The evolving role that pharmacists play in the field of substance misuse, particularly over the past decade, has seen the development and expansion of services to help people using drugs and alcohol on their recovery journey. The large number of locations and extended opening hours make community pharmacy one of the most accessible healthcare services available, second only to A&E. The pharmacist can be consulted confidentially and without an appointment or having to register.
This high level of flexibility means that pharmacists often see people who do not currently access other substance misuse services, as well as supporting those who are already on their road to recovery. For those whose progress has faltered, the pharmacist may be the first health professional to witness a set-back – for example, if an individual starts using services such as needle exchange. Because the pharmacist is often a trusted, visible and accessible professional within their community, they are generally well placed to respond.
Substance misusers typically lead chaotic lifestyles and have multiple problems, requiring help from a range of health, social care and other providers. Uniquely, community pharmacy is at the interface of health and social care and can signpost people towards a range of treatment and other support according to where they are on their recovery journey, and some pharmacists can (and do) refer people directly into services. Once in treatment, particularly if opioid substitution treatment (OST) is prescribed, pharmacists are able to improve the effectiveness of the prescribing, including providing supervised consumption of medication.
Of the 204,473 adults receiving drug treatment in England, four-fifths are heroin users and NICE recommends substitute prescribing as the most effective treatment for them, alongside talking therapies to change behaviour. Not all pharmacies supply methadone, but in those that do the pharmacist sees addicts more regularly than any other health professional.
A wide range of services
It is not, of course, just about illicit drugs. A significant number of pharmacists provide a screening and brief intervention service for those people who use alcohol in a harmful or hazardous manner. Some provide a specialist service for those using steroids or other performance and image enhancing drugs, and some are able to offer advice to those who feel they may have an addiction to prescribed or over-the-counter medicines. A number of pharmacies also host regular sessions with local drug workers within their consultation rooms.
An increasing number of pharmacies now offer blood-borne virus (BBV) screening and vaccination services, and this is proving particularly useful for those who are currently not accessing mainstream treatment services. For some injecting drug users, the road to recovery begins with the decision to start using clean needles and syringes. Investment in widespread needle and syringe provision, including through pharmacies, has contributed to England having one of the lowest rates of BBVs among injectors in the Western World – despite having one of the largest populations of people who use opiates and crack.
More people than ever before report receiving a test for HIV and being vaccinated against hepatitis B. National prevalence of hepatitis C among injectors has remained static since 2009. The highest ever proportion of people report being tested for hepatitis C, and the highest ever proportion of people are aware of their hepatitis C infection.
As well as more pharmacy-based services being developed, pharmacists themselves are finding that their role in the field of substance misuse is evolving. A significant number of pharmacists now prescribe within this field of medicine. Consultant Pharmacist in Substance Misuse for Birmingham Drug and Alcohol Action Team, Kevin Ratcliffe, describes his role: “I currently prescribe at a primary care clinic and also within the prison service. However, I am also responsible for the commissioning and service development of pharmacy-based substance misuse services in over half of the 270 pharmacies across the city. This varied role has enabled me to work with other primary care professionals and service users to design and deliver care, and to work with local specialist treatment providers to provide integrated care.”
Sharpening the recovery focus
The Government Drug Strategy makes clear that the provision of OST for the treatment of heroin addicts is a key component of their treatment, but, “too often what should be the first step on the road to recovery risks ending there. This must change”. To address this, the NTA established an expert group of clinicians, academics, service providers and service users to re-examine the evidence about the potential contribution of prescribing practice to recovery.
The group’s interim report, published in July 2011, acknowledges that some of the practice of OST by treatment services in the recent past has not fully reflected clinical guidance. They anticipate that by following the guidance and best clinical practice more closely in future, more individuals will move on from their treatment more quickly. In particular, they emphasise the range of support that individuals need alongside OST, including individual recovery care planning, psychosocial interventions, and integration with peer support networks and mutual aid groups like Narcotics Anonymous.
The group says: “We need to hold on to what is good, and use it as a platform from which to achieve more. We have listened and heard evidence from drug users and colleagues around the country that, too often, people with addiction problems could be better supported in their recovery, and that there could be greater ambition for and focus on their potential to make further progress.” The final report from the expert group will be published this year.
From April 2013 local authorities will have responsibility for drug and alcohol treatment, through Directors of Public Health working alongside health and well-being boards. Decisions about commissioning public health services will be made locally, with a new national agency – Public Health England (PHE) – coordinating and supporting from the centre. The NTA’s functions will transfer to PHE, whose role will be to protect and improve the health and wellbeing of the population, and reduce inequalities in outcomes.
The Government recently published the new Public Health Outcomes Framework, listing 65 national outcome indicators, to set the strategic direction for the new public health system. Successful completion of drug treatment is one of these indicators, marking it out as a key measure of improvement in population health within the new structure. Community pharmacists have an important role and unique opportunity to support individuals into and through their recovery journey, and crucially to ensure that individuals have the best possible chance of making a safe and sustained recovery.
Further information For detailed information about drugs, including their effects, the NTA has published ‘A Summary of the Health Harm of Drugs’ available at www.nta.nhs.uk/publications.
Steve Taylor is Programme Manager (Skills and Development Team) at the National Treatment Agency for Substance Misuse