ADDICTION


increases as addiction and dependence to the drug deepens. (https:// harmreductionjournal.biomedcentral. com/articles/10.1186/1477-7517-1- 3#CR12)


By trying to understand the reasons that people actually use drugs, the help and support that we as pharmacists provide may actually be tailored to that individual. Psychoactive agents (ie, drugs that have an effect on the brain) can alter a person’s consciousness, mood and thought process. They do so by acting on the brain function and associated receptor pathways, which normally regulate mood, thought and motivation. Any substance that produces a ‘reward’ when taken can lead the person to repeat its use, which ultimately leads to dependence, of all drugs used by patients the most commonly reported drug was cannabis (66 per cent), followed by benzodiazepines (37 per cent) and then cocaine (35 per cent). Reasons for abuse of these drugs are complex but can include: enjoyment, experimentation, boredom, peer pressure, and one of particular concern is self-medication, which warrants further discussion. If a person suffers from an existing condition, they may choose to take a drug to improve their symptoms, for example if a person suffers from pain, they may self-medicate with opioid pain killers, which, if medical advice is not sought, may lead to dependence. However, more commonly in this context, self- medication refers to when the patient has a pre-existing mental illness and tries to alleviate the symptoms by taking a substance. This can be alcohol, tobacco or illicit drugs.


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 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


40 - SCOTTISH PHARMACIST


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 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 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, in which 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 are methadone oral solution, normally prescribed as 1mg/1ml and buprenorphine sublingual tablets - alone or in combination with naloxone.


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 every-day 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, they can produce ‘cravings’ and a psychological desire to keep on using them – 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 percent of this group said they had taken them for more than a year. This could potentially mean that more than 900,000 people in the UK are misusing if not abusing these drugs, resulting in dependence and addiction. Further alarming information was presented by the survey as almost of third of those who took these medicines said they were unaware that codeine-based painkillers could be in any way addictive.


While codeine in the isolated form is a prescription only drug, over-the- counter 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 a few hours from different surrounding pharmacies; during which, very few questions were asked by the pharmacists in the shops. In fact, in only one case was the risk of addiction explicitly clarified, and in three cases not one single question was asked. (http://www.itv.com/ news/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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