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 #04 (Jan 2016)

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

PHE statistical reports: Adults (18 and over) in alcohol and drug treatment and a report for young people (under 18) receiving help for drug and alcohol use (Dec 2015)
PHE are reporting their statistics on drug and alcohol treatment figures together for the first time in two reports published late last year; one for adults and separately for young people (under 18) who are in treatment for drug and alcohol problems. The reports show that fewer under-18s are accessing specialist substance misuse services with figures having fallen by 33% since 2009/10; and that the main substances that young people are presenting for are cannabis (52%) and cocaine (23%). Almost half of the adults in treatment for opiate use now are 40 years old and over. The reports are available on the links below:
Adult statistics for drug and alcohol treatment (PDF)
Young people's statistics for drug and alcohol treatment (PDF)

Care Quality Commission commences inspection of substance misuse services (Jan 2016)
The Care Quality Commission have commenced their inspections of "standalone" substance misuse services this year. Whilst standalone substance misuse services are not currently given ratings, there are plans to rate them in the future. The feasibility of inspecting and separately rating substance misuse services offered by other providers (such as NHS Trusts, GP practices and independent providers that also offer other services, is still being investigated. However, inspection of substance misuse services delivered by any providers of substance misuse services will be carried out if risks are identified. A list of the standalone services that will be inspected from January to May 2016 can be found here.

The questions the CQC inspectors will be asking, include:

As part of the feedback process information is gathered from a variety of sources and the CQC are particularly interested in hearing about the experiences of people who are in the most vulnerable or marginalised circumstances and who are using substance misuse services. People using substance misuse services are encouraged to contact the CQC with their experience via the CQC website and a "Share your Experience" form and guidance is provided.

Changing patterns of substance misuse in adult prisons and service responses (HM Inspectorate of Prisons, Dec 15)
A report by HM Inspectorate of Prisons highlights that two-thirds of prisons reported having a significant issue with New Psychoactive Substances in 2014-15, such as synthetic cannibinoids and stimulants. This reflects the wider increase in the availability and use of these substances in the general population.

New Psychoactive Substances in Prisons: A Toolkit for Prison Staff (PDF. PHE, Jan 16)
Public Health England have produced a toolkit to help prison staff address the increasing use of NPS in secure environments from a clinical and psychosocial perspective.

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SMMGP Clinical Update

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

Association between alcohol and substance use disorders and all-cause and cause-specific mortality in schizophrenia, bipolar disorder, and unipolar depression: a nationwide, prospective, register-based study
Hjorthøj C, Østergaard MLD, Benros ME, Toftdahl NG, Erlangsen A, Andersen JT, Nordentoft M. The Lancet Psychiatry 2015, Sep;2(9):801-8

This Danish prospective cohort study took people who had been diagnosed with schizophrenia, bipolar disorder and unipolar depression. They matched these people to data found for treatment of substance use disorders, date of death, primary cause of death, and education level.

They found that 41,470 people with schizophrenia and lifetime substance use disorder had a standardised mortality ratio (SMR) of 8.46 compared to 3.63 for those without. The 11,739 people with bipolar and substance use disorder had an SMR of 7.46 versus 2.93. And the same calculation for people with depression gave SMRs of 6.08 for those with and 1.93 for those without depression. In schizophrenia all the types of substance use disorders were associated with increased all-cause mortality: alcohol, cannabis and "hard drugs". In people with bipolar disorder and depression only the alcohol and "hard drugs" were associated with increased mortality.

Commentary: A big study from the Lancet stable is usually worth a good hard look. What does this one tell us? It showed that 22% of patients with schizophrenia were considered to have a hard-drug use disorder and the mortality from comorbid substance misuse disorder is sky high. People with a dual diagnosis are vulnerable with multi-problems and the challenges can quickly stack up; they are rarely straightforward to help. The study also found that about one in six of the deaths were accidental - largely poisonings and overdoses - and it was considerably higher in the group with comorbid substance use disorder. The accompanying commentary by Lynskey, Kimber and Strang picks up on this thread and it highlights an important area where clinicians and workers can concentrate their efforts. This would be a good group to target for overdose prevention efforts - providing naloxone for instance. (And, in Denmark, they have supervised drug consumption facilities.)

Many of our patients have good access to mental health services, yet how many of us have had the experience of being told a patient isn't eligible for treatment due to their substance use? This study makes the need for quality services for those with dual diagnosis very clear. Whether you are looking to develop services in your area or you are an individual clinician looking at your personal development plan, this study emphasises you would be very justified in picking out mental health disorders as an area to prioritise in 2016.

No evidence for reduction of opioid-withdrawal symptoms by cannabis smoking during a methadone dose taper
Epstein DH, Preston KL. Am J Addict 2015, Jun;24(4):323-8

This study took data from a 10-week methadone taper phase of a randomised controlled trial. There were 116 participants who were using heroin and cocaine with 46 who were found to be cannabis users. The outcome measurements were weekly urine screens for cannabinoids and assessments of opiate withdrawal symptoms. There was no difference between opiate withdrawal scores in cannabis users versus cannabis non-users.

Commentary: You will have heard it in the clinic. The person who is substituting one substance for another; perhaps an increase in alcohol as the heroin comes down, perhaps a few benzos to take the edge of a rattle. I've certainly had a few who have described using cannabis to help manage their withdrawal from heroin or help with their desired OST reductions. This article is specifically about the usefulness of smoking cannabis to ease withdrawal symptoms.

The title of the paper is a spoiler but the wider interpretation of this paper is limited given the nature of the sub-group style analysis here. They were looking at people who were already smoking cannabis - it wasn't being investigated as an intervention as such. Technically, what this paper truly shows is that there is no association between being a cannabis user and reduced withdrawal symptoms. The difference is subtle but it is an important one.

If someone tells you that cannabis is easing their withdrawal symptoms it is not going to be good practice to rubbish the suggestion - it is their experience after all. The authors of this paper offer a thoughtful and reasoned conclusion, recognising the limits of this report and, overall, they are right that this tilts the scant evidence away from cannabinoids as a useful measure to treat opioid withdrawal.

Sex differences in outcomes of methadone maintenance treatment for opioid use disorder: a systematic review and meta-analysis
Bawor M, Dennis BB, Bhalerao A, Plater C, Worster A, Varenbut M, et al. CMAJ Open 2015;3(3):E344-51

This systematic review and meta analysis searched for all observational and randomised controlled studies that involved adults who received methadone treatment. They only included the studies if the reported outcomes included gender differences. After they had completed the systematic review a meta-analysis was possible. They were able to include 20 studies with 9,732 participants. In total 18 were observational studies and two were RCTs. The odds of (self reported) alcohol use while on methadone were lower among women than men at 0.52 (95% CI 0.31 to 0.86). The odds of amphetamine use were greater in women (OR 1.47, 95% CI 1.12 to 1.94) but there were no other significant differences in substance use patterns. Women were less likely to report arrests or other legal involvement and were less likely to be employed during treatment. Otherwise the opioid use patterns were similar between men and women. Overall, the authors noted that there was a risk of bias and the quality of the evidence was generally low.

Commentary: Perhaps one of the most important things for the development of methadone maintenance treatment is the need to more closely examine its effects across individual subgroups. When taken in the round methadone treatment has improved outcomes for people. However, there is undoubtedly, as with anything, harms as well as benefits and the exploration of subgroups will enable treatment to be more closely tailored to individuals and should help to improve long-term outcomes. It is revealing that even the most basic subgroup analysis - the differences between men and women - does not provide really high quality evidence. This study showed that actually most of the studies that were examined had a moderate to high risk of bias and this does have an impact on how confidently we can interpret findings from this result. The meta-analysis showed that women were more likely to use amphetamines and men were more likely to report involvement in crime. However, this may also just be a representation of different associations in the general population.

Evaluating drug trafficking on the Tor Network: Silk Road 2, the sequel
Dolliver DS. Int J Drug Policy 2015, Nov;26(11):1113-23

The original Silk Road website was an online illicit drug retail market that was shut down by the FBI in October 2013. One of the underpinning pieces of technology that facilitated Silk Road was the Tor Network. This provides internet access that is secure and highly anonymous for millions of people around the world. Inevitably, when the first Silk Road website disappeared it was only a short period of time before Silk Road 2 was launched and filled the gap. This research study compared this website to the original and looked to see if there were any indications of the presence of more sophisticated drug-trafficking operations.

Data were collected during August and September 2014 using web crawling software. The results found that Silk Road 2 was a much smaller marketplace than the original website. Out of 1834 unique items for sale, 348 were drug items sold by 145 individual vendors. They shipped from a total of 19 countries and most of the drugs advertised were either stimulants or hallucinogens. The United States is the number one country for sales and for the ultimate destination.

Commentary: The advent of internet-based sales is potentially where the entire future of drug use lies. At the moment, there is no meaningful impact on day-to-day drug use and people still buy from street level vendors in physical and personal interactions. Clearly, this results in lots of ongoing problems for anybody who uses and anyone involved in consultations will be involved in those discussions where people mention the difficulties of continually being in contact with people who want to push and make a sale. It is a recurrent concern with daily pharmacy collection of medications. I'm not sure that necessarily having easy access on the internet will reduce the risk of usage but it will certainly change the dynamic. It may take a generation or more but given the speed of change with technology it may be sooner and it is one to watch for the future.

Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain

"...Opioids Aware [is], a new resource for all prescribers, patients and their carers to support safe and rational use of opioid medicines. The resource has been developed by healthcare professionals and policy groups. Contributions from several medical royal colleges, the Royal Pharmaceutical Society, the British Pain Society, NICE (and others) have helped to ensure that Opioids Aware is relevant for everyone involved in the decision to prescribe and take opioid medicines".

Commentary: This is a Public Health England project and includes plenty of good guidance for prescribers on the appropriate use of opioids. It doesn't delve too far into the complexities of managing people on opioid substitution therapy and such topics as hyperalgesia etc. However, it is unquestionably a good resource for getting this challenging area right. Another one for the personal development plan for 2016.