SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Network No 32 (May 2011)

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In this issue

Alistair Sinclair describes the origins and the underlying principles of the UK Recovery Foundation, an organisation that embraces recovery while recognising the importance that treatment services can play in this process.

Fabrizio Schifano gives us insight into the fast growing and often confusing world of legal highs, and provides a few tips on how to identify and meet the needs of those who are using them.

Paul Hayes takes us through the next steps of the Drug Strategy and argues that doctors will have a vital role to play in securing the future of effective drug and alcohol treatment locally.

Though we have improved detection of hepatitis C in recent years, we could be doing much better at getting people into treatment. Euan Lawson draws our attention to the issues.

David Nutt outlines what is understood about the complex relationship between addiction and the brain.

Tim Sampey describes how the London User Forum used its strengths when its funding was cut to produce an even stronger organisation.

In the rush to meet targets and provide evidence based practice we can miss an essential element of care. Teresa Wirz discusses the importance of being kind when working with people.

The prevalence of mental health problems is high amongst those in contact with addiction services but how good are we at assessing for this? Scott Payne gives us some food for thought and a few ideas on how to improve our practice.

Jack Leach provides advice about managing a patient who does not appear to be progressing in treatment.

Chris Ford is Dr Fixit to a GP who is wondering whether or not to prescribe benzodiazepines to a patient.

See all the latest courses and events.

We hope you enjoy this issue.
Kate Halliday
Editor

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Editorial

Welcome to the Royal College of General Practitioners Working with drug and alcohol users in primary care 16th National Conference edition of Network. The theme of this year's conference is The public health agenda: making patient centred care the imperative and we like to give a flavour of the event to those who are not able to attend by featuring a number of articles by people who are presenting including: our cover article Alcohol: the real public health emergency by Stephen Willott, Hepatitis C: individual aspects of a public problem by Euan Lawson, Addiction and the brain by David Nutt and an article on the London User Forum by Tim Sampey.

This is a time of great change for SMMGP as our founder and Clinical Director Chris Ford retiresChris Ford retires in June after 15 years at the helm.

She will be greatly missed, though we are reassured that she is not disappearing altogether as she will continue to work with us on a number of projects, not least in her new role as Clinical Director of International Doctors for Healthy Drug Policies (IDHDP). We are also delighted to introduce Steve Brinksman as SMMGP's new Clinical Director. Steve, a GP from Birmingham, was instrumental in setting up the very successful shared care scheme in the city, and is RCGP Regional Lead in Substance Misuse for the West Midlands. Steve delivers RCGP Certificate training for both the drugs and alcohol courses and works as a GP with special interest with young substance users. We are very much looking forward to working with him!

Finally, don't miss SMMGP's 6th National Primary Care Development Conference in Birmingham on 13th October. It has never been more important to keep an eye on the latest policy and best practice in primary care based treatment. To find out more, please visit the Courses & Events section.

Enjoy this issue!
Kate Halliday, Editor

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Alcohol: the real public health emergency

Whichever way you look at it, alcohol related problems dwarf those of drug dependency, resulting in 2.5 million deaths each year worldwide. No wonder the World Health Organization (WHO) has declared the harmful use of alcohol the world's third largest risk factor (and second largest in Europe) for premature mortality, disability and loss of health (Ref 1).

And then there's the social impact reaching deep into society, including violence, risk of traffic accidents, teenage pregnancy, child neglect and abuse, loss of work and negative effect on coworkers, relatives, friends and even strangers.

Never mind the White Paper (Ref 2) and who precisely will have responsibility for alcohol in the brave new world, we all need to own this problem and address it. Health care professionals (and those working with people who use drugs in particular) have many opportunities to do this.

Whether you are seeing folk in general practice or a shared care substance misuse clinic or commissioning services, my message is quite simple: we need to wake up and address the whole spectrum of alcohol misuse in the people we see. I think there are four main barriers to doing so.

Figure 1: Common risk factors and how much illness they cause (WHO 2000)
Figure 1: Common risk factors and how much illness they cause (WHO 2000)

We underestimate the scale of the problem

The impact of alcohol misuse is widespread, encompassing alcohol related illness and injuries as well as significant social impacts. As alcohol has become increasingly affordable (65% more than in 1980 (Ref 3)) consumption has increased: by 121% between 1950 and 2000. One in four adults now drinks above safe government recommended limits and there has been a corresponding rise in alcohol related disease and mortality; the cost to the NHS alone is an estimated £2.7 billion a year, and if social costs are included then it's a whopping £25 billion (Ref 4).

Excessive drinking is a major cause of disease, accounting for 9.2% of disability-adjusted life years (DALYs) worldwide with only tobacco smoking and high blood pressure as higher risk factors (Ref 5).

Figure 2: Increased risks of ill health to harmful drinkers
Figure 2: Increased risks of ill health to harmful drinkers

There are also ugly inequalities issues relating to alcohol use:

Finally, there are consistent findings that one-in-three drug-related deaths involve alcohol (Ref 8) (though anecdotally in the last year in Nottingham city, almost all included alcohol and 8 of 11 had levels five times over the drink drive limit). So, although it is important to address alcohol in the 1 in 4 adults drinking over safe daily levels, it is all the more important to consider it regularly in our shared care clinics.

2. We think interventions make little difference

There is a wealth of evidence to support a range of primary care interventions. We should not ignore anyone on the alcohol harm spectrum, many of whom are unaware of how alcohol may be affecting their health.

Most alcohol-related harm (especially that caused to others) is caused by drinkers whose consumption exceeds recommended drinking levels, rather than by drinkers with severe alcohol dependency problems. The former tend not to be seeking help for alcohol problems when they present but are more receptive to advice than dependent drinkers. The interventions they can be offered include feedback on alcohol use and harms, identification of high risk situations for drinking and coping strategies to deal with these situations, increased motivation and the development of a personal plan to reduce drinking.

Brief interventions are effective in reducing alcohol consumption (Ref 9) and interestingly, longer counselling has little additional benefit. In GP settings, for every 8 individuals targeted with a brief intervention, one will significantly reduce their alcohol intake (Ref 10). But this does not mean we should give up on dependent drinkers. In their latest set of alcohol guidance the National Institute for Clinical Excellence are in favour of offering psychological interventions for those mildly dependent and suggest offering structured assisted withdrawal programmes for the more heavily dependent (Ref 11).

3. Lack of time or skills

Whereas our drug services are generally well rewarded, alcohol tends to play Cinderella: Primary Care Trusts (PCTs) generally spend only a tenth on alcohol treatment compared to drug treatment (Ref 12). This means that there is an inevitable, often sub-conscious, lower priority given to talking to people about their drinking. Some GPs tell me they shy away from "opening a can of worms" they fear they may not be able to deal with. Arguably it is unethical to uncover a problem that help cannot be provided for, hence it is incumbent on all PCTs to ensure there is a fully joined up alcohol pathway that meets the needs of people however much they are drinking, and in an acceptably short time frame.

In Nottingham, we have converted the Directed Enhanced Service to a Locally Enhanced Service which goes a little way to making more sense of getting brief advice to the right people. It's the brief advice or motivational interviewing techniques that make the difference, not logging audit scores. However we need to have at our fingertips not only the most appropriate screening tool but the vocabulary of brief advice or motivational interviewing so it trips off the tongue easily. AUDIT C (screening for consumption) questions take only 30 seconds (Ref 13) and the SASQ even less: "How often do you have more than 6 units (female) or more than 8 (male)?" which is positive if the answer is monthly or more often (Ref 14).

Whether you have the DES or a LES, use of GP targeting skills can lead to greater gains. If, for example, 10-20% of those screened are higher risk drinkers and knowing 1 in 8 see reductions in their drinking as a result of brief interventions, then in an untargeted approach 40-80 patients need to be screened for 1 patient to reduce their consumption to low-risk drinking as a result brief advice from their GP. But if GPs target screening and two thirds of those talked to about alcohol are drinking above safe levels, only 12 patients need to be screened and given brief advice where appropriate for 1 patient to reduce their consumption to low-risk drinking.

If more training is what you need then why not try the online module on the alcohol learning website (www.alcohollearningcentre.org. uk) or sign up for the RCGP certificate course which can often be run in your area if there is sufficient interest (or find a good local alternative). However as a first step, you could just try talking about alcohol more in your consultations - you will be surprised how many people are willing to discuss it, and you will get used to talking about alcohol until it becomes ingrained as a habit.

4. Not our problem

We may argue that because the key levers of alcohol pricing and advertising are operated beyond primary care that our efforts are futile. It's true that these high level changes have the potential to turn the tide in a similar way to the smoking ban in public places, and as key opinion leaders in the community we can play a part - who knows, the government may even listen to us if we have a strong enough voice.

Whilst the drinks industry generates £30bn and one million jobs, calls for them to behave responsibly are not given sufficient clout by the government. Evidence suggests that in the UK a minimum pricing of 50p per unit would gradually reduce alcohol-related admissions in NHS Nottingham City by up to 500 a year (calculated on a reduction of around 150 per 100,000 of the population (Ref 15)).

A University of Sheffield report commissioned by the Department of Health found that policies which lead to price increases reduce alcohol consumption (Ref 16). In the US, it has been calculated that doubling the alcohol tax would reduce alcohol-related mortality by an average of 35%, traffic crash deaths by 11%, sexually transmitted disease by 6%, violence by 2%, and crime by 1.4%. The authors' conclusion is that these studies establish beyond reasonable doubt that alcohol taxes and prices are inversely associated with health across a population (Ref 17). And yet our own government is reluctant to support any level of minimum pricing that would actually make a difference to even the cheap strong ciders/beers that mean it is all too affordable to become dependent.

Conclusion

In primary care it is widely accepted we do see most people (about 78%) on our list every year and there is evidence that drinkers attend twice as often. Have we got our antenna up to spot those windows of opportunity when people are ready to make a life saving change? As over 70% of accident and emergency attendances at night are alcohol related, can we engineer the teachable moment to spur movement on the cycle of change? I think it is counterproductive (and often hypocritical!) to be anti-alcohol but we need to learn how to balance a harm reduction approach with encouraging sensible drinking, both on an individual level with the patient in front of us and with an eye for campaigning for alcohol related health policy in the brave new world of alcohol services being commissioned by public health and/or GP consortia.

- Stephen Willott
Clinical Lead for Drug Misuse and Alcohol, NHS Nottingham City

References

1. World Health Organization (2011) Global Status Report on Alcohol and Health 2011

2. Department of Health (2010) Health lives and healthy people: our strategy for public health in England

3. Office for National Statistics (2007)

4. Department of Health (2008) Reducing Alcohol Harm: Health services in England for alcohol misuse

5. Prime Minister's Strategy Unit 2004

6. British Medical Association Board of Science (2008) Alcohol misuse: tackling the UK epidemic Available at www.bma.org.uk.

7. BMA 2008

8. Ghodse H, Corkery J, Ahmed K, Naidoo V, Oyefeso A, Schifano F (2010) Drug-related deaths in the UK: Annual Report 2010 St George's University of London National Programme on Substance Abuse Deaths (np-SAD)

9. Kaner et al (2007) Effectiveness of brief alcohol interventions in primary care populations

10. Moyer A, et al (2002) Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction. Mar;97(3):279-92.

11. National Institute for Clinical Excellence (2011) Alcohol use disorders: management of alcohol dependence

12. Addiction today - Sept 2010

13. www.alcohollearningcentre.org.uk

14. www.sips.iop.kcl.ac.uk

15. www.nottinghaminsight.org.uk

16. Booth, A., O'Reilly, D., Stockwell, T., Sutton, A., Wilkinson, A., and Wong, R. (2008) Independent review of the effects of alcohol pricing and promotion: Part B modelling the potential impact of pricing and promotion for alcohol in England: results from the Sheffield Alcohol Policy Model Version 2008 (1-1), Sheffield, University of Sheffield for Department for Health.

17. Wagenaar A.C., Tobler A.L., Komro K.A. (2010) "Effects of alcohol tax and price policies on morbidity and mortality: a systematic review". American Journal of Public Health: 2010, 100(11), p2270-2278

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Chris Ford retires as SMMGP Clinical Director

Chris Ford retires as SMMGP Clinical Director

Chris Ford is retiring as SMMGP Clinical Director. Chris has worked tirelessly in the role from the moment she set up the organisation in 1996. She has an amazing ability to work across many levels, from writing guidance and training, and working strategically, to working at her "real job" as a GP in a busy London practice. It is impossible to list all her achievements during her time with SMMGP, but here are just some of them:

Throughout every aspect of her work runs a deep commitment to treating patients using drugs and alcohol as individuals with a range of needs, rather than reducing them to the substance they happen to be using - her mantra is "treat the patient, not the drug!" - and a belief that primary care is the perfect place to treat drug and alcohol users and their families. Chris has always insisted on involving service users in the development of new projects to ensure they remain at the heart of the services she provides.

Chris has had an enormous influence on the drug and alcohol treatment field and it is unlikely that there would be the range and quality of treatment available in primary care without her work over the years. She leaves a healthy and thriving organisation and a legacy which will continue long into the future. We admire Chris' infectious enthusiasm, her awesome drive, her magnificent leadership skills which are coupled with the ability to be a team player, her creativity, and the strong value base that underpins every aspect of her work. All of these are expressed in an unparalleled capacity for hard work - followed by an equal investment in having fun! We will strive to continue to honour these attributes in all aspects of SMMGP's future work. However, we are pleased that this is "fare thee well" rather than "goodbye" as Chris will continue to be "on call" for SMMGP's burgeoning range of projects.

She will continue to work for the next couple of years as a partner at the Lonsdale Medical Practice, where she has worked for the past 25 years and where her interest in working with people who use drugs and alcohol began. She has always enjoyed this work seeing it as a privilege, and says she has learnt all she knows from her patients. She has recently become Clinical Director of IDHDP, and we wish her every success, and will work closely with her in this important work to develop healthy drug policies internationally (Ref 1).

- SMMGP team

References

1. For more information see www.idhdp.com

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The UK Recovery Federation

The UK Recovery Federation

Alistair Sinclair describes the origins and the underlying principles of the UK Recovery Foundation, an organisation that embraces recovery while recognising the importance that treatment services can play in this process. Ed.

"We make the path by walking it"

This phrase, taken from the Spanish cooperative movement, has been embraced by the UK Recovery Federation (UKRF) and sums up our central approach. Together we make new paths, open up new possibilities and support the release of the many diverse strengths all people have. We are all assets. We all have value.

In January 2010 a group of activists from the recovery community met in Glasgow to plan the second UK Recovery Walk. We wanted to build on what had been achieved the previous September when the first UK Recovery Walk (organised by SHARP in Liverpool) saw around 1000 people out on the streets of Liverpool celebrating their achievements and making recovery visible. We felt there was a need for an organisation that would ensure a UK Recovery Walk took place each year, learning from each year's experience and developing as a significant articulation of recovery which would challenge the stigma associated with substance use. Glasgow saw nearly 2000 people marching on the 25th of September last year and we expect numbers to increase at the next Walk in Cardiff on the 10th of September this year.

We felt there was also a need for a grassroots peer-led body that would focus on the building of recovery capital within communities through the establishment of new and diverse Recovery Networks. Out of this vision, our version of the Big Society, the UK Recovery Federation (UKRF) was born.

We have avoided subscribing to any one definition of recovery. We believe that if recovery is going to be owned by each individual and by communities then they must define its terms. However we have found William White's definition helpful:

"the experience (a process and a sustained status) through which individuals, families, and communities impacted by severe alcohol and other drug (AOD) problems utilise internal and external resources to voluntarily resolve these problems, heal the wounds inflicted by AOD-related problems, actively manage their continued vulnerability to such problems, and develop a healthy, productive and meaningful life." (Ref 1)

Whilst there is a clear and crucial need for recovery-oriented services (and a need for research in this area where rhetoric often dominates) we believe that recovery, in essence, sits within individuals in the environment in which they live. We understand recovery to be an asset-based approach, as opposed to many current state-sponsored treatment interventions that are often deficit based and reductive. We believe that we can learn a lot from educationalists like Paulo Freire, community activists like Saul Alinsky and John McKnight, Larry Davidson within the mental health field, William White, George De Leon and Bruce Alexander in the substance use field. But principally we believe we learn most from listening to individuals and communities. Through this listening, this engagement as equals in a shared learning environment, we believe we can develop and support new forms of community-focused practice that will facilitate shifts from cultures grounded in unhealthy dependencies to new cultures of recovery.

Because we believe that strong recovery values must sit at the centre of all our work we have developed a set of UKRF Recovery Principles, building on three years of work in the US by the Centre for Substance Abuse Treatment (CSAT):

  1. Recovery lies within individuals, families and communities and is self directed and empowering.
  2. Recovery lies within our "connectedness" to others, is holistic and has many cultural dimensions.
  3. Recovery is supported by peers, families and allies within communities.
  4. Recovery involves the personal, cultural and structural recognition of the need for participative change, transformation and the building of recovery capital.
  5. Recovery involves a continual process of change and self-redefinition for individuals, families, organisations and communities.
  6. Recovery challenges all discrimination and transcends shame and stigma.
  7. Recovery emerges from hope, gratitude, love and service to others.
  8. There are many pathways to recovery and no individual, community or organisation has the right to claim ownership of the "right pathway."
  9. Recovery exists on a continuum of improved health and well-being.
  10. Recovery transcends, whilst embracing, harm reduction and abstinence based approaches and does not seek to be prescriptive.
  11. Honesty, self-awareness and openness lie at the heart of recovery.
  12. Recovery is a reality and contagious.

The UKRF aims to promote these Recovery Principles and support the development of a diverse UK Recovery Movement. We believe it is time to radically re-evaluate the nature of support that is offered to people with substance use issues, just as it is time to re-evaluate what is offered to all those that receive welfare. It is time for change. By working together, embracing our differences and celebrating our similarities as human beings we can make new paths.

- Alistair Sinclair, UKRF

For more information see www.ukrf.org.uk or contact alistair@ukrf.org.uk or annemarieward@ukrf.org.uk.

References

1. White WL. Recovery (2008) Old wine, flavor of the month or new organizing paradigm? Subst Use Misuse 2008;43:1987-2000.

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Legal highs: novel psychoactive substances

Legal highs: novel psychoactive substances

Fabrizio Schifano gives us insight into the fast growing and often confusing world of legal highs, and provides a few tips on how to identify and meet the needs of those who are using them. Ed.

Novel psychoactive chemicals, sometimes called designer drugs or legal highs represent a rapidly expanding problem that is being increasingly recognised as associated with both psychological and physical threats for misusers and society as a whole. Although legal highs may be derivatives of well known, mostly classified, psychoactive chemicals such as phenethylamines, tryptamines, piperazines, cathinones and ketamine, they are advertised as legal and of high purity, making them more attractive to users and particularly to teenagers. However, the content of these products is often unknown.

Typically, the history of diffusion of any novel psychoactive compound starts in closed settings, within restricted groups of "educated" and technologically literate users, the psychonauts. Most recreational drugs consumers access the internet to obtain and exchange drug-related information. As legal highs become known to government officials and are banned, new molecules appear on the market and the cycle repeats itself.

A well known example of this cycle in the UK is the latest NRGseries molecules, which started to be energetically advertised online in April 2010, just days after mephedrone (a cathinone derivative) was controlled.

"very few related pharmacological, toxicological, epidemiological and clinical data are available in scientific literature. As a consequence, it is difficult for the practicing clinician to be kept regularly updated"

Mephedrone elicits stimulant and empathogenic effects similar to amphetamine, methylamphetamine, cocaine and MDMA. Due to its sympathomimetic actions, mephedrone may be associated with a number of both physical and psychopathological side effects. Recent preliminary analysis of recent UK data carried out in 65 related cases have provided positive results for the presence of mephedrone at post mortem. Within the UK, diffusion of mephedrone may have been associated with an unprecedented combination of a particularly aggressive online marketing policy and a decreasing availability and purity of both ecstasy and cocaine.

Just a few days following the mephedrone ban, NRG-1 was proposed as a legal cathinone derivative, prior to being eventually controlled in the UK in July 2010. Soon afterwards, a number of novel products (including NRG-2, NRG-3, NRG-4, NRG-5 and NRG-6) appeared online. The situation is even more complex, because products labeled as NRG-1 (naphyrone) may indeed contain either mephedrone or a range of different non psychoactive, and possibly toxic, chemicals.

Most European Union (EU) countries are taking into account the possibility of classifying a drug following the completion of some level of risk assessment. However, this is problematic because the technical knowledge on novel recreational compounds is hardly obtained through reference books and scientific journals. In fact, very few related pharmacological, toxicological, epidemiological and clinical data are available in scientific literature. As a consequence, it is difficult for the practicing clinician to be kept regularly updated. At the EU-wide level, most popular novel psychoactive substances seem at present to include a range of molecules, most typically associated with stimulant and/or psychedelic effects (see list below).

Overview of some of the most popular novel psychoactives:

In line with this, the European Monitoring Centre on Drugs and Drug Addiction (EMCDDA) and Europol reported that in 2009, 24 new psychoactive substances were notified by the EU Early Warning System, compared to 13 in 2008 (Ref 1), including synthetic cannabinoids, tryptamines, phenethylamines, and synthetic cathinones.

Health professionals should be aware of the ever-changing nature of recreational drug use and the potential mental and physical health issues that may be caused by the consumption of new psychoactive molecules. Patients should be asked about their use of legal highs, as well as other substances used. Conversely, because of the lack of detailed scientific knowledge on the pharmacological, metabolic, toxicological and pathological aspects of new substances when they initially appear, it is important that clinicians and other health professionals dealing with emergency presentations treat the presenting symptoms.

Doctors and other health professionals need to keep a watching brief on trends in substance use so that they are conversant with current usage patterns and the potential effects of such substances. From this point of view, the European Commission has recently funded projects such as the 2010-2012 Recreational Drugs European Network (ReDNet (Ref 2)). ReDNet is a research project which aims to develop and pilot innovative and effective information communication technologies (ICT) preventive approaches focused on novel psychoactive compounds/legal highs and combinations. Piloted ICT tools include the use of interactive websites, SMS alert, social networking (for example Facebook and Twitter), multimedia (for example YouTube), Smartphone applications ( for example iPhone), and seminars for professionals in the virtual learning environments (Second Life) (Ref 3, Ref 4). These tools are developed through the use of technical/scientific information, appropriately adapted and updated, that have been previously identified and carefully monitored by the different EU research centres. ReDNet relies on the experience of two previously EC-funded research projects, Psychonaut I and II (Ref 5), which particularly focussed on web monitoring. Thorough attention is also given to health professionals working directly with young people showing problematic behaviours who constantly need to receive updated and accurate information about these new substances. ReDNet has a network which is operational in eight countries; the UK, Spain, Germany, Italy, Belgium, Poland, Hungary, and Norway.

The main objectives of the ReDNet are:

Finally, future studies should better assess both the acute and chronic toxicity of legal highs. With a better understanding of these drugs' clinical pharmacology, it is hopeful that related clinical management levels will improve. Furthermore, the characteristics of those consumers who take advantage of the online available information on mephedrone and similar compounds should be better assessed and, as a result, the stereotypical image of drug users may need to change6.

If you would like to know more about legal highs and the European Commission-funded ReDNet project (Principal Investigator: Professor F Schifano) updates visit the project's website at www.rednetproject.eu

- Professor Fabrizio Schifano
Chair in Clinical Pharmacology and Therapeutics, Consultant Psychiatrist (Addictions),University of Hertfordshire

References

1. EMCDDA & Europol. (2009). EMCDDA-Europol 2009 Annual Report on the implementation of Council Decision 2005/387/JHA - In accordance with Article 10 of Council Decision 2005/387/JHA on the information exchange, risk-assessment and control of new psychoactive substances. Lisbon, European Monitoring Centre for Drugs and Drug Addiction & The Hague, Europol. Available at:

2. www.rednetproject.eu

3. Davey Z, Corazza O, Deluca P, Schifano F(2010). Mass-information: mephedrone, myths, and the new generation of legal highs. Drugs and Alcohol Today, 10: 24-28, 2010

4. Demetrovics Z, Ghodse AH; Psychonaut Web Mapping; ReDNet Research Groups. (2011) Mephedrone (4-methylmethcathinone; "meow meow"): chemical, pharmacological and clinical issues. Psychopharmacology (Berl), 214: 593-602, 2011

5. www.psychoanutproject.eu

6. Littlejohn C, Baldacchino A, Schifano F, Deluca P(2005) Internet pharmacies and online prescription drug sales: a cross-sectional study. Drugs: Education, Prevention and Policy, 12: 75-80, 2005

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The Drug Strategy: next steps

The Drug Strategy: next steps

Paul Hayes takes us through the next steps of the Drug Strategy and argues that doctors will have a vital role to play in securing the future of effective drug and alcohol treatment locally. Ed.

The government's Drug Strategy sets out a new ambition for anyone dependent on drugs or alcohol to achieve recovery, and to lead a drug-free life.

It charts a clear direction of travel for the drug treatment field in general, and for the National Treatment Agency (NTA) in particular. It is also buttressed by a series of reforms in the NHS and public health that will dramatically change the landscape in which drug treatment and recovery is delivered.

When it published the NHS white paper last year, the government announced that as part of these changes the NTA would cease to exist as a separate organisation and our key functions would be transferred to a new national service, Public Health England (PHE).

The companion public health white paper subsequently made clear that reducing drug use, and enabling people to overcome dependency, recover fully and contribute to society, would be a key priority for this new public health service. The Department of Health is now taking forward the transition to PHE, under which services will in future be commissioned by local authorities through Directors of Public Health, supported by Health and Wellbeing Boards.

During the interim period the NTA will drive the transformation from a treatment system to a recovery system to provide a solid foundation on which PHE can build.

Treatment is only the first step on the road to recovery, and ensuring people achieve long-term recovery will demand substantial change across the sector, and require engagement with housing, employment, education, children services, families, communities and the mutual aid movement.

Our challenge is to work with the providers and professional bodies involved in drug and alcohol treatment to ensure that the principles of recovery are firmly embedded in the system. This fundamental task is enshrined in the public consultation on a new national framework "Building Recovery in Communities to replace Models of Care".

It also underpins our continuing efforts to support employers in the Substance Misuse Skills Consortium, develop patient placement criteria to deliver better clinical outcomes, and take forward initiatives like the Payment by Results pilot schemes to incentivise the system to deliver recovery outcomes.

Our aim is to work with others to build a recovery system that focuses not only on helping people to get into treatment, but also on supporting them into full recovery, leaving dependency behind and successfully contributing to society.

The Drug Strategy acknowledged the gains made by the treatment system in recent years: in reach, prompt access, and low drop-out. It also accepted that preventing drug-related deaths, restricting the spread of blood-borne viruses, and reducing crime remained key best-practice outcomes in any recovery-oriented system.

To build on this progress, NTA local teams are now working with local partnerships to focus in particular on safe and sustainable treatment completions. The numbers of people leaving treatment having successfully overcome dependency doubled from over 11,000 in 2005-6 to almost 24,000 in 2009-10. Thus far in 2010-11 there has been a further 18% increase, suggesting that over 28,000 people will complete treatment successfully this year.

Such advances will be underpinned by the commitment from central government to maintain the level of funding of the pooled treatment budget, and continue to invest in programmes to fund drug treatment in prison and ensure drugrelated offenders get access to treatment.

Nevertheless, the aim of any recoveryoriented system should be to go further and enable as many individuals as possible to become free from their dependence; something we know is the aim of the vast majority of people entering drug treatment.

The Drug Strategy recognised that substitute prescribing has a vital role to play in the treatment of heroin dependence, both in stabilising drug use and supporting detoxification. Medically assisted recovery can, and does, happen. There are many people in receipt of such prescriptions in our communities today who have jobs, positive family lives and are no longer taking illegal drugs or committing crime.

"In this rapidly changing landscape, GPs with a special interest in drug and alcohol treatment have a crucial role to play in defending the gains made in the past while also leading the changes needed in future"

However, no-one should be "parked" indefinitely on methadone or similar opiate substitutes without the opportunity to get off drugs. We must ensure that all those on a substitute prescription have opportunities to engage in recovery to maximise their chances to leave treatment free of dependency.

So we are working with an expert group of practitioners under Professor John Strang to develop new clinical protocols to make the treatment experience more dynamic for clients, prevent drift into unplanned long-term maintenance, and focus on overcoming dependence as the desired outcome of all treatment interventions.

These clinical protocols will reflect the optimum balance of medical and psychosocial interventions, and seek to ensure that all individuals receive an integrated treatment offer which provides them with the best support on their recovery journey.

In this rapidly changing landscape, GPs with a special interest in drug and alcohol treatment have a crucial role to play in defending the gains made in the past while also leading the changes needed in future.

Under the government's wider reforms, GP consortia will be responsible for spending 60 per cent of the NHS budget. GPs or their representatives will be commissioning the majority of health care received by drug users as ordinary consumers of health services. This puts a huge responsibility on the profession to make the new system work for their patients.

At the same time, the creation of health and well-being boards gives GPs an opportunity to influence local authority decisions on investment in drugs and alcohol. While Directors of Public Health will be in the frontline of the commissioning process, GP consortia will have seats on their local boards, and an important role to play in commissioning decisions on public health.

The stage is set, therefore, for a major shift in the dynamics of the debate from a national stage to a multitude of local theatres. The Drug Strategy has set an agreed direction of travel for drugs and alcohol. Although there remain some strident voices who would like to impose an even more radical approach, the issue now is how to implement change on the ground.

I believe GPs have a critical role to play as local advocates for a balanced treatment system with a range of recovery options. That may be an uncomfortable position for some, who may prefer to focus on treating their patients rather than stand accused of playing politics. However, the challenge is out there in the very mechanisms the government is creating to enable the voice of GPs to be heard.

The risk is that if GPs are unwilling to rise to that challenge, and abdicate the responsibility they have been given, others may seek to occupy the space and distort the debate. Public understanding about the benefits of treatment, and the recovery services required by a vulnerable and stigmatised client group is fragile at the best of times. In my view it would be a tragedy if it was damaged by default because doctors did not speak up for their patients.

- Paul Hayes
Chief Executive, National Treatment Agency

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Hepatitis C: individual aspects of a public problem

Hepatitis C: individual aspects of a public problem

Though we have improved detection of hepatitis C in recent years, we could be doing much better at getting people into treatment. Euan Lawson outlines the issues. Ed.

The problem with hepatitis C is that everyone knows it is a large public health problem but this doesn't necessarily reflect the attitudes and behaviours of individuals. One might think that the numbers would speak for themselves - the Health Protection Agency estimates there are around 250,000 infected in the UK but some estimates have suggested the prevalence could be as high as 466,000 (Ref 1, Ref 1). Yet, the issue of hepatitis C virus (HCV) infection in the UK seems to have had very little impact on the consciousness of general practice beyond those services and clinicians with a specific interest in substance misuse. Overall, we are managing to detect more HCV but the number of individuals heading through into treatment remains very low: there are 13,000 new cases of hepatitis C infection in the UK per year yet we are only treating around 5,000 (half of whom will be successful in eradicating the virus) (Ref 3).

We know that the majority of hepatitis C infections are found in injecting drug users (IDUs) with an estimated 90% of infections in this group. This heavy weighting toward IDUs has meant that the two biggest areas that have been identified in a public health response are: 1) providing access to sterile injecting equipment and 2) offering opiate substitution therapy to reduce or stop infection. These have both been shown to be effective measures. The effectiveness of the public health approach, led by the 2004 Hepatitis C Action Plan (Ref 4) is less clear. A recent study has looked at the impact of this plan and there has been little change in anti-HCV prevalence among recent initiates over the period - it has remained the same in 2008 (Ref 5). This also fits with the outcomes from a recent paper in the Journal of Infectious Diseases (Ref 6). A cohort of IDUs in Baltimore followed since 1988 showed a decline in HIV - dramatically illustrated by the fact that not a single new HIV infection occurred within the first year of follow-up in the cohorts recruited from 1998 onwards. This has not been the case for HCV. There were some modest reductions in the HCV incidence and prevalence in the same period amongst younger and new initiates to injecting. However, older injectors and those with longer injecting histories still had practically the same HCV burden.

Individual attitudes and behaviours

There is evidence in a recent study in the States that highlighted nearly a quarter of young IDUs still shared needles and syringes and two-thirds shared other equipment at some time (Ref 7). However, there was a significant reduction in these numbers if their injecting partner was known to be HCV positive. It highlights the point that individuals aren't utterly self-destructive - they will modify their behaviour when necessary. Importantly, this study also pointed out that there was no difference when the injecting partner was HCV negative or when they simply didn't know the HCV status of the injecting partner. This points toward the importance of detecting HCV and advising IDUs of their status - even if they choose not to be referred for treatment.

We need to remember just how poorly IDUs are engaged with health services in general. One predominant theme when drug users are interviewed about health care is that they often feel they have difficulty accessing care and they perceive hostility towards them when they do. As a consequence they have low expectations of health care and it is perhaps not unduly surprising that a positive hepatitis C result doesn't significantly change this for many people (Ref 8). It isn't realistic to expect a positive test to transform someone's attitude to health services - particularly when the treatment is lengthy, requires regular monitoring, is associated with multiple side effects and the individuals may have poor social support.

A couple of papers have looked at the attitudes of nurses and family doctors to the provision of hepatitis C care. A survey of Canadian family physicians showed that those who were involved were more likely to be older males, who practice in a rural setting, have IDUs in their practice and have higher levels of knowledge about the initial assessment (Ref 9). This leads on to the authors' suggestions that educational programmes need to target those likely to provide HCV care - i.e. family physicians in urban areas and those who don't treat IDUs. A survey of nurses' attitudes found, encouragingly, that nurses hold compassionate attitudes to people with hepatitis C irrespective of how the virus had been acquired (Ref 10). However, it is not all rosy as the study showed that nurses employ differing infection control practices when caring for a client with known hepatitis C and these were felt to reflect negative stereotypes and caring attitudes.

Shifting toward an individual approach

Hepatitis C is an escalating problem and detection and diagnosis of the disease is clearly a fundamental step. However, it is just a step and we need to start thinking harder about how we will translate increased detection into increased treatment. It is crucial to consider how we engage individuals with the virus and it will be necessary to work out how we best engage individual clinicians in wider general practice beyond those already involved in substance misuse.

- Euan Lawson
Clinical Lead for the RCGP Certificate in the Detection, Diagnosis and Management of Hepatitis B and C in Primary Care

References

1. Health Protection Agency (2009) Hepatitis C in the UK: Annual Report 2009 London:

2. The Hepatitis C Trust and the University of Southampton (2005) Losing the fight against hepatitis C London

3. The All Party Parliamentary Hepatology Group (2010) In the dark. An audit of hospital hepatitis C services across England London

4. Department of Health (2004) Hepatitis C Action Plan for England

5. Hope V, Parry JV, Marongui A, Ncube F (2011) Hepatitis C infection among recent initiates to injecting in England 2000-2008: Is a national hepatitis C action plan making a difference? J Viral Hepatitis 2011. Available online ahead of publication.

6. Grebely J, Dore GJ (2011) Prevention of hepatitis C virus in injecting drug users: a narrow window of opportunity J Inf Diseases 2011;203:571-574

7. Hahn JA, Evans JL, Davidson PJ, et al (2010) Hepatitis C virus risk behaviours within the partnerships of young injecting drug users Addiction 2010; 105: 1254-1264

8. Beynon C, Roe B, Duffy P, Pickering L (2009) Selfreported health status, and health service contact, of illicit drug users aged 50 and over: a qualitative interview study in Merseyside, United Kingdom BMC Geriatrics 2009; 9:45

9. J Viral Hepatitis (2011) Knowledge, attitudes and behaviours associated with the provision of hepatitis C care by Canadian family physicians. Available online ahead of publication.

10. J Adv Nursing (2011) Hepatitis C virus in primary care: survey of nurses' attitudes to caring 67:598-608

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Addiction and the brain

Addiction and the brain

David Nutt outlines what is understood about the complex relationship between addiction and the brain. Ed.

Addiction is a major health problem that costs as much as all other mental illnesses combined and about as much as cancer and cardiovascular disease. In essence, addiction is a state of altered brain function that leads to fundamental changes in behaviour that are usually resisted - though unsuccessfully - by the addict. The key features of addiction are a state of habitual behaviour such as drug taking or gambling that is initially rewarding though can eventually become self-sustaining or habitual. The urge to engage in this behaviour can become so powerful that it interferes with normal life, overtaking work, personal relationships and family ties to the point that the addict's whole being is directed to their addiction. Moreover feelings of intense distress emerge when the addiction is thwarted and these can lead to dangerously impulsive and sometimes aggressive actions. In the case of addiction to drugs, the situation is compounded by the occurrence of withdrawal reactions which cause further distress and motivate desperate attempts to find more of the addictive agent; this urge to get the drug may be so overpowering that addicts will commit seemingly random crimes to get the resources to buy more of the drug. It has been estimated that about 70% of all acquisitive crime is associated with drug and alcohol use.

Addiction is occasioned by a complex set of internal and external factors. Although most addiction is to alcohol and other drugs, addiction to gambling and other behaviours, for example sex and spending, can occur. These tell us that the brain can develop hard-tocontrol urges independent of changing its chemistry with drugs. All addictions share a common thread of being initially pleasurable activities, often extremely so. This had lead to the theory that they hi-jack the brain's pleasure-reward systems so that naturally rewarding activities become devalued and the more excessive addiction behaviours take over.

"...addiction can be seen as a lossof- control over what starts out as a voluntary behavior. This is not as some like to suggest simply a lifestyle choice but reflects an enduring, probably permanent change in brain function..."

However, not everyone who engages in drug use or other rewarding behaviours becomes addicted to them so clearly other factors are important. These are not well understood but include concepts such as excessive rewarding effects in some people, a failure of adaptive coping strategies in others and aberrant habit learning as well. Some addicts may have a mixture of several of these vulnerability factors and there are also genetic predispositions to some of them. Also a significant amount of drug use is for self-medication for example cannabis for insomnia, alcohol to reduce anxiety, opioid for pain, stimulant for undiagnosed/untreated attention deficit hyperactivity disorder (ADHD) and this use can develop into addiction in some people though by no means all.

The rewarding effects of addictions are mediated either through the release of dopamine (cocaine, amphetamine and nicotine) or through activation of endogenous opioid systems (heroin) or both (alcohol). The pleasures are then laid down as deep-seated memories, probably through the changes in glutamate and GABA-A receptors that are involved in all memories. These memories link the location, persons and experiences of drug use (or other addictive behavior) with their pleasurable effects. These memories are often some of, if not the most powerfully positive ones the person may ever experience, which explains why so much effort is put into recreating them. When they re-occur in abstinence, they are experienced as cravings that can be profound, urgent and lead to relapse.

A great deal of research has been conducted into the role of dopamine in addiction and we now know that a low density of dopamine receptors seems to predispose to excessive dopamine response from stimulant use. This excessive response is thought to initially occur in the reward centre of the brain (the nucleus accumbens) but then move into other dopamine-rich areas especially the caudate/putamen where habits are laid down. This shift from voluntary choiceuse to involuntary habit-use explains well a common complaint of addicts that they don't want to continue with their addictions, and even that they don't enjoy the behaviour anymore, but can't stop themselves. In this sense addiction can be seen as a loss-of-control over what starts out as a voluntary behavior. This is not as some like to suggest simply a lifestyle choice but reflects an enduring, probably permanent change in brain function which can be modeled in animals.

We know that personality traits such as impulsivity predict excess stimulant use and in animals this can be shown to correlate with low dopamine and high opioid receptor levels. Similarly in humans, low dopamine and high opioid receptor levels predict drug use and craving. These observations give new approaches to treatment, both psychological interventions such as behavioural control, and anti-impulse drugs such as those used for ADHD for example atomoxetine and modafinil. Another major relapse precipitant is stress; this may work through increasing dopamine release in the brain so priming this pathway or by interactions with other neurotransmitters such as the peptide substance P. As antagonists of these neurotransmitters are now available they are being tested in human addictions.

- Professor David Nutt
Chair in Neuropsychopharmacology Imperial College London

Further reading

Nutt DJ Lingford-Hughes A (2008) Addiction the clinical interface Brit J Pharmacology 1-9

Nutt DJ, Law FD (2008) Pharmacological and Psychological aspects of drug abuse. New Oxford Textbook of Psychiatry 2nd edition

Robbins TR, Everitt B, Nutt DJ (2010) The Neurobiology of Addiction - New Vistas. OUP

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A snowflake is one of God's most fragile creations, but look what they can do when they stick together

A snowflake is one of God's most fragile creations, but look what they can do when they stick together

Tim Sampey describes how the London User Forum used its strengths when its funding was cut to produce an even stronger organisation. Ed.

The old London User Forum (LUF) was created by the National Treatment Agency (NTA) in the very early days of service user involvement. In existence for almost ten years, it provided the only meeting place that any service user could walk into from anywhere in London and discuss with their peers some of the issues and events that were taking place in their local services and Drug and Alcohol Action Teams (DAATs). Often chaotic and somewhat argumentative in the early days, and prone to a variety of incarnations, it nevertheless served a unique purpose. By giving service users a place where we could meet and discuss our ideas and work, it gave birth to an enormous amount of inspiration and resolve, and can be credited with encouraging a great many individuals to return to their boroughs invigorated and determined to make a difference. Indeed, it is not unreasonable to suggest that the majority of those men and women who have worked so hard to transform service user involvement from an idea into a solid reality met at the London User Forum.

Last year, having created the London Regional User Council (LRUC), the NTA called it a day for the London User Forum. It is interesting to note that this action clearly demonstrated how far service user involvement had come, because it immediately became clear that some among us not only disagreed with this decision but were more than willing to do something about it. Service user involvement had grown up and was ready to leave home.

"To the best of my knowledge this is the first time that service users have worked collectively in partnership with service providers on this scale and what happens next could change service user involvement forever"

It was strongly felt that there was a definite need for an open service user forum in London; a place where we could network, support and encourage each other, share ideas and exchange good practice. After all, how could we continue to grow and develop if we never got to meet each other? Speaking personally, my peers have been inspiring and teaching me for years, and I for one did not want to lose that.

An open letter, an exchange of e-mails between those of us that knew each other from years of attending the old LUF, a telephone call to the service provider Foundation 66 (who to their great credit stepped straight up to the mark and offered us a venue for an open meeting - thanks Mr Gray!) and then a simple e-mail blitz of all those service users we collectively knew, and an extraordinary meeting was called.

It was the simplest of ideas. Let's go into partnership with the service providers we work with every day and recreate the Forum. If they take it in turns to provide the venue and some food, we, the service users, will organise the Forum, provide speakers, and do our collective best to take service user involvement forward across London.

It was one of my favourite days of last year. In three hours we elected a steering committee, came to an arrangement with the great majority of service providers in London and launched a new Forum! How? By keeping it simple.

The steering committee comprised: two service user coordinators; two service user representatives from the LRUC; three service user leads; a representative from the London service providers; and a DAAT representative from one of the 33 London boroughs. The only other criteria we had related to the service user representatives. We asked for someone who was maintenance prescribed, someone who was a member of the 12 step fellowship, and individuals who had come from substance use backgrounds that were specifically opiate, stimulant and alcohol based. We wanted as broad a church as was possible. Names went into a hat and we had a committee.

We decided in that meeting to abandon terms of reference or codes of conduct as an unnecessary complication, but agreed instead that cooperation, diversity and a spirit of partnership would allow us to move forward immediately and begin to organise our first Forum as fast as was possible. We agreed to abandon any ideas of seeking funding for the first year, but instead to volunteer our services for free in the management committee and work with the service providers to obtain anything else we needed.

We should not underestimate the potential for what we have started. To the best of my knowledge this is the first time that service users have worked collectively in partnership with service providers on this scale and what happens next could change service user involvement forever. There is no doubt about it, we have come of age.

We have held two highly successful open Forums and are currently in the process of organising the third. The steering group has every intention of building on this success step by step. The LUF will be designed, implemented and run by London's service users, and if we get it right, the LUF should become a major force for service user involvement across London.

The world is changing and partnership is the way forward. Any bitterness some of us may feel toward the NTA for disbanding the old London User Forum should perhaps be viewed in the following light. The NTA birthed the original London User Forum, and without that none of us would be here. Our collective experiences over the past ten years as service user coordinators and service user leads have allowed us to take our destiny into our own hands. We have outgrown being managed by others and now face the challenge of joining together and standing on our own. We are service users. We are the London User Forum. We are the future.

- Tim Sampey
Service User Coordinator, Kensington and Chelsea

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Practice with kindness: the forgotten art?

Practice with kindness: the forgotten art?

In the rush to meet targets and provide evidence based practice we can miss an essential element of care. Teresa Wirz discusses the importance of being kind when working with people. Ed.

Kindness is defined as the quality of being friendly, generous, and considerate. It is also about being emotionally attractive - an attribute that helps to build effective and strong therapeutic relationships with others. Kindness should not be confused with being nice or soft, but can be the bedrock on which further effective and more sophisticated communication is built. It has been said that we need to be more inspirational for our clients who - by the nature of their addiction - will often be in a state of ambivalence. It has been well documented that the quality of the relationship along with feeling accepted and understood is one of the most important factors associated with positive outcomes. Our communication is more likely to be well received and the therapeutic alliance boosted if we ask ourselves and think more explicitly in terms of how we want that person to feel. This can be challenging when we are dealing with busy waiting rooms full of people, but some simple shifts in attitude and approach can be highly effective.

Things that need changing may start well before the patient arrives for the first appointment at a GP practice or drug clinic. At one service I worked in, the "invitation" letter threatened sanctions and discharge; similarly the patient treatment agreements contained long lists of "musts" and "do nots" that could impact negatively on the relationship before it even started. When I attended my own GP surgery recently, digital screens were constantly flashing warning messages about missed appointments and their consequences, to which I found myself feeling defensive, and somewhat annoyed. These things risk communicating all the wrong messages, creating an immediate negative barrier and are not kind. A careful look at the hidden messages in letters and notices displayed in waiting rooms, as viewed by someone on the receiving end, might result in these being reframed to describe the behaviours we want to see rather than those we don't.

People by nature find it much more comfortable to follow clear instructions about what is required of them rather than being told what not to do. In reference to kindness we need to ensure that messages have therapeutic purpose and put the welfare of the patient as well as staff at the centre; ultimately they make the patient feel they can positively relate to the service and want to come back.

Senior staff need to challenge mediocre practice particularly when it comes to poor communication, as the frightening thing we know is that poor treatment can be damaging and can actually make clients worse. Managers and clinicians who lead by example create healthy team dynamics, starting with a very clear expectation that manners towards each other and clients are placed high up on the hierarchy of shared values. This can be very effective, especially if practiced by the leadership (Ref 1).

Kindness has an important role in managing conflict. Conflict can be healthy when it allows us to bring issues to the surface, move forward and make changes. However situations that have been rumbling on for years can be quite damaging and impact negatively on how we feel about our team (our collective identity) and very importantly how we then communicate with our patients and the outside world. A receptionist I worked with some time ago had high levels of conflict with colleagues and clients and was often outwardly quite aggressive. Linda (Ref 2) excelled at her job in other respects and had over twenty years' experience - but on a bad day, she was terrifying. Yet we all put up with her outrageous behaviour. Recently, I went to a workshop on partnership working where a patient representative was asked how they would know that good partnership existed between services. I was poised with my answer about "ratified joint information sharing protocols, good shared governance forums and clearly identified referral pathways", when the patient representative replied "I would say I know this when I am there and my keyworker phones up another service and doesn't roll their eyes, and the conversation with the person on the line is upbeat and friendly when they deal with my referral". What clearly came through was the value placed on a friendly exchange observed by the client which gave her a sense of confidence in the referral process. Reflecting on this now, it deeply concerns me that an outside caller had ever spoken to Linda on a bad day.

Kindness has a range of facets including friendliness, consideration and generosity. Although clearly we are not working to make friends with our patients, smiling (friendliness) takes no extra time. Acknowledgement that someone has attended an appointment or apologising if we are running late (consideration), and making someone in distress a cup of tea or spending that little bit of extra time to find out what's actually wrong or explaining

something in more depth (generosity) can go a long way. It can take courage to be kind. One evening as we were locking up the clinic a client came to the door. He was a day late for an appointment and the doctor had left so we could not issue a prescription - yet the nurse responded calmly with sustained politeness and care in the face of multiple protests. The client needed to understand that the clinic was now closed and could not be reopened.

The message could have been: I am really irritated you have pounced on me on my way out (my train leaves soon) and I am exasperated that you are incapable of attending any of your appointments on time, you brought this on yourself and now you will have to deal with the consequences; or, as it was on that day: I value you and have time for you but unfortunately not now. I acknowledge that you have tried to come; it is good that you want to see me. I really want you to come back first thing in the morning and I will make time for us to sit down and look at how we can help you to get here during clinic hours and ensure your treatment progresses. The boundary is exactly the same, but the therapeutic alliance is preserved and protected in a response tempered by kindness. Kindness removes the need for hostility. Clients often talk about "us" (clients) and "them" (staff) and although there may be many reasons for this, being kind can help to soften this perceived barrier - which could be the client unconsciously communicating a fear of stigma - and enable us to connect more directly with them.

A little kindness goes a long way. We need to manage our communication in such a way that the most vulnerable experience our services positively. Being a bit more friendly, considerate and generous in our interaction with our patients may encourage more people to come to services as the message is carried that the service is a good place to find help. Ultimately it could impact far beyond the clinic environment.

- Teresa Wirz
Manager, Addiction and Offender Care Services Directorate, The Junction Drug and Alcohol Service

References

1. National Treatment Agency August (2009)Towards successful treatment completion: a good practice guide.

2. Name of the staff member has been changed for the purposes of this article

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Managing common mental health disorders in addiction services

The prevalence of mental health problems is high amongst those in contact with addiction services but how good are we at assessing for this? Scott Payne gives us some food for thought and a few ideas on how to improve our practice. Ed.

Epidemiology

Dual diagnosis is a somewhat nonspecific term that encompasses a wide spectrum of heterogeneous conditions (Ref 1). However, epidemiological studies consistently show that both in the community and in drug and alcohol treatment services, mild to moderate or common mental health disorders (CMD) are by far the most prevalent co-existing with substance use disorders.

The renowned COSMIC study (Ref 2) showed that of the 75% of patients in addiction treatment services who also had a past year diagnosis of mental illness, 68% (drug) and 81% (alcohol) were diagnosed with an affective or anxiety disorder compared to equivalent figures of 9% and 19% for a severe and enduring condition (SEMI). Using detailed diagnostic instruments, Strathdee et al (Ref 3) identified 83% of patients in substance use services as having co-morbidity, again with more than twice the number suffering with CMD compared to SEMI.

Aetiology

One issue that arises from such prevalence studies is how to distinguish between independent and substanceinduced disorders. The PRISM is a semi-structured interview that was developed to assist this process (Ref 4). Using this tool, Torrens et al (Ref 5) aggregated data from several clinical and community based samples of illicit drug users. Apart from reporting again that CMD were the most common type of mental health condition detected, perhaps the most interesting find was that independent disorders were significantly more prevalent than induced. For depressive disorders 10% were deemed to be induced and 18.8% independent whilst for anxiety disorders only 1.1% induced against 14.3% independent.

Although theoretically important, caution is needed as attempts at differentiation can in practice fuel the inconsistent and often unhelpful use of terms such as "primary disorder", "secondary disorder", "drug-induced" and "self medication". Even experienced clinicians find it difficult to distinguish in alcohol dependent patients with depression which condition pre-dated the other and which patients may improve after detoxification (Ref 6).

Screening:

As few as 27% of affective disorders detected by formal assessment tools in addiction treatment populations are identified by the keyworkers of comorbid patients (Ref 2). Potential explanations for this include the difficulty of making a formal diagnosis amongst the "noise" of highly prevalent anxiety and depressive symptoms in these populations, staff lacking psychiatric experience and services not prioritising mental health treatment. These ideas are discussed further by Maisto and Kivlahan (Ref 7) who explore why there is such a wide variation in the use of mental health screening tools in addiction services in the United States.

The Quality Outcomes Framework (Ref 8) recommends the use of CMD screening tools in primary care in conditions where prevalence is known to be high, for example coronary heart disease and diabetes mellitus and to assist in supporting a clinical diagnosis. They are also widely used by IAPT (Improving Access to Psychological Therapies) services to inform treatment approach based on condition severity and to monitor progress.

"As few as 27% of affective disorders detected by formal assessment tools in addiction treatment populations are identified by the keyworkers of comorbid patients"

There is significant heterogeneity in studies assessing mental health screening instruments in substance use populations. Various tools have been studied in dissimilar treatment populations (for example harm reduction versus inpatient), in different drug using groups (for example cocaine users versus dependent alcohol drinkers) and with significant variation in the consideration of potential confounders (for example level of substance use or stability on medication). Studies have often reported different cut off scores to represent a case than when the same tools are used in the non co-morbid population.

Due to these issues with generalisability, I am currently part of a research team working alongside the University of York, examining the psychometric properties and acceptability of the PHQ-9 and GAD- 7 screening questionnaires in Leeds Community Drug Treatment Services (CCAS - Case-finding and Co-morbidity in Addictions Services). Preliminary results suggest that when compared to gold standard diagnostic instruments, these tools are as effective in our patients as they are in non substance using populations.

Service Delivery:

Addiction services are familiar with and adept at dealing with a wide range of both physical and psychiatric co-morbidity alongside their everyday business of treating dependence and its associated harms. Common mental health disorders are arguably the most prevalent of these co-morbidities and impact significantly on patient outcomes. Unfortunately many if not most go untreated despite there being a developing body of guidance (Ref 9, Ref 10, Ref 11) on how dually diagnosed patients should be managed.

With blood-borne virus Infections, it is now routine practice to screen and pro-actively manage positive cases either through clear referral pathways or occasionally in-house. Indeed there are even targets on this. To provide a comparable package for CMD, further work needs to be undertaken to strengthen the use of validated screening tools and to utilise these to inform treatment options and monitor outcomes.

Pockets of joint work between addictions and IAPT services exist (Ref 12), but these are by no means ubiquitous and often come with strict inclusion and exclusion criteria. This joint working is clearly to be encouraged but does not necessarily help those with more complex needs, who may benefit most from working with a therapist who is dually trained and experienced in both substance use and mental health treatment (Ref 13).

This philosophy of integration, either of individual treatments or between appropriate services, is at the heart of good management of dual diagnosis (Ref 14). It is important that this ethos is not lost in the complex and varied way services are now commissioned, nor that these patients with possibly less likelihood of a successful outcome are overlooked or excluded in any cherry-picking that Payment by Results may engender. Perhaps more than ever the challenge exists to ensure the building blocks are in place (screening, pathways, treatment programmes) to provide equitable and effective care wherever the co-morbid

patient presents in the treatment system.

- Scott Payne
Psychiatrist, Leeds Community Drug Partnership

References

1. Department of Health. (2002). Mental health policy implementation guide: Dual Diagnosis Good Practice Guide. London: Department of Health. London.

2. Weaver, T., Madden, P., Charles, V., Stimson, G., Renton, A., Tyrer, P., et al. (2003). Co morbidity of substance misuse and mental illness in community mental health and substance misuse services. The British Journal of Psychiatry, 183(4), 304-313.

3. Strathdee, G., Manning, V., Best, D. et al. (2002). Dual diagnosis in a primary care group (PCG): a step-by-step epidemiological needs assessment and design of a training and service response model. London: Department of Health.

4. Hasin, D.; Trautman, K.; Miele, G.; et al. (1996c) Psychiatric Research Interview for Substance and Mental Disorders (PRISM): Reliability for substance abusers. American Journal of Psychiatry 153:1195-1201, 1996c

5. Torrens, M., Gilchrist, G., & Domingo-Salvany, A. (2011). Psychiatric co-morbidity in illicit drug users: Substance-induced versus independent disorders. Drug and alcohol dependence, 113 (2-3), 147-156.

6. Schuckit, M.A, Tipp, J.E, Bergman, M, Reich, W, Hesselbrock, V.M and Smith, T.L (1997). Comparison of induced and independent major depressive disorders in 2,945 alcoholics, American Journal of Psychiatry, 154, 948-57 .

7. Maisto and Kivlahan, (2008) Screening for psychiatric disorders among adults. Int J Ment Health and Addiction; 6:32-36

8. www.qof.ic.nhs.uk

9. NICE CG51 (2007) Drug misuse: psychosocial interventions: full guideline

10. NTA/BPS (2010) Psychosocial interventions in drug misuse: a framework and toolkit for implementing NICErecommended treatment interventions

11. Lingford-Hughes A.R, Welch S, Nutt DJ (2004) Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from the British Association for Psychopharmacology, Journal of Psychopharmacology 18(3) 293-335

12. NTA (2011) - personal correspondence

13. Hughes et al, (2006) Closing the Gap: A Capability Framework for Working Effectively with People with Combined Mental Health and Substance Use Problems.

14. Department of Health. (2007). Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive.

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Dr Fixit on managing patients who are not doing well in treatment

Dr Fixit on managing patients who are not doing well in treatment

Jack Leach provides advice about managing a patient who does not appear to be progressing in treatment. Ed.

Question

Dear Dr Fixit,
I wonder if I could ask your help with Eddie? He is forty-eight-years old, has been a patient of the practice for several years but only came to see me about his drug problem one year ago. He was using heroin (injecting 1gm a day) and benzodiazepines when he could get them. He drank in binges. He requested a quick detox, which we agreed to only after we gave him all the evidence of different treatments. He didn't complete the detox and then decided he needed a period of maintenance in order to try again. He managed to do this with psychosocial support but only remained drug-free for 10 days. After this he started using again at increased amounts. He asked to go back on maintenance to which I agreed. He has now titrated up to 80mg methadone but continues to take nonprescribed benzodiazepines and his last 2 urines have been positive for heroin but he refuses increases to his methadone dose. His health has not improved and he is about to be made homeless for nonpayment of rent. Care and assessment have refused paying for rehab because they say "he is not ready". Treatment doesn't seem to be helping Eddie - could you suggest how I should take this forward, especially as our commissioner is demanding more people should get off oral substitute treatment?

Answer

Eddie's situation is not unusual to that of a substantial minority of clients in drug treatment services. They do not appear to be doing as well as we, and they, would like. Before writing them off as treatment failures who need to be either discharged, detoxified, or prescribed a more radical opiate replacement medication, it is worth asking yourself a number of questions. Against what are you judging their progress? Is this a blip or a trend? We tend to compare a client's progress against our expectations, the stated goals of the client or perhaps how they were at first presentation, or maybe a combination of all three. But the real comparators are how they would be if they were not in treatment, or how they would be if they were in an alternative treatment programme. Unfortunately, even if we think about this, we can only guess. Eddie could be doing worse if he was not in treatment at all. Assuming changes to his treatment programme could improve things for him, what changes might be helpful for Eddie? I would first:

  1. Address his immediate physical and mental health problems; there is anecdotal evidence that promoting and improving the health of people with drug dependence not only reduces their short and long term health implications but also helps them tackle their drug problems.
  2. Help him with financial problems; it may help his social situation and enable him to tackle his drug problems. If statutory services are unable to help, various local and national voluntary organisations such as Citizen's Advice Bureau and Shelter may be of help.
  3. Use focused psychological support such as motivational interviewing and international treatment effectiveness programme (ITEP) to reduce and change his substance using behaviour.

Eddie seems to have problems from his opiate, benzodiazepine and possibly alcohol use. Should these be tackled together or separately? The problems from them will be accumulative and make treatment less successful and more problematic as these illicit and prescribed drugs interact (Ref 1, Ref 2). There is no definitive answer to this. In general in the community I would suggest tackling one at a time, whilst not taking your eyes off the other. Which to tackle first is based on which the client perceives as most problematic combined with our judgment of which is potentially the most dangerous and which we can have most effect on. Usually overall, regular injecting of heroin is more problematic than regular oral benzodiazepine use and excessive drinking and there is an effective medication to combine with psycho-social interventions. So what medication changes might be helpful? One might consider:

  1. Increasing his dose of methadone is likely to be helpful. All controlled studies of methadone suggest that methadone's effectiveness is dose-related (Ref 1). However, he is not keen to do this. It is worthwhile finding out the reasons for him not wanting to increase his dose, check he is taking his current prescribed dose and frankly discuss with him the potential benefits and disadvantages of increasing his dose.
  2. An alternative opiate replacement medication. Eddie is currently on too high a dose for conversion to buprenorphine. For intractable injecting drug use, other alternatives include adding or replacing with an injectable opiate medication, such as methadone for injection or diamorphine. There have been a few controlled trials comparing injectable diamorphine to oral methadone in the international literature (Ref 3). They have not shown a clear advantage. A Dutch study indicated that a combination of oral methadone and diamorphine seemed to give some of the most favourable results. If injecting is not so intractable then another oral opioid might be considered of which the most promising is long acting oral morphine preparations, though this is not currently a licensed use (Ref 2).
  3. If benzodiazepine use (BZD) is particularly problematic, should you prescribe a replacement such as diazepam? This is highly controversial. Unfortunately there is no more than opinion to guide, as research has not shown converting illicit to prescribed benzodiazepines reduces overall benzodiazepine use, reduces problems from BZD use or improves physical and mental health.

The new national drug strategy 2010 Reducing demand, restricting supply and building recovery: supporting people to live a drug free life attributes the ills of poor communities on drug use, in a similar way to the social devastation in USA attributed to cocaine in the 1960s and 70s and calls on community action to reduce this demand. Unfortunately it seems that it is social deprivation and inequalities that encourage problematic drug use and until social conditions are improved it is unlikely that these communities will reduce illegal drug markets and drug use. The strategy describes recovery as a single predictable path to abstinence from both illicit and prescribed opiate drugs. It suggests that abstinence will enable people to become economically active, coming off state benefits. This constructs people dependent on drugs as a homogenous group of welfare recipients who need to be free of all drug use before they can become proper members of society. Problem people rather than people with problems. However, I believe recovery is a complex concept and consists of different paths for different people at different times.

Should Eddie follow this recovery rhetoric and detoxify and live a drug free life? Unfortunately, Eddie seems to have problems doing this. His previous detox attempts have been unsuccessful and even on a methadone maintenance programme he is still not able to completely stop his illicit drug use. If his methadone was reduced rapidly it is difficult to see how he could stop both his illicit and prescribed drug use in his current situation. So how about inpatient detoxification followed by residential rehabilitation? The cost of this treatment will be high, during which he will stay on state benefits and it is likely he will have to give up his home. Research suggests that the majority of people completing detoxification and residential rehabilitation treatment will relapse within the year following their discharge (Ref 4, Ref 5, Ref 6), and that inpatient setting outcomes do not differ greatly from community. All studies of community opiate treatment suggest that longer-term programmes are more effective that short-term programmes in reducing and stopping illicit drug use, promoting health and reducing risk of death (Ref 1). Eddie may not feel willing or ready to come off prescribed drugs and spend months in a residential rehabilitation unit. So the zeal to implement policy by the commissioners should be tempered by what is likely to help Eddie in practice and this will include what Eddie feels would be helpful to him and what he is able to commit himself to.

- Answer by Jack Leach
Lead General Practitioner in Substance Misuse, Smithfield Services, Manchester

References

1. Ward J, Mattick R, Hall W (editors) (1998). Methadone maintenance and other opioid replacement therapies. Amsterdam:Harwood Academic Publishers.

2. Department of Health (England) and the devolved administrations (2007). Drug misuse and dependence: UK guidelines on clinical management. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive.

3. Stimson G, Metrebian N (2003). Prescribing heroin: what is the evidence? Findings September 2003. Joseph Rowntree Foundation.

4. Mattick R, Hall W (1996). Are detoxification programmes effective? Lancet;347:97-100.

5. Gossop M, Marsden J, Stewart D, Rolfe A (1999). Treatment retention and 1 year outcome for residential programmes in England. Drug and alcohol dependence; 57(2):89-98.

6. Day E, Ison J, Strang J (2005). Inpatient versus other settings for detoxification for opioid dependence. Cochrane database of systematic reviews 2005, Issue 2. Art No CD004580. DOI: 1002/14651858. CD004580. Pub2.

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Dr Fixit on Benzodiazepines

Dr Fixit on Benzodiazepines

Chris Ford is Dr Fixit to a GP who is wondering whether or not to prescribe benzodiazepines to a patient. Ed.

Dear Dr Fixit,
I am really struggling with one of my patients Daniela, and her benzodiazepine problem. She is 36-years-old, lives alone and suffers from depression which she relates to being abused and in care as a child. She was stabilised on 70mg of methadone mixture by the local specialist drug services where she had been a patient for 6 months after moving from Scotland and then transferred to me 4 months ago. The specialist service told me she had a long-standing benzodiazepine problem but they had completed a 3-week detoxification 6 months ago and that I shouldn't prescribe benzodiazepines for her, although all her urines had been positive for benzodiazepines and methadone since this time.

She has settled well into the surgery and continues to be opioid free except for methadone but all her urines continue to be positive for benzodiazepines. At each appointment she begs me to prescribe benzodiazepines for her as she says they are getting increasingly difficult and dangerous to obtain. She feels suicidal and ill if she does not take them every day. Her previous GP in Scotland had prescribed them for her for 6 years before she moved here. They were the first drug she used and she has used them constantly for over 20 years. She has never injected, drinks less than 4 units of alcohol a week and takes no other drugs.

I spoke again to the consultant at the drug services and she is still advising me not to prescribe benzodiazepines to Daniela. I know that this is also the advice given in the 2007 Clinical Guidelines (Ref 1), but I feel it doesn't deal with the reality of this problem. Daniela is a vulnerable woman and I am beginning to think more and more that I should prescribe them and would welcome your advice.

Answer

Thank you for your letter, it's a difficult but common issue and I will do my best to offer some advice. We have a lot of information in her history: she was abused as a child and probably started using benzodiazepines as a coping mechanism; she has used them constantly for over 20 years; she has a history of depression; all urines are positive for benzodiazepines; and her previous GP had prescribed them for 6 years. There can be no doubt that she is dependent on them and would have great trouble coming off them after one quick detoxification, hence I agree with you that you should probably prescribe benzodiazepines to Daniela.

"The issues of benzodiazepine prescribing are complex and controversial and there is often a wide divergence between published guidelines and clinical practice"

The issues of benzodiazepine prescribing are complex and controversial and there is often a wide divergence between published guidelines and clinical practice. We know that the number of people worldwide who are taking prescribed benzodiazepines is enormous and in the UK about 2 per cent of the adult population have used prescribed benzodiazepine hypnotics or tranquillisers regularly for 5-to-10 years or more. Studies have shown that between 30-50% of long-term users, such as Daniela, have difficulty in stopping benzodiazepines because of withdrawal symptoms.

There is no typical benzodiazepine user with use occurring across the age groups and genders. They are used extensively in mental illness and used and abused by people who use illicit drugs and/or alcohol, though there has been little research involving people who have comorbidity problems with mental health and substances.

In Daniela's case, the Department of Health guidance1 to prescribe for only 2-4 weeks is obviously not going to work and is too simplistic. The evidence base is limited so in clinical practice we need to balance the risks and benefits of prescribing benzodiazepines. They are useful drugs, when used wisely and usually short-term and nearly all the disadvantages and problems with benzodiazepines result from long term use, as in Daniela's case, arising from issues related to tolerance and dependence.

Illicit benzodiazepine use, particularly by opioid users, is prevalent and a major problem for people who use drugs both in and out of treatment. Up to 90% of people attending drug treatment centres reported benzodiazepine use in a one-year period and there is a high prevalence of benzodiazepine use in methadone maintenance patients (Ref 1). There is still no gold standard treatment for benzodiazepine dependency and little evidence for the value of substitute prescribing of benzodiazepines. I feel this pushes most of us to treat all people who take benzodiazepines as the same, which they clearly aren't, and this often leads us to have to resort to opinionbased medicine.

In some patients I do prescribe maintenance benzodiazepines and find them very useful in certain selected patients and would put Daniela in this group. I would advise to try 10-20mg, increasing to a maximum of 30mg of diazepam on a daily pick up and see how she gets on.

Benzodiazepine addiction is a serious problem that I do not want to underestimate, but they are also incredibly useful drugs so let's not throw the baby out with the bath water.

- Answer by Dr Chris Ford
GP Lonsdale and Clinical Lead for SMMGP

Draft guidance for the use of benzodiazepines and similar drugs in general practice, by Chris Ford, Fergus Law and Jean-Claude Barjolin is currently out for consultation

References

1. DOH (Department of Health) (1999). Drug Misuse and Dependence- Guidelines on Clinical Management. London: The Stationery Office.

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