Commentary: Decline in methadone-related deaths probably relates to increased supervision of methadone in UK

The global diversion of pharmaceutical drugs: opiate treatment and the diversion of pharmaceutical opiates: a clinician's perspective

AIM

To provide a clinician's perspective on the problem of diversion of prescribed pharmaceuticals.

METHODS

The paper provides a personal account of working in a treatment context where diversion from opioid substitution treatment (OST) became a political issue potentially compromising the continued delivery of OST. It summarizes evidence on the impact of diversion, and measures to contain it, from the United Kingdom 1986-2006, Australia 1996-2008 and the United States and France from the mid-1990s.

RESULTS

Opioid diversion to the black market occurs in proportion to the amount of opioids prescribed to be taken without supervision, and in inverse proportion to the availability of heroin. Diversion for OST programmes using supervision of dosing is less than diversion of opioids prescribed for pain, which is now a growing public health problem. Adverse consequences of diversion include opioid overdose fatalities, an increased incidence of addiction (particularly in jurisdictions where heroin is scarce) and compromising the public acceptance of long-term opioid prescribing. All long-term opioid prescribing requires monitoring of risk and appropriate dispensing arrangements--including dilution of methadone take-aways, supervision of administration for high-risk patients and random urine testing. Clinical guidelines influence practice, although prescribing often deviates from guidelines.

CONCLUSION

Clinical guidelines and clinical audit to enhance compliance with guidelines are helpful in maintaining the quality and integrity of the treatment system, and can contribute to keeping diversion within acceptable levels.

Community pharmacies and the provision of opioid substitution services for drug misusers: changes in activity and attitudes of community pharmacists across England 1995-2005

AIMS

In England, the role of community pharmacy in service provision to drug misusers was studied in 1995. Extensive involvement was identified, and considerable underused capacity was noted. This study explores these and potential new roles 10 years on.

DESIGN

Cross-sectional national study. Postal survey (three mailshots), plus a fourth telephone follow-up using a structured questionnaire based on the 1995 questionnaire.

SETTING

Community pharmacies in England.

MEASUREMENTS

Involvement in opioid substitution therapy services (e.g. methadone, buprenorphine) and related activities. Attitudes towards service provision and novel services.

FINDINGS

A 95% response rate was obtained. This was higher than in 1995, due largely to the use of a telephone follow-up. There had been an increase in the proportion providing substitution therapy dispensing services from 51% to 63% and in the average current case-load (from 5.9 to 9.2); and consequently a large increase in the numbers being treated (approximately x 1.9). Similarly, supervised consumption of methadone and buprenorphine was being provided more widely (increasing from 0 to 59% of all responding pharmacists). Attitudes towards existing roles were more positive than in 1995, and providers tended to be more positive than non-providers. For newer roles (e.g. supervise medications for comorbidity; provide hepatitis B vaccination), there was support from around one-quarter of respondents.

CONCLUSION

Community pharmacy continues to play an important role in delivering treatment, including prescribing services, to drug misusers. There still appears to be untapped capacity, and moderate support for newer roles.