SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Clinical & Policy Updates:
SMMGP News & Updates - Issue #1 (Oct 2015)

A combined update including SMMGP Clinical and Policy Updates as well as Post-Its from Practice and other sector news.

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Adobe Acrobat DocumentDownload the PDF version of this Update here! (PDF*, 308K)

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SMMGP Policy Update

SMMGP Naloxone Briefing (includes supply protocol example)
SMMGP has produced a briefing regarding the change to the legislation relating to the supply of naloxone, the drug for reversal of opioid overdose. We are grateful to Inclusion for providing their example of a Naloxone Supply Protocol, which can be adapted for local requirements.

Deaths related to drug poisoning in England and Wales (2014)
The figures from the latest official figures in the ONS report about drug related deaths - the worst since 2001 - have rightly attracted much attention since they were published. The report records a staggering 64% rise in deaths involving heroin/morphine. Read more...

There are three important surveys this month:

State of the Sector Survey 2015 (closing date 14th October 2015)
The annual snapshot survey of the State of the drug and alcohol sector (which was conducted by Drugscope in the past) is now being conducted by Adfam. Do the surveys here...

Residential Rehab - Survey 2015 (closing date 14th October 2015)
Public Health England is carrying out its second annual (online) survey of the residential rehabilitation sector. Read more...

PHE Needle Exchange Survey (closing date end October 2015)
Public Health England is running an online survey of providers and commissioners of needle and syringe programmes. Responses to these surveys will be used to show the value of investment in interventions that reduce drug-related health harms. Access the needle exchange surveys here...

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SMMGP Clinical Update

The SMMGP Clinical Update is compiled by Euan Lawson. This issue includes:

Contraceptive use and pregnancy outcomes among opioid drug-using women: a retrospective cohort study
Cornford CS, Close HJ, Bray R, Beere D, Mason JM. PLoS One 2015;10 (3):e0116231

This was a retrospective cohort study that looked at general practice records in the UK alongside Treatment Outcomes Profile (TOP) and National Drug Treatment Monitoring System (NDTMS) data. The cohort consisted of 376 women aged 20 to 61 years old and they were all in active treatment.

The main outcomes in this paper were age-adjusted prevalence estimates for contraceptive use in pregnancy outcomes in these women. All the women came from two specialist primary care practices in Middlesbrough.

They found that drug-using women used planned (non-condom) contraception less frequently (24% vs 50%, p <0.001) when compared with age-matched population data. They also found a higher incidence of chlamydia (1.1% vs 0.33%). They found lower use of oral contraceptives, IUCDs, and sterilisation but there was a higher rate of injectable contraceptives (6% vs 3%). Nearly two-thirds of the children aged less than 16 years born to this group of women did not live with their mother. They didn't find any individual risk factors that significantly explained this low level of contraceptive use or types of non-condom contraception used.

Commentary: I'm sure we've all had the experience of managing women in drug treatment services who have presented pregnant - sometimes early, sometimes late, often unexpected and not necessarily a happy event. It can be an uncomfortable moment for treatment services and it is frequently easy to spot, with the benefit of hindsight, that contraception hasn't been offered or for some reason hasn't been grasped by the women.

The implications for practice from this paper are fairly obvious. As the authors highlight there is an urgent need to improve services amongst drug users. This study found that there were not particularly strong associations for contraceptive use with factors such as current drug and alcohol use, perceived health status, sexual abuse or domestic violence. Rather than being a disappointment this, as quite rightly stated by the authors, can be turned on its head as it suggests that these factors should not be considered a barrier to uptake of services. Indeed, they also noted the high uptake of cervical smear testing in their data shows that it is possible to deliver good quality women's health services.

Drug quality assessment practices and communication of drug alerts among people who use drugs
Soukup-Baljak Y, Greer AM, Amlani A, Sampson O, Buxton JA. Int J Drug Policy 2015, Jul 2

This study was based in British Colombia in Canada. They followed an interpretive and descriptive methodology and used questionnaires and focus groups to interview 32 people who use drugs (PWUD). They wanted to investigate the effect of the drug alerts that are issued when there is believed to be a risk to users; such as when there's been an increase in overdose deaths or a particularly pure, or contaminated, batch of heroin is suspected to be on the streets.

Their findings suggested that there were two main groups of people that PWUD regarded as trusted when it came to information about drug quality. These were a) trusted dealers and b) peer-based social networks. Most PWUD noted that the information they receive through health service providers wasn't particularly timely and, importantly, it did not discuss drug quality with them. The participants went on to suggest ways in which drug alerts could be improved: the use of language in drug alerts should avoid ambiguity and imply harm; drug alerts should give practical advice on the drug effects to be on the watch for; and they should suggest appropriate responses to overdose, e.g. advice on the use of naloxone. It was also suggested that it was important the posters were dated and that they were removed at appropriate times lest the community became desensitised to them.

Commentary: The comment from the participants about dating posters will resonate with many readers. I can immediately picture the A4 printout posted in the waiting area of my community drug clinic; paper browning and edges curling, it has been there for months and it is now all but invisible.

We've reported before on studies of drug alerts that have suggested that, paradoxically, reports of heroin with increased purity can actually cause people to seek out that heroin. We all receive the emails that warn us about drug batches that are dangerous but it's difficult to know exactly what effect they have. Undoubtedly, they make the person that sent them feel better and that may be the extent of their effectiveness. This paper has some useful guidelines that can inform how you might want to go about making drug alerts useful in your treatment service.

The health consequences of injecting tablet preparations: foreign body pulmonary embolization and pulmonary hypertension among deceased injecting drug users
Darke S, Duflou J, Torok M. Addiction 2015, Jul;110(7):1144-51

This was an analysis of consecutive cases based in Sydney and they came up with a total of 373 individuals showing signs of foreign body pulmonary embolisation. They looked at the full autopsy reports, microscopy of tissue samples, and the toxicology reports. They were able to then describe the extent of the embolisation, clinical signs of pulmonary hypertension, and also whether there were signs of right-sided heart failure.

Cases had increased from just three in 1997 to 58 in 2013. Two-thirds of the cases died of accidental overdose. In just over 43% of all cases foreign particles were "moderate-abundant" in extent. These cases were more likely to have injection sites other than in the arm (OR 2.4). In just under 7% of cases emboli were also found in other organs. There were signs of a foreign body inflammatory response in 45%, vascular scarring in 8%, signs of pulmonary hypertension in just over 10%, and signs of right-sided heart pathology in 5.4%.

Commentary: The marked increase in foreign body pulmonary embolisation in Sydney is very eye-catching but is likely to be due to the heroin shortage in Australia in the early part of the century.

There are some useful clinical messages for anyone with an eye on the physical health consequences from injecting crushed tablets. Users (and healthcare professionals for that matter) may be unaware of the specific health risks of injecting crushed tablets. The high levels of pulmonary hypertension and right-sided heart pathology may be detectable clinically and important to follow up with anyone who injects crushed tablets - especially in those who inject in places other than the arm. As ever, abstinence is the counsel of perfection but ignores the reality of injecting drug use and there may be some scope of harm reduction measures in those who persistently inject tablets. The authors suggest the use of syringe filters - known to be effective in reducing the small particles that are getting blasted into a person's vasculature and lodging in their organs to such damaging effect.

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Post-Its from Practice - Ask the right question!

Dr Steve Brinksman writes the regular "Post-its from Practice" articles for Drink & Drugs News (DDN) Magazine. They appear with kind permission from DDN.

Marco rarely came to the surgery; he was a 44 year old restaurant owner with two young children but on a routine screen had been picked up as having high blood pressure. He had been given advice to lose a little weight and exercise more but this made no significant difference to his blood pressure. He was started on an anti-hypertensive and his blood pressure improved but 12 months later it was up again and as he was adamant he was taking his medication every day, a second drug was added in. Three months after this he had come back to see one of our registrars and she had noticed his blood pressure was again poorly controlled. She decided to discuss this with me as part of her learning portfolio.

His notes showed he had been overweight but his BMI (Body Mass Index) was now 26 so this was unlikely to be a significant factor, he had stopped smoking when his first child was born 7 years earlier, his renal function was normal and no significant past medical history was recorded. I asked her if he drank alcohol. "I'm not sure," she said and indeed nothing was recorded in his notes about alcohol consumption. I explained that excessive alcohol use was a major factor for hypertension and cardiovascular disease a fact unknown to many patients - and quite a few medics as well!

He was due for review the following week and told her he drank a bottle of red wine every day, as it was good for his heart! She explained to him about the effect alcohol has on high blood pressure and cardiovascular disease and he had been shocked by this. He decided to try and cut his alcohol down rather than take a third medication. His blood pressure improved over the next few weeks and it was possible to stop one of his tablets.

I was the next person to see him and this time his blood pressure was within the normal limits albeit that he was still taking a single drug to control his blood pressure. He told me he had reduced his alcohol to half a bottle one night during the week and half a bottle each day over the weekend. I wonder how many patients have physical and mental health problems related to their drug or alcohol use that pass unnoticed because a health professional doesn't ask.

SMMGP have launched an introductory online training module about the Community Management of Alcohol Use Disorders which can be completed free of charge on the SMMGP e-Learning website.

- Dr Steve Brinksman
Birmingham GP, SMMGP Clinical Director, RCGP Regional Lead in Substance Misuse for the West Midlands