Community pharmacy harm reduction services for

Journal of Public Health | Vol. 29, No. 4, pp. 350 – 357 | doi:10.1093/pubmed/fdm064 | Advance Access Publication 6 November 2007

Community pharmacy harm reduction services for drug misusers: national service delivery and professional attitude development over a decade in Scotland Catriona Matheson, Christine M. Bond, Michela Tinelli Department of General Practice and Primary Care, Foresterhill Health Centre, University of Aberdeen, Westburn Road, Aberdeen AB25 2AY, UK Address correspondence to Catriona Matheson, E-mail: [email protected]

A B S T R AC T

charted over a decade. Methods A cross-sectional postal questionnaire of all Scottish pharmacies (n ¼ 1166) was undertaken. Descriptive data were collected on services provided, attitudes, training and demography. Data were compared with data from 1995 and 2000. Results Needle exchange provision increased slightly to 12.5% from 9.7% (2000) and 8.6% (1995). The mean number of needle exchange clients increased significantly to 37.7 from 20.3 (2000) and 12.5 (1995). Methadone was dispensed by 79.1% of respondents, and 90.9% of those supervised self-administration. The total number of methadone patients increased to 12 400 from 8809 in 2000 and 3387 in 1995. Of those taking methadone, 57% have supervised self-administration. A quarter dispensed buprenorphine to 190 patients. Attitudes improved significantly but training levels have not changed since 2000. Conclusion More commitment to harm reduction was evident through improved attitudes and increased services. Service delivery has increased more for dispensing services than for needle exchange. Strategies for delivering future needle exchange and substitute dispensing services are required if demand approaches capacity. Keywords community pharmacy, dispensing, drug misuse, needle exchange, treatment

Introduction Community pharmacists play an important role in the UK in the provision of harm reduction services and in the treatment of drug misusers. They distribute clean needles through exchange or sale and dispense substitute drugs ( primarily methadone) for maintenance and detoxification, often supervising the self-administration in the pharmacy to ensure it is taken by the intended person. Although pharmacists play a role internationally in delivering services to drug misusers, their involvement is not widely documented. Several European countries are reported to provide dispensing services through pharmacies but distributing clean needles through pharmacies is less common.1 Australian pharmacists provide needle exchange and dispense both methadone and buprenorphine.2 UK pharmacy services have been reported through national surveys in Scotland and England in 19953,4 and in Scotland in 2000.5

350

Although part of the UK, Scotland ( population 5 million) has a devolved government with responsibility for health, education and criminal justice, including drugs policy. Scotland has a long history of drug misuse, particularly heroin injecting; the estimated prevalence of problem drug misuse in 2000 was 2% in 15 –54-year olds,6 that is, an estimated 56 000 individuals. This paper reports a third Scottish survey providing 10-year follow-up, giving unique insight into how pharmacy services have expanded and how the pharmacy profession has accommodated the challenges of drug misuse.

Catriona Matheson, Senior Research Fellow Christine M. Bond, Professor Michela Tinelli, Research Assistant

# The Author 2007, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.

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Background Community pharmacy contributes to drug misuse management and reduced spread of blood-borne disease through distributing clean needles and substitute drug dispensing. This paper reports a third Scotland-wide survey of pharmacies enabling service delivery to be

CO M M U N I T Y PH A RM AC Y H A R M R E D U CT I O N S ERV I C E S FO R DRU G M I S U S E RS

† pharmacists’ attitudes towards drug misusers and providing pharmacy-based services; † levels of service provision and whether these are related to attitudes; † prescribing patterns in drug misuse; † training levels and needs.

Methods The questionnaire used in 1995 and 2000 was used but updated to include buprenorphine dispensing, and a question on sharps disposal facilities (for used needles/syringes). The development of the original questionnaire is described in a previous publication.3 The questionnaire was posted to the pharmacy manager of all community pharmacies in Scotland (n ¼ 1166). The mailing included a covering letter with instructions for completion and return of the questionnaire, a reply paid envelope and an identifiable postcard. Responders were asked to return the postcard separately but concurrently allowing responses to remain anonymous but enabling

non-responders to be followed up. The questionnaire was mailed in January 2006 (5 years and 2 months after the previous survey) with reminders sent after 4 and 8 weeks. To boost response, the survey was noted in a news item in a national drugs newsletter and local Specialist Pharmacists in Substance Misuse were asked to encourage response. To allow comparison between responders and nonresponders, a sample of 50 non-responders was randomly selected and briefly interviewed by phone. They were asked why they did not complete the questionnaire and minimal information about their methadone dispensing. The structured questionnaire contained 63 questions. Part one assessed attitudes towards drug misusers and services provision, part two asked about service involvement with drug misusers, part three covered dispensing practice, part four training and part five demography. In part three, the section on dispensing practice, pharmacists who were currently dispensing for drug misusers were asked to give detailed information on the prescriptions currently held in their pharmacy, including supervision requirements and source of prescription, i.e. general practice or specialist clinic/hospital. Questionnaire data were entered by an administrator into SPSS. Data entry was checked by a researcher in a random sample of 30 questionnaires. All data were stored and managed confidentially in line with university research governance guidelines. Attitude questions were computed into an attitude score. Responses to statements were scored from 22 (strongly agree) to 2 (strongly disagree) and a total score calculated per respondent. Negative statements were reversed before this procedure. Higher scores indicate more positive attitudes towards drug misusers and service provision. Data were analysed using mainly descriptive statistics. The relevant key variables from 2006 were entered into an existing database of 1999 and 2000 data. Comparisons were done on the basis of three separate populations rather than a cohort. The means of normally distributed continuous variables were compared using t-tests. One-way analysis of variance was used to compare the means of two or more continuous variables and chi-squared was used for categorical variables. The Chair of a Multi Research Ethics Committee advised investigators that the study did not require ethical approval, as it was a national audit.

Results Demography and response

The questionnaire response rate was 68% (789/1166). There were 715 postcard replies indicating that 74 postcards were


Previous surveys of Scottish community pharmacies found the involvement of pharmacies in methadone dispensing and supervision increased dramatically between 1995 and 2000, yet the number of pharmacies providing needle exchange services had not changed.5 In recent years, there has been an increased awareness of the rising levels of hepatitis (B and C), thus increasing the recognition of the need for better distribution of clean injecting equipment. This has been reflected in improved payment for pharmacies providing these services, a change in the Lord Advocates guidance on the numbers of clean needles which can be distributed7 and guidance from the Royal Pharmaceutical Society of Great Britain on needle exchange services. Several other changes have taken place since the last national survey of pharmacies. Drug services are moving towards an Integrated Care Model in Scotland, buprenorphine has been introduced as a licensed treatment for maintenance and general medical practitioners in the UK have a new contract in which drug misuse services are an optional enhanced service. It is not known what effect these changes have had on services. Charting changes over time in a population gives professionals and policy-makers a powerful tool to explore the effects of major policy changes, e.g. changes in contracts, remuneration or major training initiatives. This gives direction to future initiatives aimed at managing the public health issues associated with drug misuse. The aim of this research was to explore and compare (with 1995 and 2000 data):

351

352

J O U RN A L O F P U B L I C H E A LTH

not returned or lost and some respondents who had already returned a questionnaire may have received an unnecessary reminder. The mean age of respondents was 38.35 years (range 22 –69 years, SD 11.39); 39.9% (n ¼ 315) of respondents were male and 59.7% (n ¼ 471) were female. Rural-based pharmacies accounted for 18.1% (n ¼ 143), urban, 50.6% (n ¼ 399) and city centre 27.6% (n ¼ 213). Single outlet pharmacies accounted for 15.2% (n ¼ 120), small multiples (two to nine pharmacies) 23.4% (n ¼ 185), large multiple, 49.4% (n ¼ 390) and Health Centre pharmacies 1% (n ¼ 8) (10.9% missing values).

Table 2 Comparison of categorical variables in 1995, 2000 and 2006 Variable

Do you provide needle/

1995

2000

2006

% who

% who

% who

answer

answer

answer

yes

yes

yes

p value

8.62

9.75

12.48

0.010

4.63

5.68

8.47

0.003

58.94

73.33

82.59

,0.001

54.08

69.37

79.09

,0.001

73.38

84.05

85.65

,0.001

37.05

82.80

90.92

,0.001

49.43

59.63

83.56

,0.001

43.30

63.01

72.50

,0.001

31.77

66.84

68.97

,0.00

74.44

70.51

71.10

0.145

28.54

35.17

26.44

0.303

77.37

79.41

77.25

0.950

syringe exchange? Are you considering offering a needle/syringe exchange? Do you dispense drugs prescribed for drug misusers? Do you dispense methadone

Needle exchange services

to anyone prescribed it for drug misuse? Do any of your regular clients receive other drugs on prescription? For those receiving a daily dose do you supervise the consumption? Would you be prepared to supervise? Have you ever stopped dispensing to a drug misuser for any reason? Have you ever had professional training on drug misuse? Would you like further training on drug misuse? Have you ever had training

Table 1 Provision of needle/syringe exchanges by NHS area (n ¼ 769)

on the prevention of blood-borne diseases?

NHS area

Number

Number of

Yes, %

Yes, %

Yes, n (%)

Would you like further

sent

respondents

(1995)

(2000)

(2006)

training on prevention of

(2006)

(2006)

blood-borne diseases?

1

100

67

0

5.5

1 (1.5)

2

89

52

8.2

8.5

5 (9.6)

3

25

21

4.5

0

0 (0)

4

31

21

7.4

3.7

3 (14.3)

5

77

56

11.6

10.2

7 (12.5)

6

66

44

5.8

26.3

10 (22.7)

7

125

100

10.7

10.3

11 (11.0)

8

222

121

5.8

6.1

18 (17.9)

9

45

24

8.8

4.9

3 (12.5)

10

9

6

12.5

28.6

2 (33.3)

11

111

78

2.6

7.0

11 (14.1)

12

177

119

14.5

10.2

14 (11.7)

89

60

13.7

14.9

11 (18.3)

1166

769

8.6

9.5

96 (12.5)

13 Total

Selling injecting equipment

Willingness to sell injecting equipment has reduced significantly over time. Only 32.7% (n ¼ 254) are willing to sell injecting equipment compared with 41.3% (n ¼ 400) in 2000 and 55% (n ¼ 484) in 1995. Sharps disposal facilities were available in 43.1% (n ¼ 340) of pharmacies in 2006 (no previous data). Drug dispensing

Regarding dispensing services, 82.2% (n ¼ 626) of respondents were dispensing drugs ‘for the management of drug misuse’. Methadone was dispensed by 79.1% (n ¼ 618) of


About 12.5% (n ¼ 96) of pharmacies provided a needle exchange service with considerable variance by NHS board (the largest administrative division within the NHS in Scotland) and a small but significant increase since 1995 (P ¼ 0.01) (Tables 1 and 2). Lack of demand was the most frequently noted reason for not providing needle exchange (37%, n ¼ 282) followed by lack of time/staff/facilities (18.2%, n ¼ 139). The mean number of ‘regular’ needle exchange clients per pharmacy has increased significantly (P , 0.001) and steadily from 12.5 in 1995 to 20.3 in 2000 to 37.7 in 2006 (Table 3). The most frequently cited drugs ‘believed’ to be used by needle exchange service users were heroin (n ¼ 212), followed by cocaine (n ¼ 42) and steroids (n ¼ 32).


Table 3 Comparison of results of continuous variables in 1995, 2000 and 2006 Variable

Number of regular needle/

P-value

2000

2006

mean

mean

mean

response

response

response

12.50

20.31

37.75

,0.001

7.34

13.15

20.10

,0.001

7.00

9.44

19.18

,0.001

3.71

6.65

10.68

,0.001

1.17

1.77

8.79

,0.001

syringe exchange clients Number of drug misusers dispensed methadonea Number of methadone clients considered ‘regular’ Number of daily dispensing prescriptions on general practice formsa Number of daily dispensed forms from hospital/clinicsa Number of SSAM clientsa

6.93

8.68

13.12

,0.001

Age of pharmacist

39.93

39.05

38.35

0.021

Number of years registered as

16.94

16.02

15.46

0.026

4.19

5.20

7.46

,0.001

pharmacist Attitude score

Buprenorphine was dispensed by 21.4% (n ¼ 161) of respondents to 190 individuals (mean of 1.48 buprenorphine patients per dispensing pharmacy).Over half of these prescriptions come from hospital/clinic prescriptions (108 from hospital/clinic and 77 from general practice, five missing values). Of buprenorphine patients, 28.9% (n ¼ 55) received supervised self-administration. Attitudes

Attitude scores were normally distributed (Fig. 1) with a mean of 7.5 (range 36 –45, SD 12.53). The mean is significantly higher than that in 2000 and 1995 (P , 0.001). The comparison of score distribution over the three surveys is displayed in Fig. 1. There was no significant difference in score according to key demographic variables (Table 4). There was a significant correlation between attitude score and provision of key services as displayed in Table 4. Those providing needle exchange, methadone dispensing and SSAM had a significantly more positive attitude than those not providing these services. Training

t-test used. a

Pharmacists were asked to look at the prescriptions they had in their

pharmacy that week when completing this question. Thus, data present a cross-sectional ‘snapshot’ of prescribing and dispensing.

respondents. Of these, 90.9% provided supervised selfadministration of methadone (SSAM) for some patients, which equates to 72.3% of all respondents. These percentages are significantly higher than those in previous surveys (Table 2). Significantly more pharmacists are also prepared to provide SSAM compared with previous years (P , 0.001). The mean number of methadone patients per pharmacy has risen significantly to 20 from 13 in 2000 and 7.3 in 1995 (P , 0.001) (Table 3). Other drugs being dispensed included dihydrocodeine, 55.9% (n ¼ 349) of respondents, benzodiazepines, 49.2% (n ¼ 307) of respondents and diazepam, 18.8% (n ¼ 117) of respondents. Respondents were asked to give information on numbers and sources of prescriptions. From these data 12 400 individuals were being dispensed methadone and 57% of these had SSAM. In 1995, 3387 individuals were receiving methadone (of which 32.9% had SSAM), and in 2000, 8809 received methadone (of which 65.1% had SSAM). There was an increase in the total number of hospital prescriptions (4799 from 1943 in 2000 and 871 in 1995) but little change in total general practice prescriptions (GP10 forms) since 2000.

Training levels and perceived training need displayed little or no change (Table 2). Training was divided into questions on drug misuse and prevention of blood-borne viruses. Regarding drug misuse, there had been a significant change between 1995 and 2000 (P , 0.001) but no further change in 2006. Numbers receiving training in blood-borne disease remain low at just under one-third of respondents over the three surveys. Training needs have not changed over time with 70% wanting training on drug misuse and 77% wanting training on blood-borne diseases. Non-responders information

Of the 50 non-responders contacted by telephone, 49 answered key questions. The majority, 71.4% (n ¼ 35), dispensed methadone and provided a supervised consumption service (59.2%, n ¼ 29). These percentages are slightly smaller than those for responders. The 49 non-responders were dispensing methadone for 626 individuals, and of these, 79.4% (n ¼ 497) were receiving SSAM.

Discussion Main findings of the study

Data indicated a continued increase in methadone dispensing, SSAM and numbers of methadone patients over a 10-year period. There has been a small increase in the participation of pharmacies in needle exchange services and an


1995

353

354


increased use of existing needle exchange services. Attitudes overall have become more positive and are associated with service provision. Needle exchange services Participation in needle exchange has increased overall but more so in some NHS areas than others. It is still relatively low having only increased from 9.7 to 12.5% compared with England where 19% of pharmacies provide this service.4 Significantly more regular clients use pharmacy needle exchange services, despite a decrease in new individuals reporting injecting heroin use nationally in Scotland in 2004.8 A detailed study of needle exchange services in Glasgow found that pharmacy exchanges had a good uptake and return rate but suggested that a variety of needle exchange outlets were still needed to meet the needs of the diverse range of injecting drug users.9 Overall uptake of needle exchange services may have improved in the injecting drug population. It has been acknowledged for some time in parts of Scotland that it is very difficult to recruit pharmacies into

needle exchange services. Research examining this found a variety of barriers, including concern over safety, effect on other pharmacy customers and inappropriate facilities.10 A more recent study also identified the negative effect of security staff on supermarket and shopping centre based premises and that there were few official requests to provide the service.11 A review of pharmacists’ perceptions regarding a range of public health services found that pharmacists were more comfortable with services that centred around medicines.12 It may be that needle exchange is still too far outside pharmacists’ professional comfort zone of medicine-related services. The potential importance of active recruitment is highlighted in the comparative data for NHS areas over time. Considering two areas the investigators have detailed knowledge of: in the last 5 years, there has been no active recruitment in NHS area 7 (Table 1) and the proportion of needle exchange pharmacies there has hardly changed. In contrast, in area 8, there has been an active recruitment over recent years and the proportion of pharmacies there has increased considerably from 6% in 2000 to 18% in 2006 ( personal


Fig. 1 Distribution of attitude scores of respondents over time.


Table 4 Attitude scores for demographic and service provision variables Categories

Mean

P-value

attitude score Demographic variable Location of pharmacy

Gender Type of pharmacy

City centre

8.72 (12.95)

Urban

6.99 (11.52)

Rural

7.83 (14.26)

Male

8.61 (13.48)

Female

6.77 (11.77)

Large multiple

7.27 (10.95)

Small multiple

8.03 (13.80)

Health centre

6.43 (11.40)

Single outlet

9.43 (15.04)

0.058 0.162

—

0.510

Length of time registered

—

—

0.420

Service provision variable Yes

14.54 (11.76)

No

6.32 (12.31)

Provision of methadone

Yes

8.90 (11.94)

dispensing

No

2.08 (13.26)

Supervise methadone

Yes

9.10 (11.85)

consumption

No

6.82 (13.45)

Provision of

Yes

9.35 (12.88)

buprenorphine dispensing

No

6.97 (12.41)

Supervise buprenorphine

Yes

11.21 (15.22)

consumption

No

8.07 (11.17)

,0.01 ,0.01 0.20 0.04 0.21

communication, C. Hunter). At a community level, this indicates the importance of active, localized recruitment. Selling injecting equipment

Guidance from the Royal Pharmaceutical Society recommends that pharmacies do not sell injecting equipment unless they had sharps facilities for disposal.13 Almost half of the respondents did have sharps disposal, yet pharmacists still seem unwilling to sell injecting equipment. Staff may be concerned that they will have to handle used equipment even though they are not in a designated needle exchange pharmacy (nor paid as such). The increased provision of needle exchange could account for some of the unwillingness to sell injecting equipment. However, the increase in needle exchange provision is relatively small compared with the reduction in willingness to sell over the time period. Drug dispensing Dispensing for drug misuse continued to rise. The majority of pharmacies will dispense drugs for ‘drug misuse’ and this is largely methadone dispensing. The rise in numbers of individuals being prescribed methadone is considerable

SSAM in pharmacies The proportion of pharmacies supervising methadone consumption has also increased significantly. This indicates the widening acceptance of methadone supervision as part of a pharmacists’ professional remit. Of the 12 400 individuals being dispensed methadone, 57.7% are taking this under supervision. Surprisingly, this proportion is lower than that in previous surveys. Examination of the breakdown of supervision according to NHS areas found one area with a particularly low proportion of SSAM. This area has a different approach than other areas ( personal communication, E. Rankin). This could explain the overall reduction in the proportion of SSAM. Absolute numbers of SSAM patients have increased so the reduction in the proportion could reflect that some pharmacies may have too many to handle: the mean number of methadone patients per pharmacy has increased from 13.1 to 20.1 and the mean number of supervised patients has increased from 8.7 to 13.1. Thus, workload for pharmacists is considerable and a change in approach by prescribers may have been required. National Guidelines14 recommends SSAM for the first 3 months of methadone treatment. Some areas/prescribers were previously required SSAM for considerably longer but may now be supervising more in accordance with the guidelines to free space for new patients requiring supervision. Attitudes The attitude of pharmacists has improved significantly between 2000 and 2006 indeed more than between 1995 and 2000. Given that the levels of training have not increased between 2000 and 2006, this positive increase may reflect increased exposure, experience and understanding of drug misusers and drug misuse services. Pharmacists who provide any drug services have a significantly higher attitude score than those who do not. This is most notable for needle exchange services. The relationship between attitude and practice has been explored in detail before,3 and this current survey confirms that the situation has not changed. Prescribing patterns Few areas in Scotland have buprenorphine on their local drug formularies for maintenance, although some include it


—

syringe exchange

from 8809 to 12 400. If we extrapolate the data from the non-responders contacted [in which 626 patients were being dispensed methadone from 49 pharmacies (mean of 12.8 per pharmacy)] to all non-responders, there will be an estimated further 4826 more patients on methadone giving an extrapolated total of 17 226 individuals.

0.206

Age

Provision of needle/

355

356


Training Levels of training increased significantly between 1995 and 2000 for drug misuse (but not on blood-borne disease prevention) but have not changed significantly between 2000 and 2006 for either drug misuse or blood-borne disease prevention. There were national training initiatives in the 1995 – 2000 period but not in 2000 –2005. Given that the demand for training is still high, it is time for further training initiatives. Training should target pharmacists newly providing services and pharmacists with experience who need both ‘refresher’ courses and opportunities to develop skills. For example, a training needs survey in one area indicated an interest in counselling skills.16 High training needs, despite considerable practical experience, may reflect a lack of confidence in this area or it may simply reflect a keen interest in the field and a desire to expand their current knowledge base.

that involvement in particular service delivery is linked to a more positive attitude. What this study adds

This third survey indicates that the involvement of community pharmacy has increased significantly in the areas of dispensing but less so for needle exchange provision. Pharmacies are dispensing more and pharmacists are also more positive about their professional role in managing drug misuse. However, pharmacists clearly feel more positive about involvement in dispensing than needle exchange services. The willingness of pharmacists to be involved drug misuse treatment provides a great resource for future developments to improve service delivery at a national and community level, e.g. introducing ‘enhanced dispensing services’ such as supplementary prescribing, brief interventions and direct referral. The volume of methadone dispensing is considerable and there may come a time when pharmacy dispensing is at maximum capacity. The lack of widespread involvement in needle exchange indicates that policy makers will have to review how to widen access to clean injecting equipment. Other means of distributing injecting equipment beyond pharmacies need consideration as well as carefully targeted campaigns of pharmacies in areas of need. Limitations of this study

A limitation of the study is that the response rate was lower than that was previously 79 and 82% in 1995 and 2000, respectively, despite additional measures to boost response. Results from contacting non-responders indicate that they are less involved in drug services, thus perhaps less interested in the topic. There are also considerable changes in community pharmacy at present with new NHS contracts being introduced. This, along with general survey fatigue, may have affected response.

Acknowledgements The authors also thank all pharmacists who took the time to complete the questionnaire.

Conflict of interest None.

Funding What is already known on this topic

It was already known that pharmacists input into drug misuse services had increased between 1995 and 2000 and

The authors would like to acknowledge the Chief Scientist Office of the Scottish Executive for funding this project. The views expressed are those of the authors.


for detoxification. The level of buprenorphine dispensing was currently low. A Cochrane review of buprenorphine compared with methadone concluded that methadone should still be the drug of choice for maintenance.15 However, buprenorphine has perceived advantages, i.e. being safer in overdose and not requiring daily dosing (every 2 –3 days is possible). Reviews of prescribing/ dispensing data over time will plot its uptake into clinical practice. There have been changes in the source of prescriptions over time. Between 1995 and 2000, there was a large increase in the number of general practice prescriptions and hospital/clinic prescriptions. However, between 2000 and 2006, there has been a slight decrease in general practice prescriptions but a considerable increase in hospital/clinic prescriptions (from 1943 to 4799). Indeed, much of the increase in volume of methadone prescribing comes from hospital/clinics (i.e. specialist centres). The reasons behind this need further exploration. Specialist services in Scotland have generally increased staff numbers over the last 5 years, thus increasing their capacity. However, the change in the general practitioner (GP) contract, making management of drug dependence an enhanced service, may have had some influence on some areas. There may be a need to revisit the area of general practice service provision to assess whether there is sufficient knowledge, skills and support for general practitioners in this field.


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