Community pharmacists have a vital role in helping substance misusers recover through guided methadone consumption, writes Kathy Oxtoby

Lorraine Maden, lead clinical pharmacist for the mental health, drug and alcohol charity Addaction, is passionate about the role of community pharmacy in substance misuse.  ‘Pharmacists have so much to offer and are the healthcare professionals who have most contact and potential impact with substance misuse service clients,’ she says.

But she believes that in general, more could be done to help pharmacists better understand substance misuse services. ‘The more we can do to educate, the greater the benefit to all involved,’ she says.

Her work involves supporting substance misuse services, including supervised consumption services, from setting them up to dealing with ongoing day-to-day clinical queries. Supervised consumption services are commissioned by public health departments, local councils or via agencies such as Addaction.


Assessing the situation


Ms Maden explains that when a client is referred to this service, they should initially have a detailed assessment with an assigned recovery worker who will then give them ongoing support with the psychosocial element of their recovery and may need to assist with longer term support, such as addressing housing needs or employment training. Clients then see a prescriber to discuss initiation on prescribed treatment if this is indicated.

She says one of the aims of this service is to provide an ‘extra layer of safety for new clients’, who are starting prescriptions to replace heroin and other opioids, using substances such as methadone or buprenorphine.

Initial transfer to oral substitution therapy (OST), for example, ‘has the potential risk of respiratory depression, which can be fatal if titration isn’t undertaken safely’, she says.

Pharmacists should be trained to monitor for signs of concern and toxicity, she advises. ‘If any dose is missed during the titration period or the person is intoxicated, a prescriber must be consulted.’


Looking out for the ‘danger zone’


After initial stabilisation, tolerance can rapidly be lost and ‘we can enter the danger zone again after three missed doses,’ she says. So even if a client has been stable and collecting for some time, if they miss over
a bank holiday Monday, then restart on the Tuesday on the usual dose this ‘could lead to overdose’, she says.

Another service aim is to minimise misuse by both increasing adherence and reducing the likelihood of supplies leaking into the illicit market, Ms Maden explains.

Clients may be re-referred for supervised consumption if, say, collections are erratic, there is concern that the prescribed drug is being diverted or used inappropriately, there are safeguarding concerns or the client shows a continued and unstable pattern of misuse.


Knowing your role in supervised consumption


Anna Ruthven, national healthcare development manager for commissioned services at LloydsPharmacy’s parent company Celesio, says most service specifications require pharmacists to supervise the consumption, but some may allow other trained members of the pharmacy team to deliver the service. ‘In this case, the pharmacist would maintain overall responsibility,’ she says.

Richard Daniszewski, deputy superintendent pharmacist at Wicker Pharmacy in Sheffield, says that a successful supervised consumption service will involve the whole pharmacy team. ‘There is no reason why trained and competent members of staff cannot administer and run the service as long as the pharmacist clinically checks the prescriptions and supervises the overall process and service,’ he says.

Supervised consumption is ‘a prime example of how a service can involve all the skills of the pharmacy team’, he adds.


Treating patients with respect


Mr Daniszewski believes the service is valuable because it can ‘help prevent misdirection of controlled drugs, and this in turn can reduce drug-related deaths in the community’. And from a business point of view, ‘it is also another potential income stream that cannot be overlooked in these challenging times that community pharmacy faces,’ he says.

Supervised consumption users, as with all patients, should be entitled to a high standard of care and respect, which includes ensuring the service takes place as discreetly as possible. Mark Joynson, pharmacy manager at The Hub Pharmacy’s Manchester Road branch in Warrington, Cheshire, says the service ‘should take place in a confidential and safe environment forboth patient and provider’.

He explains that one of the consultation rooms is dedicated to the supervised consumption service. The room is fully closed off from the rest of the pharmacy, and features a hatch connecting to the dispensary, ‘which enables us to provide supervised administration that is out of view of the rest of the pharmacy’, he says.

During consultations, pharmacists should treat patients with ‘dignity and respect’, says Ms Maden. ‘All these clients are someone’s relative and no one chooses to end up in this situation. Many individuals have had really chaotic lives and potentially poor historic engagement with any professionals.

‘A high proportion have had adverse childhood experiences. Treating them with dignity and respect can make a huge difference to them, their day and their overall recovery journey.

‘I know of clients who have walked miles to keep to the pharmacy where they aren’t talked down to.’

Mr Joynson says all his patients are treated the same ‘whether they use our service for drug dependency or to collect any other prescription’.

‘Our patients are often going through battles we know nothing about – we keep this at the forefront of the way we help and support our community. The relationships we have built with all of our patients show our dedication to their treatment,’ he says.


The right training


Most supervised consumption services require pharmacists to complete the Centre for Pharmacy Postgraduate Education (CPPE) substance use and misuse training or to complete the declaration of competence for substance misuse training via the CPPE website, says Ms Ruthven.

Some commissioners may also require attendance at awareness or engagement events at the start or during the contracted period.

As well as delivering a supervised consumption service, service users can benefit from in-house pharmacy services such as needle exchange, repeat prescription ordering and collection, monitoring and offering advice on the service user’s general health and well-being, and signposting them where necessary to different care providers, advises Mr Daniszewski.


Be prepared for the unpredictable


Some clients may present with challenging behaviours. Mr Daniszewski says it is important to remember that many supervised consumption users have a mental health condition, ‘which is easily forgotten when dealing with someone who, at times can be very impatient, irritable, short tempered and volatile’.

‘If the pharmacy team remains cool, calm and supportive with an understanding attitude when serving supervised consumption users, this can help to prevent incidents or confrontation,’ he says.

To help deal with these situations, Ms Ruthven emphasises the importance of ‘three or four-way agreements’ such as arranging set times for pick-up, setting expectations early, and how clients may be demanding or erratic on occasion.

‘The whole team are involved in managing the patient so they are also aware of what to recognise as well as the pharmacist, can manage expectations and behaviours, so it doesn’t have an impact on other customers.’

In Mr Joynson’s experience, ‘this group of patients has posed no more of a challenge than any other in any pharmacy I have worked in. I put this down to making sure we approach and treat every patient the same; every patient must leave feeling cared for and respected,’ he says.


Benefits of a supervised consumption service


Summing up the value of delivering a supervised consumption service, he has also found that it has allowed him ‘to have some of the best and most meaningful consultations with patients over the years’.

‘I have had the pleasure of supporting two patients in beating their addiction. Through treatment provided by local drug teams and the support offered by pharmacies, this service is so rewarding for our team, who genuinely care for their community.’

And that value of this service can be shared, Ms Maden believes, by encouraging ‘all pharmacists to contact their local service and see if they can spend some time there, to understand what goes on’.

Kathy Oxtoby is a freelance journalist