1. Enhanced Pharmacy Provision in Edinburgh:
A Six Week Pilot and Follow Up
Susan Carmichael RGN
Con Lafferty RMN
Amir Kirolos Public Health Specialty Registrar
This graph shows how many patients engaged with the interventions on offer.
Of the 60 clients who engaged with the enhanced service 49 (49/60=82%) were tested for blood borne viruses, 29 (29/60=48%) took Naloxone and 44 (44/60=73%) were given safer injecting advice.
Introduction
Results
Lothian has seen an increase in hepatitis-C infections (an increase from 7% to 48%) and now almost half of people who inject drugs in Lothian are living with hepatitis-C. There has also been a record number of drug related deaths in the last year (an increase of 30%). A review of regular IEP (injecting equipment provision) users in Edinburgh has shown that 83% use community pharmacies (which provide a very basic IEP service) and 89% of these exclusively so (Kirolos, A et al., 2017). To raise awareness of these issues, and to improve access to blood-borne virus (BBV) testing and Naloxone, an Enhanced Pharmacy Service (EPS) project was developed. The term EPS refers to the provision of a more informed injecting equipment provision (IEP) service alongside dry blood spot testing for BBVs, Naloxone training, and safer injecting advice within the pharmacy. This was a 6 week trial placing staff from the NHS Lothian Harm Reduction Team and 3rd sector agencies (Lifeline and Turning Point) into 4 pharmacies in Edinburgh. The four pharmacies were chosen in an attempt to close a gap in IEP and specialist services caused by neighbouring Substance Misuse Hub changes.
Figure1: Craigmillar was the busiest pharmacy and the attach rate was 84% . The high numbers may be due to the pharmacist’s positive relationship with the clients and his proactive approach to promoting the EPS. In Lloyds Wester Hailes the attach rate was 77%. The numbers here were high due to Lifeline canvassing for known clients in the shopping centre the pharmacy is based in. L&G had the lowest attach rate at 39%. Clients were more reluctant to engage and did not want to use the service as they stated they had workers providing the services already. MacKinnon pharmacy had a high attach rate but the service in general was not well attended.
Aims
To raise awareness of the recent increase in hepatitis C instances and overdoses in Edinburgh and the Lothian’s.
Improve access to blood borne virus testing, Naloxone and safer injecting advice.
Provide a specialist service, improving on basic IEP services within pharmacy provision.
Figure 2: This graph shows how many patients engaged with the interventions on offer. Of the 60 clients who engaged with the enhanced service 49 (49/60=82%) were tested for blood borne viruses, 29 (29/60=48%) took Naloxone and 44 (44/60=73%) were given safer injecting advice.
Methods
The EPS was targeted at people who inject drugs using the pharmacy IEP service, their family and friends and those attending for opiate substitute medication, as many continue to inject or are around others who do. Four pharmacies in and around the City of Edinburgh were chosen in relation to perceived service need. Leaflets were designed and distributed 2 weeks prior to the commencement of the EPS. The EPS was run in partnership with 3rd sector staff and a meeting took place to co-ordinate the approach. Two nurses from the NHS oversaw the service, took two pharmacies each and took the lead in delivering enhanced services. Recording sheets were used to gain as much information about the patient to capture general client details such as date of birth and substance used, any current treatment received, self report of BBV status, vaccination status, sharing of equipment status (self report) any enhanced interventions and sign posting carried out. The 3rd sector staff observed the intervention as a learning point, or delivered IEP whilst the nurse conducted the enhanced intervention. BBV tests obtained took approximately one week for results to come back. Negative results were given in a variety of way depending on obtain ability of patients. Positive results were given face to face using the number given by patients at time of intervention. The follow-up questionnaire was used to collect the views of patients who used the service. This was completed over a 2 week period by contacting the patient directly using a phone number provided or by visiting each pharmacy for a 4 hour session to complete questionnaires in person
Figure 3: Of the forty nine people tested nine clients tested antibody positive (Ab+). Four of these clients tested Ab+, antigen negative (Ag-). This means that these clients had come into contact with the hep-c virus; however, their body may have cleared the infection naturally. Three of these clients tested Ab+ and antigen positive (Ag+) which indicates an active hep-c infection. These clients were referred to the BBV team to discuss treatment options. Two clients Ag results were inconclusive which may indicate a low level infection. No clients tested positive for HIV or hep-B.
Conclusions
The EPS was a unique opportunity to train 3rd sector staff in BBV testing, Naloxone and safer injecting advice. NHS staff were able to ensure that a high quality service is available in 3rd sector localities. The feedback was overall positive and highlights that clients who used the service now have an enhanced knowledge of issues such as BBV transmission routes and overdose prevention. There is an obvious need for enhanced pharmacy service as the only health care contact for many injecting drug users is exclusively through pharmacy related care.
Acknowledgements
Staff from The Harm Reduction Team, NHS Lothian would like to thank Dr. Duncan McCormack (Public Health), Amir Kirolos (Public health registrar), staff from all 4 pharmacies (Craigmillar Pharmacy, Lloyds Wester Hailes, Lindsay & Gilmour, Crewe Road North and MacKinnons pharmacy) and staff from CGL and Turning Point.
References
Kirolos, A et al., Harm Reduction in Edinburgh: A Health Needs Assessment With People Who Inject Drugs.