Substance Misuse / Substance Misuse
Substance misuse may be of an illegally produced ‘street’ drug or might involve misuse of legally obtained substances such as codeine bought over the counter as an analgesic, laxatives or alcohol bought for recreational use. It covers a wide range of topics:
 
Alcohol consumption
Smoking
Solvent abuse
Smoking, ingestion and injection of narcotics
 
This section will focus on the latter two elements, alcohol and smoking cessation are more thoroughly covered as topics in the health improvement section in that context. The use of disulfiram in alcohol dependence is discussed below in the Harm Minimisation / Risk Reduction section.


Prevention Harm minimisation and Risk reduction

Pharmacists play an important part in controlling the availability of medicines, in providing information and advice about substances liable to misuse and the associated risks and in providing harm reduction programmes e.g. methadone and the supply of injection equipment.  
Prevention roles include:
  • Supplying health promotion materials such as ‘Safe Storage of Methadone, ‘Methadone and your Teeth’ and overdose prevention information.
  • Disseminating information about infected batches of street drugs, high strength batches etc. to their methadone and injection equipment supply patients when appropriate.
  • Ensuring that they and their counter staff are aware of OTC sales of substances liable to be abused e.g. codeine or dihydrocodeine containing preparations and stimulant preparations such as pseudoephedrine.
  • Having SOPs in place outlining how patients suspected of misusing OTC or prescription medicines are dealt with.
 
Harm minimisation and risk reduction is not just for the patient but also for the benefit of society by for example, preventing the accidental exposure to the paraphernalia of substance misuse such as used syringes with the attendant risk of the possible transmission of Hepatitis, HIV and other Blood Borne Viruses or reducing the level of crime and petty theft by stabilising patients on methadone or suboxone therapy.
 
Provision of clean injecting apparatus at Injecting Equipment Provider (IEP) pharmacies
Clients may obtain clean supplies of injecting equipment and return used syringes to pharmacies registered to provide this service. A map of pharmacies offering this service is available from Glasgow Addictions Services on 0141 276 6600 
 
Substitution therapy
Pharmacies may supply substitution therapies. The most commonly supplied are methadone, suboxone and buprenorphine therapies for opiate dependency and disulfiram for alcohol dependency. It is important that they refer to the NHSGGC Standards for the Supervision of Substitution Therapies in Community Pharmacies find link for this
This is also seen as a useful contact point with otherwise hard to reach patients so it is important that the pharmacist can sign post the client to other services as necessary giving advice on wound care and management, safer injecting practices and reminding the client of the importance of safe disposal of syringes.
 
Child protection guidelines
Guidance is provided in the NHSGGC Supervision of Substitution therapies in Community pharmacies (only available via N3 connection).
Overdose awareness
Prompt management of an accidental overdose can save lives. Naloxone (Narcan) can be administered in life threatening circumstances where an overdose of an opiate has been taken. Legislation has been amended to allow the use of this prescription only item in an emergency circumstance by a non healthcare worker and drug user’s friends, families and carers where appropriate have been trained to administer this.
Much useful information including health promotion material is available on the Glasgow Addictions Services page http://www.glasgow.gov.uk/en/residents/care_support/drugs_alcohol/
 
Vaccination and Hepatitis B
Vaccination against Hepatitis B is a vital way to reduce the harm caused by accidental transmission of this virus. Glasgow community addiction teams (CATs) will routinely offer vaccination to ‘at risk’ clients.
They may also offer vaccination against Hepatitis A and tetanus which can pose a risk to some clients due to their poor lifestyle and environment. Hepatitis A is not a blood borne disease but is spread by the oral faecal route and through contaminated water
Pharmacy staff dealing with clients in IEP pharmacies should have a course of hepatitis B injections to provide them with protection. It should be noted that this is not a vaccination routinely offered by a GP practice. Employees are asked to access hepatitis B vaccination through their occupational health service.
Refer to the Communicable disease hyperlink this section for more information
 
Hepatitis C and HIV.
Significant health risks are posed by transmission of HIV and Hepatitis C virus.
It is estimated that 1 in 40 people may be infected with hepatitis C but many will be asymptomatic.
One in five individuals will spontaneously recover from an acute attack but if the virus is present for more than six months then it is judged a chronic infection. 
Although there is no vaccination against Hep C available it is treatable.
It is important to treat this as long term infection can lead to cirrhosis and liver failure.
To learn more about the disease and its treatment visit the Hepatitis C Scotland website at www.hepcscotland.co.uk
Human Immunodeficiency Virus (HIV) infection continues to rise in Scotland.
There is no cure for, or vaccination against, this but it may be treated and development of the infection into Acquired immune Deficiency Syndrome may be significantly delayed.
Treatment is usually with a combination of three drugs. For more information go to the HIV Scotland website www.hivscotland.com
For more information on HIV and Hepatitis B and C go to the Blood Borne Virus section (link to section)
 
Needle stick injury
It is vital that pharmacy staff know how to deal with needle stick injuries. Careful adherence to SOPs and procedures should minimise the possibility of this and information on how to deal with such an injury may be found here
 
Support
It is important to ensure that the appropriate support processes are in place in the pharmacy to optimise the provision of services for clients and patients with substance misuse issues.
Pharmacists should
  • Ensure SOPs are in place for addiction services offered in the pharmacy, reviewing and standardising procedures for a consistent approach from all staff and locums and ensuring these are followed.
  • Be mindful that patients being treated with substitution therapy may still require other healthcare support and should consider provision of care through eMAS to treat side effects of substitution therapy such as constipation
  • Be aware that dental pain is often significant, poor dental health especially of methadone patients is common and can be caused by several factors such as poor oral hygiene, reduced saliva production and the acidic nature of methadone.
  • Respond appropriately to pain symptoms. Methadone is an opiate substance, but it must be remembered that the analgesic effect of methadone is different to that of normal opiates as the effect only lasts about 3-4 hours so the pain killing effect of a once daily methadone dose is minimal
 
Key links for NHSGGC pharmacies
 
(Only available via N3 connection). 
 
 
 
Other related topic linksNarcotics Anonymous        http://www.ukna.org/
Hepatitis C –  C-level    0141 332 2520          www.c-level.org.uk
SDF –    0141 221 1175       www.sdf.org.uk
Know the Score     0800 587 5879        www.knowthescore.info
Frank                    0800 776600        www.talktofrank.com     
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