Clinical & Policy Updates:
SMMGP Policy Update August 2011
|Download the PDF version of this Update here! (PDF*, 106K)|
The NTA - on behalf of the Department of Health - asked Professor John Strang to chair a group to provide guidance to the drug treatment field "on the proper use of medications to aid recovery and on how the care for those in need of effective and evidence based drug treatment is more fully orientated to optimise recovery". There is acknowledgement in the document that the drive for the guidance was a political one, following the election of the coalition government and subsequent review of the Drug Strategy in 2010. The interim report highlights the initial findings and the direction of travel of the expert group.
The report recognises the strong body of evidence for opioid substitute treatment (OST), but cautions against medical interventions becoming "detached and isolated" from other interventions including care planning, psychosocial interventions, and mutual aid/peer support. The group acknowledges that most of the interventions they felt were necessary for effective treatment were already described in existing guidance, and that they see their role as building upon, rather than dramatically changing, existing service provision.
The report suggests that there has been an imbalance in the system with an emphasis on retention, leading to an over reliance on medication, and a failure to consider alternative methods to maximise personal recovery.
Innovative concepts of the document include:
- Patient placement criteria: providing models that allow for an understanding of differential rates of recovery probability, which can be used at assessment.
- Developing a set of indicators to support the identification of interventions which might best benefit the patient.
- Encouraging services to link to recovery communities/peer led support- and making explicit and visible to patients that they can, in the future, successfully exit treatment. This includes focusing on developing patients' social networks involving families where appropriate.
The full report (which will be published later this year) will go into more detail as to how balance can be achieved between the "reduction of negatives and accrual of positives". In the meanwhile, it suggests several ways in which the recovery orientation of treatment that includes prescribing can immediately be improved. It contains a 12-point checklist of immediate actions that treatment services can take to review patients and ensure they are working to achieve abstinence from their problem drugs, and give them the opportunity to come off medication when they are ready to do so.
We welcome the fact that OST is acknowledged as a central plank to drug treatment and that the group found that the majority of elements seen as essential for good drug treatment were in existing guidance. The report's emphasis on needs led, personalised regular reviews is very much in line with the 2007 Clinical Guidelines (Dept. of Health 2007, "Drug misuse and dependence. UK Guidelines on clinical management") and Royal College of General Practitioners Guidance.
The most innovative element of the guidance will be the further investigation into what supports recovery, including a focus on strengthening links with recovery/mutual aid/peer led support, and the consideration of this as an approach at the beginning of treatment, and SMMGP looks forward to future findings of the group. A treatment system which offers hope, ambition, and a range of approaches to patients is something we fully support.
There are a few inconsistencies within the report. Whilst there is an emphasis on personalised treatment and the patient "owning" their treatment, there is also an expectation that "all those on a substitute prescription engage in recovery activities"; which without defining these is a rather prescriptive approach for personalised treatment. Whilst the patient placement criterion is an interesting concept, the suggestion that patients should be divided into "treatment" and "recovery" groups indicates that those going for "treatment" are not "recovering".
In their response, DrugScope make the important point that the services required for recovery - housing, training and employment services are beyond the treatment gates. These services are experiencing cuts in the current climate and this also applies to drug and alcohol services. This will without doubt affect providers' ability to deliver the aspirations set out in this report.
It is clear that primary care is well placed to contribute positively to the future of drug treatment as envisioned by the report, by continuing to work closely with patients in their best interests. It provides the platform on which to build, where prescribing is an important part of treatment, but is offered alongside other systems (e.g. psycho-social interventions) and linked with community and peer support initiatives, to help patients maintain stability in recovering from problematic drug use. Primary care will continue to play its vital role in a multi-disciplinary drug treatment system, and we await the final report with interest.
Since the eight payment by results (PBR) pilot sites were identified in April 2011, work has been taking place to look at how to incentivise drug and alcohol recovery systems to improve delivery of outcomes. As part of this process, the government has set the following high-level outcomes:
- Free from drug(s) of dependence
- Health and well-being
A Co-design Group - consisting of representatives from local partnerships in the pilot sites and central cross government departments and experts from the field - has been developing proposals to measure these outcomes and set eligibility criteria. The Co-design Group recently invited comments from the sector on draft proposals.
Although the time has passed to make comments, it is interesting to look at the detail of some of the draft outcome measures. There are suggested interim outcomes for all the categories which should allow for people to make progress as they move through treatment. All outcomes are measurable, for example the interim outcome for employment, which indicates readiness for employment, is for the individual to be discharged from treatment in the last 12 months free of drug(s) of dependence including alcohol. There is a reliance on TOPs as a measurement throughout the document. The health and well being category includes the harm reduction measures of cessation of injecting and vaccination against hepatitis B. This category sets interim outcomes, but appropriately has no final outcome!
The draft outcomes highlight some significant challenge for commissioners, providers, and patients together with the inevitable difficulties involved in setting payments for outcomes with a complex group of patients. For example, the final measure for "free from drug(s) of dependency" requires the individual to not present to treatment services for a year, and also not to present to criminal justice services for any offence for a year, potentially a difficult outcome to achieve with many patients. The group also identify the potential for perverse incentives; for example in the "offending" outcome the potential for providers to cease work to tackle an individual's offending behaviour once the individual has committed an offence is identified (as this work with the patient will no longer result in a payment). Using a 12 month measure for reducing offending may make patients who do well early on in treatment, but then stay in treatment, unattractive to providers (as once they have cease offending, they cannot continue to reduce offending). The potential for "gaming" (distorting figures in the chase for payments) is recognised. Finally, the interim measure for employment, for the individual to be discharged from treatment in the last 12 months free of drug(s) of dependence including alcohol, does not recognise those who find employment while in treatment.
We welcome the opportunity for people form the sector to comment on the draft outcomes, and feel that the questions raised in the document identify many of the challenges posed in a payment by results system. Some of the outcomes do appear to be difficult to achieve for those who have opioid dependency given what research tells us about the long term and relapsing nature of this condition. Throughout the document those involved are clearly attempting to address the potential problems PBR raises with relation to providers cherry picking "easy win" patients, and giving up on those who do not yield results.
It also strikes SMMGP that the monitoring of this system has the potential to create a large bureaucracy that appears to be counter to the government's desire to cut down on back room functions and middle management. It will be with interest that we read the results of the pilot sites in 2014.
In March 2009 the then Home Secretary requested advice from the ACMD on "legal highs". The ACMD have looked at a number of substances to date and provided advice on GBL, the piperazines (including BZP), the synthetic cannabinoids (including "Spice) and mephedrone and related compounds. Naphyrone; (NRG-1; Energy1; or O-2482) remains outside the generic definition in which a number of cathinones, including mephedrone and MDPV were controlled under the Misuse of Drugs Act 1971 on 16th April 2010. Since then, websites that had previously offered sales of mephedrone have switched to products purported to be naphyrone and other alternatives. Some naphyrone suppliers are marketing the drug for as little as 25p a dose (£12.50/gram) (or 1kg for £2,500). Some internet based retailers are selling naphyrone (NRG-1) as a premium based plant food or pond cleaner.
Naphyrone is usually sold as a white crystalline powder. As with other so-called "legal highs", users of NRG-1 (believing it to contain naphyrone) may insufflate or swallow the substance, either by dabbing or wrapping in a cigarette paper and "bombing". Consistent with the known or reported harms of the cathinones and traditional amphetamines the predicted harmful effects of naphyrone include adverse effects on the heart and blood vessels, hyperthermia, dependence liability, and psychiatric effects including psychosis and anxiety. In extreme cases amphetamine-like drugs can cause death due to cardiovascular collapse or heat shock.
The ACMD recommendations include a public health and educational campaign on the dangers of the compound, including the inconsistencies in the content of these products, and that naphyrone and related compounds should be controlled as Class B substances under the Misuse of Drugs Act 1971.
Phenazepam is a benzodiazepine drug, ("street" names include, "Bonsai" and "Bonsai Supersleep") and it is being sold as a "legal high" on the internet in various ways: under its own name as a single substance; in combination with dimethocaine (one example "brand" name is "Dimethocaine Phenazepam Legal Powder"); and, as a counterfeit for "Valium" (diazepam) on line. Phenazepam is being sold in pure material in powder form and as a 1mg per ml solution in dropper bottles.
Phenazepam acts as a depressant and was originally developed in the 1970s by the former Soviet Union, and is now produced in Russia. There is no recognised use in the UK. The potency of phenazepam is around five times that of diazepam increasing the risk of overdose. It may potentially be more dangerous than other benzodiazepines due to the 60-hour half life of the substance. There is the potential for users to re-dose before the onset of the effects of the original dose, since peak effects are not reached until 2 to 3 hours after an oral dose has been taken and this increases the risk of overdose.
The ACMD recommends that phenazepam be controlled under the Misuse of Drugs Act 1971 as a Class C substance and scheduled as a schedule 3 substance under the Misuse of Drugs Regulations 2001.
The ACMD have been busy in July and it is good to see that they are reacting to recent drug trends, and attempting to combat the issues raised by sale over the internet. The reports provide useful advice on the substances involved, and in the case of naphyrone places a public health and education campaign at the top of its recommendations. However, a recent survey found that the popularity of mephedrone surpasses other drugs, both legal and illegal, despite having been banned by the UK government, and that legal status was not a deterrent to users (Measham, F et all 2011, "The rise in legal highs: prevalence and patterns in the use of illegal drugs and first- and second-generation 'legal highs' in South London gay dance clubs" Aug 2011, Vol. 16, No. 4, Pages 263-272: 263-272.). Together with the increasing voices of a call to end the war on drugs, SMMGP wonder whether the banning of legal highs will have the desired impact of reducing harm.
Kathy Gyngell Centre for Policy Studies
This report caused much media attention on Sunday 19th June when the BBC aired its views. In a nutshell, the report suggests that the current drug policy favours methadone prescribing with the aim of cutting the cost of crime, over other services but that OST in fact delays people's recovery from addiction. It goes on to criticise payment by results as continuing this situation, in particular by having proxy measures, and by failing to include residential rehab in its pilot sites. The report advocates one simple measure of success, abstinence from drugs and alcohol for six months.
We don't think we can top DrugScope's response to this document, which highlighted major inconsistencies and inaccuracies in the way the report presented its facts. In particular they were concerned that the Centre for Policy Studies (CPS) had made claims that were "simply wrong" in relation to overestimating the true costs of OST and that the CPS was underestimating the achievements of the current treatment system. DrugScope have also complained to the BBC about presenting factually incorrect information throughout the day on its news channel. SMMGP supports their final point:
"It is a shame that, in trying to bring attention to the issue of access to residential rehabilitation, the CPS has so seriously misrepresented facts about drug treatment. The report and its coverage risk undermining public support for drug treatment and for much needed investment in services which are key to improving outcomes and supporting recovery."