David J Temple
WHAT ELSE CAN COMMUNITY PHARMACISTS DO?
Most community pharmacists are deeply disturbed by the rise in misuse of drugs and are extremely conscious of the misuse potential of this type of product. Their response to reminders from the RPSGB over the years, accompanied by an increasing demand from certain members of the public, has been to remove the main “culprit”
products from the shelves in the public area of their premises. In most pharmacies, codeine linctus, and some other preparations, are stocked only in the dispensary (if at all) and sold only rarely to customers with “genuine” coughs. The usual ploy is to say that they are “out of stock” and recommend pholcodine linctus instead.
(This product is an effective cough suppressant, but seems to have a low misuse potential.) One result of this has been a move by misusers away from the traditional products to an ever increasing range of “substitutes” or the exhaustive search by the misuser for a “friendly” pharmacist who is willing to oblige. Such pharmacists are likely to be deluged with customers. In the case cited above, it appeared that the pharmacist was serving 30 to 40 people per day with codeine linctus.
Alternative approaches
For those who have no interest in quitting their OTC misuse, their activities are often covert and may not be known to the pharmacist. However, there may be many people who knowingly or unwittingly misuse OTCs who could be helped by the pharmacist.
As previously described, one way of dealing with the problem in the short term is simply to remove the items from show and refuse to sell them. However, two ques-tions have to be posed:
“Where will the misuser turn to seek other (perhaps more dangerous) supplies of the drug or an alternative, if no pharmacist is prepared to sell the products requested?”
“What is the harm to the individual and society, if the individual consumes on a regular basis products such as codeine linctus, which have been sold openly and legally by a pharmacist?”
It is clearly very difficult to answer these questions definitively, since very little research has been carried out in these areas. Many pharmacists feel that some of the misusers they see (especially older persons) have become dependent on products which were initially purchased for real health reasons.
Some community pharmacists may want to help patients who appear to be dependent on OTC medicines, but are otherwise not part of the drug misuse scene.
The official guidelines on the clinical management of drug misuse (Departments of Health, 1999) have been published primarily for general practitioners and contain very little advice on management of dependence of this type of product. In the past, some of these patients have been offered methadone maintenance through local drug agencies. This seems inappropriate, although the earlier Government guidelines for the management of drug misuse (Department of Health, 1991) have included a table of methadone equivalents, including an equivalent for codeine.
Practical help to such patients is a role that should be encouraged in order to reduce the chance of some misusers graduating into more serious problems. But how can community pharmacists offer a service which is acceptable to the ethical
constraints of the profession? Clearly they must not act alone. This is the main criticism laid out in Statutory Committee rulings (e.g. Anon, 1992). The recommen-dations for GPs are that “a multidisciplinary approach to treatment is essential”
(Departments of Health, 1999). How then can local liaison best be organised in order to help such patients?
A hypothetical scenario has been put forward by the author to various drug misuse groups and published in the pharmaceutical press (Temple, 1996). This sug-gests that the pharmacist maintains the therapy of the patient, through allowing con-trolled access to the preferred drug product, following a signed contract with the patient, which allows for full collaboration with the local community drug team (CDT) and/or GP and extensive record keeping. Unfortunately to date it has not been possible to examine this suggestion in a pilot scheme.
However, in the meantime, there is a real need for pharmacists to maintain closer contact generally with GPs and community drug teams (CDTs) in order to discuss issues relating to OTC drug misuse in a generic way. Indeed it would seem to be entirely compatible with the policy statement issued by the Royal Pharmaceutical Society in August 1991, which included the comment: “Liaison with medical practitioners and community drug teams is essential to ensure a co-ord-inated approach to the provision of services to drug misusers in each locality” (Anon, 1991), although this statement did not mention services with respect to sale of OTC preparations. This would create the right atmosphere locally to offer some positive help to an OTC misuser who seeks help or who accepts the need to deal with a prob-lem that has been highlighted by the pharmacist. Although pharmacists by and large are not trained in counselling techniques, they could spend some time with the drug user discussing their problem with them and trying to assist them to identify some potential solutions. With their permission, it would be possible to discuss their spe-cific case with others, although patient confidentiality must be respected. Working with a patient and a CDT in this way would create an ideal means of specific train-ing for the pharmacist, who would be better adapted to deal with future patients. The clinical psychologist or equivalent could well act as a mentor in such a scenario.
Creating new and improved opportunities to discuss the local drug misuse scene would have additional benefits. For instance it should be feasible to establish an early warning system through the Local Pharmaceutical Committee and/or CDT when there is indication of a misuse of a specific product in the locality. A good example of this was discussed above in the case of Sleepia®in Glasgow.
CONCLUSIONS
A range of issues relating to misuse of OTC preparations of relevance to the commu-nity pharmacist have been covered in this chapter. This includes specific interactions with users of hard drugs covered in other chapters, but also introduces a range of other clients in the pharmacy, from those primarily dependent on OTC products, either through initial bona fide use or as a deliberate act of experimentation, to those seeking advice to avoid accusations of cheating from sporting bodies. In all cases, the pharmacist is recommended to maintain close contacts with other professionals in the area, both to share knowledge as part of continuing professional development and to better help a specific client.
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