From Mrs D. K. Roberts, FRPharms and Mr D. A. M. Thomson, MRPharmS
SIR,-Mr Finberg (PJ, June 10, p883) requests guidance for all pharmacists as to harm minimisation in regard to drug misusers. While we are not in a position to offer definitive guidance, we thought it might be useful to share with readers our experiences in obtaining the necessary approval for the supply of citric acid through approved pharmacy needle exchanges in Greater Glasgow and Lanarkshire, acknowledging the variations between the different legal systems existing in Scotland England and Wales.
Until recently, most drug users in the West of Scotland used one of the twin sachets of Abdine health drink as their preferred source of citric acid. The manufacturer ceased trading in May, 1999, and the product quickly disappeared from the market. It was quickly recognised that there was an urgent need to provide a reliable and legal source of citric acid so that alternatives such as vinegar, proprietary lemon juice (Jif), and steriliser cleaning crystals were not used.
A paper setting out the legal, ethical and public health issues relating to the supply of citric acid to drug misusers was put to the Greater Glasgow drug action team (DAT) in July, 1999. Members of the DAT unanimously agreed that the matter should be forwarded to the Lord Advocate for Scotland, asking for his advice.
The regional procurator fiscal (RPF) for Glasgow and Strathkelvin agreed to contact the Lord Advocate on behalf of the DAT. A subsequent response from the Lord Advocate's Office indicated that he would not instruct the RPF to prosecute any pharmacist for selling citric acid to drug misusers provided they continued to participate in an approved needle exchange scheme.
As some of the Greater Glasgow health board (GGHB) primary care trust pharmacy exchanges are outwith the city of Glasgow, it was therefore necessary to obtain the approval of the RPFs for the adjoining areas of Hamilton and Paisley. Once more the RPF for Glasgow and Strathkelvin was instrumental in obtaining the agreement of his colleagues. This additional approval allowed the harm reduction services in Lanark-shire to seek and obtain equivalent approval from the RPF in Hamilton.
It was essential to gain the support of a number of key bodies in developing this pilot. The Royal Pharmaceutical Society's professional standards directorate and local inspector and the Home Office and Strathclyde police force drugs co-ordinator were consulted and kept informed of developments throughout. A training day has taken place and a patient information leaflet has been produced and distributed to participating pharmacies. The board of the National Pharmaceutical Association has agreed that the association would provide members with indemnity and legal defence for the supply of citric acid as part of the approved scheme.
At present, we are actively seeking a UK supplier of single use, sterile sachets of 100mg citric acid similar to those currently being supplied through needle exchange pharmacies at Ivry sur Seine in France. We are grateful to colleagues in Ivry for their collaboration and for the provision of sufficient 200mg sachets to undertake a successful initial pilot in one of the GGHB pharmacy exchanges.
Finally, if we have advice to give, it is that there is a need to be patient, to put the case for citric acid supply clearly and succinctly, and actively to seek support from all parties involved, including the local drug action team, the Society, Home Office, the police, public prosecutors, professional colleagues, public health consultants and, most importantly, participating pharmacists and their clients.
D. K. Roberts
Area Pharmacy Specialist, Drug Misuse
D. A. M. Thomson
Director of Pharmacy, Greater Glasgow Primary Care NHS Trust, St Vincent Hospital, Glasgow