Services for Drug Users
Supervised Administration, Prescription Support, Injecting Support and Health Promotion
Pharmacy Standards
Pharmacists can play a key role with drug users, often seeing clients on a daily basis and, by means of supervised consumption, providing a system that allows prescribers to be confident that treatment is being monitored and “diversion” of supplies is being kept to an absolute minimum. Supplies of clean injecting equipment along with health promotion advice is a key to harm reduction particularly for those that are not in contact with other agencies.
These standards cover:
- Supervised Administration - Supervised administration of oral methadone
- Prescription Support - Support to users collecting their dispensed prescriptions for methadone and other drugs used in the management of drug misuse along with feedback to prescribers.
- Injecting Support - Syringe and needle exchange scheme for injecting drug users
- Health Promotion(a) Advice on harm reduction methods and
(b) supply of condoms
Community Pharmacists should be able to contract with their PCT to provide the above services, in areas where these are required:
For Elements 1,2 & 4a - to people with a drug dependencyreceiving prescriptions for methadone and other drugs used in the management of drug misuse. For Element 3 - to any Drug User who self refers to the service. For all elements the user must agree to:
- Abide by the “rules” of the scheme
- For Elements 1 & 2, agree to a relaxation in “confidentiality” by signing a Client Registration Form to allow the pharmacy to share certain information with the prescribing team, with the Service Administrator and with any other pharmacy that the patient may transfer to.
The following criteria will apply to pharmacies wishing to participate in the scheme:
Pharmacies participating in the scheme must be “registered” with the Service Administrator..
Participation in the Supervised Administration & Prescription Support will be made available to all pharmacy contractors who wish to be involved and who are willing to operate within the standards set for the scheme and agree to accept up to 8 patients on Prescription Support (of which up to 4 may be on Supervised Administration). Pharmacies may accept more than this number if they so wish. The suggested figures allow for patients to be allocated a collection “time slot” so that the pharmacy generally only has to deal with one methadone patient per hour. It is felt that with back up this degree of activity should be within the capabilities of a majority of pharmacy contractors.
Participation in the full Injecting Support Scheme will not be compulsory, but a pharmacy providing supervised administration will be asked to consider providing needle exchange facilities and, as a minimum, should agree to sell syringes, needles, condoms and sharps containers where requested. In addition they must have facilities to accept used sharps returned in small sharps containers - a suitable sharps container + a collection service is should be available via the Health Authority / PCT.
Pharmacies providing Supervised Administration & Prescription Support should, where possible, provide an area for medication to be consumed out of view of other members of the public. It is recognised that this objective is, to some extent, a long-term aim and will be dependent on grants being made available to modify premises.
Each pharmacy contractor who wishes to take part in the scheme should name the pharmacist responsible for providing the service and liaising with HA/PCT
It is desirable that the pharmacist nominated should have completed (or be undertaking) the CPPE distance learning package on substance misuse or a similar course.
All pharmacies involved must operate a non-discrimination and equal access policy.
The participating pharmacy must agree to complete and return the necessary paperwork in a timely manner in order to meet the deadlines set. These include:
1.Pharmacy Registration to take part in the scheme
2.Client Registration for new clients
3.Recording of missed doses
4.Recording of number of current clients supervised, number of clients collecting and their prescriber, on a monthly basis (Recording Forms will be provided).
5.Return of the above information by the 5th working day of the following month to the Service Administrator.
The participating pharmacy must agree to contact the prescriber by phone or fax in any of the following circumstances:
1.Following 3 sequential failures to collect medication.
2.Evidence of increasing health, emotional or other problems
3.Breach of the “contract” to which the service user has agreed
4.Any other occasion when the pharmacist is concerned about the user’s well being.
The participating pharmacy should make available information/ leaflets supplied via other agencies on drug abuse topics particularly covering harm reduction, availability of Injecting Support (Needle Exchange) and self help groups.
Where necessary, the participating pharmacy should refer clients to other suitable services that work with drug users.
Advice and counselling will be provided to all users of the service.
Where a prescription calls for methadone mixture (or buprenorphine tablets) to be consumed in the pharmacy, the prescribed quantity should be provided to the client in a properly labelled container, with the top removed prior to handing over. The client should consume the item in front of the pharmacist. Water should be available for the client to drink if required. The pharmacist should be satisfied that the dose has been consumed. Any significant comments or observations should be noted and fed back to the prescriber where this is necessary.
Any difficult incidents that may occur should be reported back to the Service Administrator and/or prescriber as appropriate.
The Service Administrator will supply:
A range of back up services to include
Registration forms for clients, recording charts, “Methadone Files”, a passport photo service, information on how to operate the system including a “Yellow Card/Red Card” client warning system..
Monthly payment
Placement of clients with other pharmacies where there has been a breach of rules.
The Health Authority/ PCT will provide:
Supplies of equipment to be supplied via the Injecting Support service.
Sharps containers
Collection of full sharps containers
Element 3 - Injecting Support :
In order to maximise pharmacy recruitment to Injecting Support various levels of involvement may be negotiated. This could lead to different pharmacies offering:
1.Full Scheme
2.Limited supply (say to “regulars only”)
3.Sale (as opposed to free supply) of injecting equipment
4.Strict exchange - one for one only policy
All pharmacies involved would, as an absolute minimum, have to supply sharps containers and accept “returns” and to have a written handout setting out the service that they provide.
Drug users would be able to “vote with their feet” as to whether or not they wished to avail themselves of the lower levels of service.
Other points to note include:
Recording sheets and monthly returns would be of a standard format to tie in with those used by other Drugs Projects in the area and enable the Service Administrator to undertake computer analysis of the returns.
Additional recording forms may be necessary in order to keep track of the Health Authority’s stock of Injecting Equipment.
All forms to be returned to the Service Administrator in a timely manner in order to facilitate data entry, payment and computer analysis of supplies.
The service to be provided in a discreet manner. However, those clients who fail to keep to the rules may be refused supply.
The pharmacist will ensure that, where appropriate, users of the service are referred to other services that work with drug users. In particular clients should be referred , where appropriate to services where they can access screening and vaccination (specifically to include Hepatitis B and C & HIV screening).
The pharmacy will carry information leaflets on harm reduction, injecting techniques and information on self help and support services. These to be supplied by the Service Administrator and others.
Draft dated : 15 October 2018
Martin Bennett
Associated Chemists (Wicker) Ltd
61-71 Wicker, Sheffield S3 8HT Tel 0114 272 7676 Fax 0114 272 6431 Email
Appendix
1. Rules - Instalment Supplies
2. Rules - Injecting Support
3. Rules - Yellow Card
Instalment Prescriptions -The Rules
To make life easier for everyone it is important that you are aware of the limitations and rules that apply :
- The supplyhasto be made on the date specified on the prescription. So if you forget to collect and come in the following day, you can't have it. That applies even when the supply due is for a number of days. So if you should have collected a four days supply yesterday but forgot, we can't supplyanyuntil the next due date.
- Where the prescriber states "supervised administration", you will be supplied with the liquid in a container and will be expected to drink it in front of the pharmacist.
- You will be issued with a computer identification card when you bring in your first prescription. We may also require an up-to-date passport style photograph for our records. It isyour responsibility to keep your card safe and show it in order to identify yourself when collecting your dispensed items. Failure to provide adequate identification may result in delay or refusal to supply until adequate identification is forthcoming.
- You mustcollect each instalment in person. We will not supply to a third partywithout prior agreement direct with the prescriber and a written, dated and signed request for that specific supply.
To avoid delays and disputes we would like to make the following suggestion.
{Allow 30 minutes after opening (or re-opening at lunch) before you arrive to collect your medication. This enables us to prepare and check everything.
{Do not bring friends with you. Come into the pharmacy on your own.
{Always check your medication in the pharmacy when the item is handed to you. This means that any discrepancies between what you receive and what you were expecting can be resolved immediately. Then keep it safe - don't leave it unattended unless locked away. Remember, lost, stolen or dropped items can't be replaced - you would need another prescription.
Please remember that we have other patients, customers and telephone queries to deal with, so it is not always possible to attend to you immediately. It helps if you can sit down or stand to one side so that we have sufficient space to speak with other patients privately.
Behaviour
We expect you to behave in a similar manner to the other customers that we deal with. In addition, we hold you responsible for behaviour of any friends or acquaintances that arrive with you. Things that we, or our other customers, take particular exception to are:
* Noisy disruptive behaviour * anyone that steals from us * anyone that is abusive or violent
*anyone that tries to “deal” or beg in or near the pharmacy * anyone that discards used “works” in an unsafe manner * anyone that “queue jumps” * anyone that tries to alter a prescription or presents a forged prescription.
Where individuals behave in the above manner they will be referred back to the prescriber and their current prescription will be cancelled. We will also refer the matter to the Police where appropriate. It is also likely that we will refuse to dispense any future prescriptions or serve you in this pharmacy.
Needle Exchange - The “Deal”:
We provide an Injecting Support Service as a harm reduction measure for the benefit of drug users. Provided the user keep to the rules, we undertake the following:
- A confidential service - (we record initials, date of birth and district only) - but you should note that transactions may be recorded on video.
- A returns service for destruction of used “works”. Returns should be in small sized black “sin bins”. Larger sizes should be returned direct to the ...... Drugs Project.
The maximum supply to one person is normally:
We try to serve you as quickly as possible - but please be patient -
Customers both in the pharmacy and on the phone also require attention and the pharmacist can only do one thing at a time!
RU16?
If you appear to us to be under 16 and cannot prove otherwise, then youmust obtain equipment from the ...... Drugs Project. We also recommend that those under 18 should obtain their supplies from ...... where an appropriate assessment can take place
Your side of the “deal”:
We expect you to behave in a similar manner to all the other customers that we deal with.
We hold you responsible for the behaviour of any friends or acquaintances that are with you.
Things that we (or other customers) take particular exception to are:
noisy, disruptive behaviour
anyone that steals from us
anyone that is abusive to us
People that appear to “jump the queue”
The above list applies to all our customers whilst those that follow tend to specific to drug users
anyone that "deals" in or near the pharmacy
anyone that discards used "works" in an unsafe manner.
People who behave in this manner will not be served.
IMPORTANT
Where our “rules” are broken, we reserve the right to report this to the Police and provide them with the appropriate video evidence. Once the rules have been broken by an individual, our obligation concerning the confidentiality of their transactions no longer applies.
DRAFT LETTER
Date:
Dear ...... ,
Unacceptable Behaviour- Yellow Card
Further to the conversation with myself on ...... , this letter is to confirm that you have now had your FINAL WARNING with regard to your behaviour. The enclosed leaflet, which you have already had, sets out clearly the rules that apply.
You broke these rules in the following manner ......
I want to make it quite clear that any repetition of this or any of the other items mentioned in the leaflet will result in us refusing to dispense any further prescriptions, to sell any goods or to include you in the needle exchange scheme. To put it bluntly you will be "banned".
I hope this makes it perfectly clear - in football terms you have been yellow carded - a second yellow card will result in an automatic red card & sending off!
We try to offer an excellent service and like to have a pleasant relationship with all our customers but in return we do expect reasonable behaviour.
Yours sincerely,
Pharmacist
Copy to Prescriber
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