Community pharmacist provision of contraception services for women receiving opiate substitution treatment

Women who are addicted to opiate medicines (e.g. heroin) often find that their periods (menstruation) stop and that they cannot successfully get pregnant and give birth in the normal term. This loss of fertility happens through the combined effects of their drug use, poor diet, and subsequent weight loss. Individuals can be prescribed opiate substitution treatment (e.g. methadone, buprenorphine) which manages the physical addiction and helps relieve cravings for heroin. Once stabilised on opiate substitution treatment their lifestyle and diet improves, and these factors lead to a return of fertility for most women. However this can often happen without women noticing as they may ovulate (produce an egg) before their periods return. This means that women may continue to have unprotected sex believing that they are unable to get pregnant. Indeed, higher rates of unplanned pregnancy occur amongst these women compared to women in the general population [3-5]. A survey of women attending a community drug team (for any addiction) found that 88% had experienced one or more pregnancies, and half of these women had terminated one or more pregnancies [4]. Furthermore this and another survey of women attending community drug teams found most women report never receiving family planning advice or access to contraception [3, 4]. This is important because without this advice women may be less able to make choices about when they would like to start a family.

Women prescribed opiate substitution treatment attend their community pharmacy on a daily to weekly basis to receive this medication. Community pharmacists may therefore be well placed to provide brief, and on-going contraception advice and facilitate access or provide clinically appropriate contraception for women receiving opiate substitution treatment. The aim of this early phase research is to gather evidence on the design and feasibility of a novel and proactive contraception intervention to be offered by community pharmacists for women receiving opiate substitution treatment. The research will be carried out in two locations (Somerset and London). These two locations have been chosen as the types of public health service community pharmacies provides can vary by region. This variation can occur because the public health services that community pharmacies provide (including sexual health and contraception services) are commissioned through local authorities and clinical commissioning groups rather than NHS England so that they can respond to the specific public health needs of the local population [19].

A qualitative approach will be taken, to allow an in-depth exploration of the views of women and community pharmacists on this topic. We will conduct one-to-one interviews with up to 40 women (aged 18-49 years) receiving opiate substitution treatment to explore the factors, that affect their access to contraception and contraception advice and the factors which have affected their past and current contraception use. In these interviews we will also explore with women whether they would feel comfortable receiving contraception advice from community pharmacists, and if so, their views on what should be included in the contraception intervention. We will also carry out observations of 20 community pharmacists' routine practice and conduct in-depth interviews with them to explore how community pharmacists could integrate a contraception intervention into their current practice and the factors that could prevent successful delivery of this intervention.

The findings from the interviews and observations will be drawn together to develop a contraception intervention that can be piloted and evaluated in future research. The ultimate aim of this intervention for women receiving opiate substitution treatment would be to increase their knowledge about their fertility, provide advice on and access to contraception so that if they don't want to get pregnant they can make this choice.

Women with an opiate addiction often experience a reversible loss of fertility due to the combined effects of their drug use, poor diet and weight loss [1]. Once stabilised on opiate substitution treatment (OST, e.g. methadone) fertility returns, often without the woman's realisation, who may continue to have sex without contraception under the assumption that she is unable to conceive [1,3]. Unplanned pregnancies are common amongst women receiving opiate substitution treatment (WRO). Despite this, fewer than half of WRO receive advice or access to contraception [3, 4].
WRO attend their community pharmacy on a daily to weekly basis to receive their OST. Community pharmacists (CPs) may be well placed to provide brief, and on-going contraception advice and facilitate access to contraception for WRO. Taking a qualitative approach this early phase study aims to design and develop a multi-faceted CP led intervention to support WRO in accessing contraception advice and contraception. The objectives of the research are to 1) explore the factors that affect WRO contraception decisions, accessing and using contraception and advice, 2) determine whether a CP-led intervention to encourage contraceptive use would be acceptable to WRO and, if so, what the intervention would look like 3) develop a model of the processes, mechanisms of action and outcomes of this intervention; 4) evaluate how a contraception intervention could fit into CPs' current practice, what training or resources are needed, and what the potential barriers to delivering this service are. Data collection will involve observations of CPs' current practice and semi-structured interviews with WRO and CPs to address the research objectives. Data will be analysed using framework analysis [14,15] with the COM-B system (Capability, Opportunity, Motivation to Behaviour) [16] as the theoretical framework. The analysis will inform the development of a CP-led contraception intervention to reduce unplanned pregnancies.