People with substance use disorders need more compassion from community pharmacy

Stigmatising people who use drugs, by ignoring or rejecting them, is “the equivalent of an electric shock in the cycle of drug addiction”, says Nora Volkow, director of the National Institute on Drug Abuse (NIDA) in the United States^​1​. “It’s a powerful social penalty that spurs further drug taking.”  

This is the reality for a growing number of people in the UK. The Office for Health Improvement and Disparities (OHID) reported in December 2023 that 290,635 adults contacted drug and alcohol services in 2022/2023 — an 8% increase on the 268,390 adults who contacted these services five years earlier in 2017/2018^​2,3​.

To manage this growth in demand, the UK government published its ten-year drug strategy ‘From harm to hope’ in 2021, with a strategic priority to expand treatment capacity by 20% by 2024/2025, while embracing an “all-hands-on deck” approach^​4​. 

But to achieve this across England will require motivated and highly trained professionals to provide evidence-based interventions in a stigma-free environment — something that is not currently happening in a consistent way across the country.

Understanding is crucial

Addiction is a chronic and treatable health condition, requiring life-saving clinical and non-clinical evidence-based interventions. Yet people who use drugs and alcohol are frequently exposed to negative attitudes and stereotypes within our community — broadly categorised as stigmatisation — which denies them the care they need. 

There is significant evidence that clinicians have a worse attitude towards people with substance use disorder (SUD) than towards those with other mental and physical health diagnoses. This may be attributed to clinicians’ lack of exposure to individuals in recovery, a lack of time and resources to adequately care for people with SUDs, or a perception of ‘substance misuse’ as a moral failing^​5​. 

Volkow’s article in The New England Journal of Medicine, published in April 2020, recognised that people with SUD might be compelled to use unlawful means to support their habit, such as stealing, lying and aggression, primarily when ‘experiencing withdrawal or intoxication-triggered paranoia’.  Such behaviour may alienate the person’s support system and eventually leave them stigmatised among family, strangers and healthcare workers.

Prolonged stigmatisation of people who use alcohol and other drugs can lead them to avoid seeking medical help, creating a missed opportunity for early intervention. It can lead them to receive a poorer quality of care. It can also cause increased drug use and reduced access to harm reduction initiatives such as naloxone supplies, needle exchange programmes and immunisation against blood-borne diseases^​6,7​. 

It is therefore imperative that tailored education and training about stigmatisation and discrimination is routinely provided to all healthcare professionals dealing with people who use drug and alcohol treatment services. This should start early in the pharmacy education pathway, with students made aware of the consequences of negative stereotypical attitudes on care provision by exposing them to individuals in treatment and recovery^​5​. The NHS Addictions Provider Alliance (APA) recognised strategies for overcoming stigmatisation must include education to correct inaccurate stereotypes and drug policy reform^​8​. Using the ‘#StigmaKills’ awareness campaign, the NHS APA continually pledges to tackle stigma. 

All people with SUD must be treated the same regardless of their health condition, and clinicians should be supported to mitigate the impact of their personal and socio-cultural perceptions on their care for these individuals.

Disparity in service provision

As part of the drive towards equitable access to care for people with SUD, a holistic, collaborative approach between community pharmacy teams and drug treatment services is crucial in helping them recover and in reducing treatment dropout rates. 

OHID data show that, of the 290,635 adults who contacted drug and alcohol services between April 2022 and March 2023, 137,749 people entered treatment for substance use — 48% of them owing to opioid-related problems^​2​. Nearly all (98%) of these people received community-based structured treatments, but only 46% completed treatment with drug and alcohol services. 

Using interventional tools in community pharmacy, such as supervised consumption, signposting potential patients to local drug treatment services and providing harm reduction advice, is therefore vital. 

However, there is currently a significant disparity in the provision of supervised consumption services for opioid-substitution therapy (OSTs) among community pharmacy contractors — fuelling stigmatisation of this patient group.

Public Health England recognised supervised consumption of opioid-substitution therapy (OSTs) as an evidence-based intervention for promoting compliance to treatment among people who use drugs^​9​. Where these services are offered, they are locally commissioned as a ‘local enhanced service’, (LES) either through the local authority or via subcontracted providers under drug treatment service provision, using public health grants^​10​. As a LES, community pharmacy contractors may decide to opt in or out and remunerations for the service are usually agreed locally between the local pharmaceutical committees (LPCs) and service commissioners. It is important to note that supervised consumption of OSTs is not a legal requirement under the Misuse of Drugs 2001 Regulations^​10​.

A proactive approach by NHS England to recognise supervised consumption of OSTs as a core essential service within the Terms of Service — meaning all pharmacies would need to offer it — or rather a well-funded National Enhanced Service (NES) may prove beneficial in the fight against opioid-related deaths. The national COVID-19 vaccination service was delivered as a NES, commissioned by NHS England and NHS Improvement, allowing for service specification and remuneration to be discussed and agreed nationally^​10​.  

Remuneration to support services

A comprehensive national drive to support the remuneration and service provision of OSTs would move the health system a step closer to ending the stigmatisation of people with SUD.

Dispensing of medicines and appliances ordered on NHS prescriptions remains an essential service under the NHS Community Pharmacy Contractual Framework^​11​. This framework does not allow for discrimination if the medicine ordered is on a standard FP10 (commonly used in primary care) or a blue FP10MDA prescription (commonly used by drug treatment services for their service users). However, clinicians within drug treatment services have witnessed instances where pharmacy contractors refuse to order medicines prescribed on FP10MDAs owing to a host of reasons, contrary to the service specifications. 

Issues raised by pharmacy contractors include: poor remuneration for the effort required to prepare OSTs compared with delivering other national services such as Pharmacy First; increased time involved in supervising consumption of OSTs; staff shortages; and an increased focus on lucrative private services, such as travel vaccinations. 

Experiences across NHS Inclusion drug treatment services

The NHS Inclusion drug treatment services currently span five integrated care boards across England, with varied experiences of factors driving the improvement and quality of service delivery across the footprint. The negative characterisation of people living with addiction remains conspicuous within clinical and community settings and, in some cases, extends to friends and family members.

Drug treatment services are also experiencing a reduction in allocated slots at community pharmacies for supervised consumption of OSTs, with some patients refused entry to the pharmacy.

Common themes experienced by our clinicians include patients being permanently banned from the pharmacy premises owing to unlawful behaviour, patients being classed as ‘unworthy’ or too ‘unkempt’ to enter premises, patients being seen as ‘chasing away potential customers’ and patients arriving outside of ‘set times’ specified by the pharmacy managers to supervise consumption — but not having stipulated these times in the service level agreement. 

As a result, people who use our services continue to drop out of treatment — with an increasing number overdosing on opioids — and our clinical staff members are frustrated at the situation. Routinely seeking alternative pharmacy providers that are willing to take on patients has created an additional burden on drug treatment services that have already faced unprecedented real-terms funding cuts since 2015/2016.  Forcing drug treatment services to negotiate their own competitive prices with pharmacy contractors for supervised consumption of OSTs has worsened disparity in its provision across the country^​12​. 

Equitable access to evidence-based interventions remains vital in the fight against the scourging opioid overdose crisis in the UK. Providing compassionate care — not penalising people who use drugs and alcohol — will curtail the social pain associated with their health condition. Pharmacy teams must help bear the burden of substance use disorders in our communities by challenging stigmas.