Over the past ten years the involvement of Glasgow's community pharmacists in the area's methadone maintenance program has increased dramatically. In 1993 a major review of drugs services in Glasgow suggested that the high prevalence of injecting drug use prior to 1993 was because, before that date, little use was made of "successful" substitute prescribing of methadone [1
This 1993 report proposed new service developments including the setting up of a specialist service and a drug crisis center. Methadone was recognized as the main therapeutic intervention, as it possessed the best chance of success, in terms of reducing morbidity and mortality. General (office based medical) practice was identified as the most appropriate setting for this to be carried out [2
The 1995 report of the (Scottish) Ministerial Drugs Task Force "Drugs in Scotland: Meeting the Challenge stated that 'there was considerable potential for pharmacists to play an even greater role in "frontline" services to drug misusers. This report recommended that health boards should consider how best this could be developed [3
In the United Kingdom, a special license is not required by a medical practitioner to prescribe methadone for the treatment of addiction or organic disease. However, methadone prescriptions must satisfy certain statutory requirements. Valid prescriptions can be dispensed at any registered community pharmacy. There is no legal requirement for methadone prescriptions to be dispensed daily nor for the consumption of the doses to be supervised [4
Until the development of the Glasgow supervised methadone program it was common practice in the United Kingdom for methadone to be supplied to patients to take away for consumption elsewhere. The dispensing of a supply for a whole week or longer was commonplace and a supply for one month was not unusual [5
Anecdotally the catalyst for what has become the pharmacist-supervised consumption of methadone program was a personal request from one general practitioner (GP) to her local community pharmacist in 1992[6
]. The pharmacist was asked if she would be prepared to supervise the consumption of methadone in her pharmacy on a daily basis for one specific patient about whom the GP was concerned. The success that resulted from this intervention led to the emulation of the idea by other local GPs and pharmacists.
Another reason for supervised consumption of methadone in Glasgow was previous experience of an unstructured and unsupervised system in the late 1970s-early 1980s. Public opinion was extremely antagonistic to methadone as a treatment modality. Great caution was thus required to gain acceptance of its reintroduction as a treatment option. To this day there is still a high level of public resistance to the concept that methadone is the drug of choice for the treatment of opiate dependence.
By the time of the Health Board review in 1993, a small number of prescribing GPs had followed the example of their colleague. In 1994, when the Glasgow Drug Problem Service was set up, it was decided to actively promote the concept of supervised consumption of methadone in community pharmacies. In 1997 Scottish Office Department of Health published guidance on the planning and provision of Drug Misuse Services and cited supervised methadone consumption by community pharmacists in Glasgow as innovative practice in drug misuse services [7
In 1999 the United Kingdom Departments of Health published "Drug Misuse and Dependence – Guidelines on Clinical Management" [8
]. These guidelines advised that in order to ensure compliance and reduce diversion new prescriptions [of methadone] should be taken under daily supervision for a minimum of three months.
In the same year the Greater Glasgow Drug Action Team (DAT) published its strategy for 1999–2003 [9
]. The DAT's action plan listed a number of specific objectives including:
To reduce the sharing of injecting equipment
To reduce the frequency of drug injecting
To reduce levels of drug use among current drug users
In the following year a report from the UK Advisory Council on the Misuse of Drugs (ACMD) went even further by advising that normal practice should be for methadone to be taken under daily supervision for six months or longer [10
]. The ACMD report went on to recommend that this " should be varied only exceptionally, and if a strong case can be made out in the individual instance".
The number of Glasgow pharmacies dispensing prescriptions of methadone for the treatment of opiate addiction has steadily increased from 46% (97/212) in 1994 to 84% (181/215) in 2003. The number of pharmacies where supervised consumption (self-administration) of doses of methadone on the premises takes place has increased from 20% (43/212) in 1994 to 80% (173/215) in 2003. The number of patients visiting the pharmacies has increased from an estimated 2800 in 1997/8 to 6300 in 2003[11
]. In contrast, the number of pharmacies offering a needle exchange service rose from 8 active participants in 1996 to 15 in 2002/3. A major review of Glasgow's needle exchange scheme in 2001 recommended that this number should be increased by 100% to 30 [12
]. Financial constraints meant that the expansion was delayed but on target to be completed by early 2005. In addition, the views, beliefs, attitudes and objections of residents, other businesses and community representatives must be taken into account when a new pharmacy exchange is opened. These factors mean that it can take longer than anticipated to complete the process of opening a new exchange.
A Scottish Executive (Scottish Government): Effective Interventions Unit research report highlighted the success of Glasgow's existing pharmacy needle exchanges between 1997 and 2002. Over that period the total number of attendances at pharmacy exchanges rose by 686% from 11589 in 1996/7 to 79493 in 2001/2. There was a similar percentage increase in the number of sets of equipment from 8014 in 1996/97 to 558176 in 2001/02. The percentage of used equipment returned to the pharmacies for disposal rose from 70% in 1996/7 to 86% in 2001/02 [13
]. The data used to produce the report are routinely collected at all needle exchange outlets in Glasgow. A common data collection form is used. This made it possible to compare activity at the pharmacies with the other outlets. Over the study period the number of new clients attending the pharmacy exchanges increased by 474% from 220 in 1996/97 to 1262 in 2001/02. The number of attendances increased by 686% from 11589 to 70493.
In terms of the national prevalence of problematic drug misuse it was estimated that there were 55,800 individuals misusing opiates and benzodiazepines in the year 2000 within Scotland. These figures correspond to a prevalence rate of 2% in the Scottish population aged between 15 and 54 (95% CI 1.5–2.7%) The minimum number of drug users identified as being in contact with services or identifiable from criminal justice sources was 22,795 (40% of estimated total)[14
]. For Glasgow the 2000 estimates were 15,975 problem users giving a prevalence of 3.1% of the population between the ages of 15 and 54 [15
As previously mentioned, there are 215 community pharmacies operating within the Greater Glasgow area. They serve a population of about 900,000 covering the City of Glasgow, the whole of the local authority area of East Dumbartonshire and parts of North and South Lanarkshire and East Renfrewshire. Though most of the area is inner city or urban there are some parts of the Lanarkshires and East Dumbartonshire that are rural in nature. The dispensing of National Health Service (NHS) prescriptions and other pharmaceutical services paid for by the NHS comprise approximately 80% or more of the business of a majority of pharmacies in Scotland. The supervision of the consumption of methadone by patients attending the pharmacy and the provision of pharmacy-based needle exchange service are both considered to be supplementary NHS services and are paid for by the health service. In order to receive a contract to provide such services pharmacists must have undertaken specified training programs and provide the service to set standards and criteria. Both schemes attract an annual retainer fee together with an additional fee for each supervision or needle exchange supply.
Very soon after the inception of the supervised methadone program in 1994/5 it was recognized that the participating pharmacists were in need of specific professional, clinical and practical support.