SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Network No 2 (July 2002)

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Primary Care Responds to the Challenge

Recent statistics show that the government's target on GP involvement in drug dependency treatment (originally 20% subsequently increased to 30% in the NHS plan) were not as wide of the mark as many people thought. Recent research involving a 10% sample of all GPs in England commissioned by SMMGP in collaboration with the National Addiction Centre showed 25% of GPs doing some substitute prescribing with 19.8% of GPs doing this in shared care. This is backed up by the National Treatment Agency's statistics gathered from Drug Action Team treatment plan returns, which showed 19.4% of GPs involved in shared care. The Audit Commission Report (Ref 1) found that 25% of GPs felt confident in treating drug users.

These statistics do, however, mark very significant regional variations. In some areas most GPs are involved in drug dependency treatment, some areas officially claiming 100% involvement. In other areas very few are involved even as low as an official 0% involvement. Even in such cases there are usually a few committed GPs doing the work quietly. With publication after publication (Ref 2) supporting primary care based services and the Royal College of General Practitioners (RCGP) obtaining funding for a second round of 'special interest' GP training, the 30% GP involvement target should be obtainable. There is recent Department of Health guidance that dual diagnosis treatment is now the responsibility of mainstream mental health (Ref 3). This may well assist improved treatment delivery in specialist and GP based services, but we will have to wait and see how this gets translated into practice. SMMGP would very much like to hear from anyone in areas with very low involvement to explore strategies to support primary care involvement.

References

1. See Audit Commission Report below.

2. See policy document review below.

3. Dual Diagnosis Good Practice Guide, Department of Health, 2002 - see review below.

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The Audit Commission Report 2002

Changing Habits: The Commissioning and Management of Community Drug Treatment Services for Adults.

We will be regularly referring to this excellent report (see Network Issue 1). It highlights amongst other things the need for more support to be given to primary care and principles for effective treatment:

Read the full version at www.audit-commission.gov.uk.

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Urine Screening - The Benefits & Limitations

An interesting report (Ref 1) from a Paris addiction treatment service tells us much about good medical treatment with methadone as well as showing the benefits and limitations of urine drug testing in the clinical environment. These researchers reiterate that urine testing should never be used punitively but more as a clinical guide or reminder.

They state that such testing is 'still used by some as a disciplinary measure despite recommendations of clinicians and epidemiologists'. They reiterate and support with numerous references that 'It should not be performed as a repressive imposition which will probably lead drug abusers to falsify their urine samples'.

The study's sub-group of the clinic population was comprised of 41 long-term methadone maintenance treatment patients with mean age 33, 57% male, 92% injectors. Dose ranges were also typical with 90% receiving between 30 and 120mg daily (mean dose 72mg). 5% were prescribed in excess of 120mg. The overall clinic's annual retention rate appeared to be a staggering 96%.

All patients had at least one test every 2 months during the 12 months of the trial that examined results in comparison with clinical history given to health professionals. The simplified addiction severity measure used self-report of drug use and medical/social consequences. There was a 'very poor agreement' with urine test results. The authors conclude that urine test results should be used as a surveillance to alert the physician to early relapse and to schedule earlier consultations for action to be taken such as dose adjustment, counselling, etc.

This report underlines that urine testing has still not been proven to have any effect on the outcomes of treatment or prevention, despite popular belief of a therapeutic benefit from such surveillance. Urine testing, as long as it is effectively conducted and tested can provide evidence for research into medical, legal or epidemiological aspects of psychoactive drug use. It probably also has a place in improving clinical outcomes but this remains to be proven by comparative research.

1. Fellous J, Lowenstein W, Gourarier L, Bonan B, et al.
Relevance of urinalysis monitoring of methadone maintenance patients: a clinical-biological agreement on 41 patients. Addiction Biology (2000) 5:313-318

- Dr Andrew Byrne, GP

75 Redfern Street
Redfern
New South Wales
2016 Australia
E-mail: ajbyrne@ozemail.com.au
Web: www.drugpolicy.org/library/byrne_contents_methadone2.cfm

A Safe Approach to Urine Screening for GPs

The Clinical Guidelines make some minimum recommendations regarding urine screening, which you are well advised to read in full and follow. For example, if you are initiating prescribing independently as a GP or as part of a shared care arrangement, as a minimum you should always:

  1. Conduct a urine screen as PART of the initial assessment to help indicate dependency, to advise treatment and for medical legal protection. Never initiate prescribing without taking and recording actions to confirm dependency.

  2. If you do not have time for a full assessment or if you feel pressured to prescribe, ask the patient to come back to complete a full assessment. Take a urine and partial assessment on the initial consultation.

  3. The patient will feel that they are receiving care and being taken seriously. It will also allow you time to take advice, confirm any given patient history with other providers and arrange support for you and the patient - a planned response.

  4. Conduct random urine screening at least twice a year to ensure that methadone is in the system; to help confirm treatment compliance, to check for other drug use (e.g. cocaine) and for medical legal protection.

  5. Do not work in isolation and as a minimum take advice and ideally receive on-going support for you and the patient.

  6. If you are unsure, where possible have the patient assessed and any prescribing initiated by specialist services or a 'specialised generalist' GP colleague. If you are confident you can receive on-going advice and support, you can consider taking on the prescribing once the patient is stable.

On How to Use Urine Screening - We Would Advise:

  1. Using screening results to discuss dependency and treatment issues, rather than using it punitively (e.g. three strikes and you are out). Look at urine results as a means to have open discussion about any current drug use or possible relapse.

  2. Treatment is more productive where patients feel they can disclose the ups and downs of their drug dependency. Periods of stability with periods of relapse or some continued drug use are often 'normal' within treatment for dependency. Remember that people are generally better off in treatment than out of treatment.

  3. Many have argued that supervised urine screening is against human rights unless fully informed consent has been given and the patient has not been coerced into giving the specimen - even then it can be argued to be an affront to personal liberty.

Excellent chapter (10) on urinalysis in the Classic Revisited book reviewed below.

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Alcohol - What is a Brief Intervention?

A brief intervention can range from 5-10 minutes of information and advice given to an excessive drinker to 2-3 sessions of motivational interviewing or counselling. Brief interventions are targeted at people drinking beyond recommended sensible limits (Ref 1) but not yet experiencing major problems from their consumption. They are not designed and are not as helpful for dependent drinkers. The aim of the intervention therefore is to convince the recipient they are drinking at levels that could be harmful to their health and encourage them to reduce consumption to sensible limits in order to reduce the risk of future health problems.

References

1. Sensible limits - Men 3-4 units a day, regularly drinking 4 or more units of alcohol a day indicates an increased risk to health. Women 2-3 units a day, regularly drinking 3 or more units of alcohol a day indicates an increased risk to health. Drinking above sensible limits is described as excessive or hazardous drinking and could lead to alcohol related problems. If someone is drinking more than 35 units per week (women) or 50 units per week (men) they are likely to develop physical and/or mental problems, and have a higher risk of becoming alcohol dependent.

Brief interventions are usually opportunistic; the person has not complained about a problem with alcohol use and is seeking help for reasons other than an alcohol problem. In some cases the presenting conditions may be alcohol related, such as gastrointestinal problems, high blood pressure or depression. Targets for intervention are usually identified through the application of a screening tool (Such as the Brief Alcohol Use Disorder Identification Tool, Brief AUDIT, featured in Network Issue 1) which indicates they are drinking at hazardous levels. Non-alcohol specialists such as general practitioners and other primary care staff can give brief interventions. Brief interventions are also given to people expressing concern or wanting advice about their alcohol consumption but not dependent on alcohol.

How Do You Deliver Brief Interventions?

Brief interventions involve offering advice on reducing consumption in a persuasive but non-judgemental fashion. Brief interventions are mainly motivational; they involve encouraging people to change behaviour. They should be personalized containing an assessment and discussion of the patient's consumption level and how it relates to general population consumption. The practitioner should discuss the potential health problems excessive alcohol use can cause and help the client set goals for lowering consumption. The advice should be supported by the provision of self-help materials. Recipients should be offered a follow up appointment.

Recipients of brief interventions will be at various stages of 'readiness to change'. People who do not accept they are drinking too much may not be ready to reduce consumption but providing them with advice and information about the potential health dangers of alcohol use may help them recognize the harm drinking excessively can cause and encourage them to think about changing behaviour. Some people will have considered the fact they are drinking too much and are aware excessive alcohol use can be harmful but need encouragement and support to reduce consumption. It is with this group that the greatest success can be achieved through brief intervention. It is important to help people find and express their own motivation to reduce consumption and provide them with confidence that they can alter drinking behaviour. Brief interventions can help instigate a natural change process, from pre-contemplation, to contemplation to action.

FRAMES - Miller and Sanchez (1993) list six elements shown to be effective in brief interventions which can be described using the FRAMES model.

F Feedback, assessment and evaluation of the problem.
R Responsibility - emphasizing that drinking is by choice.
A Advice - explicit advice on changing drinking behaviour.
M Menu - offering alternative goals and strategies.
E Empathy - empathic listening and accurate reflection is essential.
S Self-efficacy - instilling optimism that the chosen goals can be achieved (Bien et al, 1993).

Conclusion

Brief interventions provide a way to prevent people experiencing severe alcohol related problems including dependence by tackling alcohol misuse in its early stages. They are an effective type of intervention and can lead to an average 24% reduction in alcohol consumption in the large group of people drinking excessively, which is estimated to be 20% of patients presenting to primary care. Wallace et al (1989) calculated that implementation of an alcohol intervention programme by GPs throughout the UK would result in a reduction from excessive to low-risk levels of consumption in 250,000 men and 67,000 women a year. This in turn should lead to long-term reductions in morbidity and health care costs. The widespread implementation of brief interventions in primary and secondary health care settings would be a public health approach to tackling alcohol misuse.

- Anna Wood, Alcohol Concern Primary Care Information Officer.

Source/References

Alcohol Concern Factsheet: Brief Interventions
Web: www.alcoholconcern.org.uk/Information/Factsheets/Brief%20Interventions%20factsheet.htm

More information is available on Motivational Interviewing, the cycle of change and brief interventions at www.alcoholconcern.org.uk

Alcohol Concern has a dedicated service to support primary care professionals working to prevent and treat alcohol misuse, the Primary Care Alcohol Information Service. Alcohol Concern produces its own regular newsletter for primary care professionals, Primary Concern.

If you would like to join the mailing list or would like advice or information on tackling alcohol misuse in primary care contact Anna Wood, Primary Care Information Officer on 020 7922 8668 or e-mail awood@alcoholconcern.org.uk.

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Specialists, GPs with Special Interest (GPsWI), & GPs Working as Specialists

What are the differences and what is the future?

A view from a specialist - Dr Tom Carnwath

The Royal College of General Practitioners (RCGP) certificate in drug dependence is an exciting development. It is well timed, as the National Treatment Agency tries to establish agreed models of care, which will inevitably require substantial medical input(Ref 1). So far developments have been hindered by a shortage of interested doctors, both GPs and specialists. It is vital that the new GPs with a Special Interest (GPsWI) are enabled to continue their training and to receive proper support, and not be left in situations where they are out of their depth(Ref 2). Drug dependence is a risky area for prescribers. It is has been known to spawn maverick doctors, but even those who prescribe responsibly may find themselves dangerously exposed if for example they encounter a series of overdoses. It is essential therefore that GPsWI are tied into the PCT clinical governance system and have specialist back up, for the purposes of consultation, onward referral and continued training. This principle is embedded in the rationale of the RCGP GPsWI(Ref 2) certificate course and in the DH Orange Guidelines.

Unfortunately, there is a shortage of specialists, at present about seventy whole time equivalents in the country, for the most part clustering round urban units. The Royal College of Psychiatrists recommends at least one specialist per old health district, and more in inner city areas. They also believe that every district should have an in-patient unit of at least twelve beds for substance misuse. Apart from their use in opiate and alcohol detoxification, inpatient beds have an important role in severe cocaine dependence and in stabilising patients with dual diagnosis.

The role of the specialist addiction psychiatrist is to lead a multi-disciplinary team (in my view the best arrangement is for the team to deal with alcohol, drugs and nicotine); to treat patients with complex needs, both as inpatients and outpatients; to take a lead in developing local services in partnership with DATs and PCTs; to promote audit, evaluation and research; to support GPsWI and other GPs, to ensure ongoing training and updating of skills; and to increase co-ordination with other agencies, for example young people and elderly services, prisons and probation, obstetric and liver units - the list is very long, which is one reason why the job is so interesting.

Whoever performs this role needs to be well trained and confident in their skills. At present addiction psychiatrists must pass their MRCPsych examination, which has quite a large addiction component. They then have to do three years as specialist registrar (SpR), of which at least one should be full-time in addiction treatment, and one in general psychiatry. In practice, most specialists do two years in addictions. Currently we are arguing that all of them should do so. SpR training has a defined syllabus, and ensures the acquisition of specified competencies. Those who complete it are well qualified, but unfortunately there are not many of them. The College is currently advocating a four-fold expansion, but with the best will in the world, we are unlikely to see this happen in the near future.

The development of GP specialists - There are also a small number of GPs who are operating at a specialist level by virtue of their extensive experience, although mostly only in drug rather than alcohol dependence. Clare Gerada (Chair of RCGP Expert Advisory Group on Substance Misuse) rightly stressed the importance of core competencies. These should include good knowledge of psychological and social interventions, in addition to safe and effective prescribing. The National Treatment Agency is committed to establishing National Occupational Standards for all workers in drugs and alcohol: it would be strange if doctors were excluded from this process. The RCGP Certificate is not intended to produce specialists, nor could it be expected to do so in five days. There is a danger however that commissioning bodies may be tempted to employ certificate-holders as if they were specialists. It is therefore very important that a proper syllabus and training process is established whereby GPs and other doctors can achieve recognition as having skills equivalent to a specialist. This of course fits in very well with new GP contract, and the need for GPs to access ongoing career development.

Faculty of Addiction Medicine - An official working group has just been established between the RCGP and RCPsych, partly to consider higher training in addiction. At a time of skill shortage, co-operation rather than competition is essential for all who wish to see excellent addiction services in this country. An encouraging first observation is that there is very little in the present core drug and alcohol components of the specialist addiction psychiatry syllabus which would not be relevant to GPs wishing to specialise in the field. However, it is recommended that this training take two years. How to adapt this for the needs of GPs can form a useful basis for our discussions. It is equally clear that psychiatric training would benefit from more experience in primary care. Personally I would love to see the development of a faculty of addiction medicine, as is now happening in Australia. This would be open to suitably qualified doctors from a variety of backgrounds including general medicine, public health and psychiatry. Under current European and British law this is a hard concept to push forward, but there may be no better time than the present to have a go.

References

1. The NHS Plan, the new GP contract and PCTs look towards creating new roles for GPs and nurses and as the NHS plan states; shattering the old demarcations.

2. The RCGP is proposing that the GPsWI will need to undertake at least 3 days CPD per year (inclusive of half a day appraisal) to work as a GPsWI - as well as have the Certificate in Drug Misuse. See Accreditation, Appraisal and Revalidation (for GPsWI in Drug Misuse). Paper prepared on behalf of Royal College of General Practitioners National Expert Advisory Group in Drug Misuse.

A View From a Specialised GP
Balancing the roles of the addiction psychiatrist and the GP with special interest

I agree with most of what Tom talks about. GPsWI are important - but they do not replace specialists and indeed should not work in the absence of a specialist. They are not there to replace a specialist service and certainly not to provide a cheaper option. GPsWI working in the absence of specialists are in danger of being exploited and their patients being denied specialist opinions, prescribing and interventions. However, GPs can be specialists as can public health doctors and physicians and I agree with Tom that the addiction specialism must opened out to embrace all disciplines - similar to the Australian model.

I think that there needs to be training for psychiatrists in the addictions. After all, we are told that 50% of all psychiatric patients have drug or alcohol problems, yet most do not receive training in this discipline. Generalists naturally turn to psychiatrists as the experts and it is important that the RCPsych grasps this nettle urgently.

- Clare Gerada, Chair of RCGP Expert Advisory Group on Substance Misuse

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Up to Speed on Clubbers' Health?

Every weekend thousands of young adults routinely use one or more of the clubbers' 'staples' of ecstasy, speed and, increasingly, cocaine. Many will also be using cannabis, alcohol and tobacco more regularly: drugs they are more likely to persevere with into later life, with health implications that don't need rehearsing here. The recent launch of new 'Safer Clubbing' guidelines by the Home Office (Downloadable from www.drugs.gov.uk/ReportsandPublications/Communities) prompts reconsideration of how we respond to the health issues that accompany this pattern of drug use, which has become integral to the leisure lifestyle of a sizeable minority of young adults. Although the vast majority of clubbers do not experience any immediate health problems from their drug use, a minority will present with symptoms that are caused or exacerbated by it. Very occasionally, this will be dramatic and severe, such as the psychoses that can result from stimulant use, or the dependence which can occur with any 'recreational' drug, including cannabis.

The combination of drugs and clubbing is also an important cause of accidents, with alcohol remaining the main culprit. Far more frequently, drug use will simply be one of the many factors that should be taken into consideration when young adults present with problems such as sleep or appetite disturbance, anxiety or mood disorders. In some cases it will be clinically significant - in others not. The normalisation of drug use means that, more than ever before, the ability to elicit an accurate drug history should be seen as a crucial and core skill for practitioners.

The new 'Safer Clubbing' guidelines highlight a range of related health promotion and public health issues, such as the importance of targeting harm reduction information at clubbers. PCTs have a potentially important part to play in promoting young adult's health by helping to ensure that the guidelines are translated into practice through local Drug Action Teams.

- Neil Hunt Kent

Institute of Medicine and Health Sciences/KCA (UK)
Research and Development Centre
University of Kent at Canterbury
Canterbury
Kent CT2 7PD
E-mail: N.Hunt@ukc.ac.uk
Tel/Voicemail: +44 (0)1227 824 090

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Classics revisited - Methadone Maintenance Treatment & Other Opioid Replacement Therapies

Edited by Jeff Ward, Richard P. Mattick and Wayne Hall, Harwood Academic Publishers reprinted 1998.

This book was first published in 1992 as 'Key Issues in Methadone Maintenance Treatment' and played a role in establishing methadone maintenance as a valid treatment. It has now been updated, improved and extended. It now includes other opioid replacement therapies and a new section on training, which although written for Australia, is valuable. This book is a 'must read' for all providing care to opiate dependent patients. It provides an excellent review of all the 'real' evidence for the value of providing opioid replacement therapies. It is a valuable and enjoyable read and makes us question any of our attitudes that are based on opinion rather than research.

The first section of the book evaluates the safety and effectiveness of opioid replacement therapy, mainly of methadone, as this is where the research has been undertaken. It includes the value of treatment, what effects outcome, how it has helped to reduce the transmission of HIV and even its cost-effectiveness. The second section reviews evidence on the contribution that various components of methadone maintenance treatment make on illicit opioid use and crime. It includes how to deliver effective methadone treatment, review of the research evidence, the pharmacology of methadone and the relationship between methadone dose, retention in treatment and heroin use. It also deals with how best to monitor patients, urinalysis, counselling and the under-researched issue of optimal duration of treatment.

The third section deals with training, providing treatment in prisons, in pregnancy and in co-morbidity patients. The final section is equally interesting on the future of opioid replacement therapy and raises exciting points well worth considering.

I highly recommend this book and would suggest it for your essential reading, if it isn't already there!

- Chris Ford

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Review of Recent Papers, Articles & Reports

1. Ball J.C., Lange W.R., Myers C.P., Friedman S.R. Reducing the risk of AIDS through methadone maintenance treatment

Journal of health and Social Behaviour 1988; 29: 214-226

This paper is an old one but well worth reading. It helped to establish methadone maintenance as an effective treatment (it is also used in the Classic Revisited book reviewed above). The paper reports the results of six methadone maintenance treatment programs in three US cities. It found that methadone maintenance had a dramatic impact on injecting drug use and crime. It also found that there was a wide range in the effectiveness of different programmes. The more effective programmes used higher doses of methadone and had maintenance rather than abstinence as their treatment goal. They also offered better quality counselling services and provided more medical services. They also better relationships with their patients and low staff turnover.

2. Lewis D, et al. General practice or drug clinic for methadone maintenance? A controlled comparison of treatment outcomes. International

Journal of Drug Policy, 2001; 12: 81-89

This paper compares 36 patients entering methadone maintenance at one GP surgery with support from a drug clinic, with 89 patients entering into the same local clinic. Outcomes at nine months or greater were compared in the two treatment settings. There were no significant differences in retention at 9 months. There was significantly higher retention in primary care at 20 months. Other outcomes were mixed but patients in primary care were 6-7 times more likely to be immunised against hepatitis B or tested for hepatitis C.

Policy Document Review - Policy in Brief

1. Waiting Times Guidance, Making the System Work

National Treatment Agency 2002

This document highlights engagement of GPs as the first factor to consider in the reduction of waiting times for community treatment for drug dependency. It sets targets for waiting times of 3 weeks for specialist agencies by April 2004 (6 weeks by 2003) and 2 weeks in general practice (4 weeks by 2003). Whether there should be a differential here is open to question. It cites 8 causes of waiting times and has 23 action points for areas to implement.

You can see the full text on www.nta.nhs.uk.

2. The Government's Drug Policy: Is It Working?

Home Affairs Select Committee, December 2001.

A wide-ranging report recommending many changes in the way society deals with drugs. It recommends a substantial increase in resources for training GPs at both undergraduate and postgraduate level. It recommends that the RCGP and the British Medical Association take a greater interest in this field and encourage their members so 'that a handful of General Practitioners are not left to shoulder the burden alone'.

Read in full on www.parliament.uk/commons/selcom/hmafhome.htm.

3. Mental Health Policy Implementation Guide, Dual Diagnosis Good Practice Guide

Department of Health, 2002

For the first time it has been officially stated where responsibility for treating people with severe mental illnesses and serious drug problems lies. On page one in bold letters it states 'This should be delivered within mental health services' and goes on to explain that this is what they are calling 'mainstreaming' of this issue. This resolves a long running dispute and will help in the future planning of services.

Read it on www.doh.gov.uk/mentalhealth/dualdiag.pdf.

4. Models of Care

National Treatment Agency/Department of Health, 2002

This document is currently out for consultation and is likely to act as a de facto national service framework for the treatment of drug dependency. It has primary care as one of the core treatment delivery sites within a tiered system of service provision.

The final document is likely to see quite a few changes but see the draft on www.doh.gov.uk/nta/models.htm.

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Dr Fixit's Advice - Under-Dosing

Dr Fixit

Question

I am a GP who is relatively new to prescribing for drug users. I accepted a woman patient from the local specialist service who said she was stable on 45 mls methadone but she continues to have urines positive for opiates. When I assessed her after transfer, she said 45mls wasn't enough and she was continuing to have to use heroin on top. She wants to stop heroin as she is getting into debt. Can you offer some advice?

Answer

This is a common situation and one that raises a number of issues including:

Specialist services may not always provide treatment that is ideally suited to each individual. People may be discharged back to the GP before they are really stable, or at a level of stability that an individual GP feels able to manage. This situation can arise as services attempt to encourage throughput in order that waiting lists remain short. In this instance, a phone call to the specialist service may elicit some helpful information (such as the result of her urine toxicology before discharge) and advice.

The time of transfer provides an opportunity to take a full history, not only of her drug use (e.g. how often is she having to use heroin, does she know how to inject safely), but also of other health issues (e.g. risk of blood borne viruses and sexual risks) and social issues (e.g. does she have a partner who is using drugs). She may have other needs, although she may not be able to consider these until she is stable on an adequate dose of methadone.

Nevertheless, such history taking (which may be on going) also serves to improve the doctor's relationship with someone who may have low self-esteem and hidden health needs.

It is essential to remind ourselves of what we are trying to achieve. We should not be aiming for abstinence unless and until this is the patient's goal. It follows from this that we should not be aiming to keep doses as low as possible either. Our primary aim is harm reduction - to reduce the harm associated with injecting heroin. There are a number of subsidiary goals that will go some way to reduce harm and their appropriateness will depend on the needs and circumstances of the patient at the time. Apart from the dangers of injecting itself, of blood borne viruses and of overdosing there are also the dangers of having to raise money to pay for the illegal drugs. Is she having to steal or is she tempted to work in the sex industry to raise the money - both activities associated with further risk. In addition, using on top will also continue to have an impact on her social relationships and her emotional health. We may have reduced all these risks by putting her on 45mls of methadone but we obviously haven't eliminated them. To reduce the dose or take her off methadone as a punishment for using on top will obviously lead to an increase in the harm she is doing to herself and others.

We seem to have almost a fixation in the UK that lower doses of methadone are better than higher doses. But as long as we ensure that we are not giving too much (that she is not drowsy 4-6 hours after taking her methadone) and that the methadone is taken by her and not diverted, then a higher dose may be better than a lower dose. The evidence suggests that most people who have injected need 60mg methadone or more per day to stop the craving and to block the effects of injecting heroin on top.

It would seem self-evident then that the way to respond to this patient who is using on top of a prescription for methadone is to increase the dose. In general it is important to find out why each individual is using on top - some people may be happy with their methadone dose but like to use on top once or twice a week. Increasing the methadone dose in this situation is unlikely to affect their illicit drug use.

In my experience people on methadone often know how much more they will need to prevent them needing to use on top although if anything they will underestimate this. Sometimes we may even need to persuade people on methadone to take a bit more so that they are comfortable and not craving other drugs.

In this situation the safest way of approaching this is to negotiate with your patient. How much does she think she will need to stop her using heroin? She may well need 60mg or more and the important thing is to establish the dose she requires to cut down and hopefully stop her additional use of drugs. And yet it is important to make it clear that you will not be willing to increase the dose indefinitely if it is having no effect on her use of additional drugs. The dose should be increased gradually, by 5mls at a time, at weekly intervals. To be on the safe side, methadone consumption should be supervised until she is stable on the higher dose.

Negotiate with her a reasonable 3-month goal. It might be to have urine samples clear of opiates or it may be more realistic to accept occasional (safe) heroin use. In summary, there's no point on having someone on methadone unless the dose is adequate, urine toxicology should not be used punitively but in order to encourage change, and there is more to caring for someone who uses heroin than prescribing a small dose of methadone.

In summary, there's no point on having someone on methadone unless the dose is adequate, urine toxicology should not be used punitively but in order to encourage change, and there is more to caring for someone who uses heroin than prescribing a small dose of methadone.

- Judy Bury

Primary Care Facilitator
Primary Care Facilitation Team
22-24 Spittal Street
Edinburgh EH3 9DU

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Hot Topics - The French connection - Substitute Prescribing & Reduction in Deaths & Crime

Reports from France highlight the spectacular public health success brought about through the initiation of substitute prescribing. In France there was no prescribing of opiates until 1990 when a very limited number of people (mostly with HIV) were prescribed methadone. Widespread prescribing did not start until 1995 with the advent of buprenorphine prescribing through primary care. This resulted in a drop of 80% in opiate overdose when at the same time, overdoses increased in many other western countries (NB there are multiple problems with reporting of deaths in France, as there are in the UK, but the trend if definitely real). Additionally there was a four-fold drop in HIV cases and drug related crime dropped by a factor of three. This is pretty convincing evidence for the effectiveness of substitute prescribing. It has been reported that up to 60% of France's injecting users are currently in treatment. This compares with less than 20% according to US estimates and probably fewer than 40% according to Australian figures.

The French are now planning to extend methadone prescribing out from the specialist clinics into primary care alongside existing buprenorphine prescribing.

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Hot Topics - Heroin Prescribing - Will This Affect GPs?

A headline in the Observer (Sunday 26th May) was incorrect and unhelpful in stating that GPs will be encouraged to prescribe heroin to addicts. The Select Committee report that it quotes(Ref 1) recommends an increase in heroin prescribing by 5 times, but not specifically by GPs. In the actual report GPs are not named as the doctors to deliver heroin prescribing. The implication is that 'specialists' with adequate facilities (supervised injecting rooms etc) would provide it. It is important that primary care remains aware of the key issues. Some thoughts on the matter of GPs prescribing heroin are:

  1. We need to get consistent good basic drug treatment for all before we move on to heroin prescribing.

  2. The RCGP line does not support prescribing of heroin in General Practice. Promoting the idea of heroin prescribing is likely to discourage GPs involvement and undermine the development work in the management of drug misuse as mainstream. We would need to ensure that the drug is not diverted onto the streets and this is not something a standard GP practice can do.

  3. Another view is that there is a place for heroin prescribing by a few experienced and supported practitioners (specialists and who may in some case also be GPs) working within a specialist organisation or working with adequate support and facilities. It provides another choice for opiate dependent people and has been shown in several countries (Switzerland, Netherlands and the UK) to be effective when used in a small group of 'treatment-resistant' users under very controlled conditions.

  4. GP heroin prescribing could only be for those few with adequate training and experience that are specifically working as specialists with specialist team support and facilities. This option is clearly NOT for generalist GPs or doctors just starting this work. It is also not for GPs with special interest or specialised generalists.

1. The Government's Drug Policy: Is It Working? Home Affairs Select Committee, December 2001. (See our review above).

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Hot Topics - Your Contract Your Future, Explanatory Notes from the GPC April 2002

The proposed new contract for GPs outlines a much smaller range of core activities within the contract with all other services being 'additional' or 'enhanced' and requiring payment. In theory this should put an end to the debate as to whether dependency treatment is or isn't General Medical Services. It now definitely falls into the category of or additional or enhanced; the likelihood being that it will fit into the enhanced category. It is therefore definitely within the potential remit of the GP if they should chose to 'opt into' it and it should merit some form of remuneration, either on a nationally or locally agreed basis.

For further explanation see SMMGP Article or read the whole document on www.bma.org.uk.

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