Network No 27 (October 2009)
|Download the PDF version of this newsletter here! (PDF*, 814K)|
Effective pain management for drug users in acute hospital settings is something that appears to be difficult to achieve. Dawn Wintle describes how a team approach that treats the patient with dignity can work.
Ayesha Hurst describes the increase in use of alcohol, amphetamines, cannabis, cocaine and ecstasy amongst young people.
John Dunn, National Treatment Agency has written an article for SMMGP on "Preventing Unplanned Discharges from Drug Treatment Services". The full article can be found on our website in the Other Resources section.
Gerry Woodley and Charlie Lowe describe their approach to young people's services in Plymouth.
Marcus Roberts takes us through the twists and turns of drug policy over the past decade, and the effect this has had on the drug treatment field.
Most of you agreed with the UKDPC recovery statement - but what are the implications for general practice? Roy Robertson gives his view.
Release step in as Lawyer Fixit to provide some excellent housing advice to a GP whose patient is homeless.
Claudia Rubin outlines some of the legal campaigns in which Release are involved, and highlights just how important this organisation is for the protection of drug users' rights.
Methadone deaths have increased over the past few years. Penny Schofield examines possible reasons for this and the steps clinicians can take in order to reduce the risk of methadone-related deaths.
Caryl Beynon describes how in Liverpool they have designed a system to give a clearer picture of when drug use has been involved in an individual's death, in order that the right lessons can be learned.
See the latest news on the RCGP Certificate in the Management of Alcohol Problems in Primary Care.
Sharyn Smiles and Lisa Mallen discuss the difficulties involved in the employment of service users in drug treatment services, the way these problems can be overcome, and the rewards for those who employ service users to deliver treatment.
Joy Barlow argues for earlier intervention for children with parents who are problematic alcohol and drug users in order to limit harm.
Dr Fixit Jack Leach provides an answer to a GP regarding the use of Suboxone.
Nazmeen Khideja is Pharmacist Fixit to a GP who is confused about writing prescriptions for controlled drugs post Shipman.
You can also find out about the latest courses and events.
Don't forget to become a member for free and receive regular clinical and policy updates - the newsletter can also be e-mailed to you - all for free!
We are very pleased to have timed this edition to be published for our 4th National Primary Care Development Conference in Barnsley on 9th October, Partnerships in Progress: Working Together. For those of you who are not lucky enough to be with us in Yorkshire, watch our website for the course presentations.
To emphasis the importance of partnership working, as the most pressing issues we have had questions on have been outside his competency, Dr Fixit has asked colleagues in other professions to help. We are very pleased to introduce Lawyer Fixit, who answers questions about homelessness, and to welcome back Pharmacist Fixit, who gives advice regarding prescription writing post Shipman. Drug services work best as a multi disciplinary team! But don't worry, Dr Fixit has not been made redundant - you can find an extract of an answer regarding working with Suboxone from Dr Fixit Jack Leach in this edition (the full version can be found in the Dr Fixit's FAQs) section of the site), together with advice on working with young people from Dr Fixit Charlie Lowe.
We have had so many interesting articles for Network 27 that we couldn't fit everything in to our usual 16 pages so this is a 20 page edition. We have a piece by Marcus Roberts on drug policy, an article by Sharyn Smiles and Lisa Mallen on employing service users in the drug treatment field, articles by Penny Schofield and Caryl Beynon on drug related deaths... and much more - we think we have something for everyone! We are excited to welcome Euan Lawson to the SMMGP team as our new Clinical Update writer. He has already provided an excellent round up of the latest research in our August update and we delighted to have him as a member of our team. Welcome Euan!
Finally here is one for your diaries - the Royal College of General Practitioners 15th National Working with Drug & Alcohol Users in Primary Care Conference, Integrating Practice and Policy: Everyone's Business on Thursday 22 - Friday 23 April 2010 at the SECC, Glasgow. Watch out for flyers for the event, and why not put in a paper, poster, or other form of media? You might win a free place at the 2011 event!
Are you missing ketamine use as a possible issue when assessing patients? Rachel Ayres, Fergus Law and Angela Cottrell discuss the rise of ketamine use and the need to consider this when patients present with bladder and abdominal symptoms. Ed.
Association of ketamine with unexplained bladder and abdominal symptoms
Increasing numbers of people are using ketamine recreationally throughout the UK. It is especially prevalent amongst younger people and many users are seeking help from their GPs but may not be disclosing their ketamine use.
Background: Ketamine is an N-methyl-D-aspartate (NMDA) receptor antagonist, developed in the 1960s as an anaesthetic. Amongst recreational users with low tolerance a dose of 10-30mg (a "bump") will induce a mild "trippy" euphoric feeling. As the dose is increased the dissociative effect becomes more marked. It is this dissociative state that most recreational users seek when they use ketamine. This state can be reached with around 50-100mg in non-tolerant users. Ketamine is increasingly becoming a drug of daily and habitual use amongst younger people, with elements of loss of control, compulsion and a move from social to more solitary use. These users report a rapid increase in tolerance to the drug and a distinct psychological withdrawal syndrome. During detoxification, severe anxiety with physical symptoms and increasing urinary tract pain may occur. Ketamine users who are dependent may be using anything from 1-15 grams per day and suffer a range of side effects including cognitive impairment, increasingly restrictive friendship groups, vulnerability (it is impossible to look after yourself or your belongings whilst under the influence of ketamine), lack of energy, anxiety and urinary tract problems. It is this last issue that we wish to highlight in particular.
Ketamine associated ulcerative cystitis has only recently been described in the literature (Ref 1, Ref 2, Ref 3, Ref 4, Ref 5). Its symptoms are well known in the ketamine using community but users may not be aware of the long term implications or the imperative to cut down or stop their use once such symptoms have developed. The symptoms can be severe enough to require hospitalisation, progress to severe complications, and can result in irreversible bladder and renal damage. Although commoner among those who use ketamine daily or at high doses, it can also occur with lower dose recreational ketamine use.
Why ketamine causes these problems
While the cause of these ketamine related symptoms is not fully understood, what is known is that:
- The urinary cystitis like symptoms are caused by ulceration of the bladder. This may progress to chronic problems with a shrunken inflamed bladder and suprapubic pain, dysuria and haematuria, as well as urgency, frequency and incontinence. Ketamine and at least one of its metabolites appears to be toxic to the epithelial lining of the urinary tract system.
- The renal and urinary systems may become obstructed with a gelatinous precipitate, which is probably sloughed epithelium. This may progress to a narrowed or scarred ureter with subsequent renal problems.
- The biliary tree may also become obstructed and dilated (which has been associated with a raised ALT or Alk Phos). This may be the cause of the severe abdominal pains, well known to ketamine users as 'K cramps'. These symptoms often occur prior to the development of urinary tract symptoms.
"Our experience in Bristol has been that patients are presenting to their GPs with urinary symptoms, but not telling them about their ketamine use and being treated repeatedly with antibiotics"
Patient profile to look out for: If you have a patient who fits the following profile we strongly recommend you ask them directly whether they have used ketamine:
- Any male with symptoms of cystitis.
- Females with symptoms of cystitis, unresponsive to antibiotics or with negative microbiology.
- Males or females with unexplained abdominal pains.
Recommended management is primarily preventative:
- Establish a link: Aim to establish a clinical link between the symptoms and use of ketamine - most ketamine users are well aware of this link, so do ask them.
- Provide the patient with information about causes and outcomes: Explain to the patient the cause of the symptoms (inflammation and ulceration of the bladder), and that if ketamine use is continued, it can result in irreversible bladder damage with chronic suprapubic pain and chronic urinary symptoms (which may require chronic urinary catheterisation or surgical interventions such as removal of the bladder or formation of a new bladder). If urinary symptoms are severe, refer to local urological services for further investigation. If your local urologists feel they need clinical support, the Urology Department at Southmead Hospital, Bristol, now have considerable experience in treating ketamine users and may be able to advise (Ref 6).
- Harm reduction: Encouraging the patient to reduce or ideally stop their ketamine use is important. Cystitis like symptoms should resolve if the patient stops completely before the damage has gone too far. However, patients with severe urinary tract symptoms tend to be reliant on ketamine itself as an analgesic to control the associated pain, so cutting back may only occur if there is good alternative pain control.
- Seek further help from others if your treatment strategy has not worked: If the patient has difficulty stopping, then encourage them to seek advice from a local drugs agency. Chronic ketamine use often results in anxiety and depression which can get worse during a detoxification. Success in stopping will depend on active management of these symptoms plus a substantial amount of psychotherapeutic support. In Bristol, severely dependent users have been detoxed as inpatients, using a reducing benzodiazepine regime to control severe anxiety or have detoxed in the community using oral opiates (e.g. modified release morphine) to control severe urinary tract pain.
Confirmation of ketamine use, explanation of cause and possible outcomes of urinary tract symptoms, plus a referral to an urologist and local drugs agency can be a supportive way forward. In Bristol the Primary Care Trust has written twice now to local GPs and pharmacists alerting them to the problem and encouraging active engagement. Please note that routine urine screens do not test for ketamine.
Most users snort ketamine, but worryingly, we know there is an increase in young people injecting ketamine (intramuscular or intravenous), in the belief that they will be able to use less, get a better hit and avoid some of the adverse effects. All the usual safer injecting advice should be given, plus advice that injecting is unlikely to avoid urinary tract symptoms or K cramps.
If you would like further advice, please contact one of the authors listed below.
1. Chu et al (2007) "Street ketamine"-associated bladder dysfunction: a report of ten cases. Hong Kong Medical Journal, Aug;13(4) :311-3.
2. Chu et al (2008) The destruction of the lower urinary tract by ketamine abuse - a new syndrome? British Journal of Urology International, 102 (11): 1616-1622.
3. Cottrell et al (2008) Urinary tract disease associated with chronic ketamine use. British Medical Journal, 336: 973.
4. Cottrell & Gillatt (2008) Consider ketamine misuse in patients with urinary symptoms (editorial). The Practitioner, 252(1711): 5.
5. Shahani et al (2007) Ketamine-associated ulcerative cystitis: a new clinical entity. Urology, 69(5): 810-812.
Effective pain management for drug users in acute hospital settings is something that appears to be difficult to achieve. Dawn Wintle describes how a team approach that treats the patient with dignity can work. Ed.
Working in an acute hospital it is becoming increasingly evident that the number of patients being admitted with a history of drug use is a growing problem, which in turn is having a direct impact on the hospital and social setting.
Social prejudice and stereotypical perceptions of drug users amongst healthcare professionals can often lead to minimal care being afforded to this client group. It is often perceived that drug users' problems are caused by their lifestyle leading to stigma and resulting in many individuals going untreated and, in some cases, to their problems being exacerbated. Pain management is often sub-optimal for drug users and their opiate withdrawal largely ignored, as their behaviour is seen as "drug seeking". This can lead to patients becoming disruptive, abusive and aggressive, putting both staff and patients at risk.
Good patient assessment is, therefore, paramount and a non-judgemental and positive attitude is essential in order to encourage a good relationship and an honest discussion. Boundaries should be agreed upon with the client, including the consequences that will result if they are breached. Reassurance and support is vital for drug using patients to obtain the best input from healthcare professionals. Obtaining a full drug history is essential to provide a foundation for appropriate management and prompt treatment of withdrawal. Detoxification is not appropriate during an acute illness. The medical problem should be addressed and, given the correct information and support, the patient may choose to engage with drug agencies at a later stage.
"Social prejudice and stereotypical perceptions of drug users amongst healthcare professionals can often lead to minimal care being afforded to this client group"
Good pain assessment is vital, bearing in mind that patients who use street drugs tend to report higher pain scores for an extended period of time (hyperalgesia). This is due to repeated illicit drug use causing changes in the brain neurons. Other factors such as stress, genetics and environmental issues are thought to affect the move from drug use to drug addiction rather than drug tolerance, causing the hyperalgesia.
All patients in acute pain need a balanced, multi modal approach and drug users are no exception. Paracetamol 1g four times a day and a non-steroidal anti-inflammatory drug (unless contra indicated) is recognised as being especially beneficial and should be used to augment opiate analgesia. Tramadol 100mgs four times a day is usually well tolerated by this client group and is now recommended by National Institute for Health and Clinical Excellence. Dihydrocodeine is often best avoided due to its high street value and addictive potential.
Withholding strong opiates from a drug user in severe pain can cause patients to become distressed and at times abusive. This behaviour on admission to hospital can give rise to fear and anxiety amongst staff. Using intravenous morphine via patient controlled analgesia +/- a background infusion gives the patient control, leading to less distress for both patient and staff. Due to these individuals being highly opiate tolerant, they can usually be given as much as required to control their pain; respiratory depression is unlikely even when large doses are given.
Whilst treating their pain the patient's opiate dependence should also be considered and their opiate substitution should run alongside their analgesia. The vast number of drug users admitted to hospital require opiate analgesia and methadone is recognised as the most effective treatment in relieving symptoms of withdrawal. If currently receiving a methadone script, the dose should be checked with the prescriber or pharmacist and continued. If commencing methadone in hospital, care must be taken to avoid overdose. A simple flowchart can be used to do this safely and effectively. As the patient is in an acute area the dose can be titrated more quickly than in the community as they can be observed much more closely. This in turn will reduce the risk of illicit drug use whilst in hospital. Neuropathic pain can be a challenge to treat and the following medication may be considered:
- Amitriptyline, though this can take 7-10 days to have an effect.
- Gabapentin, the dose titrated from 300mgs once daily to 300mgs three times a day over a 3 day period.
- Oxycontin modified release with Oxynorm liquid for breakthrough pain is very effective. The community pharmacist may be willing to dispense this opioid with the patient's daily dose of methadone.
Effective links with drug agencies, GPs and pharmacists is essential. Information can be shared, with patient consent, usually easy to obtain if the patient knows that all are working for their benefit, and are treating them with dignity and respect.
The key elements to effective pain management with drug users in acute settings are effective communication, reassurance, education and patient involvement. To improve care for this patient group there has to be a concerted effort by the entire clinical team, supported by outside agencies. This will ensure a well co-ordinated and seamless service to provide the same high standard of care afforded to any other patient.
Are drug treatment services keeping up with changing patterns of drug use? Ayesha Hurst describes the increase in use of alcohol, amphetamines, cannabis, cocaine and ecstasy amongst young people, and the implications this has for adult services as this group mature. Ed.
The Centre for Public Health, Liverpool John Moores University conducted an investigation into the changing profile of substance use amongst those in contact with structured drug treatment services in the North West of England. This study focussed on individuals stating non-opiate substance use, incorporating alcohol, amphetamines, cannabis, cocaine and ecstasy (AACCE). The original ACCE profile was coined by Howard Parker, Emeritus Professor at Manchester University and one of the co-authors of the report. Initially used as an acronym for alcohol, cannabis, cocaine and ecstasy use, the ACCE proposition recognised that in many regions in England young people's services were primarily engaged with under 18s presenting to treatment due to alcohol and cannabis use, with cocaine and ecstasy use also featuring. Amphetamines were included in profile for the research as, in some areas of the North West; use of this drug is high amongst non-opiate users in contact with treatment. Analysis was conducted to determine whether AACCE clients were a separate group when compared to opiate users.
Background and results
Structured drug treatment services in England have, for many years, been dominated by individuals presenting to treatment for problems associated with heroin use. Nationally, the majority of individuals in contact with structured drug treatment report the problematic use of heroin as their primary substance of misuse (Ref 1). The Drug Strategy, Drugs: protecting families and communities (Ref 2) puts a priority on the treatment of those problematic drug users (PDUs) who use opiates and/or crack cocaine. However, whilst the adult drug treatment sector continues to focus on the treatment of PDUs, contrasting drug using patterns are evident amongst younger drug users in the general population. Cannabis, along with cocaine, amphetamines and ecstasy, are the most popular illicit drugs in the UK, in particular amongst 16-24 year olds (Ref 3). Furthermore, levels of alcohol consumption amongst young people who drink in the UK have risen from 5 units per week in 1990 to 11 units in 2006 (Ref 4).
Table one: Percentage of 16-24 year olds and 16-59 year olds stating last year use of amphetamines, cannabis, cocaine and ecstasy (Source: British Crime Survey, 2007/08)
Analysis of the North West National Drug Treatment Monitoring (NDTMS) data revealed that these patterns of consumption are now beginning to impact on the drug treatment population, with the majority of individuals in contact with young persons treatment agencies reporting the problematic use of alcohol and cannabis, and very few reporting the use of heroin. Those individuals who did not report opiates as a problematic substance were a distinct and growing group, confirming an age related shift in the substance use profile of those in drug treatment. AACCE clients were significantly younger, entered treatment via different referral routes and engaged in different treatment interventions when compared to traditional opiate users. Three quarters of under 25s in contact with structured drug treatment had an AACCE profile, highlighting the importance of this type of substance use within young person's specific services. AACCE clients, on the whole, were more likely to be referred into treatment via "other" referral routes, for example, Connexions, pupil referral units and education services and criminal justice services. A substantial number of non-opiate drug users are coming into contact with the Drug Interventions Programme and entering the treatment system via this route. Once in treatment, AACCE clients entered different interventions of treatment when compared to opiate clients who, on the whole, entered either a specialist or GP prescribing treatment intervention.
Analysis of national data also revealed a shift in the substance use of younger clients in London and the North West from opiate use to an AACCE using profile. This suggests that the North West may act as an indicator of a phenomenon which will eventually impact on the whole of the country. This changing profile will have a significant impact on many aspects of the current drug treatment system whilst also having implications for future drug treatment provision in this country.
Figure one: Age of individuals in contact with treatment by AACCE and opiate use (Source: North West NDTMS, 2007/08)
"An increase in proficiency in non-opiate interventions within adult services may also need to be coupled with consideration as to how attractive, accessible or appropriate current adult treatment services are to those who do not use heroin"
Whilst the AACCE profile is principally an issue for young people's treatment provision at the moment, the changing epidemiology of substance use of those in treatment has the potential to become increasingly important as these AACCE users become older and move into the adult treatment sector. In terms of needs assessment, treatment planning and service development, there needs to be an awareness of the growing problematic use of AACCE substances amongst younger people in treatment and the potential increase in demand for transitional services and adult treatment services to address problematic use of these substances. There is strong evidence from this study that AACCE clients are receiving structured psychosocial and other non prescribing treatment interventions, especially in young people's services. This suggests a need for enhanced competence in psychosocial interventions, not only in the young people's sector, but across the whole drug treatment system. An increase in proficiency in non-opiate interventions within adult services may also need to be coupled with consideration as to how attractive, accessible or appropriate current adult treatment services are to those who do not use heroin. Non-opiate drug users may not wish to attend a treatment service dominated by those presenting with issues surrounding opiate use regardless of the type of interventions offered.
The study also highlights the increasing importance of alcohol use amongst younger clients. The NDTMS dataset used to conduct the research did not collect information on adults regarding the primary problematic use of alcohol during the period in which the study took place. However, in this time period NDTMS did collect this information from young people's treatment providers. Therefore, it was possible to determine that, amongst younger individuals in treatment, alcohol and cannabis use was predominant. This finding suggests that there may be an increased need for community alcohol services or integrated substance misuse services to deal with young adults with hazardous or harmful drinking patterns and secondary cannabis or other drug use.
This study brings attention to the distinct substance use and treatment needs of younger AACCE drug users within structured drug treatment. The National Treatment Agency (NTA) report, "Getting to grips with substance misuse amongst young people" (Ref 5) recognises the changing drug using patterns of young people in treatment in comparison to the predominantly opiate using adult treatment sector. The NTA also highlight the need for transitional arrangements and care pathways between young people and adult drug treatment. If there are no transitional arrangements or if drug treatment services, both in the young person's and adult sector, are dominated by heroin and crack clients, it seems unlikely that treatment services will appear attractive to young AACCE users in need of structured treatment. In order to respond to the needs of younger, non-opiate drug and alcohol users, drug treatment services may need to be reconfigured to reflect changing needs and attitudes.
Hurst A, Parker H, Marr A, McVeigh J (2009). AACCE (non-opiate) substance use in the North West of England- The changing profile of substance users engaged in treatment and its implications for future provision. Liverpool: Liverpool John Moores University.
This report is available on the Centre for Public Health website.
1. National Treatment Agency for Substance Misuse (2008). Statistics from the National Drug Treatment Monitoring System (NDTMS) 1 April 2007-31 March 2008. London: NTA.
2. Home Office (2008). Drugs: protecting families and communities - 2008-2018 strategy. London: Home Office.
3. Hoare J & Flatley J (2008). Drug Misuse Declared: Findings from the 2007/08 British Crime Survey England and Wales. London: Home Office.
4. Fuller E (2006). Smoking Drinking and Drug Use among Young People in England in 2006. London: NCSR and NFER.
5. National Treatment Agency for Substance Misuse (2009). Getting to grips with substance misuse amongst young people. London: NTA.
John Dunn, Consultant Psychiatrist and Clinical Team Leader, NTA has written an article for SMMGP on the important subject 'Preventing unplanned discharges from drug treatment services'. Here is a summary of the article, which can be found on our website in the Other Resources section. Ed.
The article is based upon the findings of the recent National Treatment Agency paper Towards successful treatment completion - a good practice guide (2009).
The article identifies the range of reasons for unplanned discharges, the commonest being dropping out of treatment, followed by going to prison, treatment being withdrawn, the client declining the treatment offered or moving away and losing contact with the treatment service. It highlights the fact that there has been a downward trend in unplanned discharges from 71% of individuals leaving drug treatment in 2004/05, to 66% in 2005/06, 58% in 2006/07 and 48% in 2007/08, which adds credence to the potential for optimising further the number of planned discharges that can be achieved. Finally the article identifies a range of interventions can help to engage and retain clients in treatment. These include: the use of encouraging reminders for appointments; interventions to boost motivation to engage with treatment; quicker entry times to treatment; a more structured induction phase to treatment; accompanying clients to appointments; and the use of elements of assertive outreach to enhance engagement. The paper concludes that further integration of the principles of recovery into the drug treatment system is likely to be the next challenge to improve treatment outcomes and increase the proportion of clients who successfully complete treatment and leave treatment services in a planned way.
Rread the full article on our website, a must for all treatment providers!
Gerry Woodley and Charlie Lowe describe their approach to young people's services in Plymouth. They discuss the common dilemmas including legal issues, and the difficulties in engaging clients whilst at the same time setting boundaries, and argue that a team approach is essential to this area of work. For more on young people's services visit our Dr Fixit's FAQs section for Charlie Lowe's advice to a GP on treating young people. Ed.
Young people or adolescents who misuse substances present particular challenges to the delivery of harm reduction and specific interventions. Compared to their parent's generation they are more exposed to drugs and alcohol, both of which are becoming relatively cheaper to buy. They live in a chemical rich world with rapid communication through text/Facebook/Twitter and have had to adapt new ways to survive. The traditional frictions between young people and the adult world add spice to working with individuals at such a crucial stage in their personal development. We recognise that working with young people is not everyone's bag, but hope this article will give you a flavour of how this important work is delivered and show that it is more than just dressing in more casual clothes!
As a specialist service we do see some highly vulnerable young people (under 18 years old) at the more extreme end of the scale when risk taking can be severe, for example, a 15 year old drinking 270 units of alcohol each week. Complex presentations occur with co-morbidity such as a 16 year old on Subutex alongside significant anorexia. More commonly we encounter worried parents whose teenager risks leaving school with nothing due to smoking too much dope, or young people from second or third generation families with entrenched substance use, unreliable parenting, and unstructured lifestyles experiencing a lack of protection from a variety of traumas, often with Youth Offending Service (YOS) involvement. We frequently encounter a significant gap between the emotional and physical development of these young people. The reality that nobody learns new skills whilst they are repeatedly off their face comes home to roost when the young person becomes stable enough to see this. This then leads to a need to catch up on lost time, particularly around social and educational skills, to allow a chance for substance using young people to reintegrate with their peers. We are pleased to see more innovative interventions springing up to support young people in making these changes encompassing housing, training and employment opportunities as well as family and mental health input. The process is often slow, demanding patience and persistence as the young person progresses around the cycle of change at their own pace. It often seems too soon for a young person to be moving on to adult services at the age of 18, where there will often be less available time and opportunity to tailor care individually.
In our service the primary drug of referral in the past year was (in order of frequency) cannabis, alcohol, heroin and solvents. Alcohol use has become more risky and more recognised as such by referring professionals. Even when alcohol is a secondary drug it represents higher risks than in the past. The Plymouth Children and Young People's Trust currently commissions a 12 week intervention although at times the actual length of this service may exceed a year. Self or parent referrals are accepted whilst professionals (Education, Social Services, YOS, Youth Services) must refer using the DUST (Drug Use Screening Tool) that quantifies risks by substance use, mental health and social parameters (Ref 1).
We operate a tier 3 specialist service which involves a comprehensive assessment and structured interventions according to a care plan. In the main the interventions are psychosocial and on a one-to-one basis, but occasionally involve group work. Pharmacological interventions are not the norm (5.6% of clients) and over the past 3 years there have been about 3 prescriptions at any one time for young people compared to about 1,000 adult scripts covering a total Plymouth population of 240,000. Buprenorphine (Subutex) is the first line choice for opiate dependency for young people at a dose of 16mg by daily supervised consumption due to its blockade effect and the fact that it is licensed for use for 16 year olds. Periodically methadone is used as a second line treatment after an unsuccessful trial of buprenorphine. Methadone is licensed for use for 18 year olds, requiring experienced prescribers to act outside of licensing guidance for young people and team/colleague consultation over treatment rational; decisions need to be clearly recorded for clinical governance purposes. We have only prescribed diazepam once as an adjuvant to a problematic buprenorphine induction.
A vital aspect of working with young people relates to the legal responsibility for parents to consent to any assessment or treatment interventions given to their child. Often this is willingly provided and the young person is happy for parents to be fully involved in their care plan. But where family communication and support has broken down, or at times sadly never been available, we have to ensure that the young person has the competency to take decisions about their own wellbeing and is supported by other appropriate adults. The Fraser Guidelines (Ref 2) act as a reference in such an assessment and when we work without parental consent, then the weekly team meeting becomes the forum to debate the risks and benefits of the situation on an ongoing basis with all discussions and decisions being carefully recorded. At times social workers or legal guardians become involved in this process. It is not unusual for the unmet parenting needs of a young person to surface as they become engaged with our service and advocacy on their behalf is an extended role of the team.
"We frequently encounter a significant gap between the emotional and physical development of these young people. The reality that nobody learns new skills whilst they are repeatedly off their face comes home to roost when the young person becomes stable enough to see this"
Plymouth Young People's Service
Both authors have been involved with the Plymouth Young People's Service (YPS) since its inception in 2002 and have witnessed a growth in both the team and referral rates. Harbour is a charitable organisation that employs all team members except the GP Specialist Prescriber who is employed by the Primary Care Trust (PCT) for half a session per week. We do not have dedicated premises and see young people in many locations such as home, coffee shops, school, the YOS offices, youth clubs, Pupil Referral Units (PRU), GP surgeries or other youth service venues. We do not see young people in adult services in keeping with good practice guidelines to protect their vulnerability from contact with long term and entrenched users.
YPS has grown in size and now consists of a manager, full-time administrator, practice supervisor and 5 substance misuse specialist workers with different roles. These include workers based in the YOS, the youth service and the sexual health outreach project. The latter post aims to address the needs of sex workers and provides chlamydia screening/pregnancy testing as well as transitional support for young people moving to adult services. This team along with the GP Specialist Prescriber meet weekly in a structured format that covers new referrals, prescribing and risk issues, case presentations and performance management. Monthly team supervision led by a Child and Adolescent Mental Health (CAMHS) Consultant Psychiatrist is very valuable and has built a useful bridge for young people with significant mental health problems. It is not at all unusual to encounter Attention Deficit Hyperactivity Disorder, autism or learning disability in this client group.
The prescribing author is the PCT's Clinical Lead for Substance Misuse in Primary Care with 15 years experience and also a qualified Family Therapist. Over time it has become clear that the presence of the GP prescriber at regular team meetings is not just about prescribing - as numbers are so limited. The purpose of the prescriber's involvement seems to be two-fold namely the need to be familiar with the using habits of local young people and the collateral services that become involved in their care, and secondly to bring their particular medical skills and biological understanding into the team mix as complex risk management decisions are made.
The reflections of a senior clinician, from a more detached position, add an important safety feature to team working with young people. This relates to the frequently encountered dilemma for workers of striking a balance between being the young person's new mate to engage them into treatment, whilst at the same time setting down a boundary when behaviours demand one, thereby risking losing that young person's trust. This type of role involves knowledge and skills of team and interpersonal dynamics as well as psychological development and treatments. You have to be an active member of the team, including attending team events and parties, to have the credibility for your opinions to be received into the decision making process.
A variety of models have been adopted across the UK to provide substance misuse prescribing to young people and in the main these have been provided by either GPs or CAMHS Psychiatrists. Adult Addiction Psychiatrists do not have a remit to practice on clients under 18 years.
Unfortunately there is no official route to qualify for this task although Tom Aldridge Young Person's Manager with the National Treatment Agency is supporting a steering group between the Royal College of General Practitioners (RCGP) and Royal College of Psychiatrists to developing a training certificate for doctors working with young people.
It would be advisable for all GPs in this role to have acquired both the Part 1 and 2 RCGP Certificate Courses which will adequately cover prescribing. However there remains a gap in provision of suitable training for the extended role of working with young people other than the Masters course at Keele University run by Ilana Crome, Professor of Addiction Psychiatry. Those GPs already working with young people may wish to make contact with a fledgling special interest group by contacting Jo Betterton at the RCGP Substance Misuse Unit (Ref 3).
Surveys have revealed that young people most appreciates confidentiality, trust, accessibility and service quality. It is important to provide a service that is sensitive to all young people's needs, provides a welcome from friendly staff, has a readiness to see clients now or later even if busy, and a service that is easy to get to where young people feel safe.
Marcus Roberts takes us through the twists and turns of drug policy over the past decade, and the effect this has had on the drug treatment field. He suggests that the policy focus on crime may not have delivered the best treatment, and argues that a return to a compassionate approach that emphasises reintegration is the way forward. Ed.
On first entering government in 1997, Tony Blair was quick to declare that drug use would be a policy priority. Within a year, New Labour had appointed a drug tsar - Keith Hellawell - and published a ten year national drug strategy (Ref 1). In 2001 it set up the National Treatment Agency (NTA) to improve the availability, capacity and effectiveness of treatment in England. While drug tsardom is an increasingly distant memory, the NTA is still with us - with an annual operating budget of around £11.5 million - and we are over a year into a second ten year plan (Ref 2). Drug policy continues to have a political profile that would have been simply unthinkable twenty or thirty years ago. Over £800 million is being invested in drug treatment annually. Drug treatment capacity has more than doubled since Labour took office, there has been a huge expansion in the treatment workforce, people get into treatment much more quickly (waiting times have been slashed) and stay in treatment longer (retention times have increased).
Despite all this, when the NTA published its Annual Report in 2007, saying precisely this, it was described by the then Shadow Home Secretary, David Davis, as "an absolutely shocking revelation", which "spoke volumes about the government's incompetence and distorted priorities". So what was the problem? To cut a long story short, it's one thing to get nearly 200,000 people into drug treatment (and not to keep them waiting for it), but how many are coming out of it, and what sort of outcomes are being achieved? The "shocking revelation" was that "only" 5,829 people - 3% of the total - had been discharged from treatment "drug free" in 2006-07. This also raised eyebrows and hackles in the media: soberly, in a notable BBC report by Mark Easton; more shrilly in the tabloids. The Daily Mail complained of a "£1.9 million bill to help just one drug addict kick the habit", while the Sun announced that "the NHS blows £130 million curing 70 junkies".
This new mood was described as "The New Abstentionism" in an article by Mike Ashton, editor of Drug and Alcohol Findings, published in DrugScope's magazine, DrugLink, in January/February 2008. Its rallying cry was the complaint that the drug treatment system had become excessively dependent on methadone - not only to stabilise people while other interventions kick in, but over long (and sometimes indefinite) periods. The figures are striking. In 2006-07, 118,107 people were being prescribed substitute drugs, compared to 5,350 people receiving treatment in a residential rehabilitation centre funded by the drugs pooled treatment budget.
So was this evidence that drug treatment was failing? This was one of the questions posed at a series of DrugScope debates in 2008. There was little evidence at events in Edinburgh, Manchester or London that the drug field had any appetite for dividing into factions under the banners of "abstinence" and "methadone", and slugging it out to the death. On the contrary, there was agreement that drug treatment services should support a range of approaches - it was about providing the right intervention, to the right person, at the right time and in the right way.
There is a strong evidence base for substitute prescribing. The National Institute for Health and Clinical Excellence recommends methadone and buprenorphine for opioid dependency. At the same time, it was widely accepted that 'parking' people on methadone - for long periods and without other forms of help and support - is (a) far too common and (b) not nearly good enough. So, Peter McDermott of The Alliance, who spoke about the vital role that methadone had played in his own recovery, also commented that "there are quite a few people who work in the drug treatment system who do see methadone as about control ... who have very low expectations of and aspirations for the people they work with ... and who do not have faith in the ability of service users to make positive changes to their lives".
"One of the reasons for the prevalence of methadone maintenance and limited aspiration has been a narrow fixation on crime reduction"
At this point, a sub-tributary of "New Abstentionism" is not a million miles away from another source of criticism that is not uncommon among front-line services. At one of DrugScope's 'Great Debate' sessions, Senior Lecturer David Best commented that too often "little treatment is actually delivered. The chronic relapsing condition mantra has become a self-serving prophecy. This has contributed to a demoralisation of a workforce attempting to meet quantitative targets not client change". In a recent DrugLink article, an anonymous frontline worker - "Beth" - conveyed the day-to-day reality of work in this kind of environment: "I have on my lap a 27-page assessment form, a risk assessment and a TOP (Ref 3) form ... he tells me ... he has never really talked to anyone about the difficulties in his life. I put the forms on the floor and say 'Would you like to tell me about yourself?'"
So what is the prognosis for drug treatment? There are signs of a genuine shift in drug treatment policy and practice - consider, for example, the focus on social (re)integration and personalisation in the 2008 drug strategy or the new emphasis on quality from the NTA. We should also recognise the risks. The commitment to social (re)integration has manifested itself in a Welfare Reform Bill currently before parliament, that gives JobCentres unprecedented powers to investigate claimants they suspect of having drug problems (including, in some circumstances, requiring them to take drug tests) and to require them to have treatment, all under threat of benefit sanctions. Similarly, questioning methadone is one thing, but evidence-based treatment has been hard won and should not be lightly or inadvertently surrendered. Whatever the pros and cons of methadone maintenance, it is not for politicians or newspapers to decide issues of clinical effectiveness - we must beware of treatment modality by plebiscite.
One of the reasons for the prevalence of methadone maintenance and limited aspiration has been a narrow fixation on crime reduction (not a disreputable policy objective in its proper place). The big challenge now is to argue for investment in drug treatment on the basis of compassion and effectiveness, not simply fear. We were therefore encouraged to find that the public may be much more supportive of drug treatment services than is sometimes assumed. DrugScope commissioned a DrugScope/ICM poll, which found that, of 1,039 respondents: 76 per cent agreed that "investment in drug treatment is a sensible use of government money, so long as it benefits individuals, families and communities", and 88 per cent agreed that "drug treatment should be available to anyone with an addiction to drugs who is prepared to address it".
As well as highlighting the importance of drug policy to his new administration, another of Tony Blair's earliest announcements following that historic election victory in 1997 was the establishment of a social exclusion unit, reporting directly to the Prime Minister. Thereafter, drug policy was co-opted by the crime reduction agenda, and parted company with social inclusion policy to a surprising extent. With a new emphasis in the 2008 drug strategy on social (re)integration, there is a chance that it may be coming home ... then again, who knows what lies around the corner, with a change of government possible and the economic storm clouds gathering. We will need to lobby hard and shrewdly both to defend the ground gained and continue to push things forward.
Director of Policy and Membership, DrugScope
"Drug Treatment at the Crossroads - What's it for, where it's at and how to make it even better", is available on the DrugScope website. If you would like a hard copy or have any comments on this article or the report, you can e-mail Marcus Roberts.
1. Department of Health (1998) Tackling Drugs to Build a better Britain The Government's Ten-Year Strategy for Tackling Drugs Misuse
2. Her Majesty's Government (2008) Drugs: Protecting Families and Communities - The 2008 Drug Strategy
3. Treatment Outcomes Profile
Most of you agreed with the UKDPC recovery statement - but what are the implications for general practice? Roy Robertson gives his views. Ed.
In July/August last year, SMMGP consulted its membership to get their views on the UK Drug Policy Commission (UKDPC) facilitated Recovery Consensus Statement (see results). Overall, members reacted very positively to it and 74% agreed with the statement (46% fully "endorsed" it, and only 12% disagreed with it).
To recap, the UKDPC statement is a consensus reached by 16 individuals (of which I am one) with a variety of backgrounds and expertise. The group includes several people in recovery, family members, local commissioners and practitioners involved in 12-step approaches, substitute prescribing, general practice, residential rehabilitation and peer and family support groups. The final consensus statement is as follows:
The process of recovery from problematic substance use is characterised by voluntarily-sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society.
Given the much publicised (and often unhelpful) "abstinence vs maintenance" debate which persists in the drug treatment field, reaching a consensus might be considered a significant achievement in its own right. However, these carefully chosen words matter little unless those seeking to help problem drug users are prompted to consider whether or not they are genuinely recovery-oriented. For GPs, it reaffirms the crucial role that we can play in the recovery process, and suggests we should be mindful of the following three vital elements of recovery:
1) Personalisation and choice
We come into contact with a much wider spectrum of people with drug problems than more specialised drug treatment professionals. Addiction can present itself in a thousand different ways both as a side issue and as the presenting problem, and each situation will be unique. This means that a full range of clinical and other interventions will need to be utilised, from needle exchange to maintenance programmes and withdrawal programmes - and everything in-between. As one SMMGP member succinctly responded, "Surely it is whatever works - when did one size fit all?!"
However, it is also important to encourage patients to take ownership of their recovery, determining their own goals and the steps required to achieve them. The need for self-motivation means that, perhaps even more so than with other conditions, the GP must avoid being prescriptive and instead provide viable options and enough guidance to allow patients to make considered choices. "Recovery should be something that the individual should have some responsibility for", responded one SMMGP member. "They should be able to make informed decisions about treatment."
2) Recovery capital
Recovery also embraces reintegration into society to build a satisfying and meaningful life (something which realistically can only be defined by the individual themselves). Although the primary focus of the GP should, of course, be to address the patient's drug use and other health problems, it is virtually impossible for doctors to separate out an individual's recovery in health terms and their recovery in social terms. This makes us particularly well placed to understand the full complexity of addiction in their lives and to work with partner agencies, something that unfortunately takes time but should be a core function of our work.
Recovery can occur, or at least begin to emerge, in response to all sorts of events and personal experiences. If we know whether our patients are 'moving on' in other aspects of their lives, we can help our patients better judge whether it is time to also move on in their substance use. The concept of "recovery capital" helps us to consider the internal and external resources that a person can draw upon to initiate and sustain recovery. These "resources" are things like personal confidence, supportive relationships with family and friends and with recovery communities such as Narcotics Anonymous (NA), a meaningful vocation and good housing. Some patients might have enough recovery capital to "naturally" recover without clinical interventions. Others will not be so fortunate, and GPs will want to be confident that their patients have a care plan that addresses all of the important issues relating to their recovery, not just their drug use.
3) Being positive
Self-belief and self-motivation are key aspects of recovery and if we are optimistic about our patients' prospects we can encourage them to foster a positive outlook. This might sometimes be a challenge for both doctors and patients who have experienced, and are at times wearily resigned to, relapse. Nevertheless, we must recognise it is impossible to be sure when recovery might begin and under what circumstances. At this point it might be worth reminding ourselves that abstinence is not the same as recovery, so this is not about measuring success solely in terms of someone becoming "drug free". We can therefore still be optimistic for those patients for whom long term use of methadone (or other opiate substitutes) is an essential part of their recovery, not a barrier to it.
The process of recovery might sometimes only result in small gains (or maintaining existing ones) such as abstinence from injecting, a reduction in illegal drug use, engaging with services, reorganising a chaotic life or re-establishing contacts with family and friends. Recovery can be slow and beset with setbacks, or progressive and surprisingly rapid, and the "distance travelled" and "end point" will be different for every individual. We should help patients to regularly reassess their goals and how they aim to achieve them to ensure that motivation is maintained and health and wellbeing really are maximised.
Our profession can surely rise to the challenge presented by the concept of recovery. For if nothing else it means doing something that GPs are traditionally very good at doing: listening to our patients and putting them at the heart of the process.
Follow the link for more information on the UKDPC recovery statement.
Release step in as Lawyer Fixit to provide some excellent housing advice to a GP whose patient is homeless. Ed.
Mary has been a patient of mine for years. She is very settled on maintenance drug treatment and wants to remain so at the moment. Her main problem is housing - Mary lived with her ex-husband and Doris, her mother-in-law until her death a few months ago.
After Doris's death she was turfed out of the house with no funds and has had to go and sleep on the sofa at her daughter's home. This property is very overcrowded as her daughter has 2 children and lives in a small 2 bedroom flat.
Mary has a number of medical problems including chronic hepatitis C, diabetes and high blood pressure. She has never applied for benefits or housing and she is worried because she has a drug problem. She wants me to write a letter to say she is mentally ill, (not mentioning that she has used drugs) and that she needs housing urgently. I agree that she needs housing urgently but can you advise the best way I can help her get housed? And what laws do I need to be careful about?
Mary's housing situation will depend on what her status was when living at Doris's and whether the local authority deems her as being made "intentionally homeless" as a result of the eviction. The main piece of legislation which would assist here is the Housing Act 1996.
Whether Mary would have been made intentionally homeless is defined by section 196 of the Housing Act 1996 as follows: "A person becomes threatened with homelessness intentionally if he deliberately does or fails to do anything the likely result of which is that he will be forced to leave accommodation which is available for his occupation and which it would have been reasonable for him to continue to occupy."
Was Doris's home a council property? If so, and if Mary's name was on the tenancy there, and she was evicted against her will by her ex through no fault of her own, then her rights will be greatly strengthened. The local authority may well have a duty to re-house her immediately and in this situation Mary should go to a specialist housing solicitor for help as soon as possible.
If Mary's name was on the tenancy but the eviction was for rent arrears for which she was even partly responsible (a common situation), then it is likely that she will be seen to have made herself intentionally homeless. In this situation, the council's duty to re-house her is limited and will depend on whether she is in "priority need". This is discussed in more detail below.
If Mary's name was not on the tenancy then she would have been seen as just having had a "licence" to occupy the property, which is not a secure right and could have been deemed to end when Doris died. She would still have a right to be re-housed if she can be said to be in priority need.
For the local authority to have a duty to re-house Mary in her current situation she should be defined as "homeless". A person is classed as homeless when:
- There is no accommodation that they are entitled to occupy; or
- They have accommodation but it is not reasonable for them to continue to occupy this accommodation (Housing Act 1996).
Because of the overcrowding at Mary's daughter's house, most people would agree it is not reasonable for her to occupy her current accommodation.
However, because of the increasing overcrowding and shortage of properties in inner city areas, many local authorities might try to assert that she is not actually homeless at present. If this is the case, Mary would be in a stronger position if her daughter were to end her licence to live at this property by telling her she must leave. She would then be threatened with homelessness which would establish a basic duty. The good thing is that having her daughter there will establish a local connection for Mary to be housed in that borough.
So, assuming that Mary is seen as homeless or threatened with homelessness and that she was not made intentionally homeless to begin with, the next question that she must satisfy in order to be re-housed by the local authority is whether she is deemed as being in "priority need" or not.
Priority need is defined in section 189 of the Housing Act 1996. In Mary's case, the relevant definition would be: "A person who is vulnerable as a result of old age, mental illness or handicap or physical disability or other special reason". Mary has chronic hepatitis C, diabetes, high blood pressure and a drug problem.
Depending on the severity of her symptoms, there is an argument that she could be seen as being in priority need. You clearly cannot say that Mary has a mental health problem if she does not, as this is a breach of professional conduct rules. However, a strong letter to the local authority outlining all her health problems at their worst should help her. The drug use does not need to be mentioned but it might be worth having a word with Mary about this, as it could assist her to disclose her situation in full; there is in fact case law to say that if someone is on drug maintenance and risks relapse by being homeless then they should be deemed as priority need (Crossley v City of Westminster).
Again, there is a caveat that many local authorities in overcrowded inner city areas are making the threshold for being in priority need higher and higher so that sometimes even the worst cases are not deemed as satisfying the criteria. If the local authority deems Mary is not in priority need then there is a duty under the Housing Act to give written reasons as to why this is. When Mary receives this letter she should be referred immediately to a housing solicitor, who can assist her in appealing this decision.
Sometimes the local authority find there is "apparent priority need" and so accommodate someone in emergency housing (usually a hostel or B&B), while they do a fuller assessment. At the end of this assessment period (usually about 3 months), that person should be given permanent accommodation if they are found to be in priority need. Again, if the person is found not to be in priority need then the local authority needs to inform them in writing of this decision and it can be appealed through a solicitor as above.
It should be remembered that whatever Mary's situation, the local authority does have a discretion (as opposed to a duty) to house her and there is always a duty under the Housing Act to provide advice and information about housing. Mary should also be advised to apply for benefits, in her case Employment Support Allowance and possibly Disability Living Allowance, which would help her in obtaining some income and having easy access to Legal Aid. Once she has accommodation she will also be eligible for housing and council tax benefit.
For further advice please call the Release helpline on 0845 4500 215 (Monday-Friday 11am-1pm and 2pm-4pm).
Claudia Rubin outlines some of the legal campaigns that Release are involved in, and highlights just how important this organisation is for the protection of drug users' rights. For more from Release, see the Lawyer Fixit on housing. Ed.
When it comes to campaigning for drug policy reform, Release is spoilt for choice
In selecting the issues for Release's campaign for drug policy reform, there are unfortunately too many issues in need of attention: with so much potential for harm, where do you start?
Complementing the services we provide to the drug using community, Release campaigns for changes to UK drug policy to bring about a fairer and more compassionate framework to manage drug use in our society. We strive to defend the rights of drug users from discrimination, prejudice and stigma. We help drug users to gain better access to legal advice, health care and basic social services such as housing and benefits. We also campaign for the fairer treatment of drug users by the press. We know that by caring better for and improving the lives of dependent drug users, we impact positively on crime and the wider society. The criminal justice approach to drugs has spawned generations of people isolated from mainstream society and suffering from the harmful effects of longterm drug use. Our current campaigns are chosen to address some of the worst aspects of this strategy.
Nice People Take Drugs
Our latest campaign to attract wideranging support in the UK and overseas, is the Nice People Take Drugs campaign. We believe that breaking the taboo on drugs is the first step to reducing the harm that they can cause. We must shift the perception that drug users are 'bad' and that all drug use is 'evil'. Over one third of the adult population of England and Wales has used illegal drugs. A focus on banning substances and arresting those who experiment with them has been at the expense of the absence of a robust and comprehensive public health campaign, and adequate treatment for dependent users. If measures to reduce the harm caused by drugs are to be successful, they must be premised first and foremost on the reality of the many forms that drug use takes, and a realistic portrayal of who drug users are. We are looking for people from all walks of life - every age, class, race and profession - to support the slogan by wearing our t-shirts and badges.
Another of our campaigns has been in the media a lot lately as we are taking action at the High Court against the British Transport Police for their use of sniffer dogs to detect drugs. These dogs are an ineffective and intrusive strategy that does nothing to reduce the harm caused by drugs. Release has made several Freedom of Information requests to police forces throughout the country, which show that in over 75% of searches (resulting from a dog sniff) no drugs were found.
Release believes that this approach criminalises people disproportionately; it contravenes our right to go about our daily business without unjustified police interference and the considerable costs are a waste of taxpayer's money.
The rate of hepatitis C infection amongst the injecting drug user community continues to rise steadily and access to treatment for these individuals is inconsistent at best. National Institute for Health and Clinical Excellence guidelines clearly state that injecting drug users should not be denied treatment, and it is clear that an effective public health strategy to curtail the spread of hepatitis C relies on current and past drug users receiving treatment. Release is looking for information from health practitioners as well as from patients to strengthen our campaign to ensure better access to treatment for all.
Release aims to achieve the introduction of a regulatory system that allows people in the UK to legally use the cannabis plant as a form of pain relief. We often hear from individuals who use cannabis to relieve the symptoms of their chronic pain and who would not only benefit from receiving a prescription form of pain relief, but who find themselves subjected to unnecessary harm by a criminal prosecution for growing their own plant. The law on personal use of cannabis is absurd and fruitless at the best of times but when it comes to medicinal use, policy reform is essential.
Release aims to amend section 9a of the Misuse of Drugs Act to include all drug paraphernalia so that more items can be distributed as part of a public health and harm reduction strategy.
If you would like to know more about any of our campaigns, or how you can support us, please contact:
Methadone deaths have increased over the past few years. Penny Schofield examines possible reasons for this and the steps clinicians can take in order to reduce the risk of methadone-related deaths. Ed.
Methadone maintenance is a key evidence-based treatment for opioid dependence. It is recommended by the National Institute for Health and Clinical Excellence (NICE) (Ref 1). Methadone treatment programmes have been shown to be clinically effective in reducing illicit opioid misuse, reducing injecting and HIV risk behaviour and reducing rates of overdose death. The NICE technology guidance notes that the mortality risk of those with heroin dependence is around 12 times that of the general population. It reports meta-analysis of observational studies showing that heroin users who were not in methadone treatment were four times more likely to die of overdose than those who were in treatment. However, methadone treatment is not without controversy: not least because it involves prescribing a potentially dangerous drug.
Despite methadone treatment protecting opioid misusers from overdose, deaths involving methadone have increased in England and Wales during the past five years. This increase is paralleled in other countries. In England the increase has to be seen in the context of a rapid and sustained increase in the number of drug users in effective treatment.
There are two important sources of information on drug-related deaths in England and Wales. The Office of National Statistics (ONS) collects data based on the registration of deaths in each calendar year. Deaths are included if the underlying cause of death is regarded as having resulted from drugrelated poisoning. The database includes accidents and suicides involving drug poisoning as well as poisonings due to drug abuse and drug dependence.
The National Programme on Substance Abuse Deaths (np-SAD) is a UKwide reporting system that receives information on drug-related deaths on a voluntary basis from the coroners in England and Wales, or in Scotland from the Procurator Fiscal. Np-SAD publishes their results in an annual report.
The ONS data set is complete and therefore more suitable for analysing epidemiological trends. It is used by the Department of Health to monitor progress against the UK Drug Strategy target to reduce drug-related deaths. Np-SAD data is more detailed, but less complete and more suitable for looking at possible causes of death that might be amenable to change.
The ONS and np-SAD reports for 2007 published in 2008 both showed an increase in methadone deaths. The ONS report (Ref 2) found that in England and Wales there were 167 deaths attributable to methadone alone (compared to 125 in 2006, and 74 in 2003) and 325 deaths in which methadone was implicated along with other drugs (as compared to 241 in 2006, and 201 in 2003). The np-SAD report (Ref 3) states:
"A recurrent theme in the np-SAD annual reports has been deaths due to methadone. The number of such fatalities continues to rise (from 159 in 2004 to 295 in 2007), as has the proportion of all deaths in which it is implicated (from 12.4% to 20.2% over the same period)."
It is important to remember that the postmortem interpretation of methadone toxicology is complex and that tolerant individuals will have very high serum levels. Most deaths, including methadone deaths, involve multiple drugs including heroin, benzodiazepines, cocaine and alcohol. We also know that the relationship between prescribed and illicit methadone and between opioid and methadone deaths is a complex one. Methadone is highly effective at reducing the morbidity and mortality associated with opioid addiction. However, methadone's long, variable half-life, the variability in metabolism between individuals, interactions with other drugs and varying degrees of tolerance makes it a potentially very dangerous drug when misused or carelessly prescribed. Careful assessment and dose induction taking into consideration the use of other sedative drugs including alcohol and benzodiazepines, appropriate use of supervised consumption and open discussion with clients on the dangers of methadone both for self and others provides the foundation for prescribing that is safe for both the individual and the community.
The majority of methadone-related deaths occur through diverted methadone. The np-SAD report stated, "in up to 70% of such cases (methadone deaths) methadone prescribed for one individual has been consumed by another person."
One of the functions of supervised consumption is to reduce diversion and there is some evidence that increased supervision reduces methadone deaths. Prior to the publication of the 1999 Clinical Guidelines (Ref 4) there was little supervised consumption of methadone in the UK. Methadone prescribing increased between 1993 and 1997 (Ref 5), as did deaths in which methadone was implicated, from 206 in 1993, to 398 in 1997 in England and Wales (Ref 6).
One study involving analysis of methadone prescription rates and methadone deaths showed a highly significant reduction in methadone deaths after this point (Ref 7). This study estimated the death rate from methadone per thousand treatment patient-years. Methadonerelated deaths dropped from 12-13 per thousand methadone treatment patient-years from 1993-97, to 3.1 per thousand methadone treatment patient-years in 2004. As National Addiction Centre researchers commented:
"we are left in little doubt that .... the large decline in methadone- related deaths is most likely to be related to the introduction of supervised consumption of methadone" (Ref 8).
Of course the introduction of the 1999 Clinical Guidelines was associated not only with increased supervised consumption, but also with an increased awareness of methadone risks - particularly at the start of treatment - and recognition of the need for appropriate training and support for prescribers.
However, supervision alone does not prevent methadone deaths among those being supervised. A Scottish Confidential Enquiry in to methadone deaths in 2000 (Ref 9) noted that 56% of those who died in Scotland while in receipt of a methadone prescription were supervised, and that only 1 recorded as having a methadone death died in the first 4 weeks of treatment.
Implications for clinical practice
Increased supervision at the start of treatment, the use of clinical guidelines and increased competencies of prescribers appears to reduce methadone deaths. Tax payers and the public need to have confidence in treatment programmes and there needs to be a balance between tight control and helping to normalise lives. Reduction in supervision is seen both as an incentive for positive progress and provides motivation for clients. It would be counter-productive as well as too expensive to keep clients who were stable and progressing well in treatment on supervision long term.
The 2007 Clinical Guidelines (Ref 10) state:
"In most cases, new patients being prescribed methadone or buprenorphine should be required to take their daily doses under the direct supervision of a professional for a period of time that may be around three months, subject to assessment of patients' compliance and individual circumstances."
"The majority of methadone-related deaths occur through diverted methadone. The np- SAD report stated, "in up to 70% of such cases methadone prescribed for one individual has been consumed by another person"
Stability and treatment compliance are the keys to any reduction in supervision. Is there evidence that stable clients are less likely to divert their prescribed methadone than unstable clients?
Clinical experience suggests that stable clients may reduce their dose over time and in some circumstances may take a regular dose well below that prescribed. Clearly in this situation there are both risks of diverted methadone and risk to the individual. Adherence to prescribed medication is likely to improve treatment effectiveness as well as reduce the potential for diversion (Ref 11); in this study from an inner London community drug dependency unit, which focused on adherence to medication rather than diversion, 58% of clients on methadone maintenance were found to fully adhere to their prescription, a figure similar to that found among patients with other chronic conditions.
What can be done to encourage adherence to the prescription and increase pressure to prevent diversion?
- Prescribers and key workers need to ensure close liaison with pharmacists, pay more attention to medication adherence that might include asking regularly about compliance, regular clinical assessment of injection sites and regular drug monitoring.
- Increased supervision should be considered for those who continue to use "on top" of their prescription.
- Psychosocial interventions including contingency management and education on the importance of adherence to the correct dose have been shown to improve compliance with medication.
Services can also increase pressure to prevent diversion by the use of more robust educational efforts aimed not just at service users, but also including carers and the public. Educational messages need to be repeated regularly during keyworker sessions and discussion needs to be backed up by written information. Education should include not only advice on avoiding and managing overdose and risks associated with using other drugs and alcohol, but also emphasize the risks to others of diversion and careless handling and storage of methadone. Providers should ensure robust protocols for dealing with lost and stolen medication. The wider use of take home naloxone could also contribute to a reduction in methadone deaths. The National Treatment Agency is currently piloting projects training family members to give naloxone.
Finally providers and partnerships must ensure that there are robust clinical governance structures in place that will identify problems associated with prescribing and dispensing of methadone. Clinical governance mechanisms should include regular audits of prescribing practice, identification of prescribing outside of commissioned services, critical incident reviews at which clinicians feel confident to reflect on their practice and regular training opportunities to maintain competencies. The establishment of multi-agency partnership wide groups to look at "near-misses" will help to promote better understanding of methadone risks (Ref 12).
It may not be possible to completely prevent methadone-associated overdose deaths, but they must be minimised. Accessible treatment based on the latest clinical guidelines, supported by good clinical governance mechanisms are key to achieving this, together with an increased focus on treatment planning and more intensive psychosocial interventions to improve progress through treatment combined with careful prescribing, high quality key-working and increased education.
1. Methadone and buprenorphine for the management of opioid dependence (2007) NICE technology appraisal guidance 114.
2. Office for National Statistics (2008) 'Deaths related to drug poisoning in England and Wales, 2003-07' Health Statistics Quarterly 39, 82-88
3. Ghodse H, Corkery J, Oyefeso A, Schifano F (2008) Drug-related deaths in the UK Annual Report 2008, International Centre for Drug Policy
4. Department of Health (2007) Drug Misuse and Dependence - Guidelines on Clinical Management
5. Strang et al (2003) Effect of National Guidelines on prescription of methadone: analysis of NHS prescription data 1990- 2001 BMJ; 2003, 321-322
6. Office for National Statistics 'Death related to drug poisoning in England and Wales 1993
7. Morgan O, Griffiths C, Hickman M (2006) Association between availability of heroin and methadone and fatal poisoning in England and Wales 1993-2004. International Journal of Epidemiology 35; 1579-1585.
8. Zador D, Mayet S and Strang J (2006) Commentary: Decline in methadone-related deaths probably relates to increased supervision in UK. International Journal of Epidemiology 35; 1586-7
9. National Confidential Enquiry into Methadone Related Deaths (Scotland) 2000
10. Department of Health (2007) Drug Misuse and Dependence - Guidelines on Clinical Management
11. Haskew et al Patterns of Adherence to oral methadone - Implications for prescribers (2008) Journal of Substance Abuse Treatment 35, Issue 2 109-115.
12. National Treatment Agency for Substance Misuse Harm Reduction Strategy - Guidance to support treatment-planning 2009-2010.
Caryl Beynon leads us through the maze of terminology regarding drug related deaths and describes how in Liverpool they have designed a system to give a clearer picture of when drug use has been involved in an individual's death, in order that the right lessons can be learned. Ed.
You might assume that identifying the number of people who die from drug use is straightforward; I have been researching this area for some years now and I have decided it is anything but. The situation is complicated by the existence of different definitions for which deaths can be recorded as drug related. There is the Office of National Statistics standard definition which includes deaths due to drug toxicity, mental and behavioural disorders due to drug use and assault with drugs, but includes both illicit substances and those dispensed over-the-counter and on prescription. There is the National Drug Strategy definition, which is similar with the exception that it only includes deaths arising from the consumption of drugs controlled under the Misuse of Drugs Act (1971). Finally, there is a European definition provided by the European Monitoring Centre for Drugs and Drug Addiction which defines a drug related death as an "overdose" or equivalent concepts: "deaths directly related to drug use", "poisonings" or "drug-induced deaths". All three definitions include and exclude particular deaths and so give different results (see Figure 1).
Figure 1: Drug related deaths in the UK by definition, 1996-2006 (Ref 1)
Despite their differences, all three definitions only include deaths which result from the immediate effects of taking a drug. What is not covered in these definitions of a drug related death are those which are related to drug use but which take many days, months or years to develop. Therefore, excluded from official figures on drug related deaths are deaths from, for example, hepatocellular carcinoma resulting from hepatitis C contracted via injecting a drug with a contaminated needle/syringe, infective endocarditis caused when an injection related infection passes to the heart, aspiration pneumonia initiated during opiate related depression of the central nervous system, or stimulant related cerebrovascular complications. Let's call this second category of deaths from the longer term effects of drug use "drug associated deaths" to differentiate them from "drug related deaths".
In 2004, colleagues and I at the Centre for Public Health, Liverpool John Moores University initiated a research study to consider these issues in more detail. We decided to gather information on all deaths of drug users, rather than simply on drug related deaths, and so far we have collated data on the causes of death for 504 drug users who died when in contact with treatment services in the North West of England (Ref 2). Using this approach, we were able to categorise these deaths into drug related or other, according to the National Drug Strategy definition. Surprisingly, only a third of all deaths can be defined as drug related, meaning that the majority, therefore, would not be counted in official figures relating to deaths from drug use. However, closer inspection of the deaths not categorised as drug related identified many which would likely be the result of drug (and alcohol) use and could thus be classified as drug associated deaths.
For example, there were 11 deaths from hepatitis C (plus a further 37 deaths where hepatitis C was recorded on the death certificate as a contributory or secondary cause). There were eight deaths from neoplasm of the liver, with five described as being secondarily related to hepatitis C infection. There were a further 59 deaths from liver diseases, 47 of which were alcohol related and in total, disorders of the liver is the main cause of death in 15% of all those included in the study to date. Acute and chronic infections of the lower respiratory tract accounted for 9% of all deaths, with pneumonia and chronic obstructive pulmonary disease (COPD) having the largest contribution. Drug use is strongly associated with pneumonia because those drugs which suppress the central nervous system (for example opiates) diminish the reflexes that trigger coughing and sneezing, while infections that are initiated at an injection site can spread to the lungs via the blood stream. COPD is a likely result of smoking and could be associated with the use of crack cocaine or cigarettes. Deaths from circulatory disorders also featured highly; six people died from endocarditis, 28 from other forms of heart disease, three from deep vein thrombosis and 18 from cerebrovascular diseases, a recognised consequence of stimulant use. And so the list goes on....
So why are these drug associated deaths not included in figures for deaths connected to drug use? Well, information on deaths comes from death certificates which are then coded according to the International Classification of Disease. Drug use may not be recorded as playing a part in the pathophysiological processes resulting in death, particularly if the person was not a known current drug user. In the absence of any data on drug use, we cannot definitively say the deceased was, or had been, a drug user. Only when we are sure the person had used drugs can we surmise that a hepatitis C related death, for example, was drug related. While current definitions of a drug related death are too narrow to include drug associated deaths, if we were to expand the definitions, we may inadvertently include deaths which were not caused by drug use at all.
"In our target dominated world, data are important but it is equally important to know exactly what these data mean. In the case of drug related deaths, the available figures tell us little in relation to the overall contribution of drug use on premature death"
Indeed, to complicate this matter further, deaths of non drug users are sometimes counted in drug related death figures. This conclusion arose from an investigation carried out in Liverpool in response to data published by the national programme on Substance Abuse Deaths (np-SAD; which collects data from coroners and uses its own definition of a drug related death) which reported a doubling of drug related deaths in the city between 2003 and 2004. This investigation showed that some of the deaths counted within these figures did involve drugs controlled under the Misuse of Drugs Act (1971) but were for people who did not appear to be drug users, for example, the death of a person aged over 90 with coronary heart disease who died of myocardial insufficiency with contributory carbamazepine toxicity (Ref 3).
In combination, the findings detailed here show how difficult it is to obtain accurate figures on the number of deaths arising from the use of illicit substances and thus the difficulty of measuring the impact and effectiveness of strategies initiated to prevent and reduce these deaths. In response, a new system was developed in Liverpool which has subsequently been rolled out to two other areas of Merseyside. This system operates in the following manner. Services in contact with drug users send the name, date of birth, gender and post code of people they believe to have died (irrespective of cause) to the Centre for Public Health. On a quarterly basis, details of each suspected death are cross matched with mortality databases held at the Primary Care Trust in order to confirm whether or not the person actually died, and to provide information on the causes of death where applicable. Partially anonymised details of confirmed deaths are then cross matched with the information held on the drug monitoring systems at the Centre for Public Health in order to identify which drug and alcohol services the deceased person was in contact with in the year preceding their death. These databases include the National Drug Treatment Monitoring System (structured drug services), the Drug Interventions Programme (for criminal justice related drug services), the Alcohol Treatment Monitoring System (structured alcohol treatment) and the Inter Agency Drug Misuse Database (needle and syringe programmes). Furthermore, a list of deceased people is given to the main drug treatment providers and to the Medical Director of the Primary Care Trust in order for them to gather together case notes and prescribing data. Finally, the coroner provides details of drug related deaths.
On a quarterly basis, a meeting led by the Manager of Drug and Alcohol Action Team meets to review each death in order to identify any "lessons learnt" in relation to both drug related and drug associated deaths.
In our target dominated world, data are important but it is equally important to know exactly what these data mean. In the case of drug related deaths, the available figures tell us little in relation to the overall contribution of drug use on premature death. I will leave you with this example. If a drug user decides to hang himself and the toxicological investigations conducted as part of an inquest identify no illicit drugs, his death would not be considered drug related. If however, he chooses to overdose on a cocktail of drugs which includes illicit substances, his death would be classified as drug related. I suggest that learning lessons from such deaths in the hope we may be able to prevent them in the future is more important than how we define them.
1. Eaton G, Davies C, English L, Lodwick A, McVeigh J and Bellis MA eds. (2008). 2008 national report (2007 data) to the EMCDDA by the Reitox National Focal Point. United Kingdom New Developments, Trends and In-depth Information on Selected Issues. Liverpool: Centre for Public Health, Liverpool John Moores University.
2. Hurst A, Beynon C, Marr A and McVeigh (2009). NDTMS themed report. Patterns of mortality amongst individuals in contact with drug treatment services in the North West of England - 5 years of data capture. Liverpool: Centre for Public Health, Liverpool John Moores University.
3. Beynon CM, Bellis MA, Church E and Neely S (2007). When is a Drug-Related Death not a Drug-Related Death? Implications for Current Drug-Related Death Policies in the UK and Europe. Substance Abuse Treatment, Prevention, and Policy, 2, 25.
The Substance Misuse Unit of the Royal College of General Practitioners (RCGP) has developed a course aimed at treatment and intervention for alcohol related problems in primary care. Its structure is similar to the RCGP Part 1 Management of Drug Misuse Certificate, consisting of an e-learning module which has been developed by Department of Health, and a workbook which are completed before attending of a face-to-face training event.
This course is the first of its kind, specifically dealing with working with alcohol use in primary care. The timing could not be better, as the NHS introduced a DES (Direct Enhanced Service) that provides the financial support and structure to develop new alcohol services based in primary care. The course is designed to enable candidates to deal with alcohol related problems across a wide range of issues, from identification of problem drinkers and brief interventions, to safe community detoxification. It is open to everyone working in primary care, but is aimed at GPs, including those who want to develop a special interest. Healthcare professionals already working in substance misuse who wish to gain more competence in alcohol treatment will find it useful as many clients oscillate between the use of illicit substances and alcohol, or use both together.
The RCGP Certificate in the Management of Alcohol Problems in Primary Care, the official title of the course, had its first national face-to-face training event in York on the 24th September. It will be rolled out to the rest of England over the next couple of months. The e-learning module is already available at the Alcohol Learning Centre, an online resource run by the Department of Health.
Candidates should complete the e-learning module before attending the face-to-face event. The course fee is £250, which includes the attendance at one of the face-to-face training days and a training pack. The e-learning module is free of charge.
To learn more about the certificate, or to book a place at a face-to-face event, please contact:
Substance Misuse Unit of the RCGP
Tel: 020 7173 6092
The Substance Misuse Unit of the RCGP has a list of local and national face-to-face events.
Employment in Drug Services
Sharyn Smiles and Lisa Mallen discuss the difficulties involved in the employment of service users in drug treatment services, the way these problems can be overcome, and the rewards for those who employ service users to deliver treatment. SMMGP is concerned about imminent changes to the law that allow the newly formed Independent Safeguarding Authority the power to ban staff working with vulnerable groups on the basis of past criminal offences, rather than allowing the employer to make this judgement. We hope this does not put further barriers in front of service users being employed in drug services. Ed.
A user's view
Isn't it fantastic that there are so many drug services campaigning for our rights when it comes to employment? Isn't it great that there are so many pathways now open to us; training, links to employment, education - the list is endless! I regularly hear from service users about how they have enrolled on a forklift truck licence course; "brilliant" I say, "what do you want to be?", "Oh, a drug worker!" Well I don't know about you but I haven't come across many drug services that require the skills of a forklift truck driver!
It sure is brilliant that drug services do this campaigning, because they believe in drug users, they believe that we can be better people, a productive member of society, a good asset to the workforce. Why then is it that providers have such difficulties in employing drug users and giving them opportunities to learn and get real experience, in a real service, with real people?
Obviously there are ethical considerations; however, if common sense is applied, a lot of these can be overcome. I'm not suggesting that just because someone has used drugs that they are the ideal candidate for the job, and I am not suggesting that someone in active addiction would be a reliable and productive member of staff. However, I have found that, with direction, voluntary experience, and education, drug users often make fantastic drug workers. As with any multi disciplinary team there should be a balance of skill mix.
So what are the challenges for service users to be employed within the drugs field? The challenges are few. Criminal Records Bureau (CRB) checks can be difficult - let's just say I was hardly an angel! However, working for a company that understands drug use makes this slightly easier - it's no coincidence that when my drug use stopped my criminal record stopped as well! I have the opportunity to challenge many attitudes around drug use and lifestyles and create a sense of equality within the workforce. Other than the difficulties surrounding CRB checks, the only other negative experience I have come across has been that of one of my colleagues, who despite having been stable on a script for some years, still has to attend regular appointments for drug treatment within work hours which makes it very difficult for him as he has to pick his script up in a different borough.
On the other hand, the positives far outweigh the negatives. For me it has been about a sense of achievement - I don't want a job because I used to stick a needle in my arm, I want a job because I am capable, qualified and competent. I want to make a better life for myself and be part of the society to which I belong. I am taken seriously (well most of the time) and in terms of personal growth I have managed to achieve things that I could only have dreamed of.
A staff member's view
As I sat down to write this article I was considering what it's like to have colleagues who are still involved in services. Well, it's certainly never dull! And having such a wealth of experience at your fingertips is a really valuable thing. Having worked in the field of substance misuse for a few years now, I would consider myself pretty experienced, but nothing can compare with the experience of a service user; it has really helped to be able to say to my colleagues "I'm a bit stuck here, what do you think?". I'm always offered a completely different perspective.
"I don't want a job because I used to stick a needle in my arm, I want a job because I am capable, qualified and competent"
I have been lucky enough to observe the interactions between customers and my colleagues. Who better to describe what it's like to go on a "subbie" script than someone who is on one?
I never get tired of watching customer's reactions when there is a little bit of self disclosure from the worker. The whole "well if he can do it, I can do it" thing - and it not just be lip service from an organisational point of view. There can be some real employment opportunities out there - if the employer is willing to take the chance, that is.
It's not been all plain sailing though. Individual attitudes within our organisation have been challenged. For some, it has been difficult to accept that our colleagues who are still involved in services can make as much, or sometimes more, of a contribution to our team. Thankfully, those who have struggled with this issue can now see the value of employing current service users and there is a real sense of equality amongst the staff team. The same goes for our partner agencies who are in contact on a daily basis with our staff.
Boundaries can be an issue. There have been times when, following being employed, a service using worker and a customer's relationship dynamic has changed, creating confusion for both parties. However, supportive supervision is the key to most issues that are thrown our way.
Joy Barlow argues for earlier intervention for children with parents who are problematic alcohol and drug users in order to limit harm. She suggests that services must pay attention to the types of interventions they offer, and work with other services in order to reduce the risk to children. Ed.
"About suffering they were never wrong, the Old Masters; how well they understood its human position; how it takes place while someone else is eating or opening a window or just walking dully along. ...How everything turns away quite leisurely from the disaster"
- W. H. Auden, Musee des Beaux Arts (Ref 1)
There are some who will believe that it is possible to be an adequate parent whilst still embroiled in problem, chaotic, unstable (whatever you care to call it), drug and alcohol misuse. I am not one of them. This does not mean that I condemn women like Heather Boyd, the mother of Brandon Muir, the child murdered by her ex-partner in Dundee. What I do believe from the bottom of my heart is that we can no longer "turn away quite leisurely from the disaster". Children such as Brandon and the sad litany of previous children whose deaths are due, in part, to the drug and alcohol misuse of their murderers, need our help and they need it early. So do their parents and carers. Parenting capacity is likely to be much reduced if a parent or carer's drug and alcohol misuse increases. Parents' primary relationship will be with the substance of choice rather than that with their child. We know all this, so what can we do about it?
The first essential is to look the problem in the eye, and recognise that children and families need the help of all of us, and that they need it early on. Much is said and written in government policy documents about 'early interventions'. What does this mean, how can it be delivered, and what roles and responsibilities do we have?
The heart of our response has to be assessment of the situation, and that begins with identification. Identification occurs when concerns about a child are recognised and acknowledged within any agency in contact with the child and/or the family. Those working in primary care are very well placed to identify at an early stage a child in need or indeed at risk of harm through their parents' drug and alcohol misuse. Hidden Harm (Ref 2) told us that many children go unnoticed because no one is talking about them, asking about their welfare or, when possible, observing them. We have to acknowledge that you cannot get much more socially excluded than if no one knows you exist.
After identification, professionals need to react in a proportionate way. Those in primary care will be able to give advice to a parent on reduction and stabilisation of drug and alcohol misuse, liaise with other health and social care professionals to provide support, and ensure the child is kept visible in the professional community. This is not a breach of trust in terms of patient/client relationships, nor is it creating implied or overt stigma. It should be seen as the opposite - helping the parent be the sort of parent they want to be.
"I am a good mum, except when I am on drugs"
- Heather Boyd, quoted in Scotland on Sunday, March 8th 2009
Early identification means the recognition of a child in need, before the child becomes one at risk. However, we also have to recognise that whilst interventions must be supportive, not punitive, some children will not be safe in some situations. We need to be honest with parents at the outset of our relationship with them about the impact of their behaviour on parenting capacity and child welfare. People should not be marginalised nor stigmatised because of their drug and alcohol problems. Nevertheless they have to realise that they have responsibility for the damage that they may do to others - especially children. I believe we do have to see this as a moral imperative. To act as if we must at all costs avoid saying that effects of behaviour may be intrinsically bad i.e. harmful to children, we may well be failing to protect not only the children, but parents themselves.
STRADA (Scottish Training on Drugs and Alcohol) has significant experience in delivering training and education to support the implementation of the agenda to protecting Scotland's children. We have learned the importance of multi-agency learning and development, of reflection on practice, and the necessity of management supervision and support in this challenging area of work. We have also learned that if early identification and appropriate intervention are to be achieved, there has to be a cultural change in which all accept their individual roles and responsibilities and understand the nature of other people's. We need to improve responses to children and families affected by drug and alcohol misuse. The keys to that improvement are; early identification, inter-agency collaboration and response, and honesty in our relationships with parents. Political will, strategic documents and policy impetus will not work if we do not have a greater understanding of the role and responsibilities we all have in child welfare and protection, i.e. recognition of the needs of children and of the potential harm of parental behaviour. We have to work together to bring reality to what is now a well-known phrase "It's everyone's job to make sure I'm alright" (Ref 3).
1. W.H. Auden "Musee des Beaux Arts" 'Landscape with the fall of Icarus' by Breughel
2. Advisory Council on the Misuse of drugs (2003) Hidden Harm: responding to the needs of the children of drug users
3. Scottish Government (2002) "It's everyone's job to make sure I'm alright" Report of the Child Protection Audit and Review, Scottish Executive
Jack Leach gives advice to a GP about the use of Suboxone. To read the full version, please see the Dr Fixit's FAQs section of the web site.
I am a GP in a shared care scheme. My local specialist drug service has decided to change all their patients on buprenorphine to Suboxone. The local commissioner is now saying all GPs have to do this as well. I have 6 patients very settled on buprenorphine. None of them want to change and in fact I don't want to change them. Three of these people are on weekly pick-up, two on three times a week pick up, and one daily pick up. Four of them work and are reluctant to make any change that could damage their recovery. Do I have to change them to Suboxone? If I do make this change, do the properties of Suboxone vary from buprenorphine? Finally can you crush Suboxone to aid the time it takes to absorb?
If a patient is new into treatment for their opiate dependence, or has had a gap in treatment and is suitable for buprenorphine rather than methadone national guidelines suggest this should be initially taken supervised. Now there is a potential alternative of Suboxone which would allow supervision to be removed sooner, although its overall extent on reducing misuse and diversion is not clear. It seems that your local specialist drug service have decided on Suboxone rather than buprenorphine as a general policy probably to discourage misuse and diversion.
However, the patients you mention are different. They are established in treatment, stable and not on supervised consumption. I would suggest clarifying with your commissioner and local specialist service whether their policy also includes patients already stable on take home buprenorphine. If this is the case it would increase overall cost, and, as you point out, could be unnecessary and disruptive to some patients. If there are reasons to doubt that a patient is not taking their buprenorphine as prescribed and they are continuing to use illicit drugs then it would seem reasonable to undergo a reassessment and change them to supervised buprenorphine or Suboxone or even methadone and/or consider a dose increase. If they are doing well and there are no suspicions of this, it seems unnecessary and draconian to change them against their and your wishes.
Finally to answer your query about whether you can crush Suboxone, you can but it is probably unnecessary as Suboxone dissolves more quickly than Subutex. Subutex can be crushed under certain circumstances. The National Pharmacy Association (NPA) has agreed that its Professional Indemnity Insurance policy will cover its members if they crush buprenorphine according to the joint Royal Pharmaceutical Society of Great Britain (RPSGB)/NPA protocol.
Nazmeen Khideja is Pharmacist Fixit to a GP who is confused about writing prescriptions for controlled drugs post Shipman. Ed.
I am really confused about all the changes that have occurred post Shipman in the way I need to write scripts and what my helpful local pharmacist is allowed to do and not to do! In some ways, for example, the fact that handwriting exemptions are no longer necessary, and we can use approved wording to allow dispensing of medication following missed doses, things are easier, but in others ways, for example, the length into future I can write scripts, things have got tougher. Now they say I don't need to date the script - I'm confused. Could you please explain to me what I can do, and what the pharmacist can and can't dispense?
Yes, there have been a number of changes post Shipman and it can be difficult to keep up to date with all the changes. Try the checklist below for frequently asked questions:
Changes to handwriting exemptions
Apart from the signature, the prescription can now be computer generated, including the date. Also, pharmacists can make changes to minor spelling and typographical errors where the prescriber's intentions are clear. The prescription for schedule 2 and 3 (apart from temazepam) medicines must include:
- Name and address of the patient. Where there is no fixed abode, NFA is acceptable.
- Age/date of birth is only required if the patient is under 12!
- Dose (e.g. 60mls daily, 8mg sublingually daily). 'As directed' is not acceptable.
- The form of the medicine (tablets, mixture).
- The strength of the medicine if there is more than one available.
- The intervals of collection must be specified.
- The total quantity must be written in words and figures. If the words or figures are missing then the pharmacist may add one or the other but not both. No more than 14 days of treatment should be prescribed.
- It must be signed by the prescriber - the only thing that must be handwritten.
- It must be dated. The valid date for dispensing is 28 days. If you decide to put a start date on the body of the prescription then this becomes the valid date if it is later than the date of the signing of the prescription. In other words, if there is a date on the prescription and a start date, with the two dates being different - the later of the two dates is the valid start date for 28 days. For example in the case of a prescription dated 04/09/09 with a start date of 10/09/09, the legal start date will be 10/09/09 and it will be valid for 28 days from this date. Post dating of the script should not exceed 28 days.
- The address of the prescriber must be within the UK and must indicate the qualification of the prescriber, as currently non-medical prescribers can not prescribe controlled drugs used in addiction outside of clinical management plans.
Changes to collection of instalments and missed doses
Currently, legislation means that if a patient was due to pick up more than one instalment and misses this specified pick up interval, the dose and subsequent day are forfeited. The Home Office has granted provisions to help this situation - approved wording to be used on prescriptions: For supervised consumption:
"Supervised consumption of daily dose on specified days; the remainder of supply to take home. If an instalment prescription covers more than one day and is not collected on the specified day, the total amount prescribed less the amount prescribed for the day(s) missed may be supplied."
For unsupervised consumption:
"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."
For when the pharmacy is closed: This approved wording will enable those supplying controlled drugs to issue instalments on the day immediately prior to closure should the pharmacy be closed on days when instalments are due. The wording approved by the Home Office is:
"Instalments due on days when the pharmacy is closed should be dispensed on the day immediately prior to closure."
This wording must be on the prescription to allow pharmacists to deduct the amount that was missed and dispense the remainder as per the prescription.
What's allowed on FP10MDA prescriptions (Blue)?
Any schedule 2 that is used for the purposes of addiction and is advocated for this purpose may be prescribed. The only schedule 3 drug allowed is buprenorphine sublingual tablets and Suboxone.
Schedule 4 diazepam may be prescribed. If an injectable is prescribed, then Water for Injection may also be prescribed. No other items may be prescribed on the FP10MDA form.
Can I do instalments on a normal green FP10?
The Medicines Act 1968 does not allow instalments to be prescribed on FP10 prescriptions - only one off dispensing is allowed unless the pharmacy is short of stock and fulfils the remainder at a later date. Therefore, if medicines are required to be dispensed daily and are not included on the list above for instalment prescriptions, they must be prescribed on individual prescriptions.
ID and collection of controlled drugs
Updates now mean that patients collecting schedule 2 and 3 controlled drugs will have to show identification (ID). This can be relaxed once the patient is known to the pharmacy, but at first dispensing ID is required. Variations are acceptable - it doesn't have to be a passport!
Emergency supply of medication
Pharmacists must have the script in advance of supply - no emergency supplies are allowed for schedule 2 and 3 medicines that are used in substitute medication for addiction.
Full guidance is available on the Royal Pharmaceutical Society of Great Britain (RPSGB) website.
Society for the Study of Addiction Annual Symposium, 2009
Date: Thursday 12 - Friday 13 November 2009
Venue: Park Inn, York, UK
Tel: 0113 295 2787
11th International Hepatitis C Conference
Date: Monday 16 - Wednesday 18 November 2009
Venue: Lowry Hotel, Manchester
Tel: 0207 0221890
Motivational Interviewing Skills Training
Date: Monday 23 - Tuesday 24th November 2009
Venue: 22 Lonsdale Road, Queen's Park, London NW6 6RD
Cost: £200.00 for 2 days (inc. course handbook & handouts, full refreshments)
Web: SMMGP Courses & Events page
E-mail: email@example.com Tel: 0207 604 4826
RCGP Substance Misuse Unit presents: What to do with Over the Counter Addiction?
Date: Thursday 21 January 2010
Venue: York Hotel, York
Cost: Past and current certificate candidates £130.00, all other delegates £150.00
For further information or to reserve a place, please contact:
Tel: 020 7173 6095
RCGP: Certificate in the Management of Alcohol Problems in Primary Care
Date: Friday 19 February 2010
Venue: RCGP, Hyde Park, London
Cost: £250 per person if attending a national event run by the SMU, £150 per person if attending a local event run by the DAAT or PCT
For more information about attending the events, or about how to set up a local event please contact:
Tel: 020 7173 6095
Web: SMMGP Courses & Events page
RCGP 15th National Conference: Working with Drug & Alcohol Users in Primary Care - Integrating Practice and Policy: Everyone's Business
Date: Thursday 22 - Friday 23 April 2010
Venue: SECC, Glasgow
Web: SMMGP Courses & Events section
21st International Harm Reduction Conference
Date: Sunday 25 - Thursday 29 April 2010
For further information please visit:
Book a place at both the RCGP 15th National Conference and the 21st International Harm Reduction Conference and get £50 off each event!
Network Production Group
Dr Chris Ford (Clinical Director SMMGP)
Pete McDermott (Policy Officer, Alliance)
Elsa Browne (SMMGP Project Manager)
Jean-Claude Barjolin (SMMGP Associate)
Susi Harris (Clinical Lead for Substance Misuse, Calderdale)
SMMGP Project Manager
80 London Road
London SE1 6LH
Tel: 020 7972 1980
To make changes to your subscription of Network please contact Sarah Pengelly.
Would you like to write an article for Network newsletter? Please contact the Editor.
Whilst we encourage open debate and dialogue, the views expressed within this newsletter are not necessarily the views of the SMMGP.
The production of this newsletter was sponsored by Schering-Plough Ltd. Schering-Plough did not contribute to the editorial content.
SMMGP works in partnership with The Royal College of General Practitioners (RCGP) and the National Treatment Agency for Substance Misuse (NTA).
Network ISSN 1476-6302.