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Letters to the Editor
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Methadone
Supply of methadone important for pharmacy in public health
From Dr P. J. Bates, MRPharmS
There has been much debate about whether community pharmacy is the right
setting in which to supply methadone. It should be remembered that methadone
supply and needle exchange schemes are public health policies aimed at
minimising the risks to drug users and the general public. Recent correspondence
perfectly demonstrates the typically polarised arguments about whether
these policies really work and are worth the problems they can bring.
The main concern I have is that pharmacy is in a position to have influence
and involvement in public health but rejecting certain undesirable areas
may be detrimental to our wider role.
One example of a public health initiative that pharmacy has embraced
is nicotine replacement treatment. Tobacco smoking is considered an (almost)
socially acceptable drug habit compared with heroin yet overall it costs
the country much more in terms of associated illness and subsequent treatment.
The huge potential gain in public health that could be achieved by reducing
smoking in the population means that there is little objection to NHS
prescribing of nicotine replacements.
However tobacco is a difficult addiction to beat partly because of its
important role in a smoker’s lifestyle, which bears a similar but
less extreme parallel with heroin. This also means that there are similar
problems with its treatment. Nicotine replacement is a form of drug substitution;
it is not ideal for every smoker and there is no guarantee that all smokers
will be successful in long-term abstinence. There is variation in the
surgeries and primary care trusts which participate, variation in how
long a treatment course each patient receives and variation in the support
and follow-up. It is not surprising that many smokers are unsuccessful
in quitting and like many methadone users, a relapse in terms of weakening
to the odd cigarette is considered fairly commonplace. It is therefore
unfair to expect methadone patients to perform any better than smokers.
Why then do we treat heroin addicts so differently? Threats and criminal
activity are unnerving and unacceptable but it is not fair to apply this
behaviour to all methadone users and reject the entire concept of treating
addiction in community pharmacy. Although private smoking cessation clinics
exist, it would be equally unacceptable to force all smokers seeking
help to be stigmatised in a regimented clinic rather than conveniently
obtain their treatment through their doctor and pharmacist.
Instead there appears to be a difference in attitudes towards heroin
addicts originating from our sociological perceptions and prejudices.
We may all have friends or family that smoke but not everyone knows or
understands a heroin addict. The methadone patients we see in community
pharmacy are those addicts who have made the effort to try to help themselves.
A pharmacist with a negative attitude transmits this to the methadone
patient and problems can arise. This is not to say smokers and heroin
addicts are exactly the same but they should all have the right to acceptable
treatment. Are pharmacists in a position to judge who is acceptable and
pick and choose what public health policies we want to be involved in?
Modern public health should be about treating everyone in a population
fairly and without discrimination.
Philip Bates
Southampton
Cut the condescending rhetoric
From Mr B. R. Sinclair, MRPharmS
Sometimes I despair. I would expect that “professional”, supposedly
intelligent people were open to debate. However, suggest a point of view
that is not considered politically correct, and you are castigated by the
usual holier-than-thous and hand-wringers.
I particularly enjoyed Martin
Bennett’s “simplistic” analogy
comparing heroin addicts to asthma sufferers (PJ, 13 March, p314). As I
understand it, asthma sufferers do not choose to inject themselves with
an illegal substance, thus becoming a salbutamol “junkie”.
If, as he suggests, we measure the success of the methadone programme purely
on reduction of crime, is there not an argument for locking up all addicts,
thus achieving a 100 per cent reduction, and keeping them locked away until
they are prepared to “give up”? Not very realistic. The methadone
programme should be about reducing crime by weaning addicts off drugs,
but does not work because too many GPs and pharmacists have lost sight
of this.
The feedback (ibid) to Michael
Hutchison (PJ, 6 March, p280) saddens me.
I have been threatened with a knife, spat at and been assaulted for having
the temerity to refuse needles to addicts who are on a methadone programme
or who are “high”, or because the pharmacy does not do needle
exchange. Providing needle exchange to reduce transmission of infection
is valuable, perhaps vital to society. I believe what Mr Hutchison was
offering for debate was whether community pharmacies are really the place
for it. Some of us seem less sympathetic to the feelings of other customers.
When an addict brings in needles wrapped in bloody string, uses foul language,
or is abusive to other customers, you have to question whether it is the
right place.
I have worked in pharmacies with up to 60 methadone addicts. I have always
treated them with respect. This does not always prevent shoplifting, abuse
or threats. Mr Bennett has “little sympathy” for anyone who
suffers problems with the methadone programme, presumably even when an
addict turns up at closing time with an unsigned prescription, 30 minutes
after the surgery has closed, and threatens violence if you do not dispense
his methadone. Come on Mr Bennett: “sort out the problem and provide
the service”? Is it too much to expect, to debate important issues
without the condescending rhetoric?
Barry Sinclair
Aberdeen |
The
Pharmaceutical Journal