingency management. Results. The response rate was 76% (n = 32). Clinicians usually supervise for a minimum of three months with patient‐centred criteria used to determine when to reduce or stop COP. Employment, clinical stability, family support and concerns for the safety of children in the home influenced decision making. Contingency management approaches to supervision were widely used (62%). Discussion and Conclusion. In Scotland, clinicians' practice is variable and individualised to patients, but generally cautious regarding relaxing supervision conditions. This may reflect the lack of evidence‐based guidance.[Anthony GB, Matheson CI, Holland R, Bond C, Roberts K, Mac Rae A, Whitelaw E, Priyadarshi S. Methadone prescribing under supervised consumption on premises: A Scottish clinician's perspective on prescribing practice. Drug Alcohol Rev 2012;31:342–347]     

Notes from practice: Methadone prescribing in north central London—doses,compliance, goals and treatment setting

Aims: To examine methadone prescribing in public drug treatment services in inner London; compare levels of methadone prescribing with national guidelines and surveys; investigate whether methadone reduces illicit opiate use; and compare clients treated in specialist clinics with those in shared-care in general practice.

Methods: A cross-sectional survey of four drug treatment services in north central London.

Findings: Data were collected on 715 clients. Mean methadone dose was 57.2?mg but for clients on methadone maintenance, the mean dose was 63.4?mg. Reported heroin use fell from 24.8 days in the last 30 at initial assessment to 11 days (p?<?0.001). Clients on methadone doses greater than 60?mg were more likely than those on lower doses to test negative for morphine on urinalysis (49% vs. 39.4%, p?<?0.01). Clients in GP shared-care were more likely to have been in treatment for less time, be on lower doses of methadone and have stabilization or detoxification as their treatment goal.

Conclusions: Methadone treatment is associated with a reduction in illicit opiate use but not abstinence. Inadequate doses and lack of supervised consumption may in part explain the relatively poor response to treatment. Clients in GP shared-care received substantially different treatment from those in the specialist clinics.     

Virtual pharmacist interventions on abuse of over-the-counter medications during COVID-19 versus traditional pharmacist interventions

ObjectivesThis study aimed to investigate the frequency, nature, and clinical significance of pharmacist interventions on over-the-counter (OTC) medicines with abuse potential across community pharmacies with and without virtual care.MethodsIn this prospective observational study, a trained research team observed the dispensary teams of 12 community pharmacies in the United Arab Emirates (UAE), 6 of which were operating virtual pharmacy care. A standardized data collection form was used to include information about dispensing of OTC medicines and pharmacist interventions on those with abuse/misuse potential. The clinical significance of the interventions was evaluated by a multidisciplinary committee.ResultsThe frequency of pharmacist interventions on OTC medicines with abuse potential across pharmacies with and without virtual services was 83.2% versus 91.0%, respectively, whereas the frequency of pharmacist interventions on OTC medicines with misuse potential across pharmacies with and without virtual services was 79.8% versus 41.2%, respectively. The proportions of clinically significant interventions across pharmacies with and without virtual services were 19.7% versus 10.5%, respectively. Cough medicines were dispensed significantly more across pharmacies with virtual care than across pharmacies without virtual care (25.6% vs. 9.7%, respectively; P = 0.04). Asking the patient to seek the advice of an addiction specialist (adjusted odds ratio = 4.11; P = 0.001) versus refusing to sell the drug was more likely to be associated with pharmacies with virtual services than with pharmacies operating traditional pharmacy services.ConclusionVirtual pharmaceutical care is a potential approach to reduce the abuse/misuse of OTC medicines but needs some improvements regarding detection of these cases. The UAE is the first country in the region to implement and regulate virtual pharmacy practice.     

Diversion and Injection of Methadone and Buprenorphine Among Clients in Public Opioid Treatment Clinics in New South Wales,Australia

A survey of 448 clients receiving opioid treatment in public clinics in Australia was conducted during 2005, exploring diversion and injection of supervised methadone and buprenorphine, frequency and reported effects of injecting, and the cost and availability of street-purchased pharmacotherapies. The rates of diversion in the preceding 12 months were over three times higher among participants receiving supervised buprenorphine (15.3%%) than among those receiving supervised methadone (4.3%%). While 26.5%% of participants currently prescribed buprenorphine had ever injected buprenorphine, 65.9%% of those prescribed methadone reported ever injecting methadone. The majority of participants did not appear to have extensive experience of injecting their medication and most expressed a preference for taking it as directed. Further research is required to determine the optimal approach for the supervised administration of buprenorphine that maximizes the benefits of treatment and minimizes harm and the risk of diversion. The study's limitations are noted.     

Book review of the psychodynamics of addiction by Martin Weegmann & Robert Cohen London: whurr publishers 2002, 180 pp. £19.50, ISBN 1 86156 335 3

Aims: To ascertain the level of knowledge about some of the effects of methadone and buprenorphine among 956 clients receiving treatment for opioid dependence at 9 public clinics and 50 community pharmacies in New South Wales, Australia.

Methods: A cross-sectional survey using both research-administered and self-complete questionnaires assessed medication-specific knowledge (derived from a literature review and information contained within client treatment information booklets), answered only by those receiving that treatment type. Assessment of knowledge was performed by asking participants to agree or disagree with four statements about their medication.

Findings: The majority of methadone clients were aware of the risks of overdose when methadone is taken by non-tolerant people and when methadone is mixed with other CNS depressants. Methadone clients were less aware of the protective effects of methadone in overdose and most believed that it rotted their teeth. Almost 50% of those on buprenorphine were not aware of the effects of dose increase on duration of action nor its relatively good safety profile compared to methadone. Buprenorphine clients were well informed about the importance of sublingual absorption and the risks of precipitated withdrawal.

Conclusions: This study identifies significant gaps in the knowledge that opioid-dependent clients have about methadone and buprenorphine that may lead to suboptimal use of medications and ambivalence over treatment. In addition to the provision of written material service providers need to consider systems to ensure that clinical information concerning treatment is received and understood by clients.     

Is point of access to needles and syringes related to needle sharing? Comparing data collected from pharmacies and needle and syringe programs in south‐east Sydney

Introduction and Aims. The comprehensive needle and syringe distribution system in New South Wales is partly based on the premise that different points of access to injecting equipment may attract different groups of injecting drug users. This paper examines patterns of equipment acquisition and risk for blood‐borne virus transmission among injecting drug users who use pharmacies and needle and syringe programs (NSP) in south‐east Sydney. Design and Methods. Clients obtaining injecting equipment from four NSP (n = 147) and eight pharmacies (n = 227) in 2006 voluntarily completed a self‐administered questionnaire. Respondents were grouped into three categories based on their needle and syringe acquisition patterns: exclusive use of NSP, exclusive use of pharmacies and use of both. Results. Although it was common for respondents to report using both pharmacies and NSP to obtain needles and syringes (57%), a proportion reported exclusive use of pharmacies (17%) and NSP (14%). Exclusive pharmacy users were more likely to have never received treatment for their drug use and the least likely to have had a recent test for hepatitis C. Compared with respondents who exclusively used NSP, respondents who exclusively used pharmacies were more likely to report receptive sharing of injecting equipment (adjusted odds ratio 5.9, 95% confidence interval 2.02–17.14), as were respondents who reported using both sources (adjusted odds ratio 5.8, 95% confidence interval 2.35–14.40). Discussion and Conclusions. The high prevalence of receptive equipment sharing among pharmacy clients indicates a need to improve access to needles and syringes and ancillary equipment, possibly by including ancillary equipment at no cost in existing pre‐packaged pharmacy products.[Bryant J, Topp L, Hopwood M, Iversen J, Treloar C, Maher L. Is point of access to needles and syringes related to needle sharing? Comparing data collected from pharmacies and needle and syringe programs in south‐east Sydney. Drug Alcohol Rev 2010]     

Supervised Methadone Consumption: Client Issues and Stigma

Supervised methadone consumption is an important part of methadone maintenance treatment (MMT) but may contribute to stigma for clients. Data from qualitative interviews with MMT clients (n = 64) conducted in 2002–2003 in Canada were analyzed using thematic analytic methods. Three themes dominated clients' accounts of supervised consumption (convenient access to services, relationships with pharmacists and dispensing staff, and attributes of the dispensing space) and were interwoven with experiences of stigmatization. While some dispensing contexts may help clients manage a stigmatized identity, others confer or make visible this identity. Reducing stigmatizing experiences within dispensing environments may improve MMT outcomes and decrease barriers to treatment. The study's limitations are noted.     

Practice and attitudes regarding the management of childhood diarrhoea among pharmacies in Thailand

Objectives To compare practice behaviour and attitudes of pharmacy personnel in the management of childhood diarrhoea between type I (requiring a pharmacist to be on duty) and type II (pharmacist not required) pharmacies, between those surveyed in 2008 and in 2001, and between new‐generation (graduation ≤10 years) and old‐generation (graduation >10 years) pharmacists. Methods The setting was 115 pharmacies in a city in the south of Thailand. The study was separated into two phases: a simulated client method to evaluate history taking, drug dispensing and advice giving among pharmacy personnel and a questionnaire to measure attitudes and factors affecting diarrhoea treatment. Key findings In the simulated client method study, questions asked and advice given by the providers (the pharmacists or non‐pharmacists responding to the simulated clients), especially in type II pharmacies, were insufficient. Only 5.2% of pharmacies correctly dispensed for a child with viral diarrhoea, using oral rehydration salts (ORS) alone. Appropriate ORS dispensing of providers was not affected by shop type, survey time or peer generation. However, 52.2% of providers inappropriately dispensed antibiotics for such illness. In the questionnaire study, 108 completed surveys were obtained (a response rate of 93.9%). The providers working in 2008 more strongly agreed that ORS was effective, safe, used by health professionals and requested by patients, relative to those in 2001 (P < 0.05). No potential factor influencing the actual ORS dispensing was identified. Nevertheless, antibiotic dispensing was affected by beliefs in producing recovery and high profit. Conclusions Practice and attitudes of pharmacy personnel were inappropriate in the management of childhood diarrhoea. Revision of the pharmacy curriculum did not result in improvement of practice as seen by the similarity of practice patterns among the 2001 and 2008 samples. Improvement of knowledge and practice behaviour among providers in pharmacies is needed.     

A case-linkage study of comorbidity in mental health and substance misuse care populations

This study examines the total comorbid care ‘care population’ for one geographical area. It identifies the extent of (often unrecognized) shared care between coterminous ‘care populations’ in the context of the extent of assessed need and so identifies the gap between need and service provision. The study combined anonymized data for the total secondary mental health care population and all six substance misuse agency populations within one health authority population (N?=?646,239) over three years, to identify shared ‘dual agency’ comorbid client groups (all mental health agency clients receiving specialist substance misuse treatment and vice versa). Of the total population of drug agency clients (N?=?1206), 28% had received mental health services, and of alcohol agency clients (N?=?1476), 39% had received mental health services. For a total mental health population (N?=?19,029), 2% had received specialist drug services, and 3% alcohol services. These figures are compared to previous estimates of assessed need in treatment populations to identify gaps in service provision. Two thirds of ‘dual agency comorbid’ clients were male, 40% had attended Accident and Emergency (A&E) and half had been mental health in-patients. Mental health/drug agency populations were younger and mental health/alcohol agency populations received more mental health services.     

Patient drug information and consumer choice of pharmacy

Objective — The purpose of this study was to investigate whether there is an association between the level of drug information provided in community pharmacies and business performance as measured by consumer satisfaction and consumer loyalty. Method — After an initial qualitative phase and a pilot survey, a questionnaire was administered to 253 consumers in 10 high and low information provision pharmacies. Setting — The study took place in community pharmacies in the Sydney metropolitan and Newcastle areas of New South Wales, Australia. Key findings — There was no significant difference in the summed consumer scores of behavioural intention or consumer satisfaction between the two pharmacy types. However, this study showed that up to 41 per cent of consumers (n=182) currently patronising low provider pharmacies indicated a preference for a high information provider pharmacy given equivalent convenience and no preformed loyalties to a particular pharmacist. This represents a potential net shift of 24 per cent of consumers from low information provider pharmacies to high provider pharmacies. Conclusion — This study provides initial evidence to show that the level of provision of drug information has the potential to increase consumer patronage and loyalty to a community pharmacy. The full implications of this should become more apparent as the number and convenience of high provider pharmacies increases and more low provider consumers are exposed to this type of pharmacy.