SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Network No 13 (February 2006)

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Welcome

100,000th Visitor Poster

It is an exciting time for the updated smmgp.org.uk website as we celebrated our 100,000th visitor in January. With more than a quadrupling of weekly hits over this past year, the site is now receiving as many as 2,500 regular home page hits a week not counting the discussion forums or other routes into the site. So take a look, try out the forums or download a conference brochure as we look forward to seeing you shortly in Manchester for yet another stimulating RCGP SMMGP conference on 27th and 28th April - Are we Delivering Effective Care in General Practice?

IN THIS ISSUE - We showcase the RCGP SMMGP Methadone Guidance with excerpts of the guidance summary, the rationale for methadone prescribing and advice on when to choose between maintenance and detoxification. These excerpts also highlight some of the key treatment principles which primary care has been keen to promote (See the full guidance in the Guidance Documents section).

In case you have ever felt lost interpreting your patients' jargon and the weights and measures of the illicit drugs scene, Dr Gordon Morse provides some witty and insightful tips courtesy of an ambiguous but seemingly authoritative source.

We offer a synopsis of the drug problem across Europe following EU Drugs Agency reporting - definitely worth a glance to see how our local patterns fit with the EU trends. Critically, polydrug use is now considered central to the EU drug phenomenon making a simple substance specific focus no longer appropriate.

With the EU trend towards treatment rather than prisons, Tom Carnwath's excellent outline of current and future treatment issues in prisons is most relevant and useful.

SMMGP continues to look towards supporting the key strategic role of shared care coordination for effective development and maintenance of local treatment systems. Kate Halliday has drawn together SMMGP team experience into a Briefing Paper on Shared Care Monitoring Groups.

Where the GP's responsibility lies in terms of patients on methadone who drive continues to concern many…look no further than the Methadone Guidance. A much-needed DH update on legislation and developments in the management of controlled drugs post Shipman is also presented.

Jean-Claude Barjolin, Editor

Fittingly its a multidisciplinary team that tackles the importance of integrated care and partnership working with some practical highlighting of joint working between the criminal justice, local specialist and GP services.

Dr Fixit has been doing what he does best, offering practical advice - firstly on joint working around substitute prescribing and crack, alcohol and social legal problems and secondly on how best to support a patient coming off supervised consumption. Thanks Dr Stephen Pick and Dr Judith Yates for their Fixit experience and insights.

There's also a look at how the Respect antisocial behaviour agenda is affecting vulnerable drug and alcohol patients, with updates, news, courses and the like.

Enjoy the issue and hopefully see you at the Manchester conference in April.

-Jean-Claude Barjolin, Editor

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Rationale for the Use of Methadone

Excerpt from Guidance for the use of methadone for the treatment of opioid dependence in primary care. RCGP Substance Misuse Unit, RCGP Sex, Drugs and HIV Task Group, SMMGP, The Alliance, 1st Edition 2005
(See the full guidance in the Guidance Documents section)

"Methadone is an effective substitute medication for opioid dependence for use in UK primary care."

There is an increasing body of evidence that the primary care setting is an effective means of delivering treatment for opioid dependence (Ref 10, 11, 12, 13). Methadone maintenance treatment (MMT) is now a well-established treatment modality across a variety of treatment settings and supported by both research evidence and clinical practice (Ref 14, 15, 16, 17, 18, 19).

The aim of methadone maintenance treatment is to improve the quality of life of opioid-dependent patients and to reduce the potential harm of using illicit drugs. MMT greatly reduces mortality (Ref 20), illicit drug use and criminal activity, and attracts and retains more patients in treatment than other treatments (Ref 9). There is good evidence that MMT reduces transmission of HIV (Ref 21, 22, 23), although the evidence for effectiveness at reducing transmission of hepatitis B virus and hepatitis C virus is less convincing (Ref 24, 25, 26).

There is no evidence that MMT increases the overall length of dependence (Ref 14). The positive outcomes of MMT are only sustained while patients are in treatment. Effective treatment of the parent can also have major benefits for the children of problem drug users (Ref 27).

Methadone is a highly effective maintenance treatment for chronic dependent opioid users that can deliver a wide range of harm reduction outcomes for large numbers of patients in a wide variety of settings. However, effectiveness may be reduced by departure from optimum methods of delivery. Enforced reductions in the methadone dose and putting pressure on patients to become abstinent from methadone are associated with poor outcomes (Ref 28).

The most effective MMT programmes are those that provide optimal doses (usually between 60 to 120mg daily) of methadone as part of a comprehensive treatment programme, which will include regular reviews, general medical care and psychosocial support as required, and which validates maintenance as much as abstinence as desirable treatment goals (Ref 9, 17, 29) and where patients feel they play a meaningful role in determining their optimum dose.

A summary of the evidence in 1999 concluded that given the high morbidity and mortality seen in patients with opioid dependence not in treatment, the public health challenge was to deliver safe and effective methadone treatments to as many patients as could benefit from it, while minimising the risk of diversion of prescribed medication (Ref 14). Whilst methadone clearly remains the mainstay of the public health response, there has been an increase recently in the use of buprenorphine for some patients. Also with more patients now in treatment, increasing access to psychosocial and other supportive interventions in addition to the pharmacotherapy is important.

Guidance for the Use of Methadone Summary

"Opioid dependence is common in the UK and methadone is an effective treatment."

Effective:

Maintenance and detoxification:

Methadone maintenance:

Assessment:

Titration:

Stabilisation:

Interactions:

Loss of tolerance:

Ongoing care:

Shared care:

Three day recovery to steady state from missed dose at day 10
Three day recovery to steady state from missed dose at day 10
Illustration adapted from "The Methadone Briefing" (1996)

Choosing between maintenance and detoxification

Choosing between maintenance and detoxification occurs at many points during treatment, starting at the first assessment and then at various points as appropriate. Methadone can be used as a maintenance intervention or as a detoxification agent, but is primarily now used as a maintenance drug. Methadone is probably no longer seen as the automatic first-line treatment for all patients wishing to detoxify from heroin. Many find that buprenorphine and lofexidine enable easier assisted withdrawal, although the evidence is not overwhelming (Ref 35). It is important to consider the views of the patient if they express a particular preference for any of these medications.

Maintenance is suitable for patients who want to stop using illicit opioids but are unable to achieve abstinence from all opioids at present. Prescribing is offered long-term, at effective doses (usually between 60 to 120 mg daily) individualised for each patient. The goal is harm reduction and stabilisation of life-style. It may also be prescribed on harm reduction grounds to those wanting to reduce their consumption of illicit opioids. The most powerful evidence base for methadone is for long-term maintenance, with retention in treatment being an indicator for better outcomes (Ref 9, 14). Enforced detoxification or enforced dosage reduction has been shown to be ineffective (Ref 28, 40)

Detoxification can be attempted with highly motivated, willing patients who wish to detoxify from all opioids. However, the likelihood of success with methadone will be reduced if the process is too rapid because of the long-acting nature of the drug and its prolonged withdrawal profile. It is important to assess whether the patient's circumstances are conducive to maintaining abstinence and to advise on the timing of withdrawal accordingly. Where circumstances are adverse, such as patients who are homeless or awaiting court, a further period of maintenance should be advised with support to achieve appropriate stability and psychosocial change before attempting detoxification.

There is a high relapse rate to heroin use and as such detoxification should always be seen as a stage in the process and not normally be seen as a stand-alone treatment modality. It should never be imposed, particularly since recent research has shown high mortality rates among those detoxified (Ref 41). Detoxification should be followed by a package of care, which can include: in and outpatient rehabilitation, relapse prevention, support, self-help groups and counselling. It is crucial to warn of the potential loss of tolerance to opioids after a detoxification - relapsing to heroin after a period of abstinence may be fatal.

If patients are moving from maintenance to detoxification they may need to reduce their dose of methadone before transferring to another drug such as buprenorphine. Lofexidine is still sometimes used but the evidence for its effectiveness is poor, especially used as a single agent. If in doubt seek specialist advice.

- Excerpt from Guidance for the use of methadone for the treatment of opioid dependence in primary care. RCGP Substance Misuse Unit, RCGP Sex, Drugs and HIV Task Group, SMMGP, The Alliance, 1st Edition 2005.

References

3. NTA Research into Practice 4: More than just methadone dose. National Treatment Agency: London 2004.

9. Ward J, Mattick RP, Hall W (eds). Methadone maintenance treatment and other opioid replacement therapies. Amsterdam: Harwood Academic, 1998.

10. Keen J, Oliver P, Rowse G, et al. Does methadone maintenance treatment based on the new national guidelines work in a primary care setting? Br J Gen Pract 2003; 53: 461-467.

11. Keen J, Oliver P, Mathers N. Methadone maintenance treatment can be provided in a primary care setting without increasing methadone related mortality: the Sheffield experience 1997-2000. Br J Gen Pract 2002; 52 (478): 387-9.

12. Hutchinson S, Taylor A, Gruer L, et al. One year follow-up of opiate injectors treated with oral methadone in a GP centred programme. Addiction 2000; 95: (7) 1055-68.

13. Gossop M, Marsden J, Stewart D, et al. Methadone treatment practices and outcomes for opiate addicts treated in drug clinics and in general practice: results from the capital's National Treatment Outcome Research Study. Br J Gen Pract 1999; 49: 31-4.

14. Ward J, Hall W, Mattick R. Role of maintenance treatment in opioid dependence. Lancet 1999; 353: 221-226.

15. Dole VP, Nyswander M. A medical treatment for diacetylmorphine (heroin) addiction: a clinical trial with methadone hydrochloride. JAMA 1965; 193: 80-84.

16. Gunne LM, Gronbladh L. The Swedish methadone maintenance program: a controlled study. Drug and Alcohol Dependence 1981; 7: 249-256.

17. Ball JC, Ross A. The effectiveness of methadone maintenance treatment: patients, programs, services, and outcomes. New York: Springer-Verlag, 1991.

18. Marsch LA. The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk behaviour and criminality: a meta-analysis. Addiction 1998; 93: 515-532.

19. Farrell M, Ward W, Mattick R, et al. Methadone maintenance treatment in opiate dependence: a review. BMJ 1994; 309: 997-1001.

20. Gronbladh L, Ohland M.S, Gunne L. Mortality in heroin addiction: impact of methadone treatment. Acta Psychiatria Scandinavica 1990; 82: 223-227.

21. Schoenbaum EE, Hartel D, Selwyn PA, et al. Risk factors for human immunodeficiency virus infection in intravenous drug users. N Engl J Med 1989; 321: 874-79.

22. Metzger DS, Woody GE, McLellan AT, et al. Human immunodeficiency virus seroconversion among intravenous drug users in and out of treatment: an 18-month prospective follow-up. J. Acquir Immune Defic Syndr 1993; 6: 1049-55.

23. Schoenbaum EE, Hartel D, Selwyn PA, et al. Risk factors for human immunodeficiency virus infection in intravenous drug users. N Engl J Med 1989; 321: 874-79.

24. Chamot E, de Saussure P, Hirschel B, et al. Incidence of hepatitis C, hepatitis B and HIV infections among drug users in a methadonemaintenance programme. AIDS 1992; 6(4): 430-431.

25. Crofts N, Nigro L, Oman K, et al. Methadone maintenance and hepatitis C virus infection among injecting drug users. Addiction 1997; 92(8): 999-1005.

26. Rezza G, Sagliocca L, Zaccarelli M, et al. Incidence rate and risk factors for HCV seroconversion among injecting drug users in an area with low HIV seroprevalence. Scand J Infectious Diseases 1996; 28(1): 27-29.

27. Hidden Harm: responding to the needs of children of problem drug users. A report by the Advisory Council for the Misuse of Drugs. London: HMSO, 2003.

28. Gossop M et al. Outcomes after methadone maintenance and methadone reduction treatments: two-year follow-up results from the National Treatment Outcome Research Study. Drug and Alcohol Dependence: 2001; 62, 255-264.

29. Bertschy G. Methadone maintenance treatment: an update. Eur Arch Psychiatry Clin Neurosci 1995; 245: 114-124.

35. Gowing L, Ali R, White J. Buprenorphine for the management of opioid withdrawal (Cochrane Review) in: The Cochrane Library, Issue 2, 2004, Oxford: Update Software.

40. Sees KL et al. Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence: a randomized controlled trial. JAMA 2000; 283; 1303-1310.

41. Strang J, McCambridge J, Best D et al. Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. BMJ 2003; 326: 959-60

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Dealing with Weights & Measures

Dealing with Weights and Measures

In case you have ever felt lost interpreting your patients' jargon and the weights and measures of the illicit drugs scene, Dr Gordon Morse provides some witty and insightful tips courtesy of an ambiguous but seemingly authoritative source.

Drug users confuse us with many things, but I particularly struggle with their weights and measures, because they insist on using both metric and imperial measures, and dress it all up in confusing jargon as well.

So I asked one of my punters to give me a tutorial, an l pass this on to you. But note, these things change quickly, so I cannot guarantee how long these prices and information will remain true for. I can however testify to the authority of the source!

When dealing in heroin, cocaine and crack cocaine, the following measures apply:

A typical £10 deal, bag, wrap etc will contain 0.15-0.4g of drug (note the wide range of purity). (Also note that you cannot equate ANY amount of heroin with an "equivalent" dose of methadone for reasons of purity and the variability of individual physiology*)

28g = 1 oz
7g = 1/4 oz
3.5g=1/8 oz
A "teenth" (i.e. 1/16 oz) should contain 1.75g, but is usually more like 1.5g
A "Nine Bar" is 9oz (250g), and there are 4 Nine Bars to 1 kilogram (36oz)

Cracking cocaine

A dealer will begin with a large amount of powder cocaine, say 1 kilo, or a Nine Bar. Nine Bars of good powder cocaine cost £8,000 wholesale. This can then be "re-pressed" (cut or diluted) with a pharmaceutical inert powder called Mannitol, costing £50 for 1kg.

1oz of good powder cocaine might cost £1,100, but re-pressed powder cocaine might be £800. Most cocaine sold in ounces or less will have been repressed.

"Washing up" powder cocaine into crack, using ammonia or bicarbonate etc., will generally lose some weight of cocaine. But 1oz of powder (cost £800) can be turned into £1,400 of rocks if sold in £10 amounts.

Grass is greener

The best value in dealing comes from buying grass in kilos - apparently a punter can double their money.

- Dr Gordon Morse

*As stated in the Clinical Guidelines, Department of Health; the Scottish Office Department of Health and Social Services, Northern Ireland. Drug Misuse and Dependence - Guidelines on Clinical Management. London: HMSO, 1999

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Latest on the Drug Problem Across Europe

The 2005 annual report from the EU drugs agency offers a very useful overview of the European drug phenomenon in 29 countries across Europe - giving latest trends, analysis, social, legal and political responses. So here is a synopsis - certainly worth a quick glance to see how our local patterns fit with those in Europe.

Annual Report 2005

(PDF files of printed version are available here)

Polydrug use is central to EU drug phenomenon making a simple substance specific analysis no longer realistic.

Cocaine is becoming the stimulant drug of choice for many young Europeans and a major element of the EU drug picture

Opiate use

Blood borne viruses and mortality

Rise in drug law offences in most of the EU

Countries opt for treatment over prison

Policy-makers support data collection

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Addiction Treatment in Prison

Addiction Treatment in Prison

The European trend is towards treatment rather than prisons, making Tom Carnwath's excellent outline of current and future treatment issues in prisons most relevant and useful.

Proper management of drug-using prisoners is vital, partly because often they have no other contact with treatment. Studies have consistently demonstrated very high drug use by prisoners. About half have used cocaine or heroin recently, the prevalence for each drug being about 30%, compared with less than 1% in the general population. In prison about 50% of prisoners use cannabis, 25% heroin and 15% illicit tranquillisers. Other drugs are less common. Frequency of use is usually less than outside prison. About 15% of cannabis users and 3% of heroin users use daily, but only about 2% admit injecting in prison. About 25% of prisoners who have ever used heroin use it for the first time while in prison. During the first few months after release, drug use is slightly less prevalent than before imprisonment (Ref 1, 2).

Drug withdrawal on admission is associated with self-harm. 11% of suicides occur during the first 24 hours in prison, 33% in the first week and 47% in the first month. 62% of these are problematic drug users (Ref 3). The risk of death during the first week after release is forty times higher than expected in this population, usually as a result of opiate overdose (Ref 4).

Methadone has traditionally been used in our prisons merely as a means of detoxification. Regimes have typically started at 30mg/day, reducing to zero over ten days (Ref 5), although recent recommendations propose that this should be extended to three weeks or perhaps much longer. There is scant evidence to guide this decision. Lofexidine, buprenorphine and dihydrocodeine have been used as alternatives, although the latter is now discouraged because it is not licensed for this purpose.

There is growing interest in the use of methadone maintenance treatment in prison. An Australian randomised study showed that heroin-using prisoners treated with methadone throughout their imprisonment were less likely to die after release or to come back into prison (Ref 6). The same team also showed a reduced rate of overdose, injecting and hepatitis seroconversion during imprisonment, but only if methadone doses were above 60mg/day (Ref 7). Only a few UK prisons provide maintenance treatment at present, but this will change in the near future.

The principles of induction on to methadone are the same as those used in the community. Many patients coming into prison are already on methadone prescriptions. Much caution is required, because often there is a lapse of days between their last community dose and initiation of prison treatment, as a result of temporary detention in police cells, weekend admission etc. Tolerance to opiates is lost at the rate of about 20% per day. Moreover, unless the last community dose was supervised, it is not absolutely certain that the full dose was actually taken. Prescribing the same dose as was used in the community can therefore cause fatal overdose. In most cases it is safest to start dose levels at 40mg/day or less, but possibly increasing them faster than in newly-induced patients, depending on response. Split dosing is helpful during titration. Methadone consumption in prison is always carefully supervised, and followed by a washdown drink of water, to prevent the onward sale of "spit methadone".

Some prison guidelines argue that patients require lower doses of methadone in prison than in the community, partly because there is less access to illicit drugs, but the logic of this argument is unclear (e.g. Victoria Prisons, Ref 8). The evidence quoted above suggests that effective therapy requires the same dose range in both prison and the community, namely above 60mg/day for most patients.

Buprenorphine brings less risk of overdose. Doses can be increased if required by 4mg/day as in the community. It may however cause other problems in a prison setting. It is the most common drug of abuse in many prisons. Doses are difficult to supervise, and mouthed tablets can later be injected with consequent risk of abscesses and viral infection. It is often used in detox programmes, usually over ten days.

Prison offers an excellent opportunity to provide psychological treatment and health promotion, focussing on such issues as diet, safe injecting and smoking, prevention of overdose and first aid. Many prisoners are heavy cocaine and alcohol users before imprisonment, but few use cocaine while in prison and none use alcohol. Nonetheless, treatment related to these drugs can still be effective. Indeed, the mental effect of heavy cocaine and alcohol use can sometimes render treatment very difficult while outside prison or other residential facility.

At present substance misuse treatment in prisons is quite fragmentary, being divided between, among others, detox teams, standard healthcare, counselling and throughcare staff (CARAT workers) and purveyors of brief cognitive therapy (PASRO). In April this year the NHS takes over full responsibility. There is some hope that this strange mix will be rationalised, and perhaps merged into an in-reach addiction team that will respond to needs of inmates throughout their period of stay, while linking up with outside services. The Prison Health Unit is undertaking a review of needle exchange in prisons, so there is even a possibility that this might be introduced in place of the present reliance on disinfecting tablets, but don't hold your breath!

- Tom Carnwath, Consultant Psychiatrist, Substance Misuse, Darlington

References

1. Singleton N, Farrell M & Meltzer H (1999) Substance Misuse among Prisoners in England and Wales London: Office for National Statistics.

2. Ramsay M. (ed) (2003) Prisoners' Drug Use and Treatment: seven research studies Home Office Research, Development and Statistics Directorate Research Study No. 267. London: Home Office.

3. H M Prison Service (2001), Prevention of suicide and self-harm in the Prison Service, an internal review.

4. Howells C, Allen S, Gupta J, Stillwell G, Marsden J & Farrell M. (2002) Prison based detoxification for opioid dependence: a randomized double blind controlled trial of lofexidine and methadone Drug & Alcohol Dependence.

5. Singleton N., Pendry E., Taylor C., Farrell M. & Marsden J. (2003) Drug-related mortality among newly-released offenders London: Home Office Online Report 16/03 (www.homeoffice.gov.uk)

6. Dolan, K., J. Shearer, et al. (2003). A randomised controlled trial of methadone maintenance treatment in NSW prisons. Sydney, National Drug and Alcohol Research Centre.

7. Dolan K, Hall W. & Wodak A.(1996) Methadone maintenance reduces injecting in prison BMJ 312:1162

8. Victorian Prison Opioid Substitution Therapy Program. Clinical and Operational Policy and Procedures. (2003) Victoria State, Australia: Office of the Correctional Services Commissioner.

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Shared Care Monitoring Groups

Shared Care Monitoring Groups

SMMGP continues to look towards supporting the key strategic role of shared care coordination for effective development and maintenance of local treatment systems. Kate Halliday has drawn together SMMGP team experience into a briefing on Shared Care Monitoring Groups.

"A well functioning Shared Care Monitoring Group (SCMG) is central to the ongoing development of a high quality shared care scheme."

This article seeks to clarify the roles, responsibilities and membership of SCMG's.

The concept of the Shared Care Monitoring Group (SCMG) was first introduced in the Department of Health (DH) Drug Misuse & Dependence - Guidelines on Clinical Management 1999. In 2000 the DH issued terms of reference for SCMG's which is used as the basis of this paper. However SMMGP have included additional recommendations to reflect some of the changes in policy and practice that have occurred since the guidance was issued.

How should a SCMG work?

A SCMG is in essence a strategic group that influences and informs local decision making, whilst overseeing, monitoring and coordinating shared care. A SCMG should be clear about where it's decision making capacities lie. Many decisions will be able to be made by the SCMG, however, in some instances the group may act in an advisory role making recommendations that will then need to be agreed by other groups and agencies. For example the Local Medical Committee (LMC) should be consulted regarding GPs contracts, roles and responsibilities, and the DAT regarding commissioning issues. The decision making process will be different in each area so it is therefore important for the SCMG to clarify it's decision making remit with local multi agency agreement.

Case study

A local training day involving GPs key workers and pharmacists was held as consultation for drawing up local guidelines for the new shared care scheme. The shared care coordinator then took the draft guidelines to the SCMG. The guidelines were ratified by the SCMG, on the condition that three further groups should be consulted. The PCT representative felt the Clinical Governance Lead should agree to the document, the DAT Commissioner felt that the Joint Commissioning Group should ratify the document, and the LMC representative felt it should be passed through the LMC. All other representatives felt that the consultation with their agencies was completed and agreed upon. Once full agreement was obtained, the documents were formally ratified by the SCMG.

What should a SCMG do?

The responsibilities of a SCMG will vary depending on the locality and the stage of development of the scheme, as priorities change from development, to maintenance and monitoring. The initial development of a scheme can be a busy and exciting time. However the SCMG is just as important in maintaining a scheme, when the focus can change to monitoring and improving quality, keeping up-to-date with policy support research and ongoing GP training and recruitment. Below is a list of suggested tasks for a SCMG. Those in italics were included in the existing DH guidance. Additional tasks that can be considered by a SCMG have been added to reflect the changes that have occurred since the guidance was issued. Each SCMG should clarify it's responsibilities locally with multi agency agreement. Additional tasks may be identified by local SCMG's that are not included in the list below:

Case study

The SCMG agreed the following process for ensuring good quality clinical care. Prescribing Analysis and Cost (PACT) data is collated each quarter for every surgery involved in the scheme. The shared care coordinator analyses the figures and visits each surgery involved in the scheme every six months to give feed back on how the surgery is performing compared to local and average statistics, and the evidence base. In the meeting good performance, and areas for improvement are identified and an action plan is formulated for improving quality in the future.

Carrying forward the decisions of the SCMG

The SCMG will make a number of recommendations and suggested tasks. A shared care coordinator will often carry forward the majority of the tasks identified by the SCMG. Where this post does not exist, it is important that people have time within their existing posts to carry out the development work and coordination of the shared care scheme.

Maintaining a strategic focus

It is important to have an effective chair (for many areas this is a GP who participates in the scheme) who will keep to the agenda, identify named people to take forward action points, and check that the agreed action has taken place. It is important the group remains strategic, that it has clear terms of reference, with recorded action points to support clear outcomes. Principally, it needs to avoid becoming a talking shop on operational issues.

Case Study

The SCMG met regularly but tended to discuss the same issues at each meeting (the need to recruit more GPs, and establish pharmacy guidelines) without any action taking place. The SCMG decided that although the attendees were committed to the scheme they did not have the time to carry forward the developments suggested at meetings. They put forward a proposal to the JCG for a shared care coordinator to be employed to carry out the developmental work and coordinate the scheme. The JCG agreed to the post, which was match funded by the DAT and the PCT.

Who should attend?

It is important for the SCMG to receive input from all stakeholders involved in the provision of primary care based treatment. The list below covers some of the people who ideally should be invited, or at least informed of the group's work (for example by sending minutes of meetings). Local differences in post, title and service provision will that mean that additional people may be added to this list. Service users and local practitioners from each relevant profession should be involved as they will provide essential feedback as to how the scheme is functioning. It is also important to involve local clinical leads to advise on quality and safety in clinical practice, and managerial and strategic leads to offer advice regarding local service provision.

*N.B consideration should be given to providing locum payments to self-employed members e.g. GPs, Pharmacists.

How often should the SCMG meet?

The frequency of meetings will be decided locally, but it is common for a well-established group to meet at quarterly intervals. Many areas will chose to meet at more regular intervals because of local need or where a scheme is being set up and/or going through a period of development.

Conclusion

For a SCMG to work effectively it is important that it clearly identifies it's strategic roles, responsibilities and has the right membership and effective chairing. Due to shared care's contribution in both quantity and quality of service provision in the delivery of drug treatment, SMMGP reiterates DH's guidance that SCMG's should be established in all areas, and that the group is given adequate time and resources to carry out it's responsibilities.

- Kate Halliday, SMMGP Advisor

See article in Network Issue 12: Shared Care Coordination - How to Make Shared Care Schemes Work

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Methadone & Driving

Where the GP's responsibility lies in terms of patients on methadone who drive continues to concern many… for clarity look no further than the Methadone Guidance*

Applicants or drivers complying fully with a supervised oral methadone maintenance programme may be licensed, subject to favourable assessment and normally an annual medical review (DVLA, 2004). However, patients will be subject to revocation of their licence for a minimum 12 month period where it can be shown that there has been persistent use of, or dependency on, heroin; morphine; methadone and/or cocaine**. Once the 12 month period is completed the applicant will be assessed as to whether they can be licensed whilst on a methadone maintenance programme.

It is the patient's responsibility to inform the DVLA, and it is the doctor's responsibility to inform the patient of this. It is important to record that this advice has been given to the patient.

The DVLA and GMC also state that if doctors are aware that patients continue to drive in a dangerous way, then they should first press such patients more forcibly not to drive. If the patient continues to drive, doctors (at their discretion) should break confidentiality, inform DVLA and inform the patient that they are doing so. This is a very difficult area of practice. Doctors may not want to endanger the relationship with patients, but it would certainly be both tragic, as well as highly problematic, for any doctor, if patients hurt or kill people while driving in a manner already known to be unsafe.

More information is available on the DVLA website.

*Excerpt from Guidance for the use of methadone for the treatment of opioid dependence in primary care. RCGP Substance Misuse Unit, RCGP Sex, Drugs and HIV Task Group, SMMGP, The Alliance, 1st Edition 2005
(See the full guidance in the Guidance Documents section)

[**Ed. This may mean that people need to discontinue driving when they first come into treatment]

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Safer Management of Controlled Drugs: Early Action

A much-needed DH update on legislation and developments in the management of controlled drugs post Shipman.

Introduction and Background

The Shipman Inquiry was set up on 31 January 2001 and was chaired by Lady Justice Janet Smith DBE as an independent public inquiry into the issues arising from the case of Harold Shipman. The Inquiry's Fourth Report was published on 14th July 2004. It focuses on the methods used by Harold Shipman to divert large quantities of potentially lethal controlled drugs and the reasons it was possible for him to do so for so long without detection.

The Shipman Inquiry concluded that there were serious shortcomings in current systems, and made a number of recommendations to strengthen the prescribing of controlled drugs and the ability to monitor their movement from prescriber to dispenser to patient (the "audit trail").

The government's response was published in December 2004 as Safer management of controlled drugs. The response accepts the case for some strengthening of current systems provided this can be done in a way that does not impede appropriate use of controlled drugs to meet patient needs. A comprehensive action programme to address the recommendations of the report is set out in the final chapter of the response.

Action so far

Some early changes in the legislation governing controlled drugs have now been implemented by amendments to the Misuse of Drugs Regulations. The principal changes are to allow:

The changes came into force on 14 November 2005. You can access full details and a copy of Statutory Instrument 2005 No 2864 by clicking on the link www.circulars.homeoffice.gov.uk and is numbered HOC 48/2005.

Action planned for 1 April 2006

A number of further changes will be introduced, subject to Parliamentary approval where required, on 1 April 2006. In some cases the changes will be affected through professional guidance and in others through further amendment to the Misuse of Drugs Regulations. The key changes are:

Health Bill - Controlled drugs

The Health Bill, currently before Parliament, contains a series of clauses intended to strengthen the monitoring and inspection of controlled drugs in health and social care settings.

The key elements of the provisions are:

- Reprinted with kind permission of DH

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Integrated Care & Partnership Working - Getting it Right

A multidisciplinary team tackles the importance of integrated care and partnership working with some practical highlighting of joint working between the criminal justice, local specialist and GP services.

Introduction

The current government's public service reform agenda seeks to change the way in which government policies are delivered by encouraging local partnerships and innovation. New forms of resource allocation (e.g. Action Zones) and performance evaluation (e.g. Best Value) are emerging to allow such initiatives to develop, at the same time, providing assurances that public resources are being employed effectively. In the drugs field, we often need to work across agencies. Getting it right can improve treatment for drug users but how can we do this and what are the main obstacles?

What do we mean by integrated care and what is partnership working?

A variety of terms have been used to describe integrated working within the drugs field ranging from the Home Office definition of partnership work in 1992:

Partnership working case study

Michael aged 29 years came to treatment through the criminal justice system in Brent. He had a long history of heroin and cocaine problems and had never really engaged with treatment. He had been allocated a Drug Treatment Testing Order (DTTO) after appearing in court for credit card fraud. The DTTO support and group work ran from the Addaction Tier 2/3 services and a local GP was asked to help Michael with his mental health issues and for prescribing for his drug problems. The GP diagnosed depression with anxiety, commenced Cognitive Behavioural Therapy with the practice drug counsellor, prescribed antidepressants and titrated methadone to 120mg for his opiate dependence. He gained additional support from the compulsory DTTO group attendance together with keyworking around his crack problems. The regular good personal communication between the local GP, the counsellor, the DTTO worker and the keyworker at the Tier 2/3 service, placed Michael clearly at the centre of well coordinated, appropriate and effective care.

Therefore, despite its various guises, partnership working can ultimately be seen as a multi-agency collaboration at both strategic and operational levels which has patients and service users' needs as its unifying concern and delivers a coordinated range of services in a variety of settings in order to address those needs.

Who benefits from partnership working?

Working together with other organisations can bring considerable benefits to services, their users and the wider community. How so? By working in unison with other agencies, drug services will enjoy the potential to develop work that may not be possible for a single agency to undertake. For example, to offer crack specific harm reduction, needle exchange and advice on benefits to GPs or counselling services offering Cognitive Behavioural Therapy. Joint working fully utilises available skills by using staff from different organisations, breaking down barriers to develop a better understanding of other services' skills and priorities, and enabling better communication between services.

There are also significant benefits to be reaped from engaging a community in genuine partnership. These benefits result in better-tailored services, and can assist in the development of the skills and capacity of the community as a whole. Services will be more able to target the community's needs through a comprehensive approach to the planning, commissioning and delivery of services, as well as promoting community involvement in the planning and delivery of services.

What factors can hinder partnership working?

Partnership working calls for effective management, governance, performance management, democratic control and accountability. However, a number of difficulties can become apparent when organisations work in partnership across the health, social care and criminal justice sectors. Inherent tensions include:

Conclusion

Partnership working and integrated care are essential if drug services and other agencies are to ensure that they are providing coordinated care for service users. Although difficulties may occur, it is imperative that we work together to overcome them. All agencies involved need to clearly assign roles and responsibilities, developing protocols for information sharing, developing agreed performance targets and ensuring clear funding arrangements. Partnership is achieved when all of the individuals involved listen, share and respect each other's opinions, knowledge and mutual differences all with the patient clearly at the centre.

- Michelle Williams, Community Crack Link Worker;
- Michael Lawson, Team Leader;
- Eyal Remon, DTTO Practitioner, Addaction Brent;
- Chris Ford, GP Brent.

References

1. Home Office (1992) Partnership working in dealing with offenders in the community. London: Home Office.

2. Department of Health (1995) Reviewed shared care arrangements for drug misusers: executive letter: EL (95) 114. London: Department of Health.

3. Effective Interventions Unit (2002) Integrated care for drug users: principles and practice. Edinburgh: Scottish Executive.

4. National Treatment Agency (2002) Models of care for treatment of adult drug misusers: part 2. London: NTA.

5. National Treatment Agency (2005) Working in Partnership. London: NTA.

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Dr Fixit on Joint Working

Dr Fixit on Joint Working

Question

Roy aged 31 years, has just presented to me for help with his drug problem. He has been registered at the practice for a long time but has not sought help before for his drug problem. He tells me that he is using 1/2 gram of heroin by injection daily, but also crack and alcohol. He is drinking at least 75 units/week and this increases after he uses crack, which he does at least 3 times/week.

Because of his drug problem he has rowed with his parents and they have thrown him out of the house and he is now homeless and sleeping in various friends, also users, houses. He was also arrested a few weeks ago and the case comes to court in a couple of week's time. His solicitor has told him he will probably get a DTTO.

I am confident about substitute prescribing but I really need help with his crack and alcohol problems, as well as his housing and legal problems. What do you suggest? Where can I get this additional help?

Answer

Your question raises many important issues and is particularly relevant because the government and NTA now have multidisciplinary working high on their agendas. It can also be used to demonstrate how good integrated care pathways can work effectively. Good shared care is to do with coordination, cooperation and communication and all play a part if a vulnerable patient such as Roy is to benefit.

Roy is about to become involved in many agencies, all intending to help him. Hopefully he will be able to make the most of the help available and use it to motivate himself to make lasting changes in his life. However if the care is not good he may feel lost in the workings of the different agencies and become disillusioned. You say that you are confident in his substitute prescribing and you seem aware of the limitations of your knowledge and your role as his GP; this is an excellent basis for the establishment of good shared care. As his GP you will have a pivotal part in making sure all his difficulties are being dealt with but you will also need to let other agencies give the care that they are good at and you are unable to help with. In prescribing you should also be aware of the need to start safely and to titrate him at a rate which is quick enough to retain him with you but that is still safe.

Getting his heroin use under control will enable you to build a good relationship in which he will have trust and confidence and this can be a mainstay for him when sorting his other issues out, so take care not to underestimate its importance. You should advise him about BBVs and all the issues around his injecting career.

There are many agencies that can become involved with Roy. I would hope that you have a Drug Service Unit that you can refer him to and that they are part of a shared care scheme. Some DSUs will do the initial titrating for you. You will find that you will be involved with a mixture of:

  1. Partnership work between the criminal justice system and health care.
  2. Joint working between the various drug related services, statutory and non statutory, so as to obtain a hopefully seamless care package.
  3. Shared care which will link key workers, pharmacists yourself in primary care and secondary care and maybe a GPwSI if you have one.
  4. Integrated care which will try to combine all of these. It is important that you work in the area that you feel confident with and allow those others to help you in their speciality.

So you may need to refer Roy to the specific alcohol service and ask the specialist DSU where the best place for him to get help with his crack use is. Referring him to these places does not mean you don't need to understand the problems. As his GP you will need to know about them because there may be medical issues that occur. There is excellent guidance on Crack produced by the RCGP (Ref 1). He may be involved with the Drug Interventions Program as he was arrested and they will have knowledge and connections with housing and street/homeless services, probation and social services. Getting to know your pharmacists is also very useful. I think that it would also help you if you made contact with the various services in your area and even visited them - time consuming but well worth the investment.

- Answer by Dr Stephen Pick

Reference:

1. RCGP Drug and Alcohol Misuse Training Programme, RCGP Sex, Drugs and HIV Task Group, SMMGP (2004), RCGP Guidance for Working with Cocaine and Crack Users in Primary Care

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Dr Fixit on Coming Off Supervised Consumption

Dr Fixit on Coming Off Supervised Consumption

Question

Sally, a 26 years old patient of mine is doing well on methadone maintenance. She lives with her partner, who also uses drugs and their two children 3 months and 3yrs. She came back into treatment during the last pregnancy having relapsed about a year before that. She tried reducing in the latter stages of pregnancy but struggled to not use heroin on top so she eventually stabilised 3 weeks post delivery on 120mg.

She has been on supervised consumption for this whole treatment episode of 5 months and has been stable with no other drugs in her urine for just over 2 months. Previously the urines had showed some cocaine and cannabis use. The baby is well, as is the older child and they are both well cared for. Unfortunately her partner has declined treatment.

She has requested to come off supervised consumption as it is getting increasingly difficult to manage the children and have her methadone supervised. She has also found previously that it helps her if she splits her dose.

What issues should I consider before responding to her request?

Answer

You have done an excellent job, in engaging this young mother and helping her to stabilise on an optimal dose for her methadone maintenance, despite her previous poly drug use, the difficulties of the postnatal period and the obvious triggers which must be offered by a partner who is using and is not yet in treatment. After only two months avoidance of street drugs she will realise that she has a high risk of relapse and is likely to need your continued support.

The DH Clinical Guidelines 1999 (Ref 1), and indeed the Guidance for the use of Methadone in Primary Care" (Ref 2) suggest that methadone should be supervised for the first three months of a new episode of treatment. However both suggest that exceptions may be made and employment, child care or travel difficulties should be taken into consideration, so there is no doubt that you will be well within guidelines and would have peer group support if you decide to prescribe daily take home methadone for Sally at this stage. Indeed I would probably have considered this step earlier in the postnatal period.

However, before this is done, there are two main areas of danger which Sally would need to consider. The most important is the danger of accidental ingestion by young children where methadone is stored in the home. In Dublin it was found that 25% of households stored or measured methadone in unsuitable household containers, such as babies' bottles (I can see they would appear enticing, with their handy volume markings) (Ref 3). In a different audit of 160 patients it was found that the vast majority of patients did not store their methadone in a locked or secure location (Ref 4).

The other area of uncertainty is the partner you suggest has declined treatment. If Sally has stored methadone at home, how will she avoid the pleas of her partner, on days of heroin famine? I would suggest that if Sally feels it would be helpful, she should certainly now stop having supervised consumption, but remain on daily dispensing, which will be another step towards regaining her self esteem and control in her life, but first she should acquire a locked container or cupboard as she is intending to split her daily dose and has young children in the house.

[Ed. Some patients perceive a benefit from split dosing, but with the long half-life of methadone the pharmacological rationale is unclear] Then concerted efforts should be made to understand and if possible to overcome her partner's reluctance to come into treatment, in order to reduce his effect as a trigger for Sally, and to enable the couple's available time, attention and money to be directed towards their children.

If he is to continue to be part of the family group, then his engagement in treatment would be vital for the continued well being of Sally and the children, so a bit of an effort to use the offer of take home doses for Sally as a bribe to encourage him in, might be thought worth a try. However I would offer this only as a suggestion to Sally, who would be the best judge of the likely therapeutic effectiveness of the move. She might be grateful for a lever to entice him in to see you, but her own excellent progress would justify a move to daily take home doses, and her successful treatment cannot become dependant on his.

- Answer by Dr Judith Yates, GP

References:

1. Department of Health: Drug Misuse and Dependence - Guidelines on Clinical Management. 1999 (See the Clinical Guidelines section)

2. Guidance for the use of Methadone for the treatment of opiod dependence in Primary Care (Ford C et al, RCGP 2005) (See the full guidance in the Guidance Documents section)

3. Harkin K, Quinn C, Bradley F: Storing methadone in babies bottles puts young children at risk. BMJ 1999 318:329-330

4. Bloor R, McAuley R, Smalldridge N: Safe storage of methadone in the home - an audit of the effectiveness of safety information giving. Harm Reduction Journal 2005 2:9

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The Impact of 'Respect' on Substance Misusers

The Impact of Respect on Substance Misusers

The Governments Respect agenda covering a raft of antisocial behaviour measures, whilst attempting to tackle offending can also impact support to some of the most vulnerable affected by drug and alcohol problems, as highlighted in London.

"Rachel Hassan from WDP says it's important to remember users are part of the community while Victor Adebowale called the Respect Action Plan 'a mistake.'"

Frontline workers are concerned at the impact of the Government's Respect Agenda on drug and alcohol users. Services working with substance misusers say the increasing use of antisocial behaviour initiatives does not solve drug and alcohol-related problems and impacts disproportionately on those who are most vulnerable. Turning Point chief executive Victor Adebowale called the Respect Action Plan launched earlier this year a "mistake" that "smacks of a quick fix solution to very serious and significant social problems".

A raft of antisocial behaviour measures affect drug and alcohol misusers including ASBOs, Acceptable Behaviour Contracts, Controlled Drinking Zones, on-the-spot fines, Dispersal Orders and crack house closures. Some specific concerns expressed by frontline workers interviewed by LDAN News were:

Rachel Hassan, from the Christopher Project, a community development initiative run by Westminster Drugs Project, says partnership working is proving effective in the borough but adds it is important to remember both sides of the debate when discussing antisocial behaviour. "The mentality 'let's get rid of these people from the community, let's move them on' forgets that these people are part of the community so we need to be talking about the support they need at the same time as dispersal zones". She adds that some of those most affected by drug misuse - users' families and carers - are usually absent from the debate because they are isolated and can lack support.

Article reprinted with kind permission of LDAN News, the monthly publication of the London Drug & Alcohol Network - a membership network for drug and alcohol agencies across London. Registered Charity number 1089549.

Contact Roseanne Sweeney about articles, ad rates or to subscribe free to the e-newsletter:
E-mail: roseanne.sweeney@ldan.org.uk
Web: www.ldan.org.uk
Tel: (020) 7704 0004
Fax: (020) 73569 1317

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A Time of Change - A Big Thanks to Our GP Leads

We would like to thank Clare Gerada who has recently handed over leadership of the RCGP Substance Misuse Unit, for her enormous energy, vision and resolve in helping lead the development of primary care in this field, and her contributions to both the SMU and SMMGP networks. We would also like to warmly welcome Linda Harris who is now standing in as the SMU Lead.

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Prescribing News

Handwriting Exemptions No Longer Required

As from the 14th November 2005 doctors no longer need to obtain a handwriting exemption from the Home office. Regulation 15 Misuse of Drugs Regulations 2001 has been amended to enable prescriptions to be written in any form, with only the signature necessarily being handwritten. The date may now be electronically produced.

Instalment dispensing - prescription wording to cover missed pick ups

As reported in the Pharmaceutical Journal - The Home Office has recently confirmed that the following wording can be used by those prescribing Controlled Drugs by way of instalment in accordance with the Misuse of Drugs Regulations 2001 ("Regulations"), as amended. This text is in addition to the usual Controlled Drug prescription requirements (words and figures, etc.). The text reads: "Instalment prescriptions covering more than one day should be collected on the specified day; if this collection is missed the remainder of the instalment (i.e. the instalment less the amount prescribed for the day(s) missed) may be supplied." Use of this wording will enable those supplying Controlled Drugs to issue the remainder of the instalment prescription where a person fails to collect the instalment on the specified day. If a prescription does not reflect such wording, the Regulations only permit the supply to be in accordance with the prescriber's instalment direction.

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RCGP News

The RCGP Part 1 Certificate in the Management of Drug Misuse is to be managed by the RCGP SMU from April, now that the development phase undertaken by SMMGP is complete. We would like to thank the SMU for their close partnership working on the project and thank Dr Jenny Keen for her extraordinary contribution and dedication as Clinical Lead for the Part 1. Important thanks to Chris Ford for developing the Part 1 proposal and championing it's ongoing development. (Part 1 Clinical Lead for RCGP Certificate in the Management of Drug Misuse sought - see Bulletin Board).

A time of change no doubt, as we also need to thank Nat Wright for all his solid support as NTA GP Clinical Lead and welcome Susi Harris into post - the quality and scope of GP leadership available no doubt testament in some way to the effectiveness of the GP development networks.

Want to attend a Part 1 RCGP Certificate in the Management of Drug Misuse?

The Part One consists of two e-learning modules and one face-to-face training day aimed at primary care health providers wishing to develop their skills and expertise from generalist through to Intermediate level.

Upcoming national events:

Contact tinkelaar@rcgp.org.uk
Tel: (0207) 173 6093

Upcoming local events that are willing to take other GPs on are

Contact Mark Birtwistle
E-mail: mark.birtwistle@bstmht.nhs.uk
Tel: (0161) 772 3546

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Bulletin Board

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Network Production

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SMMGP NEWSLETTER IS SPONSORED BY SCHERING-PLOUGH LTD
SMMGP works in partnership with The Royal College of General Practitioners; Bolton, Salford & Trafford NHS Trust; Trafford Substance Misuse Services; and the National Treatment Agency for Substance Misuse.
Network ISSN 1476-6302.