More detail on the recommendations
Naloxone must be available from every community pharmacy and staff trained to use it. Naloxone should also be kept in first aid boxes for emergency use in any clinical setting where people who use drugs attend, and pharmacy teams in those locations be among the staff trained to use it.
A recent study into take home naloxone programmes found that ownership and carriage of the medicine were lower than desired. (1) Supplying patients with naloxone and impressing upon them the importance of carrying it is fundamental to the success of the programme.
Community pharmacy teams are ideally placed to make these vital interventions. The Drug Misuse and Dependence: UK Guidelines on Clinical Management state that ‘it is good practice for the pharmacist to engage the patient in a discussion regarding risk management to ensure all harm reduction options have been addressed (such as overdose awareness and provision of naloxone where available)’. (2) Every community pharmacy team should be able to offer naloxone to anyone they believe to be at risk of an overdose or to anyone who may witness an overdose. This should be offered as part of a package of care which promotes not only the safe use of naloxone but also the importance of carrying it and of naloxone being accessible.
Pharmacists based in other settings, e.g. specialist services, GP practices, should also be engaging patients in conversations about harm reduction. They should be offering education around naloxone and ensuring patients have a supply.
The guidelines also recommend that ‘opportunistic interventions (such as hepatitis interventions, injecting equipment, and overdose and naloxone training) can be crucial to maximise engagement in potentially life-saving interventions.’ Community pharmacists are the most accessible healthcare professional which makes these interventions possible on a regular, sometimes daily, basis. This is true for not only patients but also family members, friends and those in the community. Interventions can also be offered at times when patients are particularly vulnerable to overdose, for example, during the initial stages of treatment or upon release from prison or hospital. This accessibility also makes community pharmacy ideally placed to hold a stock of naloxone for use in the event of an emergency in the immediate vicinity. However, we also believe that naloxone should be included in the emergency boxes in any clinical setting where people who use drugs may attend and first aid staff trained to use it, including pharmacy teams.
Pharmacy teams in all settings should have the tools to prevent and identify possible dependence on prescribed or over the counter medicines (OTC) and carry out brief interventions where appropriate.
The principles of brief interventions (3) could be applied to prescribed or over the counter (OTC) medicines allowing trained pharmacy staff to engage patients in a non-confrontational way. Brief interventions are a tool to motivate and support patients to think about their medicine use and identify if a change may be required to reduce harm. They can be a way to identify any additional needs and signpost accordingly.
The Drug Misuse and Dependence: UK Guidelines on Clinical Management (2) make reference throughout to brief interventions and suggest they are beneficial for young people, those at initial assessment of drug misuse or where the person is perhaps not at the threshold of requiring more structured help, which is often the case with prescribed or OTC medication dependence. The guidelines also recognise the invaluable resource that pharmacists can be in identifying problems, harm reduction and the provision of brief interventions, particularly for the ageing drug treatment population with complex comorbidities.
Pharmacists, and pharmacy teams, are ideally placed to make an impact on patient care through brief interventions. Interventions can take place in any setting the patient may attend, do not require any formal arrangements to be made and are quick, making them ideal for patients presenting at a community pharmacy, general practice surgery, custodial setting, or even when receiving their discharge medication from hospital.
Use of brief interventions would ensure that every contact the pharmacy team has counts. To achieve this, carefully developed tools will be required with clear, distinct messages to educate and support patients in a way that means these interventions are meaningful and effective. Previous campaigns have used communication bundles (4) to ensure that safety messages are delivered specific to that medicine every time it is dispensed/sold. This model which would work well with prescribed and OTC medicines susceptible to dependence. The whole pharmacy team must be involved and trained to deliver a consistent and professional message to patients, with aide memoirs supplied to reinforce the message.
Community pharmacy teams should have a method of recording over the counter medication purchases to help identify over or misuse, and enable action to prevent harm.
Sales of OTC products, particularly pain relief and sleeping aids, are continuing to increase. (5) Pharmacists and pharmacy teams could provide much needed awareness, interventions and education on the dependent nature of some of these medicines. (6) Public health campaigns such as those mentioned below would be a starting point to get these messages across but, with patients still able to make multiple purchases from different community pharmacies with no way of this being monitored or recorded, the risks of harm are still high.
A method of recording OTC sales of medicines liable to abuse or dependence would help address this issue. Patients registering with one pharmacy could facilitate this. The records would need to be accessible to others, where appropriate, and relate to a particular patient. A shared patient record would enable this to be done in a quick and unobtrusive manner while recording what could be valuable and potentially lifesaving information ( see Recommendation 6).
The expansion of the existing new medication/high risk medication tools in community pharmacy should include medicines with a risk of dependence to encourage and enable education to start at the point of prescribing and dispensing.
High risk medicines are defined as medicines that have a high risk of causing injury or harm if they are misused or used in error, (7) Medicines with a risk of dependence come under this definition. Pharmacy teams can use existing high risk medicine tools to identify harm or deterioration in patients taking these medicines. They can intervene to prevent harm and to structure a timely response if harm occurs.
Extension of the current community pharmacy new medicine tool to include the classes of medication with a risk of dependence would allow community pharmacy teams to educate patients at the point of dispensing, building on information provided during the consultation with the prescriber (who may be a pharmacist or another professional). This will encourage person centred working with realistic expectations from the outset, as well as patient awareness of the risks and limitations of treatment. It also allows an opportunity for discussion on non-pharmacological treatments which may be of benefit and ensure a holistic approach to care.
Community pharmacies are ideally placed to host targeted public health campaigns around dependence on prescribed, illicit, and over-the-counter meds. Pharmacy teams in any setting can highlight and reinforce these messages.
Public health is an intrinsic part of pharmacy practice. Pharmacists and pharmacy teams, working in all settings, can support people with dependence on medicines and/or drugs and prevent dependence from happening by promoting public health messaging. Teams can educate patients on the importance of adhering to maximum treatment times and dosing, self-management and seeking help with concerns about personal use.
For campaigns to be successful all pharmacy team staff must be trained and involved. Public health campaigns around smoking cessation have been very successful in the past. Organisations enhance their impact by working together and utilising visual aids, posters, leaflets, and training. Trained staff can then engage patients and get the important messages across.
Campaigns are needed to raise public awareness of a growing issue of prescribing (8) and dependence on certain groups of medicines. It would also work well in targeting those purchasing medication over the counter and online. There is also a role in educating the general public on drug treatment options as a way to try to de-stigmatise seeking drug treatment. (9) As the most accessible healthcare professionals, community pharmacy teams are ideally placed to deliver a campaign’s key messages. These messages could be reinforced across healthcare settings with posters and materials. Pharmacy teams in all settings can also raise awareness of risks while ensuring patients do not stop medication abruptly or inappropriately.