Community pharmacists are increasingly supervising treatments

Motivations for and barriers to community pharmacy services for drug misusers

Objective

To investigate what motivated pharmacists to provide drug misuse services and, conversely, what barriers prevented service provision.

Method

Telephone interviews were conducted with a purposive sample of 45 volunteering respondents to a national questionnaire survey to gain in-depth information.

Setting

Forty-five community pharmacists in Scotland.

Key findings

Pharmacists were found to be motivated to provide services by an awareness of the needs of the community, a desire to reduce the spread of blood-borne diseases and a desire to expand their professional services. Barriers to service provision were concerns for the effect on other customers, safety, workload and poor remuneration.

Conclusion

The active encouragement of local health boards, professional endorsement, further education and remuneration might encourage pharmacists' participation in drug misuse services. This would enable the principles of harm reduction to be widely practised.

The role of methadone in drug-related deaths in the west of Scotland

AIMS

To determine the incidence of methadone as either the principal cause of death or as a contributing factor in drug related deaths in the Strathclyde Police region of Scotland and to assess the impact of supervised consumption of methadone on the number of deaths that occurred within each health board area within this region.

DESIGN

Retrospective analysis of records held within the Department of Forensic Medicine and Science based at the University of Glasgow over the 11-year period 1991-2001.

SETTING

The Strathclyde Police region of Scotland (population approximately 2.25 million).

FINDINGS

In 1991, there was one death recorded which was attributable to methadone. Following the introduction of the methadone maintenance programme (MMP) in Glasgow during 1994, there was a 100% increase in these deaths compared to the previous year, a trend which continued over the subsequent 2 years. Following a confidential enquiry into these deaths and a greater compliance from pharmacies supervising methadone consumption, deaths involving methadone had decreased by 48% in 1997. This was particularly evident in the Greater Glasgow Health Board Area, where methadone prescribing has continued to rise annually. However, some difficulties still exist. Multiple take home doses are sometimes prescribed when a pharmacy is closed, which may lead to inadvertent overdose or facilitate diversion of legitimate supplies. In addition, continued use of heroin was found in approximately one-fifth of MMP patients, suggesting possible underdosing.

CONCLUSIONS

A growing prevalence of heroin misuse has resulted in an increase in the number of individuals entering the MMP. Despite a continuing increase in the amount of methadone prescribed, methadone deaths in Strathclyde have decreased since 1996 due possibly to changes in both prescribing and clinical care. With efficient management to establish that the patient is complying with the guidelines of the programme and has stopped heroin misuse, methadone can be a safe drug for substitution therapy.

Practice-based buprenorphine maintenance treatment (BMT): how do French healthcare providers manage the opiate-addicted patients?

France was the first country to promote the extensive use of buprenorphine for the treatment of drug-addicted subjects through the primary care system. To assess both professional commitment and patients' characteristics, all the physicians and pharmacists of a French area having prescribed/dispensed buprenorphine from 2/12/96 (the official release date) to 1/31/98 were identified from data files of the Health Insurance and then interviewed. During the first 61 weeks of buprenorphine maintenance treatment (BMT), 27.5% of physicians and 51.2% of pharmacists of that area were involved; 142 patient records were documented. Features of the clinical routines spontaneously implemented for practice-based BMT were: a high level of on-site supervised dispensation by the pharmacist (71% at treatment induction and 23% thereafter); the absence of objective measurement of illicit drug use; and a low buprenorphine dosage. These features are consistent with the lack of physicians' experience and training, and also the relatively good status of the population treated (no HIV-positives, heroin use duration averaging 4.2 +/- 3.1 years, and 81.7% with stable accommodations). Despite liberal regulations guiding BMT, a negligible proportion of cases had a "nomadic" attitude (multiple buprenorphine prescribers/deliverers). The treatment outcomes (no deaths, three drug overdoses, improvement in occupational status) are encouraging.

CONCLUSION

Practice-based BMT appears to be a safe and acceptable response to moderate heroin addiction, but further training of the professionals involved and longitudinal investigations of individual outcomes are needed.