Counter culture

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As the friendly and regular face at the heart of community-based medicine, the pharmacist has an opportunity to profoundly influence welfare, as DDN reports.

Lee Collingham: ‘The pharmacy is central to everyone’s treatment… it’s not about checking people out, it’s about helping.’

‘If you’re struggling, you say, “I’m alright”. People pass you and ask, “Are you OK?” and you say, “Yes, I’m fine.” It’s just a normal greeting. But you could say, “You’re going to wish you’d never asked me that. Do you really want to know? I feel like shit, I can’t be arsed with anything, I’m just going through the motions.”’

Lee Collingham is explaining how it can feel when you’re trying to stay in treatment for problematic drug use. He speaks from personal experience and as a service user advocate and peer supporter.

‘You may not have seen your drug worker for a month. You may have had a breakdown, got yourself back together, had another breakdown.’

And from his own experience: ‘I’ve regularly started to miss doctor’s appointments. Sometimes it’s because it’s the opposite week to when I get paid and I have to walk two miles. Or it might be because my appointment’s at 8.30am and with me not sleeping well, I might have dropped off at 7am.’

He sees his local pharmacist regularly, just a short walk away, and points out that at the heart of an overloaded treatment system, the pharmacy has an increasingly important role.

‘The pharmacy is central to everyone’s treatment and they see people more often than anyone else in the system. So there’s a lot of stuff they can do.’ He reels off a list of basic interventions and harm reduction advice, as well as the opportunity to introduce patients to the right kind of hepatitis C treatment to suit their condition – ‘if you’re on OST [opioid substitution treatment] you get one kind of treatment, if you’re a drinker you get another one, and so forth.’

But there’s an overseeing role that can be equally important as far as he’s concerned. ‘The chemist is the one place they will attend regularly, and there could be better integration with other services,’ he says.

‘Some people might come in for daily OST pick-up on a Monday, then miss Tuesday and Wednesday. They’re just keeping in treatment, but what are they doing for the other two days if they’re not needing their script? Are they still using? It’s not about checking people out, it’s about helping them to reach their goals and where they want to be – about not making it problematic so they can’t even come forward with an issue.’

Personally, he values the regular contact and the concern for his welfare – the little chat while waiting for medication to be made up. ‘They’ll say “are you alright Lee? You seem a bit quiet” or “you seem a bit off these last few days”. It’s the conversation that leads to help with all aspects of health and wellbeing.

‘As services and needle exchanges are cut, your prime relationship is more and more with your pharmacist,’ says Nick Goldstein, who is tasked with helping to make this relationship a positive one. Called upon as a representative of the drug-using community (a label he is uncomfortable with, as ‘we’re not all alike’), he is involved in an initiative by Martindale Pharma with Boots, supporting current and former service users to engage with pre-reg pharmacists as part of their addictions training programme.

Goldstein is cautious about overvaluing his role for several reasons. He is talking to pharmacists at the start of their career, rather than decision-makers in charge of culture change. He only has a slot of about half an hour in the training day – not enough time to go into the level of detail he would like, although questions from participants often take the session beyond its allocated slot.

‘If I was cynical I’d say it was a case of saying, “hey, come and watch the bear dance”. It’s a show for them,’ he says. ‘In a dry academic day I turn up and I’m a little bit different. And they’re always fascinated, always paying attention.’

But while paying attention, he hopes they are picking up the core points he’s giving them – and while doing so, that the sessions are helping to address stigma and personalise the process of coming to the pharmacist for OST. ‘I try to get them to look beyond the reductive labeling and see that we should be treated as individuals,’ he says.

Beginning the training three years ago, Goldstein came face to face with the scale of his task.

‘I realised after doing a few of these sessions that pharmacists have a huge miscomprehension about why people are actually in treatment – they seem to think we’re there for one long party on the state,’ he says. ‘And you have to explain to them that that’s not true, especially nowadays. No one goes into treatment for a gig or a good time. You’re there because you’ve lost control of your life, basically. And that’s a very scary thing.’

The stigma is not usually deliberate, but the product of ‘a mixture of ignorance and apathy’, he says.

‘They have preconceived prejudices until someone points it out – that these people are more than the label you’re slapping on them. They’re people’s husbands, fathers, sons, mothers, daughters, and they have careers and a whole range of interests, fears and fantasies. The difference is that they’re addicted to drugs, but apart from that they are just like you. They’re not from Mars.’

While they ‘don’t even realise beforehand that their attitude could be described as problematic’, there’s a slow dawning process that ‘addiction’s just a label and these are human beings just like them, and should be treated with the same respect’.

With chemist shops moving more and more into community-based medicine, we have a ‘golden oppor­tunity’ to give pharmacists a better frame of reference for interacting with the community, says Goldstein.

In his short, rushed training slot, he is aware that staff from a large pharmacy chain are going to be restricted by standard shop layout and company protocol, relating to the routines they can influence – things like whether OST should be dispensed from a separate window – but he introduces the idea of ongoing dialogue.

‘I’ll say to the pharmacists, ask your clients what they want and at least take that into account when making your decision. Don’t just present them with a fait accompli because that just disenfranchises people from the process and from the treatment.’

Both Collingham and Goldstein talk about the importance of fair play on both sides of the counter. Collingham mentions behavioural contracts as a way of establishing a respectful relationship, for example: ‘I promise that I won’t treat you like an idiot by stealing from your shop – and on the pharmacy side, I won’t keep you waiting past clients that come in after you, or identify you as an OST user.’

Goldstein sometimes comes across pharmacists who are keen to share episodes of bad behaviour that took place in their shop, and agrees there are responsibilities that the client must sign up to. He reminds them: ‘We are individuals. Some of us are fat, some of us are thin. Some of us are nice guys and some of us are assholes. Be clear about this – but believe in giving the assholes a fair break.’

He is also acutely aware that pharmacists just entering their profession will have no influence over long-established company protocols. ‘You can point out the dangers of these protocols till you’re blue in the face, but it’s not going to help because they’re not responsible for them. Somebody needs to talk to head office and say “hey guys, have you thought about x,y and z?”’

But through the modest training initiative, Goldstein hopes to awaken a desire to know more – and there is a lot to learn. For instance, they are ‘completely ignorant’ about naloxone. ‘Out of the few hundred I’ve trained now, I’ve had only two or three who know what it is. They’re pretty clueless about it,’ he says, adding, ‘Naloxone is one of those things that should have been around for years, and now it’s happening that’s a great thing. But the way it’s being implemented and put out there leaves a lot to be desired.’

In the limited time he has with the trainee pharmacists, he hammers home the increasingly important role they have to play: ‘You see your key worker once in a blue moon. You see your consultant even more infrequently. You see your pharmacist fairly regularly, so I point out that they become a key point of contact in the treatment chain.

‘And that can be the difference – their attitude and behaviour – between someone staying in treatment and someone leaving. That’s the difference between life and death in some cases.’

This article has been produced with support from Martindale Pharma, which has not influenced the content in any way.