Clinical & Policy Updates:
SMMGP Policy Update September 2009
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The Beckley Foundation's report which reviews and evaluates current drug control policies for cannabis for the United Nations General Assembly Special Session (UNGASS) 2009 was published last month. The report was produced by a group of international drug experts with a view to exploring ways forward in developing cannabis policy in a changing world. It offers a blueprint for nations to develop a more rational and effective approach to the control of cannabis, and asks policy makers to consider issues in developing more effective cannabis policies that minimise the harms associated with its use and control.
In reviewing the evidence the authors reach important conclusions which cover the impact of cannabis on physical and mental health; the cannabis prohibition regime; future options; the impacts of cannabis policy reforms; looks beyond the current drug conventions; and offers paths forward from the impasse - many of which directly challenge the international status quo on cannabis policy.
In drawing conclusions about cannabis use and its harms, and the effects of current policies on cannabis control, the report suggests that the principal aim of a cannabis control system should be to minimise harms from cannabis use, including by "in our view ...allowing use and attempting to channel such use into less harmful patterns (e.g. by delaying onset of use until early adulthood and encouraging all users to avoid daily use or driving a car after using)". It goes on to make recommendations that include looking beyond prevailing international treaties that prevent depenalisation: Conclusions and recommendations.
SMMGP welcomes the shift in emphasis from law enforcement to prevention that is emphasised in this report. Cannabis is the most widely used illicit substance in the UK - and most of the western world - with use being most common in the 16-29 year old age group. About 10% of users develop dependence - with a range of physical and mental health problems - although only 7% of those who seek drug treatment cite cannabis as their major drug of concern. This rational helpful review of drug policy is essential and welcome. With increased use comes the need for practical guidance for the management of cannabis problems in primary care (any volunteers?)
The Medicines and Healthcare Products Regulatory Agency (MHRA) this month announced new advice on OTC medicines containing codeine and dihydrocodeine to minimise the risk of overuse and addiction. The revised guidance include clear warnings, prominently displayed, on the labels and patient information leaflets (PIL) about the risk of addiction and the importance of not taking these medicines for longer than three days. Large packs of effervescent codeine products (more than 32 tablets) will no longer be sold over the counter in pharmacies.
This action is being taken in parallel with the Department of Health's review of the policy on addiction to prescription and OTC medicines. For more information see the MHRA website.
This is a start for an increasing and difficult problem, but there are still no official statistics documenting the extent of dependence on legal non-prescription drugs. Although addiction to codeine combined in OTC painkillers has been recognised for many years, anecdotal reports suggest this problem is increasing and we need large scale research to assess and monitor the extent of the problem. It was investigated in 2005 by the MHRA (and others) who concluded that although misuse was significantly under-reported, it was exceedingly small compared to the amount of daily sales. This information came from 'yellow-card' reporting from doctors and pharmacists, and likely shows the very small tip of a clinical iceberg.
The lack of clinical guidance regarding this matter was acknowledged at the recent 14th RCGP conference - so a section has been included in the forthcoming opioid guidance and there is training (What to do with over the counter medication addiction) in York on 21 January 2010 - book your place now!
Evidence for the Effectiveness and Cost-Effectiveness of Interventions to Reduce Alcohol-Related Harm
Handbook for Action to Reduce Alcohol-Related Harm
The World Health Organisation European Region has the highest proportion of total ill health and premature death caused by alcohol in the world. A new publication from their European Region department on the "Evidence for the effectiveness and cost-effectiveness of interventions to reduce alcohol-related harm" summarises the evidence of effective alcohol policies, for mainly North America and northern Europe, but the general principles highlighted are applicable across societies and countries.
It reviews what is known and not known about the health, social and economic impact of alcohol, education and information campaigns, public support for alcohol policies, health sector response, work place and drink driving policies.
The summary of the evidence concludes that the most cost-effective policy option to reduce alcohol-related harm is taxation.
Also published by WHO European Region this month is the "Handbook for action to reduce alcohol-related harm" which aims to help countries in this region to review, adjust or strengthen their plans to reduce the harm caused by alcohol. It explores ten areas for action including pricing, availability, marketing, drink-driving and health care interventions.
Both publications are available free of charge on the WHO European Region website.
Important work to raise awareness of the health damage caused by alcohol is also being undertaken by the Alcohol Health Alliance UK (a public health coalition set up by the Royal College of Physicians last year). In line with the WHO publication mentioned above, they identified, amongst other key issues, that the most effective and cost effective strategy for reducing alcohol harm is to increase tax and reduce availability.
It is sobering to note that despite evidence that increasing tax on alcohol by only 10%, could decrease alcohol related deaths by up to 30%, alcohol has become over 50% more affordable in the last 25 years.
With the increase in alcohol related hospital admissions and health related harm experienced in the UK over the last decade, it is important to consider policy as well as health care interventions for alcohol use. These publications are useful in that it highlights the effectiveness or otherwise of strategies used in other countries. Alcohol causes much more harm than drugs and must not be overlooked when treating people who use drugs - hence the timely new RCGP Certificate in Alcohol and the forthcoming alcohol special edition of our Network newsletter.
The National Institute for Health and Clinical Excellence (NICE) consultation on the first draft of "Alcohol use disorders - clinical management" commenced during September. NICE is developing three pieces of guidance relating to alcohol use disorders over the next two years. Each piece of guidance will focus on a different element of the care pathway, from the prevention and early identification of alcohol use disorders to the clinical management of acute alcohol withdrawal and alcohol related liver disease and pancreatitis. A third piece of guidance on the management of alcohol dependency and psychological interventions will be developed.
SMMGP has registered as a stakeholder for this important consultation and will be canvassing our membership via our website for comments to feed in to the consultation. For more information on the scope of the current consultation, please read the document on the NICE website.
A recent NTA publication highlights the programmes that ensure that problem drug users in the criminal justice system have access to the same quality of treatment as those in the community. As well as improving offender health and welfare, having access to good health care in prison offers greater possibilities of long term rehabilitation and reintegration, reducing the likelihood of more crime being committed by the individual in future. The report highlights that the NTA's IDTS (Integrated Drug Treatment System) in prisons is already having a significant impact where it is operating - and about a quarter of new inmates in these prisons are receiving drug treatment.
Also from the NTA, the recent welcome announcement about "Changes to the TOP Reporting Frequency" - a reduction in the frequency that clinicians and key workers need to submit TOP (treatment outcomes profile) data. TOP works at three different stages:
- The start of a client's treatment journey - "Treatment Start TOP".
- Periodically throughout the client's treatment journey - "Review TOP".
- When the client leaves the treatment system - "Treatment Exit TOP".
The change to the reporting process is at stage 2 - during the client's treatment journey, at the Review TOP stage. Previously, the protocol required that Review TOP be reported in 12-week cycles - typically as part of the care-plan review cycle. But following consultation with the field, the NTA has agreed that the Review TOP can now be reported less often. The revised protocol for Review TOP now asks that that clinicians and keyworkers report in 26-week or six-month cycles. The NTA says that this will not compromise the ability of TOP to capture information about the important treatment benefits that occur early in the treatment journey.
You were heard! The NTA TOP team requested a meeting with an RCGP/SMMGP advisory group during June this year to consult on possible changes to the TOP reporting frequency, providing an opportunity for SMMGP membership views on this process to be made known.
SMMGP are also about to report back to the NTA on the results of our consultation with members on the above - so this is your last chance to let us have your views. Please see the consultation documents on our website and send your comments to SMMGP Project Manager at firstname.lastname@example.org as soon as possible.
The importance of SMMGP and our membership sharing their views and experiences of policy in practice cannot be over-emphasised as it provides the opportunity for your views to be represented and inform policy at the centre.
And finally from the National Treatment Agency - a paper "Towards Successful Treatment Completion - A Good Practice Guide (2009)"
This paper identifies the range of reasons for unplanned discharges, the commonest being dropping out of treatment, followed by going to prison, treatment being withdrawn, the client declining the treatment offered or moving away and losing contact with the treatment service. It points towards numbers of unplanned discharges falling steadily each year from 71% in 2004/05 to 48% in 2007/08.
A range of interventions can help to engage and retain clients in treatment and the paper concludes that further integration of the principles of recovery into the drug treatment system is likely to be the next challenge to improve treatment outcomes and increase the proportion of clients who successfully complete treatment and leave treatment services in a planned way.
Read an article on this subject on our website soon - a must for all treatment providers.
The International Harm Reduction Association (IHRA) Board of Directors have released a position statement defining the term "harm reduction", to outline a set of underlying principles which best describe this approach. The term "harm reduction" came to prominence after the emergence of HIV in the 1980s, but the origins go back further. Because the approach has developed over time and in several places, there has been some debate regarding an exact definition and more recently, this has led to concerns that some organisations may adopt the term to describe or justify interventions and policies which are not true to the original principles of harm reduction and/or "harm reduction" has been reduced to "providing clean equipment". The IHRA now offer a definition to apply equally to policies, programmes and practices, and to all psychoactive drug use including controlled drugs, alcohol, and tobacco:
"Harm reduction refers to policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community."
See the IHRA website for more information.
It is important to uphold the true principles of harm reduction in the treatment field and ensure its rightful place in the spectrum of available treatment - not set apart from recovery. See also "SMMGP position statement on recovery" on our website.
The Effectiveness Bank on www.findings.org.uk is an excellent online resource for research articles and publications in the drug treatment field. They have recently updated the search function on their website allowing for broad searches by topic e.g. on 'alcohol' - with filters e.g. 'young people', 'medical treatment':
One of the studies reviewed by Findings this month is on when "Counsellor Skill Influences Outcomes of Brief Motivational Interventions".
Not many studies achieve the depth and breadth of analyses needed to identify what makes for successful counselling, but an interesting Swiss study addresses the key issue of how.
It analyses the interactions during brief interventions when unexpectedly (for the patient) their drinking is addressed while they are seeking help for something else entirely. The implication of the study is that the impact of the interview with heavy drinkers depends on the ability of the counsellor to embody the spirit of the approach of motivational interviewing, not in exhaustive detail, but rather more broadly. Another implication is that while training plays a part in developing this ability, yet there were differences between counsellors, presumed to relate to the degree in which they could implement what they had been taught.
The Findings article concludes that the spotlight must therefore inevitably fall on staff recruitment - get it right, with training and supervision, and brief interventions may fulfil their promise of tackling drinking problems, get it wrong and much effort may be wasted.
We wholeheartedly agree with the point made about recruiting the right person for the job. Earlier this year the NTA in collaboration with the British Psychological Society published a useful document on "Psychosocial interventions in drug misuse: a framework and toolkit for implementing NICErecommended treatment interventions" which provides support to develop evidence-based psychosocial interventions.
From the Scottish Recovery Network, a small scale qualitative research study which involved four carer support groups was undertaken in Scotland and the report is now available on their website
The study seeks to address the gap in research on the role of carers in mental health recovery. From the survey results, recovery was constructed as:
- A recognisable state indicated by physical and social characteristics.
- A state that could be influenced by various behaviours and practices.
- A process that could be influenced by coworking between the carer, the person being supported and formal services.
- A process that may be negatively influenced by a lack of recognition of the carer's potential role in negotiations with formal service providers.
Key themes emergent in focus group discussions emphasised that carers are well placed to influence the progress and direction of recovery because of their intimate knowledge of the person they are supporting.
Everybody deserves to have someone who cares about them. This important research reaffirms the value of carers in people's recovery.