Guidance

Community pharmacy: delivering substance misuse services

Published 24 January 2024

Applies to England

Introduction

This guidance is for community pharmacists and pharmacy teams. There is also guidance for commissioners, which is clearly stated as being for commissioners, but most of the guidance is for pharmacy teams. If the guidance is for a specific role, this is also specified.

The guidance outlines good practice for services delivered by community pharmacies in England to people who use and misuse, or are dependent on, drugs and alcohol (mostly abbreviated in this document to drug and alcohol use).

It aims to:

• assist the commissioning and delivery of high quality, safe and effective care that can engage more people in drug and alcohol treatment
• reduce harms associated with drug and alcohol use, including deaths from accidental overdose

Community pharmacy is vital to the care of people who use drugs and alcohol. Pharmacies are well-placed in local communities to deliver high impact and accessible services.

Supporting people who use drugs and alcohol

Community pharmacy teams

Community pharmacy teams include:

• registered pharmacy professionals (pharmacists and pharmacy technicians)
• dispensing assistants
• counter assistants
• trainees and students
• delivery drivers
• locum and sessional staff

Registered pharmacy professionals include superintendent pharmacists who are responsible for the professional and clinical management of a pharmacy and the administration of the sale and supply of medicines. Responsible pharmacists are in charge of the registered pharmacy whose role is to secure the safe and effective running of the pharmacy when it is operational.

The role of community pharmacy

Each member of your pharmacy team should be aware of their roles and responsibilities in providing substance misuse services. Community pharmacies have regular, often daily, contact with people who use drugs and alcohol. You can offer easily accessible and meaningful interventions to people, both as part of locally commissioned services and alongside the complementary care provided by pharmacy staff. This is part of the essential services in the Community Pharmacy Contractual Framework (CPCF), which includes:

• healthcare advice
• public health interventions
• information about medicines
• promotion of self-care
• signposting to relevant organisations and services
• safeguarding

Community Pharmacy England provides more information about the CPCF.

Local substance misuse services and community pharmacies should work together to help provide an effective service to people who use drugs and alcohol. This includes encouraging person-centred and trauma-informed treatment with shared decision-making.

It is important that pharmacy staff understand the impact of trauma (including adverse childhood experiences) that a person may have experienced, and the effect that this might have on their drug and alcohol use, behaviour and recovery.

Accessing pharmacy services

Pharmacy substance misuse services usually need to be available every day, depending on the opening times of the pharmacy and local commissioning arrangements.

Permanent pharmacy staff should make locum staff aware of all the services that the pharmacy provides, as well as the associated procedures and contact details of local organisations.

Staff should complete all relevant records at the same time as they provide an intervention to a person. Staff should get informed consent from people and record it before providing interventions (such as dispensing, testing and vaccination).

You should tell all service users about any changes to opening times as soon as possible. You should also inform local drug and alcohol services and commissioners so that they can plan prescriptions or make other arrangements (see section on out of hours care).

You should keep your service provision information up to date on the NHS find a pharmacy directory. Similarly, local drug and alcohol services should let you know if there are changes to their service times or contact details.

As well as providing interventions such as needle and syringe programmes or supervised consumption, community pharmacies are well placed to help transport and distribute medicines, devices and correspondence (such as safe storage boxes and paraphernalia). They can also ensure continuity of care and harm reduction interventions when people move from one place to another.

Avoiding stigma

You should avoid using stigmatising language and respect the person’s privacy and dignity. There are resources which can help you understand stigmatising language, including the:

• Scottish Drugs Forum’s Moving beyond ‘people-first’ language
• ‘Words Matter!’ language statement and reference guide from the International Network of People who Use Drugs

Consultation rooms are now a requirement of all pharmacies providing NHS pharmaceutical services, because of the increased clinical role of pharmacists in providing these services. Where appropriate, pharmacists should use these rooms to support patients who are accessing substance misuse services. People should not usually be required to use separate entrances or queues, though they may choose to do so. Everyone should be treated with compassion and understanding, and not judged if they relapse and use drugs and alcohol again.

Service delivery considerations

Oversight

To enable continuity of care between substance misuse services and pharmacies, it is good practice for a designated person in each pharmacy to co-ordinate the substance misuse services you offer.

Where locums or part-time staff mainly operate the pharmacy, there should be an identified lead person who acts as a named contact, in addition to the responsible pharmacist.

Staffing levels

Pharmacies should have sufficient staffing levels to ensure you are providing safe and effective services, in line with your contract. In the current absence of nationally agreed standards, the superintendent pharmacist should determine the level of staffing needed and the responsible pharmacist should monitor this locally.

Lone working should be avoided wherever possible. In exceptional circumstances, where lone working is unavoidable, the pharmacy should have safeguards in place, which are described in its operating procedures.

Confidentiality and refusing service

To maintain confidentiality, you should usually offer services in a private area of the premises. You should make reasonable efforts to accommodate requests for access to services.

You should only refuse services to a person on professional grounds, for example if the pharmacy is at capacity or the person is currently banned from the premises. In these cases, you should signpost the person to an alternative service, and inform the local substance misuse service or prescriber that you have done this.

It is good practice for the pharmacy and local substance misuse service to document all actions taken to support people accessing services, for evidence and audit purposes.

Quality assurance

Commissioners can include a contractual requirement for pharmacies to demonstrate that they are working in line with locally defined processes. You can demonstrate your compliance by taking part in local commissioners’ audits or quality assurance visits.

You should provide all services in line with General Pharmaceutical Council (GPhC) requirements and your own internal policies, procedures and locally defined processes. This includes:

• infection control measures (such as using disposable cups and personal protective equipment)
• stock management processes (including ordering, correct storage, safe disposal and expiry date checks)

Pharmacy contractors should ensure there is adequate indemnity to cover the services they offer, particularly when they introduce new services. The health and safety of pharmacy staff remains the responsibility of the pharmacy contractor and responsible pharmacist. GPhC provides information about Professional indemnity requirements.

Remuneration

Commissioners should pay pharmacies for the services they provide as soon as possible. The commissioner may request evidence from the pharmacy for the post-payment verification process to support payment claims the pharmacy has submitted. This evidence could include supporting information such as pharmacy records or monitoring forms specific to substance misuse services provided.

Fees paid to pharmacies should cover:

• pharmacy staff time and resources to provide the service
• all record keeping
• audit and training activities
• VAT (where applicable)

Commissioners and pharmacy contractors should work together to ensure appropriate services are available that meet the needs of local people. There should be regular meetings (usually at least once a year) between the pharmacy and the commissioner. At these meetings, the pharmacy is usually represented by the local pharmaceutical committee (LPC). You can learn more about the role of an LPC and find information about each LPC through the Community Pharmacy Local website.

Commissioners should give pharmacies appropriate notice of any changes to funding or contractual requirements that affect service provision. You should implement any changes to services in a way that minimises disruption for people needing them. Both the commissioner and pharmacy have the right to withdraw from the contract if changes are not acceptable.

Electronic methods of recording and reporting activity (including missed doses or supervised consumption) usually enable easier invoicing and auditing. Where a pharmacy’s systems allow it, you can include other information like instructions to put a prescription ‘on hold’ pending agreement from the service to recommence dispensing. However, you will need to have the appropriate information governance processes in place.

Multidisciplinary team and joint working

Sharing information

Organisations involved in a person’s care (including treatment service providers, pharmacies, GPs and hospitals) need to work together so that their care is seamless and to share information so they can make quick changes in what they provide when the person’s needs change.

Organisations should only share information with each other in line with:

• professional codes of conduct
• legislation (including the UK General Data Protection Regulations and the Data Protection Act 2018)
• local confidentiality agreements

Communication

Timely and consistent communication between everybody involved in a person’s care is essential. The urgency of the message may determine how it is communicated, but if you provide information verbally, you should follow it up in writing.

If a person is receiving a pharmacological intervention, such as opioid substitution treatment, it is essential that there is regular communication between the prescriber (or other substance misuse service staff) and the community pharmacy team. This will help them check that the person is following the prescription. It will also enable them to build relationships, which will be useful if particular issues arise that need quick communication, like informing each other about people missing doses.

The prescribing service and pharmacy contractor should agree on a preferred way of communicating. This is to ensure they regularly check messages and can take action on any requests as quickly as appropriate.

The person’s chosen pharmacy should be included in their clinical records, because you may need to provide information to other services who are providing care to them. For example, you may need to provide information to hospital staff if the person is admitted as an inpatient.

Good communication supports accurate medicines reconciliation (the actual medicines a person is taking), and enables safe prescribing, dispensing, supply and administration of these medicines.

Information sharing may also include confirming:

• prescription details
• when the last dose was collected
• details of the collection regimen

You should never disclose this information without asking the responsible pharmacist. The responsible pharmacist should take the necessary steps to satisfy themselves that any disclosure being asked for:

• is appropriate
• meets the legal requirements covering confidentiality
• meets the conditions for lawfully processing personal data

You can find more information on steps to take to protect confidential information in the GPhC resource In practice: guidance on confidentiality.

Transfer of care

You must take particular care when transferring a person’s treatment, for example between criminal justice, primary and secondary care settings. When a person’s care is transferred to community pharmacy, before you continue to dispense a prescription you should clarify that:

• the supply is intended to continue
• any prescriptions held reflect the correct doses
• dates are correct for when the person is restarting their collection or supply

You should update the person’s patient medication record (PMR) to reflect any changes and should contact the prescribing service to obtain a new prescription if necessary.

Where substitute medicine is required, it is vital that you continue a person’s supply with as little break as possible.

Criminal justice, secondary care or out of hours service providers should not usually dispense substitute medicine as a take home supply, unless in exceptional situations or where local agreements exist.

CPCF essential services resources include guidance on how to communicate the transfer of a person’s care between secondary care and community pharmacies.

Medicines reconciliation

You should clinically assess the different prescriptions provided to someone, including by looking at their summary care record.

Organisations involved in providing care (drug and alcohol treatment and other healthcare services) should update a person’s community pharmacy and GP as soon as possible when there are changes, highlighting any relevant information. This includes:

• when people have been admitted to the organisations providing care
• when people have been discharged by the organisations providing care
• where any changes to medicines or doses have been made

For people who have left prison, you should contact the releasing prison to obtain the very latest information.

When the prescribing service refers a person to a community pharmacy, it is good practice for the service to provide correspondence to accompany the prescription. This should include details of the person’s point of contact in the substance misuse service, which is usually their keyworker. You should record this information on the person’s PMR.

Substance misuse services should inform you about proposed changes to prescribing or dispensing arrangements.

Problems, concerns and troubleshooting

People engaged with a substance misuse service should have a prescribed treatment agreement in place when they are receiving a prescribed intervention. This is an agreement between the prescribing service, the supplying pharmacy and the person, which is signed by all parties and sets out the expectations from all signatories.

With their consent, people receiving prescribed medicines should provide their contact details and pharmacy staff should regularly review them, so they are up to date. This allows you to contact the person when you need to, for example if opening times are changed at short notice.

You should usually inform the prescriber within one working day if you have concerns about:

• a person’s missed attendance
• changes in a person’s presentation (such as intoxication)
• any safeguarding issues

Missed attendance includes:

• missed doses during a titration period
• missing 3 consecutive doses of opioid substitute medication
• sporadic attendance
• unusual non-attendance

The prescribing service should provide a point of contact for this purpose. Where possible, pharmacy staff and substance misuse services should provide each other with a direct dial number (ideally a line that is not the main number) and an email address, both of which are regularly monitored so they can communicate quickly.

Prescribing services should ensure that any method of communication they use has appropriate safeguards in place. This is to ensure that any information provided is auditable, secure and will only be received by the intended recipient.

You should quickly implement business continuity plans if there are unplanned closures or other issues that mean you cannot provide the service. These plans should include quick communication with the prescriber or substance misuse service, and with all prescribed individuals affected (where possible). This is so they can make alternative arrangements to get their medicines.

Out of hours care

Substance misuse services should make sure they provide clear information to you about how and when to refer to specialist services (such as their own service, mental health or perinatal services). This should include clear arrangements for when you need advice and support out of hours, or if the usual source of information and advice is unavailable.

For out of hours support and on weekends, it is essential that there is a local agreement between the substance misuse service and the community pharmacy contractor about what the support involves. These arrangements should be stipulated in service level agreements.

Where no locally commissioned out of hours care exists (including for emergency supply requests), the responsible pharmacist should use their clinical judgement and act in the best interests of the person when determining what action to take. For example, this could include providing harm reduction interventions and withdrawal symptom management advice. Where this relates to prescribed interventions, you should usually inform the person’s prescriber or substance misuse service about what actions you took, within one working day if possible.

Incident, feedback and complaint reporting

To support learning, you should report all incidents, any feedback and complaints to relevant stakeholders. You should do this as soon as possible (ideally within one working day) and following local requirements. Relevant stakeholders could include the:

• service commissioners
• NHS England controlled drugs accountable officer (CDAO)
• prescriber or substance misuse service

You should also document any incidents, feedback and complaints in line with the pharmacy’s own internal reporting systems and report them to the superintendent pharmacist as needed. Service commissioners, the prescriber or substance misuse service and pharmacy contractors should regularly review incident, feedback and complaint reporting for clinical governance purposes. This can help to identify ways to improve services, share learning and prevent issues happening again.

Safeguarding

Children and vulnerable adults

Pharmacy teams have an important role in safeguarding children and vulnerable adults. So, staff should be trained in national safeguarding policies and procedures as outlined in the CPCF. This includes knowing:

• how to identify different types of abuse
• what action to take
• who to contact
• how to report any concerns

If you need to signpost a person to safeguarding services, you should have a range of relevant information resources available. These should be in an accessible format and include details of local services and agencies.

You should record any safeguarding interventions you provide, as well as the outcome of these interventions. You should keep this record in a way that enables audit and makes sharing information with relevant services easier when referring the person on. Using electronic referrals are better for audit and communication, so this should be the primary method if possible. Some services will need to make Disclosure and Barring Service checks (checking someone’s criminal record), depending on the services they provide.

The responsible pharmacist or superintendent pharmacist is accountable for the competency and suitability of pharmacy staff who interact with children and vulnerable adults.

Safe storage of medicines

When discussing the risks and mitigation measures for people keeping medicines at home, you should consider both illicit and other legally sourced substances and paraphernalia. You should tell the person to store and use substances out of the sight and reach of children or vulnerable adults. This helps to avoid:

• the risk of accidental overdose
• diverting the medicine to the illicit market
• other harms

Where required, the prescriber, substance misuse service or pharmacy should offer:

• lockable safe storage options
• child-resistant containers
• written information about safe storage suited to the needs of the person

Before dispensing any medicines, you should ask the person about any mitigations they have in place to store them safely.

Other safeguarding risks

Dispensing and supply arrangements should consider other safeguarding risks a person faces, such as:

• coercive behaviour from others to acquire their medicine
• cognitive impairment
• suicidal thoughts

Role of pharmacy staff in safeguarding

If pharmacy staff identify risks, and it is not the responsible pharmacist who has identified the issue, they should discuss it with the responsible pharmacist. You should then contact the prescriber as a priority and signpost the person to the relevant services that can help to safeguard them.

Prescribing

Ideally, the same pharmacist should not dispense or administer a medicine they have prescribed, though in some circumstances this may be unavoidable. When it occurs, pharmacies should have processes in place to manage risk. For example, building in a time delay between prescribing the medicine and dispensing it, and using second checkers (like another pharmacist, or technician or assistant).

You can use any available patient specific direction (PSD) and patient group direction (PGD) to manage substance misuse. You can find resources to support prescribing in the:

• Royal Pharmaceutical Society’s (RPS) pharmacy guide on prescribing
• Specialist Pharmacy Service advice on patient specific directions

Dispensing medicines

Providing medication for problematic drug and alcohol use

Dispensing of medicines is an essential service in the CPCF, mandated in The National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013. The person receiving substance misuse treatment should choose the pharmacy to dispense their medicines in all but exceptional circumstances. And the substance misuse service should inform the pharmacy in advance that they have been chosen, before sending the prescription.

The supplying pharmacy, substance misuse service and person should also have a prescribed treatment agreement in place before dispensing (see section on medicines reconciliation).

Community pharmacy staff and the person should agree mutually convenient times for the person to collect or receive a delivery of their medicines. If a person comes to the pharmacy outside of these times, staff should not initially refuse them their medication dose. However, staff should tell them to attend at the agreed times and advise the prescribing service if this becomes a regular problem.

Where a prison clinician writes a direction to supply medicines, they should make sure that local arrangements enable the person’s care to be transferred from prison to community services during the high-risk time following release (usually the first 2 weeks). This means that the person should be able to pick up their medication straight after release and be engaged in the treatment service as soon as possible.

For liquids, you should use plastic containers to avoid breakage if possible. You should provide multiple doses in separate containers where this is specified on a prescription, and prescriptions should use appropriate Home Office-approved wording for prescribing controlled drugs to support this. When a person receives multiple doses in a single container, you should provide a measuring device and check their ability to correctly measure out doses.

Prescription management

The pharmacist should expect to receive legally and clinically correct written prescriptions from the prescribing service to be able to quickly supply medicines.

Once the pharmacist receives the prescriptions, it’s vital that they do a quick clinical assessment to ensure that it’s safe and appropriate to provide the medicines to the person. They should escalate any issues to the prescriber as soon as possible. This minimises the risk of any problems with the medicines affecting a person’s safe and effective care provision. The pharmacy and prescribing service should agree an appropriate timeframe for responding to prescription queries.

You should have processes in place to ensure:

• a person has quick access to the medicines they have been prescribed
• a person is clear about how to access their medicine in a way that retains confidentiality and dignity
• all medicines are prepared, labelled, recorded and stored in line with legal and best practice guidance, such as the Medicines, Ethics and Practice (MEP) guide (RPS membership required to access)

Any prescriptions that have not yet been dispensed from but have been rescinded or superseded (for example dose changes resulting in a new prescription being issued), should be clearly marked ‘VOID’. And you should add a note to the person’s PMR with the reason for the change. The pharmacist should destroy the prescription in line with legal and best practice requirements, and they should make the prescribing service aware when they have done this.

Where the pharmacist has not dispensed doses or has purposefully omitted doses (for example due to the person being intoxicated), they should clearly document the detail of this on both the prescription and the PMR. They should include the reasons why they have not dispensed and the dose information. They should also inform the prescriber.

Providing additional medicines

As well as substitute medicines for dependency, the prescriber or substance misuse service can prescribe medicines for:

• harm reduction
• detoxification
• relapse prevention

If local commissioning arrangements allow, the pharmacy can provide these medicines using a variety of frameworks, such as with a PGD. For detoxification and withdrawal management, you can sell adjunctive supportive medicines over the counter (OTC) where the medicine is licensed for that use (for example, loperamide for diarrhoea).

In some cases, if it’s been agreed or commissioned, you can supply medicines dispensed by other providers (for example to treat tuberculosis, HIV and hepatitis C) as part of a structured pathway. This may be because other providers:

• have concerns about safe storage
• want to improve the person’s access to medicines
• want to help the person stick to their treatment plan, for example for people who are homeless or have memory issues

If you hold multiple prescriptions for a person, you should ensure that the person is provided with all medicines and on the correct pickup days.

Identifying people who require support for problematic drug and alcohol use

To reduce the risk of supplying medicines to the wrong person, you should have an appropriate system in place to identify people, especially if they have not used the pharmacy before.

You should have a prescribed treatment agreement in place for people registered with substance misuse services, before the doctor starts prescribing (for more information, see section on medicines reconciliation). If someone new presents to the pharmacy without any notification from the prescribing service, you should contact the service to get all the relevant information you need about the person (for example, ongoing prescription changes).

You should check the identity of new or unfamiliar people, as outlined in the Community Pharmacy England guidance on controlled drug prescription forms and validity. And where possible, the treatment service should help the person to access photographic identification for this purpose.

Management of missed doses

If a person misses 3 consecutive doses (or any doses during titration) for an opioid substitute, the pharmacist should put the prescription ‘on hold’. The pharmacist (or another designated pharmacy staff member) should then contact the prescriber to discuss if it’s suitable to continue to supply the opioid substitute. If they cannot contact the prescriber (for example when working out of hours), the person may be refused one or more doses. The pharmacist should record all refusals (with associated rationale) on the person’s PMR and on the prescription, and they should tell the prescriber as soon as possible.

Communication between pharmacy staff and substance misuse services

You should contact the prescriber or substance misuse service if:

• the person appears unwell or intoxicated
• the person misses multiple doses or collections within a 2-week period (particularly during titration or consecutive doses or if a pattern emerges)
• the person does not take the whole dose
• the person behaves unacceptably, such as shoplifting, verbal and physical abuse, diverting their medicines
• there are any concerns about the suitability of supplying a medicine, such as safeguarding concerns, or worries about the dose or medicine
• there is a dispensing error or ‘near miss’ (a dispensing error caught in time) and if there are any accidents or injuries
• the person continues to make requests for someone other than themselves to collect their medicine where this is not formally agreed with the prescriber or pharmacist

If the person appears intoxicated, or their condition suggests that giving the dose would be clinically unsuitable (for example if they are not in withdrawal before starting buprenorphine), you should document this in their PMR. And where appropriate, you should ask the person to return later that day to be reassessed to see if they are able to be supplied with medicine.

Supervised consumption and administration

Carrying out supervised consumption

Pharmacy contractors are typically commissioned to supervise the consumption of oral methadone and buprenorphine. But this may be extended to include other medicines. And this can happen in the pharmacy or another designated location, such as a care home.

Supervised consumption should be used for as long as it is deemed appropriate by the prescriber, based on an individualised risk assessment. You should only carry out supervised consumption in line with the directions of the prescriber. This is because providing supervision where it’s not indicated may result in overdose. The aim of supervised consumption is to help ensure that the person receives the prescribed dose, while reducing the risk of diversion and safeguarding issues (such as safe storage concerns).

Supervised consumption also provides an excellent opportunity for the pharmacy team to:

• make regular assessments of how well the person is sticking to their care plan
• regularly check their wellbeing
• provide additional harm reduction and health interventions

You should show the medicines to the person before administration. This is so they can confirm the medicines are as they expect. You should stick to the preparation specified by the prescriber, in line with legal and best practice requirements (such as The Human Medicines Regulations 2012 and the RPS MEP guide).

Sublingual oral preparations

You should place sublingual oral preparations (for example, buprenorphine sublingual tablets) into a disposable pot before handing them to the person to place under their tongue. You should provide water for the person to drink before they take the medication. You should encourage the person not to swallow the tablet and advise them not to swallow saliva while the medicine is dissolving. Do not give them water immediately after administration and ask them to keep any excess saliva in their mouth for as long as possible to maximise absorption.

However, due to the risk of dental problems with oral buprenorphine, you should advise them to rinse their mouth with water afterwards. And while you should encourage them to have good oral hygiene, they should wait at least an hour after they take their medication before brushing their teeth.

You should not crush tablets without agreement from the prescriber, as this is off-label use (use of an approved medicine outside its approved uses). There may be more suitable licensed alternative formulations available.

After the tablet is dissolved, you should encourage the person to speak, and you can visually check their mouth to confirm they have taken their dose.

Oral lyophilisates

You should give oral lyophilisates (for example, buprenorphine oral lyophilisates) the same way as oral buprenorphine outlined above. But the person should place these tablets on their tongue, rather than under it. You can administer lyophilisates from the original packaging as appropriate and they should be taken immediately after opening the blister.

For both oral lyophilisates and sublingual preparations, you should observe the person to make sure they are taking the medicine correctly (holding it in the right part of their mouth) before and during the dissolution process. Different formulations may have different dissolution rates.

Liquid oral formulations

You should give liquid oral formulations (such as methadone) directly from the person’s labelled dispensing bottle. You should encourage the person to speak and ask them to drink some water (provided by pharmacy staff) before and immediately after administration to confirm they have swallowed the dose.

Solid oral formulations

You should place solid oral formulations (such as diazepam) into a disposable pot and hand it to the person for them to administer themselves. They should drink water (provided by pharmacy staff) before and after administration.

You should not crush tablets without agreement from the prescriber, as this is off-label use. There may be more suitable alternative licensed formulations available.

You should encourage the person to speak after swallowing. And you can check their mouth to confirm they have swallowed the dose.

Injectable preparations

Staff can only administer injectable preparations (such as long-acting injectable buprenorphine subcutaneous injections or implants) once they have been trained and assessed as competent, with an appropriate contractual framework in place.

You can find more information in the Specialist Pharmacy Service guidance on long-acting injectable buprenorphine and the National Institute for Health and Care Excellence (NICE) evidence summary Opioid dependence: buprenorphine prolonged-release injection.

Needle and syringe programmes

Aim of needle and syringe programmes

The aim of needle and syringe programmes (NSP) is to provide injecting equipment (and other equipment) to people who use drugs to reduce the potential harms associated with reusing or sharing equipment, and not safely disposing of used equipment. Harms include:

• transmission of blood borne viruses (BBVs)
• discarded needles and syringes
• injection site infections and damage

Equipment can include:

• needles and syringes
• filters
• cookers (containers used for mixing and heating a drug solution)
• acidifiers
• water for injections
• foil for smoking
• wipes

Pharmacy needle and syringe programmes

Providing community pharmacy NSP can help ensure that equipment is available from the widest range of places at the most convenient times, reducing the risk that people will need to reuse or share equipment.

Equipment and services pharmacies can provide

Commissioners should usually specify that pharmacies supply low dead space injecting equipment (reducing the risk of spreading BBVs), in line with the NICE public health guideline Needle and syringe programmes.

NSP may also distribute equipment to encourage people to take drugs in ways other than injecting, such as foil for smoking. They might also supply additional products like condoms. The products you supply should be suited to a person’s needs, ideally using a ‘pick and mix’ approach. This is so they can pick what they need from a range of different equipment rather than being given pre-made packs. This provides the greatest choice.

Unless you are specifically commissioned to deliver specialist NSP (for example specialist injecting advice about neck or groin injecting), you should encourage people to go to the local specialist substance misuse service provider for specialist advice.

The commissioning service should provide pharmacies with display materials (for example, to put up in the pharmacy window) to show people that they can access NSP there. This should include the national NSP scheme logo. You can buy a national needle exchange symbol window sticker and other related products from the Exchange supplies website.

Harm reduction advice

You should offer harm reduction advice, including advice about overdose prevention and alternative routes of administration. Doing this might also give you an opportunity to provide additional services, such as take-home naloxone and vaccination and testing for BBVs, if these are available in the pharmacy.

If you know a person receives a prescribed intervention for their drug and alcohol use, you should encourage them to have open discussions with their prescriber or substance misuse service so their medicines can be further optimised.

Young people

Unless you are specifically commissioned to deliver NSP for young people, you should only offer (limited) supplies to a young person if they refuse to access specialist services, or are unable to. The responsible pharmacist must determine the young person’s suitability to receive NSP.

You should signpost the young person to access specialist services where possible.

Returning used equipment

You should provide NSP free of charge and returning used equipment should not be a prerequisite for new equipment being supplied, though you should always encourage returns. If individuals do not return used equipment, you should:

• ask why
• explain associated risks
• offer safe sharps disposal containers

Injecting waste collection

The frequency of waste container collections will depend on the pharmacy’s requirements and done in line with the locally commissioned framework. Waste should be clearly segregated, stored in a designated area, and used only for NSP returns.

Quantity of injecting equipment

Where people are taking emergency (‘one-hit’) kits in quantities that you feel are excessive, you should offer supplies in larger quantities that may better meet the person’s needs.

You should be able to assess requests for large quantities of equipment for onward distribution to others (secondary distribution). You should meet these requests if you believe it is genuine and is likely to reduce risk. Or you should stall the person and escalate any concerns to the commissioning service and seek advice if you need it.

Litter and injuries

You should have the contact details of the relevant local organisation in case you get enquiries about needle litter outside the pharmacy premises This organisation (which will vary depending on how the council runs its services) should be able to arrange for the needle litter to be cleared up.

Your team should also know the internal process for managing needlestick injuries.

Take home naloxone

Drug services, which include community pharmacies, can issue injectable and nasal take home naloxone (THN) to people without the need for a prescription, PSD or PGD. So, you can supply THN to people who are at risk of opioid overdose, or to people who are supporting them, including family or friends. You may also need to administer naloxone if you witness a suspected opioid overdose.

Commissioners should include the following elements in their service specification for THN provision in community pharmacies, so they provide a good quality service.

1. Information to help people recognise symptoms of opioid overdose and how to respond.
2. Advice on how and when to administer THN.
3. Advice about safe storage and safe disposal of THN.
4. Information about how to get more THN supplies.
5. Encourage people to return THN before the expiry date to collect a new supply. People do not need to return expired THN packs before receiving a new pack, but they should be encouraged to do so. Where systems allow, staff should send reminders about expiry dates to the person who holds the THN.
6. Supplies should be labelled (where possible) using pre-printed labels which do not obscure important information such as expiry date or affect the opening of the container. The label should conform to the appropriate current legislation, including the date of supply and the supplying organisation’s name. Supplies are usually anonymised so the person’s name will not appear on the label and it will not be added to their PMR.

You should usually supply one pack per person, but you can issue more in exceptional circumstances, at the discretion of the responsible pharmacist or if advised by the commissioner (for example, in response to a formal drug alert). You should only refuse people supplies of THN in exceptional circumstances, using the professional judgement of the responsible pharmacist.

You should only supply young people with THN if they refuse to access specialist services or are unable to. You can supply young people if you are specifically commissioned to do so. The responsible pharmacist should determine if it is suitable to supply the young person.

Vaccinations

You can provide vaccinations, where you have been commissioned to do so.

For hepatitis B vaccinations, pharmacists should usually use the very rapid (super accelerated) vaccination schedule (vaccinations on days 0, 7 and 21, and a booster after one year). For hepatitis A and B, combined vaccines are preferable to single vaccinations. You can refer to the UK Health Security Agency (UKHSA) Green Book for the latest information on vaccines and vaccination procedures.

If you are commissioned to provide vaccinations, you should provide these free of charge, using UKHSA Immunisation PGD templates where these are locally agreed to be made available. If people do not meet the PGD criteria, you should refer them to another provider, which should usually be the local substance misuse service.

Pharmacy staff who have completed training to administer intramuscular vaccinations (such as COVID-19 and flu vaccinations), and meet relevant PGD requirements, will be considered competent to administer BBV vaccinations. You should have appropriate measures in place to manage adverse reactions to vaccinations, including administering adrenaline in cases of anaphylaxis.

For BBV vaccinations, the same principles apply as with any other vaccination administered by community pharmacies. Community Pharmacy England has advice on providing vaccination services.

You should update the person’s PMR after each vaccination and inform the GP and substance misuse service in writing (ideally electronically) after every dose. This is in line with GPhC standards.

You should emphasise the importance of completing the vaccination course and confirm arrangements for any additional doses at the time of each vaccination. You should also provide additional BBV and harm reduction advice and interventions if needed and signpost the person to other relevant services if they need further help.

Psychosocial interventions including alcohol brief interventions

Pharmacy staff are ideally placed to deliver brief interventions in line with the NICE clinical guideline Drug misuse in over 16s: psychosocial interventions. You can be commissioned to provide psychosocial interventions, including using screening tools.

If someone is identified as drinking dependently, you should refer them to an appropriate local substance misuse service for assessment and treatment, as well as investigation for liver disease in line with NICE guideline Cirrhosis in over 16s: assessment and management.

Brief interventions designed to engage people into thinking about their substance use should include a screening tool to determine what further interventions they need. For people who drink alcohol, the screening tools could include the alcohol use disorders identification test for consumption (AUDIT-C) or the fast alcohol screening tool (FAST). You can use these tools to identify people who are at-risk drinkers (and may not be aware) or those who are potentially dependent drinkers. The World Health Organization provides more information on screening and brief interventions for substance use problems.

You should know how to refer people to services that provide specialist psychosocial interventions and encourage them to engage with local substance misuse services. You should keep a record of the interventions that people are receiving and any relevant outcomes. This will help with audits and improve information sharing with other services. You should refer people electronically wherever possible. You can deliver interventions face to face or online, and one-to-one or as a group. You can find advice about delivering interventions remotely in the Office for Health Improvement and Disparities guidance Substance misuse: providing remote and in-person interventions.

Mental health

You should look out for how changes in a person’s substance misuse affects their mental health.

Where you identify new or worsening mental health problems, you should quickly escalate these to the prescriber or other relevant specialist services. You can also signpost people to local mental health services or their GP for help and advice where appropriate. You should consider formal escalation routes with backup arrangements for high-risk people who are experiencing worsening mental health.

You should also consider the mental health of carers and signpost them if they need help themselves (from local mental health services or elsewhere).

Resources are available to help you support people with mental health problems. These include:

• RPS guidance The role of pharmacy in mental health and wellbeing
• NHS England’s Framework of core mental health competencies for all pharmacy professionals

Physical health

Essential and commissioned services

Pharmacy teams should regularly advise people with physical health conditions on the available range of in-pharmacy services provided as part of the CPCF. These services include advice on:

• nutrition
• weight management
• blood pressure monitoring
• general health

Pharmacy staff and local substance misuse providers should work together to encourage people to engage with local health promotion services. Where you identify unmet needs for a group of people, you should work with commissioners to address these needs.

Examples of essential and commissioned services that may be important to people who use substances include the following.

Dental care

You can provide dental care, including:

• dental health advice
• oral hygiene products
• signposting to appropriate local treatment services

This is especially relevant for people using opioids or for people with known poor dental hygiene and diet.

Sexual health advice

You should proactively signpost people to local sexual health services. Locally commissioned services might include:

• testing for sexually transmitted infections
• chlamydia treatment
• emergency hormonal contraception
• providing barrier methods, like condoms

These services may also be available from the pharmacy to buy over the counter.

You should prioritise interventions for people who have disclosed they are involved in sex work. And, where relevant, you should encourage women to attend cervical screening (a smear test).

Wound care

If your pharmacy is part of a commissioned needle and syringe programme, you should advise service users about injection site care and safe injecting techniques if you know they are injecting substances.

You should direct the person to appropriate support services for help and advice, such as their GP, local substance misuse service or, in more urgent situations, emergency services (for example, if you suspect they have sepsis).

Smoking cessation

People can buy nicotine replacement products directly from pharmacies. These and other interventions are also supplied (often alongside other prescribed interventions) through commissioned smoking cessation services.

Pharmacy teams are also well placed to offer brief psychosocial interventions to help people stop smoking. If you suspect someone has respiratory problems, you should refer them to other appropriate services, such as their GP.

You can find more information on supporting people to improve their own health and wellbeing on NHS England’s Making Every Contact Count e-learning website.

Identifying signs and symptoms of overdose and intoxication

You should be able to identify signs and symptoms of suspected overdose or intoxication. Local substance misuse services can provide training for pharmacy staff who want to provide more in-depth interventions. Where a pharmacy staff member identifies suspected overdose risk or intoxication, they should discuss this with the substance misuse service for further management advice and support or seek emergency assistance as appropriate.

You can find free online training packages such as the NHS England alcohol identification and brief advice programme. Other training programmes help staff to identify more common or concerning physical health conditions related to substance misuse. These conditions often require quick escalation or referral to specialist services (such as sepsis, and decompensating liver disease associated with chronic alcohol use).

Providing support to specific groups

Some groups may need special consideration when treating their substance misuse, especially if they are being prescribed medicines off-label. You can find more information about prescribing for special groups in:

• Drug misuse and dependence: UK guidelines on clinical management
• the British National Formulary (BNF)
• a manufacturer’s summary of product characteristics on the electronic medicines compendium

Specific groups may include the following.

Pregnant women

If you think that someone you are prescribing to is pregnant or planning to become pregnant, you should be able to signpost them to where they can access pregnancy support services (with substance misuse specialists where available). Once pregnancy is confirmed, you will need to be more vigilant, especially for:

• continued substance misuse
• withdrawal symptoms
• consideration of the need for changing doses of prescribed interventions

In the perinatal period, people who are using drugs and alcohol are likely to need more intensive support, and the pharmacy team has an important role to play in the multidisciplinary team. There are resources from the Specialist Pharmacy Service on formulating your advice on the use of medicines in pregnancy and the UK Teratology Information Service on the best use of medicines in pregnancy.

Young people

Prescribed interventions for young people (usually considered to be under 18 years) are rarely required. But where they are needed, the prescriber will have considered the need to adjust the dose.

Pharmacy services for young people should be commissioned separately. Community pharmacy teams should approach provision of substance misuse pharmacy services for young people in a similar way to how they provide any other enhanced service for young people (such as supplying emergency hormonal contraception). So, the team should be competent to assess a young person’s capacity to provide informed consent in line with established, locally endorsed frameworks. Examples of frameworks include NSPCC Learning’s Gillick competence and Fraser guidelines. People aged 16 and over are assumed able to provide consent in the same way as an adult, unless they have defined intellectual disabilities or there are concerns about their ability to understand the information being provided to them.

Young people aged 16 and over should provide the pharmacy with a contact number. If the number is for a parent, carer or other responsible adult then, by providing the number, the young person is assumed to have given their consent for you to contact the adult. You should record all consent given by the young person in the PMR, including their consent to treatment. You should also tell the young person that they can withdraw their consent at any time.

The responsible pharmacist should usually manage any requests relating to young people and direct them to specialist services as appropriate. Examples of specialist services include:

• children and adolescent mental health services
• social services
• NHS talking therapies (formerly improving access to psychological therapies)

Where young people are not engaging with treatment or treatment plans which involve the community pharmacy, you should inform the local substance misuse service.

Older people

When prescribing for older people (usually people over 60 years old), you should look out for:

• the need for dose adjustments
• comorbidities
• polypharmacy and associated drug interactions

You should also signpost older people to specialist services where necessary.

People in contact with the criminal justice system

Community pharmacy staff should be aware of the risks associated with the misuse of prescribed medicines in prison. For example, these could include:

• substitute medicines
• antidepressants
• antipsychotics
• hypnotics
• sedatives

The Royal College of General Practitioners (RCGP) Secure environments group resources may be helpful.

You can play an important role in supporting people after they have been released from prison, which is a high-risk time for overdoses. You may also be commissioned to help monitor people with community sentence treatment requirements, including:

• alcohol treatment requirements
• drug rehabilitation requirements

You can speak to prison healthcare teams by searching for a prison’s contact number using the HM Prison and Probation Service list of prisons in England and Wales. This is particularly useful when you need more information from a prison healthcare team about prescriptions you have received from a prison or if you have queries about a person who has recently been released.

People experiencing homelessness

You should be aware of different issues that people may encounter when experiencing homelessness or rough sleeping. These can affect how people access services, such as:

• a lack of contact details
• issues with safe storage
• not being able to go online

You should also be aware of how to signpost people to local housing providers and other specialist health and social care support.

Drug alert cascade

Pharmacy teams are ideally placed to get local intelligence about substances. This includes substances that may pose a public health risk. You can also play an important role in disseminating consequent drug alerts, for example with a CDAO and the local drug intelligence network. You can read further guidance on drug alerts in Issuing public health alerts about drugs.

The responsible pharmacist should be aware of how to escalate intelligence and cascade information received through local and national public health processes. This includes information relating to:

• adulterated, contaminated, or harmful substances
• novel uses of substances
• counterfeit medicines

The responsible pharmacist should also be aware of appropriate associated terminology. For example, avoiding terms like ‘dangerous’ to ensure that the message is not sensationalised.

You should report any adverse reactions using the Yellow Card scheme. You should also encourage people to self-report through the Yellow Card scheme.

You will need to support anyone affected by an adverse reaction to seek any required medical attention. You may also need to provide any relevant harm reduction advice.

Testing for substances

You may be commissioned to perform on-site drug and alcohol testing, for example using saliva screening tests and breathalysers. This may be under a commissioned framework to inform prescribing or make decisions about whether a person should be supplied with medicines on behalf of a prescriber (such as assessment during detoxification).

Pharmacy staff involved in drug and alcohol testing must be aware of the limitations of different tests and how to interpret the results. And staff should operate within the scope of their training.

There should also be a local process that enables you to report test results, and any associated concerns, with relevant parties. You should ensure that people have consented before testing, including consenting to the reporting of results to inform their care.

Over the counter and prescription-only medicines

Pharmacy staff are well placed to identify people who are misusing OTC medicines or prescription-only medicines (POM) and can refer them to the local substance misuse provider.

The pharmacy team should regularly update their skills and knowledge as the use and misuse of POM and OTC medicines changes. This includes recognising medicines that have been recently identified or reclassified as having potential for misuse (for example, gabapentinoids). You can get training on these medicines and should look out for behaviour like ‘doctor shopping’ or ‘pharmacy shopping’ where people try to access supplies from multiple sources. You should be able to contact local substance misuse services for support.

Resources that might be helpful include the RCGP factsheet on prescription and over the counter medicines (pdf, 476kb) and Public Health England’s Prescribed medicines review: report.

When you are supplying medicines, you should be aware of the possibility of misuse. Indicators for concern include when the person:

• makes frequent requests for emergency supplies of prescription only medicines
• shows withdrawal symptoms
• is intoxicated
• makes repeat purchases of over-the-counter medicines

Awareness of the risks of OTC sales is already part of the training to become a qualified medicines counter assistant, or registered pharmacy professional. This training includes using WWHAM (who, what, how long, action taken, medicines) questioning with every sale. It also includes how to signpost people to appropriate services.

Each pharmacy should have a system for staff to raise concerns to their responsible pharmacist.

Misuse of OTC and POM medicines is associated with harms. There is a potential for interactions between substances used, medicines prescribed for dependency, and other medicines and products bought OTC or supplied on prescription. You should carefully consider these interactions when they are supplying medicines.

Local substance misuse services should tell people to share information about any prescribed interventions for substance misuse they are taking when they buy OTC medicines, particularly where they use a different pharmacy from the one they usually get their prescriptions from. This is especially important to prevent additive effects, such as excessive sedation, respiratory depression, or increased serotonin levels, which can be fatal.

You should consult the manufacturer’s summary of product characteristics on the electronic medicines compendium and the BNF to check relevant interactions between medication.

Drug checking

Drug checking is testing drugs for potential consumers, to provide information on what they contain and how much.

There is increasing interest in innovations like using drug checking as a harm reduction and engagement tool, and commissioners can explore this as an option involving community pharmacy contractors. Community pharmacies are accessible because they are widely available, have long opening hours and are a walk-in service. So, they well placed to support drug checking.

Further information about using drug checking as a harm reduction tool is available in the European Monitoring Centre for Drugs and Drug Addiction report Drug checking as a harm reduction tool for recreational drug users: opportunities and challenges.

Staff education and training

Overview

Pharmacy teams will be familiar with controlled drug requirements, and they can find additional advice about substance misuse in:

• Drug misuse and dependence: UK guidelines on clinical management (the ‘orange book’)
• the Novel Psychoactive Treatment UK Network (NEPTUNE) (for new psychoactive substances)
• the NHS England alcohol identification and brief advice programme (for alcohol brief interventions)

Providing pharmacy staff education and training should be included in all service level agreements because harm reduction interventions are vital to substance misuse services, and high-quality interactions with service users will help them to achieve good outcomes.

Assessing staff competency

When assessing staff competency to deliver interventions like THN and NSP, an assessor needs to ensure that the person being trained has met all the required criteria and fully understands all the requirements to deliver the service. The assessor could be someone who is deemed competent by the commissioner or substance misuse service providing the training, or an assessor from an authorised external provider.

Training can be provided individually or in groups and can be provided remotely where it is appropriate to do so. Where the training is demonstrating the use of medicines, only placebo packs should be used.

Pharmacy staff may find it useful to complete an accredited relevant training programme, for example through the Centre of Pharmacy Postgraduate Education.

As many pharmacy staff in the team as possible (depending on required skills, qualifications and accreditations) should undergo relevant training to provide the required services. Then the pharmacy will not need to temporarily close the service or intervention if there are not enough trained staff around.

The responsible pharmacist (or superintendent pharmacist) should ensure that the staff delivering the service have received appropriate training, including completing the relevant competencies and accreditation, and associated health and safety training.

All staff involved in handling sharps (such as those delivering NSP and POCT) should have hepatitis B vaccination. They should also know how to manage needle stick injuries.

The pharmacy is required to retain training records.

Staff can self-declare the competences they have recorded. Also, commissioners may ask pharmacy staff to demonstrate competency in providing the service, perhaps by asking how they have addressed incidents. 

If your pharmacy uses PGDs, you might need to specify relevant additional requirements for staff (for example, attendance at annual update training), depending on what service the PGD is being used for. You should allow for reasonable reimbursement of time spent on training.

You should ensure that all relevant pharmacy procedures are read and signed (either on paper or digitally) by all relevant pharmacy staff involved in providing services.

Mandatory and additional training

Commissioners should ensure pharmacy staff receive mandatory training to start delivering a service. They should also arrange at least one training event per year (face-to-face or online) on relevant topics. Each pharmacy team in the area should be represented by at least one member of staff at these events, where possible. The events should usually be available to the wider pharmacy team (including locum staff), to:

• support staff competency development
• help staff share learning with colleagues
• give staff more confidence in delivering the service

Commissioners should also ensure that additional training and support for specific contracted services is available to the pharmacy team so they can deliver services safely and effectively. This training should usually be provided by the local substance misuse service provider.

Pharmacy staff should update their training if there are changes in:

• the types of substances being used
• guidelines
• legislation

There are also added benefits for pharmacy professionals to join professional organisations for peer support, networking and further educational opportunities, such as the:

• Association of Pharmacy Technicians UK
• College of Mental Health Pharmacy
• Royal Pharmaceutical Society