SPECIALIST PHARMACOLOGICAL & BIOCHEMICAL INTERVENTIONS
The general model of shared-care dictates that specialist services are directly responsible for provision of prescribing services to more complex clients and for the induction of opiate substitutes for all clients, whilst GPs will prescribe for less complex and more stable clients. There are two options available to specialist services with regard to dispensing - provision of prescriptions for dispensing at community pharmacies or direct dispensing of medication to clients.
Although direct (on-site) dispensing will not be suitable for all clients, especially those in rural areas with poor transport facilities, there are potential advantages of making such a service available from the main specialist service site. There is some indication that this may improve outcomes for individual clients (Wolff et al, 1996). Potential advantages include:
- Reduced cost to the health economy.
- Daily observation of the client.
- Direct confirmation of collection of medication.
- Ease of provision of supervised consumption service.
- Rapid induction onto holding dosage of opiate substitute medication.
- Daily dispensing of non-opioid controlled drugs.
- Community team site detoxification service provision.
- Improved compliance with clinic attendance leading to improved engagement with other specialist services.
- Reduced offending.
REDUCED COST
Community pharmacy dispensing can be up to twice as expensive as on-site dispensing because of daily dispensing charges and the reduced cost of methadone to hospital as opposed to community pharmacy purchasers. In addition to these direct savings, further cost reductions and improved cost-effectiveness will accrue as described below.
DAILY OBSERVATION OF THE CLIENT
The dispensing nurse will have the opportunity to observe clients on a daily basis. The importance of this is clear when considering the complex and chaotic nature of the client group which will receive a prescribing service from specialist services. This may be of especial relevance to dual diagnosis cases.
DIRECT CONFIRMATION OF COLLECTION OF MEDICATION
More chaotic clients may fail to collect medication on a daily basis as prescribed. This can lead to loss of tolerance and danger of overdose when collection resumes. The methadone regime will need to be reviewed or stopped if a client fails to collect for 2 to 3 days concurrently.
EASE OF PROVISION OF SUPERVISED CONSUMPTION SERVICE
The Clinical Guidelines (DoH) state that clients should routinely be dispensed for on a supervised consumption basis for the first three months of treatment. This is easily arranged for within specialist services, but is more difficult in the community where many pharmacists have not engaged with the Supervised Consumption Scheme.
RAPID INDUCTION ONTO HOLDING DOSAGE OF OPIATE SUBSTITUTE MEDICATION
The Clinical Guidelines (DoH) require that starting doses of methadone should not usually be in excess of 30mg daily, and that the client should be monitored closely while methadone dosage is increased in small increments over a period of weeks to months. In effect, in order to comply with guidelines, a busy GP is restricted to increasing methadone at a rate of 10mg weekly. Final holding dosage of methadone will usually be between 60mg and 120mg daily (DoH Clinical Guidelines). This leaves a difficult period of weeks or months during which the client is in effect compelled to use illicit substances on-top of prescribed medication.
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- Specialist statutory substance misuse services should consider the need to develop on-site dispensing services from their main base.
- The potential advantages of on-site dispensing include reduced cost, daily observation of the client, direct confirmation of collection of medication, ease of provision of supervised consumption service, rapid induction onto holding dosage of opiate substitute medication, daily dispensing of non-opioid controlled drugs, day-care detoxification service provision, and improved compliance with clinic attendance leading to improved engagement with other specialist interventions.
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Through a process of 'tolerance testing' (described below), specialist services with on-site dispensing facilities can induct clients onto a holding dose within one week.
DAILY DISPENSING OF NON-OPIOID CONTROLLED DRUGS
Whilst the Law only allows for the daily dispensing in the community of methadone and Subutex by means of a single prescription, the provision of daily dispensing for other controlled medication can be just as important clinically. The commonest example of this is the prescription of benzodiazepines, but services wishing to develop dexamphetamine and injectable opioid prescribing services would also benefit from the availability of on-site dispensing facilities. Currently, individual prescriptions for benzodiazepines and dexamphetamine must be written for each day's medication which is both time-consuming and expensive in terms of community dispensing charges.
DAY-CARE DETOXIFICATION SERVICE PROVISION
All specialist services should provide a community detoxification service as part of the range of detoxification services available to clients. Alcohol detoxification protocols include the provision of Pabrinex injections on the first three days of detoxification, while opiate detoxification protocols often include the provision of a naloxone injection. Such injections can only be given where emergency medication and medical help are available. Whilst it may be possible to administer such injections in the client's GP's surgery in some instances, such an arrangement has a high cost in terms of use of nursing time. The administration of injections at a central site allows a single nurse to administer injections to a number of clients, rather than on a one-by-one basis.
In addition to the provision of injections, community detoxification protocols require twice daily home visits by nursing staff, and the support of a carer who is available at the client's home 24 hours a day. The availability of a suitable central site with dispensing facilities will enable some clients to attend this site during working hours and return home overnight. As well as decreasing the cost of community detoxification through a saving in nurse time, such an arrangement will allow some clients with working partners to receive a community rather than in-patient detoxification.
IMPROVED COMPLIANCE WITH CLINIC ATTENDANCE LEADING TO IMPROVED ENGAGEMENT WITH OTHER SPECIALIST INTERVENTIONS
Together with the provision of on-site alternative therapies, on-site dispensing services are well recognised as being a major factor in attracting clients and ensuring clinic attendance. Substance misusing clients are typically poor attenders for healthcare interventions of all kinds. Specialist services have the potential to improve up-take of a variety of interventions by offering a 'one-stop' shop which provides a range of bio-psycho-social services aimed at improving health and social outcomes. Attraction of clients into this 'one-stop shop' (through provision of on-site alternative and dispensing services) in the first place is an essential component of improving attendance of the various services provided on-site.
Next page .. THE OPIATE ADDICTION TEST
The above information is copyright of Dr Bruce Trathen MBBS MRCPsych (2006). ISBN 0-9545164-0-0. The author grants permission for these guidelines to be downloaded, copied and distributed freely, but does not grant permission for their sale.
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