Clinical & Policy Updates:
SMMGP Policy Update May 2011
|Download the PDF version of this Update here! (PDF*, 266K)|
Towards the end of last year; and arising from a piece of work that we are aware had been around for a while, the Department of Health commissioned two reports: "Addiction to Medicine" from the National Treatment Agency (NTA), and a joint literature review by Kings College and the University of Bristol. The full NTA report is available online.
The NTA project took the form of a consultative review to investigate prescribing patterns and the services and support available to people who develop problems. The three main aspects of the consultative review were:
- An analysis of relevant National Drug Treatment Monitoring System (NDTMS) data and prescription data to investigate prevalence and trends.
- Structured interviews with targeted PCTs/partnerships about the commissioning, governance (including of prescribing) and provision of drug treatment services.
- Surveys and structured interviews with specialist drug treatment providers and dedicated providers of treatment for prescription and over the counter medicines dependency to determine what is being provided and how local services are configured.
The reports, which were launched via a written ministerial statement to Parliament on 11 May 2011 will inform future guidance and policy for the use of benzodiazepines and similar drugs. The reports found that people can become dependent on tranquillisers, sleeping pills and opiate based painkillers such as codeine, particularly if taken at high doses for prolonged periods. Although the reports reveal that overall prescribing of benzodiazepines is falling, prescriptions of benzodiazepines for the treatment of anxiety continue to increase as do the sale and prescription of opioid painkillers.
Key points that came out of the Addiction to Medicines report are:
- Most prescribing is within current guidelines.
- Long term prescribing increases the likelihood of dependency, but does not make it inevitable.
- Over the past 19 years dispensing of benzodiazepines has decreased, however, there has been an increase the prescribing of anxiolytic benzodiazepines and in the sale and prescription of opioid painkillers.
- Dependence may be overcome if individuals are supported to gradually reduce their medication.
- In 2009/10 there were 32,510 people reporting problems with prescription only or over the counter (POM/OTC) medication, which is 16% of the treatment population (total 206,889).
- 3,735 (11%) of those in drug treatment reported their primary dependency was only with POM/OTC drugs and a further 27,775 people whose primary dependency was illegal drugs reported additional problems with over the counter and prescription medicines.
Although the NTA report found that most local areas provide some treatment for people who develop problems in relation to medicines, it suggested that the numbers in treatment reporting dependency on medicines may be under representative of problems experienced by the wider population, and there were few dedicated POM/OTC services and most were via local drug treatment services. Both reports concluded that more research is needed to determine the level of unmet need.
The importance of addressing this growing issue cannot be stressed enough. At the Harm Reduction International conference in Beirut in April, SMMGP attended a seminar hosted by IDHDP (International Doctors for Healthy Drug Policies) on drug policy around the world where it was reported by a doctor from the US that a growing trend amongst young people is that as many are using pain relievers as marijuana, as their first illicit drug use. As far back as 2007 problems with over the counter medication was highlighted in a DDN "Post It from Practice" by Chris Ford.
With perfect prescience, SMMGP offered a successful special interest training day on over the counter and prescribed medication in May 2011 and DH presented their findings at our training day, or as DH called it, our "GP summit".
A copy of the presentation from the report is available on our website.
Although the "Addiction to Medicine" title is jarring, the report is a welcome step forward in getting to grips with the extent of the problem in the UK, and both reports provide some much needed data as background to what we know about it in practice. However, we know there are problems with primary care data reporting and how outcomes are measured in this group as services provided by GPs are not always reported to NDTMS.
If you are interested in finding out about holding an "Over the Counter" training day in your region, please drop an e-mail to Elsa at firstname.lastname@example.org.
DH have published the above document which takes forward plans for and sets out the function of the NTA in the transitional period up to 2012. During this period the NTA will continue to support the development and delivery of effective and local recovery-oriented systems, whilst preparing for its key functions to be absorbed by PHE as determined by DH, across the broad goal of building recovery in communities and moving towards a whole systems approach. The full document is available on the NTA website.
We are committed to support the principles of the NTA Action Plan and their adherence to the broader Drug Strategy in this transitional period.
One of the areas that remain a challenge for primary care is the collection of NDTMS data from providers that will enable sound data analysis - for example, providing detailed analysis on patients that have been in treatment in primary care for a period of time.
As data will become even more important as a way of evidencing success in treatment, SMMGP is committed to working with the NTA in various ways to highlight where there are particular problems and to investigate how the collection of data in primary care can be improved, so that it does not leave primary care drug treatment data open to negative interpretation as far as outcomes go.
The WMA and IFHHRO issued a statement during May 2011 condemning the operation of administrative (government run) drug detention centres for users of controlled substances. The call for their closure by these organisations is based on the blatant violation of human rights of people detained in these centres and the lack of adherence to accepted medical practices in these facilities.
An estimated 400,000 people worldwide are held against their will in facilities that often offer no treatment (e.g. where labour regimens are imposed) and without regard to legal standards, procedural safeguards or actual need for treatment. While doctors sometimes work in these centres, they are typically run by police or the military with no regard for the recognition that treatment of addiction, like any other condition, should be undertaken according to established principles of medical ethics and as with other forms of medical care should be voluntary and carried out in supportive environments.
From more than 40 years of research, it is known that opioid substitution therapy works to reduce injecting drug use and the harms that can be associated with drug use, and the introduction of methadone and buprenorphine in countries struggling to address epidemics of HIV and injecting drug use is to be commended, whilst the appalling practice of detaining drug users against their will without access to decent medical care, cannot be permitted to continue without challenge.
International Doctors for Healthy Drug Policies (IDHDP) www.idhdp.com has supported the call from the above organisations for the closure of these inhumane and unethical detention centres. SMMGP now adds our voice to the call to bring an end to this brutal practice, which will never succeed in its misdirected goal.
Towards the latter part of last year William White and Lisa Mojer-Torres from the US published a landmark monograph entitled Recovery Oriented Methadone Maintenance and it was first reported on in our January 2011 Policy Update.
"The Art of Life Itself" website has now published the first instalment of an excellent discourse between Stephen Bamber and William White which explores further, in an accessible "question and answer" format and in the style of an informal dialogue, some of the issues covered in the original tome. William White talks about the shift in his own thinking that resulted from a confluence of opinions over a period of time to a point where he - from an original "personal position of great animosity towards methadone", arrived at a turning point when he really started listening to patients in long-term methadone assisted recovery, as opposed to merely accepting the evidence.
In this first instalment (dedicated to the memory of Lisa Mojer-Torres) Bill White communicates a particularly pertinent message at the outset of the interview that the recovery orientation of methadone maintenance diminished during its widespread dissemination and needs to be restored (and further developed). The interviews will be available in instalments (the first one is available now) in a readable format and can be accessed via the Art of Life Itself website. Register on the website for regular updates.
William White is an inspiring leader and thinker in the recovery movement and it is interesting to discover how his view changes from animosity towards medically assisted recovery to recognition of the role it plays. It does not diminish the value abstinence-based recovery for him, but he comes to accept there is more than one way.
His opinion is based on his experiences of methadone treatment in the US, but much of what he says resonates with current UK rebalancing of the treatment system and the growing recovery movement in this country in recent years. Whilst all this is going on, our caveat is - with decisions often in the hands of non-clinicians, and further influenced by poor quality data - we need to be careful that we do indeed achieve and maintain a treatment system which is balanced and based on individual needs.
For SMMGP, latterly this has meant constantly evaluating and adjusting our thinking, including about how we use language, whilst being aware of the dangers of being drawn into politicising it. The primary care conference in Harrogate, which was successful on so many levels, attracted a lot of comment both directly in feedback to SMMGP and indirectly in the shape of the ever-growing practice of blogging and on various forum discussions, and much of the discourse came down to the use of language. We welcomed the healthy exchanges that resulted, which helped us to recognise the importance of continuing to focus on our core business: to promote the provision of effective care for drug users on their journeys and to support and encourage GPs and other primary care workers who provide treatment for drug users.
William White challenges what he describes as the gulf between medically assisted recovery and drug free recovery, with a vision of treatment settings where all people seeking help will have a comprehensive menu of services to support them across the stages of recovery. And to us, that sounds like a perfect description of good drug treatment in primary care.
Release, the national expert organisation on drugs and drugs law, is currently campaigning for better laws around the issue of drug policy. In a letter to the Prime Minister they call for a review of current UK drug policies, with a view to decriminalisation of possession for all drugs. This letter has been signed by leading QCs, three former Chief Constables, academics, politicians amongst others - and Dr Chris Ford, SMMGP outgoing clinical lead. To support this important campaign, sign up on the Release website.
A copy of the letter is available on the Release website.
A group of influential people, including former Presidents of Brazil, Colombia , Mexico and Switzerland , Prime Minister of Greece, Kofi Annan, Richard Branson, George Shultz, and Paul Volcker have called for a major paradigm shift in global drug policy.
"The war on drugs has failed to cut drug usage, but has filled our jails, cost millions in tax payer dollars, fuelled organized crime and caused thousands of deaths. We need a new approach, one that takes the power out of the hands of organized crime and treats people with addiction problems like patients, not criminals", said Richard Branson, founder of the Virgin Group and cofounder of The Elders, United Kingdom. "The good news is new approaches focused on regulation and decriminalization have worked. We need our leaders, including business people, looking at alternative, fact based approaches. We need more humane and effective ways to reduce the harm caused by drugs. The one thing we cannot afford to do is to go on pretending the 'war on drugs' is working".
For more visit www.globalcommissionondrugs.org
We welcome the fact that this view appears to be becoming more and more mainstream. The effects of criminalisation on drug users can often be as - or more damaging - than the drug use itself. The Global Commission on Drug Policy has done well to pull together this impressive group of individuals to support its cause and call for an end to this pointless "war".
We welcome to the SMMGP project team Steve Brinksman, who has officially taken up the job of clinical lead for SMMGP.
Steve has been a GP in Quinton in Birmingham for 20 years, working with drug and alcohol users from the beginning. Steve's career has included working in both adult and young people community drug teams and he was one of two lead GPs in substance misuse employed by Birmingham DAT to develop the highly successful primary care based drug treatment model in that city.
He has also recently been appointed by the DAAT as an alcohol lead for primary care and is also a GPwSI in South Birmingham. He has been the RCGP's regional lead in substance misuse for the West Midlands since 2004.
We are excited about working with Steve and look forward to his clinical leadership for SMMGP.