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 September-October 2011

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Independent research reveals fall in heroin and crack use

See the full report on the NTA web site.

The NTA recently published independent research from the Centre for Drug Misuse Research at the University of Glasgow (prevalence data) in a report which indicates that the number of people who use heroin and crack in England is decreasing.

Estimates show that there were 306,150 users of heroin and/or crack in 2009-10, a statistically significant decrease from the 2008-9 estimate of 321,229, and about 25,000 fewer heroin and/or crack users since the 2005-07 estimate of 330,000.

An NTA summary of the research also highlights an estimate of 103,185 injecting drug users, a fall of 12% from the previous count. The overall figures for comparison to 2004-5 is:

Period 2004-05, Estimate = 327,466
Period 2009-10, Estimate = 306,150

Heroin and crack are the most problematic illicit substances, because of their potential for entrenching dependency in individuals and their social impact in fuelling drug-related crime, worklessness and welfare dependency. The trend identified by Glasgow University reflects the reduction in new presentations to services recorded by the National Drug Treatment Monitoring System (NDTMS) in recent years, and is consistent with the NTA view of an ageing drug using population in England.

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Drug treatment and recovery in 2010-11

The NTA have published a report on their annual snapshot of figures extracted from NDTMS data, which echoes the trends indicated in the Glasgow prevalence figures (above) of fewer drug users coming into treatment. For the first time this yearly report on the data has been augmented by the availability of six years' worth of data for analysis.

The analysis revealed that 255,556 adult drug users have entered a treatment programme for the first time since 2005, mainly for addiction to heroin. The figures show that 28% (81,887) of these people have successfully completed their treatment over the past 6 years and have not come back into treatment.

The number of heroin and crack users aged 40 or over entering treatment has levelled off (after consistent rises up to 2009-10). The over-40's remain the largest age group starting treatment in 2010-11 with around 80% of those for heroin and/or crack. However, the numbers of people needing treatment for heroin and crack has fallen by almost 10,000 in just 2 years.

There is an encouraging decline in the numbers of young people coming into treatment for heroin and/or crack use. Interestingly, the report shows that the only drug for which increasing numbers of young people (18-24 year olds) are seeking treatment, is cannabis, despite the British Crime Survey suggesting that fewer of them are using cannabis.

Read the full report on the NTA web site.

SMMGP comment

Ignoring the report's superfluous emphasis to reflect the impact of the rebalancing of the treatment system since the 2010 Drug Strategy, we focus on the numbers, which speak for themselves.

The severe impact on individuals and society from the illicit use of heroin and crack and the potential for addiction and its subsequent effects, are generally accepted. For this reason alone, the reduction in the number of people presenting for treatment for addiction to these drugs is heartening. It is very encouraging to learn from the report too that 28% of people have completed their treatment and not returned.

Recent reports from the NTA have shown that there is a trend away from heroin for younger people who use drugs. It follows, and the NTA report acknowledges this, that the population of heroin users in treatment includes a group of people who are ageing. This latter group is likely to need more intensive treatment as they grow older, and there is no better place for them to go to for their health and wellbeing than their GP. SMMGP will continue to work hard to raise awareness amongst GPs generally and to support GPs and other primary care practitioners in best practice for the treatment of people who use heroin and crack.

This estimated reduction in heroin and crack use is not a reason to rest on our laurels; use of other drugs including legal highs, alcohol, over-the-counter and misuse of prescribed medications are an increasing cause for concern, and it is important that primary care continues to provide support for people getting into problems with substance use, whatever the substance is. SMMGP will continue to keep the field up-to-date with the latest new developments and trends.

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NTA: Proposals to Amend the NDTMS dataset collected for drug and alcohol treatment

The NTA has issued a document this month outlining their plans for changing how interventions are recorded in NDTMS, with a view to making it more relevant to the ambitions of the Drug Strategy, ensure that it reflects evidence, and improve accuracy and consistency in recording.

Responses are required by Tuesday 18 October on the pro forma.

The proposed changes in the modality codes will be replaced by three principal components:

1. Intervention type
(including pharmacological, psychosocial and other recovery supports).

Looking a bit more closely at the category for pharmacological interventions - currently there are two prescribing interventions in the NDTMS core dataset (specialist prescribing and GP prescribing) and both include a psychosocial element. It is now proposed to remove the latter component for NDTMS purposes, because - whilst all prescribing interventions should include a psychosocial intervention - there are wide variations in practice and a more accurate picture is needed. The proposal is to include a mandatory field of four options that describe the goal of prescribing:

The proposal also is to collect information on the type of medication being prescribed, and the consultation document asks a direct question over whether this information should be collected only on medications for opiate dependence, or on all medications used in drug treatment (if the latter route is chosen, it will probably have to be by drug name). If for opiate dependence only, the options are:

This is proposed in order to enable effectiveness of medications to be evaluated for different groups of patients and to reveal patient need and choice.

Case management - this is not currently recorded and it is proposed to introduce this category to allow case management to be recorded where there are no prescribing interventions as part of the treatment intervention.

Psychosocial interventions - current providers record 90% of all psychosocial interventions as "other psychosocial intervention" which is clearly not representative.

Recovery support - two new codes are being proposed that describe recovery support, including post treatment (which may not be provided by drug and alcohol services).

(where interventions are delivered).

The proposed changes are intended to more accurately reflect what is being delivered and to allow for greater accuracy when making outcome comparisons between different settings.

(categorised by the number of hours per week to record level of intervention).

A measure of intensity will be applied to treatment namely low, medium, high and very high. Definitions are contained in the appendices to the NTA document.

SMMGP comment

Data, although the cause of much woe, is important and cannot be ignored. We've been aware for a while, from anecdotal reports, that there are problems with the way that primary care prescribing is being recorded and reflected in NDTMS. It is therefore welcome that this overhaul is under way that will hopefully more accurately reflect the situation in the field regarding prescribing, because reliable data collection is necessary not least for commissioning of services.

One of the proposals in the consultation document is to separate out psychosocial treatments from prescribing. It is clear that with 90% of psychosocial interventions being recorded as "other" - despite there being 5 choices in that category - there are improvements that could be made to reveal more accurately the particulars of this intervention and treatment too. There's a bit of a Catch 22 in that it's no good complaining that data is inaccurate, because as we all know, what goes in comes out. Regarding the question asked about whether to record the name of the drug, this would seem to make more sense because if you have the drug name (e.g. naltrexone) then the information that it is an antagonist is also implicitly available (but not the other way round). With the interest in addiction to prescription medication, it would also make more sense to record information on all drugs in a prescribing modality.

The consultation period for this exercise is very short given the wide-reaching changes that are being proposed. SMMGP will be submitting a response to the paper and welcome input from our membership, a thread has been started on the forums, please post your comments.

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NICE: Quality Standard for Alcohol Dependence and Harmful Alcohol Use

NICE: Quality Standard for Alcohol Dependence and Harmful Alcohol Use have been launched (collectively described as "alcohol misuse" in the standard) which defines clinical best practice for this area. It covers care for children, young people and adults. There are 13 quality standards related to this topic across the spectrum of care required; including identifying the needs of carers and families.

NICE Quality Standards make an important contribution to the knowledge bank for high quality and cost effective treatment and allow health practitioners to make decisions about care based on evidence and best practice; provide patients with an understanding of what service to expect when they enter treatment and commissioners to be confident about the quality of service provision.

SMMGP comment

SMMGP is a registered NICE stakeholder and participates in consultations on subjects in our field. This is a welcome contribution to the body of work that outlines what constitutes quality treatment for people who experience problems with alcohol use. The Quality Standards assimilates evidence and best practice and sets markers that are clear and concise.

See the NICE web site for more information.

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NICE: Neuropathic pain: the pharmacological management of neuropathic pain in adults in non-specialist settings

NICE is consulting as part of a review of an earlier guideline on the pharmacological management of neuropathic pain, and in particular looking at concerns around the associated costs of pregabalin as a first line treatment for adults with neuropathic pain.

SMMGP comment

It is important that addiction bodies are represented in the consultation response on the treatment of neuropathic pain and SMMGP is planning to submit comments to NICE.

Pregabalin (and gabapentin) have been the subject of discussion in the SMMGP forums in terms of use in prisons. There is evidence that pregabalin can be abused and prisoners with substance misuse issues often report the use of pregabalin in combination with other substances. This illicit use can lead to demand on medical services in prisons and raises difficult issues for clinicians when seeking appropriate prescribing options for those with neuropathic pain. The NICE guidance review is driven mainly by cost implications but it is important that the full range of clinical opinion is presented in the consultation. We would urge you to share your views and experiences with SMMGP via the forum and we will include these in any submission.

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Survey: Answers on a postcard

The Recovery Partnership is comprised of the Skills Consortium, Drugscope and the Recovery Group UK. In mid-November the partnership will be making representation to the Inter-Ministerial Group on Drugs on important issues facing the sector in delivering the drug strategy. In order to draw on as wide a range of opinions as possible, a survey is being conducted by them, including the opportunity to do a "Postcard to the Minister".

See the Recovery Group UK web site for more information.

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Survey: Recovery on prescription

The Alliance is preparing a paper on the impact of the Drug Strategy on treatment, and is undertaking a survey on access to and experience of maintenance prescribing. Participation in the short survey (5 questions) is anonymous and will assist The Alliance in their ongoing endeavour to reliably represent the experience of those who are making progress in treatment whilst on a prescription for opioid substitute medication. If you wish to contribute, or you have a patient who could do so, please see the survey entitled "Continued Access to Maintenance Prescribing".

SMMGP comment

We urge SMMGP members to complete surveys as much as possible - be heard! As evidenced by the recent overwhelming response to the round table discussion which was organised by Stephen Bamber in August 2011, the role of a "maintenance script" in the recovery of many people cannot be ignored or overlooked in the tide of the government's sweeping changes to the treatment system.

SMMGP clinical lead, Steve Brinksman, was quoted in an article in the BMJ (BMJ 2011; 23 September 2011) when he warned against the simplistic view that people can be free of addiction easily by being detoxed and having a spell in rehab. It is important that harm reduction in all its facets remains on the agenda for serious consideration by the powers that be. The survey by The Alliance is another important building block in contributing to the understanding of the complexities of drug treatment.