Role of community pharmacies in relation to HIV prevention and drug misuse: findings from the 1995 national survey in England and WalesBMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7052.272 (Published 03 August 1996) Cite this as: BMJ 1996;313:272
- Janie Sheridan, research pharmacista,
- John Strang, professor of the addictionsa,
- Nick Barber, professor of the practice of pharmacyb,
- Alan Glanz, lecturera
- aNational Addiction Centre, Institute of Psychiatry and Maudsley Hospital, London SE5 8AF
- aCentre for Pharmacy Practice, School of Pharmacy, London WC1N 1AX
- Correspondence to: Dr Sheridan.
- Accepted 3 June 1996
Objectives: To establish activity levels of community (high street) pharmacies in the provision of HIV prevention services to drug misusers and to compare these findings with the levels identified in 1988.
Design: Self completion questionnaire (four mailings) to a random 1 in 4 sample of all community pharmacies, stratified by family health services authority.
Setting: England and Wales.
Subjects: Data provided by pharmacist in charge of the dispensary, on service provision at the pharmacy.
Main outcome measures: Quantitative reports of current activity levels for (a) dispensing of controlled drugs to drug misusers, (b) sale of needles and syringes, (c) needle and syringe exchange.
Results: 74.8% response rate (1984/2654). In 1995, 50.1% (992/1980) of pharmacies were dispensing controlled drugs (mostly methadone), compared with 23.0% (562/2457) in 1988; 34.5% (677/1962) of pharmacies were selling injecting equipment, compared with 28.0% (676/2434) in 1988; 18.9% (366/1937) were providing a needle exchange service, compared with 3.0% (65/2415) in 1988.
Conclusion: Activity levels increased substantially across all three service areas. Increased activity included greater individual activity as well as higher proportions of pharmacies participating. The network of community pharmacies represents an underused point of contact for this Health of the Nation target population.
Many communities pharmacies have a role in providing HIV prevention services for injecting drug misusers—such as dispensing controlled drugs on prescription, selling injecting equipment, and operating needle exchange schemes
Since 1988 the proportion of pharmacies dispensing prescribed controlled drugs has dou- bled, and the proportion taking part in needle exchange schemes has increased sixfold
A large reservoir of untapped potential still exists among community pharmacists
The community pharmacist has a high level of contact with often “hard to reach” drug misusers; the potential for maximising such contacts should be explored
There are more than 10 500 community (high street) pharmacies in England and Wales. It is now eight years since the last (and only previous) national survey of community pharmacies and their role in preventing the spread of HIV among injecting drug misusers.1 The number of misusers notified annually to the Home Office Addicts Index2 has continued to rise by approximately 20% a year, and the proportion of those injecting remains over 50%.2 3 The number of prescriptions written for methadone continues to rise,3 and most of these will be taken to community pharmacies. Many “hard to reach” injectors may use community pharmacies as a source of clean injecting equipment.4 5
Against this shifting landscape and with the recent publication of a new government response,6 it is important to explore how community pharmacists have responded to these changes and to changing professional advice from both without4 5 and within their profession.7 8 9 10
The study population comprised all (about 10 500) of the registered community pharmacies in England and Wales (source, the Royal Pharmaceutical Society of Great Britain's database). A random 1 in 4 sample (n = 2654) of community pharmacies was taken, stratified by family health services authority. Data were provided by the pharmacist in charge of the dispensary.
The postal questionnaire used in this study was adapted from that of Glanz.1 Three further mailings were posted to non-respondents. We have compared items that were common to this questionnaire and the 1988 one.
FINDINGS FROM THE 1995 SURVEY
After four mailings the overall number of respondents was 1977—a 74.8% response rate.
Controlled drugs dispensing—In all, 50.1% (992/1980) of community pharmacies were supplying controlled drugs on prescription to people being treated for drug misuse. Of these, 566 pharmacies dispensed to three or fewer misusers, 52 dispensed to 20 or more, and 8 were high volume pharmacies dispensing to over 50 misusers a day. The most common reason for not providing a dispensing service was lack of demand; other reasons related to misusers' behaviour, effect on business, and effect on other patients. Tables 1 and 2 give details of the controlled drugs and forms of dosage currently dispensed by the responding pharmacies.
Sale of injecting equipment to known or suspected drug misusers—Pharmacies were asked how many known or suspected injecting drug users had asked to purchase needles or syringes (excluding needle exchange). In all, 31.0% (552/1778) had received one or more requests in the previous week (total number of requests = 2273). For these pharmacies the median number of injecting drug users making requests was 2 (interquartile range 1 to 4; range 1-190), with 63.4% (350/552) of pharmacies having had two or fewer requests. In all, 34.4% (677/1962) of pharmacies were currently selling injecting equipment on request—with a further 812 willing to do so, while 473 were not willing. The most commonly stated reason for not being willing to sell injecting equipment was that injecting drug users should use an exchange service; pharmacists also had concerns over the users' behaviour. Of the 677 pharmacies currently selling equipment, 583 gave information on weekly sales, including details of the number of “injecting units” (equipment purchased for one injection—a needle, a needle and barrel, or a complete syringe). The total number of injecting units sold per week was 8754 (median = 5; interquartile range 1-20; range 0-300). The median number of units sold on each occasion was 10 (2-10; 1-30). Most of the pharmacies were supplying 1 ml and 0.5 ml disposable insulin syringes.
Provision of other services—Table 3 shows the pharmacists' responses to questions about participation in other specific forms of service provision. Nineteen per cent were participating in needle exchange schemes. The most common reasons for not participating were that there was another needle exchange scheme nearby, drug users' behaviour, and lack of time and space.
DIFFERENCES BETWEEN THE 1988 AND 1995 SURVEYS
Figure 1 compares the levels of service provision to injecting drug users by pharmacies in 1988 and 1995.
Dispensing controlled drugs—In 1988, 23.0% (562/2457) of pharmacies were dispensing to an estimated 7700 injecting drug users. By 1995, 50.1% were dispensing to an estimated 30 000 users. The mean number of users per dispensing pharmacy rose from 3.5 to 5.9 over this period.
Sales of needles and syringes—In 1988, 28.0% (676/2434) of pharmacies were selling injecting equipment to injecting drug users, compared with 34.4% in 1995. The pool of willing suppliers (currently selling or willing to sell) remained largely unchanged (74.0% and 73.9% respectively). The estimated number of injecting units sold in a week in England and Wales was 40 000 in 1988 and 47 000 in 1995.
Participation in needle and syringe exchange schemes—Three per cent of pharmacies participated in needle exchange schemes in 1988, compared with 18.9% in 1995, with the pool of pharmacies willing to participate in such a scheme unchanged since 1988 at 55%.
Substantial increases have occurred since 1988 both in the overall contribution of community pharmacies to the provision of services to drug misusers and in individual levels of activity across all three areas that we have studied. This has included the emergence of pharmacies with more specialist involvement with drug misusers. Community pharmacies now represent an extensive network of points of contact with drug misusers, not all of whom will take part in formal treatment programmes. Injecting drug users are now a specific Health of the Nation target population,11 and these underused opportunities for intervention should be explored urgently.
The dispensing of controlled drugs to drug misusers was reported by half our sample—more than double the proportion in 1988; the drug most usually dispensed was methadone.12 However, this increase has only occurred by each dispensing pharmacy dispensing to, on average, double the number of drug misusers as in 1988. If the opiate problem continues to grow, more pharmacies may need to develop a special interest in dispensing controlled drugs to supplement the lower levels of activity from other pharmacies.
Community pharmacists are frequently overlooked both as members of the primary health care team and as potential members of community drug teams. With such regular (often daily) contact, community pharmacists are ideally placed to gather information on the progress of patients who are drug misusers. They could, for example, provide information on compliance with methadone substitution programmes by reporting on regularity of patients picking up their prescribed supplies and on apparent levels of intoxication. Additionally, if suitable detection and intervention protocols could be developed, it might be possible to exploit more fully the therapeutic potential of contacts with hard to reach users. Many community pharmacists are willing to participate more in such shared care arrangements, but we see little evidence of this long overdue collaboration.
Funding This project was supported by a grant from the Department of Health and the Welsh Office. (The views expressed are those of the authors and do not necessarily represent those of the Department of Health or the Welsh Office.)
Conflict of interest None.