SERVICE SPECIFICATION
– SERVICE AREA 3
Service
Authority Lead
Pharmacist Supervised Consumption of Prescribed
Opiate Substitution Therapy (OST)
Jo Melling
Period
Date of Review
Ongoing
January 2015
1. Population Needs
1.1 National/local context and evidence base
Background
The National Institute for Health and Clinical Excellence (NICE) Clinical Guidelines recommend the use of opiate substitution therapy (OST) to treat individuals with addiction to opiates 1 .
Pharmacological treatments are broadly categorised as maintenance (also known as
'substitution' or 'harm-reduction' therapies), detoxification or abstinence. The aims of the maintenance approach are to provide stability by reducing craving and preventing withdrawal, eliminating the hazards of injecting and freeing the person from preoccupation with obtaining illicit opioids, and to enhance overall function. To achieve this, a substitution opioid regimen (a fixed or flexible dose of methadone or buprenorphine to reduce and stop illicit use) is prescribed at a dose higher than that required merely to prevent withdrawal symptoms. The aim is for people who are dependent on illicit opioids to progress from maintenance to detoxification and then abstinence (when a person has stopped taking opioids).
Introduction of supervised methadone dosing has resulted in substantial declines in deaths related to overdose of methadone 2
Opiate Substitutes such as methadone and buprenorphine should be administered daily, under supervision, for at least the first 3 months of treatment. Supervision should be relaxed only when the patient's compliance is assured. Both drugs should be given as part of a programme of supportive care 1 .
In Oxfordshire we commission a range of services to meet the needs of substance misusers, and the provision of OST dispensed with supervised consumption is a core component of the treatment pathway.
1
TA114 - Methadone and buprenorphine for the management of opioid dependence, NICE, January 2007
2
BMJ2010;341:c4851

1.2 Social Value Considerations
The delivery of OST services including supervised consumption address priorities which disproportionately affect socially disadvantaged communities in Oxfordshire. These include reduction of substance misuse and supporting individuals to make choices to reduce the harms caused to themselves, their families and the wider community. This includes a reduction or complete abstinence from illicit drugs which in turn results in ceasing injecting so a reduction in injecting site wounds and abscesses, and a reduction in needle stick injuries in the general public resulting from discarded needles. It also reduces death from accidental overdose from illicit use, and the spread of blood borne viruses. The services also promote access to the Recovery Service to support the Service User in achieving abstinence. OST alongside supervised consumption reduces the risk to communities in a number of ways including overuse or underuse of medicines, diversion of prescribed medicines onto the illicit drugs market and accidental exposure to the dispensed medicines,
Therefore, the delivery of these Services improve the Service ’s health in the longer-term, as well as improve the economic and social well-being of Oxfordshire by keeping Service
User’s healthier for longer and decreasing demand on health and social care services and well as criminal justice services.
2. Key Service Outcomes
Service Providers will ensure that the supervised consumption of opiate substitution treatments is in accordance with NICE Clinical and quality standards, including and not limited to the following:-

Evidence that the supervised consumption of opiate substitution therapy is conducted in accordance with NICE clinical guideline TA1141 1

Provide an opportunity for the pharmacist to build a rapport with the Service User thus improving professional, user and carer satisfaction and the retention of Service Users in treatment.

Provide an opportunity for the pharmacist to make a daily assessment of compliance with the programme and of the general health and wellbeing of the Service User and advise and signpost to other services accordingly.

Reduce the complications from drug use and the prevention of transmission of blood borne viruses associated with drug use.
3. Scope
3.1 Aims and Objectives of service
Aims

The principle aim of supervised consumption in the clinical context is to provide a comprehensive, service to drug users that will reduce drug-related harm and the potential for death. This Service will require the Service Provider to provide a supervised consumption of prescribed opiate substitution therapy medications to Service Users living in Oxfordshire.
This will involve the dispensing and supervised consumption of either methadone or buprenorphine. The Service Provider will offer a user-friendly, non-judgmental, Service
User-centred and confidential Service
3.2 Service description/pathway
The prescriber requests supervision of consumption of a substance used in the treatment of opioid addiction, on a regular basis, either as part of a detoxification programme or maintenance treatment
‘Regular’ is defined to mean ‘weekly for a minimum of eight weeks’ or as ‘a minimum of six consecutive days’
Service Users are prescribed:-

methadone solution 1mg in 1ml

buprenorphine sub-lingual tablets, there is some evidence which suggests that crushing buprenorphine prior to its supervised consumption does reduce diversion, this is a clinical decision should be made by the pharmacist on a case by case basis.
The Service Provider will:

Ensure compliance with an agreed care plan by dispensing prescribed medication in specified instalments

Ensure each supervised dose is correctly administered to the patient for whom it was intended (doses may be dispensed for the patient to take away to cover days when the pharmacy is closed)

Liaise with the prescriber, named key worker and others directly involved in the care of the Service User (where the Service User has given written permission)

Monitor the Service User ’s response to prescribed treatment; for example if there are signs of overdose, especially at times when doses are changed, during titration of doses, if the Service User appears intoxicated or when the Service User has missed doses and if necessary withholding treatment if this is in the interest of
Service User safety, liaising with the prescriber as appropriate

Provide Service Users with regular contact to healthcare professionals

Provide referral or signposting to other related services
The Service Provider will work in partnership with drug treatment providers and General
Practitioners. The Service Provider will promote harm reduction to the Service User, carer and families and referral to drug services as relevant.

3.2.1 Criteria for participation in the scheme
There are two bands of Service delivery available:-
Band One
The Service should:

Identify a pharmacist who has successfully completed either the distance learning pack Substance use and misuse CPPE 2010 or RCGP Part One Certificate in the
Management of Drug Misuse (or equivalent as approved by the Council) to take responsibility for the Service on the premises

Comply with Guidance for Primary Care Drug Misuse Public Health and NHS
Oxfordshire 3 rd Edition 2010 ( or more recent edition), professional guidance and national treatment guidance

Provide safe storage conditions for the supply of methadone and maintain appropriate standard operating procedures for the safer management of controlled drugs

Provide advice on safe storage of methadone and buprenorphine at home

Provide advice and display health promotion leaflets relating to harm reduction

Maintain sufficient Staff in place to provide and/or support the service

Provide a continuous Service on all days of opening

Provide safe disposal and destruction of clinical waste and items which may identify
Service Users.
Band Two
A Band Two Service Provider will be determined by need, as agreed by the Council but the following criteria must be met in addition to the above.
A Band Two Service Provider will have:

A pharmacist who has completed the RCGP Certificate Management of Drug Misuse
Parts One and Two working a minimum of 40% of the Services opening hours per week in each Service location where band status is applicable

A minimum of twenty Service Users regularly supervised on a continual basis

A private consultation area which must meet the following principles: a. The Service User and the pharmacist can sit down together b. The Service User and pharmacist can talk at normal speaking volumes without being overheard by Staff or customers c. The area is clearly signed as a private consultation area (a closed room is not necessary).
3.2.2 Monitoring
The Service Provider shall:

Provide a minimum data set for each transaction which should be recorded within the calendar month of the transaction occurring, using the web-based system provided by the Commissioners (currently NEO); data should be input and retrievable by the
Council within 7 days of the end of the previous month.

Payments will be made according to the number of transactions, and as such the data entered onto this system will determine the level of payment to each provider. Where this
Service User information is not input onto the system within the required timescales this may result in payment for those Service Users not being able to be made to the Service
Provider.
The information required for each transaction may be developed to reflect the C ouncil’s monitoring requirements along with the development of newer monitoring systems.
3.2.4 Audit/Review
The Service Providers shall:

Participate in organised audit of Service

Participate in audit of prescribing

Co-operates with any locally agreed assessment of Service User experience

Demonstrate that key Staff have undertaken continuous Professional Development relevant to this Service

The Council will review the service, on a regular basis as well as responding to issues which may require a more urgent review

Review of the LES will take place on an annual basis by the Council, or earlier if required
3 .3 Population covered
Oxfordshire residents
4. Applicable Service Standards
4.1 Applicable national standards
All Service Providers will adhere to NICE Clinical Guidelines and Quality Standards, relevant standards include but are not limited to QS23, CG51, CG52 and TA114. These standards are expected to be met as well as the following standards:-

The Service Provider must employ pharmacists registered with General
Pharmaceutical Council;

The Service Provider must conform to General Pharmaceutical Council; Standards for registered Pharmacies 3 and Standards of conduct, ethics and performance 4 ;

Any concern around controlled drugs must be reported to the LIN;

Information for providing the Supervised Consumption LES should be made available for locums, to ensure continuity of the provided Service;

Ensure staff delivering the Service are trained and experienced in dealing with
Substance Misuse issues;

Service Users receiving prescribed medication for opioid substitution will not be refused access to SWOP packs; the Service Provider will encourage the Service
User to discuss this with their prescriber or addictions nurse;
3 Standards for registered pharmacies, General Pharmaceutical Council, September 2012
4 Standards for conduct, ethics and performance, General Pharmaceutical Council, July 2012


Provide support and advice to colleagues and other professionals;

Identify a lead Staff member working at the Service Provider who has successfully completed the learning pack Substance use and misuse CPPE 2010 or RCGP
Certificate in the Management of Drug Misuse Part 1
5. Location of Service Provider Premises
5.1 This intention of the Council is to select in the region of 100 outlets to deliver supervised consumption scheme in locations across Oxfordshire to ensure a good geographical spread of provision.