those using illicit drugs or substances, in what they believe to be a recreational manner may be in denial of the risks they face, or may not even be aware of them at all.

for example, many of those using ecstasy or cannabis deny that there is anything harmful about their use, and those that regularly use heroin or cocaine have stated that they are capable of leading a ‘normal’ life, ie, maintaining a job, looking after a home and raising a family.

furthermore, it has been shown in research that young people may have an unrealistic idea of how easy it is to give up their chosen drug when ‘the time comes’. Patients may however reach a stage where they feel they have to make a compromise and balance their enjoyment of the drug against the health and dependency problems that are being created as a consequence. We as pharmacists need to help those facing addiction reach this point.

In previous years, pharmacists have focused mainly on harm reduction policies, yet there now has been a shift towards focusing on recovery from addiction.

the key policy in northern Ireland and the UK governing professional responses to substance users is one of reducing the impact of misuse through prevention and early intervention, enforcement and effective protection of those affected by substance misuse and delivering effective opportunities for recovery from substance misuse.

therefore, within this context, harm reduction continues to play an important role in reducing the physical health problems associated with illicit drug and substance abuse. Harm reduction can be viewed as the first step in facilitating patients on the ‘road to recovery’.

Aspects of harm reduction which are of interest to pharmacists and their teams include: • reducing the physical health impacts of substance use

• reducing the risk of drug-related disease, including the spread of blood-borne viruses

• improving all aspects of health for individuals

• reducing the incidence of drug -related deaths

one of the main efforts of harm reduction as facilitated by the pharmacist’s role to reduce drug- related harm focuses on provision of advice and information. Pharmacists can supply a range of education and advisory materials for people who use or inject drugs, through needle exchange schemes for example.

Community pharmacies are often the outlet for these kinds of materials. In addition, all pharmacists can: • advise on mental health issues, eg, anxiety, depression, paranoia

• offer advice and help on physical health problems, eg, constipation or pain relief (opioids)

• advise on how to avoid risky combinations of drugs or that of drugs and alcohol

• advise on how to prevent, recognise and treat an overdose

• provide information where patients are concerned about blood-borne viruses or refer on to specialist services

• direct those affected to other local treatment and care services or an A&E department

• advise on safe storage of prescribed medicines or injecting equipment – particularly where children are in the household

A major role we play as pharmacists within northern Ireland in an individual’s plan for recovery from dependency on heroin or other opioids, may be to provide a substitute medication within a framework of medical, social and psychological treatment.

Referred to as opioid replacement therapy, medication may be prescribed as part of an on-going care plan or be part of a detoxification regimen. this supports patients to: • minimise or prevent withdrawal symptoms

• moderate a confused lifestyle and reduce illicit drug use

• improve physical and mental health

• act as a stepping stone to personal recovery - including employment, training, re-establishing personal and community relationships.

the two medications licensed for the treatment of opioid dependence in northern Ireland are methadone oral solution, normally prescribed as 1mg/1ml and buprenorphine sublingual tablets - alone or in

combination with naloxone. In the most recent statement (2015) published by the Public Health Agency, 865 patients received substitute prescribing treatment in the region, which was a five per cent marked increase upon the previous year; 46 per cent of patients receiving methadone and 46 per cent receiving buprenorphine, while the remainder treated was unknown.

Use of substitute medicines through pharmacy provision has been shown to retain patients in treatment and reduce the intake of illicit drugs, further reducing the risk of contracting HIV, tuberculosis and hepatitis.

However, as with other opioids, there is the potential for dependency and overdose.

Drug dealing and addiction may be commonly thought as a venture associated behind closed doors or in ‘dark alleyways’, however, as we all know, it is an unfortunate everyday occurrence within our own pharmacies over the counter.

Despite the guidelines for the sale of codeine-based painkillers being tightened in 2009 to minimise the risk of overuse (prominent warnings were placed on packets about the risk of addiction and the importance of not taking them for longer than three days was emphasised), it has been found that more than 900,000 people across the UK could be misusing otC painkillers containing codeine.

Commonly used to treat pain and fever, codeine is commonly and inappropriately thought to be harmless, however, codeine is an opioid, a derivative of morphine, and therefore could be used as a gateway to further drug use and abuse. thus the importance on the tight regulation of sale cannot be undermined.

As an opioid - part of the opiate family - it can induce feelings of calm, relaxation and lethargy. If used for longer than the recommended three days it can produce 'cravings' and a psychological desire to keep on using it - akin to the addictive effects of the more dangerous opiate heroin, which like codeine, is derived from the poppy plant.

In a survey conducted on the use of codeine-based products over the counter from pharmacies involving 2000 people, 75 per cent of those asked had used codeine-based painkillers and of those one fifth admitted to using more than the recommended daily dose.

Almost half of the people who had used otC painkillers said they took them for more than three days in a row and almost six per cent of this group said they had taken them for more than a year.

While codeine in the isolated form is a prescription only drug, otC combinations contain aspirin, ibuprofen and paracetamol, and if people are taking more as their tolerance to codeine increases then they start to take seriously harmful amounts of these drugs too.

this can lead to many complications including kidney failure, enlarged liver, stomach ulcers and intestinal issues.

Additionally, despite the introduction of tighter regulations in 2009, it has been found that bulk buying of these medications is still very possible.

this was demonstrated by a reporter who was capable of buying 576 tablets within very few hours from different surrounding pharmacies.

During the purchasing process very few questions were asked by the pharmacists in the shops, and in only one case was the risk of addiction explicitly clarified.

Most alarming was the fact that three pharmacists didn’t ask a single question. ( 2015-07-10/tonight-over-the-counter- addiction/)

therefore, with codeine, as with all abusive substances, we, as pharmacists, cannot underestimate our power and position at the forefront to safeguard medicines use, and empower our patients with the knowledge and motivation surrounding addiction issues in our practice. •


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