SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Network No 34 (April 2012)

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In this issue

Steve Brinksman discusses the challenges facing primary care treatment in his article.

Owen Bowden-Jones describes the changing nature of drug use and how his London clinic has met the challenges of working with people who use club drugs.

Asking drug and alcohol patients how to improve communication with their GP revealed many common threads; some things that worked well and others that could improve their treatment experience, as Claire Brown and Chris Ford explain.

Swanswell describe how their primary care model has developed to provide a full range of recovery focused treatment in Birmingham.

Paul Hayes sets the scene for the move of funding to Public Health England. He warns primary care that now is not the time to rest on our laurels.

Elsa Browne describes the benefits of following us on Twitter, and SMMGP's journey into using social media.

With the increasing emphasis on abstinence in the drug treatment field, Nat Wright explores the evidence base for opioid detoxification. He compares what happens in the community with what happens in prisons, with some interesting results.

Judith Yates provides advice to a GP who is working with an older drug user.

See the latest information on courses and events.

We hope you enjoy this issue.
Editor

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Editorial

Welcome to this edition of network which reflects the effects of the policy changes that are happening in the drug and alcohol field. As the National Treatment Agency prepare to make the transition to Public Health England, it is time for us to step forward and take the reins as Steve Brinksman argues in his article, and Paul Hayes challenges us to do in his piece. This is going to be the theme of our 7th annual conference "It's over to us now: the future of primary care based treatment" on 25th October in London. If you want to prepare yourself for the new environment, hold the date and contact Sarah for more details.

This edition also reflects other changes that have been taking place, of a technological nature. SMMGP has been developing the way we communicate by using web based media. Our forums have always been lively and we hope this extends to our blogs - watch out for these in the near future. This will give people more of an opportunity to discuss and comment on issues as they arise.

We have been encouraged by our growing following on Twitter; Elsa Browne describes how following us can increase your knowledge, and how our profile has evolved and continues to grow. Regular readers may have noticed that this edition is smaller at 12 pages than its usual 16. This is not because we have run out of things to say, but rather because we are aiming to publish more on our website which is about to be revitalised, so watch this space.

Finally, here are a few training dates for your diary. SMMGP are holding a masterclass on Addiction to medicines on 10th May in Cardiff. Why not stay an extra day and attend the RCGP 17th Conference "Going for gold: right treatment, right place right time" on 11th May in Cardiff.

Enjoy the issue!
Kate Halliday, Editor

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Responding to change: the challenge for primary care

Responding to change: the challenge for primary care

There are many changes afoot in the health and social care sectors and substance misuse services are mirroring this. In the 20 years I have worked with drug and alcohol users services have undergone dramatic development. I believe that those who commissioned and worked in these services should be proud of the significant improvements they have wrought; the changes in attitude towards the treatment of drug and alcohol users and the large numbers of people brought into treatment have been of immense benefit and there are many people alive today because of this.

At the same time I embrace the concept of recovery albeit that it is framed within the definition of an individual's own journey and not simply a one size fits all approach. Recovery has always been an important part of good treatment systems even if sometimes it was lost in the shadows of counting numbers in treatment. One of the significant issues we face is to maintain the hard won yards in working with drug and alcohol users in primary care; large numbers of patients are treated in GP surgeries and many more GPs and other primary care practitioners now see this as an important part of their role. This expanded, better trained and motivated workforce will be vital as we embrace the challenges ahead such as tackling the agendas around alcohol use and addiction to medicines which would both fit readily into the primary care setting, as well as the challenges of the newer illicit drugs being used as raised in Owen Bowden-Jones' article on club drugs.

It has been suggested in some areas that primary care be decommissioned from the treatment system. Turning back the clock to an era when GPs were discouraged from working with those who use illicit drugs and having everyone seen in "drug clinics" is not only retrograde but doesn't fit in with either the NHS commitment to moving care closer to home or the individual choice about treatment agendas. This bizarre time warp feeling is added to by some suggestions that we should bring back time limited treatment and even consider imposing dose ceilings. An evidence base carefully garnered over years is at risk of being hidden at the back of the filing cabinet whilst politicians and commissioners play with shiny new recovery models. I am not trying to diminish the value of recovery but I do seek to get those driving policy and commissioning services to reflect that good practice doesn't become bad practice as the result of political change. The emphasis may change but the evidence that underpins what we do continues to evolve and should be a key component in deciding what services should be offered.

We need to address the erroneous assumption that the term shared care is synonymous with long term maintenance and has no recovery focus. Recovery can and does happen in primary care, recovery which encompasses all phases of the journey; harm reduction, stabilisation, medically assisted recovery and abstinence. In this issue we provide an example of this in the Swanswell article about their Primary Care Recovery Project in Birmingham.

Primary care is comfortable with the concept of some people needing long term help and treatment and the fact that no one is ever discharged from primary care helps to facilitate this. This doesn't mean patients in primary care based treatment should just be left isolated; a key part of providing good quality care is to regularly review people and look at their recovery capital and ability to undergo change. It is my ambition that all my patients may recover but at the same time common sense dictates this may happen over a variety of timescales and that some may progress further on that journey than others, in the meantime primary care has a duty to keep people safe and to minimise the health impacts their drug use may expose them to.

"we now have to seize the day and take the opportunities offered by the current political environment whilst defending our patients' right to the best treatment for them as individuals"

The demographics of the UK population are changing and again we see this within the drug treatment sector. The number of those in treatment is falling especially amongst younger users. The age of people who present for treatment is rising and this is a trend visible throughout Western Europe. This will become more marked over the next decade with the effect of producing a cohort with significant co morbid physical health problems along side their drug use. The holistic approach and ability to deal with chronic physical illness that GPs possess will be invaluable in providing high quality services to this group as shown by Judith Yates in her answer to the Dr Fixit query on working with older people.

Primary care drug treatment has come a long way, we now have to seize the day and take the opportunities offered by the current political environment whilst defending our patients' right to the best treatment for them as individuals. Paul Hayes Chief Executive of the National Treatment Agency acknowledges the huge part primary care has played so far but warns us that this position of strength is not inviolable. The old Chinese curse has been bestowed upon us as we do indeed live in "interesting times" and we need to meet the challenges that are coming to us.

- Steve Brinksman
SMMGP Clinical Director

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New generation, new drugs: the rise and rise of club drugs

New generation, new drugs: the rise and rise of club drugs

Owen Bowden-Jones describes the changing nature of drug use and how his London clinic has met the challenges of working with people who use club drugs.

With heroin, crack and powder cocaine treatment presentations declining, along with a reduction in injecting, there is justified room for optimism with regard to drug treatment (Ref 1). Many factors will have influenced these positive changes, one of them being the increased availability of evidence based drug treatment.

All of this good news must however be tempered by other changes in drug use, particularly in younger groups. One trend that has been increasingly reported is the rise in the use of club drugs (Ref 2, Ref 3). The term club drug describes a group of substances generally thought to have originated in the context of the dance music scene but which have more recently spread beyond the clubs.

One of the first and most common of the club drugs was ecstasy, a drug with both hallucinogenic and stimulant effects. Subsequent club drugs often have a similar profile, enhancing and intensifying the experience of the music and lights while the stimulant effect allows the user to dance for prolonged periods.

Currently, mephedrone, ketamine and GBL/GHB are reported as some of the most widely used club drugs. Mephedrone and GHB/ GBL were initially sold legally before being banned (Ref 4). However a range of newer legal highs have been rapidly developed to meet demand. Typically bought from the internet and delivered by post the next day or purchased from specialist "head shops", they include hundreds of brand names such as MXE, GoGaine, China White and the rather ominously named Research Chemicals. Internet purchasing may be changing the commercial model for those selling drugs and some argue that the supposed legality and ease of access have led to new groups trying drugs.

Those of us working in the treatment sector will probably have heard reports of these club drugs being widely used by particular groups including the lesbian, gay, bisexual and transgender community, students and clubbers (Ref 5). However, despite these reports, the numbers of people presenting to drugs services, as reported by the National Drug Treatment Monitoring System (NDTMS), remains very small. So what is going on?

"Club drug users may not feel that traditional drug services meet their needs and therefore do not present for help"

There are a number of possibilities. First, the use of club drugs may be over-estimated. Encouraged by sensational media reports ("Legal High Causes Vandalism!" Ref 6), the developing narrative of an epidemic of club drug use may simply be untrue.

A second option is that club drugs are widely used but that their use is largely harmless. This could explain the low numbers reported by NDTMS, although this gives us no indication of tier 2 presentations or presentations to other services such as accident and emergency.

Finally, it could be that people are using club drugs and indeed developing problems from their use, but are not presenting for treatment.

Let's examine this last possibility in more detail. UK drug services are well equipped to assess and treat heroin and crack cocaine problems but generally have little knowledge or experience of club drugs. Reports suggest that club drug users are generally younger, more affluent and better socially networked than heroin and crack users. As a result, club drug users may not feel that traditional drug services meet their needs and therefore do not present for help.

A few specialist club drug services have developed in reportedly high prevalence areas and these have certainly attracted referrals. This suggests that if services are seen as credible by club drug users, the users will indeed engage.

One such service is the Club Drug Clinic, in West London (Ref 7). The service was established in response to an increase in club drug presentations, particularly from those attending the local HIV services. Frequent comments from users about the local drug services' lack of expertise in club drugs led to the specialist clinic being established.

I have been involved since the clinic's inception and clearly recall the first day we opened when we had little idea of the likely level of demand. Twelve months later, the Club Drug Clinic has treated nearly 200 people despite operating with a very small team. Crucial factors in the clinic's success have been the ability of users to selfrefer irrespective of place of residence (the sexual health service model) and the use of technology to engage users. We have worked hard to learn about the new drugs and are still assessing whether established, evidence based treatments are effective for this group of users.

Nationally, the next step is to better understand the prevalence and harms of these drugs. Some patterns are already emerging. Ketamine is known to cause damage to the bladder, mephedrone can cause psychosis and GBL/GBH has been show to cause severe dependence with life threatening withdrawal symptoms.

The newer legal highs remain troubling for clinicians. Little is known about their use, with apparently rapid changes in availability and some suggestion that the chemical constituents of a particular brand also frequently vary. There are certainly a number of case reports suggesting harms, although there is little systematic research on treatment to date.

Five years from now, we may look back and find that the use of club drugs was a brief threat, which receded as drug culture moved on. However, if club drugs use is here to stay, services will need to quickly learn how to help a completely new group of users.

- Owen Bowden-Jones
Consultant Psychiatrist and Lead Clinician for Club Drug Clinic, Addictions Directorate Central and North West London NHS Foundation Trust

References

1. National Treatment Agency. (2011) Drug treatment and recovery.

2. Home Office (2011) Drug Misuse declared: Findings from the 2010/11 British Crime Survey.

3. Winstock et al. (2011) Mephedrone, new kid for the chop. Addiction. Jan; 106 (1): 154-61.

4. Advisory Council on the Misuse of Drugs. (2011) Consideration of the novel psychoactive substances. Home Office, London.

5. UKDPC (2010) Drugs and diversity: Lesbian, gay, bisexual and transgender (LGBT) communities.

6. http://www.bbc.co.uk/news/uk-england-hampshire-16411125

7. www.clubdrugclinic.com

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"Doctor can you hear me?" Ways forward to improve communication between GPs and patients who use drugs and alcohol

Doctor can you hear me? Ways forward to improve communication between GPs and patients who use drugs and alcohol

Asking drug and alcohol patients how to improve communication with their GP revealed many common threads; some things that worked well and others that could improve their treatment experience, as Claire Brown explains.

"GPs play an important role in the recovery process. They can be an effective catalyst to someone's recovery journey, knowledgeably informing a patient of their support options, signposting them to the correct services in their community and offering a listening ear," says Rebecca Daddow, researcher at the RSA (Royal Society for the encouragement of Arts, Manufactures and Commerce), who developed a film The role of GPs in the recovery process (Ref 1).

At the recent national service user involvement conference, Together We Stand, an interactive session was facilitated by Ossie Yemoh, chair Brent Service User's Group, B3 London and GPs Chris Ford and Steve Brinksman which looked at communication with GPs. Participants were first asked if they had a GP and it was encouraging to see that over 90% did. They were then asked their opinion of effective communication with their GP. What followed was a rich mix of frank feedback on what helped or hindered drug and alcohol patients in communicating with their doctors.

"I felt stigma at the doctors and it made me run a mile"

Ossie talked passionately about how often the first port of call for someone seeking help for a problem with drugs or alcohol is their GP and the importance of ensuring that that contact is good. Unfortunately it hadn't been like that for him: "If I'd had rapport with my GP I'd have found recovery a lot earlier," said Ossie. "Each time I went to my GP I couldn't find the strength to discuss my problems and the doors weren't open to ask for help. I felt stigma at the doctors and it made me run a mile." But his experience has led him to work for improvements and he is helping to pilot the RSA film locally and presenting in an SMMGP webinar. He also described how things had improved since he had been involved with B3 and the local shared care scheme.

A common barrier identified was apparent lack of interest but many, including Nathan from Wales, felt this was an issue of lack of training. Nathan also discussed another issue that was raised several times, that some GPs are great and others are not, and suggested changing if you did not feel your GP was listening. His first experience was difficult "I couldn't get to see my doctor for ages - it's a massive hindrance. I don't want to make my problem an emergency," but in contrast he said of his current GP "he dresses down and makes me feel comfortable". Pat from Norfolk reinforced this message powerfully: "I now have a new GP who's good, but the first wasn't - he made me feel like dog shit. The second made me feel OK, so it was a totally different experience." Most people register with the closest GP and don't realise that they can change easily without having to give an explanation and can complain about their current service. Some suggested asking their local drug or alcohol service or pharmacist where they might find a good GP.

Ignorance from practice staff at all levels was identified as another barrier to communication, leading to mistrust and stigmatisation and being "treated as another bloody alcoholic who probably isn't telling the truth". How past history is recorded was also identified as a potential problem as Paul from Bristol pointed out: "I haven't had a hit for 20 years, but on my medical notes it says 'injecting drug user'. Is that really me?"

Lack of training was mentioned often as a cause of poor communication. SMMGP and the Royal College of General Practitioners have been addressing this for nearly 20 years but there is still work to be done and GPs need people who use drugs or alcohol to play an important part in this.

Others said a lack of signposting had a negative impact: "One GP set back my recovery by a long time," said John. "He dismissed my drinking and put it down to a stressful job - he wanted to give me tranquillisers for stress. He didn't want to talk about alcohol and didn't know that alcohol services existed. I never went beyond him and I should have."

It was agreed unanimously that the most important things for effective communication were:

  1. to be treated like a human being and to acknowledge that anyone can have a drug or alcohol problem, regardless of age, class or gender and
  2. to be treated as a whole person not as a "drug or alcohol misuser" as Sunny from Wolverhampton put so well: " they must take account of the whole person, so that ten percent is about the drugs and the rest is about the person and what helps them get better".

Chris pointed out that evidence shows that at least 25% of GP consultations are directly related to problems with alcohol and almost the same number are indirectly related to alcohol use. She said that GPs should always be ready to ask about alcohol use and if they don't know how to treat alcohol issues then they should know how to refer on to services.

Summing up the discussion, Ossie said: "We started this meeting with looking at communicating as a service user. We now need to look at the medical side and the way to get GPs on board. We have to keep knocking on the door." Chris said "We can, we are and we will continue to improve communication with patients and this will improve care", and Steve said "we will continue to campaign for drug and alcohol knowledge to be included routinely in doctors training"

Communication checklist

  1. Treat your patient with drug and/ or alcohol issues as a person with integrity, as with any other patient. Create a partnership based on respect.
  2. Reduce stigma by involving all staff at the surgery in training focused on treating patients with respect. Use appropriate language and avoid negative labeling. Create a practice equality statement which is clearly displayed.
  3. Make the waiting room a welcoming environment. Include information on all conditions including drugs and alcohol, hepatitis C, including where to access local services.
  4. Ask all patients about alcohol, drug and tobacco use without making assumptions.
  5. Take every opportunity to improve your knowledge.
  6. Engage people who use drugs and alcohol in training sessions at your surgery.
  7. Improve signposting to other drug and alcohol services and support services such as psychological, housing and training and work placements. Make sure that if you can't directly help with an issue, you know someone who can.
  8. Look out for patients who need extra support and understanding, for example people with learning difficulties who might have trouble articulating their needs.
  9. Demonstrate that you have time to listen properly to the patient's problem, even if that means asking them to pop back at the end of surgery for another discussion.

- Claire Brown
Editor of the monthly magazine Drink and Drugs News (DDN). The interactive session took place at DDN's annual service user involvement conference - visit DDN's website for the conference special issue.

- Chris Ford
Clinical Director IDHDP (international Doctors for Healthy Drug Policies)

References

1. SMMGP Featured Videos

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Swanswell Recovery Model: building on shared care success

Swanswell Recovery Model: building on shared care success

Swanswell describe how their primary care model has developed to provide a full range of recovery focused treatment in Birmingham

Swanswell has been delivering successful shared care services in Birmingham for over a decade with substance misuse workers already well established in GP practices.

Here, sessions are integrated in to existing surgeries and systems at no cost to the surgery, and strong collaborative relationships between team members, GPs, clients and pharmacists have been developed which make information sharing and access to specialist services easier.

This environment was the perfect place to develop and pilot The Swanswell Recovery Model, which puts the client in charge of their recovery journey.

What makes it different?

The Swanswell Recovery Model supports self responsibility for behaviour change and works to help people towards their own identified goals to create positive treatment outcomes.

Among the findings from the pilot:

Quotes from those involved

"We found that the majority of service users wished to become free from illicit drugs and substitute medication, but had concerns that their substitute medication would be withdrawn too quickly."

"It's great to be clean. I've got my old life back again. I have far more energy."

To read the full article visit our Other Resources section.

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Primary care, drugs and Public Health England

Primary care, drugs and Public Health England

Paul Hayes sets the scene for the move of funding to Public Health England. He warns primary care that now is not the time to rest on our laurels.

GPs and others in the primary care health team are already the bedrock of the NHS. If the Health and Social Care Bill has passed through Parliament by the time you read this, GPs will also have official confirmation of their opportunity to exert even more influence in future through clinical commissioning groups (CCGs). The views of the medical professional bodies about this have loomed large in recent controversy about the government's healthcare reforms, but far less attention has been given to the important implications of these changes for drug treatment as it moves into the public health system.

As most of you will be aware, the functions of the National Treatment Agency (NTA) will be moving into the new national organisation, Public Health England (PHE). In its role as the authoritative national voice and expert service provider for public health, PHE will work with partners to provide the expert evidence and intelligence, including cost-benefit analysis, needed locally to support the commissioning of safe and effective substance misuse services. We are working to ensure a seamless transition during 2012-13, but in many ways the most significant aspect of the reforms is not what happens at the centre, but the changes taking place locally as local authorities prepare to take over responsibility for public health - and the commissioning of drug and alcohol treatment services - from April 2013.

It goes without saying that GPs and the rest of the primary care health team, sitting at the heart of their communities, will continue to have a vital role to play in the treatment and recovery of drug and alcohol users. They can provide cost-effective care for those not yet ready for recovery but not needing specialist secondary care. They can deliver more intensive and ambitious care in partnership with others. Their community links will help those who are recovering to access essential recovery support and build their recovery capital. And they will need to respond to an ageing population of current and former substance users with complex and demanding health needs.

I gather an increasing number of GPs and other primary care staff are taking the Royal College of General Practitioners (RCGP) certificate courses to improve their understanding of drug misuse and their ability to provide generalist and specialist care. This is welcome. GPs clearly make an important contribution to drug treatment and the broader integrated recovery systems in which treatment sits. The emerging issue is what additional role they can play in shaping and influencing those systems.

GPs potentially have powerful voices in their local areas. Already in this period of severe funding pressures, arguments need to be made to protect the gains the treatment sector has made in recent years, and to position the sector to deliver the government's ambition for recovery. The fact that the pooled treatment budget has remained unchanged for the third successive year at £407m is a tremendous vote of confidence in the treatment system's ability to deliver a challenging agenda. It puts the onus on local partners to respond positively and not disinvest from those extra services they have funded in recent years from their own resources. I know that members of SMMGP are not shy about expressing their views within the network. Their voices deserve to be heard by wider audiences, and the current reforms offer just that opportunity at a local level.

All doctors specialising in drug treatment will need to address the clinical governance and clinical leadership challenges of a changing system, in which drug and alcohol treatment is to be commissioned by local authorities. It is timely that the joint project by the RCGP and the Royal College of Psychiatrists to update their roles and responsibilities document is coming to a conclusion. This will clarify the competencies required of all doctors caring for substance misusers, and reinforce the importance of their clinical leadership.

Where that clinical leadership role will be played out most crucially will be within the new CCGs, and their partnership with local Health and Wellbeing Boards. The relevant Director of Public Health will be a crucial figure in determining priorities for local health and wellbeing strategies, but doctors on local CCGs will be able to exert influence too. They will have a say both in the direct commissioning of some treatment services, and through the commissioning of adjunctive services for drug users as ordinary patients. There is also a tremendous opportunity for all local partners to work together to ensure the proper integration of health and social care.

GPs offer services to everyone, and liaise with a range of specialists in the public, private and voluntary sectors. As professionals they are extraordinarily flexible, and well-placed to see the big picture. Their relevance at this time of radical change is not in question. However, that is not a guarantee that GPs will necessarily hold on to the work they are commissioned to undertake at the moment.

I am choosing my words carefully, but I think it is fair to say that some GPs are still not wholly signed up to the recovery agenda. I recall one saying to me, "I entirely agree with the recovery model but unfortunately it doesn't apply to any of my patients." I think it is time we moved beyond pretending to agree when really we don't, and grasp the opportunities open to us to improve people's lives.

I am well aware that some people have a mental map which puts 5% of dependent clients in recovery, and expects the other 95% to stay in treatment where they are safe, and doing less damage to themselves and others. On the other hand, others will contend that 95% of clients can recover and the rest are being thwarted from achieving their true potential in life. Let us not delude ourselves that because both extremes are using the same language, they mean the same thing.

"Just because partnerships allocated a lot of responsibility with primary care at one point in time does not mean this pattern will stay unaltered as local needs are reassessed and local capabilities change"

For some time now the NTA has advocated a balanced treatment system, in which the effort to get people who use drugs off the street and retain them in treatment is matched with a determination to help them overcome their dependency and sustain their recovery. Prof John Strang's expert group is currently trying to identify good practice and translate that balance into clinical protocols.

His interim report last summer urged doctors to review their practice to ensure everyone on a script was given an opportunity to recover. The outcome of any review has to be agreed between the provider and the service-user. If he or she is not ready to come off a script, or doesn't want to take that step, then it should not happen.

On the other hand, we know that plenty of people come into treatment without any intention of staying on a script, yet find they are not actively encouraged to come off, and describe being actively discouraged from leaving it behind. It is all a question of striking the right balance for the individual.

The treatment system never intended to drag large numbers of people in, script them, and keep them there indefinitely. Equally, we don't want people to be bounced out prematurely when it is not safe to do so. There has to be a balance. That calls for sensible commissioning which doesn't destabilise systems and place patients at risk, but does create credible pathways out. It also calls for higher levels of skill on the part of drugs workers, a willingness by service users to make brave decisions, and the willingness of GPs to support them in this.

The treatment system has always been dynamic, and the latest expression of that is the transformation into a system with a clear recovery orientation. Traditionally, work has flowed from specialist services to primary care and the voluntary sector. That doesn't mean it is going to carry on in this direction for ever. Just because partnerships allocated a lot of responsibility with primary care at one point in time does not mean this pattern will stay unaltered as local needs are reassessed and local capabilities change. If GPs are delivering within this over-arching approach they will stay relevant through the changes ahead.

- Paul Hayes
Chief Executive, National Treatment Agency

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Twitter: a whole new world of tweets and peeps

Twitter: a whole new world of tweets and peeps

Elsa Browne describes the benefits for following us on Twitter, and SMMGP's journey into using social media.

Sometime last year SMMGP joined half a billion others on the planet by opening a Twitter account. At first it just sort of sat there, occasionally activated by one of the team producing a tentative tweet about a weighty report, and with the total number of followers hovering around a dozen or so for a while. By the time the decision was taken to add the Twitter feed to the home page, thereby entering the realm of communication by social media in a serious fashion, the group of followers numbered just in the double figures.

Social media as an important method of communication is evolving rapidly, and much has already been written about having goals and best practice - and naturally there's also plenty of advice around on adopting a strategic approach which focuses on stakeholders etc. when using Twitter. But there is no real short cut to having millions of followers, and starting anything from scratch can be truly daunting.

"One great thing about tweeting is the repeated thrill of discovery, because you'll never know who likes what you post until you put it out there"

Many organisations have highly skilled communications teams who work hard at developing an online audience. SMMGP is a small team with a big enough "day job" remit and a somewhat organic approach to social media. So, all this online wisdom - totweet, to-whom? And what to choose to retweet from the dizzying array of information generated by each tentative hashtag search? What of the plethora of information from the cybernetic army of researchers out there who provide a flow of information like never before - handed to you on a plate (or should that be a screen!).

One of the reasons given for people avoiding online sharing is not being sure what to say. One great thing about tweeting is the repeated thrill of discovery, because you'll never know who likes what you post until you put it out there. Another is finding out - as we all do from to time - that what is obvious to you is amazing to someone else. Getting a RT (retweet), marked a favourite (or favorite) or getting a mention, or being credited as a news spotter, is such encouragement that we don't even mind when our tweets are MT (modified tweet). Especially given that 92% of RTs are due to interesting content, and 84% humour (Ref 1).

There's also the sense - when reading other people's tweeted conversations - of sitting in the back of the virtual classroom whilst the rebels pass notes and you sneak a quick peek as they cross your desk: "...healthcare needs a Moses - and a Steve Jobs". Or the one that recently made me laugh out loud: If we don't find a word ourselves soon, the PC brigade will be calling us "people who used drugs but don't anymore" open brackets PUDDAM close brackets. SMMGP is a friendly organisation, and whilst we mainly use our Twitter account to convey important and necessary information, tweeting gives us licence to be human on occasion - which is why we couldn't resist a RT of one of our own favourites amongst those we follow "We tell the kids to get high on life, but they develop a tolerance, which is why we need harm reduction". It comes as no surprise that the world of Twitter is populated by sharp witted people.

Sometimes at conferences, when there is a bunch of us twits in the same room, we face the fun challenge of capturing in real time what the speaker is saying, in 140 characters, before he or she moves on to the next point. That's when RT really comes into its own, and cribbing from a friend is acceptable for once, as we nod and thumbs up to each other across the room when our words magically and minutely appear as it is sent on to - sometimes many thousands - followers of followers all before the click of the next slide. It's a bit like being able to read the mind of the person sitting two rows along from you. And if you can't be there - with most conferences nowadays having a Twitter tag, it's an exciting way of keeping up with the action - especially as there is no time for press release spin involved!

Part text message, part e-mail, part micro-blog, here are just some of the many reasons we love Twitter:

One year on, at well over 500 (Ref 2), our numbers of followers are still modest compared to some, but whether each one of them in turn has 2, 20 or 2 million followers of their own, they may learn from our tweets, or we from them, but together we educate, reach out and communicate what's going on with drug and alcohol treatment all over the world, right now.

- Elsa Browne
Project Manager SMMGP

Follow SMMGP on Twitter at www.twitter.com/SMMGP

References

1. http://twitter.com/#!/ThebrprGroup/statuses/138665925334401024

2. 62% are from the UK, 11% from USA and 12% from London. www.tweetsmap.com

Twitter trivia - did you know?

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Evidence based approach to detoxification methods in opioid dependence

Evidence based approach to detoxification methods in opioid dependence

With the increasing emphasis on abstinence in the drug treatment field, Nat Wright explores the evidence base for opioid detoxification. He compares what happens in the community with what happens in prisons, with some interesting results.

Recovery is currently the buzz word in the treatment field. You're expected to have a view on it, the only problem is that if your view of recovery doesn't fit with that of your neighbour then it could strain neighbourly relations! "It's all about abstinence" ..."it's not all about abstinence"... "it's rebalancing a treatment system that over-emphasises maintenance" ..."the evidence base is for opiate maintenance so things are in balance" and so on and so on.

What is undeniable is that detoxification is a gateway to abstinence, most users aspire to it, and over time a significant number achieve it. Recently twenty-seven-year follow up data (a significant period of follow-up!) was published on outcomes of almost 800 drug users in treatment services in the UK. Key findings were that 35% were abstinent from drugs after such an extensive period of time. Eighty five percent of the cohort had had exposure to opiate maintenance therapy and the risk of death reduced by 13% for every year spent on maintenance (Ref 1). However exposure to opiate maintenance was inversely related to a user's chances of achieving long term cessation of injecting. Therefore the recovery emphasis for drug users should be one of supporting both those seeking to become abstinent and those requiring maintenance therapy for a period of time. Opiate maintenance should not be time limited but patients should receive ongoing support to achieve abstinence at a time and pace that is optimal for the individual. Some patients will require many years of maintenance therapy. Treatment services should retain a positive therapeutic approach through these years to support health, embrace hope and enhance motivation to achieve changes in harmful behaviours.

Recently evidence has emerged that prison settings can help individuals achieve abstinence from opiates. A randomised control trial of methadone versus buprenorphine for prisoners seeking to detoxify from opiates showed that at eight days post completion of the prescribing regime, both drugs were equally effective in supporting patients to become abstinent. However those in prison at follow-up were approximately fifteen times more likely to be abstinent compared to those who were released and followed up in the community (Ref 2). However a word of caution, abstinence rates were low for both drugs; approximately 20% at 3 months. These rates for abstinence concur with an Irish prison-based study which showed similar abstinence rates for those starting a detoxification regime in the prison setting (Ref 3). Also there are increased risks of drug-related death post release from residential treatment settings (Ref 4). Specifically for prison populations research carried out pre-Integrated Drug Treatment System highlighted an increased risk of drug related death postprison release (Ref 5). Rates were reported from the male estate as 37/1000 per annum in the week immediately post release (95% drug related); and 26/1000 per annum from the female estate in the week immediately post release (all drug related).

"Detoxification in itself is not a treatment but a gateway to lasting abstinence"

Therefore prison can be a helpful setting for some individuals to achieve abstinence providing they make an informed decision on the possibility of relapse. Whilst informing patients of the possibility of relapse it is worth bearing in mind that neither the number of previous attempts at detoxification nor the route of administration of illicit opiates (i.e. smoking or injecting) are predictors of successful detoxification (Ref 2).

Detoxification in itself is not a treatment but a gateway to lasting abstinence. Whether patients are resident in community or prison settings when they seek to detoxify, there are a host of wider interventions that have an evidence base. The National Institute for Health and Excellence (NICE) recommend that naltrexone can be helpful for those with high levels of motivation (Ref 6). There has been a perceived need to undertake a liver function test prior to initiating therapy. However this is not routinely required unless there are signs of acute liver failure. Recent research has demonstrated that naltrexone does not have a potently toxic effect on the liver (Ref 7). In fact it is often prescribed as a relapse prevention therapy to those with a history of alcohol dependence, many of whom will have sustained chronic liver damage. Therefore in the absence of clinical symptoms or signs of active liver disease, there is no longer a requirement to routinely take liver function tests prior to initiating naltrexone therapy.

NICE also recommend motivational interviewing and other talking therapies - family support, and contingency management - as interventions for which there is an evidence base to support drug users (Ref 8). The key ingredient appears to be motivation delivered through a positive therapeutic alliance between practitioner and patient. There is evidence for example from early studies that boot camps harm recovery (Ref 9, Ref 10). Such boot camps delivered paramilitary discipline in an effort to train users into a drug free life. Faced with such findings there is now evidence of boot camps shifting emphasis from paramilitary discipline to one of motivation and rehabilitation (Ref 11).

In summary, drug users find achieving abstinence hard but they are more likely to achieve it in prison. For many methadone maintenance will reduce the risk of death but at a price of an increased drug injecting career. Methadone or buprenorphine remain the principle pharmacological agents to support detoxification and should be delivered alongside psychosocial interventions that have a framework of motivation.

- Nat Wright
Clinical Director, Leeds Prisons

References

1. Kimber J, Copeland L, Hickman M, Macleod J, McKenzie J, De Angelis D and Robertson JR. (2010) Survival and Cessation in Injecting Drug Users: prospective observational study of outcomes and effect of opiate substitution treatment. BMJ 2010; 340:c3172 doi: 10.1136/ bmj.c3172.

2. Wright NMJ, Sheard L, Adams CEA, Rushforth BJ, Harrison W, Bound N, Hart R and Tompkins CNE.(2011) Comparison of methadone and buprenorphine for opiate detoxification (LEEDS trial): a randomised controlled trial. British Journal of General Practice 2011; 61: 723-724

3. Crowley D. (1999) The drug detox unit at Mountjoy prison - a review. Journal of Health Gain 1999; 3(3): 17-19.

4. Strang J, McCambridge J, Best D, Beswick T, Bearn J, Rees S and Gossop M.(2003) Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. British Medical Journal 2003; 326: 959-60.

5. Farrell, M and Marsden, J. (2008) Acute risk of drug-related death among newly released prisoners in England and Wales. Addiction 2008; 103: 251-255.

6. National Institute for Health and Clinical Excellence 2007. Naltrexone for the management of opioid dependence: NICE technology appraisal guidance 115. http://www.nice.org.uk/nicemedia/pdf/TA115NICEguidance.pdf.

7. Yen M, Ko H, Tang F, Lu R and Hong J. (2006) Study of hepatotoxicity of naltrexone in the treatment of alcoholism. Alcohol 2006; 38(2): 117-120.

8. National Institute for Health and Clinical Excellence. (2008) Drug misuse psychosocial interventions: National Clinical Practice Guideline Number 51. London: The British Psychological Society and the Royal College of Psychiatrists, 2008.

9. Lutze FE and Brody DC. (1999) Mental abuse as cruel and unusual punishment: do boot camp prisons violate the Eighth amendment? Crime and Delinquency 1999; 45: 242-255.

10. Benda BB. (2001) Factors that discriminate between recidivists, parole violators, and non-recidivists in a 3-year follow-up of boot camp graduates. International Journal of Offender Therapy and Comparative Criminology 2001; 45: 711-729.

11. Kempinen CA and Kurlychek MC. (2003) An outcome evaluation of Pennsylvania's boot camp: does rehabilitative programming within a disciplinary setting reduce recidivism? Crime and Delinquency 2003; 49(4): 581-602

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Dr Fixit on working with older drug users

Dr Fixit on working with older drug users

Question

Dear Dr Fixit,
Mandy is a 59-year-old patient who has been with my practice, and on methadone, for 15 years. During this time she has moved from a chaotic lifestyle to become stable, has raised her daughter who is now in her 30's and for the last 6 years Mandy has worked part time in retail. She has also been successfully treated for hepatitis C, and has managed her diabetes well, but is now getting pains in her legs, caused by poor peripheral circulation, because of injecting in the past, and also the effects of diabetes. She no longer uses heroin, crack or alcohol (once her drugs of choice) though she does smoke cannabis regularly.

Her keyworker tells me that we must be offering Mandy the chance to detox and be "in recovery" and is encouraging her to think she can live without methadone. However, Mandy became very anxious at this suggestion, and tells me she is happy on her current dose of methadone and does not wish to reduce or detox. She describes a general low mood and lack of motivation, though nothing "too bad"; she has a PHQ 9 score of 7. She has a good relationship with her keyworker who has suggested a number of psychosocial interventions but Mandy does not want to get involved. I feel a bit stuck, is there anything I can do to support her?

Answer

Dear GP colleague, I would like to congratulate you on your care of Mandy, which has helped her make such excellent progress, keeping herself and her family safe while she has built up what might now be called "psychological and social capital". She is part of the increasingly large group of older drug users who struggle with the problems associated with aging as well as the complications of long term drug use.

Office of National Statistics figures (Ref 1) show that the number of drug users aged 40 years and over entering treatment has more than doubled since 2003/04. They suggest that this is due to an ageing cohort of drug users rather than to people starting to use drugs at a later age. Patients who were young adults when heroin first flooded my local area in the 1980s are now, like Mandy, reaching their 50s and 60s. Fortunately the same statistics show that the number of 18-24 year olds using heroin is at last going down, giving some hope that the heroin "epidemic" may be past its peak in our society.

You describe two problems: Mandy has increasingly complex physical health problems, because of her age combined with the effects of long term drug use. She is also becoming anxious because she has perceived a change in emphasis by her drug worker, from whom Mandy feels an increased pressure to move towards abstinence. She is fearful that her script may be taken away, and that she will not be able to cope, particularly as her legs are becoming increasingly painful.

The trusting relationship you have built up over the years will enable you to reassure Mandy that treatment will continue to be focussed on her personal health needs, rather than any externally imposed regime. At the recent DDN (Drink and Drug News) conference (Ref 2), Paul Hayes referred to Prof Strang's review of prescribing guidelines, due to be published shortly: "I say categorically that it will not be recommending that any time limit should be imposed on a methadone script" He also said that "if the service user does not want to come off a script, or doesn't want to take that step, then it should not happen."

Having reduced Mandy's understandable anxiety and fear of externally imposed change, it is possible that her prescribing could be reviewed. It may now be more appropriate to treat her for pain relief, rather than for dependency. She will of course need a careful physical review of her leg pain. Does she have peripheral neuropathy, or peripheral vascular disease, or some other cause for her pain? Sometimes other medications such as slow release morphine (MST) or fentanyl patches, or indeed gabapentin are more effective for some people than methadone for pain relief. Each of these has its own risk of misuse and dependency, (including of course gabapentin, which is in great demand in prisons) and you will need to have a careful discussion with Mandy about this risk. It is possible the local pain clinic specialist may be helpful.

Some of my older patients have indeed "grown out of" their craving for opiate induced oblivion, but still need powerful analgesia to allow a comfortable life, because their tolerance to opiates is high, and they have physical ill health causing pain. One of my patients, a 61 year old man, stopped methadone last year, and also stopped drinking alcohol. He was prescribed gabapentin for his peripheral neuropathy. Although when younger he had been very keen on all mind altering substances, he now likes to have a clear head, and did not like the "fuzzy head" this gave him. He is now feeling much better, having eventually been prescribed a smallish dose of tramadol, which had initially been refused him because of his history of opiate dependency. He does not show any tendency to misuse or overuse them, and finds them very effective for his particular problems.

Once Mandy understands that she is still in control of her own treatment plan, she may feel that with your help, she would like to try moving towards a detox from all opiates, on the understanding that you will still be there to help her, if she finds an opiate free life intolerable. Paul Hayes again confirmed at the DDN conference that "the drug strategy does not say that everyone should become abstinent".

"Fortunately there are no 'age barriers' in the rather wonderful cradle-to-grave primary care system"

Perhaps a third of drug users can become abstinent within a year or two of coming in to treatment, and another third will follow once their social and psychological capital has increased sufficiently, but Mandy may turn out to be one of the last third who have more complex problems, and may well need long term support and indeed continuing opiate substitute therapy in order to gain and maintain a good quality of life (this is my own "rule of thirds" but does not seem far from the available research).

In view of her low mood, you might suggest she considers moving away from cannabis, as she may be showing signs of "amotivational syndrome" characterised by social withdrawal and apathy, described by some daily cannabis users. Her key worker could help her to find ways to reduce and stop, or she might like to try an online psychological therapy tool like breakingfreeonline.com (Ref 3). I am sure Mandy will already know that if she is taking cannabis with tobacco there are clear physical health risks in view of her diabetes and poor circulation. If she could stop smoking tobacco she would improve her long term health and well-being far more than any gain from stopping her methadone.

The Royal College of Psychiatrists recently recognised the growing difficulties faced by older drug users in their report, "Our Invisible Addicts" (Ref 4), suggesting that "Local policies regarding older people with substance use problems should be developed: access on the basis of need, elimination of age barriers, easy transfer between services, joint working and decisions regarding who will be the lead service in these circumstances."

Fortunately there are no "age barriers" in the rather wonderful cradle-to-grave primary care system, and Mandy is lucky to have a good therapeutic relationship with her GP. Her complex and interrelated physical and psychological health needs are likely to be best supported by yourself, and the primary care team. A recent report by the Office of National Statistics, described in the British Medical Journal (Ref 5), found that happiness is "U shaped" , being highest in the teens and in the 70s, so hopefully the last part of Mandy's life, with your help, can be the happiest.

- Answer by Judith Yates
GPwSI Birmingham

References

1. http://www.nta.nhs.uk/uploads/healthharmsfinalv1.pdf

2. http://cjwellings.com/ddn/DDNmar12/

3. http://www.breakingfreeonline.com/

4. Royal College of Psychiatrists.(2011)Our Invisible Addicts. http://www.rcpsych.ac.uk/files/pdfversion/CR165.pdf

5. http://www.bmj.com/content/344/bmj.e1534

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