Network No 21 (February 2008)
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John Richmond gives a personal perspective on the process of recommissioning of drugs services in his area.
Vanessa Crawford reviews what is known about dual diagnosis from available research and policy. She concludes that a multi-agency approach is essential when working with people who are both using drugs, and have mental health problems.
Gary Slapper describes the complexities of the legislature regarding drugs, and gives an interesting historical analysis of cannabis and the law.
Jim Barnard gives us a history of the treatment of drug users in primary care. He describes how the pioneering spirit of a group of doctors in the nineties has contributed to the enormous development of drug treatment provided by GPs over the past two decades.
Dr Prun Bijral and Kate Hall discuss the role of the in-patient unit as a valuable component of tier 4 provision. They challenge the idea that individuals need to move through the tiers in a chronological order to access in-patient services, and suggest that in-patient units can offer more than just detox.
Hidden Harm is often referred to as an influential report, but has practice improved regarding reducing the potential harm of parental substance misuse on the children of substance users? David Best, Saffron Homayoun, and John Witton discuss the findings of their survey of drug treatment services.
Hugh Campbell offers advice to a GP who wants to provide the best treatment for a patient who is being treated for drug use with dihydrocodeine and is experiencing problems with his mental health.
Andy Lane replies to a GP who is treating a patient for both their drug use and their alcohol problem
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It is important to remember how much providers' approach towards service users effects the outcomes of treatment, and this is rarely communicated more clearly than in Sharyn Smile's article "High walls and no entry signs". She highlights the need for services to continually ask whether they are accessible, approachable, and provide for the full range of needs that drug users have.
The NICE guideline on opioid detoxification continues to cause debate in the field, and in this edition Dr Prun Bijral and Kate Hall discuss the role that in-patient treatment can play within the treatment system, offering an alternative view to that of James Bell's in the previous edition of Network. In particular they emphasise the importance of preparation and aftercare as key to successful treatment outcomes.
On the centre pages Jim Barnard gives a historical tour of drug treatment in primary care, and even gives Network a plug! An uplifting trip down memory lane, bringing us up to the present day.
The RCGP conference "Meeting the needs of diverse populations: hard to reach or easy to ignore?" is in Brighton on 24th and 25th April 2008. This year's conference promises to be exciting and interesting, asking how services can meet the needs of those who may find it difficult to access treatment, for example homeless people, people from Black and Minority Ethnic communities, stimulant users, steroid users and sex workers. As always we will also have a range "bread and butter" workshops for those who are new to the field. You can find full details on our web site. Don't miss it!
When I think of a barrier, I think high walls and "no entry" signs. So when drug users are asked about "barriers" what do they think of? Probably the same as me. When you ask a drug user "What stops you going for help? What are the problems getting treatment? Why don't you like picking up your script?", then we start to get a sense of what the real barriers are.
Where do I start? Being a former drug user myself I remember the reasons I didn't want to attend that notorious 9am appointment. It wasn't because I was "non compliant", "untreatable" or "incapable of change", which is how I had been described on numerous occasions! It was more to do with spending days, months, years on the streets completely mentally and physically addicted to drugs and not having the facilities to clean myself up from whatever beating I had had the night before. Funnily enough, I found attending drug treatment humiliating enough without having to sit in an unfriendly, back alley waiting room for an hour with workers and other users complaining about the smell - and besides that did I really want to give up my best friend? After all it was all I had, all I lived for, that next hit, the only way out of reality.
I spend my days now talking to drug users, researching drug use and highlighting the issues facing users. Over the last three years I have formally interviewed around 2500 drug users in the North East of England, looking at anything from treatment effectiveness and service redesign to the implementation of the Treatment Outcomes Profile (TOP) and exploring issues facing those involved in the hidden sex industry. There is no doubt that drug services have run marathons to get better since I accessed treatment, so how has treatment changed? And how can we improve things further?
It's bad enough being addicted drugs, with every waking minute thinking about having that hit. Even when you're just about to have a hit your mind is racing, thinking about the next one. In reality, when was the last time you had a patient/client/drug user sitting in front of you saying "My life is absolutely fantastic, my only problem is my drug use"? Homelessness, family breakdowns, blood borne virus infection, domestic violence, physical and mental abuse, stigma, depression, child protection issues, sex work, exploitation, bullying, self harm, mental health issues, dual diagnosis, poly drug use, generally topped off with financial difficulties; when we start to scratch the surface these are often the issues drug users face.
Many of the drug users I come into contact with have major difficulties with housing. "I've been on the streets for two years now" is not an uncommon statement. I had the privilege of interviewing a 21 year-old female recently who told me "I can't get a house, I need to go on the waiting list". When I asked why didn't she go on the list she replied "I can't 'cause I cannot fill the forms in, they don't make sense". It emerged that the respondent couldn't read or write. Off we went to housing, got the forms, filled them in, popped them in the box and used my work address as a "Care Of"; time taken, 25 minutes, cost nil, and funnily enough she was re-housed last week. Now this lady had been accessing drug treatment for two years - why didn't drug services pick up on this? Probably because they didn't ask. I know every case isn't as simple as this, but isn't that extra few minutes worth it, to have such a massive impact on some ones life?
I'm sure we've all been into a clothes shop to purchase that shirt that you just have to have (or at least some of us have?). You ask one assistant for the item, who will simply say "No, not in stock" and carry on with their work. However, if you ask their colleague they will say "No sorry we haven't got it in that size, but I can order it for you, you can get it over the internet, we have it in a different colour, can I interest you in a store card?" Like any business, the attitude and perceived helpfulness of front line staff has a massive impact on customer satisfaction. "I hate going there they look down and you and make you feel worse than when you went in", "No wonder people lose it with them, it's their attitude and you can't say anything to them or I'll get kicked out", "All the receptionists talk about is their new handbags and holidays, your sitting there in a s**t hole rattling your ass off, it just makes you feel crap, when I get there all I want to do is get out". I can honestly say that some drug workers I know are the most miserable and unhelpful people I have ever met! A philosophy I hold close to my heart is happy staff, happier customers - after all, do any of us like spending time with miserable and unhelpful people?
Now, I haven't met many families of drug users who are absolutely delighted at the thought of their loved one being addicted to drugs. On the rare occasion I used to go home my mum and dad would run to hide money or anything of value. I could see the strain and worry etched into their faces. My dad, otherwise a healthy easy go lucky kind of guy, was diagnosed with angina apparently caused through stress. Family problems are a major issue for the vast majority of drug users," I avoid my family like the plague, it's not cause I don't love them it's just I don't want them to see me like this, they kick off cause I lie to them all the time, but I'm only trying to protect them". I believe drug services are in a strong position to help - how long does it take to give someone a number for the local carers" centre, to give advice or support or to inform them of that long awaited negative drug test? Not long, and the impact this can have on family relations is massive.
The stigma surrounding blood borne viruses is high not just within the general public, but also amongst drug users themselves. Only last week I was in a drug service which has "Joe is a scruffy c**t with Hep C" engraved into the wood of the reception desk. Now given that this drug service has posters advertising events from 2004, I hardly think removing this colourful addition to the reception desk is going to be high priority!
I was diagnosed with hepatitis C in prison. In fact, I was informed in front of a number of inmates and prison officers in a medication queue and released the day after. The only things I knew about hepatitis was what I'd heard from my drug using counterparts, "Your eyes go yellow and then you go blind", "Your liver rots away and you bleed to death internally", and "Your kidneys pack in and you have to have a bag to s**t in". Upon informing my parents of this I was swiftly given my own plate, knife and fork accompanied by plastic cups for my rare visits home, and to be fair who come blame them? Every time I turned up my mum would throw me in the shower and give me "hair and mane detangler" designed for horses just to get a brush through my hair!
It took two years of waiting for internal bleeding, to go blind, die or have a colostomy bag fitted before I came across a drug worker who gave me information on hep C and made a referral for treatment. Now, I have no doubt this drug worker has no idea how significant that ten minute conversation was, but it changed my life. I realised that I might have a future, that I could get better and that I could succeed. It is absolutely crucial that we get this right; misinformation and stigma is rife amongst the drug using population and drug workers alike. I have heard drug workers on more than one occasion put people off having treatment because "it's worse than the hep itself". I'm not trying to say a year of injecting myself with interferon and taking copious amounts of ribavirin every day was the best experience of my life - but it was worth it!
Drug use is not just about taking drugs, drug use is about a lifestyle, it's about a way of thinking, acting and doing. Someone doesn't wake up and think "Oh, I'm a bit bored today, I know, I'll become a heroin addict". This is something that happens over time and it's not going to change overnight. Drug treatment is not just a simple case of medical intervention, it is a case of "real life" treatment. We've got a handle on the big ones - a script within 3 weeks, numbers in treatment, retention etc, but can we effectively treat problematic drug use without addressing the wider issues? I think not. I am not suggesting that we turn into "all singing all dancing all things to all people", but if we are using effective care planning, then surely that extra little time for a smile, a pleasant hello, or making that all important call to the homeless unit is all worth it. Wouldn't you agree?
John Richmond gives a personal perspective on the process of recommissioning of drugs services in his area. He describes the unsettling effects that this process can have on practitioners as individuals, and on the service as a whole. However, he concludes that the newly commissioned service should provide a better service for drug users. Ed.
This article gives a personal view on how the service I provide has changed in the past year. It will give some insight into more general changes that are happening throughout the NHS, and highlight how the reform agenda impacts on us all as individuals.
I used to work as the lead clinician for drug services for a Primary Care Trust (PCT) that no longer exists. As the PCT was being restructured there was a parallel process of recommissioning occurring in the drug service led by the Drug Action Team (DAT). I will discuss the PCT change first.
Unusually, our Mental Health Directorate was housed within the PCT so that there was a great deal of uncertainty as to where the new drug service would lie politically and geographically. The decision was made that the Mental Health Directorate would come out of the PCT and join a local Mental Health Trust. The final decision as to where we were going to go was uncertain until days before the change. I visited a number of people at this time to suggest that it would be sensible to take drug services out of the Mental Health Directorate and set them up as a community based directorate of the new PCT. This structure would have suited my agenda as a General Practitioner with Special Interest and I think was more appropriate for the patient population that we were seeing. However, this remained an academic argument as the bottom line was that no one had the time to devote any thinking space to this idea as there was just so much else going on. I understood this but it had major repercussions for my life, as I will explain.
The second part of the change was the recommissioning process that was occurring led by the DAT. The Young People's Service had already gone out to tender and had been won by a charitable organisation who had approached myself and a colleague to provide clinical input around training of staff and prescribing. The next recommissioning was the Criminal Justice part of the treatment portfolio.
Before I go any further I should first explain my position in, and relationship with, the new organisation that I had been absorbed into, the Mental Health Trust. This organisation had approached me in the past as to ask whether I would be interested in becoming the lead clinician for their Community Drug Team. Several meetings followed this, and it seemed likely that they would employ me. However there then followed a prolonged delay during which time I was left in limbo not knowing where my life would be heading. Eventually, the Mental Health Trust offered me a locum position until things could be sorted out.
I was not prepared to leave the secure job I had at the time (with the now disbanded PCT) for a locum position and declined this offer. Therefore I experienced some trepidation about being absorbed into the Mental Health Trust, as I was now working for an organisation that I felt had mismanaged my employment in the past. I also felt that their agenda was as much a psychiatric led drug service as mine was a primary care led drug service, and as a result I expected a clash in approach.
I hope that sets the scene for the criminal justice bid that was happening during and after the period of uncertainty regarding who my employer was going to be. Throughout the bidding process my colleague and I had indicated that we would be prepared to look at providing a prescribing service that would work along side any prospective winner of the contract. We were under the impression that the then current provider (the Mental Health Trust I ended up being absorbed into) thought they would be very likely to win the contract again and were not too concerned, whereas we thought that they would have to work quite hard to keep it in the face of the strength of the various other organisations bidding, both statutory and charitable. In the event they were not even short-listed.
That was it for me - the writing was on the wall. Shortly thereafter the charitable organisation we had done the young persons work with became the preferred provider and I handed in my notice ready to start work in earnest on preparing to provide the prescribing element of the contract. Then my colleague handed in his notice, and the game was on.
However, this was not the end of the story and the worry had only just begun...
I have learnt that "preferred provider" does not mean the deal is done. It just means the cards are dealt. The contract based on the service specification was still to be put together, reviewed by solicitors and signed. There was a long drawn out process of discussion over the exact meaning and interpretation of the TUPE (Transfer of Undertakings [Protection of Employment]) arrangements for staff transfer to the new service. This meant that there was extreme uncertainty for those members of staff regarding their future and their family finances. There was also a tendency for stagnation within the current provider in the development of their service as it was unclear as to what was going to be left once the process was all over.
We were due to start at the beginning of April 2007 but during March further problems made it clear that this was unrealistic and the start date was delayed by a month. It felt like a very nervous time for everyone and although the contract was signed at the beginning of May there was still a great deal of doubt as to whether there might be some other challenge to the process that would see it all crumbling away from beneath us. Personally, I felt unable to commit to any other work offers and saw my personal finances eroding away as the months went by creating the real possibility of having to start afresh in another line of work. To make things worse we had to invest in office space, computer hardware and software, an office manager etc.
Eventually, four days before the start day we had a meeting to discuss patient transfer! There had been countless meetings in preparation for this day where multiple tasks had been handed out to a variety of people who had plenty of other work to do without any guarantee that it would be worth the effort. We had done as much as we could despite this uncertainty but when it came to "D-day" there were a number of loose ends, not least of which was transfer of patient information. I will not bore you with the details of this but suffice to say that it was not a smooth process and the first few weeks of our service running was a very tense time. We did not have a clear list of who was being transferred to the new service but we did have two weeks "grace" of scripts to tide us over whilst we found this out.
I could say a lot more but hope that I have given an overview of the process from a personal perspective. Things seem to have settled down and we are hopeful of making a positive impact on the delivery of treatment to patients. It would be interesting to get the viewpoints of other parties, as I am sure these perspectives might make the process look very different. However, one thing I am sure of is that everyone to a greater or lesser degree would have felt very unsettled by the whole process. This is part of a culture change within the NHS that has been a long time coming and even though I have been prepared for it to a greater degree than most (given the GP perspective), this does not lessen the impact on real peoples lives. One has to ask what further impact this uncertainty can have had on the patients we are supposed to be helping? Hopefully, but rather sinisterly having just read the seventh Harry Potter, it will be for "the greater good".
Vanessa Crawford reviews what is known about dual diagnosis from available research and policy. She concludes that a multi-agency approach is essential when working with people who are both using drugs, and have mental health problems. For advice regarding the treatment of dual diagnosis see Hugh Campbell's reply, Dr Fixit. Ed.
What are the issues?
Dual diagnosis as a term is a simplistic description of a complex concept. The definition can be as wide or as narrow as you choose in mental health services. However, to be exclusive is to ignore the diversity involved in dual diagnosis. Primary care cannot pick and choose its patients. Treatment needs to be individualised, the risk shared across service providers, and complex cases should have multi-agency input, including case conferences. Good communication and joint working are essential.
When reviewing eleven years of policy and research (Ref 1) the issues that arose in trying to draw conclusions and critique the literature were as follows:
- Definitions differ in different research papers.
- Study settings differ, as do interventions that cannot be compared.
- Dual diagnosis is a secondary question in a larger study.
- The changing prevalence of drug use over the years means the research is rapidly out of date.
The number of potential interrelationships between drug use and mental health issues depends on whether you look at "misuse" or "dependence", and "symptoms" or "disorder". The following list outlines the possible relationships between the substance misuse and mental health issues:
- One precipitates the other
- One causes the symptoms
- One causes the disorder
- Both run in parallel
The Epidemiological Catchment Area (ECA) was an extensive US adult population study (Ref 2) which found that 47% of those with schizophrenia and 57% of those with bipolar disorder have a lifetime diagnosis of substance abuse or dependence. Findings suggested that people with bipolar disorder have a tendency to choose drugs that intensify the high when manic, hence adding to the problems associated with mania.
The National Treatment Outcome Research Study (NTORS) (Ref 3) researched 1075 adults in drug treatment services in the UK, 90% of whom were opiate dependent. The study found that the greater the number of drugs used, the greater the psychiatric symptomatology.
The Office for Population Census & Survey (Ref 4) surveyed 10,000 households, 750 institutions and 1060 homeless people. The homeless sample reported increased levels of drug use and mental illness when compared to other categories, suggesting high comorbidity in the homeless population.
The census also indicates that consumption of drugs was particularly high among adults with phobic disorder, panic disorder and depression.
|The Office for Population Census & Survey 2001|
|Drug Use "ever"|
|5%||household (2% dependent)|
Another significant article looks at suicide by prisoners (Ref 5). This two-year study looked at 172 suicides. Of the sample, 49% were on remand, 32% committed suicide within seven days of incarceration, and 72% had a history of mental disorder (of which 27% was recorded as drug dependence).
Mental Health Policy Implementation Guide
Dual Diagnosis Good Practice Guide
"Substance misuse is already part of mainstream mental health services and this is the right place for skills and services to be"
Professor Louis Appleby (Ref 6)This guidance acknowledges the need for local definitions of dual diagnosis across statutory and non-statutory sectors, depending on the population profile. Essentially it states that all staff working in mental health services should be trained to work with dual diagnosis. It is clear that all service users with substance misuse and severe mental health problems should be subject to the care programme approach (CPA) and should have a full risk assessment. It gives a figure of substance misuse affecting 33-50% of people with severe and enduring mental illness, with alcohol misuse being more common than drug misuse.
This guidance highlights the fact that that 10% of male remand prisoners have moderate drug dependency, and 40% have severe dependency. Of those who are drug dependent, 79% have two or more additional mental disorders. The guide identifies that having comorbidity, as compared to a single diagnosis, is particularly detrimental for the following issues:
- Worsening psychiatric symptoms.
- Increased use of institutional services.
- Poor medication adherence.
- Increased homelessness.
- Increasing risk of viral infection.
- Poor social outcomes.
- Increased contact with the criminal justice system.
- Increased violence and suicidal behaviour.
- Increased occurrence of homicides committed by people with a mental illness - substance misuse features in over 50%.
The guidance suggests that assessment of people with dual diagnosis should include:
- Assessment of carer involvement and need.
- Assessment of knowledge of harm minimisation in relation to substance misuse.
- Assessment of treatment history.
- Determination of the individual's expectation of treatment and their degree of motivation for change.
- The need for pharmacotherapy for substance misuse.
- Notification to the National Drug Treatment Monitoring System.
- A risk assessment.
Treatments should be staged according to the individual's readiness for change and engagement and should:
- Adopt a harm reduction approach.
- Be optimistic and have a longitudinal perspective.
- Be flexible and have an adaptive therapeutic response.
- Pay attention to social networks of clients, meaningful daytime activity and to sound pharmacological management.
- Have an integrated care approach as this appears to confer superior outcomes over serial or parallel treatment.
In an eleven-year review of the literature from 1990-2001 (Ref 1) the following themes emerged:
Patients who appear to be difficult and have no insight into reasons for changing their substance use may have neurocognitive impairment. Confirmed impairment in an individual may lead to a change in staff attitudes towards what may previously have been viewed as bad behaviour.
Substance misuse amongst dual diagnosis patients is rarely limited to one substance and there are links between the use of substances and mental health issues:
- Early onset nicotine use is linked to depression and alcohol use.
- Smoking before the age of thirteenyears- old is linked with an increased risk of drug dependence.
- Anxiety symptoms are common with cannabis use.
- Opiate users demonstrate a significant correlation between the number of lifetime drug dependence diagnoses and the number of comorbid psychiatric diagnoses.
There is no correlation between psychiatric status at start of treatment and treatment retention in cocaine users.
Specific Comorbid Psychiatric Conditions
- Bipolar affective disorder (BPAD) has the greatest risk of any Axis 1 disorder for comorbid substance misuse.
- There is earlier onset and worse course of illness in those with BPAD and a drug or alcohol disorder than those with BPAD alone.
- Those with schizophrenia are three times more likely than those without to abuse alcohol and six times more likely to abuse drugs.
- Those with schizophrenia who use cannabis have significantly higher rates of re-hospitalisation and poorer psychosocial functioning than those who do not.
- Diagnosis of personality disorder does not necessarily predict poor treatment outcome.
- Pre-existing post traumatic stress disorder increases the risk of subsequent alcohol and drug abuse and dependence.
- A history of traumatic events should be addressed during treatment for substance misuse to enable recovery.
- There is a relationship between violence risk and psychotic symptom severity.
- Drug misuse is over-represented in people who commit suicide. In 2177 suicides by psychiatric patients, 566 (26%) had a known history of drug misuse.
In summary, dual diagnosis is a simplistic description of a complex, heterogeneous population. There is no simple solution but excellent communication and interagency working can optimise the outcome.
1. Crawford, V., Crome, I. and Clancy, C. (2003). Coexisting Problems of Mental Health and Substance Misuse (Dual Diagnosis): a literature review. Drugs: Education, prevention and policy, Vol 10, May, Supplement, S1-S74.
2. U.S. Dept. of Health and Human Services, National Institute of Mental Health (1980-1985). Epidemiologic Catchment Area Study.
3. Marsden, J., Gossop, M., Stewart, D. Et al (2000). Psychiatric symptoms among clients seeking treatment for drug dependence. Intake data from the National treatment Outcome Research Study. British Journal of Psychiatry, 176, 285-9.
4. Farrell, M., Howes, S., Taylor, C. et al. (1998) Substance misuse and psychiatric comorbidity: an overview of the OPCS national psychiatric comorbidity survey. Addictive Behaviours, 23, 909-18.
5. Shaw, J., Baker, D., Hunt, I.M. et al (2004), Suicide by Prisoners, National Clinical Survey. British Journal of Psychiatry, 184, 263-267.
6. Mental health policy implementation guide (2002) Dual Diagnosis Good Practice Guide Department of Health
Useful web sites
Gary Slapper describes the complexities of the legislature regarding drugs, and gives an interesting historical analysis of cannabis and the law. Ed.
If a-Methylphenethylhydroxylamine is one of the simplest drugs among hundreds listed on the pages of your text, then you'll either be reading a pharmacology text book or the schedules to the Misuse of Drugs Act 1971. The legal classification of drugs is an exceptionally detailed business. There are now over 250 proscribed (prohibited) drugs.
The law on cannabis is rather chaotic. There is a strong case for it being clarified and for whatever status is chosen, for the drug to be clearly explained to the public with strong supporting scientific evidence. At the moment there seems to be much confusion. According to a Home Office British Crime Survey published in October 2007, 2.6 million people between the ages of 16 and 59 used cannabis in the last year.
Earlier this year, in August 2007, the Prime Minister asked the Advisory Council on the Misuse of Drugs (ACMD) to reconsider the decision in 2004 to downgrade cannabis from a class B to a class C drug. This reconsideration is in the light of evidence that some current strains of cannabis can cause mental illness in some users. In November 2007, senior police officers called for cannabis to be reclassified from a class C to a class B drug. Three years ago the Association of Chief Police Officers (ACPO) supported the drug being downgraded but now wants a return to the previous position.
How does the law classify drugs?
The drug classifications appear in schedules to the 1971 Act. Class C, the lowest category, includes substances such as anabolic steroids, class B, includes drugs like amphetamines, and class A includes opium and cocaine. The higher the legal class of a drug, the more serious is any offence connected with it. The current consultation on reclassifying cannabis is part of a review of the entire UK drugs strategy.
The penalties for drug offences depend on the class of drug involved
Penalties for drug offences:
|Class A||Ecstasy, LSD, heroin, cocaine, crack, magic mushrooms, amphetamines (if prepared for injection).||Up to seven years in prison or an unlimited fine or both.||Up to life in prison or an unlimited fine or both.|
|Class B||Amphetamines, Methylphenidate (Ritalin), Pholcodine.||Up to five years in prison or an unlimited fine or both.||Up to 14 years in prison or an unlimited fine or both.|
|Class C||Cannabis, tranquilisers, come painkillers, Gamma hydroxybutyrate (GHB), Ketamine.||Up to two years in prison or an unlimited fine or both.||Up to 14 years in prison or an unlimited fine or both.|
One of the functions of the law is to prevent people from taking the harmful substances it has identified. This isn't so much to stop self-harm or high-risk behaviour as such (it isn't illegal to do "tombstoning" jumps from cliffs or rock climbing without ropes) but more to control the social effects of some drugs. So legislation makes it illegal to manufacture, distribute or possess certain substances.
The regulation of drugs presents very tricky challenges to the law for two main reasons.
First, because the science on which the classifications are made is always developing, and so are the drugs themselves. During the last hundred years, cannabis has gone from being legal to illegal, then graded as a middle-ranking drug, then down-graded, and now seems set to be re-graded back to the middle bracket. Before 1977, when the law was changed, the chemically-engineered drug ecstasy was not unlawful.
Second, drug law is tricky because social attitudes or political policies change. In the 17th century coffee houses were seen as dens of iniquity whereas now they are where people go to escape dens of iniquity. The drug amphetamine sulphate (speed) wasn't seen as a degenerate or dangerous thing for some time during the last century. It was taken as a pep by all sorts of people including military men, film stars, and housewives. Then policy changed and it became a controlled drug in 1964.
The way that the law divides legal and illegal substances isn't based exclusively on pharmacological knowledge. So it is not helpful to see everything illegal as equally bad and everything legal as generally good. Alcohol is legal but during the last ten years has been responsible for over 300,000 deaths. Caffeine has been clinically recognised as a drug more addictive than morphine. As Milton Berle noted, coffee is a pretty powerful stimulant. He said "I had a friend who drank twenty cups a day at work. He died last month, but a week later he was still mingling in the company lounge".
The back-story to the criminalisation of cannabis shows that it was not universally seen as a health hazard. The Hague Convention of 1912 (an international governmental agreement about opium), aimed to stop organised crime from getting into the business of drugs distribution. The use of drugs, though, was commonly seen only as a weakness or vice but not as criminal. In America, legislation in 1914 put a nominal tax on the supply of opium through pharmacies (one cent per ounce) - but the aim of the law was simply to get drug distribution formally recorded and registered. It didn't make consumption illegal.
In Britain, the Dangerous Drugs Act 1932 said that "any extract or tincture of Indian hemp" was a substance whose manufacture, import and export was prohibited unless licensed. The same drug is also known as marijuana (a Mexican colloquial name for the substance) and cannabis.
The first major and dedicated legislation on cannabis came in America in 1937. It only became federal law, though, after the legislature credulously accepted evidence such as the virulently racist contributions of Harry J. Anslinger, the head of the Federal Bureau of Narcotics. Mr Anslinger contended that most crime was being committed by "coloureds" with big lips, luring white women with "voodoo-Satanic" music (jazz) and marijuana.
The legislation was promoted by the Bureau of Narcotics, which was keen to expand its areas of operation. The law was passed without substantial debate. In the Congressional hearings in April and May 1937 (in a committee of the legislature), the representative of the American Medical Association, Dr William C. Woodward, challenged the Bureau's contentions that marijuana was harmful to health and in widespread use among children, and asked for the evidence behind such claims but he was given no answers.
Much has changed socially, politically, and in the science and business of drug manufacture since the last major piece of drugs legislation was passed in 1971. A wide range of political views now exists in respect of drugs policy, from the opinion that the answer lies in a complete decriminalisation of all drugs, to the opinion that the answer lies in a zero tolerance approach. The problems posed to legal policy makers are aggravated by the changing designs of some drugs, the international issues of the funding of organised crime, and transnational policing. This quagmire of issues is further complicated by an evidently enormous phenomenon of secondary, drug-related offending: theft by drug users, and money laundering by organised crime. The more thoroughly all such issues are digested in the current governmental review, the better will be the resultant law.
His latest book How the Law Works is published by HarperCollins
Jim Barnard gives us a history of the treatment of drug users in primary care. He describes how the pioneering spirit of a group of doctors in the nineties has contributed to the enormous development of drug treatment provided by GPs over the past two decades. Ed.
People are still sometimes negative about the extent and quality of drug treatment in primary care. Therefore we feel it's important to occasionally remind ourselves how far we've come, so that we can put any present day challenges into perspective. The first overt attempt by the Department of Health to reengage GPs in treating drug dependency (following their largely successful removal from the treatment field in the 1960s) is usually traced back to 1995 when the executive letter EL 14 (95) was sent to all Health Authorities to review their shared care arrangements for drug misusers. Prior to this the original Community Drug Teams were supposed in theory to engage with GPs but were largely unsuccessful. At the time of the executive letter there was very limited primary care involvement, with the Royal College of General Practitioners (RCGP) estimating that around 3% of GPs were involved in drug treatment. There were a few independent enthusiasts and there were some embryonic shared care schemes (e.g. Berkshire). Some areas, such as West Dorset and Mid Hampshire relied entirely on GP prescribing because there was no specialist prescriber.
GPs were not paid for their work in England (though they were in some embryonic schemes in Scotland). There were no contractual requirements for drug treatment in primary care so no quality standards could be set for GPs. Involvement was usually as a result of secondary care services cajoling GPs into joining their scheme; this meant there was often little GP ownership of shared care schemes. Paradoxical extremes of practice existed. In some schemes GPs signed scripts but worked entirely to the agenda of the secondary care service without having any actual say in what was prescribed, whilst in other schemes, such was the desperation to get GPs "on board" that drug workers would pander to whatever prescribing prejudices the GP had, however far away from effective practice this was.
At this time there was no accredited training, with occasional ad hoc events organised locally. GPs often felt very unskilled in this area. Many were working in isolation from any support, often working through knowledge and experience gained on the hoof. There were no local guidelines for GPs to follow and the existing 1991 national guidelines said methadone maintenance was too complex for GPs, who should just stick to reduction prescribing. Most Local Medical Committees strongly advised their members against becoming involved in this area of work.
If we go forward a few years to 1999 when the next set of clinical guidelines was published the situation had moved on a bit. The new guidelines allowed for GPs to prescribe methadone and to work at a special interest level. They even had GPs on the expert group who wrote them! In the mid nineties a network of GP enthusiasts had started to emerge, using their membership of the RCGP to initiate a national conference, entitled "Management of drug users in general practice" in 1996, which had been growing year on year. The attendees, and others, kept in touch via a newsletter (this one in fact!). However the system was still very ad hoc. Shared care had developed a fair bit, but was almost entirely managed by secondary care, many of whom had little understanding of the peculiarities of general practice. There were still no contractual agreements, which made systems vulnerable (the previously successful schemes in Southampton and Mid Hampshire folded by this time).
There was widely varying quality of provision between different practices which was often philosophical, and there was still no nationally accredited training. The level of GP involvement varied enormously from one locality to the next and on the whole amounted to what one might call the British "non-system".
So let's look at the situation now. Approximately 40% of practices are involved in the provision of drug treatment, and round half of community prescribing is done in primary care (58,000 people according to NTA data). Many schemes are now primary care led, usually via Primary Care Trusts. Most schemes are developed and maintained alongside primary care. The RCGP conference is now the largest conference in the UK in this field and is struggling to find venues big enough to host it. The SMMGP web site is the best used clinical site in this field in the UK.
The training agenda has moved on to a staggering extent. The Royal College run a two level certification programme covering all competencies, up to special interest level, which is supported by a wide-ranging continuing professional development programme. Substance misuse is now part of the core curriculum for the new Member of the Royal College of General Practitioners exam (nMRCGP), which all GPs must take. There is a full career structure for GPs in this field, all the way up to specialist level, with an acknowledgement of the existence of the "addiction specialist-primary care" in the joint paper on roles and responsibilities (Ref 1) (written by the RCGP and the Royal College of Psychiatrists), also acknowledged in the 2007 Clinical Guidelines. Appraisal tools designed for GPs working in drug treatment have been developed by the RCGP. To top off all of this, in 2007 a secure environments version of the RCGP certificate was developed specifically for clinicians working in prisons and police stations. It has been very well attended and received and has met a significant training gap for those working in these difficult settings.
Robust contractual frameworks have been developed. The 2004 GP contract made the treatment of drug dependency an enhanced service and most GPs work under enhanced service contracts. However, many work under contracts with PCTs or service providers as GPs with special interest or specialists. GPs are taking an increasing role in delivering criminal justice interventions and treatment in prison since the transfer of prison healthcare to the NHS. There is now robust clinical governance in place with local and national guidance available, strategic groups responsible for overseeing quality, good reporting and communication mechanisms and the increasing involvement of patients in decision making, both about their own care, and regarding service improvement.
In short, we now have a "system" for primary care based drug treatment. Local Strategic Partnerships are accountable for the development of drug services in primary care via their treatment plans and will soon be expected to do detailed yearly audits of their service provision. Formal care planning is now in place, as are formal care pathways, between primary and secondary care. A whole range of different services are now being delivered in primary care, so much so that the term "shared care" no longer adequately describes these services, and the 2007 Clinical Guidelines refer to "primary care based treatment".
In the future we will hopefully see all substance misuse reporting forms (National Drug Treatment Monitoring System [NDTMS] and Treatment Outcome Profile [TOPs]) incorporated into mainstream GP computer systems. We will also see a whole host of new mechanism for developing services being used, such as practice based commissioning and alternative providers of medical services (APMS). We will see the wider use of nonmedical prescribing, with independent prescribing of controlled drugs likely to become possible for non-medical prescribers very soon. Whilst it is impossible to predict the details, the future will be one of positive developments in treatment service provision in primary care.
To summarise, thirteen years ago drug treatment in primary care was unusual, disorganised, unskilled and undervalued. It is now mainstream, fit for purpose, expanding, organised, energetic and vibrant.
1. Royal College of General practitioners and the Royal College of Psychiatrists (2005) Roles and Responsibilities of Doctors in the Provision of Treatment for Drug and Alcohol Misusers
Dr Prun Bijral and Kate Hall discuss the role of the in-patient unit as a valuable component of tier 4 provision, providing an alternative view to that of James Bell's in the previous edition of Network. They challenge the idea that individuals need to move through the tiers in a chronological order to access inpatient services, and suggest that in-patient units can offer more than just detox. They emphasise the importance of preparation to the success of in-patient detoxification, and also the essential role of postdetox support, something that can be provided by a number of agencies. They conclude that a multi-agency approach to in-patient treatment is essential if we are to provide the best service for drug users. Ed.
"More treatment, better treatment, fairer treatment..."
The familiar mantra of the NTA but what is "treatment"? It can have such a different meaning depending on who you ask, and there is a general acceptance that there are many different treatment approaches within the field of substance misuse. Over the last ten years the industry has demonstrated a huge improvement in the "more treatment" category. Better and fairer treatment? Again, this depends on who you ask but inevitably the issue of choice, accessibility, suitability and outcomes will be important factors to consider.
There is an acknowledgement nationally that we have a shortage of specialist inpatient treatment units. Alarmingly many in-patient detoxes are still occurring within a generic psychiatric ward (Ref 1). The recent Department of Health injection of capital investment within the tier 4 sector demonstrates a commitment to retaining and indeed strengthening this treatment option. So what positive effect can admission to an in-patient treatment unit have on substance users?
"many people arrive at inpatient units believing that this is the final hurdle in their quest for recovery. In reality it is only the beginning"
The key to a more probably successful outcome is preparation. Unfortunately, many people arrive at in-patient units believing that this is the final hurdle in their quest for recovery. In reality it is only the beginning and in readiness for this, referrers have a duty to ensure that the service user understands the process way in advance of any referral being made. There are ways to ensure this happens, for instance, accessing open days within local units and establishing a "link worker" system between tiers 2, 3 and 4. It is important that referrers know enough about the unit to adequately inform the service user being referred. Providers have a responsibility for equipping referring agencies with up-todate information including:
- Unit philosophy
- Rights and responsibilities
- What to expect
- What to bring
In some instances it is possible for the service user to visit the unit before committing to admission and web based virtual tours of units are also available.
Realistic goal setting and preparation for admission should not be confused with creating barriers, or making people jump through hoops. We happily set "SMART" (specific, measurable, achievable, realistic, and timely) objectives for ourselves; how about doing the same for our service users? A thorough assessment of need, including challenging inconsistencies and recommending alternatives should not be seen as professional arrogance. Indeed, not to talk through the realities of undertaking the step to enter inpatient treatment should be considered negligent.
Being admitted to an in-patient unit is an important part of a service user's journey a journey that should be well planned in advance. It is recognised that inpatient treatment, which lasts in excess of three months (including the pre and post-admission period), produces better outcomes.
It is highly improbable that people will be discharged completely out of the treatment system from an in-patient unit. So where do they go? It is acknowledged that better treatment outcomes are seen when there is effective linking of detox to aftercare services, including residential rehab (Ref 1). Many more go to another service than the one they were referred from. We are now starting to see a much wider range of aftercare providers, including structured day programmes (abstinence focussed), sober living/recovery houses, and supported housing linked to day treatment. There are also many more examples of links to employment training and education than we've ever seen.
This variety of options post detox provides an opportunity to further research the effectiveness and viability of such pathways, as these facilities are more plentiful than when past research was conducted. Service users would previously complain and object to being referred back to the tier 3 community drug team and, indeed, it does seem wholly inappropriate for someone drug free... but better than nothing? Thankfully more choice of community based abstinence provision is emerging to include the recognition that self-help (Narcotics Anonymous [NA]/Alcoholics Anonymous [AA]/Cocaine Anonymous [CA]) has an important contribution to make.
Of course not all who enter into in-patient treatment manage to achieve their aim of becoming totally drug free, but then how many of us have given up smoking/lost weight the first time we try? Knowing and affirming that it is possible is invaluable. Staff focus on positive gains, what has been achieved rather than what has not, can provide the service user with an alternative perspective, albeit short lived. Even admissions as short as three days have been shown to have considerable benefits up to six months later (Ref 2).
Detoxing from opiates is risky. The Specialist Clinical Addiction Network (SCAN) definitions have moved away from the term "detox" and towards the term "assisted withdrawal". Within specialist units this assistance is medically managed or monitored and within our own unit, staff have had the benefit of being trained in node-link mapping via the NTA International Treatment Effectiveness Project (Ref 3) and thus have moved away from an emphasis on purely physiological withdrawal and recognise the importance of other spheres, in particular psychological and social, that will determine longer term prognosis.
It is now far more likely that patients admitted to in-patient units will have a dependency on more than one substance, for example, alcohol, benzodiazepines and cocaine, and NICE suggest this group benefit from access to in-patient units (Ref 4). It is vital that robust harm reduction information is provided pre, during and post in-patient admission. It can be surprising how uninformed service users are when they are admitted to our unit (hepatitis C, what's that?). Exploring and improving service users" knowledge, both one-to-one and within a group environment can, arguably, save lives.
"educate and inform service users and referrers of the importance of preparation, expectation and philosophies of approach"
On the face of it, many admissions may seem to be a waste of time, and inpatient units can be very frustrating, labour intensive places in which to work. The answer is not to condemn in-patient treatment, but rather to educate and inform service users and referrers of the importance of preparation, expectation and philosophies of approach. NICE recommends further research be conducted into the comparisons between settings of detoxification to examine factors such as completion rates, likelihood of continued abstinence and cost effectiveness (Ref 4). In order to realise that recommendation, there needs to be access and choice for service users.
Recommending alternatives to in-patient treatment is absolutely not denying effective treatment, but removing the choice to access in-patient treatment is to deny and exclude one of the most effective elements of treatment interventions. We have to include service users in their choice of treatment. The NTA user survey indicates many service users are aspiring to be drug free and are feeling that they are in the wrong modality and uncertain about how to proceed (Ref 5).
Whilst acknowledging that service users will require support pre, during and post admission, what is also required is a joined-up commissioning approach to tier 4 which would allow the modality to positively interact with the rest of the treatment system; this will require creative thinking, new ways of working and a complete review of how current pathways for entry into, and exit from, in-patient units are developed.
Traditionally the entry to tier 4 has come via tier 3 but this has led to some professionals believing people must pass through the modalities chronologically. What about shared care? What about GP Referrals? GPs involved in treating substance misuse are ideally placed to assess and refer to either community detox or in-patient units but have historically been prevented from doing so. This was born out of the belief that secondary care (Community Drug Teams) knew best. Can we still be confident that this is the case?
So ...do users within shared care have adequate access to tier 4 facilities, or do the bulk of admissions continue to come from Community Drug Teams? The "severity paradox" is open to challenge. We should think about entry from tier 2, shared care schemes, Drug Intervention Programmes and triage schemes. Perhaps the treatment naive population are looking for something other than substitute prescribing?
But let's put all this into perspective. The NTA aspirational target is that in any year 10% of the "in treatment" population will access tier 4 services (and this is tier 4 as a whole not just in-patient units). Nationally we are nearer the 3% mark. Surely we can do better than that? In-patient treatment most definitely has a place for stabilisation, titration, assessment and observation, but it also is the most effective way of becoming drug free, an opportunity and an aspiration we must hold on to.
Both from Substance Misuse Directorate Bolton, Salford and Trafford Mental Health Trust
1. E Day, J Ison, J Strang (2005) Inpatient versus other settings for detoxification for opioid dependence . (review). Cochrane Database of Systematic Reviews 2: CD004580.pub2.
2. Chutuape, MA, Jasinski, DR, Fingerhood, MI (2001) One-three and six month outcomes after brief in-patient opioid detoxification, American journal of Drug and Alcohol Abuse; 27(1):19-44.
3. National Treatment Agency research publication (2007) The International Treatment Effectiveness Pilot.
4. National Institute for Clinical Excellence Guideline (2007) Drug Misuse - Opioid Detoxification.
5. National Treatment Agency (2007) Survey of User Satisfaction In England.
David Best, Saffron Homayoun, and John Witton discuss the findings of their survey of drug treatment services, and conclude that while some advances have been made, practice amongst drug services is variable. Ed.
Surely Hidden Harm was a good thing?
There is a small but consistent research evidence base about the risks faced by children of drug using parents. They have been found to be at elevated risk for a range of adverse health and welfare outcomes including early onset of alcohol and tobacco use and higher rates of adolescent illicit drug use, when compared to the children of nondrug using parents (Ref 1). Cleaver and colleagues (Ref 2) summarised the potential adverse effects of parental problematic drug use in four categories:
- Educational impact - such as poor school attendance.
- Health impact- such as missed medicals.
- Relationship and identity impact- such as taking on adult roles.
- Emotional and developmental impact- including depression and anxiety.
As a consequence the focus directed at this area by the 2003 Advisory Council on the Misuse of Drugs (ACMD) report was particularly welcome (Ref 3). Among the headline findings of "Hidden Harm" (Ref 3) was that, in England and Wales, there were estimated to be between 250,000 and 300,000 children with at least one parent who has a serious drug problem - representing 2-3% of children under 16, and an even greater figure in Scotland. The survey commissioned by ACMD showed evidence of good practice but considerable variation in provision across the range of relevant services, and relatively weak inter-agency working. A total of 48 recommendations were made, about routine recording of problem parental substance use, joint working, training and service provision, and a request for further research.
So what has happened since?
Although the initial Government response was muted (in contrast to the positive commitment made by the Scottish Executive), ACMD took the unusual step of commissioning a follow-up group to look at implementation. As part of this process, the researchers commissioned to carry out the original survey (including two of the three authors of this article) were asked to repeat the survey in specialist drug services.
The follow up survey was conducted in 2006 to investigate implementation of the recommendations of the original report and to examine cases of good practice that had arisen since the 2002 survey. The resulting report, "Hidden Harm Three Years On: Realities, Challenges and Opportunities" (Ref 4), was highly encouraging in terms of good practice development and cited a number of flagship services where innovative and exciting work was taking place. The findings from the survey of specialist services were given far less prominence, possibly because they were significantly less encouraging! Part of the disappointment was the small sample size - a total of 259 specialist drug services completed and returned the questionnaires (an overall response rate of 20.6%).
Yet given that the participating services had an average of 198 clients receiving some form of structured treatment, this relates to a total caseload of over 50,000 clients attending participating services. And the findings were decidedly bleak - 93 services (35.9%) reported that they had specialist services for drug using parents, while 26 services (23.6%) reported that they had services specifically dedicated to the children of drug-using parents. For specialist provision of services for drug-using parents, and for their children, this actually represents a decrease in provision between 2002 and 2006, a period that has seen a huge proliferation of drug services across the UK.
Changes in forms of service provision since Hidden Harm:
|2002 survey||2006 survey||Change|
|Services for clients with dependent children||53.0%||41.2%||-11.8%|
|Services for children of drug using parents||31.0%||27.6%||-3.4%|
|Protocols for working with pregnant drug users||33.0%||48.0%||+15.0%|
|Training for staff working with clients with dependent children||30.0%||47.5%||+17.5%|
|Regular liaison with GPs||86.0%||95.4%||+9.4%|
Although there are more protocols, better training and better interagency liaison, there are fewer services for parents and for their children. While this may reflect a national mainstreaming agenda, it suggests that nationally we have not made the progress that Hidden Harm promised and that there is only an increase in the sense of a "postcode lottery" for specialist services for drug using parents and their children.
So where did it all go wrong?
The first point to make is that it didn't. In many areas across the UK, Hidden Harm has initiated a process of reflection and change that has led to increased funding and improved training and working practices. However, the upbeat tone of the "Three years on" report notwithstanding, we are in a position where the local picture is even more fragmented, where the failure to establish minimum standards in this area has meant that for hard-pushed commissioners and service providers it is not a priority (because it does not equate to a target). And while these beacons of success do exist, and current practice has advanced in many areas, how much that will continue as funding reduces is uncertain and would suggest that specialist drug services cannot be relied upon to measure parental substance use or to address the resulting needs of children.
1. Clark, B., Parker, M., Lynch, G. (1999). Psychopathology, substance use and substance related problems. Journal of Clinical and Consulting Psychology, 28, 333- 341.
2. Cleaver, H., Unell, I., Aldgate, J. (1999) Children's needs - parenting capacity. London: Stationery Office.
3. UK. Advisory Council on the Misuse of Drugs. (2003) Hidden harm: responding to the needs of children of problem drug users. London: Home Office.
4. UK. Advisory Council on the Misuse of Drugs. (2007) Hidden harm. Three years on: realities, challenges and opportunities. London: Home Office.
Hugh Campbell offers advice to a GP who wants to provide the best treatment for a patient who is being treated for drug use with dihydrocodeine and is experiencing problems with his mental health. Ed.
Andrew is a 35-year-old, single, unemployed patient of mine. He transferred from another GP when he moved house. He came with a letter, which I confirmed by phone, asking me to continue prescribing his dihydrocodeine 30mg x 20 daily, on weekly scripts, for previous heroin dependence. He had been on the same script for five years.
He asked me to continue the prescription because it helped him. When I asked about his health he volunteered that he had had no keyworking and had rarely had urine drug screening. He admitted that he had started to use heroin to self medicate for his severe anxiety and what he described as his "bad thoughts", and the dihydrocodeine had previously worked well. When I asked him more about his bad thoughts he admitted that voices had told him to hurt himself because he was evil.
He also said his anxiety was getting worse and he was finding it difficult to get out. He refused any referral to psychiatric services. He didn't seem to be sectionable and would not contemplate a change in medication.
I'm really worried about the risks Andrew presents, but I want to balance that against losing him to treatment, and so leaving him with increased risks. Can you help please?
Registration of any client provides a golden opportunity to reassess their true needs. Unfortunately, this man's previous treatment has been far from ideal. Because of the length of time, and the way he has been prescribed high dose dihydrocodeine (DHC), he has come to expect a "prescription only" style of care which is thoroughly unhelpful. Before any headway can be made it is essential to build a meaningful relationship with him, which will take time, and hopefully allow you to help him face his ambivalence to change. His needs cannot be assessed in one long appointment and if I was looking after him, would see him on a minimum of a weekly basis until I was satisfied with the standard of his care. His psychological symptoms i.e. anxiety and auditory hallucinations, possibly suggestive of early psychosis (in the absence of use of agents such as stimulants and cannabis, which may be possible psychotomimetric chemical triggers), may provide a ray of light for change which should be thoroughly explored.
A full history of his substance misuse is very important including how he started to use opiates, length and style of use, type of opiate use and any other substance use. It is important to know exactly how he takes his DHC - is his intake regular, is there a binge pattern or is it related to episodes of anxiety? The short acting nature of dihydrodeine makes it a poor substitute to prevent opiate withdrawal. Has he ever considered or been prescribed methadone or buprenorphine? Maybe he has been prescribed them but his experience was aversive in some way. Maybe the style of prescription support that he received was punitive or poor standard in some way. A general medical history including infection screening is also important. It is essential to conduct an assessment of his past and present mental health history. Did his psychological/psychiatric symptoms pre or post date his substance use or did they occur together? Objective tests for both prescribed and illicit substances are mandatory and need to be interpreted with care. A negative screen for opiates at first presentation should arouse suspicions about possible diversion of his prescription (DHC has significant street value) or may indicate that he is taking his DHC in batches rather than daily.
His presentation with substance use and symptoms suggestive of mental disorder may indicate a "dual diagnosis". There is debate around the use of this term (Ref 1) and much that is written is from a specialist mental health rather than a primary care perspective. A preferable term is "multi co-morbidity" reflecting the multi needs of these clients, and their need for a holistic approach which should include both a clinical and psychosocial perspective. It is extremely common, in my experience, to see a combination of substance use with lesser degrees of mental disturbance, particularly anxiety, mood disorder and, less frequently though of high significance, psychosis. Clients with so called "dual diagnosis" are best assessed from the view point of their needs, and a formulation of these in a care plan is much more constructive for management than a series of sterile DSMIV-ID10 diagnoses which may if anything by their nature, when associated with substance use, exclude them from access to services (e.g. personality disorder).
It would be wise for him to have an in-depth assessment with a keyworker that might clarify the sense of risk which you are experiencing. Formal screening for self-harm, violence and child protection risk may be insightful. A keyworker with mental health experience would be a bonus. Including a keyworker might help reduce the sense of professional isolation you are feeling, and increase the umbrella of support for the client.
Until the assessment is complete I would continue the prescribing of DHC at the same dose level but add no other agents at this point. DHC ought to be supplied on a short, probably daily, interval. Preparation of daily prescriptions can be laborious and time consuming but may be important from a clinical governance viewpoint should a significant event occur. I would give strong consideration to either a slow graduated community DHC detox, or strongly try to convince him of the wisdom of re-titration from DHC to another opiate agent such as methadone. Depending on the severity of his anxiety, contact with a skilled practice counsellor or community psychiatric nurse may be useful for possible limited cognitive behavioural therapy or other brief therapy.
Evidence (Ref 2) suggests that the type of mental disturbance experienced by this patient is significantly improved with non-prescribing treatments. I have found that when there is client resistance to contact with the mental health service there may be very good reasons for this. One way of overcoming this problem is to arrange for the client to be seen in a GP surgery setting. His anxiety may be linked to earlier disturbing psychotic symptoms, in which case a mental health assessment is especially important. If his substance use and management of his DHC prescribing is ably managed in primary care it may be easier to access community mental health support. Another option might be to refer to a dual diagnosis team but these are not available in all areas and tend to be highly selective about which clients they accept for treatment.
Other agents may be useful in this situation. These include olanzapine, risperidone, quetiapine or possibly clozapine. However, I would not start any of these agents unless guided by a specialist mental health team. I would strongly resist requests to prescribe benzodiazepines, though diazepam is licensed for short-term use as an anxiolytic, for up to two weeks at no more than 30mg per day. However my experience of this latter agent, given its addictive potential and the susceptibility of the client, is that it is easy to slip from short-term acute use into longer-term dependent use.
In summary, this client, although in some ways unusual, represents the tip of an iceberg, where substance use and mental disturbance of varying severity can present together in primary care. The evidence is that at least 80% of these clients are wholly managed in primary care without adequate support. This case serves as a healthy reminder that a mental health assessment is a crucial part of a holistic assessment of any substance user. Mental health needs may be a potent reason for continued substance use, and both need to be carefully assessed and treated for a favourable outcome.
1. Edited by Clare Gerada (2005) RCGP Guide to The Management of Substance Misuse in Primary Care 22 317-331.
2. National Institute for Clinical Excellence (2004) Guideline for the Management of Anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. CG22.
Andy Lane replies to a GP who is treating a patient for both their drug use and their alcohol problem. Ed.
Lucy is 36 years old and has been a patient of mine for two years. She has stabilised well on 80mg of methadone mixture which she picks up on a daily basis. Lucy previously smoked about 1gm of heroin daily, but now uses no heroin, and only occasionally uses crack. Her primary problem has always been alcohol, which she started using aged 14 years. Since that time she has undertaken a number of community and in-patient detoxifications but has never remained alcohol free for long. She is hepatitis C negative, her liver function tests are mildly deranged and she has no liver signs.
Lucy lives alone but has had a series of partners, all of whom have been drinkers. She was recently found drinking outside the practice and had been asked to leave by one of the other doctors. Lucy came to see me the next day to apologise. She was very drunk and requested to start another community detox as soon as possible. She is currently drinking 10 cans of beer a day 500mls, 7.5% (37.5 units). Lucy also requested a regular prescription of diazepam, as she feels that this will help her reduce her drinking.
I feel we have managed her drug problem well but we are really struggling with Lucy's alcohol problem. We have used drink diaries, attempted CBT (which she didn't stick with), and undertaken a couple of community detoxifications. I'm not sure another is going to help, do you agree? Lucy is a delight and we would be grateful for any suggestions you can provide to help her. Do you think we should give her another detox? So far we have declined her request to prescribe diazepam, what do you think?
Lucy's story is all too familiar and complex. Alcohol consumption often precedes the first use of heroin in young people (Ref 1). The reasons why people become dependant on drugs and alcohol can be considered under four headings:
- Biological, involving the development of tolerance and withdrawal.
- Hereditary - 25% of severe alcoholics have a genetic predisposition (Ref 2).
- Personality-disorder, anxiety/depressive, thrill seeking, introvert, antisocial.
- Psychological - continue the drug fearing withdrawal symptoms.
Levels of alcohol use tend to reduce when a regular illicit heroin habit develops (Ref 3). However some evidence suggests that successful opiate treatment can result in an increase in alcohol intake (Ref 1). Methadone treatment is often associated with an increase in alcohol problems as it blocks the intoxicating effect of opiates, leading the addict to look for an alternative intoxicating substance. In Lucy's case, as alcohol preceded her heroin use, she resorted to the former.
Prevalence of drinking problems in clients on methadone programs range from 30%-50% in the majority of studies (Ref 4). The CPY3A enzyme is responsible in the main for methadone metabolism and is induced by alcohol on the liver. A high alcohol intake especially when associated with alcoholic binges will stimulate the liver enzymes, resulting in increased methadone metabolism and symptoms of opioid withdrawal, leading to the risk of relapse or increased alcohol use. It is thought that SSRIs and some other drugs inhibit the same enzyme system with the potential for opioid toxicity (Ref 5).
Those clients with a lifetime history of alcohol dependence are more likely to have a similar dependence to benzodiazepines and cocaine. Benzodiazepine use causes a five-fold increase in drug related death; 60% of methadone related deaths in a survey in Ontario had benzodiazepines present and 30% had alcohol (Ref 5).
You state that Lucy uses crack cocaine on occasion, which would be unusual on its own. Is there any suggestion that she may be a more regular cocaine user who enjoys the coca-ethylene effect with alcohol?
One of the major risks of repeated benzodiazepine alcohol detoxifications is the kindling effect. Essentially this describes the phenomenon whereby people undergoing repeated cycles of intoxication, followed by abstinence and withdrawal, experience increasingly severe withdrawal symptoms with each cycle. This will increase the risk of seizures, anxiety, neurotoxicity and altered perception of alcohols effect. All of these symptoms lead to a higher rate of relapse and potential brain damage. Further conventional community detoxification using chlordiazepoxide or diazepam will present Lucy with a risk of seizures.
Both alcohol and benzodiazepines share the same Gammaaminobutyric acid (GABA) pathway (which explains why we use them as first choice for alcohol detoxification). It would be unwise to prescribe diazepam to this lady as the potential for overdose is extremely high and cross dependence likely if not already a factor. I don't think you need be concerned about the methadone prescribing provided you are happy she is illicit drug free. It would of course be of concern with alcohol and diazepam.
In the ideal world, Lucy would benefit from an in-patient detoxification followed by a prolonged period of residential rehabilitation (up to twelve months). For a number of reasons this may not be appropriate and a further community based outpatient detoxification could be considered. Her opioid maintenance can continue as prescribed.
My personal plan would be to complete a full health assessment on Lucy and assess her level of dependence. There are a number of simple tools available for this purpose. However, I favour the Severity of Alcohol Dependence Questionnaire (SADQ [developed by the Addiction Research Unit at the Maudsley Hospital, it is a measure of the severity of dependence. You can see a copy at www.prisonmentalhealth.org.) If the score is <30 this indicates mild to moderate dependence and she can be considered suitable for out-patient detoxification.
A higher reading should trigger an in-patient treatment referral. Include an up-to-date liver function test (fortunately she is hepatitis C negative). Ensure that her hepatitis B vaccinations are completed. If possible it is worth identifying a family member or friend to support Lucy. She is obviously well liked and I am sure that with your encouragement this can be achieved.
Out-patient detoxification is not urgent in this situation and you will have time to plan the process, prepare Lucy and arrange a start day convenient to you both. Controlled drinking prior to this day is a good idea and motivational support and encouragement are essential (though can be time consuming in a busy general practice).
I favour starting acamprosate, 333mg, four or six daily in divided doses, depending on Lucy's weight prior to complete cessation of drinking. This drug is now well evidenced to help reduce cravings in alcohol cessation. Add thiamine 200-300mg daily and vitamin B strong, 2 a day.
Consider the use of carbamazepine as an alternative to chlordiazepoxide, it will reduce the risk of seizures due to the kindling effect and, if tolerated, is as efficient as a benzodiazepine in reducing withdrawal symptoms. Although this is not common practise in UK primary care, following a randomised control trial (Ref 6) there is an emerging evidence base for using this drug in scenarios similar to Lucy's. Dosage starts at 800mg daily in divided doses, reducing to 200mg by day 7.
Daily contact is important and this could be with the practice nurse or yourself. This will involve Lucy coming to the surgery every day to receive both a daily prescription and encouragement for her. She is seeing her pharmacist daily who will be assessing her prior to dispensing her methadone (consider supervised consumption if concerned for a short period). Mobile text messaging and telephone triage allow for added contact and reassurance.
Once Lucy has completed 2-3 days alcohol free and provided the LFTs are not too deranged (a clinical judgement) please consider disulfiram 200mg tablets on a starting dose of 800mg on day one, reducing by 100mg daily to a maintenance of 200mg daily (scored tablet). Clear instruction on this drug can be part of the pre-detoxification planning. Disulfiram can be continued for 3-6 months and this allows time for psychosocial interventions (you may wish to discuss disulfiram with a local addiction specialist). Remember to discuss a 12 step support program. AA is available throughout the country and can offer timely help. They will arrange for Lucy to be introduced to a local group. I hope this gives you some options.
1. Edwards (2003) The Treatment of Drinking Problems, 4th edition Cambridge University Press.
2. Cook C.C.H.(1994) Aetiology of alcohol misuse. In Seminars in Psychiatry: Alcohol and Drug Misuse, Chick et al London. Royal College of Psychiatrists. 94-125. Cited Edwards G. (2003)The Treatment of Drinking Problems,4th Edition. Cambridge. Cambridge University Press.
3. Rounsaville (1982) The significance of alcoholism in treated opiate addicts. Journal of Nervous and Mental Disease.170,479-88 cited Edwards (2003) The Treatment of Drinking Problems, 4th edition (Cambridge University Press.
4. Leibson (1973) Alcoholism among methadone patients. A special treatment method. American journal of Psychiatry. 130, 483-5 cited Edwards (2003) The Treatment of Drinking Problems, 4th edition (Cambridge University Press.
6. Malcolm (2002) The effects of carbamazepine and lorazepam on single and multiple previous alcohol withdrawals in an outpatient randomised trial. J Gen Internal Medicine 2002.17,349-355.
The 13th National Conference: Management of Drug Users in Primary Care - Meeting the Needs of Diverse Populations: Hard to Reach or Easy to Ignore?
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