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 #07 (Apr 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

Trends in Drug Misuse Deaths in England: 1999 to 2014 (Public Health England, April 2016 [PDF])

The Office for National Statistics (ONS) reported an alarming 17% increase in drug misuse deaths registered in England in 2014, following an increase of 21% in 2013.

This new report by Public Health England presents an analysis of year-by-year data on drug misuse deaths in England from 1999 to 2014 and incorporates the latest ONS data. This document is an update to a previous report published in the wake of a national summit on drug-related deaths held in January 2015.

The analysis confirms the depressing upward trend in drug related deaths - higher than at any time since records began - and highlights a number of factors such as the complex needs of older opioid users, a jump of a decade in the average age of death and the trend towards increased polydrug use and use of drugs and alcohol. The report suggests that being in treatment is a protective factor.

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SMMGP Clinical Update

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

Advancing patient-centered care for structurally vulnerable drug-using populations: a qualitative study of the perspectives of people who use drugs regarding the potential integration of harm reduction interventions into hospitals
McNeil R, Kerr T, Pauly B, Wood E, Small W. Addiction 2016, Apr;111(4):685-94

This study explored the views of people using drugs who were admitted to hospital and discharged against medical advice within the past two years. All study participants had been hospitalised multiple times over the previous five years.

They completed semi-structured qualitative interviews with 30 people. The participants highlighted that they would find harm reduction interventions particularly helpful and the enforcement of abstinence-based drug policies worked against patient centred care. They would also like increasing responsiveness to their health needs, such as pain withdrawal symptoms, and they were keen that efforts were made to foster "culturally safe" care. (This was particularly related to the experience of aboriginal participants in Vancouver who experienced both anti-drug stigma and racism which led to poor treatment.)

Commentary: This extravagantly titled study is based upon hospital services in Canada. So what possible links could this have to primary care in the UK? Plenty. This is a rather glorious paper, full of insight into how treatment systems can stigmatise and systematise poor care. In addition, this is an important sub-group of people to study further. We all know people that have bounced in and out of hospital in the recent past and who we are struggling to engage in services. There has been very little evidence that has drawn together risks for this group - though at least one linkage study in Scotland has shown large increases in mortality up to a year after any hospital admission.

There are huge opportunities for us to improve care for vulnerable people with serious and significant physical co-morbidities. One way that might address this is by ensuring that community drug workers, and clinicians, have a regular slot in their schedules to visit patients who are currently admitted. Or people who have had hospital admissions should be red-flagged and out-reached by services where ever possible. At the very least, when having a consultation with someone recently admitted we need to keep in mind the increased mortality and difficulties in engaging this group. Healthcare systems and protocols that embrace abstinence-based policies, in this case hospitals but it could apply to any primary care service, need to recognise that for many patients this is unrealistic and works against retention. It also means that subjective health needs, such as pain or the discomfort of withdrawal, are marginalised and the notion of patient-centred care is subverted by the system's determination to enforce the policy. One participant "Joseph" summed this up:

"You could just show a little more compassion and gentleness. Understand that good people are also addicts. Not everybody is a criminal. Maybe not to deny them proper medications whether it's an opiate or not just because of their addiction. Give them a chance to heal and get better."

ACMD review of alkyl nitrites "poppers"
Advisory Council on the Misuse of Drugs (2016). London: Home Office

Available at

Alkyl nitrites dilate blood vessels and increase blood flow leading to relaxation of smooth muscle that can facilitate anal and vaginal sex. Users also claim they can help prolong erections as well as increasing libido. There can be some reductions in blood pressure as well as warm sensations and facial flushing due to the vasodilation - all this can add to users' perceptions of some kind of rush. However, poppers do not cross the blood-brain barrier and, with this in mind, the ACMD have concluded that poppers do not fall within the current definition of a "psychoactive substance" as there is no direct action on the brain.

Commentary: The new Psychoactive Substances Act 2016 has been widely criticised and the ACMD weren't consulted about it. Belatedly, the government has asked the ACMD about poppers - and following their advice they have been exempted so at least in the case of poppers a further group of people will not be criminalised. There have been some harms associated with poppers and some deaths due to methaemoglobinaemia. In total, between 1993 and 2013, the Office for National Statistics recorded 11 drug related deaths where only an alkyl nitrite was mentioned on the death certificate. They can potentially cause a chemical burn on the skin and people who use them heavily may develop skin lesions with a "distinctive yellow tint around exposure areas, including the nose, mouth, lips, and face". There have also been some case reports suggesting that there is a risk of maculopathy or retinopathy. Some people could run into difficulty due to the lowered blood pressure and increased heart rate with a higher risk of problems if taken in combination with sildenafil, another vasodilator.

Effects of cannabis use on human behavior, including cognition, motivation, and psychosis: a review
Volkow ND, Swanson JM, Evins AE, DeLisi LE, Meier MH, Gonzalez R, et al. JAMA Psychiatry 2016, Mar 1;73(3):292-7

This review paper in JAMA psychiatry sets out to answer three main questions:

Does cannabis use affect cognitive capacity? It is known that cannabis use can cause acute impairment of learning and memory, attention, and working memory. The longer term effects are less clear-cut. The authors cite two different meta analyses which show that cannabis users performed worse on measures of global neuropsychological function including cognitive capacity. However, the second of these analyses also showed that when the analysis was confined to studies where cannabis users had stopped using and been abstinent for one month there was no discernible difference. There is certainly emerging evidence that cannabis use is more likely to affect adolescents and, in particular, male adolescents may be more severely affected.

Does cannabis use decrease motivation? This is the stereotypical "stoner" scenario where the user who sits around smoking dope with all self-volition gone. There is some evidence that goes all the way back into the 19th century that heavy use of cannabis can be associated with reduced motivation. This has, inevitably, been given a label, cannabis amotivational syndrome, and is characterised by apathy and diminished ability to concentrate. There is evidence that long-term heavy use of cannabis is associated with educational underachievement and impaired motivation.

Does cannabis use increase the risk for psychosis? This is perhaps the most well-known controversy around the use of cannabis. There is no doubt about the association between adolescent cannabis use and psychosis. There could be a directly causal effect, or it could be some kind of shared aetiology, or there could be other reasons such as self-medication for morbid symptoms. It is known that tetrahydrocannabinol can cause acute psychosis and prospective, longitudinal epidemiological studies consistently report an association that precedes psychosis.

Commentary: The remarkable backdrop to this paper is that cannabis has now been legalised for recreational use by adults in four American states with 23 others now regulating cannabis use for medical purposes. I'm not sure if we're at a tipping point but it could be that cannabis is going to become widely and legally available within a generation or sooner. This article is certainly well worth reading and sets out some reasonable concerns around a widespread increase in cannabis use. Harms may be small in comparison to the heavyweights of alcohol and tobacco smoking but they are real. There are some persistent concerns around vulnerable populations including children, adolescents, the elderly, and people with existing mental and physical disorders. There are going to be far more questions than answers and it may be problematic for healthcare professionals to give definitive answers about risks.

Methadone, buprenorphine and preferences for opioid agonist treatment: A qualitative analysis
Yarborough BJ, Stumbo SP, McCarty D, Mertens J, Weisner C, Green CA. Drug Alcohol Depend 2016, Mar 1;160:112-8

This was a qualitative study based in the USA. They recruited and interviewed 283 adults with opioid dependence from two different health systems. The results revealed that there were seven areas of consideration for opioid substitution treatment (OST) decision-making: 1) awareness of treatment options; 2) expectations and goals about duration of treatment and abstinence; 3) prior experience with buprenorphine or methadone; 4) need for accountability and structured support; 5) preference to avoid methadone clinics or associated stigma, 6) fear of continued addiction and perceived difficulty withdrawal and; 7) pain control.

Commentary: The findings from this make for familiar reading for anybody who has had the consultation where methadone and buprenorphine are being weighed up. Some of this study is highly specific to the USA where buprenorphine has been slow to get established - and the two health systems were for people with private insurance. This may have been a factor in that 61% reported that prescription drugs were the primary source of problem opioid use in the past year with only 20% reporting the problem as being heroin. Of course, the USA has a far greater prescription opioid problem than we have in the UK but the lessons are the same. More than anything, stigma looms large in these discussions, particularly methadone stigma. Whether it is the "getting in your bones", or "rotting your teeth" methadone is often the bad guy. Many also related better experiences with methadone but it is clear that careful patient-centred consultations (though I'd suggest "myths" should be challenged) are needed to unpick genuine bad experiences and concerns.

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SMMGP to develop new training module -
"Drug Misuse and Dependence: UK Guidelines on Clinical Management (2016)"

SMMGP is delighted to have secured funding from Public Health England (announced earlier this year) to further our aims of supporting best practice in drug and alcohol treatment and making a contribution towards people overcoming their dependence on drugs and/or alcohol. The funding is earmarked for investment in updating and improving our website, including developing our popular e-learning site.

As part of the work funded we will develop an e-learning module on the review of the Drug Misuse and Dependence: UK Guidelines on Clinical Management (the "Orange Book") when it is published later this year. Our training course will be aimed at making the content of the guidance readily available in an easy-to-follow format for all interested parties including clinicians, non-medical prescribers, drug workers, nurses, people currently in treatment and those entering treatment.

The course will consist of an e-learning module plus a face to face training day (to be held early in 2017). The course will be endorsed by the RCGP Substance Misuse and Associated Health Unit and recognised by the Federation of Drug and Alcohol Professionals (FDAP) as part of CPD.