Irish Pharmacy Journal May 2004

Treating Addiction as a Chronic Illness: Methadone Services in Primary Care

Opiate addiction is an epidemic of modern Ireland with considerable implications for public health. Methadone maintenance treatment has improved health outcomes for opiate users, however to be really effective access to good support services in primary care is essential. Community pharmacists are key to provision of quality methadone services. In Autumn 2003, the ICCPE launched a new training programme for pharmacists supporting delivery of quality methadone services in the community. Over 40 delegates attended accredited training in Dublin in October and in March the roadshow visited Limerick as part of the ICCPE Spring programme. Julie Cronin reports.

Communication and cooperation between GPs and community pharmacists is critical to the ongoing success of the Methadone Protocol Scheme. Speaking at a Joint Educational Initiative for Pharmacists and GPs in Limerick, Dr. Denis O'Driscoll, Liaison Pharmacist with the East Coast Area Health Board (ECAHB), notes that pharmacists and GPs must work together strategically to enhance provision of services to methadone patients. According to Dr. O'Driscoll "Pharmacists are quite integral to the methadone treatment process but are often forgotten in terms of strategic development."

This point was reiterated by Dr. Margaret Bourke, GP Coordinator with ECAHB, who pointed out that, although 3,610 of the 6,885 methadone patients in Ireland are being treated in community pharmacy, national guidelines issued in May 2003 were drafted without consultation with pharmacists. This is despite the fact that the GP Coordinator and Liaison Pharmacists within the Methadone Protocol Scheme provide both initial and ongoing support, training and education to GPs and pharmacists in the community on a daily basis and that a National Central Treatment List accessible to both GPs and pharmacists has been established by the Scheme.

A key message from this Joint Educational Initiative, organised by the Irish Centre for Continuing Pharmaceutical Education, is that the approach to the treatment of drug addiction should be similar to the approach taken in treating people with long term illnesses. As Dr. Bourke notes, "the ethos is that addiction is an illness like any other illness and it should be treated as a chronic illness." Indeed, she likens the management of addiction to the management of illnesses such as diabetes. Similarly, Kay Roberts, a pharmacist and member of the UK and Scottish Advisory Councils on Misuse of Drugs, notes that a holistic process is necessary in dealing with methadone patients. "We are usually faced with a situation where we are implementing a methadone treatment programme in a chaotic life," she says. "Treatment must deal with all areas of a patient's life." Dr. Bourke restates this by noting that "social factors and economic factors play a huge part. Employment plays a huge part. The Celtic Tiger, in some ways did help people because it provided employment across the board. The incentive to keep employment has helped patients in staying stable in methadone treatment."

Alongside the problems inherent in the environment of the drug user, other physical and medical symptoms can complicate the treatment process. "The easiest patient to treat is a straightforward heroin addict," says Dr. Bourke. "However, more and more people are presenting with poly-drug abuse." Such abuse may include misuse of illicit drugs, alcohol, and prescription medication. Alongside this, the increased instance of HIV, Hepatitis C and psychiatric illnesses among drug users present further complications and considerations in the treatment process. Pregnancy is a further consideration: "Your patient is also the unborn child," points out Dr. Bourke. "If you are prescribing for its mother, you are ipso facto prescribing for the unborn child." Added to this is the fact that when the mother has given birth, her incentive to remain "clean" may have considerably diminished. Dr. Bourke also notes that the stable methadone patient may often be more difficult to monitor than the unstable patient. The stable may have "slips" she notes but these should not be overplayed. "A slip is a slip. It is not a destabilising," she says.

All speakers at the ICCPE lecture agreed that the question of the success of methadone treatment must be framed in a realistic context. Helen Johnston, ECAHB Liaison Pharmacist says: "I don't think we should think of success as achieving complete abstinence from drug taking." In contrast, she notes that the success of methadone treatment lies in the stabilisation of the patient's circumstances and the achievement of low methadone maintenance; she notes that methadone treatment programmes decrease mortality rates by a factor of 10-13, reduce morbidity and greatly improve patients' quality of life. In contrast, Dr. Margaret Bourke cited that total abstinence has limited success: 80 per cent of people who do not substitute heroin use with methadone treatment will return to drug use within six months.

Alongside its Methadone Protocol Scheme, the ECAHB seeks to minimise the risks of intravenous drug use among the drug using population by operating several open access needle exchanges and by providing advice on drug use habits. As the transit from drug use to methadone treatment may take up to four weeks, such schemes are viewed as a means of linking drug users to health services. Nihal Zayed, Liaison Pharmacist with ECAHB, observes that the approach is a pragmatic one. "The pragmatism behind harm reduction is that it accepts that drugs are part of our society and, although they carry risks, from a community perspective, pragmatism means that efforts are made to contain drug-related harms rather than trying to eliminate drug use entirely, she says. Such harm minimisation is provided in the form of pre-packed needles and condoms which are distributed by care teams consisting of GPs, nurses and pharmacists at needle exchanges such as the one at Merchant's Quay in Dublin. All dealings at these exchanges are confidential. As Nihal Zayed notes, "The harm reduction approach is to treat drug misusers with dignity and respect and as normal human beings. It acknowledges that the misuser will set the goals in his or her own hierarchy."

The ethical dilemma for pharmacists providing methadone treatment and needle exchange programmes was acknowledged. What of patients picking up needles and syringes that are on methadone treatment? As Nihal Zayed notes, "this should be considered a failure to the methadone treatment programmes and not the patient. In the end," she continues, "pharmacists working for Needle Exchange schemes are contracted to provide an anonymous, confidential service and so there is an ethical and contractual obligation to keep information about who is using the exchange confidential."

Since its inception, the Methadone Protocol Scheme has increased its number of treatment centres from two to twelve, while treatment programmes have been introduced in the South Eastern Health Board, the MidWestern Health Board, the Midlands Health Board and in the prison services. A National Central Treatment List has been established for GPs and pharmacists and Liaison Pharmacists and GP Co-ordinators continue to recruit professionals to prescribe and dispense methadone, while grants enable community pharmacies to adapt premises for methadone dispensing. At the core of these developments and critical to the continued expansion of the Methadone Protocol Scheme, is the working relationship between GP and community pharmacist.

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