“No worries, me duck. You take your time. You’ll be caring properly for others soon!”
When Ismael Ali started his preregistration placement in a community pharmacy in Northamptonshire in 2019, he noticed that it was his patients with addiction who were most forgiving of his inexperience. They encouraged him to take his time, they were always keen to hear how his studies were coming along, and they even gave him insight into their lives. Together, they built great relationships.
Ali was shocked to hear how badly these patients had been treated by their pharmacists in the past and this spurred him to share his findings in a blog — ‘Our patients with addiction often feel little more than ‘animals’ in the pharmacy: we must change’ — published by The Pharmaceutical Journal in July 2020.
As academics with an interest in drug addiction, we read Ali’s story with mixed feelings. With dismay, at someone new to our profession describing patients facing stigma from the professionals he should be looking up to. But also with hope, because he recognises that there is so much more that pharmacy teams can do to support the health and wellbeing of this patient group.
Pharmacists set the tone
Ultimately, patients with addiction are at the mercy of those providing their treatment; they are totally dependent on their opiate substitution therapy (OST) with methadone or buprenorphine to prevent horrific withdrawals. So they have to accept the services they are given. This power imbalance means that stigma towards them is often just tolerated. “What can you expect? I’m a junkie”: these are the self-deprecating words often heard in the clinic.
In our experience, people who experience addiction are being failed by being treated differently from other patients, and this is backed up by our research
. For example, in September 2020, a systematic review and synthesis of 37 qualitative studies looking at recovery in OST across Europe, the United States and Australia reported the views of more than 1,200 staff and service users
. Unsurprisingly to us, stigma was identified as a theme that cut across all levels of society, even in the pharmacy setting.
Four of the studies included in the review were directly relevant to pharmacy practice in the UK
. They uncovered specific problems with services in this setting, such as patients with addiction being asked to use a different entrance or exit to other patients, or being asked to attend the pharmacy alone.
There were also personal slights against this patient group: they had been made to feel unwelcome; made to wait longer than other customers; were ‘looked down the nose at’; and had assumptions made about their behaviour, despite the individual not having done anything wrong
. It is also apparent that the usual clinical checks (applied so diligently to other types of prescriptions) and counselling on medication safety, interactions and side effects are often not afforded to this patient group
Another area where inadvertent stigma can arise is by carelessness in protecting confidentiality. Patients often describe these breaches, with pharmacy team members saying within earshot of others in the pharmacy, “[Patient] is here for his methadone”; asking patients to consume on premises in front of other pharmacy users; or handing patients methadone to take home without a bag, with blue prescription in hand. People who experience addiction are sensitive to being treated in this way but they often feel unable to challenge it, for fear of not receiving their dose or ‘making things worse’
A systematic review of recovery in OST set the groundwork for a qualitative study, in which researchers undertook 25 in-depth interviews with OST service users, staff and key stakeholders in Bristol
. Preliminary findings of this study identified many of the same issues but, overall, experiences of the pharmacy varied.
Participants who spoke positively of their pharmacy experience highlighted the ways pharmacists had become an important source of support and interaction for them, including being made to feel welcome, the pharmacist using their name and being treated in the same way as any other customer.
Sadly, other experiences were less positive. The interviews revealed breaches of confidentiality (described as feeling like wearing a ‘badge of shame’); pharmacists making assumptions about patients’ lifestyles; pharmacy staff making them wait for prolonged periods; or serving them only after all other customers. The study also identified unnecessary restrictions on collection times as another important issue: these restrictions made finding and holding down employment a major challenge for patients with addiction.
Unwittingly deterring patients
This stigma is not acceptable: this prejudice goes against patients’ rights to receive healthcare regardless of their background, condition or demographics. It also goes against the General Pharmaceutical Council’s standards of professionalism set for registrants
But the Scottish Drug Deaths Taskforce, chaired by pharmacist Catriona Matheson, suggests there is evidence that this stigma actually contributes to loss of life from addiction by deterring people from treatment, owing to negative language, attitudes and behaviours
. OST reduces the risk of drug-related death, but patients must engage for this treatment to be effective
Staying in treatment with substitution therapy, such as methadone or buprenorphine — especially at adequate dose and for prolonged periods of time — prevents overdose, prevents death from other causes and reduces HIV infection, thus protecting others too
. The taskforce knows this and “recognises that tackling stigma could make a significant contribution to reducing drug-related deaths”
In 2018, 234,101 people were on OST treatment in England and Wales — data is not available for Scotland — yet, in the same year, there were 4,104 drug-related deaths across these nations
. In 2019, drug-related deaths in Scotland increased by 6%, from 1,187 deaths in 2018 to 1,264 deaths in 2019 — Scotland’s highest ever recorded number and more than double the number of deaths recorded in the nation a decade earlier (545 deaths in 2009)
. Could any of these deaths have been prevented by challenging stigma in pharmacy?
A good person is a good pharmacist
It is clear we need to eradicate stigma in community pharmacy towards people with addiction.
We should start with our pharmacy students. We have found that undergraduate education is woefully lacking content that provides students with a detailed evidence base for addiction and how to manage people who experience it. This must change.
At the University of Bath, however, we cover addiction care over several weeks. This includes a half-day placement at Bristol Drugs Project needle exchange for each student and a workshop with patients who bring their experience of using pharmacy services into the classroom. Over the years, students have fed back how much they value interacting with these patients, and hearing their experiences, both good and bad. These sessions have shaped their confidence to work with this patient group and increased their respect for them. These pharmacists will go on to influence their teams’ attitudes.
At this juncture, it is important to note the many pharmacy teams are already providing excellent care, and here are the actions we can learn from them:
- Consciously consider the patient’s journey, from when they enter the pharmacy to when they leave. Offer a welcoming greeting, “hello, how are you?” and perhaps chat about the weather. These are the basic ingredients of our day-to-day interactions with strangers in the UK, and people with addiction will appreciate being ‘treated like everyone else’.
- If you provide supervised consumption, think about privacy. Recognise that when people are low in self-esteem they may not care who sees them, but remember your own professional responsibility to uphold confidentiality and treat the person with dignity. This includes putting medication or needle exchange packs in bags for the patient’s discretion.
- Simply, remember people’s names. For example, one patient that we know of has been going to the same pharmacy for ten years, and no one has ever called him by his name.
- If your clinical knowledge on addiction needs a polish, think about following the Centre for Pharmacy Postgraduate Education’s programme on addiction, misuse and dependency to support you.
We need change from the top
We cannot tackle this issue on our own — we need support from those in leadership. Support is already being garnered in parts of the UK; in July 2020, Scotland’s Drug Deaths Taskforce published its strategy against stigma, which it recognises as a huge barrier to engaging in care
. The rest of the UK must follow suit.
We hear how a pharmacist can be the most important person in the life of a person with addiction, and those at the top need to hear this too.
Pharmacy, as a profession, could lead on this front. This patient group lacks choice over many aspects of their lives, while our profession can choose whether to be part of the problem or part of the solution.
Jenny Scott, prescribing drug service pharmacist, and senior lecturer in pharmacy practice, University of Bath; Vicky Carlisle, PhD student, University of Bristol
 Carlisle V, Maynard O, Padmanatha P et al. PsyArXiv 2020. doi: 10.31234/osf.io/f6c3p
 Carlisle V, Kesten J, Thomas K et al. 2020. Available at: https://sphr.nihr.ac.uk/research/factors-influencing-retention-and-completion-in-opioid-substitution-treatment-ost/?cookiebanner=true (accessed December 2020)
 Medina-Perucha L, Scott J, Chapman S et al. Soc Sci Med 2019(222):315–322. doi: 10.1016/j.socscimed.2019.01.022
 Ayres RM, Eveson L, Ingram J et al. J Subst Use 2012;17(1):19–31. doi: 10.3109/14659891.2010.513756
 Neale J, Nettleton S & Pickering L. Drug Alcohol Depend 2013;127(1):163–169. doi: 10.1016/j.drugalcdep.2012.06.030
 Notley C, Holland R, Maskrey V et al. Drug Alcohol Rev 2014;33(1):64–70. doi: 10.1111/dar.12079
 McPhee I, Brown A & Martin C. Drugs Alcohol Today 2013;13(4):244–257. doi: 10.1108/DAT-05-2013-0022
 Yadav R, Taylor D, Rogers PJ et al. Can community pharmacists do more to prevent opiate-related deaths in people who use drugs? A national survey of community pharmacists in England. [unpublished manuscript in preparation]
 General Pharmaceutical Council. 2017. Available at: https://www.pharmacyregulation.org/sites/default/files/standards_for_pharmacy_professionals_may_2017_0.pdf (accessed December 2020)
 Scottish Drug Deaths Taskforce. 2020. Available at: https://drugdeathstaskforce.scot/about-the-taskforce/tackling-stigma (accessed December 2020)
 Degenhardt L, Grebely J, Stone J et al. Lancet 2019;394:1560–1579. doi: 10.1016/S0140-6736(19)32229-9
 UK Government. 2020. Available at: https://www.gov.uk/government/publications/united-kingdom-drug-situation-focal-point-annual-report/united-kingdom-drug-situation-focal-point-annual-report-2019#drug-treatment (accessed December 2020)
 National Records of Scotland. 2019. Available at: https://www.nrscotland.gov.uk/files/statistics/drug-related-deaths/2019/drug-related-deaths-19-pub.pdf (accessed December 2020)
 Scottish Drugs Deaths Taskforce. 2020. Available at: https://drugdeathstaskforce.scot/news-information/publications/policy-and-strategy/stigma-policy-and-strategy/ (accessed December 2020)