Not wanting to sound pedantic (!!), but I just wondered where pharmacists stood in terms of being suitably qualified to supervise Subutex dispensing. The service I work for dispenses Subutex in house and this is supervised by qualified nursing staff (who are trained to supervise medication consumption). Given that pharmacists do not recieve training of this kind, does this practice in community pharmacies breech regulations concerning controlled drugs?

I said it was going to sound pedantic!

Cheers

James

James,
I'm sure Pharmacist's are able to work out what it means to supervise sublingual administration of a drug. I don't think you are pedantic more condescending ! If this was directed at Nurses i'd be furious, as it is i'm sure the Pharmacsist's will advise you of the error of your ways.

Hi James
Do you know many Pharmacists?If not, it would be great to get to speak to one of the many that are already supervising Subutex. We do have a certain amount of knowledge of drugs, how they work and the different methods of administration! In addition there are plenty of Continuing Professional Development programs we can study surrounding Substance Misuse. If we have a contract with the PCT or DAT to supervise, they also arrange an Annual Training event.
I myself, have been appointed (by a multiple), to look at, and improve the services that we give to service users. One of the areas I look at is Supervision, particularly discretion,but for Subutex, the issue of diversion. I think that you can be pretty confident that if a Pharmacist is supervising Subutex that they are fully aware of thier responsibilities and any consequences of inadequate supervision!
I am being serious in suggesting that you should introduce yourself to a Pharmacist. I do have a contact for the guy who does my role in Cardiff, I am sure he would talk through with you any of his concerns
Claire

Simon

I know what you mean and I did feel a little embarrassed posting such a seemingly idiotic question. However, this was a question raised by our organisations' expert in such matters. We are currently going through retendering / restructuring of services, and one of the positives of our service is in-house dispensing and supervision. Supervision of subutex does pose difficulties generally for community pharmacies, not least due to the length of time it takes for it to dissolve and the pharmacist being switched on to issues of diversion. More specifically though, nurses have demonstrable skills in being able to determine someones suitability for their dose on any given day (if they present intoxicated, objective measures can be taken). The role of the pharmacist is quite different,- are these skills included in pharmasists training, bearing in mind that supervising medication has been 'tagged on' to their role in recent years?
My colleagues suggestion that pharmacists may not be suitably qualified is an interesting one although I realise it could be interpreted as a little offensive! As a mere 'drugs worker' who is technically not allowed to do anything responsible concerning the administration of controlled drugs I am certainly well aware of the potential to cause offence!

I'm off to flog myself right now

Cheers

James

Hi James

I remember from exchanges that we had over a year ago that colleagues with whom you were working (maybe in a different Welsh service then though) considered that it was only nurses who were competent to deliver drug treatment interventions.

Colleagues in Wales do seem to be, perhaps, overly concerned about issues of professional demarcation.

Simon

Simon

Hi Simon

I think you've hit that nail quite squarely on the head. I'm in a different service now, but I suppose the obsession with legitimacy to perform ones' roles and responsibilities in South Wales has led to everyone questioning everyone elses competence!

If you cant beat em....

James

Great stuff
Prescriptions and dispensing bags at dawn.
Wonderful image
Best
Tony B

Seriously now
I do remember standing outside my local pharmacy to do a little 'on the spot' research and i was shocked at the reality of supervised subutex com. Sorry Jim consumption .
23 minutes first one, 26 the next and by that time my poor little maltese terrier was getting really fed up with the whole business.
When i returned on another day, for a chat, indeed we had an interesting one.
This practice was indeed average and 'normal' and i am at present mourning the loss of this Gentle and Humane man to misionary work in Africa.
Now we have a Corp take over and already receiving letters about times for dispensing to this 'special' client grp. AaAAAAAAARRRGGhHHH.
Can't see these guys waiting 25mins.
Best
Tony B

James,
Sorry to have come to this discussion so late but i would like to point out that supervising methadone and subutex is not rocket science! All pharmacists are educated to degree level followed by one year in practice and, if they are part of a structured scheme, whould have at least the same training as nurses and probably eventhe same as the staff who work at your in house service ie this is how it's done, and these are the potential problems that could arise ie diversion. Also James, supervising consumption is not the same as administering a medication and the only regulatons are very generic.
Pharmacists see patients every day when they have a daily prescription and have usually had to deal with all a multitude of scenarios both real and invented such as 'my bottle broke', 'i lost my script', ' I was mugged' etc, so they have lots of experience.
For those who don't know me you may have realised by now that i am a pharmacist!
So I think your inference that pharmacists may not be trained enough only demonstrates that, as someone has already suggested, you need to go and talk to a few. I am happy to be one of them - and I'm quite approachable really despite my rant!
Heather

[QUOTE]Originally posted by James:
Simon

I know what you mean and I did feel a little embarrassed posting such a seemingly idiotic question. However, this was a question raised by our organisations' expert in such matters. We are currently going through retendering / restructuring of services, and one of the positives of our service is in-house dispensing and supervision. Supervision of subutex does pose difficulties generally for community pharmacies, not least due to the length of time it takes for it to dissolve and the pharmacist being switched on to issues of diversion. More specifically though, nurses have demonstrable skills in being able to determine someones suitability for their dose on any given day (if they present intoxicated, objective measures can be taken). The role of the pharmacist is quite different,- are these skills included in pharmasists training, bearing in mind that supervising medication has been 'tagged on' to their role in recent years?
My colleagues suggestion that pharmacists may not be suitably qualified is an interesting one although I realise it could be interpreted as a little offensive! As a mere 'drugs worker' who is technically not allowed to do anything responsible concerning the administration of controlled drugs I am certainly well aware of the potential to cause offence!

I'm off to flog myself right now

Cheers

James,
Sorry you felt you had to flog yourself but well if you like that sort of things
I'm not sure that in-house supervision is a great positive. I do it if I can't get a community pharmacist to supervise. It's an expensive option when I could be seeing other patient's. The pharmacist gets paid extra to do this and I don't. I know we could argue that the pharmacists don't get adequate reward for the time it takes, but that is probably another debate. Another point might be normalisation and popping into a community pharmacy might be more akin to what the rest of the population do.
The Pharmacists i'm sure will be able to tell if someone is intoxicated and which recedptor site was involved We do get calls and pharmacists do withold or ask people to come back later or go to the surgery if they don't look like they need the dose.
Also not only do pharmacists supervise we have a growing band of prescribing pharmacists, so it's neck on the line stuff.
Your colleague does I think need to go and speak to pharmacists ask them about the role they have and maybe ask about how, where and why drugs work in the body and then they may change the view that they have.
sorry if I seemed a little heavy handed in my earlier post.

Hi Simon,
"Another point might be normalisation and popping into a community pharmacy might be more akin to what the rest of the population do".

I know what you mean, but supervised consumption is not the 'norm' to what the rest of us do... but that's another debate I guess.

On the subject of s/c I agree pharmacists do this job well and probably know the drugs better than i and many others... I just can't see s/c of subutex really working, perhaps in some areas but nationally I think it's impractical.. can you imagine a pharmacist trying to supervise whilst dispensing medications as well. For the 'norm' of the population this will lead to huge queues... another thing to blame drug users for eh?

Joe, If you crush the buprenorphine it takes a minute for supervision. I know this because i have done a small study on it. The reason pharmacists are paid to supervise is becuase you are buying their time and hence will not ( or should not) be dispensing at the same time!
Many patients these days need advice from pharmacists about their medication which will often take longer than a minute, quite a few go to pharmacists for minor ailments schemes which take much longer, so your theory about drug users creating, and then getting blamed for, long queues is not accurate. However, when buprenorphine is not crushed ....- don't start me on that old chestnut.
Your're right about the S/C not being the norm though Joe but as you say another debate for another day.
Heather

Joe,
I think it's fair to say that Pharmacist's have been an un-tapped resource, things are changing. We now see Pharmacist's doing medication review's which previously the GP/Nurse would have done. Other things we are seeing is diabetes testing, INR bloods will no doubt soon happen,Malaria prophylaxis advice. It may be seen as the norm that people are seen in a private consultaion area in the Pharmacy, just like somebody on supervised consumption.

Hi Heather.. I was being sardonic really, so ignore that one.
Simon: That's one interpretation and in some ways a seperate point you make because the other functions are tests and screenings, NOT having to take the treatment in front of someone because the inference is you cannot be trusted to take it like most of the pop..

just seen the NICE guidelines, pages 8-9 "The relatively slow onset of action and
long half-life mean that methadone overdose and toxic effects may become
life threatening several hours after a dose is taken". I know this is about methadone but the principle of s/c covers this too.. my question is, How does this make it safer for the client? Unless you want to stop diversion to 'others' i see no real safety benefit as inferred by the NTA etc..

Heather

Just a quiery about crushing subutex. I understood that this was inadvisable, as powdered subutex results in lots of saliva and hence a lot of the dose being swallowed. I understood that the reason for it taking a while for the tablet to dissolve sublingually is that it takes the tablet that long to be effectively absorbed. Please correct me if I'm wrong.

Cheers

James

Joe: "How does this make it safer for the client? Unless you want to stop diversion to 'others' i see no real safety benefit as inferred by the NTA etc.."

...because one can be SURER about a patient's likely tolerance of the dose level being administered
e.g.
* have had regular recent supervised attendances: CAN BE SURE that dose is being consumed in full by patient, and that the patient will have tolerance to this dose level, and could tolerate an increased dose

* have not had regular recent supervised attendances: CANNOT BE SURE that dose is being consumed in full by patient, and that the patient will have tolerance to this dose level, or that an icreased dose will be tolerated

It's not just about possible diversion but about being able to establish and confirm regular daily taking of meds and tolerance.

Simon

One of our pharmacists is asking for us to request that subutex is crushed on supervised scripts due to the time it takes to dissolve - by writing it on the script. I gather this is off licence - any thoughts?

crushing subutex is a controversial one and yes it's going off licence. However so is giving e.g. methadone ampoules to drug users or some chemotherapeutic agents for cancer. In other words licencing is primarily a commercial necessity to allow a product to be used in a country. It does of course have some clinical governance validity but is not primarily a clinical governance tool (compared to for example orange book guidance in which you'd have to have good reasons why you deviated). My view on crushing subutex is that it's certainly not for every drug user as those with good social support etc etc it is nothing short of patronising. However in areas of reduced demand of drugs (e.g. prison) or intense poverty (e.g. homeless populations) there's merit where there's a real risk of diversion.

James, i think what you have heard is a theory but in practice in Australia where it has been done for years and from 2 years of local experience it does not appear to be a problem. Yes it is off licence and there are issue with that but as Nat says so are other things including methadone tablets in the management of addiction which many people don't even realise.