Substance Misuse and Pharmacy (DONE)

Question 1

What is substance misuse?

Answer 1

The harmful or hazardous use of psychoactive substances, including alcohol and illicit substances

Question 2

What is dependence syndrome?

Answer 2

A cluster of behavioural, cognitive and physiological phenomena that develop after repeated substance misuse

Question 3

Psychological dependence

Answer 3

Impaired control over drug use in terms of onset, levels of use and termination
Compulsion or craving to use substance resulting in drug-seeking behaviour
Persisting with use even in the knowledge that it is harmful
Increased tolerance

Question 4

Physical dependence

Answer 4

Withdrawal symptoms experienced when the substance is withdrawn as the body becomes accustomed to it
Symptoms relieved by administration of the substance
Examples: opiates, benzodiazepines, alcohol, caffeine
Increased tolerance

Question 5

Tolerance

Answer 5

A decrease in response to a drug dose that occurs with continued use
Increased doses of the drug are needed to produce the effects originally produced by lower doses
Can be physical, behavioural or psychological

Question 6

Withdrawal syndrome

Answer 6

A group of symptoms which occur on cessation or reduction of use of a psychoactive substance that has been taken repeatedly, usually for a prolonged period and/or in high doses
May be accompanied by signs of physiological disturbance
Time of onset and symptoms will vary according to drug
Symptoms are generally relieved by administration of the substance causing the withdrawal

Question 7

Opioid withdrawal symptoms

Answer 7

Flu-like symptoms which may be severe
Stomach cramps
Sweating and goose flesh
Yawning 
Irritability
Insomnia
Vomiting
Diarrhoea
Pain
Muscle spasms

Question 8

Alcohol/benzodiazepine withdrawal

Answer 8

Sudden withdrawal can be dangerous
Tremor 
Sweating
Anxiety
Agitation
Depression
Nausea
Malaise
Can be complicated by grand mal seizures, strokes and heart attacks in high risk patients

Question 9

Why provide substance misuse services?

Answer 9

Treatment is effective
Individuals in treatment are less likely to use drugs, commit crime to pay for drugs and to overdose
Individuals in treatment also reduce their risk of acquiring blood-borne infections as their injecting is reduced

Question 10

Pharmacy services for substance misusers

Answer 10

Two main services seen in pharmacy: dispensing and supervised consumption of oral opioid substitution therapy, and needle and syringe programmes
Harm reduction is a core principle of these services, not necessarily abstinence

Question 11

Opioid substitution and supervised administration

Answer 11

Patients are treated with behavioural interventions combined with pharmacotherapy
Methadone or buprenorphine
These are the standard but can see others, e.g. heroin reefers (cigarettes laced with diamorphine)

Question 12

Methadone

Answer 12

Synthetic opioid agonist
Active orally with a half life of 24-36 hours (once daily dosing)
Normally dispensed in a 1mg/mL solution (other strengths available)
5mg tablets also available
Good cross tolerance with other opiates, providing relief from withdrawal effects of heroin

Question 13

Methadone side effects

Answer 13

Euphoria, pain relief, drowsiness, nausea and vomiting, respiratory depression, constipation, sweating
Does not cause significant lack of coordination, slurred speech or reduction in cognitive ability

Question 14

Methadone dose

Answer 14

Initiation- can take 5 to 7 days for drug to reach full effect, starting doses of up to 30 mg are normally used
Dose is normally increased in increments of 5 to 10 mg a day
Dose normally stabilised between 60-120mg daily
Missed doses- if a patient misses 3 or more days supply they must be referred back to prescriber (possible loss of tolerance)

Question 15

Buprenorphine

Answer 15

Semi-synthetic opioid, partial opiate agonist
Duration of action up to 12 hours at low dose or 48-72 hours at high dose
First dose should be given at least 8 hours after last use of heroin or 24-26 hours after last dose of methadone
Patients are advised not to use any other opioids to relieve withdrawal- unlikely to work and delay stabilisation

Question 16

Misuse of drugs scheme

Answer 16

Substitute prescribing is recognised as an effective harm reduction intervention
May lead in the long term to detoxification, although the process may take several years
Harm reduction vs. abstinence- methadone: most cost effective medical intervention available

Question 17

The role of the pharmacist

Answer 17

Supporting drug users in complying with their prescribed regime- reducing incidents of accidental overdose
Supervision- keep to a minimum the misdirection of controlled drugs
Daily contact allows for better monitoring and advice on general health and well being
Liaising with prescriber, named recovery worker and others
Help ensure positive impact of treatment

Question 18

Accepting a new patient to the service

Answer 18

Prescriber will ask the patient which pharmacy they would prefer to attend
The prescriber will contact the pharmacist before issuing the first prescription to ensure the pharmacist has the capacity to accept the service user at that time
The prescriber or key worker should inform the service user that they will need to bring ID when they come to the pharmacy

Question 19

Client Pharmacist agreements

Answer 19

Service users may have a written agreement with the pharmacy, part of which covers behaviour in the pharmacy
The aim of the contract is to reduce the potential of misunderstandings
Service users should be informed in advance of what arrangements you make for when the pharmacy is closed
Not used as often anymore due to the risk of further alienating an already isolated group of patients

Question 20

Instalment prescriptions

Answer 20

Allow CDs to be dispensed at an interval decided by the prescriber
Maximum 14 days supply
28 day period of validity: sch 2, 3 and 4 must have first instalment dispensed within 28 days of signing or appropriate date
The remainder of the prescription must be dispensed following instalment instructions

Question 21

Emergency supply

Answer 21

Schedule 2 and 3 CDs cannot be given in emergency supply except phenobarbital for the treatment of epilepsy
Doses should never be given in advance of receipt of a valid prescription at the pharmacy, phoned or faxed prescriptions for controlled drugs are also illegal

Question 22

Preparation of medication

Answer 22

Methadone- daily amount should be measured into a suitable container, capped and labelled, when the service user arrives the measured dose may be poured into a disposable cup
Buprenorphine- tablets should be removed from the foil and placed in an appropriate container, this way the service user can confirm their dose before the medication is taken

Question 23

Sugar free and colourless methadone

Answer 23

Sugar free or colourless methadone mixture should only be dispensed if specifically requested on the prescription
The prescription should also state if the buprenorphine tablets are to be crushed
Should be as discreet and as efficient as possible

Question 24

Endorsing

Answer 24

Pharmacists will endorse the prescription with the volumes dispensed at each pick up
An additional packaged dose fee of 55p can be claimed per additional bottle of oral liquid methadone supplied
The number of additional packaged doses claimed must be clearly endorsed on the prescription as payment of this fee will be based on the endorsement given only

Question 25

Prescription fees

Answer 25

All prescriptions for oral liquid methadone receive an item level fee of £2.50 per prescription
FP10MDA forms should be placed together in the prescription bundle so they are easily located and can be looked at separately by a pricing authority exception handler

Question 26

Endorsing buprenorphine and other CDs

Answer 26

Pharmacists should use the right hand side of the prescription to endorse with the volumes dispensed at each pick up episode
Payment is based on each time the patient collects their drug from the pharmacy

Question 27

Needle exchange scheme

Answer 27

Aims to reduce the transmission of blood borne viruses and other infections caused by sharing injecting equipment, by providing sterile injecting and ensuring its safe disposal
Pharmacies provide needles, syringes and sharps bins
The return or appropriate disposal of used injecting equipment should be strongly promoted

Question 28

Other injecting paraphernalia

Answer 28

Other paraphernalia that can be supplied: swabs, utensils for preparation of CDs, citric acid, ascorbic acid, filters, sterile water
Must signpost to other source of supply if full range not carried

Question 29

Harm reduction

Answer 29

Needle exchange pharmacies should also provide:
Advice on the risk of injecting
Advice on how to avoid overdose
Encouragement to register with GP
Info on safe disposal of sharps
Referral to blood-borne virus screening, vaccination and treatment services

Question 30

Substitute medication and driving

Answer 30

Client is responsible for informing DVLA
Dr is responsible for informing the client of this
They can have a driving license, but is subject to an assessment and annual review