Research paperCommunity pharmacy services for people with drug problems over two decades in Scotland: Implications for future development
Introduction
Community pharmacy services for people with drug problems (PWDP) have undergone rapid development over the last 20 years. Pharmacy services include dispensing opiate replacement treatment (ORT) (e.g. methadone or buprenorphine), supervising consumption of ORT, needle exchange services and providing general advice on both substance misuse and general health. Each pharmacy holds detailed data on the number of patients receiving ORT, and individual prescription details including whether medication should be consumed on the premises under pharmacist supervision (to avoid leakage into the illicit market and prevent accidental overdose). Similarly, numbers of clients using a needle exchange and the drugs reportedly being used are recorded. Analysis of this data can determine whether a policy development, such as a drive to provide more needle exchange services, has been effective. These records may represent an underused source of information for service providers, on the impact of treatment policies and ongoing demand for services.
The development of pharmacy services in the UK has been charted through national surveys of community pharmacies in Scotland (Matheson et al., 1999, Matheson et al., 2002, Matheson et al., 2007) and England (Sheridan et al., 1996, Sheridan et al., 2007) In 2006, there were 1166 community pharmacies in Scotland. Of these, 82.6% dispensed drugs for PWDP and 79.1% dispensed methadone specifically. The number of reported methadone patients rose from 3387 in 1995 to 12,400 in 2006. Fifty-seven per cent of these patients consumed their methadone under pharmacist supervision in 2006 (Matheson et al., 2007). This earlier work in Scotland coincided by chance with similar work in England (Sheridan et al., 1996, Sheridan et al., 2007). A review of the international literature on community pharmacy services found these UK studies have since been replicated and built on in Australia (Lawrinson et al., 2008, Nielsen et al., 2007), Finland (Uosukainen, Turunen, Ilomaki, & Bell, 2014) and New Zealand (McCormick, Bryant, Sheridan, & Gonzalez, 2006) as well as in regional parts of the UK (Britten & Scott, 2006).
In Scotland pharmacies are paid for each prescription dispensed and receive an additional payment for supervising the consumption of medication by patients. Pharmacies are paid a small retainer and a per transaction fee to provide needle exchange services. Payment for both these services is via their local NHS board. Since the last national Scottish survey in 2006, there have been policy changes that may have influenced the level and nature of pharmacy services. These include a new national Drug Strategy which emphasises ‘recovery’ (defined as moving on from problem drug use towards a drug-free life and becoming an ‘active and contributing member of society’ (Scottish Government, 2008a)), increased inter-agency working and a Hepatitis C Action Plan that promotes wide provision of clean injecting equipment (Scottish Government, 2008/2); a programme to widen access to “take-home naloxone” to reduce drug related deaths (Naloxone.org.uk, accessed July 30th 2015) and the development of pharmacist prescribing. Similar developments are happening beyond Scotland so have international relevance.
For some time pharmacist supplementary prescribers in the UK have been able to prescribe Controlled Drugs if included in the agreed patient specific Clinical Management Plan (NES, 2009). More recently changes in the UK Misuse of Drugs regulations have allowed pharmacist independent prescribers in the UK to prescribe Controlled Drugs (e.g. opiates/opioids). The contribution of this prescribing role to the management of drug misusers has not been previously reported.
Scotland is a devolved country within the UK. The Scottish government has complete autonomy over Health and Criminal Justice Policy. The population is 5.29 million and 70% live in the more densely populated central belt including Glasgow and Edinburgh. Scotland has a long standing drug problem. The prevalence of problem drug use (opiates and benzodiazepines) is 1.7% for 15–64 year olds (ISD, 2014) and there were 526 drug related deaths in 2013 (Barnsdale, Gordon, & McAuley, 2015). The research advantage of a small country such as Scotland is that it is manageable to study changes over time at a population level and thus explore the impact of policy without the methodological caveats of sampling. For example there is a strategy to reduce the number of drug related deaths through the Scottish Naloxone programme. This programme aims to train and distribute naloxone to those at risk of a drug related death. Using the community pharmacy network is one means of distributing take-home naloxone (THN).
This study aimed to collect current data and undertake a comparative analysis with previous surveys from 1995, 2000 and 2006 that would allow consideration, at a population level, of how the attitudes of the pharmacy workforce and the level of service provision for PWDP have changed over time. Furthermore the study aimed to determine involvement in the new initiatives of pharmacist prescribing and take home naloxone.
Section snippets
Methods
A cross-sectional postal survey was conducted in 2014 for the comparison of four population cohorts of Scottish community pharmacists in 1995, 2000, 2006 and 2014.
To maximise validity of comparison, the 2014 study utilised the questionnaire used in the previous three surveys with minor amendments to reflect developments in drug treatment since 2006. Amendments were: (i) pharmacists’ involvement in the national naloxone programme; (ii) pharmacist prescribing activity and (iii) recent integrated
Results
In 2014, there were 709 respondents to the postal questionnaire (57%, n = 1246) and a further 164 (18.8%) by telephone giving a response of 873 to key variables on service provision (70%). Respondents’ median age was 40 years (interquartile range 22–68 years) with 37.1% male (n = 263) and 62.6% female (n = 444). Pharmacy location and type of business are displayed in Table 1. Three-quarters (74.8%, n = 530 sd 21.2, 35 missing) had had previous training on drug misuse and 47.2% (n = 335 sd 16.6, 21
Discussion
This repeated population survey has provided unique 20-year trend data on the contribution of the pharmacy workforce to the provision of services to people with drug problems. In general, attitudes have improved with time and more services have been provided. The data also allows reflection on how practice has changed and what this might indicate for future community based services in countries that have a well-regulated community pharmacy network.
Conclusion
The Scottish pharmacy workforce has positively embraced service provision for people with drug problems over the last twenty years such that it is now a core function of community pharmacy practice. Training has been key to these positive changes. The community pharmacy workforce is becoming involved in new initiatives such as the naloxone programme and pharmacist prescribing. There is considerable scope to develop these services further as well as looking at how pharmacy should support
Acknowledgements
This work was funded by a research grant from Chief Scientist Office of the Scottish Government (CZH/4/998). The authors would like to thank them for their support. Thank you to the pharmacists who took the time to complete this questionnaire and to Aileen Bryson, RPS Scotland and all the Specialist Pharmacists in Substance Misuse who encouraged local pharmacists to participate.
Conflict of interest statement: None.
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