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 #03 (Dec 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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SMMGP Policy Update

Comprehensive Spending Review
There are big challenges ahead for drug and alcohol services as the Comprehensive Spending Review announced reductions of 3.9% per year for the rest of Parliament. This will affect anyone delivering treatment whether in the so-called "Third Sector" or the NHS. On the following links are two commentaries from Andrew Brown (Making Every Adult Matter) and Paul Hayes (Collective Voice).

Shooting Up: Infections among people who inject drugs in the UK (PDF. PHE, Nov 2015)
People who inject drugs are vulnerable to a wide range of viral and bacterial infections. These infections can result in high levels of illness and death. Public health surveillance of infectious diseases and the associated risk and protective behaviours among this group provides important information. This annual national report describes trends in the extent of infections and associated risks and behaviours among people who inject drugs in the UK to the end of 2014. Notably, the report finds that changing patterns of psychoactive drug injection are increasing risk (pdf).

Widening the availability of naloxone (PHE, Nov 2015)
A new factsheet has been released by the Department of Health, Medicines & Healthcare products Regulatory Agency, and Public Health England (PHE). Regulations introduced on 1 October 2015 widened the availability of naloxone, a medicine which reverses the effects of a heroin (or other opiate) overdose. This factsheet explains the regulations and how they can be implemented. The fact sheet is available on the gov.uk website and also on the SMMGP website.

Medications in Drug Treatment - tackling the risks to children, one year on (PDF. Adfam, Nov 2015)
Adfam has published a follow up report on the risks of opioid substitution (OST) medication to children, building on the initial report released last year and provides recommendations to practitioners and policymakers on how to reduce the risk and incidence of serious events involving children. The report finds that there is cause for concern.

Substance Misuse Services for MSM - involved in "chemsex" (PHE, Nov 2015)
PHE have published a briefing for commissioners and providers of substance misuse services about men who have sex with men (MSM) involved in chemsex. It contains background information, recent data and prompts for local areas and services including: understanding local need; supporting services to meet need; and recognising and responding appropriately to individual need.

Co-morbidity of Substance Use and Mental Disorders in Europe (EMCDDA, Nov 2015)
This publication looks at the co-occurrence of drug use problems and mental health disorders, taking in the theoretical background of psychiatric comorbidity, the tools for clinical diagnosis and the prevalence and clinical relevance of the problem in Europe.

Online Survey of Codeine Use - Your Help Needed!

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SMMGP Clinical Update

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

"Chemsex" and harm reduction need among gay men in South London
Bourne A, Reid D, Hickson F, Torres-Rueda S, Steinberg P, Weatherburn P. Int J Drug Policy 2015, Jul 26

Chemsex is a term used to describe the use of drugs during sex. Typically the drugs involved are GHB/GBL, mephedrone, and/or crystal methamphetamine. This paper reports on in-depth interviews conducted with 30 men who identified themselves as being gay. They lived in south London and had been using illicit substances either immediately before or during sex in the past 12 months.

The results noted that about half of the participants had already been using various different drugs over the years. However, there were others who had only just been introduced to the drugs, often by partners who expressed a desire to enhance the sexual session. There was not a good understanding of appropriate dosing and the majority described situations where they had overdosed, particularly when it came to using GHB/GBL.

In addition, the effects of the drugs, especially when the environment involved group sex, complicated negotiations around sex, and a few of the men reported concerns regarding consent. The results also noted that a significant proportion of the men had expressed concern that they were experiencing some kind of physical or mental health harms. However, very few had accessed professional support because of fear of judgement or concern that the practitioners would have little understanding or knowledge around chemsex.

What is chemsex and why does it matter?
McCall H, Adams N, Mason D, Willis J. BMJ 2015;351:h5790

This short editorial sets out the key concerns with chemsex and signposts the reader to further resources. People engaging in chemsex report that they have better sex with increased arousal and reduced inhibitions. Potential harms are set out: psychological and physical dependence with the use of some of these drugs; users presenting too late for post-exposure prophylaxis; and with data suggesting that unprotected sex is the norm there is an increased risk of transmission of HIV and HCV infection.

Commentary: It's a hot topic at the moment. "Chemsex", in one form or another, has always been going on but the rise of novel psychoactive substances have brought it into sharper focus and increased attention as it seems to be associated with high risk activities. These papers set out the areas of concern. Overall, there is clearly potential for a substantial amount of harm in a different range of circumstances surrounding chemsex. The authors suggest that generic drug services are unlikely to have the necessary resources to provide information to gay men who are engaging in chemsex. This seems highly likely but will take time to change. Meantime, it is certainly a topic that should be on the PDP list of any healthcare professional that will consult with men who are potentially at risk from the harms associated with chemsex. These two papers are a good start and there is also an extensive guidance document on club drugs and novel psychoactives (PDF), published by the Novel Psychoactive Treatment UK Network (Neptune) available.

High-dose benzodiazepine dependence: a qualitative study of patients' perception on cessation and withdrawal
Liebrenz M, Gehring MT, Buadze A, Caflisch C. BMC Psychiatry 2015;15:116

This paper was a qualitative study conducted with adult Swiss patients who had a long-term history of dependent use of benzodiazepines. Patients who were using more than 40 mg per day, or were using in some otherwise problematic way, were included. They conducted a series of 41 unstructured, narrative, in-depth interviews and then used a content analysis approach to evaluate the findings.

The participants reported the reasons and motivations for wanting to withdraw from benzodiazepines. They reported concerns about their health and they also noted the feelings of being addicted. In addition, external social factors were regarded as being important: for instance, pressures from partners or families or the risk of losing their children. The participants described their previous benzodiazepine withdrawal attempts. Many had tried withdrawing frequently and were not successful. They found withdrawal difficult, complicated and unpredictable. They preferred being at home but found that inpatient treatment was more effective. There was also a general theme that gradual tapering is better than sudden cessation but not much else helped. They also made it clear that they regarded abstinence as the goal but weren't sure if they could reach that.

Commentary: At the time of interview the majority of these patients were actually in inpatient treatment so they may not be fully representative of all the patients we would see in the UK with benzodiazepine problems. There is a great deal of anxiety about how to manage benzodiazepine dependence and this open access paper is a useful read with a wealth of quotes for anyone who wants to consider, in a little bit more depth, some of the challenges faced. The researchers noted that most people, on admission, were switched to a long-acting preparation that was then tapered. There was a poor understanding of this and the equivalent dosage calculations amongst the participants. The perception that a different brand name was being used, or the dose was insufficient was often a major factor in decisions for participants to carry on with treatment. It might be an area where we can be more careful to explain and discuss.

The impact of low-threshold methadone maintenance treatment on mortality in a Canadian setting
Nolan S, Hayashi K, Milloy MJ, Kerr T, Dong H, Lima VD, et al. Drug Alcohol Depend 2015, Sep 28

This short report looks at the delivery of low threshold methadone maintenance therapy (MMT) in Vancouver in Canada. They looked at the association of MMT with all-cause mortality between May 1996 and December 2011.

Out of 2335 people who inject drugs (PWID) they found there were 511 deaths with a mortality rate of 3.4 deaths per 100 person-years. In the multivariable regression analysis, after adjusting for confounders, they found that MMT enrolment was found to be associated with lower mortality and gave an adjusted hazard ratio of 0.73 (95% CI: 0.61 - 0.88).

Commentary: Overall, the mortality rates were very high for PWID and this is not unexpected. Neither is the finding that methadone maintenance is associated with lower mortality new. What did come out of this analysis, and is very much worth considering, is that participation in low threshold MMT was associated with significantly improved survival. In this case, the low threshold model is similar to standard UK treatment - MMT is provided free of charge, with no limitation on dosage, and no mandatory requirement for abstinence. This stands in contrast to other models in North America where stringent conditions create hurdles for participants.

Low threshold in the UK is more about reducing unnecessary discharges from services. People who may have missed appointments at treatment services are not discharged and are maintained on small doses with daily supervision. This all fits with evidence showing it is the transitioning in and out of methadone maintenance treatment where much of the harm is to be found. Low threshold treatment, the UK version, can bridge potential gaps in treatment, smoothing out the risks, keeping people alive. Retention is a proxy marker but remains a key metric when it comes to monitoring treatment outcomes.

It has to be acknowledged that there can be much discomfort about low threshold methadone in many services. There is fear that limited contact with patients is somehow putting the patient, the prescriber and the organisation at risk. This paper reminds us that patients are less likely to die with methadone and, of course, there is daily contact in the pharmacy as they receive their supervised methadone. Many people in treatment establish very positive relationships with the pharmacy staff - they are a key part of the structure of providing care alongside opiate substitution therapy.

Misuse of non-prescription codeine containing products: Recommendations for detection and reduction of risk in community pharmacies
Van Hout MC, Norman I. Int J Drug Policy 2015, Sep 30

Misuse of pharmaceutical opioids is a global public health issue but the misuse of over-the-counter (OTC) codeine-based products is particularly important in the UK. The first point worth making is that codeine does not actually compare that well to other analgesics such as NSAIDs or paracetamol when it comes to analgesia. It does seem a little bit more useful when combined with paracetamol but it unquestionably has abuse potential. The widespread retail availability of codeine has made quantifying the extent of the problem very challenging.

Pharmacists may spot misuse behaviour: when customers request repeatedly codeine-containing products by name; where they refuse to consider single ingredient products such as paracetamol or ibuprofen; where they request specific pack sizes; and if they get agitated when pharmacists intervene. Currently pharmacies can remove codeine products from display at the point-of-sale or can refuse or restrict the amount that they sell if they have concerns.

The authors make the point that given some of the difficulties of these measures we need alternative methods for detecting codeine misuse in community pharmacies. There are no known validated screening tools. All of the measures that could be considered are hampered by the lack of privacy in the pharmacy environment.

Commentary: This paper is mainly aimed at pharmacies and pharmacists. It has been show that when pharmacists intervene there is an association with increased help seeking behaviour. There is something here for everyone as the strategies that people who are misusing codeine adopt are an important part of the discussion when it comes to assessing their pattern of misuse. Codeine misuse remains a largely hidden problem with substance misuse services configured in ways that are not necessarily able to accommodate people with non-heroin drug dependence. There may be a role for pharmacies to offer harm reduction advice, screen for codeine misuse, and offer brief interventions.