Clinical & Policy Updates:
SMMGP Policy Update May-June 2013
|Download the PDF version of this Update here! (PDF*, 109K)|
New commissioning guidance for the NHS and local authorities on how to respond to the needs of people who are addicted to medicines was published by Public Health England (PHE) during June 2013. The guidance sets out PHE's expectation that support should be available in every area for people with a dependency on prescription or over-the-counter medicines, based on a full assessment of local need. Depending on local need, the response may be developed with local GPs, delivered via existing services that deal with a range of drug and alcohol issues, or may be provided or complemented by separate, dedicated addiction to medicines services and support groups. The guidance has been produced with input from experts on addiction to medicines and includes a list of medicines liable to misuse or dependence.
Prof James Bell, National Addiction Centre, King's College London.
The above report, endorsed by the Royal College of Psychiatrists, identifies the stigma surrounding addiction as one of the main barriers to safe and effective pain relief for people in this group. It highlights the dangers facing A&E patients with a past history of addiction, now in recovery, for whom exposure to strong analgesics and failure to provide adequate pain relief can result in relapse with potentially tragic consequences. It warns that disapproval of addiction amongst health-care professionals, and shame and guilt felt by addicted individuals may prevent hospital staff from identifying a patient's history related to addiction and place these patients at serious risk in an emergency situation.
Recommendations from the report include: improved communication and collaboration between health professionals; and in complex patients whose treatment is outside the usual experience of hospital staff, the need for access to addiction specialists; and ensuring that GPs, as the people with prime responsibility for co-ordination of care, have basic competence in addiction medicine and pain management.
Public Health England (PHE). See Guidance Documents.
PHE have published a guide for professionals working in custody settings, to support best practice in diagnosing, assessing and managing the symptoms of persistent pain among prisoners. The guide has been written in association with to the Faculty of Pain Medicine of the Royal College of Anaesthetists, the Royal College of General Practitioners and the British Pain Society, and is supported by the Department of Health.
Figures from the report say that among the prison population 16% have musculoskeletal disorders, 5% have cardiovascular disease and 5% have neurological conditions. Detoxification from opioids and other drugs may cause previously masked pain symptoms to emerge. Prisoners in the high security prison estate, or serving long sentences elsewhere, may develop long-term ill health that can contribute to their reports of persistent pain. This new guide is an overview of best practice in managing persistent pain and describes how this practice might be implemented in secure environments, including prisons, police custody and immigration removal centres. It offers advice on confirming a diagnosis of persistent pain in a secure setting.
This online learning module, designed to address the needs of patients who experience problems with prescribed medication was developed with the Royal College of General Practitioners (RCGP) to provide healthcare professionals with a better understanding of how to recognise patients who may have an addiction to prescription or over-the-counter (OTC) medicines. The learning module helps health professionals appreciate the issue of addiction and how to approach and help these patients with suggested treatment interventions. The e-module is currently available on the CPPE website (payment of a small registration fee is required to access it) and it will in due course also be available on the RCGP SMAH website. The course is listed on the SMMGP website on the "Useful links" page under "Training and Education" or on the CPPE website.
Whilst the PHE catch-all phrase "Addiction to Medicine" is slightly grating, it does broadly describe what many see as a hidden problem - addiction to drugs that are not illicit, and are readily available, not only on the high street, but also via the internet.
General practice and primary care is central to providing leadership in the area of treatment of addiction to medicines. SMMGP has been aware that this area is of interest to our membership and we have been at the forefront of offering training for addiction to over-the-counter, prescription only medication and benzodiazepines for some time. We welcome the addition of the CPPE e-module to further provide training for primary care professionals, particularly GPs, to be equipped with a firm knowledge in this area and to work closely with community pharmacists in identifying patients who are or have the potential to become addicted to prescribed medications.
The PHE guidance on how to provide services for people addicted to over the counter or prescription medicines is much needed and timely, and the pain report from the National Addiction Centre, with its inclusion of case studies and the question of pain management in current or previously addicted patients, highlights it relevancy even more.
Whenever we hold a training day on "Addiction to Medicines", it is clear that the problem of pain relief in secure settings is a huge problem area, with feedback requesting that more time is given to address this specific area. Due to the overwhelming success of our recent Addiction to Medicines training day we are planning a repeat of it later this year, and we will pay heed to the calls to devote more time specifically to misuse of pain medication. Watch this space.
In the meantime, again in response to demand, Martyn Hull will be presenting a workshop on benzodiazepines at our 8th Primary Care Development Conference in Manchester on 24 October - book your place now.
PHE has convened a national expert group to focus on preventing drug-related deaths and the transmission of blood-borne viruses and other infections. At this time, with changing patterns of drug use and new populations using new drugs in different ways, coupled with the continued existence of more established types of drug use and the associated harms it is important not to lose sight of the importance of reducing harm. The intelligence network will cover novel substances, patterns of injecting, outbreaks of infection, drug related death "hot spots" and examples of effective practice. The expert group met during June for the first time, and SMMGP will represent the voice of primary care.
See Other Resources.
This brand new report from NAT provides a detailed account of the emerging trends in injecting behaviour and associated new health risks. It gives recommendations on how to respond to these injecting behaviours, in particular the use of newer drugs by gay and bisexual men in the context of high risk sexual behaviour, and the injecting of image and performance enhancing drugs.
Of key importance is the improvement of the range and quality of services for people who inject drugs in relation to HIV risk, especially the continuing provision of harm reduction programmes such as Opioid Substitution Therapy (OST) and Needle and Syringe Programmes (NSPs). The report calls on Public Health England to restate clearly its support for evidence-based provision of OST and to ensure policy and financial levers/incentives do not inappropriately prioritise treatment exit over other treatment outcomes.
The Government has accepted the advice of the ACMD to allow for the lawful provision of foil by drug treatment providers as a harm reduction measure. The available evidence shows that the provision of foil can encourage people to take their first steps into treatment, reducing the immediate harm and facilitating the onward journey towards recovery and abstinence. It is recognised that providing drug paraphernalia such as foil at treatment centres "does increase the number of individuals who engage with the services".
The 23rd International Harm Reduction Conference on the theme of "The Value(s) of Harm Reduction" was held in Vilnius, Lithuania in early June and was an unqualified success. For a summary of the highlights, and a selection of film clips of speakers, see the IDHDP June newsletter.
SMMGP contributed to the round table held by the National AIDS Trust which formed the basis of their excellent report, and as mentioned above, we are on the PHE group convened as a national intelligence network for harm reduction.
In a recent interview for The Fix, Ethan Nadelmann, Director of the Drug Policy Alliance (US), when asked about the relationship of his goals as a harm reduction advocate and those of abstinence based treatment, notes that harm reduction - with its recognition of peer groups and the dignity it provides to people who use drugs - is a natural place of support for many, and a health-giving alternative to the achievement of abstinence. We could not agree more, and will continue to join with other colleagues in the field to be vigilant about maintaining the necessary balance and keep harm reduction where it fits: in treatment and with recovery.
The Home Secretary has decided to ban khat as a Class C drug, anyone caught trafficking or supplying khat will face up to 14 years in prison and an unlimited fine. This, despite a report earlier this year from the Advisory Council on the Misuse of Drugs (ACMD) which advised against banning the plant, instead the ACMD made a number of recommendations including a need to educate primary health care professionals and others directly involved with members of communities in which khat use is prevalent; specifically, education about the health and social problems and requirements of these populations. Drugscope summarised the widespread disappointment expressed from the field with the decision, read their full response here.