Clinical & Policy Updates:
SMMGP Policy Update March 2014
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Supplementary Advice from the Recovery Orientated Drug Treatment Expert (RODT) Group, PHE, December 2013
The report is supplementary to the 2012 report "Medications in recovery: re-orientating drug dependence treatment".
It describes the nature of the various essential review processes that should take place during drug treatment in order to provide patients and clinicians opportunities to revise the treatment plan. It includes advice on:
- The frequency at which an individual receiving treatment for addiction should be reviewed (to determine the benefit of treatment and thus which alternative treatments should be tried)
- The structure of the review meetings including how to assess the benefit a patient is receiving, tools for decision making etc.
- Drug treatment should be reviewed based on an assessment of improvement or the preservation of benefit across the core domains of successful recovery.
To enable this clinical advice to be implemented locally, the report suggests that commissioners will want to ensure that their services have the resources (e.g. sufficient staff with appropriate competencies); monitor a range of recovery outcomes to demonstrate and understand the benefits being derived; have access to a diverse range of interventions, intensities and settings (including residential) to optimise treatment. The advice is set in the context of the continuing ambition for treatment to be sensitive to the needs and circumstances of each patient. It acknowledges that for many, despite effective treatment, dependent drug use is a long term disorder and that both short- and long-term considerations are important to improve long term benefit.
The report also says that "It is important that strategic reviews do not become unduly narrow in focus, particularly for those patients who have prescribed substitute or other medication" and then goes on to qualify this statement further "successful progress in recovery for those on substitute medication, whilst needing properly to take account of the continued use of necessary medication, must be based on assessment of improvements across all the core domains of successful recovery".
"Turning Evidence into Practice" Briefing PHE, January 2014
This briefing is aimed at addressing the issue of those people in drug treatment who benefit from the various treatment factors that help to encourage positive change and promote recovery (such as using optimal doses of OST, providing flexible and responsive services, and offering psycho-social interventions).
It outlines a comprehensive recovery framework for optimising OST against the evidence base for competent and regular reviews of patients. The briefing references the 2012 Medications in Recovery Report's finding that arbitrarily curtailing or limiting the use of OST does not achieve sustainable recovery and is not in the interests of people in treatment or the wider community.
The briefing includes useful prompts for self audit of local systems at the end of each section.
From the above we can deduce that someone who has been in treatment for many years on an appropriate dose of OST, getting on with their lives as a responsible member of society, would be supported by their treatment review to continue doing well; often they are happily being treated in primary care. Regrettably these people are not always viewed as success stories as evidenced by the frequency with which we hear of them (many on very low doses of OST) having to deal with a certain amount of tension being created around the need for them to now become abstinent. It begs the question - could it be that their very success in OST treatment, makes them an "easy win" objective in the scramble for ticking the box that says "successful completions"?
Dr Stephen Parkin is a sociologist from the University of Huddersfield, with an interest in public health, community safety, harm reduction and drug related deaths. His report is based on research conducted over seven years in various areas of the country, focussing on street based injecting drug use, including interviews with 71 people who inject drugs in a "street based environment"; and with 169 individuals who work in settings affected by this behaviour. He finds that the "effects of place" emphasises and amplifies the opportunities for drug related harm to occur.
Dr Parkin believes that sociology as an academic discipline has much to contribute to the wider debate in drug policy and the politics of drug use in the UK. His approach directly advocates and supports a harm reduction approach to injecting drug use and drug related issues. He reminds us that harm reduction is a legitimate aim of public health policy that aims to reduce drug related harm. Dr Parkin presents his report in a short film where he talks about his research and findings.
Karen Duke, Rachel Herring, Anthony Thickett and Betsy Thom. Drug and Alcohol Research Centre, Middlesex University, The Burroughs, Hendon, London, UK, 2013
This paper is based on analyses and interviews with 20 key informants during 2012, examining the shift in the British drugs policy towards "recovery" and the role of substitution treatment, from the perspectives of major stakeholders. It explores the ways in which opioid substitution treatment (particularly methadone maintenance) was challenged and defended by key stakeholders over a period of time and how a "recovery" focus was negotiated as the organising concept for British drug treatment policy when a "policy window" was opportunistically seized.
Historical changes in stakeholder roles are analysed in a detailed and thorough reflection on drug policy since the publication of the Rolleston Committee Report in 1926 (after which the key stakeholders for the next 40 years were general practitioners) to the present time. Although the expansion in drug treatment during the "NTA years" led to a heterogeneous system, clinicians (increasingly psychiatrists) remained the influential stakeholders around policy and the practice of substitution treatment, and crime reduction became an important clinical goal for treatment.
As most of us working in the field are well aware, during the period between 2004 and 2008 debate regarding the place of harm reduction and methadone maintenance in treatment was never far from the surface as other stakeholders entered into the arena e.g. the Centre for Social Justice, and even the media. Various arguments were raised - and sometimes heated debates arose - that the policy of prescribing on a maintenance basis was not successful in helping individuals ultimately to become drug free.
The scene was set for "policy windows" to open up and for "policy entrepreneurs" to emerge.
The Kingdon model of agenda setting is employed to explain the processes involved in the shift towards a recovery-based policy in the UK and identifies three streams that impact on the development of policy and demanding of attention: the problem stream - issues which become recognised and defined as important; the policy stream - ideas or proposals for change; and the political stream which relates to the wider political environment including public opinion.
It identifies the conditions during a time when substitution treatment could be both challenged and defended by the major stakeholders (policy makers, advocacy organisations, professional and scientific societies, the treatment sector, researchers and scientists; and economic stakeholders including pharmacists). The agenda setting approach of the Kingdon model usefully provides a way of understanding how the drug treatment system in the UK has arrived at the current status quo.
This is a very interesting analysis that makes sense of the events of recent years in UK drug policy. An article in the BMJ this month highlights the report by the Select Health Committee in February 2014 which found that Public Health England has "not yet found its voice" and "speaks with a faltering voice", and this has been met with sage nods of agreement in discussions over cups of coffee all over, when we are out and about.
PHE Alcohol and Drugs (Health and Wellbeing Directorate) is widening its responsibilities to include other addiction areas such as tobacco, and seeks to broaden its aims to include a focus on prevention. Alongside this, we detect from our membership and contacts in the field a sense of renewed vigour around the benefits of harm reduction in drug treatment, strengthened by international lobbying for health as the cornerstone (see item below).
And, with health as the cornerstone of drug treatment, a firm foundation towards recovery from problem drug use is provided by robust and readily available harm reduction measures. The resilience of this principle - preserved in the Drug Strategy - is proof of its continued success in engaging and keeping people in treatment.
Dr Judith Yates, SMMGP forum moderator attended the CND conference in Vienna this month in her capacity as Chair of the Board of IDHDP (International Doctors for Healthier Drug Policies). A side event was held at this collaborative event to discuss why health must become the cornerstone of drug policy discussions in the lead up to the next session in 2016.
Michel D. Kazatchkine, UN Secretary General's Special Envoy on HIV/AIDS in Eastern Europe and Central Asia expands on Europe's stance on drug policy.