OPIOIDS
OVER-THE-COUNTER (OTC) AND PRESCRIBED OPIOID ANALGESIC DEPENDENCY (OAD) IS NOW RECOGNISED AS A KEY CONCERN AND PATIENT SAFETY ISSUE BY PHARMACISTS AND THEIR STAFF. ANNAMARIE MCGREGOR, PRACTICE DEVELOPMENT LEAD AT ROYAL PHARMACEUTICAL SOCIETY (RPS) SCOTLAND, TELLS SP HOW PHARMACISTS NEED TO TAKE OWNERSHIP OF THIS ISSUE…
OPIOID ANALGESIC DEPENDENCY:
ur focus on opioids really started about three years ago in response to the
Which? campaign regarding OTC supply, in response RPS made a number of commitments to improve quality in OTC assessment.
Around that time, Dr Mags Watson, Senior Research Fellow from the Centre for Academic Primary Care, University of Aberdeen and the RPS North East Local Practice Forum, developed a workshop to support teams to address the need for improvement. Training in consultation, assessment and negotiation skills is required.
I found this approach extremely proactive and relevant and so I adapted it to help participants meet the General Pharmaceutical Council premises standards and repeated it across Health Boards. I was surprised that - for practically every group of pharmacists and their teams – the most difficult conversation was about approaching people whom we think were taking too much OTC opioids.
In one group in Lanarkshire there were two pharmacists who talked about one person in their town, who was known for going from pharmacist to pharmacist buying OTC opioids. The pharmacists knew this person had a problem, but didn’t know what to do, but wanted to help. This is a complex area, where yes or no are not necessarily the correct answer.
Not long after that, Amanda Laird and Patricia Armstrong from West
60 - SCOTTISH PHARMACIST
of Scotland Local Practice Forum helped me to devise a workshop (with assistance from Jennifer Kelly, a pharmacist working with Indivior and a former prescriber in Glasgow Alcohol and Substance Misuse Team), which was aimed at providing pharmacists with the tools that can effect change. We embedded research with Catriona Matheson’s longitudinal work and included a prevalence study from University of Strathclyde, which was delivered by the three pre-registration trainees involved: Jayne Stewart, Mandy McCabe and Kelly Preston
high-profile death of the singer Prince. At the same time, the Royal College of General Practitioners (RCGP) had just published factsheets on addiction to OTC and prescribed medicines. This provided a great joint working opportunity to tackle the issue.
The workshops were very well attended and the feedback that we received was extremely positive. Many of the attendees said that their understanding of this issue had greatly increased as a result of what they’d heard.
I also discussed the issue with the Scottish Specialist Pharmacists in Substance Misuse, Scottish Public Health Network, Scottish Prescribing Advisors Association and all agreed that the profession had to take more ownership of this issue and lead the changes required. While we initially started out focusing on OTC, however, it soon became clear after speaking to these groups that we needed to extend our remit to include prescribed opioids. Liz Grant, a Public Health Pharmacist from NHS Greater Glasgow and Clyde helped me with ‘re-framing’ the conversations in line with recent thinking in motivational techniques.
The workshop began in September 2015 and was jointly run by nine Health Boards and RPS. It focussed on the prevalence of OTC and prescribed OAD and how to identify, manage and reduce OAD. The dangers of OAD were very much on everyone’s mind at the time as a result of the
In the workshops we focussed on issues such as how the pharmacist can deal on a practical level with the initial intervention with the patient, which is, for any pharmacist, the trickiest aspect of the approach. Using existing knowledge of the cycle of change and brief interventions that pharmacy teams use in smoking cessation is a good start.
The common theme for many pharmacy team members is that, if approached, many people become aggressive. Some attendees stated that patients often seem taken aback at the pharmacist challenging them on this subject. They probably expect a GP to intervene in terms of refusing to prescribe any opioids, but they certainly don’t expect the community pharmacist to do so.
It also became clear through talking to pharmacists that we need to adapt the manner in which we approach a patient and the language that we employ in doing so. From my time
ADDRESSING THE ISSUE O
as a community pharmacist, I have learnt from experience that using phrases such as ‘you are taking too many painkillers’ doesn’t work, so it’s a matter of reframing the approach by saying, for example, ‘are you concerned that you are taking too many?’, or, ‘can you tell me about your pain?’, or using empathy by introducing the subject with phrases such as ‘this must be costing you a fortune…..’
The key thing is making it safer – identifying people who are taking high, unsafe doses of paracetamol or ibuprofen or aspirin to get the level of codeine they need. We can have conversations with their GP and can suggest a safer way of doing this.
We also can’t forget that OAD more often than not starts with sub-optimal pain control. We need to work better with our customers and patients to manage pain effectively and stop opioids quickly if they are not working
There’s no doubt that we are on a long journey in trying to address this issue, but, at the end of the day, we can only do so much. It is, at the end of the day, up to the person whether or not they wish to address their dependence – as it is in the case of any dependence. They may not want our help and, if that is the case, then we have to accept that. We may, however, have have sown a seed for change.•
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