Clinical & Policy Updates:
SMMGP Policy Update June 2014
|Download the PDF version of this Update here! (PDF*, 70K)|
Richard Phillips, April 2014
This useful review of the evidence base for mutual aid is concerned with those organisations that have a strong presence in the UK and are specifically mentioned by NICE when defining mutual aid - Alcoholics Anonymous (AA); Narcotics Anonymous (NA) and SMART Recovery. The author declares an interest in his capacity as Chief Executive of SMART Recovery.
The vast majority of peer reviewed studies into mutual aid are from the USA and focus on AA. Because it cannot readily be assumed that these research findings will generalise to the UK; to other substances of dependence; to other 12 step fellowships and to non-12 step groups; the paper considers whether the findings are likely to generalise whether mutual aid will improve recovery outcomes for people in the UK.
Discussion of the key conclusions take into account that most research studies into mutual aid are methodologically weak, which has led some commentators to conclude that there is little or no evidence for this form of support. The paper asserts that this is an outdated position and that there is strong evidence that participation in mutual aid groups improves recovery outcomes, with evidence that greater levels of participation are associated with better outcomes.
The author reaches the important conclusion that for most people who currently approach treatment services, mutual aid is not an effective replacement for treatment. Rather, the combination of treatment plus mutual aid is likely to be better than either alone. The author expresses concern that mutual aid may become seen as a way to replace necessary professional treatment with a "free" alternative and that this would be "misguided, dangerous and do a great disservice to the mutual aid organisations". Some significant deficits in the evidence base are identified and areas where more research is urgently needed are outlined at the end of the paper.
Public Health England (PHE) published two guides during May 2014 calling on the treatment sector to strengthen its links with mutual aid organisations, to ensure that everyone in treatment can benefit from this support. A new toolkit of resources has been developed for use by commissioners and the drug and alcohol treatment workforce, to improve access to mutual aid via treatment services.
- Improving access to mutual aid: a brief guide for commissioners (PDF)
- Improving access to mutual aid: a brief guide for alcohol and drug treatment service managers (PDF)
The concept of utilising mutual aid to support people with addiction problems is now an established part of the picture in the UK treatment landscape. Alongside the changes in the structured treatment field, the grassroots recovery movement in England has developed from a sometimes messy and contradictory state a few years ago to making a real contribution on many levels. Recovery advocates are particularly active on social media platforms - in Facebook groups, blogs posts, on Twitter - some days no matter where you click there's a recovery discussion going on, including on the SMMGP forums.Available on the NICE web site
With increasing numbers of people across the country injecting themselves with steroids, the National Institute for Health and Care Excellence (NICE) has updated its guideline on the provision of needle and syringe programmes for adults and young people with new recommendations about services for those who use image and performance enhancing drugs. Conservative estimates suggest almost 60,000 people aged between 16 and 59 in England and Wales have used anabolic steroids in the last year. But needle and syringe programmes have reported rapidly increasing numbers of steroid users attending their services.
Needle and syringe programmes were successfully introduced during the '80s and '90s in the face of the UK's AIDS epidemic. They now face the challenge of a change in the type of people who inject substances.
The summary of the updated NICE guidance is neatly presented on the Drug and Alcohol Findings website in PDF format.
PHE, April 2014
A briefing from PHE addresses the issue of drug related deaths being higher in England than in most other European countries. This is explained as being due in part to the ageing population of injecting drug users in England, and that people with long histories of drug dependency are more likely to be in poor health. Deaths are often due to the use of a combination of drugs as well as opioids, with alcohol and stimulants mentioned in death certificates. Deaths attributed to novel psychoactive substances have also increased in recent years.
Local early warning and alert systems can enhance provision and to this end examples of good practice in various areas around the country are also included.
A series of prompts are included under various headings, such as:
- Preventing overdose.
- Responding to overdose.
- Reducing risks of prescribed medications.
- Reducing risks from changed settings and stages of treatment.
- Reducing mortality risks from: delayed or chronic drug-related health problems and new psychoactive substance and volatile substances.
The briefing suggests that a robust local review process - usually achieved via local providers' governance systems - can help areas to learn more about the events leading up to drug-related deaths.
National Intelligence Network (NIN) Meetings on the Health Harms Associated with Drug Use
Notes for directors of public health, commissioners, service providers and needle and syringe programmes from the third NIN meeting can be found on the PHE web site (PDF).
PHE, June 14
A new resource designed to assist commissioners, providers and clinicians in maximising the value of addiction specialist doctors working in local recovery orientated treatment systems has been published by Public Health England. The resource builds on the standards described in Delivering quality care for drug and alcohol users: the roles and competencies of doctors (Royal College of Psychiatrists and Royal College of General Practitioners, 2012). Both documents are available on our website.
The resource identifies a number of essential functions which can usually only be carried out by addiction specialist doctors. With the increasing shift towards a mixed economy in the free market awash with retendering, it is vital that the expertise of doctors who are specialists in addiction is retained and developed to achieve the best possible health and recovery outcomes for all. Prompts from PHE in this document include:
- Commissioners and providers work collaboratively to ensure ongoing reviews of specialist training posts in alcohol and drug misuse services are available. This will involve engaging with the appropriate deanery (responsible for managing and delivering postgraduate medical education and supporting the continuing professional development of all doctors), which in most cases would be the role of the provider. The Royal Colleges of Psychiatrists and GPs may be able to help with this.
- Commissioners and providers may want to be aware of the increased risk to existing posts when contracts pass from one provider to another, and consider making provision to mitigate these risks in tendering processes.
The PHE Business Plan published during June 2014 mentions both alcohol and tobacco and also emphasises the PHE commitment to drug treatment and recovery. There's not much in it in the way of outlining drug related harm reduction policy though.
A neat summary of the alcohol ambition and framework for actions in the Business Plan can be found on the Alcohol Policy UK web site.
Despite the steady flow of information from PHE Alcohol, Drugs and Tobacco, how policy is interpreted in different local areas is apparent in the inconsistencies that we come across in the course of working with various commissioners and providers across the country. This is across the board from treatment provision, to staff training, to development of clinical governance.
As said from the floor at a recent 4th National Intelligence Network (NIN) meeting on the health harms associated with drug use convened by PHE - "prompts" are easily ignored, and as PHE is not in a position to issue instructions to local areas, shaping systems in terms of implementing practice is largely in the hands of providers, and this can be variable.
It would be good if the PHE Alcohol, Drugs and Tobacco division had a clearer website identity for communicating with the field. For example, we are still directed to the "NTA legacy" website to find out what's current in drugs and alcohol, yet the NTA itself is very much a thing of the past. It all contributes to the sense of dilution of important messages.
National organisations such as ours - and their members - continue to play important roles in in supporting a consistent message and maintaining high standards in the treatment of problematic alcohol and drug use. And currently, it is up to us and other stake holders in the field to continue to emphasise the need for the inclusion of high quality primary care services in all local areas. In support of the harm reduction agenda, we are this year incorporating a Harm Reduction Café prior to SMMGP conference, further details to follow.
Adfam, April 2014
Adfam published a report in April which examines the dangers to children when their parents or carers are prescribed Opioid Substitution Treatment (OST) medications.
The report highlights that:
- Medicines used to treat adults' drug addiction can be lethal to children in their care;
- Child ingestions happen "regularly" and national lessons are not being learned from Serious Case Reviews;
- The "rare but real" use of methadone as a pacifier for small children.
The report found that too many children are being put at risk to due insufficient safeguards to protect them from the drug treatment medications prescribed to parents and carers, and that professionals are not sufficiently prioritising the safety of the children when making decisions about medication. 20 serious case reviews over the past 10 years involving ingesting of drug treatment medications are examined in the report and 19 of the cases involved methadone and was the cause of 15 deaths, mostly of children aged three and under. Calls for action on this issue include:
- Better national data collection on the number of parents allowed to take home OST medicines and the number of children admitted to hospital after ingesting them;
- Improved national analysis of Serious Case Reviews involving drug ingestions by children;
- Drug treatment agencies to be included on local Safeguarding Children Boards;
- Re-emphasising the importance of safeguarding children when making decisions about OST;
- Improved training for drug services, pharmacies, GPs and social workers to highlight the dangers of OST medication where children are involved;
- Agreed safety plans, including lockable storage boxes for anyone with childcare responsibilities and OST medication at home.
SMMGP has been aware of the issue of minimising the dangers to children where OST is prescribed, and the need for training, but this report has starkly highlighted just how important it is. We are therefore including a workshop on safeguarding at our national conference in Birmingham in October. The workshop will be led by Michael O'Kane, PHE Programme Manager, Alcohol, Drugs & Tobacco - Families and Prevention. For more details about the conference, see the SMMGP Conference section.
The National Primary Care Network (NPCN) was established in 2013 and is an informal group of over 500 senior healthcare professionals from across primary care. Participants include some of the country's most senior figures in commissioning with representatives from all key fields: general practice, nursing, dentistry, optometry and pharmacy, creating a unique and proactive platform for colleagues to network and discuss the key issues currently facing the NHS. A report on The Future of Primary Care published by NPCN in April 2014 says that an overhaul of primary care is needed in order to truly make integrated care a reality. Dr James Kingsland, Chair of the NPCN calls for a unified or linked action plan across all primary care services at this critical time. Recognising the key role played by pharmacists formed an important part of the discussions which underpin the report. The full report makes interesting reading and is available on the NPCN web site.
Collaborative working with other clinical and professional groups including pharmacists is core to the success of any model in alcohol and drug treatment. We are therefore interested to hear Dr James Kingsland President, National Association of Primary Care as the key note speaker at our annual conference - "Treating Alcohol and Drug problems in Primary Care: You know it Makes Sense" which will be held in Birmingham on the 23rd October 2014 (see the SMMGP Conference section for details).
Khat became controlled drug on 24 June 2014. Public Health England has produced advice for local commissioners on the ban and on implications for strategic and service responses to local populations who have used the drug. The guide includes advice given by the Advisory Council on the Misuse of Drugs (ACMD), details of the new legislation and its possible impacts, considerations for commissioners and support offered by PHE.