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 #05 (Feb 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

Association of Directors of Public Health survey results: Impact of funding reductions on Public Health (Feb 2016)
Following the 2015 Comprehensive Spending Review announcement, the Association of Directors of Public Health surveyed members to discover the potential impact of further reductions in the Public Health (PH) ring-fenced grant for English Local Authorities. The survey was sent to all 132 DsPH in England and 87 validated responses were received (66%).

The main messages are:

It is regrettable (and very worrying) that drug and alcohol services are shown in the report as being affected, particular going forward into the 2016/17 financial period.

The full report is available here (PDF).

Emerging consensus on measuring addiction recovery: Findings from a multi-stakeholder consultation exercise (Joanne Neale, Daria Panebianco, Emily Finch, John Marsden, Luke Mitcheson, Diana Rose, John Strang & Til Wykes. 2016)
There has been increasing acceptance in recent years that recovery from addiction encompasses a return to health and wellbeing with gains achieved in a range of life areas that include housing, health, employment, relationships, self-care, use of time, involvement in community, and general welfare.

Through extensive consultation, the authors of this paper have identified 27 recovery indicators that a diverse group of stakeholders within the addiction field consistently rank as important.

Their findings indicate that the concept of recovery from addiction has the potential to be measured in a meaningful way.

Health Matters: Harmful Drinking and Alcohol Dependence PHE (Jan 2016)
Public Health England have published the above guidance as a resource for local authorities, NHS services, the voluntary sector and policy makers. The resource includes a section on assessing need, planning and commissioning alcohol treatment systems; and information on what makes a good treatment service.

SMMGP has a free-to-access e-learning module on the Community Management of Alcohol Use Disorders. The one hour free course is also an introduction to our advanced RCGP accredited course on the management of alcohol use disorders (fee payable).

The FREE course is available at

More information about enrolling for the SMMGP Advanced Certificate in the Management of Alcohol Use Disorders which includes sections on alcohol commissioning and service design is available from: Sarah Pengelly on

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SMMGP Clinical Update

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

Bone mineral density and its determinants in men with opioid dependence
Gotthardt F, Huber C, Thierfelder C, Grize L, Kraenzlin M, Scheidegger C, Meier C. J Bone Miner Metab 2016, Jan 8

This was a cross-sectional study of men in Switzerland who had been on methadone and had opioid dependency for more than 10 years. The median duration of opioid consumption was 21 years. All of them were on some kind of opioid substitution therapy (OST) with 69% on methadone, 25% morphine, and 6% on buprenorphine.

There were 144 who agreed to participate in the study. (They also recruited 35 healthy age- and BMI-matched men as controls.) They found that 74.3% of men had low bone mass density (BMD). In the older men, aged over 40, 29.2% were classified as osteoporotic. Just under half were classified as osteopenic. In younger men there were 65.8% who had low bone mass. In all the age groups the BMD was significantly lower than in the matched controls. In the multivariate analysis they found that testosterone levels were significantly associated with a low bone mass density at the lumbar spine but not at the hip.

Commentary: This is an interesting but challenging topic that is slowly building evidence. It is absolutely known that low bone mass is associated with people who have been illicit drug users on long-term methadone maintenance. However, it has been less clear about whether this is due to other co-morbidities such as smoking, alcohol intake, liver disease or other general problems with nutrition. There are a lot of factors here to unpick.

The evidence suggests that any forcible time limiting of methadone causes problems but bone mineral density is one area that could well prove to be an important factor for people, particularly an ageing population of people still in treatment, that are making a decision about whether they should continue with methadone treatment or pursue a detox plan when they are otherwise happy and stable. This paper suggests that testosterone has an independent role on bone mass. There has also been a large cross sectional study showing methadone can suppress testosterone in a dose-dependent way.

When we get down to the nitty-gritty we need to think beyond BMD and the key questions to ask is this: is there an increase in osteoporotic fractures in this group? No, it's not shown in this study, but the numbers may simply not be big enough and one can't help thinking it is a problem we are building up for the future as the opioid-dependent population age. The high prevalence of osteoporosis in men aged over 40 (nearly 30%) makes a compelling case for DEXA scans in those with more than 10 years of opioid dependency.

Interestingly, as an aside, while just one man (1%) of the control group had suffered a trauma-related fracture, a whopping 52 men (36%) with long-term opioid dependency had a trauma-related fracture. It is a telling number and while unlikely to be related to BMD speaks volumes about the hazards of living with opioid dependency and the likely prevalence of disability and chronic pain.

Comparison of brief interventions in primary care on smoking and excessive alcohol consumption: a population survey in England
Brown J, West R, Angus C, Beard E, Brennan A, Drummond C, et al. Br J Gen Pract 2016, Jan;66(642):e1-9

This study was based in England and they collected data from a representative sample of 15,252 adults via household surveys. Rather than use GP records they went to the patients and they then asked them to recall brief interventions on smoking and alcohol use and they assessed current smoking and alcohol consumption patterns.

They found that out of the 1,775 smokers there were 50.4% who could recall receiving a brief intervention on smoking. The smokers who were more likely to have received this were: older, female, disabled and who had previously tried to quit. Out of 1,110 people who were found to be drinking excessively (AUDIT score of ≥8) 6.5% had received advice from their surgery. Those who did get advice were more likely to be have higher AUDIT scores and less likely to be female.

Managing older people's alcohol misuse in primary care
Rao R, Crome IB, Crome P. Br J Gen Pract 2016, Jan;66(642):6-7

This editorial explores the concerns with alcohol misuse in an older population. Hospital admissions that are attributable to alcohol in people aged over 65 have nearly doubled in the past six years. The authors suggest that one may wish to consider the use of age-appropriate screening tools - such as the Short Michigan Alcoholism Screening Test - Geriatric version (SMAST-G).

Commentary: The major challenge with the Brown et al study is going to be the potential for recall bias but it is a different, and important, patient-based angle given the potential for recording bias in GP notes. With that firmly in mind we can then look at the results. The major discrepancy between what smokers report getting in the way of brief interventions and what drinkers get is marked. We've certainly discussed this in the past and it is another example of the cultural challenge that exists in tackling alcohol consumption. The fact is we almost certainly need to incentivise brief interventions for alcohol problems in primary care - I suspect the only way to get GPs to change their behaviour in the circumstances is to pay them. That's a policy issue but at the individual level we need to keep this disparity in mind and keep pushing with alcohol screening and brief interventions.

If you are serious about finding more alcohol problems in the older population then take a look at the SMAST-G - it is easy to find online with a quick Google. It has 10 straightforward questions that appear to be more age-appropriate. Print it off and keep it handy in your desk. If you remain reluctant to use a questionnaire you may wish to bear in mind several studies that have shown doctors are not very good at picking up alcohol misuse without them.

Vaping cannabis (marijuana) has the potential to reduce tobacco smoking in cannabis users
Hindocha C, Freeman TP, Winstock AR, Lynskey MT. Addiction 2016, Feb;111(2):375

This short letter in Addiction touches on the use of vaporisers in the context of cannabis smoking. They felt that the use of vaporisers to deliver cannabis was a topic that had been overlooked. They argue that "one of the greatest harms associated with cannabis is its strong relationship with tobacco, and vaping cannabis has the potential to reduce both cannabis-related pulmonary harms and tobacco addiction." They quote from the annual Global Drug Survey that suggests just 8% of the 30,000+ cannabis users were commonly using vaping but they rated it is an important harm reduction strategy that had a "positive/neutral effect upon pleasure".

Commentary: There are certainly strong associations between cannabis and tobacco smoking. It has even been labelled a "reverse gateway" due to the fact that adolescents who use cannabis are more likely to smoke later in life. There is hope that the use of vaping could help to dissociate cannabis and tobacco. So, what lessons for the clinician? For me it is about having the conversation and promoting this harm reduction approach. We see enough COPD clogging up the clinics and anything we can do to break down the association between cannabis and tobacco is likely to be helpful.

Usefulness of the Brief Pain Inventory in patients with opioid addiction receiving methadone maintenance treatment
Dennis BB, Roshanov PS, Bawor M, Paul J, Varenbut M, Daiter J, et al. Pain Physician 2016, Jan;19(1):E181-95

This analysis was done as part of the Genetics of Opioid Addiction (GENOA) prospective cohort study. They wanted to assess the usefulness of different pain measures to see if they predicted opioid relapse. The two main `pain measures' were the Brief Pain Inventory (BPI) and a single question "are you currently experiencing or have been diagnosed with chronic pain?" They were able to assess relapse through positive opioid urine screens.

They had 444 people who were included and the BPI was highly sensitive - identifying 281 of the 297 classified as having pain (94.6%). The single question was less sensitive and identified 154 of 297 (51.8%). However, the single question had a high positive predictive value (PPV) at 89.6% (95% CI: 83.7, 93.9). People who were positive on both these measures had an estimated 7.8% increase in positive opioid screens and a four times greater risk of high-risk opioid use.

Commentary: This paper suggests that the Brief Pain Inventory is a highly sensitive questionnaire but it isn't terribly good at predicting the impact of pain on illicit opioid use - at least for patients on methadone maintenance treatment. In fact, it is arguably far too sensitive as it defined 63% of this population as having chronic pain and its predictive value is watered down. It is also relatively time consuming in the consultation and it has never been satisfactorily validated for this population having been originally developed in cancer and rheumatoid arthritis patients. The single question hasn't been formally validated either but is far more appealing to the time-pressed primary care clinician. Simply ask: "are you currently experiencing or have been diagnosed with chronic pain?".

Of course, it is not just about identifying those at more risk of relapse - it is good practice and basic decent care to work to identify people with chronic pain. I'm not under any illusions about the success rate for the management of chronic pain in the general population, never mind a population with problems of opioid dependency, but the need is great and this question is a pragmatic option that could be added to your clinical assessment templates.