Opioid dependence revolution

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Opioid dependence revolution

Shaheen Bhatia has played an integral role in what has been described as “the biggest change in opioid treatment for 40 years.” The Independent Pharmacy Awards winner talks to Neil Trainis

 

 

Shaheen Bhatia is as emphatic as she is passionate about the healthcare services her pharmacy, embedded in a bustling east London high street, provides her local population.

“I would like to specialise in the opiate treatment world because the way things are going now, pharmacies are going to be forced to specialise because there’s going to be a wide range of services,” the Independent Pharmacy Innovation Award winner says authoritatively as we sit and talk in one of her consultation rooms.

The challenges presented by opioid addiction to communities and health systems across the world, notably the US, have been well documented but Shaheen, who has run P&S Chemist in Ilford since 1987, is determined to tackle the issue head on in the UK.

She has made great strides too having been approached by health commissioners in Redbridge to create a pharmacy-led buprenorphine (Buvidal) pilot to treat opioid dependence. She did not need to be asked twice.

To prepare, she studied previous pilots of the service in the US and Australia, completed her training to administer subcutaneous injections, helped create a patient-specific direction, carried out risk assessments, observed a private clinic providing the service and ensured her locums were fully trained.

Shaheen was also a member of the Buvidal Working Group, a multi-disciplinary team consisting of psychiatrists, nurses and local authority commissioners. 

“It’s our history. We actually helped to do the first pilot for supervised methadone in 1995, so we also had a good working relationship with our local drug and alcohol (services),” she says.

“Even with other services that are piloted, things like the morning after pill which was also piloted with us, we did the training videos here.

“The company Camurus who makes Buvidal which is a depot version of buprenorphine, the rep who used to work as a key worker and a drug adviser in our local drug and alcohol, as soon as the opportunity came up, he came and discussed it with the public health and when they were told about it, they were really driven to pilot it.

“What was great was they said ‘we want to be looking at a pharmacy model’ and they are the ones who actually approached me. I was really honoured.

“At the moment, people complain about the commissioners, there’s no new services coming along, there’s not enough help happening to boost pharmacy, that was the one time where you’ve got commissioners coming together, you’ve got local agencies like drug and alcohol, ourselves, everybody coming together to make this partnership work. It was such a pleasure.

“At the time when we started, we were the first UK pilot to do it but since then, some have already sprouted out from other parts of the country. I’ve been getting calls from all over.”

 

Revelation

The Buvidal “depot” service is timely given The Guardian’s revelation in November that there are only two free services in the UK designed to help with opioid painkiller addiction, one in Bradford and one in north Wales.

“Recently, I got a call from Wandsworth and Richmond about their drug service. They are so impressed with how this has taken off because this is going to be the next new enhanced service certainly in drug treatment and opioid treatment,” Shaheen continues enthusiastically.

“They wanted me to come in and see if I could help do some training with their pharmacists over in their borough. And I’m getting calls from lots of other drug services from around the country to have a look at our pharmacy model.”

She insists the service, which she describes as a “really big game-changer in opioid treatment,” is still in the pilot stage having started towards the end of May last year.

“At the time, we decided the minimum period would be one year. So it’s still ongoing. We’ve got about 13, 14 clients. We’ve deliberately not looked to take on that many because the whole point of the early stages, and that was my involvement, it was not only to get myself trained up to provide the depot injections but pharmacists don’t normally give depot injections.

“Initially, the NPA and (General) Pharmaceutical Council, when asked for advice on how do I get round looking at the governance for this and making sure all liabilities are covered, all I got told was ‘make sure all the risk assessments are done really well’ and give it to them to look over.

“We had to create SOPs from scratch as well as the training. Also, with medicines management, we had to come up with the protocol itself. There is something called a patient specific direction as well. It’s a PGD version for a CD. And my latest consent form, it’s an ongoing developing model.

“I was actually at a mini conference with the company and they had invited all these main drug services from around the UK who have started this up.

“There were people from Glasgow, Liverpool, Wales and about four or five others who have only just started as well. We were sharing the experience and it was fantastic to see.

“They were quite impressed with what we’ve done and each of us was looking to each other to share that experience. After being a pharmacist for so long and I have piloted many services, it’s one of the true ones where you can really get behind this 100 per cent.”

 

No longer feel like addicts

Shaheen suggests the service has made it easier for addicts to receive treatment because it has normalised the process for them. In short, they no longer feel like addicts.

“We have people who are homeless and can’t keep down a job. As pharmacists, we take for granted that some of these clients who come in to pick up methadone, buprenorphine, how they have a vision of themselves.

“I think it confirms their identity as addicts even more when they come in (to the pharmacy) to pick up and I didn’t realise as much either.

“And it looks like from the other services, the fact they weren’t coming in daily especially for that, they could then no longer consider themselves an addict, comments like ‘I suddenly don’t feel like an addict for the first time in 20 years. I feel like a normal person because I’m not picking this up (daily).’

“Or ‘I don’t have to give excuses to my work any more as to why I have to leave early’ because they don’t want to tell the work people.

“One person (at the conference), I think from Wales, they’ve only had a handful (of patients), one of her clients, a young woman in her 30s, a highly erratic drug user who had to be restarted on buprenorphine or methadone probably six, seven times, resorted to sex work to pay for the drugs on top.

“She lost her three kids over it, they were taken away from her. Her mother gradually brought her in and they had spoken to her about this injection alternative and they started her on it, the Buvidal.

“When they are given an oral dose, it peaks and troughs and you can’t get away from that. The advantage with the injection is that it gives you a steady state once you’re on the monthly one.

“You no longer feel the dips any more. That helps to get rid of their craving and the need to use on top. Just two or three weeks later, this woman comes in and you’d barely recognise her.

“She had smartened herself up, cleaned herself up and she just said ‘I want to make my life work.’

“The health physician said she herself was shocked with the change and she is saying this ought to be rolled out nationally. This was a drug service in Wales. They’ve also got a massive problem in Wales.

“There is a pharmacist prescriber in Glasgow and he is actually prescribing Buvidal there but getting the nurse to administer it and that obviously is a different model.

“But what seems to be the overall thing is we do want more pharmacists to be trained up for this and for it to be rolled out because that’s the way treatment is going.

“This is the biggest change in opioid treatment for about 40 years and it’s obvious that’s the way it is going to go now.”

 

Extreme deprivation and poverty

Shaheen insists the opioid issue in her area of south Ilford is “quite a big problem.” That part of town, she says, has “extreme” deprivation and poverty.

“The drug problem in this area has kept increasing. We have a high rate of immigrants coming into this area. They haven’t got jobs straight away and there’s homelessness. I’ve seen it increase myself in the last 20 years.

“I work quite closely with my homeless centre and that also gives me a perspective. I go there on a regular basis to provide health information, give them their flu jabs and when I talk to the nurses and the people who work there, they said they can’t believe how, in the last few years, how many homeless people there are.

“In the last five years, it has suddenly, sharply increased. They were shocked about it. They had an infestation of scabies. They provide some beds and they have a day centre and a night shelter. Half (the homeless) have got GPs, half haven’t. How can you help?

“We said ‘look, we run a minor ailments service. As a responsibility to our local population, we can even provide you with the treatment for free. Those who have a GP, let them have it through the scheme, the rest we’ll provide it so we can help to eradicate it.’

“That’s part of pharmacy, that’s the way I look at it. It’s my community and it’s the same with the drug clients. I’ve had my pharmacy here since 1987.

“This is why we started the initial pilot when we first started supervised because there were only four pharmacies in the borough who provided needle exchange. At that time, the way people used to talk was ‘I don’t want drug clients in my pharmacy, they’re just trouble. We don’t want to deal with them.’

“There was no structured service. We’ve got harm reduction now. I started getting parents saying ‘there’s no-one else to speak to but I think my son and my daughter are doing (drugs). Who do I go to? What do we do?’

“And that’s when we realised this problem is escalating because I was starting to get more and more queries. There was a drug and alcohol service. We approached the PCT and they said ‘it’s not a problem big enough for us to worry about.’

“Myself and the drug service, we still said ‘we’re still to do a pilot any way between us to see if we can address this and once we did it, the PCT were interested.

“That’s always been my attitude since then. We don’t have to wait for services to fall into our lap. If you see the problems in your community, if you try and address those yourself and think ‘how best can we come up with a solution’ rather than complain about what aren’t we being given.”

 

Community pharmacist consultation service

Shaheen’s proactive approach to community pharmacy care has reaped its rewards, to the benefit of her local population.

She does, however, reveal that referrals to her pharmacy though the community pharmacist consultation service are “a bit slow at the moment” and is concerned that pharmacies will end up with lots of people at their doors but no payment from the NHS if GPs refer through word of mouth rather than digitally.

“I would be interested to see to what level this goes. In our area, we still have the minor ailments service and that can be used on top any way,” she says.

“They’ve been threatening to get rid of it for the last three or four years but it’s still there because in some of the deprived areas, the GPs don’t want it to go because they won’t be able to handle the extra appointments.

“My only thing with this consultation service, our worry, is will the GPs actually refer people properly digitally? Or are they going to just tell people to come to the pharmacy because if they do that, obviously, we’re not going to get paid.

“So we have to make sure we all follow the pathway if we’re going to benefit from it. It’ll be beneficial all round because if you do it in the structured way, you’re going to get evidence and records rather than if someone just turned up.

“I have regular meetings with my local surgeries where I go in and say ‘are you aware that we’re doing this, this and this?’ Even when we were doing the NUMSAS service which was for the emergency supplies, I remember the GPs saying they weren’t aware of that.

“And it is odd even now that when you speak to GPs who have been practising for quite some time and you talk to them about emergency supplies and they say ‘oh, we just thought it was something really easy for pharmacists who just hand it over’ and you have to say ‘well, no, it’s not quite like that.’

“And you have to explain the legality behind it. It’s not as easy as someone just turning up and then handing it over. I don’t think we can ever assume. It’s only because the GPs don’t understand how we actually work and our own regulations.”

There is much to occupy Shaheen and all those who work at P&S Chemist as commissioning structures change and primary care networks (PCNs) continue to find their feet in a bold new era of preventative community care.

She is asked if she would like to be the nominated pharmacist lead in her area for the local PCN. She seems like the perfect choice.

“I don’t mind being involved but I’ve more or less thrown myself into this (Buvidal) service and people are asking me to come and talk about it.

“I’m starting to think I would like to specialise in the opiate treatment world because the way things are going now, pharmacies are going to be forced to specialise because there’s going to be a wide range of services.

“There’s only going to be so much work you can take on. We will have to decide where we specialise.”

 

 

 

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