Harry Punitharajah Project Proposal K1803526

Developing and testing pharmacy simulations for misuse of drugs

Executive summary
Drug misuse (DM) and addiction was responsible for 2,996 deaths in 2020 – the
highest number in the UK since records began.[1] By working in primary care,
pharmacists are placed in a valuable position to identify, manage and reduce the
detrimental effects that surround DM. However, with the number of drug-related
deaths rising annually – it is evident that there is more that healthcare professionals
(HCP’s) can do to battle this ongoing crisis. Pharmacists must be able to
successfully reflect the 9 standards for pharmacy professionals such as
demonstrating leadership, effectively working in a team and using professional
judgement when dealing with all aspects of DM. To do this, training must be provided
to student pharmacists early in their career – so they’re aware of DM, interventions
available in the pharmacy and the tough realities of consulting patients that are
misusing drugs.

However, currently at Kingston University, there is a lack of resources that level 6

(L6) and 7 (L7) students can use to guide and prepare them for deterring DM in their
future role as a competent pharmacist. Therefore, by creating realistic ‘mini-
simulations’ that provoke students to: use the GPHC standards in their consultations,
understand the extent of DM in the UK and be aware of the help available for
patients – will, in hand, reduce the adverse effects that DM proposes in future
generations.[2]
Aims and objectives
This study will aim to fulfil these following objectives:
- Analyse and evaluate the Needle Exchange Service (NES) provided in pharmacies
- Recognise the risk associated with selling pseudoephedrine and highlight what
pharmacists can do to minimise misuse
- Understand the harm related with opioid abuse and what pharmacists can do to
make patients aware of it
- Create realistic simulations where L6 and L7 pharmacy students are able to fulfil
various standards for pharmacy professionals when dealing with DM.

Literature review
Needle exchange services (NES), a locally commissioned service, plays an integral
factor in reducing harm in patients by providing access to sterile injection equipment.
Harry Punitharajah Project Proposal K1803526

Patients who inject opioids are at greater risk of mortality, overdose and blood-borne
infections such as Human Immunodeficiency Virus (HIV) and Hepatitis C (HCV); as a
direct result from the use of unsterile injection paraphernalia. NES has allowed for
the safe disposal of discarded needles which has not only reduced harm on an
individual level but has also reduced the health and social care burden in wider
communities. By providing sterile paraphernalia, pharmacists have direct access to
misusers, granting them the opportunity to: signpost support groups, emphasize the
danger of overdose, encourage testing for blood-borne viruses and promote healthy
living.[3] Pharmacists should seek to showcase the various standards for pharmacy
professionals in every consultation regarding NES to ensure that optimum health
outcomes are achieved.

Pharmacists need to consistently demonstrate awareness of ethical issues and have

[4]
the practical skills to deal with moral uncertainty. Over-the-counter (OTC)
medicines containing pseudoephedrine has potential room for misuse due to its part
it plays in the production of illegal stimulants such as methylamphetamine; a drug
that has well-documented devastating personal and societal effects . [5] The Royal
Pharmaceutical Society (RPS) recommends that, ‘Pharmacy teams should have the
tools to prevent misuse on OTC medicines and carry out patient-centred brief
interventions where appropriate’, in order to minimise and recognise DM in all
settings. Pharmacists must use brief interventions to convey clear, distinct messages
to educate and supports patients in understanding their drugs in a non-
confrontational manner.[1] However, they should also remain vigilant during these
brief interventions and have the confidence to refuse the sale backed up by laws,
ethics and professional judgment if need be.

The use of opioid therapy for chronic pain has dramatically increased over the last
twenty years together with an increase in prescribed opioid abuse and accidental
overdoses. On the front lines of dispensing, pharmacists can provide medication-
related advice and serve as a first line of defence in deterring opioid misuse. HCP’s
can practise safe opioid prescribing by conducting Medicine Use Review (MUR), an
advanced serviced offered by pharmacies in the UK. MUR allows opportunity for a
review of medicines, ability to give extra information, opportunity to discuss side
effects and highlight any concerns. Therefore, through conducting structured MURs
Harry Punitharajah Project Proposal K1803526

on opioids – pharmacists can help patients use prescribed opioids and other
analgesics safely and effectively. [1]

Simulation-based education (SBE) has been a successful teaching method that has
improved students’ knowledge, understanding and essential skills within
undergraduate pharmacy.[6] Simulation, an example of active learning, provides
students with a safe environment where they can deal with high-risk situations and
grants the opportunity to learn from any mistakes made. [9]

Methodology
SBE is defined as , ‘An array of structured activities representing actual or potential
[6]
situations in education and practise’. Thus, it is vital that pharmacy students are
provided with realistic simulations that reflect the tough realties of DM that
pharmacists are faced with. The content for the simulations will be based on the
answers gathered at various meetings undergone with a support worker at Ealing
Rise – a rehabilitation centre in West London. Ealing rise offers a pathway to
recovery for adults that have been challenged by the use of drugs by providing:
counselling, one-to-one sessions, needle-exchange and giving advice regarding
mental and physical wellbeing. [10] Therefore, by preparing well-structured questions
in these meetings; simulations will be able to reflect how real-life consultations go
and thus give students realistic experiences in their learning.

The questions that will be asked in the meetings with Ealing Rise:
1. What are your goals with patients at Ealing Rise?
2. How consultations normally look like with drug misusers?
3. Do you have any tips for Pharmacists in reducing bias when tackling DM?
4. How does the Needle Exchange Service work?
5. Are pharmacists doing enough to support misusers?
6. What problems do you encounter when dealing with misusers?
7. How could pharmacists do better to battle misuse?

The main aim of this project is to expose students to real-life situations whilst
providing them with a controlled environment where they can make mistakes without
repercussions. Description Role-play (RP) is an established learning practise where
a student’s impersonates a patient/caregiver/HCP within the context of a clinical
Harry Punitharajah Project Proposal K1803526

[7]
scenario. Researchers have reported that, through RP, students have improved in
communication skills, counselling and carrying out motivational interviewing.
Moreover, RP is considered a simple simulation method due to its lack of need for
many resources other than finding sufficient space where they can be undergone.
Fortunately, this can be overcome as the simulations can be done in the Pharmacy
labs in the University. Therefore, through the delivery of description Role-play
simulations based upon NES, opioid and OTC medicine abuse – pharmacy students
will be able to start developing the competency and the confidence to deal with the
harsh realities of drug misuse.

Pharmacy professionals should be able to use different questioning techniques

during consultations in order to gather the necessary information to make informed
management decisions. Questioning techniques such as, ‘TED’ and ‘ICE’ should be
used to ensure that both parties consistently get the most out of every consultation.
[11]
Although, pharmacists need to demonstrate all 9 standards in their work – it is
especially important that they provide patient-centered care and show leadership
when dealing with DM. This can be done by removing biases, spotting red flags,
promoting shared decision making and minimising potential harm. So, when students
are conducting these simulations – they will be assessed on the quality of their
consultation and whether they can display these standards.

To carry this out, a selection of L6/L7 Pharmacy students will be invited to a learning
session where RP simulations will be carried out. Participants will engage in a 2-hour
session where they will be taught about different aspects about DM encompassing
NES, OTC medicine abuse and the dangers of prescription opioids. They will then be
able to apply the skills they have learnt to the simulations provided. The scenarios
will allow students to work in a trio where they will take the roles of a pharmacist,
patient and an assessor. The objective of this simulation practise is giving a good
approximation to how students would behave in the real clinical setting; allowing
them to not just account for clinical components but also assess their clinical
performance in their learning.[8]

Once the sessions are given, the same participants would be then invited to a focus
group. The focus group will serve as an open conversation, where the students
 Harry Punitharajah Project Proposal K1803526

would share their thoughts, ideas and any suggestions regarding the simulations.
Participants will be each handed a topic guide that contains open-ended questions
that will provide a rough direction for the conversations that take place. Any audio
recordings taken during the focus group will be destroyed once it has been
transcribed. The transcribed script will then be examined via thematic analysis
following Braun and Clarkes 6-step framework. Initial codes will be generated using
NVIVO – a tool commonly used to analyse data in qualitative research. These codes
will then be used to search, review and define connections between data items and
preliminary ideas which will be finally presented in the report. [12]

Details of the programme of work

20-Oct 30-Oct 9-Nov 19-Nov 29-Nov 9-Dec 19-Dec 29-Dec
Read the standards for the intial education of trainee pharmacists

Research the needle exchange service

Research the impact of Prescription opioid abuse

Research how pharmacists can 'refuse to sell'

Start writing executive summary

Decide on the aims and objectives

Attend Ealing Rise meeting

write and finish the methodology

Have the first drafts of the three mini simulations ready

submit ethics

Have final drafts of simulations ready

Frame the question'

set a working hypothesis

Design strategy and choose methods

collection of data (run the simulations)

analyse data

Fig 1 – Time scale of aims and objectives (GANTT chart)

Potential limitations
Millers pyramid clearly indicates that SBE was designed to assess observable
behaviour, rather than cognitive skills. The limitation with using observation-based
assessment is that it lacks for the assessment for the process of diagnostic
reasoning as it automatically assumes that the correct diagnosis correlates to correct
Harry Punitharajah Project Proposal K1803526

reasoning. Moreover, this limitation will also make it difficult to differentiate students
with different degrees of reasoning investment as their thinking would not be properly
translated into observable behaviour. [7] Furthermore, the level and prevalence of DM
in the UK is always changing with new laws and drugs being misused. Therefore, to
prevent the simulations becoming outdated it’s vital that the lessons are updated
annually – which could be a tedious task.
Furthermore, a few limitations could arise through the interview conducted with
Ealing rise. As the answers were gathered from support workers rather than HCPs –
they may not purely represent the same situations faced by a pharmacist. Although
they provide NES, Ealing Rise will not be able to provide any insight on prescription
and OTC drug abuse – omitting their involvement in two of the simulations. Lastly, as
Rise operates only in London – this could pose as a limitation to students when
consulting a patient from outer London.

In addition, the use of focus groups to gather qualitative data can also expose any
potential limitations. Since attendance is voluntary, an insufficient number of
participants may turn up rendering any gathered opinions void. The use of pre-
existing groups can arise issues relating to the disclosure of potentially stigmatising
topics which might lead to make people uncomfortable to share their opinions.
Conversely, there might be situations where disclosure is more comfortable in pre-
existing groups rather than in stranger groups. Also, as the focus is more on a group
rather than individual opinions – this may reinforce a bias or a false consensus within
the participants. It is vital to create a safe environment in the focus groups where all
students feel valued to prevent dominant personalities from overpowering and
steering the groups response during the intervention.

Conclusion
The main aim of this project is to provide students with an opportunity to develop
their observable clinical skills and open their eyes to the realities of drug misuse in
the UK. Through the utilization of SBE, future pharmacists are given a space to
make mistakes and practise consulting drug misusers without any repercussions –
an experience yet to be provided at Kingston University.

References
Harry Punitharajah Project Proposal K1803526

1. Royal Pharmaceutical Society. Improving care, reducing harm and preventing death
in People Who Use Drugs: Pharmacy’s role [Internet]. 2020 [cited 2022 Nov 15].
Available from:
https://www.rpharms.com/recognition/all-our-campaigns/policy-a-z/drug-deaths-and-
the-role-of-the-pharmacy-team
2. Garnier A, Vanherp R, Bonnabry P, Bouchoud L. Use of simulation for education in
hospital pharmaceutical technologies: a systematic review. European Journal of
Hospital Pharmacy. 2021 Dec 22 [cited 2022 Nov 13]. Available from:
https://ejhp.bmj.com/content/early/2021/12/22/ejhpharm-2021-003034
3. Fernandes RM, Cary M, Duarte G, Jesus G, Alarcão J, Torre C, Costa S, Costa J,
Carneiro AV. Effectiveness of needle and syringe Programmes in people who inject
drugs–An overview of systematic reviews. BMC public health. 2017 Dec [Cited 2022
Nov 16];17(1):1-5.
4. Hibbert D, Rees JA, Smith I. Ethical awareness of community pharmacists.
International Journal of Pharmacy Practice. 2000 Jun [Cited 2022 Nov 17];8(2):82-7.
5. Webster JL. Assessing community pharmacist engagement in a policing partnership
strategy to reduce the illicit diversion of pseudoephedrine products. Research in
Social and Administrative Pharmacy. 2013 Nov 1 [Cited 2022 Nov 18];9(6):903-17.
6. Korayem GB, Alshaya OA, Kurdi SM, Alnajjar LI, Badr AF, Alfahed A, Cluntun A.
Simulation-Based Education Implementation in Pharmacy Curriculum: A Review of
the Current Status. Advances in medical education and practice. 2022 Jul 1[cited
2022 Nov 18]:649-60.
7. The Pharmaceutical Journal. Simulation-based training: applications in clinical
pharmacy [Internet]. 2021 [cited 2022 Nov 18]. Available from:
https://pharmaceutical-journal.com/article/research/simulation-based-training-
applications-in-clinical-pharmacy
8. Lin K, Travlos DV, Wadelin JW, Vlasses PH. Simulation and introductory pharmacy
practice experiences. American journal of pharmaceutical education. 2011 Dec 1
[cited 2022 Nov 18];75(10).
9. NHS. Alcohol addiction – support for family and friends [Internet]. 2022 [cited 2022
Nov 19]. Available from: https://www.nhs.uk/services/service-directory/cgl-ealing-rise-
london/N10870481
10. The Pharmaceutical Journal. Making consultations in community pharmacy matter
[Internet]. 2021 [Cited 2022 Nov 20]. Available from: https://pharmaceutical-
journal.com/article/ld/making-consultations-in-community-pharmacy-matter
11. Tausch PA, Menold N. Methodological aspects of focus Groups in Health Research:
Results of Qualitative Interviews with Focus Group Moderators. Sage journals
Harry Punitharajah Project Proposal K1803526

[Internet]. 2016 March 14 [Cited 2022 Nov 21]. Available from:

https://doi.org/10.1177/2333393616630466
12. Kiger ME, Varpio L. Thematic analysis of qualitative data: AMEE Guide No. 131.
Medical teacher. 2020 Aug 2;42(8):846-54.