key: cord-1028012-zdhjpke1
authors: McAuley, D. Michael
title: Substance misuse prescribing challenges during the pandemic
date: 2021-11-16
journal: Prescriber
DOI: 10.1002/psb.1956
sha: bdb348f0173143d14fe65e8fbe91c9d1ab6de9d0
doc_id: 1028012
cord_uid: zdhjpke1

The COVID‐19 pandemic has necessitated a paradigm shift in the way substance misuse services are delivered, with a move from face‐to‐face to remote consultations. This article discusses the challenges substance misuse healthcare providers have faced adapting to these changes and how technological innovations have helped ensure treatments are prescribed or supplied as safely as possible.

A very rapid reconsideration of substances misuse services that deviated from the 'standard approach' was required during the COVID-19 pandemic. This necessitated a change in approach towards consultations, but also with regard to how patients could be provided with their prescriptions for opioid substitution therapy or other treatment, while minimising the number of interactions needed between patients, the public and healthcare professionals.

The need to balance the risks posed by the pandemic versus the risks of diversion, as well as intentional and unintentional overdose, in this cohort of patients (who could potentially be leading a chaotic lifestyle, through the possession of a large quantities of medication, alongside less frequent interactions with healthcare professionals) meant that the safest possible model of delivery needed to be implemented. The pandemic mandated substance misuse healthcare pro-viders to leap towards technological solutions, including remote telemedicine and telephone consultations, distant prescription printing and summary care record access.

Asking patients to attend a service and collect their prescription is one method of engagement that enables a wellbeing check to take place and any safeguarding or medication-related problems to be identified, but due to the pandemic, the secure couriering of signed prescriptions for patients has been a necessary modification to this pathway. Figure 1 shows how people entering substance misuse treatment are classified into different substance repor ting groups. 1 Though traditionally the medicines provided through substance misuse services would not be prescribed following a remote consultation, following the necessary adaptations implemented during COVID-19, many of the existing Substance misuse prescribing challenges during the pandemic

The COVID-19 pandemic has necessitated a paradigm shift in the way substance misuse services are delivered, with a move from face-to-face to remote consultations. This article discusses the challenges substance misuse healthcare providers have faced adapting to these changes and how technological innovations have helped ensure treatments are prescribed or supplied as safely as possible. SPL wchh.onlinelibrary.wiley.com obstacles have been overcome. Ensuring medicines are prescribed or supplied in a clinically appropriate manner with the necessary safeguards in place is paramount, especially as the patient cohort potentially has access to illicit drugs or medicines liable to misuse, particularly those that pose a risk of overdose, eg opioids, sedatives and gabapentinoids. 2 This is one of the reasons why primary care providers and substance misuse services must maintain good lines of communication, preferably utilising digital media, so that updates on any relevant changes are provided in good time. Cer tain information is essential to ensure clinical safety, such as substance misuse clinicians knowing if the patient was being prescribed medications that may have significant interactions with anything prescribed by them, but also to keep primary care practitioners informed of the interactions that may occur. Should opioid-based medication, gabapentinoids or benzodiazepines need to be initiated by the GP , the risk of overdose and possible misuse would require a multidisciplinary discussion.

Prior to the pandemic, an overwhelming majority of consultations occurred face to face, but with concerns around supervised consumption in community pharmacies, remote medical reviews became standard and a longer-interval pickup model was implemented, though most services chose to do so in a staggered manner and only after a thorough and individualised risk assessment.

In substance misuse services, particular principles should be viewed as essential when conducting remote consultations, with the prescriber satisfying themselves that they can perform a suitable assessment through the establishment of a dialogue with the patient and by obtaining their consent to proceed. Upon commencing any remote consultation, the clinician should provide their name and designation, particularly if face-to-face contact has not previously been made between the pair, and they should also explain how the remote consultation will work and what should be done if the patient has any concerns or questions. 3 The clinician must have adequate knowledge of the patient's health, including access to the patient's medical and treatment records, as some medications (eg citalopram, tramadol and amitriptyline, which can prolong the QTc interval) may have significant interactions with methadone, a mainstay of opioid substitution therapy. 4 In addition, it is ideal to have access to the last 12 months of pathology results, liver function tests (LFTs; given the possibility of cirrhosis due to Hepatitis B/C or alcohol use disorders), full blood count (FBC; due to the many effects of alcohol use disorders on components of the blood system), HIV serology, urea and electrolytes (U&Es) and the last 36 months of any ECG results.

The General Pharmaceutical Council (GPhC) has provided guidance to assist pharmacist prescribers undertaking remote consultations, which is also practical for other prescribers, in particular when prescribing in substance misuse. Patient safety must be of paramount concern, with particular emphasis on utilising a patient's medical records and other sources of information to establish any allergies or drug interactions. Both the prescriber and the patient must come to a mutual decision about treatment and should be satisfied that the medicine serves the patient's needs. 5 Special care needs to be taken when prescribing unlicensed medicines or for 'off-label' indications, 6 such as benzodiazepines for use with certain withdrawal regimens. Figure 2 summarises the considera- 

The clinician also needs to take into account the drawbacks of the medium they are utilising, including picking up body language cues, the lack of a physical examination and the possibility of other individuals being in the immediate vicinity, which may constitute a safeguarding or exploitation concern. In addition, the clinician is unable to perform a physical examination and a urine drug screen, which is deemed essential during an initial consultation due to the risk of death to the patient should they be opioid naïve. A consultation undertaken remotely would therefore require a urine drug screen to be arranged separately and before treatment initiation, though previous interim Public Health England guidance stated that if only remote assessments were possible and drug testing was not possible, it may be suitable to proceed with buprenorphine titration in known opioid-dependent patients. 8 In addition, there must be a robust process in place to check the identity of the person if they are unfamiliar to the clinician, eg by keeping to the Identity Verification and Authentication Standard for Digital Health and Care Services, as well as ensuring the contact details of their regular prescriber are obtained and consent to contact them is gained, as treatment cannot proceed without this consent. Systems should be in place for circumstances when the person does not have a regular prescriber (a particular concern in substance misuse prescribing), or if there is refusal of consent to share information but the prescriber still wishes to issue a prescription. On such occasions, a clear record is needed, setting out the justification for prescribing, ie the exceptional circumstances, how risks have been mitigated and why there is an immediate need to prescribe. 7 Other issues that may be affected include the ability to assess if the patient has the capacity to decide about their treatment, while always working within national and local prescribing guidelines and good practice guidance.

In substance misuse services, the risks involved with remote prescribing take on a different dimension, due to several factors, such as the mental state of some patients accessing the service, the utility of performing a urine drug screen and the Under nor mal circumstances, patients in receipt of opioid substitution therapy should undertake regular trips to the pharmacy in order to receive their medication, which in almost all cases is daily when treatment starts, or where there is a concern about patient compliance, safety or the possibility of diversion. Levels of supervision should be based on an individual risk assessment for, and with, each patient, including a review of compliance and individual circumstances, such as whether the home environment is suitable for safe storage of medications. 9 This is done under the supervision of a pharmacist, whose vigilance supports treatment compliance and as a consequence reduces overdoses and drug-related deaths.

During the pandemic, updated guidelines by Public Health England meant patients could be supplied with larger quantities of medication 10 as a means of minimising travel and social contact. The University of Bath's Depar tment of Pharmacy and Pharmacology has studied the impact of this increased pickup volume on patients receiving opioid substitution therapy. The findings suggest that the majority of patients interviewed are coping well with the changes in prescribing practice and are able to manage their own medication and take their prescribed dose. Many patients welcomed the reduced trips to the pharmacy, affording them more freedom as well as the financial benefit of reducing their use of public transport. Consequently, the lockdown may have helped some patients take control of their addiction.

Downsides have yet to be established, though the reduced contact with addiction recovery services, along with friends and family, has led to struggles with loneliness. This is a particular challenge for patients in addiction treatment, within an isolated environment, potentially alongside other individuals who are enabling their addiction, leading to a deterioration in physical and mental health and adding further complexity to treatment. 11 Figure 3 shows the mental health need and treatment received for people starting substance misuse treatment in England from 2019 to 2020.

The danger that came with these changes to patient-prescriber interactions during the pandemic included the strong possibility of disengagement, either due to a reduction in supervision or the ability to use the pandemic as a reason for nonattendance at appointments or drug screenings. Moreover, naloxone provision from community pharmacies was and must continue to be prioritised, as the larger quantities of opioid substitution therapy being dispensed during the ongoing pandemic mean that overdose risk continues to be a possibility. In 2020, there were 4561 people in England and Wales dying from drug poisoning, the highest number since records began in 1993, 12 and a stark regional variation in mental health deterioration during the pandemic was a probable contributing factor. 13 Ensuring patients receive medication storage boxes for their residence alongside other strategies that can help mitigate risk, such as verbal and written harm reduction advice, is also essential. 8 Many of the technological innovations initiated during the pandemic will continue into the future, while the pandemic remains a reality. The utility of such approaches to consultations and pickup regimens, given the relative success for a small cohort of patients, is hard to ignore. The full picture of mortality during the pandemic is more difficult to disentangle, and yet to fully emerge, with myriad factors potentially playing a part, such as co-mor- bidities and untreated or undetected medical conditions. The percentage of patients on supervised consumption regimens has been rising in recent months, and will likely continue to do so before stabilising as restrictions are eased. The relative risk rating allotted to a patient must be considered when deciding on the suitability of a remote approach, versus a pre-pandemic approach, to optimise the delivery of a high-quality service.

The power of the patient-prescriber bond cannot be underestimated and the potential deleterious effect of remote consultations must be further studied in order not to undermine this impactful relationship. One possible treatment avenue to consider is that of the prolonged-release injectable buprenorphine formulation Buvidal, which can negate some of the treatment barriers previously mentioned and provide reassurance to prescribers that patients are receiving their prescribed medication as agreed and on time, supporting compliance and reducing the risk of accidental overdose.

Myriad benefits exist for remote consultations and diagnostic tools in an increasingly technology-driven world, such as telemedicine, which is increasingly accepted by patients and the public. The enormous challenges faced in substance misuse are due to the cohort of complex patients that require treatment, with the need for patient engagement to check on safety and diagnostic tests, as well as risks created by providing larger quantities of medication, alongside reduced patient contact. The pandemic has caused a paradigm shift in how services are delivered, but the risks will continue to change as technology evolves, and as patient and prescriber knowledge and familiarity with this approach increase, with the greatest risk being complacency and a lack of safeguards. Above all else, the safety and the welfare of patients must remain at the heart of the great work these services continue to provide.

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ethical-guidance-for-doctors/good-practice-inprescribing-and managing-medicines-anddevices/deciding-if-it-is-safe-to-prescribe 4. Department of Health and Social Care. Drug misuse and dependence: UK guidelines on clinical management

GPhC launches new guidance for pharmacist prescribers

The Human Medicines (Amendment) Regulations

19-guidance-forcommissioners-and-providers-of-servicesfor-people-who-use-drugs-or-alcoholcovid-19-guidance-forcommissioners-and-providers-ofservices-for-people-who-use-drugs-or-alcohol 9. Department of Health. Drug misuse and dependence. UK guidelines on clinical management

Deaths related to drug poisoning in England and Wales: 2020 registrations. 3

Drug poisoning deaths in England and Wales reach record high. The Guardian 3