SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Clinical & Policy Updates:
SMMGP Policy Update January 2011

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Drug Strategy 2010: Reducing demand, restricting supply, building recovery: supporting people to live a drug-free life

See Home Office web site.

The Drug Strategy was published in early December 2010 and - with its orientation towards an overarching ambition for recovery - heralds a change of emphasis to government policy.

The strategy

The work is to be built around three themes: reducing demand, restricting supply and building recovery in communities. It has an ideal for people to lead drug-free lives as this, it believes, is the underlying goal of most people who come to seek help for their problematic use of drugs. But it also recognises the success of harm reduction measures and acknowledges the place of prescribing in treatment and medically assisted recovery (MAR): "...medically-assisted recovery can, and does, happen. There are many thousands of 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".

It aims to put the individual at the heart of the treatment system. It seeks to create a system that builds on recovery capital of individuals - social (e.g. support from family), physical (e.g. money and somewhere to live), human (e.g. health and wellbeing, having skills to find a job), and cultural - values, attitudes and beliefs.

The system will be locally led and driven by community needs, with Directors of Public Health overseeing commissioning of services as a core part of their work - and all services are to be outcome-focussed. The detail of how this will look in practice remains to be seen once the framework for Public Health England emerges.

SMMGP comment

Since the publication of the Drug Strategy in December there has been much discussion about it already, and we reflect more fully on it in an edition of Network which will be out soon.

Despite the brief consultation period, there was an overwhelming response (more than 1400). Perhaps because of the consideration of these responses, it is more balanced than may have been initially expected. We find nothing contentious about its aims to support people to overcome dependency, particularly as it accepts that substitute prescribing continues to have a role to play in the treatment of opioid dependence, and also includes needle exchange provision as a necessary component of a balanced treatment system.

We are concerned that local decision making brings with it the possibility of disinvestment in drug and alcohol services, and it is important that we keep an eye on what is happening in our area and advocate for services.

How success in overcoming dependency will be measured in terms of "money follows success" now needs to be properly defined in the Payment by Results pilots.

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Recovery-oriented Methadone Maintenance

William White MA and Lisa Mojer-Torres (JD 2010)

Published towards the end of last year (but without much fanfare) this treatise (168 pages) is dedicated to "those who are stepping out of the shadows to put a face and voice on medication-assisted recovery". It is organised into four sections - Historical context; Recovery and Methadone; a Vision Statement and Long-term strategies to reduce the stigma attached to addiction, treatment and recovery within the city of Philadelphia.

The authors are respectively a world renowned recovery-focused historian in the addictions field and an eminent lawyer and advocate for people involved in methadone maintenance treatment. As each section is designed to stand alone, we summarise section III (Recovery and Methadone) here.

White and Mojer-Torres affirm that despite more than four decades' worth of scientific evidence of the effectiveness of methadone maintenance as a medical treatment for opioid addiction, methadone patients continue to be marginalised and their recovery status continues to be a matter for debate - not only within communities of recovery but also by professionals in the field.

Yet there is growing professional consensus that the stabilised patient on methadone who does not use alcohol or illicit drugs, and who takes methadone (and other prescribed drugs) only as indicated by competent medical practitioners, meets the [first] criterion for recovery. Thus, denying these patients the status attributed to those who are "drug free" or even "abstinent" based solely on them being methadone maintenance patients, inhibits rather than supports them on their long-term journey of recovery.

The authors feel that it is time for recovering patients on methadone maintenance to be welcomed into the recovery communities and afforded the same opportunities to pursue reintegration as citizens in society.

The most powerful antidote to the stigma of being on methadone will come from healthy and fully functioning methadone maintenance patients and they therefore call for an expansion of the range and quality of clinical and peer-based support services with a vision of recovery (which they describe as being in remission, having global health, and achieving citizenship) to include methadone maintenance patients.

SMMGP comment

The paper on recovery oriented methadone maintenance is a US publication but relates equally to the UK situation. It could be said that the grassroots recovery movement here, which has itself "stepped out of the shadows" over the past 10 years or so, has achieved relative mainstream status with recovery being enshrined in the drug strategy.

As primary care practitioners, we will continue to work in a patient-centred manner with individuals who seek help for their drug use, whilst supporting those who struggle and applauding the successes of patients - and acknowledging that a patient on medication striving to maintain stability is no less in recovery than someone who aims to uphold abstinence. Prescribing has an important place and we need to get it right. With this in mind we are pleased to announce the updated Guidance for the use of substitute prescribing in the treatment of opioid dependence in primary care - available on the SMMGP website within the next 2 weeks.

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Building Recovery in Communities (BRiC)

See NTA web site.

The NTA have launched their consultation on the document which will replace the Models of Care framework. It articulates the aspirations for a recovery oriented system as outlined in the NTA business plan (and which in turn reflects the government's drug strategy priorities). It outlines a system to provide better access to a complete range of services in order to support people in sustaining their recovery.

Key issues that are being explored include whether treatment for drug and alcohol dependence should be integrated more closely, and how to more seamlessly bring together treatment in prison with treatment in the community. In line with the drug strategy, it addresses the problem of dependence in a broad sense and therefore includes addiction to over the counter medication and prescription medication.

The question that needs to be answered in this consultation is: what should a recovery oriented drug treatment system look like?

SMMGP comment

We have anticipated the arrival of this draft document since December, but we believe that Ministers' close scrutiny of it and interest in it contributed to its launch being delayed until now. Drug and alcohol treatment is a "big hitter" politically, and whilst SMMGP is not a political organisation, we need to use our influence where we can, when it is necessary to do so.

We also need to be seen to be representative of the view of primary care practitioners, and by doing that, be worthy of ongoing funding, as we provide a vital conduit of information for the government agencies that will shape the future we have to work in. The consultation period for this document is until early May 2011 and we will discuss how to best respond to it organisationally at our next project team meeting. In the meanwhile, if you have any thoughts that you would like us to include in the collective SMMGP response, please e-mail Elsa Browne, SMMGP Project Manager at elsa.browne@smmgp.org.uk.

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Payments by Results - Pilots

One of the key actions of the drug strategy is to test new approaches to commissioning and delivery of drugs recovery systems that reward achievement of outcomes.

Just before the end of last year, with a closing date for submission of pre-qualification questionnaires a mere three weeks later, an Invitation to Participate proposal was launched for local areas for potential pilots to implement a Payment by Results (PbR) approach to recovery for individuals who are dependent on drugs.

No additional funding is being made available for these pilots, rather local areas are expected to re-organise current treatment delivery systems into PbR models within their available budgets.

The work is being overseen by a cross-Government Steering Group - including the NTA - whose project team is responsible for the co-design of the pilots from April 2011, with the aim of going live in September this year for a minimum of two years, again a very tight turn-around.

The invitation paper asks for expressions of interest from local areas who are able to demonstrate fully joined up partnerships and can evidence strong commissioning arrangements across a range of partners (PTB, DIP, Community Care budget, mainstream PCT, etc). Payments will be made against a series of high level outcomes which are broadly:

A two-part system is envisaged with part payment available on achievement of initial or interim outcomes; and final outcomes. From the submissions (closing date is already past) to participate in a pilot programme, approximately 15 areas will now be approached to submit a full proposal (by 20 February). Partnerships who hold budgets, and with a track record in managing the pooling of budgets; and who also demonstrate being open to innovation (one of the major aims) are likely to be in the running for selection.

SMMGP comment

Primary care needs to be involved in this opportunity to have input into something which will hopefully produce a transparent funding system. To get it right when defining the outcome measures during this co-design period, is crucial.

We have had early reports of lack of clarity in the Invitation to Participate paper e.g. an Interim Outcome for "Free from drug(s) of dependence" suggests that clinicians will need to be satisfied that an individual has overcome their dependence and are no longer using drugs in a problematic/addictive fashion - using the NDTMS record of drug use in the 28 days prior to discharge - an established measure in the current system. However, in the context of PbR and with new providers coming on board, this could be interpreted that people who present for treatment must be in and out of the system in 28 days - clearly from years of good solid evidence unachievable.

It is necessary to keep pace with the speed with which these changes are being brought about and SMMGP will continue to keep you updated during the co-design phase. PbR is more fully discussed in an article by Linda Harris which will be on our website this week.

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The likely impacts of increasing alcohol pricing: a summary review of the evidence base

See Home Office web site.

This Home Office review aims to summarise the research evidence around the likely impact of policies designed to increase the price of alcoholic drinks. The report's findings include that (on balance) the international evidence base suggests that policies designed to increase the price of alcohol may be effective in reducing harms caused by alcohol.

However, it is only one of numerous factors that may influence or affect levels of alcohol consumption - others are individual, cultural, situational and social. The report finds that there is limited UK based research on alcohol pricing and criminal harm related to alcohol consumption, that a number of potential impacts of increasing alcohol price are under researched in this update. It concludes that on the basis of the evidence reviewed, it is not possible to determine which alcohol pricing policies may be the most effective.

The paper therefore finds that there is insufficient evidence to fully endorse the approach of increasing alcohol pricing to reduce its health harms.

SMMGP comment

Whilst the government has now tabled a form of minimum pricing, it is clear from our reading and responses by many focus groups that only a relatively large increase in price would have significant impact. We feel that this tweak from the Home Office is far too little to make any impact on the enormous and growing problem of alcohol.

It also stands in stark contrast to a recent American paper reviewing the area of alcohol pricing. ("Effects of alcohol tax and price policies on morbidity and mortality: a systematic review". Wagenaar A.C., Tobler A.L., Komro K.A. American Journal of Public Health: 2010, 100(11), p2270-2278)

This presents the evidence on how low tax/price levels of alcohol result in poorer health and higher death rates. The authors' conclusion is that these studies establish beyond reasonable doubt that alcohol taxes and prices are inversely associated with health across a population. Doubling alcohol taxes would on average reduce alcohol-related mortality by 35%, traffic crash deaths by 11%, sexually transmitted diseases by 6%, violence by 2%, and crime by 1.2%.

The total cost to the UK economy of alcohol-related death, illness, crime and other adverse impacts has been estimated at up to £25.1 billion a year. It is extraordinary that the Home Office hasn't woken up to the scale of the problem and responded with some purposeful evidence-based policy.

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Drug-related deaths: setting up a local review process

Drug-related deaths: setting up a local review process is now available on the NTA web site.

The guide contains ideas and examples of local areas investigating and reviewing the causes of drug-related deaths, and is designed to help local agencies to work together to investigate and learn lessons from drug-related deaths.

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RCGP Certificate in Harm Reduction, Health and Wellbeing - Update

A training day for trainers for the new RCGP Certificate in Harm Reduction, Health and Wellbeing was held recently and the certificate will now be finalised based on feedback from our group of high-calibre participants, for full launch towards the end of March 2011.

The idea to develop this certificate arose a while ago from the now seemingly distant Harm Reduction Action Plan and was finessed over time to include health and wellbeing as a natural progression towards whole person recovery. It is therefore an exciting time to be launching this certificate which fits in perfectly with the current drug strategy. It is designed as an introduction to consider the health, wellbeing and harm reduction of substance users for front line practitioners who have not yet completed Part 1; as well as being a refresher certificate for past Part 1 completers.

For more information contact Marianne Thompson, RCGP SMU: mthompson@rcgp.org.uk.

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Have you visited the SMMGP forums lately?

We are fortunate enough to have a popular web site where our forums are vibrant and dynamic. Many of the items covered in this policy update are currently being discussed on our forums, including payments by results, alcohol pricing, and the Building Recovery in Communities paper. Why not visit the SMMGP community discussions and have a browse!