The Pharmaceutical Journal
Vol 276 No 7387 p164
11 February 2006

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Independent prescribing of CDs to addicts by pharmacists is long overdue

By Inga Boenneken, John Gallagher, Mohammed Sessay, Colin O’Gara and Jason Luty

Since April 2003, pharmacists, nurses and midwives have been able to assume new roles as supplementary prescribers. A joint position statement has now been produced by a working party of national representatives from both the UK Psychiatric Pharmacy Group and the College of Mental Health Pharmacists to highlight the impact of supplementary prescribing and its relevance to mental health pharmacy. Pharmacists may now prescribe Controlled Drugs, such as methadone and buprenorphine (Subutex), to heroin addicts within the limits specified by a clinical management plan that has been agreed with the patients and doctor.

Pharmacists probably have more contact with treatment-seeking addicts, especially heroin addicts, than any other professional group. The requirement for daily dispensing and supervision of methadone and buprenorphine often means a pharmacist will see a patient six times each week. Although these are often brief contacts they often exceed the weekly, or even monthly, key working sessions provided by staff at the community drug team (CDT). Contact with the pharmacist will almost certainly exceed any contact with a doctor.

Now, new legislation allows pharmacists to act as independent prescribers. They will be able to prescribe any licensed drugs, but not CDs. In our view, this does not go far enough.

Psychiatry, especially addiction psychiatry, is a relatively unpopular specialty. For example, in 2001, the NHS employed approximately 2,960 consultant psychiatrists with 500 consultant posts vacant in the UK. Hence the prescribing of CDs at CDTs is often performed by a locum doctor or a local GP who may have little or no experience of addictions. Although, in theory, doctors are responsible for prescribing decisions, in effect, these decisions are often determined by more experienced, non-medical members of the CDT. There is no reason why pharmacists, who have prolonged periods of training and experience, should not be more closely involved in these prescribing decisions, especially considering their unusually close relationship with these patients. It is almost certain that primary care trusts and other commissioners would insist that a period of mandatory training was completed before permitting pharmacists to prescribe CDs. However, considering the protracted period of training that pharmacists already undergo, we would expect any interested pharmacist to have little difficulty in developing the required skills.

Many doctors are concerned, and often opposed, to prescribing by other professions. Of course, professional self-interest and the loss of doctors’ prescribing monopoly is likely to influence this position. There are only a few studies evaluating the pharmacists’ participation in the drug-prescribing process within the mental health setting. In the US, where pharmacist prescribing has been in place for some time, the availability of pharmacists in the mental health clinic has provided relief to psychiatrists’ excessive workloads. With pharmacists available to handle patient follow-up visits which require routine laboratory work, medication adjustments and fill requests, psychiatrists have a greater opportunity to attend to the more difficult patients.

What are the advantages of prescribing CDs to addicts by pharmacists? First, there will be professional recognition — and, presumably, financial reward — that is long overdue. Indeed, we believe that the total lack of professional discretion imposed by CD legislation has been an insult to the training and expertise of pharmacists. Secondly, many pharmacists have more experience of working with addicts than the locum doctors who staff a significant proportion of CDTs. Thirdly, as indicated earlier, many patients on methadone and buprenorphine have more contact with the pharmacist than any other professional. Finally, in our experience, pharmacists follow rules better than doctors. There is currently a widely publicised case being heard by the General Medical Council against several private doctors who work in addictions. Most of the charges against these doctors involve failure to adhere to Department of Health and Home Office guidelines, especially in the prescribing of methadone.

We recently contacted over 100 substance misuse teams through the UK and discovered that around one-quarter of opiate dependent people who start substitute prescriptions for methadone were not supervised by a pharmacist or other medical professional (in other words the methadone was given to the client to take away). This is despite the fact that Department of Health and Home Office guidelines state that supervised consumption of methadone is mandatory for the first three months.

One thing that becomes rapidly apparent to doctors who prescribe CDs is the rigid adherence of pharmacists to the letter of the various drugs laws. We would expect pharmacists to be more likely to follow good practice guidelines than doctors, particularly in respect of CDs. What is also becoming clear is the greatly increased safety of buprenorphine (Subutex) compared with methadone. Whereas pharmacists may well have concerns about prescribing methadone, there is really no reason why a pharmacist could not safely initiate and supervise treatment of opiate dependence using buprenorphine, provided simple protocols were agreed with the CDT. Although there have been periods when the widespread prescribing of buprenorphine (Temgesic) lead to a significant black market in some regions, daily dispensing and supervision of buprenorphine (Subutex) is likely to prevent any repetition of these events. Moreover the much greater safety of Subutex in overdose compared with methadone makes diversion onto the black market far less of a public health problem. Recent plans to license Suboxone (a combination of buprenorphine and naloxone) are also likely to prevent the risks of injecting that has been reported to be a problem with other forms of buprenorphine.

What are the disadvantages? There is a common tendency for paramedical staff to be given increasingly responsibility without any additional pay. However, unlike many NHS employees, pharmacists’ have been able to negotiate their contracts to provide specific remuneration for additional services. Of course, many pharmacists have little or no interest in dispensing to addicts, and modest financial compensation is not likely to change their views, especially considering the potential disruption that these clients may cause in community pharmacies.

Fortunately a significant proportion of pharmacists are willing to engage with clients of substance misuse services. Moreover the staff at many of these premises report much less disturbance than would be expected from the numerous horror stories that are often circulated.