Features

How supplementary prescribing can work in a substance misuse service

Substance misuse might not seem an obvious choice for supplementary prescribing. First of all there are the additional legal requirements around Controlled Drugs. Then, in this post-Shipman era, there is the need to ensure transparency. And that is before considering the challenges of this patient group.

But a number of pharmacists have overcome the problems. One of them is Stuart Notman, who operates a supplementary prescribing service from his community pharmacy in Aberdeen.

And Mr Notman has done something else, something that will be music to the ears of many supplementary prescribers: he is computer-generating his prescriptions.

For those pharmacists who have stopped prescribing because the process of hand-writing prescriptions is too time-consuming, Mr Notman’s solution will seem frustratingly simple.

He has produced a standard computer document which contains slots for the prescription information laid out as it is on a paper prescription. “When I need to print a prescription, I just enter the details then tear the top sheet off the prescription pad and feed it into the printer. And out comes a computer-generated prescription,” he says. “This has been very easy for me to do because I just prescribe methadone so there is only ever one item on the prescription.”

It is his use of tailored IT that has made his prescribing service operate smoothly. “The computer system operates a number of tabs so I have all the information at hand when I see a patient. There is a tab for the clinical management plan, previous appointments, attendance record, previous prescriptions and the current appointment, and it is easy to flick between them during a consultation,” he explains.

Mr Notman wrote the programme himself and is operating a paper back-up for the time-being until he is sure that the system has no glitches.

Mr Notman’s interest in treating substance misuse is long-standing, having provided a supervised methadone consumption service for a large number of patients for years (PJ, 24 January 2004, p90).

“My idea was to provide a prescribing service from the pharmacy because that is where we are based,” he says. “One of the great things about operating the service from the pharmacy is I can offer an immediate response to problems. Patients consume methadone at the premises every day and supplementary prescribing means that, if a patient has a crisis, I can sit down with [him or her] and sort it out, rather than them having to wait for a [GP’s] appointment,” he says.

Whether or not he can keep up this level of flexibility depends on how many people use the service in future — numbers are being kept low while the service is being developed.

Another factor that makes substance misuse appropriate for a community pharmacy setting is the lack of blood tests. “It is not like other clinical areas where you need laboratory results to make prescribing decisions. Our clients do have urine tests at the GP surgery but they are simply a positive or negative result for drugs,” Mr Notman explains.

How the service operates

Mr Notman started the service with one surgery but has recently extended it to a second. His clinic operates on a three-month clinical management plan (CMP) and he prescribes on a fortnightly basis, after which patients come in daily for supervised consumption. His CMPs are based on a protocol that outlines standard treatment, but each CMP is individualised by stating the patient’s starting dose.

“I didn’t want to have to write everything out for each patient, which is why we produced the standard protocol. But anything specific to the patient is listed separately in the CMP,” he explains.

The protocol includes gradual dose reduction, maintenance doses and emergency dose increases. “If I have to increase a dose, I prescribe for seven days and refer the patient back to the doctor within those seven days for a review,” he explains.

After each appointment, Mr Notman sends a report to the GP surgery either by NHS-net e-mail or by fax from his computer (the fax numbers are pre-programmed to avoid dialling errors). The report summarises his management of the patient, and includes prescription details and patient attendance.

The surgeries had been concerned about constant paperwork so each report contains the details of all appointments (both that day’s appointment and previous ones): this means the surgery staff can just remove the old copy from the patient’s notes and insert the new, up-to-date version in its place.

Separating prescribing and dispensing is an issue for many supplementary prescribers. How has Mr Notman solved this? “All my prescriptions are looked at by a fresh pair of eyes. I write the prescription and then it is passed to the dispensary, where an assistant enters the details into the computer,” he says.

The fact that the prescriptions are for daily dispensing also makes a difference because another pharmacist always sees them on Mr Notman’s days off.

Referral to the service is controlled by the GPs and, initially, the selection criteria have been strict. “We are selecting nice easy patients at the the moment. This is because it helps build confidence in the service and gives me a chance to prove the system,” he comments.

“Easy” patients are those on methadone only; those who have additional problems with benzodiazepines or alcohol are currently excluded.

Future

Mr Notman may have got the service working but it has taken three years of hard work. “The biggest barrier was that doctors were just not informed about supplementary prescribing,” he comments. “Setting up a service really comes down to having a good GP behind you.”

As far as the future is concerned, Mr Notman has recently started discussing options with the local substance misuse team and one possibility is its extension into hospital clinics. But he is also keen to ensure he builds confidence in the service as it currently stands.