Blog: Patient harm reduction: medications, substances, and community pharmacy

Today, 31st August, marks International Overdose Awareness Day. Overdose is an emotive topic, whether accidental or not. Community Pharmacy has a role to play in supporting people – and is well placed to do this – as most people have easy access to a pharmacy. Pharmacy teams can support people with substance misuse habits (through supervised consumption programmes) or engage people picking up prescribed medications. Overdose can occur with prescribed medications and illicit drugs, so it is important that support is available for all.

The government is consulting on expanding the list of professionals who can access Naloxone without the need for a prescription. This includes pharmacists. Naloxone reverses the effects of an opioid related overdose and is available in a pre-filled syringe or nasal spray. It can be administered in emergency situations and may be kept in outreach centres and halfway houses.

This consultation forms part of Dame Carole Black’s independent review of drugs. In 2020, the CCA responded to phase two of this review which was on prevention, treatment, and recovery. We outlined the role of community pharmacy in supporting vulnerable patients particularly through the pandemic. In our response advocated for increased access for Naloxone, and recommended that the ‘take home Naloxone’ scheme be made available nationally.

The need for increased access to Naloxone is evident in the last week as Public Health England released a National Patient Safety Alert for a synthetic opioid called isotonitazene (with a potency similar to fentanyl, which is about 100 times that of morphine). There has been an unprecedented number of overdose deaths in London, South East and South West England. This spike is among people who primarily use heroin and may not be aware of the increased risk with the synthetic opioid. There is good evidence that Naloxone would be effective in counteracting this powerful opioid, and therefore expanded access must be supported to prevent future deaths.

However, the drawback is that Naloxone is essentially a sticking plaster.  It deals with the consequences and not the causes of overdose. Additionally, Naloxone can’t countereffect all overdose cases because it only works against opioid based drugs. It can restore normal breathing to a person whose respiration has been depressed because of an opioid overdose.

More can be done, and should be done, to raise awareness of the risks of all drugs and medications, among both healthcare professionals and patients. This includes medications that have been taken as prescribed leading inadvertently to dependency. Medication is not always the solution to pain management, but availability of alternative therapies is poor.

High numbers of patients are dependent on prescribed medications used to treat pain, anxiety depression and insomnia. The Public Health England report on prescribed drug dependence and withdrawal looked at five categories of commonly prescribed drugs (benzodiazepines, z-drugs, gabapentinoids, opioids and anti-depressants). The report found that patients need more support with withdrawal than is currently available and that patients in areas of deprivation are more likely to be prescribed some of these drugs. This is a complex problem, and solutions need to deliver on a local and national scale.

However, the solution must start with the creation of patient centred services, such as therapeutic services to tackle the cause of dependence. Pain management and addiction specialists can support patients with a personalised approach with therapies including cognitive behavioural techniques, exercise, meditation, and socialising as an alternative to long-term use of prescribed drugs. These medications become less effective the longer they are taken, and doses are likely to increase over time. As a result, it becomes harder for patients to withdraw. This cycle can increase the risk of unintended overdose and side effects from long term use of the medicines themselves- which patients report can be more damaging than the pain for which the medication may have been originally prescribed. Patients can lose autonomy and freedom in their lives by taking high strength prescribed drugs for pain relief over a long period, as this story shows.

What more can be done?

The CCA has led on engagement of a wide range of stakeholders to raise awareness of community pharmacy’s role at the face of patient care and harms reduction.

The CCA has a Professional Practice Group (PPG) and supports a sector wide Patient Safety Group (PSG). Both working groups are forums for the sharing of best practice as well as raising awareness about concerning trends.

Collectively, the PPG and PSG are working with the Centre for Pharmacy Postgraduate Education (CPPE) to develop training for pharmacists to recognise signs of dependence. Additionally, this training aims to build knowledge and confidence among pharmacy team members and give them the skills to initiate difficult conversations with patients and prescribers. Hidden issues may also be driving patients to access over the counter medicines including codeine. The CPPE training will support pharmacists to take a patient centred approach based on an individual’s needs.

However, this is only a small part of the wider systems approach needed to tackle drug and medicine dependence. The CCA awaits the NHS response to the Public Health England report and hope that it provides a well-resourced and joined up infrastructure of support for patients.

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