Catriona Matheson

Views of illicit drug users on their treatment and behaviour in Scottish community pharmacies: implications for the harm-reduction strategy:

A recent harm-reduction strategy has brought drug users into community pharmacies. During 1996, 124 illicit drug users in and around Aberdeen, Dundee, Edinburgh and Glasgow were interviewed to elicit their experiences of pharmacies. Many interviewees had experienced negative treatment, and some had demonstrated negative behaviour. Drug users preferred pharmacies in which they had experienced positive treatment, and this has consequences for resource allocation. Stigma was a key issue, and a poor self-image combined with apparent negative treatment may provoke negative behaviour. Education of pharmacists to promote positive attitudes, and education of drug users on what to expect from pharmacies, would encourage a more harmonious relationship and enable effective health promotion.

Pharmacy customers' views and experiences of using pharmacies which provide drug misuse services

This study aimed to determine whether pharmacy customers are deterred from using a pharmacy that offers services to drug misusers. If patients are deterred, what are their specific concerns? The study was qualitative and three different groups were interviewed about their views on pharmacies providing services to drug misusers (i) pharmacy customers, (ii) local community councils and (iii) local drug forums. This paper focuses on pharmacy customer interview results. Interviews were conducted in 10 pharmacies, five in Aberdeen and five in Glasgow, both areas of high drug misuse. The pharmacy customers were attending pharmacies with high, medium and low involvement with drug misusers and were located in city centre, suburban and rural locations. Pharmacy customers were generally supportive of pharmacies offering services to drug misusers. However, their support was often qualified by a wish to see a private area provided for methadone consumption. Pharmacy customers were more knowledgeable of the rationale for and supportive of needle exchange services compared to methadone maintenance and supervised consumption. The results of the study demonstrate that the majority of pharmacy customers are supportive of drug misuse services, provided there is adequate privacy in the pharmacy. These results should be used to encourage more pharmacists to provide drug misuse services.

Reducing drug related deaths: a pre-implementation assessment of knowledge, barriers and enablers for naloxone distribution through general practice.

BackgroundThe Scottish Naloxone Programme aims to reduce Scotland’s high number of drug-related deaths (DRDs) caused by opiate overdose. It is currently implemented through specialist drug services but General Practitioners (GPs) are likely to have contact with drug using patients and their families and are therefore in an ideal position to direct them to naloxone schemes, or provide it themselves. This research gathered baseline data on GP’s knowledge of and willingness to be involved in DRD prevention, including naloxone administration, prior to the implementation of primary care based delivery.MethodsMixed methods were used comprising a quantitative, postal survey and qualitative telephone interviews. A questionnaire was sent to 500 GPs across Scotland. An initial mailing was followed by a reminder. A shortened questionnaire containing seven key questions was posted as a final reminder. Telephone interviews were conducted with 17 GPs covering a range of demographic characteristics and drug user experience.ResultsA response rate of 55% (240/439) was achieved. There was some awareness of the naloxone programme but little involvement (3.3%), 9% currently provided routine overdose prevention, there was little involvement in displaying overdose prevention information (<20%). Knowledge of DRD risk was mixed. There was tentative willingness to be involved in naloxone prescribing with half of respondents willing to provide this to drug users or friends/family. However half were uncertain GP based naloxone provision was essential to reduce DRDs.Factors enabling naloxone distribution were: evidence of effectiveness, appropriate training, and adding to the local formulary. Interviewees had limited awareness of what naloxone distribution in primary care may involve and considered naloxone supply as a specialist service rather than a core GP role. Wider attitudinal barriers to involvement with this group were expressed.ConclusionsThere was poor awareness of the Scottish National Naloxone Programme in participants. Results indicated GPs did not currently feel sufficiently skilled or knowledgeable to be involved in naloxone provision. Appropriate training was identified as a key requirement.

Public opinion of drug treatment policy: Exploring the public's attitudes, knowledge, experience and willingness to pay for drug treatment strategies

BACKGROUND Research evidence is strong for opiate replacement treatment (ORT). However, public opinion (attitudes) can be at odds with evidence. This study explored the relationships between, attitudes, knowledge of drugs and a range of socio-demographic variables that potentially influence attitude. This is relevant in the current policy arena in which a major shift from harm reduction to, rehabilitation is underway. METHODS A cross sectional postal questionnaire survey in Scotland was conducted where the drug, treatment strategy has changed from harm-reduction to recovery-based. A random sample (N=3000), of the general public, >18 years, and on the electoral register was used. The questionnaire was largely structured with tick box format but included two open questions for qualitative responses. Valuation was measured using the economic willingness-to-pay (WTP) method. RESULTS The response rate was 38.1% (1067/2803). Less than 10% had personal experience of drug, misuse but 16.7% had experience of drug misuse via a friend/acquaintance. Regression modelling revealed more positive attitudes towards drug users in those with personal experience of drug misuse, (p<0.001), better knowledge of drugs (p=0.001) and higher income (those earning >£50,000 per, annum compared to <£15K; p=0.01). Over half of respondents were not willing to pay anything for drug treatment indicating they did not value these treatments at all. Respondents were willing-to-pay most for community rehabilitation and least for methadone maintenance treatment. Qualitative analysis of open responses indicated many strong negative attitudes, doubts over the efficacy of methadone and consideration of addiction as self-inflicted. There was ambivalence with respondents weighing up negative feelings towards treatment against societal benefit. CONCLUSIONS There is a gap between public attitudes and evidence regarding drug treatment. Findings suggest a way forward might be to develop and evaluate treatment that integrates ORT with a community rehabilitative approach. Evaluation of public engagement/education to improve knowledge of drug treatment effectiveness is recommended.

Community pharmacy services for people with drug problems over two decades in Scotland: Implications for future development

BACKGROUND In Scotland community pharmacies are heavily involved in service delivery for people with drug problems (PWDP) as documented through surveys of all community pharmacies in 1995, 2000 and 2006. A further survey in 2014 enabled trends in service demand/provision to be analysed and provides insight into future development. METHODS The lead pharmacist in every Scottish pharmacy (n=1246) was invited to complete a postal questionnaire covering attitudes towards PWDP and service provision and level of involvement in services (needle exchange, dispensing for PWDP and methadone supervision). Additional questions covered new services of take-home naloxone (THN) and pharmacist prescribing for opioid dependence. Telephone follow-up of non-responders covered key variables. A comparative analysis of four cross-sectional population surveys of the community pharmacy workforce (1995, 2000, 2006 and 2014) was undertaken. RESULTS Completed questionnaires were returned by 709 (57%) pharmacists in 2014. Key variables (questionnaire or telephone follow-up) were available from 873 (70%). The proportion of pharmacies providing needle exchange significantly increased from 1995 to 2014 (8.6%, 9.5%, 12.2%, 17.8%, p<0.001) as did the proportion of pharmacies dispensing for the treatment of drug misuse (58.9%, 73.4%, 82.6% and 88%, p<0.001). Methadone was dispensed to 16,406 individuals and buprenorphine to 1777 individuals (increased from 12,400 and 192 respectively in 2006). Attitudes improved significantly from 1995 to 2014 (p<0.001). Being male and past training in drug misuse significantly predicted higher attitude scores (p<0.05) in all four years. Attitude score was a consistently significant predictor in all four years for dispensing for the treatment of drug misuse [OR=1.1 (1995 and 2006, CI 1.1-1.3, and 2014 CI 1.1-1.4) and 1.2 (2000), CI 1.3-1.5] and providing needle exchange [OR=1.1 (1995 and 2006), CI 1.1-1.2, 1.1-1.3 and 1.2 (2000 and 2014), CI 1.1-1.3 and 1.1-1.5]. In 2014, 53% of pharmacists felt part of the addiction team and 27.7% did not feel their role was valued by them. Nine pharmacists prescribed for opioid dependence. CONCLUSION It is possible for pharmacy workforce attitudes and service engagement to improve over time. Training was key to these positive trends. Communication with the wider addiction team could be further developed.

Does training in motivational interviewing for community pharmacists improve outcomes for methadone patients? A cluster randomised controlled trial

Feasibility of pharmacist delivered motivational interviewing (MI) to methadone patients has been demonstrated, but its efficacy is untested. This study aimed to determine whether pharmacists trained in MI techniques can improve methadone outcomes.

Prevalence of common chronic respiratory diseases in drug misusers: a cohort study.

BACKGROUND A randomised controlled trial of substance misuse indicated that many patients who use methadone have respiratory symptoms and/or are prescribed respiratory medications. There is little research in this area. AIMS To determine the prevalence of respiratory disease and prescriptions among drug misusers. METHODS This historical cohort study of drug misusers and matched controls analysed routinely collected primary care data. The prevalence of common chronic respiratory diseases, class and number of respiratory medications were examined. RESULTS The cohort of 18,570 patients (9,285 per group) was mostly male (64%, n=11,890) and aged 31-59 years (76%, n=14,060). After adjusting for age, gender, deprivation and smoking status, the results showed that more drug misusers than controls had a diagnosis of asthma or chronic obstructive pulmonary disease (17.1% vs. 10.9%; adjusted odds ratio (OR) 1.61, 95% confidence interval (CI) 1.46 to 1.77, and 2.4% vs. 0.8%; OR 1.86, 95% CI 1.42 to 2.44, respectively) and were prescribed more chronic respiratory medications: short-acting β(2)-agonists (16.4% vs. 7.9%; OR 2.00, 95% CI 1.80 to 2.22), long-acting β(2)-agonists (1% vs. 0.4%; OR 1.93, 95% CI 1.29 to 2.89), and inhaled corticosteroids (10.6% vs. 7.6%; OR 1.49, 95% CI 1.33 to 1.67). All differences were statistically significant (p<0.001). CONCLUSIONS Drug misusers have a significantly higher prevalence of respiratory diseases and respiratory prescriptions than matched controls. Further work is needed to determine the reasons for this.

A pilot randomised controlled trial of brief versus twice weekly versus standard supervised consumption in patients on opiate maintenance treatment

INTRODUCTION AND AIMS Methadone maintenance remains the mainstay of treatment for opiate dependence in Scotland. Guidelines recommend supervised self-administration for at least 3 months, yet this is often interpreted as long-term supervision. However, there is no evidence base for deciding the optimal period of supervision. We tested the feasibility of conducting a randomised controlled trial (RCT) of different supervision models. DESIGN AND METHODS Three armed pilot RCT, set in three Scottish treatment areas, recruited opiate-dependent patients who had received methadone treatment for 3 months. Participants were randomised to: (i) no supervision; (ii) twice weekly supervision; or (iii) daily supervision for further 3 months. As a pilot, key process measures were: recruitment rates, follow-up rates and treatment fidelity. We also wanted to estimate effect sizes of two co-primary outcomes for a full RCT: treatment retention and illicit heroin use. The recruitment target was 60 participants. RESULTS One hundred and two eligible patients were identified, 60 (59%) participated, and 46 followed up (77%). Study fidelity was good with two participants moving group. Those randomised to no supervision were significantly happier with their group allocation. No significant differences were found in primary outcomes, although retention decreased with increased supervision, while illicit heroin use was least in those most supervised. DISCUSSION AND CONCLUSIONS It is possible to recruit and randomise participants to an RCT comparing different forms of supervised consumption. Pilot data suggest increased supervision may reduce illicit heroin use, but may decrease retention. This should now be tested in a large-scale multicentre RCT.

Changes in mental health during opiate replacement therapy: A systematic review

Aim: To determine whether changes in mental health occur over the course of opiate replacement therapy (ORT). Methods: Medline, Embase, PsycINFO, CINAHL and the Cochrane Library were searched from 1996 to 2011. Reference lists of identified reviews were hand-searched. Randomized controlled trials (RCTs) and national cohort studies which measured an aspect of mental health at baseline and follow-up, and reported significance testing over time, for individuals receiving ORT were included. Double data extraction was conducted. Findings: Twenty-two studies comprising 19 RCTs and three national cohort studies were included. Nineteen different instruments measuring various aspects of mental health were identified. Mental health significantly improved for all groups receiving ORT in 14 studies in either some or all of the domains assessed. There was tentative evidence to suggest methadone is less effective at improving mental health than other types of ORT. Improvements occurred early in the treatment process and were not always sustained. Conclusions: Mental health generally improves during ORT but this improvement may not continue beyond 12 months. Standardization of tools is recommended following comparative assessment of the sensitivity and specificity of different measures.

Management of drug misuse: an 8-year follow-up survey of Scottish GPs

This study repeated a Scotland-wide survey of one-in-four GPs from 2000, to compare findings with 2008. A 60% response was achieved (of 1065). Almost 44% of GPs were treating drug misusers (62% in 2000). Enhanced services were provided by less than half of practices. Seven per cent of responders were only comfortable prescribing below the recommended minimum dose of 60 mg methadone, (33% in 2000). Over 70% offered blood-borne virus screening and 71% were aware of patients using psychostimulants. Recent changes, particularly the new GP contract may have decreased GP involvement in treating drug misusers.