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Letters to the Editor
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Community pharmacy
Treat all customers professionally
From Ms W. A. Stone, MRPharmS
I strongly disagree with J.
S. Bowman (PJ, 14 February, p184) who would
keep drug misusers out of community pharmacies. I am ashamed of his attitude
towards drug-dependent patients. Does he include nicotine-dependent patients
or are they acceptable to him?
He complains of hassles of storage, checking for accuracy of prescriptions
and incredibly, “necessary book-keeping involved”. Does he
also complain when recording a supply of morphine to a patient in severe
pain?
Perhaps in his role as a locum pharmacist he does not have the chance
to get to know the patients and establish a rapport with them.
We aim to treat all our patients and customers in the same professional
manner and most respond accordingly. When a patient does not conform
to expected behaviour, then is the time to consider withdrawal of service.
I agree that some patients can be abusive, threatening, demanding and
intimidating but this behaviour is by no means exclusive to drug-dependent
patients.
Contrary to Mr Bowman’s view, I see every reason to treat drug-dependent
patients in the community as another step towards their rehabilitation.
Wendy Stone
Bristol
Patients are grateful for drug misuser services
From Mr M. C. Harvey, MRPharmS, and Ms M. Saunders
In response to the letter from J.
S. Bowman (PJ, February 14, p184),
we are concerned about the generalisations and lack of professional understanding
he shows. We have worked in many pharmacies that provide services to
the drug misusers whom Mr Bowman wants to eject from community pharmacy.
First and foremost, they are patients and need treatment. Secondly, we
are professional health care providers in the community. Since these
patients belong to the community, it is the pharmacist’s role to
assist them. If we are looking for enhanced pharmacy roles why turn them
away?
Community-based patients are not all of the personality type Mr Bowman
describes. Many are grateful for the service and thankful to see any
glimpse of a helpful attitude to their plight. Indeed a positive attitude
to the care of these patients may well contribute greatly to their rehabilitation.
M. C. Harvey
Chichester,
West Sussex
Michelle Saunders
Final-year Pharmacy Student
University of Portsmouth
Pharmacists can build a supportive relationship with drug misusers
From Miss E. R. Mills, MRPharmS
I was saddened by J. S.
Bowman’s views on the treatment of drug
misusers in community pharmacies (PJ, 14 February, p184). I work for
a drug and alcohol service
co-ordinating a supervised administration of methadone scheme from community
pharmacies. Providing a service to drug misusers can be rewarding, and
not just because of the payment received each month.
Department of Health guidelines have emphasised the importance of community
pharmacists in the care of drug misusers as part of shared care arrangements.1 Much work has been done to ascertain pharmacists’ views on, and
involvement in, the care of drug misusers. A questionnaire to community
pharmacists showed that 69 per cent of pharmacists were interested in
supervised methadone consumption and 67 per cent in shared care arrangements.2 Another study looked at the opinions of pharmacy support staff. Positive
attitudes were associated with service provision; over half of all staff
were happy to be involved in service provision and two thirds believed
the pharmacy was an appropriate place for providing these services.3
I agree that drug misusers can be a security risk to the store and that
staff can feel threatened and intimidated. Shoplifting and dealing with
intoxicated users is a common problem — whether providing a service
to drug misusers or not. Clients in a treatment programme are generally
well behaved. They have a lot to lose if they are withdrawn from the
programme. Pharmacists involved in supervised administration of methadone
report few serious incidents and contact with the police does not change
significantly after the introduction of the service.4 So surely we should
be supporting such programmes to encourage drug misusers to seek help
and minimise the problem of intoxicated clients in our pharmacies?
There are hassles associated with dispensing methadone. However any Controlled
Drug prescription can be written incorrectly. In my experience, drug
misusers are much more understanding about the inconvenience caused by
an incorrectly written prescription, than, for example, a relative collecting
morphine for a palliative care patient. We should be liaising with GPs
to ensure they understand the importance of the CD prescription regulations,
not withholding services from patients.
A separate clinic prescribing and dispensing for drug misusers is not,
in my opinion, a viable option. Many clients are prescribed for by their
GP, and these numbers will increase as shared care agreements are implemented.
One of the strengths of community pharmacy is its accessibility. Most
clients pick up their methadone daily. This provides stability and routine
for the client trying to get some order back into his or her life. It
offers an opportunity for a brief assessment of their physical and mental
well being, and reduces the risk of leakage of methadone on to the streets
and the risk of accidental overdose. Many clients do not live near a
clinic and visiting one may involve an hour’s journey each way.
This is not practical on a daily basis, especially if the client wishes
to start work, and is likely to demotivate the client and risk them leaving
treatment.
Drug misusers are the only patient group that pharmacists will see daily
and such contact allows them to build a supportive relationship with
clients. Once in treatment, the improvement in a client’s physical,
mental and social well-being can be dramatic and being part of that process
is extremely rewarding.
Elizabeth Mills
London NW3
References
1. Department of Health. Drug misuse and dependence — guidelines
on clinical management. London: The Department; 1999.
2. Jesson J, Wilson K, Barton A, Pocock R. Exploring the potential for
supervised consumption and shared care contracts with drug users. The
Pharmaceutical Journal 2000;265(Suppl):R37.
3. Sheridan J, Cronin F. Community pharmacy support staff and their opinions
on services for problem drug users in inner London. The Pharmaceutical
Journal 2001;267:885–9.
4. Sheridan J, Cronin F. Supervised self-administration of methadone
at community pharmacies: the introduction of a new service. The Pharmaceutical
Journal 2002;268:471–4 (PDF
125K)
Give respect to gain respect
From Miss R. E. Hossack, MRPharmS
I disagree with J. S. Bowman (PJ, 14 February, p184) about drug-dependent
patients. I have worked in a busy city centre store in Edinburgh with
a large number of methadone patients and needle exchange users and I
believe that a community pharmacy is undoubtedly a suitable setting for
dealing with their needs. Often drug misuse clinics are understaffed
and under-resourced, sometimes only opening for short periods. Community
pharmacies, however, are easily accessible and increasingly open longer
hours, catering, for example, for those patients in full- or part-time
employment. There is the opportunity for patients to access information
and advice from pharmacists and other pharmacy staff with regard to other
aspects of both their own and their families’ health. Pharmacies
also allow patients to be included in community life and to build relationships
with people outwith their usual circle, and to be treated like a human
being rather than “the least desirable members of the public”.
I accept that problems can arise but these can be managed by simple measures
to allow these patients to have access to the health care advice and
services that I and my colleagues give to all our patients. A written
contract (with photograph attached for identification) between the pharmacy
and user stating times convenient to the business at which the patient
can attend is a valuable tool. Simple guidelines can be included as to
how all patients are expected to behave with a statement that the pharmacist
has the right to discontinue dispensing the prescription if bad behaviour
occurs. With clear boundaries, the vast majority of patients behave in
an acceptable and often exemplary manner and those who do not are dealt
with swiftly.
In my experience, it is frequently the way in which any patient is treated
or spoken to that dictates their response and I have always found that
by giving respect I gain respect. I look forward greatly to the day when
these patients are treated without prejudice in the community sector.
R. E. Hossack
Bathgate,
West Lothian
Mutual respect is key
From Miss A. R. Hudson, MRPharmS
When I first qualified, as a young woman in charge of a pharmacy I admit
I was apprehensive about dispensing methadone. I was unsure of how I
would deal with any potential problems with drug misusers. I had heard
horror stories similar to those mentioned by J.
S. Bowman (PJ, 14 February,
p184).
However, I have since found the majority of patients collecting methadone
to be courteous to me, the pharmacy staff and other customers. They are
polite while waiting for prescriptions and generally appreciative of
the service offered. In return, I always ensure methadone is dispensed
first thing in the morning to allow swift collection by the patient,
and that I am friendly and professional towards each patient. Mutual
respect is the key to a successful patient-pharmacist relationship.
Of course, I have experienced an occasional drug misuser who causes disruption.
However I have also had “challenging” patients from all sections
of the community, young and old.
The provision of needle exchange or methadone services is a good way
for community pharmacists to be involved in the rehabilitation of patients
who misuse drugs, and is one way the patient can feel normal and not
sidelined into a “special” clinic.
Although I now only work occasionally in community pharmacy, I look forward
to treating all members of the community on those days, whatever their
needs.
I am sorry that Mr Bowman’s experience has been so negative. Perhaps
he could liaise with his local drug misuse treatment team to overcome
some of the difficulties he has had in the past.
Allison Hudson
Wokingham, Berkshire
A most one-sided view of the treatment of drug misusers
From Ms C. S. Charlton, MRPharmS
J. S. Bowman (PJ, 14 February, p184) has presented a most one-sided
view of the treatment of drug misusers in the community. Once a patient
has been prescribed methadone or another treatment for his or her problem,
they are embarking on a pathway which, given the necessary support, may
lead that person back to a useful and rewarding life. Community pharmacists
are in an ideal position to offer support, with regular contact with
the patients.
I do not expect Mr Bowman treats other categories of patients with such
disdain. Like Mr Bowman, I work as a community pharmacist in the north
east of England. My experiences are different. I have also been abused,
threatened and met demanding and intimidating people in the course of
my working life. Yet none of my methadone clients has ever been involved
in these situations. Shoplifting is not to be tolerated, and in the shops
where I work we make it clear to our patients that if it does happen
they will no longer be able to have their methadone dispensed from our
premises. Well-motivated people do not risk being thrown off a well-run
scheme.
Drug misusers are people and should be treated as such, not excluded
from our lives. If a family member of Mr Bowman’s ever made a mistake
which led to drug addiction, I wonder if he would then consider it correct
to deny that person access to the type of health care which is the right
of each and every one of us.
I am sure that Mr Bowman’s belief that “no one believes that
methadone or other treatments of drug-dependent patients should be dispensed
from a community pharmacy” is wrong.
Carol Charlton
Darlington, Co. Durham
Complaints about drug misusers' behaviour are negligible
From Mrs H. L. Walker, MRPharmS
Although I can understand J.
S. Bowman’s discrimination (PJ, 14
February, p184) against drug misusers who are in treatment on the grounds
that he may have had unpleasant experiences in the past, to justify it
due to the problems arising from incorrect prescriptions, storage problems
and book keeping difficulties seems wholly inappropriate.
A reason to support their treatment in the community is that there is
extensive evidence that treatment reduces injecting behaviour and therefore
the spread of HIV and hepatitis C.1 It also reduces crime, and improves
physical and psychological health.2 These benefits of methadone maintenance
have now been demonstrated in primary care where pharmacists played the
crucial role of supervising consumption.3
Surely to see any patient improving in so many aspects of their life
should be incentive enough; the extra payment given is intended to cover
the workload involved.
The difficulty of substance misusers can be greatly exaggerated and usually
is done so by those who have a greater ignorance of the subject and who
do not get involved. The Shared Care Scheme in East London covers nearly
900 patients treated by 150 GPs and 50 pharmacists and the number of
complaints about patients’ behaviour is negligible.
As health care professionals our duty of care is to help patients, not
turn our backs because of a few isolated incidents.
H. L. Walker
Shared Care Substance Misuse Manager
Mile End Hospital, London E1
References
1. Ward J, Darke S, Hall W, Mattick R. Methadone maintenance and the
human immunodeficiency virus: current issues in treatment and research.
British Journal of Addiction 1992;87:447–53.
2. Gossop M, Marsden J, Stewart D, Edwards C, Lehmann P, Wilson A et
al. The national treatment outcome research study in the UK: six month
follow-up outcomes. Psychology of Addictive Behaviours 1997;11:324–37.
3. Keen J, Oliver P, Mathers N. Methadone maintenance treatment can be
provided in a primary care setting without increasing the methadone-related
mortality: the Sheffield experience 1997-2000. British Journal of General
Practice 2002;52:387–9.
Last words
From Mr W. D. Fisher, MRPharmS
The final paragraph of Bob
Dunkley’s letter (PJ, 21 February,
p215) puts me in mind of the following. About a decade ago, while I was
still in Glasgow, two “methadonians” were quietly awaiting
their turn to receive their supervised dose and were chatting about their
respective stays in London, courtesy of Her Majesty, in Wormwood Scrubs.
A dodgy character entered the pharmacy and they turned on him: “You!
Out of here! No shoplifting! They look after you in here!”
Walter Fisher
Whitefield, Lancashire
Drug misuse services contribute to society
From Ms F. Donachie, MRPharmS
Since the 1960s when the two Brain Committee reports were published, the
view of drug addiction in Britain has been considered to be a condition for
which treatment could and should be provided. Over the years this has led
to the development of specialist services. These services are run by a wide
range of professionals who have contributed greatly to the well being of the
clients they see and also to our society as a whole.
The UK government and the devolved Scottish Executive continue to take the
view that this group of people should be actively helped with their addiction
and just as importantly, with the wider social problems that they experience.
In 1999 the “Orange Guide” (Drug Misuse and Dependence — Guideline
on Clinical Management) was published throughout the UK and in Chapter 1 it
states: “Drug misusers have the same entitlement as other patients to
the services provided by the NHS.” I mention specifically “other
patients” because this is one of the points which J.
S. Bowman (PJ,
14 February, p184) fails to appreciate.
Various papers have shown that many community pharmacists want to engage actively
with this group of patients and that their work benefits the individual and
society as a whole. The idea of a central clinic for all clients is not an
appropriate way forward for the service or the client — it is expensive,
isolating for staff and client and, most importantly, stigmatises a group
of people who are an easy target.
I agree that this group of patients is not an easy group to deal with at times.
However, work has been carried out which shows that, with appropriate training
and support, pharmacists can and do provide a valuable service to their communities.
I would suggest to Mr Bowman that he should contact his local addictions service
for advice and assistance. There are also training and coaching packages available
that may help when dealing with any patient who may have specific difficulties.
Frances Donachie
Specialist Pharmacist in Substance Misuse,
Ayrshire & Arran Primary Care NHS Trust
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