The recent upscheduling of codeine has pushed issues around drug dependency into the spotlight. So how can community pharmacists help minimise harm at the front line?
There’s a man in his early 60s who frequently visits Irvine Newton’s pharmacy in Melbourne. He’s well-educated, charming to the point of disarming, and as a former accountant, may have even done your tax return not so long ago.
‘But he was more and more frequently coming in to purchase Nurofen Plus,’ said Mr Newton, the 2017 PSA Pharmacist of the Year and Inaugural Chairman of PSA’s Harm Minimisation Committee in Victoria.
It was then Mr Newton had to break it to the man: he had developed a codeine dependency. ‘And he really had no issue about me saying so. He knew he had one,’ Mr Newton said.
He recommended to the man, and his GP, that he start using Suboxone. ‘He did brilliantly. Said he hadn’t felt as good for a long time,’ he said.
Harm minimisation efforts
As the scenario above highlights, drug dependency can take a hold of people from all walks of life.
Fortunately, slowly but surely, more and more measures are being put in place to enable pharmacists to take a larger role in harm minimisation.
Melanie Walker, CEO of the Australian Injecting and Illicit Drug Users League (AIVL), said the availability of naloxone, through community pharmacy was a great step forward.
‘Obviously in Australia we have a rising incidence of prescription opioid overdose. There’s a really strong role for pharmacists to play in facilitating the rollout of naloxone,’ Ms Walker said.
PSA and AIVL also recently teamed up to launch an online training module named ‘Normal Day’, which is designed to enhance communication and understanding between people who use drugs and pharmacists.
How pharmacotherapy can differ
Traditionally, there has been a lot of variation between states when it comes to harm minimisation approaches, said Dr Suzanne Nielsen, Pharmacist and Senior Research Fellow at the National Drug and Alcohol Research Centre.
‘In Victoria, patients can commence on methadone and buprenorphine in community pharmacies,’ said Dr Nielsen, who became the Deputy Director of the Monash Addiction Research Centre in April.
‘In New South Wales, patients are stabilised traditionally in clinic settings and transferred to community pharmacies later, though that is expected to change, which will make treatment more accessible for many.’
Angelo Pricolo, a member of PSA’s Harm Minimisation Committee and PSA 2008 Pharmacist of the Year, added that the number of pharmacies providing Opioid Substitution Treatment has dramatically increased over the last three to five years.
In fact, the number of private prescribers offering the treatment stood at 1,653 in 2013. In 2016, it had risen to 2,316 with 87% of opioid pharmacotherapy dosing points being pharmacies.
In 2018, the Victorian Government will also rollout SafeScript, which will provide health professionals with real-time access to their patients’ prescription history for certain high-risk medicines. It will be the second state after Tasmania to launch real-time prescription monitoring.
‘These people who are drug dependent who’ve been shopping around, going to a million GPs and pharmacies – we’re going to be able to identify them much more easily,’ Mr Newton said.
Ms Walker said the upscheduling of codeine could place more pressure on referral pathways for people managing pain.
‘A study done for the Department of Health and Ageing a couple of years ago estimated between 200,000 and 500,000 people were being turned away from drug and alcohol treatment in Australia each year because capacity couldn’t meet demand. That was before the upscheduling of codeine,’ Ms Walker said.
Mr Pricolo added that another issue is that naloxone is only available on the PBS when on a prescription.
‘The system still revolves around the doctor rather than the patient. That’s one of the things that really needs to be changed,’ he said.
In the meantime
So what are some practical ways community pharmacists can best assist those suffering from addictions?
Dr Jacinta Johnson, Specialist Pharmacist, Clinical Educator and a lecturer in UniSA’s School of Pharmacy and Medical Sciences, said providing a welcoming, non-judgmental environment where people feel comfortable to discuss their drug use was a good start.
‘The pharmacist has the responsibility to ensure all pharmacy staff are adequately trained. A poor experience with a pharmacy assistant can be enough to put a patient off coming back in,’ she said.
Dr Nielsen added the language one uses is critical. ‘For example, terms such as addict and abuser are no longer used by the World Health Organization and others as they perpetuate stigma.’
She said for regional and rural communities where people often know each other, having confidential dosing areas for methadone and buprenorphine made a big difference.
Mr Pricolo, on the other hand, prefers to have his dosing areas in the same place he treats people for diabetes and hypertension.
‘We aim to normalise the treatment and alter the stigma attached with addiction,’ he said. Mr Newton said while providing a normalised environment and service for drug dependent patients can be difficult, it’s a critical step for pharmacists.