In episode 4 we heard from drug users and healthcare professionals in their tug-of-war between government imposed regulations and exhibiting a duty of care. Now we delve into the world of the pharmacist, the GP and a drug user, just trying to fill a script – or collusion?
Brian : “Pharmacists deal with practically nothing other than drug users, but that's not what you mean.”
That’s Brian. Brian is a pharmacist with over 20 years of experience, who deals with drug users on a fairly regular basis. We learn pretty quickly that Brian is a straight-talking, ‘tell it as it is’ kind of guy.
Brian tells us that in addition to being involved in the pharmacies that he has worked in, he’s also been involved in some community work in his local area and has no problem offering advice on how he thinks the methadone programme should be run, what it does, and doesn’t do.
Brian : I've always had a very simple approach - you know, there's a contract that most pharmacists get a new client to sign, which says, I will do this and you will do this ... it goes on for several pages, and when I've done that my statement then is okay, you sign there, now I'll give you my rules. You treat me right, I treat you right, you treat me wrong, you're gonna have a problem. Which we all understand.
And I don't have problems. Anyone that's difficult on a particular day, I do nothing on the day and the next time they come in I say, "Your behaviour yesterday wasn't wonderful, let's try and see that it doesn't happen again."
I wouldn't call it a skill, it's a reality for me. I've got my problems, you've got your problems. Let's try and not hurt each other with the problems we've got, we look after each other and do what we need to do to have a successful outcome on both sides. And that means politeness, and normal behaviour.
Kim probes a little further to see if there is a difference in attitude towards drug users in a pharmacy, is there a difference for someone picking up their methadone versus their heart medication after years of eating fatty foods and not exercising? Brian tells us this story about providing the same service, regardless…
Brian : Any pharmacy I work in, yes, they would. Some pharmacies I know don't. A long-term friend of mine, you know, in a town far from where I am, who I call into see on holidays once in a while, he said, "You involved in this?" I said "Yes." He said, "What do you think?" I said, "Well, what do you mean?"
He said, "I've got a line right behind a girl in a window, a lock-up window. When they come, they come into the line and knock on the window, and I've got their dose, I'll give them their dose, so that my other customers don't have to see them."
…and then my favourite bit, that made us all fall a little bit more in love with Brian.
Brian : I tore into him. I have never and will never treat anybody who comes into the shop differently than anyone else. It's ... well, you know, they've got their problems, for whatever reason one of them is they've got a problem that needs regular medication. I've got other problems, I don't necessarily want to hear it, I want to help, so I can. But to treat them as unclean almost I think is very, very wrong and this comes back to what I said earlier, I apparently not at all judgemental. I had a father that said, "Treat everybody well, be a little careful who you invite into your home." And I've stuck to it.
We wondered then how a methadone program is supposed to be run. What is the desired experience for the pharmacist and the drug user involved?
Brian explains that they have a separate dedicated area that’s a bit more ‘semi-private’. Methadone clients seem to know where they need to go, while ‘other customers’ intuitively realise that area is not for them. Brian seems to be as reluctant about the government imposed paperwork as most people who have to fill out forms, but he knows he needs to report on who they’ve dosed. Other than that, it seems like a fairly run of the mill kind of transaction. They engage in some small talk, either take the dose there and or bag up their take-away doses, and then they’re on their way to the register for payment.
Brian : Now, some of those people, like all of us, have money problems. Some of them get behind in payment. I've heard of pharmacies that say, "If you don't pay me up-to-date in advance, I will cease dosing you." I've never been able to do that with a clear conscience. But I gently chide, I suppose, I would say. You realise, I know you've got money problems, et cetera, so does everybody, but I cannot continue to supply this unless you can make an effort to pay for it as well as you can.
That varies from pharmacy to pharmacy. Within the same pharmacies, different pharmacists have different attitudes towards it, so a vexed question, shall we say?
Kim : Well it is, because- from a basic sort of human aspect- denying them the treatment, you know, could force them onto the street into a dangerous situation.
Mm-hmm (affirmative), yeah. Absolutely. Absolutely. There have been all sorts of convoluted schemes to make it part of the free inverted commas medicine scheme. The logistics just don't seem to work. You've got pharmacists in relatively large ... looking after ... people ... and somewhere that's gotta be paid for. And there are costs involved. It can't be free in the terms a lot of us would like it to be. Now, I think the clinics- the government-run clinics don't charge.
But yeah, when you get someone that rings up and says, "Look, I've got a choice of him coming in today, and dosing, or finding some food for the kids for tonight." What do you do? You say, "Come in anyway and we'll sort it out tomorrow or the next day."
But, you know ... I've never been comfortable in refusing people, in any either sorts of treatments or any other medication. For the sake of a couple of dollars.”
Jude tells Kim about a Christmas period when she had to renew her script and she had three days – before that shut down period where most us are counting down the days to the sales.
Jude : For some reason I'd forgotten, and 25 years I've been on this programme, so I think people know about my ... They know me better than I know myself probably, so I couldn't get to see a doctor. I couldn't get a script, so the chemist in other situations would give you ... Because when I was on antibiotics I would get a packet of antibiotics to take until my script came through, but because it was methadone, the chemist was too frightened to give me the methadone to cover that period.
Kim : Too frightened or legally not allowed to?
Jude : He could have done it because they do it with other drugs, but because it was ... It's happened before. I know it's happened. Other people have had it happen to them, so, no, it's this fear about drug users and drugs.
Professor Gowing suggests that in some cases it’s not so much the fear of drug users and drugs, rather the strict government sanctions that are in place to be part of the program.
Linda : It's one of those issues that we have to deal with when you're working with drugs that are subject to regulatory restrictions and that's something that is not going to change in a hurry because methadone or slow release oral morphine, or all of these preparations, they're Schedule 8 drugs, which means that there are controls placed on the prescribing and dispensing of those, and while I can appreciate that clients feel that this is an indication of a lack of trust in them, it's one of those practical things that you really have to live with.
We raise with Brian, Jude’s story over the holiday period and her fear of not being able to get a script in time before everything closes. Brian sighs and explains that unfortunately they have to have a valid, current prescription with an authorisation that the person presenting is approved to have the medication – there’s just no legal way around it, and he can get into a lot of trouble. In saying that, he has thought about it.
Brian : …We have a system where we start reminding people a week before their prescription runs out.
I've tried to get a system going with the main clinic here, that when they see someone they make the next appointment and they give us a couple of cards with times on it so we can remind them earlier. It does happen, and then you've got the panic of trying to ring it up to get a fax, et cetera, et cetera, et cetera. And of course, it's gonna be Friday or Saturday or Sunday when this happens.
Brian acknowledges the stress that a patient can go through if they can’t get to their GP to get a script and tells us that the computer system they use knows when a patient’s script is about to expire and lets them know a week in advance. It’s just one device they are trying to work within the constraints of the system. Brian also says that a patient’s GP can generally authorise a week or two extras if necessary until they can get in to see the doctor and get their prescription.
Brian : You know, look, some of the clients are brilliant at keeping their tabs on dates and things. Some are hopeless, and that's like the rest of us. We're good at some things and bad at other things. You gotta learn- well, you get to know your customers, I suppose, is one way to put it. You get to know your clients and you get to know which ones you can help easily, which ones need a little bit more help. And on you go.
Jude turns the conversation to the communication that happens between the doctor and the pharmacist, she reminds us that this is one of the reasons that ‘passing’ is so important.
Jude : Of course they talk to each other and a chemist will ring up the doctor and says, "Oh, you know, so and so came in looking a bit shady today." The next time the doctor gets to see her for a script he'll be running up and down her arms. Yeah.
You make sure that you're well-presented so they think you ... There's signs and signals which we all know that tell people whether you're managing or not , so you get to know what they are and you make sure you present them.
Brian – what do you think of that?
Brian : What we also try and encourage is- well, this is a bit of a hobby horse. You go to the doctor every three or six months to get your prescription. You scrub up, you're nice and clean and bright and shiny and wouldn't hurt a fly. And the doctor sees you and says, "Okay that's fine, I'll see you in sixth months."
We see them four of five, six times a week, but they would probably benefit from ringing a pharmacy member and casually saying, "How's Brittany going? How's Julie going? Is she dosing regularly? Is she coming in?" You know, et cetera. Does not happen very often. That's an area where, if necessary, I will ring a doctor and say, "Hey listen, you better have a look at so and so." But that doesn't happen much in general amongst most pharmacies, I'm afraid.
Kim digs a little deeper to see if there is a physical legal requirement for the GP and pharmacist to be talking to each other.
Brian : No legal requirement. I have always- me, and I don't know about anyone else, but I've always felt you have things the doctor should know. But I came from a small town and the four clergy from the various churches, the police, the doctors, the pharmacists, and a couple of other people in town would regularly ring someone, one other person in their group and say, "John, it'd be a good idea if you spoke to Suzy." And it just happened. It doesn't happen in big places, and it's missing, and I think there's still a lot of pharmacists who are frightened to ring a doctor and tell him anything at all because he or she might then get cranky because "I'm a pharmacist."
I've never felt that. I'm a professional in a different area to the doctor, right, we both have responsibilities, we should be working together. I've never had a problem talking to a doctor about anything.
…and from David our GP?
David : Okay, with opioid substitution, there's a big framework. The pharmacist must ring the prescriber if the patient appears intoxicated. That's a legal requirement, and then the prescriber then has a dilemma. What do they do? They have to then make a very quick decision. Is it safe for the pharmacist to dispense medication to someone who maybe is intoxicated? Because of the risk of drug overdose which can be fatal.
Kim moves the conversation to take-away doses.
Kim : What's the difference, tell me a little bit about the programme in terms of, so obviously the take away, taking away of methadone from the pharmacist is providing you with a level of trust.
Jude : Little personal agency. Yes. That's right, and trust, and that's patronising. Yes. There's all these layers. Yeah. No. You're absolutely right. It is patronising. You behave, and we'll give you this. Pat you on the head.
Brian explains that it’s the GPs that determine who gets take away doses – not the pharmacist. Brian goes on to explain the regulations around takeaway doses. The idea is that a dose is served every day and after a period of ‘stability’ normally around 3 months, a patient can have one takeaway dose. As the patient continues to improve the takeaway doses might increase to up to 4, well that’s Brian’s experience anyway. He also did mention that there are special circumstances like having a job where the patient’s work hours prevent them from being able to get to the pharmacy – these patients can have up to five.
Brian : And yeah, I, thinking back, I've tried to ease up I think once or twice where I've said, oh, I'd be a bit careful. And I think there's a growing appreciation that giving people ownership of their problem, you are and they are as excited to have four take-aways a week, please prove me right in what I'm saying, and I think once you're able to do that, and do that with your head held high, it's good for your stability.
One of the things- I've got a few years under my belt. One of the things in which I near get quite a degree of pleasure within pharmacy is seeing people come onto this programme and become more stable and start to get a grip on their lives and start to be able to benefit from a regular regime, even though they hate it- and yeah, the ones that call them chemical handcuffs, they're absolutely right- but if it means they can get other areas of their life into some sort of a more stable routine, and they then start to benefit from that, I'm quite pleased to see that happen..
According to Associate Professor Gowing, South Australia does not permit patients to have ‘take-aways’, while in NSW, it is possible for patients to have a number of take-aways each week. Some of this take-away methadone finds itself sold as a commodity, selling for between $0.50 and $1 per ml.
Linda : When there's someone who's prepared to pay money for a commodity, there's always someone who's prepared to supply it. I mean, this is part of the reason for the communication between the prescriber and the dispenser, it's part of the reason why methadone is largely now provided under supervision, whereas buprenorphine, which is less easily diverted to the black market, there is a little bit more freedom in how that's able to be dispensed.
Not on Brian’s watch.
Brian : ... I suppose I need to be delicate ... and it wouldn't work, but there are some people where the doctors think okay, if I give this prescription to this person, it might end up somewhere other than where it ought to be and it might be then used incorrectly. Now in fact, that cannot happen because of the way the authorities work it. Anyone, in the geographical area that I'm in, if someone came in, a stranger with a methadone prescription you would have a lot of questions, and it wouldn't work…
So where does that leave us?
Linda : We can work within the system as much as we can to I guess acknowledge the autonomy of the individual but unfortunately not all people, whether they're drug users or not, not all people can be trusted and there is that difficult environment out there, so the communication between the prescriber and the dispenser is one of those regulatory situations that governments insist on.
I think Brian shapes this better than anyone we spoke to – human nature, in any circumstance…
Brian : Yes, it's the ninety-five and the five percent. It's the five percent of whatever that don't use these properly and ruin it for the other ninety-five percent.
In this episode, we heard about how the pharmacists are also effected by a highly regulated industry – but there are still ways to work within that system and provide care to their customers. We met and loved Brian and found that he was a wealth of knowledge when it came to his experience working with drug users – his panache for people. Brian provides plenty of advice to his peers and cohort of medical professionals regarding how to include and make someone feel comfortable, rather than segregate.
In this series, while we focused on something so seemingly simple as visiting the GP and getting a script, as we dug deeper it was revealed that it was so much more than that for drug-users and healthcare professionals alike.
We hope that whether you are a drug-user, a healthcare professional or anyone who took the time to listen, that you’ve been exposed to the other side of a story that you might not have been privy to before – and even just starting to think about the interaction between drug-users and healthcare professionals and introducing a dialogue, is more than we could have hoped for in the making of this series.
Make sure you check out the resources to help support a normal, uneventful, ordinary – trip to see the doctor or pharmacist.