Dr Fixit's FAQs:
Pharmacy Fixit on Methadone and Alcohol (Feb 2010)
[Note: This article was written by Nazmeen Khideja to accompany Network 28.]
Dear Pharmacist Fixit,
I am a GP and have been prescribing methadone to Aaron for 5 years. Aaron is 36 and has done so well in treatment, stopping his heroin use 2 years ago, and his crack use a year ago. He is on 90mls of methadone, twice a week pick up. He lives at home with his mother who is very supportive of him. In the last few months I have become worried about his alcohol use. He is normally a good attendee, but has missed a few appointments lately, and turned up late on one occasion smelling strongly of alcohol and clearly drunk. When I asked him about his alcohol use he says he is drinking up to 10 pints of Stella (5%) lager a day on most days and between half and 1 bottle of brandy most weekends. We are working towards trying to decrease his alcohol use, but Aaron is struggling to make significant changes. He has declined an inpatient alcohol detox but I am increasingly worried about his risk of overdose, which I have talked to him about. I was wondering whether there is anything I could do with my local pharmacist to reduce this risk? And what should they do if he turns up to the chemist affected by alcohol?
Aaron's case is complicated and consideration needs to be given to his motivation for alcohol consumption, the effect of his alcohol consumption on his otherwise stable substance substitution therapy and his reasons for refusing inpatient alcohol detoxification.
The National Treatment Agency (NTA) "Models of Care for Alcohol Misusers" (Ref 1) highlights four tiers of possible interventions:
Tier 1 - Alcohol-related information, pro-active screening and brief advice.
Tier 2 - Alcohol specific interventions that are open access and non-care-planned.
Tier 3 - Community-based, care-planned alcohol treatment.
Tier 4 - Specialist inpatient treatment and residential rehabilitation.
Refusing inpatient alcohol detoxification has meant that Aaron has refused tier 4 services for now, but the key is to continue Aaron's engagement with substance misuse services i.e. his contact with his prescribing GP and dispensing pharmacist. A number of roles with respect to alcohol screening and management through pharmacy are possible and focus on the provision of healthy lifestyle advice and brief interventions (tier 1 and 2) (Ref 2). Also, there is scope to be involved with the Patient Group Direction (PGD) supply of medicines aimed to reduce alcohol intake, as well monitoring these medicines for compliance and undertaking blood tests accordingly (tier 3).
The "Review of the Effectiveness of Treatment for Alcohol Problems" (Ref 3) considers a range of effective treatments, prominent amongst which are treatments that encourage cognitive behavioural changes. Linking this with Scottish Intercollegiate Guidelines Network guidance (Ref 4), GPs and other healthcare professionals are encouraged to undertake opportunistic brief interventions where possible with individuals who have been identified as hazardous or harmful drinkers. This intervention should be linked to cognitive behavioural changes like relating the patient's perceived benefit of alcohol use with the negatives of continuing the presented drinking routine.
Up until now, Aaron has been compliant with collection of his methadone, it appears he had a routine and his twice weekly attendance at the pharmacy would provide a significant platform for regular brief interventions. By liaising with the GP as part of a three way agreement for substance misuse, multidisciplinary working can be extended to incorporate a harm reduction approach. Using the pharmacist in this public health role for tier 1 and 2 services allows for brief advice, screening, intervention and referral.
The use of the alcohol screening tools can be used to establish drinking patterns and Aaron's perception of his drinking. Aaron has already highlighted his current drinking pattern, but it is worth noting that he may be under reporting his alcohol use. The use of alcohol screening tools like the FAST questionnaire (Ref 5) will help quantify drinking and provide a starting point for discussions around the pros and cons of the current pattern in the pharmacy setting (Ref 6).
Feedback could include discussions around options fro cutting down and highlighting the three way partnership between the pharmacy, GP and Aaron, as well as highlighting risks associated with excessive alcohol consumption, risk of overdose and the consumption of methadone as part of opioid substitution programme. Part of the agreement for collection of methadone may be linked to attending the pharmacy in a manner where Aaron is not intoxicated. Consideration may also include returning to daily pick ups and/or supervision of methadone to try and re-introduce routine and regular contact with a healthcare professional.
In terms of pharmacological management and moving into tier 3 services consideration may be given to pharmacological management of alcohol consumption in conjunction with cognitive and behavioural support. Antabuse 200 mg tablets (disulfiram) is licensed to be used as an alcohol deterrent in co-operative patients, but should be accompanied by appropriate supportive treatment. Dosing instructions are available from the manufacturer's Summary of Product Characteristics (Ref 7).
The use of acamprosate 333.0mg tablets (Campral EC) may be considered at a dose of 2 tablets three times a day with meals for weight +60Kg, but is only indicated when abstinence from alcohol has been established as concomitant alcohol use will negate the benefits of using acamprosate (Ref 8). A PGD may be considered as part of a full alcohol screening and management programme, or if prescribed, compliance can be encouraged as appropriate. Both products should be used as per guidelines.
The key to the management of Aaron's condition lies within regular and consistent behavioural support.
1. Department of Health (2006), Models of care for alcohol misusers (MoCAM) p20-23.
2. Department of Health (2008) Pharmacy white paper Pharmacy in England: building on strengths - delivering the future.
3. National Treatment Agency (2006) The Review of the effectiveness of treatment for alcohol problems provides the evidence base for effective treatments.
4. SIGN (2003). Scottish Intercollegiate Guidelines Network. The management of harmful drinking and alcohol dependence in primary care. A national clinical guideline. Edinburgh: SIGN.
6. Pharmaceutical Services Negotiating Committee (PSNC). Accessed online on 20/11/2009.