SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Clinical & Policy Updates:
SMMGP Clinical Update June-July 2013

Compiled by Dr Euan Lawson

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Papers & Reports

"I can't be an addict. I am." Over-the-counter medicine abuse: a qualitative study
Cooper RJ. BMJ Open 2013;3:e002913-3

This study, published in the open access journal BMJ Open, recruited a sample of 25 adults via two internet support groups ("Overcount" and "Codeinefree"). The aim was to find people who considered themselves to be addicted to over-the counter (OTC) medicine. The semi-structured interviews, mainly conducted over the telephone, were carried out over an 18-month period. These were recorded, transcribed and analysed.

The majority (23/25) started using OTC medication for a genuine medical condition and just two started with an initial intention to abuse the medication. The analysis categorised them into three types: Type I never exceeded the maximum dose (7/25); Type II slightly exceeded the maximum dose (8/25); and Type III considerably exceeded the maximum dose (10/25). The participants described the ease with which they were able to obtain medications. Most did describe incidents when they were challenged and had strategies to avoid detection such as varying pharmacies and observing shop workers' regimes. Many considered self-treatment as the first stage of management when they became aware of problems but the lack of appropriate services for OTC medicine abuse was raised. Some highlighted concerns about their addiction being recorded on their medical notes so avoided going to their GP for that reason.

Commentary: This study covered a lot of ground and, like many qualitative studies, there is a great deal to be gained from reading the study in full. Most of the people who perceived they had OTC medicine addiction started with a genuine medical problem. The discussion section of the report highlights that clinicians and pharmacists may be unsure of the best way to approach people when they have concerns. The authors suggest several questions that have emerged from the study and could be helpful. These include asking people if their medicine use has affected their work or social life, or if they felt they had lost control of their medicine use.

However, the one that sticks out as perhaps most useful is one that can be brought immediately into all of our clinical practice. Ask: have you ever taken more than the recommended maximum dose? That said, many felt they were addicted at low doses - but the sample for this study was a self-selected group who regarded themselves as addicted so it is possible they would not meet the typical criteria for dependence. Nevertheless, it raises interesting issues about how we identify anybody people who perceive themselves to have a problem and how we manage them.

The CPPE (Centre for Pharmacy Post-Graduate Education) offers an e-learning programme, "Addiction, misuse and dependency: a focus on over-the-counter and prescribed medicines". They have developed this programme with the Royal College of General Practitioners (RCGP) to provide healthcare professionals with a better understanding of how you can recognise patients who may have an addiction to prescribed or over-the-counter (OTC) medicines and how you can approach and help patients. More information is available on our Latest News page.

Acute and chronic respiratory symptoms among primary care patients who smoke crack cocaine
Leece P, Rajaram N, Woolhouse S, et al. J Urban Health 2012;90:542-51

This study took 20 patients who had smoked crack in the past 30 days and assessed the prevalence of acute and chronic respiratory symptoms. The participants were all visiting a drop-in primary care clinic in downtown Toronto, Canada and they completed an interview-administered survey on respiratory symptoms, diagnoses, tests and medications.

Overall, the mean age of participants was 44 years, they reported using crack for a mean of 20.4 years, and their crack use averaged just over 15 days per month. The results showed that 95% (19 out of 20) reported at least one respiratory symptom in the previous week. This was reported as bothersome by 13/19 (68.4%). The most commonly reported symptoms reported were black sputum and shortness of breath. There was a diagnosis of asthma or COPD in 12/20 (60%) and 4/20 (20%) had a diagnosis of both. Most of them had been prescribed inhalers - 16/20 (80%) and 100% smoked tobacco.

Commentary: The researchers described this as a "pilot study". This is often code for a study that is under-powered and from which only limited conclusions can be drawn. There are some issues of that nature with this study - there was no comparison group for a start and there is no way to disentangle the high use of tobacco, a major confounder, from the findings. Yet, there are some interesting wrinkles here too and it merits publication and scrutiny by clinicians.

It was interesting that the single most common symptom reported was black sputum - reported by 75%. How many of us ask this in a consultation? It would usually result in an immediate chain of events if reported in a consultation - clearly, it doesn't suggest malignancy in this context but there is an issue, raised by the authors, about how it should be managed. That said, this sits within the greater problem of how much time is being spent on addressing respiratory health at all in this group of patients. Clinical experience suggests it is very little but evidence, beyond the anecdotal, is growing about the need to ensure this area of practice is addressed.

Hepatitis C treatment access and uptake for people who inject drugs: a review mapping the role of social factors
Harris M, Rhodes T. Harm Reduct J 2013;10:7

This was a review of the social science and public health literature around hepatitis C treatment in people who inject drugs. They found that many of the clinical and individual level barriers to treatment are well documented - they include patient and provider concerns about adherence to treatment, co-morbidities and side effect management. There is less clear evidence on the social factors.

The authors drew them out into several domains: Social stigma. There is considerable evidence of this - and they noted that the health care setting is the most common site for discrimination with consequences that affect testing and treatment uptake. Housing. Homelessness and HCV are associated and there are additional barriers for the homeless person who injects drugs when trying to access services. Few people are enthusiastic about managing the side effects of HCV treatment while living on the street. Criminalisation. One example is people who inject drugs being subject to recurrent incarceration with a knock-on effect on care as they move in and out of treatment. Health care systems. Hospital-based treatment is particularly challenging for people who inject drugs to access given problems with referral waiting times, inflexible appointments, and geographical distance. Gender. There is evidence emerging that women may experience more stigma from injecting drug use and HCV infection.

They also identified factors that could facilitate access to treatment: combination interventions that addressed social as well as the medical; low threshold access to opiate substitution therapy; and integrated multidisciplinary care.

The contributions of viral hepatitis and alcohol to liver-related deaths in opioid-dependent people
Larney S, Randall D, Gibson A, et al. Drug Alcohol Depend 2013;131:252-7

It is known that alcohol and chronic HCV infection are the big contributors to liver disease - a rising problem in an ageing opioid dependent people. What is less clear is the relative contribution of these two factors and this Australian study aimed to quantify these effects.

Their study population was those individuals receiving opiate substitution therapy (OST) in New South Wales. All 20,869 patients registered between 1997 and 2005 on OST were included. They then linked those people to the National Death Index and mortality ratios were worked out. They also got frequency counts for viral hepatitis and alcohol mentions in underlying liver deaths. Overall, there were 208 liver deaths, nearly 10 times greater than the comparable rate of liver deaths for the general population. They also noted that the mortality from liver deaths was rising over time. Viral hepatitis was mentioned in 76% of deaths and alcohol in 43% of underlying liver deaths.

Commentary: It's no secret that liver deaths are rising in the UK. This study suggests, in Australia at least, that HCV is a bigger factor than alcohol in those dependent on opioids. Interestingly, the authors highlight in their introduction that there is a Scottish paper that found alcohol to be the dominant force. Without lurching into national stereotyping one can imagine how this would be consistent with the cultural influences in the north of the UK.

The Harris and Rhodes paper sets out some of the social factors influencing uptake of treatment for HCV. There is a remarkable richness in this paper and it is highly recommended for anyone with an interest in HCV treatment. If nothing else, the final section of this paper "Discussion: creating an environment enabling of HCV access" should be mandatory reading for anyone looking for ways to develop a hepatitis C treatment service. There are also obvious messages for GPs in practice - educating the practice workforce is likely to help reduce stigma and discrimination. It is a shocking finding from this paper that the most stigma experienced by people with chronic HCV is to be found in the healthcare setting.

Predicting biopsychosocial outcomes for heroin users in primary care treatment: a prospective longitudinal cohort study
Parmenter J, Mitchell C, Keen J, et al. Br J Gen Pract 2013;63:499-505

This paper reported on a longitudinal prospective cohort, started in 1999, which recruited patients who attended a primary care addiction service in Sheffield. Outcomes at 11 years had been examined using the Opiate Treatment Index (OTI). At the 11-year follow up the drug-free discharge rate was 22.0%, medically-assisted recovery was 30.9% and there was a mortality of 6.5%. In total, 14.6% had dropped out of treatment and not returned so their outcomes were unknown. At baseline, 31 out of 33 patients were using heroin and 28 were injecting. At follow-up just 5 out of 33 were using heroin with one person injecting. The best predictor of a drug-free discharge was continuous uninterrupted treatment.

Commentary: It is all too common for studies to have very limited follow up and cohort studies over a decade offer a valuable insight into the potential for primary care. Some aspects of care will vary from place to place - this was a specialist GP run service rather than one embedded in practices themselves. The authors make the point that the OTI captures information on a wide range of areas including social functioning and this study is one of the few that highlights factors that constitute "recovery capital". The important fact about this study is that it has demonstrated that opiate substitution therapy, delivered in a primary care setting, offers low mortality rates, medically-assisted recovery and drug-free discharge over an extended follow-up.

Problem alcohol use among problem drug users in primary care: a qualitative study of what patients think about screening and treatment
Field CA, Klimas J, Barry J, et al. BMC Family Practice 2013;14:98

This paper reports on a qualitative study conducted in primary care in East Ireland. The participants were recruited by their prescribing GPs. They recruited 28 people and semi-structured interviews were conducted and analysed. The interview followed a topic guide which was derived from a literature review and a pilot study and explored three main areas: demography and descriptive data including the AUDIT screening questionnaire; experience of screening and treatment for problem alcohol use; and attitude towards screening and treatment for problem alcohol use.

Three-quarters of the 28 participants were men and the mean age was 39.4 years. Heroin was the drug of choice in 23/28. The AUDIT scores showed that nine patients were in the low risk category, eight were in the hazardous drinking category, and five were in the highest risk category - suggestive of dependent drinking. The qualitative results were presented in several different areas: Patients' experience of being screened. Patients recalled "being asked" about screening but had no recollection of formal tools such as AUDIT or the use of LFTs. Patients' experience of interventions.

They recalled being told about the negative consequences of using alcohol - particularly the effects on the liver. Some were treated with medications such as chlordiazepoxide and most recalled a positive experience with counsellors. Patients' attitudes to therapeutic interventions. Those who reported positive experiences may have raised the issue of alcohol themselves or felt that the healthcare professional was acting out of concern for them. Others experienced negative reactions that included fear, embarrassment and resentment. Some feared repercussions such as increased supervision of methadone. Patients' relationships with healthcare professionals. The majority had positive relationships but many admitted to friction in the past. Those who had more negative experiences reported how "once you have used drugs you will never be trusted by a doctor". Patients' views on service improvement. The patients emphasised a couple of areas: the professional-patient relationship and the need for support and encouragement.

Commentary: The majority of these participants had issues with dependence on heroin - it's easy for the alcohol problems to be under-addressed. This is despite problem alcohol use in over a third of people on methadone treatment. One of the key findings of this paper is that the patients themselves placed a high degree of importance on the practitioner-patient relationship. They recognised it is an essential element in their treatment and progress toward recovery. This does seem to be, as the authors suggest, previously unreported in this group - yet it is entirely familiar to primary care. Almost everyone with a chronic illness values continuity and their relationships with their GP. Yet it is rarely appreciated in those who commission services - whether it's for diabetes, depression or, in this case, dependence. It's might be difficult to measure but to neglect it means that perhaps the single most valuable aspect of care in a chronic illness is marginalised.

Khat: A review of its potential harms to the individual and communities in the UK
Advisory Council for the Misuse of Drugs 2013

Khat is a herbal product produced from the leaves and shoots of the shrub Catha edulis. It is chewed and users get a mild stimulant effect. It is imported into the UK from the main growing regions of Kenya, Ethiopia and Yemen. It is generally used socially - in family homes, communities and in cafes. The main chemicals are cathinone and cathine. Chewing khat is an efficient method of extracting active cathinone but it is slow and the bioavailability is low so it takes time. It's also bitter and the need for prolonged chewing puts off many potential users. Typically a bundle of Kenyan khat costs around £3 per bundle and most users chews one or two bundles in an average session - which takes four to six hours.

This is a comprehensive review of khat. The ACMD have surveyed the peer review articles in the literature, various surveys and sources of information on social harms. In addition they have undertaken community BME visits and had discussions with Council leaders. The report given to the Home Secretary stated that:

"In summary, the evidence shows that khat has no direct causal link to adverse medical effects, other than a small number of reports of an association between khat use and significant liver toxicity."

The mechanism for liver toxicity is unknown but case series of unexplained hepatitis have been described and seem to be attributable to khat use. High levels of tobacco use are often associated with khat use and this complicates the picture. In addition, lower levels of literacy and problems with accessing medical care in some BME groups confound the evidence. The report struggled to find a causal link between khat and societal harms - but there is evidence that it is certainly associated with some adverse outcomes.

Commentary: This is an extensive, rational and scientific review of the harms of khat. It is worth familiarising oneself with the clinical picture as you won't be informed one iota by the Home Secretary's decision to ban khat and make it a class C drug. And as far as clinicians are concerned there are limited reasons for concern. There is some weak evidence that khat could be associated with myocardial infarction but it's difficult to pull it out from the higher tobacco use. By the same token, respiratory concerns are also difficult to attribute to khat alone and an added complication is that waterpipe smoking is common in cafes where khat is used. Practices who have high numbers of people from horn of Africa countries (Somalia, Yemen and Ethiopia) in particular are more likely to meet people using khat regularly. However, given the other health issues likely to be faced by this group, some of whom are fleeing civil war, it is unlikely that khat will feature prominently as a primary concern for clinicians.

A pilot outcomes evaluation for computer assisted therapy for substance misuse -- an evaluation of Breaking Free Online
Elison S, Humphreys L, Ward J, et al. J Subst Use 2013. Published online ahead of print.

Breaking Free Online is a computerised assisted therapy (CAT) program that is available online and in an abbreviated form as a mobile app. It uses various multi-media formats, including video and audio, to deliver psychosocial interventions. This study followed up 34 individuals who had engaged in treatment for their substance misuse issues and were also using Breaking Free Online. Participants were recruited via various online social media platforms. No exclusion criteria were applied and anyone using Breaking Free Online as part of their recovery program was included. Participants self-reported data as part of the baseline assessment and this included frequency of substance use. They also completed the Leeds Dependence Questionnaire (LDQ) and the Personal Wellbeing Index (PWI). After a 90-day period during which the participants had access to the online resources the tests were repeated.

The results showed that many users did show reductions in substance misuse and some did achieve abstinence during the period they were in treatment and had access to Breaking Free Online. Significant reductions were found in all the LDQ items and most of the PWI scores (except for satisfaction with relationships and religion).

Commentary: There's no question that, increasingly, the internet provides avenues for care that need to be explored. It was fully declared that this study was funded by Breaking Free Online Limited - a commercial provider of computer assisted therapy. It's challenging to draw firm conclusions about the efficacy of online help from this study - there was no comparison group and it's impossible to know which bit of the intervention, if at all, improved outcomes. The qualitative comments haven't been subjected to any thematic analysis but most were positive. One participant did make the comment that "the money spent on this program would be far better spent on group therapy and/or counselling" and it is important that online resources are placed appropriately in care. No data were presented in this report on the actual amount of time the online program was used or accessed. As a preliminary study this is fine but we need more robust evidence to integrate community assisted therapy into care. It seems likely they have a role but they should not be seen as a cheap and cheerful alternative by providers in a race to the bottom to impress tight-fisted commissioners.

You can read more about the options for the future from guest blogger, Russell Webster, in his post "Drug Treatment Goes Online" on the SMMGP Blog.