Family Practice Vol. 16, No. 4, 375-379
© Oxford University Press 1999
Prescribing and dispensing for drug misusers in primary care: current practice in Scotland
Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen AB25 2AY, UK.
Matheson C, Bond CM and Hickey F. Prescribing and dispensing for drug misusers in primary care: current practice in Scotland. Family Practice 1999; 16: 375–379.
Received 2 July 1998; Revised 2 December 1998; Accepted 29 March 1999.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodResultsDiscussionReferences |
|---|
Background. Substitute prescribing has increased in Scotland, as in the rest of the UK. Both GPs and pharmacists are becoming increasingly involved in service provision for drug misusers, but anecdotal evidence has suggested considerable variation in prescribing and dispensing practice.
Objective. We aimed to gain baseline data on (i) current prescribing practice by medical practitioners and drug agencies, (ii) dispensing practice by community pharmacists across Scotland for the management of drug misuse and (iii) variations in practice between health boards.
Methods. A structured questionnaire was posted to all community pharmacies in Scotland (n = 1142), in order to gather information on prescribing from prescriptions held at the time of the survey and information on current dispensing practice in managing drug misusers.
Results. The response rate was 79%. Sixty-one per cent of pharmacists were currently dispensing drugs for the management of drug misuse. The most frequently prescribed drug was methadone, dispensed by 46% of pharmacists, followed by diazepam (37%), dihydrocodeine (26%) and temazepam (25%). Sixty-five per cent of methadone prescriptions were dispensed daily on request from the prescriber. Of the 3387 people receiving a methadone prescription, 32.9% had to consume their daily dose on the pharmacy premises under a pharmacist's supervision. Nineteen per cent of pharmacies currently provided a service to supervise the consumption of methadone by clients and a further 14% were prepared to but had no current demand. The proportion of prescriptions requiring supervision of methadone consumption varied considerably between health board areas.
Conclusions. Methadone is the most widely prescribed drug for drug misuse across Scotland, but there is considerable variation between health board areas in how prescribing is managed. Prescribing practice should be revised locally, in a process involving GPs and pharmacists. Pharmacists have an important role in preventing drug misuse in primary care, but need further support to optimize good practice.
Keywords. Methadone, pharmacy, prescribing, substance abuse..
|
Introduction |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Substitute prescribing, the deliberate prescribing of drugs in a controlled manner to reduce the use of illicit drugs, has increased greatly in recent years. It attempts to introduce some order and control into drug misusers' often ‘chaotic’ lifestyles. Methadone is the drug of choice in the UK,1–4 where its use as a maintenance treatment is supported by a body of research evidence.5 It is an opioid with a long half-life, which in Scotland is taken as a single oral daily dose,2 invariably as the liquid preparation, and is therefore reasonably controllable. In England and Wales injectable methadone is sometimes prescribed.4
Many drug misusers in Scotland are treated under shared care arrangements, which is taken to mean sharing the care of drug misusers between specialist drug problem services and general practice. Often the drug problem service performs an initial assessment, initiates the care plan and then passes the care to the GP when the patient is ‘stabilized’. Some drug misusers are treated solely by their GP. Under both arrangements, the GP usually signs the standard prescription form which authorizes the supply. Some drug misusers are treated from a clinic using specific, readily identifiable prescription forms.
Prescribed drugs for drug misusers are usually dispensed by a community pharmacist (a High Street pharmacist). Anecdotal evidence has suggested that the management of drug misusers varies considerably between pharmacists. Furthermore, increased methadone prescribing in Scotland1 has dramatically increased contact between drug misusers and pharmacists. This survey aimed to quantify the nature and extent of that contact.
Prescribing and pharmacists' provision of dispensing and other services to drug misusers has been quantified at a national level in England and Wales.6,7 This is the first such study in Scotland. It provides baseline information on pharmacists' current involvement in service provision, dispensing trends, attitudes and training.
|
Method |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Content-setting, semi-structured interviews were held with community pharmacists to identify topics to be covered in a questionnaire. A questionnaire was then compiled including: demographic information, current involvement with drug misusers, training in drug misuse, attitudes to issues relating to drug misusers and willingness to participate in a follow-up telephone interview. Closed and open questions were used to gain factual information. The questionnaire was piloted in a random sample of 51 pharmacies, following which minor changes were made.
The questionnaire was sent to the remaining 1091 pharmacies in Scotland in October 1995. A reply-paid postcard was enclosed which responders were requested to return separately but at the same time as the questionnaire. Non-responders could then be identified while maintaining anonymity of the questionnaires. Two reminders were sent.
This paper reports current prescribing and dispensing practice across Scotland. Attitudinal results are reported elsewhere.8
|
Results |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
A 79.2% (n = 864) response rate was achieved from the main questionnaire. Pilot questionnaire results were included (n = 894) where questions did not alter between the pilot and main questionnaire.
Drugs prescribed
Sixty-one per cent of all responders dispensed drugs for the management of drug misuse. Drugs dispensed were methadone (46%), diazepam (37%), dihydrocodeine (26%) and temazepam (25%). Other drugs dispensed by less than 5% of responders were nitrazepam, DHC Continus, chloral hydrate, buprenorphine, chlordiazepoxide, lofexidine and Diconal.
Methadone prescribing and dispensing
In total, 54.6% (n = 464) of pharmacies dispensed methadone, and there were 3387 methadone users, a rate of 0.66 methadone users per 1000 population in Scotland, as presented in Table 1
.
|
Most prescriptions (74.6%) are written on form GP10 (equivalent of FP10 in England) by GPs as opposed to specialist clinics or hospitals. Sixty-five per cent of methadone dispensing is on a daily pick-up basis (Fig. 1
).
|
Level of pharmacy involvement in methadone dispensing
Some pharmacists had considerable involvement with drug misusers, with an average of 7.3 methadone clients per pharmacy. Of the 464 pharmacists dispensing methadone at the time of the survey, 61.6% had one to five current clients, 29.9% had 6–20 current clients and 8.0% had over 20 current clients. (Current was defined as the number who had used that pharmacy for a methadone prescription in the past week.)
Pharmacy supervision of methadone consumption
Supervised consumption of methadone consumption varied considerably between health board areas (similar to Health Authorities); see Table 2. Correspondingly, the current involvement and willingness of pharmacists in providing a supervised service varied as shown in Table 3.
|
|
Methadone dispensing practice in pharmacies
Dispensing practices were quantified and results are presented in Table 4
.
|
Community pharmacy health promotion services to drug misusers
Pharmacist provision of verbal or written health promotion information on drug misuse and HIV prevention to their drug misusing clients was extremely low (see Table 5
).
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
The high response rate to this postal questionnaire indicates the importance of this subject to pharmacists. Care of drug misusers in general practice has been encouraged9,10 despite negative attitudes from GPs towards drug misusers.11,12 Considerable evidence supports the use of methadone in both maintenance5 and detoxification. The use of benzodiazepines and dihydrocodeine is more controversial. Although individual clinicians have found dihydrocodeine beneficial,13 little published research supports its use. A quarter of Scottish pharmacists were dispensing dihydrocodeine for drug misusers in this survey. It is not known what proportion of substitute drug users are represented in this survey, but the Drug Misuse Database for 1995/6 revealed that 5% of new clients reported being prescribed dihydrocodeine.14 Drug misusers with concurrent benzodiazepine and opioid dependence may need to be prescribed benzodiazepines in the short term owing to the dangers of abrupt withdrawal. More extensive use is controversial. A survey of pharmacies in England and Wales,4 undertaken at approximately the same time as this survey, found that methadone was similarly the most frequently prescribed drug.
Amphetamine and diamorphine are prescribed in England and Wales.7 In Scotland, 4.6% of new clients stated amphetamines as their main drug of use,14 yet there was no evidence of prescribed amphetamines in this survey. Perhaps amphetamine prescriptions may be dispensed from other sources such as hospital pharmacies. Alternatively these results may reflect differences in services, with fewer private clinics in Scotland compared with England and/or differences in attitudes of professionals to prescribing for drug misuse.
Buprenorphine was formerly fairly widely misused in Scotland. This survey found dispensing of buprenorphine to be low, correlating with a low current prevalence of buprenorphine misuse.14 This appears to be the result of increased control of buprenorphine prescribing.
There is evidence that prescribed methadone leaks onto the illicit market,15 but this can be largely reduced by pharmacist supervision of methadone consumption, which has to be requested by the prescriber. Pharmacists are not contractually obliged to supervise methadone consumption. However, those not prepared to provide this service cannot dispense the prescription and must ensure that the drug misuser attends a pharmacy which will.16 The proportion of methadone prescriptions dispensed daily and requiring supervision of consumption reflects management and prescribing priorities. Both varied considerably by health board area.
The reasons for the low rate of supervision, or even daily dispensed methadone in some areas, are unclear. In some areas with a known high prevalence of drug misuse, these were low. There may be a lack of guidance for GPs, concern for the privacy of the drug misuser or concern for the implications for pharmacists. Enforced supervision of methadone raises human rights issues, but these should be balanced against evidence that illicit methadone can be the first opioid used,17 with the possibility of progression to injecting opioids.
The role of community pharmacists in supervising methadone consumption must be considered carefully. Pharmacists in Glasgow are remunerated for this service and those in other areas more recently so. This may encourage more pharmacists to provide what can be a time-consuming service.8 Another issue is privacy in the pharmacy.18 Assistance from health boards with the construction of ‘private areas’ within pharmacies may encourage more pharmacists to provide this service,8 although drug misusers do not necessarily want a private area but rather respect for their privacy.18 Even if these issues are addressed, there is still a proportion of pharmacists who are unwilling to undertake this role. If the number of people prescribed methadone and requiring supervision of consumption increases, this may need to be addressed in order to prevent pharmacies currently providing this service from becoming overloaded.
It was common practice for pharmacists to establish ground rules with new methadone clients regarding times to collect prescriptions and general behaviour in the pharmacy, and to request identification. This is rarely done with other prescription clients, indicating that pharmacists treat drug misusers differently, despite what they believe. Written contracts were not widely used, perhaps because these are seen as a potentially confrontational practice. Such contracts for drug misusers are already used by prescribers (GPs and drug agency staff) and could be extended to involve pharmacists.
Provision of health promotion services to drug misusers is low. Further evidence from this survey (not reported here) indicates this may be because the appropriateness of giving such advice in a pharmacy is disputed. Many pharmacists see drug misusers frequently, and this is a good opportunity to pass on a number of important health promotion messages. Pharmacists should be encouraged, through training and local support, to develop health promotion services.
In summary, there is substantial variation in prescribing and dispensing practice across Scotland. The results are important for planning the future management of drug misusers and the control of substitute prescribing. Local prescribing policies and practice should be reviewed to determine whether prescribers need support or training. Given that training may be needed for both GPs and pharmacists, it would be feasible and desirable to undertake this jointly, promoting understanding and communication as well as providing a forum for addressing local issues. Community pharmacists have considerable contact with drug misusers, and pharmacy services should be refined to consolidate good practice with the appropriate support of health boards and local prescribers.
|
Acknowledgments |
|---|
The authors would like to thank the Chief Scientist Office, SODOH for funding this project and all the community pharmacists who participated. The views expressed are those of the authors and do not represent those of the funding body.
|
References |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
1 Scottish Working Group. Good Practice in Substitute Prescribing. Edinburgh: Scottish Office Department of Health, HMSO, October 1996.
2 Drug Misuse Statistics Scotland. Edinburgh: ISD Publications, 1995.
3 Strang J, Sheridan J. Heroin prescribing in the ‘British System’ of the mid 1990s: data from the 1995 national survey of community pharmacies in England and Wales. Drug Alcohol Rev 1997; 16: 7–16.[Medline]
4
Strang J, Sheridan J, Barber N. Prescribing injectable and oral methadone to opiate addicts: results from the 1995 national postal survey of community pharmacies in England and Wales. Br Med J 1996; 313: 270–272.
5
Farrell M, Ward J, Mattick R et al. Methadone maintenance treatment in opiate dependence: a review. Br Med J 1994; 309: 997–1001.
6 Glanz A, Byrne C, Jackson P. The role of community pharmacies in the prevention of AIDS amongst injecting drug misusers: finding of a survey in England and Wales. Br Med J 1989; 299: 1076–1079.
7
Sheridan J, Strang J, Barber N, Glanz A. Role of community pharmacies in relation to HIV prevention and drug misuse: findings from the 1995 national survey in England and Wales. Br Med J 1996; 313: 272–274.
8 Matheson C, Bond C. Attitudinal factors associated with community pharmacists' involvement in services for drug misusers. Addiction (in press).
9 Scottish Drugs Task Force Drug Misuse in Scotland: Meeting the Challenge. Edinburgh: Scottish Office, Department of Health, HMSO, 1995.
10 The Task Force to Review services for drug misusers, Report of an Independent Review of Drug Treatment Services in England. London: Department of Health, HMSO, 1996.
11 Abed RT, Neira Munoz E. A survey of general practitioners' opinion and attitudes to drug addicts and addiction. Br J Addiction 1990; 85: 131–136.[ISI][Medline]
12 Glanz A, Taylor C. Findings of a national survey of the role of general practitioners in the treatment of opiate misuse: dealing with the opiate misuser. Br Med J 1986; 293: 486–488.
13 Robertson JR. Dihydrocodeine—A second strand of treatment for drug misusers. Drug Alcohol Rev 1996; 15: 199–201.[Medline]
14 Scottish Drug Misuse Database 1995/6 Information and Statistics Division Scotland. The National Health Service in Scotland. Edinburgh: NHS, October 1997.
15 Neale J. Drug users' views of prescribed methadone. Drugs Educ Prev Policy 1998; 5(1): 33–45.
16 Law Department of the Royal Pharmaceutical Society of Great Britain (personal communication).
17 Matheson C. An investigation of young people's knowledge of illicit drug use in Aberdeen. (MSc report.) Department of Public Health, University of Aberdeen, 1994.
18 Matheson C. Privacy and stigma in the pharmacy: illicit drug users' perspectives and implications for pharmacy practice. Pharm J 1998; 260: 639–641.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||